CAD/CAM international No. 1, 2018
Cover
/ Editorial by Dr Scott D. Ganz
/ Content
/ 2018—Changing the way we communicate
/ Immediate restoration in the digital workflow
/ Chairside CAD/CAM immediate restorations
/ From digital planning to the mock-up and final restoration
/ Digital workflow: From planning to restoration
/ Immediate full-arch restoration in the maxilla
/ Cone beam supplement
/ “Good design will pay off”
/ European Parliament adopts new medical device regulations
/ US dental prosthetic market set to grow with digitalisation
/ Non-original abutments are “a lottery that you cannot win” - Interview with Prof. Matthias Karl
/ “A truly open solution” - Interview with Sigrid Smitt Goldman, CEO and Executive
Chairman of the 3DISC group
/ International Events
/ Submission guidelines
/ International imprint
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[1] =>
issn 1616-7390 • Vol. 9 • Issue 1/2018
1/18
CAD/CAM
international magazine of digital dentistry
research
Immediate restoration
in the digital workflow
case report
From digital planning
to the mock-up and final restoration
cone beam supplement
Dynamic navigation
in fully edentulous maxilla
[2] =>
© MIS Implants Technologies Ltd. All rights reserved.
Open Frame Design
Access for Irrigation
and Anesthesia
Single Handed Procedure
MAKE IT SIMPLE. WE KNOW HOW!
The innovative design of the MIS MGUIDE and its surgical kits
simplifies digital dentistry. The use of CAD/CAM, allows for a
prosthetically driven, safe and accurate procedure. To learn more
about the MIS MGUIDE, go to www.mis-implants.com
®
P A R T
O F
T H E
M C E N T E R
G R O U P
[3] =>
editorial
|
Dr Scott D. Ganz
Editor-in-Chief
To merge or not to merge?
Is that the question?
Dear Readers,
The art and science of dentistry has dramatically
changed with the advent of digital tools that are currently
available for the diagnostic, treatment planning and restorative phases for each patient that we are privileged to
treat. While clinicians worldwide predominantly continue
to practise as “analogue” dentists, more and more have
adopted these technological advances as they understand the benefits of the new digital workflow.
Of course, today in 2018, it is difficult to remain totally within the digital workflow without having some analogue component either in the operatory or in the hands
of the dental laboratory technician. Perhaps the workflow
starts with the first patient visit, where we can capture
the initial clinical presentation with a video or still picture
with either a sophisticated camera or our smartphone—
all digital. If the patient will require dental implants, crown
and bridgework, or porcelain laminate veneers, it is always necessary and desired to capture the pre-existing
intraoral condition with either an analogue impression or
intraoral digital scan. However, a physical impression or
poured stone cast will require conversion to a digital file.
This process has become the foundation of our digital
universe, via the standard triangulation language or STL
file. What happens next is crucial to the ultimate success
of any case: the diagnosis and treatment planning phase
through a merging of technology, combining the skill of
both the clinician and the dental laboratory technician. It
is the correlation of the different data sets with sophisticated software applications that provides the foundation
for success.
Currently, we can create an analogue or digital wax-up
to analyse and assess and compare the before to the desired after before ever touching the patient with a drill or
a scalpel. In order to accomplish this task, we must have
the technical knowledge of the software applications that
are available today for both the clinician and the laboratory
technician. Whether creating a CAD/CAM restoration for
a natural tooth preparation or a surgical guide for implant
placement, the workflow has forever changed through our
digital tools. Therefore, the question of whether to merge
or not to merge may be completely transparent to many
clinicians, but an essential and necessary part of the digital workflow equation today. It is the goal of this publication to expose our readership to state-of-the-art concepts and applications to enhance the everyday practice
of dentistry. Happy New Year to all, and enjoy the articles
contributed by expert clinicians from around the globe.
Dr Scott D. Ganz
Editor-in-Chief
CAD/CAM
1 2018
03
[4] =>
| content
editorial
To merge or not to merge? Is that the question?
03
Dr Scott D. Ganz
opinion
2018—Changing the way we communicate
06
Chris Barrow
page 22
research
Immediate restoration in the digital workflow
08
Drs José Eduardo Maté Sánchez de Val & José Luis Calvo Guirado
case report
Chairside CAD/CAM immediate restorations
16
Drs Feng Liu & Xing Liu
From digital planning to the mock-up and final restoration
22
Dr Cyril Gaillard & Jérôme Bellamy
page 26
industry report
Digital workflow: From planning to restoration
26
Drs Jan Kielhorn, Siegfried Hoelzer & Björn Roland
Immediate full-arch restoration in the maxilla
32
Drs Massimo Frosecchi, Eugenio Longo & Alessandro Certini
cone beam supplement
page 44
“Advanced knowledge and a supporting community via the Internet”
38
Dynamic navigation in fully edentulous maxilla
40
Prof. Dr Hakan Uysal & Dr Noyan Başal
feature
“Good design will pay off”
44
business
Cover image courtesy of MarinaGrigorivna/
www.shutterstock.com
issn 1616-7390 • Vol. 9 • Issue 1/2018
1/18
CAD/CAM
international magazine of digital dentistry
European Parliament adopts new medical device regulations
48
US dental prosthetic market set to grow with digitalisation
50
Salma Mashkoor & Jeffrey Wong
interview
Non-original abutments are “a lottery that you cannot win”
52
“A truly open solution”
54
meetings
International Events
56
about the publisher
research
Immediate restoration
in the digital workflow
case report
From digital planning
to the mock-up and final restoration
cone beam supplement
Dynamic navigation
in fully edentulous maxilla
04 CAD/CAM
1 2018
submission guidelines
57
international imprint
58
[5] =>
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[6] =>
| opinion
2018—Changing the way
we communicate
Chris Barrow, UK
It is always simultaneously tempting and dangerous
to make predictions about the future of dentistry. A recent personal review of the articles I have written over
the years revealed that I seem to get things right half
the time. The challenge is figuring out which half! So,
looking at 2018, what does the landscape look like?
I am conscious that you, dear readers, are an international community and so I will resist the temptation
to have a good old-fashioned moan about post-Brexit
Britain moving into the Dark Ages while our politicians
attempt to leave the EU without leaving it. Or, for that
matter, riffs and rants about dictatorial pothead leaders
playing dice with our futures to further their own agendas, whether that is in politics, media or sport.
The Internet of things
The smartphone has changed the way we live
(Apple-manufactured or otherwise), and the most dominant economic forces on earth are no longer nation
economies; they are Google, Microsoft, Amazon, YouTube and Facebook (and let us not forget WeChat—
the largest social media platform in China). The figures
for the combined revenues of and cash mountains
owned by these organisations are mind-boggling, and
the way in which those financial reserves are reinvested will have the biggest impact on the world we
live in by Christmas this year.
I recently returned from a dental lecture tour in India, whose 1.2 billion population has overtaken the
US to become the largest nation of Facebook users
in the world, with around 250 million Indians checking
into their profiles every day. It is hardly surprising that
my Delhi hotel was populated by fresh-faced young
Americans sporting Facebook employee T-shirts, no
doubt building a commercial base to accommodate
the demands of this new and expanding audience.
Globally, figures for e-commerce over Christmas
2017 were a record, and as we learn to purchase every conceivable commodity online, the high street
trembles, looking at those real estate and staff costs
under the watchful eye of their investors and accountants.
There is more to it than just e-commerce though.
We are learning to live online, reading, watching, listening, reviewing, commenting, liking and connecting
to an extent that our parents could never have imagined. Buying more and more.
© a-image/Shutterstock.com
Actually, what I want to talk about is us, you and
me, ordinary folk going about our business, pursuing
careers, raising families and trying our best to make
sense of the world around us. What I want to address
is how I think our lives are going to change in the next
12 months, as dental practice owners, managers and
team members, but also as members of the public.
06 CAD/CAM
1 2018
India is registering 40 million new smartphones every 12 weeks and is representative of a connective
revolution that is gender, age, religion and socio-economically egalitarian—everyone is getting online.
With over 75 per cent of website visits to my clients’ dental sites now taking place via smartphones,
how your website looks on a desktop no longer mat-
[7] =>
opinion
ters. How it looks and performs on a smartphone is
what counts.
Dentistry is going to have to learn how to communicate with patients online to a greater extent than ever
before. I am already seeing tech start-ups looking at
the dental space and thinking about how best to keep
patients informed of their oral health and how to make
their patient experience seamless.
Wearable technology
This brings me to how that communication will take
place (between patient and dentist and vice versa) as
the year unfolds. The start-ups I mentioned are developing electric toothbrushes that send data back to an
application that monitors not just brushing technique
but also simple issues around patient health. Data is
analysed and then sent back to the patient’s smartphone to provide dental health education.
Notwithstanding the issues around the confidentiality of that data and its storage, we are seeing the beginning of wearable tech playing a major role in healthcare generally. E-zines and blogs like those published
by Dr Bertalan Meskó (the Medical Futurist) show that
progress is exponential. Cue the watch that can feed
back dental health information, allowing both patient
and dentist to predict problems before they occur.
Getting attention
The science and technology are compelling for early
adopters and frightening for laggards. Any debate as
to the future of digital dentistry has long since left the
late adopters behind, and I am seeing many of my clients racing to keep up with change. However, independent dentistry is a business whose purpose is to
solve patients’ problems, but whose objective has to
be to make an ethical profit, so we cannot ever afford
to be distracted from the focus on attracting the right
type of new patient and from charging the right price
for what we do. These are the challenges that occupy
the majority of my time with clients, and the changes
I have referenced in the first part of this article have to
be embraced in order to survive and prosper in business.
Experts estimate that, as consumers, we are bombarded by up to 5,000 advertising impressions per
day, so how do dentists make themselves heard
among this noise? In my experience, there is little point
in trying to shout loudest by spending money on advertising. The average e-commerce company in the
UK now has to invest about £30,000 per month to be
heard in the digital marketplace, so a dentist investing £500 per month in search engine optimisation or
|
Google AdWords is unlikely to succeed. In any event,
digital advertising in dentistry often attracts price
shoppers and bargain-hunters.
The good news is that social media channels allow us to generate internal digital patient referrals
in numbers that could never be foreseen in the old
days of word of mouth. Thus, a carefully planned and
well-executed social media marketing plan is now an
essential component of every practice’s overall goals
for new patient generation. Facebook, Instagram and
YouTube are the marketing domains of 2018.
Prices
The interesting irony here is that digital dentistry,
once we have moved from the innovation stage of the
adoption cycle, through early adopters to the late majority, will actually have the effect of reducing the cost
of providing dental healthcare and treatment. I have
clients right now who innovated in digital dentistry and
are seeing a consequent improvement in their bottom line profit as costs of sales reduce. That may not
sound like great news for laboratory and materials
suppliers, but that is the inevitable consequence of
technological progress.
I am also realistic enough to agree that little of that
cost-saving is being passed on to the patients at
the moment. That is because we are still in the early
stages of the digital adoption cycle, and the pressure
on prices will not occur until much later in that cycle. It
is time, indeed, for the innovators to make hay. Prices
will stay firm in 2018; costs can reduce.
An interesting year ahead
2018 will see the continued acceleration of the impact that digital communication and commerce will
have on our lives. The dental practice of the future will
fully embrace not only digital dentistry but also the
way in which they connect with their patients online.
The smartphone will be the place that happens, until
smartphones are replaced by the next generation of
wearable devices.
contact
Chris Barrow is the founder of the
Coach Barrow consultancy practice.
An active consultant, a trainer and a
coach to the UK dental profession, he
regularly contributes to the dental press
and social media and elsewhere online.
Barrow can be contacted at
coachbarrow@me.com.
CAD/CAM
1 2018
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| research
Immediate restoration
in the digital workflow
Drs José Eduardo Maté Sánchez de Val & José Luis Calvo Guirado, Spain
In addition to several ideas aimed at
Endosseous implants have
limiting crestal bone resorption, the
consistently achieved high
concept of platform switching ap
success rates in partially and
pears to be promising. Platform
completely edentulous patients.
switching refers to the use of a
Clinicians have therefore begun
smaller-diameter abutment on a
to offer selected patients imme
larger-diameter implant collar. This
diate and early implant place
type of connection shifts the perime
ment options. The long-term
ter of the IAJ inward toward the central
success of immediately loaded
axis of the implant.12,13 The time limita
implants has been investigated
in animals1,2 and humans,3 with Fig. 1: Implants and abutments used (left to right). tion in implant treatments is an import
encouraging results. However, blueSKY implant, SKY esthetic abutment titanium, ant bias when it comes to planning and
developing rehabilitation therapies. In
most of the studies were per SKY elegance abutment.
this sense, the inclusion of new mate
formed with implants placed in
rials that allow for immediate loading in a single session
the anterior mandible, where primary implant stability is
without having to replace prosthetic components facili
easily achieved.
tate optimal results in terms of gingival attachment and
minimize peri-implant bone loss after prosthetic abut
In the anterior maxilla, clinicians seeking to load im
ments have been manipulated. Ceramically reinforced
plants immediately must be concerned not only about
PEEK is of great interest as it allows a single attach
achieving adequate implant stability, but also about ful
ment to be retained in place throughout the entire treat
filling patients’ desires for aesthetic results that resem
ment and avoids handling-related overload. Its mechan
ble the natural dentition. To achieve this, it is essential to
ical and physical properties have been tested in animal
maintain as much of the bone height around the implant
4
experiments and in humans, showing the material to be
neck as possible, controlling the biologic width.
ideal for one-step Xprotocols.
