936704 JOO Journal of OrthodonticsCousley
Cutting Edge
Introducing 3D printing in your
orthodontic practice
Richard RJ Cousley1
Abstract
Many orthodontists are aware of the potential applications of three-dimensional (3D) printing in orthodontics but are
hesitant in introducing this technology into their clinical practice and workflow. Therefore, this article explains the
hardware and software requirements, plus the workflow.
Keywords
3D printing, digital orthodontic workflow, retainers, orthodontic aligners
Date received: 30 April 2020; revised: 24 May 2020; accepted: 2 June 2020
Introduction
Intra-oral scanning has been a major technological
breakthrough and has created a paradigm shift in ortho-
dontics such that scanning has become an established
technique, supplanting dental impressions in many
orthodontic clinics across the world, and with multiple
scanner options available. However, while digital dental
models have many diagnostic and treatment planning
applications, they cannot directly produce physical
models and appliances. The ‘missing links’ in this three-
dimensional (3D) workflow are computer-aided design
and manufacturing (CAD-CAM), i.e. the methods of
processing the digital data and then creating an accurate
3D physical model.
Additive manufacturing, generally known as 3D print-
ing, was invented in the 1980s (Hull, 1986), but it has
only incorporated into dentistry much more recently. This
time lag was due to the initial prohibitive costs, plus the
speed, accuracy and physical size limitations of the early
3D printers. Fortunately, the cost of a suitable printer has
fallen dramatically in the last five years to between £2000
and £8000. At the same time, the range of print materials,
including biocompatible resins, has increased rapidly.
Hence, it is now feasible for 3D printing to be performed
within orthodontic clinics, rather than solely in dental
laboratories. The purpose of this article is to describe the
hardware and software technologies and workflow
required for the successful integration of 3D printing in a
clinical setting.
Journal of Orthodontics
1­–8
https://doi.org/10.1177/1465312520936704
DOI: 10.1177/1465312520936704
© The Author(s) 2020
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There are four common desktop printer technologies:
- fused filament fabrication (FFF);
- polyjet;
- stereolithography (SLA);
- digital light processing (DLP).
Polyjet printers jet layers of resin (as thin as 16 µm) onto a
build tray to produce highly accurate dental models (Brown
et al., 2018; Camardella et al., 2017). However, this paper
focuses on SLA/DLP printers since these provide sufficient
accuracy for clinical applications and are most commonly
used in clinics. These printers build models layer-by-layer
from liquid resin, using either an ultraviolet laser (SLA) or
visible light projector (DLP) for photopolymerisation. The
DLP process may result in a faster model print time because
a whole layer of resin is cured simultaneously, whereas
SLA involves the laser moving sequentially across the print
layer (Kim et al., 2018). SLA/DLP printers form the model
on a metal build platform such that models are suspended
upside down and ‘pulled’ out of the resin (Figure 1). The
platform is raised incrementally as each target area of resin
1
The Priestgate Clinic, Peterborough, UK
Corresponding author:
Richard RJ Cousley, The Priestgate Clinic, 26 Priestgate, Peterborough
PE1 1WG, UK.
Email: r.cousley@priestgateclinic.co.uk
2 Journal of Orthodontics 
Figure 1.  Photograph of a Formlabs 3B printer build
platform in its raised position, above the resin tank, at the
end of a print cycle. Multiple models may be seen attached
to the platform via vertical supports.
is cured. Models may either be printed as solid or hollow
items, provided that hollow versions have 2–3-mm thick
surfaces for sufficient strength (Figure 2). This is a worth-
while option for larger models since it saves resin (and
costs) without reducing the model accuracy (Sherman
et al., 2020). The final feature of SLA/DLP printing, and
relative workflow disadvantage, is that printed models
must be post-processed to avoid shrinkage and distortions
(Camardella et al., 2017). First, an alcohol solution removes
uncured surface resin, then a combination of an ultraviolet
light and heat (in a curing box) hardens the material.
