ORIGINAL ARTICLE

The uses of 3-dimensional printing

technology in orthodontic offices in
North America
Tarek ElShebiny,a Yahaziel Simon,a Catherine A. Demko,b and Juan Martin Palomoa
Cleveland, Ohio

Introduction: The purpose of this study was to examine the use of orthodontic 3-dimensional (3D) printing
technology in North America and to understand why orthodontists are, or are not, incorporating 3D printing
technology in their practices. Methods: A survey questionnaire was delivered on a secure online platform,
RedCap (Case Western Reserve University Clinical and Translational Science Award; no. UL1TR002548).
The survey consisted of 14-34 items with branching logic. The association between participant demographics
and in-house 3D printing was assessed using a chi-square test of independence. Results: A total of 518 re-
sponses were recorded. The highest number of responses came from respondents in the 36-45-year age
group. Most of the respondents were practice owners; 46.9% had 3D printers in their office. Chi-square tests
of independence were performed on the data to see which associations existed. The strongest statistical
associations with using an in-house 3D printer are seen with patient load, practice type, years since
residency, and orthodontist’s position. Conclusions: Approximately 75% of orthodontists use 3D printing tech-
nology in some capacity in North America. Major factors that influenced orthodontists to incorporate 3D printing
technology into their office were self-interest and research. Major factors that have prevented orthodontists from
not incorporating 3D printing technology into their office were space for equipment/ventilation and digital
workflow training deficit. Orthodontists use their 3D printers mostly to make plastic retainers from printed
models. The strongest associations with using in-house 3D printers are seen in patient load, practice type,
years since residency, and orthodontist position. Increasing patient load and being in private practice
increases the likelihood of having a 3D printer. (Am J Orthod Dentofacial Orthop 2024;166:76-80)

