RESEARCH AND EDUCATION

Effect of print orientation, storage conditions, and storage time

on intaglio surface accuracy of implant surgical guides fabricated
by using a stereolithography technology
Alma L. Salazar Rios, DDS, MS,a Matthew J. Kesterke, PhD, MA,b George D. Pylant, III DDS,c
Abdul B. Barmak, MD, MSc, EdD,d Elias D. Kontogiorgos, DSD, PhD,e and
Marta Revilla-León, DDS, MSD, PhDf,g,h

ABSTRACT
Statement of problem. The accuracy of printed implant surgical guides can be affected by different factors that negatively impact the
planned implant position. How print orientation, storage time, and conditions influence manufacturing accuracy remains uncertain.
Purpose. The purpose of this in vitro study was to evaluate the influence of print orientation, storage conditions, and storage time on the
intaglio surface accuracy of implant surgical guides manufactured by using a stereolithography (SLA) printer.
Material and methods. A tooth-supported maxillary implant surgical guide design (control file) was used to fabricate the specimens
(N=40, n=10). Four groups were created based on the print orientation used: 0 (Group 0), 45 (Group 45), 70 (Group 70), and 90 degrees
(Group 90). The specimens were fabricated using an SLA printer (Form 3B+) and a biocompatible dental resin (Surgical Guide Resin V1)
following the manufacturer’s recommended protocol. Each group was divided into 2 subgroups based on the storage conditions: light
(L subgroup) and dark (D subgroup) settings. Each specimen was digitized by using a desktop scanner (Medit T710) at days 0, 1, 7, and 14.
The control file and each digitized specimen were superimposed by using the best-fit technique with a metrology program (Geomagic
Control X). The root mean square (RMS) error was used to calculate the discrepancies between the control files and specimen files.
Three-way ANOVA and pairwise comparison Tukey tests were used to analyze trueness. The Levene test was used to assess
precision (α=.05).
Results. Significant trueness discrepancies were found among the groups tested (P<.001), but no significant differences were found among
the subgroups (P=.100) and the storage times analyzed (P=.609). Additionally, the Tukey test showed significant RMS error mean value
discrepancies between Group 0 and Group 45 (P<.001), Group 0 and Group 90 (P<.001), Group 45 and Group 70 (P<.001), and Group 70 and
Group 90 (P<.001). The Levene test revealed significant SD discrepancies among the groups tested (P<.05).
Conclusions. The trueness and precision of the intaglio surface of the implant surgical guides manufactured by using the printer and
material tested were affected by the print orientation. However, storage conditions over a 14-day period did not impact the intaglio
accuracy of the specimens. (J Prosthet Dent xxxx;xxx:xxx-xxx)

Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
a
Graduate student, Graduate Program in Prosthodontics, Comprehensive Dentistry Department, School of Dentistry, Texas A&M University, Dallas, Texas.
b
Assistant Professor, Department of Orthodontics, School of Dentistry, Texas A&M University, Dallas, Texas.
c
Adjunct Professor, Department of Periodontics, School of Dentistry, Texas A&M University, Dallas, Texas.
d
Associate Professor, Clinical Research and Biostatistics, Eastman Institute of Oral Health, University of Rochester Medical Center, Rochester, NY.
e
Clinical Professor and Director, Graduate Program in Prosthodontics, Comprehensive Dentistry Department, School of Dentistry, Texas A&M University, Dallas, Texas.
f
Affiliate Assistant Professor, Graduate Prosthodontics, Department of Restorative Dentistry, School of Dentistry, University of Washington, Seattle, Wash.
g
Faculty and Director of Research and Digital Dentistry, Kois Center, Seattle, Wash.
h
Adjunct Professor, Department of Prosthodontics, School of Dental Medicine, Tufts University, Boston, Mass.

