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INNOVATIONS AND TECHNOLOGY

Accuracy of digital light processing


printing of 3-dimensional dental models
Stephen L. Sherman,a Onur Kadioglu,b G. Frans Currier,b J. Peter Kierl,b,c and Ji Lid
Baton Rouge, La, and Oklahoma City and Edmond, Okla

Introduction: This study aimed to investigate whether a digital light processing (DLP) printer could perform effi-
ciently and with adequate accuracy for clinical applications when used with different settings and variations in the
orientation of models on the build plate. Methods: Digital impressions of the oral environment were collected
from 15 patients. Subsequently, digital impressions were used to make 3-dimensional printed models using
the DLP printing technique. Three variables of the printing technique were tested: placement on the build
plate (middle vs corner), thickness in the z-axis (50 microns vs 100 microns), and hollow vs solid shell. After
being printed with different printing techniques and orientations on the same printer, a total of 240 maxillary
and mandibular arches were measured. These variables generated 8 printing combinations. Tooth and arch
measurements on each model type were compared with each other. Intraobserver reliability of the repeated
measurement error was assessed using intraclass correlation coefficient. Results: All mean differences among
the printing variations were statistically insignificant. The Bland-Altman plots verified a high degree of agreement
among all model sets and printing variations. In addition, the measurements were highly reproducible; this was
demonstrated by the high intraclass correlation coefficient for all measurements recorded. Conclusions: The
DLP printer produced clinically acceptable models in all areas of the build plate, with hollow and solid model
shells, and at its high-speed setting of 100 microns. The applications of the DLP printer tested should be a
viable option for printing in a clinical environment at a high-speed setting while filling the build plate and
printing with less resin. (Am J Orthod Dentofacial Orthop 2020;157:422-8)

S
uccess in orthodontics can be achieved with and models need to be analyzed for accuracy and repro-
proper diagnosis and treatment planning. Diag- ducibility in order for clinical application to be justified.3
nosis is primarily based upon factors taken from Many studies have been performed to compare the
dental models, including spacing, crowding, tooth size, accuracy of digital dental models acquired from
arch form, and dimensions, along with tooth-arch dis- different methods of extraoral scanning (ie, desktop
crepancies.1 This success can be limited by the accuracy scanners for scanning models or impressions).2,4-12
of the records. Although the majority of record-keeping However, only a few studies have examined the
has changed from paper to digital records, the transition accuracy and reproducibility of dental models
from plaster casts to digital impressions and printed produced from different 3-dimensional (3D) printing
models is not as widespread.2 As the necessity for techniques and styles of printing. Previous studies
evidence-based dentistry increases, new forms of records have had limited sample populations and have left out
dimensional measurements of the dental arches.13,14
Only 1 study has evaluated the accuracy of the JUELL
a
Private practice, Baton Rouge, La.
b 3D printer (Park Dental Research Corporation, New
Division of Orthodontics, Department of Developmental Sciences, College of
Dentistry, University of Oklahoma Health Sciences Center, Oklahoma City, Okla. York, NY) in comparison with stone models and a polyjet
c
Private Practice, Edmond, Okla. 3D printer at the most accurate printing settings and re-
d
College of Public Health, University of Oklahoma Health Sciences Center, Okla-
ported no clinical differences.15 To date, there have been
homa City, Okla.
All authors have completed and submitted the ICMJE Form for Disclosure of Po- no studies conducted to evaluate the accuracy of
tential Conflicts of Interest, and none were reported. different printing techniques and orientations with a
Address correspondence to: Onur Kadioglu, Division of Orthodontics, Depart-
digital light processing (DLP) printer. In general, the
ment of Developmental Sciences, College of Dentistry, University of Oklahoma
Health Sciences Center, 1201 N Stonewall Ave, Room 400, Oklahoma City, DLP technique is accepted to be more efficient and faster
OK 73117; e-mail, onur-kadioglu@ouhsc.edu. than the stereolithography technique, which is also
Submitted, September 2018; revised and accepted, October 2019.
commonly used for in-office printing.14 This is possible,
0889-5406/$36.00
https://doi.org/10.1016/j.ajodo.2019.10.012 because it uses an arc lamp, liquid crystal display panel,

