Complete Digital Workflow for Fabricating an

Occlusal Device Using Artificial Intelligence–

Powered Design Software and Additive
Manufacturing: A Dental Method
Gabriela Panca Sabatini, DDS, MSc
Department of Prosthodontics, University of São Paulo (USP), São Paulo, Brazil; Department of
Reconstructive Dentistry and Gerodontology, School of Dental Medicine, University of Bern, Bern,
Switzerland.

Hyung-In Yoon, DDS, MSD, PhD

Department of Prosthodontics, School of Dentistry and Dental Research Institute, Seoul National
University, Seoul, Republic of Korea; Department of Reconstructive Dentistry and Gerodontology,
School of Dental Medicine, University of Bern, Bern, Switzerland.

Ahmet Orgev, DDS, MS, MSD

Department of Restorative Dentistry, School of Dental Medicine, University at Buffalo, Buffalo,
New York, USA.

Manrique Fonseca, DDS, MSD

Department of Reconstructive Dentistry and Gerodontology, School of Dental Medicine, University of
Bern, Bern, Switzerland.

Pedro Molinero-Mourelle, DDS, MSD, PhD

Department of Reconstructive Dentistry and Gerodontology, School of Dental Medicine, University
of Bern, Bern, Switzerland; Department of Conservative Dentistry and Orofacial Prosthodontics,
Complutense University of Madrid, Madrid, Spain.

Burak Yilmaz, DDS, PhD

Department of Reconstructive Dentistry and Gerodontology and Department of Restorative, Preventive,
and Pediatric Dentistry, School of Dental Medicine, University of Bern, Bern, Switzerland; Division of
Restorative and Prosthetic Dentistry, The Ohio State University, Columbus, Ohio, USA.

Gülce Çakmak, DDS, PhD

Department of Reconstructive Dentistry and Gerodontology, School of Dental Medicine, University of
Bern, Bern, Switzerland.

Artificial intelligence (AI) has been expanding into areas that were thought to be reserved for human experts
and has a tremendous potential to improve patient care and revolutionize the healthcare field. Recently
launched AI-powered dental design solutions enable automated occlusal device design. This article describes
a dental method for the complete digital workflow for occlusal device fabrication using two different AI-
powered design software programs (Medit Splints and 3Shape Automate) and additive manufacturing.
Additionally, the benefits and drawbacks of this workflow were reviewed and compared to conventional
workflows. Int J Prosthodont 2024;37(suppl):s275–s284. doi: 10.11607/ijp.8941

A
rtificial intelligence (AI) has been expanding into areas that were thought to be
reserved for human experts and has a tremendous potential to improve patient
care and revolutionize the healthcare field.1,2 In recent years, the capabilities Correspondence to:
Dr Gülce Çakmak,
of AI have expanded into the computer-aided design (CAD) stage, in addition to their guelce.cakmak@unibe.ch
usage for diagnostic purposes and treatment outcome evaluations.3–6 With the aid of
commercially available AI-powered dental software programs, the crowns, copings, Submitted November 6, 2023;
accepted March 8, 2024.
inlays, models, removable partial dentures, and occlusal devices can be automatically ©2024 by Quintessence
designed.7–13 Automated restoration design may provide many advantages, such as Publishing Co Inc.

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 Fig 1   (a and b) Intraoral view
of the maxilla and mandible,
respectively. (c and d) Digital
scans of the maxilla and man-
dible, respectively.

