CAD/CAM international No. 3, 2014
Cover
/ Editorial
/ Content
/ Utilizing the Tempcap abutment with CAD/CAM
/ Intra-oral scanning with 3M True Definition Scanner - realisation with CARES
/ “One cannot just replace a technician with a machine”
/ Contribution of CAD/CAM technology to implant-supported screw-retained restorations
/ Immediate implantation and full-ceramic restoration in the maxillary anterior region
/ An implant-supported prosthetic restoration concept for edentulous atrophied maxillae
/ “It is fantastically simple!” In this interview - Vanik Kaufmann discusses the advantages of KaVo’s new ARCTICA CAD/CAM system
/ Planmeca and the University of Turku found Nordic Institute of Dental Education
/ Adentatec Competence in Dental
/ Ease of use meets restorative flexibility in the new NobelProcera Hybrid
/ Bionic restoration: Take the next step. Imitate nature. Imitate the best.
/ International Events
/ Submission guidelines
/ Imprint
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Standard_300dpi
CAD0314_01_Title 22.08.14 13:30 Seite 1
issn 1616-7390
Vol. 5 • Issue 3/2014
CAD/CAM
digital dentistr y
international magazine of
3
2014
| CE article
Utilizing the Tempcap abutment
with CAD/CAM
| special
Intra-oral scanning with
3M True Definition Scanner,
realisation with CARES
| case report
Contribution of CAD/CAM technology
to implant-supported screw-retained restorations
[2] =>
Standard_300dpi
The natural choice
ATLANTIS patient-specific abutments
™
DENTSPLY Implants does not waive any right to its trademarks by not using the symbols ® or ™. 32670183-USX-1312 © 2013 DENTSPLY Implants. All rights reserved
For all major
implant
systems
Give your patients excellent function and natural esthetics.
ATLANTIS patient-specific abutments go beyond CAD/CAM to deliver:
• Freedom of choice in implant system and material
• Optimal emergence profiles and soft tissue margins
• Anatomical support for the final restoration
• A simplified restorative procedure
To learn more about ATLANTIS patient-specific prosthetic solutions,
contact your local DENTSPLY Implants representative or visit our website.
We have you covered
ATLANTIS abutments are backed by a
comprehensive warranty program.
For full warranty terms and conditions,
visit www.atlantisdentsply.com.
ATLANTIS patient-specific abutment
Stock abutment
www.dentsplyimplants.com
32670183-USX-1311_ad_ATLANTIS Clinician_A4.indd 1
2014-01-08 13:55
[3] =>
Standard_300dpi
CAD0314_03_Editorial 22.08.14 13:32 Seite 1
editorial _ CAD/CAM
I
Current state of
CAD/CAM in dentistry
_Digital technologies are everywhere in our daily life. We no longer go to post offices to send letters to
our friends; we e-mail them instead. We no longer have walls of CDs or DVDs, but a tiny hard drive containing
thousands of albums and movies. Newspapers, books and magazines are available in digital format and we store
them in our tablets to take them wherever we go. In this context, dentistry is no exception and the last decade
has seen the rise of the digital age in dentistry. As a result, the range of digital equipment available to dentists has
increased significantly. New technologies in dentistry offer patients modern treatments for their dental problems.
Prof. Selim Pamuk
An increasing number of dentists and laboratory technicians are adopting a digital workflow, and the uptake
of digital technologies has been more rapid for dental laboratories than dental practices. For many of them,
the high cost of equipment, apparently long learning curves, and selecting the most suitable and up-to-date
equipment are still reasons for hesitation. Like all revolutions, the digital revolution has started slowly while the
technology has grown and matured.
During the last several years, we have seen an increasing number of new intra-oral scanners in the dental
market. With these, dentists are able to achieve faster, more accurate digital impression taking, which is more
comfortable for patients. Systems rely on a single image and video camera to record the digital file that is the
foundation for an accurate outcome. There is no doubt that in the near future intra-oral scanners will be cheaper,
smaller and integrated into dental units.
Intra-oral scanners are a wedge technology for in-office CAD/CAM solutions. With the adoption of this
technology, dentists will be able to produce same-day single-unit restorations using in-office milling systems.
As the majority of restorations fabricated for dental offices are single-unit restorations and three-unit bridges,
in-office milling machines will become increasingly indispensable equipment in dental offices. Therefore, the
market for chairside milling will grow at a faster pace than today. New companies are gaining a large share of
the market, which is currently led by CEREC and E4D.
Chairside milling systems will be the impetus for new millable material. A large spectrum of materials that
can be processed via digital options are available. Companies are investing significant amounts in developing
new millable materials. Eventually, analogue methods and materials will be replaced by fully digital workflows.
Dental laboratories have been quick to make the transition from analogue to digital. They will be a valuable
resource for dentists, offering immediate restoration to dental practices in close proximity. Nothing can take
the place of a dental technician and a dentist working together to manufacture high quality restorations; there
is still no replacement for skilled professional handwork on the horizon.
In this decade, dental CAD/CAM has reached a very high level of development. According to forecasts,
more than 50 per cent of dental services will be performed using CAD/CAM technology by 2050. This figure
demonstrates the importance of keeping pace with this fast moving technology. As the leading companies in
dentistry are investing in this area, we would be wise to investigate it for our future.
I can say without question that the age of CAD/CAM dentistry is here. It is time to be part of it.
Prof. Selim Pamuk
Founder of the Society of Digital Dentistry in Turkey
President of the Turkish Academy of Esthetic Dentistry
CAD/CAM
3_ 2014
I 03
[4] =>
Standard_300dpi
CAD0314_04_Content 22.08.14 15:02 Seite 1
I content _ CAD/CAM
page 12
I editorial
03
page 16
34
Current state of CAD/CAM in dentistry
page 20
An implant-supported prosthetic restoration concept for
edentulous atrophied maxillae
| Dr Frank Zastrow
| Prof. Selim Pamuk
I industry report
I CE article
06
40
Utilizing the Tempcap abutment with CAD/CAM
| Dr Les Kalman
I industry news
I case report
12
“It is fantastically simple!”
| In this interview, Vanik Kaufmann discusses the advantages of KaVo’s
new ARCTICA CAD/CAM system
42
Intra-oral scanning with 3M True Definition Scanner,
realisation with CARES
| Planmeca
43
| Dr Marcus Engelschalk
Planmeca and the University of Turku
found Nordic Institute of Dental Education
Adentatec Competence in Dental
| Adentatec
I feature
16
44
“One cannot just replace a technician with a machine”
| Interview with the Agnini brothers, dentists and prominent specialists in
fixed prosthetics, periodontology, and implantology
| Nobel Biocare
46
issn 1616-7390
Contribution of CAD/CAM technology to
implant-supported screw-retained restorations
| Dr Richard Marcelat
26
Bionic restoration: Take the next step. Imitate nature.
Imitate the best.
| Schütz Dental
I case report
20
Ease of use meets restorative flexibility in the new
NobelProcera Hybrid
Immediate implantation and full-ceramic restoration
in the maxillary anterior region
| Dr Arndt Happe & Andreas Nolte
page 26
04 I CAD/CAM
3_ 2014
Vol. 5 • Issue 3/2014
CAD/CAM
digital dentistry
I meetings
international magazine of
3
2014
48
International Events
I about the publisher
| CE article
Utilizing the Tempcap abutment
with CAD/CAM
| special
Intra-oral scanning with
3M True Definition Scanner,
realisation with CARES
| case report
Contribution of CAD/CAM technology
to implant-supported screw-retained restorations
49
| submission guidelines
50
| imprint
Cover image courtesy of
Institut Straumann AG (www.straumann.com).
page 43
page 48
[5] =>
Standard_300dpi
More than efficiency.
Cost-effective
workflow solutions.
What does efficiency mean to your business?
ѹѹ Newly introduced one-step and cost-effective implant restorations, titanium base and full-contour crown were added to
Straumann® CARES® X-Stream™’s 1 scan, 1 design and 1 delivery
ѹѹ Directly veneerable TAN Abutment for a quick path to your
final restoration
ѹѹ New CARES® Screw-retained Bridges and Bars increase
treatment flexibility
ѹѹ Ability to connect your CADCAM system to Straumann®
CARES® Prosthetics – no additional investment or training
required, visit: www.straumann.com
Ad_Cares 8.8_A4_Vorlage.indd 1
01.04.14 10:26
[6] =>
Standard_300dpi
CAD0314_06-11_Kalman 22.08.14 14:00 Seite 1
I CE article_ Tempcap abutment
Utilizing the Tempcap
abutment with CAD/CAM
Combination of Tempcap, in-office CAD/CAM
and e.max allows for final restoration
Author_Dr Les Kalman, USA
Fig. 1
Fig. 2
Fig. 1_Tempcap abutment.
Fig. 2_Retentive pins.
_Abstract
The E4D in-office CAD/CAM unit (Editorial
note: Planmeca E4D Technologies) has been
employed in an investigative laboratory study
to design and mill an unconventional IPS e.max
restoration that would be coupled with the
Tempcap as a final implant-supported crown. The
combination of the Tempcap, in-office CAD/CAM
procedures and IPS e.max allows the clinician to
create an immediate final restorative product
with ideal characteristics.
_ce credit CAD/CAM
This article qualifies for CE
credit. To take the CE quiz, log
on to www.dtstudyclub.com.
Click on ‘CE articles’ and
search for this edition of
the magazine. If you are not
registered with the site,
you will be asked to do so
before taking the quiz.
06 I CAD/CAM
3_ 2014
The procedure is a simple, efficient and effective solution for the restoration of implants.
acceptance. Several techniques for the temporization exist, but the process has proved to be
time-consuming and frustrating. The Tempcap
abutment and the process for temporization were
created to provide a simple yet effective approach.1 With the advent of CAD/CAM technology
and e.max, the potential of the Tempcap to act
as a final abutment seemed likely and suitable for
investigation.
_Background
Following the surgical placement of a dental
implant, several requirements must be met to
maximize healing and osseointegration of the
implant body to bone:
_Introduction
The temporization of a dental implant following surgery, particularly in the anterior region, is
a necessary procedure. The temporization allows
for surgical healing, preservation of the gingival
architecture and, most important, replacement
of a tooth in the edentulous space for patient
_Minimal forces, if any, should be exerted on the
implant body, permitting proper healing and
preventing a non-osseous union.2
_The gingival architecture must be managed
meticulously to prevent contamination, minimizing the risk of peri-implantitis and possible
failure.3
[7] =>
Standard_300dpi
CAD0314_06-11_Kalman 22.08.14 14:00 Seite 2
CE article_ Tempcap abutment
_There must be sufficient time for the process
of osseointegration.4
_Temporization and immediate restorations should
not violate these factors.5
The Tempcap is a healing cap and restorative
platform combined (Fig. 1). It has an all-metal
construction, and it contains two to three retentive pin projections (Fig. 2). Tempcap is available
in different widths and heights to accommodate
different implant sizes (Fig. 3) and is compatible
with existing instrumentation (Fig. 4).
I
Fig. 3
Fig. 4
Fig. 5
Fig. 6
The function of the Tempcap is:
_to allow for optimal gingival healing;
_prevent contamination of the surgical field;
_minimize forces and micro-vibrations on the
implant;
_facilitate the simple yet successful restoration
of the implant (Fig. 5).
CAD/CAM stands for computer-aided design
and computer-aided manufacturing. CAD enables
the individual to digitally capture an image of a pre-
Fig. 3_Tempcap with Straumann
implant.
Fig. 4_Use of existing instruments.
Fig. 5_Temporization form
and function.
Fig. 6_Tempcap on soft-tissue
model with Ankylos implant
(DENTSPLY Implants).
Fig. 7_Digitization with
E4D camera (Editorial note:
Planmeca E4D Technologies).
Fig. 8_Digitized images of arch.
Fig. 7
Fig. 8
CAD/CAM
3_ 2014
I 07
[8] =>
Standard_300dpi
CAD0314_06-11_Kalman 22.08.14 14:00 Seite 3
I CE article_ Tempcap abutment
Fig. 9
Fig. 10
Fig. 11
Fig. 12
Fig. 9_Tempcap digitized.
Fig. 10_Digitized delineation
of Tempcap.
Fig. 11_Development
of emergence profile.
