RESEARCH AND EDUCATION

Fit of interim crowns fabricated using photopolymer-jetting

3D printing
Hang-Nga Mai, DDS, MS,a Kyu-Bok Lee, DDS, PhD,b and Du-Hyeong Lee, DDS, PhDc

Interim restorations are essen- ABSTRACT

tial not only for the protection Statement of problem. The fit of interim crowns fabricated using 3-dimensional (3D) printing is
of pulpal and periodontal tis- unknown.
sues but also for the mainte-
Purpose. The purpose of this in vitro study was to evaluate the fit of interim crowns fabricated
nance of oral function and
using photopolymer-jetting 3D printing and to compare it with that of milling and compression
esthetics.1 To meet these goals, molding methods.
special care should be taken to
ensure the shape and fit of Material and methods. Twelve study models were fabricated by making an impression of a metal
master model of the mandibular first molar. On each study model, interim crowns (N=36) were
such restorations.1,2 The fit of
fabricated using compression molding (molding group, n=12), milling (milling group, n=12), and 3D
restorations depends largely polymer-jetting methods. The crowns were prepared as follows: molding group, overimpression
on the fabrication methods.1,3 technique; milling group, a 5-axis dental milling machine; and polymer-jetting group using a 3D
The techniques used for fabri- printer. The fit of interim crowns was evaluated in the proximal, marginal, internal axial, and
cating interim crowns can be internal occlusal regions by using the image-superimposition and silicone-replica techniques. The
divided into direct and indirect Mann-Whitney U test and Kruskal-Wallis tests were used to compare the results among groups
methods according to the (a=.05).
4,5
manufacturing process. In Results. Compared with the molding group, the milling and polymer-jetting groups showed more
the direct method, the interim accurate results in the proximal and marginal regions (P<.001). In the axial regions, even though the
crown is fabricated immedi- mean discrepancy was smallest in the molding group, the data showed large deviations. In the
occlusal region, the polymer-jetting group was the most accurate, and compared with the other
ately on the prepared tooth,
groups, the milling group showed larger internal discrepancies (P<.001).
whereas in the indirect
method, the interim crown is Conclusions. Polymer-jet 3D printing significantly enhanced the fit of interim crowns, particularly in
fabricated on a stone cast and the occlusal region. (J Prosthet Dent 2017;118:208-215)
then delivered to the oral
cavity.5 Although the direct method is fast and straight- distance in the low-molecular-weight monomers used.8
forward, it has disadvantages. The exothermic heat This shrinkage causes dimensional discrepancies in
released during resin polymerization in the direct method the marginal, interproximal, and occlusal regions.9
6
may cause thermal trauma to the tooth pulp. Moreover, With the indirect method, the thermal and chemical
the residual resin monomer could harm the oral mucosa, risks to the tooth and mucosa are eliminated and
causing lichenoid reactions or allergic stomatitis.7 the adaptation of the crown to the tooth is improved
Another disadvantage of the direct method is the because the polymerization process is performed on a
resin shrinkage caused by the reduction of the atomic stone cast.5

Supported by Basic Science Research Program through the National Research Foundation of Korea funded by the Ministry of Science, Information and
Communication Technologies and Future Planning grant NRF-2014R1A1A1006073.
a
Graduate student, Department of Prosthodontics, School of Dentistry, Kyungpook National University, Daegu, Republic of Korea.
b
Professor, Department of Prosthodontics, School of Dentistry, A3DI, Kyungpook National University, Daegu, Republic of Korea.
c
Assistant Professor, Department of Prosthodontics, School of Dentistry, A3DI, Kyungpook National University, Daegu, Republic of Korea.

