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Cad Cam International3 2015all PDF
Cad Cam International3 2015all PDF
6 • Issue 3/2015
CAD/CAM
digital dentistry
international magazine of
3 2015
| review
Abutment selection
and long-term success
| case report
Implant-prosthetic restorations
| interview
The impact of CAD/CAM on dental practices
DSi 6000 Impression Scanner
REVOLUTION
Bite registration
Triple tray scanning with automatic
bite registration. O tim
Opt
timett
For more information please contact us: Phone: +972-2-5482900 ext. 2946
Email: Hilit.Hochman@optimet.com | www.optimet-dental.com Beyond any measure
editorial _ CAD/CAM I
Dear Reader,
_As I think back to my younger days, I used to love to take things apart and try to put them
back together. That progressed into a hobby as a bike mechanic. Cable replacement, greasing the
bearings, wheel truing…I loved it all. I had minimal tools, but I had the know-how of how to get the
job done. When I got my dream job as a shop mechanic, I was amazed that there was actually a
proper tool for every job. The wrenches and ratchets were literally the tools of the trade. It occurred
to me, the mechanic needed to understand what the tools were for, how to use them and especially
how to care for them. I realised and appreciated the importance of the tools, but did not want them
to be the limiting factor. Dr Les Kalman
Dentistry is experiencing a truly remarkable period with many ‘tools’ of digital dentistry available
to the clinician and technician. These tools are not only providing increased accuracy and improved
efficiency, but are also improving the experience for the patient, clinician and technician. Commu-
nication has also been expanded with digital dentistry, allowing for easier translation of informa-
tion to the patient, the insurance company, colleagues and the laboratory. With an open-source
approach, the technologies have the opportunity to be merged and shared. Add in the advances in
mobile technology, the portability and the utilisation of technology becomes even more appealing.
From an academic and research perspective, I can attest that I am truly a tech junkie. I love gadgets.
Technology seems to improve every aspect of my day. I find the technological solution to a problem
a unique driving force that harnesses limitless passion. It appears to be an exciting time!
The spectrum of digital dentistry has become quite overwhelming. There are technologies that
provide numerous approaches for image acquisition, easy-to-use design packages, milling/print-
ing solutions, implant stability assessment and even real-time guided implant surgery. The tech-
nologies seem to represent every aspect of diagnoses, treatment planning and treatment delivery.
This issue entirely reflects that statement. Whitepeaks Dental Solutions provides insight into their
scanners, CNC and CAD/CAM. CAD/CAM is explored in greater detail, as Dr Ferencz reviews its
impact on dental practices, while Dr Zamanian discusses its use with implant abutments. Lastly,
a clinical guide to Max Align is presented. Max represents a new technology that not only offers a
digital alternative to the facebow/facial analyser, but also provides a unique set of patient records.
It appears to be a very exciting time!
In dentistry, we have the privilege of improving the oral health of our patients. There can be
little comparison to a bike mechanic, as the human body presents a unique set of complex systems.
However, the technologies in digital dentistry represent tools. These tools have a purpose and
we must be able to understand what the tools are for and how to use them. The tools cannot act as
substitutes to fundamental principals. As clinicians and technicians, we must rely on our knowledge,
skills and evidence-based experience to act as our guide. From the subjective aspect of patient
informed consent, to the rigorous protocols of implant surgery, let us exercise what our compre-
hensive training has taught us. The tools are merely there to assist us on our mission.
As we, clinicians, technicians, educators and researchers, look to advance dentistry in a modern
technological world, let’s keep the digital dentistry toolbox open to more tools. Let’s always pose the
question ‘why’ and try to find a solution to ongoing problems. Let us keep the aspect of accessibility
in mind, with the development of open-source and affordable technologies. Lastly, let us merge our
knowledge, skills and experience with the tools of digital dentistry to propel our profession as lead-
ers in healthcare simulation.
Yours faithfully,
Dr Les Kalman
CAD/CAM
3_ 2015 I 03
I content _ CAD/CAM
I special I feature
06 Cast mounting using MaxAlign: The clinical component 48 The impact of CAD/CAM on dental practices
| Dr Les Kalman | Interview with Dr Jonathan L. Ferencz who shares his experiences with
CAD/CAM technology in dental practice
I review
12 Abutment selection and long-term success I industry news
| Dr Julia-Gabriela Wittneben 50 New VCONCEPT by MIS delivers true innovation
to implant dentistry
I case report | MIS
I technique
36 Veneering options for fixed implant-retained restorations Cover image courtesy of
| Prof. Stefan Holst Planmeca (www.planmeca.com).
04 I CAD/CAM
3_ 2015
©MIS Corporation. All Rights Reserved
Cast mounting
using MaxAlign:
The clinical component
Author_ Dr Les Kalman, Canada
06 I CAD/CAM
3_ 2015
CONFIDENCE LIES
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I special _ mounting of casts
Fig. 3 Fig. 4
lacking.6 Without records, communication with clinical information that is vital for the labo-
the laboratory can be even more limited. Com- ratory, third-party insurance, the clinician and
munication tools must be employed7, 8 to provide the patient.
information so that laboratory technicians can
satisfy laboratory requisitions. Lack of infor- _Clinical protocol
mation results in guesswork, assumptions and
incorrect dental work that is ultimately returned A healthy 36-year-old female patient with
to the dental laboratory.9 a non-contributory medical history presented
for consultation regarding elective anterior
_Background: MaxAlign aesthetic treatment. Records consisted of algi-
nate impressions using stock trays, which were
The MaxAlign application (Max; Whip Mix) is poured in JADE STONE (Whip Mix), and utili-
a communication tool for the clinician that sation of Max.
captures essential patient information. It is a
tablet-based technology that offers a unique The Max app was downloaded onto a Samsung
set of records, enabling the accurate mount- tablet (provided) and launched (Fig. 2). Patient
ing of casts complete with a patient image. information was input (Fig. 3). The tablet was
Max provides a calibrated photograph with positioned in the tablet clamps (provided) and
clinical information and a novel technique for the clamps were tightened to ensure a vertical
Fig. 5_Patient–tablet position. the mounting of casts. This case report will orientation (Fig. 4). The tablet must be placed
Fig. 6_Max capture mode. explore the effective use of Max to acquire such that the Samsung logo is on the right, so
Fig. 5 Fig. 6
08 I CAD/CAM
3_ 2015
special _ mounting of casts I
Fig. 7 Fig. 8
that the camera is located to the right. The The next step is to verify occlusion. This was Fig. 7_Patient image.
patient was in the upright position, with the done with standard 8 µ shimstock while the Fig. 8_Recording occlusion.
occlusal plane parallel to the floor, while the patient is in maximum intercuspation (Fig. 8).
tablet was placed on the instrument delivery The contacts were observed and input into the
stand (Fig. 5). Max has anatomical guides for second Max screen (Fig. 9). This screen repre-
positioning: maxillary incisor midline and edge, sents the quadrants of the dentition, and each
location of orbits and inferior facial outline. box represents a tooth. In order to record occlu-
The delivery stand was positioned close enough sion, one touches the box that corresponds to
to the patient for her facial features to line up the teeth contacting (Fig. 9).
with the guides on Max (Fig. 6). Cheek retractors
were employed to offer a clear view of the The image and record of occlusion are saved
dentition (Fig. 6). Once the patient was in the and the operator has the option to exit the
correct position, the “arm auto capture” button app or proceed with the laboratory component.
was pressed. The tablet then captured a photo- If the mounting will be delegated to a laboratory,
graph, with a flash, of the patient (Fig. 7). Once this concludes the clinical component of Max.
the photograph has been taken, the clinician The clinical information can then be e-mailed to
has the ability to maximise patient position the respective laboratory as a JPEG or PDF file.
by sizing or moving the image. The width of The laboratory would utilise the information ac-
the central incisors can be selected from the cording to the instructions in Max, as well as the
boxes (Fig. 7). Once completed, the image is peripherals, to mount a set of casts accurately Fig. 9_Inputting occlusion.
saved. (Fig. 10). Fig. 10_Mounted case.