Plastic 3D printing is most commonly used in orthodon-
tic to produce working models (for retainers, aligners, indi-
rect bonding trays and mini-implant guides) and directly
print appliances, e.g. mouthguards (in a biocompatible
material). Indeed, in the near future, it is likely that direct
printing of biocompatible and relatively flexible retainers /
aligners will be feasible (Cole et al., 2019; Jindal et al.,
2019; Sherman et al., 2020). The critical considerations for
clinical applications are accuracy, precision, ease of use
Figure 2.  Digital images of the same maxillary arch model (STL file) with (a) a solid base and (b) a hollow base. The estimated
amount of resin required for these two versions of this model was 22.5 mL and 13.3 mL (after the addition of virtual supports).
and speed of printing. Accuracy refers to the degree of
closeness of a 3D-printed model to the dimensions of its
digital version. Precision is the repeatability or reliability of
this process. Appliance fabrication requires both parame-
ters to be within clinically suitable limits. Ease of use and
print speed are important in terms of the workflow. Print
speed and accuracy may be balanced, such that it is quicker
to print a model with 100-µm layers than 50-µm layers
without affecting the accuracy needed for retainer fabrica-
tion (Brown et al., 2018; Kim et al., 2018; Sherman et al.,
2020).
Advantages and disadvantages of
in-house 3D printing
As with the introduction of any new technology, there are
potential benefits and difficulties of scanning and in-house
printing compared to traditional techniques (dental impres-
sions and plaster models). These are summarised below.
Advantages
The advantages are as follows:
- Full integration with a digital workflow: 3D print-
ing represents the final stage in the full utilisation of
intra-oral scanning and digital models.
- Accuracy: SLA/DLP printers provide similar levels
of accuracy to high-quality plaster dental models
(Brown et al., 2018; Hazeveld et al., 2014).
However, conventional models are prone to clinical
technique errors, distortion of impressions and
shrinkage of model materials. In contrast, a
3D-printed model is a reliable reproduction of the
dentition and is much more robust, allowing a plas-
tic model to be used multiple times.
- The ability to identify and repair scan defects
before model printing. These defects are due to
insufficient acquisition of surface data during the
scanning stage.
Cousley 3
- Potential labour and material cost savings relative
to conventional model processes and materials. A
full intra-oral scan takes a similar amount of time to
taking alginate impressions and an occlusal regis-
tration. However, dental impressions then need to
be disinfected, bagged, the model material poured
into each impression and the models trimmed. This
involves direct staff time and indirect time delays
while the impressions disinfect and the model mate-
rial hardens. In contrast, an increasing number of
the digital software and physical steps are becoming
automated, reducing staff involvement. The overall
time differences between conventional and digital
processes still need to be quantified and will depend
on the staff learning curve to become proficient as
well as the efficient management of printer capac-
ity. For example, a large build platform increases
productivity by enabling more models to be pro-
duced per print cycle.
- No need to out-source ‘simple’ appliances, e.g. ortho-
dontic retainers and aligners, which reduces turnaround
time and potentially both direct and indirect costs.
Disadvantages
The disadvantages are as follows:
- A switch to 3D printing requires a capital invest-
ment for the purchase of the 3D printer and post-
processing hardware. Additional software (or
licences) is also needed if one wishes to produce
in-house orthodontic aligners. Then there are recur-
ring costs for consumables, e.g. printer resin. Given
the rapidly evolving market for suitable 3D printers,
it is not possible to provide exact costs here. In
2020, a complete printer package (including post-
processing kit) currently costs between £4000 and
£10,000 (including 20% UK value added tax)
depending on the printer size.
- The need for dental staff to master new skills may
be a major initial obstacle since they may be com-
pletely unfamiliar with 3D computer software and
hardware. Hence, the introduction of a digital work-
flow requires clinical downtime for staff training
and possibly slower through-put speeds during the
learning phase. This is helped by provision of step-
by-step instruction documents for staff on the key
stages (digital model preparation, printing and post-
processing) in order to minimise errors and waste
and maximise efficiency. It is also worth using any
online training facility offered by the printer manu-
facturer or attending a suitable training course.
