Virtual Simulation of Periodontal Surgery Including Presurgical CAD/CAM Fabrication of Tooth-Colored Removable Splints on the Basis of CBCT Data: a Case Report

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Virtual Simulation of Periodontal Surgery Including Presurgical CAD/CAM Fabrication of Tooth-Colored Removable Splints on the Basis of CBCT Data: A Case Report

Jan-Frederik Güth, Dr Med Dent1 Complex clinical situations require Ana Elisa Colle Kauling, DMD2 a specialized interdisciplinary treat- Josef Schweiger, MDT3 ment team for precise planning and Jan Kühnisch, Dr Med Dent4 operative intervention. The main 1 Michael Stimmelmayr, Dr Med Dent aim of those interdisciplinary ap- proaches is to determine predict- Innovative digital diagnostic, design, and manufacturing technologies able outcomes, in terms of function combined with high-performance polymers offer new possibilities to and esthetics. New digital diagnos- facilitate complex interdisciplinary treatment procedures. This article reports tic, design, and manufacturing tech- on the interaction of different digital technologies, from presurgical digital nologies, combined with innovative simulation of periodontal surgery to final prosthodontic rehabilitation, in a case of amelogenesis imperfecta in a 17-year-old girl. The aim was to digitally computer-aided design/computer- determine the treatment outcome by three-dimensional simulation of the assisted manufacture (CAD/CAM) soft tissue removal and to create computer-aided design/computer-assisted materials (eg, high-performance manufacture tooth-colored splints before the clinical treatment. The case polymers [HPPs]), offer great pos- report shows the synergy of the combination of multiple digital technologies sibilities to manage difficult clinical for a predictable periodontal and prosthetic treatment outcome. Int J cases and complex treatment pro- Periodontics Restorative Dent 2017;37:e310–e320. doi: 10.11607/prd.2769 cedures.1–3 Periodontal surgery (eg, crown lengthening) is often necessary before prosthetic or orthodontic treatments can be carried out properly. However, the correct level and in- vasiveness of the surgical procedures is often difficult to estimate.4–7 Analog measures (eg, wax-ups and mock-ups) have their limitations, 1Associate Professor, Department of Prosthodontics, Ludwig-Maximilians University, and the periodontal surgeon has to Munich, Germany. operate without an objective guide. 2 PhD Student, Visiting Researcher, Department of Prosthodontics, Ludwig-Maximilians The combination of already existing University, Munich, Germany. 3Master Dental Technician. Department of Prosthodontics, Ludwig-Maximilians University, digital technologies (eg, cone-beam Munich, Germany. computed tomography [CBCT], 4Associate Professor, Department of Conservative Dentistry and Periodontology, three-dimensional [3D]-scanning University Hospital, Ludwig-Maximilians University, Munich, Germany. technology, CAD software), offers

Correspondence to: Dr Jan-Frederik Güth, Department of Prosthodontics, the opportunity to visualize the ex- Dental School of the Ludwig-Maximilians University Munich, Goethestraße 70, act anatomical structures, define the 80336 Munich, Germany. Fax: +49 (0) 89 4400 – 5 - 95 02. intended treatment aims, and simu- Email: [email protected] late the treatment before surgical ©2017 by Quintessence Publishing Co Inc. procedures are carried out.8,9

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a b Fig 1 Extraoral findings of the initial situation.(a) Misbalance of the facial proportion with decreased height of the lower third of the face. During smiling, the patient showed a high amount of surplus gingival tissue in the maxilla and mandible.

The aim of the planning procedure was to digitally define the treatment outcome, simulate the soft and hard tissue removal, and manufacture CAD/CAM tooth-colored splints before the clinical treatment. This case of a 17-year-old girl affected by amelogenesis imperfecta (AI) provides an example of the use of multiple digital technologies for a a predictable treatment plan and outcome, including digital simulation of periodontal surgery and presurgical manufacture of CAD/CAM tooth- colored splints.

