IP Indian Journal of Orthodontics and Dentofacial Research 2021;7(3):208–215

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IP Indian Journal of Orthodontics and Dentofacial Research

Journal homepage: https://www.ijodr.com/

Review Article
Thinking forward: 3-D printing in orthodontics

Nausheer Ahmed1 , Shreya K Shetty1, *, Haritha Urukalan1 , Nikhil P M1 ,

Abrar Younus 1 , Ranjan K R Bhat1
1 Dept. of Orthodontics and Dentofacial Orthopedics, Government Dental College and Research Institute, Bangalore,
Karnataka, India

ARTICLE INFO ABSTRACT

Article history: Advancements in the field of digital technology has vastly influenced various industries including dental
Received 28-09-2021 practice. 3-D printing is one such development that has revolutionized the manufacturing industry and has
Accepted 21-09-2021 become a subject of great interest in the field of dentistry. With the greatest advantage of 3-D printing being
Available online 22-10-2021 customization, it has become an important tool in delivering precise appliances and surgical guides.
This article reviews the applications and incorporation of 3-D printing technology and recent advances
applicable into dental practice, oral surgery and orthodontics.
Keywords:
3D printing This is an Open Access (OA) journal, and articles are distributed under the terms of the Creative Commons
Additive manufacturing Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon
Digital work flow the work non-commercially, as long as appropriate credit is given and the new creations are licensed under
Digital orthodontics the identical terms.
For reprints contact: [email protected]

1. Introduction been valuable to construct true–to–life models in the field of

medicine and dentistry for educational, research, treatment,
3-D printing which originated as a tool for rapid prototyping
and surgical planning purposes.
rapidly found its application in various fields of science and
art and is recently being applied in the field of medicine, In the field of dentistry, it has been incorporated into
dentistry including surgery. various treatment modalities.
The word 3-D printing is used to describe a This article reiterates applications and recent advances in
manufacturing method that builds objects layer by 3-D printing technology applicable to orthodontia.
layer. This process is termed additive manufacturing, and Hideo Kodama of the Nagoya Municipal Industrial
can also be referred to as rapid prototyping. 1,2 Research Institute in Japan discovered a way to print layers
This technology has remarkable applications in dentistry, of material to create a 3-D object in 1981. Sadly, Kodama
and with newer innovations in 3-D imaging and designing failed to get his patent for the technology approved.
technologies such as cone beam computed tomography and In 1986, Charles Hull an American, created a prototype
intraoral scanning, and CAD/CAM technologies, it will for a process called stereolithography (SLA). 3
become of increasing importance. Stereolithography uses STL format to interpret the data
With the radical development of 3-D printing in medicine in a CAD file. The data interpreted includes information
and dentistry, 3-D printing guarantees better patient care and on size, shape, color, and thickness, and the texture of the
improves the clinician’s efficiency in providing better care. object to be printed. Hull used acrylic-based materials which
3-D printing is capable of providing customized transformed from liquid to solidupon exposure to ultraviolet
treatment based on an individual’s anatomic records. It has lights. Hull is known as “the father” of 3-D printing. 4
* Corresponding author. Hull’s 3-D printing as described in the U.S patent is as
E-mail address: [email protected] (S. K. Shetty). follows