Fig. 9 Fig. 10
CAD/CAM
3_ 2015 I 09
I special _ mounting of casts
10 I CAD/CAM
3_ 2015
Comprehensive solutions for all phases of implant dentistry
www.dentsplyimplants.com
I review _ implant abutment
Abutment selection
and long-term success
Author_ Dr Julia-Gabriela Wittneben, Switzerland
Fig. 2
12 I CAD/CAM
3_ 2015
review _ implant abutment I
Fig. 3 Fig. 4
Customising an abutment gives the clinician possible to choose titanium as a material. Another
the freedom to individualise its position and advantage is individualisation regarding the an-
angulation. In the case of a bone level implant, it gulation and design of the abutment to support
is also possible to individualise the emergence the veneering ceramic.
profile and future crown margin position of
the final restoration. It allows abutments to be Traditional cast gold abutments can be used
designed to provide optimal support for the for screw- and cement-retained single crowns
veneering ceramic material, especially for screw- and bridges, and are available for implants placed
retained reconstructions. Individualisation may at soft tissue or bone level. Their advantages
be achieved using CAD/CAM technology, gold consist in the facilitation of the screw retention
abutments produced with traditional lost-wax with bridges. Disadvantages, however, are that
casting methods, or titanium base abutments gold abutments are technique-sensitive, require
(Fig. 2). more time, and generate higher manufacturing
costs. An in vivo histological study in dogs has
Customised abutments manufactured via demonstrated that gold alloys also have dis-
CAD/CAM can be made of titanium or zirconium advantages in terms of soft tissue integration.
dioxide for bone- and tissue-level implants. They Histologically, an apical shift of the barrier ep-
can be used for cement- or screw-retained single ithelium and the marginal bone around gold alloy
crowns or cement-retained bridges. The benefits abutments has been shown.3
of the CAD/CAM abutment include the possibility
of using a high-performance ceramic material, The third group of customised abutments on
which again offers many advantages, especially implants are the titanium base abutments. They
in aesthetic sites. In patients with a thin tissue are two-piece abutments with a titanium base.
biotype, no visible grey will shine through with Clinicians are sometimes concerned about the
a white-coloured abutment. However, it is also handling of complications with a full ceramic
Fig. 5 Fig. 6
CAD/CAM
3_ 2015 I 13
I review _ implant abutment
Fig. 7 Fig. 8
abutment regarding the retrieval of broken-off indicated for abutments supporting provision-
ceramic fragments in the implant, which can be als—especially for bone-level-type implants—to
difficult. The main advantage of this abutment customise the emergence profile and individu-
type is that there is no ceramic material inside the alise the peri-implant mucosa with soft tissue
titanium implant connection. However, the dis- conditioning.5 The materials of choice for abut-
advantage lies in the lack of evidence in published ments for final restorations are titanium, gold,
clinical data to date. zirconium dioxide, and aluminum oxide-based
ceramic.
In particular, the soft-tissue reaction regard-
ing the bonding gap, especially in bone-level Titanium and zirconium dioxide will be dis-
implant cases in the aesthetic zone, remains cussed in this article regarding clinical and histo-
unknown. In consequence, this type of abutment logical performance. Titanium is the biomaterial
should be used with this current limitation in of choice regarding long-lasting and well docu-
mind.4 However, use with soft tissue-level im- mented behaviour under functional loading for
plants with a microgap above bone level might both soft and hard tissues. It has excellent bio-
be less of a concern. An example of a soft tissue- compatibility, mechanical strength, and is re-
level implant case is presented step-by-step on sistant to corrosion. Therefore, it is the abutment
the following pages (Figs. 3–15). material of choice for posterior sites. However,
the expectations of patients in the anterior
_Implant abutment material zone are increasing. In aesthetic sites, mucosal
thickness plays an important role. An animal
Different biomaterials are available for implant study comparing different dental materials
abutments. Polymethyl methacrylate (PMMA), under different mucosal thicknesses showed
titanium, and polyether ether ketone (PEEK) are that titanium induced the most prominent
Fig. 9 Fig. 10
14 I CAD/CAM
3_ 2015
review _ implant abutment I
Fig. 11 Fig. 12
colour change. Zirconium dioxide did not induce _Conclusion and clinical
visible colour changes in 2 and 3 mm thick recommendation
mucosa.6
Abutment selection in aesthetic sites
With the background of the available clinical
evidence and systematic reviews, no differences Implant abutments are located in a transition
were found between zirconium dioxide and metal zone where they are in contact with the implant
abutments in clinical performance based upon and the surrounding peri-implant tissues. There-
aesthetic, technical, or biological outcomes.7–10 fore, the choice of abutment is of major impor-
In vitro studies have shown statistically signifi- tance, especially in a sensitive region like the
cant greater wear of zirconium dioxide than aesthetic zone.
of titanium abutments inside the titanium im-
plant.11 However, the clinical relevance remains For single-unit reconstructions, zirconium
unclear. dioxide abutments are indicated, which can be
either standard or customised depending on the
In our clinic, we have been using Straumann prosthetic position of the implant. For multi-unit
CARES CAD/CAM fabricated zirconium dioxide reconstructions, zirconium dioxide abutments
abutments since 2009 on a daily basis in aesthetic are recommended for cement-retained bridges,
cases with bone level implants, and have had no
issues with abutment fractures so far. The correct
CAD/CAM design of a zirconium dioxide abut-
ment and the quality and precision of the con-
necting part into the implant play a crucial role in
long-term success. Focusing on the outcome of
histological studies, an in vivo study shows that
there were no visible differences in soft tissue
health in peri-implant mucosa adjacent to zirco-
nium dioxide and titanium abutment surfaces.12
Fig. 13
Another study found that soft tissue around zir-
conium dioxide heals faster than when in contact
with titanium.13
CAD/CAM
3_ 2015 I 15
I review _ implant abutment
16 I CAD/CAM
3_ 2015
I case report _ treatment of edentulous maxilla
Fig. 1 Fig. 2
18 I CAD/CAM
3_ 2015
case report _ treatment of edentulous maxilla I
Fig. 7 Fig. 8
During the healing period, the patient was provided incision from region 16 to 26 with relief incisions
with an immediate temporary denture that was re- buccally in region 16 and 26 as well as buccally and
lined several times to minimise soft-tissue trauma. palatally in region 11/21. The six ANKYLOS C/X implants
were placed slightly subcrestally in regions 15, 14, 11,
_Surgical treatment 21, 25, and 26, using a conventional drilling protocol
(Fig. 2). The placement heads were removed and
Seven weeks after the extractions (Fig. 1), a mu- replaced by cover screws. This first stage of the two-
coperiosteal flap was elevated by making a crestal stage surgical protocol was completed with tight
Fig. 11 Fig. 12
CAD/CAM
3_ 2015 I 19
I case report _ treatment of edentulous maxilla
_Prosthetic treatment
20 I CAD/CAM
3_ 2015
case report _ treatment of edentulous maxilla I
Fig. 26 Fig. 27
Caps, was checked and the framework then removed introduced in the summer of 2014, and the abutments Fig. 19_Tooth setup in wax for the try-in.
from the mouth (Fig. 15). A new impression was taken were only available with a 4-degree angle. Fig. 20_Acrylic teeth placed with
using an individual tray and polyether impression composite on a pink opaque framework.
material to pick up the cobalt-chrome framework Due to the perfect retention with that angulation, the Fig. 21_Prosthetic jig
(Fig. 16). The six ATLANTIS Conus abutments were not patient had some problems removing the prosthesis for for acrylic pulverisation.
replaced by the gingiva formers again. Therefore the cleaning. Therefore, a decision was made to remove two Fig. 22_Processed prosthesis
temporary denture had to be largely adjusted to pro- of the ATLANTIS Conus abutments (14 and 25) and seal in acrylic on the model.
vide space for the abutments, and relined once again. those implants with gingiva formers. This made it easier Fig. 23_Final prosthesis, occlusal view.
for the patient to remove the prosthesis, but could still Fig. 24_Final prosthesis, basal view.