- A change of work patterns, e.g. a staff member
needs to process the scan file and manipulate the
digital models before printing, requiring ‘protected’
time.
- The need for post-print washing and curing phases
if SLA/DLP printers are used. While these steps can
be relatively automated, they increase the time from
scan to appliance fabrication.
- The need to update practice health and safety guide-
lines on the handling and storage of new materials.
While uncured resins and cleaning solvents are skin
irritants, the use of standard gloves avoids this, and
product information is easily obtained from manu-
facturers’ websites.
The digital workflow
The process from digital ‘impression’ to appliance will be
discussed in chronological order:
1. Intra-oral scanning
2. Digital model manipulation
3. 3D printing
4. Post-print processing
5. Appliance fabrication
1.  Intra-oral scanning
Intra-oral scanning creates a topographical map of the den-
tition and adjacent soft tissues. While the resultant digital
model is viewable within the scanner software, for physical
purposes it needs to be exported as a standard tessellation
language (STL) file. This universal 3D format represents
surface geometry as thousands of linked triangles and ren-
ders it suitable for CAD software manipulation.
2.  Digital model manipulation
Most current 3D printer software tends to focus on the imme-
diate print preparation, e.g. model orientation, and the addi-
tion of model supports. However, the virtual model produced
by a scanner is hollow with a very thin shell (Figure 3), which
is too flimsy for printing and subsequent appliance fabrica-
tion. Hence this digital model requires solidification (in-fill-
ing) (Figure 2a) or substantial thickening of the sides before
printing (Figure 2b). Notably, the base does not need to be as
deep and trimmed in the same manner as traditional study
models, since the purpose of the base is to make the resultant
physical model stable and relatively flat (Figure 2a). There
are three software options available to prepare models:
•  The scanner or orthodontic manipulation software, e.g.
3Shape Trios software (https://www.3shape.com/en/
software/ortho-system; accessed 20 April 2020) may be
used to base the digital models and render them solid
(Figure 4a). This is particularly useful if one aims to cre-
ate orthodontic aligners, since each upper/lower base is
prepared and trimmed only once, then this base is
4 Journal of Orthodontics 
Figure 3.  Illustration of a typical STL file exported from
intra-oral scanner software. The external surface is shown in
grey, the internal surface in pink. The hollow nature and very
thin boundary walls of this virtual model are apparent.
replicated for all aligner models. This is followed by
tooth segmentation, tooth movements, attachment addi-
tions and treatment sequencing, before aligner model
printing (which is outside the scope of this paper).
•  Some 3D printer software, e.g. Formlabs PreForm™
(https://formlabs.com/uk/software; accessed 20 April
2020), offers the option of automatically repairing and
basing the model immediately after import (Figure 4b).
This process may take 1–2 minutes, but it is an easy and
reliable way of rendering digital models suitable for
printing. Notably, the model is not usually finished with
a flat base, meaning that the base needs to utilise sup-
ports to link it to the print platform.
•  An open-source third party CAD software may be used to
base the models, e.g. the Microsoft Windows™ 3D Builder
Figure 4.  Computer illustrations of digital models where (a) a base has been added and then trimmed using the 3Shape scanner
software package and (b) where Formlabs PreForm printer software has been used to repair and base the model. The model
shown in (a) has a completely flat base whereas in (b) the base is uneven since this software does not extend and then cut the
base along a flat plane.
(https://www.microsoft.com/en-gb/p/3d-builder/9wzdncrfj
3t6?activetab=pivot:overviewtab; accessed 20 April 2020),
Meshmixer™ (www.meshmixer.com; accessed 20 April
2020) and Blender™ (www.blender.org; accessed 20 April
2020). The typical steps involved in ‘manual’ model prepa-
ration using generic 3D design software are:
- Identification followed by repair of surface (mesh)
defects (Figure 5a).
