3D PRINTING IN ORTHODONTICS

LIBRARY DISSERTATION SUBMITTED TO

MAHARASHTRA UNIVERSITY OF HEALTH SCIENCES, NASHIKIN THE

PARTIAL FULFILLMENT OF REGULATIONS FOR THE AWARD OF THE

DEGREE OF

MDS

IN

Orthodontics and Dentofacial Orthopaedics

2022
 CERTIFICATE

This is to certify that the Library dissertation entitled “3D Printing In

Orthodontics” has been prepared by Dr. Tanvi Panvalkar under my direct
Supervision and guidance in partial fulfillment of the regulations for the Award of the
degree of MDS in Orthodontics and Dentofacial Orthopaedics.

Her work on the subject has been checked by me from time to time. I am satisfied
regarding the authenticity of her observations and research regarding the library
dissertation.

Date:

Place:

Dr. Tushar Patil

(Guide and HOD)
 ACKNOWLEDGEMENT

I bow my head and thank Almighty God, for all his blessing.
It gives me great pleasure to express my deep gratitude and my humble gratefulness to
my guide Dr. Tushar Patil, Professor and HOD, Department of Orthodontics and
Dentofacial Orthopedics. Without his continuous optimism concerning this work,
enthusiasm, encouragement and support, this study would hardly have been
completed. He has been a great source of inspiration and provided me just the right
impetus through my years of postgraduate study. I feel very much privileged to have
worked under his affectionate guidance.
I am very much thankful Dr. Avinash Mahamuni, Professor, for his helping hand at
all times of my need, moral support and advice in taking me towards the goal. He
gave tireless efforts through discussions and valuable suggestions ensured the success
of this undertaking.
I am also very thankful to Dr.Abhijit Misal, Professor, Department of Orthodontics
and Dentofacial Orthopedics, YCMM & RDF’s Dental College and Hospital,
Ahmednagar without his humble heart, friendly nature, continuous optimism
concerning has motivated me to be a constant learner.
I would like to express my heartfelt gratitude to my esteemed teacher Dr.Rajlaxmi Rai
and Dr.Reyali Gajare for their guidance, encouragement and inspiration, insightful
guidance and thought provoking views and also contributing your vast wealth of
knowledge to further my education in the field of orthodontics. I have learned so
much from all of you that I will take with me the rest of my life
It would be unjust if I do not acknowledge help and advice rendered at various points
of my research work to my co-pgs Dr. Ketki Laware, Dr. Charul Patel, Dr. Pradip
Musale , Dr. Swapnil Andhale. It was my great fortune to express my heartfelt thanks
to my juniors Dr.Megha Markand, Dr.Yadnya Rane, Dr.Surbhi Deshmukh , Dr.Shruti
Tale, Dr Manorama Wakale, Dr. Rajshree Gudadhe , Dr.Disha Dhondge , Dr.Simran
Nanthani, Dr.Kanchan Bhangare , Dr.Mithil Shah for their help and assistance for my
study.
I am forever grateful to my family Sneha Panvalkar, Shrikant Panvalkar, Ajit
Panvalkar and my husband Amit Dashasahastra for all that they sacrificed for me.
Their unconditional love, constant encouragement and support gave me the strength to
strive for my goals.
Dr Tanvi Panvalkar
INDEX

SR. TITLE PAGE NO.

NO.
1. Introduction 1

2. History 4

3. What Is 3-D Printing? 7

4. Intraoral scanners 9

5. Classification Of Manufacturing Techniques 13

6. General Principles 16

7. Types Of 3-D Technology 18

8. 3-D Printers used in orthodontics 40

9. 3-D printing process 44

10. The Digital Workflow 47

11. Applications Of 3-D Printing In Orthodontics 55

12. Materials Used For 3-D Printing 104

13. References 110

INTRODUCTION
Three-dimensional (3-D) technology is a true modern-day miracle. It is a perfect
example of how advancement in one particular technological area can trigger an
exponential effect in different industries. This technology has made its way into
different fields and revolutionized the production industry.
Diagnosis, teaching tools, treatment modalities and surgical techniques have
improved significantly with the help of digital technology during the last few
years.Digital technology started to make its way into dental and orthodontic offices
with the introduction of computerized scheduling in the 1974.
Today digital technology has touched on every aspect of orthodontic treatment. It is
now common place to perform virtual treatment planning as well as translate the plans
into treatment execution with digitally driven appliance manufacture and placement
using various CAD/CAM techniques from printed models, indirect bonding trays and
custom-made brackets to robotically bent wires.
Furthermore, it is also becoming possible to remotely monitor treatment and control
it.Intraoral scans and three-dimensional radiography are rapidly replacing study casts
and two-dimensional radiography.1
3-D technology has evolved greatly in the last two decades and has found application
in orthodontics.This has led to the transformation of diagnosis and treatment planning
from a traditional two-dimensional (2D) approach into an advanced three-dimensional
(3-D) technique.
Such advancements have made orthodontic treatment a boon by saving time and
improving precision.
This technology allows the production of 3D structures with high shape complexity
with accuracy.
3-D printing has provided comfort to orthodontists and improved the quality of work.
Use of 3-D technology has led to reduction in the chairside time and increased the
accuracy ensuring a perfect fit.
The key idea of this innovative method is that the three-dimensional model is sliced
into many thin layers and the manufacturing equipment uses this geometric data to
build each layer sequentially until final desired product is completed.
Amalgamation of recent advancements in technology and digital solutions have
reformed diagnosis andtreatment planning in dentistry leading to the change in
approach, from atraditional two-dimensional (2D) intoan advanced three-dimensional
(3D) technique.

1
Rapid prototyping (RP) is one of such advanced techniqueswhich is considered as
group of relatedtechniques that are used to build physical 3D models layer by layer
basedon CAD-CAM (computer-aided design and computer-aided manufacturing).

It accurately reproduces almost allforms of shapes including complex external and

internal anatomic structures.2

Its orthodontic application includesdigitization of models used for diagnosis and

treatment planning, fabrication of orthodontic removableappliances, impression trays
for indirect bonding, surgical stent for implant placement and customized
lingualbrackets.

3-D technology in medicine has been used to develop patient specific prosthesis,
implants and surgical guides.

Rapid prototyping also helps us in making orthognathic surgical procedure more

refined andpredictable. Prototype models can also be used for education and training
purposes or while explaining thetreatment procedures to patients and their families for
betterunderstanding.

It has advantages of simplicity, flexibility, reliability, accuracy, better visualization

and time saving, but still theclinical judgement remains vital.2

Fig 1:Process of 3-D printing

3D printing has allowedorthodontists to take control of their practiceoverhead and

treatment planning individuality,and in many cases even become their own
manufacturerfor a wide variety of appliances.

2
3D printingtechnology hasrevolutionized the patient and doctor experience,leading to
a new era of digital treatment planning,customization, and efficiency.3

The clinical implementation of 3-D printing processes in the orthodontic field today is
technologicallysuperior to most of the older existing processes, however, it does
require theknowledge and skillsets not regularly taught in medical faculties.4

Most digital intraoral scanners work in conjunctionwith cloud-based technology

where raw images once scanned can be securely transmitted tothe cloud storage
facility and further processed/refined for diagnostic purposes.

Fig 2: Traditional versus digital workflow in the orthodontic office

3
HISTORY
Charles Hull is said to be the father of 3-D print technology.

Fig 3: Charles Hull

1981–1984: The Early Minds

In April 1980, Hideo Kodama of Nagoya Municipal Industrial Research Institute
invented two additive methods for fabricating three-dimensional plastic models with
photo-hardening thermoset polymer, where the UV exposure area is controlled by a
mask pattern or a scanning fiber transmitter.
On July 2, 1984, American entrepreneur Bill Masters filed a patent for his Computer
Automated Manufacturing Process and System. This filing is on record at
the USPTO as the first 3D printing patent in history; it was the first of three patents
belonging to Masters that laid the foundation for the 3D printing systems used today.
On 16 July 1984, Alain Le Méhauté, Olivier de Witte, and Jean Claude André filed
their patent for the stereolithography process. The application of the French inventors
was abandoned by the French General Electric Company (now Alcatel-Alsthom)
and CILAS (The Laser Consortium). The claimed reason was "for lack of business
perspective".5

1984–1988: The Invention of Stereolithography

In early 1984, Robert Howard started R.H. Research, later named Howtek, Inc to
develop a colour 2D printer using Thermoplastic (hot-melt) plastic ink.
Later in 1984, Chuck Hull of 3D Systems Corporation filed his own patent for
a stereolithography fabrication system, in which layers are added by

4
curing photopolymers with ultraviolet light lasers. Hull defined the process as a
"system for generating three-dimensional objects by creating a cross-sectional pattern
of the object to be formed". Hull's contribution was the STL (Stereolithography) file
format and the digital slicing and infill strategies common to many processes today.
In 1986, Charles "Chuck" Hull was granted a patent for his system, and his company,
3D Systems Corporation released the first commercial 3D printer, the SLA-1.6

1988–1992: An Era of Innovations

Charles’s patent for stereolithography marked the beginning of the 3D printing
industry. There were other printing technologies that were invented during this era.

SLS (selective laser sintering)

In 1988, the same year that the SLA-1 was introduced, another 3D printing
technology was invented. This was the selective laser sintering (SLS), the patent for
which was filed by Carl Deckard, an undergraduate at the University of Texas.

Deckard’s machine, the first SLS 3D printer, was called Betsy. It was able to produce
only simple chunks of plastic. However, as the main purpose of the printer was to test
the idea for the SLS, object details and print quality weren’t the highest priorities.5

FDM (fused deposition modelling)

In the meantime, while the patent for SLS was awaiting approval, another patent for
an additive manufacturing technology was submitted to the US government.

This was for fused deposition modeling (FDM). Despite being the simplest and most
common of the three technologies, FDM was actually invented after SLA and SLS.

The patent for FDM was submitted by Scott Crump, who is today well known
for being the co-founder of Stratasys. Founded in 1989, the Minnesota-based
company is one of the market leaders for high precision 3D printers.

In 1992, the patent for FDM was finally issued to Stratasys, which marked the start of
the intense development of the technology. One of the first industries to take on the
technology in the early 90s was medicine.
The year 1993 also saw the start of an inkjet 3D printer company initially named
Sanders Prototype,Inc and later named Solidscape, introducing a high-precision
polymer jet fabrication system with soluble support structures, (categorized as a "dot-
on-dot" technique).
In 1995 the Fraunhofer Society developed the selective laser melting process.7

5
In 2012, Filabot developed a system which allows for any FDM or FFF (fused
filament fabrication) 3D printer to be able to print with a wider range of plastics.
In 2014, Benjamin S. Cook and Manos M. Tentzeris demonstrate the first multi-
material, vertically integrated printed electronics additive manufacturing platform
(VIPRE) which enabled 3D printing of functional electronics operating upto 40 GHz.5

6
WHAT IS 3-D PRINTING?
Also known as additive manufacturing, 3-D printing is a technology whereby
sequential layers of materials are deposited on top of one another to take the shape of
an object. It is the opposite of subtractive manufacturing, in which a block of material
is carved away to form the object (milling units)
3-D printers use 3-D CAD software that measures thousands of cross-sections of each
product to determine exactly how each layer is to be constructed. The 3-D machine
dispenses a thin layer of liquid resin and uses a computer-controlled UV laser to
harden each layer in the specified cross-section pattern. At the end of the process,
excess soft resin is cleaned away through use of a chemical bath.8

Fig4:3D printing process

It is possible to accurately customize complicated orthodontic appliances according to

the patient’s need using 3-D printing technology. There is reduced wastage of
material in additive manufacturing as compared to subtractive manufacturing. 3-D
printing reduces manual laborleading to decreased appliance delivery time and shorter,
fewer appointments.

7
Fig 5: traditional and 3D printing workflow
Intraoral scanning for the preparation of 3-D printed models reduces patient
discomfort caused by making impressions. These models are superior in accuracy and
precision as compared to the models made manually.8

8
INTRAORAL SCANNERS

Three-dimensional digital impressions were first introduced in 1987 by CEREC 1

(Siemens,Munich, Germany) using infrared camera and optical powder on the teeth to
create a virtualmodel. Over the years, computer hardware and software developments
have dramaticallyimproved the technologies completely replacing traditional alginate
and polyvinyl siloxane(PVS) impressions in a large number of dental and orthodontic
offices.

Advantages
Traditional alginate and polyvinyl siloxane (PVS) impressions have been associated
withnumerous limitations which include complex workflow, lack of precise
reproduction, lacerationson the margins, poor dimensional stability, limited working
time, plaster pouring andsolidification, and problems of transport and packaging.
A general disadvantage of theconventional impressions is also the need to start over if
an impression fails or take additionalimpressions (e.g., study models and appliance
fabrication). In addition, the contact betweenthe tray and the teeth could cause
discomfort for the patient and trigger a bad gag reflex.
Digitalimpressions eliminate all those negative aspects. They streamline and expedite
the traditionalworkflow, reduce the number of patients’ visits, and maximize the
efficiency and cost savingsin the orthodontic office.
Besides the better control and improved accuracy of the directlyobtained digital
models, scanners add the plug-and-play capability of an automatic exchangeof patient
information within the office or outside laboratories. Lost or broken appliances
couldeasily be refabricated using the digital files from a database in the Cloud.8

Optical scanning technologies8

Several scanning technologies using different optical components and structured
light sourcesare currently employed in orthodontics:

 Confocal Laser Scanner Microscopy (CLSM)

Confocal laser scanning microscopy (CLSM or LSCM) is a technique for acquiring
images withhigh-resolution and in-depth selectivity. Images are projected point-by-
point, line-by-line, ormultiple points at once and three-dimensionally reconstructed
with a computer, rather thanobtained through an eyepiece.
The key feature of confocal microscopy is its ability toproduce optical slices of the
objects at various depths with high resolution and contrast in thex, y, and z
coordinates. Spatial filtering is employed to eliminate out-of-focus glare or light
ofbackground information. Change of display magnification and image spatial
resolution,termed the zoom factor, is enabled by altering the scanning sampling
period.

9
  Optical triangulation
Optical triangulation measures distance to objects without touching them with
accuracy froma few millimeters to a few microns. Triangulation sensors are
particularly useful inacquiring high-speed data in inspecting delicate, soft, or wet
materials where contacts areundesirable. The system uses a lens, a laser light source,
and a linear light sensitive sensor.The laser irradiates a point on a specimen forming a
light spot image on the sensor surface.
The distance from the sensor to the surface is then calculated by determining the
position ofthe imaged spot and the baseline angles and length involved.

 Optical Coherence Tomography (OCT)

Optical coherence tomography (OCT) is an interferometric technique that performs
cross-sectionalhigh-resolution imaging of the internal morphology of biological
materials andtissues. It is equivalent to ultrasound imaging, except that it uses light
instead of sound.
Micron-scale measurements of distance and microstructure are obtained from
backscatteredor back reflected light waves in real time and in vivo. Although OCT
imaging depths are notas deep as with ultrasound, resolution of 1 to 15 μm can be
achieved, 10 to 100 times higherthan standard clinical ultrasound. The relatively long
wavelength light is able to penetrate intothe scattering medium up to 2-3 mm deep in
most tissues.

 Accordion Fringe Interferometry (AFI)

Accordion fringe interferometry (AFI) employs a revolutionary linear interferometry
technologythat traditionally projects to three dimensions. AFI delivers the most
precise laserfringe projection available which quickly digitizes the shapes of 3D
objects with the highestaccuracy of point cloud data. AFI employs laser beams from
two-point sources to illumine theobjects and uses a charge-coupled device (CCD)
camera to capture the curvature of the borders. AFI is less sensitive to ambient light
which gives the ability to capture and measure awider variety of surface coatings,
textures, and finishes than structured light.

 Active Wavefront Sampling (AWS)

Active wavefront sampling (AWS) uses a 3D surface imaging technique, which
requires onlyone optical path of an AWS module and a single camera to acquire depth
information.
The optical wavefront traversing a lens is sampled at two or more off-axis locations
and a single image is recorded and measured at each position. Target feature image
rotation can be usedto calculate the feature's distance to the camera.

10
Scanning systems8

 iTero® , Align Technology

The iTero® digital impression scanner was developed by Cadent Ltd. in 2006, and
acquired byAlign Technology, Inc. (San Jose, CA) in 2011 [15]. iTero® employs
confocal laser scannermicroscopy technique. The device projects 100,000 parallel
beams of red laser light which passthrough a probing face and a focusing optics to
reach the teeth. The reflected light is thentransformed into digital data through the use
of analog-to-digital converters.

 True Definition, 3M ESPE

The 3M True Definition scanner was officially launched in 2013 as an updated
version of the Lava™ chairside oral scanner which has been widely used in general
and restorative dentistry
since 2006. The True Definition scanner captures 3D images using activewavefront
sampling on the principle of structured light projection. 3M ESPE named thisscanning
technique “3D-in-motion video technology”. The system employs a rotatingaperture
element placed off-axis in the optical apparatus either in the imaging or the
illuminationpath which measures the defocus blur diameter. The user should first dry
and lightlydust with powder the entire arch so the scanner can locate the reference
points.

 Lythos™, Ormco Corporation

The Lythos™ Digital Impression System was introduced by Ormco Corporation
(Orange, CA)in 2013. The intraoral scanner uses accordion fringe interferometry
technology to capture andstitch together a 3D data in real time, acquiring high-
definition details at all angulations of thetooth surface. Lythos™ provides 3D video
imagery of 2.5 million points per second.

 CS 3500, Carestream
Carestream Dental (Atlanta, GA) launched the portable digital impression system, CS
3500, atthe end of 2013. The scanner employs confocal laser scanner microscopy
techniquewhich allows capture of true-color 2D and high-angulation 3D scans of up
to 45º with a depthof field of -2 to 13 mm. The image resolution is 1024 x 728 pixels
and the accuracy measuresup to 30 microns. The system is trolley-free and uses a
wand with a single, forked USB cablethat can be plugged in any computer,
eliminating the need for a dedicated workstation. Twoscanning tip sizes are included
to accommodate children and adults.

 TRIOS®, 3Shape
3Shape (Copenhagen, Denmark) announced the TRIOS® intraoral scanning solution
inDecember 2010. The system operates by the principle of confocal microscopy, with
a fast-scan rate. Hundreds to thousands of 3D pictures, corresponding to different time

11
instances and to respective different positions of the focus plane of the illumination
pattern,are combined to create the final 3D digital impression. The high-definition
camera featuresteeth shade measurement and provides scans in enhanced natural
colors or in a standardnoncolor pattern. The scanning wand does not require the use of
powder, has an autoclavabletip and an anti-fog heater. It takes approximately 5
minutes for a full mouth scan.

 FastScan®, IOS Technologies

Glidewell Laboratories’ IOS FastScan® intraoral camera and modelling system was
commercializedin July 2010. The digital impression system uses the principle of
activetriangulation with sheet of light projection. Ego-motion technology is used to
optimizeimage stabilization by having the camera moving automatically on a track
within the housingwand. That built-in motion detection software eliminates hand-
movement distortion, capturinghigh-resolution surface detail. The camera scans 40
mm per second throughout a depth offield that is greater than 15 mm. An application
of titanium dioxide powder is required.

