RESEARCH AND EDUCATION

Influence of print orientation and wet-dry storage time on the

intaglio accuracy of additively manufactured occlusal devices
Marta Revilla-León, DDS, MSD, PhD,a Rocío Cascos-Sánchez, DDS,b Jonathan M. Zeitler,c
Abdul B. Barmak, MD, MSc, EdD,d John C. Kois, DMD, MSD,e and Miguel Gómez-Polo, DDS, PhDf

ABSTRACT
Statement of problem. Different factors can affect the manufacturing accuracy of additively manufactured dental devices; however, the
influence of print orientation and wet-dry storage time on their intaglio accuracy remains uncertain.
Purpose. The purpose of this in vitro study was to assess the effect of print orientation (0, 45, 70, and 90 degrees) and wet-dry storage time (0,
30, 60, and 90 days) on the intaglio accuracy of additively manufactured occlusal devices.
Material and methods. An occlusal device design was obtained in a standard tessellation language (STL) file format (control file) which was used to
fabricate all the specimens by using a stereolithography printer (Form 3+) and a biocompatible resin material (Dental LT Clear Resin, V2). Four groups
were created based on the print orientation used to manufacture the specimens: 0, 45, 70, and 90 degrees. Each group was divided into 4 subgroups
depending on the time elapsed between manufacturing and accuracy evaluation: 0, 30, 60, and 90 days. For the subgroup 0, a desktop scanner
(T710) was used to digitize all the specimens. The 30-day subgroup specimens were stored for 30 days with the following daily storage
protocol: 16 hours inside a dry lightproof container, followed by 8 hours in artificial saliva (1700-0305 Artificial Saliva) inside the same lightproof
container. The specimens were then digitized by following the same procedures used for subgroup 0. For the subgroups 60 and 90, the
identical procedures described for subgroup 30 were completed but after 60 and 90 days of storage, respectively. The reference STL file was
used to measure the intaglio discrepancy with the experimental scans obtained among the different subgroups by using the root mean square
error calculation. Two-way ANOVA and post hoc Tukey pairwise comparison tests were used to analyze the data (a=.05).
Results. Print orientation (P<.001) and usage time (P<.001) were significant predictors of the trueness value obtained. Additionally, the 0-
degree print orientation at day 0 group demonstrated the best trueness value among all the groups tested (P<.05). No significant
trueness discrepancies were found among the 45-, 70-, and 90-degree print orientation, or among the 30, 60, and 90 days of storage. A
significant precision difference was found in the variance between print orientation groups across usage time subgroups.
Conclusions. The print orientation and wet-dry storage times tested influenced the trueness and precision of the intaglio surfaces of the
occlusal devices manufactured with the 3D printer and material selected. (J Prosthet Dent 2023;-:---)

Among the different additive manufacturing (AM) cate- provides options for fabricating dental devices and resto-
gories,1 vat polymerization, including stereolithography rations including occlusal devices.2-6 The manufacturing
(SLA) and digital light processing (DLP) technologies, accuracy and mechanical properties of AM dental devices

Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
a
Affiliate Professor, Graduate Prosthodontics, Department of Restorative Dentistry, School of Dentistry, University of Washington, Seattle, Wash; Faculty and Director of
Research and Digital Dentistry, Kois Center, Seattle, Wash; Affiliate Professor, Graduate Prosthodontics, Department of Prosthodontics, School of Dental Medicine, Tufts
University, Boston, Mass.
b
Postgraduate Advanced in Implant-Prosthodontics, Department of Conservative Dentistry and Prosthodontics, School of Dentistry, Complutense University of Madrid,
Madrid, Spain.
c
Director of IT, Kois Center, Seattle, Wash.
d
Assistant Professor Clinical Research and Biostatistics, Eastman Institute of Oral Health, University of Rochester Medical Center, Rochester, NY.
e
Founder and Director, Kois Center, Seattle, Wash; Affiliate Professor, Graduate Prosthodontics, Department of Restorative Dentistry, University of Washington, Seattle,
Wash; Private Practice, Seattle, Wash.
f
Associate Professor, Department of Conservative Dentistry and Prosthodontics, Director of postgraduate program of Advanced in Implant-Prosthodontics, School of
Dentistry, Complutense University of Madrid, Madrid, Spain.

