DENTAL TECHNIQUE

Silicone key device for maxilla orientation and occlusal plane

recording in a digital workflow
Lucas Q. Caponi, DDS, MSc,a Yazan Taha, DDS,b Nicolas Gutierrez, DDS, MSc,c and
Miguel Roig C, MD, DMD, PhDd

Digital techniques and pro- ABSTRACT

cedures are replacing analog This article describes a technique for recording the maxilla’s orientation in esthetically driven oral
ones in an unprecedented rehabilitation and transferring its position by using computer-aided design and computer-aided
manner,1,2 with advantages manufacturing (CAD-CAM) technology. The protocol uses a Fox plane and a bubble level to orient
that include time efficiency, an addition silicone key of the maxilla parallel to the occlusal reference plane. The silicone
reliability, repeatability, and reference key was scanned, superimposed over the maxilla intraoral standard tessellation
overall increased treatment language (STL) file, and adequately oriented in a CAD software program. (J Prosthet Dent
3 2021;-:---)
quality. Many dental tech-
niques and procedures have
become digitalized, although digital and analog maxillary computed tomography (CBCT) files.4 Virtual reality may also
cast mounting and occlusal plane orientation remains be used to replace the mechanical facebow in order to
controversial.4 Mounting the casts accurately on an simulate real jaw movements.9 The recently introduced
articulator is a prerequisite for a successful complete virtual mounting protocols have highlighted the importance
mouth rehabilitation.5 of this technique in modern dentistry.8,9
Occlusal plane orientation is one of the factors that helps The aim of this manuscript was to present a
establish an occlusion compatible with the function and straightforward and reliable way of recording the maxil-
parafunction of the stomatognathic system.6 The recording lary cast position and orienting the occlusal reference
and transfer of the maxillary occlusal plane parallel to the plane by transferring standard tessellation language
horizon in the frontal view and parallel to the Camper plane (STL) files to a computer-aided design (CAD) software
in the sagittal view is key to the esthetic and functional program in a completely digital approach.
outcome of complete mouth rehabilitations.7 Correct
orientation of the maxillary cast in 3-dimensional space can TECHNIQUE
also help diagnose and avoid esthetic problems such as
This dental technique was demonstrated in a patient
canting the anterior segment.6 Following recent advances in
requiring a complete mouth rehabilitation.
digital dentistry, the cast mounting procedure has been
digitalized through a wide range of techniques to address 1. Scan the maxillary (STL 1) and mandibular denti-
the shortcomings of the traditional facebow and to integrate tion (STL 2) intraorally (TRIOS 3; 3Shape A/S) to
the orientation of the maxillary cast into the digital work- obtain STL data (Fig. 1A, 1B).
flow.8 The maxillary dentition can be mounted accurately 2. Scan the maxillomandibular relationship record
using a technique combining intraoral scans with cone beam (STL 3) in maximum intercuspation position or

a
Graduate, Department of Restorative Dentistry, School of Dentistry, International University of Catalunya, Barcelona, Spain.
b
Resident, Department of Restorative Dentistry, School of Dentistry, International University of Catalunya, Barcelona, Spain.
c
Assistant Professor, Department of Restorative Dentistry, School of Dentistry, International University of Catalunya, Barcelona, Spain.
d
Chairman and Professor, Department of Restorative Dentistry, School of Dentistry, International University of Catalunya, Barcelona, Spain.

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Figure 1. Digital preview of diagnostic intraoral scans with toggled STL views. A, Maxillary STL occlusal view (STL 1). B, Mandibular STL occlusal view
(STL 2). C, Maxillomandibular relationship record at proposed intermaxillary treatment position. STL, standard tessellation language.

Figure 2. Maxillary position recording. A, Orient Fox plane by means of bubble level and adjust until plate horizontal to frontal view and parallel to
Camper plane on profile view. B, Mark 2 perpendicular lines corresponding to facial midline and horizon and then perform 2 incisions. C, Maxillary arch
scan with PVS index in place (STL 4). PVS, polyvinyl siloxane; STL, standard tessellation language.

Figure 3. CAD step 1: Maxillary orientation. A, File matching of maxillary scan (STL1) and intraoral scan of PVS index reference (STL4). B, File matching of
maxillary scan (STL1), intraoral scan of silicone reference (STL4), and plane generated parallel to bottom surface of PVS index (GVM 1). C, Maxillary right
central incisor design based on clinical references and plane generated parallel to GVM 1 touching incisal edge of element (GVM 2). CAD, computer-
aided design; GVM, generic visualization mesh; PVS, polyvinyl siloxane; STL, standard tessellation language.

centric relation depending on the required treat-
ment position (Fig. 1C).
3. Place a polyvinyl siloxane (PVS) index (Hydrorise
Putty; Zhermack SpA) over a Fox plane and posi-
tion it parallel to the horizon in a frontal view and
parallel to the Camper line in a profile view. Orient
the plate properly in the frontal view by using a
bubble-level device (Hot Shoe Level; ChromLives-
Direct) placed over the Fox plane (Fig. 2A).
4. Once the PVS index has polymerized, transfer a
vertical line corresponding to the facial midline and
a horizontal line parallel to the Fox plane over the
surface of the PVS index. Mark these 2 lines first
and use them as a guide to make 2 incisions with a
scalpel over the PVS index (Fig. 2B). If necessary,
trim the PVS index to leave the second sextant
clearly exposed to allow the intraoral scanner to
capture the teeth and PVS index properly.
5. Duplicate the scan of the maxillary dentition (STL
1) and intraorally scan (STL 4) the maxillary arch
with the PVS index in place starting from the
exposed area of the teeth. This method ensures
that STL 1 and 4 have the same XYZ spatial co-
ordinates (Fig. 2C).
6. Clinically verify and measure the incisal edge po-
sition based on esthetic and functional parameters.

