Cerec doctors magazine q2 2013 by GO TO TRAINING

INTRODUCING

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From Humble Beginnings ... In 2007, Dr. Sameer Puri came up with the idea of publishing a magazine that would be a quality resource to inspire and motivate the CEREC user. From the inaugural issue in July 2008 to this, our 20th issue, we hope we have accomplished our goal. These are exciting times in dentistry and we are honored to be a part of them with you. Thank you from the entire cerecdoctors.com team.

cerecdoctors . com

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CONTENTS Q2 | 2013

2 From The Editor

It Feels Like ... | By Mark Fleming, D.D.S.

Practice management

4 The Complete Dentist

Implementing Any New Idea | By Imtiaz Manji

10 Dr. Sandi Calleros

A Study in Implementation Success By Mark Fleming, D.D.S.

PM inNovation

8 Ivoclar Vivadent: Leading Innovations in Digital Dentistry

By Donald Bell

12 CAD/CAM Materials in Dentistry

By J. Robert Kelly, D.D.S., M.S., DMedSc

20 New Materials for CEREC SW 4.2 By Mike Skramstad, D.D.S.

24 Cover Story: Introducing

CEREC SW 4.2

The Latest From Sirona for the CEREC System By Sameer Puri, D.D.S.

66 The Doctors Abroad

cerecdoctors.com Mentor Group in Germany By Sameer Puri, D.D.S.; photos by Dr. Yao-Lin Tang

Inside Back Cover: From Humble Beginnings

case DFstudies

32 Saving Time With the P Crystallization CH Speed Technique By Rich Roseblatt, D.M.D.

PM 38 Life-changing I

By Darin O'Bryan, D.D.S.

42 "We've Got You Covered!" By Bradley Sutton, D.D.S.

46 Setting the Standard at cerecdoctors.com

profile CH

By Neal Patel, D.D.S.

52 Dr. Werner Mörmann

What is the Future of Dental Ceramics? By Sameer Puri, D.D.S.

56 Dr. Gregory Mark

Why CEREC Is ‘Superior to All the Rest’ By Mark Fleming, D.D.S.

58 Dr. Arun Garg

Training Thousands in Implantology By Franklin Maximo, D.D.S.

CS DF discussion forum CS62 Open DF Margin a Product of Prep Flaws? P CH P CH happenings in Cad/CAM PM e.max Abutment Block I68 The PMSameer Puri, D.D.S. I By

A Celebration of 20 Issues of cerecdoctors.com Magazine

BONUS DIGITAL CONTENT: Visit www.cerecdoctors.com/magazine/issues for a digital version of this issue; throughout the magazine, click the icon for a bonus video, discussion thread and/or RST file.

f r o m t h e e d i to r

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by mark fleming, d.d.s.

It feels like ... Twenty Issues in, cerecdoctors.com Magazine Is Going Strong • you know how when you are sitting around The new Move In this issue, there is talking with people and you think, “It feels like and Rotate a preview of the new it was just the other day that ...” Well, when tool are chairside software for putting this issue — our 20th — together, I had combined CEREC. I believe the that feeling. It feels like just the other day that users of this technology Dr. Sameer Puri said that cerecdoctors.com will be pleased with was going to do a magazine and how would what they see. It is I like to be editor? I said sure, even though I amazing the amount of knew nothing about being an editor. However, change that can happen it sounded exciting and challenging to be so quickly now with the involved. And here we are today. 4.x platform. And you It takes a lot of time and help to produce the can bet the improvemagazine. I would like to personally take this ments will continue. time to thank them. First is cerecdoctors.com Several years ago I founder Sameer Puri, D.D.S., whose vision not remember reading a CEREC user lamenting the lack of develonly drives this magazine but also everything that is cerecdocopment of new materials to keep up with the progress of the tors.com. Product Manager Liz Davison is a great help to me in CEREC software. I’m sure you would agree that recently that “herding cats,” keeping us on schedule and much more. Lauren is certainly not the case. And with the release of 4.2, there are more material choices. Be sure to check out the articles that “We assure you we will put forth detail these improved materials. our best efforts to provide you with a • quality resource in dentistry that is In the first issue of the magazine we said to you our readers, “We assure you we will put forth our best efforts to provide you with sure to inspire and motivate you.” a quality resource in dentistry that is sure to inspire and motivate you. We look forward to helping you achieve great success in your practice and we thank you for your support.” Once again, thank Vasquez gets the opportunity to use her skills (all the way from you! And know, while we are pleased with what we have accomLondon) with first edits from our contributors. Craig Kurtz plished, we are even more driven to provide you with information designs what you see and read. A special thanks to my partner in to take you and your practice to the next level. Enjoy! crime, John Roark, without whose help I would be totally lost. His help on editing has been invaluable and definitely helps me look good. And finally, to all of you who have contributed artiFor questions and additional information, Dr. Fleming can be cles and you who read the magazine. reached at mark@cerecdoctors.com.

» contributors | Donald Bell; Mark Fleming, D.D.S.; J. Robert Kelly, D.D.S., M.S., DMedSc; Imtiaz Manji; Franklin Maximo, D.D.S.; Darin O'Brien, D.D.S.; Neal Patel, D.D.S.; Sameer Puri, D.D.S.; Rich Roseblatt, D.M.D.; Mike Skramstad, D.D.S.; Bradley Sutton, D.D.S.; Yao-Lin Tang, D.D.S.

For sales and membership information, please contact:

» product manager | Elizabeth Davison; liz@cerecdoctors.com; 877-295-4276; cerecdoctors.com 2

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Putting It Into Practice The Three Steps to Implementing Any New Idea does the following scenario sound familiar? You spend a weekend at a continuing-education workshop that really sparks something within you. You understand that what you’re learning could make a big difference in your practice. You get excited and you can hardly wait to get back to the office and start implementing these new ideas. So, you come back and assemble the team and give them a “this is the way it’s going to be from now on” pep talk. Then reality bites back. Before long, you start coming up against obstacles. Where do we find the time? How can we change old habits to new in a sustainable way? The team, which never had the chance to get as excited as you were to begin with, begins

disturbance — and, not surprisingly, they don’t bring the hoped-for results. That’s because (as we all know in our hearts) it’s the parts of the strategy that you are most tempted to skip that are probably the most important. 3 Steps to Getting Implementation to Stick A lot of things in life — in fact, most things worth doing — are like this. Whether it’s schooling, or athletic excellence or making a marriage work, a cherry-picking approach seldom works. You have to commit fully. There are many great things that are possible in a dental practice — any dental practice — but they all require impassioned effort. They require what I

Excitement is not enough — you also have to give people a reasonable path to success. to lose its enthusiasm and starts coming up with objections. “This isn’t working,” they say, and, before you know it, you’re being held back by the anchor of the old ways. A lot of dentists have experienced this many times, to the point where they eventually anticipate the difficulties of introducing transformative changes in the practice, and so start to hedge their bets. They still get excited by new ideas, but when it comes to implementation, they try to cherry-pick. “Maybe if I just do this part and this part ...” But, of course, the parts they choose to implement are usually the easiest — the ones that offer the least resistance and are likely to cause the least

call “end-to-end implementation.” That means no shortcuts, no half-measures. They also require an engaged and committed team. There are a lot of great clinicians who haven’t made the leap to being great dentists running great practices because they haven’t mastered this part of the equation. They can’t deliver great care because very few people know what they’re truly capable of, including the people around them. Having an enthusiastic team aligned with you on what you’re trying to achieve is the secret to unlocking success in just about everything in the practice. That’s why every successful implementation strategy is ultimately about achieving total team buy-in, and that usually comes

down to three key steps: step 1: Get them excited. They must be excited about the result you’re aiming for, excited about the possibilities for the patients and the practice. And, most importantly, they must be excited about their role in making it happen. Remember, it can take an entire weekend of sustained, off-site instruction at a workshop to really get you committed and energized about something new. It’s not fair for you or the team to expect them to get that same feeling from a 30-minute debrief when you get back. You need to take the time to get them to understand the “why” before they can fully commit to the “what” and the “how.” (There is a great TED talk on this subject by Simon Sinek — it’s worth Googling.) What it takes to get them to this point depends on what it is you’re trying to implement. Simple measures can be addressed in a well-thought-out staff meeting. For more complex matters, you may need to spend a day with the doors closed and devote focused time to your plan. For anything really significant, you need to get away. A major change in thinking requires a change in environment, whether that means taking the team with you to a workshop or away to an off-site “team retreat” when you get back. I know I do my best creative, long-term thinking when I am on vacation. Just getting away from the office environment — an environment where I am used to solving today’s problems — seems to open my mind to bigger possibilities. I’m sure you have felt that too, and so have the people on your team. Keep in mind that these are the people you are counting on to carry out your mission. It pays to take the time at the

4 | BONUS DIGITAL CONTENT: Visit www.cerecdoctors.com/magazine/issues for a digital version of this issue; click the icon for a bonus video, discussion thread and/or RST file.

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outset to make sure they want it as much as you do. It pays to get them excited. step 2: Break it down to get started. Excitement is not enough—you also have to give people a reasonable path to success. It’s human nature to want to do new and exciting things. But it’s also human nature to want to be good at your job and to want a life that is as free as possible from disturbances. Introducing change can be upsetting to those desires. That is the fundamental conflict people feel when faced with something new. They may be excited at first, but if changes are implemented too quickly or too broadly, or without the right understanding for the ultimate goal or their role in the process, they’ll start to put the brakes on — because it’s “too hard,” or because they are afraid to fail or look foolish, or because they simply don’t know where to begin with a big task. This is where you have to make change

around those steps to ensure that the pull of the “old way” doesn’t defeat your progress. Often, that means weekly or even daily monitoring and evaluating until a new idea takes hold and becomes automatic. To take a simple example: Say you intend to make it part of your morning meeting to identify any hygiene patients in the schedule with incomplete treatment that could be treated by CEREC that day. That’s a concept that can be introduced in a simple team meeting, but it can’t just be a matter of having everyone agree that it would be a good idea and expecting it to occur. You have to assign responsibility and create a structure for follow-up. Who is going to look through the hygiene charts in advance? The frontdesk admin person? Each hygienist? The treatment coordinator? Who will talk with the patient? Who decides? What will be the protocol for reporting back to the team on the results of that discus-

Seek out the resources that support your style of leadership. And you don’t have to look very far. manageable. You have to break it down into distinct steps and you have to give everyone clarity for exactly what they need to do. They have to be energized by the ultimate goal but, just as importantly, they have to see how what they are doing right now fits into the plan. It’s about putting their actions in context so they can see the purpose behind each task. And it’s about giving them the freedom to explore and make mistakes as they figure things out. Most of all, it’s about getting them started, which is the biggest step of all. step 3: Provide structure for accountability and momentum. Once you have worked out the steps that need to be taken, you need to introduce accountability 6

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sion? These are all things that needed to be decided and understood. And, for the first several weeks, you should be following up to ensure that the plan is being implemented as discussed and addressing any speed bumps before they become roadblocks. Before long, it will be a fully integrated part of the morning agenda, and you can turn your attention to introducing the next new thing. • This method of implementation is really a summary of what being a leader is all about: creating an inspiring vision, showing each team member how they fit within that vision, and giving the clarity for what they need to do now and what they need to do next.

Help is Out There There are some dentists who are natural leaders for whom this all comes easily. They just seem to know how to inspire their team, how to communicate exactly what they want to accomplish, and how to engage everyone so that they execute fully at every level. For most, however, the process is a little harder. Maybe you have no trouble getting everyone excited at the beginning, but you find it difficult to sustain that initial enthusiasm. Or maybe you are great at working out the details and systematizing the process, but you can’t seem to motivate the team to get as excited as you are, and you want to get them in front of someone who will light a fire under them. This is why I suggest you seek out the resources that support your style of leadership. And you don’t have to look very far. For instance, at Spear we offer Creating The Yes Practice, an annual workshop for CEREC dentists that is all about making the most of the possibilities in digital dentistry today. Many dentists bring their teams to this event. Those who don’t often wish they did because they want their teams to feel the excitement they feel when they walk out into the warm Scottsdale night with a head full of ideas and a weekend full of memories. We also have many dentists who use our Digital Campus courses as the centerpiece of regular team meetings. It’s a way of keeping the team engaged and growing on a week-to-week, month-to-month basis. By having a series of graduated lessons to follow together, to discuss and to implement as a team, you build a way of creating that special philosophical alignment. Finally, here is the biggest secret about what it takes to get to the next levels of success: the ideas and strategies themselves are not that difficult to learn. The hard part is always putting them into practice. Solve the riddle of execution and you are well on your way.

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i nno v a t i on

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by d on a l d b e ll

Ivoclar Vivadent: Leading Innovations in Digital Dentistry ivoclar vivadent strives to be the leader in digital dentistry. The company continually updates and refines existing products, and develops new products to expand indications and the use of CAD/ CAM technology to meet clinician and

IPS e.max CAD Bridge Solutions Multiple size blocks, shades and translucencies allow clinicians to design, mill and finish multi-unit bridges. IPS e.max CAD B32 size block is available in a variety of low translucency shades, and is obtainable for up to threeunit anterior bridges â&#x20AC;&#x201C; premolar forward â&#x20AC;&#x201C; offering high durability and esthetics. IPS e.max CAD B40 size block used in conjunction with IPS ZirCAD in the CAD On zirconia process offers three- to four-unit bridges designed with optimal strength and uses high-translucency shades for excellent esthetics to create bridges ideal for posterior indications.

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patient needs. From the CEREC 27 and a Half event last August and continuing to The International Dental Society (IDS) Meeting in Cologne this past March, we saw the launch of several new products from

Ivoclar Vivadent to streamline and expand digital dentistry. For questions and additional information, Mr. Bell can be reached at Donald.Bell@IvoclarVivadent.us.

IPS e.max CAD Fast Crystallization Upgrade Redesigned with the release of new firing parameters, the streamlined firing tray continues to optimize and reduce complete crystallization firing times: now to less than 15 minutes. Going faster and achieving complete crystallization ensures optimal strength, durability and esthetics for clinical success.

Telio CAD Telio CAD is available in B40 and B55 size blocks as well as a variety of shades, and allows a clinician to place highly durable and esthetic temporary bridges.

IPS e.max CAD Abutment Solutions The dynamic application of IPS e.max CAD is the chairside abutment solution â&#x20AC;&#x201C; the centerpiece of the solution being the â&#x20AC;&#x153;block with a hole in itâ&#x20AC;? that allows the clinician to design, mill and place customized implant abutments or screwretained abutment crowns in one visit. The shade offering allows for supragingival margins, unmatched esthetics and predictable clinical success.

Multilink Automix Next Generation Ivoclar Vivadent introduced the next generation of the Multilink Automix System for the adhesive cementation technique. The range has been broadened to include a new white (B1 range) shade (in addition to the transparent, opaque and yellow), matching try-in pastes and the product Air Block Liquid Strip. The formula of the luting

composite has been further enhanced to allow excess material to be even more easily removed and features temperature stability, eliminating the need for refrigeration. The strength of this clinically proven universal cementation system lies in its ability to generate high bonding values that ensure the long-lasting adhesion of the restoration to the tooth structure. quarter 2

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pr a c t i c e m a n a g e m e n t

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by m a rk f l e m i ng , d . d . s .

Dr. Sandi Calleros A Study in Implementation Success dr. sandi calleros of el segundo, Calif., has been practicing dentistry for 26 years. During that time, she, her team, and her practice have gone through a lot of changes. She is always focused on growth and taking the next big step, and she has learned the power of proper execution strategies. Last year, she took her whole team to Creating The Yes Practice program in Scottsdale. We talked to her about that experience, and about her thoughts on making change happen within the practice. what was it like for you and your team to experience an event like creating the yes practice? My team has been hearing me talk about the courses I’ve been taking at Scottsdale Center for years, so I thought, “This would be perfect. Finally, they can see for themselves.” Imtiaz (Manji) is very dynamic and motivating, and I can’t get these ideas across in the same way he can. And just being there — immersed as a team for two days, with no distractions — it makes a huge difference. what was the first thing you did when you got back? I knew that as excited as they were, that would wear off if we didn’t get right into doing something fun that involved everyone. A lot of Creating The Yes Practice centers around the new patient experience, and a big part of that is building the Walls of Fame. So we got into that right away. Everyone gathered pictures of themselves with family and with pets, and they each wrote a paragraph on why they love being a part of our practice. It was a great way to get started and get everyone on board with the process. how do you maintain that level of interest and keep them engaged? The way I see it, you just have to be prepared to put in the time to keep that 10

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momentum going. If you’re going to spend 30-something hours a week on clinical care, why wouldn’t you spend at least one or two or three hours a week just focused on how to improve as a practice? It can’t happen by itself. and what do you spend that time on? We really enjoy going through the lessons on Spear Digital Campus. We started watching some of them right away, and I had the team watch some on days when I was away at a course. Now we’re going through them as a team and using the discussion resources that come with them. It’s great because it’s not just going through material in a book. They get to see and hear Imtiaz and the other instructors again and that kind of gets them re-charged. have you seen measurable changes in the practice as a result? Absolutely. The results came very quickly. The problem now is keeping up with demand. We are getting more new patients than ever before through invitations, and case acceptance has gone up significantly. We’ve had some of our best months ever recently. what is next for you and the team? Well, for one thing, we’re going to Creating The Yes Practice again this year. I had one dentist ask me, “Why would you go back?” and I said because last time we learned it, and now we’re going to master it. And I want to give the team that experience to look forward to again. I just know that Imtiaz is going to acknowledge us for how far we have come since last time and I want them to experience that. It gives them further motivation, and it’s going to make them feel great to go back as a team that made it happen.

