RESEARCH AND EDUCATION

Accuracy of 3-unit fixed dental prostheses fabricated on

3D-printed casts
Yeon Jang, MPH,a Ji-Young Sim, MS,b Jong-Kyoung Park, PhD,c Woong-Chul Kim, PhD,d
Hae-Young Kim, DDS, PhD,e and Ji-Hwan Kim, PhDf

The quality of a fixed dental ABSTRACT

restoration is determined by its
Statement of problem. Three-dimensional (3D)eprinted casts are used successfully as diagnostic
marginal and internal fit.1-6 casts in orthodontics. However, whether 3D-printed casts are sufficiently accurate to be used as
Accurate replication is essen- definitive casts for fixed dental prostheses (FDPs) is unclear.
tial to ensure a precise fit.7-10
Purpose. The purpose of this in vitro study was to evaluate the fit of 3-unit FDPs fabricated on
Hence, precision in making
3D-printed casts made by digital light processing and to investigate the clinical applicability of
impressions and replicas is 3D printing.
extremely important.
Definitive casts can be Material and methods. A master model was fabricated from epoxy resin. Stone casts were made
from dual viscosity impressions (conventional stone cast [CS] group, n=10). The 3D-printed casts
fabricated using the con-
were fabricated using a 3D printer after obtaining digital virtual casts by digital scans (3D-printed
ventional methoddelastomeric cast [3DP] group, n=10). All FDPs were fabricated with a 5-axis milling machine. The master model
impression and stone castdor a and intaglio surface of the milled FDPs was superimposed using 3D analysis software to measure
digital scan of the teeth with an the accuracy. Two-way ANOVA was performed to identify a significant difference between the
intraoral scanner. Stone casts groups (3DP and CS) and sides (pontic side, nonpontic side) and their interactive effects (a=.05).
have been used for diagnosis, The Tukey honestly significant difference test was used for post hoc analysis.
treatment, and prostheses Results. Two-way ANOVA showed significant differences between the 2 groups (3DP and CS) in the
fabrication for many years. marginal and internal root mean square (RMS) values (P<.001). However, no significant difference
However, they are susceptible was found in the marginal RMS values (P=.762) between the pontic and nonpontic sides. The 3DP
to damage.11 Moreover, they showed significantly higher RMS values than the CS (P<.001).
are difficult to store as they are Conclusions. The fit of FDPs produced from 3D-printed casts was inferior to that of conventional
bulky. Three-dimensional (3D) stone casts; however, all FDPs showed clinically acceptable accuracy. These results suggest that
digital virtual casts obtained 3D-printed casts have clinical applicability but that further improvement of the 3D printer is
from an intraoral scanner can necessary for their application in prosthodontics. (J Prosthet Dent 2020;123:135-42)
avoid these problems. They are
saved in a digital format and can be transmitted digi- prosthetic procedures, definitive dental casts are still
tally.12-14 The data are obtained directly from the teeth, required.16
thereby eliminating the need to fabricate a definitive cast Definitive dental casts can be fabricated from 3D digital
after making an impression.15 However, for some virtual casts by subtractive or additive manufacturing.

a
Doctoral candidate, Department of Dental Laboratory Science and Engineering, College of Health Science, Korea University, Seoul, Republic of Korea.
b
Doctoral candidate, Department of Dental Laboratory Science and Engineering, College of Health Science, Korea University, Seoul, Republic of Korea.
c
Research Professor, Institute of Health Science Research, Department of Dental Laboratory Science and Engineering, College of Health Science, Korea University, Seoul,
Republic of Korea.
d
Professor, Department of Dental Laboratory Science and Engineering, College of Health Science, Korea University, Seoul, Republic of Korea.
e
Professor, Department of Public Health Sciences, Graduate school, Korea University, Seoul, Republic of Korea.
f
Professor, Department of Dental Laboratory Science and Engineering, College of Health Science, Korea University, Seoul, Republic of Korea.