a b

c d

the elimination of intensive laboratory work, increased To the present authors’ knowledge, there is limited
time efficiency, decreased human-related errors, and information on the digital workflow for occlusal de-
improved chairside dental treatment procedures.13,14 vice fabrication, including automated design with AI-
Further, this automated design outcome may be adjusted powered software followed by AM. In an in vitro study.
if needed.13,14 Recently launched AI-powered dental Kois et al14 reported the design discrepancies of occlusal
design solutions, such as Medit Splints (Medit) and Au- devices made with Medit Splints and Automate com-
tomate (3Shape), enable automated designing of oc- pared to the designs of experienced dental technicians.
clusal devices.14 Both software programs use articulated However, the clinical fabrication steps have not yet been
intraoral scan data.14 Although Automate15 provides an reported. Therefore, the purpose of this dental method
automated design option only for night guards, Medit is to present the complete digital workflow for occlusal
Splints16 provides design options for different occlusal device fabrication using two different AI-powered design
splint types, including Michigan, flat plane (FPS), and software programs (Medit Splints and Automate) and
nociceptive trigeminal inhibition (NTI) splints. AM. Additionally, the benefits and drawbacks of this
Regardless of whether the design is analog or au- workflow in comparison to conventional workflow will
tomated, computer-aided manufacturing (CAM) tech- be reviewed.
nologies, including additive manufacturing (AM) and
subtractive manufacturing (SM) methods, can be used MATERIALS AND METHODS
to fabricate occlusal devices. CAM of occlusal devices
may have advantages such as reduced cost, reproduc- This complete workflow consists of four stages: (1)
ibility, time-efficiency, and fewer laboratory stages17–22 data acquisition, involving intraoral scans and record-
than traditional occlusal device–fabrication methods of ing the centric relation; (2) design (Medit Splints and
thermoforming, sprinkle-on, and lost wax techniques. Automate); (3) CAM; and (4) device delivery with clinical
Although SM has been preferred over AM for fabricat- adjustments.
ing occlusal devices for many years due to the better In the data-acquisition stage, first the maxillary and
mechanical properties of SM resins,21 newly introduced mandibular arches are digitized using an intraoral scan-
3D-printed resins have promising mechanical proper- ner (Trios4, 3Shape), including the most distal molars,
ties. Due to AM’s several advantages (eg, less material according to the manufacturer’s recommended scan
waste, reduced cost, and high productivity by fabricating protocol (Fig 1). Then, place an anterior deprogrammer
multiple objects with complex geometries at the same (Kois Lucia Jig, Kois Center) on the maxillary incisors and
time), AM-generated occlusal devices are increasingly fix it with silicone bite registration material (Prestige Bite,
used.21,22 Vannini Dental Industry). Instruct the patient to gradually

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 Sabatini et al

Fig 2  (a) Anterior deprogrammer. (b to d) The anterior deprogrammer was fixed

on the maxillary incisors using silicone bite registration material and centric relation
registration of the mandible.

b b c

a b

Fig 3  Representative pro-

cedures of the Medit Splints
AI-powered software: Gen-
erating the model. (a) Selec-
tion of occlusal device type.
(b) Selection of AI-powered
automated design and/or
design parameter settings.
(c) Adjusting the parameter
settings. (d) Occlusal device
margins determined by the
software after confirming oc-
clusal device creation.
c d

occlude mandibular incisors on the occlusal plate of the Splints version 3.1.3). After creating a new patient in
deprogrammer until the posterior teeth have a maximum Medit Splints, import the maxillary and mandibular STL
disclusion of 2.0 to 2.5 mm. Record the centric relation of files. Then, open the “Medit Splints” tool and assign
the mandible and complete the maximum intercuspation the maxilla and mandible data using the “Assign Data”
scans for both sides (Fig 2). Process the virtual models of tool (Fig 3). The bite scan enables the software program
articulated maxillary and mandibular arches and export to virtually articulate the intraoral scans of both arches.
the standard tessellation language (STL) files. Select the arch (maxilla or mandible) and device type
In the design stage, an occlusal device is virtually de- (stabilization splints; Michigan or FPS and an NTI splint)
signed using the AI-powered dental software (Medit and confirm. In the present dental method, Michigan

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 a b

c d

e f
Fig 4   Representative procedures of Medit Splints AI-powered software after the automated design is completed, review of automated
design in different 3D views. (a) Visualization of the occlusal contacts in static occlusion (occlusal contacts and collisions) with color map.
(b to d) Visualization of the design from right lateral, frontal, and left lateral views, respectively. (e and f) Outside and intaglio surfaces, re-
spectively.

Splint was selected. Then, choose “Auto Creation” and needed. Proceed with the “Design Mode” tool by visual-
customize design parameters in the occlusal adjustment izing the occlusal contacts with color maps and making
mode, such as the distance to antagonists (occlusal thick- further adjustments, either using the “sculpting” tool
ness, 1.5 mm); inner surface creation mode: inner surface (add, remove, smooth, morph) or the “Adjust Distance
offset (0.03 mm), smooth surface (maximum), block out to Antagonist Tool” as needed (Fig 4). In the presented
angle (0.1 degrees), retention (0.10 mm); outer surface dental method, no further adjustments were made.
creation mode: peripheral thickness (1.5 mm), smooth Complete the occlusal device design (labeling can be
surface (maximum), and dual layer splint (off). Once the done) and export the STL design file.
virtual device is automatically created, check the device In the design stage of the occlusal device using anoth-
borders. To improve its retention, extensions of the oc- er AI-powered software (Automate, version R1.1), save
clusal device should cover the height of the maxillary the maxillary and mandibular STL files as a zipped folder.
teeth contour, while borders on the palate should cover Open the website, login, and select “Nightguards.” Ad-
a few millimeters of the gingiva.20 If needed, manually just design preferences for the maxilla: occlusal thickness
customize the extensions using “Outline Designation (1.5 mm), inner surface offset (0.03 mm), crevice block
Mode.” If additional adjustments are made, press “next out (Moderate), minimum thickness (1.5 mm), inward
tool” to recreate the occlusal device. After generating, retention (0.10 mm), CAM orientation (flat was selected
change the lingual and buccal thickness and smooth- in the present study), and select the turnaround time and
ness in the “Outer Surface Creation Mode Tool” when price of accepted design (10-minute or 10-hour design

