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Esthetic integration area concept in digitally guided veneer rehabilitation: A

dental technique

Article in Journal of Prosthetic Dentistry · July 2024

DOI: 10.1016/[Link].2024.05.023

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 DENTAL TECHNIQUE

Esthetic integration area concept in digitally guided veneer

rehabilitation: A dental technique
Patricia Elias-Ortiz, DDS,a Juan Ruiz-de-Gopegui, DDS, MS,b Carlos Eduardo Toro-Chacón, DDS, MS,c
Nicolás Veneri-Rodriguez, DDS, MS,d Carlos Oteo-Morilla, DDS, MS, PhD,e and Wenceslao Piedra-Cascón, DDS, MSf

Adequate treatment planning ABSTRACT

from a diagnostic waxing is
Computer-aided design and computer-aided manufacturing (CAD-CAM) technologies have been
essential for successful esthetic integrated into the dental digital workflow. However, pretreatment virtual veneer preparations
restorations.1–6 Through the and the digital design and manufacturing of guided preparation and cementation templates has
advancement of intraoral scan­ not yet been incorporated into the clinical routine. This article presents a novel protocol for
ners (IOSs), computer-aided digitally guided veneer rehabilitation by following the esthetic integration area concept,
design (CAD) software pro­ facilitating precise control over tooth structure removal and obviating the need for interim
grams, and computer-aided restorations. (J Prosthet Dent xxxx;xxx:xxx-xxx)
manufacturing (CAM), an accurate digital workflow for maxillary ceramic veneers from dental preparation to ce­
diagnostic treatment planning has become available.7–26 mentation in the same clinical appointment.
Despite advances in the digital workflow, the most wide­
spread guided treatments have been surgical,27–29 with
TECHNIQUE
fewer solutions for guided preparations to receive tooth-
supported prostheses. In a conventional approach for ve­ A 25-year-old woman was referred to a private practice
neer preparations, tooth preparations have been controlled for prosthodontic treatment. Her chief complaint was
by the use of silicone indices.30 However, the conventional poor esthetics.
method has constraints, depending on the technical ability
of the clinician, resulting in an unregulated determination Step 1. Clinical Procedure. First Appointment
of the restorative space, potentially leading to over­
contoured restorations as specified by the esthetic in­ 1. Make 2 digital photographs of the patient’s face with a
tegration area (EIA) concept.31 The EIA concept is based digital single-lens reflex camera (EOS 750D; Canon), 1
on restorations that do not exceed the maximum buccal smiling and 1 with cheek retractors (Fig. 1).
volume of the soft tissues nor the maximum volume of the 2. Make an intraoral digital scan of the patient´s dentition
papillae interproximally.31 The present article describes a with an IOS (Itero Element 5D; Align Technology)
step-by-step digital protocol to plan, design, and additively under 1000 lux ambient lighting measured by using a
manufacture 3 dimensional (3D) templates for fully guided luxometer (LXB1033B; Dr. Meter). Once the digital

The authors declare the following financial or non-financial interests which may be considered as potential conflicts of interest: The following authors have commercial
interests with FirstFit Technologies: P.E-O., N.V-R., and C.E.T-C.
a
Private practice, Madrid, Spain.
b
Affiliate Faculty Graduate, Esthetic Dentistry Program, Complutense University of Madrid (UCM), Madrid, Spain; and Private practice, Madrid, Spain.
c
Private practice, Madrid, Spain.
d
Private practice, Madrid, Spain.
e
Affiliate Faculty Graduate, Esthetic Dentistry Program, Complutense University of Madrid (UCM), Madrid, Spain; and Private practice, Madrid, Spain.
f
Doctoral student, Doctoral Progam in Dental Science, Stomatology Area, Department of Surgery and Medical-Surgery Specialties, University of Santiago de Compostela
(USC), Santiago de Compostela, Spain; and Affiliate Faculty, Esthetic Dentistry Program, Complutense University of Madrid (UCM), Madrid, Spain; Private practice,
Oviedo, Spain; and Researcher, MovumTech, Madrid, Spain.

