RESTORATIVE DENTISTRY

Workflow of digitally guided direct composite resin

restorations using open source software and 3D printing:
a clinical technique
Camila S. Sampaio, DDS, MS, PhD/Julia Puppin-Rontani, DDS, MS, PhD/Gustavo Tonolli, DDS, MS/
Pablo J. Atria, DDS, MS

Objective: To describe how to perform, in a simple manner, a to parafunction, and restored with direct composite resin res-
digital wax-up with open source software for a clinical applica- torations. Conclusions: Thanks to the technology that was used
tion involving direct composite resin restorations. Report: The in this case, fast, affordable and accurate results could be ob-
clinical technique described presents a simple and highly pre- tained. In addition, digital files can be stored, saving material,
dictable way of performing direct restorations with the help of time, and space, and allowing identical replication of the work
a digital wax-up made with open source software. It uses an either virtually or printed at any time, if needed. (Quintessence Int
open source digital tooth library to reestablish a more harmoni- 2021;52:104–110; doi: 10.3290/j.qi.a45426)
ous smile architecture, specifically of teeth that were worn due

Key words: 3D printing, composite resin, digital dentistry, digital wax-up, direct restoration, wax-up

Elective esthetic restorative treatments are highly sought in A wax-up is a tool conventionally used for diagnostic pur-
today’s clinical practice, as improving esthetics represents one poses, traditionally executed by a lab technician, on a patient’s
of the main goals of dental interventions. It is desirable that cast, by addition of wax in order to modify tooth morphology,
whenever a tooth is restored, the restorative material should emulating the final prosthodontic outcome and improving clini-
blend with the surrounding tissue, promoting an imperceptible cian-patient-technician communication.1,2,8,9 Once the wax-up is
aspect, and avoiding unnecessary preparations.1-3 For doing so, finished, it is shown to the patient and used to fabricate mock-
a correct diagnostic and treatment plan must be executed. ups, prior to the definitive treatment, allowing a better under-
The composition of composite resins has significantly standing of the patient’s expectations and previewing the out-
evolved since 1950, leading to enhanced optical and mechani- come of the final restorations beforehand. When a direct resin
cal properties,4 and turning them into first-choice materials restoration is performed, wax-ups can also be used for per-
when replicating natural tooth appearance. They allow a purely forming silicone indexes to guide the desired anatomy,5,6,10 and
additive and adhesive procedure, without the need for tooth to achieve appropriate tooth width proportions when closing
preparation, are easy to repair, and require shorter clinical time diastemas,11 among other uses.
compared to prosthetic procedures.5 However, an important With the evolution of digital dentistry, digital wax-ups have
disadvantage is that the technique is strongly dependent on been widely adopted; they are done with the scanned patient’s
the clinician’s skills, and focus on meticulous details regarding mouth or stone cast, and by performing virtual alterations of
color, morphology, and superficial textures is required.5-7 tooth morphology in computer software, to later 3D print the

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 Sampaio et al

1a 1b

1c 1d

Figs 1a to 1d Initial photographs for the analyses of the smile: (a) Frontal view of the smile. (b) Close-up of the central incisors.
(c) Lateral view of the right side of the teeth. (d) Lateral view of the left side of the teeth. Note the fractures, wear, and lack of
proportions of the teeth and former restorations, and the disparity in the color of the maxillary central and lateral incisors and
canines compared with the other teeth.

model. Different methods have been proposed to modify tooth days, affordable 3D printers, along with open source software,
morphology digitally, such as using an existent or self-made offer opportunities for their use in all areas of dentistry; how-
tooth library,1,2,5,8 performing a biogeneric tooth copy,12 mirror- ever, the use of digital dentistry in an affordable manner is still
ing an intact adjacent tooth,13,14 or using a contralateral tooth poorly documented. The present clinical technique describes
as reference.7 It is assumed that the digital alteration of tooth how to perform a digital wax-up, made with open source soft-
morphology has the advantages of reducing the wax-up time, ware for a clinical application involving composite resin restor-
material manipulation, and the number of error-introducing ations, which allows the clinician to perform a digital wax-up
steps.2 without needing to purchase expensive software.
With the success and growth of using intraoral scanners
and 3D-printing technology, advances in this field present a
Case report
major impact on dentistry. Recent literature focused on observ-
ing the axial tooth contour and symmetry of conventional and A 29-year-old woman presented to a private office unsatisfied
digital wax-ups,1,2 performing and printing digital wax-ups for with the esthetics of her smile. The patient’s chief complaints
making transparent guides and copying tooth anatomy,5,6 and were the short and slightly rotated anatomy of her previous
developing complete digital prosthetic, orthodontic, and composite resin restorations in the maxillary incisors and
implant treatments.14,15 However, most studies used expensive canines. Clinical evaluation showed that the previous restor-
software2,5,7,8 that are not always available to clinicians. Nowa- ations were stained, fractured, lacking pleasant proportions,

