3D打印医疗器械和组织结构的工艺、材料和监管考量

Long Ng Wei ,  Jia An ,  Chee Kai Chua

工程（英文） ›› 2024, Vol. 36 ›› Issue (5) : 154 -176.

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工程（英文） ›› 2024, Vol. 36 ›› Issue (5) : 154 -176. DOI: 10.1016/j.eng.2024.01.028
研究论文

3D打印医疗器械和组织结构的工艺、材料和监管考量

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Process, Material, and Regulatory Considerations for 3D Printed Medical Devices and Tissue Constructs

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摘要

三维（3D）打印是一种高度自动化的平台，能够以逐层方式沉积材料，按需制造预先确定的3D复杂结构。这是一种针对于制造个性化医疗器械，甚至专用于患者的组织结构的非常有前景的技术。每种类型的3D打印技术都有其独特的优势和局限性，选择合适的3D打印技术在很大程度上取决于其预期用途。在本文中，我们展示并强调了3D打印个性化医疗器械的一些关键工艺（打印参数、构建方向、构建位置和支撑结构）、材料（批次之间的一致性、回收利用、蛋白质吸附、生物相容性和降解性能）和监管考量（无菌性和力学性能）。本文旨在让读者对3D打印的各种关键考量（工艺、材料和监管）有很好的理解，这对于生产制造更好的专用于患者的3D打印医疗器械和组织结构至关重要。

Abstract

Three-dimensional (3D) printing is a highly automated platform that facilitates material deposition in a layer-by-layer approach to fabricate pre-defined 3D complex structures on demand. It is a highly promising technique for the fabrication of personalized medical devices or even patient-specific tissue constructs. Each type of 3D printing technique has its unique advantages and limitations, and the selection of a suitable 3D printing technique is highly dependent on its intended application. In this review paper, we present and highlight some of the critical processes (printing parameters, build orientation, build location, and support structures), material (batch-to-batch consistency, recycling, protein adsorption, biocompatibility, and degradation properties), and regulatory considerations (sterility and mechanical properties) for 3D printing of personalized medical devices. The goal of this review paper is to provide the readers with a good understanding of the various key considerations (process, material, and regulatory) in 3D printing, which are critical for the fabrication of improved patient-specific 3D printed medical devices and tissue constructs.

关键词

3D打印 / 生物打印 / 生物制造 / 医疗器械 / 组织结构

Key words

3D printing / Bioprinting / Biofabrication / Medical devices / Tissue constructs

引用本文

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Long Ng Wei,Jia An,Chee Kai Chua. 3D打印医疗器械和组织结构的工艺、材料和监管考量[J]. 工程（英文）, 2024, 36(5): 154-176 DOI:10.1016/j.eng.2024.01.028

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1 动机

三维（3D）打印技术在制造个性化3D医疗器械和组织结构方面的应用代表了医疗保健领域的一次范式转变，它为新型医疗保健方法提供了无数的可能性，包括用以患者为中心的模式取代曾经医疗保健领域的一刀切方法。这种模式能够根据每个患者的独特生理机能和需求进行量身定制。3D打印医疗器械是可用于诊断、治疗或预防疾病的物理仪器或工具，包括医疗植入物[1]、手术模型[2]、手术器械和个人防护装备[3]；而3D生物打印的组织结构则是使用患者细胞制造的，主要用于修复和重建的受体组织[4‒8]。3D打印技术为现代医疗提供了一个多功能和高度自动化的平台，可以前所未有的精度和复杂度制造专用于患者的3D医疗器械或组织结构。将3D打印技术引入医疗领域的主要动机包括设计和制造与患者身体结构完美匹配的定制化3D医疗器械、植入物和假体。

全球3D打印医疗器械的市场份额预计将从2022年的27亿美元增长到2028年的69亿美元，年复合增长率为17.1% [9]。市场上，对个性化3D打印医疗器械或组织结构有着较高的需求，原因包括：①定制化、②更高的复杂性和③按需打印能力。值得注意的是，3D打印医疗器械和组织结构的开发和生产涉及与工艺、材料和监管要求相关的复杂考量。这些方面对于确保3D打印件的安全性、功效性和质量至关重要，深入理解这些关键因素，对于开发满足患者要求并符合监管指南的3D医疗器械和组织结构至关重要。本文旨在强调和讨论制造3D个性化医疗器械和组织结构的各种关键考量，包括接下来各节中的工艺、材料和监管。

2. 3 D打印技术的出版物情况

根据美国材料与试验协会（ASTM）的标准分类，共有7种主要的3D打印技术，包括材料挤出成型、材料喷射成型、粉末床熔融成型、立体光固化成型、黏结剂喷射成型、直接能量沉积成型（DED）和薄片层压成型，如图1（a）所示。在过去十年中，根据Web of Science数据库平台，使用以下关键词发表的有关3D打印医疗器械和组织结构的论文数量不断增加：“3D打印”+产品——“医疗植入物”“手术模型”“手术器械”“个人防护装备”或“组织结构”[图1（b）]。使用以下关键词，在Web of Science数据库平台上，对用于制造3D打印医疗器械或组织结构的3D打印技术进行了进一步分析：“3D打印”+ 3D打印技术（①材料挤出成型——“挤出”；②材料喷射成型——“喷射”；③粉末床熔融成型——“选择性激光熔融”“直接熔融激光烧结”“选择性激光烧结”与“电子束熔化”；④立体光固化成型——“立体光刻”与“数字光处理”；⑤“黏结剂喷射成型”；⑥“直接能量沉积成型”；⑦“薄片层压成型”）+医疗器械——“医疗植入物”“手术模型”“手术器械”“个人防护装备”或“组织结构”。我们检索的初步结果反映了3D打印医疗器械和组织结构的总体出版物情况。用于制造医疗器械和组织结构的最常用3D打印技术是材料挤出成型（53.98%），其次是粉末床熔融成型（16.81%）、立体光固化成型（16.52%）、材料喷射成型（8.85%）、黏结剂喷射成型（2.36%）、直接能量沉积成型（0.88%），最后是薄片层压成型（0.59%）[图1（c）]。所有7种3D打印技术都可用于制造3D打印医疗器械——材料挤出成型（41.83%）、粉末床熔融成型（22.71%）、立体光固化成型（19.92%）、材料喷射成型（10.36%）、黏结剂喷射成型（3.19%）、直接能量沉积成型（1.2%）和薄片层压成型（0.8%）[图1（d）]。而制造3D生物打印的高浓度细胞组织结构只适用材料挤出成型（88.64%）、立体光固化成型（6.82%）和材料喷射成型（4.55%）[图1（e）]。需要指出的是，需要对其他已发表论文[10]进行进一步的科学计量学分析，才可获得更详细和深入的调查结果。在下面几节中，我们将更全面地讨论各种3D打印技术的工艺考量、材料考量和监管考量。

