A digital process for additive
manufacturing of occlusal splints:
rsif.royalsocietypublishing.org
Research
Cite this article: Salmi M, Paloheimo K-S,
Tuomi J, Ingman T, Mäkitie A. 2013 A digital
process for additive manufacturing of occlusal
splints: a clinical pilot study. J R Soc Interface
10: 20130203.
http://dx.doi.org/10.1098/rsif.2013.0203
Received: 4 March 2013
Accepted: 2 April 2013
Subject Areas:
bioengineering, biomaterials,
biomedical engineering
Keywords:
computer-aided design, computer-
aided manufacturing, additive manufacturing,
rapid prototyping, rapid manufacturing
Author for correspondence:
Mika Salmi
e-mail: mika.salmi@aalto.fi
†
These authors contributed equally to this
study.
a clinical pilot study
Mika Salmi1, Kaija-Stiina Paloheimo1, Jukka Tuomi1, Tuula Ingman2,†
and Antti Mäkitie1,2,†
1
Department of Industrial Engineering and Management, BIT Research Centre, Aalto University,
School of Science, PO Box 15500, Aalto 00076, Finland
2
Department of Otolaryngology – Head & Neck Surgery, Helsinki University Central Hospital and University of
Helsinki, PO Box 220, HUCH 00029, Finland
The aim of this study was to develop and evaluate a digital process for man-
ufacturing of occlusal splints. An alginate impression was taken from the
upper and lower jaws of a patient with temporomandibular disorder
owing to cross bite and wear of the teeth, and then digitized using a table
laser scanner. The scanned model was repaired using the 3DATA EXPERT soft-
ware, and a splint was designed with the VISCAM RP software. A splint was
manufactured from a biocompatible liquid photopolymer by stereolithogra-
phy. The system employed in the process was SLA 350. The splint was worn
nightly for six months. The patient adapted to the splint well and found it
comfortable to use. The splint relieved tension in the patient’s bite muscles.
No sign of tooth wear or significant splint wear was detected after six
months of testing. Modern digital technology enables us to manufacture
clinically functional occlusal splints, which might reduce costs, dental tech-
nician working time and chair-side time. Maximum-dimensional errors of
approximately 1 mm were found at thin walls and sharp corners of the
splint when compared with the digital model.
1. Introduction
Temporomandibular disorder (TMD) is a common clinical entity [1,2]. The
prevalence of TMD in the adult population ranges from 25 to 50 per cent [3].
There is an increased risk for TMD in patients suffering from malocclusion,
such as cross bite, open bite or crowding [4,5], deep bite or mandibular retro-
gnatia [6]. Also bruxism, significant teeth wear, temporomandibular joint
(TMJ) problems or facial traumas may lead to TMD [7,8]. Traditionally, TMD
treatment starts with an occlusal splint. Usually, if there is no response
during the first one to six months, there is a need for additional examination
and treatment [9]. The conventional process to produce an occlusal splint com-
prises inter-occlusal wax bite registration and alginate impressions of the upper
and lower dentition to make working models. The manufacturing process when
performed by a dental technician is labour intensive. Digital manufacturing
processes are suggested as an alternative to a hand-made occlusal splint. Addi-
tive manufacturing (AM, Rapid Prototyping, Layer Manufacturing, Freeform
Fabrication) is a process where parts are manufactured directly from a digital
three-dimensional model by adding material, usually on a layer-by-layer
basis as opposed to subtractive manufacturing methodologies, such as tra-
ditional machining [10]. One of the advantages of an automated AM process
comes from the ability to print a large number of individual splints in a
short time period.
Indirect AM has been used for clear and hard tooth aligners by digitizing
teeth, virtually straightening them and fabricating a pattern for vacuum heat
process by AM [11]. A combination of computed tomography and rapid proto-
typing has been used to produce a physical copy of unusual tooth root anatomy
& 2013 The Author(s) Published by the Royal Society. All rights reserved.
[12]. A computer-assisted method for design and fabrication 2
of hard occlusal splints was developed by scanning for stone patient

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casts and milling for manufacturing [13]. AM has been used
for rapid tooling to create soft oral appliances by moulding
[14]. There are commercially available hard clear aligners, plaster model
which are made by digitizing dentition, virtual straightening, from teeth
fabricating a mould by AM, vacuum forming and finishing
[15]. The accuracy of wax patterns for facial prostheses pro- digitization of intraoral
plaster model scanner
duced by AM has been found to be better than conventional
duplication [16]. An AM model has been used as a mock-up
for manufacturing obturator prosthesis from acrylic poly- three dimensional
methyl methacrylate [17]. Laser surface digitizing with

