VOLUME 44 NUMBEP 1 JANUAPY 2013 29

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PROSTHODONTICS
as Western Europe and the United States.
7

Only a few years ago, euphoric statements
were made that impressions and computer-
generated abutments would likely replace
traditional restorative protocols and become
the standard for dentistry.
9
Today, this
would seem to be truewith the exception
of scanning large edentulous areas, digital
techniques are already capable of replac-
ing conventional workows.
7,911

In advertisements and dental journals,
computer-based procedures are often
praised as being safer and more economi-
cally efcient, comfortable, and precise
than their predecessors.
9,12,13
And indeed,
although conventional putty impressions
are considered equally precise as digital
impression techniques,
11
other benets
associated with computer-aided design/
computer-assisted manufacture (CAD/
CAM)generated dental restorations
include access to new, nearly defect-free,
industrially prefabricated and controlled
materials; an increase in quality and repro-
ducibility; data storage commensurate with
a standardized chain of production; an
improvement in precision and planning;
and an increase in efciency.
7,8
As a result
of continual developments in technology,
new methods of production and new treat-
ment concepts are to be expected.
7

Clinicians must have certain basic knowl-
edge if they are to benet from these new
procedures. This article describes the full-
mouth reconstruction of a patient using an
entirely digital workow.
A combination of public media,
1
new ma ter-
ials, and advanced techniques have fueled
an esthetic cultural revolution
2
that has left
clinicians to address the esthetic expecta-
tions of todays patients. Since positive
effects on a patients self-esteem and qual-
ity of life were identied during this revolu-
tion,
3
an emphasis on enhancing personal
appearance is demonstrated in patients
increasing demands for esthetic proce-
dures.
2

