CLINICAL REPORT

Digital fixed complete-arch rehabilitation: From virtual

articulator mounting to clinical delivery
Luca Lepidi, DDS, MDSc,a Carmela Suriano, DDS,b Hom-Lay Wang, DDS, MS, PhD,c Stefano Granata, DDS,d
Tim Joda, DMD, MSc, PhD,e and Junying Li, DDS, MSf

For complex oral re- ABSTRACT

habilitations, an accurate
The virtual articulator is a tool that reproduces the relationship between the jaws in a virtual
maxillomandibular relation- environment. The purpose of this clinical report was to describe a completely digital protocol
ship and harmony with starting from the virtual articulator mounting to developing static and dynamic occlusion in a
mandibular movements are complex prosthetic rehabilitation. (J Prosthet Dent 2020;-:---)
key factors in the successful
planning and delivery of treatment.1 The mechanical CLINICAL REPORT
articulator has been used in prosthodontics2 because it
can simulate the condylar position and the movement A 37-year-old woman with a history of unsuccessful
of the jaws. With the advance of technology, virtual orthodontic therapy and a maxillary left lateral incisor
articulators are becoming important tools in digital restored with a crown presented with the complaint of
dentistry.3 Virtual articulators can be completely not being satisfied with her smile. A skeletal class III
adjustable or mathematically simulated.4-6 Their chal- malocclusion was diagnosed (Fig. 1A, 1B). The proposed
lenges include the difficulty in transferring the masti- treatment plan comprised an interdisciplinary approach
catory movements that depend on the patient’s including orthodontics, orthognathic surgery, and pros-
muscles, which have to be adjusted by computerized thetic treatment. The orthodontics and orthognathic
axiography.7 surgery provided a skeletal class I relationship, but with
Various methods for mounting physical casts on vir- maxillary diastemas (Fig. 1C-E). The prosthetic therapy
tual articulator systems have been described8-12; how- was carried out in the following phases: trial restoration,
ever, it is now possible to perform a virtual mounting in virtual mounting and diagnostic waxing on a virtual pa-
maximal intercuspal position (MIP) for virtual waxing and tient, and provision of the definitive restorations.
subsequent computer-aided design and computer-aided A diagnostic waxing was developed as per the design
manufacturing (CAD-CAM) processing. from the Digital Smile Design system (Smile Creator;
The purpose of this clinical report was to describe exocad GmbH),13 a waxing cast was fabricated by 3D
a protocol for virtual mounting as per the technique printing, and a silicone index was produced from it. The
described by Lepidi et al 12 and to show how to first trial restoration was made intraorally with an interim
develop static and dynamic occlusion and simulate composite resin (Luxatemp Fluorescence; DMG) and was
mandibular movements in a completely digital used as the interim prosthesis during the entire planning
workflow. phase (Figs. 1F, 2).

a
Senior Lecturer and research fellow, Department of Clinical and Experimental Medicine, University of Foggia School of Dentistry, Foggia, Italy.
b
Graduate student, Department of Orthodontics of University of Foggia School of Dentistry, Foggia, Italy.
c
Research fellow and clinical lecturer, Department of Clinical and Experimental Medicine, University of Foggia School of Dentistry, Foggia, Italy.
d
Resident, Department of Neuroscience, School of Dentistry, University of Padova, Padova, Italy; and Private practice, Modena, Italy.
e
Professor, Department of Reconstructive Dentistry, University Center for Dental Medicine Basel, University of Basel, Basel, Switzerland.
f
Clinical lecturer and research fellow, Department of Periodontics and Oral Medicine, University of Michigan School of Dentistry, Ann Arbor, Mich.

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Figure 1. A, Initial intraoral presentation. B, Cephalometric radiograph before orthognathic surgery. C, Cephalometric radiograph after orthognathic
surgery. D, Intraoral view after orthodontic treatment. E, Smile before first trial restoration. F, Smile with first trial restoration.

