DENTAL TECHNIQUE

Creating three-dimensional virtual patients by superimposing

intraoral and facial digital scans guided with an aligner
system: A dental technique
Xabier Amezua, BEng, MSc,a Gaizka Erkizia, BEng, MSc, PhD,b Mikel Jauregi, BEng, MSc,c and
Eneko Solaberrieta, BEng, MSc, PhDd

Various aligner systems have ABSTRACT

been developed to guide the A technique for creating 3-dimensional virtual patients (3DVPs) by superimposing intraoral and
superimposition of intraoral facial digital scans guided with a novel aligner system is described. This aligner system supports
and facial digital scans to design modifications to adapt to different facial scanning methods (FSMs) and reduce the
create 3-dimensional virtual impact of FSMs on the accuracy of 3DVPs. Two different designs of the aligner system are
patients (3DVPs). They have described: one for use with less-accurate FSMs and another for use with more-accurate FSMs.
been used for different clinical These virtual designs are available for download and use. (J Prosthet Dent 2022;-:---)
purposes, including obtaining
virtual facebow records or performing facially driven digital scans acquired by using these FSMs is important
digital diagnostic waxing procedures.1-11 Intraoral digital and can be achieved by intervening in the design of the
scans are acquired by using intraoral scanners (IOSs), aligners.20,21
whereas facial digital scans can be acquired by using For a 3DVP to be accurate, the regions of the aligners
various facial scanning methods (FSMs). Although most involved in the superimpositions should be extensive and
aligner systems can be used to superimpose intraoral contain sufficient shape details because superimpositions
digital scans with facial digital scans acquired with any are performed by using best-fit algorithms. To avoid
FSM, the accuracy of a 3DVP is greatly influenced by superimposition errors, all methods used to scan these
which FSM is used, being more accurate when using regions of the aligners should be able to capture shape
more accurate FSMs.12,13 details.22 In general, FSMs have less ability to capture
Most accurate FSMs, such as stationary facial scan- shape details than IOSs and laboratory scanners, and
ners or professional handheld scanners, however, may be less-accurate FSMs have even less ability than more ac-
unsuitable for many dental clinics, principally because of curate ones.18,19,22
14,15
their high cost. Therefore, alternative FSMs have This article describes a technique for creating 3DVPs
been proposed, with mobile device-compatible 3D by superimposing intraoral and facial digital scans guided
sensor cameras attracting the most interest, principally by a novel aligner system that supports design modifi-
because of their low cost and ease of use.15-19 However, cations to adapt to different FSMs in order to reduce the
improving the accuracy of 3DVPs created with facial impact of FSMs on the accuracy of 3DVPs. Two designs

Funding: Supported by the University of the Basque Country UPV/EHU, Spain (grant number GIU21/051), Gipuzkoa Provincial Council, Spain (grant number 20/2021), and
MINECO Ministry of Economy and Competitiveness, Spain (grant number PID2019-108975RA-I00).
a
Research Assistant, Department of Graphic Design and Engineering Projects, Faculty of Engineering Gipuzkoa, University of the Basque Country UPV/EHU, San Sebastian,
Spain.
b
Assistant Professor, Department of Graphic Design and Engineering Projects, Faculty of Engineering Bilbao, University of the Basque Country UPV/EHU, Bilbao, Spain.
c
Associate Professor, Department of Mechanical Engineering, Faculty of Engineering Gipuzkoa, University of the Basque Country UPV/EHU, San Sebastian, Spain.
d
Associate Professor, Department of Graphic Design and Engineering Projects, Faculty of Engineering Gipuzkoa, University of the Basque Country UPV/EHU, San Sebastian,
Spain.

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Figure 1. Virtual designs of aligners for less-accurate facial scanning methods. A, Frontal view of virtual design of buccal aligner. B, Posterior view of
virtual design of buccal aligner. C, Virtual designs of forehead aligners.

Figure 2. Virtual designs of aligners for more-accurate facial scanning methods. A, Frontal view of virtual design of buccal aligner. B, Posterior view of virtual
design of buccal aligner. C, Virtual designs of forehead aligners.