 3D progress, MHT Optic research

The 3D Progress digital impression system is supplied by Medical Height Technology
(MHT)company (Verona, Italy) and MHT Optic research (Zurich, Switzerland).
Thetechnology beyond the product is a confocal scanning microscopy with a Moiré
patterndetector. A Smart pixel sensor supports precise and quick capture of up to 28
scans persecond which are stitched in a single 3D image in less than one tenth of a
second. 3D Progressallows a wide focus of acquisition, ranging between 0 to 18 mm
depth of field [40]. The scanningprocess can be paused and re-started at any moment
and parts of the scan can be modified orupdated with new data acquisitions. A full
mouth digital impression can be completed inapproximately 4 minutes.

 PlanmecaPlanScan®, E4D Technologies

Formerly known as the E4D NEVO scan and design system, the PlanmecaPlanScan®,
drivenby E4D Technologies (Richardson, TX), is an intraoral scanner widely utilized
in restorativedentistry. PlanScan® uses optical coherent tomography with blue laser
technology. Point-and-stitch image reconstruction occurs at video-rate scanning speed.
The singlesmaller wavelength of 450 nm is more reflective, capturing sharper images
of various hardand soft tissue translucencies, and dental restorations. Adjustable field-
of-view software
optimizes the target window while scanning in order to avoid capture of extraneous
data such
as lips, cheeks, and tongue. Intraoral fogging is prevented by the use of actively
heated mirrorson the scanning tip.

12
CLASSIFICATION OF
MANUFACTURING TECHNIQUES
1) Formative
2) Subtractive
3) Additive
Formative (injection moulding, casting, stamping and forging)
Formative manufacturing typically forms material into the desired shape via heat and
pressure. The raw material can be melted down and extruded under pressure into a
mould (injection moulding/die casting), melted and then poured into a mould (casting)
or pressed or pulled into the desired shape (stamping/vacuum forming/forging).
Formative techniques produce parts from a large range of materials (both metals and
plastics). For high volume production of parts, formative manufacturing is often
unrivalled in cost. The main limitation of formative manufacturing is the need to
produce a tool (mould or die) to form the part. Tooling is often expensive and
complicated to produce, increasing lead times and delaying the manufacturing of a
part. This large upfront investment is why formative manufacturing is generally only
cost effective at high volumes. The design of formative tooling is also complex with
the need for mould features like spurs or runners to assist in the formation of parts.
Parts that are produced via formative manufacturing also have design constraints like
draft angles and uniform wall thickness to aid in the forming process.9

Subtractive (CNC, turning, drilling)

Subtractive manufacturing begins with a block of solid material (blank), and utilizes
cutting tools to remove (machine) material to achieve a final shape. CNC milling,
turning (lathe) and machine operations like drilling and cutting are all examples of
subtractive techniques. Subtractive manufacturing is capable of producing highly
accurate parts with excellent surface finish. Almost every material is able to be
machined in some way. For majority of designs, subtractive manufacturing is the most
cost effective method of production. Subtractive manufacturing is limited by a
number of factors. Most designs require Computer Aided Manufacturing (CAM) to
plot tool paths and efficient material removal. This adds time and cost to the overall
process. Tool access must also be considered when designing parts for subtractive
manufacturing as the cutting tool must be able to reach all surfaces to remove material.
While machines like 5-axis CNC eliminate some of these restrictions, complex parts
will need to be re-orientated during the machining process, further increasing cost and
lead time. Subtractive manufacturing is also generally considered a wasteful process,
due to the large amounts of material that is often removed to produce the final part
geometry.9

13
Additive (3D printing)
Additive manufacturing (more commonly known as 3D printing) is the process of
additively building up a part one layer at a time. There are a range of 3D printing
technologies with each having their own benefits and limitations and each being able
to print parts from different materials. Parts can be produced in almost any geometry,
which is one of the core strengths of 3D printing (even though there are still rules that
must be followed per technology). Also, 3D printing does not rely on expensive
tooling having essentially no start-up costs. The advantage of this is the rapid
verification and development of prototypes and low volume production parts. One of
the biggest limitations of 3D printing is the inability to produce parts with material
properties equivalent to those made via subtractive or formative techniques. Most 3D
printing technologies produce parts that are inherently anisotropic or not fully dense.
3D printing also has limitations on repeatability, meaning parts will often have slight
variations due to differential cooling or warping during curing.9

14
TYPES OF MANUFACTURING PROCESSES:

Fig 6: types of 3D printing technologies.

3D printing over CAD CAM technology: -
1. Subtractive methods such as CAD CAM has some limitations in relation with 3 D
printing.
2. Large amount of raw material is wasted because of unused portions of the mono-
blocks which are discarded after milling and recycling of the excess ceramic is also
not feasible.
3. Milling tools are prone to heavy abrasion and wear which shortens their cycling
time.
4. Due to brittle nature of ceramic microscopic cracks can be introduced during the
process of machining.9

15
GENERAL PRINCIPLES
The general principles of 3-D printing include: -
1) Modelling
2) Printing
3) Finishing

Modelling
3D printable models are created with a computer-aided design (CAD) package, via
a 3D scanner, or by a plain digital camera and photogrammetry software. 3D printed
models created with CAD result in relatively fewer errors than other methods. Errors
in 3D printable models can be identified and corrected before printing. The manual
modelling process of preparing geometric data for 3D computer graphics is similar to
plastic arts such as sculpting. 3D scanning is a process of collecting digital data on the
shape and appearance of a real object, creating a digital model based on it.
CAD models can be saved in the stereolithography file format (STL), a de facto CAD
file format for additive manufacturing that stores data based on triangulations of the
surface of CAD models. STL is not tailored for additive manufacturing because it
generates large file sizes of topology optimized parts and lattice structures due to the
large number of surfaces involved. A newer CAD file format, the Additive
Manufacturing File format (AMF) was introduced in 2011 to solve this problem. It
stores information using curved triangulations.10

Printing
Before printing a 3D model from an STL file, it must first be examined for errors.
Most CAD applications produce errors in output STL files, of the following types:

1. holes
2. faces normals
3. self-intersections
4. noise shells
5. manifold errors
A step in the STL generation known as "repair" fixes such problems in the original
model. Generally, STLs that have been produced from a model obtained through 3D
scanning often have more of these errors as 3D scanning is often achieved by point-
to-point acquisition/mapping. 3D reconstruction often includes errors.
Once completed, the STL file needs to be processed by a piece of software called a
"slicer," which converts the model into a series of thin layers and produces a G-
code file containing instructions tailored to a specific type of 3D printer (FDM

16
printers).This G-code file can then be printed with 3D printing client software (which
loads the G-code, and uses it to instruct the 3D printer during the 3D printing process).
Printer resolution describes layer thickness and X–Y resolution in dots per inch (dpi)
or micrometers (µm). Typical layer thickness is around 100 μm (250 DPI), although
some machines can print layers as thin as 16 μm (1,600 DPI). X–Y resolution is
comparable to that of laser printers. The particles (3D dots) are around 50 to 100 μm
(510 to 250 DPI) in diameter. For that printer resolution, specifying a mesh resolution
of 0.01–0.03 mm and a chord length ≤ 0.016 mm generate an optimal STL output file
for a given model input file. Specifying higher resolution results in larger files without
increase in print quality.
Construction of a model with contemporary methods can take anywhere from several
hours to several days, depending on the method used and the size and complexity of
the model. Additive systems can typically reduce this time to a few hours, although it
varies widely depending on the type of machine used and the size and number of
models being produced simultaneously.10

Finishing
Though the printer-produced resolution is sufficient for many applications, greater
accuracy can be achieved by printing a slightly oversized version of the desired object
in standard resolution and then removing material using a higher-resolution
subtractive process.
The layered structure of all Additive Manufacturing processes leads inevitably to a
stair-stepping effect on part surfaces which are curved or tilted in respect to the
building platform. The effects strongly depend on the orientation of a part surface
inside the building process.
Some printable polymers such as ABS, allow the surface finish to be smoothed and
improved using chemical vapour processesbased on acetone or similar solvents.
Some additive manufacturing techniques are capable of using multiple materials in
the course of constructing parts. These techniques are able to print in multiple colours
and colour combinations simultaneously, and would not necessarily require painting.
Some printing techniques require internal supports to be built for overhanging
features during construction. These supports must be mechanically removed or
dissolved upon completion of the print.
All of the commercialized metal 3D printers involve cutting the metal component off
the metal substrate after deposition. A new process for the GMAW 3D printing allows
for substrate surface modifications to remove aluminum or steel.10

17
TYPES OF 3-D TECHNOLOGY

PROCESS DESCRIPTION TECHNOLOGY

material extrusion The material is fused filament

selectively dispensed fabrication (FFF)
through a nozzle or commonly referred to
orifice. as fused deposition
modelling (FDM)

vat polymerization A liquid Stereolithography

photopolymer in a vat (SLA) and direct light
is selectively cured by processing (DLP)
light activated
polymerization.

18
Powder bed fusion Thermal energy Selective laser
selectively fuses sintering (SLS), direct
regions of a powder laser metal sintering
bed. (DMLS) also known as
selective laser melting
(SLM)and
Electron beam melting
(EBM)

Material jetting Droplets of material Material jetting (MJ),

are selectively drop on demand
deposited and cured (DOD)
on a build plate.

Binder jetting A liquid bonding Binder jetting (BJ)

agent selectively binds
regions of a powder
bed.

Direct energy deposition Focused thermal Laser engineering net

energy is used to fuse shaping (LENS), laser
materials by melting based metal deposition
as they are being (LBMD)
deposited.

19
 Each of these techniques relies on different technologies to produce 3D constructs
and requires different physical properties of materials in order to achieve good
printability, including rheology, voxel solidification, interlayered coalescence, and
dimensional accuracy.11

1] MATERIAL EXTRUSION
Material extrusion is an additive manufacturingmethodology where a spool of
material (usually thermoplastic polymer) is pushed through a heated nozzle in a
continuous stream and selectively deposited layer by layer to build a 3D object.

(A) FUSED DEPOSITION MODELLING (FDM)

Fused Deposition Modelling was developed by Schott C Rump. A thermoplastic
filament material is extruded through a nozzle controlled by temperature and the
material hardens immediately (within .1 sec) after extrusion. 12
FDM works on the principle of laying down material in layers. A plastic filament or
metal wire is unwound from a coil and supplies material to an extrusion nozzle which
can turn the flow on and off. The nozzle is heated to melt the material and can be
moved in both horizontal and vertical directions by a numerically controlled
mechanism, directly controlled by a software package. The model or part is produced
by extruding small beads of a thermoplastic material to form layers as the material
hardens immediately after extrusion from the nozzle. Stepper motors or servo motors
are typically employed to move the extrusion head. 13

The motion of the nozzle head is controlled by a processor and traces and deposit the
material in extremely thin layer on to a subsidiary platform. Building complex
geometries usually necessitates the usage of a second extruder – for example, might
extrude a water-soluble support material. Accuracydepends upon the speed of travel
of the extruder, as well as the flow of material and the size of each ‘step’. This is the
process that is used by most low cost ‘home’ 3D printers. It allows for the printing of
crude anatomical models without too much complexity. 12
Several materials are available with a range of strength and thermal properties. As
well as acrylonitrile butadiene styrene (ABS) polymer, polycarbonates,
polycaprolactone, polyphenylsulfones and waxes, a water-soluble material can be
used for making temporary supports while manufacturing is in progress. This soluble
support material is quickly dissolved with specialized mechanical agitation
equipment.13

20
Fig7:Fused Deposition Modelling

Steps for the printing process:

1) A spool of filament is loaded into the printer and fed through to the extrusion head.
2) Once the printer nozzle has reached the desired temperature, a motor drives the
filament through the heated nozzle melting it.
3) The printer then moves the extrusion head around, laying down melted material at
a precise location, where it cools down and solidifies.
4) Once a layer is complete, the build platform moves down and the process repeats
building up the part layer-by-layer.12

2] VAT POLYMERIZATION
Vat polymerisation uses a vat of liquid photopolymer resin, out of which the model is
constructed layer by layer. An ultraviolet light is used to cure or harden the resin
where required, whilst a platform moves the object being made downwards after each
new layer is cured.14

(A) Stereolithography (SLA)

The term “stereolithography” was first introduced in 1986 by Charles W. Hull, who
defined it as a method for making solid objects by successively printing thinlayers of
an ultraviolet curable material one on top of the other.SLA uses a layer-by-layer
approach to fabricate 3D microstructure. This technology encompasses traditional

21
lithography techniques, which build geometries from top to bottom. This technique
relies on a UV light source and a moveable stage, which is in contact with a reservoir
containing a photocurable resin to selectively cure monomers in the desired location.
Once a layer has been completed, a new layer of liquid resin is introduced and
crosslinked with the previous layer by photoinduced polymerization. The process
continues in a layer-by-layer fashion until the desired 3D object is produced. The
process uses mirrors, known as galvanometers or galvos, (one on the x-axis and one
on the y-axis) to rapidly aim a laser beam across a vat, the print area, curing and
solidifying resin as it goes along. This process breaks down the design, layer by layer,
into a series of points and lines that are given to the galvos as a set of coordinates.
Most SLA machines use a solid-state laser to cure parts.14

Steps for the printing process:

1) A 3D model of the desired object is created in a CAD program.

2) A software package slices the CAD model up into thin layers, which may be
anything from 5 to 20 layers per millimetre and the more layers the better the
resolution.
3) The laser scans the liquid resin in the vat and it sets, thus creating the first layer.
4) The platform drops down into the vat by a fraction of a millimetre and the laser
scans the next layer.
5) 5)This process is repeated layer by layer until your model is complete.
6) Once the run is complete, the objects is rinsed with a solvent to remove
uncured and then placed in an ultraviolet oven that thoroughly cures the resin.
In classical SLA, a liquid resin is selectively photopolymerized by a rastering laser of
UV light to afford the desired structure. In newer methods such as digital light
processing (DLP), the same basic principles are applied; however, unlike SLA, which
relies on point-source illumination to pattern one voxel at a time, DLP permits a layer
resin to be cured using micromirror array devices or dynamic liquid crystal masks to
project a mask or pattern onto the reservoir of liquid resin. As a consequence of this,
DLP is generally much faster than SLA as an AM technique.
Generally, SLA, is advantageous as an AM technique as the amount of resin or
materials required for the manufacturing process is reduced in this material efficient
technique.
The main drawback of SLA is the limitation in materials available as the reagents
must be UV-curable, be low in viscosity, and optically transparent to fully realize the
potential of this technology.
A new technique, the two-photon polymerization technique relies on focusing a laser
beam into a very small volume of resin by means of a high numerical aperture
objective.

22
As is common with many 3D printing technologies, there is an inherent compromise
between printer resolution, build volume, and printing speed. In this instance, highly
complex microarchitectures can be constructed using two-photon polymerization, but
a limit to the overall dimensions (c.1 cm3) is often observed.
Because of the nature of the SLA process, it requires support structures for some parts,
specifically those with overhangs or undercuts. These structures need to be manually
removed. In terms of other post processing steps, many objects 3D printed using SLA
need to be cleaned and cured. Curing involves subjecting the part to intense light in an
oven-like machine to fully harden the resin.14

Fig8:Stereolithography (SLA) printer

(B) Direct light processing (DLP)

DLP is identical to SLA except for the light source: a projector is used to cure an
entire layer at a time, in contrast to the SLA laser, which must draw the entire layer to
cure it. Similar to the difference between stamping and drawing an object, this results
in significantly faster print times. The major difference is the light source. DLP uses a
more conventional light source, such as an arc lamp with a liquid crystal display panel,
which is applied to the entire surface of the vat of photopolymer resin in a single pass,
generally making it faster than SLA. One advantage of DLP over SLA is that only a
shallow vat of resin is required to facilitate the process, which generally results in less
waste and lower running costs.
In this process, once the 3D model is sent to the printer, a vat of liquid polymer is
exposed to light from a DLP projector under safelight conditions. The DLP projector

23
displays the image of the 3D model onto the liquid polymer. The exposed liquid
polymer hardens and the build plate moves down and the liquid polymer is once more
exposed to light. The process is repeated until the 3D model is complete and the vat is
drained of liquid, revealing the solidified model. DLP 3D printing is faster and can
print objects with a higher resolution.
The heart of the DLP projector is a chip developed by Texas Instruments. Known as a
digital micromirror device, the chip contains hundreds of thousands of tiny mirrors
that are able to move in two directions, on and off, thousands of times per second.
Because a DLP printer builds a model in voxels rather than layers, there are no visible
steps, making the finish quality the best of all 3D printing technologies. Many media
are available for DLP printers, from ABS plastic to materials designed for burn-out
casting.14

Fig 9:Direct light processing (DLP) printer

Steps for the printing process:

24
 1) The build platform of a 3D printer is positioned inside thetank that is filled
with liquid photopolymer. The height between the build platform and the tank
is approximately one layer long.
2) After having the build platform correctly positioned, a ray of light from the
light source is allowed to pass. This ray of light creates the next layer by
selectively curing and solidifying the photopolymer resin. The light ray has a
predetermined path on which it travels. Here is where galvanometers play a
huge part. Since the path is predetermined galvanometers are placed at
intervals to monitor this path. After solidifying one layer, the same process is
repeated for the other layer.
3) The build platform moves at a safer distance as soon as the solidifying of one
layer is finished. Alongside the movement of the build platform, the sweeper
blade is constantly re-coating the surface.
4) For parts that demand very high thermal and mechanical properties, post-
processing under light rays is required. That is done in the fourth step which is
optional sometimes.
The solidifying of liquid resin is a process that is called photopolymerization.
During this solidification, the monomer carbon chains that compose the liquid
resin are activated by a ray of light.
This activation creates solidification and unbreakable bonds between each
other.
Because this process is irreversible, it is not possible to convert parts that are
manufactured by DLP 3D printing, back to the liquid phase. DLP 3D printing
using thermoset polymers and not the usual thermoplastic polymers.14

Comparison Between DLP and SL

Fig 10: Comparison between DLP and SL.

25
There is a benefit when using DLP 3D printer over the SLA printer. The difference
between them is speed. DLP printers are speedier to operate and produce a print faster
than SLA 3D printers.

The primary difference between SLA and DLP printer is the light source. SLA uses a
UV laser beam while DLP uses UV light from projector.
In DLP, the UV light source remains stationary and it cures the complete layer of
resin at a time. In SLA, the laser beam moves from point to point tracing the geometry.
Since the curing (hardening) of the resin is done from point to point, SLA 3D printing
is more accurate and the quality of the print is also better in comparison to DLP 3D
printing.
In DLP 3D printer, the operator can control the intensity of UV light source and
thereby control its effect on the resin. In SLA, the intensity of the laser beam cannot
be adjusted and you have to change the laser light completely for different resin effect.
DLP is more suitable to build one-off small and intricate part while SLA is more
suitable for printing several intricate parts in one go.
DLP printers are more expensive as compared to SLA printers which are available in
all ranges.

