The challenge of combining TFZ to e.max in one case / For professionals by professionals – SR Nexco goes one step further / 3-D virtual planning concepts for implant-retained full-arch mandibular prostheses: The bone reduction guide
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lab tribune 1C
Dental Tribune Middle East & Africa Edition | January-February 2015
The challenge of combining TFZ to e.max in one case
Dental Tribune
Note. Our clinical case example here is a part of a whole
case history started in Dental
Tribune
> Dental Tribune MEA page 10-11
By Aiham Farah, Syria
T
he challenge of this
case.
The way to think about
combination cases, where you
have glass ceramic veneers next
to zirconium oxide bridges, is
different than having only one
kind of restorative material in a
case. Lots of factors have to be
Fig. 11
taken into account, most important is the optical properties of
both materials and the fact that
they need to match (Not just
from a dental technician point
of view, but also from a dental
point of view and the way he adjust his/her preparation accordingly).
It was difficult to find an equivalent to our chosen SiO2 material
for the veneers (IPS e.max Press,
in this case), with its outstanding
esthetic and life like appearance,
but going to Zirconium oxide
option to restore the posterior
bridges was necessary since the
IPS e.max is indicated for a maximum of 3 units bridges up to the
second premolar region, and in
our situation here our bridges go
further to the molar area.
Material Selection Judgment
Before you choose where to
outsource your Zirconia work,
you have to make sure that the
brand of Zirconia to be used
will fulfill your requirements of
translucency-opacity level, and
the shade concept will easily
match your IPS e.max veneers
work in the front esthetic region.
No method would enable you to
make sure, better than milling
different kind of Zirconia, and
trying them all in, together with
the IPS e.max veneers, to check
the matching level yourself.
In my case scenario here, to narrow down my options I based on
a study for 3M ESPE showing
a comparison between several
kind of high translucent zirconia. (Fig. 11)
Showing that; Lava Plus (from
3M ESPE) & Zenostar Zr Translucent Pure (from Wieland) are
the top in their range when it
comes to translucency levels.
The advantage of Zenostar in
our case situation over the Lava,
was the important factor of the
shading concept of Zenostar and
how its coordinated with the IPS
e.max press Ingot shade and coloring concept.
In terms of; MO (Medium Opacity) ingot from IPS e.max Press
has a match in the Zenostar Zirconia, which is also called MO
(Medium Opacity).
LT (Law Translucency) Ingots
from IPS e.max Press have
equivalent in the Zenostar Zirconia which is also called (T=
Translucent).
Nothing left to do but to try the
material on a dummy case and
make sure of the match myself.
(Fig. 12)
Zenostar Pure & Light
From the (T=Translucent) Zirconia and according to the final
shade chosen by our patient for
her veneers & bridges restorations which is BL4 (according
to Ivoclar Vivadent shade guide
A-D), we had to choose between
two Zr blanks from the bright
colors (light & pure). Since the
intensity and brightness of a
color would change relatively
with changing the thickness
of the material, I decided to go
for both colors, then we choose
what matches our veneers better on the day of the try in. (Fig.
14)
Contact Information
Aiham Farah. CDT
Technical Training Consultant
Near East & Orient
IvoclarVivadent
Email:
aiham.farah@ivoclarvivadent.com
Fig. 13
LIFELIKE ESTHETICS –
EFFICIENTLY PRESSED
Fig. 12
Fig. 14
For professionals by professionals
– SR Nexco goes one step further
By Ivoclar Vivadent
A
new flask has been developed in collaboration with
expert users of the press
technique.
SR Nexco Flask is a new type of
flask with the help of which lightcuring veneering composites
can be pressed on dental frameworks. In order to effectively address the practical challenges of
functionality, ergonomics and
design, the flask has been developed in close cooperation with
industry professionals.