https://doi.org/10.18231/j.ijodr.2021.034
2581-9356/© 2021 Innovative Publication, All rights reserved. 208
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“Briefly, and in general terms, the present invention Though there is some amount of material wastage,
provides a new and improved system for generating a three- milling is advantageous over printing as the material used
dimensional object by forming successive, adjacent, cross- is intrinsically homogeneous and unaffected by operating
sectional laminae of that object at the surface of a fluid conditions. Milling requires little post-processing, and the
medium capable of altering its physical state in response to equipment is by far less expensive. 11
appropriate synergistic stimulation, the successive laminae
being automatically integrated as they are formed to define 2.3. Applications in restorative dentistry
the desired three-dimensional object.” 5
He established the company 3-D Systems which Intraoral scanners are increasingly being used to scan
introduced the first commercially available 3-D printer the prepared tooth surfaces. This has necessitated the
named SLA-250 in 1988. 6 employment of 3-D printers to make physical models from
the scanned data.
Though it is not always necessary to prepare physical
2. Applications of 3-D Printing in Dentistry
models16 for fabrication of restorations, the models required
2.1. Study models when veneering materials have to be added. The models are
also needed for the display of the restorations even when
The earliest application of 3-D printing was in the making these restorations and digitally fabricated. 11
of anatomic study models. 7
CBCT along with 3-D printing technology has
2.4. Orthognathic surgery
transformed diagnosis and treatment planning in the
field of dentistry. 8,9 The success of orthognathic surgery hinges on accurate
The CBCT provides volumetric data to the 3-D printer to diagnosis and treatment planning.
produce a detailed model of the bone structure in question. Conventionally orthognathic surgery planning involves
This allows the clinician to gain a clear idea of unusual, or 2 stages- radiographic simulation with cephalometric
unfamiliar anatomy to draw up the most favorable treatment planning and manipulation of physical dental models in
plan. the desired direction. This process is essential to establish
The ability to clearly understand the anatomy and to a postoperative occlusion which is then used to fabricate
produce suitable cutting guides using the technology has a surgical wafer. 3-D imaging technologies like CT and
paved the way for newer surgical approaches which are CBCT provide accurate data to develop study models,
less invasive and have better predictable outcomes. In both digital and physical which are required for treatment
reconstructive surgeries, 3-D printing has been used to planning.
prepare customized reconstruction plates and prostheses. Simulated repositioning of jaws using digital study
This can also be used as an alternative to invasive autologous models can be performed and surgical wafers can be
bone grafting procedures. 10 accurately fabricated using 3-D printing technology.
This eliminates the arduous process of plaster model
2.2. Applications in designing prosthesis making and facebow recording and in turn minimizes the
errors and imprecisions.
The use of intraoral optical scanners enables the The wafer fabrication stage involves virtual filling in the
development of precise virtual models of implant positions, void between the upper and lower digital dental models
prepared tooth surfaces, and even the complete dental in their final occlusal positions. After the approval of the
arches. For prosthodontics rehabilitation, prosthesis and digital surgical wafer by the technician and clinician, the
restoration can be designed using CAD software. The data surgical wafers can be 3-D printed prior to the surgery. 15
of the designed prosthesis can be milled using CAD-CAM
software or can be 3-D printed. 11
3. Orthodontics
Fabrication of metallic structures using 3-D printing can
be achieved by either indirect methods like printing in burn- In orthodontics, computer-aided designing and
out resins or waxes for a lost-wax process or directly in manufacturing technologies along with 3-D printing
metal alloys. 12 are replacing traditional laboratory setup.
Printing in resin/wax and then using a traditional casting This necessitates a different workflow. With the digital
approach is beneficial as there is a reduced need for post- workflow treatment planning, appliance designing and
processing procedures when compared to that in the direct fabrication can be performed precisely and without delay.
3-D printing of metal casting alloys. 13 The digitally printed models are durable and precise.
Printing directly in metals is found to be more expensive They also enable corrections before printing.
as they require the use of costly technologies 14 and also With the use of digital software, an orthodontist can
demand elaborate post-processing before components may remove the existing brackets and appliances from the
be ready for use. scanned dataset and design a new appliance. Thus, the
210 Ahmed et al. / IP Indian Journal of Orthodontics and Dentofacial Research 2021;7(3):208–215