O
ver the last several decades, technological ad-
vancements have shaped orthodontics and den-
tofacial orthopedics into the effective,
innovative field it is today.1 Three-dimensional (3D)
printing has exponentially grown in orthodontics,
changing the way many orthodontists structure their of-
fices and perform tooth movement.2,3 With the right im-
plementation, 3D printing technology can reduce the
number of appointments, laboratory turnaround times,
and laboratory fees.4 Software can be used to repair or
modify digital models quickly before printing. Several
a
b
Department of Orthodontics, Case Western Reserve University, Cleveland, Ohio.
Department of Community Dentistry, Case Western Reserve University, Cleve-
land, OH.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
Address correspondence to: Tarek ElShebiny, Department of Orthodontics,
School of Dental Medicine, Case Western Reserve University, 2124 Cornell Rd,
Cleveland, OH 44106; e-mail, tme18@case.edu.
Submitted, July 2023; revised and accepted, March 2024.
0889-5406/$36.00
Ó 2024 by the American Association of Orthodontists. All rights reserved.
https://doi.org/10.1016/j.ajodo.2024.03.014
76
software programs can also be used to digitally remove
brackets and appliances. Thus, an orthodontist can
deliver a transpalatal arch the day after an expander is
removed or retainers are removed immediately after de-
bonding.4 When patients lose their retainers, the printed
resin models are strong enough to be reused for making
replacements. Because this is an emerging advancement
in this field and is still in its infancy, it is not fully known
to what extent practitioners have implemented or
considered making the switch from analog to digital.
In evaluating the use of 3D printing, researchers and
clinicians were focused on the accuracy of 3D printed
models and the workflow of fabricating clear aligners,
retainers, and splints with these printed models using
the conventional workflow.5-10 However, there is a lack
of information on the process of how this technology
is implemented and incorporated in the orthodontic
office. Therefore, the purpose of this study was to
address these knowledge gaps and characterize the
users and uses of 3D printing in orthodontic care. The
survey seeks to examine the association of
demographic factors, training experiences, and office
ElShebiny et al
characteristics with the in-office and outsourcing of 3D
technology. Furthermore, the study assessed the popu-
larity of software applications for 3D printing.
MATERIAL AND METHODS
Statistical analysis
A 34-item survey (Supplementary Material) with
branching logic was created to ask practicing orthodon-
tists about their experience with 3D printing. The survey
asked whether 3D printing applications were in-office,
outsourced, or not used; the rationale for why orthodon-
tists incorporate 3D printing technology or not; what
type of 3D software is used; and perceptions on the ap-
plications, uses, pitfalls, and benefits of 3D printing. In
addition, survey items included the number of printers
in the office, the procedures for which printers are
used, and questions about their 3D laboratory. If the
orthodontist does not have a 3D printer in the office,
additional questions inquired why not and if they plan
to include 3D printers in the future. Finally, personal
and office characteristics were collected to describe the
respondents and to evaluate potential associations be-
tween the use of 3D printing and demographic variables.
The study survey was developed and administered on
a secure online research platform called REDCap (Case
Western Reserve University Clinical and Translational
Science Award; no. UL1TR002548). To reach the widest
audience, the survey was distributed using 3 methods.
The first method was via the American Association of Or-
thodontics (AAO) Partners in Research program. The
AAO program randomly selected 2200 Partners in
Research members to receive a survey link inviting and
welcoming them to complete the questionnaire. Only a
portion of the AAO membership is sampled for any
survey to avoid “survey fatigue” from repeated requests
to complete surveys. Respondents who were active or-
thodontists in the United States and Canada, including
orthodontic faculty, were included in the analysis.
Retired orthodontists and orthodontic residents were
excluded from the study. The second method of survey
distribution was through an orthodontic Facebook
group called Orthodontic Pearls, with the link placed
on the group’s Web site, inviting them to participate.
An invitation and the REDCap survey link were provided
to interested members. Finally, business cards with quick
response codes linked to the REDCap survey were
distributed at the American Association of Orthodon-
tists’ in-person meeting in Miami, Florida, in 2022.
Because of multiple distribution pathways, respondents
were asked not to complete the survey more than once.
Because of the large map of the United States included
on the first page of the survey, we were confident that
American Journal of Orthodontics and Dentofacial Orthopedics
77
respondents would recognize the survey. The data for
this study were collected between February 1, 2022
and June 30, 2022, from orthodontists practicing in
North America.
The data were analyzed using SPSS software (version
27.0; IBM, Armonk, NY). Descriptive statistics were used
to analyze the frequency of responses. Associations be-
tween participant demographics and in-office 3D printing
were assessed using a chi-square test of independence. A
binary logistic regression model was constructed to assess
the strength of the association between independent vari-
ables and the presence of an in-office printer. Significant
variables from the chi-square test were included in the
model. Odds ratios and 95% confidence intervals are re-
ported. Statistical significance was defined as P #0.05.
This study was approved by the Case Western Reserve
University Institutional Review Board.
RESULTS
A total of 518 responses were received, and all re-
sponses were included in the data analysis. A total of
268 (51.70%) responses came from the Facebook group,
followed by 182 (35.10%) responses from the in-person
meeting, and 68 (13.1%) responses came from the AAO
survey link. The response rate from the AAO link was very
low (3%), whereas response rates from the Facebook
group and in-person meeting cannot accurately be
determined. The highest number of responses came
from the 36-45-year age group (32.8%) and from those
who have been in practice for .10 years (51.2%). Most
respondents were practice owners (60.8%), working in
private practice (82.6%), and practicing primarily in a
suburban area (62.8%). The greatest number of respon-
dents treat 45-60 patients daily (31.5%).
Approximately 73% of respondents use 3D printing
applications in some capacity, whether in-office or out-
sourced. Over half (53%) of the respondents reported
they had training in the use of 3D printing. The most
common training method among those with training
was reported as self-taught (38.4%), followed by
continuing education (28.6%). Among orthodontists
with an in-office printer, more than half (53%)
have .2 years of experience. Respondents were most
often familiar with digital light processing (35.1%).
Among all respondents, 46.9% had a 3D printer in their
office; among those, 45.4% had 1 printer, whereas 54.6%
had $2. Among the clinicians with 3D printers in their of-
fice, 57% use both in-office aligners and full-service
aligners companies, 16% use only in-office aligners,
13% use only full-service companies for aligners, and
14% do not use aligners therapy. The percentage of re-
spondents with in-office printers from each of the 3 survey
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Fig 1. Three-dimensional Printing applications for orthodontists who have in-office 3D printers. The
most common application for an in-office 3D printer is printing models to make plastic retainers.
methods was 50.4%, 45.1%, and 38.2% for Facebook, in-
person meetings, and AAO, respectively. The difference in
distribution across the methods was not statistically signif-
icant (P 5 0.064). Sprintray (Los Angeles, Calif) was the
most owned printer (47.0%), followed by Formlab (Somer-
ville, Mass) (23%) and Anycubic (London, United
Kingdom) (14%). Printing models for plastic retainers
was the most popular use of a 3D printer in a practitioner’s
office (90.9%) (Fig 1) and was also the most common
application among outsourced applications for offices
without an in-office printer (64.8%). Overall, the most
common application of 3D printing technology was for
printing in-office and outsourced retainers (81.9%), fol-
lowed by printing models for in-office aligners (70.6%).
The most common reason orthodontists initially incorpo-
rated 3D printers in their offices was due to self-initiated
research or interest in 3D printing. Practitioners with a
3D printer were very pleased with it, as 96.3% reported
it meeting their expectations.
Among orthodontists who did not use 3D printing in
any capacity in their practice (n 5 141), 33.3% said it
was because they were not the decision-makers in their
office (Fig 2). In addition, respondents reported they
had a training deficit in digital workflow (27%) or had
a lack of interest in 3D printing (27%). Finally, 39.3%
of the 141 said they were interested in or planned to
implement 3D printing in their office in the future.
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ElShebiny et al
The relationship between demographic variables and
the use of an in-office printer was investigated in the
Table. Compared with those without an in-office printer,
those with an in-office printer had graduated from
residency .5 years ago (75.3%; c2 5 7.914; P 5
0.005), were more likely to be an owner/partner
(79.3%; c2 5 15.411; P \0.001) and more likely to be
in private practice (89.3%; c2 5 13.367; P \0.001). A
higher average daily patient load also increased the like-
lihood of having an in-office printer (Somer’s d 5 0.109,
P \0.001). Furthermore, patient loads of .45 patients
daily increased the odds of in-office printer use by
73% (adjusted odds ratio 5 1.73 [95% confidence inter-
val, 1.15-2.60]; P 5 0.009) when tested in the presence
of other associated variables, and it remained the only
significant predictor of in-office printer use. Region of
the country, practice setting, and age group were not
associated with in-office printer use.
DISCUSSION
Our survey was answered by 518 practicing orthodon-
tists in North America, and the data that was obtained rep-
resented the opinions of these practitioners. Most of the
respondents were found to be practice owners, practicing
in the suburbs, and graduated from their respective resi-
dency programs over 10 years ago. A 2017 workforce
report by AAO described practicing orthodontists as
ElShebiny et al 79

