SCIENTIFIC SESSION

The decision-making process

in interdisciplinary treatment:
digital versus conventional approach.
A case presentation

Nikolaos Perakis, DDS

Private Practice, Bologna, Italy

Renato Cocconi, MD, DDS, MS

Director, Face Ortho Surgical Center, Parma, Italy

Correspondence to: Dr Nikolaos Perakis

Via Albertoni 4, 40138 Bologna, Italy; Tel: Landline +39 051 6360616, Mobile +39 347 6438148;
Email: nikperakis@gmail.com

212 | The International Journal of Esthetic Dentistry | Volume 14 | Number 2 | Summer 2019

Abstract
The digital technology can be a GPS in designing a
multidisciplinary treatment that involves orthodontics
and restorative dentistry. A proper hierarchy of deci-
sions and responsibilities need to be defined. Form is
everything but position and size.
For this reason the orthodontist first needs to set up
the proper occlusion deciding the position and the
available size that will be necessary for the restorative
dentist to obtain the proper form with a minimally in-
vasive preparation.
The International Journal of Esthetic Dentistry | Volume 14 | Number 2 | Summer 2019
PERAKIS/COCCONI
This case report illustrates with a step-by-step ap-
proach all the clinical issues of the treatment, from
diagnosis to orthodontic guided position of Tads, ma-
terials of choice and laminate veneers realization
passing through all the interactions between the den-
tal team members explaining who does what and
when and proposing a clear hierarchy of decision. A
review of digital and classical possibilities for the real-
ization of laminate veneers is proposed with its pros
and cons.
(Int J Esthet Dent 2019;14:212–224)
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 SCIENTIFIC SESSION
Fig 1 Extraoral examination: an asymmetrical dental arrangement
of maxillary teeth affects the patient’s smile.
Introduction
The development of new technologies and restorative
techniques has led to significant improvement in pa-
tient treatment modalities and also to the specializa-
tion of dentists. A multidisciplinary approach is often
necessary in order to take advantage of such innova-
tions and improve clinical outcomes by reducing the
invasiveness of treatments. A minimally invasive ap-
proach should be preferred to more invasive tech-
niques; in fact, tooth structure preservation is of para-
mount importance in order to respect biology and
guarantee the best biomechanical situation for dental
restorations.1-4
Furthermore, it has been observed that dentin ex-
posure during teeth preparation for laminate veneers
can affect the long-term result.5,6 To optimize the re-
sults, all the team members should take part in defin-
ing the steps of the workflow. It is essential to establish
214 | The International Journal of Esthetic Dentistry | Volume 14 | Number 2 | Summer 2019
Fig 2 Extraoral examination: a mild skeletal class II and a biretrusion
are present.
the role that each professional should play in the dif-
ferent treatment stages: each single phase should be
supervised by a team leader who makes decisions
with the support of the other team members.
A digital workflow helps the team members to in-
teract and verify each step without the need to actual-
ly see the patient.
The aim of this article is to describe our interdisci-
plinary workflow and to show how digital technolo-
gies can obtain very precise results and save time. The
article also aims to demonstrate how combining digi-
tal technologies with traditional laboratory procedures
allows for a wide range of options of currently avail-
able restorative ceramic materials.
Case presentation
The patient was a 27-year-old female with a missing
maxillary left lateral incisor and a small lateral on the
 PERAKIS/COCCONI

Schema 1 Sequence in the decision-making process

Hierarchy of decision: position Hierarchy of decision: form

1st step: Mandibular & maxillary incisors’ inclination ORTHODONTIST 4th step: Final position of teeth for restorative RESTORATIVE + ORTHO

Extractions/anchorage Step I: Ideal maxillary central incisors’ volume/MIP RESTORATIVE/LAB

Curve of Spee/Wilson Step II: Ideal maxillary lateral incisors’ position & volume RESTORATIVE/LAB
Step III: Ideal maxillary canine position & volume/MIP RESTORATIVE/LAB
2nd step: Class 1 occlusion ORTHODONTIST

