Lab Tribune Middle East & Africa No. 4, 2021
“Dental technology advances dentistry” / Fully digital workflow with a twist
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DTMEA_No.4. Vol.11_LT.indd
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Published in Dubai
www.dental-tribune.me
July-August 2021 | No. 4, Vol. 11
“Dental technology advances dentistry”
By Iveta Ramonaite, Dental Tribune
International
With its transformative power, digital dentistry is slowly taking over
dental practices and laboratories all
around the world. In this interview,
prosthodontist Dr Ryan C. Lewis
talks about how digital dentistry can
help improve workflow efficiency
and highlights some of the latest advancements in digital dentistry.
Dr Lewis, digital technologies are
being taken up in dental practices
worldwide. In your opinion, is it
still possible to imagine dentistry
without them?
Dental technology advances dentistry by increasing communication,
efficiency and accuracy. The most
important technologies that I currently utilise are CAD/CAM milling,
intra-oral scanning, digital implant
planning, 3D printing and photography.
We initially integrate digital technology with CAD/CAM milling abutments and digitally design restorations. If we compare this to UCLA
casting abutments and hand waxing porcelain-fused-to-metal restorations, we do not only save significantly on our gold costs, but we are
also able to increase the efficiency
of fabricating the restorations. If we
then consider intra-oral scanning
and the ability to digitally submit
cases to the laboratory, plus the savings in impression material, shipping costs, time to ship, and cases
getting lost or delayed in shipping, it
is easy to appreciate the benefits that
digital dentistry offers.
All of my implant cases are now
digitally planned. After using digital
planning and fully guided surgery,
my surgeon no longer wants to
place implants the traditional way.
It provides peace of mind knowing
that the implant will be positioned
ideally, the referring doctor will be
happy with the work and the patient
will have the desired outcome.
laboratory perspective, it is a great
tool to utilise.
For many dentists, the new technology changes their workflow significantly and takes time to integrate
into their traditional workflow. Because of this and the startup costs,
it is difficult to switch to digital dentistry when using a traditional pathway has brought success in the past.
However, as in my practice, once
the digital pathways have been integrated, going back to a traditional
one would increase overhead and
decrease efficiency significantly.
3D printing has changed the way
that we produce surgical guides. 3D
printers have become so accurate
and inexpensive that any dentist can
now afford to have them in his or her
office and print surgical guides as
well as casts for diagnostic purposes
or aligners at a relatively low cost.
Additionally, photography has become essential when communicating with my dental technicians. The
accuracy and quality of my restorations would suffer significantly without it.
What are some of the latest, most
notable advances in digital dentistry?
Digital implant treatment planning,
intra-oral scanning and 3D printing.
With digital implant treatment planning, we can significantly improve
the accuracy of our implant position.
We now can integrate facial scans
and intra- oral scans without fullarch digital wax-ups. This ensures
that we are accurately planning our
new tooth positions. Because our
digital diagnostic wax-ups are so accurate, we can also plan our full-arch
implant positions with confidence.
This allows us to place implants immediately at the time of extraction
in cases where we would have previously recommended extraction of
teeth and healing first.
3D printing is now very predictable
and accurate. It allows us to print the
surgical guides in the office without
worry or concern about the accuracy
of the guide. My full-arch immediate
How has the SARS-CoV-2 pandemic
changed your view, or that of your
colleagues, on the relevance of digital dentistry and the importance of
adopting digital solutions?
The pandemic has highlighted the
potential contamination risks associated with transferring impressions or other components from the
patient to the laboratory. Intra-oral
scanning offers the safest solution,
the one with the least risk of crosscontamination. Unfortunately, this
is a problem that is likely not going
to go away any time soon, so this is
great not only now, but also as we
move forward into the future.
Dr Ryan C. Lewis, a prosthodontist and owner of Longmont Prosthodontics
load provisionals are printed on the
same printer as my surgical guides.
Dental laboratories seem more
ready and willing to adopt digital
solutions compared with dental
clinics. How do you think this
could be explained?
