DENTAL TECHNIQUE

Virtual diagnostics and guided tooth preparation for the

minimally invasive rehabilitation of a patient with extensive
tooth wear: A validation of a digital workflow
Hyeonjong Lee, DMD, PhD,a Vincent Fehmer, MDT,b Kung-Rock Kwon, DMD, PhD,c Felix Burkhardt, DDS,d
Ahran Pae, DMD, PhD,e and Irena Sailer, Prof Dr Med Dentf

Recent developments in dig- ABSTRACT

ital technologies in dentistry
The recent evolution of digital technologies in dentistry has enabled virtual 3D diagnostic analysis
have led to significant of a dentition before treatment, allowing for virtual, minimally invasive treatment planning. In this
changes of treatment con- report, an extensively worn dentition was 3D virtual analyzed at an increased vertical dimension of
cepts in prosthodontics. occlusion. Virtual waxing (exocad DentalCAD; Exocad) and subsequent analysis of the need for
Optical scanning allows digi- minimally invasive preparations were performed. Areas of each tooth without adequate clearance
talization of the initial clinical for the minimal thickness of a definitive restoration (set at 1.5 mm in the software), including the
situation, delivering virtual amount of tooth substance to be removed (GOM Inspect; GOM), were visualized in color. A
preparation guide was virtually designed according to this diagnostic plan (3-matic; Materialise) and
files of the initial status of the
3D printed (Connex3 Objet260; Stratasys) from resin (VeroMagenta RGD851; Stratasys). The teeth
dentition in the standard were minimally prepared using the guide, and the amount of preparation was validated by
tessellation language (STL) superimposing the scan of the prepared model on the initial scan and comparing it with the
format. The STL files can be diagnostic plan. (J Prosthet Dent 2020;123:20-6)
input into a computer-aided
design (CAD) software program and analyzed.1 Digital composite resin materials and cemented with adhe-
diagnostics, including digital waxing and trial restora- sive material as an alternative to conventional fixed
tions, can then be performed. Subsequently, the type prostheses.3,4
and design of the planned restorations can be exported Studies have shown5,6 that conventional preparation
as digital files and milled or printed by means of of complete coverage ceramic crowns necessitates ante-
computer-aided manufacturing (CAM) technology to rior or posterior tooth reduction ranging between 40%
fabricate CAD-CAM trial restorations.2 After tooth and 70%. In contrast, tooth reduction for ceramic veneers
preparation, the planned restorations can be fabricated on maxillary central incisors ranges between 17% and
with the CAD-CAM technology. 30%.5,6 Extensive tooth preparation can cause hyper-
Different types of ceramic and composite resin sensitivity and pulpal damage.7-11 For this reason, and
materials have been developed for fabrication, open- consistent with the development of materials and ad-
ing up new prosthetic treatments. Less-invasive hesive dentistry, current prosthodontic concepts have
restorations, such as veneers, onlays, and partial- proposed less-invasive restorations before preparing a
coverage crowns, can be milled from ceramic or crown.

a
International Scholar, Division of Fixed Prosthodontics and Biomaterials, University Clinic of Dentistry, University of Geneva, Geneva, Switzerland; and Assistant Professor,
Department of Prosthodontics, School of Dentistry, Pusan National University, Yangsan, Republic of Korea.
b
Master Dental Technician, Division of Fixed Prosthodontics and Biomaterials, University Clinic of Dentistry, University of Geneva, Geneva, Switzerland.
c
Professor, Department of Prosthodontics, School of Dentistry, Kyung Hee University, Seoul, Republic of Korea.
d
Resident, Division of Fixed Prosthodontics and Biomaterials, University Clinic of Dentistry, University of Geneva, Geneva, Switzerland.
e
Professor, Department of Prosthodontics, School of Dentistry, Kyung Hee University, Seoul, Republic of Korea.
f
Professor, Division of Fixed Prosthodontics and Biomaterials, University Clinic of Dentistry, University of Geneva, Geneva, Switzerland.

20 THE JOURNAL OF PROSTHETIC DENTISTRY

January 2020 21

Figure 1. Analysis of clearance between maxillary and mandibular dentition after optimal increase of vertical dimension for restorative space.
A, Occlusal view. B, Lateral view. C, Cross-sectional rear view at second molar area. D, Virtual diagnostic waxing on maxillary dentition.

Figure 2. Virtual arbitrary relief in pit and fissure areas on maxillary cast Figure 3. Construction of 2-mm-thick structure surrounding maxillary
for better adaptation of guide. model.

