TECHNO BYTES

Accuracy of 3-dimensional printed

dental models reconstructed from
digital intraoral impressions
€ns Currier,a Onur Kadioglu,a and J. Peter Kierlb
Gregory B. Brown,a G. Fra
Oklahoma City, Okla

Introduction: A rapidly advancing digital technology in orthodontics is 3-dimensional (3D) modeling and
printing, prompting a transition from a more traditional clinical workflow toward an almost exclusively digital
format. There is limited literature on the accuracy of the 3D printed dental models. The aim of this study was
to assess the accuracy of 2 types of 3D printing techniques. Methods: Digital and alginate impressions of the
oral environment were collected from 30 patients. Subsequently, digital impressions were used to print 3D
models using digital light processing (DLP) and polyjet printing techniques, and alginate impressions were
poured up in stone. Measurements for the 3 model types (digital, DLP, and polyjet) were compared with the stone
models. Tooth measurements (first molar to first molar) included mesiodistal (crown width) and incisal/occlusal-
gingival (crown height). Arch measurements included arch depth and intercanine and intermolar widths.
Intraobserver reliability of the repeated measurement error was assessed using intraclass correlation
coefficients. Results: The intraclass correlation coefficients were high for all recorded measurements, indicating
that all measurements on all model types were highly reproducible. There were high degrees of agreement be-
tween all sets of models and all measurements, with the exception of the crown height measurements between
the stone and DLP models, where the mean difference was statistically significant. Conclusions: Both the DLP
and polyjet printers produced clinically acceptable models and should be considered viable options for clinical
application. (Am J Orthod Dentofacial Orthop 2018;154:733-9)

