CAD/CAM international No. 3, 2013

Cover / Editorial / Content / E4D chairside CAD/CAM restorations: Case presentations and lessons learned / Using in-office CAD/CAM technology and lithium disilicate to fabricate efficient and predictable restorations / CAD/CAM technology: Setting the standard and achieving success / Non-extraction treatment of a Class II case with a missing mandibular central incisor using a CAD/CAM lingual orthodontic system / Immediate restoration in the edentulous mandible / Bridge construction in the anterior region of the maxilla / Dentures produced using 3-D printing versus casting and milling / Experience business solutions with Straumann CARES customized prosthetics solutions / 3Shape releases CAD solution for post and core restorations / From veneers to bridges: Zirconia reinforced composite / Nobel Biocare announces new digital workflow and new regenerative product at Global Symposium in New York / Meetings: IDS 2013 sets new records / Meetings / Submission guidelines / Imprint

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CAD0313_01_Title 20.09.13 17:06 Seite 1

issn 1616-7390

Vol. 4 • Issue 3/2013

CAD/CAM
digital dentistr y

international magazine of

3

2013

| CE article
CAD/CAM technology:
Setting the standard and achieving success

| case report
Bridge construction in the anterior region of the maxilla

| feature
Dentures produced using
3-D printing versus casting and milling

[2] => CAD0313_01_Title

P R O F E S S I O N A L

M E D I C A L

C O U T U R E

EXPERIENCE OUR ENTIRE COLLECTION ONLINE
WWW.CROIXTURE.COM

[3] => CAD0313_01_Title

CAD0213_03_Editorial 20.09.13 17:07 Seite 1

editorial _ CAD/CAM

Dear Reader,
_ It is a great honour and distinct pleasure to present the third 2013 issue of CAD/CAM to you! 2013 is a
memorable year for dentistry. The 35th International Dental Show in Cologne in Germany will be remembered for
the significant number of companies exhibiting upgrades and introducing new products in the field of CAD/CAM
and digital dentistry. Countless booths with eye-catching designs and product displays demonstrated the
latest trends and technological developments, including CAD/CAM chairside/in the laboratory, computer-guided
implantology, 3-D dental imaging, CAD/CAM materials, computerised orthodontics, digital impressions, software,
management and education. IDS established that digital dentistry is no longer the future; it is already the present.
In this issue of CAD/CAM, you will find beautifully illustrated and well documented articles that report on
CAD/CAM restorations, CAD/CAM lingual orthodontic system and implantology.

Tzvetan Deyanov
BDM & Business Partner CAPP &
Dental Tribune Middle East & Africa

I am pleased to announce that the CAD/CAM is the official publication of the second Asia Pacific CAD/CAM
and Digital Dentistry International Conference, organized by CAPP Asia, which will take place in Singapore on
4 and 5 October 2013. The event is already becoming a major platform for shaping the future of digital dentistry
in the Asia Pacific region. It will attract the crème de la crème of opinion leaders in dentistry, who will be sharing
their knowledge and experience with the world’s dental elite. The objectives of the main scientific session and
the dental technicians’ parallel session will be to exchange valuable knowledge, to help cultivate a spirit of
collaboration in the dental team, and to enable networking. These sessions are expected to spark heated
discussions on the latest methods and techniques and on how to improve them, thus paving the way forward
in dentistry. The exhibition will provide hands-on access to the latest digital dentistry systems. The event will
facilitate direct interaction with the leading dental manufacturers, discussions on the scientific relevance of
their products, and gathering of useful feedback from current and prospective users. It is from this valuable
feedback that the companies taking part in the event will be able to develop their 3-D technologies further,
with a view to best meeting the needs of the dental team.
We are proud to welcome to this year’s conference in Singapore some of the most exciting names in digital
dentistry, who will be presenting papers during the conference: Dr Lutz Ritter, Germany; Dr Andreas Bindl,
Switzerland; Dr Eduardo Mahn, Chile; Prof. Tae Weon Kim, South Korea; Morten Ryde, DT, Denmark; Joachim
Maier, MDT, Germany; Dr Bernd van der Heyd, MDT, Germany; Werner Gotsch, MDT, Germany; Dr Chanchai
Kingawattanagul, Thailand; Dr Simon Kold, Denmark; Dr Khaled Abouseada, Egypt; and Dr Kurt Dawirs, Germany.
A parallel session targeted at dental technicians will be held on the second day of the conference, with presentations by Rik Jacobs, the Netherlands; Carsten Kelm, Germany; Ike Intoratat, Thailand; Barış Çakır, Germany;
Christopher Adamus, DT, Poland; Simon Docker, UK; and Ralf Oppacher, MDT, Germany.
In December 2012, CAPP joined the elite group of international continuing medical education providers who
are accredited by the American Dental Association. Hence, delegates attending can expect to enjoy cutting-edge
presentations in the dental field and to benefit from top-quality scientific discussions.
The conference exhibition will be honoured by the presence of the leading dental manufacturers, including
Sirona, Ivoclar Vivadent, 3Shape, DeguDent, AmannGirrbach, Wieland Dental, Roland DG, Dentegris and eCligner,
all of which will be showcasing their latest masterpieces. There will also be other important industry players at
the conference. We look forward to welcoming you to the vibrant city of Singapore.
Yours faithfully,