THE JOURNAL OF PROSTHETIC DENTISTRY 1

2 Volume xxx Issue xx

printer (Form 3B+; Formlabs). The null hypotheses were

Clinical Implications that the print orientation, storage conditions, and sto­
The implant surgical guides fabricated by using the rage time tested would not have a significant effect on
printer, material, and printing strategy tested can the intaglio accuracy (trueness and precision) of the
implant surgical guides fabricated by using the SLA and
be stored in a light or dark dry condition for up to
14 days without impacting the accuracy of the biocompatible material tested.
intaglio surface. Additionally, a 0-degree print
orientation is recommended to maximize the
intaglio accuracy of the surgical implant guides MATERIAL AND METHODS
manufactured by using the printer and material A maxillary implant surgical guide with a standard de­
analyzed. sign that included the planning of a single anterior im­
plant was obtained in a standard tessellation language
Prosthetically driven computer-aided surgical implant (STL) file format (control STL file). The tooth-supported
planning techniques aim to improve the accuracy of implant surgical guide design extended from the right
implant placement1–3 and minimize risks associated first molar to the left first molar had rounded internal
with damaging vital anatomic structures such as nerves angles18 and a minimum thickness of 2 mm. A posterior
and vessels.4,5 Additionally, tooth position is used to transversal bar was added from the lingual surface of the
guide the implant placement to obtain a more favorable right first molar to the lingual surface of the left first
implant position in relation to the definitive prothesis, molar (Fig. 1).
ease prosthetic designs and esthetic results, and mini­ The control STL file was used to manufacture all the
mize biological and mechanical complications.6–10 specimens by using an SLA printer (Form 3B+; Formlabs
Stereolithography (SLA) additive manufacturing Inc) and a biocompatible dental resin material (Surgical
(AM) technology can be used for the fabrication of dif­ Guide Resin V1; Formlabs Inc). The printer was calibrated
ferent dental devices, including implant surgical following the protocol endorsed by the manufacturer
guides.11–16 Various factors that can influence the ac­
curacy of dental devices fabricated by using SLA tech­
niques such as printer and material used,17–19 printing
parameters selected17 including print orientation20,21 or
layer thickness22,23 and postprocessing procedures per­
formed have been identified.17,21,24–26 The optimization
of the printing strategy should be based on the tech­
nology, printer, material selected, and the clinical ap­
plication of the dental device.17
The influence of print orientation and storage time on
the manufacturing accuracy of SLA implant surgical
guides has been identified,27–29 but with contradictory
results regarding the optimal print orientation for max­ A
imizing the accuracy of vat-polymerized implant surgical
guides. The different findings may be explained by the
different printers, materials, and printing strategies tested.
Additionally, volumetric changes in SLA implant surgical
guides after 36 hours of dry storage conditions have been
reported based on an in vitro study.30 Therefore, the
optimal print orientation based on the technology,
printer, and material selection and the volumetric dis­
tortion of the SLA implant surgical guides under different
storage conditions and times remain uncertain.
The purpose of the present in vitro study was to
measure the effect of print orientation (0, 45, 70, and 90
degrees), storage conditions (light and dark container),
and storage time (0, 1, 7, and 14 days) on the manu­ B
facturing accuracy (trueness and precision) of the in­
taglio surface of implant surgical guides (Surgical Guide Figure 1. Implant surgical guide design. A, Intaglio surface. B, External
Resin V1; Formlabs) manufactured by using a SLA surface.

THE JOURNAL OF PROSTHETIC DENTISTRY Salazar Rios et al

Month xxxx 3

A B

C D
Figure 2. Representative print orientation tested. A, Group 0. B, Group 45. C, Group 70. D, Group 90.

before manufacturing any specimens for the study. All
the specimens were printed by a single operator (A.S.).
The control STL file was imported into the printer soft­
ware program (PreForm; Formlabs Inc). Four groups were
created based on the print orientation used: 0 (Group 0),
45 (Group 45), 70 (Group 70), and 90 (Group 90) (Fig. 2).
The manufacturer recommends a 0-degree print or­
ientation; therefore, Group 0 was considered the control
group. Except for print orientation, all the remaining
printing parameters were identical for the different
groups tested. A layer thickness of 100 µm was selected,
following the manufacturer’s recommendations. Five
specimens of each group were printed at the same time,
limited by the build platform size. The support material
was automatically generated by the printer software
program.
After printing, the specimens were postprocessed
following the manufacture’s protocol. The specimens
were removed from the build platform by using a re­
moval tool and submerged in a bath (Form Wash;
Formlabs Inc) of clean 99% isopropyl alcohol (IPA)
(Isopropyl alcohol 99%; Cumberland Swan) for 20
minutes, dried with compressed air, ensuring the ab­
sence of particles or unpolymerized resin. The
specimens were placed on a dry clean paper towel and
allowed to dry at a constant ambient temperature of
24 °C for 30 minutes and then placed in an ultraviolet
(UV) polymerization unit (Form Cure; Formlabs Inc) for
30 minutes at 70 °C. The polymerization machine was
allowed to cool to 24 °C between polymerization cycles.
No polishing or additional postprocessing procedures
were done (Fig. 3).
Each group was divided into 2 subgroups based
on the storage conditions: light (L subgroup) or dark
(D subgroup). For the L subgroup, the specimens were
stored inside a clear plastic container maintained in a
room with windows, without direct sunlight, at a
constant temperature of 24 °C. For the D subgroup, the
specimens were stored inside light-proof containers
inside a closet located in the same room as the L
subgroup.
The volumetric discrepancies among the specimens
from each subgroup were tested 0, 1, 7, and 14 days after
printing. At each measurement time evaluated, in­
dividual specimens were digitized by using a desktop
scanner (T710; Medit) following the scanning protocol
recommended by the manufacturer and replaced in their
storage location. The laboratory scanner was calibrated