3 工艺考量

3.1 不同的3D打印工艺

3.1.1 材料挤出成型

材料挤出成型是第一大常用3D打印技术，常用于3D打印医疗器械的制造，如假体[11‒13]、骨科植入物[14‒16]、手术导板[17‒19]、手术模型[20‒22]、定制化个人防护装备[23‒24]和类组织结构（如骨[25‒28]、心脏[29‒32]和软骨[33‒35]）。一些常用材料包括聚合物（水凝胶[36‒40]或热塑性塑料[41]）、金属[42‒43]和陶瓷[44‒45]。在材料挤出成型工艺中，材料通过喷嘴或孔口选择性地挤出，以逐层沉积的方式制造复杂的3D打印件[46]。材料挤出成型工艺可分为两大类：①高温熔融沉积材料——熔融沉积建模（FDM）、熔丝沉积制造和螺杆辅助增材制造（AM）[47‒48]；②基于气动或机械的材料挤出成型——墨水直写打印和熔融电纺打印[49‒52]。

熔融材料挤出方法取决于众多工艺参数，包括温度（喷嘴、打印机床面和腔体）、喷嘴速度和切片厚度[53‒56]。最佳喷嘴温度（略低于材料分解温度）有助于提高3D打印件的熔接强度。有文章研究了喷嘴温度（210~250 °C）对丙烯腈丁二烯苯乙烯（ABS）丝材（分解温度范围为360~450 °C [57]）熔接强度的影响，发现在最高喷嘴温度（250 °C）时，可以获得最大熔接强度[58]。最佳的打印机床面温度（取决于丝材类型）有助于改善第一打印起始层的黏附性，并最大限度地减少3D打印件内部热应力的累积[59‒60]。最佳的打印机床面温度因所使用的丝材类型而异：对于ABS丝材，须使用115 °C的床面温度[59]；而对于纯聚丙烯和玻璃纤维增强聚丙烯，则须使用接近室温的打印机床面温度[60]。打印机的床面温度通常需要低于喷嘴温度，以启动材料固化过程。此外，增加打印层的厚度有助于提高弹性模量[61]。材料挤出成型工艺中打印件的尺寸精度由各种材料和工艺相关参数决定，如材料收缩度[62]和腔体温度[63]。可通过优化工艺参数[64]、切片策略[65‒66]、部件构建方向[67‒68]和化学处理[69‒70]来改善最终3D材料挤出打印件的表面光洁度。表面光洁度、打印构建时间和支撑结构被视为影响打印件品质的决定性因素，其有助于最小化或消除过多的支撑结构，并改善整体表面光洁度[71]。

基于挤出成型的生物打印技术是一种专门为使用活细胞和生物材料等生物材料制造复杂3D组织结构而设计的3D打印技术。在基于水凝胶挤出成型的生物（组织结构）打印过程中，存在一些重要的工艺考量因素，包括生物墨水的打印适用性[72]、剪切应力[73‒74]和潜在的喷嘴堵塞问题[75]。在基于挤出成型的生物打印技术中，生物墨水的打印适用性可由损耗正切值（tanδ）表示，其系损耗模量（G''）与储存模量（G'）的比值，在合适的“打印适用性窗口”内打印对于获得形状保真度良好的3D组织结构至关重要。此外，在基于挤出成型的生物打印过程中，在挤出成型生物墨水中的包被细胞的细胞活力，取决于其所承受的剪切应力，这受到生物墨水黏度、喷嘴几何结构、喷嘴直径和打印压力的影响。当使用小喷嘴（直径约100 μm）打印高细胞浓度的生物墨水时，可能存在喷嘴堵塞问题。可打印生物墨水的最佳黏度在10~107 mPa∙s的范围内[76]，最大细胞浓度约为107 个∙mL-1（高细胞浓度生物墨水可能会干扰水凝胶的形成）[77‒78]。在基于挤出成型的生物打印中使用的不同类型的高细胞浓度生物墨水，包括海藻酸盐基（5%~8% w/V）[79‒80]、明胶基（5%~10% w/V）[81‒86]、透明质酸基（1.5%~2.5% w/V）[87‒90]、聚乙二醇（PEG）基（20% w/V）[91]和Pluronic F-127（≥ 20% w/V）[92‒93]。此外，通常使用从各种组织/器官中提取的脱细胞细胞外基质（dECM）生物墨水（浓度为1%~4% w/V），凭借基于挤出成型的生物打印工艺进行打印[94]。dECM生物墨水一般在不超过15 °C的低温下进行打印，以减轻预凝胶化，在37 °C时，其会发生温度依赖性交联。

3.1.2 粉末床熔融成型

粉末床熔融成型是第二大常用3D打印技术（16.81%），它可用于制造3D打印医疗器械，如骨科植入物[95‒97]、牙齿植入物[98‒100]和手术器械[101‒102]，并且可以用各种粉末（如聚合物粉末、金属粉末和陶瓷粉末）[103‒107]进行加工（表1）。在打印过程中，利用热能进行选择性地熔融，形成铺撒在建造平台上的粉末床区域，以获得3D成品件。针对打印过程，首先在惰性条件下将预先确定的3D计算机辅助设计（CAD）模型及其支撑结构定位于构建体积内，然后在设置预先确定的一组打印参数后针对扫描路径进行扫描，最后再涂覆一层新的粉末颗粒[103]。粉末床熔融成型工艺的方式包括：①选择性激光熔融（SLM）；②直接熔融激光烧结（DMLS）；③选择性激光烧结（SLS）；④电子束熔化（EBM）[103‒104]。SLM和DMLS之间的主要区别在于加工粉末所使用的温度——在SLM中，粉末在高温下完全融化以达到熔融状态；而在DMLS中，粉末表面在较低温度下会熔接在一起[105]。基于激光的粉末床熔融成型工艺通常在惰性环境中进行，而基于电子束的粉末床熔融成型工艺则在真空腔体内进行[103]。此外，在EBM工艺中，打印的每一层粉末都会轻微烧结，以使得静电荷和粉末颗粒排斥的累积达到最小，然后再沿相同的工具路径进行扫描，熔融这些已烧结的粉末。通过真空方式除去过量粉末，并进行如涂层、烧结或渗透等进一步的后处理。