Bone loss around the implant always occurs when an
The physical and mechanical properties of the pros
abutment is connected to a dental implant at the crestal
thetic components govern the success of the long-term
level. It has been demonstrated that the gap between the
restoration. Resistance to occlusal loads such as masti
implant and the abutment has a direct effect on bone loss,
catory movements and parafunction should be adequate
regardless of whether the two parts are connected at the
5
to allow denture survival. The modulus of elasticity and
time of integration of the implant or later. This phenomenon
bending resistance of the material should be adequate
occurs whether the implant is loaded or not and appears
5,6
to prevent undesirable fractures or micromovements.13
to be unrelated to the type of implant surface. Hermann
et al. demonstrated that crestal bone remodels to a level
about 2.0 mm apical to the implant-abutment junction
Furthermore, components used require a high degree
5, 7, 8
(IAJ),
while Lazzara and Porter reported crestal bone
of biocompatibility to prevent the occurrence of abnor
levels about 1.5 to 2 mm below the IAJ at one year after
mal tissue reactions such as initial peri-implant inflam
9
restoration. Tarnow et al. documented a horizontal com
mation and mucositis, which may result in more severe
complications such as peri-implantitis.14 Polyetherether
ponent that results in 1.3 to 1.4 mm of resorption from the
IAJ to the bone in a horizontal direction.10,11 When the bio
ketone (PEEK) is a polymer from the polyaryletherketone
family, a relatively newly developed family of high-tem
logic width is in the wake of such osseous changes, the
perature thermoplastic polymers having of an aromatic
soft-tissue architecture, including the appearance of the
backbone interconnected by ketone and functional
papillae, is affected. The interproximal bone influences
ether groups.1 In medicine, PEEK has been found to be
the interdental papillae by acting as a guidepost for the
soft-tissue contours.
an excellent substitute for titanium in orthopaedic appli
08 CAD/CAM
1 2018
[9] =>
research
cations15,16 and has been used in dental implants, pro
visional abutments, implant-supported bars, or clamp
material in removable dentures.17, 18 PEEK is biocompati
ble and has a natural tooth-coloured appearance, unlike
metal reconstructions.
Ceramically reinforced PEEK materials were devel
oped to improve the mechanical properties and the
colour of dental restorations. One of these materials is
BioHPP (bredent medical, Senden, Germany). In abut
ments, the BioHPP is directly injection-moulded to a ti
tanium base and forms a monolithic hybrid abutment
called “elegance” abutment, with a screw seat in tita
nium for long-term stability plus a resilient body made of
ceramically reinforced PEEK.
To shorten procedures and eliminate intermediate
prosthetic steps, digital technologies were developed
that allow the intraoral scanning of models and attach
ments with a high degree of precision and reproducibility.
Chairside CAD/CAM systems such as CEREC (Sirona)
allow direct scanning of the abutments and the realization
of immediate crowns. The ceramically reinforced hybrid
abutments with a PEEK body and titanium base are eas
ily scannable, yielding restorations of high quality with a
good prognosis. Problems caused by removing and re
inserting different prosthetic components—such as loss
of soft tissue or early marginal bone loss—are reduced or
eliminated. This article demonstrates the reliability of the
single-session protocol using digital methods for scan
ning and producing crowns complemented with platform
switching and evaluates the peri-implant soft-tissue seal.
|
Material and methods
Animal protocol
An animal experiment was conducted to evaluate
an implant placement protocol with immediate load
ing using PEEK and CEREC and to assess the peri-im
plant soft tissue. Forty-eight blueSKY implants (bredent
medical) were placed in healing bone. Thirty-two SKY
elegance abutments (bredent medical) were used in the
test group and sixteen titanium abutments in the control
group (Fig. 1).
A randomization scheme was generated using the
website www.randomization.com. The Ethics Com
mittee for Animal Research of the University of Murcia,
Spain, approved the study protocol, which followed the
guidelines established by Directive 2010/63/EU on the
protection of animals used for scientific purposes. Six
American Foxhound dogs approximately one year of
age, each weighing approximately 13–15 kg, were used
in the study.
Day 0 (first stage)
The animals were pre-anaesthetized and taken to the
operating theatre where, at the earliest opportunity, an
intravenous catheter was inserted into the cephalic vein
and propofol was infused at the rate of 0.4 mg/kg/min
as a slow constant-rate infusion. Conventional dental
infiltration anaesthesia was administered at the surgi
cal sites. Premolar and molar extractions (P2, P3, P4,
M1) were performed in both mandibular quadrants of
each dog.
Fig. 2a
Fig. 2b
Fig. 2c
Fig. 3a
Fig. 3b
Figs. 2a–c: Animal study protocol with immediate loading. Figs. 3a & b: Linear measurements (in mm): peri-implant mucosa (PM), buccal bone crest (BC), lingual bone crest (LC),
top of the implant shoulder (IS), bone crest (BC), distance from the implant shoulder at buccal bone crest (IS-BC), distance from the implant shoulder at lingual bone crest (IS-LC).
CAD/CAM
1 2018
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| research
Day 60 (second stage)
After drilling, the sequence of placement of four implants by hemi-mandible was randomly planned (using randomization as mentioned). The implants were
inserted in healed bone at the sites of the mandibular
premolars and molars (P2, P3, P4, M1), with an insertion
torque of 30 Ncm or more (Figs. 2a–c).
Analysis (eight weeks after implantation)
–– Histological and histomorphometric analysis of the
bone-to-implant contact area (BIC) with linear measurements in millimetres: peri-implant mucosa (PM), buccal bone crest (BC), lingual
bone crest (LC), top of the implant shoulder
(IS), bone crest (BC), distance from the implant shoulder at buccal bone crest (IS-BC),
distance from the implant shoulder at lingual bone crest (IS-LC)(Figs. 3a & b).
–– Primary stability was evaluated by measuring the ISQ by Osstell Mentor at the time of
placement.
–– The radiological analysis was performed using a standardized protocol.
Human protocol
The research protocol called for recruitment of subjects among patients referred to
the Department of General Dentistry, University of Murcia, Spain, during an 18-month
period. All those in need of a
nterior oral rehabilitation that would include single-implant
placement were invited to take part in the
study, which was overseen by the institutional review board.
teotome. The manufacturer’s implant p
lacement protocol for blueSKY implants (bredent medical) was followed.
After placement, the site was closed using 4/0 polypropylene single sutures.
–– Postsurgical care: All patients received anti-
inflammatory treatment (NSAID), ibuprofen 3 x 400 mg/
day for three days and two chlorhexidine 0.12 % rinses
per day for two days.
–– Implants: Ten blueSKY implants (bredent medical)
3.5–4 mm in diameter and 10–12 mm in length were
randomly assigned and placed crestally in the pre
molar zone (P1 or P2) of the maxilla.
– Abutments: Ten BioHPP SKY elegance abutments (Fig. 4) were connected at the time of implant placement (immediate loading). The SKY
elegance is a hybrid abutment with a body
made of BioHPP moulded directly onto the titanium base without a gap. These abutments are
used for single-session immediate-restoration
treatments, since they combine the properties of a temporary and a definitive abutment, i.e. it is not necessary to change the
abutment. All crowns were realized using the
CEREC system (Sirona, Bensheim, Germany)
with IPS Empress CAD CEREC/InLab (Ivoclar
Vivadent, Schaan, Liechtenstein) feldspar
ceramics. The crowns were cemented with
RelyX self-adhesive cement (3M ESPE, Neuss,
Germany). All implants were loaded using a
platform-switching protocol.
Analysis
– Radiological analysis: Standardized radiographs were taken on the day of placement
and at one, three and five months using a
one-position paralleling system. The analyAdditional criteria for inclusion in the study
sis was performed with the ImageJ software
included sufficient bone height and width to
(Wayne Rasband, NIH, Bethesda, USA). The
allow the placement of implants with a minidistances between the platforms and the points
mum diameter of 4.1 mm and a minimum length
of first bone contact were recorded.
of 10 mm and an occlusal pattern that allowed
for bilateral stability. All subjects needed to have Fig. 4: SKY elegance – ISQ stability analysis: Stability measurements
were made on day 0 to assess the primary staat least 3 mm of soft tissue (vertically) to allow
abutment.
bility of the implant required for the immedifor the establishment of an adequate biologic
ate-loading protocol. An ISQ of 65 was defined as the
width and to reduce bone resorption. Exclusion criteria
minimum value needed (Osstell Mentor; Osstell, Göteincluded severe maxillomandibular skeletal discrepanborg, Sweden).
cies, non-controlled diabetes, haemophilia, metabolic
–– Mucogingival analysis and clinical findings: The bleedbone disorders, a history of renal failure or radiation
ing index was recorded one, three and five months after
treatment of the head or neck region, ongoing chemoimplant placement by means of a special peri-implant
therapy, pregnancy, drug or alcohol abuse, poor oral
probe. Moreover, any post-insertion loss of peri-implant
hygiene, insufficient bone volume at the recipient site,
mucosa or height were recorded. Bleeding on probing
and the need for bone augmentation prior to implant
(0 = absent, 1 = present) was measured at one, three
placement.
and five months. The insertion length was measured
with a conventional plastic probe by one examiner per
Day 0 (surgical planning and protocol)
examination period and six m
easurements for each imA full-thickness incision was made with a No. 15c
plant. The results were presented as means of six meablade, combining an intrasulcular with a crestal incision
surements.
in the palatal area. A full flap was reflected using a perios-
10 CAD/CAM
1 2018
[11] =>
research
–– Statistical analysis: Values were recorded as mean ±
standard deviation (SD) and median. The non-para
metric Friedman test was applied to compare sample
values. The level of significance was set at p < 0.05.
The success of immediately placed implants has
been investigated in various studies with encourag
ing results already. But what is rather simple in the an
terior mandible needs more attention when it comes
to the anterior maxilla. Here, clinicians are o
ftentimes
concerned not only about achieving
adequate im
plant stability, but also about fulfilling patients’ desires
for aesthetic results that resemble the natural denti
tion. To shorten procedures and eliminate intermedi
ate prosthetic steps, digital technologies were devel
oped that allow the intraoral scanning of models and
attachments with a high degree of precision and re
producibility.
Rationale for immediate restoration
Research has shown that, for two-stage implants,
marginal bone loss occurs primarily during the first year
following placement and that this has mainly been at
tributed to the establishment of biologic width adjacent
to the implant.19 Some studies have shown that bone re
modelling can be biologically ascribed to bacterial col
onisation of the microleakage present in a two-stage
implant system and subsequent inflammation.20 The
crestal bone loss around implants has both horizontal
and vertical components. Following abutment connec
tion, c
restal bone has been shown to recede from the
implant/abutment junction microgap by 1.3 to 1.4 mm,
measured horizontally.21
Animal study
Immediate implant placement and restoration minimise
the harmful contamination of the peri-implant biological
space and the resultant bone resorption. Immediate load
ing requires that certain prerequisites are met. The best
way to objectively quantify the feasibility of immediate
loading clinically is to analyse implant stability either by
measuring the insertion torque, recommended at above
30 Ncm, or using the Osstell Mentor ultrasonic stability
measuring device that returns ISQ values, which if above
65–70 allow us to load immediately with some confi
dence (Tab. 1).
Changes in the peri-implant tissue can be quantified
by histomorphometry and histological evaluation in ex
perimental studies (Tabs. 2 & 3). The radiological re
sults of the animal experiments are documented in Fig
ures 5a & b and Table 4. The histological connection
between the soft tissue and the SKY elegance abut
ment is tight. In combination with platform switching,
this produces a high level of bone stability at the implant
collar (Figs. 6a & b).
ISQ value
Insertion
|
p value
Mean ± Sd
Median
BioHPP abutment
74.46 ± 4.55
74.46
0.16
Titanium abutment
74.19 ± 4.29
74.19
0.23
Tab. 1: Friedman test of ISQ analysis and measurements at initial day. Results as mean and
medians. No significant differences with p < 0.05 were found.
BIC (%)
Titanium
PEEK
p value
Mean ± Sd
61.29 ± 1.45
62.52 ± 4.63
0.32
Median
61.29
62.52
Tab. 2: Friedman test of BIC values. Comparison between titanium and hybrid PEEK-Ti abutments. Follow-up eight weeks after implant placement. Data shows mean, Sd and medians. No
significant differences with p < 0.05 were found.
PM-BC
PM-LC
PM buccal-IS
PM lingual-IS
IS-BC
IS-LC
Titanium
PEEK
p value
Mean ± Sd
2.74 ± 0.41
3.11 ± 0.26 *
0.032
Median
2.74
3.11
Mean ± Sd
2.91 ± 0.03
3.71 ± 0.18 *
Median
2.91
3.71
Mean ± Sd
2.35 ± 0.87
2.95 ± 0.53 *
Median
2.35
2.95
Mean ± Sd
2.65 ± 0.43
3.57 ± 0.38 *
Median
2.65
3.57
Mean ± Sd
2.04 ± 0.11 *
1.53 ± 0.21
Median
2.04
1.53
Mean ± Sd
1.93 ± 0.14 *
1.41 ± 0.19
Median
1.93
1.41
0.008
0.015
0.003
0.011
0.029
Linear measurements in millimetre: PM-BC: distance from the peri-implant mucosa to the buccal bone
crest; PM-LC: distance from the peri-implant mucosa to the lingual bone crest; PM buccal-IS: distance from
peri-implant mucosa to the implant shoulder in the buccal aspect; PM lingual-IS: distance from peri-implant
mucosa to the implant shoulder in the lingual aspect; IS-BC: distance from the top of the implant shoulder
to the first bone-to-implant contact in the buccal aspect; IS-LC: distance from the top of the implant shoulder to the lingual bone crest. Values as mean ± Sd and median.
Tab. 3: Non-parametric Friedman test to related samples. (*) Significant differences with p < 0.05.
CAD/CAM
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[12] =>
| research
Lingual BC
Buccal BC
Fig. 5a
Lingual BC
Buccal BC
Fig. 5b
Fig. 6a
Fig. 6b
Figs. 5a & b: Radiological analysis. Comparison between a titanium abutment (a) and a SKY elegance abutment (b). Figs. 6a & b: Histological analysis of the SKY elegance
abutment. Detail of platform switching and connective-tissue insertion over platform. Connective tissue at four weeks (a). Connective tissue at eight weeks (b).
and soft-tissue in growth at the top of the platform
by reducing bacterial migration and, consequently,
of soft-tissue ingrowth and peri-implant bone loss.
