Additive Manufacturing Techniques in Prosthodontics:

Where Do We Currently Stand? A Critical Review

Nawal Alharbi, BDS, MSc1/Daniel Wismeijer, DDS, PhD2/Reham B. Osman, BDS, MSc, PhD3

Purpose: The aim of this article was to critically review the current application of additive
manufacturing (AM)/3D-printing techniques in prosthodontics and to highlight the influence
of various technical factors involved in different AM technologies. Materials and Methods:
A standard approach of searching MEDLINE, EMBASE, and Google Scholar databases was
followed. The following search terms were used: (Prosth* OR Restoration) AND (Prototype
OR Additive Manufacture* OR Compute* OR 3D-print* OR CAD/CAM) AND (Dentistry OR
Dental). Hand searching the reference lists of the included articles and personal connections
revealed additional relevant articles. Selection criteria were any article written in English and
reporting on the application of AM in prosthodontics from 1990 to February 2016. Results:
From a total of 4,290 articles identified, 33 were seen as relevant. Of these, 3 were narrative
reviews, 18 were in vitro studies, and 12 were clinical in vivo studies. Different AM technologies
are applied in prosthodontics, directly and indirectly, for the fabrication of fixed metal copings,
metal frameworks for removable partial dentures, and plastic mock-ups and resin patterns
for further conventional metal castings. Technical factors involved in different AM techniques
influence the overall quality, the mechanical properties of the printed parts, and the total cost
and manufacturing time. Conclusion: AM is promising and offers new possibilities in the field
of prosthodontics, though its application is still limited. An understanding of these limitations and
of developments in material science is crucial prior to considering AM as an acceptable method
for the fabrication of dental prostheses. Int J Prosthodont 2017;30:474–484. doi: 10.11607/ijp.5079

C omputer-aided design/computer-assisted manu­

facture (CAD/CAM) was first introduced in
the dental field in the 1970s by Duret and Preston.1
It is now a well-established technology in most
dental laboratories and clinics to fabricate vari-
ous dental prostheses and restorations.2 All CAD/
CAM systems share three domains: data acquisi-
tion or scanning, computer-aided design (CAD), and
computer-assisted manufacture (CAM).
1PhD Candidate, Oral Implantology and Prosthetic Dentistry,
Academic Centre for Dentistry Amsterdam (ACTA), Universiteit van
Amsterdam and Vrije Universiteit, Amsterdam, The Netherlands;
Lecturer, Prosthetic Dental Science Department, College of Dentistry,
King Saud University, Riyadh, Saudi Arabia.
2Professor of Oral Implantology and Prosthetic Dentistry, Head of the
Department of Oral Implantology and Prosthetic Dentistry,
Academic Centre for Dentistry Amsterdam (ACTA), Universiteit van
Amsterdam and Vrije Universiteit, Amsterdam, The Netherlands.
3Lecturer, Removable Prosthodontics Department, Faculty of Dentistry.
Cairo University, Cairo, Egypt.; Research Fellow, Department of Oral
Implantology and Prosthetic Dentistry, Academic Centre for Dentistry
Amsterdam (ACTA), Universiteit van Amsterdam and Vrije Universiteit,
Amsterdam, The Netherlands.
Correspondence to: Dr Nawal Murshed Alharbi, Department of Oral
Implantology and Prosthetic Dentistry, Academic Centre for Dentistry
Amsterdam (ACTA), Gustav Mahlerlaan 3004, 1081 LA Amsterdam,
The Netherlands. Email: nawalmurshed@gmail.com
©2017 by Quintessence Publishing Co Inc.
In dentistry, most of the current CAM systems are
based on the subtractive approach. The subtractive
technique uses a cutting tool to mechanically trim the
material and achieve the desired geometry following
computer-guided instructions. Additive manufactur-
ing (AM), also known as 3D printing, is the process
of building the material layer by layer directly from 3D
digital data. AM offers various advantages over the
traditional subtractive (milling) techniques. The ad-
ditive technology allows manufacturing of an object
regardless of its dimensional complexity and quan-
tity.3 Material waste can be reduced to 40%, and de-
tails finer than the milling bur size can be fabricated.4
Recent literature reflects the increased application
of various AM techniques in several dental disci-
plines,5–8 namely the fabrication of dental models,9,10
surgical guides,11,12 and occlusal devices.13,14 On the
contrary, the implementation of the technology in
the prosthodontic field has not been adequately ad-
dressed. Furthermore, the influence of various tech-
nical factors and their effect on the overall quality and
mechanical properties of the printed restorations/
prosthetics has not been investigated.
Therefore, the aim of the present article is to criti-
cally review the current application of AM/3D print-
ing technology in prosthodontics, and to highlight the
influence of various technical factors involved with
different AM techniques.

