RESTORATIVE DENTISTRY
The 3D-printed prototype: a new protocol for the
evaluation and potential adaptation of monolithic
all-ceramic restorations before finalization
Juan Legaz, DDS/Duygu Karasan, PhD, DDS/Vincent Fehmer, MDT/Irena Sailer, Prof Dr med dent
The prototyping protocol to evaluate and make the potential
adjustments prior to finalization of the monolithic restorations
was described by two clinical situations. In the first case report,
following the digital impressions using an intraoral scanner
(3Shape Trios, 3Shape) for an implant-supported four-unit fixed
dental prosthesis, a digital design (3Shape Dental System,
3Shape) was performed and a prototype using subtractive CAM
(milling) (PMMA, Telio CAD, Ivoclar Vivadent) was fabricated.
The second case highlights the 3D-printed prototyping (addi-
tive CAM) (Sheraprint Model Plus UV, Shera) following digital
Key words: CAD/CAM, ceramics, diagnostic procedure, digital workflow, prosthodontics
To achieve long-term success in restorative dentistry, compre-
hensive diagnostics and treatment planning followed by effi-
cient communication among the dental practitioner, dental
technician, and patient are crucial.1-3 The evolution of dentistry
in recent years has provided tools and materials to enhance the
predictability and precision of the restorations by digital
design,4 allowing a wider range of manufacturing methods of
the selected reconstructions and the associated materials.5,6
Based on systematic reviews, the estimated 5-year survival
rates of multiple-unit fixed dental prostheses (FDPs) are
reported as 94.4% for metal-ceramic and 90.4% for all-ceramic
densely sintered zirconia when tooth-supported,7 and as 98.7%
for metal-ceramic and 93.0% for zirconia ceramic/monolithic
zirconia when implant-supported.8 Of the 5-year cumulative
complication rates of zirconia ceramic, the most common tech-
nical complication was reported as fracture or chipping of the
veneering material, with a rate of 50% (95% confidence interval
[CI] 29.1% to 72.1%).8
538 QUINTESSENCE INTERNATIONAL | volume 51 • number 7 • July / August 2020
impressions using an intraoral scanner and digital design in a
patient requiring two opposing open-end three-unit fixed den-
tal prostheses. By means of prototyping, the esthetic, fitting,
and functional properties could be tested and the adjustments
were completed on the prototypes. It is suggested that proto-
typing is an efficient tool that minimizes the clinical adjustment
need for the final restoration while improving the communica-
tion between the dental practitioner and the technician.
(Quintessence Int 2020;51:538–544; doi: 10.3290/j.qi.a44635)
There is a fundamental difference between the veneered
and monolithic restorations when it comes to their adjustabil-
ity.9 Monolithic high-strength ceramic restorations demon-
strate difficulty in clinical adjustment, which can lead to a
potential loss in initial strength following the adjustments.10 It
was reported that micro-roughness, as a result of grinding on
the surface of monolithic restorative materials, leads to crack
propagation originating from those areas.11,12 Thereby, this can
jeopardize the mechanical superiority of those materials rec-
ommended for use in high stress-bearing areas.11,12 Therefore, it
is important to minimize the need for chairside adjustments of
monolithic zirconia restorations. By means of the technologic
developments and increased variety of material alternatives,
fabricating prototypes by either additive or subtractive meth-
ods became viable. The esthetics, fit, and functional properties
can be tested by these prototypes, prior to the fabrication of
the definitive prostheses. Accordingly, the necessity of clinical
adjustment may be minimized.