5th step: Analog/digital workflow RESTORATIVE +

LAB TECHNICIAN
3rd step: Volumes available for restorations ORTHO + RESTORATIVE
RESTORATIVE +
6th step: Minimally invasive preparation LAB TECHNICIAN

other side, together with an impacted maxillary left ca-

nine. The patient’s main reason for seeking treatment
was to improve her dental esthetics and smile without
considering the option of orthognathic surgical inter-
vention (Fig 1). The extraoral examination showed a
mild skeletal class II with a biretrusion and a projected
long nose (Fig 2). The patient did not want any change
to her face.
Intraorally, the patient had significant crowding in
the mandible and an asymmetrical dental arrange-
ment in the maxillary anterior area due to a diminutive
maxillary right lateral incisor and two mobile primary
Fig 3 Frontal view at the beginning of the orthodontic phase. Two
teeth still present in place of an agenetic maxillary left primary teeth in place of an agenetic left lateral incisor and
lateral and an impacted maxillary left canine (Fig 3). significant crowding in the mandible is present.
In order to select the best treatment strategy for
the patient, we needed to follow a specific sequence
in the decision-making process (Schema 1).

Establishing the correct tooth positions

The orthodontist had the responsibility of defining the

appropriate maxillary and mandibular incisors’ position
and inclination. This affects the final decision of open-
ing or closing spaces for maxillary laterals, considering
the space requirement in both arches.
We used a three-dimensional (3D) virtual rendering
to define the proper position of the anterior and pos-
terior occlusal segments (Fig 4). After setting the oc-
clusion, we predefined the available spaces for the
volumes of the anterior maxillary teeth to maximize Fig 4 Digital setup of the expected tooth position at the end of the
the esthetic outcome (Fig 5). At the beginning of the orthodontic treatment.

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 SCIENTIFIC SESSION
Fig 5 Digital wax-up to evaluate tooth shapes according to the
new dental position.
treatment, we wanted to visualize and approximately
define how to position these teeth at the end of the
orthodontic treatment so as to facilitate the minimally
invasive restorative procedures to be performed at a
later stage. The orthodontist was responsible for de-
ciding whether to extract the two mandibular first bi-
cuspids due to lack of space. As a result, we decided
to extract the diminutive right lateral incisor (12) and
the two maxillary left primary teeth (62 and 63), to
substitute the maxillary laterals with maxillary canines,
and the maxillary canines with maxillary first bicuspids.
Fig 7 Orthodontic supporting appliance anchored to palatal
implants.
216 | The International Journal of Esthetic Dentistry | Volume 14 | Number 2 | Summer 2019
Fig 6 Cone beam computed tomography (CBCT)-guided position
of palatal implants.
After space closure, the restorative dentist indicated
the final orthodontic position of these teeth to opti-
mize a maximal intercuspation position and to set the
space for minimally invasive laminate veneers.
A fully digital orthodontic approach was used for
the palatal implants positioning and to obtain an ade-
quate orthodontic supporting appliance. This was
used to support a provisional, to disclude the impact-
ed canine (23), to mesialize the canines and posterior
buccal segments, and to maintain the maxillary mid-
line position (Figs 6 and 7).
Interaction between position
and tooth shape
As previously mentioned, when the tooth position was
almost achieved, the restorative dentist directed the
finishing orthodontic stage and defined the correct
tooth shape. This step was essential for a minimally
invasive approach with thin laminate veneers. At the
first clinical restorative check, the tooth positions were
very close to what had been defined at baseline in the
digital wax-up. Only a few modifications were required.
The positions of teeth 14 and 13 were correct, and
their axes were compatible with a minimal tooth prep-
aration approach.
The gingival margins of the central incisors had to
be aligned and their axes tilted. Tooth 23 had to be dis-
talized to give more room to the interdental papilla and
to better distribute the volume of the final restorations.
Tooth 24 had to be torqued and intruded to reduce the
invasiveness of tooth preparation (Figs 8 and 9).

