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Advanced smile diagnostics using CAD/CAM mock-ups

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 CLINICAL RESEARCH

Advanced smile diagnostics using

CAD/CAM mock-ups
Manuel Sancho-Puchades, DDS
Clinic of Fixed and Removable Prosthodontics and Dental Material Science,
University of Zurich

Vincent Fehmer, MDT

Clinic of Fixed and Removable Prosthodontics and Dental Material Science,
University of Zurich
Department of Oral and Functional Rehabilitation, University of Geneva

Irena Sailer, Prof Dr med dent

Clinic of Fixed and Removable Prosthodontics and Dental Material Science,
University of Zurich
Department of Oral and Functional Rehabilitation, University of Geneva

Correspondence to: Manual Sancho-Puchades, DDS

Plattenstrasse 11, CH 8032 Zurich, Switzerland; E-mail: sancho.puchades@gmail.com

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 SANCHO-PUCHADES ET AL
Abstract
Diagnostics are essential for predict-
able restorative dentistry. Both patient
and clinician must agree on a treatment
goal before the final restorations are de-
livered to avoid future disappointments.
However, fully understanding the pa-
tient’s desires is difficult. A useful tool to
overcome this problem is the diagnostic
wax-up and mock-up. A potential treat-
ment outcome is modeled in wax prior
to treatment and transferred into the pa-
tient’s mouth using silicon indexes and
autopolymerizing resin to obtain the pa-
tient’s approval. Yet, this time-consuming
procedure only produces a single ver-
sion of the possible treatment outcome,
which can be unsatisfactory for both the
patient and the restorative team. Con-
temporary digital technologies may pro-
vide advantageous features to aid in this
diagnostic treatment step. This article
reviews opportunities digital technolo-
gies offer in the diagnostic phase, and
presents clinical cases to illustrate the
procedures.
(Int J Esthet Dent 2015;10:XXX–XXX)
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Introduction
Patients asking for an esthetic improve-
ment of their smile often have a desired
goal in mind. The image of this dreamed
appearance can vary greatly between
individuals, which makes the develop-
ment of a treatment goal challenging
for the restorative team. It is the task of
the team comprising the dental techni-
cian, dentist, and patient to determine
the desired outcome before the restora-
tive treatment is performed. This diag-
nostic phase, which aims to understand
the patient’s needs and to agree on the
appearance of the final restoration, is
key to obtaining satisfactory results in
comprehensive restorative dentistry.1-4
Moreover, foreseeing the final outcome
allows for the early identification of spe-
cific complementary treatments, such
as crown lengthening procedures or or-
thodontic movements. It also guides the
tooth preparations, since the restorative
space needed can be accurately as-
sessed with the help of silicon keys.
The diagnostic outcome can be as-
sessed at three time points. The first
and ideal time point is before any inva-
sive treatment is performed. Once the
patient has entered the dental office in
pursuit of assistance, and a thorough
medical and dental anamnesis and
examination has been performed, a di-
agnosis must be executed. The restora-
tive team will gather all the information
registered at the first appointment and
will start the intellectual process of di-
agnosing periodontal, endodontic, cari-
ologic or functional pathologies. Addi-
tionally, other equally relevant issues
have to be identified, such as the pa-
tient’s esthetic concerns and the choice
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of reconstructive materials. A detailed
esthetic analysis is necessary to im-
prove the understanding of the patient’s
needs.5 However, considering the com-
plex and subjective nature of esthetics,
an objective materialization of all these
parameters is indispensable to ensur-
ing that all points of view have been cor-
rectly interpreted.1,3
A diagnostic wax-up is a useful tool to
achieve the goal of an objective material-
ization.3,6,7 It improves the communica-
tion between patient, clinician, and tech-
nician, and gives a three-dimensional
representation of the tentative treatment
outcome.1,3,8 Usually, the dental techni-
cian models a possible dental configu-
ration in wax using as references clinical
photographs and anatomical landmarks
on the diagnostic cast (existing occlusal
plane and length and position of the re-
maining teeth). This process requires a
significant amount of time and energy,
since the technician must integrate all
the esthetic guidelines and adapt them
to each individual case. The wax-up is
later tried in the patient’s mouth using
silicone matrices and autopolymeriz-
able resin to evaluate its integration into
the patient’s smile and face, on what is
called a diagnostic mock-up.1
However, this procedure proves to be
impossible in certain clinical situations.
It will only be effective when an addi-
tive reconstructive attempt is intended.
In other words, since the mock-up lies
over the unprepared teeth, only con-
tours placed more buccally, or larger
volumes, will be feasible. In cases where
subtractive procedures are necessary,
the intraoral transfer of the wax-up will
need to be performed in a later treat-
ment stage.
 SANCHO-PUCHADES ET AL
The provisional phase represents the
second time point at which the esthetic
and functional outcome of the prospec-
tive reconstruction can be evaluated.