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2a 2b

2c 2d

Figs 2a to 2d Intraoral scanning of the maxillary arch; (a) editing and (b) manipulation of the digital model. (c) Cutting of
irregular areas and creation of a base. (d) Selection of digital tooth library.

and the incisors were worn due to parafunction (Fig 1). Initial ing 35% phosphoric acid (Ultra Etch 35%, Ultradent Products)
intra- and extraoral photographs were taken and after explain- on the sound enamel, followed by washing and air drying. The
ing the possible treatments, the patient opted for new compos- adhesive (Single Bond Universal, 3M Oral Care) was applied,
ite resin direct restorations. gently air dried, and light cured with an LED device (Ultradent
A digital impression of the patient arches was performed Products). Later, the silicone index was positioned, and teeth
with an intraoral scanner (Cerec Omnicam, Dentsply Sirona) were incrementally built with composite resin (Empress Direct,
and virtual models were obtained. The Cerec software SW 4.6 Ivoclar Vivadent; Shades BL dentin, BL L enamel, Trans 20)
(Dentsply Sirona) exported the virtual model as an .STL file, (Fig 4).
which was exported into open source software (Autocad After the restorative procedure, the teeth were finished
Meshmixer). In the software, the digital wax-up was performed and polished with a sequence of burs (Komet Dental), abra-
by choosing the tooth shape and proportions considering the sive disks (Soflex Polishing Disks, 3M Oral Care), sandpaper
facial analyses, teeth, and age of the patient (Figs 2 and 3). strips (Epitex, GC), and a polishing system (Diacom Plus, EVE
After the patient’s approval, the wax-up was 3D printed in a America). A sequence of photographs was taken after the fin-
DLP 3D printer with 0.1-mm resolution (Anycubic Photon) and ishing and polishing procedures. In the final photographs
a silicone index was obtained using a polyvinyl siloxane putty (Fig 5) it is possible to notice that the shape, color, and func-
consistency impression material. tion were reestablished, and an esthetically harmonious smile
For the clinical procedure, previous restorations were care- was achieved.
fully removed, and the bonding procedure took place by apply-

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 Sampaio et al

3a 3b

3c 3d

Figs 3a to 3d Final digital wax-up and 3D-printed version of the digital model. The silicone index was made over the
3D-printed model.

Step-by-step procedure for the digital wax-up ■ Obtain one of the many available tooth libraries from the
internet (eg, ODOS libraries, https://bit.ly/2NOBJwa; Chris-
■ Obtain patient’s .STL file. This can be achieved with either tian Brenes libraries, https://bit.ly/38psXhC). In this case
an intraoral or an extraoral scanner, by directly scanning the the ODOS libraries were used, and the desired tooth
patient’s mouth or the stone casts. selected and imported into the design software.
■ Import the .STL file into the design software, in this case ■ Once the desired teeth/tooth are imported into the soft-
Meshmixer, to create the digital wax-up. ware, locate them with the Transform tool, as performed
■ By using the Transform tool, locate the .STL file in the grid with the intraoral .STL file. Once the tooth is in position,
from the software, in order to facilitate the manipulation different sculpting tools can be used in order to reshape
and visualization of the files. and model the files into their final desired aspect.
■ Select the .STL file and with the Plane Cut tool, get rid of the ■ Once the final wax-up is finished, select all the files from
irregular areas from the .STL file. After this, select the bor- the object browser (View – Show Object Browser) and
ders of the model and with the tool extrude (Select – Edit combine them into one single .STL file.
– Extrude) select the offset mm and direction, in order to ■ Finally, export the digital wax-up as an .STL file in order to
create the model’s base. print it with the desired desktop 3D printer.
■ Making the model hollow is an optional step but will save ■ After printing and post-processing, a silicone index can be
material when printing the final digital wax-up. In order to obtained in order to perform the composite restorations.
do this, select the Hollow tool from the Edit menu.