Salazar Rios et al THE JOURNAL OF PROSTHETIC DENTISTRY

4 Volume xxx Issue xx
Figure 3. Representative specimen of each group tested.
before use and after every 10 scans. Before digitizing
each specimen at day 0, the intaglio surface of every
implant surgical guide was coated with scanning spray
(Renfer Scanspray; Renfert Corp) by applying as a thin
and uniform layer as possible at a distance of 1.5 to 2 cm.
The scanning spray coat was only applied at the 0-day
measurement. The manufacturer of the desktop scanner
selected reports a scanning accuracy of 4 µm. The files of
the digitized implant surgical guides were exported into
an STL file format.
The control and experimental STL files were im­
ported into a reverse engineering software program
(Geomagic Control X; 3D Systems). The volumetric
discrepancies between the control and experimental files
were assessed only on the intaglio surface of the speci­
mens, as the other surfaces of the specimens had sup­
port material. The control and experimental files were
defined and aligned using the best fit technique.31 The
control file was segmented, and the intaglio surface was
isolated and identified as the selected area for analysis.
The root mean square (RMS) error calculation was
computed in the intaglio surface area using the fol­
lowing formula:
n
i = 1 (X1, i X2, i )2
RMS = , where X1,i is the reference
n
data, X2,i is the scanned data and n indicates the total
number of measurement points measured at each ana­
lysis (Fig. 4). The discrepancy calculations for each group
were used to analyze the data. Trueness was defined as
the average RMS error discrepancies between the re­
ference file and experimental scans, while precision was
described as the RMS error variations per group or
standard deviation (SD).32,33
THE JOURNAL OF PROSTHETIC DENTISTRY
The Kolmogorov-Smirnov test indicated that the
data were normally distributed (P>.05). A three-way
ANOVA followed by the pairwise comparison Tukey
tests were used to analyze trueness (α=.05). The
Levene test was used to assess precision (α=.05). A
statistical program (IBM SPSS Statistics for Windows,
v28; IBM Corp) was used to perform the statistical
analysis.
RESULTS
The mean ±standard deviation of the RMS error mea­
surement discrepancies among the subgroups tested are
presented in Table 1. Regarding trueness, the 3-way
ANOVA analysis of variance revealed significant RMS
error mean value discrepancies among the groups tested
(df=3, MS=0.00740, F=33.422, P<.001), but no significant
differences were found among the subgroups (df=1,
MS=6.09e-4, F=2.750, P=.100) and storage times as­
sessed (df=3, MS=1.35e-4, F=0.611, P=.609) (Fig. 5A).
Additionally, the Tukey test showed significant RMS
error mean value discrepancies between Group 0 and
Group 45 (P<.001), Group 0 and Group 90 (P<.001),
Group 45 and Group 70 (P<.001), and Group 70 and
Group 90 (P<.001). The 0-degree print orientation de­
monstrated the highest manufacturing trueness among
the print orientations tested.
Regarding precision, the Levene test revealed sig­
nificant standard deviation discrepancies among the
groups tested (Fig. 5B). The Group 90 had the lowest
precision mean values among the groups evaluated.
Salazar Rios et al
Month xxxx 5

0.0500 .0500

0.04 0.04

0.03 0.03

0.02 0.02

0.01 0.01

0.0000 .0000

–0.01 –0.01

–0.02 –0.02

–0.03 –0.03

–0.04 –0.04

–0.0500 –.0500

A B

0.0500 0.0500

0.04 0.04

0.03 0.03

0.02 0.02

0.01 0.01

0.0000 0.0000

–0.01 –0.01

–0.02 –0.02

–0.03 –0.03

–0.04 –0.04

–0.0500 –0.0500

C D
Figure 4. Representative color map discrepancy for each group tested. Max. range: 50 µm, Min. range: −50 µm. Tolerance: ±10 µm. A, Group 0. B,
Group 45. C, Group 70. D, Group 90.