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by J . R ob e r t K e lly, D . D . S . , M . S . , D M e d S c

CAD/CAM Materials in Dentistry

An In-depth Look at the Make-up of Chairside Restorations dental ceramics and resin-based composites are presented within a simplifying framework, allowing for facile understanding of their development, composition and indications. This simplifying framework is then used to explore what is known about the clinical performance of both materials. In the case of CAD/CAM ceramics, we have the best and longest clinically studied materials in the history of dentistry. From this rich clinical evidence come well-based indications for specific commercial systems. Resin-based materials perform clinically no better whether fabricated in a laboratory, by the manufacturer or directly intraorally, and are inferior to ceramics with respect to wear, fracture and loss of restorations. There is no new class of material termed a “resin nano ceramic,” as just a few years back there was no new class of material termed a “polyglass” – both derive from marketing minds, not materials science. Confused about CAD/CAM materials? Essentially, CAD/CAM ceramics can be predominantly glassy, particle-filled glasses or polycrystalline with no glass content. Polycrystalline ceramics can be of alumina, zirconia or even combinations of the two. Ceramic parts can be machined fully sintered or partially sintered from data sets derived from scans of patients, impressions or patterns that are either net-shaped or over-sized. Ceramic parts can be mono-layer or bi-layer, and either can be 12

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made using automated systems. Ceramics can be further characterized by translucency, grain-size, wear-kindness, shade, polish-ability and sensitivity to moisture. Along with resin-based composites, ceramics are correctly thought of as being composites, but resin-based composites (even highly filled nano-particle ones) are not correctly characterized as being ceramics. Now, if this clears things up for you, then read no further – if not, then welcome aboard!

Background Concepts in Materials Science There are two quite useful concepts that help demystify dental materials by providing a structure within which to organize thinking. First, there are only three main classes of dental ceramics: 1) predominantly glassy materials; 2) particle-filled glasses, and; 3) polycrystalline ceramics.1-3 Defining characteristics will be provided for each of these ceramic types, as they are represented in

Fig. 1: Ceramic classifications Fig. 2: Ceramic composition

3 Fig. 3: Feldspathic glasses 3-D network Figure 1. Second, virtually any ceramic within this spectrum can be considered as being a “composite,” meaning a composition of two or more distinct entities (to be explained below). This concept is then helpful in comparing and contrasting resin-based composite CAD/ CAM block materials – essentially one having a resin matrix filled with particles, and the other a glass matrix filled with particles. Quite a number of seemingly different dental ceramics can be shown to be very similar or closely related to each other when reviewed within the framework these two simplifying concepts provide. Two examples of the utility of these concepts include these basic truths: 1) highly esthetic dental ceramics are predominantly glassy, and higherstrength substructure ceramics are generally crystalline, and; 2) the history of development of substructure ceramics simply involves an increase in crystalline content to fully polycrystalline. Figure 2 provides basic composition details and commercial examples of many esthetic and substructure dental ceramics organized based on their matrix and filler. Predominantly Glassy Ceramics Dental ceramics that best mimic the optical properties of enamel and dentin are predominantly glassy materials. Glasses are 3-D networks of atoms having no regular pattern to the spacing (distance and angle) between nearest or next-nearest neighbors; thus, their structure is “amorphous,” or without form. Glasses in dental ceramics derive principally from a group of mined minerals called feldspar, and are based on silica

(silicon oxide) and alumina (aluminum oxide), hence feldspathic porcelains belong to a family called aluminosilicate glasses.2 Glasses based on feldspar are resistant to crystallization (devitrification) during firing, have long firing ranges (resist slumping if temperatures rise above optimal) and are extremely biocompatible. In feldspathic glasses, the 3-D network of bridges formed by silicon-oxygen-silicon bonds is broken up occasionally by modifying cations such as sodium and potassium (and yes, even a smidgen of lead) that provide charge balance to non-bridging oxygen atoms (Fig. 3). Modifying cations alter important properties of the glass; for example, by lowering firing temperatures or increasing thermal expansion/ contraction behavior. Lead in Dental Ceramics? During the summer of 2009, the media was full of alarming news about an FDP (fixed denture prosthesis) in Columbus, Ohio, outsourced from a lab in China that contained lead and was alleged to have damaged the woman’s mouth in which it was inserted. As the dust settled, it became obvious that dental porcelains are a really lousy source of dietary lead. Far better to get your lead by drinking water or eating bread, fruits and soups. On a daily basis, these foods will provide you with thousands of times more lead.4 Further, lead from these natural sources is more easily digested than that from dental porcelain. So, hands down, if you want to maintain blood lead levels, stick with the health food supermarket, where lead is available at far higher levels, is more easily

absorbed and is far more economical than it is from the dental office. All tongue-in-cheek aside, the above is spot-on accurate. Bottom line is that lead is found as a trace element in virtually everything that comes into contact with earth. Plants grown in soils along with surface water and ground water all extract tiny amounts of lead. In 2005, a comprehensive study was published analyzing the French diet. Forty-one different categories of food including regional, seasonal and national sources were analyzed.4 Turns out, the average French person eats 18.4 micrograms of lead each day. “Ah, maybe this explains the French!” you say. (And they would respond, “But who in France is average?) Some perspective for those finding this information challenging: one microgram is one millionth of a gram. With gold at $960 an ounce, 18.4 micrograms of gold would fetch 6.25 one-hundredths of a penny (0.0625¢). Back to dental restorations. The Ohiovia-China prosthesis of ill repute referred to was found to contain about 300 partsper-million of lead, actually a bit less, but let’s stay with 300 parts-per-million to be conservative. Assuming all the porcelain from this crown is eaten in 10 years (which we know is absurd), the daily plus-up in lead would be .078 micrograms. That’s a whopping increase of .000004 percent. If this crown were eaten over one year, .00004 percent. Particle-Filled Materials Filler particles are added to the glass or resin matrix composition in order to improve mechanical properties and to quarter 2

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control optical effects such as opalescence, color and opacity. These fillers are usually crystalline, but can also be particles of a higher-melting glass. Such compositions based on two or more distinct entities (phases) are formally known as “composites,” a term often reserved in dentistry to mean resinbased composites. Thinking about dental ceramics as being composites is a helpful and valid simplifying concept. Much confusion is cleared up in organizing ceramics by 1) what the matrix is, 2) what filler particles they contain (and how much), and 3) in the case of ceramics how they got into the glass. Moderate-strength increases can also be achieved with appropriate fillers added and uniformly dispersed throughout the matrix, a phenomenon termed “dispersion strengthening.” The first successful strengthened substructure ceramic was made of feldspathic glass filled with particles of aluminum oxide (app. 55 mass%).5 Leucite is also used for dispersion strengthening, at concentrations of around 40 to 55 mass%, in products such as Empress CAD for CEREC (Ivoclar). Commercial ceramics incorporating leucite fillers for strengthening also include a group that are pressed into molds at high temperature (OPC, Pentron; Empress Esthetic, Ivoclar Vivadent; Finesse All-Ceramic, Dentsply Prosthetics), and a group provided as a powder for traditional porcelain buildup (OPC Plus, Pentron; Fortress, Mirage Dental Systems). Volume%, instead of mass% (or weight%) is a more useful measure for comparisons among resinbased composites, since the density of the fillers is much higher than the matrix. Filler loading is generally no higher than 60 volume% to 65 volume%, even for composites claiming 80 mass% to 90 mass% filler content. Beyond thermal expansion/contraction behavior, there are two major benefits to leucite as a filler choice for dental 14

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4 acid etch and rinse ceramics

Glass-matrix ceramic

acid etch and rinse

Fig. 4: Removal of glass or filler phase for bonding Fig. 5: Simple cubic crystalline lattice

5 ceramics; the first intended, and the second probably serendipitous. First, leucite was chosen because its index of refraction is very close to that of feldspathic glasses — an important match for maintaining some translucency. Second, leucite etches at a much slower rate than the base glass, and it is this “selective etching” that creates a myriad of tiny features for resin cements to enter, creating a good micromechanical bond. Etching of resin-based composites can theoretically involve the selective removal of the surface filler phase, but etch depth and microporosities are limited to the size of the filler particles (e.g. nanometers). This difference is illustrated in Figure 4. Silane treatment of the etched ceramic provides further chemical bonding not available with resin-based composites. Glass-Ceramics (special sub-set of particle-filled glasses) Crystalline filler particles can be added mechanically to the glass; for example, by simply mixing together crystalline and glass powders prior to firing. In a more recent approach, the filler particles are grown inside the glass object (prosthesis or pellet for pressing into a mold) after the object has been formed. After forming, the glass object is given

resin-matrix composite

a special heat treatment, causing the precipitation and growth of crystallites within the glass. Since these fillers are derived chemically from atoms of the glass itself, it stands to reason that the composition of the remaining glass is altered as well during this process, termed “ceraming.” Such particle-filled composites are called glass-ceramics. The main commercial example today is the glassceramic containing 70 vol% crystalline lithium disilicate filler (Empress 2, now e.maxPress and e.maxCAD, IvoclarVivadent). Visiting the factory in Schaan, Liechtenstein, you will see CAD/CAM blocks of a nearly clear (slightly amber) glass – following an additional heat treatment crystallizing the lithium silicate these blocks turn blue. Polycrystalline Ceramics Polycrystalline ceramics have no glassy components; all of the atoms are densely packed into regular arrays that are much more difficult to drive a crack through than atoms in the less dense and irregular network found in glasses (Fig. 5). Hence, polycrystalline ceramics are generally much tougher and stronger than glassy ceramics. Polycrystalline ceramics are more difficult to process into complex shapes (e.g., a prosthesis) than are glassy ceramics. Well-fitting prostheses made from polycrystalline ceramics were not practical prior to the availability of computer-aided manufacturing. In general, these computer-aided systems use a 3-D data set representing either the prepared tooth or a wax model of the

desired substructure. This 3-D data set is used to create either an enlarged die upon which ceramic powder is packed (Procera, NobelBiocare, Zurich, Switzerland) or to machine an oversized part for firing by machining blocks of partially fired ceramic powder (Cercon, Dentsply Prosthetics.; Lava, 3M-ESPE; Y-Z, Vita Zahnfabrik). Both of these approaches rely upon well-characterized ceramic powders for which firing shrinkages can be predicted accurately.6,7 Polycrystalline ceramics tend to be relatively opaque compared to glassy ceramics; thus, these stronger materials cannot be used for the whole-wall thickness in esthetic areas of prostheses. These higher-strength ceramics serve as substructure materials upon which glassy ceramics are veneered to achieve pleasing esthetics. Laboratory measures of the relative translucency of commercial substructure ceramics are available, both for a single-layer of materials and for those that are veneered.8,9 Green Machining of Oversized Parts Machining of tougher structural ceramics such as alumina and especially transformation-toughened zirconia (see following section) was much more difficult, requiring heavier machinery and longer milling times, and quite often involved limited tool life. Further advances in the manipulation of 3-D data sets, along with the fruits of a decade of research into ceramics processing, provided the underpinning for an innovative solution proposed by Filser and Gauckler at the University of Zürich involving machining of an oversized part from a ceramic block only lightly sintered to what is termed the “initial sintering” stage.10-12 With very careful control over both the ceramic powder particle size distribution and particle packing density, it become possible to predict the oversized shape needed that would then

shrink to the desired “net shape.” This technique has been variously termed “green machining” or “soft machining” in dental literature. This technique allowed the individually customized and high-tolerance-parts dentistry required to be manufactured from polycrystalline ceramics such as alumina and zirconia. As of today, the last major advance in dental ceramics comes with the introduction of transformation-toughened zirconia.12-14 This ceramic is arguably the most complex material ever introduced for dental use and, as will be discussed later, its introduction has not been without a “learning curve” that we are still going up. Two other major changes currently underway involve: 1) the establishment of dedicated industrial-quality manufacturing centers for fabrication of prostheses; and 2) the application of engineering design research into clinical and laboratory practices to optimize durability and esthetics. Transformation-Toughened zirconium Oxide Potentially the most interesting polycrystalline ceramic now available for dentistry, transformation toughened zirconia, needs further explanation since its fracture toughness (and hence strength) involves an additional mechanism not found in other polycrystalline ceramics. While fracture toughness and strength are outside the scope of this paper, it is sufficient here to understand toughness simply as meaning the difficulty in driving a crack through a material. Unlike alumina, zirconium oxide is transformed from one crystalline state to another during firing. At firing temperature, zirconia is tetragonal and at room temperature monoclinic, with a unit cell of monoclinic occupying about 4.4 percent more volume than when tetragonal. Unchecked, this transformation was a bit unfortunate since it would lead to crumbling of the material on cooling.

In the late 1980s, ceramic engineers learned to stabilize the tetragonal form at room temperature by adding small amounts (approximately 3 – 8 mass%) of calcium and later yttrium or cerium.13 Although stabilized at room temperature, the tetragonal form is really only “metastable,” meaning that trapped energy still exists within the material to drive it back to the monoclinic state. It turned out that the highly localized stress ahead of a propagating crack is sufficient to trigger grains of ceramic to transform in the vicinity of that crack tip. In this case, the 4.4 percent volume increase becomes beneficial, essentially altering material conditions around the crack tip and shielding it from the outside world (more formally stated, transformation decreases the local stress intensity). Although most dental zirconia is a bit opaque and coping need to be veneered for high esthetics, these prostheses can be quite life-like. Zirconia is not as opaque as In-Ceram alumina, and can be internally colored as can lithium disilicate. With fracture toughness twice or more than that of alumina ceramics, transformation-toughened zirconia represents an exciting potential substructure material. Possible problems with these zirconia ceramics may involve long-term instability in the presence of water, porcelain compatibility issues, and some limitations in case selection due to their opacity. However, as of this writing, three-year clinical data involving many posterior single-unit and threeunit prostheses (plus one five-unit) have revealed no major problems (discussed more fully below). Zirconia Porcelain/ Substructures Issues Two issues are of concern with zirconia; one quite real and one potential. Of real concern are reports of significant percentages of single-unit and multi-unit quarter 2

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prostheses having porcelain chipping and cracking (e.g., 25 percent to 50 percent).12 Of potential concern is the propensity for partially stabilized zirconia to auto-catalytically transform at surface grain boundaries due to an interaction with water (discussed momentarily) that may create major structural issues in the future. Many “authorities” have offered numerous explanations for porcelain chipping that simply do not withstand critical thinking or analysis, including: 1) non-anatomic substructure design; 2) unsupported porcelain; 3) weaker porcelain; 4) thermal expansion/contraction mismatches, and; 5) poor porcelainzirconia bonding. More well-considered hypotheses have included; 1) residual stresses arising from thermo-mechanical parameters;15 2) auto-catalytic transformation during porcelain firing;16 and; 3) enhanced auto-catalytic transformation of green-machined structures at mouth temperature.17 As yet-unpublished

S. Chu, H. Yamamoto and C. Stappert). These clinicians reported that their laboratories were aware of the need to cool slowly. Numerous dental materials companies now include a caution to slow cool in written and web-based informational materials. This continues to be an active area of research. All ceramics are susceptible to subcritical crack growth and corrosion effect cause by water, which breaks the bond between atoms at the crack tip. This leads to slow growth of cracks and resuls in a decrease of materials’ strength. Partially stabilized zirconiabased materials are uniquely susceptible to auto-catalytic transformation of the crystals, from tetragonal to monoclinic, at relatively low temperatures, called low-temperature degradation (LTD).18 While generally studied at autoclave temperatures of a few hundred degrees centigrade, significant percentages of transformation can be extrapolated

Many clinical authorities report that they stopped having porcelain problems when they enforced a slow-cooling protocol. research from our laboratory strongly supports, transient stresses within the porcelain developing as a result of toorapid cooling acting on flaws present from too rapid heating. In addition, many clinical authorities report that they stopped having porcelain problems when they enforced a slow-cooling protocol (including Drs. Avi Sadan and Ed McLaren – personal communications). One paper given at the 2010 meeting of the International Association for Dental Research (IADR) on clinical data from four private practices reported only 2 percent porcelain chipping in two years to three years for 702 prostheses (authors; D. Nathanson, 16

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as being possible at oral temperatures using activation energy data from ceramics literature (Chevalier). Another striking clinical study presented at the 2010 IADR examined partially stabilized zirconia discs embedded in the flanges of mandibular partial dentures, demonstrating a much higher rate of transformation for a dental zirconia in two years to three years than predicted for an engineering zirconia by Chevalier (author; Tomaž Kosmac, Jožef Stepfan Institute). Water can “catalyze” the process at surface grain boundaries, and the transformation of crystal continues from layer to layer through the entire body,

leading to micro-cracks formation, grain pullout and a decrease in strength.13 This phenomenon was particularly important in causing the failure of zirconia hip prostheses submitted to autoclave sterilization. Although the information presented above raises concern, both published clinical trials and those presented at international research meetings evidenced no bulk fracture in dental restorations under the observation time — indicating that LTD has no major influence on the clinical behavior of dental restorations.19 Clinical Indications Based on Clinical Research There is much supporting data from clinical studies of most important ceramics being used in dentistry today.20-52 The general message is that for a single crown on any single-rooted tooth, numerous systems are indicated – some need to be bonded and some can be cemented or bonded. For single-unit posterior teeth, the choices involve the veneered alumina or zirconia systems, veneered or fullthickness lithium disilicate, or full-thickness zirconia. For three-unit anterior FDPs, veneered alumina and zirconia and full-thickness (non-veneered) lithium disilicate have good track records. For posterior three-unit FDPs only veneered or un-veneered zirconia are considered to be suitable.53 Comparison of Resin-Based Composites vs. Ceramics Two groups of materials can be considered for fabricating indirect esthetic restorations from manufactured blocks via chairside CAD/CAM. Data from relatively long-term clinical studies is demonstrating the superiority of ceramics as the most durable option with the longestlasting esthetics as well for all types of restorations. The first generation of laboratoryfabricated composite resins, introduced

in the 1980s, had several limitations such as low fracture and wears resistance, and color instability.54-56 This poor clinical performance drove development of enhanced materials. Changes in the composition, polymerization and improved particulate reinforcement resulted in more durable direct and laboratory-fabricated composites. Improved formulations in filler size, shape, composition and concentration resulted in superior mechanical characteristics.56 Changes in the polymerization system led to a more uniform cure and an enhanced level of polymerization, and this has resulted in increased flexural and tensile strength, increased resistance to abrasion and fracture, and improved

indicating, “… the more time-consuming and expensive inlay technique may not be justified.”60 Most clinicians would likely assume that composite cured under laboratory conditions would be superior to materials cured intraorally. This is not the case from a materials viewpoint, given that properties of set resin-based composites are based on their “degree of cure,” which is not much different whether they are cured in the mouth or the laboratory. “Degree of cure” or “percent conversion” means the number of double bonds (i.e., monomers) that have reacted to form polymer. Essentially a conversion of 75 percent means that the set composite still has 25 percent unreacted monomer.

