Additive Technology: Update on Current Materials

and Applications in Dentistry

Abdullah Barazanchi, BDS, Kai Chun Li, BDentTech(Hons), PhD, Basil Al-Amleh, BDS, DClinDent,
Karl Lyons, BDS, MDS, PhD, & J. Neil Waddell, HDE, PGDipCDTech, MDipTech(DentTech), PhD
Department of Oral Rehabilitation, Sir John Walsh Research Institute, Faculty of Dentistry, University of Otago, Dunedin, New Zealand

The article is associated with the American College of Prosthodontists’ journal-based continuing education program. It is accompanied
by an online continuing education activity worth 1 credit. Please visit www.wileyhealthlearning.com/jopr to complete the activity and
earn credit.

Keywords
Additive; 3D printing; direct metal laser
sintering; cobalt chromium; CoCr; milling;
subtractive; prosthodontics; dentistry; digital
workflow.
Correspondence
Abdullah Barazanchi, School of Dentistry,
University of Otago, PO Box 647, Dunedin,
9054, New Zealand. E-mail:
A.Barazanchi@gmail.com
The authors deny any conflicts of interest.
Accepted May 8, 2016
doi: 10.1111/jopr.12510
Abstract
Additive manufacturing or 3D printing is becoming an alternative to subtractive
manufacturing or milling in the area of computer-aided manufacturing. Research on
material for use in additive manufacturing is ongoing, and a wide variety of materials
are being used or developed for use in dentistry. Some materials, however, such as
cobalt chromium, still lack sufficient research to allow definite conclusions about
the suitability of their use in clinical dental practice. Despite this, due to the wide
variety of machines that use additive manufacturing, there is much more flexibility in
the build material and geometry when building structures compared with subtractive
manufacturing. Overall additive manufacturing produces little material waste and is
energy efficient when compared to subtractive manufacturing, due to passivity and the
additive layering nature of the build process. Such features make the technique suitable
to be used with fabricating structures out of hard to handle materials such as cobalt
chromium. The main limitations of this technology include the appearance of steps
due to layering of material and difficulty in fabricating certain material generally used
in dentistry for use in 3D printing such as ceramics. The current pace of technological
development, however, promises exciting possibilities.

In the past few decades the world has undergone a digital rev-
olution. This has not only impacted how we go about our daily
lives, but also in our general problem-solving approach to cur-
rent social issues.1 A similar trend is occurring in the medical
and dental fields, where more accurate scanning and manufac-
turing techniques allow for better planning, wider networking,
and more automated production techniques. The incorporation
of digital technology into dentistry has become so important
that it is one of the main themes at international conferences in
prosthodontics.2
The increasing use of technology in dentistry has given the
operator the opportunity to eliminate manual handling of speci-
mens throughout the various processing steps; some have given
this approach in dentistry the term “digital workflow.”3,4 The
basic premise of digital workflow is based around three ele-
ments. First is data acquisition, such as various scanning tech-
nologies. This is followed by manipulation and processing of
data, created using a computer-aided design (CAD) software,
and finally the processed data are used for manufacturing of
structures in the desired material through computer-aided man-
ufacturing (CAM).5 In the manufacturing step, a fast growing
alternative to milling methods, also known as subtractive man-
ufacturing, is known as three-dimensional (3D) printing. This
technology, also termed “additive manufacturing” and “rapid
prototyping,” has been replacing certain manufacturing previ-
ously performed by subtractive manufacturing.
One material increasingly used for the manufacture of dental
prostheses is cobalt chromium (CoCr). The popularity of this
alloy is attributed to its relatively inexpensive cost and good
physical properties, making it an ideal material for certain den-
tal restorations such as crown substructures. This is because
traditional manufacturing methods, such as casting, are usually
difficult due to the high melting point of CoCr, its hardness, and
lack of ductility.6 This article will review current applications,
materials, advantages, and limitations of additive manufactur-
ing. Because of its emerging use within manufacturing tech-
nique, particular focus will be given to current research and the
manufacturing method of CoCr alloy.
Additive manufacturing
The alternative to subtractive manufacturing in the CAM step
of the dental workflow is the additive manufacturing tech-
nique (3D printing). Additive manufacturing is defined by the

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Barazanchi et al Additive Technology

American Society for Testing and Materials (ASTM) as “the

process of joining materials to make objects from 3D model
data, usually layer upon layer, as opposed to subtractive man-
ufacturing methodologies.”5 Additive manufacturing has also
been used as an efficient method for rapid prototyping when
highly customized models are required,7 thus making it suitable
for the highly individualized prostheses required in dentistry.
The increased acceptance of this technique into general man-
ufacturing is evidenced by a fourfold predicted increase in the
market size by 2020 to around $5 billion dollars.8
Charles Hull introduced the principle of additive manufactur-
ing in 1986. While additive manufacturing technology has been
available since then, as were early subtractive manufacturing
based machines, there have been barriers to overcome. In addi-
tion to issues with image acquisition, the amount of experience
required to get repeatable results was challenging; however, that Figure 1 Example of an experimental jig made from PLA.
is becoming less of an issue since the original patents have ex-
pired, allowing for more companies to develop and simplify the
wax-ups of complex prosthodontic cases.5 Another group of
technology for new users. The speed of development is particu-
polymers commonly used in additive manufacturing are photo-
larly evident in laser sintering technology. While early samples
initiated resins. Stereolithography (SLA) machines usually use
were porous and rough,9 more current machines produce al-
this type of polymer as a build material, curing one layer at a
loys at a high rate with good physical properties compared to
time using UV light or laser. These polymers offer much more
traditional casting methods.10 Because of the basic principle
flexibility in color, rigidity, and modification of components.
