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Contents lists available at ScienceDirect

Journal of Prosthodontic Research

journal homepage: www.elsevier.com/locate/jpor

Technical procedure

Digital protocol for creating a virtual gingiva adjacent to teeth with

subgingival dental preparations
Rubén Agustín-Panadero a, Ignazio Loi b, Lucía Fernández-Estevan a,∗, César Chust c,
Cristina Rech-Ortega a, Jorge Alonso Pérez-Barquero a
a
Department of Oral Medicine, Faculty of Medicine and Dentistry, University of Valencia, Spain
b
Private Practice, Cagliari, Italy
c
Laboratory technician, Valencia, Spain

a r t i c l e i n f o a b s t r a c t

Article history: Purpose: This article describes a digital technique used to record gingival emergence profiles modeled for
Received 8 May 2019 the prosthetic restoration of teeth prepared using biologically oriented preparation technique (BOPT).
Revised 25 September 2019
Accepted 18 October 2019 Materials and methods: The description of the technique of intraoral recording, manipulation of digital
Available online xxx files, and chairside protocol of prosthetic restorations is developed in the present manuscript on two an-
terior teeth treated with vertical and subgingival dental preparations for restoration with ceramic crowns.
The manipulation of the digital files registered with an intraoral scanner with software that allows its
alignment (best-fit) and the performance boolean of operation manages to create a virtual gingival emer-
gency like the one it presents when it is adapted on the cervical part of the interim prosthesis.
Conclusions: The technique allows the dentist and laboratory technician to obtain a digital reproduction
of the subgingival soft tissues around the prosthetic crown, unaffected by the collapse of the gingival
sulcus when the provisional crown is removed, as well as an exact copy of the provisional restoration,
making it possible to fabricate a definitive prosthesis that ensures precise anatomy, and so good compat-
ibility with periodontal tissues.
© 2019 Japan Prosthodontic Society. Published by Elsevier Ltd. All rights reserved.

1. Introduction producing gingival emergence profiles without gingival collapse in

The introduction of digital technologies for recording data for
the purposes of placing tooth- and implant-supported fixed pros-
theses has brought about great improvements in the quality of this
type of restoration, in the ease of communication between clinical
and laboratory staff, and both patients’ and dentists’ satisfaction
with treatment outcomes.
Intraoral scanners are becoming increasingly common in den-
tal clinics and have streamlined treatment protocols and sequences
in the field of prosthodontics [1]. Due to their speed, these tech-
nologies are rapidly replacing traditional techniques of impression
taking in both implant-based and dental treatments. Nevertheless
they still suffer a number of limitations when it comes to re-
producing dental preparations with subgingival finish lines, or re-
∗
Corresponding author. Dr. Lucía Fernández-Estevan, Department of Oral
Medicine, Faculty of Medicine and Dentistry, University of Valencia, C/ Gascó Oliag,
1. 46021 Valencia, Spain.
E-mail addresses: loi.ig@tiscali.it (I. Loi), lucia.fernandez-estevan@uv.es (L.
Fernández-Estevan).
apically positioned implants, in complete tooth-supported rehabil-
itation, or when registering complete arches supported by more
than six implants. But technology is developing so fast that these
drawbacks will surely be overcome in the near future [1–4].
Dental preparation techniques for restoration by fixed prosthe-
ses are undergoing a significant change; horizontal finish lines
(short or long chamfer, straight shoulder, beveled shoulder, etc.)
are now being replaced by preparations without finish line, fol-
lowing the biologically oriented preparation technique (BOPT) as
described by a number of authors [5–9] in recent years [2]. This
procedure is characterized by the creation of a non-dental, pros-
thetic finish line situated at a depth of 0.5–1 mm in the periodon-
tal sulcus, first preparing the tooth with a vertical axial plane be-
tween the anatomical crown and the root. To date this has required
conventional impression taking due to the inefficiency of intraoral
scanners when it comes to detecting subgingival dental anatomy.
Moreover, the provisional crown, necessary for correct healing of
the surrounding gingival tissues, presents a cervical emergence and
ovoid contouring, which produces healthy gingival adaptation with
the same shape as gingival tissue adapted to the convex emergence

https://doi.org/10.1016/j.jpor.2019.10.006
1883-1958/© 2019 Japan Prosthodontic Society. Published by Elsevier Ltd. All rights reserved.

