Accuracy of 3D Printed Implant Casts Versus Stone Casts: A

Comparative Study in the Anterior Maxilla

Ayman Banjar, BDS, MS,1,2 Yo-wei Chen, DDS, MS, FACP ,2 Aikaterini Kostagianni, DDS, MS ,2
Matthew Finkelman, PhD,3 Aikaterini Papathanasiou, DDS, MS,2 Konstantinos Chochlidakis, DDS, MS,
FACP ,4 & Panos Papaspyridakos, DDS, MS, PhD 2,4
1
Department of Restorative Dentistry, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia
2
Department of Prosthodontics, Tufts University School of Dental Medicine, Boston, MA
3
Department of Public Health and Community Service, Tufts University School of Dental Medicine, Boston, MA
4
Department of Prosthodontics, University of Rochester Eastman Institute for Oral Health, Rochester, NY

Correspondence
Panos Papaspyridakos DDS, MS, PhD,
Associate Professor, Department of
Prosthodontics, Tufts University School of
Dental Medicine, One Kneeland Street,
Boston, MA, 02111.
E-mail: panpapaspyridakos@gmail.com
Disclosure Statement: The authors do not
have any financial interest in the companies
whose materials are included in this article.
Accepted January 14, 2021
doi: 10.1111/jopr.13335
Abstract
Purpose: To conduct an in vitro comparison of the amount of three-dimensional
(3D) deviation of 3D printed casts generated from digital implant impressions with
an intraoral scanner (IOS) to stone casts made of conventional impressions.
Material and Methods: A maxillary master cast with partially edentulous anterior
area was fabricated with two internal connection implants (Regular CrossFit, Strau-
mann). Stone casts (n = 10) that served as a control were fabricated with the splinted
open-tray impression technique. Twenty digital impressions were made using a white
light IOS (TRIOS, 3shape) and the Standard Tesselation Language (STL) files ob-
tained were saved. Based on the STL files, a digital light processing (DLP) and a
stereolithographic (SLA) 3D printer (Varseo S and Form 2) were used to print casts
(n = 10 from each 3D printer). The master cast and all casts generated from each
group were digitized using the same IOS. The STL files obtained were superimposed
on the master cast STL file (reference) to evaluate the amount of 3D deviation with in-
spection software using the root mean square value (RMS). The independent-samples
Kruskal-Wallis test and Dunn’s test with Bonferroni correction (for post hoc compar-
isons) were used for statistical analyses.
Results: The Varseo S group had the lowest median RMS value [77.5 µm (IQR =
91.4-135.4)], followed closely by the Conventional group [77.7 µm (IQR = 61.5-
93.4)]. The Form 2 had the highest mean value [98.8 µm (IQR = 57.6-87.9)]. The
independent-samples Kruskal-Wallis test revealed a significant difference between
the groups (p = 0.018). Post hoc testing revealed a significant difference between
Varseo S and Form 2 (p = 0.009).
Conclusion: The casts generated from the Varseo S 3D printer had better 3D ac-
curacy than did those from the Form 2 3D printer. Both the Varseo S group and the
conventional stone casts groups had similar 3D accuracy.

An accurate impression is a prerequisite to produce an error-
free stone cast, which contributes to the fabrication of a
definitive restoration with accurate fit.1,2 Several factors im-
pact the three-dimensional (3D) accuracy of implant impres-
sions: the properties of the impression material, the type of
impression coping, the impression technique, the implant an-
gulation, and the connection type.3–5 According to a system-
atic review by Papaspyridakos et al, the splinted implant im-
pression was reported to be the most accurate, regardless
of the impression material used and the selected tray tech-
nique for both partially and completely edentulous cases.4
However, patient gagging, taste irritation and risk of pa-
tient suffocation are among the drawbacks of conventional
impressions.6–8 The use of intraoral scanners (IOS) for tak-
ing digital scans has emerged as an alternative approach to
the conventional impression technique for both partially and
fully edentulous patients.9–20 The IOSs produce standard tes-
sellation language (STL) files that can be utilized to fabri-
cate casts and/or dental restorations through computer-aided
designing/computer-aided manufacturing (CAD/CAM).9–20
The STL files are sent and stored electronically, improv-
ing efficiency. This technology offers simple, comfortable,
and time-effective treatment workflow for the dentist and the
patient.