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Sherman et al 423

or projection source to cure an entire layer of resin in the collection of records for this study. All patients had pre-
x-y axis at one time instead of laser tracing the image.14 viously completed comprehensive orthodontic treat-
With the advent of 3D printing technology being ment with all permanent teeth present first molar to
relatively new, there is limited literature on the accuracy the first molar in both dental arches.15
of these printed models.2,3,7,15 Current research has Digital impressions were taken at the 1-year reten-
shown clinically acceptable models with high accuracy tion appointment for all patients between December
for these printers.13-20 Most of the studies performed 2016 and February 2017. Digital impressions were re-
on 3D printing of orthodontic models have had some corded using a single CEREC Omnicam intraoral scanner
limitations. All except 3 of the previous studies have (Dentsply Sirona, York, Pa). All aspects of record collec-
excluded arch dimension measurements.13,15,20 If 3D tion followed the manufacturer's recommendations.15
printers are to find a place in a practitioner's daily work- All digital models generated with the intraoral scan-
flow, the accuracy of the arch dimension measurements ner were converted to stereolithography (STL) file format
needs to be evaluated, which is crucial if the printers are using additional 3D Imaging Software (Dolphin Imaging
used for fabrication of orthodontic appliances. In addi- & Management Solutions, Chatsworth, Calif). The STL
tion, except for the studies by Hazeveld et al18 and files were cleaned and prepared for 3D printing using
Brown et al15, previous studies have had small sample Netfabb additive manufacturing and design software
sizes of 10 patients or less.13,14,16,17,19,20 (Autodesk, San Rafael, Calif). The prepared STL file for
The advent of 3D printing is changing the way each patient was printed using a DLP technique (JUELL
dentistry and medicine are practiced. If a 3D printer is 3D Flash OC; Park Dental Research Corporation, New
to be clinically acceptable in the health care field, its ac- York, NY). All models were printed in a horizontal orien-
curacy, precision, and reproducibility need to be thor- tation with a horseshoe-shaped base.15
oughly tested. The transition to a 3D model alternative The study models were printed using variations in
will enable the daily office flow to become more efficient printing techniques and different orientations. These
and will appeal to patients as up-to-date dental care.3 If variations included, (1) a model set in the middle (M)
the DLP printer can perform with clinically acceptable of the plate vs a maxillary model in all 4 corners (C) on
accuracy at different settings and model orientations, the plate; (2) solid (S) vs hollow (H) shelled models;
a more efficient and economical approach may be and (3) models printed at 50 (50) and 100 (100) microns
possible. It was hypothesized that the DLP printer would in the z-axis. The combination of these variables allowed
print 3D models with reproducible and consistent accu- for a total of 8 different printing combinations (100 SC,
racy while filling the build plate, printing at a high-speed 100 HC, 100 SM, 100 HM, 50 SM, 50 HM, 50 SC, 50 HC).
setting, and using less resin via printing with hollow Each of the 30 models was printed using these printing
models. combinations.
A total of 120 maxillary and 120 mandibular arches
were measured. These were 30 total arches, with each
MATERIALS AND METHODS being printed using the 8 printing combinations types.
Ethical approval for this study was obtained by the All measurements of the physical models were obtained
University of Oklahoma Institutional Review Board for using a calibrated digital caliper (Orthopli, Philadel-
the Protection of Human Subjects (no. 8366) on phia, Pa), and the teeth measured to the nearest
November 27, 2017. 0.01 mm directly from the models. However, the arch
A power analysis was done based on similar precursor measurements were measured using the digital caliper
studies.15,18 A total of 15 patients, or 30 arches, were from a 1:1 scale photocopy of the occlusal views. For
required for this study in order to attain an 80% proba- all teeth, first molar to the first molar in both dental
bility of generating a 95% confidence interval with a arches, tooth measurements recorded included: (1)
margin of error 0.15 mm for tooth measurements and the mesial-distal widths from point contact to point
0.5 mm for arch dimension measurements. contact (clinical crown width) and (2) the incisal-
The data collection protocol followed the guidelines gingival heights from gingival zenith to cusp tip or
outlined by Brown et al.15 The printing of additional incisal edge (clinical crown height). Incisal-gingival
models also followed the protocol used by Brown et al. measures were used to describe the clinical crown
Patients were randomly selected from a pool of retention heights for both anterior and posterior teeth. Arch
patients who received orthodontic treatment at the Uni- dimension measurements for both arches included:
versity of Oklahoma Graduate Orthodontic Clinic. A (1) intercanine width from cusp tip to cusp tip, (2) inter-
patient was considered in retention if his/her orthodon- molar width from mesiolingual cusp tip to mesiolingual
tic appliances were removed six-18 months before cusp tip, and (3) arch depth from the midline of the

