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Received: 28 November 2022 Accepted: 6 February 2023

DOI: 10.1111/jopr.13664

ORIGINAL ARTICLE

Reverse scan body: A complete digital workflow for prosthesis

prototype fabrication

Panos Papaspyridakos DDS, MS, PhD1,2 Armand Bedrossian DDS, MS3

Yukio Kudara CDT, MDT1 Panagiotis Ntovas DDS, MSc1 Abdullah Bokhary BDS,
MSc4 Konstantinos Chochlidakis DDS, MSF, FACP2

1
Department of Prosthodontics, Tufts University
School of Dental Medicine, Boston,
Massachusetts, USA
2
Department of Prosthodontics, Eastman Institute
for Oral Health, University of Rochester,
Rochester, New York, USA
3
Department of Prosthodontics, University of
Washington, Seattle, Washington, USA
4
Department of Dental Public Health, Faculty of
Dentistry, King Abdulaziz University, Jeddah,
Saudi Arabia
Correspondence
Panos Papaspyridakos, Associate Professor,
Department of Prosthodontics, Tufts University
School of Dental Medicine, One Kneeland Street,
Boston, MA 02111, USA.
Email: panpapaspyridakos@gmail.com
Abstract
Purpose: To assess the accuracy of fit of prosthesis prototypes fabricated via a com-
plete digital workflow protocol with a reverse scan body skipping intraoral scanning
for implant data acquisition.
Materials and methods: A maxillary stone cast with four multiunit abutment implant
analogs (Screw-Retained Abutments, Institut Straumann AG, Basel, Switzerland) with
adequate anteroposterior spread simulated a common clinical patient situation. This
stone cast served as the master cast and an interim screw-retained prosthesis was fab-
ricated on it. Novel reverse scan bodies were connected to the interim prosthesis, and
extraoral scanning was performed with a white light intraoral scanner. The produced
standard tessellation language (STL) files were then imported to computer-assisted
design software and after the digital design, the STL file was exported to a computer-
assisted machining milling machine and a three-dimensional (3D) printer to produce a
total of 50 milled and 50 printed fixed complete denture prototypes, respectively. Two
clinicians assessed the accuracy of fit of each digitally fabricated prosthesis prototype
on the master cast, utilizing the screw-resistance test and radiographic evaluation. Out
of the 100 prototypes, 94% (94/100) were fitting accurately. Fisher’s exact test was
used to test the difference among the groups. The test revealed statistically significant
results (p = 0.027).
Results: Out of the 50 digitally fabricated milled prosthesis prototypes, 50 (100%)
presented with accurate fit under in vitro assessment. Out of the 50 digitally fabricated
3D printed prototypes, 44 (88%) presented with accurate fit under in vitro assessment.
Conclusions: Accurately fitting digitally fabricated prosthesis prototypes can be milled
after extraoral scanning with reverse scan bodies without intraoral implant data
acquisition.

Full-arch digital implant scanning with intraoral scanners
(IOS) for the fabrication of prosthesis prototypes and
definitive zirconia implant fixed complete dental prostheses
(IFCDPs) is gaining popularity.1-12 Full-arch digital implant
scans for completely edentulous patients are technique-
sensitive procedures mainly due to the absence of anatomical
landmarks such as teeth, making the superimposition of scans
with scan bodies and interim prostheses challenging.1-6 The
double digital scanning technique with the use of fiducial
markers has been introduced for complete digital workflow
for prosthesis prototype fabrication.2 Fiducial markers are
used to aid in data acquisition during edentulous jaw intrao-
ral scanning and to assist in the merging of multiple digital
scans.7-12 However, even with the use of fiducial mark-
ers, intraoral scanning especially in the edentulous mandible
remains challenging. The presence of saliva, sensor fog-
ging, and lack of keratinized mucosa coupled with advanced
mandibular resorption may affect negatively data acquisition
with intraoral scanning.3,4
The purpose of this in vitro study was to assess a digital
workflow protocol with the use of a novel reverse scan body
that is connected to the interim prosthesis for extraoral scan-
ning. The extraoral scanning captures prosthesis contours,
intaglio surface, and three-dimensional (3D) implant position

