3D Printing in Restorative Dentistry Ebook

D R .
WA L LY R E N N E
DR. MICHAEL DEFEE
3D Printing
in Restorative Dentistry

INTRODUCTION
Into the Future

This small ebook is designed to explore some applications of My intention is to tell you in a very clear, organized way some
3D printing in dentistry. I mostly show Flexcera resin of my secrets in 3D printing that have taken me years to
applications by Desktop Health but many of the techniques master and develop. I also have many tutorials on YouTube
can be applied to other resins. This material was designed to and on my web site www.TheMODInstitue.com.
have the strength of a glass ceramic with the exibility of a
super polymer. I want to preface this document by saying I am Please understand this document is a work in progress, and I
biased, I currently work for Desktop Health as the VP of welcome feedback..
Clinical Strategy. However, I will attempt to include tips and
techniques that are universally applicable to printing in Best,
dentistry.
We need to unite behind technology and push the profession

of dentistry into the future.
Dr. Wally Renne
Copyright © 2022 The MOD Institute Published by WRMDSV II LLC, in the United States of America. First
Publication March, 2022
All rights reserved. All rights reserved. This book or any portion thereof
may not be reproduced or used in any manner whatsoever without the 320 Broad St. #210
express written permission of the publisher except for the use of brief Charleston, SC 29401
quotations in a book review. USA
www.themodinstitute.com
Front cover image by Dr. Wally Renne. Names, places, products and
events are the sole opinion of the author.
3 D P R I N T I N G I N R E S TO R AT I V E D E N T I S T R Y | D R . WA L LY R E N N E

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This guide is dedicated to my friend and mentor Dr. B ob Holmes.
Gone but not forgotten.

EPIGRAPH
In that moment,
the patient is all that
exists in the world.
The most important step to anything in life is the step you are on. B e in the moment and
dedicate all your focus, all you energy and all your skill to the task at hand, the very step
you are on. Do not dwell on what came before, or what needs to be done after, rather focus
in the moment. If it is cutting a inish line on a tooth, nothing else should be on your mind
except the bur as it presses on the tooth, the tactile feedback of the handpiece in your
hand. You see the rotation of the bur, the diamond particles as they smooth the enamel.
Nothing is
more important.
— DR. BOB HOLMES
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TA B L E O F CO N T E N T S
1. The Numbers 6
2. Monolithic Dentures 10
3. Split File Denture 27
4. Metal Free Partial 38
5. The Final Restoration 45
6. Implant Provisionals 65
7. Occlusal Guards 79
8. Quick Reference 83
CHAPTER 1
The Numbers
Flexural strength is the holy grail of meaningless laboratory numbers that marketing teams have brainwashed into our heads as the value
that means everything. The value that we should use to compare dental materials to each other to determine if a material is strong enough.
What exactly is exural strength and do we have data that correlates higher exural strength to greater clinical success?
Marketing teams have built a story around lexural

strength to play number games that do not matter.
1
In a recent Meta-analysis, Heintze et al looked at laboratory values such as exural strength and tried to determine if these
laboratory values have any correlation to clinical success of direct resin restorations. They found that the only real correlation
between clinical and laboratory outcomes for survivability was a material property called fracture toughness. Interestingly, exural
strength was loosely correlated with wear but that is about it. Therefore, the number that we have been told as the number to focus on
is actually quite meaningless. Fracture toughness is the real number that we should all be looking at as a predictor of clinical success.
Flexural Strength Fracture Toughness
Flexural strength is measured by applying a load to a material Fracture toughness (K1c) is related to the energy required to
that is typically a bar shape as determine by ASTM or ISO propagate a crack. In this test, a de ned notch is cut into a bar
standards. The bar is supported at each end, which combines of material. The bar is placed on a xture that supports either
the forces found in compression and tension. Typically, ISO end and the stylus is positioned above the notch in a 3-point
6872 standard is used in dentistry. Bar-shaped specimens are bend con guration similar to that used for exural strength. A
printed, milled or cut into dimensions 1mm x 4mm x ~12mm high fracture toughness re ects a high ability of a material to
and then polished. Testing is conducted using a test xture prevent crack propagation. Fracture toughness is typically
with a 10mm span and a crosshead speed of 1mm/min in a measured according to ISO 6872 where a notch is cut using
universal testing machine like an Instron. the V-notch option in bar-shaped specimens but variations
exist based on the material type and particle size. Testing is
typically done with a crosshead speed of 0.5mm/min. K1c is
calculated from the failure load, notch depth, and specimen
dimensions. If we look at fracture toughness of some popular
ceramic materials we can see an interesting trend that may
have been able to predict recent material ops that over
promised and under delivered.
6 | CHAPTER 1: THE NUMBERS

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CHAPTER 1: THE NUMBERS
Here we see fracture toughness all the way on the right. Dental materials typically range from 1-5 depending on the material. 3Y
Zirconia is typically a 5, with certain 4Y and all 5 Y zirconias usually between 2 and 2.5. A value of 2 and above for fracture
toughness seems to indicate a material is going to be a forgivable material for intraoral longevity.
Fracture Toughness
J LUBAUER, R BELLI, H PETERLIK ET AL., GRASPING THE LITHIUM HYPE:

I N S I G H T S I N T O L I T H I U M S I L I C AT E G L A S S C E R A M I C S , D E N TA L M AT E R I A L S .
L I N K E D : H T T P S : / / D O I . O R G / 1 0 . 1 0 1 6 /J . D E N T A L . 2 0 2 1 . 1 2 . 0 1 3
It’s not that materials with a lower fracture toughness can not prove to be an extremely viable long lasting dental material, it just
means that those materials are probably more technique sensitive and, therefore, less forgiving to technique errors in bonding
and material thickness. Those materials that fall below 2 and are between 1-2 are generally materials that rely heavily on resin
bonding to reinforce them to the tooth structure. Printed materials fall in this range and therefore must be bonded.
Recently, one 3D printer manufacturer released a high exural modulus material touting the high exural modulus as an
important material breakthrough. This property is actually contrasting to materials like Flexcera and Crystal Ultra that have
speci cally been formulated to have a lower exural modulus. What is exural modulus and is this something that is good for a
printed material? As previously postulated by Magne, et al,2 a lower exural modulus correlates to increased deformation under
load. This means a material with a low exural modulus is more likely to absorb the stress than a material with a high exural
modulus. In addition, the combination of high strength with low modulus like Flexcera Ultra + translates to greater resilience.
Resiliency is the capability of the material to absorb energy when it is deformed elastically and then to recover its size and shape
upon unloading. Type III Gold has the incredible ability to deform while remaining resilient under load. Flexural Modulus is
represented by the area under the curve in the elastic region of the stress-strain curve; the units are of pressure (MPa). Materials
with high exural modulus tend to be sti and brittle and are poor materials for absorbing impact.
7 | CHAPTER 1: THE NUMBERS

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Wear is another big concern for printed materials. Typically to test wear in a laboratory setting sophisticated machines are used.
Specimens (8 mm diameter x 2 mm thickness) are designed with CAD and 3D printed according to manufacturer’s instructions.
All excess material is removed by polishing with 600 grit SiC paper. Specimens are stored in water for 48 hours.
The specimens are then placed in a wear testing machine which applies a 20N load and slides a distance of 2mm to simulate
bruxism. Steatite balls (diameter 2.5 mm) are used as opposing stylus. The test is run for 400,000 cycles at 1Hz. A circulating
arti cial saliva media is used as a liquid lubricant.
CUSTOMER WEAR MACHINE F S E AT I T E B A L L W E A R I N G AG A I N S T S P E C I M E N
Volumetric Wear
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Specimens are scanned before and a er wear testing using a non-contact 3D surface measurement instrument (Keyence VHX)
and superimposition so ware material (ProForm so ware, Scantron Industrial Products) to determine the volumetric wear of the
materials.
M AT E R I A L W E A R I N A 3 D H E AT M A P
Using this method at an independent university, it was found that Flexcera smile ultra + was extremely resistant to wear, with half
the wear at 400,000 chew cycles compared to other printed materials.
Wear is one of the biggest issues facing printed materials and one that is critical for restoration success. Unfortunately, good
independent data on material properties is hard to come by. The above study was done at University of Alabama, and is a study
that directly compared materials using the same exact methods in the same study. Be cautious of drawing comparisons across
di erent studies due to lack of complete standardization. For example, it is very hard to draw comparisons between di erent
studies on exural strength and fracture toughness because even small changes in the protocol such as temperature can lead to
drastic di erence in the results even within the guidelines of ASTM and ISO. Therefore, more studies need to be conducted with
direct comparisons in the same study with identical laboratory and testing equipment. Data on printed materials is limited, and
materials are advancing rapidly with independent data unable to keep pace with material releases. Therefore, it is with caution
that you should adopt new materials.
We need long term clinical data and longevity studies. We can try to draw conclusions from the nanoceramic and hybrid ceramic
literature but even then printed materials behave very di erently than hybrid ceramics. I started using Flexcera Smile Ultra+ only
on implant restorations. Once I saw success I moved into permanent inlays, onlays and veneers. It is important to remember
these materials, as complex and innovative as they are, are still composite resins and currently no perfect material exists in
dentistry. It is important to weigh the pros and cons of each material for each speci c patient scenario. With that said, printed
materials are a viable alternative option to more traditional materials as long as the limitations are understood by both the
clinician and the patient.
REFERENCES
1)Heintze SD, et al. Laboratory mechanical parameters of composite resins and their relation to fracturs and wear in clinical trials—A systematic review. Dent Mater (2016))
2) Magne P, Paranhos MP, Burnett LH Jr, Magne M, Belser UC. “Fatigue resistance and failure mode of novel-design anterior single-tooth implant restorations: in uence of material selection for type III veneers
bonded to zirconia abutments.” Clin Oral Impl Res. 2011 Feb; 22 (2): 195-200. 157)
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CHAPTER 2
Monolithic Dentures
For years I thought we
would never have a
printed denture that I
would put up against
the best milled
dentures.
I have said several times that a milled denture is the best
denture possible. I have tried every printed dental
material and have had major concerns about aesthetics,
t, color stability and durability. Printed dentures
seemed to wear at an alarming rate, causing a collapse of
vertical dimension. Then Lucitone came along as the
rst printed material that I was moderately satis ed with
as a permanent base material. It has great esthetics and
durability and I still consider this denture base material a
great material. Flexcera Base is a next generation
denture base resin that according to Desktop Health has
mechanical properties that appear to have surpassed
that of Lucitone.
10 | CHAPTER 2: MONOLITHIC DENTURES