Case Report b c

A 17-year-old girl was referred to the Fig 2 Initial intraoral findings: Frontal (a), and lateral views (b, c) showing gingival hyperplasia, relative microdontia, spaced teeth, and an unstable occlusal relationship with Department of Prosthodontics for traumatic anterior occlusal contacts. The clinical findings led to a suspected diagnosis of final oral rehabilitation. In general, amelogenesis imperfecta. the patient complained about sensi- tive teeth, limited function, speech, and esthetics. The general anamne- sis showed no pathologic findings. exhibited a receding chin. Intraoral- most of the teeth, areas of dentin Extraoral findings included a misbal- ly, all teeth were diagnosed as caries were exposed and only small ar- ance of the facial proportion with free but hypoplastic and could be eas of enamel could be identified decreased height of the lower facial linked with the typical appearance (Fig 2). Teeth were not fully erupted third (Fig 1). In addition, the patient of amelogenesis imperfect (AI). In and were covered by keratinized

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Fig 3 Radiographic diagnostics. The initial panoramic radiograph showed a generalized hypoplastic enamel, dislocated maxillary canines and right first premolar and mandibular second molars, and classic formation and eruption characteristic of amelogenesis imperfecta.

Fig 4 Transfer from conventional to digital articulator. (a) Casts of the presurgical situation mounted joint-related after facebow registration and in centric relation into a conventional articulator. (b) Models scanned (Zfx-Evolution, Zfx-Dental) and transferred by a synchronizer (Zfx-Dental) in correct jaw position into computer-aided design software with a virtual articulator.

a b

gingiva. This gingival hyperplasia second molars), intrapulpal calcifica- treatment; condition after surgical with a high amount of keratinized tion, gingival hyperplasia, crown re- palatal expansion; retained maxil- gingiva caused relative microdon- sorption, and root dilacerations. For lary canines and maxillary and man- tia and spaced teeth. The occlusal better analysis of the situation, initial dibular second molars; and gingival relationship was unstable. The mid- plaster casts were articulated after hyperplasia with relative microdon- line shifted about 4 mm to the right facebow registration in centric rela- tia and spaced teeth. Similarities (Fig 1b). Retrospectively, physiologic tion (Fig 4a). The functional model of the diagnoses to findings in the tooth eruption seemed to be patho- analysis confirmed the unstable oc- literature led to the suspicion of an logically affected. All permanent clusal relationship with traumatic enamel renal syndrome (ERS).10 Al- teeth erupted but were delayed and contacts in the anterior region. The though ERS is very rare, the patient incomplete; there was no develop- plaster models in the correct jaw was recommended to attend a ne- ment of the vertical dimension of position were scanned (Zfx-Evolu- phrologist regularly to avoid pos- occlusion (VDO) and the teeth did tion, Zfx-Dental) and transferred by sible long-term consequences. not reach regular occlusion. a synchronizer (Zfx-Dental) into CAD The aim of the treatment was The panoramic radiograph (Fig software with a virtual articulator to establish masticatory and pho- 3) and the CBCT showed a gener- (Fig 4b). netic function, to immediately en- alized absence of enamel, altered On the basis of the initial find- hance esthetics, and to enable tooth eruption pathways (maxillary ings, the following diagnoses could subsequent orthodontic treatment. canines and right first premolar), de- be drawn: AI; unstable occlusal After a detailed analysis of the cur- layed tooth eruption (maxillary ca- relationship (malocclusion); con- rent situation, and after discussing nines and maxillary and mandibular dition after previous orthodontic possible treatment alternatives with

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Fig 5 Digital simulation of periodontal surgery on the basis of a CBCT dataset. (a, b, c) Due to the density differences in human tissue, the soft tissues could be filtered out and an STL surface dataset (d) representing the hard tissues (bone and teeth) could be generated. This dataset a served as the basis for further design and manufacture of the tooth-colored splints.

c d

the patient and her parents, the ered tooth structures and bone to sion 5180, Zirkonzahn), and the re- multidisciplinary team, which includ- be uncovered (Fig 5). The resulting movable splints were designed (Fig ed a pedodontist, a periodontist, surface dataset could be exported 6). Initially, the datasets were com- prosthodontists, orthodontists, and in standard tessellation language puted using the bite splint module a dental technician with experience (STL) data (Fig 5d). The datasets to block out undercuts (0.1 mm) and in digital technologies, agreed to from the maxilla and mandible were create a virtual offset (comparable the following treatment steps. then imported into Geomagic Qual- to analog thermoforming films) 0.06 ify Software (Version 2012.1.2, 3D mm thick to work as a spacer for the Systems) and aligned with the previ- tooth-colored splint. Afterward, the Step 1: Virtual Simulation of ously scanned situation models. As modified datasets of the mandible Periodontal Surgery on the a result of this superimposition, the and maxilla were exported as STLs Basis of CBCT Data datasets with uncovered teeth were and reimported into the same soft- now in the correct joint-related posi- ware, but into the crown and bridge The CBCT served as the basis for tion and centric relation. module to create the tooth-colored the virtual simulation of surgical splints in a similar manner to fixed crown lengthening. The Digital Im- dental prostheses. Here, it was im- aging and Communications in Med- Step 2: Design of Tooth- portant to set the cement spacer to icine (DICOM) data was imported Colored CAD Splints on the zero to achieve optimal friction of into analysis software (Invesalius 3.0, Basis of Virtually Uncovered the splints on the teeth. Renato Archer Information Tech- Teeth and Virtual Try-In Using a The use of the virtual articula- nology Center). This software gen- 3D Face Scan tor allowed static and dynamic oc- erates a 3D surface dataset from clusion to be checked. Because DICOM data using differences in The STL datasets of maxilla and the designed splints penetrated the density of diverse human tis- mandible with uncovered teeth in virtually into the gingival tissues, sues. This enabled the soft tissue to correct jaw position were imported there was no possibility for a clini- be filtered out and the clinically cov- into CAD software (MODELiER ver- cal try-in (Fig 7). Therefore, the