of forming a structure through layering, a few differences with
They too can be mixed with biocompatible and bioactive com-
subtractive manufacturing are highlighted here.
ponents such bioactive glass. Studies have also shown that they
allow for even distribution of added compounds and display
Material in additive manufacturing
bioactive properties in vitro.12 Light-cured resins may also be
Unlike subtractive manufacturing techniques, the sheer variety used as a substitute for the manual wax-up step in the lost-
of additive procedures allow for a large range of raw materials wax casting process,13 which can create equally precise final
to be used for fabrication of structures, due to a diversity of structures once invested into a mold for casting.14
methods used to manufacture structures using additive and lay-
ering principles. The majority of the raw materials for additive Ceramics
manufacturing used for dental and medical purposes may be
Various additive techniques have been used for production of
grouped into binder/powder material combinations including
ceramic structures for use as tissue scaffolds or dental ceramic
polymers (including resins and thermoplastics), ceramics, and
prostheses. This includes selective laser sintering (SLS) of ce-
metals.
ramic or extrusion of the green form of ceramic, then sintering
the product to achieve full strength. FDM and the use of a jetted
Polymers
binder to bind specially coated ceramic powders together to pro-
They include a wide variety of substances. Additive manufac- duce the green form of the ceramic is then sintered to achieve
turing machines use polymers as the raw material for building full strength.15 Use of SLS technology to produce ceramics
programmed structures. Thermoplastics are one example of involves either ceramic powder or a pre-sintered ceramic. To
such polymers. They are generally used by fused deposition date, however, direct SLS of ceramic powder has only yielded
model (FDM) machines, where filaments of the thermoplas- porous structures difficult to post-process to high density, so it
tic material are heated then extruded through the nozzle to has been mainly used to produce modified glass-ceramics for
build precise structures. Examples include acrylonitrile buta- fabrication of bioactive tissue scaffolds.16 However, SLS tech-
diene styrene (ABS) (Fig 1) and the more environmentally niques on porcelain slurry have achieved a dense final ceramic
friendly polylactic acid (PLA) polymer. The latter is much more structure.17 Another additive technique, involving powder-bed
suitable for use in the oral cavity, albeit as a provisional mate- inkjet 3D printing and vacuum infiltration, has been found to
rial, due to its strong impact resistance, and non-toxic surface produce dense alumina-reinforced-ceramic structure with high
finish compared to ABS.8 Some studies have added biologi- density and satisfactory strength.18 Crude zirconia prosthe-
cal compounds into the build filaments extruded by FDM ma- ses have also been produced using a similar method.15 Dense
chines. Thermoplastics-infused biodegradable polyester with alumina-reinforced ceramic structures were also successfully
bioactive tri-calcium phosphate has been shown to be a promis- and fabricated with alumina loaded with photo-initiated resins
ing prospect for use in building tissue scaffold structures in in SLA machines. This technique is a promising prospect, be-
dentistry.11 Wax is another polymer commonly used in ad- cause SLA machines are regarded as one of the most accurate
ditive techniques. Although it is usually dispensed by vari- additive technologies currently available.19 However, ceram-
ous additive techniques as a support material for the build, it ics produced using additive techniques still have issues with
has also been used in its own right as a build material for anisotropic shrinkage when sintering the fabricated green state

Journal of Prosthodontics 26 (2017) 156–163 

C 2016 by the American College of Prosthodontists 157
Additive Technology
ceramic and display a stair-step surface effect due to the nature
of the fabrication process, and as yet have only been shown to
be useful as a tissue scaffold.20
Binder/powder combination
With inkjet 3D printing technology, the powder bed is sprayed
with a specific binder at high accuracy. These binder/powder
combinations can vary greatly, ranging from gypsum to various
metals and ceramics; the latter two are discussed in detail under
their own respective headings.
Metals
Research in this area has mainly focused on use of the SLS
additive technique for production of metallic structures made
from titanium, CoCr, and nickel alloys. The early structures
were generally porous with a poor surface finish due to various
factors. Where polymer was used to help bind metal powder
together during sintering, a porous structure was produced, as
the binder was removed during laser sintering, and further steps
involving infiltration were required to reach sufficient density.
Also, early SLS machines did not use a vacuum in the building
process, and laser diameter and strength were improperly con-
figured to produce a dense final product. This all made early
SLS machines inefficient and cumbersome to use for produc-
tion of metallic structures for use in load-bearing capacity.9,21,22
However, these issues have been largely overcome in the past
few years. While nickel-containing alloys are no longer used
in dental prostheses due to the risk of nickel allergy, research
on titanium structures fabricated using additive techniques has
been shown to have a favorable yield strength, ultimate tensile
strength, and ductility, albeit with some surface roughness.23
Clinical trials have also demonstrated that the produced struc-
tures are biocompatible for use in maxillofacial prostheses24,25
and that the intrinsic surface roughness aids osseointegration
of implants.26,27
While there have been many well designed studies on the
properties of titanium alloy (particularly Ti6Al4V) fabricated
using SLS, little has been produced on other materials that
may be produced using the same technology.23 Potential raw
materials include the base metal CoCr and precious metals,
and the potential for using additive manufacturing techniques,
such as direct metal laser sintering (DMLS), to overcome the
difficulties encountered during traditional casting and milling
techniques of hard material such as CoCr is a great prospect to
examine. These difficulties, such as shrinkage during casting
and high hardness of CoCr during milling, are surpassed when
using DMLS technology, because there is no active force appli-
cation during the fabrication of structures.28 The low amount
of unrecyclable waste produced when using DMLS fabrication
techniques makes the use of precious metals in digital man-
ufacturing a real possibility, albeit still a relatively expensive
one.29
Cobalt chromium
When compared with precious alloys, the use of the base
metal CoCr for use in the substructure of dental prostheses
has increased in popularity, partially due to the increased cost
158 Journal of Prosthodontics 26 (2017) 156–163 
Barazanchi et al
Figure 2 Highly polished DMLS-manufactured CoCr alloy.
