CAD/CAM international No. 3, 2011
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CAD0311_01_Title
CAD0311_01_Title 13.12.11 10:39 Seite 1
issn 1616-7390
Vol. 2 • Issue 3/2011
CAD/CAM
digital dentistr y
international magazine of
3
2011
| case report
Simple and efficient crown fabrication
with an advanced CAD/CAM system
| clinical technique
TRIPOD—A new protocol for immediate
loading of complete implant-supported prostheses
| practice management
Connectivity in the dental world
[2] =>
CAD0311_01_Title
emax_2010_ad_coachman_e_A4.qxd
22.2.2010
13:47 Uhr
Seite 1
“SUCH A SIMPLE
SYSTEM.
SO MANY
OPTIONS.”
Christian Coachman, Dentist, Ceramist, Brazil.
Regardless of the indication, IPS e.max offers a
suitable all-ceramic solution: from thin veneers to
12-unit bridges – without compromising esthetics.
ic
m
a
r
e
all c
need
u
o
y
all
www.ivoclarvivadent.com
Ivoclar Vivadent AG
Bendererstr. 2 | FL-9494 Schaan | Principality of Liechtenstein | Tel.: +423 / 235 35 35 | Fax: +423 / 235 33 60
[3] =>
CAD0311_01_Title
editorial _ CAD/CAM
I
Dear Reader,
_Dentistry goes is digital! Today, digital dental technology is part of the everyday
dental practice just like drills, X-rays and rubber dams. The rapid developments of recent
years have resulted in increased precision and enormous time and cost savings for patients,
dentists and dental technicians.
Vera Baptist
But how do YOU keep up with the latest developments? How do you wish to be educated on the latest trends and how do you find out about what educators—dental schools,
companies, associations, etc.—are offering?
caD/cam offers you the overview! The magazine is committed to accompanying the
current developments by informing its readers about the latest treatment concepts and
technologies and how these can be integrated into today’s practice for the benefit of everyone involved—the patients and the dental professionals.
caD/cam strives to serve as a platform for information exchange. To further support
and promote this, we have created a new rubric—digital platforms—that will be introduced
in the first issue of 2012. Here, dental schools, companies, associations, societies and continuing education providers are invited to announce their course schedules. We will also include course schedules on our website www.dental-tribune.com and link to the online course
registration forms via QR codes in the magazine.
I would like to encourage everyone—dentists, dental technicians and industry—to participate in this exchange.
Yours sincerely,
Vera Baptist
Product Manager
caD/cam
3_ 2011
I 03
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CAD0311_01_Title
CAD0311_04_Content 13.12.11 17:13 Seite 1
I content _ CAD/CAM
I editorial
03
I special
Dear Reader
28
| Vera Baptist, Product Manager
If you are smart enough to be a dentist,
you are smart enough to be interesting
| Dr Paul Homoly
I case report
06
Immediate restoration in the fully
edentulous maxilla region
I feature
34
| Dr Max J. Cohen
10
The Nordic masters of dentistry
| Daniel Zimmermann
Simple and efficient crown fabrication with an
advanced CAD/CAM system
I industry news
| Dr Brian Buehler
36
CAMLOG Congress to be hosted in Lucerne
| CAMLOG
I news
14
38
Researchers develop software to improve attachment
for dental crowns
Innovation Days at Sirona
| Sirona
I meetings
I clinical technique
16
TRIPOD—A new protocol for immediate loading of
complete implant-supported prostheses
| Dr Jean-Nicolas Hasson et al.
I practice management
22
40
International Events
I about the publisher
41
42
| submission guidelines
| imprint
issn 1616-7390
Vol. 2 • Issue 3/2011
CAD/CAM
digital dentistry
international magazine of
3
2011
Connectivity in the dental world
| case report
| Shane Hebel
Simple and efficient crown fabrication
with an advanced CAD/CAM system
| clinical technique
TRIPOD—A new protocol for immediate
loading of complete implant-supported prostheses
| practice management
Connectivity in the dental world
26
The passive income practice
| Dr Phillip Palmer
04 I CAD/CAM
3_ 2011
Cover image courtesy
of Ivoclar Vivadent.
[5] =>
CAD0311_01_Title
C-522-76-V0-10
CEREC.
Made to inspire.
NEW
CEREC SW 4.0
For many years CEREC has been inspiring users worldwide. Often dentists, who were initially
skeptical about CAD/CAM technology, become its most enthusiastic practitioners. And not only
users are inspired. State-of-the-art treatment during a single appointment is a totally new
experience for patients. Word of this spreads fast and it soon becomes the flagship of the dental
practice. For dentists the defining feature of CEREC has always been greater job satisfaction. Now
this has been further enhanced with the entirely new intuitive software 4.0. Discover for yourself
the unique - and inspirational - potential CEREC offers. Enjoy every day. With Sirona.
www.sirona.com/cerec-inspired
C-522-76-V0-10_210297.indd 1
22.09.11 09:03
[6] =>
CAD0311_01_Title
CAD0311_06-08_Cohen 13.12.11 17:14 Seite 1
I case report _ implant placement
Immediate restoration
in the fully edentulous
maxilla region
Author_ Dr Max J. Cohen, USA
Fig. 1
Fig. 2
Fig. 1_Pre-op SimPlant planning
showing the scan prosthesis.
Fig. 2_Pre-op SimPlant planning
showing Virtual Teeth.
Fig. 3_Immediate Smile model with
analogues inserted.
Fig. 4_Immediate Smile denture
used to mount case.
Fig. 5_SurgiGuide orientation and
registration on articulator.
Fig. 3
_This clinical case required optimal implant
placement based upon a restoratively driven treatment plan and guided surgery. To achieve this goal, we
made use of CT scans, SimPlant (Materialise Dental)
planning software, the new Zimmer Guided Surgery
Instrumentation and the new Immediate Smile model
(Materialise Dental). The patient was a 49-year-old
female in good health, completely edentulous in the
maxilla and wore a complete upper denture. On the
lower, she wore an implant-retained over-denture.
The planning phase for the case began with a CT
scan utilising the i-Cat and the Dual Scan protocol
Fig. 4
06 I CAD/CAM
3_ 2011
(Materialise Dental). The patient’s existing denture
was transformed into a scan prosthesis by gluing
eight Dual Scan Markers onto the surface. A radiolucent bite index was made to secure the prosthesis
in the correct position.
The patient was first scanned in the i-Cat 17-19
while wearing the scan prosthesis and the bite index.
In a second scan, the scan prosthesis was scanned
alone. The resulting CT data was loaded into SimPlant, and the scan prosthesis was superimposed
upon the study using the SimPlant Dual Scan wizard
(Figs. 1a & b).
Fig. 5
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CAD0311_01_Title
case report _ implant placement
I
Fig. 6_Pre-op occlusal view
of the maxilla.
Fig. 7_Tissue punch.
Fig. 8_View of the punched maxilla
after tissue removal.
Fig. 9_SurgiGuide orientation
in the patient’s mouth.
Fig. 6
Fig. 7
Fig. 8
Fig. 9
Using SimPlant, the optimum implant positions
were determined, based upon available bone, a minimum of 3 mm between implants, and the design of
the final restoration (Figs. 2a & b). The resulting
treatment plan was submitted to Materialise Dental
for fabrication of a SurgiGuide and an Immediate
Smile model.
ten drilling instructions and a prolongation report
detailing the depth and size of each osteotomy.
I received the Immediate Smile model, which
contained a duplicate of the scan prosthesis, a bone
model with a silicone soft tissue, and a mucosa-supported SurgiGuide. The bone model came with eight
openings corresponding to each of the eight implant positions as designed in the SimPlant plan and
corresponding exactly in size to the dimensions of
Zimmer analogues.
The bone model came with a screw fixation system, which allowed me to recover the analogues.
The silicone soft tissue on the model also corresponded to realistic soft tissue. I also received writ-
Fig. 10
Zimmer analogues were placed in the Immediate
Smile model (Fig. 3). The duplicate of the scan prosthesis was used to mount the bone model with the
soft tissue on an articulator (Fig. 4), giving correct
orientation and vertical dimension. This made it
possible to fabricate a provisional that would be
used for immediate loading following implant
placement.
The mounted model was then used to create
an orientation jig for the SurgiGuide (Fig. 5). The jig
assured that the SurgiGuide was positioned in the
mouth exactly the same way as the scan prosthesis
had been positioned in the mouth. This is a very important step for a mucosa-supported SurgiGuide
because of the flexibility of the soft tissue (mucosa).
Both the duplicate of the prosthesis and SurgiGuide
fit perfectly onto the Immediate Smile model, al-
Fig. 11
Figs. 10 & 11_Creating guided
osteotomies.
Fig. 12_Occlusal view of the
implants and abutments.
Note the healing heads on the two
implants with sinus lifts.
Fig. 12
cad/cam
3_ 2011
I 07
[8] =>
CAD0311_01_Title
CAD0311_06-08_Cohen 13.12.11 17:14 Seite 3
I case report _ implant placement
Fig. 13
Fig. 15
Fig. 14
Fig. 13_Provisional hollowed out to
fit over the temporary abutments.
Fig. 14_Provisional with bite
registration for alignment in mouth.
Fig. 15_Completed
screw-retained provisional.
lowing for fabrication of an accurate orientation jig
on an articulator.
The surgical guide was placed in the patient’s
mouth, and the tissue was punched utilising a tissue
punch (Figs. 6–8). Then, the surgical guide was again
oriented in the patient’s mouth with the orientation
jig created on the articulator and stabilised with three
Fig. 16b
Fig. 16a
Figs. 16a & b_Final restoration.
Fig. 17_Post-op CT scan.
Fig. 17
08 I CAD/CAM
3_ 2011
SurgiGuide fixation screws (Fig. 9). Utilising the Zimmer Guided Surgery Instrumentation and Guided
Surgery drills, all eight osteotomies were created and
completed using minimally invasive flapless surgery
(Figs. 10 & 11). The Zimmer guide is a SAFE system, accurately providing for depth and size.
The right and left molar (teeth #3 and 14) osteotomies were created short of the maxillary sinus.
Then, using the new Sinus Crestal Approach Kit
(Zimmer), I extended
these two osteotomies into the left and
right maxillary sinuses. Alloplastic bone
(Puros, Zimmer) was
placed into the sinus
cavity through the
osteotomy and spread
using the paddleshaped spreading bur.
Then, all eight implants were placed.
Each had initial stability exceeding 35 Ncm.
I decided to immediately load only the six implants that did not involve the sinus cavity. Therefore, healing heads were placed on implants #3 and
14, and non-engaging titanium temporary cylinders were placed on #5, 6, 8, 9, 11 and 12 (Fig. 12).
The provisional, which the laboratory fabricated,
was attached to the titanium cylinders using cold
cure acrylic, thus creating a screw-retained provisional (Figs. 13 & 14).
A post-operative CT scan
showed how accurately the eight
implants had been placed in the
bone using a mucosa-supported
SurgiGuide with orientation jig
(made on the Immediate Smile
model; Figs. 16a, b & 17). The accuracy and success of this case
were achieved through CT scanning,
SimPlant planning with restorative
model overlay, the Zimmer Guided
Surgery Instrumentation and the Immediate Smile
model. The surgical guide allowed for minimally
invasive surgery and greatly reduced surgery time.
The Immediate Smile model also reduced chair time
by allowing for fabrication of the temporaries well
in advance of surgery. The final restoration for this
case is a milled zirconia, screw retained appliance.
_Acknowledgement
Laboratory procedures and photographs were
provided by Dr Marcelo Silva._
_contact
CAD/CAM
Dr Max J. Cohen
4700 Chamblee Dunwoody Road
Dunwoody, GA 30338
USA
MaxJCohen@hotmail.com
www.DrMaxCohen.com
[9] =>
CAD0311_01_Title
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[10] =>
CAD0311_01_Title
CAD0311_10-13_Buehler 13.12.11 17:15 Seite 1
I case report _ crown fabrication
Simple and efficient crown
fabrication with an advanced
CAD/CAM system
Author_ Dr Brian Buehler, USA
Fig. 1
Fig. 1_The patient presents after
undergoing endodontic treatment
one week earlier.
Fig. 2_Temporary material remains
on tooth #13. Additionally, decay
and tobacco stains are noted
on the adjacent teeth.
Figs. 3 & 4_Tooth #13 after
preparation.
