Received: 25 December 2018 Revised: 2 February 2019 Accepted: 17 February 2019

DOI: 10.1111/jerd.12464

CLINICAL ARTICLE

Workflow description of additively manufactured clear silicone

indexes for injected provisional restorations: A novel technique
Marta Revilla-León DDS, MSD1,2,3 | Joshua Fountain DDS4 |
Wenceslao Piedra Cascón DDS, MS3,5 | Mutlu Özcan DDS, DMD, PhD6 |
Amirali Zandinejad DDS, MS1

1
College of Dentistry, Texas A&M University,
Dallas, Texas Abstract
2
Graduate Prosthodontics Program, University Objective: The present article describes the digital workflow protocol for additive manufactur-
of Washington, Seattle, Washington ing (AM) of a clear silicone index to be used for an injected provisional restoration fabrication.
3
Revilla Research Center, Madrid, Spain Clinical considerations: The incorporation of CAD software and AM technologies have allowed
4
AEGD Program, College of Dentistry, Texas the integration of a new way to fabricate conventional diagnostic wax-ups and silicone indexes
A&M University, Dallas, Texas
for preparing diagnostic mock ups, direct composite restorations, or provisional restorations.
5
Esthetic Dentistry, Complutense University,
Although the conventional concept remains, the protocol differs.
Madrid, Spain
6
Conclusions: This workflow provides a more efficient and accurate procedure with the reduc-
Dental Materials Unit, Center for Dental and
Oral Medicine, University of Zürich, Zürich, tion of time and cost compared to conventional technique.
Switzerland Clinical Significance: The digital workflow protocol described for AM of a clear silicone index to
Correspondence be used for an injected provisional restoration fabrication is time and cost efficient compared to
Marta Revilla-León, College of Dentistry, conventional procedures.
Texas A&M University, 3302 Gaston Avenue,
Room 713 Dallas, TX 75246.
Email: revillaleon@tamhsc.edu KEYWORDS

3D printing, additive manufacturing, computer-aided design, injected technique, provisional

restoration

1 | I N T RO D UC T I O N Both dental and open source CAD tools provide a powerful vir-
tual diagnostic assessment for restorative planning.34,35 Moreover,
Within the incorporation and development of intraoral scanners, com- open source software provides an inexpensive software that also
puter aided design (CAD) software, and additive manufacturing (AM) allows more freedom in design possibilities compared to the dental
technologies, a complete digital workflow for restorative procedures can CAD software. The materialization of the digital design is obtained
be protocolled.1,2 Moreover, the digital workflow has been shown to be through the computer aided manufacturing (CAM) technologies,
more efficient, cost effective and less time consuming than the conven- namely subtractive or milling, and additive technologies.36,37
3,4 5,6
tional workflow, and has shown better acceptance by patients. Additive manufacturing (AM) technologies involve the fabrica-
Different studies have analyzed the relationship between technol- tion of an object layer-by-layer.38 The ASTM international commit-
ogy employed by an IOS system and the accuracy of its acquisition tee F42 on AM technologies has determined seven AM categories:
procedure.7–17 Factors that could impact the accuracy of a digital stereolithography (SLA), material jetting, material extrusion, binder
impression performed by IOS18 have also been studied, namely handling jetting, powder bed fusion (PBF), sheet lamination and direct
19,20 21 22–24
and learning curve, calibration, scanning protocol, AMbient energy deposition.38
25 26–29 30
light scanning conditions, surface characteristics, mobile tissue, The direct light processing (DLP) AM is very similar to stereolitho-
reflective restorations, and/or presence of saliva.19,31–33 Digital impres- graphy (SLA). A vat of liquid photopolymer is exposed to light from a
sion techniques are a clinically acceptable alternative to conventional projector under safelight conditions. The DLP projector displays the
impression methods in fabrication of tooth and implant-supported image of the 3D model onto the liquid photopolymer. The exposed
7–17
crowns and short fixed dental prostheses (FDPs). liquid polymer hardens, the building platform then moves down, and