J. Prosthodont. 2023;1–6. wileyonlinelibrary.com/journal/jopr © 2023 by the American College of Prosthodontists. 1


2 PAPASPYRIDAKOS ET AL.
FIGURE 1 Master cast with reference interim prosthesis.
all at the same time, hence eliminating the need for intrao-
ral scanning of scan bodies for data acquisition. The primary
outcome measure was the assessment of accuracy of fit of
the digitally fabricated prosthesis prototypes after extraoral
scanning of the interim prosthesis with reverse scan bodies
and fabrication with milling (subtractive) technique. The sec-
ondary outcome was the assessment of accuracy of fit of
the digitally fabricated prosthesis prototypes after extraoral
scanning of the interim prosthesis with reverse scan bod-
ies and fabrication with 3D printing (additive manufacturing)
technique.
MATERIALS AND METHODS
This study is an in vitro study, which was performed at
the Department of Prosthodontics at Tufts University School
of Dental Medicine. A maxillary stone cast with four mul-
tiunit abutment (MUA) implant analogs (Screw-Retained
Abutments; Institut Straumann AG, Basel, Switzerland) with
adequate anteroposterior spread simulated a common clini-
cal scenario. This stone cast served as the master cast for the
fabrication of an interim screw-retained prosthesis (Figure 1).
The interim screw-retained prosthesis was passively fitting in
the master cast. An experimental reverse scan body (Institut
Straumann AG, Basel, Switzerland) was created for this study
and was screw-retained to the interim prosthesis, to simu-
late a digital equivalent for the back-pouring technique of the
conversion prosthesis.
In the clinical scenario, it is imperative for the clinician
to assure the interim conversion prosthesis is passively fit-
ting, has appropriate hygienic intaglio contour, is restored at
the appropriate vertical dimension of occlusion, and meets
the esthetic and phonetic parameters for the patient. Once
assured, the interim prosthesis can be used for this technique.
Similarly, in the present in vitro study, the interim prosthe-
sis was fabricated on the master cast, and passive fitting was
confirmed, prior to the digital scanning procedures.
Fifty digital scans were completed after connecting reverse
scan bodies to the interim prosthesis (Figure 2). The dig-
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F I G U R E 2 Reverse scan bodies connected to the interim prosthesis.
This step skips intraoral scanning of the scan bodies and interim prosthesis
for data acquisition and standard tessellation language (STL) merging.
F I G U R E 3 Standard tessellation language (STL) file of the interim
prosthesis using the reverse scan bodies.
ital scans were taken with a white light IOS (TRIOS 4;
3Shape A/S, Copenhagen, Denmark) producing the standard
tessellation language (STL) files, without removing the scan
bodies to eliminate the effect of scan bodies. The 50 STL
files were then imported to computer-assisted design (CAD)
software (exocad DentalCAD; exocad GmbH, Darmstadt,
Germany), and CAD design was completed (Figure 3). One
experienced operator (AB) performed all digital scanning
procedures upon calibration. The operator had been prior cal-
ibrated after performing 20 trial scans with the same IOS
system. The verified dentate scan path recommended by the
manufacturer (TRIOS; 3shape) was used for all 50 digital
scans.
At the laboratory, the 50 CAD design STL files were
imported into CAD software (exocad DentalCAD; exocad
GmbH, Darmstadt, Germany) coupled with a computer-
assisted machining milling unit (PrograMill PM7; Ivoclar,
Amherst, NY, USA). Prosthesis prototypes were copy-milled
from prefabricated polymethylmethacrylate discs (Telio CAD
LT; Ivoclar, Amherst, NY, USA). Each one of the 50 STL
files generated one milled prototype, for a total of 50 milled
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REVERSE SCAN BODY 3