American Journal of Orthodontics and Dentofacial Orthopedics March 2020 ! Vol 157 ! Issue 3
424 Sherman et al

central incisors to a perpendicular line crossing through However, mean differences for the intercanine widths,
the mesial contacts of the first molars (Fig). Three cali- although not statistically significant, were on the
brated researchers (LV, BF, and SS) measured and re- higher side of clinically acceptable for the 50 SM vs 50
corded the data. A singular examiner was assigned to SC, 100 SM vs 100 SC, and 100 HM vs 100 HC. The
gather all data for each of the respective measurements arch depth was also on the higher side of clinically
for consistency of landmark identification. One acceptable, although not statistically significant, for
researcher (LV) measured mesial-distal, 1 researcher comparison of the 50 SM vs 50 SC and the 100 HM vs
(BF) measured incisal-gingival, and 1 researcher (SS) 100 HC. Finally, the intermolar widths were on the
measured arch dimensions for all models. higher side for the 100 HM vs 100 HC and the 100 HC
vs 100 SC as well as 100 HC vs 50 HC, and the 100
Statistical analysis HM vs 50 HM.
Bland-Altman plots were used to evaluate the agree-
ment of the mesial-distal, incisal-gingival, intercanine, DISCUSSION
intermolar, and arch depth measurements among the The accuracy of the DLP printing technique using the
different 3D printed models. These comparisons JUELL 3D Flash OC printer by Park Dental Research Cor-
included mean differences as well as limits of agreement poration was evaluated. This study is the first to evaluate
for the 4 model types. A total of 20% of each model type the accuracy of the DLP technique using different print-
was measured a second time with a 2-week interval be- ing variations and orientations and one of the earlier
tween measurements. The intraclass correlation coeffi- studies to use digital scans that were acquired from an
cient was used to assess the intraobserver reliability of intraoral environment similar to a clinical practice
the repeated measurement error.15 setting.
Though there were no statistical differences in the
RESULTS means of the measurements of any of the printed model
A total of 6720 tooth measurements were recorded sets, one still should consider the clinical differences and
from the 240 maxillary and mandibular arches along their relevance. Previous studies have defined the
with an additional 720 arch dimension measurements acceptable accuracy, in terms of clinical relevance, to
for a final total of 7440. Measurements on the printed be in the range from 0.20 mm to 0.50 mm.7,9-11,21,22
model combinations were found to be highly reproduc- All of the measurements fell within this acceptable range
ible with a high intraclass correlation coefficient for all of error and within previously suggested acceptable clin-
measurements based on the repeated measurement ical ranges based on findings from the 5 most recent
error (Table I). Only the arch depth of the 40 repeated studies. Those arch measurements that did not fall
arch measurements for the 50 HC models was slightly within the strictest clinical acceptance range varied
larger. from 0.01 mm to 0.15 mm over the accepted range.
High agreement between all model sets in the mesial- When considering the recommendations of clinical
distal, incisal-gingival, intercanine, intermolar, and arch acceptance from previous studies, all variations of the
depth measurements was found among all the model 3D printing methods produced clinically acceptable
sets (Tables II-IV). The limits of agreement and the P models that could be considered practical alternatives
values for the mean differences vs 0 are also presented in clinical application.
in these tables. The mean differences for all model Of the 3 variables studied, the placement on the
comparisons did not significantly differ from 0. build plate displayed the most variation in both mean

Fig. Arch measurements.

