Written by: Melissa Zettler, DDS
While digital dentistry is often showcased in high-end, influencer-driven social media posts, its real-world applications can be helpful even for dentists who just want to try it. Practitioners can embrace digital tools like iTero, exocad, and SprintRay to offer workflows that are easy and predictable. This case demonstrates how incorporating digital design and case planning can provide terrific results at fees that benefit many patients.
The Patient’s Situation
An 80-year-old woman, the primary caregiver for her husband, broke her front tooth (No. 9). Her health was good, but much of her time and money was spent caring for her husband. She expressed a desire for a replacement for her missing tooth that would not be removable. She asked about an implant, but after the discussion, she decided she could not afford it. She could not afford a porcelain bridge either, although she preferred this workflow over an implant. When presented with a removable option, she reaffirmed that she wanted a fixed option that looked good, would function well, and was affordable to her. Willing to accept this challenge, after discussing the most common options, a printed bridge was presented. The patient liked this choice. After a candid conversation about the aesthetics, price, and durability, this is what she chose.
The Plan
Using digital tools, a digital mockup of the area to be restored was created, replicating the patient’s existing teeth shapes and incisal lengths. This digital mockup would serve as the basis for printing the restorations that would serve as her final prosthesis.
The Care and Procedure
Preparation and planning: An iTero scanner (Align Technology) was first used to capture the patient’s teeth before extraction, providing a reference for design (Figure 1). The teeth shapes and lengths were preserved in the scan. This was useful in creating a restoration that allowed the patient to keep her existing look, which she liked. The preoperative scan was imported as a ply file into exocad software (ply means the scan is transferred in color, where an STL is not in color). Within the software, the case was set up using the mirror copy function to duplicate existing teeth Nos. 7 and 9. Then, exocad was used to design a digital bridge by copying the shape of tooth No. 9 and placing it in the position of tooth No. 8. Tooth No. 7 was duplicated and superimposed over Tooth No. 10. The software allowed visualization of where to make adjustments. The areas that didn’t align were highlighted in yellow, and the design was adjusted accordingly (Figure 2). The design was exported and printed using Die and Model grey resin (SprintRay). The STL was brought into RayWare (SprintRay) and the finest print setting a Pro 95 s 3D printer would allow was chosen. The finest setting was chosen to minimize the lines that are often visible on printed models. The patient was now ready to have her nonrestorable tooth removed.
Figure 1. Preoperative image.
Figure 2. Mockup wax-up.
Extraction and Preparation
On preparation day, we began by drawing blood from the patient’s arm and placing the vial into a centrifuge to create a fibrin plug. While the blood was spinning, an OptraGate (Ivoclar) was placed into the patient’s mouth to isolate the field, and the teeth to be restored were prepared. Once the preparations were completed, the nonrestorable tooth was atraumatically removed, and the PRF plug was placed into the extraction site to promote healing. The iTero was used again to capture a digital scan of the prepared teeth (Figure 3). A temporary bridge fabricated as a same-day workflow was not yet an option due to the time-consuming nature of the project. To make the temporary, the wax-up model was used as a template. A putty copy of the wax-up was created with Panasil Putty (Kettenbach Dental), which extended at least one tooth past the areas to be restored to allow for firm seating. The putty was placed over the model, shaped, and allowed to set. Once set, it was removed and trimmed in a scalloped fashion. Luxatemp (DMG) was used to fabricate the temporary bridge by inserting it into the matrix and placing it over the preparations. Once the Luxatemp was set, the putty matrix was removed, the restorations retrieved from the putty, trimmed, polished, and delivered. The patient was seated up, and the temporary was checked to ensure it was level and looked as she wanted it to.
Figure 3. Prepared teeth after extraction.