Tzvetan Deyanov
BDM & Business Partner CAPP & Dental Tribune Middle East & Africa

CAD/CAM
3_ 2013

I 03

[4] => CAD0313_01_Title

CAD0313_04_Content 23.09.13 12:02 Seite 1

I content _ CAD/CAM

I editorial
03

I feature

Dear Reader

32

| Tzvetan Deyanov

Dentures produced using 3-D
printing versus casting and milling
| Interview with Master Dental Technician Dieter Spitzer

I CE article
06

E4D chairside CAD/CAM restorations:
Case presentations and lessons learned

I industry news
36

| Dr Wally Renne, USA

12

Using in-office CAD/CAM technology and lithium
disilicate to fabricate efficient and predictable restorations

| Straumann

38

| Dr John C. Schwartz, USA

16

CAD/CAM technology:
Setting the standard and achieving success

20

40

| Dr Khaled M. Abouseada, Saudi Arabia

24

Immediate restoration in the edentulous mandible
According to the Maló procedure using the
CAMLOG Guide System and Vario SR abutments
| Dr Ferenc Steidl & Sebastian Schuldes, Germany

From veneers to bridges: Zirconia reinforced composite
| Schütz Dental

42

Non-extraction treatment of a Class II case
with a missing mandibular central incisor
using a CAD/CAM lingual orthodontic system

3Shape releases CAD solution
for post and core restorations
| 3Shape

| Dr Matthew Krieger, USA

I case report

Experience business solutions with Straumann CARES
customized prosthetics solutions

Nobel Biocare announces new digital workflow and new
regenerative product at Global Symposium in New York
| Nobel Biocare

I meetings
issn 1616-7390

46

IDS 2013 sets new records

Vol. 4 • Issue 3/2013

CAD/CAM
digital dentistry

international magazine of

3

2013

48

International Events

I about the publisher

| CE article
CAD/CAM technology:
Setting the standard and achieving success

| case report
Bridge construction in the anterior region of the maxilla

| feature

28

Bridge construction in the anterior region of the maxilla
| Dr Steffen Wolf, Germany

04 I CAD/CAM
3_ 2013

49

| submission guidelines

50

| imprint

Dentures produced using
3-D printing versus casting and milling

Cover image courtesy of
Dr Ferenc Steidl & Sebastian Schuldes.

[5] => CAD0313_01_Title

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Scan the QR code to register.

[6] => CAD0313_01_Title

CAD0313_06-10_Renne 20.09.13 17:08 Seite 1

I CE article _ practical lessons in CAD/CAM

E4D chairside CAD/CAM
restorations: Case presentations
and lessons learned
Author_ Dr Wally Renne, USA

Fig. 1

Fig. 2

Fig. 1_Patient presents with crown
missing from tooth #9.
Fig. 2_E4D Dentist System is used
to take a digital impression,
then the restoration is designed
using E4D DentaLogic Software.
(Photos courtesy of Dr Wally Renne)

_ce credit CAD/CAM
By reading this article and then
taking a short online quiz, you
can gain ADA CERP CE credits.
To take the CE quiz, visit
www.dtstudyclub.com. The quiz
is free for subscribers, who will
be sent an access code. Please
write support@dtstudyclub.com
if you don’t receive it. Non subscribers
may take
the quiz
for a
$20 fee.