Journal of Prosthodontics 0 (2021) 1–6 © 2021 by the American College of Prosthodontists 1

Accuracy of 3D Printed Casts for Partially Edentulous Anterior Maxilla
Until recently, subtractive manufacturing has always been as-
sociated with the CAM element of the digital workflow. In this
approach, the object is created by milling it from a prefabri-
cated block of the material desired. The limitations of the sub-
tractive technique include: the inability to create fine details, as
it is highly dependent on the milling burs’ smallest radius, con-
siderable waste of material associated with the milling, which
can reach 90%, and the limited number of objects that can be
produced per milling session.21,22
Additive manufacturing (AM) also referred to as 3D print-
ing, is a process by which an object is constructed one layer
at a time.23,24 Several categories are available for AM: Vat
polymerization, material jetting binder jetting, material extru-
sion, power bed fusion, sheet lamination, and direct energy de-
position. Essentially, in Vat polymerization 3D printing, the
printer’s software slices the STL file of an object into multi-
ple two-dimensional (2D) layers in the X and Y planes. Next,
the printer begins building up the layers on top of each other
successively until the object is formed completely. Using this
technology allows minimal material waste and produces ob-
jects with highly detailed geometries.21–27
Vat polymerization 3D printers utilize different printing tech-
nologies; for example, stereolithography (SLA) and digital
light processing (DLP) are those used most commonly for den-
tal applications.21 Largely, SLA and DLP printers use the same
process for printing, but they differ in the way they deliver the
curing light to the resin. Stereolithography is the oldest and
most common method used for 3D printing. This method in-
volves projecting a rapidly moving ultraviolet (UV) laser beam
into a tank filled with light-sensitive liquid resin to draw the
details of each layer of an object. The cured layer is attached
to the printer’s building platform rather than to the resin tank.
Once a layer is complete, the building platform rises slightly,
a new layer is formed on top of the previous one, and this pro-
cess continues to repeat until the object is formed fully. Digital
light processing is an alternative method to deliver light in 3D
printers. Rather than using a laser beam to scan one layer at a
time, DLP printers project a silhouette of an entire layer simul-
taneously and cure it with curing light, which permits relatively
faster printing.24–27
Dental casts for fixed and implant prosthodontics derived
from digital scans and constructed through 3D printing are
becoming popular. Although an IOS can offer the clinician a
complete digital workflow without the need for a physical cast,
some complex prosthodontic procedures, especially in the an-
terior maxilla, may still require physical casts. To the authors’
knowledge, there are no studies evaluating the accuracy of 3D
printed implant casts generated from digital scans using IOS in
the partially edentulous anterior maxilla. Hence, the purpose of
this in vitro study was to compare the accuracy of 3D printed
casts generated from one SLA and one DLP 3D printer to stone
casts made out of conventional implant impression for the sce-
nario of a partially edentulous anterior maxilla with two im-
plants. The hypothesis was that the stone casts fabricated using
conventional impressions have less 3D deviation compared to
casts generated from the two 3D printers. On the other hand,
the 3D accuracy of the printed casts generated from the two
3D printers would be the same. The null hypothesis was that
the groups have equal 3D deviation.
2 Journal of Prosthodontics 0 (2021) 1–6 © 2021 by the American College of Prosthodontists
Banjar et al
Materials and Methods
A partially edentulous maxillary master cast was fabricated
with two bone-level internal connection implants (Bone Level
RC, Straumann) to simulate a clinical scenario of a partially
edentulous anterior maxilla that would be restored with a 4-
unit implant-supported fixed dental prosthesis. The two im-
plants were within 5° angulation to each other simulating ideal
implant placement. Four locating notches were made on the
master cast to standardize the process by which conventional
impressions were made.
Ten open tray splinted implant level impressions were made
with polyether impression material (Impregum, 3M ESPE). To
standardize the procedure, implant impression copings were
splinted with urethane dimethacrylate-based visible light-cured
resin bars (Triad gel) at standardized dimensions. The bars
were sectioned with thin discs and then attached to the impres-
sion copings with a minimum amount of Triad gel.9 The open
tray impressions were made with polyether impression mate-
rial in the fabricated custom tray. The impression copings were
screwed into the implant replicas, and the impressions were
poured with type IV stone (Resin Rock, Whipmix Corp).
Subsequently, scan bodies made of poly(etheretherketone)
(PEEK) (CARES Mono Scan Body, Straumann) were tight-
ened to the implants on the master cast with the 10Ncm torque.
Twenty digital scans were made from the master cast using a
white light IOS (TRIOS, 3shape) following the manufacturer’s
recommendation and STL files were exported. Prior to digi-
tal scanning, the scanner tip was calibrated using the calibra-
tion tip provided from the manufacturer. Additionally, one cal-
ibrated operator performed all digital scans. Calibration was
achieved prior to the initiation of the study after performing 20
trial scans.