Please cite this article as: R. Agustín-Panadero, I. Loi and L. Fernández-Estevan et al., Digital protocol for creating a virtual gingiva
adjacent to teeth with subgingival dental preparations, Journal of Prosthodontic Research, https://doi.org/10.1016/j.jpor.2019.10.006
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of the natural emergence profile of an untreated tooth. This means

that when the provisional prosthesis is removed for impression
taking, the gums collapse onto the tooth making it impossible to
obtain a digital record of the dental preparation, the gingival sul-
cus, or its emergence [3,10–13].

1.1. Objectives

The aim of this paper was to describe a digital technique for re-
producing the subgingival part of a tooth prepared without finish
line (BOPT) and the adjacent dento-gingival sulcus without varia-
tions derived from gingival collapse. This technique is able to cre-
ate a ‘virtual gingiva’ with the same emergence morphology as
when the provisional prosthesis is cemented in place on the tooth.

2. Materials and methods

2.1. Tooth preparation

The tooth is prepared and a provisional prosthesis fabricated

following the BOPT procedure described by Loi [5–7]. The clini-
cal sequence for BOPT is as follows: 1. Double probing: periodontal
examination must be performed using a periodontal chart and a
series of radiographs, ensuring that the case is free of any peri-
odontal pathology. To do this, the gingival sulcus (sulcular epithe-
lium) and junctional epithelium (attachment) are probed with a
periodontal probe (CP12 Silver. Hu-Friedy); the latter should mea-
sure 1.6–2.4 mm [14–15] and be free from signs of inflammation,
alterations in color, hemorrhaging, (Löe and Silness gingival index,
IG=0), and bacterial plaque (Löe and Silness plaque index, IP=0).
Afterwards, the distance from the gingival margin to the bone crest
is measured in order to confirm that the teeth present no bone
problem and that both cortices are intact (2.7–3.2 mm) [14–15].
The exact measurement to the bone level must be determined as
this structure must remain untouched by dental preparation. When
probing to the bone, the position of the tooth’s cemento-enamel
junction (CEJ) should be detected (under normal conditions this
is situated 1 mm apical of the gingival margin and 2 mm coro-
nal of the alveolar crest) [16,17], as this point will determine the
depth of dental preparation inside the gingival sulcus. To do this
the patient is anesthetized and a calibrated periodontal probe is
inserted in the sulcus parallel to the tooth’s axis until it reaches
the bone crest. When it is resting on the bone and laterally on the
tooth, it is withdrawn gently in coronal direction in touch with the Fig. 1. (a) Image of the patient before treatment with BOPT; (b and c) Teeth milled
with horizontal finishing line after removal of previous fixed prosthesis.
root anatomy until it reaches the start of anatomical crown emer-
gence. At this point the movement stops and the distance to the
gingival margin is measured. This distance will determine the ex-
tent of dental preparation inside the sulcus. 2. Supragingival dental has been milled, to prevent the bur tip from damaging part of the
preparation: the tooth’s incisal edge or occlusal face is reduced by tooth root, the angle of the bur is altered so that it runs parallel to
2 mm, beveling the vestibular face of the incisal edge or the ex- the tooth axis; in this way, the convexity of the anatomical crown
ternal slope of the functional cusp to an angle of approximately beyond the cemento-enamel junction is eliminated. To complete
45º. The tooth’s axial walls are reduced by 1 mm supragingivally preparation, the bur is inclined slightly in occlusal/incisal direction
with a conical shaft turbine diamond bur, of 1.4 mm diameter, with to give the axial walls of the tooth the correct convergence (6º).
100 μm granulometry. This reduction creates a chamfer finish line By milling the tooth and gum at the same time, dental preparation
2 mm from the gingival margin. In the interproximal area, scal- creates a vertical axial plane; the bur interacts with the tooth sur-
loped dental preparation is carried out following the anatomy of face and the epithelial element of gingival insertion (as far as the
the papilla but without touching it. In cases of retreatment with cemento-enamel junction) performing controlled de-epithelization
fixed prostheses, this step should be omitted as the tooth has al- of the sulcus’ free and junctional epithelium (Fig. 2). This cre-
ready undergone subgingival preparation (Fig. 1a, b, c). 3. Subgin- ates a blood clot in the apical area, which is then stabilized by
gival dental preparation: milling of both tooth and gum are per- the design of the provisional prosthesis. Stabilization produces cell
formed simultaneously (rotary gingival curettage) with a 1.2 mm differentiation for the formation of new gingival tissue and new
diameter diamond flame bur with 100 μm ganulometry. The bur structuring of the periodontium around the prosthetic emergence’s
is inserted in the gingival sulcus obliquely at an angle of 10–15º to new morphology. The function of the provisional prosthesis is to
the dental axis; in this way, the tooth is milled with one side of the shape a new prosthetic angular component with a new prosthetic
bur while the gingiva is curetted with the other side and the bur cemento-enamel junction (PCEJ) situated in the gingival sulcus at
tip. When the first millimeter of the anatomical crown emergence a depth of 0.5- 1 mm (respecting biologic width). The intrasulcular