THE JOURNAL OF PROSTHETIC DENTISTRY 135

136
Clinical Implications
Precise casts are essential for fabricating accurate
prostheses. If digital scans obtained with an
intraoral scanner are routinely used in dental offices,
other types of casts would be necessary as
alternatives to stone casts. One such alternative is
the 3D-printed cast.
Subtractive manufacturing has simplified the prosthesis
fabrication process and improved accuracy.17-19 However,
reproducing complex shapes and undercuts with this
manufacturing method is difficult because the axes of the
milling machine are limited.20 Furthermore, this method
results in significant waste and can lead to error (called drill
compensation) because of the diameter of the milling
bur.21
In contrast, additive manufacturing, also known as 3D
printing, transforms the designed CAD files into slice
data, builds them layer by layer, and creates the desired
shapes.22-24 Minimal material is wasted, and features
such as undercuts and complex internal shapes can be
created.20 Furthermore, several products can be manu-
factured simultaneously. These advantages have pro-
moted interest in 3D printers, which are being used
increasingly in prosthodontics. Moreover, the original
patent for 3D printer technology has expired, reducing
the costs associated with 3D printers.25
Digital light processing (DLP) 3D printing uses the
photopolymerization method. The 3D printer flashes a
single image of each layer on the entire platform at one
time. Therefore, DLP can reduce printing time as all
layers are exposed at once. The accuracy of the cast varies
with the type of 3D printer.26 Moreover, the DLP method
has been reported to be more accurate than the other
types of 3D printers for fabricating diagnosis casts.27
At present, 3D printers are mainly used to fabricate
orthodontics casts and surgical guides for dental implant
surgery. However, they are expected to be used more
widely for not only fabricating prostheses but also
fabricating definitive casts for prosthodontics.5
Studies have evaluated the accuracy of 3D-printed
orthodontic diagnostic casts. However, studies on 3D-
printed definitive casts for fixed dental prostheses
(FDPs) are sparse. Therefore, the purpose of this
in vitro study was to evaluate the marginal and in-
ternal fit of FDPs fabricated on a 3D-printed cast
(3DP) and evaluate the accuracy of 3D-printed casts
compared with a conventional stone cast (CS). The
null hypothesis was that no statistically significant
difference would be found in the marginal and inter-
nal fit between groups (CS and 3DP) and sides (pontic
side and nonpontic side).
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Volume 123 Issue 1
MATERIAL AND METHODS
A maxillary resin typodont (AG-3 ZPVK; Frasaco
GmbH) was prepared for a 3-unit FDP with the right
first premolar and first molar as abutments. The abut-
ment preparations had 1.2-mm, 360-degree chamfer
margins. The prepared typodont was duplicated in
epoxy resin (Modralit 3K; Dreve Dentamid GmbH) as a
master model. To obtain reference data, the model was
digitized with an optical scanner (Comet LED 3D
scanner; Steinbichler Optotechnik GmbH) with 6-mm
precision.
Ten custom trays (SR Ivolen; Ivoclar Vivadent AG)
were fabricated after applying a layer of baseplate wax on
the master model and coated with tray adhesive (Iden-
tium Adhesive; Kettenbach GmbH). Dual viscosity im-
pressions (n=10) of the master model were made
according to the manufacturer’s recommendations. To
ensure complete polymerization, the impressions were
removed from the master model after 10 minutes (3
times longer than the time recommended by the
manufacturer),28 stored for 8 hours at 23
C, poured with
Type IV dental stone (FujiRock; GC), and separated after
45 minutes. After storage for 48 hours, the stone casts
were digitized with a reference scanner (Comet LED 3D;
Steinbichler Optotechnik GmbH) and saved as a stan-
dard tessellation language (STL) file (CS group).
To fabricate the 3D-printed cast (3DP group) (n=10),
the master model was scanned by an experienced clini-
cian with an intraoral scanner (CS3500; Carestream
Dental LLC). The corresponding exported STL files
(digital virtual casts) were used to fabricate 3D-printed
casts with a 3D dental model printer (3Dent; Envi-
sionTEC GmbH) (n=10). The 3D printer had a resolution
of 50 mm and printed 10 casts in approximately 1.5 hours.
These casts were then digitized with the reference
scanner (Comet LED 3D; Steinbichler Optotechnik
GmbH) and saved as an STL file (3DP group).
The 3-unit FDPs were designed by CAD software
(DentCAD; Delcam PLC) using an STL file (stone cast
data and 3D-printed cast data). The occlusal, axial, and
margin cement spacers were set as 0 mm, and the radius
correction was set at 0.6 mm. The design files were im-
ported with CAM software (GO2dental; GO2cam Intl).
The 3-unit FDPs were milled from a polyurethane block
(innoBlanc model; innoBlanc GmbH) with the 5-axis
milling machine (DWX-50; Roland DG Corp). After
milling, the intaglio of the completed 3-unit FDPs was
scanned with a reference scanner and saved as an STL
file.
For accurate superimposition, all STL files were
reduced to the area of interest by removing artifacts and
errors using 3D analysis software (Geomagic Verify 2015;
Geomagic GmbH). To superimpose data, the master
model data and 3-unit FDPs intaglio scan data were first
Jang et al
January 2020
Figure 1. Three-dimensional analysis process. FPDs, fixed dental prostheses.
autoaligned. The best-fit alignment command was
applied for accurate alignment (Fig. 1). Then, the whole
deviation was determined using values from a color map,
and the tolerance ranges were set as follows: upper/lower
(±10 mm); maximum/minimum (±100 mm). Root mean
squares (RMSs) were used to measure dimensional dif-
ferences between the master model and the intaglio
surface data of the digitized 3-unit FDPs.29 RMSs were
calculated by the following equation:
sffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
1 Xn
RMS=pffiffiffi ðx1;i −x2;i Þ2 ;
n i=1
where n is the sum of the measured points, x1,i is the
measuring point of the master model, and x2,i is the
measuring point of the data scanning the intaglio surface
of the milled 3-unit FDPs. In this study, a low RMS score
indicated an accurate 3D match. In addition, 3D data
were measured by dividing the casts into marginal and
internal areas based on a sharply curved line toward the
axial wall (Fig. 2A) and into the pontic and nonpontic
side, based on a line dividing the mesiodistal part of each
abutment into halves (Fig. 2B).
Statistical software (IBM SPSS Statistics, v22.0; IBM
Corp) was used for the statistical analysis. A 2-way
Jang et al
137
ANOVA was used to determine whether there was a
difference in RMS values based on the type of group and
side and the interaction between them. The post hoc
Tukey HSDhonestly significant difference (HSD) test was
conducted to identify significant differences among the
groups (a=.05).
RESULTS
Table 1 shows the mean RMS values and standard
deviation values for marginal and internal discrepancy.
Marginal (entire) RMS values were 37.2 mm and 44.5
mm in CS and 3DP, respectively, and internal (entire)
RMS values were 28.5 mm and 55.7 mm in CS and 3DP,
respectively. Significant differences were found in the
internal RMS values based on the group (P<.001) and
side (P=.007) (Table 2). In addition, a significant inter-
action between the cast group and side type was
observed (P=.009). However, no significant difference
was found in the marginal RMS values based on the
side (P=.762), and no interaction effect was found be-
tween the cast group and side type (P=.571) (Table 3).
The post hoc Tukey HSD test revealed that the mar-
ginal and internal RMS values of 3PD were significantly
higher than those for CS (P<.001).
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138 Volume 123 Issue 1