Designing the Printed Restoration
Digital Design: The digital scans of the prepared teeth and the opposing arch were imported into exocad as a ply file to begin designing the final restorations. A new case had to be set up in exocad. This time, mirror and copy were not used, and the case was set up as a bridge and crown. iTero was used to capture the prepared teeth (Figure 4), and a mockup of the desired restoration was already available and ready for use. Within exocad, the mockup STL was merged with the preparation scan using a feature called “align meshes”. This function allowed the design to be overlaid with the defined preparations. The merger of the 2 files ensured that the final restorations matched the original design, preserving the natural appearance of the patient’s teeth and her occlusion. The software was used to mark and adjust margins, refine connectors, and create restorations that fit. The merger did create a design that needed some refining, as it was not an exact copy—the tools within the program allowed for this. exocad guides you through the process in a step-by-step procedure; however, there is a learning curve (Figure 5).
Figure 4. Preparation in occlusion.
Figure 5. Merged design with preps.
Printing the Final Restorations: Once the design was complete, it was exported from exocad for printing. The STL file was imported into RayWare. Two sets of restorations were printed using B1 Crown and Bridge resin (SprintRay). This was the only shade on hand at the time, and the patient was informed of the available color and that the restorations would be tinted to match as closely as possible. To print 2 bridges, the original STL was duplicated in SprintRay’s platform, and the nesting was refined after the AI set it up. It was important that each incisal edge have 3 supports for printing, but the software does not reliably provide them. Once printing was complete, the restorations were hand washed, dried, and the supports removed. The intaglio was cleaned thoroughly, ensuring no pools of resin remained that could affect seating. The restorations were then stained with Empress Direct composite stains (Ivoclar) and spot cured with an appropriate light. Next, a thin layer of the crown-and-bridge resin used to print the bridge was applied over the top and spot-cured. The restorations were placed in food-grade glycerin to cure and minimize the formation of inhibition layers. SprintRay’s cure oven was used and set to match the resin for proper curing. Once fully cured they were removed and cleaned with soap and water (Figure 6).
Figure 6. Restorations.
The Delivery
When the patient returned, her healing was underway, and the temporary restoration was removed. The teeth were cleaned with Conspesis Scrub (Ultradent) mixed with pumice. The final restorations were tried in, and one set was selected. The gingival levels of teeth Nos. 8 and 9 were not even, but did not show when the patient smiled, so this compromise was accepted (Figure 7). The restorations were cleaned, sandblasted, and treated with Monobond Plus (Ivoclar). They were seated after etching with 38% etch, using Variolink Esthetic Resin (Ivoclar) and Prime & Bond Universal adhesive (Dentsply Sirona). The occlusion was checked, and minimal adjustments were made. Radiographs were taken to ensure complete cement removal (Figure 8).
Figure 7. Retracted restorations.
Figure 8. (a) Finished restorations seated. (b and c) Postoperative x-rays.
The Outcome
The final result was a nonremovable, aesthetic bridge and crown that blended with the patient’s remaining teeth. The patient was thrilled with the outcome despite not wanting to see the 2 sets of restorations to help choose which one to cement. The restorative solution provided a balance of aesthetics, function, and affordability—delivered using digital dentistry tools (Figure 9).
Figure 9. Happy, smiling patient.
CONCLUSION
This case exemplifies how digital dentistry can offer practical solutions for patients with limited budgets, while still achieving excellent functional and aesthetic outcomes. It also highlights the ease with which digital tools can be integrated into general practice, as this provider is neither an influencer nor a long-time digital dentist.
ABOUT THE AUTHOR
Dr. Zettler is a respected dentist practicing in Savage, Minn. A graduate of the University of Minnesota School of Dentistry, she further advanced her training with a one-year general practice residency at the Minneapolis Veterans Hospital. Dr. Zettler holds distinguished credentials, including Fellowships in the Academy of General Dentistry and the Congress of Oral Implantologists, and accreditation from the American Academy of Cosmetic Dentistry, reflecting her pursuit of excellence in the field. Committed to continuous learning, Dr. Zettler is passionate about adopting innovative techniques to ensure her patients receive the highest standard of personalized care. She places great emphasis on understanding the unique needs of each individual, striving to deliver optimal oral health and aesthetic outcomes. Patients value her compassionate approach, attention to detail, and ability to blend advanced dental practices with a focus on comfort and satisfaction. She can be reached at [email protected] or on Instagram at the handle @drmeldds.
Disclosure: Dr. Zettler reports no disclosures .