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CHAPTER 2: MONOLITHIC DENTURES
Work Fracture
Flexcera Base is made out of a proprietary long chain oligomer technology. Flexcera Smile Ultra+ adds ceramic ller particles to this
chemistry providing more rigidity than Flexcera Base but less exibility than Flexcera Base. Flexcera Smile Ultra + is designed to be a wear
resistant and color stable permanent tooth solution . I struggled to nd a printed tooth material that I liked until Flexcera Smile Ultra +.
Before, I always milled my teeth and bonded them to a printed base. However, Flexcera Smile Ultra+ solved the major issues I had with
previous materials for printed denture teeth, which was esthetics and wear. These material innovations provide a high impact denture that
also solves one of the problems that has plagued 3D printed materials, water sorption. Based on FDA ling data, Flexcera soaks up 2x less
water than competitor printed denture materials. These materials have a low exural modulus with noted thermoplasticity, meaning that
if you put them in hot but (but not boiling) water they can be formed (similar to Keystone so ). Flexcera Base is resilient and is able to
de ect impact also making it suitable for exible partial dentures due its the ability to undergo elastic deformation. 3D printing is evolving
so rapidly, with manufactures releasing new resins what seems like almost daily, that it could be by the time you read this new resins are
already realized that surpass the properties of Flexcera.

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Monolithic Dentures, Tryin Dentures, or the Easy

Copy Denture Technique
One of my favorite things to do in digital dentistry is the modern copy denture technique. It is so easy it is cheating. The patient typically
presents with an older denture that is a little loose, stained, possibly broken or missing a tooth. The rst thing that I do is evaluate the
denture esthetics and vertical dimension and make any changes to the denture that is needed. This may involve making such changes as
opening the vertical dimension, changing incisal edge length, or relining with a so functional reline material. I typically reline with a so
reline material or light body polyvinyl siloxane. I o en alter the anterior a little with composite in the cases where the teeth are worn at.
If the vertical is o , I open the vertical using a Lucia jig, deprogrammer or custom centric relation jig and I keep that aside for later when
scanning the bite.
D E N T U R E S B E F O R E M O D I F I C AT I O N S
Step 1: Copy Relined Denture

The rst step is to scan the denture a er all the necessary modi cations have been made. This typically is done in a laboratory scanner or
with a hand held intraoral scanner. In this case, the denture is out of the mouth and the clinician is scanning the denture as they rotate it in
their hands. A good scan pattern is essential for accuracy using this technique. It typically takes 5 or more minutes to scan the entire
denture including the outside and tting surfaces.
AN EXAMPLE OF A COPY DENTURE SCAN FORM AN IOS

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Once the denture is scanned 360 degrees, the opposing arch is scanned in the mouth. If the opposing is also a denture then this is scanned
out of the mouth using the same technique. In the case above this denture was opposing a natural dentition. The natural lowers were
scanned in the mouth. The next step is to capture the bite. The denture is placed in the mouth and the patient is instructed to close; the
arch relationship is captured in maximum intercuspation. If, however, you want to change the vertical dimension, the bite is made with an
anterior jig which maintains the new vertical at the proper centric relation. Then the bite is scanned bilaterally into the scan so ware. This
extra bite information allows for occlusal modi cations if needed.

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From here several options exist. One can copy the denture exactly as scanned and print a monolithic replica, or one can place the denture
into an advanced design so ware to separate out the teeth from the base and make tooth pockets for printing the base pink and the teeth
white.
In this case I am showing the monolithic copy technique and how So what is the best way to turn a monolithic white print into a
to characterize the monolithic denture. This is my technique but work of art? How do you protect those stains from brushing o
many others exist with many di erent materials. Above we can see over time? The answer is not so simple. If you spend the time to
a monolithic copy denture, Flexcera Smile Ultra + printed in turn this print into something that is full of custom colors, the
bleach color and the characterized restoration below on the next last thing you want is it to wear away. I have developed a long
page was made using TAUB Products LMD Elixirs and a speci c lasting technique. The teeth are treated di erently than the
protocol I will teach you. tissue using di erent materials. Once you learn these
techniques you can do anything with monolithic prints.
PRO TIP
Characterize Before You Cure the Material but A er Appropriate Washing Steps
Get TAUB Products LMD Elixirs if you are in the USA. The rest of the world try to use Optiglaze colors and match them to what I am
showing or use Shofu lite art. You can also use Anaxdent orTriad-type composite. Here, I am going to demonstrate this technique using
an All-On- X prosthetic but the technique for characterizing a denture is the same

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Step 2: Clean Your Print
Make sure the print is clean, all supports removed. Microabrasion is recommended followed by alcohol to clean. Here we did digital
festooning of the STL le on an iPad app called Nomad Sculpt. This App is the best so ware I have found for adding really advanced
gingival texture and shape.

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Air abrasion with 30 micron aluminum oxide is recommended. Make sure to clean with 90% or greater alcohol a er air abrasion to remove
all particles. Use gloves to avoid getting oils from your ands on the prosthetic. Make sure your environment is clean and free of dust and lint.
If you did not take the time to festoon digitally this is the time to do it using acrylic burs.
Step 3: First Coat of Taub No. 4 Bubble Gum Pink
The rst coat that I do is a light bubble gum pink coat. This material is labeled No. 4. I always start with a light pink coat regardless of the
nal desired shade. Be careful not to get the material on the teeth although a little is probably inevitable. Do not wast time coating the teeth
with a separating agent because it is very easy to remove with a diamond or air abrasion a er the last coat.

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Step 4: Accentuate the Deep Areas With Dark Pink.
Everything we do is to accentuate depth and color. Here we apply elixir No. 10 to the deep areas. This makes the deep areas appear even
deeper. Be carful not to overdo the dark. Taub elixirs dry really quickly and for that reason I dip the brushes into the jars rather then
dispensing onto a tile or glass slab. I also dip the brushes into the brush thinner between colors to clean the brush.
Step 5: Accentuate the Mucosa (Unattached Gingiva) With Bright Red Taub 13.
This layer is accentuating the more vascular and o en more red area of the tissue. Once again, be careful here to not overdo it and give the
allusion that the patient has erythema. Also, be careful to avoid getting this stain on any attached gingiva, otherwise, it will look like the
patient has severe gingivitis.

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Step 6: Tone Down the Color With No. 1
This step is optional and depends on how bright your patient’s tissue is. In this case I painted a even coat of No. 1 on the entire surface of
the prosthetic. This coat helps blend any irregularities in the other layers. Here you can see I was rushing and got some material stains on
the teeth. This is not a problem as you will see in the next steps.

Step 6: White
To me this is actually the most di cult and yet the most critical step to making tissue look natural. The white is put on the attached gingiva
in a very light splotchy way using a ared brush rather than a ne tip brush. This technique will take some practice to get it the way you want
it. You want the white to not be runny when you put it on so avoid putting too much on the brush.
NEEDS TITLE
Notice the splotches of white, very subtle way of making tissue natural. Also apply to frenum.