Figure 2. Subdivisions of 3-unit FDPs intaglio scan data. A, Yellow shades indicate marginal area, and green shades, internal area. B, Lines divide
mesiodistal area of each abutment into pontic side and nonpontic side. FPDs, fixed dental prostheses.

Table 1. Mean RMS values for marginal (entire) discrepancy and internal the internal and marginal area appeared similar except
(entire) gap of fixed partial dentures (mm) for the internal area of 3DP (Figs. 4, 5).
RMS (mm)
Area Group N Mean ±SD 95% CI
Marginal discrepancy CS 10 37.2 ±3.5 34.7-39.7 DISCUSSION
3DP 10 44.5 ±2.5 42.6-46.4
The results of this study supported the rejection of the
Internal gap CS 10 28.5 ±2.0 27.0-30.0
null hypothesis because differences were detected in the
3DP 10 55.7 ±2.4 53.9-57.5
marginal and internal fits between groups (CS and 3DP)
CI, confidence interval; CS, conventional stone cast; 3DP, 3D-printed cast; RMS, root and sides (pontic side and nonpontic side). The use of
mean square; SD, standard deviation.
intraoral scanners is a major advance for dental offices.
Once this method becomes more prevalent, alternatives
The color difference maps presented the discrepancies to stone casts, such as 3D-printed casts, will be required.
between the master model and the intaglio surface of the The present study compared the marginal and internal fit
FDPs. The internal area of 3DP is shown in blue (nega- between FDPs fabricated on 3D-printed casts and FDPs
tive discrepancies) on the vertical slopes and in red fabricated on stone casts.
(positive discrepancies) on the occlusal surfaces (Fig. 3). This study compared the entire digital workflow, from
In the marginal area of 3DP, more red color areas (pos- obtaining the scan to fabricating the prosthesis, with the
itive discrepancies) were displayed than in CS (Fig. 3). conventional workflow. Previous studies8-11 compared
The color maps of the pontic side and nonpontic sides in the accuracy of the casts, and therefore, errors in the

