Use of Technology in Dental Education

3D Printed Teeth for the Preclinical

Education of Dental Students
Christian Höhne, Marc Schmitter
Abstract: A need for more realistic tooth models for education has often been expressed by dental students. The aim of this study
was to design and create 3D printed teeth with anatomical details for use in preclinical dental education. A tooth with realistic
carious lesions and pulp cavity was designed, and this tooth was used in 2018 with 47 dental students for preclinical education
in caries excavation, direct capping of the pulp, core build-up, and crown preparation. The students had the ability to identify the
carious lesions by a simulated radiograph and by tactile sense of the consistency. The benefits of the 3D printed tooth were evalu-
ated by a questionnaire. The printed tooth was evaluated by grades (1=excellent, 2=good, 3=satisfactory, 4=adequate, 5=poor).
The students gave the tooth an overall mean grade of 1.9, with a grade of 2.0 for the haptic impression, 1.5 for the exercise, 1.9
for the examination, and 1.5 for high practical relevance in contrast to a standard model tooth. The new features of the printed
tooth were given a mean grade of 2.0 for the radiograph, 2.3 for consistency of the caries, 2.0 for the tooth filling, and 1.7 for the
pulp capping as realistic. The students had the possibility to generate a complete concept for prosthodontic tooth treatment on an
artificial 3D printed tooth.
Christian Höhne, DMD, is Research Associate, Department of Prosthodontics, University of Wuerzburg, Germany; and Marc
Schmitter, DMD, is Professor and Director, Department of Prosthodontics, University of Wuerzburg, Germany. Direct corre-
spondence to Dr. Christian Höhne, Department of Prosthodontics, University of Wuerzburg, Pleicherwall 2, 97070 Wuerzburg,
Germany; +49931-201-74809; hoehne_c@ukw.de.
Keywords: dental education, preclinical education, prosthodontics, printed tooth, 3D printing
Submitted for publication 8/2/18; accepted 2/20/19; first published online 5/27/19
doi: 10.21815/JDE.019.103

C
omputerized dentistry has become an es-
sential part of dental education and dental
practice. In the last decades, new fabrication
methods were introduced in dentistry and found
their way into dental education. The combination
of 3D scanners, cone-beam data, and 3D printers
has enabled the replication of anatomical structures
in artificial teeth for dental education.1-4 Even the
construction of complex 3D tooth models of natural
teeth by micro-computed tomography has become
possible for education.5-7
Despite these developments, until now only
very simple tooth models have been available for stu-
dents’ education in preclinical and clinical courses in
prosthodontics. These models had neither a pulp cav-
ity nor carious lesion or the need for a core build-up.
Students had to prepare “intact” teeth with no need
to prepare them at all. They had no chance to train
in different situations, and the learning effect started
in the clinical course. Preclinical training, however,
would be useful to achieve more skills in the correct
treatment of standard situations. Variations in the
training models would lead to better diagnostics and
improve the decision-making process.
The aim of this study was to design and cre-
ate 3D printed teeth with anatomical details for use
in preclinical dental education. The training tooth
was to be used for training of caries excavation,
pulp capping, core build-up, and crown preparation
combined in one, with success of caries removal
checked by a blue LED light. Our hypothesis was
that the 3D printed tooth would have benefits for
education in contrast to a standard model tooth in
training of a complete prosthodontic situation with
caries excavation, pulp capping, core build-up, and
crown preparation.
Materials and Methods
The University of Wuerzburg Institutional Re-
view Board determined this study was exempt from
oversight. The printed tooth was designed to fit into a
standard dental study model (KaVo, Biberach an der
Riß, Germany). This study model was scanned by an
InEos X5 scanner (Dentsply Sirona, York, PA, USA).
A cone beam computed tomography (CBCT) scan of
an extracted first permanent molar was acquired by