F I G U R E 4 Digitally fabricated prosthesis prototypes were F I G U R E 5 Accurate fit is shown with the adequate seat of the
copy-milled from prefabricated polymethylmethacrylate (PMMA) discs. prosthesis prototype onto the multiunit abutments (MUAs) of the master
Each one of the 50 standard tessellation language (STL) files generated one cast.
milled prototype, for a total of 50 milled prosthesis prototypes. Each one of
the 50 STL files generated one three-dimensional (3D) printed prototype,
for a total of 50 printed prosthesis prototypes.

prosthesis prototypes (Figure 4). An additional step was

taken, and the same 50 STL files were imported into a
3D printer (Form 3B; Formlabs, MA, USA) to produce a
total of 50 3D printed prosthesis prototypes with standard
resin (CB resin; Formlabs). The digitally designed prosthe-
sis prototypes were 3D printed following the manufacturer’s
recommendation, with 50 μm resolution, wash and cure
original set, 20 min alcohol bath, 20 min air-dry, and post-
cured with 1.25 mW/cm2 of 405 nm LED light for 60 min
(Metalight; Primotec, Norwalk, CT, USA). One experienced
lab technician (YK) performed all laboratory procedures
for the fabrication of the milled and 3D-printed prosthesis
prototypes, respectively. F I G U R E 6 Non-accurate fit is shown with the gap between
The titanium inserts (Variobase for bridge for SRA; Insti- the three-dimensional (3D) printed prosthesis prototype and multiunit
tut Straumann AG, Basel, Switzerland) were cemented to abutments (MUAs). Screw resistance, periapical radiographs, and visual
each prototype prosthesis using resin cement (Panavia V5; expectation were used to identify misfit.
Kuraray America Inc, New York, NY, USA). Freehand
cementation of the titanium inserts was done without any
3D-printed or stone casts. The accuracy of fit of each milled
(n = 50) and 3D-printed (n = 50) prototype prosthesis was As an additional method of assessing accuracy of fit, radio-
then tested on the master cast (Figure 5). Two experienced graphs were taken after tightening the milled and 3D-printed
clinicians (PP, AB) tested the accuracy of fit of each proto- prototypes on the master cast. Prior to taking each radiograph,
type prosthesis on the master cast using the screw-resistance the prosthesis prototype was torqued to 15 N cm to simulate
test, visual inspection, and periapical radiographs.12-15 For the clinical scenario. Four radiographs were taken for each
each prototype to be tested, the prosthesis prototype was cast including the master cast to assess the accuracy of fit on
placed on the master cast, anthe prosthetic screws were each MUA (Screw-Retained Abutments; Institut Straumann
placed and hand-tightened in a sequence from one termi- AG, Basel, Switzerland). To standardize the procedure, all
nal abutment to the other starting from the maxillary right radiographs were taken by a single operator (PN) using the
side to the maxillary left side (maxillary right molar, max- same size sensor and the same machine settings. Furthermore,
illary right canine, maxillary left canine, and last maxillary a radiographic ring positioning system was used to ensure
left molar).7,10,13-15 During the tightening of each prosthetic parallelism, and clear utility wax ropes were used to stabi-
screw, if complete seating required more than half a turn of lize the sensor while taking the radiograph. The radiographic
the screwdriver after initial resistance was felt, it was deemed examination of fit of each digitally fabricated prosthesis pro-
a misfit (Figure 6).7,10,13-15 Cohen’s κ-score was used for totype was used as asupplement to reveal any noticeable gaps
assessment of inter-examiner reliability. or misfits (Figure 7).

