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Vol. 2, No. 1 – February 2010
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Contents and Contacts
Palmeri Publishing
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Publisher: Ettore Palmeri, MBA, AGDM, B.Ed., BA
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Editorial
Shape and Surface Design
Ettore Palmeri, MBA, AGD, B.Ed., BA
Andreas Piorreck, MDT
Editor-in-Chief: Dr. Robert Zena Clinical Editor: John A. Sorensen, DMD, Ph.D Technoclinical Editor: Ed McLaren, DDS Office Administrators: Janeen Kerswill Bahar Palmeri, B. Sc. Frank Palmeri, H.BA, M.Ed Gino Palmeri Elena Sorokin, B. Acc. Graphic Art: Samira Sedigh Lindsay Hermsen, B. Des. Hon.
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Internet Marketing Director: Rashid Qadri
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Canadian Office: 35 -145 Royal Crest Court, Markham, ON L3R 9Z4 Tel: 905-489-1970, Fax: 905-489-1971
Don’t Fear Demanding Patients! Part I
Zircon is not Always the Same
Markus Stang, MDT
Shahab Esfarjani, MDT
Email: ettore@palmeripublishing.com Website: www.palmeripublishing.com dental labor international plus is published six times a year and distributed to Dental Technicians in the English speaking world. The journal is committed to improve continuing education for dental laboratories in order to optimize patient care. Articles published express the viewpoints of the author(s) and do not necessarily reflect the views and opinions of the Editor and Advisory Board. All rights reserved. The contents of this publication may not be reproduced either in part or in full without written consent of the copyright owner.
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Publication Dates: February, April, June, August, October, December Printing: Point-one Graphics Inc.
Customized Abutments
Printed in Canada. Canadian Publications Mail Product
José de San José González, MDT
Sale Agreement 40020046. Spectrum Dialogue (dental labor international plus) ISSN # 17105560 is published six times a year by Palmeri Publishing Inc., 2210 Guilderland Ave., Schenectady, NY 12306, USA. Periodicals Postage Rates paid at Niagara Falls, NY 14304.
CE Credit Test 1 .................................................................................. 33 CE Credit Test 2 .................................................................................. 34
U.S. Office of publication 2424 Niagara Falls Blvd, Niagara Falls, N.Y. 14304. U.S. Postmaster send address corrections to: Spectrum Dialogue, 2210 Guilderland Ave., Schenectady, NY 12306, USA.
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Contacts Contacts Editorial Editorial
Let’s plan to leave a mark.
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Ettore Palmeri, MBA, AGD, B.Ed., BA
e are in the midst of the holiday season and I am sitting here in my home study as I am writing this editorial for the February issue of Dental Labor International Plus. I am enjoying my espresso and I am thinking how to structure my thoughts. At the same time I am trying to listen to what Arianna, my four and half year old daughter, is doing in the play room. My wife, Bahar, has gone out boxingday shopping; Tommy Hilfiger, had a sale and despite my warnings about crowds and false advertising, she has ventured out. I catch myself day dreaming and I refocus on the job at hand. Mostly, I am thinking of about the importance of having a vision and setting up the objectives necessary to achieve success in life and in business. I must admit, though, it is not easy. I realize that the bigger I dream, the more our organization grows, the more challenges I face as an individual and as a team. My mission in life is very simple. I want to help dental professionals become extraordinary and their businesses more successful by providing cutting edge education in a different format. In turn, we can all make the world a better place. This is not just a business to me, it is my vocation. But, the higher I reach, the more I get tested. Sounds familiar? But challenges are good. We grow when we face them. The leaders among us smile in the face of adversity. They know that life tests all of us, however, only the strong get to sing their heart song.
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So, as we face 2010, I commit to embrace all the challenges it will bring. I will consciously keep my eyes focused on my mission. Because, I know this world belongs to dreamers like you and me. In the end, it will not be important if we win every battle. What is important is that we make a difference to our world, and that is good enough for me.
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Aesthetics and Techniques for New Materials Achieving success for the Dental Team This admirable and clear text is updated and enriched by an interesting and vast iconography which originated from the enthusiasm of two competent men who are experts in their professions. The cooperation between the two authors, dental technician Paolo Smaniotto and Dr. Alexander Beikircher, has been a fortunate one. Both have always managed to give their professions a cultural impulse, seeking and finding, both in Italy and all over the world, renovating sources and worthy teachers, from whom they have drawn knowledge, advice and exchange of ideas. After so much effort, they have become cultural reference points over the last few years thanks to their conferences and books, now crowned by this valuable text.
Authors Paolo Smaniotto, MDT Dr. Alexander Beikircher
$179.00 214 pages, 11.5 x 9.5 inches
“Attention is f the teacher o every detail”
This text is the keeper of decades of professional activity and constant updating, thanks to which the authors have been able to find a balanced mixture between theoretical concepts and practical applications. They have proposed recent topics of modern dentistry and dental techniques, comparing them with consolidated methodologies. They have also been able to elaborate and describe fortunate personal intuitions, further enriching their work. Through detailed descriptions, the authors have constantly underlined the fundamental importance of teamwork; premises to achieve success in the challenging prosthodontic sector are persistently pointed out in every chapter: competence, updating, good materials, adequate instruments buy, more importantly, commitment, great responsibility, mutual respect and deep sense of collaboration. This book represents the ‘future oriented state-of-the-art’, and I am confident that readers, neophytes and expert prosthodontists will derive many lessons from reading and consulting the ‘Smaniotto - Beikircher’.