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Clinical Implications
When using the stereolithography printer and
biocompatible resin tested for fabricating occlusal
devices, a 0-degree print orientation maximizes
manufacturing accuracy. When stored between 30
days and 90 days after their manufacture, no
changes in the intaglio accuracy of the dental
devices should be expected.
have been reported to be affected by the AM technology,
printer, and material used,7,8 printing parameters (layer
thickness,9-11 print orientation,12-28 position in the build
platform),27 and postprocessing methods.7,27,29 The effect
of other factors on the manufacturing accuracy and me-
chanical properties of AM dental devices, including the
composition of the printed biocompatible material,
optimal manufacturing protocol based on the AM tech-
nology, printer and material used, mechanical properties,
and clinical performance of vat-polymerized AM occlusal
devices, is still unclear.6,7
Studies on the influence of print orientation on the
manufacturing accuracy of casts,15,20 interim dental
restorations,13,18,20,26 castable patterns,17 complete den-
tures,14,16 silicone indices,19 and surgical guides are
sparse.12,21,27 Additionally, print orientation could also
affect surface roughness,20,22 fit,17,23,26 mechanical prop-
erties,18,25,27-35 printing time,21 and material consump-
tion.21 The authors are aware of only 1 previous study23
that evaluated the influence of print orientation of the
clinical fit of SLA AM occlusal devices, which reported no
differences between the occlusal devices manufactured
with different print orientations. Therefore, the optimal
print orientation for maximizing the manufacturing ac-
curacy of AM devices is unclear. Additionally, if the
manufacturing conditions (AM technology, printer, and
material) and the fabricating protocol change, the
outcome would be expected to vary.
Storage time has been reported as a variable that may
reduce the dimensional stability of AM occlusal devices
and surgical implant guides.36-38 However, the available
data are scarce. Additionally, variations in resin compo-
sition among the biocompatible resins used to fabricate
occlusal devices may produce different results.
The aim of this in vitro study was to assess the effect
of different print orientations (0, 45, 70, and 90 degrees)
and wet-dry storage time (0, 30, 60, and 90 days) on the
manufacturing accuracy (trueness and precision) of the
intaglio surface of SLA vat-polymerized occlusal devices.
The null hypotheses were that no difference would be
found in the trueness and precision values of the intaglio
surfaces of the occlusal devices manufactured with
THE JOURNAL OF PROSTHETIC DENTISTRY
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Figure 1. Occlusal device design (reference file).
different print orientations or after the different wet-dry
storage times tested.
MATERIAL AND METHODS
An occlusal device design was obtained in a standard
tessellation language (STL) file format (reference STL file)
(Fig. 1). The STL file was used to manufacture all the
study specimens by using an SLA printer (Form 3+;
FormLabs) and a biocompatible resin material for fabri-
cating occlusal devices (Dental LT Clear Resin, V2; For-
mLabs). The printer had been previously calibrated
according to the manufacturer’s protocol. All the speci-
mens were fabricated using nitrile gloves by a prostho-
dontist with 6 years of previous experience handling
3-dimensional (3D) polymer printers.
Four different groups were created based on the print
orientation used to fabricate the specimens: 0- (group
0 or control group), 45- (group 45), 70- (group 70), and
90-degree (group 90) print orientation (Fig. 2). The
manufacturer of the material and printer selected rec-
ommended 0-degree print orientation; therefore, group
0 was considered the control. All the specimens were
manufactured using the same printing parameters with
automatic support generation, except for the print
orientation, that varied depending on the experimental
group. All the specimens were produced from the same
new resin bottle, and the identical postprocessing pro-
cedures were completed for all the groups.7 After print-
ing, the specimens were removed from the build platform
with a removal tool provided by the manufacturer. Then,
the specimens were fully submerged in a bath (Form
Wash; FormLabs) with 99% isopropyl alcohol (IPA)
(Isopropyl alcohol 99%; Cumberland Swan) for 15 mi-
nutes and subsequently submerged in a second bath with
clean 99% IPA for 5 minutes. The specimens were placed
on a paper towel, dried in ambient air for 30 minutes, and
then placed in the ultraviolet (UV)-polymerization ma-
chine (Form Cure; FormLabs) for 60 minutes at 60
C
Revilla-León et al
- 2023
Figure 2. Representative print orientation tested. A, Group 0. B, Group 45. C, Group 70. D, Group 90.
according to the manufacturer’s recommendations. The
support material was removed from all specimens by
using a removal tool provided by the manufacturer. No
further polishing or postprocessing procedures were
completed. The specimens were stored in a lightproof
container for no more than 24 hours until the initial ac-
curacy measurements were made.
Each group was divided into 4 subgroups depending
on the time elapsed between the manufacturing of the
occlusal device and the accuracy evaluation: 0 (subgroup
0), 30 (subgroup 30), 60 (subgroup 60), and 90 days
(subgroup 90). For subgroup 0, no later than 24 hours
after manufacturing, a laboratory scanner (T710; Medit)
was used to digitize all the occlusal devices. The labora-
tory scanner was calibrated before starting data acquisi-
tion and after every 10 scans by following the
manufacturer’s calibration protocol. The manufacturer of
the laboratory scanner reports a 4-mm scanning accuracy
according to the International Organization for Stan-
dardization (ISO) 12 836/2015 standard.39
For subgroup 30, the specimens were stored with a
daily storage protocol designed to replicate the clinical
use and storage time of an occlusal device. Every day, the
occlusal devices were stored in a dry lightproof container
for 16 hours, followed by 8 hours submerged in artificial
Revilla-León et al
3
saliva (1700-0305 Artificial Saliva; Pickering Laboratories)
inside a lightproof container. After 30-days of this storage
protocol, the specimens were placed on a paper towel
and dried in ambient air for 10 minutes. Subsequently,
the specimens were digitized by following the same
procedures as in subgroup 0. For subgroups 60 and 90,
the same storage and digitizing procedures described for
subgroup 30 were completed, but the specimens were
digitized after 60 and 90 days of storage, respectively.
The reference STL file was used to measure the
discrepancy with the experimental scans obtained for the
different subgroups tested. The discrepancy was assessed
only on the intaglio surface of the specimens, as the other
surfaces could have been altered by the removal of the
support material. The STL files were imported into a
reverse engineering software program (Geomagic Con-
trol X; 3D Systems). The reference STL file and the
experimental file were defined and aligned by using the
best fit technique.40 The root mean square (RMS) error
calculation was computed in the same area using the
rffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
Pn ffi
ðX 1;i −X 2;i Þ 2
following formula: RMS = i=1
n , where X1,i are
the reference data, X2,i are the scan data, and n indicates
the total number of measurement points measured in
each analysis (Fig. 3). The discrepancy calculations for
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Figure 3. Representative color map of intaglio surface discrepancies measured among 0-degree print orientation subgroups. A, 0-day subgroup. B, 30-
day subgroup. C, 60-day subgroup. D, 90-day subgroup.

