3D Printing and Digital Processing Techniques in Dentistry: A Review of Literature

REVIEW
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3D Printing and Digital Processing Techniques in

Dentistry: A Review of Literature
Liwei Lin, Yingfeng Fang, Yuxuan Liao, Gang Chen, Chunxia Gao,* and Peizhi Zhu*
for commercial applications, such as DTM

In recent years, the rapid development of 3D printing technologies lead to its Corporation,[4] Z Corporation,[5] Solid-
new applications in the area of healthcare and medicine, including dentistry, scape,[6] and Objet Geometries.[7] With the
orthopedics, cardiovascular, pharmaceutics, neurosurgery, engineered tissue rapid development of 3D printing technolo-
gies, 3D printing gained much attention in
models, medical devices, and anatomical models. Dentistry is widely
public due to its excellence in precision,
acknowledged to benefit from 3D printing technologies due to its needs for extraordinary material savings, freedom in
the customization and personalization of dental products. In this review, the design, and personalized customization.
authors discuss and summarize various 3D imaging technologies and the The 3D modeling, image, and simple
recent advances of 3D digital processing techniques in dentistry in an effort workflow of 3D printing are shown in
Figure 1. 3D printing was first applied in
to give a new perspective and greater understanding of the current
dentistry in the early 2000s, when the
development of 3D printing technologies in dentistry. It is anticipated that technology was first used to make dental
this review will explore why 3D printing is important to dentistry, and why implants and custom prosthetics.[8] The up-
dentistry motivates development in 3D printing applications. Further, current to-date medical applications of 3D printing
challenges and further perspectives are also discussed which helps research- can be briefly divided into the following
ers to optimize the 3D printing technology in dentistry, improve 3D printing categories: tissue and organ fabrication,[9]
creating prosthetics,[10] implants,[11] and
strategies, and direct future dental bioprinting and translational applications.
anatomical models,[12] as well as pharma-
ceutical research concerning drug discov-
ery,[13] delivery,[14] and dosage forms.[14] The
greatest advantage that 3D printing provides
1. Introduction for medical applications is the freedom to produce custom-made
medical products and equipment.[15] Therefore, the applications of
Three dimensional (3D) printing refers to the process that 3D printing to customize prosthetics and implants can create
materials are mixed or solidified together (such as liquid molecules inestimable value. Additionally, 3D printing can produce custom-
or powder grains being fused together) to create a 3D object under ized jigs and fixtures and custom-made implants, fixtures, and
computerized control.[1] As one of the advanced fabrication surgical tools for surgeries.
techniques, 3D printing is also referred to as additive manufactur- Dentistry has greatly benefitted from 3D printing and is
ing (AM) and rapid prototyping technology, which requires embracing the trend of digital dentistry. Different from
automated processes and standardized materials as building traditional fabrications, 3D printed artificial teeth and dental
blocks to enable the creation of 3D objects from personalized and implants have become more easily available due to its rapid
specific computer-aided designs.[2] The first 3D printing process, production of high precision and personal customization.[16]
called as “stereolithography”, was invented by Charles Hull in Moreover, 3D printing designed for dental applications can now
1983.[3] Since then, many companies have developed 3D printers help dentists provide for patients with more personalized service
at a substantially lower cost and also simplify the complex
Prof. P. Z. Zhu, Dr. C. X. Gao, L. W. Lin, Y. X. Liao workflows regarding to the production of dental appliances.
Institute of Biomedical and Tissue Engineering Currently, the demand for 3D printing in dental industry has
School of Chemistry and Chemical Engineering increased due to the advancements in technology, which enables
Yangzhou University dentists to perform the dental procedures with great accuracy,
Yangzhou, Jiangsu 225009, P. R. China
high efficiency and minimal trauma to patients. In order to
E-mail: cxgao@yzu.edu.cn; pzzhu@yzu.edu.cn
improve the production efficiency of the denture, increase the
Prof. Y. F Fang
Yangzhou Stomatological Hospital quality of denture production and shorten the treatment time,
Yangzhou researches related to 3D printing in dentistry has become a hot
Jiangsu 225009, P. R. China spot for scholars at home and abroad.
Dr. G. Chen Dental materials consist of implants, core materials, restor-
Northern Jiangsu People’s Hospital ative materials, impression materials, dental cement, and
Yangzhou bonding agents.[17] Among these materials, crowns and bridges
Jiangsu225009, P. R. China
sector accounted for 34.2% of the global market in 2016.[18] It is
DOI: 10.1002/adem.201801013 predicted that this segment would dominate the whole market
Adv. Eng. Mater. 2019, 1801013 1801013 (1 of 28) © 2019 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim
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due to the rising prevalence of dental caries and increasing

incidence of tooth loss owing to injury and accident. The dental Liwei Lin is now a B.S. student
implants and dentures sector is anticipated to grow at a high rate under Prof. Peizhi Zhu’s
during the forecast period due to the increasing aging population surpervision, at Yangzhou University
worldwide and the rising demand for cosmetic dentistry to of Chemistry and Chemical
enhance the quality of life. The global dental 3D printing market Engineering, China. He is a research
is expected to be worth US$3,427.1 million by the end of 2025 assistant at the institute of
from US$903.0 million in 2016. biomedical and tissue engineering,
Therefore, this review intends to offer an integrated review of Yangzhou university. His research
3D printing technologies and their applications in dentistry. In interests are in the field of 3D
the present review, various 3D printing & imaging technologies printing technology and materials
and the recent advances of 3D printing & digital processing for dental restoration.
techniques in dentistry are summarized. Furthermore, current
challenges and further perspectives are also discussed which will Dr Chunxia Gao is an associate
benefit researchers to optimize the 3D printing technologies in professor in the School of Chemistry
dentistry, improve 3D printing strategies and direct future dental and Chemical Engineering, at
bioprinting and translational applications. Yangzhou University. She received
her PhD degree in Functionnal
Polymer Materials from Shinshu
2. 3D Printing Technologies and Their University (Japan) in 2012. She then
Applications in Dentistry joined the Graduate School of
Engineering, Nagoya Institute of
In dental industry, the development of the medical device Technology (Japan) as Postdoctoral
manufacturing industry and the dental medical services comple- researcher. She joined Yangzhou University in 2018. Her
ment each other. Combining 3D printing technology and 3D- research interests include biomaterials for bone and tooth
visual models brings viable and user-friendly technique that regeneration and controlled drug delivery.
benefits both dentists and diagnosing process. Dental 3D printing
allows a dentist to produce customized designs for various
Peizhi Zhu obtained his B.S. and
categories of products. The efficiency of the digital design ranging
M.S. degree in Chemistry from
from the initial stages to the production stage ensures the accuracy
Nanjing University, China, in 1993
of products in the market. 3D dental printing involves the
and 1996, respectively. He then
combination of computer-aided design and manufacturing (CAD/
worked as a lecturer in the School of
CAM), oral scanning, designing, and 3D printing, as is shown in
Chemistry and Chemical Engineering
Figure 2. These include products include dental crowns, bridges,
at Shanghai Jiao tong University
and different types of orthodontic appliances manufactured for
from 1996 to 2000. He got his Ph.D.
treating various oral diseases. CAD and CAM have explored the
degree in Physical Chemistry from
various potentials in producing dental parts from a CAD design,
the University of Hong Kong in
and most of the manufacturers are changing their way to develop
2003. He then conducted postdoctoral research in the
dental devices by using 3D printing techniques.
Scripps Research Institute. and became an assistant
3D printing has become a contemporary way of quick and
professor in 1994 in the University of Miami. From 2005
inexpensive production to manufacture medical products.[21] With the
to 2013 he was Senior Research Fellow in Department of
rapid development of advanced medical imaging methods, applica-
Chemistry at University of Michigan-Ann Arbor. In 2013
tions of this technique in the dental industry have been continuously
he became Jiangsu distinguished Professor in the School
rising.[22] 3D printing technologies used in dentistry include polyjet,
of Chemistry and Chemical Engineering at Yangzhou
selective laser melting, fuse deposition modeling, stereolithography,
University.
etc. The principle, structure, advantages and disadvantages of each
technology have been described and summarized in Table 1.
support structure. Its main functions are as follows: 1)

2.1. Selective Laser Melting/Sintering (SLM/SLS) Underlying the subsequent unformed powder layer to prevent
the laser from collapsing when scanning to excessively thick
2.1.1. Principles of SLM/SLS metal powder layers; 2) Melting of the powder due to heat during
the forming process. After cooling, internal shrinkage stress
As is shown in Figure 3, SLM technique is designed to use a high occurs, causing problems like warping of the parts. The support
power-density laser to melt and fuse metallic powders together, structure connects the molded part with the unformed part,
as shown in Figure 3. The process of SLM and SLS is similar, and which can effectively suppress the shrinkage, and can maintain
SLM is considered to be a subcategory of SLS. Unlike SLS, SLM the stress balance of the molded part.
has the ability to fully melt metal into a solid 3D structure. The functions and advantages of SLM are complementary and
However, SLM process generally requires the addition of a interrelated. SLM account for more than 99% of the 3D printing
Figure 1. a) Slicing a 3D model. b) The 3D printer. c) Simple workflow demonstrates process from imaging through planning and printing to surgery.
of standard metal and the mechanical properties of SLM which is then accumulated to get the required parts. Compared
products are comparable to the conventional ones.[27] The types with the conventional working process (Figure 4a), the process of
of machinable materials continue to increase, and the processed 3D metal printing has strongly performed the advantages of
parts can be welded at a later stage. The price of SLM is high simple operation (Figure 4b).
while the speed is low. The accuracy and surface quality are
limited and can be improved by post-processing.[23] Using a
selective laser sintering (SLS) technique, high-power lasers are 2.1.2. Dental Implant Printing with SLM
used to bake small particles of metal powder such as alloys,
copper, and aluminum into a desired three-dimensional shape. The dental implant root fixture is embedded in the maxilla and
Further, the 3D shape is converted into a complete set of mandible bones for fixing the tooth crown and denture. The
slices. The sintering machine passes these slices layer by layer, dental implant is placed into the jawbone via surgery, where it
Figure 2. 3D printing process.[19,20]
Table 1. 3D printing modalities and materials.
Techniques Advantages Disadvantages Materials Ref.