Published online ahead of print 27 May 2019  ■  Journal of Dental Education e1

 an Orthophos XG 3D (Dentsply Sirona, York, PA,
USA). Autodesk Inventor 2017 (Autodesk, San Ra-
fael, CA, USA) was used for creation of the model.
The STL file from the scanner and the CBCT were
used for the design.
The tooth had a cavity for the pulp and an
extended carious lesion (Figure 1, panel a). A radio-
graph of the tooth was designed using a look-through
image from the computer-assisted design (CAD)
model. This image was modified with GIMP 2.10.4
(GNU General Public License) using different filters to
mimic a radiograph (panel g). The vestibular carious
lesion was designed to be probably misinterpreted in
the simulated radiograph as a complication for caries
excavation. However, this finding in the simulated
radiograph was caused by the overlapping part of
the vestibular carious lesion. Another challenging
situation was the closest relationship of 0.3 mm to
the mesial pulp cavity, which had to be managed by
the students (Figure 2, panel b).

Figure 1. The design and steps of creation of the printed tooth

Note: Steps were as follows: computer-assisted design of the tooth with pulp in red and carious lesions in yellow (panel a); tooth after
the 3D print with support structures around it and cover for pulp under tooth (panel b); occlusal view of printed tooth into the carious
lesion (panel c); filled carious lesion (panel d); covered carious lesion (panel e); completed tooth with removed supports, filled, and
sealed pulp (panel f); and designed radiograph of the tooth with visible carious lesions and pulp (panel g).

Figure 2. Single steps of tooth therapy on the printed tooth

Note: Steps were as follows: after complete caries excavation, the pulp was visible through the material (panel a); the mesial cavity
(panel b); selective opening of the pulp (panel c); direct pulp capping (panel d); core build-up (panel e); and crown preparation (panel f).

