Professional Documents
Culture Documents
Dominic P Laverty
Matthew BM Thomas, Paul Clark and Liam D Addy
Three-Dimensional (3D) printing is a process of each other to create a 3D object.2 with dentistry quick to embrace the use of this
of making a 3D object from a digital file. The The use of 3D printing is technology, particularly with regards to dental
3D object is created using an additive process expanding, with the entire 3D printing implant reconstructions.8
whereby successive layers of material are industry currently worth around $700 million, A number of published articles
placed until the object is created. These layers and is expected to grow to an estimated $8.9 have described the use of 3D printing in
are thin horizontal 2D cross-sections of the billion industry in the next 10 years.3 Even medicine to produce cell cultures, blood
eventual 3D object.1 NASA have used 3D printing to produce a fuel vessels and vascular networks,9 bandages,10
It was Charles Hull in the early injector and plan to have a 3D printer on board bones,11 ears,12 exoskeletons,13 windpipes14 and
1980s who invented 3D printing. He described their next space flight.4 corneas.15 The use of 3D printing is also being
the process of stereolithography or the This expansion in 3D printing is investigated in repairing or replacing defective
printing of successive layers of material on top also being experienced within the medical organs, such as kidneys, the heart and skin.5
field.5 The current 3D printing industry is worth In dentistry, 3D printing can
Dominic P Laverty, BDS(Hons), $11 million for medical applications but is produce metallic, polymer16 and ceramic-based
MFDS RCSEd, ACF/StR in Restorative projected to have exponential growth over the objects.1 It has been used to produce a variety
Dentistry, Birmingham Dental Hospital, next 10 years to $1.9 billion.6 of dental objects including stereolithographic
(dominiclaverty560@hotmail.co.uk), One of the advantages that 3D models, implant fixtures and components,
Matthew BM Thomas, BDS(Hons), MPhil, printing offers in its medical application removable prosthesis frameworks, fixed
MFDS RCS, MRD RCS, FDS(Rest Dent) RCS, is the ability to allow customization and prosthesis and maxillofacial structures (hard
Consultant in Restorative Dentistry, Cardiff personalization of medical products and and soft tissue).17-26
University Dental Hospital and Paul Clark, equipment, at relatively low costs (as the Denture frameworks have
Chief Dental Prosthetic Technologist, cost of the first item is the same as the last)5 traditionally been produced using the lost
Cardiff University Dental Hospital and Liam and produced relatively quickly.7 Hence, 3D wax technique and metal casting; however,
D Addy, BDS, MFDS, MPhil, FDS(Rest Dent), printing is ideal for making one of a kind items 3D printing methods are now available.
Consultant in Restorative Dentistry, Cardiff at cost-effective prices.5 These offer quicker and more cost-efficient
University School of Dentistry, Heath Park, 3D printing has been applied in production with reduced recasting. Removable
Cardiff, UK. medicine and dentistry since the early 2000s partial dentures are still a well-recognized
826 DentalUpdate November 2016
Prosthodontics
process is carried out within a controlled inert In both methods, layers are of jobs and the height of the jobs.
atmosphere35 (Figure 1). built on top of one another with the build DMLS can be used to create
The 3D object being created has platform being lowered each time to allow the crowns and bridges,18,20,22 crown copings
to be adequately supported during the DMLS application of the next layer of powder for metal ceramic crowns,18, 25,26 bridge
process and thus have supporting structures (Figure 2). frameworks, denture frameworks,21,23 implant
designed into the 3D object. These are Once complete, the excess abutments and implant fixtures.17,19,24 (Figures
produced during 3D printing. The supporting powder is removed and the metal framework 3 and 4).
structure ensures that the object is fixed in is carefully separated from the underlying There are a number of papers that
position to the underlying baseplate and baseplate. They then undergo a heat treatment have demonstrated the use of laser sintering in
ensures geometric accuracy, which is a vital process called annealing which advances the production of denture frameworks.6,21,23
part of the DMLS process. These supporting the material to its equilibrium state.37,38 This In comparing the use of DMLS to
structures will then need removing after the involves heating the framework above the conventional lost wax technique and CAD/
production process. critical temperate and then cooling.38-40 CAM milling in their use in producing metal
The DMLS process is performed by This annealing process produces a more dental prosthesis, it has been demonstrated
one of two methods, powder deposition or the homogeneous metallic structure,38,41 and that the marginal fit of prosthesis produced
powder bed method:33 affects the microstructure and hardness of the by DMLS is equal to, if not better than,
In the powder deposition method, the alloy.39,40 these other methods.36,42-44 It has also been
metal powder is sintered in a hopper then The framework is then finished shown that restorations fabricated using this
deposited in a thin layer onto the build which includes removal of the supporting method produced good surface properties,
platform; structures, sand blasting, polishing and such as proper hardness, homogeneous
In the powder bed method, a re-coater arm ultrasonic cleaning.34,35 microstructure, and also showed sufficient
distributes a thin layer of powder onto the The printing time varies and is corrosion resistance, and is appropriate for
powder bed and is then sintered. dependent on the 3D printer used, the number dental use.45
Figure 3. Variety of DMLS dental products produced by 3D Systems Leuven. (By kind permission from
3D Systems Leuven).