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4a 4b

4c 4d

Figs 4a to 4d Restorative procedures of the maxillary central incisors. (a) Frontal view of the smile after the removal of the old
composite resin. (b) 35% phosphoric acid application for 30 seconds. (c) After application of the adhesive and light curing, each
tooth was restored with the help of a silicone index. (d) Finishing textures performed with burs after the restorative procedures
completed; after that, polishing was performed as described.

Discussion When performing any type of restoration, understanding

natural tooth arrangements, positions, proportions, shapes,
The digital revolution is completely changing our profession color, and morphologies is the foundation to mimic nature as
with the introduction of different devices, machines, and soft- closely as possible,17 and mostly when performing such restor-
ware.16 The presented clinical technique describes a case where ations directly on the patient’s mouth, caution must be taken
a digital wax-up was made using open source software, en- to successfully copy the tooth’s proportions, as this technique
abling a more straightforward procedure, saving time in a sim- requires practice and skill.
ple and affordable manner, storing the digital file for the future, It was previously described that tooth morphologic sym-
as well as allowing the clinician to perform the digital wax-up metry is improved after wax-ups,2 and more prominently for
him/herself. Although a digital intraoral scanner was used for digital than conventional ones, which is related to the mathe-
acquiring the digital impressions of the patient, this technique matical determination of the tooth morphology.2 Through the
also allows the clinician to make a conventional impression and process of a digital wax-up, an average tooth shape is selected
ask a laboratory to digitalize it with an extraoral scanner; after and fitted to the tooth that will be modified. The present tech-
that, the digital wax-up can be performed in the open source nique was used to perform direct composite resin restorations,
software and 3D printed, as described. Nowadays, several la- promoting a more pleasant architecture of six worn teeth with
boratories have affordable 3D printers and the costs of such altered incisal morphology. This technique can also be exe-
procedures have decreased. cuted to restore a fractured tooth where it was intended to only

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 Sampaio et al

5a 5b

5c 5d

Figs 5a to 5d Final photographs for the analyses of the smile. (a) Frontal view of the smile. (b) Close-up of the central incisors.
(c) Lateral view of the right side of the teeth. (d) Lateral view of the left side of the teeth. Note the color correlation of all teeth,
and the harmony and adequate shape of the teeth.

return the “missing piece,” by copying exactly the intact adja- post-processing procedures, which still limit the use of such tech-
cent tooth and promoting a harmonious restoration, using a nologies in the day-to-day dental practice. However, companies
mirror tool, among other applications.18 are investing in developing and trading low-cost or more afford-
Several other applications for this technology have been able printers, so that in the short term, this will play an essential
proposed in the literature, ranging from fabrication of digital and common role in the dental practitioner’s routine.
guides for sinus grafting,19 custom trays for multiple implant
impressions,20 complete dentures,21 fabrication of custom den-
Conclusion
tal implants,22 and the use of 3D files to enhance dental anat-
omy learning methods.23 One of the drawbacks of using open The clinical technique described presents a simple and highly
source software is the fact that some of them were not devel- predictable way of performing direct restorations of teeth that
oped originally for dental applications and have been adapted were worn due to parafunction and required a more harmoni-
over time. Clinicians and technicians should focus on using ous architecture mostly of the incisal surfaces, with a high level
published protocols that demonstrate that the technique can of acceptance. Thanks to the technology that was used in this
be trusted. case, fast, affordable, and accurate results could be obtained.
Despite the great boom in digital dentistry, there is still a In addition, digital files can be stored, saving material, time,
learning curve related to the use of scanners, software, and 3D and space, and allowing identical replication of the work either
printers, as well as a relatively high initial cost for pre- and virtually or printed at any time.

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Disclosure

All authors declare there are no conflicts of interest in relation

to this manuscript.

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Camila S. Sampaio Camila S. Sampaio Assistant Professor, Department of Biomat-

erials, Universidad de los Andes, Santiago, Chile
Julia Puppin-Rontani PhD, Department of Restorative Dentist-
ry, Dental Materials Area, State University of Campinas, UNICAMP,
Piracicaba, Brazil
Gustavo Tonolli Private Clinician, Piracicaba, SP, Brazil
Pablo J. Atria Assistant Professor, Department of Biomaterials,
Universidad de los Andes, Santiago, Chile; and Program of Digital
Dentistry and 3D Technologies, Universidad Finis Terrae, Santiago,
Chile

Correspondence: Dr Camila S. Sampaio, Faculty of Dentistry, Universidad de los Andes, Av Monseñor Alvaro del Portillo, 12455, Santiago,
Chile. Email: [email protected]

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