Another important development has
been the use of computers in dentistry,
which has led to new research foci and new
opportunities with regard to clinical work-
ows and dental restoration manufactur-
ing.
48
Production stages in dentistry are
becoming increasingly automated, as is the
case in many other industries.
7
The price of
dental laboratory work has become a major
factor in treatment planning and therapy,
and automation could enable more com-
petitive production in high-wage areas such
1
Private Practice, Munich, Germany; formerly, Assistant
Professor, Department of Prosthodontics, Propedeutics, and
Dental Materials, Christian-Albrechts University at Kiel, Kiel,
Germany.
2
Director, Byrnes Dental Laboratory, Wheatley, Oxfordshire,
United Kingdom.
3
Chair, Department of Prosthodontics, Propaedeutics, and Dental
Materials, Christian-Albrechts University at Kiel, Kiel, Germany.
Correspondence: Dr Christian Mehl, Volkartstrasse 5, 80634
Munich, Germany. Email: cmehl@proth.uni-kiel.de, christian.
mehl@hardermehl.de
Prosthodontics in digital times: A case report
Christian Mehl, DDS, Dr Med Dent
1
/Soenke Harder, DDS, Dr Med Dent
1
/
Ashley Byrne, Dental Technician
2
/Matthias Kern, DDS, Dr Med Dent, PhD
3
Dentistry has not been exempt from changes in this era of technology-driven revolution.
Entire workows are already digitalized, and restorations are designed and manufactured
using computer-aided solutions. This case report describes the reconstruction of 24 teeth
using digital techniques. (Quintessence Int 2013;44:2936)
Key words: CAD/CAM, case report, ceramic, crown, digital, imaging, polyurethane,
scanning, veneer
30 VOLUME 44 NUMBEP 1 JANUAPY 2013
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Mehl et al
Fig 2 An esthetic wax-up of the anterior teeth to
determine the extent of the preparation.
Fig 1 The initial situation.
CASE REPORT
A 46-year-old woman presented with a
need for conservative and prosthodontic
treatment. Esthetically, the patient was
unhappy about the position and color of her
teeth, as well as the large composite res tor-
ation in the maxillary right central incisor. In
addition, she lacked the condence to smile
wholeheartedly due to the discolored mar-
gins of her posterior teeth (Fig 1). Clinically,
the composite restorations in the maxillary
and mandibular anterior teeth were suf-
cient, and the overall periodontal situation
was stable. The patient decided to proceed
with veneers on the maxillary and mandibu-
lar anterior teeth as an elective and entirely
cosmetic procedure. In the premolar and
molar regions, the teeth had previously
been restored with porcelain-fused-to-metal
(PFM) crowns with insufcient margins.
Additionally, all crowns were splinted,
thereby complicating interdental oral
hygiene. The posterior teeth had been con-
servatively treated with clinically unaccept-
able resorcinol-formaldehyde resin root
oanal hllings (Pussian rod)
14,15
and had
loose and leaking core buildups. The con-
servative treatment plan consisted of an
oral hygiene phase, the replacement of all
root canal treatments, and new core build-
ups. The prosthodontic phase included
veneering the maxillary and mandibular
right canines through left canines and plac-
ing single crowns on the previously crowned
posterior teeth.
Clinical procedure
Following a professional cleaning, an algi-
nate impression (Alginat Super, Pluradent)
was taken. After mounting the stone casts in
an articulator, a wax-up up of the maxillary
and mandibular right canines through left
canines was made in the dental laboratory
(Fig 2). With the help of thermoformed
splints, the wax-up was tried on as a mock-
up to ensure that the patient was making an
informed decision with regard to electively
placing veneers on otherwise intact anterior
teeth. After the patient opted to proceed,
the posterior crowns were removed and the
root canal llings revised. The previous clin-
ician had used a toxic resorcinol-formalde-
nydo rosin root oanal hlling matorial (Pussian
red), which led to heavy discoloration of the
teeth that was, in some cases, impossible to
remove and replace.
14,15
After nishing the
b a
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Mehl et al
Fig 3 Teeth prepared for taking impressions.
Fig 4 Stylized image of digital impressions using
parallel confocal imaging.
root canal treatments, core buildups were
adhesively placed (Clearl DC Core,
Kuraray) and the teeth covered with cement-
ed provisional restorations (Luxatemp,
DMG). Three months after the endodontic
treatment, none of the posterior teeth
showed apical pathologies or caused pain,
and the restorative treatment was started.
After the application of a local anesthetic
(Septanest, Septodont), the maxillary and
mandibular teeth were prepared and digi-
tally scanned on two consecutive days
using triple zero retraction cords (Ultradent)
(Fig 3). Prior to scanning, a small perma-
nent bonding (Tetric EvoFlow, Ivoclar
Vivadent) was placed on the unprepared
mandibular right second molar. Also,
removable interocclusal records were built
on the maxillary and mandibular left second
molars and on the all four central incisors as
a front jig (Tetric EvoCeram, Ivoclar
Vivadent) to ensure a proper transfer of the
bito to tno digital data sot. Booro tno digital
impression was taken, an astringent gel
(Expasyl, Piorro Polland) was plaood or 1
minute. After thorough rinsing of the gel with
water, the digital impressions were taken
(iTero, Align Technologies) (Fig 4). At rst,
the maxillary arch was digitally scanned. On
the following day, a digital impression of the
mandibular teeth, as well as the interocclu-
sal records, were taken (Fig 5).
The digital scans were performed using
parallel confocal imaging, which utilizes
laser and optical scanning to digitally cap-
ture the surfaces and contours of teeth and
gingival structures. This technique cap-
tures 100,000 points of reected laser light
in a focus at 300 focal depths of the tooth
structure. These focal depth images are
spaced approximately 50m apart.
Booauso tno intorooolusal rooords nad
to be taken on three different areas (right,
left, and anterior teeth), two of the three
records were always placed on the antago-
nistic sides. After taking the digital impres-
sions, the astringent gel was again placed
for 1 minute and rinsed. Conventional
impressions were then taken as controls
(Pim-look trays, Pormadyno, 3M ESPE). Tno
provisional restorations were cemented with
a liner (Kerr Life, Kerr) to allow stability and
at the same time, retrievability of the restor-
ations. After sending the case to the labora-
tory, the initial digital le (STL format) was
cleaned and processed with computer soft-
ware (Align Technologies). The nalized
STL le was received at the dental labora-
a b
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Fig 5 Digital images of the scanned
teeth after marking the preparation mar-
gins in the dental laboratory.
Fig 6 Working and soft tissue casts made of polyurethane material using the digital set of data from the
scanning procedure.
a b
d c
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Mehl et al
Fig 8 Choosing the height of the cobalt-chromium
metal blank to mill the framework of the fxed dental
prosthesis in one piece.
Fig 7 Virtual design of the anatomically reduced
framework using the digital set of data from the
scanning procedure.
Fig 9 Anatomically reduced milled ceramic frame-
works before individualized feldspathic veneering.
tory computer workstation (iTero CAD work-
station, Align Technologies), and the cast
was designed virtually. Additionally, the
removal dies and contact points were con-
gured. The occlusion and margins were
checked by the laboratory before transfer-
ring the digital le to a milling center
(Straumann European Milling Centre).
The casts were milled from a solid block
of polyurethane (Fig 6). The STL scan le
was exported (Fig 7) to the CAD/CAM sys-
tem (CS2, Straumann). Using the CAD soft-
ware, the restorations were designed and
checked at the dental laboratory for porce-
lain support and that they tted within the
milling blook sizo (Fig 8). Postorations or
the maxillary right through left rst molars
and mandibular right rst molar through left
canine were milled as individual anatomi-
cally reduced lithium disilicate glass-ceram-
ic crowns/veneers (IPS e.max CAD, Ivoclar)
(Fig 9), which provided excellent clinical
results.
1618
The xed dental prosthesis for
the mandibular left rst premolar to second
molar was milled from a solid cobalt-chro-
mium alloy block (Coron, Straumann)
b c
a
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Fig 10 Finished laboratory work on the cast produced from the digital set of data.
(Fig 9). Each restoration was checked for t
and passivity before being veneered with
porcelain (Initial, GC) and hand-polished to
achieve natural esthetics (Fig 10). The
occlusion was checked and adjusted before
the restorations were sent to the dental
ofce.
Three weeks after the impressions were
taken, the ceramic crowns were tried in
clinically. After cleaning the teeth with pum-
ice and a chlorhexidine solution, radio-
graphs were taken to check the t of the
restorations. All full-coverage restorations
were cemented with glass-ionomer cement
(Ketac-Cem, 3M ESPE), while the veneers
were bonded to the teeth using rubber dam
and transparent adhesive cement (Variolink
II, Ivoclar Vivadent). Figures 11 and 12
show the restorations at a recall visit 3
months after cementation.
DISCUSSION
Digital techniques are already capable of
replacing traditional workows.
7,9,11
With the
exception of scanning large edentulous
areas, digital impressions showed trueness
and precision equal to conventional tech-
niques.
11,19
One advantage of digital impres-
sions compared with the conventional
techniques with putty is that missing areas
or imperfections can easily be rescanned
and added to the existing virtual model,
thus reducing discomfort for the patient.
Another major advantage of the computer
technique is the availability of the data of
the virtual model and the restoration, allow-
ing technicians to rst check function and
esthetics.
20