Fig. 2
Fig. 3
10 I CAD/CAM
3_ 2011
_Today’s computer-aided design and manufacture (CAD/CAM) technologies contribute greatly
to restorative dentistry and provide clinicians with
advanced treatment options for various indications,
including inlays, onlays, fixed partial dentures and
full dentures, thin veneers and crowns.1,2 These systems also allow use of many restorative materials,
including metal, metal-ceramic, composite and allceramic, to best meet the needs of the case and patient.1,2 Further, CAD/CAM systems are available for
both chairside and laboratory applications, so dentists now have the ability to create highly aesthetic
and strong restorations in office.1,2
Fig. 4
Unlike earlier generations of in-office systems
that presented clinical challenges, today’s technology and materials are cost effective and efficient.
Past systems lacked advanced software to control
the tool path accurately and design a restoration,
and inadequate scanning technology made it difficult to detect the delicate margins created during
tooth preparation.1,3 The lack of advanced material
sciences also contributed to a number of clinical
challenges experienced with early CAD/CAM technology, and dentists struggled to properly seat
CAD/CAM-processed restorations. To address the
clinical challenges experienced with early CAD/CAM
technology, manufacturers have developed systems that offer many advantages, including greater
cost effectiveness, simplicity and efficiency.1,4
_The CEREC system
Amongst this new generation of CAD/CAM
systems is CEREC (Sirona), which was developed to
address many concerns dental professionals had
regarding the set-up of conventional CAD/CAM
software and machines.5,6 The milling chamber is
now separated from the image capture and design
hardware, allowing dental professionals to simultaneously design one restoration while milling
another.5,6 With significantly higher speeds and
greater memory, CEREC 3-D design software allows
users to view tooth designs as they would if evaluating traditional stone models.5,6
Today’s CEREC system includes a light-emitting
diode (LED) camera (CEREC Bluecam, Sirona) for
greater accuracy and higher quality images than
previous infrared-emitting camera systems, and the
recent addition of CEREC Connect (Sirona) allows
impression and restoration information to be digitally acquired and transmitted over the Internet to
dental laboratories.5,6 Laboratories can then fabricate restorations using the CEREC inLab System
(Sirona).5,6
[11] =>
CAD0311_01_Title
CAD0311_10-13_Buehler 13.12.11 17:15 Seite 2
case report _ crown fabrication
I
The CEREC MC XL system (Sirona) is a powerful
and accurate low-noise chairside CAD/CAM milling
system that offers simplicity and efficiency for processing single-tooth restorations in six minutes and
quadrant restorations in three to four minutes in a
single appointment.5–7
The CEREC MC XL demonstrates precision and
accuracy within the range of +/- 25 µ, and the 7.5 µ
milling resolution creates restorations with improved fit and smoother surfaces.5–7 Additional
features include automatic software downloads,
simple display guides and network connectivity,
and the milling chamber design enables easy block
clamping without tools.5–7
Fig. 5
Fig. 6
_Material considerations
To address CAD/CAM material concerns, manufacturers have developed new ceramic materials
that provide improved strength and aesthetics.5
These newer ceramics withstand CAD/CAM processing without chipping or fracturing and can be
brought to full contour during milling to improve
fit and function.5 Dentists can choose adhesive
bonding or conventional cementation when seating
these restorations, which ensures that case requirements are met.5 Improvements to cementation and
adhesive systems have also enabled dentists to
provide a strong bond between the restoration and
underlying tooth substrates.1,4
_IPS e.max CAD
Composed of 70 % by volume needle-like crystals in a glassy matrix, lithium disilicate glassceramic (IPS e.max, Ivoclar Vivadent) offers many
improvements to previous generations of ceramic
materials.8 Available in a pressable format (IPS e.max
Press) or for CAD processing (IPS e.max CAD), the
material demonstrates strength values between
360 (Press) and 400 MPa (CAD).8
Fig. 8
Fig. 7
#13 (Fig. 1) and was unhappy with the tooth’s appearance. Along with decay on the adjacent dentition, tobacco stains were also present because the
patient was a smoker (Fig. 2). Although the patient
requested that treatment be confined to only tooth
#13, after a routine head, neck and oral cavity
examination, the patient was informed of multiple
treatment needs and advised that a comprehensive
treatment plan should be started as soon as possible.
Treatment plan
The patient brought to the office the endodontic
report from his other clinician, advising that a good
prognosis was expected from his endodontic treat-
Fig. 5_The preparation of tooth #13,
surrounding dentition and soft
tissues are sprayed with CAD/CAM
scanning powder prior to scanning.
Fig. 6_The IPS e.max CAD lithium
disilicate crown after milling
in CEREC MC XL.
Figs. 7 & 8_The lithium disilicate
crown is tried in the patient’s mouth
to confirm fit, contour and anatomical
harmony prior to firing.
Fig. 9_Tobacco stains are placed on
the crown to mimic the surrounding
dentition, and the crown is crystallised.
Fig. 10_Luting composite is placed
on the internal surfaces of the crown.
IPS e.max also demonstrates lifelike optical qualities that enable dentists to create highly aesthetic
and naturally appearing restorations in a variety of
cases.8 The versatile material is indicated for anterior
and posterior restorations, including thin veneers
(0.3 mm), minimally invasive inlays and onlays,
partial crowns and crowns, implant superstructures, three-unit anterior/premolar bridges (press
only), and three-unit bridges (zirconium-oxidesupported IPS e.max CAD only).8
_Case presentation
A 53-year-old male patient presented after
undergoing recent endodontic treatment on tooth
Fig. 10
Fig. 9
CAD/CAM
3_ 2011
I 11
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CAD0311_01_Title
CAD0311_10-13_Buehler 13.12.11 17:15 Seite 3
I case report _ crown fabrication
Clinical protocol
After thorough examination and
prophylaxis, tooth #13 was prepared
for restoration with a CAD/CAM (CEREC
MC XL) processed lithium disilicate
crown (IPS e.max CAD) and the temporary material removed. A specialised
mouthpiece (Isolite, Isolite Systems)
was placed intra-orally to ensure total
isolation was achieved (Figs. 3 & 4).
Fig. 11
Fig. 12
Fig. 11_The crown is seated on the
preparation of tooth #13.
Fig. 12_Initially, excess cement
is removed from the cervical
and interproximal areas
with a micro-brush.
Fig. 13_Pressure is applied with
dental forceps to ensure that the
crown remains in proper position
after initial excess cement removal.
Fig. 14_Applying pressure to the
crown, excess cement is removed
from the interproximal spaces
with dental floss.
Fig. 15_The crown is cured on the
buccal, lingual and distal surfaces
with the bluephase LED curing light.
Fig. 16_Dental floss is used to
remove any remaining cement from
the interproximal spaces.
Fig. 17_The final restorative result.
Fig. 14
ment. Although the report did not detail the possible need for crown lengthening or gingivectomy
procedures, these were areas of diagnostic concern
in this case. However, biological width encroachment did not appear to be an issue during cleaning
and probing.
To address the patient’s concern with the aesthetic appearance of tooth #13, high-translucency
and high-strength, lithium disilicate glass-ceramic
would be CAD/CAM processed into a crown. Milled
to as thin as 300 µm axially, the lithium disilicate
crown would instil a contact lens effect on the gingival–facial margin of tooth #13.
The crown would then be bonded in place with
an adhesive that demonstrates high radiopacity to
ensure that excess cement was not inadvertently
left behind, specifically in the deep distal margin in
this case. The adhesive bonding agent also ensured
that cementation was predictable. When complete,
the tooth would appear natural and indistinguishable from the surrounding dentition.
Fig. 15
12 I CAD/CAM
3_ 2011
Fig. 13
Fig. 16
Prior to scanning, the tooth #13
preparation, the surrounding dentition and the soft tissues were sprayed
with a CAD/CAM powder (Fig. 5). The
anatomical form of the dentition and
soft tissues was then captured using
an LED scanning unit (CEREC Bluecam). After scanning, 3-D software (CEREC 3D) was used to design
the desired crown contours and occlusal relationships. A prefabricated high translucency lithium
disilicate block (IPS e.max CAD) was then milled
chairside (CEREC MC XL) into a crown for tooth #13
(Fig. 6). Lithium disilicate was the material of choice
in this case because it demonstrates high strength
and lifelike optical properties.
The crown was tried in the patient’s mouth over
the tooth #13 preparation to evaluate fit, contour
and anatomical harmony (Figs. 7 & 8). Upon confirmation of proper fit and function, the crown was removed, cleaned and dried. Stains were then placed
on the crown surface to mimic the tobacco stains on
the surrounding dentition. However, it was decided
that cervical stains to mimic the decay on the natural dentition would not be placed. After staining,
the lithium disilicate crown was crystallised and
ready for immediate seating (Fig. 9). The specialised
mouthpiece (Isolite) was repositioned in the mouth
to isolate the tooth during cementation.
Fig. 17
Dual-curing luting
composite (Multilink
Automix, Ivoclar Vivadent) was used to seat
the crown. Indicated
for use with metal,
all-ceramic, metalceramic and composite restorations, the
luting composite offers a strong hold on
all surfaces and is
available in transparent, yellow or opaque
shades to ensure
proper aesthetics are
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CAD0311_01_Title
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case report _ crown fabrication
I
achieved. Additionally, the cement
does not need to be protected from
ambient light during mixing and
placement.
Prior to application, the primer liquids (Multilink A/B) were mixed in a 1:1
ratio. A micro-brush was used to apply
and lightly scrub the primer mix on
the preparation enamel and dentine
for 15 seconds. The priming agent was
allowed to set on the enamel and dentine for 30 seconds, after which time
air was used to evaporate the primer
solvents. Because the primer is selfcuring, light-curing was unnecessary.
The luting composite (Multilink
Automix) was extruded from the mixing tip and placed directly on the inner
surfaces of the lithium disilicate crown (Fig. 10). The
luting composite was placed carefully to ensure that
all internal surfaces were fully covered. The lithium
disilicate crown was then seated on tooth #13 and
slight pressure applied (Fig. 11).
A micro-brush was utilised initially to remove
excess cement from the interproximal spaces and
cervical areas of the crown (Fig. 12). Further pressure
was applied with dental forceps to ensure the crown
remained seated in the proper position during initial
clean-up (Fig. 13). While still applying pressure to
the seated crown, excess cement between the interproximal areas of the crown and surrounding dentition was removed with dental floss (Fig. 14). After
flossing, the crown was cured with an LED curing
light (bluephase G2, Ivoclar Vivadent) on the buccal,
mesial, lingual and distal surfaces (Fig. 15). The interproximal spaces were then flossed to ensure that
all excess cement had been removed (Fig. 16).
Upon completion of the case, the CAD/CAMprocessed lithium disilicate glass-ceramic crown
cemented with the dual-curing luting composite
demonstrated excellent fit, function and strength
(Figs. 17–20). Additionally, a post-operative radiograph confirmed that all excess cement had been
removed and excellent internal/marginal adaptation achieved (Fig. 21).
The patient was very pleased with the aesthetics
of the crown, which appeared natural and indistinguishable from the surrounding dentition. Further,
the patient was pleased that he did not have to
return for another appointment because the chairside CAD/CAM system allowed the restoration to
be scanned, designed, milled and seated in a single
appointment.
Fig. 18
Fig. 19
Fig. 20
_Conclusion
I use the CEREC CAD/CAM system almost exclusively in my practice because patients appreciate
the quality, immediacy and not having to return for
additional appointments. Restorations milled with
CEREC demonstrate the form and fit required for
restoring even the most challenging cases. Patients
also enjoy the high aesthetics and strength of
lithium disilicate glass-ceramic IPS e.max that has
been milled with CEREC._
Fig. 21
Figs. 18–20_The final restorative
result demonstrates excellent fit,
function and lifelike aesthetics.
Fig. 21_The final radiograph
confirms that proper internal and
marginal adaptation has been
achieved, along with complete
removal of excess cement.
Editorial note: A complete list of references is available
from the publisher.
_about the author
CAD/CAM
Dr Brian Buehler has been
practising dentistry for more
than 20 years. He received his
DDS from the University of
Southern California’s School of
Dentistry in Los Angeles and
his BA in Economics from
the University of California,
Los Angeles. Buehler has worked as a beta-tester
for both Sirona and E4D. He still works as an advisor
to Sirona in product development and placement.