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Materials and Methods
MEDLINE, Google Scholar, and EMBASE databas-
es were searched using the following search terms:
(prosth* OR restoration) AND (prototype OR additive
manufacture* OR compute* OR 3D-print* OR CAD/
CAM) AND (Dentistry OR Dental). Hand searching the
reference lists of the included articles and personal con-
nections revealed additional relevant articles. Selection
criteria were any article written in English and reporting
on the application of AM in prosthodontics from 1990
to February 2016. Figure 1 shows the search flow chart.
Results
A total of 4,290 relevant articles were identified. Of
these, only 33 articles were relevant to the applica-
tion of AM/3D printing in the field of prosthodontics,
of which 3 were narrative reviews,5,15,16 18 were in vi-
tro studies,17–34 and 12 were in vivo35–46 studies. Data
on technique used, its prosthodontic application, and
major findings were extracted as shown in Table 1. The
findings were categorized based on the fabrication
technique and are presented in the following section.
Fig 1   Search strategy flowchart.
AM Techniques in Prosthodontics
Removable complete dentures, partial dentures, metal
frameworks, and copings for fixed restorations are all
fabricated using different AM techniques through either
a direct or an indirect approach5,6 (Table 1).
A wide range of materials has been applied, such
as wax, resin, metals, and more recently, in an experi-
mental phase, zirconia. The most common techniques
applied are stereolithography (SLA), digital light pro-
cessing (DLP), selective laser sintering/melting/direct
metal laser melting (SLS/SLM/DMLS), and direct de-
position modeling/jetting. Figure 2 provides a sche-
matic drawing of the common AM technologies used
in prosthodontics. The advantages and disadvantages
of each technique are listed in Table 2.
SLS/SLM/DMLS Process
In the SLS/DMLS process, the layers are built sequen-
tially by fusing powder particles using a CO2 laser
beam that traces a path on a powder bed based on the
desired CAD design. In each layer, the laser elevates
the temperature to the melting point, which fuses the
powder particles. The process is repeated until the ob-
ject is completed. SLM, on the other hand, is based on
melting the powder rather than sintering it.47 Several
materials can be used with SLS, such as ceramics,
polymers, and metals, whereas DMLS is used to sinter
metal particles.12
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Alharbi et al
Records identified through
database search (MEDLINE,
EMBASE, Google Scholar)
Filter: abstract available; written
in English; published between
1990 and February 2016
n = 7,931
Titles screened and
duplicate records removed
(3,641 records excluded)
n = 4,290
Abstract and full-text screening;
only records reporting on the
Hand search
application of AM in
(n = 3)
prosthodontics are included
(4,260 records excluded)
Included records
3 narrative 18 in vitro 12 in vivo
reviews studies studies
SLS/SLM/DMLS in Fixed Prosthodontics.
Laser melting/sintering techniques have been used
to manufacture crowns and metal frameworks for
fixed metal-ceramic (MC) restorations that exhibit
marginal adaptation comparable to those fabricated
using conventional techniques, with values in the
range of 75.0 to 99.0 μm.40–43 Huang et al40 found
similar marginal fit (75.6 ± 32.0 μm) of SLM cobalt-
chromium (Co-Cr) MC crowns to that of cast Au-Pt
crowns (76.8 ± 32.0 μm) and better fit than that of
cast Co-Cr crowns (91.0 ± 36.0 μm). In the same
context, Quante et al41 found a mean marginal gap
in the range of 67 to 99 µm for base metal and pre-
cious alloy MC crowns fabricated using SLM. On the
other hand, the occlusal gap was greater for SLM-
fabricated crowns (309 μm) compared to convention-
ally cast MC crowns (249 μm).40 A clinical study on
39 patients rehabilitated with 60 single posterior MC
crowns fabricated using LS revealed a cumulative
failure rate of 1.7% after a 47-month follow-up pe-
riod.43 The reported modes of failure were extraction
of abutment teeth after endodontic treatment, crown
debonding, and endodontic treatment rather than ac-
tual mechanical complications.
In accordance, in vitro studies reported compara-
ble or even improved marginal fit of SLM-fabricated
crowns and frameworks compared to the convention-
ally cast and milled counterparts. The marginal gap
Volume 30, Number 5, 2017 475
Additive Manufacturing Techniques in Prosthodontics

Table 1   Description of Included Articles

Article Year Printing technique Type of study Type of material Indication/use
Abduo et al5 2014 – Review – –