The STL files obtained from the TRIOS scanner were im-
ported into CAD software and processed by an experienced
laboratory technician. Twenty casts were printed using two dif-
ferent 3D printers. In Group 2, ten casts were printed with the
Varseo S DLP printer (Varseo S 3D printing system, BEGO).
In Group 3, another ten casts were printed with the Form 2
SLA printer (Form 2 3D printer, Formlabs). The casts were
positioned at 45° angulation to the build platform and a layer
thickness resolution of 100 µm was selected for both printers.
The Varseo S printer allows only one cast to be printed at a
time, while the Form 2 printer can print up to eight casts at a
time. In this study, two casts were 3D printed at a time with
the Form 2 printer. All printed casts were cleaned with 99.9%
isopropyl alcohol in an ultrasonic bath for 15 minutes and then
postcured in a curing unit (Metalight trend, Primotec® ) with
ultraviolet light of 405 nanometer wavelength for 60 minutes.
Subsequently, implant analogs (Straumann digital reposition-
able analogs) were retrofitted into the printed casts so they
could be used as working casts from the digital pathway.
The same IOS (TRIOS) was used to scan and digitize the
stone and the 3D printed casts from the three groups, in order to
eliminate the effect of the scanner (Fig. 1). Prior to each scan,
polymer scan bodies (CARES Mono Scan Body, Straumann)
were tightened with the 10Ncm torque on the first test cast and
then scanned with the digital scanner. The scan bodies were
transferred from the first cast to the second cast for scanning.
Banjar et al
Figure 1 Casts digitization procedure. (A) SLA cast printed with Form 2 3D printer, (B) conventional stone cast, (C) DLP cast printed with Varseo S 3D
printer.
Figure 2 Superimposition of STL files of master cast and printed cast
generated from the digital scan.
This process was repeated for all ten casts of the three groups,
in order to eliminate the effect of the scan bodies.
Finally, the master cast was digitally scanned with the same
polymer scan bodies tightened on the implants in order to cre-
ate a reference STL file. All scanning procedures were com-
pleted by one calibrated operator. The STL file of each cast
from the control and the test groups were superimposed to the
STL file of the master cast in the 3D inspection software (Ge-
omagic Control X, version 2018.1.1; 3D Systems) using the
best-fit alignment algorithm (Fig. 2). The software was utilized
to calculate the 3D deviation of each cast by the use of the root
mean square (RMS) error.
The statistical software package nQuery Advisor (Version
7.0) was used to perform a sample size calculation. Based on
the results of Alshawaf et al22 the anticipated means (SDs)
were 53.49 (9.47) µm for the conventional group and 108.09
(9.59) µm for the digital groups. Under these assumptions, the
sample size calculation found that a sample size of n = 10
per group would be adequate to achieve a power greater than
99% alongside a Type I error rate of 0.05. Descriptive statistics
(mean, median, standard deviation, interquartile range, min-
imum, and maximum) were calculated for each group. The
Shapiro-Wilk test was used to assess the normality of the data.
Accordingly, the nonparametric Kruskal-Wallis test (p < 0.05)
Journal of Prosthodontics 0 (2021) 1–6 © 2021 by the American College of Prosthodontists
Accuracy of 3D Printed Casts for Partially Edentulous Anterior Maxilla
was used to test for significant differences among the three
groups. Dunn’s test with the Bonferroni correction (p < 0.05/3
≈ 0.0167) was used for the post hoc comparisons. A statistical
software program (IBM SPSS Statistics, v25; IBM Corp) was
used in the analysis.
Results
Descriptive statistics are illustrated in Table 1. The median
RMS error was 77.7 µm [IQR = (61.5, 93.4)]) for the con-
ventional group, 77.5 µm [IQR = (91.4, 135.4)] for the Varseo
S group, and 98.8 µm [IQR = (57.6, 87.9)] for the Form 2
printer group. The assumption of normality was assessed us-
ing Shapiro-Wilk test and was significant (p < 0.05 in both 3D
printed cast groups). The independent-samples Kruskal-Wallis
test revealed a significant difference (p = 0.018).
Post hoc testing via Dunn’s test with Bonferroni correction
showed a significant difference between Varseo S and Form 2
printers (p = 0.009). The difference between conventional and
the Form 2 printer group (p = 0.024) would have been sig-
nificant at a significance level of 0.05, but was not significant
when using the more stringent Bonferroni correction.
Discussion
The objective of this in vitro study was to compare the 3D
accuracy of conventional stone casts with 3D printed implant
casts generated from two printers with different printing tech-
nologies. The null hypothesis was rejected in part, as the stone
casts and 3D printed casts had similar accuracy only with the
Varseo S printer, which demonstrated better accuracy than did
the Form 2 printer.