Eggshell indirect provisionals are pre-
ferred when a new smile configuration
is intended.9 Patients who do not have
sufficient restorations or whose dental
appearance is unsatisfactory profit sig-
nificantly from this provisionalization ap-
proach, since the esthetic improvement
is perceived immediately after the initial
teeth preparation.
The third and last time point to de-
termine the desired restoration design
corresponds with the wax-up try-in. Af-
ter the final impression is performed,
and before the framework is produced,
a new tentative configuration is made
over the prepared abutments on the fi-
nal cast. This step takes into account
the patient’s and restorative team’s
impression derived from the previ-
ous two diagnostic steps (diagnostic
mock-up and provisional phase). Us-
ing tooth-colored wax, the technician
produces a wax try-in that will simulate
the color and contour of the final res-
toration. When the case involves eden-
tulous spans or multiple units, the wax
structure can require a metal or resin
framework to improve its strength. An
advantage of this diagnostic maneuver
lies in the plasticity of the wax, which
allows immediate modifications of pos-
sible imperfections discussed during
the try-in appointment. Once the pa-
tient and restorative team have agreed
on the optimum restorative outline, the
wax try-in will be used as a reference
to determine the shape and thickness
of the framework and the veneering of
the final reconstruction.
As previously mentioned, significant
efforts are made to identify and mimic
the desired esthetic outcome before
the technician begins producing the
final restoration. Despite the time and
energy invested to come up with a di-
agnostic draft, the obtained result may
neither match the patient’s physiognomy
or personality nor represent the desired
result expected by the patient and the
restorative team. In these cases, small
changes can be attempted to modify
this initial draft. However, the range of
modifications is limited, and often a new
diagnostic version is necessary. The in-
ability to achieve the expected esthetic
result with a try-in leads to patient dis-
satisfaction and, worse, the frustration
of the restorative team, and involves in-
creased time and economic expenses,
since it means further diagnostic steps
are necessary.
New computerized technology pro-
cedures may be helpful to overcome
these limitations. Computer technology
is increasingly transforming the way
dentistry is being performed. Comput-
er assisted design/computer assisted
manufacturing (CAD/CAM) processes
are transforming what were previously
manual tasks into easier, faster, cheaper,
and more predictable mechanized meth-
ods.10 Current industrial product devel-
opment would be impossible without
CAD technologies. Today, no engineer
would consider designing a prototype by
layering or carving a structure manually;
instead, a virtual environment is used,
where different versions can be tried-in
without significantly increasing the time
invested and with no impact on the costs
involved. Carving shapes manually has
evolved into designing volumes virtually
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 CLINICAL RESEARCH
by means of dedicated software. In re-
storative dentistry, the wax and modeling
are evolving into software and mouse-
clicks. The restorative team can profit
from virtual libraries from where differ-
ent tooth morphologies can be selected
(Exocad, 3Shape, Dental Wings, Siro-
na). These software tools offer numer-
ous different tooth shapes categorized
according to parameters such as size,
patient’s age or phenotype. Moreover,
real teeth can be used as a reference
to generate tooth morphology propos-
als.11 These standard shapes can later
be modified and adapted to individual
patient situations. Working time is sub-
stantially reduced by eliminating the
mechanical handwork needed for con-
ventional waxing techniques. This allows
the technician to focus solely on shapes
and tooth arrangements. Furthermore,
certain software allows for the integration
of photorealistic three-dimensional (3D)
reconstructions of the patient’s face into
the virtual design software.12 The face is
integrated by means of two-dimensional
(2D) digital photographs projected onto
a 3D virtual skull or by means of 3D facial
scanners. This allows for virtual smile de-
sign, taking into consideration important
facial reference planes such as midline
verticality, smile line, or the true horizon-
tal plane. A further benefit is the possibil-
ity of rapidly modifying an initial design
version in order to effortlessly try in oth-
er tooth arrangements. This grants the
technician freedom to generate multiple
versions of the future restoration in an
efficient manner. Being able to offer dif-
ferent versions at a single appointment
streamlines the diagnostic phase and
potentially better fulfills the wishes of the
most demanding patients and clinicians.
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Until now, subtractive CAM process-
es have dominated dental manufactur-
ing routines. Restorations are obtained
by trimming a solid block of material in-
to the desired 3D object by means of a
computer-controlled milling machine.13
However, these procedures present sev-
eral shortcomings, such as the waste
of considerable amounts of material,
the impossibility of creating geometries
that lie below the milling bur diameter,
and the impossibility of mass produc-
ing components.10,14 These restrictions