Fig 8 First restorative check: the axes of the anterior teeth should
be corrected and the gingival margins aligned.
Fig 10 Frontal view at the end of the orthodontic treatment. Two
maxillary canines are positioned in place of the lateral incisors, and
two premolars in place of the canines.
Final tooth shape definition and
communication with the patient
At the second restorative check, once the ideal dental
position had been achieved and the incisal margins of
teeth 13, 12, and 23 had been reshaped, the next stage
of treatment could be planned. Tooth 24 could not be
intruded more due to the root position with respect to
the cortical buccal bone (Fig 10). The major restorative
issue of this case was to transform the maxillary ca-
nines to lateral incisors, and the first bicuspids to ca-
nines, ending up with good esthetics and a functional
canine guidance.7
Overall, there were three clinical possibilities for
evaluating the final shape of the anterior teeth:
■ The first possibility was completely digital, with a
digital smile design and virtual wax-up, as was done
The International Journal of Esthetic Dentistry | Volume 14 | Number 2 | Summer 2019
PERAKIS/COCCONI
Fig 9 The maxillary left canine should be distalized to give room to
the papilla.
Fig 11 Composite mock-up performed directly in the patient’s
mouth.
at the beginning of treatment. This digital simula-
tion would then need to be tested in the patient’s
mouth before tooth preparation. A mock-up would
then need to be prepared in a second appoint-
ment, once the new shape of the anterior teeth
had been accepted by the patient.8,9
■ The second possibility was to send a series of ex-
planatory notes to the laboratory for a classical
wax-up, and from this fabricate a mock-up. Both
these possibilities do not allow the clinician to eval-
uate all the esthetic and functional parameters
from the beginning. This can only be done after the
realization of the mock-up.
■ The third possibility was a composite mock-up car-
ried out directly in the patient’s mouth (Fig 11).
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 SCIENTIFIC SESSION
Fig 12 The patient’s smile improved after the composite mock-up
realization.
Fig 14 Intraoral view of the mock-up: esthetics, phonetics, and dynamics are carefully evaluated.
The final option was chosen because it involved the
patient in the process of improving her smile. The
composite was applied without adhesive and was
polymerized for 2 to 3 s, so that it was easy to remove
it at the end of the consultation. This rapid simulation
allowed the clinician not only to evaluate esthetics,10
phonetics,11 and function (guidance, overbite, overjet,
relationship to lips and tongue), but also to get imme-
diate feedback from the patient, and to make any re-
quired changes and adjustments (Fig 12). Once the
shape had been approved, some simple photos, an
impression, and a facebow registration for the spatial
orientation of the casts were taken. This 3D and func-
tional information could be transferred to the labora-
tory for the wax-up, with the aim of improving and
218 | The International Journal of Esthetic Dentistry | Volume 14 | Number 2 | Summer 2019
Fig 13 Silicone index of the fully additive wax-up.
refining what was constructed in the mouth. In this
case, the wax-up would be performed using the trad-
itional technique, and the technician was able to man-
age the esthetic details with greater ease. At the third
restorative appointment, a silicone index of the fully
additive wax-up was prepared (Fig 13), and a resin
mock-up was pressed onto the teeth to enable the
patient to see the new appearance of her smile (Fig 14).
Minimally invasive tooth preparation
The mock-up was also used as a guide for dental re-
duction12 (Fig 15). The teeth were prepared in the most
conservative way, allowing for the maximum preser-
vation of enamel (Fig 16) and an adequate thickness of

Fig 15 The mock-up can be used as a guide for a minimally
invasive tooth preparation.
the ceramic veneers (Fig 17). After the teeth had been
prepared, an impression was taken.
Eight ceramic laminate veneers were needed to
improve the patient’s smile.
Provisionals were fabricated using the same sili-
cone index that had already been used to place the
mock-up, so that the occlusal design could be dupli-
cated and the patient could retain the same level of
comfort. Provisional restorations could be pressed
and cemented simultaneously using the spot-etch
technique.13 This procedure allowed the teeth to be
stabilized during the provisional phase.
Laminate veneers realization:
classical versus digital approach
All laboratory steps have been documented in a paral-
lel sequence in order to describe and compare the
classical and digital approaches. The materials used
most frequently to fabricate porcelain veneers are
feldspathic ceramics baked on refractory dies and
heat-pressed lithium disilicate ceramics. Both tech-
niques need a physical cast to be realized. Computer-
aided design/computer-aided manufacturing (CAD/
CAM) procedures can also be used with these mater-
ials. Nevertheless, a physical cast is always necessary
to finish the ceramic as well as for final checks before
delivery.
In the present clinical case, eight feldspathic ce-
ramic laminate veneers (Noritake EX-3; Kuraray Norita-
ke Dental) were used to restore the patient’s smile.
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PERAKIS/COCCONI
Fig 16 Final preparations. Due to the attentive tooth structure
reduction, no dentin is exposed and the margins are placed in a
junta-gingival position.
Fig 17 A detail of the final feldspathic ceramic veneers.
The classical workflow started from a definitive
impression recorded using a polyvinylsiloxane (PVS)
material (Express; 3M ESPE). This impression was
poured twice in the laboratory to obtain a working
cast and a solid cast (Quadro Rock; Picodent) (Fig 18).
The working cast was mounted in an articulator and
its stone dies duplicated in a refractory material to
fabricate the feldspathic ceramic laminate veneers. A
purely digital workflow is not available at present, as
the absence of a physical cast limits the material
choice to CAD/CAM monolithic ceramics and does
not allow for the checking of the final prosthesis be-
fore delivery. For this reason, we followed a partially
digital workflow that benefits from the advantages of
digital technology without having to abandon those
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MASTER CAST SOLID CAST REFRACTORY DIES

