Oral Health Labs Fall 2015 by Annex Business Media

oralhealth

w w w. o r a l h e a lt h g r o u p. c o m

LABS

FALL 2015

DIGITAL DENTISTRY NO LONGER A DREAM

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A t

A NEW WAY TO

CONDUC T BUSINESS

Carestream Dental’s CS 3500 intraoral scanner is a work of art – one that can create big opportunities for your lab. With our preferred lab program, you can help practitioners hit the right notes by providing a convenient method of submitting digital impressions to your lab at no fee. You’ll gain more control, save time and maximize profits by offering no update or license fees. We’ll even help you advertise your lab’s new capabilities, so you benefit from the perfect harmony of cutting-edge technology and increased business. READY TO GET STARTED? Find out how at www.carestreamdental.com/CS3500 or by calling 800-933-8031.

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contents

editorial

Collaborations

Laboratories and Practices

Entering Into The World of Additive Manufacturing

A Powerful Partnership to Advance CAD/CAM Technology

Strong Arguments for 3D Printing

Digital Dentistry Is Here To Stay!

The Evolution of Digital Dentistry

case report

Challenges and Opportunities: Everything Will Be Connected

EDITORIAL DIRECTOR

Catherine Wilson (416) 510-6785 cwilson@oralhealthgroup.com ASSISTANT EDITOR

The Complete Denture Treatment Today

PRODUCTION MANAGER

DENTAL GROUP ASSISTANT

Karen Samuels (416) 510-5190 karens@newcom.ca

Kahaliah Richards (416) 510-6777 krichards@oralhealthgroup.com

CIRCULATION

SENIOR SALES MANAGER

SENIOR PUBLISHER

Melissa Summerfield (416) 510-6781 msummerfield@oralhealth group.com

Jillian Cecchini (416) 442-5600, ext. 3207 jcecchini@oralhealthgroup.com

Mary Garufi (416) 442-5600, ext. 3546 mary@newcom.ca

Tony Burgaretta (416) 510-6852 tburgaretta@oralhealthgroup.com

VICE PRESIDENT

ART DIRECTOR

DENTAL MARKETPLACE – CLASSIFIED

ASSOCIATE PUBLISHER

Jim Glionna

Carolyn Brimer

Karen Shaw (416) 510-6770 kshaw@oralhealthgroup.com

Hasina Ahmed (416) 510-6765 hahmed@oralhealthgroup.com

Joe Glionna PRESIDENT

ORAL HEALTH LABS IS A SUPPLEMENT TO ORAL HEALTH

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editorial

COLLABORATIONS It was the fall of 2012, and the first edition of Oral Health Labs had just been published. The inaugural issue was 23 pages in length, and included 16 pages of education articles, authored by two international laboratory technicians and a Canadian dentist. Three years later and we again find ourselves with the fall issue. Ironically throughout my tenure as the editor, the editorials have endeavored to highlight the joint custody of the magazine amongst the readership, and to encourage a diverse and meaningful exchange of technical information and ideas. Titles such as “Into the Future”, “Navigating The Landscape”, and “Taking The Journey” are a reflection of many and varied collaborations that exist between our peers, colleagues, clinicians and patients. These collaborations are necessary if we are to succeed both dentally and professionally, whilst dental fabricating procedures are evolving at an incredible rate. Within one generation, technology has moved from the pioneering days of the application of dental ceramics, as illustrated in the book, “The Science and Art of Dental Ceramics” written by Dr. John McLean, to a fully integrated digital tecno-clinical fabricating process. This “digital landscape” is crowded, and as previously stated in Oral Health Labs, needs to be carefully navigated, for the continued pursuit of patient treatment excellence. Collaborations and relationships evolve and change with time, as to allow for a continuous evolution of ideologies and to also allow a variety of voices to be heard. I encourage as many voices to be heard as possible. After three years of editorial duties to this magazine, I feel the time has come to give other voices an opportunity to speak. I trust the editorial emphasis will be of a professional nature, with the ultimate goal of empowering dental technicians to strive for a higher level of education, professionalism and synergy, with both clinicians and patients. I would like to take this opportunity to thank all of the staff at Oral Health for their support, and to the contributors and authors of the educational articles that have been published during this time. My best wishes to Oral Health Labs and to the readership for the future.

Trevor Laingchild, RDT, AAACD

Trevor Laingchild’s sense of adventure has taken him on an international road in his profession. After formal Dental Education in London, England, he managed a Dental Laboratory in Germany and served as Chief Dental Technician for an American Hospital in Saudi

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Arabia. Further experiences included, expanding his technical horizons whilst working in Norway, Scandinavia. He currently owns and operates dentalstudios in Burlington and in Yorkville, Toronto. Trevor is an Accredited member and an Examiner within the American

Academy of Cosmetic Dentistry, in addition is a Certified LVI Master Aesthetic Technician. Trevor is very active lecturing and teaching whilst conducting numerous hands on courses in all aspects of restorative aesthetics, of which, he has had numerous articles published.

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SIRONA CELEBRATES

YEARS 30 of CEREC

IN LAS VEGAS

hirty years old and more innovative than ever – the CEREC CAD/CAM system celebrated its anniversary with an exceptional event in Las Vegas. Jeffrey T. Slovin, president and CEO of Sirona, officially opened the celebration in front of an audience filled with thousands of excited professionals. At the event, Sirona hosted a blend of expert presentations, collegial exchanges and entertainment. In over 40 informative technical lectures, top-class speakers considered the various aspects of treatment with restorations or implants in one sitting, the integration of CEREC in practice and treatment workflows and new solutions for ordering transparent aligners for orthodontic applications. Amongst the 6000 participants, we spoke with Dr. Dhesi from Calgary, Alberta, who said that “technology [like CEREC] has driven my passion for dentistry.” The lectures were complemented by exceptional and diverse celebrity entertainment. The captivating presentation by leadership coach and financial adviser Tony Robbins was well received, as was the inspirational speech by three-time Superbowl champion Emmitt Smith. Dr. Bobby Chagger, with practices in Oakville, Mississauga and Burlington, Ontario, said “the tipping point has occured; digital dentistry is well accepted.” One very special announcement was revealed on the final day of CEREC 30 – the launch of Sirona’s online community, SIROWORLD. This community offers users, academics and experts from the dental industry the opportunity to exchange experiences and receive information relating to innovations and other products. The community provides access to registration for exclusive training events, e.g., training at Sirona in Bensheim, Germany. All those interested can find further information at: www.cereconline.com/siroworld-events. FALL 2015

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LABORATORIES PRACTICES

A Powerful Partnership to Advance CAD/CAM Technology

ver the past decade, computeraided design and manufacturing (CAD/CAM) has expanded from the laboratory to the dental practice. Digital workflows have become increasingly common and the technology behind scanners and CAD/CAM has been exponentially improved. However, there are questions that many labs and practitioners are asking as they watch this technology slowly be adopted by other colleagues. How will a digital workflow benefit my business? How difficult is it to incorporate digital equipment into my practice? Is now the time to invest in this technology? If labs and doctors want to continue to see CAD/CAM advance, they will need to promote open systems and establish a strong network of labs/practices/manufacturers across the country. The future and continued advancement of CAD/CAM depends on a powerful partnership between labs and practices.

George Cowburn, D.D., began researching digital dental solutions in 2003 while studying denturist technology at the Northern Alberta Institute for Technology. He went on to cofound one of the largest denture clinics in Western Canada. For the last five years, Cowburn has

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From the Lab to Chairside

CAD/CAM in dentistry first became prevalent in Europe in the 1970s and 80s. At that time, the equipment was oversized and the advanced technology required specialists to operate it. Dentists lacked both time and resources to add CAD/CAM to their own practices, so labs became CAD/CAM specialists. Inevitably, manufacturers began focusing on the introduction of CAD/CAM into practices as a way to expand. Early in-office systems were bulky, expensive and intensive to maintain; therefore, the dental industry was somewhat slow to adopt the technology. However, within the past 10 years, manufacturers have been tailoring in-office CAD/CAM systems to better fit within the dental practice workflow: portable chairside scanners, intuitive design software and printer-sized milling machines are now commonly employed in dental offices across the country. In addition, ease of use has significantly helped digital workflows become more popular. With early CAD/CAM tech-

been dedicated to researching and developing digital treatment workflows. This passion for digital solutions was fully realized with the launch of Perfit Dental Solutions, a company dedicated to facilitating the adoption of digital technology in the dental industry.

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nologies, only computer experts could run a 3D scanner. Now, a dentist or assistant can be scanning arches intraorally after only minutes of training. As user-interfaces continue to improve, practitioners and patients will be able to increase their collaborative involvement in the design of the restorations. The result of advancements in both technology and usability is that in-office CAD/CAM systems are giving practitioners a bigger role in the process of creating restorations from their own offices, allowing them to perform tasks that once could be done only by labs.

