Additive Manufacturing 22 (2018) 243–255

Contents lists available at ScienceDirect

Additive Manufacturing
journal homepage: www.elsevier.com/locate/addma

Full Length Article

Accuracy in dental surgical guide fabrication using different 3-D printing T

techniques
⁎
Mamta Junejaa, Niharika Thakura, Dinesh Kumara, , Ankur Guptab, Babandeep Bajwac,
Prashant Jindala
a
University Institute of Engineering & Technology, Panjab University, Chandigarh, India
b
Total Dental Care Clinic, New Delhi, India
c
Unicorn Denmart Ltd., New Delhi, India

A R T I C LE I N FO A B S T R A C T

Keywords: Accuracy in dental prosthesis plays a significant role. Surgical guides are widely used for accurate positioning of
Implant dental implants. Designing of guides using modern software is useful in achieving precision; however, translation
CAD of these images into actual fabricated parts can be achieved using Three-dimensional (3-D) printing.
CAM Conventionally, guides were fabricated using vacuum forming technique which leads to several dimensional
Rapid prototyping
inaccuracies. Computed Tomography (CT) images of patients with missing teeth are modeled to design surgical
CT
guide using Computer Aided Design (CAD) / Computer Aided Manufacturing (CAM) software which is then
combined with surface scan files in Standard Tessellation Language (STL) formats to design the guide. In this
work, surgical guides have been 3-D printed using different technologies like Material Jetting technology (MJT),
Vat photopolymerization (VP) and Material extrusion (ME). Depth, diameter, Area and Volume of the printed
guides have been calculated using vernier caliper and scan measurements. These dimensions have then been
compared with the dimensions obtained from software modeled images. Least error has been found for the
guides fabricated using MJT. The experimental work in this paper, hence, suggests MJT be the most preferred
printing technique due to its superior accuracy for printing dental prosthesis like aligners, implants, and crowns,
etc.

1. Introduction pressing gave a slightly better marginal fit for the slip-cast than for the
heat-pressed copings [3]. Daniel et al. 2005 evaluated the concept in-
The field of dentistry includes the replacement of missing teeth and cluding a treatment planning procedure based on CT scanned images
their supporting structures with artificial prosthesis anchored into the and prefabricated fixed prosthetic reconstruction for immediate func-
jawbone. Here the artificial root that replaces the natural root of the tion of upper jaw using flapless surgical technique. They found that
tooth is known as a dental implant. Implants are metal posts or frames each prosthesis was functional in this case [4]. The 3-dimensional
surgically positioned into the jawbone beneath the gums. Some of the model of surgical guide allows the surgeon to visualize the site of sur-
research studies in this field are as follows: gical bone prior to implant placement and improve the placement of
Eufinger et al. 1995 reviewed the CAD/CAM techniques for pre- implant. The inputs required for this procedure were in the form of CT
operative modeling of the implant based on CT data. It was concluded and STL files for both upper and lower jaws [5]. Balshi et al. 2006
that the reconstruction of craniofacial bone defects with individual described a procedure using medical imaging and computer technology
implants based on CAD/CAM manipulated CT data proved to be su- to virtually place dental implants and construct surgical template for
perior to conventional methods of cranioplasty [1]. Hence, the desire to connection of implant. In this case, identification of the bone anatomy
perform low risk and accurate surgery led to the discovery of computer- in relation to the teeth before surgery allowed the surgeon to place
aided surgical planning [2]. Bindl et al. 2005 evaluated the internal and implants in areas where the implant-bone interface could be maximized
marginal fit of molars and found that CAD/CAM techniques show the [6]. Also, Nascimentor et al. 2008 gave a capacity analysis of Selective
same accuracy as conventional techniques. They analysed that the Laser Sintering (SLS) and three-dimensional printing (3-DT™) models to
conventional fabrication techniques such as slip-casting and heat- for reproduction of craniomaxillary anatomy with a dimensional error.

⁎
Corresponding author.
E-mail addresses: [email protected] (M. Juneja), [email protected] (N. Thakur), [email protected] (D. Kumar),
[email protected] (A. Gupta), [email protected] (B. Bajwa), [email protected] (P. Jindal).

https://doi.org/10.1016/j.addma.2018.05.012
Received 18 September 2017; Received in revised form 4 May 2018; Accepted 7 May 2018
2214-8604/ © 2018 Published by Elsevier B.V.
M. Juneja et al. Additive Manufacturing 22 (2018) 243–255