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Step 7: Protect That Art

This is arguably the most important part. Coat the stains with liquid Flexcera. I use Flexcera Light Pink because it is almost clear and does
not impact the colors at all. This also lls in some anatomy which is why I like to festoon in great detail as some of it gets lled.
Step 8: Cure in Otto ash

Now place in the Otto ash and do 3000 ashes, then ip and do another 3000 ashes. Now we can characterize the teeth! Other cure
boxes might not work as well since Flexcera cures best at 385nm with high intensity. You will notice an oxygen inhibited layer on the print.
Clean with 90% or higher alcohol. Alternatively, you could cure in a nitrogen or glycerin bath. However, I nd that it is not necessary to take
these steps with the oxygen inhibited layer as it is very thin and comes o when polished.
R E M OV E T H E P I N K F R O M T E E T H A N D A D D S U R FAC E T E X T U R E
Step 9: Get the Pink O the Teeth

This is actually very easy and fast. I use a ame shape diamond as shown above and follow the CEJ. This is a good time, while you have the
diamond out , to add any surface texture you want to the teeth. This might also be a good time to take a thin double sided diamond disc
and accentuate facial embrasure and incisal embrasures.
You now have 4 options to get the tooth looking good.

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Step 10: What Do We Do With the Teeth?

1) If you want to have a surface nish that will last forever, the best thing to do at this point is to use a scotch bright type wheel, followed
by pumice, followed by a so cotton bu with a light tough and Zirconia diamond polishing paste and just polish the teeth.
2) Alternatively, sand blast and clean with alcohol then paint a thin coat of liquid tooth colored Flexcera smile Ultra + and cure. I cure with
a hand held light with a 385nm bulb, The Ivoclar Vivadent Powercure unit. This is the best for curing Flexcera out of the Otto ash.
3) Use resin stains like IPS Empress Direct resin stains and coat with a light cured lled clear resin like VOCO Easy Glaze.
4) Use the scoop technique, which is a lingual cutback to apply colors from within and then this void gets lled with Flexcera. We will
cover this later as this is the most advanced technique and deserves a special section.
For this restoration, I choose option 3 so I will attempt to highlight that below for you. Pros and cons exist for each option that we can
discuss later.

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T H I S R E P R E S E N T S T H E M O D C H E AT C O D E F O R C O L O R I N G A N Y T O O T H . COPYRIGHT © 2022 THE MOD INSTITUTE
These colors can be found in almost any resin stain kit but a er many years of doing this I nd IPS Empress Direct to be the best
photopolymer stain. They last the longest and the color is the best. I have some that are over 5 years out and the stains are still in place. The
most important part is curing the stains well and covering with a clear color stable resin that is ceramic lled, for this we use VOCO Easy
Glaze or actual Flexcera resin. Note: EZ glaze will slightly lower the value of the restoration.
Teeth Step 1: Brown
IPS Empress Direct resin stain brown: Mix a tiny dot of brown with a drop of VOCO glaze or Flexcera resin and mix until a uniform color is
achieved that has no swirls. Apply to the new mixture cervical area and a little inter-proximal. It is important not to streak this. This is also a
very quick way to turn a bleach into an A1 or darker, by applying a thin coat all over the teeth. Cure with the Ivoclar Vivadent Powercure for
5 seconds each tooth.

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Teeth Step 2: Violet or Gray
A thin coat of violet or gray is applied to the incisal 1/3 of the tooth and cure with the Ivoclar Vivadent Powercure for 5 seconds each tooth.
Teeth Step 3: Blue
Up until now I have used a brush, however, for blue you want to use an Endo le or spreader. I prefer a spreader. Apply an ultra thin layer of
blue as close to the incisal edge as you can get. This stain should be almost not visible. Slight curve up the Mesial and distal. Cure each
tooth for 5 seconds with the Ivoclar Vivadent Powercure.

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Teeth Step 4: Opaque White (Called Opaque)

Ivoclar has the perfect cream color, called opaque, use this color for the halo and mamelon e ect if desired.
T H E F I N A L R E S U LT
Teeth Step 5: Clear Coat or Flexcera Top Coat

VOCO has a light cured nano illed clear glaze called VOCO easy glaze. Place a fresh drop on the glass slab and coat the entire surface of
each tooth with a very thin coat. Be quick and do not glob it. Cure each tooth for 5 seconds. An alternative technique I like a lot is using a
thin coat of Flexcera tooth resin on top of the cured resin stains and then cure using the Ivoclar Vivadent Powercure. Alternatively brush
liquid Flexcera as the top coat of resin on the teeth. I nd this to be the most durable surface to protect the stains.
Teeth Step 6: Final Cure

Place the prosthetic in the Otto ash for 1800 more ashes. You now have a product ready for delivery.

 
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UNICORN
Bonus Content: Airbrushed Denture

I joke that we are now entering unicorn territory anytime a technique might be overwhelming to a new user so you will see these denoted
with a Unicorn symbol.
I am going to show you how to airbrush your dentures. This saves time, and makes a more even coat and avoids brush marks. This is my
favorite way to make a white denture pink . It is not without its own issues though. The things you will need:
THE BEAUTY OF AN AIRBRUSHED DENTURE
The items you will need:
A) IWATA air brush ne control

B) Airbrush speci c compressor
C) All the hoses
D) Time to practice
The Taub Elixers are the perfect consistency for airbrushing a denture. Place about 5ML of each color in the airbrush and just
go to town.
PRO TIP
Practice Using Less Expensive Inks on Paper First

Run some Taub brush thinner through the airbrush to clean it. Use the same exact color sequence I taught you above. Play around and
have fun. This technique does take patience and practice.

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UNICORN
Gingival Mask
This technique was rst described openly by Dr. Ross. A technique that is
rumored to be patented and not found as a default feature in even the most
advanced design so ware.
Another unicorn technique where a monolithic denture or other

prosthetic is digitally cut back where you can print a tissue part that is
inserted into the main part. This technique can be accomplished in
several advance dental design so wares with the proper case set up. The
tissue is bonded on the same way teeth are bonded to a denture base as
described in the next chapter. This at top all on X prosthetic is designed D R . M AT T H E W R O S S
for a bone reduction conversion prosthetic. D I G I TA L D E N TA L S P E C I A L I S T

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CHAPTER 3
Split File Denture
PHOTO BY DR. ANTHONY MENNITO
This Beautiful Denture Is all Flexcera.

Made by Jack Marrano From Absolute Dental Services.
Hand Polished With no Stains.
This technique is my favorite way to make a denture, as it requires less artistic ability compared to the monolithic technique and the entire
denture can be hand polished for a lasting shine. The Flexcera original pink is beautiful as it gets. Pumice followed by a so cotton bu with
some diamond paste and a light touch will bring out a nice nish. (Only a properly cured denture will polish). Here I am going to take you
through the steps on how to bond the tissue to the teeth and then how to characterize the tissue if you desire. I will say I am starting to lean
towards just hand polished as the way to go, but I will show you how to do both ways.
If you are trying to turn a scan of a denture into a split le, currently no advanced dental so ware has this as a standard feature, but it can be
accomplished combining work ows across multiple so ware platforms. If you wish to learn more about this design work ow please attend
one of my removable classes or search for some of my Youtube tutorials.
27 | CHAPTER 3: SPLIT FILE DENTURE

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CHAPTER 3 : SPLIT FILE DENTURE
The Digital Impression…

“Just Because You Can Do Something Doesn’t Mean You Should.”
If designing a denture from scratch, and not copying a denture, the best way to do it is still is with a custom tray and make physical
impressions with proper borders. I start with a digital impression to make a 3D printed custom tray. The tray is then used to make physical
impressions with border molding. It is not that a digital impression of edentulous arches can not be easily obtained with modern scanners,
it is that the movable tissues will be di cult to capture and the denture borders will be poorly captured as the patient can not undergo
muscle movements during scanning to determine the best borders. Some clinicians look at the color of the tissue in the PLY le of the IOS
scan to determine the borders. I have not found this to be very successful. Some clinicians love the mucostatic t form a complete digital
scan.
I prefer 3D printed custom trays made from a digital impression and a border molded physical nal impression.
This type of scanning is best accomplished with a laboratory scanner, However it is possible with an intraoral scanner. From this
information it is easy to design a digital denture with split le design. I typically like a 200 micrometer pocket gap or spacer between the
teeth and the base.

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I recommend exporting the le and importing it into the iPad and use the NOMAD sculpt app to festoon, and re-export for printing.
This allows incredible control using the Apple pencil.
I know what your are thinking! That looks way too intense almost like that denture li s heavy weights ! Remember my staining though, I
add colors and then a thick coat of Flexcera on top to protect everything. The top coat lls a lot of the anatomy in. Let’t take a look at
the bottom image and see the anatomy starting to become less intense a er top coating.
The tissue is nished. I added my traditional Taub Elixers and my top coat of Flexcera and the combination of these tones down the
anatomy greatly. If this denture was hand polished only I would not design such aggressive anatomy but since a coat of Flexcera is
applied, and this lls in a lot of the anatomy I over do the festooning.