of the aligner system are described: one for use with less- online) in a material that meets biocompatibility
accurate FSMs (Fig. 1), such as some mobile device- requirements23,24 (Surgical Guide Resin; Formlabs,
compatible 3D sensor cameras, composed of aligners Inc) with an AM machine (Form 3B; Formlabs, Inc)
with fewer shape details in regions that are scanned by according to the manufacturer’s protocol (Fig. 4).
using FSMs (Fig. 1A, 1C) (Supplemental File 1, available 3. Assemble the buccal aligner and its tray by inserting
online), and another for use with more-accurate FSMs the tip of the tray into the hole of the buccal aligner
(Fig. 2), such as some professional handheld scanners (press them together until they are firmly attached)
composed of aligners with more shape details in the (Fig. 5).
regions that are scanned by using FSMs (Fig. 2A, 2C) 4. Acquire the patient’s maxillary, mandibular, and
(Supplemental File 2, available online). As the technique occlusal digital scans by using an IOS (TRIOS 3;
is the same with both designs of the aligner system, the 3Shape A/S) as per the manufacturer’s protocol
use of only 1 is described. (Fig. 6).
5. Acquire the patient’s facial digital scans by using an
TECHNIQUE FSM such as a smartphone with an integrated 3D
sensor camera (iPhone 12 Pro; Apple, Inc)
1. Manufacture the virtual designs of the alignersd1 controlled with a mobile application (Heges 3D
copy of the virtual design of the buccal aligner Scanner; Marek Simonik) as per the manufacturer’s
(Supplemental File 1A, available online), 1 copy of protocol (Fig. 7). First, acquire a reference facial
the virtual design of the central forehead aligner digital scan with the additively manufactured
(Supplemental File 1B, available online), and 2 aligners placed on the corresponding areas of the
copies of the virtual design of the lateral forehead patient’s face (Fig. 7A): the forehead aligners on the
aligner (Supplemental File 1C, available online)din forehead area (the central one in the center and the
an opaque material that meets biocompatibility re- lateral ones on the sides close to the temporal line of
quirements23,24 (VisiJet M2R-WT; 3D Systems, Inc) the frontal bone), fixed to the head by a headband
with an additive manufacturing (AM) machine (Elastic tape; William Prym Holding GmbH), and
(ProJet MJP 2500 Plus; 3D Systems, Inc) according the buccal aligner over the buccal area, fixed to the
to the manufacturer’s protocol (Fig. 3). maxillary arch with high- and low-viscosity polyvi-
2. Manufacture the virtual design of the tray of the nyl siloxane impression material (VPS Hydro; Henry
buccal aligner (Supplemental File 3, available Schein, Inc) loaded onto its tray. Place the forehead

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Figure 3. Additively manufactured aligners. A, Additively manufactured buccal aligner. B, Additively manufactured forehead aligners.

Figure 4. Additively manufactured tray of buccal aligner. Figure 5. Additively manufactured buccal aligner and its tray assembled.

aligners first and, before placing the buccal aligner,

instruct patients to avoid moving their eyebrows
until all facial digital scans have been acquired.
Check that the forehead aligners do not move in the
absence of eyebrow movement (otherwise, correct
their placement). After acquiring the reference facial
digital scan, obtain at least 1 definitive facial digital
scan with the buccal aligner removed (carefully,
without separating it from its tray) and the forehead
aligners in place in a specific facial expression such
as at rest (Fig. 7B).
6. Acquire the digital scan of the back of the buccal
aligner with the IOS (Fig. 8).
7. Superimpose intraoral and facial digital scans to
create a 3DVP (Fig. 9). For that, import all previous
digital scans to a dental computer-aided design Figure 6. Intraoral digital scans.
software program (exocad; exocad GmbH) and
perform the following steps: first, superimpose the (Fig. 9B); third, superimpose the reference facial
digital scan of the back of the buccal aligner with digital scan with the virtual design of the buccal
the maxillary digital scan (Fig. 9A); second, super- aligner (Fig. 9C); fourth, superimpose the definitive
impose the virtual design of the buccal aligner with facial digital scan with the reference facial digital scan
the digital scan of the back of the buccal aligner (Fig. 9D); and, finally, if necessary, superimpose the

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Figure 7. Facial digital scans. A, Reference facial digital scan. B, Definitive facial digital scan at rest.

mandibular and occlusal digital scans with the

maxillary digital scan. Perform all superimpositions
by using a best-fit algorithm after selecting the re-
gions of the digital scans to be superimposed (Fig. 9).