粉末床熔融成型打印方法的一些关键工艺和材料参数包括能量输入、粉末再涂覆、聚结和冷却[108]。粉末床熔融成型打印方法的优势为无需支撑结构（尤其是聚合物）即可制造具有良好表面光洁度的复杂结构，而其局限性为由于粉末重涂速度和激光扫描速度较慢，会导致制造速度较低。一些最新策略旨在通过重熔方法降低热应力积累并消除裂纹和扩展[109‒111]，以及实施多激光扫描以提高制造速度[112‒114]，从而以更高的吞吐率使得3D打印件具有更好的密度和表面光洁度。

3.1.3 立体光固化成型

立体光固化成型是第三大常用3D打印技术（16.52%），它可用于制造3D打印医疗器械，如矫正设备[115‒117]、助听器[118]和手术导板[119‒121]，以及组织结构（如骨[122‒125]、软骨[126‒128]、肝脏[129‒131]和神经组织[132‒135]）。立体光固化成型工艺中使用的不同材料，包括聚合物树脂[136‒137]、金属[138‒140]甚至陶瓷[140‒142]的悬浮液（表1）。当光源投射到表面以启动自由基光聚合过程时，光固化树脂会选择性地交联以获得完成的3D零件[136]。立体光固化成型工艺可分为两大类：立体光刻（SLA）和数字光处理（DLP），并且可根据光源的位置（自下而上或自上而下）进一步分类。在自下而上的SLA打印工艺中，光源位于树脂槽底部的窗口下方，用于交联树脂；而在自上而下的SLA打印工艺中，光源直接位于树脂槽和建造平台上方，用于交联树脂。数字微镜器件（DMD）常用于DLP工艺，以促进整个树脂层的快速交联，而在SLA中只有单束光斑，因此DLP的打印速度明显更快[143]。值得注意的是，最佳照射持续时间可确保在打印层界面处获得足够的大分子转化，从而实现界面融合，同时最大限度降低过度暴露以防止周围树脂发生仅有部分聚合的不良情况。最新研究表明，在打印具有高纵横比的聚二甲基硅氧烷（PMDS）结构时，针对每一打印层[144]，其最佳紫外线暴露时间为2.5 s。具有高摩尔消光系数（ε）的树脂将有助于较小体素量的交联并缓解过度固化情况。通过降低光敏引发剂（PI）的浓度或减少染料/光敏吸收剂的使用，可以增加光的渗透深度。在树脂中加入非活性染料组分或光敏吸收剂，可以改善打印分辨率，因为它会与PI争相吸收光线。立体光固化成型工艺的一些关键考量因素包括：激光源、打印参数、树脂槽设计、树脂黏度、激光/树脂相互作用，以及光固化树脂的配方（生物相容性、所用溶剂和自由基副产物的形成）[136]。

与通过喷嘴沉积活细胞的其他生物打印技术（基于挤出成型和喷射成型的生物打印）不同，基于立体光固化成型的打印技术使用生物相容的液态生物树脂，用于制造高细胞密度的复杂3D高浓度细胞组织结构[145]。在基于立体光固化成型打印组织结构时的一些重要工艺考量，包括使用合适的激光波长[146‒147]和生物相容的PI [148]。据报道，较短波长对活细胞的危害更大，因为更高的能量会导致细胞DNA损伤加剧。此外，理想的PI应该具有高度亲水的特性（存在更多亲水基团会降低PI的细胞摄取，从而减少对活细胞的细胞毒性效应）[149‒150]，并且能在长波长下交联（在短波长下形成的、由紫外线引发的自由基，对细胞活力的影响最为严重）[148]。基于立体光固化成型的生物打印技术目前已取得了重大进展，对于制造高分辨率结构且细胞密度高的复杂3D组织结构有卓越贡献。用于基于立体光固化成型的生物打印的不同类型生物墨水，包括：藻酸盐基（5%~8% w/V）、明胶基（2.5%~15% w/V）[151‒153]和聚乙二醇基（10% w/V）[154]。

3.1.4 材料喷射成型

材料喷射成型是使用的第四大3D打印技术（8.85%），可用于制造3D打印医疗器械（如矫正设备[155‒157]、解剖模型[158‒160]）和组织结构（如肺泡[161‒164]、视网膜[165‒168]和皮肤[169‒172]）（表1）。使用基于材料喷射成型系统的可打印材料包括聚合物[172‒174]、金属[175‒177]甚至陶瓷[178‒180]的悬浮液（表1）。在基于材料喷射成型的工艺中，分散的液滴被选择性地沉积在基底表面上，以制造3D打印件。基于材料喷射成型的系统有不同种类的变体，包括基于喷墨成型的系统[连续或按需喷滴（DOD）] [181]和电流体动力喷射打印系统[182]。在打印过程中，打印头水平移动用以沉积功能性墨水液滴[通常在皮升（pL）或纳升（nL）的范围内]。从传动机构施加的压力脉冲克服墨水的表面张力，使分散的墨水液滴从喷嘴孔中喷出。沉积在基底表面的液滴会融合并交联，形成该层所需形状，后续层的液滴将沉积在前一层上，最终获得3D成品件。

其打印适用性受墨水（黏度、表面张力和密度）和喷嘴半径的物理性质影响，可由Ohnesorge数（Oh）的倒数——Z值（其系雷诺数与韦伯数平方根之比）表示，用于表征基于材料喷射成型工艺中的墨水打印适用性[183]。喷嘴尺寸对打印分辨率有着重大影响（约为喷嘴直径的1.2~2倍）。尽管喷墨打印机头能够以高打印频率工作（高达30 kHz），但建议以低于500 Hz的打印频率对液滴进行沉积（因为高打印频率下喷嘴内压力不一致）[184]。由于大多数基于喷射成型的打印系统的喷嘴直径相对较小，所以它只能使用黏度范围窄（3~30 mPa∙s）的墨水进行打印[185]。