J Esthet Restor Dent. 2019;1–9. wileyonlinelibrary.com/journal/jerd © 2019 Wiley Periodicals, Inc. 1

2 REVILLA-LEÓN ET AL.

FIGURE 1 A, Occlusal view of the left mandibular second molar with the disto-lingual cusp, disto-buccal cusp and distal marginal ridge broken.
B, Periapical radiographic evaluation of the initial clinical situation

FIGURE 2 Diagnostic digital wax-up. A, Frontal view. B, Occlusal view of the diagnostic wax-up of the maxillary arch
REVILLA-LEÓN ET AL.
FIGURE 3 Open source CAD design of the flexible silicone index and rigid custom tray. A, Determination of the extension and uniform
thickness of the flexible index. B, Virtual determination of the hole access for the injection technique for the provisional restoration
elaboration. C, Final design of the custom tray over the flexible index, with the customized hole access for the provisional elaboration using
the injection technique
the liquid polymer is once more exposed to light. The process is
repeated until the 3D model is built and the vat is drained of liquid,
revealing the solidified model.38–40
In prosthodontics, multiple applications of the polymer AM tech-
nologies are currently available, such as AM diagnostic casts, custom
37
trays, silicone indexes, or surgical guides. Previously, an additively
manufactured silicone index has been described to connect the virtual
digital wax up to the patient’s mouth using a diagnostic mock-up,34,35
direct composite esthetic restorations on the maxillary anterior
teeth,34
or provisional restorations for ceramic veneers. 35
However,
the digital workflow can be also used to fabricate a clear silicone index
for the resin composite injection technique, which predictably trans-
lates the diagnostic wax-up into provisional restorations or direct
composite restorations. 41–43
The present article describes a complete digital workflow protocol
for the fabrication of the flexible clear silicone index and rigid clear
custom tray for a provisional restoration using the injection technique.
The workflow includes the intraoral digitizing procedures, the specific
dental and open source CAD tools needed for the diagnostic wax-up
elaboration, the additive manufacturing technologies selected for the
fabrication of the flexible clear silicone index, rigid clear custom tray,
3
and finally, the milled lithium disilicate onlay restoration cementation
for a mandibular molar.
2 | CLINICAL REPORT
A 37-year-old male patient came to the Advance Education in
General Dentistry (AEGD) residency program at the XXX University
College of Dentistry to receive oral care. The extraoral, intraoral,
and radiographic evaluations revealed acceptable oral health. Tooth
#18 presented an occlusal amalgam restoration with the disto buc-
cal and disto-lingual cusps and distal marginal ridge broken
(Figure 1A,B). Tooth was vital, no periapical radiolucency was
observed on radiographic evaluation, tooth response to cold test
was normal, and no sensitivity on percussion was reported. A lith-
ium disilicate onlay restoration was planned. A digital diagnostic
wax-up was elaborated to restore the disto-buccal and disto-lingual
cusps and distal marginal ridge of tooth #18, a diagnostic digital
wax-up, an AM silicone index was manufactured for fabrication of
the provisional restoration using an injection technique. The follow-
ing technique is recommended:
4 REVILLA-LEÓN ET AL.