4 PAPASPYRIDAKOS ET AL.
F I G U R E 7 (a) Radiographic interpretation of an accurately fitting
prosthesis; (b) radiographic interpretation of prosthesis misfit.
STATISTICAL ANALYSIS
The agreement of fit assessment between the two experienced
clinicians was tested with κ statistics (Cohen’s κ-score). The
nonparametric Fisher’s exact test was used to test for the
presence of significant differences between the two groups.
The (α) type I error was set at 0.05. The statistical analysis
was conducted using a statistical software program (SPSS 29;
IBM Corporation, Armonk, NY, USA).
RESULTS
Using the SPSS software (IBM Corp, Armonk, NY, USA),
descriptive statistics were calculated for each of the two
groups (milling vs. 3D printing). The assumption of normal-
ity was indicating that the data were not normally distributed.
Hence, the nonparametric Fisher’s exact test was used to test
for the presence of significant differences between the two
groups.
Agreement between the two experienced clinicians (PP,
AB) was tested with κ statistics. The κ score was 1 indi-
cating complete agreement between the examiners. The
screw-resistance test combined with visual inspection and
radiographs resulted in acceptable fit for 50 out of the 50
milled prototypes (100%). The screw-resistance test com-
bined with visual inspection and radiographs resulted in
acceptable fit for 44 out of the 50 3D-printed prototypes
(88%). Fisher’s exact test indicated a statistically significant
difference between the milled versus 3D printed prototypes
(Table 1: p = 0.027).
DISCUSSION
The findings of this in vitro study showed that out of the 50
digitally fabricated milled prosthesis prototypes, 50 (100%)
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TA B L E 1 Fit assessment of the prosthesis prototypes (milled vs. 3D
printed)
Acceptable Non-acceptable
Groups fit n (%) fit n (%) p
Milled 50 (100) 0 (0) 0.027*
3D printed 44 (88) 6 (12)
Total 94 (94) 6 (6)
*Statistically significant (p < 0.0).
presented with accurate fit under in vitro assessment with
screw-resistance test combined with visual inspection and
radiographs, whereas accurate fit was found for 44 out
of the 50 3D-printed prosthesis prototypes (88%). Clinical
implications from these findings can be drawn that accu-
rately fitting digitally fabricated prosthesis prototypes can
be milled after extraoral scanning with reverse scan bod-
ies skipping implant data acquisition with intraoral scanning.
This reduces the number of required appointments and most
importantly allows for implant data acquisition in the edentu-
lous mandible which has been reported to be problematic.3–10
The fact that 44 out of 50 3D-printed prosthesis prototypes
presented with acceptable fit highlights the limitations with
3D printing full-arch prototypes that may include the resin
being used, the nesting orientation of the STL file, and
the post-processing procedures. The same STL files were
used for both milling and 3D printing, yet 88% fit was
achieved with 3D printing compared to 100% fit with milling.
The potential misfit of the prototype highlights the impor-
tance of making a verification jig when using a complete
digital workflow.15,16 This can easily be done with different
approaches such as intraoral splinting of copings or abut-
ments and then connecting analogs prior to pouring a jig
cast or similarly back-pouring the immediately loaded con-
version prosthesis after attaching analogs and pouring with
low expansion stone.9
In this context, the reverse scan body protocol simulates
the back-pouring technique in a digital workflow. Clinical
implications include the innovative approach to overcome
the challenges of intraoral scanning, especially in the eden-
tulous mandible. In a clinical setting, prior to the extraoral
scanning of the immediately loaded interim (conversion)
prosthesis, it is incumbent that the clinician torque tests the
MUAs to ensure they are not loose prior to extra oral scan-
ning. Similarly, if the interim prosthesis is done after implant
osseointegration, the clinician needs to assess the accurate fit
of the interim prosthesis prior to extra oral scanning.
In regard to the effect of the fabrication method used for
each prosthesis prototype, Fisher’s exact test indicated a sta-
tistically significant difference among the groups (p = 0.027).
All the milled prototype prostheses presented with acceptable
fit, whereas the prototypes fabricated with the Form 3b printer
(44/50) did not. Errors during the wash and cure original set,
during the alcohol bath cleaning, and post-curing could have
created a cascade of errors that culminated in the misfit of
6 out of 50 prosthesis prototypes. A previous in vitro study,
using different types of 3D printers for fabrication of printed