基于喷射成型的生物打印是推动3D组织或器官制造的3D打印技术先驱之一。各种基于喷射成型的生物打印技术包括基于喷墨成型的生物打印[186]、激光诱导前向转移（LIFT）/激光辅助生物打印[187]、基于声学的生物打印[188]、基于微阀的生物打印[189‒191]和电流体动力喷射生物打印（也称为生物电喷雾）[192]。它已成为生物技术和再生医学快速发展领域的一项重要技术，用于以喷射出液滴的方式操纵、成形和组装生物相关材料（如细胞、生物分子和生物材料），以按需喷滴方式实现特定生物功能。在使用基于喷射成型技术打印组织结构时的一些重要工艺考量，包括液滴撞击速度[193]、生物墨水黏度[194]、剪切应力[195]和细胞均匀性[196‒198]。据报道，低黏度（数量级为1 mPa∙s）液滴的撞击速度对细胞活力有显著影响，随着液滴撞击速度的增加，剪切应力急剧增加，细胞损伤呈指数增长。此外，研究还表明，每个点至少20 nL的液滴体积，有助于缓解蒸发引起的细胞损伤[193]。相反，由于较高聚合物浓度导致生物墨水黏度增加，即便在较高的液滴撞击速度下，细胞在液滴撞击基底表面时受到额外的缓冲作用（更高的能量耗散）也会提高细胞活力[194]。另一项研究认为，即使在喷射过程中短时间暴露于高剪切应力（> 5 kPa）也会对细胞活力及其长期增殖状况[195]产生损害。另一个重要考量是基于喷射成型打印过程中生物墨水内的细胞均匀性[196]。随着时间的推移，悬浮在生物墨水中的细胞会发生沉降并黏附在打印墨盒内表面，导致细胞不均匀。据报道，使用基于聚乙烯吡咯烷酮的生物墨水有助于减少细胞黏附，并缓解打印过程中的沉降问题，从而提高生物墨水内的细胞均匀性[197]。用于基于喷射成型生物打印的不同类型的生物墨水，包括藻酸盐基（< 2% w/V）[199‒201]、胶原蛋白基（0.2%~0.3% w/V）[202‒205]、明胶基（最高4% w/V）[206‒207]和透明质酸基（最高2.5% w/V）[208‒209]。

3.1.5 黏结剂喷射成型

黏结剂喷射成型是第五大常用3D打印技术（2.36%），用于制造3D打印医疗器械，如颌面部假体[210‒211]、骨科植入物[212‒214]和手术模型[215‒216]。粉末（聚合物、金属或陶瓷——典型颗粒尺寸≥30 μm）是黏结剂喷射成型工艺中的基本构建单元，理想的粉末材质应具有均匀流动性，颗粒之间无明显作用力[217]。在黏结剂喷射成型工艺中，新鲜的粉末材料被铺撒成一层，然后通过有机液态黏结剂选择性地逐层沉积并连接成预先确定的形状，获得最终的打印件生胚（通常易碎且多孔）。在取得打印件生胚后，可以进行渗透和（或）烧结等额外的后处理步骤，以提高其力学性能。黏结剂喷射成型工艺的一些潜在优势包括制造过程中粉末材料的可用范围较广、可在正常室温和空气环境中打印、无需支撑结构和打印速率快。而其局限性包括需要进行后续处理（烧结和渗透）、打印件在密实化过程中可能发生变形、表面粗糙度高和打印分辨率较低[218]。

改善粉末流动性的一些策略包括使用添加剂和（或）粉末涂料以及干粉[219‒220]。在黏结剂喷射成型工艺中，选择合适的黏结剂很重要，应该选择可打印黏度低、液滴分配一致、净化燃烧特性良好的黏结剂[221‒223]。黏合过程非常复杂和多变，黏结剂/粉末相互作用的性质与粉末材料的润湿特性、几何结构、直径和密度差异极大，这种相互作用影响着打印件的几何精度、力学性能和成品表面粗糙度。液滴撞击和黏结剂渗透是导致打印缺陷的主要原因，液滴撞击力高，可能导致细粉从原位置被抛出（弹道喷射）[224]，而黏结剂渗透缓慢会导致液滴在粉末床表面聚结，从而干扰后续层的粉末铺撒[225]。克服这些问题的一些策略包括添加化学固化剂以增强粉末床的凝聚力、改善粉末材料的润湿特性[226]，以及减小液滴直径以增加黏结剂渗透率[227]。

从未黏合粉末中取出生胚（金属）后，对其进行一系列后处理（去黏和烧结）。首先是去黏过程，即在烧结循环前从打印成品件中去除黏结剂，该过程中尽量减少残余应力至关重要。不同的去黏方法包括加热去黏、催化去黏、溶剂去黏和蜡芯去黏[228‒229]。接下来进行烧结过程，指通过高温热处理使生胚密实化和强化[230]。颗粒的烧结能力取决于其颗粒尺寸[231]和颗粒形态[232]。在烧结过程中，材料收缩度是一个常见问题，可以通过使用不同的多模粉粉末粒度来解决[233]。可以使用其他后处理方法打造近乎全密度的零件，这些方法取决于孔隙类型——闭孔或开孔。对于闭孔打印件，可采用热等静压法以大量减少乃至消除孔隙[234]，而对于多孔打印件，则可采用渗透工艺通过毛细润湿的方式将液体填充到其多孔部分。一些常见的渗透材料包括用于聚合物件的环氧树脂或丙烯酸酯[235]以及用于金属件的青铜[236]。