March 2020 ! Vol 157 ! Issue 3 American Journal of Orthodontics and Dentofacial Orthopedics
Sherman et al 425

Table I. Repeated measurement mean error Table II. Agreement between model measurements
(position on the build plate)
Mesial- Incisal- Arch
Model* distal gingival Intercanine Intermolar depth Mean Limits of
100 HC 0.04 0.02 0.07 0.08 0.11 differences agreement
100 HM 0.09 0.01 0.04 0.05 0.04 Measurement (mm) (mm) P
100 SC 0.08 0.01 0.05 0.05 0.04 Agreement between (1) 50 SM and (2) 50 SC
100 SM 0.08 0.02 0.03 0.09 0.06 Mesial-distal 0.002 –0.15 to 0.15 0.972
50 HC 0.06 0.02 0.06 0.06 0.22 Incisal-gingival –0.002 –0.06 to 0.06 0.975
50 HM 0.06 0.02 0.08 0.08 0.05 Intercanine –0.21 –0.61 to 0.02 0.607
50 SC 0.08 0.02 0.06 0.04 0.18 Intermolar 0.04 –1.2 to 1.29 0.958
50 SM 0.06 0.02 0.08 0.05 0.04 Arch depth –0.22 –0.77 to 0.33 0.609
H, Hollow; C, corner; M, middle; S, solid. Agreement between (1) 100 SM and (2) 100 SC
*The repeated measurement error equals 1 minus the intraclass cor- Mesial-distal –0.02 –0.02 to 0.16 0.755
relation coefficient. Incisal-gingival 0 –0.06 to 0.06 0.994
Intercanine –0.35 –0.84 to 0.14 0.381
Intermolar –0.07 –0.96 to 0.83 0.932
Arch depth –0.14 –1.15 to 0.87 0.748
differences and limits of agreement (Table II). Of those,
Agreement between (1) 50 HM and (2) 50 HC
higher means and limits of agreement were found in the Mesial-distal –0.004 –0.17 to 0.16 0.951
arch measurements, whereas all mean differences in tooth Incisal-gingival –0.004 –0.13 to 0.12 0.947
measurements varied from 0.0 mm to 0.004 mm. Also for Intercanine –0.13 –0.52 to 0.26 0.74
tooth measurements, the differences in agreement varied Intermolar –0.19 –1.46 to 1.09 0.813
Arch depth –0.08 –1.08 to 0.93 0.851
from –0.05 mm to 0.05 mm for the incisal-gingival mea-
Agreement between (1) 100 HM and (2) 100 HC
surements in the 100 HM vs 100 HC comparison. The Mesial-distal –0.001 –0.07 to 0.69 0.984
largest was –0.17 mm to 0.16 mm in the mesial-distal Incisal-gingival 0.00 –0.05 to 0.05 0.998
measurements for the 50 HM vs 50 HC comparison. Intercanine –0.29 –0.72 to 0.13 0.465
Twenty comparisons were evaluated for each variable Intermolar –0.26 –1 to 0.48 0.728
Arch depth –0.29 –1.33 to 0.75 0.498
with 5 measurements for each of the 4 different model
comparisons as shown in Tables II-IV. Of the 20 Note: The mean difference equals the (2) measurements minus the
(1) measurements. Thus, a positive value represents, on average,
comparisons used in evaluating the model placement
that the (2) measurements are overestimated compared with the
on the build plate, 16 of the mean differences were (1) measurements. Conversely, a negative mean difference repre-
negative. This finding showed a trend that the majority sents, on average, that the (2) measurements are underestimated
of the models in the middle presented higher values compared with the (1) measurements.
than those in the corners of the plate. A total of 4 H, Hollow; C, corner; M, middle; S, solid.
mean differences were calculated for the intercanine
measurements, with 3 of the 4 on the higher end of When compared with the other 2 variables tested, the
clinically acceptable, a difference of .0.2 mm. This hollow vs solid comparisons demonstrated the lowest
finding suggests that the intercanine distances in the mean differences and closest limits of agreements. All
models printed in the middle were greater than those mean differences for tooth measurements varied from
in the models printed in the corners of the plate. In 0.00 mm to 0.01 mm (Table III). The smallest limits of
addition, 2 of 4 arch depth comparisons and 1 of the agreement were –0.05 mm to 0.05 mm in the incisal-
intermolar width comparisons were higher than gingival comparison between the 100 HM and 100
0.2 mm. The arch depth and intermolar widths for the SM. The largest limits of agreement were in the
models printed in the middle were potentially higher mesial-distal measurements for the 100 HC vs 100 SC
than those printed in the corners. Although all of the comparison. In evaluating 20 comparisons of the hollow
differences recorded were small for models in the vs solid models, 12 presented with positive values, which
middle vs the corner of the build plate, the differences demonstrated a relatively balanced difference of the
in these 2 variables were more apparent than those means. This finding suggests that there was not a size
found when evaluating the thicknesses in the z-axis or difference between the hollow and solid models. Similar
when comparing the solid vs hollow models. This trend to the other variables tested, the largest mean differ-
showed that the models printed in the middle of the ences and limits of agreements were found in the arch
plate can be larger than those printed in the corners of measurements. 3D printing with hollow models vs solid
the plate. This finding could be important if one were models may mean significant cost savings. Although the
to try to fill the build plate with more models in order height at which each model was placed on the build plate
to print as many arches as possible at one time. in the z-axis was not standardized, the differences in