The new flask offers the following important benefits: It allows
composite materials to be efficiently and quickly pressed to
dental restorations, including
long-span bridges. The results
are highly accurate, showing
hardly any difference between
IPS e.max PRESS MULTI
®
THE WORLD’S FIRST POLYCHROMATIC PRESS INGOT
amic
all cer need
u
all yo
For professionals by professionals – SR Nexco goes one step further
• Monolithic LS2 restorations showing a lifelike shade progression
• Exceptional combination of strength, esthetics and efficiency
• For crowns, veneers and hybrid abutment crowns
• Coordinated with high-precision Programat press furnaces
• Maximum cost effectiveness in the press technique
www.ivoclarvivadent.com
Ivoclar Vivadent AG
Bendererstrasse 2 | 9494 Schaan | Liechtenstein
Tel.: +423 235 35 35 | Fax: +423 235 33 60
> Page 4C
[2] =>
2C lab tribune
Dental Tribune Middle East & Africa Edition | January-February 2015
3-D virtual planning concepts for
implant-retained full-arch mandibular prostheses:
The bone reduction guide
Fig. 2a-c
Fig. 1. Regardless of the image acquisition process, there are four
standard views that need to be fully appreciated in the diagnosis
phase. These include the cross-sectional (A), the axial (B), the panoramic (C), and the 3-D reconstructed volume (D).(Image: Dr Scott D.
Ganz)
By Dr. Scott D. Ganz, USA
T
he process of accumulating patient information to
determine which course
of dental implant treatment
should be considered can be
described under the category of
pre-surgical prosthetic planning.
The first step in patient evaluation involves conventional peri-
apical radiographs, panoramic
radiographs, oral examination,
and mounted, articulated study
casts. These conventional tools
allow the clinician to assess several important aspects of the patient’s anatomical presentation,
including vertical dimension of
occlusion, lip support, phonetics,
smile line, overjet, overbite, and
ridge contours, and to obtain a
Fig. 3a-b
Fig. 4a-b
Fig. 5a-b
Fig. 6a-b
Fig. 7a-b
Fig. 8a-b
Fig. 9a-d
basic understanding of the underlying bone structures.
The accumulation of preliminary
data afforded by conventional
diagnostics provides the foundation for preparing a course of
treatment for the patient. However, the review of findings is
based upon a 2-D assessment of
the patient’s bone anatomy and
may not be accurate in the appreciation of the spatial positioning of other vital structures, such
as the incisive canal, the inferior
alveolar nerve, or the maxillary
sinus. In order to understand
each individual patient’s presentation fully, it is essential that
clinicians adopt an innovative
set of virtual 3-D tools. Through
the use of advanced imaging
modalities, new paradigms have
been established that, in the author’s opinion, will continue to
redefine the process of diagnosis
and treatment planning for dental implant procedures for years
to come. Without the application
of computed tomography (CT)
or lower radiation dosage cone
beam computed tomography
(CBCT), an understanding of the
3-D anatomical reality cannot
be accurately determined, potentially increasing surgical and
restorative complications.
The utilisation of 3-D imaging
modalities as part of pre-surgical prosthetic planning can take
several paths as demonstrated in
the flow chart. The first involves
acquiring a 3-D scan directly,
without any prior planning or
ancillary appliances. The scan
process can be accomplished at
a local radiology centre or via an
in-office CBCT machine, now
widely available. The scan itself
can be completed within several
minutes. Once the data has been
processed, it can be viewed via
the native software of the CBCT
machine used and evaluated for
potential implant recipient sites,
followed by the surgical intervention. A second path requires
the fabrication of a radiopaque
scannographic appliance that
incorporates vital restorative information and will be worn by
the patient during the acquisition of the scan. In this manner,
the tooth position can be evaluated in relation to the underlying
bone and other important anatomical structures, such as the
maxillary sinus or the inferior
alveolar nerve. The scan data
can again be visualised via the
CBCT machine’s native software
and a plan can be determined
based directly upon the restorative needs of the patient.
The scan data is formatted into a
nonproprietary data interchange
protocol referred to as DICOM
(Digital Imaging and Communications in Medicine). The
DICOM data can be exported
for use in third-party software
applications that incorporateadditional tools to aid clinicians
in the diagnosis and treatment
planning functions.
The use of interactive treatment
planning has expanded dramatically in the past ten years as
computing power has increased
exponentially. There are at least
two paths that can be taken once
a virtual plan has been estab-
lished. The first allows the data
to be assessed, providing important information to the clinician
who will perform the surgical
intervention free-hand based
upon the software plan. This has
been termed CT-assisted intervention by the author. The second path involves the fabrication
of a surgical guide or template
that is remotely constructed
from the digital plan usually
through rapid prototyping or stereolithography. This method has
been described as CT-derived
template-assisted intervention
and is considered to be more
predictable than any previous
methods. The use of advanced
imaging modalities for presurgical prosthetic planning is essential for any type of implant
surgical and restorative intervention, including single-tooth
and multiple-tooth restoration,
full-arch fixed and removable
overdenture reconstruction.