[23]
Selective laser melting Good mechanical properties and increasing Low efficiency, limited quality Metal materials.
machinable materials. and high cost.
[24]
Polyjet High precision and high efficiency. High cost and short service life. Multiple materials.
[25]
Fused deposition modeling Efficient, environmental and cheap. Product surface is easy to rough. Low melting point plastic materials.
[26]
Stereolithography High efficiency, high precision, good processing effect. Complex structure and high cost. Photopolymers and metal.
obtains tissue for the retention of a solid support in the jawbone, 2.3. Fused Deposition Modeling (FDM)
and connects to the tooth crown through the abutment. Dental
implants are usually fabricated out of biocompatible metal or FDM, also known as fused deposition, is an additional material
ceramic materials. The types of steel most commonly used for manufacturing technology, which is formed by single layer
dental implant fabrication are stainless steel, Co–Cr alloy steel, contour superposition. After the filamentous raw material is
and titanium–aluminum–vanadium alloy.[28] Computer-aided melted, the control system controls the nozzle to squeeze the
manufacturing is the traditional fabrication method for dental molten wire into the single layer of the layered model and overlay
implants. However, CAM technology is becoming increasingly on the worktable (Figure 7). After the solidification, the material
prominent and has been widely used in the biomedical field will form a single layer of two-dimensional contour, and then
widely, because it can print the dental crown, dental bridge, and circulate through the two-dimensional filling and superposition
removable partial denture. The crown, fixture, abutment, and of the layer by layer to form 3D entities.
screw are typically fabricated out of titanium material alloy by Compared with other 3D printing technologies, FDM
SLM/AM technology for biocompatibility, as is shown in molding technology has the following advantages: 1) Low cost.
Figure 5. The crown can be printed with the ceramic material The FDM molding technology uses a resistance heater to melt
to increase abrasive resistance.[29] the raw material. Compared with the equipment that uses a laser
as energy, it does not damage the structure. The equipment and
maintenance are simple, and its technical operation cost is low.
2.2. PolyJet Low cost with simple and quick operation performance makes
FDM technology widely applied in the field of mold development
PolyJet technology uses array-type showerheads. According to the and manufacture. 2) Materials that can melt through this
model slice data, hundreds to thousands of array-type shower- equipment and have certain bonding properties can meet the
heads spray liquid photosensitive resin layer by layer onto the requirements of use. At present, most of the plastic materials
platform. During operation (Figure 6), the print head is moved with a low melting point plastic materials such as ABS, PLA, PC,
along the XY plane. After the photosensitive polymer material and nylon have been widely used in the production of plastic
is sprayed onto the table, the roller flattens the jetted resin parts. With the development of FDM molding technology, the
surface, and the UV lamp cures the light-sensitive
polymeric material. After one layer of jet printing
and curing is completed, the built-in table of the
device will drop the thickness of one molding layer
extremely accurately, and the nozzle continues
spraying the photosensitive polymer material for
printing and curing of the next layer.[31] This
will repeat until the entire workpiece print job is
completed. Compared with other 3D printing
technologies, PolyJet exhibits several advantages:
1) It can spray different materials at the same time,
which is suitable for multiple materials and multi-
color materials to print at the same time. It can
meet different color, transparency and stiffness
requirements. 2) The processing precision is high.
The printing layer thickness is as low as 16
microns, and the product details are precise. On
the contrary, the disadvantages are as follows: 1)
The product is usually not suitable for long-term
use. 2) The material is expensive. Both the replace-
ment materials and the material consumptions in
the printing process are larger than the SLA, but Figure 3. The SLM process has the ability to fully melt the metal material into a solid 3D-
the production cost is high. dimensional part.
Figure 4. a) Conventional working process. b) The process of 3D metal printing.
application of material will be further improved. Particularly, the support, thus making the support structure simple to remove,
production of low melting point metal die by FDM molding and the surface quality of molding parts has little influence. 7)
technology has important research significance and prospect. 3) The forming speed is faster. The molding speed can be
There is no pollution to the environment. The process of FDM accelerated by reducing the packing density when there is no
forming mainly consists of a transformation between the solid special requirement for the structural strength of the parts. For
and the melting state of the material. There is no chemical some products with special structure, the molding speed can be
reaction, and the whole molding process does not produce increased to 60 cm3 h1 by reducing the filling density. After
harmful gases or dust. Further, the raw materials used in the further optimization and improvement, the molding speed can
FDM forming process are relatively clean and will not be be increased to 200 cm3 h1.
qualitative, thus easy to be preserved. Therefore, FDM molding The mechanical structure of the FDM system mainly includes
technology does not cause pollution to the surrounding the wire feeding system, the nozzle, the heating module, the
environment, and there is no special requirement for its drive system of the sprinkler, and the 5 parts of the worktable.
application environment. 4) Relatively speaking, the FDM The structure functions of the FDM system are as follows:
molding equipment is small and easy to handle. 5) FDM
molding technology results in high molding efficiency, less 1) The nozzle part is the most important and the most complex
material waste and recyclable waste. 6) The post-processing is part of the whole FDM molding equipment. The feed,
simple. The post-processing after 3D printing has great melting and extrusion of the wire are completed by the
influence on the quality of the molded parts. For the parts with nozzle part, which includes the wire feeding mechanism, the
the supporting structure, the support structure may not be heating module, the filament material guide tube, etc. The
thoroughly removed or cause damage to the surface of the structure is complex, and the layout is compact. The filament
molded parts when removed. Both the conditions may affect the material depends on the feeding mechanism of the wire
quality of the product. Compared with SLS, and other processes, feeding system. The filament material reaches the end of the
FDM molding technology can adopt water-soluble material as nozzle and then heated by the heating module to melt into a
Figure 5. A process of measuring crown preparation geometry.[30]
2) The heating module is mainly providing the required

temperature for melting the material in the nozzle. It consists
of high-temperature resistant materials, including the nozzle,
the heating rod, the thermocouple, the heat dissipation part of
the aluminum block, etc. The heating module can generally
provide high temperature around 240 C, then the material can
melt at the end of the nozzle in time.
3) The wire feeding mechanism can select the raw material
ranging from 1 to 3 mm in diameter for the spray head. The
1.75 mm diameter wire is widely used at present. The diameter
of the nozzle is generally 0.2, 0.3, and 0.4 mm. The difference
between the raw material and the diameter of the nozzle
ensures the pressure of the inner cavity of the nozzle so that the
molten wire can be squeezed out from the nozzle and coated on
the workbench to solidify. The wire feeding system must
provide the continuous and stable feed of the filament material
to ensure its continuous extrusion of the filament material
from the nozzle and match the two-dimensional filling speed
of the nozzle, so as to avoiding breaking the wire or accumula-
Figure 6. The polyjet rapid prototype fabrication system showing the
tion of the tumor.
three axis movement of the components.[32]
4) The motion mechanism includes X, Y, and Z these three axial
movements. The FDM forming technology works by dividing
viscous flow. Presently, the raw material in the guide tube the solid geometric model with a certain structure into multi-
plays the role of the piston under the action of feed force. The layer contour to be stacked layer by layer. Therefore, for
molten wire is extruded from the nozzle with a certain the three-axial motion control, its only needs the linkage of the
pressure. The nozzle has the molten wire along the model X-Y axis instead of the three-axis linkage of the motion
layer under the action of the transmission system. The mechanism. Through the linkage of the X-axis and the Y-axis of
surface of the surface is coated on the worktable layer by the worktable, the filling and shaping of the profile are
layer. After the cooling and solidification of the material, the completed.
outline of a single layer can be obtained. Each layer is coated
with the solidified outline quickly and solidifies. Therefore,
the solid product can be obtained by stacking layer by layer.
2.4. Data Analysis of the Two Technologies (FDM and
PolyJet)
The differences between natural teeth and reproductive teeth

manufactured by FDM and PolyJet technologies are of great
significance in statistics (Table 2). However, they are well within
Table 2. Details of the FDM and PolyJet and their modeling materials.
Variable FDM PolyJet

Printer dimensions (L W H) (mm) 837 37 1143 826 620 590
Printer weight (kg) 150 95
Working space (X Y Z) (mm) 205 205 350 295 192 150
Production space (X Y Z) (mm) 255 255 305 300 200 150
Layer thickness (mm) 0.178,0.254,0.330 0.016
Resolution(X Y Z) (mm) 0.1 0.1 0.5 0.04 0.04 0.03
File format STL files STL files or SLC files
Material
Tensile strength (MPa) 38 50–70
Figure 7. The principle of the process is that the material is first drawn
into a filament shape, fed into the nozzle through a wire feeding Tensile modulus (MPa) 2325 2500–3500
mechanism, and heated and melted in the nozzle. The nozzle moves Tensile elongation (%) 3.5 10–15
along the cross-sectional profile of the part and the filling trajectory. At the Flexural strength (MPa) 55 70–100
same time, the molten material is extruded, and the material is rapidly
Flexural modulus (MPa) 2200 2250–3200
solidified. The materials are bonded and stacked.
medically acceptable range. The data indicate that 3D printed time it needs to produce a single composition is based on the size
reproductive teeth, which are widely used in orthodontic and the complex composition of the design. The time of printing
clinical diagnosis and treatments and require higher preci- can range from hours to more than a day.[35] 3D printed models
sion.[33] and designs are skilled enough to be machined and applied to
the production of master patterns. Another superiority of SLA
technology is the resistance of temperature and freedom of
2.5. Stereolithography (SLA/SL) printing complicated geometric figures. However, the necessity
of making the support structures of objects has been the main
2.5.1. Principals of SLA/SL limitation. This may consume more materials and make a great
improvement to the production and need processing time as
SLA/SL is a form of 3D printing technology which is used to well.[36]
create models, prototypes, patterns, and produce parts in a layer- Even though SLA can be applied to produce most synthetic
by-layer way with the help of photopolymerization. SLA uses an designs, it is often relatively expensive. Since 2012, public
ultraviolet (UV) laser to immerse the building platform in a interest in 3D printing has inspired the design of several
liquid resin polymerized. After the layer is polymerized, the consumer SLA machines that can cost as little as $3500 or less,
falling distance of the building platform equals the thickness of such as Formlabs’ Form 2 or XYZ Printing’s Nobel 1.0. (From:
the layer, allowing the uncured resin to fill and cover the previous https://www.hisour.com/zh/stereolithography-40605/amp/).
part. This process repeats several times until the constructed
object is established. The laser uses a set of lenses to focus and
then reflects two electric scanning mirrors (galvanometer). The 2.5.2. Applications in Dentistry
scanning mirror directs the precise laser beam to the UV-
sensitive resin reservoir to solidify the layer. As is shown by The application of SLA in the medical field started with the
Figure 8, the layer thickness is determined by the printers’ generation of human anatomy entity models based on CT data.
modeling standards, ranging from 15 to 150 μm with a shallow Later, it was applied in the design of individual implants in
roughness of about 35 to 40 μm Ra.[30] surgery, such as skull formation, frame bottom repair, and
The most extraordinary advantage of stereolithography is its mainly in the production of titanium implants. Nowadays, the
speed. The core of the machine, equal to the most functional mold or model of the object is commonly used to give surgical
compositions, can be produced within a day. The duration of guides for dental implants. The scope of application has
gradually extended to lost wax castings and the production of
resin models for temporary crown bridges. Additive manufactur-
ing through SLA or DLP process is applicable for high-resolution
prototyping and manufacture of bio-medical apparatus, such
as dental implants and patient-specific scaffolds for tissue
regeneration.[37]
3. Scanning Imaging Technology

With the rapid development of 3D printing technologies,
individualized 3D scanning imaging technology, the accuracy
of printers, and special medical printing biomaterials which can
be applied to printing have become the focus of attention.[17]
However, among these, scanning imaging technology is based on
individual disease. The different types of different hard and soft
tissue environments and high precision designs have become the
focus of constant human explorations and discoveries. Table 4
summarizes eight kinds of 3D modeling and scan imaging
methods which are used in the process of 3D printing, including
the 3D scanner, CAD, manufacturing system, cone beam
computed tomography, computed tomography, scanning electron
microscope, and computer-aided engineering. The most impor-
tant ones are highlighted in Table 3.
3.1. 3D Scanners
Surface scanning is performed through a 3D-intra-oral surface