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a b

c d e Fig 6 Computer-aided design (CAD) of maxillary removable tooth-colored splints. (a) Datasets from CBCT were imported into the bite splint-module of the CAD software (MODELiER version 5180, Zirkonzahn). (b) Undercuts were blocked out (0.1 mm) to create a virtual offset. (c) Modified datasets are exported as STLs and reimported into the same software, but now into the crown and bridge modules. (d, e) CAD of the tooth-colored splints in a similar manner to fixed dental prostheses.

restorative team decided to conduct a 3D face scan (Pritimirror, Pritidenta) (Fig 8a). Subsequently, the align- a ment of the maxilla and mandible model with the face scan dataset enabled the first blueprint of the splints to be estimated (Fig 8b). After digital 3D evaluation of the restoration design, the splints were milled from a b flexible high-performance polycarbonate blank (Temp Premium Flexible, Zirkonzahn) using a five-axis milling machine (Fig 9).

c Step 3: Surgical Crown Lengthening to Uncover Teeth and Placement of Prefabricated Splints

d The outer form of the tooth-colored splints were transferred onto the situation models, and vacuum splints (Duran 0.5 × 125 mm clear, Schau Dental) were manu- Fig 7 Computer-aided design (CAD) of maxillary tooth-colored factured to show the previously planned tooth length splint. (a) Maxillary dataset of the initial situation. (b) Dataset of and gingival margins to the periodontist during surgery. the filtered maxillary teeth on the basis of a CBCT, aligned with the dataset of the initial situation. (c) CAD of the maxillary splint in These surgical guides were placed on the teeth and tooth form and color. (d) Transparent dataset of the initial situation gingiva at the beginning of surgery to guide the outline allowing evaluation of the penetration depth of the splints. Due to the penetration of the designed splint under the gingival tissues, of the gingival incision (Figs 10a and 10b). Subsequent- no try-in could be conducted. ly, a full-thickness flap was reflected, the teeth were

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a b c Fig 8 Three-dimensional (3D) facescan allowed a virtual try-in of the digitally designed restoration. (a) The scanner (Pritimirror, Pritidenta) used a stripe light projection to generate 3D surface data in object file format. (b) The face scan data were superimposed with the designed restoration for virtual 3D evaluation of the restoration blueprint. (c) Patient 10 days after periodontal surgery and immediate placement of removable tooth-colored splints.

a b Fig 9 Milling of removable tooth-colored splints. (a) After digital evaluation of the outline and form of the design, the splint datasets were nested into the blank. (b) Milled splints from polycarbonate high-performance polymer (Temp Premium Flexible, Zirkonzahn).

uncovered, and the excess connec- Once the splints were placed, splints were used as templates to tive tissue and epithelium were re- their distance to the crestal bone guide the surgical procedures (Fig moved. Because of the hyperplastic could be measured using a peri- 10f). Remodeling of the bone on interdental gingiva, the papillae also odontal probe (PCP 12, Stoma) (Fig the buccal and palatal surfaces was had to be reflected to gain access 10d). Due to overgrowth of the performed with round burs (sizes to the interdental bone (Fig 10c). marginal bone, iatric bone remod- 012, 014, and 016, Komet Dental) As soon as the surfaces of the teeth eling was indicated (Fig 10e). To re- and on the interproximal with we- were accessible, the tooth-colored move the optimal amount of bone delstaedt chisels (Stoma). After splints were snapped onto the teeth, to establish the correct biologic the appropriate bone level was without any luting procedure. width and tooth length, the milled established, the soft tissues were