Mail orders to: Palmeri Publishing Inc., 35-145 Royal Crest Court, Markham, ON L3R 9Z4 Canada Phone orders: 905.489.1970 Fax orders: 905.489.1971 or order online at www.spectrumdialogue.com
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Rationality and Efficiency
Shape and Surface Design Andreas Piorreck, MDT
High quality, efficiency and rationality should not be in contradiction with each other. Manual skills are still essential when it comes to the design and the aesthetic result of a restoration. This is true even in times of CAD/CAM supported fabrications. Designs created with rotary tools are still an essential part of any restoration fabrication. We will demonstrate how easy it is to use the Noritake Meister Point Set for the fabrication of aesthetic restorations. Keywords: shape, ceramic, morphology, grinding, grinding tool, ceramic facing
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he initial situation was an insufficient bridge restoration region 13 to 23 (Fig. 1). This restoration was about one year old. The patient came to us requesting an aesthetic enhancement: he disliked the color, the insufficient length of the anterior teeth and the fact that the restoration did not blend in with his natural teeth. He requested a new bridge. We decided on a Vita A2 veneer to give it a bright and natural characteristic without an agebased individualization in terms of color. We chose Keramicgold P6 (manufactured by Goldquadrat) as the alloy. We did not use zirconium dioxide for this restoration due to the long span of the bridge. The facing was done with the refractory ceramic EX-3 manufactured by the Japanese company Noritake (Fig. 2).
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Fig. 1: Initial state before the treatment. Notice the length of tooth 23. It resulted in an uneven occlusal surface. Age of restoration: about one year
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Fig. 2: Body and enamel core ready for the first dentine firing
Fig. 3: Completion of the build-up with Luster compound
Fig. 4: Firing result ready for finishing
A wax-up helped us to determine the aesthetic aspect and was the basis for the transformation in ceramic afterwards. The metal-ceramic EX stands out due to its natural appearance. Figure 3 shows the dentine core with a margin of enamel material, which guarantees a uniform distribution in the incisal third. The enamel compounds are applied Fig. 5: Noritake Meister-Point-Set very sparingly with this particular ceramic; they have the characteristics of an effect compound. An internal stain firing to individualize the dentine core was not necessary. Now we can finish the tooth shape with Luster material. These Luster materials reproduce the natural opalescence and fluorescence of enamel and are an important part of the Noritake EX-3 ceramic set. Figure 4 shows the prepared bridge ready for the final shaping. We should always aim for an accurate modellation to avoid unnecessary rework.
Design The Noritake Meister-Point-Set (Fig. 5) was especially designed for the shaping of ceramic facings. It consists of dense sintered diamond grinding tools, of which each guarantees long wear and durability. These grinding tools combine a high grinding performance with the ability to create an ergonomic design. The polishing material Pearl Surface by Noritake in combination with mechanical polishing lets you achieve perfect surfaces and a natural looking result.
Fig. 6: Corrective adjustments of the contact points
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Fig. 7: Marking of the pontic
Fig. 8: Pontic reduction with a lenticular grinding tool
I start with the contact points adjustment. For this step the elongated grinding tools are used; they are designed for this kind of work with their shape and
lateral f lanks (Fig. 6). Next, I place the bridge and design the pontic with a lenticular grinding tool DP 08 (Figs. 7 and 8).
Fig. 9: Contouring of the palatal surfaces with DP 08
Fig. 10: With the help of the lenticular grinding tools the contouring in the approximal surface is a breeze
Fig. 11: Even delicate structures can be created easily in the palatal area.
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Fig. 12: In order to achieve a tridimensional effect, the approximal surfaces need to be contoured
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Fig. 14: Marked surface structure
Fig. 13: Length adjustment with the DP 10 tool
Fig. 15: My tools for the surface design: UP 71, DP 05, DP 01, DP 02
Fig. 16: Carbide bur for enamel fractures
Morphology Figures 9 to 13 show my approach for the creation of a natural morphology. Different kinds of grinding tools can be used. It is important to create a tridimensional tooth shape; the contouring of the approximal surfaces with the proper grinding tools is a must (Figs. 10 and 12).
Fig. 18: Creating and rounding off of the vertical structures
Fig. 17: Creating the vertical texture
Fig. 19: Applying of vertical structures
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The surface design is an important step when fabricating an aesthetic restoration. It is often noticeable in seminars that this subject is overlooked. Only with an appropriate age-based surface design can a restoration be integrated harmoniously in its surroundings. With the help of a few tools and a couple of tricks, it is possible to achieve a surface that is identical Fig. 20: The Noritake Meister Cones are the ideal device for the to that of natural teeth reconstruction of perikymata (Figs. 13 to 20). I use the Noritake Detail Checker (Figs. 21 and 22) to check the created surface details. The Detail Checker enables me to notice surface detail and color clearly before the glaze firing; it contains an oily substance, which burns completely without leaving any residue. The surface texture should be a little thicker at this point. After the glaze firing and the mechanical polishing, we finalize the surface texture and the gloss level. The thick surface texture is very noticeable for a 50 year old patient and has to be corrected. After the glaze firing we polish with Pearl Surface polishing material Fig. 21: Surface detail verification with the Detail Checker (Figs. 23 to 25).
Fig. 22: Noritake Detail Checker
Fig. 23: The result after the glaze firing
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Fig. 24: Mechanical polishing with Pearl Surface material
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Fig. 25: The Pearl Surface Set
Fig. 26: Before…
Conclusion With the use of basic means an efficient and economic result is guaranteed. The Noritake Meister-Point-Set allows us to create the shape and surface structures of a ceramic facing with little effort. The result is an aesthetic pleasing ceramic restoration. In combination with the polishing material Pearl Surface and a mechanical polishing, it is possible to easily achieve the utmost aesthetic reproduction of natural effects present in natural surfaces (Figs. 26 to 28). Fig. 27: …and after Acknowledgment: The clinical images were done with the kind assistance of Dr. Kathleen Berger, Saxonia-Klinik Leipzig.
• CE Credit Test 1 on page 33 Fig. 28: A pleasing result
About the Author Andreas Piorreck, MDT Contact: Avantgarde Dentaltechnik GmbH Stöhrerstraße 3b 04347 Leipzig Tel. 0341-6964043 Email: Andreas.Piorreck@gmx.de
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Good Planning with a Special Touch
Don’t Fear Demanding Patients! Part I Markus Stang, MDT
“That is a very difficult patient” is a common excuse when a restoration is doomed to fail in spite of intensive efforts or it does not meet the patient’s expectations. Why are some patients so hard to please? Is he/she too demanding? Was poor planning the reason or maybe the influx of information could not keep up with the current fabrication process? There might be countless reasons but one thing is sure, the reason for failure does not lie with the patient. In this article, Markus Stang points out ways in which even sophisticated patients can be satisfied because special demands require special methods! Keywords: CAD/CAM, framework design, ceramic, long-term prosthesis, mock-up, facing, wax-up
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he patient, whose case we are documenting, introduced herself with the following words: “Good day, are you the person who will do my teeth? You must know that I do not want beautiful teeth; I prefer my teeth to be crooked! Do you understand what I mean? I do not want to be beautiful; I prefer to be unique because that is me: I am unique and my teeth should be unique as well.”