DLP 3D printers produce the boxy surface finish. The voxels of these printers are
rectangular, so curved sections of a print does not tend to have a very smooth finish
compared to SLA printers. But this problem can be solved by sanding after the part is
printed.11

3] POWDER BED FUSION

Thermal energy is used to selectively fuse regions of a powder bed. Different powders,
from metals, nylons, and other polymers are fused with a laser or electron beam
source.Laser based additive manufacturing, such as selective laser melting (SLM) and
selective laser sintering (SLS), is accomplished by directing a high-power laser using
mirrors at a substrate consisting of a fine layer of powderWhere the beam hits the
powder, it creates a melt pool and the powder particles fuse together. After each
cross-section is scanned, the powder bed is lowered by one layer thickness, a new
layer of material is applied on top, and the process is repeated until the part is
completed.13

Powder bed fusion is in wide use around the world due to its ability to make very
complex geometries directly from digital CAD data.13

26
Compared to other methods of additive manufacturing, SLS/SLM can produce parts
from a relatively wide range of commercially available powder materials. These
include a wide range of polymers such as polyamide to produce a facial prosthesis,
ultra-high molecular weight polyethylene, polycaprolactone to provide functionally
graded scaffolds, mixtures of polymers such as polycaprolactone and drugs to act as
drug delivery devices and composites such as mixtures of hydroxyapatite and
polyethylene and polyamide to produce customized scaffolds for tissue
engineering.The physical process can involve full melting, partial melting, or liquid-
phase sintering. Depending on the material, up to 100% density can be achieved with
material properties comparable to those from conventional manufacturing methods.In
many cases large numbers of parts can be packed within the powder bed, allowing
very high levels of productivity.13

This technology requires a fair amount of postprocessing and is used for printing
cobalt chrome and titanium frameworks for fixed and removable prosthetics in
dentistry.9

Fig 11:Basic functionality of PBF-based 3D printers. note that each specific process
has a unique arrangement and will visually differ from this basic diagram.

Steps for the printing process:

27
 1) The first step is taking a 3D CAD model and converting it into an .STL file-
or a file that can be cut into layers by a so-called slicing software. After
slicing, the file is loaded into the printer and is oriented to minimize supports
and maximize part volume (if making many copies).
2) Then the interior space known as the powder chamber is filled with powder
material either with a hopper or an automatic cartridge. The powder chamber
is often heated to reduce the energy expenditure of the heat source, and
sometimes is filled with an inert gas/brought to vacuum.
3) The roller/re-coater then uniformly deposits a thin layer of powder from the
powder stock chamber onto the build platform, where any excess powder is
caught in an overflow reservoir.
4) Once this layer is evenly flat, the energy source sinters/melts the first 2D
cross-section of the part. As described, sintering a powder only welds solid
particles together, while melting a powder causes it to fully liquefy.
5) After the material has solidified, the elevator increments down on the z-axis,
and the powder stock chamber raises the exact same height, ready for the
next layer to deposit. This process continues until the part is complete, where
it is then dug out of the powder chamber and post-processed for use.

An important distinction between PBF techniques and other additive manufacturing

methods is its lack of support structures. Though sometimes used for complex
geometries, supports are not as necessary in PBF as they are in FDM/FFF, SLA, or
other printing types, as the surrounding unheated powder will naturally support
overhangs/voids. The only caveat to this is that PBF finds difficulties with completely
enclosed voids, as there is no way to remove the unheated powder inside without
breaking open the part. Despite this, PBF parts are much easier to post-process,
requiring less support/surface clean-up thanother additive manufacturing methods.13

TYPES OF POWDER BED FUSION PROCESSES

28
 (A) Selective Laser Sintering (SLS)
 One of the first PBF methods, SLS was patented in the late 1980’s at the
University of Texas at Austin. SLS implements a laser (typically a pulsed
CO2 laser) to sinter powder together in a heated powder chamber.

 A laser solidifies powder evenly distributed by a roller on a build platform and

repeats this process until the full part is finished.
 The sintering process creates a fair amount of porosity in the material
(sometimes up to 30% air throughout), making its surface naturally grainy.

Advantages:

 SLS accepts a wide range of materials from polymers such as polyamides and
PEKK, Alumide (a blend of aluminum and polyamides), rubber-like material,
glass, ceramics, etc.
 SLS is great for functional prototypes, as its prints are strong and can be very
complex without the need for lengthy post-processing.
 The surface is porous (also a disadvantage in some applications)

Disadvantages:

 The surface is porous (can be an advantage in some applications)

29
  Printers are very expensive and large, reserving SLS for industrial use
 SLS is useful mostly for industries that need only a small amount of high-
quality objects, making it a poor choice for high-volume applications.15

(B) Selective Heat Sintering (SHS)

 Recently patented by Danish company Blueprinter, SHS is a similar process to
the popular SLS method, except instead of using a laser to sinter powder
together, SHS implements a thermal print head.
 This change not only reduces the necessary size of the printer but also saves
money because thermal heads are cheaper and are less energy-intensive.
 Thermoplastic powder is so far the only accepted material in SHS, which is
the same material used in FDM printing (except SHS uses a powder form).
 The basic operation of SHS machines is the same layer-by-layer approach,
where a powder material is spread out onto a build platform, heated, solidified,
and lowered so that another layer can be deposited.

Advantages:

 SHS is cheaper and more energy-efficient than SLS.

 SHS comes in smaller sizes and accepts more common thermoplastic materials,
making it more useful for desktop applications.

Disadvantages:

 SHS only accepts a narrow range of materials so far.

 SHS needs time to catch up to other PBF methods, and also has to compete
with FDM printers.15

(C) Selective Laser Melting (SLM)

 SLM is like SLS in form but achieves full melting when heating powder and it
is used to print metal parts. Just as SLS, SLM selectively melts parts in a thin
deposit of metal powder and incrementally adds layers on top.
 SLM requires an inert atmosphere (argon gas) so that the metal powder does
not oxidize/nitride, meaning its powder bed is completely enclosed in an
airtight chamber.

Advantages:

30
  SLM creates fully-metal parts that are extremely dense and strong.
 SLM can reduce part numbers by printing whole assemblies, rather than
producing individual components.
 With time, SLM could speed up metal manufacturing techniques, reducing
delays in repairs, and increase the pace of production.

Disadvantages:

 Only certain metals are acceptable in SLM such as single-component

aluminum, stainless steel, titanium alloys, cobalt chrome, tool steel, and other
specified materials with good flow characteristics.
 SLM is a high-energy process, leading to temperature gradients that can
stress/dislocate parts and compromise structural integrity.
 SLM parts need additional support structures and require a source of inert
gas.13

(D) Direct Metal Laser Sintering (DMLS)

 Trademarked by German company EOS GmbH, DMLS uses the same
technical principles as SLS/SLM but is much more accepting material-wise,
being able to use nearly any metal alloy.
 This is primarily due to the decreased temperatures of DMLS, where metal
powder is sintered together instead of reaching full melt as in SLM.
 The functionality of DMLS is like SLS/SLM, where a thin layer of metal alloy
powder is deposited onto a build platform via a roller/re-coater, and a laser
selectively sinters the material in a layer-by-layer process. Just as SLM,
DMLS is performed under an atmosphere of inert gas.

Advantages:

 DMLS has a huge range of metal alloy powders from which to choose
 DMLS parts are free of residual stresses and internal defects, making them
perfect for high-stress applications. For this reason, they do not need to be heat
treated either, saving on fabrication time
 Less energy is used in DMLS than in SLM.

Disadvantages:

31
  DMLS is expensive and reserved for very high-end applications (aerospace,
automotive, etc.)
 DMLS typically cannot use the metal powders used in SLM designs
 DMLS parts need additional support structures and require a source of inert
gas.13

(E) Electron Beam Melting (EBM)

 EBM deploys a high-energy electron beam to melt powder on the build
platform. It requires an enclosed powder chamber at a full vacuum to work
effectively.
 It accepts a limited range of metal powders such as titanium alloys and cobalt
chrome but forms very dense models once printed.
 These parts are also less susceptible to the residual stresses and defects of
SLM parts but require more secondary post-processing to reach a desired
surface quality.

Advantages:

 EBM is much faster than SLS and SLM

 EBM parts are dense, reliable, and generally free of defects, great for uses in
the aerospace industry
 EBM uses less energy than SLS/SLM technology.

Disadvantages:

 The EBM process emits dangerous X-ray radiation when in use, requiring an
enhanced level of safety
 EBM parts require additional post-processing procedures to reach intended
uniformity
 EBM is limited in material choice.13

(F) Multi-Jet Fusion (MJF)

 MJF is a proprietary PBF method developed by Hewlett-Packard that produces
parts with a turnaround time of as little as one day.
 Powdered material (nylon/other polyamides) is fed into a build chamber using
a roller and is progressively built up in a layer-by-layer process however, an
inkjet array selectively applies fusing and detailing agents across the layer of
powder, which then solidifies upon the second pass with a thermal energy
source.

32
  The build platform lowers, and more powder is added until the whole part is
printed. This process is much lower energy, as the agents sprayed onto the
powder chemically react and fuse particles upon contact with heat.
 After printing, the part is removed from the printer (inside the modular powder
bed) and placed in a separate processing station, where the loose powder is
recovered and parts are bead blasted for final use.
 This PBF process stands out from the other types, using no laser technology
and using much less heat than other thermal designs.

Advantages:

 MJF provides quality surface finishes, fine feature resolution, and consistent
mechanical properties across all parts, and has a high output volume.
 MJF takes much less time than other methods, sometimes as fast as a day.
 The modular, station-based approach of MJF is easy to use and supplemented
by software which makes using this technology easier to understand than other
PBF printers.

Disadvantages:

 MJF is very expensive to use.

 MJF has a limited range of materials (nylon/nylon impregnated with glass)
 The system is complex and will require regular maintenance by trained
technicians if used in high volume applications (which it most likely will be)15

5) MATERIAL JETTING

Material jetting creates objects in a similar method to a two-dimensional ink jet

printer. Material is jetted onto a build platform using either a continuous or Drop
on Demand (DOD) approach.
This process ensures that physical objects are built up one layer at a time. The
material jetting manufacturing process allows for different materials to be 3D
printed within the same part.
Material is jetted onto the build surface or platform, where it solidifies and the
model is built layer by layer. Material is deposited from a nozzle which moves
horizontally across the build platform. Machines vary in complexity and in their
methods of controlling the deposition of material. The material layers are then
cured or hardened using ultraviolet (UV) light.
As material must be deposited in drops, the number of materials available to use is
limited. Polymers and waxes are suitable and commonly used materials, due to
their viscous nature and ability to form drops.

33
Steps for the printing process:

Fig12:Printing process of material jetting

1) The print head is positioned above build platform. The print heads and the
light sources are suspended along the same X-axis carriage.
2) Droplets of material are deposited from the print head onto surface where
required, using either thermal or piezoelectric method.
3) Droplets of material solidify and make up the first layer.
4) Further layers are built up as before on top of the previous.
5) Layers are allowed to cool and harden or are cured by UV light. Post
processing includes removal of support material11

34
 TYPES OF MATERIAL JETTING PROCESSES

(A) Drop on demand (DOD)

 DOD material jetting printers have two print jets: one to deposit the build
material and another for dissolvable support material.
 DOD 3D printers follow a pre-determined path and deposit material in a
point-wise fashion to build the cross sectional area of a component.
 These machines also employ a fly-cutter that skims the build area after each
layer to ensure a perfectly flat surface before printing the next layer.
 DOD technology is typically used to produce wax-like patterns for lost-wax
casting/investment casting and mold making applications, making it an
indirect 3D printing technique.11

(B) PolyJet
 PolyJet 3D printing technology was first patented by the Objet company, now
a Stratasys brand.
 The photopolymer materials are jetted in ultra-thin layers onto a build tray in a
similar fashion compared to inkjet document printing.
 Each photopolymer layer is cured by UV light immediately after being jetted.
The repetition of jetting and curing steps, layer after layer produces fully cured
models that can be handled and used immediately.
 The gel-like support material, which is specially designed to support complex
geometries, can easily be removed by hand or by using water jetting.11

(C) NanoParticle Jetting (NPJ)

 This material jetting technology, patented by XJet, uses a liquid, which
contains building nanoparticles or support nanoparticles, that is loaded into the
printer as a cartridge and jetted onto the build tray in extremely thin layers of
droplets.
 High temperatures inside the build envelope cause the liquid to evaporate
leaving behind parts made from the building material. This technique is
suitable for metals and ceramics.11

Advantages:

35
  Due to the precise deposition of the tiny droplets of material, layers can be
printed as thin as 0.013 mm, allowing for parts with a very smooth surface
finish and enabling parts with small but highly accurate features to be
produced.
 Material Jetting can be used for full-colour and, more notably, multi-material
3D printing, as the printhead used in the printing process typically
incorporates multiple nozzles.
 Although Material Jetting requires support structures, these can be easily
dissolved in an ultrasonic bath. When dissolved correctly, the supports don’t
leave marks on the surface after removal.

Disadvantages:

 Objects produced with Material Jetting are typically weaker, particularly when
compared to other 3D printing techniques like SLS.
 Material Jetting is somewhat constrained by the speed of the printing process.
Because small droplets of material are deposited over a small part of the build
area at a time, the process takes more time to create a part.
 For Material Jetting, typically only viscous materials can be successfully
printed. However, the number of viscous materials which are able to be used
in the printing process is currently rather limited. 11

6) BINDER JETTING (BJ)

The binder jetting process uses two materials; a powder-based material and a
binder. The binder acts as an adhesive between powder layers. The binder is
usually in liquid form and the build material in powder form.

A print head moves horizontally along the x and y axes of the machine and
deposits alternating layers of the build material and the binding material. After
each layer, the object being printed is lowered on its build platform.

It is a non-beam-based additive manufacturing method in which a liquid

binder is jetted on layers of powdered materials, selectively joined, and then
followed by densification process.

Steps for the printing process

36
Fig13:Printing process of binder jetting

1) Powder material is spread over the build platform using a roller.

2) The print head deposits the binder adhesive on top of the powder where
required.
3) The build platform is lowered by the model’s layer thickness.
4) Another layer of powder is spread over the previous layer. The object is
formed where the powder is bound to the liquid.
5) Unbound powder remains in position surrounding the object.
6) The process is repeated until the entire object has been made.

Advantages:

 Parts can be made with a range of different colours.

 Uses a range of materials: metal, polymers and ceramics.
 The process is generally faster than others.
 The two-material method allows for a large number of different binder-powder
combinations and various mechanical properties.

Disadvantages:

 Not always suitable for structural parts, due to the use of binder material.
 Additional post processing can add significant time to the overall process.10,14

7) DIRECT ENERGY DEPOSITION

37
Directed Energy Deposition (DED) is a 3D printing method which uses a focused
energy source, such as a plasma arc, laser or electron beam to melt a material which is
simultaneously deposited by a nozzle. As with other additive manufacturing processes,
DED systems can be used to add material to existing components, for repairs, or
occasionally to build new parts.

A typical DED machine consists of a nozzle mounted on a multi axis arm, which
deposits melted material onto the specified surface, where it solidifies. The process is
similar in principle to material extrusion, but the nozzle can move in multiple
directions and is not fixed to a specific axis. The material, which can be deposited
from any angle due to 4 and 5 axis machines, is melted upon deposition with a laser or
electron beam. The process can be used with polymers, ceramics but is typically used
with metals, in the form of either powder or wire.Typical applications include
repairing and maintaining structural parts.10

Steps for the printing process:

1) A4 or 5 axis arm with nozzle moves around a fixed object.

2) Material is deposited from the nozzle onto existing surfaces of the object.
3) Material is either provided in wire or powder form.
4) Material is melted using a laser, electron beam or plasma arc upon deposition.
5) Further material is added layer by layer and solidifies, creating or repairing new
material features on the existing object.

Fig14:Printing process of direct energy deposition

38
Advantages:

 Ability to control the grain structure to a high degree, which lends the process
to repair work of high quality, functional parts.
 A balance is needed between surface quality and speed, although with repair
applications, speed can often be sacrificed for a high accuracy and a pre-
determined microstructure

Disadvantages:

 Finishes can vary depending on paper or plastic material but may require post
processing to achieve desired effect
 Limited material use.
 Fusion processes require more research to further advance the process into a
more mainstream positioning.11

3-D PRINTERS USED IN

ORTHODONTICS

The global additive manufacturing industry has been dominated by three large
companies:

Stratasys, Ltd. (Eden Prairie, MN), 3D Systems (Rock Hill, SC), and EnvisionTEC
(Gladbeck,Germany), with market shares of 57%, 18%, and 11%, respectively.
As of January 2014,Stratasys sells 3D printing systems that range from $2,200 to
$600,000 in price and are employedin several industries: aerospace, automotive,
architecture, defense, medical and dental, amongmany others (Figure 22). MakerBot
and Objet are the 3D printers recently acquired by Stratasysand currently used in
dentistry and orthodontics. For example, ClearCorrect employs Objet inthe aligner
manufacture process while Invisalign uses the 3D Systems' SLA technology.
Othercompanies like Concept Laser (Lichtenfels, Germany), Realizer (Borchen,
Germany), and SLMSolutions (Lübeck, Germany) are also offering printing
technologies and new materials to beused in dental 3D printing.

39
Furthermore, a broad line of innovative professional 3D printers,orthodontic practical
solutions, and price points exist for generating full-color parts, waxpatterns, and
investment castings.

Objet30 OrthoDesk (Stratasys, Ltd., Eden Prairie, MN) employs the PolyJet
printingtechnologyand is suitable for orthodontic offices and small- to medium-sized
orthodontic labs. The 3D printer is able to fabricate durable orthodontic models with
high feature detail andultrafine layers of surface quality. Every print run can create up
to 20 models. Three dentalmaterials, specially engineered for dentistry, come with the
printer in sealed cartridges:

VeroDentPlus (MED690), a dark beige, acrylic-based material prints layers as fine as

16 micronswith accuracy as thin as 0.1mm used for most appliances; Clear
biocompatible (MED610), a transparent material medically approved for temporary
intraoral applications and surgicalguides; and VeroGlaze (MED620), an acrylic-based
material for veneer models or diagnosticwax-ups in A2-shade color match that can be
used in the mouth as long as 24 hours.8

Fig15:The Objet30 OrthoDesk (Stratasys, Ltd., Eden Prairie, MN) 3D printer.

ProJet® 3510 MP (3D Systems, Rock Hill, SC) is one of the several healthcare
printing solutions,used for uniformly accurate thin wax-ups of crown, bridges, and
partial dentures. The systemcan also produce any size dental or jaw models with a
choice of two materials in smooth ormatte printing mode. Up to 24 quad cases can be
built at one time.

40
Fig16:The ProJet® 3510 MP (3D Systems, Rock Hill, SC) 3D printer.

The 3D Systems professional printers support the VisiJet® line of materials, specially
engineeredto meet a wide range of applications. ProJet® 3510 series come with three
UV curableacrylic materials: Dentcast, a dark-green, wax-up material, which burns
out cleanly for ashfreecastings; PearlStone, a while material with a solid stone
appearance; andStoneplast for transparent, clear or stone finish dental models.
VisiJet® S300 is the fourthmaterial which is a non-toxic white wax material for
hands-free melt-away supports.14

Fig 17:Dental wax-up and casting manufactured with ProJet® 3510 MP.

ULTRA® 3SP™ Ortho (EnvisionTEC, Gladbeck, Germany) employs the Scan, Spin,
andSelectively Photocure (3SP™) technology, a DLP variant, which utilizes a laser
diode with anorthogonal mirror spinning at 20,000 rpm. The printer is able to produce
highlyaccurate and stable dental models that could be used for orthodontic appliance
fabrication.
The models are resistant to high temperature and have negligible water absorption.14

41
Fig 18:The EnvisionTEC (Gladbeck, Germany) 3D printers used in dentistry and
orthodontics.

ULTRA® 3SP™ Ortho also comes with specially engineered photosensitive resins
for dentaland orthodontic applications: Press-E-Cast (WIC300), a wax-filled
photopolymer forproductionof copings with extremely thin margins as well as up to
16 multiple unit bridge; EDenstone(HTM140 Peach), a peach color material able to
achieve the look and feel oftraditional gypsum models with a high-accuracy detail;
and D3 White, a fast-growing, toughmaterial with similar characteristics to ABS
plastic and the most common medium for dentalmodel manufacturing for the
production of orthodontic appliances.
A variety of low-cost printers are also available for home use such as the
MakerBotReplicator2 (Stratasys, Ltd., Eden Prairie, MI). Some of those low-cost
devices have the ability to locallyprint objects in an astonishing number of materials,
including ice, chocolate, rubber caulk,frosting, and ceramic clay. Low-cost printers,
however, still lack supports for overhanginggeometry and their use in orthodontics
could be problematic. The machines are often fragilewith temperature, deposition, and
position controls not accurate enough to make functionalend-parts.8

42
3-D PRINTING PROCESS
Step 1 – 3D Model creation

First a 3D model of the object to be printed is created using computer-aided design

(CAD) software or a 3D object scanner. Since the part will be exact replica of the 3D
model, every detail needs to be right and modelled to the right shape and size and
needs to fully define its external geometry.