Fig 18 Classical workflow: a master cast and a solid cast were obtained from a polyvinylsiloxane impression of the maxillary arch. The stone
dies were duplicated in refractory material and inserted in the alveolar cast.

STL FILE MODEL BUILDER

Fig 19 Digital workflow: an intraoral scan of the maxilla was taken. The STL file was then processed through model-builder software to
fabricate physical resin-printed casts.

Fig 20 Digital workflow: the resin dies were duplicated in refractory material.

220 | The International Journal of Esthetic Dentistry | Volume 14 | Number 2 | Summer 2019
 PERAKIS/COCCONI

clinical and laboratory procedures that until now

have obtained the best esthetic results. The STL file
derived from the intraoral scanning of the prepared
teeth (Trios; 3Shape) had been processed by the
technician using model-builder software (Fig 19).
Digital master casts can be obtained either by mill-
ing14 or 3D printing.15 In this clinical case, a precise
physical cast was obtained using two different,
high-quality 3D printers (Stratasys Object Eden 500
for the alveolar cast; DWS DigitalWax 028Jplus Jew-
elry for the removable dies). The first printer uses a
PolyJet technology, where small drops of a photopo-
lymerizing resin are deposed on a work tray and im- Fig 21 The feldspathic ceramic was layered on the refractory dies.
mediately cured by UV light. Layers are 12-μ thin, al-
lowing the casts to be very precise.16 The second
printer uses stereolithography (SLA) technology. A
building platform moves vertically into a bath of liquid
resin that is cured by a UV laser. The laser beam is
very thin, allowing one to obtain a very smooth sur-
face, with an accuracy of 10μ.16
The resin dies were then duplicated in refractory
material and inserted in the alveolar cast (Fig 20). In
this way, the dental technician could layer the feld-
spathic ceramic directly on the physical cast (Fig 21).
Once layered and finished on the resin and stone
master casts, the laminate veneers were respectively
checked on the stone solid cast (Fig 22) and on the
3D-printed cast (Fig 23).
Fig 22 Classical workflow: the ceramic laminate veneers were
Final control and adhesive cementation checked on the solid cast.

Before the final luting steps, the laminate veneers were

evaluated in the patient’s mouth: a homogeneous and
thin layer of Fit Checker (GC) material was used. The
marginal precision was clinically assessed using 5x
magnification loupes and a sharp probe. The quality of
the interproximal contact area was verified with thin
dental floss. Both digital and classical workflows end-
ed up with precise laminate veneers. No adjustments
were necessary, and, clinically speaking, no difference
in precision was found.
Regarding the treatment of the restorations, feld-
spathic ceramic was etched with 9% hydrofluoric acid
for 120 s, after which the restorations were rinsed and
then placed in an ultrasound bath with alcohol for Fig 23 Digital workflow: the ceramic laminate veneers were
3 min to completely eliminate etching debris.17 A thin checked on the 3D-printed cast.