Figure 2. Digital workflow procedure according to digital smile design. A, STL file from intraoral scan after orthodontic treatment. Brackets still in place.
B, Procedure to evaluate golden proportion of teeth. C, After matching between STL file by intraoral scanner and 2D photograph of smile. D, Result of
digital smile design. E, Esthetic digital waxing. F, Intraoral view, esthetic trial restoration in situ. STL, standard tessellation language.

A cone beam computed tomography (CBCT) scan of canal, and another rod was aligned to the Bergstrom
her was made 6 months after orthognathic surgery with point12 (10 mm anterior to the center of external auditory
the direct trial restorations in place. The CBCT scan meatus and 7 mm inferior to the Frankfort horizontal
included the maxilla, infraorbital point, and external plane), indicating the transverse horizontal axis of the
acoustic meatus. This scan was used as a virtual facebow mandible. The skull cast together with the rod was im-
to mount the intraoral scans onto the virtual articulator ported into Exocad. A maxillary scan made by using an
with the following steps.12 A 3D model of the skull was intraoral scanner (CS 3600; Carestream) was super-
generated from the CBCT images by using a dental CAD imposed to the skull cast by superimposing the teeth
software program (Exocad; exocad GmbH). This model (Fig. 3A). By registering the references on the skull, the
was imported into a standard tessellation language (STL) scans were mounted on the virtual articulator (Fig. 3B,
fileeediting software program (Meshmixer; Autodesk). A 3C). The mandibular cast was registered to the maxillary
3D rod was aligned to the upper margin of each ear cast with an interocclusal optical record in MIP (Fig. 3D).

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Figure 3. 3D skull reconstruction from CBCT images made with a facebow in place. A, Superimposition procedure of maxillary arch to skull. B, 3D
reconstructed skull with shafts passing through Bergstrom points (10 mm anterior to center of external auditory meatus and 7 mm below Frankfurt
horizontal plane) and upper margin of each ear canal. C, Alignment transverse horizontal axis of skull with joint axis of virtual articulator: shafts used to
align skull model to virtual articulator Type A. D, Intraoral scans oriented on skull so virtual mounting obtained. CBCT, cone beam computed
tomography; 3D, 3-dimensional.

The virtual articulator parameters used in the present adhesively bonded with a resin cement (Variolink
treatment were Bennett angle of 10 degrees; lateral side Esthetic Cement; Ivoclar Vivadent AG). The occlusion
shift of 0.5 mm; and sagittal condylar inclination of 35 was compared with the diagnostic waxing by evaluating
degrees. The simulation of the movements started from a the occlusal contacts with 2 thicknesses of articulating
reference position of the jaws in occlusion passing paper (Bausch Articulating Papers Blue and Red; Bausch)
through a condylar axis at the rest position. A digital (Fig. 6). She was recalled 6 months later and the occlu-
waxing (Fig. 4) was designed with an increased occlusal sion reevaluated (Figs. 7-9).14
vertical dimension (OVD) of 0.9 mm in the posterior
region (Fig. 5). The occlusal contacts in protrusion and
DISCUSSION
lateral excursion were verified during the diagnostic
waxing phase. The second trial restorations were made A fully digital prosthetic protocol is presented that used a
from autopolymerizing composite resin (LuxaCrown; virtual articulator in the diagnostic waxing phase of the
DMG) to test the function and adaption to the new occlusion, starting from MIP. Virtual articulators have
OVD.2 been developed for CAD-CAM processing,4 including
The tooth preparations were minimally invasive. For those using an electronic system for recording mandib-
the posterior teeth, the preparations were limited to ular movements such as the Jaw Motion Analyzer5,6
buccal and interproximal surfaces between the second (JMA+nalyser; Zebris Medical GmbH) and mechanically
premolars and first molars. Preparation of the occlusal simulated virtual articulators that record and reproduce
surfaces of the posterior teeth was not necessary because the mandibular movements for dynamic occlusion, as
of the increased OVD. For the anterior teeth, the prep- well as occlusal contacts in a static position.
arations included the axial surfaces of the central incisors This novel digital approach enabled tooth-supported
and the facial and mesial surfaces of the canines (Fig. 6). restorations starting from a virtual waxing that had
Subsequently, both arches were scanned with the developed optimal static and dynamic occlusion. Never-
intraoral scanner with the patient in MIP. The definitive theless, the accuracy needs to be verified with a clinical
restorations were designed and fabricated by CAD-CAM study.
(Fig. 5). The occlusal scheme was mutually protected In this clinical report, the virtual mechanically simu-
articulation. Eight lithium disilicate maxillary veneers and lated articulator was used because it is straightforward to
2 crowns (IPS e.max Ceram; Ivoclar Vivadent AG) were use, and the static occlusion in MIP can be designed with

