CAD/CAM international

Cover / Editorial / Case acceptance in complex-care dentistry / Use of an X-ray phantom in dental 3-D diagnostics in digital volume tomographs / The treatment of toothless jaws—A case for CAD/CAM / Three-unit - full-contour ceramic bridge in one sitting / Real-virtual modelling of CEREC temporary crowns: A new approach / An interview with Dr Steven Guttenberg & Dr John Flucke / CBCT applications in dental practice: A literature review / Combination of digital and analogue techniques / Step-by-step restoration with Tizian CAD/CAM / Haptic input improves digital dental restoration design / White Peaks Dental Systems / Meetings / International Events / Submission Guidelines / Imprint

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CAD0210_01_Titel 11.11.10 10:46 Seite 1

issn 1616-7390

Vol. 1 • Issue 2/2010

CAD/CAM
digital dentistr y

international magazine of

2

2010

| case report
The treatment of toothless jaws

| research
CBCT applications in dental practice

| meetings
Touchdown for digital dentistry:
CADapalooza ’10 scores!

[2] => CAD0210_01_Titel

CEREC ® 3D Software powered by Biogeneric:
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Natural form and function is now as easy as scan, click, mill.
CEREC Biogeneric Software effectively reads the morphology of the patient’s own dentition to predict the
right form and function for all restorations. Based on comprehensive morphological analysis of thousands
of actual teeth instead of arbitrary “tooth libraries,” CEREC Biogeneric Software allows you to create inlays,
onlays, crowns, veneers and temporary bridges with just a single click. Ideal form, function and occlusion—
CEREC 3D Software powered by Biogeneric does it with ease. Simply scan, click, mill and admire.
s #LINICALLY AND FUNCTIONALLY VALID PROPOSALS EVERY TIME
s !UTOMATIC PROCESS A SINGLE CLICK PRODUCES THE NATURAL RESTORATION
s 5NRIVALED EASE OF USE LETS YOU FOCUS ON YOUR PRACTICE AND NOT COMPLEX SOFTWARE MANIPULATION

4O EXPERIENCE THE POWER AND SIMPLICITY lRSTHAND
CONTACT YOUR 0ATTERSON REPRESENTATIVE

800-873-7683
www.CEREConline.com

CAD/CAM FOR EVERYONE

SI20-104818_BioGenericAdV5_CCMag.indd 1

7/22/10 4:15:57 PM

[3] => CAD0210_01_Titel

CAD0210_03_Editorial 11.11.10 10:46 Seite 1

editorial _ CAD/CAM

Dear Reader,
_Dentistry is on the move! Today’s patients expect to be treated with the latest technology and materials to maximise their dental experience. As clinicians, we owe it to our profession and to our patients to utilise the newest technologies according to best practices that
will elevate our care without compromise. I have adopted this approach to dentistry by integrating chairside CAD/CAM dentistry (E4D Dentist System, D4D Technologies) and in-office
CBCT (i-CAT, Imaging Sciences International) into my practice.
With the E4D system, I am able to control my indirect restorative dentistry, without having
to eliminate the laboratory or the technician. I am able to more appropriately coordinate single
tooth treatment chairside with IPS Empress CAD and IPS e.max CAD materials (Ivoclar Vivadent),
as well as provide more comprehensive options to meet my patients’ needs. In today’s world,
CAD/CAM dentistry has given us the ability to offer reliable, in-office, same-day and high quality indirect restorations to our patients. With the laser scanning capability of E4D, I can scan
in the mouth, off an impression or off a model, providing total flexibility in patient treatment.
In addition, the ease of use of the software and flow of production make it easy to delegate
procedures to properly trained dental assistants for beautiful and functional results.

Dr Sharnell Muir

Generally, the same applies to the benefits of utilising my i-CAT. I can offer my patients
the latest in cone-beam technology for diagnosis and treatment planning without having to
go elsewhere or make additional appointments. The future combined use of technologies
utilising intra-oral scans and CBCT data provides a unique view of a virtual patient prior to
completing any treatment. This will provide the clinician, office team, dental laboratories and
especially the patient with a unique view of the treatment plan, eliminate surprises in implant
placement and harmonise anticipated results when all have the same ‘view’ of the entire case,
from start to finish. The goal is to experience true restorative-driven implant therapy.
D4D Technologies and the Imaging Sciences group, with the groups from Gendex (CB500)
and Instrumentarium (Scanora), are developing a software solution that combines digital
data from intra-oral scans with 3-D surgical data (CBCT) to provide complete control and
make restorative-driven implant therapy a reality. Through the dynamic collaboration of
these dental technology leaders, future dentistry will use these technologies in harmony.
For the general dentist, the collaborative efforts of leading digital scanning companies and
cone-beam manufacturers will enable the expansion of same-day restorative care to sameday surgical placement of implants using cone-beam guidance and the immediate placement
of an in-office and CAD/CAM restoration.
My patients are 3-D and I believe my treatment should be as well. Practising in this manner
offers great advantages in treatment options and predictability. Dentistry is on the move, so
our patients don’t have to! Get on board with the latest in modern dentistry—you, your team,
your practice and your patients deserve it.
Yours faithfully,

Dr Sharnell Muir
Kelowna Dental Centre
Kelowna, BC, Canada

CAD/CAM
2_ 2010

I 03

[4] => CAD0210_01_Titel

CAD0210_04_Content 11.11.10 10:47 Seite 1

I content _ CAD/CAM

page 10

page 14

I editorial

I industry report

03

30

Dear Reader
| Dr Sharnell Muir, Guest Editor

Combination of digital and analogue techniques
| Dr Gunpei Koike

34

I special
06

page 22

Step-by-step restoration with Tizian CAD/CAM
| Eliza Ivanova

Case acceptance in complex-care dentistry

38

| Dr Paul Homoly

Haptic input improves digital dental restoration design
| Bob Steingart

I case report

I industry news

10

41

Use of an X-ray phantom in dental 3-D diagnostics
in digital volume tomographs

White Peaks Dental Systems
| White Peaks

| Dr Georg Bach et al.

14

The treatment of toothless jaws—A case for CAD/CAM
| Dr Sven Rinke

18

I events
42

Three-unit, full-contour ceramic bridge in one sitting

Congress on 3-D dentistry again
exceeds goals in education

| Chris Leinweber

| Imaging Sciences International & Gendex Dental Systems

43

I clinical report
20

Real-virtual modelling of CEREC temporary crowns:
A new approach

CEREC 25th Anniversary Celebration
—A milestone event in dentistry
| Sirona Dental Systems, Inc.

44

| Dr Mikhail Antonik et al.

Touchdown for digital dentistry:
CADapalooza ’10 scores!
| D4D Technologies LLC

I feature
22

46

An interview with Dr Steven Guttenberg,
i-CAT & Dr John Flucke, GXCB-500 HD

The new challenge in dentistry
| Dr Dobrina Mollova

48

International Events

I research

I about the publisher

24

49
50

CBCT applications in dental practice: A literature review
| Dr Mohammed A. Alshehri et al.

page 24

04 I CAD/CAM
2_ 2010

| submission guidelines
| imprint

page 30

Cover image:
NobelProcera optical scanner,
courtesy of Nobel Biocare.

page 34

[5] => CAD0210_01_Titel

Anzeige.pdf

28.10.2010

14:05:23 Uhr

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US-FDA and DIN ISO 13485

,

White Peaks Dental Systems GmbH & Co. KG,
Langeheide 9, D-45239 Essen, Germany
www.white-peaks-dental.com
info@white-peaks-dental.com

[6] => CAD0210_01_Titel

CAD0210_06-09_Homoly 11.11.10 10:47 Seite 1

I special _ practice management

Case acceptance in
complex-care dentistry
Author_ Dr Paul Homoly, USA
_I enjoy seeing the articles in CAD/CAM in
which clinicians recount their creation of magnificent works of art through digital restorative
dentistry. In most of the case studies I’ve read, I am
sure the patient fees reach well over US$15,000 or
more.
Let me ask you this: what percentage of your
patients whose fee is US$15,000 or more are
ready to start care immediately after you present
their treatment plan? I have directed this question to thousands of my dentist audience members over the last decade and the overwhelming
response is “fewer than 5 per cent”. Is this because
patients do not understand dentists’ treatment
recommendations? Or is it that the fee does not
fit into their budgets? Chances are that both these
apply.
As dentists we are pretty good at helping patients
understand us and our treatment recommendations. What we are not good at is understanding our
patients and the manner in which our treatment
recommendations must fit into their lives. If you
have heard it once, you have heard it a thousand
times: the key to case acceptance is patient education. Go to dental seminars, read journals, listen
to consultants; most of it sounds the same―
educate, educate, educate. Now let me ask you this:
is it true? Is patient education the solution to case
acceptance?
If it is, then why do many new patients who have
been thoroughly examined, educated and offered
comprehensive treatment plans leave your practice
and never return for care? Is it that you did not
educate them sufficiently? Or is it that in the challenge of case acceptance, patient education is not
the only answer?
Let’s consider the new patient process and case
presentation and learn when patient education
works for us and when it chases patients out the
door.

06 I CAD/CAM
2_ 2010

_Inside-out versus outside-in
How do we get patient education to work for us?
Let’s first make the distinction between an insideout versus outside-in new patient process. The traditional new patient process is inside-out. It begins
by studying the inside of the patient’s mouth―
the examination, diagnosis and treatment plan. It is
after this inside look that we educate the patient
with regard to all his/her problems―how he/she got
them and what we can do about them, for example
case presentation. After case presentation, we
quote our fees and discuss financial arrangements.
It is only once we have gone through our inside
process that we discover what is happening outside
the patient’s mouth―his/her budget, work schedule, time and significant life issues.
The flow of conversation starts with insidethe-mouth conditions and ends with outside-themouth issues. I label this traditional way of managing the new patient the inside-out process (Fig. 1).
For patients with uncomplicated dental needs
―fees of US$3,500 or less―the inside-out approach with appropriate patient education works
well. Here’s why:
First, patients with minimal clinical needs are
often unaware of them. Patients with conditions
such as periodontal disease, asymptomatic periapical abscesses and incipient carious lesions must
be made aware of them and educated regarding
their consequences. Patient education is the driver
of case acceptance when patients are unaware of
their conditions.
Next, the inside-out process works well for
patients with fees of US$3,500 or less because the
outside-the-mouth issues―fees, time in treatment
and life issues―are such that most patients can
proceed with your treatment without undue
hardships or inconvenience. Dental insurance reimbursements, patient payment plans such as

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CAD0210_06-09_Homoly 11.11.10 10:47 Seite 2

special _ practice management

CareCredit and credit cards usually sooth the sting
of fees for US$3,500 or less. Fees at this level are not
insurmountable and usually do not anger or embarrass patients out of your office. But what if you
present complex dentistry for more than US$3,500?
Let’s suppose your fee is US$10,000 and it
involves multiple, long appointments and your
patient would lose time from work? Do outsidethe-mouth issues get in the way of case acceptance now? Yes, they do. Does patient education
make the unaffordable affordable? No, it does not.
How do I know? You have proven it, have you not?
It is with the patient whose fee is greater than
US$3,500 that I recommend an outside-in approach. Employing an outside-in approach involves
initiating your new patient procedures with conversations―telephone and the in-office new patient
interview―that focus on understanding what is
happening outside the patient’s mouth, such as significant life issues, budget and work obligations.
Later in this article, I’ll show you how.

She goes as far to recommend another appointment
with her so she can show you how to keep your
house clean before you buy one. She does all this
before she has any idea of what you can afford
and where you want to live. What would you think?
You would think about finding another estate agent,
would you not?
How many of your complex-care patients, after
experiencing your inside-out process, find another
dentist for the most likely reason that you spent
a bunch of time educating them on inside-themouth details before you had any idea what was
suitable for them? You educated them right out
your door.

After we have an understanding of outside-themouth issues, we do our examination. Then, during
the post-examination conversation and case presentation, we link our treatment recommendations
to the realities of their outside-the-mouth issues.
Let me show you how.
The flow of conversation starts with outsidethe-mouth issues and ends with inside-the-mouth
treatment recommendations. I label this an outsidein process (Fig. 2). An excellent example of an outside-in process is the purchase of a home. Imagine
you and your spouse decide to buy a new house.
You go to a real estate agent and, just a few minutes
into the conversation, you talk about price range,
neighbourhood, schools, proximity to work, financing and down payment. These are all big picture,
outside-the-home issues. Once you settled on the
broad outside-the-home issues then, and only then,
does it make sense to begin discussing the detailed
inside-the-home issues, such as room size, carpet
and tile selection, lighting, etc. Good estate agents
discover what the suitability factors of home buying
are (price, down payment, monthly payments, location, etc.) before they get into the inside details. In
other words, the flow of conversation is outside-in.
Now imagine you and your spouse go to the
estate agent, but this time she is a former dentist and
uses the traditional inside-out process she used as
a dentist. As soon as you sit down she begins educating you on the inside-the-house issues―the difference between cement slabs versus crawl space
foundations and vinyl siding versus brick exteriors.

Fig. 1

An outside-in process works best for complexcare patients. Here patient education is not the
driver of case acceptance. This is why: first, patients
with complex needs often come into your office
with a specific complaint―embarrassment about
their appearance, aggravation by their dentures
or fear of losing their teeth. They do not need to be
educated about their chief complaint. They may not
be aware of all their conditions, but it is most likely
that they have lived with the complaint that brought
them into your office for a long time.
Next, many complex-care patients have heard
the patient education lecture about plaque, pockets
and sugar many times before. It’s old news and
thus not a subject that distinguishes you. For many
patients, patient education efforts bounce off like
BB’s fired at icebergs. Expecting to influence them
into a US$10,000 treatment plan that does not fit
into their budget by showing them how to floss well
is naïveté.

CAD/CAM
2_ 2010

I 07

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CAD0210_06-09_Homoly 11.11.10 10:47 Seite 3

I special _ practice management
Let me be clear at this point: we are going to
spend some time on the patient education process
with complex-care patients, it is just not one of the
first conversations we will have.
The first conversations we will have with complex-care patients are about discovering outsidethe-mouth issues—just like the suitability conversation with the estate agent. The outside-the-mouth
issues of budget, time, work schedule, health issues
are what I call fit issues. These are the issues into
which your treatment plan must fit. Become good at
discussing fit issues and you will save an incredible
amount of time, you will sell much more dentistry
and you will no longer blow patients out of the
water—and out of your practice.

short, any issues dominating the patient’s energy
and attention. When you present complex-care
dentistry, it has to fit into the patient’s life.
Think about it. If you offer most patients a
US$10,000 treatment plan, something in their life
has to happen. People need to wait to receive their
tax refund, wait for a child to graduate from college, become more settled in their new job, or take
a much-needed vacation. Knowing the manner in
which your complex-care treatment plans fit into
the current or foreseeable circumstances of your
patient’s life is a mandatory skill for practising
complex-care dentistry. Without fit, there is no case
acceptance, regardless of the level of dental IQ or
your zeal for patient education.

_Discovering fit issues
Your team often knows what is going on in the
patient’s life. How do they know? They talk―they
chit-chat with the patients and they make friends.
Another purpose of chit-chat is to learn about
those fit issues in your patient’s life impacting their
treatment decision. When chit-chat is intentional,
I call it fit-chat—an indirect way of discovering
patient fit issues.
When you fit-chat, be curious and listen more
than talk. Listen to the manner in which patients
spend their time and what’s creating stress in their
life―health, money and/or family issues. If they
mention something you believe may influence
a treatment decision, be curious, listen attentively
and encourage them to talk more about it. Through
indirect fit-chat, you’re going to discover what’s
going on in patients’ lives.