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 Sabatini et al

a b

c d

e f
Fig 5   Representative procedures of 3Shape Automate AI-powered software (version R1.1). (a) Selection of design preferences. After comple-
tion, the automated design can be reviewed in different 3D views in the results tool. (b) Path of insertion (blue arrows) and blocked-out areas
(green). (c) Margin lines of the occlusal device. (d) Static occlusion (occlusal contacts and collisions). (e) Thickness and retention evaluation. The
material provides inward deviation. (f) The “Further Adjustments” tool can be used if needed.

options) (Fig 5). Then, drag and drop the zipped order printer (DLP). Select the occlusal splint resin (Keysplint
folders and wait nearly 3 minutes until the automated Hard, Keystone Industries) and layer thickness (100 µm)
design is completed. After, review the automated design from the DLP’s proprietary software library (Composer,
in the results tool. In different 3D views, review the path Asiga). Import the STL file of the AI-powered occlusal
of insertion and blocked-out areas, margin lines of the device designs into the software, orient the outer sur-
occlusal device, static occlusion (occlusal contacts and face so it is facing and parallel to the build platform,
collisions), and thickness and retention (material pro- and generate support structures automatically. Con-
viding inward deviation). In the presented method, no trol the support structures and add or eliminate them
further adjustments were made. However, when further as necessary. Before using the resin, mix it for nearly
adjustments are needed, click the “Edit/View 3D” tool. 1 hour (Resin mixer, Manfredi Reddish Stone) to obtain
Surface smoothness, occlusal clearance, and thin areas the appropriate consistency and to prevent bubbles,
can be adjusted in this step. Then, accept the occlusal and allow the resin to reach ambient temperature (20º
device design (labeling can be done if selected in the to 25ºC). Print the occlusal device using a DLP-based 3D
settings) and export the STL file of the design. printer (MAX UV, Asiga). After a 10-minute drip time,
In the CAM stage, the automated-designed occlu- remove the occlusal device from the build platform and
sal device is fabricated using a digital light processing wash it in an ultrasonic bath of 98% isopropyl alcohol

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 a b

c d

e f

Fig 6   (a to d) Frontal, lateral, occlusal, and intaglio surface views, respectively, of the additively manufactured occlusal device.

(IPA) for 3 minutes (Isopropanolum rein, Cristoffel- pumice slurry under firm and consistent pressure from a
Apotheke) to remove excess unpolymerized resin parts. cloth wheel (Muslin Buffs, 4”x42, Keystone Industries).
Then, wash the device for 2 minutes with fresh iso- Steam-clean the surface and apply prepolishing via a
propyl alcohol (IPA). Use a soft-bristle brush or cotton polishing compound and cloth wheel (Tripoli Polishing
swab dipped in IPA when excess resin is still present. Compound, Keystone Industries) under firm pressure.
Dry the occlusal device using an air syringe and allow Steam-clean the surface again and apply a high-shine
it to dry for at least 10 minutes to ensure that there polishing compound via cloth wheel (Beige Paste
is no alcohol residue, then polymerize using a xenon Polish Bar, Keystone Industries) under light pressure
lamp-polymerization unit (Otoflash G171, NK Optik) for (Fig 6).
4,000 lighting exposures (2,000 flashes per side with- In the delivery stage, visually inspect the occlusal de-
out nitrogen gas, allow 5-minute cool-down between vices for sharp edges and potential problems. Place the
the two sets of exposures; Fig 6). After postprocessing, occlusal devices intraorally, and check the borders, fit,
cut support structures using a side cutter and remove and retention. Identify whether any tilting points or axes
remnant printing lines/texture and residual material are present by pressing on four different regions (second
from the surface using an abrasion disc sanding wheel molars and lateral teeth).23 Evaluate the occlusal device’s
(Blue 400-grit disc, Keystone Industries). Polish using a retention and occlusal contacts in static and dynamic

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 Sabatini et al

a b c

d e f
Fig 7   Clinical try-in of an occlusal device designed by Medit Splints AI-powered software. (a to c) Right lateral, central, and left lateral views
in centric occlusion, respectively. (d to f) Right laterotrusion, protrusion, and left laterotrusion views before adjustments, respectively.