Step 2 – STL file creation

The CAD file is then converted to a standard AM file format called standard
tessellation language (STL), which was developed by 3D Systems in late 80s for use
in its Stereolithography (SLA) machines.The STL file format is the most commonly
used file format for 3D printing. When used in conjunction with a 3D slicer, it allows
a computer to communicate with 3D printer hardware.The main purpose of the STL

43
file format is to encode the surface geometry of a 3D object. It encodes this
information using a simple concept called “tessellation”.Tessellation is the process of
tiling a surface with one or more geometric shapes such that there are no overlaps or
gaps.

Step 3 – STL file transfer

STL file is then transferred to the printer often using the custom machine software,
where model will be manipulated to orientate for printing. At this stage machine
software might create its own file with extra information it needs to build the part
such as support structure, temperature etc.

Step 4 – Machine set up

Each additive technology and its variants have its own steps and requirements to set
up a new printing job. This includes material selection, orientation, printer
temperature, support structure, build platform levelling etc. It also involves loading
print material, binders and other consumables into the machine.

In order to reduce the cost of printing multiple parts can be set up and waste can also
be minimised by choosing the right orientation.

Step 5 – Build

Once the build started, it gradually builds the design one layer at a time. A typical
layer is around 0.1mm in thickness but depending on the technology and the material
used it can go down to 20 microns.

Depending on the build size, the printing machine, AM technology, material and the
printing resolution, this build process could take hours or even days to complete.

Step 6 – Part Removal

After building the part or multiple parts in some cases, it may need a cooling off
period before the parts can be removed from the machine. Again depending on the
machine and technology, removal could vary from simply peeling off the build
platform to wire eroding from the build pate.

44
Step 7 – Post processing

Almost all the additive manufacturing techniques will require some form of post
processing. Depending on the AM technology used and the end use of the part, it
varies from simply cleaning and polishing to machining and heating treating the
part.16

45
46
THE DIGITAL WORKFLOW
The process from digital ‘impression’ to appliance fabrication is described below:

1. Intra-oral scanning
Intra-oral scanning creates a topographical map of the dentition and adjacent soft
tissues. While the resultant digital model is viewable within the scanner software, for
physical purposes it needs to be exported as a standard tessellation language (STL)
file. This universal 3D format represents
surface geometry as thousands of linked triangles and render it suitable for CAD
software manipulation.

2. Digital model manipulation

Most current 3D printer software tends to focus on the immediate print preparation,
e.g., model orientation, and the addition of model supports. However, the virtual
model produced by a scanner is hollow with a very thin shell, whichis too flimsy for
printing and subsequent appliance fabrication.

Fig 19:A typical STL file exported from intra-oral scanner software. The external
surface (grey) and the internal surface (pink) showing the hollow nature and very thin
boundary walls.

47
Fig20:(A) A base has been added and then trimmed using the 3Shape scanner
software package and (B) where FormlabsPreForm printer software has been used to
repair and base the model. The model shown in (A) has a completely flat base
whereas in (B) the base is uneven since this software does not extend and then cut the
base along a flat plane.

Hence this digital model requires solidification (in-filling) or substantial thickening of

the sides beforeprinting.
Notably, the base does not need to be as deep and trimmed in the same manner as
traditional study models, since the purpose of the base is to make the resultant
physical model stable and relatively flat. There are three software options available to
prepare models:
1. The scanner or orthodontic manipulation software, e.g.3Shape Trios software
may be used to base the digital models and render them solid. This is
particularly useful if one aims to createorthodontic aligners, since each
upper/lower base isprepared and trimmed only once, then this base is
replicated for all aligner models. This is followed bytooth segmentation, tooth
movements, attachment additionsand treatment sequencing, before aligner
modelprinting (which is outside the scope of this paper).
2. Some 3D printer software, e.g.,FormlabsPreForm™, offers the option of
automatically repairing andbasing the model immediately after import.This
process may take 1–2 minutes, but it is an easy andreliable way of rendering
digital models suitable forprinting. Notably, the model is not usually finished
witha flat base, meaning that the base needs to utilise supportsto link it to the
print platform.
3. An open-source third party CAD software may be used tobase the models, e.g.,
the Microsoft Windows™ 3D Builder,Meshmixer™and Blender™.

48
The typical steps involved in ‘manual’ model preparationusing generic 3D design
software are:

- Identification followed by repair of surface (mesh) defects.

- Levelling of the model’s free edges, by removing any extraneous soft-tissue sections.
This step may be skipped if the intra-oral buccal/ labial scanned height is relatively
consistent.

- Extrusion of the model’s external edge to create a flat base which is reasonably
parallel to the occlusal plane.

- Trimming the base height. This avoids unnecessary model thickness where little
soft tissue coverage is required for retainer and aligner fabrications. It also reduces
resin usage and possibly the print time. In addition, thin model bases allow many
more vertically orientated models to be fitted on the build platform. However, if a
deep model is required, e.g., when full palate depth is needed for appliance fabrication,
then the model should be left with sufficient height to accommodate this.

- Solidification of the model. In-filling makes the subsequent printed model

sufficiently robust and avoids both print failure (due to the model fragmenting during
the print process) and subsequent model distortion under high vacuum/ pressure
forces (during appliance fabrication).

- Alternatively, the model may be hollowed, to leave a sufficiently thick surface layer
before the solidification step. This results in less resin usage and is therefore
particularly suitable for ‘deep’ models, such as those includingfull palate depth.

- Ideally each digital model should be labelled in order to avoid confusion over patient
identification and/or aligner sequence. Otherwise, staff need to record each patient’s
model positions in the print set-up. Aligner software provide this capability and are
easier to use than trying to add labels within third party software.

49
Fig21:These computer snapshots illustrate key stages when using Meshmixer CAD
software to prepare dental model STL files for printing. (a) The ‘holes’ in the model
surface have been identified (by the pink tabs), ready for semi-automated repair. (b)
Superfluous edges of the model can be highlighted (in orange) then trimmed using a
‘cutting’ tool. (c) The model base has been ‘extruded’ to extend the non-dentate part
into a deep, flat base. (d) The height of the extruded base has been reduced to a
manageable size for retainer and aligner fabrication. This has been achieved using a
‘plane cut’ tool, producing a flat base surface. (e) Solidification produces a model
with sufficient density for printing. (f) Alternatively, the model may be hollowed
before the solidification step.

3. 3D printing
The two 3D printers used for descriptive and illustration purposes are the Photocentric
LC Precision 1.5 DLP printer and the Formlabs Form 3B SLA printer. These have
small (121 × 68 × 160 mm) and medium (145 × 145 × 185 mm) size print platforms,
respectively. However, the details described here are generalisable to most SLA/DLP
printers used for dental purposes. These 3D printers differ from one another in terms
of:

a) The build platform size, especially its surface area, and consequently the maximum
number of models feasible per print cycle.
Print platforms may be categorised as small, medium or large. In general, a small
platform may allow relatively rapid printing of several ‘horizontal’ models, such as
retainer models for a debond case.
However, it can neither facilitate a large number of ‘flat’ models, even for slow
printing, or many vertically orientated models for a large batch print. Therefore, the
smaller the platform size then the greater the need to prepare ‘thin’ models (with little
base depth) if they are to be accommodated even at a vertical orientation. This
configuration may be workable for retainer / aligner models, but not for appliances
which need a ‘deep’ model to include the palatal vault, buccal (alveolar) areas or
mandibular lingual depth.

50
If an orthodontic practice / clinic needs more than four models printed per day, then a
medium size of print platform provides a practical solution. In addition, large but
more affordable dental-specific printers are justbecoming available, e.g., the
Photocentric LC Dental (310 × 174 × 200 mm) and the Formlabs 3L (335 × 200 ×
300 mm). These are certainly appropriate for dental laboratories but may also suit
large orthodontic practices with a high volume of retainer and aligner model
requirements.

b) Print resolution and speed.

The higher the resolution setting then the greater the level of detail and the smoother
the surface finish, since this entails a higher number of print layers on the vertical (z)
axis.
Resolution and speed are inter-dependent: the lower theresolution then the faster the
print. Overall, 100-μm layerthickness appears to be adequate for orthodontic
purpose,when compared to slower print times with resolutions of 25μm and 50 μm.
Print speed is also affected by the orientation of themodels on the build platform
(rather than the number ofmodels per se), such that models orientated parallel to
theplatform print relatively quickly, because the z axis (totalheight) is fairly low. In
contrast, vertically oriented models(where the horseshoe models are placed
perpendicular tothe platform in order to fit more models on it) will have aslower print
time because of the distance from the platformto the furthest model surface (typically
an incisor labial surface).
Print times for dental models, at 100-μm resolution,are commonly in therange of 1–10
hours, depending onhorizontal and vertical model set-ups, respectively. A shortprint
time is useful for same-day appliances such as retainers,after including the post-
processing and appliance fabricationtimes. Conversely, a 10-hour print (perhaps
runningovernight) is suitable for non-urgent printing of multiplemodels in a single
cycle.

c) The range of suitable printable resins.

It is worth noting that most printers are configured to only use their own brand of
plastic resins, rather than being open source, i.e. being able to print with any resin
material. One exception to this in the dental field is the newly released
Photocentric LC Dental.
At this time, it is difficult to predict whether open source printers will become more
common, so the range of available resins is currently as important a consideration for
most printers as the actual printer hardware.

d) Supports.
These are vertical struts and inter-connecting scaffolding bars that add structural
integrity to the model. They are particularly important when the model base is
irregular. Supports vary in terms of their shape,length, diameter and density (number
per millimetre square),so clinicians will find it much simpler to allow the softwareto

51
automatically add these. Individual supports may then beedited, especially if their
touch point is on a key tooth surface.
Interestingly, the position of supports (and the likelihoodof tooth surface contact)
changes with the verticalorientation of the model. When a model is relatively
parallelto the platform then it is unlikely that there will be touchpoints on the teeth. In
contrast, supports tend to connect totooth surfaces, especially incisors, when the
model is verticallyorientated. Consequently, the author prefers to tiltmodels by 20°–
70° to the platform if supports are required,depending on the number of models to be
accommodated.
In general, the greater the number of supports, then the more resin that is used and the
increased model finishing required. However, this does not necessarily require a
longer print time. Conversely, supports may make it easier to remove the models
(undamaged) from the platform immediately after printing. In effect, the model is
spared torsional forces as the supports break during separation from the platform
surface. Finally, it may be beneficial to quickly scroll through the virtual models
along the Z axis, layer by layer, to double check that there are no ‘floaters.’ These are
islands of unsupported plastic that may be lost as the model is printed (given that the
model is effectively produced upside down, suspended from the base). An extra
support may then be added at this point, or the tilt of the model adjusted (to make it
more parallel to the platform).

e) Ease of use.
This relates to both the user-friendliness of the printer software (in terms of model
preparation) and the physical aspects of handling the printer such as resin filling
andcleaning requirements. In particular, software manipulationof the models should
be as automated as possible in termsof their orientation (on the build platform) and
supportadditions.
Automation of the digital model ‘repair’ stage isalso very useful for as rapid a print
set-up as possible.
Finally, it is convenient if the printer software can be usedremotely, since this enables
the orthodontist to preparemodels for printing and start the print job, off-site.
As outlined already, the orientation of models on the buildplatform affects the
numbers of models that can be producedin one print run and the print speed. In theory,
models may beplaced ‘flat’ / horizontal on the platform, without supports,provided
they have a completely flat base. However, printfailures (due to high peel forces as
the individual print layersare formed) and potential difficulty in removing the
modelsfrom the platform (while they are still relatively weak beforefinal curing) mean
that horizontal models are not widely recommended.
Instead, most manufacturers recommend at least20° of model tilt (to orientate the
incisal edges furthest awayfrom the build platform). The model is then linked to
theplatform using supports.

52
4. Post-print processing
These vary according to the resin used, so the printer manufacturer’srecommendations
should be followed regardingthe following two finishing stages:

a) Model washing.
After printing, the models are typically washed for 10minutes in isopropyl alcohol
(IPA), with at least 95% concentration, to remove any uncured residual surfaceresin.
This is best achieved with the assistance of mechanical
agitation, i.e. using either an ultrasonic bath or aprinter-specific washer, to
continuously stir the IPA solution.
Notably, IPA is a volatile and flammable chemicalcompound, so washing in a closed
chamber and goodroom ventilation are recommended. The models shouldthen be air-
or blow-dried to remove any residual IPA.

b) Model curing.
The model surface would gradually harden in daylight.However, both for workflow
efficiency and to ensure fullmodel curing, it is best to expose the models to a
combinationof an ultraviolet light and heat (e.g. 60 °C). Many
printer manufacturers sell curing boxes that will reliably setthe model surface in 30
minutes. The models are then readyfor use and may be handled without gloves at this
stage.

5. Appliance fabrication
This stage replicates conventional techniques for productionof both orthodontic
retainers and aligners, where avacuum or pressure forming machine is used to form
thethermoplastic material around the model. Fortunately,3D-printed models are much
more robust than their plastercounterparts and may be easily stored and re-used if
necessary.
This is particularly helpful if a patient breaks or losesa retainer or aligner, since a
patient appointment and potentialdelay may be avoided. Even if the working model
isunavailable, a new one can be printed using the digital file,again without requiring
patient attendance.

53
Fig22:Computer illustrations of digital model manipulation within 3D printer
software. This small virtual platform can accommodate (a) two models at a relatively
low inclination to the platform surface or (b) four vertically orientated models (shown
with the supports added). (c) This medium size virtual platform is shown with 15
relatively vertical models, in order to maximise the number of models per print cycle
without supports. (d) Photograph of eight printed models, still on the build platform.
The multiple, interconnecting supports and their small circular bases are present, but
only several of the touch points are present on the palatal surfaces of incisors, as seen
in two models on the left-hand side. (e) A cross-sectional view of a virtual maxillary
model, obtained by scrolling through the build layers (the blue vertical line on the
right side is the scroll bar), where the software has highlighted a floating piece of
model with a red circle. This relates to the palatal surface of the maxillary left central
incisor, as identified by a red mark on the model surface view (f).

There is clearly great potential for 3D printing applications in clinical dentistry and
perhaps most obviously in orthodontics. While this involves a transition from
conventional methods to a fully digital workflow, especially in mastering
the software and different physical processes, there is no doubt that this technology is
here to stay and that it will evolve even further for orthodontic uses. Provided that the
correct preparation and printing steps are followed, 3Dprinting produces accurate and
robust dental models, without the mess and errors associated with conventional dental
impressions and plaster models.17
a typical STL file exported from

intra-oral scanner software. The external surface is shown in

54
APPLICATIONS OF 3-D PRINTING IN
ORTHODONTICS
The field of orthodontics has seen a rapid incorporation of 3D technology in recent
years. Intra-oral scanning, Cone Beam Computed Tomography (CBCT), 3D printing
and Computer Aided Design and Computer-Aided Manufacturing (CAD-CAM)
appliances have been at the forefront of this digital workflow revolution.

The ultimate goal of incorporating CAD/CAM technology into the field of

orthodontics can be best summed up as improving reproducibility, efficiency, and
quality of orthodontic treatment.

In addition to precise and customized milling of orthodontic appliances, the

application of 3D technology allows the practitioner and patient to utilize virtual
treatment planning software to better identify case objectives and visualize treatment
outcomes. Practitioners are able to compare different treatment plans, including
extraction versus non-extraction treatment options or substitution versus prosthetic
replacement in cases of missing teeth. The end result is improved communication
between the practitioner and patient, allowing for more realistic expectations of
treatment outcome and an increased degree of informed consent.

Clear Aligners

Clear aligner therapy involves a series of minor tooth movements achieved through
application of a corresponding series of individual aligners, which are changed in
sequence over the duration of treatment. Interestingly, the concept of applying a series
of positioners to accomplish major tooth movements through small sequential
movements was first proposed in 1945 by Dr. Harold Kesling, who concluded “at
present, this type of treatment does not seem to be practical…its practical application
might be developed in the future.” Indeed, Kesling’s prediction was realized with the
release of the Invisalign® system by Align Technology, Inc. in 1999, which leverages
digital scanning, computer-aided design, and additive manufacturing technology to
produce a series of aligners from a single impression. The Invisalign® system and
comparable clear aligner systems generally involve digital manipulation of a digital
impression of the dentition of the patient to develop a series of small sequential tooth
movements from the initial condition to the desired final outcome. Physical models of
the arches corresponding with each step then are fabricated via 3D printing. The series
of physical models support the fabrication of a corresponding series of clear aligners
through a thermoforming process and subsequent trimming. Given the prominent role
of 3D printing in the current workflow for clear aligner production, this article will
review the basic components of the workflow for aligner fabrication, highlight
considerations in the 3D printing of models to support fabrication of clear aligners,

55
and offer discussion of challenges and future directions in 3D printing applications in
clear aligner fabrication.8

Fig 23:Workflow for clear aligner fabrication harnessing digital and 3D printing
technologies.

TRADITIONAL WORKFLOW FOR CLEAR ALIGNER FABRICATION

Digital Image Acquisition

The modern workflow for clear aligner fabrication begins with acquisition of a digital
representation of the dental anatomy of the patient, using either a direct or an indirect
approach. Indirect workflows involve application of traditional impression materials,
such as alginate or vinyl polysiloxane, with standard techniques to register the patient
anatomy. Plaster models cast from the impressions enable acquisition of a digital
representation of the model surfaces through use of a variety of scanning technologies,
which currently include optical and computed tomography scanners. In some cases,
scanners and associated software allow generation of a digital model directly from a
scan of the impression, bypassing the need to cast a plaster model for scanning.
Alternatively, intraoral scanning devices facilitate digital registration of the patient
anatomy directly without taking a physical impression. Each pathway culminates in
the generation of a digital representation of the initial presentation of the patient
dentition that supports planning orthodontic tooth movement with clear aligners.

Treatment Planning and Model Manipulation

Various software platforms allow a clinician to plan a series of sequential tooth

movements from the initial positions to desired final positions in the treatment of the
patient. An early step in the digital planning involves segmentation to isolate the
crown of each tooth on the digital model. Some software platforms support
importation and overlay of data from computed tomography scans, if available, on the
intraoral scan data to provide visualization of the root structures when planning
treatment. The clinician then manipulates the positions of the teeth to desired

56
positions and plans sequential movements of the teeth within reasonable limits for
each stage. Some tooth movements warrant the use of auxiliaries such as attachments,
and many software platforms support the design and application of attachments in the
digital set-up. The digital workflow results in the development of a series of virtual
models with teeth in the planned positions associated with each stage, and the
software exports files corresponding to the arches at each virtually planned stage to
drive model production (usually in a standard tessellation language or .stl file format).