Fig. 12_Occlusal view of restoration.
Fig. 13_Lingual view of restoration.
Fig. 14_Facial view of restoration.
Fig. 13
pared tooth or structure and then design an indirect
(out of the mouth) restoration by using software.6
After the ideal restoration has been produced,
the design is then fabricated out of a material by
a milling machine. In-office E4D units (Editorial
note: Planmeca E4D Technologies) are currently
available to allow for immediate chairside fabrication without the use of a commercial laboratory.
IPS e.max (Ivoclar Vivadent) is a relatively
new metal-free dental material used in indirect
Fig. 14
08 I CAD/CAM
3_ 2014
restorations. It is an aesthetic material composed
of lithium disilicate and has ideal physical and
aesthetic properties, allowing it to be the first
choice for CAD/CAM restorations. IPS e.max has
strength second only to gold and has the ability
of detailed CAM production.7
_Methodology
The Tempcap was selected and placed on an
Ankylos (DENTSPLY Implants) implant body (master cast with soft tissue) (Fig. 6). Digitization was
[9] =>
Standard_300dpi
CAD0314_06-11_Kalman 22.08.14 14:00 Seite 4
CE article_ Tempcap abutment
achieved by using an E4D camera (Editorial note:
Planmeca E4D Technologies) (Fig. 7), in which several images were captured to compile an accurate
image (Figs. 8 & 9). CAD design was used with E4D
software (Editorial note: Planmeca E4D Technologies) to determine and delineate margins (Fig. 10).
Tooth design was initiated incorporating several parameters:
_ideal aesthetics and emergence profile (Fig.11);
_adequate proximal contacts;
I
Fig. 15
Fig. 16
Fig. 17
Fig. 18
_appropriate occlusal scheme;
_material thickness requirements;
_internal surface morphology to adapt to
Tempcap;
_design that can be milled via CAM technology.
Numerous design iterations were required
to achieve the desired design requirements
(Figs. 12–14). IPS e.max was selected for milling
(Fig. 15) and was executed by an E4D CAM unit
(Editorial note: Planmeca E4D Technologies) (Fig. 16).
Milling limitations, such as bur contact and pros-
Fig. 15_IPS e.max CAD/CAD block
(Ivoclar Vivadent).
Fig. 16_E4D CAM unit (Editorial note:
Planmeca E4D Technologies).
Fig. 17_Milled IPS e.max restoration.
Fig. 18_Ivoclar furnace.
Fig. 19_Staining and glazing.
Fig. 20_Facial aspect
of final restoration.
Fig. 19
Fig. 20
CAD/CAM
3_ 2014
I 09
[10] =>
Standard_300dpi
CAD0314_06-11_Kalman 22.08.14 14:00 Seite 5
I CE article_ Tempcap abutment
Fig. 21
Fig. 22
Fig. 23
Fig. 24
Fig. 21_Internal aspect of restoration.
Fig. 22_Final CAD/CAM
IPS e.max restoration.
Fig. 23_Ankylos implant with complex
Tempcap and milled IPS e.max crown.
Fig. 24_Internal aspect of IPS e.max
crown for three-pronged Tempcap.
10 I CAD/CAM
3_ 2014
thesis fracture, required CAD design modifications. Reiterations in CAD/CAM design were
carried out until a successful restoration was
achieved (Fig. 17).
The unfired IPS e.max crown was tried for fit
and aesthetics and then subsequently fired (Fig.
18), resulting in its colour change. The crown was
further stained, glazed and fired (Fig. 19), resulting in a highly aesthetic final restoration (Fig. 20).
The restoration’s internal aspect (Fig. 21) was
assessed for path of insertion, retention and fit.
_Discussion
This study has determined that the Tempcap
can be successfully and accurately digitized
and milled by in-office CAD/CAM technology
(Editorial note: Planmeca E4D Technologies) to
create an ideal prosthetic crown from IPS e.max
within a laboratory setting. CAD software can
be manipulated to generate forms beyond the
scope of the unit.
The IPS e.max prosthetic crown was further
assessed for fit, taking into account marginal fit,
occlusion and proximal contacts (Fig. 22).
Complex units, such as the three-pronged
Tempcap may be successfully designed and
milled. IPS e.max has the capability to be milled
in complex patterns, while still maintaining its
structural integrity.
A secondary investigation utilized a more
complex Tempcap to assess the limit of the
CAD/CAM unit’s capability. A stand-alone Ankylos
(DENTSPLY Implants) implant body was coupled
with a Tempcap abutment with three retentive
pin projections (Fig. 23). The abutment was digitized with the same methodology as described.
An IPS e.max crown was executed and assessed
(Figs. 24 & 25).
However, further laboratory studies, quantitatively assessing stresses and strengths and
utilizing a larger sample size, are required to
validate the concept. Subsequent clinical investigations are required to assess the clinical
significance and viability of the Tempcap with
CAD/CAM technology. The potential to fabricate
the Tempcap entirely from e.max should also be
considered.
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CE article_ Tempcap abutment
I
_Conclusions
In-office CAD/CAM technology can be utilized
and manipulated to generate digitized forms
beyond the scope of the morphogenesis. CAM
manufacturing has limiting factors that must be
realized when producing modified prostheses.
CAD modifications must account for these discrepancies. IPS e.max has the ability to be milled
in extremely detailed designs.
The Tempcap can be optically scanned and
digitized in order to design and create a CAD/CAM
IPS e.max restoration using E4D technology.
The utilization of the Tempcap as a successful
provisional abutment has been documented1;
the utility of the abutment as a simple, efficient
and cost-effective component seems promising.
These advances simplify the procedure and
reduce the cost, ultimately allowing a greater
accessibility for both patients and clinicians._
Editorial disclaimer: Dr Les Kalman is the co-owner of
Research Driven and the inventor of the Tempcap.
Editorial note: This article was originally published in
implants CE magazine 1/2013.
_References
1. Kalman, L. Technique for the temporization of an
anterior implant. Dentistry Today. 2011. Vol. 30,
No.10: 128–130.
2. Mijiritsky, E., Mardinger, O., Mazor, Z. and Chaushu, G.
Immediate provisionalization of single-tooth implants in freshextraction sites at the maxillary
esthetic zone: up to six years follow-up. Implant
Dentistry. 2009. Vol. 18, No.4: 326–330.
3. Mijiritsky, E. Plastic temporary abutments with provisional restorations in immediate loading procedures: A clinical report. Implant Dentistry. 2006. Vol.
15, No. 3: 236–238.
4. Romanos, G. Bone quality and the immediate loading
implantscritical aspects based on literature, research, and clinical experience. Implant Dentistry.
2009. Vol. 18, No. 3: 203–206.
5. Vela-Nebot, X., Rodriguez-Ciurana, X., RodadoAlonso, C. and Segela-Torres, M. Benefits of an
implant platform modification technique to reduce
crestal bone resorption. Implant Dentistry. 2006.
Vol. 15, No. 3: 313–318.
6. Berlin, M. Wowing the patient with chairside
CAD/CAM. Dental Economics: 2008; 98(4): 92–96.
7. Ivoclar Vivadent: IPS e.max lithium disilicate: The
Future ofAll-Ceramic Dentistry. 2009; 1–15.
Fig. 25
_about the author
CAD/CAM
Fig. 25_Final implant-supported
IPS e.max crown with Tempcap.
Dr Les Kalman, DDS,
graduated from the University
of Western Ontario with a
doctor of dental surgery degree
in 1999. He then completed
a GPR at the London Health
Sciences Centre. He has been
involved in general dentistry
within private practice since 2000. He has served
as the chief of dentistry at the Strathroy-Middlesex
General hospital. In 2011, he transitioned to
full-time academics as an assistant professor
at the Schulich School of Medicine and Dentistry.
Kalman’s research focuses on medical devices,
including the Virtual Facebow and the Tempcap.
Kalman is also the Director of the Dental Outreach
Community Services (DOCS) program, which
provides free dentistry within the community.
Kalman has authored articles ranging from
pediatric impression to immediate implant surgery
in both Canadian and American journals. He has
been a product evaluator for several companies,
including GC America and Clinician’s Choice. Kalman
is the co-owner of Research Driven, a company
that deals with intellectual property development.
Kalman is a member of the American Society for
Forensic Odontology, International Team for
Implantology, Academy of Osseointegration, American
Academy of Implant Dentistry and the International
Congress of Oral Implantology. He has been
recognized as an Academic Associate Fellow (AAID)
and Diplomate (ICOI). In his spare time, Kalman enjoys
photography as an accredited MotoGP photojournalist.
He can be contacted at: lkalman@uwo.ca.
CAD/CAM
3_ 2014
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CAD0314_12-15_Engelschalk 22.08.14 14:11 Seite 1
I case report _ digital solutions in implantology
Intra-oral scanning with
3M True Definition Scanner,
realisation with CARES
Author_Dr Marcus Engelschalk, Germany
Fig. 1
Fig. 2
_Introduction
considered when developing a scanning protocol
for implant-borne restorations.
Based on studies on the accuracy of the scanning
methods employed1, 2, as well as the resulting models3, 4 and restorations5–7, it appears that the combination of intra-oral scans and CAD/CAM-based
restorations is today regarded as standard in conventional prosthetics. The question that arises is
how this workflow is realised for implant prostheses. The special requirements of implants for
intra-oral scanning have led to changes in the
information to be transferred and to the principles
of the present implant workflow. This needs to be
Fig. 3
Fig. 4
12 I CAD/CAM
3_ 2014
_Case report
A 48-year-old female patient presented with
a gap that had been left untreated for many years
after extraction of tooth 46. The adjacent teeth had
been restored prosthetically and were free of caries.
It was decided to provide restoration with an implant rather than a bridge restoration. Owing to
the lack of loading, bone resorption had already
commenced in a buccolingual direction. The soft
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case report _ digital solutions in implantology
tissue was healthy and exhibited a broad region of
keratinised gingiva.
_Procedure
Treatment planning
An implant-borne full-ceramic single crown cemented on to a titanium abutment was planned to
reconstruct the lost tooth. The patient did not wish
to undergo augmentation measures in the bone area.
Surgical procedure
Implant placement in region 46 was performed
with a crestal incision only, while maintaining the
Fig. 5
Fig. 6
Fig. 7
Fig. 8
I
papillae in regions 45 and 47. As planned, a Straumann
Standard Regular Neck implant (SLActive; D 4.8 mm,
L 12 mm) was inserted in a central position. The
implant was left submerged for two months to heal
and a healing cap was inserted after uncovering
the implant and left in situ for four weeks for softtissue healing (Fig. 1).
Prosthetic procedure
For the intra-oral scan, the healing cap was replaced with an intra-oral Regular Neck Straumann
CARES Mono Scanbody (D 4.8 mm, L 10 mm; Fig. 2).
Here, the occlusal inclined section was aligned
buccally on the implant. The mouth was kept
dry with OptraGate (Ivoclar Vivadent) and the
Fig. 9
Fig. 10
CAD/CAM
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I case report _ digital solutions in implantology
Fig. 11
Fig. 12
Fig. 13
Fig. 14
entire area to be scanned was lightly powdered
(Fig. 3).
With the aid of the 3M True Definition Scanner
(3M ESPE), the mandible could be imaged with
the Scanbody, as well as the maxillae (Figs. 4 & 5).
For digital bite registration, scanning of habitual
intercuspation, the Scanbody was unscrewed again,
as the standard height of 10 mm did not allow
unimpaired occlusion in this case (Fig. 6).
This was followed by checking of the digital
image of the Scanbody in region 46 for complete
image capture of all of the surfaces, as well as the
approximal areas of the adjacent teeth. The occlusal
Fig. 15
Fig. 16
14 I CAD/CAM
3_ 2014
surfaces, as well as the relationship to the antagonist teeth and bite registration, could then be
checked prior to defining the precise reconstruction
area in region 46 with appropriate marking of the
different data volumes for later transfer (Figs. 7 & 8).
As part of the order to the laboratory, using the
3M True Definition Scanner software, the implant
data was described alongside the patient data,
including information on the position of the tooth,
abutment material (titanium/zirconium dioxide),
implant platform (Wide Neck, Regular Neck, Narrow
Neck, Regular CrossFit Connection or Narrow
CrossFit Connection) and the type of restoration
(abutment and/or superstructure).