Dr Brian Buehler
Laguna Beach Dental Group
31796 South Coast Hwy.
Laguna Beach, CA 92651
USA
www.lagunabeachdental.com
CAD/CAM
3_ 2011
I 13
[14] =>
CAD0311_01_Title
CAD0311_14-15_Researchers 13.12.11 17:16 Seite 1
I news _ 3-D software
Researchers develop
software to improve
attachment for dental crowns
Between July 2009 and July 2010, 477,060 dental
crown treatments were done in Sweden. Chalmers
researchers calculated that the treatments cost
more than US$258 million, of which a large proportion was paid from tax monies through dental
health insurance. A crown manufactured in a laboratory costs around US$760.
When a treatment is necessary, dentists first
have to grind down the patients’ teeth to which the
crowns are to be attached. This is a handicraft job
that is entirely dependent on the individual dentist’s
eye and skill. However, according to the Swedish researchers, dentists will soon benefit from a computer program being developed at the initiative of
Nobel Biocare, Swiss-based provider of innovative
restorative and aesthetic dental solutions. The researchers are now planning to run clinical tests.
Visualisation of a tooth showing
the optimal shape that should remain
after the tooth has been ground
down in order to be fitted with
an artificial dental crown.
14 I CAD/CAM
3_ 2011
_Researchers at Chalmers University of Technology in Gothenburg are currently developing a
method to determine exactly how a tooth should be
ground down in order to attach a dental crown to it.
The method is expected to result in significantly
cheaper and faster treatment, with a reduced risk of
patients having problems with their crowns. Additionally, the researchers have developed 3-D software
for dental students to learn how to grind down teeth.
“With our software, you can feed in the existing
tooth’s measurements, done by laser scanning the
tooth,” explained Chalmers researcher Evan Shellshear. “The software then calculates how much of
that tooth should be ground down, and the output
is a 3-D model of the optimal shape of the tooth.
You also get a 3-D animation showing precise suggestions for manœuvring the grinding tool in order
[15] =>
CAD0311_01_Title
CAD0311_14-15_Researchers 13.12.11 17:16 Seite 2
news _ 3-D software
to achieve the objective without colliding with the
teeth or mouth parts.”
The software is based on advanced mathematical models and on state-of-the-art visualisation
technology. The researchers have based their work
on international guidelines on how teeth should be
shaped before being fitted with dental crowns. The
guidelines cover the ratios between the height and
width of the tooth and the extent to which a layer
needs to be ground down in order to leave enough
space for the crown, for example.
The researchers report they have converted every
guideline into an equation, dividing each tooth into
10,000 sections. From that, the software performs
an optimisation, leaving as much of the tooth as
possible. “Most dentists are very skilful, but no human being can achieve this sort of optimisation as
efficiently as a computer program,” said Chalmers
researcher and dentist Matts Andersson. “If the
tooth does not have a good fit with the crown, bacteria can accumulate in the gaps, resulting in caries
and loosening of the teeth. A bad fit can also lead
to problems with the jaw joint—or to the dental
crown simply falling off.”
According to the researchers, their new method
should therefore reduce the risk of such problems.
It would also shorten the time needed for treatment
and save large amounts of money.
to grind teeth. Currently, students have no access
to simulation programs with defined objectives.
“There are other simulation tools available but the
main contribute of our simulator is that we have
defined objectives i.e. the student can immediately
see how close they get to the optimal result, and
they know what to aim for,” Chalmers researcher
Staffan Björkenstam told CAD/CAM.
The researchers have also produced 3-D software that dental students can use for learning how
The above images show the original
tooth in transparent with the
optimal tooth preparation inside,
colour coded by depth, i.e. how much
material that has been removed.
(Photos courtesy of
Staffan Björkenstam, Chalmers)
The research into tooth grinding is based on
methods originally produced for vehicle manufacturing and derived from automatic path planning
for industrial robots, something that production
researchers and mathematicians at Chalmers are
working on jointly with the motor industry.
The project is a cross-disciplinary collaboration, financed by Nobel Biocare and VINNOVA, a
Swedish government agency that administers state
funding for research and development. The collaboration partners are the Department of Product
and Production Development at Chalmers, the
Fraunhofer–Chalmers Research Centre for Industrial Mathematics, and Nobel Biocare._
Editorial note: A 3-D animation demonstrating the
precise manœuvring of the grinding tool is available
on www.dental-tribune.com/articles/content/id/6619 or
simply scan the QR code with your smartphone.
_contact
“I estimate that the treatment sessions would
be 10 per cent shorter,” said Andersson. “That would
result in savings of US$27 million per year. However,
the biggest benefit would probably be an improvement in quality, increasing the life of the dental
crowns and reducing the number of remakes.”
I
CAD/CAM
Fraunhofer-Chalmers Centre
Chalmers Science Park
Sven Hultins Gata 9D
41288 Göteborg
Sweden
www.chalmers.se
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I clinical technique _ TRIPOD
TRIPOD—A new protocol for
immediate loading of complete
implant-supported prostheses
Authors_ Dr Jean-Nicolas Hasson, Dr Jacques Hassid & Dominique Fricker, France
_Immediate loading of complete maxillary implant-supported bridgework is an increasing request
by patients who have high aesthetic and functional
demands and attach great importance to a neat appearance and their self-image. Since 1977, positive
results have been obtained in immediate loading,1,2
but these were limited to mandibular, bar-retained
removable dentures. In 1997, Tarnow et al. 3 published
Fig. 1b
Fig. 1a
Figs. 1a–c_Precision positioning
of dental implants is mandatory
for adequate abutment and
screw placement.
a study showing similar results for maxillary and
mandibular full-arch, implant-supported bridgework,
and, more recently, the focus has turned to the development of computer-based techniques for improved results.
Highly sophisticated technical tools such as
NobelGuide (Nobel Biocare) and the SAFE SurgiGuide
(Materialise Dental) have entered the market and related techniques such as All-on-4 (Nobel Biocare) are
being promoted4,5 to help meet patients’ demands.
All techniques are based on full maxillary bridgework
with a screw-based retention. The screw-retained
bridgework allows all procedures to be performed
during the treatment, i.e. impression taking, bridge
modification and repair for aesthetic or functional
purposes.
Amongst the more challenging difficulties in carrying out such a therapy is implant positioning, espe-
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cially for a single crown in the anterior region. Precise
placement is essential in achieving good aesthetics,
phonetics, function and cleanability. Most of the
time, implant placement has to be within the limits
of 0.5 mm (Fig. 1). Another factor to consider is the
possible loss of alveolar bone after tooth extraction,
leaving a minimal residual volume, and thereby increasing the difficulty of the procedure.
Fig. 1c
The positioning of implants depends on the
guide’s positional accuracy in a definitive place at the
time of the surgery and on the accuracy of the guide
itself. In the case of NobelGuide, accurate positioning
depends on the patient’s ability to bite reproducibly
and precisely, with even gingival thickness and consistency, and assumes that bone shows a similar degree of hardness at different screw-retention sites.
Unfortunately, as recently reviewed by Schneider
et al. 6 and de-tailed by Valente et al.,7 the deviation
between entry point and orientation consistently
differs between the planned and actual position of
the implants. This generally accounts for the results
obtained by guides used in flapless surgery. Other
failure factors may be related to poor cooling ability
during the drilling procedure.8
As cited above, inaccuracies may arise from the
positioning of the guide or of the patient, or be related
to the radiological technique itself. In the case of flap-
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clinical technique _ TRIPOD
e
a
b
c
d
Fig. 2_The Positioning TRIPOD is
based on a temporary implant (a)
and two residual teeth (b & c).
Fig. 3a_The radiographic template
fixed on the Positioning TRIPOD
with standardised X-ray opaque
resin pins.
f
a
b c
Fig. 2
Fig. 3a
less surgery, the position of the guide is conditioned
by the thickness and consistency of the underlying
soft tissue, as well as the patient’s ability to bite
precisely in a replicable manner. In addition, there is
always some degree of patient movement during
the CT scan, which can hardly be controlled, an inaccuracy termed a “mechanical artefact”. Of course,
any study performed on cadavers or models cannot
reproduce this particular radiological aspect.9,10
We propose a new protocol in this article with the
aim of reducing inaccuracies in terms of reliability,
aesthetics and function.
Other inaccuracies are related to the radiological
equipment itself and include geometric, hardening
and threshold artefacts. Geometric artefacts are related to the ability of software to reconstruct a 3-D
space based on the serial addition of 2-D images that
are filtered by the software.11,12 Hardening artefacts
are due to the different densities of adjacent objects.
An X-ray beam is composed of individual photons
with a range of energies. As the beam passes through
an object, it becomes stronger, that is, its mean energy
increases because the lower-energy photons are absorbed more rapidly than higher-energy photons.13
The last significant artefact, the digital artefact, is due
to the segmentation masks that are used to obtain
volumes. In order to obtain a mask, an interval of radiodensity is defined by using the Hounsfield values
at both ends of the tissue(s) under interest. By using
this method, an area of lower or greater density can
be discarded and missed in the final volume. This may
be particularly true when digitally producing a surgical template based on hard or soft tissue. Finally,
images produced by available techniques are too unreliable to be used directly for this type of treatment.
Fig. 3b
I
_TRIPOD:
Description of a new clinical technique
Initially, a treatment plan is performed to evaluate
a case adequately, propose alternate solutions and
decide whether the patient is a suitable candidate
for a fully implant-supported maxillary bridge. This
requires a first assessment that includes a possible
wax-up and a radiographic stent for visualising the
crown position on the CT scan, as well as an evaluation of a potential need for bone- and soft-tissue
augmentation procedures. Patients often present
with their own cement-retained bridgework on
natural teeth in place that, when adequate, may be
used as a reference guide for implant placement. It
is essential to evaluate the implant site in the maxillary bone precisely. In order to perform these measurements, a Positioning TRIPOD and a Computing
TRIPOD need to be determined.
The term “Positioning TRIPOD” is used to denote
the selected pre-existing three fixed points (Figs. 2a–c)
in the mandible or maxilla, which can be based on:
_teeth that are sufficiently stable to support the
surgical guide during surgery;
_implants placed in posterior areas;
_temporary mini-implants that will be removed at
the end of surgery.
Fig. 4
Fig. 3b_The Computing TRIPOD.
Fig. 4_The position of standardised
X-ray opaque resin pins allows the
calculation of implant coordinates.
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Fig. 5a_The implant coordinates
for the transfer table.
Fig. 5b_The drill sleeves being
placed in the radiographic template
with the transfer table.
Fig. 5a
Fig. 5b
The choice of appropriate bases for the Positioning
TRIPOD is critical for its accuracy. Owing to its compressibility, soft gingival tissue has to be avoided. Problems with remaining teeth may arise owing to advanced periodontal disease causing excessive mobility.
In some cases, temporary mini-implants are used, but
often the amount of maxillary residual bone is so reduced that these implants only interfere with definitive implant placement. Nevertheless, they may be useful when no other alternative is available. Anecdotal
cases in which there is sufficient bone for temporary
and definitive implants at the same time have been reported, but are rare. The best choice is to use posteriorly placed implants before inserting anterior implants. In this case, an extremely precise positioning is
not required, since the large volume of the corresponding teeth provides some degree of freedom to the
laboratory technician designing the prostheses. These
posterior areas often require some bone reconstruction (such as sinus lift or onlay bone grafts), thereby
prolonging time to loading. The corresponding implants will then ensure the most precise positioning
not only for radiographic templates and surgical
guides, but also for the occlusal guide and impression
tray, since all these parts will be screw-connected to
these previously placed and osseointegrated implants.
TRIPOD. The position of the standardised X-ray opaque
reference pins is detected by the software, building the
Computing TRIPOD (Fig. 3b), and used to calculate
the implant coordinates (Fig. 4). This data is then set
in the transfer table (Fig. 5a) to place the drill sleeves
accordingly and transfer the radiographic template to
a surgical guide (Fig. 5b).
In order to transfer the planned implant position
from the planning software to the surgical guide,
a Computing TRIPOD is necessary. This Computing
TRIPOD is made with three SKYplanX reference pins
(bredent) placed on the radiographic template with the
reference plate (Fig. 3a). The patient is scanned with
the radiographic template fixed on the Positioning
Fig. 6_Initial impression of two
initially placed implants.
Fig. 7_Surgical guide placed on teeth
and screwed onto previously placed
implants forming the Positioning
TRIPOD.