Fig. 2

_Fit versus change
The earlier influencers in my dental career emphasised that a significant part of being a good
dentist is to get patients to change. Change the way
they clean their teeth, change what they eat and
change the priorities in their life and put dental
health at the top. It took me ten years and thousands
of patients to realise that patients change when
they are ready, not when I tell them to.
I learned to replace the concept of change with
the concept of fit. Instead of telling patients they
need to change to accommodate my treatment
plan, I learned to accommodate my treatment plan
to fit their life situation. Patients, especially the more
mature, complex-care patients, have complex fit
issues. These include finances, family hassles, work
schedules, special current events, travel, stressors,
health factors, significant emotional issues; in

08 I CAD/CAM
2_ 2010

Some patients do not fit-chat well. They are
simply not talkers. I am that way. When I get my hair
cut, the last thing I want is a chatty experience.
When you have a complex-care patient who will
not fit-chat, you can try a more direct approach to
discovering fit issues.
Here is an example of a direct approach: “Kevin,
I know from the line of work you are in that you are
busy and travel quite a bit. I also know you are aggravated by food trapping around your lower partial
denture. Let’s talk about your choices and how we
can best fit your dentistry into what is going on in
your life. Is now a good time to talk about this?”
Here is another example of a direct approach:
“Kevin, most people like you are busy, on-the-go and
have lots of irons in the fire. I need to know if any
of these irons are affecting the amount of stress
you are under, the amount of time you can spend

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CAD0210_06-09_Homoly 11.11.10 10:47 Seite 4

special _ practice management

here with us, or if there are financial issues I need to
consider when planning your care. I want to reassure you that I am very good at helping patients fit
their dentistry into what is going on in their life.”
Whether you are using an indirect fit-chat or
a direct approach to discovering fit issues, an absolute prerequisite to a comfortable conversation is
for you to have a connected communication style.
This means you hold good eye contact, listen carefully and patiently; you maintain a conversational
tone of voice and your speaking rate is relaxed.
Be sure to pause long enough to let what you are
saying sink in.
If you attempt to use a direct approach to fit
issues but have a disconnected style (do not look
the patient in the eye, speak too quickly, do not
listen attentively), your conversation may be perceived as being inappropriate, unprofessional and
seeking to diagnose their pocketbook sneakily.

_Advocacy
Advocacy is the experience of patients when they
realise that you are guiding them towards and not
selling them into dental health. To be an advocate is
to be a guide. To guide patients into complex care
effectively you need to take the fit circumstances
of their life into account and help them find a way
to fix their teeth in light of those circumstances. This
may mean fixing their teeth now, later, or over time.
Here is something you say that propels the advocacy experience. It occurs after the examination,
but before any detailed conversation about clinical
findings. Here is where you link the fit issues you
discovered to your clinical findings.
“Kevin, now that I have looked at your teeth,
I know I can help you. We treat many patients like
you with partial dentures that do not work well.
I know I can help. What I do not know is whether this
is the right time for you. You mentioned you travel
a lot and your company is in the middle of a big
reorganisation. Do you go ahead with your treatment
now? Do we wait until later? Or do we do it over time?
Help me understand how I can best fit your treatment
into everything that is going on in your life.”
This advocacy statement leads to a conversation about the patient’s fit issues. This conversation
reveals what treatment fits and what does not. You
will find that this approach results in many complex-care patients doing their treatment over time,
allowing them to stay within the limitations of their
fit issues. This is a good thing. I would rather treat
two patients for US$5,000 each than no patients

Fig. 3

for US$10,000. It also yields lifetime patients for
you. Patients will exhibit fierce loyalty to you when
they experience advocacy.

_The decision to educate
The decision when to educate and when to advocate is situational. Figure 3 demonstrates that
the impact of patient education on case acceptance
is highest when the complexity of the care (and its
associated fee) is minimal. Patient education is the
driver of case acceptance when a patient’s conditions and fees are minimal. However, when the complexity of care increases, the role of advocacy takes
over. Advocacy is the driver of case acceptance when
the patient’s conditions are complex and fees are
high. Copy Figure 3 and keep it in area where you will
see if often. Then, right before you go into case presentation, look at it and ask yourself: does this patient
need education or advocacy? Let the situation guide
you. When you do, you will discover how to keep
from educating your patients out the door._

_about the author

CAD/CAM

Dr Paul Homoly is a world-class
leader in dental education.
As a comprehensive, restorative
dentist and acclaimed educator
for over 25 years, he is known
for his innovative and practical
approach to dentistry. Dr Homoly
is now offering YES! On-Line
as the solution for dentists and
their teams to excel at case acceptance. This on-line,
seven-module curriculum, which is supported by a
matching set of DVDs, takes your dental team step-by-step
through the essential dental team-patient conversations,
and has proven successful for over 30 years.
Distinguished by his focus on outcomes, Dr Homoly is
legendary for his ability to teach and lead in a practical
and engaging manner. For more information, visit
www.paulhomoly.com or call Homoly Communications
at +1 800 294 9370.

CAD/CAM
2_ 2010

I 09

[10] => CAD0210_01_Titel

CAD0210_10-12_Bach 11.11.10 11:52 Seite 1

I case report _ 3-D diagnostics

Use of an X-ray phantom
in dental 3-D diagnostics in
digital volume tomographs
Authors_ Dr Georg Bach, Christian Müller & Alexander Rottler, Germany

Fig. 1a

Fig. 1b

Figs. 1a & b_DVT phantom
(the maxillary sinus floor and alveolar
nerve of the mandible are simulated
with radiopaque wire structures).

_Undoubtedly, digital volume tomography
has significantly expanded the range of dental
imaging diagnostics. Just as Paatero ushered in
a new era of dental radiology at the end of
the 1950s with the development of the orthopantomograph and the resulting introduction
of panoramic view imaging, 3-D processes will,
in turn, replace panoramic view imaging.
Although digital volume tomography has to
date been mostly used for pre-implantological
planning and in reconstructive surgery, now
other dental disciplines are beginning to appreciate the value of this process. It is in orthodontics,
endodontics, dental surgery and periodontics
that digital volume tomography represents a
significant improvement of the possibilities of
imaging processes. Its significance in the current
domain, pre-implantological diagnostics, can be
assessed as even greater.

_Available digital volume tomographs
Digital volume tomographs (DVTs) have been
on the market for a good decade, and the number
of suppliers of such devices has increased dramatically. When observing the device market,

10 I CAD/CAM
2_ 2010

two clear trends are evident: the trend towards
an all-in-one device (also called dual use) and the
trend towards DVTs of various volumes.
All-in-one devices
In addition to offering 3-D diagnostics, the majority of DVTs available on the market also provide
the option of producing panoramic view images
(real images, not reconstructed from a data record)
and sometimes even lateral cephalogram. These
devices thus cover the entire range of dental largescale diagnostics—in contrast with the first generation, which only offered the DVT option.
The DVTs of today’s generation are often similar in design and appearance to traditional DVTs.
The position of the patient with these and other
frame devices is typically standing or sitting,
while the once dominant supine patient position
of the first-generation device is passé, except for
that required by one DVT manufacturer.
Various volumes
The first-generation devices featured very large
volumes that required time-consuming reworking

[11] => CAD0210_01_Titel

CAD0210_10-12_Bach 11.11.10 11:52 Seite 2

case report _ 3-D diagnostics

Fig. 2

_small volume (4 x 5 cm) for oral surgery and dental procedures;
_medium-sized volume (8 x 10 cm and higher) for
oral surgery and reconstructive surgery; and

Fig. 3

_large volume (18 x 20 cm and higher) for oral
surgery and reconstructive surgery.
Problems with small and medium-sized
volume devices
Small- and medium-sized volume devices
are generally used for pre-implantological diagnostics, oral surgery, and orthodontic and
endodontic procedures. The limited volume
size requires careful device setting and patient

Fig. 2_DVT phantom in a DVT
(Kodak 9000 3D, small volume)
fixated on the original patient
biting aid.
Fig. 3_Device settings: with the
aid of the light visors, the volume
is placed on the region to be
captured (here region 26 and
the maxillary sinus floor).

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sending a written cancellation to OEMUS MEDIA AG, Holbeinstr. 29, 04229 Leipzig, Germany.
Signature

OEMUS MEDIA AG Holbeinstraße 29, 04229 Leipzig, Germany
Tel.: +49 341 48474-0, Fax: +49 341 48474-290, E-Mail: grasse@oemus-media.de

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CAD0210_10-12_Bach 11.11.10 11:52 Seite 3

I case report _ 3-D diagnostics
images using the preview function and check whether the
setting was correct. In the
event of incorrect settings, a
better image can immediately
be generated. In this manner,
there is a direct learning curve.
Using the DVT phantom for
preparing a patient image

Fig. 4

For new users and those who only take volume
tomograms once in a while, this correct setting
can pose difficulties, which was our motivation
for developing a DVT phantom that can be used
for training purposes and for direct preparation
of an image with a patient.

Time-consuming and tedious setting (aiming) of the
DVT on a patient who is already
in the device is likely to be
uncomfortable for the patient. This is where
presetting the device with the aid of the DVT
phantom comes in handy. The desired region is
captured with the phantom and, if needed, is
checked with the preview function. Then, the
phantom is removed and the patient is positioned
in the device. Generally, only one device setting
for the patient’s body size and small fine-tuning
are required before the image is set.

_The DVT phantom and its application

_How to obtain a DVT phantom

The DVT phantom is an X-ray phantom that
depicts a medium-sized mandibular and maxillary dental arch with the teeth positioned in ideal
denticulation.

A DVT phantom can be produced in cooperation
with practising dental technicians. The plastic teeth
containing barium sulphate are available on the market and a phantom can be made in the manner described above. An easier option is to send a DVT positioning aid of your device to dtcmfreiburg@aol.com
or through www.dtcmfreiburg.de. Master Dental
Technician Christian Müller will then mount a prepared DVT phantom on your positioning aid. Industrially manufactured plastic teeth containing
barium sulphate (SR Vivo Tac/SR Ortho Tac, Ivoclar
Vivadent) will be used, which are then incorporated
into a mandibular and maxillary model made of
transparent plastic.

Fig. 5

Fig. 4_DVT phantom image of the
maxilla with the DVT phantom.
Fig. 5_DVT phantom image of the
mandible with the DVT phantom.

positioning so that the relevant structure is accurately captured.

The phantom, which consists of a mandible
and maxilla, is mounted on the individual bite
or positioning support of the respective device.
Barium sulphate is added to the plastic teeth so
that they are visible in the X-ray image. These
teeth are made by the manufacturer especially
for X-ray applications. The DVT platform is then
mounted on the device with the original bite
support instead of a patient. The device setting
can be done in two different ways:
a) The desired volume is preset using the device
programme and then manually fine-tuned.
b) The device is manually set directly upon the
region to be captured with the aid of the light
visors.
Thereafter, the set positioning is saved.
Using the DVT phantom for training and practice
With the aid of the DVT phantom and the abovementioned setting techniques, new users, who are
training to become dentists or dental technicians,
can learn how to set the device for the regions
to be examined, generate one or more individual

12 I CAD/CAM
2_ 2010

We hope that the fascinating field of 3-D diagnostics will establish itself quickly in dentistry and
remain an imaging procedure that significantly
expands upon the hitherto range of dental X-ray
diagnostics in the long term._

_contact
Dr Georg Bach
Rathausgasse 36
79098 Freiburg/Breisgau
Germany
doc.bach@t-online.de

CAD/CAM

[13] => CAD0210_01_Titel

emax_2010_ad_guerel_e_A4.qxd

31.5.2010

8:31 Uhr

Seite 1

“THAT’S ALL
I NEED!”
Galip Gürel, Dentist, Turkey.

Many different indications and many different
materials to choose from – this scenario is a thing
of the past. The IPS e.max system allows you to
solve all your all-ceramic cases, from thin veneers
to 12-unit bridges. Dental professionals all over
the world are delighted.

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all c
need
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all

www.ivoclarvivadent.com
Ivoclar Vivadent AG
Bendererstr. 2 | FL-9494 Schaan | Principality of Liechtenstein | Tel.: +423 / 235 35 35 | Fax: +423 / 235 33 60

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CAD0210_14-17_Rinke 11.11.10 10:51 Seite 1

I case report _ toothless jaws

The treatment of toothless
jaws—A case for CAD/CAM
Author_ Dr Sven Rinke, Germany
_Prosthetic devices can be fitted in various
ways. Digital technologies have left their mark in implantology and provide options for high quality solutions. Classical indications for implant-prosthetic
treatments include dentures for the toothless jaw.
For this type of denture, clinical studies document
a high survival rate of about 85 to 90 % with observation periods of up to 20 years.1,2

However, there was also evidence that, in particular, the choice of fitting elements in a removable
denture, for example magnets, ball-heads, bridges
and telescopes, has an influence on patient satisfaction. With respect to stability and retention power, as
well as achievable patient satisfaction, a comparative
cross-over study demonstrated that magnets are
inferior to the fitting with ball-heads.6,7 A comparison of ball-head elements and overdenture attachments used for the fitting of an implant-retained
cover denture prosthesis did not demonstrate any
differences with regard to patient satisfaction.8
However, there proved to be a significant difference
in the rate of technical complications.

Fig. 1
Fig. 1_Subjective and objective
prosthetic success criteria.

Various prosthetic concepts have established
themselves for the fitting of superstructures according to the number of inserted implants.3 Generally,
there is either a fixed denture mounted on six to
eight implants and borne by these only, or a removable denture with a reduced number of implants.
The selection of a suitable denture depends on
subjective criteria—patient expectations, financial
constraints—and on clinical aspects—anatomic criteria, technical and clinical reliability of implants and
superstructure. Accordingly, the success of the prostheses depends on the following factors (Fig. 1):
_subjective criteria (patient satisfaction and quality
of life);
_objective criteria (probability of survival); and
_necessary maintenance effort during the lifetime
of the denture.

_Criteria for the selection of the type
of denture
Fixed, as well as removable implant-prosthetic
dentures in the toothless jaw, as opposed to the con-

14 I CAD/CAM
2_ 2010

ventional full denture, have proven to significantly
increase patients’ satisfaction and improve their
ability to chew.4,5 Hence, the insertion of two to four
implants can lead to a clear improvement of quality
of life. Therefore, the removable implant-supported
and implant-retained cover denture prosthesis is
nowadays considered an effective therapy.

Within an observation period of three years,
prostheses fitted with ball-heads required 6.7 repairs,
whereas the group of bridge-fitted prostheses required 0.8 repairs per patient only. Hence, overdenture attachments as fitting elements for removable
superstructures guarantee high patient satisfaction.
Owing to their low rate of technical complications,
they require less maintenance than alternative fitting
elements,8 which is an important criterion for the
long-term success of the prosthesis.
High maintenance requirements demand more
practice visits and take the time of both the patient
and the care provider. Furthermore, if there are
technical complications that have led to the failure
of superstructure elements, an intervention by a
dental technician might be necessary to reconstruct
or replace individual components. This is also connected with additional costs in order to maintain
function.
When evaluating overdenture attachment constructions as fitting means, the various types and
forms available must be considered. On the one hand,

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CAD0210_14-17_Rinke 11.11.10 10:51 Seite 2

case report _ toothless jaws

there are individually shaped bar attachments, and
on the other hand, there is the classic round bar,
which can be manufactured either by casting or by
combination of pre-fabricated elements.
The overdenture attachment fitted on four
implants is a classic fitting element for a purely
implant-supported cover denture prosthesis in a
toothless upper or lower jaw. A retrospective study
with 51 patients compared individually shaped
bar attachments and round bars for the fitting of
cover denture prostheses.9 Twenty-six patients
were equipped with round bars, while 25 patients
received a superstructure with an individual bar
attachment on four implants each. After a surveillance period of five years, the survival rate of the
implants was 100 %. Larger technical complications
that required a renewal of the mounting elements
occurred in the round bars only in the form of fractures in the extension areas. The fractures on the
extensions of the overdenture attachments, which
were exposed to high mechanical stress, were due
either to porosities in the cast object or to inhomogeneities in the area of the points of attachment.
Furthermore, it was determined that low-grade
complications (activation of hanks) occurred three
times as often in the round bars as in the bar
attachments. Thus, two causes of defects can be
deduced: firstly, defects due to faults in the manufacturing technique (casting and joining processes);
and secondly, defects causatively connected with
the design of the superstructure.
Two versions are described in the literature for
the fitting of attachments in the toothless upper
jaw: the fitting of attachments on four implants
in the anterior segment and the fitting of two
attachments on three to four implants on the lateral segments (mostly after a previous sinus floor
augmentation). Additionally, for the application of
attachments in the toothless upper jaw, data from
clinical studies has been published.9 Both attachment concepts featured almost identical survival
rates after five years: 98.4 % for the attachments
in the anterior segment and 97.4 % for the attach-

Fig. 4

Fig. 3

Fig. 2

ments fitted on six to eight implants in the lateral
segments of the upper jaw.
In particular, fitting by bar attachments appears
to be a therapeutic means with guaranteed success of
the fitting of purely implant-supported cover denture
prostheses in the upper and lower jaw. It excels with
a low rate of technical complications, as well as low
maintenance requirements. Hence, bar attachments
constitute clinically tested fitting elements for implant-retained and implant-fitted removable superstructures in the toothless upper and lower jaws.
No clinical data for the fitting of removable superstructures in the toothless upper jaw for magnets and
for ball-head attachments is available. Additionally,
the application of so-called locators for the fitting
of removable implant superstructures cannot be considered to be based on evidence, according to the
currently available data. To date, no results of clinical
studies have been presented for this fitting element.