A useful tool in the iTero CAD worksta-
tion is the measurement of the interocclusal
distance immediately after the scanning
procedure.
4
Clinically, this helps to ensure
the correct material thickness and also
make sure that there is enough space for
the technician to design anatomically cor-
rect occlusal surfaces. For the dental tech-
nician, various benets emerge from the
use of digital dentistry. The manufactured
polyurethane casts have a higher resis-
tance to wear when used in the dental labo-
ratory and have a plasterlike color similar to
conventional casts. With the exception of a
total loss of the jaw relationship, there is no
need to take the bite. The occlusal jaw rela-
tionship is scanned directly and transferred
to a standardized articulator, which signi-
cantly reduces time for both the clinician
and dental technician.
4
Moreover, casts can
easily be replicated with the same quality
since the same set of data can be reused.
4

With regard to esthetics, the use of one
cast, which serves as a working and master
model when soft tissue structures are still
intact, reduces valuable chair time, since
fewer try-ins are necessary.
4
Furthermore,
digitalization of clinical and laboratory work-
ows enables the industry to process
homogenous, standardized materials,
which reduces material-induced failures.
8,20
Notwitnstanding all tno bonohts or
patients, clinicians, and dental technicians,
the use of digitalization in dental proce-
b a
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Mehl et al
Fig 12 The fnished situation with single individu-
ally veneered crowns and a fxed PFM dental pros-
thesis.
Fig 11 Finished work clinically with retracted lips.
dures still has its limitations. Digitalization
cannot be utilized when removable prosth-
odontic concepts are applied, since the
digital scanners are not able to stitch and
merge large edentulous areas.
20

Furthermore, the computer resources and
stability of the software are compromised
when larger sets of data are produced.
Additionally, the handling of the scanner
head, which can be heavy, requires prac-
tice. The greatest time and workow benet
can be drawn from digital scanning sys-
tems when small restorations in one or two
quadrants are placed.
CONCLUSION
Compared with conventional techniques,
digital workows benet patients, clinicians,
and dental technicians alike in terms of cost
and precision. Future studies are neces-
sary, however, to determine whether the
longevity of restorations is also positively
inuenced.
b a
c
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