Model Production

The virtually planned tooth movements presently require generation of tangible

models to support fabrication of clear aligner appliances. A variety of computer-aided
manufacturing technologiesexists in the orthodontic space for production of physical
orthodontic models from digital design files and generally involves additive or
subtractive manufacturing approaches. Subtractive manufacturing technologies, such
as milling, apply computer-controlled tool bits to remove material selectively from a
starting block of material to realize the desired model. Alternatively, additive
manufacturing techniques, such as 3D printing, build a part layer-by-layer from a
precursor material. While orthodontic models produced by milling and 3D printing
support thermoforming of clear aligners for clinical application, 3D printing presently
stands as the dominant technology for orthodontic model production in clear aligner
therapy, due in part to the decreasing cost of 3D printers.

Aligner Fabrication

The final phase in clear aligner fabrication involves thermoforming aligners on the
physical copies of the digital models developed for each stage during the virtual
planning. Some clinicians prefer to outsource model production and/or aligner
fabrication to companies or orthodontic laboratories, while others engage in aligner
fabrication in-house. Each path applies a thermoforming process to conform a
polymeric film selected from a variety of available materials and thicknesses on the
contours of each physical model to generate each aligner. Once trimmed and polished,
the clinician delivers the aligners to the patient in the appropriate sequence. As
production of orthodontic models by 3D printing typically involves non-recyclable
materials now, production lines generally destroy or discard the models used to
support aligner fabrication. In some cases, clinicians deliver the final-stage models to
the patient for keeping, in the event they are needed in the future to make replacement
retainers. While increasing numbers of orthodontists embrace 3D printing
technologies in their offices, various factors and preferences influence when in-house
model production may be appropriate. For example, some orthodontists may fabricate
aligners for all of their clear aligner cases in-house, while others might prefer to apply
in-house production in limited movement cases that involve a lesser number of stages.
In all cases, a range of considerations in the 3D printing process influence the

57
efficiency of model production and the potential clinical utility of the models
produced. 8

3D PRINTING CONSIDERATIONS IN CLEAR ALIGNER FABRICATION

3D Printing Technologies

From the many 3D printing technologies available for manufacturing applications, the
dominant technologies currently marketed in the orthodontic space for model
production include stereolithograpy (SLA), digital light processing (DLP), PolyJet
photopolymerization (PJP), and fused deposition modeling (FDM). While the
technologies differ in terms of the details underlying part production, each ultimately
builds a part layer-by-layer from a precursor material. Accordingly, the 3D model
must be prepared for printing using software that slices the model into the various
layers to be printed in sequence to build the whole part. The fidelity of the printed
model depends on each step of the workflow, from acquisition of the digital model of
the patient anatomy to post-print processing of the printed part. The following
sections will focus on considerations associated with the 3D printing phase of the
workflow in clear aligner production and the potential impacts on workflow
efficiency and clinical utility of the fabricated appliances.

Model Design and Preparation for Printing

The preparation of a digital model for 3D printing involves a number of factors that
may influence the efficiency of the workflow and the dimensional fidelity of the
printed part. As previously mentioned, the model must be processed into a series of
slices to drive the building of the part layer-by-layer. The slice thicknesses must
correspond with print layer heights supported by the 3D printing technology to be
used, which can range from approximately 0.016 mm for PJP printers to 0.35 mm for
FDM printers. The layer heights can be selected from options available to the user
with some printing technologies, and the options available may depend on the
particular material to be printed. Print layer height selection influences the temporal
efficiency of the printing workflow, as decreasing the layer height increases the
number of layers and time required to print a given model. The print layer height also
affects the surface quality of the printed model, with smaller layer heights resulting in
smoother model surfaces. 8,19

58
Fig24:Palatal views of the incisors of 3D printed models showing increasing surface
smoothness with decreasing layer heights of 0.100 mm, 0.050 mm, and 0.025 mm.

Interestingly, the smaller layer heights might not always translate to greater
dimensional fidelity of the printed models, and the effect of print layer height on
model accuracy can differ across printers. Accordingly, selection of appropriate print
layer heights requires consideration of several factors, including the accuracy and
surface smoothness requirements of the model for clear aligner fabrication and the
workflow efficiency requirements of the practice.

Although 3D printers presently require selection of a single print layer height, future
development of printers capable of supporting multiple layer heights within a given
print may enable application of adaptive slicing approaches, in which larger layer
heights are applied to less important areas, such as the model base, and smaller layer
heights are applied to the critical areas of the model, such as the dentition, to balance
efficiency and dimensional fidelity.

Preparation of digital model files for printing also requires selection of an appropriate
part orientation with respect to the printer platform and design of supporting
structures, if needed, to enable realization of the virtual design. As 3D printers build
parts layer-by-layer, the part should be oriented such that regions of each layer
connect with the previously printed layer, otherwise unsupported regions may fail to
incorporate into the model.

Printer-specific software packages typically facilitate selection of a print orientation

and incorporation of supporting structures, if needed, in appropriate regions of the
part to assist printing. One should avoid inclusion of supporting structures in contact
with critical regions of the model, such as the dentition, as removal of the supports
may impart dimensional deviations in these regions.

Incorporation of supporting structures requires additional material in production of the

model and may require additional time in the printing and processing of the model.
However, some print orientations support production of a model of an appropriate
design without addition of supporting structures. For example, orthodontic models
may be oriented with the model base in contact with the build platform of the printer,

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such that the occlusal surfaces of the teeth are approximately parallel with the build
platform (i.e., “flat orientation”), or oriented with the occlusal surfaces approximately
perpendicular to the platform and the posterior region of the model in contact with the
platform (i.e., “perpendicular orientation”).

Fig 25:Examples of model orientations with respect to the build platform for 3D
printing, with an occlusal plane approximately parallel with the build platform
(“flat”), an occlusal plane approximately perpendicular to the build platform
(“perpendicular”), and offset at a 20-degree angle with inclusion of supporting
structures to facilitate printing (“20 degrees”).

Depending upon the model design and the anatomy present on the particular model,
the flat and perpendicular orientations commonly support printing of models without
inclusion of supporting structures, as the model supports itself.

A recent study demonstrated that the orientation of the model during printing can
affect the dimensional accuracy of the model, with perpendicularly oriented models
under the conditions investigated demonstrating underbuilding of the facial surfaces
of anterior dentition and underbuilding of distal surfaces of the most posterior
dentition, which might be associated with print error propagation and unsupported
model regions, respectively. The selected model orientation affects the efficiency of
the printing workflow, as flat models will require fewer print layers than the same
models with a perpendicular orientation (and in turn less time), but more models can
be accommodated on a build platform at a time with a perpendicular orientation
relative to a flat orientation. Print layout describes the arrangement of models on the
build platform for printing, and the layout can affect the efficiency of the workflow
with some printing technologies. For example, SLA and PJP printers involve
movement of physical parts and/or scanning of a polymerization-initiating light
source in the printing of each layer.

The travel time of the moving parts across the platform often depends upon the layout
of the parts for the print job, which can affect the total time required for printing.
Aspects of the design of the model can also be tuned to influence the efficiency of the
3D printing workflow. For instance, the base of the model to be used in clear aligner

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fabrication can be trimmed digitally to a “horseshoe” shape corresponding with the
alveolar arch to reduce the amount of material and time required to print the model.
Although the efficiency of the printing workflow may be increased with the use of a
horseshoe base design, transverse dimensional deviations at the posterior region of
such models were reported in some cases, which may be reduced through
incorporation of a transverse bar for stability in the region. Hollowing of the interior
of models presents an additional design approach to reduce the material and time
required for model production. Specifically, the model can be manipulated digitally to
produce a hollow shell-like structure, minimizing the material in the interior of the
model while maintaining the shape and dimensions of the model surface.
However, the effect of hollowing on the dimensional accuracy of the printed models
remains to be investigated.

Fig 26:Digital orthodontic model illustrating “hollowing” or digital removal of

structure from the base of the model prior to 3D printing to increase workflow
efficiency.

Although hollowing can increase operational efficiency in printing models, it is

essential that the printed model present sufficient structural stability to support
fabrication of a clear aligner via thermoforming without deformation that might have
an impact on the fit and clinical utility of the aligner.
The material applied in 3D printed model production must also be considered in the
workflow for clear aligner fabrication. Currently, orthodontic model production by 3D
printing generally involves acrylic resins, although alterative materials such as
ceramics and composites have been used. The optimal printing parameters for a given
material typically require the use of specific printers capable of achieving those
conditions, so the material selected must be compatible with the format, make, and
model of the 3D printer to be used. Otherwise, the anticipated physical properties,
such as mechanical strength, of the printed material might not be achieved. Clear
aligner fabrication requires that the 3D printed models present sufficient mechanical

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strength, structural integrity, and thermal stability to support thermoforming of the
aligner without deforming beyond clinically acceptable tolerances. Additionally,
potential effects of the materials themselves on patients and personnel should be
considered, as residual resin monomer might present toxicity to patients if transferred
with the appliance, and patients and personnel may develop allergies to acrylics with
exposure.18,20

Post-print Processing

Workflows for 3D printed model production typically involve post-print processing

steps before application of the model in thermoforming of clear aligners. For instance,
models printed using SLA and DLP printers generally require washing in a solvent
such as isopropyl alcohol to remove excess resin followed by drying in air to allow
residual solvent to evaporate from the model surface. The parts then generally
undergo post-print exposure to ultraviolet light and/or heat under controlled
conditions to facilitate continued polymerization of the resin, which may be necessary
to achieve optimal physical properties of the model. Post-print processing also may be
warranted for some ceramic-based models, as post-print processing in the form of
heat exposure was found to improve significantly the compressive mechanical
properties of 3D printed calcium sulfate-based models. The post-print processing of
3D printed models involves additional materials, personnel time, and the associated
costs, which collectively affect the operational efficiency of the workflow and should
be considered. Post-print processing may also affect the dimensional accuracy of the
printed model under certain conditions. Some studies suggest that polymerization
shrinkage associated with the 3D printing and post-print curing of resin models can
contribute to negative deviation of the model relative to the digital design file.
Additionally, insufficient removal of residual resin prior to post-print curing may
result in incorporation of excess material into the part, especially in areas where it
may tend to settle, such as central grooves, gingival margins, and interproximal
spaces, which may manifest as a positive deviation of the part in these regions.
Similarly, insufficient evaporation of solvent from the models prior to post-print
curing could result in solvent swelling artifacts at the model surface.

Dimensional Accuracy of 3D Printed Models

Clear aligner fabrication demands suitable dimensional accuracy of the 3D printed

orthodontic model on which the aligner is thermoformed to enable appropriate fit and
clinical utility. The dimensional fidelity of 3D printed models has been a popular
subject of investigation in the literature in recent years, with many studies concluding
that 3D printed models are acceptable alternatives to plaster models for orthodontic
applications. However, some studies suggest that 3D printed models are not
acceptable under the conditions investigated. The differences in the findings among
the articles tend to reflect differences in the conditions and workflows applied in the
studies. Indeed, comparison of the results from various studies requires consideration

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of the workflow applied and the potential contributions of error within the individual
steps to the overall error observed.

Recognizing the influence of workflow on model production, some studies have

investigated the dimensional fidelity of 3D printed models derived from different
workflows. One study assessed the accuracy and reproducibility of linear measures
taken on typodonts, plaster duplicates made from alginate impressions of the
typodonts, digital models obtained from a laboratory scan of the typodonts, and 3D
printed duplicates. The authors reported no statistically significant differences in the
measures between the various models, indicating an equivalence of the plaster, digital,
and 3D printed models. 3D printed models produced from intraoral scans of 28
volunteers were compared to plaster models derived from alginate impressions of the
same volunteers in another study. The study found statistically significantly smaller
intermolar distances on the 3D printed models, which the authors attributed to
potential polymerization shrinkage of the horseshoe shaped model design applied.

The study concluded that the 3D printed models were not acceptable for diagnosis and
treatment planning, and that the dimensional differences likely would have negative
implications for fabrication of clear aligners and retainers. A different study compared
linear transverse measurements between plaster models from alginate impressions and
3D printed models from intraoral scans of 40 patients, reporting statistically
significant differences between plaster and 3D printed models.

While the 3D printed models were found to be smaller than the plaster models in the
intercanine and intermolar measures, the authors deemed the differences to not be
clinically significant. Wesemann et al. also investigated indirect and direct
digitalization workflows for 3D printed model production, and recommended a
traditional workflow involving conventional impressions, cast plaster models, and
desktop scans of the plaster to generate digital models for orthodontic applications.
However, the authors suggested that intraoral scanners are acceptable for use in
workflows for manufacturing orthodontic appliances.

Just as the method with which a digital model is obtained can influence the outcomes
of the 3D printing workflow, the type of 3D printer used for model production can
also affect the outcomes. Several studies have investigated application of various 3D
printers in orthodontic model production.

A report by Hazeveld et al. applied DLP, PJP, and powder-based printers in

duplicating models from patients with various malocclusions and evaluated
differences in linear measures of crown height and width for each tooth. The authors
concluded that the models reproduced by each technology were clinically acceptable
for select applications in orthodontics that involve interpretation of the models, such

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as plaster models produced using a PJP printer and a FDM printer, concluding that
models from both printers investigated could potentially replace plaster casts.

Another study compared SLA and PJP printers in reproducing models from 2 cases
using digital superimposition analysis techniques. While statistically significant
differences were found between the 2 technologies, the authors concluded that both
likely are suitable for diagnosis and treatment planning. However, the article did not
discuss potential suitability of the models for appliance fabrication. Favero et al.
compared models produced on various SLA, DLP, and PJP printers marked for
orthodontic applications, finding statistically significant differences in overall
dimensional accuracy between printers. The authors concluded that the requirements
of the envisioned application of the models to be printed should guide selection of the
appropriate printer. Models from DLP and PJP printers were compared in a study by
Brown et al., in which it was concluded that models from both printers were clinically
acceptable.

Zhang et al. compared 3 DLP printers and 2 SLA printers, finding higher accuracy in
DLP prints of models at 0.100 mm layer heights compared to SLA prints at the same
layer height. The authors offered that the accuracy requirements of models depend
upon the envisioned application.

A study by Kim et al. evaluated dental models manufactured with SLA, DLP, fused
filament fabrication (FFF), and PJP, finding PJP and DLP outperformed FFF and
SLA in terms of precision, with PJP presenting the highest accuracy. Overall, findings
vary with the printers applied in the studies, and differences in the applied methods
limit comparisons that can be made between studies.

As the literature reflects, evaluation of the dimensional fidelity of 3D printed models

can involve a multitude of measures and outcomes. Some studies evaluate accuracy of
3D printed models in terms of “trueness” and “precision,” where trueness reflects the
closeness of a measured value from a model to a reference value and precision reflects
the closeness of measurements of a particular quantity of interest across repeatedly
printed models. A variety of linear measurements have been applied in studies of the
dimensional fidelity of 3D printed models, and they typically include measurements
of landmarks in the x-plane (e.g., intercanine distance), y-plane (e.g., molar-to-molar
distances on the same side of the arch), and z-plane (e.g., crown height).
Discrepancies in measures in the z-plane, particularly in crown height, were reported
in several studies, with 3D printed models presenting significantly smaller measures
than the reference models.

Many studies applied linear measurements made with digital calipers on physical
models and/or virtual calipers on digital models. Difficulty in landmark identification
presents a common limitation discussed in studies applying linear measures with
physical calipers on 3D printed models. Some studies report that a reduction in

64
surface detail on 3D printed models contributes to the difficulty in identifying
landmarks. A study characterizing the surfaces of 3D printed models by scanning
electron microscopy, profilometry, and stereomicroscopy noted that the surfaces of
models from an SLA printer were smoother than those of plaster models, which has
been suggested to contribute to difficulty in positioning calipers correctly on the
surfaces of acrylic models.

Accordingly, some studies incorporated reference markers on the models to facilitate

measurements, but inclusion of markers on dentally relevant landmarks may alter the
anatomy in those regions and have implications on the printing associated with those
areas of the model. The anatomy present on the model can also affect linear measures
taken on the models, especially in cases of crowding, where the crowding may
sterically interfere with positioning of the calipers or other measurement tools.
Crowding may also hinder accurate scanning of the associated dentition, and the
anatomy of the crowded teeth may lead to loss of detail in the crowded region of a
printed model. Studies comparing linear measures taken from 3D printed models with
corresponding measures taken on digital models note that the digital nature of the
linear measurements in software and manipulation of the digital model (e.g.,
magnifying regions of interest) can contribute to differences observed between the
two modalities.

Other studies have applied computer-controlled coordinate measuring instruments

with associated software to determine differences in measurements of landmarks on
3D printed models with respect to a reference model to minimize operator error.
While linear measures can provide insight into the dimensional fidelity of 3D printed
models, the complexity of the dental anatomy and the arch form required for clear
aligner therapy might not be evaluated adequately with linear measures alone. Some
argue that arch dimension measures must also be evaluated for 3D printed models
envisioned to support fabrication of clear aligners and other appliances to ensure
suitability of fit. Other studies have applied 3D dimensional analysis methods to
quantify dimensional deviations between the surfaces of 3D printed models and the
corresponding reference models.
Many of these studies applied metrology software to superimpose digitally the
reference model (e.g., the digital model file used as the input for 3D printing) and a
surface scan of the 3D printed model, followed by quantification of the dimensional
deviations between the models across the region of interest. The digital 3D
comparison software often enables visualization of the regions of the model
presenting deviations and the relative magnitudes and directions of the deviations.

65
Fig 27:Illustration of 3D comparison data from digital superimposition of a scan of a
3D printed model (Printed STL) and the digital file used as the input for printing
(Master STL). Colors represent different magnitudes and directions of dimensional
deviation across the model, as depicted in the cross-sectional view and associated
inset.

Accordingly, the 3D analysis methods reflect the complexity of the anatomy of the
dentition and present greater relevance in the evaluation of the overall dimensional
accuracy of 3D printed models for clear aligner fabrication applications than linear
measures alone.
While many studies have reported statistically significant differences in linear and/or
3D comparison measurements between 3D printed and reference models, the
differences should be considered in the context of the requirements of the envisioned
clinical application.
Specifically, statistically significant differences may not necessarily be clinically
significant. A range of clinical tolerance values has been discussed in the literature in
the evaluation of 3D printed orthodontic models, with many studies applying
tolerances in a range of 0.10 mm to 0.50 mm for the purposes of study model
production. However, numerous studies underscore the importance of consideration
of the envisioned application of the model in determining appropriate tolerances for
clinical acceptability. While evidence-based tolerances for 3D printed models for
clear aligner fabrication remain to be developed, several values have been applied in
the literature in this context.

For example, Zhang et al. proposed use of a tolerance of less than 0.05 mm for
models to be used in clear aligner fabrication, while Kim et al. suggested that the
deviations must be less than 0.25 to 0.3 mm for an aligner fabricated on the model to
exert an orthodontic force.
66
 Alternatively, Wesemann et al. proposed that deviation requirements for orthodontic
applications could be described in grades, with deviations less than 0.03 mm being
“excellent,” less than 0.14 mm being “very good,” less than 0.25 mm being
“acceptable,” and more than 0.25 mm being “unacceptable”.

In addition to consideration of the magnitude of dimensional deviations on a 3D

printed model, the locations at which deviations occur also should be considered.
One study suggested that loss of detail observed on the incisal edges and cusp tips on
some 3D printed models may affect the seating of an appliance, such as a clear aligner,
on the occlusal surface, while another study suggested that loss of detail at the
cervical margins, fissures, fossae, and cusp tips might not be critical for production of
appliances.8,21

FUTURE DIRECTIONS IN CLEAR ALIGNER FABRICATION

Technological advances enabled a paradigm shift in orthodontics by making the

workflow for production of Kesling-style tooth positioning appliances practical. The
next paradigm shift in clear aligner therapy will likely involve 3D printing of the
aligners directly from digital designs.