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Fig. 6
Some days prior to the full-arch surgery, once an
adequate TRIPOD has already been planned and initial
implants placed, an initial impression (Fig. 6) will be
taken for the model to prepare the impression tray,
occlusal guide, surgical guide from the radiographic
template, and the provisional prostheses. The surgical guides are produced in sterilisable resin with radiopaque sleeves (DéPlaque). Special attention is given
to the impression tray that will extend to all maxillary
surfaces, but room for the impression material is exclusively limited to the planned implant sites. They
must be ready at the time of surgery.
On the day of the surgery, the practitioner begins
by reducing all remaining crowns that would interfere
with the surgical guide, which is then placed on teeth
or preferably screwed onto previously placed implants,
forming the Positioning TRIPOD (Fig. 7). A CT is performed to verify all drilling sites. If any modification
has to be done, there is still time to adjust the drill
sleeves to suitable positions and to re-sterilise the
guide.
The next step is the transfer of the occlusion to the
articulator. Usually an occlusion guide is engineered
before surgery and screwed into a suitable position. It
Fig. 7
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is then adjusted and some silicone material is added
to ensure a perfect bite (Fig. 8). The transfer is made to
the articulator before starting surgery. It is sometimes
possible to retain a molar with compromised prognosis until the definitive prosthesis is placed, thereby
keeping a reference point of initial occlusion.
When all materials are sterile, surgery can be initiated under the usual conditions. The flap is raised, the
remaining teeth planned for extraction are removed
and the surgical guide is placed on teeth or screwed
onto implants. Holes of 2.0 and 2.8 mm are drilled
through the sleeves using the VECTOdrill (Thommen
Medical) with a smaller tip fitting in and following the
prepared drill hole. Control of the depth is visual, since
depth marks on the drills can be easily seen on the facial aspect of the surgical guide. Speed and torque are
according to the manufacturer’s instructions. Cooling
is performed on the facial side (Fig. 9); the flap is maintained properly by the guide on the palatal side.
Once the drilling has been completed, the surgical
guide is removed and the last step of implant site
preparation is done using implant-specific drills, bone
spreaders or piezosurgery inserts. The choice of the
implant relies not only on the diameter, but also on the
implant length and profile to achieve the best possible
implant stability. Implants with advanced surface
technology, providing additional security in the early
healing phase such as the super-hydrophilic Thommen implant lines ELEMENT (cylindrical profile) and
CONTACT (conical-cylindrical profile) with INICELL
(Thommen Medical), are preferred. In order to perform
immediate loading, the implant should be inserted
with a minimum torque of 25 Ncm. If the bone provides poor primary stability, then a two-stage ap-
Fig. 8
Fig. 9
proach is required to ensure proper osseointegration
before placing the prostheses. VARIOmulti abutments
(Thommen Medical) are connected to the implants by
selecting proper width, height and angulation. Next,
impression copings are connected to the VARIOmulti
abutments and bone-grafting material such as BioOss
(Geistlich) is then spread on the facial bone in order
to avoid facial bone resorption.14 All synthetic bone
graft material is covered by a thin and long-lasting
membrane such as BioGuide (Geistlich), and flaps are
sutured with particular attention to ensuring wound
closure.
Fig. 8_Occlusal guide screwed
onto posterior implants.
Fig. 9_Adequate cooling and
visualisation during drilling.
The impression tray is connected to the initially
placed implants and silicone material is injected into
the tray around implant transfers where room has
been allowed for the impression material (Fig. 10).
Once the impression tray has been removed, protective
caps are positioned on the VARIOmulti abutments
in order to maintain gingival spacing during the last
laboratory prosthetic phase. A panoramic X-ray is performed to ensure proper positioning of implants and
abutments, and to ensure that no radiopaque sterile
silicone material remains.
Fig. 10a
Fig. 10b
Fig. 10c
Fig. 10d
Figs. 10a–d_Second impression
taking at time of surgery.
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Fig. 11_Second impression secured
to reduced initial model.
Fig. 12_Modified model: the yellow
part corresponds to the initial
impression; the pink part was poured
at the time of surgery.
Fig. 11
Fig. 12
The maxillary plaster model is trimmed to leave
space for abutment analogues and plaster is poured to
fill this open space after the impression tray has been
secured to the trimmed model (Fig. 11). The modified
model simultaneously shows two parts: the first part
corresponding to the initial impression and the other
corresponding to the second impression (Fig. 12). The
provisional prostheses are fitted to the model and occlusion is validated. When this laboratory phase is over,
the protective caps are removed, and the prostheses
are screwed into position (Figs. 13a & b). If done well,
occlusal adjustments should be minimal, even perhaps
none being required. Temporary caps on VARIOmulti
are filled with temporary light-cured material to close
the screw channel and the patient is advised to treat
the temporary bridgeworks carefully.
is still sufficiently small to be handled by the dental
technician for ideal prosthetic screw placement. Nevertheless, the initial implant placement cannot exceed
this limit, which requires very precise initial drilling and
an additional step to verify that the surgical guide is
actually suitable for use.
Sutures are removed after ten days. Aesthetics is reevaluated three months after surgery, before initiating
the final prostheses, owing to subsequent loss of tissue volume. Additional temporary bridgework is often
required to ensure that the final aesthetic will be adequate before proceeding with the definitive prostheses.
Compared with flapless techniques, open flap surgery not only allows the visual capacity opportunity
for controlling bone site preparation, but also retains
precious keratinised tissue that is important for both
marginal tissue stability and volume. The patient’s reaction to this procedure, with its associated pain and
discomfort, still has to be examined in future studies.
Another benefit of this procedure is that sterility
is maintained throughout the surgery, since all materials used can be sterilised, which is not the case
with common guides such as NobelGuide or the SAFE
SurgiGuide, which are both made of a stereolithic resin
and are currently not capable of undergoing sterilisation. In addition, the precision of the procedure allows
the impression tray to remain unmodified—and thus
sterile—throughout the surgery.
_Discussion
There are multiple technical benefits of the TRIPOD
procedure. Precision implant placement is achieved by
removing positional and mechanical artefacts, particularly when the actual surgical guide is screwed onto
stable implants. In other words, there is no movement
evoked by a bite variation or tissue differences, and if
the patient moves during the CT scan, the guide moves
with the anatomical structures. However, there is no
way to conquer geometric, hardening or digital artefacts. There is still room for a small degree (<1 mm) of
freedom in implant placement and, if necessary, final
correction can be done after the initial drilling with the
2.8 mm drill. This results in a maximum freedom of approximately 0.7 mm in diameter for a final implant site
with a diameter of 3.5 mm. However, considering that
the last drill at the centre is just half of this value, this
freedom corresponds radially to 0.35 mm, providing
an opportunity to adapt the implant site preparation
to anatomical conditions slightly. This distance of
0.35 mm is sufficiently important to become particularly significant for leaving some buccal bone, but it
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Yong and Moy8 state that implant loss in their study
was probably primarily related to the absence of proper
cooling ability with NobelGuide use, since most of the
late implant failures involved long implants in cases in
which the guide was used directly at the gingival contact. Indeed, only the rear part of the drill (thus far from
the tip) can be cooled efficiently, and this probably
makes the cooling procedure ineffective. In contrast,
during the TRIPOD procedure described, the guide is
placed on the gingiva at the time of fabrication, leaving
an open space for cooling at the time of the open flap
surgery. In addition, the bone becomes visible, which allows the practitioner to visualise the depth marks of the
drill right at the crestal ridge, making the instrumentation less expensive and easier, as no special drill with
mechanical depth limitation is required. Site preparation may be modified through piezoelectric bone surgery, since this device can grind bone on a particular
wall from the previous drilling, in contrast to conventional drilling, which grinds all walls from the previous
drilling, with a preference for softer tissue, which results in facial bone perforation. In some situations, one
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Figs. 13a & b_Initial provisional
bridgework in place.
Fig. 13a
Fig. 13b
might also consider changing from drills to bone
spreaders; this would compact the surrounding bone
and provide additional stability to the corresponding
implant. Finally, the implant could be adapted to a recipient site by choosing an appropriate diameter, length
and even profile (e.g. from conical to conical-cylindrical) once site preparation has almost been completed.
survival in different clinical environments, specifically
investigating adequate positioning between planned
and final implant position, and the need to verify the
surgical guide after the learning process has been
completed. Finally, a study on patients’ satisfaction
with the procedure in terms of pain and aesthetic outcome needs to be performed. We must still determine
whether the benefits of open flap surgery in combination with surgical guides outweigh the related discomfort and pain for the patient: does this pose a
major problem for patients, is the final aesthetics improved by preserving keratinised tissue, and does such
a technique fulfil expectations, considering that bone
volume loss is often difficult to limit in these areas?
The previously placed implants provide not only
useful precision to implant site preparation with the
guide, but also essential stability to immediately loaded
bridgework in an area where stability in the initial healing phase is probably vital to success. Most patients are
already older, with a history of periodontitis, tooth loss
and associated impaired medical conditions, and possibly reduced healing capacity. Therefore, it is of major
interest to be able to assess the healing capacity by the
stability of previously placed implants, before undertaking a full-arch maxillary bridge immediately loaded
on implants, preferably with advanced surface technology. Most of the cases require some sort of bone
grafting in the posterior areas and this technique leaves
time for initial healing before occlusal loading. In fact,
some of the implants could be subjected to immediate
loading, while others—the most critical in terms of
bone volume availability and location—could be loaded
according to a classical schedule. This should be considered when making a comparison with other procedures with surgical guides.
The INICELL surface of Thommen Medical implants
showed more bone-to-implant contact and a higher
removal torque at two weeks than unconditioned implants did.15 This aspect should be particularly useful in
the early stages of healing and providing additional
stability in this crucial phase. In addition, this company
provides implants of various diameters, length and
profiles to satisfy various implant site requirements
and which provide the best possible stability.
_Conclusion
The TRIPOD protocol is based on our latest clinical
experience. It utilises CBCT and the vast developments
of implant placement planning software and computer-guided implant dentistry. The efficiency of the
technique must still be validated by analysis of implant
The proposed TRIPOD procedure is certainly more
labour intensive than current flapless guide systems,
since a flap has to be raised and no definitive prosthesis is placed right after surgery. Nevertheless, it is
also more versatile because maintaining or increasing bone volume is considered in the treatment plan
and is adapted to the individual situations. The risk of
failure is considerably reduced by connecting immediately placed implants to osseointegrated implants.
Furthermore, this procedure allows use of the last
millimetre, as typical cases show reduced bone volume and require the widest and longest implants
within anatomical restrictions. Although knowledge
and close collaboration with the laboratory technician are required, this procedure adds fundamental
security and predictability for success, and can certainly be adapted to different practice situations and
one-day procedures._
Editorial note: A complete list of references is available
from the publisher.
_contact
CAD/CAM
Dr Jean-Nicolas Hasson
5 Rue du Werkhof
68100 Mulhouse
France
hasson@hrnet.fr
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I practice management _ world wide web
Connectivity
in the dental world
Author_ Shane Hebel, Canada
_We live in a time in which things are changing
exponentially and the way that we go about doing
business is drastically evolving. The Internet has
become a major player in businesses that never
thought that it could apply to them. Instead of battling the Internet with a long stick and keeping it out
of the dental industry, it has always been our philosophy to leverage it in new and innovative ways
that can be used to the advantage of health-care
professionals worldwide.
After a lot of research and brainstorming, we discovered that the real reason that people are online and
using products is because of a little thing called connectivity. Many people are online because it allows
them to connect and engage with other people who
have similar ideas, views or interests. We knew that our
mission of serving as a communications and learning
hub was lacking, as we were not serving every aspect
of our clients’ needs in this area of dentistry. This led to
a few feverish weeks of programming, writing and
networking to bring you the latest suite in the ‘Hub’.
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_Introducing My Dental Buddies!
My Dental Buddies is a network of dental bloggers,
community members and dentists, who can collaborate to provide information to the dental community at large. This free initiative is a social network
that allows users to connect and engage with fellow
dentists around the world! This is a HUGE opportunity
to learn in a collaborative and innovative way to increase your efficiency and effectiveness in your own
personal practice.
In one day, more than 100 million people signed
onto Facebook. Twitter generated more than 300 million tweets. Approximately 3 million people ‘checked
in’ to their current location and 35,000 hours of
video was uploaded to YouTube. The Internet is an
extremely busy place for all of that to happen in a
single day!