Torabi et al15 2015 – Review – –

Lima et al16 2014 – Review – –

Complete denture
Chen et al17 2015 Jetting In vitro Wax CD try-in

Maeda et al35 1994 SLA Clinical Polymer CD shell try-in

Inokoshi et al36 2012 Jetting-DLP Clinical Polymer CD try-in

Sun et al37 2009 Jetting-binder Case study Plaster Individualized flask for CD
Gao et al38 2009 LRF Clinical Titanium CD base
Removable partial denture
Wu et al18 2012 SLA In vitro Polymer RPD-resin pattern
Bibb et al39 2006 SLM Clinical Co-Cr, 316L stainless steel RPD framework
Eggbeer et al34 2005 SLA, jetting-DLP, DLP In vitro Polymer RPD resin pattern
Williams et al45 2006 SLM Case report Co-Cr RPD framework
Kattadiyil et al46 2014 SLA Case report Polymer RPD framework
Fixed prosthodontics­—Metal-based restorations
Huang et al40 2015 SLM Clinical Co-Cr MC crowns

Quante et al41 2008 SLM Clinical Co-Cr, Au-Pt MC crowns

Pompa et al19 2015 SLM In vitro Co-Cr 3-unit FPD framework

Wu et al20 2014 SLM In vitro Co-Cr Mechanical flexural strength + bond strength

Tamac et al42 2014 DMLS Clinical Co-Cr MC crowns

Kim et al21 2013 DMLS In vitro Co-Cr 3-unit FPD

Bilgin et al22 2016 DMLS In vitro Co-Cr Cast post and core

Örtorp et al23 2011 DMLS In vitro Co-Cr 3-unit FPD

Ucar et al24 2009 SLS In vitro Co-Cr Metal anterior coping

Abou Tara43 2011 SLS Clinical Co-Cr, Au-Pt MC posterior crowns

Castillo-Oyague et al25 2013 DMLS In vitro Co-Cr Metal coping cemented on implant
Akova et al26 2008 SLS In vitro Co-Cr Shear bond strength

Xiang et al27 2012 SLM In vitro Co-Cr Bond strength

Hoang et al28 2015 Jetting-DLP In vitro Resin Coping for casting
Fixed prosthodontics­—Tooth-colored based restorations
Puchades et al44 2015 Jetting-DLP Clinical Resin Mockup

Alharbi et al29 2016 SLA In vitro Hybrid resin Crown

Alharbi et al52 2016 SLA In vitro Hybrid resin Crown
Osman et al53 2017 DLP In vitro Hybrid resin Crown
Chang et al30 2015 Jetting-binder In vitro Ceramic Teeth models
Wang et al31 2006 Jetting In vitro Ceramic Crown and tooth model
Ebert et al32 2009 Jetting In vitro Zirconia Crown
Silva et al33 2010 Jetting In vitro Zirconia Coping and 3-unit ceramic
Co-Cr = cobalt chromium; Au-Pt = gold-platinum; Ni-Cr = nickel-chromium; CAD/CAM = computer-aided design/computer-assisted manufacture;
SLA = stereolithography; DLP = digital light processing; LRF = laser rapid forming; SLM = selective laser melting; DMLS = direct metal laser sintering;
SLS = selective laser sintering; FPD = fixed partial denture; RPD = removable partial denture; MC = metal-ceramic.

values reported for SLM-fabricated Co-Cr and Ni-Cr
frameworks fabricated by lost wax technique were 43.9
µm and 47.5 µm, respectively.19 Similarly, Örtorp et al23
revealed better marginal fit for DMLS Co-Cr three-unit-
FPD frameworks (84 µm) compared to conventional
lost wax (133 µm), milled lost wax (117 µm), and milled
frameworks (166 µm). In contrast, Ni-Cr frameworks
fabricated by lost wax technique showed better inter-
nal adaptation (54 µm) than Co-Cr SLM frameworks
(58.7 µm).19 Castillo-Oyague et al25 evaluated the

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 Alharbi et al

Treatment phase Major findings

– The review covers the available CAD/CAM techniques based on subtraction milling and the potential use of the
additive approach.
– The review reports on different laboratory procedures used with AM. It covers technical reports published from
2003–2013. The exclusion criteria were meticulous clinical and excessive technical procedures.
– The review covers the application of rapid prototype in removable denture framework.

Planning The adaptation of the wax pattern of a maxillary complete denture on the edentulous cast produced by the CAD and
3D-printing method is comparable with the traditional manual method.
Planning The technique is feasible in the planning phase and for assessing the esthetics and phonetics of the denture.
Planning The mean deviation was –0.005 ± 0.19 mm in the maxillary denture and –0.023 ± 0.16 mm in the mandible.
Still, prosthodontists rated the stability and esthetics better with conventional CD. Chair time was longer with the
3D-printed CD.
Planning Digital workflow was described for CD, 3D-printing was used to fabricate individualized flasks for casting.
Definitive The base was subjectively judged as acceptable.

Planning Digital workflow for designing RPD framework.

Definitive Co-Cr RPD framework exhibits good fit.
Planning It is an acceptable technique that can be applied in future to replace conventional wax-up framework pattern procedures.
Definitive Co-Cr RPD framework exhibits good fit.
Definitive Resin pattern was used for cast metal framework.

