DENTAL TECHNIQUE

Guided tooth preparation device fabricated with a complete

digital workflow: A dental technique
Yazan Taha, DDS,a Fady Raslan, DDS, CAGS,b Akram Ali, DDS, PhD,c and Miguel Roig, MD, DMD, PhDd

Digital technology has revolu- ABSTRACT

tionized restorative dentistry
Guided tooth preparations allow clinicians to provide fixed dental prostheses for dentate patients in
with the introduction of an efficient manner. One approach uses a digital preparation device technique where the
computer-aided design preparation of a tooth needing a crown is guided by a device. Compared with conventional
and computer-aided techniques, this method allows for accurate abutment preparation more efficiently and with
manufacturing (CAD-CAM) improved quality. By controlling tooth preparation, this method preserves natural tooth structure
protocols.1 Digital workflows and provides adequate clearance for the restorative material. To illustrate this technique, an
have created a more struc- adhesive minimally invasive fixed complete-mouth rehabilitation was provided by using a 3D-
printed digital preparation device. (J Prosthet Dent 2021;125:221.e1-e4)
tured, efficient, and cost-
2
effective clinical process. Modern digital dentistry con- practitioners or young clinicians compared with pros-
sists of 4 basic phases: data acquisition, data preparation thodontists has been reported,10 compromising the
and processing, data production, and clinical application restorations or the supporting teeth.11 As the conser-
3
of the produced data. Optical scans for the digitization vation of tooth structure is stressed in contemporary
of the initial clinical situation are converted into a virtual fixed prosthodontics, it is essential to control and guide
digital file in standard tessellation language (STL) each clinical step to achieve a minimally invasive
format.4 This STL file is then imported into a CAD outcome.11,12
software program with which it is analyzed and used for Minimally invasive treatment options have become
applications such as virtual diagnostic waxing and increasingly feasible in prosthetic dentistry because of
restoration design.5 Finally, the designs are exported to a the introduction of adhesive techniques in combination
milling machine or 3D printer for the definitive restora- with esthetic restorative materials13 that can be used
6
tions to be fabricated with CAM technology. Deter- for monolithic restoration.14 Among these materials are
mining how much tooth structure should be removed composite resins, silica-based ceramics, infiltration ce-
remains one of the biggest problems during tooth ramics, and oxide high-performance ceramics.14 Reli-
7
preparation. able resin bonding has enabled conservative
The tooth preparation is a critical step that must be preparations15 that reduce the risk of pulpal involve-
properly executed to ensure the longevity of the ment, minimize damage to the abutment, and optimize
restoration and the underlying abutment tooth.8 The esthetics.16
success rate of a dental restoration is influenced by the Techniques to measure depths and distances of tooth
selection of restorative material, material thickness, preparation have been described, but improvements can
occlusal scheme, occlusal load, esthetics, and abutment be made by using digital technology.17 The authors are
9
tooth geometry. A higher rate of undersizing or unaware of a previous report of a digital 3D-guided
underestimating linear measurements by general preparation device.

a
Resident, Department of Restorative Dentistry, School of Dentistry, International University of Catalunya, Barcelona, Spain.
b
Assistant Professor, Department of Restorative Dentistry, School of Dentistry, International University of Catalunya, Barcelona, Spain.
c
Associate 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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221.e2 Volume 125 Issue 2

Figure 1. Digital preview of diagnostic intraoral scans with toggled STL views. A, Maxillary STL occlusal view. B, Mandibular STL occlusal view. C, Aligned
STLs treatment position at proposed intermaxillary treatment position. STL, standard tessellation language.

Figure 2. Virtual diagnostic waxing of imported STL files in CAD software program (exocad DentalCAD; exocad GmbH) at established vertical
dimension. A, Complete waxing of maxillary dentition. B, Deselected anterior virtual diagnostic waxing. C, Maxillary and mandibular dentition in
occlusion. CAD, computer-aided design; STL, standard tessellation language.