Please cite this article as: R. Agustín-Panadero, I. Loi and L. Fernández-Estevan et al., Digital protocol for creating a virtual gingiva
adjacent to teeth with subgingival dental preparations, Journal of Prosthodontic Research, https://doi.org/10.1016/j.jpor.2019.10.006
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Fig. 2. BOPT dental preparation showing the creation of blood clot in the apical
area of milled sulcus.
Fig. 3. Clinical image 12 months after BOPT and provisional crown fabrication.”.
area of the provisional restoration supports the gingival margin cir-
cumferentially. The healing process then produces reinsertion and
gingival tissue thickening, which will adapt to the new emergence
profile. It is important to remember that the provisional must not
be removed from the tooth for the first four weeks in order to
avoid gingival healing problems. Later, until the complete matu-
ration of soft tissue (8–12 weeks), the shape of the provisional can
be modified to achieve the correct modeling of the gingival mar-
gin. To obtain good provisional prosthesis adaptation on vertical
tooth preparations, the prosthesis must be fabricated before dental
preparation is performed. The provisional is fabricated by the lab-
oratory technician from an initial pre-treatment model. The tech-
nician mills the tooth model, which then acts as a post to support
the (juxta-gingival) provisional prosthesis. The provisional is fabri-
cated from acrylic resin of very fine thickness (0.3 mm). This will
function as an “egg-shell” provisional, facilitating relining without
compromising its seating. When the tooth has been prepared, the
fit of the provisional is checked and then it is relined with self-
polymerizing acrylic resin (Sintodent. Sintodent S.R.L). Lastly, while
the relining material is setting, the provisional can be adjusted on
the tooth and inserted 0.5–1 mm inside the gingival sulcus (con-
trolled invasion of the gingival sulcus) The provisional prosthesis
will remain cemented on the tooth until the gingival tissues have
matured completely (Fig. 3).
2.2. Impression technique: intraoral scanner
The classic analogue impression technique for reproducing
BOPT and gingival sulcus morphology is the two-stage wash tech-
nique with double-cord retraction. This presents a major problem
because of the possibility of gingival tissue collapse, which will
cause error when it comes to registering the intrasulcular area. In
addition, due to the de-insertion of the provisional prosthesis and
Please cite this article as: R. Agustín-Panadero, I. Loi and L. Fernández-Estevan et al., Digital protocol for creating a virtual gingiva
adjacent to teeth with subgingival dental preparations, Journal of Prosthodontic Research, https://doi.org/10.1016/j.jpor.2019.10.006
[m5G;November 28, 2019;4:59]
3
Fig. 4. STL-1 file of the maxilla with the prosthesis cemented onto the prepared
tooth.
the placement of two retraction cords, there is a risk of altering
the real position of the gingival margin and sulcular anatomy. For
this reason, it is important to follow an impression taking protocol
that will reproduce the real position of the gums when the provi-
sional is in place on the prepared tooth, and that is reproducible
and does not depend on clinical skill.
The present technique uses a True Definition intraoral scanner
(3MESPE). This scanner captures data in three dimensions; it uses
active wavefront sampling and requires an application of titanium
oxide powder to ensure precision, capturing images optically by
means of video, which records a number of 3D takes per second.
The scanner generates a network of points creating a tessellation,
in the form of an STL (Standard Tessellation Language) digital file,
a standardized format for representing three-dimensional archives
as polygons made up of edge-to-edge tessellations of equilateral
triangles.
The scanning protocol recommended by the manufacture pro-
duces STL files of the gingiva, first scanning the occlusal face, fol-
lowed by the vestibular and lingual aspects.
The data obtained are downloaded from the 3 M Connection
Center, providing one STL file per scan.
2.3. Chairside protocol technique: step by step
In this way, digital impression taking creates a virtual model
of the gingiva used to fabricate the crown; the entire procedure
follows a chairside protocol with the following clinical sequence:
2.3.1. Six intraoral scans generate six types of STL file. The first
STL file (STL-1) is obtained by scanning the provisional pros-
thesis cemented onto the tooth, reproducing its morphology
and adjacent gingival emergence. When doing this, it is im-
portant to reproduce the other teeth in the arch (Fig. 4).
2.3.2. The second scan captures the provisional crown removed
from the mouth. It is important to reproduce the intrasul-
cular emergence of the cervical area of the crown as this
will define prosthetic invasion of the gingival sulcus, both
vertically and horizontally under conditions of periodontal
health. To do this, the prosthesis is placed on a vertical wax
rod, supporting the incisal edge with the internal part and
emergence placed upwards (Fig. 5a). In this way, the crown’s
entire internal surface and peripheral cervical area can be
scanned (Fig. 5b). Then, to reproduce the whole crown and
ensure best-fit alignment of the surfaces, the prosthesis is
replaced on the wax rod the other way up, placing the in-
ternal part and emergence on the rod with the incisal edge
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Fig. 5. (a) Physical support to stabilize the provisional prosthesis in digital scanning. (b) Digital registration of the internal and cervical part of the provisional prosthesis. (c)
Digital registration of the external and cervical part of the provisional prosthesis. (d) STL-2 file of the provisional prosthesis’ anatomy (outside the mouth).