You may ask why that is relevant to you. Fantastic,
you say, more teenagers are uploading pictures of the
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party they went to last night. You may be thinking
that this massive amount of sharing has no more
value than the latest episode of Jersey Shore. However, this is where you may benefit from a change in
perspective! Although social media started as just
that, a place to socialise, it has expanded into a massive enterprise that has since evolved into a realm
with numerous applications for anyone in the world.
Let us take a few minutes to really dig into what
social media is and why it can benefit YOU. Who cares
about how it can benefit Lady Gaga or President
Obama. I want to know how it can benefit ME in my
life and why it is such a big deal.
Unfortunately, this time around our good friend
Wikipedia let us down. Wikipedia defines ‘social
media’ as “the use of web-based and mobile technologies to turn communication into interactive
dialogue”. Okay, so that tells us the specifics of what
social media does. It allows people to connect online.
Well, that’s cool. E-mail did that. Why is social media
so special?
Let us bring it down a peg and see if we can
gain some further insight. “If you make customers
unhappy in the physical world, they might each tell
six friends. If you make customers unhappy on the
Internet, they can each tell 6,000 friends,” Jeff Bezos,
CEO of amazon.com, said. WOAH, now that provides
a lot of insight! Social media allows people to interact with thousands and thousands of people
that they would not have access to otherwise. And
they can tell them whatever they want. Uncensored.
Fantastic!
So, social media allows people to say whatever
they want online without being censored. Social
media is a +1 for free speech. However, we still have
not answered the question: what does that mean for
you? Well, let us go down one step further with some
specific examples. If your customers are telling 6,000
people that they are at the dentist and they are lovin’
it—that’s really good. If they are telling 6,000 people
that your office is terrible—that’s not so good for you.
Being part of the social network and getting involved
in communication areas that your patients are in
will give you an unprecedented look into your ‘online
reputation’ and give you a chance to really see what
your patients are saying.
So now we’re spying!? Fantastic, just what you
want to do in the health-care industry. The news
industry recently tried that and the resulting News
Corp and James Murdoch phone-hacking scandal
has resulted in worldwide embarrassment for both
the media industry and the governments in which
those companies operated. However, there are more
aspects of social media that are very beneficial to you,
and not in a creepy kind of way. When people think of
social media, their minds immediately jump to huge
websites like Facebook and Twitter. While these websites embody the values of social media, they’re not
the end-all and be-all of the social media landscape.
Social media is about connecting and collaborating online. Take a look at LinkedIn, tumblr, YouTube
and the many other social media websites out there
today. These are social media tools. These are social
networks. These are YOUR networks. They are places
where you can come to connect with fellow people,
to collaborate and to LEARN. That is the most important part of all of this! Social media provides an
extremely effective medium for active learning, participation and collaboration.
Social media is one major player on the Internet,
but it is not the only way that the Internet is changing the dental industry. The Internet has a vast array
of resources that are making our world faster paced,
more dynamic and more thought-provoking. It is
also changing the way that we compete and how we
do business. The health-care industry has long been
a profession in which competition is not considered
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a large factor. Many individuals stayed with a healthcare professional for their entire lives and that was
the end of it. Once again, the Internet has played
a part in upsetting the status quo and changing
the way that people view healthcare. Websites like
WebMD.com and the online directories of healthcare professionals in different areas have opened
up the possibility of competition where one did not
exist before. Dentists and other health-care professionals are starting to have to change the way
that they do things in order to compete in this new
marketplace.
One of the most important things that dentists
do in their practice is selling. Now, this is not the way
things have been done in the past. Many dentists
still operate under the belief that patients come to
them for health care, not to be sold to. However, let’s
look at some of a dentist’s vocabulary in sales terms
and see what happens:
_diagnosis: which product will work best for the
patient
_case options: pitching
_case acceptance: making the sale
_treatment: delivery of product.
Are you still as convinced that sales do not exist
in the dental industry? The Internet is responsible for
a huge number of changes in the dental industry and
as a result health-care professionals are constantly
having to be innovative in order to survive in a more
competitive and dynamic workplace.
I stumbled across this cool article recently that
talks about innovation in the workplace, a fascinating read and very applicable to the dental industry!
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This is one area where dentists are currently lacking.
It is so easy to fall into a set routine and not think
about new or different ways to do things. I mean, why
bother? Your practice is making money. Why do you
need to be innovative?
Emily Ford, The Sunday Times, recently wrote
an article on that very topic. Innovation is a huge
new part of the dynamic connected world. People
are constantly collaborating to come up with more
and more innovative solutions to problems and it
is important to keep up with this changing environ-
ment. Ford suggested a few tips for innovating at
work, which have been given a dental twist to make
them especially applicable to your practice.
Make innovation a priority
Always look for new ways you can do things, new
products you can use and new ways of interacting
with your staff and patients. Not only will it make
your days new and exciting, it will benefit your practice in the long run too!
Take risks and embrace failure
If you buy a new instrument and it does not work,
what did you lose? A little bit of time and money?
What would have happened if it worked? You may
have saved a ton of time, made the quality of treatment increase and made a patient’s ordeal less
painful. Do you think that it is worth it? I definitely do!
By embracing failure, you can learn new things
quickly, learn what works and what does not in your
practice, and ultimately help your practice to succeed
with the increased knowledge that you will have.
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Eyes on the future
Think of it this way: when you know where you’re
going, you can figure out the fastest and easiest
way to get there. By planning ahead, you can spend
time thinking of innovative and new ways of doing
things that will make your future endeavours that
much easier. By knowing where you’re going, you can
constantly be on the lookout for things that will help
you get there, making the whole process faster and
more efficient.
I
Here is a new and interesting thought: why don’t
you ask your employees for their ideas? Your employees may have a ton of cool and innovative ideas for
ways that you could make your practice more efficient and effective. However, they are probably not
telling you these ideas! Why not? Well, for starters,
you never asked! Many people won’t share their opinions about some things (especially business) because
they are scared that they will seem like they do not
know what they are talking about. No one likes that
feeling!! If your employees know that their ideas are
welcome you will probably find them flooding in!
Foster creativity at all levels
Encourage your staff to do the same as you! Ask
them to be constantly thinking about ways they
could change the way that they do things. Would
something else work better than what they’re currently doing? Could they use a new tool to make their
job easier? No one will know the answers to these
questions better than them, so have them start thinking about it! Your staff are a huge resource in coming
up with creative and innovative ideas in your practice.
Break the rules
Ask a ton of questions! Why do you do something
a certain way? Has anyone ever tried doing it another
way? We get so entrenched in our beliefs, habits
and routines that over time we stop thinking about
why we do things and just do them. Bring that back!
Question the things you do everyday—ask yourself
why you do them and whether there’s a better way.
Chances are that you’ll find a few things that will
make your practice a more productive and efficient
place!
What does this all boil down to? It comes down
to connectivity and collaboration. That’s it. Those two
simple words are what the future of the dental industry (and every other industry) is going to come down
to. The ability to collaborate with other like-minded
individuals, share ideas, innovate and ultimately create
a better working system are what the Internet, social
media and connective sites are all about.
This is what we are about at My Dental Buddies.
My Dental Buddies is a connective website for you, for
dentists, staff and other health-care professionals in
the dental industry. We recognise the importance of collaborating socially and innovating together and want
to bring that to you. It is a portal, a blank slate that the
users of the site can fill with whatever content they feel
is important to them. That is the beauty of the uncensored Internet; whatever is most important to the largest
number of people is what gets talked about. We strive
to leverage the Internet to make your dental practice
the best that it can be. Please help us to do the same!_
Editorial note: A complete list of sources is available from
the publisher.
Collaborate across boundaries
Everyone has insights to share. Your receptionist
or assistant may notice things that you do not. Get
them involved in the process! Chances are that they
have some great ideas of things that you could be
doing in your practice that you are not. Using your
staff effectively is one of the best things that you
could do and by involving them in this process you
are giving them ownership of the success of the practice and motivating them to make it better!
Innovating does not have to be a one-man show
either. The Internet is connecting us in ways that
we could not have even dreamed of in the past and
it is important to be involved in every way that you
can. Although the Internet provides both a valuable
resource and fierce competition for your time and
your professional career, it is not the only tool for
collaboration and shared learning that is out there
today.
_about the author
CAD/CAM
Shane Hebel is currently a
student studying Finance and
Accounting at the Schulich
School of Business. He is a
sales and marketing executive
for My Dental Hub. He is
involved in a number of
organisations that promote
collaboration, connectivity and education, including
Impact Entrepreneurship Group, Standard
International and, of course, My Dental Buddies.
shane@mydentalhub.com
www.about.me/shane.hebel
www.linkedin.com/in/shanehebel
www.twitter.com/shane_hebel
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I practice management _ passive income
The passive income
practice
Author_Dr Phillip Palmer, Australia
_Exit planning has traditionally been a fairly
simple task for dentists. The choices a dentist faced
were either winding down the number of days
worked, thereby gradually easing into retirement,
or working until three to six months before wanting
to stop, and then advertising the practice for sale.
After negotiations with the buyer, dentists would
sell and walk away—much like a house sale. Sometimes there would be a good handover of patients
and staff, and sometimes this process would be less
than ideal.
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More recently, other options for exit planning
have become available for practice owners. Over the
last three to four years, for example, many dentists
in Australia having sold their practices stayed on to
work as employee dentists for the new owner. This
model in particular has increased in popularity recently with corporate entities often being the buyer.
Another model is deferred sale/employee with view,
whereby a new dentist (Dr Junior) works for a year
as an employee for Dr Senior. If all goes well, a contract is signed for the purchase of half (or even all)
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the practice in some years hence. The employed
dentist continues to work as an associate, and
the transaction is settled after the agreed time.
This technique assures Dr Senior both a buyer and
extra income from Dr Junior during the years as
an employee. Through the incremental percentage
technique, after a similar trial period, the practice
contracts are exchanged and incrementally each
year a further percentage of the practice changes
hands from Dr Senior to Dr Junior.
In each case, after the practice is sold, the exowner commonly takes the money he made from
the sale, goes on a holiday and then invests whatever is left in real estate or the stock market to fund
his retirement. For a practice here in Australia grossing say AUS$800,000 per year, if sold on the open
market could bring up to AUS$500,000. If that
entire sum were used to purchase a residential investment property, one would be lucky to net more
than AUS$30,000 per year, and probably less, to
fund retirement.
Another way to exit plan and fund a dentist’s
retirement is to establish the passive income practice, also known as the “never sell concept”. Using
this method, the practice is set up in such a way as
to be self-managed, with little effort (1 day/month)
needed from the owner when the practice is mature.
The profit from the practice can be as high as 30 %
after payment of all normal expenses and clinicians’
wages.
deep knowledge and understanding of the systems
needed to run a practice.
Some degree (the more, the better) of management, leadership and business skills is also required
by the owner, including the ability to look at and
analyse the right numbers or to motivate key staff
members to manage the practice and outperform
through the judicious use of incentives, including
well-designed bonus systems. As the owner dentist
is no longer present full-time in the passive income
practice, there also needs to be regular training
in communication and the provision of service, i.e.
clinical training.
There definitely needs to be more than one clinician. Rarely is there sufficient profit over and above
the employee dentist’s wage (40 % after lab) to warrant running the practice as a business with such
a small staff.
There are plenty of horror stories out there,
especially after the global financial crisis, of retired
dentists needing to return to practice because the
practice sale did not fund their retirement the way
they expected it to. The never sell concept represents
a new way of looking at the asset that is your practice and how it can bring you returns long after your
clinical career comes to an end._
_about the author
If maintained as a going concern and run properly, there is no reason to expect a return from
the AUS$800,000 grossing practice of less than
AUS$200,000 p.a. (and still maintain an asset worth
at least AUS$500,000).
Obviously, for this option to work, the practice
and the staff need to be trained to be self-managed
and to provide a certain level of service and communication. Basically, they would need to have a
I
CAD/CAM
Former dentist Dr Phillip
Palmer is currently Director of
Prime Practice and Dentist Job
Search and regarded as
Australia’s leading expert in
the business of dentistry.
He can be contacted at
info@primepractice.com.au.