Marginal bone loss is drastically reduced and the
objective criteria for peri-implant inflammation are
greatly improved.22
Human study
Table 5 lists clinical parameters from human studies at one, three and five months. Figures 7a to h show
radiological findings at one, three and five months.
Figures 8a and b show the customisation of a SKY
elegance abutment.
Rationale for single-stage treatments
Figs. 7a–h: Radiological analysis. Preoperative (a, e), at one month (b, f), at three months (c, g),
and at five months (d, h).
Rationale for platform switching
The switch in implant platform diameter prevents apical migration of the epithelial attachment
Buccal bone
Lingual bone
Successive insertions and reconnections when restoring an implant according to conventional protocols provoke bacterial invasion and colonisation of the
biological space and mark the onset of marginal bone
loss. Offering treatment in a single session provides
the biological benefits described and saves time and
money, increasing patient satisfaction.23
Titanium
PEEK
p value
Mean ± Sd
1.96 ± 0.21 *
1.43 ± 0.11
0.013
Median
1.96
1.43
Mean ± Sd
1.78 ± 0.33 *
1.28 ± 0.43
Median
1.78
1.28
0.031
Tab. 4: Radiological analysis of bone first contact distance to the implant shoulder. Values as mean ± Sd and median. Non-parametric Friedman test analysis.
(*) Significant d ifferences with p < 0.05.
12 CAD/CAM
1 2018
[13] =>
research
Fig. 8a
|
Fig. 8b
Figs. 8a & b: Customisation of a SKY elegance abutment.
1 month
3 months
5 months
p value
First bone contact to platform (mm)
0.50 ± 0.41
1.07 ± 1.12
1.17 ± 0.87
0.044
ISQ value (%)
68.10 ± 4.93
69.34 ± 1.22
71.43 ± 3.01
0.12
Bleeding on probing (0–1)
0.21 ± 0.01
0.16 ± 0.05
0.06 ± 0.02
0.014
Insertion length (mm)
3.64 ± 1.02
4.19 ± 1.05
4.11 ± 1.02
0.029
Mean ± Sd
Tab. 5: Human study, values as mean ± Sd. Non-parametric Friedman test. Values of bleeding on probing (0 = no bleeding on probing and 1 = bleeding on probing).
Intraoral scanning
Fabricating a CEREC crown requires a step prior to
intraoral scanning, namely the adaptation of the pros
thetic support. The SKY elegance abutment can be cut
and customised in the mouth, more or less like dentine,
which means a reduction in time and cost. Also required
are a delicate surface polish and preparation of the pro
Fig. 9: Customising the SKY elegance abutment and crown design with CEREC.
CAD/CAM
1 2018
13
[14] =>
| research
Fig. 10a
Fig. 10b
Fig. 10: Final restoration at the day of surgery (a). Detail of soft-tissue attachment (b).
files to be recognised by the intraoral scanner. The restoration margins should be well-defined and prepared to
the gingival or subgingival level.24, 25 The SKY elegance
abutment anatomy allows to create a proper emergency
profile that can be customised for each patient (Fig. 9).
The next step is to obtain relative isolation, with any hint
of moisture removed, to ensure a good intraoral impression. The savings in terms of time and money are evident,
as is the increase in patient comfort.
Fabricating a CEREC crown
The choice of restorative material to use on an implant
requires familiarity with the way masticatory forces are
transmitted via the crown and abutment to the boneto-implant contact area. Biomimetics is the study of the
materials that allow us to adapt prosthetic elements to
their intended proper function, based on similarity to the
receiving environment.26 Knowing how forces are transmitted is essential to avoid loads that can lead to bone
loss or implant failure.
The SKY elegance is a hybrid abutment with a titanium base and a ceramically reinforced PEEK body, so
the transmission of forces from the crown to the implant
proceeds gradually and progressively. This helps avoid
crown fractures due to internal or external tension between a ceramic crown and an all-ceramic abutment.
Using a hybrid abutment approach, there is a choice
of resin or ceramic base materials, from feldspar ceramics to ceramics with a silicate base. This still leaves the
interface to consider; here, the crown is best connected
to the abutment using a resin-based composite cement
that facilitates the gradual transmission of forces; also,
14 CAD/CAM
1 2018
these cements are more stable bio
mechanically than
ionomer cements or derivatives (Figs. 10a & b).
Conclusion
The establishment of a stable peri-implant seal to
maintain gingival health around implant-supported restorations must be a primary objective of any implant treatment. The single-stage approach allows the establishment of an initial peri-implant soft-tissue attachment that
will be preserved as the abutment is not removed; hence,
no violation of the biologic space will occur, allowing for
greater tissue stability and yielding better aesthetics and
an improved bone and soft-tissue stability.
The integration of digital technology (CEREC) in the
implant/restorative process shortens the treatment time
and reduces the cost for the patient. The SKY elegance
abutment helps treat patients with predictable results.
Editorial note: A list of references is available from the
publisher.
This article was first published in EDI Journal No. 1/2016.
contact
José Eduardo Maté Sánchez de Val
Plaza de Luceros n. 15, bj. izq.
03004 Alicante, Spain
jemate@ucam.edu
[15] =>
Dentsply Sirona does not waive any right to its trademarks by not using the symbols ® or ™. 32671431-USX-1801 © 2018 Dentsply Sirona. All rights reserved
Planning and
guided surgery
Digital
impression
Restorative
solutions
Digital implant workflow
Connect to the future
From data capturing, planning, guided surgery to the final restorative
solution, with the digital implant workflow from Dentsply Sirona you have
all the support you need to save time, grow your business and provide
patients with the best possible care.
www.dentsplysirona.com
[16] =>
| case report
Chairside CAD/CAM
immediate restorations
Anterior no-preparation ultrathin veneers
Drs Feng Liu & Xing Liu, China
Fig. 1
Fig. 2
Fig. 1: No-preparation veneer is adapt to the teeth with flat surface. Fig. 2: When the teeth have apparent curvature, no-preparation veneer may have weak
contact area. Micropreparation veneer is more appropriate.
Introduction
No-preparation ultrathin veneer is one of the most
minimally invasive restorations. Its thickness ranges from
0.3 to 0.5 mm. In the right circumstances (Figs. 1 & 2) it
can show excellent aesthetic appearance, and provide
long-term stability and health of soft- and hard-tissue.
immediate scan, design, milling and restoration quickly
and conveniently. It is the same for the no-preparation ultrathin veneer. For chairside CAD/CAM systems, CEREC
is the most developed system.
Manufacturing inlays, onlays, crowns and veneers
chairside with a CAD/CAM system has become established in most dental offices. This technique can produce
The biocopy mode, which is widely used for restoration
design, has target contours such as wax-up. In this mode,
the operator should scan the original tooth shape in the
mouth or on the model first, then wax up and re-scan
the wax-up shape into the CEREC system. Both optic impressions will transfer into the virtual model, and match to
each other to obtain the restoration contour information.
Depending on the 3-D data, chairside milling can be complete in few minutes. Post-milling processes usually contain shaping and polishing. In some conditions, it may be
necessary for additional staining and glazing.
Fig. 3
Fig. 4
The overall structure of ultrathin veneer is flexible, in
that its neck can gradually change from thick to thin, and
the border can be knife edge-like or thin round-convex
(Figs. 3 & 4).
Fig. 3: Ideal gradual thinning no-preparation veneer. Fig. 4: Acceptable round-convex no-preparation veneer margin with a little thickness.
16 CAD/CAM
1 2018
[17] =>
[18] =>
| case report
Fig. 5
Fig. 6
Fig. 8
Fig. 7
Fig. 9
Fig. 10
Case report (Figs. 5–32): Fig. 5: Frontal view pre-operation. Fig. 6: Frontal smile view pre-operation. Fig. 7: Upper-anterior dentition view pre-operation.
Fig. 8: Upper jaw view pre-operation. Fig. 9: DSD dentition view pre-operation. Fig. 10: DSD smile view pre-operation.
Case report
A 57-year-old female patient presented, whose dentition had apparent colour changes and abrasions that had
occurred gradually over time. These problems resulted in
an unaesthetic smile and made her appear older than her
age. She also made a request for a highly comfortable
and minimally invasive treatment plan, and expected an
improvement in the colour and shape of her upper anterior teeth, which would rebuild her smile and self-confidence (Figs. 5 & 6).
It was found that due to the abrasion which had occurred
over several decades, the labial surface was plane and flat,
the incisors had been worn to a straight line and also had
abrasion-associated defects (Figs. 7 & 8). The no-preparation veneer that would occupy the “outer space” of the
teeth would eliminate the slight wrinkles around the lips.
These effects were part of the patient’s expectations and
the treatment plan was accepted.
Taking the treatment requirement and oral condition
into consideration, the patient was prepared for the ultrathin no-preparation veneer. Digital Smile Design (DSD)
was done based on the pre-operation photos (Figs. 9 &
10), and the patient was satisfied with the aesthetic appearance of the design.
The patient wanted her teeth colour to seem natural and to
disguise the discoloration. The treatment plan was confirmed
as CEREC designed and manufactured Mark II (VITA) veneer
of 0.3 mm thickness, 1M1 shade, and the material was chosen for its excellent aesthetic performance and translucency.
18 CAD/CAM
1 2018
The manufacture of no-preparation veneer could depend on the precise wax-up of pre-operation. This step
could save the patient’s chairside waiting time; the biocopy technique can simplify the design process; milling
the restoration with a 0.5 mm original thickness and polishing after milling will decrease the risk of milling defect.
The exact process can be concluded as:
1. Obtain a precise pre-operation impression, and make
the model. Use a CEREC scan to obtain information
about the abutment teeth (Figs. 11 & 12).
2. Depending on the DSD result, make a wax-up on the
pre-op model. The thickness of wax-up should be from 0.3
mm to 0.5 mm. Get the biocopy scan of the wax-up model,
and match accurately with the pre-op model (Figs. 13–15).
3. Setting the margin of the abutment teeth, the marginal
edge line is not fixed because of the no-preparation technique. The direction of insertion should be defined first,
which can cover most areas of the labial surface, incisor
edge and adjacent surfaces. The border of the covered
area should be the margin of the restoration (Fig. 16).
4. Shape formation of the restoration: Copy the target
shape of the biocopy model, the restoration should be
calculated automatically. If there is any defect, it can
be adjusted and corrected by the tools. If there are any
areas not thick enough for 0.5 mm, it should be added
to 0.5 mm to avoid fractures during the milling process
(Figs. 17 & 18).
5. Modification and polishing of the initial restoration to
0.3 mm thick after milling. And fine polishing of the final
restoration (Figs. 19 & 20).
6. Intraoral try-in, fine adjustment and cementation
(Figs. 21–24).
[19] =>
case report
Fig. 11
Fig. 14
|
Fig. 13
Fig. 12
Fig. 16
Fig. 15
Fig. 19
Fig. 17
Fig. 20
Fig. 18
Fig. 11: Precise pre-operation model. Fig. 12: Pre-operation scan. Fig. 13: Wax-up based on pre-operation model. Fig. 14: Biocopy model. Fig. 15:
Biocopy optic model accurately match with pre-operation model. Fig. 16: Setting the insertion direction and margin of the restoration. Fig. 17: Finished
restoration design. Fig. 18: Designed restoration prepared to mill. Fig. 19: Ready veneers before cementation. Fig. 20: The thickness of the finished
restoration is 0.3 mm.
Fig. 21
Fig. 23
Fig. 22
Fig. 24
Fig. 21: Try-in: frontal view of upper anterior dentition. Fig. 22: Try-in: incisal view of upper anterior dentition. Fig. 23: Try-in: lateral view of smile.
Fig. 24: Try-in: lateral view of smile.
CAD/CAM
1 2018
19
[20] =>
| case report
Fig. 25
Fig. 26
Fig. 31
Fig. 27
Fig. 28
Fig. 29
Fig. 30
Fig. 32
Fig. 25: Four-year follow-up: frontal view of upper anterior dentition. Fig. 26: Four-year follow-up: frontal view of smile. Fig. 27: Four-year follow-up: lateral
view of upper-anterior dentition. Fig. 28: Four-year follow-up: lateral view of upper-anterior dentition. Fig. 29: Four-year follow-up: lateral view of smile.
Fig. 30: Four-year follow-up: lateral view of smile. Fig. 31: Four-year follow-up: frontal view of face. Fig. 32: Four-year follow-up: lateral view of face.
7. Four-year follow-up and recheck. The restorations
are as excellent as before and the margins are tightly
sealed, the colour is stable, there is no margin colorised or whole colour changing. The patient is very satisfied with the aesthetic performance and function. A
charming smile appearance has given her more confidence and vigour (Figs. 25–32).
Conclusions
The no-preparation veneer is a kind of restoration with
high precision requirement and manufactured difficulty.
It is usually finished in laboratory. Getting benefit from
chairside CAD/CAM techniques, immediate restorations
in one appointment can be achieved; dentists can invite
the patients to observe the process of restoration design
and manufacture, and even get involved into the design.
Patients may feel that they are participating in the treatment, establishing an emotional connection with the restoration, which may also make them more easily accept
and love their restoration. The value of increasing the satisfaction should not be ignored.
Biocopy design is the combination of traditional aesthetic design and digital virtual design. It is also the most
convenient and fast technical route. Nowadays, 3-D vir-
20 CAD/CAM
1 2018
tual technique is becoming more and more established.
Using 3-D techniques directly to make a virtual design
may also get wonderful restoration performance, it can
be predicted that this pattern will become the mainstream of digital aesthetic design in future.
about
Dr Feng Liu
is a Clinic Professor and Vice Director
of Clinical Division of Peking University
School and Hospital of Stomatology.
He is also the director of the Clinical
Division Esthetic Dentistry Training
Center and member of many scientific
associations worldwide.
Dr Xing Liu
is a dentist, working at Peking Univer
sity Hospital of Stomatology. He is also
a member of many scientific associations worldwide.