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case report _ digital solutions in implantology
Fig. 17
Fig. 18
The dental model was produced by Innovation
MediTech after online transfer via Straumann
CARES based on the STL files. Then the appropriate
repositionable Straumann Regular Neck implant
analogue was placed in region 46 (Figs. 9 & 10).
In parallel, the planned abutment, customised via
Straumann CARES X-Stream, and the corresponding zirconium dioxide coping were fabricated
and transferred to the model situation (Figs. 11–13).
Veneering of the crown cap was performed using
a suitable veneering porcelain (Figs. 14–16).
fixed implant restoration to come as close to these
requirements as possible via customised reconstructions.
For integration purposes, the CARES titanium
abutment was screwed firmly into the implant.
After try-in and adaptation of the peri-implant
gingiva, the crown was definitively cemented using
RelyX Unicem (3M ESPE; Figs. 17 & 18).
I
Maintaining gingival dimensions and health is
a decisive factor for the long-term success of implant reconstructions; after all, a healthy and functional peri-implant gingiva forms a barrier against
the penetration of micro-organisms and bacteria.
This enables long-term preservation of the periimplant bone (not considering bone resorption
induced by malfunction or overloading)._
Fig. 19
Editorial note: A complete list of references is available
from the publisher.
_about the author
CAD/CAM
_Conclusion
The success of implant treatment does not depend on correct implant surgery alone. Prostheses
too can contribute to avoiding peri-implantitis and
to the long-term success of an implant by creating
an optimal emergence profile. In this context, the
individual abutment is to be regarded as the basis
for successful implant prostheses. The intra-oral
scan and consequent dispensing with plaster models ensure that the digital prosthetic workflow is
integrated right from the start (Fig. 19).
This leads to significant simplification of the
fabrication steps, with increased precision, and
avoids sources of error. Individual abutment shapes
can thus be designed and fabricated optimally via
CAD/CAM together with the corresponding restoration. In addition, this procedure enables reduced
changing of screws and manipulation of the implant, which can lead to a reduction in peri-implant
bone resorption.8, 9
Dental technicians and prosthodontists should
be aware of the importance of an emergence
profile at the time of temporary and definitive
prostheses. It should therefore be the goal of any
Dr Marcus Engelschalk
has a degree in general
dentistry with specialisation in
Oral Surgery and Implantology.
He obtained a Master of
Science in Lasers in Dentistry
from RWTH Aachen University
in Germany in 2007.
He has maintained a practice specialising in
periodontology and implant dentistry in Munich in
Germany since 2000. He has been an affiliated
dentist of the Arabella hospital in Munich since
2002. He is a regular speaker on oral surgery
and implantology, as well as fixed prostheses,
particularly regarding aesthetics, at national
and international conferences, an author on these
topics and a member of the editorial board
of an implantology journal.
Frauenplatz 11
80331 Munich
Germany
info@dr-engelschalk.de
CAD/CAM
3_ 2014
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CAD0314_16-18_Agnini 22.08.14 14:18 Seite 1
I feature _ interview
“One cannot just replace
a technician with a machine”
Interview with the Agnini brothers, dentists and prominent specialists
in fixed prosthetics, periodontology, and implantology
Author_John Battersby, Singapore
Fig. 1_Drs Allesandro Agnini
and Andrea Mastrorosa Agnini.
Fig. 1
_Brothers Dr Andrea Mastrorosa Agnini and
Dr Alessandro Agnini presented a series of lectures
on digital dentistry and mastering the fully digital
workflow at IDEM Singapore 2014 in April. The doctors were two of the star speakers at the Dental
Technician Forum introduced for the first time at
this year’s IDEM Singapore. Between their packed
schedule of lectures and open panel discussions,
the brothers took time out to answer some questions on their experiences in Asia, the current state
of digital dentistry, CAD/CAM, and 3-D printing, and
the direction in which they see these technologies
developing in the future.
_John Battersby: Have you observed any difference between Asian and European technicians
when it comes to their familiarity with and adoption
of the latest digital dentistry technology?
Dr Andrea Mastrorosa Agnini: We have not
really had the opportunity to work closely with any
16 I CAD/CAM
3_ 2014
Asian technicians yet, so we do not know with which
technologies they are familiar or which technologies have already been widely adopted in Asia. What
we have seen is that there is massive and growing
interest in all aspects of digital dentistry, not only
among technicians but also among all members of
the modern dental team.
Dr Alessandro Agnini: Yes, this is why there are
more events like the Dental Technician Forum at
IDEM Singapore and other similar events around
Asia, just like one sees in Europe and the US. We were
here in Singapore last November for the CAD/CAM
conference and we will be back again later this year
for another.
_How did you find your Asian audiences
at IDEM Singapore? We (Asians) have a reputation for being very shy when it comes to asking
questions; did you have many questions or much
feedback?
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feature _ interview
I
Figs. 2 & 3_Digital workflow
by Drs Agnini.
Fig. 2
Dr A. Agnini: Actually, we had quite a few questions from the floor and via the SMS system they
used for the Dental Technician Forum. The audience
can text any questions they have to a number and
we can answer them after the presentation during
the Q & A session.
Dr A. M. Agnini: The SMS system worked really
well because people could ask us anything and
often they asked us about something we had not
had time to cover in the presentation or had not included because we were not sure whether it would
interest people. With such questions, we thus could
cover such topics too.
_It has been suggested that Asia might not be
as quick to adopt digital technologies as Europe
and the US because skilled labour costs here are still
comparatively low, so there are not the same savings
to be made by giving some of the technicians’ jobs
to machines. Do you think that is true?
Dr A. M. Agnini: One cannot just replace a
technician with a machine. In Europe or anywhere
else, one still needs a dental technician who is well
trained in using all these new digital technologies;
it is not easy for anyone to use these new digital
technologies for the first time. One needs a great
deal of training to fabricate a final restoration that
is precise, predictable and of the same quality as that
achieved via traditional protocols and craftsmen
technicians. Software can help the clinician, the
technician and the patient, but on its own cannot
solve the problem; one still needs a skilled person
behind the machines to tell them what to do.
Dr A. Agnini: The machine does not know what
to do; it cannot look at a restoration and see where
we need more support, or whether a molar needs to
be done this way or another way. We need a person
with the skills, knowledge and training to decide
how to shape this framework if we are to achieve the
outcome of long-term predictable restorations.
_But now, a well-trained and knowledgeable
technician using CAD/CAM can dramatically improve his or her productivity.
Dr A. Agnini: That is true, one advantage of
CAD/CAM is one can speed up production. Another
advantage for the dental technician is that one can
reduce the variables without reducing the quality.
The third advantage is that it can level the playing
field between technicians and make standards more
homogeneous. Before, especially for large restorations, the technicians’ skill with their hands was
Fig. 3
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I feature _ interview
Fig. 4
Fig. 5
Fig. 4_Surgical guide made with
3-D printer (Objet Eden260V,
Stratasys) on the model.
Fig. 5_Surgical guide made with
3-D printer (Objet Eden260V,
Stratasys) in patients mouth.
crucial in producing high-quality restorations, but
with new technologies perhaps technicians who are
less skilled in traditional manual manufacturing
techniques can produce high-quality restorations.
ciding factor. Today, the clinician has the option of
organising his or her work as he or she prefers, but
doing everything by himself or herself is, in our opinion, something that is not convenient or practical.
_While everyone agrees that digital dentistry is
the way of the future, there does seem to be one area
where not everyone agrees. Everyone agrees that the
first two steps of the process, that is the acquisition
of data via some form of scanning and CAD, are
essential, but when it comes to the CAM component,
there seems to be a divergence of opinions.
It is a different matter if the clinician has in his
or her clinic a well-trained dental team who can
manage the digital workflow from beginning to end.
Such a team would have to include an expert dental
technician devoted to studying and mastering all of
the latest digital possibilities. Only this way can this
quality be achieved and the clinician be satisfied
from a business and economic standpoint.
One of the other speakers at IDEM Singapore, Mr Rik
Jacobs, seems to think that 3-D printing can already
cope with most laboratory manufacturing and, once
the latest biologically compatible materials currently
being developed have been tested and approved, 3-D
printing will be able to do everything, including implants. Do you see that happening or do you think precision milling will be with us for many years to come?
Dr A. Agnini: We do not have much experience
with 3-D printing machines. For sure, they will one
day revolutionise the future of dentistry, but right
now I do not think they can match the precision
achieved by milling machines. For the time being,
I think milling machines are a gold standard that
will be difficult to surpass.
_As scanning and CAD/CAM technologies, and
especially the software that links the three stages,
improve, do you think more dentists or at least the
larger dental practices will start to do more manufacturing in-house rather than using external laboratories? And if that is the case, what can laboratories and technicians do to retain their customers?
Dr A. M. Agnini: The in-house milling process is
a hot topic nowadays in dentistry. Everything has to
begin and end with the quality of the final restoration in mind, and that will always have to be the de-
18 I CAD/CAM
3_ 2014
Another solution is to team up with an external
expert laboratory that can design, customise and
produce the prosthetic elements. This way, one
does not have to invest in the initial start-up costs
involved in setting up a dental laboratory.
In summary, on the one hand, the craftsmanship
of the dental technician cannot be replaced by digital dentistry; it will still be necessary to work with
someone in-house or externally who is capable and
up-to-date with the technology. On the other hand,
if the dental laboratories want to keep themselves in
business, they have to incorporate the latest digital
solutions into their practice, understand and invest
in them, and work out how to make the most of
them. It is the only way dental laboratories will
survive this digital dentistry era.
_The buzzwords at this year’s IDEM Singapore
were definitely “CAD/CAM” and “3-D printing”, but
what do you predict the buzzwords will be in 2018?
Dr A. Agnini: I think in 2018 the buzzword will
be “full digital workflow”, meaning a completely
predictable digital process, and “full-arch rehabilitation”. Today, it is still too early to manage complex
cases with the intra-oral scanner; the average error
is still too large._
[19] =>
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• Non-precious dental alloys on nickel-chrome
base System KN and System NH
• Non-precious dental alloys on cobalt-chrome
base System NE and System Duro
• Partial alloy System MG
• CAD/CAM discs on cobalt-chrome
base System NE-Blank and System Soft-Blank
• CAD/CAM disc on titanium base System Ti5-Blank
Ringstr. 38 - 44 50996 Koeln-GERMANY
Phone + 49 2 21 - 35 96 - 100 Fax + 49 2 21 - 35 96 - 170 info@adentatec.com
www.adentatec.com
[20] =>
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CAD0314_20-25_Marcelat 22.08.14 14:22 Seite 1
I case report _ full-arch restoration
Contribution of CAD/CAM
technology to implant-supported
screw-retained restorations
Use of a full-arch bridge in the maxillae: A case report
Author_Dr Richard Marcelat, France
Fig. 1a
Fig. 1b
Fig. 1a_Initial status.
Fig. 1b_Pre-op panoramic
radiograph.
Figs. 2a–c_DentaScan images.
Fig. 2a
_In dental implantology, the optimal and truly
passive fit of the framework is essential for the longterm success of a restoration owing to the physiology
of bone tissue around implants. For a multiple-unit
implant-supported restoration, the traditional pouring technique is rather complex and challenging. The
difficulty of achieving a passive fit is directly correlated
to the number of components used and the volume
of the framework. CAD/CAM technology provides such
a high level of accuracy that it has revolutionised the
field of restorative dentistry.
_Patient presentation
Today, many implant manufacturers collaborate
with industrial companies to develop state-of-the-art
The male patient was a former smoker and 51 years
old when the treatment was initiated. He presented
Fig. 2b
20 I CAD/CAM
3_ 2014
machining solutions for their implant-supported
frameworks. In that regard, the concept developed
by Simeda (Anthogyr) is innovative and supported by
many years of proven success in the fabrication of
CAD/CAM dental restorations. The major advantage of
CAD/CAM technology is that it guarantees a highly
accurate and predictable fit (< 10 µ). This clinical case
report demonstrates the high potential of this novel
digital solution.
Fig. 2c
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case report _ full-arch restoration
I
with high blood pressure
and took Tahor (Pfizer) on
a daily basis. In addition,
he had been on Kardegic
(Sanofi) therapy since a
heart attack in 2005. For
functional and aesthetic
reasons, he wanted a fixed
prosthesis in his maxillary
arch (Figs. 1a & b).