T
he evolution of digital technologies in orthodon-
tics has influenced the traditional clinical work-
flow toward an almost exclusively digital
format.1,2 One of the most rapidly advancing digital
technologies is 3-dimensional (3D) modeling that uses
scanned data or digital impressions to create digital
models.3-6 These digital impressions can be acquired
either indirectly from a patient's models or impressions
using a desktop or intraoral scanner, or directly from
the patient's oral cavity using an intraoral scanner.
The authors of most previous scanner studies have
evaluated the accuracy of digital models produced
from indirectly acquired digital impressions.1,5,7-10
a
Department of Orthodontics, College of Dentistry, University of Oklahoma
Health Sciences Center, Oklahoma City.
b
Department of Orthodontics, College of Dentistry, University of Oklahoma
Health Sciences Center, Oklahoma City; private practice, Edmond, Okla.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
Address correspondence to: Onur Kadioglu, 1201 N Stonewall Ave, Room 400,
Oklahoma City, OK 73117; e-mail, onur-kadioglu@ouhsc.edu.
Submitted, September 2017; revised and accepted, June 2018.
0889-5406/$36.00
https://doi.org/10.1016/j.ajodo.2018.06.009
However, the current digital workflow in orthodontics
predominantly relies on digital impressions directly
acquired from the oral environment with an intraoral
scanner.11,12 This inconsistency between research and
practice demonstrates a need to test the accuracy of
the latter, as has been done for the former.
The advantages of digital models include no physical
storage requirement; instant accessibility; ability to do
digital diagnostic or treatment simulations; positive pa-
tient perceptions; ability to immediately send to an
outside laboratory; no risk of breakage, wear, degrada-
tion, or loss; and an overall improved continuity of
care; in addition, digital models are less labor inten-
sive.5,13-15 Although the advantages are numerous,
digital models come with at least 1 important
disadvantage. Without a physical model, treatment
planning for complex cases in a teaching environment
can be challenging, and a physical model is still
required for appliance fabrication.2,16
Rapid prototyping provides a solution to this limita-
tion by producing a physical replica of a digital model. In
orthodontics, the most common rapid prototyping tech-
nique is 3D printing.11,16 Two of the most common 3D
techniques in the marketplace today are digital light
733
734
processing (DLP) printing and polyjet printing.17 Both
techniques use additive manufacturing to fabricate a
3D model, layer by layer, based on a digital model.18-20
DLP printing uses a conventional light source such as an
arc lamp, liquid crystal display panel, or projection
source to cure the surface layer of a vat of photo-
polymerizing resin in a specific orientation based on a
digital model. Polyjet printing uses jet heads that spray
or jet the resin in the desired areas. As the jet heads
make subsequent passes, each sprayed layer is cured us-
ing an ultraviolet light source. In both printing tech-
niques, the initial layer of resin is cured onto a build
platform or a build plate, with each subsequent layer
cured directly to the previous layer of cured resin in
the z-axis to create a 3D object. The build plate lowers
at a predetermined increment, which determines the
thickness of each layer of resin that is cured.20,21 The
process of producing a 3D printed model from a
digital impression is summarized in Figure 1.
There is limited literature on the accuracy of 3D
printed dental models. Most previous studies have
concluded that 3D printed models are reasonably accu-
rate and may be suitable for clinical use.16,22,23
However, these studies have had limited sample sizes,
did not measure arch dimensions, and used digital
impressions that were not recorded directly from the
patient. The authors of a recent study investigated
the accuracy of 3D printed models produced from
digital models acquired from the oral environment
and measured multiple arch dimensions.11 However,
they used a limited sample size and did not compare
the printed models with stone models, which have
been established as the gold standard in previous
studies.16,17,22,23
The accuracy of a 3D printer must be confirmed
through research for it to be mainstreamed into the or-
thodontic specialty. Therefore, this study was designed
to assess the accuracy of 3D digital models and printed
models in the context of a commonly used digital work-
flow in orthodontic practice.
MATERIAL AND METHODS
Ethical approval for this study was obtained from the
Institutional Review Board for the Protection of Human
Subjects at the University of Oklahoma (Institutional Re-
view Board number 7132; reference number 655134) in
Oklahoma City.
A power analysis was done based on a similar precur-
sor study.16 A total of 22 patients were required for this
study to oftain an 80% probability of generating 95%
confidence intervals with margins of error less than
0.1 mm for tooth measurements and 0.25 mm for arch
dimension measurements.
November 2018  Vol 154  Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics
Brown et al
Thirty patients were randomly selected from a pool of
retention patients who received treatment at the
University of Oklahoma Graduate Orthodontic Clinic. A
patient was considered in retention if the appliances
had been removed 6 to 18 months before records
collection for this study. The inclusion criteria were
(1) orthodontic treatment at the Graduate Orthodontic
Clinic, (2) complete comprehensive treatment, and
(3) all permanent teeth, first molar to first molar, in
both dental arches.
Both the digital and alginate impressions were taken
at the 1-year retention appointment for all patients. Dig-
ital impressions were recorded using a chairside intraoral
scanner (Omnicam; Dentsply Sirona, York, Pa). Jeltrate
fast-set alginate (Sirona Dentsply) was used to make im-
pressions with stock impression trays. The alginate was
mixed using Cadco Alginator II electric mixer (Patterson
Dental, St Paul, Minn). Impressions were poured with
white ISO type 3 orthodontic model stone (Whip Mix,
Louisville, Ky) and mixed using a Vac-U-Mixer (Whip
Mix). All aspects of record collection followed the
manufacturers' recommendations. Alginate impressions
were poured with dental stone within 24 hours.
All digital models generated with the intraoral scan-
ner were converted to .STL file format using additional
3D imaging software (Dolphin Imaging and Manage-
ment Solutions, Chatsworth, Calif). The .STL files were
cleaned and prepared for 3D printing using Netfabb ad-
ditive manufacturing and design software (Autodesk,
San Rafael, Calif). The prepared .STL file for each patient
was printed using two 3D printing techniques: DLP
(Juell 3D Flash OC; Park Dental Research, New York,
NY) and polyjet (Objet Eden 260VS; Statasys, Eden Prai-
rie, Minn). Models were printed successively from their
respective printers. The workflow for collecting patient
records and producing study models is summarized in
Figure 2. All 3D printed models were printed as solid
models with a horseshoe-shaped base and in the hori-
zontal position. Figure 3 illustrates both 3D printed
model types.
A total of 240 maxillary and mandibular arches were
measured with 60 arches from each of the 4 model
types (stone, digital, DLP, and polyjet). All measure-
ments of the physical models were obtained using a
calibrated digital caliper (Orthopli, Philadelphia, Pa)
and measured to the nearest 0.01 mm directly from
the models, with the exception of arch depth, which
was measured using the digital caliper from a 1:1 scale
photocopy of the occlusal view. Measurements of the
digital models were all obtained using Dolphin Imaging
software. For all teeth, first molar to first molar, in both
arches, the tooth measurements included (1) the mesio-
distal widths from point contact to point contact
Brown et al
Fig 1. The process of producing a 3D printed model.
Fig 2. Study flow chart.
(crown width) and (2) the incisal/occlusal-gingival
heights from gingival zenith to cusp tip or incisal
edge (crown height). For both arches, arch dimension
measurements included (1) intercanine width from
cusp tip to cusp tip, (2) intermolar width from
mesiolingual cusp tip to mesiolingual cusp tip, and
(3) arch depth from the midline of the central incisors
to a perpendicular line crossing the mesial contact of
the first molars. Crown height measurements for the
digital models were not possible because of the
inability of the software to replicate the same measure-
ment technique used on the physical models. All other
digital measurements were collected using the same
measurement technique as on the physical models.
Three calibrated researchers measured and recorded
the data, with 1 researcher measuring either crown
width, crown height, or arch dimensions for all models.
American Journal of Orthodontics and Dentofacial Orthopedics
735
Statistical analysis
Bland-Altman plots24 were used to evaluate the
agreement of the crown width, crown height, interca-
nine, intermolar, and arch depth measurements between
the stone, digital, DLP, and polyjet models. Table I lists
the comparisons and what each evaluated. Ten percent
of each model type was measured a second time with
a 2-week interval between measurements. Intraclass
correlation coefficients (ICC) were used to assess the in-
traobserver reliability of the repeated measurement
errors.
RESULTS
A total of 5760 tooth measurements were recorded
from 240 maxillary and mandibular arches. An addi-
tional 720 arch dimension measurements were recorded
November 2018  Vol 154  Issue 5
736 Brown et al