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Fig 10 Illustration of periodontal-surgical procedures in the maxilla. (a) Surgical guide in accordance with the form of tooth- colored splints. (b) Outline of gingival incisions. (c) Exposed teeth and bone a b structure after elevation of a full-thickness flap. (d) As expected during the planning procedure, a violation of the biologic width could be observed after placement of the removable tooth-colored splints. (e) Artificial remodeling of the bone to establish a correct biologic width. (f) The tooth-colored splint served again as a c d guide for bone-remodeling procedures. (g) Adaption of soft tissue. (h) Situation postsurgery with placed removable splints that were fixed by the undercuts.

e f

g h

fixed using horizontal mattress sutures at the base of the papillae and interproximal sutures to adapt the papillae tips (Mopylen 6-0, Re- sorba) (Fig 10g). Immediately after surgery, the patient could wear a removable splints and functional and esthetic enhancement could be achieved (Fig 10h). The splints could be snapped into undercuts, meaning that no cementation was necessary and the splints could be removed for oral hygiene purpos- es. The patient received oral hygiene instructions and guidance on how to use the splints. The patient b c was monitored closely at short re- Fig 11 Clinical situation 10 days postsurgery: Frontal (a) and lateral views (b, c) display the clinical situation 10 days postsurgery, before suture removal. The removable splints call intervals (3, 7, and 10 days). The enabled optimal oral hygiene and good wound healing. Additionally, immediate functional clinical situation 10 days postsur- and esthetic enhancement could be achieved. gery is shown in Fig 11.

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Fig 12 At 3 months after surgery and placement of splints, no-prep long-term temporary restorations were manufactured from nanoceramic resin on the basis of an intraoral scan.

a b

Step 4: Fixed, Single- Tooth, No-Prep Temporary Restorations

At 14 weeks after surgery, no-prep temporaries manufactured from nanoceramic resin (LAVA Ultimate, 3M ESPE) on the basis of an intraoral scan (True Definition Scanner, 3M ESPE) were adhesively luted (Scotchbond Universal, 3M ESPE; a Rely X Ultimate, 3M ESPE) on single teeth (Figs 12 and 13). This enabled the movement of single teeth during further orthodontic treatment with fixed appliances. The treatment was met with the full acceptance and satisfaction of the patient, despite the remaining gaps that could be closed by subsequent b c orthodontic treatment. Fig 13 Clinical situation 7 days after adhesive luting of long-term provisional restorations. Frontal (a) and lateral views (b, c).

Step 5: Future Treatment Plan

The aim of the future orthopedic treatment is to distalize the premolars and molars using fixed appliances to enable the alignment of the maxillary first premolars and right canine into the tooth row and subsequent prosthetic restorations (Fig 14). The alignment of the mandibular second molars Fig 14 Panoramic radiograph before orthodontic treatment.