The findings of this study showed that the least amount of
3D deviation, when expressed as the median of RMS error,
was found in the Varseo S group, followed closely by the con-
ventional stone cast group, while the Form 2 group had the
highest amount of 3D deviation. The Varseo S printer did not
print the casts reliably when compared to the Form 2 printer,
as the Varseo S group had a total of eight misprints, while the
Form 2 printer had no misprints. Further, the Varseo S printer
failed to initiate the printing process on five occasions. Never-
theless, the findings of this in vitro study indicated that Varseo
S performed better than did the Form 2 at a printing layer
thickness of 100 µm. This finding is consistent with that in
3
Accuracy of 3D Printed Casts for Partially Edentulous Anterior Maxilla
Table 1 Mean, median, standard deviation (SD), interquartile range (IQR), minimum, and maximum 3D deviations (μm)
Mean Median SD
Conventional 85.9 77.7 30.2
Form 2 111.8 98.8 26.1
Varseo S 89.5 77.5 55.1
*
p-Value from Kruskal-Wallis test. In post hoc comparisons (Dunn’s test with Bonferroni correction), the level of significance was 0.05/3≈0.0167. The difference
between Form 2 and Varseo S was statistically significant (p = 0.009), but the differences between conventional and Varseo S (p = 0.722) and conventional and
Form 2 (p = 0.024) were not statistically significant when using the Bonferroni correction.
Revilla-León et al’s28 study, which evaluated the positional ac-
curacy of implants in casts printed with different 3D printing
technologies. Their study found that the DLP 3D printer can
produce definitive implant casts with accuracy comparable to
the conventional method. With respect to SLA printing, Bohner
et al’s29 results are also consistent with this study’s findings.
Their investigation also compared implant SLA 3D printed
casts to conventional stone casts, and they found no signifi-
cant differences in the linear measurements of the entire cast
area. It must be highlighted that although the difference be-
tween the 3D printed cast groups in this investigation was sta-
tistically significant from the nominal point of view, this differ-
ence may not be clinically relevant. According to the literature,
the reported clinically acceptable threshold of misfit lies below
150 to 200 µm.12–14 This suggests that the printed casts from
each group tended to be clinically acceptable for restoration
fabrication.
An attempt to compare the findings of this in vitro study
with those of research published previously was not feasible
because of the paucity of such research. Previous studies that
have evaluated the accuracy of 3D printed and/or milled im-
plant casts are limited, and there was great variability in the
clinical scenarios and methods of testing used, as well as con-
flicting results.22,23 In an in vitro study by Alshawaf et al30 the
authors compared the accuracy of 3D printed casts (also us-
ing the Varseo S printer) generated from digital scans to stone
casts generated from conventional impressions. The authors re-
ported that 3D printed casts had more 3D deviations than the
conventional stone casts.30 In contrast, this study found that
printed casts from the Varseo S printer had 3D accuracy sim-
ilar to that of stone casts with two implants placed in the an-
terior maxilla. Another in vitro study by Lin et al5 compared
the accuracy of milled definitive casts made from digital scans
to conventional stone casts. The authors stated that the digital
workflow produced less accurate casts compared to the con-
ventional method when the implant divergence was at 0° and
15°.5 Although direct comparison cannot be made because of
the difference in the fabrication method (milling vs printing),
this study found that 3D printed casts produced in the digital
workflow had comparable accuracy to the conventional stone
casts with two implants placed at 5° divergence.
Many factors involved in 3D printing can affect the accuracy
of this approach: build angle and direction of printing, print-
ers’ resolution, degree of support, type of resin, laser speed
and intensity, and postcuring process.31 Build angle refers to
the printing orientation, which determines the way the software
4 Journal of Prosthodontics 0 (2021) 1–6 © 2021 by the American College of Prosthodontists
Banjar et al
IQR Min. Max. p
(61.5, 93.4) 55.8 157.4 0.018∗
(91.4, 135.4) 87.7 153.8
(57.6, 87.9) 42.5 238.1
slices the object for printing. This can affect the mechanical
properties, quality, and time required for printing significantly.
Thus, the build angle must be managed carefully to avoid any
deviation in the printed object.31 In a study conducted by Al-
harbi et al,32 it was found that the build angle affected the 3D
specimens’ accuracy significantly. The authors reported that
135° (45°) and 210° build angles had the lowest RMS error,
in which the former was more favorable.32 However, no study
in the literature has reported the most appropriate build angle
for dental casts. In this investigation, all of the 3D printed casts
were printed at 45°, which allowed the implant platform’s po-
sition to be parallel to the build platform. This was based on
the printing trials performed before the study, which showed
consistent outcomes with no deviations. Further, the addition
of sufficient supporting structures was important to brace the
printing and avoid distortions within the cast. However, we did
not test these parameters and observations in this study and
further investigation is needed for dental casts.