can be overcome by the introduction of
additive processing routes, such as lay-
ered fabrication.15 An example of these
technologies is 3D printers, which allow
for the manufacturing of several objects
at the same time in a precise and cost-
efficient manner. These 3D printers work
by jetting photopolymerizable materials
in ultrathin layers. Each layer is cured
by ultraviolet light immediately after it
is deposited, producing fully cured ob-
jects.16 The dual jetting printing proced-
ure requires two materials: a hard fun-
damental material and a gel-like support
material. The support material is neces-
sary to sustain complex geometries of
the fundamental material during fabri-
cation and is easily removed by water
jetting after printing. Micron-accurate
shapes can be printed in different com-
binations of photopolymers, producing
materials with specific mechanical and
visual properties. Products with different
levels of strength, rigidity, color, trans-
parency, heat resistance or texture can
be obtained. This production modality
has widened the indication spectrum of
restorative computer-assisted dentistry.
The aim of this article is to illustrate the
benefits a CAD/CAM workflow provides
 SANCHO-PUCHADES ET AL
Fig 1    Conventional workflow vs digital diagnostic
workflow. A time progress bar is depicted under
each treatment step to show the relative time/effort
needed for the completion of each step.
to the diagnostic processes during a
comprehensive restorative treatment. A
computer-assisted diagnostic treatment
sequence will be described in detail and
clinical examples given to illustrate the
possible outcome that can be obtained.
CAD/CAM mock-up
workflow
Figure  
1 illustrates the different treat-
ment steps and estimated time invest-
ment needed to carry out a digital and a
Fig 2   Volumetric information obtained by direct
intraoral optical scanning.
Fig 3    Plaster model being digitalized using a la-
boratory optical scanner.
conventional esthetic diagnostic proto-
col. The anatomical data acquisition of
the patient’s jaws can be obtained either
by directly capturing the volumetric infor-
mation using intraoral optical scanners
or by digitalizing a plaster model using
a laboratory optical scanner (Figs  2 and
3).17 The .STL data generated is trans-
ferred into a software package that allows
dental restoration design. After selecting
the abutment teeth to reconstruct, a spe-
cific tooth shape set is chosen from the
virtual library. The projected tooth forms
are manually arranged by the dental
7
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 CLINICAL RESEARCH
Fig 4    Virtual design of prospective reconstruction
using digital design software.
Fig 5    3D printer simultaneously producing different mock-up versions of a clinical case. Virtual printing
tray, where the different .STL versions are arranged before printing (left). Printer simultaneously producing
multiple resin blueprints (right).
8
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technician onto the dental arch (Fig  4).
Variations on the mesiodistal, bucco-
oral, and occlusogingival dimensions, as
well as tooth axis or tooth composition
can easily be performed with the design
software. Once a first version has been
completed and saved on the computer,
new versions can be efficiently created
with a couple of clicks. For example, by
simply dragging a virtual point, a stand-
ard tooth arrangement can easily be indi-
vidualized by intruding or rotating teeth.
The chosen blueprints, saved as .STL
files, are then exported to a 3D printer that
will layer the restorations (Fig  5). Nowa-
days, biocompatible photopolymers are
available to produce rigid tooth-colored
restorations. However, even though they
are biocompatible, manufacturers rec-
ommend the limitation of mucosal mem-
brane contact to 24 hours (see http://
www.stratasys.com/materials/polyjet/
bio-compatible). Consequently, the ma-
terial is suitable to produce diagnostic
mock-ups but not to manufacture provi-
sionals. The ease, speed, and reduced
costs derived from this diagnostic work-
flow, in conjunction with the accuracy of
the mock-up, make the procedure highly
efficient and recommendable.
 SANCHO-PUCHADES ET AL
Fig 6a    Preoperative photographs of the patient.
The three clinical cases that follow il-
lustrate the previously described pro-
cedures.
Clinical cases
Case 1
A 35-year-old female patient attended
the Clinic for Fixed and Removable
Prosthodontics and Dental Material Sci-
ence of the University of Zurich dissat-
isfied with her restorations on teeth 11
and 21. Her main complaints were the
unsatisfactory interincisal diastema and
the excessive length of both central inci-
sors (Fig  6a). The biological examination
proved inconspicuous (vital teeth with no
periodontal pathology and satisfactory
crowns); however, further assessments
were necessary to obtain an esthetic di-
agnosis. A diagnostic wax-up was fabri-
cated over a duplicate of the initial study
model. Since the prospective recon-
struction was intended to be shorter than
the current crowns, a direct preoperative
mock-up was unfeasible. Based on the
wax-up, eggshell provisionals were fab-
ricated and intraorally relined after the
old restorations had been removed. The
patient was satisfied with the length of her
new restorations but did not like the teeth
shapes. Therefore, further diagnostic
maneuvers were needed before the final
restoration was initiated. Since a diag-
9
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 CLINICAL RESEARCH