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Now on to the teeth.
I pumiced and polished the teeth with no glaze, this toned down the anatomy and gives the surface a more natural look. Let me break down the
steps on a di erent denture to show you how to characterize the pink. Remember this is all optional, straight out of the printer and just hand
polished is still a smoking hot denture!
Let Me Show a More Intense Example Before We Dive Into the Details.
This is the denture immediately a er cleaning with no post print processing. The supports were removed from the base but le on the
teeth. The teeth have not been bonded yet to the base. Notice the intense characterization. This look is totally personal style, and some
would think this is overkill.

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Here you can see the tissue has been nished, characterized and coated with a top coat of Flexcera Base.
The teeth have been characterized using the IPS Empress direct technique already discussed coated with a thin layer of excera as the glaze.

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The nal denture, and yes in case you are wondering, the front teeth are misaligned on purpose. This individual wanted a natural
setup the way his teeth looked before he lost them, so that no one would know he had a denture.
Okay, Let’s Get Into the Steps of Pink Characterization…

For demonstration purposes, the next case the teeth have supports le on them, and they have not been bonded to the base yet. I am
using them as a platform to take the photos.
Here we can se the way I positioned this denture on the platform. We can discuss nesting a little later but a special feature here in the RP
slicers so ware is called Auto Pilot where no supports actually touch the tissue surface, only the border has supports around it. This
makes nishing very easy.

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Step 1: White Around the Attached Gingiva and Root Eminence
Step 2: Dark Taub No. 10 Apply a Thin Coat of Dark Red in the Deeper Areas.
Be Carful Not To Apply Too Much.

Step 3: Bright Red Taub No. 13 for the Un Attached Mucosa Area.
Step 4: Coat the Denture With Flexcera Base.

Here we can see how I o en position the teeth on the printer build platform. If I am in a rush I will print at, but if not I will print at a 45
degree angle like shown.
From here the supports are removed from the teeth and the teeth are bonded into the base. The best way to bond the base to the teeth is
as follows:
1. Place a nice thick coat of liquid Flexcera base into the tooth wells.
2. Press the teeth into the tooth wells and hold tight.
3. While holding the two together use a brush to clean excess resin
4. Cure with the Ivoclar Vivadent Powercure with 385nm light 10 seconds each tooth.
5. Place in Otto ash for 3000 cycles, let cool, then ip over and cure another 3000 cycles.
6. Pumice and polish
7. Cure again for 1000-1800 ashes.

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Bonus Content: FP1 Case

This is a complete arch FP1 implant case where Flexcera Ultra + saved me.
Several things are wrong withe this case, and the patient had a failing dentition. We removed all her failing prosthetic work, placed implants
and fabricated a new prosthetic at a new vertical in centric relation. Digital smile design was used to generate the optimal prosthetic.

Flexcera Smile Ultra + was fabricated out of bleach resin and hand polished and place on the implant abutments.
The patient was able to wear this prosthetic at the new vertical for 6 months to make sure a stable joint position was achieved and that
her smile was to her liking. In this way 3D printing is completely revolutionary and all large implant cases I use printing as a way to make
sure everything is perfect before jumping to nal restorations. One day, probably not too far o , 3D printed nals will be the norm.

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CHAPTER 4
Metal Free Partial

30 million
Americans wear a
complete
denture, and
even more wear
partial dentures.
Therefore , it is very common to have to
make a partial denture for a patient.
Flexcera Base is optimally designed to ex
but not break. The base material is more
exible compared to the Flexcera Smile
Ultra + which has more ceramic ller
particles compared to the pink base
materials and for that reason I almost
always make split le partial dentures with
the pink material composing the clasps
and tissue tting surfaces and the Flexcera
Smile Ultra + composing the teeth, and
bonding the two together. The only time I
make a monolithic partial is during an
emergency when I need to print a partial
really fast.
On the Einstein, a Flexcera Smile Ultra + partial can print inn under 30 minutes which means same day partials are easily achievable. Due
to the speed of fabrication and low cost of a few dollars an arch, printed partials are good backup options when doing an immediate load
implant in the anterior and you don’t achieve torque.
38 | C H A P T E R 4 : M E TA L F R E E PA R T I A L
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C H A P T E R 4 : M E TA L F R E E PA R T I A L
Let’s Take a Closer Look at a Case…
This patient presented with the missing teeth #5, 9 , 10 , 12 and a severely compromised #8 due to carries and fracture.
With the technology we were able to provide de nitive prosthetics same day.
The rst step I did a crown on tooth number 8 using digital impressions and e.max on the Planmeca 30 S mill.
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While the mill was making the restoration for #8, I exported the arches and the crown design and merged everything in
my digital design so ware and designed the partial denture to t around the new crown, before ever delivering the crown.
I designed the partial while the crown was milling.
Because I was able to export the digital design of #8 and merge it to the upper arch and use this as my working arch to
design the partial, I was able to avoid the step of seating the crown and scanning the patient again.
Using several Einstein printers, I dedicate one printer to each material. In this case it means more e cient chair time as I can print pink
material on one printer, and at the same time print the teeth. Notice the at orientation for speed.
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The teeth are printed and bonded to the Flexcera Base using liquid Flexcera Base as outlined below. I leave the supports on the
teeth and use them as a handle.
Here we can see the teeth bonded to the base and now I have to customize these teeth to match her natural dentition .
To accomplish the customization, I used IPS Empress Direct Resin stains and VOCO Easy Glaze as a protective coat .

The ultimate test now is how will this look in the mouth? Lets take a look and see if we have a perfect match. They always look better in the
mouth than on the bench.
We are ok here but if you have not noticed the lateral incisor number 10 has the neck of the tooth tipped mesiallyl, the worst possible angle to tip
a lateral. This fact was a design error that should have been caught early on. The patient however was in tears she was so happy. The power of
digital dentistry is life changing for our patients. To think this was all accomplished in a single 2 hr appointment to include the crown and nal
partial denture is amazing.

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PRO TIPS
Try to keep clasps 2 mm thick and at least 4 mm tall inciso-gingivally. Use Flexcera Base as the partial material because it is able to ex a little. If
things do not t, put in hot water for 2 minutes and seat in mouth since Flexcera Base is thermoplastic as well. You must make sure to cure
Flexcera Base properly.
Before curing: Bond teeth using the technique described below using liquid Flexcera Base in the wells and pressing the Flexcera Smile Ultra +
teeth into the wells. Spot Curing using a hand held light with a 385 nm bulb like the Ivoclar Powercure light.
Let’s Take a Closer Look at a Bonding…
Bonding Step 1: Fill the Tooth Pockets With Liquid Flexcera Base
Bonding Step 2: Press & Cure

Press the teeth into the wells, use a brush to wipe excess liquid Flexcera Base o the teeth and cure using a composite resin curing light with a
385nm bulb like Ivoclar Bluephase PowerCure.
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Bonding Step 3: Otto ash Curing

Then place the prosthetic in Otto ash for 3000 Flashes Let cool, ip and do another 3000 ashes.
Note: Otto ash has a broad spectrum light and is best for curing Flexcera, but be careful if you over heat Flexcera it can warp.
Bonding Step 4: Characterize or Polish
Pumice and diamond paste to polish. Then 1000-1800 more ashes. NOTE: IFU states 1000 but I nd 1800 works better.
This is a polished denture made using Flexcera Base Original Pink and Flexcera Smile Ultra + shade A1. NOTE: if you are bonding milled
teeth (PMMA) to Flexcera Base make sure you micro abrade the PMMA teeth really well before bonding with liquid Flexcera Base.
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CHAPTER 5
Final Restoration
Flexcera Smile
Ultra + and Bego
Vareo Smile Plus can
be used as a
permanent
restoration as they
both are FDA
cleared for
permanent use in
the following
indications: inlay,
onlay, veneers,
crowns, implant
crowns.
F L E X C E R A U L T R A + O N A N I M P L A N T C U S T O M A B U T M E N T B Y T R U A B U T M E N T.
S C O O P T E C H N I Q U E U S E D F O R C H A R AC T E R I Z AT I O N
Now I love a good e.max restoration, and that is the most common material used in my practice, followed by ZirCAD Prime. However,
Flexcera has become my standard for a few restoration types: onlays, No prep veneers and implant crowns. Let's start with implant
crowns and discuss why I feel this material o ers several advantages.
45 | C H A P T E R 5 : T H E F I N A L R E S TO R AT I O N
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C H A P T E R 5 : T H E F I N A L R E STO RAT I O N
Building a Forgiving Implant Restoration