_Debridement and
pre-implant surgery
Owing to the periodontal condition of his remaining maxillary teeth, all of them were atraumatically removed. Then, mechanical debridement was performed
through alveolar curettage and copious irrigation with
Betadine. A maxillary complete overdenture was fabricated and placed on the same day of the extractions.
After a healing period of four months, DentaScan
images (GE Healthcare) were obtained to evaluate the
bone height. The scans showed significant bone
resorption in the posterior sections of the maxillae
(Figs. 2a–c): SA-4, according to Misch’s classification,
since the residual ridge height was less than 5 mm.
Sinus grafting was deemed necessary and implant
placement had to be delayed by five to six months, until
Fig. 3
Fig. 4
complete healing and good initial stability had been
achieved.
Bilateral sinus lift was performed under local
anaesthesia from a lateral approach using the technique described by Tatum. The Schneiderian membrane was lifted gently. As there were no perforations,
platelet-rich fibrin was used for coverage of the sinus
floor. Maxgraft (botiss biomaterials) allografts were
placed to elevate the maxillary sinus floor, and then
covered with a Bio-Gide (Geistlich) collagen membrane
and platelet-rich fibrin.
After a healing period of five months, the patient
underwent a CT scan wearing a scan prosthesis of
Fig. 3_Scan prosthesis.
Fig. 4_An osteotensor.
Fig. 5a_Implant placement planning
in SIMPLANT (DENTSPLY Implants)
software.
Fig. 5b_Implant placement planning
in SIMPLANT (DENTSPLY Implants)
software.
Figs. 5c–d_CT cross-sections.
Fig. 5a
Fig. 5b
Fig. 5c
Fig. 5d
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I case report _ full-arch restoration
Fig. 6
Fig. 7a
A trans-parietal approach was used for
insertion of the Bone Matrix Osteotensor
(Victory) after a minimally invasive flapless
protocol (Fig. 4). Endosteal stimulation results in osteogenic activation and allows
evaluation of the mechanical strength of
the grafted areas by probing. Owing to this
simple and minimally invasive technique,
the initial quality of the future recipient bone
site is easily assessed. These techniques have
been successfully used in orthopaedics for
ten years. In view of the excellent response
to osteogenic activation, it was decided that
implants would be placed 45 days later.
_Treatment planning
Fig. 7b
Fig. 7c
Fig. 6_Axiom PX implant (Anthogyr).
Fig. 7a_Panoramic radiograph
showing the temporary bridge
placed 48 hours earlier.
Figs. 7b & c_The high-rigidity
temporary bridge made
of cobalt–chromium and resin.
acrylic resin and commercially available teeth for
visibility of the desired tooth location in the CT images
(Fig. 3). The CT examination showed adequate bone
volume in the grafted posterior regions and an even
sinus floor with homogeneous allografted areas.
The dome-like shape of the vestibulo-lingual crosssections was indicative of the absence of material
leakage into the maxillary sinuses
(Fig. 5a).
_Osteogenic activation
I performed osteogenic activation of the processed maxgraft
bone used for sinus lift using the
technique described by Scortecci.
Fig. 8
Fig. 9a
Fig. 9b
Fig. 9c
Fig. 9d
22 I CAD/CAM
3_ 2014
The case was planned in the SIMPLANT
(DENTSPLY Implants) treatment planning
software. The scan prosthesis is critical for
determination of the correct position and
axial alignment of the implants; visualisation of the
emergence profile; and determination of the size,
position and axial alignment of the abutments.
Furthermore, it allows optimal use of the available
bone height. At this stage, special attention should
be paid to 3-D positioning of the implants and particularly to the emergence profile in order to facilitate the fabrication process of the final restoration. Straight or angled conical abutments are now
clearly visible on the vestibulo-lingual cross-sections.
Ten Axiom PX implants (Anthogyr) were planned
for a maxillary screw-retained bridge restoration
(Figs. 5a-c).
_Implant placement
Implant placement was performed under
local anaesthesia using the case-specific
surgical guide. For this patient, I used a specific implant design (Axiom PX, Anthogyr)
with symmetrical double-lead threads (selfdrilling and self-tapping) and a reverse conical neck (Fig. 6). Its unique design, combined
with a special drilling protocol, promotes
bone condensation even in soft bone, ensuring excellent initial fixation. The BCP (biphasic calcium phosphate) sandblasting technique yields an implant surface with superior
osteoconductive properties that positively
influence the development of osteoblastic
cells in the early stage of osseointegration.
A flapless technique was used for implant
placement. The flapless technique has definite advantages: preservation of the subperiosteal blood vessels, and improved patient
comfort owing to a shorter operating time
and simple post-operative care.
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case report _ full-arch restoration
Fig. 10
Fig. 11a
Fig. 11b
Fig. 11c
_Temporary bridge and immediate loading
It was agreed with the patient that the implants
would be immediately loaded, provided that good
initial stability was obtained. The temporary removable prosthesis would be worn for a limited period.
Fortunately, adequate stability was achieved, allowing for immediate loading. Each implant (except #27)
was torqued to 35 Ncm or more. On the same day,
an impression was made using the pick-up technique,
with a previously prepared impression tray. First,
the final straight conical abutments were hand tightened into the implants using a torque of 15 Ncm.
They were intended to accommodate the screwretained provisional and then the final screwretained prosthesis.
The Axiom PX implant system offers two major
advantages: platform switching and indexing trilobe
Morse taper connection. The latter greatly facilitates
Fig. 12a
I
Fig. 11d
abutment placement. A tight stable connection guarantees integrity of the soft tissue (Fig. 8).
In the laboratory, the master model with the
embedded analogue was used to fabricate a master
plaster cast. A high-rigidity cobalt–chromium and
resin temporary bridge was fabricated, tried in, and
transferred to the patient’s mouth 48 hours after the
implants had been placed. This provisional device
would serve as an external fixator during osseointegration of the implants.
A control radiograph was taken to confirm the
passive fit of the framework. The temporary bridge was
hand tightened to a torque of 10 Ncm. The occlusion
was accurately adjusted (Figs. 7a-c). The patient wore
the temporary bridge for six months. During that period, a number of parameters were evaluated, including occlusion, osseointegration status, oral hygiene,
mastication, phonetics, aesthetics and lip support. The
Fig. 8_Healing status
at six months post-op.
Fig. 9a_The impression.
Fig. 9b_The interconnected
pick-up transfer copings.
Fig. 9c_The wax bite block.
Fig. 9d_The master model.
Fig. 10_A wax-up of the framework.
Figs. 11a–d_CAD of the model.
Figs. 12a–c_Machining
from a titanium block.
Fig. 12b
Fig. 12c
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I case report _ full-arch restoration
Fig. 13a
Fig. 13b
Fig. 13c
Fig. 13d
Fig. 13e
Fig. 13f
Figs. 13a & b_The machined
titanium framework.
Figs. 13c–f_The final bridge.
temporary bridge should be rigid (framework) and
easily removable (screw fixation). Site #27 healed uneventfully, protected as it was from mechanical stress.
_Final bridge
At the end of the six-month healing period, preparation for the final restoration began. Wearing the temporary bridge had allowed adjustment of the abovementioned parameters (e.g. aesthetics, phonetics and
lip support) and validation of the vertical dimension
and intermaxillary relationship.
The temporary bridge was removed, an implant
stability percussion test was performed, and control
radiographs were taken. The straight conical abutments that had been placed concomitant with the
implants were tightened to 25 Ncm (as recommended
by the manufacturer), except abutment #23, which
was angled (Fig. 8).
Fig. 13g_The patient’s new smile.
Fig. 13h_A post-op panoramic
radiograph with the bridge in place.
Fig. 13g
An impression of the final bridge was taken with the
same impression tray used for the temporary bridge.
Fig. 13h
24 I CAD/CAM
3_ 2014
Pick-up transfer copings were interconnected using
LuxaBite resin (DMG), and the impression was made
using Impregum (3M ESPE). The master model, including the conical abutment analogues and silicone soft
tissue (representing the patient’s gingiva), was fabricated and then validated in the dentist’s office via
a wax bite block (into which extra-hard plaster material was poured). The wax bite block was then tried in
(Figs. 9a–d).
Using silicone indices (vestibular, occlusal and
palatal) from the temporary bridge, a wax-up was fabricated in the laboratory (Fig. 10). The wax-up had to
meet the aesthetic demands of the patient and be an
exact replica of the temporary bridge (both anatomically and aesthetically). The validated master model
and wax-up were sent to the SIMEDA machining centre, where the master model was scanned and a CAD
model was designed (Figs. 11a–d). A PDF 3-D file is used
to validate the design, after which the manufacturing
process can be initiated. All pieces are machined from
titanium blocks using high-precision five-axis milling
machines (Figs. 12a–c).
Titanium is a lightweight material and,
more importantly, it is highly biocompatible
and has superior mechanical properties. It is
four times lighter than commonly used semiprecious alloys. Actually, it is the lightest metal
used in dentistry. Furthermore, titanium is
a self-passivating metal: it readily reacts with
oxygen in air to form a tough layer of oxide,
which protects against corrosion. Titanium is
known to resist corrosion and chemical attacks extremely well. Furthermore, it is bactericidal, a key advantage for dental implants.
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case report _ full-arch restoration
I
Fig. 13i
Material density is a crucial factor in implantology.
We believe that the weight of a maxillary implantsupported prosthesis is the most important factor for
the outcome of the restoration.
A few days later, we received the framework for
try-in. It had a perfect passive fit and was returned to
the laboratory for veneering. The metal preparation in
the laboratory entailed sandblasting, titanium etching
and the application of opaque porcelain to conceal the
metal core. The bisque-baked restoration was then
tried in to allow the patient to validate the aesthetics
of the restoration. This step is necessary to assess static
and dynamic occlusion and perform minor adjustments (Figs. 13a–g). The bisque-baked restoration was
then returned to the laboratory for fine tuning and
glazing.
_CAD/CAM benefits
Although conventional casting techniques have
evolved, they are still fraught with inaccuracies owing
to the nature of the materials and to their handling.
This includes the risk of errors during investment processing, risk of metal deformation and poor metal
homogeneity. The CAD/CAM technologies used for
producing metal frameworks are essential to the
quality of the final restoration (Fig. 13i). The CT scan
data is converted into a format that allows the 3-D images to be utilised by the selected treatment planning
software. The case is then planned in the software.
The CAD software has databases that allow the
creation of virtual models for the desired restoration
using different materials, including zirconia, titanium,
cobalt–chromium, IPS e-max and PMMA.
If the dental laboratory has its own scanner, an STL
file is sent directly to the production centre by e-mail.
Otherwise, both the model and the wax-up are forwarded to the production centre by courier.
If the computer settings are correct, one is ensured
of perfect reproducibility in the manufacturing process
and consistency in the result (i.e. a truly passive frame-
work fit). Optimal setting of the coping thickness
parameter or the pontic connection parameter may
prevent torsion or deformation of the framework during firing of the ceramic. Subtractive manufacturing,
combined with digital modelling, eliminates the risk of
alteration of the material structure. The resulting metal
framework will have optimal homogeneity and density.
Fig. 13i_Overview of Simeda
process stages.
As regards fabrication of implant superstructures,
machining is the technique of choice for achieving high
precision and near passive fit. Practitioners can expect
consistent and reproducible results, excellent framework fit, and regular, accurate prosthetic seals.
_Conclusion
Today, dental laboratories are using high-tech
scanning equipment, which allows digitisation of the
master model (to determine the implant index) and
the wax-up. CAD/CAM offers a level of quality and accuracy unsurpassed by any of the traditional techniques. Passive fit, which is critical to the outcome of
an implant-supported prosthesis, is a determinant of
the long-term success of a restoration. Passive fit of
the framework for a long-span restoration is much
easier to achieve and reproduce with CAD/CAM than
with the traditional pouring techniques.
The use of CAD/CAM machining for implantsupported restorations guarantees a highly accurate
and predictable framework fit (< 10 µ). In addition, machining centres can produce restorations using fully
biocompatible materials, such as titanium and zirconia.