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January 2020 139

Table 2. Mean ±SD RMS values for internal (pontic side and nonpontic Table 3. Mean ±SD RMS values for marginal (pontic side and nonpontic
side) gap of fixed partial dentures (mm) side) discrepancy of fixed partial dentures (mm)
Side Side
Pontic Side Nonpontic Side Pontic Side Nonpontic Side
Group N Mean ±SD Mean ±SD Group N Mean ±SD Mean ±SD
CS 10 28.6 ±1.4A 28.7 ±1.2A CS 10 40.8 ±2.4A 40.0 ±2.5A
3DP 10 49.0 ±4.7B 54.4 ±3.3C 3DP 10 44.5 ±3.2B 44.7 ±3.0B

CS, conventional stone cast; 3DP, 3D-printed cast; RMS, root mean square; SD, standard CS, conventional stone cast; 3DP, 3D-printed cast; RMS, root mean square; SD, standard
deviation. P (group)<.001, P (side)=.007, P (group×side)=.009. Different superscript deviation. P (group)<.001, P (side)=.762, P (group×side)=.571. Different superscript
letters represent statistical differences among groups by 2-way ANOVA (with Tukey HSD letters represent statisitcal differences among groups by 2-way ANOVA (with Tukey HSD
test). test)

Figure 3. Color difference maps of discrepancies. A, Internal fit of CS. B, Internal fit of 3DP. C, Marginal fit of CS. D, Marginal fit of 3DP. CS, conventional
stone cast; 3DP, 3D-printed cast.

prosthesis fabrication process were excluded. Therefore,
the entire fabrication workflow was not assessed. As the
present study was conducted under standardized con-
ditions, the overall fabrication errors at each stage of the
workflow were minimized.
The marginal and internal fit of prostheses can be
measured using 2D or 3D methods. The 2D measure-
ment method includes the replica technique, direct view
technique, and cross-sectioning technique.1 These
methods measure the degree of discrepancy on images
obtained by a stereomicroscope or equivalent methods.
The main disadvantage of 2D measurements is that it can
measure the discrepancy at only a single location. By
contrast, the 3D analysis measures the entire thickness at
many points in the marginal and internal area in virtual
space. Therefore, no data are lost that could occur from
measuring just a single point, and it has the advantage of
visually expressing the entire discrepancy through a color
map.1
Silicone impression materials exhibit thermal
contraction of the material due to the temperature dif-
ference between the oral cavity and the room tempera-
ture.30 This study did not replicate these errors because
the impression was made at room temperature. There-
fore, the conventional impression control was more ac-
curate than a clinical impression.
Mously et al2 reported that the internal gap increased
with increasing spacer thickness setting. Furthermore,
other studies have suggested that the fit of the prosthesis
varies depending on the spacer thickness setting.3,14,22 In
the present study, the spacer thickness was set at 0 to
obtain an exact RMS value.
The marginal and internal fit also vary depending on
the material used for the prosthesis.4 In this study, a