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Fig. 1: This patient has the highest standards: most of her teeth are missing but she requests a fixed prosthesis
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Fig. 2: We have to place 5 pontics in this large interdental space
Fig. 3: Limited space complicates our work
Findings Large interdental spaces from 22 to 13 as well as 16 and 36, minimal spacing, a patient with very high standards and very detailed wishes (Figs. 1 to 3). In the mandibula we decided on a zirconium oxide bridge and in the maxilla we preferred a fixed restoration as well. Due to the large interdental space the dentist chose a solid gold alloy.
Fig. 4: The existing bridge had to be removed because an abutment was missing
Case History The patient had already lost some teeth at an early age and had since then received treatments with fixed restorations. So far only one bridge was satisfactory. However, it had to be removed since yet another abutment tooth was lost. We used this bridge as a guideline (Figs. 4 and 5). The patient insisted that none of the previous dental technicians ever dared to place crooked teeth in the gap. We decided to accept the challenge!
Fig. 5: The present restoration was not “crooked enough” according to the patient
Fig. 6: With the patient’s wishes in mind, we created a wax-up in the lab
Fig. 7: The position of the teeth was determined by the patient beforehand dental labor international plus – Vol. 2 No. 1 – February 2010
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Wax-up The detailed wishes of the patient were recorded, impressions for the sit model and the saw model were done, photos were taken and drawings were created. We set up an appointment with the patient for the aesthetic fitting. We wanted to propose shape and positioning of the teeth and discuss additional details.
A wax-up was prepared in the lab according to the patient’s ideas (Fig. 6). She gave us precise instructions regarding the position of each tooth (Fig. 7). The palatal and occlusal surfaces were designed as close to natural dentition as possible and aligned harmoniously with the mandibula (Figs. 8 to 10). The tooth shape had to be optimized at the same time. The entire restoration had to be very unique and have an overall “true to nature” color appearance (Figs. 11 to 13).
Fig. 8: The palatal surfaces were designed to look natural and to be functional
Fig. 9: The posterior teeth all line up harmoniously
Fig. 10: The artificial teeth seem to “grow” out of the edentulous jaw
Fig. 11: The shape of the teeth matches the patient’s overall look
Fig. 12: The marginal line was designed individually, tooth by tooth
Fig. 13: It is hard to tell that only a few abutments are left, even from the side view
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The First Fittings Deep draw foil was used to transfer the anterior area into acrylic and tried in the mouth as a mock-up (Figs. 14 to 16). At the first fitting appointment the patient was not satisfied; she found the teeth too short and not crooked enough (Figs. 17 and 18). Even with setbacks like these we have to stay positive and fix it on the spot to assure the patient that his/her wishes can be realized perfectly. Fig. 14: For the first fitting the wax-up is transferred into acrylic
Fig. 15
Fig. 16
Figs. 15 and 16: We now have to create details and pay special attention to the parodontal space
Fig. 17: The first fitting reveals that the invisibility of the teeth is unsatisfactory. Tooth 12 is almost covered by the lower lip
Fig. 18: The side view reveals that the entire anterior area is too short, the individual characteristics are not visible
In order to get a better idea of the spacing situation of the overlapping anterior teeth we presented the patient with a design made of artificial teeth (Fig.19). After getting the patient’s approval, we transferred the result in the lab to the wax-up. The following images show the changes done after the first trial fitting (Figs. 20 to 23). For the second fitting, we created an acrylic mock-up of the new situation (Fig. 24). The patient was thrilled with our design (Figs. 25 and Fig. 19: We did not want to confuse the patient and evaluated the 26) and a happy smile confirmed situation with the help of a wax-up that our efforts paid off. dental labor international plus – Vol. 2 No. 1 – February 2010
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Fig. 20: The adjustments are transferred into the wax-up
Fig. 21: The front is lengthened by 1.5mm and the basic shape of the four incisors is changed considerably
Fig. 22: The patient emphasized again that the anterior teeth should overlap more and have a more unique look Fig. 23: The palatal surfaces were adjusted aesthetically and functionally
Fig. 24: The new situation is transferred into acrylic with the help of a deep draw foil
Fig. 25: The visibility of the anterior teeth has improved significantly. The individual characteristics are much more noticeable
Fig. 26: Despite the prominent positioning of the teeth, we achieved a harmonious lip/teeth appearance
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The Prosthesis Our next step was the fabrication of a long-term restoration with the possibility of making necessary adjustments even after a few weeks. We decided on a metal reinforcement. It had to be cost-effective yet fit perfectly under the modeled teeth. With these prerequisites in mind, I decided on a titanium bridge milled with the Kavo-Everest-System. This way I did not need to worry about an accurate fit for this wide-span bridge.
Figs. 27 and 28: The models and each stump are scanned with the Scan-Pro and transferred to the computer
Fig. 29: The fabricated mock-up replaces the mush-bite as a counter-bite. We spray it with occlusal spray and scan it as well
Fig. 30: We get an accurate image of the waxup in the computer
Fig. 31: All areas that are not part of the waxup have to be removed
Fig. 32: This way the individual components can easily be faded in and out during construction
Fig. 33: From the start, the pontics were not perfectly created under the wax
Fig. 34: A 3D cross line lets us position the pontics with ease in the specified space
Fig. 35: The pontics can be rotated, bent, moved and their dimension changed
Fig. 36: The wax-up can be opaque or transparent in color. It helps with the evaluation of individual positions
We started by scanning the models and the individual stumps with the Scan-Pro (Figs. 27 and 28). I used the already fabricated mock-up as a counter bite in place of a mush-bite, misted it with occlusal spray and then scanned it as well (Fig. 29). The result is a perfect transfer of the wax-up into the computer program (Fig. 30).