One prerequisite for minimally invasive prosthodontic
treatment is thorough pretreatment diagnostics to define
the treatment goals. To provide the least invasive
approach, clinicians should determine the exact area and
amount of tooth preparation needed before clinical
treatment. To define the preparation needed, pretreat-
ment diagnostics, including diagnostic waxing of the
planned restorations, are essential. The conventional
methods of transferring this information to the patient
are trial restorations and silicone matrices. Trial restora-
tions reproduce the diagnostic waxing and can be
transferred to the existing dentition. They are used to
visualize and communicate the treatment outcome to the
patient, dentist, and dental laboratory technician.2 Once

Lee et al THE JOURNAL OF PROSTHETIC DENTISTRY

22 Volume 123 Issue 1

Figure 4. A, Sectional view between both dentitions. B, Sectional view after creating 2-mm-thick outer offset on maxillary cast (cast A) and
1.5-mm-thick offset on mandibular cast (cast B). Orange arrow shows point exposed on guide. C, Subtraction of cast B from cast A. Area within 1.5-mm
interocclusal clearance exposed. D, Posterior view of designed guide (blue).

approved, silicone matrices of the waxing can be used to
define the tooth preparation.12-20
Limitations of this conventional workflow include the
time and effort needed to produce a conventional diag-
nostic waxing and trial restoration and their associated
costs. One further limitation is the predictability of the
transfer of this plan to the patient. Silicone matrices may
help evaluate the area and amount of tooth preparation
needed during the procedure, but the predictability of the
procedure is not ensured. Silicone matrices deliver 2D
information during the preparation and are limited to 1
or 2 buccolingual or mesiodistal slices. To ensure minimal
invasiveness and optimal standardization, a 3D prepa-
ration guide is desirable.
The 3D information of maxillary and mandibular
dentitions obtained by means of optical scans can be
used for virtual diagnostics and treatment planning.
Furthermore, in clinical situations with reduction of the
vertical dimension of occlusion (VDO), a virtual increase
of VDO can be performed.21,22 Optimal interocclusal
clearances can also be determined in the 3D analysis by
following the recommendations for different restorative
materials. Locations without sufficient clearance are color
coded on the 3D image (virtual 3D diagnostics), indi-
cating the amount of tooth substance to be removed
based on the 3D virtual diagnostics. To transfer this 3D
information predictably to the clinical situation and to
ensure least invasive tooth preparation, CAD-CAM
preparation guides need to be designed and produced.
In this report, restoration of an extensively worn
maxillary dentition without the loss of VDO but with
space available is presenteddcategory 2 according to the
treatment options in the restoration of an extremely worn
dentition.23 The VDO was increased to obtain space, but
some preparation was still needed on the posterior teeth
to achieve the minimal clearance for ceramic restorations.
The casts of a previously treated patient were used to
evaluate this concept. A 3D diagnosis was performed to
determine the needed amount of VDO increase and
define the areas with insufficient clearance for the plan-
ned reconstructions after a virtual VDO increase. A 3D-
printed guide based on the virtual 3D diagnostics was
named K-L (Kwon & Lee) preparation guide, and it was
used for the minimally invasive preparations.