Fig. 6. (a and b) STL-3 file of maxilla with teeth prepared by BOPT, without the provisional crown.

upwards, so that the complete morphology and the prosthe-
sis’ peripheral cervical emergence can be scanned (Fig. 5c).
Accurate reproduction of the cervical part is of key impor-
tance for correct alignment of the two scans, which are then
used to generate a 3D virtual reproduction of the whole
provisional, an STL file (STL-2) of the complete prosthetic
anatomy (Fig. 5d).
2.3.3. The third scan captures the teeth prepared with BOPT,
recording all tooth walls (Fig. 6a) and the gingival area
(Fig. 6b), which will have collapsed due to the removal of
prosthetic support (STL-3). It is also important to reproduce
the rest of the arch (both teeth and gingival tissue) in order
to ensure better accuracy in future alignments.
2.3.4. The fourth scan records the antagonist arch (teeth and
gingival tissue). The fifth and sixth scans register occlusion
in maximum intercuspation on the left and right sides. The
STL files generated from these scans have not been included

Please cite this article as: R. Agustín-Panadero, I. Loi and L. Fernández-Estevan et al., Digital protocol for creating a virtual gingiva
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Fig. 7. Front view showing changes from STL-1 to STL-3. The right side of the image
shows a 21 color gradient. Each color corresponds to a range that indicates the
degree of difference between the STL files, ranging +200 micrometers and -200
micrometers.
in the present article as they do not represent any innova-
tion in the clinical procedure described.
2.3.5. When all the digital files have been generated, they are
exported to design software (Geomagic; 3D Systems) to cre-
ate a digital model of the gums. This ’virtual gingiva’ process
begins by superimposing STL-1 (patient’s arch with bonded
provisional[s]), which acts as a reference for the entire align-
ment process, and STL-3 (patient’s arch with prepared tooth
stumps), which acts as a ‘floating’ archive. For correct align-
ment, it is important to select the surfaces that are com-
mon to both STL files. When digital alignment has been per-
formed, its quality can be checked by creating a color map,
which will highlight any surfaces presenting variations be-
tween the scans; when any variations between one scan and
the other are identified, the corresponding surfaces should
be eliminated from the points selected for purposes of align-
ment before repeating the alignment process. Fig. 7 shows a
color map that includes +- 200 micrometers, whereby any
deviation – any area subject to error – within this range will
be marked in color, taking on the most extreme color on the
map’s color gradient. Most of the superimposed areas that
represent hard tissues show an error of +- 20 micrometers,
with the exception of the central areas, as this figure shows
the superimposition quality of STL-1 and STL-3, whereby in
STL 3 the central incisors have been milled. The grey area
represents those parts of the STL-3 file that does not contain
information in either of the two files (in this case STL 3),
which corresponds to the area of incisor milling. It should
be noted that the interproximal area, as well as the gingi-
val sulcus, are typically ‘noisy,’ so these should be omitted
when it come to performing best fit. Soft tissues have less
dimensional stability than hard tissues so these should also
be omitted when it comes to areas to be superimposed, as
these may be a source of error in the superimposition.
2.3.6. STL-1 (reference) and STL-2(floating) are then aligned. To
do this, only the provisional crown in the complete arch
(STL-1) is selected for alignment with the visible part of
the cemented provisional in STL-2, in other words the con-
