DENTAL TECHNIQUE

A diagnostically and digitally driven tooth preparation protocol

by using a patient monitoring tool with an intraoral scanner
Marco Valenti, DDS,a Johannes H. Schmitz, DDS, PhD,b Davide Cortellini, DDS, DMD,c Alessandro Valenti, DDS,d
and Angelo Canale, CDTe

Challenges during tooth ABSTRACT

preparation include the choice Finding the right balance between the preservation of tooth structure and providing adequate
of finish line (margin geome- space for the restorative material is a major challenge in prosthetic dentistry. A technique is
try) and the thickness required presented using the patient monitoring tool available in standard software programs of an
for the restoration.1 Excessive intraoral scanner to constantly monitor preparation dimensions in relation to the optimal
tooth preparation may lead to definitive restoration. (J Prosthet Dent 2021;-:---)
the need for endodontic
treatment.2 However, when additional space is provided, reduction for the specific restoration planned by the
it will be easier to fabricate restorations with optimal clinician.17,25,27
3 ,4
contours and esthetics. New materials and techniques
have enabled minimal tooth reduction,5-7 with minimum
thickness restorations being placed with minimal or no TECHNIQUE
tooth reduction.8-16 However, tooth preparations may be
This technique can be used during the preparation pro-
inadequate for the planned restoration.17
cedure of natural teeth for ceramic veneers, crowns, or
Different strategies have been developed to achieve a
fixed partial dentures. To control the preparation both in
diagnostically driven conservative tooth preparation
terms of space and shape, it is necessary to scan the ideal
while providing adequate space for the restorative ma-
initial situation or initial ideal scan (IIS) of the tooth to be
terial. These strategies include the use of rotary in-
1,18 restored. If a tooth needs a restoration because of abra-
struments with a known cutting depth and the use of
sion or erosion, a dental laboratory technician can pro-
a silicone tooth preparation guide obtained from diag-
19-21 duce a digital waxing that will be used to create a trial
nostic waxing or from trial restorations. More
restoration. This will serve as the initial ideal situation
recently, 3-dimensionally printed tooth preparation
22-24 than can then be scanned as the IIS. When a tooth needs
guides from a virtual waxing or completely digital
25-27 an extensive restoration or when it is malpositioned, the
preparation guides have been developed.
initial scan can be substituted by a digital waxing that can
Digital technology can allow precise control over the
be imported into the intraoral scanner software program
thickness obtained during the preparation procedures.
(TRIOS; 3Shape A/S) and is referred to as the initial
Digital feedback has been shown to be helpful by dis-
reference scan.
playing how much tooth structure has been removed, in
16
improving preparation skills, and in giving indications 1. Start producing the IIS, which will act as the refer-
regarding the appropriateness of the preparation ence scan for the next steps (Table 1).

a
Private practice, Pordenone, Italy.
b
Private practice, Milan, Italy.
c
Private practice, Riccione, Italy.
d
Private practice, Pordenone, Italy.
e
Dental Lab owner, Rimini, Italy.

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Table 1. Types of initial ideal scan which will act as reference scan for
subsequent steps
Initial Scan Digital Waxing
Used as Used as Trial Restoration
Initial Reference Scan Reference Scan Used as Reference
Tooth Type Scan for Analysis for Analysis Scan for Analysis
Ideal tooth Yes Yes No No
Additive Yes No No Yes
approach
Subtractive Yes No Yes No
approach
Inadequate
tooth form