- Levelling of the model’s free edges, by removing
any extraneous soft-tissue sections (Figure 5b).
This step may be skipped if the intra-oral buccal/
labial scanned height is relatively consistent.
- Extrusion of the model’s external edge to create a
flat base which is reasonably parallel to the occlusal
plane (Figure 5c).
- Trimming the base height (Figure 5d). This avoids
unnecessary model thickness where little soft tissue
coverage is required for retainer and aligner fabrica-
tions. It also reduces resin usage and possibly the
print time. In addition, thin model bases allow many
more vertically orientated models to be fitted on the
build platform. However, if a deep model is
required, e.g. when full palate depth is needed for
appliance fabrication, then the model should be left
with sufficient height to accommodate this.
- Solidification of the model (Figure 5e). In-filling
makes the subsequent printed model sufficiently
robust and avoids both print failure (due to the
model fragmenting during the print process) and
subsequent model distortion under high vacuum/
pressure forces (during appliance fabrication).
- Alternatively, the model may be hollowed, to leave
a sufficiently thick surface layer before the solidifi-
cation step (Figure 5f). This results in less resin
usage and is therefore particularly suitable for
‘deep’ models, such as those including the full pal-
ate depth (Figure 2b).
Cousley 5

Figure 5.  These computer snapshots illustrate key stages when using Meshmixer CAD software to prepare dental model STL
files for printing. (a) The ‘holes’ in the model surface have been identified (by the pink tabs), ready for semi-automated repair. (b)
Superfluous edges of the model can be highlighted (in orange) then trimmed using a ‘cutting’ tool. (c) The model base has been
‘extruded’ to extend the non-dentate part into a deep, flat base. (d) The height of the extruded base has been reduced to a
manageable size for retainer and aligner fabrication. This has been achieved using a ‘plane cut’ tool, producing a flat base surface.
(e) Solidification produces a model with sufficient density for printing. (f) Alternatively, the model may be hollowed before the
solidification step.

- Ideally each digital model should be labelled in
order to avoid confusion over patient identification
and/or aligner sequence. Otherwise, staff need to
record each patient’s model positions in the print
set-up. Aligner softwares provide this capability
and are easier to use than trying to add labels within
third party software.
3.  3D printing
The two 3D printers used for descriptive and illustration
purposes in this paper are the Photocentric LC Precision 1.5
DLP printer (https://photocentricgroup.com/product/liq-
uid-crystal-precision-1-5; accessed 20 April 2020) and the
Formlabs Form 3B SLA printer (https://dental.formlabs.
com/form-3b; accessed 20 April 2020). These have small
(121 × 68 × 160 mm) and medium (145 × 145 × 185
mm) size print platforms, respectively. However, the details
described here are generalisable to most SLA/DLP printers
used for dental purposes. These 3D printers differ from one
another in terms of:
a) The build platform size, especially its surface area,
and consequently the maximum number of models
feasible per print cycle.
retainer models for a debond case (Figure 6a). However, it
can neither facilitate a large number of ‘flat’ models, even
for slow printing, or many vertically orientated models for
a large batch print. Therefore, the smaller the platform size
then the greater the need to prepare ‘thin’ models (with lit-
tle base depth) if they are to be accommodated even at a
vertical orientation (Figure 6b). This configuration may be
workable for retainer / aligner models, but not for appli-
ances which need a ‘deep’ model to include the palatal
vault, buccal (alveolar) areas or mandibular lingual depth.
If an orthodontic practice / clinic needs more than four
models printed per day, then a medium size of print plat-
form provides a practical solution (Figure 6c). In addition,
large but more affordable dental-specific printers are just
becoming available, e.g. the Photocentric LC Dental (310
× 174 × 200 mm) (https://photocentricgroup.com/lcden-
tal; accessed 20 April 2020) and the Formlabs 3L (335 ×
200 × 300 mm) (https://formlabs.com/uk/3d-printers/
form-3l; accessed 20 April 2020). These are certainly
appropriate for dental laboratories but may also suit large
orthodontic practices with a high volume of retainer and
aligner model requirements.
b) Print resolution and speed.