orthodontist can deliver a new appliance immediately upon technologies is listed in Table 1.
the removal of the old one. For example, the patient can
be provided with a retainer immediately after debonding,
3.2. Review of recent literature involving 3-D printing
eliminating the waiting period or perhaps a second visit. In
case of breakage or loss of retainer, a replacement can be technology incorporated into orthodontics
easily fabricated either by using printed models or from the
In a study conducted to compare 5-axis machining and
digitally archived data. 16
3-D printing it was observed that 5-axis machining can
The Invisalign® system can digitally realign the patients’
achieve the 0.01–0.02 mm accuracy level that is required
teeth and make series of 3-D printed models for the
by the dental industry standard. However, a 5-axis milling
manufacturing of ‘aligners’. These aligners progressively
machine can fabricate only one model at once. Conversely,
reposition the teeth over a period of several months. 17
3-D printing though less accurate (about 0.03–0.05 mm) had
Yetanother example for printing with multiple materials
the advantage of multiple simultaneous productions. 25
using orthodontic CAD software is manufacturing of
indirect bracket-bonding splints, printed in rigid and flexible A study was conducted to evaluate the accuracy of a
materials for precise bracket placement. 18 model made using the computer-aided design/computer-
With the aid of CAD/CAM software bracket, production aided manufacture (CAD/CAM) milling method and 3-
and bracket positioning can be performed simultaneously. 19 D printing method and to confirm its applicability as a
In neonates and infants with syndromes affecting the working model for dental prosthesis production. This study
craniofacial region, it is crucial to begin the treatment at concluded that the accuracy of the 3-D printing method is
the earliest. Conventional alginate impression techniques in superior to that of the milling method. 26
these patients could be life-threatening. Intraoral scanning A study was conducted to determine the possibility
followed by digital workflow can be a more suited option. 20 of implementing a fully digital workflow clinically with
With a fully digital workflow, complex appliances individually designed and three-dimensional printed (3D-
like Tübingen Palatal Plate (TPP) and palatal plates for printed) brackets. This study concluded that it is possible
infants can be fabricated accurately by rapid prototyping. to perform treatment with an individualized 3D-printed
This enables the prototype to be digitally altered as brackets system by using the proposed fully digital
per clinical needs and as well eliminates the need for workflow. 27
conventional impressions and physical models to fabricate
the appliance. 21,22
With the use of virtual set-ups, customized bracket
printing, and robotic wire-bending, Dr. Wiechmann created
a fully customized lingual appliance over 15 years ago.
The desired treatment outcome was virtually set up and
then fully customized brackets were digitally designed to
conform to the lingual surface of the teeth and were then
3-D printed in wax and cast in gold. This has enabled the
creation of low-profile brackets which are well tolerated by
patients.
This technology has also been incorporated into the
manufacturing of labial appliances with the introduction of
Insignia 9 by ORMCO (Ormco, Glendora, CA, USA) as
Fig. 1: Chuck Hull with the first ever 3D printer, the SLA-1 28
a system of customized labial appliances which are then
indirectly bonded.
Indirect bonding trays are can be printed accordingly and
then the brackets are simply placed into the positioning jigs
for accurate positioning. This method has been shown to
reduce chairside time as well as bracket positioning errors
during indirect bonding. 23

3.1. Scanners and printers

New intraoral scanners are rapidly being introduced into
clinical practice. 24 Though the detailed description of all the Fig. 2: Illustration of digital work flow
available technologies is beyond the scope of this article,
a brief listing of the available scanning and 3-D printing
 Ahmed et al. / IP Indian Journal of Orthodontics and Dentofacial Research 2021;7(3):208–215 211

Table 1:
Confocal Laser Scanner Microscopy (CLSM)
Optical triangulation
Optical scanning technologies Optical Coherence Tomography (OCT
Accordion Fringe Interferometry (AFI)
Active Wavefront Sampling (AWS)

iTero®
Align Technology
True Definition
3M ESPE
LythosTM
Ormco Corporation
CS 3500
Carestream
Optical Scanning systems: TRIOS®
3Shape
FastScan®
IOS Technologies
3-D progress
MHT Optic research
E4D Technologies
Planmeca PlanScan®
Desktop scanners: Ortho Insight 3-DTM (Motion View Software, LLC, Chattanooga TN)
VECTRA M3 Imaging System
3-DMDface System (3-DMD, Atlanta, GA, USA)
Facial scanners : Rainbow 3-D Camera (Genex Technologies, Inc., Kensington, MD, USA),

3-D Vectra (Canfield Imaging Systems, Fairfield, NJ, USA)