06 I CAD/CAM
3_ 2013

_Despite the increasing popularity of the current CAD/CAM laboratory systems and continuing
technical advances, some clinicians have remained
reluctant to incorporate the very same CAD/CAM
techniques into their clinical chairside practices. Two
often-repeated misconceptions relate to the perceived lack of strength and lack of aesthetics of the
ceramics available for use with these systems. A wide
variety of materials are available to use with the E4D
Dentist System (D4D Technologies), and each has a
separate set of aesthetic and mechanical properties
that must be considered. This article will review current materials and show clinical examples of restorations made using the E4D Dentist System.
One distinct advantage of chairside CAD/CAM is
having the ability to make restorations in a single visit
from a solid pre-manufactured block that is essentially flawless in construction. A pre-manufactured
block is made in ideal conditions, and as a result, has
an ideal density with none of the residual porosity
found in many layered or pressed porcelains.
Porosities may act as a weak point and lead to the
build-up of internal tensile stress in the ceramic and
eventually cause a catastrophic failure. Monolithic
restorations have several distinct advantages over

layered restorations when it comes to mechanical
properties. Layered restorations are often veneered
with weak feldspathic glasses that can chip or break,
especially if not supported properly by the framework.
Furthermore, one does not need to worry about delamination and micro-chipping of the veneering porcelain, which has been reported to be as high as 25 per
cent for porcelain-fused-to-zirconium restorations.1
IPS Empress (Ivoclar Vivdent) is a feldspathic glass
with approximately 45 % leucite crystals for dispersion strengthening. The 5 µm leucite crystals improve
strength and fracture toughness by acting as “roadblocks” to prevent crack propagation. IPS Empress is
an aesthetic material and is available in polychromatic
blended shades that give the restoration a layered appearance. Empress Multiblock has a flexural strength
around 160 MPa and requires isolation and attention
to detail when bonding to ensure long-term success.
IPS Empress has been on the market for approximately 24 years, and as a result, good clinical research
on the longevity of these restorations exists in the
literature. A literature review conducted by Brochu
and El-Mowafy evaluated and summarized six clinical studies that met their inclusion criteria. They

[7] => CAD0313_01_Title

CAD0313_06-10_Renne 20.09.13 17:08 Seite 2

CE article _ practical lessons in CAD/CAM

Fig. 3

concluded the survival rates for IPS Empress inlays
and onlays ranged from 96 per cent at 4.5 years to
91 per cent at seven years. IPS Empress crowns had
a survival rate ranging from 92 per cent to 99 per cent
at three to 3.5 years.
For both crowns and onlays, most failures were due
to bulk fracture.2 In general, IPS Empress has higher
failure rates in the posterior than the anterior and
higher fracture rates on molars compared with premolars.3–6 Therefore, IPS Empress is an excellent
material choice in the anterior for aesthetically demanding patients. However, alternative materials
exist for posterior use.

_Case presentation
A new patient called the office and said his crown
“exploded.” He presented to the clinic with the crown
missing on tooth #9 (Fig. 1). The E4D Dentist System
was used to make a digital impression of the preparation and the bite registration. Using the intuitive
design features in the E4D software, a restoration
was designed (Fig. 2). An IPS Empress CAD Multi
A1 restoration was milled and characterized using
IPS Empress Universal Stains. For delivery, the crown

was prepared by etching with 4.9 % hydrofluoric acid
for 60 seconds and silanated for 60 seconds with
Monobond-Plus (Ivoclar Vivadent). The tooth was
pumiced; Optibond XTR (Kerr) was applied and cured
for 20 seconds; and Nexus 3 resin cement (Kerr) was
used to bond the crown (Fig. 3).

Fig. 4

Fig. 3_An IPS Empress DAC Multi A1
restoration is milled and custom
characterized using IPS Empress
Universal Stains.

The use of IPS Empress has been selective partly
because of the popularity of IPS e.max CAD (lithium
disilicate). IPS e.max CAD comes in a lithium metasilicate state (blue colour) that is not fully crystallized
but can be easily machined. The milled restoration is
then placed in the oven for 19 to 26 minutes to crystallize the glass. During crystallization, the lithium
metasilicate crystals are replaced with lithium disilicate crystals, increasing flexural strength from
around 160 MPa to 360 MPa.
IPS e.max was introduced to the market in 2006.
Gehrt and colleagues followed 104 IPS e.max crowns
in 44 patients and found the corresponding survival
rate for all restorations was 97.4 per cent after five
years and 94.8 per cent after eight years of clinical
service with location not significantly impacting survival rate.7 These results were for IPS e.max press
restorations that were cut back and veneered. It

Figs. 4–6_In this case, a patient who
was not happy with the aesthetics of
an amalgam restoration presented
with recurrent caries on the mesial
of tooth #13. The E4D Dentist System
was used to make a digital model,
and restorations were milled out of
IPS e.max CAD HT A2 blocks.