Fig. 2_Fracture of a bar attachment
construction manufactured by
casting in the area of the extension.
Fig. 3_Casting of the implants in
the pick-up technique with
a high strength casting material.

Telescopes as fitting elements for removable
superstructures are popular particularly in the German-speaking countries, as they are very hygienic
and easy to expand. However, these advantages are
offset by the high technical requirements and costs.
Clinical studies on the suitability of double crowns
as fitting elements in implant prostheses demonstrate that they are generally suitable and they point
out the advantage of combining the natural teeth
with implants for the fitting of a removable construction, as opposed to attachments.

Fig. 5

Fig. 4_Tooth arrangement
produced on the work model.
Fig. 5_Virtual construction
of the bar attachment construction
with distal attachments.

CAD/CAM
2_ 2010

I 15

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CAD0210_14-17_Rinke 11.11.10 10:51 Seite 3

I case report _ toothless jaws
Fig. 6_Compartis ISUS bar
attachment made of pure titanium;
the attachment could be inserted
without manual post-processing.
Fig. 7_Completed implant-retained
prosthesis for the lower jaw.

Fig. 6

Fig. 7

_Optimising the manufacturing
technology

computerised numerical control (CNC) process began
more than ten years ago. In vitro examinations using
this CAM technology demonstrated that the precision achievable in such constructions, with median
gap widths between 20 and 30 µm, is better than the
accuracy of fit achieved with cast frames made of noble metals.12 Modern scanning and software technology allows expansion of this manufacturing principle
to virtual construction. Hence, the already wellknown process of CNC cutting is supplemented with
the option of a purely virtual construction. Several
manufacturers offer this technology, for example
Compartis ISUS (DeguDent).

Despite the high and well-documented survival
rates of attachment constructions, the question
arises as to whether the strategies can be further
optimised in order to avoid defects attributable to
the technique. The traditional way of manufacturing
attachment constructions is by casting. However, the
larger the cast object, the more difficulties arise in
terms of porosity and warpage, which increase the risk
of mechanical failure and impair the proper fit (Fig. 2).10
Relatively early on, the well-known casting problems led to the establishment of alternative techniques. The application of pre-fabricated implant
components, which were then joined by means of
soldering or laser welding, was one way to improve
the fit. However, with large constructions in particular, this procedure has the disadvantage of very
time-consuming manual post-processing. Furthermore, there is the risk that the mechanical ability to
cope with pressure may be reduced in the area of the
joining point.
From an economical point of view, it would make
sense to use largely bio-compatible material of sufficient mechanical strength for manufacture, such as
pure titanium or a Co-Cr alloy. However, the processing of such alternative materials does not provide
a sufficiently exact fit with the current casting techniques. In vitro examinations of cast implant superstructures made of non-metallic materials showed
gaps of 200 to 300 µm between the superstructure
and the implant arrangement.11 Compared to this, cast
structures made of noble metals featured median
gap widths of 40 to 50 µm.12 The use of alternative
materials therefore requires an alternative processing technology in order to achieve the necessary
precision. In the ideal case, the superstructure is cut
from a prefabricated solid material in order to safely
exclude inhomogeneities.
With this in mind, the manufacture of superstructures with cutting technological means utilising the

16 I CAD/CAM
2_ 2010

_Case presentation
The manufacturing process of an attachment
utilising the Compartis ISUS system is documented
below. After exposure of the implants, the next
appointment was devoted, as usual, to making a
casting with impression material that has a high final
hardness and hence guarantees a secure fixing of
the casting posts (for example, Impregum, 3M ESPE;
Monopren transfer, Kettenbach Dental; Fig. 3).
In the ideal case, the casting appointment would
entail the determination of the jaw relations and
a casting for the model of the opposing jaw. After
that, the work model is manufactured with the help
of a removable gingiva mask in the area of the implants. When the first check-bite is taken, a first provisional model can be mounted immediately. Based
on this working material, a tooth arrangement is prepared from plastic. It is useful if the information
about the colour and the shapes of the teeth is already
available during this work step (Fig. 4).
The tooth arrangement can be tried on at the next
appointment and corrected if needed. The exact jaw
relations can thus be determined and sufficient information will be collected for the definitive tooth
arrangement. At this appointment, the precision of
the casting should also be checked with a transfer
jig. For this jig, the posts on the work model can
be blocked with plastic and a metal reinforcement.

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case report _ toothless jaws

The jig must then fit onto the implants in the mouth
without causing tension or shifting around. For the
exact determination of the accuracy of the casting fit,
it is advisable to perform the Sheffield Test. A screw is
mounted and fastened on the post on one side of the
distal implant. When fastening the screw, the transfer
jig must not lift off the other implants. Furthermore,
there must not be any gaps. If the screw can be fastened without making the transfer jig move, it can be
concluded that the impression has exactly copied the
situation in the mouth. In case of a negative result,
a transfer defect can be assumed. In this case, the
transfer jig should be separated and all posts should
be fastened with screws so that a new impression
casting can be taken.
Once an exact impression has been secured and
the tooth arrangement has been adjusted, the CAD/
CAM manufacture of the superstructure can begin.
First, the work model and the tooth arrangement
are sent to a Compartis ISUS Planning Centre. There,
the virtual construction of the attachment is made
according to the specifications of the dentist(s) and
dental technician(s). In the present case, a bar attachment construction made of titanium with distal
attachments (Preci-Vertix, CEKA) was chosen.
The tooth arrangement determines the space
available for the superstructure and alignment towards the chewing area. This information then constitutes the foundation for CAD of the superstructure, the CAD process. For this purpose, special
scan posts are initially screwed onto the implants,
in order to determine the position of the implants
with a first scan. Then, a second scan is done with the
wax arrangement, in order to determine the available
space and the orientation of the superstructure.
Thereafter, the desired superstructure is designed
with the help of special software. This constitutes
the basis for the manufacture of the superstructure
utilising the CNC process (Fig. 5).
Dental technicians and care providers will then
receive the construction suggestion of the Compartis ISUS Planning Centre by e-mail with a request
for release or for advice regarding changes. As soon
as the release is obtained, the manufacture of the
attachment begins. The Compartis ISUS system uses
modern cutting machines and special cutting strategies and ensures perfect quality of the surfaces, rendering manual post-processing dispensable (Fig. 6).
The dental laboratory can now commence with
the fabrication of the secondary construction. In the
present case, a secondary structure was initially made
by means of electroplating (Solaris, DeguDent) and
the plastic matrix for the Preci-Vertix retaining elements was incorporated. Thereafter, a cast tertiary

structure was made of a Co-Cr alloy and bonded
with the galvanoplastic structure. The superstructure
was completed using the existing tooth arrangement
(Fig. 7). Several in vitro examinations have proven the
excellent accuracy of fit in these CAD/CAM-manufactured constructions (Fig. 8). In a comparison of five
different techniques for the manufacture of implant
superstructures, the CAD/CAM structures demonstrated a median accuracy of fit of 25 µm, while cast
structures had median gap
widths of 78 µm.13
However, the advantage of
the CAD/CAM technology is
not only the highly precise
manufacture of superstructures made of pure titanium
and Co-Cr alloys, but also its
applicability to a broad range
of indications. Starting from
the scan data, virtual construction allows for a wide
range of variations in terms of various forms of superstructures, from the simple round bar to retaining element attachments or to a bridge frame for fixed constructions. With a CAD/CAM system, it is also possible
to virtually incorporate active holding elements such as
extra-coronal retaining joints, bars and press buttons.

Fig. 8
Fig. 8_Good fit with a
CAD/CAM-manufactured attachment
construction made of pure titanium.

In summary, it can be said that CAD/CAM technology is also ideal for the processing of alternative
materials on titanium and non-precious metal basis.
It provides the following advantages:
_high mechanical resilience due to homogeneous
pore-free materials;
_tension-free fit due to precise CNC-manufacturing
technology; and
_suitability for a large width of indications due to
individual CAD.
The integration of virtual design supplements the
trusted manufacturing technology based on cutting
and hence opens up possibilities for new indications
for alternative materials in implant prosthodontics._
Editorial note: A complete list of references is available
from the publisher.

_contact

CAD/CAM

Dr Sven Rinke
Geleitstr. 68
63456 Hanau
Germany
rinke@ihr-laecheln.com

CAD/CAM
2_ 2010

I 17

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CAD0210_18-19_Leinweber 11.11.10 10:51 Seite 1

I case report _ ceramic bridge

Three-unit, full-contour
ceramic bridge in one sitting
Author_ Chris Leinweber, Canada

Fig. 1

Fig. 2

18 I CAD/CAM
2_ 2010

Fig. 3

_In the following case, the CEREC 3D system
and its one appointment capabilities played an essential part in the treatment. The patient suffered
from facial myalgia and could not handle a repeat
visit for a second try in/insert, owing to the potential stress it would cause. She had previously experienced involuntary facial episodes—the drill had
been bitten on—causing more trauma.

could support an I-14 TriLuxe Forte (VITA), which
would be used to manufacture the bridge.

The patient had broken tooth #31 at the gumline.
The rest of the tooth had been removed some time
ago, leaving a gap. All treatment options were explained to her. We offered her a same-day ceramic
bridge and informed her that this would be entirely
experimental, even though I have made many of
these types of full contour bridges.

The patient did not wish for her lower teeth to be
straightened, and therefore our goal was to restore
her original smile. She felt that this would be a more
natural result and did not wish the aesthetics to be
obvious when she smiled.

Dr Boyko then prepared the tooth #41 and
32 abutments. Following, he created a temporary
bridge that would be used by the CEREC system as a
temporary reference. Simultaneously, we measured
the shade of the surrounding teeth (Fig. 1).

Dr Carl Boyko, Welcome Smile Dental (Calgary,
Canada), and I created the bridge. Firstly, Dr Boyko
measured the span of the area that needed to be
bridged. Once measured, we discovered that the area

Once the temporary bridge had been put in place,
the temporaries were coated with titanium-dioxide
powder. This creates a reflective surface that allows
the CEREC 3D Bluecam to capture the optical impressions of the preoperative (occlusion) images.
Once the temporary reference images had been

Fig. 4

Fig. 5

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CAD0210_18-19_Leinweber 11.11.10 10:51 Seite 2

case report _ ceramic bridge

Fig. 6

captured, the temporary was removed and titanium
dioxide was sprayed onto the abutments once
again. We then used the CEREC Bluecam to capture
the abutments (Fig. 2).
The bridge we wanted to copy virtually overlapped the prepared model. The gold colour model
underneath was the original prepared image and
the grey image on top was the correlation model.
It was evident that the model matched from the
speckled look to the grey model, as it perfectly overlaps the prepared model. We need this kind of speckled look to occur because there is a 20° pitch and roll
yee and yaw of the camera in order to match up the
images. Although the CEREC software merges the
images this does not mean that the images will correlate 100 %. The correlation may thus be reduced
even though we have a virtual model (Fig. 3).
When using the correlation design technique,
one can draw the margin starting with any one of
the abutments. Simply start to draw the margin
close to the interproximal. As one draws around the
preparation, do not close the loop on the preparation on which you started. Continue to draw the
margin out onto the tissue, thus creating a second
margin on the imaginary pontic area. Continue on
to the next abutment, draw around the next abutment, then continue back onto the tissue to continue the lingual margin of the pontic. Finally, join
the rest of the margin to the original abutment to
close the loop. Once the loop has been completed,
one can carry on to the next window. In this way, we
fool the CEREC software into thinking this pontic
loop is one crown (Fig. 4).
Figure 5 shows our completed bridge that was
milled using the VITA Forte block, which is not a plain
monochromatic block. The final result will have
a natural gradient built into it when completed, as
it is has four colour steps to it (Fig. 5).
In order to achieve the proper shading for our
ceramic, I used Quick Match (Hankins Laboratories),
which can be used to mimic the stump shade value of
the abutments (Fig. 6). Next, I used the Ivoclar Stump

Fig. 7

Fig. 8

Shade Guide to match the shade tab to the appropriate colour on the Quick Match syringe. I injected the
fireable stump shade material into the bridge abutments. Once the Quick Match had been injected,
I started applying the glaze. The glaze turned the
ceramic into a window showing us the internal core
value. This makes staining the ceramics an easy
process once firing is completed. The process can be
repeated should more stain be required (Fig. 7).
I personally find that using the Quick Match
product not only creates the right stump shade
value, but is also great to use
when firing small abutments
that will not fit a peg (Fig. 8).
The final result is a bridge
that is virtually indistinguishable from the original. This
was all completed in a twohour visit and the patient was
very pleased with the final result. In this particular
scenario, I was not worried about the bridge failing
because of the size of the connecters. I know that
using a feldspathic ceramic is not the number one
choice; however, the amount of load on the anteriors
will not be such that the bridge will fail (Fig. 9)._

_about the author

Fig. 9

CAD/CAM

Chris Leinweber is the owner
of Kensington Dental Ceramics
located in Calgary. He is a
registered dental technologist,
a certified dental technician
and an ISCD-certified
CEREC trainer. He currently
provides two-day advanced
CEREC courses at Vident CEREC University in Brea,
California, USA. He lectures internationally
and is the creator and host of the innovative
CEREC Made Easy DVD training series. All his
training material and an updated course schedule
are available online at www.cerecmadeeasy.com.

CAD/CAM
2_ 2010

I 19

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CAD0210_20-21_Murashov 11.11.10 10:52 Seite 1

I clinical report _ crowns

Real-virtual modelling of
CEREC temporary crowns:
A new approach
Authors_ Dr Mikhail Antonik, Dr Mikhail Murashov & Dr Natalya Muraviova, Russia

Fig. 1

Fig. 2a

Fig. 1_Electronic axiography.
Figs. 2a & b_Lateral X-rays.

Fig. 3

Fig. 3_Slavicek analysis.

Fig. 4_Partial wax-up and
master casts.
Fig. 5_Partial wax-up and
master casts in articulator.

20 I CAD/CAM
2_ 2010

Fig. 2b

_The creation of a functional occlusion is
the goal of any prosthetic treatment and can be
very difficult to achieve in cases of full-mouth
rehabilitation, especially
in the case of temporomandibular joint (TMJ)
dysfunction. In these
clinical situations, provisional restorations are
an excellent diagnostic
instrument. Aesthetics,
phonetics and function,
after evaluation and acceptance by the patient
after try-in of the provisional restorations, should
be accurately transferred to the final restorations
to ensure the same clinical success.1–2

The aim of this study is to demonstrate the
manner in which individual movement characteristics of a patient’s TMJ can be included in
traditional CEREC temporary crown fabrication.
New occlusal relations need to be created with
respect to the individual characteristics, such as
mandibular and hinge axis positions, Bennett and
sagittal angles. The incorporation of occlusal
plane formation principles is essential to improve
and ease a patient’s adaptation to new occlusal
relations, as well as to reduce the probability
of TMJ dysfunction. However, CEREC software
does not enable the inclusion of TMJ parameters.

Fig. 4

Fig. 5

Following, we describe a technique that enables
the fabrication of temporary CEREC restorations
with respect to a patient’s TMJ parameters.

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CAD0210_20-21_Murashov 11.11.10 10:52 Seite 2

clinical report _ crowns

Fig. 6

_Step I: Electronic axiography and
lateral X-rays

diagnostic display with display options for virtual
modelling using CEREC software (Fig. 6).