Mutual Benefits to Practice, Lab and Patient

While doctors and their staff have become more comfortable with CAD/CAM, labs can lead the way in growing this partnership by evolving their own services to support the changing needs of customers and practices. Today’s marketplace of customized products, competitive pricing and same-day shipping/delivery supports a consumer experience based on high expectations. Dental patients are no different: they want a comfortable, affordable, high-quality product as quickly as possible. As dental service providers, we have to accept the modern consumer mindset and position ourselves to deliver high-quality products in a timely manner. In essence, if something is in patients’ best interests, it should be the lab’s goal to pursue, practice and support it. When using traditional methods, practitioners rely on physical impression material, which is uncomfortable and can cause patients to gag. Patients may also be unable to provide a correct bite for various physiological reasons. In either case, the accuracy is negatively impacted. This directly influences every task performed downstream in the lab and ultimately affects the accuracy of the final product. These inaccuracies increase post-insertion issues, drive up the cost of corrective lab services and decrease patient satisfaction; all of which result in higher cost to patients and reduced profitability for practitioners and labs. Reliance on conventional methods when working to increase volume requires a trade-off: either accept a decrease in quality or incur additional costs to expand staff or pay for outsourced capacity. The solution to these costly problems is provided by digital production methods and technologies. Digital scans significantly reduce human error, enabling the practitioner to be more efficient and confident in their work. Digital workflows can decrease or even eliminate costs associated with performing adjustments; sterilization; accommodating multiple tryins; and re-work. Cases can be completed accurately and quickly, resulting in happier patients and positive word of mouth. All in all, digital workflows can have an immediate and lasting impact on the profitability of your business,

benefitting practice and lab alike and leading to the greatest benefit for the patient.

Is Now the Time to Invest in Digital Technology?

In North America, CAD/CAM dentistry has had time to mature. Scanning technology today is versatile. For example, intraoral scanners can be used as desktop scanners to scan stone models. The cost of intraoral scanners has also decreased and will continue to do so as economies of scale are further realized. For a few hundred dollars a month, labs and practitioners can scan patients or models, which opens the door to a whole new world of digital design and computer-assisted manufacturing. Like any medical advancement, it can take time for these advances to be trusted and adopted by consumers. Research on the innovation adoption lifecycle shows us that the first people to use or adopt a new technology are called “innovators” (2.5 percent), followed by “early adopters” (13.5 percent), the early majority (34 percent), the late majority (34 percent) and finally “laggards” (16 percent). In between early adopters and the early majority is a chasm or point at which the early majority contemplates investing in the technology. Digital dentistry in North America is at the chasm point and ready for adoption by the early majority. In parts of Europe it’s already achieved that level of adoption. Labs and practitioners who position themselves properly and can adapt will have the greatest competitive advantage moving forward. Given the versatility of the technology and the future growth potential, this is the time to invest in digital technology. After you’ve made the decision to adopt digital technology, the next step is to communicate the benefits to patients, practitioners, partners and colleagues involved in your workflow. When working with practices that are considering a switch to CAD/CAM, labs can share the benefits of such technology as a way to facilitate a practice’s informed decision. When working with CAD/CAMenabled practices, labs can let doctors know that as they have the ability to accept digital impression files—doctors can design their own restorations and then access the lab for its advanced milling capabilities. Labs can also offer expanded service (and demonstrate their expertise in digital impressions) by offering to check the accuracy of scans while the patient is still in the doctor’s chair.

How Can Labs Facilitate and Accelerate Digital Adoption?

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THE EVOLUTION OF DIGITAL DENTISTRY

here was tension and excitement in the room as the lights were slowly dimmed in the auditorium. For the next two hours, there was a glimpse of the future of dentistry. The topic was something out of a science fiction novel, and it instilled in the audience a sense of awe, wonder and just a touch of fear. As the auditorium lights came up, everyone sat in stunned silence as they contemplated all the possibilities offered by the presenter…dentistry going digital. That presentation was given over 20 years ago by one of digital dentistry’s pioneers, Francois Duret, on the application of computer-assisted design/computer-assisted manufacturing (CAD/CAM) technology into restorative dentistry. While it took slightly longer than anticipated to integrate into the daily practice of dentistry, the new millennium seemed to be the catalyst for change in digital dentistry, as more than ten different CAD/CAM systems have now been introduced as solutions for restorative dentistry. Dentistry has cautiously welcomed this influx of technology that was promised so long ago. Based on technology adopted from aerospace, automotive, and even the watch-making industry, this technology is being accepted now due to its advantage of increased speed, accuracy, and efficiency without a compromise in quality. Today’s CAD/CAM systems – both chairside and laboratory, are being used to design and manufacture implant abutment/bars, metal, and zirconia frameworks, all-ceramic full-contour crowns, inlays, and veneers that may be stronger, fit better, and are more esthetic than restorations fabricated using traditional methods. The dentist’s, dental team members’ and dental technician’s primary role in indirect restorative dentistry is to perfectly copy all functional and esthetic parameters that have been defined by nature into a restorative solution. It is an architect/ builder relationship. Throughout the entire restorative process,

Fig. 1: Planmeca FIT™, Open CadCam System

from the initial consultation through treatment planning, provisionalization (if needed), and final placement, the communication routes between the clinician and the laboratory technician require a complete transfer of information pertaining to existing, desired, and realistic situations and expectations to and from the clinical environment. Functional components, occlusal parameters, phonetics, and esthetic requirements are just some of the essential types of information that are necessary for the technician to complete the fabrication of successful, functional, and esthetic restorations. In the past, the primary and conventional tools of communication between the dentist and the technician were photography, written documentation, and impressions of the patient’s existing dentition, the clinical preparations and the opposing dentition. From this information, models are created and mounted on an articulator, which simulates the jaw movements of the mandible. As restorative dentistry evolves into the digital world of image capture, computer design and creation of dental restorations through robotics, our perceptions and definitions of the dental laboratory must also evolve. First, in order to fully understand this concept, we must clearly define what a laboratory is. At first thought we might say that a lab is the place where a dentist sends his or her patient’s impressions, which are then processed by that laboratory into restorations, then

Lee Culp, CDT is the CEO of Sculpture Studios, a dental laboratory, research and product development center for new and innovative diagnostic and restorative and digital applied applications to surgical and restorative dentistry.

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sent back to the dentist for adjustment and delivery. This definition does seem to fit well with the traditional concept of a dentist-laboratory workflow. However, just as the internet has forever changed the landscape of communication through related computer technology, the possibility to use CAD-CAM restoration files electronically has provided the catalyst for a significant change in the way we view and structure the dentist-lab relationship. Let us imagine first that our laboratory is not a place, does not have walls, and exists only in the talents of the partners in the restorative process – the dentist, auxiliaries, and technician. The equipment we use to create the restoraFig. 2: 3Shape D2000 Scanner tion may be located next to the chair, in an in-office laboratory area, remotely, or all of the above. Our “laboratory” is actually nothing more than a workflow, which is flexible to the plex characterization or can be more efficiently created in an degree that our abilities, access and equipment will allow. The indirect manner (Figure 2). primary decision becomes where the hand-off from one partThe dental profession currently regards CAD-CAM technolner to another should occur. Moreover, a dentist who has the ogy as just a machine that fabricates full contour ceramic resability to optically scan intraorally for impressions, and who torations or frameworks. Digital dentistry and the digital denoften choose CAD-CAM restorations as the best treatment op- tal team represents a totally new way to diagnose, treatment tion for their patients, have enhanced freedom as to where I plan and create functional esthetic restorations for our pabelieve the hand-off to the technician partner should occur. tients in a more productive and efficient manner. CAD-CAM The lab is no longer a place, it is to a large degree, a virtual and dentistry will only further enhance the dentist/assistant/techfluid entity. nician relationship as we move together into this new era of In some instances, it makes sense for the dentist to work patient care. independently and to prepare, design and finish the restoraAutomation has been slow in coming to dentistry and altion chairside in a single visit, with the obvious advantages a though new equipment has been introduced to make our jobs clinical CAD-CAM system has to offer (Figure 1). easier, we still create complex dental prosthetics using techThese might include less complex restorations or fewer num- niques that are thousands of years old. And, even though the bers of restorations for the same patient that does not require “lost wax” technique is still a tried and true method of fabricaany special characterization, other than perhaps stain and tion, there will come a day in the near future when all frameglaze or polish. Other times, it is advantageous to engage the works and full anatomical crowns will be designed on a comservices of the restorative partner, a dental technician, because puter. Only then will we truly realize the wonder and awe of he or she possesses the skill and perhaps more importantly, dental CAD-CAM technology that were initially introduced so the time to create restorations that either demand more com- long ago. FALL 2015

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Challenges and opportunities: EVERYTHING WILL BE CONNECTED

isruptive innovations. Radical changes. Continuous adaptation. These are the buzz phrases of our time. They

appear in virtually all areas of life and work, and of course this includes dentistry and dental technology. These concepts represent both a challenge and opportunity in this sector with ultimately the patients benefiting the most.