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In order to properly import the virtual wax-up, all surrounding areas have to be removed (Figs. 31 and 32). This way the individual components are easily faded in and out during the construction. Unfortunately, the pontics are not properly constructed under the wax-up (Fig. 33). With the CAD-software the pontics can be placed effortlessly in the specific situation with the help of a 3D cross line (Figs. 34 to 36). They can be rotated, bent, moved and their dimension changed. In the cross section view the position of the pontic under the wax-up
Fig. 37
is clearly visible (Figs. 37 and 38). The three different views of the object enabled us to look at every pontic separately (Figs. 39 and 40). We were able to work on the pontics and the connection bars individually (Fig. 41). The dimension may be changed in any direction and if needed an individual cross section shape can be determined. The cross section dimensions of the connector are always available. The data and the bar turn red if the predetermined minimum dimension reaches a low point (Figs. 42 and 43). The dimension of each cap can also be adjusted (Fig. 44).
Fig. 38
Figs. 37 and 38: In the cross section view, we can see the position of the ponitc very clearly
Fig. 39: These three different views let us easily look at each pontic
Fig. 40: The pontic in the posterior area can be placed effortlessly
Fig. 41: The connection bars can be finished in no time with little effort just like the pontics
Fig. 42: The dimension of the connectors can be changed in any direction with or without a cross section design
Fig. 43: Point-and-click and the selected cross section is transferred to the other side
Fig. 44: Even the individual caps can be changed in their dimension
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Fig. 45: The finished construction under the opaque wax-up
Fig. 46: The finished construction under the transparent wax-up
Figures 45 to 47 show the finished construction with and without the scanned-in modellation. The titanium bridge can be placed on a blank by itself. Any unused space is saved on the computer and lets us mill additional bridges or crowns on the same blank in the future (Fig. 48). The computer helps with the cutting task as
Fig. 47: The finished construction without wax-up
well, except for a few bars the machine cuts the bridge after completion from the blank, therefore reducing the finishing time! Conclusion: with little effort we achieve a custom-fit framework (Figs. 49 to 51). The deep draw foil can be placed on the finished framework (Fig. 52). The tedious cutting and grinding of
Fig.49
Fig. 48: The position of the titanium bridge on the blank is saved on the computer so that additional bridges or crowns can be milled in the future Fig.50 Figs. 49 and 50: With a little effort, we created a custom-fit titanium framework. The tedious cutting and grinding of sprues is therefore eliminated
Fig. 51: The same result on the unsawn model, a perfect fit, no distortions, no bubbles
Fig. 52: The deep draw foil can easily be placed on the finished framework
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Fig. 53: Opaquer was applied to the framework and pressed with a special tooth colored acrylic for prostheses
Figs. 55 and 56: An additional pressing with acrylic lets the restoration appear very natural even at this stage Fig. 54: In the second step, the dentine was reduced and individualized Fig.55
Fig.56
Fig. 57: The wear of the long-term prosthesis should form a thin sulcus in the edentulous jaw portion
sprues is therefore eliminated. The over pressing of the framework with tooth colored acrylic specially designed for prostheses is now a breeze (Fig. 53). In the second step, the dentine is reduced and individualized (Fig. 54). A second pressing with transluscent acrylic finalizes the procedure (Figs. 55 and 56). We pay special attention to the edentulous jaw section during the finishing process of the long-term prosthesis. Usually we encounter an epithelia resilience of up to 1.2mm in the anterior maxilla but not in this case. The gingiva section in the anterior interdental space is very tight and is attached firmly to the jawbone. The marginal run of the five connecting units has been designed uniquely and should integrate harmoniously even under poor conditions. We slightly outlined the run border on the cast model. With the help of the long-term prosthesis the anterior gingiva area can be molded uniquely. After a three months wear of the prosthesis a significant improvement is noticeable: the marginal anterior teeth area has perfectly molded itself into the gingiva (Figs. 57 and 58). …to be continued in the next issue. • CE Credit Test 1 on page 33
About the Author
Fig. 58: After a three months wear of the long-term prosthesis: a noticeable improvement!
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Markus Stang Contact: Carl-Orff Str. 15 69214 Eppelheim Tel.: 0151 14183352 Email: stangmarkus@arcor.de
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CAD/CAM – Intelligent Outsourcing
Zircon is not Always the Same Shahab Esfarjani, MDT
In the meantime CAD/CAM generated zirconium restorations are a standard feature at many dental laboratories worldwide. In coming years the wax knife will be replaced more and more by the PC mouse, however the dental technician's task of designing dental prostheses in an ideal manner will remain the same. Shahab Esfarjani has been working with the material zirconium dioxide since 2002 and has gained a great deal of experience with this material by processing almost 1900 units. He places a particular emphasis on the natural aesthetics of his work. Keywords: CAD/CAM, Outsourcing, Quality assurance, Scanner, Software, Processing, Zirconium dioxide Fig. 1: Zircon rock
Why Zircon?
What is Zircon?
Metal ceramics are a sound basis for aesthetic restorations, regardless of whether they are used for individual teeth or bridges. We have achieved excellent results with them over many years. But times change. The divide between patients who can afford high-quality prostheses and those who can only draw upon health insurance has grown considerably. One can increasingly see that the requirements and desires of patients have changed in the field of aesthetic dentistry. Many patients wish to have an aesthetic, pleasant smile, not only at work. Such results cannot be achieved with conventional metal ceramics, since they are not transparent and can therefore not be used to copy the natural characteristics of teeth, such as translucency, opalescence or natural anisotropy, just to name a few. In addition to these facts, the price of alloys has increased considerably, which means one has to select and calculate the material carefully.