a b c d
Figs 1a to 1g Digital workflow with subtractive prototyping by means of a provisional restoration. (a) Baseline situation, (b) with PEEK abut-
ments for an intraoral scanning. (c) Provisional implant-supported restoration after 4 months, and (d) after retrieving the provisional restoration,
showing the final shape of the gingival architecture. (f) Monolithic zirconia biscuit try-in (identically to the subtractive CAM prototype). (g) Final
restoration in place after 1 month of clinical service.
In the following two clinical scenarios, monolithic zirconia
reconstructions have been completed following two different
CAM prototyping methods, subtractive and additive, with the
aim to minimize necessary clinical adjustments and, thereby, to
avoid weakening the reconstructive material.
Clinical reports
Case 1
A 55-year-old man attended the University of Geneva for the
rehabilitation with fixed implant-supported FDPs in the second
quadrant. An intraoral optical impression was performed
(TRIOS 3 Wireless, 3Shape) and the acquired data were sent
online to the dental laboratory via the respective communica-
tion account (3Shape). In order to achieve an optimal result for
the final reconstruction, a fixed implant-supported four-unit
long-term provisional FDP was designed using the specialized
software (3shape Dental Designer 2018, 3Shape) and manufac-
tured out of polymethyl-methacrylate resin (PMMA, Telio CAD,
Ivoclar Vivadent). This long-term provisional was bonded onto
titanium bonding bases for dental prostheses (Variobase,
Straumann) and inserted for a period of 4 months to test the
functionality, shape, and esthetics of the reconstruction.
In this case, regarding the clinical adaptation, the patient’s
comfort and his ability to clean the reconstruction required
only minor changes. Therefore, the initially digitally designed
QUINTESSENCE INTERNATIONAL | volume 51 • number 7 • July / August 2020
Legaz et al
e f g
file of the provisional restoration was slightly adjusted and cop-
ied as a new CAD project to adapt its parameters, such as min-
imal wall thickness and cement gaps to the requirements of the
chosen reconstructive material. Finally, the full contour mono-
lithic FDP (Lava Esthetic A2, 3M) was milled (Wieland Zenotec,
Ivoclar Vivadent) in a white-stage and sintered to its final den-
sity. For the try-in appointment, the reconstruction was glued
onto the titanium bonding bases using superglue (Super Attak
Zeta, Loctite).
For final delivery of the implant-supported screw-retained
FDP, the restoration access holes were filled with polytetra-
fluoroethylene tape (also known as Teflon tape) and a light cur-
ing temporary restorative material (Telio, Ivoclar Vivadent).
After 1 month in function, the restoration was checked, the
screw access holes were closed with composite resin (Tetric
EvoCeram, Ivoclar Vivadent), and a radiographic control was
performed (Fig 1).
Case 2
A 70-year-old man attended the University of Geneva for the re-
habilitation of the first and fourth quadrants (Fig 2). After a care-
ful analysis of the case, the treatment plan was to restore quad-
rants with all-ceramic tooth and implant-supported monolithic
zirconia FDPs.
As the first step, the existing metal-ceramic tooth-supported
FDP in the first quadrant was removed, and the abutment teeth
539
 RESTORATIVE DENTISTRY
a b
a b c d
were prepared and re-shaped. Subsequently, a direct provisional
with autopolymerizable resin was fabricated (Protemp 4, 3M
Espe). After a period of 4 weeks, an intraoral partial optical impres-
sion was taken (TRIOS 3 Wireless, 3Shape) and the acquired data
were sent to the dental laboratory via the respective communica-
tion account (3Shape).
Thus, following the digital design, prior to the manufactur-
ing of the monolithic frameworks the same CAD data were
used to create printed prototypes made of a 3D printable resin
(Fig 3) (Sheraprint Model Plus UV, Shera Werkstoff-Technologie)
with a digital light processing printer (Rapid Shape, Straumann)
in order to have the possibility to verify all essential parameters
such as marginal adaptation, overall fit, dimensions, contact
points, and most importantly the occlusion intraorally. If neces-
sary, adjustments can be performed clinically, and be trans-
ferred to the laboratory in order to modify the CAD data
accordingly for the restoration manufacturing process (Fig 4).
540 QUINTESSENCE INTERNATIONAL | volume 51 • number 7 • July / August 2020
Figs 2a to 2c (a) Initial situation lateral
view; (b and c) occlusal view showing
some technical complications.
c
Figs 3a to 3d CAD of the final
restorations and printed prototypes
after post-processing.
The key points for how to transfer the modifications into
the software are:
■ Minor modifications on the final design; the desired changes
can be visualized and communicated with the dental techni-
cian before milling the framework.
■ Major corrections on the final design; following the adjust-
ments the 3D-printed prototype placed intraorally should
be re-scanned in order to transfer the new intraoral situa-
tion to the CAD software in which dental technician can
superimpose and modify the CAD design in order to
achieve the final desired volume.
Once the 3D-printed prototypes were validated, and required
minor corrections were made, the initial digital designed files
were slightly adjusted on the specific CAD software (3Shape Den-
tal Designer 2018) before they were milled (Wieland Zenotec) in
a white-stage (Lava Esthetic A3) and sintered to its final density.