Table 1. Trueness and precision values measured among subgroups

each group were used to analyze the data. Trueness was tested
defined as the average RMS error discrepancies between Trueness
the reference file and experimental scans, while precision ±Precision
Group (Print Orientation Subgroup (Usage Time in (RMS Error
was described as the RMS error variations per group or in Degrees) Days) Mean ±SD) (mm)
standard deviation (SD).41,42 Group 0 0 0.156 ±0.066
The Shapiro-Wilk and Kolmogorov-Smirnov tests 30 0.200 ±0.038
indicated that the data had a normal distribution (P>.05). 60 0.220 ±0.038
Two-way ANOVA and post hoc Tukey pairwise com- 90 0.223 ±0.039
parison tests (a=.05) were used to analyze the data. A Group 45 0 0.217 ±0.149
statistical program (SPSS Statistics for Windows, v27; 30 0.269 ±0.043

IBM Corp) was used to perform the statistical analysis. 60 0.274 ±0.064
90 0.282 ±0.058
Group 70 0 0.251 ±0.061
RESULTS
30 0.258 ±0.051
The mean ±SD trueness and precision values of all 60 0.262 ±0.045
subgroups tested are presented in Table 1. Regarding 90 0.288 ±0.055
trueness, 2-way ANOVA showed that print orientation Group 90 0 0.243 ±0.099
(df=3, MS=0.081825, F=19.93, contribution=14.94%, 30 0.256 ±0.030

P<.001) and wet-dry storage time (df=3, MS=0.041779, 60 0.269 ±0.040

90 0.291 ±0.043
F=10.17, contribution=7.63%, P<.001) were significant
predictors of the trueness (RMS) value obtained RMS, root mean square; SD, standard deviation.

(Fig. 4A). With respect to the group factor, the Tukey

pairwise comparison revealed significant trueness value demonstrated the best trueness value (lowest mean
discrepancies among the different print orientations RMS error=0.199 mm) among all the groups tested
tested. The group 0 (0-degree print orientation) (P<.05). The 45 (trueness mean value of 0.261 mm), 70

THE JOURNAL OF PROSTHETIC DENTISTRY Revilla-León et al

- 2023 5

Boxplot of RMS Error

0.45
*
0.40 *
0.35 *

RMS Error (mm)

0.30 *
0.25
**
0.20
*
*
0.15

0.10
*
0.05
Subgroup 0 30 60 90 0 30 60 90 0 30 60 90 0 30 60 90
Group 0-degrees 45-degrees 70-degrees 90-degrees
A
Multi-Vari Chart for of RMS Error by Group-Subgroup
0.300

0.275

0.250
RMS Error (mm)

0.225

0.200

0.175

0.150
0 day 30 days 60 days 90 days
Subgroup

Group
0-degrees 45-degrees 70-degrees 90-degrees
B
Figure 4. A, Trueness boxplot. B, Trueness multi-vari chart.