Fig28:Photograph of a clear aligner fabricated directly via 3D printing in a resin

cleared for intraoral use for production of occlusal splints. The aligner was designed
digitally to fit a scan of a typodont and is shown after removal of the supporting
structures.

Direct printing of aligners would bypass the model printing and thermoforming steps
of the current workflow, considerably increasing the efficiency and decreasing the
environmental impacts of clear aligner production.

Recent literature suggests the feasibility of aspects of the workflow, as demonstrated

in experimental fabrication of retainers directly by 3D printing. Direct printing of
clear aligners could enable new horizons in clear aligner mechanics, by enabling

67
spatial control of aligner properties, such as thickness, which is not feasible with
current thermoforming methods. Existing software tools could be applied toward
design and fabrication of clear aligners directly by 3D printing, but the development
of specialized software tools would be warranted to expand capabilities and to
simplify workflows. Even with appropriate software tools, aspects of the design of the
appliance, such as the appropriate offset from the surface of the dentition, will need to
be investigated.

The major barrier on the pathway to directly printing aligners is the unavailability of a
material suitable for the application at present. Although the number of 3D printable
resins cleared for intraoral use on the market in the United States continues to increase,
none known presently satisfies the requirements for clear aligner fabrication.

Among a variety of material design requirements for the application, a resin for
printing clear aligners directly must be compatible with 3D printing, esthetic, durable,
stable, biocompatible, cost-effective, and present appropriate mechanical properties.
While development of a material that satisfies these requirements is not a trivial
pursuit, reports suggest that a material for clear aligner production will be available in
the near future. Even with a suitable material for the application, the clinical utility of
3D printed aligners will depend upon realization of the digitally designed part
dimensions. Tunable aspects of the 3D printing workflow have been shown to affect
the dimensional accuracy of 3D printed orthodontic models, and these findings will
likely translate to the fabrication of clear aligners by 3D printing.

However, the complexity of the aligner design, comprising a thin shell-like structure,
and the transparency of the material present additional challenges for 3D printing.
For instance, over-penetration of initiating light while 3D printing small patent
features in clear materials can present a challenge and may require inclusion of
biocompatible photoquenchers. Additionally, analysis of the dimensional accuracy of
3D printed clear aligners will present challenges, as optical scanning of clear
materials typically requires application of a spray or powder to facilitate scanning and
may affect the measurements. Ultimately, the fit of 3D printed aligners will need to be
assessed, and few methods for quantification of the fit of clear aligners have been
reported. Moreover, tolerances for the clinical acceptability of 3D printed clear
aligners remain to be developed. Considering the many challenges, direct fabrication
of clear aligners does not appear to be practical presently, but continued advances in
3D printing and other technologies may soon enable the next paradigm shift in clear
aligner therapy.

Many factors can affect the clinical utility of 3D printed orthodontic models for clear
aligner fabrication and the efficiency of the workflow associated with their production.
Emerging technologies may enable fabrication of clear aligners directly via 3D
printing in the future. In either case, research and the requirements associated with

68
clear aligner therapy should inform evidence-based selection of appropriate 3D
printing factors and workflows in clear aligner fabrication.8

Customized Brackets

One of the most comprehensive CAD/CAM orthodontic appliances on the market is

Ormco®’s Insignia™, which was available in standard and self-ligating applications
with optional use of esthetic ceramic brackets. The process begins with an intraoral
scan of the patient’s dentition.

A virtual buccal-lingual boundary is constructed from the soft tissue outline of the
intraoral scan. Recently, the Insignia software has added integrated roots segmented
from CBCT or virtual added from a digital library.The technicians then complete a
virtual setup for ideal archform and occlusion that is sent to the clinician for approval.

The software allows the clinician to manipulate the digital setup to refine the 3-
dimensional position of individual teeth, adjust the archform, alter the smile arc when
needed, and detail the dental contacts in final centric occlusion.Once the clinician
approves the treatment plan and virtual setup, the Insignia system is reverse-
engineered in one of several ways depending on the clinician’s choice of bracket.22

If metal twin brackets are selected then they are individualized by precision-cutting
the slots in the milled-in faces, while metal self-ligating brackets are customized by
varying the thickness and angulations of the bracket base.The selection of ceramic
twin or self-ligating brackets limits the amount of customization that can be achieved;
however, stock brackets that most closely match the torque prescriptions in the
Insignia Approver software are selected and a custom based pad is laser welded to the
brackets. Further adjustments to the positioning jigs and archwires allow for a high
degree ofindividualization.

Fig 29:The custom base and connector; it is the custom connector that provides most
of the prescription used to align the dentition.

69
Custom wires are also included in the system. The size and dimension of the virtual
archform is precisely milled into metal plates and nickel titanium, stainless steel or
beta-titanium wires are fabricated from these plates.

The next step of the Insignia system is precisely delivering the customized brackets in
the ideal position on each tooth to maximize the effectiveness of the individualized
appliance. Bracket transfer jigs are custom milled to fit the occlusal surfaces of the
teeth, allowing for indirect placement of the appliances.23

Fig30:The complete set of custom bases and connectors are shown in this figure.
Each of these custom bases have a connector with a unique shape that mimics the
shape of the slot and wing component to facilitate accurate laser welding.

This step is crucial to the success of the system since imprecise bonding of brackets
will not allow the custom straight wire to produce the planned tooth movement.23

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Fig 31:The complete set of Chrome Cobalt custom printed brackets are shown in this
figure along with the custom wire hand bent from a 2D 1:1 printed wire card.

Fig32:This figure shows the custom indirect transfer tray fabricated for our example
custom lingual appliance system on the left and an indirect transfer tray used with the
Incognito lingual appliance system offered by 3M Unitek on the right.

Customized Wires

Historically, the majority of product development in the field of customized

appliances was focused on brackets with customized tip and torque. OraMetrix® has
taken a unique approach to CAD/CAM orthodontics and focused on the wires instead.

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Like other CAD/CAM orthodontic systems, OraMetrix®’s SureSmile™ provides
digital software that the clinician can utilize for diagnosing and treatment planning but
it is the fabrication of robotically bent archwires which makes SureSmile unique from
other customized appliances.

Since the technology is based on fabrication precision archwires of varying

dimensions, the system can be used with any conventional orthodontic brackets with
no special consideration during the delivery of the appliances. The process begins
with a scan of the patient’s dentition using an intraoral scanner or cone-beam
computed tomography (CBCT). 22

This can be done by the following procedure:

1) Before the bonding appointment, in which case a customized indirect bonding tray
(Elemetrix IDB) can be ordered or

2) After brackets have been bonded.

Fig33:The three main types of wire forms are shown above: straight, mushroom, and
individual. The straight wire form is convenient with respect to sliding mechanics;
however, it will result in brackets with a larger profile to account for the first order
compensations. The mushroom arch form reduces the required first order
compensation in the area of the canines and still allows for some sliding mechanism
the anterior and posterior. The individual wire conformation leads to bracket slots
that are as close as possible to the lingual surface of the tooth, but is less convenient
with respect to space appropriation and space closure.

The data from the intraloral scan is used to construct a digital model of the patient’s
dentition. A 3D bracket library with the precise manufacturer’s dimensions for each
bracket is superimposed over the scanned brackets to allow higher precision of slot
dimension.The teeth can then be moved to their desired final position. Linear, angular

72
measurements can be made from the software including a Bolton analysis and arch
length discrepancy. Once the clinician approves the digital dental setup, the software
calculates the archwire bends needed to create the final dental setup using the precise
location of the bracket slot on each individual tooth. Wire-bending robots fabricate
the custom alignment and/or finishing archwires in the material and cross-section
specified by the orthodontists.24

Fig34:A digital bracket slot and wings are digitally suspended on the “wire”. The
wire, bracket slot, and wings are “tools” used to create the custom bracket bases and
connector.

There are two approaches to use SureSmile in clinical practice. One approach is to it
as a comprehensive system and order Indirect bonding tray with the aligning and
finishing wires. Alternatively, the clinician can start standard nickel titanium aligning
wires. After alignment stage is completed, scans are taken and customized finishing
wires are ordered to refine and detail the case. A useful application for the SureSmile
wires is for limited objective cases in which only specific teeth, such as incisors are
planned for movement. The customize wires can be designed to be passive in the
posterior segment where the occlusion is ideal and active in the anterior segment
where the alignment is desired.25

3-D printed retainers

Ahmed A. Nasef reported a procedure for using 3-dimensional cone-beam computed

tomography imaging, computer-aided design, computer-aided manufacturing, and
rapid prototyping to design and produce a retainer.
The procedure starts with obtaining the digital replica of the patient's teeth. After
debonding, the patient's dentition is scanned using CBCT. The area of interest
(maxilla or mandible) is centralized in the machine's focal trough. The CBCT data are
exported in a DICOM format. The DICOM images are imported into the software
(Invivo Dental; Anatomage, San Jose CA)10

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Fig35:Three-dimensional volumes with the maxillary and mandibular arches
separated.

The DICOM data are then used to generate a 3D model of the skull. The threshold
desired is one that maximizes the visualization of the dentition while eliminating the
soft tissue and any noise artifacts. Then the region of interest (maxillary or
mandibular dentition) is cropped out of the whole 3D Skull.

Fig 36:Separated maxillary arches: A, frontal view; B, occlusal view.

This is facilitated by the intermaxillary separation done during scanning. The 3D

model for the area of interest is then exported as a .stl format file, which is late
converted to .obj format.

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The data in .obj format are opened via another 3D handling software, ZBrush. In
ZBrush, the retopology concept isapplied. Retopology is creating or modifying a new
objecton the surface of another object that accurately conformsto the old object. The
ZSphere tool is used to create a base mesh with clean topology. 26
TheZSphere starts out with a simple sphere that one canextract from until obtaining
the basic shape of the modelto be sculpted on. The topology (surface contour) of
thedentition is drawn via selection of points contoured tothe surface of the teeth.
The points are placedon the teeth intended for the future retainer and accordingto the
desired extensions needed to avoid soft-tissueimpingement of the future retainer.
These points are connected to each other forming polygons.
An important criterion while placing the points is to preserve the symmetric geometry
that allows creating a uniform mesh. The more symmetric and uniform (rectangular or
square) the polygons are, the better the topology that is created, and the more uniform
and accurate the mesh will be. No triangles or unsymmetrical polygons should be
drawn.26

Fig 37:Topology points: A, extended as desired; B and C, connected points forming a

uniform network that will later form the mesh (foundation) of the virtual retainer.

This topology forms the mesh or framework, which is the foundation of the future
virtual retainer. The virtual retainer is checked for extensions and uniformity; then an
adaptive skin is created.

Fig 38:A and B, Completed mesh; C, adaptive skin on the teeth.

The current data ofthe virtual retainer are exported as an.obj format backagain to the
3ds Max software, where it isgiven a customthickness. The thickness chosen hereby is
0.7mm.In this instance, the virtual retainer could be exported asan .stl file.

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Fig 39:Virtual retainer when it is given thickness. The finished digital
retainer . before being sent to 3D printer.

The .stl file is sent to the 3D printer rapid prototyping

machine (Formiga P100; EOS, Munich, Germany). This 3D printer is a selective laser
sintering machine.
The material used is called Fine Polyamide PA 2200 (EOS). It is white and feels
powdery to the touch. The material melts at 80˚C and consists of spherical powder
that has an average grain size of 60 mm.
An advantage of this 3D printer is the simple and quick removal of the support
material compared with other processes. For delicate parts, compressed air is used to
blow away the powder. The laser requires some time to warm up. After the retainer is
fabricated, it is simply taken out and checked that the smooth surfaces conform to the
teeth with the extensions as designed on the 3D software.10

Fig 40:Three-dimensional printed retainer.

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After the retainer is fabricated, it can be checked on
the patient's physical dental model and finally in the patient'smouth. It should have
smooth surfaces that conform to the teeth and the desired extensions as designed on
the 3D software. The retainer's edges and corners should be away from the patient's
soft tissue, with no sharp edges.26

3D-Printed Orthodontic Auxiliaries

The 3D printing process starts with a digital scan of either the dental arches or the
working casts, using an intraoral scanner or a 3D model scanner.

An auxiliary is designed with a modeling software which slices the digital model into
thousands of virtual layers and translates the data into a numerical-control
programming language called G-code.

The specifications are then sent to a stereolithographic (SLA) or fused deposition

modeling (FDM) printer, which forms the auxiliary layer by layer from a plastic
filament or resin material.27

Fig 41:Digitization of working cast using 3D model scanner.

1) Retraction Hooks

The customized retraction hook consists of a 1.5mm tube with an attached hook, 6mm
long and 1.5mm thick at its curve. This hook is designed to withstand a maximum
350g of force.

A rectangular stainless steel archwire is inserted through the tube before being
engaged in the brackets. In the case shown here, the retraction hook was positioned
between the lateral incisor and canine brackets. To place the hook exactly in the
middle of the interbracket span, a rigid spacer can be crimped distal to the hook.

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Commercially available crimpable hooks are less esthetic; moreover, if the crimping
is insufficient to hold the hook in place, it must be welded or soldered to the archwire
at the chair.

The 3Dprinted hook causes no patient discomfort and is held snugly by the fit of the
rectangular archwire in the tube. It is sturdy enough to withstand retraction, with the
distal end of the tube acting as a stop to the distally directed forces.27

Fig
42:A. Design of customized retraction hook for fabrication with SLA printer. B.
Placement of retraction hook on .019" × .025" stainless steel archwire.

2) Bite Turbos

Customized bite turbos can be fabricated with a 3D printer for patients with severe
deep bites.

After the palatal surfaces of the upper anterior teeth are scanned, the bonding bases of
the bite turbos are designed to match the palatal contours. In this example, a 5mm ×
5mm bite ramp was built to contact the lower incisors at an angle of 90°; the ramp
dimensions can be increased in cases with palatally impinging, retropositioned
mandibular incisors.

The 3D-printed bite turbos will conform precisely to the palatal surfaces of the
maxillary anterior teeth. Each turbo has enough bond strength to withstand the forces
of occlusion.27

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Fig 43:A. Deep-bite patient requiring bite turbos before bonding of fixed appliances.
B. Bite turbos customized to palatal surfaces of upper central incisors on scanned
model. C. Retentive grooves designed on bite turbo’s bonding surface. D. FDM-
printed† bite turbos. E. Patient after bonding of bite turbos.

3) Lingual Bonded Retainer

A bondable retainer strip can be digitally designed to match the lingual contours of
the anterior teeth after orthodontic treatment. The retainer strip shown here was
printed 1.5mm-2mm thick, with 4mm × 4mm bonding pads. In an extraction case,
extensions can be added to incorporate the occlusal or lingual surfaces of the
premolars.

Bonding pads for each tooth facilitate easy and efficient bonding, although the
flowable composite should be carefully applied so that the adhesive does not spread
between the teeth or to the other surfaces of the retainer.

Commercially available prefabricated lingual retainers require accurate size selection

and wire bending for proper adaptation before bonding. Digitally printed, metal-free
retainers eliminate the need to make complex wire bends to achieve a precise fit.27

Fig 44: A. Bondable retainer strip designed on digitized model. B. Retentive grooves
on bonding-pad surfaces. C. Bonded retainer strip in place.

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 4) Aligner Attachments

Modeling software can be used to design bondable ramps, bumps, and buttons as
adjuncts to clear-aligner therapy. An SLA printer was used to print the attachments
shown here, with dimensions ranging from 3mm × 4mm × 1mm to 5mm × 1.5mm ×
1mm. TThe 3D-printed attachments are more easily and reliably debonded than
composite attachments, and they eliminate the need for excess flash removal.
Companies that supply the aligner trays can also provide templates for SLA-printed
attachments, thus improving the accuracy of clear aligner treatment.27

Fig 45: A. Scanned model with digital attachments designed for various facial
surfaces of teeth during clear aligner treatment. B. Bondable aligner attachments
fabricated from clear resin using SLA printer. C. Mock-up of bonded attachments
used to check accuracy. D. Patient after bonding of attachments and placement of
clear aligner.

5) power arm

The power-arm is a miniature device, which may have various designs dependingon
the place of bonding, which can be either tooth surface or the orthodontic wire.

The orthodontic power-arm intended for the tooth surface has a part with a
bondingsurface for attachment to a tooth. This part is called a base, which could be
either prefabricated(slightly curved) or individualized (exactly matching a particular
tooth surface).The base is intended for a vestibular or lingual tooth surface.

An arm of the power-armextends gingivally and is intended for engaging a tractive

device (usually elastic bands).The length of the arm is different depending on the
distance between the place bondedand the center of resistance of that particular tooth.

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It also provides a leverage to a forcevector applied to the end of the power-arm,
enabling the preferably orthodontic bodilytooth-movement.

After bonding, it must by resilient, aesthetic, and compliant with intraoralanatomy,

providing an anchorage for intraoral elastics to control the application of
thebiomechanical force vector on the tooth.

Fig 46: Power arm design

To create an individual base in a power-arm, any free, simple modeling software

canbe used, as this process does not require a special 3D modeling skillset.

1. First step is to import intraoral scan, usually in STL format, and also a universal 3D
model of power-arm (variant I (Figure 8) or II) with generic base;
2. Second step is to position the power-arm as clinical aspects require, with respect to
patient oral anatomy;
3. Third step is to apply Boolean Difference subtraction of tooth shape from the
generic
base of the power-arm. This results in individual base of the power-arm, that shall be
finally exported as STL and 3D printed using clear resin or metal.4

Fig 47: (A) on vestibular fixed appliance, (B) with clear aligner therapy, (C) first 3D
printed power-arm.

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3D Printed Surgical Guides

The surgical guides help the surgeon to insert the implants, they are also reliable, safe
and when used, the surgery is minimally invasive, giving the patient a better after
surgery recovery experience. Being autoclavable and biocompatible, the resin used in
3D printed surgical guides helps the practician and to fulfill a wide range of needs.

The template for the surgical guide can be made either using a customized
conventional treatment surgical method or a computer generated one. For achieving
stability of the surgical guide during implant placement, retention criteria has to be
reached.

This way, they provide enough accuracy for placing the implants as previously
established on the digital setup with no damage to the surrounding anatomical
landmarks, this way increasing the success rate of the miniscrews.

Careful assessment is done before setting up the implants for excluding the possibility
of dental complications.

Fig 48: Palatal

implant digital planning - transversal and axial view

After the radiographic setup of the miniscrew placement, a visualization on the 3D

digital model is needed for selecting the positions of the guiding cylinders.

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Fig 49: Adaptation of model with the CBCT. Final implant position on digital cast.

Fig50: Digital setup of surgical guiding cylinders on virtual model.Final position and
3D representation of the surgical guiding cylinders.

Once the lab setup is accepted by the orthodontist, a 3D printed model and surgical
guide are manufactured. On the printed cast, the hybrid expander will be printed.

After receiving the appliance on the printed guide, the screws are removed using the
finger screwdriver. Once the appliance is being checked in the patients’ mouth, the
surgical guide is inserted and checked too. If the surgical guide does not fit perfectly,
it can be corrected using occlusal spray.

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 Under local anesthesia, if there is a need for drilling, this procedure will precede the
miniimplant placement and will be planned during the digital setup using the drilling
sleeve inserted in the surgical guide.