Computer analysis of jaw movements with
electronic axiography is useful for determining the
joint parameters (Fig. 1). Using mechanical tracing,
axiography enables the collection of data on a
patient’s TMJ, such as curve and inclination of
the condylar path, mouth opening, Bennett and
sagittal angles, mandibular protrusion and course
of the mediotrusive tracks. Lateral X-rays provide
data on movement by including the condylar
tracks (Figs. 2a & b).

_Step V: Milling

Fig. 6_Step-by-step virtual modelling
in CEREC software.

The temporary restorations were traditionally
milled (Fig. 7).

_Step II: Slavicek analysis3
We used CADIAX (Gamma Dental) to analyse
the X-rays in detail (Fig. 3). Here, the distances,
spaces and tooth relations are of considerable importance. The vertical dimension and the special
position of the occlusal plane, the Spee’s curve and
the various occlusal tables of the laterals were
determined. In the lateral X-ray, we paid particular
attention to the occlusion tables of the molars,
especially tooth #6.

_Step III: Partial wax-up
A partial wax-up of the individual occlusal
surface was modelled on the master casts with
respect to the TMJ angles and occlusal pattern of
sequential functional guidance occlusion with
canine dominance (Figs. 4 & 5).4–6

Fig. 7

_Conclusion

Fig. 7_Temporary restorations
after cementation.

The method of real-virtual modelling described
in this article enables us to guide the anatomical
form of restorations using wax reference points
with respect to the dynamic TMJ parameters of the
patient. The method is a combination of a partial
wax-up in the articulator and virtual computer
modelling. With CEREC software, we are able to
create temporary restorations with respect to individual jaw movements._
Editorial note: A complete list of references is available
from the publisher.

_Step IV: Scanning
The partial wax-up was scanned and combined
with the virtual images of the teeth stumps and
virtual restorations from the CEREC software database. Thus, we were able to easily control the form,
cusp position and inclination of the teeth with respect to individual TMJ movement characteristics
and peculiarities of the facial skeleton. We used the

_about the authors

CAD/CAM

Dr Mikhail Antonik, Dr Mikhail Murashov and
Dr Natalya Muraviova from the Moscow State
University of Medicine and Dentistry in Russia can
be contacted at mmurashov@yahoo.com.

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I feature _ interview

“Three-dimensional imaging
touches all aspects of dentistry”
An interview with Dr Steven Guttenberg & Dr John Flucke, USA
_Imagine a technology that brings the most detailed knowledge of the patient’s dental anatomy and
greater treatment predictability right into the dental
office. A good imagination is no longer necessary to
achieve this goal. That technology, CBCT imaging, is
not just a dental daydream but also a reality every day
in many dental offices nationally and internationally.
Three-dimensional technology is already redefining dental outcomes across a broad spectrum
of treatment options, including
implants, bone grafting, oral
surgery, orthodontics and endodontics. The ability to capture a
3-D image of the mouth and to
view it from all angles, together
with the capability of rotating
that 3-D mode and zooming in
on details, can only result in
more effective dental treatment.

Fig. 1
Fig. 1_Proficient technology:
Restorative-driven implant planning.

With cone beam, all of the
information can be coordinated for integration with other
applications, such as guided
implant placement software or
CAD/CAM. Since the i-CAT and the GXCB-500 capture
scans in DICOM format, clinicians can combine this
high-resolution data with digital 3-D impression
scan data to perform restorative-driven implant
planning and take advantage of CAD/CAM milling
(Fig. 1). Software navigates the clinician through the
planning process using virtual implants. CAD/CAM
yields a surgical guide that ensures the plan translates into precise placement of the actual implants
and facilitates final implant restoration milling. Paring these two technologies ultimately reduces the
risk of poorly placed implants.
Dentists who have already implemented 3-D
technology are seeing results, from more proficient
diagnosis to more defined treatment planning and
increased case acceptance. CAD/CAM spoke to
Dr Steven Guttenberg, owner of i-CAT, and Dr John
Flucke, owner of GXCB-500 HD, who share their
experiences on how CBCT is helping to change the
face of dentistry across a wide range of procedures.

22 I CAD/CAM
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_CAD/CAM: How is dental imaging broadening
the scope of dental procedures for the general dentist
as well as specialists?
Dr Guttenberg: With 3-D imaging, the dental
profession is experiencing a real paradigm shift.
Dental radiography has come a long way from the
first X-ray taken by Wilhelm Roentgen of his wife’s
hand in December of 1895. However, even with a panoramic radiograph, we are getting a 2-D representation and making diagnostic and treatment decisions
for a 3-D object.
CBCT imaging gives dentists the opportunity to
diagnose and plan treatment more efficiently. While
I thought that I would use my i-CAT primarily just
for implant procedures, I now use it for everything—
taking out a tooth that is close to the nerve, exposing
a tooth for orthodontics, for implants, TMJ treatment
and trauma. Three-dimensional imaging touches
all aspects of dentistry, from endodontics looking
at teeth cross-sectionally, to orthodontics for nonsurgical treatment or for integration for SureSmile
robotic archwire technology.
When I think about the many ways that scans
can be viewed and the scope of information that each
scan provides (Fig. 2), the list of procedures that can benefit from this technology just keeps getting longer—
I use it for extraction, pathology, orthognathic surgery,
airway studies, dento-maxillofacial trauma, implants,
bone grafts and evaluation of the paranasal sinuses.
_What type of dentist really needs 3-D imaging?
Dr Guttenberg: Being at the International Congress
on 3-D Dental Imaging last year was an eye-opening
experience. I witnessed how doctors of different
specialties and general dentists use this innovation.
For any practice to expand and improve, a dentist
must embrace change. Physicist Thomas Kuhn, who
first coined the term paradigm shift in 1962, noted that
scientific advancement is not evolutionary, but is
rather “a series of peaceful interludes punctuated by
intellectually violent revolutions. In those revolutions
one conceptual world is replaced by another.”
Cone beam, to me, represents a revolutionary
concept in imaging. Six or seven years ago, it was just

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being looked upon with curiosity, but now it is becoming the standard of care for dental radiography.
Education in the possibilities that 3-D imaging brings
to the practice is invaluable.
While 2-D still has its place in the dental practice,
many patients need more for optimal care. Change is
not easy, but it is necessary to change, to move forward and to provide patient care in a better manner.
Three-dimensional imaging is definitely a paradigm
shift, letting dental professionals see the same information in an entirely different way. Nothing else
really describes what is going on here.
_What do you tell general practitioners who
may feel intimidated by this technology?
Dr Flucke: That question is exactly the reason that
I entitled my seminar Scrabble and Alphabet Soup
—Bringing Simplicity to Cone-Beam Technology. There
is a lot of hesitation on the part of some general
dentists that cone beam is just for the realm of the specialist or the dental school. When faced with acronyms
such as CBCT, cone-beam computerised tomography,
or terms such as voxel, the 3-D equivalent of a pixel,
they get intimidated by the mishmash of initials and
unfamiliar words. They just want an X-ray.
After becoming educated about 3-D imaging,
they realise that it is not as intimidating as they first
expected. I am not an electrical engineer or radiologist; I am just a dentist who uses 3-D cone beam to
improve patient care, and that is why it is important
to hear about this technology from people like me.
Far more important than the Scrabble and alphabet
soup, imaging is all about providing the best possible
outcome for the patient.
_Can you share a case from your own practice?
Dr Flucke: There are so many cases, but this case
in particular was very satisfying. A new patient arrived
at my practice eight months after seeing her previous dentist, who she had seen for the past ten years.
The patient had always been diligent, almost fanatical, about her dental health, but was two months
overdue for a cleaning.
We took a CBCT scan and found an undetected
cyst growing in the mandible almost to the point
of causing a fracture of the mandible (Fig. 3). When
we pointed this out, the patient responded, “Maybe
that is why my lip goes numb sometimes, and I get
these shooting pains in my jaw.”
While the patient wondered why, even throughout
her regular visits to the dentist this condition went
undiagnosed, I recognised that the previous dentist
was not really at fault. The dentist had been taking the
necessary required radiographs over the years, 20 film

2-D surveys, but this patient
needed more. Because of the
various options in viewing 3-D
technology, I sent the scan out
to a radiologist and subsequently
referred the patient to an oral
surgeon. The CBCT showed that
as the cyst grew, it was putting
pressure on the nerve, causing
the pain and numbness.
Four different outcomes
were possible for this condition, and two could have either
been life-altering or life-threatening. Fortunately, the situation
turned out to be benign, necessitating some extractions and
bone grafting. Afterward, the patient asked, “Why did I go somewhere else for ten years, and
the dentist never saw this, when
you found this after ten minutes?” It was all thanks to CBCT.

Fig. 2

Fig. 3

_What is your main message
to dentists contemplating implementation of CBCT?
Dr Flucke: I’m a general dentist. I use and believe
in this technology. I have seen so many scans that
have changed the course of treatment or provided
the missing information for difficult diagnoses. By
being a speaker at the International Congress on 3-D
Dental Imaging, this is what I want people to know:
Don’t be afraid to use 3-D imaging. Use it because
it is the smart and the best thing to do. The end game
is making the lives of our patients better and conebeam 3-D imaging is the best way to do that.

Fig. 2_Amazing views into
a patient’s anatomy.
Fig. 3_Previously undiagnosed
disease found on a CBCT scan.

Dr Guttenberg: To say it with George Bernard
Shaw’s words: “Progress is impossible without
change, and those who cannot change their minds
cannot change anything.”_

_about the interviewees

CAD/CAM

Dr John Flucke practices in Lee’s Summit, Missouri, USA. He is a well-recognised expert and educator in dental technology.
Dr Steven Guttenberg is an oral and maxillofacial
surgeon, practicing in Washington, DC, USA, where
he is director of the Washington Institute for Mouth,
Face and Jaw Surgery.

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CBCT applications in dental
practice: A literature review
Authors_ Dr Mohammed A. Alshehri, Dr Hadi M. Alamri & Dr Mazen A. Alshalhoob, Saudi Arabia
_Two-dimensional imaging modalities have
been used in dentistry since the first intra-oral
radiograph was taken in 1896.
Significant progress in dental imaging techniques has since been
made, including panoramic imaging and tomography, which enable
reduced radiation and faster processing times. However, the imaging geometry has not changed
with these commonly used intraoral and panoramic technologies.

Fig. 1
Fig. 1_Impacted teeth in close
proximity to vital structures should
be evaluated with CBCT.

Figs. 2a & b_Peri-apical lesion
shown as peri-apical
radiograph (a) and CBCT (b; images
courtesy of Dr Fred Barnett).

Fig. 2a

Cone-beam computed tomography (CBCT) is a new medical
imaging technique that generates
3-D images at a lower cost and absorbed dose
compared with conventional computed tomography (CT). This imaging technique is based on
a cone-shaped X-ray beam centred on a 2-D
detector that performs one rotation around the
object, producing a series of 2-D images. These
images are re-constructed in 3-D using a modification of the original cone-beam algorithm
developed by Feldkamp et al. in 1984.1 Images
of the craniofacial region are often collected with
a higher resolution than those collected with a
conventional CT. In addition, the new systems are
more practical, as they come in smaller sizes.2
Today, much attention is focused on the
clinical applications—diagnosis, treatment and

Fig. 2b

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follow-up—of CBCT in the various dental disciplines. The goal of the following systemic review
is to review the available clinical and scientific
literature pertaining to different clinical application of CBCT in the dental practice.

_Materials and methods
Clinical and scientific literature discussing
CBCT imaging in dental clinical applications was
reviewed. A MEDLINE (PubMed) search from
1 January 1998 to 15 July 2010 was conducted.
Cone-beam computed tomography in dentistry
was used as key phrase to extend the search to all
the various dental disciplines. The search revealed 540 papers that were screened in detail.
Owing to a lack of relevance to the subject, 406
papers were excluded. Thus, the systemic review
consisted of 134 clinically relevant papers, which
were analysed and categorised (Table I).

_Analysis
Oral and maxillofacial surgery
CBCT enables the analysis of jaw pathology,3–11
the assessment of impacted teeth (Fig. 1), supernumerary teeth and their relation to vital structures,6,12–21 changes in the cortical and trabecular
bone related to bisphosphonate-associated osteonecrosis of the jaw5,22–23 and the assessment
of bone grafts.24 It is also helpful in analysing and
assessing paranasal sinuses6,25 and obstructive
sleep apnea.27–28
As the images are collected from many different 2-D slices, the system has proven its
superiority in overcoming superimpositions and
calculating surface distances.28–29 This advantage
made it the technique of choice in mid-face fracture cases,30–31 orbital fracture assessment and
management32 and for inter-operative visualisation of the facial bones after fracture.33–34 Since it
is not a magnetic resonance technique, it is the
best option for intra-operative navigation during
procedures, including gun-shot wounds.35–36

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CBCT is largely used in orthognathic surgery
planning when facial orthomorphic surgery is
indicated that requires detailed visualisation of
the inter-occlusal relationship in order to augment the 3-D virtual skull model with a detailed
dental surface. With the aid of advanced software, CBCT facilitates the visualisation of soft
tissue to allow for control of post-treatment
aesthetics, for example in cleft palate cases to
evaluate lip and palate bony depressions.37–42
Research is underway to assess its ability to
detect salivary gland defects.43 Honda et al.44
describe a clinical case in which the time needed
to complete a tooth auto-transplant case was
significantly shortened owing to the application
of CBCT.
Endodontics
CBCT is a very useful tool in diagnosing apical
lesions (Figs. 2a & b).21,45–56 A number of studies
have demonstrated its ability to enable a differential diagnosis of apical lesions by measuring the
density from the contrasted images of these lesions, in whether the lesion is an apical granuloma
or an apical cyst (Figs. 3a & b).49,55–57 Cotton et al.46
used CBCT as a tool to assess whether the lesion
was of endodontic or non-endodontic origin.
CBCT also demonstrated superiority to 2-D
radiographs in detecting fractured roots. Vertical
and horizontal root fracture detection is described in several clinical cases.21,46,55–59 It is also
agreed that CBCT is superior to peri-apical radiographs in detecting these fractures, whether
they are bucco-lingual or mesiodistal.60–61
In cases with inflammatory root resorption,
lesions are detected much easier in early stages
with CBCT compared to conventional 2-D X-ray.21,62
In other cases, such as external root resorption,
external cervical and internal resorption, not only
the presence of resorption was detected, but also
the extent of it.21,46,54,56,63–64

Fig. 3b

Fig. 3a

CBCT can also be used to determine root
morphology, the number of roots, canals and
accessory canals, as well as to establishing the
working length and angulations of roots and

Specialty

Figs. 3a & b_Apical cyst shown as
orthopantomogram (a) and CBCT (b).

Number of articles

in %

Oral and maxillofacial surgery

26.86

Endodontics

23.88

Implantology

16.42

Orthodontics

11.94

General dentistry

10.45

Temporomandibular joint disorder

5.97

Periodontics

3.73

Forensic dentistry

0.75
Table I

canals.21,25,46,55–56,58,65–67 It also is accurate in assessing root-canal fillings.47,51,56,58 Owing to its
accuracy, it is very helpful in detecting the pulpal
extensions in talon cusps68 and the position of
fractured instruments.69
It is also a reliable tool for pre-surgical assessment of the proximity of the tooth to adjacent vital structures, size and extent of lesions,
as well as the anatomy and morphology of roots
with very accurate measurements.21,46,48,50,54–58,69–72

Fig. 4a

Fig. 4a_Orthopantomogram for
a full-mouth rehabilitation case.
Only limited data can be obtained
from this image.
Fig. 4b_CBCT images for the same
patient. Data obtained from these
images regarding bone quality,
implant length and diameter,
implant location and proximity
to vital structures is magnificent.