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bout 40 years ago, liquid crystal displays on clocks foreshadowed the decline of the analog era. Who knew at the time where this would lead: “Digitalization is the entire process from recording and processing of analog information to the storing it on a digital storage medium.” Analog data is replaced by digital data—technically, simply, and with no fanfare. For society, however, this process actually represents something new, complex, and revolutionary. In particular, the options for processing and quickly exchanging data have defined how digitalization has evolved and continue to influence it today: The Internet as well as global networking are inconceivable without the transmission and distribution of digital data. However, digitalization is not just a matter of data distribution but also: • The manufacturing methods used for products: Digitalization allows great individuality without creating exorbitant additional costs for the customer. • Services: Many are only possible thanks to digitalization—from communication to delivering the weekend shopping. • New methods and procedures for staying healthy: Early identification and management of problems is a

fundamental human concern, and digitalization is a valuable aid in this regard. Greater treatment safety and patient comfort Digitalization in the dentistry sector started around 30 years ago. In 1985, CEREC was the first digital impression method used to fabricate dental restorations. At the same time in 1986, the first commercial digital X-ray system, introduced under the name of “radiovisiography”, came onto the market1 along with the first software for dental practices. Over the course of these 30 years, the possibilities for digital data collection, data processing, and mechanical or automated manufacturing have grown considerably and are more than likely not yet exhausted. As the leading biennial dental trade fair International Dental Show (IDS) demonstrates time and again, digital technologies have changed and especially improved the procedures used as well as how patients experience them. This is especially apparent with regard to imaging techniques. X-ray is a key technology. It provides greater certainty with difficult diagnoses and is a less time-consuming and efficient tool. Initially, many still thought that the image taken using digital radiography would be the same as the old film image, simply on a computer. Today there is no doubt that FALL 2015

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In the long term, analog imaging techniques in dental practices will probably also be replaced digital images, which can now even be prepared as 3D images, are equal and in some cases, even superior to analog images.2 This is also apparent in traditional photography, where virtually everything is done digitally. In 2013 and 2014 alone, 1.2 billion and 1.8 billion photos respectively were uploaded onto social mediaâ&#x20AC;&#x201D;this feat would have been unimaginable with analog technology. In the long term, analog imaging techniques in dental practices will probably also be replaced. Digital technology is already state-of-the-art for fabricating restorations: CAD/CAM-supported construction and fabrication processes are part of the daily routine in many dental practices and even more so in dental labs. Extensive use of digital technology is seen even in treatment centers today: Twenty-one years ago, Sirona launched the C1â&#x20AC;&#x201D;the first digitally controlled treatment center featuring displays on the dentist and assistant element. This is now standard for virtually all treatment centers on the market today. Additional functions have been incorporated, such as digital control of the treatment center and the instruments themselves, digital access to patient data by networking with the practice software, additional digital applications such as implantology and endodontics including ApexLocator, and hygiene features for the instrument hoses. The next step in digital technology allows all these to be linked together to create integrated systems. Networking and integrating functions into one system, which would otherwise require external devices, benefits dental practices in several ways. Workflows become simpler and easier to control, safety and quality improve thanks to the reproducibility of processes, and there is more added value for the practice. As far as the use of digital systems in the dental practice is concerned, the question is no longer whether a digital workflow can be implemented in the practice but instead how this can best be done. After all, many digital processes ensure that patient manage-ment, treatment planning, and special types of treatment are carried out even more efficiently for the dental practice. Completely integrated systems CEREC is a good example of the application of this concept: It starts with a digital impression using the CEREC Omnicam, the smallest powder-free, color video camera on the market.

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The resulting data can either be sent to a dental lab via the Sirona Connect portal or used to fabricate the restoration in the practice. The restoration is constructed using the new CEREC SW 4.4, which develops excellent initial proposals based on the entire scanned areas using the new biojaw algorithm. Fabricating the planned restoration using one of three different CEREC milling machines is the final step in the workflow. The integration capability of CEREC is especially apparent in the field of implantology: A prosthetic proposal created with CEREC is combined with the 3D X-ray data to form the ideal basis for implant planning. In order to implement this precisely in reality, the practitioner designs and produces a surgical guide (CEREC Guide 2). After insertion, CEREC supports the design and production of the suprastructure. The practitioner always has full control over the entire process, enabling the patient to complete the entire treatment in just one session. An especially striking example of integration is the new

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SIDEXIS 4 imaging software, which can be used to view intraoral, panoramic, and 3D images simultaneously. Evaluating images and accessing the patient’s treatment history is made even simpler and cross-comparisons can also be made. The many interfaces also allow SIDEXIS 4 to be incorporated into other systems. Dare to try new methods and technology The challenges of the advancing digitalization are not only of a technical nature. The associated changes also affect those

involved. Dentists should be open to new technologies and also dare to use them. They need appropriate education and training for this. Working with digital processes in the practice should feel as natural as using a turbine. The shape of digital dentistry in the future depends in large part on the dentists themselves: The best technology is of little use when those who are supposed to use it cannot see and implement the advantages associated with it for themselves. This is why the manufacturers of dental equipment are especially directing their energies towards making the application of digital technology even easier—the name of the game here is intuitive operation. In this way, practitioners can fulfill their high demands for quality in their work for the good of their patients. Visit the digital edition of Oral Health Labs for an interview with Dr. Tarun Argaval on the Digitalization of Dentistry. 1

DGZMK Digitale Radiographie, Stellungnahme 2009.

DGZMK Digitale Radiografie, Stellungnahme 2009; s2k-Leitlinie Dentale digitale Volumentomographie, DGZMK 2013 [DGZMK Digital Radiography, Statement 2009; s2k Guideline for Dental Cone-Beam Computed Tomo-graphy, DGZMK 2013]

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ENTERING INTO THE WORLD OF

ADDITIVE MANUFACTURING: Strong Arguments for 3D Printing with The BEGO Varseo System

printers are revolutionizing work in many sectors of the economy. Dentistry has also been using this technology for several years. At the International Dental Show (IDS) 2015, BEGO launched its 3D printer, an expertly designed integrated system that now makes 3D printing in the laboratory a reality for dental techni-

cians – this system is now also available on the Canadian market. This article presents the advantages of both 3D printing and the Varseo system. The author also provides valuable information on how the technology works, as well as tips on how to enter this future-oriented sector successfully.

A few years ago, 3D printing was the preserve of visionaries, enthusiasts and industry. All that has since changed: 3D printing is moving out of its niche and making inroads into everyday life. When it comes to creativity the sky is the limit. Using virtual designs, a 3D printer can produce objects in practically any shape. In common parlance, 3D printing is used to refer to about eight different additive methods, two of which have proven particularly suitable for the dental industry and dental requirements: selective laser melting (SLM) and stereolithography (SLA). The Bremenbased dental specialist has been using both methods for many years and now also offers, in addition to the centralised production of SLM metal frames, a coherent integrated system in its new

Dipl. Wirt. Ing. Dennis Wachtel Head of Product Management BEGO Bremer Goldschlägerei Wilh. Herbst GmbH & Co. KG., Product Manager Devices at BEGO, head of Product Management since 2010, BEGO specialist for devices, alloys, 3D printing.

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SLA 3D Varseo printer, which is used in the laboratory for the fabrication of dental restorations from high-performance resins, especially when centralized production would prove too time-consuming. How does additive manufacturing work and how does it benefit dental laboratories? In the case of 3D printing, the shaping process during the production of objects is reversed. During conventional CAD/CAM production, the material is removed by milling or grinding (known as the subtractive procedure). By contrast, 3D printers work additively to build up material, which offers many advantages compared to conventional production methods. BEGO, the Bremen-based dental company from Germany, has more than 15 years of experience working in selective laser melting ad-

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BEGO VARSEO 3D PRINTER SPECIFICATIONS

t The BEGO Varseo

IMAGES © BEGO

THE BEGO VARSEO SYSTEM IS CHARACTERISED BY THE FOLLOWING FEATURES:

• Open STL file unit • Design freedom, taking into account anatomical conditions (design diversity relating to splints, drilling templates, impression trays, etc.) • Reproducibility • Precision (exact fit) • High build speed (20 to 40 mm/h) • Low material consumption, saves resources (only the material really needed is used) • Material diversity (there is a special material for each indication) • Short set-up time when changing the printing material (changing BEGO Varseo cartridges: 15-30 seconds) • Easy to use • Little or no reworking required during fitting • No tool wear (no milling): light is used as a “tool”.

Height

857 mm

Width

456 mm

Depth

443.5 mm

Weight

50 kg

Rated voltage

100–240 VAC, 50/60 Hz

Rated power

100 VA

Build volume (L x W x H)

96 x 54 x 85 mm

Resolution

50 μm (± 25 μm)

Layer

50–100 μm

Build rate

20–40 mm/h

ditive manufacturing and has brought it to market maturity within the dental industry. This technology involves the CAM data being used to control a laser, which then creates the frame additively using metal powder. The powder-metallurgical manufacturing of the primary material (e.g., Wirobond® C+, a tried and tested veneerable cobalt-chrome alloy) and the materialpreserving process achieves an exceptionally homogeneous structure, which guarantees very high mechanical strength and high corrosion resistance. The low ion release rates reduce the risk of undesirable biological reactions (e.g., allergies) and thus ensure high biocompatibility. Due to its surface microstructure, the frame prepared for veneering provides high shear bond strength and optimum bonding properties for the veneer material. The company has used its extensive know-how and many years of experience with both SLM and SLA technology to develop an SLA 3D printing system, which is based on the principle of using layers to create the print object from liquid resin by means of UV light. Varseo offers dental technicians the opportunity to quickly, simply and cost-effectively produce various dental designs made from high-performance resins in the laboratory. Working closely with dental technicians, the company has succeeded in developing a user-friendly and highly efficient integrated system. With an optimally coordinated portfolio featuring 3D printers, scientifically proven materials, software tools and comprehensive service, Varseo offers dental laboratories a complete solution. What does Varseo offer? The Varseo system offers various materials for the manufacture of splints, drilling templates, CAD/cast partial denture frames, or impression trays. In future, it will also cater to other indications. The specific properties of each of the materiCONTINUED ON PAGE 28