Digital technology greatly increases
the efficiency of the technician. This
decreases overhead expenses and
treatment costs. It also increases the
accuracy of the restorations. Many
laboratories now report that digitally
designed and milled crowns provide
the lowest number of remakes by
percentage out of any product they
offer. Typically, these are modeless
crowns that are manufactured without a printed or stone cast. From the
Editorial note:
The webinar, titled “Advancements
in contemporary digital dentistry,” is
available on demand at Straumann
Campus (https://campuslive.straumann.com). The registration is free of
charge.
AD
www.cappmea.com/dtim-2021
[2] =>
DTMEA_No.4. Vol.11_LT.indd
B2
LAB TRIBUNE
Dental Tribune Middle East & Africa Edition | 4/2021
Fully digital workflow with a twist
By Dr Marco Tudts & Bob Bosman
Elst, Belgium
A 61-year-old male patient presented
suffering from severe tooth wear,
which can be classified as attrition,
abrasion or erosion depending on
its cause. The entire smile line had
been lost and even became negative
(Fig. 1). The patient was an extrovert,
and hence a new nice smile would
impact his social life positively.
The destructive wear of his teeth had
already caused several endodontic
treatments and temporomandibular joint dysfunction caused by the
loss of the vertical dimension and
resulting in tense and tired muscles.
Severe tooth wear had caused morphological change of occlusal tooth,
decrease of vertical dimension, pulp
pathology, occlusal disharmony and
changed masticatory function. In
this condition, more complex therapies are needed, such as endodontics,
periodontics and full coronal coverage.
A digital impression was taken, and
the master model was printed. A
digital wax-up/mock-up was made
in exocad DentalCAD (exocad) using
the Smile Creator module. A standard length of 10.8mm and width of
8.4 mm was used, as described by
Mauro Fradeani.
Fig. 1: Smile before the treatment.
This set-up was a really nice starting
point for this patient’s biotype. The
idea was to verify the integration because the vertical dimension had to
be increased by several millimetres
and the patient wanted to rejuvenate
his smile inconspicuously, as naturally as possible, in addition to all the
comfort of a balanced occlusion.
This digital wax-up/mock-up was
printed in GC Temp PRINT (GC) as
veneers so that it could be placed
in front of the teeth (Fig. 2); a small
support towards the palatal side was
present so that it could be placed
over the natural dentition in a sta-
Fig. 2: Mock-up (GC Temp PRINT, GC) in the mouth.
ble manner. This made it possible to
evaluate both the aesthetics and the
musculature’s response to the new
occlusal height.
The patient could also take this printed wax-up home, giving him the opportunity to show it to his partner,
but also to check it for himself in
his own private space and without
any time pressure or pressure from
strangers. Having his or her smile
remodelled is something really drastic, so the patient should be given as
much time as he or she needs with
all the possible tools.
After the patient’s consent had been
obtained, it was possible to proceed
with the treatment plan: the veneers
were adapted in DentalCAD and
printed again as temporary crowns
(GC Temp PRINT, light shade).
These crowns were relined with
G-ænial Universal Injectable composite (Shade A2, GC; Fig. 3a) and
manually polished. Optionally,
they could have been glazed with
OPTIGLAZE colour (GC). The cervical border was sandblasted (50 μm
is sufficient) so that it could be easily connected to the composite and
then only the relined part had to be
polished again (Fig. 3b).
The vertical dimension was increased by 8 mm. To ensure that
this would be comfortable for the
patient, three months were taken to
revise the situation. The patient suffered no headaches, muscle stress
or any other problems. Hence, the
first phase of the aesthetic adaptation was begun. Minor gingivectomy
with bone correction was carried out
ÿPage B3
Fig.3a: Printed temporary restorations relined with G-ænial Universal
Injectable (GC).
Fig.3b: Temporary restorations in the mouth after relining with G-ænial
Universal Injectable.
Fig. 4: Smile with the provisional restorations in zirconia, characterised
with GC Initial IQ Lustre Pastes NF (GC).
Fig.5a: Putty key on the provisional restorations.
Fig.5b: Putty key on the substructure.
Fig. 6a: Wash firing: GC Initial IQ Lustre Pastes NF.
Fig. 6b: Wash firing: GC Initial IQ Lustre Pastes NF, sprinkled with GC Initial IQ Lustre Pastes NF CL-F (anterior).