Fig 6c    Printed mock-up versions being tried in on the

patient.

Fig 6b    Versions of possible treatment out- Fig 6d    Preoperative view, chosen mock-up, and final
come: rounded, square, and butterfly shapes. restoration.

Fig 6e    Preoperative view, different mock-ups, and final restoration.

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 SANCHO-PUCHADES ET AL
nostic wax try-in over the final prepared
abutments was needed, a computer-as-
sisted workflow was chosen to offer the
patient different teeth shapes and ar-
rangements. After the final preparation of
the abutments was performed, a digital
impression was taken with an intraoral
scanner (iTero, Align Technology). The
.STL data generated was transferred to
virtual design software (Exocad, Exocad)
and three versions of the possible treat-
ment outcome were designed: rounded,
square, and butterfly shaped arrange-
ments (Fig  6b). The three .STL files were
sent to a 3D printer (Objet Eden260V,
Stratasys), which produced the try-ins in
an A3 colored resin (production time: 28
min) (PolyJet MED610, Stratasys). The
Fig 7a    Preoperative photographs of the patient.
mock-ups were tried in, and the patient
and restorative team could evaluate and
compare the result on the patient’s den-
tal and facial appearance (Fig  6c). It was
agreed that the rounded version best
matched the patient’s physiognomy and
character, and was therefore used by the
technician as a reference for the final res-
toration (Figs  6d and 6e).
Case 2
A 52-year-old male patient attended the
Clinic for Fixed and Removable Pros-
thodontics and Dental Material Science
of the University of Zurich asking for a
comprehensive rehabilitation of his de-
teriorated dentition (Fig  
7a). His main
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Fig 7b    Versions of possible treatment outcome.
concerns were to recover masticatory
function and to improve the appearance
of his smile. After a thorough ­anamnesis
and exploration, the biologic patholo-
gies and esthetic flaws were identified.
However, the diagnosis of the ideal con-
tour of the prospective reconstruction
needed further investigation. A wax-up
was fabricated and tried in as a direct
mock-up over the patient’s teeth. Likes
and dislikes were analyzed in conjunc-
tion with the patient, and the corre-
sponding modifications were made to
the diagnostic wax-up. Based on these
corrections, eggshell provisionals were
made. These restorations only partially
fulfilled the patient’s initial wishes, since
he could eat and speak again comforta-
bly. He was not, however, totally satisfied
with the appearance of his new smile.
Therefore, before the framework of the
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final reconstruction was designed, a di-
agnostic try-in appointment was sched-
uled. The conventional master models
were optically scanned (IScan D104,
Imetric), and three versions of the pos-
sible maxillary reconstructions were pro-
jected utilizing virtual design software
(Exocad). These three versions were
then printed in A3 colored resin (PolyJet
MED610) using a 3D printer (Objet Eden
260V) (production time: 58 min) (Fig  7b).
The digitally generated mock-ups were
tried-in and critically evaluated by the
patient and the restorative team (Figs  7c
and 7d). It was agreed that the version
with no diastema and converging incisal
borders best fit the patient’s smile and
face. This version was then taken as a
reference for the final restoration pro-
duction (Figs  7e and 7f).
 SANCHO-PUCHADES ET AL