THE JOURNAL OF PROSTHETIC DENTISTRY 1

2 Volume xxx Issue xx

A B C
Figure 1. Pretreatment planning data set. A, Smiling. B, With cheek retractors. C, Maxillary STL file. STL, standard tessellation language.

scans are completed and processed, export them as a Step 3. Clinical Procedure. Second Appointment
standard tessellation language (STL) file: STL1 (max­
illary) and STL2 (mandibular). 5. Use an autopolymerizing bis-acryl interim resin
(Voco Structur 2 SC, Bleach; Voco GmbH) to
Step 2. Computer-aided Design evaluate trial restorations. After polymerization,
remove the silicone index (Fig. 2C).
3. Import STL1 and STL2 into a dental CAD software 6. Reshape the interproximal and cervical areas if
program (exocad DentalCAD; exocad GmbH) to needed to obtain a natural emergence profile be­
perform a virtual diagnostic waxing of the teeth fore definitive preparation.31 Make a scan of the
(Fig. 2A, B). Export the waxed STL file (STL3) and reshaped teeth by following the same protocol
3D print it from a cast material (Nextdent Model described in step 1.2. Export the STL file as STL4
2.0; Nextdent) using an SLA-DLP 3D printer and send it to the dental laboratory technician.
(Nextdent 5100; Nextdent) with a 50-µm-layer
thickness. Step 4. Laboratory Procedures
4. Make a silicone index using polyvinyl siloxane
putty and light-body materials (Virtual Putty, 7. Import STL3 and STL4 into a specific CAD software
Virtual Light Body; Ivoclar AG). program (FirstFit; Viax Dental Technologies) to

A B C
Figure 2. A, Superimposition of smile position photograph with initial maxillary STL file. B, Digital diagnostic waxing facially driven. C, Trial
restorations made from bis-acrylic resin. STL, standard tessellation language.

A B C
Figure 3. Digital data set. A, Virtual simulation of veneers preparation based on diagnostic waxing. B, Digital design of preparation guides. C, Digital
design cementation guide.

THE JOURNAL OF PROSTHETIC DENTISTRY Elias-Ortiz et al

Month xxxx 3

A B C D
Figure 4. Veneer preparation phase. A, 3D printed guide placed in mouth. B, Specific dental handpiece and calibrated diamond rotary instrument for
incisal reduction. C, Guided facial preparations on maxillary central incisors. D, Teeth prepared for ceramic veneers.

perform digital veneer preparations (Fig. 3A). Ex­ Step 5. Clinical Procedure. Third Appointment
port the STL file as STL5.
8. Design the 3D rigid tooth preparation guides based 11. Place the rigid 3D preparation guides and prepare the
on STL5 (FirstFit; Viax Dental Technologies) teeth using a special handpiece (FirstFit; Viax Dental
(Fig. 3B). Export them in an STL file and use a Technologies) and specific diamond rotary instru­
material jetting polymer 3D printer (ProJet MJP ments (Shape A B; Hager-Meisinger GmbH) (Fig. 4).
2500 IC; 3D Systems) and polymer material (Visijet 12. Evaluate each veneer individually for marginal fit
M2R-CL; 3D Systems). and proximal contacts. Seat the veneers in the 3D
9. Import STL5 into a dental CAD software program printed cast and bond them provisionally into a
(exocad DentalCAD; exocad GmbH) to digitally semirigid 3D printed positioning tray (Fig. 5A).
design the veneers. Combine the designed restora­ 13. Prepare the ceramic restorations by following the
tions and the cast and export it as STL6. Manufacture manufacturer´s recommendations. Then, etch the
the ceramic veneers in lithium disilicate monolithic tooth surfaces with phosphoric acid (Total Etch;
material ([Link]; Ivoclar AG). Ivoclar AG) for 30 seconds. Rinse, dry, and apply a
10. Import STL6 into a CAD software program (exocad universal adhesive (Adhese Univeral Vivapen;
DentalCAD; exocad GmbH) and design and 3D Ivoclar AG) followed by a light-polymerization
print the maxillary tray (Max 2; ASIGA) using a resin cement (Variolink Esthetic LC; Ivoclar AG)
specific polymer resin (Imprimo LC IBT; Scheu- placed in the veneers. Seat all veneers at the same
Group) (Fig. 3C). time (Fig. 5B). Spot-polymerize each veneer for 3

A B C
Figure 5. Veneer cementation. A, Veneers placed in cementation guide. B, Veneers delivered. C, Frontal view.

A B C
Figure 6. Three months after treatment. A, Frontal view. B, Emergence profile view. C, Evaluation of esthetic integration area.

Elias-Ortiz et al THE JOURNAL OF PROSTHETIC DENTISTRY

4 Volume xxx Issue xx

seconds (Bluephase G4 pin-point 2 mm; Ivoclar SUMMARY

AG). Remove the semirigid cementation guide and
The application of a specialized digital workflow for digital
remove excess cement. Polish the margins (Optra
veneer preparation enables precise control over tooth
Fine; Ivoclar AG). Evaluate function.
structure removal, ensuring uniform teeth preparations.
14. After 3 months, re-evaluate the veneers and soft
This approach also results in a cost-effective workflow as
tissues by following the EIA concept (Fig. 6).
the need for interim restorations can be eliminated.