J R Soc Interface 10: 20130203

model of patient teeth
computer-aided design (CAD)/computer-aided manufactur-
three dimensional additive occlusal
ing (CAM) techniques has been used for developing facial design of occlusal
prostheses and for casting prosthetic parts [18,19]. Optical splint manufacturing splint
three-dimensional imaging and CAD/CAM systems have
been deployed in designing and fabricating facial prostheses Figure 1. The process for planning and additive manufacturing of occlusal
more precisely than by conventional manual sculpturing tech- splints. The dashed line defines the digital steps of the process.
niques [20]. The accuracy of the photographic three-
dimensional imaging system has been found sufficient for clini-
cal description of the mid-face structures and may be
potentially useful for AM of facial prostheses [21]. Direct AM
applications in the medical field are still rather rare. There are
case studies on custom-made implants [22–25] and dental
crowns and bridges [26] made by these technologies. Direct
AM has been suggested as an effective methodology also for
patient- and operation-specific instruments [27]. Dental splints
for orthognathic surgery have been manufactured, using addi-
tive manufacturing and three-dimensional reconstruction from
computed tomography images as a template [28].
The aim of this study was to develop a digital method
for producing custom-made occlusal splints by AM. The
approach selected combined CAD, AM and digitization of
the patient’s dental arches. The secondary aim was to
obtain information regarding patient adaptation, i.e. conven-
Figure 2. The patient’s dentition. (Online version in colour.)
ience, tolerance and its effect to bite muscle pain, and to
study the side effects of this oral appliance.
2.2. Scanning
Teeth can be scanned straight from the mouth, using an intraoral
scanner, or indirectly by taking a plaster model and scanning it.
2. Material and methods The indirect method was selected because currently intraoral
Our approach to an occlusal splint was to use three-dimensional scanners are usually designed only for scanning a single tooth
digitizing to create a three-dimensional model from the patient’s or a few teeth for crowns and bridges. Plaster models from the
upper and lower teeth and to use the model as a basis for AM patient were taken and digitized using the 3Shape D710 Multi
from an appropriate material. A flow chart of the process is Die Scanning table laser scanner (3Shape A/S, Denmark) and
demonstrated in figure 1. the SCANSERVER v. 1.0.4.3 software (3Shape A/S, Denmark). The
scanner comprises a laser, two cameras with 1.3 megapixel
(Mpx) resolution and three-axis motion. Scanning the plaster
2.1. Patient model took approximately 60 s. The accuracy of the D710 Multi
The process started with dental examination of the patient with Die Scanning is 20 mm. All teeth were selected in focus in
cross bite on the right- and left-hand sides, severe teeth wear order to achieve maximal accuracy on every surface of the
and bite muscle pain. The patient was a generally healthy teeth. The format used for surface was STL (Stereolithography/
27-year-old male, with no allergies or medications. He had not Standard Tessellation Language), which describes a triangulated
received any orthodontic treatment and had no history of facial surface by the unit normal and vertices. The scanned model had
traumas or snoring. The periodontal tissues were clinically a few holes and triangulating errors but those were easily
healthy. His profile was straight, with an orthognathic maxilla repaired using manual and automatic repair tools. The STL file
and a slightly prognatic mandible. The horizontal overjet was was repaired using 3DATA EXPERT v. 9.1 (DeskArtes Oy, Finland).
4 mm, the vertical overbite was 21 mm and the molar relation-
ship was cusp to cusp on the right-hand side and AI on the
left-hand side. The maximal opening of the mandible was 2.3. Three-dimensional design
55 mm, and its lateral movement was 10 mm to the right and The splint was designed with the VISCAM RP v. 4.0 software
7 mm to the left. The protrusion of the mandible was 7 mm. (Marcam Engineering GmbH, Germany), which is an engineer-
The patient had minor bite muscle tension, but no TMJ clicking, ing software package for preparation of CAD/CAM data for
crepitation or pain on palpation. The patient’s dentition is shown AM. The scanned and repaired three-dimensional model of
in figure 2. upper teeth was used as a starting point. First, all tooth surfaces