3.1.6 直接能量沉积成型

直接能量沉积成型是第二不常用的3D打印技术（0.88%），主要用于制造3D打印医疗器械，如骨科植入物[237‒240]。在直接能量沉积成型工艺中，可以使用各种金属甚至陶瓷，包括铬、H13工具钢、625镍基合金、不锈钢、钛合金和钨等[241]。在此工艺中，使用聚焦热能源（来自激光、电子束[242]或等离子体/电弧[243]）熔化同时沉积的金属材料（粉末或丝材），在沉积路径上形成一个金属熔池和底层热影响区（HAZ）[244]。通过计算机数值控制（CNC）来控制基板相对于沉积头的移动，通过逐层重复制造工艺获得成品。需要使用保护气体创造惰性环境来缓解打印过程中的氧化反应，同时需要载气将金属材料通过沉积头输送到金属熔池中。典型的DED工艺中使用的基板（基底）与预制件的材料成分相似，成品在打印完成后会从基板上移除。在DED工艺中使用红外相机和（或）测温仪进行热监控，这对于数据采集和反馈控制很有用[244‒246]。

DED工艺的主要优势是能够制造具有不同材料/合金浓度的功能梯度的零件，并可用于潜在的修复/包覆[247‒248]。DED工艺中使用的预制件可以是粉末或丝材形式。粉末供给和丝材供给DED工艺均有其独特的优势和局限性。粉末供给DED工艺的使用更为普遍，因为可以实时控制吹出的粉末动态，并可通过改变粉末动态以实现更高精度复杂结构的制造[249‒250]。通常使用气体雾化、水雾化和等离子体旋转电极法（PREP）等方法生产用于DED工艺的球状粉末（直径为10~100 μm）[251]。使用球状粉末有助于最小化熔池中捕获的惰性气体量，从而降低最终成品的整体孔隙率。相比之下，丝材供给DED工艺可获得更好的表面质量和工艺效率，但需要更精细的控制以避免潜在的振动问题[252]。

在DED工艺中需要考量的一些关键因素包括使用最佳工作距离[253]和热畸变[254‒255]。DED工艺中的最佳工作距离取决于几个关键参数，如激光衰减、粉末浓度分布、热量和转移到熔池中的质量[253]。DED打印工艺产生高温梯度，导致残留应力和塑性形变，从而影响打印件的结构性能和冶金学性能。DED打印件的热畸变受预热/冷却条件、打印参数以及打印件几何结构的影响[256‒257]。尤其是在DED过程中，在冷基底上进行第一层沉积时，高温梯度会产生最大残余应力，而减小基底尺寸可因较低的热通量和刚性而降低残余应力[255]。

3.1.7 薄片层压成型

薄片层压成型是最不常用的3D打印技术（0.59%），仅用于制造3D打印医疗器械，如颌面部假体[258]。它可以运用各种材料（如聚合物、金属、陶瓷，甚至复合材料）进行打印[259]。在薄片层压成型工艺中，预先确定的形状/几何结构的材料板层被黏合在一起，形成3D成品件。打印层的厚度取决于材料板的厚度，并决定了打印件的最终质量。薄片层压成型有不同的黏合机制，包括胶黏/黏接、热黏合、夹紧固定和超声波熔接。胶黏/黏接工艺需要使用背胶板材，提供相邻层之间的黏合。热黏合工艺通过在惰性环境中将材料略微加热至熔点以上，来促进相邻层的黏合。夹紧固定工艺需要螺栓和（或）夹紧构件将板材固定在一起，该工艺产生的夹紧固定力垂直于层压界面，存在层离的可能性。超声波熔接工艺在材料板上施加超声波和机械压力，促进扩散键合[259]。黏合/成型顺序可分为“先黏合后成型”或“先成型后黏合”工艺，两种工艺的优势和局限性将在下文中进行讨论。

“先黏合后成型”工艺包括板材对准、板材黏合，最后是成型过程（按照切片轮廓切割）。通常使用加热辊筒将黏合剂熔化，并黏合相邻的板层（厚度为70~200 μm），然后用激光/机械切割确定每层的形状/几何结构。剩余的材料板为后续层提供支撑。重复该过程则可获得3D成品件。“先黏合后成型”的薄片层压成型工艺的优势包括材料收缩度低、制造速度快、制造材料种类多，以及材料、机器和工艺成本相对较低；而缺点包括黏合剂的存在导致力学和热性能不均匀、由于材料板厚度不一致导致尺寸精度控制差，以及难以实现细小的内部结构[260]。对于“先成型后黏合”工艺，从材料板上切割出定义的形状/几何结构，然后与前一层基底黏合，直至获得3D成品件。“先成型后黏合”工艺能够制造出错综复杂的结构和通道，避免了切割到前一层的情况，并免去了材料去除步骤，但它需要一个打印对准系统，以实现相邻层之间的精确黏合[260]。

在前文中，我们对各种3D打印技术的工艺考量、材料考量和应用进行了全面的讨论。表1 [42‒45,53‒56,103‒108,136‒142,172‒180,221‒227,253‒257,259‒261]展示了用于制造医疗器械和组织结构的不同3D打印技术的分析。

3.2 构建方向和位置

在不同的增材制造工艺的构建体积内，CAD模型的构建方向和位置对打印件的性能影响至关重要。构建方向由X、Y和Z轴表示（字母顺序基于从最长到最短的尺寸递减），构建位置是指部件在构建体积内的空间位置[262‒263]，如图2（a）所示。

针对给定零件，为其选择最佳构建方向，可以提高打印成品件的质量[264‒266]。为了确定最佳构建方向，人们进行了大量研究，优化过程可以减少支撑结构[267‒272]、改善表面粗糙度[267,269,272‒274]、降低材料成本[267,272‒273]、缩短构建时间[267,269,272]、改善力学性能[267]，最后提高打印精度[273]。在熔融沉积建模工艺（材料挤出成型AM工艺）中，构建方向影响着打印件的延展性和失效行为，与以直立（ZXY）方向打印的打印件相比，以边缘（XZY）方向和平面（XYZ）方向打印的打印件具有更高的抗拉强度、弯曲强度和刚性[263]。另一项研究评估了选择性激光熔融工艺（粉末床熔融成型工艺）中构建方向的影响，以三种不同方向（边缘、平面和直立）打印的Ti-6Al-4V打印件显示出相似的α晶粒尺寸和prior-β晶粒尺寸，无论构建方向如何，其弹性模量相似[275]。然而，构建方向的变化影响了打印样品的延展性，平面定向打印的样品显示出了最低的断裂延伸值。这可能是由于平面定向打印样品的卷曲问题导致在加工后续层时产生缺陷[275]。另一项研究评估了在不同构建方向下使用PolyJet 3D打印机制造的3D打印件（使用材料喷射成型工艺）的拉伸性能,微观结构分析显示，表面裂纹/孔隙的方向取决于构建方向[276]。构建方向对通过立体光固化成型制造的零件的影响表明，直立方向构建的样品具有最高的断裂负荷值[277]。