A new master cast was created in the laboratory. provide the comfort of a fixed restoration when chewing. Fig. 25_Panoramic radiograph with
The framework was used to create a bite registra- abutments and prosthesis in place.
tion (Fig. 17). After defining the plane of occlusion, To avoid this problem, the ATLANTIS Conus abut- Fig. 26_Final prosthesis in situ,
the tooth setup was made in the laboratory (Fig. 18). ments are today only available with a 5-degree angle._ occlusal view.
Before finalizing the removable prosthesis, the wax Fig. 27_Final prosthetic restoration.
tooth setup was sent by the laboratory for the final
clinical try-in (Fig. 19). _authors CAD/CAM
_Conclusion
CAD/CAM
3_ 2015 I 21
I case report _ implant restorations
Implant-prosthetic restorations
The challenge of creating an aesthetically
pleasing smile in an edentulous patient
Author_ Cristian Petri, Romania
Fig. 1 Fig. 2
Fig. 1_Aesthetic evaluation prior _Rehabilitation of the edentulous jaw can be solution can be found for almost every patient and
to treatment: the edentulous upper achieved with various treatment modalities. Remov- budget.
jaw had been provided with able implant-supported overdentures can provide
a conventional complete denture. a comfortable, aesthetic and functional option even Generally, overdentures offer several advantages
Figs. 2 & 3_After the healing in cases in which only a limited number of implants over conventional removable prostheses, including
and osseointegration process can be used. Since the number of patients desiring an improved stability, functionality, comfort, confidence
of the four implants, an impression alternative to complete dentures is on the rise, this in the ability to interact socially, straight forward
of the oral situation was taken. treatment option is becoming a frequent choice. rehabilitation and easy maintenance for the patient.
The impression posts were splinted Quite simply, overdentures result in a significant
together prior to impression taking. Patients’ expectations regarding prosthetic tooth improvement in the quality of life of the patient.
replacements are similarly high compared with
fixed ceramic veneered restorations. With the emer- In our case, a 58-year-old patient presented at
gence of new materials and their combination with the practice with discomfort caused by her complete
Fig. 4_Implant model for the CAD/CAM technology, outstanding clinical outcomes maxillary denture. When looking at her history, we
reconstruction of the overdenture. can be achieved for this indication. An adequate found a prosthetic restoration retained on six im-
Fig. 3 Fig. 4
22 I CAD/CAM
3_ 2015
case report _ implant restorations I
Fig. 5 Fig. 6
Fig. 7 Fig. 8
plants in the lower jaw and a complete maxillary Our protocol required primary telescope crowns Fig. 5_The models mounted
denture that was aesthetically and functionally in- milled from zirconia at an incline of 2 degrees and on the articulator clearly demonstrate
adequate (Fig. 1). An initial aesthetic evaluation secondary copings obtained by electroforming. the challenges involved
established that the shape and shade of the teeth This approach combines the advantages of zirconia in this clinical case.
were inappropriate. In addition, the midline was mis- (primary telescopes) with those of hydraulic retention Fig. 6_Try-in of the wax set-up
aligned and the curvature of the maxillary anterior (galvanic copings). After a complication-free period and evaluation of the
teeth was shaped incorrectly. of healing and osseointegration, the four implants aesthetic parameters.
were uncovered and a preliminary impression was Fig. 7_Customised titanium
The poor stability of the denture was caused by taken. Also, a customised tray was created from the abutments.
insufficient prosthetic support and by the method resulting model. Fig. 8_Reconstruction of the primary
with which it had been produced. Taking the patient’s structure after scanning the model,
requirements and financial constraints, as well as In order to proceed to the next stage of the treat- abutments and set-up.
the clinical condition of the maxillary prosthetic field, ment, we required a functional impression that would
into account, we decided in favour of an implant- transfer the exact position of the implants. For this
supported prosthetic treatment modality. The plan purpose, the four impression posts were splinted
was to insert four maxillary implants to retain an together on a custom tray with composite material
overdenture prosthesis using the double-crown (Figs. 2 & 3). After creating the working models Figs. 9 & 10_Grinding and
method. This procedure is frequently followed in such (Fig. 4), we determined the patient’s vertical dimen- smoothing of the primary structure
cases and has seen constant improvement with the sion of occlusion, the length of the future teeth, as made from zirconia in a milling unit
emergence of new technologies and materials. well as the gingival smile line, by means of an occlusal using CAD/CAM technology.
Fig. 9 Fig. 10
CAD/CAM
3_ 2015 I 23
I case report _ implant restorations
_Primary structure
A try-in of the set-up was performed to check the
phonetics, aesthetics and occlusion (Fig. 6) and then
a silicone key was created over the set-up. This acted
as a guide in the subsequent working steps. In order
to manufacture the primary structure, the four tita-
nium abutments were customised (Fig. 7), the result-
ing abutments were scanned together with the model
and set-up (double scan), and these datasets were
imported into the design software. The CAD program
proceeded to suggest the shape, height and angula-
tion of the telescope crowns, which we adjusted and
Fig. 11 optimised as required (Fig. 8). The primary telescopes
were milled from zirconia and sintered to their final
Fig. 11_Intra-oral bonding of the plate (bite rim). In the upper jaw, the occlusal rim was density at 1,500 °C. After the accuracy of fit had
electroformed secondary structure shaped in such a way that 2 mm of the edge was vis- been checked, the zirconia crowns were permanently
with the tertiary structure. ible when the upper lip was in rest position. The lower bonded to the titanium abutments (Multilink Hybrid
edge of the rim was aligned parallel to the bipupillary Abutment, Ivoclar Vivadent). Finally, the zirconia tel-
plane and smoothly followed the curve of the lower escopes were adjusted using a laboratory turbine and
lip when the patient smiled. On the maxillary rim, the parallelograph. The walls of the telescopes were given
midline, the smile line and the line of the canines were a 2-degree incline and smoothed using appropriate
outlined. A facebow was used for the transfer of the diamond grinding tools and sufficient water-cooling
maxillary position in relation to the base of the skull. (Figs. 9 & 10).
Once all of the relevant ratios had been obtained, _Secondary structure
the models were mounted on the articulator (Fig. 5).