a b c

d e f

Fig 8  Clinical try-in of an occlusal device

designed by 3Shape Automate AI-powered
software. (a to c) Right lateral, central, and
left lateral views in centric occlusion, respec-
tively. (d to f) Right laterotrusion, protrusion,
and left laterotrusion views before adjust-
ments, respectively. (g and h) Right and left
laterotrusion after adjustments, respectively.

g h

occlusion (Figs 7 and 8). Instruct the patient to perform paper (Bausch Arti-Check, Bausch Articulating Papers)
all applicable functional movements, including lateral and trim using a carbide acrylic bur (HM129FX-023-HP
movements, protrusion, retrusion, sipping water, and Laboratory Carbide Bur, Meisinger) (Fig 9). Deliver the
swallowing. Evaluate the occlusion for any premature occlusal device to the patient if there is no tension or
contacts and interferences using 40-µm articulating pressure.

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 Fig 9  (a and b) Occlusal
contacts of an occlusal device
fabricated with Medit Splints
AI-powered software before
and after adjustments, re-
spectively. (c and d) Occlusal
contacts of an occlusal de-
vice fabricated with 3Shape
Automate AI-powered soft-
ware before and after adjust-
ments, respectively.

a b

c d

DISCUSSION maxillary teeth, flat and smooth occlusal surfaces, bal-

anced and simultaneous occlusal contacts of the man-
The presented dental method describes a process for dibular teeth (except incisors), and centric freedom. The
fabricating an occlusal device supported by AI-powered Medit Splints occlusal device had no premature contact
automated design software. The main advantage of the in static or dynamic occlusion. Therefore, no further
AI-powered software is the automatic design of occlusal adjustments were made, which can help save time. Even
devices within a few minutes of importing maxillary though the occlusion type was anterior guidance and
and mandibular scans and selecting design parameters, the disclusion of mandibular teeth during lateral and
which simplifies procedures by reducing the time for protrusive motions was adequate, the canine guidance
analyzing undercut areas and blocking out and defin- ramps were not high enough and may need to be manu-
ing the path of insertion, thereby substantially reducing ally adjusted in some cases. In the Automate software,
the working time.14 In other words, the AI-powered premature contacts existed in the second right and left
automated design software may ease the burden of an molars in static and dynamic occlusion. The disclusion of
intensive laboratory workload and can be applied chair- mandibular teeth during lateral movement was obtained
side.14 Moreover, the work efficiency of this automated in the molar region rather than canine teeth and it was
design workflow may be advantageous over convention- > 2 mm before adjustments. After further adjustments,
al human-based workflows, which may depend on the group function occlusion was achieved. For canine guid-
operator’s expertise.13,14 In addition, both AI-powered ance, further adjustments should be made in the design
automated design softwares discussed herein are based to create canine ramps.
on open systems that accept STL files from third-party In both DLP-based software, the program automati-
intraoral or laboratory scanners.14 cally determined the occlusal device borders, but, they
The occlusal devices were fabricated without any fur- may be further adjusted if necessary. In the presented
ther intervention in both tested AI-powered automated dental method, the retention of occlusal devices in both
software. One contact per tooth was achieved in both DLP-based software was adequate. The extension of the
occlusal devices. A Michigan splint was selected when occlusal device may affect its retention and fit. There-
using the Medit Splints software. The designed occlusal fore, further adjustments (including offset values and
device provided the following characteristics as defined retention values) may be required if the splint borders
by the Michigan splint parameters24: coverage of all are designed to be shorter or if the retention is not

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 Sabatini et al

adequate, depending on the CAM procedure. Medit Conceptualization: G.Ç., G.S., and H.Y.; methodology: G.Ç., G.S.,
Splints DLP-based software can also be used to design M.F., and P.M.; software: G.S. and G.Ç.; validation: G.Ç., A.O., and
B.Y.; investigation: G.Ç., G.S., and H.Y.; data curation: G.Ç. and H.Y.;
other types of occlusal devices, such as FPS and NTI
writing—original draft preparation: G.Ç., A.O., and H.Y.; writing—
splints. Even though the occlusal device was designed review and editing: H.Y., G.Ç., M.F., and B.Y.; visualization: G.Ç.;
in maxilla in the present dental method, both software supervision: G.Ç. and B.Y.; project administration: G.Ç. and B.Y.; and
enable design options for the mandible. funding acquisition: G.Ç. All authors have read and agreed to the
Careful clinical data acquisition is required for clinical published version of the manuscript.
success. It has been well reported that the maxilloman- The data that support the findings of this study are available from the
dibular relationship and occlusal device thickness affect corresponding author upon reasonable request. The authors declare
no conflicts of interest.
treatment outcomes of temporomandibular joint (TMJ)
disorders.20,25,26 Therefore, maxillomandibular relation-
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