Fig 3. Three-dimensional printed model types: A, polyjet; B, DLP.

Table I. Comparisons of models to evaluate accuracy Table II. Repeated measurement mean errors (mm)

Comparison Evaluation Crown Crown Intercanine Intermolar

Stone and digital Clinical accuracy of digital impression Model width height width width Arch depth
Digital and DLP Accuracy of the DLP printing process Stone 0.03 0.04 0.07 0.08 0.06
Digital and polyjet Accuracy of the polyjet printing process Digital 0.04 NA* 0.07 0.08 0.04
Stone and DLP Clinical accuracy of DLP printer DLP 0.03 0.05 0.07 0.07 0.06
Stone and polyjet Clinical accuracy of polyjet printer Polyjet 0.02 0.07 0.08 0.08 0.06

*NA indicates that repeated measurement mean errors were not

from the same sets of arches, for a total of 6480 mea-
surements. The ICC values were high for all recorded
measurements based on repeated measurement error,
indicating that all measurements on all model types
were highly reproducible (Table II).
The Bland-Altman plots24 demonstrated high
agreement between (1) stone and digital models for
crown width, intercanine, intermolar, and arch depth
measurements; (2) stone and polyjet models for all
measurements; and (3) digital and polyjet models for
crown width, intercanine, intermolar, and arch depth
measurements (Table III). The limits of agreement are
given in Table III. In addition, the Bland-Altman plots
showed high agreement between stone and DLP
models and between digital and DLP models for crown
width, intercanine, intermolar, and arch depth mea-
surements. However, the mean difference was statisti-
cally significant for crown height measurements
between stone and DLP models. The mean crown
height measurements of the DLP models were
calculated due to the inability to replicate the same measuring tech-
nique digitally as was done physically with a digital caliper.
significantly lower than the mean crown height mea-
surements for stone models by 0.29 mm, suggesting
that the DLP printed models underestimated the true
crown height dimensions.
DISCUSSION
The accuracy of two 3D printing techniques
commonly used in orthodontics was assessed in this
study. A unique aspect of this research was that the 3D
printed models were produced from digital impressions
acquired directly from the oral environment and then
compared with stone models. The importance of this
comparison was the ability to evaluate the entire digital
workflow from directly acquiring a digital impression
from the oral environment to producing a 3D printed
model of it. To our knowledge, no previous studies
have made such a comparison that would evaluate the