A natural tooth has an 80 micrometer wide periodontal ligament ( PDL) composed of collagen bers that act as a shock absorber during
chewing and normal function. An implant does not have a PDL and, therefore, placing a rock solid unforgiving material like zirconia on
an implant means all the forces are being transmitted from the restoration down to the implant which can lead to early crestal bone loss
and potentially implant failure. The selection of a favorable combination of crown and abutment material for implant supported
restorations is recommended to mediate the stress distribution pattern to the peri-implant bone. The unique combination of a less
rigid crown with a rigid underlying abutments might enhance force absorption capacity and preserve the restorations force absorption
behavior over time.
Pascal Magne previously suggested this fact as an important consideration when retiring implants. 1 Here he said “The present work
con rmed that the inclusion of composite resin restoration allowed dental implants to demonstrate a signi cantly increased damping
behavior.”
I feel this work ow leads to a more forgiving implant restoration. Many types of implant restorations are successful, but the incorporation
of 3D printed Flexcera screwmentable restorations into my practice has been an incredibly e ect cost e ective way to provide a high
quality restoration.
I typically use the TruAbutment work ow where a digital impression is made in the following steps:
SOF T TISSUE SCAN WITH S CA N B O DY S CA N . U S E A SCAN THE OPPOSING

H E A L I N G A B U T M E N T O F F. T R UA B U T M E N T S CA N B O DY F O R AND ALSO THE BITE.
T H E S P E C I F I C I M P L A N T YO U
H AV E P L AC E D, I F U S I N G T H E
T R U A B U T M E N T W O R K F L O W.
1. Make a digital impression using a TruAbutment scan body for the speci c implant that was placed. Please note that a complete digital
impression includes the above steps.
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With this scan data, TruAbutment will make a custom abutment and send you the crown le to print. You can ask for screw-retained or
cement-retained. If cement-retained, the design will not have a hole in it and the clinical work ow is to try the abutment in the mouth, take
a check radiograph to con rm seating of the abutment, then try the crown in. If crown ts, torque the abutment then bond the crown. I try
to avoid this because I do not like cleaning excess cement in the mouth. If using a Flexcera Smile Ultra + material, a resin bonding protocol
must be accomplished in the mouth.
F L E X C E R A S M I L E U L T R A + O N A G O L D A N O D I Z E D A B U T M E N T F R O M T R U A B T U M E N T.
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Cement Retained Implant Crown Intraoral Technique:

The steps of this can be accomplished in many di erent ways but I use an Ivoclar Vivadent system or Panavia V5.
Ivoclar Vivadent makes an abutment cement that is autocure only called Hybrid Abutment Cement. It is designed to be used out of the
mouth for Screwmentable restorations and is perfect for that application. However, The intraoral bonding protocol I use is a little
di erent.
1. Titanium abutment treatment: Monobond Plus is placed on the titanium surface a er cleaning.
Note: Titanium can not get contaminated at this point.
2. Sandblast the crown with 30-50 micrometer aluminum oxide.
3. Clean the particles o the crown using alcohol.
4. Place an MDP containing adhesive in the crown like Adhese Universal and air thin.
5. Load crown with a ultra thin coat of resin cement like Variolink Esthetic White.
6. Seat crown and removed all excess cement before curing for 10 seconds on each surface.
If implant placement allows, I always choose a screw-retained crown design, even if it means using an angled screw channel. This work ow
typically allows me to bond the printed crown onto the abutment before the patient ever arrives. Thus the term “screwmentable”. You
cement it out of the mouth on the abutment, this allows for perfect cleaning of the cement, then you screw the crown in during delivery.
The perfect blend of both worlds. This dramatically simpli es the delivery appointment.
The delivery appointment is typically under 15 minutes and involves screwing the crown in, checking with a radiograph and nal torque.
A er te on is placed in the screw access channel and I add Ivoclar Vivadent’s Tetric PowerFill to the access to seal it. Once nice thing about
Flexcera Smile Ultra + is that it bonds to itself amazingly well so if the proximal contact needs to be tighter all you have to do is sandblast
the contact and ow some liquid Flexcera on and cure. I use the same bonding protocol above except follow the IFU for Ivoclar Vivadent
Multilink Hybrid Abutment Cement.
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An Aesthetic Finish
Polishing
A highly polished restoration is critical for long term aesthetics.
Step 1: Komet 9845C Step 2. Komet 9845M

Step 3. Komet 9489M Step 4. Komet 9489F
The Final Result Should Have a Durable Long Lasting Shine.
UNICORN
Bonus Content: Scoop Technique

Despite the debated origins and arti cial complications the scoop technique, also called the “back door” technique , is a way to add internal
color to an anterior printed restoration by cutting back the lingual, creating a window but keeping the facial about 0.5m-0.8mm thick. It is
much easier than doing a facial cutback. The cutback can be accomplished with a bur, or digitally. In this case I digitally cut the lingual back and
printed it like this using Flexcera smile Ultra +. You can see the colors added using IPS Empress Direct resin stains Then liquid Flexcera is
used to cover the window, protecting the stains forever. The restoration is then polished and you ever have to worry about the colors wearing
o !
To practice this technique, please download this ile.
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Bonding Flexcera Smile Ultra + to Tooth
Step 1
Microabrade the restoration using 30 micrometer aluminum oxide particles. This adds roughness to the surface for a
micromechanical bond.
Step 2
Add an MDP-containing adhesive to the restoration and blow thin (do not cure). Place restoration in a dark area to avoid premature photo
polymerization. I typically use Ivoclar Vivadent Adhese Universal as the MDP-containing adhesive to coat the printed restoration with.

Step 3
Prepare the tooth with a selective etch technique.
Step 4
Place the adhesive system on the tooth (Ivoclar Vivadent Adhese Universal ), air thin, and cure.

Step 5
Load the cement and seat the restoration and follow with meticulous cleanup. The choices for bonding are heated composite, light cure
cement, or dual cure cement. I personally use dual cure in the posterior (Variolink Esthetic DC ) and light cure only in the anterior
(Variolink Esthetic LC).
A recent independent University looked at bond strength of resin cement to Flexcera Smile Ultra + and this is what they found:
Supporting Data
A recent independent University looked at bond strength of resin cement to Flexcera Smile Ultra + and this is what they found:
Sandblast plus adhesive had over 30MPa of shear bond strength while adding a MDP containing saline before adhesive placement leads
to over 35 Mpa of shear bond strength.
 
No Prep and Minimal Prep Veneers
This tooth is printed in bleach color Flexcera Smile Ultra + on the Einstein Printer by Desktop Health. Let's see what a little internal color
can do to this. This is a fun exercise you can do to get better at characterization. I used a combination of internal and external
characterization for this one. Using IPS Empress Direct Resin stains and Voco Easy Glaze to protect everything. The restoration was
sandblasted to ensure the resin stain photopolymer bonded to the Flexcera and also to ensure the surface was clean. As you can see, the
material is naturally beautiful and with a little color can be indistinguishable from nature. I am excited about the aesthetics of this printed
material. That leads me to my next favorite application, Veneers. Flexcera can be printed on the Einstein 300 microns thick.
This means no prep veneers and minimum prep veneers are possible. I like this due to the economics of printing it opens up many new
opportunities for patients to get veneers. For example, I can print an entire smile of 8 veneers in under 25 minutes with the Einstein Pro
Printer by Desktop Health and under 30 minutes with the Einstein. These veneers were printed in 25 minutes and are paper thin.