Figs. 6-7: Ivoclar Vivadent CAD-on restoration

Today’s systems achieve as good as 75 percent to 80 percent, and extra heat, pressure or light does little if anything to improve conversion. Compositionally, laboratory and direct resins are virtually identical as well (i.e., same filler particle sizes and concentrations). Four popular indirect resins were recently examined for their degree of conversion, which was found to vary from 63 percent to 81 percent, right in the range of direct-cure systems.61,62 Unlike ceramics, improved properties are not found with resin-based composites cured under industrial conditions as in the manufacturing of CAD/CAM blocks.

color stability.54-58 Unfortunately, neither the physical properties nor, more importantly, the clinical performance distinguishes indirect composites from direct composites. One five-year follow-up and one 11-year study of direct versus indirect resin-based composite restorations revealed no significant differences in wear, morphology, fracture or secondary caries.59,60 By 11 years, indirect restorations had a slight, but statistically insignificant, advantage in these categories,

Alarmingly, in one head-to-head comparison of CAD/CAM resin and ceramic single-tooth restorations, 200 CAD/CAM restorations were followed for three years.63 For the first 120 restorations, patients were randomly assigned to each material. Vanoorbeek et al (2010)63 reported that, “Due to early occurring complications and inferior results with the composite resin restorations, only all-ceramic crowns were placed thereafter until the required number of restorations for the study was achieved (n = 200)”. Cumulative success rates after three years were 55.6 percent for the composite resin, and 81.2 percent for the ceramic. Even with nano-scale filler particles, these materials are still particle-filled resins – not “resin nano ceramics”! They are simply not ceramics. Disturbing early failures of the CAD/CAM composite crowns reported by Vannoorbeek et al (2010)63 likely reflect: 1) the flexibility of this material (low elastic modulus), and; 2) a poor bond (as discussed above). This is not a new class of material and may not even be an incrementally improved over the previous resin-based CEREC block. Complete Prosthesis Automation Figures 6 and 7 present a very exciting next step in CAD/CAM processing of esthetic and structural prostheses. Within the CEREC design software is the capability of designing simultaneously the structural zirconia substructure and the overlying esthetic porcelain or lithium disilicate. These two components are then joined either by a special firing step (Ivoclar Vivadent, Inc.) or by bonding (Vita Zahnfabrik). While no clinical data yet exists for either system, the concept seems fundamentally sound.

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Summary CAD/CAM technologies have widened the materials available for dentistry, having an ability to mimic the optical characteristics of enamel and dentin. In the case of ceramics, we can add their excellent biocompatibility and chemical durability as well. Clinical data for allceramic systems is becoming increasingly available, and results exist for many commercial materials, providing guidance regarding clinical indications. Resinbased systems as either laboratory-fabricated or factory-produced restorations perform clinically no better than direct resin-based composites curing intraorally. Ceramic restorations represent the best long-term solution for CAD/CAM patients and the only single-unit or multiunit FDP solution. For questions and more information, Dr. Kelly can be reached at kelly@nso1.uchu.edu. R EFER ENC E S 1 Weinstein M, Weinstein LK, Katz S and Weinstein A. Fused Porcelain-to-Metal Teeth. US Patent n. 3,052,982, 1962. 2 Kelly JR. Ceramics in restorative and prosthetic dentistry. Annu Rev Mater Sci 1997; 27:443-68. 3 Giordano R. A comparison of all-ceramic restorative systems: Part 2. Gen Dent 2000; 48:38-40, 43-45. 4 LeBlanc J-C, Guérin T, Noël L, Calamassi-Tran G, Volatier J-C, Verger P. Dietary exposure estimates of 18 elements from the 1st French total diet study. Food Additives and Contaminants, 2005;22(7):624-641. 5 McLean JW, Hughes TH. The reinforcement of dental porcelain with ceramic oxides. Br Dent J 1965; 119:251-67. 6 Andersson M, Odén A. A new all-ceramic crown. A dense-sintered, high-purity alumina coping with porcelain. Acta Odontol Scand 1993; 51:59-64. 7 Raigrodski AJ. Clinical and laboratory considerations for the use of CAD/CAM Y-TZP-based restorations. Pract Proced Aesthet Dent 2003; 15:469-76. 8 Heffernan MJ, Aquilino SA, Diaz-Arnold AM et al. Relative translucency of six all-ceramic systems. Part I: core materials. J Prosthet Dent 2002; 88:4-9. 9 Heffernan MJ, Aquilino SA, Diaz-Arnold AM et al. Relative translucency of six all-ceramic systems. Part II: core and veneer materials. J Prosthet Dent 2002; 88:10-15. 10 Filser FT. Direct ceramic machining of dental restorations. Zurich: Swiss Federal Institute of Technology Zurich; 2001. PhD thesis. 11 Filser F, Kocher P, Gauckler LJ. Net-shaping of ceramic components by direct ceramic machining. Assembly Autom 2003; 23(4):382–90. 12 Denry I, Kelly JR. State of the art of zirconia for dental applications. Dent Mater 2008; 24:299-307. 18

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13 Kelly JR, Denry I. Stabilized zirconia as a structural ceramic: an overview. Dent Mater 2008; 24(3):289-98. 14 Denry IL. Recent advances in ceramics for dentistry. Crit Rev Oral Biol Med 1996; 7:134-43. 15 Swain MV. Unstable cracking (chipping) of veneering porcelain on all-ceramic dental crowns and fixed partial dentures. Acta Biomaterialia 2009; 5:1668-1677. 16 Tholey MJ, Swain MV, Thiel N. SEM observations of porcelain Y-TZP interface. Dent Mater 2009; 25:85762. 17 Kim JM, Covel NS, Guess PC, Rekow ED, Zhang Y. Concerns of Hydrothermal Degradation in CAD/CAM Zirconia. J Dent Res 2010; 89:91-95. 18 Kobayashi K, Kuwajima H, Masaki T. Phase change and mechanical properties of ZrO2-Y2O3 solid electrolyte after aging. Solid State Ionics 1981; 3-4:489–93. 19 Kelly JR. Dental ceramics: current thinking and trends. Dent Clin N Am 2004; 48:513-530. 20 Probster L (1993). Survival rate of In-Ceram restorations. Int J Prosthodont 6:259-63. 21 Pang SE. A report of anterior In-Ceram restorations. Ann Acad Med Singapore 1995;24:33-37. 22 Probster L. Four-year clinical study of glass-infiltrated, sintered alumina crowns. J Oral Rehab 1996;23:147-51. 23 Scotti R, Catapano S, D’Elia A. A clinical evaluation of In-Ceram crowns. Int J Prosthodont 1995;8:320-3. 24 McLaren EA, White SN. Survival of In-Ceram crowns in a private practice: a prospective clinical trial. J Prosthet Dent 2000;83:216-22. 25 Scherrer SS, De Rijk WG, Wiskott HW, Belser UC. Incidence of fractures and lifetime predictions of all-ceramic crown systems using censored data. Am J Dent 2001;14:72-80. 26 Segal BS. Retrospective assessment of 546 all-ceramic anterior and posterior crowns in a general practice. J Prosthet Dent 2001;85:544-50. 27 Bindl A, Mörmann WH. An up to 5-year clinical evaluation of posterior in-ceram CAD/CAM core crowns. Int J Prosthodont 2002;15:451-6. 28 Fradaeni M, Aquilano A, Corrado M. Clinical experience with In-Ceram Spinell crowns: 5-year follow-up. Int J Periodontics Restorative Dent 2002;22:525-33. 29 Bindl A, Mörmann WH. Survival rate of mono-ceramic and ceramic-core CAD/CAM-generated anterior crowns over 2-5 years. Eur J Oral Sci 2004;112:197-204. 30 Oden A, Andersson M, Krystek-Ondracek I, Magnusson D. Five-year clinical evaluation of Procera AllCeram crowns. J Prosthet Dent 1998;80:450-56. 31 Odman P, Andersson B. Procera AllCeram crowns followed for 5 to 10.5 years: a prospective clinical study. Int j Prosthodont 2001;14:504-509. 32 Fradeani M, D'Amelio M, Redemagni M, Corrado M. Five-year follow-up with Procera all-ceramic crowns. Quintessence Int 2005;36:105-13. 33 Walter MH, Wolf BH, Wolf AE, Boening KW. Six-year clinical performance of all-ceramic crowns with alumina cores. Int J Prosthodont 2006;19:162-3. 34 Zitzmann NU, Galindo ML, Hagmann E, Marinello CP. Clinical evaluation of Procera AllCeram crowns in the anterior and posterior regions. Int J Prosthodont 2007;20:239-41. 35 Lehner C, Studer S, Brodbeck U, Schärer P. Shortterm results of IPS-Empress full-porcelain crowns. J Prosthodont 1997;6:20-30. 36 Fradeani M, Aquilano A. Clinical experience with Empress crowns. Int J Prosthodont 1997;10:241-7. 37 Sorensen JA, Choi C, Fanuscu MI, Mito WT. IPS Empress crown system: three-year clinical trial results. J Calif Dent Assoc 1998;26:130-6. 38 Sjögren G, Lantto R, Granberg A, Sundström BO, Tillberg A. Clinical examination of leucite-reinforced glass-ceramic crowns (Empress) in general practice: a retrospective study. Int J Prosthodont 1999;12:122-8. 39 Fradeani M, Redemagni M. An 11-year clinical evaluation of leucite-reinforced glass-ceramic crowns: a

retrospective study. Quintessence Int 2002;33:503-10. 40 Toksavul S, Toman M. A short-term clinical evaluation of IPS Empress 2 crowns. Int J Prosthodont 2007;20:168-72. 41 Marquardt P, Strub JR. Survival rates of IPS empress 2 all-ceramic crowns and fixed partial dentures: results of a 5-year prospective clinical study. Quintessence Int 2006;37:253-9. 42 Taskonak B, Sertgöz A. Two-year clinical evaluation of lithia-disilicate-based all-ceramic crowns and fixed partial dentures. Dent Mater 2006;22:1008-13 43 Suputtamongkol K, Anusavice KJ, Suchatlampong C, Sithiamnuai P, Tulapornchai C. Clinical performance and wear characteristics of veneered lithia-disilicatebased ceramic crowns. Dent Mater 2008;24:667-73. 44 Sjögren G, Lantto R, Tillberg A. Clinical evaluation of all-ceramic crowns (Dicor) in general practice. J Prosthet Dent 1999;81:277-84. 45 Haselton DR, Diaz-Arnold AM, Hillis SL. Clinical assessment of high-strength all-ceramic crowns. J Prosthet Dent 2000;83:396-401. 46 Sorensen JA, Kang SK, Torres TJ, Knode H. In-Ceram fixed partial dentures: three-year clinical trial results. J Calif Dent Assoc 1998;26:207-14. 47 Vult von Steyern P, Jönsson O, Nilner K. Five-year evaluation of posterior all-ceramic three-unit (In-Ceram) FPDs. Int J Prosthodont 2001;14:379-84. 48 Olsson KG, Furst B, Andersson B, Carlsson GE. A longterm retrospective and clinical follow-up study of InCeram Alumina FPDs. Int J Prosthodont 2003;16:150-6. 49 Kern M. Clinical long-term survival of two-retainer and single-retainer all-ceramic resin-bonded fixed partial dentures. Quintessence Int 2005;36:141-7. 50 Esquivel-Upshaw JF, Anusavice KJ, Young H, Jones J, Gibbs C. Clinical performance of a lithia disilicatebased core ceramic for three-unit posterior FPDs. Int J Prosthodont 2004;17:469-75. 51 Suárez MJ, Lozano JF, Paz Salido M, Martínez F. Three-year clinical evaluation of In-Ceram Zirconia posterior FPDs. Int J Prosthodont 2004;17:35-8. 52 Sailer I, Fehér A, Filser F, Gauckler LJ, Lüthy H, Hämmerle CH. Five-year clinical results of zirconia frameworks for posterior fixed partial dentures. Int J Prosthodont 2007;20(4):383-388. 53 ISO 6872 54 Koczarski MJ. Utilization of ceromer inlays/onlays for replacement of amalgam restorations. Pract Periodontics Aesthet Dent. 1998 May;10(4):405-12. 55 Jackson RD. Indirect resin inlay and onlay restorations: a comprehensive clinical overview. Pract Periodontics Aesthet Dent. 1999 Oct;11(8):891-900. 56 Miara P. Aesthetic guidelines for second-generation indirect inlay and onlay composite restorations. Pract Periodontics Aesthet Dent. 1998 May;10(4):423-31. 57 Chalifoux PR. Treatment considerations for posterior laboratory-fabricated composite resin restorations. Pract Periodontics Aesthet Dent. 1998 Oct;10(8):969-78. 58 Leinfelder KF. Indirect posterior composite resins. Compend Contin Educ Dent. 2005 Jul;26(7):495-503. 59 Wassell RW, Walls AWG, McCabe JF. Direct composite inlays versus conventional composite restorations: 5-year follow-up. J Dent 2000;28:375-382. 60 van Dijken JWV. Direct resin composite inlays/onlays: an 11 year follow-up. J Dent 2000;28:299-306. 61 Sousa ROA, Özcan M, Michida SMA et al. Conversion degree of indirect composites and effect of thermocycling on the physical properties. J Prosthodont 2010;19:218-225. 62 Ferracane JL. Current trends in dental composites. Crit Rev Oral Biol Med 1995;6(4):302-318. 63 Vanoorbeek S, Vandamme K, Lijnen I, Naert I. Computer-aided designed/computer-assisted manufactured composite resin versu ceramic single-tooth restorations: A 3-year clinical study. Int J Prosthodont 2010;23(3):223-230.

with unique functionality.

Use it anywhere you’d use glass ceramic— only with more confidence. Lava™ Ultimate Restorative is made with resin nano ceramic technology, resulting in fracture-resistant, natural-looking restorations. • Excellent durability backed by a 10-year warranty • Less wear to opposing dentition than glass ceramics • Absorption of chewing forces which reduces stress • Adjustability for occlusion with additive or subtractive techniques • Fast, no firing and easy to mill Ideal for any single-unit indication, including implant-supported crowns. The 2013 CDT code classifies Lava Ultimate restorative as a ceramic—like other milled porcelain/ceramic materials.