Alternatively, maxillary and mandibular impressions can be made

with an irreversible hydrocolloid impression material (Hydrogum
5; Zhermack, SpA) in a conventional metal impression tray. Pour it
with dental stone type IV (Fujirock EP; GC Corp) according to the
manufacturer's instructions and digitize the casts with a labora-
tory scanner (R1000; 3Shape) to obtain an STL1 file of the casts.
2. The STL1 file was imported to the specific CAD dental software
(Dental system; 3Shape). Use the software-specific tools to elabo-
rate the diagnostic wax-up involving the desired teeth. When this
process is complete, export the STL2 file of the virtual wax-up.
In the present case, the objective of the virtual additive diagnostic
wax-up was to restore the disto-buccal and disto-lingual cusps
and distal marginal ridge of tooth #18 (Figure 2A,B).
3. The STL2 file was imported to an open source CAD software
(Blender, version 2.77a; The Blender Foundation) with the plugin
Open Dental CAD enabled to design the silicone index and the
custom tray (Figure 3A-C)
3A. The tool “Splints” on the menu was used to mark the index out-
line, including at least two teeth further to the last tooth involved
on the diagnostic wax-up if possible, to obtain stability of the
index. A uniform thickness of 2.5 mm was designed (Figure 3A).
3B. The tool “Create” on the menu was used with the tool “cylinder”
of the software to design the hole through which the restorative
material will be injected. The cylinder from the designed index
was subtracted using the Boolean operation “difference” of the
software (Figure 3B). Select the diameter of the cylinder based
on the dispenser characteristics of the dental restorative material
selected for the planned procedure. In the present case, the
diameter used was 4.5 mm, since that was the diameter of the
provisional material dispenser tip was 4 mm.
3C. The step 3A was repeated on top of the flexible silicone index cre-
ated in step 3B over the previous designed index to obtain the rigid
custom tray for the flexible injection index, giving a thickness of
4 mm.
3D. The step 3B was repeated in order to obtain the access hole to
inject the restorative material.
3E. The “difference” Boolean operation tool of the software was used
to subtract the 4 mm index obtained in step 3B to index obtained

FIGURE 4 Additive manufactured clear indexes. A, Flexible and clear

silicone index manufactured using a DLP printer, before the removal
of the supportive material. B, Flexible silicone index after the removal
of the supportive material. C, rigid and clear custom tray over the
flexible index

1. During the first clinical appointment, digital impression of the

applicable maxillary and mandibular quadrants and an interocclu-
sal record was made with an intraoral scanning device (iTero
Element; Cadent LDT) following the manufacturer’s recommenda-
tions. After placing a lip retractor (OptraGate, Ivoclar Vivadent),
the scan area should be dried to achieve relative isolation when
the digital impression is made. When the digital impression is
completed, the intraoral scanner device creates an STL1 (Standard FIGURE 5 Occlusal view of the onlay preparation on left mandibular
Tessellation Language) file. second molar
REVILLA-LEÓN ET AL.
FIGURE 6 Digital impression (iTero Element; Cadent LTD) of the tooth preparation for the onlay restoration of tooth #18. A, Maxillary
quadrant. B, Mandibular quadrant with the tooth preparation. C, Interocclusal registration
in step 3A. The final result is a custom tray of 2.5 mm for the flexi-
ble injection index (Figure 3C).
3F. The STL files of the virtual designs were exported: first, the flexible
silicone index design (STLI) and second, the rigid custom tray (STLT).
4. The STLI file was used to manufacture the flexible clear silicone
index with a DLP 3D printer (RapidShape D30 Printer, Rapid-
Shape), with a 25 μm layer thickness of flexible photopolymer
(Nexdent Ortho IBT, Nexdent Vertex Dental), (Figure 4A,B). When
the additive manufacturing procedure was completed, the index
was removed from the building platform using a putty knife. The
index was rinsed twice in a 96% isopropyl alcohol solution in an
ultrasound bath to eliminate any excess of non-polymerized mate-
rial. The first rinse time was 3 minutes, and the second time was
2 minutes in a clean 96% isopropyl alcohol solution. After clean-
ing and drying the index, it was placed in a UV-light polymeriza-
tion device (Otoflash; Bego) for 10 minutes at 385 nm for final
polymerization. Afterwards, the supportive structures were
removed.
The STLT file was also used to manufacture the rigid clear custom
tray with the same DLP 3D printer, with a 25 μm layer thickness
of flexible photopolymer (Nexdent Ortho Clear, Nexdent Vertex
Dental; Figure 4C). After the additive manufacturing process, the
same post-processing procedures were completed.
5
5. During the second clinical appointment, the tooth preparation
was performed. For the presented clinical case, an onlay prepara-
tion with cuspal coverage of the disto-lingual and disto-buccal
cusps on tooth #18 was performed using a diamond bur
(845KR.31.016 M FG; Brassler) and a finishing diamond bur
(8845KR 018; Brassler). The internal angles were rounded, and
the tooth preparation was non-retentive. The finishing line was
placed supragingival (Figure 5).
A digital impression of the involved maxillary and mandibular quad-
rants was made, as well as, an interocclusal record with an IOS
device (iTero Element; Cadent LDT) following the manufacturer’s
recommendations (Figure 6A-C). After placing a lip retractor
(OptraGate, Ivoclar Vivadent), the scan area was dried to achieve
relative isolation when the digital impression was made. When the
digital impression was completed, the intraoral scanning device cre-
ated an STL3 file.
Alternatively, a maxillary impression can be made with an irrevers-
ible hydrocolloid impression material and a mandibular impression
with a polyvinyl siloxane impression material in a conventional
metal impression tray. The impression should be poured with dental
stone type IV according to the manufacturer's instructions and the
casts could be digitized with a laboratory scanner to obtain a STL3
file of the casts.
6 REVILLA-LEÓN ET AL.