DISCUSSION
A technique to create 3DVPs by superimposing intraoral
and facial digital scans guided with a novel aligner sys-
tem is described. The aligner system is composed of 4
reusable aligners: 3 forehead aligners and 1 buccal
aligner, with a removable and disposable tray (a
removable and disposable tray is used to enable the use
of both standard and custom trays without the need to
remanufacture the buccal aligner as was required with
Figure 8. Digital scan of back of buccal aligner.
most previously developed aligners of this type). The
aligners, as well as the tray of the buccal aligner, can be
additively manufactured, taking into account that they shape details (this design should only be used with FSMs
should meet or exceed the biocompatibility requirements that cannot capture the shape details of the first design).
established for medical devices in contact with intact skin The buccal aligner is a further innovation of the aligner
surfaces and, in the case of the buccal aligner and its tray, system. The regions involved in the superimpositions are
also with intact mucosal membrane surfaces, the duration notably more extensive than those of most previously
of contact being long term for aligners and limited for the developed aligners of this type,1-11 which favors the ac-
tray of the buccal aligner.23,24 The aligners should be curacy of the superimpositions, and therefore that of the
sterilized before reuse by following the instructions of the resulting 3DVPs. Even so, there is no need for a labo-
manufacturer of the material used to manufacture them. ratory scanner to obtain its digital scan after acquiring the
An innovation of the aligner system is that it supports reference facial digital scan because only the digital scan
design modifications to adapt to different FSMs in order of its back is necessary (Fig. 8); this can be obtained by
to reduce the impact of FSMs on the accuracy of 3DVPs. using an IOS. In addition, the regions of the buccal
Almost all previously developed aligner systems propose aligner that are scanned by using FSMs (Figs. 1A, 2A) do
a single design for all FSMs1-11 without taking into ac- not coincide with those scanned by using IOSs (Figs. 1B,
count that not all FSMs have the same ability to capture 2B), which enables the independent adaptation of the
shape details and that not capturing shape details of the shape details of those regions. Thus, the difference be-
aligner regions involved in the superimpositions may tween the 2 described aligner system designs is only in
lead to errors that affect the accuracy of the resulting the shape details of the aligner regions that are scanned
3DVPs.22 That is why 2 different aligner system designs by using FSMs (Figs. 1A, 1C, 2A, 2C), whereas the shape
are described: one for use with more-accurate FSMs with details of the regions scanned by using IOSs are similar
a greater ability to capture shape details and another for (Figs. 1B, 2B) as all IOSs have a similar ability to capture
use with less-accurate FSMs with less ability to capture shape details.

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Figure 9. Superimposition of intraoral and facial digital scans. A, Superimposition of digital scan of back of buccal aligner with maxillary digital scan.
B, Superimposition of virtual design of buccal aligner with digital scan of back of buccal aligner. C, Superimposition of reference facial digital scan with
virtual design of buccal aligner. D, Superimposition of definitive facial digital scan with reference facial digital scan. E, Three-dimensional virtual patient
created by superimposing intraoral and facial digital scans. Blue indicates regions selected for superimposition with best-fit algorithm.

Limitations of the novel aligner system include that the need for an AM machine with high accuracy or the
its buccal aligner should be manufactured accurately, as presence of a laboratory scanner in the clinic, reusable
its virtual design is involved in the superimpositions buccal aligners could be manufactured externally, and
(Fig. 9B, 9C), and therefore, manufacturing errors may the disposable trays and reusable forehead aligners
lead to superimposition errors that affect the accuracy could be manufactured in-house on a more accessible
of the resulting 3DVPs. However, if this is not possible, AM machine.
it could be manufactured less accurately, and its digital Virtual designs of the novel aligner system can be
scan acquired with a laboratory scanner could substi- downloaded and used by the dental community.
tute the virtual design in the superimpositions. To avoid However, studies are needed to assess the accuracy of

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3DVPs created with this technique, to optimize the 13. Amezua X, Iturrate M, Garikano X, Solaberrieta E. Analysis of the impact of
the facial scanning method on the precision of a virtual facebow record
aligner system, and to develop new designs for different technique: an in vivo study. J Prosthet Dent. 13 December 2021. https://doi.
FSMs. org/10.1016/j.prosdent.2021.10.025 [Epub ahead of print].
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16. Liu J, Zhang C, Cai R, Yao Y, Zhao Z, Liao W. Accuracy of 3-dimensional
traoral and facial digital scans guided with a novel aligner stereophotogrammetry: comparison of the 3dMD and Bellus3D facial scan-
system is described. The aligner system supports design ning systems with one another and with direct anthropometry. Am J Orthod
Dentofac Orthop. 2021;160:862e871.
modifications to adapt to different FSMs in order to 17. Gallardo YNR, Salazar-Gamarra R, Bohner L, De Oliveira JI, Dib LL,
reduce the impact of FSMs on the accuracy of 3DVPs. Sesma N. Evaluation of the 3D error of 2 face-scanning systems: an in vitro
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Two designs of the aligner system are described: one for 2021.06.049 [Epub ahead of print].
use with less-accurate FSMs and another for use with 18. D’Ettorre G, Farronato M, Candida E, Quinzi V, Grippaudo C. A comparison
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more-accurate FSMs. Their virtual designs are available for three-dimensional face scanning. Angle Orthod. 2022;92:358e363.
for download and use. 19. Knoops PGM, Beaumont CAA, Borghi A, Rodriguez-Florez N, Breakey RWF,
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This is an open access article under the CC BY-NC-ND license (http://
scan to a 3D face scan for a virtual facebow technique: an in vitro study.
J Prosthet Dent. 12 March 2021. https://doi.org/10.1016/j.prosdent.2021.02.007 creativecommons.org/licenses/by-nc-nd/4.0/).
[Epub ahead of print]. https://doi.org/10.1016/j.prosdent.2022.09.008

THE JOURNAL OF PROSTHETIC DENTISTRY Amezua et al