Definitive Marginal fit of SLM Co-Cr MC crowns was 75.6 ± 32.6 µm, cast Au-Pt was 76.8 ± 32.0 µm, and cast Co-Cr was
91.0 ± 36.0 µm. The difference was statistically significant between cast SLM and Co-Cr.
Definitive Mean marginal discrepancy was in range of 67 to 99 µm for both alloys; difference was not significant.
Definitive Mean marginal discrepancy was 47.56 µm for traditional casted Ni-Cr, 55.6 µm for milled Y-TZP, and 43.92 µm for
SLM Co-Cr alloy.
Definitive Mean tensile strength was significantly higher for SLM than for cast alloy. The bond strength was similar to the
cast alloy (55.78 ± 3.0 MPa).
Definitive Mean marginal gap was 86.64 µm for milled, 96.23 µm for DMLS, and 75.92 µm for traditional casting (P = .082).
Definitive The mean values of absolute marginal discrepancy, marginal gap, and internal gap were significantly larger in the
DMLS framework than in traditional lost wax Ni-Cr counterpart (P < .001).
Definitive DMLS post and core performed similarly to traditional cast post and core (fracture load was 608.89 N for TC and
689.40 N for DMLS), milled cast post and core showed higher fracture load (959.26 N) (P< .01).
Definitive Mean gap µm (SDs) were 84 ± 60 for DMLS, 117 ± 89 for milled wax-lost wax technique, 133 ± 89 for conventional
lost wax, and 166 ± 135 for milled Co-Cr. Significant difference was found between milled and DMLS Co-Cr (P < .05).
Definitive Mean internal gap was 58.21 ± 19.92 µm for cast Ni-Cr, 50.55 ± 25.1 µm for cast Co-Cr, and 62.57 ± 21.62 µm
SLS Co-Cr (P = .42).
Definitive The cumulative failure rate was 1.7% after 47 months follow-up period.
Definitive Laser-sintered Co-Cr shows better fit over traditional cast alloy.
Definitive The bond strength was 81.6 ± 14.6 MPa for cast Ni-Cr, 72.9 ± 14.3 MPa for cast Co-Cr, and 67 ± 14.9 MPa for
SLS Co-Cr (P > .05)
Definitive The mean shear bond strength was 44 ± 5 MPa for SLM Co-Cr and 43 ± 4 MPa for cast Co-Cr (P = .42).
Planning DLP printers were unable to reproduce a uniform internal gap within the same group.

Planning Incorporation of digital technology in the planning phase enhances patient-clinician-technician communication without
increasing cost.
Definitive Build direction influences the compressive strength of 3D-printed provisional restorations.
Definitive Build direction and support configuration influences the dimensional accuracy of 3D-printed provisional restorations.
Definitive Build direction influences the dimensional accuracy of 3D-printed provisional restorations.
Attempts to print ceramics A shrinkage rate of 53% was found when printing the coronal part of the tooth.
Attempts to print dental porcelain Fabrication of tooth shape as physical models, not as dental restorations.
Attempts to print zirconia Preliminary trial to fabricate dental crown.
Attempts to print zirconia Preliminary trial to fabricate dental coping and 3-unit framework.

marginal fit and microleakage of cement-retained and
implant-supported DMLS Co-Cr and conventionally
cast Co-Cr and Ni-Cr-Ti copings using SEM and digital
microscope. The results revealed that DMLS copings
had the least vertical gap when compared to the other
two types.25 Further, resin-modified glass-ionomer
and acrylic/urethane-based cements showed greater
microleakage than dual-cured resin cements.
In contrast, Kim et al21 reported mean values of
absolute marginal discrepancy (AMD), marginal gap

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Additive Manufacturing Techniques in Prosthodontics

SLA DLP

Building Building
platform platform
Photopolymerization

Resin vat Resin vat

Motor Motor
Laser light Lens
source

LED light DMD

source

Direct jetting Jetting-DLP Binder-based jetting

Direct deposition/jetting

Reservoir
(material) Reservoir
Reservoir
(material)
(binder)
Roller Building
Building Building platform
platform platform

Lens
Powder
LED light tank Excess
source powder tank
DMD

Laser
light source
direct metal laser melting)
(selective laser sintering,
selective laser melting,
Laser sintering

Roller Building
platform

Powder
tank
Excess
powder tank

Fig 2   Schematic drawings of common AM technologies used in prosthodontics.