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CELTRA DUO

Minutes

14:30 MIN

Molar crown, block size C14, standard milling program sponsored case study

www.dentsplyceltra.com

CERAMICS - IN THE SAME TIME. S

SIGNIFICANTLY STRONGER THAN LEUCITE GLASS

A NEW CLASS OF RESTORATIVE MATERIAL Bobby Chaggar B.Sc., DDS

The key result of the collaboration was the creation of a new class of restorative material â&#x20AC;&#x201C; ZLS. The name is short for Zirconia reinforced Lithium Silicate. ZLS is a glass ceramic produced out of Silicon Dioxide, Phosphates, Alumina, Lithium composition, Terbium Oxide, Ceria and Zirconium Dioxide. It was the addition of 10% Zirconium Dioxide being completely dissolved in the glass matrix that led to the creation of this new class of material. The incorporation of the Zirconia had the added effect of creating a crystalline structure that was smaller than the one that is present in a Lithium Disilicate material. (Figure 1a) This effect has had an effect upon polishability, machinability and esthetics (being flouresence, translucence and opalescence). The smaller crystalline structure, which was a result of the incorporation of zirconium dioxide in the glass matrix, allowed for excellent extra-oral and intra-oral polishability of the final restoration. No zirconium dioxide crystals are visible. (Figure 1b) The restoration can also be stain and glazed in a porcelain furnace and further polished manually. The incorporation of the Zirconia had the added effect of creating a crystalline structure that was smaller than the one that is present in a Lithium Disilicate material. (Figure 1a) This effect has had an effect upon polishability, machinability and esthetics (being flouresence, translucence and opalescence).

Figure 1a - Lithium Disilicate Crystalline Structure

Figure 1b - ZirconiaLithium Silicate Crystalline Structure (Celtra Duo)

Polishing

Restorative dentistry requires practitioners to identify restorative materials which balance esthetic appeal with the durability required for intra-oral function. Three companies, DeguDent (A Dentsply Company), Fraunhofer and Vita Vident participated in a study to improve dental materials being used in both CEREC Chairside and Commercial Laboratories. These three companies brought their pre-eminent researchers to Germany to review current restorative materials and to discuss new dental material innovations.

ZLS also has a flouresence of natural teeth and due to the smaller crystalline structure, has remarkable translucence and opalescence. This structure has allowed the material to have a chameleon like effect with the natural dentition as it allows for an almost imperceptible colour transition from restoration to tooth. An interesting phenomenon occurred when the material was tested after crystallization. The material had a flexural strength of up to 420 MPa, yet the material was machinable in the CEREC milling chamber. This ability to be milled in the crystallized form in the CEREC milling chamber is due to the smaller crystalline structure that occurred from the incorporation of the zirconia in the glass matrix. The advantage of having a ZLS CEREC block in the crystallized stage (called Celtra DUO, developed by Dentsply) is that once it is milled, it can be tried in the mouth to check marginal fit, contacts and esthetics. The colour of the restoration can be verified next to the adjacent teeth. At this point one has 2 choices of either manually polishing the restoration or glazing the restoration in the porcelain furnace. Under testing, it has been shown that the flexural strength of the ZLS material drops to approximately 200 MPa after milling. This flexural strength rises to approximately 210 MPa after manual polishing. This flexural strength of 210 MPa is remarkable as it is 25 to 80 percent higher than other glass ceramics presently available for Chairside use with CEREC. In addition, one has the option to glaze this final restoration in the porcelain oven and see a dramatic rise of the flexural strength to approximately 370 MPa due to surface enforcement independent from glaze which is needed to get a glossy surface.

Option 2 - Strength Figure 2

In the demonstrated case (Figure 2), tooth #14 has been endodontically treated and in need of full coverage, tooth #15 has decay both mesially and distally and tooth #16 has decay mesially. Both teeth #15 and #16 do not require full coverage with a crown. After excavation of the decay, it became apparent that tooth #15 had a substantial amount of tooth structure removed and tooth #16 had a minimal amount removed. (Figure 3a and 3b)

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CELTRA

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Molar crown, block size C14, standard milling program

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CERAMICS - IN THE SAME TIME.

A NEW CLASS OF RESTORATIVE MATERIAL

SIGNIFICANTLY STRONGER THAN LEUCITE GLASS

Figure 3b

Polishing

Figure 3a

Bobby Chaggar B.Sc., DDS

Seating

o f

Figure 5

The decision was made to fabricate an onlay for #15, inlay for #16 and crown for #14 and have the restorations fabricated with CELTRA Duo. The proposals for the restorations with the CEREC are presented (Figure 4). After fabrication of the restorations, they were checked intra-orally for marginal fit and contacts. Due to the size of the restorations, the restorations on teeth #14 and #15 were further stain and glazed in a porcelain oven. This was done to increase the flexural strength of the material to 370 MPa. A decision on tooth #16 was made to polish the inlay. The inlay had not compromised the cusps of the tooth and as such did not need to be glazed in the oven. After polishing of the inlay at tooth #16, we felt the flexural strength of 210 MPa would allow for a very successful restoration. The cemented restorations are demonstrated in Figure 5. All the restorations were first cleaned in an ultrasonic bath prior to try-in intra-orally. The inlay on tooth #16 was polished utilizing a porcelain polishing system. Diamond polishing bodies with a size of less than 60microns is recommended. Care was taken to polish the occlusal surface with the porcelain polishing wheels only. The use of tungsten carbide burs on the material is contraindicated. Celtra Stains and Glazes were utilized to finish the restorations on teeth #’s 15 and 14. Due to the fact that Celtra Duo does not have a dimensional change after firing, the restorations may be placed directly on the firing tray or on a firing pad when being placed in the porcelain oven. The use of metal pins is contraindicated during the firing process.

THE ADVANTAGES OF CELTRA DUO ARE: 1. Shade verification and contact check of the restoration before stain and glazing or polishing. 2. Clinician choice is present to insert the restoration glazed or polished. The flexural strength is 370 MPa for glazed and 210 MPa for polished restorations. 3. A material that can both be used in the anterior esthetic region or in the posterior. With the incorporation of CELTRA Duo in their practice, one has the ability to incorporate a Zirconia Lithium Silicate (ZLS). This material allows for the fabrication and utilization of a highly esthetic and functional material for both the anterior and posterior regions of the oral cavity.  Dr. Bobby Chagger, B.Sc., DDS, FICOI graduated from the University of Waterloo, and obtained a DDS from University of Toronto. Bobby later graduated from the Misch International Implant Institute and studied Advanced Functional Esthetics at LVI. He became a CEREC Educator, CEREC Software BetaTester, and traveled across North America, Asia and Europe to work with companies like Sirona to understand how new technology is changing possibilities in dentistry. He has published articles on CEREC technology and now trains other dentists in both basic and advanced dentistry utilizing CEREC 3D. Bobby’s clinical gains from innovation, and specific interests in cosmetic dentistry, dental implantology and CEREC have led him to create a new model for practice management. Bobby is a Fellow of the ICOl, is certified in IV Sedation and professionally affiliated with The CDA and ODA. He is a proud father and supports numerous community and charitable organizations in the Halton-Peel Region.

Option 2 - Strength

Figure 4

Prior to cementation, the restorations were etched with a hydrofluoric acid etch for 30 seconds. Following this porcelain etch, the restorations were thoroughly rinsed and silane was applied for 60 seconds. Calibra resin cement was utilized to cement the restorations.

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The Words Out! Digital Dentistry Is Here To Stay!

igital dentistry is no longer a dream. It isn’t about the future. It is here and now – in both the dental practice and the dental laboratory.

Digital dentistry continues to make dramatic inroads within the dental operatory. Digital impressioning systems have revolutionized the accuracy and precision of dental restorations. Yet, as with any fast-evolving methodology, doctors now have an abundance of choices on how to handle their digital scanning requirements. The challenge for the laboratory is in handling all the resulting file formats generated. The complication is that just because a laboratory CAD system is “Open” does not mean that it can read ALL open STL files. At Core3dcentres, as we have gained experience with the STL files created by different systems, we have found that they are anything but the same. So, what is a lab to do? The first key to success is extensive communication. For a lab to be ready to accept digital cases, it is essential to know what system the files are going to be originating from – and well before the cases start coming! Of course, the optimal situation is to be able to guide the doctor to a system the laboratory has confidence in. Unfortunately, this is not always possible. Labs are often left to gather information about the system and files when the clock is already ticking on a case. The second key is to take a proactive approach to the digital question. Let’s start by being honest; the typical laboratory alone cannot be all things to all people with digital dentistry. It’s prohibitively expensive to have the lab equipped to handle any and all

Mr. Mark Ferguson graduated from the American Institute of Medical/Dental Technologies in Provo, UT in 2001. Mark has applied his broad experience in developing and teaching the Core I, II and III curriculums for Core3daCADemy. He also consults widely

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outside the aCADemy on-site with a range of laboratories on applying and perfecting Digital and CAD/CAM technologies in their operations. He currently serves on the Editorial Advisory Board of Dental Lab Products.