Fig. 6c: Wash firing: GC Initial IQ Lustre Pastes NF (posterior).
[3] =>
DTMEA_No.4. Vol.11_LT.indd
B3
LAB TRIBUNE
Dental Tribune Middle East & Africa Edition | 4/2021
◊Page B2
first. An impression was taken, and
long-term provisional restorations
were manufactured in full zirconia.
Those were characterised with GC Initial IQ Lustre Pastes NF (GC) and cemented temporarily (Fig. 4). A recall
was planned for three months later.
This period also allowed the soft and
hard tissue to heal properly after the
periodontal surgery.
At that point, definitive work could
begin; however, owing to a skiing
accident, the definitive impression
needed to be postponed for another
three months. This did not pose a
Fig.7: Creation of the neck.
Fig.8: After application of the dentine material, the horizontal line was checked with
the putty key.
Fig.9a: Mamelons and cervical surfaces: 50% FD-91 + 50% DA2 (green), A1 (dark pink),
50% A1 + 50% E58 (blue).
Fig.9b: The enamel blocker (50% A1 + 50% E58; blue) was also used on the cervical part.
Fig. 10: Central incisor with GC Initial IQ
Lustre Pastes NF CL-F.
Fig. 12: Enamel firing.
Fig. 11: Colour firing with GC Initial IQ Lustre Pastes NF CL-F.
Figs. 13a: Correction firing.
Figs. 13b: Correction firing.
Fig. 14a: Restorations before polishing.
Figs. 13a: Correction firing.
Figs. 13b: Correction firing.
Fig. 14a: Restorations before polishing.
problem because of the highly durable provisional restorations.
However, a digital impression could
have been used as well.
For cases like this, the comfort of the
patient is always the priority. Hence,
after six months, the definitive impressions were taken, both digitally
and conventionally. The conventional impression was used to create
the master working model. This was
mostly due to familiarity with the
procedure. We feel that what we are
men- tally comfortable with will also
yield the best possible end result.
For the substructure, multilayered
zirconia (Shade A2) was used. The design was a small, adapted copy of the
provisional restorations. A 0.4 mm
buccal cut-back was done for the posterior teeth and the canines.
For the four anterior teeth, a 0.6 mm
cut-back was done and the incisal
height was decreased by 0.4 mm.
To maintain control of the horizon-
tal line, a palatal putty index of the
provisional restorations was made
for use as a key during the ceramic
build-up (Figs. 5a & b).
opportunity to sandblast after the
wash firing without damaging the
colour. Moreover, it ensured that the
colours would not slip down.
The zirconia substructure was slightly adapted and went into the furnace
for a regeneration firing. Thereafter,
the workflow continued with the
wash firing. After application of the
GC Initial IQ Lustre Pastes NF (Fig. 6a),
the Initial CL-F (Clear Fluorescence)
powder was sprinkled on top of the
wet paste (Figs. 6b & c). This gave the
Zirconia does not absorb heat well,
and the heat must be carefully adjusted to avoid chipping. The problem of chipping is also a consequence
of poor adjustment of the heating
program. The larger the volume of
zirconia, the slower the heating up
and cooling down should take place.
In this case, the heating temperature
was dropped by 30°C per minute,
and the cooling down should have
a similar rate. To keep it simple: the
time to heat up should be more or
less the same as the cooling down.
The part until the CL-F was the first
layer. For the neck, IN-42 (Terracotta; 40%) was used with A2 (60%),
and then the main colour was A2
(Fig. 7). After applying DA2 to the
ÿPage B4
[4] =>
DTMEA_No.4. Vol.11_LT.indd
B4
LAB TRIBUNE
Dental Tribune Middle East & Africa Edition | 4/2021
◊Page B3
full contour (Dentin A2), the horizontal line was checked with the
putty key (Fig. 8). After the cut-back,
the mamelons were shaped. FD-91
(Fluo Dentin Light; 50%) with DA2
(50%), A1, and A1 (50%) with E58
(Enamel; 50%) were alternated, as
shown in Figures 9a & b.