e2 Journal of Dental Education  ■  Published online ahead of print 27 May 2019

 After the CAD was completed, the tooth was
imported into PreForm 2.15.1 (Formlabs Inc., Somer-
ville, MA, USA) as an OBJ file and prepared for 3D
printing in a Form2 3D printer (Formlabs Inc.). White
photopolymer resin (RS-F2-GPWH-04, Formlabs
Inc.) was used for the print of the tooth models. A to-
tal of 110 teeth were produced on one build-platform
of the printer in ten hours and 31 minutes. A cover
for the pulp was printed under the tooth (Figure 1,
panel b). The teeth were washed 20 minutes after the
production with 95% isopropanol and cured for 30
minutes in the Form Wash & Cure units (Formlabs
Inc.). The automated production time of a single tooth
was therefore approximately six minutes.
Afterwards, the cavity for the carious lesion
was filled with Dentalon (Heraeus, Hanau, Germany).
Dentalon was a self-curing resin and was used to
simulate the caries (Figure 1, panel d). The filled
carious lesion was covered by white photopolymer
resin (RS-F2-GPWH-04, Formlabs Inc.) and cured
again in the Form Cure unit (panel e). The pulp cav-
ity was filled with Impregum Penta DuoSoft Light
Body (3M Espe, Seefeld, Germany). The material
was applied by an automix syringe and hardened
after mixing in the syringe. Duosoft was a polyether
impression material and simulated the pulp concern-
ing color and consistence. The pulp was closed with
the printed cover and sealed with white photopolymer
resin (RS-F2-GPWH-04, Formlabs Inc.) and then
cured for 30 minutes (panel f). The completion of
the tooth was done in approximately two minutes for
every tooth. The cost for the complete material for
one tooth was $0.38. The price for the printer and the
printing equipment were together $4,550. Therefore,
the production was not expensive or time-consuming.
A total of 47 fourth-year dental students in their
first clinical course in prosthodontics (28 women and
19 men, from 20 to 49 years of age with a mean age
of 26) were trained in a voluntary hands-on course
with 141 printed teeth. These students used standard
model teeth during their preclinical education. All the
participating students had already removed caries and
prepared teeth in one clinical course on patients and
also had experience on real-teeth models. They had
done at least ten dental fillings and three root channel
treatments on patients.
Each student had the opportunity to prepare
three identical printed teeth. The students could detect
the carious lesions with the radiograph: optically by
the darker occlusal areas of the printed tooth (Figure
1, panels e and g) and by tactile sense of the consis-
tency with a dental probe or by removement with a
Published online ahead of print 27 May 2019  ■  Journal of Dental Education
round bur. After this process, the core build-up was
completed. The tooth was surrounded by a dental
matrix band (KerrHawe SA, Bioggio, Switzerland)
and fixed by a tofflemire band holder. The cavity
was filled with Rebilda DC white (Voco, Cuxhaven,
Germany) (Figure 2, panel e). The tofflemire was
removed, and the tooth was prepared for a crown
(panel f). After removal of the carious lesion, some
students opened the pulp unintentionally (panel c).
To simulate a realistic situation, the pulp was capped
with Kerr-Life (Kerr, Orange, CA, USA), a com-
mon calcium-hydroxide material for pulp capping
(panel d) and was covered by a resin modified glass
ionomer cement (FujiCEM, GC Corporation, Tokyo,
Japan) followed by the light cured core build-up
material. In reality, a common complication after a
direct pulp capping is an endodontic treatment. To
simulate this situation, the tooth was not directly
prepared for a crown, and the student used another
tooth for training.
The material combination of the printed tooth
and the carious lesion were selected to enable the
students to control the correct caries excavation and
the core build-up by a blue 395nm LED light in a
closed photo box with a camera to prevent harmful
effects to the retina. The different colors of the materi-
als were caused by the different organic compounds
in the resins. Under the LED light, the tooth material
was visible in blue, the core build-up material was
reddish, and the caries material had a greyish yellow
shade (Figure 3). During complete removement of
the caries material, the yellow shade will disappear,
and the tooth material will become visible in blue.
Photographs were taken by a camera (Nikon D500,
Nikon Corporation, Tokyo, Japan) equipped with a
macro lens (AF-S VR Micro-Nikkor 105 mm 1:2,8G
IF-ED, Nikon Corporation, Tokyo, Japan) under blue
LED light and afterwards colorized to illustrate the
findings to students. Figure 3 shows good and bad
caries excavations performed by students. The tooth
was designed with deep mesial and distal carious
lesions. This situation was challenging for students
during application of the core build-up and the crown
preparation.
The benefits of the 3D printed tooth were
evaluated by all 47 students with a questionnaire. The
printed tooth was compared with a real tooth and the
standard model tooth. The evaluation was generated
with EvaSys (Electric Paper Evaluationssysteme
GmbH, Lüneburg, Germany) by the Institute for
Medical Teaching and Medical Educational Research
at the university. The questionnaire was tested before
e3


Figure 3. Control of tooth therapy performed by two students under blue LED light
Note: The tooth was colorized: vestibular view (panels a and e); mesial view (panels b and f); distal view (panels c and g); and occlusal
view (panels d and h). The core build-up material can be seen in red, remaining caries appear in yellow, and the prepared tooth was
visible in blue.