打印件的力学性能直接受构建位置的影响,不同位置（如中心与边缘）的能量输出差异导致打印件的力学性能不同。一项针对构建位置的影响的研究表明，使用电子束熔化工艺制造的打印件在其顶部显示出更细的微观结构，而在其底部显示出更粗的微观结构[278]。此外，据报道，在不同位置制造的AM零件的断裂韧性变化显著[279]，如图2（b）所示。因此，构建方向和位置对影响打印件的力学性能方面都起着关键作用。

3.3 支撑结构

支撑结构的存在为使用3D打印技术制造高度复杂的几何形状提供了更多的设计自由度[280]。对于复杂结构的设计和制造，使用支撑结构是至关重要的，在3D打印过程中使用的支撑结构的数量、类型和位置会影响3D打印件的力学性能和几何精度[281]。值得注意的是，不同3D打印工艺（如材料挤出成型、粉末床熔融成型和立体光固化成型）的临界悬挂角也是不同的[281]。通常使用自动算法来确定支撑结构的最佳数量和位置，以最大限度减少材料浪费。对于更复杂的结构，则可能需要人工干预。因此，分析打印件的几何结构（悬挂角、高纵横比特征、内部特征和薄型特征）很重要。尽管可以通过物理或化学方法去除支撑结构，但去除过程往往会导致表面凸起或残留物。

针对修改后的CAD模型，优化后的拓扑结构和构建方向的组合可使得所需的支撑结构数量最小化[282‒284]。在熔融沉积建模工艺中使用拓扑结构优化措施，显著减少了支撑结构的数量，通过使用熔融沉积建模工艺而进行的多次试验验证，证实了所提出的支撑结构约束拓扑结构优化方法的稳健性和效率[285]。此外，还可采用单步骤优化过程，同时优化拓扑结构、构建方向和支撑结构，以最大限度地减少粉末床熔融成型过程中的支撑结构数量。与固定方向方法相比，所提出的多优化方法（在二维设置中使用简化的支撑成本模型进行测试）可以在更短的时间内获得高质量的解决方案[286]。另一项工作是使用MATLAB算法执行了两个步骤的优化过程，以优化构建方向和网状结构，从而实现最小的支撑结构[287]。根据另一项研究报道，在使用直接熔融激光烧结打印Ti-6Al-4V零件时，使用体积分数低至8%的晶格支撑结构，可以减少制造支撑结构所用的材料和时间[288]。一项类似的研究评估了不同晶格支撑结构对激光粉末床金属增材制造最大归一化残留应力的影响，对角线晶格支撑结构的应力最小化效果最为显著（图3）[289]，见表2。

4 工艺考量

4.1 材料批次之间的一致性

确定原材料和最终3D打印件的一致性至关重要，因为打印过程可能会导致材料发生一些化学和（或）物理变化。确保材料一致性的一系列步骤包括适当地记录材料成分和针对不同AM技术进行评估测试。打印材料成分（原材料、添加剂、交联剂或加工助剂）的正确记录包括记录材料供应商、材料名称及其美国化学文摘社登记号（CAS）、材料规格和材料分析证书（COAs）。此外，根据每种特定AM技术所使用的材料类型（金属、陶瓷和聚合物）和形式（粉末、丝材、流体和水凝胶）进行适当的表征和老化测试也很重要。不同材料类型的表征测试包括评估金属、金属合金或陶瓷材料的化学成分，以及评估聚合物的化学成分、分子量分布和温度[玻璃化温度（T g）、熔化温度（T m）和结晶温度（T c）]。不同形式材料的表征测试包括评估粉末直径、粉末粒度分布及其流变行为，评估丝材直径及其公差，以及评估流体黏度或黏弹性及其使用寿命。

4.2 材料回收

一些3D打印工艺中的材料（如在黏结剂喷射成型、直接能量沉积成型、粉末床熔融成型工艺后剩余的粉末）回收，以及使用立体光固化成型工艺后剩余的树脂，都引起了人们对材料性能可能从初始状态发生改变的担忧。打印后回收的粉末可能会因打印床的床面温度升高和过度烧结而导致存在缺陷，而树脂材料在光交联过程中可能会存在部分聚合状况。

从黏结剂喷射成型工艺中回收的粉末在真空中存放过夜并在180 °C的温度下进行干燥处理以去除水分，并通过45 μm筛网进行过滤。在未使用的不锈钢粉末中观察到了变形的粉末颗粒，在重复回收过程后，较大颗粒（> 30 μm）与较小颗粒（< 10 μm）的比率有所增加[290]，如图4（a）所示。有趣的是，使用新鲜粉末与回收粉末所制成的打印成品件，即使密度存在差异（新鲜粉末烧结件比回收粉末烧结件密度高出约1.5%），其硬度和屈服强度仍然相当[290]，如图4（b）所示。

另一项研究指出，从粉末床熔融成型EBM工艺回收的钛粉显示出更多细小颗粒的数量增加情况，但流动性降低；而从粉末床熔融成型SLM工艺回收的镍基合金粉末则显示出较粗颗粒的数量增加情况和更高的流动性[291]。尽管新旧选择性激光熔融粉末显示出类似的微观结构，但使用回收粉末制造的零件存在更高的孔隙率。新旧粉末的抗拉强度和屈服强度相当，但回收粉末的延展性和冲击韧性有所降低[291]。

最近的一项研究评估了材料回收对用于立体光固化成型的氧化锆基浆料的影响，观察到氧化锆出现了结块情况[图4（c）]，浆料黏度有所增加[图4（d）]。此外，烧结件的密度从全新样品的大于99%，显著下降到回收样品的约90%。尽管两种样品的烧结件显示出类似的硬度，但回收样品的抗弯强度[图4（e）]和杨氏模量[图4（f）]显著降低。因此，陶瓷基浆料可能不适合在立体光固化成型3D打印技术中进行材料回收[292]。到目前为止，对在不同3D打印工艺中回收材料的适用性的研究还很有限，因此，有必要对不同的3D打印工艺进行一系列进行更广泛的测试，来仔细评估材料回收的适用性。