Figure 8. The printing process of microstereolithography (m-SLA) using scanner, and data is stored as surface tessellation language (stl-)
ultraviolet (UV) resin liquid.[34] files.[57]
Table 3. Illustration of several modeling scan imaging methods.
Measurement Measurement
Categories Technology Format Working theory accuracy period Application areas Ref.
[53] [54]
Mainstream 3D scanner 3D (stl.) The laser line is irradiated on the object. Two cameras capture Camera 0.6 s 1.Build a medical
3D-imaging the three-dimensional scan data at this moment. pixels:1360 1024 model and
Technology artificial bone
[55] [56]
2.Manufacturing
biologica organs
[20] [52]
CAD Data import,compo-sition imaging. 0.1 mm Immediately 3.Plastic surgery
[50,51]
CAE Data import, composition imaging, numerical analysis 0.1 mm Immediately 4.Manufacturing
controlled
[48] [49]
Assisted 3D- SAM Based on the interaction of electrons and substances Magnification is 10 min
imaging more than 10 000
Technology times
[44] [45]
MRI Combined with Computer Aided Design (CAD), Computer Relatively low 1–7 days 1.Medical
Aided Manufacturing (CAM), Computer Numerical Control diagnosis
(CNC), Precision Servo Drive, Laser and Materials Science. 2.Surgical [46] [47]
planning
3.Prosthetics,
bones and
tissues and
organs
production
[42] [43]
FDM Through an intraoral and transfer. Relatively low 2 days
Mainstream CBCT 2D Using of cone-beam X-ray scanning, requiring only 360 0.125 mm 15 s 1.Precision [40] [41]
2D-imaging (DICOM.) degrees of rotation to obtain all the original data. medicine
Technology 2.Restoration of
the edentulous
arch
CT The X-ray beam is used to scan a certain thickness of a certain 0.125 mm 50 ms 3.The root canal [38] [39]
part of the human body. treatment
3.1.1. Dental Scanning and Disposing the need to manually reposition the object. In case the virtual
models were generated, they are transferred into programs
In previous studies, the casting models are obtained and which are used for prototyping by producing physical prototypes
digitized through a 3D oral scanner.[21] The captured images are that uniquely reproduce anatomy of interest. The program
systematically processed by specialized dental software, creating allows to do the followings: determine the position, adjust the
a “stl” file for every model.[58] Then, the operators use the Print scale and rotate the part, and to convert it into printing
Screen keyboard command to collect the maxillary incisor and instructions (called GCode) and printed in a 3D printing
mandibular dental arch images. When being exported to machine.[21]
vectoring software, the images can be cropped.[59] On account
of the shape of the dental arch, the references are the edges of the
incisors, cusp tip of the canines, buccal cusp tip of the premolars
and molars, thus establishing Angle’s line of occlusion.[60] 3.1.3. Applications of 3D Scanners
Measurement and analysis of tooth jaw model: 1) Distance

measurement, the distance (length) measurement on the model
3.1.2. Supporting Technology is the basis of the analysis model. With the mouse on the model
to take two points, the computer automatically calculates the
The healthy tooth is chosen to serve as a standard of the distance between the two points (a plane distance, or a spatial
generation of virtual models and prototypes. Subsequently, distance, as specified by the operator). Alternatively, upon using
researchers found that a tooth was placed in a contact scanner,[21] the mouse to take any number of points on the model, the
which allows for an object to be rotated around the vertical axis computer can automatically calculate the length of the curve
and at different tilts to the vertical axis. This allows for an object segment fitted through these points. Through the measurement
to be entirely scanned in one scan set. This hardware has an of distance and length, it is convenient to calculate the indexes
advantage of automatically scanning several scan sets without required for analyzing the dental jaw model, such as the width of
Table 4. The comparison of different biological materials.
Materials Basic properties Characteristic Ref.

Polycaprolactone(PCL) Density: 1.146 g/mL at 25 C Great biocompatibility [92]
Melting point: 60 C (L) Good Biodegradability

Form: pellets Good solvent solubility
High crystallinity and low melting point
The polylactic Density: 1.20–1.30 kg L1 Good biodegradability [93,94]
acid(PLA) Melting point: 155–185 C, Good mechanical and physical properties

1
Intrinsic viscosity IV: 0.2–8 dL g Good compatibility and degradability
Glass transition temperature: 60–65 C, Good gloss and transparency
Heat transfer coefficient: 0.025 λ(w/m k) Good tensile strength and elongation
Tensile strength: 40–60 MPa Good air permeability, oxygen permeability and dioxygen dioxide properties, it
Elongation at break: 4–10% also has the characteristics of odor isolation.
Elastic modulus: 3000–4000 MPa

Flexural modulus: 100–150 MPa
Izod impact strength (unnotched): 150–300 J m1
Izod impact strength (notched): 20–60 J m1
Rockwell hardness: 88
Acrylonitrile butadiene Density: about 1.04 to 1.06 g cm3. Good overall performance [95,96]
styrene(ABS) High strength and low weight. High impact strength

3
Specific gravity: 1.05 g cm Chemical stability
Molding shrinkage: 0.4–0.7% Good electrical properties
Molding temperature: 200–240 C High impact resistance
Drying condition: 80–90 C/2 h. High heat resistance
[97,98]
Poly(lactic-co-glycolic All PLGAs are amorphous. Different monomer ratios can Good biocompatibility
acid)(PLGA) produce different types of PLGA. Good biodegradability
Controllable degradation rate
No (low) biological toxicity
the anterior segment of the upper and lower arch, the width of 3.2. Cone Beam Computed Tomography (CBCT) and
the posterior segment, the width of the crown, the degree of Medical Computed Tomography (CT)
crowding, the Pont index, and the Bolton index. 2) Area
measurement, using the mouse to take several points along the Determining the shape of the root is important information for
edge of the area to be measured on the model. The computer dentists, especially orthodontists. The increasing use of CBCT,
automatically calculates the area of the polygon determined by which makes it possible to measure the shape and size of
these points. It can be used to calculate the crown area, and it can human roots in 3D. Clinicians use of three-dimensional virtual
also be used to calculate the area of a single jaw. 3) Angle reconstruction technology to obtain anatomical information of
measurement, from any three points taken on the model with the patient’s three-dimensional personalized crown and roots.
the mouse, the computer automatically calculates the size of the They can help clinicians to make a more accurate diagnosis,
plane or space defined by these three points. 4) Extraction and determine the personalized treatment plan, make the treatment
rowing, to perform tooth extraction and simulation on the digital result more accurate, and personalize the accurate virtual model
model. It can image and accurately simulate orthodontic simultaneously. It can also be applied to make individualized
treatment and orthognathic surgery, predict the treatment brackets and positioning, individualized arch wire production,
effect, provide a scientific basis for formulating and selecting and simulation of surgical effects.
a treatment plan, and help doctors and patients to communicate
with each other. 5) Dynamic simulation of upper and lower jaw
tooth occlusion. Occlusal relationship simulation for the pre- 3.2.1. Operation of CBCT Images
treatment or post-treatment data model, the occlusal relation-
ship can be directly simulated on the computer screen to Digital imaging and communication (DICOM) files are normal
understand the contact between teeth and facilitate symptomatic reservations to preoperative CBCT images of models with a voxel
treatment. size of 0.125 mm.[57] Data is stored and downloaded precisely
as a surface mosaic language (STL) file. The data of CBCT is more difficult to divide the mandible relative to the maxilla. In
transferred into a planning and projecting software which is addition, the sharper the root tip of multiple teeth is, the lower the
suitable for the guided implanting surgery.[61] The software allows CBCT image resolution will be, which can be clearly demonstrated
to create a visualized image of a commercialized design with a total from the length of the tooth. The segmentation process is mainly
length of 37 mm, a working length of 18.5 mm and a diameter of performed on the axis of the CBCT image. Into the teeth, the long
1.5 mm.[62] In addition, a virtual guidance with an inner diameter axis of the tooth is not consistent, so the cross-section of the teeth is
of 1.5 mm, an external diameter of 2.8 mm and a length of 6 mm is an oblique cut surface. Consequently, the tissue in the cut surface
designed for planning aims.[63] Virtual dental drill accumulates on shows uneven density, which increases the difficulty of the division
each tooth for direct, simple and easy access to the top third of the process. The smooth function of the image can make the
root canal.[59] To further study the design and create a thoughtful segmented geometry look better, which increases the applicability
template, the surface scan is uploaded to the implant planning of the segmentation result, but it also changes the volume of the
software.[32] By aligning the crown, the scan and CBCT data are segmented object. The smoothing function of the software in this
highly matched.[29] Eventually, virtual templates are designed study can reduce the volume fraction of the teeth. Therefore, when
using software averages. The factors that take into account the using the splitting model, it is necessary to control its accuracy
position of the sleeve are in the planning. The exported STL file based on its different uses.
guides the 3D printer to produce the template.[57] The acquired and
available CBCTscan data are converted into stereolithography files
so that the 3D printer is under processing.[64] 3.2.4. Applications of Cone Beam Computer Tomography
(CBCT)
3.2.2. Data Acquisition of CBCT Each template is precisely scanned with a CBCT which works on
a high-resolution agreement designed for objects. However, it is
For data acquisition of CBCT in dentistry, the interval between not intended for patients with the following acquisition
two slices is the most important, being smaller than 1 mm can settings.[68] A template of each object is chosen and sterilized
ensure a high-precision reconstruction model.[65] In a study using the autoclave, and the others are sterilized using gas
regarding to the orthodontic force model, the scan is taken using plasma.[69] After sterilization, each template is scanned using the
a CBCT scanner.[66] The images of the maxillofacial region are same CBCTprotocol as pre-sterilization, forming and organizing
restored on a disk in a DICOM format file.[67] Through the three groups: TAT group, splint group, and surgical guide group
scanning process, the patient’s oral lap remains open to prevent (Figure 9a).[70] In each group, there are four templates: original
the teeth from contacting during the scan, so the maxilla and STL object, one pre-sterilized, one post-sterilized heating, and
each tooth can be separately reconstructed conveniently.[61] one post-sterilized gas (Figure 9b).[68]
Furthermore, a high-resolution (0.3 mm) CBCT scan of the
maxilla serves as a vital part of the normal protocol for a pre-
3.2.3. CBCT Image Segmentation operative assessment for a patient who becomes a candidate for a
maxillary sinus lift procedure.[69] On the other hand, CBCT root
So far, there is no standard CBCT image segmentation method. canal application includes diagnosis of periapical inflammation,
Image segmentation is largely based on different image detection of internal and external root absorption, diagnosis of
thresholds. CT has some classical thresholds for the segmenta- vertical root fracture, evaluation of root canal morphology and
tion of different tissues and can be used directly. It is often used monitoring of root canal treatment results.[71]
for segmentation of bone tissue. However, the density of teeth In the case of periodontal disease, CBCT can assist with a
varies from the crown to the apex of the teeth, and the contrast customized treatment plan by precisely 3D evaluation of forked,
between the roots of the teeth is significantly reduced. If a single vertical and angular bone defects.[72] When evaluating window
threshold is used for segmentation, it is not possible to obtain an opening, caution is inevitable due to the tendency to overesti-
accurate crown or root image at the same time. Therefore, mate its incidence during CBCT examination. In normal
imaging of the teeth should be segregated based on multiple orthodontic surgery, complex 3D software is being developed
thresholds. In this study, according to changes in the density of for 3D virtual diagnosis, treatment customization plans, and
the crown to the root, the threshold for segmentation was outcome evaluation. In addition, future developments are
adjusted to at least three times. The segmentation operation was expected to overcome current obstacles to “static” diagnostics
in a subjective judgment process, although the difference to ensure “dynamic” diagnostics that simulate various functional
between the two operators was statistically significant, the activities.[62] STL files acquired from intraoral scanning can
segmentation result was relatively stable for the same operator. be step-by-step superimposed on the STL files acquired from
Many studies have shown that the quality of the mandibular the reconstruction of CBCT with proprietary so ware for the
CBCT image is better than that of the maxilla, which may be due to guidance of surgery planning.[59,63] CBCT is a needful tool in
the better contrast between the mandibular alveolar bone and the the diagnosis and treatment of invaginated root canals. In
cortical bone, and it is difficult to distinguish the maxillary complicated cases, it may also allow stereolithographic printing
anatomy. However, in this study, we did not find the segmented of 3D models to facilitate treatment planning and education.[73]
maxillary, or the difference between the jaw teeth. This study found On the basis of CBCT scanning, digital dental pulp treatment
that the density of the root and the cortical bone is similar, but the is achieved with the help of computer software(Figure 10a–f).
mandibular root is too close to the cortical bone, which makes it Based on these scans, the pulp guide has been designed to use
Figure 9. a) The original objects in STL format: Orthognathic splint, surgical guide and TAT. b) The 3D printed objects: Orthognathic splint, surgical
guide and TAT.[68]
digital design and rapid prototyping for planned treatment.[29] of these surgical cases, allowing for the determination of tooth
CBCT systems vary in their radiation, depending on the thickness, the nature of periapical lesions and the inclination of
machine, the size of the radiated region, as well as the number the root, all of which were relevant factors for preoperative
of milliamps and kilovolts of the system. However, the doses are assessment of the pulp surgery. The manufacture of 3D printed
lower than medical computed tomography systems.[67] In some models and custom retractors shed light on how existing CBCT
cases, the use of CBCT significantly enhanced the management scans can be used to further improve patient management.[74]
Figure 10. Surgical and prosthetic 3D planning: a) overlapping of intraoral scan and CBCT; b) overlapping of intraoral scan and CBCT with molded
provisional restorations; c) overlapping of intraoral scan and CBCT with modeled provisional restoration and implant planning (occlusal view); d)
overlapping of intraoral scan and CBCT with modeled provisional restoration and implant planning (side view); e) implant planning (cross sections); f)
implant planning (panorex).[63]
3.2.5. CT Scanning for 3D Structural Analysis Volume data can be around the skull of the beam and individual
360 rotation of sensors. Compared with conventional CT, CBCT
CT scan generates three-dimensional reconstruction (model) in features lower entry dose and higher axial resolution.[32]
voxels for qualitative three-dimensional structural analysis, and
voxels can be converted into coordinates for quantitative
morphological analysis. In addition, compared with the original 3.2.7. Comparisons between CBCT and Intraoral Surface Scan
imaging planes, the 3D model allows 2D images to be
reconstructed in various planes to improve the observation of In order to understand the advantages of CBCT, CBCT was
anatomical or pathological features (e.g., sagittal images from compared with intraoral surface scanning through special
original axial slices). software of previous studies. This allows the virtual custom
In theory, 3D CT has enhanced the image analysis ability when programming to best access the cavity up to the top third of the
compared with traditional 2D radiographs. In regenerative root.[64] In this tool, the 3D printing template directs the custom
therapy, the 3D datasets can be used not only for medical bit to the orifice of the root canal. Routine root canal therapy was
diagnosis, but also for 3D printing of custom skull implants and performed after root canal consultation. In this case, the former
periodontal scaffolds. The observation that major mistakes can be report indicated that using the tool to treat minimally invasive
associated with replication of anatomical structures (such as holes, and apically expanded access cavities in mandibular incisors is
sutures, grooves, nodules and teeth) emphasizes the importance of feasible.[80] In dental surgery, CBCT scanners are becoming
referring to raw CT or MRI images during surgery and dental more and more mainstream. Dental professionals are becoming
treatment. In fact, image quality and data accuracy may be well accessible, acquainted and proficient at working with large
influenced by beam hardening, ring artifacts and other artifacts volumes of digital data.
(such as from metal restorers) that can be partially corrected but at a
potentially increased risk of image distortion.[75] A model of the
dental tissue can be further generated from CTscan or optical scan 3.3. Computer-Aided Design and Manufacturing (CAD/
to be united with or trimmed by jaw bone structure to provide a CAM)
detailed description of the surgical field.[76] The dental impression
model and intraoral scanner image only record oral data without In the past few years, CAD/CAM technology has been used in
the tooth root information. The tooth root and crown designs are prosthodontics, including implants and total dentures. The
based on x-ray photos and CT jaw scans (Figure 11b). The X-ray development of rapid prototyping has stimulated CAD/CAM
photo is the radiation passed through the body to appear on an production of metal RPD frames, with the advantages of
x-ray film, which is able to record the dental root information conformity, simplification of manufacturing, reduction of
(Figure 11c).[77] However, it is not easy to be applied in the 3D additional costs, and processing time. In addition, CAD/CAM
rebuilding. The CT scanning is for 3D reconstruction, where the technology can help make alternative denture frames with
CT data is processed to generate into 3D dental cloudy point data variable applications of traditional imprinting and casting
and STL data file. The CT scan data is saved in a Digital Imaging techniques, especially for patients with nasal obstruction or
and Communications (DICOM) format (Figure 11a). The DICOM intolerant design for better support and reservation. In brief, it is
is a protocol that describes the formatting and exchanging of more efficient to design dental prostheses with the help of CAD/
image-related information.[78] CAM, as it can save materials, time and effort, and even
stimulate mass production.
3.2.6. Comparisons between CBCT and Medical CT