In order to take advantage of the accuracy of CAD/CAM,
using safe and reliable implant systems with superior
biological and biomechanical characteristics is required.
CAD/CAM will soon be essential. Current CAD/CAM
solutions are easily accessible to any dentist and do
not require fundamental changes to his or her work
habits._
Acknowledgement: Special thanks to G. Nauzes and
J. Bellany, laboratory technicians at Socalab.
_author
CAD/CAM
Dr Richard Marcelat
has a DDS degree in
Oral Implantology from
the University of Liège
and in Basal Implantology
from the University of Nice
Sophia Antipolis, as well as
a Postgraduate Certificate
in Implantology from
CURAIO in Lyon in France.
He can be contacted at
richard.marcelat@orange.fr.
CAD/CAM
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I case report _ implant-supported single-tooth restoration
Immediate implantation and
full-ceramic restoration in the
maxillary anterior region
Authors_Dr Arndt Happe & Andreas Nolte, Germany
_Introduction
Fig. 1
Fig. 2
Fig. 3
Fig. 1_The female patient wanted
new restorations with bright,
natural-looking crowns in
regions 12 to 22.
Fig. 2_Tooth 11 could not be saved
and was to be replaced with
an implant.
Fig. 3_The photographs and
situation models were analysed in
terms of aesthetics, and all details
diligently recorded on the
relevant form.
Implant-supported
single-tooth crowns in
the aesthetic zone are
a special challenge,
particularly when immediate implantation
is planned—if there is
insufficient bone volume and a thin biotype.
A whole chain of critical
factors need to be considered here, including
implant positioning1, 2,
hard- and soft-tissue
management 3–5 and
the natural design of
the crown.6 These days,
a number of digital
methods are available
to simplify the process
and make it safer.7
Depending on the initial situation, that is maximum
aesthetic demands, however, many dentists prefer
analogue methods, as in the following example.
_Initial findings and planning
A young female patient with full-ceramic crowns
on teeth 12 to 22 presented at our clinic desiring bright
and natural new restorations (Fig. 1). Her medical
history was unremarkable and her gingival type was
classified as thin. Tooth 11, which had undergone root
canal therapy, could not be saved and would have to be
replaced with an implant owing to a weakening of
tooth substance, resulting from excessive cavitation as
part of post-endodontic restoration (Fig. 2). In addition,
the existing crown kept coming off owing to the poorly
retentive design of the abutment.
In order to obtain the most accurate assessment
of the initial situation, the dental technician photographed the patient in his laboratory. Using the
26 I CAD/CAM
3_ 2014
photograph and initial models, he defined the shape
and colour of the planned restorations and carefully
analysed their position in the arch for the temporary
restoration (Fig. 3). Based on the data obtained, a
temporary bridge was fabricated for teeth 12 to 21 once
tooth 11 had been extracted.
_Immediate implantation and
temporary restoration
In order to extract tooth 11 with as little trauma
as possible, the surgeon first severed the periodontal
fibre system with a periotome (Fig. 4) and expanded the
coronal alveolar gap with piezo-surgical instruments.
First, the crown was luxated and extracted with extraction pliers, then the root, again with piezo-surgery,
a sharp lever and diamond pliers. This revealed that
the thin buccal bone lamella was connected to the
root (Fig. 5). The osseous margin of the alveolus was
examined carefully with a periodontal probe (bone
sounding).
Despite a lack of bone wall, an immediate implantation as planned was to be performed according to
the protocol of the University Medical Center of the
Johannes Gutenberg University of Mainz, Germany.8
With the aid of the guide prepared in the laboratory;
the positions were marked prior to preparing the implant bed (Fig. 6). Pilot drilling and further drilling steps
were performed by the surgeon without a guide and
with drill extension for optimal cooling. Insertion of the
implant (CONELOG, CAMLOG; 3.8 mm diameter, 13 mm
length) was also performed without a guide (Fig. 7).
Correct 3-D orientation of the implant was checked
with the final drill and using the drill guide. The buccal
implant shoulder should be 3 mm apical of the marginal soft tissue and distinctly palatal to the dental arch
(Figs. 8 & 9). This ensures that the subsequent implantsupported crown can be screwed in palatally. The gap
between the implant and buccal soft tissue was filled
with bone material. This was a mixture of autologous
bone gained during preparation. Granular autologous
bone harvested from the retromolar area and bovine
[27] =>
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I case report _ implant-supported single-tooth restoration
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8
Fig. 9
Fig. 10
Fig. 11
Fig. 12
Fig. 14
Fig. 13
Fig. 4_ After removing the temporary crowns on teeth 12 and 21, the supra-alveolar
periodontal attachment of tooth 11 was severed with a periotome.
Fig. 5_The root was extracted after atraumatic removal of the crown. The buccal bone
lamella connected to the root surface was lost during the process.
Fig. 6_The palatal margin of the alveolus was marked with the pilot drill through
a deep-drawn guide prepared in the laboratory.
Fig. 7_When inserting the implant, the surgeon oriented himself along the palatal
bone wall.
Fig. 8_The implant was palatally displaced in the correct position; the buccal bone
lamella no longer existed.
Fig. 9_The position of the implant in the dental arch was checked with the aid
of the guide.
28 I CAD/CAM
3_ 2014
Fig. 15
Fig. 10_ A retromolar bone cylinder was harvested with a trephine drill to obtain
autologous bone for augmentation of the buccal lamella.
Fig. 11_The space between the implant and buccal soft tissue was filled with
a mixture of autologous bone and bovine bone replacement material.
Fig. 12_ In order to obtain optimal buccal contours, a connective-tissue graft
harvested from the palate was drawn under the soft tissue and sutured.
Fig. 13_The temporary bridge was cemented with the healing cap without contact
with the pontic.
Fig. 14_The sub-crestal bone position and good cervical join of the temporary bridge
are shown on the post-operative X-ray.
Fig. 15_Good healing and successful integration of the connective-tissue graft are
evident one week after immediate implantation. The white-yellow deposits are fibrin.
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case report _ implant-supported single-tooth restoration
I
Fig. 16
Fig. 17
Fig. 18
Fig. 19
Fig. 20
Fig. 21
Fig. 22
Fig. 23
Fig. 24
Fig. 25
Fig. 26
Fig. 27
Fig. 16_After a three-month healing period, the implant was successfully
osseointegrated and the soft tissue had stabilised for final
impression taking.
Fig. 17_The peri-implant soft tissue is well formed and largely irritation free under
the temporary bridge.
Fig. 18_Good perfusion of the peri-implant soft-tissue well can be observed.
Buccal tissue thickness exceeds 3 mm.
Fig. 19_Impression taking of the prepared teeth and the implant.
Fig. 20_Following reinsertion of the temporary bridge, excess soft tissue was
observed in the area of the implant (position 11).
Fig. 21_Individual stumps made of super-hard plaster with grooves to prevent rotation
were fixed in the impression with instant adhesive.
Fig. 22_Preparation of the master model. The wax pins served as access
to the stumps on the master model.
Fig. 23_The precise periodontal and peri-implant soft-tissue situation was
represented on the master model.
Fig. 24_The marginal border of the planned implant crown was transferred
to the plaster surface.
Fig. 25_The peri-implant emergence profile was expanded and the papillae
sharpened to provide a harmonious gingival profile.
Fig. 26_Optimal hold of the wax-up during try-in through filled implant interface.
Fig. 27_Overview of abutment options (from left: CONELOG Esthomic abutment
(1.5 to 2.5 mm gingiva height) prior to and after customising,
the CONELOG Titanium base CAD/CAM.
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I case report _ implant-supported single-tooth restoration
Fig. 28
Fig. 29
Fig. 30
Fig. 31
Fig. 32
Fig. 33
Fig. 28_The Esthomic abutment,
extended with a bonding aid,
shows the palatal positioning of the
access channel.
Fig. 29_Customising the primary
abutment ensures sufficient coating
strength of the zirconium
oxide abutment.
Fig. 30_The titanium base and the
completed model of the secondary
abutment were scanned in the
laboratory. Buccal space was left for
the planned pressed ceramic veneer.
Fig. 31_The sintered abutment
left without and right with
fluorescent solution treatment.
Fig. 32_Firing of a highly fluorescent,
etchable zirconium oxide veneer
ceramic. The shape of the abutment
was optimised prior to modelling
the press cap.
Fig. 33_The layer thicknesses for
veneering the pressed ceramic caps
were checked with the aid of
the vestibular, twice-divided
silicone index.
30 I CAD/CAM
3_ 2014
bone augmentation material were used to prevent
resorption (Figs. 10 & 11).
In order to obtain the best possible soft-tissue
conditions in the sense of a thicker gingival type, the
surgeon harvested a connective-tissue graft from the
palate. Using the tunnel technique according to Azzi,9–11
this was pulled between the bone granulate and the
buccal soft tissue and fixed with a monofilament, nonabsorbable suture material (Fig. 12). Then a CONELOG
wide-body healing cap (4 mm height) was screwed in
and the temporary bridge cemented (Fig. 13). This supported the soft tissue, but did not contact the healing
cap, so that the lower section of the pontic could be
cleaned with super floss. Figures 14 and 15 show the
post-operative X-ray and the situation at the check-up
one week after immediate implantation.
After three months of implant healing, the periimplant and periodontal tissues were ready for final
impression taking (Figs. 16 & 17). To this end, double 0
sutures soaked in glycerine were placed in the sulci and
the preparation borders placed slightly subgingivally as
part of final fine preparation. Then a thicker retraction
cord, strength 0, soaked in epinephrine was placed
(adrenaline; Fig. 18). The healing cap was unscrewed
(Fig. 18) and a CONELOG impression post for open trays
screwed in (Fig. 19). Impression taking was performed
after drying and removal of the thick retraction cord
(Fig. 19) in one step with an individual open tray and
a two-phase polyvinyl siloxane (A-silicone). Following
arbitrary transfer of the occlusal relations with a bite
fork, facebow and bite registry, the healing caps and
temporary bridge were reinserted. A temporary crown
was fabricated for tooth 22 (Fig. 20). The marginal gingiva in the region of the implant had to be moved
slightly in an apical direction with the definitive
restoration owing to the excess tissue.
_Fabrication of abutments and final
crowns
Using super-hard plaster, the dental technician
fabricated root-shaped (conical) stumps to prevent
rotation. These were placed in the impression to fabricate the master model and extended with wax pins
(Figs. 21–23). A new wax-up was prepared based on the
updated aesthetic analysis and the outer cervical contour of the implant restoration was transferred to the
model (Fig. 24). The anatomical shape of the emergence
profile was then created with a fine milling machine.
The implant crown was thus given a natural emergence
contour. The papillae were slightly sharpened and
smoothed to give an optimal gingival contour. The
optimised shape of the papillae avoided concavities
occurring later in the cervical, slightly subgingival
ceramic areas, which are difficult to clean and can lead
to irritation of the gingiva (Fig. 25). The wax-up was
fitted with a pin at the implant position, which engaged
with the implant interface for better fixation of the
wax-up during try-in (Fig. 26).
A suitable abutment was selected from the
CONELOG Esthomic abutment set and the silicone indexes based on the wax-up. In this case, the CONELOG
Titanium base CAD/CAM was too low owing to the
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case report _ implant-supported single-tooth restoration
I
Fig. 34
Fig. 35
Fig. 36
Fig. 37
Fig. 38
Fig. 39
apical position of the implant shoulder. Therefore, the
dental technician decided on a considerably longer,
straight CONELOG Esthomic abutment, which was customised for use as a titanium bonding base (Figs.
27–29). He modelled a secondary abutment with wax
on the customised titanium base (primary abutment),
which was to be fabricated from zirconium oxide.
Subsequent bonding with the titanium base resulted
in a hybrid abutment with full anatomical contours,
both in the palatally and subgingivally positioned
emergence area through the soft tissue. Room was left
on the buccally visible area for a pressed ceramic veneer
to be fixed by bonding (Fig. 30). Using a double scan,
the dental technician imported the 3-D shape of the
primary abutment and the wax model of the secondary abutment into the planning software (Abutment
Designer, 3Shape; Fig. 30).