Fig 2. Reasons for not using 3D printing technology. Most orthodontists who do not use 3D printing
technology do not use it because they are not the decision-makers in the office.

printer. This difference may be due to a substantially larger

Table. Association of demographic characteristics
sample size in this study. Another explanation could be the
with the presence of in-house 3D printer
1-year difference between the 2 surveys during 2021-
In-office 3D No in-office 2022; there might be an almost 10% increase in the user
Variables printer 3D printer c2 P value number. To the best of our knowledge, this was the first
Daily patients study to delve deeper into 3D technology practices in the
\45 52 (21.4) 89 (32.4) 11.97 0.007
45-60 77 (31.7) 86 (31.3)
orthodontics office.
60-90 76 (31.3) 77 (28.0) Our study focused on who was using 3D printing tech-
.90 38 (15.6) 23 (8.4) nology, whether that was an in-office or outsourced
Practice type method. Over 72% of respondents use 3D printing tech-
Private 216 (89.3) 212 (77.1) 13.367 \0.001 nology in some capacity in their patient care. Digital light
Othery 26 (10.7) 63 (22.9)
Years since residency
processing printers were the most known type of printer,
\2 30 (12.3) 38 (13.9) 11.017 0.012 followed by stereolithography technology. Among those
2-5 30 (12.3) 61 (22.3) with an in-office printer, SprintRay was the most widely
6-10 52 (21.4) 41 (15.0) used printer, whereas uLab was the most commonly used
.10 131 (53.9) 134 (48.9) software for virtual planning. Printing models for plastic
Position
Owner/partner 192 (79.3) 175 (63.6) 18.265 0.001
retainers was the most popular application used by ortho-
Otherz 50 (20.7) 100 (36.4) dontists with their 3D printers. In contrast, one-sixth of or-
y
thodontists printed all of their aligners in their office. For
Corporate, dental service organizations, academic; zAssociate,
practitioners without an in-office 3D printer, the most
employee, other.
common application was printing models for plastic
retainer fabrication, followed closely by aligner therapy.
practice owners aged 30-54 years, often in suburban loca- The study also wanted to determine why orthodon-
tions, similar to our respondents. Most of the respondents tists are, or are not, incorporating 3D printing technology
have had training in 3D printing either by self-teaching, in in their practices. Most orthodontists who were using this
their residency program or by continuing education. Our technology were motivated because of self-interest or
study found that almost half (47%) of the practicing ortho- completing their research. Most orthodontists using
dontist respondents had at least 1 3D printer in their office, this technology felt that there were minor to very few
compared with a study by Poulos et al11 in 2021 that re- challenges in finding the workspace to use the 3D
ported that 39% of practicing orthodontists had a 3D printers and training staff using this technology. Among

