21.

9 mm 276 x 216 mm

DIGITAL
EDITED BY
CORTES

DENTISTRY
An indispensable introduction to using digital technology in dentistry
Digital Dentistry: A Step-by-Step Guide and Case Atlas provides basic information on the use of
digital resources to find a diagnosis, create a treatment plan, and execute that strategy within
different dental specialisms.

This manual includes the science behind all procedures that use digital technology and provides
a clinical step-by-step guide toward the use of these developments for every dental specialty

DIGITAL DENTISTRY
area. Users will find a wide range of areas covered, from prosthodontics, restorative dentistry,
and endodontics to oral and maxillofacial surgery and public health. This book also includes:

• A guide to all current basic digital imaging and CAD-CAM procedures, with an emphasis
on the most popular systems and software programs.
• An atlas of multidisciplinary cases that were treated with digital dentistry, from diagnosis
A STEP-BY-STEP GUIDE AND CASE ATLAS
and treatment planning to execution and follow-up, in order of complexity
• Assessment of the scientific basis for using digital dentistry in each category EDITED BY
• A presentation of clinical cases to support the use of digital methodologies in all
relevant scenarios
ARTHUR R.G. CORTES
• An exploration of the role of digital dentistry in dental public health, preventive dentistry,
and dental education

Ideal for dental clinicians—general practitioners and specialists—as well as all other dental
professionals, such as dental technologists, dental hygienists, and dental students, Digital
­Dentistry: A Step-by-Step Guide and Case Atlas is an essential tool and reference work to help
dental practitioners streamline and update their practice with the most up-to-date technologies.

The Editor

Arthur R.G. Cortes, DDS, MSc, PhD, is an Associate Professor and Acting Head of
Department, Department of Dental Surgery, Faculty of Dental Surgery, University of Malta.
He has a PhD in Oral Diagnosis after completing a one-year postdoctoral fellowship at
Harvard University, Boston, USA. He is also an Oral Implantologist, fellow and speaker of the
International Team of Implantologists (ITI) and co-founder of the European Academy of
Digital Dentistry.

Cover Design: Wiley

Cover Images: Courtesy of Arthur R.G. Cortes

www.wiley.com/go/dentistry
Digital Dentistry
Digital Dentistry

A Step-­by-­Step Guide and Case Atlas

Edited by

Prof. Arthur R.G. Cortes, DDS, MSc, PhD

Department of Dental Surgery
Faculty of Dental Surgery
University of Malta
Msida, Malta
This edition first published 2022
© 2022 John Wiley & Sons Ltd

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Library of Congress Cataloging-­in-­Publication Data

Names: Cortes, Arthur R. G. (Rodriguez Gonzalez), 1983- editor.
Title: Digital dentistry : a step-by-step guide and case atlas / edited by
Arthur R. G. Cortes.
Other titles: Digital dentistry (Cortes)
Description: First edition. | Hoboken, NJ : John Wiley & Sons, 2022. |
Includes bibliographical references and index.
Identifiers: LCCN 2022002170 (print) | LCCN 2022002171 (ebook) | ISBN
9781119851998 (cloth) | ISBN 9781119852001 (adobe pdf) | ISBN
9781119852018 (epub)
Subjects: MESH: Dental Informatics | Dentistry–methods | Case Reports
Classification: LCC RK240 (print) | LCC RK240 (ebook) | NLM WU 26.5 |
DDC 617.600285–dc23/eng/20220204
LC record available at https://lccn.loc.gov/2022002170
LC ebook record available at https://lccn.loc.gov/2022002171

Cover Design: Wiley

Cover Images: Courtesy of Arthur R.G. Cortes

Set in 9.5/12.5pt STIXTwoText by Straive, Pondicherry, India

 v

Contents

List of Contributors xi
Foreword xv
Preface xvi

Part 1 Basic Knowledge of Digital Dentistry 1

1 Introduction to Digital Dentistry 3

Renan L.B. da Silva, Jun Ho Kim, Roberto A. Markarian, Rui Falacho, Djalma N. Cortes, Alan J.M. Costa,
and Arthur R.G. Cortes
1.1 ­Definitions 3
1.1.1 Three-­Dimensional Imaging 3
1.1.2 Coordinates and Planes 4
1.1.3 Computer-­Aided Design and Computer-­Aided Manufacturing (CAD-­CAM) 4
1.1.4 Mesh 5
1.1.5 Image-­Guided Treatment 5
1.1.6 Image Superimposition/Alignment 5
1.1.7 Resolution 5
1.2 ­History of Digital Dentistry 5
1.3 ­In-­House and Outsourced Digital Workflow 7
1.3.1 The Digital Dental Clinic 7
1.3.2 Impact of Digital Technologies in Dental Clinics 7
1.3.3 The Education of the Digital Dentist 8
1.3.4 Levels of Digitalization for the Dental Clinic 8
1.3.5 Types of Dental Clinics and Business Models 9
1.3.6 Financial Aspects of Digital Dental Clinics 11
1.3.7 How to Calculate the Return on Investment (ROI) 11
1.3.8 Advantages of Digital Dentistry for Clinics 11
1.3.9 Workflow in a Digitalized Dental Clinic 12
1.4 ­Current Knowledge and Perspectives in Artificial Intelligence in Dentistry 12
References 15

2 Computer-­Aided Design (CAD) 18

Jun Ho Kim, Alan J.M. Costa, José Lincoln de Queirós Jr, Juliana No-Cortes, Danielle A. Nishimura,
Shumei Murakami, Reinaldo Abdala-­Junior, Daniel Machado, Claudio Costa, Otavio H. Pinhata-­Baptista,
Shaban M. Burgoa, Andrea Son, Lucas R. Pinheiro, Danilo M. Bianchi, Allan R. Alcantara, and Arthur R.G. Cortes
2.1 ­Digital Imaging Methods 18
2.1.1 Cone Beam Computed Tomography 18
2.1.1.1 Basic Knowledge 18
vi Contents

2.1.1.2 Step-­by-­Step Procedure 19

2.1.2 Intraoral Scanner 20
2.1.2.1 Basic Knowledge 20
2.1.2.2 Step-­by-­Step Procedures 22
2.1.3 Desktop Scanner 27
2.1.3.1 Basic Knowledge 27
2.1.3.2 Step-­by-­Step Procedures 28
2.1.4 Facial Scanner 30
2.1.4.1 Basic Knowledge 30
2.1.4.2 Step-­by-­Step Procedures 31
2.1.5 Clinical Photographs 33
2.1.6 Magnetic Resonance Imaging 38
2.1.6.1 Factors Affecting MRI Quality 38
2.1.6.2 MRI Assessment of Soft Tissue Anatomy 39
2.1.6.3 Diagnosis of Soft Tissue Lesions with MRI 40
2.1.6.4 Temporomandibular Joint Assessment 41
2.1.6.5 Analyzing Bone Structure with MRI 41
2.1.6.6 Three-­Dimensional Reconstructions from MRI 41
2.1.6.7 Studies Using MRI in Digital Workflow 42
2.2 ­Software Manipulation 42
2.2.1 Types of Software Used in CAD 42
2.2.1.1 Nondental Open-­Source Software Programs 42
2.2.1.2 Dental Commercial Software Programs 44
2.2.2 Types of Files Used 45
2.2.2.1 Digital Communication in Medicine (DICOM) 45
2.2.2.2 Standard Tessellation Language (STL) 46
2.2.2.3 Polygon File Format (PLY) 47
2.2.2.4 Object Files (OBJ) 47
2.2.2.5 Files from Clinical Photographs 48
2.2.2.6 Video Files 50
2.2.3 Combining Data: The Virtual Patient 50
References 52

3 Computer-­Aided Manufacturing (CAM) 55

Mayra T. Vasques, Gabriel S. Urbano, Ivan O. Gialain, Jacqueline F. Lima, Fábio Andretti, Ricardo N. Kimura,
Danilo M. Bianchi, Dionir Ventura, Fabricio L. Gebrin, Adriano R. Campos, and Arthur R.G. Cortes
3.1 ­Fused Deposition Modeling (FDM) 57
3.1.1 Basic Knowledge 57
3.1.2 Step-­by-­Step Procedure 58
3.1.2.1 Calibration 58
3.1.2.2 Printing and Postprocessing 60
3.2 ­Liquid Crystal Display (LCD) 60
3.2.1 Basic Knowledge 60
3.2.2 Step-­by-­Step Procedure 60
3.2.2.1 Acquisition 61
3.2.2.2 CAM Software Settings 61
3.2.2.3 Slicing 61
3.2.2.4 Object Printing 62
3.2.2.5 Washing/Postcure 62
3.2.2.6 Conclusion 63
3.3 ­Stereolithography (SLA) 63
 Contents vii

3.3.1 Basic Knowledge 63

3.3.2 Step-­by-­Step Procedure 64
3.3.2.1 Printer Installation 64
3.3.2.2 Equipment Leveling 64
3.3.2.3 Personal Protective Equipment (PPE) 64
3.3.2.4 Resin Reservoir Preparation (Vat) and Build Plate Installation 64
3.3.2.5 Resin Types 64
3.3.2.6 Resin Preparation 64
3.3.2.7 Resin Supply 64
3.3.2.8 Printing Parameters 64
3.3.2.9 Job Upload 64
3.3.2.10 Print 65
3.3.2.11 Removal of the Build Plate 65
3.3.2.12 Removal of Uncured Resin 65
3.3.2.13 Postcure 66
3.3.2.14 Resin Filtration 66
3.3.2.15 Resin and Solvent Disposal 66
3.3.2.16 Preventive Maintenance 66
3.4 ­Digital Light Processing (DLP) 66
3.4.1 Basic Knowledge 66
3.4.2 Step-­by-­Step Procedure 67
3.5 ­Milling 68
3.5.1 Basic Knowledge 68
3.5.2 Step-­by-­Step Procedure 69
3.5.2.1 Laboratory Milling 69
3.5.2.2 Calibrating and Testing the Milling Device 70
3.5.2.3 Chairside Milling Procedures 75
References 78

Part 2 Clinical Applications of Digital Dentistry 79

4 Digital Workflow in Prosthodontics/Restorative Dentistry 81

José Lincoln de Queirós Jr, Thiago Ottoboni, Gabriel S. Urbano, Danilo M. Bianchi, Renato Sartori,
Juliana No-­Cortes, Jacqueline F. Lima, Roberto A. Markarian, Alan J.M. Costa, Shaban M. Burgoa, Charles Melo,
Newton Sesma, Florin Cofar, Eric Kukucka, Alexandre D. Teixeira-­Neto, Guilherme Saavedra, Diogo Viegas,
Andrea Son, Maria L. Gainza-­Cirauqui, and Arthur R.G. Cortes
4.1 ­Clinical Procedures for Intraoral Scanning 81
4.1.1 Teeth Preparations 81
4.1.2 Implant Scanbodies 82
4.1.2.1 Step-­by-­Step Procedures: Dental Implant Impressions 83
4.1.2.2 Stereophotogrammetry: An Accurate and Fast Alternative 84
4.2 ­Setting Up the Virtual Patient 85
4.2.1 Importing Intraoral Scans to the CAD Software 85
4.2.2 The Virtual Articulator 85
4.2.2.1 Step-­by-­Step Procedure for Using a Virtual Articulator in a Digital Workflow 85
4.2.3 Esthetic Analyses and Digital Smile Design 88
4.2.3.1 Esthetic Analyses 89
4.2.3.2 Two-­Dimensional Digital Design of the Smile 89
4.2.3.3 3D Image-­Obtaining Methods for Esthetic
Analysis 89
viii Contents

4.2.3.4 Step-­by-­Step Procedure for 3D Dentofacial Esthetic Analyses 90

4.2.4 Dynamic Smile Analysis 91
4.2.4.1 Step-­by-­Step Procedure for Dynamic Smile Analysis 92
4.3 ­Digital Workflow for Restorations/Prostheses 92
4.3.1 Single Crowns 95
4.3.1.1 Tooth-­Supported Single Crowns 95
4.3.1.2 Working with Dies 116
4.3.1.3 Implant-­Supported Crowns 116
4.3.1.4 CAD-­CAM Copings 120
4.3.1.5 Customized Abutments 120
4.3.2 Splinted Crowns and Fixed Bridges 123
4.3.2.1 Step-­by-­Step Procedure to Design and Mill a Fixed Bridge 123
4.3.3 Laminate Veneers 133
4.3.4 Inlay and Onlay Restorations 144
4.3.5 Digitally Guided Direct Resin Composite Restorations 149
4.3.5.1 Step-­by-­Step Guide 149
4.3.6 Digital Complete Dentures 152
4.3.6.1 Removable Prosthodontic Rehabilitation Workflow: The BPS-­SEMCD Method Summarized 152
4.3.7 Complete-­Arch Implant-­Supported Prostheses 168
4.3.7.1 Utilizing CAD-­CAM for Full-­Arch Prosthetics 168
4.4 ­Three-­Dimensional Printing in Prosthodontics 172
4.4.1 3D-­Printed Resin Restorations 172
4.4.2 3D-­Printed Dental Casts 176
4.4.2.1 Importing the File 176
4.4.2.2 Handling the File 177
4.4.2.3 Cleaning the Mesh 177
4.4.2.4 Smoothing the Mesh Edge 178
4.4.2.5 Creating the Base 179
4.4.2.6 Making It Solid 179
4.4.2.7 Making It Hollow 180
4.4.2.8 Cutting the Plane 181
4.4.2.9 Exporting 181
References 183

5 Digital Workflow in Periodontology 185

Ana P. Ayres, Alexandre D. Teixeira-­Neto, and Arthur R.G. Cortes
5.1 ­Periodontal Surgical Planning 185
5.2 ­CAD-­CAM Surgical Guides for Clinical Crown Lengthening 186
5.2.1 Planning for Periodontal Surgical Guide Manufacturing 188
5.3 ­Image-­Guided Periodontal Surgery 190
5.4 ­Surgical Guide for Soft Tissue Graft 192
5.5 ­Research Evidence 194
References 195

6 Digital Workflow in Implant Dentistry 197

Otavio H. Pinhata-­Baptista, Roberto A. Markarian, Shaban M. Burgoa, Alan J.M. Costa,
Jesus T. Garcia-­Denche, Baoluo Xing, Oscar I. Velazquez, and Arthur R.G. Cortes
6.1 ­The Concept of Prosthetically Driven Surgical Planning 197
6.2 ­Static Image-­Guided Implant Surgery 197
6.2.1 Dual CBCT Scanning Technique 198
6.2.1.1 Tomographic Guide 198
 Contents ix

6.2.2 Using Combined CBCT and Intraoral Scans 199

6.2.2.1 Virtual Waxing 199
6.2.2.2 Virtual Implant Surgery Planning Software 199
6.2.3 Full-­Arch Implant Rehabilitations 205
6.2.3.1 The Concept of Digital Image-­Guided Implant Surgery for Full-­Arch Rehabilitations 205
6.2.3.2 Advantages of Guided Surgery 205
6.2.3.3 Dental Teamwork and Technical Requirements for Planning Guided Surgeries 205
6.2.3.4 General – Performing Surgery 206
6.2.3.5 Step-­by-­Step Procedure for Full-­Arch Image-­Guided Surgery, from Planning to Surgery 207
6.2.3.6 Additional Remarks 213
6.2.4 Zygomatic Implants 213
6.3 ­Dynamic Guided Implant Surgery 218
6.3.1 Surgical Technique 218
6.4 ­Bone Graft Volumetric Planning 219
6.4.1 Socket Preservation 219
6.4.2 Sinus Lifting 223
6.4.3 Onlay Bone Grafts 225
References 226

7 Digital Workflow in Oral and Maxillofacial Surgery 227

Daniel Negrelle, Alexandre M. Borba, Isabella Romão Candido, Shaban M. Burgoa,
Luiz F. Palma, and Arthur R.G. Cortes
7.1 ­Image-­Guided Surgical Removal of Impacted Teeth 227
7.2 ­Surgical Planning of Orthognathic Surgeries 227
7.2.1 Virtual Skull Construction 227
7.2.1.1 Coronal Panoramic Image 235
7.2.1.2 Three-­Dimensional Reconstruction and Segmentation of the Bones 235
7.2.1.3 Importing Dental Scanning 235
7.2.1.4 Mesh Clean-­Up 237
7.2.1.5 Osteotomy Design 237
7.2.1.6 Virtual Skull Orientation According to the Natural Head Position 240
7.2.1.7 Cephalometric Points: Locating and Defining 241
7.2.2 Virtual Planning: Bone Movements 242
7.2.3 Surgical Splint Creation 246
7.2.4 Comparison of Results from Virtual Planning 248
7.3 ­Surgical Guides: Types and Classification 248
7.4 ­Virtual Planning of Trauma Surgeries 253
References 256

8 Digital Workflow in Endodontics 257

Daniel M. Kier, Lucas R. Pinheiro, Maria Clara R. Pinheiro, and Arthur R.G. Cortes
8.1 ­Digital Imaging in Endodontics 257
8.1.1 Recommendations for Endodontic Imaging 257
8.2 ­Electronic Apex Location 258
8.2.1 Step-­by-­Step Procedure for Using an EAL 258
8.3 ­Use of the Dental Operating Microscope in Endodontics 258
8.4 ­CAD-­CAM Guided Endodontics 259
8.4.1 Indications and Advantages 259
8.4.2 Step-­by-­Step Procedure to Perform CAD-­CAM Guided Endodontics 260
8.4.2.1 Take a CBCT of the Involved Tooth 260
8.4.2.2 Surface Scan 260
x Contents

8.4.2.3 Import Both CBCT and Surface Scans 260

8.4.2.4 CBCT Preparation 260
8.4.2.5 Merging of CBCT and Surface Scan Images 260
8.4.2.6 Guided Access Planning 260
8.4.2.7 Surgical Guide Design 262
8.4.2.8 Approval of Planning and Printing of the Guide 262
8.4.2.9 Guided Surgery Access 262
Acknowledgments 262
References 263

9 Digital Workflow in Orthodontics 264

Guilherme S. Nakagawa, Juliana No-­Cortes, Adriano G.B. de Castro, Fernando Barriviera, Maurício Barriviera,
and Arthur R.G. Cortes
9.1 ­CAD-­CAM Guides for Orthodontic Brackets 264
9.2 ­CAD-­CAM Guides for Orthodontic Miniscrews 264
9.2.1 Technique 267
9.2.2 Discussion 276
9.3 ­Orthodontic Aligners 276
References 286

10 Digital Workflow in Dental Public Health, Preventive Dentistry, and Dental Education 287
Anne-­Marie Agius, Nikolai J. Attard, Gabriella Gatt, and Arthur R.G. Cortes
10.1 ­Digital Dentistry in Public Health 287
10.1.1 The Role of Teledentistry 288
10.1.2 The Expected Role of CAD-­CAM in Public Health 288
10.2 ­Digital Workflow in Preventive Dentistry 289
10.3 ­Digital Dentistry in Dental Education 289
References 291

Part 3 Case Atlas 293

11 Multidisciplinary Clinical Cases 295

Alan J.M. Costa, Alexandre D. Teixeira-­Neto, Jun Ho Kim, Allan R. Alcantara, Daniel Machado, Gustavo Giordani,
Marcelo Giordani, Florin Cofar, José Lincoln de Queirós Jr, Luis E. Calicchio, Djalma N. Cortes,
Arthur R.G. Cortes, Guilherme Barrella, Fábio Cabral, Guilherme S. Nakagawa, Richard Leesungbok,
Hossam Dawa, and Daniel No
­References 371

Index 372
 xi

List of Contributors

Reinaldo Abdala-­Junior, DDS, MSc, PhD Fernando Barriviera, DDS

Professor Masters Student
Department of Radiology, UniFSP Department of Oral Radiology
Avaré, Brazil São Leopoldo Mandic Institution
Campinas, Brazil
Anne-­Marie Agius, BchD, MSc
Assistant Lecturer and PhD Student Maurício Barriviera, DDS, MSc, PhD
Department of Oral Rehabilitation and Professor
Community Care Department of Radiology, Catholic University of Brasilia
University of Malta Brasilia, Brazil
Msida, Malta
Danilo M. Bianchi, DDS
Allan R. Alcantara, DDS Dental Clinician
Dental Clinician Private Practice
Odonto Postale São Paulo, Brazil
São Paulo, Brazil
Alexandre M. Borba, DDS, MSc, PhD
Fábio Andretti, DDS, MSc, PhD Professor of Oral Surgery
Assistant Professor University of Cuiabá
Faculdade AVANTIS Cuiabá, Brazil
Department of Operative Dentistry and Biomaterials
Florianópolis, Brazil Shaban M. Burgoa, DDS, MSc
Professor and CFO
Nikolai J. Attard, BchD, MSc, PhD Beyond Digital Solutions
Professor Curitiba, Brazil
Head of the Department of Oral Rehabilitation and
Community Care Fábio Cabral, DDS
University of Malta Dental Clinician
Msida, Malta Cabral Concept
São Paulo, Brazil
Ana P. Ayres, DDS
PhD Student Luis E. Calicchio, DDS
Department of Stomatology Dental Clinician
School of Dentistry, University of São Paulo Carbon Smile Clinic
São Paulo, Brazil São Paulo, Brazil

Guilherme Barrella, DDS Isabella Romão Candido, DDS, MSc

Dental Clinician PhD Student
Private Practice University of Cuiabá
São Paulo, Brazil Cuiabá, Brazil
xii List of Contributors

Adriano R. Campos, DDS, MSc Adriano G.B. de Castro, DDS, MSc, PhD
PhD Student Professor
Department of Prosthodontics Department of Orthodontics, Catholic University
School of Dentistry, UERJ of Brasilia
Dental Clinician Brasilia, Brazil
Software Engineer
Rio de Janeiro, Brasil José Lincoln de Queirós Jr, DDS
Dental Clinician
ClickDent Digital Dentistry
Florin Cofar, DDS
Brasilia, Brazil
Dental Clinician
DENTCOF Rui Falacho, DMD, MSci, PgD, PhD
Timisoara, Romania Assistant Professor
Faculty of Medicine
Arthur R.G. Cortes, DDS, MSc, PhD University of Coimbra
Associate Professor Coimbra, Portugal
Acting Head of the Department of Dental Surgery
Faculty of Dental Surgery, University of Malta Maria L. Gainza-­Cirauqui, DDS, MSc, PhD
Msida, Malta Lecturer and Head of the Department of
Dental Surgery
Djalma N. Cortes, DDS University of Malta
Dental Clinician Msida, Malta
Private Practice
São Paulo, Brazil Jesus T. Garcia-­Denche, DDS, MSc, PhD
Full Professor of Oral Surgery
Juliana No-Cortes, DDS, MS Complutense University of Madrid
Clinical Tutor and PhD Student Madrid, Spain
Department of Restorative Dentistry
University of Malta Gabriella Gatt, BchD, MSc, PhD
Msida, Malta Lecturer and Head of the Department of
Child Dental Health & Orthodontics
Alan J.M. Costa, DDS University of Malta
Professor and CEO Msida, Malta
Beyond Digital Solutions
Curitiba, Brazil Fabricio L. Gebrin, DDS, MSc, PhD
Founder and Research Manager
Claudio Costa, DDS, MSc, PhD Makertech Labs
Associate Professor Curitiba, Brazil
Department of Stomatology
Ivan O. Gialain, DDS, MSc, PhD
School of Dentistry, University of São Paulo
Professor
São Paulo, Brazil
University of Cuiabá (UNIC)
Cuiabá, Brazil
Renan L.B. da Silva, DDS, MSc
PhD Student Gustavo Giordani, DDS
Department of Stomatology Dental Clinician
School of Dentistry, University of São Paulo Studio Giordani
São Paulo, Brazil São Paulo, Brazil

Hossam Dawa, DDS, MSc Marcelo Giordani, DDS

Professor and PhD Student Dental Clinician
CESPU University Private Practice
Gandra, Portugal Alphaville, Brazil
 List of Contributors xiii

Daniel M. Keir, DDS Charles Melo, DDS, MSc

Senior Lecturer Dental Clinician
Department of Oral Rehabilitation and Private Practice
Community Care Curitiba, Brazil
University of Malta
Msida, Malta Shumei Murakami, DDS, MSc, PhD
Professor
Department of Radiology, Osaka University
Jun Ho Kim, DDS, MSc Osaka, Japan
PhD Student
Department of Stomatology Guilherme S. Nakagawa, DDS, MSc
School of Dentistry, University of São Paulo Dental Clinician
São Paulo, Brazil NKS Clinic
Curitiba, Brazil
Ricardo N. Kimura, BS Daniel Negrelle, DDS
CEO Oral and Maxillofacial Surgeon
Done3D Private Practice
Ribeirão Preto, Brazil Curitiba, Brazil

Eric Kukucka, DDS Danielle A. Nishimura, DDS, MSc

Dental Clinician PhD Student
The Denture Center Department of Radiology, Osaka University
Toronto, Canada Osaka, Japan

Richard Leesungbok, DDS, MSc, PhD Daniel No, DDS

Head Professor, Department of Biomaterials & Dental Clinician
Prosthodontics Harbor Modern Dentistry
Director, International Exchange Committee Costa Mesa, USA
in Dental School Hospital Thiago Ottoboni, DDS
Head, Center of Dental Remodeling Dental Clinician
& Implant Blumenau, Brazil
Kyung Hee University School of Dentistry
Seoul, South Korea Luiz F. Palma, DDS, PhD
Full Professor, Postgraduate Course in Dentistry
Jacqueline F. Lima, CDT Ibirapuera University (UNIB),
CAD and Dental Technician São Paulo, Brazil
DentalQuick Lab
Otavio H. Pinhata-­Baptista, DDS, MSc
Tarragona, Spain
Head of the Implantology Clinic
Military Hospital of São Paulo Area (HMASP)
Daniel Machado, DDS, MSc PhD Student
CEO and Dental Clinician Department of Stomatology
Próspere Clinic School of Dentistry, University of São Paulo
São Paulo, Brazil São Paulo, Brazil

Roberto A. Markarian, DDS, MSc, PhD Lucas R. Pinheiro, DDS, MSc, PhD
Dental Clinician Oral and Maxillofacial Radiologist, Radioface Clinic
IMPLART Dental Clinic Professor of Radiology, CESUPA
São Paulo, Brazil Pará, Brazil
xiv List of Contributors

Maria Clara R. Pinheiro, DDS, MSc Gabriel S. Urbano, DDS

PhD Student Masters Student
Department of Radiology Department of Stomatology
School of Dentistry, University of Campinas (UNICAMP) School of Dentistry, University of São Paulo
Piracicaba, Brazil São Paulo, Brazil

Guilherme Saavedra, DDS, MSc, PhD Mayra T. Vasques, DDS, MSc, PhD
Associate Professor Founder, INNOV3D
Department of Dental Materials Collaborator Professor at Hospital Israelita
and Prosthodontics Albert Einstein
School of Dentistry, State University of São São Paulo, Brazil
Paulo (UNESP)
São José dos Campos, Brazil Oscar I. Velazquez, DDS
Masters Student
Renato Sartori, DDS, MSc Department of of Oral Surgery
Clinical Professor Complutense University of Madrid
São Leopoldo Mandic Institution Madrid, Spain
São Paulo, Brazil
Dionir Ventura, CDT
Newton Sesma, DDS, MSc, PhD Dental Technician
Assistant Professor Ventura Lab
Department of Prosthodontics Curitiba, Brazil
School of Dentistry, University of São Paulo
São Paulo, Brazil Diogo Viegas, DDS, MSc, PhD
Assistant Professor
Lisbon Dental School, FMDUL
Andrea Son, DDS, MSc
Lisbon, Portugal
Research Analyst
Department of Research and Development
Baoluo Xing, DDS
Plenum Bioengenharia (PLENUM)
Masters Student
São Paulo, Brazil
Department of Oral Surgery
Complutense University of Madrid
Alexandre D. Teixeira-­Neto, DDS, MS Madrid, Spain
Professor and COO, Beyond Digital Solutions
Curitiba, Brazil
Dental Clinician
Batel Soho Clinic
Curitiba, Brazil

Foreword
Dentistry has been facing major changes, and along
with this transformation come challenges. A catch-
phrase would be: evolution will always be accompanied
by initial difficulties. Here we are today.
I understand, dear reader, the natural resistance that we
have when looking at new directions and techniques,
because as human beings, we love a place called the
“comfort zone”: a lovely place where nothing happens.
My father, a retired dentist, had the same resistance that
I see in a large number of colleagues today. In the past, we
heard that, if you are used to a technique and material,
you shouldn’t change it because it would be working
“right” for you. Nothing more wrong and misleading, oth-
erwise, no major evolution would have taken place and
we would be using candles instead of electricity because
“it’s been working so far.” The future comes in huge waves
of change, which initially obviously cause suffering.
The digitalization of dentistry has impacted processes
and procedures, as well as workflows and time involved
in clinical procedures. Make no mistake: it’s not the
future, it’s the present.
I don’t deny that there will always be room for indi-
vidual talent, superb handicraft, and brilliant creativity
xv
in a unique case within our profession. But I believe that
all art and creation will be accompanied by a less manu-
ally driven process and many digitalization tools, as we
have already seen in plastic art and architecture.
This book fills a space in the high-level literature,
related to the processes and techniques of digital den-
tistry. In a way, it can be a great relief for the difficulty
that some professionals have faced in accepting new
technologies, an analgesic with an extremely detailed
package leaflet. Conceptual resistance can only be dealt
with by consistent information. After a long period of
COVID and its restrictions and doubts, we know more
than ever that only science can overcome old concepts
and preconceptions.
Like me, you the reader will be able to reduce doubts
and opinions based on concepts that are often outdated,
and face the new, with KNOWLEDGE.
Ronaldo Hirata DDS, MS, PhD
Assistant Professor of Biomaterials NYU
Private practice in Curitiba, Brazil
International lecturer with more than 150 papers and
four books published
xvi
Preface
As dental professionals, we should always make sure
that our knowledge and skills are up to date to improve
our ability to care for our patients. In the current con-
gresses and symposia, a number of exhibitors have been
demonstrating technological products to be used in
most areas of dentistry. On social media, it is also com-
mon to see professionals showing interesting clinical
results after using these new products and related tech-
niques. Even in dental research, we can see many new
articles and even some new scientific journals focused
on digital dentistry.
As a young professor who had just come back from
Harvard University to Brazil in 2015, I was very excited
to bring the new methodologies to the dental clinic of
my family in São Paulo. My main research interest at
that time, however, was magnetic resonance imaging
in dentistry. Furthermore, as a clinician, I was dedicated
almost solely to implant dentistry and was not fully con-
vinced about the benefits of image-­guided surgeries.
Similarly, my father was already performing CAD-­CAM
crowns, but still using conventional impressions
with the polyvinyl siloxane materials that he always
loved to use.
Three years later, I met some of the opinion leaders of
digital dentistry, who are now very good friends of mine.
We were lucky that dentistry in Brazil has always been
very well developed and respected. As a result, several
congresses and conferences brought us opportunities to
see new courses and exhibitors, always with the most
novel and exciting technologies and techniques for digi-
tal workflow in dentistry. Several clinicians were doing
an amazing job in applying the new technologies to
enhance predictability in performing the principles of
dentistry, which were actually the same. Despite every-
thing seeming so promising, I realized that the train
of digital dentistry was still at the station as regards
research and evidence-­based knowledge. At that point,
I changed the main focus of my research to CAD-­CAM
and digital dentistry, and since then I have been in love
with the topic.
After obtaining clinical and scientific knowledge on
CAD-­CAM, and talking to expert friends, I began to won-
der: what if we had a book in the form of a step-­by-­step
guide to provide evidence-­based knowledge of the tech-
niques that professionals might want to perform using
these new tools to improve their practice? In addition,
what if this could come along with an atlas of clinical
cases, performed by me, my father, and the profession-
als that I have always admired in digital dentistry?
As a result of a huge team effort, this book aims to
help colleagues who are dentists, dental technicians,
and other members of the dental team to improve their
skills to promote patient care. We did our best to try to
help our community here. On the other hand, we know
that several techniques and approaches are still being
developed and investigated. So, this book shows what
we know so far, and what we have been doing with the
existing tools, techniques, and knowledge, rather than
trying to define what is the best approach for every clini-
cal situation. There are three initial chapters describing
basic knowledge of CAD-­CAM and eight other chapters
covering all applications of digital dentistry. Since we
also want the new methods to benefit all patients in a
collective and inclusive way, there is also a chapter on
the role of digital dentistry in preventive dentistry and
public dental health. The final chapter is basically an
atlas of clinical cases performed by the experts whom
I have admired most in the field.
I really hope this book can be useful at some point in
all our dental practices, and I thank all my co-­authors
and my team at the University of Malta for all the sup-
port that I have received.
Thank you very much,
Professor Arthur R.G. Cortes
 1

Part 1

Basic Knowledge of Digital Dentistry

 3

Chapter 1
Introduction to Digital Dentistry
Renan L.B. da Silva, Jun Ho Kim, Roberto A. Markarian, Rui Falacho, Djalma N. Cortes, Alan J.M. Costa,
and Arthur R.G. Cortes

SUMMARY

This chapter will discuss all the terms and definitions that the dental professional needs to know to understand the proce-
dures discussed in the following chapters. Such definitions include abbreviations and general concepts of digital imaging and
digital workflow. The chapter also presents a history of the use of CAD-­CAM in dentistry in the last two decades, and the basic
knowledge required plus ideas and alternatives to start with digital dentistry.

1.1 ­Definitions distortion, magnification, superimposition of anatomi-

Digital dentistry is the term used to describe the differ-
ent modalities of dental treatment workflow that are
mostly performed with the use of digital technologies.
Several digital methods have been incorporated to
dental practice to replace conventional methods and
techniques in order to enhance treatment planning and
predictability of execution. Nowadays, digital dentistry
is considered a whole field of study within dentistry. As
with any other field of study, digital dentistry involves a
learning curve to be mastered and used in the clinical
routine. Ultimately, the dental professional is responsi-
ble for using existing digital tools appropriately for
patient treatment. In other words, the basic theories of
dentistry are still the same and should be very well
known by the professional, who will be able to use these
new digital tools to enhance predictability in executing
the treatment plan.
In order to become familiar with digital dentistry
and take advantage of its benefits, it is required to
learn a series of important concepts and abbrevia-
tions. The most important of these are discussed below.
1.1.1 Three-­Dimensional Imaging
Conventional two-­dimensional (2D) imaging modali-
ties usually have several limitations such as image
cal structures, and lack of three-­dimensional (3D) infor-
mation for diagnosis and planning. In this context, 3D
imaging modalities such as cone beam computed
tomography (CBCT), intraoral and facial scanning sys-
tems provide 3D digital images for dentistry [1–3].
CBCT imaging allows for visualization and assessment
of bone structures with high diagnostic accuracy and
precision. For CBCT images, the professional needs to
understand image acquisition parameters, since the
quality of the image affects the quality of the work in
digital dentistry. There are several CBCT acquisition
parameters, such as field of view size (FOV), peak kilo-
voltage (kVp), milliamperage (mA), and voxel size. Each
of these parameters has an influence on CBCT
quality [2–5].
Intraoral and facial scanning can capture 3D patient
images that can be used for digital treatment planning
systems (Figure 1.1). The software will then develop a
digital representation of the 3D object surfaces availa-
ble, which will be automatically converted into 3D
images composed by wireframe models.
Any 3D images can be rendered and edited in the 3D
space, before being converted and saved in a specific file
format [5]. As discussed in the next chapter, three file
formats are commonly used in digital dentistry: OBJ,
STL, and PLY. These files are based on the geometric
reconstruction of objects by vectors, triangles or

Digital Dentistry: A Step-by-Step Guide and Case Atlas, First Edition. Edited by Arthur R.G. Cortes.
© 2022 John Wiley & Sons Ltd. Published 2022 by John Wiley & Sons Ltd.
4 Digital Dentistry: A Step-by-Step Guide and Case Atlas
Figure 1.1 Three-­dimensional objects imported in different
coordinates of the 3D space (screen capture of MeshMixer
software, Autodesk). Note that the fixed bridge is closer to
the screen than the molar crown. The dynamic grid is used to
orientate the spatial disposition of the 3D objects.
polygons, considering their positioning in a 3D space.
After all data is ready, it is possible to store the shape of
a model and other details such as color or texture.
Three-­dimensional images can be manipulated in
various ways, depending on the characteristics of the
software. For example, with DICOM and STL files,
using the CAD software one can plan and perform digi-
tal surgery of dental implants and wax-­up of future
prostheses. After digital planning, the implant surgery
guide, temporary crowns, and definitive crowns can be
printed with additive manufacturing devices or milled
by subtractive manufacturing devices [5, 6].
1.1.2 Coordinates and Planes
All 3D images are created or rendered in a virtual space
of coordinates and planes. Any objects that are digitally
designed within the 3D coordinates can be fully edited
in the virtual space, before being manufactured. The
coordinate system is a method of assigning numbers to
points. In three dimensions, three numbers are required
to specify a point. Plain 2D images have numbers related
to only two coordinates (x and y). The coordinate that
represents the third dimension is usually an axis called
z. The z-­axis is perpendicular to both the x-­axis and the
y-­axis (Figure 1.2).
The coordinates and the respective planes provide ref-
erences for the location, size, and volume of the 3D
images. All 3D objects have their coordinates fixed in a
virtual plane of the imaging software. It is important to
Figure 1.2 A 3D object (reconstructed model of a maxillary
CBCT scan) is positioned in the 3D space of a software
(Ultimaker Cura) to be 3D printed. Note the three axes
depicted by the software in different colors (x-­axis in red,
y-­axis in green, z-­axis in blue).
make sure that multiple 3D objects to be manipulated or
aligned are positioned in the same spatial coordinates,
which can be used as spatial references. Therefore, 3D
files from different imaging methods should be in the
same 3D coordinates in order to be superimposed or
combined with the aim of creating a virtual patient, as
explained further in this chapter.
1.1.3 Computer-­Aided Design and
Computer-­Aided Manufacturing (CAD-­CAM)
The term computer-­aided/assisted design is usually
abbreviated as CAD. The methods used for image acqui-
sition (CBCT, scanning imaging, photographs) and
manipulation (software programs) can be included in
CAD. On the other hand, computer-­aided/assisted man-
ufacturing (CAM) includes processes such as 3D print-
ers (additive manufacturing) and milling devices
(subtractive manufacturing). CAD-­CAM technologies
are currently used in biomedical engineering, clinical
medicine, customized medical implants, tissue engi-
neering, dentistry, artificial joint manufacture, and
robotic surgery. Furthermore, the use of CAD-­CAM
technologies has been increasing in various fields of
study of medicine and dentistry [5, 6]. Among the main
devices that can be digitally designed and manufactured
are different types of dental restorations and prostheses,
surgical guides, occlusal splints, dental casts, and ortho-
dontic aligners [5, 7]. Details of the main clinical appli-
cations of CAD-­CAM in dentistry are further addressed
in the next chapters.

1.1.4 Mesh
The term mesh is used to describe the surface of a 3D
object composed of triangular or polygon faces. A mesh
object does not have any actual curvature. Instead, the
appearance of curvatures in a 3D image composed of
meshes is obtained by increasing the number of sur-
faces. The most common file format of these 3D images
is the STL file [5], which will be discussed in detail in
the next chapter.
1.1.5 Image-­Guided Treatment
Since 3D patient scans are taken prior to dental treat-
ment, CAD-­CAM technology can be used for the fabri-
cation of surgical guides, preparation guides, and
maxillofacial surgical templates. Most of these applica-
tions require 3D hard and soft tissue images generated
by CBCT and optical scanning image modalities, respec-
tively. Based on such images, CAD-­CAM guides can be
designed and manufactured to orientate directions of
drilling procedures and incisions [5].
1.1.6 Image Superimposition/Alignment
Distinct 3D image files like DICOM and STL can be
overlaid or aligned using CAD software. In the field of
digital dentistry, aligning DICOM and STL is useful to
plan implant placement. Details of image alignment
will be addressed in the next chapter.
1.1.7 Resolution
In 2D images, the resolution depends on the number of
pixels. A pixel is the smallest unit of a digital image that
can be displayed and represented on a digital display
device, also known as a picture element (pix = picture,
el = element). A pixel is represented by a dot or square
on a computer display screen. Pixels are the basic build-
ing blocks of a digital image or display and are created
using geometric coordinates. Depending on the graphics
card and display monitor, the quantity, color combina-
tion, and size of pixels vary and are measured in terms of
the display resolution. A full high-­definition (full HD)
image is 1920 pixels in width and 1080 pixels in height,
totaling 2.07 megapixels. Ultra HD (also known as 4 K)
resolution has 3840 × 2160 pixels, totaling 8.3 megapixels.
The 3D version of a pixel is called a voxel. In general,
the smaller the voxel size is, the better quality a 3D
reconstructed model will have.
The quality of radiographic images depends on con-
trast resolution and spatial resolution. Contrast resolu-
tion is proportional to the size of the contrast scale
Chapter 1 Introduction to Digital Dentistry 5
available to produce the image. As a result, the higher
the contrast resolution of an image, the easier it will be
to distinguish between multiple densities. In digital
imaging, contrast resolution depends on the bit-­depth
of the imaging method, following a logarithmic scale.
Therefore, a panoramic radiograph produced with an
8-­bit system can show 28 = 256 different gray-­scale lev-
els distributed from black to white. A CBCT device with
a 12-­bit system will offer 212 = 4096 gray-­scale values.
Spatial resolution is the ability of an imaging method to
identify the actual limits and differentiate two adjacent
structures [2–4].
Resolutions in 3D CAD files basically depends on the
size and densities of the meshes. The quality of the
respective manufactured device, however, is also
dependent on factors related to CAM (e.g., resolution of
3D printers or milling devices). For 3D printers, there
will be factors related to the resolution such as the num-
ber of layers and layer thicknesses. For milling machines,
the resolution will be dependent on the number of axes
and size of burs (see Chapter 3).
1.2 ­History of Digital Dentistry
Science and technology are the foundations of human
development. From the rudimentary creation and
improvement of stone tools, accompanied by the break-
through in learning to control fire and the Neolithic
revolution, which multiplied the sustenance availabil-
ity, to the significant invention of the wheel which
allowed humans to travel and produce machinery, or
the overcoming of physical barriers with advancements
in communications, technology is what sets human-
ity apart.
Alongside technology, a lexicon development has
always been necessary to provide a common under-
standing of innovations in the meaning and usage of
new or existing words. The technological lexicon expan-
sion will often plainly exhibit a novel sense in use but
also a rationalization as to why a fresh sense has sur-
faced. This derives from the need to name new inven-
tions, and when these ascend to a well-­known state, so
does the correlated terminology. A widespread example
of this lexicon expansion is the “digital” concept which,
in the last century, underwent a huge increase in usage
and meaning as an unswerving consequence of modern
computing.
However, contrary to what is customary in technol-
ogy, the term “digital” is by no means a new word. With
its etymology in the Latin word digitus, meaning finger
or toe, “digital” has come a long way since. In the
6 Digital Dentistry: A Step-by-Step Guide and Case Atlas
fifteenth century, the word was used to identify Arabic
numbers from 1 to 9 and 0 as digits. It was not until the
twentieth century that the term became widespread and
gained significance. In the 1930s and 1940s, the existing
analogue computing devices which computed data with
the normal decimal system were replaced by new
machines which functioned with data represented as
sequences of discrete digits.
In the late 1970s, electronics using the digital concept
were no longer limited to research institutions and com-
panies. As their cost dropped, the general public started
to have access and myriad information sources and
equipment were converted to the digital era. From a
simple CD to a more complex digital sensor camera,
radiovisiography or 3D scanner, the world was changed
forever.
The construct of “digital” did not stop with machine
development but acquired a broader meaning. It has
evolved to encompass everything linked to digital or
computer technology, as well as to describe any
computer-­mediated equivalent of an object or entity
that exists in the palpable world. Daily uses of this con-
cept are digital shopping carts and digital books, among
others. Not only ordinary objects but also professions,
expertise fields, and whole organizations acquire the
digital connotation when they embrace technology
(either hardware or software) for their activities.
Examples of this are the many references to digital den-
tistry or the thriving European Academy of Digital
Dentistry that quickly became one of the most respected
and widespread scientific societies in the dental field.
Although the twentieth century was overflowing with
the word “digital” as the most significant technological
innovation in human history, it is predictable that the
twenty-­first century renders the word “digital,” but not
the concept, obsolete. As digital becomes the norm, the
need to identify it as such becomes archaic. Fields like
digital dentistry will overrun the previous model as all
dentistry becomes digital, thus eliminating the need for
an alias. Similar to the previously named “digital com-
puters,” so digital wax-­ups, digital photography, and
many more entities will lose the superfluous prefix.
Having discussed the past, present, and future general
notions of digital, it is imperative to clarify the current
concept of digital dentistry, as it may not comply with
the ingrained notion promoted and labeled by the
industry. Although more widely marketed in oral reha-
bilitation and surgery fields, digital dentistry has a vast
predominance in endodontics, cariology, periodontics,
orthodontics, and occlusion, among others. Nowadays,
it is clear that digital dentistry encompasses all areas
and not only the well-­marketed misconception of
“digital” as a synonym of CAD-­CAM dentistry, a com-
mon buzzword in oral healthcare. CAD-­CAM technol-
ogy presents a vast sea of innovation opportunities and
is undoubtedly one of the drivers of development in
modern dentistry. Nonetheless, according to the con-
cept regulated by the European Academy of Digital
Dentistry, “Digital dentistry encompasses any and all
scientific, clinical or laboratory techniques and/or pro-
cedures with the purpose of examining, diagnosing,
treating, assisting directly or indirectly in the treatment,
production of medical devices or any other techniques
used by dentists and dental technicians to better pursue
the goal of improving patient treatment, comfort and
outcome, as well as the healthcare professional’s work
environment.”
Taking the aforementioned concept, it is perceivable
that dentistry areas such as endodontics present an even
higher digitalization than other more well-­known digi-
tal fields, as endodontists dwell in a fully digitalized
workspace where all clinical procedures are performed
with the aid of technology – diagnostics with 2D or 3D
radiology, microscopes and cameras, apex finders, ultra-
sonic technology for accessing root canals, static and
dynamic endodontic guides, instrumentation with
highly advanced digital motors, irrigation activation
techniques, and warm obturation methods.
The mandatory multidisciplinary approach in digital
dentistry renders the task of defining a clear historical
timeline impossible, as innumerable events, develop-
ments and clinical or laboratory fields are involved and
intertwined in the modern concept.
However, focusing on oral rehabilitation and the
developments in computer-­aided design and manufac-
turing, the first CAD-­CAM systems in dentistry date to
1971 when Dr François Duret introduced them in his
DDS graduation thesis “Optical Impression,” but the
technology had been used since the 1960s in the auto-
mobile and aircraft industries.
In 1984, Dr Duret patented a CAD-­CAM device,
which was presented at the Chicago Dental Society
Midwinter Meeting of 1989, where a dental crown was
fabricated in a record time of 4 hours. In parallel, Dr
Werner Mormann worked on the development of a digi-
tal scanning system to be used by the general dentist,
which was branded CEREC 1 and launched in 1985.
This innovative system was composed of a three-­
dimensional digital scanner and milling machine which,
when combined, would allow dentists to produce chair-
side ceramic inlays and onlays in single appointments.
Since then, the technology has greatly improved and
dentists and dental technicians experience a time when
CAD-­CAM can produce results that resemble pure magic,

which is what happens when technology is advanced
enough. The next two chapters of this book will cover
CAD-­CAM technology and available procedures in depth.
The advent of 3D printing is revolutionizing several
dentistry fields, improving the quality and precision of
surgical techniques, and gaining a massive preponder-
ance in restorative dentistry. The term 3D printing
defines a manufacturing process in which additive tech-
niques are used to build objects one layer at a time, in
contrast to milling techniques that require a material
block to be ground to the final desired shape.
Engineer Charles Hull introduced the first 3D print-
ing technology in 1986 with his patented stereolithogra-
phy (SLA) system and 4 years later, Scott Crump
patented the fused deposition modeling (FDM) tech-
nique. Widely used in a multitude of manufacturing
fields for the last 30 years, 3D printing with newly devel-
oped materials is on the verge of radically changing gen-
eral medicine and dentistry. From the production of
surgical guides, study casts, mock-­ups, temporary indi-
rect restorations, occlusal splints, and orthodontic align-
ers to the more recent production of long-­term resin
restorations, complete dentures and even titanium den-
tal implants, this additive technology is thought to be
the future of CAM, with some much anticipated innova-
tions in materials and techniques that will soon allow
ceramic restorations to be printed with higher customi-
zation possibilities and lower raw material waste.
With the advent of diagnosis, patient and case docu-
mentation, treatment planning, novel treatment tech-
niques and more recently throughout the workflow in
oral rehabilitation, digital dentistry is a reality with a
promising future. However, much more is yet to come
and other fields such as artificial intelligence (AI) will
play a major and currently unimaginable role in over-
coming all known boundaries. Already considered a ris-
ing field, AI technology in dentistry has been the focus
of serious research. Software with deep learning capa-
bilities is already helping to improve orthodontic treat-
ment outcomes, caries diagnosis, diagnosis and
prediction of periodontal diseases, risk assessment of
oral cancer, treatment plan suggestions, patient data
analysis, and smile design, among others.
Companies like Pearl, Smilecloud, and LM
Instruments, among many others, lead the develop-
ment of new tools and software capable of autono-
mously predicting pathology, suggesting treatment
plans or providing solutions to improve clinical man-
agement and maximize cost-­effective approaches, as
well as patient safety.
Within its many limitations and shortcomings, digital
dentistry is an unavoidable new reality. However, it
Chapter 1 Introduction to Digital Dentistry 7
should not be considered as a means of solving all prob-
lems and dentist/dental technician errors, but rather as
a tool to maximize and improve processes already per-
formed adequately.
Since the dawn of time, technology has brought forth
what lies inside each of us in a sense that both medioc-
rity or greatness may emerge. Indubitably, a careful and
knowledgeable dentist will see his/her work potentiated
and productivity increased, but mediocre work will be
emphasized by the technology. Hence, dentists and den-
tal technicians should not look for refuge in technology
or take it as a means of solving preexisting problems, but
rather focus on acquiring knowledge and performing
high-­quality dentistry that respects all the basic princi-
ples and then potentiate it through a digital approach.
1.3 ­In-­House and Outsourced
Digital Workflow
1.3.1 The Digital Dental Clinic
For many years dental professionals have been deliver-
ing dental treatments based on analogue workflows and
well-­established principles of dental procedures. With
the introduction of digital dentistry, many of the conven-
tional steps in dental procedures are being changed for
digital procedures, by means of computerized software,
apps, hardware, equipment, materials and techniques.
Current and recent research projects have been
addressing the actual benefits of the new digital meth-
odologies arising in the field of dentistry. The need for
such projects is also being investigated, considering that
there would be no point in changing established work-
flows and implementing new technological methods
without clear benefits for patients and professionals.
Among the research findings that are further discussed
in this book is the fact that digital workflows can increase
quality and predictability, deliver faster results, stand-
ardize processes, and enhance communication among
the dental team and the patient [8]. These findings mean
that the adoption of digital workflows is becoming more
popular in several countries. Nevertheless, only a small
number of dental clinics and practices are actually
adopting in-­house CAD-­CAM systems in their daily
clinical routine.
1.3.2 Impact of Digital Technologies
in Dental Clinics
The digital era is completely transforming the ways in
which people interact, work, and live. In many areas,
8 Digital Dentistry: A Step-by-Step Guide and Case Atlas
the number and types of jobs available are changing. At
the same time, entire professions, markets, products,
and services rise or disappear. The dental profession is
also being impacted by the digital transformation. In a
digital dental clinic, treatment workflows use comput-
erized technology that can affect dental teamwork at all
levels: administration, support personnel, receptionists,
dentists, hygienists, and dental technicians.
Administration personnel and secretaries can quickly
store and analyze large amounts of patient data, using
dedicated management software, improving efficiency
and diminishing the quantity of paper used. The dental
hygienist will need to be able to understand and use
high technology equipment such as dental scanners and
digital x-­rays, while support personnel should also be
able to maintain biosafety measures in highly sensitive
machinery. This means that, for instance, the hygienist
could perform intraoral scans and be able to analyze
and correct mistakes during the procedure if necessary,
using specialized software under dentist supervision.
Currently, dental hygienists and even dental techni-
cians in most countries do not have digital dentistry
training in school, making the selection of specialized
personnel in the market more difficult. Therefore, with
the adoption of digital trends, members of the dental
team will need special education for the use of work-
flows, equipment, materials, and methodologies.
Another important aspect is that digital dentistry
adds tools to aid in treatments that still follow the same
principles of dentistry. The adoption of digital dentistry
allows for enhancement of treatments and abilities
obtained using conventional analogue techniques. For
instance, oral surgeries can be more accurate and faster
by using surgical guides to orientate drilling procedures
(see Chapters 6 and 7). Digital imaging and new soft-
ware tools are useful to enhance oral diagnosis. New
materials such as zirconia and new ceramics improve
esthetic outcomes. Machinery can work continuously
with accuracy and speed that no human is able to
achieve.
1.3.3 The Education of the Digital Dentist
The need for education in digital dentistry is also very
clear for dentists, who might have a key position in the
dental team. The role of the digital dentist is to plan,
execute, and coordinate the dental staff while delivering
digital treatments. Ideally, the digital dentist needs to
make decisions, and thus has to fully understand both
analogue and digital dental procedures. A growing
number of studies are increasingly supporting satisfac-
tory clinical outcomes with digital technologies. As a
result, the reliability of CAD-­CAM restorations is creat-
ing a growing demand from practitioners and students
to learn about digitalization.
To support this trend, dental schools are increasingly
improving their schedules with new information on
digital technology for dentistry students. The student
can be presented with concepts of digital dentistry
applied in several areas of dentistry, but they are rarely
allowed to conduct clinical cases, nor to receive more
in-­depth information.
Some academic discussions suggest that digital den-
tistry will advance to be a major field of study. One of
the reasons for this is that the dentist needs to master
new knowledge, skills, and training to conduct dental
treatments [9]. This suggests that digital dentistry
should be considered a separate specialty degree in the
field of dentistry. On the other hand, others believe that
digital concepts are merely a new way to resolve tradi-
tional problems, and therefore digital dentistry is to be
considered a subfield derived from the main specialties
(i.e., digital prosthodontics using the principles of con-
ventional dental prosthodontics). Either way, digital
dentistry represents a large field of study for young den-
tal professionals and more experienced practitioners.
Most practices that decide to purchase their first digi-
tal equipment are generally given technical training
that could last some days. However, this initial educa-
tion is likely to be an introduction to the theoretical con-
cepts, technical features, and capabilities of the
equipment and/or software. At this initial point, further
education on courses, books, and scientific publications
helps to fill the gaps in training while the equipment is
used in a dental clinical routine.
Typically, the initial production of digital dental work
will focus on basic procedures but over time, as the digi-
tal dentist becomes more and more experienced, a mind
change is likely to occur and a digital way of thinking
emerges, providing new insights into planning and exe-
cuting current dental procedures in novel ways. The
dental clinic may thus be organized by digital dentists
with expertise in digital technologies to organize and
supervise the creation and outcomes of dental
treatments.
1.3.4 Levels of Digitalization for the
Dental Clinic
There is nowadays a paradox in the dental market as the
most advanced treatments and materials are found in
digital dentistry but only a minority of dental practices
are digitalized. Factors which may be impairing a more
widespread use of technology in dentistry include

investment costs, technical education, and cultural
resistance to change. There can be a misconception
among dentists that in order to use digital technology,
one must first invest large amounts of money and that
the return on investment would be hard to obtain.
The reality is that virtually any dental practice can
offer digital treatments, not necessarily initially produc-
ing their own work in house but outsourcing to third-­
party clinics or laboratories more advanced in
digitalization. Other possibilities can start with mobile
phones, by using dedicated apps that allow smile plan-
ning, for example. The complete digital clinic, in which
every single procedure is conducted with digital equip-
ment, delivering automated, standardized, cheaper, and
reliable results, is beginning to be suggested as a feasible
idea by some research findings [9, 10].
The actual digital clinic may be situated somewhere
between the two extremes of lack of adoption and large
investment for hard users. In a more realistic approach,
the dental clinic and dental professionals can be digital-
ized in different levels. For instance, one orthodontic
clinic may be digitalized for intraoral scans only, out-
sourcing the set-­up, planning, and fabrication of align-
ers. Meanwhile another clinic is able to deliver same-­day
restorations produced with in-­house equipment and
personnel. The decision on the degree of digitalization
for the practice will depend on the specialty of the den-
tal clinic and the focus on their more specific needs.
1.3.5 Types of Dental Clinics
and Business Models
The rise of digital technologies is also modifying the
dental clinic business itself, bringing innovations that
can enhance traditional niche clinics and create new
business models. As the equipment used in digital den-
tistry is highly specialized, different business models
may be required, depending on the specific field of study.
Some examples of equipment and set-­ups that can be
created for special purpose clinics are shown in
Table 1.1. However, multidisciplinary practices may
eventually influence the hardware and software needed.
●● Digital imaging diagnostic and radiology centers: may
invest in digital imaging equipment (panoramic radi-
ographies, CT scanner). Depending on the services
offered, some practices could provide intraoral scan-
ning (or model scanners) and digital pictures for out-
sourced surgical planning. There is dedicated software
available for imaging centers to provide better diag-
nostics and send back the requested information to
the clinician.
Chapter 1 Introduction to Digital Dentistry 9
●● Digital esthetics: there will be a large demand for
ceramic restorations (veneers, crowns). Practices
could invest in smile design software, 3D printers,
and single-­unit ceramic milling machines.
●● Digital implantology: a digital implantology center
would probably need in-­house imaging equipment
and an intraoral scanner to correctly diagnose and
create treatment plans. Additionally, guided surgery
software would be needed to fabricate surgical stents,
with a 3D printer. If digital restorations are to be exe-
cuted, additional equipment similar to oral rehabilita-
tion practices will be required.
●● Oral rehabilitation and prosthodontics: oral rehabilita-
tion is a complex area that encompasses many of the
main specialty areas of dentistry. Therefore, a digital
prosthodontics clinic could require equipment and
software to create at least some items in house, while
outsourcing more complex work. To do so, good addi-
tions would be an intraoral scanner, chairside soft-
ware to design restorations, a small ceramic milling
machine to produce single-­unit same-­day restora-
tions, and a ceramic furnace. If more complex in-­
house prosthetic production is desired, a dedicated
internal digital laboratory can be created.
●● In-­house dental laboratory: there is no limit to the
work that can be created by an in-­house dental labo-
ratory when compared to commercial counterparts,
since the same equipment and software can be
acquired. However, a complete laboratory set-­up
would require a more robust financial investment in
machinery, software, and materials. Additionally, a
dedicated space is needed with special infrastructure
planning to accommodate the hardware, and special-
ized personnel are needed to operate the machinery.
The size, organization, and production rate of devices
must be compatible with the desired workflow.
Equipment for digital dental laboratory would include
that required for a traditional lab plus a desktop scan-
ner, a milling machine for 5-­axis capability for large
blanks and ceramic blocks, a ceramic furnace, a sin-
tering furnace, CAD software to design prosthetics,
and a resin 3D printer.
●● Orthodontics: the digital orthodontist can enhance their
practice with intraoral scanners. It is possible to acquire
dedicated software and 3D printers to plan treatment
outcomes, as well as in-­house fabricated aligners.
●● General practitioner: can invest in intraoral scanners
in order to easily digitalize their orthodontic, restora-
tive, and prosthetics patients. Digital sensors for radi-
ographies are also widely used.
●● Surgery: oral and maxillofacial surgeons can acquire
dedicated software to plan orthognathic surgeries and
Table 1.1 Estimate of the amount of machinery, equipment, dedicated software, specialized personnel, and physical space dedicated structure to operate different types of digital
dental business models.

Intraoral Desktop Digital 3D Small Large Ceramic Sintering Physical space Specialized Dedicated
scanner scanner imaging printer milling machine milling machine furnace furnace structure personnel software

Orthodontics X x x x x
General X X X x x x
practitioner
Esthetic X X X X x x x
dentistry
Dental X X X X X X xx xx xx
implantology
Oral X X X X X X X X xx xx xx
rehabilitation
Surgery X X x x x
Dental X X X X X X xx xxx xxx
laboratory
Imaging centers X X x x xx
and diagnostics
Planning center X X x xxx
Scan services X X x
Milling centers X X X x xx x

would need at least desktop scanners to digitalize mod-
els, although an intraoral scanner would be preferable.
●● Planning centers: a digital planning center is a new busi-
ness model aiming to provide outsourced services to
any dentist or practice, by means of dedicated software.
The range of services provided can encompass ortho-
dontics, implant surgery, smile design, oral surgery,
prosthetic design, and so on. Software licenses can be
expensive and require initial investment and often sub-
scription updates charged yearly. Additionally, profes-
sionals are highly trained in software and can discuss
the design with the dentist before delivery. The outcome
of a digital treatment plan can be a physical item such
as a surgical template or even digital files or pictures.
●● Scan services: for those who do not possess an intraoral
scanner but would like to use one, scan services bring
the scanner to the customer’s practice in order to reg-
ister the digital impression. This novel business model
can occur as a standalone company or be offered by
digital dental laboratories.
●● Milling centers: a digital milling center is a specialized
dental laboratory focused on the production of milled
structures or restorations. Specific materials such as
cobalt-­chromium structures are commonly used in
prosthodontics but as highly dense materials, they are
extremely hard to mill, requiring specialist and expen-
sive tools and machinery. Therefore, many small labo-
ratories tend to outsource their metal milling to
milling centers. Depending on the focus and services
offered by milling centers, other materials can be used
such as zirconia, ceramics, PEEK or PMMA.
1.3.6 Financial Aspects of Digital
Dental Clinics
The digital clinic can be more complex than a regular
individual private practice, which generally presents
lower complexity, operational costs, and levels of docu-
ment digitalization and a smaller professional adminis-
tration team. Therefore, the operation of a digital dental
clinic is similar to a business company, something that
dentists may not be used to. Potentially higher financial
investments are necessary to equip a digital dental
clinic, which makes it difficult for any clinic to enter the
market. It is noteworthy that these issues are less likely
to be experienced by larger dental clinics and hospitals.
A digital dental clinic can be potentially bigger than a
regular practice, but not necessarily a more profitable
business. As a practice grows and enlarges its operation,
facilities, and employees, there is an increase in profits
and liabilities in the same proportion. Therefore, in the
Chapter 1 Introduction to Digital Dentistry 11
real world, studies of economic viability of dental clin-
ics, or related to some specific equipment incorporation,
can determine if a company will perish or thrive. More
than ever, a successful dental practice needs a combina-
tion of highly skilled dentists and entrepreneurial skills.
1.3.7 How to Calculate the Return on
Investment (ROI)
The return on investment is a ratio between net income
and the funds spent on the investment, over a period of
time. Applied to a dental clinic, the ROI calculation may
predict how long it will take to return the money to the
entrepreneur.
The estimation of ROI is based on complex calcula-
tions comparing initial costs, earnings, and projected
estimate of cost/benefit after making an investment. To
achieve the same production end, more than one digital
solution is available and can be compared [9].
Return on investment calculations have three aspects.
●● Earnings: how much revenue will the investment
bring? Will there be an increase?
●● Costs: how much will the investment save (time, clini-
cal steps, personnel costs, consumables)?
●● With this information mapped, it will be possible to
create a break-­even estimation, which is the predic-
tion of when in time the investment will return.
Reaching anything more than the break-­even is con-
sidered profitable.
Estimations of ROI must take into consideration that
after the equipment is acquired, it may require regular
maintenance and consumables. Additionally, the obso-
lescence of the equipment must be included as technol-
ogy evolves over time and may need to be replaced with
new financial investment. Finally, to represent a good
inversion, the digitalization of dental care workflows
should provide quantifiable advantages in terms of
quality, time consumption, and personnel cost reduc-
tion. As ROI calculation can be complex, professional
advice on these economic aspects should be taken.
1.3.8 Advantages of Digital Dentistry
for Clinics
Before digital dentistry, it was common for the client to
visit the dentist for multiple consultations to diagnose
and plan dental treatments, while procedures could last
long periods of time. However, dental practices are now
able to diagnose, plan, and treat their patients much
faster and with fewer clinical steps and less chair time
using digital technology.
12 Digital Dentistry: A Step-by-Step Guide and Case Atlas
Besides the potential financial benefits, the imple-
mentation of digital solutions can offer indirect bene-
fits. The patient experience tends to be better and more
comfortable when using digital treatments, with a sense
of quality and a high level of technological innovation.
Aspects of treatments such as planning can be easier for
the patient to understand. 3D digital simulations and
impressions can improve patient engagement and
approval, especially when esthetics are involved.
With the adoption of digitalized procedures, labora-
tory and clinical procedures tend to cooperate better
with administrative records, treatment planning, and
fabrication through standardized workflows.
1.3.9 Workflow in a Digitalized
Dental Clinic
The term workflow refers to a sequence of predefined
tasks executed by various people within the work envi-
ronment. The establishment of workflows creates
mindsets throughout the organization that ensure a
standardized exchange of data along the dental work-
flow from planning to therapy [10]. Each dental clinic
may determine its own internal workflows, and how
they would interact when some outsourced help is
needed. Some procedures can eventually be planned to
be exclusively digital, and there can be a mix of ana-
logue and digital components (Figure 1.3).
Furthermore, dental clinics commonly have several
professionals who can conduct treatments with different
levels of expertise. In this context, treatment workflows
Figure 1.3 Digital workflow involving imaging and planning centers. All treatment plans are ultimately to be approved by the
dental clinician responsible for the case.
lead to standardization of outcomes and skill levels
among the dental team. This enables a more consistent
and controllable production outcome.
1.4 ­Current Knowledge and Perspectives
in Artificial Intelligence in Dentistry
Artificial intelligence (AI) is a term commonly used to
represent the concept of artificially created human-­like
intelligence [11]. AI has revolutionized several fields of
scientific research and development, with improve-
ments ranging from facial recognition on our smart-
phones to genome analysis. AI has been developed in
different sectors of society to solve various tasks by uti-
lizing data more optimally, including health areas like
medicine and dentistry. Data science is an umbrella
term that refers to the interdisciplinary area dedicated
to the analysis of structured and unstructured data,
which aims at the application of statistical methods for
data analytics. The work of data scientists includes
using advanced techniques such as machine learning.
Machine learning is a subfield of AI, in which algo-
rithms are applied to learn patterns intrinsic to data
structures, which allow data predictions (supervised
machine learning) and data reduction and data han-
dling (unsupervised machine learning) [12]. One of the
factors associated with the adoption of this methodol-
ogy would be that AI is especially suitable for overcom-
ing the variability in subjective individual examination
and for increasing the effectiveness of diagnosis [13].

Unsupervised machine learning is used for reducing
the dimensionality of such datasets, increasing inter-
pretability. Clustering uses metric variables as input to
group data, enabling reduction of data into smaller
groups, with categorical variables as outputs. Principal
component analysis (PCA) also enables data reduction
by grouping variables that correlate with each other.
Multiple correspondence analysis (MCA) is used for
data reduction and data handling of categorical varia-
bles that associate with each other. Unsupervised
machine learning is very suitable for handling a large
amount of data and for data mining, acquired through
dental patients’ records for example [14].
Supervised machine learning, defined by its use of
labeled datasets, is used for prediction. Accuracy will
therefore depend on the size and quality of the database,
as well as the labeling and training method. Supervised
machine learning uses linear regression, logistic regres-
sion, ensemble models, and neural networks (NNs). The
main component of supervised machine learning is
labeling the dataset to train the algorithms and to accu-
rately classify data or predict results (Figure 1.4).
Neural networks are particularly useful for complex
data structures, such as imaging data, as these models
are capable of representing an image and its hierarchical
resources, such as edges, corners, shapes, and macro-
scopic patterns [15, 16]. During the training process, the
corresponding data and labels are transmitted repeatedly
by the NNs. The computational power of these NNs
depends on the quality and quantity of training data,
which allow these networks to update the weights
assigned to each variable of the model in question, and
this training can be supervised or not. NNs can also be
associated in several layers. The term deep learning is a
reference to deep (multilayered) NN architectures [12].
Figure 1.4 LabelImg AI software tool being used to label
the dataset.
Chapter 1 Introduction to Digital Dentistry 13
Recently, convolutional neural networks (CNNs) have
been developed and applied in many aspects of the
health field, including dentistry, with the performance
of various tasks like image classification and object
detection [11, 12]. CNNs use a clever trick to reduce the
amount of training data needed to detect objects under
different conditions. The trick is basically to use the
same input weights for multiple artificial neurons – so
that all those neurons are activated by the same pat-
tern – but with different input pixels. Every convolu-
tional layer responds to stimuli only in a restricted
region of the image’s field of interest, known as the
receptive field. This structure differs from conventional
image classification algorithms and other deep learning
algorithms, as the CNN can learn the type of filter cre-
ated manually in conventional algorithms [15, 16].
When training image datasets are entered into a
machine learning system, the learning procedures are
automatically repeated, without the need for a manual
definition of the image characteristics. In this way,
machine learning methods (with or without deep learn-
ing) can adaptively learn image characteristics and
simultaneously perform image classification [16]. Thus,
the results from models that use machine learning differ
greatly from systems that operate with conventional
programming. From the moment that a NN is trained,
weights are assigned to the characteristics of the sample
data, and the results are intrinsically linked to the sam-
ple used for training this model. Therefore, more favora-
ble results can only be found with AI training with a
new, larger, and more accurate sample.
Methods based on machine learning depend on the
quantity and quality of information that can be learned
(based on a set of training data). A smaller sample size
can reduce the potential for identification accuracy in
test images, thus decreasing the sensitivity and specific-
ity of the test. Furthermore, a large sample can be cre-
ated by using data augmentation, which is a feature
used to increase the sample of images by using image
rotation and resizing. Thus, based on a limited number
of data, it is possible to increase the sample size, which
can help researchers to work with small samples and
avoid overfitting. Overfitting occurs when the intrinsic
data of a specific sample are prioritized; thus, the per-
formance of the model for the images not belonging to
the sample ends up being much lower than the perfor-
mance related to the sample used for training.
Several authors have reported high precision using
NNs for object detection in the classification of dental
elements [17], periodontal disease [18], dental car-
ies [19], apical lesions [20], cystic lesions and tumors
[21, 22], dental fracture diagnoses [23], and sinusitis in
14 Digital Dentistry: A Step-by-Step Guide and Case Atlas

the maxillary sinus [24], among other factors, with the
use of deep CNNs applied to panoramic radiographs
and digital periapical radiographs. However, although
methods for object detection via deep CNNs are rapidly
progressing, object detection can still be challenging, as
it is dependent on a large database and computational
processing [25, 26].
Object detection software using AI already exists.
Second Opinion®, for example (Hello Pearl, Los Angeles,
USA), is an AI-­driven assistant for diagnostics and treat-
ment planning. The software offers a computer vision
platform that can instantly detect dozens of common
pathologies (Figures 1.5–1.8).
In addition to object detection in radiographic analy-
sis, NNs have been used for automatic identification.
Examples include comparison between antemortem
and postmortem panoramic radiographs (human post-
mortem identification) [25], diagnosis of osteoporosis
on panoramic radiographs [26–28], and malocclusion
diagnosis [29, 30].
Another important possibility with the use of CNNs is
the automation of identification and selection of struc-
tures in CBCT DICOM images. With this method, auto-
mated mandibular canal detection [31] and automated
mandible segmentation [32], an approach to dental
implant planning [33], are possible.

Figure 1.5 Screen capture of the software Hello Pearl (Los Angeles, USA) showing automatic detection of a maxillary area
with bone loss.

Figure 1.6 Screen capture of the software Hello Pearl (Los Angeles, USA) showing automatic detection of a mandibular area
with bone loss.
 Chapter 1 Introduction to Digital Dentistry 15

Figure 1.7 Screen capture of the software Hello Pearl (Los Angeles, USA) showing automatic detection of marginal
discrepancy of a metallic restoration.

Figure 1.8 Screen capture of the software Hello Pearl (Los Angeles, USA) showing automatic detection of calculus.

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18

Chapter 2
Computer-­Aided Design (CAD)
Jun Ho Kim, Alan J.M. Costa, José Lincoln de Queirós Jr, Juliana No-Cortes, Danielle A. Nishimura,
Shumei Murakami, Reinaldo Abdala-­Junior, Daniel Machado, Claudio Costa, Otavio H. Pinhata-­Baptista,
Shaban M. Burgoa, Andrea Son, Lucas R. Pinheiro, Danilo M. Bianchi, Allan R. Alcantara, and Arthur R.G. Cortes

SUMMARY

This chapter provides a step-­by-­step guide and research evidence on all computer-­aided design (CAD) procedures involved in
digital workflows in dentistry, from setting up digital imaging methods to work with digital design and treatment planning.

2.1 ­Digital Imaging Methods
2.1.1 Cone Beam Computed Tomography
Cone beam computed tomography (CBCT) is a tech-
nique that allows for three-­dimensional (3D) observa-
tion of structures related to the maxillofacial area. CBCT
uses a round or rectangular cone-­shaped x-­ray beam
with a two-­dimensional x-­ray sensor to scan, perform-
ing 180–360° rotations around the head of the patient
(Figure 2.1). During the scan, a series of projections is
acquired, providing the raw data for volumetric recon-
struction (3D). Multiplanar reformatting (MPR) of the
primary 3D reconstruction allows studies of any selected
plane in 2D or 3D views [1]. The CBCT image is a matrix
composed of small cubic units called voxels (volume ele-
ment, the 3D version of a pixel, described in the previ-
ous chapter). Similar to pixel values, each number
assigned to a voxel represents the linear x-­ray attenua-
tion coefficient of the inside structure with a specific
level of gray and numerical value (voxel value) [2].
2.1.1.1 Basic Knowledge
In recent decades, CBCT devices have been used in
dentistry much more frequently than medical com-
puted tomography (CT). The latter is an expensive
device usually found in hospital settings. Medical CT
devices can have single or multiple detectors that use a
collimated, fan-­shaped x-­ray beam moving in a 360°
circle within the detector ring (known as the “gantry”).
The CT image is recorded and displayed as a matrix of
individual 3D blocks that are the voxels. Similar to
CBCT, multiplanar CT imaging acquired from axial
scans (2D) may be reformatted by interpolation to ren-
der a 3D image [2].
When compared to medical CT, CBCT has advantages
such as lower radiation dose, faster imaging, and higher
spatial resolution of bone [3]. Modern CBCT devices can
offer lower fields of view (FOV), which means that only
the region of clinical interest is scanned, resulting in even
lower radiation doses. The use of CBCT is well estab-
lished in implant planning for the evaluation of bone
thickness, height, density (estimated using pixel values),
and volume [4–6], and others as endodontics [7], perio-
dontology [8], orthodontics [9], oral and maxillofacial
surgery [10], and temporomandibular disorders [11].
Images from MPR are usually available in three differ-
ent orthogonal planes – axial, sagittal, and coronal – to
be used in diagnosis and treatment planning. However,
it is also possible to obtain curved images by using the
axial scan to draw a curve following the shape of the
dental arch. These images usually show coronal pano-
ramic reconstructions and a set of transaxial/parasagit-
tal images representing cross-­sections of the alveolar

Digital Dentistry: A Step-by-Step Guide and Case Atlas, First Edition. Edited by Arthur R.G. Cortes.
© 2022 John Wiley & Sons Ltd. Published 2022 by John Wiley & Sons Ltd.
 Chapter 2 Computer-­Aided Design (CAD) 19

Figure 2.1 A CBCT device integrated with cephalometric and panoramic radiographic functions (Cranex® 3D, Soredex, Tuusula,
Finland).