Then the secondary abutment was ground from
zirconium oxide ceramic with CAM technology and
immersed unsintered into a fluorescent solution
(Fig. 31). The screw channel was prepared prior to
sintering. As zirconium oxide cannot be etched, the
dental technician had to fire a thin layer of etchable,
highly fluorescent zirconium oxide veneer ceramic
on to the buccal surface and preparation margin of
the hybrid abutment prior to modelling the cap for the
pressed ceramic veneer (Fig. 32). Fluorescence ensures
the transmission of light in the gingival area. This has
a positive effect, particularly in the case of a thin
gingiva. Then, the dental technician fabricated and
veneered the pressed ceramic caps for the crowns
and veneers (Figs. 33–35).
After a successful aesthetic try-in in the laboratory
(Figs. 36 & 45), the individual parts were combined.
First, the titanium base was sand-blasted and conditioned, then the secondary zirconium oxide abutment
was conditioned. Both parts were bonded with special
composite. Then the inner side of the veneer and the
sintered zirconium oxide veneer ceramic of the hybrid
abutment were etched with hydrofluoric acid, conditioned and bonded with dual-curing composite
(Fig. 37). Then, the transition areas were smoothed and
polished (Fig. 38).
_Insertion
The crowns were mounted by bonding and the
implant-supported veneer crown was screw-retained
(Figs. 39 & 40). This was followed by a careful check of
the approximal contacts and function. The final X-ray
confirmed successful osseointegration of the implant
and harmonious emergence of the implant-supported
restoration from the bone (Fig. 41). Figures 42 to 45
show the aesthetically successful outcome and a very
satisfied patient.
_Discussion
Fig. 34_Modelling of the mamelon
for the implant-supported veneer
from a palatal view.
Fig. 35_After glaze firing and
polishing, the natural anatomy and
surface characteristics of the
restoration were checked.
Fig. 36_Aesthetic try-in: The patient
and her dental technician, Andreas
Nolte, appreciating the highly
successful outcome and nearly
completed treatment.
Fig. 37_The pressed ceramic veneer
was mounted on the previously
bonded hybrid abutment by bonding
with dual-curing composite.
Fig. 38_The transitions between the
abutment and the veneer were
smoothed and polished to a high
gloss with a brush and polishing
paste.
Fig. 39_The implant restoration is
screw-retained. For biomechanical
reasons, the screw access channel
was placed in the zirconium oxide
section.
The example demonstrates successful immediate
implantation in the anterior maxilla of a female patient
with a thin biotype and high smile line. In addition, the
buccal bone lamella was missing, so that the bone and
soft tissue had to be augmented as part of immediate
implantation—without preparing a flap. This demanding task can only succeed when the surgeon and if
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I case report _ implant-supported single-tooth restoration
Fig. 40
Fig. 41
Fig. 42
ing structures. This requires a precise clinical and radiographic analysis of the initial situation, appropriate
planning and a high degree of expertise. Impression
taking also followed conventional techniques.
Fig. 44
Fig. 43
Fig. 40_The palatally inserted
crowns and the sealed screw access
channel of the implant crown.
Fig. 41_The X-ray check-up
confirmed successful
osseointegration and the natural
emergence profile of the
implant-supported restoration.
Fig. 42_The close-up shows the
healthy peri-implant soft tissue and
the natural surface of the restorations.
Fig. 43_The side profile also shows
the natural contours of the
restoration and the successful
interplay between red and white.
Fig. 44_The patient’s relaxed smile
confirmed that the effort and
attention to detail were appreciated.
Dental technician:
Enamelum et Dentinum
Andreas Nolte
Königsstraße 46
48143 Münster
Germany
www.enamelum-et-dentinum.de
32 I CAD/CAM
3_ 2014
applicable the prosthodontist and the dental technician work together as an optimal team and use suitable
methods and materials. In the case presented, surgery
and prosthetics were performed by the same dentist,
who had been working together intensively for many
years with the dental technician in the same location.
At the beginning of treatment, the patient presented
to the laboratory for an aesthetic analysis to give the
dental technician a detailed understanding of the
situation.
In order to obtain adequate tissue volume in the
implantation area, the surgeon employed proven
bone and soft-tissue surgical procedures. These included using a bone mixture for augmentation and
a tunnel technique for thickening the buccal soft tissue.10, 11 The literature shows that stable tissue volume
and a constant marginal soft-tissue border can be
achieved in this way5, 12 even in the case of an impaired
implantation site with missing bone lamella.8, 13 This
procedure is not (yet) recommended in the current
consensus statements by the professional associations owing to difficult predictability of individual
results.14
_Analogue and digital
A large part of the treatment and technical work
steps were performed with conventional surgical
prosthetic and craft-dominated technical dental
methods (analogue). Computer-supported planning
was not employed, so that the surgeon was not guided
but implanted freely in accordance with the surround-
A speciality here is the use of a two-part hybrid
abutment as the base for the pressed ceramic veneer.
In order to obtain a biochemically optimal titanium
bonding base, a straight CONELOG Esthomic abutment
was customised in place of the alternative CAD/CAM
component. The secondary zirconium oxide abutment
was waxed up. Then, both components were scanned.
This is where the CAD/CAM process came into play with
the fine-tuning of the design on the screen and machine fabrication of the zirconium oxide secondary
abutment. Despite using a titanium primary abutment,
the dental technician achieved a natural light effect
by the consequent use of fluorescing materials.
As all components of the implant-supported restoration were bonded in the laboratory, the dentist
was able to screw them in place together as a single
piece and in a single session. This meant fewer treatment sessions for the patient, who did not have to
return to the practice after impression taking until final
insertion. The aesthetic try-in before final bonding of
the individual parts was performed in the laboratory.
The procedure described is only possible in close cooperation and with full confidence between the team
partners._
Editorial note: A list of references is available from the
publisher.
_contact
Joint practice Drs Happe
Schützenstraße 2
48143 Münster
Germany
info@dr-happe.de
www.dr-happe.de
CAD/CAM
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CAD0314_34-39_Zastrow 22.08.14 14:29 Seite 1
I case report _ restoration of atrophied maxillae
An implant-supported prosthetic
restoration concept for
edentulous atrophied maxillae
Author_Dr Frank Zastrow, Germany
Fig. 1
Fig. 2
Fig. 1_The initial clinical situation
of the old telescopic restoration.
Fig. 2_Radiograph
of the initial situation.
Fig. 3_3-D representation of the
maxillae and mandible.
Fig. 4_The horizontal bone loss
in the premolar region.
Fig. 3
_Autogenous bone block grafts, bone grafting material or a combination of both can be used
to restore an implant site of adequate dimensions
in an atrophied maxilla. If the vertical height of
the bone is inadequate in the posterior region,
a sinus floor lift is often indicated to stabilise the
implants safely.
In the case presented here, surgical treatment
based on Prof. Fouad Khoury’s1, 2 biological concept for bone grafting using a combination of
Fig. 4
34 I CAD/CAM
3_ 2014
autogenous bone block grafts and particulate
bone chips is described.
The case report also describes the layering
technique as part of a sinus floor lift in conjunction with bone grafting material. The objective
of the treatment is a restoration with longterm stability and a good aesthetic result. An
implant-supported bar-latch design based on
Dr Friedrich-Wilhelm Pape’s prosthetic concept
(Schellenstein concept) was used.3
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case report _ restoration of atrophied maxillae
Fig. 5
_Initial situation
The 60-year-old patient was referred to the
practice with a telescopic restoration on natural
abutment teeth 11, 21, 22 and 23. Crown and
bridge restorations were used in the mandible;
however, teeth 21 and 22 could not be preserved
and were extracted. Abutment teeth 11 and 23
could not be preserved, but served as abutments
for the temporary restoration until fabrication of
the final prosthetic restoration.
In the premolar region specifically, pronounced horizontal and vertical bone defects that
required comprehensive augmentative measures
were identified in the preoperative 3-D CBCT
images (Figs. 1–4).
_Surgical treatment
The surgical treatment consisted of three procedures, each performed at three-month intervals. In the first procedure, performed under general anaesthesia, a FRIOS MicroSaw (DENTSPLY
Implants) was used to harvest a bone block
from the retromolar region of the right mandible
(Figs. 5 & 6). The harvested bone plate was thinned
and then placed at a distance using osteosynthesis screws (micro-screw, Prof. Khoury and stoma)
for horizontal expansion of the right maxilla and
the resulting space was filled with particulate
autogenous bone chips (Fig. 7).
Particulate bone causes an increase in the
surface and therefore better vascularisation of
the augmented bone. In the second quadrant, an
external sinus floor lift was performed based
on the layering technique (Fig. 8). A slow resorbable phycogenic bone grafting material (FRIOS
Algipore, DENTSPLY Implants) was placed in the
cranial region, while the caudal region was filled
with autogenous bone chips. This arrangement of
bone grafting material and autogenous bone
chips meant that the implants were placed in
approximately 10 mm of autogenous bone, accelerating the healing phase. With this technique,
the bone grafting material introduced in the
cranial region prevented rapid resorption due to
the pressure of the maxillary sinus.
The sinus window was covered by a nonresorbable membrane made of medical-grade
I
Fig. 6
Fig. 5_Bone block harvesting
with the FRIOS MicroSaw.
Fig. 6_Thinning of the harvested
bone block.
Fig. 7_The thinned bone block
placed at a distance. The area
is prepared for filling with particulate
autogenous bone chips.
Fig. 8_Sinus floor lift. The surgical
site is filled with FRIOS Algipore.
Fig. 7
Fig. 8
CAD/CAM
3_ 2014
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I case report _ restoration of atrophied maxillae
Fig. 9
Fig. 10
Fig. 11
Fig. 12
Fig. 9_The XiVE implant with TempBase
inserted into the surgical site.
Fig. 10_Covering the sinus window
with a FRIOS BoneShield membrane.
Fig. 11_Radiographic control after
grafting and implant insertion.
Fig. 12_Insertion of the additional
implants in the grafted region.
Fig. 13_Insertion of the additional
implant in region 14.
Fig. 14_Insertion of the additional
implant in region 16.
Fig. 13
titanium (FRIOS BoneShield, DENTSPLY Implants)
that was fixed using three membrane tacks (FRIOS
Membrane Tacks, DENTSPLY Implants; Figs. 9 &
10) for position stability.
A mucoperiosteal flap was used for soft-tissue
coverage in which the periosteum was slit to ensure tension-free closure over the grafted bone.
In the course of this first procedure, four XiVE
implants (DENTSPLY Implants) were inserted into
regions 12, 22, 24 and 26 (Fig. 11).
Fig. 14
36 I CAD/CAM
3_ 2014
After three months, as a part of the second
surgical procedure, the previously augmented
area was opened. The site appeared to be well
regenerated and vascularised. In the procedure,
two additional XiVE implants in regions 14 and
16 were inserted, resulting in a total of six implants available with uniform abutment distribution in the maxillae as a basis for later prosthetic
restoration (Figs. 12–15).
After another three-month healing phase,
the last surgical procedure exposed the implants
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case report _ restoration of atrophied maxillae
Fig. 15
Fig. 16
Fig. 17
Fig. 18
by means of an apical sliding flap. The natural
mucogingival junction was then restored and
gingiva formers inserted (Figs. 16–18).
technique with transfer copings inserted into the
implants (closed-tray impression) and an initial
impression taken with a stock tray (Fig. 19).
_Impression
This impression was used in the laboratory to
fabricate an initial cast and to prepare a second
impression using the pick-up technique. The impression posts were rigidly attached to the cast
using PATTERN RESIN (GC). This index was separated again between the implants in the laboratory and the impression posts were placed in the
patient’s mouth in the second session (Fig. 20).
The soft tissue took three weeks to heal around
the gingiva formers. For the prosthetic treatment
phase, four appointments were necessary for
completion of the final restoration based on
Dr Pape’s prosthetic concept.3 In the first session,
an impression was taken with the repositioning
I
Fig. 15_Good regeneration of the
augmented region.
Fig. 16_Gingiva formers inserted
and the surgical site sutured closed.
Fig. 17_Gingiva formers
in situ after healing.
Fig. 18_Radiographic control after
exposure of all of the implants.
Fig. 19_Impression with a stock tray.
Fig. 20_Preparation of the second
impression. The impression posts
splinted with PATTERN RESIN.