They used Invesalius software to segment CT images using thresholding

and converted them to STL format. Thereafter these STL files were
converted to 3-DP™ and SLS using rapid prototyping. Finally, linear
measurements were made using electronic caliper and data was ana-
lysed for performance using descriptive statistics to compare the sam-
ples using statistical t-test. Analysis showed that 3-DP™ model had a
lower final costing than SLS model. However, SLA printed model was
found to be most expensive. But prototypes of SLS have higher precision
in dimensions and accuracy of reproduction than 3-DP™ prototypes [7].
Similarly, Ibrahim et al. 2009 presented an analysis study of capacities
of SLS, 3-DP™ and PolyJet™ models to reproduce the anatomy of the
mandible and find their dimensional errors. They started with the ac-
quisition of CT images from a dry mandible and performed manipula-
tions on it using Invesalius software and converted them to STL format.
These files were then converted into SLS, 3-DP™ and PolyJet™ printed
models. Here also analysis showed that SLS prototype had the most
exceptional dimensional accuracy amongst the three prototypes. But
cost analysis showed that 3-DP™ technique had the lowest final cost [8].
In this field, the fabrication of the surgical guide templates is based on
CAD/CAM technology which solves three major challenges of restora-
tion, appearance, and accuracy [9]. Thereafter, Figliuzzi et al. 2012
gave a procedure for fabrication of implants using direct laser metal
forming. MIMICS was used as a 3-D reconstruction software to con-
struct a 3-D projection of the roots and MAGICS was used to prepare the
STL files to design the implant [10].
Further, Margreet et al. 2012 presented a study for validation and
reproducibility for dental models using intraoral scanners. They in-
itially scanned the dentition using chair side oral scanner. These
scanned files were then corrected for missing data by computer pro- Fig. 1. Procedure for developing a surgical guide and preplanning the implant
surgery.
grams and were converted into digital models by using software such as
Orthoproof. Finally, the files were converted to 3-D printed models
using the 3-D printer with 3 M ESPE algorithm. The measurements of extraction and modeling of tooth/teeth from x-ray and CT images. The
dentition and stereolithographic models were performed using a digital paper concludes with challenges and approaches to deal with these
caliper and that of the digital models were performed using the challenges [15]. In case of dental prosthesis, 3-D printing techniques
Digimodel software. Measures used for the analysis were widths of are beneficial for designing of dental prosthesis like aligners, implants,
teeth, transversal distances, skull segments, dimensions of stereolitho- crowns, etc. These designs are based on printing techniques such as
graphic and digital models. According to the analysis, differences were Stereolithography (SLA), SLS, Fused Deposition Modelling (FDM) and
clinically insignificant. The standard values used for analysis were the PolyJet. SLA prints 2D layers of the photoreactive resin material in
mean measurements of the skulls with cut offs for segments of 0.2 mm, successive layers by using ultraviolet light. In SLS printing laser melts
widths of mesiodistal of 0.1 mm, arch discrepancies and transversal the bed of powder to apply and get the shape of the 3-D model. In FDM
distances of 1.0 mm and discrepancies in tooth size of 1.5 mm [11]. printers, a polymer wire filament deposits on the predefined locations
Later, Hazeveld et al. 2013 developed a rapid prototyping approach according to the shape of the model [11]. On the other hand, PolyJet
with its significance to create replicas of plaster models. In this study system works by addition of photopolymer resin layers which builds
authors initially scanned the plaster models to form 3-D Surface models detailed models with smooth surfaces [16].
in STL format using dual sensor laser scanner. They then transformed In the proposed work, both CT scan and surface scan are used due to
these STL files to physical models using 3-D rapid prototyping methods better accuracy than the conventional designing technique which uses
such as a jetted photopolymer, digital light processing, and 3-D only CT scans. MJT and VP printing techniques are used to print the
printing. Height and width measurements of these models were carried models of materials Durus White and Grey Resin respectively. Durus
out by using a digital caliper. On analyzing the performance of the white is a material similar to polypropylene which offers a variety of
proposed approach mean difference for measurements of clinical features like flexibility, strength, and appearance. Whereas, the surgical
crowns were recorded as 0.04 mm for the digital light processing guide made of Grey resin uses a laser to polymerize photosensitive
models, -0.02 mm for jetted photopolymer models and 0.25 mm for the resin, producing higher-resolution printed objects with complex geo-
3-D printing models. Similarly, for the width of teeth, systematic mean metry [17]. Also, Poly Lactic Acid (PLA), Acrylonitrile butadiene
differences were -0.05 mm for digital light processing model, -0.08 mm styrene (ABS) and Polyethylene Terephthalate Glycol (PETG) are
for jetted photopolymer models and -0.05 mm for the 3-D printed printed using ME which begins with a software process which processes
models. But this study lacks its performance in some cases due to dis- an STL file by mathematically slicing and orienting the model for the
tortions in STL files after conversion and manipulation [12]. build process. ME uses a small temperature-controlled extruder to force
Also, Parthasarathy, 2014 reviewed the recent trends of custom out a thermoplastic filament material and deposit the semi-molten
implants and 3-D modeling in craniofacial reconstruction. This was polymer onto a platform through a layer by layer process. The designed
concluded that custom implants for the reconstruction of craniofacial object is fabricated as a three-dimensional part based on the precise
defects gained importance due to better performance [13]. To analyze deposition of thin layers of the extrudate [18].
existing approaches Marro et al. 2016 reviewed innovations on the PLA is a linear aliphatic biodegradable polyester, produced by ring
application of 3-D printed objects using medical imaging data. It was opening of lactic acid monomers and lactides using fermentation of
concluded that 3-D printing combined with medical imaging could be sugar feeds, corn starch or cassava roots. This is commonly used in
successfully used to create anatomical models to assist surgeries [14]. biomedical applications due to its remarkable mechanical properties
Recently, Thakur et al. 2017 presented a review of approaches used for such as tensile strength, surface quality and creation of high-resolution

244
M. Juneja et al. Additive Manufacturing 22 (2018) 243–255

Fig. 2. Planning an implant surgery.

Fig. 3. Printed surgical guides.