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New Materials on the Block for CEREC SW 4.2 More Choices From Vita, Dentsply, Sirona and Ivoclar with sirona's exciting release of software version 4.2, we also have the introduction of new materials by multiple manufacturers. These blocks will offer many more clinical options both esthetically and functionally. Some will even allow us to do additional procedures not possible in earlier versions of the software. Here is a brief look at these new materials and how they will affect your clinical workflow. Vita and Dentsply The collaboration of VITA Zahnfabrik, Degudent GmbH and the Faunhofer Institute for Silicate Research ISC has lead to the development of a new generation of glass ceramics called ZLS (zirconia-reinforced lithium silicate). The material will be marketed by VITA under the name Suprinity and by Dentsply as Celtra. What distinguishes this new material from others is that it has around 10 percent zironia by weight (not volume) infused into the glass ceramic. This proportion is close to 10 times higher than that of a traditional glass ceramic. It also has a homogenous structure due to the uniform, fine-grain size of roughly 500nm. The images (Fig. 1, VITA Suprinity, and Fig. 2, Dentsply Celtra), show two types of blocks. The see through glass blocks on the left are partially crystallized blocks that require a firing cycle (VITA Suprinity and Celtra CAD). The blocks on the right are fully crystallized and have the option to be simply hand polished (VITA Suprinity FC and Celtra Duo). Specific kits will be available for this 20

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2 polishing procedure. The 3-point flexural strengths of the two materials are around 420MPa for the partially crystallized blocks and 200MPa for the fully crystallized version. These materials have been shown to have impressive edge stability and precision. They will be indicated for anterior and posterior crowns, implant crowns, inlays, onlays, and veneers. Expect to see the Suprinity blocks released in the fall and the Celtra blocks with a limited shade release in late summer. Sirona Dental Systems When visualizing the natural tooth, we have an interaction between chromatic dentin and translucent enamel. When

Fig. 1 Vita Suprinity Fig. 2 Two forms of Dentsply Celtra Fig. 3 Sirona CEREC Bloc C Fig. 4 View of dentin core of Bloc C Fig. 5 Selecting color of Bloc C in Mill Phase Fig. 6 Adjusting the thickness of incisal enamel Fig. 7 Position of restoration in block

trying to restore a tooth with a ceramic, we should visualize the same. This has been difficult for a number of reasons, but the main limiting factor has been the position of the restoration within the block. Sironaâ&#x20AC;&#x2122;s CEREC Blocs C (Fig. 3) and the software algorithm created for these blocks have solved this issue. If you look at a software diagram of these blocks, you can see the dentin core in the center (Fig. 4). This core is modeled after the shape of dentin in natural teeth. The rest of the block is translucent enamel. The key to the process is using an algorithm to correctly position the restoration in the block. This will lead to correct color and translucency. If you selected Sirona CEREC Blocs C in

4 the administration phase of the software, you will have an additional step in the Mill Phase called â&#x20AC;&#x153;Select Color.â&#x20AC;? After clicking that prompt, there are two options that need to be set. First, enter the tooth color and thickness of the incisal enamel in the software (Fig. 5). This will automatically position the restoration within the block to achieve the color indicated. The next step allows adjustment of the thickness of the incisal enamel (Fig. 6). The beauty of this step is that it allows adjustment of the enamel without losing the desired color set in the previous step. After adjusting the color parameters accordingly, the final proposal of the restoration is visible within the block that mimics the desired interaction between dentin and enamel (Fig. 7). CEREC Blocs C will come in one block size and 11 different shades. The capabilities of this block from an esthetic point of view are impressive and it will be a wonderful new material in our arsenal. Ivoclar Vivadent With the release of the 4.2 software, some of the more anticipated new materials are coming from Ivoclar Vivadent. These materials will allow chairside applications not available prior to 4.2. Some of these new applications include anterior bridges, hybrid abutments and hybrid abutment

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crowns. The full spectrum of IPS e.max CAD (Fig. 8) shows the four new blocks — C16, B32, A14(L), and A16(L) — to go with the existing arsenal of LT and HT chairside blocks (missing are the array of Impulse blocks). Following are descriptions of the new blocks: ips e.max cad c16: Often when designing anterior restorations that are long (particularly canines and centrals), there was difficulty fitting the restoration within the C14 block. It was necessary to do multiple rotations and movements in the Mill Phase to correct this, sometimes to no avail. The e.max C16 block allows these long restorations to fit within the block with little effort. It is a welcome addition to those who do many anterior restorations. ips e.max cad b32: The e.max B32 is the first CEREC block approved for full contour permanent bridges. Ivoclar has released this block specifically for anterior full contour bridges (Figs. 9 and 10). Ivoclar’s research concluded that with a connector cross section of 16mm², it is safe and reliable to do e.max full-contour bridges with this block. Since the 4.2 software allows this e.max block to be used for full contour bridges, there are other uses and options never available before in the chairside software. Some include resin-bonded (Maryland) bridges over 18mm in length and splinted anterior and posterior crowns. This is another great option for prosthetic needs. ips e.max abutment blocks: The most highly anticipated blocks in recent memory are Ivoclar’s two abutment blocks, the MO A14(L) and the LT A16(L) (Fig. 11). With the addition of the abutment design mode in software V4.2, it is now possible to produce chairside custom e.max abutments in a single visit. Moreover, a screw-retained hybrid abutment crown a can be fabricated, skipping the abutment all together. Both blocks have specific purposes. The LT A16(L) is mainly used for one-piece 22

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Figs. 8-15: IPS e.max CAD choices and uses.

screw-retained hybrid-abutment crowns. The milled restorations are bonded to a Sirona titanium base (one for each supported implant manufacturer) using an implant resin by Ivoclar (Fig. 12). This attachment is a precise, premanufactured attachment since no margins need to be milled. Furthermore, there is a custom antirotational notch built in for further stability (Fig. 13). The final restoration (Fig. 14) shows there is no need to drill through the restoration to create a final screw access hole; it is premade to the position designed in the software. It is a custom, one-piece screw-retained restoration that can be fabricated in a single appointment. If cement-retained implant restorations are desired, the MO A14(L) is available. This medium opacity block is perfect for blocking out the titanium base in areas

where esthetics is at a premium. One example is an anterior custom abutment (Fig. 15). Creating a hybrid abutment and a separate cementable crown is often advantageous over a one-piece hybrid-abutment crown due to screw access location. • Usually one or two new materials every few years will come out to aid certain indications. Software version 4.2 has allowed for a material explosion with more functional and esthetic options and materials that provide additional restorative capabilities. What an exciting time to be a part of CAD/CAM dentistry! For questions and more information, Dr. Skramstad can be reached at mike@cerecdoctors.com.

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Use your CEREC # scanner with our Inclusive Scanning Abutments to restore your implant cases without the mess and hassle of conventional impressions. Using digital impressions, you’ll receive an unsurpassed level of precision for your custom implant abutments, BioTemps® provisionals and final ceramic restorations. To best support your every need, we’ve created a dedicated full-service dental implant department of specially trained technicians to restore your cases.

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by Sameer Puri, D.D.S.

cerec users have been anxiously awaiting an update to the 4.0 software for their CEREC machines. Good news: the wait is finally over. Iâ&#x20AC;&#x2122;m proud to introduce you to the much-anticipated follow-up to the 4.0 software â&#x20AC;&#x201D; CEREC SW 4.2. This article will cover some of the features that are incorporated into the

CEREC SW 4.2

4.2 software. Video tutorials are available on www.cerecdoctors.com/ software with complete descriptions and information on all the features listed below and more. You can also download and design practice cases to become proficient with the new software. For questions or more information, Dr. Puri can be reached at sameer@cerecdoctors.com.

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Introducing the Latest Update From Sirona for the CEREC System

One software version for both Omnicam and Bluecam

Now Omicam and Bluecam users will enjoy using the same robust software. 4.2 is compatible with both camera systems, allowing users to review cases and files from either camera. The universal software ensures that cross-compatibility remains and, more importantly, Bluecam users can utilize the full features and benefits of the new software.

Administration phase

The all-new look to the Administration phase includes an entirely new screen for patient input and selection (images at left). By organizing the names of the patients in this manner, the user is able to filter through the different cases with more ease. Older cases are easier to find and finding cases from the past is much easier due to an advanced filtering algorithm. Users will find the new screen more organized and easier to use. The Administration phase allows the user to select multiple restorations more quickly and easily. The layout is similar to the inLab software in that there are fewer sub menus to navigate and users can get started with multiple restorations with ease. Selecting four units at once, for example, means that the user does not have to go to the sub menu to select the type of restoration and the design type individually. This can be done all at once.

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dimensioning toolS

Both the Scale and Dimension tools are now leaner. One tool will automatically allow users to move and rotate the restorations. The Scale tool has been combined into one tool, allowing for ease-of-use and streamlined usability. These new tools allow for easier and faster design.

New View options

Several changes have occurred in the View options of restorations. The cursor detail is fixed in the lower-left corner, meaning the numbers do not follow the cursor or get in the way of designing the restoration. When using the Form tool, the user can decide whether or not to hide the adjacent teeth. In the previous version of the software, with adjacent restorations, once you activated the Form or Scale tools, half of the adjacent restoration was removed from view. Now users can choose whether or not to make the adjacent teeth visible when using the tool. Finally, in the View menu, users can choose to see the local view (the selected restoration) or the global view (the entire arch). This comes in particularly handy when doing smile designs.

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Chairside treatment of implants

CEREC 4.2 allows the clinician to perform chairside treatment of implant restorations. This is the most exciting feature of the new 4.2 software update. The software has the ability to use the standard Tibase Scan Body or the new intraoral Scan Post that allows the user to scan intra-orally, this helps eliminate the problem of intraoral imaging of the standard Scan Body. The workflow is similar to the inLab software with regards to the tools and sequence of the design. The implant design process allows for an additional gingival mask catalog where the user can scan in the soft tissue to obtain proper embrasures and contours of the final restoration. Three new parameters (abutment anatomic, abutment framework and crown veneering structure) have been added to this workflow; they allow the user to control not only the contours but also the final restorations created from the abutment software.

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Virtual articulation

A built-in virtual articulator allows the user to perform functional movements on a restoration. The critical steps are that the user needs to scan at least to the contra-lateral canine. Once this is done, the software will automatically perform the functional movements on the models. An animation can also be played that shows the jaws in function. While this is more for patient education, it can also show the clinician the anticipated movement of the jaws. The virtual articulator can be fully programmed (condylar inclination, Bennet angle, etc.), or an average series of data points can be used. There currently is no interface to facebow systems.

Model Axis

This new feature is in addition to the insertion axis. By positioning the model into the appropriate area of the arch form, the software is able to give much better proposals. Model axis is another feature that has been in the inLab software and allows the user to more accurately design proposals. This feature is especially noticeable when designing multiple anteriors in the Biogeneric mode.

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Smile Design

This is probably the most robust feature of the new software. The Smile Design feature allows a user to import the patientâ&#x20AC;&#x2122;s face into the software to help with design of the restorations. The clinician can use the face as a guide to design the restorations to determine the proper incisal edge position, facial position and much more. To get a complete overview of how this process works, view the video tutorials on www.cerecdoctors.com.

C Block

This new block from sirona allows the user with a single block to have virtually any shade in the mouth. The shade of the block is determined by how much of the underlying dentin shows through the tooth structure. The user simply selects the shade and the software automatically positions the block with the appropriate amount of dentin and enamel. While the user has the ability to adjust the restoration, one should know that the shade of the restoration will be lost if the user over rides the software position of the restoration.

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Grouping

The new grouping feature allows the clinician to link up adjacent restorations. For example, in the case shown the user was designing 4 upper and 4 lower restorations. In previous versions of the software, if the user wanted to move all 4 upper units more towards the opposing arch, they would have to select each individual unit and move it manually. With the grouping feature in 4.2, the user is able to group all 4 units by clicking and linking them together and then whatever movements are done to one unit, are done to all the units. This greatly simplifies the design with multiple units.

Incisal Variation tool

This tool enables the user to enhance the incisal edge of anterior restorations. The user can adjust the intensity to take into account the age of the patient by making the incisal edge smooth or more enhanced anatomically. You can adjust this on single or multiple restorations.

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The NEW 4.2 Software is here

SIRONA INTRODUCES

CEREC SW 4.2 See a full set of videos in the digital learning section on cerecdoctors.com detailing all the new software upgrades. You must be premium member to watch.

Get all of this information on the NEW Software at: WWW.CERECDOCTORS.COM/SOFTWARE CONTACT: LIZ DAVISON AT 877.295.4276 OR LIZ@CERECDOCTORS.COM

CASE STUD Y

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by R i c h R o s e nbl a t t, D . M . D .

Saving Time With the Speed Crystallization Technique Creating an In-office Posterior Lithium Disilicate Restoration in-office cad/cam processing has shortened the time required for dentists to deliver fully functional and esthetic restorations to their patients. Yet, despite the reduced number of required office visits, many clinicians still look for ways to make the treatment and fabrication processes more efficient without sacrificing predictability. Among the materials that can be processed using in-office CAD/CAM techniques is lithium disilicate (e.g., IPS e.max CAD, Ivoclar Vivadent).1 Typically, lithium disilicate restorations undergo a four-stage firing or crystallization cycle. This cycle involves: evaporating and drying of Object Fix; heat transfer to the restoration; burn out of glaze paste organics; sintering and melting of glaze and shade materials; and, ultimately, crystallization of the lithium disilicate material. The stages in this process are drying and closing, heating, holding and cooling, all of which usually take a combined 19 minutes and 50 seconds in order to ensure a flexural strength of 360 MPa (± 60); a linear thermal expansion of 10.5 ± 0.5; standard A-D optical properties; and chemical solubility of <100.2 While it might seem ideal to simply shorten all of these stages for faster material crystallization, each stage does serve a specific function significant to completing full crystallization. Therefore, arbitrarily shortening any or all of these stages can lead to negative ramifications to the restoration, including poor glaze, shade mismatch, reduced strength, cracking or residual lithium silicate, which is highly soluble.3 Recently, the four stages of the crystallization process 32

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were examined to determine where potential processing time could be saved while still achieving complete crystallization and without negatively affecting material quality. The drying stage, which requires 1.5 minutes, could not be shortened — this stage is necessary for drying out the organics in the glaze and object. A fixed amount of energy is required and

The Speed Crystallization technique resulted in an esthetic and accurately fitting restoration in less time than is normally involved with chairside lithium disilicate restorations. cannot be modified. Likewise, the cooling stage, which takes 5.5 minutes, depends upon time to reduce the temperature of the restoration. Cooling too fast generates residual stress in ceramic, leading to cracks. However, the heating stage (approximately 5.5 minutes) and holding stage (approximately 7 minutes) are areas in which times could be reduced. The heating stage can be reduced due to the higher initial temperature in phase one, while the holding phase can be reduced due to better temperature control. By focusing on these two stages, the overall crystallization time can be reduced from 19:50 to 14:50 minutes, while still achieving complete crystallization, strength and optimum esthetics.

The Speed Crystallization Process As a result of these investigations, a speed crystallization process has been introduced for CAD-fabricated lithium disilicate restorations (IPS e.max CAD). This can help dentists save time during the in-office fabrication process while still producing highly esthetic and durable restorations. This speed crystallization process for lithium disilicate (IPS e.max CAD) now takes 14 minutes and 50 seconds and still produces restorations with the requisite physical characteristics. The Speed Crystallization process incorporates the use of the Programmat CS Oven P3, as well as a new speed crystallization tray (IPS e.max CAD Speed Crystallization Tray). Suitable for use for crystallizing a maximum of two restorations, the process is designed for use only with IPS e.max CAD Crystallization Glaze Spray, and only with HT and LT blocks (not for Impulse Shades). The smaller speed-crystallization tray, which is composed of silver nitride, requires less energy for heating and cooling, thereby contributing to an accurate and efficient process. The Speed Crystallization technique can only be properly completed using the smaller tray, since it takes less time to heat up and cool down. This is part of the four-minute reduction in the cycle. Additionally, the new firing program for the Programmat CS (i.e., P3) produces a stand-by temperature of 550° C. This ensures a complete transition from lithium-metasilicate to lithium-disilicate for long-term clinical success. It also achieves the correct shade and translucency for optimum esthetics. The following case study describes the protocol followed to produce an in-office

Fig. 1: Preoperative image of the crown to be removed with recurrent decay Fig. 2: Preoperative image of crown prior to removal Fig. 3: Image of the preparation. What remained was stained hard dentin

4 IPS e.max CAD restoration using the Speed Crystallization process.

Fig. 4: Screen shot of the preparation as imaged using the CEREC camera Fig. 5: Screen shot of the pre-existing tooth being copied in the software Fig. 6: The CEREC software produced a proposal of the restoration prior to milling

Case study A patient presented with a pre-existing crown restoration affected by recurrent decay (Fig. 1). After closer evaluation and excavation, an in-office CAD-fabricated crown was decided upon. Because the crown anatomy was good, occlusion was perfect and the patient was comfortable with the buccal/lingual width, the Biogeneric copy function was used to duplicate and recreate the anatomy and morphology of the existing restoration (Fig. 2). To accomplish this task, preoperative impression scans were taken prior to removing the existing restoration and preparing the tooth. This involved applying an opaquing spray (CEREC Opti-Spray, Sirona) to the existing restoration. Then, impression scans were taken using CEREC for designing the chairside restoration (IPS e.max CAD).