of precious alloys and economic pressure on patients.30 Re-
search on the properties of CoCr has revealed it to not only
have an advantage over precious alloys in terms of cost, but it
also has good bonding characteristics with porcelain, a higher
Young’s modulus, higher hardness, lower density, and good
corrosion resistance compared to other metals used in pros-
thetic substructures.31 These properties make it more tolerant
to load in longer-span prostheses and more stable in an oral
environment long term.
Current manufacturing of CoCr structures
Base metals are more difficult to cast than precious alloys and
require considerable experience to fabricate consistently. This
is due to the shrinkage that can occur during the solidification
phase, which can result in the distortion of the framework dur-
ing cooling. The inherent high hardness of the alloy also makes
adjustments performed by technicians or dentists more difficult
post-casting.30 In comparison, digital workflow methods are
improving and becoming on par with the sometimes less pre-
dictable traditional techniques; however, as noted earlier, the
current subtractive manufacturing technique has issues with
material wastage, stress on cutting tips, and shrinkage during
processing. This can make milling machines less than ideal for
the fabrication of CoCr structures.6
Additive manufacturing of CoCr structures
Additive manufacturing is a promising method of CoCr produc-
tion. In the past, SLS-based machines produced rather weak and
porous structures that required extensive post-processing.32 A
variation of the technique, however, called direct metal laser
sintering (DMLS), has promise, producing dense end products
(Fig 2). Studies comparing the accuracy of porcelain fused to
metal (PFM) crowns produced using DMLS technology have
found it to have a satisfactory marginal misfit for use in dental
prostheses.33
Properties of DMLS-manufactured CoCr
structures
In terms of the properties of the CoCr produced for use as a
substructure in PFM crowns, only a few studies have been pub-
lished on the subject,23 and many do not satisfactorily test
the properties sought. With the exception of one study, all
were done within the last 2 years. Most compared structures
C 2016 by the American College of Prosthodontists
Barazanchi et al
produced by three commercially available machines: PM
100/PXM (Phenix Systems, Riom, France), Eosint M270/M280
(EOS GmbH, Munich, Germany), and Bego (Bego Medical,
Bremen, Germany), with the Eosint machines being the most
popular of the three. When testing DMLS-fabricated CoCr for
use in PFM prostheses when compared to current fabrication
techniques, certain properties have to be examined. This in-
cludes physical testing of the CoCr to ensure good support for
the veneering ceramic in PFM restorations, which include in-
vestigation of the elastic properties and hardness of the metal.
Another point of investigation should be the microstructural
components and organization of the metal to substantiate the
physical properties noted in its natural state and after firing
cycles. Micro-structural analysis should be conducted on the
porcelain-to-metal bonding surface to explain the properties
seen with the mentioned testing. Testing of adhesion strength
between the porcelain and the metal should focus on the ability
to accurately detect the failure point using loading tests. One
experimental set-up to investigate PFM adhesion energy is the
method adapted by Suansuwan and Swain. Their method tests
bi-layered dental materials by introducing a pre-crack then, us-
ing a 4-point bend test, measuring the strain energy release
rate of a stable crack extension along the bi-layer interface.34
Fracture sites also require careful examination to deduce the
mode of failure, as different types of failures indicate different
types of issues with the porcelain-to-metal bonding, including
adhesive/cohesive or mixed. When reviewing available studies,
it appears that they have investigated all these properties well
enough. For tensile testing of DMLS-fabricated CoCr, most did
not use specimens with dimensions or methodology according
to standardized testing criteria.35-38 Others did not analyze the
adhesion strength between porcelain and metal, although it is
one of the most common modifications to CoCr metals in dental
prostheses and is also the most likely site of failure.6,10,35,39,40
Even when adhesion testing was done, the number of speci-
mens used was either too small for proper statistical analysis,41
did not use a known standard testing method,42 or appears to
have been done incorrectly.43 In the case of Serra-Prat et al,43
the shrinkage of porcelain during the firing phase of the speci-
men was not accurately compensated for, and approximate di-
mensions were used, which may have affected the final results
and makes reproducibility of study results difficult. Further-
more, there was a lack of microscopic examination of fracture
sites post-testing to deduce failure type.10 One reason this is
required is to ensure that procedural errors (particularly dur-
ing the veneering process) were not a factor in the result. The
overall impression of the DMLS-produced metals for use in
dental prostheses when contrasted with current manufacturing
methods, subtractive manufacturing and lost-wax casting, is fa-
vorable; however, in the case of CoCr use in dental prostheses,
most current studies do not stand up to rigorous critiquing of
their methodology to allow definitive conclusions to be made.