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Brown et al 737

variables not otherwise controlled, such as saliva,

Table III. Agreement between the different model
tongue, lips, cheeks, or movement. The authors of the
measurements (mm)
only study that has assessed the accuracy of an intraoral
Mean Limits of scanner under clinical conditions suggested that oral
Measurement difference (mm) agreement (mm) conditions do affect the accuracy.12 In addition to
Stone (1) vs digital (2) comparing 3D printed models produced from two 3D
Crown width 0.06 –0.27 to 0.38
Crown height NA* NA*
printed techniques with stone models, we evaluated
Intercanine 0.03 –0.41 to 0.47 the accuracy between the digital models and the 3D
Intermolar 0.09 –0.54 to 0.71 printed models. This comparison solely assessed how ac-
Arch depth 0.11 –0.41 to 0.63 curate the 3D printing techniques were by eliminating
Digital (1) vs DLP (2) variables introduced during acquisition of the digital im-
Crown width 0.01 –0.30 to 0.32
Crown height NA* NA*
pressions. All previous studies investigating the accuracy
Intercanine –0.09 –0.64 to 0.46 of 3D printed dental models have expressed the need for
Intermolar –0.15 –0.72 to 0.41 studies with larger sample sizes. We used a sample 3
Arch depth 0.02 –0.48 to 0.52 times larger than the next largest study. With the excep-
Digital (1) vs polyjet (2) tion of 2 previous studies, all failed to assess the accuracy
Crown width –0.01 –0.36 to 0.35
Crown height NA* NA*
of arch dimension measurements and focused only on
Intercanine –0.06 –0.55 to 0.42 measurements specifically related to the teeth.11,14
Intermolar –0.10 –0.63 to 0.44 Arch dimension measurements may not be critical if
Arch depth 0.01 –0.49 to 0.50 the sole purpose of a model is to be used for Bolton
Stone (1) vs DLP (2) analysis, as previous studies have done. However, to
Crown width 0.06 –0.20 to 0.43
Crown height –0.29 –1.04 to 0.46
maximize the use of a 3D printed model, arch
Intercanine –0.06 –0.61 to 0.49 dimension measurements must also be evaluated
Intermolar –0.07 –0.61 to 0.47 because these measurements are critical if a 3D printed
Arch depth 0.13 –0.37 to 0.63 model will be used to produce an appliance or aligner,
Stone (1) vs polyjet (2) as many orthodontists are already doing in practice.
Crown width 0.05 –0.33 to 0.43
Crown height 0.08 –0.57 to 0.73
Both 3D printing techniques used in this study, DLP
Intercanine –0.04 –0.48 to 0.41 and polyjet, have been documented to provide excellent
Intermolar –0.01 –0.51 to 0.49 accuracy and surface finish.19-21 A number of previous
Arch depth 0.11 –0.32 to 0.55 studies have shown that the polyjet printing technique
The mean difference equals the (2) measurements minus the (1) has produced more accurate models compared with
measurements where (1) represents the gold standard. Thus, a pos- other printing methods.11,16 In this study, the DLP and
itive value represents on average that the (2) measurements are over- polyjet printed models showed a similar mean
estimated compared with the (1) measurements. Conversely, a
negative mean difference represents on average that the (2) mea-
difference and had similar limits of agreement when
surements are underestimated compared with the (1) measurements. compared with a stone model for all recorded
*NA indicates that agreement between model measurement assess- measurements, with the exception of the crown height
ments were not possible due to the inability to replicate the same measurement (z-axis). The agreement between polyjet
measuring technique digitally as was done physically with a digital and stone models was high for this measurement,
caliper.
whereas the agreement between DLP and stone models
was low, with a mean difference of 0.29 mm and
accuracy of this technology the way it is currently being limits of agreement from –1.04 to 0.46 mm.
clinically implemented. The DLP printer used here prints to a minimum thick-
Only 1 study has evaluated the application of using ness of 50 mm. The polyjet printer used here prints to a
digital impressions to produce 3D printed models that minimum thickness of 16 mm. Both printers were set to
were directly acquired from the patient.11 However, the their most accurate settings. Accuracy and surface finish
method did not include stone models. In our opinion, of a 3D printer are limited by the thickness of the layers
including stone and digital model comparisons provides that are successively added in the z-axis, with thicker
a more complete picture when testing for accuracy. Tak- layers leading to greater inaccuracy.17,19,21 The
ing digital impressions from the oral environment variation in thickness of the layers that build the
without stone models, while lacking data on the accu- model in the z-axis may explain the variations found
racy of the scanner under clinical conditions, would in the crown height measurements in this study. It
make it difficult to evaluate whether any errors in the ac- would be expected that the polyjet printer, which
curacy of the 3D printing technique were due to prints thinner layers in the z-axis, ought to produce