About the authors:
Bob Bosman Elst
He graduated in 1991 as a dental technician. While working at his own independent dental laboratory in Belgium,
he has continuously been working on
expansion and developing innovative
techniques for the dental industry. Over
the years, he has participated in more
than 40 master courses, including those
by Brüsch, Tyszko, Cagaro, Adolfi, Galle,
Hegenbarth, Sieber and Polansky, either
as a lecturer or as an active participant.
His work has been recognised by many
in the field. In 2007, Elst won the third
prize (in the Young Ceramics category)
during the world tour of Nobel Biocare
in Las Vegas in the US. He came in as
the first European of all the participants
in this highly reputable event. He set
up a help desk for dentists, covering all
aspects of implant-supported restorations and porcelain. In 2017, he became a
trainer of the GC Europe Campus, where
he found the perfect forum for sharing
his passion and experience.
In the cervical part, this mixture was
also used. This mixture could be
called an enamel blocker; it works
as a softer transmitter of the colour.
This mixture can also be used as a
transition towards the enamel in the
incisal third; however, in this case, it
was used as a softer, lighter cervical
part. It is all about breaking the light
with a chameleon effect inside the
material.
If the mamelons are to be clearly distinguished from the dentine material, CL-F should be applied on top of
the mamelons (Fig. 10). For floating
mamelons, a wall of CL-F is applied to
the cut-back, then the mamelons are
created and then again a layer of CL-F
is applied. In this case, it was chosen
to have the mamelons differentiated
from the dentine material.
This first bake is the colour firing
(Fig. 11); if the colour is not chromatic
enough or already too chromatic, it
is easier to adapt in this phase. After
application of the enamel material,
colours should no longer be adapted
because this will destroy the appearance, which could become very greyish.
The enamel firing could be considered the morphological firing. For
the enamel, a mixture of E58, EI-14
(Enamel Intensive Yellow) and EOP
Booster in three equal parts was used
(Fig. 12). The program was exactly the
same as for the colour firing.
Fig. 18: Final result, portrait. The patient
was satisfied with the aesthetics and
function of his new smile.
Fig. 17: Night guard to protect the restorations and periodontal tissue.
The correction firing was done with
the same mixture, but diluted with
a fourth part of CL-F (Fig. 13). The
temperature was dropped by 5°C. In
case another firing is necessary, the
temperature can be dropped by an
extra 2 °C.
After finishing of the structure, the
crown was glazed with just some
liquid, at 50°C lower than normal.
The intention was to seal the sur-
face. After this firing, the crowns
were hand polished with a mixture
of pumice and 50 μm aluminium
oxide (Fig. 14). The preparations
were cleaned and isolated with retraction cords (Fig. 15). The crowns
were cemented with a resin-modified glass ionomer (GC Fuji PLUS
CAPSULE, GC). The cement excess
was easily removed when the rubbery state was reached, and margins were polished.
Increasing the vertical dimension is
often a challenging task. The temporisation phase was used to evaluate
the influence of the increase on the
temporomandibular function. Aside
from the function, restoring the vertical dimension had a positive influence on the aesthetic appearance. After treatment, a better balance in the
facial dimensions as well as a fuller,
more youthful smile could be seen
(Figs. 16–18).
Editorial note:
This articles was published in CAD/
CAM—international magazine of
dental laboratories vol. 12, issue 1/2021.
Dr Marco Tudts
He graduated as a dentist from KU Leuven in Belgium in 1991 and completed his
postgraduate qualification in aesthetic and
prosthetic dentistry in 1994. For 12 years, he
was a part-time associate at KU Leuven,
complex rehabilitation being his major
research topic, and participated in various
multicentre studies. In 1996, he started a
multidisciplinary private practice, specialised in complex rehabilitation, which he is
still running. In 2004, he obtained an MSc
in dental implantology from Montefiore
Medical Center in New York in the US. In
2008, he opened a look-over-shoulder
training facility for dentists focusing on
implantology, 3D technology, CAD/CAM
and 3D guided surgery. He is the developer
of the Navigator System for guided surgery
(Zimmer Biomet Dental). Since 2015, he has
been a staff member in the Department
ofOral Health Sciences at Ghent University
in Belgium. Here, he is currently preparing
his PhD dissertation on 3D-guided surgery
under Prof. H. De Bruyn.
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