THE JOURNAL OF PROSTHETIC DENTISTRY Lee et al

January 2020
Figure 5. A, Information of location and amount of tooth to be prepared.
White region indicates area over 1.5 mm of clearance. Each color on color
bar shows each relative clearance within 1.5 mm. B, Designed guide of
left side. C, Designed guide of right side.
TECHNIQUE
1. Scan maxillary and mandibular dentitions to obtain
STL data by using intraoral digital scans or a lab-
oratory scanner (IScan D104; Imetric) to scan
diagnostic casts.
2. Diagnose the optimal increase in VDO, that is, the
opening in the incisal area, considering the
Lee et al
23
minimum thickness of restorations in the posterior
region and esthetics in the anterior area. Establish
this with a 3D virtual analysis software program
(GOM Inspect; GOM) (Fig. 1A, B).
3. Fabricate an anterior guide at the established VDO
(Pattern resin LS; GC) to make a clinical occlusal
registration (Jet bite; Coltène) based on the previ-
ous 3D virtual analysis.
4. Align the maxillary and mandibular STL files ac-
cording to the occlusal registration by applying a
best-fit algorithm (GOM Inspect; GOM) (Fig. 1C).
5. Relieve the maxillary cast to virtually fill in pits and
grooves on the teeth that might interfere with the
adaptation of the guide (3-matic; Materialise)
(Fig. 2).
6. Construct a 2-mm-thick structure, resembling an
occlusal device, to cover the teeth and surrounding
structures of the maxillary model (cast A) (Fig. 3).
7. Define a 1.5-mm occlusal clearance on the
mandibular cast (cast B). This clearance is defined
by the minimum thickness of the material selected
for the definitive restoration (for this restoration, it
is lithium disilicate glass-ceramic) (Fig. 4A, B).
8. Virtually subtract cast B from cast A. The areas not
fulfilling the space requirements are thereby visu-
alized. Subsequently, design 2 separate prepara-
tion guides (first quadrant, second quadrant) to
allow for removal of the respective parts from cast
A (Figs. 4C, D, 5).
9. Fabricate the preparation guides by using a 3D
printer (Connex3 Objet260; Stratasys) and place it
on the cast for analysis of the needed preparation
(Fig. 6A-C).
10. Perform the guided tooth preparation by removing
only the tooth substance extending beyond the
guide. Use a football-shaped diamond rotary in-
strument (no. 250/4250 red, Guided Universal Prep
Set; Intensiv) (Fig. 6D).
After tooth preparation, the result was compared with
the initial virtual plan for validation of the concept. The
clearance obtained from the guided preparation was
evaluated by scanning the cast after the preparation and
superimposing the STL file on the file of the plan. The
results indicated accurate transfer of the guided prepa-
ration plan to the clinical execution (Figs. 7, 8).
DISCUSSION
With the development of reinforced ceramic materials
and adhesive dentistry, minimally invasive partial
coverage restorations with increased VDO can be
selected in preference to complete coverage crowns to
restore an extensively worn dentition. However, suffi-
cient clearance for the restoration in the posterior area
may not be possible even with an increase of VDO.
THE JOURNAL OF PROSTHETIC DENTISTRY
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Figure 6. A, Guide fabricated by 3D printer. B, C, Guide placed on cast. D, Preparation using high-speed handpiece.
Turner and Missirlian23 identified 3 distinct categories for
the restoration of extensively worn dentitions in relation
to VDO and treatment options. An increase of VDO
should be determined considering various conditions. In
this patient, the increase of VDO was established from
the anterior esthetics and optimal posterior material. An
area with insufficient clearance can be specified through
3D analysis with the presented method. Subsequently,
the preparation guide can be designed and fabricated
based on the previous 3D analysis to transfer the virtual
plan to the clinical situation.
The thickness of the guide in this report was set to 2
mm, considering clinical and mechanical aspects.
Determining the VDO increase is an important step in
the treatment. Virtual 3D diagnostics of clearance be-
tween both dentitions can be made after defining the
amount of virtual VDO increase. The tentative amount of
increase can be virtually planned with the help of this
analysis. However, due to the possible error of a virtual
VDO increase, clinical occlusal registration by using an
anterior occlusal registration device is also
recommended.
In 2008, Vailati and Belser18-20 introduced a 3-step
technique to rehabilitate extensively worn dentitions.
This technique comprised 3 laboratory steps alternated
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Volume 123 Issue 1
with 3 clinical steps, allowing for the predictable mini-
mally invasive esthetic and functional rehabilitation of
patients with dental erosion. The concept in this report
can be integrated into the 3-step technique to virtually
plan for complete mouth adhesive restoration of exten-
sively worn dentitions. Conventionally, analysis of the
mounted cast is one of the main factors in determining
the amount of VDO increase. A tentative amount of
VDO increase was performed through visual inspection
of the mounted cast in the articulator. With the help of a
3D digital software program, a virtual vertical increase of
VDO is now possible.21,22 Precise evaluation of maxillary
and mandibular dentitions can be obtained.
The K-L preparation guide was virtually designed,
CAM fabricated, and used for the minimally invasive
tooth preparation for this patient. Once the STL files of
both dentitions and the occlusal registration were ac-
quired, the guide could be designed automatically by
inserting intended clearance values. As this guide was
designed by using a CAD software program, the shape
and dimensions of the guide were predictable and clearly
defined. The magenta color of the guide helped to easily
distinguish the needed amount of tooth reduction
(Fig. 9). Virtual 3D occlusal analysis indicated the amount
of insufficient clearance and, hence, needed tooth
Lee et al
January 2020 25

Figure 7. Validation between before and after preparation using guide. Differences visualized in colordwhitish color shows the area with >1.5-mm
clearance and colored regions show areas and amount of teeth to be prepared to obtain at least 1-mm clearance. A, Right side before preparation.
Color shows area that should be prepared. B, Left side before preparation. C, Right side after preparation. D, Left side after preparation.

Figure 8. Cross-sectional view to validate clearance change before and after preparation. A, Section at right second molar. B, Section at left second
molar.

Lee et al THE JOURNAL OF PROSTHETIC DENTISTRY

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Figure 9. Clinical application of guide. A, Guide placed on posterior area. B, Minimally invasive preparation performed according to contour of guide.
reduction. It provided visualized information on the
location and amount of teeth to be prepared. This 3D
diagnostic tool can be used for patient consultation and
minimally invasive preparation. In addition, although this
technique was introduced for VDO increase in the pre-
sent patient, it may also be applied in various other
clinical situations. If the functions used in this report
could be integrated into a commercial dental CAD soft-
ware program, the presented procedure would be easier
to apply in daily practice.
SUMMARY
The K-L guide based on 3D virtual diagnostics indicates
the location and amount of tooth substance to be
removed. It can be easily designed and printed using the
CAD-CAM technology.
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Corresponding author:
Dr Irena Sailer
Division Prothèse Fixe et Biomateriaux
Clinique Universitaire de Medecine Dentaire
Université de Genève
Michel Servet 1, 1211
Geneva
SWITZERLAND
Email: Irena.Sailer@unige.ch
Acknowledgments
The authors would like to express gratitude to the ITI Foundation for providing
the ITI scholarship to the first author at the University of Geneva, enabling the
present developments.
Copyright © 2019 by the Editorial Council for The Journal of Prosthetic Dentistry.
https://doi.org/10.1016/j.prosdent.2018.11.023
Lee et al