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Pharmaceutical 3D printing has emerged as a technically powerful approach for producing personalised, flexible, and on-demand dosage forms. Its appeal lies in the ability to vary dose, geometry, release profile, and patient acceptability without requiring a new conventional manufacturing line for every product variant. Despite this promise, the field remains constrained by a persistent mismatch between design capability and translational readiness. Many studies demonstrate sophisticated printed tablets, films, lattices, and personalised dosage forms, yet far fewer address the manufacturing controls, release strategies, and regulatory evidence needed for routine clinical implementation. This critical review evaluates pharmaceutical 3D printing through the connected lenses of design logic, manufacturing constraints, and regulatory readiness. The review treats additive manufacturing not as one technology but as a family of processes whose material requirements, process risks, and quality attributes differ substantially. The review concludes that pharmaceutical 3D printing will not translate through formulation novelty alone. A technology-agnostic, risk-proportionate regulatory pathway combined with scalable, PAT-integrated manufacturing platforms is essential to move from promise to practice.