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1. Model with socket for lab analog.

types of digital cases coming in every day. Labs should make that decision themselves upfront, considering key factors such as volumes expected by technology, the return on investment on those volumes, which ones they want be prepared for, and then find partners to handle the cases they can’t or don’t want to handle internally. These partners can also open up new business for a lab by opening up new networks not previously available to them. Now, let’s look at what I consider the next big wave in the impact of digitization in dentistry – restorations fabricated without models. In my opinion, monolithic restorations based on accurate digital scans can be fabricated without a model today – end of story. Modeless lab work has been done for years with monolithic restorations, even those with a cutback. Other restoration types can require a bit of a leap of faith. I am often asked “can a lab guarantee fit of a standard restoration without a model”? The dilemma is when a lab does so and then has trouble fitting that restoration to the model they receive. Through a series of tests, we have determined the cause of this is more likely inaccuracies in the model based on how it was fabricated, not in the restorations. The thing to remember here is that the digital data collected from an intraoral scanner is the most accurate data to work from. With proper parameters in the design software, a lab should have the utmost confidence that modeless restorations can be counted on to fit. That being said, when these cases start to involve implants, the workflow gets a little harder to decipher. An implant case has additional considerations. Will the model have a replica of the designed abutment or will it be created with a socket for a lab analog? Where did the doctor purchase the scan body? An intraoral scan with an approved scan body from an implant library with the dimensions of a lab analog has the most accurate and streamlined workflow. Scan bodies are connected to implant libraries — and are not able to be used without their particular library if you want to achieve an accurate result. Depending on the implant library, it may, or may not, be possible to fabricate a model with a lab analog. With this type of implant library, the lab has the widest range of options for how to process the case. On the laboratory front, dental laboratories are really old hands at applying digital technologies. Dental labs have been using CAD/CAM technology in various forms for more than a decade now. With a greater understanding of today’s machines and software, the dental lab can provide more precise restorations while still improving turnaround time. Yet, the technology continues to amaze people as it progresses and grows. Today, we are seeing different technologies in several areas being developed at the same time in parallel, giving rise to some exciting partnerships. For example, the newest materials are

2. iTero printed model. 3. Example from Implant library. 1.

getting more and more aesthetic, stronger, and predictable. This, in particular, is very exciting because we are now able to design things on our CAD stations that, prior to the development of these new materials, could not be manufactured cost effectively. Back in my early days in the industry as a technician at an innovative lab, we used our design software to enhance communication with our doctors. This is something I strongly encourage and something every lab should consider doing today. The most used communication method in our lab was simple screen shots. These were used to show draw issues on bridges, space concerns, or to show potential improvements in prep design. When we can show a doctor visually exactly how open a margin will be due to draw issues, our communication is infinitely more effective than possible with a simple phone call. We can now enhance this communication by sending of STL files. I have a free STL viewer app on my phone so I can look at files from anywhere. This really adds to the communication and service you can offer your clients. Often the need for many screen shots can be fixed by simply sending a couple STL files. The bigger issue here comes down to patient privacy compliance. Sending these files through conventional email is not compliant. In conclusion, digital workflow has evolved over the past few years. I believe now is the time to get on board with digital technology. As more elements of the dental field become digital, we can expect a higher quality of restoration in a shorter amount of time. Missteps aren’t as costly as they once were, there are more and more companies to partner with to help you get the most out of the technology, and the sooner you adapt to the technology, the easier it will be. FALL 2015

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THE

COMPLETE DENTURE TREATMENT TODAY: CASE REPORT

ABSTRACT Today, edentulous patients can be restored with several prosthetic solutions, thanks to the availability on the market of different implant supported or retained systems. However, complete denture principles remain essential for the planning of implant restorations. Today, complete dentures allow to treat edentulism when patients refuse implant treatment because of economic aspects, complicating surgery or medical conditions. This paper describes the clinical and laboratory steps performed during the rehabilitation of an edentulous patient using a “closed-mouth” impression technique. Although this protocol allows clinicians to save time, it can be used to guarantee all the functional and aesthetic aspects that improve patient’s satisfaction. Thanks to Ivoclar Vivadent for this original submission

uring the last decades several studies have described a reduction of tooth loss in all the developed countries thanks to the prevention of decay.1 However, in the next years, the expected demographic aging is going to determine a rise in the need for edentulous rehabilitations.2 It is reported that edentulusness has adverse effects; not only in the oral functions but also in the quality of life and daily activities of the patients caused from a frequent loss of self-esteem.1 For many years, the complete denture was the unique possibility of rehabilitation in these

cases, however, the coming of osseointegrated implants has permitted us to treat edentulism with different restorations – fixed and removable.3 Today it is largely proven that there is an increase of comfort and quality of life of patients using implant supported or retained prosthesis. Actually, the two mandibular implants overdenture is accepted as the gold standard treatment for edentulous people.45 In spite of implant restoration becoming a part of the daily clinic activity for general dentists, the complete denture reconstruction principles remain crucial to the approach of implant treatments.6 Moreover, a

Dr. Alessio Casucci received his D.D.S degree from University of Siena in 2004. He holds a Master Degree in Periodontology and a Master of Science in Dental Biomaterials at the University of Siena, where he also completed his Ph.D. in Dental Biomaterials and Their Clinical Applications. He has participated as an educator at the post-graduate program “Complete Denture and Occlusion” at the University of Siena, and he is a lecturer in several courses on complete denture and implant supported prosthodontics. He has published different papers in international journals. He is a member of I.A.D.R. (International Association for Dental Research) and ICP (International College of Prosthodontics)

and A.I.O.P. (Italian Academy of Prosthodontics). He mainly devotes the clinical practice to edentulous patients rehabilitation.

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Odt. Alessandro Ielasi obtained his Odt diploma at the Fermi Institute of Perugia. Over the years, he has attended courses in complete denture aesthetics at the University of Zurich with Prof. S. Palla, and Dr. B. Ernst, at SICED of Brescia with the J. Stuck. Since 2003, he collaborates with Dr. A. Della Pietra and A. Zollo for complete denture courses. In 2013, he obtained the 2nd place award at the Polcan’ Prize with a case presented with Dr. Alessio Casucci.

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solid knowledge in complete dentures can facilitate the clinician in the determination of all the parameters required for implant prosthodontics, such as establishing vertical dimension or the relationship between the arches, or in a proper evaluation of aesthetic and phonetic parameters. Complete dentures are a valid treatment option for economic reasons or when for general health reasons, implant treatments are not accepted. In spite of the current surgery techniques, they have reduced their morbidity as some patients still refuse implants because of previous negative experiences or fear. Frequently, the age or the medical condition may determine low self-sufficiency in edentoulus patients, thus complicating the capability to access dental care. For this reason, conventional treatments based on five to six appointments can be precluded to them. Over the years, several protocols have proposed a reduction of the number of appointments.7,8,9,10 The clinical case presented was performed using a “closed-mouth” impression technique. This protocol expects to record the centric relationship and to

take the functional impressions at the same appointment, ensuring the accuracy of the treatment. 1WHO. International Classification of Functioning, Disability and Health Geneva, Switzerland, 2001. 1C. W. Douglass, A. Shih, and L. Ostry, “Will there be a need for complete dentures in the United States in 2020?” Journal of Prosthetic Dentistry, vol. 87, no. 1, pp. 5–8, 2002. 2F. M¨uller, M. Naharro, and G. E. Carlsson, “What are the prevalence and incidence of tooth loss in the adult and elderly population in Europe?” Clinical Oral Implants Research, vol. 18, supplement 3, pp. 2–14, 2007. 3Adell R, Lekholm U, Rockler B, Bra°nemark PI. A 15-year study of osseointegrated implants in the treatment of the edentulous jaw. Int J Oral Surg 1981;10:387e416. 4Feine JS, Carlsson GE, Awad MA, et al. The McGill consensus statement on overdentures. Mandibular two-implant overdentures as first choice standard of care for edentulous patients. Gerodontology 2002;19(1):3-4. 5Thomason JM, Kelly SA, Bendkowski A, Ellis JS. Two implant retained overdentures-a review of the literature supporting the McGill and York consensus statements. J Dent. 2012 Jan;40(1):22-34 6Carlsson GE. Facts and fallacies: An evidence base for complete dentures. Dent Update 2006;33(3):134-136, 138-40,142. 7Helft M et al.Combining final impressions with maxillomandibular relation records in stabilized record bases. J Prosthet Dent 1978; 39(2):135-138. 8Ansari IH. A one-appointment impression and centric relation record technique for compromised complete denture patients. J Prosthet Dent 1997; 78(3):320-323 9Preti G, Notaro V, Bernardo S, Ceruti P, Gassino G. Benefits of the simplified edentulous treatment (SET) method in communicating with the laboratory. Minerva Stomatol. 2012 Apr;61(4):113-23 10Harvey WL, Brada BJ. Update of a one-appointment master impression and jaw relation record technique. Quintessence Int 1992;23:547-550