Fig. 5

Fig. 6

CAD/CAM
3_ 2013

I 07

[8] => CAD0313_01_Title

CAD0313_06-10_Renne 20.09.13 17:08 Seite 3

I CE article _ practical lessons in CAD/CAM

Fig. 7

Fig. 9

Fig. 8

Figs. 7–9_With the strength
of IPS e.max, predictable restoration
of second molars using the
E4D Dentist System is possible.

Figs. 10 & 11_In this case,
a 37-yearold male presented
with severe acid erosion and
abrasion from gastroesophageal
reflux disease and bruxism.

Fig. 10

can be hypothesized that monolithic chairside milled
IPS e.max may perform better.
In a 10-year study, Kern et. al. found three-unit
fixed partial dentures (FPDs) made from monolithic
lithium disilicate ceramic showed five- and 10-year
survival and success rates that were similar to those
of conventional metal-ceramic FPDs.8 They concluded that for the monolithic lithium disilicate
FPDs, the calculated survival rate was 100 per cent
after five years and dropped to 90.8 per cent (when
considering only catastrophic ceramic fractures) and
87.9 per cent (when considering catastrophic ceramic fractures and biological failures) after 10 years.8
It is interesting to note that all catastrophic failures
occurred in molars.8 Single-unit monolithic IPS e.max
can be expected to perform better than FPDs in this
study.
Interestingly for both clinical studies mentioned,
the restorations that were conventionally cemented
performed just as well as those that were bonded.7,8
Therefore, assuming proper retention and resistance
form has been achieved, it is acceptable to conventionally cement monolithic IPS e.max restorations.
Because of the incredible flexural strength of
IPS e.max, some clinicians were concerned that

Fig. 11

08 I CAD/CAM
3_ 2013

IPS e.max may be aggressive on the opposing dentition. In a clinical study, Silva et. al. found IPS e.max
to be more gentle on the opposing enamel than
feldspathic ceramics with a wear rate on enamel
similar to natural definition.9 Chairside CAD/CAM
allows the clinician to predictably provide more
conservative restorations, such as IPS e.max inlays
and onlays, that have a longevity similar to full
coverage crowns.10 The advantage to onlays over
crowns is the conservation of healthy tooth structure and subsequent prolonging of the tooth’s
life cycle.
Chairside milled onlays are an ideal restoration
compared with direct resins. Despite their popularity, large posterior resin-based composite (RBC)
restorations last only six to seven years.11,12 RBC
restorations have poor clinical longevity, higher
recurrent caries and greater need for replacement
compared with the alternative, high-copper amalgam.13–17
Amalgam and cast gold are not a popular option
for many patients because of aesthetic concerns, and
an E4D onlay restoration is the ideal treatment for
many patients who refuse these alternative treatments. Milled inlays and onlays have been shown to
be very successful.

[9] => CAD0313_01_Title

CAD0313_06-10_Renne 20.09.13 17:08 Seite 4

CE article _ practical lessons in CAD/CAM

Fig. 12

One study found a success rate of 90.4 per cent
after 10 years with older feldspathic ceramics as well
as older milling and design technology.18
In this case, the patient was not happy with the
aesthetics of the amalgam restorations, and she
had recurrent caries on the mesial of tooth #13. The
E4D Dentist System was used to make a digital model,
and the design software proposed well-contoured,
anatomical restorations that were milled out of e.max
CAD HT A2 blocks. For delivery, the restorations were
prepared by etching with 4.9 % hydrofluoric acid
for 20 seconds and silanating for 60 seconds with
Monobond-Plus (Ivoclar Vivadent). The tooth was
pumiced clean; Optibond XTR (Kerr) was applied and
cured for 20 seconds; and Nexus 3 resin cement (Kerr)
was used (Figs. 4–6).
Despite the benefits of onlays, single-unit crowns
are still the preferred restoration for the general dentist, and the E4D Dentist System fabricates excellent
restorations with a short learning curve. With the
strength of IPS e.max, predictable restoration of second molars using the E4D Dentist System is possible
(Figs. 7–9).
Once the learning curve of single-unit restorations
is mastered, it will not be long before the benefits of
the E4D Dentist System become apparent for more
complicated cases. A 37-year-old male presented
for a consult for dentures. He had been to several
dentists and an immediate denture was the treatment plan he had selected. He presented with severe
acid erosion and abrasion from a combination of
gastroesophageal reflux disease (GERD) and bruxism
(Figs.10 & 11).

position and had a severe anterior deviation from
centric relation.