Applications of additive manufacturing
The wide range of materials and fabrication techniques in ad-
ditive manufacturing are leading to extensive research on its
applications to medical and dental sciences. According to data
from Thomson Reuters Web of Knowledge, the fabrication of
Journal of Prosthodontics 26 (2017) 156–163 
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Additive Technology
biomodels for diagnosis, surgical training, and planning appears
to be the most common uses of additive technology, followed
by application for direct manufacture of implantable devices.44
In maxillofacial surgery and implantology, the advancement of
transmission-based scanning methods (CT and MRI) has meant
an increase in the ability to scan structures to high accuracy be-
fore any invasive procedure is done.45 This aids in pre-planning
of procedures and the accurate manufacturing of structures that
may be required. The use of additive manufacturing in max-
illofacial prosthodontics, the fabrication of facial prostheses,
and cranial reconstruction has increased use of additive man-
ufacturing. When fabricating a facial prosthesis, a degree of
discomfort is associated with the use of impression material
on patients to create a model of the defect site; however, facial
scanning can forgo that step and directly create a 3D model of
the site.46 Also when symmetry is deemed to be critical, such
as with microtia (small ear), then technicians with high skill
sets are paramount during the wax-up step; however, with the
ability to simply copy the contralateral ear, adjust it with CAD
software, and either print the ear directly or print out a negative
mold for the opposing ear for pouring, the reliance on the tech-
nician is greatly reduced, as is the overall prosthesis production
cost.47 While silicone prostheses start showing changes within
18 months,48 human ears stay much the same; hence having
a digital copy that may be used over and over again greatly
simplifies the process of remaking the prosthesis for operator
and patient.49
In maxillofacial surgery, printing out a model based on scans
of the area of interest allows for more thorough pre-planning of
complex cases and the ability to test fit the fabricated parts prior
to the procedure. This has been to shown to lead to an increase in
fit accuracy of fabricated prostheses and a reduction in operative
time by 30 to 90 minutes.50 Furthermore, customized cranial
reconstruction implant prostheses are required when treating
large cranial defects. The use of custom titanium implants,
fabricated using DMLS additive technology, for such defects
has been demonstrated to be much quicker to fabricate and place
during surgery than conventional methods. This is due to high
accuracy and ease in which various modifications are made to
suit each case at the design stage.24,25 In implantology the use
of surgical guides has been strongly recommended to facilitate
better planning and reduce the risk of operative complications.51
The accuracy of surgical guides produced using SLA has been
shown to be fairly accurate, with an angular deviation of 2° and
linear deviation of 1.1 mm at the hex and 2 mm at the apex52
(Fig 3). The fabrication of custom implant screws has also been
researched. The SLS additive process can create implants with
complex geometry and a porous surface. This has been shown to
increase osseointegration53,54 and has been successfully tested
in patients.26,27
Another area of interest is the potential application of ad-
ditive manufacturing for use in tissue scaffolding. Other than
being able to easily add and evenly distribute biocompatible and
bioactive particles, such as calcium and phosphate, within the
scaffold,12 the additive process also allows for a much higher
level of precision during manufacturing of tissue scaffolds. In
conventional methods, it is difficult to precisely control geom-
etry, size, and spacing of pores in the scaffold.55 Scaffolds are
recommended to have pore sizes greater than 300 μm to allow
159
Additive Technology
Figure 3 3D-printed fully guided implant surgical stent.
for vascularization and osteogenesis. Additive manufacturing
machines are able to produce pores with adjustable dimen-
sions due to high printing accuracy.56 These techniques may
be used for bone graft applications with customizable scaffold
material allowing for controlling overall hardness and rate of
dissolution.57
For intraoral prosthodontic applications, the use of additive
manufacturing techniques has had several applications includ-
ing printing stone models from intraoral scans, and direct fabri-
cation of dental prostheses5 and custom build-ups, usually done
via labor-intensive dental wax-ups, for planning or investment
of definitive prostheses.58 Fabrication of metallic prostheses
using SLS technology is being investigated for production of
titanium frameworks and CoCr structures. The use of additive
manufacturing to directly produce CoCr removable partial den-
tures was investigated by Bibb and Eggbeer and found to be
satisfactory for use in patients.59 An in vivo study investigated
the use of CoCr-based PFM crowns fabricated using the DMLS
manufacturing technique.60 In this study, marginal adaptation
was measured and shown to be within clinically acceptable
accuracy for use. While zirconia crowns have been success-
fully produced using additive technology and show promise
for the future, they still require prolonged post-processing due
to porosity produced during fabrication, so further research is
necessary if they are to be used in clinical dental settings.20
Due to the wide range of production methods and materi-
als available, many other applications are being investigated
using this technology, including fabrication of full maxillary
and mandibular acrylic dentures,61 SLA technology to assist
with auto-transplantation procedures,62 and production of re-
alistic dental and medical anatomical educational models.63
These applications, along with an expected drop in prices of
additive manufacturing machines and rapidly improving tech-
nology, are expected to further improve the technology in the
coming years.5
Accuracy of current additive
manufacturing machines