tact points, subgingival area and internal area are omitted as
these features are not visible in either STL files and so are of
no use for purposes of superimposition. Again color mapping
is used to check the precision of the superimposition as in
the previous alignment (Fig. 8).
Please cite this article as: R. Agustín-Panadero, I. Loi and L. Fernández-Estevan et al., Digital protocol for creating a virtual gingiva
adjacent to teeth with subgingival dental preparations, Journal of Prosthodontic Research, https://doi.org/10.1016/j.jpor.2019.10.006
[m5G;November 28, 2019;4:59]
5
Fig. 8. Front view showing changes from STL-1 to STL-2. The right side of the image
shows a 21 color gradient. Each color corresponds to a range that indicates the
degree of difference between the STL files, ranging +200 micrometers and -200
micrometers.
2.3.7. In this way, STL files 1, 2, and 3 are now correctly aligned
and the virtual gingiva can now be generated. STL files 4, 5
y 6 obtained from scans 4, 5, and 6 respectively, are used
for designing the prosthetic crown and are not required for
producing the virtual gingiva. When a sagittal cross-section
of the three aligned scans is examined, the third file shows
the collapsed gingiva; when the provisional was removed
this caused the gingiva to move centripetally inwards to-
wards the tooth, filling the space formerly occupied by the
provisional. To avoid this collapse and obtain a gingival po-
sition identical to that achieved when the provisional was
in place, a virtual gingiva is created, erasing the collapsed
gingiva to create gingival morphology adapted to the provi-
sional crown’s cervical emergence.
2.3.8. A Boolean operation is used to generate the virtual gin-
giva. This is a process that creates an object through a math-
ematical operation, in which two objects can remain, inter-
sect or unite to form a new object. In the present technique,
the software’s ’remain’ tool is used. To do this it is neces-
sary to reproduce the most apical contour of the provisional
crown, so STL-2 must be as precise as possible; as in STL-1,
the most apical portion of the provisional is not visible as it
is positioned subgingivally.
2.3.9. The Boolean operation generates a new master model
with an open gingival sulcus (Fig. 9a), which can then be ex-
ported in the software’s STL format to CAD software (Fig. 9b)
(Exocad; Exocad GmbH) in such a way that the definitive
crown can follow the gingival anatomy created by the provi-
sional (Fig. 9c).
2.3.10. Lastly, CAD-CAM software designed for fabricating dental
restorations (Exocad) is used to fabricate a metal-free crown
(made of lithium disilicate, monolithic zirconia, or resin
nano-ceramic) using completely digital techniques (Fig. 10a)
and maintaining the exact morphology of the provisional
prosthesis used to generate the biocopy (Fig. 10b). The term
digital biocopy refers to the ideal morphology of the defini-
tive prosthesis based on a duplicate of the provisional pros-
thesis, which has been seen to present healthy periodontal
conditions around its cervical anatomy. In this way, the tech-
nique ensures that the definitive crown is adapted to peri-
odontal tissue on all aspects (vestibular, lingual and palatal)
in exactly the same way as the provisional. Whenever this
non-metallic crown design protocol is used is it advisable
to mill a test sample from transparent resin to check the
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Fig. 9. (a) Digital gingiva after applying Boolean operation. (b) Digital transversal section showing the silhouette of the collapsed gingiva and the (non-collapsed) virtual
gingiva. (c) Transversal section showing the silhouette of the provisional crown emergence, collapsed gingiva, and the non-collapsed gingiva.