Fig. 4. Measurements of surgical guides.

parts. PLA also exists in distinct forms due to its chiral nature and can to different chemicals. It is a terpolymer in which rubbery poly-
be converted into fibers and films like other thermoplastics [19]. butadiene particles are dispersed in the styrene-acrylonitrile matrix.
ABS is a commonly used thermoplastic due to its toughness, the ABS has a wide range of applications which include building and con-
impact of resistance, the stability of dimensions and chemical resistance struction of materials, electronic devices, medical devices and many

245
 M. Juneja et al.

Table 1
Dimensions of surgical guides (Implant region) printed through different material with their absolute error (AE) for depth and diameter.

Dimensions Software Vernier Measurements Scan Measurements

produced
image
Durus White AE Grey AE PLA AE PETG AE ABS AE Durus AE Grey AE PLA AE PETG AE ABS AE
(MJT) Resin (ME) (ME) (ME) White Resin (ME) (ME) (ME)
(VP) (MJT) (VP)

Patient Depth (mm) 5.31 5.74 0.43 5.9 0.59 4.2 −1.11 6.5 1.19 4.7 −0.61 5.12 −0.19 4.95 −0.36 4.04 −1.27 5.87 0.56 3.40 −1.91
1 Diameter 3.02 3.09 0.07 2.73 −0.29 2.5 −0.52 2.46 −0.56 1.87 −1.15 3.04 0.02 2.94 −0.08 2.95 −0.07 3.89 0.87 2.30 −0.63
(mm)
Patient Depth 7.12 7.58 0.46 7.97 0.85 5.75 −1.37 8.61 1.49 6.49 −0.63 6.97 −0.15 6.8 −0.32 5.79 −1.33 7.72 0.6 4.73 −2.39
2 (mm)
Diameter 6.45 6.54 0.09 5.86 −0.59 5.43 −1.02 5.22 −1.23 4.14 −2.31 6.49 0.04 6.33 −0.12 6.35 −0.1 8.15 1.7 5.24 −1.21
(mm)
Patient Depth 5.17 5.56 0.39 5.73 0.56 4.03 −1.14 6.34 1.17 4.88 −0.64 5.01 −0.16 4.84 −0.33 3.93 −1.24 5.75 0.58 3.28 −1.89

246
3 (mm)
Diameter 4.10 4.15 0.05 3.84 −0.26 3.55 −0.55 3.38 −0.72 2.5 −1.6 4.15 0.05 4.03 −0.07 4.01 −0.09 4.99 0.89 3.48 −0.62
(mm)
Patient Depth 4.79 4.34 −0.45 4.21 −0.58 5.92 1.13 6.01 1.22 5.4 0.61 5.01 0.22 4.44 −0.35 6.02 1.23 4.26 −0.53 6.67 1.88
4 (mm)
Diameter 3.09 3.17 0.08 3.42 0.33 2.52 −0.57 3.67 0.58 4.22 1.13 3.06 −0.03 3.15 0.06 3.15 0.06 2.19 −0.9 3.7 0.61
(mm)
Patient Depth 6.69 7.1 0.41 7.43 0.74 7.81 1.12 5.53 −1.16 7.29 0.60 6.87 0.18 7.07 0.38 7.97 1.28 6.14 −0.55 8.61 1.92
5 (mm)
Diameter 5.92 5.84 −0.08 5.46 −0.46 4.83 −1.09 7.12 1.2 3.87 −2.05 5.89 −0.03 5.83 −0.09 6.01 0.09 4.41 −1.51 3.86 −2.06
(mm)
Patient Depth 6.56 6.11 −0.45 5.89 −0.67 5.4 −1.16 7.74 1.18 5.97 −0.59 6.39 −0.17 6.91 0.35 5.26 −1.30 7.1 0.54 4.66 −1.90
6 (mm)
Diameter 5.17 5.11 −0.06 5.6 0.43 6.16 0.99 4.14 −1.03 3.23 −1.94 5.22 0.05 5.1 −0.07 5.09 −0.08 3.89 −1.28 4.55 −0.62
(mm)
Patient Depth 4.09 4.49 0.40 3.56 −0.53 4.99 0.9 3.14 −0.95 4.52 0.43 3.9 −0.19 3.75 −0.34 3.26 −0.83 3.53 −0.56 5.97 1.88
7 (mm)
Diameter 3.03 3.12 0.09 2.72 −0.31 3.59 0.56 3.6 0.57 4.21 1.18 2.99 −0.04 3.11 0.08 2.97 −0.06 3.91 0.88 3.66 0.63
(mm)
Additive Manufacturing 22 (2018) 243–255
 M. Juneja et al.

Table 2
Dimensions of surgical guides (Implant region) with their relative error (RE) for depth and diameter.