FIGURE 8 Provisional restoration using the injection technique. A,

Silicone indexes placed in the patient’s mouth. B, Occlusal view of the
provisional restoration of tooth #18

composite resin material was selected to fabricate the provisional

7. The STL3 file was imported on the dental CAD software (Dental
FIGURE 7 Try-in of the additively manufactured silicone indexes for
injected provisional restoration technique. A, Occlusal view of the
intraoral fit of the flexible clear silicone index. B, Occlusal view of the
intraoral fit of the flexible clear silicone index and rigid clear custom
8. For the last clinical appointment, the restoration was delivered.
tray. C, Closer view of the indexes fit on the patient’s mouth
The desired ceramic shade was selected using a shade guide (VITA
3D master; VITA). On the presented clinical case, shade 2M1 was
selected. All the photographic documentation needed was
completed.
6. To conclude the second clinical appointment, the 3D printed sili-
cone index and the custom tray was tried in the patient’s mouth
(Figure 7A-C). Complete seating on the teeth was ensured. A
restoration using the injection technique (Figure 8A,B). Then the
custom tray was removed, followed by the flexible index.
System; 3Shape) to virtually design the restoration on the desired
tooth. On the presented case, an onlay restoration was designed
using the specific tools to define the finishing line of the prepara-
tion, determine the path of insertion and create the onlay restora-
tion.
When the restoration was designed, the STL4 file was exported
and used it to manufacture the desired restoration. On the pre-
sented case, a monolithic milled lithium disilicate (IPS e.max CAD
LT A3; Ivoclar Vivadent) onlay restoration was fabricated.
On the presented case, the onlay restoration was cemented using
a composite resin cement (Rely × Unicem 2 clicker, translucent;
3M ESPE) with complete isolation (Figure 9A).
The onlay restoration was cleaned with distilled water in an ultra-
sonic bath for 5 minutes, and dried. Afterwards, the intaglio surface
of the lithium disilicate onlay restoration was etched using 4%
hydroflouric acid (Porcelain Etchant; Bisco) for 25 seconds, rinsed
thoroughly with water and dried. A layer of silane (Silane primer;
Kerr) was applied. A complete isolation of tooth #18 was obtained
REVILLA-LEÓN ET AL.
FIGURE 9 A, Occlusal view of the lithium disilicate onlay restoration
cemented. B, Periapical radiograph evaluation of the cemented
restoration
using a dental clamp (Clamp #27; Henry Schein), a rubber dam (Nic
Tone Medium Rubber Dam; Nic Tone) and a metal rubber dam
frame. The enamel of the preparation was etched using 32% phos-
phoric acid (Uni-Etch 32%; Bisco) for 30 seconds and rinsed thor-
oughly with water and dried. A self-etching resin cement
(Rely × Unicem 2 clicker, translucent; 3M ESPE) was applied on the
intaglio surface of the onlay restoration and seated in place. Excess
of cement was removed using microbrush and light-cured all margins
for 20 seconds. The interface surfaces were polished (Soflex discs;
3M ESPE). A final radiographic evaluation was performed to ensure
the complete seating and removal of the resin cement (Figure 9B).
3 | DISCUSSION
The treatment protocol presented involves a complete digital work-
flow, from the digitizing procedures to the milling manufacturing pro-
cess of the lithium disilicate onlay restoration. The technique
described includes the virtual digital wax-up procedure performed
using a specific dental and open source CAD software, and virtually
designed and additively manufactured silicone index for the provi-
sional restoration fabrication using the injection technique. This tech-
nique provides an important improvement with the incorporation of
7
the AM index and custom tray for the provisional restoration elabora-
tion compared to conventional procedures namely accurate reproduc-
tion the digital diagnostic wax-up, control of thickness, extensions and
path of insertion of the silicone index, double rigidity of the indexes
(flexible silicone index and rigid custom tray), and storage of the
designs in the cloud for easier recovery.