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I special _ public speaking
If you are smart enough to
be a dentist, you are smart
enough to be interesting
Author_ Dr Paul Homoly, USA
_Have you ever imagined yourself a leader in
advancing digital restorative dentistry to our profession? When you attend seminars and listen to
speakers, do you ever think, “I can do that!” Considering the surge of interest in digital dentistry and the
technology advances happening every day, if you are
ready to get up in front of an audience, lead a study
club, or teach/mentor one-on-one, there is no better
time than now to get started.
_The Sirona Speakers’ Academy
3_ 2011
_It pays to be interesting
I usually do not watch reality television shows. If
I happen to catch a bit of one while channel surfing
(… frenzied contestants racing across the wilderness …)
I get irritated and think, “Don’t these people have jobs?”
That was my thought when I accidentally caught
the finale of 2008’s American Idol. I was about to flip
to the Golf Channel when David Cook, the winner of
that year’s competition, glided up to the microphone,
surged into his farewell anthem and in a heartbeat
made it impossible for me to change the channel. So
I flopped down on the couch and took my surroundsound volume way up to marvel at it all. As David
crescendoed into his final verse a blizzard of confetti
showered down. I can easily imagine thousands upon
thousands of television audience viewers simultaneously rising up to cheer him on and if it were not for my
cat sitting on my lap, I would have been on my feet, too!
Fig. 1
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way to speak in order to influence your listeners to take
action. The examples that follow are for speaking to an
audience. However, they also apply to one-on-one
conversations with patients, staff, friends and family.
In December 2010, I partnered with Sirona Dental
Systems to host the Sirona Speakers’ Academy, a
speaker-development programme created to advance digital, restorative dentistry and digital imaging. Speakers, experienced and inexperienced alike,
attend a three-day workshop to learn the structure
and delivery of presentations that encourage listeners to take the next steps to bringing digital restorative dentistry into their practices.
When it was over, I switched to the Golf Channel
and turned the sound off (no need for a commentator saying someone missed a putt). In the tranceinducing qualities of watching golf, my thoughts
return to American Idol. What is it about David Cook,
a 25-year-old bartender, that earns him a roaring,
standing ovation? How is it that a singing bartender
can grip the attention of thousands when you and
I have seen leading dental experts speaking at major
meetings lose their audience’s interest seconds after
they begin to speak?
The academy’s curriculum is based on the successful principles of influence I have taught for the last two
decades. Here, in a nutshell, is an explanation of the
It happens to us, too. Think about the times when
we are speaking to patients about important dental
health issues and you cannot help but notice that
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I
far-away look in their eyes. I came away from that
evening of watching American Idol with sharper clarity regarding our careers. It is time for us to change our
tune and learn what entertainers build on from day
one—it pays to be interesting. If we are smart enough
to be dentists, we are smart enough to be interesting.
_Get interesting
Listener interest typically is at its peak at the beginning and the end of your talk, with a slump in listener
attention in between. This chart shows a typical listener pattern (Fig. 1). Let us say you are presenting
a 45-minute talk to a study club. Count on listener
attention slumping a few minutes into your talk.
Here is why a listener’s attention slumps:
_They have a lot on their minds.
_They think much faster than we talk.
_The time of day invites slumping.
_They make poor food choices.
_They are in the habit of multi-tasking.
The key to becoming an effective leader/speaker
is the ability to create peaks of interest, breaking
listeners out of their slumps. Your timing creates
peaks of interest with relevant content, in other
words, get interesting right before you get relevant.
I call it “peak, then point”—peak their interest, then
make your point (Fig. 2).
You decide what is relevant based on your experience. This requires much clarity on your part.
Too many speakers think that everything is important.
It is not. There are many ways to create peaks of interest: humour, storytelling, vocal variety, movement,
metaphors and visual aids. The crux of this? Becoming
interesting makes you more influential because what
you are saying sinks in. Why? Because your listeners
are paying attention to you while you are saying it.
Fig. 2
of us that is not true. Our profession selects its members on our cognitive abilities, not our personalities.
Consequently, I know many highly knowledgeable
but uninteresting dentists.
Most dentists are really good at following a process. Give us a cookbook and we can make things
happen. Here is the cookbook for creating peaks of
interest—it is called the Leader’s Pyramid (Fig. 3).
Think of this process as if it is a pyramid with four
distinct layers. Each layer represents a specific aspect
of the listener’s experience. You build listener interest
in the direction of the arrow, starting with connection
and ending with content.
The first layer of the Leader’s Pyramid is connection. Connection is when the listener feels he or she
is having a personal experience with you. Another
word for connection is relationship. The next layer
is movement. Movement gives the listener a sense
of your confidence. The third layer is dynamics.
Dynamics is the sound of your voice that enables
your listeners to feel your energy/emotion. The top
layer is content. Content is the intellectual value of
your talk that creates logical appeal.
Being interesting is the first prerequisite to being
influential. Too many dental speakers think their
expert content is enough to hold listeners’ attention.
You and I know it is not true. How many times have
we drifted off listening to a dental expert’s lecture?
Just because you are an expert does not make you
interesting! Some experts bristle when I recommend
they lighten up a bit and suggest they use some
humour, tell a few stories and have some fun. I remind
them: no one ever lost credibility by being interesting.
_Creating peaks of interest
Creating peaks of interest is the heart of being influential. Some speakers have it in their personalities;
they are naturally interesting to listen to. For most
Fig. 3
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eye contact around the room, never making meaningful connection. This distances the speakers from
their listeners, thereby minimising the speakers’
influence.
Disclosure
Disclosure is the experience of the listener when
he or she discovers a bit of who you are aside from
your role as an expert. Disclosure reveals your secondary roles, husband, wife, son, daughter, golfer,
hobbies, family, cat lover or Chicago Bears fan. The
truth is that you and your listeners are more alike
than different. Revealing your sameness is engaging
and highly interesting to listeners.
Fig. 4
_Connection
At the base of the pyramid is connection, the most
fundamental aspect to creating peaks of attention
(Fig. 4). Connection is when the listener feels he or
she is having a personal relationship with you. When
a listener feels you are connecting with him or her,
his or her attention naturally peaks. There are two
ways to connect with listeners: eye connection and
disclosure.
Punctuated eye connection
Let us start by discussing punctuated eye connection when speaking to a group. Punctuated eye
connection is a process where your eye contact with
your listeners is linked to the punctuation of your
sentence structure. Eye contact is held with an individual listener through an entire thought. It might
be a few sentences or an entire paragraph. Then,
when the thought is complete, change eye contact
to another listener at the punctuation mark: a period,
a comma, colon or semi-colon, or a new paragraph.
Too many speakers do not link their eye connection with their thought structure. They spray their
Fig. 5
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You usually have more in common with listeners
in your secondary roles than your primary role. It is
the “in-common” bit that listeners feel, creating the
positive experience of connection. Consequently,
listeners frequently find experts more interesting in
their secondary roles than in their primary role.
Looking at the “in-common” experience a little
more closely, why do listeners find an expert’s secondary roles so interesting? Because it is in these
roles the listener can see a bit of himself or herself,
and seeing oneself is always interesting. Seeing oneself in an expert leads to some remarkable outcomes.
From the listener’s point of view, seeing himself or
herself in the speaker/expert boosts the believability
of the expert—seeing leads to believing.
Disclosure and storytelling
Story telling is the most powerful technique of
disclosure. Stories offer the most complete way for
listeners to learn who you are beyond your primary
role. Here is a good example:
Sometimes during workshops I tell a simple story
about spending a week at a professional water-ski
school, the Benzel Ski Center in Groveland, Florida.
It is run by Dave Benzel (six-time world champion)
and his wife Cindy (three-time world champion).
During the story, I mention that we skied all week
being yanked around by muscular, Master Craft
competition ski boats on slick ski ponds. The point of
the story is how Dave Benzel thinks about winning
—“make winning a familiar experience”.
During a break after telling this story, a woman
attendee approaches, throws her arms around me,
hugs me hard and says with weepy eyes, “Oh Dr
Homoly, I just loved your water-ski story!” “What did
you like about it?” I asked. It is always a good practice
to learn why someone likes you. “Master Crafts! You
skied behind Master Crafts”, she cried. “My brother
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worked for Master Craft and he just died of leukaemia.” She went on to tell me all about her brother
and how much she loved him.
My point here is that you never know what listeners will connect to from your disclosure. My water-ski
story is about Dave Benzel’s philosophy about winning, but for her it was about her brother. This is
the delicious mystery of not knowing where our influence resides within our disclosure; listeners are
selective about what they are influenced by. Because
of one, small detail within my story—Master Craft—
this woman became my biggest fan.
I
_Movement
Movement is the second level of the Leader’s Pyramid. It signals confidence, which helps earn attention
(Fig. 5). If your movement signals a lack of confidence
or sends a mixed message, listeners may be reluctant
to act and/or will not pay attention.
Movement is what you do with your body while
speaking. Movement includes walking left and right,
advancing and retreating, leaping/squatting and
body posture. I am not including facial expressions,
rotations and hand/arm gestures as movement.
You tell a story that is meaningful to you and in
that story exists a hundred different opportunities
for listeners to latch onto something that is meaningful to them. Disclosure is what people are really
hungry for and is at the heart of what leverages your
ability to be interesting and influential. The stories
you tell shape your image in the listeners’ minds, so
it is crucial to be strategic and purposeful about the
stories you share. You may be like many of the experts
I work with who tell me, “I do not have any really good
stories to tell.” Yes you do!
Discovering your stories is a matter of imagination and the right coaching. Here’s a quick, sixstep process of discovering your story to get you
started:
Fig. 6
The roles of movement
1. Pull together those items that have documented
your past, like photo albums, day timers, Outlook
calendars, diaries.
2. As you look through your past events, think of the
places and people associated with those events
that had an impact on you, for better or worse.
3. Think back to those places and people and answer
this question: “How did this place and/or these
people change me or someone else?”
4. As you answer this question your story emerges.
Great disclosure stories are about what we have
learned in life, how we learned it and how it has
changed us.
5. Do not think your disclosure story(ies) must
have an intriguing plot. Plot-centred stories tend
to get too long and do not work well for the
purpose of disclosure. Think of your disclosure
story(ies) as simple memories. Focus more on the
people in your story and how the event changed
you.
6. Also, do not think your story has to be heroic
(“I lost both arms saving orphans from napalm
in Vietnam.”), stupendous (“After I came back
from Climbing Mount Everest I won Wimbledon.”),
or tragic (“… and my fiancé died in my arms at
the altar on our wedding day.”). You will be amazed
how simple, well-told memories resonate.
Movement plays several roles in creating peaks
of interest; it
_signals your confidence to the listener;
_adds emphasis to specific content;
_creates authenticity during narratives (stories and
memories);
_signals transitions between logical and emotional
domains;
_boosts the listener’s experience of connection.
Movement and energy
Movement is one of the things that will hurt you
more than help you. When it is done correctly, movement will not make a bad talk good, but done incorrectly it can make an otherwise good talk BOMB!
It pays to keep movement under control—less is more.
Consequently (and ironically), the most important
aspect of powerful movement is knowing the way to
stand and deliver with minimal movement.
Minimal movement means not pacing back and
forth or advancing and retreating (front to back
movement). However, even though I am advocating
minimal movement, I will endorse liberal gestures,
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rotations and facial expressions. Think conservative
movement and liberal gestures.
There are three sources of energy within your
delivery that the listener experiences as you speak.
These sources are movement, gestures and dynamics
(the energy of your voice; Fig. 6). You are your most
interesting self when listeners experience the highest
energy first from your dynamics, then from your
gestures and the least from your movement. Think
high-energy voice, medium-energy gestures and
low-energy movement.
Do you see yourself in this story? Has there been
a time that a song rekindled strong feelings from
a memory? I bet there is. When I hear the song Just
you and me by Chicago I get transported back to 1975
when I was … Well, I will save that story for another
time.
My point is that sound, not just songs and music,
but sound moves us emotionally. What do you remember/feel when you hear wind and rain, a firecracker pop, or ambulance sirens, or the sounds of
a carnival? I do not know what specific sounds move
you, but I do know that there is one sound that all of us
resonate to—the sound of a voice. The sound of a voice
makes us feel—for better and worse. I save short, voicemail messages from my fiancée, Lisa, on my cellphone.
When I am stuck in some airport terminal, tired and bitter at air travel, I will listen to an old “I love you” voicemail. When Lisa leaves voicemail messages she sounds
like a cartoon character and it brightens my moments.
Dynamics—the sound of your voice—brightens
your listener’s moments.