Dimension Software Vernier Measurements Scan measurements

produced
image
Durus RE Grey RE PLA RE PETG RE ABS RE Durus RE Grey RE PLA RE PETG RE ABS RE
White Resin (ME) (ME) (ME) White (MJT) Resin (ME) (ME) (ME)
(MJT) (VP) (VP)

Patient Depth 5.31 5.74 8.09 5.9 11.11 4.2 −20.9 6.5 22.41 4.7 11.48 5.12 −3.57 4.95 −6.7 4.04 −23.9 5.87 10.53 3.40 −35.96
1 (mm)
Diameter 3.02 3.09 2.31 2.73 −9.6 2.5 −17.21 2.46 −18.54 1.87 −38.07 3.04 0.6 2.94 −2.6 2.95 −2.31 3.89 28.8 2.30 −20.86
(mm)
Patient Depth 7.12 7.58 6.46 7.97 12.00 5.75 −19.3 8.61 20.98 6.49 −9.70 6.97 −2.10 6.8 −4.49 5.79 −18.67 7.72 8.42 4.73 −33.67
2 (mm)
Diameter 6.45 6.54 1.39 5.86 −9.3 5.43 −15.89 5.22 −19.12 4.14 −35.86 6.49 0.62 6.33 −1.9 6.35 −1.55 8.15 26.5 5.24 −18.78
(mm)
Patient Depth 5.17 5.56 7.54 5.73 10.83 4.03 −22.05 6.34 22.63 4.88 −12.37 5.01 −3.09 4.84 −6.38 3.93 −23.98 5.75 11.21 3.28 −36.55

247
3 (mm)
Diameter 4.10 4.15 1.21 3.84 −6.34 3.55 −13.41 3.38 −17.67 2.5 −39.10 4.15 1.21 4.03 −1.70 4.01 −2.19 4.99 21.70 3.48 −15.12
(mm)
Patient Depth 4.79 4.34 −9.39 4.21 −12.10 5.92 23.59 6.01 25.46 5.4 12.73 5.01 4.59 4.44 −7.30 6.02 25.67 4.26 −11.06 6.67 39.24
4 (mm)
Diameter 3.09 3.17 2.58 3.42 10.9 2.52 −18.44 3.67 18.77 4.22 36.56 3.06 −0.97 3.15 1.94 3.15 1.94 2.19 −29.12 3.7 19.74
(mm)
Patient Depth 6.69 7.1 6.12 7.43 11.2 7.81 16.74 5.53 −17.33 7.29 8.96 6.87 2.69 7.07 5.68 7.97 19.13 6.14 −8.22 8.61 28.69
5 (mm)
Diameter 5.92 5.84 −1.35 5.46 −7.89 4.83 −18.54 7.12 20.33 3.87 −34.78 5.89 −0.50 5.83 −1.52 6.01 1.52 4.41 −25.56 3.86 −34.8
(mm)
Patient Depth 6.56 6.11 −6.85 5.89 −10.3 5.4 −17.68 7.74 17.98 5.97 −8.99 6.39 −2.59 6.91 5.33 5.26 −19.81 7.1 8.23 4.66 −28.96
6 (mm)
Diameter 5.17 5.11 −1.16 5.6 8.5 6.16 19.23 4.14 −19.98 3.23 −37.56 5.22 0.96 5.1 −1.35 5.09 −1.54 3.89 −24.78 4.06 −21.53
(mm)
Patient Depth 4.09 4.49 9.77 3.56 −12.95 4.99 22.13 3.14 −23.42 4.52 10.55 3.9 −4.64 3.75 −8.31 3.26 −20.42 3.53 −13.69 5.41 32.35
7 (mm)
Diameter 3.03 3.12 2.97 2.72 −10.23 3.59 18.48 3.6 18.81 4.21 38.94 2.99 −1.32 3.11 2.64 2.97 −1.98 3.91 29.04 3.66 20.79
(mm)
Additive Manufacturing 22 (2018) 243–255
 Table 3
Dimensions of surgical guides printed through different material with their Relative error(RE) for Volume and Area.

Dimensions Software Vernier measures

M. Juneja et al.

produced
image
Durus White RE Grey RE PLA (ME) RE PET-G (ME) RE ABS (ME) RE
(MJT) Resin (VP)

Patient 1 Volume 378.81 407.56 28.75 428.63 49.82 309.09 −69.72 479.37 100.56 356.04 −22.77
(mm3)
Area 71.34 71.00 −0.34 72.64 1.3 73.59 2.25 73.74 2.4 75.75 4.41
(mm2)
Patient 2 Volume 326.39 340.52 14.13 410.80 84.41 318.28 −8.11 491.71 165.32 422.14 95.75
(mm3)
Area 45.84 44.92 −0.92 51.54 5.7 55.354 9.514 57.11 11.27 65.04 19.2
(mm2)
Patient 3 Volume 337.62 361.29 23.67 383.47 45.85 276.48 −61.14 440.83 103.21 359.13 21.51
(mm3)
Area 65.30 64.98 −0.32 66.92 1.62 68.60 3.3 69.53 4.23 73.59 8.29
(mm2)
Patient 4 Volume 340.11 306.45 −33.66 291.83 −48.28 435.20 95.09 408.24 68.13 348.41 8.3
(mm3)
Area 71.00 70.61 −0.39 69.31 −1.69 73.51 2.51 67.92 −3.08 64.52 −6.48
(mm2)
Patient 5 Volume 341.11 367.26 26.15 409.37 68.26 470.05 128.94 214.03 −127.08 486.55 145.44
(mm3)
Area 50.98 51.72 0.74 55.09 4.11 60.18 9.2 38.70 −12.28 66.74 15.76
(mm2)
Patient 6 Volume 377.31 354.39 −22.92 317.36 −59.95 263.04 −114.27 503.45 126.14 419.75 42.44