Fig. 19
Fig. 20
CAD/CAM
3_ 2014
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I case report _ restoration of atrophied maxillae
Fig. 21
Fig. 22
Fig. 23
Fig. 24
Fig. 21_The master cast
with a gingival mask
and the tooth set-up in wax.
Fig. 22_Bar try-in with teeth 11
and 23 extracted.
Fig. 23_Tension-free fit
of the bar before positioning
of the final restoration.
Fig. 24_Buccal view of the bar
with “bolt eye” clearly identifiable.
Fig. 25_Radiographic control
after bar placement.
Proper fit is easily recognised.
38 I CAD/CAM
3_ 2014
The separation gaps were reconnected intraorally with PATTERN RESIN to ensure high precision for the second impression (Impregum,
3M ESPE) by stiffening of the posts (open impression with custom tray). In the laboratory, a master
cast with a gingival mask was fabricated and
a tooth set-up prepared for aesthetic try-in
(Fig. 21).
Fig. 25
_Prosthetics
In the third prosthetic session, the wax try-in
(aesthetic try-in) was carried out on the patient.
The master cast, related antagonist bite impression and tooth template were sent to the milling
centre in Hasselt in Belgium for fabrication of the
CAD/CAM framework (ATLANTIS ISUS, DENTSPLY
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case report _ restoration of atrophied maxillae
I
Implants). The dental technician can use the free
ATLANTIS ISUS Viewer software in the laboratory
to view in 3-D and finalise digitally the bar design
proposed by the milling centre. The bar was then
milled from cobalt–chromium at the milling centre and the restoration shipped to the dentist’s
private laboratory. Owing to the precision of the
impression and industrial fabrication, the bar
framework exhibited a tension-free fit and served
as the basis for fabricating the final superstructure in the laboratory.
In the final session, before positioning the
finished restoration, the fit of the bar in the patient’s mouth was checked using the Sheffield
test. The fit of the bar again appeared tension free,
allowing the bar to be permanently screwed to
the implants (Figs. 22–24).
The primary splinting of the implants by the
bar gives the restoration great stability in the
augmented bone in particular. Owing to the uniform distribution of the implants in the ridge
and creation of a large support polygon, good
force distribution across the implants is possible,
which in turn achieves a good long-term result.
Because the bar construction is screw-retained,
the risk of leaving excess cement in the periimplant region, which poses the risk of periimplantitis and should not be underestimated,
according to the latest studies, is avoided.4
The removable palate-free prosthesis is provided with latches (MK1 attachment) on both
sides to anchor the prosthesis to the bar firmly.
The latches counteract pull-off forces and prevent abrasive wear on the bar when the canine
guidance is set and the resulting friction loss of
the bar-latch design (Figs. 25 & 26).
_Conclusion
Owing to primary splinting of the implants with
a bar construction and the large support polygon
created, maximum stability is achieved directly in
the augmented bone. In atrophied maxillae, it is
often observed that the maxillae are smaller than
the mandible owing to centripetal shrinkage. The
advantage of the bar restoration over a telescopic
restoration with regard to this problem is the decoupling of tooth and implant position. The bar can
be placed in front of the alveolar ridge and, despite
an unfavourable initial situation, still achieve good
occlusion and lip support.
Fig. 26
tion, access for cleaning is not affected in any way
because the restoration is removable. The use of
latches takes into account the patient’s desire for
a fixed restoration and the requirement for longterm stability, which is the basis of the easy-toclean design. Furthermore, the removable restoration allows quick and easy repair, and chipping is
never an issue because ceramics are not used.
Fig. 26_The integrated
bar-latch restoration.
Unlike a fixed restoration, no aesthetically or
phonetically compromising cleaning channels
are required. The cleaning channels of fixed implant bridges often make it difficult for patients
to form the ‘s’ sound. This can bring into question
the success of the entire restoration because it
can make the patient feel uncomfortable and insecure owing to speech impediment. In contrast,
the restoration presented here does not affect
pronunciation at the buccal plate.
The final restoration exhibits a functional, aesthetically pleasing, and phonetically unimpaired
result that meets the patient’s wishes. Therefore, this treatment concept is a good option for
restoration of edentulous atrophied maxillae._
Editorial note: A complete list of references is
available from the publisher.
_about the author
CAD/CAM
Dr Frank Zastrow is in
private practice in Wiesloch in
Germany. He can be contacted
at www.frankzastrow.com.
The bilateral latches for this restoration give
the patient direct control of the anchoring of the
restoration and thus a feeling of security. In addi-
CAD/CAM
3_ 2014
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CAD0314_40-41_KaVo 22.08.14 14:34 Seite 1
I industry report _ interview
“It is fantastically simple!”
In this interview, Vanik Kaufmann discusses the advantages of
KaVo’s new ARCTICA CAD/CAM system
_When it comes to state-of-the-art CAD/CAM
technology in dental laboratories, patients are in
good hands with master dental technician Vanik
Kaufmann-Jinoian. His numerous lectures on the
subject are impressive proof of this. The proprietor
of the Cera-Tech dental laboratory in Liestal near
Basel has been a CAD/CAM user from the very beginning, as well as provided valuable input into the
technology’s development through his active participation in it. Recently, he became a user of KaVo’s
new ARCTICA CAD/CAM system. We asked him about
his first impressions of working with the system.
Vanik Kaufmann
Fig. 1_Completed milled
connecting bar with screwed locators
fabricated in the ARCTICA Engine.
Fig. 2_Two connecting bars with
implant connectors milled from
a titanium block.
Fig. 3_A range of materials
is offered: ARCTICA Elements of
titanium, zirconium, glass-infused
ceramics and plastic; in addition,
an exchangeable holder offers the
option of using third-party materials.
Fig. 1
_CAD/CAM: You recently started using KaVo’s
ARCTICA CAD/CAM system. You have extensive
experience with CAD/CAM systems. What do you
consider ARCTICA’s advantages to be?
Vanik Kaufmann: First, there is the striped light
scanner. I particularly like that it is a semi-automatic design. With fully automated systems, I often encounter
problems with cumbersome re-scans when the first
scan was incomplete. Scans that require essentially no
corrective work can be achieved with very little experience. In addition, it works extremely quickly. Even in cases
in which the scan shows gaps, the model can be repositioned accordingly, perhaps by tilting, and the software
applies any subsequent corrections automatically.
_And what are your experiences with the grinding unit?
I really appreciate that it is a compact five-axis system that uses blanks very economically. Furthermore,
I am finally able to process metal, something that until now had not been possible with small systems.
_Is zirconium dioxide still important nowadays?
There are still dentists who request metal frameworks. When cobalt–chromium alloys are required,
Fig. 2
40 I CAD/CAM
3_ 2014
we have them externally made by selective laser
sintering. When biocompatibility is required, we
have to use titanium. We process a large number
of titanium connecting bars and until now had to
have them fabricated externally.
Now, we are able to do this in house, and the
design is simple and fast using the accompanying
software.
_How practical is the software?
It is fantastically simple. For example, during
the design of an anterior bridge, the automatically
proposed crown can be moved and rotated through
key combinations, making the process considerably
faster and simpler than with solutions that require
multiple key clicks. Also, its operation is intuitive:
within half an hour of receiving it, I was able to do
a bar design without a hitch and without any training. KaVo’s hotline with remote support is equally
fantastic and useful, especially in the early stages
when one might have the occasional problem. The
consultants are highly competent, they can log in
remotely and point out mistakes on your own
screen and give hints on how to do things even
faster.
_The multiCAD dental CAD/CAM software has
an open interface, but not every scanner supplier
offers an open interface. To what extent can you
transfer data?
We are able to do this not only with manufacturers that provide STL files, but also with those that still
believe in the advantages of proprietary systems.
We use Dental Shaper for Rhinoceros (CIMsystem)
for this purpose; it can convert all relevant data sets
to compatible STL files. One could also use a printer
(Solidscope).
Fig. 3
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industry report _ interview
I
Fig. 4_Navigation of the multiCAD
dental CAD/CAM software is logical
and intuitive.
Fig. 5_ARCTICA Engine: a compact
five-axis wet milling and grinding
centre.
Fig. 4
Fig. 5
_Do you use ARCTICA data in multiCAD as well?
Yes. We have decided to no longer do the wax
coating for precious metal castings by hand, as
this can be done very simply and quickly in the
KaVo software. We design the framework on computer and transfer the STL data directly to the
printer. The printer is very accurate and saves us a
great deal of work.
cate our own plastic and wax blocks too, which we
can use via the exchangeable holder.
_Besides KaVo’s blocks of titanium, zirconium, glass-infused ceramics and plastic, there
is the option of using other materials. Do you use
them?
We have the open system and do both. Alongside KaVo’s materials, we use VITABLOCS RealLife
and VITA CAD-Temp blocks (both Vident). We fabri-
_Could you share your experience with the implant module in multiCAD?
We fabricate connecting bars from titanium with
bonded bases. We also use titanium bonded bases
for our zirconium abutments, since we have had
bad experiences with whole zirconium abutments
with screw connections—they loosened over time.
For lateral applications, we also fabricate titanium
abutments, which we weld to the bonding base. The
design of these abutments too is amazingly simple:
one draws what one has in mind.
_contact CAD/CAM
KaVo Dental GmbH
Alexia Valera
9th Floor
Rotana Arjaan Tower
Dubai Media City
UAE
alexia.valera@kavo.com
www.kavo.com/mea
_Thank you very much for the interview.
AD
Be inspired by nature. The “Bionic Restoration “.
Tizian Zirconia Reinforced Composite
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CAD0314_42_Planmeca 22.08.14 14:35 Seite 1
I industry news _ Planmeca
Planmeca and the University
of Turku found Nordic
Institute of Dental Education
Fig. 1_The objective of the new institute is to export and share Nordic expertise in digital dentistry
on the basis of academic knowledge and technologies. (Photo: Planmeca)
_Dental technology company Planmeca and
the University of Turku have founded a joint venture
company, the Nordic Institute of Dental Education.
The institute will offer high-quality continuing
education courses to dental professionals.
The objective is to export and share Nordic
expertise in digital dentistry on the basis of the
academic knowledge of the University of Turku and
the technologies developed by Planmeca, as well
as their global dental networks.
The courses will be held at the University of Turku
and at Planmeca’s headquarters in Helsinki from autumn 2014. The course topics cover rapidly evolving
dental technologies and their application in modern
dentistry, including 3-D imaging, prosthodontics,
endodontics, biomaterials science, orthodontics
and CAD/CAM technologies.
The University of Turku awards ECTS credits
(a standard for higher education in Europe) and
course certificates to the students. The joint venture
company complements Planmeca’s broad range
of training activities and collaboration with uni versities around the world.
The University of Turku is an active participant
in the export of education. “We have now established
a partnership with one of the world’s leading companies in dental technology. Together with Planmeca we
are a strong education provider globally,” stated Prof.
Kalervo Väänänen, Rector of the University of Turku._
_contact
CAD/CAM
Course registrations: www.nordicdented.com
More information:
Jenni Pajunen, Chief Executive Officer (CEO)
Nordic Institute of Dental Education
Tel. +358 20 779 5348
jenni.pajunen@nordicdented.com
Fig. 1
42 I CAD/CAM
3_ 2014
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CAD0314_43_Adentatec 22.08.14 14:36 Seite 1
industrie news _ Adentatec
I
Adentatec Competence
in Dental
_Adentatec, based in Cologne in Germany, is a
global dental company specialising in the production and distribution of non-precious dental alloys on a cobalt–chromium and a nickel–chromium
base, as well as CAD/CAM discs on a cobaltchromium and a titanium base. The medical devices distributed by Adentatec are exclusively produced in Germany and are certified to the highest
standards (CE marking and US Food and Drug Administration). Adentatec is committed to the strict
implementation of the quality and process requirements of DIN EN ISO 13485 and DIN EN ISO 9001 in
relation to the entire manufacturing process.
The company was established in 1997 and its focus at that time was the distribution of sand-blasting material and plaster to dental laboratories all
over Germany. In 2003, Adentatec started production of high-quality dental alloys, for which it implemented a quality management system. Its products undergo biocompatibility and corrosion resistance tests, among others, and are manufactured
from high-quality raw materials to ensure consistent quality. Adentatec has always given priority to
patient health. Since 2005, the company’s export
business has increased steadily. Adentatec now has
more than 20 agents worldwide who represent its
product range.