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426 Sherman et al

Table III. Agreement between model measurements Table IV. Agreement between model measurements
(hollow vs solid) (z-axis thickness)
Mean Limits of Mean Limits of
differences agreement differences agreement
Measurement (mm) (mm) P Measurement (mm) (mm) P
Agreement between (1) 50 HC and (2) 50 SC Agreement between (1) 100 SC and (2) 50 SC
Mesial-distal 0.001 –0.17 to 0.17 0.994 Mesial-distal 0.007 –0.19 to 0.2 0.92
Incisal-gingival 0.001 –0.06 to 0.06 0.993 Incisal-gingival –0.001 –0.07 to 0.07 0.986
Intercanine –0.03 –0.5 to 0.45 0.945 Intercanine 0.12 –0.3 to 0.54 0.766
Intermolar 0.15 –1.18 to 1.47 0.851 Intermolar 0.18 –0.7 to 1.06 0.814
Arch depth –0.01 –0.97 to 0.95 0.983 Arch depth 0 –1.0 to 1.01 0.992
Agreement between (1) 100 HC and (2) 100 SC Agreement between (1) 100 SM and (2) 50 SM
Mesial-distal –0.022 –0.73 to 0.68 0.733 Mesial-distal –0.016 –0.19 to 0.16 0.804
Incisal-gingival 0.001 –0.06 to 0.06 0.984 Incisal-gingival 0.00 –0.06 to 0.06 0.994
Intercanine –0.05 –0.56 to 0.46 0.903 Intercanine –0.03 –0.42 to 0.37 0.949
Intermolar 0.29 –0.6 to 1.18 0.699 Intermolar 0.07 –1.09 to 1.24 0.925
Arch depth 0.11 –0.95 to 1.17 0.803 Arch depth 0.08 –0.38 to 0.55 0.845
Agreement between (1) 50 HM and (2) 50 SM Agreement between (1) 100 HC and (2) 50 HC
Mesial-distal –0.006 –0.15 to 0.14 0.929 Mesial-distal –0.016 –0.73 to 0.69 0.804
Incisal-gingival –0.002 –0.13 to 0.12 0.979 Incisal-gingival 0 –0.06 to 0.06 0.994
Intercanine 0.05 –0.32 to 0.41 0.909 Intercanine 0.1 –0.39 to 0.58 0.812
Intermolar –0.08 –1.27 to 1.11 0.92 Intermolar 0.32 –0.94 to 1.59 0.679
Arch depth 0.13 –0.31 to 0.58 0.759 Arch depth 0.12 –0.79 to 1.02 0.767
Agreement between (1) 100 HM and (2) 100 SM Agreement between (1) 100 HM and (2) 50 HM
Mesial-distal –0.003 –0.18 to 0.18 0.96 Mesial-distal –0.014 –0.19 to 0.16 0.835
Incisal-gingival 0.002 –0.05 to 0.05 0.976 Incisal-gingival 0.004 –0.11 to 0.12 0.95
Intercanine 0.01 –0.26 to 0.28 0.982 Intercanine –0.06 –0.35 to 0.23 0.874
Intermolar 0.09 –0.73 to 0.92 0.902 Intermolar 0.25 –0.64 to 1.13 0.747
Arch depth 0.04 –0.91 to 0.82 0.919 Arch depth –0.09 –1.1 to 0.91 0.831
Note: The mean difference equals the (2) measurements minus the Note: The mean difference equals the (2) measurements minus the
(1) measurements. Thus, a positive value represents, on average, (1) measurements. Thus, a positive value represents, on average,
that the (2) measurements are overestimated compared with the that the (2) measurements are overestimated compared with the