Zircon is the oldest and most common mineral in the earth's crust. Its age is estimated to be approximately 4.4 billion years and it belongs to the silicate group (chemical formula: ZrSiO4). Its natural colour varies between golden yellow, red, brown, green and blue up to black (Fig. 1). It was discovered by the German chemist Martin Heinrich Klaproth in the year 1789. After years of development and usage in medical science, for example for artificial hip joints, it is now also used in dentistry. Zirconium dioxide is distinguished for its excellent material properties:
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• • • • •
CET: 10.2 Density: 5.7 g/cm3 Melting point: 2680 C° Boiling point: 5000 C° Flexural strength: 1400 mpa
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What is the Difference? There are two types of zirconium oxide: pre-sintered and hipped (HIP = hot isostatically pressed) zirconium dioxide. The pre-sintered type is milled and then re-sintered again in order to obtain its final density. The HIP material is milled in fully sintered condition. The production process also has a great influence on the quality of the material (Fig. 2). The strength, margin fit, millability, long-term stability and transparency of the material are influenced by: • Different types of zirconium dioxide
powder • Compression methods and compression conditions • Zirconium dioxide staining procedure • Pre-sintering conditions
Processing Step
Processing Parameter
Clinical Properties • Transparency • Strength • Durability • Sintering behaviour • Hydrolytic stability
Compression
• CO precipitated (with most types of powder) • Mixed oxide process • Grain size (0.07–0.3 μm) • Spray drying and organic additives
Pre-sintering
• • • •
Powder
Axial compression Pressure (800–3000 bar) Isostatic compression Clean room (no faults due to air pollution)
• Strength • Margin fit • Transparency • Processability • Margin fit
Processing Staining
• Temperature • Duration • Fluids • Pigments (part of powder processing)
Final Sintering
• Duration • Temperature (1360 – 1530°C)
• Margin fit • Strength • Transparency • Durability • Strength • Transparency • Durability • Hydrolytic stability
Fig. 2: Production process
Fig. 3: Blanks
But how can you protect yourself from cheap materials and quality risks? The dent al practice and dent al laboratory are responsible for quality assurance and clinical and technically perfect restorations, which is why the usage of brand products should be ensured already when placing orders. You will not put the patient's health at risk and will maintain the mutual trust between the dentist, patient and laboratory if these materials are processed appropriately.
What is Quality? Trust is Good, Control is Better.? According to a report of the American Dental Association (ADA), leaded compounds have been detected in fully ceramic dental prostheses and in alloys manufactured in China. These "grey products" also include, for example, ZrO2 blanks (Fig. 3) without retraceable sources and without quality assurance, often even with a fake CE label or brand signet. Faulty grain structures had caused porosity and shape distor tions after sintering and subsequent fractures. This has put the reputation of zirconium dioxide at stake, and likewise the trust between the dentist, patient and laboratory. The "Geiz ist geil (thrifty is nifty)" mentality has become a trend. To save costs, materials from indefinable sources are processed.
Quality control centres regularly check the quality of the products and subject them to numerous endurance tests, which put them under a greater strain than that caused by everyday life. Certified products, such as those from Straumann, are checked regularly by independent institutes. In addition, numerous internal quality assurance and inspection measures are taken to ensure best-possible reproducible production quality. The material structure is essential for flexural strength and long-term durability. Continuity can be ensured only by constant quality control, up-to-date studies and careful processing.
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Why Outsourcing? The constantly increasing modernisation and mechanization in the field of dentistry also constantly raise more questions: CAD/CAM – yes or no? Which scanner or which copy milling device? In-house production or outsourcing? What are the decisive criteria for my decision? The increasing use of computers in the field of dentistry is, of course, fascinating and also a welcome change from usual day-to-day work. However, staff must be trained for each new accomplishment. From my own experience, I can confirm that new equipment is not always beneficial and does not always increase production. Several years ago I bought a semi-automatic complete system. At the time the device was the ne plus ultra. However, the indications were limited and the frameworks had to be modelled conventionally first. They were then clamped into an automatic copy milling device, scanned, milled and subsequently sintered. They did not fit perfectly, which means a great deal of time was spent on subsequent refitting. The disadvantages are obvious: no time saved at the technician, costs for maintenance of the system (blanks, electricity, milling cutters etc.), limited indication, limited utilisation of the system. The only advantage was that one did not
Outsourcing Advantages:
Disadvantages:
In-house Production • Flexible • Innovative • Low staff and qualification requirements • Staff motivation • Open for all customary materials • No system required • No maintenance and repair costs • Independent from a technical point of view • Low capital commitment • Low risk of failure
• Marketing tool • Independent of suppliers • Quick in production • Economic in the event of high utilisation • Shipping costs saved
• Time loss • Shipping costs • Reliability of the suppliers
• Very high capital expenditure • Shifting of the personnel costs • System requirement • Low flexibility • Technical risk • Maintenance and repair costs • Expensive blanks
Fig. 4: Outsourcing versus in-house production
Fig. 5: Zirconium framework
Fig. 6: Metal framework
have to wait on suppliers and milling centres. The market quickly changed in the following years, the degree of precision was improved and the variety of materials increased. In other words, our system was now outdated! With a scanner with up-to-date software, you are always on the innovative side and produce reproducible results of high quality, even if you have to rely on suppliers (Fig. 4).
Software and Scanner
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I saw the Straumann CAD/CAM scanner at a colleague's practice. The perfect results and the quick production persuaded me to work with this system myself. We are now able to work with all customary materials: zircon (Fig. 5), aluminium oxide, titan, CoCr alloys (Fig. 6), plastic and glass
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Fig. 7: Initial situation of front dental bridge
Fig. 8: Scanning Data
fibre reinforced polyamide for provisional solutions. The operation of this software does not require any great EDP skills. However, one should take the time to receive detailed instruction in the software. The laser scanning technology works extremely precisely and records all surface data of the prepared tooth stumps and the remaining teeth, and the preparation limit is identified automatically. Parameters such as the cement gap, ceramic support, wall thickness reinforcement or porcelain shoulder can be set separately without any difficulty. The convincing software allows frameworks to be produced with up to 14 elements, primary parts or customised abutments. The modelled framework can be modelled and checked from any angle. Regular updates keep the software up-to-date and the indication width is constantly extended.