Figure 2.2 Screen capture of the Horos open-­source DICOM viewer software (Horos Project), showing an MPR. Note the
periapical lesion of the mesial root of a first molar located in the three orthogonal planes.

ridge (Figure 2.2). These cross-­sectional images are
commonly used for implant planning.
Another option is to use the raw CBCT axial images to
render 3D reconstructed models to analyze the spatial
disposition (angle, length, and diameter) of implants,
screws, surgical or endodontic guides, prosthetic com-
pounds, and orthodontic components. The raw data from
CBCT or CT must be obtained in the DICOM® (Digital
Imaging and Communication in Medicine) extension
(described in the previous chapter) (Figure 2.3) to be read
in the software and later exported as a 3D image in the
Standard Tessellation Language (STL) extension.
2.1.1.2 Step-­by-­Step Procedure
●● Prior to the examination, the patient should be asked
to remove any metal objects, such as eyeglasses and
jewelry. Removable prostheses should also be removed
in most cases.
●● Radiation protection measures (e.g., lead aprons, etc.,
as established by local regulations).
20 Digital Dentistry: A Step-by-Step Guide and Case Atlas
Figure 2.3 Screen capture of the Horos open-­source DICOM viewer software (Horos Project) showing a 3D reconstructed
model rendered from CBCT DICOM files. The threshold color edition tool (bottom of the screen) enables visualization of
structures in the bone, such as the roots of the teeth.
●● Patients should always be positioned properly in the
CBCT device (Figure 2.4). It is suggested that the best
position for image quality of the sinuses, mandible,
and maxilla is the prone position, rather than supine
and oblique positions [12]. The patient’s face needs to
be aligned in the scanner with the head positioned
between the x-­ray source and the sensor. This position
should then be further adjusted to ensure the disposi-
tion of the desired anatomical structures within the
limits of the selected FOV. Such adjustment is gener-
ally conducted with the aid of chin and head supports,
Figure 2.4 Patient positioning with adequate posture in the
CBCT device.
and with a laser alignment beam that projects an illu-
minated line onto the face of the patient.
●● Explain the procedure and ask the patient to swallow
and avoid moving during the scan. (For image-­guided
surgeries, it is important for the patient to use lip
retractors in occlusion during the scan, as further
explained in Chapter 6.)
●● Define the imaging parameters and the FOV to be
scanned on the scout image (Figure 2.5).
●● Initiate the scan following the manufacturer’s
instructions.
●● Save the scan in the DICOM format (a folder with one
file per axial slice will be created), which can be
opened using a DICOM viewer for diagnosis
(Figures 2.2 and 2.3) or a CAD software dedicated for
dental treatment planning (further discussed in the
following chapters).
2.1.2 Intraoral Scanner
2.1.2.1 Basic Knowledge
The conventional workflow using trays and impression
materials has been improved for many decades.
However, a previous study found that about 50% of the
impressions sent to a laboratory result in inadequate or
inaccurate models. This can occur because, until the
end of the service, many materials are used, each one
with its particular work technique. Careful analysis is
required at each stage of the process, as any failure will
 Chapter 2 Computer-­Aided Design (CAD) 21

Figure 2.5 CBCT scout image (left) used to define the FOV of the scan (right).

not be corrected by the next stage, thus compromising ●● CS 3700® – Carestream (USA).
the final result of this flow. ●● 3D Progress – MHT SpA (Italy) and MHT Optic
Currently, digital impressions, by the use of intraoral Research AG (Switzerland).
scanning, can generate an STL file, which represents the ●● iTero – Align Technologies (USA).
first step of the digital path, in which the clinical situa- ●● Bluescan®-­I – A•TRON3D® GmbH (Austria).
tion can be fully moved to a virtual environment. ●● DPI-­3D – Dimensional Photonics International,
However, when necessary, physical molds can still be Inc. (USA).
manufactured from the same STL files using rapid pro- ●● E4D – D4D Technologies, LLC (USA).
totyping technologies. ●● IOS FastScan – IOS Technologies, Inc. (USA).
Regarding patient-­based outcomes, digital impression ●● Lava™C.O.S. – 3M ESPE (USA).
leads to less patient anxiety, is more comfortable, causes ●● MIA3d™ – Densys 3D Ltd. (Israel).
less nausea and allows the patient to observe the area of ●● DirectScan – HINT – ELS GmbH (Germany).
interest on the computer display. From the point of view ●● Panda P2® – Pingtum Technologies (China).
of process agility compared to the entire process from ●● Medit i700® – Medit Corp (South Korea).
molding to patient rehabilitation, digital flow, with ●● Vectra 3D – Canfield Scientific (USA).
intraoral scanning, reduces process steps and promotes
fast communication with the laboratory.
Using intraoral scanning ensures immediate deter-
mination of print quality; virtual 3D models of patients
are obtained, which can be saved to the computer with-
out the need for a physical model. This economizes on
time and space and provides the ability to easily send
models to the lab using email, reducing time and costs.
The clinician can save money on purchasing impres-
sion materials and manufacturing plaster models; it is
possible to store virtual models of patients without hav-
ing to dedicate a space inside the clinic to them. Not
least, the clinician can have a powerful marketing tool
for more effective communication with the patient.
Intraoral scanning technology has been developed
very fast. Currently, there are more than 10 different
intraoral scanners on the market and companies are
developing devices and methodologies from more than
eight countries.
●● TRIOS® 4 (Figure 2.6) – 3Shape A/S (Denmark). Figure 2.6 The TRIOS® 4 intraoral scanner (3Shape A/S),
which uses confocal technology and enables integration with
●● CEREC® Omnicam (Figure 2.7) and Primescan – CAD software programs and CAM devices from other
Dentsply Sirona (USA). manufacturers.
22 Digital Dentistry: A Step-by-Step Guide and Case Atlas
Figure 2.7 The CEREC Omnicam intraoral scanner
integrated with a milling device from the same manufacturer
(Dentsply Sirona).
The intraoral scanner is a medical device consisting
of a handheld camera (hardware), a computer, and soft-
ware. Its purpose is to accurately capture the 3D geom-
etry of an object.
The most widely used format of the 3D digital file
extension of images captured by the intraoral scanner is
STL. Among the main technologies for scanning an
object are triangulation, confocal, AWS (active wave-
front sampling), and stereophotogrammetry.
Triangulation
Triangulation is based on the principle that the position
of a point on a triangle can be calculated, provided that
two points of view have known positions and angles.
Examples of intraoral scanners using triangulation
technology are Cerec Omnicam (Dentsply Sirona), IOS
FastScan (IOS Technologies, Inc.), Medit i700 (Medit
Corp), and MIA3d (Densys 3D Ltd).
Confocal
Confocal imaging is based on acquisition of both focused
and nonfocused images from different depths. This tech-
nology enables detection of image sharpness to infer dis-
tances in relation to the object, according to the focal
length of the lens. The level of sharpness obtained in the
scan is directly proportional to the dexterity of the opera-
tor. Examples of confocal intraoral scanners are TRIOS 3
and TRIOS 4 (3Shape), iTero Element2 and Element5D
(Align Technologies), and 3D Progress (MHT SpA).
Active Wavefront Sampling (AWS)
The AWS technique enables the capture of a surface
image using a camera and an aperture off the optical
axis of a module that rotates around this axis. Distance
and depth information can be derived and calculated
from the outcome of each point. An example of an AWS
intraoral scanner is the Lava C.O.S. (3M ESPE).
Stereophotogrammetry
Stereophotogrammetry estimates all coordinates (x, y, z)
solely by using an image analysis algorithm. As this
approach relies on passive light projection and software
rather than active projection and hardware, the camera is
relatively small and easier to handle, and it is less expen-
sive to produce the images. An example of a stereophoto-
grammetric device is the Vectra 3D (Canfield Scientific).
Clinical differences have been reported among IOS
devices employing the same technology. These differences
are usually related to the time it takes operators to become
familiar with the ergonomics and usability of the software
for each intraoral scanner. It is noteworthy that the learn-
ing curve of intraoral scanning may be initially slow.
Dental tissues have several reflective surfaces, such as
enamel crystals or polished surfaces. These surfaces
could prevent the software from capturing a point of
interest due to overexposure. To avoid this, profession-
als could slightly change the camera’s orientation or
employ systems that use cameras with a polarizing filter.
Scanning strategies refer to the order of intraoral
scanner movements in relation to the dental arch to
increase the quality and accuracy of the virtual model.
Recent studies have shown the impact of the scan path
on the accuracy of the resulting 3D models. During
scanning, a regular and continuous movement should
be maintained, ideally with a constant distance and cen-
tered in relation to the object. The main general steps for
intraoral scanning are summarized below.
2.1.2.2 Step-­by-­Step Procedures
The following step-­by-­step procedure is described using a
TRIOS 3 (3Shape) device. Most of the steps, however, are
similar for most of the other systems and manufacturers.
●● Connect the intraoral scanner to the computer with
the specific software of the equipment to be used,
which has a valid license key (for scanners attached to
a cart, it will already be connected to the dedicated
computer).
 Chapter 2 Computer-­Aided Design (CAD) 23

●● Connect the equipment to power and turn it on.
●● On the desktop screen, double click on the icon for
the scanner software.
●● On the initial screen of the intraoral scanner software
(Figure 2.8), choose “new patient” to register an
unregistered patient, or “new case” to perform a new
scan on an already registered patient.
●● Choose the laboratory (or email address) to which to
send (export) the scan when it finishes.
Define in the options that the software offers the type
●●
folders on the computer hard disk or to temporary
storage devices (memory cards or external hard disks).
●● Choose the type of file extension of the scan to be
exported (some software programs work only with
STL files; others additionally allow for exporting poly-
gon file format [PLY] or OBJ files).
Intraoral Scanning of Edentulous Patients
The scanning technique mostly recommended for the
edentulous ridge is the “zigzag” scanning strategy. This

of restoration to be performed (scan only, implant

technique helps to maintain the continuity of the images
planning, anatomy, abutment, bridge, etc.).
following the palatal vestibule direction, always starting
Click on the “next” icon to proceed to the scan.
from the left side toward the right side, or vice versa
●●

Follow the steps indicated in the specific workflow

without interruption and complementation of the palate
●●

bar that appears on the software’s scan screen.

region during capture. Conventionally, most profession-
Scan both maxillary and mandibular dental arches,
als who choose to scan the toothless arch use the file to
●●

always following a scanning protocol (Figure 2.9) and

make an individual tray that can be produced manually
avoiding repeat scanning of the same regions (Figure 2.10).
on printed work models or directly by additive manufac-
In addition, perform the digital bite registration.
turing in special resins, after drawings made in the soft-
Correct any failures in the mesh as indicated by the
ware. The individual tray would be able to capture the
●●

software. After scanning both dental arches and bite

areas that might not have been captured by the intraoral
registration, proceed with the other complementary
scanner. Compared to the maxilla, the mandible usually
scans (dental preparations, scan bodies, etc.), as well
presents greater difficulty when obtaining the scan due
as recording the occlusion scan.
to the presence of a mucosa with greater mobility.
Once the scans are finished, carry out the mesh post-
The recommended scanning technique that will
●●

processing (Figure 2.11) by using software tools (some

ensure greater accuracy of results performed in a fully
systems perform part of this process automatically).
digital workflow, based on publications that used TRIOS
With the postprocessing done, we are ready to export
scanners [13, 14], and related scientific evidence, fol-
●●

the scans (Figure 2.12).

lows the sequence below.
●● It is possible to export or directly send the scan files to
a laboratory or client using the specific tools of each 1) Prior selection of a U-­shaped lip retractor with ade-
software. All files could also be downloaded into quate dimensions for the patient and capable of

Figure 2.8 Screen capture of the main screen of the IOS software.
Figure 2.9 Example of an established intraoral scanning protocol.

Figure 2.10 Intraoral scanning procedure (top left: maxillary scan; top right: mandibular scan; bottom images: digital bite
registration performed at both sides).

Figure 2.11 Mesh trimming procedure to remove unnecessary areas from the scan. This leads to smaller file sizes while
preparing the shape of the mesh to further produce a 3D-­printed model from the scan.
 Chapter 2 Computer-­Aided Design (CAD) 25

Figure 2.12 Intraoral scans ready.

retracting and stabilizing the oral tissues while

occlusal view, heading toward the opposite side of the
avoiding overextension. The clinician should ideally
arch. Then, migrate the position of the scanner to the
have an assistant for the proper use of the retractor
middle of the arch in the anterior portion, from there
and possible saliva aspiration if necessary. A fluid,
completing the entire palatal area, traversing the region
radiopaque resin that adheres to the mucosa can be
from one side to the other. The scanner must complete
applied in the form of small spheres (1–2 mm) in
the scan in a fluid and uniform way, ensuring the union
areas without mobility at different points in the arch
of the scanned areas. The following steps need greater
to increase surface characterization, facilitating
care as the scanner can be lost due to the presence of
scanning, if necessary. These tags can be removed
brakes and bridles. Therefore, the scanner must be posi-
later in planning software, or in the scanner’s own
tioned in the posterior region, starting again in the
software after scanning is complete.
tuberosity region, but capturing the vestibular region.
For the maxilla (Figure 2.13), the recommended scan- To complete the other side, the scanner must be paused
ning path has the following sequence: selection of one and positioned in the posterior region, capturing simi-
side of the arch in the tuberosity region through the larly to the previously finished side. It is recommended
26 Digital Dentistry: A Step-by-Step Guide and Case Atlas
Figure 2.13 Superimposition of two intraoral scans performed on the edentulous maxilla of the same patient, in the same session
with the same scanner (CS3600, Carestream Health). Note the very low 3D deviation values between the two scans (green area).
that the scanner be tilted slightly so that it can capture
the transition from the occlusal to the vestibular
mucosa. With practice, the user will be able to perform
the scan continuously without interruption of the scan-
ner, preventing any image overlapping.
For the mandible, the recommended scanning path
has the following sequence: selection of one side of the
arch in the retromolar region with the scanner tilted
slightly to the lingual, frequent capture until the retro-
molar region on the opposite side, followed by inclina-
tion of the scanner to the vestibular region, ending the
scan following the entire vestibular to the opposite side,
taking care that the scanner is positioned so that it can
capture the occlusal and vestibular area, ensuring image
union. If the patient has the ridge resorbed, it is recom-
mended that the strategy be segmented by capturing first
on one side and then on the other. Thus, the scanning
would start in the retromolar region on one side until the
middle of the arch, proceeding to the vestibular region
on the same side, ending again in the retromolar region.
From there, the scanner would be positioned again in
the middle of the arch, proceeding to the lingual region
of the missing side and ending by the buccal region on
the same side to the retromolar region. During the break,
excess saliva could be removed and the patient could rest
for a while until scanning resumes.
To perform the bite registration and capture the
VOD (vertical occlusal dimension), an interocclusal
device adapted to the maxilla and mandible can be
made with materials such as light and heavy silicone
so that it is fully adapted to the ridge and allows for
ideal positioning of the mandible for the patient occlu-
sion. This device can be scanned using the intraoral or
extraoral (desktop) scanner and later the file can be
used by the planning software for alignment of the
maxilla and mandible scans using the best-­fit algo-
rithm that seeks the best possible alignment from
records from similar areas. An adaptation of this tech-
nique would be the application of cutouts in this
record, enabling the visualization of the patient’s edge
and scanning the record in the mouth. For the occlusal
registration, the scanner normally searches for similar
information, finally generating the alignment of the
identified meshes. The technique is easier to perform
when the patient has tooth remnants or an existing
prosthesis; otherwise, the ideal would be for the patient
to have prefabricated evidence bases to facilitate
occlusal registration.
2) After the scan is finished, the files are postprocessed
and inspected to verify the need for possible correc-
tions and then exported for use in planning software.

An alternative to intraoral scanning, but using the
same equipment, would be to scan the base of the
patient’s relined prosthesis. Current software allows the
scanned meshes to be inverted, allowing for later use
within the normal workflow.
For the planning and production of the prosthesis to
be made, the clinician can choose to use the CAD-­CAM
system present in the clinic or send the records to a labo-
ratory. The next steps would cover generating an indi-
vidual tray, base plate, recording of vertical dimension,
occlusal plane, lip support, length of maxillary central
incisors and midline adapted to the patient. The next
step is assembly in an articulator with information on
face bow and mandibular relationship, assembly of
teeth and extension of the prosthesis. Depending on the
user’s expertise, most steps can be reduced and simu-
lated directly within the planning software according to
the records made due to the possibility of overlapping
several files from the same patient.
Scans of edentulous patients are also used for plan-
ning guided surgery, in addition to making removable
prostheses, serving as a basis for the production design
of immediate surgical and temporary guides.
Additional scans such as bite occlusal registration and
facial scans can be performed using different devices to
provide greater predictability of results. Another benefit of
using digital tools is the possibility of producing different
prototypes at different stages, allowing for greater cer-
tainly prior to the production of the definitive prosthesis.
Currently, definitive prostheses can be made by either sub-
tractive manufacturing or additive manufacturing. In this
context, milling complete dentures is still the best option.
The techniques described require further clinical vali-
dation, as the lack of differentiation of the scanned sur-
face presents scanning difficulties. The use of the
retractor is an excellent solution covered in the most
recent articles, but incorrect use can cause overexten-
sion that causes lack of retention of the total denture.
However, several studies have reported numerous prob-
lems caused by the conventional molding method, such
as the presence of bubbles or holes and distortions
related to the plaster model. With the increase in use of
scanning technology, we will likely see a continuous
advance in both clinical and laboratory expertise, pre-
senting advances and improvements in the quality of
files obtained and work carried out.
2.1.3 Desktop Scanner
2.1.3.1 Basic Knowledge
The use of digital technology is currently an essential
part of many aspects of life, in food manufacturing, social
Chapter 2 Computer-­Aided Design (CAD) 27
interactions, entertainment, and especially in health
[15, 16]. Revolutionary changes in dentistry were only pos-
sible with advances in digital technologies, such as the use
of photographs, digital radiographs, CT, and mainly by the
computer-­aided use of scanners associated with computer-­
aided design and computer-­aided manufacturing (CAD-­
CAM) [17]. The first commercially available system used
for intraoral scanning dates back to 1987; known as the
CERC system, it basically worked on light triangulation
principles and required an opaque powder coating.
The introduction of digital technology has increased
the options available for dental treatment. Clinicians
have been using plaster models as the main tool for diag-
nosis and fabrication of restorations, prostheses, plan-
ning and communications, but these models have
disadvantages such as fractures, degradation, and loss of
surface structure, and require substantial storage
space [18, 19]. The study models allow the clinician to
obtain a copy of the morphology and spatial relation-
ships of the teeth, but this information may be incorrect
due to the molding process [18], which depends on the
operator, and material failure can occur. For example,
after preparing a dental element for making a single
prosthesis in the conventional method, several steps are
necessary before production of the final restoration, with
possible errors such as choice of appropriate material,
molding technique, disinfection protocol, transport, type
of plaster and even the time between individual steps
influencing the accuracy and final result [15].
The introduction of the CAD-­CAM system in dentistry
resulted in a more accurate fabrication of prosthetic
structures and greater accuracy of dental restorations,
and this technology has been improving since 1980. The
automation and optimization of this process increase the
quality of restorations through the use of new biocom-
patible materials, particularly high-­performance ceram-
ics such as zirconia and lithium disilicate.
The fully digital workflow is not yet a reality for many
professionals, probably due to the high costs of equip-
ment and the need to implement new procedures in daily
routine and reorganization, but using digital flow tools
can reduce steps, increase predictability, increase patient
acceptance and, of course, provide greater precision.
Intraoral scanners have limitations in taking direct
digital impressions, including highly reflective surfaces,
very deep subgingival preparations, moisture and bleed-
ing, yet it is necessary in these situations to employ con-
ventional impressions or plaster molds by indirect
design, in order to combine the well-­established proce-
dure of using elastomeric materials for a conventional
impression and avoid the disadvantages of casting plas-
ter, digitizing the impression itself with a flatbed scanner.
28 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Three models of desktop scanhner can be used:
mechanical scanners with probe, which can have great
disadvantages due to the possibility of causing distor-
tions in the materials, laser scanners, and white light
scanners, which are the most used currently [17].
Newly developed light desktop scanners have advan-
tages over laser scanners in that they analyze a pattern
of multiple streaks, whereas laser scanners analyze a
pattern of lines.
Basically, desktop scanners have a focus where the
objective will be exposed to a light or laser and a scan
will be made, giving rise to a digital model that can be
used in CAD software. The main advantages of using a
desktop scan are lower cost, reduced steps in the proce-
dures, predictability, planning, precision, speed (some
cases that would conventionally need five steps can be
reduced to two), ability to store information in the
cloud, thus reducing the need for physical space, com-
munication with the laboratory, reduced processing
errors, and greater patient acceptance. It can be used for
obtaining a model for digital diagnostic waxing, making
single crowns, inlays, onlays, overlays, making individ-
ual tray for total dentures, crown implants, recording of
the maxillomandibular relationship with conventional
joint scanning, and scanning for making housing plates.
Regarding disadvantages, we can mention studies that
compare the veracity and precision of desktop scanners
using impressions, plaster models, and resin models
printed on 3D printers, with impressions being the
worst situation with small significant discrepancies
[16, 17]. One study reported that plaster cast models
may show discrepancies in relation to interior models,
but interior models in plaster and resin did not show
clinically significant differences.
The desktop scanner can make life easier for the clini-
cian because it is a versatile, accessible tool that uses intui-
tive software that is easy to learn, promoting improvements
in clinical results, but depending on some conventional
steps that may be relevant in some cases [17].
2.1.3.2 Step-­by-­Step Procedures
Using the desktop scanner can be a satisfactory option
to help the clinician without relying on a laboratory. The
steps required to use this equipment are simple; each
device may have some differences but for the most part
the steps are very similar.
It is necessary to have some space to install the scan-
ner and a computer that will be used to install the scan-
ning software, store, and possibly send the files. It is
important that this computer is used only for this func-
tion, avoiding routine functions, which can lead to mal-
functions and slowdown, making it difficult to use the
equipment.
By following this step-­by-­step description, the clini-
cian will be able to use the desktop scanner without dif-
ficulty (Figure 2.14). It is important that the professional

Figure 2.14 1 Desktop scanner calibration device. 2 Automatic desktop 3Shape scanner with calibration device properly fitted
for the calibration process. 3 Model printed in resin, which will be scanned, recalling that desktop scanners have the ability to
scan resin models, plaster models, and negative impressions. 4 Support table for the model properly adjusted with silicone
material to support the model. 5 Model properly fitted with occlusal surface facing the light source; an accessory light will turn
on automatically, warning that the model is ready to be scanned. 6 Activation of automatic scanning by software; the scanning
table will move in 360° to allow scanning of all interfaces of the model.
 Chapter 2 Computer-­Aided Design (CAD) 29

follows the specific instructions for each scanner model,
but the steps are mostly similar.
●● Unpack the scanner from the box and check that all
items that come with it are present, such as power
supply, accessory parts such as adapter for the model
and calibration part.
●● Use a UPS to connect the scanner to the electricity,
checking the indicated voltage. The vast majority of
scanners come with a CD or pen drive to install the
software on the computer. Some minimum require-
ments may be necessary regarding the internal mem-
ory configuration of the computer used.
●● After installing the software, start the desktop
scanner calibration. This can be requested by the
system weekly, for better precision and accuracy of
the scan.
●● During the aforementioned steps, it is important that
some information is fed to the planning software
inside the computer.
●● After performing the steps created in Figure 2.15, we
will proceed to the steps described in Figure 2.16.
The countersink process using the specific software
of each scanner is extremely simple and intuitive.
However, some steps can interface with the final result,
such as molding failure, bubbles in the plaster, type of
plaster chosen to cast the model, not periodically cali-
brating the scanner, etc. These can all affect the accu-
racy and quality of the final work generated.
It is possible to perform the following jobs from a scan
performed on a desktop scanner.
●● Digital diagnostic wax-­up.
●● Individual trays for complete dentures.
●● Evidence bases for complete dentures.
●● Veneers, crowns, inlay/onlays, in ceramic, zirconia
and even metal.
●● Occlusion plates.
●● Surgical guides.
●● Structure for implant prostheses.
●● Implant prostheses; in these cases a scan body is neces-
sary, as well as a request for replacement for full crowns
on teeth, increasing the accuracy of the scan [16].
The accuracy of desktop scanners is well reported in
the literature. In addition, they are affordable and can
provide clinicians with facilities for planning and execu-
tion of simple and complex cases during clinical
routine [1].

Figure 2.15 7 After starting a new project in the 3Shape software, a display with all teeth present will be shown and then the
tooth that will be worked on must be selected. Also the type of work to be a performed, such as a crown, veneer or diagnostic
wax-­up, must be selected in the upper right field. 8 A prescan is performed for the entire arch; this takes about 9 seconds, but it
does not have as many details. 9 Then we select the area for which we want more details, such as a specific tooth. 10 After this
selection, one more scan is performed, for a little longer, giving a more accurate and faithful model to the scanned element.
30 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Figure 2.16 11 For prosthetic or surgical work, it is necessary to scan the main and antagonist arches. 12 After scanning the
element and the antagonist arch, we must register the occlusion. For this purpose, it is important that a guide is made in the
mouth, which can be in acrylic resin, in wax or using silicon for occlusal registration. Some scanners even allow scanning of the
articulator in the maximum intercuspation position. 13 After overlaying the occlusion record with the working and antagonist
models, the scanner itself will establish the maxillomadibular relationship between the models. 14 After completion, an STL
file is generated, which can be exported to CAD software, such as Inlab®, DentalCAD® or even Meshmixer®.

To overcome these 2D face assessment problems, sev-

2.1.4 Facial Scanner
2.1.4.1 Basic Knowledge
Three-­dimensional facial scanning is rapidly develop-
ing in dentistry but has applications in many other
fields, such as biomedical engineering, design, and 3D
animations. Working with a virtual patient who offers
information on their facial profile in association with
the various CAD-­CAM systems has made it possible to
design and manufacture complete dentures fully in a
digital way [20].
A conventional method of prosthetic rehabilitation
requires only dental arch models mounted on an articu-
lator, radiographs, and photographs so that a 2D assess-
ment of the maxillofacial region can be obtained [21].
However, the human face is a complex geometric struc-
ture with different depths and textures. It is difficult to
simulate the real face in a 2D image and assessment of a
facial deformity or face asymmetry is also prone to error
because 2D analyses do not show the volume of facial
proportions that are related to facial harmony. As a con-
sequence, prediction of results and prognosis of treat-
ments can be limited in 2D images [22].
eral 3D facial scanning methods were introduced such
as stereophotogrammetry, laser scanning, and struc-
ture light scanning [23–26]. These methods provide a
3D simulation of the facial structure surface by gener-
ating a digital face model that can be superimposed
with radiographic images for 3D face analysis and vir-
tual treatment planning or realistic surgery simulation
[9]. Furthermore, the collected scan data can be uti-
lized for multidisciplinary purposes in research and
education as well as treatment.
The use of face scanning in dentistry has increased
over time and it has applications in the areas of implant
dentistry, esthetics, prosthodontics, and periodontics.
With the advancement of technology, face scanning can
be performed in a way accessible to the professional [27].
Acquisition can be done from smartphones, tablets, and
cameras, and also using photogrammetry to generate
3D files. The facial scan file is usually exported in OBJ
file format. A study conducted by Mai et al. revealed
that the accuracy of digital face models generated by
portable scanners was not significantly different from
that of stationary face-­scanning systems [22].

Figure 2.17 Workflow with facial scans in oral rehabilitation.
The main use of face scanning is to have the patient in
a virtual format without the need for the patient to be
present at the time of planning (Figure 2.17). With face
scanning, overlaying of all volumetric files allows rec-
reation of the entire patient virtually. There is still much
debate about the accuracy of this method but the accu-
racy reported by the studies seems clinically acceptable.
The big issue is how these files are precisely superim-
posed on one another [22].
The use of a face scanning fork is a reliable way to
spatially determine the maxillary position about the
face scan, just as the facebow determines the assembly
of the semi-­adjustable articulator. The fork can be
designed and printed on 3D printers. In esthetics and
prosthodontics, face scanning is used to determine the
entire dental esthetic analysis guided by the face, such
as ideal tooth position, anatomical portions of the face,
and soft tissue profile. In periodontics, it is useful to
determine the correct proportion of tissues and teeth in
cases of clinical crown enlargement. In implant den-
tistry, the facial scan can be used to provide a prostheti-
cally driven plan of the rehabilitation of partially and
totally edentulous patients.
2.1.4.2 Step-­by-­Step Procedures
Using Mobile Device Applications
The following step-­by-­step procedure uses an applica-
tion (illustrated here using the FaceApp application)
running on an Apple iPhone XR (Cupertino, CA) mobile
Chapter 2 Computer-­Aided Design (CAD) 31
device. With a mobile phone such as iPhone X or supe-
rior, a facial scan can be obtained with an app that uses
the camera of the mobile device to capture images and
render them into 3D reconstructed models [28]. The
scanned files can be basically exported in three formats:
STL, PLY, and OBJ. The scanning process is free but to
export the scan file a fee has to be paid.
1) Install Bellus3D FaceApp on your mobile device.
2) Ensure that the subject can turn their head 90° to the
left and right.
3) Launch the FaceApp application and select the
desired facial scan option.
4) Follow the orientation of the app, positioning the
phone directly in front of the face at a distance that
causes the red oval to turn green. Once the oval turns
green, push the white button at the bottom of the
phone display to initiate the scan.
5) The app will ask to turn 90° to the left, then back to
the middle, 90° to the right, and then back to the
middle. If the “FACE + NECK” or “FULL HEAD”
scanning modes were selected, the app will also
prompt to tilt the head up and down during the pro-
cedure (Figure 2.18).
6) Once the scanning is complete, the app will stitch
together the various perspectives to form the 3D
model (Figure 2.19). You will have the option of sav-
ing the scan and/or exporting it in one of the sup-
ported 3D file formats (OBJ, GLB, or STL; Figure 2.20).
A fee applies for each 3D image exported.
Figure 2.18 Facial scanning procedure with a mobile device application.

Figure 2.19 Left: screenshot of the Bellus3D software after completing a facial scan. Right: screenshot of the Meshmixer
software showing the mesh structure of the resulting STL file.

Figure 2.20 clOner facial scanner (Done3D, Ribeirão Preto, Brazil).


Using Stand-­Alone Facial Scanning Devices
In contrast to facial scanning apps for mobile devices,
stand-­alone facial scanners are physical devices solely
dedicated to capturing 3D images and exporting them as
3D data such as STL or OBJ files (Figure 2.20). The pro-
cedure is generally faster and easier, compared with the
use of mobile devices. One of the reasons for this is the
number of cameras available to capture images of the
face at the same time. On the other hand, these devices
are relatively heavy, therefore offering limited portabil-
ity. The images can be exported in different formats
(mainly STL and OBJ) to a CAD software program, to be
used for dental treatment planning purposes.
Facial Scanners Integrated with CBCT Devices
Some CBCT devices are being developed to offer solu-
tions such as integrated panoramic and facial scanning.
This leads to fast imaging and easy integration and
superimposition of different 3D images to create the vir-
tual patient. One example is the X1 device (3Shape A/S),
which comes with other important features such as
movement correction and voxel size from 75 μm.
Another important advantage is that these devices also
work with both DICOM and STL files, which facilitates
the combination and analyses of such files.
2.1.5 Clinical Photographs
Clinical photography is an essential tool to be devel-
oped for successful dental practice. Taking proper pho-
tographs combined with thorough diagnostics allows
you to plan, execute, document, and preserve cases
much more predictably [29]. The digital revolution we
are experiencing has allowed greater efficiency in our
field, improving communication between dental pro-
fessionals and patients. There are numerous applica-
tions for the use of digital photography in dental
practice [29, 30].
●● Diagnosis, treatment planning and preservation of
cases: photography, if performed in a standardized
way, is invaluable in the diagnosis and planning pro-
cess. The images are sharp in detail and show specific
points to be analyzed by the clinician or specialist.
●● Legal documentation: the images document the con-
ditions prior to treatment, in addition to monitoring
the changes and completion of the agreed treat-
ments. It is essential that the professional collects
images for documentation, always supported by free
and informed consent.
●● Forensic documentation: identification of human
remains, and analysis of remains and tooth-­related
trauma can assist in providing accuracy and repro-
ducibility of detail.
Chapter 2 Computer-­Aided Design (CAD) 33
●● Communication with the laboratory: photographs
allow a quick and standardized way to communicate
about anatomical characteristics. Color matching is
also a fundamental step in which we can benefit from
photography.
●● A multidisciplinary tool: photography can help the cli-
nician to guide the specialist in a specific case.
●● Patient education and motivation: periodic digital
photographs of the patient’s clinical condition can
provide immediate visual illustration of the disease
process (caries, gingivitis, periodontitis).
●● Marketing is communication: photography is a power-
ful communication tool, as an image can express dif-
ferent feelings or situations. The market is increasingly
disputed and the use of photographs is a way to publi-
cize your work to other patients. However, we must
always respect the professional code of ethics and the
patient must authorize the use of images.
Dental photography requires a basic knowledge of the
general principles of photography, but suitable equip-
ment and workflow for the proposed purpose are
equally essential.
At least three types of equipments are needed to
assemble a set suitable for dental photography: the
macro flash (circular or twin), the macro lens, and the
camera body (Figure 2.21). In addition, some profes-
sionals may prefer to set up a photographic study, using
the beauty dish or soft box flash, which loses in quality
compared to the twin or circular flash but can be an
option for more artistic photos. Another recent option is
the use of smartphones with high-­resolution cameras,
always aided by accessory lighting such as “ring-­light”
type circular flashes, which are economical options that
lose a little quality.
●● Circular flash: the circular flash is a great choice for
those who want to be practical when taking photo-
graphs as it does not require adjustments to change
the incidence of light.
●● Twin flash: the twin flash is a more detailed lighting
option and can be of two types – wired or wireless. It
is indicated for cosmetic dentistry due to its ability to
take accurate images.
●● Macro lens: in dentistry we use a macro objective
(lens) with a fixed focal length of 100 mm for Canon or
105 mm for Nikon. They feature 1:1 promotion repro-
ducing full-­size images with virtually no distortion.
●● Camera body: entry-­level models with a DSLR system
are the most suitable due to low cost and the ability to
take high-­quality photographs. The DSLR or reflex
system uses a mirror for image reproduction, and the
vast majority have a display on the back where the
user can regulate the basic parameters.
34 Digital Dentistry: A Step-by-Step Guide and Case Atlas
Figure 2.21 1 Canon DSLR camera body. 2 10 mm macro lens. 3 Circular flash. 4 Twin flash. 5 Speedlight flash. 6 Flash adapter
beauty dish speed light. 7 Soft-­box flash. 8 Smartphone model with high-­resolution camera. 9 Flash model for photography
with ring light cellphone.
To simplify the application of the principles of pho-
tography in dentistry, we must understand the basics to
know how to set up the camera.
●● Aperture of the diaphragm: this is displayed as “f” and
usually varies from 2.8 to 32. The lower this number,
the wider the aperture and the brighter the image will
be. The “f” values will usually differ between facial
and intraoral photographs.
●● Shutter speed: this controls the amount of light that
hits the sensor during each photograph.
●● ISO (International Organization for Standardization)
refers to the standard of digital sensor sensitivity in
relation to light gathering. The ISO can vary between
100 and 3200 and the lower the ISO, the darker the
photo but the cleaner the image; the higher the ISO,
the lighter the image but with more noise. It is recom-
mended to use ISO between 100 and 200.
●● White balance (WB): this is used to control the white
levels in order to obtain realistic colors in the image.
Ideally, WB should never be set on automatic mode.
Commonly used parameters (always with the camera
set in manual mode) are:
●● Camera program – M or manual
●● ISO – 100
●● Speed – 1/125
●● Aperture (f) – ranging between 8 and 22–32
●● White balance (WB) – daylight or 5260 and 5500 K
●● Image quality – JPEG LARGE (L)
●● Lens focus – automatic (af)
●● Neutral image style.
An important tool to aid in the accuracy of photographs
is the histogram (Figure 2.22). The histogram in photog-
raphy is essential both when taking the photo and during
postproduction of images. It is nothing more than a graph
that quantifies the luminosity of a photograph. This helps
you find the best exposure for your photo. However, don’t
think that there is a histogram in the photograph that is
the ideal one to follow, as there isn’t. This is because some
photos may have a predominance of midtones (average
key), light tones (high key) or dark tones (low key), for
example, which changes the reading of the graph.
So, on the right side of the histogram in the photo-
graph you will find the light areas, in the middle, the
midtones and, on the left side, the dark tones.
To take photographs suitable for the diverse planning
requirements in dentistry, we have to use accessories
such as retractors and mirrors (Figure 2.23).
●● Occlusal retractor: essential during occlusal photo-
graphs for analyzing the occlusal surface and spatial
positioning of elements in the arch; required in ortho-
dontic, prosthetic, and surgical planning.
●● “V” retractor: used to take photographs in occlusion
to assess the posterior teeth.
 Chapter 2 Computer-­Aided Design (CAD) 35

Figure 2.22 Left: Underexposure photography. Middle: Balanced exposure photography. Right: Overexposure photography.
Histogram.

Figure 2.23 1 Occlusal retractor. 2 “V” retractor. 3 “U” retractor. 4 Mirrors for occluded or lateral photographs. 5 Black
background.

●● “U” retractor: used for taking frontal intraoral photo-
graphs and during mandibular movements.
●● Mouth mirrors: for taking occlusal and lateral
photographs.
●● The black background is widely used when matching
colors or when taking photographs for planning in
esthetic rehabilitation.
The photographic protocol to be used during digital
workflow in dentistry requires a minimum of 17 total
photographs: six face photographs (Figures 2.24
and 2.25), two smile photographs, and nine intraoral
photographs (Figures 2.26–2.29). The patient should
preferably be seated on a rotating base in order to take
photographs at 45° and 90°. A clean environment
without major external light interference is also
necessary [29].
Facial photographs should give the clinician an over-
view of the relationship of the patient’s facial structure
with the dental arrangement. Facial photographs with a
smile help during planning, whether esthetic or func-
tional, and when using methodologies such as DSD or
SmileCloud to simulate a smile or even in diagnostic
waxing software.
Use of the protocol shown above will allow the clinician
to carry out corrective planning, using digital diagnostic
36 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Figure 2.24 Initial photographs of the patient at rest (left) and smiling (right).

Figure 2.25 45° and 90° photographs for right and left sides.

Figure 2.26 Photograph with lips at rest to assess the exposure of central incisors, photographs with a smile without touching
the teeth, and photograph with a U-­shaped retractor without dental contacts to assess the promotions between the dental arches.
 Chapter 2 Computer-­Aided Design (CAD) 37

Figure 2.27 Photograph with MIC retractors with evaluation of the right and left occlusion key and central overbite.

Figure 2.28 Photographs with mandibular movements, protrusion (top), right laterality and left laterality (bottom).

and simulation software, in addition to increasing the investment in photographic equipment such as a DSLR
added value of the procedure, improving communication camera, a 100 mm macro lens and circular or soft-­box
with the patient and with the laboratory; it is also possible flash will be of great help during clinical practice, provid-
to communicate with a multidisciplinary team. Therefore, ing predictability and accuracy.
38 Digital Dentistry: A Step-by-Step Guide and Case Atlas
Figure 2.29 Occlusal photographs of the maxilla and mandible using a U-­shaped retractor and mirror.
2.1.6 Magnetic Resonance Imaging
Magnetic resonance imaging (MRI) is a 3D technique that
has excellent soft tissue contrast, is a noninvasive proce-
dure and, most importantly, does not use ionizing radia-
tion. The MR images are formed from radiofrequency
signals generated from the nuclei of hydrogen atoms,
which can be found in water and bone in matrix protein,
and water and fat in bone marrow [31]. When there is no
magnetic field, the hydrogen nuclei are randomly ori-
ented but when they are placed in a strong magnetic field,
they align and begin the movement of precession. The
application of a radiofrequency pulse causes a temporary
alignment of the protons against the field. After the pulse,
the protons relax back to their initial state within the mag-
netic field. A coil inside the MRI records the intensities of
signals, the magnitude and rate of energy release that
occurs when returning to the initial alignment (T1 relaxa-
tion time), and the oscillation (precession) of the protons
during the process (T2 relaxation time).
Because of the different environment surrounding
hydrogen nuclei and the overall concentration of
hydrogen nuclei, different tissues have different T1 and
T2. On T1-­weighted images, fat appears bright (hyper-
intense), while on T2-­weighted images fat appears rela-
tively dark (hypointense). In contrast, water and liquids
appear relatively dark on T1-­weighted images and
bright on T2-­weighted images. T1-­weighted images
show the anatomy of soft tissue and fat and T2-­weighted
images show fluids and pathologies (tumors, inflam-
mation, trauma). Therefore, it is important to have both
T1-­ and T2-­weighted images, to provide complemen-
tary information.
Comparing MRI to CBCT and CT, MRI has some dis-
advantages. It requires more time for image acquisition
compared to CBCT and CT. Some ferromagnetic metals
can adversely affect image quality because of distortion
of the magnetic field, although this image distortion is
limited to the area of the material and does not affect
the titanium implants [32].
2.1.6.1 Factors Affecting MRI Quality
The choice of correct imaging protocol is the most
important aspect of controlling MRI quality; an acquisi-
tion is required for each specific clinical process with
respect to detail (blurring), noise, and acquisition time.
Image quality (spatial resolution, contrast resolution) is
directly influenced by the magnetic force field. MR
images are measured by the strength of the magnet, in
units of tesla (T). The higher the tesla, the stronger the
magnet. The majority of clinical MRI are either 1.5 T or
3 T, but there are also higher T, for example 7 T, 9 T, 11 T,
and 15 T [33]. The quality of MR images is not only
dependent on the quantity of tesla; 3 T may be better
than 1.5 T but it also depends on the coil and the correct
use of protocol.
The signal-­to-­noise ratio (SNR) is what comes from
the patient’s body during the exam which is received by
the coils placed near the part being imaged. Image qual-
ity increases in proportion to the SNR. High-­field MRI
systems can result in higher SNR and allow for acquisi-
tion with higher spatial resolution. However, high-­
resolution scans may require long acquisition times,
which can increase discomfort for the patient and create
more risk of movement [34].
When there is more noise in an image, the quality is
lower because it reduces the visibility of contrast objects
and differences between tissues. Most of the noise in
MR images is the result of a form of random RF energy
from the patient’s body. We can control the amount of

noise from the patient’s body by selecting appropriate
characteristics of the RF receiver coil but the amount of
noise from the patient’s body often increases with field
strength because of adjustments in the bandwidth for
the higher fields. Bandwidth is the range of frequencies
(RF) that the receiver is regulated to receive. When the
bandwidth is increased, this reduces the chemical shift
artifact but more noise enters the receiver.
Detail in MRI is determined by the size of the tissue
voxels and corresponding image pixels. The dimension
of a voxel is determined by the ratio of the field of view
(FOV) and the size of the matrix. If the voxel size is
increased to decrease noise, blurring is increased.
Therefore, voxel size must be chosen correctly to pro-
vide an appropriate balance between blurring and noise.
The smaller image FOVs and smaller voxels produce
better visibility of detail. The level of noise that appears
in an image depends on the ratio of the signal strength
from the individual voxels and the noise strength com-
ing from a region of the patient’s body. The visible noise
is reduced by increasing signal strength. This can be
done by increasing the magnetic field strength, increas-
ing voxel size, increasing TR, and decreasing TE [35].
Contrast can be controlled by repetition time (TR)
and echo time (TE). When TR is reduced to decrease
image acquisition time, image noise can increase. And
when long TE is used, this can also increase image noise.
Figure 2.30 Target segmentation. After setting a cursor at the margin between the target and surrounding tissue in the
semi-­automated segmentation mode, the border is automatically created (yellow; parotid gland, red: masseter muscle, blue:
submandibular gland).
Chapter 2 Computer-­Aided Design (CAD) 39
2.1.6.2 MRI Assessment of Soft
Tissue Anatomy
In dentistry, MRI is widely used as an accurate method
for evaluating the soft tissue image of craniofacial struc-
tures. For example, it is used to examine salivary glands,
soft tissue tumors, maxillary sinuses, and especially the
temporomandibular joint.
One MRI application that could be used in different
ways in digital dentistry is the assessment of soft tissue
anatomy. Dr Shumei Murakami and collaborators are
currently investigating the normal growth process of
each organ and tissue in the oral and maxillofacial region
using longitudinal MRI data in childhood [36, 37]. As
part of this, they are semi-­automatically extracting the
masseter muscle, submandibular gland, and parotid
gland and displaying them in three dimensions by seg-
mentation. For the segmentation, medical imaging soft-
ware (Analyze 12.0) was used (Figures 2.30 and 2.31).
Figure 2.30 shows the segmentation lines of the
parotid gland (yellow), masseter muscle (red), and sub-
mandibular gland (blue). In addition, a 3D model was
created from these and superimposed on the skull
imaged by CT (Figure 2.31). For the 3D model, medical
imaging software (Osirix MD, Pixmeo) was used. Using
this method, we can examine changes over time in the
volume and position of the center of gravity of each
organ or tissue.
40 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Figure 2.31 3D model. Six organs (three pairs) are shown three-­dimensionally from the segmentation shown in Figure 2.30.
A 3D model of the skull was created from the CT data.

Figure 2.32 Salivary gland benign tumor. Left: A case of pleomorphic adenoma in submandibular gland. The MRI sequence
used was spin-­echo T1-­weighted (TR: 350, TE: 8). This is a so-­called ball in hand finding. Right: A case of malignant lymphoma
in submandibular gland. MRI sequence is fast spin-­echo T2-­weighted (TR: 3600, TE: 120, ETL: 16). The tumor is invasive. The
adjacent submandibular gland is not displaced and the border is not seen.

One of the drawbacks of MRI is the long imaging
time. However, advances in hardware and software in
MRI equipment have made it possible to acquire cross-­
sectional images in 0.1 seconds.
2.1.6.3 Diagnosis of Soft Tissue Lesions
with MRI
Because of its high contrast among soft tissues, MRI is
often used for diagnosing neoplastic lesions in soft
tissues. For example, in tumors of the salivary glands
(Figure 2.32) and squamous cell carcinoma in the tongue
(Figure 2.33), MRI examination is very effective [38].
Unlike CT, MRI does not have a relative absolute
voxel value. Therefore, it is difficult to automatically
extract or select (segment) a targeted disease such as a
tumor. However, if the voxel value between the target
and the surrounding normal tissue is significantly dif-
ferent, the target can be segmented semi-­automatically.

Figure 2.33 MRI diagnosis of tongue cancer. Left: A case of squamous cell carcinoma in tongue. The MRI sequence used was
fast spin-­echo T2-­weighted (TR: 3600, TE: 120, ETL: 16) with fat suppression. Right: A case of mucoepidermoid carcinoma in
tongue. The MRI sequence used was fast spin-­echo T2-­weighted (TR: 3600, TE: 120, ETL: 16) with fat suppression.
2.1.6.4 Temporomandibular Joint Assessment
Magnetic resonance imaging is often applied to the
diagnosis of temporomandibular disorders because of
the clear depiction of the articular disk at the temporo-
mandibular joint [39, 40]. Since there is no radiation
exposure in MRI examination, repeated imaging is pos-
sible, and it is used not only for diagnosis before treat-
ment but also for confirmation after treatment.
2.1.6.5 Analyzing Bone Structure with MRI
Studies have demonstrated that MRI can detect caries,
pupal/periapical diseases, lesions in the mandibular
canal, impacted mandibular third molars, and early
bone changes. Recently, researchers have shown that
MRI can also be used for implant planning, showing
strong correlations with measurements performed with
CBCT [41].
Previously, it was thought that MRI could not be used
for bone tissue analysis, because it cannot reproduce the
image directly from the mineral content of the bone, but
from images of fluids in or around the bone (water, fat,
and hematopoietic tissues). This is because bone is
mainly composed of calcium hydroxyapatite, which has
only one proton that does not move. On MRI, bone
appears as a hypointense image (black), due to the very
short decay time and minimal signal, while fluids
appear as hyperintense (white). However, other tech-
niques to analyze bone have been developed, with good
results, such as the use of “black bone” and solid-­state
phosphorus-­31.
Chapter 2 Computer-­Aided Design (CAD) 41
Black bone MRI uses short TR and short TE associ-
ated with a low flip angle, enhancing the bone–soft
tissue boundary by minimizing the signal returned
from tissues to demonstrate the bone–tissue interface.
It results in high image contrast between bone and
soft tissues. In this case, the bone appears as a dark
signal intensity. This approach is also known as UTE
or ultrashort TE. This technique makes it possible to
segment bone to produce 3D reconstructed images of
the craniofacial skeleton and 3D printed anatomical
models [42–44].
Phosphorus-­31 (31P) solid-­state MRI produces quanti-
tative 3D images of the phosphorus distribution in tis-
sue by direct measurement. 31P is an important
component of bone mineral, NMR-­active and has
nuclear rotation angular momentum. Comparing 31P
and 1H, 31P requires a separate set of RF coils and ampli-
fiers tuned to this lower resonance frequency. The
nuclear sensitivity and concentration of 31P metabolites
are lower than 1H, resulting in a weaker signal. However,
even at 1.5 T, it is possible to achieve good-­quality phos-
phorus spectra with relatively sharp peaks [45–47].
2.1.6.6 Three-­Dimensional Reconstructions
from MRI
After the exam, the MR images are stored in a format
known as DICOM. DICOM format ensures that patient
information and images data stay together, and provides
the ability to transfer that information between devices
that support the DICOM format.
42 Digital Dentistry: A Step-by-Step Guide and Case Atlas
After data acquisition from MRI, the DICOM files are
transferred to CAD software for data manipulation and
processing, and finally, the processed data can be used
for the fabrication of structures through computer-­aided
manufacturing – 3D printing. There are many different
CAD software programs and 3D printing machines, each
with different qualities and characteristics.
Many studies investigate CBCT and CT data, using
their DICOM files to export patient images, using volu-
metric data and assisting in virtual planning combined
with CAD-­CAM software. MRI is useful for 3D recon-
structions and 3D printing and thus could also be
expected to be increasingly useful in digital workflows
for dentistry.
2.1.6.7 Studies Using MRI in Digital Workflow
3D MRI for Implant Planning and Surgical Guides
Studies have demonstrated that MRI can be used in dig-
ital workflow to assist in implant planning and 3D
reconstruction of the surgical guide. Most of these stud-
ies used 3 T MRI and showed that it is possible to per-
form guided implant surgery based on matching a
surface scan with an MRI and printing a virtually
designed template with accuracy. It is also possible to
provide diagnostic information through direct visuali-
zation of soft tissues such as the alveolar inferior
nerve [48]. For example, Mercado et al. used intraoral
scanners, MRI and CBCT, and these images were
extracted by DICOM, matched and uploaded into soft-
ware for implant planning (coDiagnostiX) [49]. Another
study evaluated the transferability of the virtually
planned implant position using MRI; deviations
between virtually planned and final implant position
were studied, and the result was acceptable for clinical
application [50].
3D MRI for Tooth Reconstruction
Magnetic resonance imaging has been used to develop
tooth reconstruction; one study investigated the accu-
racy of tooth surface reconstructions in patients with
dental restorations and indicated for dental implant.
Both CBCT and MRI were assessed by comparison with
digitized stone models. Comparing CBCT and MRI,
CBCT was the more accurate and reliable imaging tech-
nique for tooth surfaces in vivo but MRI also allows for
tooth surface reconstruction in satisfactory detail and
within acceptable acquisition times [51].
3D MRI for Endodontic Treatment
Magnetic resonance imaging was used for virtual plan-
ning in an endodontic treatment. A study by Drăgan et al.
used a 7.04 T MRI, and InVesalius software was employed
for the 3D reconstruction of the tooth scanned volume.
They showed that high-­resolution MRI enables a clear
view of the tooth and root canal anatomy [52].
3D MRI for Model Reconstruction
In a study by Chen and collaborators, they made a 3D
soft palate model using 3 T MRI data. The DICOM
MRI files were transcoded into Analyze 7.5 format by
MRI Convert so that they could be manipulated in
multiple 3D modeling software. The resulting 3D
model generated a patient-­specific modeling demon-
stration for clinical decisions and education-­related
purposes [53]. Another study had the objective of
using a high-­resolution MRI dataset to serve as a digi-
tal impression of human teeth. Two prepared teeth
were measured using MRI 1.5 T. From the acquired
MRI data, a model was constructed to depict the
tooth’s surface in a 3D dataset, which served for CAD-­
CAM fabrication of a fixed partial denture. The MRI
data were sufficiently achieved to allow fabrication of
a dental restoration [54].
Another study demonstrated the feasibility of 2D and
3D models based on CT-­MRI image fusion for the visu-
alization of jaw tumors. Both preoperative CT and MRI
1.5 T image data were acquired in DICOM format and
imported into Surgicase CMF software. Then, the struc-
tures were segmented and reconstructed in 3D texture.
The resulting 2D images and 3D models provided a
powerful tool for the visualization of jaw tumors. This
method could help surgeons in preoperative planning,
surgical simulation, and intraoperative guidance for jaw
tumors [55].
2.2 ­Software Manipulation
2.2.1 Types of Software Used in CAD
2.2.1.1 Nondental Open-­Source
Software Programs
The word “software” is intrinsic to the concept of digi-
tal dentistry, which involves digital planning of a clini-
cal case and turning a virtual object into a physical
object. Like many other concepts in dentistry, CAD-­
CAM originally came from engineering and related
areas. Consequently, several of the software programs
available are not fully focused on our area.
Open nondental software are programs that allow for
opening any file in 3D format (OBJ, STL, PLY, etc.) and
transforming it into an object to be 3D printed or milled.
Also, these software programs are generally open-­source

and free, unless a specific optional module to facilitate
digital design is to be downloaded. Consequently, open
software does not have specific tools for dentistry, but
provides general tools that the professional can use for
certain tasks.
An example of how we can use this software is in a
crown design. It is possible to verify that there is a proxi-
mal contact point of a crown between adjacent teeth,
but it is not possible to measure this contact intensity or
reduce it automatically without losing the anatomy
(something that a paid-­for program would be able to do).
Another common application of nondental open soft-
ware is bruxism plaque design. With the patient’s scan
file, it is possible to develop a myorelaxant splint, with
reliefs, simultaneous bilateral contacts and anterior
contacts, but there is still no efficient virtual articulator
where protrusive and lateral movements can be assessed
to ensure a better fit in the mouth. However, in open
software, it is also possible to do a canine-­to-­canine wax-
­up, using the patient’s facial photo and the intraoral
scan to make a mock-­up of the case. Surgical guides
such as the periodontal guide are also feasible. First, a
probing or a tomography of the patient is obtained and
then a virtual wax-­up is performed. If the probe has
been carried out, the wax-­up will follow the measure-
ments taken in the mesial, middle, and distal third of
that tooth. If a tomography has been performed, a match
can be made between the scanning and tomography
teeth, and the JEC (enamel–cement junction) can be
used as a reference for the wax-­up. Then, simply, a guide
is made on top of this wax-­up and a higher guide thick-
ness of 3 mm will be left, respecting the biological space.
Figure 2.34 Dental model made in Meshmixer, front and base view.
Chapter 2 Computer-­Aided Design (CAD) 43
Therefore, it is possible to carry out a large part of the
planning for projects in open software, but this requires
time, knowledge of the software tools, and understand-
ing that there are limitations to its use, especially when
oral rehabilitation and the use of maxillomandibular
references are involved.
The most used and most popular nondental open soft-
ware programs among dentists and technicians are
Meshmixer® (Autodesk’s official software) and Blender®
(Blender Foundation).
Due to its popularity and ease of use, Meshmixer is
currently the most popular and is the software with the
most descriptions in scientific literature, internet
searches and videos of how to use it on YouTube. It is a
development software, with tools for sculpting, selec-
tion, predefined object formats, the possibility of view-
ing different objects and different colors, stamping
shapes and analyzing the shape of the mesh being exe-
cuted, calculating distances between points, matching
different meshes, object alignment, and so on.
One of the most basic examples of how to use
Meshmixer is the formulation of a dental model
(Figure 2.34). After importing the 3D file, using a selec-
tion tool, it is possible to trim the edges of the file (fol-
lowing the same criteria used to trim a plaster model)
and then a base is created. After that, this base needs to
become solid before the model can be 3D printed or
milled. The final model can be either hollow or solid.
Blender is a programming software that can perform
everything that Meshmixer does, but only after pro-
gramming the software to do so. One of the widely used
ways to save time in Blender is the use of “presets” or
44 Digital Dentistry: A Step-by-Step Guide and Case Atlas
preprogramming tools that the professional can use in
dentistry. As there is no need for previous program-
ming, Meshmixer is the most used open software among
dental professionals who are users of CAD-­CAM sys-
tems to edit meshes in a free and intuitive way.
In conclusion, open nondental software brings us the
advantage of enabling treatment planning and design
for free in a reasonable time after acquiring the required
CAD knowledge and training.
2.2.1.2 Dental Commercial Software Programs
Dental commercial software programs are one of the
options to work with the digital workflow. The use of
these software programs is easier and faster compared
to nondental software since it is specifically designed for
dentistry. The majority of the software programs are
compatible with a wide range of different importation
and exportation language data. Automated tools and
specific features are already installed in these software
programs, such as teeth libraries and adjustment to the
antagonist arch, which enable you to create and design
digital appliances and restorations intuitively. The auto-
mations simplify the learning experience and facilitate
the whole process of creation. And above all, it makes
communication either with the lab or with the patient
faster and simpler.
There are two ways of working with dental software
programs – either with an open ecosystem or an inte-
grated ecosystem. Software programs from an open sys-
tem, such as Dental Studio (3Shape A/S), allow the
professional to integrate intraoral scans to manufactur-
ing machines of other companies. In contrast to open
Figure 2.35 Screenshot of the DentalCAD software being used in an in vitro experiment.
systems, integrated CAD-­CAM systems require that the
entire digital workflow is performed with the hardware
and software of the same company in order to acheive
compatibility to scan, design, and manufacture the final
product. Generally, the majority of software programs
accept communication with a range of different open
hardware programs.
The software programs mentioned are only one part
of the workflow of a whole-­system solution, but inde-
pendent dental software programs such as Blue Sky and
DentalCAD (Exocad GmbH; Figure 2.35) are also
broadly used in dental digital workflow because of the
number of useful tools, the user-­friendly interface for
dental professionals, and flexibility [56]. Common dif-
ferences between such software programs include cost
of license, software program interface, license renova-
tions, and/or STL exportation fees.
The majority of dental software systems cover at least
three important areas of dentistry: prosthodontics/restor-
ative dentistry, implant dentistry, and orthodontics.
Different automated features are presented in the pro-
grams depending on each field.
The CAD software for prosthodontics/restorative
dentistry can be used in dental laboratories or clinics
(chairside digital workflow). Several different jobs can
be done with those programs including crowns, cop-
ings, veneers, in/onlay, bridges, temporary crowns,
removables, and dental appliances. CAD software pro-
grams such as ChairsideCAD from Exocad offer a sim-
plified user-­friendly interface for dental professionals to
perform digital waxing using a step-­by-­step approach.
For advanced operators, these software programs allow
 Chapter 2 Computer-­Aided Design (CAD) 45

Figure 2.36 Screenshot of the Modellier software being used to outline the margins of a preparation to design a crown. The
prostheses designed in this software can be transferred to CAM software programs and devices of the Zirkonzahn system to be
milled, using an integrated digital workflow.

for working with a master menu with more complex 2.2.2 Types of Files Used
tools and options. Some of these software programs can
2.2.2.1 Digital Communication in
be part of an integrated CAD-­CAM system, such as the
Medicine (DICOM)
Modellier software from Zirkonzhan (Figure 2.36). In
With the increase in modalities and commercial brands
contrast with nondental CAD software programs, den-
providing digital imaging equipment, there was a need
tal commercial software programs have several automa-
to establish a standard not only for archiving different
tions leading to a more intuitive, simpler and faster
medical images, but also their transmission.
experience. This allows the clinician to deliver a faster
DICOM files were developed in the late 1980s,
service, in some cases in a single patient appointment.
designed to allow the connection of systems used for
The CAD software programs for dental implants, such
producing, storing, viewing, processing, sending, and
as ImplantStudio (3Shape A/S), coDiagnostiX (Dental
printing medical images, as well as optimizing the
Wings) and Exoplan (Exocad GmbH), are used for den-
workflow related to medical images. This standard is
tal implant planning (which can be prosthetically
constantly maintained and evaluated by the Medical
driven) and to create surgical guides to orientate implant
Imaging & Technology Alliance (MITA). In 1993, the
site drilling based on the virtual surgical plan. Aligning
ACR-­NEMA Standards Publication PS3 was released,
CBCT and intraoral scanning data enables prostheti-
also called DICOM 3, a much more robust standard
cally driven surgical plans, which lead to high accuracy
than the first ones. Currently, DICOM 3 is the standard
of implant placement, as well as high predictability and
for systems of image archiving and communication,
success of cases (see Chapter 6) [57].
supported by most devices that work with digital medi-
The CAD software dedicated for orthodontics can be
cal information.
used to design and produce aligners or even plan bracket
DICOM files carry information such as patient
placement to manufacture bonding trays in the Indirect
name, equipment that performed the scan, date and
Bonding Studio software. This is an open system soft-
location of the exam, acquisition parameters, etc. All
ware that requires the purchase of a license. Invisalign
this information is encoded and can be read by any
(Align Technology) is another software program where
DICOM viewer software. This maintains the integ-
aligners can be planned and manufactured but in a
rity of the data present in the exam, thus having legal
closed system. Patient cases are sent to the company on
value and wide portability. Raw CBCT data are
the Invisalign webpage so when the treatment planning
­usually available as DICOM files. As a result, these
is ready, the dentist approves the manufacturing of the
files are largely used in dental surgical planning
aligners, paying for the specific case approved (see
(Figure 2.37).
Chapter 9).
46 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Figure 2.37 Dental implant planning performed on DICOM files using ImplantStudio software (3Shape A/S).

2.2.2.2 Standard Tessellation Language (STL)

The STL file describes the surface geometry of an
object in 3D, showing attributes common to CAD
(three-­dimensional object) models (Figure 2.38). The
first 3D printing process using an STL file, stereo-
lithography, was introduced in 1984 by Charles Hull,
who developed a way for a 3D printer to correctly
interpret geometric information modeled in CAD soft-
ware; the standard 3D file format that is recognized by
all CAD software developers, the STL format, was also
created. The STL set of letters was initially created not
as an acronym, but by using some letters of the word
“stereolithography” but over the years it has been
transformed into an acronym, including meanings
such as Standard Triangle Language and Standard
Tessellation Language.
These files are usually generated by a CAD software
program. The STL file is perhaps the most important
item in any 3D print job. It contains the 3D model that is
used to make a physical object, a model for creating mul-
tiple design prototype options, and as a standard data
format, using a series of linked triangles to recreate the
surface geometry of a solid model. These files usually
have a relatively small file size. Nevertheless, STL files Figure 2.38 Top: STL file image sample. Bottom:
have limitations. Because tessellation only covers the Corresponding STL mesh.
surface, STL files are representations of surface geome-
try with no representation of color or texture. Another file sizes. This, in turn, may make the time required to
limitation of these files is the working resolution. recreate or manipulate the files considerably longer.
Retaining high resolution or encoding larger objects In dentistry, STL files are commonly used as the for-
requires a higher number of triangles, resulting in larger mat for images from intraoral and desktop surface
 Chapter 2 Computer-­Aided Design (CAD) 47

scanners. In addition, DICOM files of CT methods can

be converted to STL format, in order, for example, to
produce a prototyping model with information from the
patient’s oral and maxillofacial hard tissues.

2.2.2.3 Polygon File Format (PLY)

PLY is a file format for storing graphic objects that can
be described as a collection of polygons. The format was
first introduced in 1994 by researcher Greg Turk and
was based on the OBJ file. The purpose of this file was to
provide a simple, easy-­to-­implement format that could
be used by a wide range of models, in addition to facili-
tating the exchange of information between different
software.
PLY can be subformatted in two ways: ASCII
(American Standard Code for Information Interchange)
and a smaller binary format. The PLY file is widely
used in several areas, including dentistry, but it is cer-
tainly not the most used. However, it is very important
when you need real textures and colors applied to the
digital model. This is then the main advantage of the
PLY file over the more commonly used STL. Another
advantage is the file size, which is slightly smaller. As
a disadvantage, some software does not read PLY files
or does not import the image file with the actual tex-
ture and color information.
Therefore, the main use of the PLY file is the sharing
of digital model files with real colors and textures. A
simple example is an intraoral color scan performed
using an intraoral scanner and exported to third-­party
CAD software (Figure 2.39). The archive has also been
widely used, more recently in scientific publications.
Some publishers already use and encourage illustra-
tions in 3D models in the digital versions of journal
articles.

2.2.2.4 Object Files (OBJ)

Files with an .Obj (object) extension refer to three-­
dimensional graphic objects (3D vectors) with spatial
coordinates defined in height, width, and depth. They
represent geometric bodies exclusively through surface
information; that is, they are a virtual reconstruction of
the surface topography of real objects. This file format,
developed by Wavefront, stores objects composed of
points, polygonal lines and shapes without curves and
surfaces, generating a map of the surface of the real
object through a mesh of triangles (polygonal) such as
an STL or PLY, being a file extension widely used in
graphical tools, including modeling and animation.
The OBJ file is a simple data format that represents
only the 3D geometry of the object, not containing color
Figure 2.39 Top: PLY file image sample. Middle: PLY file
image with texture and color. Bottom: OBJ file mesh.
definitions of each surface, which are referenced in a
material library file (.mtl extension) that must always
accompany the file. This file describes the surface shad-
ing properties, in addition to the reflective properties of
light on each surface so that the object can be rendered
on the computer (Figure 2.40).
The MTL also contains the color environment informa-
tion (RGB), in addition to the diffuse, specular and areas
of transparency which ultimately define the entire
­surface texture of the 3D object. As the final composition
48 Digital Dentistry: A Step-by-Step Guide and Case Atlas
Figure 2.40 Left: OBJ file image sample. Right: OBJ file mesh.
of the set of files that bring the complete information of
the 3D object, the final color and texture mapping is opti-
cally copied from the object, generating an “open” 2D
texture in various space projections as an open map, that
is, a series of photographs coupled in different directions
around the copied object that will “cover” the polygonal
3D model with the colors and textures copied from the
original object. Usually this file has the extension .jpg or
.png. The OBJ format, which has been used for many
years in design, animation, and engineering, is now the
most used for facial scanning files.
When it comes to facial scanning in medicine and
dentistry, the most traditional way of obtaining 3D
images is through computed tomography (CT) which,
through ionizing radiation, enables volumetric recon-
struction of both internal structures and the facial sur-
face. This volumetric information (voxels) is able to
reassemble the geometric structure of the surface, but
cannot contain in DICOM files the texture and color
registers of the fabrics, even obtaining the same geo-
metrical format as the OBJ.
Likewise, STL files show complex structures better
than OBJ, but they also do not bring surface color and
texture information, and hence surface volume infor-
mation. In view of this need, the most widely used
methodology in dentistry today is the association of
volumetric structures obtained through CT, with STL
files for intraoral scanning and spatial orientation using
extraoral photographs, that is, 2D photogrammetry.
Two-­dimensional photogrammetry is easy to access
and low cost and consists of taking a photographic facial
survey and linear measurements in computer software
by scaling the images with clinical anthropometric
measurements. Its limitations are great due to distor-
tions and angulations in photographic shots and the
impossibility of volumetric measurements. In the pho-
togrammetry process, it is possible to evolve to the
acquisition of 3D surface images with the use of soft-
ware that performs a computerized analysis of photo-
graphs for measurements in the physical world through
computer vision algorithms. Through several photos
from different angles of the same object, processing is
done by capturing fixed points (points in common
between the shots) in order to estimate the dimensions
of the photographed object, and the algorithms process
the images by identifying and marking reference points.
Then, there is a new process for 3D digitization to gener-
ate a cloud of points and a 3D coordinate system, obtain-
ing a 3D model and even extracting its colors. The final
processing of these images, called 3D photogrammetry,
generates OBJ files to be used in 3D modeling software.
Thus, 3D photogrammetry is an alternative method to
CT for obtaining facial data (facial scanning), mainly
because it is less invasive, less costly and offers less risk of
side-­effects to the patient if used repeatedly. It can also be
a viable complementary alternative to volumetric bone
reconstructions, complementing the facial surface tex-
ture when these two 3D files (OBJ + DICOM) are aligned.
In treatment plans, it has many advantages, such as quan-
tification of angles, surface areas and volumes, in addi-
tion to linear distances, definition of spatial coordinates x,
y, and z as in STL and PLY and a wide variety of statistical
analyses of shape, in addition to the possibility of captur-
ing surface data at high color resolution and at fast speeds.
2.2.2.5 Files from Clinical Photographs
As previously explained in this chapter, clinical photog-
raphy is the starting point of all esthetic and virtual
analysis for the patient’s treatment plan. In this context,
files of clinical photographs should offer image quality

which is good enough to conduct a series of assessments
of the patient’s face.
Facial esthetic analysis initially aims to identify the rela-
tionship of bilateral symmetry, harmony, and facial pro-
portions. The first two reference lines to be drawn for this
analysis are the median and bipupillary lines, which will
be reference lines for all other relationships of soft tissue,
bone, gum, and dental planes in the vertical and horizon-
tal planes. The midline is drawn through the glabella, tip
of the nose, philtrum, and mentum. The height of the face
is determined by the distance between the hairline and
the chin, and the width of the face is determined by lines
that tangent the zygomatic bones. This information gives
us face shape: square, rectangular, or circular.
The horizontal lines parallel to the bipupillary line pro-
vide us with important references for determining the
thirds of the face. The upper third is determined by the
eyebrow and hairline lines; the middle third is delimited
by the eyebrow line and the line of the base of the nose
(subnasal), and the lower third extends from the base of
the nose to the chin. These lines provide us with impor-
tant information about the proportions of the facial thirds
and are seen in both frontal and profile photos.
Other horizontal lines parallel to the bipupillary line
bring us important information about the lips, teeth,
and gums: they are the edge line or incisal plane, gingi-
val margin line, and labial commissure line. The plane
of the gingival margin must be parallel to the bipupil-
lary lines and the labial commissures; when it is not par-
allel to the bipupillary line, it demonstrates labial
asymmetry. An important horizontal reference is the
curve of the upper edge of the lower lip, which must be
parallel to the curve of the dental arch (line of the incisal
edges and cusps of the posterior teeth – smile arc).
The lips bring us important references when they are
sealed in terms of thickness and proportion between
them and lip support, but even more important refer-
ences when they are at rest, becoming the frame of the
smile and the transition between extraoral esthetic anal-
ysis and intraoral.
Transferring the horizontal and vertical references of
the face to the intraoral region, it is possible to observe
the dental midline and the incisal plane, also establish-
ing the dental proportion mathematically or graphi-
cally. Photographs in digital dentistry are very important
not only for esthetic treatment planning, but also for
generating spatial references for 3D tomographic recon-
structions (DICOM), for intraoral scanning (STL) and
facial scanning (OBJ) models. With software alignment
tools, the photograph provides references of the face in
relation to the ground (provided that photographic
Chapter 2 Computer-­Aided Design (CAD) 49
protocols are followed) and consequent inclinations of
the arches in relation to the face, making it possible to
generate spatial coordinates (x, y, and z) for the 3D
meshes, which allows us to work on intraoral scans, for
example, with the maintenance of the facial esthetic ori-
entation previously described.
JPEG or JPG (Joint Photographic Experts Group)
This type of image file is named after the group of pho-
tography specialists who developed the compression
algorithms for this format, which take up much less
space. It is the most used format due to the high compat-
ibility and ease of reading of the various systems, both
internet and other printing devices and systems, which
makes it the standard format for photographic cameras.
It has 8 bits for each RGB (Red, Green, Blue) pixel
color channel in the photograph, enabling a maximum
of 16 million colors in the image, keeping the brightness
very similar to the original file before compression
(RAW). It guarantees different levels of compression,
but the more the image is manipulated and compressed,
the more it loses details such as texture and contrast.
The main advantages are compatibility and recording
speed, in addition to the reduced size, but it does not sup-
port transparencies within the images and loses quality,
limiting the possibilities of postprocessing these images.
RAW
This format generates images exactly as they were cap-
tured by the digital camera’s sensor without editing or
compression, as if it were a digital negative, which
explains the file name “raw.” Because it is the raw file, it
takes up a lot of space, 3–4 times larger than JPEG in high
quality, and ends up having its recording time on the
memory card increased, which hinders a fast sequence of
multiple photographs, for example. Because it is still a
digital negative, the photograph cannot be viewed in pre-
processing software like Photoshop or Lightroom.
Usually, professional photographers use this format,
as it is the best for editing and has legal certification,
and RAW photography can even be used for criminal
evidence, for example. It features high image quality
and greater color depth; 12-­bit RAW files can achieve 68
billion different colors, while 14-­bit RAW formats can
achieve 4.3 trillion colors.
TIFF
Developed by Microsoft, these files are larger than JPEG
but with much higher compression quality, that is, pre-
serving much more quality with 8 or 16 hits, and may
contain billions of colors. TIFF stands for Tagged Image
50 Digital Dentistry: A Step-by-Step Guide and Case Atlas
File Format and is the standard format used by the
printing and publishing industries.
It is an extremely flexible format and compatible with
almost all image editing software and applications. It
can preserve transparencies and save Photoshop layers
for further editing, just like Photoshop PSD files. It is
the best format for storing image files while preserving
image quality. Some cameras already generate images in
this format but in general, most photographers recom-
mend capturing images in RAW and compressing them
in TIFF to preserve maximum quality and reduce the
size of files to be stored, but there is little compatibility
of this file format on internet systems.
GIF (Graphic Interchange Format)
These are extremely compressed files, developed spe-
cifically for the internet, as they are light files and sup-
port moving images (animated gifs), being also used for
web graphics, icons, and illustrations. They have a very
limited range of colors and 8 bits and support a maxi-
mum of 256 colors.
PNG (Portable Network Graphics)
This format is based on a GIF file type, but without
much loss of quality. It enables a higher bit rate, ensur-
ing millions of colors, preserving background transpar-
ency, and minimizing jagged edges. It is a very good file
type for photos, being a good alternative to GIF for use
on the web, especially when transparent files are
needed, as they are a little smaller than the TIFF format.
2.2.2.6 Video Files
Esthetic analysis of the smile through photographs as
the only diagnostic tool ends up being very limited and
dynamic analysis of the smile becomes essential, which
we are now able to achieve through video recordings. In
general, photography is able to show the patient’s social
smile, not the spontaneous smile, which is more easily
reproducible in video recordings, which ensure a more
detailed analysis of the patient’s expressions during the
smile, allowing the identification of the type of smile
and the dynamics of muscle movement. Also during
speech and rest, the relationship of the upper teeth with
the lip can be observed.
There are several video file formats named according
to the brand that developed the system, the information
contained in the file, and the purpose for which it was
developed.
●● WMV: an abbreviation for Windows Media Video,
developed by Microsoft, so it comes as a standard for-
mat for video files in Windows, directly compatible
with Windows Media Player, without the need for
codecs, which are encoders/decoders of files.
●● AVI: an abbreviation for Audio Video Interleave, also
developed by Microsoft. This format stores audio and
video tracks that are played back synchronously, but
can be separated more easily. It is compatible with
Windows as well as DVD and Blu-­ray players, which
support the DivX codec.
●● MOV: developed by Apple for the Quick Time Player
(also available for Windows). It has specific codecs for
Quicktime for iPod, iPhone and iPad, and can also be
used for video streaming.
●● MPEG (Moving Pictures Experts Group): created by
ISO in order to standardize the compression and
transmission of audio and video. There are different
standards in this format: MPEG-­1 (used for VCD),
MPEG-­2 (used for DVD), and MPEG-­4.
●● MKV: created by the Matroska Association, to store
audio, video, and subtitles tracks, supporting several
formats, including attachments such as JPEG, lyrics,
and music, as well as decoder filters. It is usually used
for high-­resolution videos but it is necessary to use a
specific program and/or package of codecs compati-
ble with the file.
2.2.3 Combining Data: The Virtual Patient
One of the most important aspects of digital workflow
in dentistry is adequate preparation of the project. The
digital project contains all the files acquired (digital
exams) in a comprehensive and organized pattern that
gives the clinician a “virtual patient” on which to start
planning the case. It is important to understand that
many of the exams will be performed with the devices
and methods previously explained in this chapter,
including CBCT, intra-­ and extraoral scanners, clinical
photographs, videos from cameras, etc., in diverse for-
mats such as DICOM, STL, PLY, JPEG, etc.
A suitable software program should be selected
according to the requirements of each case. Software
programs for virtual planning will allow the profes-
sional to start the project by importing all the files. It is
important to verify which types of files are compatible
with the software to be used, since some programs may
not accept a variety of file formats. In some cases, a file
conversion process may be needed before importing
data. For instance, it is important to have the CBCT data
offered as DICOM files, since most software programs
are compatible with this extension.
Dental software programs generally have a particular
step-­by-­step procedure to import and prepare files. The
preparation of files may include manual or automatic
 Chapter 2 Computer-­Aided Design (CAD) 51

correction of errors, such as irregularities in the mesh of
an STL file, alignment of photos taken with the bipupil-
lary plane nonparallel to the horizon or CBCT threshold
regulation to obtain reliable 3D reconstructed models.
After preparation, the next step is alignment. All pho-
tos and 3D models in the project, called meshes, have to
be in the same position. Therefore, if all meshes in the
software 3D ambience are imported in different coordi-
nates, alignment of these files is necessary to move
them into the same coordinates. This process enables
the creation of the virtual patient (Figures 2.41 and 2.42).
Once the virtual patient is ready, we can proceed with
digital planning. Different types of planning may include
prosthetically driven digital planning for smile 3D design,
surgical planning for guided surgery [57], ortho set-­up for
aligners, endodontic planning for the EndoGuide tech-
nique (see Chapter 8), etc. The aim of digital planning is
to simulate treatment options such as virtual 3D position-
ing of implants according to the bone and virtual wax
patterns. Once planning is finally determined, the 3D
models that will be manufactured are designed. As
explained before, this would be the CAD phase. The plan-
ner or CAD technician may design different types of 3D
models such as surgical guides, bars, copings, crowns,
abutments, etc. These 3D models will be exported in file
formats recognized by 3D printers and milling machines.

Figure 2.41 Surgical planning performed on a virtual patient.

Figure 2.42 The same surgical planning as Figure 2.40, after removing the visualization of the CBCT scans, which allows the
professional to assess and visualize the dental implant planning in relation to the patient’s anatomy and future full-­arch
prosthesis.
52 Digital Dentistry: A Step-by-Step Guide and Case Atlas
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Chapter 3
Computer-­Aided Manufacturing (CAM)
Mayra T. Vasques, Gabriel S. Urbano, Ivan O. Gialain, Jacqueline F. Lima, Fábio Andretti,
Ricardo N. Kimura, Danilo M. Bianchi, Dionir Ventura, Fabricio L. Gebrin, Adriano R. Campos,
and Arthur R.G. Cortes
SUMMARY
This chapter provides a step-­by-­step guide and research evidence on all computer-­aided manufacturing (CAM) procedures
involved in digital workflows in dentistry.
Three-­dimensional (3D) printing, also known as addi-
tive manufacturing and rapid prototyping, is relatively
new in dentistry. In addition to equipment and software,
3D printing demands profound knowledge, which
requires a learning curve to achieve mastery. This chap-
ter addresses the main types of 3D printing technology
used in dentistry and the most important characteristics
and materials used.
In general, additive manufacturing works by layering
agglutinating particles through different processes until
the desired 3D object is obtained. Unlike subtraction
processes used in milling machines, where the material
removed may not be reused, this technology saves mate-
rial and produces little waste because it adds only the
necessary material. Usually, the object is printed from a
STL or OBJ file format, but there are several variations
according to software and equipment. These files are
originated from images acquired from scanning and
cone beam computed tomography (CBCT) and are pro-
cessed in computer-­aided design (CAD) software. After
obtaining the final STL file, the software performs the
slicing to be sent for printing on the 3D equipment.
Three-­dimensional printing has become more afford-
able in recent years and has quickly evolved for use in
dentistry. This generated great competition among
equipment manufacturers and a race for more affordable
technology developments to serve different fields. This
ultimately leads to equipment with more reasonable
prices, increasing the demand for different materials and
encouraging input industries in dentistry to develop
Digital Dentistry: A Step-by-Step Guide and Case Atlas, First Edition. Edited by Arthur R.G. Cortes.
© 2022 John Wiley & Sons Ltd. Published 2022 by John Wiley & Sons Ltd.
55
high-­performance intra-­ and extraoral materials for vir-
tually all specialties. In addition, 3D printers have
become essential equipment in dental laboratories and
are quickly arriving at offices and clinics.
Three-­dimensional printers indicated for dental use
include FDM (fused deposition modeling), SLS (selective
laser sintering), and SLA (stereolithography) technolo-
gies – the latter is the most used today.
The FDM 3D printer, also known as a filament printer,
is the most straightforward technology, with the most
affordable equipment and supplies, and available in vari-
ous brands and models. It uses thermoplastic materials
that generate objects by material deposition through an
automated extrusion process at high temperatures, with
layer thicknesses ranging from 100 to 300 μm. This type
of printer is also known as FFF (fused filament fabrica-
tion). It uses a wide range of materials such as ABS
(acrylonitrile butadiene styrene), ASA (acrylonitrile sty-
rene acrylate), PLA (polylactic acid), PETG (polyethyl-
ene terephthalate glycol), and nylon, in the form of
filaments sold in rolls and ready to be introduced into
the machines. Despite its cost-­effectiveness, its use in
dentistry is limited to producing models that do not
require high definition and complexity, such as study
models and biomodels, hollow models for study in
orthodontics, and tools such as photoretractors, holders,
and stock trays. The most used materials for printing
these objects are ABS and PLA, as they have reduced
cost, ease of handling, and a range of colors and settings
for the vast majority of FDM printers on the market.
56 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Selective laser sintering (SLS) technology uses
high-­power laser to aggregate particles by sintering.
Sintering can be defined as a thermophysical process
activated by a laser source, which makes a set of parti-
cles of a particular material to be joined, arriving at the
desired structure with high mechanical resistance. The
materials used for this type of 3D printing are found in
powder in various polymeric compounds, metals, and
ceramics. These materials include nylon, PEEK (poly-
ether ether ketone), metals such as titanium, and ceram-
ics. In dentistry, this method can manufacture structures
for fixed dentures, implant dentures, removable partial
dentures, dental implants, and dental crowns. Advantages
of this type of process, such as no need for supports, low
waste rate, excellent mechanical properties of materials,
and high precision, make this technology highly prom-
ising. However, the high value of equipment and sup-
plies, the need for specialized labor for maintenance,
the large size of the equipment, and the high complexity
of the machines’ operation mean that it is not currently
used in dentistry and dental laboratories.
Among all the additive manufacturing technologies,
the most used today in dentistry is SLA, which we will
emphasize here. By definition, stereolithography is a 3D
printing technology that uses photochemistry, that is,
chemical components cured by a light source, layer by
layer, whereby light causes monomers and oligomers to
cross-­link to form polymers constituting the 3D body.
Different SLA technologies stand out today in den-
tistry, the main ones being laser (light amplification by
stimulated emission of radiation), DLP (digital light
processing), and LCD (liquid crystal display) (Table 3.1).
All typically use light sources with wavelengths that can
range from 380 to 405 nm.
Laser printers are commonly referred to as just SLA as
they were the first affordable desktops on the market.
However, the correct nomenclature would be SLA-­laser.
They are characterized by using an ultraviolet (UV)
laser beam and a system of motors and mirrors that
move in combination to obtain the design of each layer.
Due to this feature, they are usually slower when creat-
ing several objects, as they need to move across the
entire layer, unlike DLP and LCD printers that project
an entire layer at a time. The print results are excellent,
and definition depends on the laser focus size and
speed. They have high prices, maintenance costs, and
replacement parts with high values.
SLA-­DLP 3D printers use DLP technology initially
developed in 1987 by Larry Hornbeck of Texas
Instruments, based on optical micro-­electromechanical
technology composed of digital micromirror devices.
Initially, this technology was used for other purposes
such as front projectors for cinemas, home cinemas,
projectors for classrooms, and televisions. In the 1990s,
DLP technology started to be implemented in additive
manufacturing. The first DLP printers used mercury
lamp projectors and, after industrial improvement, min-
iprojectors that use LED UV (light-­emitting diode ultra-
violet). The equipment ranges from medium to high
prices, delivers excellent definition and finish, and the
printers currently offer improved repeatability, safety,
and low maintenance, but with high-­value replacement

Table 3.1 Main types of technology and printers used in dentistry, their synonyms, advantages, and disadvantages.