Fig. 4b

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Additionally, in cases in which teeth are assessed
after trauma and in emergency cases, its application can be a useful aid in reaching a proper
diagnosis and treatment approach.46,55,73–74
Recently, owing to its reliability and accuracy, CBCT has also been used to evaluate the

Fig. 5b

Fig. 5a

Fig. 5a_Clinical picture of multiple
implants placed in 2005.
Fig. 5b_Peri-apical radiograph
for the implants replacing teeth #8
and #9. Little data can be
collected from such an image.
Fig. 5c_The CBCT image clearly
demonstrates the amount
of bone loss.

canal preparation in different instrumentation
techniques.75–76
Implantology
With increased demand for replacing missing
teeth with dental implants, accurate measurements are needed to avoid damage to vital
structures. This was achievable with conventional CT. However, with CBCT giving more
accurate measurements at lower dosages, it is
the preferred option in implant dentistry today
(Figs. 4a & b).2,6,11,18,70,77–89
With new software that constructs surgical
guides, damage is also reduced further.77,84,90–93
Heiland et al.94 describe a technique in which
CBCT was used inter-operatively in two cases
to navigate the implant insertion following microsurgical bone transfer.
CBCT enables the assessment of bone quality
and bone quantity.18,26,70,80–81,85,88,95–97 This leads
to reduced implant failure, as case selection can
be based on much more reliable information.
This advantage is also used for post-treatment
evaluation and to assess the success of bone
grafts (Figs. 5a–d).18,88
Orthodontics
Orthodontists can use CBCT images in orthodontic assessment and cephalometric analysis.6,70,84,98–99 Today, CBCT is already the tool of
choice in the assessment of facial growth, age,
airway function and disturbances in tooth eruption.100–103

26 I CAD/CAM
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CBCT is a reliable tool in the assessment of the
proximity to vital structures that may interfere
with orthodontic treatment.104–105 In cases in which
mini-screw implants are placed to serve as a
temporary anchorage, CBCT is useful for ensuring
a safe insertion106–108 and to assess the bone density before, during and after treatment (Fig. 6).109–110

Fig. 5c

Having different views in one scan, such as
frontal, right and left lateral, 45-degree views
and sub-mental, also adds to the advantages
of CBCT.111,124 As the images are self-corrected
from the magnification to produce orthogonal
images with 1:1 ratio, higher accuracy is ensured.
CBCT is thus considered a better option for the
clinician.113
Temporomandibular joint disorder
One of the major advantages of CBCT is its
ability to define the true position of the condyle
in the fossa, which often reveals possible dislocation of the disk in the joint, and the extent
of translation of the condyle in the fossa.18,56,114
With its accuracy, measurements of the roof of
the glenoid fossa can be done easily.115–116 Another advantage of some of the available devices
is their ability to visualise soft tissue around the
TMJ, which may reduce the need for magnetic
resonance imaging in these cases.117
Owing to these advantages, CBCT is the imaging device of choice in cases of trauma, pain, dysfunction, fibro-osseous ankylosis and in detecting condylar cortical erosion and cysts.70,87,118–120
With the use of the 3-D features, the imageguided puncture technique, which is a treatment
modality for TMJ disk adhesion, can safely be
performed.121
Periodontics
CBCT can be used in assessing a detailed morphologic description of the bone because it has
proved to be accurate with only minimal error

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margins.56,122 The measurements proved to be as
accurate as direct measurements with a periodontal probe.56,123 Furthermore, it also aids in
assessing furcation involvements.20,56,116
CBCT can be used to detect buccal and lingual
defects, which was previously not possible with
conventional 2-D radiographs.56,124 Additionally,
owing to the high accuracy of CBCT measurements, intra-bony defects can accurately be
measured and dehiscence, fenestration defects
and periodontal cysts assessed.56,125–127 CBCT has
also proved its superiority in evaluating the
outcome of regenerative periodontal therapy.124

demonstrate that 134 papers were clinically relevant and that the most common clinical applications are in the field of oral and maxillofacial
surgery, implant dentistry, and endodontics.
CBCT has limited use in operative dentistry owing
to the high radiation dose required in relation
to its diagnostic value.

General dentistry
Based on the available literature, CBCT is not
justified for use in detecting occlusal caries, since
the dose is much higher than conventional radiographs with no additional information gained.
However, it proved to be useful in assessing proximal caries and its depth.20 Table II shows examples of typical doses of various dental radiological procedures in dental practice.
Forensic dentistry
Many dental age estimation methods, which
are a key element in forensic science, are described in the literature. CBCT was established
as a non-invasive method to estimate the age of
a person based on the pulp–tooth ratio.128

_Discussion
CBCT scanners represent a great advance in
dento-maxillofacial (DMF) imaging. This technology, introduced into dental use in the late
1990s,129 has advanced dentistry significantly.
The number of CBCT-related papers published
each year has increased tremendously in the last
years. The above systematic review of the literature related to CBCT-imaging applications
in dental practice was undertaken in order to
summarise concisely the indications of this new
image technique in different dental specialties.
Cone-beam computed tomography in dentistry was used as key phrase in this systemic review.
Other terminology encountered in the literature,
such as cone-beam volumetric scanning, volumetric computed tomography, dental CT, dental
3-D CT and cone-beam volumetric imaging, did
not result in additional relevant papers.130
The clinical applications for CBCT imaging in
dentistry are increasing. The results of this review

Fig. 6

Fig. 5d

The literature on CBCT is promising and needs
further research, especially with regard to its use
in forensic dentistry, in order to explore more
potentially beneficial indications in that area.
No literature concerning direct CBCT indications
in prosthodontics was found. However, several
overlapping indications were found in other dental specialties attributing to the final standard of
care in prosthodontic treatment. These indications include but are not limited to bone grafting,
soft-tissue grafting, prosthetically driven implant placement, maxillofacial prosthodontics
and temporomandibular joint disorder. CBCT images can also be of great value in special cases
in which multiple teeth have to be assessed for
restorability (Figs. 7a–e).
The latest CBCT units have a higher resolution,
lower exposure, are less expensive and designed for
use in dentistry. Additionally, the flat-panel detectors appear to be less prone to beam-hardening
artefacts. There are, however, several important
disadvantages as well, such as susceptibility to

Fig. 5d_Total buccal plate destruction
is evident in this CBCT image.
Fig. 6_CBCT image to assess the
bone density during treatment.

Table II_Typical doses of various
dental radiological procedures.

Intra-oral (F speed, rectangular collimator)

0.001 mSv

Intra-oral (E speed, round collimator)

0.004 mSv

Full-mouth set (E speed, round collimator)

0.080 mSv

Lateral cephalogram (F speed, rare-earth screen)

0.002 mSv

Dental panoramic technique (F speed, rare-earth screen)

0.015 mSv

CBCT (both jaws)

0.068 mSv

Hospital CT scan (both jaws)

0.6 mSv
Table II

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movement artefacts, low contrast resolution,
limited capability to visualise internal soft tissues
and, owing to distortion of Hounsfield Units,
CBCT cannot be used for the estimation of bone
density.
It is crucial that the ALARA principle (As Low
As Reasonably Achievable) is respected during

Fig. 7b

Fig. 7a
Fig. 7a_Multiple endodontically
treated teeth with a history
of peri-apical surgery.
Fig. 7b_Peri-apical image showing
a compromised crown-to-root ratio.
Fig. 7c_CBCT image showing the
absence of the buccal plate and
a compromised palatal plate,
indicating that the teeth need to be
extracted and site grafting performed
before implant placement.

treatment, as far as the radiation dose of CBCT
imaging is concerned. CBCT imaging will improve
patient care, but users have to be trained to be
able to interpret the scanned data thoroughly.
Dentists should ask themselves whether these
imaging modalities actually add to their diagnostic knowledge and raise the standard of dental care or whether they only place the patient at
a higher risk. Continuous training, education and
thorough research are thus absolutely essential.
One of the most clinically useful aspects of
CBCT imaging is the highly sophisticated software that allows the huge volume of data
collected to be broken down, processed or reconstructed.131 This makes data interpretation much
more user friendly, if the appropriate technical
and educational knowledge is available.
The increasing popularity of CBCT resulted in
numerous CBCT-unit manufacturers, frequent
presentations at conferences and an increase
in published papers. This resulted in an uncontrolled and non-evidence based exchange of radiation dose values and attributed to the limited
technical knowledge about medical imaging devices for new-user groups. As a result, the European Academy of DentoMaxilloFacial Radiology
has developed the following basic principles on
the use of CBCT in dentistry:132
1. CBCT examinations must not be carried out
unless a history and clinical examination have
been performed.
2. CBCT examinations must be justified for each
patient to demonstrate that the benefits
outweigh the risks.

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3. CBCT examinations should potentially add new
information to aid the patient’s management.
4. CBCT should not be repeated on a patient
‘routinely’ without a new risk/benefit assessment having been performed.
5. When accepting referrals from other dentists
for CBCT examinations, the referring dentist
must supply sufficient clinical information

Fig. 7c

(results of a history and examination) to allow
the CBCT practitioner to perform the justification process.
6. CBCT should only be used when the question
for which imaging is required cannot be
answered adequately by lower dose conventional (traditional) radiography.
7. CBCT images must undergo a thorough clinical evaluation (radiological report) of the
entire image dataset.
8. Where it is likely that evaluation of soft tissues will be required as part of the patient’s
radiological assessment, the appropriate imaging should be conventional medical CT or
MR, rather than CBCT.
9. CBCT equipment should offer a choice of volume sizes, and examinations must use the
smallest that is compatible with the clinical
situation, if this provides a lower radiation
dose to the patient.
10. Where CBCT equipment offers a choice of
resolution, the resolution compatible with an
adequate diagnosis and the lowest achievable dose should be used.
11. A quality assurance programme must be
established and implemented for each CBCT
facility, including equipment, techniques and
quality-control procedures.
12. Aids to accurate positioning (light-beam
markers) must always be used.
13. All new installations of CBCT equipment
should undergo a critical examination and detailed acceptance tests before use to ensure
that radiation protection for staff, members
of the public and patient are optimal.
14. CBCT equipment should undergo regular routine tests to ensure that radiation protection,

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for both practice/facility users and patients,
has not significantly deteriorated.
15. For staff protection from CBCT equipment,
the guidelines detailed in Section 6 of the
European Commission document Radiation
protection 136: European guidelines on radiation protection in dental radiology should
be followed.

logist or by a clinical radiologist (medical
radiologist).

_Conclusion
CBCT is most frequently applied in oral and
maxillofacial surgery, endodontics, implant dentistry and orthodontics. CBCT examination must

Fig. 7d

Fig. 7e

16. All those involved with CBCT must have received adequate theoretical and practical
training for the purpose of radiological practices and relevant competence in radiation
protection.
17. Continuing education and training after
qualification are required, particularly when
new CBCT equipment or techniques are
adopted.
18. Dentists responsible for CBCT facilities, who
have not previously received ‘adequate theoretical and practical training’, should undergo a period of additional theoretical and
practical training that has been validated by
an academic institution (university or equivalent). Where national specialist qualifications in dento-maxillofacial radiology exist,
the design and delivery of CBCT training
programmes should involve a DMF radiologist.
19. For dento-alveolar CBCT images of the teeth,
their supporting structures, the mandible
and the maxilla up to the floor of the nose
(for example, 8 cm x 8 cm or smaller fields of
view), clinical evaluation (radiological report)
should be done by a specially trained DMF
radiologist or, where this is impracticable,
an adequately trained general dental practitioner.
20. For non-dento-alveolar small fields of view
(for example, temporal bone) and all craniofacial CBCT images (fields of view extending
beyond the teeth, their supporting structures, the mandible, including the TMJ, and
the maxilla up to the floor of the nose), clinical evaluation (radiological report) should
be done by a specially trained DMF radio-

not be carried out unless its medical necessity
is proven and the benefits outweigh the risks.
Furthermore, CBCT images must undergo a thorough clinical evaluation (radiological report) of
the entire image dataset in order to maximise the
benefits.

Fig. 7d_Extractions done for teeth
#7, 8, 9 and 10 were atraumatic
and bone grafting was performed.
Fig. 7e_Temporisation done and
healing of the grafted sites for future
implant placement is awaited.

Future research should focus on accurate data
with regard to the radiation dose of these units.
CBCT units have small detector sizes and the
field of view and scanned volumes are limited,
which is the reason that CBCT units specific to
orthodontic and orthognathic surgery are not
yet available. Additional publications on CBCT
indications in forensic dentistry and prosthodontics are also desirable._

Editorial note: A complete list of references is available
from the publisher.

_about the authors

CAD/CAM

Dr Mohammed A. Alshehri is a Consultant
for Restorative and Implant Dentistry at the
Riyadh Military Hospital, Department of
Dentistry and Assistant Clinical Professor
at the King Saud University, College of Dentistry,
Department of Restorative Dental Sciences.
He can be contacted at dr_mzs@hotmail.com.
Dr Hadi M. Alamri and Dr Mazen A. Alshalhoob
are interns at Riyadh Colleges of Dentistry
and Pharmacy.

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I industry report _ IPS Empress CAD Multi

Combination of digital
and analogue techniques
Author_ Dr Gunpei Koike, Japan

Fig. 1
Fig. 1_Pre-op situation showing
an irregular incisal line.
The patient considered her teeth
too “angular and big”.

_Nobody will deny that aesthetics play a
crucial role in the restoration of anterior teeth,
irrespective of whether the restorations are placed
in male or female patients. As the final outcome is
dependent on the skills of
the clinician, the aesthetic
differences may be tremendous even if state-ofthe-art techniques and
materials are utilised. For
the anterior restorations
in the case presented,
I used IPS Empress CAD
leucite glass-ceramic blocks.
These blocks are offered
in two different levels of
translucency by the manufacturer. Additionally, a
Multi block featuring multiple shades is available.
As these blocks are industrially processed, restorations of consistent quality are achieved. The glassceramic material is easy to polish or reduce, which
enables the milled restoration to be veneered subsequently. As a result, the final aesthetic outcome
can be optimised in a simple fashion.
I usually work with the polychromatic IPS
Empress CAD Multi blocks, as they feature a trueto-nature gradation of shades combined with
optimum levels of brightness and translucency.
Consequently, they blend in seamlessly with
the natural oral environment. In addition, they
demonstrate lifelike fluorescence.

Fig. 2_Tooth #12 had been restored
with a crown in the past and
tooth #21 showed pronounced
discolouration.
Fig. 3_Preparation for a CAD/CAMfabricated all-ceramic restoration
with rounded angles and transitions.

30 I CAD/CAM
2_ 2010

Fig. 2

Today, patients’ needs and expectations differ
widely. They may include quick healing, but also
long-term stability or enhanced aesthetics. The use
of IPS Empress CAD Multi blocks in combination
with the CEREC 3 (Sirona) chairside CAD/CAM system allows restorations to be fabricated that meet
the needs of today’s patients. In the case presented,
a restoration was fabricated with an IPS Empress
CAD Multi block. A highly aesthetic result was
achieved that left nothing to be desired.

_Case study
A 32-year-old female patient presented to my
office dissatisfied with the aesthetic appearance
of her upper anterior teeth. The incisal edges
showed an irregular contour and discolouration
was present (Fig. 1). The initial examination revealed an inconsistent incisal line and dark discolouration visible during smiling. Tooth #12 had
previously been restored with a crown, while
tooth #22 had received a composite restoration
(Fig. 2). Prior to the start of the treatment, a CRT
test was conducted. The results indicated a low
caries risk level and good oral hygiene. Therefore,
the restorative treatment could be started immediately.
The restorative options available to the patient
were discussed with her. Her priorities included
the lightening of the discoloured teeth, as well as
the creation of softer, more feminine tooth shapes
and the creation of long-lasting restorations.

Fig. 3

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Fig. 4_The die model constituted
the basis for the mock-up.
Fig. 5_Creation of the wax-up;
as desired by the patient, tooth
shapes that were more rounded
were established.

Fig. 4

Fig. 5

Based on her wishes, an anamnesis and a diagnostic analysis were conducted. In the next step,
I set up a treatment plan that included teeth #11,
12, 21 and 22.

Based on the mock-up, which had been discussed with the patient earlier, a wax-up was created on the model and an optical impression was
taken (Fig. 5). The recorded model served as a guide
for the construction procedure, which was carried
out using the quadrant mode.