The spray was cleaned from the tooth, after which the crown was removed. The crown preparation was refined using a series of diamonds for a smoother preparation. Old build-up material was removed, and caries detect was placed to determine if any residual decay remained. What remained was stained hard dentin (Fig. 3). The ideal shade (A3) was chosen for the lithium disilicate block. Opaquing spray was again applied, and scans were taken of the preparation using the CEREC camera (Fig. 4). The images obtained of the existing crown prior to its removal were used to duplicate cusp tips, fissure depths and overall morphology. They were then applied to the preparation scans in order to render a new restoration that matched the original (Fig. 5). Essentially, the pre-existing tooth was copied in the CEREC software. The white line was redrawn, and anything inside of it was copied at 1:1 with the original. The CEREC software produced a quarter 2

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proposal of the restoration prior to milling (Fig. 6). After milling and while in the purple stage, the IPS e.max CAD A3 restoration was tried in to check marginal fit and interproximal and occlusal contacts (Fig. 7).4 The IPS e.max CAD restoration was placed in a steam cleaner to remove oil and residue from the milling process and any adjustments (Fig. 8). Then, the cervical third of the restoration was imparted with gingival shading using the IPS e.max Shade 2 (Fig. 9). IPS e.max Shade 4 was used to create occlusal pit-and-fissure characterizations; white was applied to the descending cusps; and blue was placed on the buccal aspect of the outside cusps (Fig. 10). Once the stains were fixated, three separate coats of IPS e.max CAD Crystallization Glaze Spray were placed (Fig. 11). Time was allowed for the glaze to dry in between applications. Following application of the Glaze Spray, the Programmat CS over hood was opened, and the restoration placed on the new, smaller firing tray. The P3 program was selected to begin the optimal short firing cycle. Conclusion The Speed Crystallization technique resulted in an esthetic and accurately fitting restoration in less time than is normally involved with chairside lithium disilicate restorations (Fig. 12). This manufacturer-approved process ensured that the desired brightness and opacity for the restoration would remain stable. It also helped to maintain appropriate material solubility and the final gloss of the restoration. Other speed programs of less than 14 minutes and 50 seconds pose risks to the microstructure, physical properties and esthetics of CAD-fabricated lithium disilicate restorations. For questions and more information, Dr. Rosenblatt can be reached at richrosenblatt@gmail.com. 34

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10 Fig. 7: While in the purple stage, the IPS e.max CAD A3 restoration was tried in to check marginal fit and interproximal and occlusal contacts Fig. 8: The IPS e.max CAD restoration was placed in a steam cleaner Fig. 9: The cervical third of the restoration stained with IPS e.max Shade 2 Fig. 10: IPS e.max Shade 4 was used to create occlusal pit-and-fissure characterizations; white was applied to the descending cusps; and blue was placed on the buccal aspect of the outside cusps Fig. 11: Three separate coats of IPS e.max CAD Crystallization Glaze Spray were placed Fig. 12: View of the final IPS e.max CAD restoration in the mouth

References 1. Kurbad A, Reichel K. CAD/CAM-manufactured restorations made of lithium disilicate glass ceramics. Int J Comput Dent. 2005 Oct;8(4):337-48. 2. Guess PC, Zavanelli RA, Silva NR, Bonfante EA, Coelho PG, Thompson VP. Monolithic CAD/CAM lithium disilicate versus veneered Y-TZP crowns: comparison of failure modes and reliability after fatigue. Int J Prosthodont. 2010 Sep-Oct;23(5):434-42. 3. Lin WS, Ercoli C, Feng C, Morton D. The effect of core material, veneering porcelain, and fabrication technique on the biaxial flexural strength and weibull analysis of selected dental ceramics. J Prosthodont. 2012 Jul;21(5):353-62. doi: 10.1111/j.1532849X.2012.00845.x. Epub 2012 Mar 29. 4. Lin WS, Harris BT, Morton D. Trial insertion procedure for milled lithium disilicate restorations in the precrystallized state. J Prosthet Dent. 2012 Jan;107(1):59-62. doi: 10.1016/S0022-3913(12)60020-1.

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CASE STUD Y

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b y D a r i n O ’ B rya n , D . D . S .

Life-changing ‘Someone told me I had a beautiful smile and I started to cry.’ the sentence above was a text i received the other day from a patient. We touch our patients’ lives every day. Sometimes it is just alleviating their physical pain. Then there are those times we can really change a life. A person’s smile changes how they feel about themselves and how they present themselves to the world. So, when my orthodontist called me up and asked me to help out a girl who was missing her laterals, I agreed.

duplicated to allow for a wax-up to be done and also a guide to be fabricated based on her presenting dentition. Based on the lip-at-rest photo (Fig. 3), 0.5 mm of incisal length would be added and gingival re-contouring would be done to lengthen the teeth without giving a “toothy” look to the smile. The original model was scanned with the CEREC Bluecam, as was the diagnostic wax-up. This was done in Biocopy

implant placement based on the restorative plan. By having a 3-D representation of the bone, I was able to determine the size of the implants needed and also at what depth to place them. We judge the depth by the emergence profile we want from our restorative design and the type of abutment we want to use. The top of the implant needed to be at least 2 mm from where the proposed margin for the crowns would be (Figs. 7 and 8).

to allow for transfer of the wax-up over the existing dentition model (Fig. 4). The two implant crowns on #7 and #10 were then designed in the edentulous spaces while leaving the preoperative conditions on the other teeth (Fig. 5). By leaving the preoperative condition, the designs could then be uploaded to the CBCT scan (Figs. 6 and 7). With this information, it was determined where the final lateral incisor position would be, thus allowing for planning the

I decided to utilize Astra implants and TiBase custom abutments in this case. By planning out implant placement based on the restorative plan, we get a much more predictable esthetic result. Once the placement of the implants was determined, the models, scan plate and CBCT data were sent to SICAT in Germany for a classic surgical guide fabrication. Guide fabrication takes six working days from the time it arrives in Germany. Once the guide was fabricated,

Case study The patient is in her early twenties, with congenitally missing laterals (Fig. 1). She had metal-winged Maryland bridges that kept de-bonding. She would hold them in place with her tongue, causing the metal wings to score the lingual of the centrals and canines (Fig. 2). I saw her for a consultation, and discussed her options. Together, we opted for implants in the lateral incisor areas and then thin, full-coverage crowns on the centrals and canines. With the prior removal of bicuspids for orthodontic treatment, the patient was left with dark buccal corridors. We discussed veneering the bicuspids to broaden her smile. Photos and diagnostic models were taken, and a CBCT scan was done with a bite plate to help with surgical guide fabrication. The models were 38

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10 Fig 1: Frontal pre-op view Fig. 2: Occlusal pre-op view Fig. 3: Lips at rest Fig. 4: Transfer of pre-op wax-up Fig. 5: Implant crowns proposals Figs. 6-7: Designs with CBCT scan Figs. 8-9: Proposed implant placement Fig. 10: Provisional implant crowns

9 a drill protocol was sent from SICAT. This drilling protocol informs what drills were needed, the keys needed for each implant site and which implant drivers to utilize for implant placement. After all of the diagnostics were done, it was time to get started. The patient came in for initial preparation and implant placement. The surgical guide was placed and a tissue punch was used through the guide to access the osseous crest. Based on the pre-op photos, clinical exam and CT scan, it was determined that there was enough keratinized gingiva to utilize a tissue punch without risk of having a poor esthetic outcome. After the tissue was removed, the Facilitate kit from Astra was used with disposable Astra drills to create the osteotomy through the SICAT surgical guide.

With the full-guided ability of the Astra Facilitate kit, you can thread the needle and the implants are placed to the exact depth and angulation that was designed from our diagnostics (Figs. 8 and 9). Having complete confidence in where the implants are going to be also allows for a very fast and stress-free surgery. Once the implants were in place, the adjacent teeth were prepared for minimal thickness, full-coverage crowns and temporaries fabricated. Then, resin temporary abutments were placed and screw-retained temporary crowns were fabricated (Fig. 10). After the implants had fully integrated, the patient came back for the final preparations and imaging. The temporaries had been adjusted for proper occlusion, and the patient was happy with the shape and esthetics. She did say she wanted the centrals a little longer if that was possible. This would be easy to accomplish through the use of the Biocopy function for restoration fabrication. The temporaries were scanned in Biocopy and then removed. The preparations were then finalized. Full coverage was done for #6, #8, #9 and #11. Veneer preparations were done on #5 and #12 to help fill in the empty buccal corridors. Sirona TiBases were placed on #7 and #10, and images of all the preparations quarter 2

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and TiBases were done with the inLab 4.0 software. Images for both the preparations and for the gingival mask were done. The restorations were designed from the temporaries (Fig. 11). Once I had the design finished, I used the split tool on #7 and #10. Here is where I started to run into difficulty. When doing a Biocopy case over implants, it can be very challenging to fit the TiBase abutment under the Biocopy of the wax-up. If we look at the implant placement, it is evident that the implants were placed in a very ideal position: mesial-distal and buccal-lingual (Figs. 8, 9, 12 and 13). The depth is also good. The problem lies with the TiBase metal substructure. It will tend to poke out the top of the zirconium abutment (Fig. 14). This leaves a very thin section of the crown. The solution to this is to design the ideal abutment, and then trim the metal substructure after it has had the zirconium abutment bonded on, and then place and reimage in the mouth. 40

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16 The abutment designs were then sent to InfiniDent, where they were milled and centered. While the abutments were being created, the rest of the restorations were milled in-office and initial shaping was done with diamond burs

Fig. 11: Crowns and veneers proposals Fig. 12: Radiograph of implant placement Fig. 13: Radiograph of implant placement Fig. 14: Abutment proposal Fig. 15: TiBase and abutment Fig. 16: TiBase being trimmed

and wheels. The decision was made to use the Impulse blocks. Because we had a mixture of restorative substrates, we needed a material that had some opacity to cover the zirconium abutments but still allowed for translucency at the incisal edges. Once the abutments were received from InfiniDent, the TiBase and abutment were bonded together. The TiBase was sandblasted to allow for better bonding of the zirconium to the titanium. The two pieces were bonded together using Multilink Implant. Then the metal TiBase that was sticking out of top of the abutment was trimmed back and modified (Figs. 15 and 16). At this point, the abutments were placed in the mouth with the other restorations and then scanned to get a final design. This could be done in Biocopy if we wanted to keep the screw-retained temporaries in while we placed the other restorations. I decided to see what the design would look like if I went with Bioindividual. The patient then returned for the final seating appointment. She was anesthetized and the temporaries were removed. The restorations that had already been milled were tried in and final contours were shaped with diamond burs. The abutments were then tried in as well. Then, retraction cord was placed, and the abutments were scanned with the restorations in place. The crowns were designed for the abutments and milled. They were then tried in with the other restorations to make sure all the contours, lengths and angulations were in order. The occlusion was verified and excursive movements were checked. The restorations were then taken back to the lab and characterization was done with diamond burs. Developmental grooves, perikymata and other minor characterizations were done. Then the restorations were stained, glazed and fired. Since the impulse blocks are a value system, instead of the traditional

Vita system, there are no direct correlating stain colors. Since we were using the impulse V1 blocks, adding a little B1 at the cervical gave it a bit more saturation of color and some warmth. The B1 was also placed in the developmental grooves to give some depth. The white characterization stains were placed on the incisal edges and then drawn down to highlight the line angles and create characterization. Incisal blue stain was placed on the lingual towards the incisal edge to give a subtle translucent halo. All the stains were done so that they are not highly noticeable once the restorations were fired. This requires not only very small amounts of stain, but to make sure that they are blended to allow for subtle transitions. After characterization and staining were done, the restorations were fired on the full-length e.max cycle. Impulse blocks cannot be fired on any of the shorter cycles. It really did not matter in this case since we were firing eight restorations at one time. After the restorations were cooled, they were cleaned and put in place one more time with Variolink Veneer try-in paste value zero. The overall esthetics were then evaluated, and the patient was given time to really look them over and make sure she was happy. An easy way to tell if they are pleased is if they start crying from happiness. That is what happened in this case. The restorations were etched for 15 seconds with 9 percent HFl acid. Monobond Plus was placed on the inside of all the restorations and let to sit for one minute. It was then air dried for 10 seconds to form a nice, thin layer of ceramic primer. The teeth were isolated with an OptraGate and cotton rolls. All of the preparations were cleaned with Consepsis and rinsed. The teeth were etched for 20 seconds and then thoroughly rinsed for 10 seconds. Excite was placed on the teeth and scrubbed in for 15-20 seconds.

The manufacturer says scrub for 10; I like to scrub for 10, air thin, and apply more for another 10 seconds, then air thin again. The Excite was then cured for 10 seconds on each tooth. Variolink Veneer cement medium value zero was placed in the restorations and seated. The excess was cleaned up, then the restorations were cured for 20 seconds both buccal and lingual. Any residual cement that was left over was removed with an IPC instrument and then refined with fine fluted carbide finishing burs.

17 Fig. 17: Final result I always have the patient return in one week for final photos and occlusion refinement. The beauty of having the patient wear the temporaries and work out the occlusion and esthetics is there are very few refinements needed at the one-week post-op. The patient and her mother came in for the final appointment. The patient was so happy with her new smile (Fig. 17) that both she and her mother gave me a big hug and had tears in their eyes. She also brought me a lovely gift and a card with these words: “Nobody has ever and will never be able to have the amount of impact on my life they way that the both of you do.” Those words were worth every penny I didn’t make. For questions and more information, Dr. O’Bryan can be reached at drobryan@onemorereasontosmile.com. quarter 2

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by br a d l e y s u t t on , d . d . s .

‘We’ve Got You Covered!’ Offering the Option of Partial-coverage Onlays during cerec 27 and a half, i was astonished when Dr. Gordon Christensen told us the percentage of full-coverage crowns versus partial-coverage onlays done in the United States. According to his numbers, the ratio of full coverage versus any type of partial coverage was 98 percent to 2 percent, respectively. Meaning the vast majority of teeth treated with indirect restorations last year were full-coverage crowns. What caused those treating these teeth to choose full- versus partial-coverage? Was it easier? Was it just more convenient? Give a set of X-rays, a few symptoms and an intraoral picture of a tooth needing restoring to 20 different dentists, and you would likely get 30 different answers as to how and why they would treat it. Don’t believe me? Read the forum on cerecdoctors.com sometime; you’ll see all the differing opinions out there. Conversely, I would guess that if those same 20 dentists had the exact clinical presentation and symptoms in their own mouth, their aforementioned diagnosis would oft times differ from what they placed or would have placed on that patient’s tooth. Why do some dentists have differing standards for what they want done with their own teeth than they do for their patients? Why do we place such blinders on our own eyes and not routinely offer the benefits of a well-prepped and -fabricated onlay when it would be ample treatment for the situation? If it’s something you’d want in your own mouth, shouldn’t we be giving the patient the same consideration? So, let’s clarify a few fundamentals. What is an onlay? “An onlay has been 42

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defined by U.S.A. dental benefit companies as a restoration that covers at least one cusp of a multi-cusp tooth.”1 To be a little more specific, if more than one-third of the occlusal table is compromised, the cusps adjacent to the affected area need to be covered. This is where our training and ability to make evidence-based decisions comes into play. If the mesial portion of the tooth is intact or affected in less than one-third of its intercuspal space, and the distal has a broken cusp or the decay extends beyond 1/one-third of the occlusal surface, then the tooth by definition needs an onlay with cuspal coverage on one or both distal cusps (Figs. 1-2). Delta Dental issued a statement to me over the phone that “with X-rays and the surfaces specified, as long as the tooth meets the criteria, we will reimburse it as a major service, but without the proper criteria, we will only reimburse it as a normal filling.”2 Having written a proper narrative and provided the necessary documentation (including a photo when needed), I have never had an onlay rejected by an insurance company. At times I’ve had to call and speak with their consultants, but they have allowed benefits when the situation dictated coverage of one or more cusps. At the risk of sounding too harsh, we, as a dental community, have the obligation to seek out better solutions for our patients, no matter the barrier that exists to prevent it. A favorite prosthodontics professor of mine at Marquette University, Dr. William O’Brien, D.D.S., M.S., made a point of saying to his classes that “Dentists solve problems!” His mantra (and because of him, the mantra of our class) was “If you don’t know something now, FIGURE IT OUT!”3 We have

3 all the tools at our disposal — between our current education and the ability we all have of continuing our 4 education — to find the answers to each set of issues we face. Our patients deserve the very best we have to offer; which should be an evolving set of solutions as we learn and practice our profession. Another thing we need to remember is that we are at the helm. No one else will dictate what type of prep we do besides us. We can make our preps as conservative as they can be, but also we can alter the prep according to the morphology of the underlying tooth. Even our full-coverage crowns can be prepped to preserve important tooth structure on the facial and lingual surfaces (Fig. 3). So-called “crownlays” can be a go-between when all of the cusps need coverage but the facial and lingual surfaces are intact (Fig. 4). Dr. Dennis Fasbinder, a renowned research clinician and program director of the Advanced Education in General Dentistry program at the University of Michigan School of Dentistry, has said, “Onlays are a very conservative and excellent restorative choice when addressing a moderately damaged tooth.”4 Dr.