Fig. 9: Scanning data after automatic preparation identification
Bridge Construction Based on the work for a patient, I will now describe the production of a framework for a front teeth bridge from 13 to 23 with additional supports 11 and 21. For the automatic identification of the preparation lines, all stumps below the preparation edge must be under-chamfered considerably (Fig. 7). The project is then set up with the patient and practice ID, number of supports, pontic, ceramic support, colour of the framework etc. Once the work has been scanned (Figs. 8 and 9), the stump and preparation limit are checked and the push-in direction defined (Fig. 10).
Fig. 10: Determining the push-in direction
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The software can be used to create a full model within a minimum amount of time (Fig. 11), which is then reduced in order to obtain a perfect ceramic support (Fig. 12). To avoid subsequent trouble due to chipping, the frameworks must be designed in a hump-supporting manner. The festoons used to support the veneer ceramics should also not be forgotten (Figs. 13 and 14). This was described very well in the article by Karl Christian Adt (dental labor 3/2009). Finally the connectors are checked again, and then, the entire data is sent to the milling centre via the Internet (Figs. 15 and 16). At the latest, after 72 hours, you receive the finished work, which is placed on the stumps with ease and fits one hundred percent (Fig. 17).
Fig. 11: Full model
Fig. 12: Reduction by the amount of x
Fig. 13: Design of the festoons
Fig. 14: Festoon (ceramic support)
Fig. 15: Finished model
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Conclusion
Sources:
My experience and the points I have made in this article have led me to cooperate with the Straumann CAD/CAM production centre in Leipzig. The advantages are obvious to me. The software pays attention to slightest inaccuracies and minimum thicknesses of connectors or caps already during the modelling process, which are subject to strong deviations during manual production. Human errors are ruled out more and more by the central production. The milling machines work completely vibration-free and so precisely that the maximum positional deviation is 0.001 mm. We can only be reliable and trustworthy if we work precisely at reproducible quality.
• Prof Dr D.Edelhoff, CAD/CAM Technologien und innovative Werkstoffe (CAD/CAM technologies and innovative materials). www.dental-onlineommunity.de • R. Riquier (master dental technician), Ohne Limits – Auswirkungen innovativer CAD/CAM Systeme (Without limits – effects of innovative CAD/CAM systems). www.dental-onlineommunity.de • Ch. Thiesen, U. Heermann, Outsourcing versus Inhouse-Fertigung (Outsourcing versus in-house production). Quintessenz Zahntech 2008;34(7):879-883
• CE Credit Test 2 on page 34
Fig. 16: Milling machines
Fig. 17: Finished framework on model
About the Author Shahab Esfarjani Al dente – Oral Design-Center Idstein Höhenweg 10 65510 Idstein, Germany Tel: +49 (0) 61 26 - 22 71 37 Email: oral-design-center-idstein@gmx.de After passing his A-levels, Shahab Esfarjani completed a three-year training course as dental technician in Helmstedt in 1984. He then gained practical experience at different laboratories, including employment as a dental technician in New Zealand from 1986 to 1989. After successfully attending the school for master dental technicians in Dusseldorf, he opened the dental laboratory Al dente in November 1993, where he produces ceramic front and side prostheses with the focus on functionality and naturalness. He has been a technical consultant of the companies Servo Dental and Wohlwend Ceramic AG in Liechtenstein since 1998 (Vision Ceramic). In 2001 his laboratory was renamed "oral design-Center Idstein", which means Esfarjani is one of five oral designers in Germany. He became a consultant of the company Creation Willi Geller International in Switzerland in 2001 too. He publishes regularly in scientific journals and holds lectures and courses in India, New Zealand, Iran and the United Arab Emirates. In February 2004 he opened a second laboratory in Dubai called "Center Dubai" for aesthetic front tooth restorations and training courses for Willi Geller Creation. He has been a member of the international oral design group since 2007. Opening of EDC Esfarjani & Partner Dental Concept in 2009.
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The basis for an aesthetic and functional optimal result
Customized Abutments José de San José González, MDT
Keywords: Abutment, CAD/CAM, Implant Construction, Customized Abutment, Set-up, Software
Limitations of Conventional Abutments The use of prefabricated abutments is often labor intensive and costly when we deal with difficult cases and when the result we wish to achieve should have a high level of function, aesthetics and durability. Customized abutments like the ones made by Atlantis, on the other hand, are designed without the need for grinding and adjusting and even in the most difficult cases optimal treatment options are available to us. One particular challenge that we have to face quite often in our daily work in the lab, for example, is an implant that was not positioned properly prosthetically because the structure of
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the jawbone might have prevented it. In such cases the technician is required to find an appropriate prosthetic solution that lets him achieve a good and durable overall therapeutic result. The limitations of conventional abutments as illustrated is based on the case of a patient who received two implant systems , which had been placed divergently in completely different directions (Fig. 1). In this case castable abutments were used. It was possible to create a common insertion direction for a screw-retained bridge (Fig. 2). This approach, however, is not only costly and time-consuming but always carries the risk of failure due to misfit or miscast. Even with
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Fig. 1: Two implant systems placed divergently in different directions
an apparently perfect fit it can happen that continual applied pressure due to occlusal force causes problems that lead to unphysiological load increase. With customized abutments, which were fabricated with the help of modern CAD/CAM technology, we achieve a result without much effort even in difficult conditions. The result meets the intraoral situation as well as the patient’s generally high expectations of function and aesthetics. As we demonstrate in the following examples, it is not important whether zirconium oxide or titanium is used or whether the space closure should be done with single crowns or a multiunit restoration.
Practical Approach
Fig. 2: A time-consuming solution: castable abutments
Fig. 4: The implant position does not match the abutment angle Fig. 3: Even angle-forming abutments are not an optimal solution
In the maxilla of our patient three implants in position 13, 14 and 16 had been inserted previously (Fig. 5), which were supposed to receive single crowns with a mesialisation of 16. With the impression taken by the dentist, in this case a closed impression, an implant model made of dental stone with a removable flexible gingival analog was fabricated (Fig. 6).