DISCUSSION PATIENT CONSENT

The incorporation of a 3D CAD software program en­ Informed patient consent has been obtained.
ables the superimposition of the digital scans on 2-di­
mensional facial smile photographs to determine the
functional and esthetic parameters of the oral rehabilita­ REFERENCES
tion. This approach improves communication between
1. Goldstein RE. Esthetics in dentistry. Vol 1: Principles, communication,
dental laboratory technicians and clinicians. If modifica­ treatment methods. Ontario: BC Decker,; 1998:3–51.
tions to the diagnostic waxing are needed, the clinicians 2. Chiche GJ, Pinault A. Esthetics of anterior fixed prosthodontics. Chicago:
Quintessence,; 1996:33–50.
should modify it intraorally during the trial restoration 3. Fradeani M. Esthetic rehabilitation in fixed prosthodontics. Vol 1: Esthetic
step and make a new digital scan for the dental laboratory analysis: A systematic approach to prosthetic treatment. Chicago:
Quintessence,; 2004:22–30.
technician to consider in the definitive restorations. The 4. Rufenacht CR. Fundamentals of esthetics. Chicago: Quintessence,;
technique presented in this article enables the required 1990:205–241.
5. Spear FM, Kokich VG. A multidisciplinary approach to esthetic dentistry.
tooth reduction to be determined to assess the adequate Dent Clin North Am. 2007;51:487–505.
available space for guided veneer preparations. This is 6. Ackerman MB, Ackerman JL. Smile analysis and design in the digital era. J
Clin Orthod. 2002;36:221–236.
achieved through the EIA concept, avoiding over­ 7. Revilla-León M, Sánchez-Rubio JL, Besné-Torre A, Ö zcan M. A report on a
contoured restorations or excessive tooth preparation. diagnostic digital workflow for esthetic dental rehabilitation using additive
manufacturing technologies. Int J Esthet Dent. 2018;13:184–196.
The technique described has advantages that include 8. Revilla-León M, Besné-Torre A, Sánchez-Rubio JL, Fábrega JJ, Ö zcan M. Digital
the accuracy of the tooth preparation, enabling the di­ tools and 3D printing technologies integrated into the workflow of restorative
treatment: A clinical report. J Prosthet Dent. 2019;121:3–8.
gital calculation of an ideal insertion path for the veneers 9. Revilla-León M, Fountain J, Piedra Cascón W, Ö zcan M, Zandinejad A.
and ensuring uniform tooth preparations. Additionally, Workflow description of additively manufactured clear silicone indexes for
injected provisional restorations: A novel technique. J Esthet Restor Dent.
interim restorations are not required with the presented 2019;31:213–221.
technique. Furthermore, fewer and shorter clinical ap­ 10. Patzelt SB, Vonau S, Stampf S, Att W. Assessing the feasibility and accuracy
of digitizing edentulous jaws. J Am Dent Assoc. 2013;144:914–920.
pointments are possible, as the methodology enables 11. Joda T, Zarone F, Ferrari M. The complete digital workflow in fixed
tooth preparation and cementation of the definitive re­ prosthodontics: A systematic review. BMC Oral Health. 2017;17:124–131.
12. Khraishi H, Duane B. Evidence for use of intraoral scanners under clinical
storations at the same clinical appointment. Once the conditions for obtaining full-arch digital impressions is insufficient. Evid
learning curve is overcome, the total time needed to Based Dent. 2017;18:24–25.
13. Renne W, Ludlow M, Fryml J, et al. Evaluation of the accuracy of 7 intraoral
prepare and cement 10 veneers is about 1 hour. scanners: An in vitro analysis based on 3- dimensional comparison. J
The preparation and cementation guides are made Prosthet Dent. 2017;118:36–42.
14. Rutkunas V, Geciauskaite A, Jegelevicius D, Vaitiekunas M. Accuracy of
with a multijet printing additive manufacturing tech­ digital implant impressions with intraoral scanners. A systematic review. Eur
nology that allows for 3D printing without support J Oral Implantol. 2017;10:101–120.
15. Medina-Sotomayor P, Pascual-Moscardo A, Camps I. Relationship between
structures. The technology minimizes deformation of the resolution and accuracy of four intraoral scanners in complete-arch
guided surfaces,32 ensuring accuracy in the dental pro­ impressions. J Clin Exp Dent. 2018;10:e361–e366.
16. Abduo J, Elseyoufi M. Accuracy of intraoral scanners: A systematic review of
cedures presented. influencing factors. Eur J Prosthodont Restor Dent. 2018;26:101–121.
Limitations of the presented technique include the 17. Takeuchi Y, Koizumi H, Furuchi M, Sato Y, Ohkubo C, Matsumura H. Use
of digital impression systems with intraoral scanners for fabricating
need for the patented handpiece with the use of specific restorations and fixed dental prostheses. J Oral Sci. 2018;60:1–7.
calibrated diamond rotary instruments and the need for 18. Tomita Y, Uechi J, Konno M, Sasamoto S, Iijima M, Mizoguchi I. Accuracy of
digital models generated by conventional impression plaster-model
interproximal preparations in the reshape phase before methods and intraoral scanning. Dent Mater J. 2018;37:628–633.
the design of the guided preparation templates. When 19. Malik J, Rodriguez J, Weisbloom M, Petridis H. Comparison of accuracy
between a conventional and two digital intraoral impression techniques. Int
comparing digital guided and free-hand tooth prepara­ J Prosthodont. 2018;31:107–113.
tions, there is a notable increase in direct costs attributed 20. Nedelcu R, Olsson P, Nystrom I, Ryden J, Thor A. Accuracy and precision of
3 intraoral scanners and accuracy of conventional impressions: A novel in
to the fabrication of preparation guides. However, these vivo analysis method. J Dent. 2018;69:110–118.
costs are mitigated by a reduction in the number of re­ 21. Patzelt SB, Emmanouilidi A, Stampf S, Strub JR, Att W. Accuracy of full-
arch scans using intraoral scanners. Clin Oral Investig.
quired clinical appointments and the accuracy obtained. 2014;18:1687–1694.
However, in vitro and in vivo studies are necessary to 22. Mennito AS, Evans ZP, Lauer AW, Patel RB, Ludlow ME, Renne WG.
Evaluation of the effect scan pattern has on the trueness and precision of
assess the accuracy of the digital workflow for the veneer six intraoral digital impression systems. J Esthet Restor Dent.
preparations provided in the presented technique. 2018;30:113–118.