Figs 7c and 7d  Mock-up

versions of possible treatment
outcome.

13
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Fig 7e    Preoperative view, chosen mock-up, and final restoration.

Fig 7f    Preoperative view, different mock-ups, and final restoration.

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 SANCHO-PUCHADES ET AL
Fig 8a    Preoperative photographs of the patient.
Case 3
A 47-year-old female patient attended
the Clinic for Fixed and Removable
Prosthodontics and Dental Material
Science of the University of Zurich dis-
satisfied with the result of a recently
delivered dental rehabilitation (Fig  8a).
She complained about the esthetics
and the generalized gingivitis that had
developed around every crown since
the restorations had been cemented.
The dental examination revealed over-
hangs and narrow interdental spaces
in nearly every crown, which required
that the dental rehabilitation be redone.
Eggshell provisionals were fabricated
and were to be relined at the same ap-
pointment that the old reconstructions
were to be removed. Since the patient’s
esthetic concerns were difficult to de-
termine, a digital impression was taken
intraorally (iTero), and different smile
proposals were designed virtually (Ex-
ocad) and printed in A2 colored resin
(PolyJet MED610) using a 3D printer
(Objet Eden 260V) (production time: 64
min) (Fig  8b). The digitally generated
mock-ups were tried in and critically
evaluated by the patient and restora-
tive team (Fig  8c). The version that was
agreed upon to be the best was taken
as a reference for the final restoration
production (Figs  8d and 8e).
15
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Figs 8b and 8c    Mock-up versions of possible treatment outcome.

Fig 8d    Preoperative view, chosen mock-up, and final restoration.