Facial Insight 3-D (Motion View Software, LLC, Chattanooga TN, USA)
Fused Deposition Modelling (FDM)
Selective Laser Melting (SLM)
Selective Laser Sintering (SLS)
Electron Beam Melting (EBM)
3-D printing technologies : Stereolithography (SLA)
Inkjet 3-D printing
Digital Light Processing (DLP)
Laminated Object Manufacturing (LOM)
Objet 30 Ortho Desk
(Stratasys, Ltd., Eden Prairie, MI)
ProJet® 3510 MP
(3-D Systems, Rock Hill, SC)
3-D printers in commonly used in ULTRA® 3SPTM Ortho (EnvisionTEC, Gladbeck, Germany, SC)
orthodontics:
Perfactory® Micro Ortho (EnvisionTEC, Gladbeck, Germany)
Maker Bot Replicator 2
(Stratasys, Ltd., Eden Prairie, MI)
FORMIGA P 110
(EOS, Munich, Germany)
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3.3.3. 3-D printing

3-D printers differ from each other in terms of:

3.3.3.1. Size of the build platform and number of models

printable in one print cycle. Print platforms may be
cataloged as small, medium, and large.
Printers with small platforms allow relatively rapid
printing of several horizontal models. These printers require
the models to be thin and are suitable for the fabrication
of aligners and retainers. These are not recommended for
models in which full palatal depth is required for appliance
fabrication. In clinical orthodontic practice, a medium-size
Fig. 3: Illustration of digital laboratory set-up printer is adequate.
For dental laboratories which requires printing of a
large number of retainers and aligner models, large printers
3.3. Digital workflow specifically designed for use in dentistry are apt. 29
3.3.1. Intra-oral scanning
3.3.3.2. Printing speed and resolution. Speed and
Using intra-oral scanner virtual models of teeth and soft resolution are interdependent. With a higher resolution
tissues are obtained. setting greater surface detail and smoother finish is
The data set is exported as a standard tessellation obtained. This is due to an increase in the number of
language (STL) file. 29 print layers. Hence, a longer time is required to print
high-resolution data. 29
3.3.2. Digital model manipulation Overall, 100-µm layer thickness appears to be adequate
The virtual model obtained by scanning is hollow and wafer- for the orthodontic purpose, when compared to slower print
thin. The models obtained from such data are too fragile times with resolutions of 25µm and 50µm. 30
and are not suitable for appliance fabrication. Therefore, the The orientation of the models on the build platform
virtual models should be made bulky by in-filling before also influences the speed. Models oriented parallel to the
printing. The base does not have to be as bulky as the platform is printed faster.
conventional model but should be flat and provide essential Print times for dental models, at the 100-µm resolution,
stability to the model. Any suitable CAD software can be are commonly in the range of 1–10 hours, depending on
used for this purpose. horizontal and vertical model set-ups, respectively.
Several steps are involved in the digital manipulation
With a shorter print time, it is possible to deliver
of a virtual model using 3-D design software. They are as
the appliances on the same day after post-processing and
follows:
appliance fabrication.

1. Identification of surface irregularities and repair of the 3.3.3.3. Supports. To add to the structural integrity of
surface the models, bars are incorporated into the model design.
2. Attaining uniform model edges by removing These bars are called supports. They are helpful when the
unimportant soft tissue segments. model base is irregular. Supports do not have a standard
3. Designing a flat base parallel to the occlusal plane. measurement of density. They are usually added by the
4. Adjusting the base height to avoid excessive model software automatically. An increased number of supports
thickness thus reducing printing time and material does not necessarily mean an increase in print time. They
wastage. enable the safe removal of the model from the print
5. In-filling of the model. This adds sufficient bulk to platform. On the other hand, an increased number of
the model and avoids disintegration during printing and supports requires more resin and a greater finishing.
appliance fabrication.
6. On the other hand, the model can be hollowed 3.3.3.4. User-friendliness of the printer software. The
leaving sufficient thickness. This is suitable for models software used can automatically decide the orientation,
requiring full palate depth. This avoids excessive resin support addition required for printing. The software can be
usage. used by the orthodontist from a different place to make any
7. Labeling of the model should be done for patient additional alterations. The data can be stored in the software
identification. 29 and reprinted if the need arises. 29
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3.3.4. Post-print processing and tolerates processing procedures of appliance fabrication