248
(mm3)
Area 57.5 58.00 0.5 53.88 −3.62 48.71 −8.79 65.04 7.54 70.31 12.81
(mm2)
Patient 7 Volume 291.58 318.15 26.57 258.78 −32.8 341.23 49.65 214.54 −77.04 291.93 0.35
(mm3)
Area 71.29 70.85 −0.44 72.69 1.4 68.38 −2.91 68.32 −2.97 64.58 −6.71
(mm2)

Dimensions Scan measures

Durus White RE Grey Resin RE PLA RE PET-G (ME) RE ABS (ME) RE

(MJT) (VP) (ME)

Patient 1 Volume 364.77 −14.04 354.98 −23.83 289.54 −89.27 391.06 12.25 252.78 −126.03
(mm3)
Area 71.24 −0.1 71.71 0.37 71.66 0.32 66.62 −4.72 74.34 3
(mm2)
Patient 2 Volume 316.68 −9.71 319.91 −6.48 271.24 −55.15 203.48 −122.91 269.35 −57.04
(mm3)
Area 45.43 −0.41 47.04 1.2 46.84 1 26.35 −19.49 56.94 11.1
(mm2)
Patient 3 Volume 325.55 −12.07 318.23 −19.39 258.89 −78.73 338.98 1.36 226.29 −111.33
(mm3)
Area 64.98 −0.32 65.75 0.45 65.87 0.57 58.95 −6.35 68.99 3.69
(mm2)
(continued on next page)
Additive Manufacturing 22 (2018) 243–255
M. Juneja et al. Additive Manufacturing 22 (2018) 243–255

more [20].

−87.24
PETG is a modified version of Polyethylene terephthalate with the

147.06

114.28
−3.25

−3.31
111.8

5.71

4.74
addition of glycol during polymerization. PETG is a clear, less brittle,
RE

durable and is easy to use in comparison to its base form of PET with
the irregular structure of molecules which belongs to the polyester fa-
mily. It is commonly used in day to day life as water bottles, clothes,
food containers, etc. [21].
ABS (ME)

451.91

488.17

290.07

405.86
For analysis of accuracy, the measurements of absolute and relative
67.75

56.69

62.24

67.98
error were taken in depth and diameter for the printed surgical guides
using Vernier Calliper.

2. Materials and methods

−21.74

−56.84
47.14

12.25

−4.8
3.73

95.7

9.12
This section presents the approach used for designing of the surgical
RE

guide using various series of steps. The approach started with the direct
scanning of the patient’s mouth using 3 shape intra oral scanner. High-
quality pre-treatment mandibular and maxillary CT scan and surface
PET-G (ME)

scan data of seven patients, seeking treatment of their missing teeth,

318.37

388.25

473.01

234.74

was obtained. Hence, a duly approved consent form was obtained from
74.73

63.23

66.62

66.49

the patients with the declaration that their data can be utilized by the
authors for research purpose. A sequential procedure for designing of
surgical guides and implant placement was followed which begins with
the input of Digital Imaging and Communications in Medicine (DICOM)
and STL files. Fig. 1 shows the procedure followed for developing a
−71.38

−58.25
−0.29

−0.84
85.56

58.55

surgical guide and preplanning of the implant surgery.

0.66

0.28
RE

Fig. 2 shows the sequential procedure of the steps followed by

placing the implant position correctly and making a surgical guide after
its placement. DICOM and STL files were obtained from 3Shape TRIOS
High-Speed Intraoral 3-D Impression scanner which has an accuracy of
6.9 microns. The planning of implant surgery was performed using CAD
425.67

399.66

305.93

233.33
70.71

50.14

58.16

71.57
(ME)

technology with 3 Shape Implant Studio Software. This software is used

PLA

for the design of surgical guides to pre-plan the surgeries based on

knowledge of experts, information of optimal aesthetics, final intended
restoration, bones available and overall clinical situation.
Initially, to pre-plan an implant surgery, a CT scan data set of pa-
−26.16

−25.68

tients in DICOM format along with the surface scan data in STL format
−0.29

−0.39
25.24

24.03
0.83

0.58

was obtained after scanning the patients through the intraoral scanner.
RE

Thus, DICOM and STL files were given as an input. After obtaining the
files, the missing teeth were indicated so that implants could be placed
for the missing teeth. After the indications, crown anatomy was per-
Grey Resin

formed where virtual crowns were placed at the site of missing teeth.
313.95

366.35

401.34

265.90

Either the design of tooth can be anatomically designed or can be

70.71

51.81

58.08

70.90
(VP)

copied from the existing patient’s tooth. In this case, the existing tooth
was copied at the edentulous site. Operations like morphing, wax knife
and other automatic tools were performed for designing of the virtual
crown. Thereafter, the DICOM image of CT scan was cropped to the
extent that only that part of the file was kept like the upper jaw or the
−12.38

−12.81
−0.39
16.34

11.09

lower jaw where an implant had to be placed. Then, the identification

0.14

0.28

0.19
RE

of the nerve canal was performed. The implant was thus placed at the
edentulous site. After the positioning of the implant, surgical guide was
designed by creating patches on the adjacent teeth. Finally, STL file
Scan measures

Durus White

obtained after preparation of surgical guide which was then converted

into a G-Code file and then printed using three different additive
356.45

352.20

364.93

278.77
(MJT)

71.14

51.26

57.11

71.48

manufacturing techniques – MJT, VP, and ME.