[21] =>
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[22] =>
| case report
From digital planning to the
mock-up and final restoration
Presentation of a modern work concept on the
basis of a veneer fabrication
Dr Cyril Gaillard & Jérôme Bellamy, France
Introduction
The demand for cosmetic treatments is also increasing in dental practices. The Internet provides patients
with virtually limitless access to a wealth of information
on this topic. And with it comes an increase in expectations. This can pose a conundrum to the dentist: patients want to be promised the desired results, yet, they
should not be given undue expectations in the run-up to
the treatment.
The challenge
One of the challenges in day-to-day dentistry is the fact
that the mock-up presented to the patient is produced
from a wax-up, and is often not consistent with the final
outcome of the treatment (e.g. ceramic veneers). Several research studies have been initiated to overcome this
problem. The SKYN concept is a result of this research.
a
The solution
The SKYN concept is based on a unique approach: it
uses natural tooth shapes to create a mock-up directly in
the patient’s mouth. A wax-up is created on the basis of
tooth shapes that reflect the anatomy and morphology of
natural teeth in terms of height, width, curvature and surface
texture. The predictability of the result is ensured by using
CAD/CAM technology to scan the mock-up, make adjustments in the oral cavity, and then mill the veneers to achieve
lifelike results. The reproducibility of the mock-up and the
accuracy of the result arise from, among others, the performance of the CAD/CAM system, allowing the expectations
of the patient to be met both promptly and effectively.
CAD/CAM technologies have brought about a revolution in dentistry. They enable the efficient manufacture
of customised ceramic veneers with high accuracy and
within a short period of time.
b
Figs. 1a & b: Initial situation. Severely stained restorations in the upper anterior region (a). It does not bother the patient that her upper lip is asymmetrical and
her gum line is visible when she laughs (b).
22 CAD/CAM
1 2018
[23] =>
Fig. 2
Fig. 3
Fig. 4a
Fig. 4b
Fig. 6
Fig. 5
Fig. 8
Fig. 7a
Fig. 7b
Fig. 9
Fig. 2: SKYN models (according to Dr Jan Hajtó) for the fabrication of the wax-up. Fig. 3: The composite (IPS Empress Direct) is applied into the silicone key.
Figs. 4a & b: The composite veneers created with the help of the silicone key show a natural shape and surface texture on the model. Tooth 11 (a). Teeth 15
to 25 (b). Fig. 5: The mock-up is placed in the mouth. The surfaces are being reworked slightly. Fig. 6: Completed mock-up. Photos and videos are used to
assess it. Figs. 7a & b: The surfaces of the mock-up are being reworked slightly. Side view (a). Front view (b). Fig. 8: Targeted preparation of the teeth with
the mock-up in place. Fig. 9: Close-up of the prepared anterior teeth.
Furthermore, the restorations present an accurate
copy of the aesthetic wax-up. The different working steps
involved in the SKYN concept are demonstrated in the
following clinical case.
Case report
Initial situation
The patient visited the practice with a request that
mainly concerned aesthetic criteria. She felt that her anterior restorations looked too yellowish and their shape
did not fit in. The restorations had been in her mouth for
several years and the patient wanted to change them.
First, a series of digital pictures was taken to examine
the situation more closely. The patient had a high smile
line. However, the fact that her gums were visible when she
smiled and her upper lip was asymmetrical did not bother her
(Figs. 1a & b). The periodontal apparatus was healthy. The
soft tissues did not show any signs of abnormalities either.
Treatment planning
We recommended the patient to have the anterior region restored with veneers stretching from teeth 15 to
25, and advised her to have the premolars included in
the restoration to achieve a harmonious appearance. The
patient agreed with our proposal. We drew up the following treatment plan:
–– Wax-up using composite veneers to reproduce the
natural shape and texture of the teeth.
–– Mock-up according to the SKYN concept using a
light-curing nanohybrid composite (IPS Empress Direct).
–– Intraoral digital data scan of the mock-up.
–– Preparation of the teeth with the help of the mock-up.
–– Digital impression of the preparation using an optical
camera.
–– Fabrication of the temporaries.
–– Machining of the glass-ceramic veneers (IPS Empress
CAD).
–– Incorporation of the veneers.
Fabricating the wax-up
The aim of the ceramic veneers was to give more volume
to the teeth. The teeth should appear stronger and longer.
Adjusting the dental proportions was requisite to creating a
harmonious appearance between the teeth and the smile
on the patient’s face. To create the wax-up, we used the
SKYN models (“Anterior Model Set” by Dr Jan Hajtó) as reference (Fig. 2). This is a reproduction of natural teeth. Upon
request by the patient, tooth selection was performed with
the help of both the Digital Smile Design programme and
the VisagiSMile design and visualisation software.
CAD/CAM
1 2018
23
[24] =>
| case report
Fig. 10
Fig. 11
Fig. 12
Fig. 13
Fig. 10: The CAD data of the digital impressions of the prepared teeth and the mock-up are superimposed. Fig. 11: Veneers ready for placement. Fig. 12: Restorations
on the model after CAD/CAM-supported fabrication of the ceramic veneers. Fig. 13: Adhesive cementation of the ceramic veneers with a rubber dam in place.
Transfer to the mock-up
We created a silicone key of the vestibular surfaces
with the help of the wax-up and applied a thin layer of
composite material into the key using a spatula (IPS Empress Direct; Fig. 3). Once light-cured (Bluephase with
Polywave LED), the resulting composite veneers for teeth
15 to 25 were placed on the model and stabilised with
wax (Figs. 4a & b). Once the wax-up was finalised, it was
duplicated and cast in stone. We created a silicone key
from this model to assist the dentist in the preparation of
the teeth. The silicone key was created in two steps using
two different silicone materials, one with a high hardness
(Silico Dur, Cendres+Métaux) and the other with a low
hardness (3M ESPE Express). The silicone key served to
create the mock-up and the temporaries.
Tooth preparation and data transfer to the lab
The mock-up was inserted with the help of the silicone key and the surface texture was reworked using a
polishing system (Astropol; Fig. 5). The aesthetic effect
was validated with photographs and videos. The patient
could also inspect the pictures (Figs. 6 & 7). Then, the
teeth were prepared using a ball-shaped bur whilst the
mock-up was in place (Galip Gürel 2003) (Fig. 8). This
procedure meets the requirements of minimally invasive
dentistry. An impression of the prepared teeth (Fig. 9)
was taken using an intraoral scanner and the temporaries
were fabricated with the help of the silicone key.
24 CAD/CAM
1 2018
At this point, the dentist is required to take two optical
impressions: first, an impression of the prepared teeth
and, second, an impression of the temporaries in the
mouth. In addition, a conventional silicone impression of
the prepared teeth is taken. The dental technician will use
this impression to produce a physical model to check the
fit and contact points of the milled ceramic veneers.
Creating the final restoration
For the CAD construction, the two data sets (temporaries, prepared teeth) were superimposed in the software
(Fig. 10). Subsequently, the shape of the temporaries was
matched to the preparation margins. Each component
was examined (preparation margin, thickness, contact
points, etc.) separately before the data was transmitted to
the milling unit for machining (Fig. 11). For the fabrication
of the veneers, we decided to use the IPS Empress CAD
Multi blocks, which feature a lifelike shade transition from
the dentine to the incisal. We selected a block in shade
A1. Each veneer was positioned in the block in such a
way that the translucency of the incisal area matched our
requirement. Once the veneers were milled, we checked
their fit on the prepared dies of the model and assessed
their contact points with each other. The surface texture
was lightly reworked (Fig. 12). To achieve a highly aesthetic result, we additionally characterised the veneers
with Stains and Essence materials (IPS Ivocolor) before
we glaze-fired them (Fig. 11).
[25] =>
case report
Fig. 14
Fig. 16a
Fig. 15
Fig. 16b
|
Fig. 14: Close-up of the veneers after seating. Fig. 15: Texture and tooth shape look natural and harmonise with each other. Figs. 16 a & b: Lip appearance (a)
and portrait picture (b) with the completed restorations. The expectations of the patient have been met.
Seating the ceramic veneers
At the try-in, the shade and fit were checked. All ten
veneers showed an excellent fit in the mouth. The next
step was adhesive bonding. Prior to the bonding procedure, a rubber dam was placed to isolate the treatment
field and to keep it dry. As the natural teeth were not discoloured, we were able to use a translucent luting composite (Variolink Esthetic) to insert the veneers (Fig. 13).
The veneers were seated using the following protocol:
–– The restorations were etched with hydrofluoric acid for
60 seconds, rinsed under running water and dried with
compressed air.
–– The veneers were then conditioned with silane. A universal primer (Monobond Plus) was applied, allowed to
react for 60 seconds and dried.
–– The prepared teeth were etched with 37% phosphoric
acid gel (Total Etch) and rinsed.
–– Fluoride-releasing Excite F DSC adhesive was applied
(without light-curing).
–– The veneers, which were coated with luting composite, were seated.
–– The luting composite was tack-cured for 1 to 2 seconds (Bluephase with Polywave LED) to facilitate the
clean-up of excess luting composite.
–– Final light-curing of all veneers for 40 seconds.
–– Removal of the rubber dam and occlusal check. At the
last step, the restorations were polished.
–– The ceramic restorations show an appealing aesthetic
appearance in the mouth and harmonize beautifully
with the smile of the young patient. The planned situation was accurately transferred to the final restoration
(Figs. 14–16).
Conclusion
Modern materials in aesthetic dentistry allow pleasing results to be achieved with considerably more ease
than before. It may be considered a substantial progress
that the resulting restorations meet not only high aesthetic requirements, but also essential functional criteria.
State-of-the-art planning tools, digital auxiliaries, CAD/
CAM-supported manufacturing and promising materials
lead to excellent results and ensure high patient satisfaction. However, regardless of the relatively new CAD/CAM
technologies, the skills and experience of a seasoned
dental technician will remain indispensable.
contact
Dr Cyril Gaillard
Jérôme Bellamy
14 Rue Montesquieu
33000 Bordeaux
France
contact@cyrilgaillard.com
CAD/CAM
1 2018
25
[26] =>
| industry report
Digital workflow:
From planning to restoration
Drs Jan Kielhorn, Siegfried Hoelzer & Björn Roland, Germany
High-quality treatment results that are individual to
each patient can be drawn up for the edentulous jaw
in the combination of innovative procedures for implant
surgery and reasoned prosthetic concepts. In this article,
the authors describe the digital workflow for the triedand-tested immediate restoration concept SKY fast &
fixed and discuss the possibilities of transverse screwing, amongst others.
Introduction
Digital technologies help simplify the process involved
in implantology and often accelerate the process, whilst at
the same time offering a high level of accuracy. High-precision results can be achieved in an efficient manner by
combining the digital production of the superstructure.
In addition to digital know-how, proven fundamentals
are promising factors. This includes patient compliance,
a sound dental and dental technical knowledge, surgical and manual skills, the perfect materials and products
and close consultation within the treatment team. On the
basis of this, modern computer-guided procedures offer
an optimum basis for re-interpreting tried-and-tested implant prosthetic concepts such as the SKY fast & fixed
(bredent medical). This article shows the digital workflow
using a patient case as an example.
Anchoring
Fig. 1: Transverse screwing: the thread for the bolt screw is located in the
bridge framework. The bolt screw (A) and the cylindrical surfaces (B and C)
form a unit. The prosthetic coping is fixed as a three-point fixation using the
bolt screw and the short cylindrical surfaces. Due to the short cylindrical
surfaces, the coping locks itself once attached.
Fig. 2
The “fixed” treatment option has become important
for edentulous jaws and jaws that are becoming edentulous. Many patients state that they are not satisfied
with the classic removable total prosthesis; in particular,
if they lose the last few teeth they still have. They want
an aesthetic, functional implant prosthetic restoration.
However, areas of limitation, such as suboptimal anatomical circumstances, are often encountered. In order
to be able to avoid bone augmentation, measures where
Fig. 3
Figs. 2 & 3: Initial situation: conventional X-ray measurement (two-dimensional) and situation model.
26 CAD/CAM
1 2018
[27] =>
industry report
|
possible in these cases, as well as problematic implant
positions and limited aesthetics, suitable implant prosthetic solutions are sought. The SKY fast & fixed concept
is one of those.
In principle, a distinction is made between screwed
and cemented prostheses in fixed implant prosthesis. In
an edentulous jaw, we generally prefer a screwed reconstruction. In contrast to cementing, the main benefit is
the fact that the restoration can be removed from the
implants without problems. For example, if an abutment
were to loosen or a repair be required, the restoration can
be carried out with ease. What is more, hygiene measures are simplified, which is an important aspect, particularly with regard to professional implant aftercare.
Fig. 4
The treatment concept
In the SKY fast & fixed therapy, the implants are inserted in the local bone in such a way that they can be
restored immediately after insertion with a fixed temporary bridge. Osseointegration is supported by means
of primary interlocking. In order to be able to insert the
implants into the jaw without augmentation measures
where possible, meticulous preoperative investigations
and an implant component especially designed for use
in this situation are pre-requisites. This objective can generally be achieved by means of angled insertion of the
posterior implants. The immediate temporary restoration
is guaranteed by means of screwing onto the implants,
resulting in stable interlocking. The pre-fabricated interim
restoration is made from plastic. Due to the relatively low
elasticity module, the load application on the implants
can be cushioned during the healing phase. Following
successful osseointegration, several prosthetic configurations lead to the desired result. The primary requirement of the restoration is the tension-free fit on the implants.
Fig. 5
Fig. 6
Fig. 4: Three-dimensional planning of six implants, based on a DVT. Figs. 5 & 6: Digitalised
situation model (STL): determining the drill template design.
Transverse screwing
screwing involves bolting in the true sense of the word.
The thread for the bolt screw is located in the bridge
framework. The bolt screw and the cylindrical surfaces
form a unit (Fig. 1). Fixation is carried out as three-point
fixation, which prevents tilting. Thanks to the slightly inclined position of the bolt screw, the prosthetic coping
is “pressed” onto the abutment platform without showing a gap once it is tightened. The treatment team benefits from the transverse bonding of the dental prosthesis
with the implants with excellent aesthetics and a complete lack of tension.
