Received: 20 February 2021 Accepted: 3 May 2021

DOI: 10.1111/jerd.12787

CLINICAL ARTICLE

Digital scanning under rubber dam: An innovative method for

making definitive impressions in fixed prosthodontics

Víctor Henarejos-Domingo DDS, MSc1 | Victor Clavijo DDS, MS, PhD2 |

Alvaro Blasi DDS, CDT3
| Sara Madeira DDS, MSc 4
| Miguel Roig MD, DMD, PhD5
1
Private practice, Barcelona, Spain; and Assistant Professor, Department of Restorative Dentistry, School of Dentistry, International University of Catalunya,
Barcelona, Spain
2
Private practice, Indaiatuba, Brazil; and Visiting Professor, Advanced Program in Operative and Adhesive Dentistry, Division of Restorative Sciences, Herman Ostrow
School of Dentistry, University of Southern California, Los Angeles, California, USA
3
Private practice, Barcelona, Spain; and Adjunct Assistant Professor, Department of Restorative Sciences, Dental College of Georgia at Augusta University, Augusta,
Georgia, USA
4
Private practice, Barcelona, Spain; and Assistant Professor, Department of Integrated Dentistry Department, School of Dentistry, International University of
Catalunya, Barcelona, Spain
5
Private practice, Barcelona, Spain; and Chairman and Professor, Department of Restorative Dentistry, School of Dentistry, International University of Catalunya,
Barcelona, Spain

Correspondence
Dr Sara Madeira, Department of Integrated Abstract
Dentistry Department, International University Objective: To provide a comprehensive protocol for final impressions making under
of Catalunya, Facultad de Odontología, Carrer
Josep Trueta s/n (Hospital Universitari General rubber dam isolation by using an intraoral scanner.
de Catalunya), Sant Cugat del Vallès 08195, Clinical consideration: Impression making after tooth preparation with rubber dam
Barcelona, Spain.
Email: saramadeira@uic.es isolation are impossible with conventional physical impressions, which are not with
intraoral scanners. Digital technologies have disrupted dentistry in the last decades,
bringing new, straightforward, and more time-efficient protocols for dental practice.
Conclusions: Taking in consideration the beneficial properties of scanning under rub-
ber dam this protocol can be highly recommended for everyday use for making defini-
tive intraoral scans for tooth-supported restorations.
Clinical significance: The described protocol offers the possibility to make a final
impression in a stress-free environment, without blood or saliva, to obtain a better
visualization and scanning of the finish line, and the potential of save time on defini-
tive impression making.

KEYWORDS
CAD/CAM, digital dentistry, operative dentistry, prosthodontics

1 | I N T RO DU CT I O N prosthodontics.5-9 IOSs may provide numerous advantages over conven-

tional physical impressions, including better patient acceptance, greater
In recent years dentistry has been disrupted and revolutionized by digital standardization of the impressions, instant evaluation of the digital model,
innovations.1-4 The state of the art considers digital tools, such as scan- and no need of physical casts.10-17 Moreover, it has been shown that digi-
ners or computer-aided design and computer-aided manufacturing (CAD- tal scans are a trustworthy option to conventional impression making for
1
CAM) technologies, as providers of advantages to clinicians and patients. unitary and short-span fixed dental prostheses.18,19 Nevertheless, the
Intraoral scanners (IOSs) are widely used by clinicians in the daily learning curve of the digital workflow, and the initial investment cost of
practice as an alternative to conventional impressions in fixed these digital tools are important things to consider.7,16

J Esthet Restor Dent. 2021;1–6. wileyonlinelibrary.com/journal/jerd © 2021 Wiley Periodicals LLC 1