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Figure 4. Main steps of second waxing and trial restoration after mounting in virtual articulator to reproduce correct alignment of maxillary arch.
A, Initial smile. B, Virtual waxing. C, Smile with trial restoration. D, Intraoral photograph of second trial restoration with esthetic and functional criteria.

Figure 5. Occlusal vertical dimension increased by 0.9 mm at premolar Figure 6. Interocclusal record of maxillary and mandibular arches in
region. maximal intercuspal position.

the correct morphology without interfering in the She was satisfied with the outcome. The occlusal
mandibular movements. As shown, the virtual mounting contacts of the definitive restorations were consistent
of the jaws in a virtual articulator can generate an ani- with those simulated in the virtual articulator. Laboratory
mation of mandibular movements around a first inter- and clinical time for occlusal adjustments were short-
condylar transverse horizontal axis in the initial rest ened, although studies are encouraged. This proposed
position that allows a virtual simulation of mandibular digital workflow for fixed complete-arch rehabilitation
movements and dynamic occlusion. To reduce inaccur- with a virtual articulator possesses advantages in the
acies during the direct acquisition of the arches by phase of treatment planning and for the establishment of
intraoral scanner, some tips have been adopted: scanning a harmonious occlusion from the virtual space to the
occlusal tooth surfaces with as few acquisitions as actual patient. However, a CBCT scan with a large field of
possible to have less overlapping is more suitable for view was needed, which increased the radiation
alignments.15-18 exposure.

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Figure 7. Virtual mounting and evaluation of movements versus clinical evaluation.

Figure 8. Occlusal contacts of digital design and definitive restorations.

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Figure 9. Occlusal views at 6-month recall. Left: contact points in static occlusion. Right: contact points in static and dynamic occlusion.

SUMMARY conventional method for transferring the maxillary cast to a virtual articulator.
J Prosthet Dent 2015;113:191-7.
10. Solaberrieta E, Garmendia A, Minguez R, Brizuela A, Pradies G. Virtual
This clinical report demonstrated a completely digital facebow technique. J Prosthet Dent 2015;114:751-5.
workflow for fixed complete-arch rehabilitation. The 11. Lam WY, Hsung RT, Choi WW, Luk HW, Pow EH. A 2-part facebow for
CAD-CAM dentistry. J Prosthet Dent 2016;116:843-7.
application of a virtual facebow transfer and virtual 12. Lepidi L, Chen Z, Ravida A, Lan T, Wang HL, Li J. A full-digital technique to
articulator enabled a simulation of jaw movements and mount a maxillary arch scan on a virtual articulator. J Prosthodont 2019;28:
335-8.
occlusal contacts in a virtual environment. As a result, 13. Garcia PP, da Costa RG, Calgaro M, Ritter AV, Correr GM, da
comprehensive rehabilitation planning was performed in Cunha LF, et al. Digital smile design and mock-up technique for esthetic
treatment planning with porcelain laminate veneers. J Conserv Dent
a straightforward way, and predictable clinical outcomes 2018;21:455-8.
were achieved. 14. Afrashtehfar KI, Brägger U, Igarashi K, Belser UC. A modified technique for
the intraoral assessment of static occlusal contacts. J Prosthet Dent 2018;119:
909-11.
15. Ender A, Mehl A. Accuracy of complete-arch dental impressions: a new
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