CLINICAL RESEARCH

The importance of esthetic

integration through laboratory
adaptation profiles in the
biologically oriented preparation
technique

Antonello Di Felice, CDT

Private Practice, Rome, Italy

Cristian Abad-Coronel, DDS, MSc, PhD

Principal Professor, Faculty of Dentistry, University of Cuenca, Ecuador

Vincenzo Giovane, DDS

Professor, University Complutense of Madrid, Spain

Ignazio Loi, DDS

Private Practice, Cagliari, Italy

Guillermo Pradíes, DDS, MSc, PhD

Chairman, Prosthodontics Department, Faculty of Dentistry, Universidad Complutense,
Madrid, Spain

Correspondence to: Dr Cristian Abad-Coronel

Avenida Solano 11-67, Cuenca, Ecuador, CP 010107; Tel: +593 7281 2368, mobile: +593 9983 01596;
Email: cabad02@ucm.es, cristian.abad@ucuenca.edu.ec

76 | The International Journal of Esthetic Dentistry | Volume 17 | Number 1 | Spring 2022


Abstract
The biologically oriented preparation technique
(BOPT) has revolutionized the execution of fixed pros-
thetic treatments, ensuring tissue stability and the
integration of the gingival tissue with the prosthetic
restorations. BOPT follows both a clinical and labora-
tory sequence; the two must be perfectly integrated
and synchronized, with the phase of preparation and
temporary restorations in the clinic correlating with
a well-founded and protocolized execution of the
laboratory steps. In turn, prosthetic work returned to
the clinic must show perfect integration between the
The International Journal of Esthetic Dentistry | Volume 17 | Number 1 | Spring 2022
DI FELICE ET AL
prosthesis, the preparation, and the periodontal tissue,
with a balance between pink and white esthetics. The
clinical case in the present article illustrates the close
relationship between the clinical and laboratory steps,
including the technical laboratory procedures, that
make it possible to achieve these objectives. The aim
of the article is to introduce the concept of the pros-
thetic adaptation profile of new restorations, establish-
ing the definition, importance, and direct relationship
of this profile with the success of the rehabilitation
treatment.
(Int J Esthet Dent 2022;17:76–87)
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CLINICAL RESEARCH
Introduction
Nowadays, the esthetic results of a restora-
tive treatment involve not only the white
esthetics but also the comprehensive
solution of the pink esthetics. Therefore,
the long-term objective of a restoration
is to achieve the rehabilitation of the lost
hard dental tissue as well as its integration
with the periodontal soft tissue. The bio-
logically oriented preparation technique
(BOPT) is a philosophy of treatment for
fixed prosthodontics that combines verti-
cal preparation; gingitage (rotatory gingi-
val curettage); temporary restorations; the
formation and stabilization of the tissue
from the clot; and the laboratory tech-
niques, including the creation of new
coronal profiles.
The original BOPT protocol, published
in 2008,1 proposed to record in a clear and
well-differentiated way the intrasulcular
portion of the ‘feather-edge’ dental prepar-
ation type without a finishing line so it can
be transferred to the laboratory with a view
to the correct management and handling
of the prosthetic lines and profiles of the
new restorations. In other historic articles,2,3
the concept of ‘adaptation profile’ was pro-
posed. This concept is defined as the new
architecture of the marginal zone of the res-
toration, the function of which is the tissue
conditioning of the gingival margin portion
of the emerging area of the prosthesis. The
objective of the adaptation profile is to im-
prove the symmetry of the coronal portion
specifically and the entire smile generally,
especially in dentogingival exposures. The
purpose of the present article is to describe
the technical procedures necessary to de-
velop a new adaptation profile as well as
a new prosthetic cement limit (prosthe-
tic cement junction) to replace the natural
cementoenamel junction (CEJ) of the pre-
pared tooth, according to the BOPT pro-
tocol (BOPT in Lab) through a clinical case
78 | The International Journal of Esthetic Dentistry | Volume 17 | Number 1 | Spring 2022
(Fig 1). With this objective, the conceptual
criteria of the laboratory procedures related
to BOPT are proposed.
BOPT laboratory criteria
The BOPT laboratory criteria are based on
two basic principles of the vertical prepar-
ation: 1) The prosthetic margin is located on
a vertical plane and is not clearly defined with
a horizontal termination line; therefore, it can
be located in the laboratory by the dental
technician.4 2) The clinician creates a ‘vertical
termination zone’ by eliminating the anatom-
ical landmarks of the intrasulcular portion
(Fig 2), allowing the laboratory technician to
‘freely’ manage a new CEJ and new restora-
tion profiles. Based on these two principles,
three fundamental steps can be applied, as
described in the following paragraphs.
Step 1: Positioning of the prosthetic
margin in the termination area
The prosthetic margin is positioned on the
working model poured with Type IV gyp-
sum (Fujirock; GC), orienting itself and giv-
ing priority to the gingival level. For this, the
following protocol is recommended:
■ Preparation of the model with remov-
able dyes (Giroform; Amann Girrbach).
■ Demarcation of the gingival margin on
the surface of the stump (Fig 3).
■ Removal of the gingiva and exposure of
the finishing area (trimming; Fig 4).
■ Positioning of the margin by removing
the most apical preparation zone (ditch-
ing; Fig 5).
This protocol is executable if the impression
taken by the clinician transfers a significant
intrasulcular portion of the preparation to
the laboratory. Note that the margin must
always be located above the epithelial junc-
tion, in the marginal free gingiva, in order not
to invade the supracrestal tissue attachment
 DI FELICE ET AL