First, I fabricated a mock-up, which was to serve
as a basis for the discussion with the patient. Her
wish of having teeth with a more rounded shape
and thus with a softer, more feminine appearance
was taken into account during the fabrication of
the mock-up. The teeth were prepared according
to standard procedures (Fig. 3). A fibre-reinforced
endodontic post and core was seated in tooth #12.
This was done to prevent root fracture but still
ensure an aesthetic restorative result. In tooth #11,
caries was detected in the area of the mesial angle.
Following removal of the carious tissue, the cavity
was filled with composite resin. Tooth #21 received
a full-crown preparation. A rounded shape was
prepared to ensure even distribution of the force to
which the restoration would be exposed. In tooth
#22, composite material was applied in the area
of the medial angle.
The CEREC software features a tool termed
correlation mode. This mode enables users to take
an optical impression. As the patient had a very
clear idea of the future appearance of her teeth,
I decided to use this mode to match my ideas with
hers. Therefore, a silicone impression was taken
after the teeth had been prepared and a model was
poured (Fig. 4).

Fig. 6

In the fabrication of anterior restorations, it is
advisable to check the size and dimension of the
incisal build-up from the palatal aspect continuously
by means of a silicone matrix. This significantly facilitates the modelling procedure. Moreover, by proceeding in this way it becomes apparent immediately
if data has been lost during optical impression taking.
A loss of information in the area of the incisal edge
usually renders the construction of anterior restorations considerably more difficult. The precise recording of data is of utmost importance, especially if the
patient requests a particular tooth shape (Fig. 6).
The 3.6 version of the CEREC 3D software has
a milling preview feature, which allows users to
‘place’ the restoration in the virtual block as needed
in accordance with the gradation of shades from
cervical to incisal (Fig. 7). This enables the operator
to make use of the opaque/translucent areas or
the gradation pattern of the block in an optimal
fashion. If several teeth are restored simultaneously, there are now various options to utilise the
different areas efficiently. Consequently, it is even
possible to fabricate restorations that do not require individual characterisation or cutting back.

Fig. 7

Fig. 6_The restoration was designed
on the computer screen. The silicone
matrix was scanned in order
to be able to construct the incisal
area easily and quickly.
Fig. 7_Virtual positioning of
the restoration in the IPS Empress
CAD Multi block.

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Fig. 8_The milled restorations seated
on the model show an excellent fit.
Fig. 9_The adhesively cemented
IPS Empress CAD Multi restorations
demonstrate the typical gradation of
shade from the cervical to the incisal
area and thus harmoniously blend
into the oral environment.

Fig. 10_The lip line of the happy
patient three years after completion
of the treatment. The restorations
are in an impeccable state and are
still aesthetically pleasing.

Fig. 10

Fig. 8

Fig. 9

The versatility and flexibility of the IPS Empress
CAD Multi block is thus further enhanced. After the
restoration had been milled, it was seated on the
model. The restoration had an excellent fit. Owing
to the gradation of opaque and translucent shades
from the cervical to the incisal region, the restoration had a very natural appearance (Fig. 8).

Figure 10 shows the restorations three years
after completion of the treatment. The restorations
still look attractive and the gingival tissue has
a healthy colour. We are proceeding on the assumption that the dark triangle between the two
front teeth will become smaller over time. The four
teeth were restored with IPS Empress CAD Multi
block in a very satisfactory fashion, and the patient
was very pleased with the result.

In the case presented, the restorations were
glazed but did not have to be characterised because of the IPS Empress
CAD Multi block’s lifelike
aesthetics. The reason that
I glazed the restoration was
not primarily to improve
its aesthetic appearance,
but to impart it with even
higher strength. In the literature, glaze firing is generally referred to as a means
of increasing the strength
of IPS Empress CAD restorations. I would like to
point out however that IPS
Empress CAD restorations also possess sufficient
strength to ensure successful, long-term results
if they are merely polished. Following try-in, the
restorations were adhesively cemented (Fig. 9).
Particularly in the cementation of veneers, strict
adherence to the cementation protocol is crucial to
ensuring long-lasting results. Normally, I use Variolink II luting composite, since it allows (thin) allceramic restorations to be reliably, durably and
aesthetically cemented. In the case presented, I decided to use the universal luting composite Multilink Automix, as it is very easy to use and convenient.
The restorations were reliably cemented in just
two steps. The high bond strength and long-lasting
adhesion that are achievable with this system have
been confirmed by numerous studies conducted in
recent years. In contrast with Variolink II, Multilink
Automix is only available in three different shades
(yellow, transparent and opaque). As the patient’s
teeth did not show any severe discolouration, the
choice of materials was sufficient in this case.

32 I CAD/CAM
2_ 2010

_Summary
In Japan, it is generally assumed that conventional, laboratory-based restorative procedures
are superior to computer-assisted techniques.
Some experts are of the opinion that CAD/CAMbased systems even pose a threat to the profession
of laboratory technician as a whole. In my opinion,
this is a huge misconception. On the contrary,
CAD/CAM technology and the manual skills of
laboratory technicians can be ideally combined to
achieve optimal results. The flexible use of digital
and analogue techniques helps to better fulfil
patient needs and advances modern dentistry.
This position is corroborated by the case presented
in this article, which was restored by making full
use of the possibilities offered by the CEREC system
and the IPS Empress CAD Multi block. I will continue to provide my patients with high-quality
restorations, also by using sophisticated procedures. These procedures ensure that durable results and thus a high level of patient satisfaction
are achieved._

_contact

CAD/CAM
Dr Gunpei Koike
Koike Dental Clinic
1-20-1 Nobi Yokosuka
Kanagawa 239-8041
Japan
www.koikedc.com
www.cerec.jp

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© Nobel Biocare Services AG, 2010. 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.

NobelProcera

Unique and precise scanning
technology – from copings to
screw-retained implant bridges.

Ability to scan complex cases.

Open-air design for ease of use.

The highlight of NobelProcera is
an easy-to-use optical scanner that
provides high accuracy scanning of
complex geometries. Combined with
the scanner is a cutting edge userfriendly CAD software package featuring intuitive tools such as full anatomical tooth library and cutback functions. In future, the functionality will

also include impression scanning.
NobelProcera provides a comprehensive product and material range
such as implant bars, shaded zirconia
abutments and temporaries, with
precision of fit, quick turn-around
times and consistent and predictable
results. All products are individually
manufactured from materials that

are certified for excellent strength
and homogeneity and come with
a 5-year warranty.*
Nobel Biocare is the world leader
in innovative and evidence-based
dental solutions.
For more information, visit
our website.
www.nobelbiocare.com

* Provisional restorations are excluded from the 5-year warranty.
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.

NobelProcera LAB A4 CADCAM.indd 1

10-11-11 15.26.52

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I industry report _ Tizian CAD/CAM

Step-by-step restoration
with Tizian CAD/CAM
Author_ Eliza Ivanova, Bulgaria

Fig. 1

Fig. 2

Fig. 3

_Established in 1994, Art Dental Ltd., a fast
developing dental laboratory, has more than
16 years of professional experience in all types
of highly aesthetic dental restorations. New generation materials and modern layering techniques ensure the production of consistent and
high quality restorations. In view of the latest
trends in modern dentistry, the laboratory specialises in the production of restorations placed
over implants, as well as large constructions, for
example 16-unit bridges on implants with no
other teeth available.
For the past two years, Art Dental has produced
more than 500 constructions using ZrO2, non-

precious alloys and PMMA composite/temporary
constructions in combination with the Tizian
CAD/CAM system (Schütz Dental). The following
cases aim to demonstrate the significant advantages of ZrO2 in combination with Tizian
CAD/CAM.

_Case I (Figs. 1–15)
This 45-year-old female patient suffered from
very serious periodontal problems. The treatment
plan involved extraction of all maxillary teeth
and subsequent placement of six implants. In
order to find the ideal place for perfect osseointegration and to avoid sinus lift intervention, the

Fig. 4

Fig. 5

Fig. 6

Fig. 7

Fig. 8

Fig. 9

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Fig. 10

Fig. 11

Fig. 12

Fig. 13

Fig. 14

Fig. 15

two implants in the area of the distal premolars
were fixed at a 35° angle.

excellent accuracy of fit. Such level of precision
can be achieved manually only at a high time cost.

Two attachments were placed on teeth #12
and 22, which enabled direct restoration. Many
aspects had to be taken into consideration in order to achieve an enhanced stability, excellent
shape adaptation and lifelike aesthetic results.
We decided that the permanent construction was
to be done using ZrO2 and Tizian CAD/CAM.

A unique type of insertion was performed in
the next step in order to determine the best position for the construction in the blank and to
avoid undercuts, so no further actions would have
to be done manually. After milling and sintering,
the bridge showed an excellent accuracy of fit. We
reduced the thickness of the cement gap and the
crown border parameters, removed undercuts
and received perfect results (demonstrated by the
green arrows over each crown in Figure 5).

We began by loading the model and the bite
scans into the modelling software, which detected the preparation line of each unit individually. Owing to the flexibility of the software,
the preparation lines of the attachments and the
35° placed implants were easily detected. Additionally, the process was fast and easy with an

The software proceeded by automatically loading the anatomical shapes. A large variety of software tools provided excellent, lifelike results with
regard to the natural tooth structure, morphology,

Fig. 16

Fig. 17

Fig. 18

Fig. 19

Fig. 20

Fig. 21

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Fig. 22

Fig. 23

symmetry and composition. In this case, which
would have been a challenge for every CAD/CAM
system on the market, the Tizian Creative RT design
software demonstrated significant advantages
during the shape-forming process, especially for
the attachments and the distal implants.
We were able to call the antagonists every time
we needed to during the entire modelling process.
The software automatically arranged the occlusal
and approximal contacts but these can also be
adapted manually if necessary. After the construction had been adapted to the bite, we proceeded to
shrink the crowns and pontics. With the entire

Fig. 26

Fig. 25

palette of forming tools available for reshaping, we
reduced as much as we needed to. The connectors
were set quickly and easily, while one was able to
choose between different shapes, move in all directions, and change height, weight and thickness.
Figures 9 to 15 show the final construction before
and after being seated in the patient’s mouth.

_Case II (Figs. 16–24)
This 40-year-old female patient was not satisfied with the look of her smile. By restoring her
teeth, we were able to change the way the patient
felt about her appearance. We selected a 12-unit
zirconium framework with ceramic cover, a highly
aesthetic solution.

_Case III (Figs. 25–27)
For this 54-year-old female patient, we created two temporary constructions from advanced

36 I CAD/CAM
2_ 2010

Fig. 24

PMMA composite materials for teeth #15 to
25 and #35 to 45. The two bridges, which she was
required to wear for three months, were then
replaced by zirconium constructions. The two
bridges were placed on implants. The modelling
process followed was the same as described in the
previous cases.

_Conclusion
The Tizian CAD/CAM system enables rapid
manufacture of highly accurate restorations, both
permanent and temporary. With user-friendly
software and a large variety of software tools, as

Fig. 27

well as a fast and easy scanning, modelling and
milling process, the materials are processed quickly
and accurately with results hardly distinguishable
from natural teeth. This exceptional piece of technical equipment proved to provide reliable and
consistent results and product quality, as well
as excellent bio-compatibility of the materials.
Additionally, compared to cast-metal techniques,
considerably less time was needed, while accuracy
of fit and precision increased._

_contact
Art Dental
Hristo Botev 40
7000 Russe
Bulgaria
artdental.bg@abv.bg

CAD/CAM

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Unbenannt-2 1

11.11.2010 9:54:52 Uhr

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I industry report _ SensAble Technologies

Haptic input improves digital
dental restoration design
Author_ Bob Steingart, USA

Fig. 1
Fig. 1_Full upper digital partial.

_For more than a hundred years, dental laboratories have designed dental restorations the same way
by using a lost-wax process in accordance with which
the design is first modelled by hand in wax, then
reviewed, refined, invested and finally burned out in
the process of creating a mould that will be used for
casting. Twenty-five years ago, early dental CAD/CAM
solutions, such as Sirona’s CEREC system, applied
technology proven in automotive and aerospace
design to the design of
zirconia substructures
(or copings) for crowns,
allowing part of the process to go digital. However, while copings are
simple, thimble shapes
and relatively straightforward to design digitally, other types of
commonly prescribed
removable restorations,
such as partial dentures,
are not, owing to their
highly irregular and intricate shapes. In addition,
dental laboratory technicians are skilled artisans—
having honed their manual dexterity, artistic style and
design techniques over many years—not tech savvy
engineers. These factors make it extremely difficult for
them to use traditional dental CAD/CAM systems to
create complex, organic-shaped dental restorations.
Creating dental restorations is partly science and
partly an art. Each individual’s mouth and tooth
shape is uniquely his/her own, meaning that a dental
restoration is an individualised work of art, sculpted
from scratch in bite-sized form. Computers can greatly speed the design process and add precision, for
example by eliminating steps such as the need for a refractory model, applying digital wax thicknesses consistently and automatically, and assuring fast design
iterations or a remake, if needed. Furthermore, having
digital clasp designs and mesh patterns at your fingertips also helps accelerate the design process.
Until recently, dental CAD/CAM systems were
either surface or solid modellers, utilising the same

38 I CAD/CAM
2_ 2010

parametric technology and the accompanying rigid,
hierarchical workflow as CAD/CAM systems that are
used for industrial design. These traditional dental
CAD/CAM systems also require that the laboratory’s
restoration designer use a 2-D computer mouse to
manipulate the design, which prevents the designer
from leveraging the dexterity and artisanship they
have spent years perfecting. While the laboratory
technician may be able to see the restoration on
screen, with a mouse they cannot feel the contours
of the teeth and tissues, or the thickness or smoothness of a restoration’s surface—pivotal feedback that
allows them to design accurately and efficiently.
In 2008, SensAble introduced what some dental
authorities have called a revolutionary 3-D touchenabled solution for dental restoration design. The
company’s SensAble Dental Lab System remains the
only proven digital solution to support the design
and production process for removable partial frameworks and has since been expanded to handle full
contour crown and bridge work and, with additional
software, veneers.
The system is based on voxel technology (think
of voxels as 3-D pixels), which provides unparalleled
speed and design flexibility. This 3-D modelling approach means that laboratory technicians can handle
even the most challenging cases and can literally design any type of restoration they can imagine. If they
can wax it, they can design it on the SensAble system.
This ability to use one system to create multiple types
of restorations allows dental laboratories to leverage
their investment across more lines of business, an
important option in challenging economic times.
With the SensAble system, dental laboratory technicians use a haptic device, which the company calls
a 3D Virtual Touch stylus, instead of a mouse, allowing
them to literally feel the evolving restoration that they
are designing on screen as they carve and smoothdigital wax. The result, according to numerous European
dental laboratories, is business changing. When dental restoration designers are suddenly offered a way
to design digitally in which they can still use their
sense of touch in the design process, they can transition more easily to working in the digital domain

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and design restorations with unmatched speed, consistency and precision. Laboratories are reporting
that they are able to create vastly more work with the
same number of staff and in some cases compete for
large-volume business, such as government-funded
restorations, because the laboratory’s cost structure
has suddenly become more favourable.
Suddenly, the painstaking task of working in
wax has been elevated to state-of-the-art design.
Numerous laboratory owners stated that the appeal
of haptics has helped them to attract, quickly train
and retain younger computer-savvy technicians entering the dental laboratory field. Other laboratories
have reported that because of haptics, they have been
able to teach individuals who are not trained laboratory technicians to use the system correctly and productively, expanding the pool of people from which
they can hire.

_What is haptics
Haptics refers to sensing and manipulation
through touch. The word haptics originated from the
Greek words haptikos and hapthesthai, which means
to grasp or to touch. Haptic devices enable computer
users to touch and manipulate virtual objects by feel
within a true 3-D space.
SensAble’s founders pioneered the development of
a type of haptics now called force feedback, where the
computer receives the force exerted by a person’s natural touch and then returns a resulting force to the user
as he/she manipulates 3-D models on screen. What
dental laboratory technicians experience is that when
they move their hand, the movement sends haptic input—data about force and position—to the computer
via the haptic device. The computer makes appropriate
graphical changes to the 3-D model of the dental
restoration on screen—sometimes called rendering—
while it calculates and sends the correct amount of
force feedback back to the user through the haptic device. An easy way to think about this type of haptics is
to imagine the forces that you experience against your
hand and arm when pushing open a heavy glass door.