The difficulty of this case was that we had to make The primary crowns could now be prepared for
allowance for the existing mandibular restoration in manufacturing the secondary crowns by means of
the design of the maxillary rehabilitation. The implant the electroforming technique. For this purpose, the
axes of the mandibular prosthesis in particular posed zirconia surfaces were covered in a thin coating
some problems. Shade selection was dictated by the of conductive silver using the airbrush method.
mandibular restoration and, consequently, our room Upon completion of the process, the galvanised gold
for decision-making was reduced to deciding on the crowns were detached from the telescopes and the
shape of the teeth. To this end, a photograph of the conductive silver coating was removed with a so-
patient as a young adult was useful, as it was her wish lution containing nitric acid. In the process, a highly
that the shape and size of her teeth as they were accurate secondary structure was obtained.
when she was young should be re-established in the
prosthetic reconstruction. With the aim to attain as _Tertiary structure
Figs. 12 & 13_Detailed view perfect a prosthesis as possible and to make the most
of the completed denture: of the available space, we created a wax set-up using All of the components were repositioned on to
customised prefabricated teeth prefabricated denture teeth (SR Phonares II, Ivoclar the working model. Before the tertiary structure was
and soft-tissue parts. Vivadent). fabricated, the electroformed crowns were covered
Fig. 12 Fig. 13
24 I CAD/CAM
3_ 2015
case report _ implant restorations I
Fig. 14 Fig. 15
in a thin layer of wax to create the space neces- (SR Nexco). To this end, the vestibular surfaces of Fig. 14_The macro-texture
sary for the cement that would later be used. The the anterior teeth and the corresponding pink parts and shade effect of the denture
tertiary structure was invested, cast in a cobalt– were sand-blasted. SR Connect (Ivoclar Vivadent) was were individualised in a straight
chromium alloy using induction casting technology applied and the teeth and prosthetic gingiva were forward manner to achieve
and then finished. The tertiary structure was intra- characterised with SR Nexco. The shape was adjusted a result that is true to life.
orally cemented on to the electroformed telescopes in accordance with the requirements of the patient. Fig. 15_The implant-retained
(Multilink Hybrid Abutment and Monobond, Ivoclar Final polishing was carried out with biaxial brushes overdenture in the patient’s mouth.
Vivadent) in order to obtain a tension-free restora- and pads. The result proved very lifelike (Figs. 12–15).
tion (Fig. 11).
_Conclusion
_Aesthetic design
Many patients are reluctant to be given removable
The structure obtained was covered in an opaque dentures. If dentures are optimised by adding the
light-curing laboratory composite (SR Nexco, Ivoclar stability of implants and the effectiveness of tele-
Vivadent) in pink and white prior to finishing the scopes, dental professionals will be able to help
prosthesis. Again, the silicone key was used as a guide. patients overcome their reservations and offer them
The SR Phonares II teeth were repositioned from the a tooth replacement that provides the level of com-
wax set-up to the framework. The occlusal parame- fort they expect. Completely edentulous patients
ters were checked again and then we proceeded to have the same high aesthetic expectations as patients
complete the restoration. In order to reconstruct the requiring fixed restorations. However, some of these
pink gingival portion, we used the IvoBase Injector requirements are more difficult to satisfy in the eden-
system (Ivoclar Vivadent). First, the denture was in- tulous patient, because we have to replace soft tissue
vested in two specially designed flask halves using in addition to missing teeth. In order to achieve this,
Type III and IV plaster. After removing the wax and we need to find a way to create harmony between the
isolating the plaster surfaces, we prepared an IvoBase pink and white aspects of the denture.
capsule and placed it together with the flask into
the polymerisation chamber. The IvoBase injection Today’s patients tend to be well-informed. They
and polymerisation process is fully automated and have ever higher expectations of the aesthetic and
takes about 60 minutes. Users can choose between functional aspects of tooth replacements. Therefore,
two programme options. Running the standard we need to be well trained and know which materials
programme takes about 40 minutes. If the RMR pro- and technologies can aid our work and increase our
gramme is additionally activated, the pressing time efficiency. This will enable us to solve any clinical case,
increases, as a result of which the monomer concen- regardless of its difficulty._
tration is reduced to less than one per cent. This aspect
is beneficial to patients because the risk of allergies
and irritation of the mucous membrane is virtually _contact CAD/CAM
eliminated.
Cristian Petri is working
After the injection programme was complete, as a dental technician at
the flask halves were opened, and the denture di- Artchrys Dental Laboratory
vested from the stone core and processed with milling in Cluj-Napoca, Romania.
and polishing instruments. In order to create a tooth He can be contacted
replacement that closely met the expectations of at office@artchrys.ro.
the patient, we decided to customise the visible
areas of the denture by applying additional material
CAD/CAM
3_ 2015 I 25
I case report _ implant restorations
_The demands of treatment with implants are diagnosis and therapy involving the various dental
high, particularly in the aesthetically relevant areas. specialties. Science-based therapies need to be imple-
In the case of difficult morphological conditions, the mented with surgical and prosthetic precision and
individual wishes of patients regarding their natural require the active participation of the patient both
appearance represent a major challenge for the treat- during and after treatment. A 29-year-old patient was
ment team. A host of materials and techniques for referred to our oral surgery practice with the request
crowns and abutments allow for perfect imitation of for implant therapy in the anterior maxilla. He had lost
the tooth structure. However, aesthetic restoration is the upper left incisor in an accident some months
only successful if a natural periimplant hard and soft before. The gap had been treated with a flipper by the
tissue profile can be preserved or reconstructed. The referring dentist. The removable restoration strongly
following case study illustrates the complexity of affected the social well-being of the young man.
implant treatment for combined horizontal and verti-
cal bone resorption after the traumatic loss of the left Examination showed advanced horizontal and ver-
central incisor. tical bone resorption (Fig. 1). An extended plastic shield
on the flipper was to visually compensating for bone
_Dental history and treatment plan loss (Fig. 2). This untoward design of the flipper exerted
continuous pressure on the alveolar ridge owing to
The most predictable, stable long-term aesthetic the rotary freedom around the clamping axis, particu-
results are achieved through a synergistic process for larly during removal but also during chewing motions.
Fig. 3 Fig. 4
26 I CAD/CAM
3_ 2015
case report _ implant restorations I
The unphysiological force induction influences the block graft. In order to ensure the success of the surgi- Fig. 5_A loop thread around the
progression of bone resorption. To avoid further trau- cal intervention for the 3-D placement of the implant, adjacent teeth illustrates
matisation of the hard and soft tissue, we removed the we opted for a two-stage procedure. In other words, the bone deficit.
gingival plate of the flipper and created a pontic-like the planned implant is inserted after regeneration of Fig. 6_The bone block was harvested
design for region #21 (Fig. 3). With the exception of the the bone. in sufficient size from the Corpus/
pronounced bone deficit in region 21, there were no Ramus mandibulae.
negative findings during examination of the anterior _Reconstruction of the bone defect Fig. 7_The bone graft was stored
tooth region (Fig. 4). in physiological solution
After administering local anaesthetic in both the until further processing.
We took impressions of the situation, prepared donor and the host regions, a mediocrestal incision Fig. 8_The autologous bone block
models and performed articulations. Then all thera- with vertical relieving incisions was performed in the was adapted to the shape of the host
peutic options were weighed against each other. anterior maxilla, distal to the adjacent teeth. In order to site. The focus was on the forming
We prepared a biological and financial cost-benefit allow sufficient mobilisation of the mucoperiosteal of the juga alveolaris.
analysis for each solution.1, 2 We discussed all options flap and tension-free adaptation of the margins, the Fig. 9_The cavities were filled with
in-depth with the patient. The justification for implan- relieving incisions were extended over the mucogingi- ground autologous bone chips and
tation was that both adjacent teeth were free of caries val margin. Care was also taken to ensure that the flap Bio Oss® was applied to the bone
and should not be ground. Knowing that a correctly edges were positioned on the local bone as this is where edges to protect against resorption.
placed implant would prevent further resorption of the the growth factors for marginal regeneration origi- Fig. 10_The X-ray control image
jaw bone, we prepared the most suitable treatment nate. The mucoperiosteum/mucosal flap was prepared. shows the fixated bone block in the
plan for the patient in our view. To ensure blood supply to the flap, this was opened upper jaw and the donor site
5 mm apical to the mucogingival margin. The degree of in the lower jaw.