Veneers this thin is something milling can not accomplish. I o er these restorations at a price point between a direct resin and a ceramic
veneer. For most practices that will be $500-700 a unit. Ceramic veneers are still o ered, but this now gives me a more a ordable option
to present to my patients. It is important to discuss proper polishing of veneers and proper bonding protocols. One of the most critical
aspects of a veneer is color stability and bonding. Flexcera smile Ultra + soaks up 2X less water and stains compared to other resins.
However, time will tell if it is as color stable as an all ceramic material. I know it is better than most direct resins and on par with the very best
direct resins and milled resins. My favorite way to polish the veneers is to to use Komet Acrylic Polishers intended for dentures.
One extremely easy way to create a lasting high shine without polishing
is to paint a thin coat of liquid Flexcera on the veneer and cure it. You
can do this on top of applied resin stains as well.
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Onlays and Crownlays
This Flexcaera Smile Ultra + restoration was rst hand polished and then characterized Using Empress Direct Resin stains and VOCO
Easy Glaze. Nobody knows how long the resin stains will last, and debates exist on the bene t of stains compared to just hand polishing.
Some resin glazes collect plaque and discolor over time, therefore a good hand polish may be the best long term result. Voco glaze is a
nano- lled clear resin that seems to hold up better than many.
Case Example: Crownlay

This is my tooth. A 10-year-old SonicFill resin. It is about 6mm deep and sits right over my nerve. It is de nitely in need of replacement .
We decided to go with an ultra thin printed restoration. You can see the open margin and crack on the distal marginal ridge and facial.
This tooth is symptomatic to biting.
Dr. Anthony Mennito removed the SonicFill and perspective is hard to tell from the photo but it is very deep. No decay was under the
restoration, the dark color is old amalgam stain. A resin buildup was bonded in the tooth using a selective etch technique. A printed inlay
could have been a viable option here as well .
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A er the buildup a Crownlay prep was made with just 0.5 mm of reduction. Dr. Mennito wanted to do more, but I would not let him. I
designed the crown in Exocad and exported the STL to the Einstein printer.
The restoration printed in 15 minutes and we tried it in a er the appropriate cleaning and curing procedures were followed which includes
a 5 minute wash in 99% alcohol, 3000 ashes on both sides of the restoration
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The restoration was bonded using the bonding protocol described for veneers. Here we see the nal bonded restoration. I am a clincher
and grinder as you can see on my premolar. I am not concerned about the 0.5 mm thick bonded Flexcera Smile Ultra + here on my tooth.
However , the recommended minimum material thickness is 1.5 mm so keep that in mind. I am willing to go thinner on my tooth because I
would rather my crown break than my tooth fail or break. I also tend to prep conservatively for my patients too with this same philosophy. I
do not recommend going against the manufacture suggested 1.5mm thickness.
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Case Example: Veneers

This patient presented as an emergency patient with an old veneer that was o and lost from tooth 10. We scanned and designed a new
veneer using a mirror image technique found in Exocad so ware. This enables an easy perfect mirror image of tooth 7 onto 10.
Here we can see the veneer tried in right out of the printer a er washing. The nal restoration bonded in place using the protocols
mentioned above.

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Please not this is immediately a er bonding and the cord is still in place.
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Case Example: Multiple Unit No Prep Veneer Case
This patient presented with de cient vestibular reveal and an

asymmetrical smile. It was determined using smile design so ware
that no prep veneers on teeth 4, 5, 7, 8, 12, and 13 would achieve the
desired esthetic outcome that the patient wanted. A 3D face scan
was made and the veneers were designed in PlanCAD Premium with
patient feedback. It is possible to print 200 micrometers thick
allowing an almost translucent zone in the cervical which leads to a
nice contact lens e ect during delivery.
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Here we can see the no prep veneers at tryin. The supports are le on as a handle and then are removed a er bonding,
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The veneers are prepared for bonding using the same protocol already outlined.
With an extremely conservative approach using no prep veneers and custom staining we’re able to provide the
patient with a little more length and a more full buccal corridor providing an aesthetic result.

CHAPTER 6
Implant Provisionals
Printing has dramatically simpli ied the

provisionalization process for implant restorations.
You can get as simple or as complex as you want and
Here we will cover both the simple and the complex.
65 | CHAPTER 5: IMPLANT PROVISIONALS

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CHAPTER 6: IMPLANT PROVISIONALS
Case 1: Simple Technique - a Digital Crown With a Hole in It.

Most implant planning so wares allow you to export the crown design that was used to plan the surgical guide, and also export an
implant extension tube. This can be then placed in Meshmixer and a subtract tool (boolean di erence) can be used to cut a hole in
the crown exactly where the temp cylinder would emerge.
To do this, highlight the crown then the cylinder in Meshmixer and click Boolean di erence. You have to make the tube a solid rst
for the most ideal cut. The restoration is designed slightly out of occlusion, the implant is virtually planned and then the objects are
exported to cut the hole where the implant tube is extending. In Meshmixer, the Boolean operation is achieved and the les can be
exported to print.

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The day of surgery you have a guide, a printed temp and a temp cylinder.
The surgical guide is placed and the implant is placed to depth at the proper location. If torque is achieved, the case can be immediately
loaded and the provisional made from the previously printed plan can be placed. I only ever attempt this premolar forward. The temp
cylinder is placed and the printed restoration is then picked up around the temp cylinder using owable resin composite cement such as
Ivoclar Vivadent Variolink Esthetic DC.
Once the resin is locked on to the temp cylinder you can then unscrew the entire provisional, add to and polish the subcritical contours of
the restoration. Then, you remove the extended titanium from the occlusal and polish the surface.

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Once the provisional is polished and sculpted you can then screw the restoration into the xture, verify no contact in occlusion and then
make a check radiograph to ensure everything is seated correctly.
Te on tape is then placed in the access hole, followed by any composite material you have.
This technique was the way I provisionalized implants 5 years ago. Now, I tend to go direct to xture using timed guides. I prefer this
method, even though it requires meticulous attention to detail. I like the printed connection which acts as the weak link in an immediate
load prosthetic where if the forces are too great it will break at the connection functioning much like a fuse in an electrical system designed
to protect the system. In this instance, the connection will break letting the patient and the clinician know the forces are too great, possibly
alerting that a problem exists before implant failure occurs due to heavy forces.

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Case 2: Using a Virtual Extraction and Mirror Image of an Adjacent Tooth

To Capture Subcritical Contours for the Printed Prosthetic.
Here a patient presented with missing tooth number 8. Using the same technique described above with one minor change, the
contralateral root was segmented out of the CBCT, merged with the new digital design of tooth 8 and used to fabricate the
subcritical contour of the provisional.

A digital impression is made, tooth number 8 is waxed. This le is merged with the CBCT. A virtual implant is placed and a guide fabricated.
An abutment is created in the so ware that corresponds to the temp abutment or Tibase dimensions. Also the root of tooth #9 is
segmented. The root, the design of #8, the implant location and extension are all exported into Meshmixer, where the root is mirror imaged
and merged with the crown design. The root is cut at the level of the abutment margin.
The restoration can be printed and attached to a Tibase before the surgery . On the day of surgery you have a printed guide, a premade
provisional with a natural contour that is a perfect mirror image of the natural tooth..

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The implant is placed, and the temp cylinder is placed and the restoration is picked up on the temp cylinder, except this time it bottoms out
at the temp cylinder margin at the correct vertical height due to the added step of recreating the temp cylinder virtually in the implant
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Case 3: Timed Guide and Premade Temp Direct To Implant, or TiBase, or

Custom Abutment.
This patient is also another tooth #8 case. She lost tooth #8 in an accident. She fell, avulsed the tooth, fractured the facial cortical plate
and arrived to my o ce with tooth in hand. I did guided bone regeneration and now the patient is ready for an implant. She has an event
coming up and does not want to go with the removable appliance that was made in the anterior. For this case I used Planmeca Romexis to
plan using the option to attach a scan body to the implant plan and then export that into a design so ware for restoration fabrication .
Step 1
A high quality intraoral scan is made and tooth number 8 is digitally waxed and merged with the CBCT.

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Step 2
A virtual scan body is attached to the case using the feature in the Romexis implant planning so ware.
Step 3
A timed surgical guide is designed and fabricated.

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Step 4
Guide is printed and sleeve bonded in.
Step 5
The models are exported from the implant planning so ware, including the scan body . These les are imported into a laboratory
so ware and a prosthetic is designed. From this information, you can design a custom abutment and nal restoration. A
restoration on aTiBase, or a monolithic direct-to- xture restoration. Her you can see in this case I designed a screw-retained
restoration on a TiBase using a Uris implant and TruAbtument TiBase. I also have the option to print this direct to xture.

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These are the three options for the time of surgery: 1) A printed custom healer that can be delivered in case I do not get torque; 2) A
restoration printed monolithic that is designed to be placed direct to xture, and 3) a restoration that sits on a TruAbtument TiBase;.
These crowns are fresh o the printer and still wet with resin. A er cleaning up the restorations, I decided to go with the direct-to-
xture restoration that had the printed hex included. Many printers will struggle with the accuracy of the hex and the screw channel. If
this is the case, the best bet is a TiBase.
Here is the TiBase version. A perfect t on the tibase. Notice the base is hexed. That means the implant must be placed-timed. If you are
concerned you can buy a non-engaging TiBiase with no hex. However, using a timed guide this should be pretty routine. I will keep this
TiBase version as a backup in case the monolithic printed hex fails.

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Here you can see the monolithic restoration being tted on the implant for demonstration purposes. It is important to verify t and
evaluate everything, especially when using new techniques such as this direct-to- xture printed prosthetic.
On the day of surgery the guide is placed and veri ed for t. Here the guide ts perfectly.

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The osteotomy is made through the guide and to depth. Notice the drill has a depth stop drastically lowering the risk of errors during
osteotomy preparation.
The implant is placed through the guide and to depth. Special attention is placed on the timing of the implant where the vertical notch on
the sleeve aligns with the vertical notch on the implant drive.