(trueness mean value of 0.265 mm), and 90 (trueness
mean value of 0.265 mm) groups were not significantly
different from each other (P>.05) (Fig. 4B). With respect
to the subgroup factor, the Tukey pairwise comparison
showed significant trueness values discrepancies among
the different wet-dry storage times tested (P<.05).
Subgroup 0 (0 days) demonstrated the best trueness
value (lowest mean RMS error= 0.217 mm) among all
the subgroups tested (P<.05). The 30 (trueness mean
value of 0.246 mm), 60 (trueness mean value of 0.256
mm), and 90 (trueness mean value of 0.271 mm) sub-
groups were not significantly different from each other
(P>.05) (Fig. 4C).
Regarding precision, a significant difference was
found in the variance between print orientation groups
across the wet-dry storage time subgroups using the
Levene test for equality of variance (nonoverlapping
confidence intervals showed significant difference)
(P<.001) (Fig. 4D).
DISCUSSION
Based on the results obtained in this in vitro study, the
print orientation and wet-dry storage times tested
influenced the manufacturing accuracy of the intaglio
surfaces of the occlusal devices manufactured with the
SLA 3D printer and material selected. The 0-degree

Revilla-León et al THE JOURNAL OF PROSTHETIC DENTISTRY

6 Volume - Issue -

Main Effects Plot for RMS Error

Fitted Means
Group Subgroup
0.28

0.27

RMS Error (mm) 0.26

0.25

0.24

0.23

0.22

0.21

0.20

0-degrees 45-degrees 70-degrees 90-degrees 0 day 30 days 60 days 90 days

C

Test for Equal Variances: RMS Error vs Group, Subgroup

Multiple comparison intervals for the standard deviation, α=.05
Group Subgroup
0-degrees 0 days
30 days
60 days
90 days
45-degrees 0 days
30 days
60 days Multiple Comparisons
90 days P<.001
Levene’s Test
70-degrees 0 days
30 days P<.001
60 days
90 days
90-degrees 0 days
30 days
60 days
90 days
0.00 0.05 0.10 0.15 0.20
If intervals do not overlap, the corresponding SDs are significantly different.
D
Figure 4. (Contined). C, Main effects plot for trueness. D, Test for equal variances. RMS, root mean square.

printed specimens evaluated within 24 hours after
manufacturing showed the best trueness and precision
values among the different print orientations and wet-
dry storage times tested. Additionally, the higher the
print orientation degree and the longer the wet-dry
storage time, the lower the manufacturing trueness and
precision values measured. However, the accuracy dis-
crepancies were not statistically significant between the
45-, 70-, and 90-degree print orientation and were also
not statistically significant between the 30-, 60-, and 90-
day wet-dry storage time.
While digital techniques have been reported for
fabricating single- and dual-material additively manu-
factured occlusal devices,2-4 the optimal printing protocol
and clinical manufacturing accuracy tolerance for these
devices is unclear. In the present study, the
manufacturing accuracy discrepancies measured among
the different print orientations tested ranged from 0.156