Types of
Technology 3D printer Synonyms Benefits Disadvantages

SLA Laser SLA High definition, repeatability, print Specialized maintenance, equipment price,
table size, low distortion high spare parts price, slow print speed for
large quantities of objects, unique formulation
resins, generally closed for configurations
DLP Projector High definition, repeatability, Specialized maintenance, equipment price,
printers excellent speed, low distortion, high price of spare parts, some equipment
equipment durability, printing table closed for configurations
size, greater variety of resins
LCD MSLA Low price, cheap spare parts, open They break more often and have more
configuration for all types of resins, distortion in the corners of the screen
good speed, printing table size, larger
variety of resins, small and light
FDM FDM FFF Low price of inputs and equipment, High print time, poor definition for most
recyclable materials dental indications, lack of registered materials
for intraoral use, constant maintenance, energy
consumption

parts. Their reservoirs also use PDMS silicone or fluori-
nated ethylene propylene (FEP) film on the bottom.
SLA-­LCD 3D printers utilize a LCD and LED UV light
source to generate the print layers. LCDs were not ini-
tially designed for this use and have been used in TV
monitors, cellphones, displays, clocks, radios, and other
equipment since their creation in the mid-­1960s. The
idea of a LCD based on TFT (thin-­film transistor) was
conceived by Bernard Lechner of RCA Laboratories in
1968. The light source is located inside the printer, right
below the LCD. When projecting the image of each layer,
the LCD releases the passage of light and polymerizes
the resins. The number of LEDs and lenses varies
according to brand and model. The models differ mainly
according to the type of LCD used, ranging from mono-
chrome, color, size in inches, and different resolutions
(full HD, 2, 4, and 8 K). These devices have attractive
prices and low maintenance costs, so they are usually
the first choice of those wanting to enter the world of 3D
SLA printing. However, they are more fragile and
because of the LCD’s location just below the reservoir,
they tend to break quite often.
SLA resins are liquid composites mainly composed of
oligomers and monomers, but they need other additives
to work in each type of equipment, such as UV blockers,
inhibitors, dispersants, pigments, photo activators, and
other types of fillers. The formulation of each resin
depends exclusively on its indication and the equipment
that will be used. The choice of formulation compo-
nents is directly linked to each need and physical char-
acteristics, such as the equipment’s wavelength, flexural
strength, tensile strength, impact resistance, cycling,
viscosity, biocompatibility, color, odor, etc. As an exam-
ple, we can mention the resin used for making tempo-
rary and definitive crowns, which uses loads similar to
the composite resin in the office, such as glass or ceram-
ics. Resins for SLA printers in dentistry are divided into
two large groups, biocompatible and nonbiocompatible,
and we can see their types and indications in Table 3.2.
Most of the components of a 3D SLA resin are ther-
moset elements derived from petroleum which, unlike
thermoplastics, are not recyclable in their solid state
(after printing). This factor represents a significant risk
to the environment since 3D printing is generating more
and more residues that will remain in the ecosystem for
long periods. In addition, in liquid form, contamination
is highly harmful to aquatic environments after wash-
ing or disposing of the bottles, especially for mixed
polarity resins, so-­called “water-­soluble,” as they dis-
perse more easily in water, offering more significant tox-
icity. Regarding sustainability, companies that produce
inputs must think about how to reuse solid materials
Chapter 3 Computer-­Aided Manufacturing (CAM) 57
Table 3.2 Types of materials used in resin and filament 3D
printers, and their indications in dentistry.
Materials Indications (dentistry)
Biocompatible Surgical guides, occlusal splint,
resins retainers, temporary and extended-­use
teeth, orthodontic bonding guides, total
and removable denture bases,
individual trays, mouthguards
Nonbiocompatible Study models, die-­cast models, working
resins models, biomodels, artificial gingiva for
models, elements for metal casting,
elements for lithium disilicate injection
Filaments Models and biomodels for study,
hollow models for orthodontics,
retractors for photography, positioners,
and stock trays
and create biodegradable materials, and the end-­users
must become aware of responsible disposal. Some com-
panies are already developing sustainability projects in
this sector, such as Makertech Labs, the first Brazilian
company in 3D resins, which receives material from its
largest customers, transforms it into powder in grinders,
and inserts it into civil construction materials, reducing
the environmental impact.
3.1 ­Fused Deposition
Modeling (FDM)
3.1.1 Basic Knowledge
Fused deposition modeling technology, also known as
FFF, is an additive manufacture procedure where a
thermoplastic material (presented as a filament) is
heated into a semisolid state to form, layer by layer, a 3D
geometry. The FDM printing process involves generic
components, such as the printing bed, axes motors­
(X, Y, and Z), extruder motor, and heated extruder.
The basic principle of FDM printing is that thermo-
plastic filament heats inside the extruder, and the
extruder motor pushes the filament through the extrud-
er’s nozzle. The extruder, nozzle, and cooling fans move
through the X, Y, and Z axes. Four motors control the
material deposition (X, Y, Z, and extruder) over a print-
ing bed that heats. The material is superimposed in lay-
ers, fusing the new layer over the last. After cooling
time, all layers are fused, forming a 3D object.
While preparing for printing, one should carefully
place all parts over the printing bed or previously
printed layer. If there are any overhanging parts,
58 Digital Dentistry: A Step-by-Step Guide and Case Atlas

preprocessing software may create additional supports
that postprocessing will remove.
Most FDM printers and filaments are cost-­effective
compared with other 3D printing technologies, making
this method very suitable for dental offices, especially
for beginners in the digital workflow. Other advantages
of this technology are the relatively simple operation
and low postprocessing time.
On the other hand, the main disadvantage of FDM is
the lower printing resolution (compared with SLA and
DLP, for example), which is around 100 μm on the Z-­axis.
Even though some high-­resolution FDM printers can
achieve a 20–50 μm Z-­layer resolution, these printers are
more expensive. Other disadvantages are dimensional
accuracy and reproducibility. Since FDM technology uses
thermoplastic material (Table 3.3), autoclave sterilization
may not be achievable for most materials available, but
low-­temperature sterilization methods can be used.
The majority of FDM printings for dental purposes
use ABS and PLA materials, but other materials, such
as TPU (thermoplastic polyurethane), PC (polycarbon-
ate), PETG, and other polymers can be used. The main
advantages of ABS are cost (cheaper than PLA),
machinability (the final part can combine additive and
subtractive manufacturing procedures), and that it can
be recycled. On the other hand, PLA is biodegradable
(usually made from corn starch), needs lower printing
temperature, and has lower shrinkage.
Some biopolymers and other filaments are in develop-
ment, and further studies may demonstrate different
applications in dentistry, including flexible materials.
Other filament materials may be available for FDM
usage, but they are mainly used for artistic or engineer-
ing purposes.
In implant dentistry, FDM printers are mostly used
for fabricating study and work biomodels (Figure 3.1),
individual impression trays, prototypes for bone regen-
eration scaffold guides, and surgical guides.
3.1.2 Step-­by-­Step Procedure
The workflow with an FDM printer has four main
processes: calibration, preprocessing, printing, and
postprocessing.
3.1.2.1 Calibration
●● Each printer has its own calibration process, but in
this step-­by-­step guide, a low-­cost FDM printer
(Anycubic) will be used.
●● After assembling the printer (if needed), check that
the frame is squared and all belts are correctly ten-
sioned. If something is wrong, the printing will not
have dimensional accuracy.
●● All parts of the printer must be cleaned and lubri-
cated (where needed) to prevent excess friction
between components and to allow the correct func-
tion of all cooling fans.
●● Tray leveling: there are usually four knobs under the
printing tray that regulate the bed height to be parallel to
the X and Y movement. Some printers have an auto tray
leveling feature that helps to ensure correct tray leveling.
The most common technique used to level the bed is to
put the nozzle in various points over the bed (at the
same Z distance) and regulate the distance until a regu-
lar piece of paper fits between the nozzle and the bed.
This technique is straightforward (but not very accurate)
for adjusting bed height, but more advanced techniques
use equipment and tools, such as a feeler gauge or dial
indicator. If the nozzle is too far away from the bed,
the print may detach from the print bed and if the nozzle
is too close, the filament may create a print line with
excess material on the sides (elephant’s foot effect).

Table 3.3 Materials used for filament 3D printing.

Material Indication Advantages Drawbacks

ABS Fabricate biomodels, Stiff and durable material, low cost, Produces toxic gases while printing,
impression trays, recyclable high printing temperature, warps easily
PLA surgical guides Biodegradable, low warping, low Water absorption, low impact strength,
temperature to print, easy to print may clog the nozzle
PETG Smooth finishing, food-­safe, moisture Low wear resistance, high printing
resistance temperature, not so many options as
PLA and ABS
PC Thermal resistance, mechanically strong More challenging to print, high printing
temperature, higher pricing
TPU Simulate soft tissue in Flexibility, wear resistance, chemical More challenging to print, high printing
biomodels resistance (oils) temperature, higher pricing

(a)
(c)
Figure 3.1 (a) Calibration of the filament 3D printer. (b–d) Dental model manufacture.
●● The nozzle and filament tube must be clear of any clog-
ging. If there is any filament clogging, it can affect cor-
rect extrusion and cause print failure. There is a specific
needle to clear blockages, and this procedure must be
done with the extruder at printing temperature.
●● All axes’ motors must be calibrated. A printing blank
is printed to check X, Y, and Z calibration (usually a
calibration cube with known dimensions), and the
printed cube must be measured. If there are any dis-
crepancies, the steps/mm option must be adjusted. For
print smaller than the 3D file, the steps/mm should be
increased using a simple proportion calculation, and
this adjustment must be made for all three axes.
●● The nozzle must be at printing temperature to calibrate
the extruding motor, and a mark with a permanent
marker should be made at a 110 mm distance from the
extrusion motor’s entry. After making the mark, order
the printer to extrude a smaller distance than the mark
(100 mm). The remaining distance between the mark
and extruder’s entry should be 10 mm. Following the
Chapter 3 Computer-­Aided Manufacturing (CAM) 59
(b)
(d)
same instruction as for X, Y, and Z, the extruder’s steps/
mm should be calibrated.
●● Each material must be printed at a specific tempera-
ture, but the printing temperature may slightly change
even among batches of the same material and manu-
facture. For improved results, test printings are avail-
able to test several printing temperatures in one print,
and the user can choose the best for each situation.
Usually, manufacturers advise the temperature range
to print with each material.
●● There are more advanced calibration processes,
but these are the initial steps to print with an FDM
printer.
After the FDM printer is calibrated, the next step
is to adjust the geometry in CAD software. In this
example, open-­source software will be used (Autodesk
Meshmixer®, version 3.5.474) to prepare a maxillary
arch study biomodel. These are the steps for the pre-
processing phase.
60 Digital Dentistry: A Step-by-Step Guide and Case Atlas
●● Import the STL file created from intraoral scanning.
●● Since the file may have undesired geometries, it must be
cleaned. This process is achieved by selecting the sec-
tions that are not going to be printed and deleting them.
●● After cleaning the unwanted sections, the model must
be transformed into a closed volume since the 3D printer
software recognizes closed meshes. To close the geome-
try with a flat surface, the boundaries can be smoothed
and extruded (by selecting the border triangles and
using “smooth boundary” and “extrude” tools), and
lastly creating a closed mesh with the “make solid” tool.
●● Export the printer-­ready STL file and open the slicing
software. In this example, the Ultimaker Cura slicer
(version 4.6.1) was used, and the model was rotated to
create a need for support material.
●● Choose the print parameters adjusted for the printed
and filament material and save the G-­code file. For
this example, a PLA filament was used with nozzle
temperature of 200 °C, layer height of 200 μm, and
20% infill (a solid infill would take more time and
material but not increase print quality). The total time
for printing is approximately 1 hour and 55 minutes,
using 12 g (or 4.12 m) of filament.
3.1.2.2 Printing and Postprocessing
When the G-­code file is ready, it must be sent to the
printer, either via a micro-­SD card or using a wi-­fi con-
nection. The printer should automatically adjust the
bed and nozzle temperatures and print the object with-
out any issues. After printing time is over, the supports
must be removed using clippers, and the final model
is ready.
3.2 ­Liquid Crystal Display (LCD)
3.2.1 Basic Knowledge
Liquid crystal display is a vat photopolymerization
technology known as masked stereolithography
apparatus (MSLA). It consists of an array of LEDs and
an LCD screen that acts as a dynamic mask, allowing
the light to reach the resin through its off pixels, forming
the design of the printing layer. LCD is part of the
second generation of SLA which uses the projection of
an entire layer of light to cure the resin instead of a
single laser beam, making the technology significantly
faster than the original SLA [1].
In this equipment, the resin vat is placed over the
LCD surface with the FEP film in direct contact. As the
LED is the weakest light source in vat 3D printing, it
must be as close as possible to the polymerizing resin.
The light power is an essential characteristic because it
can damage the LCD pixels. Another factor is the risk of
resin leakage from the vat which may permanently
damage the LCD surface [2].
The lifetime of the LCD is extended by reducing
the polymerization of each layer to the minimum
required to make the material rigid and maintain the
object dimensions without distortions. Considering
the photoinitiators, the use of specifically formulated
resins also favors the performance of LCD printers.
LCD printers can use most of the materials used by
DLP printers, but the light exposure time has to be
higher to obtain the same results. Due to this charac-
teristic, it is mandatory to finish the polymerization in
a UV light chamber to achieve the best materials
properties [3].
The LCD resolution is an essential factor for accuracy
of the printed object, considering it is formed by square
pixels, making actual curves impossible to reproduce.­
A high-­resolution screen minimizes the geometric
effect; another way to improve the object surface is the
anti-­aliasing that changes to average edge boundary pix-
els. The cooling system is another primary focus for
equipment longevity, and appropriate LED cooling
reduces the damage caused to the LCD screen, allowing
the best air circulation [4, 5].
The most significant advantage of LCD is its lower
price, as the light source is cheaper compared to other
types. LCD technology is often the first choice for begin-
ners. The equipment parts are shown schematically in
Figure 3.2.
3.2.2 Step-­by-­Step Procedure
As with any dental procedure, 3D printing requires a
step-­by-­step process to carry out the project. This
Building Platform
Vat
LCD Screen
Emitting Light
LED
Cooling System
Figure 3.2 Schematic presentation of the parts of an LCD
printer.

section describes how 3D printing is done on the most
common LCD printers on the market.
Liquid crystal display printing popularized 3D print-
ing with resins. With the emergence of numerous man-
ufacturers, 3D printing became efficient and cheap,
enabling many dentists and technicians to venture into
the world of digital dentistry. The operation of these
printers is as simple as their price is affordable. Briefly,
LCD is a screen with a UV light filter, which turns on or
off as requested by the software.
At the bottom of the printer is a UV light source
emitted to the LCD above it. At this time, the LCD is
off, not letting the light through. As soon as it reads the
file that it was asked to print, it turns on the image of
the layer that was requested in the file at that instant.
In this way, UV light passes through the LCD and
polymerizes the region of that slice predefined in the
slicing software.
Three-­dimensional printing is composed of five steps:
STL file acquisition, settings in software, slicing, object
printing, washing/postcure.
3.2.2.1 Acquisition
The STL format is a universal extension of 3D objects
that can be recognized by all development software
(Meshmixer, Blender®, DentalCAD®, among others).
The acquisition can be performed with an intraoral
scanner or a bench-­top scanner.
Figure 3.3 Project screenshot ready to be sliced, showing object layer thickness and exposure time settings.
Chapter 3 Computer-­Aided Manufacturing (CAM) 61
3.2.2.2 CAM Software Settings
The development of the required object file will depend
on what software will be used and the purpose (printing
or milling). Due to the type of manufacture, it is neces-
sary to understand the minimum thickness. Because 3D
printing is done in an additive way, we get thinner thick-
nesses than regressive manufacturing (which is the case
with milling). Because of this, it is necessary to keep in
mind what will be done with that object to avoid distor-
tions and maximize its definition.
3.2.2.3 Slicing
A 3D printed object can be compared to a notebook, in
that it is composed of several sheets (layers). The system
deposits material in multiple layers. The sheets are the
layers/slices of 3D printing, and the notebook is the
printed object. Therefore, all 3D printing (whether resin
or filament) is made from the union of several superim-
posed layers, which can have different thicknesses and
polymerization times. That is what the slicing software
does – slicing the object to be polymerized one layer at a
time, making it build as planned.
There are several slicing software programs on the mar-
ket, and each one generates a file extension that the printer
will read. Two of the most famous slicing software pro-
grams for LCD printers are Chitubox Basic® (CBD-­Tech,
Shenzhen, China) and Photon Workshop® (Anycubic,
Shenzhen, China), both free of charge (Figure 3.3).
62 Digital Dentistry: A Step-by-Step Guide and Case Atlas
Still thinking about the notebook example, imagine
the manufacture of sheets: each sheet can have a differ-
ent thickness. Thicker sheets, despite greater strength,
are cut faster, and their “finish” may be inferior. On the
other hand, thinner leaves take longer to cut, and their
“finish” (definition) tends to be superior.
In 3D printing, we can follow the same reasoning.
When slicing an object, it is necessary to inform the soft-
ware how thick each layer will be cured. The most com-
mon thicknesses in dentistry are 100 and 50 μm. In
addition, it is necessary to tell the software what the light
exposure time of each layer will be. The thicker the layer,
the longer the exposure time needed, as the light has to
go through a greater thickness. However, exposure time
is not directly proportional to thickness. For example, if
it takes 2 seconds to print at 50 μm, it does not mean that
4 seconds will be needed to print at 100 μm. So, printing
at 100 μm is much faster when compared to printing at
50 μm, or even an impression made at 25 μm. However,
the thicker the layer, the smaller the object definition.
In practice, when doing 3D printing, it is necessary to
think about the purpose of the printing. When printing
a model to obtain bleaching trays (Figure 3.4), there is
no need to print a template with very high definition.
A model that faithfully reproduces the shape and
­silhouette of the scanned teeth is enough. Therefore,
a 100 μm template could be printed. On the other hand,
if the intention is to obtain a mock-­up, where a higher
definition is needed to analyze areas of reflection, tex-
ture, shape, and position of the cervical area and the
zenith and developmental grooves, the most exciting
thing is to print at 50 μm.
As layering defines 3D printing, the higher its num-
ber, the longer it takes to print that object. After the
­project is sliced, it must be exported to the printer
(see next topic).
Figure 3.4 Occlusal view of a 3D-­printed model at 50 μm,
with a vacuum-­formed bleaching tray.
Another essential aspect that we will cover is the
printing material, in this case, the printing resins. Each
resin has optical characteristics (color and transpar-
ency), mechanical strength properties, and specific pur-
poses. There are resins on the market for different
purposes: for models, bruxism plates, surgical guides,
flexible resins, resins for dentures, resins for provision-
als, of different brands. Each resin has a correct expo-
sure time to be established in the calibration so that the
printed object is faithful to the project. Therefore, the
exposure time will depend on the layer thickness, resin
color, and resin type. Resins with a filler in their compo-
sition need a longer exposure time than model resins,
which do not need resistance.
One can see that it takes several steps before printing
in order to get a good impression. It is necessary to
design in the software, slice, and then print. Therefore,
all these parameters must be taken into account before
printing is performed.
3.2.2.4 Object Printing
Despite the endless options on the market, with lower
and lower costs and increasingly higher performance
when comparing LCD and SLA/DLP printers, most
printers have the same printing system, changing only
the layout.
After exporting the sliced file, it can be transmitted to
the printer via a reader/USB port or wi-­fi.
When removing a print from the print tray, consider-
able force is usually required, so each time a print is per-
formed, the Z-­axis needs calibration to parallel the print
tray level to the LCD, depending on the printer type. It is
necessary to unscrew the Z-­axis damper, lower the tray
to the “home” or “idle” position and make it parallel to
the LCD. After doing this, tighten the screws again.
3.2.2.5 Washing/Postcure
Once the printing is finished, it is necessary to wash and
postcure the printed object.
Washing
This can be done manually or using a device with
vibrating movements. The most common way is to put
the alcohol in ultrasound or even put it in a pot and let
it stir in a plaster vibrator. Another way that has been
gaining popularity is to use washing and curing
machines which have a washing mode and then the
cure mode. Regardless of the washing method, it
should be carried out for a maximum of 5–10 minutes,
as the resins are alcohol soluble. Therefore, washing
for over 10 minutes can generate distortion in the
printed object.
 Chapter 3 Computer-­Aided Manufacturing (CAM) 63

and practicality. 3D printing has to be easy, objective,

and comfortable to do. The possibilities of applying 3D
printing in dentistry are fascinating and are already a
reality in clinical and laboratory everyday life.

3.3 ­Stereolithography (SLA)

3.3.1 Basic Knowledge

Figure 3.5 Printed occlusal splint being placed in a light
chamber.
After washing, it is necessary to wait for the object to
dry completely. Once the object is printed, the outer
layer is still gelatinous, sticky, or viscous. This is because
the outer layer is inhibited by oxygen. It is not advisable
to dry with paper, another absorbent, or even a triple
syringe. The alcohol used is absolute; it has a low boil-
ing point, allowing it to dry naturally or even using a
heat chamber. Once the glossy surface takes on a matte
look, postcure is possible.
Postcure
Postcuring must be done so that the object is completely
polymerized. The protocol will depend a lot on the resin
used. The postcuring time varies from 15 to 45 minutes.
It must be performed in a device that emits UV light
with a wavelength between 385 and 410 nm and power
above 36 W so make sure the light chamber has these
features (Figure 3.5).
3.2.2.6 Conclusion
In conclusion, 3D printing carried out in the dental
world requires definition and quality suitable for every
need. Therefore, it is necessary to balance resolution
The SLA process is the oldest additive manufacturing
process, patented in 1988, whose use spread only after
the patents expired in the early 2000s [6]. The process
involves the polymerization, layer by layer, of photosen-
sitive liquid resins using a UV laser beam. In this pro-
cess, the resin is dispersed in a reservoir, and the light
beam hits the resin exactly where the object will be
formed on a building platform. By using two moving
mirror galvanometers, one on the X-­axis and one on the
Y-­axis, the laser beam can reach the entire printing plat-
form. By combining the movements of the mirrors, the
light beam is directed to each part of the current layer
until it is fully printed. The incidence of this light pro-
vides enough energy to initiate the polymerization reac-
tion, forming a small slice of the object on the build
plate. The build plate then moves upwards or down-
wards, depending on the SLA printer type, according to
the thickness of the next layer. This process repeats until
the object is fully formed [7]. Table 3.4 presents the pri-
mary materials used in SLA printers.
After the printing process is complete, the object goes
through the postcure process, which comprises three
essential steps [6]. The object needs to be washed in a
resin solvent (usually isopropyl alcohol) to remove the
uncured resin from its surfaces [7], then, after the object
is completely dry (solvent volatilization), it must be
exposed one more time to a source of UV light but now

Table 3.4 Materials used for SLA 3D-­printing.

Material Indications Advantages

Draft resin Thermoforming models, orthodontic appliance Fast printing

models, diagnostic models
Model resin Diagnostic models, clear aligner models, Multipurpose resin that is
orthodontic models, implant models, crown and suitable for any printing model
bridge models, segmented bone models
Surgical guide Surgical guides Biocompatible, autoclavable
Temporary crown, splint and Temporary crowns, denture teeth and base, Biocompatible, long-­term use
denture base resin esthetic mock-­ups, splints
IDB resin Indirect bonding for orthodontic brackets, guided Flexible
resin restorations
64 Digital Dentistry: A Step-by-Step Guide and Case Atlas
inside a chamber in order to complete the polymerization
process [8]. Finally, one carefully removes the supports
to avoid damaging the object [8].
The main advantages of SLA printing are the accu-
racy and surface smoothness of the printed object
compared to other techniques. The minimum thick-
ness of each layer is 0.025 mm (or 25 μm), allowing a
very smooth transition between layers; in addition, a
more subtle finish is possible due to the light beam
projecting a circular-­shaped beam, allowing for
sharper curves, unlike the square pixel used in other
printing techniques [9].
Finally, newer processes, such as DLP and MSLA,
which project a layer of light in the shape of a
polymerizing object, are more agile. For the same
reason, the number of parts in the equipment is smaller,
reducing equipment cost [9].
3.3.2 Step-­by-­Step Procedure
The following guide is an example of how to work with
3D SLA printers.
3.3.2.1 Printer Installation
The installation location should be protected from the
sunlight; it must also be ventilated, allowing proper
cooling of the equipment and avoiding the concentra-
tion of vapors from the resins in the environment.
Stable room temperature (approximately 25 °C) is
­recommended for predictable results of the 3D printing
process.
3.3.2.2 Equipment Leveling
The surface on which the equipment is installed should
be leveled horizontally and guarantee stability during
the printer’s movements.
3.3.2.3 Personal Protective Equipment (PPE)
During use of the printer, PPE such as nitrile gloves,
protective goggles, and masks is recommended.
3.3.2.4 Resin Reservoir Preparation (Vat) and
Build Plate Installation
The build platform must be installed on the printer
stand firmly to prevent movement. Its leveling must be
checked if recurrent failure of resin adhesion is noticed.
The resin reservoir has a transparent surface, and it is
crucial to ensure the integrity and transparency of the
material to maintain print quality. Before starting to
print, one must check that there is no residue, no whit-
ish or blurred areas. The fluidity, homogeneity, and
absence of pieces of polymerized resin deposited in the
reservoir must also be evaluated. After printing, the
resin should not be stored in the reservoir for long peri-
ods as it can damage the surface, cause cracks in the
reservoir, and perforations in the flexible plastic film.
The cleaning process should be done with flexible spat-
ulas with rounded tips to avoid damaging the reservoir.
3.3.2.5 Resin Types
Resins for 3D printing using the SLA technique are
based on polymethyl methacrylate oligomers,
photoinitiators, dyes, and inorganic fillers. Several types
of resins have been developed for applications such as
model prototyping, making partial and total dentures,
flexible devices such as orthodontic bonding guides and
artificial gingiva in models, occlusal plates, surgical
guides, among others. Table 3.4 gives the indications
and advantages of the most used SLA resins.
3.3.2.6 Resin Preparation
Before pouring the resin into the reservoir, it is recom-
mended to agitate the bottle of resin to homogenize the
liquid and avoid printing failures due to components
that may settle, such as the pigments that give color to
the resins. Follow the manufacturer’s instructions.
3.3.2.7 Resin Supply
Resin reservoirs generally have indications of the mini-
mum and maximum level. Shortage of material can
result in incomplete parts, while excess can lead to over-
flow, damaging the printer. Some printers have an auto-
matic resin refill system that keeps the resin level topped
up during the process.
3.3.2.8 Printing Parameters
The printer parameters (Figure 3.6) that must be
observed to avoid distortions and failures are as follows.
●● Proper object orientation prevents hollow volumes or
cavities in a model. The resulting suction can cause
separation between printed layers, structural defects,
warping, and print failures. Inclining flat surfaces
10–20° also reduces the amount of contact the print
has with the reservoir and increases the success rate.
●● Generating supports for unconnected or critical areas
with unsupported minima and overhangs (areas
without self-­support and extending over the
main body).
3.3.2.9 Job Upload
After defining the printer parameters, the software will
slice the object into several layers according to the
thickness chosen and will convert all settings into a

Figure 3.6 Screen capture of a 3D-­printing software. (a) Crown positioned at the center of the printing platform. (b) Supports
generated facing the occlusal portion to avoid interference with the internal part. (c) Resin type and layer thickness. (d) Details
of the printing settings.
sequence of commands to the printer that will be
uploaded to the equipment (using wi-­fi or flash memory)
3.3.2.10 Print
The printer will start building the object designed, layer
by layer until the object is finished and ready to be
removed (Figure 3.7). At this point, the layers are
partially polymerized, and the surface is covered by
uncured resin. The object needs to be cleaned and cured.
Figure 3.7 Crown prototype printed successfully hanging on
the printing platform.
Chapter 3 Computer-­Aided Manufacturing (CAM) 65
3.3.2.11 Removal of the Build Plate
Protect the operator from contact with the liquid resin,
using gloves, mask, and safety goggles. If the resin
comes into contact with the skin, immediately wash it
off with soap and water and consult the material’s
Technical Data Sheets. If spillage occurs, clean it up
immediately before the resin damages the equipment,
such as the optical glass window.
The object must be well adhered to the build plate,
and it may be difficult to remove the object, which may
require the use of metal spatulas or pliers.
3.3.2.12 Removal of Uncured Resin
At the end of the printing process, the object is covered
by uncured resin that must be removed. The most com-
mon product used for this process is isopropyl alcohol,
although some water-­based resins have been developed
recently.
The process consists of washing the printed parts in
two steps using independent alcohol reservoirs. The
first receives the part just removed from the printer, and
the second, containing “cleaner alcohol,” receives the
piece after the first bath. Solvent exposure time will vary
according to the brand and type of resin used, and it is
essential to always seek information from the manufac-
turer. Using ultrasonic devices or devices that generate
66 Digital Dentistry: A Step-by-Step Guide and Case Atlas

vortex to agitate the alcohol is recommended to promote 3.3.2.16 Preventive Maintenance

a greater degree of cleanliness than simply immersing
the part into the solvent. At the end of this process, the
object must be completely dry.
3.3.2.13 Postcure
The postcure process is necessary to finish the object
polymerization to ensure the material’s best properties,
according to the manufacturer’s specifications.
By using a light chamber emitting UV light (wave-
length range between 385 and 405 nm), the object can be
polymerized homogeneously; the process is time and
temperature dependent and varies by material, accord-
ing to the manufacturer’s instructions.
After the postcuring process, the supports should be
removed to guarantee dimensional stability, using
delicate fine-­nosed pliers or tweezers that allow a slight
twist of the support, detaching it from the object’s
surface without causing damage. If necessary, it is
possible to polish the surface, further improving the
final surface quality.
3.3.2.14 Resin Filtration
The resin remaining in the reservoir needs some care
before being stored in the bottle again. The resin must
be filtered in a paint or oil filter with a fine or 190 μm
mesh to avoid resin contamination with partially
cured resin or other impurities dispersed in the resin
reservoir.
Equally important is the container used for resin stor-
age. Using the original pack or opaque bottle to protect
the resin from light is recommended.
Preventive maintenance is essential to anticipate
potential problems, prevent the equipment from
unexpectedly stopping, and avoid printing distortions.
It is essential to check the integrity of the resin
­reservoir and building platform, and the cleanliness
of the optical glass window before every printing
process.
There are calibration files which can be printed and
used to check printing quality. The frequency of this
procedure varies with the printer and resin manufacturer.
Refer to manufacturers’ support materials for further
information.
3.4 ­Digital Light Processing (DLP)
3.4.1 Basic Knowledge
Digital light processing 3D printers are among the addi-
tive manufacturing machines in the vat photopolymeri-
zation family [10]. These machines use projectors
equipped with hundreds of thousands or millions of
micromirrors moved by electrostatic energy, whose
function is to reflect and direct UV light to the printer’s
vat [11].
Three-­dimensional printing technology via DLP is
one of the most suitable for users who need high pro-
duction volumes (Figure 3.8). The long service life of

3.3.2.15 Resin and Solvent Disposal

The uncured resin used in 3D printing is toxic and must
never be discarded in its original state, as it can contam-
inate soil and water. It is essential to polymerize it com-
pletely before disposal, just by exposing it to sunlight (or
other UV light source) until it fully sets. The same care
should be taken with the materials used to clean and­
dry the printed objects, such as solvents, paper towels,
and consumable parts such as resin bottles and used
resin reservoirs.
It is recommended to store the solvents in a bottle for
a few days to wait for the resin particles to settle. Then
the liquid’s upper part can be filtered and reused in the
first bath recipient, and the bottom part should be
exposed to the sun to set before disposal.
Remember to protect the operator from contact with
the resin, using gloves, masks, and goggles, to avoid pos-
sible health damage. Figure 3.8 A DLP 3D printer (FlashForge Hunter).

Figure 3.9 A DLP 3D printer’s light engine. The digital
micromirror device [14] is built into the projector.
light engines – the projectors used in this type of 3D
printer – translates into smaller amounts of mainte-
nance interventions, unlike MSLA printers which use
LCD screens as a way of masking and LED arrays as a
light source (Figure 3.9).
This type of machine is generally taller than SLA or
MSLA printers, as it is necessary to have available space
to accommodate the projector and distance to fit the
projection size to the printable area. On machines with
larger print areas, the projector is usually farther away,
and in smaller areas, it is closer to the print area.
Figure 3.10 STL files are organized in the software with support structures represented in green.
Chapter 3 Computer-­Aided Manufacturing (CAM) 67
The main advantages of DLP 3D printers are printing
speed, high accuracy, precision, and resolution [12].
However, they are generally more expensive equipment
than SLA or MSLA 3D printers.
3.4.2 Step-­by-­Step Procedure
The installation procedure of DLP 3D printers is rela-
tively similar to other types of 3D printer previously
mentioned in this chapter. DLP printers, however, usu-
ally do not need to be calibrated, although the printing
parameters should be set specifically for each type of
resin used. The following step-­by-­step guide is based on
the procedures used for a specific 3D printer (Hunter®,
FlashForge Corporation).
1) Import the STL files to be printed into the printer
software. In this example, the software used is
FlasDLPrint [13]. Once the 3D files are on the soft-
ware, the tools to move and rotate objects are used to
organize the files in the build area (Figure 3.10).
2) Support structures are generated, taking into account
the volume of the piece and its geometry.
3) The file is sliced according to the particularities of the
material to be used in the printing process. Each resin
has specific parameters for exposure time, projector
light intensity, and dimensional adjustments when
there is material contraction (Figure 3.11).
4) The sliced file is sent to the 3D printer through wireless
internet, cable, or USB memory. These are not STL
files any more; they become G-­codes, an extension
widely used for controlling CNC machines worldwide.
68 Digital Dentistry: A Step-by-Step Guide and Case Atlas
Figure 3.11 Files sliced in the software, ready to be sent to the printer.
Figure 3.12 3D-­printed objects being rinsed with isopropyl
alcohol and postcured with UV light.
5) Fill the printer vat with resin. The CAM software
determines the amount needed. Select the models to
be printed and start the 3D printing process.
6) Rinse the models in isopropyl alcohol to remove the
uncured resin (Figure 3.12).
7) Postcure 3D prints in UV light of the same wave-
length as the light engine’s light (Figure 3.13).
3.5 ­Milling
3.5.1 Basic Knowledge
Subtractive manufacture is the sum of techniques applied
to achieve the desired geometry from removing material
from an initial body (usually a block). Several methods
have been used by the human race to create tools and
equipment by removing material, such as stone arrow-
heads and wooden spikes. Subtractive manufacture can
be seen in different art expressions, especially in sculp-
ture. Artistic geniuses like Italian sculptor Michelangelo
or Brazilian sculptor Aleijadinho transformed blocks of
marble, wood, or soapstone into art pieces that thrill mil-
lions worldwide. Subtractive manufacture can be achieved
using hand tools or mechanically driven equipment.
With its steam-­powered machines and later electrical
equipment, the Industrial Revolution changed the time
and human resources needed to manufacture objects and
tools from metal or other raw materials. Machines were
specially designed to achieve this purpose, such as the
mechanical lathe, drill, and milling machines. Further
technological improvements created the computer as an
essential controller of the process. Instead of manual
adjustments and positioning, digital files control every
minor movement, increasing reproducibility with preci-
sion and accuracy. This technology is called computer
numerical control (CNC) and comprises a combination
of software and hardware, creating a physical object from
a virtual geometry with high precision and detail.
Milling can be explained as the act of removing mate-
rial (subtractive manufacture) using a rotating tool,
either by rotating the material block or by rotating the

Figure 3.13 Completed 3D-­printed models, washed and postcured.
cutting tool (endmills). The cutting tool is positioned
either vertically or horizontally to the raw material. The
variety of endmills enable the milling machine to
achieve the desired geometry and smoothness of the
final product. Milling machines can use rotary cutters
and perform gridding by using diamond-­coated instru-
ments. For didactic purposes, in this section, the method
will consistently be named “milling.”
Different materials can be used to fabricate the raw
blocks used in dental milling machines, such as ceramic,
resin, wax, or metal. Working with CNC enables the pro-
fessional to fabricate inlays, onlays, single or multiple
crowns, metallic or ceramic coping, etc., without the
necessity of finishing or polishing. However, some ceramic
blocks may still need characterization staining or glazing
for better esthetics and surface smoothness. Various block
sizes and shapes are available, allowing the professional to
choose the best size to fabricate either a single crown or
multiple restorations with one block. A major setback of
the milling process is the high material waste; the final
work may be only around 10% of the initial block volume.
The machines usually function with a vertical or hori-
zontal spindle rotating the cutting tool, but profession-
als may not understand the concept of a four-­or five-­axis
milling unit. The block can be moved inside the milling
machine in three linear axes (X, Y, Z), but movement
can also be made in three more axes (A, B, C), which
represent rotational movement in the X, Y, and Z planes.
There are six possible axes of movement but most mill-
ing machines operate in four or five axes (X, Y, Z, and
one or two rotational axes). Laboratory milling units are
usually prepared for large-­scale production, and smaller
Chapter 3 Computer-­Aided Manufacturing (CAM) 69
units are designed to be used inside the dental office
(chairside). Dental professionals who own a chairside
milling unit can fabricate an indirect restoration during
the patient’s appointment, thus decreasing the number
of sessions, interventions, and procedures.
3.5.2 Step-­by-­Step Procedure
3.5.2.1 Laboratory Milling
CAD/CAM systems are based on three fundamental
components: image acquisition (scanner), CAD soft-
ware, and computer-­assisted manufacturing (additive
or reductive) systems. They have been used in dentistry
mainly to produce fixed prostheses such as crowns,
bridges, and veneers.
After scanning the area of interest (dental prepara-
tions), whether using an intraoral scanner or scanning
models, the image is transferred to a computer-­aided
drawing program (Exocad’s DentalCAD Galway, Amann
Girrbach’s Ceramill Mind®, Zirkonzahn’s Modellier®, or
Dentsply Sirona’s InLab SW®, among others), using
which the operator can then draw the prosthetic struc-
ture from the virtual form. At this stage, it is imperative
to correctly create the work order, choosing the type
of restoration and the material used, as well as the
­minimum thickness, cementing space, and other
parameters. This step is crucial, as each restorative
material has specific features and the milling software
needs to establish the correct machining strategy.
Regardless of the system, the work order will guide the
rest of the project through to completion.
70 Digital Dentistry: A Step-by-Step Guide and Case Atlas
There are many materials available for milling, but
the most used are prefabricated blocks of lithium
disilicate, hybrid ceramics, indirect resins, feldspathic
porcelains, various types of zirconia, titanium, and
acrylic resin (PMMA). One significant advantage of
using these systems is the possibility of working with
very resistant materials, such as zirconia. Currently, zir-
conia is the most resistant ceramic available for use in
dentistry, indicated for the construction of extensive
bridges and total fixed rehabilitations.
This chapter will present a clinical case report, from
receiving the STL file to completing a zirconia rehabili-
tation, focusing on laboratory manufacturing (milling)
aspects.
When it comes to implant-­supported prostheses, it is
necessary to use scanning abutments. The implant
brand, the model (platform), and the measurement of
the intermediate abutments are essential information
for the accurate capture, design, and, ultimately, adapta-
tion of the restorations. In this phase, it is also necessary
to define whether the zirconia will be milled directly at
the implant level or if an intermediate link will be used,
on which the zirconia prosthesis must be extraorally
cemented.
Extra scans of the antagonistic arch and the provi-
sional prosthesis are of extreme importance because
they are the basis for the definition of all the esthetic
and functional adjustments.
Figure 3.14 Internal view of the Zirkonzahn
M1 milling device.
The correct alignment and coincidence of all meshes
related to the project will define the success of the treat-
ment. Therefore, at this stage, mistakes are not allowed.
At this stage, it is necessary to inform all the charac-
teristics of the project. In this case, correctly inform the
location of the implants, pontics, cementation links,
artificial gingiva, type of material to be milled, reference
models, and other information relevant to the project.
At the end of the project, the design software gener-
ates two files: STL with the three-­dimensional design of
the structure and a constructionInfo file (or construc-
tion information file) that allows automatic sharing of
information such as marginal line, implant direction,
and implant interface geometry directly to third-­party
CAM softwares (Ceramill Match 2®, Amann Girrbach).
3.5.2.2 Calibrating and Testing
the Milling Device
In general, the installation of a new milling device will
be followed by a group of initial procedures, such as
calibrating and testing the device. Calibration will
ensure that manufacturing quality will be reasonably
standardized for every milling procedure performed by
the machine. In this context, several milling devices
have an automatic calibration feature in their software
programs. The following guide gives an example of the
main steps of a milling device calibration procedure
(Figures 3.14–3.22).
Figure 3.15 Metal pin used for calibration of the
Zirkonzahn M1.
Figure 3.16 Calibration procedure.

Figure 3.17 Calibration procedure follow-­up in the CAM software of Zirkonzahn (Frasen).

Figure 3.18 Milling materials and drills used in the

Figure 3.19 Milling device ready to receive milling disk.
Zirkonzahn M1.
72 Digital Dentistry: A Step-by-Step Guide and Case Atlas
Figure 3.20 Tool organizer, to ensure that the drills are
inserted in the correct order before the procedure.
Figure 3.21 Drill holder to be placed into the
milling device.
1) Checking installation: check that all cables are con-
nected properly. Make sure a vacuum cleaner is prop-
erly connected to the milling device. Check the
grinding control for water supply, which is required for
Figure 3.22 Milling procedure in progress (Zirkonzahn M1).
wet milling, to mill titanium and glass ceramics (such
as lithium disilicate). Set up air pressure (a compressor
is required to provide 6–8 bar air pressure).
2) Start calibration (click on the button at the bottom of
the screen).
3) Fit the calibration plate, and lock it with the
small levers.
4) Use a screwdriver to secure screws.
5) Check to see if there are any warnings.
6) Follow the steps on the screen (remove drills
magazines).
7) Make sure the platform is absolutely clean before
calibrating (both sides will be offered by the machine
to be cleaned).
8) Test the calibration by touching the platform (lights
should appear).
After milling, it is necessary to add the esthetic fin-
ishes and details. The prosthesis is removed from the
block, finished, cleaned, and sintered in a special fur-
nace for sintering zirconia for approximately 12 hours at
1480 °C. After sintering, the stabilizer bar and excesses
are removed. In this case, the buccal layering was car-
ried out with effect pastes and enamels and the applica-
tion of ceramic gingiva. As the latest generations of
multilayered zirconia combine strength and esthetics, it
is possible to carry out extensive restorations without
the need for ceramic layering, using zirconia make-­up
shades and stain kits.
Figures 3.23–3.32 illustrate a procedure of milling
full-­arch implant-­supported prostheses, which were
fabricated in zirconia with ceramic layering on the buc-
cal surfaces, enamel, and gingiva.
 Chapter 3 Computer-­Aided Manufacturing (CAM) 73

Figure 3.23 STL file from an intraoral scan of the maxilla with the scanning abutments in position.

Figure 3.24 STL file of the scan of the antagonistic arch

and upper temporary prosthesis of the patient that will serve Figure 3.25 The long axis of the scanning abutments
as a reference for the design of the new prosthesis in concerning the opposing teeth demonstrates the correct
zirconia. inclination of the implants.

Figure 3.26 Screenshot of the project creation window in the software (DentalCAD, Exocad).
Figure 3.27 Screenshot taken during the CAD step. Note the reduction of the structure before fabrication with zirconia.

Figure 3.28 Screenshot of the CAM strategy organized in the software (Ceramill Mind).

Figure 3.30 Zirconia framework removed from the blank

and ready to go to the sintering furnace for approximately
12 hours at 1480 °C. Note the incisal and buccal
Figure 3.29 Zirconia structure milled before sintering. cutback areas.
 Chapter 3 Computer-­Aided Manufacturing (CAM) 75

(a) (b)

Figure 3.31 (a,b) Examples of the structure after sintering, ready to apply the ceramic material.

(a) (b)

(c) (d)

Figure 3.32 (a–d) Final aspect of the full-­arch implant-­supported prostheses (Ventura Lab, Curitiba, Brazil).

3.5.2.3 Chairside Milling Procedures
Milling is a machining process that uses cutting­
tools to remove material. It is a subtractive manufac-
turing method that a laboratory or clinician can­
use to fabricate indirect restorations. The milling­
process replaces the manual build-­up of porcelain
techniques, reducing them to more superficial­
layers and shading or stain applications, which ulti-
mately is time-­saving without losing the quality of
the work.
A file in STL format generated through CAD software
is used to carry out a milling process. This file will be
opened via CAM software and manufactured in the cho-
sen material.
76 Digital Dentistry: A Step-by-Step Guide and Case Atlas
Current milling machines are available with four-­axis
or five-­axis motors, which differ in milling speed and
treatment limitations. In general, both types of equip-
ment offer equivalent accuracy, but five-­axis milling
machines can mill blocks and disks, thus allowing man-
ufacture of larger and more complex restorations, such
as protocols and metal infrastructures. The choice of a
four-­axis or five-­axis milling machine is ultimately
related to professional requirements, but it is accepted
that four-­axis milling machines are standard equipment.
Regardless of the milling machine used, there is a
wide variety of materials available on the market,
including lithium disilicate, feldspathic porcelain, resin
for provisionals (PMMA), zirconia, wax, metal (cobalt,
chromium), and PEEK.
In summary, lithium disilicate is commonly used in
posterior prostheses and monolithic works of up to
three elements. In contrast, feldspathic is used in ante-
rior or posterior single-­unit restorations in patients
without a history of fractures or bruxism since the
mechanical strength of this material is lower than disili-
cate. PMMA resins are used for provisionals, and for try-­
ins of wax-­ups. In addition, PMMA resins designed
explicitly for surgical implant guides are available.
Milling time varies according to the size of the part,
the material used, and even the equipment itself. Some
brands offer equipment that mills a porcelain crown in
a few minutes so that the professional, equipped with an
intraoral scanner, CAD-­CAM software, and a sintering
oven, can perform a treatment without having to dis-
miss the patient, avoiding including the need for mak-
ing a provisional. In clinical practice, chairside milling
is already a reality. Generally speaking, it comprises
lithium disilicate, feldspathic porcelain, and even mon-
olithic zirconia, where the variety of jobs offered is
related to the operator’s experience.
Chairside practice has excellent advantages, as it is
very convenient for both the patient and the dentist, sav-
ing much time without losing quality in the treatment.
The following explanation of the step-­by-­step chair-
side milling process uses a Cerec® MCXL milling device.
Milling Extension Software
To carry out a milling process of an external file in STL,
it is necessary to use CAM software, which acts as an
extension of the milling machine.
Connect the Milling Machine
For the manufacturing process, the milling machine
must be connected to the same local area network as the
computer on which the software is installed, or it can be
connected directly to the computer through a network
cable. In the latter case, one must also set the IP Address
and Netmask manually both on the mill and on the
computer to communicate using the TCP/IP protocol.
Starting the Milling Process
●● Fill out the patient record.
●● Choose the equipment that will be used. This is an
important step if there is more than one machine con-
nected to the network.
●● Then generate a new task by importing the STL file.
●● Each software program will have its own way of carry-
ing out the detailing of the task, but it is necessary to
fulfill all the requirements of the work to be
performed.
●● Choosing the correct “work type” (crown, inlay,
veneer, etc.) is a crucial step for the software to iden-
tify the STL file correctly.
●● Choose the manufacturer and material to be used. It
is not beneficial for the milling machine to manufac-
ture a material different from the one chosen in the
software. This error can decalibrate the sensor read-
ing and recognition of the motors over time, causing
failures in the milling process.
Margin Delimitation
●● At this stage, the part that was imported in STL must
have its margin marked with the tool offered by the
software. A line will be created that will make the
inner and outer portions of the part clear, allowing
the milling machine sensor to accurately calculate the
proposal (Figure 3.33).
●● A margin with a poorly marked line can impair the
sensor reading so that it generates a failure in the
milling process, where the most common of these
errors is the poor quality of the internal portion of
the part.
Check the Block Size and Placement of the Sprue
With the margin outlined, it is necessary to position the
virtual part in the block or on the disk, avoiding leaving
the sprue (material left over from milling) in the mesial
and distal portions of the restoration, so that it does not
change the accuracy of the proximal contacts and adap-
tation of the part, achieved in the CAD software
(Figure 3.34).
Moving the Block on the Milling Machine
●● Check that the block size and the material chosen in
the CAM software do not differ from the embedded
block. The same attention is required in cases of man-
ufactures on disks, on five-­axis milling machines.
●● Then, the milling process will be ready to start.
 Chapter 3 Computer-­Aided Manufacturing (CAM) 77

Figure 3.33 Margin delimitation of the imported STL restoration file (inLab CAM SW 18.1).

Figure 3.34 Positioning the restoration inside a lithium disilicate block (e.Max CAD, C14, Ivoclar Vivadent) to be milled (inLab
CAM SW 18.1, inLab MC XL milling machine, Dentsply Sirona).

Finishing of the Restoration ●● Zirconia is acid resistant, meaning that cementation is

●● After milling, the professional evaluates the type of
finish needed for the manufactured case using a
chairside technique. Often, just a polishing followed
by a glaze application is enough for the treatment to
be successful. In this case, it only takes a few minutes
in the sintering oven for the piece to be finished.
●● In lithium disilicate manufacturing, in addition to
polishing, the material requires firing in the oven
since the block is available in a presintered form. This
procedure takes around 40 minutes, from entering the
oven to cooling the part.
achieved by mechanical imbrication. The acid etching
time (10% porcelain hydrofluoric acid) of the piece
varies according to the material. More acid-­resistant
porcelains, such as feldspathic, require 2 minutes of
treatment while for disilicate, 30 seconds is enough.
●● Glass ionomer-­based cement generally has dual polym-
erization characteristics (chemical and photoactivated),
so that the chemical polymerization is activated from the
tertiary amine. This cement cannot be used with lithium
disilicate crowns and prostheses, since the catalyst can
react with the porcelain and discolor the restoration.
78 Digital Dentistry: A Step-by-Step Guide and Case Atlas
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 79

Part 2

Clinical Applications of Digital Dentistry

 81

Chapter 4
Digital Workflow in Prosthodontics/Restorative Dentistry
José Lincoln de Queirós-Jr, Thiago Ottoboni, Gabriel S. Urbano, Danilo M. Bianchi, Renato Sartori,
Juliana No-­Cortes, Jacqueline F. Lima, Roberto A. Markarian, Alan J.M. Costa, Shaban M. Burgoa,
Charles Melo, Newton Sesma, Florin Cofar, Eric Kukucka, Alexandre D. Teixeira-­Neto, Guilherme Saavedra,
Diogo Viegas, Andrea Son, Maria L. Gainza-­Cirauqui, and Arthur R.G. Cortes

SUMMARY

This chapter provides a step-­by-­step guide and research evidence on digital workflow in prosthodontics/restorative dentistry.

This chapter will cover the main digital workflow tech-
niques currently used in the field of prosthodontics and
restorative dentistry. It is important to remember that,
although the knowledge detailed herein is very impor-
tant, clinicians may find some of the procedures to be
time-­consuming for general practitioners. One solution
for this issue is collaboration with planning centers (see
Chapter 1) and working with CAD-­CAM dental labora-
tories that the dentist trusts. Dental technologists who
become CAD technicians can usually also help to inte-
grating the different steps of digital restorative dentistry
further explained in this chapter.
Two types of digital workflow are currently used in
dental clinics: the chairside or the “labside” digital
workflow. As discussed in Chapter 1, the choice of
workflow will basically depend on the knowledge, time,
and devices available (in-­house or outsourced). In sum-
mary, digital dentistry usually requires not only the
knowledge offered in this book, but also adequate team-
work and communication between professionals.
4.1 ­Clinical Procedures for Intraoral
Scanning
4.1.1 Teeth Preparations
There are several accepted ways to perform adequate
preparations for CAD-­CAM prostheses. In the first place,
these preparations should be performed considering the
minimum acceptable thickness for the chosen material,
especially in the case of milled prostheses. Zirconia,
for instance, is hard but thin, and therefore fragile.
A zirconia-­made crown should have a minimum thick-
ness greater than 1.0 mm. In addition, all teeth prepara-
tions of cases treated with digital workflow should have
an adequate insertion axis, regular surfaces and well-­
defined finish lines. Sharp finish lines, however, should
generally be avoided during margin preparation. Failure
to do so may lead to inaccurate milling of the digitally
designed shape, resulting in an inadequate fit on the
margin area. Moreover, sharp cusps should be avoided as
they will be difficult for the milling bur to access, which
could cause the final product to be too thin in this area.
The procedure of intraoral scanning teeth prepara-
tions is considered to be highly reproducible and
straightforward. Nevertheless, there are several details
in the methodology that should always be taken into
consideration to achieve satisfactory outcomes of the
respective tooth-­supported prostheses. Intraoral scan-
ning can be limited by mouth opening, size of scanning
device, and adjacent oral structures. Excessive proximal
height of contours could also limit the scan direction
and angulation. After scanning a tooth preparation,
check the margin line, make sure there is no undercut,
and that it was sufficiently prepped. Lack of proper soft
tissue retraction may lead to slower scans and large data
volume. Also, when unnecessary data accumulate,
capacity increases. This results in scan data not aligning
to the correct position. In addition, as for silicone
impressions, digital impressions need information on a
number of adjacent teeth to make an accurate

Digital Dentistry: A Step-by-Step Guide and Case Atlas, First Edition. Edited by Arthur R.G. Cortes.
© 2022 John Wiley & Sons Ltd. Published 2022 by John Wiley & Sons Ltd.
82 Digital Dentistry: A Step-by-Step Guide and Case Atlas
prosthesis. If a preparation tooth is a posterior tooth, it
is necessary to scan 1.5–2 adjacent teeth. If it is an ante-
rior tooth, it would be better to get the full anterior scan
data. Among the reasons for this is the importance of
capturing adequate images of the occlusal surface, con-
tact points, and height contour.
In case of gingival or subgingival margins, gingival
retraction is necessary. If the margin is subgingival, the
line is not easy to scan as it is under the gingiva [1]. On
the other hand, supragingival margins are easier to out-
line during virtual waxing. Silicone impressions create a
gap between the tooth and the gingiva caused by the
impression material. The impression can then be taken
with cord packing as the gingiva is separated with
applied pressure, which does not happen during digital
Figure 4.1 Gingival retraction with double-­cord packing for
two CAD-­CAM laminate veneers and one CAD-­CAM crown
(right). Source: Case by Dr Renato Sartori.
Figure 4.2 Finish line preparation (left) and ideal gingival retraction at the time of scanning (right).
impressions. Therefore, adequate gingival retraction and
management is required to capture accurate intraoral
scan data (Figure 4.1). The finish lines can be exposed
using cord packing or a laser, but it is best for the margin
placement to be supragingival. If the margin is subgingi-
val, insert two cords for proper gingival retraction. The
second cord does not usually need to be inserted com-
pletely under the gingival tissue. This cord should be
removed directly before intraoral scanning (Figure 4.2).
Finally, it is essential to control saliva and blood
before scanning. Undesirable stagnant saliva should be
removed from the teeth. The oral cavity should be dry
enough to eliminate any fluid on the teeth’s surface and
prevent bubble creation. Careful cord packing and gin-
gival management is also essential to prevent the pres-
ence of blood, which in turn may significantly decrease
scan quality. Similarly, unhealthy gingival tissue affects
the accuracy of scan data. After carefully checking all
the aforementioned factors, the professional can per-
form the intraoral scans of the dental arches and prepa-
rations following the strategies discussed in Chapter 2.
4.1.2 Implant Scanbodies
Implant scanbodies are components used as markers to
transmit the tridimensional position of one dental
implant into the CAD software. Most dental implant
manufacturers have developed their own scanbodies
and the corresponding digital libraries of implants and
abutments to allow users to create digital implant-­
supported restorations. The digital dental implant

libraries contain sets of dedicated components (scanbod-
ies, titanium bases, dental implant analogues) specially
developed under the manufacturer’s specifications.
Although a dental preparation scanning is generally a
more straightforward procedure, the digital impression
of implants often requires additional steps to register
more data, such as gingival contours, location of the
implant, and the contours of previous restorations. To
be easily recognizable by the CAD software, the scan-
body contains at its top position a geometric shape and/
or visual pattern that will be compared within the digi-
tal dental implant library in the software. If there is a
match between the scanbody and the implant library, a
unique signature is created with the tridimensional
coordinates for the dental implant, referred to other
implants and the surrounding oral tissues.
On the opposite side of the scanbody, the coupling inter-
face is designed to match one specific implant model/brand
or connection type. Therefore, the user must be sure to use
the correct scanbody for each dental implant. If a dental
implant is scanned with the incorrect scanbody, a new scan
would be required because the dental technician will gen-
erally not be able to repair the mistake in the software.
While scanning, the user must make sure to copy all the
intraoral surfaces, avoiding gaps, superimpositions, imper-
fections, or leftovers into the scanned mesh that could lead
to distortion or loss of important data. By scanning directly
intraorally, the restoration can be produced more efficiently
when compared to regular impressions by reducing clinical
and laboratory fabrication steps, avoiding inaccuracies that
can occur from impression materials and gypsum deforma-
tion, requiring less intervention during the processes, and
reducing the chance of human error.
Alternatively, the dental implant scanbodies can also
be connected onto implant analogues in a gypsum cast
and the impression can be recorded digitally using a
laboratory desktop 3D scanner. After designing the res-
toration, the technician will be able to project a corre-
sponding model containing all the elements of a
conventional model, such as a gingival mask and one
dental implant digital analogue.
4.1.2.1 Step-­by-­Step Procedures: Dental Implant
Impressions
Although the intraoral scanner software will guide the
user through a scanning sequence, the information
gathered is similar among different scanner brands.
Therefore, correct use of an intraoral scanner is a pow-
erful and fast method for the acquisition of dental
implant and oral tissue data including implant tridi-
mensional location, noncompressive impression of soft
tissues, gingival emergence profiles, previous prosthesis
contours, occlusion/bite and vertical dimension, oppos-
ing arch, and oral tissue colors and textures.
Chapter 4 Digital Workflow in Prosthodontics/Restorative Dentistry 83
Previous prostheses scan: information on a previous
restoration is generally useful, sometimes even without
being perfect, because it helps the designer with more
visual references. Sometimes if restorations such as
ceramics are present in the mouth, scanning powder
can be applied to oral tissues and restorations to dimin-
ish light reflexion and provide a faster scan.
Implant tridimensional position: positioning a dental
implant scanbody intraorally can be as simple as install-
ing any other component, but to ensure precision of the
procedure it is mandatory to double-­check the coupling
interface to avoid misfits (Figure 4.3). To access the fit
of the scanbody onto the implant in subgingival cases,
the user can take oral radiographs. However, some
intraoral scanbodies are fabricated with polymers such
as PEEK, that impair radiographic verification.
Additionally, polymer-­based scanbodies may have a
limited time of use because the coupling interface may
be distorted more easily than metallic interfaces. When
taking the digital dental implant impression, the scan-
ner locates and registers surface reliefs indistinctly, in
order to construct a tridimensional mesh (Figure 4.4).
Most scanners are not able to automatically determine
the dental implant and scanbody position. In subse-
quent steps, the location of the dental implant as well
as other dental structures must be marked by the user.
However, more recent dental scanner systems and new
scanbody versions contain graphical patterns that can
be automatically recognized by the software. As a
result, the dental implant position will appear aligned
to the other dental structures in the CAD software,
allowing the design of the final restoration, including
the hexagonal position when the antirotational effect is
desired (Figure 4.5).
Soft tissue impression: intraoral scanning is a fast tech-
nique to record soft tissue contours, which is a challeng-
ing task in conventional impressions. The user can
record delicate structures such as the gingival profile
emergence for a restoration after tissue conditioning,
with high accuracy and virtually no distortions. For this
purpose, a scan of the implant/abutment without the
scanbody should also be performed.
Opposing arch, occlusion and vertical dimension: while
scanning, the user will be prompted to record the oppos-
ing arch, and subsequently both arches are aligned while
the patient occludes in the desired position (maximum
intercuspation or centric relation [CR]). The interlock-
ing between the dental arches enables the use of a virtual
articulator within the CAD software and provides impor-
tant references for the creation of a correct restoration,
such as the vertical dimension, predicted occlusion, and
behavior during mandibular movements.
Additional information: intraoral cameras and soft-
ware are continuously evolving to enable a faster and
84 Digital Dentistry: A Step-by-Step Guide and Case Atlas
Figure 4.3 Clinical intraoral view of a scanbody attached to an implant (bottom left). A small amount of scan powder was
applied to improve the scan. The geometrical shape at the top of the scanbody must be completely and carefully scanned.
Source: Case by Dr Roberto A. Markarian.
Figure 4.4 The scanbody position is recorded by the
intraoral scanner.
more precise procedure. Additional information can be
gathered by the system that can be useful for the CAD
designer and clinician, such as dental and gingival
shades and textures.
4.1.2.2 Stereophotogrammetry: An Accurate and Fast
Alternative
One alternative to the intraoral scans of dental implants
is stereophotogrammetry, which is a method of making
precise measurements by using reference points within
photographs without any contact with the measured
object. A recent stereophotogrammetric system has
been developed for capturing implant positions, called
precise implant capture (PIC). To perform the PiC
method, the professional needs a stereoscopic camera
Figure 4.5 The digital alignment of the implant allows the
project of the implant-­supported restorations.
(PIC camera; PIC Dental) to record the implant posi-
tions. First, the code of each PIC abutment (PIC trans-
fer) must be entered into a software program and then
placed on each abutment. Then, the PIC camera is
placed 15–30 cm away from the dental arch with a maxi-
mum angle of 45° in relation to the transfers. The infor-
mation captured from the photogrammetric abutments
in the camera (PIC file) can then be processed by the
software program (PIC Cam Soft v1.1). This software
calculates the average distances and angles between
implants shown in the photographs, which leads to an
accurate relative position of each implant platform in
vector format. The resulting 3D images can be saved and
exported as STL files.

4.2 ­Setting Up the Virtual Patient
4.2.1 Importing Intraoral Scans to the
CAD Software
After collecting clinical history and chief complaint,
and performing the initial clinical and imaging
examinations to assess the patient’s diagnosis, the
next step in digital treatment planning of oral reha-
bilitation will be to import the imaging data to a CAD
software. When using a dental commercial software
program, the user will be prompted to choose the
files of the scans prior to commencing the virtual
waxing procedure. If the STL files obtained with the
intraoral scans of main and antagonist dental arches
are in the same virtual coordinates, the software will
likely import them into occlusion. If this is not the
case, bite registration scans can also be imported and
integrated with the existing meshes of main and
antagonist STL files. Intraoral scans of the main
and antagonist dental arches are the minimum
requirement to perform a clinically relevant digital
waxing procedure.
4.2.2 The Virtual Articulator
The virtual articulator is a digital tool with a function
similar to the physical articulator, that is, to analyze the
dynamics of the occlusion. For this purpose, excursive
movements can be simulated in the CAD software to
orientate virtual waxing.
Figure 4.6 Maxillary and mandibular scans imported in the same coordinates, which automatically set them in occlusion.
Source: Case by Dr José Lincoln de Queirós Jr.
Chapter 4 Digital Workflow in Prosthodontics/Restorative Dentistry 85
There are various ways to work with virtual articula-
tors. One acceptable technique is to transfer the posi-
tion of stone models mounted in the physical
articulator into the CAD software. It is important to
note that use of a scanner that supports dynamic occlu-
sion registration and virtual articulation facilitates this
procedure to achieve satisfactory patient-­specific out-
comes. Parameters such as the Bennett angle, immedi-
ate side shift, and condylar angle can be virtually
adjusted in the software. Another acceptable tech-
nique is to import jaw motion data from other meas-
urement devices. Such data can be combined with a
virtual articulator.
The following step-­by-­step procedure used the
Ceramill® Mind software (Amann Girrbach AG) and its
semi-­adjustable virtual BIOART A7 PLUS articulator
for articulating the intraoral scans. The virtual models
were performed following a sequence of procedures
inspired by the traditional assembly in articulators
described by Queiros Jr. and Lopes [2], in which an
index of transference of the three-­dimensional position
of the facebow was used.
4.2.2.1 Step-­by-­Step Procedure for Using a Virtual
Articulator in a Digital Workflow
●● Import the intraoral scans into the software. In this
step, the maxillomandibular relationship obtained
with the occlusion record will be automatically
rearticulated according to the facial arch
(Figure 4.6).
86 Digital Dentistry: A Step-by-Step Guide and Case Atlas

●● Scan the facebow along with the transfer index. This
step is performed with the intraoral scanner and the
resulting 3D image exported along with the arches
scans. The registration of the facebow with the index
is brought into Exocad as a generic mesh, as well as
the virtual index that will orientate the correct posi-
tion of the facebow. After importing the aforemen-
tioned 3D meshes, the facebow should be lined up
with the placeholder (Figure 4.7).
●● Align the mesh of the maxilla with the facebow. As
with the traditional set-­up, the maxillary scan can be
aligned with the mesh of the occlusal registration of
the facial arch. Thus, the digitized upper arch migrates
to the position registered in the patient’s mouth
(Figure 4.8).
●● Import the reference of the maxillomandibular rela-
tionship to assemble the lower scan in the articulated
set-­up. In this step, the virtual record of the articulation

Figure 4.7 Intraoral scans of the facebow and transfer index (yellow). The latter is used to orientate the virtual position of the
facebow mesh.

Figure 4.8 Virtual position of the maxillary intraoral scan aligned with the facebow mesh.
 Chapter 4 Digital Workflow in Prosthodontics/Restorative Dentistry 87

of the arcades is imported. Instead of bringing the bite
record files, the associated arcades are brought in a sin-
gle file. Thus, the alignment of the meshes becomes
more precise and predictable due to the greater amount
of similar information between the three-­dimensional
meshes. After aligning the occlusion record file, the
bottom scan is finally aligned, proceeding to the last
step of articulating the models (Figure 4.9).
●● Final check of the assembly and adjustments of the
articulator. With the models in position, it is possible
to open the articulator module and select the desired
model, in this case the standardized BIOART A7
PLUS. By activating the visualization of the extra
meshes, you can validate the index and facebow
assembly and fits, as well as the models in position.
After this step, measurements of the condylar and
Bennett angles are made, and finally the simulation
of movements that will be registered and used in all
stages of the design process of the previously pro-
posed work (Figure 4.10).

Figure 4.9 Mandibular intraoral scan aligned with the articulated set-­up.

Figure 4.10 Virtual articulator ready for dynamic occlusion analysis.

88 Digital Dentistry: A Step-by-Step Guide and Case Atlas
Multidisciplinary assessment in dentistry allows for a
more comprehensive and assertive diagnosis, a more
rationalized planning and the construction of a work-
flow that achieves success, fulfilling the goals estab-
lished at the treatment planning. For this purpose,
several technological methods have been developed to
allow the professional to use a digital workflow to
increase predictability of outcomes [1]. In this context,
knowledge of the work protocol and techniques to be
used is essential.
4.2.3 Esthetic Analyses and Digital Smile Design
Esthetic dental rehabilitation requires a comprehensive
multidisciplinary treatment concept where coordina-
tion between specialties and careful assessment to for-
mulate the diagnostic approach, plan and carry out the
treatment plan are essential elements for a successful
outcome in cases of prosthetic treatment/restorative
complexes (Figure 4.11). Even when using several
Figure 4.11 Flowchart of digital esthetic analyses.
technological resources to assist in the diagnosis, for-
mulation of the treatment plan and choice of therapies
that will be applied in the treatment, careful and sys-
tematic clinical examination is essential in all types of
analyses in dentistry. In this context, different plans for
the same case can be presented, but always with a single
and precise diagnosis.
Treatment planning in oral rehabilitation should
consider both esthetic and functional aspects.
Occlusion analysis is also important to assess struc-
tural and/or pathological conditions. All etiological
factors of such conditions, as well as the clinical strate-
gies to solve them in an expected long-­term follow-­up,
should be identified. For this purpose, it is necessary to
have a database composed of the clinical history of the
patient, an objective clinical exam, and complemen-
tary exams.
The database will be used to create a flowchart of pro-
cedures (for details on each imaging examination men-
tioned herein, see Chapter 2). The role of each area of
dentistry in the patient’s treatment will be decided

based on a list of priorities, intentions, and interven-
tions to achieve the aim of the treatment based on
patient needs, chief complaint, and expectations. This
treatment approach using digital workflow requires
technical and therapeutic knowledge of the procedures
to be performed. Furthermore, the treatment approach
chosen should be individualized and driven by the
patient’s characteristics, such as gender and age, as well
as facial and esthetic parameters. For instance, young
patients are statistically more suitable to receive con-
servative treatments, which are frequently useful to pre-
serve the existing teeth structure. Such individual
aspects should always be considered during the initial
steps of treatment planning in esthetic dental rehabili-
tations [3]. On the other hand, there are some aspects of
the treatment that are challenging for the professional
to control (Table 4.1).
4.2.3.1 Esthetic Analyses
There are several aspects to be considered by the profes-
sional performing digital esthetic analyses in dentistry.
The project of a new smile will be created based on the
patient’s diagnosis and conditions. For this purpose, a
series of facially driven analyses with photographs and
reference lines are performed, aiming at correction of
any asymmetries or discrepancies.
Esthetic facially driven analyses usually follow pro-
portions defined by different points of interest and lines
of reference. In this context, several facial reference
points have been used in dentofacial esthetic analyses
(Figure 4.12). Since digital dentistry offers tools for basi-
cally the same concepts, general dental esthetic guide-
lines [4] applicable in conventional workflows should
also be taken into consideration. Similarly, discrepancy
Table 4.1 Treatment factors classified according to the
potential of being controlled by the professional.
Controlled Limited or not controlled
Treatment planning Patient’s habits
Quality of the materials Biological alterations
Reproducibility of the Patient’s physiology
procedures
Satisfactory predictability Patient’s adherence to clinical
of the technique recommendations
Chapter 4 Digital Workflow in Prosthodontics/Restorative Dentistry 89
points should also be identified and carefully consid-
ered during treatment planning.
Dentolabial esthetic principles should also be applied
along with dentofacial analysis. Among the main objec-
tives of dentolabial esthetic analyses are establishing
the proper parallelism between the occlusal plane and
horizontal reference lines, the correct inclination and
disposition of the teeth with the vertical reference lines,
establishing the ideal height of the lower third of the
face, and establishing the correct dominance
(Figure 4.13).
4.2.3.2 Two-­Dimensional Digital Design of the Smile
Several techniques and graphic manipulation tools in
digital clinical photography have been proposed in
recent years to perform a two-­dimensional (2D) digi-
tal design of the smile. Among the main techniques
are the Photoshop® Smile Design (PSD) [5, 6], and the
Digital Smile Design (DSD) [7]. These 2D methods
enable measurement of proportions between the den-
tal elements and correction of location and size to
obtain harmony between facial compositions, facial
tooth, and gingival tooth. The major disadvantage of
these methods is the parallax effect. For instance, in
the analysis of frontal records, the distance of a struc-
ture can vary in size and depth, such as in the case of
retrusive jaws. One advantage, however, is that several
2D methods of smile design use popular software pro-
grams, such as PowerPoint® (Microsoft) or Keynote®
(Apple). Some studies have also described the use of
2D photogrammetry, which uses frontal and profile
photographs to obtain photogrammetric measure-
ments. However, these are still 2D images that are a
snapshot of a 3D dynamic object. Evidence in the lit-
erature shows that such techniques still require
patient cooperation during acquisition [8].
Furthermore, magnification and distortion may still
occur, while no volumetric measurements can be per-
formed. One acceptable method, however, is the asso-
ciation of 2D and 3D dentofacial esthetic
analyses [9, 10].
4.2.3.3 3D Image-­Obtaining Methods for Esthetic
Analysis
Most of the limitations of 2D analyses can be over-
come by using 3D photogrammetry or facial scans
(see Chapter 2). Such methods will create 3D images
90 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Figure 4.12 Facial reference points.

as OBJ files, which can be superimposed and inte-

grated with the intraoral scans. The following step-­by-­
step procedure was conducted with the NemoSmile®
software (Nemotec) and can be performed after
obtaining a clinical history and examination, as well
as intraoral and facial scans of the patient.

4.2.3.4 Step-­by-­Step Procedure for 3D Dentofacial

Esthetic Analyses
●● Import the maxillary intraoral scan of the patient into
the software.
●● Align the intraoral scan with the photograph of the
patient. This is done to perform an initial 2D dentofa-
cial analysis of the patient with dentofacial reference
lines (Figure 4.14).
●● Design a digital mock-­up of the case, based on the
resulting position of the reference lines (Figure 4.15).
●● Align the resulting digital mock-­up with the facial
Figure 4.13 Main components of dentolabial esthetic scan of the patient (Figure 4.16).
analysis. Note the red line, corresponding to the inner
●● Based on the ideal teeth shapes that resulted from
contour of the lower lip. CS, crown shape; CP, contact point;
GZ, gingival zenith; HWP, height-­width proportion; IC, incisal the analyses and on the patient’s needs and expecta-
curve; IS, incisal space; TA, tooth axis. tions, select a digital teeth library. This library will
 Chapter 4 Digital Workflow in Prosthodontics/Restorative Dentistry 91

Figure 4.14 Intraoral scan. Note the different facial reference lines assessed in the software. Top left: incisal curve; top
middle: sagittal midline; top right: inner corner of the eye – canine line; bottom left: golden proportion ruler; bottom middle:
height-­width proportion analysis; bottom right: gingival curve, influenced by the location of the gingival zenith of each tooth.
Source: Case by Dr Charles Melo and Dr Alexandre D. Teixeira Neto.

be used in the process of virtual waxing (further dis- 4.2.4 Dynamic Smile Analysis
cussed later in the chapter). Alternatively, teeth
Stereophotogrammetry is a facial scanning method
shapes can be taken from an intraoral scan of
obtained by means of several cameras located at differ-
another patient, for instance, a relative of the
ent angles in relation to the individual. According to
patient [11]. This technique has been called “the smile
this concept, images can be captured in a single expo-
donation concept.” Finally, it is also possible to use
sure. Therefore, this technique allows high speed and
artificial intelligence-­based dental software pro-
accuracy in making 3D facial models. The main advan-
grams, such as Smilecloud®, to select the teeth
tage of stereophotogrammetry is that the speed of data
library and contribute to the digital design of the
acquisition minimizes the risk of involuntary facial
patient’s smile.
92 Digital Dentistry: A Step-by-Step Guide and Case Atlas
Figure 4.15 Digital mock-­up designed on the intraoral scan
based on the resulting reference lines.
muscle movements and promotes the accuracy of 3D
geometry. This technique uses multiple 2D images to
generate a 3D reconstruction of the face and smile.
Furthermore, the method does not require extensive
training and is radiation free [12, 13].
The superposition of intraoral scans and facial scans
allows the creation of a 3D virtual patient and significantly
assists in the analysis of the smile and rehabilitative plan-
ning in the esthetic zone [14]. However, even using 3D
models, static images have limitations as they do not repro-
duce the dynamics of the smile [15, 16]. Thus, other tools
are needed to record facial movements, such as video
recording [17]. In the present technique, a computer pro-
gram was used to convert the data into a realistic 4D patient
with animation of the lip dynamics during a smile [18].
The planning phase, including DSD which was previ-
ously done in 2D photographs, is now developed in 3D files.
The goal remains the same: to create smile designs guided
by the face, so that the 3D position of the anterior teeth is in
harmony with the face and the dynamics of the smile.
Thus, esthetic planning can be conducted from different
angles and perspectives of vision, increasing visual percep-
tion and making clinical results more predictable [19, 20].
Figure 4.16 Alignment of facial and intraoral scans with
the digital mock-­up of the case.
4.2.4.1 Step-­by-­Step Procedure for Dynamic
Smile Analysis
●● Obtain a facial scan in a stereophotogrammetry cabin:
position the patient in a natural head position with
the aid of laser-­projected reference lines. Sixteen syn-
chronized cameras capture images in 0.5 seconds. The
photographs are taken in maximum smile and rest
and exported together in JPG format (Figure 4.17).
●● Create the 3D mesh: import the photographs into a 3D
modeling software program. Apply the point georefer-
encing tactic to process the data and create the 3D
mesh (Figure 4.18). Save the file in OBJ format.
●● Intraoral scan: obtain an intraoral scan of the maxilla,
mandible, and intermaxillary relationships. Save data
in STL format (Figure 4.19).
●● Merge intraoral scan and facial scan: perform file
alignment in a CAD software/app using common ref-
erence points in both scans.
●● Smile animation: develop the smile dynamic path
from the rest position to the maximum smile with the
help of animation software. Render data and generate
a video of the smile to create the 4D virtual patient
(three dimensions with lip movements) and allow
dynamic analysis of the smile (Figure 4.20).
4.3 ­Digital Workflow for Restorations/
Prostheses
Once all relevant images are acquired and imported to
the CAD software, and the virtual patient set-­up is com-
plete for the case, the next step is virtual waxing of the
 (a)

(b)

Figure 4.17 (a) Facial scanning cabin; (b) photographs. Source: Case by Dr Newton Sesma.

(a)

(b)

Figure 4.18 (a) 3D mesh without texture; (b) colored 3D mesh.

94 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Figure 4.19 Intraoral scans of the patient.