In the next step, we created a set-up consisting of artificial teeth with proper occlusion and articulation, which will serve as the basis for the individual structures later on (Fig. 7). Here, it is very important that the set-up is removable and strong enough to be scannable on the model as well as individually. The implant model, the articulated set-up and the counterbite model were afterwards mailed in free-of-charge shipping
Fig. 5: Three maxilla implants that are supposed to receive single crowns
Fig. 6: Implant model with removable flexible gingival analog dental labor international plus – Vol. 2 No. 1 – February 2010
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Fig. 7: Set-up with artificial teeth
Fig. 8: Model with prefabricated abutment made of zirconium oxide and matrix
Fig. 9: A custom fit: abutment shape and the run of the preparation border
Fig. 10: The custom fit zirconium abutments are ready for the trial fitting
Fig. 11: Ceramic copings fitted with ceramic facing
Fig. 12: The finished restoration in the patient’s mouth
boxes to Astra Tech in Sweden, where the models were scanned and the necessary data recorded with the help of a patented 3D process. Based on this virtual model, which reproduced the situation in the patient’s mouth in detail, specialists designed the abutments in their desired form with the aid of the software Atlantis VAD (Virtual Abutment Design). They proceeded in a manner similar to the grinding of a tooth by taking the shape of the finished crown and designed the abutment accordingly (backward planning). Just how the connection between implant shoulder and
artificial crown matches the conditions in the patient’s jaw and to which extent his wishes were meeting his needs is clearly evident in the run of the preparation border as well as in the overall shape. The finished virtual model images are sent via email to the dental technician afterwards for verification. Only if he approves the design will the abutment be fabricated (Figs. 8 to 10). In this illustrated example the ceramic copings were created with the aid of the CAD/CAM system and after wards fitted with a ceramic facing (Figs. 11 and 12).
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Fig. 13: Four implants in the maxilla that are supposed to receive a bridge
Fig. 14: The set-up
Fig. 15: Titanium abutments
Fig. 16: We choose a retentive surface
Fig. 17: The verification of the individual abutments in the model
Fig. 18: Model with a ceramic supported zirconium framework and matrix
Free Choice of Material and Surface Design
precisely modeled interdentium (Fig. 14). An abutment made of tit anium is preferable in this case. The technician may chose between a machined and a retentive surface. In this case, we decided to go with the retentive one because the cement bonds better with this kind of surface (Figs. 15 to 17). Afterwards, a ceramic supported zirconium framework was created, milled and f inally the individual ceramic facing was applied (Figs. 18 to 20).
Atlantis abutments are uniquely designed and are available not just in zirconium oxide but also in titanium. To demonstrate this further: the patient had four implants in position 11, 13, 21 and 23 placed in the maxilla for a multi-unit restoration (Fig. 13). When constructing the set-up it is important to pay attention to the size and shape of the teeth and worry less about the
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Fig. 19: Fitting of the finished bridge with individual ceramic facing
Fig. 20: Finished restoration with gingival analog.
Conclusion
A modern computer supported design of the implant prosthetic restoration plays an important role in the improvement of aesthetic results. Optimal fit as well as good material properties and durability are essential preconditions for a perfect result in the work of any dental technician. The combination of function and aesthetics turns a technical fabricated implant prosthetic reconstruction into a superior product. The Atlantis VAD-Software solution provides the possibility of creating abutments based on the ideal crown situation, which conforms to patient-specific requirements. Due to the adjustment of the abutments to the intraoral situation it is possible to achieve, furthermore, an ideal anatomical emergence profile. The fact that the Atlantis abutmens are offered in zirconium oxide, titanium and titanium nitride and that they are available for all major implant systems guarantees a high degree of flexibility.
Sources: • Prof Dr D.Edelhoff, CAD/CAM Technologien und innovative Werkstoffe (CAD/CAM technologies and innovative materials). www.dental-online-ommunity.de • R. Riquier (master dental technician), Ohne Limits – Auswirkungen innovativer CAD/CAM Systeme (Without limits – effects of innovative CAD/CAM systems). www.dental-onlineommunity.de • Ch. Thiesen, U. Heermann, Outsourcing versus Inhouse-Fertigung (Outsourcing versus in-house production). Quintessenz Zahntech 2008; 34(7):879-883
• CE Credit Test 2 on page 34
About the Author José de San José González, MDT González Zahntechnik Hauptstraße 4c 69469 Weinheim Tel: 06201 340013 Email: gonzalez-zahntechnik@t-online.de www.gonzalez-zahntechnik.de José de San José González, MDT, born 1964, did his dental technician training from 1982 to 1986 at the Strubel-Zahntechnik laboratory. Afterwards he worked in different departments in various laboratories, for example, as department supervisor and laboratory manager. He received his master’s degree in 1994 from the Chamber of Trade in Karlsruhe. He started his own business in 1999 in Weinheim on the scenic “Bergstraße”. José de San José González is involved in the training of dental technician trainees at the master school in Karlsruhe. For 15 years he has been a consultant for dentists and dental technicians in the field of functional analysis and communication skills between clinicians and laboratories.
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TEST FOR NBC & RDT CREDITS dental labor international plus – Vol. 2 No. 1 Each article in this continuing education series is worth 0.5 credit from the NBC. To get your Scientific CE credit for this article, circle the correct answers to the questions on the short test below. The correct answers can be found within the text of the article. Then simply complete the form and submit it to Palmeri Publishing Inc., to receive your credit. It’s that easy!
Questions for: Shape and Surface Design by Andreas Piorreck & Don’t Fear Demanding Patients! Part 1 by Markus Stang
1.
Which of these should not be in contradiction with each other? A. Quality, efficiency and rationality B. Time, rationality and quality C. Efficiency, rationality and materials D. Quality, efficiency and time
2.
Which skills are still essential for aesthetics? A. Good CAD/CAM equipment B. Good eye for colour C. Good manual skills D. Good communication
3.
What helped determine the aesthetic aspect? A. A good pre-op model B. A photograph C. A computer image D. A wax-up of the case
4.