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 SCIENTIFIC SESSION
Fig 24 Intraoral view of the final restorations.
layer of a silane (Monobond Plus; Ivoclar Vivadent)
was then applied and left in place for 60 s.
A light-curing resin cement (Variolink Esthetic; Ivo-
clar Vivadent) with its adhesive system (Adhese Univer-
sal; Ivoclar Vivadent) was used to bond the veneers.
The resin cement excesses were carefully removed,
and each surface was light cured for 60 s using a LED
curing unit (Elipar S10; 3M ESPE). All margins were
then covered with a glycerin gel and light cured for a
further 20 s.
The rubber dam was then removed and the occlu-
sion finally checked.
After 1 week (Fig 24), and again after 1 year (Fig 25),
the restorations appeared very well integrated. The pa-
tient was satisfied with the esthetics and function.
Discussion
In interdisciplinary cases, the exact control of the clin-
ical steps is of paramount importance. For this reason,
the treatment planning and sequence should be care-
fully assessed, and one should define when and how
the dental team should intervene with clinical checks
and suggestions. Modern digital technology allows
one to visualize the final tooth position and form as
well as standardize and plan all these steps. This can
help the communication between the members of
the team and with the patient. It can also reduce time
and redundant steps. Only two clinical checks by the
restorative dentist were necessary during the ortho-
dontic phase.
222 | The International Journal of Esthetic Dentistry | Volume 14 | Number 2 | Summer 2019
Fig 25 Intraoral view of the restorations at the 1-year follow-up.
The fully digital positioning of orthodontic palatal
implants and supporting structures helped greatly to
achieve the final orthodontic position, and for patient
communication and cooperation.
The finishing orthodontic stage aimed to produce
the small changes that the restorative dentist needed
so as to maximize the esthetic outcome with a mini-
mally invasive procedure.
A fully digital restorative workflow implies the use
of face scanners, optical impressions, and virtual
articulators in which the patient’s movements are
recorded during function. Unfortunately, it is not
easy to utilize this solution because most digital
interfaces are not available at present, and these
tools are not linked in one integrated digital work-
flow.18 The absence of a physical cast limits the
choice of material to monolithic ceramics only when
realized with CAD/CAM technology. There is also no
possibility of checking and finishing the prosthesis
before fitting, which implies long and complicated
clinical checks before cementation, especially in dif-
ficult cases.
Therefore, when choosing the restorative strategy,
the following factors need to be taken into consider-
ation:
1. The most-used materials for porcelain veneers are
feldspathic and lithium disilicate ceramic.
2. These materials can be produced following the
classical techniques (baked-on refractory dies and
heat pressed, respectively) as well as with the digi-
tal method using CAD/CAM technology.
 PERAKIS/COCCONI

3. A precise physical cast is necessary to layer and
finish the ceramic laminate veneers as well as to
control the precision and quality of the final restor-
ations.
Starting from these requirements, one can examine
the possible treatment options. The completely ana-
log workflow has been used in prosthetics for decades
and allows for good clinical results. Nevertheless, nu-
merous laboratory steps can be reduced and im-
proved upon using digital technologies.19 The mixed
workflow proposed in this article allows one to take
the most from current digital possibilities and obtain a
high standard of work.
The direct intraoral scanning of the prepared teeth
has several advantages. The impression process is
more pleasant for the patient and avoids the impreci-
sion associated with the use of classical clinical and
laboratory materials (impression materials and stone
plaster). The quality of the impression can be immedi-
ately checked at high magnification on a monitor.
The space available with respect to the opposing
teeth can be easily verified. The STL file of such a dig-
ital impression can be reutilized by the laboratory at
any time, which seems to be more accurate than an
impression obtained by the laboratory scanning of
the stone casts20,21 when a CAM method is chosen.
Furthermore, digital impressions allow one to obtain
precise 3D-printed physical casts that can be mount-
ed in an articulator to manage both static and dynam-
ic occlusion, and can be used to produce laminate
veneers.
Conclusion
New digital technologies have significantly improved
patient treatment modalities, especially in interdisci-
plinary cases. A digital workflow helps the team mem-
bers to plan the clinical case, to interact during the
treatment, and to verify every clinical step effectively.
Nevertheless, a fully digital approach in the restorative
phase is not available at present. Combining digital
technologies and traditional laboratory procedures
may be the solution for maintaining a wide range of
options of currently available restorative materials.
Acknowledgments
We express our gratitude to Mr Gianluca Dallatana and
Mr Giuseppe Mignani for their precious collaboration,
and Dr Francesca Zicari for her help with editing the
manuscript.

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