Due to the type of screwing of the dental prosthesis, a choice can be made between two variants in the
described concept. In addition to occlusal screwing, a
bonding element is also offered for the transverse (horizontal) screwing. This offers an aesthetic benefit in many
situations. Orthograde screwing—screw channel emerging occlusally, often especially means a compromising
solution in the anterior region in terms of aesthetics.
The seal of the screw channel in the visible region of the
front teeth limits the dental technician with regard to the
aesthetic design. Adequate alternatives include normal
bonding elements in the region that is not visible.
Patient case
The SKY fast & fixed abutment with horizontal circumferential groove is available for this and is restored using
a pre-fabricated transverse screwed coping. This type of
The 48-year-old patient came for a consultation in the
practice due to an unsatisfactory removable dental prosthesis in the maxilla. Teeth 11 to 23 were still present, but
CAD/CAM
1 2018
27
[28] =>
| industry report
Fig. 7
Fig. 8
Fig. 9
Figs. 7 & 8: The drilling template and the pre-fabricated temporary restoration with palate for optimum positioning. Fig. 9: Inserted implants with the corresponding superstructures for the SKY fast & fixed concept.
severely damaged periodontally. A fixed restoration was
requested. The high mobility grade of the teeth would
not permit a stable anchoring of a new dental prosthesis. Therefore, following a discussion with the patient, extraction of the teeth and immediate implant prosthetic
restoration was planned in accordance with the SKY fast
& fixed concept.
Planning
As a planning base, a situation model was initially
produced (Fig. 2). This was digitalised in the laboratory
scanner (D800, 3Shape) and an STL data set was created. In order to validate the implant positions, the two-dimensional X-ray image only yielded limited information
about the available bone (Fig. 3). A three-dimensional image (DVT) was therefore compiled, without a scan template being required for this.
Thanks to the allocation of space for the anatomical
structures, a detailed analysis of the jaw was now possible. Using the planning software (coDiagnostiX, Dental
Wings), six implants were planned in the local bone
based on the visualisation of the anatomical structures
and the digital set-up (ideal position of the prosthesis;
Fig. 4). By angling the distal implants, anatomically vital
structures were circumvented and augmentation measures avoided.
Fig. 10
The angle of the implants is between 30 and 45 degrees for the SKY fast & fixed concept. In addition to the
individual surgical components, special prosthetic superstructures are integrated in the complete concept. A
drilling template for the navigated implant insertion and
a temporary restoration were created from the planning
software for the immediate restoration (Figs. 5 & 6). In order to guarantee accurate positioning in the mouth, both
objects were designed with a palate, whereby the temporary dental prosthesis is produced with target fracture
sites, in order to guarantee a palate-free design of the
screwed bridges (Figs. 7 & 8).
Implantation and immediate restoration
At the time of the surgical procedure, the existing teeth
were extracted atraumatically and six implants (blueSKY,
bredent medical) were inserted with the help of the drilling
templates. The implants were inserted in a primary stable
manner with a torque of between 30 to 45 Ncm (Fig. 9).
The abutments were applied and the area sutured. The
pre-fabricated temporary restoration was inserted without an impression needed. The palate provided support
in order to ensure the reliable referencing of the mouth.
The temporary restoration was bonded with the abutment for a tension-free intraoral fit (Qu-resin, bredent
medical), lined and the bridge was then processed and
produced (Figs. 10 & 11).
Fig. 11
Fig. 10: Long-term temporary restoration with target fracture sites in front of the intraoral adhesion and lining. Fig. 11: Bridges screwed onto the implants
(long-term temporary restoration following removal of the palate) for immediate restoration.
28 CAD/CAM
1 2018
[29] =>
industry report
Fig. 12
Fig. 13
|
Fig. 14
Figs. 12–14: The implant model for manufacturing the final restoration (transverse screwed bridge).
Manufacture of the final restoration
The postoperative progress was free of problems. The
patient was able to participate in social activities without
restriction during the healing phase. Osseointegrated implants and stable hard- and soft-tissue conditions were
seen after three months. Following a pick-up impression, the temporary restoration was removed and the implant situations were modelled using an individual tray
(Figs. 12–14). A screwed restoration was also planned
for the final dental prosthesis. The framework made from
non-precious-metal alloy (NEM) should be veneered using a high-quality composite material. In order to give the
aesthetic design ample space, transverse screwing (bolting) of the dental prosthesis with the implants was considered. In principle, a restoration screwed onto implants
places a high demand on the framework fit. In complex
restorations of this type, this involves a considerable challenge in the production procedure. Due to the implant’s
rigid bond with the bone, even a low amount of force can
cause considerable displacement of the implants.
The highest level of precision is required from both the
dentist and the dental technician. Digital manufacturing
technologies come into play here. These offer a perfect
framework fit and a high material quality—the icing on the
cake is that production is also efficient. In the CAD software, the data relating to the pick-up impression is superimposed on the data relating to the implant master model
(matching) and a framework is constructed in a smaller
anatomical crown shape. In the software, the bonding elements for the transverse bolting were integrated in the
framework (Figs. 15–17). CAM milling of the NEM framework was carried out in the laboratory’s own high-performance milling machine. The thread for the transverse
bolting was then incorporated within the cavity incorporated in the bridge framework (Fig. 18).
A framework try-in in the mouth confirmed that this was
the perfect fit. The individual veneering of the restoration
was carried out using pre-fabricated veneers (novo.lign,
bredent medical). The veneers were fixed to the framework with a dual-hardening adhesive and the individual
fine touches were added with a veneer plastic (crea.lign,
bredent medical). The multiple-layer veneers (high-impact PMMA composite) and the light-curing composites
support the simple manufacture and the individual, aesthetic characterisation. In order to achieve efficient pro
gress, the cushioning properties against chewing pressure of the composite are combined, which are important
to consider, particularly in implant prostheses.
Fig. 15
Fig. 16
Fig. 17
Fig. 15: CAD construction with the bonding elements for the transverse bolting.
Fig. 16: Digitalised set-up. Fig. 17: Construction of the framework in a smaller,
anatomical crown shape.
CAD/CAM
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29
[30] =>
| industry report
Fig. 18
Fig. 19
Fig. 21
Fig. 20
Fig. 22
Fig. 18: CAD/CAM-manufactured framework before the try-in in the mouth: the transverse bolting in the cervical-palatine area is easily recognisable. Fig. 19:
The final restoration is fixed to the implants by means of transverse bolting. Fig. 20: Final X-ray image. The posterior implants were positioned obliquely in the
local bone in accordance with the SKY fast & fixed concept. Fig. 21: Wonderfully healed soft tissue on recall (continuous hygiene phase). Fig. 22: The final
restoration is fixed to the implants by means of transverse bolting.
Insertion and aftercare
The bridge was fixed using the prosthetic copings
(SKY uni.cone transverse prosthetic coping) and bolting
in the practice. As this was carried out as three-point fixation, tilting or rotation of the dental prosthesis can be
ruled out. Thanks to the slightly inclined position of the
bolt screw, the prosthetic coping is “pressed” onto the
abutment platform without showing a gap once it is tightened. This elegant type of fixation combines high-quality
aesthetics with a tension-free position. The “screw channels” are located in the palatine region of the cervical
area, which does not lead to any aesthetic or functional
impairments. Following final fitting, the functional, aesthetic and periodontal hygiene factors were subjected to
a final check and the patient was discharged from the
practice with an aesthetic, fixed restoration (Figs. 19 &
20). The superstructure was designed in such a way as
to ensure optimal hygiene was guaranteed.
The patient was given comprehensive instructions in
this regard. An important pre-requisite for the long-term
success and therefore for a stable periodontal situation is
aftercare in the practice. For the first year after treatment
with an implant, in particular, a continuous, specific recall
system is recommended. The patient had a consultation
in the practice every three months. Once the superstructure was removed, professional cleaning and disinfection
of the components of the dental prosthesis bearing the
implant were carried out. The peri-implant soft tissue remains exemplary to date (Fig. 21).
30 CAD/CAM
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Summary
The success of a total concept such as SKY fast &
fixed is based on a coherent procedure. From the surgical components to the prosthetic materials—the philosophy is to combine the components in an optimal manner. This requires a high level of cooperation between
the practice and laboratory, which can be experienced
more intensively and effectively in the digital workflow.
Various concepts are offered for the final prosthetic restoration and the individual details are therefore taken into
consideration. In order to rule out an aesthetically compromising solution, in this case orthograde screwing of
the dental prosthesis—screw channel emerging occlusally—was avoided. A normal bond was achieved in the
region that was not visible by means of transverse bolting. The access to the bolting, which was easily achieved,
made it possible to easily remove the dental prosthesis
in the practice.
contact
Dr Jan Kielhorn
Specialist in Oral Surgery
Private practice
Verrenberger Weg 15
74613 Öhringen
Germany
info@praxisklinik-kielhorn.de
www.praxisklinik-kielhorn.de
[31] =>
[32] =>
| industry report
Immediate full-arch
restoration in the maxilla
Drs Massimo Frosecchi, Eugenio Longo & Alessandro Certini, Italy
Initial situation
The patient was a 53-year-old male non-smoker at the
time of treatment, although had a history of heavy smoking for many years before treatment (Figs. 1–3). General
health conditions were good, but the patient suffered
from severe chronic periodontitis, probably with a juvenile onset (Figs. 4a–c). A periodontal chart and X-ray periodical status were checked to assess the severity of the
periodontitis and the therapeutic prognosis (Figs. 5a–n).
Only nine teeth were remaining in the maxilla after pre-
Fig. 1
Fig. 4a
Fig. 2
Fig. 4b
Fig. 3
Fig. 4c
32 CAD/CAM
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vious extractions. Mobility, migration of teeth, and lack
of vertical dimension of occlusion were observed. Most
of the maxillary teeth were splinted to improve function
(Fig. 6). The mandible was in a better condition, with
the preservation of all natural teeth, no restorations, and
with minor mobility and migration (Fig. 7). Before any implant-borne reconstruction was considered, periodontal
treatment was provided in order to obtain the necessary
biologic condition and patient compliance for long-term
implant survival. The treatment was finalised in 2016
(Figs. 8 & 9).
[33] =>
industry report
Fig. 5a
Fig. 5b
Fig. 5g
Fig. 5h
Fig. 5k
Fig. 5l
Fig. 5c
Fig. 5d
Fig. 5e
Fig. 5f
Fig. 5i
Fig. 5m
|
Fig. 5j
Fig. 5n
Fig. 6
Fig. 9a
Fig. 9b
Fig. 9g
Fig. 9h
Fig. 9c
Fig. 9d
Fig. 9e
Fig. 9f
Fig. 7
Fig. 8a
Fig. 9i
Fig. 9j
Fig. 8b
Fig. 8c
Fig. 9k
Fig. 9l
Fig. 9m
Fig. 9n
Fig. 9o
CAD/CAM
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[34] =>
| industry report
Fig. 10
Fig. 11
Fig. 13a
Fig. 12
Fig. 13b
Fig. 13d
Fig. 13c
Fig. 13e
Treatment planning
Fig. 13f
The treatment plan included the placing of six implants in the maxilla (Straumann BLT, 4.1 mm diameter,
12 mm length, Roxolid SLActive), followed by full reconstruction of the entire jaw (Figs. 10–13). The planned
implant placement modality was type 1 (immediate,
postextraction) and the planned loading modality was
immediate loading. Lab staff received treatment planning in preparation for surgery.
implant beds were prepared according to the pre-surgical planning (Figs. 17 & 18). Next, six Straumann BLT
implants (Roxolid SLActive) were placed (Figs. 19 & 20).
Two tilted implants in the posterior maxilla were specifically used to avoid a sinus lift procedure and achieve
very high primary stability. There was no need to use
any biomaterials or bone grafting procedures. After
implant placement, titanium bridges and a temporary
abutment were placed, and primary closure of the flaps
was obtained with a single suture (Fig. 21).
Surgical procedure
Prosthetic procedure
Prior to the surgery, the patient was instructed in intraoral professional hygiene and in a mouth rinsing protocol. Antibiotic prophylaxis (amoxicillin 800 mg and
clavulanic acid 200 mg) was also prescribed. Next, all the
remaining teeth in the maxilla were extracted (Fig. 14),
and a prosthetic guide was used to check its stability
and correct orientation and congruity with the lower jaw
(Figs. 15 & 16). A full-thickness flap was raised to expose all recipient sites. A bone remodelling procedure
was performed to remove thin parts of alveolar bone
from the extraction sockets. Using the prosthetic guide,
In accordance with our immediate loading protocol,
a prosthetic surgical guide was used as an impression
tray. This atypical impression was made directly using a titanium temporary abutment as an impression
transfer. A self-curing resin was injected to block abutments to the guide (Figs. 22 & 23). A full-arch temporary bridge was then delivered and stabilised in the patient’s mouth (Figs. 24 & 25). The patient was recalled
after three days, one week and one month for suture
removal, adjustment of occlusal contacts, and a general check-up (Figs. 26 & 27).
34 CAD/CAM
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[35] =>
industry report
Fig. 14a
Fig. 14b
Fig. 15
Fig. 16
Fig. 19
Fig. 20
Fig. 22a
Fig. 23a
Fig. 17
Fig. 18
Fig. 21
Fig. 22b
Fig. 23b
Fig. 22c
Fig. 24a
Fig. 25
Fig. 27a
|
Fig. 24b
Fig. 26
Fig. 27b
Fig. 27c
CAD/CAM
1 2018
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[36] =>
| industry report
Fig. 28
Fig. 30
Fig. 29a
Fig. 29b
Fig. 29c
Final result
After a period of osseointegration (about six weeks)
(Fig. 27) and complete soft tissue remodelling and stabilisation (Figs. 29 & 30), the temporary denture was
removed and replaced with the final one. The final restoration was produced based on the data acquired
for preparation of the temporary bridge (Figs. 31–35).