The restoration is then screwed into place. In this case, a roll gra was utilized to gain keratinized tissue thickness on the facial.
This is the patient 6 months later ready for nal restoration. You can see very little wear and the color and texture is nearly identical to
when the restoration was originally placed.
REFERENCES
1) Magne P, Silva M, Oderich E, Bo L, Enciso R. Damping behavior of implant-supported restorations.Clin. Oral Impl. Res. 00, 2011, 1–6 doi: 10.1111/j.1600-0501.2011.02311.x )

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CHAPTER 7
Occlusal Guards
I love printed occlusal guards. The digital guard

design is in my opinion a more ef icient, and
accurate way to dial in perfect occlusion.
79 | CHAPTER 7: OCCLUSAL GUIDES

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CHAPTER 7: OCCLUSAL GUARDS
Two materials that I like for occlusal guards are Keystone So and E-Guard So . All my occlusal guards come from intraoral scans. I
typically scan in CR at an open vertical dimension using a custom jig.
Here we have a so ball of heated custom tray material that is placed on #8 and 9 and the patient is manipulated into CR using chin point
or bimanual manipulation and then cured. The jaw is then hinged into the polymerized material to verify CR. The jig is placed when
scanning the bilateral bites. From here the les are exported into a digital design so ware and a guard can be custom fabricated.
Alternatively, a design service can be utilized that will design the guard for you and send you the le to print. Neither E-Guard So or
Keystone So are actually “so ”materials. They are hard plastics but have the ability to be so ened in hot water and slightly formed. I do
this sometimes at delivery if the guard is too tight. Typically, for a full arch permissive splint all the teeth touch in centric relation at
maximum interuspation. Then during dynamic movements you have anterior guidance and posterior disclusion. This is the most basic
guard.
Here we can see the digital bite is made open, and the jaws are stable at this centric position due to the custom jig holding the teeth in place
in CR. From here a printed full arch permissive splint is easily designed and fabricated.

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UNICORN
CBCT Mounting Technique

Using a CBCT to make a virtual face bow in CR and mount this on the virtual articulator for digital design is a common technique I do. For this
technique an IOS is made with the same custom CR jig described above, and then a CBCT is made with the CR jig in place. The models are
then all exported and the CBCT is used to virtually mount the models in the articulator and also condylar inclination is measured and entered
into the articulator. Here a full skull Ultra Low Dose CBCT was made on the Planmeca Viso G7. Intraoral scans were merged to the CBCT.
Condylar inclination is measured using a line drawn from porion to orbitale, then a line drawn from the crest of the gleniod fossa to the
articular eminence. The angle of where these lines bisect is the condylar inclination. From here this information is exported into the design
so ware. The virtual models are then mounted using Bergstrom’s point which is 10 mm anterior to Porion and 7 mm inferior to Frankfort
Horizontal . This point is used to align the skull on the virtual articulators.
In this case, PlanCAD Premium is used as described above and the

models are mounted on the virtual articulator. Also, custom condylar
inclination is entered as measured on the CBCT. In this way the
dynamic articulation is nearly identical to reality and the need for jaw
motion is dramatically diminished. One step beyond this would be to
use 4D jaw motion tracking such as MOD Jaw or Planmeca 4D jaw
motion tracing and then import the XML data into the so ware for
custom patient movements. I nd this to be overkill in most cases
using the CBCT and mounting with custom condylar inclination
leads to perfect design of the guard with no adjustments needed.

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The Copy Guard

Some patients have existing guards that they love and have worn for years but they are starting to crack and stain. One technique is to scan
the guard and then print and exact duplicate. This is achievable with most intraoral scanners and some patience. Use titanium dioxide
spray to opaque the guard for scanning. This patient presented to me with a bag full of new guards made at other o ces. He had one 5
year old guard he loved and wore every single night. He complained the other guards did not feel right and he asked me if I would make him
a new one. Rather than start over and attempt to make a new appliance for him, I simply scanned his old one . A er scanning the guard I
also scanned the lower arch, and then placed the guard in the mouth and then scanned the bite.By doing this I have the ability to edit the
guard virtually if needed and have the virtual bite information.
Using this information I printed a new guard that was an exact copy of
his old guard with the same t and same wear facets. He was so happy
I was able to do this for him. The supports were removed , the guard
was cleaned in alcohol, cured then polished.
More sophisticated guards can be fabricated including dual arch

guards. Also sleep appliances can be fabricated and printed using this
material but I actually nd Flexera Base the best material for sleep
appliances because of the extreme toughness it has. It is outside the
scope of this little eBook to venture into these more sophisticated
appliances but know that with 3D printing you are only limited by
your imagination.

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CHAPTER 8
Quick Reference
This chapter is a quick guide to many of the
concepts mentioned in the book.
Finishing of Flexcera Smile:

1. Hand Polish
2. Stain and glaze
3. Flexcera glaze coat
1. Hand Polish
To hand polish Flexcera Smile you must cure Flexcera in Otto ash appropriately to hand polish (3000 ashes, ip and another 3000
ashes). Then use these in order:
• Komet 9845C
• Komet 9845M
• Komet 9489M
• Komet 9489F
• If you have a lathe, polish the teeth with a clean polish rag wheel with nothing on it using a light touch. This will nalize the high shine.
• A er polish cure for another 1000 - 1800. ashes
83 | CHAPTER 8: QUICK REFERENCE

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CHAPTER 8: QUICK REFERENCE
T H I S R E P R E S E N T S T H E M O D C H E AT C O D E F O R C O L O R I N G A N Y T O O T H . COPYRIGHT © 2022 THE MOD INSTITUTE
2. Stains & Glaze

Do not Cure Flexcera in Otto ash before characterization this way.
I recommend using IPS Empress Direct resin stains cut with Voco Easy Glaze. Never apply the IPS Empress Direct to the Flexcera in full
thickness. Always try to cut it with the glaze. A small drop of IPS Empress Direct stain to a 5x bigger drop of glaze provides the ideal
consistency. The glaze will evaporate quick so do not remake the mixture, make it fresh and apply immediately. Custom colors can be made
by mixing colors using the guide above. For example, halo cream can be made by mixing 1 part brown and 3 parts white. Alternatively the
opaque color that comes with the IPS Empress Direct kit makes a great halo. These are light cured, a er curing each layer to get a nice shine
paint a thin coat of Flexcera on top and cure with the Ivoclar Vivadent Powercure hand held light. (You must have a hand held curing light
with a 385nm bulb). A er cured with the hand held light you now must put the teeth in the Otto ash. To hand polish Flexcera Smile Ultra +
use in order . You must cure Flexcera in Otto ash appropriately to hand polish (3000 ashes, ip and another 3000 ashes)
3. Flexcera Overglaze Coat

Do not cure Flexcera in Otto ash before characterization this way.
One of the easiest ways to create a shine on Flexcera is to coat it with a thin layer of uncured Flexcera Smile Ultra +, using the same color
used to make the print. Then cure the thin coat with the hand held cure unit like the Ivoclar Vivadent Powercure light that contains the 385
nm bulb. A er this place in the Otto ash for 3000 ashes , then ip over and cure 3000 ashes again.

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Finishing of Flexcera Base:

1. Hand Polish
2. Stains
1. Hand Polish
To hand polish Flexcera Base you must cure Flexcera in Otto ash appropriately to hand polish (3000 ashes, LET COOL , ip and
another 3000 ashes) . The extra step of letting the material cool is because Flexcera Base is sensitive to high temperature and becomes
like a thermoplastic. The best way to polish base a er curing:
• Pumice using a lathe and light pressure
• Follow up with a ne rag wheel with nothing on it with a light touch to create a high shine.
• Finalize with an additional cure of the material in the Otto ash for 1000-1800 ashes
2. Stains
To stain Flexcera Base you must not precure Flexcera in Otto ash.
My favorite base color to print is Original Pink and Medium Pink. Sometimes I mix them together to get the desired color. Because we have
a pink material to begin with characterization is minimum and optional.
1. Add Dark Red Taub # 10 to the deep areas

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2. Add Bright Red Taub #13 to the mucosa area
3. Add Minute Stain White to the attached tissue and prominent areas.
4. Coat the entire area with a thin coat of Flexcera Base using a brush and cure with a hand held light, then 3000 ashes in Otto ash, let
cool, and ip over and 3000 more ashes.