Case Report Fig. 1 Intraoral images of the complete A 68-year-old female patient was evaldenture worn by the patient uated for a new edentulous rehabilitation. The patient did not report a sigFig. 2 Frontal view of the patient nificant medical history and occlusal or temporo-mandibular disease. She has been a heavy smoker for 20 years. At the preliminary speech, the patient revealed mainly a functional discomfort due to the instability of the lower denture during mastication. The patient also reported the need to use a considerable amount of dental adheFig. 1 sives to stabilize the lower denture. From an aesthetic point of view, the patient complained that the anterior teeth were too short, however, she was quite satisfied with her appearance. Clinical examination revealed complete edentulism in both arches; the worn prostheses were originated from old removable partial dentures converted into complete denture (Figure 1). The adaptation of the prostheses to the tissues was poor and there was a lack of coverage of the supporting structures. Fig. 2 From an aesthetic point of view, the lips needed to be much more supported, the maxillar incisal edge was flat and did not correspond to the lip line and the vertical dimension of occlusion need to be increased (DVO)(Figure 2). FALL 2015

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Treatment Planning The treatment planning established was to rehabilitate the patient with new complete dentures and in a second time, to evaluate the possibility to stabilize the lower denture with two intra-foraminal implants. Clinical And Laboratory Protocol Preliminary Impression In the first appointment, two alginate impressions were taken (Normal Setting alginate Neocolloid Zhermack, Polesine Badia, Italy) using Schreinemakers trays. In order to stabilize and support the impression material, a molding wax was adapted on the surface. (Cera azzurrina morbidissima Zeta, Industria Zingardi, Novi Ligure, Italiy) The adhesive for alginate was then applied on the surface of the prepared trays (Fix Adhesive Dentsply, York, PA US) (Figure 3). The first impressions were taken through a two-phase technique. A high consistency alginate was used after removing the impression. It was prepared by removing the undercuts in order to support the relining low-viscosity alginate. The adhesion between alginates was promoted to dry the first material (Figure 4). Preliminary Models And Construction Of The Trays With Occlusal Wax Rims Preliminary models were poured using plaster class III (Elite Model Zhermack Badia Polesine, Italy) following manufacturerâ&#x20AC;&#x2122;s instructions (Figure 5). Once the models were squared and finished, the extension of the individual impression trays was drawn. Undercuts were eliminated with wax Tenasyle (Imadent, Turin, Italy) and models isolated using Separating Fluid (Ivoclar Vivadent, Shaan, Lichtestein) (Figure 6). The trays were prepared with selfcuring resin Ivolen (Ivoclar Vivadent, Schaan, Liechtenstein). The plates were

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Fig. 3 Shreinemakers trays prepared for the impressions

Fig. 4 Preliminary impressions

Fig. 5

Fig. 6 Preparation model for trays

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Fig. 7 Individual trays

Fig. 8 Checking length and thickness of the trays

Fig. 9 Checking the support of the lips and phonetic initial assessments, early RC evaluations, a black line was reported in order to highlight lip discosure and midline

finished giving a thickness of 2 mm, except for the border in the sublingual areas and the retrozigomatic areas where it was measured to 3-4 mm of thickness. The bases of the trays were melted and the wax rims simulated dental arches volume in order to facilitate the clinician to take a “closed mouth” impression. The waxes used were: lower base Tenasyle (Imadent, Turin, Italy) and for the upper, Moyco Beauty PinkX-Hard (Moyco Industries Inc., Philadelphia, US) (Figure 7). Wax Rims Preparation For the maxilla wax rim, the average distance between the vestibular sulcus and the incisal edge was set to 22 mm at the level of the central incisors, instead to 18 mm at the molar region. The incisal edge of the upper wax was positioned about 8-10 mm forward of the center of the incisive papilla, with an inclination of about 20° on the sagittal plane. Regarding the lower jaw, the rim was prepared maintaining a distance between the labial sulcus and the incisal edge of 18 mm in anterior and in the posterior region. It was positioned in correspondence of the lower alveolar ridge and tilted about 8-10° on the sagittal plane. The rims simulated an arch following the anatomic trend of the residual ridges. They were left to a thickness about

Fig. 10 Trimming phases in centric relation

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Fig. 11 Functional impressions and RC registration

Fig. 12 Models mounting in the articulator

2-4 mm in the region incisive and about of 8-10 mm in the molar region. Finally, the lower wax rim was extended posteriorly to the point where the ramus of the mandible began to come up and the upper wax rim posterior limit was set to the mesial limit of the maxillar tuberosity (Figure 7). Functional Impressions And Recording Centric Relation The stability and the adaptation of the impression trays were checked. After that, border length and thickness were verified using a silicone-based paste (FIT CHECKER II, GC, Tokyo, Japan). (Figure 8). The next phase, evaluating the support of the lips of the patient, rims were

Fig. 14 Evaluation of anterior setup

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adapted. The upper rim was orientated parallelly to the Camper’s plane and the mid line was reported on it. Thus, phonetic tests were performed (“F”,”V” and “S”) in order to establish the position of the anterior teeth and to allocate the space between the upper and lower planes and the vertical dimension of occlusion was determined (DVO). Finally, centric relation (RC) was recorded (Figure 9). At this point, the trays were trimmed with different thermoplastic sticks (ISO

Functional, GC, Corp, Tokyo, Japan and Isocompund Red, Kerr, Italy) in order to determine a selective pressure in the inner peripheral seal. The patient was also trained to activate muscle of lips, cheeks and tongue to define three-dimensionally the extension of the prosthesis margin. During the trimming phases, thanks to the possibility of bringing in contacts, the patient could complete swallowing movements. Furthermore, the repeatability of the centric position was verified several times using this approach (Figure 10). Before taking the impression, the external areas of the border were discharged to avoid hyperextension related to the overlap of the impression material. Certainly these operations did not affect the areas of inner seal. The upper tray had been drilled to facilitate the outflow of the impression material. The final impressions were recorded with polysulfide material (Permalastic Light and Regular Kerr Italia srl Italy) after applying the adhesive up on the trays surface (Permalastic Adhesive, Kerr Italia srl, Italy). Finally, the DVO and CR were confirmed, thus, a face-bow transfer was also

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Fig. 13 Anterior Setup

key. The models were then isolated using Separating Fluid (Ivoclar Vivadent, Schaan, Lichtenstein) and undercuts were rectified using a resilient resin FLEXACRYL Soft (Lang Dental Manufacturing Co., Inc.Wheeling, IL USA) while being careful to not flow to the fornix. Once the resin was polymerized, the base was prepared using Ivolen (Ivoclar Vivadent, Schaan, Lichtenstein). Setup Anterior Teeth The anterior teeth were set using the information recorded from the rims (Figure 13).

pointed out (Face-bow transfer UTS 3D Ivoclar Vivadent, Schaan, Liechtenstein) set according to the Camper’s Plane (CP). In order to complete information about the size and shape of the anterior teeth, the Form Selector was used (Ivoclar Vivadent, Schaan, Liechtenstein) Functional impressions were poured with plaster class IV (Vel Mix Classic Pink, Die Stone, Kerr Dental Laboratory Products CA, US), maintaining the perif-

erical border. The plaster was mixed under vacuum with distilled water and following manufacturer’s instructions. Before removing the impressions, models were mounted in the articulator (Stratos 300, Ivoclar Vivadent, Shaan Lichtenstein) using the face bow (Figure 12). Before removing the trays from master models, the length and position of the rims were recorded using a silicon

Evaluation Of The Anterior Setup This appointment was focused on the evaluation of aesthetic, phonetic, DVO and repeatability of CR. The patient observed and accepted the setup with a member of her family. It was decided to create two embrasures on the anterior teeth in order to reduce the length of the centrals and their dominance in aesthetics (Figure 14). Setup Of Posterior Teeth The posterior teeth were mounted using the static laser (Candulor AG, WangenBrüttisellen, Switzerland).

Fig. 15 Preparing for Flasking, and Prostheses before delivery

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Fig. 16 Checking bases during delivery

Curing And Finishing Complete Denture The posterior area seal was ditched on the model using the clinical information of the different levels of compression of the tissues. The prostheses were waxed for flasking. The polymerization was performed using IvoBase system (Ivoclar Vivadent, Schaan, Lichtenstein); a fully automatic injection system. The shrinkage of the specific PMMA resin was fully compensated during the polymerization, thus obtaining the most accurate denture base adaptation (Figure 15).

first days. Follow up visits were planned at 24 hours and at one and two weeks after delivery. Patient revealed a rapid adaptation to the new rehabilitations. Few points of pressure caused ulcerating lesions, mainly in the posterior undercut areas. Phonetic and stability were improved after treatment. Controls were repeated three, six and nine months after delivery, reporting excellent levels of adaptation and the patient revealed the need to use only small amounts of denture adhesives to improve the stability of the lower denture when she wanted to be more selfconfident during social activity (Figure 17). At the 12-month follow up visit, the patient confirmed and refused the placement of implant to stabilize the lower denture.