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Fasbinder has studied CAD/CAM restorative modalities for more than 20 years, and stands by the abilities of well-placed all-ceramic restorations — both full- and partial-coverage — to stand up against the abuse they will be subjected to in the mouth. As he and I talked about the effectiveness of an onlay compared to a conventional crown, I asked him if there were any research or articles delineating the pros and cons of onlays compared with conventional full-coverage crowns. His response was that “any evidence comparing onlays versus crowns is purely anecdotal.”4 As I tried to find more specific comparisons of crowns and onlays, the response was always similar to “we have crown studies or we have onlay studies, but nothing together.” Unfortunately, a research project needs funding, and that funding most often comes from dental manufacturers who want to show how their materials hold up compared to other similar companies. They are not as concerned if their product can be used just as effectively in one situation compared to another. Research endeavors can cost more than $300,000 to facilitate. In order to tell the dental community anything useful, more than 75-100 restorations need to be prepped, fabricated and seated by a competent team or individual, and then six-month recall appointments need to be in place for follow-up and data collection for many years thereafter. There is also the important need of having control groups, and calculation of results, not to mention the time spent putting all of those findings into a coherent and usable format for the public. The cost associated with such an undertaking is prohibitive for most private entities and, as such, a sponsor is needed. This need for funding is also the very thing that can cause the results achieved to be received with speculation by the doctors meant to benefit from it. They see nothing more than another advertising campaign touted by the very people who stand to benefit most from their positive outcomes. Dr. Fasbinder reminded me that, “research isn’t conducted so that 44

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only one person or group can get positive outcomes; it’s about being able to have data that benefits the masses.”4 So, where can we turn for information on how onlays stand up against crowns if there isn’t any reliable research to support our hypotheses? Many of us need look no further than our own practices to find our very own anecdotal answers. Dr. Christensen extrapolated that the vast majority of onlay and other partial-coverage indirect restorations are completed by dentists in the CAD/CAM world. Far and away, that is most likely to be those reading this magazine; CEREC owners who want to improve their ability to face and fix the problems coming through their doors. I was curious just how many onlays I had done in the last few years (because in my mind, I was doing them all the time), and I was shocked to see that only 4 percent to 5 percent of my indirect restorations during the last two years, respectively, were onlays. I have to admit that I am among those of us who need to see the light and better recognize that onlays are a viable and often times superior (in conserving tooth structure and serving the patient’s needs) restoration when compared to fullcoverage crowns. Although there isn’t any specific data showing when an onlay could be better suited to a situation than a crown, Dr. Christensen has tested the strengths of onlays in his lab in Provo, Utah, and released the

results in his January Clinicians Report. Among the tested teeth, where non-restored teeth were the control group, and zirconia, Lava Ultimate, Empress, and e.max CAD were used for the onlays, “all onlay materials were shown to have higher strength and resist cuspal fracture better than unrestored natural tooth structure”1 (Figs. 5-8). Conclusion Onlays are nothing new. We’ve all seen them and know that they can be highly successful and ought to be a great addition to the armamentarium we use to treat the broken-down dentition. Crowns also are a fantastic aid that we use and will continue to use for the foreseeable future. That said, I feel duty bound to my patients to offer them the opportunity to keep more of their natural tooth structure when possible and to provide more than a “one size fits all” approach to treating a fractured or decayed tooth. The CEREC machine and the CAD/CAM world in general have been so blatantly misbalanced toward the full-coverage “crown in a day” mentality, not because it hasn’t been able to attain great fits, but because we as dentists have been unknowingly unwilling to embrace anything else. Every one of us has a typodont from Sirona with multiple onlay preps that we could practice with, but most of our practice has come from the crown preps they provided. Take the time to brush up on what you need to do to make onlays a viable part of your practice because, at the end of the day, The Golden Rule still holds sway. You owe it to your patients. For questions and more information, Dr. Sutton can be reached at suttonfamilydentistry@hotmail.com. references 1 Christensen, Gordon, “Are Tooth-Colored Onlays Viable Alternatives to Crowns?” Clinicians Report. Volume 5, (January 2012): Pages 1 and 3 2 Delta Dental. Third Party Insurer. September 25, 2012. 3 O’Brien, William. Director of Milwaukee VA and Prosthedontist. 2004 4 Fasbinder, Dennis. Program Director of the Advanced Education in General Dentistry Program at the University of Michigan. September 12, 2012

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CASE STUD Y

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by n e a l p a t e l , d . d . s .

Setting the Standard at cerecdoctors.com CBCT and Sirona Bring Dentistry to a Completely Different Level as dentists we practice an art and a science — a healing art and a caring science. In the age of digital dentistry, I am comfortable stating that CBCT will someday be the standard of care. The Standard of Care is often defined as a diagnostic and treatment process that a clinician should follow for a certain type of patient, illness, or clinical circumstance. For example, adjuvant chemotherapy for lung cancer is "a new standard of care, but not necessarily the only standard of care." (New England Journal of Medicine, 2004). In legal terms, the standard of care is the level at which an ordinary, prudent professional having the same training and experience in good standing in a same or similar community would practice under the same or similar circumstances. We have hopefully all done our research. We have started the journey of integrating CAD/CAM techniques and protocols in hopes of reaching mastery. In our minds, we have locked every pearl and piece of advice we have received from trusted cerecdoctors.com faculty, mentors and respected colleagues. Sometimes we are misled into believing that dentistry is black and white … that dentistry can follow a simple equation and result in ideal treatment. Are we forgetting something? What about the Hippocratic Oath, the Golden Rule, or the advice from our loved ones! We often get confused as to how we should serve others: the Hippocratic Oath says to do no harm, while the Golden 46

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Rule says do unto others as you would have done to you, while our loved ones expect us to use our best judgment for any given situation. I for one have come to realize that the best way to practice, is to practice the art of dentistry as if you were providing treatment on your own mouth or the mouths of our loved ones. In following this moral compass, you will always “do the right thing” for any given situation. Sirona 3D Imaging and Cone Beam Computed Tomography (CBCT) technology has become part of my compass in treating patients. In fact, as I have mentioned many times before, CBCT is the cornerstone of my practice as it is useful in ALL facets of dentistry (Fig. 2). To date, there are hundreds of clinically relevant articles from universities and studies from around the world reviewing the various clinical applications of CBCT technology. So is it the standard of care? We must reflect upon the reasons why we have chosen the career of dentistry. Hopefully, it was chosen as your profession out of a deep desire to help people, to help improve the well-being and quality of life for patients and to help ease their pain by curing their disease. We spend our life dedicating our efforts, energy, and time to understanding and treating the oral cavity. What I find unfortunate is that we could find the most educated, talented and wellintentioned clinician liable if something goes wrong. It could happen to anyone of us. The excuses of “I did my best,” or “this is what has worked for my other patients,” or “this is what I my colleagues do and I

Fig. 1: The Galileos CBCT

1 thought it was the correct” are all excuses that we might come up with in our own defense. Unfortunately, there is a group of equally dedicated professionals who carve their time understanding how to protect the consumer within a lawsuit alleging dental malpractice. A universally agreeable written “standard of care” may never come to exist. Often, the term will be thrown around in pockets of the world among like-minded clinicians. It sometimes takes a clinician to declare and be vocal by literally stating a concept of treatment as the “standard of care.” Let me be the clinician. Mark my word, CBCT is the standard of care among our dedicated group of like-minded clinicians, the cerecdoctors.com doctors! We for one, see the challenges of restoring mal-positioned implants within our CAD/

comprehensive interdisciplinary care

development orthodontics endo therapy 3rd molar

evaluation of airway studies dentition

sinus tmj analysis periodontal evaluations evaluation

cerec guide

galileos  cerec  diagnosis  planning  treatment  1 appointment, 90 minutes

3 CAM environment, an environment where microns are appreciated and respected. As CAD/CAM clinicians, we share our higher standards for our restorative patients and see this continuously on the www.cerecdoctors.com forums. We are starting to see a wealth of cases being shared on the forums from clinicians who have integrated both CEREC and Sirona 3D and use these technologies on a daily basis. The “Galileos – CEREC Integration” (GCI) is no longer a concept, feature, or “sales” term — it is a definitive way of practicing implantology (Figs. 3 and 4). In fact, it has become a core procedure for many of us. For an increasing number of CEREC Doctors, GCI is the standard of care! Why are we afraid to recognize CBCT as a standard? Recognizing the subjectivity of treatment plans helps explain the

4 difficulties in interpreting the standard of care. Like a fingerprint, every patient we treat in our respective practices is unique. For any given oral condition we assess and diagnose, there is most likely

Fig. 2: CBCT imaging is applicable in all facets of comprehensive diagnostic dentistry Fig. 3: Workflow provided by the Galileos and CEREC integration for guided implant planning and placement Fig. 4: Volumetric image showing treatment plan of implant # 30 with CEREC Guide technique several treatment modalities to obtain therapeutic results (Figs. 5-8). We therefore rely upon our individual training and experiences to provide treatment in the best interest of the patient. First, “do no harm” is the ethical and legal obligation of treating any patient. Adhering to a standard of ethical conduct means you try to provide the most conservative procedure possible that is in the patient’s best interest. We all recognize that there are vast differences of opinion in dentistry. For any given oral condition that a patient may present with, we could find 10 different treatment plans provided by 10 different clinicians. Although we find 10 different treatment modalities, it does not necessarily mean that any one of them is wrong. In fact, it simply means that there are 10 different approaches to pursuing a common goal, which is the dental health of the patient Some of us make the mistake of assuming that we are treating patients within the standard of care because they are doing it the way they were taught in dental school, doing it the best we can, or doing it the way everyone else is doing it. In my opinion, the standard of care is not dependent on the number of clinicians who practice a certain way. quarter 2

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Figs. 5-8: CBCT planning of extensive implant reconstruction showing before, treatment plan in CBCT, and temps provided same day as surgery for teeth in a day It is what a reasonable, prudent dentist should be doing under the same or similar circumstances while applying scientific, evidence-based concepts. For our purposes, it is the mind of CEREC dentist that I base my assumptions. The assumption is that we agree upon the benefits of CAD/CAM dentistry. If we can agree that one profound benefit of CAD/CAM is restorative precision, then understand that CBCT provides us the same level of precision for diagnosis and surgical treatment. Although the definition of the standard of care has not changed, the method in which clinicians practice has changed and, therefore, the level of care has evolved with the development of new diagnostic tools, biomaterials, and the advent of new treatment modalities. Throw in the ever-changing variable of technology and we find ourselves confused about the “standards.” The factors that influence the standard of care include the diagnosis, the patient, advancing technologies and materials, and treatment modalities for optimal care. We must continually re-educate ourselves with the emerging technologies, materials and techniques. Certainly, having scientifically evaluated evidence to support a treatment modality is critical to defining a standard of care. As long as we are able to support the treatment decisions with 48

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great science and good judgment, put the patient’s interests first and do no harm, we may approach CBCT as the standard of care. Remember, lets not get confused about CBCT as being the “standard of care” just because it is new technology, or a the fact that it has become a “favorite” and trending technology amongst our group of CAD/CAM clinicians. Let it become the standard of care because of the proof of precision, improved diagnostics, and reduction in clinical morbidity. Let CBCT become the standard of care because we have a greater responsibility

to evaluate and treat our patients more comprehensively. Remember that as general dentists, if we choose to perform a specialty procedure on our patient, we will be held to the same standard as a specialist. In other words, if you are going to extract a third molar, you will be held to the same standards as an oral surgeon. So, if you are going to provide a procedure, make sure it is provided at the highest level. Although you and I can agree that there are different “levels” of crowns that a patient can choose (i.e. low-end vs. high-end lab), in the legal

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Figs. 9-16: The entire sequence of treatment for a patient with MVA, large defect in anterior mandible, planning using Sirona 3D imaging software, CEREC Guide Surgery, and final result with X-ray

world there is only one level of treatment for a procedure, the correct way. So if it was not done correctly, then it must be incorrect. It’s that simple! In the end, here is my advice: treat your patients like family. I believe that most of the issues and lawsuits that occur today happen due to poor communication. As dentists, we certainly envision treatment within our minds, but often fail to communicate the details to the patient because it is often too complex to put in simple terms. Galileos and CEREC integration help to streamline communication between the dentist and the patient. In today’s digital age, patients have access to a wealth of information. In my opinion, most patients don’t care to know how much you know, but care to know how much you care. As a dentist, you should look out for the best interest of your patient and I believe that our education and ability to communicate define our success. A patient who is presented with all their options including the benefits and drawback (informed consent) is a patient who is able to participate in the treatment that you have to offer. With the amount of information we know about dentistry and explanation of the research, it can be very difficult to communicate the details to the 50

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patient. At the end of the day, I believe that in order to be the best dentist, one needs access to the best diagnostic tools and compassion. To have a 16 truly successful practice, the goal is to make every patient feel like they are genuinely being cared for. Our patients are much smarter than we sometimes give them credit for. They clearly understand when a clinician is driven by money as opposed to being driven by the desire to help. If you do what’s in the best interest for your patient and you genuinely care for them, I promise you will meet the standard of care. Not only will you meet the standard of care, but you will render treatment in the highest ethical fashion because

of the compassion for the person in the chair (Figs. 9-16). CBCT and Sirona 3D in combination with CEREC will truly provide you an opportunity to practice dentistry at a completely different level. You will be forced to learn, to challenge your concepts of dentistry and raise your skill level. I hope that you take the time to consider what you are missing and define what you cannot see. Give yourself the vision, 3D vision, and join a group of us who believe that CBCT is the standard of care for diagnostics, communication, and ultimately comprehensive dental treatment. Let’s set the standard! For questions and more information, Dr. Patel can be reached at neal@cerecdoctors.com.

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by S a m e e r P u r i , D . D . S .

What is the Future of Dental Ceramics? A Conversation With Dr. Werner Mörmann About the New Hybrid Ceramic the success of the cerec system, and hence that of VITABLOCS feldspar ceramics, is owed to Professor Werner Mörmann’s pioneering work, which began more than 25 years ago. With the recent introduction of the hybrid material VITA ENAMIC, clinicians have a material that blends the best of both worlds. Prof. Mörmann discusses his expectations for its long-term success and future development of its clinical applications, including possibilities and limitations of treatment. with vita enamic, a hybrid dental ceramic is available for the first time. is this the new generation of “materials of the future” that clinicians have been waiting for? The new hybrid ceramic fits into the spectrum of established materials that make use of CAD/CAM technology, from advanced ceramics to polymer blocks. VITA ENAMIC positions itself in the middle of that spectrum by fulfilling the dream of flexible yet aesthetic ceramics. All available laboratory tests show that this material perfectly meets the requirements of chairside applications. The actual aim of this CEREC development was to enable dentists to provide 52

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the patients with ceramic restorations as quickly and easily as possible. Could we expect a ceramic with a level of flexibility adapted to hard tooth tissue? The pioneer of this esthetic hybrid ceramic is the American dentist Dr. Russell A. Giordano, who has been researching it since 1996 at Boston University. It took the most painstaking refinement work at VITA Zahnfabrik to achieve the highest product quality. I am excited to see how VITA ENAMIC fares in clinical settings in the long term. Shortterm clinical experiences have certainly been excellent, and I expect to be delighted by the long-term results. what distinguishes this hybrid ceramic from other traditional concepts of monolithic dental ceramic materials? This hybrid ceramic consists of silicate ceramic which is permeated, in a completely homogeneous and isotropic manner, with a fine polymer network. To a certain extent, this polymer network confers elastic properties to the ceramic, which are similar to those of dentin and allows, in the case of full adhesively bonded crowns, a much higher endurance than is possible with traditional ceramics. This was demonstrated by durability tests conducted by Prof.

Dr. Petra Güg at Freiburg University Hospital and Prof. Dr. Robert Kelly at the University of Connecticut. you tested vita enamic at the university of zurich from the outset, and lent constructive support to the further development of the material. which of vita enamic's material properties stood out the most in terms of clinical applications? My research shows that this hybrid ceramic can be cut faster than other monolithic restoration ceramics. And also faster than composites, whether using the fast or normal setting of the CEREC MC XL device, and with high shape accuracy. In addition, the polymer network guarantees shatter-resistant contour grinding of the thin tapering edges of dental restorations. The use of hybrid ceramic allows for the achievement of a longer service life of the diamond grinder than any other material. This significantly increases the efficiency and profitability of the CAD/CAM method, which is important in practice. Additionally, in the clinical setting, the material distinguishes itself by its easy workability and polishability. These properties correspond perfectly to the concept of an efficient chairside CAD/CAM treatment.

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what is the particular benefit of this hybrid ceramic, based on it being both resilient and elastic? in other words, why should the concept of the so-called strength of a dental material be redefined? In my view, the strength and stability of single-tooth restorations such as inlays, onlays, crowns and veneers can now be geared toward the properties of the natural tooth for stability, and less so to extremely hard, heavy-duty frameworks. The definition might be "The strength of a dental material for single restorations should, together with the residual tooth, achieve approximately the same resilience as the natural tooth." Bear in mind that the flexural strength of natural enamel is low without its sub-layer. Its strength is the result of its evolved internal (“adhesive”) alliance with the dentine. The development of CEREC was possible only on the basis of the adhesive technique, which allowed ceramic CEREC 1/VITABLOCS Mark I restorations to be lastingly and tightly cemented with posterior composite. After the usual etching with hydrofluoric acid, the new hybrid ceramic exhibits a highly retentive etching pattern, thus providing ideal conditions for long-lasting adhesive bonding. The elastic properties of the material greatly increase the resilience of the combination with the hard tooth structure, as the aforementioned studies show. This is why fracture-free, high long-term stability can be expected even in clinical settings. what were the specific objectives of the in vitro vita enamic tests you conducted at the university of zurich? were there any esults that surprised you after more than 25 years of cad/cam experience? The aim was, first of all, to examine the above-mentioned grinding properties of the hybrid ceramic in comparison to established silicate, lithium and zirconium dioxide ceramics, as well as composite and polymer materials. A further area that was worthy of interest was the surface quality that could be 54

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achieved with respect to the abrasion of the material in the contact area with the antagonist, and the abrasiveness of the material compared to the natural tooth enamel of the antagonist. Other than that, we also performed hardness measurements on all materials. What surprised me was the significantly lower hardness of the hybrid ceramic compared to established ceramics. VITA ENAMIC abrades the enamel antagonist significantly less than silicate and lithium disilicate, unambiguously making it the most enamel-friendly ceramic material of all. On machine polishing the surface of the hybrid ceramic, the same gloss values can be achieved as with the silicate ceramics; after abrasive tooth brushing in a laboratory test, the gloss obtained with VITA ENAMIC was of similar quality to that of nanocomposite. also, it wasn't just patients who were treated with vita enamic during the clinical tests conducted at the university of zurich; you had an inlay fitted on yourself. what feedback have you had from patients so far, and what are your experiences as a patient? Patients who already had some experience with CEREC restorations reported the lower hardness and the certain degree of elasticity of the material to be pleasant. This reflects my own experience as a patient. Obviously, I assume that the resistance of the VITA ENAMIC surface actually matches that of natural tooth enamel. My previous clinical observations over four to six months, especially scanning electron microscope findings in relation to wear facets, reveal a wear pattern on the hybrid ceramic which is very similar to that which is observed on tooth enamel. Our abrasion measurements in the chewing simulator confirm this with over 1.2 million chewing cycles. The enamel cusps mounted into the chewing simulator produced a 46.1 µm loss of height on VITA ENAMIC contact surfaces, and a similar 42.3 µm height loss

on control enamel surfaces. The loss of height on the enamel antagonists themselves was 54.5 µm when operating in contact with enamel, and only 27.6 µm, when in contact with the VITA ENAMIC restoration surface. Accordingly, on the one hand, the chewing-induced wear of the hybrid ceramic was practically identical to that of natural tooth enamel and, on the other hand, the hybrid ceramic clearly protects the tooth enamel. what are the possibilities and limitations of vita enamic in terms of indications and design? The degree of elasticity of the hybrid ceramic and its reduced brittleness and hardness broaden the range of properties of its silicate ceramic base, in that the hybrid structure combines the characteristics of the natural tooth substances enamel and dentin. Because of that, I would expect hybrid ceramic to be especially suitable for the treatment of devitalized side-teeth with partial and full crowns. In any case, this is the indication we come across the most in our student courses. what can you tell us about the processing and grinding characteristics of vita enamic? The particular suitability of hybrid ceramics for shape-persistent and rapid machining has already been mentioned. The easier manual machining and polishing compared to traditional ceramics makes hybrid ceramics particularly easy to work with for the dentist in clinical chairside situations. where do you see vita enamic hybrid ceramic a few years from now? In a few years' time, I envision that all of the restorations made from VITA ENAMIC hybrid ceramic will be in the same condition as that in which they are being placed in patients today. I anticipate that this material will prove itself just as much in the treatment of devitalized teeth as it has in the treatment of vital teeth in long-term studies.