CAD software
There is a variety of RPD design
software packages which include, 3Shape,
Dental Wings, Exocad and Freeform plus.
These software packages vary in complexity.
The simpler software packages can be used
on a standard computer without the need for
any additional equipment. However, more
complex software packages may require the
use of specialist equipment such as the use
of a haptic arm which often requires further
Figure 4. Completed CoCr Framework using DMLS produced by Dentwise. (By kind permission from training and experience. These software
3D Systems Leuven.) packages create an stl file which is then used
to produce the framework. The majority
of 3D printers are capable of producing
a framework from an stl file, but it's best
printers available on the market that are evidence currently available would suggest to check with the manufacturer to ensure
capable of producing an RPD metal framework that the manufacturing technique, whether compatibility of the software and the printer.
which include; the AM250 laser melting that be conventional casting, laser sintering or
additive manufacturing machine (Renishaw milling using CoCr dental alloys, has adequate
plc) and the EOS INT M 270 (Electro-optical mechanical properties satisfying the ISO
Clinical and manufacturing
systems GmBH), 3D Systems Leuven use their standards of dental alloys.47
technique
own 3D printer. The following is an example
of a design and manufacturing technique
Digital impressions
Cobalt chromium composition that has been utilized at University Dental
Intra-oral digital impression Hospital in Cardiff.
Table 2 shows different dental scanners can be used to digitalize the process
CoCr alloys used for a variety of manufacturing fully. The main intra-oral digital impression
Impression taking and conventional casting of
techniques which include; conventional systems currently available on the market
casting, CAD/CAM milling (S&S Schefner, include CEREC, Lava COS system, iTero, E4D impressions
Starbond CoS) and DMLS techniques (EOS, and TRIOS. All these systems vary in their Conventional master impressions
Cobalt Chrome RPD and Renishaw, Co-Cr- key features, such as their working principle, are taken in an appropriately prescribed
DG1). The alloys all have similar composition, light source, the need for powder coating, the special tray with addition cure silicone-based
despite having different manufacturing clinical operative process, and the output le material. This is then conventionally cast
processes and all alloys are compliant with the format.51 up (using Crystacal R Plaster) creating the
standards of the International Organization The digital scanner uses a master model.
for Standardization (ISO), as stated by the triangulation process to collect the 3D
manufacturer.49 structures being scanned. To create this, a Digital scanning of models
The CoCr dental alloys used for source of light and the receptor unit are in a The master model is then
DMLS, however, have little scientific evidence specific angle to one another; this angulation scanned using the DS30 Optical Scanner
reporting on their characteristics.50 The allows the computer to produce a three- (Renishaw plc). The light optical scanner
November 2016 DentalUpdate 831
Prosthodontics
Denture design
The TouchTM X (Geomagic) Haptic
arm and Freeform plusTM software (Geomagic)
are used by the operator to design the
prosthesis.54
The software can be used to
survey the models, block out undercuts,
identify insertion paths and guide planes and
Figure 5. DS30 Optical Scanner and Freeform plusTM software.
to design the prosthesis, offering the same
capabilities as for a traditional prosthesis.54
The haptic arm is used to design
the prosthesis and can accurately measure the
3D spatial position and the orientation of the
handheld stylus. The device uses motors to
create forces that push back on the users hand
to simulate touch and interaction with virtual
objects54 (Figure 6).
Once the design is complete,
the stl file data is then sliced into sections
by MagicsAutoFab (Materialise NV) software.
The stl file is then sent directly to the
manufacturing machine to construct the CoCr
framework.35
With a digital design it can be
electronically sent to the practitioner and/or
patient for approval prior to production; the
data can also be saved and re-used/modified
at a later date if required as well (Figure 7).
Figure 6. Use of The TouchTM X (Geomagic) Haptic arm and Freeform plusTM software.