Occlusion, aesthetics, phonetics and hygienic maintenance possibilities were investigated at the moment
Fig. 31a
Fig. 31b
Fig. 32a
Fig. 32b
Fig. 35a
Fig. 31c
Fig. 33
Fig. 35b
36 CAD/CAM
1 2018
of final restoration and confirmed to be appropriate
(Fig. 36). A final panoramic radiograph with a final prosthetic superstructure in place was also recorded to
serve as a baseline for the follow-up controls (Fig. 37).
At the 12-month follow-up visit, the patient was checked
with regards to the general hygienic maintenance of the
denture, any bone resorption, phonetics, function and
aesthetics. A new periapical radiograph was also taken
to investigate the periodontal and peri-implant situation
(Figs. 38–41).
Fig. 34
Fig. 35c
[37] =>
industry report
Fig. 36a
Fig. 36b
Fig. 36c
Fig. 38a
Fig. 38b
Fig. 38c
Fig. 39a
Fig. 39b
Fig. 40a
Fig. 40b
Fig. 41a
Fig. 41b
Fig. 39c
|
Fig. 37
Fig. 39d
Fig. 40c
Fig. 41c
Fig. 41d
Conclusions
about
No complications or adverse situations were observed at any time during the treatment, from the
planning to the final prosthetic installation. The patient
was extremely satisfied with his new denture. Overall, the treatment required a relatively low number of
appointments, with just a single surgical session. An
immediate replacement of natural dentition in the upper jaw with an implant-supported full-arch bridge was
achieved in a controlled and planned way, minimising
the risks and potential patient discomfort. The patient
appreciated the immediate loading approach, since it
enabled him to maintain a “fixed teeth” situation and
avoid a removable denture stage during the osseointegration period.
Dr Massimo Frosecchi
1992: Degree in Dentistry from the University of
Florence. 1994: Specialisation in implant surgery and
prosthetics at the University of Florence. 1995: Specialisation in Implantology and Bone Graft Harvesting at New
York State University at Buffalo. 2008–2009: Speaker
on the ‘Master of Implantology’ course at the University
of Pisa. 2008: Fellow of the Italian section of the international scientific group ITI. 2008: Visiting Professor at
the Universidade Nove de Julho, Sao Paulo. 2011: ITI Study Club Coordinator for
Toscana. 2011–2012: Director of the Implantology course at the Clinic IPENO,
Florianopolis. 2011: Speaker on the Master of Implantology course at the University of Rome Tor Vergata, in Rome and Tirana (Albania). 2013: Professor of
Implantology and Scientific Evidence at the University of Genoa
CAD/CAM
1 2018
37
[38] =>
| cone beam supplement
“Advanced knowledge and a supporting community via the Internet”
Congratulations on winning the award. How did this
come about?
This has been quite a year. We piloted QAdental in Namibia this spring. It wasn’t easy to obtain permission from
the local ministry of health and it wasn’t easy to get people excited about something totally new. We visited the
country twice. However, we managed to conduct the pilot successfully. In summary, this win feels very good and
motivates us all to continue developing QAdental.
Did you have a team to support you in the development process?
QAdental was developed by a team. Teddy Grenman
and I were the main architects, but without the rest of the
team—CEO Jani Korpela, Chief Medical Officer Jarkko
Saramäki and Project Coordinator Teemu Tanninen—we
wouldn’t have been able to conduct the pilot successfully in Namibia. Steve Jobs’s famous quote applies to
QAdental also: “Great things in business are never done
by one person. They’re done by a team of people.”
With the success of the platform, will something
change for you personally?
My focus will be completely on QAdental and I’ll pass
over most of my other duties in the company [NUOVO
NORDIC Healthcare Services] to my colleagues. This applies to Teddy also.
How do the features of QAdental help practitioners
in particular?
In Finland and many other countries, specialist services
are not available in remote areas. This means dental pro-
38 CAD/CAM
1 2018
What sets QAdental apart from other dental community platforms?
This kind of consultation or support service might be
very significant in enhancing patient safety and healthcare
quality. Our plan was to export Finnish or Western expertise to developing countries. One challenge was that these
countries cannot afford to pay for Western dental specialist consultation. That’s why we wanted to develop a way
to share the knowledge. The solution was quite obvious:
we had to create a place where all consultations, answers
and learning material are available for all members so that
the learning experience wouldn’t be limited to one person.
During the pilot project, we learnt that there’s a need
for specialist e-consultations also in Finland, especially
in remote areas. In Finland, there’s no tele-consulting
platform where information and learning experiences are
shared with several practitioners at the same time, so
QAdental serves as a kind of reverse innovation when it
comes to Western countries. Compared with other dental forums, QAdental focuses solely on consultation and
learning material. There’s always a dentist on duty taking
care of maintenance, and to make sure that the appropriate QAdental professional answers to the corresponding consultations. The officer on duty is also the quality
controller when it comes to official answers.
Will your product be globally available or only for the
Finnish market?
QAdental is open to all dental professionals globally
and membership is free. Dentists can register at www.
qadental.com.
Thank you very much for the interview.
ock.c
t te r s t
s / S hu
Hy ron
fessionals located there are obliged to work beyond their
scope. QAdental brings to them advanced knowledge
and a supporting community via the Internet. This way,
clinicians can perform more challenging procedures more
safely and discuss patient cases with their peers. The
growing international database of questions and answers
and learning material is available for all members. With the
help of the advanced search function—or maybe artificial
intelligence in the near future—clinicians may find answers
to their questions from previous questions and answers.
© Rob
In November 2017, QAdental, a new dental consultation portal, won the Innovation Award at the Finnish Dental Congress and Exhibition in Helsinki. Developed by
Dr Mikko Nyman and Teddy Grenman, Chief Dentist and
Chief Engineer at NUOVO NORDIC Healthcare Services,
respectively, the platform offers dental professionals the
opportunity to e-consult with dental specialists, serves
as a database for learning material and patient cases,
and enables forum discussions. Dental Tribune International spoke with Nyman about this pioneering solution
and the expertise it brings to remote areas and developing countries.
om
by DTI
[39] =>
[40] =>
| cone beam supplement
Dynamic navigation in
fully edentulous maxilla
Prof. Dr Hakan Uysal & Dr Noyan Başal, Turkey
Preoperative planning is the most important part
of a successful implant rehabilitation and requires multiple parameters to be considered for the precise placement of implants. The implants should be placed not only
within anatomical boundaries but also be strategically located to support a prosthesis that will fulfil both functional
and aesthetic requirements.
For years, stereolithographic static guides have been
used successfully for implant osteotomies, using detailed
information implemented through 3-D virtual images.1, 2
Static guides on the other hand present several disadvantages. The loss of tactile feeling during osteotomy and
the fact of being limited to the predesigned drilling trajectory are considered to be their major drawbacks.
3-D virtual images are being used through computer
software, which transforms CBCT scans into 3-D virtual
models. However, after a precise planning or virtual realisation of the treatment, the osteotomy should also be
executed precisely according to the plan and would likely
require guidance of the drills and the implant.
Real-time navigation
A recent technology, which provides dynamic guidance
through a real-time navigation for implant osteotomy, offers not only accuracy, but also additional valuable advantages during an operation.3, 4 With this technology, the
Fig. 3
Fig. 1
Fig. 2
Fig. 4a
Fig. 4b
Fig. 1: Patient wants a screw-retained fixed prosthesis. Fig. 2: Radio-opaque tooth set-up for prosthetic planning. Fig. 3: Scan prosthesis at try-in to check its
fit, aesthetics and maxilla mandibular relation. Figs. 4a & b: Navident H-Arm (a) and V-Arm (b).
40 CAD/CAM
1 2018
[41] =>
Fig. 5
Fig. 9
Fig. 6
Fig. 7
Fig. 8
Fig. 10
Fig. 5: Placement of an SDI as anchor mount. Fig. 6: Connecting the NaviStent Arm to the SDI. Figs. 7 & 8: Adjusted scan p rosthesis for combined scanning.
Fig. 9: Connecting the CT marker to the NaviStent. Fig. 10: Patient positioning in the CBCT scanner.
location and diameter of implants can be modified and
a flap can be incised intraoperatively whenever needed.
fidence. In the initial appointment he thus stresses his
need for a “fixed solution”.
Furthermore, dynamic navigation enables the surgeon
to adjust the surgical plan during surgery. In case of an
unexpected low bone quality, an additional implant could
be planned with the software and placed additionally.
Moreover, one of the most significant benefits of dynamic
navigation is the ability to use it also for alveoloplasty and
reshape the alveolar crest’s topography during the same
surgery, together with the implant placement.
His medical history did not reveal any specific systemic disease or condition that contraindicates oral surgery. The patient’s soft tissues on the edentulous ridges
were healthy and panoramic X-rays showed e
xpanded
sinuses at both sides and irregular alveolar ridges. The
treatment plan, carried out for a maxillary screw-retained
fixed prosthesis, included two implants at the pre-maxillary region and two tilted in the posterior maxilla to avoid
a sinus lift surgery.
The precise location of implants is case-specific and
determined by different factors. If an edentulous case is
to be restored with an implant-supported screw-retained
fixed prosthesis, implant locations should be critically examined whether they can provide screw access holes
within occlusal or palatal/lingual parts of the restoration.
Frequently, alveoloplasty is required for the recontouring
of the ridge in order to obtain sufficient bone thickness at
the level of the implant’s collar.
This crestal trimming of bone may also be necessary
in order to increase the inter-arch space and provide a
sufficient volume for the restorative material, since dentogingival prostheses are frequently required to enhance
aesthetics. In such cases, dynamic guidance can be
used to level the alveolar crests as planned on virtual images, followed by precise multiple osteotomies.
Stent placement
In order to acquire both anatomical and prosthetic information prior to the surgery, a scan prosthesis was manufactured by duplicating the maxillary denture (Fig. 2). It
is important that the scan prosthesis has the same aesthetic and functional information as the complete denture
or set-up. Thus, the scan prosthesis was checked for its
fit, aesthetics and maxilla mandibular relation (Fig. 3). The
scan prosthesis was then used together with a Navident
Edentulous Kit for CBCT imaging.
Case report
The Navident edentulous protocol consists of a SDI
(Small Diameter Implant of 2.2 mm or 2.5 mm diameter),
which is inserted into the alveolar ridge of the arch to be
operated, prior to the acquisition of the CT scan. This temporary SDI serves as a mount for the CT marker and for
the Jaw Tag used for the registration of the CT scan to the
patient and for tracking the patient’s jaw during surgery.
The following case report describes the treatment of
a 65-year-old male with an one-year history of maxillary
partial edentulism (Fig. 1). He was discontent with the
stability of his prosthesis and expressed that through the
unstable prosthesis situation he has lost social self-con-
The SDI can be placed either in a vertical position or
in a horizontal position in relation to the alveolar crest. A
special plastic arm with a proprietary aluminium bracket
is then used for the connection of the CT marker and Jaw
Tag to the SDI. Two types of arms are available: one for a
CAD/CAM
1 2018
41
[42] =>
| cone beam supplement
Fig. 13
Fig. 14
Fig. 11
Fig. 15
Fig. 12
Fig. 16
Fig. 11: Prosthetic implant planning using the Navident software. Fig. 12: Real-time feedback is provided by Navident using a Jaw Tag and Drill Tag during surgery. Fig. 13: The
alveolar crest was levelled by a rongeur. Figs. 14–16: Implants are placed exactly as planned.
vertically placed and another for a horizontally placed SDI
(Figs. 4a & b). In the presented case, the SDI has been
placed vertically to achieve the required stability (Fig. 5).
The CT marker, containing the fiducial marker used for
the registration of the CT scan to the patient, was attached to the V-type arm on the fix-plate at one end. At
the other end, the assembly was placed over the SDI’s
square head and secured to it using a setscrew which
was embedded in the aluminium bracket, with this creating a complete “NaviStent” (Fig. 6).
The scan prosthesis was then modified to accommodate the aluminium bracket before it was placed over the
maxillary edentulous ridge (Figs. 7 & 8). For accuracy
purpose, it is imperative that the scan prosthesis is stable, while at the same time it should not interfere with the
NaviStent.
42 CAD/CAM
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CT scan
The following CBCT imaging protocol for Navident dynamic navigation was applied during CT imaging. Before
the scanning procedures, both the modified scanning
prosthesis and the NaviStent had been placed into the
patient’s upper jaw (Figs. 9 & 10).
A CT marker was then connected to the NaviStent.
A scout view had been acquired prior to the actual
scan to verify the presence of the CT marker in the CT
scan. In order to allow for accurate registration, at least
three corners of the fiducial marker must be present in
the scan. In order to maintain a high level of accuracy
during navigation, it is mandatory that the slice thickness must not exceed a maximum of 0.4 mm. In this
case, the slice thickness had been set to 0.3 mm. Afterwards, the scan was exported in DICOM format, then
imported into Navident.
[43] =>
cone beam supplement
Fig. 17
Fig. 18
|
Fig. 19
Figs. 17 & 18: Optimal surgical result. Fig. 19: Exact angular position of posterior implants for angulated abutments.
Osteotomy planning
When the CT scan is imported into Navident, a propri
etary algorithm detects the fiducial’s image in the scan,
then registers it with a mathematical model of the fiducial
that is stored in the computer memory. This enables Nav
ident to map the Jaw Tag, which is the tag mounted onto
the patient, to the CT image during navigation.
For this case, Ankylos dental implants had been se
lected. The implants with a diameter of 3.5 mm and a
length of 11 mm were planned on the locations 15, 12, 22
and 25 using the Navident planning software (Fig. 11).
The following parameters were considered when osteo
tomies were planned:
1. Alveolar ridges, though they had a sufficient bone
height, were narrowing at the crestal 1/3. Without waiv
ing or compromising the restorative information, the
implant locations were planned to be deeper where at
least 2 mm of buccal plate thickness could be achieved.
2. Straight implants were placed at 12 and 22 and tilted
ones at 15 and 25.
3. Angulated distal implants were planned 1 mm mesially
to the sinus wall.
4. The angle of distal abutments was planned to be 30 de
grees to the occlusal plane to have the retaining screws
access holes placed in the denture’s occlusal aspect
since screw-retained abutments have 30 degree joints.