Studies that have evaluated the accuracy of 3D printed den-
tal casts have seldom discussed resolution. Simply stated, it
can be defined as the printer’s ability to reproduce the smallest
fine detail.25 In 3D printing, resolution becomes more complex
as it involves three dimensions: the 2D horizontal plane, X, Y,
and the vertical Z plane, which represents the layer’s thickness,
and this feature is preset by the manufacturer; hence, the selec-
tion of the printer must be based on its performance in all three
planes (X, Y, and Z). The XY resolution is the factor that influ-
ences the 3D printing quality and accuracy most, and it varies
based on the printing technology the printer uses.25,26 In DLP
printing, this feature is already fixed by the minimal pixel size
relative to the build area.21 On the other hand, in SLA printing,
the laser beam’s diameter determines the XY resolution.21–26
Hence, it can be inferred that SLA technology can offer bet-
ter resolution than DLP, as its laser beam runs throughout the
cross-section and draws the layer’s detail, rather than project-
ing light on certain areas on the resin. In this investigation, the
DLP printer did, in fact, perform better than the SLA printer
did, and the fact that the Varseo S has an XY resolution of
60 µm, which is better than that of Form 2 (150 µm), might
explain this result.25 One of the limitations of using the RMS
error to assess accuracy is its inability to determine the dis-
placement’s direction.30 Therefore, further study is required
to analyze the cause of the discrepancies between the two
technologies.
One of the principal challenges in this in vitro study was
determining the master cast’s true dimensions. The use of
Banjar et al
industrial computed tomography, extraoral scanners and coor-
dinate measurement machine has been described previously in
the literature.28,33-39 Another in vitro study used industrial com-
puted tomography to validate the extraoral scanner’s accuracy
and digital scans obtained from it were superimposed onto a
scan obtained from the industrial scanner.33 In this study, in or-
der to eliminate the effect of the scanner, the same IOS scanner
was used for digitization of the master cast and printed casts.
In addition, the possible effect of scan bodies was minimized
by using the same scan bodies for scanning all casts. Scan bod-
ies were transferred from one implant in the first cast to the
same implant in the other ten casts of each group. Potential
distortion of the screw might occur due to the small size, and
it might compromise the stability of the scan bodies. However,
the scan bodies used had a titanium base interface, which is
resistant to deformation.
The use of an intraoral scanner in an extraoral setting is one
of the main limitations in this present study. In such a setting,
intraoral factors such as saliva, soft tissues, limited space and
location of the tooth, which are all known to affect the accuracy
of the digital scan, were absent. In addition, the method used
by the IOS to scan also contributes to the accuracy of the dig-
ital scan. Some authors stated that video-based scanners may
demonstrate better accuracy due to the continuous streaming of
the images with large overlapping areas.40 The scanner used in
the present study was a white light IOS (TRIOS), which uses
optical confocal microscopy technology to create an image of
the teeth. In contrast to the video-based systems, this scanner
captures several images at a time and stitches them together
in order to create the final image.40 This may create some
errors during the scanning and virtual data acquisition. How-
ever, the digital scans in the present study were completed by
a single calibrated operator and following the manufacturer’s
recommendation.
In the present study, only one clinical scenario was tested.
It would be beneficial to evaluate different clinical scenarios
with implants placed at different levels and angulations in fu-
ture studies. Also, there are no studies assessing the accuracy
of framework fit directly fabricated from 3D printed casts.
The fabrication of prosthesis prototypes or frameworks derived
from the digital workflow and fitting them into the 3D printed
casts or stone casts is the ideal way of clinically relating 3D
accuracy and clinical fit acceptability. This will allow measur-
ing the amount of prototype or framework misfit and deter-
mine whether it falls within the clinically acceptable range or
not. For future study, it is also recommended to utilize printers
with another type of printing technology and different printing
angulation.
Conclusions
Casts generated from the Varseo S printer had better 3D accu-
racy than the Form 2 printer. Comparing the Varseo S printer
group to the conventional stone casts, both groups had sim-
ilar 3D accuracy. This indicates that 3D printed casts might
be clinically acceptable and can potentially be used to fab-
ricate implant-supported, fixed dental prostheses in a digital
workflow.
Journal of Prosthodontics 0 (2021) 1–6 © 2021 by the American College of Prosthodontists
Accuracy of 3D Printed Casts for Partially Edentulous Anterior Maxilla
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