The company’s brand-name products, such as
System KN, System MG and System NE, have long
been widely used by dental technicians. Its product
range includes plaster, investment material and
sand-blasting material. In 2009, Adentatec expanded the range to CAD/CAM discs on a cobalt–
chromium base (System NE-Blank and System SoftBlank). The high-quality discs are available in different diameters and heights, and can be used for all
open milling systems. The discs are soft, homogeneous and easily milled. The strong oxide provides
excellent metal to ceramic bonding. Importantly,
the discs have high corrosion resistance and biocompatibility. In 2012, the company’s CAD/CAM disc
on a titanium base, System Ti 5-Blank (Grade IV), was
launched.
The Adentatec team is always motivated to support their customers as best as they can. The company is represented at many dental exhibitions all
over the world to keep in touch with customers and
to introduce its products to prospective customers
face to face. Adentatec seeks to establish a mutual
relationship with its suppliers, customers and business partners._
_contact CAD/CAM
Adentatec GmbH
Ringstr. 38–44
50996 Cologne
Germany
info@adentatec.com
www.adentatec.com
CAD/CAM
3_ 2014
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CAD0314_44_Nobel 22.08.14 14:36 Seite 1
I industry news _ Nobel Biocare
Ease of use meets restorative
flexibility in the new
NobelProcera Hybrid
and more affordable, further increasing the rate of
patient acceptance.
_Precision and design in perfect harmony
The old adage “time is money” is as relevant for dental
laboratories as it is for any other business environment.
The Hybrid allows dental laboratories to process more
fixed implant restorations more efficiently. The time it
takes to design the Hybrid is kept to a minimum owing to
the NobelProcera System’s highly efficient CAD workflow.
Fig. 1
Fig. 1_The new Hybrid from
NobelProcera offers the ultimate
in restorative flexibility and can
reduce the likelihood that chairside
repairs will be required.
The design can incorporate retention
elements (right), fingers (back)
or a combination of the two (left)
to provide excellent support
for acrylic teeth.
_At some point,denture wearers return to their dentist. Perhaps they need to have their denture repaired or
maybe they would like a solution that feels more like their
natural teeth, but cost is a concern. Whatever the reason,
there is a significant opportunity for both laboratories
and restorative dentists to assist this flow of returning
patients. This is precisely where the new Hybrid fixed
implant restoration from NobelProcera (Fig. 1) can help.
_The key to more implant treatments
Dental laboratories today are looking for new ways
to distinguish themselves. In an increasingly competitive
market, they need to differentiate to develop. Fixed implant
restorations like the NobelProcera Hybrid make it possible
to do just that, offering great results for the patient.
The Hybrid brings together excellent acrylic support
with the time-efficient workflow of a fixed implant bar
at an attractive price. It offers the best of both worlds
and, importantly, is manufactured to last.
As a relatively cost-effective option, the Hybrid
offers an increased likelihood of patient acceptance.
This means a greater number of cases for the restoring
dentist and the dental laboratory, helping them to build
their businesses while dramatically improving quality
of life for the patient.
All-on-4® is a registered trademark
of Nobel Biocare.
44 I CAD/CAM
3_ 2014
Furthermore, the Hybrid is compatible with the
All-on-4 treatment concept. This clinically proven1–4
treatment enables the restoration of a fully edentulous
jaw on just four implants. It is therefore less invasive
Fingers in the anterior and retention elements in
the posterior are designed to enhance the longevity of
the restoration. The Hybrid gives the dental technician
the tools he or she needs to give acrylic and denture teeth
the best support possible. The added strength can save
the restorative dentist time by reducing the risk that
chairside repairs will be required.
_Advantageous for professionals
and patients
Theoretically, every removable denture represents an
opportunity to improve quality of life with the Hybrid. It is
a product that perfectly embodies Nobel Biocare’s goal
of helping its customers treat more patients better. It increases patient flow while offering patients a better standard of care. That is surely the objective of every dental professional, and it is the reason dental laboratories should
add the NobelProcera Hybrid to their offering today._
Editorial note: A complete list of references is available
from the publisher.
_contact
Nobel Biocare
Balsberg
Balz-Zimmermann-Str. 7
8302 Kloten, Switzerland
www.nobelbiocare.com/nobelprocera
CAD/CAM
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CAD0314_46_Schuetz 22.08.14 14:37 Seite 1
I industry news _ Schütz Dental
Bionic restoration: Take the
next step. Imitate nature.
Imitate the best.
_Schütz Dental is proud to introduce the latest
concept of “bionic restoration”. This system imitates
both the aesthetics and the physics of the natural
tooth.
Fig. 1_The combination of Tizian
Zirconia Reinforced Composite and
dialog Occlusal imitates the physics
of the natural tooth.
Fig. 2_Final treatment,
up to three units.
Fig. 3_The system is perfectly suited
to implant-supported restorations.
Fig. 1
The framework for the bionic restoration is
made from Tizian Zirconia Reinforced Composite, a
newly developed combination of high-performance
acrylics and zirconium dioxide. This CAD/CAM material stands out for both its flexibility and stability.
Owing to its flexibility, the framework acts as a
buffer, reducing pressure on the jawbone and
temporomandibular joint. This buffering effect is
particularly relevant for implant-supported restorations and bruxism patients.
The Tizian Zirconia Reinforced Composite framework is veneered with a thin layer of dialog Occlusal
veneering composite. The material is both abrasion
resistant and antagonist friendly. This combination
ensures that restorations last longer while being
gentle on the natural teeth.
Fig. 2
46 I CAD/CAM
3_ 2014
This system, consisting of both materials, imitates the physics of the natural tooth. The elastic
core evenly distributes masticatory forces, reducing impact. Furthermore, the tough veneer renders
restorations durable and aesthetic.
The bionic restoration is suitable for permanent inlays, onlays, crowns and bridges of up to
three units. More information can be found at
http://sdent.eu/bionicprinciple._
_contact
Schütz Dental GmbH
Dieselstr. 5–6
61191 Rosbach
Germany
www.schuetz-dental.de
Fig. 3
CAD/CAM
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CAD0314_48_Events 22.08.14 14:38 Seite 1
I meetings _ events
International Events
2014
FDI Annual World Dental Congress
11–14 September 2014
New Delhi, India
www.fdi2014.org.in
CEREC Desert Fest Dubai
12–13 September 2014
Dubai, UAE
www.cerecfest.cappmea.com
XXII Congress of the European Association
for Cranio-Maxillo-Facial Surgery
23-26 September 2014
Prague, Czech Republic
www.eacmfs2014.com
EAO 2014
25–27 September 2014
Rome, Italy
www.eao.org
EPA Annual Conference
25–27 September 2014
Istanbul, Turkey
www.epa2014.org
ICOI World Congress
3–5 October 2014
Tokyo, Japan
www.icoi.org
ESCD Annual Meeting
9–11 October 2014
Rome, Italy
www.escdonline.eu
155th ADA Annual Session
9–12 October 2014
San Antonio, USA
www.ada.org
Digital Dentistry Show
16–18 October 2014
At the International Expodental Milano, Italy
www.digitaldentistryshow.com
6th Dental Facial Cosmetic
International Conference
14–15 November 2014
Dubai, UAE
www.cappmea.com/aesthetic2014
ADF Meeting
25–29 November 2014
Paris, France
www.adf.asso.fr
Great New York Dental Meeting
28 November–3 December 2014
New York, USA
www.gnydm.com
2015
36th International Dental Show
10–14 March 2015
Cologne, Germany
www.ids-cologne.de
IMAGINA DENTAL
4th 3-D & CAD/CAM Digital Dentistry Congress
1–3 April 2015
Monaco
www.imaginadental.org
Roma. Photo: Phant
48 I CAD/CAM
3_ 2014
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CAD0314_49_Submission 22.08.14 14:38 Seite 1
about the publisher _ submission guidelines
submission guidelines:
Please note that all the textual components of your submission
must be combined into one MS Word document. Please do not
submit multiple files for each of these items:
_the complete article;
_all the image (tables, charts, photographs, etc.) captions;
_the complete list of sources consulted; and
_the author or contact information (biographical sketch, mailing
address, e-mail address, etc.).
I
Image requirements
Please number images consecutively throughout the article
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Please consider this when formatting your document.
Questions?
Magda Wojtkiewicz (Managing Editor)
m.wojtkiewicz@dental-tribune.com
CAD/CAM
3_ 2014
I 49
[50] =>
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CAD0314_50_Impressum 22.08.14 14:39 Seite 1
I about the publisher _ imprint
CAD/CAM
digital dentistry
international magazine of
Publisher
Torsten R. Oemus
t.oemus@dental-tribune.com
International Media Sales
Matthias Diessner
m.diessner@dental-tribune.com
Managing Editor
Magda Wojtkiewicz
m.wojtkiewicz@dental-tribune.com
Europe
Melissa Brown
m.brown@dental-tribune.com
Executive Producer
Gernot Meyer
g.meyer@dental-tribune.com
Designer
Franziska Dachsel
f.dachsel@dental-tribune.com
Copy Editors
Sabrina Raaff
Hans Motschmann
International Administration
Marketing & Sales
Esther Wodarski
e.wodarski@dental-tribune.com
Editorial Board
Prof. Albert Mehl, Switzerland
Prof. Gerwin Arnetzl, Austria
Dr Stefan Holst, Germany
Hans Geiselhöringer, Germany
Dr Ansgar Cheng, Singapore
Asia Pacific
Peter Witteczek
p.witteczek@dental-tribune.com
The Americas
Jan M. Agostaro
j.agostaro@dental-tribune.com
International Offices
Europe
Dental Tribune International GmbH
Contact: Esther Wodarski
Holbeinstr. 29, 04229 Leipzig, Germany
Tel.: +49 341 48474-302
Fax: +49 341 48474-173
Executive Vice President
Finance
Dan Wunderlich
d.wunderlich@dental-tribune.com
Asia Pacific
Dental Tribune Asia Pacific Ltd.
Contact: Tony Lo
Room A, 26/F, 389 King’s Road
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Tel.: +852 3113 6177
Fax: +852 3113 6199
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Contact: Anna Wlodarczyk
116 West 23rd Street, Suite 500
NY 10011, New York, USA
Tel.: +1 212 244 7181
Fax: +1 212 244 7185
www.dental-tribune.com
Copyright Regulations
_CAD/CAM international magazine of digital dentistry is published by Dental Tribune Asia Pacific Ltd. and will appear in 2014 with four issues. The magazine and all articles and illustrations therein are protected by copyright. Any utilisation without the prior consent of editor and publisher is inadmissible and
liable to prosecution. This applies in particular to duplicate copies, translations, microfilms, and storage and processing in electronic systems.
Reproductions, including extracts, may only be made with the permission of the publisher. Given no statement to the contrary, any submissions to the
editorial department are understood to be in agreement with a full or partial publishing of said submission. The editorial department reserves the right to
check all submitted articles for formal errors and factual authority, and to make amendments if necessary. No responsibility shall be taken for unsolicited
books and manuscripts. Articles bearing symbols other than that of the editorial department, or which are distinguished by the name of the author, represent
the opinion of the afore-mentioned, and do not have to comply with the views of Dental Tribune Asia Pacific Ltd. Responsibility for such articles shall be borne
by the author. Responsibility for advertisements and other specially labeled items shall not be borne by the editorial department. Likewise, no responsibility
shall be assumed for information published about associations, companies and commercial markets. All cases of consequential liability arising from inaccurate or faulty representation are excluded. General terms and conditions apply, legal venue is North Point, Hong Kong.
50 I CAD/CAM
3_ 2014
[51] =>
Standard_300dpi
NB_Advert_2G_scanner top25.indd 1
GMT 32593 GB 1307 © Nobel Biocare Services AG, 2013. All rights reserved. Nobel Biocare, the Nobel Biocare logotype and all other trademarks are, if nothing else is stated or is evident from the context in a certain case, trademarks of Nobel Biocare.
Product images are not necessarily to scale. Disclaimer: Some products may not be regulatory cleared/released for sale in all markets. Please contact the local Nobel Biocare sales office for current product assortment and availability.
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2014-07-10 11.40
[52] =>
Standard_300dpi
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