3-D planning concepts for the
mandible
Regardless of the image acquisition process, there are four
standard views that need to be
fully appreciated in the diagnosis phase. These include the
cross-sectional (A), the axial (B),
the panoramic (C), and the 3-D
reconstructed volume (D) as
seen in Figure 1. The ability to
interact within these images differs from software to software.
It is the ability to visualise 3-D
data with improved tools that
empowers clinicians to assess
> Page 3C
[3] =>
lab tribune 3C
Dental Tribune Middle East & Africa Edition | January-February 2015
< Page 2C
Fig. 10
Fig. 11a-d
individual patient anatomy. The
cross-sectional slice is important
for the assessment of the facial
and lingual cortical bone plates,
the intramedullary bone, and
the positioning of teeth within
the alveoli. The axial view allows inspection of the entire upper or lower jaw, the maxillary
sinus volume, the position of
the incisive canal in the maxillae, and the mental foramina in
the mandible. The panoramic
view is an overall scout image,
and can be helpful in tracing
the mandibular nerve, and assessment of the maxillary sinus floor near the nose region.
The 3-D reconstructed volumes
are invaluable in the planning
process and in communicating
information to the members of
the implant team, including the
patient and the dental laboratory
technician who will fabricate the
final prosthesis. These images
are especially useful, as they are
most readily understood and appreciated.
As represented in the flow chart,
a patient may be sent to a radiology centre for a CBCT scan of
the mandibular arch without a
scanning appliance. The 3-D reconstructed volumes are easily
understood and interpreted for
the mandible (Figs. 2a–c). In the
case demonstrated, there were
several hopeless anterior teeth
that were planned for extraction.
The extent of the bone loss can
be appreciated by the clinician
and demonstrated to the patient
as an excellent educational and
communication tool. The virtual mandible can be rotated to
reveal all views of the patient’s
individual anatomical presentation (Figs. 3a & b). With innovative software tools, the teeth can
be virtually extracted in the 3-D
reconstructed volume, aiding
the clinician in understanding
the local anatomy to identify
potential implant recipient sites
(Figs. 4a & b). In this example,
the alveolar ridge narrowed
considerably at the crest. In order to facilitate implant placement, the ridge required an alveolectomy, reducing the ridge
by approximately 8–10 mm.
Advanced software applications
allow for the bone to be sectioned based upon the desired
plan. A bone reduction template
pioneered by the author can be
simulated by the software and
then fabricated to assist in the
bone removal (Figs. 5a & b). The
reduction template fits over the
ridge, allowing complete visualisation of the residual bone to
be sectioned from the alveolar
ridge. The flattened ridge can
also be simulated, greatly enhancing the clinician’s appreciation of the remaining bone
topography (Figs. 6a & b). The
amount of bone to be removed
can be visualised as shown in
Figure 7a and then assessed
with realistic manufacturerspecific implant placement in
the bone (Fig. 7b). The occlusal
and facial views reveal the new
width of available crestal bone
for implant placement (Figs. 8a
& b). The visualisation of the
bone crest can aid in the determination of ideal implant recipient sites. However, it must be
noted that all other views must
be considered to appreciate adjacent vital anatomical structures and the remaining topography of the anterior mandible
before any plan can be finalised.
Several different options can be
quickly simulated and then discussed with the patient and all
members of the implant team.
The use of a bone reduction
template can facilitate the accurate removal of bone and the immediate placement of implants,
eliminating the need for two
separate surgical interventions
and thus mini mising patient
morbidity.
The initial plan in the case demonstrated was for the patient
to receive an implant-retained
overdenture. Therefore, recipient sites were determined based
upon the available bone in the
mandibular symphysis between
the right and left mental foramina, which were assessed in the
axial and cross-sectional views.
While it is possible to fabricate
an overdenture design with implants in the posterior region of
the mandible, the usual position
of implants is within the symphysis region. The choices were
to place two implants, three implants, or four implants between
the two mental foramina (Figs.