Fig 1 Initial case: asymmetric contours, unpleasant Fig 2 Detail of the ‘feather-edge’ preparation in the
esthetic appearance, and misfit of the restorations. intrasulcular area after the tissue stabilization process
with a provisional prosthesis for 6 weeks.

a b

Fig 3a and b Demarcation of the gingival level on the axial wall of the preparation:
detail of the model with exposure of the finishing area that shows where to position the
margin after trimming off the gingival reproduction, with exposure of the entire
intrasulcular portion of the feather edge.

Fig 4 For didactic purposes, the following have been Fig 5 ‘Ditching’ of the model, with positioning of the
marked: the gingival level (black), the gingival margin margin and removal of the most apical portion.
positioned with gingival priority (red), and the apical
limit of the sulcus reading (blue).

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CLINICAL RESEARCH
in any way.5 In this scenario, favorable bio-
logic conditions are determined to obtain
long-term stability of the gingival margin
around the prosthetic crowns, ensuring a
more predictable integrity of the dentogin-
gival junction.6
Step 2: Adaptation profile in ‘free’
increment
In the absence of anatomical landmarks typ-
ical of a preparation with a termination line,
the emergence profile in the sulcular area
is determined according to esthetic mor-
phology parameters such as the harmony
of the gingival contours with the presence
of the distal zenith and the closure of the
interproximal spaces. For all this to be pos-
sible, it is necessary to work on the master
model without reproducing the gingival
portion, feasibly accessing the entire intra-
sulcular area of the new profile (Figs 6 and
7). At this point, a zirconium dioxide-based
coping (Zircodent; Orodent) is fabricated
with a compensated structure design.
Therefore, a profile can then be repro-
duced with a ‘free increase’ of the feldspath-
ic ceramic (Creation Z-IF; Klema) that will
interact with the gingival margin, making it
possible to adapt to the new coronal shape
(Fig 8). As a reference prosthetic margin is
not determined, there will be neither an en-
velope nor an infra contour, thus surpassing
the ‘negative’ concept of an excess contour
that was expressed several years ago; this
should not be confused with overhanging
or misfit.7-9
Step 3: Modification of the gingival
geometry through the ‘prosthetic
adaptation profile’
In the last part of the laboratory work, after
the completion of the prosthetic restor-
ation, its mirror relationship with the gingival
margin can be obtained by working on an
80 | The International Journal of Esthetic Dentistry | Volume 17 | Number 1 | Spring 2022
anatomical model, originally referred to in
1987 by Martignoni and Schoneberger 10 as
a precursor to what was done in the labo-
ratory concept for BOPT and published by
Loi in 20081 (Fig 9). This model is obtained
by making a second casting of the first
master impression, as long as it does not
present areas damaged by the first master
cast (Fig 10). An alternative to obtaining this
relationship is through a pick-up impression
of the esthetic test of the restoration before
the glaze (Fig 11).
In both cases, the gingival geometry of
the model will be modified according to the
aforementioned esthetic parameters, thus
creating the space for a new prosthetic CEJ
(Fig 12). This gingival ‘conditioning’ cannot be
quantified, and the angle that will form bet-
ween the new profile and the intrasulcular
portion of the prepared tooth will be variable.
Through this laboratory protocol a new
coronal contour will be obtained, ie, the so-
called prosthetic adaptation profile, which
will not have as a reference the geometry
of the preparation or the gingival geometry,
and its extension may vary from crown to
crown and even from area to area in the
same crown. In this way, a natural mirror
relationship with the gingival profile will be
restored, adapting to the profile of the pros-
thetic crowns, and not vice versa.
Morphologic aspects of the fourth
dimension of form
Once it has been established that the devel-
opment of the tooth–prosthetic morpholo-
gy and, in particular, the emergence profile
can be constructed without taking into ac-
count the classic concepts of over-, normal
or infra contour, the criteria that determine
the construction of a prosthetic coronal
contour are exclusively esthetic and refer
to the anatomical characteristics of natural
teeth and their intimate relationship with the
periodontium, under ideal conditions.
 DI FELICE ET AL