Element Bego Jelenco Dentsply Bredent EOS Cobalt S&S Schefner Renishaw
Wironium Plus Supra chrome prosthetics Brealloy F400 Chrome RPD Starbond CoS Co-Cr-DG1
Vitallium
Manufacture built up layer-by-layer. This process is carried 2. Hull C. Apparatus for Production of Three-
The CoCr framework is produced out within a controlled inert atmosphere35 Dimensional Object by Stereolithography. US
using the AM250 laser melting additive (Figure 8). Patent 4,575,330, 1986.
manufacturing machine (Renishaw plc). It The metal supporting structures 3. Wohlers Associates. What is 3D
uses a high-powered ytterbium fibre laser to are removed from the metal framework. printing? Wohlers Report 2013. www.
fuse the fine metallic powders together, in a These supporting structures ensure that wohlersassociates.com/3D-printing.html
vacuum environment.35 the framework is fixed in position to the 4. NASA to launch 3D printer into space to help
The process is carried out by underlying baseplate and ensure geometric supply astronauts. Theregister.co.uk, October
forming a thin layer of CoCr metal powder, 40 accuracy, which is a vital part of the DMLS 1, 2013.
microns thick and sintered using the ytterbium process. This is then removed after production, 5. Schubert C, van Langeveld MC, Donoso LA.
fibre laser with the denture framework being which is similar to the removal of the sprues Innovations in 3D printing: a 3D overview
used in conventional casting techniques of from optics to organs. Br J Ophthalmol 2014;
metal frameworks. 98: 159161.
Once the framework is complete it 6. Gao B, Wu J, Zhao X, Tan H. Fabricating
can be trimmed, smoothed and polished in the titanium denture base plate by laser rapid
conventional way. forming. Rapid Prototyp J 2009; 15: 133136.
The rest of the laboratory process 7. Banks J. Adding value in additive
in the production of the prosthesis is via manufacturing: researchers in the United
conventional methods (Figure 9). Kingdom and Europe look to 3D printing for
customization. IEEE Pulse 2013; 4: 2226.
8. Ventola LC. Medical applications for 3D
Conclusion
printing: current and projected uses. P T 2014;
The use of 3D printing is 39(10): 704711.
Figure 7. Denture design using Freeform plus
expanding and it is envisaged that it will 9. Miller JS, Stevens KR, Yang MT et al. Rapid
software. have an increasing presence within dentistry. casting of patterned vascular networks for
Dental practitioners therefore need to be perfusable engineered three-dimensional
aware of what this technology can offer them tissues. Nat Mater 2012; 11: 768774.
and their patients and how this technology is 10. Jeong JE, Chan V, Cha C et al. Living
developing. microvascular stamp for patterning of
The DMLS method has been functional neovessels; orchestrated control
shown to be successful in the production of of matrix property and geometry. Adv Mater
removable prosthesis metal frameworks and 2012; 24: 5863.
has a number of advantages over conventional
11. Leukers B, Gulkan H, Irsen SH et al.
methods of production. It is a relatively
Hydroxyapatite scaffold for bone tissue
new technique for producing metal RPD
engineering made by 3D printing. J Mater Sci
frameworks and is being introduced in clinical
Makter Med 2005; 16:11211124.
practice; however, research on its clinical utility
12. Mannoor MS, Jiang A, James T et al. 3D
compared to traditional methods is limited,
Printed bionic ears. Nano Lett 2013; 13:
Figure 8. CoCr Framework once 3D printing and the process involves expensive equipment
26342639.
complete. and processes to which dental practitioners
13. Haumont T, Rahman T, Sample W et al.
may not be accustomed. It is recommended
Wilmington robotic exoskeleton: a novel
that long-term clinical trials be carried out to
device to maintain arm improvement in
provide evidence to support this technique
muscular disease. J Pediatr Orthop 2011; 31:
further.
e4449.
14. Zopf DA, Hollister SJ, Nelson ME et al.
Acknowledgments Bioresorbable airway splint created with a
We would like to thank Cardiff three-dimensional printer. N Engl J Med 2013;
Dental Hospital Dental Laboratory and Clinical 368: 20432045.
Photography and Illustration Departments, 15. Gross BC, Erkal JL, Lockwood SY, Chen C,
Mr Ed Littlewood from Renishaw Plc and Mr Spence DM. Evaluation of 3D printing and
Pieterjan Ghekiere 3D Systems Leuven for their its potential impact on biotechnology and
assistance with this article and provision of the chemical sciences. Anal Chem 2014; 86:
images used. 32403253.
16. Mueller AA, Paysan P, Schumacher R et
References al. Missing facial parts computed by a
Figure 9. CoCr Framework after polishing and
1. van Noort R. The future of dental devices is morphable model and transferred directly
trimming.
digital. Dent Mater 2012; 28: 312. to a polyamide laser-sintered prosthesis: an