REVERSE SCAN BODY
prototype prostheses, reported accuracy differences among
the three different printers.10 Further research is warranted as
the 3D printing of prosthesis prototypes and casts is gaining
popularity.
Advantages of the complete digital workflow include
fabrication of the digitally designed prototype prostheses
simplifying the rehabilitation process and shortening the
number of required appointments. Once assessing the interim
prosthesis for appropriate aesthetics, phonetics, and vertical
dimension of occlusion, this workflow maximizes the effi-
ciency for the data acquisition appointment with the ability to
capture the dentition, intaglio contour, and implants’ position
extraorally. Most importantly, the reverse scan body concept
allows for predictable digital data acquisition in the edentu-
lous mandible which is frequently challenging. The extraoral
scanning skips the intraoral scanning issues with the pres-
ence of saliva, sensor fogging, and lack of keratinized mucosa
coupled with advanced mandibular resorption. Additionally,
it eliminates the need for fiducial markers for data merging or
virtual cross-articulation of STL files. The STL file derived
from the extraoral scanning is easily superimposed with the
STL file from the intraoral scanning of the interim prosthesis
and opposing dentition.
A limitation of the present in vitro study might be the fact
that only one 3D printer was used in this study which might
have larger inaccuracies in terms of trueness as compared to
other available printers. The inherent flexibility of the resin
material of the 3D-printed prototype prostheses may also
be a limitation even though the prototypes were designed
with adequate thickness. Hence, fabrication of a verifica-
tion jig may be incumbent with 3D-printed or even milled
prosthesis prototypes. The verification jig cast will serve as
quality control during the complete digital workflow, aid
in the cementation of the titanium inserts for both proto-
type and definitive zirconia prostheses on the jig cast, and
ultimately ensure acceptable fit. The accuracy of fit of the
generated prosthesis prototype and definitive prosthesis is
crucial for long-term success as it has been shown that com-
plications with IFCDPs are frequent and time-dependent even
when all prosthodontic procedures are performed per strict
protocol.17-22 In regard to freehand cementation of titanium
inserts and the use of resin cement, even though resin cement
was used to cement the titanium inserts in place, some degree
of movement within the resin material cannot be completely
overruled.
Clinical studies assessing the accuracy of fit of prostheses
prototypes generated with a complete digital workflow are
necessary to clinically verify the feasibility and efficacy of
this promising technique. Finally, the scanning pattern and
strategy even for extraoral scanning warrant further investi-
gation for assessment of their effect on data acquisition.23,24
CONCLUSIONS
Within the limitations of this in vitro study, it was shown
that a complete digital workflow protocol with extraoral scan-
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5
ning and a reverse scan body may lead to accurately fitting
digitally fabricated prosthesis prototypes with the milling
technique. Out of the 50 digitally fabricated milled proto-
types, 50 (100%) presented with accurate fit under in vitro
assessment. Out of the 50 digitally fabricated 3D printed pro-
totypes, 44 (88%) presented with accurate fit under in vitro
assessment. Milling led to significantly better accuracy of fit
compared with 3D printing.
AC K N OW L E D G M E N T S
The present study was supported by the Straumann Group.
The authors would like to express their gratitude to Mrs Maria
Gremaud, Mr Sebastien Barriere, and Mr Charlie Vincent for
their contribution to the present study.
C O N F L I C T O F I N T E R E S T S TAT E M E N T
The authors do not have any financial interest in the
companies whose materials are included in this article.
ORCID
Panos Papaspyridakos DDS, MS, PhD https://orcid.org/
0000-0002-8790-2896
Armand Bedrossian DDS, MS https://orcid.org/0000-0002-
7603-1722
Panagiotis Ntovas DDS, MSc https://orcid.org/0000-0002-
1349-2548
Konstantinos Chochlidakis DDS, MSF, FACP https://orcid.
org/0000-0003-2250-2274
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How to cite this article: Papaspyridakos P,
Bedrossian A, Kudara Y, Ntovas P, Bokhary A,
Chochlidakis K. Reverse scan body: A complete
digital workflow for prosthesis prototype fabrication.
J Prosthodont. 2023;1–6.
https://doi.org/10.1111/jopr.13664