Complete Denture Delivery Upon delivery, the prostheses were placed in the oral cavity and were left adapting for 10-15 minutes, asking the patient to clench two cotton rolls placed bilaterally between the arches. After that, the adaptation of the bases were Discussion and Conclusions checked with a silicon based paste (FIT The protocol used in this clinical case alCHECKER II, GC, Tokyo, Japan). The pa- lowing us to achieve a high level of patient was instructed to perform func- tient satisfaction. As previously mentional movements and to speak. The tioned, the protocol based on functional length and thickness of the borders were impression and centric registration takverified with silicone based paste and corrected when it was required. (Figure 16). Finally, occlusion was checked revealing bilateral symmetrical contacts. The patient was instructed managing and cleaning the comFig. 17 Patientâ&#x20AC;&#x2122;s post-treatment frontal view plete dentures in the

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en in the same session has been reported several times in literature. The reduction of time comparing to a linear protocol of five to six sessions can be useful especially in the case of edentulous patients who have problems accessing a dental office. Another advantage of this approach is to perform swallowing during trimming and taking the impression. In addition, it is possible to avoid errors in centric recording by repeating it numerous times during the appointment. The technique obviously suffered some limitations. Firstly, it is necessary to complete the trimming in few steps in order to not expose the patient to a long and exhausting appointment. To overcome this problem, trimming could be performed with different materials (Polyvinil siloxane, Auto or Photo curing resins). However, the thermoplastic sticks permitted the shape to the border in adequate time. Lastly, it could be required to check the DVO and CR and after the detection of the impression, in order to avoid registration errors. Concluding, the prosthetic protocol rehabilitation presented ensured the functional and aesthetic expectations of the patient.

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With all practices, when doctors seek references for new CAD/CAM systems, labs can point doctors towards the technology that best fits their own workflow. Whether it is new software and equipment or items that a lab is able to resell, the opportunity is to educate practices and introduce them to a system that is accurate, easy to use and features an open architecture. For example, you could offer to loan your scanner for a day to a practitioner who is curious about this technology. In doing so, the practice will feel supported in its relationship with the lab, and the lab will thus ensure that business will continue with the practice. Though CAD/CAM has flourished and spread in the past few years, and both labs and practices are reaping the rewards, the systems in place that produce digital impression files must be chosen carefully. Closed systems create digital impression files in a proprietary format. Labs and practices that choose to work with closed systems are either restricted to working with scans from only that system or forced to invest in a process to convert each file into a stereolithography (STL) file, a universal file format that can be opened with any 3D-viewing application. As a result, closed or semi-closed systems make it difficult for both practices and labs to work with multiple clients and discourage users from adopting new technology. In addition, the conversion process takes time and can involve click-fees as well as yearly or monthly license fees. Open systems, on the other hand, produce files that are already in STL format, thus eliminating file conversion time and expense. Some open-system scanners do not require licensing fees, requiring only a one-time investment. The lab can import the files directly into design software, and several free 3Dviewing applications are already available. STLs are compatible with most design software or milling machines, allowing labs to provide support for different CAD/CAM systems. In the end, an open system increases the numbers of partners one can work with across the county for both practice and lab. The best way to support, cross-promote and implement open CAD/CAM systems is by developing a strong network of dental labs, milling centers and imaging centers. Partner with businesses that specialize in services complementary to your own and determine a strategy to make your services and area of proficiency essential to your partners. Another way to strengthen the network of CAD/ CAM partnerships across Canada is to partner with scanner manufacturers to offer systems integration. The recent partnership between exocad and Car-

Open Systems Open Doors

estream Dental’s CS 3500 intraoral scanner is a prime example of this. exocad’s dentalshare software integrates with multiple software providers, and STL files can be easily imported into exocad software without click-fees. This makes it possible for the lab to support doctors’ preferred workflow: doctor and lab can collaboratively design restorations, or the doctor designs the restoration and the lab mills it.

What’s Next for CAD/CAM?

Within the past few years, we have seen new specialty workflows being developed for CAD/CAM. Orthodontists are using scanners to create digital models—or scanning existing stone models with cone beam computed tomography (CBCT) units—that can be easily stored on the computer. This not only saves space but also makes for easier case presentation. Digital models can easily be sent to a lab for appliance fabrication. Once the model is on file with the lab, practices can quickly and easily have duplicate appliances created without having to ship a new stone model to the lab. In the field of oral surgery, digital scanners are used to create custom abutments via a scan body, and digital impressions eliminate the need to pour up models, which saves time. Scanners are also being used to fabricate highly accurate surgical guides. Even mouth guards can be made from a digital impression. Additionally, oral surgeons benefit from providing the digital impression to their referring doctors. These new workflows provide yet another opportunity for labs, milling centers, practices and manufacturers to partner on handling and storage of digital files, model printing services and creating restorations and appliances. Digital imaging centers also benefit in offering their CBCT services for implant and orthodontic treatment planning. Ensuring that various offerings, from labs to milling centers, are available to orthodontists and oral surgeons will encourage the continued growth of CAD/CAM in these fields. As we can see, CAD/CAM is spreading across the country and entering new practice specializations. With a long history as CAD/CAM specialists, labs will play a crucial and leading role in further promoting and supporting the technology and in advocating for more open systems. Progress will depend on the ability of labs and practices to partner in mutually promoting open systems and establishing a strong network. As labs work toward that community of practices, they will not only benefit themselves, practices and patients but remain relevant and profitable while leading the way to positive change and growth.

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Conta

Precise accuracy of fit on the model

Nesting using 3Shape CAMbridge software

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als – high-performance polymers – are matched to the indication in question. This provides the basis for high-quality results. Scientific research carried out by Prof. Dr. Constantin von See (Danube Private University Krems/Austria) took this aspect as its focus. Investigations into the materials confirmed, among other things, that moist environments do not trigger any dimensional change – a prerequisite for volume stability in both water and alcohol (disinfectant bath). Another result: barely detectable monomer residues on the surface. This means that no significant amount of monomer escapes from the interior of the component, thus effectively preventing for example mucosal irritation in the patient’s mouth. Finally, the high surface accuracy of the resins leads to tailor-made results. Among other things, all these key features facilitate diverse medical quality management advantages. What is needed to integrate 3D printing production into a laboratory? Space: every laboratory provides the perfect space for a Varseo. All that’s needed is a simple table and a wall socket. The table height depends on individual preference or the height of the user. As a rule, a height of 70 to 80 cm is recommended.

1 2

Software & scanner: in principle, the Varseo 3D printer is compatible with all software solutions on the market which are capable of generating an open STL data set or a BEGO DME data set. The 3Shape CAMbridge software for nesting data is included in delivery. In addition to the printer, various setting parameters relating to the modelling software play a role in ensuring that the restorations produced fit accurately. Setting parameters which have been tested by BEGO

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The unique cartridge system makes for ultra-fast material changeovers

3D printed object on a build platform

are currently available for 3Shape, exocad and dental wings coDiagnostiX. Other setting parameters for additional software solutions are currently in the process of validation.

Hardware: a conventional laboratory light curing device with a wavelength of 315 to 400 nm is required for the post-curing of printed objects.

Conclusion The advantages and added value of 3D printing technology have long been appreciated outside the realm of industrial production. It looks like this technology is set to conquer ever more fields of application at speed. 3D printing is no longer a vision of the future in dental technology. Printers, such as the Varseo, are suitable for any dental laboratory. The Varseo system, currently with four different high-performance resins, offers an excellent way to enter the world of 3D printing. Processes that are time- and material-consuming can be delegated to the laboratory’s own printer. In general, it can be concluded that 3D printing technology will continue consolidating its market position and gain successively more ground in dental laboratories. It is clear that the options have not yet been exhausted – and there is much scope. Although the dental industry is still at an early stage of 3D printing technology, dental laboratories can benefit today from the versatile advantages offered by the technology.

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Dental Marketplace

Contact: Karen Shaw • tel: 416-510-6770 • fax: 416-510-5140 • e-mail: kshaw@oralhealthgroup.com Toll free: CDA 1-800-268-7742 ext 6770 • Toll free: USA 1-800-387-0273 ext. 6770

Practices & Offices

SOUTHERN MANITOBA — ORTHODONTIC PRACTICE

Well established practice with solid referral base. Spacious, modern office in free-standing building. 6+2 ops. Newer leaseholds. Ample parking with easy access. For more information, please contact ruth@heapsanddoyle.com ph: 604-220-4830 www.HEAPSandDOYLE.com

OTTAWA, ON DENTAL CLINIC FOR SALE

Established dental clinic, 3000 sq ft with 7 equipped operatories, great location with free parking, high grossing with strong hygiene program and a loyal patient base is offered for sale. For more information please contact dentalofficeopportunities@yahoo.com

RICHMOND, BC

Well established office in city centre. Located in prominent medical/professional building. Beautiful, spacious office. Lots of natural light – beautiful views. 800 active patients. 3+1 ops. Strata unit available for purchase. Contact ruth@heapsanddoyle.com – 604-220-4830

YORKVILLE — TORONTO, ON COST SHARING OPPORTUNITY Bring your existing patient base to beautiful Yorkville. Modern operatories available Monday to Friday. Direct access to Bay/ Bloor subway. Email: info@yorkvilledental.net

BARRIE, ON

Available new retail space on busy Mapleview Dr. West. Ideal for Professional Dental Office. Attractive lease rates. Surrounded by residential. National brands in plaza. Contact Michael Pearlman at (416) 567-5101 or pearlmanmichael@gmail.com

VANCOUVER, BC

Successful Prosthodontic practice. Vendor willing to stay on for longer term transition. Beautiful office with great views. 2+1ops. Strata unit available for purchase. Contact Ruth at 604-220-4830 or ruth@heapsanddoyle.com www.HEAPSandDOYLE.com

NEAR WINNIPEG, MB

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EDMONTON, AB

General Dental Practice. Well established practice in attractive 1200 SF office with 4 ops. Gross $750,000+/ yr – 4 days per week. Excellent growth opportunity. For more information, please contact JeffGrandfield@TheLeaseCoach.com or 780-448-2645.