Your voice is powerful
Fig. 7
_Dynamics
It is a perfect spring morning. You are up just after
dawn. You have all day to yourself; no appointments, no
patients, no staff, and best of all you are out of cell phone
range—one of the few remaining perks of business
travel. You finish a hearty breakfast topping it off with a
stout cup of coffee, check out of the hotel and toss your
bag into the trunk. Now all buckled up in your rental car,
you press the convertible top toggle switch and watch
the roof disappear behind you. You punch the gas and
charge out onto the road. Your tires chirp and you smile
while revisiting those almost forgotten adolescent
driving misdeeds. You keep your foot on the gas and
within a few heart-beats you are 10 mph over the limit.
You tap in the cruise control and your day has started.
You turn on the satellite radio—an oldies station
—and that is when you hear it: the song you shared
with your first love. Its melody splashes onto your
heart, making you feel just like you did so many years
ago. At first, you smile, then you sigh. As sweet as the
memory is, it also brings lament for the many years
that have slipped by too soon. Your love song plays
on, setting off primal emotions that stir and dominate your present moment. Soon your sweet song is
over. You drive on, your thoughts on the road ahead—
yet your day is suddenly better for your re-acquaintance with this old friend of a melody.
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Use the power of your voice to enable audiences,
patients and team members to feel your words and
be stirred to action. Dynamics is the power of your
voice. Dynamics occupies the third layer of the
Leader’s Pyramid and is a foundational skill that, like
the processes of connection and movement, creates
peaks of listener attention (Fig. 7).
Notice I introduce dynamics after connection and
movement. Before you exert the power of your voice,
ensure you have established a relationship through
connection and signalled confidence through your
movement. The benefits of dynamics—your energy—
die on the vine in the absence of relationship and
listener confidence.
Words are like coins, they have two sides. One side
of a word is its definition and the way it shapes our
thinking. The other side is the word’s power to evoke
emotion, the way it makes us feel. Dynamics communicates the way we feel about our content to
our listeners. The best speakers make people feel as
the speaker feels—inspiring listeners to take action.
Speaking is like music, except in speech there are narrower changes in pitch and no melody. Composers are
intentional in the dynamic expression of every sound.
_Dynamic distinction
How interesting would a song be if it had no dynamic distinctions, with few changes in pitch and an
unchanging rhythm? Would you buy it? How inter-
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esting are you if you speak with no dynamic distinctions? Would listeners buy what you have to say?
Dynamic distinction is about creating contrasts,
high volume, followed by low, quick-paced delivery,
followed by slow, then your normal tone followed
by a regional accent. Contrasts create interest.
Contrasts are a good thing.
Your goal is to create dynamic distinctions around
the key points of your talk, making them stand out,
thereby influencing your listeners. Remember the
peak then point process? It is about re-earning listeners’ attention just before you make a critical content point: peak their interest, then make your point.
Using dynamic distinctions is one of the best tools
to peak listener interest right before you make your
key point.
I
uninteresting. However, if you are like most dentists,
you can follow a process well. Figure 8 shows a chart
that can help you bring dynamic expression to your
words, helping your listener to feel as you do.
List your key content points in the left column.
Then, in the right column, imagine the way you want
your listeners to feel, point by point. The way you
want your listeners to feel is the way you need to feel
when you deliver the point. If you feel it, your voice
will signal the way you feel; you do not have to think
about it.
The power of the pause
An important aspect of creating dynamic distinctions is the smart use of silence, the pause. The pause
serves three purposes; it:
_boosts the effect of other dynamic elements;
_allows your key content to sink in; and
_compels Blackberry addicts to pick up their heads!
Pauses are power boosters to other dynamic elements. I hesitate to use the label pause because of
the inference that silence creates an interruption in the
energy, emotion, or connection between listener and
speaker. In fact, the opposite is true. A well-placed
pause amplifies the energy and emotions of dynamics.
Because pauses are the absence of sound, they automatically contrast with all speech sounds. Remember, contrasts create interest. Listeners are influenced
during your silence, they make decisions during your
silence and they learn and feel during your silence.
Speak the way you feel
So how do you learn to speak with dynamic
distinctions that help “both sides of the coin” work?
It is easy, sound the way you feel.
Emotions are contagious. If you are authentically
excited, aggravated, happy or sad, your listeners will
feel it. If you want your listeners to feel your words,
you must feel them as you speak them. This is not
acting; this is the real thing.
Speaking the way we feel comes naturally to most
people. Unfortunately, many dentists have been
educated out of being natural. Our ‘professional
education’ makes many of us knowledgeable but
Fig. 8
_Get started
Digital impressioning, CAD/CAM technology
and imaging have come of age—it is no longer your
father’s technology. Plus, exciting new technologies added to an already successful digital, restorative world are happening every day. This surging
interest in digital, restorative dentistry and imaging creates the opportunity for you to inform
our profession of these developments. If you ever
wanted to speak to groups of dentists and/or
laboratory technicians at study clubs, associations
and seminars, or if you are already a speaker and
want to take your message to the next level, the
Sirona Speakers’ Academy can help make it happen. Visit www.SironaSpeakersAcademy.com or call
+1 800 294 9370 and find out how to get started!_
_contact
CAD/CAM
Homoly Communications
Institute, Inc.
Dr Paul Homoly
2125 Southend Drive, Suite #250
Charlotte, NC 28203, USA
paul@paulhomoly.com
www.paulhomoly.com
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CAD0311_34-35_Planmeca 13.12.11 17:26 Seite 1
I feature _ home story
The Nordic masters
of dentistry
Author_Daniel Zimmermann, Germany
par with other dental industry giants like Sirona
Dental Systems or KaVo.
It may seem unusual that all this success happened to be and is still generated from a rather
unremarkable site in Herttoniemi, an old industrial
district 10 kilometres east of Helsinki’s city centre.
There, the company recently completed the expansion of its premises by more than one third to almost
50,000 square metres, an area so large that it could
now accommodate more than seven football fields.
Besides administrative offices, the new shiny glass
façade that reflects the Nordic blue sky on sunny
days hides buzzing production facilities and a fully
automated warehouse with robotic forklifts on the
ground level.
Planmeca president Heikki Kyöstila
demonstrating a panel controlling the
new automated warehouse.
(Photos courtesy of Planmeca, Finland)
_Being a socially responsible company with
a clear vision is one thing. Being at the top of the
trade for more than 40 years is another. The Finnish
dental manufacturer Planmeca is both. Established
in the early 1970s, when computer technology promised to open a new world in industrial design, the
company was the first to incorporate microprocessors in its dental units. Since then, this idea has
spawned a new age for dental technology equipment and has set the standard for a whole industry
for decades to come.
Owing to this fact, one might reduce Planmeca’s
expertise only to dental units, like the slick and
ergonomic Compact i or their flagship product,
Sovereign. But over the years the company has also
regularly launched a number of sophisticated dental X-ray devices and imaging software onto the
market that have become household names not
only in dental practices worldwide, but also in rather
unlikely places like US military bases. Overall, the
Planmeca Group with its six affiliates generates
a turnover of €700 million worldwide (according to
own estimates), a number that puts them easily on
34 I CAD/CAM
3_ 2011
“Planning the building started only in April last
year, and despite the extremely rough winter conditions, construction stayed on schedule,” said
Heikki Kyöstila, President and owner, looking back
on the last 18 months. “With the new production
premises, we can respond to the increased demand
more effectively.”
The 65-year-old Finn and hobby golfer, who
founded Planmeca in 1971 as a small-scale import
business and has remained its president and that
of its medical device subsidiary Planmed ever since,
envisions a bright future for his company, especially
in view of the number of new products launched at
the International Dental Show in Cologne, Germany,
this year. The centrepiece of this recent market initiative is its Digital Perfection Integration concept,
which, according to Planmeca, offers a revolutionary means of combining data collected from different 3-D imaging devices to provide dental surgeons
with more detailed clinical knowledge in the preoperative phase.
Hardware-wise, dental professionals recently
saw the launch of two new versions of Planmeca’s
cone-beam volumetric tomography unit ProMax 3D
that now provides an extended selection of 3-D
volume sizes, ranging from 34 x 42 mm to 16 x16 cm,
[35] =>
CAD0311_01_Title
CAD0311_34-35_Planmeca 13.12.11 17:26 Seite 2
feature _ home story
I
Outside view of the expanded
premises with the large
glass façade.
and comes with an integrated 3-D face scan unit
called ProFace, allowing clinicians to capture a realistic 3-D photo of the patient’s face both in standalone mode or in combination with a CBVT scan.
According to the Vice-President of Digital Imaging,
Helianna Puhlin-Nurminen, the system does not
only reduce radiation exposure to patients, but also
assures enhanced clinical and aesthetic outcomes.
In addition, intra-oral surface data can now be
integrated into dental units with the new Planmeca
PlanScan scanner, available as a cart delivery system and with open connectivity, which was designed to allow dentists to capture the complete
intra-oral situation of a patient and save it as a 3-D
model for immediate design without the need for
fabricating a physical model.
All this is brought together in the Romexis
software, which has recently been expanded with
a stand-alone application for iPhone and iPad devices for clinicians to access and share 2-D and 3-D
images via mobile networks worldwide. With the
iRomexis application, for the first time dentists have
also a free native application with true 3-D surface
model rendering in the palm of their hands, the
company said.
For Kyöstila, however, this is only the beginning
of a new age in dentistry. According to him, it all
comes down to his company’s solution-oriented
thinking and passion to achieve and perfect workflow for dental surgeries.
“We believe the best way to design cutting-edge
products that really meet the needs of our customers is to listen to them closely,” he concluded.
“Observing and learning from their workflow helps
us to understand the significance of the smallest
details that can make a world of difference to the
user.”_
_about the company
The new premises including
the warehouse shown here
are larger than seven football
fields combined.
CAD/CAM
Planmeca products are currently exported to over
100 countries worldwide. Besides the company
with the same name and Plandent, the Planmeca
group comprises dental tool maker LM Instruments
as well as Opus Systemer, a practice management
software company, and Triangle Future Systems.
Planmeca Oy
Asentajankatu 6
00880 Helsinki
Finland
www.planmeca.com
CAD/CAM
3_ 2011
I 35
[36] =>
CAD0311_01_Title
CAD0311_36_Camlog 13.12.11 17:26 Seite 1
I industry news _ CAMLOG Congress
CAMLOG Congress
to be hosted in Lucerne
_CAMLOG Foundation has announced that
the fourth International CAMLOG Congress will be
hosted in Lucerne from 3 to 5 May 2012. The event
will take place at the city’s architecturally impressive
Culture and Congress Centre under the motto Feel
the pulse of science in the heart of Switzerland.
Scientific and technical precision have long been
synonymous with Switzerland. The country is not
only unmatched in watch technology, but also at
the forefront throughout the world in various other
areas of technology. This includes medical technology, in which Switzerland is traditionally well
represented—not the least by Basel-based CAMLOG
Biotechnologies, parent company of the internationally successful CAMLOG Group.
The CAMLOG Foundation engages in targeted support of gifted young scientists, the promotion of basic and applied research, and continuing training and
education to promote progress in implant dentistry
and related fields in order to better serve the patient.
As part of its scientific mission, the CAMLOG Foundation has assumed patronage of the International
CAMLOG Congresses, which are held every two years.
During next year’s congress, many recognised
speakers will present on a variety of scientific and
technical topics with regard to state-of-the-art implant dentistry. Congress participants will have the
opportunity to increase their academic knowledge
36 I CAD/CAM
3_ 2011
on the one hand and to improve the clinical results
in their daily practice on the other, the CAMLOG
Foundation said.
CAMLOG will introduce international participants
to the latest developments in implant dentistry in traditional Swiss surroundings and a most memorable
ambiance. The city of Lucerne lies at the heart of
Switzerland both topographically and emotionally.
Under the motto Let’s rock the Alps! the CAMLOG
party will be held on the evening of 4 May, and, owing
to an overwhelming demand, on the evening of
5 May. The popular event will be held at the unusual
altitude of 1,600 metres above sea level, offering a
sensational view of the Alps.