3.3.1. CAD-Based Methods
CBCT is introduced as a high-resolution imaging procedure in oral
and maxillofacial radiology. Cone beam CT has a two-dimensional Quite a few approaches to design 3D scaffold models have been
sensor that uses a cone X-ray beam instead of a fan beam (CT). invented, such as methods basing on CAD, designs basing on
Figure 11. Dental root 3D reconstruction by CT3: a) DICOM, b) Contour detection, and c) Root data.[79]
images, implicit surfaces and space-filling curves. In order to wear, and then molds can be implemented directly through
offer a well-organized method, custom 3D construction for a microscopes to measure tooth wear.[84]
specific and unique organ or tissue defect, meticulous designing First, the research need to convert the baseline 3D CAD model to
is needed.[35] CAD-based modeling is a better choice for scaffold the STL file format, which is similar to the shape of the part by
fabrication through 3D printing, because of the most simple but using the triangular face (Figure 12b, c).[85] Second, the 3D printer
powerful user-interfaces of commercial CAD software packages. processes the STL file by creating slices of the model and producing
The final design of these parts can be individually exported as each layer of the physical model at a time until it is complete.[86]
STL files that describe 3D surfaces as triangular polygons in By this means, the benchmark can be produced within a few
cartesian coordinates.[81] hours.[22,87] The physical benchmark is then measured by
Capability Maturity Model, developed to present sets of recom-
mended practices in a number of key process areas that have been
3.3.2. Advanced Application in Clinical Aspects shown to improve the data enhancement and the maintenance
capability, and evaluate the actual shapes and dimensions of the
It is worth mentioning that advancing CAD/CAM and imaging real part.[88] The use of CAD/CAM technology has been a common
technologies have made it possible for clinicians to analyze trend in the dental laboratory, a large number of which have
patients’ anatomy and to manipulate areas that need skeletal scanners and milling units of their own.[74]
reconstruction. It is reported that the technology has been used
for maxillofacial and implant procedures such as maxillary-sinus
augmentation preciously high precision.[82] In addition, with the 3.3.3. Combination of CAD/CAM and CT
guidance of sinus augmentation procedures, the present method
is similar to the guided bone-grafting and bone-reconstructive Advances in 3D image processing based on dental CT images
surgery for the purpose of lowering mental navigation and have led to the development of computer-aided design (CAD)
replacing the conventional surgical methods.[83] systems for digitizing, quantifying and visualizing alveolar bone
The use of CT scanning and stereolithography has produced uptake due to periodontitis. This system allows for digitization,
accurate and predictable results and enhanced the outcome of visualization and quantification of the resorption of alveolar
dental implant procedures.[76] This procedure allows the bone between the teeth and the roots, with the following
manufacturing of a 3D-printed CAD/CAM dental guide, which functions: 1) vertically measuring the resorption depth around
overcomes the shortcomings of the corticotomy, eliminating the the tooth in the 3D image, excluding physical obstruction; 2)
need for flap elevation. Further, no discomfort, early surgical quantifying the absorption in the bifurcation area; 3) analyzing
complications or unexpected events are observed using this results through pseudo-color maps, graphics and dynamic
technique (Figure 12a).[59] Tools can be used to make micro- images visualization. By comparing the recognition of CT
scopes to make and examine scanning images to digitize tooth images of real patients by dentists and taking into account the
Figure 12. a) A computer-aided design (CAD) model of a heterogeneous tissue construct composed of hydrogel parts 1 (shown in blue) and 2 (shown in
red), as well as the support part (shown in yellow), together with the stacked stereolithography (STL) format description of the model. b) Designed
maxillary teeth. c) 1SA CAD/CAM maxillary and mandibular models.[35,81]
absolute difference of 0.87 mm average, the resorption mea- and 2.5d image measurement were often used to precisely
surement accuracy of the surrounding area of teeth can be measure these gaps. The results of these two methods
assessed. Artificial images with mathematical authenticity can indicated that the maximum clearance was less than
also be applied for measurement and evaluation.[83] 100 mm, which met the requirements of medical operation.
3.3.4. Combination of CAD/CAM and 3D Printing Technology