(a)

(b)

Figure 4.20 Facial scan and IOS merged: (a) at rest; (b) maximum smile.

restorations and prostheses. This is the CAD phase of
the digital workflow for prosthodontics. Next, all digi-
tally designed prostheses/restorations will be manufac-
tured, either by milling or 3D printing. The main
modalities of prostheses/restorations that can be pro-
duced using digital workflow are presented below.
4.3.1 Single Crowns
The following CAD-­CAM workflows for single crowns
are the basic routine of a clinic working with digital
restorative dentistry. For these procedures, at least
intraoral scans of main and antagonist dental arches, as
well as the digital bite registration are usually required.
Furthermore, any other desired images such as facial
scans or photographs to be superimposed to the scans
should also be taken. All files resulting from these
images will then be imported into a CAD software pro-
gram along with the relevant patient data. In addition, it
is important that the finish line of the preparation is
adequately exposed and captured by the intraoral scan-
ner, which can be achieved as discussed at the begin-
ning of this chapter.
As discussed in the previous chapter, different work-
flows can be developed depending on the type of soft-
ware used. Dental commercial CAD software programs
have several similar tools and features that can be used
within an interface that is user friendly for dental pro-
fessionals. On the other hand, nondental free open-­
source CAD software programs have even more tools,
but with a more complex interface as they can be used
basically in any field of study involving digital design,
not just dentistry. As a result, nondental CAD software
programs require more CAD knowledge and training
and can be more time-­consuming, which is challenging
for dental clinics with a considerable flow of patients. In
this chapter, two step-­by-­step procedures will be pre-
sented for single crowns: one using a dental commercial
software program and one using a nondental free open-­
source software program.
4.3.1.1 Tooth-­Supported Single Crowns
As mentioned above, the first step in performing a basic
digital wax pattern of a single crown is to import the STL
files of the digital impressions and bite registration to a
CAD software program. The initial screen of most dental
CAD software programs contains the project details. The
procedure of digital waxing is similar in most of the den-
tal CAD software programs available. For this basic step-­
by-­step procedure, intraoral scans of a dental study
model were taken with a TRIOS® 4 (3Shape A/S). The
dental CAD software program chosen in this case was
Chapter 4 Digital Workflow in Prosthodontics/Restorative Dentistry 95
DentalCAD® (Exocad GmbH) since it contains one of
best known software interfaces for digital waxing. The
intraoral scans were imported to DentalCAD to design
the single crown, as explained below.
Step-­
by-­
Step Procedure Using Commercial Dental CAD
Software
●● Open the CAD software program.
●● Input patient data.
●● Select the tooth that will receive the single crown.
●● Select adjacent and antagonist teeth (Figure 4.21).
●● Select “Anatomic crown.”
●● Select the material chosen to fabricate the crown.
●● Select additional parameters if needed (Figure 4.22).
●● Click on “OK.”
●● Click on “Design” to open the actual DentalCAD soft-
ware program.
●● Select the STL file corresponding to the intraoral scan
of the main arch in the file browser that will auto-
matically open (Figure 4.23).
●● Select the STL file of the antagonist arch.
●● Using the mouse buttons, position the main arch scan
in an occlusal view, leaving all margins of the prepa-
ration visible, and click to set current view as the ori-
entation axis (Figure 4.24).
●● Click on “Next.”
●● Click on “Antagonist” (top left of the screen) to show
the antagonist arch in the screen (Figure 4.25). If a
digital bite registration is desired to articulate the
main and antagonist models, import the STL file of
the bite registration in the same tridimensional coor-
dinates of the models by clicking on “Expert
mode” → Tools → Add/remove meshes.
●● Align the virtual mesh of the bite registration with the
models by selecting points in common locations on
both meshes (Figure 4.26).
●● Click on “Align” and select the best fit option to super-
impose the meshes properly (Figure 4.27).
●● Click to change back to the “Wizard” mode.
●● Proceed with the autodetection of the preparation
margin by clicking on two different points at the edge
of the preparation margin. This will allow the soft-
ware to automatically detect the location of the finish
line of the preparation (Figure 4.28).
●● Switch to “Manual” mode to correct and perform fine
adjustments to the optimal location of the prepara-
tion margins (Figure 4.29).
●● Select the magic lantern (available in the “Tools”
menu) to change the light direction in the 3D space
(Figure 4.30). This allows determination of the optimal
location of the preparation margin with higher preci-
sion. After adjusting the margin, go to the next step.
96 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Figure 4.21 Initial screen of the Exocad workflow. The initial screen of most dental CAD software programs contains the
project details, such as date, name of patient, dentist and dental technician and particular notes of the case. This is also the
screen where the professional should select all the teeth that will receive the single crown, as well as the adjacent and
antagonist teeth. For the Exocad system, this screen is found by running the DentalDB application, from which the DentalCAD
will open at the time of designing the single crown. Other data such as tooth color and type of digital articulator to be used
can also be defined later during the procedure of digital waxing.

Figure 4.22 Selection of type of restoration, material, and parameters. In this case, a mandibular left first molar (tooth 36) was
selected to receive a single crown. For this purpose, the option “Anatomic crown” was chosen with “Wax” material. An option is
also available to inform the software if this was an implant-­supported crown. Additional parameters such as minimum
thickness and cement gap width can be adjusted later after assessing the actual tooth preparation.
 Chapter 4 Digital Workflow in Prosthodontics/Restorative Dentistry 97

Figure 4.23 If the case was not scanned within the Exocad workflow, a file browser will open along with the DentalCAD
software. Since the present case had previously been scanned using a TRIOS 4, the STL files of the main and antagonist arches
as well as the bite registration were selected in the browser.

Figure 4.24 Occlusal view of the tooth preparation leaving all margins visible before setting the current view as the
orientation axis for digital waxing.

Figure 4.25 View of the antagonist model. In most cases, the occlusion will be automatically correct. In this case, however, it
was decided to import an STL file of bite registration to make sure that the occlusion was correct.
98 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Figure 4.26 Alignment of the bite registration STL with the models. For this purpose, it is important to click on points that can
be recognized and reproduced in both models, such as the buccal pit of molars (always click first on the bite registration, and
then in the actual model).

Figure 4.27 Occlusion obtained after importing and aligning the bite registration scan to the models.

Figure 4.28 Autodetection of the preparation margins.

 Chapter 4 Digital Workflow in Prosthodontics/Restorative Dentistry 99

Figure 4.29 Manual adjustment of the margin outline. This is done by clicking on and dragging the points available
throughout the line.

Figure 4.30 The magic lantern tool is used to create shadows in the 3D space of the software. This allows for easier
recognition of the actual edge of the preparation margin.

●● The next step is to check and confirm the insertion
axis of the crown. Note that if the axis orientation is
not satisfactory, retentive parts will show in red color
(Figure 4.31a). Make sure that the preparation mar-
gins are visible and that there are no retentive areas in
the preparation (Figure 4.31b).
●● Click on the “Next” button.
●● Select the desired parameters of the crown bottoms
(intaglio surface) such as the cement gap thickness
(Figure 4.32).
●● Click on the “Next” button. A new mesh corresponding
to the minimum thickness will be created (Figure 4.33).
This will vary among the different materials. In
addition, a crown shape will be given by the software to
be positioned onto the preparation (Figure 4.34).
●● To select a crown shape from the library, choose the
desired library or switch back to the “Expert” mode to
see a full drop-­down menu of all available libraries
(Figure 4.35).
●● Adjust the crown dimensions and orientation digi-
tally. This should be done taking into consideration
the positions of antagonist and adjacent teeth
(Figure 4.36).
●● When the optimal position is established, click on the
“Next” button. The crown shape will automatically adapt
to the preparation margins that were previously outlined.
100 Digital Dentistry: A Step-by-Step Guide and Case Atlas

(a) (b)

Figure 4.31 Definition of the insertion axis orientation. (a) Wrong insertion axis orientation, leaving undesired retentive areas
(red color). (b) Corrected axis orientation with no retentive areas.

Figure 4.32 Adjustment of the cement gap thickness. A thicker cement gap could be better to avoid retentive areas of
the crown.

Figure 4.33 Minimum thickness mesh shown in red.

 Chapter 4 Digital Workflow in Prosthodontics/Restorative Dentistry 101

Figure 4.34 Crown shape to be positioned onto the preparation. At this point, several options will be available for defining
the desired crown shape. It is possible to choose a crown shape from a library, mirror the contralateral tooth, or even use an
additional scan or mesh as a reference for this crown shape.

Figure 4.35 Tooth library selection in the “Expert” mode.

102 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Figure 4.36 Adjustment of the crown 3D dimensions and position in the dental arch. The view of the model can be changed
by using the mouse right click. This allows the user to rotate, drag, expand or shrink the crown in different directions. Contact
with adjacent and antagonist teeth will be shown in colors following a scale of intensity. It is also possible to adjust the shape
of specific areas of the crown, such as a cuspid or a ridge (top right image). The antagonist arch can be shown again to adjust
the occlusion of the new crown (bottom right image).

Figure 4.37 Smoothing of the crown surface performed after the crown is automatically adapted to the preparation margins.
Different tooth colors can also be applied at this point to improve visualization of the crown.

file (Figure 4.39). The crown is ready to be fabricated

Use the brushes to adjust and smooth the surface of
(Figure 4.40).
●●

the crown (Figure 4.37).

●● Perform a final check to make sure that the crown Editor’s note: The basics of dentistry are still the
position is satisfactory (Figure 4.38). same! However, digital dentistry gives us new tools
●● Finally, click on the “Next” button. This will export and methodologies to enhance the predictability of
and save the resulting digital crown design as an STL our treatments.
 Chapter 4 Digital Workflow in Prosthodontics/Restorative Dentistry 103

Figure 4.39 Screenshots of the final design of the crown to

Figure 4.38 Final digital crown design and position be exported as an STL file.
obtained with the basic digital waxing procedure. If more
images such as photographs or facial scans were available to
be superimposed to the models, esthetic outcomes and
buccal corridor spaces could also be checked. If a virtual
articulator was used, excursive movements could also be
checked. It is very important to remember that all principles
of occlusion (e.g., canine guidance or group function in
lateral excursions, axial loading, anterior guidance in
protrusion, absence of contacts on nonworking side, etc.)
should always be checked, as the basics of dentistry are the
same using either digital or conventional workflow.

Figure 4.40 Installation of the resulting 3D-­printed single crown of tooth 36. A five-­axis milling device (Ceramill Motion 2,
Amann Girrbach AG) was used to fabricate the crown with PMMA resin (Ceramill Temp A3). No chairside adjustments were
required to fit the crown in the tooth preparation or in occlusion.
104 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Case Report 4.1 Multiple Single Crowns

(Clinical case by Professor Arthur R.G. Cortes and and the possible treatment options, the patient
Dr Djalma N. Cortes) agreed to receive three CAD-­CAM ceramic crowns.
Virtual waxing was then conducted for the three
A 71-­year-­old male patient presented to the clinic
crowns (Figure 4.43) with CAD software (Ceramill Mind).
with three fractured crowns in the esthetic area (teeth
The resulting crown designs were saved as STL files.
11, 12, and 22). The chief complaints of the patient
The patient liked the digital design of the three
were short anterior teeth and poor esthetic conditions
crowns. He also asked if it was possible to have a try-
of his smile (Figure 4.41a). The patient had a history of
­in of these crowns. It was then decided to try in a
root canal treatments in the maxillary incisors and
3D-­printed mock-­up of the crowns. For this purpose,
attrition, which had previously been treated with
three crowns were fabricated using a DLP 3Dprinter
occlusal splints. Resin posts followed by preparations
(Hunter®, FlashForge) with light-­ cured resin
were performed to install three conventional tempo-
(Makertech Labs) and tried in (Figure 4.44).
rary crowns performed with acrylic resin (Figure 4.41b).
The clinical result of the mock-­up was satisfactory
After improving the shapes of the preparations,
for the patient, so three CAD-­CAM crowns were milled
intraoral scans of the main and antagonist arch, as
in lithium disilicate (IPS e.max CAD, Shade A3.5 LT –
well as of the bite registration, were taken using a
Low Translucence; Ivoclar Vivadent AG) with a five-­axis
TRIOS 3 device (3Shape A/S).
milling device (Ceramill Motion 2, Amann Girrbach AG)
The patient was initially willing to receive only
and cemented to the respective preparations with a
three new conventional resin crowns, claiming that he
resin luting agent (RelyXTM Unicem, 3MTM ESPE). A
would not be intending to pay for any better restora-
temporary composite crown was also performed on
tions. However, after seeing a virtual mock-­ up
the right maxillary lateral incisor. As a result, the smile
(Figure 4.42) performed with the DentalCAD software
of patient was already substantially better (Figure 4.45).
After a 3-­month follow-­up period, the patient pre-
(a) sented to the clinic again to receive two other CAD-­
CAM single crowns in the esthetic zone, corresponding
to teeth 12 and 23. The above-­mentioned procedure
was performed again to fabricate two milled crowns
in lithium disilicate monolithic glass–ceramic block

(b)

Figure 4.41 (a) Initial clinical intraoral view of the case.

(b) Clinical aspect of the preparations. Note that the other
maxillary anterior teeth were heavily restored with
Figure 4.42 Virtual diagnostic mock-­up.
unsatisfactory conditions.
Figure 4.43 Virtual wax patterns of the three crowns.

Figure 4.44 3D-­printed mock-­up try-­in result.

Figure 4.47 New intraoral scan of the dental arch
superimposed to the patient’s smile.

Figure 4.45 Patient’s smile after cementation of the crowns.

Figure 4.48 Two new CAD-­CAM lithium disilicate crowns
were cemented on the preparations of teeth 12 and 23.

and luted (RelyX U200 A3 opaque). For this purpose, a

new intraoral scan was taken to perform facial
esthetic analyses, followed by digital waxing
(Figures 4.46–4.48). No posttreatment complications
were noted in a 1-­year follow-­up period.
Acknowledgements: Professor Cortes and Dr Cortes thank
CDT Jacqueline Ferreira Lima for her contribution to the vir-
tual mock-­up and Dr Jonas Alencar de Matos (Virtual Lab, São
Figure 4.46 New preparations were performed on teeth Paulo, Brazil) for his support with the CAD-­CAM procedures.
12 and 23. The authors of this case also thank the EXOCAD company.
106 Digital Dentistry: A Step-by-Step Guide and Case Atlas
Step-­by-­Step Procedure of Virtual Waxing of Single Crowns
Using Nondental CAD Software
Meshmixer® (Autodesk Inc.) is the most used program
within free nondental software. It is used by several
dental clinics and laboratories to design parts, plates,
and models. However, as a nondental software, it has
the limitations discussed in Chapter 2. As a result, vir-
tual waxing with Meshmixer takes considerably longer
and requires more training than dental commercial
CAD software programs. For this reason, an appropriate
tooth library should be selected and downloaded prior
to commencing the procedure. Teeth libraries compati-
ble with Meshmixer are currently available for free on
some webpages. The following step-­by-­step procedure
was used to perform the digital waxing of tooth 46
(mandibular right first molar).
●● Import the tooth file and library into Meshmixer.
Open the program and click on “Import” and add
the intraoral scans of upper and lower arches. Once
this is done, an object browser will automatically
open. This window is essential to identify how many
objects and which objects are to be imported into
the software. Click on “Import” in the upper left
corner, and click on “Append” to import an addi-
tional object to the same virtual space in which the
intraoral scans were imported. Then, select the
tooth to be waxed. The “Object browser” list will
show the scans and the crown to be used in digital
waxing (Figure 4.49).
(a)
Figure 4.49 (a) “Import” option on Meshmixer. (b) Intraoral scans imported into the software. Note the “Object browser”
window at the bottom right of the figure. (c) “Append” option used to import/add more objects to the virtual space. (d) Tooth
library and crown shape selection.
●● After importing, the crown will need to be positioned
on the tooth preparation in the virtual space. To do
this, press the “T” key to transform the object and
position it. The arrows indicate how to move the
plans: the semi-­circle rotates the object; the triangle
moves between all axes; the squares of each arrow
with different colors will increase or decrease the size
of the object; the white square will proportionally
change the object’s dimensions (Figure 4.50).
●● Make sure that the position of the crown on the prep-
aration covers the entire finish line and slightly
exceeds the limits of antagonist (Figure 4.51a) and
adjacent teeth (Figure 4.51b). Since there is no way to
measure the proximal or occlusal contact depth, the
software does not show with colors or densities how
much one object is entering into another.
●● Use sculpting tools for adjusting and smoothing any
areas of the crown, as desired. To do this, click on
“Sculpt,” select “Brushes” and choose the brush that
suits the requirements of the area to be smoothed.
●● Use the “Select” tool to carefully outline the prepara-
tion margins. To make it easier and more accurate,
decrease the size of the area to be selected (Figure 4.52a).
To remove any undesirable areas that were selected by
mistake, press CTRL (for Windows systems) or
“Command” (for Apple Mac systems) and unselect the
extra areas. Once the margin is selected/outlined, use
the tool “Smooth boundary” to give a flattened aspect
to the mesh of the margins (Figure 4.52b).
 (b)

(c)

(d)

Figure 4.49 (Continued)

108 Digital Dentistry: A Step-by-Step Guide and Case Atlas

(a)

(b)

Figure 4.50 (a) Object transforming to move and rotate the crown. (b) Crown positioned on the tooth preparation.

●● A new “Selection” will be created and identified with
another random color. Then, click twice on the region
with different color and click twice on the inner bor-
der of the area of the selected tooth. This will select/
outline the margins and the entire crown (Figure 4.53).
●● Click on “Edit” → Extract. Change the offset to 0.05
and accept the change (Figure 4.54). The rationale of
this step is to create the cement gap of the crown.
●● The extracted object will be still selected. Click twice
in the border with different color and press “Y,”
 Chapter 4 Digital Workflow in Prosthodontics/Restorative Dentistry 109

(a)

(b)

Figure 4.51 (a) The occlusal surface of the virtual wax pattern is slightly exceeding the limits of the mesh of the antagonist
tooth, in the area shown in gray. (b) The proximal surfaces of the virtual wax pattern are slightly exceeding the limits of the
mesh of the adjacent teeth, in the areas shown in gray.

which will separate the selected preparation from the
model, assuming an aspect similar to a die
(Figure 4.55a). Then, press “W” to see the mesh
structure of the object. Click twice in the most
external triangle of the extracted mesh and twice in
the most external triangle of the original mesh. Then,
click on “Edit” → Join (or press “J”). The resulting
area will be a digital die where the professional will
adapt the virtual wax pattern to the margins and per-
form adjustments (Figure 4.55b).
110 Digital Dentistry: A Step-by-Step Guide and Case Atlas

(a)

(b)

Figure 4.52 (a) Margin outlining with “Select” tool. (b) Margin outlined and smoothened.

(a)

Figure 4.53 (a) New “Selection” (green). (b) The entire preparation was selected.
 Chapter 4 Digital Workflow in Prosthodontics/Restorative Dentistry 111

(b)

Figure 4.53 (Continued)

(a)

(b)

Figure 4.54 (a) Edit menu and “Extract” tool. (b) Offset value adjustment.
112 Digital Dentistry: A Step-by-Step Guide and Case Atlas
●● After adjusting the crown on the preparation, the pro-
fessional needs to remove excessive areas (i.e., areas
extending further than the actual preparation) and
add areas of material that are lacking between prepa-
ration and crown. To remove excessive areas, first
press “S” to select the desired region (Figure 4.56a).
Then press “B” and accept. This will smooth the bor-
ders of the region. Then, exclude the region with “X.”
Repeat the procedure until all preparation margins
are clearly visible (Figure 4.56b).
●● The next step is to merge the meshes of preparation
and crown. To do that, use the “Select” tool and click
twice on all areas containing the preparation
(a)
(b)
Figure 4.55 (a) Extraction of the preparation mesh. (b) Digital die set-­up.
(including all areas with different colors). Then, click
on “Edit” → Flip normals (Figure 4.57a). Then, click
on the crown, hold “Shift” and click on the prepara-
tion. Select the option “Combine” to merge the
meshes (Figure 4.57b and 4.58).
●● To finalize, press “W” to visualize the mesh structure
again. Click on “Select” and click twice on the most
external triangle of the crown mesh. Then, press “J”
and accept.
●● The new digitally designed crown is ready. Click on
“Sculpt” →Brushes and select the brush type
“ShrinkSmooth” to smooth the entire border of the
crown (Figure 4.59).
 Chapter 4 Digital Workflow in Prosthodontics/Restorative Dentistry 113

(a)

(b)

Figure 4.56 (a) Selection of areas to be removed. (b) Crown aspect after removal of excessive areas.
114 Digital Dentistry: A Step-by-Step Guide and Case Atlas

(a)

(b)

Figure 4.57 (a) “Flip normals” function. (b) “Combine” function.

 (a)

(b)

Figure 4.58 (a) Mesh merging procedure. (b) Meshes finally merged.

(a)

Figure 4.59 (a) Final aspect of the crown. (b) Final CAD crown on the model.
116 Digital Dentistry: A Step-by-Step Guide and Case Atlas
(b)
Figure 4.59 (Continued)
4.3.1.2 Working with Dies
As commonly seen in cases of tooth-­supported crowns
conducted with conventional workflows, digital dies
can be designed in CAD software programs to facilitate
visualization and access to the preparation margins and
tooth shape (Figure 4.60). Digital dies can also be 3D
printed as removable dies to fit in 3D-­printed dental
casts. The presence of the 3D-­printed cast and dies is
therefore useful to try in and perform adjustments on
CAD-­CAM crowns.
4.3.1.3 Implant-­Supported Crowns
Implant positions need to be transferred to a cast set-­up
for the prosthesis to be manufactured. Using conven-
tional workflow, this is done by screwing a transfer abut-
ment to the dental implant to perform conventional
impressions with either open or closed trays. Nowadays,
several CAD-­CAM techniques are available to plan
implant therapy by creating a 3D virtual patient, as
explained in Chapter 2. In this context, implant-­supported
CAD-­CAM prostheses are the first part of implant ther-
apy to be planned, in order to achieve a prosthetically
driven implant rehabilitation (see also Chapter 6 on digi-
tal implant dentistry).
Implant-­supported crowns can be digitally designed in
a procedure similar to that for single crowns over tooth
preparations. The resulting STL files of the crowns can
be either 3D printed or milled as CAD-­CAM copings or
crowns. For this purpose, either an implant scanbody
can be intraorally scanned to digitally transfer the
implant position to the CAD software, or an implant
stock abutment can be directly scanned as if it was a
regular tooth preparation, which eliminates the need for
an intraoral scan with the scanbody in position. On the
other hand, implant scanbodies are simple to use and are
considered satisfactory to ensure accurate location of the
abutment margins and implant position. For this pur-
pose, a compatible digital abutment or implant analogue
available in the library of the implant system should be
installed to be recognized by the software.
The following step-­by-­step procedure was designed
for DentalCAD software. Several procedures are similar
to the virtual waxing of tooth-­supported single crowns.
Therefore, the following list of steps is focused on the
aspects that are particular to CAD-­CAM implant-­
supported crowns.
Step-­by-­Step Procedure for Implant-­Supported Single Crowns
●● At the initial screen, it is usually possible to input data
on the material to be used and type of prostheses (e.g.,
screw-­retained lithium disilicate crown).
●● Import the four intraoral scans into the CAD software.
●● Select the scanbody of the implant system used in the
correct library.
●● Match the image of the selected scanbody with the
intraoral scan of the scanbody on the model. Click
on “Best Fit” to make this procedure easier
(Figure 4.61).
●● This will make the digital analogue of the implant
available in the virtual space (Figure 4.62). Proceed
with the normal virtual waxing technique
(Figure 4.63), as described in section 4.3.1.1.
 Chapter 4 Digital Workflow in Prosthodontics/Restorative Dentistry 117

Figure 4.60 Digital dies used during digital waxing of multiple single crowns.

Figure 4.61 Matching between the scanbody selected from the library and the actual scan of the scanbody.

Figure 4.62 Scanbody located in the software, enabling visualization of the digital implant analogue position. Note that some
scanbodies are designed for implant fixtures, while others are designed to be screwed directly to specific abutments of the
implant.
118 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Figure 4.63 Digital waxing of a screw-­retained implant-­supported crown.

Case Report 4.2 Implant-­Supported Crown

(Clinical case by Professor Arthur R.G. Cortes)
A 4.1 × 10 mm dental implant (SLA, Institut Straumann crown with a digital workflow using intraoral
AG) was placed to rehabilitate tooth #25 of a scans [21]. No procedure-­related complications were
68-­year-­old female patient. Six weeks after surgery, observed in a 2-­year follow-­
up period
the implant was restored with a screw-­ retained (Figure 4.64–4.67).

Figure 4.64 Dental implant placed and left with a healing screw.
 Chapter 4 Digital Workflow in Prosthodontics/Restorative Dentistry 119

Figure 4.65 The four STL files resulting from the required intraoral scans (top left: with the scanbody; top right;
without the scanbody; bottom right: antagonist arch; bottom left: digital bite registration).

Figure 4.67 A CAD-­CAM lithium disilicate crown (IPS e.max

Press, Ivoclar Vivadent) was installed to rehabilitate the case.

Figure 4.66 Digital waxing of a screw-­retained implant-­

supported crown (Virtual Lab, São Paulo, Brazil).
120 Digital Dentistry: A Step-by-Step Guide and Case Atlas
4.3.1.4 CAD-­CAM Copings
Recent studies have described the use of CAD-­CAM
technology to design and fabricate copings [1, 22].
Furthermore, frameworks and copings for all-­ceramic res-
torations can be made of zirconia, which has led to satis-
factory outcomes of esthetic restorations. Zirconia is
known for its stability and toughness (Figure 4.68).
Nevertheless, sintering zirconia is not only time-­
consuming but also expensive, besides risking damage to
the surface of the ceramic material. Monolithic zirconia
copings have been widely used in oral rehabilitation but
factors such as operator experience, software, and milling
methodologies can influence the results significantly [23].
4.3.1.5 Customized Abutments
In implant dentistry, abutments represent connections
between implant-­supported crowns and fixtures. The
correct choice of abutment dimensions is essential to
achieve satisfactory functional and esthetic outcomes.
Prosthetically driven treatment planning can help to
predict which would be the best abutment for any case.
Dental implant abutments can be prefabricated, usually
offering different options of height, diameter and shape,
or customized to each patient’s clinical situation.
There are different methodologies for designing
and fabricating customized abutments. CAD-­CAM
Figure 4.68 CAD-­CAM zirconia copings assessed in a research project.
techniques have proven useful to achieve satisfactory
clinical outcomes in cases of immediate implants with
customized abutments in the esthetic area [23, 24]. One
of the main indications for custom abutments is a single
implant in the esthetic area. In such cases, obtaining an
adequate emergence profile of the implant-­supported
crown is essential to prevent unfavorable outcomes
related to variations of the marginal gingiva contour. In
this context, soft tissue healing and management can be
appropriately conducted in favorable cases (e.g., with lit-
tle or no buccal bone resorption and thick gingival bio-
type) with temporary crowns to obtain a natural contour
of gingival zenith and papilla around dental implants.
Once the design of the abutment is completed, it
can be milled in zirconia. Zirconia abutments are
more resistant to fracture and can be cemented to Ti-­
base abutments to be screwed to implants. In addition,
the temporary or final crown can be designed over the
abutment. The customized abutment design can also
be incorporated into a digital workflow prior to
implant placement. One study described a technique
to perform a segmentation of a natural emergence
profile of a failing tooth, leading to satisfactory
results [24]. With the customized abutment immedi-
ately placed at the surgery, healing of the soft tissue
over the zirconia abutment is expected to be stable,
 Chapter 4 Digital Workflow in Prosthodontics/Restorative Dentistry 121

leading to a more predictable marginal contour. After

soft tissue healing, the abutment can be scanned and
the final crown can be designed without removing the
zirconia abutment.
The procedure demonstrated in Figures 4.69–4.73
was performed in DentalCAD software and contains the
main steps to perform the customization of the emer-
gence profile for an abutment.

Figure 4.71 Virtual waxing of the crown.

Figure 4.69 Procedure of outlining the emergency profile.

Figure 4.72 A screw-­retained crown was designed.

Figure 4.70 Emergency profile adjustment.

Figure 4.73 Customized abutment (yellow).
122 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Case Report 4.3 CAD-­CAM Customized Abutment for an Immediate Implant in the Esthetic Area
(Clinical case and technique by Dr Alan J.M. Costa and Dr (Figures 4.76 and 4.77). A temporary crown was also
Shaban M. Burgoa) milled with PMMA using the same milling machine
(Figure 4.78), and then replaced by a definitive crown.
A cone Morse® 3.5 × 16 mm dental implant (Neodent®)
No procedure-­related complications were observed in
was immediately placed to rehabilitate tooth #21 of a
a 1-­year follow-­up period.
42-­year-­old male patient. A customized abutment was
designed considering a 3D segmentation of the fail-
ing tooth performed with CBCT scans in the implant
planning software (Nemotec). The 3D segmentation
was performed basically to transfer the positions of
alveolar bone and soft tissues around the failing tooth
and root to the software (Figure 4.74) [23]. The result-
ing emergency profile was therefore similar to the
patient’s natural profile before the extraction proce-
dure. The same segmentation was also used to orien-
tate digital waxing of the crown with the customized
abutment in CAD software (DentalCAD) (Figure 4.75).
The 3D design of the temporary restoration was also
exported as an STL file.
The customized abutment was fabricated with a
zirconia block (Upcera®, Liaoning Upcera) using a
milling machine (DM5, Technodrill). The resulting
abutment was then dried before sintering for 30 min-
utes at 80 °C and 10 minutes at 150 °C, followed by Figure 4.76 Zirconia custom abutment.
2 hours of high-­speed sintering at 1510 °C

Figure 4.77 Frontal view of the customized abutment.

Figure 4.74 3D segmentation of the tooth.

Figure 4.75 Resulting customized abutment. Figure 4.78 Milled PMMA temporary crown.
 Chapter 4 Digital Workflow in Prosthodontics/Restorative Dentistry 123

4.3.2 Splinted Crowns and Fixed Bridges software program of the Zirkonzahn system. Close
the door of the milling device.
Most of the procedure to digitally design splinted
●● Using the computer connected to the milling device,
crowns or a fixed bridge is similar to that described for
open the main screen of the Zirkonzahn system,
single crowns. However, since there will be connections
showing the whole sequence of software programs to
between different prostheses, a few extra points need to
be used (Figure 4.79).
be taken into consideration. One of the main points is
●● Open the software “Zirkonzahn Archiv.” To work
that a satisfactory common insertion axis for all splinted
with general STL files, click on “Create new treat-
crowns or abutments of fixed bridge should always be
ment.” Since scans from a TRIOS 4 will be used in this
found and configured in the software.
guide, the “Import” option was selected (Figure 4.80).
In addition, splinted prostheses require digital design
Directly import files from the TRIOS system
of the connectors between the involved crowns.
(Figure 4.81). A new patient project will open. Note
However, splinted crowns require only the connectors,
that more than one project can be created for the
but with no pontic elements. This contrasts with digital
same patient.
design of fixed bridges, in which pontic elements should
●● After clicking on a tooth, it will be possible to select
be defined and adjusted, according to the anatomy of
the type of work (coping, crown, abutment, etc.) and
the dental arch and alveolar ridge.
the material to be milled. Register the patient, case,
The following step-­by-­step procedure was performed
task, dentist, other teeth involved (adjacent and
on a dental study model that was scanned with a TRIOS
antagonist), type of work, and materials of the pros-
4 intraoral scanner. The prostheses were designed and
theses (Figure 4.82). For instance, select “Wax” a
manufactured using the Zirkonzahn CAD-­CAM sys-
material if production of the final crown will be
tem, which includes a previously calibrated M1 milling
done using conventional workflow. Zirconia and
device (see Chapter 3).
hard materials (e.g., raw abutment, Ti-­zinc alloy,
etc.) can also be selected. Additional scans, such as a
4.3.2.1 Step-­by-­Step Procedure to Design and Mill
previous temporary crown, could be imported using
a Fixed Bridge
the option “Situ.” A virtual articulator can also
●● Turn on the M1 milling device (green button inside).
be used.
This should always be done before turning on the

Figure 4.79 Main screen of the Zirkonzahn system. Note the logical order of software programs to be used in the digital
workflow.
124 Digital Dentistry: A Step-by-Step Guide and Case Atlas
Figure 4.80 The “Import” option was selected.
Figure 4.81 The “TRIOS Project” option was selected.
●● Save the project, and use the top-­right button on the
same screen to open the CAD software called
Modellier (note that in this case the Zirkonzahn scan-
ning software will not be used, since all intraoral
scans were previously obtained with a TRIOS 4).
●● Load the main and antagonist arches into the
Modellier software.
●● Move the model to obtain an occlusal view, and click
on “Set current view as axis” (Figure 4.83).
●● If needed, trim the digital models to correct inade-
quate or irregular shapes (Figure 4.84). This is useful
if the professional intends to use the intraoral scans to
produce 3D-­printed dental casts later.
●● Outline the preparation margin by initially selecting
the autodetection tool, and select one point in the
preparation margin (Figure 4.85). Change to manual,
to correct the remaining area of the preparation mar-
gin. Then, click “Next” and repeat the procedure for

Figure 4.82 Project details registration.
Figure 4.83 Insertion axis definition for the models containing prostheses to be designed.
all the other teeth selected as abutments of the
fixed bridge.
●● Select the best view to visualize all preparation mar-
gins of the fixed bridge at the same time and click on
“Set insert direction.” Green arrows will indicate the
resulting direction of the axes (Figure 4.86). In this
same screen, several parameters such as cement gap
Chapter 4 Digital Workflow in Prosthodontics/Restorative Dentistry 125
thickness (Figure 4.87) can also be checked and
adjusted.
●● Select the desired tooth shape from a library. It is also
possible to mirror the contralateral tooth if available.
Click on “Next.”
●● Place each crown over the preparations. For this pur-
pose, use rotation, moving, and scaling tools available
126 Digital Dentistry: A Step-by-Step Guide and Case Atlas
Figure 4.84 Digital model trimming.
Figure 4.85 Preparation margin outlining.
at the left side of the screen. Note that there are sev-
eral shortcut keys (CTRL + mouse left button;
CTRL + shift + mouse scroll; Shift + mouse scroll,
etc.) that can make the procedure faster and easier
after some practice. Also note that areas with exces-
sive contacts will be depicted in pink or other colors
(Figure 4.88).
●● Click on “Next.” All teeth will adapt to the previous
designed margin of the preparations (Figure 4.89). At
this stage, the shape of the crowns can still be edited
using the tools “Free forming: all, parts, cusps
and ridge.”
●● In the case of fixed bridges, remove the visualization of
the dental models and rotate the bridge to adjust and
smooth the cervical side of the pontics to adapt better
to the ridge anatomy (Figure 4.90). For this purpose,
use the tool “Free modellation” to add or remove mate-
rial and smooth. Select an appropriate brush type. Note
Figure 4.86 Definition of the optimal insertion axis for the fixed bridge.

Figure 4.87 Cement gap thickness definition.

Figure 4.88 Crown positioning.

128 Digital Dentistry: A Step-by-Step Guide and Case Atlas
Figure 4.89 Crown shapes editing in occlusion.
Figure 4.90 Adjustment and smoothing of the pontic cervical surface.
that pressing “Shift” will automatically switch to
removing material, instead of adding. For smoothing,
pressing “Shift” will activate the “Turbo smooth” mode.
●● Click on “Next” and select the desired area for the
connectors between all elements of the fixed bridge or
splinted crowns (Figures 4.91 and 4.92).
●● Click on “Next” when the connectors are ready. The
resulting prosthesis will now be exported and saved as
an STL file (Figures 4.93 and 4.94).
●● On the top right of the same screen, click to open the
Zirkonzahn nesting software, to configure and pre-
pare the milling protocol.
●● Click on “Blanks.” It is possible to scan the QR code of
the desired blank, which makes the software auto-
matically recognize the correct configuration for the
chosen material. In this case, the fixed bridge will be
nested and milled from a resin try-­in blank, which is a
material that allows for trying in and subsequent

Figure 4.91 Connector shape editing.
Figure 4.92 Linear measurement between preparations to orientate shape and dimensions of the connector.
scanning to produce a definitive prosthesis
(Figures 4.95 and 4.96).
●● Select the height of material (if the material will not
undergo contraction, use the original values).
●● Set the position of the bridge (nest) in a corner of the
blank to save space.
●● Double click to add a support. Keep the mouse left
button pressed and click right to remove (or
CTRL + left click). The ideal number of supports will
Chapter 4 Digital Workflow in Prosthodontics/Restorative Dentistry 129
also depend on the material. For instance, fewer sup-
ports are required for PMMA than for zirconia.
●● Once ready, click on “Save and start CAM.” There will
be an automatic file name, which can be changed.
●● Choose the type of CNC calculation. One of the most
used is “Parallel CNC calculation,” which uses more
memory but requires less time.
●● Check milling simulation (color means differences
from the original digital design).
130 Digital Dentistry: A Step-by-Step Guide and Case Atlas
Figure 4.93 Final STL file of the fixed bridge.
Figure 4.94 Digitally designed fixed bridge in occlusion.
●● Unlock CNC. From this point on, no more changes
will be allowed to the digital design.
●● Start milling in Zirkonzhan Frasen software. For this
purpose, select “Blank library: choose job.” Click on
“Start milling.”
●● The software will ask the user to insert the blank in
the milling device.
●● Insert blank, activate levers and screw them in with
screwdriver.
●● Close the door of the milling device. The software will
inform the user about the drills required for the pro-
cedure. Insert all drills in the correct spots, following
the instructions of the software.
●● Start milling procedure (Figure 4.97).
 Chapter 4 Digital Workflow in Prosthodontics/Restorative Dentistry 131

Figure 4.95 Fixed bridge nested into the try-­in blank.

Figure 4.96 Screenshot of the CAM strategy, showing the disposition of fixed bridges and supports.

●● When finished, remove the blank and detach the milling device. Please note that the compressor
manufactured prosthesis (Figure 4.98). It is important required for the milling device might need to be
to turn off the software system first, and only then the turned off as well.
132 Digital Dentistry: A Step-by-Step Guide and Case Atlas

(a) (b)

Figure 4.97 (a) Milling preparation in the Fräsen software. (b) Milling procedure in the Zirkonzahn M1.

Figure 4.98 Final result of the fixed bridge milled with resin try-­in material.
 Chapter 4 Digital Workflow in Prosthodontics/Restorative Dentistry 133

4.3.3 Laminate Veneers photographs. The following clinical case used photo-
graphs taken with a Canon EOS Rebel T4i professional
With the development of new five-­axis milling devices
camera, Canon EF 100 mm f/2.8 Macro USM lens,
and related technologies, CAD-­CAM laminate veneers
Yongnuo YN568EX II flash attached to the camera,
are becoming increasingly popular as a conservative
and Yongnuo YN468 II flash in remote mode behind
dental treatment option. As previously explained for
the patient to reduce the background shadow of the
esthetic treatment planning, the digital workflow for
ears and hair.
laminate veneers can be initiated by taking facial

Case Report 4.4 CAD-­CAM Laminate Veneers and Crowns in the Esthetic Area
(Clinical case by Dr Renato Sartori)
A 34-­year-­old male patient presented with chief com-
plaint of poor smile conditions. Treatment and esthetic
planning were conducted using digital workflow.
Among the facial photographs taken were lips at rest
(Figure 4.99) and forced smile (Figure 4.100) to ena-
ble the assessment of bilateral symmetry and lip
movement range.
The face of the patient was positioned with the
interpupillary horizontal line parallel to the ground.
The midline should coincide with the center of the
glabella and nasolabial filter. Another two vertical
lines extending from the internal corner of the eyes to
the upper canine teeth were created (Figure 4.101).
Dental inclinations and buccal corridors were evalu-
ated. Finally, another horizontal line in the region of
the premolar teeth was drawn to assess occlusal
plane inclination.
Once the initial esthetic analysis was completed
and the incisal position proposal was defined, a 2D Figure 4.100 Facial image showing a forced smile.
mock-­up was made using Keynote software. For this

Figure 4.99 Facial image with lips at rest. Figure 4.101 Facial reference lines used for esthetic
planning (see section 4.2.3).

(Continued )
134 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Case Report 4.4 (Continued)

purpose, a line is drawn and the “Edit points” tool is

selected, enabling angle creation and curve smooth-
ing (Figure 4.102). The resulting smile template was
saved to show to the patient, who approved it. The
template was used along with facial photographs and
intraoral scans to orientate the execution of a digital
diagnostic wax pattern.
To enhance the predictability of the treatment
planning, software that enables assessments with
augmented reality (Smilecloud Biometrics) was used.
This software offers an artificial intelligence tool to
conduct the choice of different dental shapes
(Figure 4.103). Minor adjustments or mirroring of con-
tralateral teeth are possible, as well as visualization
of the amount of increase in tooth length by translu-
cency. Since each tooth is presented by a STL file, after
modified smile approval, the selected teeth library
was downloaded.
The resulting facial image was imported into
DentalCAD software to be aligned to the maxillary
intraoral scan. Digital waxing was then completed
based on the predetermined 2D template performed
on Keynote and Smilecloud analysis results. The digi-
tal dental arches were then mounted on the virtual
articulator to check excursive mandibular movements
and remove any interference. The final digital wax
pattern was then superimposed to the facial image
and discussed with the patient. Among the factors to
be analyzed at this step is the length of each tooth
visualized appropriately during the forced smile
(Figure 4.104). Incisal and gingival zenith curves were
Figure 4.102 Tracing and reference lines for virtual wax-­up
also evaluated (Figure 4.105). creation.

Figure 4.103 Selection of the teeth shapes.

 Chapter 4 Digital Workflow in Prosthodontics/Restorative Dentistry 135

Figure 4.104 Final wax-­up creation and projection on the patient’s face.

Figure 4.105 Incisal and gingival zenith curves.

Digital tools aim to make the process virtually

guided during treatment execution, providing more
reliable results. The 3D files are superimposed using
different colors to analyze and measure the regions
that will be restored in cross-­ sectional slices
(Figure 4.106). Excessive volume and spaces between
wax patterns and substrate are measured in order to
calculate the tooth reduction depth executed at prep-
aration to obtain a planned shape and satisfactory
color. For cases with light shades and lack of substrate Figure 4.106 Evaluation of dental areas to be corrected.
volume, preparation reduction depth will likely be The pretreatment situation is presented in brown whereas
minimal [25]. the digital wax patterns are shown in green.

(Continued )
136 Digital Dentistry: A Step-by-Step Guide and Case Atlas
Case Report 4.4 (Continued)
The STL file resulting from digital waxing was then
3D printed, as well as an incisal height guide (Figure 4.107).
A silicone index was obtained by a two-­step impression of
the area between teeth #15 and #25 of the 3D-­printed
model to transfer the mock-­up to the patient’s mouth.
Another face photograph was taken with the dental
arches opened to check whether the dental contour
obtained from the 3D-­printed model coincided with the
facial lines on the 2D mock-­up (Figure 4.108).
The curves passing through the incisal edges, prox-
imal contacts, and zeniths were tested using the
mock-­up. The planning was now complete but it was
necessary to scan the mock-­up in the correct position
to superimpose it with the digital diagnostic wax-­up
file and correct any significant discrepancies. The
mock-­up and the incisal height guide helped orien-
tate the amount of tooth reduction to be done during
preparation (Figure 4.109).
Clinicians should understand the relationship
between substrate shades and the desired shade so
that the necessary reduction depths are achieved dur-
ing preparation in order for restorations to present
Figure 4.107 Printed model and incisal height guide.
sufficient thickness to block the background color.
Lateral incisor and canine teeth have little color satu-
ration, requiring only a reduction of one tone (light
substrate). The minimum thickness required to reduce
a color tone varies between 0.2 and 0.5 mm [25]. The
minimum space for porcelain milling is 0.3 mm, so
another diamond bur (KG Sorensen 4141) was used
here to create buccal grooves at the three cervical, mid-
dle, and incisal inclinations (Figure 4.110). It is sug-
gested to mark the bottom of the grooves with a
graphite pencil before using another diamond bur (KG
Sorensen 3215) with 1 mm diameter to create the
incisal grooves. The next step is to use the same bur to
connect the buccal and incisal grooves, keeping it
transversal for better wear control until the graphite
demarcation disappears. The restorative spaces of
0.3 mm on the buccal and 1.0 mm on the incisal sur-
faces are then present, which are sufficient for a light
substrate.
The incisal preparation should be as straight as
possible, as the milling machine drill may not be able
to create sharp corners on restorations, Porcelain
edges should be milled at least 0.4 mm thick to avoid
small cracks during the process, which corresponds to
less than half of the tip of the diamond bur used here
(KG Sorensen 3215) to prepare the finish line. This bur
was also used to create proximal grooves during the
preparation procedure.
Mock-­ups and 3D-­printed preparation guides can
be used, and it can also be validated through a second
Figure 4.108 A new facial image to check the digital
wax-­up transposition to the mouth.

Figure 4.109 Mock-­up and incisal height guide for checking esthetic conditions of the predicted result.
Figure 4.110 Performing tooth preparation.
silicone index made on the 3D-­printed model per-
formed after digital waxing. The internal space of sili-
cone index should be at least 0.3 mm, as measured
with a periodontal probe. Regions needing further
adjustments can be marked with graphite and then
adjusted. It is important to point out that the prepara-
tion should be homogeneous to prevent dark spots on
the final restoration. This may happen in cases with a
dark or very light substrate when using opaque
Chapter 4 Digital Workflow in Prosthodontics/Restorative Dentistry 137
cement or very thin material, which also impairs the
resistance of the restoration.
Dark substrate should be addressed in a different
way. The process starts with the insertion of a fine
retractor cord (number 000) to gently retract the gin-
giva and make it possible to manipulate subgingival
areas. A subgingival finish line shoulder was created
using a KG Sorensen 3101 diamond bur with 1.2 mm
diameter, offering space for planning an opaque infra-
structure of at least 0.6 mm, if necessary. The remain-
ing space can be occupied by more translucent
cement, avoiding increased saturation of the final res-
toration when compared to adjacent teeth with light
substrates. On the other hand, the palatal surface can
be improved using a little bit more than half of the
diamond bur. By the use of a silicone index, the next
step was to measure the required buccal and incisal
spaces, which were approximately 1.2 and 2.0 mm
respectively. The palatal surface, which requires at
least 0.5 mm, was prepared using a KG Sorensen 3118
diamond bur and then also measured using the sili-
cone index.
(Continued )
138 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Case Report 4.4 (Continued)

A sequence composed of KG Sorensen F diamond adjustments in the digital wax patterns (Figures 4.114
burs, 3M Sof-­ LexTM orange finishing and polishing and 4.115).
disks, and DHPRO CN 1FGPP abrasive rubbers at The file of the prostheses created over the
10 000 RPM and CCE116FP at 8000 RPM with irriga- ­prepared teeth was sent to a DWX-­42W (DGSHAPE)
tion was used to regularize surfaces, round corners, milling machine, using CG Wax 3D resin for manu-
and polish all remaining teeth. Proximal contacts on facturing. In the present case, resin was initially
anterior teeth should be regularized with metallic used due to financial reasons. Later, e-­max (Ivoclar
sandpapers to allow proper scanning. Vivadent) lithium disilicate ceramic was used
Intraoral scanning was conducted after mechanical (injected) because of its opacifying characteristic.
gingival retraction by thicker cords (in single or double The central incisors were confirmed to have 1.5 mm
steps) when the second cord was removed before scan- thickness for restoration, compatible with not using
ning (Figure 4.111). The key point is to classify the gin- infrastructure (Figure 4.116). Dental models were
giva into thin or thick biotypes and to insert the cords then printed using a DLP 3D printer (Hunter) with
carefully to avoid fiber breakage that can lead to pos-
sible gingival recession, exposing the cementation line
(an undesirable situation for dark substrates).
In the double-­cord technique, it is not necessary to
insert the second cord completely; just about half of it
is enough to keep the marginal gingiva away from the
finish line. Therefore, the second cord is removed to
gain access to the free marginal gingiva, retractor
wire, intrasulcular root surface, and finish line, which
should be 0.5 mm away from the marginal gingiva.
The STL file can now be analyzed and, if approved, the
clinician sends it to CAD prosthesis production
(Figure 4.112).
The colorimeter tool present in some scanners can
help clinicians in choosing the color of the crown.
However, this case used photographs with low flash
intensity to capture small nuances of saturation and
translucency (Figure 4.113). The 3D file of prepared
teeth is superimposed to the initial dental arch, mock- Figure 4.112 STL file depicting precisely the preparation
­up, and facial photograph files to check the need for finish lines.

Figure 4.111 Gingival retraction for exposure of Figure 4.113 Low flash intensity image for color
preparation finish line. determination.
 Chapter 4 Digital Workflow in Prosthodontics/Restorative Dentistry 139

Figure 4.114 Prosthetic virtual planning. Frontal views of the patient’s face.

Figure 4.115 Prosthetic virtual planning. Frontal views of the patient’s forced smile.

(Continued )
140 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Case Report 4.4 (Continued)

Figure 4.116 Evaluation of the available thickness of material.

Figure 4.117 Printed model with prepared teeth.


Horus Marfin resin (Figure 4.117). These 3D-­printed
models were used to try in the final ceramic crowns
(Figure 4.118).
Fine details on the ceramic cervical edges were
also checked and adjusted on the working dies
(Figures 4.119 and 4.120). This is particularly advan-
tageous in cases presenting cervical finish lines with
limited thickness.
The prostheses are individually tried in the mouth
to evaluate edge adaptation, by visual inspection and
using a fine dental explorer. Excessive contact points
should be adjusted using a finishing and polishing kit
of rubbers (Ceram Eve Diapol® H8).
The next step is color homogeneity evaluation, in
which Try-­in (Ivoclar Vivadent) was used to check
whether the cement would interfere with the final
Figure 4.118 Ceramic restorations on the model.
Figure 4.119 Ceramic cervical edge checking.
Chapter 4 Digital Workflow in Prosthodontics/Restorative Dentistry 141
color (Figure 4.121). Once approved, Variolink Veneer
Light (Ivoclar Vivadent) was applied for cementation
of canine and lateral incisor teeth because of the lim-
ited ceramic thickness on this region. On the central
incisor teeth, dual PanaviaTM V5 Color Kit Clear and
Kuraray V5 Universal A2 cement were used due to the
dual feature.
As the prostheses were made of lithium disilicate,
they were conditioned by 10% hydrofluoric acid
(Condac 37, FGM) for 30 seconds, washed thoroughly
and then dried by air jet. Monobond N Universal Refill
(Ivoclar Vivadent) was then applied and left to dry
completely. Meanwhile, teeth #15 to #25 were iso-
lated using NicTone medium rubber dam and B4
hygienic clamps (Figure 4.122).
Once the gingival retraction has been done,
cementing two teeth at a time can provide more
cleaning control. TeflonTM tape was placed over the
distal teeth so that the cementing agents did not
interfere with them, affecting the complete settle-
ment of the prostheses. Since the central incisor teeth
did not have enamel, conditioning was performed by
the primer of the Panavia kit. The clinician should rub
it for 20 seconds, remove the excess with a fine suc-
tion tip, and then rub it again for further 20 seconds.
The teeth were dried for 20 seconds with air jet and
the cement, which had already been manipulated, was
inserted into the crowns using a mixing tip of the
Panavia kit. Excess material was removed with a
Marta Kolinsky round brush and light curing (Valo,
Ivoclar Vivadent) was performed for 40 seconds on
each sextant on the vestibular, palatal, and cervical
faces (regions with the most blockage for light entry).
A scalpel handle with a 12 blade can be carefully used
for removing cement deposits in cervical regions.
Considering the presence of enamel, the lateral
incisor and canine teeth required conditioning with
Condac 37 for 30 seconds. Next, they were dried com-
pletely with air jet, and Adper™ Single Bond was
applied for 20 seconds with subsequent drying with
(Continued )
142 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Case Report 4.4 (Continued)

Figure 4.120 A final ceramic crown.

Figure 4.121 Color homogeneity evaluation.

air jet. The same procedures for removing excess

cement, as well as light curing, were used on these
teeth with Variolink Veneer cement (Figure 4.123).
The immediate aspect of the gingival papillae
shows almost complete filling of the proximal spaces
between the prostheses that remained due to the
trauma from gingival retraction during the scanning
and cementation procedures (Figure 4.124). After
2 months, however, the gingival papillae were healed,
showing a satisfactory aspect. Maximum intercuspa-
tion in habitual occlusion and lateral movements
Figure 4.122 Rubber dam application for cementation.
showed that the desired results were achieved.
Moreover, the final esthetic objectives were similar to
those planned, except for the mesioincisal angle of
the central incisor teeth, which the patient asked to
be modified shortly before the day of cementation
(Figure 4.125).
 Chapter 4 Digital Workflow in Prosthodontics/Restorative Dentistry 143

Figure 4.124 Definitive cementation of all crowns and

Figure 4.123 Cementation procedure. laminate veneers.

Figure 4.125 Three-­month follow-­up results of the case.

144 Digital Dentistry: A Step-by-Step Guide and Case Atlas

4.3.4 Inlay and Onlay Restorations Currently, through adhesive cementation, the prepa-
ration for this type of restoration has a simpler and more
With the promise of optimizing professional perfor-
conservative geometry which makes the molding and
mance, there is a technological trend of using digital
execution easier. In addition, such a conservative
workflow in many procedures and in various dental spe-
approach allows for many treatments to be performed
cialties. The digital resources are more intuitive and
in a single session through the chairside system (“one
provide greater standardization of procedures and
sit” concept) or over more appointments using the lab-­
results, with a lower percentage of operational errors
side system [33].
and a high level of satisfaction for users, meeting many
A previous study suggested a concept whose prepara-
needs of the dental world [26].
tion design should be guided by the principles of bioec-
Although there are still a few limitations in the soft-
onomy and bioreplacement, so that the preparation
ware, the effectiveness of the results is already very sim-
must present characteristics to improve the perfor-
ilar to conventional professional work. With the
mance of adhesive systems and restorative materi-
evolution of precision in automated systems, the learn-
als [34]. The preparation does not require isthmus
ing time and chances of errors are smaller when com-
reduction, but the preparation of interproximal geomet-
pared to conventional methodologies [27].
ric boxes with a homogeneous thickness of 1–1.5 mm is
However, there are some disadvantages, such as ini-
still recommended.
tial investment, learning curve, presence of blood and
The “nonretentive simplified preparation concept”
saliva, and difficulty in digitizing areas that have shad-
described by another study aims to make the restoration
ows, such as subgingival margins and complex prepara-
work as a biomechanical unit with the remaining tooth
tions as happens in the design of intracoronary cavities
structure, with the simplest possible geometry, without
for indirect ceramic restorations that traditionally fol-
isthmus preparation, and uniform thickness for restora-
lowed preparation rules with boxes, gutters, and
tion (minimum 1.5–2 mm) [35]. Interproximal boxes
rounded internal angles [28]. A practical example would
should have a “U” shape, corners and edges should be
be to make partial intracoronary restorations, such as
avoided, the transitions of the preparation geometries
inlay, onlay, and overlay.
should be smooth, and an oblique bevel in enamel
Indirect intracoronary partial restorations have been
should also be performed.
used as a conservative alternative to full crowns in the
The integrity of the adhesive interface is critical for
restorative treatment of extended loss of tooth structure,
the longevity of metal-­free restorations, especially in
and the degree of tooth remnant will guide the design of
ceramic restorations [35]. Resin cement polymeriza-
the restoration, covering variables from inlay preparation
tion stresses are influenced by several factors that are
to overlay [29], where the limits of prosthetic preparation
closely linked to the preparation design, such as cavity
should be determined by the preexisting cavity and not by
configuration factor (Factor C), preparation geometry,
the need to obtain retention and stability forms.
cement volume and adhesive substrate, which can
It is known that restorative procedures lead to reduced
result in poor marginal fit restorations that lead to fail-
tooth stability, reduced fracture resistance, and
ure, such as the development of secondary cavi-
increased deflection of weakened cusps. Choosing
ties [36]. Thus, more simplified techniques can be
among the different restorations is a challenge and
considered promising from a clinical and operative
involves biomechanical, anatomical, functional,
point of view.
esthetic, and financial considerations [30].
The following clinical case (total time: 60 minutes)
It has been shown that retention forms, such as
was performed under the concept of service in a single
occlusal boxes, can also have a negative effect on the
appointment, or “one sit,” which is growing as it opti-
fracture resistance of indirect restorative materials [31],
mizes time for the patient and professional. However, it
especially for dental ceramics. Furthermore, these
is very important to clarify that its application is not so
shapes are acquired at the expense of the wear of healthy
simple and requires significant structural and profes-
tooth structure and complex geometries, which can neg-
sional preparation of all professionals involved in the
atively impact the accuracy of digital models and are
procedures of this digital workflow.
technically more difficult to perform [32].
 Chapter 4 Digital Workflow in Prosthodontics/Restorative Dentistry 145

Case Report 4.5 CAD-­CAM Inlay Restoration in a Single Appointment

(Clinical case by Dr Guilherme Saavedra and
Dr Diogo Viegas)
A 40-­year-­old patient presented with a broken filling
on tooth #46 (Figure 4.126). Radiographically, no api-
cal lesion was present (Figure 4.127). Demineralized
tissue was removed and in the same session, an
indirect restoration was performed in feldspathic
ceramic reinforced by leucite IPS Empress® MultiCAD
(Ivoclar Vivadent), using a CS3600 dental intraoral
scanner (Carestream Dental) and CAD-­CAM technol-
ogy (Figures 4.128–4.137).

Figure 4.126 Occlusal view of the tooth remnant. Figure 4.127 Periapical radiograph of tooth 46.

Figure 4.128 After tooth preparation, a digital impression was done using a CS3600 ental scanner (Carestream Dental,
Atlanta/EUA). Bite registration and cavity evaluation were assessed.

(Continued )
146 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Case Report 4.5 (Continued)

Figure 4.129 Bite registration.

Figure 4.130 Cavity evaluation and occlusal contacts.

 Chapter 4 Digital Workflow in Prosthodontics/Restorative Dentistry 147

Figure 4.131 Cross-­sectional view of the preparation.

Figure 4.132 The file obtained in PLY extension was sent to the ChairsideCAD software (Exocad) and so the design of the
inlay restoration was determined.

(Continued )
148 Digital Dentistry: A Step-by-Step Guide and Case Atlas
Case Report 4.5 (Continued)
Figure 4.133 Digital design of the inlay restoration.
Figure 4.134 Inlay restoration was milled using a
feldspathic block of ceramic (Empress® CAD HT A2 I 12;
Ivoclar Digital).
Figure 4.135 After try-­in, prior to cementation, the
preparation was cleaned with Proxyt® prophylactic paste
(Ivoclar Vivadent). The cementation surface of the restoration
was treated with 10% hydrofluoric acid for 60 seconds,
washed, dried and then Monobond® N silane (Ivoclar
Vivadent) was applied. On the preparation, etching with
phosphoric acid was performed, the ExciTE® F adhesive
(Ivoclar Vivadent) was placed and the Variolink® N cement
(Ivoclar Vivadent), light color, was used for cementation.
Excess cement was removed with a cavibrush and dental
floss brush and the cement was then light-­cured, Bluephase®
N (Ivoclar Vivadent), for 60 seconds. Note the final
appearance of the preparation and restoration made of
feldspathic ceramic reinforced by leucite, IPS Empress®CAD
multi (Ivoclar Vivadent), color A2, cemented within a single
appointment.

Figure 4.136 Final appearance of the preparation and
restoration made of feldspathic ceramic reinforced by
leucite, IPS Empress®CAD multi (Ivoclar Vivadent), color
A2, cemented within a single appointment.
4.3.5 Digitally Guided Direct Resin
Composite Restorations
Guided procedures in dentistry have brought a new
dimension to treatments, patients, and professionals.
The possibility of foreseeing clinical situations in the
diagnostic process, as well as transporting these refer-
ences to the surgical act, has allowed for greater preci-
sion and shorter clinical treatment time. Diagnostic
techniques and guides for digitally guided indirect res-
torations have been developed, and the aim of this sec-
tion is to describe a technique developed to plan and
guide direct composite restorations in the construction
of different shade layers and in morphology.
The technique consists of planning the final morphol-
ogy of the restoration, and deconstructing this final
shape in the chromatic layers of tooth reconstruction
with composites (palatal, dentin and enamel). Two of
the greatest difficulties faced by the clinician in per-
forming polychromatic restorations with composite res-
ins are as follows.
●● Determination of the final shade of the restoration: in
polychromatic restorations with composites, there
are difficulties regarding the volume of each layer,
and how to achieve the final shade/chromatic
Chapter 4 Digital Workflow in Prosthodontics/Restorative Dentistry 149
Figure 4.137 Polishing and finishing were done after
contact points were checked using articulating paper. In
order to increase treatment longevity, occlusal contact
should be avoided on the tooth/restoration interface,
which is a critical zone.
three-­dimensionality with the combination of these
different layers. The analysis of each layer according
to the selected resin, as well as the correct thickness of
each one given by the guides, can help in the restora-
tion sculpting process.
●● Morphology: the final anatomy of a direct restoration
must observe functional and esthetic aspects, and
these are often sacrificed by the necessary occlusion
adjustments after sculpture. The possibility of guiding
esthetic texture details, as well as balancing the layers
within a project previously validated in occlusion and
functional movements, minimizes clinical time, with
greater efficiency for the professional and a better
experience for the patient.
4.3.5.1 Step-­by-­Step Guide
1) Intraoral scanning of the patient and complemen-
tary three-­dimensional exams: the digitization of
the arches and the registration of occlusion are sent
to the planning center that will carry out the study
and construction of the guides. As in traditional
operative dentistry, 3D examinations and arch
­positioning will be required depending on the
­complexity of the case; in smaller cases, scans and
150 Digital Dentistry: A Step-by-Step Guide and Case Atlas
photographs of the smile and dental substrate will
be sufficient for the study and development of the
guides. However, cases of vertical dimension
increase and substantial substrate changes, dental
shapes, regressive cases and asymmetry corrections
will need 3D references such as face scanning and
virtual articulator so that the restorative design
conforms to the face of the patient.
2) Strategic restorative design: at this stage, the virtual
models will be studied and changed depending on
the treatment objective. In additive cases, new dental
references will be incorporated in different ways,
from the use of free software and tooth libraries
(Meshmixer), through specific dental design soft-
ware (Exocad, Nemo or Dental System, for example)
or even sending the models for diagnostic and plan-
ning services based on artificial intelligence
(Smilecloud). The changes are validated by the
responsible professional working with the patient,
and from this point on, the design of the guides
will start.
Case Report 4.6 Digitally Guided Direct Resin Composite Restorations
(Clinical technique by Dr José Lincoln de Queirós Jr and
Dr Thiago Ottoboni)
1) Try in the digitally designed 3D-­printed guides in
the mouth and check the adaptation.
2) Isolation of the guides. The guides need to receive
an insulator internally, as they are also printed in
resin. The material indicated for this isolation is
cyanoacrylate, which allows isolation of the con-
tact between the resin and the guide with a very
thin layer, leaving no residues and maintaining the
planned texture design.
3) Application of the resin in its respective guide,
following the programmed sequence. For reasons
of layer strength and guide thickness, the process
is initiated by construction of the dentin layer.
After that, the palatal layer is performed and
finally the enamel layer. If greater chromatic
characterization is required, it is possible to
3) Virtual definition of chromatic layers and virtual
design of guides: at this stage, the final restorative
design will be deconstructed into three parts: palatal,
dentin, and enamel layers. Each layer will be built
following the steps of chromatic sculpture; their
thicknesses will be determined depending on the
resin to be used (decided together with the dentist
responsible for the case), the design of the dentin/
translucency desired for the case and the final 3D
construction of the color of the restored tooth. After
these definitions, each step will generate a specific
guide for the application of the respective resin (pal-
atal, dentin, and enamel).
4) Three-­dimensional printing of guides: once the design
of the guides is completed, they will be sent for print-
ing. The material selected for printing is a transpar-
ent and flexible biocompatible resin, capable of
maintaining the design after insertion of the resins
and placement in the mouth. Its design allows the
removal of cervical excess and validation of the fit-
ting position.
associate dyes between the second and third
stage of construction (palatal and enamel guide
respectively), achieving more complex chromatic
results at the end of the process
4) After construction of the restoration, it is impor-
tant to highlight that the expected texture is very
close to the postfinishing phase of the traditional
sculpture technique. Therefore, further adjust-
ments in morphology and finishing are not neces-
sary, and after the excess is removed with a scalpel
and finishing the interface between the restora-
tion and the tooth, it is possible to start the pol-
ishing sequence of the applied resins (Figures
4.138–4.147). New possibilities of this technique
are already under development, such as its use
with subtractive cases, where there is a need for
wear on the tooth structure/removal of old resto-
rations, in association with digitally planned
wear guides.
 Chapter 4 Digital Workflow in Prosthodontics/Restorative Dentistry 151

Figure 4.138 Initial smile situation. Figure 4.141 Photograph taken after cleaning the tooth
with phosphoric acid for 30 seconds.

Figure 4.142 Palatal guide try-­in after dentin layer

is ready.

Figure 4.139 3D-­printed palatal guide.

Figure 4.140 Details and adaptation assessment before Figure 4.143 Palatal shell created using the achromatic
using the rubber dam. enamel resin to achieve translucency.

(Continued )
152 Digital Dentistry: A Step-by-Step Guide and Case Atlas
Case Report 4.6 (Continued)
Figure 4.144 Buccal layer created using the buccal guide
before removing the excess.
Figure 4.145 Construction of the vestibular layers of the
other teeth.
4.3.6 Digital Complete Dentures
4.3.6.1 Removable Prosthodontic Rehabilitation
Workflow: The BPS-­SEMCD Method Summarized
Removable prosthodontic rehabilitation workflows
have shown little more than superficial change for the
past several years. You are likely already familiar with
the typical process and procedures: preliminary impres-
sions, individually fabricated impression trays, clinical
border molded final impressions, fabrication of occlusal
rims for the clinical procedure of acquiring centric rela-
tion (CR) records, fabrication and evaluation of a wax
“try-­in” denture followed by a number of necessary
changes, then, through conventional processing meth-
odologies, the clinical delivery of the prosthesis.
Today, however, we have many methodological tools
for clinically treating a removable prosthodontic situa-
tion, including the BPS-­SEMCD method, which I will
outline in greater depth later in this chapter to increase
your knowledge and understanding.
Figure 4.146 Final result with the same shape design that
was planned before and with the appropriate thickness for
the dentin, palatal and buccal layers.
Figure 4.147 Final smile result.
Let’s orient ourselves. First, two preliminary impres-
sions are taken in conjunction with a centric tray regis-
tration (preliminary CR position). We use the UTS CAD
to establish the bipupillary line and Camper’s plane of
this initial situation.
The resultant data are digitally encoded, allowing us
to fabricate two customized functional impression trays
(3D bite place), which we will use to take closed-­mouth
functional impressions in accordance with the SEMCD
technique. A gothic arch tracing device (Gnathometer
CAD) is then installed which allows us to record the
patient’s true physiological unstrained CR record.
This information is then digitized, allowing us to pro-
duce a 3D-­printed functional monoblock try-­in, which
we use to evaluate fit, form, function, and esthetic and
phonetic performance.
From here, changes can be made digitally in the soft-
ware before we produce a final definitive milled mono-
lithic removable restoration to be delivered to the
edentulous patient to improve their quality of life.
 Chapter 4 Digital Workflow in Prosthodontics/Restorative Dentistry 153

Case Report 4.7 Digital Complete Dentures

(Clinical technique by Dr Eric Kukucka) have a tremendous negative effect on the outcome if
not properly captured and registered. The effects of
The Existing Situation inaccurate vertical dimension include lack of freeway
space, inhibiting the patient from producing adequate
It is paramount to evaluate the existing situation crit-
phonetics, inability to properly function in centric
ically as it will provide vital information. We must
movements, server chronic pain in the TMJ, dispropor-
evaluate the patient’s overall vertical dimension with
tionate facial features, lip and cheek biting, to name a
the existing dentures in place (Figure 4.148) as well
few. The vertical dimension is ergonomically designed
as the edentulous situation (Figure 4.149). We must
based on golden proportion principles to fit the anat-
also ask the patient about their wants and needs for
omy of the human face. In order to measure the verti-
this prosthetic rehabilitation.
cal dimension, professionals have utilized strings,
We must always consider various factors of the exist-
Boley gauges, and calipers. The VDO gauge provides
ing situation including the current fit, form, function,
one of the simplest forms of accurately measuring
esthetics, phonetics, retention stability, and most impor-
VDO. When used in tandem with professional knowl-
tantly chief complaints. We must also critically evaluate
edge, understanding, and experience, this tool can
the existing prosthesis including the current CR
provide incredible value for the clinician and the
(Figure 4.150a) and the amount of wear on the occlusal
patient (Figure 4.151a).
surfaces of the prosthetic teeth (Figure 4.150b,c).
Measure the distance between the interpupillary
The size and shape of the teeth, the position of the
point and the commissure of the lip using the two
teeth, and how the denture measures to the anatomi-
straight, extended markers. Tighten the bolt to lock
cal and physiological structures it lies within are all
that measurement into place (Figure 4.151b). Using the
important (Figure 4.150d). It is evident in this existing
other side of the gauge, place the rounded edge (curved
situation that we must make prudent changes to the
chin marker) just under the nose and under the chin. As
vertical dimension, the CR, and the size and shape of
you can see in Figure 4.151c, the patient’s chin is defi-
the teeth.
cient from the curved part of the gauge by 6 mm.
Having the patient open until the chin touches
Vertical Dimension
demonstrates a harmonious new VD position
Properly restoring a patient’s vertical dimension of (Figure 4.151d). If the curved chin marker is perfectly
occlusion (VDO) can be central to the overall outcome in contact with the chin then the patient has a pro-
of removable prosthetic restorations but it can also portionate and adequate VDO. If the chin marker is

(a) (a)

(b) (c) (b) (c)

Figure 4.148 Evaluation of the edentulous patient. Figure 4.149 Facial evaluation of the edentulous patient.

(Continued )
154 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Case Report 4.7 (Continued)

(a) (b) (c)

(d)

Figure 4.150 Evaluation of the existing prostheses.

(a) (b)

(c) (d)

Figure 4.151 Vertical dimension assessment.

 Chapter 4 Digital Workflow in Prosthodontics/Restorative Dentistry 155

(a) (b) (c)

Figure 4.152 Digital planning of the smile.

not in contact with the chin, then the patient is over- have an clear representation of your vision and pro-
closed. If the chin marker is short of the chin, the posal for their new smile (Figure 4.152c).
patient is too open. Preliminary impressions are the foundation of suc-
cess in complete removable prosthodontics.
Digital Planning of the New Proposed Smile Preliminary impressions should be overextended but
only to the degree to assure that necessary landmarks
This remarkable technology allows those of us in
are ascertained. The dual-­phase alginate Accudent XD
removable prosthodontics to truly “begin with the
process encompasses both a heavy body alginate (tray)
end in mind”! In conventional removable prosthodon-
material for the impression base and a light body algi-
tics, patients were only able to see how we could
nate (syringe) material for high accuracy detail of soft
“improve” their smiles and overall facial appearance
tissues, peripheral borders, and underlying anatomical
at the wax try-­in stage and in some instances not
structures. The tray material is placed directly into the
until the removable prosthetics were delivered
tray as the impression base and the syringe material is
(immediate denture situation).
placed into the Accudent Monoject to capture accurate
Utilizing this technology, we can demonstrate to
detail of the surrounding hard and soft tissues.
the patient a proposed size, shape, and shade for the
The maxillary preliminary impression includes the
prosthesis. This is a very interactive stage of prepros-
buccal vestibule, buccal frenum attachments, tuber-
thetic treatment planning and consultation prior to
osities, hamular notches, throat forms, and adequate
commencement of treatment to understand the
representations of the palate (Figure 4.153a).
patient’s wants and needs. Often, utilizing a mono-
The mandibular preliminary impressions are taken
block try-­in for digital denture functional try-­in, which
utilizing a frame cutback tray (Morita) in conjunction
is one uniform color, does not give the patient an
with the Abe SEMCD technique in which the lower
ideal representation of the shade and texture of their
impression is taken in the closed mouth state.
teeth. Smile design allows you to facilitate this dem-
Important landmarks include the retromolar pads in
onstration to your patients with ease and simplicity.
their entirety, retromylohyoid fossae, mylohyoid
The process begins with uploading a frontal high
ridges, buccal and labial frenums, and full depth of the
smile photograph and setting points and rotations
lingual fossae (Figure 4.153b,c).
(occlusal plane references, interpupillary lines, and
cutting out the lip outline) to indicate the new pro-
posed overlay smile (Figure 4.152a). Centric Tray Registration
This software is also equipped with a significant
The centric tray is a CR recording device used in
amount of preloaded tooth libraries and various
establishing a preliminary intervestibular relation
molds, textures, and shades that can be modified and
(VDO) of the individual occlusal situation in edentu-
scaled with simplicity to fit the patient’s natural phys-
lous patients (Figure 4.153d). The tray has a unique
iological forms (Figure 4.152b).
design in the center portion for the patient’s tongue
Once you have finalized the scaling of the silhou-
to be retruded which facilitates guiding the patient
ette, you can propose this to the patient so they will
into a physiological unstrained position to record this

(Continued )
156 Digital Dentistry: A Step-by-Step Guide and Case Atlas
Case Report 4.7 (Continued)
(a) (b)
(d) (e)
Figure 4.153 (a) Maxillary preliminary impression. (b) Mandibular preliminary impression. (c) Patient with FCB closed
mouth state. (d) Centric tray. (e) Centric tray registration new VDO. (f) Centric tray registration.
preliminary VDO (Figure 4.153e). This device will be
utilized to mount the preliminary casts to fabricate
centric bearing devices (Gnathometer CAD) (see
Figure 4.156). The centric tray registration method is
preferred utilizing polyvinyl siloxane (PVS) impres-
sion putty (Virtual XD Regular Set) (Figure 4.153f).
UTS CAD Registration
UTS CAD (Ivoclar Vivadent) is a registration device for
measuring the angle of the occlusal plane in relation
to the bipupillary line (BP) (Figure 4.154a,b) and
Camper’s plane (CE) (Figure 4.154c). The measured
angle or deviation of the occlusal plane from CE/BP
can be transferred to the dental design software
(3Shape) (see Figure 4.156). This assists in reproduc-
ing the correct position of the occlusal plane in the
(c)
(f)
virtual design to facilitate the fabrication of a 3D bite
plate (see Figure 4.157).
Papillameter Reading
The papillameter (Candulor) is the ideal instrument
for measuring the length of the upper lip during a
high smile position and at rest. This information is
important and should be taken into consideration by
the dental technician. The lip closure line captured by
the papillameter is utilized to correlate the position
of the lip closure line in the software for proper posi-
tioning of the gnathometer within the 3D bite plate
(see Figures 4.156 and 4.157). To obtain the most
accurate measurements, the patient should be seated
in an upright position in a relaxed state. Insert the
 Chapter 4 Digital Workflow in Prosthodontics/Restorative Dentistry 157

(a) (b) (c)

Figure 4.154 (a) UTS CAD. (b) UTS CAD BP measurement. (c) CAD CE measurement.

(a) (b)

Figure 4.155 (a) Papillameter. (b) Papillameter measurement.

(a) (b)

Figure 4.156 (a) Digitally mounted casts. (b) 3D bite plate design.

papillameter carefully in a vertical direction by Digitizing the Preliminary Records

deflecting the lips and resting the device on the inci-
The maxillary and mandibular preliminary impressions
sive papilla. Allow the patient to relax their lips
and the centric tray can be scanned using either a
(orbicularis oris) (Figure 4.155). Repeat the process
3Shape desktop scanner or TRIOS intraoral scanner.
two times to verify accuracy and repeatability of the
The dental technician will create digital preliminary
measurements achieved.
casts and input the information provided by the

(Continued )
158 Digital Dentistry: A Step-by-Step Guide and Case Atlas
Case Report 4.7 (Continued)
Figure 4.157 3D bite plate.
clinician (Figure 4.156a). The technician will then digi-
tally design a 3D bite plate (a customized set of impres-
sion trays that incorporate a needle-­ point tracing
device for the intramural registration of CR)
(Figure 4.156b).
Flow Chart 1 Preliminary Records
Capturing Accurate Records
The ability to establish an accurate, verifiable, and
reproducible VDO and CR is a clinical skill in remova-
ble prosthodontics. The results will render an occlusion
that is functional, harmonious, and, most importantly,
comfortable for the patient. Achieving a repeatable CR
is paramount to the success of removable prosthodon-
tics. This process is not widely discussed or utilized due
to the perception that it is challenging and difficult but
once understood in its simplest form, it can be easily
adopted in clinical practice. Moreover, with advance-
ments in digital technology the fabrication of these
devices has superseded previous techniques.
3D Bite Plate (Figure 4.157)
This is a customized set of impression trays that
incorporate a digitally fabricated occlusal rim with
impression shims. These individual trays can incorpo-
rate an impression gap relief to create perfect uni-
formity of the final impressions. The impression shims
can be removed to register centric creation with a
needle-­point tracing device (Gnathometer CAD).
These trays can be manufactured by way of 3D print-
ing or subtractive milling methods.
Functional Final Impressions
When capturing final impressions, we must capture
the patient’s oral situation in the closed mouth state
and not under what is known as “pressure-­loaded” dis-
placement. Creating final definitive impressions in
the closed mouth state allows for an increased tissue-­
bearing surface of the prosthesis under function in
the oral cavity and also produces harmonious denture
base borders that follow the patient’s functional
movements. It is important to utilize a variety of PVS
materials in order to capture these results. The objec-
tive is to maximize the supporting area of the denture
base while taking into account the movements of the
muscles. A suction effect must be established between
the mucous membrane and denture base. The initial
impression is conducted utilizing heavy-­body PVS to
capture the physiological borders of the patient’s
movements and light-­body PVS to capture high detail
of soft tissues and anatomical structures. This is con-
ducted by asking patient to reproduce various func-
tional movements (Figure 4.158a,b).
Once the border molding with heavy-­body PVS is
completed, a light-­body PVS impression is conducted
in both the maxillary and mandibular arches
(Figure 4.158c,d). Figure 4.158e demonstrates the
finalized closed mouth functional impressions with
the impression shims in place.
Registration of Occlusal Plane
The UTS CAD (see Figure 4.154) is positioned utilizing
a specialized bite fork. The occlusal plane is recorded
in relation to Camper’s plane (Figure 4.159a) and the
bipupillary line (Figure 4.159b). The measured angle
or deviation of the occlusal plane from CE/BP can
be transferred to the dental design software for the
arrangement of prosthetic denture teeth.
Incorporating the Gnathometer CAD
The impression shims are removed from the 3D bite
plate and the Gnathometer CAD is positioned. This
has an incorporated stylus registration plate
(Figure 4.160a,b) which is positioned in the maxillary
functional 3D bite plate tray. The striking plate
(Figure 4.160b–d) is positioned in the mandibular
function 3D bite plate tray. These will be used to cap-
turing the gothic arch tracing.
 Chapter 4 Digital Workflow in Prosthodontics/Restorative Dentistry 159

(a) (b) (c)

(d) (e)

Figure 4.158 (a) Closed mouth impression movement 1. (b) Closed mouth impression movement 2. (c) Maxillary final
impression. (d) Mandibular final impression. (e) 3D bite plate.

(a) (b)

Figure 4.159 (a) UTS CAD CE measurement. (b) UTS CAD BP measurement.