The challenge of every treatment is the natural bone deficit was demonstrated visually using a thread
appearance of the restoration. The aesthetic charac- loop (Fig. 5).
teristics proposed by Magne and Belser3 are part of our
pre-prosthetic planning and are discussed by the team. A sufficiently large bone graft was harvested from
The focus is on the condition and colour of the gingiva, the Corpus/Ramus mandibulae. This was preserved in
achieving closed interdental spaces, a balanced profile physiological solution until the soft tissue at the donor
of the gingiva, interdental contact points, the shape site had been sutured (Figs. 6 & 7). We then adapted the
of the teeth, characterisation of the teeth and their cortical bone block as precisely as possible to the host
texture, the alignment and position of the teeth, as well site. In order to achieve an aesthetic overall outcome,
as the symmetry of the smile. The design of the convex attention was paid to the shaping of the juga alveolaris
structure of the alveolar bone ridge and the reshaping in the later implant region. The bone block was fixated
of the jugae alveolaris in the “red” area are just as im- with two osteosynthesis screws (Fig. 8). The remaining
portant for a natural appearance as the perfect “white” autologous bone material was ground and then used
crown reconstruction. Reconstruction of the bone to fill the spaces between the block graft and the local
deficit, both vertically and horizontally, requires a bone bone (Fig. 9). Bio Oss® was added around the graft to
CAD/CAM
3_ 2015 I 27
I case report _ implant restorations
Fig. 11_Three months post-op: protect against resorption. The bone augmentation was incorporated at the prosthetically correct implant
frontal anatomical shaping of the jaw, was covered with a resorbable Bio-Gide membrane position7, 8 and the plastic reduced as far as possible
sufficiently thick attached gingiva. (Geistlich) cut to size. A periosteal slit allowed maxi- between the adjacent teeth. This reduction also enables
Fig. 12_Occlusal view: reconstructed mum mobilisation of the flap which was shifted placing of the template during the surgical procedure
hard and soft tissue, coronally. Using horizontal mattress sutures it was with mucoperiosteal flaps and provides maximum
ready for implant insertion. adapted tension-free to the wound edges and sutured space for the angled handpiece during preparation of
Fig. 13_Two-component sleeve for tightly with individual button sutures. Precise wound the implant bed (Figs. 13–16).
CT-planning incorporated in edge adaptation is a precondition for interference-
the prosthetically correct free wound healing.4-6 The radiographic control image _Implantation
implant position. (Fig. 10) shows the fixated bone block in region 21 and
Fig. 14_Full length of the Ø 2.2 mm the donor site on the Corpus/Ramus mandibulae. Implantation was performed four months after
sleeve was utilised initially. The flipper with the shortened plastic tooth was in- bone augmentation. Following local anaesthesia, a
Fig. 15_Pilot drilling is deepened serted as temporary restoration (Fig. 11). Only little vestibular flap was prepared, the jaw bone exposed
through the 4 mm high pressure was to be exerted on the tissue during bone and the two osteosynthesis screws removed (Fig. 17).
sleeve section. healing. This required understanding by the patient and Pilot drilling was performed with the aid of a drilling
Fig. 16_Skeletonised implant modified (eating) behaviour. After ten days the patient template through the two-component CAMLOG
template creates the largest possible visited for a check-up and removal of the sutures. Three sleeve for CT planning (2.2 mm diameter; Fig. 18).
space for the head of the angled months after surgery, the natural alveolar bone profile All other drilling steps to prepare the implant site for
handpiece for pilot drilling. was stable and with a sufficiently keratinised gingiva the CAMLOG® SCREW-LINE implant, length 13 mm
Fig. 17_Exposure of jaw bone (Fig. 12). An impression of this situation was taken and and diameter 4.3 mm, were performed without a
and removal of two an implant template prepared. template.
osteosynthesis screws.
Fig. 18_Insertion of skeletonised The dental technician fabricated a skeletonised Placement of the implant was performed three-
implant template. template. A two-component sleeve for CT-planning dimensionally following the criteria for the anatomic
window according to Gomez and taking into account
the biological conversion processes associated with
implant restorations. In this patient case the implant
shoulder rested 1–2 mm below the cemento-enamel
junction of the adjacent teeth. The implant shoulder
was placed approximately 2 mm palatinal to the den-
tal arch in oro/vestibular direction. Apical placement
compensates for differences between the anatomi-
cal emergence profile of the crown and the implant
diameter. The mesio/distal distance between the
outer edge of the implant to the adjacent tooth
Fig. 17 Fig. 18
should be approximately 2 mm (Figs. 19 & 20). The
28 I CAD/CAM
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case report _ implant restorations I
implant was sealed with a cover screw, the soft tissue articulated, the dental technician fabricated a cus- Fig. 19_Placement of implant
sutured and an radiograph taken for checking pur- tomised zirconium dioxide abutment, bonded to a shoulder 2 mm below enamel
poses (Fig. 21). CAMLOG® Titanium base CAD/CAM. The customised cement margin of adjacent teeth.
shaping of the crown emergence profile is key to the Fig. 20_Placement of the implant
_Implant exposure with thickening natural appearance of a prosthetic reconstruction. according to the criteria
of the soft tissue of the aesthetic window.
A zirconium dioxide cap was fabricated over the Fig. 21_Anatomical shaping of
In order to ensure successful restoration with the hybrid abutment, which was veneered with a glass ce- the emergence profile of the crown.
implant, we paid particular attention to the soft tissue ramic (Figs. 26–28). On the day of insertion, the healing Fig. 22_Preparation of a roll flap
management when exposing the implant. For this pur- cap was removed, the implant interface cleaned, and by means of palatinal incision.
pose we employed the modified roll flap technique for the hybrid abutment inserted (Fig. 29). The surrounding Fig. 23_The flap was folded and
thickening of the soft tissue (Fig. 22). Using a diamond soft tissue was displaced by the customised crown pushed into the prepared tunnel
drill, the epithelium layer over the implant was re- emergence profile into the shape of the planned emer- using a special instrument.
moved and a pedicle flap prepared vestibularly after gence profile. After approximately 3 minutes the soft Fig. 24_Insertion of a 4 mm high
palatal preparation, surrounding the de-epithelised tissue had revascularised and was evenly coloured red. cylindrical CAMLOG® healing cap,
tissue with cut-outs for the papillae (Fig. 23). The roll The crown was seated and the overall appearance, shape suturing of soft tissue.
flaps were folded, pushed into the prepared tunnel, and of the tooth, colour and position evaluated critically.
after removing the cover screw a 4 mm high healing cap The shaping of the papillae was not yet perfect (Fig. 30).
was inserted into the implant (Fig. 24). We thickened Therefore, the positions of the contact points were
the marginal soft tissue as a matter of principle as it checked. The vertical distance between the crestal bone
could migrate in the apical direction during remodel- and the approximal contact points to the adjacent den- Fig. 25_Impression four weeks after
ling. The periimplant tissue restructures itself during tal crowns was 4 mm. Here we referred to the investiga- implant exposure.
insertion of the healing cap or the prosthetic restora- tions on papillae formation by Tarnow et al. for aesthetic Fig. 26_The model prior to
tion and the biological scope develops anew.9 For cost interdental papillae that remain stable long-term.10 digitalisation with Scanbody.
reasons we were unable to utilise the option of shaping
the soft tissue using a temporary implant crown.
