This clinical case was approved by the Research Ethics Committee of the “Victor Babeș” University of Medicine and Pharmacy, Timișoara (Approval No. 72/20.12.2024) and conducted in accordance with the principles of the Declaration of Helsinki. The patient provided written informed consent for participation in the study, including agreement for the use of clinical data and photo-video documentation.

A 30-year-old female patient presented to the Department of Prosthodontics, Faculty of Dental Medicine, “Victor Babeș” University of Medicine and Pharmacy, seeking prosthetic rehabilitation for missing maxillary first molars (teeth 1.6 and 2.6). Despite being informed about implant-supported prosthetic options, the patient declined implant therapy and opted instead for fixed dental prostheses on natural abutment.

In addition to restoring functional occlusion, the patient emphasized the importance of achieving an aesthetically pleasing outcome. Another goal of this clinical case was to evaluate importance of digital tools in the evaluation of the accuracy of occlusal contacts before and after insertion of the fixed dental prostheses. Specifically, the objective was to determine whether the occlusal contact points visualized during the CAD design phase would be accurately replicated intraorally after final cementation—without requiring any occlusal adjustments. The underlying hypothesis was that, with a fully digital workflow and minimal protocol error, the final intraoral contacts would mirror those of the digital design, both on the restorations and adjacent natural dentition.

Clinical examination revealed that teeth 1.7, 1.5, and 1.4 had previously undergone endodontic treatment and had already been prepared as abutments during an earlier, unfinished treatment. Teeth 2.5 and 2.7 were vital and restored with composite fillings.

A thorough intraoral evaluation was performed, with no clinical signs of periodontal disease. Occlusal analysis was conducted using the OccluSense system (Bausch GmbH, Cologne, Germany), which identified premature contacts on the mandibular right third molar. These interferences were corrected through selective enamel grinding to establish a functional occlusal plane prior to initiating the digital diagnostic workflow.

A comprehensive digital workflow was implemented to evaluate the initial condition and plan the prosthetic treatment. The diagnostic protocol included intraoral and extraoral photography, intraoral scanning, facial scanning, and panoramic radiography. Additionally, the patient provided a recent cone-beam computed tomography (CBCT) scan (Planmeca ProMax® 3D Mid, Planmeca Oy, Helsinki, Finland), which was integrated into the digital evaluation.

Extraoral photographs were captured using a DSLR camera (Nikon D7500, with AF-S Micro Nikkor 85 mm lens and Fixlite Twin Softbox flash system) (Figure 1). Intraoral photographs were acquired using the same setup (Figure 2). Digital impressions and bite registration were obtained using the Medit i700 intraoral scanner (Medit Corp., Seoul, South Korea) (Figure 3). A facial scan was performed using the MetiSmile facial scanner (Shining 3D, Hangzhou, China) (Figure 4). During the facial scanning protocol, the intraoral scans were imported and aligned with the facial mesh for accurate integration. The CBCT scan was also registered and superimposed with both the intraoral scans and the facial scan using the proprietary alignment functions of the Shining 3D software, resulting in a fully digitized virtual patient (Figure 4).

All collected digital data were imported into DentalCAD software (exocad GmbH, Darmstadt, Germany) for planning and design (Figure 5). A Digital Smile Design (DSD) was created using the Smile Creator module, utilizing facial reference points to guide the aesthetic planning of the final restorations (Figure 6).

Following a comprehensive assessment and discussion of treatment alternatives, a fully digital workflow was selected, including interim restorations and the fabrication of milled full-contour monolithic zirconia fixed partial dentures (FPDs) (IPS e.max ZirCAD Prime, Ivoclar).

Based on the diagnostic data and the Digital Smile Design, a virtual wax-up was created in DentalCAD (exocad GmbH, Darmstadt, Germany) (Figure 7). The design was then transferred to a 3D printer (Anycubic Photon M5s, Anycubic, Shenzhen, China) and printed using high-speed gray model resin (Figure 8), that was previously calibrated according to the manufacturer's specifications.