American Journal of Orthodontics and Dentofacial Orthopedics November 2018  Vol 154  Issue 5
738
more accurate models. The variation in the accuracy of
crown height measurements between the DLP and
polyjet printed models when compared with stone
models could also partially be explained by the fact
that the polyjet printing technique does not require
postcuring once the model is fully printed. This may
lead to greater stability during printing.20 DLP printed
models require postcuring, which can lead to additional
shrinking of the resin. The shrinkage related to postcur-
ing has the greatest impact on the z-axis.17
Few studies have defined or established a range of er-
ror that is considered to be clinically acceptable. Of
those, 0.20 to 0.50 mm has been considered an accept-
able range for clinical accuracy.14,16,25-28 The mean
difference of 0.29 mm between the DLP and stone
models, although statistically significant, is in the
range of clinically acceptable norms for 5 of the 6
studies that have discussed this topic and fell only
0.09 mm outside the strictest recommended value to
be considered clinically accurate. Given the
recommendations of previous studies and the accuracy
produced by the 3D printing techniques used here,
both the DLP and polyjet printers produced clinically
acceptable models and could be considered viable
options for clinical applications.
Crown height measurements for digital models were
not possible because of the inability to replicate the
same measuring technique digitally as was done phys-
ically with a digital caliper. In a future study, it would
be ideal to compare the crown height measurements of
the digital model with both stone and printed models.
For this study, we assumed that the statistically signif-
icant mean differences for the crown height measure-
ments between the DLP and stone models were a
result of inaccuracy in the DLP printing technique
rather than the digital impression. This assumption
was made, because both the DLP and polyjet printed
models were produced from the same initial digital
impression, and the mean differences for the crown
height measurements between the polyjet and stone
models had high agreement.
The intraoral scanner used in this study produced
digital models that demonstrated high agreement
compared with stone models. We concluded that the
digital models are clinically acceptable and could be
considered viable options for clinical applications. It
would be useful for future studies to assess the accuracy
of other scanners in the orthodontic marketplace in clin-
ical settings. The accuracy of the digital models in this
study suggested that digital impressions acquired
directly from the oral environment could serve as a
gold standard to compare the accuracy of 3D printing
techniques.
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Brown et al
Other considerations for future studies could focus
on the accuracy of 3D printing models in vertical orien-
tations, allowing for additional models to be printed at a
given time, testing hollow formats that require less resin
in the printing process, and testing in high-speed set-
tings that print with thicker layers in the z-axis.
In this study, we assessed (1) the accuracy of an in-
traoral scanner under clinical conditions, (2) the accu-
racy of two 3D printed techniques, and (3) the
accuracy of the combination of (1) and (2), which as-
sessed the clinical application of acquiring a digital
impression under clinical conditions and 3D printing a
physical model.
CONCLUSIONS
1. Both the DLP and polyjet printers produced clini-
cally acceptable models with high accuracy that
may allow them to serve as a replacement for stone
models and to be considered viable options for clin-
ical applications.
2. The polyjet printer produced models with clinically
acceptable accuracy for all recorded measurements.
Compared with the DLP printer, the polyjet pro-
duced models with closer accuracy to the stone
models.
3. The mean difference between crown height mea-
surements for the DLP and stone models was statis-
tically significant in this study, but the mean
differences were within a clinically acceptable
range.
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