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 Alharbi et al

Table 2   Advantages and Disadvantages of Different AM Technnologies

Printing technique Material Advantages Disadvantages Applications
Photopolymerization
 SLA Photopolymerized High accuracy Expensive
resin Smooth surface finish High material cost
Possible transparent objects Only photopolymerized material Surgical guides
Good mechanical strength Post curing required Resin patterns
Fine build details Single material vat Temporary restorations
Low tolerance Dental models
 DLP Photopolymerized Fast Only photopolymerized material Cast coping
resin Smooth surface finish Post curing required Wax pattern
Possible transparent objects Single material vat
Fine build details
Direct deposition printing/jetting
  Binder jetting Powder Fast fabrication Large tolerance
Low material cost Low mechanical strength
Multicolor material is possible Rough surface finish
  Material jetting Slurry Fast fabrication Large tolerance Dental models
Low material cost Low mechanical strength
Multicolor material is possible Rough surface finish
Wide material options Layers may collapse during
build process
 DLP-jetting Photopolymerized Multicolor material is possible Only photopolymerized material Resin mock-up
resin Fast fabrication Post curing required Dental models
Immediate solidification of each Occlusal splints
layer due to photopolymerization
Laser sintering
 SLS Resin, metals, and
ceramics Printed object with 100% density is Metal copings and
Expensive, thermal distortion
 SLM Metals possible frameworks
 DMLS Metals
SLA = stereolithography; DLP = digital light processing; SLS = selective laser sintering; SLM = selective laser melting; DMLS = direct metal laser sintering.

(MG), and internal gap (IG) to be significantly larger in
the DMLS-FPD frameworks compared to convention-
ally fabricated lost wax Ni-Cr counterparts (P < .001).
On the other hand, Ucar et al24 showed no differences
in the mean internal gap of cast Ni-Cr, Co-Cr, and
laser-sintered Co-Cr copings (P = .42)
Regarding fracture resistance, Bilgin et al22 report-
ed comparable values for Co-Cr cast posts and cores
fabricated using DMLS and conventional casting (CC)
techniques and higher values for milled cast post and
core. The mean fracture load values were 608.89 N,
689.4 N, and 959.26 N for CC, DMLS, and milled cast
post and core, respectively (P < .01).
The bond strength between DMLS-fabricated met-
al alloys and dental ceramics was investigated in the
literature. Akova et al26 reported no significant dif-
ference in shear bond strength developed between
dental porcelain and both laser-sintered Co-Cr alloys
(67.0 ± 14.9 MPa) and conventionally cast Co-Cr al-
loys (72.9 ± 14.3 MPa). The mode of failure, however,
was different—a mixed mode of cohesive and adhe-
sive failure for all conventionally fabricated castings—
whereas for SLM-processed alloys, half exhibited
adhesive failure to the porcelain and the remaining
half showed a mixed mode of failure. Similarly, Xiang
et al27 and Wu et al20 evaluated the bond strength and
tensile strength between ceramic and Co-Cr alloys
fabricated by SLM or CC techniques. No significant
difference was found between the metal-ceramic
bond strength of SLM Co-Cr alloys and cast Co-Cr
alloys. However, the tensile strength was significantly
higher for SLM Co-Cr alloys compared to cast Co-Cr.
SLS/SLM in Removable Prosthodontics. SLM
technique is increasingly used for the fabrication of
removable partial denture (RPD) frameworks. Using
the SLS/SLM-AM techniques, the fine and complex
structure of the framework can be accurately repro-
duced as designed.18,39
Bibb et al39 presented the use of SLM to directly
fabricate RPD frameworks using stainless steel and
Co-Cr alloys. In their report, Co-Cr alloys showed
comparable results to cast frameworks in terms of ob-
ject accuracy and quality of fit. In contrast, the clasps
of the stainless steel framework showed a tendency to
deform on repeated framework insertions. Williams et
al45 presented a single case in which SLM technology
was used to fabricate an RPD framework for a bilat-
eral lower free-end saddle case. The fit of the frame-
work was subjectively judged as acceptable. Gao et
al38 reported the use of laser rapid forming technique
to fabricate titanium complete denture bases, which
were also subjectively judged as acceptable.