208 THE JOURNAL OF PROSTHETIC DENTISTRY

August 2017
Clinical Implications
The use of PolyJet 3D printing improves the fit
of interim restorations, which enhances their
biological and mechanical functions, thereby
placing this process within the limitation of
cost effectiveness, a useful alternative for
fabricating interim crowns.
Computer-aided design and computer-aided
manufacturing (CAD-CAM) technology has recently
been applied to the fabrication of interim crowns.10 Most
commercially available dental CAD-CAM systems use
the milling method in which interim crowns are me-
chanically sculpted from a resin block by using a cutting
bur.11 Because the resin block is polymerized with a high
degree of conversion, the strength and accuracy of the
interim crown are better when fabricated with the mill-
ing method than with the conventional direct tech-
nique.12-14 However, the subtractive method has some
drawbacks. The motion range of the cutting device and
the size of the cutting bur limit the millable shape.11,15
The additive method, such as 3-dimensional (3D)
printing, produces 3D objects by layering cross-sectional
slices to form the definitive object10 and facilitates the
production of objects with complex structures.16,17
Moreover, less material is used in 3D printing than in
the milling method.11
Three-dimensional printing technologies can be
subdivided according to the material-layering method.
Stereolithography, selective laser sintering, digital light
processing, photopolymer-jetting (PolyJet), and fused
deposition modeling have been applied in the fabrication
of dental prostheses.11,12,17 Among these methods, the
PolyJet method offers high resolution and low polymer-
ization shrinkage and allows fabrication of objects with a
smooth surface.12,16 The method uses the inkjet printing
process to build up objects layer by layer. A print head
sprays droplets of the photosensitive resin liquid through
a nozzle, layering the droplets in a cross-sectional pattern
to form the definitive object. Each layer is then poly-
merized and combined with the previous layer by
applying an ultraviolet polymerization light.12 Moreover,
the mechanical properties of the 3D-printed products can
be enhanced by modifying the polymer chemical struc-
ture and adding nanofillers, which extend the application
scope of this technology.18
Although some studies have investigated the appli-
cation of 3D printing in dental restorations, as far as the
authors are aware, the fit of interim crowns fabricated
using 3D printing has not been evaluated.19,20 Therefore,
the purpose of this in vitro study was to evaluate the fit of
interim crowns fabricated using PolyJet 3D printing and
Mai et al
209
Metal master model
Silicone impression
Stone study cast
Optical scanning
Virtual cast
Overimpression
CAD
technique
Virtual crown
Milling 3D Printing
Molding group Milling group PolyJet group
Figure 1. Work flow for fabrication of interim crowns using different
manufacturing methods.
to compare those crowns with crowns fabricated using
the molding and milling methods by using the image-
superimposition and silicone-replica techniques. The
null hypothesis was that the fit of interim crowns fabri-
cated using PolyJet 3D printing would not differ from
those fabricated with the compression molding and
milling methods.
MATERIAL AND METHODS
The workflow for the fabrication of interim crowns using
different manufacturing methods is described in Figure 1.
To make the master model, a cobalt-chromium (Wirobond
C; BEGO GmbH) mandibular first molar was prepared
using an occlusal reduction of 1.5 mm and a total
convergence angle of 6 degrees. The finished margin
design was a deep chamfer with a 1.0-mm width. The
metal die and 2 adjacent metal teeth were arranged and
fixed using a base made of a clear autopolymerizing resin
(Orthodontic Resin; Dentsply Sirona) (Fig. 2). Twelve
study casts were fabricated by making the impressions
(Aquasil Ultra XLV and Aquasil Ultra Heavy; Dentsply
Sirona) of the master model and pouring them with Type
IV die stone (GC Fujirock EP; GC Europe). Three different
interim crowns were fabricated on each study cast by
using different manufacturing methods: compression
molding (molding group), milling (milling group), and
PolyJet 3D printing (PolyJet group) techniques.
THE JOURNAL OF PROSTHETIC DENTISTRY
210
Figure 2. Master model with metal dies embedded in custom resin base.
In the molding group, a die spacer (Die Spacer blue;
Yeti Dentalprodukte GmbH)21 was first applied on the
stone cast starting 1.0 mm above the finish line to obtain
a cementation space of 60 mm. The application of die
spacer was performed by 1 dental technician in accor-
dance with the manufacturer’s instructions. Next, the