5. The plane of the implant collars was planned to be
parallel to the occlusal plane.
Surgery
Before surgery, the CT marker was disconnected from
the NaviStent Arm and replaced by the Jaw Tag, which
is detected by the Navident camera. A Drill Tag was in
stalled onto the handpiece (Fig. 12). Together with the
Jaw Tag, they provide real-time feedback during surgery,
enable the surgeon to communicate with the software
and place the implant as planned.
A crestal incision was made at either side. Pilot drills
were used to start osteotomy followed by the Ankylos den
tal implant drilling protocol. All drills were navigated ac
cording to the planned trajectory, until real-time feedback
confirmed that its tip has reached the apical end of the
planned osteotomy. The alveolar crests were levelled by a
rongeur (Fig. 13). Between each trimming attempt, the pi
lot drill was touched to the trimmed surface of the crestal
bone and its level was checked on the virtual image.
The trimming of the bone was completed under the guid
ance of dynamic navigation and the pilot drill was again
touched to the newly formed alveolar crest. Implants were
inserted in the osteotomies as planned (Figs. 14–16), the gin
gival tissue placed back and sutured with coated poly-glactin
910 sutures. The patient was medicated with antibiotics and
chlorhexidine mouth rinse and was released with NSAID’s.
Conclusion
The Navident navigation surgery system achieves a
successful guidance both in alveoloplasty and implant
osteotomies in the edentulous maxilla (Figs. 17–19). In
the presented case, the proposed protocol was highly
efficient in gathering 3-D prosthetic and anatomical in
formation for the planning. Dynamic navigation provided
a precise guidance in the execution of the planned oste
otomies through a flexible surgical operation.
Editorial note: A list of references is available from the
publisher.
contact
Prof. Dr Hakan Uysal
DDS, PhD, Prosthodontist
Abdi Ipekçi Cad. 61 Tesvikiye
Istanbul, Turkey
Tel.: +90 212 2196744
uysalh@gmail.com
Dr Noyan Başal
Klinik212 dental clinic
Valikonaği Cad. No:86/A
Nişantaşi
Istanbul, Turkey
Tel.: +90 5324139118
noyanbasal@gmail.com
CAD/CAM
1 2018
43
[44] =>
| feature
Fig. 1
“Good design will pay off”
by DTI
Just as in dentistry in general, where aesthetic aspects
are becoming ever more important, dentists today are pursuing intentional design of their dental practices. With the
launch of four new design lines, Dentsply Sirona Treatment Centers presents dentists with the opportunity to
enhance workflows and treatment efficacy through clever
and cutting-edge solutions while conveying their individual
style. DTI spoke with German dentist Dr Marcus Riedl and
Dr Mona Patel from the US, both of whom have ensured
careful design of their practice environment based on their
needs and preferences with a Dentsply Sirona line, about
the role of aesthetics in daily dental practice.
Drs Mona Patel and Marcus Riedl
in talks with Dental Tribune.
Design can con
vey emotions and distinguish a
dental practice from others. In your opinion, what
relevance does design have in this regard?
Dr Mona Patel: In the US market, it has not played an important role for a long time. Now, with the newer generation
of dentists, design is increasingly significant. I think it is just
as important as the type of equipment that one purchases
or the insurance one carries, because image is everything.
In my opinion, the design of the practice is a direct reflection
of how one provides care as a dentist. This correlation was
not present in previous generations, but it is now.
Dr Marcus Riedl: I can speak for Germany and I think
design aspects were mostly neglected in the past. Now,
the influence of design in our practices is increasing. One
has to consider that we spend almost half of our lives in
our practice, so we should feel comfortable. For example, I love the mountains, skiing and the atmosphere of
the Alps. Incorporating this love for nature into the design
of my practice gives me a holiday feel at work.
When deciding on a particular design or the overall
look of your practice, what did you put special em
phasis on?
Patel: Dental anxiety is a huge component of what we
have to manage, so we need to create an environment
that first and foremost has a calming, spa-like feel and reduces our patients’ anxiety when they walk through the
door. Secondly, in my practice, I wanted the design to be
evidently smart, because that reflects my meticulous per-
44 CAD/CAM
1 2018
[45] =>
feature
|
Fig. 2
Figs. 1–3: Impressions from Dr Patel’s practice in Milwaukee in the US.
sonality. I equipped the whole office with Dentsply Sirona
products—in fact, it was the first all-Dentsply Sirona office in the US. I wanted to showcase the high-tech equipment and design a nice, simple office around that—not to
compete with the equipment, but to enhance it.
Riedl: For many of our patients, the design aspect is
just an outer shell, since they come to us for the content.
We designed our practice for patients to feel at home.
When they come into the office, they do not see any units
at first. As for dental phobia, in my opinion, reducing anxiety mainly is the responsibility of the staff. However, a
calming atmosphere is a great support, of course.
Patel: In healthcare, whole-body awareness and preventative health are becoming ever more important. A
practice today is not just about treating tooth pain, but
about establishing a dental home, creating a place where
patients can establish a relationship with their dentist and
their hygiene team.
Dentsply Sirona has developed four different design
worlds: Embellished Elegance, Cheerful Patterns,
Honest Materials and Pure Shapes. Which one did
you decide on and why?
Patel: We chose Honest Materials because our practice has all this enhanced digital technology, which
can be intimidating. I wanted to balance this digital aspect of our prac
tice with natural and organic materials. We have a lot of birch and wood—clean, sleek,
simple and balanced materials that hopefully move the
focus from the equipment. My design in general is very
monochromatic, nothing too messy or cluttered.
Riedl: We too choose Honest Materials, mainly because I like nature. In our previous office design, we used
Fig. 3
CAD/CAM
1 2018
45
[46] =>
| feature
Fig. 4
Figs. 4–6: Dr Riedl’s practice in the rural town of Stein in Germany.
the colours white, grey and green. In order to preserve
our corporate identity, we wanted to keep these and
combined them with a lot of wood and glass, because
we wanted to convey the nature aspect to our patients.
Technology is cold and patients do not want to be confronted with it directly, so we created the look of a mountain lodge. Our floors are even called “valley station”,
“middle station” and “mountain station”, for example.
Do you feel that patients appreciate the effort?
Riedl: Some do, some do not. Patients who share the
same values as we do feel more comfortable than those
who think the design is unnecessary for dentistry or think
it makes the cost of their care more expensive.
Patel: Good design does not have to be expensive.
Nevertheless, for some reason, if one puts a great deal
Fig. 5
46 CAD/CAM
1 2018
of effort into the design of one’s practice, it is perceived
as though one put a lot of money into it, which is not al
ways the case.
Would you say that the investment in the design is
also reflected in the success of the practice?
Patel: In the US, many things are based on return on
investment. It is easier to convince oneself to invest in
a CEREC or CBCT device, because one sees an immediate return on investment. However, trying to convince oneself to invest in the design with nicer cabinetry or floorplans, where there is not a direct return on
investment, is more difficult. But, I am a firm believer
that if one works in a beautiful and happy place, it reflects one’s standards and that is the greatest return on
investment. Patients see that. If one sees that love is in
every detail, the financial aspect fades in importance;
[47] =>
feature
|
Fig. 6
the design fulfils one as a person and one’s patients
appreciate the resulting work.
Riedl: Sometimes, it is about the little things. For example, my wife puts fresh flowers in every corner of the
practice, which I love. However, design polarises. It di
vides our patients into at least two groups. Those who
are interested in and impressed by our design appreciate
it, of course. Others do not. I believe that treatment units
and high-end equipment establish a sense of professionalism, quality and exclusivity. No patient can judge a dentist’s quality and knowledge at first sight, but, in the eyes
of the patient, design and technology often are equivalents for quality, so good design will pay off.
There are countless treatment units on the market
and they differ a great deal. What did you consider
when deciding on a system?
Riedl: The treatment units are our workbenches—very
expensive ones (laughs), but workbenches nonetheless.
It has to be stable, easy to use, intuitive, ergonomic and
comfortable for the patient, as well as for the dentist and
the assistants—and, of course, easy to clean. It has to
aid our treatment and therefore our daily work as a den
tist. It is like the assistance systems in one’s car or a
smartphone. A good design, of course, is welcome too.
That is why the Teneo was our system of choice.
with the Teneo is like comparing an old Mercedes-Benz
with a new one. It is the same quality. The Teneo might
be not as solid as the good old M1, but has more features that are useful.
Patel: I was designing a new office, so I had a clean
slate to work with. I did a great deal of research and com
parisons. For me, the look and the design were important, as were functionality, integration, longevity and being
able to sanitise it easily. I was instantly drawn to Teneo,
because, as I said, I do not like clutter. The fact that every
thing was integrated was an instant attraction to me.
I found solutions to all my wishes in the Teneo. It was an
easy decision to make and we designed the office around
the units.
Thank you very much for the interview.
Susanne Schmidinger, Director Product Management Treatment Centers,
Dr Marcus Riedl and Dr Mona Patel.
You both use Teneo. What sets the unit apart from
those you have used before?
Riedl: As a dentist, I have always worked with Sirona,
now Dentsply Sirona. Therefore, there was no question of
the brand I would choose. In our previous office, we used
the M1 for almost 30 years—I, of course, used it only for
about ten years—and I did not want to change my habits and movements during treatment. Comparing the M1
CAD/CAM
1 2018
47
[48] =>
| business
© Photographee.eu/
Shutterstock.com
European Parliament adopts
new medical device regulations
by DTI
The European Parliament has voted to implement two
new regulations concerning medical devices with the aim
of improving safety in medicine and dentistry. The regulations were proposed in 2012 by the European Commission and experienced several delays before being officially
endorsed at the begging of 2017. They will be applied
after a transitional period of three years from publication
for medical devices and five years for in vitro diagnostic medical devices. Publication is expected to take place
shortly in the Official Journal of the European Union.
Though the rules regarding the safety and performance of medical devices were standardised throughout the EU in the 1990s, significant progress in technology rendered these standards in need of updating. In
addition, manufacturers could interpret the three existing
directives on medical devices—which will be replaced by
these regulations—in different ways, thereby creating inconsistencies in adherence to these rules. The new regulations aim to remedy this by ensuring that this progress
and innovation continue in a way that is beneficial to the
safety of all involved. At the same time, smaller and medium-sized companies are facing the challenge of meeting
the new requirements for clinical data, new legal requirements and certifications for all dental products.
Some of the main elements of the regulations include:
–– Stricter measures on the quality, safety and performance of devices released into the marketplace, with
a particular emphasis on perceived high-risk devices.
–– A scrutiny mechanism for Class III implants and Class
IIb active products.
–– The introduction of a comprehensive database for
medical devices sold in the EU (EUDAMED), to be set
up by 2020 at the latest.
48 CAD/CAM
1 2018
–– Higher requirements for clinical data and technical
documentation before and after placement of the respective product on the market.
–– A universal device identification system that will permit medical devices to be traced more easily.
–– An implant card that will be given to patients so that
they, along with medical professionals, have access
to information about any implants they receive.
–– A set of guidelines for providing appropriate financial
recompense to patients for faulty products (the payment will vary according to the risk class and type
of device, as well as the size of the company that
manufactures the device, and will ideally expedite the
remunerative process).
–– Guidelines for manufacturers of substances that are
carcinogenic, mutagenic or toxic for reproduction, as
well as substances that can disrupt the endocrine
system, to provide alternative and less harmful products.
The regulations will be applicable in each of the EU
member states and aim to provide a clearer framework
regarding device standards to patients, professionals,
and relevant domestic and international regulatory bodies. A Medical Device Coordination Group, formed of
experts from member states and chaired by the European Commission, will be established to help organise
and enforce the correct implementation of these regulations.
In addition, conformity assessment procedures by
notified bodies—intranational organisations that evaluate medium- and high-risk devices—will continue to be
performed through joint assessments conducted with
the assistance of other member states.
[49] =>
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[50] =>
| business
US dental prosthetic market set to
grow with digitalisation
Salma Mashkoor & Jeffrey Wong, US
Digitalised dental products, whether produced by additive or subtractive technologies, are expected to disrupt the US dental prosthetic market for the foreseeable
future, according to a report by international market research and consulting company iData Research. This will
be especially true in the denture market. With increasing innovations, emerging competitors, and Food and
Drug Administration (FDA) approvals, the digital market
is expected to grow substantially over the next several
years. As digital products are offered at higher prices,
their growth will drive the total dental prosthetic market at
a compound annual growth rate (CAGR) of 1.4 per cent.
prototyping systems, report authors iData Research analysts Salma Mashkoor and Jeffrey Wong said they are
expecting that market growth will result from innovative
product applications, such as the increasing user base
of intraoral scanners or even new indications for innovative rapid prototyping systems. Unfortunately, competitive price cuts and inexpensive solutions are reducing
potential market growth. This is especially true for rapid
prototyping systems, which have an unsaturated market
relative to that of CAD/CAM materials and systems. The
digital dentistry market had an estimated value of nearly
$650 million in 2017 and is expected to grow at a CAGR
of 5.6 per cent through 2024.
“The digital dentistry market
had an estimated value of
nearly $650 million in 2017
and is expected to grow
at a CAGR of 5.6 per cent
through 2024.”
Since the rapid prototyping system market is relatively
new in comparison with the other digital dentistry markets, new indications for printers will continue to emerge,
such as 3-D temporary prostheses. Stratasys recently
received FDA approval for its VeroGlaze material, which
can be used in the mouth on a temporary basis for up
to 24 hours. Its biocompatible PolyJet photopolymer has
also been medically approved for temporary in-mouth
placement. Printers are currently too costly for an in-office setting and the technology is still advancing in this
regard. Once these barriers are overcome and the necessary FDA approvals are acquired, the use of 3-D temporary prostheses will grow, stimulating sales of in-office
printer units.