and after a course in root canal treatment and adapted
for the 3D printed tooth. At the end of the course,
every student received a single key for the digital
questionnaire. Questions were designed as closed
questions to be rated on a scale consisting of grades
(1=excellent, 2=good, 3=satisfactory, 4=adequate,
5=poor) for good discrimination. The last questions
were free text questions. The students also were asked
to rate the educational effect of the 3D printed tooth
and real teeth.
Results
The results of the comparison of the printed
tooth with a standard model tooth are shown in
Figure 4. No significant effect of students’ age was
detectable. The printed tooth was evaluated with an
overall grade of 1.9. The haptic impression during
preparation was assessed. The students rated the
printed tooth as good (Ø 2.0). The next question
was about the usability of the tooth for exercise. The
printed tooth was rated as excellent to good (Ø 1.5).
The printed tooth was even rated as good (Ø 1.9)
for an examination situation. Although treatment of
the printed tooth was much more challenging than
treatment of a standard model tooth, the students
did not report being overextended. For the students,
the printed tooth was good (Ø 2.0). The last item of
the second part of the questionnaire asked students
to evaluate the practical relevance of the printed
tooth by comparison to a real situation. The students
rated the practical relevance of the printed tooth as
excellent to good (Ø 1.5). Comments in the free-
text section of the questionnaire showed that most
students perceived the printed tooth as very realistic
and suitable for exercises.
In the next part of the questionnaire, the new
features of the printed tooth were evaluated in con-
trast to a real tooth. All the students had removed
caries and prepared teeth in one clinical course on
patients and were therefore capable of evaluating the
printed teeth. The first question was about the usabil-
ity of the tooth for exercises. The printed tooth was
rated as good (Ø 1.7). The quality of the simulated
radiograph was also rated as good (Ø 2.0). In the free
text, no criticism was expressed. The next question
was about the consistency of the caries material. The
material was rated as good (Ø 2.3), the tooth filling
was rated as good (Ø 2.0), and no proposals for im-
provement were stated. On the last question of this
part, the students rated the pulp capping as good (Ø
1.7). The good result indicated that the pulp was well
mimicked by the impression material.
The last part of the questionnaire assessed
students’ learning process. The students were asked
about their interest in improving their skills in tooth
preparation with the printed teeth and rated them
as good (Ø 2.3). The next question was about the
usefulness of printed teeth before real patient treat-
ment. The printed teeth achieved a good result (Ø
1.8). In the free text, the different hardness of the
simulation materials for the tooth, caries, and pulp
were commended several times as very good for

e4 Journal of Dental Education  ■  Published online ahead of print 27 May 2019



Figure 4. Percentage of grades for each item on questionnaire regarding evaluation of use of printed tooth
Note: Items for comparison of the printed tooth to a standard model tooth were as follows: 2.1) realistic haptic impression at
preparation, 2.2) suitable exercise option, 2.3) fair examination conditions, 2.4) easy to use, 2.5) high practical relevance. Items for
comparison of the printed tooth to a real tooth were as follows: 3.1) suitable exercise option, 3.2) realistic radiograph, 3.3) realistic
consistency of caries, 3.4) realistic tooth filling, 3.5) realistic pulp capping. Items for assessment of the learning process with the printed
tooth were as follows: 4.1) the printed tooth motivated me to improve my skills in preparing teeth; 4.2) in retrospect, I would have liked
to practice with printed teeth first and then treat a patient; 4.3) the printed tooth was very helpful for learning fundamental fine motor
skills; 4.4) the printed tooth gave me the opportunity to practice direct and indirect pulp cappings; 4.5) the printed tooth gave me the
opportunity to develop a feeling for the quantity of tooth substance removed above the pulp.

training. Furthermore, the printed teeth were rated as
good (Ø 1.9) for learning fine motor skills for tooth
preparation. The students confirmed that the printed
tooth had given them the opportunity to learn for the
first time direct and indirect pulp cappings and pre-
prosthodontic treatment. That question was evaluated
as excellent to good (Ø 1.6). Finally, the students
reported that the estimation of substance loss between
the pulp and the cavity due to caries excavation could
be trained effectively with the printed tooth (Ø 1.8).
In the free text section, this feature of the printed
tooth was addressed many times.
The blue LED light was a good tool to control
and educate the students in caries excavation. The
blue LED light could also be used to control the com-
plete core build-up for remaining carious lesions. The
correct marginal preparation of the tooth was control-
lable, which was important for complete enclosure of
the core build-up material by the preparation.
Discussion
A frequent answer to the free text question was
the expressed desire for a harder material for the
printed tooth. New materials for the 3D printer, with
optimized material properties (such as hardness),
will be introduced soon and may overcome this
problem. According to the results of our analysis, 3D
printed teeth were suitable for exercises as well as
for examinations. No criticism was expressed with
respect to the simulated radiograph in the free text.
However, some students stated in the free text sec-
tion that a more distinctive discrimination between
enamel and dentin would be helpful. The result of
the comparison to a real tooth was somewhat better
than to the model tooth, which was to be expected.
It was considered as a plausibility question of the
questionnaire and verified that the questions were
correctly answered. In the free text section, the
ability of the printed tooth of estimating substance
loss was addressed many times. This frequency was
remarkable because all the students had real patient
experience. The students were especially interested
in the simulation of the pulp for preparation. In the
clinical practice, a deep traumatic preparation was a
common complication of tooth preparation. It was
interesting that this was also a main issue for the
students to improve their training. With these results,
the hypothesis of this study was confirmed: the 3D
printed tooth had benefits for education in contrast to
a standard model tooth in the training of a complete
prosthodontic situation with caries excavation, pulp
capping, core build-up, and crown preparation.