DISCUSSION orientation. In the present study, a different manu­

The results of the present in vitro study demonstrated
that print orientation affected the trueness and precision
of the intaglio surface of AM implant surgical guides
fabricated using the SLA, material, and printing strategy
tested. The 0-degree print orientation showed the best
manufacturing accuracy values on the intaglio surface
among the print orientations assessed. However, the
storage conditions and storage times analyzed did not
significantly affect the manufacturing accuracy of the
intaglio surface of the surgical implant guides. Therefore,
the null hypothesis was partially rejected.
Reports on the influence of print orientation on the
manufacturing accuracy of AM implant surgical guides
are sparse.27–29 Tahir et al27 evaluated the influence of 3
different print orientations (0, 45, and 90 degrees) on the
accuracy of tooth-supported surgical implant guides
manufactured from a resin (SP-RH1001, SprintRay Inc)
with a digital light processing (DLP) printer (MoonRay
S; SprintRay Inc) and a 20-µm layer thickness. The
surgical implant guide extended over 6 teeth, involved a
single implant, and showed the highest manufacturing
accuracy on the intaglio surface, with a 0-degree print
facturing trinomial was tested. Therefore, comparisons
between studies were not feasible.
Rubayo et al28 analyzed the effects of print orientation
(0, 30, 45, 60, and 90 degrees) on the manufacturing ac­
curacy of surgical implant guides manufactured with a
resin (Dental SG Resin; Formlabs Inc) and an SLA printer
(Form 2; Formlabs Inc). The layer thickness used was not
described, and the extension of the surgical implant guide
involved a complete arch and 4 implants. The 0-degree
and 45-degree print orientations were reported to produce
the most accurate surgical implant guides. In the present
study, the same technology, printer, and material were
tested. Although the designs of the surgical implant guides
tested were different, similar results were found. Both
studies recommend the 0-degree print orientation to
maximize the intaglio accuracy of the surgical implant
guides manufactured by using the trinomial tested.
Dalal et al29 compared the intaglio accuracy of resin
printed (Form 2; Formlabs Inc) surgical implant guides
(Dental SG Resin; Formlabs Inc) manufactured using 3
different print orientations (0, 45, and 90 degrees) and 2
layer thicknesses (50 and 100 µm). The specimens
manufactured at a 50-μm layer thickness presented

Salazar Rios et al THE JOURNAL OF PROSTHETIC DENTISTRY

6 Volume xxx Issue xx

Table 1. Trueness and precision values measured for print orientation, was tested (Form 3B+; Formlabs Inc). Different printer
storage conditions, and storage conditions tested parameters may be used for both printers, which may
Group Subgroup Storage Mean ±SD RMS explain the discrepancies in the results found between
Time Error Trueness
±Precision (µm) the studies.
0 degrees D Day 0 68 ±9 The authors are aware of only 1 study30 that as­
L 69 ±14 sessed the influence of storage time (0 day and 1
D Day 3 67 ±12
L 70 ±16 month) on the manufacturing accuracy of tooth-sup­
D Day 7 67 ±13 ported surgical implant guides manufactured with an
L 69 ±15
D Day 14 66 ±11 SLA polymer printer (Form 2; Formlabs Inc), a polyjet
L 69 ±13 printer (Objet Eden260VS; Stratasys Ltd), and a metal
45 degrees D Day 0 91 ±14
L 105 ±11 printer (ProX DMP 200; 3D Systems Inc). The extension
D Day 3 89 ±11 of the surgical implant guide involved a complete arch
L 97 ±20
D Day 7 90 ±11 and 4 implants. The printing strategy, including
L 101 ±20 printing parameters or postprocessing methods, was
D Day 14 88 ±11
L 97 ±20 not provided. The highest manufacturing accuracy was
70 degrees D Day 0 71 ±7 reported for the surgical implant guides fabricated by
L 70 ±1
D Day 3 71 ±8 using the polyjet printer, and specimens stored for 1
L 73 ±4 month had lower manufacturing intaglio accuracy than
D Day 7 71 ±7
L 71 ±4 specimens at day 0. In the present study, the storage
D Day 14 124 ±116 time tested was no more than 14 days; therefore,
L 72 ±4
90 degrees D Day 0 83 ±6 whether volumetric changes would appear after 1
L 101 ±7 month of storage is unclear.
D Day 3 75 ±4
L 89 ±9 The stereolithography printing process places one
D Day 7 125 ±50 layer at a time, and overhangs arise when a steep slope
L 83 ±8
D Day 14 98 ±31 is formed because of printing angulation. As subsequent
L 121 ±54 layers are placed, they may extend slightly past the
D, dark; L, light; RMS, root mean square; SD, standard deviation previous layer, and gravity could distort the overhang
and affect the accuracy of the print. In addition, factors
lower dimensional discrepancy compared with those such as the size, shape, and weight of the object should
fabricated at 100-µm layer thickness, and the 45-degree be considered. Smaller objects have a reduced cross-
print orientation had the best manufacturing accuracy of sectional area. The smaller size reduces the force re­
the intaglio surface for both 50- and 100-μm layer quired to peel away from the resin tank, and has a less
thicknesses. In the present study, the same technology negative effect on the accuracy of the printed object. In
and material were used to fabricate the specimens at a addition, the shape of the model is important when
100-µm layer thickness. However, a more recent printer determining the printing orientation of the object