Net more than $455k just outside Winnipeg. Two rural practices producing well on 5.5 days will be available. Ideal for a solo dentist who is ready to hit the ground running, or two dentists to share as there is huge potential to expand. These practices are 30 minutes apart and offer an exclusive over an entire area where there are no other dentists. Live in Winnipeg and work in the country, one hour drive to the farthest one. Prompt action in response to serious inquiries. Email correspondence to DentalPracticeMB@gmail.com Associateships

ORILLIA, ON

ANCASTER, ON

Part time associate required 1-2 days per week for busy general family practice. Please forward resume to dental_2010@live.ca

Part-Time Position available in sophisticated office with excellent support staff and team environment. Must be highly ethical and dedicated to high quality comprehensive dentistry. Please respond with resume to ancdentresume@aol.com

CENTRAL MISSISSAUGA AND VAUGHAN, ON

GRANDE PRAIRIE, AB

Associate required for multidisciplinary Dental Offices located in Central Mississauga and Vaughan. Position will require some Saturdays. Please email resume to mississaugadentalarts@gmail.com

THOMPSON, MB

Westwood dental clinic in Thompson, MB team looking for experienced dentist full time or part time. Decent income plus accommodation . E-mail: westwooddental@hotmail.com

Full time associate dentist required for busy family practice. Looking for highly motivated associate. Our practice includes the latest in technology (IOC camera, digital x-rays, paperless etc.). Large existing patient base. Current associate moving, team in place to help. Please send resume to pmdcgp@telus.net 780-538-2992.

TORONTO DOWNTOWN Part time associate position available immediately at a modern dental practice in the financial district. Monday and Wednesday from 8am to 5pm to start in October. E-mail: torontodentistoffice@gmail.com

BARRIE, ON

Fast Growing Progressive Dental Practice seeking motivated and enthusiastic candidate to join us in one of our Barrie locations. This is an exceptional opportunity for growth for the dentist with an entrepreneurial mind and drive to succeed. We invite you to contact us for further information on this lucrative opportunity. Right handed dentists only, due to chair limitations. New Grads welcome! E-mail:kris@bigbaydental.ca

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Associateships MISSISSAUGA AREA, ON Full time associate dentists required for multiple practices from the Mississauga area to approximately 2 hour east of. All practices are well established with the latest in technology (IOC camera, digital x-rays, paperless etc.). One practice, French speaking would be an asset. Please send resumes to dentalresumes541@gmail.com

MISSISSAUGA, SCARBOROUGH, BARRIE, BRANTFORD, ORILLIA, ON ORTHODONTIST NEEDED Looking for an orthodontist to join our clinic. Must be available to travel between clinics as needed. E-mail: yourdentaldream@gmail.com

EDMONTON, AB Associate position available, 7 chair facility in a very busy established family practice with good new patient flow with a fantastic support team. This makes for a great place to enjoy dentistry. The office is equipped with the latest diagnostic and treatment technologies and has four RDA, 3 hygienists and three dentists. Seeking a motivated team-oriented dentist with great communication skills and commitment. Must be available to work some Saturdays and evenings. Send CV to: doctor.dentist.edmonton@gmail.com

VICTORIA, B.C.

WHITEHORSE, YK

Part-time associate required to join our dynamic team in one of the most beautiful areas of Victoria, and one of BC’s fastest growing communities. The position is for Saturdays and Mondays with the possibility of becoming full time. The position would be available immediately. Experience required and Cerec experience would be an asset. Must possess strong patient interaction and treatment presentation skills. Please email enquiries and CVs to: dawn@westshoredental.com

Locum/Full Time Dentist Required

Pine Dental is looking for a locum for the fall of 2015. This position has the potential to be full time. Pine Dental is located in the beautiful city of Whitehorse, Yukon. Come and enjoy the great outdoors and live the northern experience. Your adventure is waiting to happen. Don’t let this opportunity pass you by! Email: pinedental@northwestel.net or fax 867-668-5121.

KINGSTON, ON

Full time associate required for large group practice in a well established office in new building. Modern, digital, paperless office in a growing part of beautiful Kingston. Please contact: Suzanne@cataraquidental.com

DENTAL MARKETPLACE HELP

EDMONTON, AB Great opportunity for a motivated associate with some experience. $80,000-$100,000 per month, in a beautiful office with new equipment and a great team. Current associate is moving to another province. Potential of earning up to 45% and longterm buy-in for the right candidate. Experience is an asset but not required. Please email: EdmontonDentalCareer@gmail.com

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YOUR ADVISOR IS IN KAREN SHAW TEL: 416-510-6770 FAX: 416-510-5140 E-MAIL: kshaw@oralhealthgroup.com TOLL FREE CDN: 1-800-268-7742 ext 6770 TOLL FREE USA: 1-800-387-7742 ext 6770 WEBSITE: www.oralhealthgroup.com

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Associateships NORTHERN MANITOBA FULL TIME ASSOCIATE

EDMONTON, AB

Dentist needed for a busy general dental office in Flin Flon. Excellent net income. New grads welcome. Will help with residence and transportation. Please contact (204) 687-4214 or asfarashraf@gmail.com

MISSISSAUGA, SCARBOROUGH, BARRIE, BRANTFORD, ORILLIA, ON Exciting associate positions available for full and part time opportunities. E-mail: yourdentaldream@gmail.com

Periodontist Needed UNIQUE OPPORTUNITY. Busy, established, specialty implant surgery practice is in search of a periodontist associate who has a passion for surgical procedures. Flexible hours, prime location, great staff, modern facilities, and an existing solid referral base. This position may lead to ownership opportunities. Please email edmontonperiopractice@gmail.com

HAMILTON,ON Caring dental associate needed in Hamilton. 2 days/week, nice team to work with. If interested please send information to recruitdental@hotmail.com

MISSISSAUGA,ON ORTHODONTIC ASSOCIATE

An orthodontic associate position is available immediately for orthodontic office in Mississauga. Please call 416-999-5712 to arrange for a meeting.

KITCHENER-WATERLOO,ON We are looking for a dynamic and self motivated endodontist to join our four office practice located in Kitchener and Waterloo, Ontario. Please submit resume to: sib2@case.edu

TORONTO, ON

Full time dental associate needed immediately for busy group practice in downtown Toronto. Seeking dentist who is comfortable with a fast paced environment. Excellent earning potential. Please forward your resume to: dentistrywithcare15@gmail.com

Busy and expanding downtown family clinic is looking for a general dentist, periodontist and implant specialist. Please fax your resumes to 416-538-8422 or email to davidkourosh@hotmail.com

Careers

COME WORK AND PLAY ON THE JAMES BAY FRONTIER WEENEEBAYKO GENERAL AREA HEALTH AUTHORITY MOOSE FACTORY, ONTARIO DENTAL DEPARTMENT Phone: 705-658-4544 x 2207 Fax: 705-658-2366

Come experience northern island living and make a difference providing much needed dental services to Cree first nation’s communities. NIHB (non-insured health benefits) is a federally funded program that provides dental, pharmacological, orthopaedic and vision care to status patients. Full time, part time, locum and job share opportunities available for experienced dentists and new graduates. Competitive salary, free housing, paid travel and incentives provided to attract quality oriented, culturally sensitive, compassionate, ethical dentists to our communities. Ideal candidates must be self motivated, comfortable with surgical extractions, certified in nitrous oxide sedation and be willing to use amalgam. Nestled on an island in the Moose River, near the tip of James Bay, Moose Factory is home of the Weeneebayko General Hospital which serves the town of Moosonee, the James Bay communities of Attawapiskat, Kashechewan, Fort Albany and Peawanuck (on Hudson Bay). The James Bay Frontier is an outdoor enthusiast’s dream with kayaking, canoeing, boating, fishing, hiking, hunting, snowmobiling, and cross country skiing all at our doorstep. The community is very active offering basketball and volleyball leagues all year round and seasonal baseball and hockey. With no commuting to and from work there is plenty of time to enjoy the amenities that the area has to offer. The town of Moosonee is located on the mainland 5 km’s from the island and is accessible by boat taxi in the spring, summer, and fall. Helicopter transportation is used during freeze up and break up, and an ice road in the winter. Moosonee is the terminus of the Polar Bear Express train that runs 5-6 days a week from Cochrane depending on the season and also has an airport with connecting flights via Timmins to Toronto daily. Please visit our website for more information www.weeneebaykohealth.ca or call us directly or better yet come up for a no commitment 3 week locum and experience the beauty of the north for yourself. Janice Soltys Director of Non-insured Health Benefits, Dental Program & Chief Privacy Officer Janice.Soltys@waha.ca (705) 336-2947 x 233

Sheila Gagnon, RDH Dental Coordinator, WGH Sheila.Gagnon@waha.ca (705) 658-4544 x 2207

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