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Characterizing a Monolithic Flexcera Denture to Have Pink

If printing a monolithic tooth colored denture a lot more characterization must be done to achieve an esthetic outcome.
To stain a monolithic Flexcera Base denture you must not precure Flexcera in Otto ash.
1. Paint a base coat of Taub # 4 over the entire so tissue area. One way to do this fast is using an airbrush, although, a regular brush
works just ne. You have to move fast to avoid streaks as the material evaporates very quick. Also, do not dispense this material on a
glass slab as it will evaporate. Rather , dip the brush directly into the jar. This color is a bubble gum pink color.
2. Add Taub Dark Red #10 to the deep areas

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3. Add Bright Red Taub #13 to the mucosa area
4. Add Taub Light Pink top coat # 1 to blend colors
5. Coat the entire surface with Flexcera Base. Cure with the hand held Light such as the Powercure and then place in Otto ash
3000 ashes and ip and do another 3000 ashes. This Flexcera top coat protects all the Taub stains.

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Bonding Flexcera Smile to Base

1. Make sure the base and the teeth have not been procured in the Otto ash
2. Make sure the teeth and the base have been properly washed and dried. (5 minute wash in 99% alcohol and make sure they are dry)
3. Paint liquid Flexcera Smile or Flexcera Base into the tooth wells of the printed base material. Coat the entire tooth pocket with the material.
4. Press the Flexcera Smile teeth into the wells and hold down tight and wipe excess resin away using a brush.
5. Cure with a hand held light with a 385nm bulb such as the Power Cure for 10 seconds on each tooth.
6. Finish the cure in Otto ash 3000 ashes, let cool. Then ip over and do another 3000 ashes.
7. Polish and do another 1000 ashes
Please note: All characterizations are done before bonding of the teeth, Then the teeth are bonded in and everything is cured together so
you do not repeat unnecessary cure times. If bonding milled teeth to Flexcera Base or carded teeth, you must micro abrade the teeth using
aluminum oxide particles.
Bonding Flexcera Smile to Base

1. Micro abrade the Flexcera
2. Apply an MDP containing Adhesive such as Adhese Universal, blow thin and do not cure.
3. On Natural Teeth: selective etch, Adhese Universal, blow thin and cure. (Note other resin cement systems can be used such as
Panavia V5)
4. Load restoration with Variolink Esthetic , seat, clean and cure.

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Recommended Reading
1. Pham DM, Gonzalez MD, Ontiveros JC, Kasper FK, Frey GN, Belles DM. Wear Resistance of 3D Printed and Prefabricated
Denture Teeth Opposing Zirconia. J Prosthodont. 2021 Dec;30(9):804-810. doi: 10.1111/jopr.13339. Epub 2021 Feb 11.
PMID: 33486808.
2. Lee EH, Ahn JS, Lim YJ, Kwon HB, Kim MJ. E ect of post-curing time on the color stability and related properties of a tooth-
colored 3D-printed resin material. J Mech Behav Biomed Mater. 2022 Feb;126:104993. doi: 10.1016/j.jmbbm.2021.104993.
Epub 2021 Nov 24. PMID: 34871954.
3. Anadioti E, Musharbash L, Blatz MB, Papavasiliou G, Kamposiora P. 3D printed complete removable dental prostheses: a
narrative review. BMC Oral Health. 2020 Nov 27;20(1):343. doi: 10.1186/s12903-020-01328-8. PMID: 33246466;
PMCID: PMC7694312.
4. Li P, Krämer-Fernandez P, Klink A, Xu Y, Spintzyk S. Repairability of a 3D printed denture base polymer: E ects of surface
treatment and arti cial aging on the shear bond strength. J Mech Behav Biomed Mater. 2021 Feb;114:104227. doi: 10.1016/
j.jmbbm.2020.104227. Epub 2020 Nov 27. PMID: 33279875.
5. Scherer MD. Expedited Digital-Analog Hybrid Method To Fabricate A 3D Printed Implant Overdenture. J Prosthodont.
2021 Sep 6. doi: 10.1111/jopr.13424. Epub ahead of print. PMID: 34486196.
6. Renne W, Revell G, Teich S. The digital denture replication method (DRM): a simpli ed method to fabricate a complete
removable prosthesis. Quintessence Int. 2020;51(10):838-843. doi: 10.3290/j.qi.a45267. PMID: 32954391
7. Neshandar Asli H, Rahimabadi S, Babaee Hemmati Y, Falahchai M. E ect of di erent surface treatments on surface
roughness and exural strength of repaired 3D-printed denture base: An in vitro study. J Prosthet Dent. 2021
Oct;126(4):595.e1-595.e8. doi: 10.1016/j.prosdent.2021.07.005. Epub 2021 Aug 6. PMID: 34366117.
8. Heintze SD, et al. Laboratory mechanical parameters of composite resins and their relation to fracturs and wear in clinical
trials—A systematic review. Dent Mater (2016))
9. Magne P, Paranhos MP, Burnett LH Jr, Magne M, Belser UC. “Fatigue resistance and failure mode of novel-design anterior
single-tooth implant restorations: in uence of material selection for type III veneers bonded to zirconia abutments.” Clin
Oral Impl Res. 2011 Feb; 22 (2): 195-200. 157

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Designed with
Monday in Mind
Courses at The MOD Institute carefully emphasize practical hands-on learning and guidance
from world-class instructors that combines modern technology with evidence-backed
work lows and practices. It's the antithesis of an 8 hour lecture. From intraoral scanning to 3D
printing and digital smile design, you'll enjoy a practical approach and experience exceptional
technology, materials and equipment applied in practical, real-world scenarios.
The MOD Institute
320 Broad St. #210
Charleston, SC 29401
www.themodinstitute.com
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D R .

Into the Future

We need to unite behind technology and push the profession

Dr. Wally Renne

This guide is dedicated to my friend and mentor Dr. B ob Holmes.

Gone but not forgotten.

Marketing teams have built a story around lexural

Flexural Strength Fracture Toughness

6 | CHAPTER 1: THE NUMBERS

CHAPTER 1: THE NUMBERS

J LUBAUER, R BELLI, H PETERLIK ET AL., GRASPING THE LITHIUM HYPE:

7 | CHAPTER 1: THE NUMBERS

CUSTOMER WEAR MACHINE F S E AT I T E B A L L W E A R I N G AG A I N S T S P E C I M E N

10 | CHAPTER 2: MONOLITHIC DENTURES

11 | CHAPTER 2: MONOLITHIC DENTURES

Monolithic Dentures, Tryin Dentures, or the Easy

Step 1: Copy Relined Denture

AN EXAMPLE OF A COPY DENTURE SCAN FORM AN IOS

12 | CHAPTER 2: MONOLITHIC DENTURES

13 | CHAPTER 2: MONOLITHIC DENTURES

14 | CHAPTER 2: MONOLITHIC DENTURES

Step 2: Clean Your Print

15 | CHAPTER 2: MONOLITHIC DENTURES

Step 3: First Coat of Taub No. 4 Bubble Gum Pink

16 | CHAPTER 2: MONOLITHIC DENTURES

Step 4: Accentuate the Deep Areas With Dark Pink.

17 | CHAPTER 2: MONOLITHIC DENTURES

Step 6: Tone Down the Color With No. 1

18 | CHAPTER 2: MONOLITHIC DENTURES

19 | CHAPTER 2: MONOLITHIC DENTURES

CHAPTER 2: MONOLITHIC DENTURES

Step 7: Protect That Art

Step 8: Cure in Otto ash

Step 9: Get the Pink O the Teeth

You now have 4 options to get the tooth looking good.

20 | CHAPTER 2: MONOLITHIC DENTURES

Step 10: What Do We Do With the Teeth?

21 | CHAPTER 2: MONOLITHIC DENTURES

CHAPTER 2: MONOLITHIC DENTURES

T H I S R E P R E S E N T S T H E M O D C H E AT C O D E F O R C O L O R I N G A N Y T O O T H . COPYRIGHT © 2022 THE MOD INSTITUTE

Teeth Step 1: Brown

22 | CHAPTER 2: MONOLITHIC DENTURES

Teeth Step 2: Violet or Gray

Teeth Step 3: Blue

23 | CHAPTER 2: MONOLITHIC DENTURES

Teeth Step 4: Opaque White (Called Opaque)

Teeth Step 5: Clear Coat or Flexcera Top Coat

Teeth Step 6: Final Cure

24 | CHAPTER 2: MONOLITHIC DENTURES

CHAPTER 2: MONOLITHIC DENTURES

Bonus Content: Airbrushed Denture

THE BEAUTY OF AN AIRBRUSHED DENTURE

The items you will need:

A) IWATA air brush ne control

Practice Using Less Expensive Inks on Paper First

25 | CHAPTER 2: MONOLITHIC DENTURES

CHAPTER 2: MONOLITHIC DENTURES

Another unicorn technique where a monolithic denture or other

26 | CHAPTER 2: MONOLITHIC DENTURES

Split File Denture

PHOTO BY DR. ANTHONY MENNITO

This Beautiful Denture Is all Flexcera.

27 | CHAPTER 3: SPLIT FILE DENTURE