PolyJet Stratasys Object30 prime 3-D printer was used for MJT. It
can print with a layer thickness of 16 microns and accuracy of 0.1 mm
variation depending on the part of variable geometry, material and size.
Dimensions

SLA Form 2 desktop Formlabs 3-D printer was used for VP, where a
Volume

Volume

Volume

Volume

single model was placed at the bed center. It uses resin fill system with a
(mm3)

(mm2)

(mm3)

(mm2)

(mm3)

(mm2)

(mm3)

(mm2)
Area

Area

Area

Area

layer thickness of 0.001–0.004 inches.

Table 3 (continued)

For ME printing, LBD Makers(based on FDM) 3-D printer was used,

with a layer thickness of 0.002–0.015 inches.
In order to evaluate the dimensional accuracy of the printed spe-
Patient 4

Patient 5

Patient 6

Patient 7

cimens, again all the printed surgical guides were scanned using 3Shape
E1 lab scanner. This scanner comprises of 2 × 5 M P cameras with blue
LED multiline, the scan speed of 130 s approx. with an accuracy of

249
 Table 4
Dimensions of surgical guides printed through different material with their absolute error (AE) for Volume and Area.

Dimensions Software Vernier measures

M. Juneja et al.

produced
image
Durus Whit AE Grey AE PLA (ME) AE PET-G (ME) AE ABS (ME) AE
(MJT) Resin (VP)

Patient 1 Volume 378.81 407.56 7.58 428.63 13.15 309.09 −18.40 479.37 26.54 356.04 −6.0
(mm3)
Area (mm2) 71.34 71.00 −0.47 72.64 1.82 73.59 3.15 73.74 3.364 75.75 6.18
Patient 2 Volume 326.39 340.52 4.32 410.80 25.86 318.28 −2.48 491.71 50.651 422.14 29.33
(mm3)
Area (mm2) 45.84 44.92 −2.00 51.54 12.43 55.354 20.75 57.11 24.58 65.04 41.88
Patient 3 Volume 337.62 361.29 7.01 383.47 13.58 276.48 −18.10 440.83 30.56 359.13 6.37
(mm3)
Area (mm2) 65.30 64.98 −0.49 66.92 2.48 68.60 5.053 69.53 6.47 73.59 12.69
Patient 4 Volume 340.11 306.45 −9.89 291.83 −14.19 435.20 27.95 408.24 20.03 348.41 2.44
(mm3)
Area (mm2) 71.00 70.61 −0.54 69.31 −2.38 73.51 3.53 67.92 −4.33 64.52 −9.12
Patient 5 Volume 341.11 367.26 7.66 409.37 20.01 470.05 37.80 214.03 −37.25 486.55 42.63
(mm3)
Area 50.98 51.72 1.45 55.09 8.06 60.18 18.04 38.70 −24.08 66.74 30.91
(mm2)
Patient 6 Volume 377.31 354.39 −6.07 317.36 −15.88 263.04 −30.28 503.45 33.43 419.75 11.24
(mm3)
Area 57.5 58.00 0.86 53.88 −6.295 48.71 −15.28 65.04 13.11 70.31 22.27
(mm2)
Patient 7 Volume 291.58 318.15 9.11 258.78 −11.24 341.23 17.02 214.54 −26.42 291.93 0.12

250
(mm3)
Area 71.29 70.85 −0.61 72.69 1.96 68.38 −4.08 68.32 −4.16 64.58 −9.41
(mm2)

Dimensions Scan measures

Durus White AE Grey Resin AE PLA (ME) AE PET- AE ABS (ME) AE

(MJT) (VP) G (ME)

Patient 1 Volume 364.77 −3.70 354.98 −6.29 289.54 −23.56 391.06 3.23 252.78 −33.26
(mm3)
Area (mm2) 71.24 −0.14 71.71 0.51 71.66 0.44 66.62 −6.61 74.34 4.20
Patient 2 Volume 316.68 −2.97 319.91 −1.98 271.24 −16.89 203.48 −37.65 269.35 −17.47
(mm3)
Area (mm2) 45.43 −0.89 47.04 2.61 46.84 2.18 26.35 −42.51 56.94 24.21
Patient 3 Volume 325.55 −3.57 318.23 −5.74 258.89 −23.31 338.98 0.40 226.29 −32.97
(mm3)
Area (mm2) 64.98 −0.49 65.75 0.68 65.87 0.87 58.95 −9.72 68.99 5.65
Patient 4 Volume 356.45 4.80 313.95 −7.69 425.67 25.15 318.37 −6.39 451.91 32.87
(mm3)
Area (mm2) 71.14 0.19 70.71 −0.40 70.71 −0.40 74.73 5.25 67.75 −4.57
Patient 5 Volume 352.20 3.25 366.35 7.39 399.66 17.16 388.25 13.81 488.17 43.11
(mm3)
Area 51.26 0.54 51.81 1.62 50.14 −1.64 63.23 24.02 56.69 11.20
(mm2)
(continued on next page)
Additive Manufacturing 22 (2018) 243–255
 Table 4 (continued)

Dimensions Scan measures

M. Juneja et al.

Durus White AE Grey Resin AE PLA (ME) AE PET- AE ABS (ME) AE

(MJT) (VP) G (ME)