Flow Chart 2 Capturing the Functional and repeatable, unstrained position of the mandible in har-
Physiological Situation monious VDO. The ability to establish this occlusal
registration is invaluable in the rehabilitation of com-
Registration of Centric Relation plete dentures. It is paramount to utilize an indelible
The registration of CR is conducted with a needle-­ marker or wax pencil to mark the striking plate.
point tracing device (Gnathometer CAD). This assists in With the 3D bite plates and Gnathometer CAD
capturing the patient’s true physiological verifiable, devices securely in place in the oral cavity, verify the

(Continued )
160 Digital Dentistry: A Step-by-Step Guide and Case Atlas
Case Report 4.7 (Continued)
(a)
(c)
Figure 4.160 (a) Gnathometer CAD stylus. (b) Gnathometer CAD striking plate. (c) Stylus assembled to
3D bite plate. (d) Striking plate assembled to 3D bite plate.
VDO utilizing the same methodology explained for
the VDO gauge (Figure 4.161a,b). Once the VDO is
confirmed, the patient is instructed to advance the
mandible into a protrusive and retrusive position
(Figure 4.161c). These paths are repeated several
times to ensure the accurate capturing of the stylus
on the striking plate. The patient then produces the
most lateral movements (bilaterally) which are also
captured on the striking plate (Figure 4.161d). The
results (Figure 4.161e) represent an ideal gothic arch
tracing and the tip of this arrow delineates the most
repeatable centric position.
The centric pin receiver (clear plate) is placed on
the flat striking plate with the beveled edge and
countersink hole facing up. The center point of the
arrow is aligned with the hole in the centric pin
receiver and locked into position using a screw
(b)
(d)
(Figure 4.161f). The lower 3D bite plate is then placed
back in the oral cavity to register CR by guiding the
patient into a position where the stylus pin will
engage into the centric pin receiving hole
(Figure 4.161g). This position is maintained and bite
registration material is injected to capture this regis-
tration. Midline, ala lines, and high smile line are also
indicated in this step (Figure 4.161h). An optional but
recommended step is to conduct a monophase post-
dam in the maxillary impression surface. This assists
in avoiding any slight change that may have occurred
when capturing the CR record resulting in a slight gap
in the posterior maxillary impression (Figure 4.161i).
Tooth Selection
The facial meter (Ivoclar Vivadent) (Figure 4.162)
enables clinicians to accurately select denture teeth
by measuring the patient’s interalar width (IAW) and
 Chapter 4 Digital Workflow in Prosthodontics/Restorative Dentistry 161

(a) (b) (c) (d)

(e) (f) (g) (h) (i)

Figure 4.161 (a) Gnathometer fixed intraoral. (b) Verification of VDO. (c) Protrusive/retrusive movements. (d) Lateral
movements. (e) Gothic arch on striking plate. (f) Centric pin receiver. (g) Centric pin locked in position. (h) Final gnathometer
registration. (i) Monophase post dam.

(a)

(b)

Figure 4.162 Form selector.

correlating to the appropriate-­sized denture tooth
molds. This clinical tool assists in determining
whether the patient’s facial proportions would be
best suited to a small, medium, or large mold.
The SR Phonares II tooth mold selection (Ivoclar
Vivadent) (Figure 4.163a,b) is differentiated by soft
and bold characteristics as well as youthful, universal,
and mature. Patients expect more than just having
their basic oral functions (e.g., chewing efficiency)
restored. Individualized esthetics plays an increas-
ingly important role. A range of tooth molds designed
to match the age and characteristics of the individual
Figure 4.163 (a) SR Phonares II age characteristics. (b) SR
Phonares II living mold guide.
patient is paramount for the success of removable
prosthetics.
●● Youthful mold characteristics – naturally shaped
incisal edge, pronounced facial curvature.
●● Universal mold characteristics – slightly abraded
incisal edge, reduced facial curvature.
●● Mature mold characteristics – heavily abraded
incisal edge, flat facial curvature.
We must first determine the IAW of the nose using
the facial meter. Select an appropriately sized tooth

(Continued )
162 Digital Dentistry: A Step-by-Step Guide and Case Atlas
Case Report 4.7 (Continued)
mold (small, medium, large). The anterior teeth should
be selected directly on the patient according to their
anatomical and facial characteristics. A papillameter
reading is also recommended during this step (see
Figure 4.155a) to assist the dental technician in deter-
mining the ideal lip closure position as well as the
positioning of the anterior teeth during the tooth
arrangement step.
Flow Chart 3 Centric Relation and Tooth Selection
Digitization of Clinical Records
The patient’s functional impressions and CR records
are scanned with either a desktop scanner or intraoral
scanner to capture the intraoral situation (Figure 4.164a)
in order to create a functional try-­in. Digital technol-
ogy significantly reduces manual labor and improves
the efficiency of the workflow and, more importantly,
the overall accuracy and precision by controlling
error-­prone processes and procedures.
Digital Tooth Arrangement
We must understand that the importance of arrange-
ment of the prosthetic teeth must still follow the
esthetic, functional, physiological, and anatomical
confines of the edentulous patient. Having the ability
to morph and scale teeth to the exact physiological
position required for optimizing fit, form, function,
esthetics, retention, stability, and phonetics is para-
mount in removable prosthodontics rehabilitation.
The ability to visualize the center of the mandibular
ridge to position posterior teeth for optimal stability
is paramount. Moreover, creating a seamless anatomi-
cal bilateral balanced group function in both
semianatomic and lingualized occlusal schemes can
(a) (b)
Figure 4.164 (a) Virtual models. (b) Virtual tooth arrangement. (c) Virtual finalized arrangement.
be achieved (Figure 4.164b). The digitally designed
prosthesis is encompassed with uniform thickness of
the denture base to provide the patient with opti-
mized comfort and strength as well as esthetic gingi-
val margins (Figure 4.164c). The current tooth library
arrangement consists of Ivotion S71 Lingualized
(Ivoclar Vivadent) which contains a full arch anatomi-
cal arrangement. The full arch Ivotion tooth libraries
are based on the proven principles of removable pros-
thetics. This enables the dentures to be individually
adapted to the patient’s requirements.
Functional Try-­In
The purpose of a functional try-­in is to evaluate the
various important factors that influence the success
of a complete removable prosthesis for an edentulous
patient.
The functional try-­in (Figure 4.165a,b) is a prototype
of the new proposed digital removable prosthesis that
can be 3D printed or subtractive milled from
PMMA. The goal of the functional try-­in is to evaluate
fit, form, function, dimensions, esthetics, phonetics, and
vertical dimension (Figure 4.166a–d). The added value
of the functional monoblock try-­in is that the clinician
does not have to be concerned about any premature
tooth movement or disruption caused by the patient
conducting centric and eccentric movements that are
typically carried out in a conventional wax try-­in.
These monolithic monoblocks provide an accurate
representation of the final definitive prosthesis as
well. The clinician has the opportunity to evaluate all
the important factors listed above with confidence.
There are many instances where clinicians have uti-
lized this indication as a “test drive” and given the
(c)

(a)
Figure 4.165 (a) Monoblock try-­in side. (b) Monoblock try-­in straight.
(a)
(c)
Figure 4.166 (a) Smile side profile full. (b) Smile profile front. (c) Smile side profile close-­up. (d) Smile front profile close-­up.
patient the opportunity to take the monoblock to try
at home. The patient can present back to the clinician
and discuss any complications as well as positive
feedback prior to finalization. Moreover, if the clini-
cian needs to make modifications to the monoblock
try-­in, this can be done with simplicity with a wash
impression and a new CR record to be communicated
back to the digital dental technician to adapt these
modifications (Figure 4.167). With digital dentures,
communicating changes is no longer a challenge or a
cumbersome task as moving a midline, occlusal
planes, and increasing or decreasing incisal lengths
can be done with simplicity and precision.
Chapter 4 Digital Workflow in Prosthodontics/Restorative Dentistry 163
(b)
(b)
(d)
The changes to be made in this instance are to
slightly broaden the buccal corridor, increase the
incisal length of the laterals and centrals, and increase
the vertical dimension by 1 mm.
Flow Chart 4 Creation of the Digital
Removable Prosthesis
Finalization of the Design
Following the functional try-­in appointment, the nec-
essary adjustments can be conducted via the software
(Figure 4.168). At this time, the detail of esthetics, fit,
form, and function must be precisely confirmed as
(Continued )
164 Digital Dentistry: A Step-by-Step Guide and Case Atlas
Case Report 4.7 (Continued)
Figure 4.167 Monoblock try-­in with modifications.
well as implementation of the Ivotion Shell Geometry.
This particular case will be finalized utilizing the
monolithic PMMA Ivotion disk (Figure 4.169a).
Ivotion Disk
The internal area of the disk has what is known as the
Shell Geometry (Figure 4.169b). Geometry is a data-­
based, 3D tooth and dental arch geometry derived
from a variety of real patient situations that have
been analyzed to create this geometry. It defines the
(a)
(c) (d)
Figure 4.169 (a) Ivotion disk. (b) Shell Geometry. (c) True monolithic manufacturing. (d) Ivotion disk upper. (e) Ivotion
disk lower.
Figure 4.168 Software finalization.
transition area between the tooth and the denture
base material. This geometry is incorporated in design
software with the corresponding full arch tooth librar-
ies. Thanks to the Ivotion disk design and sophisti-
cated milling strategies, a single denture can produced
from one disk. The material is proven high-­quality
PMMA tooth and denture base materials with a truly
monolithic innovative manufacturing process for a
direct chemical bond. It is a stress-­free monolith disk
with a homogeneous high strength throughout
(Figure 4.169c). Here we can see the results of the
prosthesis directly after milling (Figure 4.169d,e).
(b)
(e)

Finalization of the Digital Dentures
Our goal is always to create a natural appearance to
any dental prosthesis. When it comes to complete
digital removable dentures, individualization and sur-
face textures play a paramount role in creating
true-­to-­nature esthetics. This can be achieved using
various carbide burrs and diamond cutting disks
(Figure 4.170a). In order to individualize and create
separations between the monolithic tooth arch struc-
ture, use of a diamond cutting disk is warranted
(Figure 4.170b). Defining the interproximal embra-
sures and contact points will create a truly individual-
ized tooth surface and structure that is both esthetic
and functional (Figure 4.170c–e), defining the labial
developmental depression, marginal grooves, lobes,
and surface textures. The dentures are then polished
for delivery (Figure 4.171a,b).
(a) (b)
(d)
Figure 4.170 (a) Carbide burs and diamond disk. (b) Diamond disk individualizing. (c) Interrproximal embrasure.
(d) Labial groves. (e) Horizontal groves.
(a)
Figure 4.171 (a,b) Final polished dentures.
Chapter 4 Digital Workflow in Prosthodontics/Restorative Dentistry 165
Flow Chart 5 Finalization of the Prosthesis
Insertion
The delivery of a new prosthesis requires significant
attention to detail. We must always insure that the
patient is comfortable and confident with their new
prosthesis. A good clinician and technician relation-
ship assists in the success of this appointment. We
must allocate the necessary amount of time to verify
patient comfort and that there are no overextensions
of the borders as well as areas of the intaglio surface
that could be harmful to the underlying structures.
Once we have confirmed the patient’s comfort, we
must evaluate all centric and eccentric occlusal con-
tacts with articulating paper to confirm that we have
achieved bilateral balanced group function. We must
also dedicate time to educating the patient on various
(c)
(e)
(b)
(Continued )
166 Digital Dentistry: A Step-by-Step Guide and Case Atlas
Case Report 4.7 (Continued)
(a) (b)
Figure 4.172 (a) Side smile close-­up. (b) Front smile close-­up. (c) Candid smile.
aspects of becoming accustomed to their new
­prosthesis, including functional habits and the initial
recommended soft food diets. Moreover, we must be
transparent about the fact that they may encounter
areas of irritation throughout the oral cavity. We
must always provide positive reinforcement and
­reassure them that we will guide them along the way
so that they can achieve an improved quality of life
(Figure 4.172a–c).
An overview of the patient’s edentulous situation is
shown in Figure 4.173a. The existing situation is
depicted in Figure 4.173b and the new prosthetic sit-
uation in Figure 4.173c. Oftentimes we forget the
importance of a smile and how it can make others
feel. The impact that a new set of complete removable
prosthetics can have on a patient’s life is remarkable.
This patient wore the same dentures for 42 years! We
should always strive to achieve excellence in this type
(a) (b)
Figure 4.173 (a) Edentulous situation. (b) Existing situation. (c) New prosthesis.
(c)
of rehabilitation to help patients who suffer from
edentulism through clinical and technical knowledge,
understanding communication, and sophisticated
technology.
Flow Chart 6 Delivering The Final Prosthesis
Reference Denture Technique
This technique in its simplest form utilizes the
patient’s existing prosthesis for custom trays and CR
recording devices (Figure 4.174a). This technique
allows the clinician to make improvements to fit,
form, function, retention, stability, esthetics, and pho-
netics by using the existing dentures as a guideline.
There is a wealth of information that lies within the
patient’s existing dentures, occlusal scheme, tooth
position, vertical dimensions, tooth morphology, labial
support, border extensions, CR, centric occlusion, wear
(c)

(a) (b)
(d) (e)
Figure 4.174 (a) Reference denture. (b) Existing denture. (c) 360 Reference denture. (d) 360 Reference denture with
impressions. (e) Functional monoblock try-­in. (f) Defintive prosthesis.
patterns, oral hygiene, shade, etc. Making closed
mouth functional final impressions within the pros-
thesis significantly improves retention and stability
and reduces postoperative adjustments. It is para-
mount that the CR is captured in the patient’s most
unstrained repeatable mandible position of.
Measuring appropriate VDO and CR is paramount.
The 360 reference denture technique follows the
same methodology and principles as a reference den-
ture but instead of taking the impressions directly in
the patient’s existing denture, the dentures
(Figure 4.174b) can be scanned utilizing intraoral or
lab scanners to create an exact duplicate of the exist-
ing situation that is 3D printed or subtractive milled
(Figure 4.174c). This method has many advantages: tray
adhesive can be applied without the concern of having
to remove it from the existing prosthesis. Any areas of
overextension/underextension or pressure can be
reduced/alleviated. If an impression gap or additional
relief in areas of hyperplastic or mobile tissues are
required, these can be incorporated. Modifications to
the posterior teeth can be conducted whether you
require the placement of additional material on the
occlusal surfaces or a reduction in occlusal surfaces.
The goal of this process is the same as the reference
denture technique (using a duplicate of the patient’s
existing dentures to take closed mouth functional final
impressions and CR record) (Figure 4.174d). Once this
Chapter 4 Digital Workflow in Prosthodontics/Restorative Dentistry 167
(c)
(f)
information is captured, a functional try-­in is created to
evaluate the intraoral situation of the new proposed
situation (Figure 4.174e). The necessary changes are
communicated and a final denture is produced.
There are many advantages to this methodology of
reference denture rehabilitation. It is often difficult to
recreate a patient’s existing situation which they have
become accustomed to physiologically, neuromuscu-
larly, and esthetically. Many clinicians have shied away
from removable rehabilitations as a whole due to the
clinical and technical complexity involved. Although
this indication is not suited for all patients, it can be
applied when the context permits.
Flow Chart 7 Reference Denture Technique
Because a digital denture’s exact specifications live
permanently in a single STL file, the digital denture
process has useful applications long after a patient
has received his or her prosthesis. I believe this to be
the system’s single greatest advantage. For example,
an exact digital record of a patient’s device can be
easily shared with a dental professional anywhere in
the world at a moment’s notice. Similarly if a patient
happens to lose his or her denture. Even better, when
the time comes for a new denture (in 7–10 years), fab-
ricating another device does not require “starting
over.” A single new imprint of a patient’s existing
(Continued )
168 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Case Report 4.7 (Continued)

denture can be merged into the existing digital record
to fabricate a new copy of the original prosthetic that
is suitably modified to accommodate any physical
changes the patient has undergone.
In all aspects of dentistry, a virtually limitless num-
ber of roads lead to a finite set of final destinations. In
many instances, we all end up at the same place, but it’s
how we get there that really matters. Only a humble
oral health professional can appropriately understand
that the success of our cases is often not determined by
our professional opinion alone. Rather, it has a lot to do
with the individual patients who put their trust in us as
dental professionals, expecting that we will provide a
service that will improve their quality of life.
Digital denture technology has created an opportu-
nity for clinicians to be more effective, efficient, and
predictable with the way in which we can treat
patients with removable prosthetics. Following my
example, you should be more confident about provid-
ing removal prosthodontics therapy for your patients.
Technology and material sciences will only improve
as time passes.

4.3.7 Complete-­Arch CAFIPs (Table 4.2). While supported by established

Implant-­Supported Prostheses
The fabrication of complete-­arch fixed implant-­
supported prostheses (CAFIP) depends on precise treat-
ment steps involving the rehabilitation planning,
implant installation, clinical and laboratory prosthetic
procedures. After the dental implants are osseointe-
grated, the clinical steps to obtain a CAFIP require the
registration of soft and hard tissue contours, along with
the implant tridimensional positions.
Prosthetic try-­in procedures can define the ideal
esthetic contours, while respecting functionality and
technical parameters such as occlusion, vertical dimen-
sion, and comfort. To achieve fully functional and
esthetic results, the information obtained in the initial
simulations must be transported to the final prosthesis.
4.3.7.1 Utilizing CAD-­CAM for Full-­Arch Prosthetics
The development of CAD-­CAM systems, dedicated mate-
rials, equipment, and software has extended the pros-
thetic outcome possibilities and workflow options for
prosthodontics concepts [37], computerized systems are
proven to enhance precision, decrease work and labora-
tory time, optimize final prosthetic outcome and esthetic
predictability, and be less dependent on human resources.
The clinician must be aware of all the possibilities of
digital dentistry available to produce CAFIPs, which can
include intraoral scanning, producing digital models,
using specially computerized components, operating
machinery and software, and selecting the framework
material, among others. Most workflows for CAFIPs will
be composed of a mix of analogue and digital procedures,
specially focused on the design and fabrication of the
structures. The more digitalized the practice and the lab-
oratory, the greater the use of digital steps and shortcuts.
The main steps involved in the fabrication of CAFIPs will
be presented as a suggestion for early adoption. While
migrating from analogue to digital workflows, the clinician
can choose how to adapt the procedures to the practice.
The following case report illustrates the major steps
for the fabrication of complete-­arch implant-­supported
fixed prostheses (Figure 4.175).

Table 4.2 Clinical and laboratory main steps for planning CAFIPs.

Clinical step Laboratory step Objective

1 Photographic records,
intraoral assessment
2 Impression of the
implants and soft tissues
3 Refinement of the wax
rim
4 In-­mouth teeth try-­in
5 Install final abutments
Smile outcome simulation
through software
Fabrication of the final work
model, wax rim, and baseplate
Teeth arrangement into the
wax rim
Silicon wall creation onto cast
model
Communicate with the patient with a
realistic outcome prediction
Obtain a precise master cast
Teeth try-­in, that should follow the
smile design created by software
Verify whether the implant positions
are ideal and estimate the use of
angled abutments
A new impression may be required
after placing new abutments on mouth
 Chapter 4 Digital Workflow in Prosthodontics/Restorative Dentistry 169

Figure 4.175 A full-­arch implant-­supported fixed prosthesis, designed using the 3Shape system, and milled in zirconia with a
Ceramill Motion 2 (Amann Girrbach).

Case Report 4.8 Complete-­Arch Implant-­Supported Fixed Prostheses

(Clinical technique by Dr Roberto A. Markarian) ●● correct nonparallel implants with angled abut-
ments, optimizing screw orifice positioning
1) Prosthetic planning and impressions
●● analyze the bone quality support and osseointegra-
2) Scanning and digitalization
tion of the previous implants
3) Prosthetic CAD design
●● retrieve implant model/brand information
4) CAM software and structure fabrication
●● verify whether the number and position of the
5) Structural material selection
implants are adequate
6) Clinical try-­in of the structure
●● check for signs and symptoms of parafunction
7) Esthetic layering
and bruxism
8) Clinical try-­in of the CAFIP
●● estimate the occlusion and opposing arch suitability.
9) Final restoration delivery
In some cases, the patient already possesses a pre-
vious prosthesis, which can provide some of the infor-
Prosthetic Planning and Impressions
mation required for prosthetic planning. However, in
The planning of the final prosthetic outcome should most cases a more detailed study is necessary to opti-
begin before surgery by means of a prosthetically mize the prosthetic outcome. This study will be used
driven planning protocol. The location of implants in further clinical steps to construct the final CAFIP.
and screw orifices should be optimized for the CAFIP, After the second stage surgery, a master cast should
improving esthetics, structural support, and frame- be fabricated after the implant impressions. A wax rim
work resistance. However, in some cases the prostho- and base plate should be carefully tried in the mouth
dontist receives the implants already placed with and adjusted. Afterwards, teeth are positioned to try to
poor planning, in nonoptimal positions. In these cases, match the initial smile computerized simulation to
planning should be carried out to: achieve optimum esthetics and functionality.
(Continued )
170 Digital Dentistry: A Step-by-Step Guide and Case Atlas
Case Report 4.8 (Continued)
The objective of the planning phase is to obtain a
wax-­up containing the maxillofacial relationships,
vertical dimension, occlusion, overall contour, and
teeth esthetics on a master cast and articulated
opposing arch.
Scanning and Digitalization
At this point all the collected information must be
digitalized. The final work model, the opposing arch
with the correct occlusion and articulation, can be
scanned with a desktop laboratory scanner.
One useful software tool available in dental scan-
ners is a dual scan protocol in which the gypsum cast
containing the implants can be superimposed with
the prosthetic wax-­ up reference, facilitating the
design of the final structure for CAFIPs. The resulting
scan file for both jaws and references merged can be
imported into the CAD software for the design of the
prosthetic structure.
Prosthetic CAD Design
In the CAD software, the scanned data gathered by the
dental technician and CAD software tools such as the
virtual articulator establish the correct design parame-
ters for final production of the structure. The smile
­simulations created in the planning phase can be imple-
mented to improve the predictability of the results.
While in CAD, the type of structure can be selected
from the possible prosthetic designs for full arches:
bars, secondary superstructures, anatomic shrunk,
screwed, cemented, complete anatomy or reduced
with cutbacks. The final contours of the structure
designed will depend on the prosthetic material
blend: metal-­acrylic, metal-­ceramic, metal-­composite,
zirconia-­ceramic. After finishing the CAD design, it is
advisable for the laboratory to submit the project to
the prosthodontist, to allow improvements before
fabrication.
Dental Implant Libraries
Dental CAD-­CAM systems allow the framework seat-
ing interface to be designed directly onto the dental
abutment or by cementing on prefabricated titanium-­
based abutments, which is generally recommended by
dental implant manufacturers. The interposition of
additional cemented components into the structures
can be indicated when the framework material is not
titanium, although this recommendation has no con-
sensus in literature. In stress-­producing situations
such as a long cantilever span, the use of such addi-
tional titanium-­based components should be avoided
because of the higher risk of debonding.
CAM Software and Structure Fabrication
After designing in CAD, the final restoration file is
exported as a universal STL file. This file can now be
imported into the desired CAM software which will
adjust the technical parameters in order to fabricate
the structure.
The fabrication method will depend on the desired
material. Most structures are fabricated through
reducing strategies (milling), while others can be built
by 3D printing additive strategies.
Structural Material Selection
The prosthetic material blend most widely used for
CAFIPs is metal-­acrylic. Besides being easy to fabri-
cate and maintain, some clinicians favor metal-­acrylic
CAFIPs for being lighter and absorbing impacts of
occlusal forces. However, neither prosthetic weight
nor material stiffness correlate with stresses and
impact forces transmitted to implants.
It has recently been established that no prosthetic
material can be considered the first choice over
another, since the clinical outcomes are similar [38],
and no prosthetic material blend can avoid technical
complications [39]. Therefore, selection of prosthetic
materials must be made between the prosthodontist
and the patient, to achieve the desired esthetic and
functional outcome, considering mechanical and bio-
logical needs [40].
There is a growing number of materials for CAD-­
CAM framework production, with different fabrication
strategies and mechanical properties.
Zirconium Oxide-­Ceramic Prostheses
Zirconium oxide (ZO) is one of the materials suited for
implant-­ supported CAD-­ CAM rehabilitations, pre-
pared via subtractive milling, as it offers good esthet-
ics, biocompatibility, shade stability, low accumulation
of plaque, good resistance to abrasion, and low ther-
mal conductivity.
A ZO structure is often constructed to be completely
veneered with ceramic. However, recent advances

have produced ZO variants with improved translu-
cency, which allow the construction of monolithic res-
torations, or with cutbacks, combining improved
esthetics and high mechanical properties.
Specific Steps While Working with ZO
●● Analysis of the precision of the work model is man-
datory because ZO cannot be soldered, in case there
are distortions in the impressions.
●● When monolithic restorations are planned, a proto-
type version can be milled in resin or prototyped by
3D printing to check esthetic and functional out-
comes and allow corrections.
●● After milling, the material requires some finishing
refinements and can be pigmented to enhance the
final color scheme.
●● The pigmented ZO needs to be sintered in a dedi-
cated furnace according to the manufacturer’s cycle
instructions, to achieve its final mechanical and
dimensional properties.
●● If the structure is designed to contain titanium-­
based abutment interfaces, they should be tested
after sintering, to fit passively into the structure
hollows.
Metal-­Acrylic Prostheses
The metal bars fabricated for metal-­acrylic prosthesis
can be fabricated via mixed digital and analogue
strategies, based on tooth arrangement. The clinical
protocol used to fabricate such structures does not
change from traditional workflows.
Meanwhile, in the dental laboratory, material
options for bar fabrication are greater. As machinery
requires financial investment, each laboratory offers
limited options of CAM strategies and materials.
Among the most common material options obtained
from milling are dense Co-­Cr alloys, agglutinated Co-­
Cr alloys, and titanium.
The fabrication of bars with CAD-­CAM techniques
has advantages of being less time-­consuming at the
laboratory and more precise, avoiding the distortions
that commonly occur with cast bars.
Metal-­Ceramic/Metal-­Composite Prostheses
The choice of base Co-­Cr alloys for CAFIP construction
has increased over the years. Manufacturers have
adapted these alloys for CAD-­ CAM workflows. The
more widespread use of Co-­Cr alloys was created for
milling machines such as the hard dense Co-­Cr or the
Chapter 4 Digital Workflow in Prosthodontics/Restorative Dentistry 171
softened agglutinated Co-­Cr. Other alloys were pre-
pared as powders for additive printing, such as selec-
tive laser melting, or combined strategies of 3D
printing and milling.
The Co-­Cr structures are highly rigid, present
favorable cost/benefit, and offer high mechanical
resistance and easy ceramic/composite application.
CAD must optimize the esthetic material layering.
Clinical Try-­In of the Structure
After production at the dental laboratory, the fit of the
structure should be verified clinically, following a
checklist.
●● A radiographic and tactile fit assessment should be
performed. All screws must be fastened with passiv-
ity and no resistance.
●● When the occlusion is present in the structure, it
should be checked, and the desired occlusal adjust-
ments should be conducted at low speed.
●● The overall contours of the structure should be ver-
ified, as well as the midline position.
●● A bite registration between the structure and the
opposing arch provides better control of the final
arch interlock and occlusion.
●● When a metal structure is fabricated, sectioned
additional steps of soldering and fit analysis may be
necessary.
●● If a misfit is detected, the metal should be sectioned
and soldered. However, if the structural material is
ZO, the clinician should consider restarting the fab-
rication procedure. As zirconia cannot be soldered,
the production of a new master cast is needed.
Esthetic Layering
After clinical approval, the structure is sent to the
dental laboratory to apply the esthetic materials and
achieve the final contours and shade.
Zirconia/Metal-­Ceramic/Metal-­Composite Material
The design and cutbacks of the structure should guide
the manufacturing pathway, facilitating an esthetic
effect of individualization of teeth and a good fit to
the crestal side. The dental technician must verify that
at least a ±1 mm space was left to be veneered with
ceramics/composite. The esthetic material must be
layered according to the manufacturer’s instruction.
After the final contours and shades of the prosthesis
are obtained, the prosthesis can be finished and
­polished, a glazing layer can be applied, and the CAFIP
is ready for an intraoral try-­in.
(Continued )
172 Digital Dentistry: A Step-by-Step Guide and Case Atlas
Case Report 4.8 (Continued)
Metal-­Acrylic Prostheses
The bar produced via CAD-­CAM procedures should be
processed at the dental laboratory, in a conventional
way for metal-­acrylic CAFIPs. It is advisable that the
teeth set-­up and waxed gingiva, attached to the bar,
should be tried in mouth before acrylization. When
the teeth arrangement is approved by the clinician
and patient, the prosthesis is ready to be acrylized,
finished, and polished.
Clinical Try-­In of the CAFIP
The finalized CAFIP must undergo a detailed inspec-
tion before being placed in mouth. The parameters to
be analyzed in this step are as follows.
●● The new gingival contours can interfere with the
prosthetic adaptation so a radiographic fit assess-
ment should be performed. All screws must be
checked for passivity.
●● The occlusion should be checked, and the desired
occlusal adjustments should be conducted at low speed.
●● The overall contours of the CAFIP should be veri-
fied. Photographs can be useful to detect regions
that need esthetic adjustments.
●● The patient should be ask to analyze if the prosthe-
sis feels comfortable and pleasant. As the final
4.4 ­Three-­Dimensional Printing
in Prosthodontics
4.4.1 3D-­Printed Resin Restorations
Temporary prostheses play an important role in dental
rehabilitation. In addition to helping to determine the
ideal diagnosis from an esthetic and functional point of
view and protecting the remaining tooth from wear and
fracture, it is the main parameter for definitive prosthe-
sis manufacturing, acting also as a tool for selecting
color and thickness and type of material, occlusal
adjustment, as well as adaptation of the patient to the
new dental anatomy.
At present, a temporary prosthesis obtaining by CAD-­
CAM can be performed using subtractive manufactur-
ing, a successful technique. However, very recently, 3D
printing has gained popularity. The available additive
manufacturing machines and materials (e.g., photopol-
ymerizable resins with biocompatible properties) have
shown a rapid, growing evolution in dentistry.
contours of the prosthesis are completely new, the
tactile sensation against oral tissues should be
assessed (volumes and textures on the gingival/
teeth anatomies).
When the professional and the patient are satisfied
with the results, a preliminary installation of the
CAFIP is recommended, with low torque on fixation
screws, for 1–2 weeks.
The patient must be instructed on proper oral
hygiene techniques, to initially follow a soft diet and
be scheduled for the follow-­up appointment.
Final Restoration Delivery
After a successful functional try-­in, final delivery of
the rehabilitation should be prepared.
●● The occlusion must be checked and adjusted if
necessary.
●● Fixation screws may receive the final torque and
screw orifices may be sealed.
●● A panoramic radiograph of the patient should be
made for immediate posttreatment assessment.
●● The patient should be scheduled for periodic
­follow-­up appointments.
Temporary prostheses milled from materials such as
PMMA (polymethylmethacrylate) are very common for
clinicians who are users of digital workflow since many
studies have demonstrated the precision, strength, and
benefits of these prostheses. The production takes place
by equipment with computer numerical control (CNC)
that generates the prostheses using milling drills on
blocks and disks. PMMA has high mechanical strength,
flexural strength, and low porosity; however, there is a
possibility of failures inherent to equipment, accessories,
materials, operator, and finishing procedures. Moreover,
the major barrier faced by clinicians in adopting milled
temporary prostheses is the greater investment com-
pared to conventional techniques performed in either
the dental office or prosthesis laboratory.
Following the evolution of 3D printers and materials
for temporary prostheses, more accessible options for
equipment and resins have encouraged clinicians to
use not only additive manufacturing but also other
solutions such as intraoral scanners and planning
software.

Among the most popular additive manufacturing
technologies are stereolithography, digital light process-
ing, and liquid crystal display. They present an ultravio-
let light source that focuses on the printing platform,
allowing the curing of photosensitive materials such as
resins. Prostheses are then produced by polymerization,
in layers, until completion (Figure 4.176). Printing time
depends on factors such as prosthesis size and volume,
selected layer resolution and thickness, and detail level
requirement. The positioning, angulation, and number
of prosthetic structures placed on the printing platform
can also interfere with printing time.
Generally, the finished prostheses need to undergo
postprocessing, which includes washing in isopropyl
alcohol – preferably in an ultrasonic cleaner – to
remove the resin remaining on the surface and curing
in ultraviolet light to complete the polymerization. As
they are customized, there is also a finishing step to
remove supports, roughen the surface, and make up
the prostheses so that the esthetic results meet the ini-
tial planning.
Other technologies such as fused deposition mode-
ling (FDM) are also widely used; however, as they do
not achieve the surface smoothness provided by tech-
nologies using UV light and resins, only study models
or orthodontic models are generally obtained
from them.
Three-­dimensional impression techniques were first
used in dentistry due mainly to the ease and cost afford-
ability. They also allow clinicians to quickly obtain
Figure 4.176 3D-­printed crowns used in a research project.
Chapter 4 Digital Workflow in Prosthodontics/Restorative Dentistry 173
different simulations in complex cases of difficult visu-
alization by patients. Not only models but biomodels
that replicate bone anatomy have been widely produced
so that treatment planning can be efficiently shown to
patients, in addition to allowing a simulation to be per-
formed before surgery.
Removable (total or partial) and fixed (unitary or
­multiple) prostheses and even copings and surgical
guides can be manufactured by 3D printing. The possi-
bility of simulation also brings advantages for rehabili-
tative treatments that demand esthetic results which are
difficult to achieve. Using planning software, virtual
tooth libraries can be superimposed on the patient’s
dental arch, as well as wax-­up scans being performed
manually by a prosthetic technician or a dental arch of
a donor. After drawing, the files are exported to another
file that can be configured by the production equipment
software for printing.
The greatest advantages of 3D printing by additive
manufacturing are related to control of material used,
the possibility of producing complicated anatomies,
which often cannot be replicated by a milling machine,
and reduction of production time for experienced users
who are familiar with the technique. Although studies
have shown excellent accuracy results for printed tem-
porary prostheses in comparison to conventional and
milled ones, their resistance and durability over time
need to be better investigated.
It is important to emphasize that there are more
accessible equipment and materials requiring lower
174 Digital Dentistry: A Step-by-Step Guide and Case Atlas
investment costs, but the final results may be somewhat
disappointing, especially for users not familiar with the
technique. Errors from the manufacturing technique
can also occur, such as shrinkage due to layer thickness,
printing process, or even after curing. Considering
the delicacy required for these prostheses (i.e., small
diameters and reduced thickness), clinicians should
choose professional equipment and certified materials.
(a)
(b)
Figure 4.177 (a) Temporary prostheses designed on DentalCAD (Exocad). (b) Virtual wax-­up designed on DentalCAD for
mock-­up shell obtaining.
The workflow for a printed temporary prosthesis
starts with 3D file acquisition using a dental scanner,
capturing the 3D image directly from the mouth
(intraoral scanning) or indirectly from plaster casts.
After validation, the files are imported to a planning
software (CAD) so that the prosthesis design follows
ideal anatomical parameters and can be processed by
printing equipment (Figure 4.177). Among the

advantages of planning digitally, controlling measure-
ments and altering configurations are highlighted. For
example, information such as facial midline, bipupillary
line, smile design, teeth proportion, papillary align-
ment, and occlusal and proximal contacts can be
precisely simulated. When scanned arches are superim-
posed on CT scans, facial scans, photographs, and
­wax-­up scans (if possible), the result is expected to be
very predictable.
The finalized file is normally exported in STL format
and transferred to the software of the equipment of
choice, which can be a milling machine or a 3D printer.
In the 3D printer software, files are placed in the print-
ing platform which is a virtual representation of the
existing physical platform where they are sliced into lay-
ers, determining the printing sequence and prosthesis
construction. In software (Figure 4.178), it is possible to
manipulate variables such as material, layer thickness,
amount of supports, positioning, and insertion of cop-
ies, besides obtaining information on the process (e.g.,
estimated production time, amount of resin required).
Since the equipment uses liquid resins, it is important
that the material is within the validity period and
homogenized. For that, there are commercially availa-
ble mixers that promote resin agitation, preventing sedi-
mentation and avoiding any error arising from an
uneven resin.
The printer should be prepared before the files are
sent to it, i.e., the equipment needs to be connected and
Figure 4.178 Temporary prostheses on the 3D printer software (FlashDLPrint®, FlashForge) for generating a file presenting
layer slices and then printing.
Chapter 4 Digital Workflow in Prosthodontics/Restorative Dentistry 175
calibrated and the raw material correctly selected and in
sufficient quantity (in cases requiring manual feeding).
Moreover, equipment parts such as the viewing window
and resin reservoir should be in good condition so that
they do not harm the light passage and then resin
polymerization.
After inspection, the files are sent to the equipment by
USB cable or pen driver or via wi-­fi. Printers typically
display information on the processes in progress, such
as print time and amount of material consumed.
Once the printing has been finished (Figure 4.179),
the prosthesis should be washed in isopropyl alcohol,
a process that can be optimized by ultrasonic cleaners.
It ensures that the remaining resin is completely
removed from the surface of the prosthesis. Then, the
polymerization is completed using a UV curing cham-
ber, which should be configured according to the resin
features.
At the end of curing, the operator proceeds with fin-
ishing by cautiously removing the support structures
responsible for retaining the prosthesis on the printing
platform. This step should be performed using micro-
motors, diamond and carbide burs, sandpapers, and
polishing rubbers.
After removing the supports, the temporary prosthe-
sis surface can be roughened using drills to provide
greater retention for pigments and glaze, which are
used in the next step for color characterization. Special
kits for printed temporary prosthesis make-­up – or even
176 Digital Dentistry: A Step-by-Step Guide and Case Atlas
Figure 4.179 Temporary prosthesis finalized and waiting
for removal from the Varseo® XS printer (BEGO). Source:
BEGO GmbH & Co. KG.
total dentures – are available, giving the possibility of
obtaining a more esthetic and personalized result.
Make-­up steps (Figure 4.180) include three applica-
tions, in layers: (i) an initial glaze; (ii) an intermediary
layer of pigments (according to the preferred tech-
nique); (iii) a final glaze, to protect the finished make-
­up. The prosthesis should be transferred to a UV curing
chamber for proper curing. Make-­up protocols may
change according to the kit selected.
Only a few studies present make-­up protocols specifi-
cally for 3D-­printed temporary prostheses, so there is not
enough information on durability. On the other hand,
manufacturing companies have increasingly developed
certified materials for clinical use and published their
recommended protocols with professional instructions.
Finalized temporary prostheses can be adapted on a
working model and printed for checking preparation or
component by both the laboratory technician and the
dental surgeon, as well as occlusal and proximal con-
tacts. Installation and cementation should follow con-
ventional protocols, using temporary or resin cement, as
they are compatible with 3D printer resins.
Additive manufacturing technology and polymers
available for temporary prostheses fabrication have
been increasingly present in the clinical and laboratory
routine of digital flow users; however, there is a learning
curve in which the users progress as they acquire expe-
rience in using the equipment and conducting the sub-
sequent steps. The raw material selected should meet
requirements such as biocompatibility, antibacterial
properties, and esthetic appearance, as well as having
mechanical properties (e.g., strength) that guarantee
precision.
Previous research has shown the clinical durability of
printed prostheses with no related complications such
Figure 4.180 Temporary prosthesis make-­up using Vita
Enamic® stains kit (Vita Zahnfabrik). Source: VITA Zahnfabrik
H. Rauter GmbH & Co.KG.
as color stability loss or fractures [41]. However, further
long-­term clinical studies are needed to gain a better
understanding of all technique features. On the other
hand, its growing clinical application will certainly
guarantee future improvements in both equipment and
raw material composition.
4.4.2 3D-­Printed Dental Casts
Obtaining a 3D cast is the first step for clinicians who
want to implement the digital workflow in their day-­to-­
day activities. Dental casts are routinely used in the
office or laboratory for prosthesis evaluation, acrylic or
acetate plate manufacturing, waxing, mock-­up design,
etc. Therefore, obtaining a 3D cast using open nonden-
tal software is an essential step in digital dentistry,
besides being the simplest one.
Making a scanned file into a physical object is the
main aim of the digital workflow. It is important to
highlight that scanned files are linear files, i.e., they
exist only on the computer since there is no volume to
become physical. For this reason, a development soft-
ware (e.g. Meshmixer) is needed to transform them into
a volumetric file able to be printed later.
Although there are several ways to obtain a dental
cast using nondental open software, this chapter will
explain a basic, easy method.
4.4.2.1 Importing the File
In order to begin model preparation, it is necessary to
import the STL files into the software. For that, after
opening, the “Import” option is selected (Figure 4.181).
In this step, there is no need to import the files in occlu-
sion since the major focus is cast preparation.

Figure 4.181 Importing the initial file. Source: Case by Dr Danilo M. Bianchi.
Figure 4.182 Model positioning before mesh cleaning.
4.4.2.2 Handling the File
A recurring question is how to move these files and how
to let them move freely. First, a proper mouse is essen-
tial since all the virtual movements are performed
through it. The selected object is rotated on X, Y, and/or
Z axes by clicking the right button and dragging them by
clicking the scroll wheel. By rotating the scroll wheel,
the object is brought closer or taken farther away. The
left button serves only to give commands.
Chapter 4 Digital Workflow in Prosthodontics/Restorative Dentistry 177
4.4.2.3 Cleaning the Mesh
The modeling process begins with mesh cleaning; the
edges are removed to obtain a cleaner model (similar to
using a dental laboratory plaster trimmer). This step
will help the software to better calculate the mesh when
making it solid.
Before mesh cleaning, the model should be positioned
at 45° to one side and not moved again (Figure 4.182).
This is because the software makes the cuts by planes
178 Digital Dentistry: A Step-by-Step Guide and Case Atlas
and not by selection. To start cleaning, the “Select” tool
on the left side of the screen is clicked, which allows
limitation of the region to be removed or kept. At this
step, a straight line is created by clicking once outside
the mesh and then once again inside the mesh area.
Next, several straight lines should be created and finally
connected, outlining a region (Figure 4.183). Then, the
“X” key is pressed to discard the selected region, a step
that should be repeated throughout the model,
Figure 4.183 (a–g) Mesh cleaning regarding one region.
addressing all the edges, including the palate and lin-
gual floor (Figure 4.184).
4.4.2.4 Smoothing the Mesh Edge
After discarding all the excess mesh edges, there will still
be irregular contours on the edges due to the edges of the
triangles that form the STL file. To obtain a linear base,
these edges should be smoothed. For that, the “W” key is
pressed to visualize the mesh of triangles (Figure 4.185).

Then, the “Select” tool is selected and then the value on
the “Size” tab is decreased to 0 (zero) (Figure 4.186). This
will make the brush (size) as small as possible, allowing
clicks on the edge. Then, the entire edge of the file should
be selected by a double click on the outermost triangles of
the mesh, i.e., the last triangles on the edge (Figure 4.187).
Then, the “B” key is pressed (or the “Edit” tool is
selected, followed by selection of the “Smooth bound-
ary” tool), which will make the entire edge smooth and
Figure 4.184 (a,b) Mesh cleaning throughout the model.
Figure 4.185 Visualizing mesh triangles.
Chapter 4 Digital Workflow in Prosthodontics/Restorative Dentistry 179
orange-­ish. Next, the “W” key is again selected to remove
the visualization of the triangles. This new base will be
finished after clicking on “Accept” (Figure 4.188). In
some preconfigured computers, it may be a different
color from the rest of the model, or not. This just repre-
sents a new mesh group created by the software.
4.4.2.5 Creating the Base
After edge smoothing, the file needs to become a print-
able model since it is still a linear model.
Once the edges have been smoothed, a robust base
should be created for a better impression. For that, the
entire edge should be selected by a double click and the
“D” key is pressed (the “Extrude” tool). The next step is
edge extension. For that, firstly, “Direction” should be
set at “Constant” and “Endtype” at “Offset” and the bar
of “Offset” should be moved to one side. The side that
turns black striped is the wrong side to drag the model,
i.e., the clinician should drag it toward the side where
the base turns orange (Figure 4.189). Once that has been
done, “Accept” will complete the process.
Now the model is almost complete but it will need
further modification to be printable.
4.4.2.6 Making It Solid
This step aims to make the model solid, volumetric, in
order to be 3D printed. For that, the “Edit” tool should
be selected on the left side of the screen. Next, the “Make
solid” tool is selected, which can take time according to
computer system demand (Figure 4.190). Then, the
model becomes solid but due to software presettings, it
loses the original format. To return the model to the
original format, the entire bars of “Solid accuracy” and
“Mesh density” tools are dragged to the right, at
180 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Figure 4.186 Decreasing brush size.

Figure 4.187 Selecting the outermost triangles of the mesh.

Figure 4.189 (a,b) Creating model base.

512 value, and “Update” is selected. After a short time,

the selection of “Accept” will finalize the process
(Figure 4.191).
Then, the model can be exported to be printed; how-
ever, since it is totally solid, more resin will be con-
sumed, leading to higher polymerization shrinkage.
Thus, conventionally, casts should be hollow and pre-
sent a reduced base area.

4.4.2.7 Making It Hollow

To make the cast hollow, the “Edit” and “Hollow” tools
Figure 4.188 (a,b) Completing mesh edge smoothing. are selected, consecutively. A thickness of 2 mm is

suggested to aid in resin shrinkage control and durabil-
ity. Conventionally, the Meshmixer software adopts this
thickness but it is important to verify it every time
(“Offset distance” tool). Following this, the software
Figure 4.190 Initial steps for making the model solid.
Figure 4.191 Finalized, solid model.
Chapter 4 Digital Workflow in Prosthodontics/Restorative Dentistry 181
transforms the inner part into solid dark gray and the
outer part into transparent, indicating that the inner
part will be deleted. By clicking “Accept,” the model will
become hollow (Figure 4.192).
Although the model is hollow and can now be
impressed, it is presenting a “cover” that will not permit
a complete resin polymerization inside. Therefore, the
bottom of the model should always be removed.
4.4.2.8 Cutting the Plane
To cut the plane, the model should be as straight as pos-
sible. For that, the “Edit” and “Plane cut” tools are
selected, consecutively. Unlike the “Hollow” tool, the
solid dark gray part will remain after “Accept.” It is
important to ensure that only the model presents a solid
dark gray color. If the base presents this color, the com-
mands should be inverted by clicking on the thicker
blue arrow (Figure 4.193). This way, the software will
delete the transparent part and the model will be ready
to be printed and sliced (Figure 4.194).
4.4.2.9 Exporting
During model exportation, it is important to check
whether the file is in STL binary format. Now, the model
can be sliced and printed (Figure 4.195).
182 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Figure 4.192 Finalizing the process for making the model hollow.

Figure 4.193 (a,b) Initial procedures for cutting the plane. Figure 4.194 (a–c). Final procedures for cutting the plane.

Figure 4.195 Exporting the file.
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Chapter 5
Digital Workflow in Periodontology
Ana P. Ayres, Alexandre D. Teixeira-­Neto, and Arthur R.G. Cortes
SUMMARY
This chapter presents a step-­by-­step guide and research evidence on digital workflow in periodontics.
5.1 ­Periodontal Surgical Planning
Nowadays, the concept of smile and dental esthetics is
no longer limited to the teeth. The essentials of a smile
involve the relationship between the three primary
components: the teeth, lip framework, and the gingival
scaffold [1]. In spite of common notions about facial
esthetics being usually based on subjective opinions
rather than proven scientific data, and being influenced
by cultural variants, emerging research shows how the
amount of gingival display significantly influences the
perception of smile attractiveness, independent of age
and sex [2]. Excessive gingival display while smiling,
also usually known as a “gummy smile,” is a common
esthetic concern among dental patients and, being
largely viewed as unesthetic, leads many patients to
seek some form of treatment to address the issue [3].
The gummy smile has been broadly defined as a non-
pathological condition causing esthetic disharmony, in
which more than 3–4 mm of gingival tissue is exposed
when smiling. The anatomical landmarks that factor
into the gummy smile are the maxilla, lips, gingival
architecture, and teeth. All these structures must lie in
harmony with one another to achieve an esthetic smile.
When diagnosing and treating patients with a gummy
smile, the clinician must accurately understand and
identify the etiology of the condition. Potential causes of
excessive gingival display involve short lip length, hyper-
mobile/hyperactive lip activity, short clinical crown,
dentoalveolar extrusion, altered passive eruption, verti-
cal maxillary excess, and gingival hyperplasia [3].
When the gummy smile brings the patient to seek
esthetic dental treatment, after thorough consideration
Digital Dentistry: A Step-by-Step Guide and Case Atlas, First Edition. Edited by Arthur R.G. Cortes.
© 2022 John Wiley & Sons Ltd. Published 2022 by John Wiley & Sons Ltd.
185
of its etiology, some conservative surgical approaches
can be of interest to solve the condition and improve
the smile harmony (Figure 5.1). When the incisal edge
position is correct, crown lengthening surgery can be
used to increase the clinical crown length as a stand-­
alone esthetic procedure. However, when the incisal edge
position is inadequate and there is excessive gingival
display, crown lengthening in conjunction with restor-
ative treatment is indicated. This surgical technique
involves apically positioning the gingival margin and
may require the removal of supporting bone. The peri-
odontal surgical procedure must also result in a proper
biological width and adequate keratinized tissue [4].
A previous study has stated that when attempting to
enhance esthetic outcomes, the influence of two bio-
logical concerns must be fully understood [5].
●● Location of the base of the sulcus, which influences the
cervical termination of tooth preparation and allows
for intracrevicular location of the restoration margin.
●● Knowledge of location of the osseous crest is required
before altering gingival levels.
Particularly in periodontal-­prosthodontic interdisci-
plinary therapy, where subgingival restorative margins
are desired, it is prudent to discuss the concept of the
so-­called biological width, which is characterized by
the tissues concerning the dentogingival junction –the
supraalveolar connective tissue attachment and the
junctional epithelium – along with the alveolar crest
and the base of the gingival sulcus [6, 7]. The total
volume of the biological width varies among individu-
als, but remains constant within each individual, and
i’s average dimension varies in the range of 1.8 and
186 Digital Dentistry: A Step-by-Step Guide and Case Atlas
Maxilla
Lips
Anatomic Landmarks
Gingival architecture
Teeth
Crown Length
Incisal Margin
Dental Analysis
Medical History
Facial Analysis
Lip Analysis
Rest Position Analysis Diagnostic Assessment
Periodontal Examination
Intraoral Scan (IOS)
Figure 5.1 Diagnosis and management of the “gummy smile.”
2.4 mm [7]. In contemporary practice, it is generally
accepted that a 3 mm distance between the osseous crest
and the clinical crown margins is the safest alternative
to prevent chronic inflammation [6].
Consideration of this width is fundamental while
planning crown lengthening procedures, whether there
will or will not be future esthetic restorations with sub-
gingival margins. That essentially means that bone
resection can be necessary along with the gingivectomy
procedure in various types of conditions.
Through performing digital exams and obtaining
three-­dimensional data corresponding to the oral tissues
of the patient (from Standard Tesselation Language
(STL) files acquired by an intraoral scan (IOS) of the
patient’s mouth) and the radiographic osseous informa-
tion from the Digital Imaging and Communications in
Medicine (DICOM®) files acquired by cone beam com-
puted tomography (CBCT), it is possible to form a virtual
patient, superimposing these puzzle pieces and allowing
for complete diagnosis and treatment planning [8].
5.2 ­CAD-­CAM Surgical Guides for
Clinical Crown Lengthening
The most important concepts concerning dentogingival
esthetics are the positioning and contour (regular, con-
cave arch) of the gingival margin, which directly affect
dental shape and proportion [1]. These factors are
related not only to clinical crown length delimitation
Short Lip Length
Hypermobile Lip
Short Clinical Crown
Dentoalveolar Extrusion
Potential Causes
Vertical Maxillary Excess
Altered Passive Eruption
Gingival Hyperplasia
“GUMMY SMILE”
Treatment Possibilities
Crown Lengthening
Surgical Procedures
Surgical Planning
Cone Beam Computed Tomography
(CBCT)
but also the dental cervical profile, strongly influencing
anatomical crown shape and the visual proportion of
the tooth (i.e., square, oval, or triangular).
The positioning and contour of the gingival margin
depend on the entire dentogingival unit, which is com-
posed of the alveolar bone, periodontal ligament, dental
enamel and cementum, connective tissue, and kerati-
nized epithelial tissue. This unit reflects the periodontal
health, the stage of eruptive development, and the phe-
notypic characteristics of the individual.
The positioning reference of the gingival margin, as
well as its esthetic and integrity characteristics, rely on
both their relationship with the cementoenamel junc-
tion (CEJ) and the association between clinical and ana-
tomical dental crowns. The clinical crown is generally
smaller than the anatomical, i.e., the gingival margin
positioning is coronally located to the CEJ. In cases of
short clinical crowns related to parafunctions and pre-
senting worn incisal edges and/or compensatory extru-
sion, clinicians expect to identify larger anatomical
crowns beneath the gingival margin. However, some-
times, the gingival margin is very close to the CEJ or
there may even be cemental exposure with normal
eruptive development, resulting in a smaller clinical
crown than the real anatomical one.
In most cases of short clinical crowns or disproportion
between width and height, clinical crown lengthening
provides an increase in crown height, an improvement
in visual proportion, and a better contour of the regular
concave arch and the interdental papillae, which

usually lead to a need to reestablish a novel contour of
the gingival margins prior to esthetic rehabilitation [1].
The final positioning of the gingival margins is tradi-
tionally determined taking into consideration the
avoidance of exposing dental cement, i.e., the novel
gingival margin should be positioned as close as possi-
ble to the CEJ or exactly over it. Considering the need
for a new creation of the biological space to maintain
gingival margin stability, plus better esthetic contour
and alveolar ridge volume, osteotomy and osteoplasty
are suggested in most cases of crown lengthening. The
extension of both surgical procedures is determined
by the patient’s periodontal phenotype and the new
proportional relationship between the clinical crown
and root attachment. Often, according to these concepts,
Case Report 5.1 Image-­Guided Crown-­Lengthening Procedure
(Clinical technique by Dr Alexandre D. Teixeira Neto)
Periodontal surgical guides orientate both the new
gingival margin contour and the real need for osteot-
omy to redetermine biological dimensions and gingi-
val margin stability as well as the longevity of the
restorative procedure that should respect biological
concepts. They can be made in a conventional, ana-
logue way (generally of acetate, resin, PET, and sili-
cone) or directly on the final esthetic wax-­up model
(Figure 5.2).
Thus, the most commonly applied techniques for
clinical crown lengthening guided by wax-­up mod-
els are performed through either gingival incisions
outlining mock-­up margins or using simple guides.
Both techniques, unfortunately, often present irreg-
ular contours, resulting in irregular incisions.
Another important limitation of the conventional
analogue process is that the new gingival margin
contour and emergence profile planned from the
Figure 5.2 An acetate periodontal surgical guide.
Chapter 5 Digital Workflow in Periodontology 187
there will be discrepancies between surgical and esthetic
periodontal planning for a novel rehabilitation or even
treatment relapse.
Another important factor is reference loss during the
periodontal surgical procedure concerning the expected
gingival margin contour planned in the final esthetic
rehabilitation. This occurs mainly when there is a need
to establish a new relationship between visual esthetic
proportion and emergence profile in cases where the
new margin does not coincide exactly with the CEJ con-
tour. Therefore, it is essential to manufacture periodon-
tal surgical guides based on the final prediction of the
esthetic rehabilitation to orientate the surgical contour
of the gingival margins, joining the surgical periodontal
and esthetic rehabilitation plans together.
esthetic wax-­up become incompatible with the ana-
tomical contours and root emergence profiles of the
teeth involved, limiting periodontal results or lead-
ing to the need for frequent changes in the wax-­up
models during treatment to follow the current peri-
odontal condition.
The novel procedures for manufacturing periodon-
tal guides by CAD-­ CAM technology combine the
entire processes of treatment planning and execu-
tion, optimizing the integration stages of esthetic
and surgical rehabilitation, minimizing errors, and
offering a final result very similar to that simulated
and presented to the patient at the beginning of the
treatment planning, either virtually or using the
mock-­up on the mouth.
The planning of guides for periodontal plastic sur-
gery follows the same principles as those for esthetic
rehabilitation (see Chapter 4), starting with facial
study in a virtual environment by photographic anal-
ysis or scanning. This step is very important for
correct visualization of dental arch inclinations, sym-
metry, and proportion between left and right sides.
Thus, clinicians can better establish the relationship
between the gingival zeniths of central incisors and
canines and between the gingival zeniths of central
and lateral incisors. The ideal ratio between the
zeniths of anterior and posterior teeth can also be
determined.
Unlike a simple intraoral analysis or those con-
ducted through analogue or digital models, periodon-
tal analysis depends on a correct facial study, with
well-­defined lip delimitation to assess the smile area
(Continued )
188 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Case Report 5.1 (Continued)

Figure 5.3 Facial images used for virtual planning of periodontal plastic surgery.

for a reliable and precise evaluation of exposure of spatial orientation of the models for correct visualiza-
teeth, papillae, and gums. For this, facial images from tion of the inclinations of the dental arches in coronal,
the patient are paramount, which will allow the sagittal, and transverse views (Figure 5.3).

5.2.1 Planning for Periodontal Surgical anatomical crown), distance to the CEJ, and the need for
Guide Manufacturing osteotomy to reestablish biological distances. Moreover,
further esthetic rehabilitation can be evaluated if neces-
With reverse planning, it is possible to analyze the
sary according to the expectations of the professional
need for gingival plastic surgery to reestablish
and patient (Figures 5.5 and 5.6).
esthetic patterns of soft tissues of the smile. This sur-
The guide presents two segments: a window for
gery can be performed with the aid of a periodontal
­cutting which will support the scalpel blade (allow-
guide, created either from tomographic analysis or
ing internal bevel incision) (Figure 5.7), laser tip, or
facial study once the references of digital wax-­up
­electrocautery (gingivectomy only), and a 3 mm
contour or even the new contour of the gingival mar-
structure for bone wear reference. The cut line design
gins in the digital surgical simulation have been
is defined according to the patient’s anatomical char-
established (Figure 5.4).
acteristics and the wax-­up obtained for cases of
Computed tomography is an important tool in this
process, allowing periodontal analysis of each tooth.
From it, clinicians can evaluate the size of anatomical
crowns, the quantity of enamel covered by gingiva (total

Figure 5.5 A tomographic study concerning periodontal

Figure 5.4 A digital surgical simulation. surgical planning.

Figure 5.6 A more complete periodontal study on the tomographic scan and intraoral scanning. The guide, model, and
tomographic images of the tissues are depicted simultaneously.
(a)
(b)
Figure 5.7 (a,b) Periodontal surgical planning and
guide design.
rehabilitation, respecting the esthetic patterns and
dental proportions and placing the gingival zeniths
slightly distalized.
The surgical guide is then impressed by a 3D device
using polymerizable resin (thickness of 1.5 mm)
Chapter 5 Digital Workflow in Periodontology 189
Figure 5.8 A periodontal surgical guide ready to use.
(Figure 5.8). Following this, the printed guide is washed
in isopropyl alcohol for 15 minutes to remove unpolym-
erized resin residues on the surface, and then it is
placed in an oven for postcuring polymerization for
30–60 minutes. Finally, the support structures are
removed and the guide is polished.
As described above on the integration of prerehabili-
tation periodontal planning, a digital workflow involv-
ing orthodontic treatment, more complex preprosthetic
surgeries, and dental implants can also be developed
before the final rehabilitation. In both provisional and
definitive rehabilitation phases, laboratory planning is
necessary, which includes the prosthetic design (CAD)
based on references determined by digital planning
190 Digital Dentistry: A Step-by-Step Guide and Case Atlas
guided by facial analysis. Therefore, the final rehabilita-
tion follows references of smile proportions according
to the characteristics of the patient’s face and natural
textures (natural algorithms) from the donor library
used in the planning phase [9].
5.3 ­Image-­Guided Periodontal
Surgery
The entire planning process for guided periodontal sur-
gery begins with a thorough initial assessment of the
patient, involving not only the anamnesis but also facial
visualization and information records before perio-
dontal examination. Facial image registration can be
performed using either photography, to record the
­exposition of gingivae (gingival smile) on smiling, or
videos, in which the dynamics of lip movements during
speech and faint and forced smiles are depicted. It is
important to highlight that many patients who are dis-
satisfied with their smile tend to hide or limit it by con-
trolling contraction of the labial levator muscles in a
spontaneous smile. On the one hand, photographs and
facial scanning require more complex equipment and
recording techniques while on the other, smartphones
provide video recordings easily and with very high
quality.
The initial clinical evaluation depends mainly on
evaluating periodontal health and establishing a diag-
nosis on probing depth, gingival level, and clinical
attachment level. Thus, it is possible to establish a cor-
rect relationship between the clinical and anatomical
crown by the determination of hidden enamel under
the gingiva (i.e., the position of both the CEJ and gingi-
val margin).
After parameterization and spreadsheet compilation
of periodontal measurements, it is possible to obtain an
overview of the possibilities of esthetic clinical crown
lengthening with dental enamel exposure only or per-
spective of cementum exposure prior to esthetic reha-
bilitation and subsequent coverage. Later, these
periodontal parameters are confirmed from tomo-
graphic exams [10], which provide greater precision,
since standard periodontal probes present 1.0 mm
markings, and tomographic exams avoid injury to the
periodontal tissues and anesthesia to evaluate the bone
crest parameters.
For a complete visualization of the soft tissues in
tomographic exams, it is extremely important to acquire
the scans with the patient’s head stabilized on the
tomography device and using lip retractors (Expandex™
or those for dental whitening) so there will be no over-
lap of lip structures on the vestibular dental mucosa and
of the tongue on lingual or palate dental mucosae [10].
These tomographic exams should be performed on each
arch separately and with caution in relation to the
device’s parameters for better visualization of soft tis-
sues. Moreover, the files should be in DICOM format
which allows complete visualization of tomographic
sections and the possibility of 3D reconstruction of den-
tal and bone structures. Virtual periodontal measure-
ments present greater accuracy on sagittal slices,
although they can also be performed on well-­fitted 3D
reconstructions. These reconstructions are essential for
periodontal guide design, even with some distortion of
the original anatomical structure due to radiological
artifacts, which are more evident on the surface of these
reconstructions.
For a more detailed and reliable reproduction of the
dental anatomy, intraoral scanning files are necessary.
The STL files from the IOS should be fully aligned with
3D bone reconstruction and consequently with the
tomographic slices. Later, they will also be aligned with
the photographs or facial scans for correct spatial posi-
tioning in relation to the patient’s face. These aligned
models are thus superimposed by the facial image,
which is cut, allowing visualization of the structures in
planes. On the external plane is the facial integument
contour; on the intermediate, the IOS shows the clinical
crowns and external gingival contour; on the innermost
one are the anatomical crowns, roots, and bone struc-
tures, obtained from 3D tomographic reconstruction of
DICOM files.
The guide designing and printing processes described
above result in the possibility of starting esthetic clinical
crown lengthening surgery with clinical guidance from
the entire process that has been planned from the vir-
tual environment. This results in precise reproduction
of the planned gingival design and a reliable orientation
regarding area and extension of osteotomy and osteo-
plasty to be performed, leading to better tissue stability
and cosmetic contour.
The internal window in the guide reproduces the
desired shape of the gingival margin contour and its
occlusal adaptation is achieved directly on the patient’s
incisal edges and natural cusps (references obtained
in the IOS). On the other hand, the upper edge of the
periodontal guide guides the osteotomy which was
planned according to tomographic reconstruction of the
DICOM files.
After anesthesia, the guide is positioned through
the occlusal insertion axis and should have small
 Chapter 5 Digital Workflow in Periodontology 191

Case Report 5.2 Minimally Invasive Image-­Guided Periodontal Surgery

(Clinical technique by Dr Alexandre D. Teixeira Neto) positioning is not visible. The osteotomy instrument is
supported by the outer edge of the guide to delimi-
The surgical process begins with internal bevel
tate the bone procedures. Then, the guide is removed
incisions orientated by the internal window on the
and full osteotomy and osteoplasty are carried out,
guide and posterior removal of the incised gingival
using the guide wherever necessary to check the
margins (Figure 5.9). After gingivectomy is completed, it
planning. Surgery ends with vertical mattress sutures
is interesting to remove the guide to observe the new
or continuous or interrupted suspensory sutures. In
gingival margin contour and to improve the procedure
this step, the guide can also be used to check whether
in areas of interproximal papillae. The virtual analysis
the gingival margin is positioned as previously
performed during the digital planning demonstrates
planned.
the exactly expected osteotomy and osteoplasty
The waiting time for final esthetic rehabilitation, if
dimensions, allowing flapless surgical techniques in
indicated, will depend on the tissue healing process,
some cases, according to the extension. If the planning
as well as surgical extension and trauma. In general,
considers flapless techniques, then the osteotomy is
clinicians should consider that the epithelium takes
performed to reestablish the biological space from the
7–15 days to heal, the connective tissue 45–60, and
new margin with a tunnel technique using surgical
the bone 90–180 (Figure 5.11). However, minimally
ultrasound, microchisel, drill, or surgical lasers.
invasive image-­guided surgeries (i.e., using advanced
In cases of flap surgery for extensive osteotomy, an
equipment such as surgical ultrasound and lasers and
intrasulcular incision is done to elevate the full-­
without flap elevation) make it possible to carry out
thickness flap until the mucogingival line and then
periodontal plastic surgeries for esthetic clinical
the guide is placed in position to orientate the oste-
crown lengthening simultaneously with esthetic
otomy (Figure 5.10) since the new gingival margin
rehabilitation.

Figure 5.9 Using the periodontal guide for orienting Figure 5.10 Using the periodontal guide for orienting
internal bevel incisions on gingival margins. bone recontour.

(a) (b)

Figure 5.11 (a,b) Initial and final aspects of a clinical case in which minimally invasive image-­guided surgery was
performed for esthetic clinical crown lengthening.
192 Digital Dentistry: A Step-by-Step Guide and Case Atlas
openings to verify adaptation on the supporting teeth.
Similarly, the upper edge, which orientates the osteot-
omy, should also be perfectly adapted to the gingiva,
facilitating ­gingival cut and providing increased stabil-
ity of the ­gingival margin, especially in thin gingival
phenotypes showing margins that will be removed by
less than 1.0 mm.
5.4 ­Surgical Guide for Soft Tissue Graft
Performing a guided soft tissue graft surgery optimizes
surgical results, reduces procedure time, and facilitates
the graft removal technique, leading to better postopera-
tive outcomes; however, the greatest benefit of the
­technique is related to virtual treatment planning.
The planning of a mucogingival surgical guide
requires a thorough intraoral and radiographic inspec-
tion in the virtual environment. The exams performed
are intraoral scanning (STL file) and computed tomog-
raphy (DICOM file) with labial and lingual retraction,
as previously described.
Figure 5.12 Initial steps of virtual planning for soft tissue graft. Source: Case by Dr Alexandre D. Teixeira Neto.
The beginning of the planning depends on a correct
alignment of the IOS with the 3D tomographic recon-
struction and slices for image superposition and visuali-
zation of STL transparency over the bone structures,
allowing full-­thickness measurements. On the digital
model, the areas requiring gingival tissue augmentation
are identified and mensurated; moreover, in the virtual
environment, it is possible to simulate drawing the
required graft and virtually positioning it for prior
­evaluation (Figure 5.12). This virtual graft is duplicated
and placed on the receptor area, between STL external
mucosa and 3D bone reconstruction, also evaluating tis-
sue availability from the donor area. It is also important
to identify the emergence of the vascular nervous bun-
dle from the greater palatine foramen in order to delimit
distal and apical graft extensions as well as the construc-
tion of a guide tube for more precise anesthesia directed
toward the foramen.
In the virtual environment, incisions on the graft area
are also simulated to create structures on the guide that
will support the scalpel blade or laser tip during surgery
(Figure 5.13).

(a)
Figure 5.13 (a,b) The incisions are simulated for the creation of structures on the guide that will help to support the cut
instruments.
(a)
Figure 5.14 (a,b) Surgical guides for soft tissue graft ready for use.
The mucosal graft guide (Mucograft®, Geistlich) is
characterized by a palatal plate with a rectangular cut
window for free gingival graft removal that can be
used as either a traditional supraepithelial graft or sub-
epithelial connective graft (after epithelium removal).
Otherwise, the guide can be designed for direct removal
of subepithelial connective tissue with length and
­thickness previously determined in virtual planning.
For that, some structures are manufactured on the
guide, promoting guided incisions in different positions,
according to Bruno’s removal technique.
The surgical guide is then impressed by a 3D device
using polymerizable resin. The printed guide is washed
in isopropyl alcohol for 15 minutes to remove unpolym-
erized resin residues on the surface, and placed in an
oven for postcuring polymerization for 30–60 minutes.
Chapter 5 Digital Workflow in Periodontology 193
(b)
(b)
Finally, the support structures are removed and the
guide is polished (Figure 5.14).
For stabilization, the Mucograft palate plate is
fixed on the mouth involving the occlusal surface of
all teeth and the buccal dental surfaces at the level
of the prosthetic equator. It can also be attached
to implant perforation guides that will need soft tis-
sue manipulation or to periodontal plastic surgery
guides for any type of gingival margin contour
harmonization.
The surgical guide use begins with initial stabiliza-
tion, anesthesia orientation to the greater palatine fora-
men, and subsequent anesthetic complementation to
the graft area. The guided incisions are done and the
graft is removed from the donor area and transferred to
the receptor area. Then, the guide is removed and the
194 Digital Dentistry: A Step-by-Step Guide and Case Atlas
(a)
(c)
(e)
Figure 5.15 (a) The surgical guide for soft tissue graft is stabilized. (b,c) Guided incisions. (d) Donor area after incisions.
(e) Subepithelial connective graft removed.
sutures are performed, if no further surgical procedure
is required (Figure 5.15).
5.5 ­Research Evidence
The findings presented herein support the importance
of careful multidisciplinary treatment planning for
periodontal treatment [8, 9]. Presurgical wax-­up may
aid the surgeon in envisioning the final outcome
planned by the restorative dentist. The wax-­up is made
(b)
(d)
using information obtained from the digital smile
design (see Chapter 4), and can be tried on the patient’s
mouth using the mock-­up technique, an objective and
efficient tool in treatment planning communication,
that can be used to confirm the treatment plan before
final preparations and evaluate final gingival margins,
within the limitations of biological and functional
considerations [11].
The planning of the surgical crown lengthening pro-
cedures has been broadly affected by the recent advent
of the digital workflow in dentistry. CAD-­CAM

techniques have helped surgeons perform more pre-
cise and predictable surgeries, which contributes to
fewer invasive procedures and better esthetic out-
comes. Before digital guided surgery techniques, it was
possible to use a vacuum-­formed or acrylic resin surgi-
cal guide, made by diagnostic waxing to establish clini-
cal crown length. However, manual measurements are
used in this waxing methodology to establish the
desired alveolar bone crest and thus the accuracy of
these measurements varies according to the periodon-
tal phenotype and site-­specific characteristics, includ-
ing buccal bone thickness, gingival recession, root
anatomy, and tooth morphology. As a result, this meth-
odology may not be precise for patients with bone
resection and may result in unpredictable esthetics
after treatment [12].
By integrating hard and soft tissue imaging data,
obtained through IOS and CBCT methods, a 3D virtual
patient can be created to noninvasively simulate an
entire treatment. This data integration, in turn, can
­predict digital workflow treatments. A systematic
review of literature analyzing 13 clinical studies has
shown that “CBCT demonstrates high accuracy in
detection of periodontal structures,” such as measure-
ment of the distance between the CEJ and the crestal
bone margin [13].
By providing precise information and allowing 3D
evaluation of the support periodontal tissues, CBCT
acquisition is important not only for the diagnosis of
the patient’s condition but also for precise and
­References
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2 Kaya, B. and Uyar, R. (2013). Influence on smile
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Chapter 5 Digital Workflow in Periodontology 195
predictable periodontal planning. Clinical case and
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of digital surgical guides to orient both the osteotomy
and gingivectomy procedures during crown lengthen-
ing surgeries have used different computer programs
to perform the periodontal profile analysis. This soft-
ware evaluation allows for estimation of the ideal
amount of tissue to be resected, by the assessment of
the tomography to observe the relationship between
biological distances and define the best surgical
approach [9].
A single surgical guide can be used to orient the
excision of both gingival and osseous tissues. The
DICOM files obtained through the CBCT exam must
be converted into STL virtual 3D meshes. Using 3D
CAD software, it is then necessary to import the STL
files, corresponding to the data from the patient’s IOS
and CBCT exam. Both meshes should be superim-
posed in order to evaluate the relationship between
the patient’s gingiva and alveolar bone. The virtual
wax-­up must be performed to assess the final result
that will be obtained after the crown lengthening
procedure. With the combined information of the
CBCT, IOS, and wax-­up, it is possible to determine
the future cervical margins of the patient’s teeth, and
to plan the excisions that will be made into the hard
and soft tissues. A surgical guide can be virtually
modeled and 3D-­printed to orient both incision and
osteotomy related to the crown-­lengthening surgical
procedure [14].
5 Kois, J.C. (1994). Altering gingival levels: the restorative
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7 Nasr, H.F. (1999). Crown lengthening in the esthetic
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8 Joda, T. and Gallucci, G.O. (2015). The virtual patient in
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9 Deliberador, T.M., Weiss, S.G., Neto, A.T.D. et al. (2020).
Guided periodontal surgery: association of digital
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10 Januário, A.L., Barriviera, M., and Duarte,
W.R. (2008). Soft tissue cone-­beam computed
tomography: a novel method for the measurement
of gingival tissue and the dimensions of the
dentogingival unit. J. Esthet. Restor. Dent. 20 (6):
366–373; discussion 374.
11 Cattoni, F., Mastrangelo, F., Gherlone, E.F., and
Gastaldi, G. (2016). A new total digital smile
planning technique (3D-­DSP) to fabricate CAD-­
CAM mockups for esthetic crowns and veneers.
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12 Liu, X., Yu, J., Zhou, J., and Tan, J. (2018). A digitally
guided dual technique for both gingival and bone
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13 Woelber, J.P., Fleiner, J., Rau, J. et al. (2018). Accuracy
and usefulness of CBCT in periodontology: a
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14 Passos, L., Soares, F.P., Choi, I.G.G., and Cortes,
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Chapter 6
Digital Workflow in Implant Dentistry
Otavio H. Pinhata-­Baptista, Roberto A. Markarian, Shaban M. Burgoa, Alan J.M. Costa,
Jesus T. Garcia-­Denche, Baoluo Xing, Oscar I. Velazquez, and Arthur R.G. Cortes
SUMMARY
This chapter presents a step-­by-­step guide and research evidence on digital workflow in implant dentistry.
Computer-­assisted implant surgeries have revolution-
ized modern implantology, optimizing final results.
Evidence indicates that the computer-­assisted dynamic
surgery method has greater accuracy and precision
compared to the static method (currently most used)
and this, in turn, is superior to the conventional tech-
nique (freehand). In short, the more superior the
results of a technique, the more complex and expen-
sive it is.
6.1 ­The Concept of Prosthetically
Driven Surgical Planning
Regardless of how the implant installation surgery will
be carried out, correct and accurate reverse planning
must be performed and strictly adhered to during the
surgical stage. As a result, the number of problems
related to the lack of proper three-­dimensional position-
ing of the installed implants also increases significantly.
On the other hand, recent technological evolution has
brought advantages and solutions that favor the ade-
quate preparation and development of the professional.
Technology has revolutionized dental practice quickly
and irreversibly. For implantology, specifically, it has
brought more security, speed, and predictability to treat-
ments. Computers and software, working together, pro-
vide dentists with tools to help, both for diagnosis and for
the surgical and restorative phases of a dental implant
treatment. As discussed in Chapter 2, a three-­dimensional
(3D) virtual patient can be created for planning dental
Digital Dentistry: A Step-by-Step Guide and Case Atlas, First Edition. Edited by Arthur R.G. Cortes.
© 2022 John Wiley & Sons Ltd. Published 2022 by John Wiley & Sons Ltd.
197
treatments and surgeries noninvasively. In this context,
digital workflow allows for sharing treatment plan data
immediately with a network of other professionals,
enhancing communication among patients, dentists, and
dental technicians [1].
In the field of oral rehabilitation, digital 3D or two-­
dimensional (2D) facial analyses such as digital smile
design were found to be beneficial for predicting the
final esthetic result. In this context, several methodolo-
gies for working with facial images of the patient during
virtual treatment planning have been described in the
literature [2–4]. Integration of DICOM® files from CBCT
and STL files from intraoral scans (IOS) enables con-
comitant use of data from hard and soft tissues during
virtual surgical and prosthetic planning [5]. Among the
advantages of the aforementioned methodology are vir-
tual wax-­up tools for easy adjustment of teeth shape,
size, and position along with enhanced prosthetically
driven virtual implant planning [2, 4].
6.2 ­Static Image-­Guided Implant Surgery
The advent of treatment with dental implants has been
one of the most important changes in the field of den-
tistry since 1983. Since then, treatment with dental
implants has become one of the most predictable ways
to replace lost teeth.
As a result, the number of problems related to the inade-
quate 3D positioning of the installed implants also increa­
sed significantly. On the other hand, recent technological
198 Digital Dentistry: A Step-by-Step Guide and Case Atlas

developments have brought advantages and solutions that The alignment of both CBCTs can be achieved by
favored the preparation and proper development of the pro- placing gutta-­percha markers in the tomographic guide.
fessional. Technology, as it has been doing in practically all Most software programs use gutta-­percha markers to
areas of various human activities, has also revolutionized align both CBCTs automatically. A total of five gutta-­
dental practice quickly and irreversibly. Computers and percha markers is recommended, all of them in the
softwares, working together, provide dentists with tools, flange, one anterior below the frenal notch and two pos-
both for diagnosis and for the surgical and restorative terior in each side of the tomographic guide.
phases of a treatment with dental implants. In order to improve the quality of the CBCT of the
Currently, two main methods are available for obtain- tomographic guide. and the resulting surgical guides,
ing orientation of the ideal three-­dimensional position- we recommend the following.
ing of dental implants during the transoperative period
●● The thickness of the tomographic guide must be at
of computer-­assisted implant surgeries: surgery through
least 3 mm to avoid holes in the surgical guide.
the use of stereolithographic guides, known as static
●● The extent of the tomographic guide must be wide
computer-­assisted implant surgery (s-­CAIS), or real-­
enough to stabilize the surgical guide during surgery.
time image browsing surgery known as dynamic
●● At least five gutta-­percha markers should be used.
computer-­assisted implant surgery (d-­CAIS). The latter
●● The tomographic guide must be well adapted to the
method uses optimized continuous tracking of surgical
mucosa. If a denture is used as a tomographic guide,
instruments, which are equipped with infrared light
it should be realigned prior to the scan to improve its
emitters. Computed tomography data are still needed,
adaptation and thickness.
as are reference markers that are used to compare the
images to the actual surgical field. On the other hand,
6.2.1.1 Tomographic Guide
stereolithographic guides favor the reliable transfer of
the surgical plane from digital images to the real surgi-
Fabrication and Scanning
cal field. For this purpose, guided perforation models
Clinically the tomographic guide follows all steps of a
are used, helping the surgeon to obtain a satisfactory
denture fabrication. It starts with the wax rim to deter-
implant installation, together with prediction of the
mine the correct VDO in CR, the occlusal planes and all
final result of the prosthesis, as well as good conditions
proportion lines to guide the tooth mounting. After the
related to soft tissue handling, emergence profile, and
tooth mounting, a consultation is needed to verify adap-
final morphology of the implant. In certain cases,
tation, stability, occlusion, and esthetics. Because the
implants can be loaded at the same surgical placement
alignment of the teeth will be used as a reference for
visit using esthetics or immediate loading systems.
implant planning in the software, all teeth must be in
the position desired for the final prosthesis.
6.2.1 Dual CBCT Scanning Technique The wax rim with the tooth mounting will be dupli-
cated in translucent acrylic to make the tomographic
Guided surgery originally was indicated for full-­arch
guide and after finishing and polishing, the gutta-­percha
cases with guides supported by the mucosa for edentu-
markers are placed.
lous patients. At the time guided surgery was proposed,
intraoral scanners were not widely available and software
Preparation for First CBCT (Scan of Patient Wearing the
for implant planning was limited because the only format
Tomographic Guide)
that was accepted to work with was CBCT. Therefore the
The patient wears the radio-­guide and final adjustments
only digital exam needed for guided surgery was CBCT.
are made. A silicone roll or wooden sticks can be used to
Dual CBCT scanning refers to the acquisition of two
stabilize the guide with occlusion during CBCT exam. Lip
exams. The first is the CBCT of the patient wearing the
retractors and/or cotton rolls are also recommended to
tomographic guide and the second is the CBCT of the
better identify the contour of the prosthesis since acrylic
tomographic guide only. Both CBCTs will be merged in
and soft tissue may look similar in CBCT plane cuts.
the software to proceed with implant planning.
Once the alignment of both exams is complete, a 3D Preparation for Second CBCT (Scan of the Tomographic
model of the tomographic guide is generated. This mesh Guide Only)
will be used as a base for the surgical guide, which During acquisition of the tomographic guide’s CBCT, a
means that all the surface of the guide that will be in radiolucent base such as sponge or polystyrene may be
contact with underlying mucosa will be copied from the used to support the guide. This technique will provide a
tomographic guide. clean 3D model, minimizing mesh errors.