3.4. Scanning Electron Microscope (SEM)
In an experimental procedure, a combination of conventional
techniques nearly has two approaches. Furthermore, CAD/CAM SEM is a widely used technique for obtaining reliable images
and 3D printing technology is used to manufacture complete that illustrate a particular sample. However, accessing 3D has
dentures. The maxillary and mandibular anodontia models are advanced micro-region processing: not only has simplified
made of silica gel. After making the gypsum model, the acrylic observations, accurate descriptions, convenient operations, but
base is made, followed by the wax edge of each model. To provide also has structures that allow access to multiple advantageous
standardized vertical and centric relationships, a bite registration objects, both external and internal. In fact, it cannot be run as a
block with edentulous maxillary and mandibular models is used regular method because it is complex to implement and difficult
to mount the working models on the articulator. Under the to access. However, owing to the quality of the research and
guidance of the anatomical markers of the gypsum model (labia new perspectives of researches, X-ray synchrotron imaging is
lacunae, arched angles), the midline and canine areas are becoming a more and more powerful research and inevitable
marked on the occlusive and labial surfaces of the wax ring. The process for studying important specimens of science.[64] SEM
smile area is adjusted according to the height of the bite involves bombarding a target with electrons, which are
alignment block on the upper edge. Through CAD/CAM and 3D automatically redirected due to the nature and morphology of
printing, a set of aligned artificial tooth systems were designed the sample. The quality of the image, and the high magnification
and manufactured, respectively, as a whole of upper jaw and of the image without any focusing depth problem, sets SEM
lower jaw arch.[35] prominently in the current study of vertebrate microremains.
The use of SEM micrographs has been particularly illustrative of
the tooth patterns of most mesozoic mammals.[90]
3.3.5. Computer Aided Engineering(CAE) However, SEM imaging has major disadvantages. Some of
these, combined with sample preparations, involves a metal
The shrinkage rates of dental restorations manufactured by 3D coating, in spite of the environmental SEM providing the
printing technology have been previously investigated, which possibility of observation without this metallization. In such an
shows good fit on the standard mold. The important conclusions environment, the observation and acquisition are made in the
are listed as follows: state of vacuum in most of the cases. This could lead to the
fracturing of micro-fractured fossil samples. The most important
1) A study on standard sample concluded the volume shrinkage is issue with this technique, however, is its combination with a
about to be 53.7%. To obtain the similar shrinkage rates, the process of specimen manipulation, that is, usually inaccessible
conditions and parameters of boundary are usually under
adjustments in the CAE models. In addition, the operation
procedure proved that the change of denture volume
contraction in CAE simulation could be controlled at 0.05%.
Another study was able to successfully apply standard sample
shrinkage to 3D printing manufacturing parameters.[89]
2) Through experimental design and recovery analysis, the
prediction and estimated shrinkage of recovery analysis have
been successfully summarized in the form of equation,
which can be used to estimate the shrinkage trend of
different material combinations.
3) CAE modeling and simulation setting can provide assistance
to engineers in comprehending dental implants deformation
after the step of sintering (Figure 13).
4) The gaps between the restorations and teeth hold significant
relevance in the clinical operations. 2.5d image measure-
ment system is a non-contact measurement technology,
which integrates advanced optical technology, electronic
technology, software development, and precision machinery.
It can be connected to a variety of external probe. In addition,
three-axis precision mobile platform and automatic focusing
and zoom system can accurately complete all kinds of Figure 13. The combination and measurements of half sintered incisor
measurement and detection work. In previous studies, CAE restoration and the standard dental mold in CAE.[89]
during the collection. Sample installation and limited mobility further research in the field. Moreover, in the study, horizontal
may result in the need to perform at least five to six operations, and vertical Young’s modulus coefficients were reported to be 13,
fixing and dismantling the sample to produce six different views as well as 12 MPa for the 90 PCL scaffold, and 19, as well as
for the overall representation of the microteeth.[90] 21 MPa for the 45 PCL scaffold, respectively. Microscopy images
SEM imaging is the most promising technique for high showed that the whole scaffold surface was covered with human
quality images of vertebrate miniature remains because it fibroblast cells. Immunofluorescence staining of ER-TR7
provides a convenient way to obtain perfect images. This kind of affirmed that fibroblasts remained alive and proliferated
microscope is very common in the laboratory. Despite its throughout the culture. According to the results of in vitro
inherent qualities, the technique is similar to a stereoscopic culture in Table 5, it can be concluded that PCL has good
microscope, providing only research samples in 2D image form. biocompatibility.
The design of the scaffold combines multi-scale cues for
clinically relevant, aligned tissue regeneration, potentially
4. Biomaterials for Dental 3D Printing enhancing the structure and functional biocompatibility of the
multi-tissue interface. The purpose of preclinical studies is to
4.1. Polymers develop mesoscale and microscale polylatin-caprolactone (PCL)
scaffolds, which demonstrate the specificity of human ligament
The accessible 3D printing materials include plastics, compo- progenitor cells, and to evaluate their ability to form an aligned
sites, metals, ceramics, biomaterials and food materials are bone-desmoid-cementoid complex in the body. To investigate
shown in Table 4. Acrylonitrile butadiene styrene (ABS), it, the PCL scaffold was designed to combine the 3D printed
polycarbonates, poly (lactic acid) (PLA), and polyetherimide bone area with the micro-graphically illustrated PCL film,
are the most popular 3D printable plastics.[91] which involved grooved supports. Human ligament cells were
inoculated in the thin-film region with bmp-7 gene transduced
fibroblasts in the bone region (Figure 14a–d) and the dentine
4.1.1. Polycaprolactone (PCL) section in the ligament region before subcutaneous implanta-
tion into the mouse model. The results proved that compared
PCL is a semi-crystalline thermoplastic resin with a degree of with the random porous PCL, the micrographic PCL film
crystallinity of about 45%. The mechanical properties of PCL are increased tissue arrangement in vivo. At 6 weeks, the depth of
similar to that of medium-density polyolefins. Its elongation at the 30 mm groove significantly enhanced the thickness of the
break and elastic modulus are between LDPE and HDPE, and its oriented collagen filaments, the overall cell arrangement and the
softness and tensile strength are similar to that of nylon. The nuclear elongation relative to the depth of the 10 mm groove.
appearance of PCL is very similar to the milky white of medium This study demonstrated for the first time that scaffolds with
density polyethylene and it has a waxy texture. PCL has a glass combined hierarchical mesoscale and microscale features can
transition temperature of 60 C, a melting point of about 63 C, align cells in vivo for oral tissue repair and have the potential
and a decomposition temperature of about 250 C.[99] Since PCL to improve regeneration responses of other bone ligament
has a low melting point and softens at about 40 C, its application complexes. This approach may have significant potential for
is limited. In addition, the presence of the lactone group in PCL clinical applications in the development of bone-ligament
provides good biodegradability and physiological compatibility, constructs for dental and orthopedic clinical scenarios.[111]
which can support the growth of fungi and be used as a carbon
source for microorganisms. It will slowly degrade in soil, with an
average degradation time of 12 to 18 months, which is an 4.1.2. Polylactic Acid (PLA)
excellent biodegradable polymer. Furthermore, PCL is an
aliphatic polyester which has good mechanical properties and PLA is a water-insoluble and bio-friendly polymer used in
a long resorption time, but poor osteoconductivity.[100] To biomedical fields.[113] Researchers consider PLA as a rigid
enhance its self-biocompatibility, it has become the vital step to polymer matrix.[114] To maximize the grip on PLA filament and
debase it with hydroxyapatite and other biomaterials. Moreover, help ensure an error-free printing experience, a baseline
further experiments are needed to determine the best ratio of the measurement has been designed, namely, 3D’s custom extruder
two in terms of biocompatibility. bolt. This can improve the efficiency of PLA printing and enable
Chosen as the dental material owing to its good biological the experiment to proceed smoothly.
property and high thermal stability, Poly (e-caprolactone) has a At the optimum condition, PLA exhibits the mechanical
molecular weight of 80 000 and a melting point of 60 C. When a property of pure 3D material, with elongation at break of
splint is made with PCL, it becomes a sort of biological 12%, tensile strength of 59.7 MPa and flexural strength of
placeholder to prop up structures while the body heals around it. 50.7 MPa.[115](diameter 1.75 mm, density 1.25 g cm3, process-
In a previous study, the PCL holder was manufactured with a ing temperature 2058 C and Tensile Strength 16–21 Kpsi)[116]
3D printing system. That the two stents by sinking patterns are PLA is a polyester extracted from renewable monomers.[117]
made on the structure to distinguish 90 PCLS stents and The recommended temperatures for 3D printing are Te at 180–
45 PCLS stents.[99] Fibroblasts were used to inoculate the 210 C and Tb at 40–60 C.[118]
scaffolds and their ability to support cells was assessed by PLA has attracted the attention of the scientific community
immunofluorescence staining.[92] These methods ensured a due to its biocompatibility, biodegradability, ease of processing
clear understanding of PCL scaffolds and might encourage and thermal stability, as well as biocompatible and biodegradable
Table 5. 3D printing for tooth regeneration: in vivo studies.
Animal model Bioprinting method Material Cells Grown factors Location Time Ref.
Rat 3D layer-by-layer PCL/HA – SDF1; BMP-7 Orthopic (mandibular incisor 9 [101,102]
apposition pocket)/(ectopic (subQ)

[103,104]
Nude mouse 3D wax printing PCL/PGA Human primary gingival BMP-7 Ectopic (subQ) 3,6
fibroblast cells
Athymic nude rat 3D direct inkjet printing PCL Human PDLCs – Ectopic (subQ) 3,6 [105,106]
Immuno- 3D layer-by-layer PCL/HA hDPSCs – Ectopic (subQ) 6 [107,108]
deficient mouse Apposition

[109,110]
Athymic rat Solid free-form PCL fiber-guiding Primary human PDLCs BMP-7 Orthotopic (mandibular periodontal 3
fabrication methods scaffolds preculture for 1d defect)
Note: PCL, poly(caprotactone); PGA, polyglycolic acid; HA, hydroxyapatite; PDLCS, periodontal ligament cells; hDPSCs, human dental pulp stem cells; subQ,
subcutaneous; BMP-7, bone morphogenetic protein 7; SDF-1, stromal-derived factor 1.
nature.[119] PLA scaffolds are generally used to hold at least in the length of the scaffold. Due to their excellent physicochemical
body cavity and may also create a lumen. The scaffold first forms properties, PLA is a good choice for making scaffolds.
a substantially tubular endoprosthesis and is placed into the In a study, in order to manufacture cell-derived decellularized
body cavity of a human or animal. The purpose of the scaffold is matrices as desirably shaped 3D scaffolds, HT-1080 cells were
to support the inner wall of the body cavity, which can cause or seeded on 3D-printed PLA scaffolds. The study confirmed that
maintain a fluid flow such as urine, blood or air when the cross- cell-derived decellularized matrices could be prepared on 3D-
section of the body cavity is narrowed, compressed, collapsed in printed scaffolds for manufacture as ideal-shaped 3D scaffolds.
any way or the lumen of the body cavity is occluded in some other However, cells were separated homogeneously on PLA scaffolds
way. There are several different scaffold designs, and each during the process of deposition of ECM components,[120] which
designed for a specific purpose. Some of the existing designs may bring certain difficulties for the experiment and may result
include helical coil-shaped scaffolds, as well as scaffolds made of in errors. Therefore, in order to ensure the accuracy of the
a net-like structure, that is, braided with wires or cut from tubes. experimental results, multiple experimental tests are necessary.
In order to anchor the scaffold to a specific location within the PLA is one of the most promising candidates to handle the
body lumen, known scaffolds may be anchored to a desired present environmental and energy problems. The programma-
location within the body lumen by expanding a portion of the ble 3D structure technique also offers PLA applications in bone
scaffold longitudinally or by expanding the entire longitudinal tissue engineering with a convenient and green platform. An
Figure 14. Surgical procedures: a) The defect area after tooth extraction; b) A scaffold was placed in the defect sites; c) Progress of implant placement; d)
Application of the prepared BMP containing a medium.[112]
innovative PLA scaffold that combined multiple functions were prepared for use within a commercially available 3D
including highly interconnected porosity, adequate nutrient printer. It was significant for us that any techniques we use be
supply, and antibacterial activity was prepared through 3D immediately scalable and adoptable. By mixing ABS with
printing. It was found to be quite desirable for cell adherence and different proportions of hydroxyapatite and producing it through
immigration to have a 67% porosity of the scaffold.[113] These industrial drawing, a composite material that can be used for 3D
excellent properties indicate that PLA is a promising material. printing is produced, and its application in dental implants is
expected to be realized in the future.
4.1.3. Acrylonitrile Butadiene Styrene (ABS)