4.3 打印件材料界面上的蛋白质吸附

材料界面上的蛋白质吸附，对调节细胞在材料界面上的黏附起着关键作用。材料界面上的蛋白质吸附是指生物流体中的蛋白质结合到材料表面的过程。材料界面上蛋白质吸附的关键机制取决于蛋白质是否能够将具有较低的熵和较高自由能的有序水分子排挤出去[293]。水分子会影响蛋白质的构象并暴露出与材料界面相互作用结合位点，从而影响蛋白质与材料界面之间的相互作用类型和强度。此外，在材料界面上的蛋白质吸附也受到其他几个因素的影响，如蛋白质结构（一级、二级、三级和四级）[294]、等电点[295]、溶解度[296]和湿润度[297]。吸附蛋白质层上的游离结合位点可促进细胞黏附和增殖，这可能有利于组织整合和伤口愈合[298]。相反，过量的蛋白质吸附可导致材料被“污染”，从而损害器件的功能，并在体内引发不良反应[299]。

诸如表面化学、湿润度和表面形貌等不同材料的表面性质可影响材料界面的蛋白质吸附和细胞黏附[300]，如图5（a）所示。大量关于表面化学的研究致力于创建具有不同化学机能的均匀涂层材料表面，以防止非特异性蛋白质的吸附，并提供生物惰性表面。表面化学在影响蛋白质吸附的类型、构象和强度方面起着至关重要的作用[301‒304]，如图5（b）所示。所吸附的蛋白质（如胶原蛋白、玻连蛋白、纤连蛋白和层黏连蛋白）的数量、类型和构造，会调节整合蛋白的结合，从而触发控制各种细胞功能的不同信号通路。细胞在表面附着后开始在表面扩散和伸展；蛋白质介导的黏附相互作用相当于机械传感器的作用，促进细胞外基质的相互作用[305‒306]。对材料表面进行功能化的最常见策略是应用各种单层/多层聚合物涂层[307]。尽管这种方法可以有效减少蛋白质吸附和血小板激活，但目前仍面临一些问题，比如在化学惰性表面上的开发均匀性和单层涂层是否能够长期稳定[308]。表面湿润度可指亲水性/疏水性，这是影响蛋白质吸附的一个重要因素。有充分证据表明，疏水表面的蛋白质的解折叠率和表面覆盖率明显比亲水表面更高[309]。由于亲水表面上存在较强的水/表面相互作用，因此蛋白质被亲水表面遮蔽，随后被解吸。最后，可以通过蛋白质吸附来操纵器械的表面形貌以控制细胞黏附。包括表面粗糙度、曲率和表面特征尺寸在内的不同表面形貌特征可诱导蛋白质结构和取向的变化，从而影响材料界面的细胞黏附[310‒311]。研究者实施了一种高通量和定量方法来研究表面粗糙度、蛋白质浓度和蛋白质类型对蛋白质/表面相互作用的影响[312]。表面粗糙度对吸附的蛋白质存在显著影响，研究表明，表面粗糙度从15 nm增加到30 nm时，会导致饱和吸附量显著增加（高达600%）。此外，纳米结构的表面促进了蛋白质在纳米孔隙内以长宽比大于0.4（取决于每种蛋白质的特性）形成蛋白质团聚体[312]。表面形貌的另一个关键参数是表面曲率，根据不同研究报道，局部曲率的增加会导致蛋白质吸附的减少[313‒314]。因此，深入了解材料表面性质对开发先进生物材料以操纵蛋白质吸附和调节材料界面的细胞黏附非常重要。

4.4 打印件的生物相容性

生物相容材料在与周围活体组织接触时不会引起任何不良反应[315]。影响打印产品生物相容性的不同因素包括化学成分[316]和表面性质[317]。最终成品可能经历一系列后处理程序，这可能会导致表面化学和表面形貌发生显著变化，进而影响生物相容性[317]。建议在各种后处理步骤（烧结、涂层、清洗和灭菌）之后，对医疗器械的最终成品形式和组成进行测试。

ISO 10993-5生物相容性测试标准的建立，旨在针对各种现有程序进行规范化，并规定了对器械进行体外细胞毒性测试的要求和指导原则[318]。体外细胞毒性测试的目标是评估器械对细胞损伤的潜力，并确保其可安全地用于人体。ISO 10993-5生物相容性测试标准涉及使用国际标准化组织专家认可的已建立的细胞系[美国模式培养物保藏所（ATCC）CCL-1、CCL-10、CCL-75、CCL-81、CCL-163和CCL-171]，用于初步调查阶段，包括通过细胞计数程序[319]、DNA水平评估[320]和MTT比色法[321]对细胞新陈代谢功能进行准确和可重复的定量测量。

4.5 3D打印件的降解性能

大多数医疗器械使用生物相容材料（金属、陶瓷或聚合物）制造，这些在人体内植入的医疗器械随时间的推移而进行降解时，可能会产生无害的降解副产物。值得注意的是，基于金属、陶瓷或聚合物的医疗器械的降解特性可能会有很大差异。金属和陶瓷在生理条件下对腐蚀和降解有很高的抵抗力，使其适合作为长期植入材料[322‒324]。相比之下，聚合物会发生水解、氧化和机械磨损等不同形式的降解情况[325‒326]。尽管可以通过使用医用涂层将植入医疗器械释放的降解副产物与周围组织隔离或使其最小化[327‒328]，但人体天生具有代谢和排除一部分这些降解副产物的能力[329]。因此，在为特定医疗器械选择合适材料时，应考量预期用途、生物力学要求和器械预期寿命等重要因素。