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Additive Manufacturing Techniques in Prosthodontics
SLA/DLP Technique
The SLA fabrication technique was initially developed
by Charles Hull in 1984 and was made commercially
available by 3D Systems in 1986. SLA is based on a
light-triggered photochemical reaction where a fo-
cused ultraviolet (UV) light beam cures photosen-
sitive liquid polymer on a layer basis following the
CAD design. The process is repeated until the object
is completed. Although SLA is expensive compared
to other AM techniques, it offers a high accuracy, a
smooth surface finish, and fine build details.6,8,48
Likewise, DLP uses a digital light projection source
(high-power LED). The built layers are illuminated us-
ing a light mask that is created by a digital micromirror
device (DMD).49 DMDs consist of hundreds of thou-
sands of individually moving micromirrors that control
the reflection path of light. Each pixel of the image cor-
responds to an individual micromirror, which switches
the orientation between several degrees to the beam
axis.50,51 The complete platform is exposed simultane-
ously, and the build time is minimized.48
SLA and DLP in Prosthodontics. The two tech-
niques are mainly used indirectly to fabricate try-in
mockups/plastic shells to verify esthetics, phonetics,
and occlusion prior to fabrication of final prosthe-
ses.35,36,44 Wu et al18 and Kattadiyil et al46 used SLA to
indirectly fabricate resin patterns for casting of RPD
frameworks in a Co-Cr alloy using the conventional
method. These authors subjectively reported the fit of
the frameworks to be excellent.
Recently, Alharbi et al29 reported on direct 3D print-
ing of a hybrid resin material that can be used as a
long-term interim dental restoration. In this study, the
influence of build direction/printing orientation on the
compressive strength of the material was evaluated.29
In another study, the influence of build angle and
support configuration on the dimensional accuracy of
3D-printed dental crowns fabricated using SLA and
DLP was also assessed and found to be relevant.52,53
Direct Deposition Printing/Jetting
In direct deposition or so-called jetting technique, the
material is extruded from a nozzle and either it solidi-
fies immediately or a binder/glue is jetted on powder
that then solidifies. Alternatively, material slurry can
be extruded and each layer cured using ultraviolet
light. The latter combines the DLP and jetting prin-
ciples in one AM technique. Due to the simplicity of
the technique, a wide range of materials, such as ther-
moplastics (waxes, filament polymers), resin, ceramic,
and zirconia slurries can be used.
Direct Deposition Printing/Jetting in Prostho-
dontics. Jetting technology is used indirectly for the
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fabrication of conventional cast metal frameworks
and FPDs. This is achieved through printing of molds,
models, and resin patterns that are later used for
conventional casting technique.5,9,17,28,37,54,55 Sun et
al37 used a binder-based jetting 3D printer to fabri-
cate individualized flasks that were later used for re-
movable complete denture fabrication. Nonetheless,
the process of CD fabrication using AM is still in an
experimental phase due to limitations in data acqui-
sition, software design, and fabrication materials.37
In an in vitro study, Chen et al17 compared the fit
of 3D-printed wax dentures and conventional wax
buildups and found no significant difference in adap-
tation between the two groups.
Hoang et al28 evaluated the precision of the print-
er to produce a uniform internal gap for jetting-DLP
printed crown copings that were used for fabrication
of conventional burnout casting and revealed the lack
of reproducibility of that particular printer brand.
A number of studies investigated the ability of
deposition/jetting techniques to fabricate dental
composites, ceramics, and zirconia-based dental
restorations. Yet, most of the presented results were
preliminary and restricted only to the research phase.
Silva et al33 and Ebert et al32 printed zirconia frame-
works and copings using jetting technology followed
by postfabrication sintering. Shortcomings reported
were nozzle clogging, structural porosity, and limited
overall dimensional accuracy and surface quality of
the printed object, deeming printed zirconia inappro-
priate for clinical application.32,33
Wang et al31 attempted slurry jetting of solid and
hollow porcelain dental crowns followed by sinter-
ing. The fabricated structures were less than optimal
and were considered not appropriate for the fabrica-
tion of ceramic-based dental restorations. In another
study, Chang et al30 used binder-based jetting to fab-
ricate ceramic teeth models. Though the study did not
specify details about the manufacturer or fabrication/
methodology, the authors reported 53% shrinkage af-
ter sintering of the fabricated pieces.
Thus, it is evident that understanding the techni-
cal factors and material requirements involved in the
different AM fabrication techniques is essential to
fabricate dental restorations with optimal physical
and mechanical properties.56 Accordingly, the proper
printing technique can be selected to fabricate the
desired dental restoration.
Factors to Be Considered in Fabricating Dental
Prostheses Using AM Techniques
When fabricating dental prostheses, dimensional ac-
curacy, mechanical and physical properties, time, and
costs are all factors to be considered. The challenges