Figure 3. The three-dimensional model of the occlusal splint.
in the three-dimensional model were extruded to a thickness of
2.0 mm. This can be done with the software’s extrude surface
or offset commands. Thereafter, the extruded surfaces were cut
off from the three-dimensional model, using a Boolean operation
to obtain a cover for teeth for a rough three-dimensional model of
the splint. At this stage, it is important to cut the edges so that the
splint will not touch the gingivae, but still has enough contact
with the teeth. Finally, the rough three-dimensional model of
the splint was cut to the desired shape using the trim and cut
tool. The smoothing command was used to achieve good surface
quality for the three-dimensional model. Smoothing, which
removes sharp corners and self-locking forms, was also used to
remove too tight fitting to the teeth. The absolute minimum
wall thickness for laser-based AM systems would be the width
of a single cured line and this is related to the diameter of laser
beam and the cure depth [29]. Therefore, the slight residual
roughness of the three-dimensional model tends to be smoothed
in AM, and very small errors have only insignificant influence to
the end product. The three-dimensional model of the designed
occlusal splint is shown in figure 3.
2.4. Manufacturing
AM is a material-adding fabrication process, which suits manu-
facturing complex geometries for either one piece or small series
production. The parts are produced automatically according to a
digital three-dimensional model. The selected additive process
for manufacturing was stereolithography (SL, SLA) because
of its good accuracy and availability of suitable materials.
Stereolithography is a process where laser hardens curable
photopolymer resin layer by layer. Parts are manufactured on
the building platform, which is located in liquid resin. After a
layer is cured, the build platform descends by one layer thick-
ness, and a new layer of resin is spread over the previous one.
This procedure is repeated until the parts are completely built.
The machine employed was SLA 350 (3D Systems, USA). For
the material, Somos WaterShed XC 11122 (DSM Functional
Materials, USA) was selected because it complies with the ISO
10993-5 Cytotoxicity, ISO 10993-10 Sensitization and ISO
10993-10 Irritation regulations. It also has USP Class VI approval.
The SLA 350 laser beam diameter is 100 mm, and features smaller
than that disappear. The layer thickness of the current process
was 0.05 mm. After the manufacturing phase, the splint was
soaked in pure isopropanol for 20 min, and clean towels were
used to scrub off any excess resin. Dry, compressed air was
used to blow excess solvent from the surface of the splint. The
splint was placed in a post-cure apparatus for 60 min after clean-
ing. The manufacturing can be done automatically overnight,
and the current cost of manufacturing one splint is approxi-
mately 60 euros.
2.5. Clinical testing 3
The patient was asked to note his impressions regarding the
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appliance use. This phase of the process and patient reporting
started with a standard dentist visit, where the occlusal splint
was trimmed to fit to the upper dental arch and to get optimal
contact with the lower dental arch. The patient was advised to
use the appliance every night, as is done with a conventional
bite splint, and to report on his own observations. The appliance
was cleaned every morning with water and tooth brush and once
a week with Corega Tabs (GlaxoSmithKline plc, UK).
After one, three and six months, the splint was examined for
possible wear and other changes. The final occlusal splint in use
J R Soc Interface 10: 20130203
is shown in figure 4.
2.6. Evaluation
Dimensional accuracy of stereolithography in medical model
production has been found to be better than 1 per cent when com-
pared with a three-dimensional model and manufactured model
[30,31]. The accuracy of medical models varies between different
materials, AM technologies and the machine used [32]. After six
months of splint use, the GOM ATOS II Triple scan 3D scanner
(GOM mbH, Germany) was used to capture a virtual three-
dimensional model of the product used. The scanner employs
structured blue light and cameras to record three-dimensional
surfaces. The accuracy of the measurement was not less than
0.02 mm. A mixture of titanium oxide and alcohol was sprayed
over the splint before measuring to gain better response for the
optical scanner. The geometry of the splint after use was com-
pared with the geometry of the three-dimensional design using
GOM Inspect V7 SR2 (GOM mbH, Germany), since the accuracy
of the stereolithography process is well known, and it can still be
estimated after use from the appliance’s surroundings where there
is no wear or trimming.
3. Results
The digitally manufactured occlusal splint was used for six
months nightly as would a conventional one made by a
dental technician. After 5 days, the splint was trimmed, since
signs of slight pressure on the upper right canine and pressure
between the upper and lower right premolars were noted. The
patient felt the splint to be tight after a couple of minutes from
the beginning of every usage, which is typical also with a con-
ventional splint. No other problems were detected, and the
patient adapted to the splint well and found it comfortable to
use. It also relieved his bite muscle tension. No sign of tooth
wear or significant splint wear was detected after the six-
month test period. The splint after a test period of six months
is shown in figure 5.
Figure 6 compares the splint, after six months of use, with
the three-dimensional model. The overall accuracy of the
described system can be estimated from those areas with no
wear of trimming. The maximum trim needed was approxi-
mately 1 mm. Wear can be estimated to be smaller than
0.2 mm. When comparing the physical model with the
three-dimensional design, dimensional errors of approxi-
mately 1 mm were found at thin walls and sharp corners.
The accuracy in other areas seems to be better than 0.3 mm.
4. Discussion
Oral appliances are frequently suggested as a treatment
option in the management of obstructive sleep apnoea,