TECHNIQUE Virtually subtract 5 square-shaped attachments on

1. Perform scans of the maxillary (STL 1) and
mandibular dentition (STL 2) to obtain STL data by
using an intraoral scanner (TRIOS 3; 3Shape A/S)
(Fig. 1A).
2. Make the intermaxillary registration, either in
maximum intercuspation position (MIP) or in
centric relation (CR), depending on the type of
treatment (Fig. 1C).
3. Import the STL files into the CAD software pro-
gram (exocad DentalCAD; exocad GmbH) to
perform diagnostic virtual waxing (STL 3) at the
established intermaxillary position (Fig. 2A).
4. Create a new STL file by deselecting the virtual
diagnostic waxing of maxillary or mandibular ante-
rior or posterior teeth. Teeth to be deselected are the
teeth needed to remain as the initial situation to be
used intraorally for the validation of the accurate
seating of the device (STL 4) (Fig. 2B).
5. Create 2 separate new orders for maxillary and
mandibular STL file 4 in the splint module. Design
a 1.5-mm-thick splint covering the anterior and
posterior dentition and calibrate the offset distance
(the maximum distance to compensate for the
blockage of an undercut) to 0.05 mm (Fig. 3A).
the maxillary central incisors, right and left maxil-
lary canines, and maxillary second molars (teeth
left in initial situation to be used for the validation
of complete seating of the device intraorally).
Design 1.5-mm round-shaped calibrated vent
holes in the buccal surface, lingual surface, central
fossa, functional cusps, and nonfunctional cusps of
the prepreparation virtually diagnostically waxed
teeth (Fig. 3B). The device can sometimes be
designed in 2 sections (as in the mandibular arch)
to prevent the software program from increasing
the offset distance (the maximum distance to
compensate for the blockage of an undercut) as it
attempts to block undercuts in case of divergent
angulations of natural teeth.
6. Save the STL files of the device designs individu-
ally and export them to a 3D printer (XFAB 2000;
DWS) to be printed in clear biocompatible resin
(3d printable resin; DWS) (Fig. 4A).
7. Immerse the 3D-printed device in an ultrasonic
alcohol bath (96%) for 15 minutes and proceed to
continuous polymerization in an ultraviolet
polymerizing chamber (Ultraviolet curing cham-
ber; XYZ PRINTING) for 10 minutes at 60  C
(Fig. 4B, 4C).