Participants can register now for the congress at
www.camlogcongress.com._
_contact
CAMLOG Foundation
Margarethenstrasse 38
4053 Basel
Switzerland
info@camlogfoundation.org
www.camlogfoundation.org
CAD/CAM
[37] =>
CAD0311_01_Title
Bella Center
Copenhagen
APRIL 26- 28, 2012 s "%,,! #%.4%2 s COPENHAGEN s $%.-!2+
Welcome to the 45th Scandinavian Dental Fair
The leading annual dental fair in Scandinavia
The 45th SCANDEFA invites you to exquisitely meet the Scandinavian dental market and
sales partners from all over the world in springtime in wonderful Copenhagen
SCANDEFA 2012
Exhibit at Scandefa
Is organized by Bella Center
and is being held in conjunction
with the Annual Scientific
Meeting, organized by the
Danish Dental Association
(www.tandlaegeforeningen.dk).
Book online at www.scandefa.dk
Sales and Project Manager, Christian Olrik
col@bellacenter.dk, T +45 32 47 21 25
175 exhibitors and 11.422
visitors participated at
SCANDEFA 2011 on 14,220 m2
of exhibition space.
Travel information
Bella Center is located just a 10 minute taxi drive from Copenhagen
Airport. A regional train runs from the airport to Orestad Station,
only 15 minutes drive.
Fotos from Bella Center, Wonderful Copenhagen
2012
Check in at Bella Center’s newly built hotel
Bella Sky Comwell is Scandinavia’s largest design hotel.
The hotel is an integral part of Bella Center and has direct
access to Scandefa. Book your stay on www.bellasky.dk
www.scandefa.dk
Scandefa_Ann_A4_ENG_2012.indd 1
01/06/11 14.16
[38] =>
CAD0311_01_Title
CAD0311_38_Sirona 13.12.11 17:27 Seite 1
I industry news _ Sirona
Innovation Days at Sirona
Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 1_Thomas Scherer,
Vice-President of Sales in Europe
and Canada, and Lionel Phelipot,
Area Sales Manager France,
speaking to the audience about the
innovation process at Sirona.
Fig. 2_Guests at the Dental Academy
reception on 6 September.
Fig. 3_Innovative show: Attendees
watching a 3-D presentation.
Fig. 4_Guests at an exhibit in the
Center of the Innovation’s foyer
(inLab made of acrylic glass).
_Dental equipment dealers from all over Europe
and Canada visited Sirona during the month of September. The dental industry’s technology leader had
invited its distribution partners to attend three Innovation Days in Bensheim, Germany. In the presence of
around 350 guests, Sirona inaugurated its newly built
Center of Innovation and presented its new products.
Each of these two-day events kicked off with a
gala in the Center of Innovation’s foyer. Product presentations alternated with performances by a variety
of renowned artists. The second day was devoted to
a series of interactive workshops, at which the attendees were able to expand their knowledge of Sirona’s
products and technologies.
The Innovation Day for guests from UK, Ireland
and Scandinavian countries took place on 12 September. Terry Patuzzo, Sales Manager for the UK,
Ireland and Iceland, demonstrated his talents as an
entertainer as he guided the attendees through the
gala programme. The German star chef Alexander
Kunz impressed guests with an exquisite menu.
In his speech, Thomas Scherer, Vice-President of
Sales in Europe and Canada, described the innovation
process at Sirona: “We exploit the synergies between
different technologies in order to develop new approaches—for example, integrated implantology,
which combines the benefits of dental CAD/CAM and
38 I CAD/CAM
3_ 2011
3-D X-ray imaging. In order to exploit the potential
for innovation we rely on the new Center of Innovation, where developers from all the various departments can work under one roof and exchange ideas.
However, the resultant products would be impossible
without our distribution partners. Our innovations
are the outcome of their trust and belief in Sirona’s
capabilities.”
All the divisional development departments are
now housed in the Sirona Center of Innovation.
The foyer provides the venue for a temporary exhibition that guides visitors through the development of
Sirona’s latest technologies and products. Over the
past six years, Sirona has invested more than US$250
million in R&D—equivalent to between 6 and 7 % of
sales revenues. The company employs more than
230 engineers and scientists in the field of research
and development._
_contact
Sirona Dental Systems GmbH
Fabrikstraße 31
64625 Bensheim
Germany
contact@sirona.de
www.sirona.com
CAD/CAM
[39] =>
CAD0311_01_Title
Post and search for jobs & classifieds
worldwide on the largest media
platform in dentistry!
Our global online classifieds and career sections are the best solution for filling
job vacancies or selling and purchasing equipment for the dental office. Your postings
will be available to over 650,000 dental professionals, all readers of the Dental Tribune
newspapers, which are published in more than 25 languages worldwide.
For more information and free posting opportunities please go to:
www.dental-tribune.com
[40] =>
CAD0311_01_Title
CAD0311_40_Events 13.12.11 17:27 Seite 1
I meetings _ events
International Events
2012
AO Annual Meeting
1–3 March 2012
Phoenix, AZ, USA
www.osseo.org
Nobel Biocare Symposium 2012
21–23 March 2012
Gothenburg, Sweden
www.nobelbiocare.com
IDEM Singapore
20–22 April 2012
Singapore
www.idem-singapore.com
SCANDEFA
26–28 April 2012
Copenhagen, Denmark
www.scandefa.dk
ITI Congress Germany
27 & 28 April 2012
Cologne, Germany
www.iti.org
CAD/CAM & Computerized Dentistry
International Conference
3 & 4 May 2012
Dubai, UAE
www.cappmea.com
IACA
26–28 July 2012
Hollywood, FL, USA
www.theiaca.com
FDI Annual World Dental Congress
29 August–1 September 2012
Hong Kong, China
www.fdiworldental.org
AAID Annual Meeting
3–6 October 2012
Washington, DC, USA
www.aaid-implant.org
EAO
10–13 October 2012
Copenhagen, Denmark
www.eao.org/eao-congress
Greater New York Dental Meeting
23–28 November 2012
New York, NY, USA
www.gnydm.com
2013
International Dental Show
12–16 March 2013
Cologne, Germany
www.ids-cologne.de
FDI Annual World Dental Congress
29 August–1 September 2013
Seoul, Korea
www.fdiworldental.org
40 I CAD/CAM
3_ 2011
[41] =>
CAD0311_01_Title
CAD0311_41_Submission 13.12.11 17:28 Seite 1
about the publisher _ submission guidelines
submission guidelines:
Please note that all the textual components of your submission
must be combined into one MS Word document. Please do not
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address, e-mail address, etc.).
I
Image requirements
Please number images consecutively throughout the article
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certain images are grouped together, then use lowercase letters
to designate these in a group (for example, 2a, 2b, 2c).
Please place image references in your article wherever they
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If you do not directly refer to the image, place the reference
at the end of the sentence to which it relates enclosed within
brackets and before the period.
In addition, please note:
In addition, images must not be embedded into the MS Word
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Article lengths can vary greatly—from 1,500 to 5,500 words—
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In short, we do not want to limit you in terms of article length,
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Please do not use underlining.
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not add tab stops.
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Larger image files are always better, and those approximately
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(The larger the starting image is in terms of bytes, the more leeway the designer has for resizing the image in order to fill up more
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Also, please remember that images must not be embedded into
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You may submit images via e-mail, via our FTP server or post
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Please also send us a head shot of yourself that is in accordance
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Any formatting contrary to stated above will require us to remove
such formatting before layout, which is very time-consuming.
Please consider this when formatting your document.
Questions?
Claudia Salwiczek (Managing Editor)
c.salwiczek@dental-tribune.com
CAD/CAM
3_ 2011
I 41
[42] =>
CAD0311_01_Title
CAD0311_42_Impressum 13.12.11 17:28 Seite 1
I about the publisher _ imprint
CAD/CAM
digital dentistry
international magazine of
Publisher
Torsten R. Oemus
t.oemus@dental-tribune.com
International Media Sales
Matthias Diessner
m.diessner@dental-tribune.com
Managing Editor
Claudia Salwiczek
c.salwiczek@dental-tribune.com
Europe
Vera Baptist
v.baptist@dental-tribune.com
Product Manager
Vera Baptist
v.baptist@dental-tribune.com
Executive Producer
Gernot Meyer
g.meyer@dental-tribune.com
Designer
Franziska Dachsel
f.dachsel@dental-tribune.com
Copy Editors
Sabrina Raaff
Hans Motschmann
International Administration
Marketing & Sales
Nadine Parczyk
n.parczyk@dental-tribune.com
Executive Vice President
Finance
Dan Wunderlich
d.wunderlich@dental-tribune.com
Editorial Board
Prof Albert Mehl, Switzerland
Prof Gerwin Arnetzl, Austria
Dr Stefan Holst, Germany
Hans Geiselhöringer, Germany
Dr Ansgar Cheng, Singapore
Asia Pacific
Peter Witteczek
p.witteczek@dental-tribune.com
The Americas
Jan M. Agostaro
j.agostaro@dental-tribune.com
International Offices
Europe
Dental Tribune International GmbH
Contact: Nadine Parczyk
Holbeinstr. 29, 04229 Leipzig, Germany
Tel.: +49 341 4 84 74 302
Fax: +49 341 4 84 74 173
Asia Pacific
Dental Tribune Asia Pacific Ltd.
Contact: Tony Lo
Room A, 26/F, 389 King’s Road
North Point, Hong Kong
Tel.: +852 3113 6177
Fax: +852 3113 6199
The Americas
Dental Tribune America, LLC
Contact: Anna Wlodarczyk
116 West 23rd Street, Suite 500
NY 10011, New York, USA
Tel.: +1 212 244 7181
Fax: +1 212 244 7185
Printed by
Löhnert Druck
Handelsstraße 12
04420 Markranstädt, Germany
www.dental-tribune.com
Copyright Regulations
_CAD/CAM international magazine of digital dentistry is published by Dental Tribune Asia Pacific Ltd. and will appear in 2011 with three issues. The magazine and all articles and illustrations therein are protected by copyright. Any utilisation without the prior consent of editor and publisher is inadmissible and
liable to prosecution. This applies in particular to duplicate copies, translations, microfilms, and storage and processing in electronic systems.
Reproductions, including extracts, may only be made with the permission of the publisher. Given no statement to the contrary, any submissions to the
editorial department are understood to be in agreement with a full or partial publishing of said submission. The editorial department reserves the right to
check all submitted articles for formal errors and factual authority, and to make amendments if necessary. No responsibility shall be taken for unsolicited
books and manuscripts. Articles bearing symbols other than that of the editorial department, or which are distinguished by the name of the author, represent
the opinion of the afore-mentioned, and do not have to comply with the views of Dental Tribune Asia Pacific Ltd. Responsibility for such articles shall be borne
by the author. Responsibility for advertisements and other specially labeled items shall not be borne by the editorial department. Likewise, no responsibility
shall be assumed for information published about associations, companies and commercial markets. All cases of consequential liability arising from inaccurate or faulty representation are excluded. General terms and conditions apply, legal venue is North Point, Hong Kong.
42 I CAD/CAM
3_ 2011
[43] =>
CAD0311_01_Title
CADCAM_Abo_A4_Implants_Abo_A4 13.12.11 15:00 Seite 1
CAD/CAM
digital dentistry
international magazine of
Subscribe now!
I would like to subscribe to CAD/CAM (4 issues per year) for
€44 including shipping and VAT for German customers, €46 including shipping and VAT for customers outside Germany, unless a
written cancellation is sent within 14 days of the receipt of the
trial subscription. The subscription will be renewed automatically every year until a written cancellation is sent to Dental
Tribune International GmbH, Holbeinstr. 29, 04229 Leipzig,
Germany, six weeks prior to the renewal date.
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Notice of revocation: I am able to revoke the subscription within 14 days after my order by sending a written
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DENTAL TRIBUNE INTERNATIONAL GMBH
Holbeinstraße 29, 04229 Leipzig, Germany, Tel.: +49 341 48474-302, Fax: +49 341 48474-173, E-Mail: n.parczyk@dental-tribune.com
[44] =>
CAD0311_01_Title
www.schuetz-dental.com
export@schuetz-dental.de
Adding Value to Dentistry
Tizian™ CAD/CAM –
The right solution for you
smaller, faster, better
Tizian™ Scan 102
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• highly precise scan results
< 10 μm
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Tizian™
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For individual offer, please visit http://bit.ly/tizian
Schütz Dental GmbH • Dieselstr. 5 - 6 • 61191 Rosbach/Germany • Phone: +49 (0) 60 03-814-365 • Fax: +49 (0) 60 03-814-907
Anzeige_CAD_CAM_engl_10_2011.indd 1
29.08.2011 19:53:05 Uhr
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