_How touchability speeds dental
restoration design
Labo W. Hoet & Co., a full-service dental laboratory
in Ghent, Belgium, which has been in business for more
than 35 years, provides restorations to dentists in the
Flemish part of Belgium, Brussels and other European
countries. The family-run laboratory employs 24 people and has worked with the SensAble Dental Lab
System for the past year. Initially, the firm purchased
the solution for use with partials, but when its owners
took a closer look at the crown and bridge software,

they decided to expand the use of the SensAble system throughout its everyday workflow. At present,
the laboratory has one person who scans full time
in preparation for designing both partials and crown
and bridge work. Another laboratory technician designs full time.
With this approach,
Labo Hoet is able to
manufacture nearly all
of its crown and bridge
restorations digitally.
For several years, Labo
Hoet owner Jan van
Ooteghem was convinced about utilising
digital solutions in the
crown and bridge division, but had not found
a CAD/CAM system for
partials that actually worked. Labo Hoet had viewed
a number of software packages but none produced
a satisfying result.

Fig. 2
Fig. 2_Digital wax upper with
housing for attachments.

When the laboratory saw partials created using
the SensAble system, it was convinced that it was
possible to use this as the main solution in its partials
division. Initially, the firm thought the haptic device—
which the team calls “the designing pen”—was just
a gimmick to be different. But the technicians soon
realised that the device really made a difference.
Now, technicians can feel in three dimensions and,
for partials, this is a particular benefit since their
curves, multiple thicknesses and individual nature
vary greatly from patient to patient. The haptic device
has actually become “a third hand for the designer”.
Labo Hoet reports that the SensAble system saves
the laboratory at least 30 % of the time it would take
to create a partial manually. In general, the partials
software has made it possible for Labo Hoet to
boost its productivity, making more partials with the
same number of technicians. Furthermore, the final
restorations are much more consistent, accurate and
detailed. With the software’s true 3-D capabilities,
technicians can save time by not having to switch
views all the time or having the software render another section. The haptic device allows the designer to
feel into an area of the restoration—behind the corner
of a restoration—in a way that is better than if they
were only able to see it. Using the SensAble Dental Lab
System, Labo Hoet is able to design partials quickly,
more consistently, and as a combined result the restorations are much easier to finish once cast. Various
conventional steps in the partial design and manufacturing process have disappeared, such as making the
refractory model, resulting in additional time and cost
savings from materials that are no longer used.

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Although they originally used separate systems
for fixed and removable restorations, Labo Hoet’s
team found it was easier to use the same scanner
and the same kind of design software for both partials and crowns and bridges instead of using multiple
systems. Very important in this workflow is 3D Systems’
rapid prototyping printer. The laboratory already used
this before they purchased the SensAble system, but
with designing partials digitally, it became even more
useful. The laboratory enjoys having the printer inhouse, but for smaller laboratories, it is also possible
to outsource the printing. Labo Hoet reports that the
printed resin patterns are very easy to cast with and
the results fit perfectly.
Additionally, the ongoing software upgrades provided by SensAble continue to expedite the design
process, giving the laboratory more time to focus
on design details. “Every software update that we
have received from SensAble is a pleasant surprise,”
van Ooteghem said. “The possibilities of the software
are virtually limitless. I think the most important limitation is our own imagination. Everyday partials,
partials with backing plates, full contour teeth, etc.
—it is all possible. If we look back one year, it is hard
to imagine the manual labour we had to do to make
a partial. Just thinking about that has made it all
worthwhile for us,” he continued.

_SOCA Networks, France
SOCA Networks, located in Bordeaux and Paris,
France, has been using SensAble’s Dental Lab System
for nearly two years to create partials, crowns and
bridges and veneers. This network of dental laboratories is one of France’s largest producers of restorations under contract to the French health-care
system, and produces thousands of restorations per
year. The network also serves as a primary production
centre for the design and production of Remedent
GlamSmile porcelain veneers.

Nicolas Thibert, an executive at SOCA Networks,
reports that the accuracy and quality of SensAbleproduced parts are definitely better than the two
other dental CAD/CAM solutions he had previously
tried out and require less time to create. Because
SOCA has multiple locations, it can leverage talent
in one office for partials or crown and bridge work
and then transfer the SensAble-created files via
FTP over its IT network. In addition to time-savings,
SOCA believes the SensAble system has helped the
firm automate small steps in the production process
to decrease human error. For example, the SensAble
system can automatically store individual dentist
specifications and ensure there is an order number
or a patient number on all parts.
SOCA also uses SensAble-created files for pressables, an increasingly popular type of fixed restoration, and even has a few dentists who upload
intra-oral scans to SOCA’s network, so that designers
can automatically access the file and route it to the
SensAble design stations.

_Dental parts are art—designing them
correctly requires touch
As humans we rely heavily on our sense of touch,
sometimes without even realising it. Additionally,
there will always be individual style and artisanship
in the making of dental restorations. By giving dental
laboratory technicians a touch-enabled CAD/CAM
solution that allows them to maintain design control and create restorations the way they know they
need to be made—together with voxel technology
for speed and design flexibility—SensAble’s system
helps European dental laboratories to transition to
a digital workflow easily; increase productivity, accuracy and consistency; and capture new business all
at the same time._

_about the author
While 70 % of its business comes from France—
and the bulk of that from government-reimbursed
restorations—SOCA produces crown and bridge work,
partials and veneers for clients across four continents,
including work for Europe, the US and Canada, Australia, the UAE, Russia and Brazil. SOCA Networks operates production facilities in both France and Vietnam.
SOCA initially purchased SensAble’s system to
accommodate its high-volume veneers business for
Remedent, but gradually began using the software
for partials in late 2009 and for manufacturing crowns
and bridges in February 2010. Using SensAble’s system,
SOCA designs approximately 100 partials, about 100
to 120 crown and bridge restorations and between
200 to 300 veneers per day.

40 I CAD/CAM
2_ 2010

CAD/CAM

Bob Steingart, President
of SensAble Dental Products,
has over 25 years of
experience in successfully
transforming innovative
technologies into commercial
solutions. He has held
executive positions in business
development, product management and marketing
at Avid Technologies, EMC, Lotus Development,
Sitara Networks and Kurzweil Applied Intelligence.
He holds an MBA from Harvard Business School,
and a BSEE and MSEE from MIT. He can be
contacted at bsteingart@sensable.com or by
contacting SensAble at www.sensabledental.com.

[41] => CAD0210_01_Titel

CAD0210_41_WhitePeaks 11.11.10 10:56 Seite 1

industry news _ White Peaks

White Peaks
Dental Systems
_White Peaks Dental Systems, a German
manufacturer, specialising in the production
of dental zirconium blanks, uses raw materials
from Tosoh (Japan) exclusively, a world leader
in dental zirconium technology. White Peaks’
blanks are certified to the highest standards
(CE, FDA and DIN ISO 13485). The Copran ZR
zirconium blanks are compatible with almost
all CAD/CAM milling and manual systems.
A large variety of blanks of high strengths and
translucency, as well as pre-coloured blanks in
shades A1 and A3 leave nothing to be desired.
White Peaks offers a variety of related products, such as zirconium colouring liquids in
16 classic shades, intensive shades for full
contour shading, Cr-Co, titanium, CE PMMA
blanks, PMMA and wax blanks for casting tech-

niques, extremely long-lasting milling burs, and
scan spray.
Calidia 4x and Calidia 5x, the new 4- and
5-axis CAD/CAM milling systems, are specially
designed for use in dental practices. With a
weight of approximately 650 kg, the systems are
sufficiently small to fit into the average laboratory, but sufficiently heavy to perform at high
milling speed. They offer the highest accuracy
and are capable of milling zirconium, Cr-Co,
titanium, lithium disilicate and feldspathic ceramic blocks. The open systems, like all materials
and components offered by White Peaks, are
obligation and royalty free.
If you already own a CAD/CAM system, check
out the new CAM software White CAM 3.0—your
way to independence. The software enables free
choice of zirconium and other materials for your
system. There is no need to touch the running
system; simply install the software parallel to

your system and use it when required. Owing to
the new inter-connection design, up to 50 units
can be placed in one blank.
For additional information on our furnaces,
scanners, equipment and materials, please visit
www.white-peaks-dental.com._

_contact

CAD/CAM

White Peaks Dental Systems GmbH & Co. KG
Langeheide 9
45239 Essen
Germany
Tel.: +49 281 206458-0
Fax: +49 281 206458-13
info@white-peaks-dental.com
www.white-peaks-dental.com

CAD/CAM
2_ 2010

I 41

[42] => CAD0210_01_Titel

CAD0210_42_3DCongress 11.11.10 10:56 Seite 1

I meetings _ 3-D Dental Imaging

Congress on 3-D dentistry again
exceeds goals in education
Authors_ Imaging Sciences International & Gendex Dental Systems, USA

Fig. 1_Exhibition hall.
Fig. 2_General session audience.
Fig. 3_Panel discussion on ROI with
Dr John Graham, Dr Steven
Guttenberg and Dr Walter Chitwood.

_The 4th International Congress on 3-D Dental
Imaging, sponsored by Imaging Sciences International
and Gendex Dental Systems, held this year in La Jolla,
California, offered attendees and the dental media an
ideal setting in which to learn about 3-D technology.
Experienced dental clinicians and professionals shared
their considerable knowledge of 3-D’s past, use today,
and development in the future. Attendees were provided with a wealth of information from speakers
and vendors to assist them in their practical application
of the quickly expanding technology.
The two-day congress utilised lectures, panel discussions, breakout sessions, and live demonstrations to al-

Fig. 2

Fig. 1

low for full participation and interaction amongst those
gathered at the event. “There was definitely a myriad
of course topics here, including detailed clinical information,” commented attendee Dr Christopher Phelps
of Charlotte, USA. “And for those of us who already have
the technology, it was helpful to have courses that focus
on non-clinical aspects, as well, such as marketing and
both Medical and Dental Insurance reimbursement.”

_contact
Imaging Sciences
International
1910 North Penn Road
Hatfield, PA 19440
USA
Tel.: +1 215 997 5666
Fax: +1 215 997 5665
info@i-cat3d.com
www.i-cat3d.com

42 I CAD/CAM
2_ 2010

A new speaker at this year’s congress, Dr John Graham focused on clinical findings not apparent using
2-D radiology and keeping pace when it comes to
dentistry’s evolving standard of care involving CBCT.
“The dentists that attended the congress were looking
to learn more about a technology that can help them
advance patient care. I believe that they came away with
a greater understanding of this and more,” he remarked.
Returning speaker and moderator, Dr Scott D.
Ganz presented on the new sense of confidence to
diagnose, plan, communicate and execute dental
implant reconstruction and related procedures, such
as bone grafting, that cone-beam data offers to

clinicians. As Dr Ganz states, “It’s not the scan, it’s
the plan!”
Dr Sharnell Muir spoke on the use of CBCT in conjunction with CAD/CAM applications which, in part,
covered the process of in-office milling of surgical
guides and restorations. “Dr Muir’s presentation gets
right to the heart of how dynamic 3-D technology is—
the ability to plan restorations and implants and make
use of CAD/CAM applications to place and restore
them is how patient-driven dentistry is accomplished,”
said Mark Hillebrandt, Director of Product Management for ISI and Gendex. “She very effectively illustrated the power of CBCT–CAD/CAM integration.”

Fig. 3

Also in attendance, Henrik Roos, President of Imaging Sciences and Gendex, noted that the attendees
were very eager to learn about the benefits of 3-D technology. “We are proud to sponsor this comprehensive
educational event that offers dentists the information they seek—how to better treat their patients and
how to expand services in their practices,” he stated.
The companies also announced that the next 5th International Congress on 3-D Dental Imaging will be held
in Dallas, USA, at the Gaylord Texan Resort and Convention Center from 4 to 5 November 2011.
Imaging Sciences International and Gendex’s dedication to education is exemplified in their collaboration in delivering quality courses on 3-D imaging.
Events include webinars, interactive regional meetings
and local training sessions provided by knowledgeable
dental professionals. Visit www.i-CAT3D.com for a
complete course listing and registration information._
Editorial note: Selected presentations were recorded and are
offered online, as C.E. accredited webinars. For programme
details and registration, please see www.dtstudyclub.com.

[43] => CAD0210_01_Titel

CAD0210_43_Sirona 11.11.10 11:00 Seite 1

I

meetings _ CEREC 25

th

CEREC 25 Anniversary Celebration
—A milestone event in dentistry
Author_ Sirona Dental Systems, Inc., USA
_Sirona Dental Systems’ CEREC 25th Anniversary
Celebration (CEREC 25), which was held from 26 to
28 August 2010, may be over, but it will not be soon
forgotten, according to the majority of the more
than 3,000 attendees and more than a dozen keynote speakers, who participated in the milestone
event, celebrating the 25th anniversary of the CEREC
CAD/CAM system.
Several lectures offered information on a number
of Sirona advancements. Dr Jay Reznick, a progressive
oral surgeon, whose lecture was entitled CEREC–
GALILEOS integration: A surgeon’s perspective, explained why the integration of CEREC CAD/CAM
information into GALILEOS Implant Planning Software
enables dental implant planning and surgical techniques that are far superior to traditional 2-D imaging and ‘freehand’ placement of dental implants. The
result is a less-invasive surgical procedure, awareness
of anatomical challenges ahead of time, increased
precision of implant placement, reduced surgical time
and enhanced patient recovery.
In his lecture CEREC Connect and digital impressioning, Dr Michael Skramstad illustrated using the
CEREC AC and CEREC Connect software to advantage
and combining CEREC chairside techniques with
CEREC Connect to maximise the use of digital technology and communication with the laboratory, for
the fabrication of everything from simple single units
and implants to complex anterior cases.
Sirona’s Internet-based service that caters exclusively for Sirona inLab and inEos Blue users is now
under the management of laboratory industry veteran
Bob Vasile. The range of materials and indications was
expanded to include full-contour restorations and
veneers made from Ivoclar Vivadent’s IPS e.max CAD
lithium disilicate and VITA’s new RealLife material.
Dental and dental laboratory professionals networked with dental industry icons who conducted
illuminating continuing education (CE) programmes
that included clinical techniques, hands-on workshops, and dynamic lectures on practice management,
marketing and hygiene. One of the many session highlights included Prof Werner Mörmann’s lecture The
Evolution of the CEREC System. Who better to give such

a presentation but the original developer of the CEREC
system? Prof Mörmann explained CEREC’s humble beginnings as a small, mobile CAD/CAM unit integrating
a computer with a monitor and keyboard, trackball,
foot pedal, and an optoelectronic 3-D mouth-scanning
camera, and its evolution into the CEREC AC unit with
Bluecam and CEREC Connect, which now represents
the industry’s most advanced CAD/CAM technology
for the dentist and dental technician.
The Introduction of the Sirona Speakers’ Academy
was another noteworthy highlight. This speakertraining programme provides both new and experienced speakers with coaching and strategies for
delivering more distinctive and compelling presentations. Graduates of the Speakers’ Academy become
preferred speakers within the Sirona community and
gain access to the latest information regarding trends,
market data, and product introductions within the
category of digital restorative dentistry and imaging,
thereby ensuring their presentation content is as
accurate and current as possible. “The CEREC 25th
Anniversary Celebration was the launch for many
new programmes and services because we wanted
our attendees to be on the inside track throughout
this exciting and important event,” explained Michael
Augins, President of Sirona USA.
CEREC 25 also featured three days of non-stop
activities, in which participants could earn up to 18 CE
credits while enjoying CAD/CAM-focused workshops,
premium entertainment, and plenty of memorable
celebrations at the luxurious accommodation provided by Caesar’s Palace. Sirona and guests closed
CEREC 25 in true Vegas style at the sophisticated
WHITE PARTY, which took place at the popular PURE
Nightclub. Most attendees agreed that the WHITE
PARTY was the hottest dental event of the decade.
“This may have been the most memorable and
exciting three days of my career,” exclaimed Michael
Augins. “The high level of continuing education programmes, networking opportunities and entertainment activity was a worthy tribute to the technology
that changed the face of dentistry. This milestone
event not only celebrated the first 25 years of CEREC
CAD/CAM, it kicked off the next 25 years of Sirona
innovation.”_