4.1.5. Poly (Lactic-Co-Glycolic Acid) (PLGA)
ABS is an oil-based, durable, light material and has recom-
mended printing temperatures of Te at 230–250 C and Tb at 80– The fused deposition modeling technique for 3DP of thermo-
105 C.[121] The researchers confirmed that in tensile test, the plastic material, such as PCL and PLGA, can set up scaffolds with
young’s modulus of 0 printing direction up to 1.81 GPa,[122] mechanical strength, high porosity, and controlled morphol-
ultimate strength of 224 MPa.[123] In creep test, the plastic creep ogy.[17] PLGA is a copolymer of polylactic acid (PLA) and
model 90 in the direction of printing the lowest was 0.2, polyglycolic acid (PGA),[57] and has been used broadly in a host of
indicating that the direction of 90 is the resistance to creep. In US Food and Drug Administration (FDA)-approved therapeutic
fatigue test, the average number of cycles under 30 N load was devices, such as sutures, grafts, and macro/micro/nanoparticles,
3796. When the load is 60 N, the average number of cycles due to its biodegradability and biocompatibility. These remark-
reduced to 128. According to the Paris law, the size of the fracture able properties and efficient performance as compared to other
was assessed at 0.75 mm, with the stress intensity factor ranging materials, make it stand out in the biomedical field.[64]
from 352 to 700 N m1/2 and the resulting fatigue crack growth Different monomer ratios can manufacture different types of
rate is 0.0341 mm cycle1.[123] All of the above shows that ABS PLGA. For instance: PLGA 75:25 denotes that the polymer
has high impact resistance and good overall performance. consists of 75% lactic acid and 25% glycolic acid. All PLGAs are
3D printed ABS architectures have been tested under amorphous and have a glass transition temperature of 40–60 C.
compressive loads for the sake of analyzing the role of printing Different from pure lactic acid or glycolic acid polymers, which
direction, density, printing time, and filler shape on their are less soluble, PLGA presents a broader range of solubility. It
stiffness, strength, and failure mechanisms. Analysis of the can be dissolved in various solvents, including chlorinated
stress–strain (σ–e) curves indicates that stiffness and limited solvents, tetrahydrofuran, acetone and ethyl acetate.
strength are rendered higher accordingly by raising the filling Moreover, destroying the ester bond causes the degradation of
content.[124] As we continue to develop this technology, we hope PLGA and the degree of degradation changes with the monomer
to reduce production costs, increase production efficiency, and ratio. The greater the proportion of glycoside is, the easier it is to
make it used more widely. degrade. Interestingly, when the ratio of the two monomers is
50:50, the degradation rate is faster, and it will spend about two
months. PLGA’s degradation products are lactic acid and glycolic
4.1.4. Comparison between ABS and PLA acid, which are also the by-products of human metabolic
pathways. They do not display toxic side effects when being used
Both ABS and PLA have quite good performances and have their in the pharmaceuticals and biological materials, with the
own merits with regard to the bone simulation effect for our exception of lactose deficiency. PLGAs are extremely thermola-
tested materials. Considering that PLA is bio-degradable, non- bile compounds When being processed at a heightened
toxic and most similar to the bone at low temperature while temperature, they may provoke the formation of toxic
experiencing the drilling operation, we hold the belief that PLA is components and structural cross-linking which in turn causes
the better choice for most of the simulation models. However, their unpredictable behavior in the recipient’s body.[126]
PLA does require constant cooling to avoid melting. On the other
hand, it is more resistant for ABS to melt and easier to cut, which
means it is easier to process.[69] The typical comparisons between
ABS and PLA are shown in Table 6. Table 6. Typical comparisons between ABS and PLA.
PLA is an environmentally friendly material, while ABS
produces an odor during the process of printing. The frizzy Parameter PLA ABS
edges usually occur during printing using ABS and are present Plastic extrusion temperature 200 C 230 C
in four of the ten ABS models, but only in one PLA model. So
Build plate temperature 50 C 110 C
PLA is more suitable for the desktop fused deposition printing in
surgical modeling applications.[125] Shells 1 1
In summary, both of these biomaterials have their own Infill 10% 10%
advantages and disadvantages, thus making them suitable for Layer height 0.3 mm 0.3 mm
different applications. Further experiments and analysis are Travel speed 100 mm s1 100 mm s1
needed to elucidate their specific applications.
Raft and support Raft þ external support Raft þ external support
Researchers are capable of generating 3D printing filaments
Extruder nozzle diameter 0.4 mm 0.4 mm
with ABS, 1% ABS, 5% ABS, and 10% ABS.[124] These filaments
PLGA has been used as a suitable material for fabricating the 4.2.2. Hydroxyapatite (HA)
biodegradable microspheres since its safety in clinical applica-
tions has been well confirmed.[127] Further, medical grade PLGA As it is the main component of bones, HA has various
has been widely used for biomaterial 3D-printing work outstanding advantages like a prefabricated material for hard
previously while maintaining the 3D-printed structure.[128] From tissue bio-printing. It can be synthesized or produced from hard
the aspect of biomedicine, it offers broad application prospects organizations and sintering processes, providing a wealth of
and deserves further research and development. PLGA 3D- resources. Some natural HA particles possess good biocompati-
printed scaffolds have well-defined architectures and regular bility and perfect osteoconductivity. In 3D printing technology,
pore sizes, and the distributions of pore size are centralized, HA can be applied in various forms such as powders, slurries or
which lead to higher transparency and porosity.[129] By adjusting granules. To acquire the fluidity required for the 3D printing
the monomer ratio, the degradation time of PLGA can be process, modified by granulation or mixing with other polymer
changed.[130] This method has been widely used in the field of solutions are normal ways.[133] Polymer solutions are often
biomedicine including skin grafting, wound closure, in-vivo served as a liquid binder for powdered HA particle coalescing
implantation, and micro-nanoparticles. PLGA scaffold provides agents and can even be incorporated into cells.
major mechanical support for the combined construct with the Apexification was first proposed by Kaiser in 1960. Most
stress of more than 1.5 MPa, which is adequate to maintain the scholars used calcium hydroxide preparations to induce apical
architecture stability of the production during either in vitro closure and received certain efficacy.[134] There are few reports
culture or in vivo implantation.[131] about the use of hydroxyapatite pastes. It has been suggested that
the paste fluidity is slightly poor, resulting in an insufficient root
canal filling, especially in the molar narrow, thus leading to the
4.2. Bio-Inorganic Materials treatment failure. It is prepared with glycerin, and iodoform
dissolved in glycerin is added to make the paste soft and paste-
The application of inorganic biomaterials in 3D printing is like. It is easy to fill, and has a certain viscosity, good adhesion,
everywhere. However, the 3D printed materials used in dentistry antibacterial effect, x-ray blocking, and convenience for clinical
are still in the developmental stage. Compared with organic examination.
polymer compounds, their therapeutic applications are narrow, Interestingly, some reports suggest that young permanent
and their use for treatments is uncommon in the oral medicine teeth should not be overfilled, irrespective of the drugs used to
community. induce the apical formation of the root. An underfill up to 2–
3 mm has been suggested to be conducive to the formation of the
apical region (Figure 15a–c). Some cases showed that 24 teeth
4.2.1. Ceramic were overfilled, and 3 teeth were underfilled. During the review,
the overfilled paste was absorbed; the root tip was formed; the
In dentistry, the use of ceramics, especially zirconia ceramics, for bone was dense, and 2 teeth failed to fill. It may be related to the
restoration has been widely promoted due to their perfect excellent biocompatibility of HA, which prevents the stimulation
aesthetic properties. In digital dentistry, zirconia dental restora- of soft and hard tissues. HA itself is not osteogenic, but it can
tions are mainly made from digital manufacturing systems (such provide a physiological matrix suitable for the deposition of new
as CAD/CAM or 3DP). After production, the sintering process is bone, guiding the regeneration of the surrounding tissue and the
essential to the improvement of mechanical properties. In fact, deposition of cementum to close the apical foramina.[136]
the prediction or control of side effects of shrinkage in the The key to the success of apical inducing angioplasty is to
sintering process is complex and cannot be studied thoroughly. control the infection in the root canal. The HA material itself
The accuracy of zirconia repair is low, especially the most vital lacks bactericidal properties. To compensate it, iodoform,
factor of recovery adaptability. Therefore, the restoration of poor erythromycin, metronidazole and other drugs are added to the
adaptability can easily lead to secondary caries or microleakage, paste. This can not only achieve the goal of permanently killing
and the teeth will decay again. The remaining teeth need to be the microorganisms in the root canal, but also absorb the root tip
completely removed. 3D printing is the targeted manufacturing exudates, which is conducive to the growth of apical granulation
process to avoid the high cost of CAD/CAM processing; after tissue. HA paste is an ideal apical induction material and worthy
sintering, 3D printing products need to be highly accurate. of clinical promotion.
However, the shrinkage of the 3DP product is hard to predict and
cannot be studied thoroughly. Therefore, in CAE analysis,
experimental design and regression analysis, different shrinkage 4.2.3. Zirconia
rates of samples in the manufacturer’s sintering specification
were first predicted. The results were then applied to the Because zirconia itself has superior mechanical properties, it
manufacture of incisor prostheses. This can help the prosthesis was first applied to the finished post and core system. An ideal
properly adapt to the patient’s mouth and greatly shorten the time dental peg: 1) it does not affect its imaging in medical images; 2)
of clinical surgery. It has successfully helped 3D print applications it allows rational transfer of stress to avoid root fracture; 3) it
into dentures. Porcelain-fused-to-metal (PFM) dental crowns must be able to provide adequate support and retention for the
have strong compressibility, tensile strength, and a white, tooth- core; 4) there is no signs of deformation and possess
like appearance, making them a popular choice for dental commendable hardness properties; 5) it can support the core
restoration.[132] and crown to maintain a good seal. Traditional cast metal studs
are manufactured by using Cr, Ni, or Co–Cr alloy. However, The digital models are printed through a stereolithographic
some people have allergies to nickel and chromium. These alloys 3D printer(SLA) with a horseshoe-shaped design. To evaluate the
will exist some ion exchange, so the increase in the amount of reliability of measurements for each model type Pearson
time may lead to patients’ discoloration of the eyelid edge, and correlation coefficient was used. The measurements on plaster
have an impact on their own aesthetics. If all-ceramic crowns are models and printed models have shown some vital differences in
used for restoration, metal posts and cores can pass through the tooth dimensions and intrench parameters, but these differ-
outer edge of the crown through the rim, which can affect the ences are not medically relevant, in spite of the transversal
repair process. Moreover, the metal studs can also interfere with measurements. The upper and lower inter-molar distances on
the NMR, which is not a phenomenon exhibited by the zirconia the printed models are of statistical significance and medically
pegs. Similarly, X-ray films can also be used to observe the degree relevant.[137]
of closeness, position, and surface of the studs. Further, Zirconia
has good biocompatibility, so it does not do harm to humans or
produce allergies and toxicity. Summarily, as a high-strength and 4.3. Metal
high-toughness ceramic material, zirconia ceramics have a very
good application prospect. With the rapid development of The dental metal material is a type of bio-metal material used
nanotechnology, nanoscale zirconia has received increased to repair tooth defects, missing dentition, and orthodontic
attention. teeth. These metal materials must be non-toxic and harmless,
have corrosion resistance and anti-tarnish properties, and have
a certain strength and wear resistance, also can adapt to the
4.2.4. Plaster soft and hard tissues in the oral cavity, and are easy to process
and use. Metals and their alloys have excellent properties
Plaster is an air-hardening cementitious material mainly required for dental metal materials and can be used to make
composed of calcium sulfate. Plaster-based cementitious filling materials for 3D printing, crowns, bridges, dentures,
materials and their products have many excellent properties, etc. Although metal is expensive, it is widely used because
and they are rich sources of raw materials and low energy of its superior performance, as well as esthetic color and
consumption in production, thus being widely used in dental appearance.
tissue engineering. Slight expansion of gypsum imparts gypsum Co–Cr alloy has high hardness index, difficult processing, and
products a smooth surface, white appearance, delicate texture, poor casting properties, but it is lightweight, and possesses high
and good processability, making it an excellent material for strength, excellent wear resistance, and good corrosion resis-
making sculptures. Plaster materials have many advantages over tance.[138] Titanium alloy has lightweight and excellent corrosion
various other materials. These include; 1) Fine particle powder, resistance properties. Its compatibility with the human body is
easy to adjust particle diameter. 2) Relatively low price and high superior to other alloys, and the price is lower than that of
cost performance. 3) Safety and environmental protection, non- precious metals. It can be used to make crowns, bridges and
toxic and harmless properties. 4) Model surface: grainy and various kinds of dental implants (dental and chin). Ti–Zr alloy
granular. 5) Color: The material itself is white, and the print has good resilience performance and is superior to stainless steel
model can achieve color. 6) Typical application: The only material for making orthotic appliances. It is a high-performance dental
that supports full-color printing and architectural model display. orthodontic wire material.[28]
Figure 15. Fabrication of a root canal simulator by slip casting: a) root canal mold positioned in a plaster block, b) hydroxyapatite slurry poured over the
cast and allowed to settle, (c) external view of a sintered artificial root canal simulator.[135]
4.3.1. Cobalt-Chromium Alloy (Co–Cr) viable alternative to the precious metal ceramic restoration in the
posterior region.
The use of cobalt–chromium (Co–Cr) alloys, which possess
excellent mechanical properties and costs lower than high-noble
alloys, has greatly increased in the field of crowns and fixed 4.3.2. Titanium-Containing Materials
dental prostheses.[139] However, some of the problems associated
with casting in the conventional manufacturing process are In the general field of biomedical devices, and dental implants,
widely known. Although casting shrinkage has largely been the superior strength of processed dental implants made of
overcome with Co–Cr alloy, the accuracy may be affected. commercially pure titanium, which may surpass that of the
Moreover, the high hardness index of the alloy makes finishing stronger Ti6Al4 alloy, has been associated with a superior fatigue
more difficult as well. Recent development in the use of CAD- resistance. Such a property would make those materials both
CAM provides better standardization.[140] biocompatible and strong alternatives to the currently used
The completed design STL format files are transferred to a titanium alloy.[144]
selective laser melting (SLM) printer (Figure 16).[141] This metal Recently, a significant amount of research has been focused
3D printing equipment uses a 100 W fiber laser power with a on augmenting the therapeutic efficacy of titanium surfaces.[145]
beam diameter of 10 mm in an Argon gas protected atmosphere, Titanium (Ti) is widely used as a biomedical material in plastic
and Co–Cr powder printing is performed in layers of 30 mm surgery and dental applications due to its high corrosion
thickness. After removing the supports carefully, 15 metal resistance, low density, extraordinary mechanical properties, and
copings are acquired.[142] No mechanical failure or retention loss satisfactory biocompatibility.[146] Its inherent bone consolidation
was detected, and there was only one crown on the mandibular ability enables direct bone contact to be formed on the surface of
molars showing smaller fragments of face porcelain on the the implant, thereby mechanically securing the implant to the
medial buccal tip. Therefore, a 100% cumulative survival rate surrounding living bone. However, the mismatch between Ti
and 99.2% cumulative success rates were recorded according to implant stiffness and host bone tissue produces a stress
Kaplan-Meier analysis. One hundred and two abutments were shielding effect at the bone-Ti implant interface, which may
found to be critical from the beginning and throughout the reduce the long-term clinical performance and stability of Ti
observational period. implants. Introducing internal pore structure into Ti implants is
The excellent clinical performance of Co–Cr SC was demon- a promising strategy to overcome this problem. By controlling
strated by United States Public Health Service (USPHS) standard pore size, distribution and interconnectivity, porous Ti is
technical evaluation.[143] Significant differences in mean peri- designed to match the mechanical properties of natural bone
odontal parameters between the test teeth and the control teeth tissue. In addition, the porous structure can affect the cell activity
were not detected in any follow-up examination. In summary, after of Ti scaffold. A few hundred microns of surface pore size allows
4 years of clinical functional verification, CAD/CAM Co–Cr single sufficient free space for the growth of the internal bone and for
crown has been proved to be an effective treatment option and a the delivery of oxygen and nutrients in the body and for the
excretion of waste, which is necessary for strong fixation of Ti
scaffolds with long-term reliability.[147]
Titanium alloy powder is used for printing implants in the
form of 300 W laser (1070 nm, 50% power) square strips
(1.2 1.2 cm2) in the presence of argon atmosphere (500 ppm
O2) using selective laser melting machine. Thin uniform metal
powder layers are deposited on the plates and the selected areas
of the powder are fused accurately by high-power focusing laser.
This process is repeated, layer by layer, until the desired
thickness (0.6 mm) is reached, and the implant is generated
accordingly.[134]
Compared with commercial pure titanium as dental implant
material, Ti–Zr alloy has good biocompatibility and reduced
elastic modulus.[148] Due to the interaction of wear and
corrosion, higher degradation of implants can occur, rather
than the sum of the two parts, resulting in shorter implant life.
The wear resistance of titanium alloy is poor, resulting in the
corresponding degradation in vivo. Wear and corrosion may
degrade simultaneously in corrosive environments. This is the
key material properties of titanium alloys used in biomedical
applications. For dental implants, the implant can withstand
wear from other implants or bone material due to inherent
loading conditions. In particular, in the oral environment,
continuous micro-movement between interfacial bone/dental
Figure 16. The printing process of selective laser melting (SLM) using implants can lead to the release of debris, which may have
cobalt–chromium (Co–Cr) alloy powder.[28] harmful effects.
The tribological corrosion behavior of titanium alloys is one of Combined with 3D printing, these technologies have been used
the focuses of current research. Although there is a study on the to customize equipment manufacturing, such as aligners and
tribological corrosion behavior of Ti–30Zr alloy, the tribological retainers.[152] The appropriate materials’ smart devices and
corrosion behavior of Ti–30Zr alloy does not exist yet. Titanium mechanical properties are highly desirable and convincing
dioxide (TiO2) incorporation in biomaterials is a promising purposes, which indicates the predictable prospects for custom
technology due to its photocatalytic and antibacterial manufacture of orthodontic brackets. In the field of biomedicine,
activities.[149] basic understanding of cartilage growth and bone biology in
animal entities is certainly under study in changing mandible
growth and regulating tooth movement. Further findings in this
5. Applications of 3D Printing in Dentistry field, including growth changes, accelerated orthodontic tooth
movement, and enhanced tooth fixation or retention, may
With the rapid development of the current 3D digital dentistry,
eventually have important medical applications in oral ortho-
3D printing technologies in the field are playing more and more
dontics. The orthodontic diagnosis and treatments can undergo
important roles. A growing number of professional 3D printing
further customization through the additional genomic and
companies for different dental treatments needs medical
proteomic information. Within the coming decades, precision
equipment for the professional, industrial production, as is
orthodontics is likely to sustain the trend of benefitting from the
shown in Table 7. In this part, we have explained the application
advances in various fields, drawing up technological advances,
of 3D printing technologies in the field of dentistry in detail.
and integrating biomedical and clinical research, thus promot-
ing excellent, efficient, safe, reliable, and repeatable personalized
orthodontic treatment.[153]
5.1. Treatment of Common Dental Diseases
Furthermore, three-dimensional force is an important factor
in determining tooth movement in orthodontic treatment. It is
Dental diseases have become the biggest impediment to direct
difficult to estimate the force and torque on the teeth prior to
human well-being. With the development of 3D printing
treatment accurately, resulting in accurate tooth movement. In
technologies, 3D printing is used in orthodontics, edentulous
orthodontic biomechanical systems, braces have a large impact
arch repair, and root canal treatment widely.[150]
on periodontal tissue including bone, teeth, and periodontal
ligament (PDL). The use of these three tissue simulation models
is a critical step in measuring the force of the teeth with
5.1.1. Advances in Orthodontics
braces.[154] Based on medical image processing, tissue recon-
struction, 3D printing, as well as PDL simulation and testing, a
The progress of precision medicine indicates that similar
model for measuring force has been designed and fabricated,
progress has been made in the field of oral orthodontics, and will
which can be potentially applied for force prediction, treatment
gradually be applied to realize personalized and customized
planning design and precise medical operation.[147]
treatment methods and improve treatment efficiency.[151] The
objective of previous research was to provide a context for the
development of computer technology and biomedical science. In
addition, their current and future applications to precision 5.1.2. Restoration of the Edentulous Arch
dental orthodontics are also concerned. The capacity for
customized treatment and bio-mechanical planning offered by Restoration of the edentulous mandibular arch with dental
3D imaging technology and innovations in computer hardware implants is becoming a satisfactory and predictable treatment
and software will be more fully realized in the coming decades. option. On the one hand, a large number of prosthodontic
Table 7. 3D printing professional fabrication services for dentistry.
Vendors 3D printing technologies Major applications of dentistry