5 监管考量

3D打印技术已经在医学和医疗保健领域获得了大量关注，世界各地的不同监管机构，如美国食品药品监督管理局（FDA）、欧洲药品管理局（EMA）和中国国家药品监督管理局（NMPA）一直积极参与3D打印医疗器械的监管和审批。FDA批准的一些3D打印技术的重要里程碑包括批准了第一款3D打印颅骨植入物（“OsteoFab患者专用颅骨装置”，于2013年02月获得了FDA的许可），由美国牛津性能材料公司开发；以及第一款3D打印钛基脊柱器械[“CASCADIA侧椎椎间系统”，于2016年01月获得FDA 510(k)许可和欧盟认证]，由K2M控股集团（2018年被Stryker收购）开发。迄今为止，根据FDA公布的数据，众多3D打印公司已获得3D打印医疗器械的FDA 510(k)许可，如图6所示[330]。自此，多项研究印证了将3D打印医疗器械植入人体的可行性[331‒334]。

尽管在3D打印医疗器械的监管方面取得了重大进展，但目前FDA还没有批准或许可任何3D生物打印组织/器官。迄今为止，在3D生物打印领域，其技术、材料和工艺方面尚缺乏标准化，这严重限制了其在临床医学中的应用。此外，相较于传统3D打印医疗器械，3D生物打印的高浓度细胞组织/器官因其更高的复杂性给监管机构带来了不少挑战。尽管在整个生物打印过程中可以采用记录细胞源、评估细胞活力和功能和保持高度无菌性的标准等良好习惯，但仍存在一些瓶颈，比如物流问题和在人体内的未知长期安全性问题。只有少数研究机构具备制造3D生物打印组织/器官的专业知识和技术，因此，来源于患者的细胞和细胞外基质需要运输到专门的生物制造机构完成组织/器官的制造和发育过程，然后将发育成熟的组织/器官送回临床机构。在物流方面，也可能存在极高的挑战性，因为活体组织/器官的运输是一个高度专业化和对时间有较高要求的过程，需要仔细协调和遵守严格的规程，才能确保3D生物打印组织/器官保持活力且适合移植。尽管如此，最近一项研究在首个同类临床试验中给我们带来了一些希望——2022年06月，第一例自体生物打印耳部植入物（由美国3D Bio Therapeutics公司开发）成功植入人体，这彰显了3D生物打印技术在转化医学中的潜力[335]。

尽管目前FDA还没有批准任何3D生物打印组织结构，但众多3D打印公司已获得3D打印医疗器械的FDA 510(k)许可。3D打印医疗器械的一些重要监管考量包括打印件的无菌性和力学性能。始终严格贯彻医疗器械的无菌性指导原则和要求很重要，这可以减少潜在感染的发生。此外，许多医疗器械（如骨科植入物、假体和手术器械）需要具备特定的力学性能，才能有效履行其预期功能，而力学性能失效则可能会在使用过程中导致严重后果。在随后的章节，我们将对这些关键领域进行更详细的讨论。

5.1 打印件的无菌性

无菌植入物可减少潜在感染的风险，确保植入过程的安全性和有效性[336‒337]。其无菌性是指没有病原微生物存在的特性，可通过加热[338]、辐射[339]和化学品[340‒342]等不同的物理/化学灭菌方法实现。无菌性保证水平（SAL）是衡量医疗器械无菌概率的一种措施，医疗器械的公认SAL为10-6（百万分之一）。

高压蒸汽灭菌法是一种利用压力产生蒸汽消除微生物的加热型灭菌过程。高压蒸汽灭菌法消除微生物的有效性取决于温度、接触时间和压力蒸汽的自由循环度[338]。然而，对于对热敏感或湿气敏感的器械，高压蒸汽灭菌法则不适用。γ射线是一种能够通过破坏微生物DNA来消除微生物的电离辐射。虽然γ射线对于对热敏感和化学品敏感的器械是一种有效的灭菌方法，但高能γ射线会逐渐损坏聚合物分子，影响其化学和物理性能。化学灭菌是指使用过氧化氢（H2O2）[340]、环氧乙烷（C2H4O）[341]或戊二醛[342]等化学品杀死微生物。化学灭菌过程包括在受控温度、湿度和持续时间下将器械暴露于化学品中以实现有效灭菌。虽然它可用于对热敏感和辐射敏感的器械，但一些化学品可能存在毒性，需要额外步骤去除残留在器械上的化学品。因此，应按照打印件的材料性能来选择合适的灭菌技术。值得注意的是，FDA于2023年08月批准了来自爱尔兰Steris Healthcare医疗保健公司的首个H2O2灭菌系统，用于3D打印医疗器械的灭菌。

5.2 打印件的力学性能

医疗器械测试考量的一个关键方面包括对专用于患者的AM零件进行力学测试[343]。在完成不同的后处理、清洗和灭菌步骤后，AM成品零件应当经受住与使用传统方法制造的零件相似的力学测试（拉伸、压缩、弯曲、疲劳、冲击测试等）。应使用最终完成件或代表性试件进行推荐测试，并应格外重视含有空隙、支撑物或孔隙区域的结构。按照器械类型和用途决定需要进行何种测试类型（如极限强度、屈服强度、模量、蠕变、疲劳和磨损测试）。此外，因为最终完成件的材料性能和性能受到后处理步骤的影响[344‒345]，对所有后处理步骤（残留物去除、热处理和最终加工）进行正确地记录很重要。如上文所述，构建方向和位置对打印件的性能有着显著影响。因此，建立严格的制造工艺并进行全面监控以确保最终完成件批次之间的一致性至关重要。

6 结论

近年来，3D打印在制造医疗器械和组织结构方面备受关注。3D打印工艺共有七种主要类型，只有在充分了解不同的三维打印工艺及其优势和局限性的基础上，才能根据预期用途选择合适的制造技术。而且，生物材料对3D打印件的力学和生物学性能起着至关重要的作用。一些关键的材料考量因素，包括原料生物材料批次之间的一致性、材料回收对其性能的影响、材料表面性质对蛋白质吸附和在材料界面的细胞黏附的影响，以及3D打印件的生物相容性和降解性能。最后，3D打印医疗器械和组织结构在无菌性和力学性能方面应遵循严格的规定，以确保其安全性和有效性。因此，及时地提供一份简明的综述来强调3D打印医疗器械和组织结构的各种重要考量因素（工艺、材料和监管）是很有必要的。我们期望人们可以对3D打印的各种关键考量因素（工艺、材料和监管）有一个良好的理解，这对制造和改进专用于患者的3D打印医疗器械和组织结构至关重要。

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