Prof Werner Mörmann,
inventor of CEREC

_contact
Sirona Dental Systems, Inc.
3030 47th Avenue, Suite 500
Long Island City, NY 11101
USA
Tel.: +1 718 482 2011
Fax: +1 718 937 5962
contact@sirona.com
www.sirona.com

CAD/CAM
2_ 2010

I 43

[44] => CAD0210_01_Titel

CAD0210_44_D4D 11.11.10 11:01 Seite 1

I meetings _ CADapalooza 2010

Touchdown for digital dentistry:
CADapalooza ’10 scores!
Author_ D4D Technologies LLC, USA
_CADapalooza ’10 certainly lived up to its reputation and delivered an exceptional programme this
summer in Dallas, Texas! Hundreds of dental professionals attended the three-day event held at the Gaylord Texan Resort and Convention Center, Cowboys
Stadium and D4D Technologies’ world headquarters
to see the future of dentistry firsthand.
The event began with a Millin’ Around welcome reception in the scenic Main Atrium at the Gaylord Texan
Resort, where registered attendees, manufacturers
and sponsors gathered for an evening of camaraderie
and celebration. On Friday, attendees were shuttled to
the new, US$1.4 bn Cowboys Stadium for a full-day
lecture programme, covering such topics as current
state-of-the-art systems and materials, and the incredible capabilities of leading edge integrated dental
technologies that are under development. Special
video messages from profession leaders Dr Gordon
Christensen and Dr Pete Dawson were played for the
crowd on the HD screens at the Main Club Level, where
attendees were also treated to a live patient demonstration by CAD/CAMbassador Sherri White, featuring
E4D’s DentaLogic software’s newest features.
Other notable presenters included Dr Paul Child,
Jr., CEO of CR Foundation, sharing his perspective
on CAD/CAM systems currently on the market; Dr
Colin Norman of 3M ESPE; Dr Santine Anderson of
THE DENTAL ADVISOR; Dr Don Deems, The Dentist’s
Coach; Lee Culp; Dr Curtis Jansen and D4D Software
Engineer Rakesh Lal, introducing the revolutionary
E4D Compass software; Dr George Tysowsky of
Ivoclar Vivadent; as well as Dr David Reznik and Rick
Willeford, providing a fresh perspective of the business side of dentistry.
Midway through the day, lunch was served and attendees were invited to step in front of an HD camera
to have their video image projected onto the massive
55-meter JumboTron. Photos were captured as souvenirs to commemorate their experience on the world’s
largest HD screen. After the break, the D4D Marketing
team prepared a series of amusing viral videos that
the crowd could watch on either the JumboTron or
back at the Club Level. Following the laughter, lectures
continued as the E4D DentaLogic and E4D Compass
software demonstrations remained on the JumboTron.

44 I CAD/CAM
2_ 2010

The programme closed that afternoon and all
participants were led up seven storeys for an evening
reception at the Dr Pepper Star Bar overlooking
the football field. Guests were greeted with hors
d’ oeuvres and cocktails as they arrived, and all had
the opportunity to tour the 3,000,000 sq. ft. stadium,
including a behind-the-scenes look at the Cowboys’
and Cheerleaders’ locker rooms, as well as a freefor-all run of the field itself. Many took photos in
the Cowboys star at the centre of the field, while
others took the opportunity to go all the way and run
for a touchdown!
On the final day, all participants participated in the
Build-a-Crown and Advanced Design workshops at
D4D Technologies’ world headquarters in the Dallas
suburb of Richardson, Texas. Bringing models of their
own, they attended workshops at pre-arranged times
to sit with CAD/CAMbassadors to see their own crown
being scanned, designed and then milled right before
their eyes in a matter of minutes! Ivoclar Vivadent,
Premier Dental and 3M ESPE’s technical specialists
were on hand to ensure each crown was left with
proper aesthetic control—with stain and glaze, characterisation, crystallisation and polishing centres.
“The support of our partners is unparalleled, having Henry Schein Dental, Ivoclar Vivadent, Premier
Dental, Imaging Sciences International and 3M ESPE
all pulling in the same direction has made this a
tremendous success and paved the way for the future
of digital dentistry,” said Dr Gary Severance, VicePresident of Marketing and Clinical Affairs at D4D
Technologies. Presenters were also on-hand at the
Advanced Design workshops to highlight upcoming
software releases and revealed the Top 10 Steps to
Restoration Design, taking their restorations from
ordinary to extraordinary, led by Lee Culp. Over
200 restorations were completed and given to the
participants and every attendee was able to Experience the Experience of what E4D can do for them,
their practice and especially their patients.
If you attended this year’s event, we sincerely thank
you for your participation and we hope you found
the experience as rewarding as we did. Be sure not to
miss next year’s event, as it promises to exceed even
the greatest expectations for the future of dentistry!_

[45] => CAD0210_01_Titel

Anschnitt DIN A4

08.03.2010

9:16 Uhr

Seite 1

[46] => CAD0210_01_Titel

CAD0210_46_CAPP 11.11.10 11:02 Seite 1

I meetings _ CAD/CAM & CDIC

The new challenge in dentistry
Author_ Dr Dobrina Mollova, Dubai

´

_For the fourth time, Dubai hosted the CAD/
CAM & Computerized Dentistry International Conference organised by the Emirates Dental Association
and the Center for Advanced Professional Practices.
The annual conference was a great success, achieving record attendance and further establishing its reputation as the industry’s
leading CAD/CAM scientific conference.
Dr Amin Hussain Al Amiri, CEO for Medical Practice and Licence and Chairperson
of the UAE Supreme National Blood Transfusion Committee, and Dr Afaf Sayed
Ja’afar, Acting Director of the Continuing
Medical Education (CME) Department,
opened the conference and expressed
their gratitude for the support of the
development of new technologies in dentistry and their appreciation of the excellent opportunity this conference offered
with regard to CME in the region.
With 480 participants from 17 different countries and with different specialties, the attendance was exceptional.
The two-day conference was chaired by
Dr Munir Silwadi, scientific coordinator,
and Dr Dina Debaybo, Nicolas & Asp University College of Postgraduate Dentistry.
The plenary presentations by internationally renowned speakers from Germany,
France, Lebanon, the UK, Egypt and the
KSA presented the latest in the field.
A wide range of topics was covered, for
example tooth preparation for CAD/CAM
technology, post, core and final restorations, proper cementation and objectives,
as well as computerised implantology and
orthodontics. Dentists and dental techni-

46 I CAD/CAM
2_ 2010

cians from both governmental and private sectors
enjoyed the high level of the scientific programme.
Guest speaker Dr Khaled Abouseada from Egypt
commented: “Thank you not only for inviting me
as a speaker to this conference but thank you for
your great efforts, which were amazing and the first
reason for the success of this conference.”
Guests from the Moscow State University and the
University of Belgrade gave poster presentations on
the use of CAD/CAM for different treatments.
This year, a new feature, a two-hour open discussion forum with the theme Zirconia—The Truth,
was introduced to the conference programme.
International experts used the opportunity to present their points of view on the topic and agreed that
Zirconias are NOT all the same. The panel members
—researchers, experienced clinicians, top industry
players and academics from universities in Sharjah,
Ajman, Boston, Moscow and Belgrade—offered a
substantial amount of information and enabled
attendees to discuss the topic and share their experiences and ideas.
Leading manufacturers, like Sirona, 3M ESPE,
Ivoclar Vivadent, DeguDent, VITA, Amann Girrbach,
Hint-ELs and GSK, generously sponsored the event
to contribute to the development of these advanced
technologies in the discipline. They exhibited their
latest products and technologies, and reported an
all-time high in terms of participant interest. Additionally, the Breakfast with the Sponsors event, which
was held every morning, offered an excellent networking opportunity. This exclusive access also offered sponsors the opportunity to share experiences
with colleagues, make new contacts and strengthen
existing relationships. Many sponsors expressed their
appreciation that this event had been arranged._

[47] => CAD0210_01_Titel

Unbenannt-1 1

02.11.2010 10:00:48 Uhr

[48] => CAD0210_01_Titel

CAD0210_48_Events 16.11.10 15:34 Seite 1

I meetings _ events

International Events
2010

International Dental Show
22–26 March 2011

Greater New York Dental Meeting

Cologne, Germany

26 November–1 December 2010

ids@koelnmesse.de

New York, NY, USA

www.ids-cologne.de

info@gnydm.com
www.gnydm.org

AAE Annual Session
13–16 April 2011
San Antonio, TX, USA

2011

info@aae.org
www.aae.org

IADR General Session & Exhibition
16–19 March 2011

ESE Congress

San Diego, CA, USA

14–17 September 2011

sherren@iadr.org

Rome, Italy

www.iadr.org

info@eserome2011.com
www.eserome2011.com
FDI Annual World Dental Congress
14–17 September 2011
Mexico City, Mexico
congress@fdiworldental.org
www.fdiworldental.org
IFED World Congress
21–24 September 2011
Rio de Janeiro, Brazil
david@team57.co.uk
www.ifed.org
International Congress
on 3-D Dental Imaging
4 & 5 November 2011
Dallas, TX, USA
nicole.serago@imagingsciences.com
www.i-cat3d.com

48 I CAD/CAM
2_ 2010

[49] => CAD0210_01_Titel

CAD0210_49_Submission_CAD0110_49_Submission 11.11.10 11:03 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
by using a new number for each image. If it is imperative that
certain images are grouped together, then use lowercase letters
to designate these in a group (for example, 2a, 2b, 2c).
Please place image references in your article wherever they
are appropriate, whether in the middle or at the end of a sentence.
If you do not directly refer to the image, place the reference
at the end of the sentence to which it relates enclosed within
brackets and before the period.
In addition, please note:

In addition, images must not be embedded into the MS Word
document. All images must be submitted separately, and details
about such submission follow below under image requirements.
Text length
Article lengths can vary greatly—from 1,500 to 5,500 words—
depending on the subject matter. Our approach is that if you
need more or less words to do the topic justice, then please make
the article as long or as short as necessary.
We can run an unusually long article in multiple parts, but this
usually entails a topic for which each part can stand alone because it contains so much information.
In short, we do not want to limit you in terms of article length,
so please use the word count above as a general guideline and if
you have specific questions, please do not hesitate to contact us.
Text formatting
We also ask that you forego any special formatting beyond the
use of italics and boldface. If you would like to emphasise certain
words within the text, please only use italics (do not use underlining or a larger font size). Boldface is reserved for article headers.
Please do not use underlining.
Please use single spacing and make sure that the text is left justified. Please do not centre text on the page. Do not indent paragraphs, rather place a blank line between paragraphs. Please do
not add tab stops.

_We require images in TIF or JPEG format.
_These images must be no smaller than 6 x 6 cm in size at 300 DPI.
_These image files must be no smaller than 80 KB in size (or they
will print the size of a postage stamp!).
Larger image files are always better, and those approximately
the size of 1 MB are best. Thus, do not size large image files down
to meet our requirements but send us the largest files available.
(The larger the starting image is in terms of bytes, the more leeway the designer has for resizing the image in order to fill up more
space should there be room available.)
Also, please remember that images must not be embedded into
the body of the article submitted. Images must be submitted
separately to the textual submission.
You may submit images via e-mail, via our FTP server or post
a CD containing your images directly to us (please contact us
for the mailing address, as this will depend upon the country from
which you will be mailing).
Please also send us a head shot of yourself that is in accordance
with the requirements stated above so that it can be printed with
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An abstract of your article is not required.

Should you require a special layout, please let the word processing
programme you are using help you do this formatting automatically. Similarly, should you need to make a list, or add footnotes
or endnotes, please let the word processing programme do it for
you automatically. There are menus in every programme that will
enable you to do so. The fact is that no matter how carefully done,
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Author or contact information
The author’s contact information and a head shot of the author
are included at the end of every article. Please note the exact
information you would like to appear in this section and format it according to the requirements stated above. A short
biographical sketch may precede the contact information
if you provide us with the necessary information (60 words
or less).

Any formatting contrary to stated above will require us to remove
such formatting before layout, which is very time-consuming.
Please consider this when formatting your document.

Questions?
Claudia Salwiczek (Managing Editor)
c.salwiczek@dental-tribune.com

CAD/CAM
2_ 2010

I 49

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CAD0210_50_Impressum 11.11.10 11:04 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
Western Europe
Antje Kahnt
a.kahnt@dental-tribune.com

Managing Editor
Claudia Salwiczek
c.salwiczek@dental-tribune.com

Eastern Europe
Grzegorz Rosiak
g.rosiak@dental-tribune.com

Product Manager
Bernhard Moldenhauer
b.moldenhauer@dental-tribune.com

Asia Pacific
Peter Witteczek
p.witteczek@dental-tribune.com

Executive Producer
Gernot Meyer
g.meyer@dental-tribune.com

The Americas
Jan M. Agostaro
j.agostaro@dental-tribune.com

Designer
Franziska Dachsel
f.dachsel@dental-tribune.com

International Offices
Europe
Dental Tribune International GmbH
Contact: Nadine Parczyk
Holbeinstr. 29, 04229 Leipzig, Germany
Tel.: +49 341 4 84 74 302
Fax: +49 341 4 84 74 173

Copy Editors
Sabrina Raaff
Hans Motschmann
International Administration
Marketing & Sales
Peter Witteczek
p.witteczek@dental-tribune.com
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
North Point, Hong Kong
Tel.: +852 3113 6177
Fax: +852 3113 6199
The Americas
Dental Tribune America, LLC
Contact: Anna Wlodarczyk
116 West 23rd Street, Suite 500
NY 10011, New York, USA
Tel.: +1 212 244 7181
Fax: +1 212 244 7185

Editorial Board
Prof Albert Mehl, Switzerland
Prof Gerwin Arnetzl, Austria
Dr Stefan Holst, Germany
Hans Geiselhöringer, Germany
Dr Ansgar Cheng, Singapore

Printed by
Messedruck Leipzig GmbH
An der Hebemärchte 6
04316 Leipzig, Germany

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 2010 with two 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
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50 I CAD/CAM
2_ 2010

[51] => CAD0210_01_Titel

CADCAM_Abo_A4_Implants_Abo_A4 16.11.10 11:07 Seite 1

CAD/CAM
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[52] => CAD0210_01_Titel

Anzeige_A4_Tizian_CAD/CAM

12.10.2010

21:00 Uhr

Seite 1

Move on to a promising future
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Tizian CAD/CAM –
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Milling at the push of a button

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Technology means: Computer-aided scanning with
Tizian™ Scan, constructing with Tizian™ Creativ RT
design design software and milling of zirconium dioxide
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iles

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[cover] => CAD/CAM international

[toc] => Array ( [0] => Array ( [title] => Cover [page] => 01 ) [1] => Array ( [title] => Editorial [page] => 03 ) [2] => Array ( [title] => Case acceptance in complex-care dentistry [page] => 06 ) [3] => Array ( [title] => Use of an X-ray phantom in dental 3-D diagnostics in digital volume tomographs [page] => 10 ) [4] => Array ( [title] => The treatment of toothless jaws—A case for CAD/CAM [page] => 14 ) [5] => Array ( [title] => Three-unit - full-contour ceramic bridge in one sitting [page] => 18 ) [6] => Array ( [title] => Real-virtual modelling of CEREC temporary crowns: A new approach [page] => 20 ) [7] => Array ( [title] => An interview with Dr Steven Guttenberg & Dr John Flucke [page] => 22 ) [8] => Array ( [title] => CBCT applications in dental practice: A literature review [page] => 24 ) [9] => Array ( [title] => Combination of digital and analogue techniques [page] => 30 ) [10] => Array ( [title] => Step-by-step restoration with Tizian CAD/CAM [page] => 34 ) [11] => Array ( [title] => Haptic input improves digital dental restoration design [page] => 38 ) [12] => Array ( [title] => White Peaks Dental Systems [page] => 41 ) [13] => Array ( [title] => Meetings [page] => 42 ) [14] => Array ( [title] => International Events [page] => 48 ) [15] => Array ( [title] => Submission Guidelines [page] => 49 ) [16] => Array ( [title] => Imprint [page] => 50 ) ) [toc_html] =>

Table of contents

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