2 HENAREJOS-DOMINGO ET AL.

In 1864, Dr. Sanford Christie Barnum introduced the use of a rubber interocclusal records (Occlusion) (Figure 2D). Follow the official
sheet to isolate a tooth,20 but it was not until the 1990s, with the rise of scan strategy of the manufacturer during all the scanning pro-
the adhesive era, that the use of rubber dam isolation became popular. cesses. Consider ambient scanning light conditions, because recent
Rubber dam isolation presents numerous advantages to the patient and in vitro studies demonstrated that it influences in the accuracy, the
the clinician, such as the prevention of accidental swallowing, protection mesh quality, and the scanning time of IOSs.24-26
of the surrounding tissues, effective control of moisture, blood, bacteria, 3. Perform a complete isolation of the operatory field with rubber dam
21
and better visual control. Despite, its multiple advantages, the daily use (Nic Tone, Manufacturera Dental Continental, S.A. de C.V., Ciudad de
it is not so extended, and the most common mentioned reason is that its México, México) (Figure 3A). Extent the isolation as much as possible
placement is time-consuming.22 Nonetheless, this procedure is considered to facilitate the subsequent intraoral scanning process. The extension
the standard of care in any restorative procedure.23 of the isolation varies on the number of teeth needing to be restored,
This article describes a comprehensive protocol for final impres- but as general rule, the isolation of one posterior and two anterior
sions making under rubber dam isolation by using an intraoral scanner. teeth, from the tooth to be treated, is the minimum isolation required.
4. Under rubber dam isolation, prepare the tooth and perform imme-
diate dentin sealing and/or deep margin elevation if it is required
2 | TECHNIQUE (Figure 3B).27,28
5. Mark in the prepreparation digital scan (Upper Pre-Prep) the tooth
This technique is suitable for tooth-supported restorations in fixed which needs to be restored with a fixed dental prosthesis
prosthodontics, whether for inlays, partial-coverage crowns, complete (Figure 4A). Proceed to the preparation scan (Upper) on the scan
crowns, fixed partial dentures, or laminate veneers. To illustrate the page. Normally, the software automatically removes a preset diam-
process a patient who had been planned for a partial-coverage crown eter around the marked tooth by default, but it may be not
in a maxillary right first molar is presented (Figure 1). enough. Trim away all the extra information that can interfere with
the area that you want to rescan (Figure 4B).
1. Turn the intraoral scan on (TRIOS 3, 3Shape A/S, Copenhagen, 6. Obtain an intraoral digital scan of the final preparation under com-
Denmark) and introduce the information of the patient. Create a plete isolation (Figure 5A). Start scanning from the occlusal surface
new order selecting the tooth to be restored, the type of restora- to facilitate the virtual matching between both scans. Once the
tion, and the material of choice. Additionally, select in the prescrip- preparation scan (Upper) is done it is recommended to rescan
tion form window a prepreparation scan as a supplementary scan the preparation area with the high definition mode on, to obtain a
(Figure 2A). higher mesh quality (Figure 5B).
2. Obtain an intraoral scan of the antagonist arch (Lower), and a pre- 7. Verify your intraoral digital scans by zooming, rotation, or turning
preparation intraoral digital scan of the initial situation (Upper Pre- off colors of the virtual models (Figure 5C,D).
Prep) (Figure 2B,C). It should be taken from the unprepared tooth, 8. Design the partial-coverage crown with a CAD software program
or from the interim restoration if it exists. Finally, scan both virtual (Dental System 2020, 3Shape A/S, Copenhagen, Denmark), and

F I G U R E 1 Initial situation of
maxillary right first molar.
(A) Lateral view in maximal
intercuspal position. (B) Lateral
close-up view. (C) Occlusal view.
(D) Periapical radiograph
HENAREJOS-DOMINGO ET AL. 3

F I G U R E 2 Intraoral digital
scan. (A) Prescription form
window. (B) Occlusal view of
lower intraoral digital scan.
(C) Oclusal view of upper Pre-
Prep intraoral digital scan.
(D) Lateral right view of Occlusion
intraoral digital scan

F I G U R E 3 (A) Occlusal view

of initial situation under rubber
dam isolation. (B) Occlusal view of
tooth preparation under rubber
dam isolation

F I G U R E 4 (A) Occlusal view

of upper Pre-Prep intraoral digital
scan with maxillary right first
molar marked. (B) Occlusal view
of Upper intraoral digital scan
with maxillary right first molar
cut-out

proceed with the successive manufacturing process to obtain the Nowadays, IOSs can expand the scope of the limits by providing
final prosthesis (Figure 6). different solutions which are not possible when making conventional
impressions. One of these is the ability to cut out and rescan as many
times as needed in specific areas, without affecting the accuracy of
the virtual casts.29 In the described protocol, the digital scan with the
3 | DISCUSSION initial situation of the unprepared teeth (Upper Pre-Prep) was used as
reference digital scan. This digital scan has relevant anatomic refer-
A digital workflow to obtain final impressions under rubber dam isola- ences to allow a proper matching with the digital scan taken after
tion by using an intraoral scanner has been described. teeth preparation. The software can fuse automatically the two
4 HENAREJOS-DOMINGO ET AL.

F I G U R E 5 Upper intraoral
digital scan under rubber dam
isolation. (A) Occlusal view.
(B) Occlusal view of standard
tessellation language file to check
mesh quality. (C) Occlusal view of
clearance analysis. (D) Close-up
view of marked finish line

F I G U R E 6 (A) Computer-
aided design process of maxillary
right first molar. (B) Occlusal view
of cementation process under
rubber dam isolation.
(C) Postoperative occlusal view.
(D) Final periapical radiograph

different datasets (pre-preparation and preparation digital scans) and rubber dam can take time and be complex, due to the possibility of
all the information about tooth position, interocclusal clearance, and the prepared finish line, even if it is supragingival, be obscured by
finish line is simultaneously integrated. blood or saliva, which interrupts or delays the process (Figure 7).
The greatest advantage of the proposed technique is the capacity One of the limitations of this technique is the handling of the
to scan in a clean, dry, and stress-free environment. Moreover, this intraoral scanner under rubber dam isolation. Larger scanner heads
protocol can be a time-efficient since allows the clinician to perform a can complicate the scanning process being difficult to reach some
rapidly definitive digital scan only of the preparation area just after areas, especially toward the distal. Sometimes the exported intraoral
tooth preparation, without the need of extra materials such as dis- digital scans as STL files can be problematic to fabricate with additive
placement cord or hemostatic agents. There is probably no better or subtractive CAM technologies, if the mesh of the files are not
retraction device to pull away the soft tissues than the rubber dam closed. However, taking in consideration the improvements of CAD-
itself. On the other hand, impression making after removing the CAM technologies, and the skills of the dental technician the reality is
HENAREJOS-DOMINGO ET AL. 5

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