Only one sleeve will be inserted at a time both for the drilling and for the insertion
stages. Afterwards, the miniimplants are placed using the guiding cap inserted in the
cap remover.

The miniimplant is attached to the guiding cap and the rubber from the cap remover is
removed. The miniscrew along with the guiding cap and the screwholder are inserted
in the counterangle and throught the miniimplant guiding sleeve that is inserted in the
surgical guide, the TAD (temporary anchorage device) is inserted.

When the wider part of the screwholder reached the guiding sleeve, the miniimplant
is totally inserted. After insertion of miniimplants, the appliance is settled in place,
first fixing screws on the miniimplants and afterwards light curing the cement from
the bands.28

Fig51: Hybrid maxillary expander attached to

the printed cast.

Diagnostic and working orthodontic models

3D printing technology may be used in orthodontics to manufacture models of

patients’ dentition. Increasing popularity and growing application of intra- and
extraoral scanners and digital dental models, contributes to a significant decrease in a
need to acquire alginate impressions and casting plaster models, thereby allowing
avoiding drawbacks of conventional orthodontic models. Digital models may be used
for orthodontic diagnostic purposes.

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Diagnostic measurements performed on digital models represent high validity,
reliability, and reproducibility, and thus may be regarded as an equal alternative to
conventional plaster models. Although in cases, in which manufacturing of
orthodontic appliances is planned, a physical model of patient’s dentition is
required.29

3D printing enables to transform digital, virtual dental model of patient’s dentition

into a physical model, omitting certain steps, which are conventionally required,
including impression taking and model casting. Moreover, rapid prototyping
technology allows to manufacture many identical copies of a digital model without
any risk of distortion or deformation, being available at any time.

Printed models have been reported and may be used to manufacture removable
orthodontic appliances, expansion appliances, indirect bonding trays, or
thermoformable orthodontic aligners. 10

Removable Orthodontic Appliances

First trials to manufacture removable acrylic orthodontic appliances using

computer-aided design and 3D printing have been made and presented by Sassaniet al.
The authors reported the application of half-automated technique to manufacture
acrylic base plates of removable appliances. A machine dedicated for this particular
purpose has been used to add and polymerize layers of acrylic, which were added
according to the computer design of the appliance.
The screws and wires however needed to be placed manually onto the working
model, their incorporation in the virtual design and manufacturing process has been
reported not to be possible at that time.30

1) Andresen activator and sleep apnea appliance

Al Mortadiet al. described a procedure of Adresen activator and sleep apnea appliance
fabrication using computer-aided design and additive manufacturing technology. The
first step in the procedure was digitalization of plaster models of patient’s dentition
using a laser scanner. Construction bite and virtual appliance design was made using
CAD software (FreeFormModeling Plus, version 11; Geo Magics SensAble Group,
Wilmington, Mass) in conjunction with special phantom (haptic) arm (Geo Magics
SensAble Group).
The acrylic baseplate of the appliance has been designed. The design
involvedmodeling of a palatal plate, bite blocks covering occlusal surfaces of
mandibular, and maxillary teeth to form a monoblock and anterior capping covering
lower incisors.
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The labial bow was bent manually in a conventional way, with 0.9 mm stainless steel
wire. To incorporate the labial bow into the acrylic, the authors designed special
guiding jigs, which enabled precise positioning of the wire in the acrylic plate.
Manufacturing process of the virtually designed activator was held using
stereolithography machine (SLA 250-50; 3D Systems).
Following printing, the appliance was cleaned in isopropanol solvent (99%) and
support structures were removed.
Post-curing was achieved by ultraviolet light polymerization to increase the degree of
polymer conversion. The manufacturing process with stereolithography has been
chosen because of the possibility to pause printing, which was necessary to attach
conventionally bent labial bow. The authors conducted clinical evaluation of the
appliance and stated that the fit and adaptation to the model surface were satisfactory,
both palatially and lingually.
The appliance surface was smooth, with no sharp edges. Labial bow was fitted firmly
into the plate and was functional.31

2) Hawley’s retainer

The next development in the field was fabrication of Hawley retainer with CAD and
3D printing. Al Mortadiet al. presented Hawley retainer manufacturing using
intraoral scans obtained with TRIOS (3Shape, Copenhagen, Denmark), eliminating
the need of conventional impression taking and pouring plaster models.10
During the stage of creating virtual appliance, the shape, thickness and range of
acrylic base plate, fitted labial bow, and Adams clasps was designed.
Wire elements were bent using cobalt-chromium alloy with 3D printing technology.
The base plate of Hawley retainer was fabricated form ClearVue resin material (3D
Systems), implementing stereolithography. In clinical assessment of the retainer, the
authors concluded that the quality of the appliance was satisfactory.
A disadvantage of the described procedure is the necessity to use complex software
and haptic phantom arm, which significantly increases cost of the procedure. On the
other hand, strictly controlled manufacturing process is reliable and repeatable,
allowing to create appliances with planned thickness, range, and shape.
Nowadays, 3D printing technology allows to manufacture wire elements, including
labial bows and clasps form metal alloys and to incorporate those parts into the base
plate of the appliance.32

3) Silicone removable appliance

Another application of additive manufacturing was to fabricate soft customized,

silicone removable appliances introduced by Salmi et al. The authors printed the
appliance using stereolithography (SLA 350 machine – 3D Systems), which was
preceded by creating the digital design. Manufactured silicone appliance was

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subjected to evaluation, which was conducted by scanning the appliance, creating its
virtual model, and digital image superimposition on computer-aided design.
Maximal deviation of 1 mm was observed on sharp edges and thin walls of the
appliance. According to the authors, the technology used enables faster production,
limits the costs, and results in fabricating appliances with high accuracy.33

Lingual orthodontic appliance

Dirk Wiechmann described a method for the 3-D printing of customized lingual
orthodontic appliance.The problems traditionally associated with lingual orthodontics
cannot be solved with conventional manufacturing processes; instead, complete
individualization of all appliance components is needed. In this method, the processes
of bracket fabrication and optimized positioning of the fabricated brackets on the
tooth, which are normally quite separate, are fused into 1 unit. Individualization of the
bracket base, a process used in various laboratory processes and always essential in
the lingual technique, takes place during fabrication of the single brackets; in other
words, each tooth has its own customized bracket, made with state-of-the-art
computer-aided design/ computer-aided manufacturing (CAD/CAM) software
coupled with high-end, rapid prototyping techniques.10

The manufacturing process: -

The first step in the manufacturing process is to takea standard 2-phase silicone
impression. The casts producedfrom this impression are used to prepare a customized
target setup. Noncontact scanning of the therapeutic setup is performed with a high-
resolution optical 3D scanner (GOM, Braunschweig, Germany).

As with human perception, the 3-dimensional (3D)scanner must examine the model
from various perspectivesto create a complete 3D representation. The outcome is a
compound surface consisting of many thousands of minute triangles (standard
triangulation language, or STL surfaces) that can be turned, observed, and processed
on a computer with appropriate design software.

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Fig52: Scanned surfaces are composed of differently
sized triangles (STL). More homogeneous surface areas are represented
by larger triangles, and less homogeneous surface
areas by smaller triangles. Minimum surface resolution: 0.02mm.

Before further processing, the arch to be bonded is aligned optimally to the later slot
plane. In contrast to conventional lingual brackets, which have standardized mesh
bases, a customized “virtual” base is generated on the lingual surfaces of each tooth.

Fig53: Digital setup with individually defined bracket bases.

Because of the extreme accuracy of the available scan, with a resolution of at least
0.02 mm, the bases are later positively locked with the teeth.
The pad surfaces generated are large enough to provide greater bond strength and
exact form-fit properties. Thebracket base is 0.4 mm thick. The bracket bodies are
freely designed with appropriate design software. The
bracket body we use has an extremely low profile compared with others, guaranteeing
absolute control over the tooth and making for a simplified ligation procedure.

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Fig 54: Conventional lingual bracket (left) and customized bracket (right).

The testing of various slot types hasshown a vertical slot with a vertical insertion
directionto be ideal.

Fig55: A, State-of-the-art maxillary incisor bracket with vertical insertion direction.

In this version, ligating can be done with simple elastic module or with German
overtie. Positioning software allows optimum angulation of hook. Accessory occlusal
hook is optional. B, First-generation premolar bracket with horizontal insertion
direction (left) and state-of-the-art premolar bracket with vertical
insertion direction (right).

The archwire thus runs like a ribbon. By using custom software, the bracket bodies
are added to the setup and the pad surfaces, and are arranged so that the slots are
aligned in the virtual archwire plane.
The vertical height, angulation, and torque are thus preset; only optimal first-order
(positioning thickness) adaptation is performed manually by shifting and turning.

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Fig56: A, Bracket bodies (blue) are loaded from bracket archive to dental arch fitted
with individual bases (yellow). Whereas second and third order are preset, bracket
body can now be shifted and turned in slot plane for optimal positioning. B, Bracket
body and bracket base are then virtually fused.

Fig57: A, in rapid prototyping, brackets are first produced in wax, applied in 0.02
mm layers. Red support wax required for 3D production is removed thermally. B,
Wax lingual brackets before casting. C, Gold lingual brackets after casting.

High-end rapid prototyping machines are used toconvert the virtual bracket series into
a wax analog andthen into a final product made of an exceptionally hard alloy with a
high gold content.
This material hasa Vickers hardness of 310 kg/mm2. Because of theextended
customized base, which permits clear-cutpositioning on the tooth, the brackets can be
directlybonded by the orthodontist. However, the more timesavingoption is indirect
bonding with a 2-phase siliconebonding tray.

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Fig58: Two-phase silicone bonding tray with precoated lingual brackets.

For this purpose, thebracket bases are first treated with silane and then fixedon the
malocclusion model with a microscopically thinplastic film. The bonding tray is made
of an inner,softer silicone (Exakt N, Bisico, Bielefeld, Germany)
and an outer, extremely hard silicone (Lutesil, Bisico).
The indirect bonding is thus no different from theconventional procedure and can be
carried out withunfilled acrylic or fiberglass-reinforced glass ionomer
cement, at the orthodontist’s discretion. As with straight-wire concepts, the archwire
geometryis yielded by the 3D location of the bracket slots.
Their exact position is known through the bracket manufacture described above in 3D
design softwareand is transmitted to a bending robot through the exportof slot
coordinate systems. This robot was a developmentof the Orthomate system
(Orametrix, Dallas,Tex). It operates with 2 grasping tools and can bendarchwires
precisely in highly complex geometries.
Superelasticarchwires are thermally reprogrammedduring the actual bending process.
This is the onlymeans of ensuring precision manufacturing.34

3-D printed Herbst appliance

The Herbst appliance is a fixed device for treatment of Class II malocclusion. Herbst
treatment is most effective at or just after the peak of pubertal growth or in the
permanent dentition.
In adults, the treatment effects are achieved by more dental than skeletal changes, but
the stability of the results is comparable with those achieved in adolescents. The Class
II improvement seems to indicate that Herbst treatment is suitable for adults,
especially those with Class II problems on the borderline between camouflage
orthodontics and orthognathic surgery.

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Dirk Wiechmann outlined a technique for attaching Herbst telescopes to a customized
lingual orthodontic (LO) appliance.
The manufacturing process of the LO appliance is based on digitized setup plaster
casts.10

Fig59: Overview of the manufacturing process of the LO appliance: a, target setup; b,

digitizing the setup models; c, virtual bracket design; d, manufactured wax bodies; e,
final bracket with arch wire placed.

The Herbst appliance consists of a bilateral telescopicmechanism connecting the

maxillary and mandibulardental arches to maintain the mandible in a
continuousprotruded position.
Each telescope consists of a tube, aplunger, 2 pivots, and 2 screws. With the pivots,
the tubeis attached to the maxillary first molar and the plunger tothe mandibular
canines. The screws prevent the tube andthe plunger from slipping off the pivots.
The length of thetube determines the amount of anterior positioning of themandible,
whereas the length of the plunger ensures theconnection to the tube during mouth
opening.
For the design of an optimal Herbst-LO appliance,known problems of traditional
(labial) device constructionmust be considered. These concern the structure of the
interface, the mandibular target position, the need for anchorage, and the ideal time
for placement of theHerbst device during various LO phases.
The strain applied to the Herbst-LO appliance during treatment necessitates a rigid
interface. For this reason, the bracket bases (0.4 mm thick) of the maxillary first molar
and the mandibular canine are extended to the labial surface—ie, are manufactured as
bands to support the pivots for the Herbst telescopes. To prevent a break between
bracket base and pivot base, both are virtually designed and manufactured as 1 unit.

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Fig60: Design of the extended bracket base to support the pivots for the Herbst
telescopes.
Designing the pivots in the CAD environment has
several advantages.
1. Pivot parallelism. Parallel pivots between the maxilla and mandible provide
correct and smooth function
of the telescope mechanism.
2. Interpivot distance. A large interpivot distance prevents the plunger from slipping
out of the tube during wide opening. This distance can be increased by placing the
pivots distally on the upper unit or mesially on the lower unit without losing
parallelism.

Fig61: Digital target setups registered in final occlusion(axial view) for assessment
of pivot parallelism, interpivotdistance, and 3-dimensional telescope-to-
toothsurfacedistance.

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3. Custom-made pivot design. Placing pivots on distally or mesially curved labial
tooth surfaces necessitates individual pivot sizes in length and width to ensure
parallelism and correct telescope distances to the dental arches.
4. Individual screw thread. Different sizes of screw threads provide various forces
with which to screw the telescopes to the LO appliance. This is helpful if heavy
mastication forces are expected.
Finding the optimum 3-dimensional position of the Herbst telescopes requires digital
registering of the target setups in Class I occlusion.

Fig62: Digital target setups registered in Class I relationship to assess possible

interferences with pivot bases and telescope and pivot positions.

Tube, plunger, and pivots can then be assessed in all planes to ensure correct
telescope adjustment with maximumpatient comfort (small dental arch-to-tube
distance).
The mandibular working position, usually the incisoredge-to-edge position, should be
adjusted clinically with the tube length.
The Herbst appliance induces proclination of the mandibular incisors.Anchorage in
traditional Herbst treatment is called moderate or partial if the maxillary first
premolars and first molars are connected with a segmental archwire and the
mandibular first premolars are connected with a lingual archwire touching the
incisors’ lingual surfaces.
One important aim of the Herbst-LO appliance is tohave different options for the
various forms of anchoragewithout using additional material—ie, buccal segments.
Compared with the anchorage in the traditional Herbst appliance, the anchorage of the
Herbst-LO appliance is always higher because of the full-arch and full-size
rectangular archwires and the reverse-torque effect on the mandibular anterior teeth
because the bracket is positioned posterior to the center of resistance, causing a
reverse moment of force on the archwire.
Anchorage can be further increased by using stiff wires, reverse third-order bends
(pre-programmed reverse torque), or unifying bracket and pivot bases.

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The ideal time for placing the Herbst telescopes is usually after the levelling and
alignment phase, when full-size archwires create rigid units of the respective
dentitions. After Herbst treatment, the supporting base of the canine pivot can be cut
off for minimal visibility.35

3-D printed occlusal splints

Occlusal splints are contemporarily used for treatment of patients presenting with
temporomandibular disorders (TMD). The conventional process of splints fabrication
in dental laboratory requires taking alginate impressions of patient’s dentition, wax
bite registration, and mounting casts in articulator. Salmi et al. introduced 3D printing
into the process of splint manufacturing.
A computer-assisted method for design and fabrication of hard occlusal splints was
developed by scanning for stonecasts and milling for manufacturing.10

Fig63: The process for planning and additive manufacturing of occlusal splints. The
dashed line defines the digital steps of the process.

Teeth can be scanned straight from the mouth, using an intraoral scanner, or indirectly
by taking a plaster model and scanning it. The splint was designed with the VISCAM
RP v. 4.0 software (Marcam Engineering GmbH, Germany), which is an engineering
software package for preparation of CAD/CAM data for AM. A scanned and repaired
three-dimensional model of upper teeth was used as a starting point. All tooth surfaces
in the three-dimensional model were extruded to a thickness of 2.0 mm. This can be
done with the software’s extrude surface or offset commands. Thereafter, the extruded

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surfaces were cut off from the three-dimensional model, using a Boolean operation to
obtain a cover for teeth for a rough three-dimensional model of the splint.
At this stage, it is important to cut the edges so that the splint will not touch the
gingivae, but still has enough contact
with the teeth. Finally, the rough three-dimensional model of the splint was cut to the
desired shape using the trim and cuttool.
The smoothing command was used to achieve good surface quality for the three-
dimensional model. Smoothing, whichremoves sharp corners and self-locking forms,
was also used to remove too tight fitting to the teeth. The absolute minimum wall
thickness for laser-based AM systems would be the width of a single cured line and
this is related to the diameter of laser beam and the cure depth.Therefore, the slight
residual roughness of the three-dimensional model tends to be smoothed in AM, and
very small errors have only insignificant influence to the end product.

Fig64: The three-dimensional model of the occlusal splint.

The splint in this study was manufactured using stereolithography. The SLA 350 laser
beam diameter is 100 mm, and features smaller than that disappear. The layer
thickness of the current process was 0.05 mm. After the manufacturing phase, the
splint was soaked in pure isopropanol for 20 min, and clean towels were used to scrub
off any excess resin. Dry, compressed air was used to blow excess solvent from the
surface of the splint. The splint was placed in a post-cure apparatus for 60 min after
cleaning.

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Fig65: The occlusal splint in use.

The digitally manufactured occlusal splint was used for six months nightly as would a
conventional one made by a dental technician. After 5 days, the splint was trimmed,
since signs of slight pressure on the upper right canine and pressure between the upper
and lower right premolars were noted. The patient felt the splint to be tight after a
couple of minutes from the beginning of every usage, which is typical also with a
conventional splint. No other problems were detected, and thepatient adapted to the
splint well and found it comfortable touse. It also relieved his bite muscle tension. No
sign of tooth
wear or significant splint wear was detected after the sixmonthtest period.

Fig66: The occlusal splint after test period.