Fig 6 In the first phase of the ceramics, the master model is used Fig 7 The model without the gingiva allows access to the
without the gingiva, configuring a ‘free increment’ profile. intrasulcular section of the adaptation profile.

Fig 8 Harmonization of marginal contours. The geometry Fig 9 Anatomical model obtained from the master impression.
of the new volumes does not find any anatomical details of the In this case, a Type III stone cast is used.
preparation.

Fig 10 The gingival geometry of the anatomical model is modified

with the harmonization of the marginal contours.

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CLINICAL RESEARCH

a b c

Fig 11a to c Also, in the case where a pick-up impression is preferred (recommended before the glazing phase), gingival geometries are
harmonized in the model.

a b

Fig 12a and b After the anatomical model has been modified it is used to carry out the firings that follow.

a b

Fig 13a and b Details during the definition of the three-dimensionality of the morphology: the use of transition lines as well as alternating
between the master and anatomical models allows the definition of the shape with a complete vision.

82 | The International Journal of Esthetic Dentistry | Volume 17 | Number 1 | Spring 2022


Fig 14 Finished crowns on the master model.
Fig 16 Completed crowns on the anatomical model and their
relationship to a modified gingival geometry in the laboratory.
As mentioned above, this adaptation
profile will support and shape the gingival
margin. Therefore, the possibility exists for
the laboratory technician to create forms,
contours, and interproximal contact areas
in relation to esthetic criteria only. During
the finishing phase of the prosthetic restor-
ation, the work carried out on the macro-
and microtexture to achieve the 3D effect
of the shape is essential. In this phase, the
tracing of the angle–axial transition lines
helps to highlight the sinuosity of the mor-
phology, which can be defined as a ‘fourth
DI FELICE ET AL
Fig 15 Detail of the individualized increase of the new prosthetic
adaptation profiles.
dimension,’ considering it as a transition
area between the three main dimensions
(length, width, and depth) (Figs 13 and 14).
New adaptation profiles are designed that
will be responsible for supporting the gin-
gival tissue (Fig 15), and new contours are
finally created to which the periodontal
tissue will adapt (Fig 16).
One of the key factors in the clinical suc-
cess of fixed restorations is the design of the
prosthesis. The joint responsibility of this lies
with the clinician and the laboratory techni-
cian. The proper design and its relationship
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CLINICAL RESEARCH
to the periodontal tissue is of vital impor-
tance to long-term clinical success.11,12 The
gingiva will adapt, and its clinical response –
without inflammation or bleeding and with-
out a texture or color change – will be key
when evaluating the success of the process
(Fig 17a). Identifying and managing these as-
pects allow the design of the shape in its
emergent contour, with the possibility of
closing interproximal spaces, conditioning
edentulous sections, and reharmonizing
the gingival contours to achieve a long-last-
ing bioesthetic integration of the restoration
(Fig 17b to d). Undoubtedly, the adequate
execution of the prosthesis is a relevant
factor in prosthoperiodontal relationships,
hence the importance of achieving har-
mony between all the components of a
prosthetic treatment, including the finishing
lines and the soft tissue.13
Discussion
The case presented in this article shows the
importance of the criteria to determine the
steps of the new adaptation profiles in the
laboratory included in the BOPT protocol.
The interaction between the laboratory and
the clinic is essential since all processes are
of relevant importance to the final result.
Once the soft tissue remodeling and heal-
ing (guided through the provisionals) has
been obtained, the laboratory technician
is in charge of handling these profiles and
their evolution in order to achieve adequate
support while respecting the position of the
supracrestal tissue.
It has been confirmed that, thanks to
the vertical preparation (which could also
be a clinically less invasive process), the
prosthetic profiles can be better managed
with excellent clinical results.14 This results
in at least three main advantages: freedom
to define the prosthetic contour, a better
prosthoperiodontal integration, and an im-
proved esthetic appearance.
84 | The International Journal of Esthetic Dentistry | Volume 17 | Number 1 | Spring 2022
The authors recommend feldspathic
porcelain-veneered zirconia as the gold
standard material for the BOPT protocol
because it has the advantage of sufficient
rigidity and resistance of zirconium dioxide
for the cervical level,15 accompanied by the
good esthetics generated by feldspathic
ceramics. In addition, its adequate biologic
coexistence in intimate contact with the
periodontal tissue should be highlighted.16
The successful use of this material has been
reported without significant differences
when compared with other horizontal
preparation designs,17,18 and it could not be
refuted when compared with traditional
materials such as metal ceramic.19 The con-
vexity of the crown in the cervical area is
essential, thus highlighting the importance
of the profile of the crown in the periodon-
tal phenotype, suggesting a very subtle con-
vexity in thin periodontal tissue with con-
tacts more toward the incisal third. In thicker
phenotypes, a more pronounced convexity
is required, with proximal contacts closer to
the gingiva, which is also related to the final
shape of the crown.20 It is essential to un-
derstand that, from a sagittal point of view,
the restoration at the subgingival level must
not exceed more than half the thickness of
the gingival tissue, and must have a design
similar to that which occurs in natural teeth
to achieve adequate plaque control, despite
the subgingival location of the margins,
confirming the importance of the relation-
ships between these two components.21
This is essential in the application of the
BOPT, which includes the preparation with
wear of the gingival wall, including the
connective tissue of the sulcus (gingitage),
generating a blood clot that must be stabil-
ized through the provisional restoration for
at least 4 weeks. It should be noted that ver-
tical preparations must be complemented
with an adequate horizontal thickness of
the prosthetic margin, referred to in this
article as the adaptation profile, so that it
 DI FELICE ET AL