Technique Evolution
The dual scanning technique has been used for decades
in guided surgery planning. The analogue step of this
technique is the fabrication of the tomographic guide to
achieve a prosthetically driven implant planning.
Nowadays this step can be done digitally with the acqui-
sition of new digital exams including photographs,
intraoral scanning and facial scanning.
A virtual 3D facially driven wax-­up can be incorpo-
rated into the full-­arch project and all the implant plan-
ning and guides design can use the initial wax-­up as a
reference. This approach will reduce the consultations
needed to create the tomographic guide, leading to just
one consultation to determine the VDO and do all
exams. This means time reduction for the treatment.
6.2.2 Using Combined CBCT and
Intraoral Scans
6.2.2.1 Virtual Waxing
In order to carry out digital planning of the ideal posi-
tion of an implant to be installed for rehabilitation of an
Figure 6.1 Diagnostic digital waxing using DentalCad® software. Source: Case by Dr Otávio H. Pinhata-­Baptista.
Chapter 6 Digital Workflow in Implant Dentistry 199
edentulous patient, we must first determine the posi-
tioning of the prosthetic restorations (Figure 6.1).
In this way, 3D images of STL files, obtained by
intraoral scanning, can be used for development of a
digital prosthetic plan or tools existing in the virtual
planning software for implant surgeries or, preferably,
the use of specific CAD software for restoration simula-
tions of prosthetic restorations.
Such virtual wax-­ups, created by software programs,
will guide the best positioning of the implants, which in
turn will support the planned prosthetic rehabilitations.
6.2.2.2 Virtual Implant Surgery
Planning Software
In today’s market, there are several software programs
dedicated to image-­guided surgical planning. Each has
specific strengths and weaknesses. Most of these
programs are third-­party (i.e., not developed by the
TCFC manufacturer), such as SimPlant® (Materialize
Dental Inc.), Invivo5TM (Anatomage), NobelClinicianTM
(Nobel Biocare), OnDemand3DTM (Cybermed Inc.), vir-
tual implant placement software (BioHorizons, Inc.),
200 Digital Dentistry: A Step-by-Step Guide and Case Atlas
coDiagnostiXTM (Dental Wings Inc.), Blue Sky Plan®
(BlueSkyBio), Implant Studio® (3Shape), and ExoPlan®
(Exocad), among others. Among the software options
developed by CBCT scanner manufacturers that offer
tools for planning dental implants are Galileo (Sirona
Dental Systems, Inc.), Tx STUDIOTM (i-­CAT), and
NewTom (NewTom).
Currently, almost all implant surgery planning soft-
ware enables the communication (merging) of DICOM
images with intraoral scanning STL files. Likewise, not
all implant planning software enables digital visualiza-
tion of prosthetic components when planning virtual
implants.
After the virtual wax-­up and subsequent virtual plan-
ning of the 3D positioning of the implants, the surgeon
may decide to proceed with bone reconstruction surger-
ies (grafts) if detecting, by virtual planning, the impos-
sibility of installing the implants in a good position.
It is also at this time that the dimensions and charac-
teristics of the implants, such as type (conical or cylin-
drical), thickness, and length, are chosen.
Alignment of Tomographic Images and Scans
Most modern implant planning software is capable of
merging intraoral scan STL files with images from
DICOM files (Figure 6.2). In this procedure, the geom-
etries of key structures are automatically recognized.
The resulting images and files can be used not only to
Figure 6.2 Virtual surgical planning for image-­guided surgery using ExoPlan software (Exocad).
define soft tissue contours and prosthetic teeth, but
also to fabricate stereolithographic models and surgi-
cal guides.
With this technology, implants and abutments can be
virtually preplanned, based on virtually combined soft
and hard tissue information, which facilitates the imme-
diate loading and restoration of implants in selected cases.
Professionals working in implantology should always
bear in mind that the ultimate goal of installing dental
implants is to support a final prosthetic restoration. In
other words, the patients are looking for teeth and not
implants, and a restorative mentality must always be
maintained.
Surgical Guide Design
A surgical template is essentially a transfer tool, whose
objective is to transfer the diagnosis and planning of
surgical and prosthetic treatment from the software to
the patient, during the implant installation surgery.
Precise surgical guides, produced using CAD-­CAM
technology, require a very careful treatment plan. The
basis of surgical guide design starts with a well-­
conceived prosthetic design, taking into account the
patient’s needs, desired esthetics, and functional results.
The surgical guide will enable the clinician to per-
form the surgery with maximum precision, transferring
the design carefully conceived during the planning
phase to the patient’s mouth.

There are numerous techniques, software, and
procedures that have been developed to carry out the
entire process of virtual implant and prosthetic plan-
ning. The main initial imaging requirements are:
●● CBCT DICOM dataset
●● intraoral surface scan dataset (STL files)
●● virtual planning of implant positions.
Combining this set of tomographic data, intraoral
scanning, and virtual implant planning with specific
software (e.g., in a single file) will provide all the neces-
sary information for preparation of the surgical guide.
Most dedicated and specific software programs for the
virtual planning of implant surgeries have tools that
enable the virtual creation of the surgical guide and
ensure that the STL drawing of the surgical guide is
then saved and exported to a CAM device (Figure 6.3),
which will then produce the surgical guide that will be
used transoperatively in order to transfer the chosen
position prior to the implant.
Surgical guides are usually in the form of acrylic plates
and are designed to fit into the patient’s oral cavity during
surgery. Most surgical guides have small metal objects
called “sleeves” inserted in the exact place where the
implant is to be inserted, in order to guide the direction of
implant perforation, as well as limit the maximum depth
that the implant must reach physically in the bone.
Figure 6.3 Surgical guide design created by the software following the surgical plan designed by the professional.
Chapter 6 Digital Workflow in Implant Dentistry 201
Surgical guides must contain openings, called “inspec-
tion windows,” at different points of their structure,
through which the surgeon can assess the correct seating
of the guide during the operation.
There are three categories of guides, according to the
type of intraoral support used during the transoperative
period, which is extremely important to achieve stabil-
ity and precision.
●● Teeth-­supported guides, which use the remaining
teeth to anchor the surgical guide in place.
●● Guides supported on the mucosa, which will receive
support only in the soft tissues.
●● Bone-­supported guides, which will necessarily be
fixed in direct contact with the bone.
Mucosal and bone-­supported guides must always be
used in conjunction with fixation pins directly inserted
into bone to help stabilize the guide.
Overall findings conclude that mucosa and teeth-­
supported guides provide more reliable support.
Preparation of the Surgical Guide
The CAD-­CAM fabrication process can be performed
via additive 3D printing processes, such as rapid proto-
typing (RP), or subtractive fabrication (computer
numerical control [CNC] machining; milling).
202 Digital Dentistry: A Step-by-Step Guide and Case Atlas
Subtractive Method
Subtractive fabrication is a generic term for various con-
trolled machining and material removal processes that
start from solid blocks, bars, plastic rods, metal or other
materials, which are molded by material removal
through cutting, milling, drilling, and grinding.
The construction data produced with the CAD soft-
ware is converted into milling tracks for CAM process-
ing and finally loaded into a milling machine. This
typically involves computation to control the CNC
milling process, including features such as sequenc-
ing, milling tools, and tool motion direction and
magnitude.
Due to the anatomical variations of dental restora-
tions, milling machines often have different sized drills.
Milling accuracy is within 10 μm. There are three-­, four-­,
and five-­axis milling devices.
A three-­axis device has degrees of motion in three
directions of the orthogonal plane. Thus, the mill way-
points are uniquely defined by the X, Y, and Z coordi-
nates. The advantages of these devices are short milling
times and simplified control via the three axes. As a
result, such machines are generally less expensive than
those with four or five axes.
With a five-­axis milling device, in addition to the
three spatial dimensions and the rotating tension bridge
(fourth axis), there is also the ability to rotate the milling
spindle (fifth axis).
Additive Method
Three-­dimensional printing enables the fast and auto-
mated fabrication of physical objects directly from
computer-­drawn, virtual 3D design data without a sig-
nificant planning process related to part features and
geometry.
This technology was initially configured to increase
the speed of prototype fabrication in the manufacturing
industry. Recently, it has also been used for different
applications in the fields of medicine and dentistry.
Additive 3D printing techniques that can be used to
produce a surgical guide include SLA, digital light pro-
jection (DLP), jet printing (PolyJet®/ProJet®), and direct
laser sintering (DLMS)/selective laser sintering (SLS).
To produce the surgical guide, the STL file of the guide
should be imported to a slicing software, as previously
discussed in Chapter 3. An adequate and resistant
light-­cured resin should be used to fabricate the guide
(Figure 6.4).
In relation to the two types of manufacture of surgical
guides mentioned (additive and subtractive), there is
evidence that those produced by additive methods have
better adaptation to the seating surface and its support.
Figure 6.4 3D-­printed surgical guide of the case. A PolyJet
3D printer was used to fabricate the guide with light-­cured
resin (Biocompatible Clear MED610®, Stratasys).
Surgical Technique
The surgical guide tested in the mouth to confirm its
correct adaptation must undergo chemical disinfection,
through submersion in an alcoholic solution at 80% for
a period of 15 minutes or chemical sterilization using
ethylene oxide, depending on the material used to make
the guide. The process of chemical sterilization by ethyl-
ene oxide involves high temperatures, which can cause
distortions and dimensional changes in the guide.
The anesthetic blockade of the region of interest is
performed, always controlling the volume of anesthetic
liquid injected into the submucosal region, because
with the change in the volume of the mucosa, it may be
difficult or even impossible to adapt and settle the surgi-
cal guide, especially in cases of fully mucosa-­supported
guides. The fully muco-­supported surgical guides or
those with bone support, after being adapted with the
aid of occlusion indexes, must be fixed using anchorage
pins (see Chapter 7).
It is noteworthy that guided surgery is not synony-
mous with “flapless” surgery. What determines whether
a surgery should be “flap or flapless” (open or closed) is
the width of the band of keratinized tissue in the region
chosen as the impact point for implant insertion.
Therefore, if there is enough keratinized tissue, the sur-
gery can then be flapless.
Once the surgical guide fits with stability, the osteot-
omy sequence for the preparation of the implant sites
can be started, using the specific order of drills of the
implant system and model chosen (Figures 6.5 and 6.6).
The same guide can also be used to place the dental
implant (Figures 6.7 and 6.8). All the above-­mentioned
steps are illustrated in the case report below.
 Chapter 6 Digital Workflow in Implant Dentistry 203

Figure 6.5 Implant site of the surgery.

Figure 6.6 Surgical guide in position to orientate implant site drilling.

Figure 6.7 The implant placement performed using the surgical guide.
204 Digital Dentistry: A Step-by-Step Guide and Case Atlas
(a)
(c)
Figure 6.8 (a) Immediate postsurgery installation of milled PMMA temporary crown. (b) Immediate occlusion, (c) Postoperative
situation after 7 days. (d) Postoperative periapical radiograph of the case.
Case Report 6.1 Image-­Guided Implant Placement
(Clinical technique by Dr Otavio H. Pinhata-­Baptista)
The huge number of kits and systems available for
performing s-­CAIS differ mainly by having different
types of surgical instruments and different sizes of
sleeves. However, the difference that most impacts
the precision and accuracy of implant positioning is
the need for instruments called “drill guides,” which
are used to adapt the diameter of surgical drills to the
inner diameter of the sleeves in the surgical guide.
In systems in which surgical drills are designed to
eliminate the need to use these “drill guides,” as they
bring in their own body a wider region that perfectly
adapts to the internal diameter of the sleeve, the pre-
cision of the position of the installed implants is supe-
rior to systems where “drill guides” are still needed.
In a software environment for planning implants,
all exams files can be imported (digital STL files of
intraoral scans and DICOM files of CT scans) and start
(b)
(d)
the alignment between them all, thus gathering all
the necessary information.
Computed tomography guarantees the generation
of clear and precise cuts in craniofacial anatomy
images of each patient, being able to analyze in detail
the thickness and height of bone.
Anatomical structures and features are identified in
the software and can be demarcated for easy visuali-
zation during planning.
Computed tomography scans should aim not only
at evaluating bone structures, but also to provide
information regarding soft tissues to facilitate their
identification and to be able to carry out the respec-
tive alignment of meshes arising from the intraoral
scanning. For this purpose, it is recommended that the
CT be performed with a labial retractor, Expandex
type, to keep the lips apart during acquisition so that
there is no interference in the capture of the teeth of

the tomographic guide and/or ridge. The tomographic
exam, in dentate patients, must be performed with the
dental arches out of occlusion.
With all these imaging exams requested, the next
step is to commence the virtual planning of the ideal
position of dental implants.
The quality of CT images can be a determining fac-
tor in enabling or preventing the alignment of the
DICOM file of the tomography scan with the STL file
of the intraoral scan. A large amount of artifacts in
tomographic images can produce imprecise meshes,
which makes it impossible to correctly align them
with the meshes generated by intraoral scanning.
The meshes from the DICOM files can be aligned
with the meshes from the STL files automatically by
the guided surgery planning software when there are
meshes of good quality and with several equal ele-
ments in their composition. If the meshes are not of
good quality, or if the number of matching elements
in them is not enough, alignment in the software may
have to be performed manually.
Step-­by-­Step Procedures for Image-­Guide
Implant Surgery
●● Perform the patient’s CT, covering the edentulous
region to be rehabilitated with a dental implant.
●● Save the DICOM file of the CT.
●● Perform intraoral scanning of the patient (edentu-
lous arch, antagonist arch, and occlusion).
●● Save the STL or PLY file generated by the intraoral scan.
●● Load the scan file into the software for the virtual
waxing of the restoration of the missing tooth.
●● Design the tooth to be restored using the specific
workflow of the design software.
●● Save the STL file of the virtual wax-­up.
●● Open the virtual implant surgery planning software.
●● Register the patient and select the tooth to be reha-
bilitated in the software.
6.2.3 Full-­Arch Implant Rehabilitations
6.2.3.1 The Concept of Digital Image-­Guided
Implant Surgery for Full-­Arch Rehabilitations
The concept of image-­guided implant surgery encom-
passes all the techniques, materials, and strategies used
to produce templates (guides) to install implants in the
optimal position, suitable for the future prostheses, by
means of computerized planning.
6.2.3.2 Advantages of Guided Surgery
The main advantages of dental implant-­guided sur-
gery are related to its precision and the delivery of
Chapter 6 Digital Workflow in Implant Dentistry 205
●● Load into the software the STL or PLY files of the
intraoral scans.
●● Also load the case’s DICOM file into the software.
●● Follow the steps of the workflow proposed by the
surgical planning software.
●● Digitally align the meshes of the DICOM file with
those of the STL or PLY files.
●● Load the STL file generated by the virtual wax-­up of
the restoration.
●● Choose from the implant library the brand, model,
and measurements of the selected implant.
●● Based on the CT images loaded and aligned with the
meshes of the intraoral scan, place in the correct
three-­dimensional position the implant selected in
the previous step.
●● Save the implant position and proceed to selection
of the specific sleeve for the case, as well as the
height that it should remain in relation to the
implant platform.
●● Design the surgical guide based on the saved place-
ment of the implant and its respective sleeve.
●● Save the surgical guide design and export the gen-
erated STL file to be printed later on a 3D printer.
●● Using an appropriate software integration tool, trans-
fer the implant positioning to the design software.
●● Once in the design software, select the abutment to
be used together with the implant in the prosthetic
rehabilitation.
●● With the abutment selected and perfectly matched
with the implant by the software, proceed to adjust-
ment of the mesh of the wax-­up, so that it adapts
properly to the selected abutment.
●● Save the generated restoration STL file for later
printing or milling.
●● Install the implant using the planned surgical guide.
●● Install the printed or milled prosthesis over the
installed implant, using, as an intermediary, the
abutment previously selected by the software.
implant positions optimized for prosthetics in a much
simpler and faster surgery than a conventional one [6].
Additionally, guided surgeries are often minimally
invasive, as the surgeon will not need to open a flap.
Instead of incisions, only a circular cutter is used and
the surgeon will trust in the guided planning and tac-
tile sensitivity to place the implants.
6.2.3.3 Dental Teamwork and Technical
Requirements for Planning Guided Surgeries
To conduct computer-­guided surgery, specific soft-
ware, hardware, and trained personnel are required.
For the planning step, a multidisciplinary integration
206 Digital Dentistry: A Step-by-Step Guide and Case Atlas
of digital radiology, implant surgeon, prosthodontist,
software specialist, and dental technician is needed.
However, as all the requirements are rarely available in
one single dental clinic, outsourcing part of the work
can be a solution for some professionals. Outsourced
planning for guided surgeries can be available through
third-­party companies such as planning centers, den-
tal laboratories, dental radiology clinics or implant
manufacturers.
Case Report 6.2 Full-­Arch Image-­Guided Implant Placement
(Clinical technique by Dr Roberto A. Markarian)
Figure 6.9 Initial image exams from the patient.
6.2.3.4 General – Performing Surgery
Most dental implant manufacturers have developed sur-
gical kits and trays, with special instruments, to allow
the realization of dental implant-­guided implant surgi-
cal procedures (Figures 6.9–6.18).
As each manufacturer develops its own specific drill-
ing protocols, professional qualification, through
accreditation courses, in the specific dental implant
system is required to perform the procedures safely.
 Chapter 6 Digital Workflow in Implant Dentistry 207

Figure 6.10 Extraoral and intraoral initial conditions. In this case, the patient approved the overall contours and
esthetics of the complete denture. As such, the virtual planning objective is to replicate the previous prosthetic results
into the future fixed implant supported version.

Figure 6.11 Virtual dental implant position, and fixation pins planned in dedicated software.

(Continued )

6.2.3.5 Step-­by-­Step Procedure for Full-­Arch
Image-­Guided Surgery, from Planning to Surgery
The rationale for full-­arch dental implant-­guided sur-
gery requires planning and teamwork following some
major steps.
1) Initial diagnostics and screening
2) Preoperative prosthetic planning
3) Digital data acquisition: CT scan, intraoral or
model scan
4) Planning software: implant positions
5) Planning software: guide design
6) Surgical guide fabrication
7) Surgery for dental implant placement
8) Provisionalization and prosthetics
Case Report 6.2 (Continued)

Figure 6.12 Virtual dental implant position related to the prostheses. The prosthetic contours can be aligned and
superimposed to the bone anatomy in the planning software.

Figure 6.13 Surgical printed guide in two parts, with the objective to install the implant for a full-­arch rehabilitation.

Figure 6.14 The surgical guide should be tried in mouth prior to surgery. The overall contours of the guide use the
prostheses as a reference.
Figure 6.15 In the first surgical step, fixation pins are positioned to secure the guide against the intraoral tissues.

Figure 6.16 The surgical procedure at different points. 1 Surgical punch. 2, 3 Bone cutters in use. 4 Implant being positioned.

Figure 6.17 Intraoral aspect directly after the surgery. The procedure was successful in using a minimally invasive
protocol. Some stitches were applied to improve soft tissue healing.

(Continued )
210 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Case Report 6.2 (Continued)

(a) (b)

(c)

Figure 6.18 Comparison of preoperative images (a,b) with postoperative panoramic radiography (c) taken to access
implant positions, that can be compared to those predicted by virtual planning.

Initial Diagnostics and Screening
After verifying that the patient presents the clinical
indication for full-­arch implants, the clinician must per-
form initial technical analysis to check if the case
is viable.
The first step is to verify through image exams such as
panoramic x-­ray and CT scan if there is enough bone to
install dental implants. If the need for major bone grafts
or bone osteotomy is detected, the patient must first
undergo these surgical procedures.
Restricted mouth opening must be assessed as it may
interfere with instrumentation and implant installation,
especially because the burs for guided surgery are sig-
nificantly longer than regular cutters.
After the patient is adequately informed and approves
the proposed treatment, the planning phase begins.

Preoperative Prosthetic Planning
The installation of dental implants in an ideal position
must preserve the requisites of the final prostheses.
Therefore, surgical planning is not possible without first
predicting what would be the best prosthetic esthetic
and functional result. Using photography, apps, and
dedicated software, the ideal smile design, tooth shapes,
and colors can be predicted, and reproduced in the fol-
lowing steps.
●● Previous prostheses and dentition analysis: the previ-
ous dentition or prosthetic rehabilitation should be
analyzed for the presence of technical desirable
requirements such as labial support, vertical dimen-
sion, tooth position overall contours, and patient
acceptance. Any valuable information should be con-
sidered for replication in future prosthetic steps and
not created from zero.
●● Reverse prosthetic planning: every case must go
through a reverse planning protocol before designing
the surgical guide. However, the steps will be different
if the patient previously edentulous or instead pre-
sents with a fallen dentition.
●● Partially dentated arch: collapsing dentition with
severe cases of tooth migration/mobility, loss of verti-
cal dimension, or unstable occlusion should undergo
planning as for completely edentulous arches. In
cases with a more stable dentition, the clinician can
opt to record the status of the remaining teeth and
soft tissues. If occlusion is not adequate, the clinician
should provide a mock-­up planned to predict the final
esthetic condition, especially tooth positions and
prosthetic volume.
●● Completely edentulous arch: fabrication of a new den-
ture with good esthetic and functionality is manda-
tory for edentulous patients. If the patient already
possesses an adequate prosthesis, a duplication can be
used for dental planning. The prosthetic duplication
may be checked intraorally to ensure a precise palatal
adaptation.
Digital Data Acquisition: CT Scan, Intraoral or Model Scan
In order to allow surgical planning, patient information
must be digitized and imported into the software. The
planning software is capable of reading CT files
(DICOM), and dental scan files (STL).
The information gathering and clinical steps required
will depend on whether the patient is partially dentated
or edentulous. The digital data from a patient can be
sent to a third-­party planning center or kept in house if
all the hardware and software are available.
Chapter 6 Digital Workflow in Implant Dentistry 211
Partially Dentated Arch
●● Scan files: an intraoral scanner is especially useful to
capture oral contours directly, as the fallen dentition
and prosthetics can be fragile. The essential intraoral
scans will be the dental arch to be treated with and
without the present prosthetics or the designed mock-
­up (dual scan), the opposing dentition, and the bite
scan. Alternatively, gypsum casts can be digitized at
the dental laboratory.
●● Image files: a CT scan of the complete arch to be
treated needs to be incorporated into the software.
Completely Edentulous Arch
●● Scan files: no scan files are needed.
●● Image files: the CT scan files will contain all the infor-
mation required to predict the internal bone anatomy
and projected prosthetic contours. To that end, two
different CT scans should be taken, one of the denture
itself (or a duplication), containing radiopaque mark-
ers, and one of the patient wearing the same denture
containing the markers.
Planning Software: Implant Positions
After importing the digital files, the software aligns and
merges the information, presenting the planning inter-
face with both the intraoral reliefs and the bone shape
and internal structure. Additional scan files can also be
imported with the desired prosthetic contours, and
alternative file types can provide additional informa-
tion such as surface textures and colors. Several tools
become available at this point to simulate the virtual
positioning of different models and shapes of dental
implants into the bone.
Most commercial dental implant manufacturers
have their libraries available in virtual planning soft-
ware. The complete library for a dental implant brand
may include dental implant shapes, sizes and availa-
ble models, and also accessories such as sleeve and
pin options.
Each virtual planning software has its own
peculiarities regarding design steps and tools, that
should be learned through a specific accreditation
course. The virtual planning for implant positioning
must follow current implantology specifications to
support full-­arch fixed restorations, such as providing
good biomechanical behavior, sufficient number of fix-
tures, and strategic positioning.
When the dental implants are virtually positioned
into the patient’s bone, the software specialist can dis-
cuss the planning phase with the implant surgeon and
212 Digital Dentistry: A Step-by-Step Guide and Case Atlas
prosthodontist. Sometimes even the prosthetic compo-
nents can be predicted and preselected. After the dental
team approves the implant positioning strategy, the
design of the surgical guide begins.
Planning Software: Surgical Guide Design
The objective of producing a surgical guide for full-­arch
surgeries is to produce a precise template for implant
installation. To achieve precision, the surgical guide
must be designed to be well adapted to hard and soft
tissues.
The surgical procedure imparts vibration and forces
to the guide so the design of its construction must be
reinforced to be sturdy, rigid, and inflexible. A poor
design may allow the displacement, bending or fracture
of the guide during surgery.
Surgical guides can be fabricated by accredited dental
laboratories, planning centers, or even in house with the
proper equipment and personnel. Depending on
whether the guide will be tooth supported or gingiva
supported, there are different strategies to the design.
●● Partially dentated arch: in cases with some remaining
teeth, the surgical guide can be supported by them. To
achieve precision, a tripodal stable support must be
obtained. The inclusion of fit checking windows on
remaining teeth can help to access the guide precision
in mouth. In regions with poor tooth support, fixation
pins can be incorporated into the design.
●● Completely edentulous arch: for edentulous cases a
strategic design may be chosen by the surgeon, as the
guide can be projected in one or two pieces. In any
case, there must be good adaptation of the guide to
the palatal gingiva. The guide design must incorpo-
rate at least three pins to ensure that the guide will be
tightly attached to the bone, and that surgical manip-
ulation will not displace it.
–– One piece resembling a base plate.
–– One piece incorporating the teeth contours and
base plate of the complete denture.
–– Two pieces: base plate incorporating implant
sleeves + removable teeth in the upper position.
Incorporating teeth extensions in the guide allows the
patient to bite while attaching the fixation pins, allow-
ing the base plate to be secured into position with
enhanced precision.
After the dental team approves the guide design, the
surgical guide can be sent to production. Some commer-
cial CAD software can produce an output file of the jaw
containing the virtually placed implants, that can be
used for prosthetic planning, or the creation of a printed
model. Additionally, a pdf file with a surgical report is
exported containing all the technical information
needed to conduct the surgery.
Surgical Guide Fabrication
After planning in CAD software, an output STL file for-
mat of the guide is created. The surgical guide can then
be fabricated by rapid 3D printing or milling in a five-­
axis machine using a translucent PMMA blank. After
printing, the guide must be washed, cured, and inspected
internally for the presence of irregularities.
The surgical guide may incorporate surgical sleeves
provided by the dental implant manufacturer. These
washers are designed to match the exact diameter for
implant placement during surgery. The sleeves are
positioned manually and then carefully glued to avoid
distortions that can compromise the procedure’s
precision.
In recent approaches, some dental implant manu-
facturers do not use metal sleeves. In this guide
design version, the resin orifice will guide the bur
placement.
Surgery for Dental Implant Placement
Upon receiving the surgical guide, it is recommended to
fit test in mouth prior to surgery to ensure that the fit-
ting to oral tissues is correct. In case of misalignments,
check the guide for internal bubbles, artifacts or rough-
ness. Some minor corrections can be made without
compromising the precision. However, if the fit is not
optimal, consider remanufacturing the device.
In the first step of surgery, the guide must be secured
in mouth by fixation of the accessory pins. The next
steps will be to prepare the implant sites, removing gin-
gival tissue with a rotatory punch and leveling the bone.
The following procedures can vary according to the
specific features of the selected dental implant model/
brand and the tools present in the surgical trays and
kits. The dentist must be trained, through accredited
courses, in the specific dental implant system in order to
be informed of the available tools.
The main surgical objective is to prepare the bone
socket, through enlarging cutters, precisely attached
to the guide sleeves. However, the guided surgery sys-
tem workflow can be performed in many ways and it
is up to the skilled surgeon to choose the best flow
according to the specific case of each patient. Some
dental implant models can be placed with the guide in
position (fully guided) while others will require

removal of the guide and the use of a manual ratchet
for final installation.
Provisionalization and Prosthetics
The strategy of provisionalization may be previously
planned together with the surgical procedure, to ensure
patient comfort and esthetics. Meanwhile the implants
are allowed to osseointegrate.
Many possibilities for temporary prostheses are pos-
sible, depending on patient and clinician preference.
Partially edentulous arches would require a transition
prosthesis supported by remaining teeth. Another
option would be the removal of the remaining teeth
after implantation, to allow placement of a complete
removable denture, previously fabricated.
For completely edentulous patients, the previous pros-
thesis can be used as a provisional guide, after rebasing.
In cases where a high implant torque is achieved during
placement, the immediate load of the implants can be
considered.
However, the main goal for guided surgery is to
achieve precise implant positioning, not necessarily
reaching a high insertion torque. Therefore, the imme-
diate load of guided implants is not mandatory, but it
can be executed by experienced surgeons, especially in
selected mandibular cases.
The creation of workflows for full-­arch implant-­
guided surgery is a main field of research today. As such
there are many experimental ideas to integrate the sur-
gical and prosthetic outcome in a full digital environ-
ment. Although consensus has not yet been reached,
the most practical approach will be to consider the sur-
gery and prosthodontics as two separate workflows.
The final prosthetic restoration can be fabricated
using specific workflows described in Chapter 4.
6.2.3.6 Additional Remarks
●● There is a learning curve for the surgeon during
guided surgery, even for the clinician experienced in
conventional dental implant surgeries.
●● In highly resorbed bone areas or when associated
grafts are needed, a gingival flap may be opened for
better visualization, and to ensure correct positioning
of the implant.
●● Edentulous patients with flexible gingiva can produce
distorted models when impressions are taken with
silicone, because of tissue compression. Intraoral
scans are preferable.
●● Any distortion in the guide can produce incorrect
implant positioning leading to disastrous results.
Chapter 6 Digital Workflow in Implant Dentistry 213
●● Research trends will improve future versions of den-
tal implant-­guided surgeries, in fields such as robotic
surgery, dynamic surgery and navigation, bone oste-
otomies and grafts, prosthetic integrated workflows,
smile planning, and prediction.
6.2.4 Zygomatic Implants
Full-­arch implant rehabilitations are currently one of
the most common and predictable treatments for eden-
tulous patients in daily clinical practice because of
their high long-­term survival and success rates. Tooth
loss, the absence of dental stimuli, and the pneumatiza-
tion of the maxillary sinus due to the increment in posi-
tive pressure lead to generalized resorption of alveolar
processes, compromising bone availability and prevent-
ing implant treatment. Among different techniques
developed for achieving sufficient bone augmentation
to allow dental implant placement, the use of zygo-
matic implants presents a therapeutic alternative to
avoid the use of regenerative techniques which are usu-
ally associated with longer surgical times and multiple
interventions.
Zygomatic implants were described by Brånemark in
1989 as 30–50 mm length implants, with a 45° angled
head and a diameter of 4.5 mm at its widest part, mainly
used for those patients with severe maxillary atrophy.
Surgical technique consisted in the creation of a sinus
window, reflection of the Schneiderian membrane and
placement of the described implants through the maxil-
lary sinus, from the palatal aspect of the alveolar pro-
cess to its anchoring in the malar body. Due to associated
esthetic and functional complications, as well as other
complications such as sinusitis, Stella and Warner
developed the sinus slot technique, which consisted in
creating a small slot in the external maxillary wall to ori-
entate the implant, improve visibility, and avoid the
Schneiderian membrane elevation. Currently, although
surgical technique has evolved in an extrasinusal
approach, the anatomical biotype of the patient deter-
mines procedure selection.
In any case, the success of these kinds of rehabilitation
is determined by correct implant positioning and angula-
tion, which allows the anchoring of the apex of the
implant in high bone density areas, maximizing bone to
implant contact (BIC) and easing the posterior prosthetic
rehabilitation. For these reasons, digital planning became
essential to increase predictability and avoid associated
technical complications [7] (Figures 6.19–6.31).
214 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Case Report 6.3 Digital Workflow for Zygomatic Implants

(Clinical technique by Dr Jesus Torres, Baoluo Xing, and Oscar Iglesias Velazquez)

Figure 6.19 Using Blue Sky Plan to process the DICOM files from the patient.

Figure 6.20 In the model Editing interface, select the segmentation tool – Advance jaw segmentation – Indicate jaw.

(a) (b) (c) (d)

Figure 6.21 (a) With the segmentation tool, we select maxillary volume in different sections within axial, coronal, and
sagittal views. (b) A change in color appears in the volume (red). (c) Selected cuts of the segmentation procedure.
(d) Segmentation in a coronal view. Once the segmentation has proceeded through the entire maxilla, performing axial,
coronal, and sagittal draw delimitations, a STL file is created.
 Chapter 6 Digital Workflow in Implant Dentistry 215

Figure 6.22 The STL file will superimpose to the original DICOM file automatically. In this step, any changes to the bone
reproduction should be considered. If any irregularity occurs in the STL file, then we should go back to the segmentation tool and
patch up the error.

Figure 6.23 In the implant selection tool, “Add implant” should be selected and maybe a custom implant should be created
for precise guide design. Then, the exact data of the implant, abutment, and guide tube should be given to the program.

(a) (b) (c)

Figure 6.24 (a) In the Advanced Surgical Guide interface, the zygomatic implant is placed. Choose the adequate length and
ideal positioning. (b) The 45° abutment tool may be used to ensure correct orientation of the implant. (c) Two guide tubes
should be used, one for the coronal side near the zygomatic process of the maxilla and one for the occlusal side. To achieve
this, you may duplicate the implant and move the duplicated guide tube to the desired position.

(Continued )
216 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Case Report 6.3 (Continued)

(a) (b)

Figure 6.25 (a) Now, in the Denture module, we can create the path of insertion for the surgical guide. This path of
insertion should give stability to the surgical guide and prevent misalignment. (b) The blue arrow in the two preview
pictures shows that the best path of insertion is from the side of the surgical guide, and from the front part to the back.

(a) (b)

Figure 6.26 (a) With this procedure, we are able to generate a new STL model file without undercuts and provide the
future guide with an excellent path of insertion. (b) In the surgical guide tool, select “Maxilla” and the draw curve tool.

(a) (b) (c)

Figure 6.27 Virtual surgical planning.

 Chapter 6 Digital Workflow in Implant Dentistry 217

(a) (b)

Figure 6.28 (a) The thickness of the guide should be between 2 and 3 mm, coronal view. (b) Occlusal view. Once the
surgical guide is created, minor adjustments may be made. Exportation of surgical guide and implant is performed.

(a) (b) (c)

Figure 6.29 (a) In Meshmixer, we separate both STL files, using the boolean difference tool. A surgical guide with great
adaptation to the maxilla without compromising the guide tube inner diameter of 3.35 mm is made (designed for the pilot
bur in zygomatic implant of 3.3 mm). (b,c) After final adjustments are made, the STL file is ready for 3D printing.

(a) (b)

Figure 6.30 During surgery, after rising the mucoperiosteal flap, the surgical guide should be positioned correctly. Thanks
to the designed path of insertion and the absence of undercuts, the guide should find its natural position automatically.

(Continued )
218 Digital Dentistry: A Step-by-Step Guide and Case Atlas
Case Report 6.3 (Continued)
(a)
Figure 6.31 The clinician may perform the drill sequence taking into account that the inner width of the guide tube
should be 0.05 mm wider than the last bur used for that guide.
6.3 ­Dynamic Guided
Implant Surgery
Dynamic computer-­assisted surgery was originally
introduced in neurosurgery to perform safer and mini-
mally invasive brain interventions. In implantology, it is
a modality of 3D surgery, performed with the aid of
software that ensures monitoring, with great magnifica-
tion, in real time, during the entire duration of the bone
perforation procedure and implant installation, with
preplanned positioning in a virtual environment, by the
use of optical motion tracking technology.
In dynamic computer-­assisted implant surgery
(d-­CAIS), the methods of digital wax-­up and virtual
implant planning remain identical to those performed
for the static surgeries described above.
Initially, to record the jaws in the navigation software, a
device with radiopaque markers (fiducial markers) is
adapted to the patient’s teeth (Figure 6.32) and a CBCT scan
is performed. The digital information obtained is transferred
Figure 6.32 Dynamic image-­guided surgical procedure – 1.
(b)
to the computer. Furthermore, if available, images from
intraoral or laboratory laser scans can be superimposed on
the patient’s anatomical information in the same software,
further facilitating the planning as a whole.
In cases of totally edentulous patients, the markers
for performing CBCT, which were previously adapted
to the teeth, are then changed by small screws (mini
implants) fixed in the bone, which remains with a part
of their body, transmucosal, appearing inside the oral
cavity. This device is removed from the patient only
after the implant surgery has been performed.
6.3.1 Surgical Technique
After waxing and virtual planning of implant placement
performed in specific software, the d-­CAIS system uses
motion tracking technology to track implant drilling
instruments and the position of the patient’s jaw.
Radiopaque markers that are attached to the jaw,
either because they are fitted to the teeth or fixed to the

Figure 6.33 Dynamic image-­guided surgical procedure – 2.
Figure 6.34 Dynamic image-­guided surgical procedure – 3.
bone of totally edentulous patients during tomography,
are used at the time of surgery to provide synergistic
movement between the corresponding anatomy in the
CT image and the surgical field.
Tracking cameras are configured during the surgical
procedure to continuously track the sensors attached to
the patient’s jaw and surgical handpiece, displaying
them in real time on the monitor overlaying the virtual
plane (Figure 6.33). Any 3D deviation of the drill and
implant from the virtual plane can be seen in real time,
and adjustment of drilling depth, angle or implant posi-
tion can be performed at any time.
These optical tracking devices can be passive or active.
Passive systems use tracking devices that reflect light
emitted from a source to stereoscopic cameras, while
active ones emit light that is tracked directly by these cam-
eras. For a passive system, for example, the device used for
tomographic recording of the jaws is again applied to the
patient during surgery, providing synergism between the
tomographic image and the surgical field (Figure 6.34).
The bone milling sequence is conventionally per-
formed, drill by drill, but the surgeon uses the navigation
Chapter 6 Digital Workflow in Implant Dentistry 219
Figure 6.35 Dynamic image-­guided surgical procedure – 4.
screen to guide and confirm in three dimensions all the
steps of the procedure.
It is important to note that no specific milling system
or surgical instruments are needed for these navigation
systems as is the case with s-­CAIS, which requires drills
compatible with the sleeves present in the surgical guide.
It is not necessary to print additional devices (stereo-
lithographic surgical guides), as well as the acquisition
of instruments (specific surgical kits) to perform this
type of surgical technique (Figure 6.35).
The lack of need to use a physical surgical guide
(printed) becomes one of the pros in favor of the
dynamic surgery method over the static method,
because, in this way, without the need to use a surgical
guide, some cases that would be contraindicated for
computer-­assisted surgery, due to limitation in the
patient’s mouth opening, become viable by use of the
dynamic method.
6.4 ­Bone Graft Volumetric Planning
6.4.1 Socket Preservation
Cone beam computed tomography has been used for vir-
tual surgical planning, mostly because of its high resolu-
tion, easy manipulation, high accessibility, low dose of
ionizing radiation, and fewer beam-­hardening artifacts
220 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Case Report 6.4 Socket Preservation Volumetric Planning

(Clinical case and technique by Professor Arthur R.G. Cortes) cleaned and irrigated with saline solution. Then,
alveolar ridge preservation was performed by com-
This patient had initially undergone CBCT (ProMax®
pletely grafting the alveolar socket (Figure 6.38)
3D, Planmeca) scans, with an acceptable imaging
immediately with an equine-­ derived particulate
protocol (e.g., 0.2 mm voxel, 90 kVp, 8 mA, field of
bone graft material (Bio-­Gen Putty, Bioteck) follow-
view of 16 cm in diameter and 6 cm in height), from
ing the CBCT volumetric measurements previously
which DICOM files were obtained and used for esti-
performed for each case. A resorbable collagen
mating the volume of each socket area to be filled by
membrane (Bio-­Gen membrane, Bioteck) was then
particulate bone grafts (Figure 6.36). For this pur-
used to cover the socket before suturing (5-­0 nylon,
pose, the area of interest is outlined in the cross-­
Ethilon). To avoid opening a flap, the collagen mem-
sectional slices, before being converted to a volume
brane was left partially exposed to the oral cavity
of interest. Alternatively, pixel threshold values could
and stabilized by the sutures.
be used to set the region of interest. Such volumetric
After a graft healing period of 5 months, another
measurements were performed in cubic millimeters
CBCT was taken (Figure 6.39) to perform virtual
(Figure 6.37) using a specific tool of a DICOM viewer
implant planning and digitally design a surgical guide.
software (OsiriX® MD, Pixmeo). From the socket vol-
The same initial surgical procedure was performed on
ume, we estimated the number of biomaterial pack-
all implants, starting with a crestal incision performed
ages required to fill the socket to achieve satisfactory
slightly palatal to the alveolar crest midline, elevation
ridge preservation.
of the mucogingival flap (Figure 6.40), surgical
All surgeries were performed by the same sur-
preparation of the implant place with osteotomy,
geon, and all extractions were performed atraumat-
appropriate placement of the implant (either BLT or
ically by using a flapless approach. The socket was

Figure 6.36 Cone beam computed tomography multiplanar reconstruction showing a region of interest (ROI) outlining the
socket area in a coronal slice, estimating the volume to be filled by particulate bone grafts. Note the challenging situation
related to the bone resorption at the site of the tooth.
Figure 6.37 Alveolar socket volumetric measurement output, showing an estimated volume of 368 mm3.

Figure 6.38 Clinical view of the alveolar socket filled with equine-­derived particulate bone graft.

Figure 6.39 CBCT image obtained after 5 months of graft

healing, showing buccal plate integrity and satisfactory Figure 6.40 Clinical view of the surgical site prior to
bone dimensions for implant placement. implant placement.

(Continued )
222 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Case Report 6.4 (Continued)

(a) (b)

(c)

Figure 6.41 Representative histological sections of the material presented in the trephine. (a) Panoramic view showing
high density of trabeculae, surrounded by thin connective tissue (hematoxylin & eosin, ×25 original magnification).
(b) Detail of the trabeculae, exhibiting immature bone with high frequency of osteocytes in lacunae. Exogenous material (*)
is also presented between the trabeculae (Masson trichrome, ×100 original magnification). (c) High magnification of the
endogenous material (*) adjacent to the newly bone matrix. Source: Courtesy of Dr Luciana Correa, University of São Paulo.

SP, Straumann) while recording the respective peak

insertion torques in Ncm, positioning of the healing
screw, and 5-­0 nylon sutures. In representative ran-
dom cases, bone samples measuring 3 × 6 mm were
retrieved for histological analysis during implant site
preparation by using a 3.0 mm diameter trephine
(Figure 6.41).
A Straumann 4.1 × 8 mm tissue level dental
implant was placed and restored after 6 weeks to
rehabilitate the site (Figures 6.42–6.44). No postop-
erative complications were noted within a 27-­year
follow-­up.

Figure 6.42 Final implant position after obtaining a peak

insertion torque of 35 Ncm.
 Chapter 6 Digital Workflow in Implant Dentistry 223

Figure 6.43 Final clinical result after installation of the

implant-­supported crown. Figure 6.44 Final periapical radiograph after a 27-­month
follow-­up.

compared to medical CT images. Besides linear meas-

urements of alveolar bone height and width, CBCT also
allows for volumetric measurements (e.g., in cubic mil-
limeters), as it is a tridimensional image-­obtaining
method [8]. The following case illustrates a technique of
volumetric planning for alveolar socket preservation.

6.4.2 Sinus Lifting

One of the main limitations for implant therapy is insuf-
ficient bone dimensions at the alveolar ridge. Edentulous
areas of posterior maxilla regions commonly present
low bone density and height between the alveolar crest
and maxillary sinus. Maxillary sinus floor augmenta-
tion allows for recovery of alveolar bone height by the
surgical placement of bone grafts, which can be com-
posed of synthetic materials [9–12].
Figure 6.45 Measurement of the desired area to receive sinus
Cone beam computed tomography scans of healed grafts in a cross-­sectional CBCT slice. This should be repeated
sinus grafted with BCP were measured for height and in the other cross-­sectional slices of the region of interest.
width. Anatomical variations of the sinuses can be
assessed on CBCT multiplanar reconstruction. These
images can also be useful to predict and follow up the
volume of particulate grafting material required to ena-
ble the desired subsequent implant planning.
The method used to perform volumetric graft planning
for sinus lift surgery may vary among different software
programs with different measurement tools. Such tools
are available in several DICOM viewer software pro-
grams. Briefly, the first step is to outline the area to receive
bone graft in all cross-­sectioned slices containing the
sinus extension to be grafted (Figures 6.45–6.47). As in
socket preservation volumetric measurements, the soft-
ware can render all 2D cross-­sectional measurements Figure 6.46 Final volumetric measurement for sinus grafting.
224 Digital Dentistry: A Step-by-Step Guide and Case Atlas

into a 3D volumetric measurement. This could orient the surgical guide could also be designed based on the CBCT
surgeon regarding the amount of particulate synthetic scans to orientate the osteotomy of a lateral window,
material required, provided that the size of granules and when such an approach is required for the sinus lifting
properties of the biomaterial are known (Figure 6.48). A procedure [13].

Figure 6.47 Volume measurement output.

Figure 6.48 Comparison of planned and actually executed sinus grafts using Horos software.

6.4.3 Onlay Bone Grafts
It is known that in cases with severe atrophy of the jaws
with lack of native bone volume, lateral and vertical
augmentation is required. A CAD-­CAM method was
developed to mill freeze-­dried allogeneic bone
blocks [5].
To test this technique, an ex vivo experiment was set up.
The technique uses CBCT DICOM files, which are opened
Figure 6.49 Virtual planning for anterior maxillary graft.
Figure 6.50 3D model of the bone graft.
Chapter 6 Digital Workflow in Implant Dentistry 225
using implant planning software and converted to be ren-
dered as a 3D reconstruction atrophic maxillary area. This
3D image was saved as an STL file. The STL mesh was
edited in a CAD software (Geomagic FreeForm PlusTM,
3D Systems) to add a new mesh representing the volume
of onlay bone graft required to overcome the atrophic area
(Figure 6.49). The resulting 3D volumetric reconstruction
was also saved as an STL file and recorded (Figure 6.50).
226 Digital Dentistry: A Step-by-Step Guide and Case Atlas
Figure 6.51 Milled allogeneic bone block as part of a
research study. The block had the same dimensions as the
STL file.
The STL file was further imported to a CAM software
(SUM3D Dental, CIMsystem) to prepare for milling of a
freeze-­dried allogeneic bone block with predetermined
dimensions. These blocks were milled in a five-­axis mill-
ing device (DWX-­50, Roland DG Corporation) to obtain
the final onlay graft shape (Figure 6.51).
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(2018). Comparison of pixel values of maxillary sinus
grafts and adjacent native bone with cone-­beam
computed tomography. Implant. Dent. 27 (6): 667–671.
10 Cortes, A.R., Cortes, D.N., and Arita, E.S. (2012).
Effectiveness of piezoelectric surgery in preparing the
lateral window for maxillary sinus augmentation in
patients with sinus anatomical variations: a case series.
Int. J. Oral Maxillofac. Implants 27 (5): 1211–1215.
11 Tosta, M., Cortes, A.R., Corrêa, L. et al. (2013).
Histologic and histomorphometric evaluation of a
synthetic bone substitute for maxillary sinus grafting
in humans. Clin. Oral Implants Res. 24 (8): 866–870.
12 Cortes, A.R., Corrêa, L., and Arita, E.S. (2012).
Evaluation of a maxillary sinus floor augmentation in
the presence of a large antral pseudocyst. J. Craniofac.
Surg. 23 (6): e535–e537.
13 Zaniol, T., Zaniol, A., Tedesco, A., and Ravazzolo,
S. (2018). The low window sinus lift: a CAD-­CAM-­
guided surgical technique for lateral sinus
augmentation: a retrospective case series. Implant.
Dent. 27 (4): 512–520.

Chapter 7
Digital Workflow in Oral and Maxillofacial Surgery
Daniel Negrelle, Alexandre M. Borba, Isabella Romão Candido, Shaban M. Burgoa,
Luiz F. Palma, and Arthur R.G. Cortes
SUMMARY
This chapter presents a step-­by-­step guide and research evidence on digital workflow in oral and maxillofacial surgery.
Featured topics include image-­guided oral surgery, orthognathic surgery and trauma surgical management.
7.1 ­Image-­Guided Surgical
Removal of Impacted Teeth
With current technology in digital dentistry, different
types of surgical guides can be designed. CAD software
enables the digital planning of the entire surgical proce-
dure and then the digital design of guides that can be
printed or milled in order to orientate the procedures.
Surgical planning of procedures involving osteotomies
allows for designing surgical guides to provide precise
access to the anatomical location and for calculating the
amount of bone to be removed. This is particularly use-
ful in cases of retrieval of foreign bodies or impacted
teeth. In addition, digital workflow allows for sharing
treatment plan data immediately with a network of
other professionals, enhancing communication among
patients and professionals [1].
Among the most important requirements for plan-
ning an image-­guided surgery is the combination of STL
files from intraoral scans (IOS) and DICOM files from
cone beam computed tomography (CBCT). Such combi-
nation allows for considering conditions of hard and soft
tissues during virtual surgical planning [2]. In cases
involving oral rehabilitation following surgery, prosthet-
ically driven virtual implant planning can also be carried
out [3]. Furthermore, digital workflow methodologies
have also been described for orientating bone grafting
procedures [4, 5]. However, despite new types of surgical
guides which have recently been designed and used in
dentistry [4, 6], it was not possible to find any article in
Digital Dentistry: A Step-by-Step Guide and Case Atlas, First Edition. Edited by Arthur R.G. Cortes.
© 2022 John Wiley & Sons Ltd. Published 2022 by John Wiley & Sons Ltd.
227
the literature describing the use of a sleeveless surgical
guide for orientating surgical removal of supernumerary
tooth impacted between adjacent roots.
A surgical technique using a CAD-­CAM surgical guide
for removal or retrieval of impacted objects in the maxilla
is presented and illustrated with the following clinical
case: an 18-­year-­old male patient who presented for
orthodontic treatment was referred for surgical removal
of a supernumerary tooth. The patient signed an informed
consent to present his treatment data in this report.
7.2 ­Surgical Planning
of Orthognathic Surgeries
Accurate presurgical planning is essential for the treat-
ment of dentofacial deformities, especially in orthog-
nathic surgeries. Virtual surgical planning is the current
gold standard method to achieve greater precision for
bone and dental movements as well as to gain a reliable
perspective of postsurgical changes to facial soft tissues.
7.2.1 Virtual Skull Construction
All virtual planning software programs, regardless of
their particularities, are based on the same steps (image
importation; virtual skull composition and orientation;
osteotomy design; cephalometric landmarks definition;
bone segment movement;splint construction). Case
Report 7.3 will show these steps using Dolphin 3D
v12.0 software.
228 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Case Report 7.1 Image-­Guided Surgical Retrieval of Impacted Supernumerary Tooth

(Clinical case and technique by Dr Shaban Burgoa)

Figure 7.1 Superimposed IOS and CBCT scans used to locate the tooth in a 2D cross-­sectional (left) and a 3D reconstructed model
(right). The purple circular area corresponds to the site volume planned to receive synthetic bone grafts (150 mm3 or 0.15 cc).

In the initial clinical appointment, clinical profile,

frontal and facial photographs of the patient were
taken. A clinical examination was then performed to
confirm satisfactory conditions of the soft tissues
(e.g., amount of keratinized tissue, low levels of gingi-
val inflammation, and normal periodontal probing
depth). In the same appointment, both maxillary and
mandibular dental arches, as well as the occlusion of
the patient were scanned using an IOS (TRIOS 3,
3Shape). In addition, a CBCT (OP 300, Instrumentarium)
was taken with the patient using a lip retractor to
facilitate alignment with the IOS images.
All CBCT DICOM and IOS STL files obtained were
imported to the same CAD software (NemoStudio®,
Figure 7.2 Axial view of 2D measurements performed
Nemotec SL). Multiplanar and three-­dimensional (3D) during surgical planning and surgical guide digital design.
reconstructions were then used for location and
segmentation of the supernumerary tooth in an
independent 3D mesh. The impacted supernumerary tooth-­supported surgical guide to orientate the
tooth was positioned in the right anterior maxilla access to the supernumerary tooth through the maxil-
between the roots of canine and lateral incisors lary anterior bone wall (Figure 7.3).
(Figure 7.1). This surgical guide was designed in two parts: the
Virtual planning of the supernumerary surgical first was the support of the guide which was designed
removal was performed by first using 2D cross-­ to be on the teeth shown in the IOS mesh (teeth-­
sectional images (Figure 7.2) and then rendering a 3D supported guide). The second part was designed over
reconstructed model to digitally design a the bone of the CBCT mesh to generate the osteotomy
 Chapter 7 Digital Workflow in Oral and Maxillofacial Surgery 229

Figure 7.3 Digitally designed tooth-­supported surgical guide used to orientate surgical removal of the impacted
supernumerary tooth.

access on the bone window created at the level of the
supernumerary tooth. Then both parts were fused with
a boolean operation tool of the software. The resulting
surgical guide (Figure 7.4a) was then exported as a
STL file and 3D printed (Hunter®, Flashforge) with
light-­
curing resin specific for surgical guides
(Makertech Labs). The volume of the remaining site
planned to receive synthetic bone grafts were meas-
ured using the same software in cubic millimeters.
A full-­thickness flap was opened with the Partsch’s
incision, performed 3 mm below the area of surgical
access. Surgical removal was then conducted by per-
forming osteotomy of the anterior maxillary wall
through the opening of the surgical guide using a
piezoelectric surgical device (DentSurg Pro-­CVDentus®,
Clorovale Diamantes) (Figure 7.4b) with osteotomy tips
that were compatible with the hexagonal shape of the
surgical guide opening. The supernumerary tooth and
its dental follicular tissue were removed using differ-
ent curettes and tweezers.
The remaining site was then grafted using syn-
thetic bone substitutes (Blue Bone®, Regener) [7].

(a) (b)

Figure 7.4 Use of the CAD-­CAM surgical guide. (a) Surgical guide in position. (b) Surgical osteotomy performed with a
piezoelectric device orientated by the surgical guide.

(Continued )
Case Report 7.1 (Continued)
The number of packages required to achieve the
grafting volume was the same as estimated during
surgical planning. A bovine collagen membrane
(Green Membrane®) was then used to close the oste-
otomy window. Vicryl sutures were used to secure the
surgical site with primary closure. Healing was une-
ventful and there were no intra-­or postoperative
complications associated with the procedure.
This case used a digital workflow for image-­guided
surgical removal of an impacted tooth. Despite the
excessive proximity with adjacent roots of maxillary
teeth, the procedure was uneventful. Such findings sug-
gest the CAD-­CAM technique used herein could also be
useful for other related situations, such as retrieval of
impacted or displaced objects or foreign bodies in the
maxillofacial area. Among the most common related
situations that could be treated using this technique is
the accidental dislocation of a tooth into the maxillary
sinus during extractions [8], or due to trauma [9].
Case Report 7.2 Digital Workflow in Orthognathic Surgery
(Clinical technique by Dr Alexandre M. Borba)
Virtual surgical planning starts with the acquisition
of imaging exams, generally a CBCT. Besides allow-
ing more comfortable positioning (sitting patient),
CBCT provides better soft tissue reproducibility and
reduces image distortion in comparison to conven-
tional tomographic scans (Figures 7.5 and 7.6).
Moreover, digitalization of plaster models and, more
Figure 7.5 CT scan, initial aspect (coronal, sagittal, and axial views, and a 3D reconstruction).
As shown in the present case, aligning superimpos-
ing intraoral and CBCT scans in a CAD software allows
the professional to plan an image-­guided surgery by
choosing and editing the desired shape of the surgi-
cal guide used to orientate the procedure. As described
in the literature, the present digital workflow provides
advantages compared with conventional surgical
planning, such as fewer patient visits and shorter
chairside times [10].
This technique also enabled adequate volumetric
calculation of synthetic material required to graft the
site of the impacted supernumerary teeth after its
removal. This finding is in agreement with previous
studies using similar techniques of graft volumetric
estimation for alveolar socket grafting [11]. Furthermore,
as observed in the present findings, the synthetic mate-
rial used here (Blue Bone) has been proven to provide
adequate new bone formation and osteoconduction
without significant levels of cytotoxicity [7].
recently, intraoral scanning have become important
factors in reducing possible artifacts that may alter
dental anatomy, reproducing faithfully the patient’s
dental characteristics (Figure 7.7).
There is a lot of software available for virtual surgi-
cal planning nowadays, such as Dolphin® 3D (Dolphin
Imaging & Management Solutions). Considering this
diversity and all the opportunities of 3D manipulation
 Chapter 7 Digital Workflow in Oral and Maxillofacial Surgery 231

Figure 7.6 CT scan slices reconstructed into a volume of the craniofacial region (frontal, lateral, and inferior views).

Figure 7.7 Upper and lower dental arches digitally reproduced (frontal, lateral, and occlusal views).

that allow oral and maxillofacial surgeons to make
diagnoses and surgical decisions from this digital
workflow, other dentistry areas such as implantology
and orthodontics might also benefit.
The first step of the workflow is the creation of the
virtual patient based on data acquisition from CT
scans (DICOM files), intraoral scanning (commonly
STL or OBJ files, including isolated dental arches and
occlusion), and facial photographs. Head orientation
is paramount to determine the axes of rotation, so
that pitch, yaw, and roll planes should be determined
according to clinical referential frames. Then, a facial
soft tissue mask, as well as upper airway volume, can
be created from the CBTC data. The composite skull

(Continued )
232 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Case Report 7.2 (Continued)

model will be finally obtained from the fusion of den-
tal anatomy obtained from intraoral scanning and the
CBCT dental anatomy, an essential stage for the exe-
cution of surgical planning (Figure 7.8).
The following phase consists of the design of
the jaw osteotomies to be used (most commonly
LeFort I and bilateral sagittal split ramus) (Figure 7.9).
The surgical movements can then be finally simu-
lated, reproduced, and shown to the patient
(Figures 7.10 and 7.11). The end of the planning takes
place with the impression of the 3D guides.

Figure 7.8 Composite skull model creation by the superimposition of dental anatomy from the digitalization of the dental arches,
volume of the upper airway space, and 3D photography, providing robust information for diagnostic and planning purposes.

Figure 7.9 Maxillary and mandibular osteotomies designed on bone surfaces, allowing surgical movements to be performed.
 Chapter 7 Digital Workflow in Oral and Maxillofacial Surgery 233

Figure 7.10 Lateral view of the preoperative status (left) compared to the postoperative simulation of changes predicted to
facial soft tissues (right).

Figure 7.11 Frontal view of the preoperative status (left) compared to the postoperative simulation of changes predicted
for facial soft tissues (right).
234 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Case Report 7.3 Image-­Guided Orthognathic Surgery

(Clinical technique by Dr Daniel Negrelle) virtual skull. They can be generated using an intraoral
scanner or by scanning plaster models.
Image Acquisition
Additional, Optional Imagining Exams: 3D
Computed tomography and dental scanning are the Photography or 3D Facial Scanning
main imagining exams used to carry out virtual
planning. Although it is not considered an essential exam for
virtual planning and is subject to acquisition errors,
Computed Tomography resulting in minor distortions, 3D photography or 3D
For a reliable virtual replication of the skull, a CT facial scanning is interesting because of texturing and
scan should be obtained with the head in the colorization of the soft tissue mesh. Therefore, a more
natural position, the mandible in centric relation- realistic view is obtained, making the patient’s clinical
ship, and with no soft tissue deformations and con- understanding easier as well.
tractions of the facial muscles. A common error Obtaining 3D photography from devices that pro-
results from deformation originating from forced ject vertical and horizontal lines of reference to the
lip sealing. patient’s face is also valuable since the virtual skull
If the occlusion leads to a mandibular position in can be better positioned by replicating the patient’s
which the mandibular heads will not remain cen- natural head positioning (Figure 7.12).
tralized into the mandibular fossae, an occlusal
splint guide is suggested. This appliance should
be adjusted by removing excess material that
would cause deformation of the lips or skin in the
oral region.
The CT scan can be performed by a cone beam
device, allowing upright positioning of the patient’s
head. On the other hand, a fan beam device can also be
used, which has a larger field of view, higher resolution,
and better image quality, but the patient is positioned
in a lying position, causing some soft tissue deforma-
tion at times.
The ideal field of view should comprise all the
patient’s head and the beginning of the neck. It is also
important to include the ears and the entire skull for
precise virtual orientation.

Dental Scanning
Due to CT limitations such as artifact generation by
metallic objects (dental restorations and orthodontic
appliances) and low resolution of dental anatomy,
dental scan files should be incorporated into the Figure 7.12 3D photography or 3D facial scanning.
 Chapter 7 Digital Workflow in Oral and Maxillofacial Surgery 235

Figure 7.13 Delimitation of the areas for creating the panoramic image of the jaws.

Figure 7.14 Identification of the maxillae and mandibular ramus and body on the coronal panoramic image.

7.2.1.1 Coronal Panoramic Image

After importing the CBCT, it is necessary to create a pano-
ramic image of the jaws from the original axial slices
(Figure 7.13). This image helps the software to identify the
maxillae and mandibular ramus and body (Figure 7.14).
7.2.1.2 Three-­Dimensional Reconstruction
and Segmentation of the Bones
Following marking on the panoramic image, the soft-
ware identifies bone areas and then the delimitation
and segmentation of the mandible and maxillae can be
done (Figure 7.15).
7.2.1.3 Importing Dental Scanning
In this step, dental scanning files are imported and aligned
with the virtual skull. Since the scanned teeth should
exactly overlap their contour on the CT scans, this step
should be extremely accurate (Figure 7.16).
236 Digital Dentistry: A Step-by-Step Guide and Case Atlas

(a)

(b)

Figure 7.15 Bone segmentation in 3D volume. (a) Maxillae. (b) Mandibular ramus and body.
 Chapter 7 Digital Workflow in Oral and Maxillofacial Surgery 237

(a)

(b)

Figure 7.16 (a) Importing and (b) overlapping dental scanning.

7.2.1.4 Mesh Clean-­Up 7.2.1.5 Osteotomy Design

Any excess mesh from tissues around the maxil- Once the virtual skull has been created, the osteot-
lae and mandible should be removed (Figures omy design can be commenced. The virtual planning soft-
7.17–7.20). ware allows clinicians to customize the cut lines, which
238 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Figure 7.17 Mesh clean-­up.

Figure 7.18 Mesh clean-­up – stretched model.

 Chapter 7 Digital Workflow in Oral and Maxillofacial Surgery 239

Figure 7.19 Mesh clean-­up – clipping slice.

Figure 7.20 Mesh clean-­up – skull model with teeth model overlay.
240 Digital Dentistry: A Step-by-Step Guide and Case Atlas
makes it possible to plan maxillary segmentation, different
types of sagittal ramus osteotomy, and simple or seg-
mented genioplasties (Figures 7.21–7.23).
7.2.1.6 Virtual Skull Orientation According
to the Natural Head Position
This is an important step. The virtual skull file hardly ever
presents a correct spatial orientation, so an orientation
Figure 7.21 LeFort I osteotomy.
Figure 7.22 Sagittal ramus osteotomy.
calibration to correspond exactly to the patient’s clinical
position (i.e., natural head position) will be needed.
Failures at this stage may result in a false deformity diag-
nosis and, consequently, the wrong surgical correction.
Therefore, under-­ or overcorrection, midline deviations,
and postoperative asymmetries may occur.
There are several methods for virtual skull orienta-
tion and more than one is generally used, which

Figure 7.23 Genioplasty.
Figure 7.24 Orientation calibration by measurements from clinical analysis.
provides better results. Replication of measurements
from a clinical analysis is a simple and effective method,
as well as measurements obtained from photographic
records. Other methods such as 3D photography with
laser beams and coupling a gyroscope to a bite guide
are also effective methods but require additional equip-
ment (Figures 7.24–7.26).
Chapter 7 Digital Workflow in Oral and Maxillofacial Surgery 241
7.2.1.7 Cephalometric Points: Locating
and Defining
Accurate and reliable identification of cephalometric
points in 3D volume requires anatomical knowledge
and experience to convert 2D to 3D points. From this
definition, the software generates the 3D cephalometric
analysis (Figure 7.27).
242 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Figure 7.25 Orientation calibration by 3D photography with laser beams.

Figure 7.26 Oriented virtual skull.

7.2.2 Virtual Planning: Bone Movements

During this step, clinicians can evaluate the planned
bone movements to correct dentofacial deformities.
Regardless of surgical preference to start orthognathic
osteotomies first with either the maxillae or mandible,
the mandible should be placed in the final occlusion
relationship with the maxilla before virtual deformity
correction planning. Using the dental ­scanning file in
the final occlusion and the piggyback tool, this mandib-
ular movement can be performed (Figure 7.28).
 Chapter 7 Digital Workflow in Oral and Maxillofacial Surgery 243

Figure 7.27 Example of location and definition of orbital point – right side.

(a)

Figure 7.28 (a,b) Mandibular positioning based on the dental scanning file in the final occlusion.
244 Digital Dentistry: A Step-by-Step Guide and Case Atlas
(b)
Figure 7.28 (Continued)
Figure 7.29 Correction of midline deviations and occlusal plane inclination (roll).
The bone movements in virtual planning are
guided by the Cartesian planes, i.e., X (pitch),
Y (roll), and Z (yaw) axes. To systematize the
­p rocess, obtain the desired movements, and avoid
issues, five steps should be carefully followed
(Figures 7.29–7.33).
Step 1 – Correction of midline deviations and occlusal
plane inclination in a front view (roll).
Step 2 – Correction of maxillary rotations (yaw) in an
axial view.
Step 3 – Vertical and anteroposterior corrections of the
position of the upper central incisor in a lateral view.
 Chapter 7 Digital Workflow in Oral and Maxillofacial Surgery 245

Figure 7.30 Correction of maxillary rotations (yaw).

Figure 7.31 Vertical and anteroposterior corrections.

246 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Figure 7.32 Correction of occlusal plane inclination (pitch).

Figure 7.33 Correction of chin position.

Step 4 – Correction of occlusal plane inclination in a 7.2.3 Surgical Splint Creation

lateral view (pitch).
Surgical splints are used during surgery to replicate
Step 5 – Correction of chin position in front and lat-
bone movements previously defined by virtual plan-
eral views.
ning. The traditional splints (i.e., intermediate and final

guides), which were manufactured from plaster models,
nowadays are planned virtually and obtained by 3D
impression or milling.
The virtual environment provides the entire skeletal
structure in high definition, which allows the creation of
(a)
(b)
Figure 7.34 (a) Surgical splint contouring and (b) obtaining.
Chapter 7 Digital Workflow in Oral and Maxillofacial Surgery 247
more modern splints than those created by the tradi-
tional method. Moreover, several other types of custom-
ized guides can be created, such as cutting, perforation,
and mentoplasty guides, aiding clinicians to reach a
more accurate surgical result (Figures 7.34 and 7.35).
248 Digital Dentistry: A Step-by-Step Guide and Case Atlas

(a) (b)

Figure 7.35 Surgical guide with extensions for dental bone support, increasing the accuracy of the bone fitting. (a) On models.
(b) During surgery.

Figure 7.36 Preoperative and postoperative photographs and superimposition of soft tissue prediction on postoperative
photography.

7.2.4 Comparison of Results 7.3 ­Surgical Guides: Types

from Virtual Planning
A great advantage of virtual planning is the ability to
visualize changes to the patient’s face after orthognathic
surgery. Although most CBCT images in software pro-
grams do not provide a perfectly accurate representa-
tion of soft tissues, it is usually sufficient for orthognathic
planning (Figures 7.36 and 7.37).
and Classification
In modern dentistry, technologies allow the clinician
to execute digitally planned treatments. Areas includ-
ing implant dentistry, prosthodontics, periodontics,
endodontics, bucomaxillofacial surgery, and dental
esthetics have benefited from the advantages of using
 Chapter 7 Digital Workflow in Oral and Maxillofacial Surgery 249

Figure 7.37 Preoperative and postoperative photographs and superimposition of soft tissue prediction on postoperative
photography.

modern dental software for digital planning and
design. Software programs are being constantly
improved and some have become truly 3D model edi-
tors with edition tools that have many possibilities for
developing different types of guides that may help the
clinician to execute clinical procedures like surgeries,
preps, mock-­ups, temporaries, etc.
This diversity of guides must be classified in
order to facilitate communication between dental
Table 7.1 Information on available surgical guides.
c­ linicians and digital planners or designers. A com-
prehensive classification of these types of guides
will be helpful to organize their indications and
possibilities.
Table 7.1 gives the reader a simplified but complete
classification of all guide possibilities currently availa-
ble (Figures 7.36–7.46).

Types of guides Required

Types of guides proposed exams
Type of guide support Field Indications described in literature by author and records

Dental supported Implant Partial implants Implant guides IOS, CBCT

(DS) Periodontics Crown lengthening Periodontics guide
Esthetics Teeth preps Palatal expansion
Orthodontics guide
Bone supported Implant Osteotomy Orthognathic guided CBCT
(BS) OMFS surgery
Dental Bone reduction guide
surgery in the mandible
Guides for bone graft
removal
Mucosa supported Implant Implant of full arch cases Guides for implant IOS,
(MS) Periodontics flapless full arch CBCT
surgery
(Continued)
Table 7.1 (Continued)

Types of guides Required

Types of guides proposed exams
Type of guide support Field Indications described in literature by author and records

Muco/bone supported Implant Osteotomy and implant Bone reduction guide IOS, CBCT
(MBS) placement in the maxilla
Muco/dental Implant Implant placement with Guide for arch Guides over IOS, CBCT
supported Periodontics few teeth support (ex. arch expansion braces
(MDS) Orthodontics with braces, few teeth) Mini implant guide Muco guide for
Soft tissue Graft removal soft tissue graft
Palatal expander
Mini implant placement
Dental/bone Implant Osteotomy in dentulous Sinus and IOS, CBCT
supported dentistry areas implant guide
(DBS) Crown lengthening Osteotomy guide
for teeth removal
Supported by Implant Guided surgery for Guides over IOS,
nonanatomical dentistry implant placement implants CBCT,
structures Magnetic guide IOS of
Stable guide implants
(SG)

CBCT, cone beam computed tomography; IOS, intraoral scanning; OMFS, oral and maxillofacial surgery.

Figure 7.38 Bone-­supported surgical guide.

Figure 7.39 Mucosa-­supported surgical guide.

Figure 7.40 Implant-­supported surgical guide.

Figure 7.41 Tooth-­supported surgical guide.

Figure 7.42 Mucosa/bone-­supported surgical guide.

252 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Figure 7.43 Tooth/implant-­supported surgical guide.

Figure 7.44 Tooth/mucosa-­supported surgical guide.


Figure 7.45 Tooth/bone-­supported surgical guide.
7.4 ­Virtual Planning
of Trauma Surgeries
Facial reconstruction after major trauma is still a nota-
ble challenge for surgeons, especially when there are
sequelae that cause esthetic and functional deformities
to the patient. Virtual planning and its ability to custom-
ize fixation materials before surgery is an alternative to
make the execution of surgical procedures faster, more
accurate, and safer.
Current 3D resources allow an anatomical region of
interest to be 3D printed and manual handling of the
surgeon to provide proper segment alignment and fixa-
tion hardware bending at the preoperative phase. This
not only provides surgical simulation but also reduces
operative time and procedure complexity and facilitates
surgical team communication.
The digital workflow for virtual planning in cases of
maxillofacial trauma involves several steps and the
Figure 7.46 Guide supported by a base guide.
Chapter 7 Digital Workflow in Oral and Maxillofacial Surgery 253
use of different software programs that enable the
creation of anatomical models. The process begins
with the acquisition of images in DICOM format,
from conventional CT, which is normally requested
during initial care of the traumatized patient, as a
diagnostic tool. From here, files of the 3D reconstruc-
tion of the segment to be operated are exported in STL
format to a 3D modeling software, such as Meshmixer
3.5.474. At this stage, selection of areas of interest,
removal of possible artifacts, mirroring of healthy
structures using contralateral facial symmetry, and
refinement of the prototype are carried out. Next, the
new improved STL file is inserted into another soft-
ware program such as Simplify3D® which allows the
correct print settings to be generated. This makes it
possible to convert to 3D printing on a printer of your
choice, using low-­cost filaments such as acrylonitrile
butadiene styrene (ABS) or polylactic acid (PLA)
(Figures 7.47–7.54).
254 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Case Report 7.4 Virtual Planning for Maxillary Fracture

(Clinical technique by Dr Alexandre M. Borba)
See Figures 7.47–7.50.

Figure 7.47 CT scan of the patient showing a fracture of Figure 7.49 Fracture reduction surgery.
the maxilla involving the left orbital floor.

Figure 7.50 Postoperative CT showing reduction of the

Figure 7.48 Plate adjusted in accordance with a rapid fracture.
prototyping model of the case.
Case Report 7.5 Virtual Planning for Mandibular Fracture
(Clinical technique by Dr Alexandre M. Borba)
See Figures 7.51–7.54.

Figure 7.51 CT of a case with mandibular fracture.

Figure 7.52 Axial view of the CT 3D reconstructed model.

Figure 7.53 Rapid prototyping model of the case.

(Continued )
256 Digital Dentistry: A Step-by-Step Guide and Case Atlas
Case Report 7.5 (Continued)
Figure 7.54 Preoperative adjustment of the titanium plate.
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planning. J. Craniofac. Surg. 30: e413–e415.
6 Tallarico, M., Kim, Y.J., Cocchi, F. et al. (2019). Accuracy
of newly developed sleeve-­designed templates for
insertion of dental implants: a prospective multicenters
clinical trial. Clin. Implant. Dent. Relat. Res. 21: 108–113.
7 da Silva, B.I., de Carvalho, J.J., da Silva Pires, J.L. et al.
(2019). Nanosized hydroxyapatite and β-­tricalcium
phosphate composite: physico-­chemical, cytotoxicity,
morphological properties and in vivo trial. Sci. Rep.
9: 19602.
8 Sverzut, C.E., Trivellato, A.E., Lopes, L.M. et al.
(2005). Accidental displacement of impacted maxillary
third molar: a case report. Braz. Dent. J. 16: 167.
9 Cai, H.X., Long, X., Cheng, Y. et al. (2007). Dislocation
of an upper third molar into the maxillary sinus after a
severe trauma: a case report. Dent. Traumatol. 23: 181.
10 Markarian, R.A., da Silva, R.L.B., Burgoa, S. et al.
(2021). Clinical relevance of digital dentistry during
COVID-­19 outbreak: a scoped review. Braz. J. Oral Sci.
19: e200201.
11 Nishimura, D.A., Iida, C., Carneiro, A.L.E. et al.
(2021). Digital workflow for alveolar ridge
preservation with equine-­derived bone graft and
subsequent implant rehabilitation: a case report.
J. Oral Implantol. 47: 159–167.