Post–print processing generally involves the following well. These models can be easily reprinted if required as
steps. the data is digitally stored. The digital workflow allows
modifications in the data set of the archived impression as
3.3.4.1. Washing the models. The printed models should per the clinical needs. Ex. Tooth movement can be simulated
be rinsed thoroughly using 95% isopropyl alcohol in an in aligner therapy before fabrication of the appliance.
ultrasonic bath for 10 minutes. This process removes any Brackets and bands can be digitally removed from the data
uncured surface resin. The models should be air-dried for before the fabrication of any appliance or retainers. The
removal of any residual isopropyl alcohol. use of digital workflow saves time and expenditures due to
outsourcing for appliance fabrication.
3.3.4.2. Curing the models. For complete curing of the
resin, the model has to be exposed to ultraviolet and
heat. Special curing units are usually provided by printer 3.6. Disadvantages
manufacturers to serve this purpose. The curing parameters Digital in-office lab has a high cost of maintenance.
should be set according to the manufactures instruction. The printers require an annual subscription to CAD/CAM
Once the model is completely cured, it can be handled software.
without gloves. 29 Soldering of the appliances while placed on a resin
model results in model distortion and there arises a need to
3.3.5. Appliance fabrication replicate the model. To avoid this laser welding is advised
This stage is similar to that of conventional appliance over soldering, this is an add-on expense. Special training of
making. To fabricate retainers of aligners a vacuum forming the staff to familiarize them with 3-D software and hardware
machine is used with a suitable thermoplastic material. is required. Adequate training and knowledge are required
in order to prepare digital models without printing and post-
3.4. How to set up a digital laboratory? processing errors. Uncured resins and cleaning solvents can
be irritating to the skin. 29 All health and safety guidelines
The digital laboratory unlike the conventional laboratory
should be followed during the handling and storage of these
does not require a stone dispenser, investment vibrator,
materials.
model trimmer, large sink with plaster trap, or designated
The costs and benefits of establishing an in-house digital
countertop space for poured casts. Instead, it requires space
lab should be carefully assessed and outsourcing should be
for a computer workstation with CAD/CAM software, the
considered if found economical.
3-D printers and resin cartridges, and the post-processing
procedures. 16 Appropriate CAD and printing technology
should be purchased as per use. The lab should be well 3.7. 3-D printing during COVID-19 pandemic
ventilated, free from dust and disturbances. For the working On 31st December 2019, 27 cases of pneumonia of
of the thermoplastic machine compressed air is necessary. unknown etiology were identified in Wuhan City, Hubei
Compressed air is also required for cleaning freshly printed province in China. 31
models. The working area depends on the type of printing The Chinese Centre for Disease Control and Prevention
technology used. Post-processing phases are different for (CCDC) analyzed the throat swab cultures and identified
different technology used. Appropriate equipment and a the causative agent which was subsequently named Severe
washing area have to be constructed. Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-
2).
3.5. Advantages On 30th January 2020, the WHO declared the outbreak of
Adopting a digital workflow has numerous benefits. For COVID-19 to be a Public Health Emergency of International
instance, it takes a smaller number of appointments with Concern. 32
shorter appointment time with increased patient comfort. 16 Following this various guidelines for prevention and
This improves patient compliance. The traditional plaster control of this disease were issued by multiple public health
models are predisposed to clinical and procedural errors agencies and local health authorities.
due to damage and distortion of impression. Technical These guidelines included social distancing, use of
errors like improper mixing of materials resulting in thin frequent hand hygiene, and masks.
casts, porosities, chalky surface, improper trimming of Orthodontic patients are required to have routine follow-
the margins can occur it is time-consuming to manually up visitations to the dental office.
prepare good plaster models. These models are susceptible With multiple travel restrictions imposed and
to damage during transport and processing. apprehension of contacting the infection, patients often
All the above problems can be eliminated by 3-D find regular dental visitations challenging. Many patients
printing. 3-D printed models are accurate, stable, durable, happen to miss their appointments, leading to unwanted
214 Ahmed et al. / IP Indian Journal of Orthodontics and Dentofacial Research 2021;7(3):208–215

treatment results and delayed conclusion of the treatment. 33 6. 3D Printing: What You Need to Know.
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