Published online ahead of print 27 May 2019  ■  Journal of Dental Education e5

 Only a limited number of studies were available
so far on this topic. The use of virtual 3D-models
was described by de Boer et al.8 They used a MOOG
Simodont dental trainer (Moog Dental Simulation,
New York, NY, USA), a virtual learning environment
with haptic feedback. They described the positive ef-
fects of the simulator on student learning. The virtual
reality enabled students to train in different situations
and achieved new skills in various fields. It was an
interesting technology, and real patient situations
could be simulated. However, that procedure was
very costly because of the simulation device. Printed
3D teeth could be produced at very low cost and
used in standard models without high investments.
Even in this situation, the students achieved realistic
experience with dental equipment.
In another study, Soares et al. used rapid pro-
totypes and virtual models to demonstrate the differ-
ences in cavity preparation for teaching students.2 In
our study, the students were trained directly on the
teeth. Different tasks had to be managed prior to the
preparation of a crown: caries excavation, pulp cap-
ping, and core build-up. 3D printed prepared teeth
were also used for the education of dental students
by Boonsiriphant et al.9 They used the printed teeth
for 3D views of prepared teeth and reported great
advantages for real 3D visual recognition and skill
acquisition in contrast to 2D images in books or
lectures. This difference was also confirmed by our
questionnaire. The students showed a lot of interest
in integrating the 3D printed teeth in their studies.
In our study, teeth were designed to train all steps
of prosthodontic treatment. Kröger et al. used 3D
printed models, based on real patients, for the train-
ing of students in different situations.10 Three models
were printed for different tasks. The first model was
for veneer preparation, the second for dental bond-
ing, and the third for interdisciplinary simulation of
caries excavation and crown removal. The models
were printed as full dental models and were fixed
to a plate. The third model simulated carious teeth,
comparable to the simulated situation in our study.
However, no artificial pulp cavity was included. The
students in our study were especially interested in
simulation of the pulp cavity for preparation. In the
clinical practice, a deep traumatic preparation was
a common complication of tooth preparation. The
model in our study was, in contrast to Kröger et al.,
a single tooth, which can be fixed into a KaVo stan-
dard dental study model similar to the model used
by Boonsiriphant et al. but with a more complex
internal structure.9
e6 Journal of Dental Education  ■  Published online ahead of print 27 May 2019
Improvements to Printed Tooth
On the questionnaire, the tooth filling was rated
as good (2.0), and no proposals for improvement
were stated. The result could be explained by the
very extended carious lesion, which was designed
to give students a reason for the crown preparation
of the tooth. Today, for patients with a regular recall
interval at their dentist, such a big unseen carious
lesion was unlikely. For the future, a model with
a smaller carious lesion and some filling material
would perhaps be more realistic.
Another point was the question about the inter-
est in improving students’ skills in tooth preparation
on the printed teeth. It was rated as good (2.3). The
evaluation result was caused in our opinion by a
summation of the potential for improvements. This
was the hardness of the material, the dimension of
the carious lesion, and the radiograph. The students
were trained with real patients and were very critical
in the evaluation, but this was good for a realistic as-
sessment of the 3D printed tooth, which would never
be possible by a preclinical course.
Complex Tooth Design
As mentioned by Kröger et al.,10 the fabrica-
tion of a tooth model is a complicated process and
requires many skills in various fields. The design of
a tooth was complicated if it was not a simple copy
of a natural tooth. The adaption of a tooth model to
a training model needed a special way of generating
the model. The main task was the conversion of the
construction file from an STL file to a modifiable
file. The direct modification of the STL file had some