Fig. 10. (a and b) CAD-CAM design of the definitive crown with parameters identical to the provisional in all parts of the surrounding gingival tissue (vestibular, pala-
tine/lingual, and interproximal).

restoration-preparation fit (Fig. 11a), evaluate dental size
(Fig. 11b), dental morphology (Fig. 11c), contact points, and
occlusion. In a case requiring slight modification of the resin
crown’s anatomy in order to adapt it to the conditions in
the oral medium (adding composite resin material or elimi-
nating material with a tungsten carbide bur) this can be per-
formed using this transparent sample. Afterwards, the modi-
fied crown is scanned with the intraoral scanner and the STL
file obtained is sent to the laboratory to carry out best-fit
with the virtual design of the previous prosthodontic work;
when all parameters have been checked for accuracy, the
definitive restoration can be machined. In this way, it can
be ensured that the definitive crown anatomy remains un-
changed and is not manipulated when it is placed on the
tooth. Moreover, when using BOPT (Fig. 12a & b), it is im-
portant to ensure by frontal and occlusal visual examination

Please cite this article as: R. Agustín-Panadero, I. Loi and L. Fernández-Estevan et al., Digital protocol for creating a virtual gingiva
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Fig. 11. (a and b) Checking marginal, morphological and occlusal fit of the CAD-CAM fabricated definitive crown with samples milled from transparent resin. This will check
for any misfit between the prepared tooth stump and the surrounding gingiva, assessing the risk of soft tissue ischemia. (c) Occlusal verification of the morphology of
restorations in resin material.

that the prosthetic emergence does not provoke ischemia at
any point in the gingival sulcus (Fig. 12c & d).
3. Discussion
Digital technologies continue to suffer certain limitations in
comparison with conventional techniques, such as the difficulty of
detecting subgingival finish lines, recording gingival emergence in
deep implants, or rehabilitating a complete arch. They also require
changes in working protocols that involve a learning curve and fa-
miliarization with the techniques involved as the use of scanners
to obtain a digital impression must be performed by an experi-
enced professional. In addition, there is the considerable economic
investment in equipment required to introduce them into clinical
practice [1–3].
Research continues into how best to establish completely dig-
italized workflows that obtain complete data about teeth and im-
plants, as well as the surrounding soft tissues, the subgingival area,
and the dentogingival sulcus [4]. In the technique described here,
the provisional crown plays an important role, providing registers
of the soft tissue response and emergence profile, which are later
reproduced exactly in the final restoration [3]. Intraoral scanners
suffer one particular drawback: when the provisional crown is re-
moved, a collapse of the gingiva is produced making it impossi-
ble to reproduce this area precisely. For this reason, the technique
described in this article offers a digital protocol capable of over-
coming this problem, a drawback that does not apply to conven-
tional impression taking techniques [4,10. The difference between
the emergence created by the provisional and the collapsed gin-
giva once the provisional has been removed, even though it may
be minimal, does affect the placement of the definitive restora-
tion; variation will also increase according to the time the patient
spends without the provisional in place [1,11].
Several authors report scanning provisional prostheses in treat-
ments involving implant-supporting fixed restorations to obtain a
digital model, which is used by the laboratory technician to fabri-
cate the definitive restoration’s prosthetic emergence using veneer-
ing ceramic [12].
BOPT [5–9], in which the tooth is prepared without a finish
line, creating a new crown emergence, presents a series of clinical
difficulties when it comes to impression taking, the management
of the collapsed gingiva when the provisional supporting it is re-
moved, or the placement of a gingival retraction cord, etc. It also
presents technical difficulties in laboratory work whereby a phys-
ical model is fabricated by making a plaster cast into which the
provisional is placed and the patient’s gingiva reproduced by sili-
con injection into the cast. But this is a laborious process and is
sensitive to variations in the manual skill of the laboratory tech-
nician. Mino states that the transference from a provisional to a
definitive restoration will be more precise when this is carried out
using CAD-CAM rather than conventional techniques [13], although
this is complicated by the scanning limitations in subgingival areas
[4].
Making use of the anatomy of the provisional prosthesis to
modify the gingival emergence profile is an important feature of