Print platforms may be categorised as small, medium or The higher the resolution setting then the greater the level of
large. In general, a small platform may allow relatively detail and the smoother the surface finish, since this entails
rapid printing of several ‘horizontal’ models, such as a higher number of print layers on the vertical (z) axis.
6 Journal of Orthodontics 

Figure 6.  Computer illustrations of digital model manipulation within 3D printer software. This small virtual platform can
accommodate (a) two models at a relatively low inclination to the platform surface or (b) four vertically orientated models
(shown with the supports added). (c) This medium size virtual platform is shown with 15 relatively vertical models, in order
to maximise the number of models per print cycle without supports. (d) Photograph of eight printed models, still on the build
platform. The multiple, interconnecting supports and their small circular bases are present, but only several of the touch points
are present on the palatal surfaces of incisors, as seen in two models on the left-hand side. (e) A cross-sectional view of a virtual
maxillary model, obtained by scrolling through the build layers (the blue vertical line on the right side is the scroll bar), where
the software has highlighted a floating piece of model with a red circle. This relates to the palatal surface of the maxillary left
central incisor, as identified by a red mark on the model surface view (f).

Resolution and speed are inter-dependent: the lower the
resolution then the faster the print. Overall, 100-µm layer
thickness appears to be adequate for orthodontic purpose,
when compared to slower print times with resolutions of 25
µm and 50 µm (Favero et al., 2017; Sherman et al., 2020).
Print speed is also affected by the orientation of the
models on the build platform (rather than the number of
models per se), such that models orientated parallel to the
platform print relatively quickly, because the z axis (total
height) is fairly low. In contrast, vertically oriented models
(where the horseshoe models are placed perpendicular to
the platform in order to fit more models on it) will have a
slower print time because of the distance from the platform
to the furthest model surface (typically an incisor labial sur-
face). Print times for dental models, at 100-µm resolution,
are commonly in the range of 1–10 hours, depending on
horizontal and vertical model set-ups, respectively. A short
print time is useful for same-day appliances such as retain-
ers, after including the post-processing and appliance fabri-
cation times. Conversely, a 10-hour print (perhaps running
overnight) is suitable for non-urgent printing of multiple
models in a single cycle (Figure 6c).
c) The range of suitable printable resins.
It is worth noting that most printers are configured to only
use their own brand of plastic resins, rather than being open
source, i.e. being able to print with any resin material. One
exception to this in the dental field is the newly released
Photocentric LC Dental. At this time, it is difficult to pre-
dict whether open-source printers will become more com-
mon, so the range of available resins is currently as
important a consideration for most printers as the actual
printer hardware.
d) Supports.
These are vertical struts and inter-connecting scaffolding
bars that add structural integrity to the model (Figure 6a, b
and d). They are particularly important when the model base
is irregular (Figure 4b). Supports vary in terms of their shape,
length, diameter and density (number per millimetre square),
so clinicians will find it much simpler to allow the software
to automatically add these. Individual supports may then be
edited, especially if their touch point is on a key tooth sur-
face. Interestingly, the position of supports (and the likeli-
hood of tooth surface contact) changes with the vertical
orientation of the model. When a model is relatively parallel
to the platform then it is unlikely that there will be touch
points on the teeth. In contrast, supports tend to connect to
tooth surfaces, especially incisors, when the model is verti-
cally orientated (Figure 6d). Consequently, I prefer to tilt
models by 20°–70° to the platform if supports are required,
depending on the number of models to be accommodated.