THE JOURNAL OF PROSTHETIC DENTISTRY Elias-Ortiz et al

Month xxxx 5

23. Kim J, Park JM, Kim M, Heo SJ, Shin IH, Kim M. Comparison of experience 30. Magne P, Belser UC. Novel porcelain laminate preparation approach driven
curves between two 3-dimensional intraoral scanners. J Prosthet Dent. by a diagnostic mock-up. J Esthet Restor Dent. 2004;16:7–18.
2016;116:221–230. 31. Ruiz-de-Gopegui J, Piedra-Cascón W, Oteo-Morilla C. Esthetic integration
24. Lim JH, Park JM, Kim M, Heo SJ, Myung JY. Comparison of digital intraoral area concept to improve the emergence profile of fixed restorations: A
scanner reproducibility and image trueness considering repetitive dental technique. J Prosthet Dent 2022.
experience. J Prosthet Dent. 2018;119:225–232. 32. Ibrahim D, Broilo TL, Heitz C, et al. Dimensional error of selective laser
25. Resende CCD, Barbosa TAQ, Moura GF, et al. Influence of operator sintering, three-dimensional printing and PolyJet models in the
experience, scanner type, and scan size on 3D scans. J Prosthet Dent. reproduction of mandibular anatomy. J Craniomaxillofac Surg.
2021;125:294–299. 2009;37:167–173.
26. Piedra-Cascón W, Adhikari RR, Özcan M, Krishnammurthy VR, Revilla-
León M, Gallas-Torreira M. Accuracy assessment (trueness and precision) of
a confocal based intraoral scanner under twelve different ambient lighting Corresponding author:
conditions. J Dent. 2023;134:104530. Dr Wenceslao Piedra-Cascón
27. Putra RH, Yoda N, Astuti ER, Sasaki K. The accuracy of impant placement Department of Surgery and Medical-Surgery Specialties
with computer-guided surgery in partially edentulous patients and possible University of Santiago de Compostela (USC)
influencing factors: A systematic review and meta-analysis. J Prosthodont Res. Rua Entrerríos s/n
2022;66:29–39. Santiago de Compostela, 15782
28. Cecchetti F, Spuntaelli M, Mazza D, Girolamo MD, Baggi L. Guided sinus SPAIN
lift: Virtual planning of surgical templates for lateral access. J Biol Regul Email: wpiedra@[Link]
Homeost Agents. 2021;35:139–145.
29. Stavola LD, Cristoforetti A, Fincato A, et al. Accuracy and technical Copyright © 2024 by the Editorial Council of The Journal of Prosthetic Dentistry.
predictability of computer guided bone harvesting from the mandible: A All rights are reserved, including those for text and data mining, AI training, and
cone beam CT analysis in 22 consecutive patients. J Func Biomater. similar technologies.
2022;13:292. [Link]

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