THE JOURNAL OF PROSTHETIC DENTISTRY Taha et al

February 2021
Figure 3. Guide design in CAD software program (exocad DentalCAD; exocad GmbH) with toggled STL views. A, Maxillary structure with 1.5-mm
thickness. B, Virtually subtracted square-shaped attachments in anterior region (maxillary central incisors, maxillary right and left canines, and maxillary
left second molar) and parametric extrusion round attachments mode for posterior region. Calibrated vent holes designed in buccal surface, lingual
surface, central fossa, functional cusps, and nonfunctional cusps of the prepreparation virtually diagnostically waxed teeth. CAD, computer-aided
design; STL, standard tessellation language.
Figure 4. Three-dimensionally printed digital 3D-guided preparation
device using clear biocompatible resin (3D printable resin;
DWS). A, Three-dimensionally printed cast (XFAB 2000; DWS). B, Device
polymerized with ultraviolet polymerizing chamber (Ultraviolet curing
chamber; XYZ PRINTING).
8. Disinfect the device by immersion in a 2% chlor-
hexidine solution for 15 minutes.
9. Place the digital 3D-guided preparation device in
the patient’s treatment dental arch and verify the
Taha et al
221.e3
accurate fitting of the device by using the virtually
subtracted square-shaped attachments in the de-
vice placed on the teeth that acts as an occlusal
stop (Fig. 5A).
10. Proceed to tooth preparation by using the device,
and measure preparation reduction by using a
calibrated periodontal probe (PCP 12, Hu Freidy)
placed through the round vent holes. Control the
amount of tooth reduction depending on material
selection by subtracting 1.5 mm (the thickness of
the device) from the total measurement (Fig. 5B).
11. Follow the same protocol in tooth preparation for
all teeth receiving fixed dental prostheses.
DISCUSSION
Magne and Belser18 presented 2 general tooth prepara-
tion techniques in fixed dental prosthesis: a nonguided
preparation driven by the existing tooth structure and a
second tooth preparation technique driven by the final
volume of the future restoration. The latter technique
aims to follow the principles of bioeconomics (maximum
conservation of healthy natural tooth structure) and
reinforcement of residual tooth structure.19 Following
this guided technique, different tooth preparation
methods have been developed,20 with silicone matrices
being used to calibrate tooth preparation based on the
final diagnostic waxing volume.18,21 Although these
methods have helped clinicians, they are technique-
sensitive and are limited to a 2D view. Adequate buc-
colingual or mesiodistal reduction is visualized, but lim-
itations exist during occlusal reduction. Other analog
techniques have used a vacuum-formed matrix made
from a duplicated diagnostically waxed cast.17 All these
techniques are subject to fabrication errors. However,
THE JOURNAL OF PROSTHETIC DENTISTRY
221.e4
Figure 5. Use of digital 3D-guided preparation device and measurement
of preparation reduction. A, Vent holes. B, Verification of seating and
preparation reduction.
with advancements of digital technologies, the limita-
tions of these analog methods can be addressed with
CAD-CAM protocols.
The digital preparation device design process controls
the thickness of the device, the offset distance, and the
location and amount of undercut block out. The CAD
software program used was calibrated to a 1.5-mm uni-
form thickness of the device according to mechanical and
clinical parameters. Controlling the actual thickness of
the device and the incorporation of calibrated vent holes
allow for the accurate measurement of the tooth prepa-
ration needed with a calibrated periodontal probe.
Another advantage of digital fabrication of the device is
controlling the offset distance, which the operator can
control in the CAD software program. This tool allows for
a precise unmatched fit of the device, the detection of
areas with undercuts, and the operator’s freedom to
choose the magnitude of undercut block out. In the
clinical situation, these advantages reflect a more accu-
rate tooth preparation by avoiding excessive preparation,
which jeopardizes tooth structure tissues or insufficient
THE JOURNAL OF PROSTHETIC DENTISTRY
Volume 125 Issue 2
preparation, which compromises the thickness of the
definitive restorations.
SUMMARY
The digital preparation device technique guides tooth
preparation, thus preserving tooth structure and
providing sufficient thickness for the restorative material.
Studies are needed to evaluate the effectiveness of this
technique.
REFERENCES
1. Beuer F, Schweiger J, Edelhoff D. Digital dentistry: an overview of recent
developments for CAD/CAM generated restorations. Br Dent J 2008;10:
505-11.
2. Alghazzawi TF. Advancements in CAD/CAM technology: options for prac-
tical implementation. J Prosthodont Res 2016;60:72-84.
3. Mangano F, Shibli JA, Fortin T. Digital dentistry: new materials and tech-
niques. Int J Dent 2016;2016:5261247.
4. Joda T, Ferrari M, Gallucci GO, Wittneben JG, Brägger U. Digital technology
in fixed implant prosthodontics. Periodontol 2000 2017;73:178-92.
5. Solaberrieta E, Otegi JR, Mínguez R, Etxaniz O. Improved digital transfer of
the maxillary cast to a virtual articulator. J Prosthet Dent 2014;112:921-4.
6. Shim JS, Kim JE, Jeong SH, Choi YJ, Ryu JJ. Printing accuracy, mechanical
properties, surface characteristics, and microbial adhesion of 3D-printed
resins with various printing orientations. J Prosthet Dent 2019;124:468-75.
7. Wisithphrom K, Murray PE, About I, Windsor LJ. Interactions between cavity
preparation and restoration events and their effects on pulp vitality. Int J
Periodontics Restorative Dent 2006;26:596-605.
8. Edelhoff D, Sorensen JA. Tooth structure removal associated with various
preparation designs for anterior teeth. J Prosthet Dent 2002;87:503-9.
9. Goodacre CJ, Campagni WV, Aquilino SA. Tooth preparations for complete
crowns: an art form based on scientific principles. J Prosthet Dent 2001;85:363-76.
10. Kaiser DA, Jones JD. Proximal contour modifications for fixed partial den-
tures: a clinical report. J Prosthet Dent 2003;89:344-5.
11. Al-Fouzan AF. Gravimetric analysis of removed tooth structure associated
with different preparation designs. Saudi J Dent Res 2016;7:1-6.
12. Edelhoff D, Liebermann A, Beuer F, Stimmelmayr M, Güth JF. Minimally invasive
treatment options in fixed prosthodontics. Quintessence Int 2016;47:207-16.
13. Magne P, So WS, Cascione D. Immediate dentin sealing supports delayed
restoration placement. J Prosthet Dent 2007;98:166-74.
14. Gracis S, Thompson VP, Ferencz JL, Silva NR, Bonfante EA. A new classi-
fication system for all-ceramic and ceramic-like restorative materials. Int J
Prosthodont 2015;28:227-35.
15. Schlichting LH, Resende TH, Reis KR, Magne P. Simplified treatment of
severe dental erosion with ultrathin CAD-CAM composite occlusal veneers
and anterior bilaminar veneers. J Prosthet Dent 2016;116:474-82.
16. Vailati F, Belser UC. Full-mouth adhesive rehabilitation of a severely eroded
dentition: the three-step technique. Part 1. Eur J Esthet Dent 2008;3:30-44.
17. Cho SH, Nagy WW. Customized occlusal reduction guide made from a
thermoplastic sheet. J Prosthet Dent 2015;114:307-8.
18. Magne P, Belser UC. Novel porcelain laminate preparation approach driven
by a diagnostic mock-up. J Esthet Restor Dent 2004;16:7-16.
19. Ammannato R, Ferraris F, Marchesi G. The “index technique” in worn
dentition: a new and conservative approach. Int J Esthet Dent 2015;10:68-99.
20. Niu E, Tarrazzi D. Use of a silicone transfer index to prepare parallel guide
planes. J Prosthet Dent 2010;104:347-8.
21. Gürel G. The science and art of porcelain laminate veneers. London: Quin-
tessence; 2003. p. 151-79.
Corresponding author:
Dr Fady Raslan
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, Barcelona 08195
SPAIN
Email: fady.raslan@uic.es
Copyright © 2020 by the Editorial Council for The Journal of Prosthetic Dentistry.
https://doi.org/10.1016/j.prosdent.2020.10.009
Taha et al