Two eggshell-type provisional restorations were digitally designed from the wax-up to serve as indirect temporaries, to be rebased intraorally following tooth preparation. The first provisional restoration spanned teeth 1.7, 1.5, and 1.4, with tooth 1.6 as the pontic; the second included teeth 2.7 and 2.5, with tooth 2.6 as the pontic (Figure 9). These provisional shells were printed using the Prusa SL1 3D printer (Prusa Research, Prague, Czech Republic) with SprintRay Crown resin (SprintRay Inc., Los Angeles, CA, USA) (Figure 10). The printer settings were adjusted to comply with the resin's manufacturer-recommended exposure parameters.

To transfer the wax-up into the patient's mouth, a silicone index (Figure 11) was fabricated using addition silicone (Variotime, Kulzer GmbH, Hanau, Germany). The silicone index was filled with a bis-acrylic crown and bridge material (LuxaCrown, DMG, Hamburg, Germany) to generate the mock-up inside the patient's mouth. This simulation served both as a functional and aesthetic preview (Figure 12) and as a guide for performing tooth preparation in a minimally invasive, prosthetically driven manner.

Under local anaesthesia, the abutment teeth were prepared for full-coverage zirconia restorations using a minimally invasive approach, guided by the provisional wax-up form. Gingival displacement was performed using a single-cord retraction technique. Given the patient's thin gingival biotype, a 000-size retraction cord (Ultrapak, Ultradent Products Inc., South Jordan, UT, USA) was selected and gently placed circumferentially below the preparation margins to ensure optimal subgingival access (Figure 13).

Following gingival retraction, digital impressions of the prepared teeth were acquired using the same Medit i700 intraoral scanner (Medit Corp., Seoul, South Korea), previously calibrated per manufacturer instructions. Full-arch scans of both the maxillary and mandibular arches were completed to capture the occlusion and spatial relationships accurately (Figure 14).

The printed eggshell provisional restorations were then relined chairside using the same bis-acrylic crown and bridge material (LuxaCrown, DMG, Hamburg, Germany) and provisionally cemented using a eugenol-free temporary cement (TempBond NE, Kerr Corporation, Orange, CA, USA) (Figure 15). This ensured temporary function and protection of the abutments while the final restorations were being fabricated.

The digital impressions, along with all preoperative data—including the Digital Smile Design, facial scan, wax-up, and photographic records—were transmitted to the dental laboratory. This comprehensive digital dataset allowed the technician to replicate the clinical situation virtually and design the final restorations with precision.

Using DentalCAD (exocad GmbH, Darmstadt, Germany), two full-contour monolithic zirconia fixed partial dentures (FPDs) were digitally designed based on the previously established esthetic and functional parameters (Figure 16). The restorations were fabricated from IPS e.max ZirCAD Prime (Ivoclar Vivadent, Schaan, Liechtenstein), a high-strength, multi-layered zirconia known for its excellent mechanical properties and lifelike esthetics.

A 3D-printed working model was produced in the laboratory to verify fit and support the finalization of the FPDs (Figure 17). The restorations were stained on the buccal surface and polished all-around to enhance characterization but deliberately not glazed, to preserve the original occlusal morphology and contact integrity established during the digital planning phase.

The completed restorations underwent clinical try-in and were evaluated for marginal fit, esthetics, and occlusal relationships. Both the patient and the clinical team approved the final result, and the FPDs were definitively cemented using a resin-modified glass ionomer cement (GC FujiCEM 2, GC Corporation, Tokyo, Japan). The cemented restorations are shown in Figure 18, and the final esthetic outcome is presented in Figure 19.

After definitive cementation of the final restorations, a full-arch intraoral scan was performed using the Medit i700 (Medit Corp., Seoul, South Korea) to capture the post-treatment situation. The occlusal contact points were assessed using both digital and conventional methods to evaluate the accuracy of the digitally designed occlusion in translating to the intraoral environment. All occlusal evaluations and adjustments were performed by the same experienced clinician to ensure consistency and reduce operator variability.