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by m a rk f l e m i ng , d . D . S .

Dr. Gregory Mark A Digital- and Technology-loving Doctor Explains Why CEREC Is ‘Superior to all the rest’ dr. gregory mark studied medicine in the former Soviet Union before graduated with honors from NYU. Today, he runs a 10,000-patient-strong practice that manages to add another 50 patients every month. He prefers working on what he calls “complicated” procedures, including sinus lifts, implant placements and fullmouth rehabilitation cases. Here, he discusses why CEREC is his CAD-CAM of choice for his favorite kind of work. how long have you been in Practice? I have been practicing dentistry since 1988, after graduating from Tashkent Medical University located in the former Soviet Union. Upon coming to the United States, I graduated with honors from the School of Dentistry at NYU in 1995. I opened my first private practice in 1996, and until recently practiced there. In January of 2006, I relocated to a new, beautifully renovated office in the heart of Forest Hills, N.Y., with stateof-the-art technology. what is the size of your practice? My office is a little over 1,500 square feet. We currently have more than 10,000 patients and are averaging about 50 new patients each month. The staff consists of three front-desk patient coordinators, one treatment-plan coordinator, a billing manager, four assistants, one full-time and one part-time hygienist, one full-time associate and one part-time periodontist. how many operatories does it have? I have five fully equipped operatories with a similar layout. There are two hygiene and three restorative/surgical operatories. One of the rooms is a 56

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dedicated surgical/implant room and the other two are general restorative rooms. what type of dentistry do you do? We are a general family dentistry practice with a concentration on esthetic dentistry and full rehabilitation cases. My associate, Lev Kandov — who graduated from Stony Brook School of Dental Medicine and did his residency there as well — was trained in CEREC restorations and full-mouth rehabilitation cases on implants. He performs general and cosmetic dentistry, sees the majority of pediatric patients, and places and restores implants. I prefer to do the more complicated procedures such as sinus lifts, bone grafting and augmentation, implant placement and restorations, and quadrant and full-mouth rehabilitation cases. We develop facially generated treatment plans utilizing programs like Dolphin, Simplant, Planmeca 3-D cone beam and CEREC. We are fully digital, using Eaglesoft for digital imaging and charting, intraoral photographs, newpatient online forms (Dentvisor software), and magnifying and recording during procedures using MagnaVu. All of these pieces of technology combine to make challenging cases easier and ensure that we end up with predictable results. why is cerec your cad/cam choice? After doing much research, I came to a realization that CEREC was superior to all of its competitors. We first joined the CEREC community in 2007. The quality of the restorations was unsurpassed. I was able to perform a higher quality of dentistry because I had full control of the restorations, thus increasing my functional and esthetic outcomes. The

patients loved the technology because we were able to avoid multiple visits to the office. It made a big difference for those patients that have emergencies or needed to travel soon and did not want to go on a trip with a temporary restoration. how does this technology fit into your office philosophy? My team and I are always looking for a new way to improve our practice so that we can provide the highest quality of care. We were looking for something that would wow our patients and give us the ability to deliver better quality, more conservative and longer-lasting restorations. This is exactly what I get with the CEREC system. We are also looking for ways to reduce the overhead of the practice. With this technology we were able to eliminate approximately 95 percent of our monthly lab bill, and it saved us chair time by reducing the two- and three-visit restoration appointments. how does cerec impact your practice? Ever since I started my journey with CEREC, I have WOWED all my patients. They recorded the designing and milling processes on their phones and posted it on YouTube and Facebook. This has led to more internal referrals than ever. The word spread among my community that we do extremely conservative, esthetically pleasing and one-visit restorations. That caused a big boom in my practice. Patients appreciate not having to come back multiple times and get multiple injections, and I appreciate not having to depend on the lab for perfect restorations. I love having full control of restoration

Dr. Gregory Mark (right) and Dr. Lev Kandov with their dental team. contours, contacts and occlusion. Furthermore, I was able to virtually eliminate my lab bill. It used to be more than $10,000 per month just for crown and bridge. what is your favorite cerec procedure? I love using CEREC in everyday dentistry, from composite restorations to multiple crowns. I love to use the inLab software with my CEREC, which allows me to make custom abutments and implant

crowns. I’d like to thank Mike Skramstad for helping me learn the software, and the whole cerecdoctors.com community for helping me improve and learn a lot of new techniques and for all the advice that you have given me. what is your most unique cerec procedure? I love to perfect my skills as a dentist and as an artist with anterior restorations. I once had a patient who never smiled in any pictures due to the poor condition

of her teeth. When I finished making the temporaries and placed it into her mouth, she started tearing up and smiling when she saw herself in the mirror. The temps made her look younger and she was finally showing her teeth. That brought a huge smile to my face and to my team. I can’t wait to deliver the final product using the CEREC Omnicam! if someone was to take your cerec away today, you would … ? It’s a good thing I have two! quarter 2

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by Fr a nkl i n M a x i mo , D . D . S .

Dr. Arun Garg

Clinician, Educator Instrumental in Training Thousands in Implantology symbiosis has two definitions, each which describe the dilemma clinicians face regarding implants placed by their specialists: • A relationship of mutual benefit or dependence • A close, prolonged association between two or more different organisms of different species that may, but does not necessarily, benefit each member Naturally, the first scenario is ideal, but because of the nature of the generalist/specialist relationship, the second scenario frequently occurs. It happens when the implants placed by your specialist don’t support your unique restorative needs. We believe an effective way to solve this dilemma is to place your own implants with CEREC restorations combined with Galieos technology. The challenge is to build mutually symbiotic relationships with implant educators who: • Agree that implant-treatment planning should be prosthetics-driven • Believe that GPs can learn to place their own implants and perform supporting graft surgeries • Have created a comprehensive curriculum designed to help GPs achieve implant excellence One such educator is Dr. Arun Garg: tell us about your teaching philosophy. My teaching philosophy has five parts: • Belief • Motivation • Knowledge • Skills • Methodology 58

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part 1, belief: If they have the desire, I believe that all dentists – whether they’re oral surgeons, periodontists or general practitioners – can and should place and restore implants. With the highly predictable procedures, instrumentation and training available today, there is no reason not to. It’s absolutely vital that dentists placing implants have that same level of belief. If they don’t, there are all sorts of negative influences out there that will convince them to stop providing this valuable service. part 2, motivation: A high level of motivation is extremely important. Without it, dentists will begin their journey, but give up too easily. The dentists who come to Implant Seminars are motivated to begin with. On our team, it’s everyone’s job to keep this motivation strong with encouragement and support, and also by providing real-world role models of dentists who, just like them, have successfully implemented implants into their practices. part 3, knowledge: Dentists need to have high levels of knowledge to go with their motivation. Dentists who are excited but don’t know what they’re doing are dangerous. In my Implant Dentistry Continuum, students receive lectures, detailed course hand-outs and text books I’ve written. In addition, they get all their questions answered from me and my team of highly trained and experienced instructors. Dentists need a solid foundation of knowledge upon which to build their clinical skills. part 4, skills: Practical clinical skills must accompany the knowledge. In my

trainings, dentists don’t just sit there and listen. They do. They refine their skills with soft tissue, prosthetic models and cadaver specimens under the watchful eyes of our faculty. Students also have the option to perform surgeries on live patients under our close supervision. Spaced repetition is essential in learning to place and restore implants. That’s why Implant Seminars prefers teaching with a continuum format. In our basic continuum presented in numerous cities around the country, we train dentists in locations near their homes during four weekend sessions over four consecutive months. This allows the students to learn a chunk of knowledge and gain a level of skill. Then, they apply these skills in their practices prior to their next session. When they return, we answer their questions and give them additional knowledge and skills. part 5, methodology: Effective methodology springs from repetition. Nothing in surgery is 100 percent predictable. To increase predictability, I created a “cookbook” approach to teaching implants. My students know the recipe for success. They have all the ingredients on hand and have learned how to mix these ingredients in the correct proportions and order to create masterful implant results in their practices. In addition, I started live patient courses abroad because I wanted to give doctors hands-on experiences they could never get otherwise. It’s great to learn techniques, but I wanted to make sure my students practiced all of the right techniques. With live courses, I’m able to watch everything they do and improve their skills with instantaneous coaching. The feedback from the doctors taking the live patient courses has been fantastic. Here are a few of their comments:

• “I feel comfortable and confident now” • (The courses will) ”rejuvenate my career” • “I placed my first implant on a lowerright molar in 45 minutes” • (This course will) “raise my production 30 percent to 40 percent. It’s a course you will have to take” what competency level should gps have before placing implants? how does your curriculum achieve this? This is a great question and one that uncovers a vital aspect of incorporating implant placement in any dental practice. The primary reason most dentists new to implantology never become good at it is they never place their first few implants. They study, study, study. They read all the books. They attend all the courses. They think they need to know everything before they do anything. This is another reason why we use the continuum method of learning. After the first weekend with us, our dentists identify potential implant cases. They do treatment planning. Then, during the timespan of the four-session continuum, they place their first implants starting with the easiest cases with the highest success rates. These cases give them the confidence to do their next cases. The entire time, we provide the support and coaching needed to do their jobs well. With a few successes under their belts, these dentists enthusiastically enroll in

our advanced continuum and progressively do more complex cases. Implant excellence isn’t a one-time event; it’s a journey. what is your position on prosthetics-driven implant placement and treatment planning? I strongly support the concept. Patients come to us for results. Their implants and restorations are simply a means of getting there. Not considering function and esthetics in implant-treatment planning and placement will result in dentists making adverse compromises when restoring the cases. In other words, dental implantology is a prosthetic discipline with a surgical component. Placing implants is like numerous areas in life: begin with the end in mind. This is true in creating a CEREC crown: visualize and design first, then mill accordingly. This is true in constructing a house: visualize and design first, then lay the appropriate foundation. This is also true in building a professional career: decide who you want to be and what you want to do first, then take the appropriate educational courses and invest in the needed equipment. how does your team approach training? is this how you advise clinicians to work? I have a very team-orientated approach to treatment planning and delivery. All of

my team members are thoroughly trained in every aspect of implant placement and restoration. They are well versed when patients ask them “outside-the-box” questions. This is vitally important because some patients ask my team members questions they would never ask me. Educating your team and having them understand the big picture is an important part of increasing the number of implants you do. Much of my time is spent analyzing cases with team members. Some dentists may view that as a compromise. I view it as a team morale booster. should all patients receiving dental implants be ct scanned? In an ideal world, yes. And, of course, dentists should have coaching on how to interpret their scans. In the real world, the aswer is no because, with the amount of litigation out there, once the literature and opinion leaders start to say that all patients receiving dental implants should be CT scanned, it means anyone who doesn’t could be up for malpractice. It is also problematic for those patients who have read erroneous reports on the radiation associated with CT scans and therefore refuse them. So, though 2013, it might be a bit premature to say it, but that day when CT scans are required IS rapidly approaching. should all implants be completed with guided placement? I recommend that almost all implants be completed with guided placement. There are several advantages: • It increases the dentists’ confidence levels, which will increase the odds they will place their first few implants • It increases the success rate of the procedures and decreases the chance of complications • It decreases the time needed to place the implants Guided placement is less important in “green light” situations such as quarter 2

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lower-anterior, two-implant overdenture cases. To maximize results and minimize complications, dentists performing implant surgery with or without guides should be trained in: • Flap reflection • Suturing techniques • Anesthesia techniques • Handling complications • Purchasing the right equipment and using it correctly should gps include implantplacement services in their practices? In order to stay current and marketable in today’s competitive healthcare landscape, implants should be an integral part of every general practitioner’s array of services —if for no other reason than to stay on the same level with Dr. Smith down the street. With so much marketing by large implant companies, the general public is much more aware of implants and their benefits. Patients come in to dental practices asking about them. If you don’t have implants on your list of services, you will be doing your patients and yourself a disservice. Of course, there will be cases you should refer to specialists. how can an implant practice separate itself from the big chain offices? Considering the emerging effect of the big chain offices, marketing will become increasingly important in the years ahead. Unfortunately, most dentists aren’t very good at it. Actually, branding comes first. When people in your area think of you, what words and images pop into their minds and what emotions do they feel? Those words, images and emotions are your brand. In my practice, I work very hard at positioning myself as the premiere dental implant expert. Confidence is the key word and emotion I promote. Dentists just need to decide what they want to be (their brand) and then spread the word 60

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effectively (marketing). Your brand is also a promise you make to people. Before their design flaws became apparent in 2010, Toyota’s brand promise was high quality. They broke their promise and are still recovering from the effects of that. This is why having the right equipment, instrumentation and skills are so important in the dental profession. They enable dentists to keep their promises. After you’ve established your brand, you need to spread the word with traditional and non-traditional marketing methods. Especially important is a website that attracts people looking for dental-specific services and then effectively influences them to call you. Most dental websites I’ve seen are just fancy brochures. Both dental implants and CEREC dentistry is associated with highend, quality work and personalized service, while much of the big chain offices are associated with just the opposite. So these things will help in branding one as a quality, highend and personal-touch office.

what is the family life of the director of implant seminars like? Busy. I have a wife and three boys who I thoroughly enjoy and love. The kids are growing up so fast — I should refer to them as young men. But to me, they will always be my little boys. They frequently accompany me on my travels. It’s a joy to show them the world, and they’re developing a real eclectic palette when it comes to dining during the travels. My wife and kids joined me on a recent trip to the Dominican Republic. It was fun to watch the kids mingle with the doctors and the Dominican people who are so warm and loving. They also had a chance to volunteer in the clinic. My wife and I can’t wait to see what the world has in store for them. Of course, three dentists in the making would be a dream for me. I can’t help but fantasize about how much more exciting and rewarding the dental profession will be for my children.

where is this headed in the future? I don’t know for sure. And that’s what makes it all so exciting! In general, I’m sure the procedures, equipment and technology will improve. There are a lot of very smart and extremely motivated people and companies out there. I know Sirona is one of the leading innovators. The quality and quantity of training will also improve. I’m looking forward to being an important part of that training piece of the puzzle.

Conclusion Dr. Garg frequently uses the word “journey.” Learning to place and restore implants isn’t a destination; it’s a journey – two journeys, actually. An outer journey where GPs attend courses, refine their skills, add equipment to their practices and provide enhanced services to their patients. And an inner journey where GPs gain confidence in their abilities and pride in their work. Don’t neglect the inner journeys of life. Outer journeys will give you financial success. Inner journeys create fulfillment. Dr. Garg offers valuable insight and encourages doctors to start or continue their journeys to implant excellence. And remember, everyone at cerecdoctors.com and Sirona are here to help along your way.

do you have plans to engage more with the cerecdoctors.com community? Absolutely. I’ve trained and/or worked with CEREC doctors Frank Maximo, Ray Kessler, Gary Torres, Daniel Vasquez, Michael Scoles, Obdulia Rondon, Francis Shin, John Jou and others. They are some of THE most dedicated and conscientious people in our profession. I look forward to adding to the list and forming more mutually beneficial relationships.

For questions and more information, Dr. Maximo can be reached at fbmaximo@hotmail.com.

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Compiled from www.cerecdoctors.com/discussion-boards/view/id/18130

Open Margin a Product of Prep Flaws? Please Advise … in this recurring section of cerecdoctors.com magazine, we share a sample of conversations occurring online: In this discussion thread, cerecdoctors.com members discuss how to achieve ideal fit with the CEREC.

Kevin Potts | Dallas

Kent Mosby | Coeur d’Alene, Idaho

A theme that seems to be recurring often enough that I wanted to see what sort of advice or downright jackslapping you guys may have for me: What are the problem areas that are either making these crowns not seat 100% or are causing the margins to be open or short? Thanks for any advice.

Mark Fleming (Faculty & Magazine Editor) Scottsdale, Ariz.

I think that this is a margination issue (Figs. 1 and 2).

This is from the underside of the prep. The margin does not reach the edge of the prep (Fig. 3).

This shows the adhesive gap not at the edge of the margin from the underside (Fig. 4). I only use the manual margin finder and if I am unsure I will look from below. I hope this helps.