Patient 6 Volume 364.93 −3.28 401.34 6.36 305.93 −18.91 473.01 25.36 290.07 −23.12
(mm3)
Area 57.11 −0.67 58.08 1.00 58.16 1.14 66.62 15.86 62.24 8.24
(mm2)
Patient 7 Volume 278.77 −4.39 265.90 −8.80 233.33 −19.97 234.74 −19.49 405.86 39.19
(mm3)
Area 71.48 0.26 70.90 −0.54 71.57 0.39 66.49 −6.73 67.98 −4.64
(mm2)

251
Table 5
Areas of surgical guides printed through different material with their Relative error(RE).

Dimensions Software Vernier measures Scan measures

produced
image
Durus RE Grey RE PLA (ME) RE PET-G (ME) RE ABS (ME) RE Durus RE Grey RE PLA RE PET-G (ME) RE ABS (ME) RE
White Resin White Resin (ME)
(MJT) (VP) (MJT) (VP)

Patient 1 Area 1064.67 1066.86 0.20 1073.56 0.83 1058.68 −0.56 1072.92 0.77 1061.90 −0.26 1068.31 0.34 1069.29 4.62 1059.52 −0.48 1074.56 0.92 1061.47 −0.30
(mm2)
Patient 2 Area 1349.35 1348.68 −0.04 1340.39 −0.66 1340.86 −0.62 1359.71 0.76 1346.96 −0.17 1353.22 0.28 1358.62 9.27 1338.91 −0.77 1363.78 1.06 1342.84 −0.48
(mm2)
Patient 3 Area 1116.25 1126.16 0.88 1124.33 0.72 1110.42 −0.52 1134.95 1.67 1114.19 −0.18 1120.50 0.38 1122.81 6.56 1107.83 −0.75 1130.96 1.31 1113.52 −0.24
(mm2)
Patient 4 Area 1043.56 1046.37 0.26 1056.69 1.25 1040.54 −0.28 1076.36 3.14 1031.43 −1.16 1049.86 0.60 1053.28 9.72 1040.26 −0.31 1079.36 3.43 1038.44 −0.49
(mm2)
Patient 5 Area 1236.71 1242.42 0.46 1245.65 0.72 1234.50 −0.17 1249.40 1.02 1233.49 −0.26 1240.11 0.27 1243.86 7.15 1230.68 −0.48 1252.53 1.27 1230.76 −0.48
(mm2)
Patient 6 Area 1221.03 1225.28 0.34 1229.54 0.69 1217.91 −0.25 1258.61 3.07 1213.04 −0.65 1224.43 0.27 1224.50 3.47 1214.39 −0.54 1259.69 3.16 1213.96 −0.57
(mm2)
Patient 7 Area 1037.93 1045.86 0.76 1049.08 1.07 1023.36 −1.40 1062.73 2.38 1034.87 −0.29 1048.68 1.03 1051.89 13.96 1021.52 −1.58 1066.67 2.76 1032.59 −0.51
(mm2)
Additive Manufacturing 22 (2018) 243–255
 Table 6
Areas of surgical guides printed through different material with their absolute error (AE).

Dimensions Software Vernier measures

M. Juneja et al.

produced
image
Durus White AE Grey AE PLA (ME) AE PET-G (ME) AE ABS (ME) AE
(MJT) Resin (VP)

Patient 1 Area 1064.67 1066.86 2.19 1073.56 8.89 1058.68 −5.99 1072.92 8.25 1061.90 −2.77
(mm2)
Patient 2 Area 1349.35 1348.68 −0.67 1340.39 −8.96 1340.86 −8.49 1359.71 10.36 1346.96 −2.39
(mm2)
Patient 3 Area 1116.25 1126.16 9.91 1124.33 8.08 1110.42 −5.83 1134.95 18.7 1114.19 −2.06
(mm2)
Patient 4 Area 1043.56 1046.37 2.81 1056.69 13.13 1040.54 −3.02 1076.36 32.8 1031.43 -12.13
(mm2)
Patient 5 Area 1236.71 1242.42 5.71 1245.65 8.94 1234.50 −2.21 1249.40 12.69 1233.49 −3.22
(mm2)
Patient 6 Area 1221.03 1225.28 4.25 1229.54 8.51 1217.91 −3.12 1258.61 37.58 1213.04 −7.99
(mm2)
Patient 7 Area 1037.93 1045.86 7.93 1049.08 11.15 1023.36 −14.57 1062.73 24.8 1034.87 −3.06
(mm2)

Dimensions Scan measures

Durus White AE Grey Resin AE PLA AE PET-G (ME) AE ABS (ME) AE

(MJT) (VP) (ME)

Patient 1 Area 1068.31 3.64 1069.29 4.62 1059.52 1074.56 9.89 1061.47

252
−5.15 −3.2
(mm2)
Patient 2 Area 1353.22 3.87 1358.62 9.27 1338.91 −10.44 1363.78 14.43 1342.84 −6.51
(mm2)
Patient 3 Area 1120.50 4.25 1122.81 6.56 1107.83 −8.42 1130.96 14.71 1113.52 −2.73
(mm2)
Patient 4 Area 1049.86 6.3 1053.28 9.72 1040.26 −3.3 1079.36 35.8 1038.44 −5.12
(mm2)
Patient 5 Area 1240.11 3.4 1243.86 7.15 1230.68 −6.03 1252.53 15.82 1230.76 −5.95
(mm2)
Patient 6 Area 1224.43 3.4 1224.50 3.47 1214.39 −6.64 1259.69 38.66 1213.96 −7.07
(mm2)
Patient 7 Area 1048.68 10.75 1051.89 13.96 1021.52 −16.41 1066.67 28.74 1032.59 −5.34
(mm2)
Additive Manufacturing 22 (2018) 243–255
M. Juneja et al. Additive Manufacturing 22 (2018) 243–255

10–12 μm. Along with the scans, Vernier Calliper was also used for
dimensional measurements. Fig. 3 shows the surgical guides printed
through different printing techniques.