involved with AM techniques start with the process
of acquiring the standard tessellation language (STL)
file and end with the actual manufacturing process.56
The initial manufacturing process involves a prepara-
tory phase in which the CAD model is virtually sliced
and oriented within the build platform. Several pa-
rameters must be defined, such as build orientation,
slice thickness, and support structure generation.
These factors are commonly interrelated and have
been shown to influence the mechanical and physi-
cal properties as well as the total fabrication time of
the manufactured objects.29,57,58
Build orientation initially determines the direction
of printing. The selection of build orientation can be
done in manual, semiautomated, or fully automated
pattern.59 In the manual mode, the user has the free-
dom to select the build orientation within the build
platform. In the semiautomated mode, selection is
based on feedback provided from the system based
on the build time and the support contact area. With
the fully automated mode, the build angle is computed
based on specific algorithms optimized to one or more
objectives (build time, support volume, support area).
Selection between these modes varies based on the
amount of user intervention.59,60
Several studies evaluated the influence of build di-
rection on a number of factors, such as build time,61
accuracy of the printed parts,58 and optimal support
structure dimensions.62 The findings revealed that
build direction influences the number of layers, which
in turn is related to surface quality, total build time,
and therefore total cost of the manufacturing pro-
cess.63 For a given object geometry, build direction/
orientation can influence the amount of support and
consequently production time, surface quality, and
time needed for finishing and polishing.60,63
In the dental literature, recent studies have evalu-
ated the influence of build direction and support con-
figuration on the dimensional accuracy of 3D-printed
dental restorations. The build direction was found to
influence dimensional accuracy. The same study also
revealed that distribution is of greater value than the
dimensions of the support structure. The authors rec-
ommended that the optimal build direction offer maxi-
mum accuracy, self-supporting geometry of the printed
object, and minimal support structure that maintains
the stability of the object during the printing process.
Thus, a dimensionally accurate restoration is printed
that requires minimal finishing and polishing.52,53
The selection of build direction is followed by vir-
tual slicing of the model into two-dimensional layers/
slices. Deposition of the sliced layers leads to a stair-
stepping effect. This effect is dependent on the object
geometry, layer thickness, and build direction. Altering
the build direction can decrease the curved surfaces
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Alharbi et al
and thus minimize the stair-stepping effect.56,59,60 In
addition, the effect can be reduced by decreasing the
layer thickness, which will inversely increase the build
time and cost.59,63
Apart from build orientation effect, each AM tech-
nique has its own inherited processing accuracy. SLA
is considered the most accurate 3D-printing tech-
nique.8,48 The high accuracy is the result of precise
control of laser beam position and exposure size in
x-y planes. However, the resolution in the z-direction,
which is determined by depth of cure in each layer,
is more critical and is controlled by the amount of
photoinitiator, particle size and shape, and exposure
variables such as wavelength, laser power, beam size,
beam speed, and exposure time/velocity.48,64,65 In ad-
dition, z-resolution is influenced by the object con-
figuration and the layer thickness.8
The precision of DLP printing is further influenced
by the optical specifications integrated in the DMD,
lens quality, pixel size, and platform resolution, as
well as the light intensity and depth of cure. A clear
lens and a smaller pixel size result in better focus and
higher resolution.49
The accuracy of the direct jetting technique, on the
other hand, is highly influenced by the nozzle diam-
eter, which must be larger than the particle size of
the jetted material.32,33,66 DLP-jetting may overcome
some of the drawbacks of the direct jetting technique.
The collapse of layers during the build process and
the low mechanical strength of parts printed by direct
jetting can be avoided by combining the basic jetting
technique with UV-curing immediately after layer de-
position. Yet, as previously discussed, factors that in-
fluence the DLP technology are still involved.
In SLS/SLM/SMLS technique, the size, shape, and
melting temperature of the particles influence the
surface quality of the printed pieces.49,64,67 Preheating
the particles close to the melting temperature can lim-
it the energy input needed from the laser to sinter the
particles and results in a more homogenous smooth
surface.64 Inability to control the melting temperature
can result in surface roughness of the printed object,
which may explain the roughness seen in the RPD
framework fabricated by SLM technique38,39,45 and
the poor adaptation of SLM-MC crowns as a result of
thermal distortion.40
Discussion
This critical review aimed to evaluate the current use
of different additive manufacturing techniques in the
fabrication of fixed and removable prostheses. The
influence of various technical factors involved in dif-
ferent techniques on the accuracy and overall quality
of printed parts was also explored.
Volume 30, Number 5, 2017 481
Additive Manufacturing Techniques in Prosthodontics
The present review overcomes the limitations of
three previously published narrative reviews on the
same topic. Torabi et al15 limited their search to the
period between 2003 and 2013 and used only two
general keywords: rapid prototyping and dentistry.
The articles selected covered the general application
of different AM techniques in dentistry rather than fo-
cusing on prosthodontic applications. Only technical
reports were included, excluding any in vivo clinical
studies. Similarly, Abduo et al5 broadly presented the
CAD/CAM techniques currently applied in prosth-
odontics, namely subtractive and additive manufac-
turing techniques, and their general use in dentistry.
The third review15 discussed only studies on remov-
able partial dentures published from 2000 to 2013. The
focus of this critical review was solely on the appli-
cation of different AM techniques for the fabrication
of fixed and removable intraoral prostheses and the
influence of the relevant technical factors on precision
and quality of the printed parts.
AM techniques are emerging rapidly and bring-
ing about a new era in digital dentistry. Development
is guided by advancements in industry and mate-
rial science. The various materials used in the field
of prosthetic dentistry necessitate the application
of different AM techniques. Metallic dental restora-
tions and frameworks can be fabricated using SLS/
SLM/DMLS, whereas tooth-colored restorations and
wax patterns are fabricated using SLA, DLP, and
DLP-jetting techniques.28,44
SLA allows the fabrication of direct and indirect
composite resin restorations. The printed resin mate-
rials can be used clinically in the diagnostic phase for
esthetic assessment,44 as well as for the fabrication of
long-term interim dental restorations.29,52,53 The pho-
topolymerization technique used in SLA permits high
dimensional accuracy of the printed parts, though the
initial cost of the machine is high. The possibility of
only a single material vat represents another limita-
tion of SLA. On the other hand, DLP-based jetting
may offer multiple-material printing with the advan-
tages of photopolymerization techniques. However,
limited data is available on the application of DLP in
the prosthodontic field. Printing of tooth-colored zir-
conia restorations has been attempted using direct
deposition/jetting, but it is still limited to the research
phase and the results are not yet optimal to recom-
mend for clinical use. Direct material jetting is fast
and cheap, but is only feasible for the fabrication of
illustration models and not for dental restorations/
prostheses fabrication, where fine details and high
mechanical strength are critical.
The majority of studies reporting on the fit of met-
al copings and frameworks were laboratory stud-
ies.19,21,23–25 Clinical studies available were only case
482 The International Journal of Prosthodontics
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NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
series with short follow-up. Most of the cases were
evaluated subjectively and lack defined success cri-
teria.40–43 Findings revealed that metal frameworks
fabricated using SLM exhibit better marginal fit than
conventionally fabricated frameworks, and compa-
rable or even better fit than their milled counter-
parts.19,23,25,40 Tolerance of milling tools is no longer an
issue, thus, better marginal adaptation can be achieved
with SLM.23 Compared to the conventional technique,
the CAD/CAM workflow allows for the elimination of
inherent inaccuracies associated with laboratory pro-
cedures and may decrease errors during fabrication.
Some of the reported contradicting results21,42 may
be attributed to differences in the quality of the digital
scanners used in addition to different study designs
and analysis methods applied.21,42
A noteworthy finding is the better marginal fit of SLM
restorations compared to the internal fit at the occlu-
sal surface and the axio-occlusal line angle.23,40,42 This
may be attributed to the use of a digital light scanner,
which can cause optical rounding of the line angles of
the scanned preparations. Another contributing factor
may be the thermal stresses involved during fabrica-
tion, resulting in distortion of small-geometry printed
parts.23,40,42
When fabricating metal copings for fixed partial
dentures using DMLS, adhesive failure is a factor to
consider.26 This might be attributed to variations in
oxide layer thickness, which can influence the bond
strength with porcelain.26,27 On the other hand, some
authors argued that SLM might create an intermedi-
ate layer that can lead to a chemical bond with porce-
lain, thus improving bond strength.20
The available articles showed that direct deposi-
tion/jetting is the most common technique to fab-
ricate tooth-colored ceramic dental restorations.
Development in this technology is still needed, as
the overall quality of printed parts is not yet optimal.
Drawbacks reported include structural porosity, fre-
quent needle blockage,32 lack of structural support
and layer collapse during printing, and critical me-
chanical properties of printed objects.33 The tech-
nique is based on extrusion of a material prepared in a
slurry form; therefore, pseudoplastic behavior, powder
size, and slurry pH values are crucial for proper print-
ability.31 Future studies should focus on developing
the best slurry composition and controlling printing
parameters such as sintering and debinding process-
es. Different printing technologies should also be ex-
plored and investigated.32,49,66–68
The application of 3D printing in complete and par-
tial removable prosthodontics is still limited due to a
lack of design software and a reference library of fre-
quent components used to design the prosthesis, and
the inability to automatically detect the undercuts and