Please cite this article as: R. Agustín-Panadero, I. Loi and L. Fernández-Estevan et al., Digital protocol for creating a virtual gingiva
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Fig. 12. (a) Frontal image of the gingival tissue of the teeth prepared with the BOPT technique after 12 weeks of healing. (b) Occlusal image of the gingival sulcus around
the teeth prepared without a termination line. (c and d), Translucent monolithic zirconia crowns (Lava Esthetic; 3 M ESPE) after 1 year of functional life.

the protocol described in this article; it is a fast procedure and is
easy to apply in cases when the gingiva does not adapt correctly.
It also makes it possible to create an intrasulcular mock-up with
ideal prosthetic cervical contours and horizontal overcontouring.
With BOPT, overcontouring is entirely different from that which
constitutes cervical overcontouring over a horizontal finishing line.
We must distinguish between what is defined as the anatomi-
cal crown and what is described as a tooth’s clinical crown [5–
8]. With BOPT the convexity of the anatomical crown is modified,
so that the prosthesis imitates the natural tooth, from which any
horizontal-convex component above the cemento-enamel junction
has been eliminated previously. But with a horizontal finishing
line, the emergence of the tooth’s clinical crown is modified; this is
where the well-known periodontal problems described in the liter-
ature arise [9], as the horizontal finishing line favors the accumu-
lation of dental plaque resulting from aberrant anatomy. It must
be understood that with BOPT, the procedure imitates the convex
anatomy of the natural tooth above its CEJ [8].
In the protocol described in the present article, information
about the provisional prosthesis’s gingival emergence is registered
digitally; the definitive dental preparation-restoration marginal fit
is taken from the scan of the prepared tooth which will reproduce
the anatomy of the dental preparation faithfully.
The protocol described here makes it possible to generate a vir-
tual model of the patient’s gingiva, an exact biocopy of the gin-
gival emergence profile created by the provisional crown present-
ing good periodontal status around a tooth prepared without finish
line, according to the BOPT concept. With this model of the pro-
visional emergence it is possible to fabricate the definitive crown
using CAD-CAM techniques, making the workflow entirely digital,
without any need for physical models.
3.1. Study limitations
The use of digital workflows in dentistry is fast becoming estab-
lished. Nevertheless, intraoral scanners demand considerable eco-
nomic investment and their correct use constitutes a steep learn-
ing curve, and requires constant updating. Intraoral scanners ob-
tain good results in terms of prosthetic precision on a small scale,
but this is not the case in full arch restorations. However, in the
case of BOPT, intraoral scanning is an innovative technique that
has not been widely reported in the literature, so further assess-
ment of soft tissue behavior is needed in the form of prospective
clinical trials with long-term follow-ups. At the same time, mono-
lithic materials milled using CAD-CAM technology obtain optimal
results in terms of strength and fit but may present limitations,
especially regarding esthetics. They cannot be individualized like
analogue restorations that are manually shaped and crafted by the
laboratory technician.
4. Conclusions
This digital protocol is of great relevance to clinicians, as it
makes it possible to reproduce anatomical dental information, soft
tissue contours, and emergence profiles exactly, without the use of
conventional impression-taking techniques, unaffected by gingival

Please cite this article as: R. Agustín-Panadero, I. Loi and L. Fernández-Estevan et al., Digital protocol for creating a virtual gingiva
adjacent to teeth with subgingival dental preparations, Journal of Prosthodontic Research, https://doi.org/10.1016/j.jpor.2019.10.006
JID: JPOR
ARTICLE IN PRESS
R. Agustín-Panadero, I. Loi and L. Fernández-Estevan et al. / Journal of Prosthodontic Research xxx (xxxx) xxx
collapse when the provisional is removed, and exactly transferring
the periodontal morphology around the provisional crown to the
definitive restoration.
Declaration of Competing Interest
No conflicts of interest.
Acknowledgements
The authors woulld like to express their thanks to D. Alberto
Alvarez Garcia-Pumarino, Global Scientific Affairs Mgr. Digital Oral
Care at 3MEspe Spain, for his advice and guidance and help in cre-
ating and managing STL files.
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