The report highlighted recent milestones in digitalisation of the US dental prosthetic market (which encompasses crowns, bridges, inlays, onlays, veneers and
dentures) beginning in 2015, when DENTCA received
FDA approval for the first resin material used to 3-D print
parts of dentures. Later in 2017, EnvisionTEC received
FDA approval to sell its E-Denture material, providing
both dental laboratories and offices with the ability to
fabricate pink denture bases. Currently, AvaDent holds
the majority of the nontraditional complete denture market, as it is the only company with a fully digitalised denture product. AvaDent has a proprietary method of milling both the pink base and white teeth from a single
puck, whereas other competitors mill out the pink denture base only and it is then integrated with teeth by a
technician in the laboratory.
In their overview of the digital dental industry, consisting of CAD/CAM systems, CAD/CAM materials and rapid
50 CAD/CAM
1 2018
CAD/CAM systems too are experiencing an uptick of
new applications, as demonstrated by intraoral scanners, Mashkoor and Wong noted. In the past, the intraoral scanner market was entirely reflective of use by general practitioners. However, in recent years, the user base
has expanded to include orthodontists and other specialists, a trend that is expected to continue in the future.
Orthodontists and dental surgeons are quickly adopting
the technology, as general practitioners are now sharing
scanners in multipractice organisations.
As the user base for intraoral scanners expands, unit
sales will increase, thereby encouraging growth of the
total CAD/CAM system market. Similarly, the increasing
applications of rapid prototyping systems will boost both
laboratory and clinical sales.
[51] =>
business
According to the report, the factor most limiting growth
of the US digital dentistry market is the emergence of
relatively inexpensive products that create more competition and threaten market growth on a national basis. Low-cost foreign brands have penetrated the CAD/
CAM zirconia material market in the US, driving the overall average selling price (ASP) downward. In addition, a
number of generic brands produced in the US have captured a sizeable portion of the market through promotional strategies, further resulting in ASP declines. These
subpremium solutions have been especially effective in
reducing the ASP of zirconia discs, as the ASP for zirconia blocks had already declined rapidly in the past. Inexpensive products have facilitated ASP cuts and competitive pricing in the rapid prototyping system market too.
In 2017, Formlabs engaged in aggressive marketing and
educational initiatives regarding its technology and the affordability of its products, attracting a large customer base.
As its machines are relatively inexpensive, many potential
clients are willing to try them out, thereby decreasing the
overall ASP for rapid prototyping systems. As with Formlabs, additional companies are entering the market with
affordable solutions, further depreciating the ASP. Furthermore, the competitive landscape is becoming more
saturated, encouraging competitive price cuts as a result.
Rapid prototyping systems are still gaining acceptance,
especially in the clinical setting. Once these systems are
widely accepted by various users in the dental industry,
the corresponding ASPs will continue to rapidly decline.
|
With regard to CAD/CAM systems, ASPs for both
CAD/CAM mills and chairside systems are declining
with the competitiveness of the market too. Amann
Girrbach and Roland DGA are examples of companies
that are introducing new products on to the CAD/CAM
mill market alongside printer products. Chairside units,
such as the closed milling systems offered by Dentsply
Sirona and E4D Technologies, command a premium
price over other CAD/CAM systems. It is more feasible for dental offices to purchase a scanner and then
outsource or run a separate open-source mill. As a result, pricing, largely set by Dentsply Sirona owing to its
market share, has been decreasing in order to remain
competitive.
Dentsply Sirona led the total digital dentistry market
in 2017 as a result of product successes in the CAD/
CAM system and material markets. This was largely
due to the diversity of mills offered by the company.
Dentsply Sirona continued to dominate the closed
chairside milling system market in 2017 through sales
of its CEREC chairside CAD/CAM system.
For this report, the authors summarized information
from two papers, titled US Market Report Suite for Digital Dentistry Devices 2018 and US Market Report Suite
for Dental Prosthetics and CAD/CAM Devices 2018,
published in December 2017. The full versions of the
two reports can be purchased on the iData Research
website.
CAD/CAM
1 2018
51
[52] =>
| interview
Non-original abutments are
“a lottery that you cannot win”
An interview with Prof. Matthias Karl from Saarland University, Germany, about the results of the research
into micromotion at the implant-abutment interface
In a recent study analysing the
effect of cyclic loading on micro
motion at the implant-abutment interface, the authors found that a
quantifiable settling effect seems
to be more pronounced in non-
original abutments.1 In the in vitro
study, the NobelProcera implantabutment interface showed the
lowest initial micromotion and minimal settling effect.
Why is it important for clinicians
to know about micromotion in
general regarding the implant-
abutment assembly?
Prof. Karl: From a prosthodontist’s perspective, the interface between the implant and what goes
on top of the implant is, in my opinion, the most critical interface in im-
Fig. 1: Study results: Micromotion before and after cyclic loading.
52 CAD/CAM
1 2018
plant dentistry. To my knowledge,
it’s still impossible to manufacture
two parts that fit perfectly. Perfect
means zero micrometres of gap,
but there is always a certain amount
of component interplay. This is also
needed by the implant manufacturers, because different parts from
different batches have to match
each other. As a consequence,
during dynamic loading and mastication, there will be some micromovement between the abutment
and the implant. This may cause
fatigue over time.
What were the findings of your
study?
We studied different abutments
for Straumann tissue level implants.
In particular, we analysed the im-
[53] =>
interview
|
Fig. 2: NobelProcera Abutments.
pact of third-party abutments on a major implant brand.
Interestingly, we found out that there are differences between different abutment manufacturers. In general, you
are on the safe side as a clinician if you go with an original abutment. Otherwise, you end up in a lottery that you
cannot win. At best you get a product that is more or less
comparable to an original one, but as we explained in the
study, the chances are low.
In particular, we analysed
the impact of third-party
abutments on a major
implant brand.
We did this investigation twice with the status of the
abutments as received from the different manufacturers and after some dynamic loading in our masticatory
simulator. These micromotion measurements showed
that with NobelProcera Abutments there is hardly any
difference in abutment seating before and after dynamic loading, which is indicative of the fact that the
NobelProcera restoration is in its final position. Once
it’s screwed in by the dentist it stays there. If you have
settling it means that the preload of your retention
screw is basically gone and this does not happen with
NobelProcera Abutments.
Are there any other implications that these findings
might have for clinicians in practice?
If you’re not sure whether the implant-abutment is fully
seated or whether it might experience some settling, you
may need to go back after a couple of weeks and retighten the abutment screw. If you have cemented your
crown on top of the abutment, then it’s a major inconvenience to take off the crown. I prefer abutments that I can
seat correctly the first time.
You talked a little bit about NobelProcera. Compared
with the other abutments in your study, how did
NobelProcera Abutments perform?
The advantage of NobelProcera Abutments over other
third-party abutments is that they’re precision-engineered individualised CAD/CAM abutments. Although it
was a Straumann implant that was used as a basis for
testing, we could demonstrate that NobelProcera Abutments showed less micromotion compared with standard abutments from Straumann for cement restorations.
What do you attribute this result to?
NobelProcera manufacturing quality is extremely high.
The result of this study is indicative of very consistent and
precise manufacturing.
Reference
1. Karl M, Taylor TD. Effect of cyclic loading on micromotion at the implant-abutment interface. Intl J Oral Maxillofac Implants. 2016.
contact
Nobel Biocare Services AG
Balz-Zimmermann-Straße 7
Kloten, Switzerland
www.nobelbiocare.com
CAD/CAM
1 2018
53
[54] =>
| interview
“A truly open solution”
by DTI
At the latest Greater New York Dental Meeting
(GNYDM), global dental imaging technology specialist
3DISC showcased its newly developed Heron IOS scanner. Dental Tribune International had the opportunity to
speak with Sigrid Smitt Goldman, CEO and Executive
Chairman of the 3DISC group, about the company’s
entry into the intraoral scanner market and what sets the
device apart from competing products.
quite surprised to find that they had very different approaches to some basic things, like how they would pick
the unit up. Some used a pen grip, others lifted it from the
top. This feedback led to several changes to the shape
of the unit and drove the design of the 360° rotating tip
that allows the scanner to be comfortably held and used
in every situation.
When will the device be available to customers and
in which markets?
We open for sales in Europe and USA in the first quarter of 2018 and the first scanners will be in clinics early in
the second quarter.
“The 360° rotating tip allows the
scanner to be comfortably held
and used in every situation.”
Sigrid Smitt Goldman, CEO and Executive Chairman of the 3DISC group, with
the company’s Heron IOS scanner during the 2017 Greater New York Dental
Meeting.
After a two-year development process, you showcased the market-ready Heron IOS in New York. What
were priorities in the development of the scanner?
The Heron’s lightweight design and ability to update
in real time make it an essential tool in the contemporary dental practice. In development, we focused on ergonomics for the dentist and comfort for the patient.
Recognising that size and flexibility in scanning are essential, we developed a small, lightweight hand- and
mouthpiece with a 360° rotating tip for maximum flexibility and comfort when scanning the upper and lower
arches.
Were there any challenges you had to overcome in
the development process?
During the development process, we took initial concepts to dentists early on in the design phase and were
54 CAD/CAM
1 2018
Increasingly, dental manufacturers are introducing
open solutions. Is Heron IOS compatible with solutions other than those of 3DISC too?
Yes, the scanner output is entirely open, providing both
STL and PLY format, and expected to be compatible with
most open dental CAD systems.
Our QuantorClinic software is a combination of our
own scan software and exocad’s DB software, with dentalshare as the primary laboratory sharing tool. It facilitates order management, scanning, validation, commenting and order submission to the laboratory.
The Heron offers an all-in-one application accessible
from one interface—a truly open solution with what we
believe is one of the market’s best-optioned CAD integrations.
Have you already planned any updates, such as introducing a wireless Heron IOS version in the future?
Naturally, the development of the solution does not end
with the upcoming launch. We primarily expect updates
on the software side, such as improvements to the free
QuantorClinic software license that comes with the scanner. This means that dentists that order the first-generation software now will automatically get the updates with
their software at no extra charge.
[55] =>
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In 2017 about 8,000 dentists,
visited SCANDEFA.
assistants and dental technicians
see
statistical information please
SCANDEFA with For further
In 2018 we are pleased to present
scandefa.dk
course programme
two fair days and a flexible
to sales, branat the Annual Meeting. In addition
Where to stay during SCANDEFA?
and therefair format gives you
ding and customer care, the
fair days require a lot of energy,
staff care, profes- Two busy
breakfast are
night’s sleep and a delicious
the opportunity for networking,
development. fore a good
a special price
sional inspiration and competence
We offer all of our exhibitors
must.
a
CopenCenter
Bella
hotels, AC Hotel Bella Sky Copenhagen
SCANDEFA is organised by
with the Annual for our three
hotel, Hotel Crowne
hagen and held in collaboration
Scandinavia’s largest design
Danish Dental Associa- –
sustainable hotels in
Meeting organised by the
Plaza – one of the leading
Marriott Hotel.
tion (tandlaegeforeningen.dk).
Denmark and 5 Copenhagen
*
How to exhibit
or contact
Please book online at scandefa.dk
Ekstrom
Sales & Relations Manager Jacob
jaek@bchg.dk
transport between
We also offer easy shuttle service
and AC Hotel Bella
the airport, Hotel Crowne Plaza
Sky Copenhagen.
SCANDINAVIAN DENTAL
12.-13. APRIL 2018
FAIR
scandefa.dk
56 CAD/CAM
1 2018
British Dental Conference and
Dentistry Show
SCANDEFA
...THAN MEETS THE EYE
12–13 April 2018
Copenhagen, Denmark
www.scandefa.dk
VISIT: WWW.THEDENTISTRYSHOW.CO.UK
18–19 May 2018
Birmingham, UK
www.thedentistryshow.co.uk
[57] =>
© 32 pixels/Shutterstock.com
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m.wojtkiewicz@dental-tribune.com
CAD/CAM
1 2018
57
[58] =>
| international imprint
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Prof. Albert Mehl (Switzerland)
Prof. Gerwin Arnetzl (Austria)
Dr Stefan Holst (Germany)
Hans Geiselhöringer (Germany)
Dr Ansgar Cheng (Singapore)
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Copyright Regulations
CAD/CAM international magazine of digital dentistry is published by Dental Tribune International (DTI) and appears in 2018 with four issues. The magazine and all articles and
illustrations therein are protected by copyright. Any utilisation without the prior consent of editor and publisher is in-admissible and liable to prosecution. This applies in particular to duplicate copies,
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published about associations, companies and commercial markets. All cases of consequential liability arising from inaccurate or faulty representation are excluded. General terms and conditions apply.
Legal venue is Leipzig, Germany.
58 CAD/CAM
1 2018
[59] =>
Your time is precious
“Many clients specifically ask for
authentic manufacturer parts,
so we are thankful to have both
the design and milling completely
done by Nobel Biocare.
”
Mr Joseph M. Apap, CDT, MDT, US
s at
V isit u
E AO:
D 3,
B o ot h l y
a
hospit
Outsource with NobelProcera Services
Save time by outsourcing scan, design and production of your precision-fit abutments,
implant crowns and implant bars. Simply send us your case and our team of skilled CAD
designers will do the rest. You’ll get the design for approval within 24 hours.
Deliver authentic products in unrivaled quality to your customers.
Visit nobelbiocare.com/nobelproceraservices
GMT 51087 GB 1704 © Nobel Biocare Services AG, 2017. 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. Please refer to nobelbiocare.com/trademarks for more information. Product images are not necessarily to scale. Disclaimer: Some products may not be regulatory
cleared/released for sale in all markets. Please contact the local Nobel Biocare sales office for current product assortment and availability. For prescription use only. Caution: Federal (United States) law restricts
this device to sale by or on the order of a licensed dentist. See Instructions for Use for full prescribing information, including indications, contraindications, warnings and precautions.
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/ Digital workflow: From planning to restoration
/ Immediate full-arch restoration in the maxilla
/ Cone beam supplement
/ “Good design will pay off”
/ European Parliament adopts new medical device regulations
/ US dental prosthetic market set to grow with digitalisation
/ Non-original abutments are “a lottery that you cannot win” - Interview with Prof. Matthias Karl
/ “A truly open solution” - Interview with Sigrid Smitt Goldman, CEO and Executive
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