EOS (From: https://www.eos.info/en) SLM Crown, denture holder
Concept Laser (From: https://www.concept-laser.de/home.html) SLM Crown
Renishaw (From: https://en.industryarena.com/renishaw) SLM Crown, denture holder
XiAn Bright Laser Technologies (From: http://www.xablt.com/home/product) SLM Crown
Farsoon Technologies (From: http://www.farsoon.com) SLM Crown
Stratasys (From: https://www.stratasys.com.cn) Polyjet, WDM Crown, dental mold, bridge wax
3D Systems (From: https://www.3dsystems.com) SLA crown wax, surgical guide plate
Solid Scape (From: https://www.solidscape.com) Ink jetting dental product wax
EnvisionTec (From: https://envisiontec.com) DLP Crown, bridge wax, temporary crown
UnionTech (From: http://www.uniontech3d.cn) SLA, DLP dental model, dental product wax
Prismlab (From: http://www.prismlab.com/Product) SLA dental model
treatments have been developed and introduced.[155] Early for 3D printing can be used in the oral cavity on account of their
implant research has focused attention on bone integration. compatible mechanical properties.
On the other hand, most of the current researches have switched
to the use of minimally invasive surgery for the functional and
aesthetic repair of implants. 5.2.1. Dental Crown
The technology of digital 3D images and computer design
(including CAD, CBCT, and 3D printing) has been improved, Interim restorations are essential for various aspects including
and these technologies have been combined with digital guided protecting pulpal and periodontal tissues, maintaining oral
surgery.[156] Digital guided surgery has the potential to be a function and esthetics. In order to achieve this goal, much
precise and simplified surgical implant. In addition, these attention must be paid to ensure the shape and suitability of such
techniques can be used to minimize the need for surgery and restorations. The fitness of the restoration depends largely on the
prove less invasive than traditional implants. It also reduces the manufacturing process.[161] According to the manufacturing
discomfort and healing period of the operation. However, process, the techniques used to make temporary crowns can be
computer-guided surgery must still overcome anatomical divided into direct and indirect methods.
barriers, especially in clinical cases where vertical and horizontal In the direct method, the temporary crown is immediately
bone grafts are required.[112] manufactured on the prepared teeth, while in the other method,
the temporary crown is cast on stone and then sent into the
mouth (Figure 17a, b). However, the heat released during resin-
5.1.3. Root Canal Treatment polymerization in the direct method may lead to heat trauma to
the dental pulp. In addition, residual resin monomers may
Root canal therapy is a method that controls the resident damage oral mucosa, leading to moss-like reactions or allergic
microbiome through disinfection, proper shaping and closure of stomatitis. Another shortcoming of the direct method is the
the root canal system to achieve periapical healing. Calcification shrinkage of the resin due to the reduction of atomic distance in
of the pulp cavity and root canal system can influence this the low molecular weight monomers used. This contraction
process and complicate root canal therapy. Calcification, also leads to differences in size between the edges, neighbors and the
named as occlusion or calcification, is related to deep damage to occlusion area. With the help of indirect methods, the thermal
the pulp of the tooth. Injuries are usually caused by disease and chemical risks of the teeth and mucous membranes were
processes (caries, loss of tooth surfaces), alveolar ridge trauma, eliminated, and the crown’s adaptation to teeth was improved as
or surgical procedures, such as pulp coverage, pulp amputation, the aggregation process occurred on the stones (Figure 17c,
and a lack of orthodontic treatment.[157] Although canal oblitera- d).[162]
tion does not necessarily lead to pulp necrosis or periapical
disease,[118] as long as it exists, canal location and negotiation
would become extremely complicated. The difficulty depends on 5.2.2. Tooth Root
the natural tooth morphology, and the nature and degree of the
superimposed calcification changes. Furthermore, the degree of The 3D digital mapping technique is used to prevent the
tooth stiffness and the entry of teeth into the mouth cannot be navigation of the ductwork that disappears during root canal
ignored. therapy to avoid iatrogenic damage to the root.[164] Based on the
In terms of the invention of the first CT scanner in the early CBCT scan and the intraoral scan of the dental column, the
1970s, there were many innovations in 3D diagnostic imaging digital dental pulp treatment plan of the anterior teeth with the
technology, which have been widely used in dental medical root canal system of severe occlusion can be realized with the
practice and research.[158] Compared with conventional 2D help of computer software. Based on these scans, digital
radiography, 3D image analysis provides excellent detail, and the designing and 3D printing fabrication provide an endodontic
additional advantages of 3D printing can be used in preoperative guide for the planned treatment.[165] The 3D-printed template
treatment planning and regenerative therapy.[159] directs the custom drill hole to the orifice of the root canal. In
The cost of this 3D planning and directional production guide stark contrast, conventional root canal treatment is performed
is considerably low and likely to fall significantly further in the after negotiation of the root canals.
future. In addition, the use of developed tools can shorten
treatment time and improve the predictability and success rate of
treating calcified abnormal teeth.[29] Using 3-D printing and 5.2.3. Abutment
bioresorbable polymeric material may thus offering advanced
applications in the field of clinical techniques of complex Available 3D printed abutment designs have been developed to
periodontal regeneration and the most advanced treatment satisfy the demands of the clinical requirement.[166] These
approaches in periodontal tissue engineering.[160] abutments are compatible with some certain implant interfaces
and provide limited choices for abutment length, the angle of
injection from the skin surface and the Angle of deviation. These
5.2. Dental Implant challenges may lead to improper insertion of a prosthetic
component, compromise to prosthesis design, and limitations to
Previous studies have shown that although the accuracy of the hygiene control. Digital technology has been used for facial
printing system is limited, the provisional restorative materials prosthesis design and manufacturing. A creative application of
CAD-CAM is in the design and milling for reserving the patients 5.3. Removable Partial Denture
with facial prosthesis specific abutments. Patient-specific abut-
ments have the potential to optimize the results. Removable partial dentures (RPDs) are applied to restore
Crown and abutment designs are of great significance to the damaged teeth and are manufactured by using the lost-wax
way the luting cement works and flows (Figure 18a, b). In the casting technique traditionally. The casting process takes time,
ideal situation, the abutment-crown structure should allow the effort, as well as skills of technician. The rapid manufacture of
best cement layer. Both provide enough crown retention and the RPD is more feasible with the development of oral scanning
limit excessive flow. The design of a base station that controls the and 3D printing technology, which shows acceptable fit and
flow of cement has been reported (Figure 18c).[167] satisfactory for clinical outcome.[168]
Studies previously conducted aimed to determine key base Teeth are supposed to keep appearance and performance for
characteristics, improve the flow characteristics of dental cement various physiological functions like masticating, swallowing,
and understand how these characteristics affect the mechanical and speaking. Any pathological, traumatic, or senile tooth loss
stability of the base under functional loads. can affect these normal functions and quality of human life.[169]
Consequently, the foundation has developed several kinds of The RPD is applied to restore lost teeth and function in the clinic,
implant design, its specially designed for dental crowns of dental which is the only option for partially edentulous patients with
cement inside the base station system, the flow channel to economic restrictions or with any other contraindication to fixed
provide laminar flow, increase the volume of base stations in to prostheses and implants.
reduce the risk of residual cement squeeze (reduce the risk of Using 3D printing technology to restore teeth, function,
excessive filling crown), increase the surface area in contact with and esthetics is full of obstacles because through knowledge,
the cement, so as to improve the strength of the crown, and add skills, and technology are needed. In spite of advances in
the screw insert in order to guide the concrete flow and protect dental materials and technology, traditional cast partial
the screw head. This information can guide future platform dentures are still manufactured by waxen technology.[170]
design to improve dental cement flow by allowing standardized Traditional wax loss techniques are limited by the required
cement loading prior to being seated and potentially reduce the time, procedural errors, and multiple adjustments of the
risk of residual cement extrusion. technician.
Figure 17. Interim crown design. a) Overall contour. b) Cross-sectional image in buccolingual direction. c) 3D printing system (Stratasys), d)
Manufactured crown.[162,163]
Figure 18. a) Abutment prototype with arm processes extending to cast indices and screw access hole subtracted. b) 3D-printed abutment prototype
positioned on definitive cast implant abutment analogs. c) Adaptations of the base abutment to include vents of various diameter location.[166,167]
In recent years, CAD/CAM technology has been widely used 3D printing associated manufacturing of wax patterns for the
in prosthodontics, which includes implant and complete denture investment casting process.[172] By means of using the integrated
prosthodontics. The development of 3D printing technology has scanning, simulation, 3D printing pattern, and casting procedure,
promoted the production of CAD/CAM for metal RPD frames, casting crowns were obtained from the first casting trial, which
with acceptable suitability, simplified manufacturing, and were free of porosity, and possessed an excellent functional
reduced costs and processing or recovery time. In addition, contour and a smooth surface.[172]
CAD/CAM can help to produce a variety of design denture For the purpose of bringing this novel integrated casting
frameworks, for better support and reservation. In brief, the method to use in the field of dentistry, there are still some
incorporation of CAD/CAM for designing dental prostheses is technical points need to be further improved. The first point is
more efficient because of the reduced requirement of materials, the geometric collection. In a previous study, the shape of the
time, efforts, and the increasing possibility of mass production. crown was a laser digitizer on a plaster model made from the
Researchers have put forward a computer-assisted design for a impression of a patient with no cavities. Secondly, digitizing the
removable denture, based on the Top-down treatment concept. geometry of teeth directly in the mouth remains complex. It was
In addition, this technique is conducive to the reconstruction of data exchanges between laser digitization, numerical simulation
functional occlusion, and accurate regaining of dental and facial and 3D printing systems that guaranteed improvements. The
esthetics. digitized geometric message must be processed and converted to
standard STL format. There is no doubt that the data processing
and consider revising at this stage is not automatic and optimal
5.3.1. Crown and Bbridge in this phase.
3D printing of a dental material for provisional crown and bridge