What camera? Adhesive gap setting? Margin thickness setting? Kevin Potts Omnicam Adhesive gap: 120 (I am assuming spacer) Milling offset: -175 Prox str: 0 Min thickness rad: 600 Min thickness Occ: 600 Margin thickness: 100 Mark Fleming (Faculty & Magazine Editor) Yes, I meant spacer. Are your interproximal contacts tight? What color on proposal?

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Kevin Potts Mark – My contacts usually have some spots of green on them, but mostly a light blue. I check them each time since it seems to vary so often ... which I wonder if it’s related to axis of insertion sometimes. On this case, I did have to do some manual adjusting to get the crown to seat, but at the time of the photo I was happy with the interproximal tightness.

Brad Dorsch | Cincinnati Kent nailed that one. That's the exact reason. Kevin Potts Kent – Thanks for pointing those areas out. I just recently tried to start experimenting with the auto margin. But it doesn't seem anywhere near as good as manual most of the time. I will switch back just to eliminate that from being a potential problem. Unfortunately, I have had this problem even when I used manual mode. And in the case I showed here, the margin was open, not just short. Since I used to not have this problem with my lab-fabricated e.max crowns. I can only assume that there is something that I am not doing good enough to keep a milled crown happy. Please don't take this as my feelings of dismay with CEREC. I just need to get much better, and FAST! So, if anyone would like to chime in and give their two cents, I am ready and happy to take any and all criticisms. Honesty helps, even if someone feels that the prep is just no good or needs significant refinement. — Kevin "Thick-Skinned" Potts Steve Nielsen | Shelley, Idaho

do everything with the coarse diamond including the margins, back in the lab days, now I am trying more and more ways to refine margins since I am seeing the crap I am scanning. Suggestions/help? Douglas Lin | Hercules, Calif. I see this quite often and it really has dampened my enthusiasm for the one-visit crown. I have yet to read anything that resolves the issue for me. These are some of possible causes I have read: 1. Camera needs calibration. Tried this and didn't resolve the problem. 2. Prepping above height of contour. Eliminated this and didn't completely resolve the problem. 3. Margination. Tried over-extending the margin. Didn't resolve it. 4. Glaze on the margin from not seating the crown completely on the putty before baking. Checked this and still have the same issues. 5. Binding. Checked this as well and didn't resolve it. It doesn't happen every time, so it's very frustrating because that makes it hard to diagnose. I have Bluecam and MCXL. I would say this started happening a lot more since I upgraded to MCXL and doing a lot more e.max.

[In response to Brad Dorsch] Agree. Good job Kent.

Mike Skramstad (Faculty) | Edina, Minn.

Brent R. Browning | Houston

Douglas – Try the 12 burs instead of the 12S and see if you have better luck.

"Porsche" polish those axial walls and gingival margins! Your lab routinely masks unforeseen rough areas. CEREC acquisition sees it as it is! Doug Sakurai | Santa Ana, Calif. Are you moving the sprue location before you mill? Kevin Potts I did move the sprue to the buccal or lingual on that. I never leave those interproximal on e.max. So, Porsche polish the prep. How does everyone like to refine their margins here? I am trying to use a size 8 round carbide at 10k rpm. Suggestions for otherwise? I used to

Kurt Kwiatkowski | Grafton, Wisc. I had that problem when I first started doing CEREC. I was prepping above the level of the gingiva by 1-2 mm in areas on the facial and lingual. I found — and granted, I've done about 100 CEREC crowns so my data pool is small — that my margins looked like that because of margination issues. For some reason, the Omnicam doesn't seem to like to stay right on that 90-degree angle. Either it marginates in giving you a ledge, or it swings down, giving you jagged lines that look like little shark teeth. Now I prep just above the gingiva, unless there is a huge wall of enamel I want to save. If that's the case, then I will marginate the best I can, and then bulk out the margins in the parameters.

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I find that being close to the tissue gives really nice margins, even if I think it doesn't look smooth on the screen. Also, try marginating those cases from a 45-degree angle visually; it seems to help delineate the spot you want to mark. Justin Gates | Marion, Virginia [In response to Kent Mosby] I had this issue at the beginning. If you can eliminate everything else that has been posted above, let me suggest one: it’s the prep! Look in the first and last picture. It’s really not bad at all, it just needed 45 seconds more refinement. I am not one to criticize, but you asked for the help. It needed a slight roll over on the cusps (functional cusp bevel or two plane reduction). It looks like there are some sharper small irregularities at the buccal or lingual/occlusal line angle. The MCXL is supposed to overmill and allow for these sharper irregularities in the prep and still seat, but sometimes it’s not enough overmill. Any sharpness or jaggedness at any line angle causes a problem when seating. Before I started rounding all the occlusal line angles more than normal lab-driven crown preps, I would have this same "not seating fully" issue. If you would have adjusted the internal aspect of the crown in the area that you see in picture 3/4 on Kent’s reply, or smoothed the cusps seen in picture 1, you would get rid of the problem. I hope this helps. Again, I think the comments by Kent are spot-on for the margination and Kurt’s are also helpful. Use the parameters to help bulk out the margin and then trim/thin it back slightly when adjusting in the purple state. One suggestion that I use to help me see these issues earlier before I image: after I have prepped and think that I am ready to image, I let one of my DAs take the opposing and buccal bite images/scans. Then, when I scan the prep arch and marginate, I reevaluate the prep before scanning. Then you can make a minor adjustment if needed. My DAs never take a buccal bite with the prep in it, so it doesn't affect stitching. P.S. I have re-looked at more than a few of my preps that I thought were great and realized they were missing just slight refinements to allow for faster appointments, which equals easier and more fun appointments. Mark Dunayer | West Nyack, N.Y. First week with CEREC (Omnicam), so I'm reading about polishing prep and margins. What specific burs or stones are in use to get "Porsche-like" smooth preps?

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Gregor Sonin | Potsdam, Germany I use these: www.kometdental.de/index.php?id= 6334&L=1. The burs work perfect. All I am adding to the final prep is a quick polish with a brownie. But leave the margins alone, only low RPM with the red burs from the kit there. Mike Skramstad (Faculty) I like the fine-end cutting diamonds from Axis. Gregory Mark | Forest Hills, N.Y. [In response to Mark Dunayer] I use KS6 or KS0 fine, 10 RPM. Robert Marcus | Poway, Calif. [In response to Mike Skramstad (Faculty)] I couldn't agree more with this. Ever since I switched exclusively to the 12 (non-S) burs, I have been having way-better-fitting restorations. I do understand that they don't last as long as the 12S burs, but I'm willing to deal with that. Mark Dunayer 10 RPM? Gregory Mark [In response to Mark Dunayer] 10 RPM on electric high speed, or 20 RPM #2 carbide bur on electric slow speed. Robert Marcus [In response to Kevin Potts] On my Bluecam I use 120 spacer. I raised it to 140 on Omni. Seems to seat better but still tight. James Kim | Tucker, Ga. [In response to Mike Skramstad (Faculty)] Is this what most mentors do?

Thomas Kauffman | Atlanta, Ga. I think your preparation design needs some refinement. Here is an example of a first molar prepped last week. Preparation smoothness leads to easy scanning and great fit. It is not so much dependent upon what burs you use but how you use it. There are many very good techniques for polishing anything, including dentin and enamel. I am not convinced that low speed is any better than high speed, mid-speed or moderate speed. Just remember that the slower the RPM, the more heat is generated. Sometimes it is easier to apply a small layer of RelyX resin or other material at the pulpal floor or other areas to provide that glass-like smoothness. This photo was prior to final margination and scanning. At this point, I give the preparation on the bicuspid and second molar a C+, first molar a B+. At least it will give you a comparison. Diamond, carbide, hand instrumentation, disc, clockwise, counterclockwise, et al. There are many paths to the resultant image data being gathered. Best margins in the world, tooth surface as smooth as glass with no roughness or irregularities. That is, and always will be, the key to a great result with CEREC. James Kim [In response to Gregory Mark] Thanks for the bur info! My last five have seriously dropped in with zero adjustments! Is there a bur that is in between the KS6 and KS0? Because the KS6 is almost too wide for my preferences. I looked on Brasseler's website but couldn't find anything.

That led to the fact that my margins were hard to define virtually. The first thing I switched to was using a #6 or #8 round bur in my slow speed set at 30k RPM. It's very smooth and requires very little pressure ... as in darn near no pressure. Only touching the very edge of the prep to ensure no enamel lip and keeps heat transfer down. Gotta use sharp burs to make that work. Second thing I needed to work on was axial wall regularity more than smoothness. Easy enough to focus on. Third was getting the axial-occlusal angle to a rounded edge around the whole prep. I tried a number of egg/ football shaped diamonds but got faceting that didn't satisfy as often. So, I started using a bur that I had plenty of from years in the past. It's a weird bur. I believe it was intended to create the shape of marginal ridges for interprox composites. It's like a cone with a gradual inverted curve. Works like a champ for me more often than other solutions. I wish I knew the name of the bur so I didn't sound like a moron. Then, since the prep is so much cleaner, I fixed the wonky margination I was doing by: 1. Using only manual mode 2. Initial margination from occlusal 3. Revising margin line at a 45-degree angle or so, and 4. Making sure that I have a regular and smooth surface that I am ending my crown on So, in review, it was purely user error. The machine is what it is: a machine. A highly sophisticated machine with a newbie user. Might as well hand me a Lambo to take around a track at top speed. It has humbled me as a clinician. And has made me better for it. I now consider my use of CEREC as 90 percent fun and rewarding and 10 percent maddening. But that 10 percent is other stuff that I need training on or need to be better at. And this forum has been unbelievably helpful in that process!

Sameer Puri (cerecdoctors.com Founder)

#6 or a #8 round bur on a slow speed handpiece.

Awesome Kevin!

Kevin Potts Barely noticed that this thread got resurrected. So, I feel that I should give an update on my personal progress. IT WAS MY PREP!

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by S a m e e r P u r i , D . D . S .

p h o t o s by d r . Y a o - L i n T a ng

THE DOCTORS ABROAD

cerecdoctors.com Mentor Group visits IDS, partners in Germany in march, 50 doctors and spouses from the www.cerecdoctors.com Mentor group embarked on a week long journey of Germany to visit the International Dental Show â&#x20AC;&#x201D; the IDS â&#x20AC;&#x201D; as well as a tour of some of the corporate partners of cerecdoctors.com We started with 2 days in Cologne Germany visiting the trade show. We then departed for the historic city of Heidelberg, where we spent a few days relaxing and enjoying the local fare. Following that was a trip to the Sirona headquarters in Bensheim where all the attendees received a factory tour of the facility. From there, we went to Stuttgart for tours of the Porsche and Mercedes museums. Next came a night in Feldkirch, Austria, where we

spent the night and went on to Lichtenstein to visit the corporate headquarters of Ivoclar. Finally, the trip concluded in Munich where we finished the event with a tour of 3M Espe's manufacturing facility. There were night dinners and all in all an incredible time to be had by all. We anxiously await the next IDS trip in 2015.

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by s a m e e r p u r i , d . d . s .

The e.max Abutment Block A Definite Game-changer i recently had the opportunity to tour the ivoclar facility in Lichtenstein, Germany, with some members of our Mentor Group. Having been to the facility before, I enjoyed the reaction of the Mentors as they saw the beauty of the countryside and took the tour that was arranged by our friends at Ivoclar. 3M and Vita had also arranged tours and educational clinics as part of the week-long European tour of CEREC’s partner companies while we were in Cologne, Germany, for the International Dental Show. At the show, we enjoyed seeing many of the new and upcoming products: cements, blocks, new CEREC hardware and more. Out of all the products, for me, there was one clear winner in terms of how it will revolutionize the practice of dentistry for CEREC owners: the e.max abutment block. If you have the inLab software, a CEREC and a Galileos cone beam, you no doubt have been enjoying the ability to create abutments using the Sirona Tibase system. In this system, a scan body is placed on a titanium base which has been screwed into the implant. This is scanned by the CEREC camera — both Omnicam and Bluecam work well scanning the scan bodies. The scan body essentially tells the software the position of the implant in the arch. From this data, the clinician has the ability to design the abutment and final crown. The shortcoming in this process thus far is that the clinician was limited to this process by using only the inLab software and the fact that the abutment that was adhered to the metal Tibase was milled from zirconia. Zirconia, as you know, is a strong material but it requires a special sintering oven, which the vast majority of dental offices do not have. The final crown could be milled out of any material (e.max, Empress, Vita, LAVA, etc.) but the zirconia had to be sent to a laboratory for processing. This process took several days, as the clinician had to wait for the zirconia substructure to arrive and cement the crown on top. The other shortcoming of the process was that the abutments were designed only in the inLab software, which the majority of clinicians do not use. If you have been to the LEVEL 5 class with Dr. Mike Skramstad, no doubt you have enjoyed the features of the inLab software. But for most clinicians, who were relegated to the chairside software, this great feature of designing your own custom abutments became something they were not able to participate in. With the release of the new 4.2 software, I believe that we have come upon a major revolution in CEREC software. The 4.2 software has Abutment Design (along with Smile Design, Virtual Articulation and more) as a part of the chairside software; the 68

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same software you use daily in fabricating crowns, inlay and onlays. While this is exciting as now clinicians can design their abutments chairside, the better news is that Ivoclar has at the same time introduced a full contour e.max abutment block that does not require a zirconia substructure. The abutment block is manufactured with a precision-milled hole that fits precisely on the Sirona Tibase. With this hole premanufactured, the fit of the e.max to the Tibase is perfect. The clinician can simply mill a full contour block, cement it to the Tibase outside of the mouth and screw the apparatus in place and cover the hole with composite, giving the patient an ideally designed, full-contour screw-retained crown. If you don’t want a screw-retained crown, and want cement retained instead, simply design the abutment crown, split the file and you now have a substructure and final crown similar to how it was done with the zirconia substructure — only you are not using zirconia for the substructure. You are essentially using an e.max MO (medium opacity) block for the substructure and an HT (high translucency) block for the final crown, completely eliminating the need to sinter zirconia in the office. It is my belief that more clinicians will incorporate the CEREC not only because of the 4.2 software, but because we have the ability to completely bring the design and fabrication of implant abutments in-house. Look at your last lab bill for a custom abutment and a crown: you probably paid more than $500, and now realize that you can do this entire procedure for about $125. Has the power of the abutment design and e.max abutment block becomes apparent? I hope other manufacturers will create their own abutment blocks. I’d love to have an abutment block made from a provisional material such as Teliocad, or maybe something from 3M made from the LAVA Ultimate material, so that we have abutment blocks for virtually every clinical situation. I encourage you to watch the abutment videos on www.cerecdoctors.com and learn this technique. We will be teaching this online but also in the Level 3 class at the Scottsdale Center. 4.2 software is revolutionary, but the shot heard around the world is coming from Lichtenstein; Bravo Ivoclar for creating this block. For questions and additional information, Dr. Puri can be reached at sameer@cerecdoctors.com.

INTRODUCING

NO MATTER WHAT YOUR SKILL LEVEL, WE’LL SHOW YOU HOW YOU CAN DO MORE!

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CEREC MASTERY -

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POSTERIOR QUADRANT AND PATTERSON PROFICIENCY BEGINNING ORIENTATION OFFERED IMPLANTS DENTAL DIRECTLYRESTORING THROUGH PATTERSON

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PATTERSON BEGINNING ORIENTATION OFFERED DIRECTLY THROUGH PATTERSON DENTAL

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POSTERIOR QUADRANT AND PATTERSON PROFICIENCY BEGINNING ORIENTATION OFFERED IMPLANTS DENTAL DIRECTLYRESTORING THROUGH PATTERSON

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PATTERSON BEGINNING ORIENTATION OFFERED DIRECTLY THROUGH PATTERSON DENTAL

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bond, proven performance.

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PATTERSON BEGINNING ORIENTATION OFFERED DIRECTLY THROUGH PATTERSON DENTAL

• July 13-14 • Aug. 3-4 (Limited Seats) • Sept. 21-22 (Sold Out) • Oct. 26-27

SON BEGINNING ORIENTATION OFFERED MASTERING MULTIPLE DIRECTLYCEREC THROUGH PATTERSON DENTAL ANTERIORS

B 2 3 4 5 6

By Darin O'Bryan, D.D.S.

L EVEL L EVEL L EVEL

e.max

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PRACTICE GROWTH: CREATING THE YES PRACTICE

CAD/CAM Materials in Dentistry By J. Robert Kelly, D.D.S., M.S., DMedSc

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Multilink Automix ®

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LEVEL

NEXT GENERATION

Update on Materials By Mike Skramstad, D.D.S.

INTRODUCING

NO MATTER WHAT YOUR SKILL LEVEL, WE’LL SHOW YOU HOW YOU CAN DO MORE!

LEVEL

LEVEL 1

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CEREC MASTERY -

LEVEL 1

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POSTERIOR QUADRANT AND PATTERSON PROFICIENCY BEGINNING ORIENTATION OFFERED IMPLANTS DENTAL DIRECTLYRESTORING THROUGH PATTERSON

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PATTERSON BEGINNING ORIENTATION OFFERED DIRECTLY THROUGH PATTERSON DENTAL

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POSTERIOR QUADRANT AND PATTERSON PROFICIENCY BEGINNING ORIENTATION OFFERED IMPLANTS DENTAL DIRECTLYRESTORING THROUGH PATTERSON

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PATTERSON BEGINNING ORIENTATION OFFERED DIRECTLY THROUGH PATTERSON DENTAL

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bond, proven performance.

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• July 13-14 • Aug. 3-4 (Limited Seats) • Sept. 21-22 (Sold Out) • Oct. 26-27

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