What was not necessary in order to individualize the dentine core? A. A try-in of the wax-up B. Internal stain firing C. External stain firing D. Grinding the surface
5.
What is considered an important step when fabricating an aesthetic restoration? A. The amount of times the crown is baked B. The amount of internal staining C. The amount of external stains D. The surface design
6.
What is the most common excuse for case failure? A. The dentist did not have enough room. B. The patient was very demanding. C. The material selection was wrong. D. The doctor selected the wrong shade.
7.
Why did the patient request crooked teeth? A. Because she thought she would be beautiful. B. Because she said she was unique. C. Because she wanted to pay less. D. Because she thought they would be done faster.
8.
What did the patient find at first fitting? A. That the teeth were perfect. B. That the teeth were too short and not crooked enough. C. That the teeth were too long and too crooked. D. That the color was wrong.
9.
What is the usual epithelial resistance encountered? A. Up to 2 mm B. 1.5 to 2.5 mm C. Up to 1.5 mm D. Over 3 mm
10. Which alloy was selected as reinforcement? A. Silver palladium B. High noble alloy C. Metal free restoration D. Titanium alloy
Once you have completed the questionnaire, fill out the information below. You can photocopy this form. Then simply complete the form and submit to Spectrum dialogue online at www.spectrumdialogue.com or by fax to 905-489-1971. It’s that easy! In order to receive credits, you must be a subscriber to dental labor international Plus. Subscriber Name: __________________________________________________ Phone #: _______________________________________ Address: ___________________________________________________________________________________________________________ Email: ___________________________________ CDT or RDT #: ________________________ Signature: __________________________ dental labor international plus – Vol. 2 No. 1 – February 2010
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TEST FOR NBC & RDT CREDITS dental labor international plus – Vol. 2 No. 1 Each article in this continuing education series is worth 0.5 credit from the NBC. To get your Scientific CE credit for this article, circle the correct answers to the questions on the short test below. The correct answers can be found within the text of the article. Then simply complete the form and submit it to Palmeri Publishing Inc., to receive your credit. It’s that easy!
Questions for: Zircon is not Always the Same by Shahab Esfarjani & Customized Abutments by José de San José González
1.
HIP refers to ... A. zircon used in hip replacement. B. hot isostatically pressed zirconia. C. hot inverted porcelain. D. soft pre-sintered zirconium.
2.
What contaminant has been found in ceramics out of China? A. Zinc B. Sand C. Silia D. Lead
3.
4.
5.
In the past what was a lot of time lost being spent on? A. Refitting the ill fitting work. B. Setting up the CAD/CAM scanners. C. Doing wax-ups. D. Discussing the case. With exception to EDP skills, what is recommended? A. Receive detailed instruction in the software B. Work in an air conditioned environment C. Good photography skills D. Good communication skills What is reduced in order to obtain perfect ceramic support? A. The time it takes to scan the model. B. The creation of a full model by CAD/CAM. C. The overall cost of materials. D. The amount of tooth structure removed.
6.
What is the particular problem often faced in daily lab work? A. Not enough time allotted B. Improperly positioned abutments C. Collapsed bites D. Controlling material costs
7.
How was the set-up created? A. Artificial teeth with proper articulation and articulation B. By making duplicate wax models C. Artificial teeth mounted 1mm out of occlusion D. Heat processed temps
8.
In order to be scannable, it’s important for the set-up to be... A. strong and removable. B. strong and non removable. C. painted with silver powder. D. opaque in colour.
9. The Atlantis (VAD) abutments are fabricated by... A. taking the final shape then backward designing the abutment. B. scaning then selecting a prefabricated product. C. casting a wax milled prototype. D. sending instructions to the lab. 10. The Atlantis abutments are available in... A. all types of gold alloys. B. titanium and zirconium. C. chrome cobalt alloys. D. plastic castable pieces.
Once you have completed the questionnaire, fill out the information below. You can photocopy this form. Then simply complete the form and submit to Spectrum dialogue online at www.spectrumdialogue.com or by fax to 905-489-1971. It’s that easy! In order to receive credits, you must be a subscriber to dental labor international Plus. Subscriber Name: __________________________________________________ Phone #: _______________________________________ Address: ___________________________________________________________________________________________________________ Email: ___________________________________ CDT or RDT #: ________________________ Signature: __________________________
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Knowledge is the basis Success is the result Modern dental technology rapid and efficient Mr. Giezendanner’s “secret” is his wide-ranging knowledge and techniques for the manufacture of porcelain veneers, developed over many years. These set new standards for quality and precision in the field of dental restorations. This valuable book should be a standard reference work for any dental technician. It contains excellent study material. A browse through the images and illustrations in this book will quickly show a wealth of important information, detailed craftsmanship and practical experience in the very latest in dental technology.
Author Paul Giezendanner
$69.00 88 pages, 9.5 x 8.25 inches
thetics s e a , s y a d e s “The ess; c c u s d e ll a c is ays is d e s e h t s s e c Suc tics.” e h t s e a d e ll a c
Trend researchers have noticed that customers are once again looking for value in certain product groups rather than simply the cheapest price. Customers exhibit dental services in their mouths, and therefore usually want the best for themselves. Therefore, dental technicians need to become involved in the interaction between provider and patient. This is not always simple, but it is a pre-requisite for patientfocused dental work. Dental laboratories must carefully consider the potentially disastrous results of a “quick and cheap” approach. Instead, they must choose to focus on our values and strengths, such as: Quality Precision Timelessness It is up to the dental technician to accept these challenges, and to take on the responsibilities. An ostrich-like attitude and passing the buck onto various bodies, policies and associations are not helpful. In this book, Giezendanner passes on the secret of a beautiful crown to anyone who might be interested in this expertise. It is then up to every individual to seize the opportunity to perfect his or her skills, and establish themselves on the market place. “Yes we can” is equally applicable to the dental industry.
Mail orders to: Palmeri Publishing Inc., 35-145 Royal Crest Court, Markham, ON L3R 9Z4 Canada Phone orders: 905.489.1970 Fax orders: 905.489.1971 or order online at www.spectrumdialogue.com
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