restorations is optimized by using a low-cost stereolithography 6. Conclusions and Outlooks
3D printer.[171] Compared to conventionally cured provisional Emergence and development of 3D printing technologies have
dental materials, its mechanical properties are improved. provided new strategies for accurately making one-off, complex
geometrical forms by the digital data, utilizing a variety of
materials with high tunability and complexity. Dental 3D
5.3.2. Casting Pattern printing allows a dentist to produce customized designs for
various categories of products. In this process, printer accuracy,
A previous study introduces a method of producing dental crowns software utility, printing materials, stent design features,
through integrating laser measuring, numerical simulation and preoperative time expenditure, clinical time savings, enhanced
safety, clinical outcomes assessment and tooth prototyping, and 1) the improvement of the accuracy of resorption region estimation
educational modeling should be considered. The efficiency of measurement; 2) more controllable and predictable geometries for
the digital design from the start until the production stage fibrous connective tissue angulations; 3) topographical approaches
ensures the accuracy of the products. Various kinds of products, to optimize cementum regeneration; 4) appropriate Food and Drug
including dental crowns, bridges, and different types of Administration (FDA)-approvable biomaterials for regenerative
orthodontic appliances are manufactured for treating various endodontics, guided tissue regeneration and wound healing. In
oral diseases. The potential of CAD/CAM technology in particular, a periodontal attachment may be the key to preserving
producing dental parts has been explored straight from the and supporting natural teeth instead of dental prosthetic implants.
CAD design imagery. Manufacturers are changing their ways, Furthermore, these promising advances are likely to provide the
resulting in the development of modern dentistry through the opportunity for huge paradigm shifts in dental tissue engineering
applications of 3D printing. In this review, we have summarized from replacement to regeneration.
the recent progress and perspectives of 3D printing, imaging,
and modeling for dentistry. Although 3D printing is becoming
increasingly widespread, more efforts should be devoted to the
cost of its operation, materials, and maintenance. Further, the
Acknowledgements
need for skilled operators, as well as the need for post-processing This study was supported by the Technology Support Program of Science
and adherence to strict health and safety protocols should also be and Technology Department of Jiangsu Province (BE2017689), Technol-
carefully considered. ogy Support Program of Science and Technology Department of
Yangzhou City (YZ2018084), the National Natural Science Foundation
Thus, multiple challenges need to be overcome for further of China (81601880), and a Project Funded by the Priority Academic
applications of 3D printing in dentistry. To develop reproducible Program Development of Jiangsu Higher Education Institutions.
strategies for peri-implant and periodontal regeneration, the
following key elements should be considered. 1) occlusal load/
bio-mechanical influences of the newly regenerated tissues; 2)
effects of microbial load and contamination of wounds due to the Conflict of Interest
microbiome in the local environment; 3) wound stability to The authors declare no conflict of interest.
maintain the 3D conformation of the wound site to reconstitute
the original periodontal topography; and 4) appropriate cellular
signals to recruit and direct cell populations to recapitulate the
tissue-regenerative response in the proper conformation at the
Keywords
tooth or implant interface. Based on these presented challenges, dental implant, dentistry, 3D imaging, 3D modeling, 3D printing
corresponding countermeasures were put forward for the future
direction of 3D printing technologies in the dentistry. Firstly, Received: September 20, 2018
anisotropy behavior is a common challenge for 3D printing, Revised: February 7, 2019
resulting in different mechanical properties under vertical Published online:
stretch or compression compared to the horizontal. In addition,
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3D Printing and Digital Processing Techniques in Dentistry: A Review of Literature

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3D Printing and Digital Processing Techniques in Dentistry: A Review of Literature

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REVIEW

3D Printing and Digital Processing Techniques in

for commercial applications, such as DTM

due to the rising prevalence of dental caries and increasing

support structure. Its main functions are as follows: 1)

Figure 2. 3D printing process.[19,20]

Table 1. 3D printing modalities and materials.

Techniques Advantages Disadvantages Materials Ref.

Figure 4. a) Conventional working process. b) The process of 3D metal printing.

Figure 5. A process of measuring crown preparation geometry.[30]

2) The heating module is mainly providing the required

The differences between natural teeth and reproductive teeth

Variable FDM PolyJet

3. Scanning Imaging Technology

Surface scanning is performed through a 3D-intra-oral surface

Table 3. Illustration of several modeling scan imaging methods.

part of the human body. treatment

Measurement and analysis of tooth jaw model: 1) Distance

Table 4. The comparison of different biological materials.

Materials Basic properties Characteristic Ref.

Melting point: 60 C (L) Good Biodegradability

acid(PLA) Melting point: 155–185 C, Good mechanical and physical properties

Elastic modulus: 3000–4000 MPa

styrene(ABS) High strength and low weight. High impact strength

3.2.6. Comparisons between CBCT and Medical CT

3.3.4. Combination of CAD/CAM and 3D Printing Technology

Table 5. 3D printing for tooth regeneration: in vivo studies.

apposition pocket)/(ectopic (subQ)

Immuno- 3D layer-by-layer PCL/HA hDPSCs – Ectopic (subQ) 6 [107,108]

deficient mouse Apposition

4.1.3. Acrylonitrile Butadiene Styrene (ABS)

Table 7. 3D printing professional fabrication services for dentistry.

Vendors 3D printing technologies Major applications of dentistry

3D printing of a dental material for provisional crown and bridge

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