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Figure 4. CAD step 2: Virtual articulator. Orientation of generated occlusal plane of reference (GVM2) coincident to Bonwill triangle A, Frontal
inclination to view GVM2 and Bowell triangle coincident. B, CAD working frontal view perpendicular to occlusal plane. CAD, computer-aided design;
GVM, generic visualization mesh.

Figure 5. CAD step 3: Complete mouth diagnostic waxing. A, CAD frontal view perpendicular to occlusal plane. B, Frontal view of file matching
complete mouth diagnostic waxing and PVS index reference scan (STL 4). CAD, computer-aided design; PVS, polyvinyl siloxane; STL, standard
tessellation language.

Figure 6. CAD step 3: Complete mouth diagnostic waxing. A, Right lateral view. B, Frontal view. C, Left lateral view.

7. Import the intraoral STL files into CAD software
(exocad DentalCAD; exocad GmbH). Add STL 4 as
“generic visualization mesh” (GVM) (a name given
to a specific type of mesh that can be added in
exocad expert mode platform that allows the user
to view an imaginary plane that can be oriented in
3 different axes). Match STL 1 and STL 4 and rotate
until the vertical and horizontal lines of STL4
coincide with the background grid lines (Fig. 3A).
8. Create a plane (GVM 1) (a name given to a specific
type of a mesh that can be added in exocad expert
mode platform that allows the user to view an

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Figure 7. Trial restorations, intraoral view. A, Maxillary occlusal view. B, Mandibular occlusal view. C, Frontal view in centric occlusion.

Figure 8. Extraoral images of treatment simulation. A, Frontal plane parallelism assessment by means of Fox plane and bubble level, frontal view. B,
Maximum smile, frontal view. C, Camper plane parallelism assessment by means of Fox plane, left profile view.

imaginary plane that can be oriented in 3 different DISCUSSION

axes) and orient it parallel to the lower surface of
the PVS index reference plane (Fig. 3B).
9. Create a second plane (GVM 2) parallel to the
previous one and raise it until it touches the incisal
edge of the planned maxillary central incisor. This
plane represents the occlusal reference for the
functional and esthetic rehabilitation (Fig. 3C).
10. Run the articulator module in the expert mode of
the CAD software program (exocad DentalCAD;
exocad GmbH) and situate the proposed occlusal
plane (GVM 2) correspondent with the Bonwill
triangle in the exocad articulator by default. Make
STL 4 visible to better position the cast in the
virtual articulator (Fig. 4A, 4B).
11. Design complete mouth virtual diagnostic waxing
by using GVM 2 (a name given to a specific type of
mesh that can be added in Exocad expert mode
platform that allows the user to view an imaginary
plane that can be oriented in 3 different axes) as a
reference plane (Figs. 5, 6). 3-dimensionally print
the maxillary and mandibular models (XFAB 2000;
DWS/Resin: Invicta 915; DWS) and fabricate a new
PVS matrix (Hydrorise Putty; Zhermack SpA).
12. Make a maxillary and mandibular treatment
simulation with interim bisacrylic resin material
(Protemp 4; 3M) and evaluate the esthetics and
function (Figs. 7, 8).
Digital dentistry has paved the way for a more efficient
dental workflow. The many tools that have been inte-
grated into digital technology have made dental pro-
cedures more accurate and simpler.10 The use of maxil-
lary orientation and occlusal plane records offers a key
step to ensuring a functional and esthetic outcome in
full-mouth rehabilitations.11
A wide range of techniques have been adopted to
position the maxillary in a 3-dimensional space and
to record the occlusal plane.5,12 One way of
orienting the maxillary model is by superimposing the
CBCT-generated Digital Imaging and Communications
in Medicine (DICOM) file over the maxillary intraoral
scan STL file; another technique consists of using virtual
reality to accurately mount the maxilla.6,9 However, one
of the most frequent techniques entails using a CAD
software platform to superimpose the extraoral frontal
view image JPEG file (at maximum smile and with cheek
retractors) over the intraoral upper maxilla scan STL
file.13 This technique poses the challenge of photo-
graphing the patient in a completely natural head posi-
tion. The natural head position is a standardized,
reproducible position, with the head in an upright
posture and eyes focused on a point in the distance at the
eye level such that the visual axis is horizontal.14,15 To
align 2 objects, the posterior and anterior points should

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be superimposed; because of the nature of frontally
captured photographs, posterior teeth and distal surfaces
are not represented adequately; therefore, the resultant
alignment will not be accurately performed in the CAD
phase. Many of the drawbacks mentioned in the latter
technique can be overcome by using the present
technique because it allows the patient’s head position to
be accurately adjusted parallel to the horizon by using a
Fox plane and a bubble level. This technique also omits
the superimposition step in the CAD phase because the
PVS index (representing the horizon frontally and
Camper plane sagittally) is scanned on a copy of the
original intraoral scan of the maxilla and has the same X,
Y, Z orientation in the CAD software program.
SUMMARY
The maxillary orientation silicone key provides a method
of virtually mounting the maxillary scan and transferring
both the functional and the esthetic occlusal reference
plane in a digital workflow. As digital technologies
continue to advance, adjustments to the technique will
be required.
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Corresponding author:
Dr Yazan Taha
Department of Restorative Dentistry
International University of Catalunya
Facultad de Odontología
Carrer Josep Trueta
s/n (Hospital Universitari General de Catalunya)
Sant Cugat del Vallès 08195
SPAIN
Email: yazantaha@uic.es
Copyright © 2021 by the Editorial Council for The Journal of Prosthetic Dentistry.
https://doi.org/10.1016/j.prosdent.2021.04.010
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