3. Results

This section presents the results obtained for different printing

techniques with objective and subjective analysis to evaluate the su-
perior one in terms of its dimensional accuracy. Fig. 3 shows the sur-
gical guides printed in different materials using different printing Fig. 8. AE in Vernier measures of Diameter(mm).
techniques.
Thereafter, the depth and diameter of surgical guides shown in
Fig. 4 are measured using vernier and scan measures to perform com-
parison and analyze accuracies.
The measurements of depth and diameter were calculated for sur-
gical guides designed using proposed methodology. Here depth of the
surgical guide is a measure of the total height of the implant to be
placed. Its value is taken as an average of measurements performed for
depth as shown in Fig. 4(a). The diameter of the implant was taken as
the inner diameter of the hole as shown in Fig. 4 (b). Also, the measure
of area and volume given in Tables 3 and 4 are performed using the
values of given in Tables 1 and 2. For calculating the area we applied
Fig. 9. AE in Scan measures of Depth(mm).

Fig. 5. Measurements of Depth(mm).

Fig. 10. AE in Scan measures of Diameter(mm).

the formula 3.14*(R2-r2). Here, R is the radius of outer circle calculated

from outer diameter of the implant region which is normally fixed in
this case i.e. 10 mm and r is the inner radius calculated from inner
diameter of the implant region which is calculated as diameter in Tables
1 and 2. Whereas, for calculating the volume we applied the formula
3.14*(R2-r2)*h. Here also, h is the height of the implant calculated as
depth in Tables 1 and 2. Finally, the area of whole surgical guide is
calculated using the publically available software MESHLAB. There-
after, the comparison was made for the measurements of the surgical
guide before printing and after printing in order to find the deviation in
the results to analyze the accuracy of the printing techniques. The ab-
solute and Relative error was also calculated for analyzing the differ-
Fig. 6. Measurements of Diameter(mm). ences between each material printed using different rapidprototyping

Fig. 7. AE in Vernier measures of Depth(mm).

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M. Juneja et al. Additive Manufacturing 22 (2018) 243–255

Fig. 11. RE in Vernier measures of Depth(mm).

Fig. 14. RE in Scan measures of Diameter(mm).

Dpg −Dsi
RE = ( )* 100
Dsi (2)

Here, Dpg refers to the dimensions of the printed surgical guide and
Dsi refers to the dimensions of software produced image of the designed
surgical guide, for both the Vernier calliper measurements and scan
measurements.
The calculations for depth and diameter recorded with the Absolute
error (AE) and Relative error (RE) for each material and printing
technique for the implant region is shown in Tables 1 and 2 respec-
tively. Similarly, Dimensions of surgical guides for implant region
printed through different material and technique with their Relative
error (RE) and Absolute error (AE) for both Volume and Area are shown
in Tables 3 and 4. Finally, the Areas of surgical guides printed through
Fig. 12. RE in Vernier measures of Diameter(mm). different material with their Relative error(RE) and Absolute error (AE)
are shown in Tables 5 and 6.
techniques. Based on the quantitative analysis, it has been analyzed that MJT
Absolute error (AE) is calculated as the difference between the di- printer has least errors in comparison to others and hence is the better
mensions of printed and software produced surgical guide using Eq. (1) amongst three. Thus, the plots for the values in Tables 1 and 2 are given
as shown below. in Fig. 5–14 to further prove the findings.
Similar to quantitative analysis, graphs also show the minimum
AE = Dpg −Dsi (1) deviation of errors in case of MJT.

Relative error (RE) is the percentage error in the dimensions of the 4. Discussions
printed surgical guide and the dimensions of the software produced
image of the designed surgical guide as shown in Eq. (2). This work presented an approach for fabrication of surgical guides
using different state of the art 3-D printing techniques like MJT, VT and

Fig. 13. RE in Scan measures of Depth(mm).

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M. Juneja et al. Additive Manufacturing 22 (2018) 243–255

ME printers using various compatible printing materials. MJT (PolyJet) innovation centre (DIC) project “Medical devices and restorative tech-
used Durus White as a material for printing, VT(SLA) printer used Grey nologies” [Reference no.17-11/2015-PN-1]. Authors are very thankful
Resin material and ME(FDM) printer used PLA, PETG, and ABS mate- to Dr. Harvansh Singh Judge Institute of Dental Sciences & Hospital,
rials. Absolute and relative errors in case of MJT printing range from Panjab University, for technical discussions.
nearly 2% to 10% in case of depth and 0.5% to 3% in case of diameter
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