The accuracy of structures produced varies according to ge-
ometries being replicated, the method of manufacture, and the
materials being used. SLA can fabricate structures with a layer
thickness of 25 μm. Inkjet printing can achieve a layer thick-
160 Journal of Prosthodontics 26 (2017) 156–163 
Barazanchi et al
ness of 12 μm, while FDM has been shown to have accuracy of
around 127 μm.32 All of these manufacturing techniques have
variations that are being investigated and are showing promise
in the production of structures to the nano-scale.64 Practically
there are a number of examples of accurate applications of ad-
ditive manufacturing. Implant abutments have been reported
to have an 11 μm vertical gap when produced using additive
manufacturing.70 However, the margins are not yet deemed to
be uniform enough, which makes subtractive manufacturing
still the most reliable method for fabricating implant compo-
nents. Implant guides produced using additive technology show
a dimensional error of 0.4 mm, and an angular deviation of less
than 5°.52 For facial prosthesis patterns, accuracy is found to be
satisfactory with an error range of 0.1 to 0.4 mm.28 However,
in the case of PFM frameworks, due to the relatively recent
maturation of DMLS technology, relatively few papers report
internal and marginal fit of fixed dental prostheses fabricated us-
ing additive techniques. Similar studies investigating marginal
and fitting accuracy of milling machines, the method of mea-
surement, the number of points being recorded, and the type
of commercial machine used have varied, making comparisons
difficult. Most studies used CoCr as a base metal, likely due
to its cost and recent rise in popularity.30 Methods used when
examining the fit of a prosthesis include the use of a silicone
replica of the fitting surface of the created prosthesis and then
manual measurements using microscopy. In other studies the
silicone replica was digitally scanned and, using a CAD pro-
gram, superimposed on a 3D model of the prepared abutment
to map out the areas of discrepancy. Others sectioned both the
fabricated prosthesis and abutment replica, then measured pre-
determined points on the fitting surfaces using a microscope
or digital photography.66 While the mean marginal gap dis-
crepancy varied from 70 to 102 μm, most authors agreed that
these results were within the acceptable clinical range for dental
use.14,33,60,65-68 Only one study found that the fit of prostheses
fabricated using DMLS was not satisfactory, with discrepancies
varying up to 162 μm.65 However, this study lacked a control
method group, such as a cast group or a milled group of spec-
imens, and therefore any issues with their methodology might
have gone undetected. The same authors also noted in a follow-
ing paper that using DMLS technology for fabrication of CoCr
PFM crowns has an average misfit of around 55 μm.14 In the
latter study they deemed the technology to produce prostheses
with adequate accuracy for use in a clinical dental setting.
Advantages in using additive
manufacturing
Compared to other digital manufacturing techniques, additive
technology has a number of advantages, including the flexibility
of using a wide variety of machines and the materials available
for use. This makes additive technology an attractive field for
research and creates a whole new field of possible applications
for use in dentistry.5 Presently there are a small number of ma-
jor manufacturers of the technology; however, due to recently
expired patents many start-up companies are producing accu-
rate machines at a lower cost. This may be seen by the fact that
older papers stated that SLA manufacturing was not popular
at the time due to the high cost of material and machines.32
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Barazanchi et al
Figure 4 3D-printed model of teeth. Note the striation creating a stair-
case like surface.
Now there are SLA machines that cost around $5000, which
are able to prepare a structure with layer thickness of 25 μm.13
The advantages of using of additive manufacturing include:
r Flexibility due to the range of available machines: Some
machines are able to print multiple materials at the same
time without having to replace the structure halfway
through the build. While this has been mainly limited to
fabrication of organic or multi-color materials, advance-
ment of the technology may one day allow the fabrication
of multi-component dental prostheses and their substruc-
ture, for complex prosthodontic cases in one machine, in
one stretch, which would fully realize digital workflow.69
r Passivity: The passive nature of this manufacturing tech-
nique also overcomes a number of the disadvantages of
subtractive. This is especially so with hard to machine
metals such as CoCr, that result in wear of the milling
heads of subtractive units, noise, and heat production dur-
ing milling as well as surface damage of the structure.28
r Low percentage of wasted raw material: Subtractive
manufacturing can remove as much as 96% of the initial
material, and this wastage is virtually unrecyclable. In
comparison, additive machines tend to mostly use what
is required for the build and have 40% less wastage. In
addition, around 95% to 98% of the waste may be recy-
cled in future production cycles.29,70 This not only brings
down the overall cost of the raw material, but is also im-
portant in situations where overall weight and size of
the raw material is an issue. Without having to rely on
the dimensions of a preformed block of material, as is the
case in subtractive manufacturing, the overall size of the
final product is only limited by the size of the building
chamber of the machine; this is usually bigger than the
size offered by the preformed disks for milling machines.
Limitations of additive manufacturing
Some limitations are associated with current additive technol-
ogy. These limitations include:
r Staircase effect: The layer-by-layer nature of additive
manufacturing still leaves a staircase effect on the fin-
ished product, unless layering thickness is tuned down to
the smallest possible resolution. This will, however, sig-
nificantly increase the building time of the structures71
(Fig 4).