Chapter 8
Digital Workflow in Endodontics
Daniel M. Keir, Lucas R. Pinheiro, Maria Clara R. Pinheiro, and Arthur R.G. Cortes
SUMMARY
This chapter provides a step-­by-­step guide and research evidence on digital workflow in endodontics.
8.1 ­Digital Imaging
in Endodontics
Dental radiography is essential for the successful diag-
nosis of oral pain, odontogenic or nonodontogenic,
treatment of the root canal system, evaluation of the
final obturation, and assessment of healing after endo-
dontic treatment. These images are necessary for visu-
alization of the pulp chamber and root canal space such
as pulp chamber location, pulp stones, pulp chamber
and root canal calcification, number of roots and canals,
canal bifurcations, dilacerations, resorptions, and root
length. The surrounding periapical tissues must be eval-
uated radiographically for radiolucent and radiopaque
areas, periodontal bone levels and defects, anatomical
structures, odontogenic and nonodontogenic patholo-
gies, and anomalous dental defects. When viewed in
total, endodontic radiography is crucial to making an
accurate diagnosis, developing an endodontic treatment
plan and executing treatment with the knowledge of
obstacles that may be encountered during treatment.
Traditionally, radiographic assessment in endodontic
diagnosis and treatment has been limited to intraoral
and panoramic radiography. These modalities provide a
two-­dimensional representation of three-­dimensional
anatomical structures. In cases with complex anatomy
and surrounding structures, interpretation of these two-­
dimensional images can be difficult and may lead to
misinterpretation of the situation.
With the advent of CBCT, images can be generated
that make it possible to view oral structures and the
Digital Dentistry: A Step-by-Step Guide and Case Atlas, First Edition. Edited by Arthur R.G. Cortes.
© 2022 John Wiley & Sons Ltd. Published 2022 by John Wiley & Sons Ltd.
257
surrounding maxillofacial skeleton and anatomical
relationships in three dimensions. While this technol-
ogy is impressive, it does have limitations such as higher
radiation dose to the patient and generation of artifacts.
Cone beam computed tomography should not be used
routinely for endodontic diagnosis or screening pur-
poses in the absence of any clinical signs or symptoms.
It should only be used when the patient’s history and
clinical examination demonstrate that the benefits to
the patient outweigh the potential risks and the need
for imaging cannot be met by two-­dimensional imaging.
In all cases, the “as low as reasonably achievable”
(ALARA) principle should be observed.
8.1.1 Recommendations
for Endodontic Imaging
●● Diagnosis: 2D should be used for the initial imaging.
3D should be used after 2D imaging for diagnosis of
patients presenting with contradictory or nonspe-
cific signs or symptoms, such as in cases of suspected
vertical root fracture.
●● Treatment: 3D imaging should be considered, after
the initial diagnosis and radiographic evaluation are
complete, for those situations where complex endo-
dontic morphology is suspected, such as mandibular
anterior teeth, maxillary and mandibular premolars
and molars or other dental anomalies such as exten-
sive dens invaginatus.
●● Intraoperative: 2D imaging should be considered the
modality of choice for working length (WL) determi-
nation, post space depth, etc.
258 Digital Dentistry: A Step-by-Step Guide and Case Atlas
●● Postoperative: 2D imaging should be considered
the modality of choice for assessment of the final
obturation.
●● Outcome assessment: 2D imaging should be consid-
ered the primary choice. 3D can be used in situations
of nonhealing previous endodontic treatment after
a sufficient posttreatment period to allow for healing
to be noted.
●● Nonsurgical endodontic retreatment: 3D should
be considered the primary choice for better deter-
mination of factors leading to the need for
retreatment.
●● Surgical endodontic treatment: 3D imaging should be
considered the primary choice for assessing anatomi-
cal structures that may be impacted during surgical
treatment.
●● Traumatic injuries: 3D imaging should be consid-
ered the primary choice for determination of any
fractures, dislocations, intrusions or impactions or
involvement of any of the other maxillofacial
structures.
●● Resorptions and perforations: 3D imaging should be
considered the primary choice for determining loca-
tion, size, and accessibility for repair.
8.2 ­Electronic Apex Location
Electronic apex location (EAL) has become more widely
used in root canal treatment for determination of WL,
replacing the more traditional radiographic method of
WL determination. EAL is highly accurate in determina-
tion of WL (92–95%) compared to radiographic determi-
nation (85%). EAL offers a means of locating the most
appropriate endpoint for root canal procedures. The prin-
ciple behind most EAL devices is that human tissues have
certain electrical characteristics that can be used in math-
ematical algorithms to determine the canal terminus.
The disadvantage or limitation of the radio-
graphic technique is that it is sensitive in both exposure
and interpretation. These limitations include operator
interpretation of the root end, film positioning, angula-
tion, and patient compliance. Also, in some cases, multi-
ple radiographs may be necessary for this determination,
thus exposing the patient to excess radiation.
Two-­dimensional and 3D radiographic techniques
are useful in determining an estimated WL. While 2D
films do not accurately reflect the 3D reality of the root
canal space, 3D imaging has its own limitations as well.
With both digital radiographic imaging modalities, the
root canal length can be estimated using the measuring
tools available in the digital radiography software; it
cannot always take into account the intraoral reference
point used during canal length determination and
instrumentation. Therefore, EAL becomes a more
accurate method for determining the WL intraorally,
with the radiographic measurement giving guidance.
8.2.1 Step-­by-­Step Procedure
for Using an EAL
●● Ensure all parts are in working order, such as the cor-
rect lip clip and file clip. Adequate battery power must
be available in the EAL.
●● Place the lip clip on the contralateral side of the oral
cavity to the tooth being treated.
●● Make sure the power is on.
●● Test for completion of a circuit by placing the file clip/
holder on the rubber dam clamp.
●● It is best to have a fairly dry root canal space when
using the EAL. Although many EALs are reported to
work well in a wet environment, it is best if any mois-
ture is in the canal, not in the pulp chamber. Any fluid
in the pulp chamber in contact with any metal may
complete the circuit and give an erroneous reading.
●● Before placing the file into the root canal to be meas-
ured, set the rubber stopper to the estimated WL.
●● Place the file into the canal to the estimated WL and
then place the file clip on the metal of the file.
●● Increase or decrease the file length within the canal to
achieve the appropriate reading on the EAL.
●● Remove the file clip from the file and adjust the rub-
ber stopper to the selected coronal reference point.
●● Remove the file from the canal and record the WL and
the reference point.
●● Repeat for all canals in a multiroot/canal tooth.
●● If there is some uncertainty regarding achieving WL
with an EAL, it is always appropriate to take a radio-
graph to aid in determining an appropriate WL.
8.3 ­Use of the Dental Operating
Microscope in Endodontics
In recent years, there have been many advances in
materials, methods, and technologies employed in
endodontic treatment, with probably the most impor-
tant being acceptance and use of the dental operating
microscope (DOM) in nonsurgical and surgical endo-
dontic treatment.
The DOM now has a permanent home in the prac-
tice of endodontics and has revolutionized the practice
of endodontics, from diagnosis, canal location, and
intracanal perforation/resorption repairs to surgical

endodontics. This results in many difficult cases being
easier to treat and raises the level of success.
With the widespread use of the DOM, there is also
been the need for advanced training on efficient use of
the microscope. Many endodontic procedures are now
performed at higher levels of magnification that can be
obtained with dental loupes. These levels of magnifica-
tion require a new set of skills in order to be able to work
efficiently and ergonomically because even slight hand
movements or hand tremors can be problematic.
Proper positioning of the clinician, patient, and assis-
tant is paramount when using the DOM to be able to
work in complete comfort. For this to happen, an invest-
ment must be made in a proper clinician chair suited for
use with the DOM as well as the chair for the assistant.
Factors in preparation for using the DOM include the
following.
●● Clinician position
●● Patient position
●● Positioning of the DOM and adjusting the inclinable
binoculars and interpupillary distance
●● Optimal positioning of the patient
●● Focusing of the DOM, gross and fine adjustments
●● Positioning of the assistant and assistance scope if used
Clinician positioning is the most important aspect in
preparing to use the DOM. If the clinician is not in the
proper ergonomic position or is constantly changing
their position around the DOM, fatigue and frustration
will develop, resulting inefficient use of the DOM.
To ensure the clinician is in the proper position, a cli-
nician or operator chair designed for use with the DOM
is essential. This chair allows the clinician to have sup-
port for the forearms and back. The clinician’s hips are
perpendicular to the floor with the knees perpendicular
to the hips, the forearms perpendicular to the upper
arms with the forearms resting comfortably on the arm-
rests of the chair and the feet flat on the floor. The back
should be erect and perpendicular to the floor with good
lumbar support provided by the chair. The eyepiece
(inclinable binoculars) is adjusted so that the head and
neck are held in a comfortable and sustainable position.
Once the proper clinician position is achieved, the
patient is moved to accommodate this position. Once
the patient is properly positioned, the armrests of the
clinician’s operating chair should be positioned so that
the clinician’s hands are comfortably resting at the level
of the patient’s mouth.
Once the proper clinician and patient positions are
established, the DOM is positioned to locate the work-
ing area and adjustments to the DOM are performed
(Figure 8.1).
Chapter 8 Digital Workflow in Endodontics 259
Figure 8.1 Dental operating microscope being used in a
clinical setting.
8.4 ­CAD-­CAM Guided Endodontics
Guided endodontics is a technique used to guide drills
in previously planned positions with the aim of locating
or negotiating a root canal. In this context, this method
was first reported in the literature by two studies pub-
lished practically simultaneously [1, 2]. Both described
an adaptation of the guided surgery technique for the
preparation of implant sites, using CBCT images associ-
ated with a digital model from an intraoral scan or plas-
ter model. This enabled the prior planning of the
location and angulation of the endodontic approach, for
subsequent three-­dimensional impression of the surgi-
cal guide and guiding the negotiation of root canals.
Since then, several studies on the subject have been
published, mostly case reports and in vitro studies.
However, some clinical studies stand out by showing a
relevant rate of success for the technique. An observa-
tional clinical study reported on the accuracy of guided
access for locating and negotiating 50 cases of single-­
adicular teeth with pulp obliteration [3]. In contrast, a
systematic review found 22 articles, with 15 case reports,
six in vitro studies and one observational clinical study [4].
The study concludes that the technique is promising but
there is still little scientific evidence. In its last Position
Statement on the use of CBCT in endodontics, the
European Society of Endodontology (ESE) highlighted
the possibility of using guided endodontics to locate root
canals in teeth with extensive pulp obliteration [5].
8.4.1 Indications and Advantages
The main indication for the endoguide is identification
of the spatial location of extensively obliterated chan-
nels. Other indications have also been reported in the
260 Digital Dentistry: A Step-by-Step Guide and Case Atlas
literature, including dens invaginatus and surgical
­treatment [1, 6, 7].
Guided endodontics, therefore, is a method that advan-
tageously provides a predictable, safe result with a lower
risk of iatrogenic events. As reported in the literature, its
use can also help reduce endodontic treatment time, in
addition to providing a minimally invasive treatment.
However, these data should be interpreted cautiously due
to the limited evidence in the literature to date [4].
8.4.2 Step-­by-­Step Procedure to Perform
CAD-­CAM Guided Endodontics
8.4.2.1 Take a CBCT of the Involved Tooth
Take a CBCT scan with small field of view (FOV),
high resolution (smallest voxel), and longest scan time
available on the machine (360° x-­ray source rotation).
In some cases, with high-­density materials present, it
might be necessary to scan a full arch. Beam hardening
artifact degrades the images, making it difficult to merge
the CBCT images with the digital model.
8.4.2.2 Surface Scan
For a perfect adaptation of the printed template, it is
necessary to obtain details of the tooth surface and soft
tissue. The surface optical scan can be obtained using an
intraoral scanner (IOS) or a desktop plaster model
scanner. This scan should cover the full arch so that the
printed template has a larger retention area.
Figure 8.2 CBCT multiplanar reconstruction (Implant Studio software, 3Shape A/S). Source: Case by Dr. Lucas R. Pinheiro.
8.4.2.3 Import Both CBCT and Surface Scans
Computed tomography images must be imported into
implant planning software in DICOM format, whereas
intraoral or plaster model scans are imported as STL files.
8.4.2.4 CBCT Preparation
CBCT image planes should be angled according to
the long axis of the involved tooth. Then, the panoramic
curve is drawn on the axial image. This will gener-
ate the panoramic, orthogonal, and tangential views
(Figure 8.2).
8.4.2.5 Merging of CBCT and Surface
Scan Images
This is one of the most important steps in the entire pro-
cess to ensure accuracy and fit of the printed template.
Depending on the software, this merging can be done
automatically, through artificial intelligence or by
marking three coincident reference points in both scan
files and then the software merges the two scans.
Manual adjustments may be necessary in some cases.
The accuracy of the merging must be evaluated and
confirmed before starting planning (Figure 8.3).
8.4.2.6 Guided Access Planning
●● Select drill diameter and length in the software. Most
software programs do not have custom drills for endo-
dontics. In general, virtual drills for printed template
fixation clamps work well. The most used drill
 Chapter 8 Digital Workflow in Endodontics 261

Figure 8.3 Confirmation of the alignment between CBCT DICOM and IOS STL files.

Figure 8.4 Guided access planning.

diameters are 0.8–1.3 mm. The length should be
decided according to the height of calcification.
●● Identify pulpal obliteration or other possible obstacle
to endodontic access in CBCT images.
●● Position the drill as close as possible to the long axis
of the tooth involved. The ideal access point should
be from the incisal or occlusal surface of the tooth
to a target point where pulp space is identified
(Figure 8.4).
●● Choose the sleeve compatible with the selected drill.
Care must be taken that the washer does not touch
the surface scanner.
262 Digital Dentistry: A Step-by-Step Guide and Case Atlas

(a) (b) (c)

Figure 8.5 (a) Marking of points on the surface model. (b) Virtual surgical guide created. (c) Creation of visualization windows
and ID tag.

Figure 8.6 Printed surgical guide, perfectly fitted to the

patient’s model.

8.4.2.7 Surgical Guide Design

For creation of the guide, it is necessary to mark points
around the surface model and the software automati-
cally creates the guide. Then viewing windows and
identification tags can be added (Figure 8.5).
8.4.2.8 Approval of Planning and Printing
of the Guide
The plan must be reviewed and approved. In some soft-
ware, after approval, no changes can be made to the
planning. After approval, the guide can be exported in
STL format to be sent for 3D printing.
8.4.2.9 Guided Surgery Access
●● Position the guide to check adaptation and stability
(Figure 8.6).
●● Mark a point through the guide sleeve to indicate the
exact region of the endodontic access cavity.
●● Remove the enamel in the marked area using a dia-
mond bur until the dentin is exposed.
Figure 8.7 Periapical radiograph showing successful access
to the calcified canal.
●● Position the guide again and with the drill chosen in
the planning, penetrate through the calcified part of
the root canal and gain access to the pulpar space.
●● Confirm access using an intraoral radiograph
(Figure 8.7).
●● Finish the endodontic treatment with the preferred
technique.
­Acknowledgments
The authors thank Dr Thayna Silva do Carmo and
Dr Christiano de Oliveira-­Santos for their support.

­References
1 Zehnder, M.S., Connert, T., Weiger, R. et al. (2015).
Guided endodontics: accuracy of a novel method for
guided access cavity preparation and root canal
location. Int. Endod. J. 49: 966–972.
2 Zubizarreta Macho, Á., Ferreiroa, A., Rico-­Romano,
C. et al. (2015). Diagnosis and endodontic treatment of
type II dens invaginatus by using cone-­beam computed
tomography and splint guides for cavity access: a case
report. J. Am. Dent. Assoc. 146: 266–270.
3 Buchgreitz, J., Buchgreitz, M., and Bjørndal, L. (2018).
Guided root canal preparation using cone-­beam
computed tomography and optical surface scans – an
observational study of pulp space obliteration and
drill path depth in 50 patients. Int. Endod. J. 52:
559–568.
4 Moreno-­Rabié, C., Torres, A., Lambrechts, P., and
Jacobs, R. (2019). Clinical applications, accuracy and
Chapter 8 Digital Workflow in Endodontics 263
limitations of guided endodontics: a systematic review.
Int. Endod. J. 53: 214–231.
5 Patel, S., Brown, J., Semper, M. et al. (2019). European
Society of Endodontology position statement: use of
cone beam computed tomography in endodontics:
European Society of Endodontology (ESE) developed
by. Int. Endod. J. 52: 1675–1678.
6 Kfir, A., Telishevsky-­Strauss, Y., Leitner, A., and
Metzger, Z. (2013). The diagnosis and conservative
treatment of a complex type 3 dens invaginatus using
cone beam computed tomography (CBCT) and 3D
plastic models. Int. Endod. J. 46: 275–288.
7 Zubizarreta-­Macho, Á., Ferreiroa, A., Agustín-­
Panadero, R. et al. (2019). Endodontic re-­treatment and
restorative treatment of a dens invaginatus type II
through new technologies. J. Clin. Exp. Dent. 11:
e570–e576.
264
Chapter 9
Digital Workflow in Orthodontics
Guilherme S. Nakagawa, Juliana No-­Cortes, Adriano G.B. de Castro, Fernando Barriviera,
Maurício Barriviera, and Arthur R.G. Cortes
SUMMARY
This chapter provides a step-­by-­step guide and research evidence on digital workflow in orthodontics.
9.1 ­CAD-­CAM Guides for
Orthodontic Brackets
Indirect bonding is an orthodontic bonding technique
in which orthodontic brackets are transferred from
working models and bonded onto the teeth surfaces
using a transfer silicone tray. This technique includes
two stages: the lab stage, where models and trays are
manufactured, and the clinical stage, where brackets
or appliances are positioned and bonded in the
patient’s mouth. Since the majority of the work is done
virtually with the software, the placement of ortho-
dontic brackets on the teeth requires less chairside
time. The indirect technique has been used for dec-
ades, but with digital technology it is even more opti-
mized and precise.
The digital workflow starts with capturing the models
as an STL file of the mouth. Using orthodontic software,
brackets are virtually positioned on the surface of the
teeth. Working with the digital method, DICOM files
can be used to determine exactly the axis of the roots
and crowns, making it even more complete then the
conventional lab method. After the designing step, a
custom tray is created which allows the transfer of
brackets to the patient’s teeth.
A generic example of CAD-­CAM technology for indi-
rect orthodontic bonding (eXceed™) is shown in
Figures 9.1–9.14.
Digital Dentistry: A Step-by-Step Guide and Case Atlas, First Edition. Edited by Arthur R.G. Cortes.
© 2022 John Wiley & Sons Ltd. Published 2022 by John Wiley & Sons Ltd.
9.2 ­CAD-­CAM Guides for
Orthodontic Miniscrews
Successful treatment of full Class II malocclusion and
bimaxillary dentoalveolar protrusion requires effi-
cient anchorage, which can be achieved with several
methods, such as headgear, transpalatal arches, and
Nance button [1, 2]. However, conventional
approaches have been associated with drawbacks such
as anchorage loss and mesial migration of posterior
dental anchorage units [3]. Furthermore, despite the
use of extraoral appliances to enable satisfactory
anchorage control [4], such methods are highly
affected by patient compliance, leading to variable
levels of outcome [5].
An alternative to conventional forms of anchorage is
the use of orthodontic mini-­implants and temporary
anchorage devices (TAD) [6–8]. In this context,
orthodontic mini-­implants allow for direct anchorage
by being loaded with reactive forces, and for indirect
anchorage, by stabilizing a dental anchorage [9]. Such
mini-­implants can be loaded immediately after inser-
tion and are generally removed after treatment
completion.
Despite the satisfactory anchorage which can be
achieved, orthodontic mini-­implants require precise
placement in interradicular spaces with satisfactory bone
conditions [10, 11]. For this purpose, a surgical guide can
(a) (b) (c)

Figure 9.1 Initial STL file imported to the software. (a) Frontal view. (b) Lateral view – right side. (c) Lateral view – left side.

(a) (b)

Figure 9.2 Initial STL file imported to the software. (a) Occlusal view of the upper arch. (b) Occlusal view of the lower arch.

(a) (b) (c)

Figure 9.3 Creation of an orthodontic virtual set-­up simulating the desired final occlusion. (a) Frontal view. (b) Lateral
view – right side. (c) Lateral view – left side.

(a) (b) (c)

(d) (e)

Figure 9.4 After checking and approving the final planning, orthodontic brackets are positioned passively on the arch. Later,
this virtual arrangement will be transferred to the initial situation. (a) Frontal view. (b) Lateral view – right side. (c) Lateral
view – left side. (d) Occlusal view of the lower arch. (e) Occlusal view of the upper arch.
266 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Upper arch Lower arch

10 20 30 40 50 60 70 80 10 20 30 40 50 60 70 80

10 10

20 20

30 30

40 40

50 50

60 60

70 70

80 80

Figure 9.5 Wire shape templates are created to be printed on paper. The final teeth positioning will follow the virtually
planned shape of the arch, leading to an extremely precise, reliable result.

Figure 9.8 Double transfer tray for indirect bracket

Figure 9.6 Models obtained by 3D printing machine for bonding – second step: a 1 mm thick sheet of polyethylene
orthodontic bracket positioning. glycol terephthalate (PEGT) applied over the EVA. The main
function of this layer is to provide rigidity and stability to
the tray.

Figure 9.7 Double transfer tray for indirect orthodontic Figure 9.9 Enamel etching with phosphoric acid for
bracket bonding – first step: a 1 mm thick sheet of ethylene orthodontic bracket bonding. Following this, the dental
vinyl acetate (EVA) is used. The main function of this EVA surfaces should be washed and dried completely and adhesive
layer is to retain the orthodontic brackets. should be applied to the base of each orthodontic bracket.
 Chapter 9 Digital Workflow in Orthodontics 267

Figure 9.10 The double transfer tray is fitted to the upper Figure 9.13 The EVA layer of the double transfer tray is
teeth and the adhesive is light-­cured. then removed.

Figure 9.11 The double transfer tray is fitted to the lower Figure 9.14 Final clinical aspect: finalization of orthodontic
teeth and the adhesive is then light-­cured. bracket bonding and wires in position.

mini-­implant positioning include improved retention

during orthodontic loading and precise control of the
force vector. Surgical guides for implants can also be
developed by means of time-­efficient digital workflows,
in which intraoral scans are performed and superimposed
to CBCT images, enabling the digital design of a surgical
guide [13]. Nevertheless, little is known about using such
digital workflow methodology for creating surgical guides
to ensure proper positioning of mini-­implants.
Thus, the aim of the present report is to describe a full
digital workflow involving combination of intraoral and
CBCT scans to virtually design and 3D print surgical
guides used to ensure mini-­implant placements in opti-
Figure 9.12 The PEGT layer of the double transfer tray is
removed.
mal locations.

be developed from CBCT scans to decrease the risk of

9.2.1 Technique
complications such as root damage, penetration into the
maxillary sinus, or lack of anchorage due to inadequate The process commences by scanning both maxillary
mini-­implant position [12]. Advantages of accurate and mandibular arches, as well as the occlusion of the
268 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Case Report 9.1 Image-­Guided Indirect Orthodontic Bonding

(Clinical technique by Dr Guilherme S. Nakagawa)
An example of indirect bonding of self-­ligating brackets in a patient presenting with a Class II deep-­bite deform-
ity (eXceed) (Figures 9.15–9.23).

Figure 9.15 Initial facial aspect. (a) Frontal view. (b) Lateral view.

(a) (b) (c)

Figure 9.16 Initial intraoral aspect. (a) Frontal view. (b) Lateral view, right side. (c) Lateral view, left side.
 Chapter 9 Digital Workflow in Orthodontics 269

(a) (b) (c)

(d) (e)

Figure 9.17 Initial STL file imported to the software. (a) Frontal view. (b) Lateral view, right side. (c) Lateral view, left side.
(d) Occlusal view of the lower arch. (e) Occlusal view of the upper arch.

(a) (b) (c)

(d) (e)

Figure 9.18 Creation of an orthodontic virtual setup simulating the desired final occlusion. (a) Frontal view. (b) Lateral
view, right side. (c) Lateral view, left side. (d) Occlusal view of the lower arch. (e) Occlusal view of the upper arch.

(Continued )
270 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Case Report 9.1 (Continued)

Upper arch Lower arch

10 20 30 40 50 60 70 80 10 20 30 40 50 60 70 80

10 10

20 20

30 30

40 40

50
50

60
60

70
70
80
80

Figure 9.19 Wire shape templates.

(a) (b) (c)

Figure 9.20 After checking and approving the set-­up and the orthodontic bracket passive positioning, the latter is
transferred to the initial planning which represents the current Class II deep-­bite deformity situation. This virtual step
shows how the orthodontic brackets will be bonded on tooth surfaces. (a) Frontal view. (b) Lateral view, right side. (c) Lateral
view, left side.

(a) (b)

Figure 9.21 Double transfer tray for indirect bracket bonding. (a) Frontal view, upper arch. (b) Frontal view, lower arch.
 Chapter 9 Digital Workflow in Orthodontics 271

(a) (b) (c)

Figure 9.22 Final intraoral aspect. (a) Frontal view. (b) Lateral view, right side. (c) Lateral view, left side.

(a)

(b)

(c)

Figure 9.23 Comparison between the final result achieved and the virtual planning set-­up. (a) Frontal view. (b) Lateral
view, right side. (c) Lateral view, left side.

(Continued )
272 Digital Dentistry: A Step-by-Step Guide and Case Atlas
patient using an intraoral scanner (TRIOS®, 3Shape).
The initial intraoral scans are first imported to a CAD
software (OrthoAnalyzer®, 3Shape) as STL files. With
this software, orthodontic model bases are digitally
applied to all resulting STL files, which can then be
3D-­printed (MoonRay®, Sprintray) and used for ortho-
dontic planning.
The patient also needs to undergo a CBCT scan con-
figured with the following diagnostic protocol: 0.25 mm
voxel, 120 kVp, 8 mA, field of view of 17 cm diameter
and 6 cm height, and scanning time of 40 seconds. From
the scan, DICOM files are generated and 3D recon-
structed images are rendered using the NemoScan®
implant planning software (v. 2017, NemoTec). A treat-
ment plan for orthodontic mini-­implant placement is
then established using both intraoral and cross-­sectional
CBCT images. For this purpose, all STL files previously
obtained were also imported in the NemoScan software,
to be superimposed with the CBCT data. Four optimal
virtual mini-­implant positions are then established: two
maxillary at the infrazygomatic crest and two mandibu-
lar at the buccal shelf, following previously described
methodology [14]. The virtual planning is performed
considering both hard and soft tissue data obtained
from CBCT and intraoral scans.
The same implant planning software is then used to
generate the digital design of a mini-­implant tooth-­
supported metal sleeve-­free surgical guide using soft-
ware tools for choosing mini-­implant hole size, the
desired extension of tooth support, and then for auto-
matically generating and exporting the digital shape of
the surgical guide as a new STL file. Before the surgical
Case Report 9.2 Image-­Guided Orthodontic Miniscrew
(Clinical case series and technique by Dr Adriano
G. B. Castro, Mauricio Barriviera and Fernando Barriviera)
A 32-­year-­old female patient presented with a Class II,
Division 1 malocclusion (Figure 9.24), characterized by
overjet and labially positioned anterior teeth
(Figures 9.25 and 9.26), and agreed to receive mini-­
implants for bimaxillary en masse retraction by signing
an informed consent. Before mini-­implant installation,
orthodontic alignment and leveling were performed by
changing arch wires progressively (i.e., from cop-
per‑nickel–titanium to the final stainless steel wire).
In the first clinical appointment for orthodontic
mini-­implants, clinical evaluation was performed
and initial CBCT (Figure 9.27) and intraoral scans
guide is 3D printed, CAD software can be used to con-
firm that the digital triangle mesh of the STL file does
not have any failures in its structure. The resulting STL
is then fabricated with polymethyl methacrylate resin
by using a calibrated 3D printer (MoonRay).
The maxillary surgical guide is then used under local
anesthesia to ensure proper positioning of the self-­
drilling mini-­implant, considering an initial point of
insertion between the first and second molar roots, and
2 mm above the mucogingival junction in the alveolar
mucosa. For this purpose, the mini-­implant is screwed
through a groove of the surgical guide, which allows for
stable insertion of the mini-­implant in the position
established during virtual planning. In this procedure,
no predrilling, flap raising or vertical slit in the mucosa
is required. Similarly, a mandibular surgical guide is
then used to ensure proper positioning of the self-­
drilling mini-­implant considering an initial point of
insertion between the first and second molar roots, and
2 mm below the mucogingival junction in the alveo-
lar mucosa.
If another CBCT needs to be taken after mini-­implant
installation for any unrelated reason, it is possible to
convert the respective DICOM files into STL files, to be
superimposed to the corresponding virtual planning
images, which enables calculation of angle and linear
precision of the procedure in the same CAD soft-
ware [15]. Alternatively, an additional intraoral scan
can be taken after implant installation to compare both
planned and final executed positions of the mini-­
implant head in the oral mucosa by using the same pre-
cision assessment by means of STL superimposition.
were taken using the methodology and devices
described above. After superimposition of DICOM
and STL files, virtual planning and placement of four
mini-­implants (12 × 2 mm, Peclab) were conducted
according to the above-­ described technique
(Figures 9.28 and 9.29) followed by application of
elastic traction with a force of 300 g (Figure 9.30).
Three weeks after the procedure, the patient under-
went a second CBCT scan due to an unrelated rea-
son (Figure 9.31). After superimposition of virtual
planning and postprocedure STL files, it was con-
cluded that all four orthodontic mini-­implants were
placed in the same position of the virtual plan, with
no significant millimetric deviations (less than 1 mm
for all implants).
(a) (b)

(c)

Figure 9.24 (a) Initial lateral projection showing overjet and labially positioned anterior teeth. (b) Structural
superimposition from McNamara cephalometric analysis. (c) Facial photographs.

Figure 9.25 Intraoral photographs of the case.

(Continued )
274 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Case Report 9.2 (Continued)

Figure 9.26 Panoramic radiograph of the case.

Figure 9.27 Initial maxillary and mandibular CBCT images showing mini-­implant virtual planning.
 Chapter 9 Digital Workflow in Orthodontics 275

(a) (b)

(c) (d)

Figure 9.28 Image-­guided mini-­implant placement. (a) Digital design of a maxillary surgical guide performed using the
combination of CBCT and intraoral images. (b) Tooth-­supported surgical guide positioned to orientate mini-­implant
placement in the infrazygomatic crest. (c) Digital design of a mandibular surgical guide performed using the combination of
CBCT and intraoral images. (d) Tooth-­supported surgical guide positioned to orientate mini-­implant placement in the
buccal shelf.

Figure 9.30 Application of elastic traction for en masse

Figure 9.29 Image-­guided mini-­implant placement in the retraction.
infrazygomatic crest.

(Continued )
276 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Case Report 9.2 (Continued)

(a) (b)

Figure 9.31 (a) CBCT 3D reconstruction showing final positions of the orthodontic mini-­implants. (b) Superimposition of STL
images confirming accuracy of the final maxillary mini-­implant positions (red), compared to the virtual implant planning (blue).

9.2.2 Discussion One of the limitations of this technique is that the

present results suggest usefulness of surgical guides
Virtual planning before placing orthodontic mini-­
only for en masse retraction cases. Future clinical stud-
implants is of great importance. According to the present
ies would be recommended to address the efficacy of
findings, it is suggested that the present full digital work-
this methodology for other applications of orthodontic
flow involving combination of intraoral and CBCT scans
mini-­implants. On the other hand, virtual prediction of
could be considered as useful to prevent complications
the angle of mini-­implant insertion could also be
such as root damage, which is in agreement with a previ-
applied to other cases. For en masse retraction cases,
ous study [12]. On the other hand, such methodology
placing mini-­implants with precise angles (i.e., 55–70°
requires knowledge and a software interface to commu-
in the infrazygomatic crest, and 60–75° in the buccal
nicate STL files from intraoral scans and original DICOM
shelf) would enable adequate immediate loading of the
files from CBCT [16, 17]. In this context, this is the first
mini-­implants, allowing for anchorage forces of up to
study addressing the use of intraoral scans combined
300–350 g taken up by each of them.
with CBCT for digitally designing surgical guides for self-­
Within the limitations of this case report, the present
tapping mini-­implants placed in the infrazygomatic crest
findings suggest that full digital workflow for orthodon-
and mandibular buccal shelf. The present findings also
tic mini-­implants using metal sleeve-­free surgical guides
support a previous study showing the usefulness of a
is useful for cases of en masse retraction in Class II
similar digital workflow for implant-­supported palatal
patients.
metallic applicances. Moreover, this report also confirms
the benefits of image-­guided surgery for mini-­implants
suggested by a previous study using only CBCT scans [12].
In contrast with the present article, other digital 9.3 ­Orthodontic Aligners
workflow methodologies for creating surgical guides
from diagnostic casts or impression scanning have been Orthodontic aligners are removable transparent devices
described [18, 19]. According to such evidence, tabletop made of thermoplastic material. Pressure is applied in
scanners have been reported as satisfactory regarding certain areas of the tooth in order to treat malocclu-
accuracy of implant placement procedures. Similarly, sions. Clear aligner therapy has been part of dentistry
the use of different intraoral scanners does not seem to for decades but it has become more popular in recent
affect accuracy and precision offered by surgical guides. years, as intraoral scanner technology has improved.
On the other hand, controversial results have been Innovations in digital dentistry, such as development of
reported for users with different degrees of experience CAD-­CAM software programs and 3D printing technol-
and expertise in CAD methodologies. ogy, have provided new possibilities such as digitizing

models at a faster pace and customizing appliances,
making the process easier and more tangible with the
help of artificial intelligence.
The workflow for clear aligners starts with the digi-
tized 3D representation of the mouth projected in the
screen of the computer. The software is used to design
orthodontic virtual set-­ups which will be used to manu-
facture the aligners. The program is specifically created
to run orthodontic treatments. Dentists or dental techni-
cians can move each tooth into the desired position with
a step-­by-­step process inside the same software program.
Case Report 9.3 Orthodontic Aligners (Clear Aligner Appliances Manufactured using Digital Workflow
Protocol: Beyond Digital Solutions (Curitiba, Brazil)
(Clinical case report by Guilherme S. Nakagawa)
The treatment was conducted after the clinician
requested intraoral scanning, panoramic radiography,
Figure 9.32 Initial STL files and photographs imported to Nemocast software – frontal view of the intraoral scanning.
Figure 9.33 Spatial orientation of the models.
Chapter 9 Digital Workflow in Orthodontics 277
Once the teeth are in the desired location, the models
can be manufactured. However, before materializing the
models, attachments must be placed on the surface of
some teeth and staging has to be performed. Attachments
are small shapes made of resin placed on the surface of
the teeth to help with difficult movements. Staging
means arranging the sequentially ordered movements in
a timeline, creating set-­ups which are going to be materi-
alized in models, so that the clear aligners can be ther-
moformed for each stage and consequently move the
teeth slowly to the desired position.
teleradiography, and extra-­and intraoral photographs
(Figures 9.32–9.48).
(Continued )
Case Report 9.3 (Continued)

Figure 9.34 Mask creation: the teeth are removed from the photograph in order to superimpose the STL file on the
patient’s facial image.

Figure 9.35 The superimposition process occurs by determining points on the STL file and photography.

Figure 9.36 Superimposition completed.

Figure 9.37 Delimitation of the cut line of the model mesh.

Figure 9.38 Extrusion and closure processes are performed on the model mesh to allow printing of a flat base model.

(a)

Figure 9.39 First step of teeth segmentation: determination of mesiodistal, buccopalatine, and occlusoapical axes.
(a) Occlusal view. (b) Frontal view.

(Continued )
Case Report 9.3 (Continued)

(b)

Figure 9.39 (Continued)

Figure 9.40 Second step of teeth segmentation: location and delimitation of the gingival margins and papillae.

Figure 9.41 Segmentation completed: the software is now able to identify teeth and gingival tissues on the model mesh.
Figure 9.42 Teeth landmarks delimitation: identification of tooth surfaces and movements that will be carried out.

Figure 9.43 Orthodontic virtual set-­up simulating the desired final occlusion.

Figure 9.44 Virtual insertion of the attachments onto teeth surfaces.

(Continued )
Case Report 9.3 (Continued)

Figure 9.45 Staging: arrangement of the movements in a timeline. The movements are sequentially ordered in a way that
avoids unnecessary collisions and increases clinical predictability.

Figure 9.46 First step of biomodel exportation: delimitation of the gingival trimming lines to remove excessive mesh
height, defining the height of the biomodel that will be exported and printed later.

Figure 9.47 The biomodels are exported, creating a

sequential series of biomodels named “subset-­ups.” These Figure 9.48 Thermoforming, cutting, and polishing of the
are transferred to the slicer software of any printer of clear aligners.
choice and prepared for 3D printing.
 Chapter 9 Digital Workflow in Orthodontics 283

Case Report 9.4 Class III Treatment with Orthodontic Aligners (Clear Aligner Appliances Manufactured using
Digital Workflow Protocol: Beyond Digital Solutions (Curitiba, Brazil)
(Clinical case report by Guilherme S. Nakagawa)

BDS™ clear aligner appliances planning and manu- open bite, and severe lower anterior crowding. It used
facture for a patient with Class III deformity on the 26 lower and 11 upper appliances, totaling 15 months
left side, Class I deformity on the right side, anterior of treatment (Figures 9.49–9.56).

(a) (b)

Figure 9.49 Initial facial aspect. (a) Frontal view. (b) Lateral view.

(a) (b) (c)

(d) (e)

Figure 9.50 Initial intraoral aspect. (a) Frontal view. (b) Lateral view, right side. (c) Lateral view, left side. (d) Occlusal view
of the lower arch. (e) Occlusal view of the upper arch.

(Continued )
284 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Case Report 9.4 (Continued)

(a) (b) (c)

(d) (e)

Figure 9.51 Initial STL files imported to the software. (a) Frontal view. (b) Lateral view, right side. (c) Lateral view, left side.
(d) Occlusal view of the lower arch. (e) Occlusal view of the upper arch.

(a) (b) (c)

(d) (e)

Figure 9.52 Virtual planning showing the desired dentomaxillofacial relationships. (a) Frontal view. (b) Lateral view, right
side. (c) Lateral view, left side. (d) Occlusal view of the lower arch. (e) Occlusal view of the upper arch.
Figure 9.53 Facial aspect virtually created with the initial dental condition – frontal view.

(a) (b)

Figure 9.54 Elastics and intercuspation for finishing of orthodontic treatment simultaneously with the last two clear
aligner appliances. (a) Lateral view, right side. (b) Lateral view, left side.

(a) (b) (c)

Figure 9.55 Final intraoral aspect. (a) Frontal view. (b) Lateral view, right side. (c) Lateral view, left side.

(a) (b) (c)

Figure 9.56 Final smile. (a) Frontal view. (b) Lateral view, right side. (c) Lateral view, left side.
286 Digital Dentistry: A Step-by-Step Guide and Case Atlas
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Chapter 10
Digital Workflow in Dental Public Health, Preventive Dentistry,
and Dental Education
Anne-­Marie Agius, Nikolai J. Attard, Gabriella Gatt, and Arthur R.G. Cortes
SUMMARY
This chapter presents a step-­
by-­
step guide and research evidence on digital workflows involved in dental public
health.
10.1 ­Digital Dentistry
in Public Health
Dental public health provides community-­based expertise
in the surveillance and measurement of oral health status
and its determinants. Data collected are utilized to plan
appropriate policy changes, prevention strategies, and
health promotion across populations. Despite all efforts,
the burden of oral disease remains a matter of global
concern.
Dental caries is still responsible for most of the oral
disease burden in populations worldwide [1]. For too
long, efforts to reduce oral diseases have focused on
dentist-­centered and technology-­focused approaches
that have been unsuccessful and too costly, especially in
low-­ to middle-­income countries. Increasing the num-
ber of dentists to decrease the dentist/population ratio
has done little to change the care index and caries levels
in some countries have remained unchanged [2, 3]. The
simplistic reduction of prevention strategies aiming to
change behaviors by health education will continue to
fail to improve oral health and further create inequali-
ties. Low caries populations in high-­income countries,
on the other hand, display a highly skewed distribution
of disease. This emphasizes the need to break away from
traditional delivery operations and embrace new para-
digms and evidence-­based technologies in order to pro-
vide the ideal care system.
Research clearly indicates that “oral diseases, like
most chronic diseases, are socially patterned” [4], with
lower socioeconomic groups bearing the brunt of oral
Digital Dentistry: A Step-by-Step Guide and Case Atlas, First Edition. Edited by Arthur R.G. Cortes.
© 2022 John Wiley & Sons Ltd. Published 2022 by John Wiley & Sons Ltd.
287
health inequalities. Likewise, the only way we can miti-
gate these realities is by encouraging behavioral change
by improving the social determinants of health. On the
other hand, this change also necessitates the coordinated
involvement and training of different healthcare teams.
Digital dentistry has the potential to provide a health ser-
vice at optimal standards that is patient centered.
Patients’ participation and involvement in decision making
will also build trust between clinicians and the public
they serve. However, the spiraling costs of treatment,
regrettably also with the introduction of more clinical
gadgetry, risk outweighing the simplification of digital
flows and therefore jeopardizing the widespread use of
some of the techniques in digital dentistry.
Recent global events, with the onset of the COVID-­19
pandemic and the need for people to isolate, have empha-
sized the need for the introduction of novel techniques
that safeguard public health, while ensuring the contin-
ued provision of health services, including dental treat-
ment. There was a need to reduce spread of infection,
decompress hospitals and dental emergency rooms, and
preserve personal protective equipment. This prompted
the successful use of remote patient monitoring systems
with patients engaging with technology, increasing access
to care and mitigating digital health disparities [5].
It is apparent that the novel approaches with digital
dentistry have an all-­encompassing scope beyond the
specific recommendations related to these global events
since the discipline has the potential of simplifying
treatment and consequently improving the oral health-­
related quality of life of patients.
288 Digital Dentistry: A Step-by-Step Guide and Case Atlas

10.1.1 The Role of Teledentistry for changes in oral health behaviors advocated at school
to be reinforced in the home setting.
Teledentistry is an emerging method that is intrinsically
The advent of hand-­held x-­ray devices, first used in
related to digital dentistry as it is based on the same prem-
forensic dentistry and in veterinary and military set-
ises of facilitating and improving patient care. It is proving
tings [7] and archaeological sciences [8], has extended
to be a valuable asset in assessing patients remotely
the use of radiographic diagnostics beyond the clinical
through digital communication. This approach avoids the
setting and into the community. These devices are used
unnecessary transportation issues and creates a collabora-
in community-­based clinics, mobile dental clinics, for
tive network that further reinforces the multidisciplinary
patients unable to attend regular dental settings or in
approach in health. It also has the potential of saving time
remote areas, offering a noninferior modality to the tra-
and human resources related to providing a domiciliary
ditional wall-­mounted device [9]. Their use in caries
service or dental trauma or orthodontic emergency con-
diagnosis and monitoring and in trauma assessments
sultations. Notwithstanding, its effectiveness within the
helps in controlling the flow and costs of patient refer-
local context of diverse members of society still needs to
rals to primary health centers.
be determined. These novel techniques obviously require
Hand-­held digital image capturing/scanning devices
acceptance and behavioral modification from the health
also have a use in community dentistry. Image capture
professionals involved as well as the client or patient. It is
of malocclusions, oral mucosal lesions, sequential
apparent that the dental team involved in these advances
images of caries and tooth surface loss lesions, or entire
require training and professional updating to mitigate
dentitions requiring rehabilitation may be taken
undesirable stances related to novel approaches.
remotely in the community. These may then be sent for
Caries risk assessment software available off the
consultation and virtual treatment planning and
internet is used to collect caries risk-­related patient
referred accordingly. Such exchange of patient data can
data to provide a cariogenic profile of the patient. The
save on travel time, clinical time, human resources, and
program classifies the patient as being at high, moder-
materials costs. In addition, radiographs and images
ate or low risk for caries. Patient-­specific preventive
related to CAD-­CAM can now be assessed remotely by
and treatment guidelines and referrals to care may then
professionals using DICOM viewers and imaging appli-
be initiated accordingly. Such a remote patient moni-
cations for mobile devices such as tablets and smart-
toring tool may be used by diverse members of the den-
phones [10]. This has been suggested to be particularly
tal team in underprivileged communities with
useful in large clinical ­settings such as hospitals.
difficulties in access to healthcare [6], thus reducing
public health costs.
10.1.2 The Expected Role of CAD-­CAM in
Online school-­based oral health programs using real-­
Public Health
time communication or prerecorded messages have
been seen to be effective in improving oral health behav- There are several advantages of digital workflow in
iors in children. Such programs have allowed for a wider ­dentistry that may offer benefits to patients in different
reach than in-­person school visits by providing added aspects of dental treatment using CAD-­CAM technol-
exchange with educators and parents. This has allowed ogy [11], as shown in Table 10.1.

Table 10.1 Suggested advantages of digital workflow in dental public health.

Digital workflow step Methods Advantages for public health

Image acquisition Mobile devices
CAD Virtual wax patterns and
treatment planning
CAM 3D printing and milling
Perform radiographs and intraoral scans of patients with
limited access to clinics and hospitals
Since all patient data are digital, images can be seen by more
professionals in less time. Fewer and faster appointments, as
well as less laboratory time are also expected
3D-­printed resin crowns have been found to offer cheap costs
at higher production rates, which is relevant for high
demands

CAD, computer-­aided design; CAM, computer-­aided manufacture.

 Chapter 10 Digital Workflow in Dental Public Health, Preventive Dentistry, and Education
10.2 ­Digital Workflow
in Preventive Dentistry
Clinical visual detection of caries has, so far, been con-
sidered the gold standard for detection of enamel car-
ies while intraoral radiographs aid mainly in the
detection of dentine caries [12]. The introduction of
oral radiography has greatly enhanced detection of
moderate to advanced interproximal and recurrent
caries with high specificity. However, there is still con-
cern regarding the sensitivity of radiographs for early
carious lesions which have the highest potential to be
reversed or arrested [13].
Efforts are continuously being made to develop
devices and software programs that allow for more
accurate caries diagnosis while also reducing the disad-
vantages of conventional methods such as radiation
from radiographs [14, 15] and probing during clinical
examination [16]. Different technologies such as quan-
titative light-­induced fluorescence (QLF), laser fluores-
cence (LF), fiber optic transillumination (FOTI), and
near-­infrared light transillumination (NIRT) have been
studied for accuracy and precision in caries detection
and some studies compared different technologies
between themselves and with the gold standards – vis-
ual detection and radiographs.
Quantitative light-­induced fluorescence systems are
good at accurately diagnosing shallow lesions and have
a better consensus with bitewing radiographs than LF
systems in in vitro studies [16, 17]. NIRT technology is
also being increasing studied as an auxiliary to visual
examination to detect interproximal carious lesions [18],
and the different technologies need to be further com-
pared to each other [14]. Discrepancies in accuracy
were found in images obtained from different intraoral
scanners and systems, but newer technologies seem to
be better at reducing these differences [19].
Intraoral scanning for digital impressions and exami-
nation is well accepted by patients, most of whom prefer
this to conventional impressions or intraoral radio-
graphs [20]. There are, however, some disadvantages to
digital images/impressions, including discrepancies
between scanning systems, inaccuracies that may result
due to patient-­specific factors such as debris and anat-
omy [21], and differences resulting from operator expe-
rience with the device [22].
Most current research about caries detection technol-
ogies is based on in vitro studies on extracted teeth
where the device caries readings are compared to the
289
histological result of the sectioned teeth. Software sys-
tems have been used to create a caries scoring system
following the ICDAS index on digital images from
intraoral scanners using caries detection technologies
[23]. This is useful for clinical patient management and
as a research tool for future studies.
In vitro studies, however, might not be fully applicable
to the clinical setting since there are many other con-
founding factors such as staining, plaque, calculus, and
restorations in the mouth that are not being accounted
for [24]. Many studies and systematic reviews pertain-
ing to caries recommend that future studies should be
carried out in vivo to account for patient factors. Studies
should also look at root caries and primary teeth using
current technologies (Figure 10.1), and also compare to
other technologies such as NIRT [14, 25]. This will
increase the clinical relevance of these studies while
informing companies about improvements that can be
made to the technologies when used in a clinical
scenario.
10.3 ­Digital Dentistry
in Dental Education
In the past decade, the advent of digital methods has
had an influence on dental education. It has been sug-
gested that digital methods could be useful even for
assessing dental student activities [26]. Furthermore,
the current COVID-­19 pandemic has also affected den-
tal students in clinical and theoretical learning, as well
as in self-­reported outcomes [27].
Considering that digital workflow in dentistry is
reproducible and reliable, it is suggested that CAD
software analyses (see Chapter 2) could be used not
only for improving teaching and training, but also for
assessing student outcomes. As discussed in Chapter 3,
3D-­printed models are useful to study anatomy
(Figure 10.2). Software and applications can also be
used for treatment planning, which could enhance the
student’s ability to understand the clinical steps to be
performed. CAD software programs could be used to
assess outcomes from students performing phantom
head training in dental study models (Figure 10.3).
Moreover, virtual reality and interactive simulators
have been found to contribute in dental educa-
tion [28]. Further research would be required, how-
ever, to confirm the usefulness of these suggestions
for universities and dental education centers.
Figure 10.1 Screenshot of the Caries Detection Aid tool of the software (3Shape A/S).

Figure 10.2 3D-­printed resin model obtained from a CBCT scan and used for studying anatomy of the maxillary sinuses.

Figure 10.3 Digital assessment of a preparation performed by a student with the DentalCAD software (Exocad GmbH). Note
the linear (red) and angular measurements of the preparation (yellow).
 Chapter 10 Digital Workflow in Dental Public Health, Preventive Dentistry, and Education
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 293

Part 3

Case Atlas
 295

Chapter 11
Multidisciplinary Clinical Cases
Alan J.M. Costa, Alexandre D. Teixeira-­Neto, Jun Ho Kim, Allan R. Alcantara, Daniel Machado,
Gustavo Giordani, Marcelo Giordani, Florin Cofar, José Lincoln de Queirós Jr, Luis E. Calicchio,
Djalma N. Cortes, Arthur R.G. Cortes, Guilherme Barrella, Fábio Cabral, Guilherme S. Nakagawa,
Richard Leesungbok, Hossam Dawa, and Daniel No

SUMMARY

This chapter presents an atlas with case reports of routine cases illustrated from diagnosis and treatment planning to final
execution and follow-­up results.

Case Report 11.1 Laminate Veneers with Guided Preparations Following Image-­Guided Crown-­Lengthening
(Case by Dr Alan J.M. Costa and Dr Alexandre D. Teixeiro-­
Neto. CAD-­CAM procedures by Dr Alexandre Rayes and CDT
Alexandre Santos from Studio Art Dental, Curitiba, Brazil)
A 40-­year-­old female patient presented to the clinic
for esthetic oral rehabilitation with a chief complaint
of being unsatisfied with the esthetic conditions of
her smile due to short upper anterior teeth. After dis-
cussing possible treatments, the patient agreed to the
option of receiving ceramic laminate veneers follow-
ing periodontal surgery for crown lengthening.
The first step was the acquisition of digital data.
The patient underwent two facial scans in occlusion
(one smiling and the other with lip retractor), clinical
photographs, intraoral scans of maxillary and man-
dibular arches along with digital bite registration, and
a cone beam computed tomography (CBCT) scan per-
formed with lip retractors to assess the need for oste-
otomy during crown-­ lengthening procedures
(Figure 11.1).
The intraoral scans were superimposed to the facial
images in the NemoSmile® software (Nemotec Dental
Systems) with facial reference lines to enable esthetic
analyses (Figure 11.2) before proceeding with digital
waxing of the anterior teeth involved in the rehabili-
tation. This was initially performed with the Nemotec
software (Figure 11.3) and finalized in the DentalCAD®
software program (Exocad) by a CAD and dental
technician.
The resulting digital wax patterns were then
exported as STL files and imported into a DICOM
viewer and treatment planning software (NemoScan®,
Nemotec Dental Systems) to check the alignment of
the digital wax patterns and the digital scanning
images of the patient (Figure 11.4).
The CBCT scan was then aligned and superimposed
to the OBJ and STL files from the facial and intraoral
scans, respectively. This is required to plan the perio-
dontal surgery for crown lengthening while visualiz-
ing the digital wax patterns of the laminate veneers
to be fabricated (Figure 11.5).
The same software (Nemotec) was also used to
digitally design a surgical guide based on the perio-
dontal virtual planning to orientate the incision and
the osteotomy involved in the procedure. For this pur-
pose, a measurement tool of the software was used to
perform linear measurements corresponding to the
length of soft tissue and bone to be removed during

(Continued )

Digital Dentistry: A Step-by-Step Guide and Case Atlas, First Edition. Edited by Arthur R.G. Cortes.
© 2022 John Wiley & Sons Ltd. Published 2022 by John Wiley & Sons Ltd.
296 Digital Dentistry: A Step-by-Step Guide and Case Atlas
Case Report 11.1 (Continued)
Figure 11.1 Methods of obtaining images used for treatment planning.
Figure 11.2 Maxillary intraoral scan superimposed to the
facial scan. Note the presence of the reference lines (e.g.,
midline and lines from the inner corner of the eyes to the
canine eminences).
the crown-­lengthening procedure (Figure 11.6). The
resulting surgical guide was exported as an STL file,
and 3D-­printed using a DLP 3D-­printer (Hunter®,
FlashForge) with light-­cured resin (PriZma® 3D Bio
Guide, Makertech Labs). The 3D printer was config-
ured with the following parameters: 1 mm offset,
0 harden, Constant Direction, 20 density, and Offset
End 4 Type.
The fabricated surgical guide was then used to ori-
entate the incision of the soft tissue. The osteotomy,
in turn, was conducted using a flapless approach with
a piezoelectric surgical device (DentSurg Pro®,
CVDentus®). The length of the osteotomy on each
tooth was controlled by following up the length
measurement of the surgical tip of the piezoelec-
tric device.
 Chapter 11 Multidisciplinary Clinical Cases 297

Figure 11.3 Digital waxing procedure for maxillary laminate veneers from first molar to first molar, performed in the CAD
software (Nemotec).

Figure 11.4 Final diagnostic digital wax patterns.

(Continued )
298 Digital Dentistry: A Step-by-Step Guide and Case Atlas
Case Report 11.1 (Continued)
Figure 11.5 Alignment of the CBCT scan (top left) with the other digital scanning images (top right). With the bone
information available, linear measurements related to the crown-­lengthening surgical planning were performed using the
same software (bottom images).
Because this periodontal surgical procedure was
performed using a flapless approach, the teeth prepa-
rations and prosthetic rehabilitation could be carried
out immediately after crown lengthening (i.e., in the
same appointment).
Two different 3D-­printed guides were used to ori-
entate the amount of tooth structure to be removed
during the preparations (Figure 11.7). These guides
work as templates based on the digital wax pattern of
each tooth. The preparation is performed with a free-­
hand technique, while the guides are positioned dur-
ing the procedure to ensure that a satisfactory amount
of tooth structured is removed, aiming at maximum
enamel preservation. The decision on the ideal crown
thickness will depend on factors such as the type of
ceramic material to be used and the color of the tooth
substrate (e.g., darker underlying substrates may need
a greater width of ceramic material to achieve a satis-
factory esthetic outcome).
One of the guides orientates the horizontal reduc-
tion (Figure 11.8), while the other one orientates the
vertical reduction of tooth structure (Figure 11.9) per-
formed with burs during the preparation procedure.
The preparations are aimed to have approximately
5 mm subgingival finish lines.
After obtaining satisfactory preparations, the sub-
strate colors were chosen considering the future
ceramic laminate veneers to be installed (Figure 11.10).
Another intraoral scan was taken of the preparations,
and aligned with the previously performed digital
wax patterns to ensure the satisfactory design of the
laminate veneers. A milled mock-­up was tried-­in for
the patient to approve the esthetic outcomes.
These were then obtained as STL files and milled
with lithium disilicate blocks (T.Lithium LT VBL 3®,
Talmax) using a five-­axis milling device (M4®,Zirkonzahn).
The resulting laminate veneers were then stained.
Thirty-­five percent phosphoric acid etching was per-
formed on the preparations, while silane and a two-­
component adhesive (OptiBond® Extra Universal,
Kerr) were used in the laminate veneers before being
cemented to the preparations using resin luting agent
(RelyX® Veneer, 3M ESPE). A satisfactory esthetic result
was achieved and approved by the patient (Figures
11.11–11.14). No posttreatment complications were
noted within a 1-­year follow-­up.
 Chapter 11 Multidisciplinary Clinical Cases 299

Figure 11.6 Crown-­lengthening surgical guide design based on linear measurements related to the length of soft and
bone tissue to be removed.

Figure 11.7 Digital design of the crown-­lengthening surgical guide superimposed to the original intraoral scan (top
image) and to the scan with the digital wax patterns (bottom image). The bottom of the band of the surgical guide was
used to orientate the incision of the gingival tissue (bottom right image). The top of the band could be used to orientate the
limit of the osteotomy if an open-­flap surgery was planned. However, in this case, a flapless approach with piezoelectric
surgery was used to perform osteotomy.

(Continued )
300 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Case Report 11.1 (Continued)

Figure 11.8 3D-­printed preparation guide used to orientate horizontal reduction (left image) to ensure the correct
execution of the preparation. A retrospective analysis with the DentalCAD software (Exocad) was performed (right image) by
superimposing the mesh of the final laminate veneers with the mesh of the intraoral scan, confirming that the correct
amount of enamel was removed in a conservative way.

Figure 11.9 3D-­printed preparation guide used to orientate vertical reduction.

 Chapter 11 Multidisciplinary Clinical Cases 301

Figure 11.10 Color selection and mock-­up try-­in.

Figure 11.11 Final esthetic result with the CAD-­CAM ceramic laminate veneers.

(Continued )
302 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Case Report 11.1 (Continued)

Figure 11.12 Final clinical intraoral view.

Figure 11.13 Final intraoral comparison.


Figure 11.14 Final facial comparison of the smile.
Case Report 11.2 Digital Workflow for Cosmetic Dentistry
(Clinical case and technique by Dr Daniel Machado,
Dr Allan R. Alcantara, and Dr Jun Ho Kim)
In a contemporary and dynamic approach to dentistry,
we can see a promising future in terms of the results
of the treatments themselves in connection with
many technological resources, the constant scientific
advance, and the development of new techniques in
dentistry [1, 2].
Perhaps orthodontics can be considered the area of
dentistry that has always sought to obtain more bal-
anced facial profiles. Some important parameters
about functional balance and proportionality of facial
structures were developed based on facial analysis
and definitions of ideal facial patterns [3].
It is not by chance that orthodontics and, more
recently, cosmetic dentistry have gained a prominent
role in terms of facial restructuring and tissue bal-
ance. With the incessant search for knowledge, the
evolution of materials currently available on the mar-
ket, and the digital resources available for individual-
ized planning, the development of new techniques
has created new opportunities for treating and
Chapter 11 Multidisciplinary Clinical Cases 303
solving structural problems such as severe facial
discrepancies.
The search for minimally invasive procedures has
grown significantly in the last decade and surgical
interventions have been gradually replaced by mini-
mally invasive procedures. Cosmetic dentistry occu-
pies a prominent place and its objective is the
restructuring of the face, rebuilding what was lost in
relation to various etiological factors such as the
presence of facial discrepancies, habits, ethnicity con-
siderations, gender considerations, and especially the
physiology of aging [4]. The latter continues slowly,
resulting in loss of skin support. In recent decades,
several types of injectable devices have been tested
in an attempt to restore facial volume [5]. Mimicking
tissue replacement has become more viable. Probably
the most significant change related to facial restruc-
turing and rejuvenation has been the introduction of
nonsurgical treatments, either for muscle relaxation
and wrinkle reduction or for recovery of volumes and
contours lost. This has caused the evolution of materi-
als, especially fillers, to advance quickly. In the past,
materials such as paraffin or silicone were used to
(Continued )
304 Digital Dentistry: A Step-by-Step Guide and Case Atlas
Case Report 11.2 (Continued)
restore lost facial volumes, but there were concerns
about biosafety of these materials. This has acceler-
ated research and recently, new materials have been
developed supported by studies on their safety and
efficacy [4, 5].
The market revolution began with the introduction
of hyaluronic acid in 2003 which paved the way for
the development of other materials and techniques
that, in combination, can promote major changes and
restore balance and harmony to the face. According to
the American Society for Plastic and Aesthetic Surgery,
more than 1.2 million procedures for injectable der-
mal filler were performed in 2008, which represents a
200% increment since 1997 [6–9].
With orthodontic correction for the repositioning
of the teeth and bone bases, the final result is not
always satisfactory, from the point of view of bal-
ance and harmony of the facial structures. A gummy
smile, a deficiency in the mandibular contour or
even a projection of the chin may not translate the
result of successful orthodontics, falling short of
expectations on the part of both the professional
and the patient. With a multidisciplinary digital
treatment plan, cosmetic dentistry techniques can
be used after orthodontic intervention for the cor-
rection of facial discrepancies and to promote satis-
factory facial esthetics.
Facial Design™ is a digital tool developed to be a
photographic protocol concept for digital face plan-
ning in cosmetic dentistry. Basically, the system uses
digital masks that have different forms for each inter-
vention and make it easier for the professional to
identify the points to be worked on. With these masks,
it is possible to digitally demarcate the patient’s face
in the photograph and plan possible procedures to be
performed [6].
Every esthetic treatment requires good diagnosis
and adequate planning that involves the patient’s
function, esthetic, physical, and emotional health. It
is worth remembering that technological resources
and excellent technical execution do not guarantee
satisfaction with the results at the end of treatment.
It is important to create a rapport with the patient
to understand their main complaints and meet their
expectations, within the bounds of what is possible.
The planning stage will guide the execution of the
treatment and will give greater predictability. Regarding
cosmetic dentistry, planning and simulation software is
still not very reliable and as we work with tissue mim-
icry related to several intrinsic and extrinsic factors and
depend on the patient’s cooperation with regard to
postoperative care, it is still very difficult to simulate
treatments and predict outcomes. The main point of
Facial Design is to add information, allowing a clearer
and more direct communication with the patient. In
addition, it enables a detailed facial analysis, digital
planning of procedures, and interdisciplinary communi-
cation and strengthens the professional–patient rela-
tionship, increasing the predictability of results and
optimizing treatment [6].
Facial Design can be performed very simply through
digital tools available in slideshow software such as
Keynote® (Apple) and PowerPoint® (Microsoft).
Digital masks can be added or removed according to
the assessment, need, and intervention proposal for
each case. With completion of digital face drawing,
the facial photo without the masks is placed next to
the same facial photo with the masks so that the
patient can view all the proposed interventions.
According to de Maio et al. [5], the lack of structural
support related to significant bone deficiencies can
result in changes in the pattern of muscle contraction
and cause a superficial deformation; these deficits in
facial structure can be remedied with injectable hyalu-
ronic acid with the goal of restoring lost contours and
volumes. It is noteworthy that the proper selection of
each product, respecting its rheological characteristics,
is essential for success of the treatment. As a result, the
loss of facial contour, as well as facial asymmetries, can
be corrected, always respecting the principles of balance
and harmony to obtain positive results, thus achieving a
more natural appearance of the facial profile [1, 5, 10].
Facial fillers using hyaluronic acid are considered the
gold standard for nonsurgical and minimally invasive
interventions, in the process of facial rejuvenation and
to increase the volume and contour of facial tissues [11].
Studies have shown that the use of hyaluronic acid can
promote safe solutions and provide excellent results in
the treatment of facial discrepancies when associated
with orthodontic treatment [7–12].

With the increasing number of noninvasive inject-
able procedures, cosmetic dentistry is gaining more
interest as an option for patients who do not wish to
have surgical corrections of facial discrepancies.
A 44-­year-­old female patient, class III, presented
with a protruding mandible. After completing the
orthodontic treatment, she felt an esthetic need for
correction of the facial discrepancy, but without hav-
ing to undergo an orthognathic surgery for maxillary
advancement. With the use of fillers with specific
characteristics for each region, use of botulinum toxin,
and mixtures for epidermal-­dermal rejuvenation, the
following treatment was carried out to correct the
facial discrepancies presented (Figures 11.15–11.24).
After a facial analysis using cephalometric points
and complete exams, the entire treatment plan was
carried out, trying to compensate for the missing
maxilla and restructuring of the middle and upper
third of the face, using fillers and botulinum toxin.
A full face treatment was performed in two stages,
filling the following regions with the quantities
mentioned in the images: temples, eyebrow arch,
dark circles, malar and zygomatic arch, nasolabial
sulcus, mandibular angle, lips and revitalization of
the frontal and perioral region with Skinbooster®. In
Figure 11.15 Digital photographs following the Facial Design digital protocol – face evaluation in frontal and 22° photos.
Chapter 11 Multidisciplinary Clinical Cases 305
addition, botulinum toxin applications were per-
formed in the upper third. The treatment objective
was achieved, bringing harmony to the face and
reducing facial bone discrepancies and the facial
aging process.
After completing the steps of facial restructuring,
the patient still complained about the smile and teeth
position, so digital planning of the smile was per-
formed using Smilecloud® planning software. This 2D
design guided the diagnostic wax-­up.
The patient was then scanned, originating an STL
model that was digitally waxed using open CAD soft-
ware (Meshmixer®) using a library of natural teeth.
Diagnostic waxing was performed, with model print-
ing for mock-­up and digital preparation of the den-
tal guide.
The treatment was then performed in a minimally
invasive way following the digital workflow, with the
help of the preparation guide and an intraoral scan-
ner model (TRIOS 3, 3Shape A/S). Digital models were
printed on a die-­cast 3D printer and the laminate
veneers were fabricated in lithium disilicate and
cemented.
No posttreatment complications occurred within a
1-­year follow-­up.
(Continued )
306 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Case Report 11.2 (Continued)

Figure 11.16 Digital photographs following the digital protocol Facial Design – face evaluation in frontal photos, 22° and
90° smiling.

Figure 11.17 Face proportion analysis masks together with lateral cephalometric radiography to assess soft tissue
position in relation to hard tissue.
 Chapter 11 Multidisciplinary Clinical Cases 307

Figure 11.18 Facial filler masks, botulinum toxin in an integrated full face treatment.

Figure 11.19 Step-­by-­step procedures of facial filling in the temple, malar and zygomatic arch, mandible angle, and dark
circles. Use of needles and cannulas.

(Continued )
308 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Case Report 11.2 (Continued)

Figure 11.20 Initial photographs of the teeth together with a mock-­up already in the mouth, models printed on a 3D
printer and STL performed with an intraoral scanner.

Figure 11.21 Intraoral scanning generating an STL file after dental preparation for making ceramic veneers.
 Chapter 11 Multidisciplinary Clinical Cases 309

Figure 11.22 Models printed on a 3D printer die-­cast to try-­in the ceramic laminate veneers.

Figure 11.23 Patient’s initial and final view in 22° and frontal view respectively, after the two stages of facial
restructuring and installation of the CAD-­CAM ceramic laminate veneers.

(Continued )
310 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Case Report 11.2 (Continued)

Figure 11.24 Final result of the patient after facial restructuring treatment and manufacture of ceramic laminate
veneers for functional esthetic treatment of the smile with a full digital workflow in both treatments.

Case Report 11.3 Digital Workflow in the Esthetic Area to Correct Gingival Discrepancies
(Clinical case and technique presented by Dr Gustavo color of her upper teeth (Figure 11.25). She had received
Giordani, Dr Marcelo Giordani, and Dr Florin Cofar) dental implants to treat dental agenesis of both upper
lateral incisors, areas presenting discrepancies con-
The present case aims to show the advantages of digi- cerning gingival margins (Figures 11.26 and 11.27).
tal tools for both planning and execution of esthetics Before evaluating the implants, as part of the work-
cases. A female patient attended a dental clinic com- flow, the future design (treatment proposal) was
plaining of poor esthetics regarding the shape and planned so that the execution steps would be better

Figure 11.25 Initial facial and oral aspects – frontal views.


Figure 11.26 A thin tissue phenotype was observed in the
areas related to dental implants, besides altered gingival
color due to lack of buccal tissue volume – frontal view.
Figure 11.28 Comparison between initial aspect and final result digitally planned – frontal views.
addressed after approval (Figure 11.28). We used
Smilecloud, developed by Dr Florin Cofar, which allows
the professional to obtain a 2D design of the case
using artificial intelligence. This technology considers
facial and intraoral points and measurements and
then performs a search – within its internal library –
for natural teeth shapes that best fit the selected case.
The software is not only a diagnostic and motivational
tool but also permits the download of the selected
teeth in 3D (STL file) (Figure 11.29), so that a digital
wax-­up can be performed on the initial scan, using any
CAD software (e.g., Meshmixer, Exocad, Inlab®).
From the design overlaid with the initial scan, the
model was printed (Figure 11.30) and an intraoral
mock-­up with bis-­acryl resin (for tooth design) and
gingiva composite resin (for gingival coverage design)
was performed (Figures 11.31–11.33).
Chapter 11 Multidisciplinary Clinical Cases 311
Figure 11.27 Occlusal intraoral view.
Once the planning had been approved, the position
of the implants was evaluated (Figure 11.34). Implants
should be positioned in such a way that allows a good
esthetic result. For this reason, a tomographic analysis
was carried out and there was no need for implant
retrieval since the tridimensional position of both
implants was acceptable (Figure 11.35). On the other
hand, an abutment and prostheses with improved
designs were planned, to support coronal migration of
the new gingival margin after connective tissue graft.
After deciding to keep the implants in position, they
were transferred (Figure 11.36) and dental prepara-
tions guided by the mock-­ up were carried out
(Figure 11.37).
Ceramic crowns and zirconia abutments were man-
ufactured to be cemented on Ti-­ base abutments
(Figure 11.38). During the appointment for abutment
(Continued )
312 Digital Dentistry: A Step-by-Step Guide and Case Atlas
Case Report 11.3 (Continued)
Figure 11.29 Digital wax-­up.
Figure 11.30 Model printed.
try-­in, clinicians should carefully evaluate all the fea-
tures of the connective tissue graft to be performed,
such as those related to accommodation and tissue
migration in coronal direction for healing in the
desired position (Figure 11.39).
Immediately after the grafting procedure (Figure
11.40), cementation of the ceramic prostheses was
performed using rubber dam (Figure 11.41). Final
sutures were done after cementation had been com-
pleted (Figure 11.42).
In conclusion, the digital tools for diagnosis,
­planning, and execution of the current case provided
a more predictable and accurate final result
(Figures 11.43 and 11.44).
 Chapter 11 Multidisciplinary Clinical Cases 313

Figure 11.31 Teeth mock-­up with bis-­acryl resin. Figure 11.32 Gingival composite resin

Figure 11.33 Final Intraoral mock-­up.

Figure 11.34 Digital evaluation of implant positioning.

(Continued )
314 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Case Report 11.3 (Continued)

Figure 11.35 Tomographic evaluation of implant positioning.

Figure 11.36 Implant transfer.

 Chapter 11 Multidisciplinary Clinical Cases 315

Figure 11.37 Dental preparation.

Figure 11.38 Ti-­base and zirconia abutments and ceramic crowns.

(Continued )
316 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Case Report 11.3 (Continued)

Figure 11.39 Free connective tissue graft removed from

Figure 11.41 Cementation of ceramic crowns.
the hard palate.

Figure 11.42 Cementation done and all the sutures in

Figure 11.40 Immediate postoperative aspect. position.

Figure 11.43 Final facial aspect – frontal view.


Figure 11.44 Final intraoral aspect – frontal view.
Case Report 11.4 Digital Workflow for Crown Lengthening and Laminate Veneers Using the Virtual Articulator
(Clinical case and technique presented by Dr José Lincoln
de Queirós Jr with the participation of CDT Wagner
Nhoncance)
The patient came to the dental office looking for bet-
ter esthetics and function. After clinical exam, some
spaces between anterior teeth were noted, which had
previously been closed with composites and were not
acceptable to the patient (Figure 11.45). Another
important aspect was an asymmetry noticed in the
diagnostic photos. The patient wanted to correct
these two aspects with a long-­term material, and the
next step was a smile design preview.
The initial design was carried out with Smilecloud
(Figure 11.46), a service that can design a simulation
Figure 11.45 Initial clinical situation.
Chapter 11 Multidisciplinary Clinical Cases 317
and propose new anterior teeth morphology and posi-
tions. An artificial intelligence algorithm proposed
the new shapes that were downloaded and imported
to Ceramill® Mind software in order to design the 3D
smile wax-­up and orientate the periodontal surgery
guide. This design was complemented by functional
parameters, achieved by an individualized face bow,
used to mount upper and lower scans in the virtual
articulator (Figures 11.47–11.49). This strategy was
necessary to orientate the asymmetry corrections and
possible treatment options.
After the above-­mentioned steps and patient vali-
dation, the digitally guided periodontal surgery was
performed (Figures 11.50 and 11.51). After healing,
new intraoral scans were done to perform a new
(Continued )
318 Digital Dentistry: A Step-by-Step Guide and Case Atlas
Case Report 11.4 (Continued)
digital wax-­up for the final teeth shapes preview.
Next, the simulation models were printed and trans-
ferred with a bisacryl mock-­up, grinding the preps.
After sending files, the laboratory superimposed them
in order to evaluate preparation measures. Final res-
torations were milled with leucite (Empress® CAD
Figure 11.46 Smilecloud software analysis.
(a)
Figure 11.47 (a–c) Use of facebow before mounting on the Virtual Articulator.
Multi, Ivoclar), stained, glazed, and cemented
(Figure 11.52). The final result met the patient’s
expectations, supported by digital tools that opti-
mized clinical steps and guided the diagnostic
findings throughout the entire treatment (Figures
11.53–11.55).
(b)
 Chapter 11 Multidisciplinary Clinical Cases 319

(c)

Figure 11.47 (Continued)

Figure 11.48 Patient’s profile with the Virtual Articulator.

(Continued )
320 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Case Report 11.4 (Continued)

Figure 11.49 Intraoral scans mounted on the Virtual Articulator.

Figure 11.50 Periodontal surgical guide. Figure 11.52 Final restorations.

Figure 11.51 Clinical aspect after periodontal surgery.

Figure 11.53 Teeth preparations.

Figure 11.54 Final intraoral photograph.
Case Report 11.5 Be Better and Faster! That’s My Goal with Digital Dentistry
(Clinical case and technique presented by Dr Luis
E. Calicchio)
We need to understand how technology can help us to
create better communication with our patients and
dental technicians, simplify procedures and achieve
predictability and replicability, which are crucial to
perform at a high level in digital dentistry.
In this multidisciplinary case, we will see how we
can use the scanner, design software, milling machine,
and 3D printer to make our workflow easier, more pre-
dictable and replicable, allowing us to solve big chal-
lenges in a short period of time.
Before we discuss the case, let’s take a look at the
digital workflow that I used in this case. It is divided
into three principal steps.
1) Diagnostic: here we need to capture all the images
from our patient in order to analyze the esthetics.
We need an initial scan to analyze function and to
superimpose it on the images from our patient,
and we need complementary exams to analyze
tooth health. With this, we can plan our step-­by-­
step treatment and share this with our patient.
2) Processing: we start the design of the new smile
considering not just esthetics but function too,
using the design software. After that, clinical pro-
cedures including mock-­ up, preparations, and
scans should be performed and sent to the digital
lab. Production of the restorations can be done by
milling machine or 3D printers and the final
Chapter 11 Multidisciplinary Clinical Cases 321
Figure 11.55 Final smile of the patient.
adjustments, polishing, and make-­up are carried
out by the dental technician. After that, dentist can
perform clinical procedures.
3) Monitoring: this step is required to help the dentist
take care of the patient with the most precise
information. Every time patient comes to the office,
we can perform a scan and superimpose the files
(old and new) to check alterations in soft tissue,
occlusion, enamel, etc. and understand what is
happening in the patient’s mouth.
In our clinical case, the initial documentation was
obtained as explained above following the protocol.
The patient was uncomfortable with her smile
(Figure 11.56), not just because she did not like her
current esthetics but also because she was having
debonding problems with many restorations. An ini-
tial scan was performed and we observed occlusion
problems like open bite in the anterior area caused by
incorrect inclination of the posterior teeth
(Figures 11.57 and 11.58). Analyzing the radiographs,
we found some irreversible problems in teeth num-
bers #11 and #22 (Figure 11.59).
A full mouth oral rehabilitation was planned to
reconstruct the occlusion and improve esthetics, mix-
ing guided surgery, zirconia abutments, and
ceramic crowns.
The first step was to figure out the new centric rela-
tion or therapeutic position. To do this, a Kois® depro-
grammer was created (Figure 11.60). After 30 minutes
a new position was determined and a new scan of
(Continued )
322 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Case Report 11.5 (Continued)

Figure 11.56 Initial occlusion – scanner view. Observe the

posterior interference and wrong teeth proportion.

Figure 11.58 Initial occlusion – scanner view. Observe

the open anterior bite as a result of posterior interferences.

Figure 11.57 Initial smile.

upper and lower arch was done. The file was sent
immediately to the lab.
A digital wax-­up was produced, recreating esthetics
and function to provide smooth and adequate pathways
according to the patient’s requirements (Figure 11.61).
Models were 3D printed and a silicone index was cre-
ated as the next step. All the old restorations were
removed and a bisacryl mock-­up was tried in both den-
tal arches (Figures 11.62–11.64). A critical analysis with
regard to esthetics and function should be done to guar-
antee that all the teeth positions are correct in relation
to the patient’s face and that excursive movements are Figure 11.59 Initial radiograph.
adequate. With the final position of the teeth deter-
mined, we can go forward to the surgical phase. biomaterial graft was performed (Figures 11.65
The right central incisor and left lateral incisor and 11.66). The healing period would be 3 months.
were extracted. The printed surgical guide was tried- During the healing period, in the anterior upper
­in and the adaptation was checked. The V3 MIS arch we continued with the oral rehabilitation, replac-
implants were placed and a connective tissue and ing the provisionals with ceramic restorations. We

Figure 11.60 Kois deprogrammer in mouth.
Figure 11.61 Digital wax-­up.
started with the lower preparations (Figure 11.67)
and a scan with iTero® Align was performed
(Figure 11.68). The file was sent to the dental lab and
the final restorations were built with lithium disili-
cate ceramic (Figure 11.69). The bonding followed the
protocol with OptiBond FL and Variolink® neutral.
The posterior upper teeth were finished following the
same approach (Figures 11.70 and 11.71).
Chapter 11 Multidisciplinary Clinical Cases 323
Figure 11.62 Mock-­up with bisacryl resin.
Figure 11.63 Mock-­up. Observe the new occlusion.
After 90 days, we started the management of the
soft tissue in the anterior area. The emergence profile
of the restorations was created with provisionals
before we began the final step of the oral rehabilita-
tion. A first scan was performed to capture the details
of the soft tissue (Figure 11.72). The scanbodies were
placed and a second scan was performed to capture
the position of the implants and the final preps of the
anterior teeth (Figures 11.73–11.75). With the result-
ing files, the dental technician can use the copy paste
technique describe by Coachman in which we can use
the same design of the mock-­up and superimpose it
to the preps scan (Figures 11.76 and 11.77). As we can
see in the figures, we can align and superimpose the
files and gain all the information about soft and hard
tissue, allowing us to create an adequate emergence
profile, contact points, and details of the final restora-
tions. Zirconia abutments were performed and lithium
disilicate restorations were milled (Figure 11.78).
(Continued )
324 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Case Report 11.5 (Continued)

Figure 11.64 Mock-­up. Esthetic result. Figure 11.66 Implants, connective tissue graft, and
biomaterial in place.

Figure 11.65 Guided surgery. Figure 11.67 Lower arch prep.

Figure 11.68 Lower arch scanned by iTero and in perfect occlusal relation.

During the try-­in process, we need to check the sup-
port that zirconia abutments are providing in the soft
tissue and the position of the interproximal contact
points of the restorations (Figures 11.79 and 11.80).
The bonding process was performed and we can see
the final result after 48 hours in Figures 11.81
and 11.82. The good relation between soft tissue and
restorations shows how precise we can be in digital
dentistry. The good relation between upper and lower
arch in a new occlusal vertical dimension (OVD) and a
good occlusion respecting all the functional move-
ments show how predictable the digital workflow is
(Figures 11.83 and 11.84). The ability to replicate the
Figure 11.69 Lower arch ceramics. Lithium disilicate on printed model.
Figure 11.70 Upper arch with posterior preps.
Chapter 11 Multidisciplinary Clinical Cases 325
same shape approved in the mock-­up step in the final
restoration shows how replicable digital dentistry is
(Figures 11.85 and 11.86). And when we look at the
final periapical radiograph, we can see the very good
fit of the restorations (Figure 11.87) and very good
positions of the implants. A full mouth oral rehabilita-
tion done with a more predictable and faster approach.
The new tools and technology are changing den-
tistry and our clinical and laboratory protocols are
fundamental to the success of our treatments. Digital
dentistry can work for your business, your team, and
your patients, which should be the goal for every
modern dentist.
(Continued )
326 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Case Report 11.5 (Continued)

Figure 11.74 Final scan of anterior upper teeth and

Figure 11.71 Upper arch with posterior ceramics during
implants.
bonding process.

Figure 11.75 Details of the scan. Observe how precise

we can be.

Figure 11.72 Emergence profile of the implants scanned

by iTero.

Figure 11.76 Final design of the restorations. Observe the

superimpositions of the files allowing us to have all the
Figure 11.73 Upper anterior preps and scanbodys in information between soft tissue and the shape of the
position. restorations.
 Chapter 11 Multidisciplinary Clinical Cases 327

Figure 11.80 Try-­in procedure.

Figure 11.77 Checking all details of emergence

profile of the restorations.

Figure 11.81 Final restorations after 48 hours of the

bonding process – 1.

Figure 11.78 Lithium disilicate restorations and zirconia

abutments on the 3D-­printed model.

Figure 11.82 Final restorations after 48 hours of the

bonding process – 2.

Figure 11.79 Zirconia abutments intraoral try-­in.

(Continued )
328 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Case Report 11.5 (Continued)

Figure 11.83 Final restorations after 48 hours of the

bonding process – 3. Figure 11.85 Final restorations – 2.

Figure 11.84 Final restorations – 1. Figure 11.86 Final patient’s smile.

Figure 11.87 Final periapical radiography.

 Chapter 11 Multidisciplinary Clinical Cases 329

Case Report 11.6 Conservative Approach with Digital Workflow for Anterior Crowns in the Esthetic Area
(Clinical case and technique presented by Professor Arthur R.G. Cortes and Dr Djalma N. Cortes)

This case illustrates a step-­by-­step procedure of digi-
tal workflow for the esthetic area using an integrated
CAD-­CAM system (Zirkonzahn). A 54-­year-­old female
patient presented to the clinic with the chief com-
plaint of a fractured crown of tooth #22, and she was
unsatisfied with the esthetic conditions of her other
maxillary lateral incisor (tooth #12). Both lateral inci-
sors were endodontically treated. Despite the crown
fracture of tooth #22, gingival management and two
posts could be done with composite resins and two
temporary crowns were immediately installed. Intraoral
scans were combined with clinical photographs of the
patient’s smile to perform a virtual wax-­up. For this
purpose, an additional intraoral scan of the temporary
crowns was merged with the other images to serve as
a reference, since the patient liked the shape of the
temporary crowns. The definitive digital wax patterns
for both lateral incisors were then performed. The
crowns were milled in a M1 milling device (Zirkonzahn)
with lithium disilicate (Figures 11.88–11.101).
Acknowledgments: Professor Cortes and Dr Cortes would
like to thank CDT David Conti, CDT Jacqueline Ferreira
Lima, and Otoniel A. da Silva from the DC Prótese
Odontológica (Santo André, SP, Brazil) laboratory for the
laboratory work involved with this clinical case.