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140
Figure 4. Color difference maps of discrepancies. A, Nonpontic side in internal area of CS. B, Nonpontic side in internal area of 3DP. C, Pontic side in
internal area of CS. D, Pontic side in internal area of 3DP. CS, conventional stone cast; 3DP, 3D-printed cast.
polyurethane block was used as the prosthetic material.
This block has the advantage of minimizing the problem
of expansion and shrinkage during milling because it is
machined to the same size as the designed form.18 In
addition, it is ideal for scanning and is suitable for 3D
evaluation as it is not a light reflective material like
ceramic, zirconia, or metal.
The marginal accuracy of a prosthesis fabricated by
CAD-CAM systems has been evaluated.4 However, the
clinically acceptable ranges of marginal fit differ, and the
clinically relevant range of marginal discrepancies is un-
clear. McLean and von Fraunhofer,6 in a 5-year clinical
study of 1000 restorations, concluded that 120 mm was
the maximum allowable marginal gap. In addition, clin-
ically acceptable values of internal fit have not yet been
defined and have been reported differently.4
The present study also showed that the RMS value
(55.7 mm) of 3DP was also high compared with that of CS
(28.5 mm) in the internal (entire) area (Table 1) (Fig. 3A,
B). Anadioti et al5 reported that the internal fit of the
prosthesis fabricated on a stereolithography (SLA) die,
one of the 3D printer methods, was significantly larger
than the fit of the prosthesis fabricated on a stone die.
Although the 3D printer method used for fabricating the
cast, the material of the prosthesis, and the measurement
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Volume 123 Issue 1
methods are different, these numerical values and results
are similar to those of the present study. The present
study showed that the RMS value (44.5 mm) of 3DP was
larger than that of CS (37.2 mm) in the marginal (entire)
area (Table 1) (Fig. 3C, D). This is consistent with the
findings of Anadioti et al,19 who concluded that the
marginal fit of the prosthesis fabricated on a stone die is
better than the fit of the prosthesis fabricated on an SLA
die.
Factors that affect 3D printer resolution and precision
include 3D printing methods, materials, manufacturers’
setup parameters, and postprocessing. For example, the
SLA method is affected by horizontal resolution, which is
determined by the diameter of the laser beam, and
vertical resolution depends on layer thickness.23 In
addition, when the setup parameters are changed, the
machining accuracy and the build time are different; this
may generate residual internal stress during the post-
polymerizing period, leading to possible deformation of
the prosthesis.
The higher RMS values of the 3DP group compared
with those of the CS group in the marginal and internal
area are attributable to the formative processes of the 3D
printer. A 3D printer works by laying down materials,
layer by layer, toward the Z axis. This layer-by-layer
Jang et al
January 2020
Figure 5. Color difference maps of discrepancies. A, Nonpontic side in marginal area of CS. B, Nonpontic side in marginal area of 3DP. C, Pontic side in
marginal area of CS. D, Pontic side in marginal area of 3DP. CS, conventional stone cast, 3DP, 3D-printed cast.
technique creates a stair-step effect on the object’s sur-
face.23 Therefore, rough surfaces and dimensional errors
can occur in the object.23 In addition, as the DLP method
used in this study is based on a bottom-up projection
where the build platform moves upwards, a polymerized
layer is sandwiched between the previous layer and the
resin vat. When the build platform is removed from the
vat during the building process, the coagulated material
can adhere strongly to the resin contained in the vat,
which can deform the object.24
Finally, the present study assessed the cast discrep-
ancies by dividing the internal and marginal fit into
pontic side and nonpontic side to subdivide the data and
accurately measure the casts. No significant difference
was found in the RMS values of the pontic side and
nonpontic side in the marginal and internal area except
for the internal RMS values of the 3DP group (Figs. 4, 5).
This result seems to be due to the properties of the
material used in the 3D printer. The resin, a material used
in the DLP method, must undergo a photo-
polymerization process. Photopolymerization leads to
material shrinkage, which can cause residual stress,
skewing, or distortion in the object.11 The resulting strain
Jang et al
141
is seen toward the pontic side, and thus, the RMS values
of the nonpontic side appear to be larger (Fig. 4).
Analysis of the results of this study showed that the fit
of the prostheses fabricated on the stone casts was better
than that of the prostheses fabricated on the 3D-printed
casts. However, the difference was not large, with all the
values falling within the clinically acceptable range (<120
mm).6 These results indicate the possibility that 3D-
printed casts could be used for fixed prostheses. How-
ever, as the impression process and digitalization are
influenced by a variety of factors within the oral cavity,
clinical studies should be conducted to evaluate 3D
printing.
CONCLUSIONS
Based on the findings of this in vitro study, the following
conclusions were drawn:
1. The marginal and internal RMS values of the 3DP
group were significantly higher than those of the CS
group.
2. However, both groups had a marginal and internal
fit within the clinically acceptable range (<120 mm).
THE JOURNAL OF PROSTHETIC DENTISTRY
142
3. Further improvement of the accuracy of 3D printers
is necessary before using 3D-printed casts in
prosthodontics.
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Corresponding author:
Dr Ji-Hwan Kim
Department of Dental Laboratory Science and Engineering
Korea University
145, Anam-ro, Seongbuk-gu, Seoul 02841
REPUBLIC OF KOREA
Email: kjh2804@korea.ac.kr
Copyright © 2018 by the Editorial Council for The Journal of Prosthetic Dentistry.
https://doi.org/10.1016/j.prosdent.2018.11.004
Jang et al