Cousley 7
In general, the greater the number of supports, then the
more resin that is used and the increased model finishing
required. However, this does not necessarily require a
longer print time. Conversely, supports may make it easier
to remove the models (undamaged) from the platform
immediately after printing. In effect, the model is spared
torsional forces as the supports break during separation
from the platform surface. Finally, it may be beneficial to
quickly scroll through the virtual models along the Z axis,
layer by layer, to double check that there are no ‘floaters’
(Figure 6e and f). These are islands of unsupported plastic
that may be lost as the model is printed (given that the
model is effectively produced upside down, suspended
from the base). An extra support may then be added at this
point, or the tilt of the model adjusted (to make it more
parallel to the platform).
e) Ease of use.
This relates to both the user-friendliness of the printer soft-
ware (in terms of model preparation) and the physical
aspects of handling the printer such as resin filling and
cleaning requirements. In particular, software manipulation
of the models should be as automated as possible in terms
of their orientation (on the build platform) and support
additions. Automation of the digital model ‘repair’ stage is
also very useful for as rapid a print set-up as possible.
Finally, it is convenient if the printer software can be used
remotely, since this enables the orthodontist to prepare
models for printing and start the print job, off-site.
As outlined already, the orientation of models on the build
platform affects the numbers of models that can be produced
in one print run and the print speed. In theory, models may be
placed ‘flat’ / horizontal on the platform, without supports,
provided they have a completely flat base. However, print
failures (due to high peel forces as the individual print layers
are formed) and potential difficulty in removing the models
from the platform (while they are still relatively weak before
final curing) mean that horizontal models are not widely rec-
ommended. Instead, most manufacturers recommend at least
20° of model tilt (to orientate the incisal edges furthest away
from the build platform). The model is then linked to the
platform using supports (Figure 6d).
4.  Post-print processing
These vary according to the resin used, so the printer manu-
facturer’s recommendations should be followed regarding
the following two finishing stages:
a) Model washing.
After printing, the models are typically washed for 10
minutes in isopropyl alcohol (IPA), with at least 95%
concentration, to remove any uncured residual surface
resin. This is best achieved with the assistance of mechan-
ical agitation, i.e. using either an ultrasonic bath or a
printer-specific washer, to continuously stir the IPA solu-
tion. Notably, IPA is a volatile and flammable chemical
compound, so washing in a closed chamber and good
room ventilation are recommended. The models should
then be air- or blow-dried to remove any residual IPA.
b) Model curing.
The model surface would gradually harden in daylight.
However, both for workflow efficiency and to ensure full
model curing, it is best to expose the models to a combina-
tion of an ultraviolet light and heat (e.g. 60 °C). Many
printer manufacturers sell curing boxes that will reliably set
the model surface in 30 minutes. The models are then ready
for use and may be handled without gloves at this stage.
5.  Appliance fabrication
This stage replicates conventional techniques for produc-
tion of both orthodontic retainers and aligners, where a
vacuum or pressure forming machine is used to form the
thermoplastic material around the model. Fortunately,
3D-printed models are much more robust than their plaster
counterparts and may be easily stored and re-used if neces-
sary. This is particularly helpful if a patient breaks or loses
a retainer or aligner, since a patient appointment and poten-
tial delay may be avoided. Even if the working model is
unavailable, a new one can be printed using the digital file,
again without requiring patient attendance.
Summary
There is clearly great potential for 3D printing applications
in clinical dentistry and perhaps most obviously in ortho-
dontics. While this involves a transition from conventional
methods to a fully digital workflow, especially in mastering
the software and different physical processes, there is no
doubt that this technology is here to stay and that it will
evolve even further for orthodontic uses. Provided that the
correct preparation and printing steps are followed, 3D
printing produces accurate and robust dental models, with-
out the mess and errors associated with conventional dental
impressions and plaster models.
Declaration of conflicting interests
The author declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author received no financial support for the research, author-
ship, and/or publication of this article.
8 Journal of Orthodontics 
ORCID iD
Richard RJ Cousley https://orcid.org/0000-0002-7393-4029
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