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Fig 8e    Preoperative view, different mock-ups, and final restoration.
Discussion
Digital technologies offer significant im-
provement opportunities in many dental
and medical fields. Restorative dentistry
has been one of the disciplines that has
profited the most from these technologi-
cal advancements.14 Among these in-
novations, CAD/CAM technologies have
greatly influenced the production of pro-
visional and definitive restorative com-
ponents.10,13,14 As the technology es-
tablishes and develops further (intraoral
optical scanners, cast optical scanners,
virtual design software, 3D printers),
new indications arise in other treatment
phases of the restorative workflow. This
article presents the advantages offered
by new digital technologies in the pros-
thodontic diagnostic phase.
Diagnostics are essential for a predict-
able treatment outcome in esthetic den-
tistry. Understanding the patient’s needs
and agreeing on a clear treatment goal
are fundamental to obtaining a satisfac-
tory end result.3 In some cases, the pa-
tient’s desires can be difficult to interpret,
and conventional diagnostics involving a
single wax-up and mock-up can be insuf-
ficient to determine the desired treatment
goal. The need for further wax-ups can
be both time-consuming and expensive.
Virtual technologies can make this treat-
ment step easier and less expensive as
they eliminate the manual work restraints
of the dental technician, enabling full
concentration to be focused on the teeth
shape and arrangement. When the pro-
spective restoration volumes have been
virtually designed, variations of this initial
sketch can be rapidly made with little ef-
fort. Several versions can be designed
and fabricated simultaneously during
the same 3D print without increasing the
costs. Moreover, the printing material is
inexpensive, which makes the protocol
17
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 CLINICAL RESEARCH
affordable (estimated material cost per
mock-up set print: 12 CHF). The oppor-
tunity to choose among a range of blue-
prints improves patient–dentist–techni-
cian communication and satisfaction, and
facilitates the decision-making process.
Nevertheless, some relative limita-
tions exist when producing mock-ups
using this additive process. Besides the
noteworthy initial economic investment
needed to purchase the hardware (opti-
cal scanner, 3D printer), difficulties arise
when attempting to achieve morphologic
details digitally. Mastering and becoming
efficient with the design software requires
time and learning on the part of the dental
technician. Even so, final fine-tuning ad-
justments (incisal edge characterization,
interincisal embrasures, surface texture,
etc) must be done manually to achieve a
high-end result. Besides this, the printer
is incapable of producing structures with
a thickness of less than 0.3  mm, which
could be a limitation when thin buccal
shells are needed to avoid a bulky ap-
pearance of the mock-up.
Moreover, the available materials for
3D printing with the presented protocol
unfortunately are not biologically and
mechanically stable enough to be used
as provisional or definitive restorations.
The 3D printing digital workflow is in-
terrupted when the final reconstruction
must be produced. In other words, a di-
rect transfer of the diagnostic blueprint
into the definitive restoration is not yet
achievable through computer-assisted
additive procedures. The manual ce-
ramic layering and contouring of the fi-
nal restoration performed by the dental
technician introduces slight differences
to the diagnostic sketches, as was ap-
preciated in the cases presented. Other
18
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CAM workflows using a subtractive ap-
proach are able to produce provisionals
and definitive restorations with the de-
sired CAD form.18,19 Even though they
are effective, these workflows present
some limitations, such as color/shade
restrictions, waste of considerable
amounts of material, the impossibility of
creating geometries that lie below the
milling bur diameter, and the impossibil-
ity of allowing for the simultaneous mul-
tiple production of restorations.10,14
Additive processing routes that would
allow polychromatic polymer printing or,
even more interesting, ceramic layering,
would be extremely valuable. Currently,
some 3D printing companies offer the
possibility of printing non-dental ceram-
ics effortlessly (Shapeways, Materialise).
The printing procedure involves a roller
that places a thin layer of ceramic pow-
der on a printing platform, and a printing
head that deposits organic binder at cer-
tain desired locations. Thin layers of the
ceramic model are overlapped as the
platform lowers and the roller spreads
new layers of powder. Once the model is
completed, it is then placed in a drying
oven to increase the strength of the ce-
ramic powder structure before it can be
conventionally fired in a ceramic oven
(Materialise – http://i.materialise.com/
materials/ceramics). Since the techni-
cal procedures are already available, it
seems reasonable to expect that these
advances will soon be available in the
dental field. Nevertheless, even though
CAM ceramic printing is feasible, there
is at present no CAD software to cap-
ture tooth color and design the polychro-
matic, ceramic powder 3D layout in the
model. However, this shortcoming is on-
ly a technical one, and it is only a matter
 SANCHO-PUCHADES ET AL

of effort being invested by the industry in nician communication without increas-

this field to develop a solution.
Despite the initial economic invest-
ment needed to enter the digital work-
flow (software, scanners, printers), the
current technical limitations of these
young technologies, and the learning
curve required to master the virtual tools
this pathway offers, dental digitalization
is an unstoppable phenomenon that
will surely push dental standards even
higher. The incorporation of these tech-
nologies into the prosthetic diagnostic
phase enhances patient–clinician–tech-
ing treatment costs. This improves the
predictability of the treatment outcome,
an aim that is crucial in contemporary
restorative dentistry.
Acknowledgements
The authors would like to thank Dr Philipp Grohm-
ann for the courtesy of the third case, and his col-
laboration during the development of the presented
concept. The authors would also like to thank Urs
Rohner for the outstanding fabrication of the final
restoration for the second case. Furthermore, the
authors declare no conflict of interest with respect
to the presented technologies.

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19
THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
VOLUME 10 • NUMBER 3 • AUTUMN 2015

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