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© 2017 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER. e318 seems questionable, and surgi- planning, radiation exposure has to protective function against effects cal extraction might be necessary be balanced with the clinical benefit caused by food and temperature. in the future. If these teeth cannot and it should not be considered an On the other hand, the polymeriza- be aligned, it is planned to remove alternative method. tion of high performance polymers them and to close the opened gaps In the future, it might be pos- (HPP) under industrial conditions by single-tooth implant-supported sible to place no-prep occlusal leads to a high conversation rate restorations. long-term temporary restorations that again leads to fewer residual designed on the basis of CBCT data monomers and therefore a higher during surgery instead of removable biocompatibility.14,15 Discussion splints. However, the accuracy of This treatment aimed to replace such a procedure has to be scientifi- lost tooth structure in the right verti- The presented case report dem- cally verified. Using the luting proce- cal dimension, providing immediate onstrates how the connection dure during surgery with reflected functional and esthetic enhance- and integration of different digital flaps and an open wound could ment without further loss of the ex- technologies can enhance the pre- pose the risk of a wound healing isting hard tissues. Once adequate dictability of clinical outcome in a disorder. Due to these problems, VDO was established, the CAD/ complex case. Presurgical simula- the restorative team decided not to CAM splints could be replaced by tion of the periodontal surgery leads fabricate fixed long-term temporar- no-prep long-term fixed interim to a more precise and safer treat- ies on the basis of the CBCT data, restorations to enable orthodontic ment procedure. However, the high instead selecting removable tooth- treatment with fixed appliances for technical effort required to conduct colored splints. In addition, these the traction of impacted teeth, to these integrated treatment-planning splints had several advantages in align translocated teeth, and to per- (ITP) procedures is time consuming. the current case: Regarding the form esthetic corrections. A resin For example, the current case re- periodontal surgery, they fulfilled nanoceramic (LAVA Ultimate, 3M quired two CAD/CAM systems, two multiple functions, being used as a ESPE) was the material of choice, software packages, one intraoral guide for soft tissue incisions and combining good milling properties, scanner, one 3D face scanner, and bone remodeling and enabling cost-effectiveness, wear-stability, one CBCT scanner. optimal dental hygiene during the and esthetics.16 The basis for the presented healing period. Previously performed orthop- treatment concept was the filtering With the help of a master dental antomograms revealed that all first of CBCT data, which exposed the technician, the team decided to use permanent molars and maxillary hard tissues and allowed the simula- a flexible but durable polycarbon- canines were fully retained and dis- tion of periodontal surgery, and the ate polymer as the splint material. located. Uncovering of these teeth presurgical milling of tooth-colored This offered high elasticity (modu- and active orthodontic movement splints. The superimposition of fil- lus elasticity 2.0 to 2.4 GPa; tensile failed to correct their position. Dur- tered surface data from CBCT with strength 55 to 75 MPa) so that the ing the previous decade of conser- datasets of the situation model re- splints could snap into the under- vative and orthodontic treatment, vealed differences within a range of cuts of the uncovered teeth without interceptive orthodontic treatment 100 μm. This means that the process any need for cementation or lut- and surgical palatal expansion were of filtering data from CBCT seems ing that might have damaged the applied with the aim of improving to offer an accuracy that is compa- wound healing. For the same rea- vertical, horizontal, and sagittal di- rable to conventional or optical im- son, the authors also waived an im- mensions. All wisdom teeth were pressions of full arches.11,12 While mediate dentin sealing procedure.13 extracted for orthodontic reasons CBCT seems to present a basis for Regarding postsurgery sensitivity and to safeguard an undisturbed precise diagnosis and treatment of the teeth, the milled splint had a tooth eruption of the second per-

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© 2017 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER. e319 manent molars. While extensive ef- forts were undertaken to simulate growth and tooth eruption, the clinical situation remained more or less unchanged. Therefore, different treatment options were considered and extensively discussed on the basis of clinical and radiologic diagnoses using all digital and clinical information. Fig 15 Clinical situation after adhesive luting of the milled no-prep long-term temporary restorations. Subsequently, the patient was referred to the orthodontic department for Besides the advantages of the further treatment. When monolithic restorations are used, the outer form, surface structure, presented approach, the limitations their translucency, and the color of the luting resin determines the esthetic appearance of also have to be considered. First, the restoration. the enormous amount of expansive equipment and the time-consuming treatment planning using multiple software packages and technolo- in dealing with digital datasets and The development of interfaces gies must be mentioned. The solely technologies. Clinicians and dental between already existing digital digital procedures also mean that technicians should work together as technologies enables innovative dentists and technicians need to ful- a well-synchronized team to enable treatment options that would not ly rely on the digital dataset interfac- estimation of the individual risk-ben- be possible with analog methods es for tasks such as superimposition efit ratio. alone. Digital technologies offer the or the filtering of datasets. There is The material applied for the possibility of early patient involve- no physical control opportunity be- fabrication of long-term provision- ment in the planning procedure and fore placement. In this context, it has als is no longer accredited for defini- provide a great communication tool. to be mentioned that there is still no tive crown restorations. However, its Despite the rapid development of cross-link validation for the applied optical and mechanical properties digital dentistry, classic analog pro- workflow. However, all the equip- suggest that this material is stable cedures are the standard for cor- ment used is officially accredited enough for medium-term applica- rect treatment in multidisciplinary by the manufacturers. Furthermore, tion.17 In the current case, the materi- rehabilitations. Complemented by during digital treatment planning, al seemed to be a perfect match for innovative CAD/CAM materials, es- whether in implantology or prosthet- combining good milling properties, pecially HPPs, digital tools enable ics, the human user still remains the allowing a no-prep approach, with dental practitioners to achieve more control authority responsible for the sufficient stability and the possibil- predictable treatment outcomes. planning and treatment outcome. ity of adhesive bracket luting for the This means that digital technolo- later orthodontic treatment. When gies are not replacing our knowl- monolithic restorations are used, Conclusions edge and individual consideration the outer form, surface structure, of clinical situations but are simply translucency, and color of the lut- Not only prosthetic treatments but tools that support us in this pursuit. ing resin determine the esthetic ap- periodontal surgery procedures can Complex treatment planning as in pearance of the restoration (Fig 15). benefit from digital technologies. In the situation described here should This means practitioners need good the current case, digital treatment only be conducted by clinicians and knowledge and information about planning of periodontal surgery and technicians who are highly experi- the optical properties of the material prosthetic therapy was the basis for enced in their specialty fields and and the bonding procedures used. successful completion, which would