9a–d). The symphysis area is not
free from risk. A cross-sectional
view is necessary for an appreciation of the thickness of the
facial and lingual cortical bone
plates, and for assessment of the
trajectory and topography of the
anterior mandible. In addition,
there are important vessels in
the region that have been shown
to cause severe haemorrhaging
if perforated. These vessels may
differ from patient to patient
and underscore the importance
of a 3-D diagnosis. In this case,
two such vessels were found in
the midline area of the symphysis (red arrows) as seen in the
cross-sectional view, which also
revealed the extensive bone loss
surrounding the hopeless teeth
(yellow areas; Fig. 10).
Virtual realistic implants were
simulated in the residual alveolar bone (Figs. 11a–d). A
simulated surgical template
was fabricated for the desired
implant positions and rested on
the reduced bone both facially
and lingually. At the midline,
where the vital vessels resided,
it was elected not to place an
implant to avoid potential surgical complications (Fig. 12). The
simulated bone-borne surgical
Fig. 12
Fig. 13a-c
Fig. 14a-b
Fig. 15a-b
Fig. 16a-d
template was visualised in various 3-D reconstructed volumes
(Figs. 13a–c). The first two revealed a midline horizontal stabilisation screw (Figs. 13a & b)
and the last showed a standard
bone-borne template without
fixation (Fig. 13c). Had additional implants been required for
improved stability or had a fixed
detachable hybrid restoration
been indicated, supplementary
recipient sites could have been
located based upon the available
anatomy.
In order to demonstrate the capabilities of the new digital paradigms, five virtual implants were
placed into the initial anterior alveolar ridge after the teeth had
been extracted virtually (Fig.
14a). The positions of implants
can be further enhanced by placing yellow abutment projections
that extend above the occlusal
plane. Using selective transparency, the various structures can
be adjusted in opacity and translucency. Using advanced software simulation, horizontal osteotomies to allow the implants
to be placed in the same vertical
position in the newly reduced
ridge were illustrated (Fig. 14b).
Implant-to-implant
relationships can be evaluated in all
dimensions (Figs. 15a & b). In
addition, it is important to provide ample clearance between
the most posterior implants and
the inferior alveolar nerve and
mental foramen. Once the positions of the implants have been
finalised, a surgical guide can be
simulated (Figs. 16a & b). Note
that the implants were all parallel, which can aid in laboratory
fabrication for overdentures and
in achieving passive fit for fixed
frameworks (Fig. 16c). The relationship between the original
tooth position and the simulated
implants can be appreciated in
Figure 16d. If a fixed detachable hybrid, full-arch CAD/CAM
zirconia restoration, or an im-
mediate restorative protocol is
desired, the ability to simulate
implant position with an accurate consideration of the desired
tooth position will enhance the
surgical, restorative and laboratory phases of treatment.
Conclusion
The advent of complete denture fabrication has evolved
into the adoption of overdenture
concepts for both natural and
implant-retained restorations.
Conventional
prosthodontic
protocols have been developed
to aid in the diagnosis, treatment
planning and laboratory phases
of the reconstruction. These
include conventional periapical radiographs, panoramic radiographs, oral examination,
and mounted, articulated study
casts. Using these, the clinician
can assess several important aspects of the patient’s anatomical
presentation, including vertical
dimension of occlusion, lip support, phonetics, smile line, overjet, overbite, and ridge contours,
and can obtain a basic understanding of the underlying bone
structures. The accumulation
of preliminary data afforded by
conventional diagnostics provides the foundation for preparing a course of treatment for the
patient. However, the review of
findings is based upon a 2-D assessment of the patient’s bone
anatomy.
In order to understand each
patient’s presentation fully, advanced 3-D imaging modalities
are essential. This article has
illustrated the use of various innovative virtual 3-D tools.
The application of CT or lower
radiation dosage CBCT provides
clinicians with an accurate understanding of the 3-D anatomical reality of our patients as an
aid in providing state-of-theart treatment. Implants will be
better positioned, with fewer
surgical and restorative complications, and reduced laboratory remakes based upon these
diagnostic tools. The benefits
will enable clinicians to better
understand the relationship between patient anatomy and the
desired restorative outcomes
in the process of achieving true
restoratively driven implant
reconstruction. The ability to
utilise digital imaging and treatment planning technology is
now within the reach of many
clinicians through the various
software products on the market. In addition, there are many
thirdparty outlets online that enable clinicians to upload their
DICOM data for evaluation,
processing, treatment planning,
and even surgical template fabrication.