major shortcomings as an STL file described a raw,
unstructured triangulated surface. Direct modifica-
tions of these files resulted in coarse surfaces, and
the process was very time-consuming.
In industry, the classic construction standard to
overcome this problem is currently a format called
Non-Uniform Rational B-Spline (NURBS). NURBS
were implemented in numerous CAD formats such
as IGES, STEP, ACIS, and PHIGS, supported by
common construction software. These formats made
it possible to generate natural surfaces and allowed
a full modifiable model. Therefore, in our study this
format was adapted to the different constructions.
The teeth were printed on an affordable Form-
labs 3D printer. Other more sophisticated printers
were available on the market (for example from
Stratasys, Rehovot, Israel) that allow one to print dif-
ferent materials in one step. With those printers, the
teeth need almost no post-production. Such a printer
(Objet 30 Prime, Stratasys) was available for our
department, but we had chosen to show this method,
which was not cost-intensive and would be available
to many academic dental institutions. Even the time
for completion of the tooth after printing was within
two minutes and thus not very long. The generation
of more natural tooth models with sophisticated
anatomical details for dental education seems to be
a task for the future. A final limitation of the study
is that since it took place at a single dental school,
its results may not be generalizable to students in
other programs.
Conclusion
With the printed teeth, students in this study
had the opportunity to practice the complete treat-
ment of a real prosthodontic situation, including
caries excavation, pulp capping, core build-up, and
crown preparation. The blue LED light was useful
in educating students in each step of the process.
Furthermore, deficits in caries excavation could be
seen and presented to students in structured feed-
back. Overall, the printed tooth had many features
to help train students. The questionnaire confirmed
the students’ perceptions of the value of such a tooth
for use in dental education.
Acknowledgments
The authors would like to thank Prof. Dr. Sarah
König, Head of the Institute for Medical Teaching
and Medical Educational Research, University of
Wuerzburg, Germany, for valuable help in creating
Published online ahead of print 27 May 2019  ■  Journal of Dental Education
the questionnaire. Special thanks to all the students
who participated and provided us with information
to improve preclinical and clinical education with
this printed tooth model.
REFERENCES
1. Cantín M, Muñoz M, Olate S. Generation of 3D tooth
models based on three-dimensional scanning to study
the morphology of permanent teeth. Int J Morphol
2015;33(2):782-7.
2. Soares PVA, Reis BR, Soares CJ, et al. Rapid prototyping
and 3D-virtual models for operative dentistry education
in Brazil. J Dent Educ 2013;77(3):358-63.
3. Chan DC, Frazier KB, Tse LA, Rosen DW. Application
of rapid prototyping to operative dentistry curriculum.
J Dent Educ 2004;68(1):64-70.
4. de Boer IR, Lagerweij MD, Wesselink PR, Vervoorn JM.
Evaluation of the appreciation of virtual teeth with and
without pathology. Eur J Dent Educ 2015;19(2):87-94.
5. Kato A, Ohno N. Construction of three-dimensional tooth
model by micro-computed tomography and application
for data sharing. Clin Oral Investig 2009;13(1):43-6.
6. Hannig C, Krieger E, Dullin C, et al. Volumetry of human
molars with flat panel-based volume CT in vitro. Clin Oral
Investig 2006;10(3):253-7.
7. de Boer IR, Wesselink PR, Vervoorn JM. The creation
of virtual teeth with and without tooth pathology for a
virtual learning environment in dental education. Eur J
Dent Educ 2013;17(4):191-7.
8. de Boer IR, Wesselink PR, Vervoorn JM. Student perfor-
mance and appreciation using 3D vs. 2D vision in a virtual
learning environment. Eur J Dent Educ 2016;20(3):142-7.
9. Boonsiriphant P, Al-Salihi Z, Holloway JA, Schneider
GB. The use of 3D printed tooth preparation to assist in
teaching and learning in preclinical fixed prosthodontics
courses. J Prosthod, forthcoming.
10. Kröger E, Dekiff M, Dirksen D. 3D printed simulation
models based on real patient situations for hands-on
practice. Eur J Dent Educ 2017;21(4):e119-25.
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