r Manufacture of ceramic structures: For the fabrication of
ceramic structures (zirconia and alumina) some progress
Journal of Prosthodontics 26 (2017) 156–163 
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Additive Technology
has been made, but the porous structures produced by
the additive technique require extensive post-processing,
which causes shrinkage. For this reason, it does not have
the uniformity that subtractive manufacturing produces
and does not bypass the problem of shrinkage when ma-
chining pre-sintered blocks of material.20
r Reproducibility: While speed and accuracy of build are
improving, many additive machines still do not print
to the accuracy or reproducibility required for certain
dental applications.28 In cases where increased accuracy
is sought, speed of production usually suffers.23
r Need for support structures: In case of FDM and SLS,
extra steps need to be added in placing support structures
that may be required for use during fabrication phases,
either manually or through pre-programming, and then
removed after the structure is built. This supports any
overhanging structures that appear during the building
process.32
r Specificity for dental use: As the technology is still matur-
ing in the dental industry, most machines currently avail-
able are not tailored for dental applications, as is the case
for subtractive manufacturing; however, some large com-
panies are producing additive technology specifically for
dentistry (3D Systems, Rock Hill, SC; Stratasys, Eden
Prairie, MN). Subtractive manufacturing also took some
time to mature in the industry, and is still not considered
as ubiquitous as it was hoped to be.72
All these issues are being thoroughly investigated, and with
the current pace of progress, should become less formidable as
the technology improves.5,32,73
Summary
The manufacturing and fabrication steps of the digital workflow
have been dominated by subtractive manufacturing techniques,
mainly milling; however, milling creates unfavorable forces
on build structures, and has high waste and limited variations
in type of material that can be used. Additive manufacturing
is an alternative manufacturing method, but the technology has
been slower to mature for use in dental settings due to its high
cost. Recently, however, expired patents have allowed for a large
decrease in pricing. The wide range of additive techniques and
available material allow the potential for many more applica-
tions in dentistry. The passive nature of additive techniques
allows for fabrication of more sophisticated build structures
without excessive force and much less non-recyclable waste
when compared to subtractive manufacturing techniques. Fab-
rication of CoCr substructures for dental prostheses is one area
of interest. CoCr has become more popular due to its cost and
favorable properties; however, it is much harder to fabricate
using lost-wax casting and subtractive techniques due to high
hardness and low ductility. DMLS additive technique promises
to bypass these difficulties when fabricating CoCr structures;
however, the properties of the produced structures do not ap-
pear to have been investigated sufficiently to draw definite con-
clusions about its properties at this time. Further research is
needed to examine the suitability of DMLS-fabricated CoCr for
use as substructure in PFM dental prostheses. While additive
161
Additive Technology
manufacturing still has its limitations, the speed of development
promises a large leap forward in applying the digital workflow
model to more dental procedures.