proximal surfaces of adjacent teeth were relieved by
scraping them 6 times with a polishing strip (Sof-Lex; 3M
ESPE) to ensure a tight contact between the interim
crown and the adjacent tooth.22 Subsequently, the
interim crowns were fabricated using the overimpression
technique.5 A complete contour waxing was fabricated
on the study cast, and silicone molds were made by
making an impression of the study cast. After removing
the waxing, an autopolymerizing acrylic resin (Alike;
GC Europe) was mixed and poured into the silicone
mold, and the mold was fitted to the study cast. After the
resin had polymerized, the silicone mold and interim
crown were removed. All the interim crowns of this
group were made by a single operator.
In the milling group, each study cast was first digi-
tized using a desktop scanner (Ceramill Map 400;
AmannGirrbach) and saved in the standard tessellation
language (STL) format. STL data were then imported
into dental CAD software (Cerec inLab 4.2; Dentsply
Sirona), which was used to design the virtual crowns
with 60 mm of cementation space, starting 1.0 mm above
the finish line (Fig. 3).3 The proximal contact area was
established in the occlusal third of the crown with tight
proximal contact. Interim crowns were fabricated using a
5-axis milling machine (Ceramill Motion 2; Amann
Girrbach) and poly(methyl methacrylate) and methacrylic
acid ester-based cross-linked resin blocks (Ceramill
TEMP; Amann Girrbach).
In the PolyJet group, interim crowns were produced
using the PolyJet technology. The same virtual crown
designed using a 60-mm cementation space was reused for
the PolyJet group. The design files were transferred to a
PolyJet 3D printer (Object Eden 260VS; Stratasys), and
THE JOURNAL OF PROSTHETIC DENTISTRY
Volume 118 Issue 2
interim crowns were fabricated by printing a biocompat-
ible photopolymer (VeroGlaze MED620; Stratasys)
(Table 1) with a layering thickness of 5 mm. The printed
crowns were then rinsed thoroughly under running water
and soaked in isopropanol for 30 minutes at room tem-
perature according to the manufacturer’s instructions.
Using these processes, interim crowns were fabri-
cated (N=36) for each study model by using different
manufacturing methods (n=12 for each group) (Fig. 4).
The fit of the interim crown was evaluated for 3 resto-
ration regions: the proximal surface, margins, and inter-
nal surface (axial and occlusal). The accuracy of the
proximal contact was evaluated by comparing the posi-
tions of the intended and actual contact points. The
intended proximal contact points in the molding group
were marked by interposing a 10-mm-thick articulating
film (AccuFilm; Parkell) in the interproximal area when
the waxed crown was seated on the study model. A
photograph of the proximal area was then made to re-
cord the position of the contact point. In the milling and
PolyJet groups, the intended proximal contact points
were determined at the crown design stage, and the
corresponding information was obtained using CAD
software. To obtain the actual proximal contact points,
the crowns were placed on the master die, the contact
points were marked using the articulating film, and the
marks were recorded by making proximal photographs.
Subsequently, the 2 proximal photographs were super-
imposed, and the deviation of the center point of prox-
imal contact was measured using photo editing software
(Adobe Photoshop CS6; Adobe Systems).
The accuracy of the marginal and internal adaptation of
the crown was evaluated using the silicone-replica tech-
nique,13,14 which models the marginal and internal
discrepancy between the restoration and prepared teeth
with an impression silicone; the resulting replica is
sectioned and measured using a microscope. In this study,
a cutting guide template was made to obtain the same
cross-sectional planes in the sectioning replicas. The
template included 2 parts: the upper part, which was a
hollow octagonal column with guiding slots, and the lower
part, which was a resin base for the die. Both parts were
closely fitted to each other (Fig. 5). The silicone replica
technique was performed using the guide template. The
crown was filled with a white silicone indicator paste (Fit
Checker II; GC Europe) and seated on the master die. A
vertical force of 50 N was applied over the crown for 10
minutes. After the paste had polymerized, the crown was
gently removed from the die and a heavy-body silicone
(Virtual; Ivoclar Vivadent AG) was applied over the die
with the guide template. When the heavy-body silicone
had completely polymerized, the guide template with the
replica was separated from the die. The replica was
sectioned in the mesiodistal and buccolingual directions,
using a razor blade (Personna; American Safety Razor) and
Mai et al
August 2017 211

