In an era where digital precision meets esthetic demand, modern dentistry continues to evolve toward minimally invasive yet highly personalized care. Digital and adhesive protocols have reshaped the landscape of restorative treatment, allowing clinicians to deliver outcomes that are both efficient and emotionally impactful.
Active patient participation in the digital design phase enables clinicians to develop restorations informed directly by the patient’s preferences. Through shared-screen communication with the technician or digital designer, the patient is able to interact in real time, offering esthetic preferences, visual feedback, and approval as the proposed restorations take shape onscreen. This dynamic collaboration ensures the patient has input in the design process and minimizes downstream revisions. Once transferred to the mouth, mock-ups can still be refined within the oral cavity itself, integrating clinical precision with emotional satisfaction. The result is a streamlined, highly personalized workflow that enhances both efficiency and patient trust, eliminating the traditional wait for provisional restorations and empowering the patient throughout.
Patient Case
A 41-year-old female patient presented with the chief complaint of disliking the extreme triangular shape of her existing maxillary anterior composite restorations, which had been in place for over eight years. Previously, her natural teeth were longer and more rounded, and she expressed a strong desire to have the original shape restored. In addition to the form, she also requested a lighter value for the final restorations to brighten her smile.
The patient had previously consulted with several dentists but had lost trust in the process after experiencing unsatisfactory outcomes and limited participation in the decision making. Involving the patient directly in the digital design process, along with the promise of same-day, in-office fabrication, was essential to her, as it gave her full control over the final shape and esthetic outcome of the restorations.
After a comprehensive discussion of her concerns and treatment expectations, the decision was made to proceed with 10 VITABLOCS® Mark II maxillary feldspathic ceramic veneers (VITA North America), fabricated in a single appointment using a fully digital, patient-guided protocol.
Diagnostic Records and Digital Design
The first clinical appointment focused on acquiring comprehensive diagnostic data: a full-mouth series of X-rays, detailed digital photographs (Figure 1 and Figure 2) and intraoral scans obtained using the Primescan® system (Dentsply Sirona). Additionally, the patient’s centric relationship was recorded using a leaf gauge, which allowed the team to confirm a stable maxillomandibular relationship and proceed confidently with the design phase.
From the comfort of her own home, the patient participated in a live, real-time design session via shared screen and connected directly with the digital technician. Through the exocad software interface (exocad), the patient was able to view, discuss, and fine-tune key esthetic parameters of the future restorations, including tooth shape, incisal edge position, proportion, and surface texture (Figure 3 through Figure 6). This session ensured full patient control over the proposed design and provided a critical communication step that reduced the need for guesswork and enhanced emotional investment in the final outcome. The patient was pleased with the process and largely selected the author’s practice for her treatment based on this determining factor.
Once the digital wax-up was completed, a putty matrix was fabricated, and a full mock-up was created in situ using a bis-acryl material (Figure 7). This step allowed immediate visualization of the final design in the patient’s mouth and enabled refinements based on occlusal comfort, phonetics, and esthetic feedback. The mock-up was completed in under an hour and served as a precise physical blueprint for the definitive restorations.
Preparation and fabrication
Treatment of the maxillary arch began with the preparation of the posterior teeth, completed in approximately one hour under local anesthesia. To ensure a highly conservative approach, all preparations were performed using depth-cutting burs with the resin mock-up left in situ, providing both a visual and physical guide for calibrated enamel reduction (Figure 8). This method allowed for maximum preservation of healthy tooth structure and precise alignment with the intended restorative outcome (Figure 9 and Figure 10).
The preparation designs followed a protocol scientifically grounded in the most current literature, as presented by Dr. Carlos De Carvalho and the author of this article in their Adhesive Rehabilitations and Tooth Preparations hands-on courses at the DentLit Academy. These preparations are specifically designed to support adhesive bonding, minimizing the need for mechanical retention, while maximizing the success of minimally invasive ceramic restorations.
Following the posterior preparation, a fully digital workflow was initiated. Intraoral scans were taken, and the restorations were designed and milled in-office using monochromatic feldspathic ceramic blocks (VITABLOCS® Mark II [1M2C]). While the posterior restorations were being milled, the anterior maxillary teeth were prepared using the same conservative protocol and then scanned.
Once posterior restorations were ready, try-in and adjustments were completed while the anterior veneers were simultaneously undergoing staining and glazing with VITA AKZENT® Plus (VITA) and fired in a ceramic furnace. The sequence allowed for seamless time management between anterior and posterior phases.
Upon finalization, the posterior restorations were delivered first, followed by the anterior veneers. All bonding procedures were conducted under isolation, ensuring optimal adhesion and clinical control.
Bonding protocol
The adhesive procedure began with a selective etch technique, using 35% phosphoric acid (K-ETCHANT syringe, Kuraray America), followed by thorough rinsing with chlorhexidine. A desensitizing agent (Gluma® Desensitizer, Kulzer) was then applied to the prepared surfaces. This was followed by the application of a self-etch primer and bonding agent (CLEARFIL™ SE PROTECT, Kuraray America), creating optimal conditions for adhesion (Figure 11).
For the final cementation, a universal MDP-containing cleaner (KATANA™ Cleaner, Kuraray America) was applied to both the tooth substrates and the internal surfaces of the ceramic restorations. A clear adhesive resin cement (PANAVIA™ V5, Kuraray America) was then used for luting. All restorations were polymerized using a high-intensity LED curing light (VALO™, Ultradent), followed by precise occlusal adjustments to finalize the integration of the veneers (Figure 12 and Figure 13).
With the maxillary restorations successfully delivered, the patient was digitally scanned for a set of Vivera retainers (Align Technology, Inc.) and was scheduled for routine follow-up care.
Conclusion
The patient was very pleased with her new smile (Figure 14) and the patient-guided design process. All restorations were designed, milled, characterized, and delivered chairside in a single appointment. This case exemplifies how the integration of advanced digital protocols with patient-centered communication can transform both the clinical and emotional experience of restorative treatment. By allowing the patient to participate directly in the design process through a live screen-sharing session with the technician, trust was re-established in a previously uncertain journey. The ability to visualize and co-create the final shapes, proportions, and surface textures of the veneers gave the patient control, confidence, and clarity long before the restorations were fabricated. This modern approach highlights the importance of restoring not just teeth, but also the patient’s confidence in the process itself.
Figures and Images
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