References
1. Barnatt C: The second digital revolution. J Gen Manage
2001;27:1-16
2. ITI: Knowledge is key. In Belser U (ed): ITI World Symposium.
Geneva, Quintessence, 2014
3. Almeida e Silva JS, Erdelt K, Edelhoff D, et al: Marginal and
internal fit of four-unit zirconia fixed dental prostheses based on
digital and conventional impression techniques. Clin Oral
Investig 2014;18:515-523
4. Brawek PK, Wolfart S, Endres L, et al: The clinical accuracy of
single crowns exclusively fabricated by digital workflow—the
comparison of two systems. Clin Oral Investig
2013;17:2119-2125
5. van Noort R: The future of dental devices is digital. Dent Mater
2012;28:3-12
6. Choi Y-J, Koak J-Y, Heo S-J, et al: Comparison of the
mechanical properties and microstructures of fractured surface
for Co-Cr alloy fabricated by conventional cast, 3-D printing
laser-sintered and CAD/CAM milled techniques. J Kor Acad
Pros 2014;52:67
7. Yan X, Gu P: A review of rapid prototyping technologies and
systems. Computer-Aided Desi 1996;28:307-318
8. Turner N, Strong R, Gold A: A review of melt extrusion additive
manufacturing processes: I. Process design and modeling. Rapid
Proto J 2014;20:192-204
9. Kathuria YP: Microstructuring by selective laser sintering of
metallic powder. Surf Coat Tech 1999;116-119:643-647
10. Wu L, Zhu H, Gai X, et al: Evaluation of the mechanical
properties and porcelain bond strength of cobalt-chromium
dental alloy fabricated by selective laser melting. J Prosthet Dent
2014;111:51-55
11. Yefang Z, Hutmacher DW, Varawan SL, et al: Comparison of
human alveolar osteoblasts cultured on polymer-ceramic
composite scaffolds and tissue culture plates. Int J Oral
Maxillofac Surg 2007;36:137-145
12. Elomaa L, Kokkari A, Närhi T, et al: Porous 3D modeled
scaffolds of bioactive glass and photocrosslinkable
poly(ε-caprolactone) by stereolithography. Comp Sci Tech
2013;74:99-106
13. Formlabs: Desktop Stereolithography (SLA) 3D Printing.
http://formlabs.com/. Accessed March 12, 2016
14. Kim KB, Kim WC, Kim HY, et al: An evaluation of marginal fit
of three-unit fixed dental prostheses fabricated by direct metal
laser sintering system. Dent Mater 2013;29:e91-e96
15. Ebert J, Ozkol E, Zeichner A, et al: Direct inkjet printing of
dental prostheses made of zirconia. J Dent Res 2009;88:
673-676
16. Scheithauer U, Schwarzer E, Richter H-J, et al: Thermoplastic
3D printing—an additive manufacturing method for producing
dense ceramics. Int J App Cera Tech 2015;12:26-31
17. Tian X, Günster J, Melcher J, et al: Process parameters analysis
of direct laser sintering and post treatment of porcelain
components using Taguchi’s method. J Eur Cera Soc
2009;29:1903-1915
18. Maleksaeedi S, Eng H, Wiria FE, et al: Property enhancement of
3D-printed alumina ceramics using vacuum infiltration. J Mater
Proc Tech 2014;214:1301-1306
162 Journal of Prosthodontics 26 (2017) 156–163 
Barazanchi et al
19. de Hazan Y, Thänert M, Trunec M, et al: Robotic deposition of
3D nanocomposite and ceramic fiber architectures via UV
curable colloidal inks. J Euro Cera Soc 2012;32:1187-1198
20. Denry I, Kelly JR: Emerging ceramic-based materials for
dentistry. J Dent Res 2014;93:1235-1242
21. Khain M, Fuh J, Lu L: Direct metal laser sintering for rapid
tooling: processing and characterisation of EOS parts. J Mater
Proce Tech 2001;113:269-272
22. Osakada K, Shiomi M: Flexible manufacturing of metallic
products by selective laser melting of powder. Int J Mach Tools
Manuf 2006;46:1188-1193
23. Frazier WE: Metal additive manufacturing: a review. J Mat Eng
Perfo 2014;23:1917-1928
24. Jardini AL, Larosa MA, de Carvalho Zavaglia CA, et al:
Customised titanium implant fabricated in additive
manufacturing for craniomaxillofacial surgery. Virt Physi Protot
2014;9:115-125
25. Jardini AL, Larosa MA, Maciel Filho R, et al: Cranial
reconstruction: 3D biomodel and custom-built implant created
using additive manufacturing. J Cranio Maxillofac Sur
2014;42:1877-1884
26. Figliuzzi M, Mangano F, Mangano C: A novel root analogue
dental implant using CT scan and CAD/CAM: selective laser
melting technology. Int J Oral Maxillofac Surg 2012;41:858-862
27. Mangano FG, De Franco M, Caprioglio A, et al: Immediate,
non-submerged, root-analogue direct laser metal sintering
(DLMS) implants: a 1-year prospective study on 15 patients.
Laser Med Sci 2014;29:1321-1328
28. Abduo J, Lyons K, Bennamoun M: Trends in computer-aided
manufacturing in prosthodontics: a review of the available
streams. Int J Dent 2014;2014:783948
29. Berman B: 3-D printing: the new industrial revolution. Business
Horizons 2012;55:155-162
30. Anusavice KJ: Phillip’s Science of Dental Materials.
Philadelphia, Saunders, 1996
31. Li KC: Microstructure and phase stability of three dental cobalt
chromium alloys used for porcelain-fused-to-metal restorations
during thermal processing. PhD Thesis, Otago, New Zealand,
University of Otago, 2015
32. Liu Q, Leu MC, Schmitt SM: Rapid prototyping in dentistry:
technology and application. Int J Advan Manu Tech
2005;29:317-335
33. Ucar Y, Akova T, Akyil MS, et al: Internal fit evaluation of
crowns prepared using a new dental crown fabrication technique:
laser sintered Co-Cr crowns. J Prosthet Dent 2009;102:254-259
34. Suansuwan N, Swain M: New approach for evaluating metal-
porcelain interfacial bonding. Int J Prosthodont 1999;12:547-552
35. Al Jabbari YS, Koutsoukis T, Barmpagadaki X, et al:
Metallurgical and interfacial characterization of PFM Co-Cr
dental alloys fabricated via casting, milling or selective laser
melting. Dent Mater 2014;30:e79-e88
36. Lu Y, Wu S, Gan Y, et al: Investigation on the microstructure,
mechanical property and corrosion behavior of the selective laser
melted CoCrW alloy for dental application. Mater Sci Eng C
Mater Biol Appl 2015;49:517-525
37. Bae EJ, Kim JH, Kim WC, et al: Bond and fracture strength of
metal-ceramic restorations formed by selective laser sintering. J
Adv Prosthodont 2014;6:266-271
38. Takaichi A, Suyalatu, Nakamoto T, et al: Microstructures and
mechanical properties of Co-29Cr-6Mo alloy fabricated by
selective laser melting process for dental applications. J Mech
Behav Biomed Mater 2013;21:67-76
39. Krug KP, Knauber AW, Nothdurft FP: Fracture behavior of
metal-ceramic fixed dental prostheses with frameworks from cast
C 2016 by the American College of Prosthodontists
Barazanchi et al
or a newly developed sintered cobalt-chromium alloy. Clin Oral
Investig 2015;19:401-411
40. Xin XZ, Chen J, Xiang N, et al: Surface characteristics and
corrosion properties of selective laser melted Co-Cr dental alloy
after porcelain firing. Dent Mater 2014;30:263-270
41. Zhang B, Huang Q, Gao Y, et al: Preliminary study on some
properties of Co-Cr dental alloy formed by selective laser
melting technique. J Wuhan Univ Tech Mater Sci Edu 2012;27:
665-668
42. Akova T, Ucar Y, Tukay A, et al: Comparison of the bond
strength of laser-sintered and cast base metal dental alloys to
porcelain. Dent Mater 2008;24:1400-1404
43. Serra-Prat J, Cano-Batalla J, Cabratosa-Termes J, et al: Adhesion
of dental porcelain to cast, milled, and laser-sintered
cobalt-chromium alloys: shear bond strength and sensitivity to
thermocycling. J Prosthet Dent 2014;112:600-605
44. Lantada AD, Morgado PL: Rapid prototyping for biomedical
engineering: current capabilities and challenges. Annu Rev
Biomed Eng 2012;14:73-96
45. Galantucci LM: New challenges for reverse engineering in facial
treatments: how can the new 3D non-invasive surface measures
support diagnoses and cures? Virt Phys Proto 2010;5:3-12.