CAD/CAM
3_ 2015 I 29
I case report _ implant restorations
Fig. 27_The abutment was The intact surrounding support structure of the procedure did not allow for a prosthetically correct
created with the 3Shape® adjacent teeth helps in the realisation of a naturally placement of the implant, a two-step procedure was
abutment designer. shaped papilla. The zirconium dioxide crown was ce- indicated. Perfect red-white aesthetics place great
Fig. 28_The customised zirconium mented with Durelon, the cement residue was carefully demands on the periimplant hard and soft tissue.
oxide abutment was bonded to the removed, and the patient left the dental practice with
titanium bonding base and a permanent aesthetic prosthesis (Fig. 31). Twelve _Conclusion
the zirconium crown was months after insertion, the patient presented in our
veneered individually. practice for a follow-up. The images show a stable In the aesthetically demanding anterior region, im-
Fig. 29_The individual hybrid periimplant hard and soft tissue situation (Fig. 32). plant therapy represents both a valuable and challeng-
abutment shapes the desired The migration of the gingiva had led to considerably ing alternative for replacing lost teeth. The surgical
emergence profile. The gingiva more natural shaping of the interdental papillae, and treatment plan based on the patient's wishes, pros-
is revascularised after the gaps had virtually closed. The aesthetic outcome thetic analysis and a wax-up, should be compiled on the
approximately three minutes. of the 3-D implant insertion in combination with the basis of the existing hard and soft tissue. The individual
Fig. 30_Immediately after insertion, intact approximal bone level of the adjacent teeth and treatment steps, as well as treatment times and costs
the crown appears to be somewhat adequate height and width of the periimplant hard should be discussed in depth with the patient._
too long in the cervical region and the and soft tissue was again confirmed at the 24-month
papillae are not shaped optimally. follow-up (Fig. 33). Editorial note: A list of references is available from the
Fig. 31_The patient displayed an publisher.
aesthetic lip appearance. _Discussion
The position, colour and shape of the
restoration blend in harmoniously The prospective implant status demonstrated in- _contact CAD/CAM
with the dental arch. sufficient alveolar ridge tissue. Aesthetic implant
Fig. 32_At the follow-up, restoration was therefore only possible with bone and Dr Jan Spieckermann
good reconstruction of the soft tissue augmentation. As a single-step surgical Joint practice for oral surgery
oro-vestibular dimension Specialists for oral surgery,
is observed. Focus on implantology
An der Markthalle 3
09111 Chemnitz, Germany
info@oralchirurgie-chemnitz.de
Jörg Wildenhain
Kauzentrum Dentallabor Chemnitz
Dental laboratory
Fig. 33_At the follow-up after two Gießerstr. 13
years, the interdental papillae were 09130 Chemnitz, Germany
Fig. 33
fully shaped and the gaps closed.
30 I CAD/CAM
3_ 2015
Maestro 3D DENTAL System
Innovative solutions for dental applications
www.maestro3d.com
IPR
Attachment designer Label designer Brackets module
Interproximal reduction
www.maestro3d.com
I opinion _ CAD/CAM and implant abutments
_The various countries in the Asia Pacific region The growth of the discount implant segment will
are all expected to demonstrate an increasing de- emerge at the expense of the premium segment and
mand for dental implant treatments as a result of as a result is set to limit market growth for dental im-
growing consumer awareness, the ageing popula- plant fixtures by lowering the market’s overall aver-
tion, growing accessibility (such as through the age selling price (ASP). In contrast, the final abutment
Fig. 1_Unit analysis of dental implant National Health Insurance Service coverage in South market is set to experience an increasing ASP owing
fixtures for Australia. By 2021, Korea), as well as greater product availability and to the growing adoption of CAD/CAM abutments in
units of premium implants other influencing factors. Traditionally, premium im- the place of stock abutments. While commoditisation
will drop dramatically to represent plant companies have dominated the dental implant of stock abutments has greatly depressed the ASP
42 per cent of the overall dental market globally. However, in recent years, discounted of the final abutment market, growing adoption of
implant fixtures in the country. implants have become increasingly popular, espe- CAD/CAM abutments is set to stimulate the final
(Illustrations © iData Research Inc.) cially in the Asia Pacific region. abutment market by pulling the ASP upwards. There-
fore, the dental implant market is set to
grow in all four countries included in the
Asia Pacific region in this report, namely
Australia, South Korea, Japan and China,
despite varying pricing trends.
32 I CAD/CAM
3_ 2015
opinion _ CAD/CAM and implant abutments I
Fig. 2
CAD/CAM
3_ 2015 I 33
I opinion _ CAD/CAM and implant abutments
_Emphasis on CAD/CAM
Celine Mashkoor
In the dental implant market, the final abutment is also a market research
market is undergoing an opposing pricing trend rela- analyst at iData Research.
tive to dental implant fixtures. CAD/CAM abutments
are being increasingly utilised in the place of cheaply
produced stock abutments. CAD/CAM development
has been relatively rapid in the Asia Pacific region in
recent years. A growing number of CAD/CAM milling
34 I CAD/CAM
3_ 2015
CC POWER
2,5kW/holder ffor
or 18 drills/5 axis
CC COSMO
0,97kW/holder for
for 20 drills/5 axis
CC TREND
TRENDY
Y
0,97KW/holder ffor
or 8 drills/5 axis
SUM 3D SW
SW,
W,, JÄGER SPINDLE
WIDEE RANGE OF MA
MATERIALS
ATERIALS
TERIAL
TERIALS
CoCr,, Zircon, Titan,
CoCr Titan, PMMA, wax, composite, glass ceramic
OPEN
N SY
SYSTEM
S
STEM
STL fformat
ormat
PROFESSIONAL SUPPOR
SUPPORTT
Fig. 1a Fig. 1b
_Case 1 (Images courtesy _An introduction The NobelProcera System guarantees unrivalled
of Dr D’Avenia et al.) to techniques and materials product quality for almost any patient situation.
Figs. 1a & b_The initial intraoral No other CAD/CAM system has such a celebrated
situation: a 20+ year old prosthesis The combination of advanced materials and manu- heritage, stemming from decades of experience in
with which the patient presented facturing techniques makes the industrial production producing the highest quality multi-unit frameworks
at the first consultation visit (a), of prosthetic components possible for every clinical sit- for both natural teeth and implants.
and the same situation without uation. Where just a decade ago only single copings could
the dentures, clearly showing be manufactured, today we are seeing manufacturing When compared to conventionally fabricated
the loss of hard and soft tissue versatility that allows not only single abutments, but frameworks, CAD/CAM frameworks demonstrate
architecture (b). multi-unit frameworks on the implant or abutment level. decisively distinctive advantages, including material
homogeneity, customised design options, and ease of
fabrication. Industrial production also guarantees
For conventional veneering, three general techniques can be used to achieve uniform high quality and consistent cost-efficiency
aesthetics and function: by reducing labour-intensive work in the dental
laboratory along with its related costs.
_The conventional hand layering technique is the most frequently used method, which
generally results in a good aesthetic outcome and proper morphologic contouring. However, Scientific data confirms that material incompati-
the specific skills and experience of the technician have a significant impact on the overall bilities between cast and machined components can
outcome and quality of a restoration utilising this technique. A manual process, hand layering be minimised or eliminated when titanium or zirconia
can sometimes be uncharitably characterised by its lack of standardisation. are used. Corrosive phenomena at the interface be-
tween dissimilar metal alloys can thus be prevented
_The ‘press technique’ is an alternative method that reduces operator-induced errors such
while facilitating precision fit at the same time. This
approach also promotes soft tissue stability and
as cracks, air trapping, etc., and ensures a more homogenous material microstructure. With this
marginal bone maintenance.
technique, a full anatomical contour is waxed, invested, and the ceramic material is pressed onto
the framework.