(1) measurements. Conversely, a negative mean difference repre- (1) measurements. Conversely, a negative mean difference repre-
sents, on average, that the (2) measurements are underestimated sents, on average, that the (2) measurements are underestimated
compared with the (1) measurements. compared with the (1) measurements.
H, Hollow; C, corner; M, middle; S, solid. H, Hollow; C, corner; M, middle; S, solid.

price for all variations of hollow from all of the solid HC vs 50 HC comparison in the mesial-distal measure-
models were about $65. The cost to print all of the solid ments at –0.56 mm to 0.55 mm. Of the 20 comparisons
models was about $300, and the cost for the hollow was that were used in evaluating the fastest (100 microns)
about $235. The current pricing from the manufacturer and the slowest (50 microns) settings, 10 of the mean dif-
ranges from $1.80 for a hollow model without a base to ferences had a positive number, which demonstrated
$3.50 for a solid model with a base as of November 2018. acceptable differences in size in the 100-micron vs the
50-micron models. Because the measurements from these
The third variable analyzed and isolated was the differ- 2 model sets did not differ, the data suggest that printing
ence in printing at the fastest setting of 100 microns vs at a lower resolution is not critical. In addition, this would
the slowest setting of 50 microns in the z-axis (Table allow for faster print speed without sacrificing accuracy.
IV). Like the previous variables, the only measurements Finally, 2 of 4 comparisons of the intermolar widths
that appeared to be higher were in the arch dimension. were on the higher end of clinically acceptable. They
All of the tooth measurements were small in comparison were both positive, which indicated that the 50-micron
with the mean differences and the limits of agreement. models could be slightly wider than the 100-micron
Mean differences in the tooth measurements varied models for the intermolar width.
from 0.0 mm to 0.03 mm. The smallest limit of agreement The higher variations in the arch measurements as
were –0.06 to 0.06 mm. This result was found in both the compared with the tooth measurements were a subject
incisal-gingival measurements for the 100 SM vs 50 SM of study limitation. As a reminder, all measurements of
comparison as well as the 100 HC vs 50 HC comparison. the physical models were calibrated digitally and
The largest limits of agreement were found in the 100 measured to the nearest 0.01 mm directly from the

March 2020 ! Vol 157 ! Issue 3 American Journal of Orthodontics and Dentofacial Orthopedics
Sherman et al 427

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