Both dental and open source CAD software provide powerful
tools to analyse, measure, or design a diagnostic wax-up or dental res-
toration. Dental CAD software is intended for the dental field which
can result in a more intuitive program for a dental professional than an
open source CAD software. On the other hand, open source software
provides an inexpensive tool with higher freedom of virtual design.
The design of the AM silicone indexes into two parts namely the
flexible index and the rigid custom tray, helps the position and
removal of those in the patient’s mouth without distortion. Moreover,
the clear characteristics of the material provide the possibility of the
adequate light polymerization of the provisional material through
it. Furthermore, in order to facilitate the insertion and removal of the
indexes, the presence of undercuts should be blocked during the CAD
procedures if needed. Furthermore, the virtual design of these indexes
allows for easy positioning of both pieces together, and the custom-
ized rigid tray reduces possible deformation of the flexible silicone
indexes while handling.
The clear material selected also allows for polymerization of light-
cured composite resin material through the silicone index. Although
attenuation of the curing light may occur as the light passes through
the clear index, complete curing may be performed after removal of
the indexes. Furthermore, the accuracy and definitive shape of such
provisional restoration may eliminate the necessary steps for shaping,
finishing and adjusting the interim restoration.
As an alternative of the described technique, the STL file of the
digital wax-up can be used to manufacture the AM diagnostic casts
from which a conventional silicone index can be elaborated. However,
this alternative may accumulate more distortion as major number of
steps are needed and there would be less control on the thicknesses
and limits of the silicone indexes compared with the present technique.
The present technique can also be applied on other more complex
clinical situations that may be needed such as multi-unit tooth-borne
provisional crowns, implant-supported provisional crowns, provisional
FDPs elaboration, and direct composite restorations with or without
increasing the vertical dimension.
Undoubtedly, the incorporation of the latest technologies in a pri-
vate practice and dental laboratory require the mastery of a learning
curve of understanding the workflow and digital tools, as well as, over-
come IOS, CAD software, and AM technologies handling. Further-
more, the higher the number of cases treated using the newest
technologies the higher the expertise of the digital workflow. Further-
more, after this learning curve is surpassed, the digital design of the
indexes using the CAD software would take no more than 10 minutes.
The new technique presented incorporates the AM of the silicone
index and the custom tray for an injection technique for a provisional
restoration fabrication. However, this technique can also be extended
to a direct composite restoration, diagnostic mock-up, provisional
veneer restoration or crown provisional restoration.
8 REVILLA-LEÓN ET AL.
4 | CO NC LUSIO NS
A technique description of a complete digital workflow protocol for
an onlay restoration is presented including the intraoral digitizing pro-
cedures, the dental and open source CAD tools needed for the diag-
nostic wax-up elaboration and virtual design of the silicone index, the
additive manufacturing technologies selected for the fabrication of
the flexible clear silicone index and rigid clear custom tray for the pro-
visional restoration fabrication using the injection technique. This pro-
tocol can also be used for a direct composite restoration, diagnostic
mock-up, provisional veneer or crown.
CONF LICT OF IN TE RE ST
The authors did not have any commercial interest in any of the mate-
rials used in this study.
ORCID
Marta Revilla-León https://orcid.org/0000-0003-2854-1135
Wenceslao Piedra Cascón https://orcid.org/0000-0002-2765-2207
Amirali Zandinejad https://orcid.org/0000-0001-8970-9611
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