THE JOURNAL OF PROSTHETIC DENTISTRY Revilla-León et al

- 2023
±0.066 mm to 0.223 ±0.039 mm at day 0 and from 0.243
±0.099 mm to 0.291 ±0.043 mm at day 90. These
manufacturing accuracy values are consistent with pre-
vious reported values.37 How these manufacturing ac-
curacy discrepancies may affect the clinical fit of these
occlusal devices is unclear. Further studies are needed to
establish the optimal printing protocol and clinically
acceptable manufacturing accuracy for fabricating AM
occlusal devices.
Print orientation has been reported to influence the
manufacturing accuracy,15,16,21,24 surface roughness,20,22
fit,17,23,26 mechanical properties,18,25,27-35 printing
time,21 and material consumption21 of AM dental de-
vices. While a print orientation may maximize the
manufacturing accuracy of a dental device, the same print
orientation may not maximize other properties of the
same printed object. If the AM technology, printer, resin,
printing parameters or postprocessing procedures vary,
the outcome of the printed device also changes. There-
fore, generalizations of these studies should be done with
care. One clinical study assessed the influence of print
orientation on the manufacturing accuracy of 3D-printed
occlusal devices at 0, 30, and 90 degrees in a patient.23
The authors reported no fit differences among the
different occlusal devices fabricated with these 3 different
print orientations; however, the sample size was small
(n=2); only 1 patient was considered; and the intraoral
scanner used to digitize the patient, the design consid-
erations and printing parameters used to produce the
devices tested, and the criteria to clinically assess fit were
not provided. Therefore, comparisons with the results of
previous studies are difficult.
Storage condition and time have been identified as
factors that can affect the dimensional stability of AM
dental devices37,38; however, contradictory results have
been reported depending on the clinical application of
the printed device.37,38 While a previous investigation
reported no influence on the dimensional stability of AM
occlusal devices by the storage condition and time,37
another study described dimensional changes on prin-
ted surgical implant guides caused by dry-condition
storage time. Reliable study comparisons should only
involve additively manufactured devices with the same
clinical application.
A previous study37 assessed the influence of the
storage conditions (dry under natural light conditions,
dry in a dark container, and submerged in water) on the
dimensional stability of the intaglio surfaces of the
occlusal devices after 1-, 7-, and 27-day storage. The
specimens were fabricated by using an SLA printer (Form
2; FormLabs) and a biocompatible resin (Dental Clear LT;
FormLabs).37 The dimensional stability evaluation was
completed by measuring the RMS error between the
Revilla-León et al
7
digitized specimen after 0 days and the scanned spec-
imen after 1 or 7 or 27 days; therefore, the virtual design
of the occlusal device was not used as a reference file. The
results revealed that the storage conditions did not affect
the dimensional stability of the occlusal devices within 27
days.37 In the present study, the virtual occlusal device
design was considered the reference file and used to
measure manufacturing accuracy at different evaluation
times. Additionally, a combination of dry and artificial
saliva submerged conditions was developed to replicate
the dry storage and wet intraoral usage conditions of
occlusal devices within 90 days. The differences in
research methodology between the 2 studies prevented
simple comparison of the respective results.
A previous study35 has revealed that AM occlusal
devices are more prone to water sorption and, there-
fore, have a higher susceptibly to aging compared with
pressed and milled devices. Dry-, wet- (water or arti-
ficial saliva) or the combination of dry- and wet-
storage conditions in laboratory settings may not
reflect the same changes over time that occur with the
clinical use of AM occlusal devices. In the present
study, a novel laboratory storage protocol was used to
simulate the 24-hour conditions of an occlusal device
worn at night; the device was stored in a dry envi-
ronment for 16 hours and then submerged in artificial
saliva for 8 hours. Clinical studies are needed to further
evaluate the clinical long-term dimensional stability of
AM occlusal devices.
Characteristics related to the occlusal device design
can also impact the accuracy of the AM device. The
different design factors include path of insertion, pres-
ence of undercuts, extension of the design, offset, or
minimum material thickness.43,44 Artificial intelligence
(AI) models are being developed for optimizing the
manufacturing procedure, which may assist in estab-
lishing the optimal printing protocol based on the
manufacturing trinomial and clinical application of the
device being printed.45,46
Limitations of the present study included the limited
vat-polymerization technologies, printers, and materials
tested, as well as the limited print orientations assessed.
Additionally, a novel storage protocol was used. Further
studies are needed to evaluate the chemical composition
and biocompatibility characteristics of conventional,
milled, and AM occlusal devices. Additional laboratory
and clinical studies are recommended to further evaluate
the printing variables that affect the manufacturing ac-
curacy of AM occlusal devices, including print orienta-
tion. Additionally, the optimal printing protocols should
be further assessed based on the AM technology, printer,
material, and clinical application of the printed dental
device.
THE JOURNAL OF PROSTHETIC DENTISTRY
8 Volume
CONCLUSIONS
Based on the findings of this in vitro study, the following
conclusions were drawn:
1. Print orientation and storage time influenced the
trueness and precision of the intaglio surfaces of the
occlusal devices manufactured with the 3D printer
and material selected.
2. The 0-degree print orientation obtained the best
manufacturing accuracy values, which coincides
with the manufacturer’s recommendations for the
printer and materials used.
3. The accuracy values decreased after 30 days of
storage time, but no statistically significant differ-
ences were found among specimens stored for 30,
60, or 90 days.
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Corresponding author:
Dr Miguel Gómez-Polo
School of Dentistry, Complutense University of Madrid
Pza. Ramón y Cajal s/n
Madrid, 28033
SPAIN
Email: mgomezpo@ucm.es
Copyright © 2022 by the Editorial Council for The Journal of Prosthetic Dentistry.
This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
https://doi.org/10.1016/j.prosdent.2022.12.005
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