Figure 3. Interim crown design. A, Overall contour. B, Cross-sectional image in buccolingual direction.

following the slots of the guide template. Four measure- Table 1. VeroGlaze (MED620) composition*
ment points were determined in the marginal, axial, cusp, Component %
and fossa regions (Fig. 6). Absolute marginal discrepancy, Acrylic monomer <30
the distance between the most extended point of the 2-Propenoic acid, exo-1,7,7-trimethylbicyclo[2.2.1]hept-2-yl ester <25

restoration margin and the external marginal line of the
prepared tooth, was used to evaluate the discrepancy on
the margin.23 For evaluating internal discrepancy, the
perpendicular distances from the internal surface of the
crown to the external surface of the preparation were
measured.23 All measurements were made at the center
points of the axial, cusp, and fossa regions. The cross-
sections were examined under a measuring microscope
(MM-40; Nikon Corp) at a magnification of ×50 (Fig. 7).
Images were captured, and image calibration was per-
formed to convert pixel measurements into absolute units
using software (Image-Pro Plus v7.0; Media Cybernetics).
All measurements were made by 1 investigator who was
blinded to the purposes of the study.
All measurements were collected and analyzed using
statistical analysis software (IBM SPSS Statistics for
Windows v22; IBM Corp). The Mann-Whitney U test and
Kruskal-Wallis test were used to determine the statistical
differences among the 3 groups at individual measure-
ment points (a=.05).
RESULTS
Table 2 lists the proximal contact patterns observed
during the insertion of interim crowns in the 3 groups.
Although the milling and PolyJet group specimens
exhibited tight proximal contacts to the corresponding
surfaces of the adjacent teeth, the molding group had
both tight and deficient proximal contacts.
As for the accuracy of the proximal contacts, the
molding group showed the highest discrepancy with a
large mean ±standard deviation (SD) 440 ±351 mm, fol-
lowed by the milling 271 ±90 mm and PolyJet groups
260 ±110 mm (P<.001) (Figs. 8, 9). The milling and PolyJet
groups showed no significant difference (P=.591).
Acrylic oligomer <15
Photo-initiator <3
Titanium dioxide <0.8
Acrylic acid ester <0.3
Carbon black 0.1-1.0
Xylenes (o-, m-, p- isomers) 0.01-0.1
n-Butyl acetate 0.01-0.1
Ethylbenzene 0.01-0.1
Propylene glycol monomethyl ether acetate 0.01-0.1
Phosphoric acid 0.0005-0.002
*Manufacturer’s information.
Data regarding the marginal and internal discrep-
ancies of the interim crowns at the measurement points
for each group are shown in Figure 10. The relative fit
varied according to the measurement points and groups.
At the margins, the mean ±SD discrepancy between the
restoration and the abutment, the absolute marginal
discrepancy, was smallest in the PolyJet group at 99 ±19
mm. The molding group showed a significantly higher
mean ±SD 163 ±86 mm (P<.001). However, in the axial
region, the mean ±SD discrepancy was significantly
smaller in the molding (87 ±62 mm) group than in the
milling (125 ±30 mm) and PolyJet (139 ±23 mm) groups
(P<.001). In the cusp and fossa regions, the mean
discrepancy was significantly larger in the milling group
(301 ±74 mm at the cusp and 328 ±108 mm at the fossa)
than in the other groups (P<.001). Although no signifi-
cant differences (P>.05) were found between the molding
and PolyJet groups, the SDs of the molding group were
large (103 mm at the cusp, 154 mm at the fossa).
DISCUSSION
The purpose of this study was to compare the fit of
interim crowns fabricated using the PolyJet 3D printing

Mai et al THE JOURNAL OF PROSTHETIC DENTISTRY

212
Figure 4. Interim crowns fabricated with different methods. A, Molding.
B, Milling. C, PolyJet.
method with the fit of interim crowns made using other
methods. Generally, the 3D-printed crowns were more
accurate and showed consistent results in the proximal,
marginal, and internal regions than did the crowns
fabricated during the molding and milling methods.
Thus, the null hypothesis, that the fit of interim crowns
fabricated using PolyJet 3D printing would not differ from
that of crowns fabricated using the compression molding
and milling method, was rejected.
The molding group showed the highest discrepancy
of the other groups, accompanied by some deficient
contacts. The main possible reason for the discrepancy is
the volumetric shrinkage of the autopolymerizing resin
during polymerization.8 Because the resin crown was
THE JOURNAL OF PROSTHETIC DENTISTRY
Volume 118 Issue 2
Figure 5. Guide template used for replica sectioning.
C F
Figure 6. Schematic showing measurement positions for marginal and
internal fit. M, Margin. A, Axial. C, Cusp. F, Fossa.
polymerized in a single piece, the dimensional change
due to shrinkage might have been large. In contrast, the
milling and PolyJet 3D printing methods used polymer-
ized blocks and cross-sectional polymerization by layer,
thereby avoiding large volumetric changes.
The present study indicated that favorable marginal fit
was obtained in the PolyJet and milling groups; those in
the molding group were less accurate. The results coin-
cide well with the findings of previous studies. Pompa
et al24 concluded that the 3D printing method was
superior to conventional fabrication methods in terms of
marginal adaptation. Kelvin et al9 reported that interim
restorations fabricated using the milling method had a
significantly smaller marginal discrepancy than crowns
fabricated using the conventional method. Based on the
findings of the present and previous studies, CAD-CAM
application in fabricating dental restoration increases
marginal accuracy.
Mai et al
August 2017 213

Figure 7. Light micrographs of cross-section of replica. A, Margin. B, Axial. C, Cusp. D, Fossa. (Original magnification ×50.)