46. Hatamleh MM, Watson J: Construction of an implant-retained
auricular prosthesis with the aid of contemporary digital
technologies: a clinical report. J Prosthodont 2013;22:132-136
47. Watson J, Hatamleh MM: Complete integration of technology for
improved reproduction of auricular prostheses. J Prosthet Dent
2014;111:430-436
48. dos Santos DM, Goiato MC, Sinhoreti MA, et al: Influence of
natural weathering on colour stability of materials used for facial
prosthesis. J Med Eng Tech 2012;36:267-270
49. Kolodney H, Swedenburg G, Taylor SS, et al: The use of
cephalometric landmarks with 3-dimensional volumetric
computer modeling to position an auricular implant surgical
template: a clinical report. J Prosthet Dent 2011;106:284-289
50. Wilde F, Plail M, Riese C, et al: Mandible reconstruction with
patient-specific pre-bent reconstruction plates: comparison of a
transfer key method to the standard method—results of an in
vitro study. Int J Comput Assist Radiol Surg 2012;7:57-63
51. Lal K, White GS, Morea DN, et al: Use of stereolithographic
templates for surgical and prosthodontic implant planning and
placement. Part I. The concept. J Prosthodont 2006;15:51-58
52. Turbush SK, Turkyilmaz I: Accuracy of three different types of
stereolithographic surgical guide in implant placement: an in
vitro study. J Prosthet Dent 2012;108:181-188
53. Huang HL, Hsu JT, Fuh LJ, et al: Biomechanical simulation of
various surface roughnesses and geometric designs on an
immediately loaded dental implant. Comp Bio Med
2010;40:525-532
54. Mangano C, De Rosa A, Desiderio V, et al: The osteoblastic
differentiation of dental pulp stem cells and bone formation on
different titanium surface textures. Biomater 2010;31:3543-3551
55. Ge Z Jin Z, Cao T: Manufacture of degradable polymeric
scaffolds for bone regeneration. Biomed Mater 2008;3:1-11
Journal of Prosthodontics 26 (2017) 156–163 
C 2016 by the American College of Prosthodontists
Additive Technology
56. Karageorgiou V, Kaplan D: Porosity of 3D biomaterial scaffolds
and osteogenesis. Biomater 2005;26:5474-5491
57. Habibovic P, Gbureck U, Doillon CJ, et al: Osteoconduction and
osteoinduction of low-temperature 3D printed bioceramic
implants. Biomaterials 2008;29:944-953
58. Sun J, Zhang FQ: The application of rapid prototyping in
prosthodontics. J Prosthodont 2012;21:641-644
59. Bibb R, Eggbeer D: Rapid manufacture of removable partial
denture frameworks. Rapid Proto J 2006;12:95-99
60. Quante K, Ludwig K, Kern M: Marginal and internal fit of
metal-ceramic crowns fabricated with a new laser melting
technology. Dent Mater 2008;24:1311-1315
61. Bidra AS, Taylor TD, Agar JR: Computer-aided technology for
fabricating complete dentures: systematic review of historical
background, current status, and future perspectives. J Prosthet
Dent 2013;109:361-366
62. Shahbazian M, Wyatt J, Willems G, et al: Clinical application of
a stereolithographic tooth replica and surgical guide in tooth
autotransplantation. Virtu Physi Proto 2012;7:211-218
63. Rengier F, Mehndiratta A, von Tengg-Kobligk H, et al: 3D
printing based on imaging data: review of medical applications.
Int J Comp Assisted Radio Surg 2010;5:335-341
64. Vaezi M, Seitz H, Yang S: A review on 3D micro-additive
manufacturing technologies. Int J Adv Manufac Tech
2012;67:1721-1754
65. Kim KB, Kim JH, Kim WC, et al: Three-dimensional evaluation
of gaps associated with fixed dental prostheses fabricated with
new technologies. J Prosthet Dent 2014;112:1432-1436
66. Ortorp A, Jonsson D, Mouhsen A, et al: The fit of
cobalt-chromium three-unit fixed dental prostheses fabricated
with four different techniques: a comparative in vitro study. Dent
Mater 2011;27:356-363
67. Tamac E, Toksavul S, Toman M: Clinical marginal and internal
adaptation of CAD/CAM milling, laser sintering, and cast metal
ceramic crowns. J Prosthet Dent 2014;112:909-913
68. Xu D, Xiang N, Wei B: The marginal fit of selective laser
melting-fabricated metal crowns: an in vitro study. J Prosthet
Dent 2014;112:1437-1440
69. Vaezi M, Chianrabutra S, Mellor B, et al: Multiple material
additive manufacturing—Part 1: a review. Virt Physi Proto
2013;8:19-50
70. Abduo J, Lyon K, Bennani V, et al: Fit of screw-retained fixed
implant frameworks fabricated by different methods: a
systematic review. Int J Prosthodont 2011;24:207-220
71. Masood SH, Rattanawong W, Iovenitti P: A generic algorithm
for a best part orientation system for complex parts in rapid
prototyping. J Mater Proce Tech 2003;139:110-116
72. Miyazaki T Hotta Y, Kunii J, et al: A review of dental
CAD/CAM: current status and future perspectives from 20 years
of experience. Dent Mater J 2009;28:44-56
73. Syam WP, Mannan MA, Al-Ahmari AM: Rapid prototyping and
rapid manufacturing in medicine and dentistry. Virt Physi Proto
2011;6:79-109
163
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