Traditionally, an occlusal splint is hand-made in a dentallaboratory. Therefore, the

costs are fairly high, and the leadtime is approximately one week before the patient is
ableto use it. Modern digital technology, including three-dimensionalscanning and
Additive manufacturing, opens up a possibility tomanufacture these splints more
efficiently and to achieveshorter lead times. Digital technology may also improve
theaccuracy of the final occlusal splint. This improved accuracyand also the more
advanced design may reduce the timeneeded for the dentist to trim the splint.
Three-dimensional design of occlusion splint is a quitestraightforward process:
extruding or offsetting teeth surfacesand then cutting the edges so that there is no

97
contact to the gingivaebut enough contact to the teeth. Every splint has
differentgeometry in terms of teeth contact, but other parts are similar.
Working with scanned data usually produces small ‘craters orspikes’ when the surface
is extruded. At the current stage,modelling is donemanually, but also semi- or fully-
automatedmodelling can be considered. Cases where some teeth aremissing may need
more manual work.36

NasoalveolarMolding Treatment in Infants With Cleft Lip and

Palate

Cleft lip and/or palate is the most common congenital craniofacial abnormality,
occurring in 1 in 500 to 1 in 1000 live births.
The principal goal of presurgical treatment of an infant with cleft lip and palate is to
reduce the severity of the cleft deformity with the intent of improving the outcome of
the primary surgical repair.
Since the introduction of NAM appliance, it has been adopted by many cleft centers
and there is now growing evidence of the benefits of NAM in both unilateral cleft lip
and palate (UCLP) and bilateral cleft lip and palate (BCLP). Traditionally, the
majority approach to fabricate NAM appliance relies on fairly intensive handcrafting,
including polyvinylsiloxane (PVS) impression and plaster model for the fabrication of
acrylic appliance. During the entire period of treatment, the NAM appliance needs to
be manually adjusted a
weekly according to the estimated growth and desirable alignment by using the
conventional method.
The continuous development of computer-aided design (CAD) and rapid prototyping
(RP) technologies allows for the production of customized dental appliances,
originally based on fairly intensive handcrafting procedures.8 Our previous studies,
developed a novel technique of presurgical NAM based on computer-aided reverse
engineering and rapid prototyping. In these cases, a plaster cast was made from the
silicone impression and was sent for laser
scanning. Starting from an initial digital model, a series of continuous digital models
of maxilla movement was virtual designed with reverse engineering software, the
solid models were printed with rapid prototyping system. The whole set of appliances
was fabricated based on these solid models, which could save clinic time tomake
adjustments.
Three-dimensional (3D) digital models have the potential to replace traditional plaster
models. Digital models were initially produced by scanning plaster casts and later by
scanning the impressions directly. There are now a number of commercially available
intraoral scanners (IOS) around the world, replacing the
need for traditional alginate or PVS impressions and plaster models.
IOS is non-invasive, accuracy, and low impact technique, it could provide increased
comfort to the patient because of reduced risk of the gag reflex. After scanning, the
3D data are immediately available. So far, IOS has not been used to digitalize a

98
neonate’s oral cavity yet, since the neonate may not keep still and the available space
in the oral cavity is very limited.
In this study, the proposed full digital workflow was: acquiring digital 3D image of a
CLP infant’s maxilla by using IOS, virtual modified the digital model to achieve a
harmonic alveolar arch, generated the models of NAM appliances based on these
virtual modified models, and manufactured a series ofNAM appliances by 3D printing.

Steps followed in the process were:

Acquiring Digital 3D Image of a CLP Infant’s Maxilla

A CLP infant’s maxilla was scanned by 3Shape TRIOS Pod (Copenhagen, Denmark)
intraoral scanner, which uses Ultrafast Optical Sectioning technology and advanced
parallel confocal microscopy principles,14 and accuracy is 0.02mm by the
manufacturer.
Surface data are built up by stitching together the many slices of data received from
the scanner, while the operator moves the scanner gradually above them. It also has
the capability to automatically reconstruct areas of missing scan data while
maintaining accuracy. The system can create a final digital 3D model instantly to
reflect the real configuration of maxilla and alveolar mucosa color.
The wand has a heater to prevent lens fogging. The probes of the intraoral scanner are
autoclavable and can be rotated 1808 on the handheld scanner for ease to use. It is a
powder-free device in the scanning process. The TRIOS system has an open system

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that can export 3D data as an STL (Stereolithographic) file, which can be immediately
opened and used by other CAD/CAM system.The 3D image data of an infant’s
maxilla were obtained with the infant fully awake and without any anesthesia.
One person holds the infant face up, with one hand supporting the head and neck. The
operator sat in the direction of infant’s head, holding and fixing the
infant’s head slightly with one hand, and the other placing the probe into the infant’s
oral cavity and moving slowly to scan the maxilla.
During the scanning, probe was needed to adjust the direction and angle for many
times to ensure that the desired maxillary anatomy was scanned, and the operator
should observe the detail of the acquired digital image data on the monitor at any time.
If the operator was not satisfied with some of the details of the recorded digital image
data, he could delete them and recapture the impression without having to repeat the
entire procedure. The 3D image of
maxilla was generated.

Fig67: 3D image of an UCLP infant’s maxilla.

Virtual Modification of the Digital Model

The digital data were converted to STL file and imported intoGeomagic Design X
2016 software. The digital model ofthe maxilla was subdivided into the two posterior
lateral alveolarsegments and the premaxilla.
In a series of steps, the segments werevirtual modified in a way that the cleft gap was
gradually narrowed,and the segments were repositioned to achieve an optimal
archform. To accommodate the growth of an infant, the models shouldbe widened
approximately 1mm per month in order to prevent anyharm to the infant’s natural
development. In addition, segmentsmolding adjustment should be limited to 1mm per
weekly.
Multiple steps should be planned on the basis of the severity ofthe initial deformity.

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Fig68: The initial 3D maxilla configuration as acquired by intraoral scanner

Fig69: The final target configuration of maxilla.

Fig70: The alveolar segments virtual modified process by shifting and/or rotating
movements from the initial to the final optimal placement.

Virtual Design of the Models of the NAM Appliances

Commercial 3D CAD software Rhino (Rhinoceros 3D Version 5.0, Robert McNeel&

Associates) was used for virtual design of the models of the NAM appliances. Based

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on the previous series of virtual designed models, the digital models of NAM
appliances could be generated in virtual environment.

Fig71: The digital model of NAM appliance with retention arm.

Fig72: A series of digital models of NAM appliances.

Manufacturing NAM Appliances by 3D Printing

The final digital design was exported as an STL file to the 3Dprinting. In this study,
an Objet30 OrthoDesk 3D Printer (Stratasys)has been used. It allows for the
production of models with aminimum layer thickness of 28 um. In principle the
process worksby taking a 3D computer file and creating a series of cross-sectionslices.
Each slice is then printed one on top of the other create the 3Dobject in a short period
of time. The process is capable of building in
fine detail (600 _ 600 _ 900 dots per inch in x-y-z) necessary todefine the features.
Bio-compatible material MED610 was used tobuild real NAM appliances, while the
SUP705 (Water Jet removable)a gel-like support material designed to uphold
overhangs andeasily removed by a Water-jet, leaving a smooth surface with nosharp
edges. The thickness of the appliance was 2.5mm.
Due to thevirtual preparation of the models, no areas were in undercuts. Therewas no
waste of material. It was possible to build a series of NAMappliances simultaneously
so long as the parts would fit within onebuildenvelope of the machine, and the
retention arm could bemanufactured without assembly. It took 3 hours to complete
thewhole series of appliances.

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Fig73: Manufacturing a series of NAM appliances by 3D printing.

For the orthodontist, advantages of full digital workflow NAM

Approach was:
(1) Improved practice efficiency, faster digital records submissionto laboratories, and
faster 3D printing appliances clinic return;
(2) Improved appliance accuracy, ability for better quality control;
(3) reduced chairtime;
(4) Improved potential for standardization in clinical research onNAM treatment.
Benefits to the patient included:
(1) Improved safety, avoided aspiration of any impressionmaterials;
(2) Reduced number of patient visits, time-saving;
(3) Easily reproducible due to stored digital data of lost orbroken appliance.37

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MATERIALS USED FOR 3-D PRINTING

 Polymers

1) Polycaprolactone (PCL)
PCL is a semi-crystalline thermoplastic resin with a degree ofcrystallinity of about
45%. The
appearance of PCL is very similar to the milky white of mediumdensity polyethylene
and it has a waxy texture. PCL has a glasstransition temperature of 60°C, a melting
point of about 63°C,and a decomposition temperature of about 250°C. Since PCLhas
a low melting point and softens at about 40 °C, its applicationis limited.
PCL is analiphatic polyester which has good mechanical properties and
a long resorption time, but poor osteoconductivity.

2) Polylactic Acid (PLA)

PLA is a water-insoluble and bio-friendly polymer used inbiomedical
fields.Researchers consider PLA as a rigidpolymer matrix.
At the optimum condition, PLA exhibits the mechanicalproperty of pure 3D
material, with elongation at break of12%, tensile strength of 59.7MPa and flexural
strength of
50.7MPa. PLA has attracted the attention of the scientific communitydue to its
biocompatibility, biodegradability, ease of processingand thermal stability, as well as
biocompatible and biodegradable nature. The material is bio-degradable, nontoxicand
most similar to the bone at low temperature. However,PLA does require constant
cooling to avoid melting. Due to their excellent physicochemicalproperties, PLA is a
good choice for making scaffolds.

3) Acrylonitrile Butadiene Styrene (ABS)

ABS is an oil-based, durable, light material and has recommendedprinting
temperaturesof Te at 230–250°C and Tb at 80–105°C. It is more resistant for ABS to
melt and easierto cut, whichmeans it is easier to process.
But since ABS has high impact resistance but increased stiffness and limited strength
makes it a poorer choice in 3-D printing.

4) Poly (Lactic-Co-Glycolic Acid) (PLGA)

PLGA is a copolymer of polylactic acid (PLA) andpolyglycolic acid (PGA), and has
been used broadly in a host ofUS Food and Drug Administration (FDA)-approved
therapeutic
devices, such as sutures, grafts, and macro/micro/nanoparticles,due to its
biodegradability and biocompatibility.
These remarkableproperties and efficient performance as compared to
othermaterials, make it stand out in the biomedical field.

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Different monomer ratios can manufacturedifferent types ofPLGA. For instance:
PLGA 75:25 denotes that the polymerconsists of 75% lactic acid and 25%
glycolic acid. All PLGAs areamorphous and have a glass transition temperature of
40–60°C.
Different from pure lactic acid or glycolic acid polymers, whichare less soluble,
PLGA presents a broader range of solubility. Itcan be dissolved in various
solvents, including chlorinatedsolvents, tetrahydrofuran, acetone and ethyl
acetate.
PLGA 3Dprintedscaffolds have well-defined architectures and regularpore sizes,
and the distributions of pore size are centralized,which lead to higher
transparency and porosity.By adjusting the monomer ratio, the degradation time
of PLGA can be
changed.This method has been widely used in the field ofbiomedicine including
skin grafting, wound closure, in-vivoimplantation, and micro-nanoparticles.
PLGA scaffold providesmajor mechanical support for the combined construct
with thestress of more than 1.5MPa, which is adequate to maintain
thearchitecture stability of the production during either in vitroculture or in vivo
implantation.38

 Bio-Inorganic Materials

1) Plaster
Plaster is an air-hardening cementitious material mainlycomposed of calcium sulfate.
Plaster-based cementitiousmaterials and their products have many excellent
properties,and they are rich sources of raw materials and low energyconsumption in
production, thus being widely used in dentaltissue engineering. Slight expansion of
gypsum imparts gypsumproducts a smooth surface, white appearance, delicate
texture,and good processability, making it an excellent material formaking sculptures.
Plaster materials have many advantages overvarious other materials. These include; 1)
Fine particle powder,easy to adjust particle diameter.
2) Relatively low price and high-cost performance.
3) Safety and environmental protection, nontoxicand harmless properties.
4) Model surface: grainy andgranular.
5) Color: The material itself is white, and the printmodel can achieve color. 6) Typical
application: The only materialthat supports full-color printing and architectural model
display.
The digital models are printed through a stereolithographic 3D printer (SLA) with a
horseshoe-shaped design. To evaluate the reliability of measurements for each model
type Pearson correlation coefficient was used.
The measurements on plastermodels and printed models have shown some vital
differences intooth dimensions and intrench parameters, but these differencesare not
medically relevant, in spite of the transversalmeasurements. The upper and lower

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inter-molar distances onthe printed models are of statistical significance and
medicallyrelevant.

2) Metal
The dental metal material is a type of bio-metal material usedto repair tooth defects,
missing dentition, and orthodonticteeth. These metal materials must be non-toxic and
harmless,have corrosion resistance and anti-tarnish properties, and havea certain
strength and wear resistance, also can adapt to thesoft and hard tissues in the oral
cavity, and are easy to processand use.
Metals and their alloys have excellent propertiesrequired for dental metal materials
and can be used to makefilling materials for 3D printing, crowns, bridges, dentures,etc.
Although metal is expensive, it is widely used becauseof its superior performance, as
well as estheticolor andappearance.
Co–Cr alloy has high hardness index, difficult processing, andpoor casting properties,
but it is lightweight, and possesses high strength, excellent wear resistance, and good
corrosion resistance.
Titanium alloy has lightweight and excellent corrosionresistance properties. Its
compatibility with the human body issuperior to other alloys, and the price is lower
than that ofprecious metals. It can be used to make crowns, bridges andvarious kinds
of dental implants (dental and chin). Ti–Zr alloyhas good resilience performance and
is superior to stainless steelfor making orthotic appliances. It is a high-performance
dentalorthodontic wire material.

 Cobalt-Chromium Alloy (Co–Cr)

The use of cobalt–chromium (Co–Cr) alloys, which possessexcellent mechanical

properties and costs lower than high-noblealloys, has greatly increased in the field of
crowns and fixeddental prostheses. However, some of the problems associatedwith
casting in the conventional manufacturing process arewidely known. Although casting
shrinkage has largely beenovercome with Co–Cr alloy, the accuracy may be affected.
Moreover, the high hardness index of the alloy makes finishingmore difficult as well.
Recent development in the use of CADCAMprovides better standardization.
The completed design STL format files are transferred to aselective laser melting
(SLM) printer. This metal3D printing equipment uses a 100W fiber laser power with
abeam diameter of 10mmin an Argon gas protected atmosphere,and Co–Cr powder
printing is performed in layers of 30mmthickness. After removing the supports
carefully, 15 metalcopings are acquired.
No mechanical failure or retention losswas detected, and there was only one crown
on the mandibularmolars showing smaller fragments of face porcelain on themedial
buccal tip. Therefore, a 100% cumulative survival rateand 99.2% cumulative success
rates were recorded according toKaplan-Meier analysis. One hundred and two
abutments werefound to be critical from the beginning and throughout
theobservational period. The excellent clinical performance of Co–Cr SC was

106
demonstratedby United States Public Health Service (USPHS) standardtechnical
evaluation.
Significant differences in mean periodontalparameters between the test teeth and the
control teethwere not detected in any follow-up examination. In summary, after4
years of clinical functional verification, CAD/CAMCo–Cr singlecrown has been
proved to be an effective treatment option and a viable alternative to the
preciousmetal-ceramic restorationin the
posterior region.

Fig74: The printing process of selective laser melting (SLM) usingcobalt–chromium

(Co–Cr) alloy powder.

 Titanium-Containing Materials

In the general field of biomedical devices, and dental implants,the superior strength of
processed dental implants made ofcommercially pure titanium, which may surpass
that of thestronger Ti6Al4 alloy, has been associated with a superior fatigueresistance.
Titanium (Ti) is widely used as a biomedical material in plasticsurgery and dental
applications due to its high corrosionresistance, low density, extraordinary mechanical
properties, andsatisfactory biocompatibility.Its inherent bone consolidationability
enables direct bone contact to be formed on the surface ofthe implant, thereby
mechanically securing the implant to thesurrounding living bone. However, the
mismatch between Tiimplant stiffness and host bone tissue produces a stressshielding
effect at the bone-Ti implant interface, which mayreduce the long-term clinical
performance and stability of Tiimplants. Introducing internal pore structure into Ti
implants isa promising strategy to overcome this problem. By controllingpore size,

107
distribution and interconnectivity, porous Ti isdesigned to match the mechanical
properties of natural bonetissue.
In addition, the porous structure can affect the cell activityof Ti scaffold. A few
hundred microns of surface pore size allowssufficient free space for the growth of the
internal bone and forthe delivery of oxygen and nutrients in the body and for
theexcretion of waste, which is necessary for strong fixation of Tiscaffolds with long-
term reliability.
Titanium alloy powder is used for printing implants in theform of 300W laser (1070
nm, 50% power) square strips(1.2_1.2 cm2) in the presence of argon atmosphere
(_500 ppmO2) using selective laser melting machine.
Thin uniform metalpowder layers are deposited on the plates and the selected areas
of the powder are fused accurately by high-power focusing laser.This process is
repeated, layer by layer, until the desiredthickness (_0.6mm) is reached, and the
implant is generated accordingly.
For dental implants, the Tiimplant can withstandwear from other implants or bone
material due to inherentloading conditions. In particular, in the oral
environment,continuous micro-movement between interfacial bone/dentalimplants
can lead to the release of debris, which may haveharmful effects.

3)Ceramic
In dentistry, the use of ceramics, especially zirconia ceramics, forrestoration has been
widely promoted due to their perfectaesthetic properties. In digital dentistry, zirconia
dentalrestorationsare mainly made from digital manufacturing systems (suchas
CAD/CAM or 3DP). After production, the sintering process isessential to the
improvement of mechanical properties.
In fact,the prediction or control of side effects of shrinkage in thesintering process is
complex and cannot be studied thoroughly.
The accuracy of zirconia repair is low, especially the most vitalfactor of recovery
adaptability. Therefore, the restoration of pooradaptability can easily lead to
secondary caries or microleakage,and the teeth will decay again. The remaining teeth
need to becompletely removed.
3D printing is the targeted manufacturingprocess to avoid the high cost of CAD/CAM
processing; aftersintering, 3D printing products need to be highly accurate.
However, the shrinkage of the 3DP product is hard to predict andcannot be studied
thoroughly.
Therefore, in CAE analysis,experimental design and regression analysis, different
shrinkagerates of samples in the manufacturer’s sintering specificationwere first
predicted. The results were then applied to themanufacture of incisor prostheses. This
can help the prosthesisproperly adapt to the patient’s mouth and greatly shorten the
timeof clinical surgery. It has successfully helped3Dprint applicationsinto dentures.
Porcelain-fused-to-metal (PFM) dental crownshave strong compressibility, tensile
strength, and a white, toothlikeappearance, making them a popular choice for
dentalrestoration.

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 4) Hydroxyapatite (HA)
As it is the main component of bones, HA has variousoutstanding advantages like a
prefabricated material for hardtissue bio-printing. Some natural HA particles possess
good biocompatibilityand perfect osteoconductivity.
In 3D printing technology,HA can be applied in various forms such as powders,
slurries orgranules. To acquire the fluidity required for the 3D printingprocess,
modified by granulation or mixing with other polymersolutions are normal ways.
Polymer solutions are oftenserved as a liquid binder for powdered HA particle
coalescingagents and can even be incorporated into cells.
There are few reportsabout the use of hydroxyapatite pastes for apexification. It has
been suggested thatthe paste fluidity is slightly poor, resulting in an insufficient
rootcanal filling, especially in the molar narrow, thus leading to thetreatment failure.
It is prepared with glycerin, and iodoformdissolved in glycerin is added to make the
paste soft and pastelike.
It is easy to fill, and has a certain viscosity, good adhesion,antibacterial effect, x-ray
blocking, and convenience for clinicalexamination.

5) Zirconia
Because zirconia itself has superior mechanical properties, itwas first applied to the
finished post and core system.
An idealdental peg:
1) it does not affect its imaging in medical images;
2)it allows rational transfer of stress to avoid root fracture;
3) itmust be able to provide adequate support and retention for thecore;
4) there is no signs of deformation and possesscommendable hardness properties;
5) it can support the coreand crown to maintain a good seal.

Traditional cast metal studs are manufactured by using Cr, Ni, or Co–Cr alloy.
However,some people have allergies to nickel and chromium. These alloyswill exist
some ion exchange, so the increase in the amount oftime may lead to patients’
discoloration of the eyelid edge, andhave an impact on their own aesthetics. If all-
ceramic crowns areused for restoration, metal posts and cores can pass through
theouter edge of the crown through the rim, which can affect therepair process.
Moreover, the metal studs can also interfere withthe NMR, which is not a
phenomenon exhibited by the zirconiapegs. Similarly, X-ray films can also be used to
observe the degreeof closeness, position, and surface of the studs. Further,
Zirconiahas good biocompatibility, so it does not do harm to humans orproduce
allergies and toxicity. Summarily, as a high-strength andhigh-toughness ceramic
material, zirconia ceramics have a verygood application prospect. With the rapid
development ofnanotechnology, nanoscale zirconia has received increasedattention.39

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