American Journal of Orthodontics and Dentofacial Orthopedics July 2024
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practitioners who were not incorporating 3D printing in
their offices, most were not the decision-makers in their
practice. Among decision-makers, the leading reasons
not to incorporate this technology were lack of interest,
lack of training with this 3D printing, or difficulties
with finding the space for ventilation. Panayi and Eli-
ades12 published suggestions to create a safe environ-
ment for 3D printing, including ventilation guidelines.
Almost every respondent using 3D printing technol-
ogy was happy with their experience. The most common
reasons that 3D printing met their expectations were the
ease of workflow, the ease of patient comfort, and the
accuracy of the printing. Out of those who felt that 3D
printing had not met their expectations, the main reason
was that they felt it to be more time-consuming than
conventional methods of orthodontics.
Of the orthodontic specialists who did not currently
practice 3D printing technology, more than one-third
of specialists (39%) expressed that they are very likely
to incorporate 3D printing in their practices in the
future. Reinforcing advantages and eliminating chal-
lenges associated with 3D printing technology, as iden-
tified in this study, may present an opportunity for more
orthodontists who wish to adopt this technology.
One of the limitations of our study was the minimal
response rate. Although survey response rates can often
be low, the exceptionally low response through the AAO
link was surprising and difficult to explain. The survey
was also made available to attendees at a national ortho-
dontic meeting and via an orthodontic Facebook group.
Response rates can be influenced by survey fatigue,
limited time to answer surveys, or perceived lack of rele-
vance to the survey (eg, the title may have led potential re-
spondents to think that if they did not own or use 3D
printing, the survey was not relevant). This can lead to
biased responses, resulting in an inflated estimate of 3D
printing use. In addition, when using a social media group
such as Facebook, some practitioners may not view these
groups on a daily basis and may have missed the posting to
fill out the survey. Nonetheless, the overall demographics
from all respondents had a number of similarities to the
American Association of Orthodontits Workforce Report,
suggesting our results provide valuable information.
Future studies could take a closer look at the number
of clinicians who switched from outsourcing to in-office
manufacturing for in-office aligners or the opposite and
whether 3D printing is more cost-effective when con-
ducted in an in-office or an outsourced manner.
CONCLUSIONS
1. Almost 75% of orthodontists use 3D printing tech-
nology in some capacity in North America.
July 2024
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ElShebiny et al
2. Space for equipment/ventilation, digital workflow
training deficit, and lack of manpower were the major
factors that have prevented orthodontists from incor-
porating 3D printing technology into their offices.
3. Orthodontists use their 3D printer primarily to make
plastic retainers from printed models.
4. The strongest associations with using an in-office 3D
printer were seen with patient load, practice type,
years since residency, and orthodontist’s position.
5. Increasing patient load and being in a private prac-
tice increases the probability of having a 3D printer.
SUPPLEMENTARY DATA
Supplementary data associated with this article can
be found, in the online version, at https://doi.org/10.
1016/j.ajodo.2024.03.014
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