Initially, in the virtual environment, the expected occlusal contacts were analysed within the CAD design software (DentalCAD, exocad GmbH) on the final restorations aligned with the opposing arch (Figure 20a). Subsequently, the Medit Occlusion Analyzer tool was used to assess occlusal contacts based on the new post-cementation intraoral scan. This allowed for a digital visualization and documentation of contact points within the patient's mouth (Figure 20b).

For physical validation, 40 µm articulating paper (BK80, Bausch GmbH, Cologne, Germany) was used intraorally with the patient in maximum intercuspation to mark static contact points (Figure 20c). These markings were photographed and compared to the digitally captured occlusal maps.

All three visualizations—from DentalCAD, Medit Occlusion Analyzer, and intraoral articulating paper—were compared side by side to assess the transfer accuracy of the digitally designed contacts into the final intraoral restorations (Figure 21). A qualitative, visual comparison of the contact positions revealed a level of consistency between the CAD-planned contacts and those observed clinically. The position of most of the contacts remained stable across all evaluation methods. However, some variations were noted in the intensity of the contacts, particularly in the digital visualizations. While the articulating paper confirmed positional accuracy, only the digital tools (Exocad and Medit Occlusion Analyzer) provided insights into the force distribution and relative pressure intensity of the contacts.

To gain a comprehensive understanding of both static and dynamic occlusion, a final occlusal analysis was performed using the OccluSense system (Bausch GmbH, Cologne, Germany). This device integrates pressure-sensitive electronic sensors with traditional ink-based occlusal marking, providing both visual and quantitative data on contact distribution and occlusal force.

The OccluSense sensor was positioned intraorally, and the patient was guided through various mandibular movements, including centric occlusion, protrusion, and lateral excursions. Data were wirelessly transmitted to the dedicated OccluSense iPad application, where occlusal contacts were visualized in full color (Figure 22), and pressure distribution was presented as a percentage for each tooth contact.

The analysis confirmed that the patient exhibited stable intercuspal contacts and occlusal harmony in maximum intercuspation (Figure 23). However, dynamic evaluation revealed premature occlusal contacts during right laterotrusion. These interferences were precisely identified using the force distribution data and were subsequently corrected through selective enamel grinding, following the digital guidance provided by the system (Figure 24).

This data-driven approach allowed for refined occlusal adjustments, improving functional balance and minimizing the risk of long-term complications such as muscle strain or restoration overload. The patient reported immediate improvement in comfort during mastication following the adjustment phase.

To further clarify the treatment chronology, a visual representation of the clinical workflow has been included (Figure 25). This timeline summarizes the sequential integration of digital tools and clinical procedures, from initial assessment to final follow-up, illustrating the structured and reproducible nature of the fully digital prosthodontic rehabilitation protocol.

The patient was scheduled for follow-up visits at 1 week, 1 month, and 3 months post-cementation. At each recall, a comprehensive clinical evaluation was performed, focusing on the integrity of the restorations, occlusal stability, soft tissue health, esthetic integration, and patient-reported outcomes.

At the 1-week follow-up, the patient reported no discomfort during mastication and expressed satisfaction with the overall appearance and feel of the restorations. Visual and tactile inspection confirmed proper marginal adaptation, with no evidence of cement washout or irritation to the surrounding gingiva. Occlusal contacts remained stable, and no further adjustments were required.

By the 1-month follow-up, the restorations had integrated harmoniously into the patient's dentition. Periodontal tissues around the abutments appeared healthy, with no signs of inflammation or recession. The occlusal scheme remained balanced and free of premature contacts, as verified with articulating paper and patient feedback during chewing simulation. Esthetically, the zirconia restorations exhibited excellent color matching and surface luster. The patient reported improved comfort and function compared to the provisional phase.

At the 3-month recall, the prostheses continued to perform successfully, with no reported functional limitations, chipping, or debonding. The gingival margins remained stable with good tissue adaptation, and oral hygiene was well maintained. The occlusion continued to demonstrate stability in both centric and eccentric movements. The patient expressed high satisfaction with the treatment outcome, particularly noting the natural appearance of the restorations and the absence of any postoperative complications. No adverse events or prosthetic complications were observed during the entire follow-up period.