Crucial choices
_Full anatomic milling from a homogenous glass-based ceramic or acrylic block material
In order to ensure longevity when restoring an eden-
utilising CAD/CAM technologies is the third option. This method produces optimal material
tulous patient with an implant-retained restoration, the
microstructure due to its use of high-quality block specimen and the complete elimination of
selection of proper materials, prepared with appropri-
manual manipulation.
ate precision, is vital. What the ideal protocol for finish-
ing/veneering CAD/CAM frameworks entails has been
36 I CAD/CAM
3_ 2015
technique _ veneering options I
Fig. 3
Fig. 2
intensively debated in recent years. Both metal-based of materials—that reduce unwanted or non-beneficial Fig. 2_Milled NobelProcera Implant
and all-ceramic framework materials can withstand in- properties and provide safe, easy-to-use (and easy- Bridge Titanium, custom designed
traoral loading; the veneering material is the weak link. to-maintain) solutions. to accommodate for material support
and retention after veneering.
Despite extensive research activities, chipping— If combined with high-strength framework mate- Fig. 3_Screenshot of NobelProcera
or the partial delamination—of ceramic veneering rials such as titanium or zirconia, polymer veneering Software displaying the custom
materials is reported as the chief reason. significantly reduces the overall cost of the restora- design options applicable
tion. Cost control, of course, must always be kept in in this case.
In addition to the options dental ceramics provide, mind, since patient expectations and financial means
polymer-based materials should also be taken into differ, clinical situations vary, and virtually every
consideration as an alternative material when finish- laboratory set-up is unique.
ing options for frameworks are considered.
_Presentation on state-of-the-art
Today, polymers are used in dentistry for a wide techniques and materials
array of applications, in which their use ranges from
impression materials to direct/indirect restorative The following case reports from some of our skilled
materials. They are used as denture base materials and partner clinicians underline the versatility and display Fig. 4_Following an intraoral
for such standard components in implant dentistry the functional and aesthetic outcomes that can be assessment of the anticipated tooth
as healing caps, impression transfer units, etc. achieved with the NobelProcera Software. set-up, which respected the
functional and aesthetic
By modifying their chemical composition and/ _Case 1 requirements, a silicon rim was
or adding filler particles to the microstructure, the used to maintain acrylic denture
physical properties and material characteristics of Dr Ferdinando D’Avenia and Master Dental teeth in position prior
polymers can be adjusted to specifically meet the Technician Cesare Ferri of Parma, Italy, utilised a to injecting pink acrylic material.
requirements of a given clinical application. NobelProcera Implant Bridge Titanium veneered Fig. 5_Proper size, shape and colour
with acrylics to accommodate for the clinical situa- of the latest generation composite
Advances in material sciences tion and the expectations of the patient. denture teeth were selected, and
minor manual superficial adaptations
Extensive research activities in recent years have A 55-year-old male patient, suffering from bi- were performed without impairing
led to new and improved materials—and entire groups maxillary severe bone atrophy, presented with dis- the mechanical properties.
Fig. 4 Fig. 5
CAD/CAM
3_ 2015 I 37
I technique _ veneering options
Fig. 6 Fig. 7a
38 I CAD/CAM
3_ 2015
technique _ veneering options I
Fig. 8 Fig. 9
Fig. 10 Fig. 11
Italy chose a NobelProcera Implant Bridge Zirconia, a natural and aesthetically pleasing appearance with- Fig. 10_The zirconia framework
manually veneered with feldspathic ceramics as a out the “Hollywood smile” effect. together with a careful layering
solution in their daily routine. technique ensures an
The treatment team had to comply with two optimal aesthetic outcome.
The 64-year-old female patient was affected by conditions: Fig. 11_The preoperative planning
generalised severe periodontal disease. She had allowed for the maintenance
been wearing an upper partial removable denture for 1) The patient did not want to be subjected to invasive of sufficient thicknesses
approximately 10 years prior to her first consultation surgical procedures. of the framework and veneering
for implant-supported restorative treatment. ceramic as well as adequate material
2) She was unwilling to wear removable dentures surrounding the occlusal screw
Her chief complaint was discomfort and lack of during the provisional phase. access channels. This gives
masticatory efficiency and aesthetics. Migration and greater resistance and reduces
increased mobility of her teeth had resulted in altered To accommodate both needs and stipulations, the the risk of mechanical failures.
speech and contributed significantly to her sense treatment team decided to go for the following solu-
of insecurity. tion: Implant treatment planning in both the maxilla Fig. 12_Clinical control of the definitive
and mandible was carried out using NobelClinician implant-prosthetic restoration.
She made it clear that aesthetics were as impor- Software. Post-extraction, immediate flapless implant Fig. 13_Radiographic control of the
tant as the functional outcome. She wanted to regain placement was done with a two-piece radiographic definitive implant-prosthetic restoration.
Fig. 12 Fig. 13
CAD/CAM
3_ 2015 I 39
I technique _ veneering options
Fig. 16 Fig. 17
40 I CAD/CAM
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technique _ veneering options I
Fig. 18 Fig. 19
Treatment choices
CAD/CAM
3_ 2015 I 41
I industry report _ composite restorations
Fig. 2 Fig. 3
42 I CAD/CAM
3_ 2015
industry report _ composite restorations I
ures; the timing was therefore ideal for implan- mission of stimuli. Hämmerle et al. have shown Figs. 9a & b_Transfer to the
tation. that the threshold of tactile sensitivity perceived CAM software for nesting (a).
with implants is on average nine times greater The zirconium dioxide blank
When selecting the material, it is important than with natural teeth.1 with the abutments milled from it (b).
to determine whether the patient already has a Fig. 10_Fitting the abutments
metal restoration. Additionally, it should be taken In order not to increase the amount of metal in on the plaster model.
into consideration that implants greatly increase the mouth, on the one hand, and to protect the Figs. 11a & b_Attaching the
the resulting masticatory pressure owing to the bones, joints and antagonists through the buffer abutments to the implant abutments
lack of Sharpey’s fibres and the restricted trans- effect, on the other hand, the bionic restoration using Sebond Implant (Schütz Dental).
Fig. 9a Fig. 9b
CAD/CAM
3_ 2015 I 43
I industry report _ composite restorations
Implant placement in
regions #15, 35 and 45
(IMPLA implant system,
Schütz Dental) using corti-
cal and extension drills pro-
ceeded without problems,
Fig. 12a Fig. 12b as was expected. All three
implants were placed dur-
ing the same appointment.
Fig. 15 Fig. 16
44 I CAD/CAM
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industry report _ composite restorations I
CAD/CAM
3_ 2015 I 45
I industry report _ composite restorations
Fig. 21 Fig. 22
550 MPa. The total elasticity of the dental prosthe- The report was first published in Dental Barometer, issue
sis helps to distribute the selective masticatory 3/15, page 40–42, Barometer Verlagsgesellschaft mbH,
strain and to reduce the stress on the implant, Leipzig/Germany
bones, joints and antagonists. The physics of the
natural tooth are mimicked. This is of benefit for _Reference
patients with temporomandibular joint dysfunc-
tion or bruxism, as well as any other patient. 1. Hämmerle CH, Wagner D, Bragger U, Lussi A, Karayiannis A,
Joss A, et al. Threshold of tactile sensitivity perceived with
Additionally, the cost factor has proven favou- dental endosseous implants and natural teeth. Clin Oral
Implants Res 1995; 6:83–90.
rable for the patient, the office and the laboratory.