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not have been possible using only 4. Gurrea J, Bruguera A. Wax-up and 11. Ender A, Mehl A. In vitro evaluation of analog methods. Currently, a dia- mock-up. A guide for anterior periodon- the accuracy of conventional and digital and restorative treatments. Int J Es- tal methods of obtaining full-arch den- logue between the digital and ana- thet Dent 2014;9:146–162. tal impressions. Quintessence Int 2015; log procedures is fundamental for 5. Kalsi HJ, Hussain Z, Darbar U. An update 46:9 –17. on crown lengthening. Part 1: Gingival 12. Giménez B, Özcan M, Martínez-Rus F, successful clinical work. tissue excess. Dent Update 2015;42: Pradíes G. Accuracy of a digital impres- 144–146, 149–150, 153. sion system based on active triangulation 6. Kalsi HJ, Bomfim DI, Darbar U. An up- technology with blue light for implants: date on crown lengthening. Part 2: Effect of clinically relevant parameters. Acknowledgments Increasing clinical crown height to facili- Implant Dent 2015;24:498–504. tate predictable restorations. Dent Up- 13. Magne P. Immediate dentin sealing: date 2015;42:230–232, 235–236. A fundamental procedure for indirect The authors reported no conflicts of interest 7. Parwani SR, Parwani RN. Surgical crown bonded restorations. J Esthet Restor related to this study, and no source of fund- lengthening: A periodontal and restor- Dent 2005;17:144–154. ing was available. ative interdisciplinary approach. Gen 14. Phan AC, Béhin P, Stoclet G, Dorin Ruse Dent 2014;62:e15–e19. N, Nguyen JF, Sadoun M. Optimum 8. Metzger MC, Hohlweg-Majert B, Schwarz pressure for the high-pressure polymer- U, Teschner M, Hammer B, Schmelzeisen ization of urethane dimethacrylate. Dent R. Manufacturing splints for orthognathic Mater 2015;31:406–412. References surgery using a three-dimensional print- 15. Phan AC, Tang ML, Nguyen JF, Ruse ND, er. Oral Surg Oral Med Oral Pathol Oral Sadoun M. High-temperature high-pres- . 1 Donovan TE, Cho GC. Diagnostic provi- Radiol Endod 2008;105:e1–e7. sure polymerized urethane dimethacry- sional restorations in restorative dentist- 9. Edelhoff D, Beuer F, Schweiger J, Brix late-mechanical properties and monomer ry: The blueprint for success. J Can Dent O, Stimmelmayr M, Guth JF. CAD/CAM- release. Dent Mater 2014;30:350–356. Assoc 1999;65:272–275. generated high-density polymer resto- 16. van Noort R. The future of dental devic- 2. Güth JF, Edelhoff D, Ihloff H, Mast G. rations for the pretreatment of complex es is digital. Dent Mater 2012;28:3–12. Complete mouth rehabilitation after cases: A case report. Quintessence Int 17. Stawarczyk B, Liebermann A, Eichberger transposition osteotomy based on in- 2012;43:457–467. M, Güth JF. Evaluation of mechanical and traoral scanning: An experimental ap- 10. de la Dure-Molla M, Quentric M, Ya- optical behavior of current esthetic den- proach. J Prosth Dent 2014;112:89–93. maguti PM, et al. Pathognomonic oral tal restorative CAD/CAM composites. 3. Kang DY, Choi SH, Jung YS, Hwang CJ. profile of Enamel Renal Syndrome (ERS) J Mech Behav Biomed Mater 2015;55: Interdisciplinary treatment for an adult caused by recessive FAM20A mutations. 1–11. patient with anterior open bite, severe Orphanet J Rare Dis 2014;9:84. periodontitis, and intellectual disability. J Craniofac Surg 2015;26:e240–e244.

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