a b

c d

Fig 17a to e Stabilized prosthetic and periodontal integration after 30 months.

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CLINICAL RESEARCH
can be perfectly integrated with the peri-
odontal tissue and ratify its long-term clini-
cal predictability.22
Another important factor in the design
of the new adaptation profiles on a vertical
preparation is the location of the contact
areas and their relationship with neighbor-
ing teeth to generate tissue that can occupy
those spaces. The position of the prosthetic
termination zone generates these favorable
conditions for the relocation of the gingival
tissue. A restoration with an adaptive profile
with a contour that ensures gingival sup-
port reduces the likelihood of cervical tooth
abrasion and possible gingival recession.
The interaction between the prosthesis and
the periodontal tissue is based on the fact
that the vertical preparations are intend-
ed to generate space for the adaptation of
the prosthetic profiles.23 The elaboration
of a second model to create symmetric
contours in the prostheses by adding the
ceramic adequately positions the gingival
shapes. In the case presented here, it is
clearly observed how the gingival tissue fol-
lows the contour around the new prosthet-
ic profiles, obtaining the necessary vertical
and horizontal support and generating an
adequate relationship between the prepar-
ation, the prosthesis, and the periodontal
tissue, demonstrated by clinical evidence
at review appointments. With this, the state-
ment by other authors24 who mention that
this therapeutic approach achieves stable
results is ratified, with an increase in tissue
thickness and health and without mechani-
cal complications.24
86 | The International Journal of Esthetic Dentistry | Volume 17 | Number 1 | Spring 2022
Conclusions
The ‘BOPT in Lab’ protocol and the concept
of the prosthetic adaptation profile are com-
plementary and interactive with the clinical
phase of BOPT and relate it to fundamental
technical aspects in order to obtain an ade-
quate integration of the restoration with its
essential biologic factors.
The transfer from the clinic to the labora-
tory (through conventional impression tech-
niques with elastomeric materials) of the in-
trasulcular portion of the vertical preparation
is key to the generation of a new coronal
profile. Regarding the use of a protocol with
a partially or completely digital workflow,
the positioning of the margin could be car-
ried out in the CAD project, requiring greater
depth and specificity in its dissemination.
Subsequently, in the laboratory stage,
separating and isolating the gingival portion
of the dental preparation allows the ceram-
ic placement, without depending on a hori-
zontal termination line, to generate a new
prosthetic adaptation profile with symmet-
ric contours that guide the gingival tissue.
The present case report confirms that
the predominance of the new forms of co-
ronary restorations guide the gingival tissue,
allowing the adaptation of the gingiva to the
prosthesis through the execution of an ade-
quate laboratory procedure. Finally, it is em-
phasized that the laboratory technician and
the clinician must be clear about the objec-
tives to be achieved in the different phases
of a BOPT treatment, maintaining constant
communication and interaction.

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