(a) (b)

Figure 11.88 Initial clinical situation. (a) Tooth #22. (b) Tooth #12.

Figure 11.89 Teeth preparations.

(a) (b)

Figure 11.90 (a) Color assessment. (b) Conventional temporary crowns.

(Continued )
330 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Case Report 11.6 (Continued)

(a)

(b)

Figure 11.91 (a) Project definition in the Zirkonzahn Modellier software. (b) Intraoral scans performed with TRIOS 3.
 Chapter 11 Multidisciplinary Clinical Cases 331

(a)

(b)

Figure 11.92 (a) Margin outlining procedure (see Chapter 4). (a) Tooth #12. (b) Tooth #22.

(Continued )
332 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Case Report 11.6 (Continued)

Figure 11.93 Insertion axes definition.

Figure 11.94 Assessment of areas with remaining undercuts (red color). These could be slightly compensated with a
higher cement gap thickness in some cases.
 Chapter 11 Multidisciplinary Clinical Cases 333

Figure 11.95 Virtual articulator set-­up.

Figure 11.96 Superimposition of the minimum thickness mesh to the photograph.

(Continued )
334 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Case Report 11.6 (Continued)

Figure 11.97 Digital wax patterns.

(a)

Figure 11.98 (a) Design of the final STL files. (b) CAM strategy chosen in the Zirkonzahn nesting software.
 Chapter 11 Multidisciplinary Clinical Cases 335

(b)

Figure 11.98 (Continued)

Figure 11.99 CAD-­CAM crown milled with lithium Figure 11.100 Final crown aspects after staining.
disilicate (E-­max, Ivoclar Vivadent).

Figure 11.101 Final smile of the patient.

336 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Case Report 11.7 Extensive Esthetic Rehabilitation with Digital Workflow Increasing the Vertical Dimension
(Clinical case and technique presented by Dr Guilherme Barrela)

Patient MM, a smoker for the last 40 years, in systemi- and fast to produce, and easy to use, with a high-­quality
cally healthy condition, presented at our office with a result in this type of situation. Both digital wax-­up and
main complaint of lack of esthetics and severely Kois deprogrammer were produced using a 3D printer.
worn-­down dentition because of abrasion, attrition, The patient returned to my office after 5 days, and
and erosion (Figure 11.102). He also reported that he we installed the Kois deprogrammer (Figure 11.106).
noticed a loss of upper lip support and volume, result- He was instructed to retain the deprogrammer for
ing in an older look. He reported a severe stress con- 20 minutes, talking and making jaw movements with
dition in recent years. the intention to deprogram his neuromuscular func-
After periodontal evaluation, the patient had no tions and obtain his CR.
significant bone loss or active periodontal disease.
In our first appointment, we performed initial
intraoral and facial photos, intraoral scanning with
TRIOS 3 and prophylaxis (Figure 11.103). We also did
an initial smile design using 3Shape Smile Design
software (Figure 11.104).
The vertical dimension of occlusion (VDO) was
checked using a Willis compass.
This showed that the VDO should be 2 mm higher
than the vertical dimensions measured at rest.
We sent the case to the laboratory to perform a digi-
tal wax-­up, with a 2 mm higher VDO (Figure 11.105).
We also asked the laboratory to produce a Kois depro-
grammer, to obtain the correct centric relation (CR) of
the patient. The Kois deprogrammer is relatively easy Figure 11.102 Initial clinical situation.

Figure 11.103 Initial intraoral scans.


Figure 11.104 Initial virtual smile design.
On this same appointment, we installed a full
mouth mock-­up, using a silicone impression of the
digital wax-­ up. We used bis-­ acryl resin (Luxatemp
Star A2, DMC). The patient was instructed to retain the
mock-­up for 7 days to evaluate his general articulat-
ing condition with the new VDO.
After 7 days, the patient came back to the office,
happy with his new VDO and provisionals, so we
started the preparation steps.
First, we scanned the patient with the provisionals,
marking the pre-­preparation scan option in Dental
Desktop software. The software used for the scan was
TRIOS 3.
We prepared the right side (upper and lower), using
the mock-­up as a prep guide, and then we prepped
the left side. Preparation included crowns, onlays, and
veneers.
After all teeth were prepared, the dual retraction
cord technique was used to guarantee proper gingival
retraction and good scan quality. First, we used a 000
retraction cord, and then a 00 cord (both by Pascal).
We waited 5 minutes, removed the 00 cord, and per-
formed the scan.
The trickiest part of this case was scanning the
patient in CR occlusion, having 24 teeth prepared at
the same time.
Chapter 11 Multidisciplinary Clinical Cases 337
After scanning all the preparation, we installed the
mock-­up again and removed all the buccal parts of
the bis-­acryl resin, leaving just the occlusal part, so
that the software could perform the occlusion scan
taking the buccal as reference, since the occlusion
scan is taken based on the preparation scan and not
the pre-­preparation.
We also used 3Shape patient monitoring to check
and compare the original condition and final prepara-
tions to make sure we had enough space for the res-
torations (Figure 11.107).
Therefore, we were able to obtain a scan in the cor-
rect occlusion position, the same that we obtained
with the Kois deprogrammer and provisionals
(Figure 11.108).
After scanning, mock-­up provisionals were installed
again and we sent the case to the lab.
Posterior crowns were fabricated with monolithic
zirconia and anterior veneers with E.Max Cad.
After 5 days, the lab sent us all 24 elements at once,
and we performed the installation all in one single
appointment because the patient was from another
country and had not much time here.
Surprisingly, we did not have to perform any proxi-
mal adjustments in any of the 24 elements, and only
minor occlusal adjustments (Figure 11.109).
(Continued )
338 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Case Report 11.7 (Continued)

(a)

(b)

Figure 11.105 (a) Virtual wax-­up to increase OVD. (b) Virtual wax-­up finished.
 Chapter 11 Multidisciplinary Clinical Cases 339

A final intraoral scan was performed to produce
occlusal protection and a stabilization splint for the
patient. We were also able to check the difference
from initial to final overall condition by using 3Shape
patient monitoring again (Figure 11.110).
The patient returned after 3 months for a check-­up.
We noticed no differences, there were no complaints
and the patient was very satisfied with the outcome.

Figure 11.106 Kois deprogrammer.

Figure 11.107 Intraoral scans of the final preparations.

(Continued )
340 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Case Report 11.7 (Continued)

Figure 11.108 Intraoral scans with the preparation at the correct occlusion height.

Figure 11.109 Final intraoral aspect.

 Chapter 11 Multidisciplinary Clinical Cases 341

Figure 11.110 Patient monitoring system.

Case Report 11.8 Top-­Down/Restoration-­Driven Implant Treatment with Digital Workflow

(Clinical case and technique presented by Dr Richard treatment option was selected through an informed
Leesungbok) consent with the patient using the panoramic radio-
graphic image. Then, the CT template was fabricated
A 60-­year-­old woman came to our department with
by duplicating the existing old dentures, and a CT
the chief complaint as follows: “Since I got upper and
image was taken. Using this CT image data, we deter-
lower full dentures, my lower jaw looks more protrud-
mined where and how many implants could be posi-
ing than when I was young, and I don’t chew well.” She
tioned to fit the selected treatment options
said she received upper and lower full dentures at a
three-­dimensionally and designed a restoration-­
dental clinic 10 years ago after all the natural teeth
driven computer-­aided surgical template, which was
were removed. The patient complained that the lower
produced with 3D printing. Through CAIS (computer-­
denture was easily dislodged and hurt when she
aided implant surgery), the four implants to be located
chewed, and that she was dissatisfied with the
in the maxilla were designed to provide immediate
esthetic appearance of the protruded lower jaw.
loading by modifying the existing full denture and we
The oral examination showed that the patient had
planned a roofless implant overdenture (IOVD) using
low OVD and mandibular prognathism, and occlusal
magnetic attachments as a final prosthesis. Six
disharmony which hindered the normal masticatory
implants to be located in the mandible were planned
functions, and also a number of sore spots and flabby
for functional loading by immediate fixed provisional
tissues present on mucosa that made it difficult to use
restoration.
the lower full denture. The panoramic radiograph
For the design of the final prosthesis, it was decided
showed maxillary sinus pneumatization and the low-
to produce a definitive zirconia fixed restoration
ered alveolar ridge due to severe resorption of the
(Prettau Zirconia, Zirkonzahn) using the Plane System
lower jawbone.
and FaceHunter 3D face scan (Zirkonzahn) image, CAD
To establish a top-­down/restoration-­driven treat-
(Modellier, Zirkonzahn), and CAD-­CAM System 5-­TEC
ment plan (Figure 11.111), the final prosthodontic
(Continued )
342 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Case Report 11.8 (Continued)

Top-Down Treatment Planning in Implant Dentistry

Biomaterials & Prosthodontics, Kyung Hee University Dental School Hospital at Gangdong, Seoul, South Korea

Top-Down Planning Treatment Options in order Face Scan & CAD

The 1st option. Fixed restorations 1. Face Scan & virtual articulator

The 2nd option. Fixed hybrid restorations

2. Plane Analyzer & Occlusal plane

The 3rd option. OVD on upper &

An imaginary end-result Fixed hybrid restorations on lower 3. Occlusal plane in frontal view

Figure 11.111 The concept of “top-­down treatment” is part of a global trend, where surgical placement is performed
only after the final prosthetic design is completed [11–18].

(Zirkonzahn). A regular clinical follow-­up program
was planned for maintenance after the final prosthe-
sis was installed in the mouth (Figure 11.112).
CAD-­CAM Procedure
After duplicating the patient’s old dentures and using
them as a CT examination template, it was modified
to a long-­span bridge shape so that it could be used
as an immediate provisional restoration immediately
after surgery in the mandible.
Using the CT image, the diameter, length, location,
depth, and angulation of the implants in the mandible
were determined according to the top-­down/
restoration-­driven planning to establish a whole plan
for CAIS (In2guide®, Cybermed).
Considering the reduced alveolar ridge height of
the lower posterior teeth area and the close proximity
of the mandibular nerve, we planned IS-­II implants
(IS-­II Active®, NeoBiotech) 5.0 mm diameter and
7.3 mm length at the #37 location and 4.5 mm diam-
eter and 7.3 mm length at the #46 location. IS-­II
implants of 4.5 mm diameter and 10.0 mm length
were selected for #33, #34, and #44 locations consid-
ering the width of the alveolar ridge.
To avoid a large bone graft and enhancement sur-
gery in maxilla, we chose IOVD as an option for pros-
thodontic treatment, considering the severely reduced
alveolar ridge height and width due to pneumatiza-
tion of the maxillary sinus floor. The #16 and #27 loca-
tions were planned for implants with a diameter of
4.5 mm and length of 7.3 mm. Considering the narrow
width of the alveolar ridge for #13 and #23 locations,
implants of 4.0 mm diameter and 8.5 mm length were
planned. We selected IS-­II implants on both the upper
and lower jaws to design a computer-­aided template
(In2guide) (Figures 11.113 and 11.114).
 Chapter 11 Multidisciplinary Clinical Cases 343

Figure 11.112 Digital workflow with the Zirkonzahn Plane System, which consists of the Planefinder®, Real
articulator PS1, Virtual articulator PS1, Plane positioner, and Software-­Tool. 1 Using the Planefinder, through the
ala–tragus plane and natural head position (NHP), we can find the exact occlusal plane for congenitally asymmetric
facial planes and esthetic positions. 2 FaceHunter is a facial scanner for 3D operation. It can create prosthetics based
on the patient’s 3D facial appearance, which can increase trust between dentists, technicians, and patients. It is
convenient to use because the patient’s face can be digitized with just one click. 3 The CAD plane tool reproduces the
angle of inclination of the occlusal plane identified by the Planefinder. 4 Model scanning. The entire articulator can be
scanned, and the space to scan to capture the entire model is particularly large, allowing recognition of all kinds of
dental articulators. There is a double scan function for modeled framework scanning. It is convenient to capture
models because it has a device that intelligently recognizes and quickly fixes them. 5 After giving this positioner a
patient-­specific inclination angle identified through the Planefinder, secure the maxillary model and mount it to the
Virtual articulator PS1.

Based on the top-­down/restoration-­driven treat-
ment plan in the virtual CAD images, three-­segmented
implant hybrid prostheses on the lower jaw were
planned considering the mandibular flexion during
maximum mouth opening.
CAIS and Immediate Loading
On the day of CAIS surgery, the computer-­generated
surgical guide was fixed to the upper jaw, sequential
drilling was performed, the implant of the preplanned
size was inserted, and the insertion torque/primary
stability was measured. For the upper jaw, the inser-
tion torque/primary stability was good at 30–35 Ncm,
so immediate loading could be carried out by the
upper old denture only with a small modification
(Figure 11.115).
After fixing the surgical guide to the lower jaw in
the same way, the implant was inserted after sequen-
tial drilling and the insertion torque/primary stability
was measured. The primary stability should be
checked at every insertion. The insertion torque/

(Continued )
344 Digital Dentistry: A Step-by-Step Guide and Case Atlas
Case Report 11.8 (Continued)
Figure 11.113 CAD for computer-­aided implant surgery (CAIS) in mandible. I designed the hypothetical final prosthesis
first, and then designed a three-­dimensional position for implant surgery (IS-­II Active, NeoBiotech).
primary stability in the lower jaw was 40–50 Ncm, so
the immediate loading could be carried out [13]
(Figures 11.116 and 11.117).
Two months after immediate loading, the soft tissue
around the implant was cured well. The transfer type
impression copings were connected to the implants
and the final impression was taken for the final pros-
thesis using silicone rubber materials.
Bite Registration
Using the prebuilt acrylic resin bite block for VD
increase, the study casts were mounted on the semi-­
adjustable articulator with CR record at the provi-
sional restoration state. After dividing the bite block
and the lower provisional restoration into two parts
at the midline, each of them was placed on the lower
implants separately and the fixture-­level bite record
was acquired in order of left and right. These two bite
records were placed together simultaneously to make
a cross-­
mount, where the lower working cast was
attached to the semi-­adjustable articulator at the CR
position [14–16] (Figure 11.118).
First CAD for Lower PMMA Prototype Restorations
The lower PMMA prototype restoration was designed
in CAD by referring to data on the shape and size of
the standard maxillary and mandibular dental arches
of Korean patients [17, 18] (Figure 11.119).
In a nondigital stage, artificial teeth were arranged
on the upper occlusal wax rim in the semi-­adjustable

Figure 11.114 CAD for CAIS in maxilla with top-­down treatment planning. I designed the hypothetical IOVD prosthesis
first, and then a three-­dimensional position for implant surgery.
articulator. The PMMA prototype restoration (PMMA,
Zirkonzhan) was produced initially by CAD-­CAM while
maintaining the same height of the new VD in CR
position. The PMMA prototype restoration was fine-­
tuned in the mouth, and the patient agreed that we
should produce the final prosthesis in the same shape.
The vertical space that recovered the height of the
highly reduced alveolar ridge in the fixed restoration
for the lower jaw was planned to be filled with pink
hybrid gum [19] (Figure 11.120).
Second CAD for Lower Zirconia Hybrid Fixed
Restorations and Upper Magnetic Overdenture
After scanning the PMMA prototype restoration again,
we made some modifications in the second CAD
Chapter 11 Multidisciplinary Clinical Cases 345
process for the production of the definitive zirconia
fixed restoration with the scan data of the PMMA pro-
totype restoration, and then produced the three-­
segmented zirconia hybrid fixed bridges of the
screw-­retained type. In the upper jaw, we checked
that the osseointegration of the four implants was
completed after 3 months and provided a magnetic
IOVD to the patient by connecting the magnetic
attachment (Magfit® EX800, Aichi Steel, Sinwon
Dental) to the IOVD [20] (see Figure 11.120).
The upper four-­ implant magnetic overture was
mounted in the patient’s mouth and the three-­
segmented lower definitive zirconia hybrid fixed res-
torations were screwed into the six implants, which
blended harmoniously with the surrounding oral
(Continued )
346 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Case Report 11.8 (Continued)

Figure 11.115 Computer-­aided implant surgery in maxilla with top-­down treatment planning. In the maxilla, to provide
a minimally invasive implant surgery with four implants (IS-­II Active, NeoBiotech) without sinus graft procedures, the
main choice as definitive prosthesis was to select a removable-­type roofless IOVD. The insertion torque of the four
implants on the upper jaw was good at 30–35 Ncm, so I carried out immediate loading to all the implants with a
temporary IOVD.

Figure 11.116 Computer-­aided implant surgery in mandible with top-­down treatment planning. In the mandible, I
placed six implants (IS-­II Active, NeoBiotech) for a three-­segmented fixed-­type prosthesis rather than a removable-­type
denture to prevent the removable denture from shaking and to maintain the functional space of the tongue unchanged.
The insertion torque of the six implants on the lower jaw was good at 40–50 Ncm, so I carried out immediate loading
to all the implants with a one-­unit immediate provisional fixed restoration.
 Chapter 11 Multidisciplinary Clinical Cases 347

Figure 11.117 I placed six implants (IS-­II Active, NeoBiotech) on the mandible, and placed temporary abutments on
them for screw-­fastening of provisional fixed prosthesis to provide chewing function immediately. 1 Temporary
abutments on six implants with rubber dam coverage on the wound area. 2,3 Connect the acrylic structure to the
temporary abutments, which was prefabricated by duplicating the lower old denture, and results of completed one-­unit
immediate provisional fixed restoration. 4 The appearance of healing screws inserted before the completed one-­unit
provisional restoration is mounted on the lower jaw. 5 Intraoral picture at the physiological rest position with upper
temporary OVD and lower screw-­fastening provisional fixed prosthesis to provide chewing function immediately. 6. VD
and occlusal plane were reestablished based on the height of 1/2 to 2/3 of both RPs (retromolar pads), an anatomical
landmark of the mandible, and an acrylic resin bite block was created to match that height.

Figure 11.118 Jaw relation record at the newly established VD occlusal plane to make the definitive upper and lower
prostheses. 1 Centric jaw position with lower screw-­fastening provisional fixed prosthesis and upper wax rim of OVD. 2,3
Divide the lower screw-­fastening provisional fixed prosthesis in half from the midline, position it in the mouth, engage it
in the correct centric jaw position with the upper wax rim, and take the bite registration with the rubber bite material.
4,5 Next to #2 and #3, take another bite registration on the opposite side equally with the rubber bite material. 6
Combine the two bites divided from #2 to #5 and mount them on the semi-­adjustable articulator at the newly
established VD and occlusal plane.

(Continued )
348 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Case Report 11.8 (Continued)

Figure 11.119 CAD procedure (Modellier Software, Zirkonzhan) for a definitive lower implant prosthesis. 1 Artificial
teeth arrangement for the definitive upper IOVD on the physical semi-­adjustable articulator at the newly established VD
and occlusal plane. 2,3 As a virtual image, VD and occlusal plane were reestablished based on the height of 1/2 to 2/3 of
both RPs, an anatomical landmark of the mandible. 4 In order to accurately secure the tongue space (lingual white dotted
line), the RP becomes an important anatomical landmark in the horizontal aspect. If teeth are arranged by invading the
lingual border of the RP, the space of the tongue is invaded, causing the patient to experience discomfort, such as
chewing the tongue during function. 5,6 Virtual teeth arrangement for the lower jaw completed through CAD. RPs must
be evident in the analogue impression and the digital image because it is always an important anatomical landmark in
the lower jaw to establish an exact VD and 3D occlusal plane.

Figure 11.120 CAD-­CAM procedure for the definitive lower implant prosthesis and the definitive upper magnetic
IOVD. 1 Occlusal view of the definitive upper magnetic IOVD. 2,3 The lower three-­segmented polymer restorations
(PMMA) as a trial version on the real semi-­adjustable articulator. 4 Intraoral adaptation of the definitive upper magnetic
IOVD and the lower hybrid trial polymer restorations at the newly established VD and occlusal plane. 5 The definitive
lower hybrid zirconia restorations as a three-­segmented screw-­fastening bridge design. 6 The definitive lower hybrid
zirconia restorations (Prettau, Zirkonzahn) and the definitive upper IOVD on the real semi-­adjustable articulator.
 Chapter 11 Multidisciplinary Clinical Cases 349

tissues. It was confirmed that the upper magnetic
IOVD was inserted, and the denture was not dislodged
during maximum mouth opening or common chewing
function, and the patient was very satisfied with the
fact that the lip line and facial appearance were main-
tained very naturally and esthetically (Figure 11.121).
Treatment Outcome and Evaluation
Since neither patient and dentist can accurately
remember all the patient’s facial appearance changes
from the beginning of treatment to the end of treat-
ment with final definitive restorations, it is very
important to record with photograph or face scan the
changes in facial appearance. Face-­Hunter 3D face
scan images were applied to CAD-­CAM restoration
production, allowing the patient to have an evalua-
tion process through virtual imaging without visiting
(Figure 11.122).
As in this case, patients who require extensive
implant prosthetic therapy are very sensitive to

Figure 11.121 Panoramic radiographs and oral clinical pictures from pretreatment to end of treatment. 1 Panoramic
radiographic image before treatment. 2 Panoramic radiographic image with immediate provisional prostheses on upper
and lower jaws immediately after CAIS. There are four implants with a temporary IOVD on the upper jaw, and six
implants with immediate fixed provisional restorations installed on the lower jaw. 3 Panoramic radiographic image with
definitive upper and lower prostheses. 4–7 Definitive upper magnetic IOVD and lower hybrid fixed zirconia restorations
before installation in the mouth. 8,9 Definitive upper magnetic IOVD and hybrid fixed zirconia restorations installed and
functioning in the mouth.

(Continued )
350 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Case Report 11.8 (Continued)

changes in their facial appearances before, during, Discussion
and after treatment. As shown in Figure 11.123, while
We can never accurately remember all the patient’s
the old denture showed the class III tendency of the
facial changes from the beginning of treatment to the
face to be concave and the lower jaw to protrude for-
end of treatment with final definitive restorations. So,
ward, the final definitive restoration improved to the
from the first time that a dentist meets a patient and
class I level after delivery.
makes plans for treatment, the dentist should be able
Prior to the treatment, immediately after implant
to explain how the patient’s treatment will proceed
surgery, immediately after completion of treatment by
and how it will end. According to the dentist’s expla-
final definitive restorations, and 2.5 years after using
nation, the patient will be able to easily decide
the definitive restorations, no significant abnormali-
whether to proceed with treatment or not. In order to
ties were found in the panoramic radiography, and no
do so, the top-­down/restoration-­driven treatment
signs and symptoms of abnormality, and the patient
concept should be well studied and the professional
was using the implant satisfactorily.
trained to prepare for it.

Figure 11.122 Intraoral evaluation from the baseline with old dentures to the final treatment results. 1 Upper and
lower old dentures in the mouth. 2 Initial edentulous state as a baseline before treatment. 3 Upper and lower duplicated
dentures of old dentures in the mouth for taking a CT. 4 Definitive upper magnetic IOVD with the definitive lower hybrid
fixed zirconia restorations as a final result.
 Chapter 11 Multidisciplinary Clinical Cases 351

Figure 11.123 For evaluation of the final treatment results, VD was measured in the patient’s profile pictures and the
appearance was compared. Old dentures (1) were installed on the left, immediate provisional restorations (2) in the
middle, and definitive upper magnetic IOVD with the definitive lower hybrid fixed zirconia restorations (3) in the right.
Finally, VD was increased by 10 mm when the definitive upper and lower prostheses (3) were installed in the mouth
compared to the old dentures (1) prior to treatment. The patient’s original facial appearance was restored from Angle
Class III to Class I.

The recovery of appropriate VD (vertical dimension)
in all extensive prosthetic treatments, including the
edentulous patient, is critical to rehabilitation of the
function and esthetic of the oral and maxillofacial
structures. In particular, if the patient has already lost
VD due to full mouth rehabilitation or loss of teeth,
the key to treatment is the establishment of a new VD
that can lead to functional and esthetic improvement
within the patient’s adaptability [21].
If a prosthesis is produced with VD set too high, the
patient’s orofacial muscles may increase tension,
cause temporomandibular disorders or pain on the
edentulous ridge, and may cause abnormally longer
face, mandibular retrognathism, and mandibular
dwarfism.
On the other hand, decreased VD can make the face
look more wrinkled and older by decreasing the
height of the lower half of the face. Because of this,
most patients have marionette lines and the labio-
mandibular fold is folded all the time, leaving them
always wet with saliva.
I could see that there was a large gap between CO
and CR due to abnormally decreased VD, and VD and
occlusal plane were reestablished based on the
height of 1/2 to 2/3 of both RPs (retromolar pads), an
anatomical landmark of the mandible, and an acrylic
resin bite block was created to match that height [22].
I used the custom-­made upper wax rim and acrylic
resin bite block for VD recovery to obtain a new
bite record in the patient’s mouth, and mounted the
upper intensive cast and lower working cast on
the semi-­adjustable articulator using the cross-­
mounting method.
After artificial teeth arrangement in the upper wax
rim, the lower PMMA prototype restoration was pro-
duced using CAD-­CAM [23, 24].
Based on my department’s paper that studied the
shapes and sizes of Korean upper and lower dental
arches, this case report aims to facilitate the addi-
tion of analogue data on upper and lower dental
arches to CAD libraries during top-­down treatment
planning [17, 18].

(Continued )
352 Digital Dentistry: A Step-by-Step Guide and Case Atlas
Case Report 11.8 (Continued)
In modern dentistry, there is an urgent need for
concepts to combine digital and analogue procedures
in the progression of implant prosthetic therapy.
Conclusion
In a patient who showed a tendency to a concave
facial profile due to severely decreased OVD, improve-
ment of mandibular prognathism and masticatory
function was achieved by increasing the OVD.
Case Report 11.9 Digital Workflow for Esthetic Rehabilitation Involving Orthodontic Aligners
(Clinical case and technique presented by Dr Guilherme
S. Nakagawa)
A 29-­year old female patient visited the dental clinic
complaining of poor dental esthetics because of a
missing upper right central incisor and caries lesion
affecting the adjacent lateral incisor (Figures 11.124
and 11.125). Her request was to receive ceramic
veneers to improve dental esthetics.
Figure 11.124 Initial aspect – a facial frontal view.
We were able to produce a more esthetic and func-
tional definitive zirconia fixed restoration for this
Korean patient by applying a database on the tooth
size and shape of Korean adults to the CAD process.
Dentists can provide patients with stable, stress-­
free, functional esthetic immediate provisional resto-
rations during the healing period after implant
surgery. The production of immediate provisional res-
toration is very important in a patient-­friendly treat-
ment approach.
The treatment planning was as follows.
●● General – orthodontic alignment and tooth
whitening.
●● Superior anterior teeth – ceramic veneers.
●● Tooth #11 – extraction, dental implant installation,
and implant-­supported crown.
●● Tooth #12 – caries lesion removal and dental
restoration.
Using digital workflow, a prosthetically driven
treatment plan was created, based on facial refer-
ences to achieve an ideal, harmonious rehabilitation
(Figure 11.126). Thus, a CAD protocol was initiated by
a digital study wax-­up performed by the BDS planning
Figure 11.125 Initial aspect – an intraoral frontal view.

Figure 11.126 Facial references used for guiding digital study wax-­up.
Figure 11.127 Digital study wax-­up.
center (Beyond Digital Solutions, Curitiba, Brazil)
(Figures 11.127–11.129).
After study wax-­up approval, tooth #11 extraction
was indicated, and then rescanning was performed
(Figure 11.130) to import the new file for the creation
of the digital orthodontic set-­up by the BDS team
using Nemocast software (Figures 11.131–11.134). A
temporary element for the replacement of tooth
#11 was included in the sequential orthodontic align-
ers for esthetic purposes (Figures 11.135–11.138).
Due to an apical infection at the time of extraction,
we waited for the alveolar bone region of tooth #11
to heal during orthodontic treatment for late implant
placement and temporary crown installation.
Following the last orthodontic aligner, another
scan was requested. This new STL was superimposed
Chapter 11 Multidisciplinary Clinical Cases 353
Figure 11.128 Digital study wax-­up superimposed on
the initial facial photograph.
to the study wax-­up obtained at the beginning of the
treatment (Figure 11.139).
Taking into consideration the overlap between the
initial wax-­up and the postorthodontic scanning
(Figure 11.140), teeth were positioned correctly,
requiring no further modifications in the study wax-
­up. Therefore, the patient could receive implant sur-
gery and ceramic veneers, as the digital prosthetically
driven plan had dictated.
(Continued )
354 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Case Report 11.9 (Continued)

Figure 11.129 Digital study wax-­up superimposed on the patient’s initial STL – an occlusal view. Note the need for
orthodontic correction in order to avoid excessive dental structure removal for ceramic veneer installation. This wax-­up
will guide dental positioning on the orthodontic set-­up.

Figure 11.130 Initial set-­up.

 Chapter 11 Multidisciplinary Clinical Cases 355

Figure 11.131 Final set-­up presenting the temporary prosthesis.

Figure 11.132 Superimposition: initial aspect and wax-­up.

(Continued )
356 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Case Report 11.9 (Continued)

Figure 11.133 Superimposition: set-­up and wax-­up.

Figure 11.134 Superimposition: set-­up and final wax-­up. Note the ideal dental position for ceramic veneer installation.
 Chapter 11 Multidisciplinary Clinical Cases 357

Figure 11.135 Staging of movements for a treatment period of 8 months, totaling 15 upper and eight lower orthodontic
aligners.

Figure 11.136 Using Meshmixer, a space is created between the aligner and the surgical wound to avoid plastic
invagination during orthodontic aligner manufacturing.

(Continued )
358 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Case Report 11.9 (Continued)

Figure 11.137 Attachment template for bonding attachments during installation of the orthodontic aligners.
 Chapter 11 Multidisciplinary Clinical Cases 359

Figure 11.138 Temporary crown manufacturing using light-­cured flow resin directly within the orthodontic aligners.

Figure 11.139 Initial scanning (left). STL from the last clear aligner (middle). Final scanning after using the last
orthodontic aligner (right).

Figure 11.140 Initial wax-­up superimposed to the postorthodontic scanning.

360 Digital Dentistry: A Step-by-Step Guide and Case Atlas
Case Report 11.10 Predictable Digital Workflow for Rehabilitation with Laminate Veneers
(Clinical case and technique presented by Dr Fábio Cabral)
Patient SZ, 25 years old, attended a private dental
clinic with the aim of improving smile esthetics. She
had as her chief complaint disharmony, wear, and
small fractures of the upper teeth (Figure 11.141).
After carrying out the initial evaluation consulta-
tion, which consisted of anamnesis, clinical and radio-
graphic examination, intraoral scanning and
photographic protocol, we started the esthetic-­
functional planning guided by vertical and horizontal
facial references.
Taking into account the absence of symptoms, good
initial dental condition, occlusal pattern, age, and
believing in a conservative and predictable rehabili-
tative dentistry, we proceeded to the digital design of
teeth #16–26, seeking to improve some esthetic and
functional factors, using CAD software (Exocad).
Figure 11.141 Initial appearance.
Figure 11.142 Mesh union (2D–3D).
For this, we used the initial photograph of the
patient’s face smiling (front view) and superimposed it
to the intraoral scan in the software (Figure 11.142). In
this way, we were able to transfer a 3D file into a 2D
image and thus work on the new smile design more
precisely and with all the necessary facial references,
remembering always that the photographs follow a
pattern of adjustment or calibration where the bipupil-
lary line presents a parallelism with the occlusal plane.
Another advantage of working in this way is the
possibility of balancing and functionally adjusting
this design in a virtual articulator, since the face pho-
tograph will have the same function as the physical
face bow used in analogue rehabilitations.
Having finalized and approved the digital project in
which we used a library of natural teeth shapes
(Figure 11.143), we fabricated a 3D-­printed model
(Figure 11.144) and created an addition silicone index
(Virtual, Ivoclar Vivadent). We then tried-­in the wax-
­up to the mouth in bis-­acryl resin and without adhe-
sion (Figure 11.145).
After validating the mock-­up through photographs,
functional and phonetic tests, we then started the
execution of the preparations using wear strategies
and adaptation of the tooth surface to ensure space,
insertion axis, adaptation, strength, and longevity of
future ceramic restorations.
On the mock-­up, we use KG Sorensen’s 4141 ringed
diamond bur to determine the desired wear depth,
respecting the buccal inclinations of each tooth.
 Chapter 11 Multidisciplinary Clinical Cases 361

Figure 11.143 Digital diagnostic wax-­up.

Figure 11.145 Mock-­up without adhesion in

Figure 11.144 Printed resin model. bisacrylic resin.

Considering that the patient had a favorable substrate

color, the 0.3 mm reduction created by this tip proved
to be sufficient for milling the ceramic blocks and for
esthetic resolution of the case.
Having defined the buccal grooves, we performed
guided incisal edge/occlusal reduction of 1 mm
guides using the KG Sorensen 3215 diamond bur with
its entire diameter. For this purpose, the diamond bur
must remain perpendicular to the long axis of the
tooth, creating a 90° angle with the buccal surface. We
noticed that, after this step, we were able to easily
remove the bisacrylic resin and visualize the few
Figure 11.146 References of vestibular and incisal wear.
areas of teeth reduction included in the treatment
(Figure 11.146).
Still with the 3215 diamond bur, we proceeded with not only of a delicate cervical chamfer but also of
teeth reduction following the guides achieved in the proximal finish lines for this type of preparation.
previous steps. Due to its cylindrical shape and An important detail during this process is the for-
rounded end, the design of this bur favors the creation mation of a critical sharp angle between the buccal

(Continued )
362 Digital Dentistry: A Step-by-Step Guide and Case Atlas
Case Report 11.10 (Continued)
and incisal surfaces. This angle must always be
rounded so as not to create a limitation during the
milling of restorations, which may cause fractures,
change in the buccal shape, mismatches, increased
cementation line or fragility of the ceramics.
At this stage, we started the surface finishing, regu-
larization of the ends and rounding of the sharp
angles using diamond burs of smaller granulation
(3215F, KG Sorensen), rubbers, and abrasive disks. The
use of guides or walls becomes extremely important
for the validation of preparations. With these guides,
we can measure spaces, inclinations, axes, and angles
before starting the digital impression process.
After insertion of the 000 retraction cord and expo-
sure of all prepared areas (Figure 11.147), we per-
formed the intraoral scanning (Figure 11.148) (TRIOS)
of the dental arches and bite registration and
Figure 11.147 Finished preparations with the gingival
margin properly removed.
Figure 11.148 Digital molding.
forwarded the file to the laboratory together with the
photographs and color shots.
For this case, we chose a ceramic reinforced with
polychromatic leucite that has excellent esthetic and
mechanical resistance characteristics (Empress CAD
Multi B1, Ivoclar Vivadent).
The waxing design was superimposed to the prep,
to check adaptation of the cervical and proximal fin-
ish lines, contact and occlusion points, emergence
profile and subsequent milling of the ceramic blocks
(Programill 7®, Ivoclar Vivadent), perpetuating every-
thing that was previously approved. The ceramic res-
torations were then removed from the blocks and,
after finishing and adaptation to the preparation
model, they underwent a micropigmentation process
for better characterization, seeking a natural
esthetic result.
After the laboratory stage, we proceeded to the dry
and wet tests of the ceramic laminates. At this stage,
we basically check the adaptation and optical charac-
teristics of the restorations and verified the need to
use colored resin cements or not.
In the clinical stage, we performed a modified
absolute isolation followed by cleaning the tooth sur-
face and conditioning with 37% phosphoric acid in
the entire prepared area. Respecting the time of
action of the acid, we washed and dried before apply-
ing the adhesive system. Without light curing the
adhesive and with the ceramic properly treated inter-
nally, we filled the veneers with light-­curing neutral
resin cement (Variolink N Transparent Base, Ivoclar
 Chapter 11 Multidisciplinary Clinical Cases 363

Vivadent) and placed then in position. After removing
and cleaning excess cement and confirming the ideal
position of the laminate veneers, we carried out the
final light curing for 40 seconds.
After removing the insulation, we carried out the
final scraping of excess cement and finishing the
cementing interface with rubbers for composite resin
(Figure 11.149). Once this was done, we assessed the
occlusion in order to remove premature contacts and
interferences and return the ideal disocclusion
movements.
The patient underwent follow-­up after 12 months
without any significant change (Figure 11.150) and
with an extremely satisfactory esthetic, functional,
muscle, and joint balance. We believe that digital
tools, when used with discretion and understanding
of their needs and limitations, can offer natural and,
mainly, predictable results.

Figure 11.149 Final appearance after cementation. Figure 11.150 Follow-­up after 1 year.

Case Report 11.11 Digital Workflow for a Posterior Onlay Restoration Using the Rubber Dam
(Clinical case and technique presented by Dr #46. There was a proximity between the failing res-
Hossam Dawa) toration and the marginal gingiva, which was fre-
quently becoming inflamed (Figure 11.151).
A 35-­year-­old male patient presented to the clinic Preparation was performed following removal of
with a failing large composite restoration on tooth

Figure 11.151 Initial clinical situation. Note the restoration margin at the mesial surface of the first molar.

(Continued )
364 Digital Dentistry: A Step-by-Step Guide and Case Atlas
Case Report 11.11 (Continued)
the failing restoration. Mild bleeding needed to be
controlled before intraoral scanning (Primescan®,
Denstply Sirona) (Figure 11.152). A rubber dam was
used to isolate the margins of the onlay preparation.
A first intraoral scanning was performed (Figure
11.153). A “lock surface” tool was used, since the
main objective of this initial scan was to register the
preparation margins and adjacent teeth (Figure
11.154). Then, the rubber dam was removed and a
Figure 11.152 Preparation and gingival management before intraoral scanning.
Figure 11.153 Intraoral scanning using rubber dam.
new set of intraoral scans was performed (i.e., main
and antagonist arches, and digital occlusion regis-
tration) (Figures 11.155 and 11.156). As a result, all
margins of the preparation were visible on the scan
(Figure 11.157). A glass ceramic restoration could
then be digitally designed and milled using a chair-
side milling device (Cerec Primemill®, Dentsply
Sirona) (Figure 11.158) and cemented onto the prep-
aration (Figure 11.159).
 Chapter 11 Multidisciplinary Clinical Cases 365

Figure 11.154 Lock-­surface tool being used.

Figure 11.155 New set of intraoral scans after lock-­surface tool was used.

Figure 11.156 New set of intraoral scans after lock-­surface tool was used.

(Continued )
366 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Case Report 11.11 (Continued)

Figure 11.158 Glass-­ceramic restoration.

Figure 11.157 Preparation aspect on the intraoral

scanning images.

Figure 11.159 Final clinical result after cementation of the onlay restoration.

Case Report 11.12 Digital Workflow for an Onlay Restoration in the Esthetic Area
(Clinical case and technique presented by Dr Daniel No) After removal of the restoration and preparation
(Figures 11.162–11.165), a temporary restoration was
A 37-­year-­old male patient presented to the clinic for a made with Telio® CS onlay (Figure 11.166) and intraoral
check-­up and cleaning. Tooth #24 presented with a fail- scans were taken. A glass-­ceramic restoration (e-­max,
ing (i.e., worn and unesthetic) distal-­occlusal composite Ivoclar Vivadent) could then be designed on the 3Shape
restoration. The buccal cuspid tip was also restored TRIOS Studio Dental software (Figure 11.167) and
(Figures 11.160 and 11.161). A CAD-­CAM onlay glass-­ milled using a milling device (Roland). After application
ceramic restoration was the treatment option chosen. of Aquacare®, 9.6% fluoric acid, Monobond Plus® and
 Chapter 11 Multidisciplinary Clinical Cases 367

Figure 11.160 Initial clinical situation of the left Figure 11.162 Execution of the preparation – 1.
maxillary first premolar.

Figure 11.161 Occlusal view of the remaining structure. Figure 11.163 Execution of the preparation – 2.

(a) (b)

Figure 11.164 (a) Preparation aspect (frontal view). (b) Color selection.

(Continued )
368 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Case Report 11.12 (Continued)

Figure 11.165 Use of the rubber dam to install a Figure 11.166 Temporary restoration.
temporary restoration.
(a)

Figure 11.167 Digital design of the final onlay restoration (a–c).

 Chapter 11 Multidisciplinary Clinical Cases 369

(b)

(c)

Figure 11.167 (Continued)

(Continued )
370 Digital Dentistry: A Step-by-Step Guide and Case Atlas

Case Report 11.12 (Continued)

Scotchbond® Universal adhesive, the CAD-­CAM onlay
restoration was cemented onto the preparation with
(a)
RelyX® Ultimate A1 (Figures 11.168–11.170). Glycerin
was also used to block oxygen.

Acknowledgments: Dr No would like to thank the sup-

port of the team at his clinic: Harbor Modern Dentistry,
Costa Mesa, CA, USA, and the Pisces Aesthetic Dental
Design laboratory (CA, USA).

(b)

Figure 11.168 Occlusal view at the final appointment.

(c)

Figure 11.169 Application of the rubber dam. Figure 11.170 (a–c) Cementation and final clinical result.

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372
Index
a Blue Sky 44
acetate periodontal surgical guide
187
active wavefront sampling (AWS)
technique 22
additive manufacturing. See three‐
dimensional (3D) printing
alveolar socket preservation,
volumetric planning for
CBCT multiplanar reconstruction
220
equine‐derived particulate bone
graft 220, 221
flapless approach 220
graft healing period 220, 221
implant site preparation,
histological analysis 222
pixel threshold values 220
Straumann 4.1 × 8 mm tissue level
dental implant 222–223
surgical site prior to implant
placement 220, 221
volumetric measurement output
220, 221
American Society for Plastic and
Aesthetic Surgery 304
aperture of the diaphragm 34
artificial intelligence (AI) 7, 12–15
“as low as reasonably achievable”
(ALARA) principle 257
automatic desktop 3Shape
scanner 28
AVI file formats 50
b 262
Bellus3D software 31
after facial scan 32
biological width 185
Blender® 43–44
Digital Dentistry: A Step-by-Step Guide and Case Atlas, First Edition. Edited by Arthur R.G. Cortes.
© 2022 John Wiley & Sons Ltd. Published 2022 by John Wiley & Sons Ltd.
arch position 264, 265
bone graft volumetric planning clinical aspect 264, 267
onlay bone grafts 225–226 DICOM files 264
sinus lifting procedure 223–224 double transfer tray
socket preservation 219–223 EVA layer of 267
bone movements for indirect orthodontic bracket
chin position correction 244, 246 bonding 266
mandibular positioning 243–244 PEGT layer of 267
maxillary rotations, correction upper teeth and adhesive 267
of 244, 245 enamel etching with phosphoric
midline deviations and occlusal acid 264, 266
plane inclination, correction orthodontic virtual set‐up
of 244 simulating 265
occlusal plane inclination STL file 264, 265
corrections 244, 246 3D printing machine 264, 266
vertical and anteroposterior virtual set‐up simulate 264, 265
corrections 244, 245 wire shape templates 264, 266
bone structure analysis, MRI 41 CAD‐CAM guides for orthodontic
bone‐supported guides 201 miniscrews
bruxism plaque design 43 image‐guided indirect
orthodontic bonding
c double transfer tray for
CAD‐CAM guided endodontics 268, 270
CBCT multiplanar reconstruction facial aspect 268
260 image‐guided indirect
CBCT scan of tooth 260 orthodontic bonding 268–272
guided access planning 261–262 intraoral aspect 268, 271
guided surgery access 262 intraoral aspect. 268
importing CBCT and surface positioning 268, 270
scans 260 STL file 268, 269, 272
indications and advantages virtual setup simulate 268, 269
259–260 wire shape templates 268, 270
merging scan images 260, 261 image‐guided orthodontic
planning and printing approval miniscrew
CBCT 3D reconstruction
surface scan 260 272, 276
surgical guide design 262 en masse retraction 272, 275
CAD‐CAM guides for orthodontic mini‐implant placement 272,
brackets 275

mini‐implant virtual planning
272, 274
overjet and labially positioned
anterior teeth 272–274
CAD‐CAM laminate veneers and
crowns in esthetic area
133–143
CAD‐CAM surgical guides, for crown
lengthening 186–190
CAD software
for dental implants 45
for prosthodontics/restorative
dentistry 44
CAFIP. See complete‐arch fixed
implant‐supported
prostheses (CAFIP)
calibration process, of FDM 3D
printer 58–60
CBCT. See cone beam computed
tomography (CBCT)
acquisition parameters 3
crown‐lengthening
procedures 295, 296, 298
imaging parameters and FOV
20, 21
integrated with cephalometric and
panoramic radiographic
functions 18, 19
lip retractors usage 20
vs. medical CT devices 18
patient positioning 20
pre‐examination 19
radiation protection measures 19
saving scan in DICOM format 20
step‐by‐step procedure 19–20
cementoenamel junction (CEJ) 186
Ceramill® Mind software 85
CEREC Omnicam intraoral scanner
22
ChairsideCAD 44
chairside milling process 75–77
advantages 76
block movement 76
connecting milling machine 76
lithium disilicate block restoration
76, 77
margin delimitation 76, 77
materials used 76
milling extension software 76
milling maachine selection 76
restoration 77
sprue placement 76, 77
STL file format 75
Chitubox Basic® 61
clinical crown lengthening
CAD‐CAM surgical guides for
186–190
minimally invasive image‐guided
surgery 191
clinical photographs, files of 48–49
GIF 50
JPEG/JPG (Joint Photographic
Experts Group) 49
PNG 50
RAW 49
TIFF 49–50
clOner facial scanner 32
coDiagnostiX 45
combined CBCT and intraoral scans,
implant surgery
alignment, of tomographic images
and scans 200
inspection windows 201
surgical guide design 200–201
surgical guide preparation
additive method 202
anesthetic blockade, of region of
interest 202
CAD‐CAM fabrication process
201
chemical disinfection/
sterilization 202
immediate occlusion 204
implant placement 202, 203
milled PMMA temporary crown,
immediate postsurgery
installation of 204
postoperative periapical
radiograph 204
subtractive method 202
surgical implant site 202, 203
virtual implant surgery planning
software 199–200
virtual waxing 199
complete‐arch fixed implant‐
supported prostheses (CAFIP)
CAM software and structure
fabrication 170
clinical and laboratory planning
steps 168
dental implant libraries 170
esthetic layering 171
final restoration delivery 172
metal‐acrylic prostheses 171, 172
Index 373
metal‐ceramic/metal‐composite
prostheses 171
prosthetic CAD design 170
prosthetic planning and
impressions 169–170
scanning and digitalization 170
structural material selection 170
zirconia/metal‐ceramic/metal‐
composite material 171–172
zirconium oxide‐ceramic
prostheses 170–171
computer‐aided design (CAD)
digital imaging methods
clinical photographs 33–38
cone beam computed
tomography 18–20
desktop scanner 27–30
facial scanner 30–33
intraoral scanner 20–27
magnetic resonance imaging 38–42
software manipulation
dental commercial software
programs 44–45
digital communication in
medicine (DICOM) 45, 46
files from clinical photographs
48–50
nondental open‐source software
programs 42–44
OBJ file 47–48
Polygon File Format (PLY) 47
standard tessellation language
(STL) 46–47
video files 50
virtual patient 50–51
computer‐aided design and computer‐
aided manufacturing
(CAD‐CAM) 4–6
computer‐assisted dynamic surgery
197
computer‐assisted implant surgery
197
computer numerical control (CNC)
technology 68
cone beam computed tomography
219, 257
cone beam computed tomography
(CBCT) 195
confocal imaging 22
contrast resolution 5
convolutional neural networks
(CNNs) 13, 14
374 Index
coordinates and planes 4
cosmetic dentistry, digital workflow
ceramic laminate veneers 305,
309, 310
face proportion analysis masks
305, 306
Facial Design™ 304
facial design digital protocol 305,
306
facial filler masks, botulinum
toxin 305, 307
facial fillers 304
gummy smile 304
intraoral scanner 305, 308
mimicking tissue replacement 303
step‐by‐step procedures of facial
filling 305, 307
COVID‐19 287
crown lengthening 195
CAD‐CAM surgical guides for
186–190
minimally invasive image‐guided
surgery 191
d edentulous patient facial
data science 12
deep learning 13
DentalCAD 44
DentalCAD® software program
199, 295
dental casts, 3D‐printed. See
3D‐printed dental casts
dental commercial CAD software
programs 95
dental commercial software
programs 44–45
dental operating microscope (DOM),
in endodontics 258–259
dental restorations/prostheses, digital
workflow for 92, 95
complete‐arch fixed implant‐
supported prostheses 168–172
digital complete dentures 152–168
digitally guided direct resin
composite restorations 149–152
inlay and onlay restorations 144–149
laminate veneers 133–143
single crowns 95–122
splinted crowns and fixed bridges
123–132
Dental Studio 44
dentogingival esthetics 186
dentolabial esthetic principles 89, 90
desktop scanner 27
accuracy of 29
advantages 28
calibration device 28
step‐by‐step procedures 28–30
DICOM files 264
DICOM MRI files 41–42
Digital Communication in Medicine
(DICOM) files 45, 46
digital complete dentures
BPS‐SEMCD method 152
capturing accurate records 158
centric relation, registration of
159–161
centric tray registration 155–156
clinical records digitization 162
3D bite plate 157, 158
design finalization 163–164
digital removable prosthesis
163–165
digital tooth arrangement 162
digitizing preliminary records
157–158
evaluation 153
existing prostheses evaluation
153, 154
finalization 165
functional final impressions
158, 159
functional try‐in 162–163
Gnathometer CAD 158, 160
ivotion disk 164
mandibular preliminary impression
155, 156
maxillary preliminary
impression 155, 156
monoblock try‐in 163, 164
papillameter reading 156–157
prosthesis finalization 165–166
reference denture technique
166–168
removable prosthodontic
rehabilitation workflow 152
smile design 155
tooth selection 160–162
UTS CAD registration 156–159
vertical dimension assessment
153–155
digital dental clinic
advantages of 11–12
education of digital dentist 8
financial aspects of 11
impact of digital technologies
7–8
levels of digitalization 8–9
types and business models 10
digital esthetics 9
digital imaging diagnostic and
radiology centers 9
digital implantology 9
general practitioner 9
in‐house dental laboratory 9
milling centers 11
oral rehabilitation and
prosthodontics 9
orthodontics 9
planning centers 11
scan services 11
surgery 9, 11
workflow 12
digital dental photography
aperture of the diaphragm 34
black background 35
circular flash 33
diagnosis, treatment planning and
preservation of cases 33
DSLR camera body 33, 34
facial photographs 35, 36
forensic documentation 33
histogram 34, 35
ISO 34
laboratory communication 33
legal documentation 33
with lips at rest 35, 36
macro lens 33
marketing 33
with MIC retractors 35, 37
mouth mirrors 35
multidisciplinary tool 33
occlusal photographs, of maxilla
and mandible 38
occlusal retractor 34, 35
parameters used 34
patient education and
motivation 33
photographic protocols 35–38
shutter speed 34
twin flash 33
“U” retractor 35
“V” retractor 34, 35
white balance 34
digital dentist, education of 8

digital dentistry 3
anterior upper teeth and implants
scan 323, 326
bonding process 325, 327, 328
computer‐aided design and
computer‐aided manufacturing
(CAD‐CAM) 4–6
coordinates and planes 4
in dental education 289, 290
diagnostic 321
digital wax‐up 322, 323
emergence profile of the implants
scanned by iTero 323, 326
guided surgery 322, 324
history of 5–7
image‐guided treatment 5
image superimposition/
alignment 5
implants, connective tissue graft,
and biomaterial 322, 324
in‐house and outsourced digital
workflow 7–12
iTero® Align 323, 324
Kois deprogrammer in mouth.
321, 323
lithium disilicate restorations and
zirconia abutments 323, 327
lower arch ceramics. lithium
disilicate on printed model
323, 325
lower arch preparations 323, 324
mesh 5
mock‐up
with bisacryl resin 322, 323
esthetic result 322, 324
occlusion 322, 323
monitoring 321
occlusion 321, 322
patient’s smile 325, 328
periapical radiography 325, 328
processing 321
in public health 287–288
CAD‐CAM 288
COVID‐19 287
dental caries 287
oral diseases 287
teledentistry role of 288
radiograph 321, 322
resolution 5
restorations 323, 326–328
smile 321, 322
three‐dimensional imaging 3–4
try‐in procedure 325, 327
upper anterior preps and scanbodys
in position 323, 326
upper arch with posterior ceramics
during bonding process.
323, 326
upper arch with posterior preps
323, 325
zirconia abutments intraoral try‐in
325, 327
digital imaging methods, CAD
clinical photographs 33–38
cone beam computed tomography
18–20
desktop scanner 27–30
facial scanner 30–33
intraoral scanner 20–27
magnetic resonance imaging
38–42
digital light processing (DLP)
printers 66
advantages 67
3D printing process
isopropyl alcohol rinsing 68
slicing 67, 68
STL file organization 67
UV light postcuring 68, 69
light engine 67
digitally guided direct resin composite
restorations
case report 150–152
chromatic layers, virtual
definition of 150
3D exams 150
3D‐printed guides 150
guides, virtual design of 150
intraoral scans 150
polychromatic restorations,
difficulties in 149–150
strategic restorative design 150
digital workflow
for anterior crowns in the
esthetic area
CAD‐CAM crown milled with
lithium disilicate 329, 335
color assessment 329
conventional temporary
crowns 329
crown aspects after staining
329, 335
digital wax patterns 329, 334
insertion axes definition 329, 332
Index 375
intraoral scans performed with
TRIOS 3 329, 330
patient smile 329, 335
STL files 329, 334, 335
superimposition 329, 333
teeth preparations 329
tooth #12 329, 331
tooth #22 329, 331
undercuts 329, 332
virtual articulator set‐up 329,
333
Zirkonzahn Modellier software
329, 330
for cosmetic dentistry
ceramic laminate veneers 305,
309, 310
in the esthetic area to correct
gingival discrepancies
face proportion analysis
masks 305, 306
Facial Design™ 304
facial design digital
protocol 305, 306
facial filler masks, botulinum
toxin 305, 307
facial fillers 304
gummy smile 304
intraoral scanner 305, 308
mimicking tissue replacement
303
step‐by‐step procedures of facial
filling 305, 307
for crown lengthening and laminate
veneers using the virtual
articulator
clinical aspect after periodontal
surgery 317, 320
clinical situation 317
intraoral photograph 318, 321
patient smile 318, 321
periodontal surgical guide
317, 320
restorations 318, 320
smilecloud software analysis
317, 318
teeth preparations 318, 320
virtual articulator 317–320
digital dentistry in dental
education 289, 290
digital dentistry in public
health 287–288
CAD‐CAM 288
376 Index
digital workflow (cont’d)
COVID‐19 287
dental caries 287
oral diseases 287
teledentistry role of 288
in esthetic area to correct gingival
discrepancies
cementation done and all the
sutures in position 312, 316
dental preparation 311, 315
digital evaluation of implant
positioning 311, 313
digital wax‐up 311, 312
facial and oral aspects 310, 311
facial aspect 312, 316
free connective tissue graft
removed from the hard
palate 312, 316
gingival composite resin 311, 313
immediate postoperative
aspect 312, 316
implant transfer 311, 314
intraoral aspect 312, 317
intraoral mock‐up 311, 313
model printed 311, 312
occlusal intraoral view 310, 311
teeth mock‐up with bis‐acryl
resin 311, 313
thin tissue phenotype was
310, 311
Ti‐base and zirconia abutments
and ceramic crowns 311, 315
tomographic evaluation of
implant positioning 311, 314
for esthetic rehabilitation involving
orthodontic aligners
adjacent lateral incisor 352
attachment template 353, 358
digital study wax‐up 352–354
Meshmixer 353, 357
Nemocast software 353, 355, 356
postorthodontic scanning
353, 359
scanning 353, 359
staging of movements 353, 357
temporary crown manufacturing
353, 359
tooth #11 extraction 353, 354
treatment planning 352
extensive esthetic rehabilitation,
vertical dimension
clinical situation 336
intraoral scans 336, 337,
339, 340
Kois deprogrammer 336, 339
patient monitoring system
339, 341
virtual wax‐up finished 336, 338
virtual wax‐up to increase
OVD 336, 338
onlay restoration in the
esthetic area
buccal cuspid tip 67, 366
RelyX® Ultimate A1 370
restoration and preparation
62‐65 366–368
3Shape TRIOS Studio Dental
software 366, 368, 369
posterior onlay restoration using
the rubber dam
clinical situation 363
glass‐ceramic restoration 364, 366
intraoral scanning using
rubber dam 364
intraoral scans after lock‐surface
tool 364, 365
lock‐surfacetool 364, 365
onlay restoration 364, 366
preparation and gingival
management before intraoral
scanning 364
preparation aspect on the
intraoral scanning images
364, 366
in preventive dentistry 289
rehabilitation with laminate
veneers
appearance 360
cementation 363
digital diagnostic wax‐up 360,
361
digital molding 362
follow‐up after 1 year 363
gingival margin 362
mesh union (2D–3D) 360
mock‐up without adhesion in
bisacrylic resin 360, 361
printed resin model 360, 361
vestibular and incisal wear
references 361
top‐down/restoration‐driven
implant treatment
bite registration 344, 347
CAD‐CAM procedure 342–345
CAIS and Immediate Loading
343, 346, 347
concept of 341, 342
first CAD for lower PMMA
prototype restorations 344–345,
348
second CAD for lower zirconia
hybrid fixed restorations and
upper magnetic overdenture
345, 348, 349
treatment outcome and
evaluation 349–351
Zirkonzahn Plane System
342, 343
digital workflow in orthodontics
CAD‐CAM guides for orthodontic
brackets
arch position 264, 265
clinical aspect 264, 267
DICOM files 264
double transfer tray 264,
266, 267
enamel etching with phosphoric
acid 264, 266
STL file 264, 265
3D printing machine 264, 266
virtual set‐up simulate 264, 265
wire shape templates 264, 266
CAD‐CAM guides for orthodontic
miniscrews
image‐guided indirect
orthodontic bonding
268–272
image‐guided orthodontic
miniscrew 272–276
orthodontic aligners
biomodels 277, 282
class III treatment with
283–285
delimitation of the cut line,
model mesh 277, 279
extrusion and closure
processes 277, 279
mask creation 277, 278
segmentation completed 277,
280
spatial orientation of the
models 277
staging 277, 282
STL files and photographs
imported, Nemocast software
277

superimposition completed
277, 278
superimposition process 277, 278
teeth landmarks delimitation
277, 281
teeth segmentation 277,
279, 280
thermoforming, cutting, and
polishing of the clear
aligners. 277, 282
virtual insertion 277, 281
virtual set‐up simulate 277, 281
dual CBCT scanning technique
alignment 198
gutta‐percha markers 198
recommendations 198
tomographic guide
fabrication and scanning 198
first CBCT preparation 198
second CBCT preparation 198
technique evolution 199
virtual 3D facially driven
wax‐up 199
dynamic computer‐assisted implant
surgery (d‐CAIS) 198, 218
dynamic image‐guided surgical
procedure 218–219
dynamic smile analysis 91
colored 3D mesh 92, 93
3D mesh without texture 92, 93
facial scanning cabin 92, 93
intraoral scan 92, 94
merging intraoral and facial
scan 92, 94
smile animation 92, 94
e milling of 226
edentulous patients, intraoral
scanning of 23–27
education of digital dentist 8
electronic apex location (EAL) 258
endodontics
CAD‐CAM guided 259–262
dental operating microscope
258–259
electronic apex location 258
imaging recommendations
diagnosis 257
intraoperative 257
nonsurgical endodontic
retreatment 258
outcome assessment 258
postoperative 258
resorptions and perforations 258
surgical endodontic retreatment
258
traumatic injuries 258
treatment 257
radiographic assessment 257
treatment, 3D MRI 42
esthetic analyses
facial reference points 89, 90
flowchart of digital 88
3D dentofacial 90–92
3D image‐obtaining methods
for 89–90
esthetic dental rehabilitation 88
ExoPlan software 45
virtual surgical planning, for
image‐guided surgery 200
f printing 7
facial esthetic analysis 49
facial scanning
fork 31
integrated with CBCT devices 33
OBJ file format 30
in oral rehabilitation 31
three‐dimensional methods 30
using mobile device
applications 31–32
using stand‐alone facial scanning
devices 33
FDM 3D printer 55
filament printer 55
financial aspects, of digital dental
clinic 11
freeze‐dried allogeneic bone block,
full‐arch implant rehabilitations
completely edentulous arch
211, 212
digital data acquisition 211
digital image‐guided
implant surgery
advantages 205
dental implant placement 207,
209–210, 212–213
dental teamwork and technical
requirements 205–206
digital data acquisition 206, 207
extraoral and intraoral initial
conditions 206, 207
fixation pins 206, 207
Index 377
patient’s initial image exams
206
planning and teamwork 207
preoperative prosthetic
planning 207
provisionalization and
prosthetics 213
surgical guide fabrication 207,
208, 212
virtual dental implant
position 206–208, 211–212
initial diagnostics and
screening 210
partially dentated arch 211, 212
preoperative prosthetic
planning 211
full high‐definition (full HD)
image 5
fused deposition modeling (FDM)
advantages 58
calibration process 58–60
disadvantages 58
materials used for 58
principle of 57
printingand postprocessing 60
fused filament fabrication (FFF). See
fused deposition modeling
(FDM) printing
g
genioplasty 241
GIF (Graphic Interchange Format)
50
gingival margin
contour and positioning of 186
final positioning of 187
periodontal guide for orienting
internal bevel incisions on
191
positioning reference of 186
gingival retraction
with double‐cord packing 82
at time of scanning 82
glass ionomer‐based cement 77
gummy smile
defined 185
diagnosis and management of
185, 186
periodontal surgical planning
185–186
gutta‐percha markers 198
378 Index
h digitally designed tooth‐supported
Hello Pearl software, automatic
detection
of calculus 15
of mandibular area with bone
loss 14
of marginal discrepancy of metallic
restoration 15
of maxillary area with bone loss
14
histogram 34, 35
Horos open‐source DICOM viewer
software
multiplanar reformatting 19
3D reconstructed model 20
Horos software, planned vs. actually
executed sinus grafts 224
i implant tridimensional position
image‐guided crown‐lengthening
procedure 187–188
image‐guided periodontal surgery
facial image registration 190
gingival margins 192
initial patient assessment 190
minimally invasive 191
periodontal health and diagnosis
190
3D reconstructions 190
tomographic exams 190
image‐guided surgical removal/
retrieval, of impacted
supernumerary tooth 227
image‐guided treatment 5
image superimposition/alignment 5
imaging recommendations, endodontics
diagnosis 257
intraoperative 257
nonsurgical endodontic retreatment
258
outcome assessment 258
postoperative 258
resorptions and perforations 258
surgical endodontic retreatment
258
traumatic injuries 258
treatment 257
impacted supernumerary tooth,
image‐guided surgical
retrieval of 227
bovine collagen membrane (Green
Membrane®) 230
surgical guide 228, 229
patient’s clinical profile 228
patient’s frontal and facial
photographs 228
superimposed IOS and CBCT
scans 228
surgical osteotomy 229
vicryl sutures 230
virtual planning of supernumerary
surgical removal 228, 229
impacted teeth, image‐guided surgical
removal of 227
implant placement, image‐guided
204–205
implant planning, 3D MRI for 42
implant scanbodies 83
dental implant impressions
83, 84
opposing arch, occlusion and
vertical dimension 83
previous prostheses scan 83
soft tissue impression 83
description 82
stereophotogrammetry 84
ImplantStudio 45
implant‐supported single crowns
116–119
implant surgery
computer‐assisted 197
static image‐guided (see static
image‐guided implant surgery)
Indirect Bonding Studio software 45
in‐house and outsourced digital
workflow 7–12
inlay and onlay restorations 144–149
International Organization for
Standardization (ISO) 34
intraoral scanner
AWS technique 22
CEREC Omnicam 22
confocal imaging 22
description 22
limitations 27
step‐by‐step procedure 22–23
stereophotogrammetry 22
STL extension 22
TRIOS® 4 21
using triangulation technology 22
intraoral scanning
digital impressions 21
of edentulous patients 23–27
procedure 22–25
Invisalign 45
j
JPEG/JPG (Joint Photographic
Experts Group) 49
k
Keynote® (Apple) 304
l
laminate veneers
in dental restorations/prostheses
133–143
image‐guided crown‐lengthening
CAD‐CAM ceramic laminate
veneers 298, 301
CBCT scan 295, 296, 298
clinical intraoral view 298, 302
color selection and mock‐up
try‐in 298, 301
crown‐lengthening surgical guide
design 296, 299
diagnostic digital wax patterns
295, 297
digital design 298, 299
digital waxing procedure 295, 297
3D‐printed preparation guide
298, 300
facial comparison of the smile
298, 303
intraoral comparison 298, 302
NemoSmile® software 295, 296
rehabilitation
appearance 360
cementation 363
digital diagnostic wax‐up
360, 361
digital molding 362
follow‐up after 1 year 363
gingival margin 362
mesh union (2D–3D) 360
mock‐up without adhesion in
bisacrylic resin 360, 361
printed resin model 360, 361
vestibular and incisal wear
references 361
using virtual articulator
clinical aspect after periodontal
surgery 317, 320
clinical situation 317
intraoral photograph 318, 321

patient smile 318, 321
periodontal surgical guide
317, 320
restorations 318, 320
smilecloud software analysis
317, 318
teeth preparations 318, 320
Virtual Articulator 317–320
laser printers 56
LeFort I osteotomy 240
liquid crystal display (LCD) printers
60–63
advantage 60
equipment parts 60
LCD resolution 60
3D printing process
CAM software settings 61
object printing 62
postcuring time 63
slicing 61–62
STL file acquisition 61
washing 62–63
m installation checks 72
machine learning 12
magnetic resonance imaging (MRI)
bone structure analysis 41
vs. CBCT and CT 38
drawbacks of 40
quality affecting factors 38–39
of soft tissue anatomy 39–40
soft tissue lesions, diagnosis of
40, 41
T1‐and T2‐weighted images 38
temporomandibular joint
assessment 41
three‐dimensional
for endodontic treatment 42
for implant planning and surgical
guides 42
for model reconstruction 42
reconstructions 41–42
for tooth reconstruction 42
mandibular fracture, virtual planning
of 253, 255–256
masked stereolithography
apparatus(MSLA) 60
material library file (.mtl
extension) 47
mature mold characteristics 161
maxillary CBCT scan, reconstructed
model of 4
maxillary fracture, virtual planning
of 253, 254
medical CT devices vs. CBCT 18
mesh 5
clean‐up, virtual skull construction
237
clipping slice 239
skull model with teeth model
overlay 239
stretched model 238
trimming procedure 23, 24
Meshmixer® 43
Meshmixer software 32
metal‐ceramic/metal‐composite
prostheses 171
milling process
chairside 75–77
description 68–69
of full‐arch implant‐supported
prostheses 72–75
laboratory milling 69–70
Zirkonzahn M1 milling device
drill holder placement 72
Zirkonzahn M1 milling device
calibration procedure 70, 71
internal view 70
milling materials and drills
used 71
tool organizer 72
minimally invasive image‐guided
periodontal surgery 191
MKV 50
Modellier software 45
monolithic zirconia copings 120
mouth mirrors 35
MOV file formats 50
MPEG (Moving Pictures Experts
Group) 50
Mucograft palate plate 193
mucosal graft guide 193
mucosal supported guides 201
multiplanar reformatting (MPR)
18
multiple correspondence analysis
(MCA) 13
multiple crowns 104–105
n of 244, 245
Nemocast software 277
NemoSmile® software 90, 295, 296
neural networks (NNs) 13, 14
Index 379
nondental free open‐source CAD
software programs 95
nondental open‐source software
programs 42–44
o
Object Files (OBJ) 47–48
occlusal retractor 34, 35
onlay bone grafts 225–226
open nondental software
advantage 44
Blender® 43–44
in crown design 43
description 42–43
Meshmixer® 43
orthodontic aligners
class III treatment
dental condition 283, 285
elastics and intercuspation
283, 285
facial aspect 283
intraoral aspect 283, 285
smile 283, 285
STL files 283, 284
virtual planning 283, 284
mask creation 277, 278
segmentation completed 277, 280
spatial orientation of the models
277
staging 277, 282
STL files and photographs imported,
Nemocast software 277
superimposition
completed 277, 278
superimposition process 277, 278
teeth landmarks delimitation
277, 281
teeth segmentation 277, 279, 280
thermoforming, cutting, and
polishing of the clear aligners.
277, 282
virtual insertion 277, 281
virtual set‐up simulate 277, 281
orthognathic surgery, planning of
bone movements
chin position correction 244, 246
mandibular positioning 243–244
maxillary rotations, correction
midline deviations and occlusal
plane inclination, correction
of 244
380 Index
orthognathic surgery, planning of
(cont’d)
occlusal plane inclination
corrections 244, 246
vertical and anteroposterior
corrections 244, 245
preoperative vs. postoperative
photographs 248, 249
soft tissue prediction,
superimposition of 248, 249
surgical splint creation 246–248
virtual skull construction 227
cephalometric points 241, 243
coronal panoramic image 235
3D bone reconstruction and
segmentation 235, 236
importing dental scanning 235,
237
mesh clean‐up 237–239
orientation calibration 240–242
osteotomy design 237, 240–241
overlapping dental scanning 235,
237
p 3D‐printed resin restorations
periodontal‐prosthodontic
interdisciplinary therapy 185
periodontal surgical planning
computed tomography 188
digital surgical simulation 188
esthetic rehabilitation 188, 189
final rehabilitation 189–190
gummy smile 185–186
reference loss 187
reverse planning 188
surgical guide 189
tomographic and intraoral
scanning 188, 189
phosphorus‐31 (31P) solid‐state
MRI 41
photographic protocols 35–38
Photon Workshop® 61
Photoshop® Smile Design (PSD) 89
pixel 5
PNG (Portable Network Graphics)
50
Polygon File Format (PLY) file 47
PolyJet 3D printer 202
PowerPoint® (Microsoft) 304
precise implant capture (PIC)
method 84
presurgical wax‐up 194
principal component analysis
(PCA) 13
prosthetically driven surgical
planning 197
prosthetic rehabilitation method 30
prosthodontics/restorative dentistry
intraoral scanning
implant scanbodies 82–84
teeth preparations 81–82
restorations/prostheses, digital
workflow for 92, 95
complete‐arch fixed implant‐
supported prostheses 168–172
digital complete dentures
152–168
digitally guided direct resin
composite restorations 149–152
inlay and onlay restorations
144–149
laminate veneers 133–143
single crowns 95–122
splinted crowns and fixed
bridges 123–132
3D‐printed dental casts 176–183
172–176
virtual patient set up
dynamic smile analysis 91–92
esthetic analyses and digital
smile design 88–91
importing intraoral scans to CAD
Software 85
virtual articulator 85–88
r planning 192
rapid prototyping. See three‐
dimensional (3D) printing
RAW 49
receptive field 13
reference denture technique
166–168
resin restorations, 3D‐printed
additive manufacturing 172, 173
impression techniques 173
temporary prosthesis 172, 173
designed on DentalCAD 174
on 3D printer software 175
finalized 176
make‐up using Vita Enamic®
stains kit 176
3D‐printed crowns 173
resins for SLA printers 57
resolution 5
return on investment (ROI) 11
s
sagittal ramus osteotomy 240
salivary gland benign tumor, MRI
diagnosis of 40
Second Opinion® 14
selective laser sintering (SLS)
technology 56
shutter speed 34
signal‐to‐noise ratio (SNR) 38
Simplify3D® 253
single crowns
customized abutments 120–122
digital dies 116, 117
implant‐supported 116–119
monolithic zirconia copings 120
multiple 104–105
tooth‐supported 95–103
virtual waxing using nondental
CAD software 106–116
sintering, defined 56
sinus lifting procedure 223–224
sinus slot technique 213
Skinbooster® 305
SLA‐DLP 3D printers 56
SLA‐LCD 3D printers 57
Smilecloud® planning software
305
soft tissue graft surgery
anesthesia 193
incisions on graft area 192, 193
mucogingival surgical guide
Mucograft palate plate
fixation 193
mucosal graft guide 193
surgical guide stabilization
193, 194
virtual planning 192
software manipulation, CAD
dental commercial software
programs 44–45
digital communication in medicine
(DICOM) 45, 46
files from clinical photographs
48–50
nondental open‐source software
programs 42–44
OBJ file 47–48
Polygon File Format (PLY) 47

standard tessellation language
(STL) 46–47
video files 50
splinted crowns and fixed bridges
cement gap thickness definition
125, 127
connector shape editing 128, 129
crown positioning 126, 127
crown shapes editing in occlusion
126, 128
digital model trimming 124, 126
final STL file 128, 130
fixed bridge nested into try‐in
blank 129, 131
“Import” option 123, 124
insertion axis definition 124, 125
milling procedure 131, 132
Modellier software 124
pontic cervical surface adjustment
and smoothing 126, 128
preparation margin outlining
124, 126
project details registration
123, 125
“TRIOS Project” option 123, 124
Zirkonzahn CAD‐CAM system
123
SR Phonares II tooth mold selection
161
Standard Tessellation Language (STL)
file 46–47
static computer‐assisted implant
surgery (s‐CAIS) 198
static image‐guided implant surgery
197, 204–205
dual CBCT scanning technique
alignment 198
gutta‐percha markers 198
recommendations 198
tomographic guide 198–199
full‐arch implant rehabilitations
205–213
using combined CBCT and
intraoral scans
alignment, of tomographic
images and scans 200
inspection windows 201
surgical guide design 200–201
surgical guide preparation
201–204
virtual implant surgery planning
software 199–200
virtual waxing 199
zygomatic implants 213–218
stereolithography (SLA) printers 56
3D printing process
advantages 64
build plate installation 64
build plate removal 65
equipment leveling 64
job upload 64–65
personal protective equipment
(PPE) 64
postcure process 66
preventive maintenance 66
printed crown prototype 65
printer installation 64
printer parameters 64
resin and solvent disposal 66
resin filtration 66
resin preparation 64
resin supply 64
resin tankpreparation 64
resin types 64
uncured resin removal 65–66
materials used for 63
stereophotogrammetry 22, 84, 91
STL files
CAD‐CAM guides for orthodontic
brackets 264, 265
CAD‐CAM guides for orthodontic
miniscrews 268, 269, 272
orthodontic aligners 277
subtractive manufacture 68
supervised machine learning 13
surgical guides
bone‐supported 249, 250
classification of 249–250
3D MRI for 42
implant‐supported 249, 251
implant/tooth‐supported 249,
252
mucosa/bone‐supported 249, 251
mucosa‐supported 249, 250
tooth/bone‐supported 249, 253
tooth/mucosa‐supported 249, 252
tooth‐supported 249, 251
surgical splint creation 246–248
t job upload 64–65
teeth preparations, intraoral scan
81–82
teeth‐supported guides 201
temporary prosthesis 172
Index 381
temporomandibular joint
assessment, MRI 41
3D dentofacial esthetic analyses
90–92
3D‐printed dental casts
cutting the plane, procedures for
181, 182
exporting file 181, 183
file handling 177
initial file importing 176–177
making cast hollow 180–182
mesh cleaning 177–178
mesh edge smoothing 178–179
model base creation 179, 180
solid, volumetric model 179–181
three‐dimensional imaging 3–4
magnetic resonance imaging
for endodontic treatment 42
for implant planning and surgical
guides 42
for model reconstruction 42
reconstructions 41–42
for tooth reconstruction 42
three‐dimensional photogrammetry 48
three‐dimensional (3D) printing
7, 55
DLP printers
isopropyl alcohol rinsing 68
slicing 67, 68
STL file organization 67
UV light postcuring 68, 69
LCD printers
CAM software settings 61
object printing 62
postcuring time 63
slicing 61–62
STL file acquisition 61
washing 62–63
in prosthodontics
3D‐printed dental casts 176–183
3D‐printed resin restorations
172–176
SLA printers
advantages 64
build plate installation 64
build plate removal 65
equipment leveling 64
personal protective equipment
(PPE) 64
postcure process 66
preventive maintenance 66
382 Index
three‐dimensional (3D) printing
(cont’d)
printed crown prototype 65
printer installation 64
printer parameters 64
resin and solvent disposal 66
resin filtration 66
resin preparation 64
resin supply 64
resin tankpreparation 64
resin types 64
uncured resin removal 65–66
TIFF (Tagged Image File Format)
49–50
tongue cancer, MRI diagnosis of
40, 41
tooth reconstruction, 3D MRI for 42
top‐down/restoration‐driven implant
treatment
bite registration 344, 347
CAD‐CAM procedure 342–345
CAIS and Immediate Loading 343,
346, 347
concept of 341, 342
first CAD for lower PMMA
prototype restorations
344–345, 348
second CAD for lower zirconia
hybrid fixed restorations and
upper magnetic overdenture
345, 348, 349
treatment outcome and evaluation
349–351
Zirkonzahn Plane System 342, 343
trauma surgeries, virtual planning of
mandibular fracture 253, 255–256
maxillary fracture 253, 254
tray leveling technique 58
triangulation technology 22
TRIOS® 4 intraoral scanner 21
two‐dimensional digital smile
design 89
two‐dimensional photogrammetry 48
u of soft tissue graft surgery 192
ultra HD 5
universal mold characteristics 161
unsupervised machine learning 13
“U” retractor 35
v 3D bone reconstruction and
vat photopolymerization technology
60
video file formats 50
virtual articulator
description 85
dynamic occlusion analysis 87
facebow and transfer index,
intraoral scans of 86
mandibular intraoral scan aligned
with articulated set‐up 87
maxillary and mandibular
scans 85
maxillary intraoral scan aligned
with facebow mesh 86
virtual implant surgery planning
software 199–200
virtual patient
alignment 51
digital planning 51
file preparation 50–51
in prosthodontics/restorative
dentistry
dynamic smile analysis 91–92
esthetic analyses and digital
smile design 88–91
importing intraoral scans to CAD
Software 85
virtual articulator 85–88
software programs for virtual
planning 50
virtual planning
for anterior maxillary graft 225
of mandibular fracture 253,
255–256
of maxillary fracture 253, 254
of periodontal plastic surgery 187–188
of supernumerary surgical removal
228, 229
virtual skull construction 227
cephalometric points 241, 243
coronal panoramic image 235
segmentation 235, 236
importing dental scanning 235,
237
mesh clean‐up 237–239
orientation calibration 240–242
osteotomy design 237, 240–241
overlapping dental scanning 235,
237
voxels 5, 18
“V” retractor 34, 35
w
white balance (WB) 34
WL determination, electronic apex
location in 258
WMV file formats 50
y
youthful mold characteristics 161
z
“zigzag” scanning strategy 23
zirconia 70, 77
zirconia copings 120
zirconium oxide‐ceramic prostheses
170–171
zygomatic implants 213
digital workflow for 218
in Advanced Surgical Guide
interface 215
advance jaw segmentation
214
implant selection tool 215
STL model file 216
surgical guide positioning 217
using Blue Sky Plan 214
virtual surgical planning 216
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