Test for Equal Variances: RMS error vs Group, Subgroup, Conditions

Multiple comparison intervals for SD, (α=.05)
Storage
Group Subgroup conditions
0-degrees Day 0 D
L
Day 3 D
L Multiple comparisons
Day 7 D
P-value <.001
Boxplot of RMS error Day 14
L
D
L
Levene test
45-degrees Day 0 D
L P-value .020
Day 3 D
175 Day 7
L
D
L
Day 14 D
150 L
70-degrees Day 0 D
RMS error (μm)

L
Day 3 D
125 L
Day 7 D
L
Day 14 D
100 L
90-degrees Day 0 D
L
Day 3 D
75 L
Day 7 D
L
Day 14 D
50 L

Storage conditions DL DL DL DL DL DL DL DL DL DL DL DL DL DL DL DL 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9
Subgroup Day Day Day Day Day Day Day Day Day Day Day Day Day Day Day Day If intervals do not overlap,
0 3 7 14 0 3 7 14 0 3 7 14 0 3 7 14 corresponding SDs significantly different.
Group 0-degrees 45-degrees 70-degrees 90-degrees
A B
Figure 5. A, Boxplot of RMS error values measured among subgroups tested. D, dark; L, light; RMS, root mean square. B, Test for equal variances.
RMS, root mean square.

THE JOURNAL OF PROSTHETIC DENTISTRY Salazar Rios et al

Month xxxx
because, as the complexity and intricacies of the part
increase, the accuracy could be negatively impacted.
Furthermore, as the weight of a printed object increases,
so does the effect of gravity and its impact on the ac­
curacy of the final product. Finally, the ideal placement
of the supporting structures is essential to preserving the
integrity of the object. The position, quantity, size, and
thickness of these supports can play a role in the accu­
racy of the final structure, and the print orientation has a
direct effect on these factors.
In the present study, the dark and light storage
conditions, up to 14 days, resulted in statistically similar
specimen accuracy. Protocols to enhance the printing
accuracy and mechanical properties of printed dental
devices, including surgical implant guides, are still in
development.17 In the present study, the recommended
fabrication protocol (printing parameters and post­
processing methods) provided by the printer and ma­
terial manufacturer was strictly followed to minimize
manufacturing discrepancies.17 For the present study,
the printing software program automatically generated
the placement of the support structures, and this could
be a limiting factor when evaluating the accuracy of the
printing orientation. Additionally, the rinsing and
polymerization units used were from the same manu­
facturer.17
Limitations of the present study included the single
manufacturing trinomial (technology, printer, and ma­
terial) and printing strategy tested, the restricted surgical
implant guide design analyzed, the limited period of
time considered, and the use of scanning powder,
needed because of the translucent and reflective char­
acteristics of the specimens. Additionally, the accuracy of
the implant positions placed using the different surgical
implant guides was not analyzed. Futures studies should
be designed to evaluate the influence of the varying
manufacturing trinomials, printing parameters, printing
strategies, postprocessing methods, surgical implant
guide designs, and materials on optimize the manu­
facturing and mechanical properties of AM surgical
implant guides.
CONCLUSIONS
Based on the findings of this in vitro study, the following
conclusions were drawn:
1. Print orientation influenced the manufacturing
trueness and precision of the intaglio surface of surgical
implant guides manufactured by using the SLA printer,
material, and printing strategy tested. However, the
storage conditions (dark and light containers) and sto­
rage time up to 14 days did not significantly impact the
manufacturing accuracy values of the surgical implant
guides assessed.
Salazar Rios et al
7
2. The 0-degree print orientation demonstrated the
highest manufacturing trueness among the print or­
ientations tested. The 90-degree print orientation ob­
tained the lowest manufacturing precision among the
print orientations assessed.
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Corresponding author:
Dr Marta Revilla-León
Department of Restorative Dentistry
School of Dentistry
University of Washington
Kois Center, 1001 Fairview Avenue
North, # 2200
Seattle, WA 98109
Email: marta.revilla.leon@gmail.com.
Copyright © 2023 by the Editorial Council of The Journal of Prosthetic Dentistry.
All rights reserved.
https://doi.org/10.1016/j.prosdent.2023.08.016
Salazar Rios et al