Figs 4a to 4c Printed prototype to
check fitting and function (note the oc-
clusal contact points) as a step before
the milling and sintering process of the
monolithic zirconia framework.
a b
Figs 5a to 5c Tooth and implant-
supported three-unit monolithic zirconia
FDPs in place.
a b
For the final steps in the manufacturing procedure and
after high-gloss polishing of the zirconia framework and apply-
ing a layer of glaze, the final restorations were delivered and
inserted intraorally (Fig 5). The prepared teeth were condi-
tioned for being adhesively luted to the monolithic zirconia
FDP. For the implant-supported FDP, the same protocol as
described for the previous case was followed.
Discussion
In this report, similar free-end tooth- and implant-supported
monolithic zirconia reconstructions were provided following a
digital workflow using both additive and subtractive CAM pro-
totypes (Fig 6). If a long-term provisional phase is required, the
use of mechanically more durable provisional material seems to
be important. However, due to time or economic reasons, com-
pleting the definitive treatment without a provisional phase
QUINTESSENCE INTERNATIONAL | volume 51 • number 7 • July / August 2020
Legaz et al
c
c
can be necessary. In these cases, to be able to predict the final
restorative treatment by 3D printing a prototype and use it as a
mock-up, provides a less costly and more efficient approach.
Improvements in digital technologies are providing a stan-
dardized and predictable fabrication process. When it comes to
digital manufacturing, subtractive methods have a longer
background and a wider spectrum of materials.6 The waste of
considerable amounts of material,6 limitations originating from
the milling bur diameter, impossibility of rapid manufacturing,
and requirement of manual finishing due to the roughness cre-
ated by the milling procedure11,12 are the main disadvantages
of this technique. Meanwhile, the use of additive manufactur-
ing (AM) in dentistry is a relatively new technology. Accord-
ingly, the available materials are limited, and in consequence
the spectrum of end products are restricted to occlusal splints,13
surgical guides,14-16 diagnostic models,17,18 mock-ups, and provi-
sional restorations.19 Additive technologies offer some advan-
541
 RESTORATIVE DENTISTRY

Fig 6 Digital workflow protocol for both subtractive and additive prototyping.

tages over subtractive methods; the possibility of rapid manu-
facturing, a lower percentage of wasted raw material,5,20 and a
cost-2 and time-efficient workflow.21 Nevertheless, the initial
investment for a 3D printer and software/hardware, the learn-
ing curve of the dental technician, the need for final fine-tuning
adjustments, post-processing requirements, and some limita-
tions when structures under 0.3 mm, are the major shortcom-
ings of this technology.2
Monolithic restorations have become an interesting treat-
ment option from both mechanical and esthetic aspects by the
development of translucent high-strength ceramics. It may be
assumed that monolithic ceramics exhibit low rates of compli-
cations due to their excellent mechanical properties.8 However,
the clinical adjustment of these high-strength ceramics remains
a risk factor.11
The use of a prototype, milled or printed, especially prior
to the manufacturing of the monolithic restorations may be
beneficial for some aspects. Firstly, the missing or short parts
can be detected during the trial of the prototype and accord-
ingly the definitive restoration design can be modified. Sec-
ondly, it is crucial to minimize the occlusal grinding com-
monly needed for free-end restorations. Executing the
adjustment on the 3D-printed prototype and transferring the
ideal occlusal geometry by scanning, is efficient to minimize
the adjustment need of the definitive restoration material
intraorally, which could lead to a potential loss in initial

542 QUINTESSENCE INTERNATIONAL | volume 51 • number 7 • July / August 2020

 Legaz et al

strength and the possibility of crack propagation originating Conclusion

from those areas,12 greater biofilm accumulation,22 and less
favorable wear behavior of the opposing natural dentition if
they are not high gloss polished.23-25 Lastly the outer shape
and esthetic result of the restoration can be checked before
the final restoration is milled and the design can be altered
accordingly.
The use of a prototype made by milling or 3D-printing proced-
ures improves the communication among the dental practi-
tioner, technician, and patient, and may lead to greater effi-
ciency and predictability of the treatment outcomes for
monolithic all-ceramic reconstructions.

Declaration
The authors declare there are no conflicts of interest with re-
gard to this manuscript.

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QUINTESSENCE INTERNATIONAL | volume 51 • number 7 • July / August 2020 543

 RESTORATIVE DENTISTRY

Juan Legaz Duygu Karasan Research Assistant, Division of Fixed Prosth-

odontics and Biomaterials, Center of Dental Medicine, University of
Geneva, Geneva, Switzerland

Vincent Fehmer Master Dental Technician, Division of Fixed

Prosthodontics and Biomaterials, Center of Dental Medicine, Uni-
versity of Geneva, Geneva, Switzerland

Juan Legaz Assistant, Division of Fixed Prosthodontics and Bio- Irena Sailer Professor and Chair, Division of Fixed Prosthod-
materials, Center of Dental Medicine, University of Geneva, Geneva, ontics and Biomaterials, Center of Dental Medicine, University of
Switzerland Geneva, Geneva, Switzerland

Correspondence: Juan Legaz Barrionuevo, Méd. Dent. Assistant, Center of Dental Medicine, Division of Fixed Prosthodontics and Bio-
materials, University Of Geneva, 1, Rue Michel-Servet, CH - 1211 Genève 4, Switzerland. Email: Juan.Legaz@unige.ch

544 QUINTESSENCE INTERNATIONAL | volume 51 • number 7 • July / August 2020

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