a. If there is already an ideal situation, choose the Figure 1. Scan of initial situation with intact teeth and correct shape.
“scan only” option in the left menu and scan the
initial situation before starting the tooth prepa- angulations relative to the tooth axis. The scan
ration (Fig. 1). comparison tool has a color scale that allows the
b. If the planned restorations are additive, the clinician to determine the 2 thresholds (too thick or
dental laboratory technician will create a digital too thin) of the preparation and identify areas that
waxing from an initial scan and then print it to need further preparation (Fig. 9).
create a silicone tooth preparation guide (Fig. 2). 6. Adjust the preparation accordingly and go back to
After trial restoration placement, it will be scan- step 3 (copy the IIS, trim the tooth prepared, scan it,
ned as the IIS. and start a new comparison with the patient
c. If it is necessary to subtract a portion of the tooth monitoring tool) until the tooth preparation is
to be restored, the dental laboratory technician satisfactory.
will create a purely digital waxing. This file can 7. When the tooth preparation is satisfactory, prepare
then be imported into the software program a new case as a prosthetic case and send it to the
(TRIOS; 3Shape A/S) as a “scan only” (Fig. 3). dental laboratory technician.
2. In a scenario similar to step 1a or 1b, start tooth
preparation using calibrated rotary instruments DISCUSSION
(Fig. 4A). Maintain a conservative approach to
gradually proceed with further corrections after The process should always start with a scan or digital
evaluation through the Patient Monitoring function waxing representing the ideal shape and size of the tooth
(TRIOS; 3Shape A/S) (Fig. 4B). to be restored to make an ideal tooth preparation to
3. Create a new case copying the IIS with the intact fabricate the restoration. If an interim restoration is used
teeth. Trim the prepared teeth and scan the same as the reference in the procedure described, it must be as
teeth that have now been prepared (Fig. 5). close as possible to the definitive restoration. An ideal
4. Open the IIS case (natural 1A, trial restorations 1B, digital waxing is preferred as a reference rather than an
or digital waxing 1C). Choose the Patient Moni- interim restoration.
toring button in the upper menu. Choose the ones The use of a physical index or tooth preparation
to be compared with the IIS (ideally the one with guide can be cumbersome and empirical.28 Further-
the prepared abutments) (Fig. 6). more, each plane in space must be analyzed sepa-
5. The software program will automatically recognize rately. It is therefore impractical to receive visual
the scans and the teeth. The “scan comparison” and feedback as the preparation progresses. Being able to
the “sectioning tool” (left menu) are now available evaluate the adequateness of the preparations before
to evaluate the preparations against the IIS (Fig. 7). sending impressions or scans to the dental laboratory
On the 3-dimensional image, a sectioning reference technician is important to improve the efficiency of the
can be added in any plane in the 3-dimensional workflow22-25 The patient monitoring tool is available
space. By moving the section tool, it is possible to for all TRIOS 3Shape users and was initially developed
evaluate the distance between the prepared surface to evaluate orthodontic movement and patients with
and the trial restoration or the initial situation, the tooth abrasion. When using a different intraoral
interocclusal space, and a 360-degree evaluation of scanner without a patient monitoring function, the
the preparation (Fig. 8). For every tooth to be prepared tooth can be compared with an ideal refer-
analyzed, the process must be repeated to erase ence scan by sending the standard tessellation lan-
the section previously used to avoid incorrect guage (STL) files generated by using a scanner to a

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Figure 2. A, Clinical treatment that required additive approach. B, Digital trial restorations of additive clinical situation. C, Cast of initial situation, digital
trial restorations, and silicone index. D, Resin trial restorations representing ideal situation to be scanned.

computer-aided design (CAD) laboratory software It is important to allow the most precise superimpo-
program (exocad DentalCAD; exocad GmbH, Dental sition of the scans. For this reason, whenever possible,
Wings Dwos; Dental Wings Inc), which allows su- the procedure should start from a preoperative scan or a
perimposition of the files and analysis of the space trial restoration scan. This file should then be copied and
achieved through the “section” function. This pro- trimmed to eliminate other teeth that can be easily
cedure is equally effective, albeit more time consuming scanned and added to the copy of the original scan. This
and less practical within the prosthetic workflow. will accelerate the scanning process and improve the

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Figure 3. Procedure to import digital waxing file produced by dental laboratory technician if initial situation not ideal.

Figure 4. A, Calibrated rotary instruments to obtain controlled and homogeneous tooth reduction. B, Tooth prepared and scanned to start patient
monitoring tool.

precision of the superimposition performed automatically

by the software program. Overall, these tools enable ideal
tooth preparation with the correct space for the restor-
ative material used.

SUMMARY
A technique that allows clinicians and dental laboratory
technicians to obtain valuable information regarding the
preparation procedure is described. Following this pro-
tocol, the clinician can see where additional preparation
is needed before commencing the procedure and can
evaluate how much space has been given for the
restorative material, improving the functional and Figure 5. Tooth trimmed from Initial Scan after abutment preparation
esthetic outcomes of the restoration and tooth. and before new scan made to start comparison.

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Figure 6. Patient monitoring window. Scans selected for comparison.

Figure 7. Scan comparison and cross-section tools on left menu.

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Figure 8. Thickness measurements. A, Longitudinal section. B, Transverse section.

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Figure 9. A, Activation of scan comparison in “patient monitoring” function reveals presence of small palatal areas lacking adequate thickness for
restoration (green and yellow colors indicating average space of 0.0 to 0.3 mm). B, After correction by clinician, scan comparison shows different shades
of red color indicating provided space, ranging between 0.5 and 0.8 mm, adequate for definitive ceramic crown.

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