In many case presentations, a
reduction of the alveolar crest is
an essential part of the surgical
phase to achieve adequate width
of the bone for implant placement. It is now possible to plan
for accurate bone reduction with
the full knowledge of the impact
on the inter-arch space and occlusal requirements. The advent
of the bone reduction template
provides one additional digital
solution that can also result in
reduced patient morbidity, especially when the process can be
completed in one surgical procedure. New paradigms have
been established that, in the
author’s opinion, will continue
to redefine the process of diagnosis and treatment planning for
dental implant procedures, both
removable and fixed implantretained alternatives, for years
to come.
Editorial Note
More information is available
from the publisher.
[4] =>
4C lab tribune
Dental Tribune Middle East & Africa Edition | January-February 2015
Global success – Sirona Connect portal now
available in eight languages
and dental technicians to connect in a very modern way – they
can exchange data conveniently
and securely via the portal. The
portal interface is integrated into
the dentist’s and technician’s
software, regardless of which
software version is being used
by either party, thus greatly facilitating workflow.
Sirona Connect links dentists
and dental technicians easily
and securely.
More and more dentists and
dental technicians are using this
service. “This year, we anticipate
60 percent more orders than last
year via the portal all around
the world,” says Ronny Kucharczyk, Product Manager Digital
Impressions. “This corresponds
to around 100,000 restorations.”
He partly attributes this growth
to CEREC users who use laboratory services for certain indications or materials. “These are
dentists who cannot or do not
want to make certain restorations themselves for various reasons.” And there is also a growing number of users of purely
digital impression systems such
as APOLLO DI or CEREC AC
Connect with Omnicam who
order their restorations via the
portal. “The high demand reflects practice routine,” explains
Kucharczyk.
Sirona Connect users come
mainly from Europe and the
US. But the number of orders
from countries such as China,
Korea, and Brazil is increasing
as well. The main reason for
this is that taking digital impressions is becoming more com-
mon in practices, especially in
these countries. Thus the Sirona
Connect portal is now available
in the language of each respective country. Dentists and dental
technicians can now communicate via the portal provided by
Sirona, the global market and
technology leader in the dental
industry, in a total of eight languages. In addition to German
and English, the available languages include French, Italian,
Spanish, Chinese, Korean, and
Portuguese.
By Sirona
B
ENSHEIM,
Germany:
Take digital impressions
and order the restoration
online, quickly and easily via
the global Sirona Connect portal. Sirona Connect is the first
innovative system for digital cooperation between dentists and
dental labs. The rapidly growing number of users is creating
a true boom in orders -this year
Sirona anticipates a 60-percent
increase in orders around the
world.
Sirona Connect allows dentists
inLab MC X5:
DENTAL LAB
FREEDOM OF CHOICE.
< Page 1C
the final restoration and the
wax-up. Moreover, the flask is
exceptionally versatile, due to
the many special details incorporated into it, which allow it
to be individually adjusted to
the specific indication and the
framework situation.
Many handy details make
work easier
SR Nexco Flask is equipped
with large, easy-grip screws.
Unlike in most other devices of
this kind, these screws are not
permanently fixed. They can
be inserted without any guides
and therefore improve flask
handling. The top part of the
flask is transparent and allows
light to pass through it. As a result, the light-curing composite
is evenly polymerized from all
sides. Apart from an additional
base plate, which enables height
adjustments to be made depending on the dimensions of the restoration involved, the flask also
includes a separate spacer for
curing smaller restorations.
The spacer reduces material
consumption to a minimum. Positioning pegs keep the top part
of the flask in place. The notches
on the sides allow the top and
bottom parts to be easily separated. The openings for the injection of Transil F clear silicone
are designed to accommodate
the product’s mixing tips. This
renders the silicone easy to handle and use in conjunction with
SR Nexco Flask. Due to its excellent flow properties, Transil F
completely encases the invested
framework.
The new flask is an extension of
the existing SR Nexco product
system. It is ideally matched to
the SR Nexco materials.
Experience new freedom in your lab processes breaking the chains of
former dependencies with inLab and the new 5 axis milling and grinding
unit inLab MC X5. Open for all restoration data, combining the largest
material range and the possibility to machine both wet and dry disks
and blocks – for no limitations to your production. Enjoy every day.
With Sirona.
INLABMCX5.COM
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Table of contents
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/ For professionals by professionals – SR Nexco goes one step further
/ 3-D virtual planning concepts for implant-retained full-arch mandibular prostheses: The bone reduction guide
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