Figure 4. The occlusal splint in use.
Figure 5. The occlusal splint after test period. (Online version in colour.)
wear areas
trimmed areas
Figure 6. The accuracy, wear and the trim needed can be assessed when comparing the used splint with the designed three-dimensional model.
TMD and for teeth protection in bruxism. The prevalence of
TMD in adult population ranges from 25 to 50 per cent [3].
Therefore, an increasing number of occlusal splints are cur-
rently manufactured for these purposes, using traditional
labour intensive process. This warranted us to design a
novel method to produce these appliances more rapidly
and with reduced costs. This study describes the process of
designing and manufacturing a novel occlusal splint and
also the first subjectively reported experiences of its use. As
in case of a conventional splint, the patient reported the pre-
sent occlusal splint being slightly tight when first put in place
but after a few minutes it felt comfortable. This may occur
due to absorption of oral fluid to the splint material or
because of simple teeth adjusting.
The aim of the present study was to describe the multi-
disciplinary process that is needed to develop and evaluate
4
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J R Soc Interface 10: 20130203
(mm) 0.917
0.600
0.300
trimmed areas 0
–0.300
–0.600
–0.900
–1.139
a novel digital process for manufacturing occlusal splints.
So far, the evidence of clinical applicability of this occlusal
splint is limited to a single patient, and testing in a patient
series is needed before considering commercial production.
However, production of a physical prototype and indivi-
dual testing usually lead to further developing phases of
the process and the product before further clinical experience
is obtained.
A commonly used and well-known CAD/CAM technol-
ogy for manufacturing of ceramic inlays in odontology is
Cerec (Siemens, Germany) [33]. It has been pointed out
that AM is the next revolution in dental device manufactur-
ing [34]. By using and developing this kind of technology,
there is a possibility to use milling to manufacture occlusal
splints from a solid block. Also, oral sleep apnoea appliances
could be partly or fully manufactured using digital
technology and AM technologies. Scanning or the software optimal. Also, mechanical properties could stand the forces 5
used could track occlusion and movement of jaws. Thereby, from teeth and jaws. The material was biocompatible with

movement of the device and interface to the teeth could be
more accurate.
Traditionally, an occlusal splint is hand-made in a dental
laboratory. Therefore, the costs are fairly high, and the lead
time is approximately one week before the patient is able
to use it. Modern digital technology, including three-
dimensional scanning and AM, opens up a possibility to
manufacture these splints more efficiently and to achieve
shorter lead times. Digital technology may also improve the
accuracy of the final occlusal splint. This improved accuracy
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low water absorption. Further, the accumulation of dental
plaque on various splint materials used in the AM process
should be investigated. We noted only minimal plaque
deposits on the tested splint after six months.
The fast development of AM processes and materials poten-
tially offers more and more direct applications in medicine.
Possibilities of AM have not been used sufficiently as this
requires multidisciplinary processes. In the future, new materials
and technologies offer the medical and dental professions
new treatment options, and therefore provide faster and more

J R Soc Interface 10: 20130203

and also the more advanced design may reduce the time
needed for the dentist to trim the splint. Our aim is to vali-
date the feasibility of the presented methodology in a case
series. Currently, another patient (the second one) has
reported his full satisfaction after four months use of an
occlusal splint made by this technology.
Three-dimensional design of occlusion splint is a quite
straightforward process: extruding or offsetting teeth surfaces
and then cutting the edges so that there is no contact to the gin-
givae but enough contact to the teeth. Every splint has different
geometry in terms of teeth contact, but other parts are similar.
Working with scanned data usually produces small ‘craters or
spikes’ when the surface is extruded. At the current stage,
modelling is done manually, but also semi- or fully-automated
modelling can be considered. Cases where some teeth are
missing may need more manual work.
The material used in the current study seemed suitable for
occlusal splint manufacturing. The consistency seemed rather
cost-efficient solutions to improve patient quality of life.
5. Conclusion
We provide proof-of-concept experiments to manufacture
clinically functional occlusal splints by using modern digital
technology without manual working phases in a dental
laboratory. In future, this might reduce costs, dental techni-
cian working time and chair-side time. Accuracy can also be
improved, since manual work phases are reduced. In this
experiment, splint fit was found as good as in the best conven-
tional splints and the accuracy of the method was excellent.
The authors would like to thank Tekes (the Finnish Funding Agency
for Technology and Innovation), Helsinki University Central Hospital
Research Funds, DeskArtes Oy, EOS Finland Oy, Vektor Claims
Administration and Planmeca Oy for financing the present research.
This study was part of the MedAMan research project.

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