Table 2. Evaluation of proximal contacts

Mesial Distal
Group Tight Deficient Tight Deficient
Molding 10 2 11 1
Milling 12 0 12 0
PolyJet 12 0 12 0

Internal discrepancies varied among groups. In the

axial region, some crowns in the molding group showed
unfavorably reduced internal discrepancies compared with
the crowns in the milling and PolyJet groups. Grajower
et al25 found that the crowns were not completely seated
when a thin cementation space was provided. Thus, a
reduced internal discrepancy in the axial region of the
molding group may be closely related to the large mean Figure 8. Results of superimposing 2 separate photographs of actual
marginal discrepancy in that group. Meanwhile, in the contact area and intended contact area.
occlusal region, the milling group showed significantly
larger discrepancy than those of the other groups. How- fabrication.17 When sharp edges or a rugged surface exist
ever, the crowns in the PolyJet group exhibited the most on an object, the object cannot be reproduced using the
accuracy in the occlusal region. This result may be attrib- milling method. In such situations, to facilitate the milling
uted to a different inherent fabrication process. In the process, the shape of the object image should be modified.
milling method, an object is fabricated in a subtractive Dental CAD software used for designing restorations
manner by using cutting burs. Accordingly, the bur has an automatic relief function, which transforms the
size and cutting motion range are limiting factors in point clouds of the image into a millable one by using a

Mai et al THE JOURNAL OF PROSTHETIC DENTISTRY

214
700
* 400
600
µm)
Mean Discrepancy of
Proximal Contact (µ
Mean Discrepancy (µ
500
400
300
200
100
0
Molding Milling PolyJet
Groups
Figure 9. Mean discrepancy of proximal contact points. *P<.05.
specific algorithm. Although this function is essential for
practical use, the process may result in a large deviation
in the occlusal region and aggravate the fit of restora-
tion.15 The 3D printing method uses an additive pattern
of applying materials layer-by-layer. Thus, this method
enables the fabrication of objects with complex struc-
tures, without the need for artificial modification of the
design.10 These findings suggest that a difference in the
fabrication mechanism affects the fit of restoration,
especially at the occlusal region, where the 3D printing
method decreases the internal discrepancy significantly
more than the milling method.
A guide for sectioning the silicone replicas was used
in this study to set the same reference plane in all rep-
licas. The replica technique included the step of cutting
the replica to obtain a cross-sectional plane where the
measurement of outcome variables was performed.
Accordingly, when the fit of restoration needs to be
compared between groups, the same reference plane
must be used. Previous studies have reported the
sectioning procedure could be problematic because it can
lead to oblique or different planes.26 Although manual
sectioning can be carried out carefully, human error
cannot be excluded. As a result, the fit can be over-
estimated or underestimated. In the present study, the
custom-made replica-sectioning guide directed the cut-
ting motion during both positioning and angulation by
using slots. Thus, it enabled all replicas to be sectioned
along the same reference planes.
Although this controlled in vitro experiment
confirmed that the 3D printing method improves the fit
of interim crowns, clinical trials with different tooth
preparations are needed to verify the present results. In
addition, other factors such as mechanical properties,
esthetics, and cost effectiveness should be considered
when using this technique in the clinical setting. There-
fore, further studies with a larger sample size and pro-
spective clinical trials will be needed to extend the
application of 3D printing to interim crowns.
THE JOURNAL OF PROSTHETIC DENTISTRY
Volume 118 Issue 2
450
Molding Milling PolyJet
*
µm)
350 *
300
250
*
200
150
*
100
50
0
Margin Axial Cusp Fossa
Area
Figure 10. Mean marginal and internal discrepancies of restoration at
measurement points. *P<.05.
CONCLUSIONS
Within the limitations of this experiment, the following
conclusions were drawn:
1. PolyJet 3D printing improved the fit of interim
crowns in the proximal, marginal, and internal
regions, and its effect was evident in the occlusal
region.
2. The accuracy of interim crowns fabricated using
PolyJet 3D printing was comparable with that of the
milling method; thus, 3D printing could be an
alternative approach to fabricating interim crowns.
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Corresponding author:
Dr Du-Hyeong Lee
Department of Prosthodontics
School of Dentistry, A3DI, Kyungpook National University
2175 Dalgubeoldae-ro, Jung-Gu, Daegu 700-705
REPUBLIC OF KOREA
Email: deweylee@knu.ac.kr
Copyright © 2016 by the Editorial Council for The Journal of Prosthetic Dentistry.

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Mai et al THE JOURNAL OF PROSTHETIC DENTISTRY