thus the optimum path of insertion.16,18,37,39 Moreover,
due to continuous movement of the soft tissue in eden-
tulous patients, digital data acquisition is difficult.46
Based on the findings of this critical review, it can
be concluded that AM offers new possibilities in the
field of prosthodontics, though its application/use is
still limited. Developments to overcome existing limi-
tations in technical and material aspects are neces-
sary. The majority of findings were based mainly on
short-term in vivo or in vitro studies. Well-designed,
long-term clinical studies are needed before various
3D-printing techniques can be fully implemented in
prosthodontics.
Areas to be explored in the future include the me-
chanical properties of printed materials, the influ-
ence of different cement types on microleakage and
mechanical properties of printed restorations, and
the effect of different technical factors on the sur-
face quality and geometric accuracy of printed parts.
Factors explored should include build orientation/
direction, support structure dimensions and distri-
bution, and position of the printed parts in the build
platform. Investigating these factors will allow imple-
mentation of printing technology in prosthodontics
based on sound scientific evidence together with a
high level of confidence in the technology from the
prosthodontic community.
Conclusions
AM offers new possibilities in the field of prosth-
odontics, though its application/use is still limited.
Understanding the technologic limitations and de-
velopments in material science is still crucial prior
to considering the AM technique as an acceptable
method for the fabrication of dental prostheses.
Acknowledgments
The authors report no conflicts of interest related to this study.
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