Should it be necessary to make an adjustment or
repair, this can be done in the patient’s mouth. The _authors CAD/CAM
veneer composite is light cured. This has shown to
be positive for the laboratory, as it means that there Dr Christian Jerecinski
are no additional outlay costs after acquiring a is a dentist with an MSc
CAD/CAM system. Furthermore, there is no shrink- in Implantology and an MSc in
age, unlike with zirconium dioxide, and this means Oral Surgery and Implantology.
it is easier to achieve a perfect fit. The colour also
reflects the final result right from the start: unlike
with ceramic restorations, the colour does not
change during the manufacturing process. However,
the tooth surface appears like ceramic and solid, Reinhild Schmidt
very similar to the natural tooth. All these proper- is a dental technician.
ties make the bionic restoration a straightforward,
reproducible, aesthetic and economical application.
_Concluding remark:
“It doesn’t rattle anymore!”
46 I CAD/CAM
3_ 2015
1 Year Clinical Masters Program TM
Registration information:
12 days of live training with the Masters
in Athens (GR), Geneva (CH) + self study Details on www.TribuneCME.com
Collaborate University
on your cases
and access hours of
premium video training
and live webinars
of the Pacific
you will receive
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University of the Pacific
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CREDITS
Tribune Group GmbH is the ADA CERP provider. ADA CERP is a service Tribune Group GmbH i is designated as an Approved PACE Program Provider by the
of the American Dental Association to assist dental professionals in Academy of General Dentistry. The formal continuing dental education programs of this
identifying quality providers of continuing dental education. ADA CERP program provider are accepted by AGD for Fellowship, Mastership, and membership
does not approve or endorse individual courses or instructors, nor does it maintenance credit. Approval does not imply acceptance by a state or provincial board of
imply acceptance of credit hours by boards of dentistry. dentistry or AGD endorsement.
I feature _ interview
_In what way has CAD/CAM made a major the only thing he talked about was the crown we
difference to your dental practice and patients? made in that one visit.
The first time I really experienced the difference If you look at this case and compare it with what
CAD/CAM has made for my patients was with one used to happen in the old days, that same procedure
patient, a very successful partner at a well-known would have taken three visits.
architectural firm. He came in on a Friday afternoon
around 2 p.m. and said, "John, I'm very sorry to Now, whenever I see an emergency in our sched-
bother you but the crown on my front tooth just ule that involves something broken, I think that we
cracked. I've got a really important dinner tonight can turn it into a definitive solution and not just
with clients and I'm going away on a 14-day ski trip a stopgap of placing a temporary and the patient
with my family. If I don't make the trip, I'm in trou- returning the next week. I know that now we can fit
ble. If you made me a temporary, I would be most a crown using a TRIOS digital impression and our
appreciative." laboratory. For patients like the one in this example,
digital is a lifesaver.
His crown was in two pieces. I told him that I be-
lieved that we could do more than just make him _Is there not a financial loss by not having the
a temporary. I thought we could make him a new follow-up visits?
crown with CAD/CAM and the laboratory. Of course,
he did not think this was possible. No, not at all. One charges the same fee regard-
less of the number of visits because the patient is
I took the broken piece and slipped it back into charged for the procedure and not per visit. So for
his mouth; it fitted perfectly, like a jigsaw puzzle. us, we actually save time and money. In addition,
I then had my assistant take a pre-preparation scan. not having to wear a temporary crown is of great
I next took the broken piece off, administered a little benefit for patients. They do not have to come back
Novocain to the patient and ground away the piece to our office.
that was still cemented. I placed a cord and scanned
the preparation with our TRIOS scanner (3Shape). _Are there more advantages of this technology?
The technician in the laboratory then designed and
milled the patient a new crown. Ninety minutes Another important advantage of digital technol-
later, the patient left with a final crown and not ogy is its potential for patient education. For exam-
a temporary. ple, I had a patient with a lateral incisor that was
perfect from the facial aspect, but from the lingual,
As a follow-up, he later told me that he must have there was an amalgam restoration, a composite
really bored his clients at dinner that night, because restoration and a vertical crack from the incisal edge
48 I CAD/CAM
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feature _ interview I
to the gingiva. But how can you show that to the There is so much information that I can now see
patient when it is on the lingual side? from looking at the enlarged scan. It is like looking
through my loupes that give four and a half times
In the old days, I would have tried with a mirror the magnification. With a scan, I can expand the
or taken a photograph and loaded it on the com- image on my screen to be as large as I like.
puter or an iPad. This would have taken 20 minutes.
The patient would have been looking at his or her Basically, I can imagine us using a scanner for not
watch, thinking about getting out of the office. just some patients, but EVERY patient. I definitely
The key in situations like these is speed. So, now what see a day when we scan each patient as part of our
I have started doing is taking a scan and obtaining routine.
a color digital impression in 3-D.
_Do you think that one day decisions on treat-
If I scan the patient, I can take the image of the ment could be made by just reviewing digital scans?
lateral incisor, flip it and point out to the patient
what I see that he or she cannot. The scan shows the Do you mean do I imagine a day when I could be
crack. The patient would ask me to suggest treat- sitting in my beach house in the Bahamas leafing
ment and I would recommend scheduling a crown. through scans on my laptop? It would be nice, but it
The patient would agree because it is such a con- will not happen because so much of our success is
vincing demonstration. We are helping patients to based on relationships and personal contact._
codiagnose.
CAD/CAM
3_ 2015 I 49
I industry news _ MIS
“The V3 is set to change the future by offering un- The second point is aesthetics. The extra bone
precedented biological advancements not previously volume affects soft-tissue volume, which is further
known in the dental implants industry—specifically, enhanced by the tulip-shaped prosthetic components,
the significant gain of bone- and soft-tissue volume realising sustainable and healthy results. With more
where it matters most,” said Elad Ginat, Product bone and soft tissue to work with from the start,
Manager at MIS Implants Technologies. clinicians can attain much higher aesthetic outcomes
and reduced healing times.
He pointed out that this claim is supported by the
placement of over 2,000 V3 implants in clinical cases The third point is simplicity, part of the MIS
performed and reported by some of implant dentistry’s “Make it Simple” philosophy. Doctors can enjoy all the
most highly respected experts. The cases date back to impressive VCONCEPT benefits of greater bone- and
2012 and were treated in collaboration with numerous soft-tissue volume without learning new protocols
well-respected research institutes and universities or procedures. In addition, a dedicated V3 surgical kit
around the world. makes procedures simple, safe and accurate.
“The triangular coronal portion of the V3 is com- “The VCONCEPT is an innovation MIS is very proud
pletely new in concept,” said Ginat. Its unique shape of, especially since it directly benefits our customers.
allows the formation of gaps between the sides of It helps dental professionals all over the world simplify
the implant and the osteotomy, creating open, com- procedures, improve success rates, reduce chair time
pression-free zones that immediately fill with blood and achieve better aesthetic results,” he concluded._
to form a stable blood clot and accelerating osseo-
integration for more rapid bone regeneration, he
explained. _contact CAD/CAM
The triangular shape further allows secure anchor- MIS Implants Technologies
age at three points and provides doctors with more P.O. Box 7, Bar Lev Industrial Park, 20156 Israel
flexibility in positioning the implant, either facing the
flat side buccally or towards an adjacent implant as www.mis-implants.com
needed, to gain more bone. It is important to note that
50 I CAD/CAM
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I industry news _ Planmeca
52 I CAD/CAM
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I industry news _ Whitepeaks Dental Solutions
54 I CAD/CAM
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about the publisher _ submission guidelines I
CAD/CAM
3_ 2015 I 57
I about the publisher _ imprint
CAD/CAM
digital dentistry
international magazine of
Copyright Regulations
_CAD/CAM international magazine of digital dentistryis published by Dental Tribune International (DTI) and appears in 2015 with four issues. The magazine
and all articles and illustrations therein are protected by copyright. Any utilisation without the prior consent of editor and publisher is inadmissible and liable
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