Fig. 13

Figs. 12 & 13_After a diagnostic
wax-up was made, the teeth were
prepared and temporized.

When evaluating the location of the gingival margins it was determined that compensatory eruption
had taken place. However, based on the closest speaking space during the production of sibilant sounds,
the patient had excess freeway space.
It was determined that the patient lost vertical
dimension of occlusion, and therefore compensatory eruption did not keep up with the rate of erosion.
Two centric-relation (CR) records were made using
bimanual manipulation, a custom triad jig and a rigid
bite material. The case was mounted on a semi-adjustable articular in centric relation and the mounting
was verified with the second CR record.
It was decided (based on freeway space, aesthetics
and phonetics) that to recapture the lost VDO the patient needed to be opened 2.5 mm in the anterior; this
correlated to around 1 mm in the posterior. A diagnostic wax-up was made. The teeth were prepared and
temporized based on the diagnostic wax-up (Figs. 12
& 13). The patient was kept in temporaries for six weeks
to verify tolerance of the new vertical dimension,
phonetics (particularly “F” and “S” sounds) and CR.
In the provisionals, anterior guidance was established with no balancing interferences during lateral
excursive movements. CR was stable and at the end
of the six-week trial period the patient was painfree upon palpation of his lateral pterygoid muscles,

Fig. 14_The E4D Dentist System
clone feature copies the occlusion
and anatomy of the
temporaries exactly.

Occlusal examination revealed a lack of anterior
guidance and posterior support. The lateral pterygoids were sensitive to palpation, and upon visual
examination it was noted that he had hypertrophic
masseters. Lip commissures were folded and he
appeared to have a collapsed vertical dimension of
occlusion (VDO). He did not close in a repeatable

Fig. 14

CAD/CAM
3_ 2013

I 09

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I CE article _ practical lessons in CAD/CAM

Fig. 15

Fig. 16

Fig. 15_The E4D Dentist System
software, DentaLogic, enables
the clinician to superimpose
the temporary “clone” model
over the restoration design
to determine accuracy.
Fig. 16_Restorations are milled
out of B1 e.max CAD LT,
prepared and seated.

and the provisionals did not show signs of malocclusion, such as fracture or accelerated wear. His
central incisors were hitting just inside the wet-dry
line of the lower lip during “F” sounds. During “S”
sounds, the closest speaking space, the patient’s maxillary and mandibular anterior teeth did not touch.
Once verified, a vinyl polysiloxane (VPS) impression of the temporaries was made along with a bite
registration. At this point, centric relation was equal
to maximum intercuspal position (MIP). The E4D
Dentist System system’s clone feature copied the
occlusion of the provisionals exactly (Fig. 14).
The software, DentalLogic, allows the clinician to superimpose the provisional “clone” model over the restoration design to determine accuracy (Fig. 15). One of the
most powerful features of the software is the ability to
turn the clone model clear and analyze how accurately
the software has copied the anatomy and occlusion.
The accuracy of this is within microns and an intuitive
colour map displays the discrepancy that exists between
the temporaries and the final crown design (Fig. 15).
The restorations were milled and prepared by
etching with 4.9 % hydroflouric acid for 20 seconds and
silanating for 60 seconds. The tooth was then pumiced,
curing solution applied and cured for 20 seconds. The
restoration was then ready for cementation.
The occlusion was identical to the provisional and
thus no adjustments were needed on the day of delivery. With the option now to use IPS e.max HT, this
case had a better aesthetic result because the LT block
appears slightly monochromatic and opaque.

_Summary
Dental patients typically want tooth-coloured indirect restorations; and with the newer ceramics that
are available for chairside milling, the same highquality ceramic restorations that labs are producing
can be fabricated in a single appointment.
With a chairside CAD/CAM system, large, technique-sensitive and inferior direct resins require less

10 I CAD/CAM
3_ 2013

treatment planning because milled IPS e.max onlays
can take their place. Chairside CAD/CAM dentistry is
not the only way to provide patients with high-quality restorations, but it certainly is the most exciting
from both a clinician’s and patient’s viewpoint.
Multiple-visit, single-unit restorations; singleunit
temporaries; difficult resins; expensive monthly fabrication fees; and bonding restorations after weeks
of contamination with temporary cement and saliva
is routine for most dentists who have not invested
in CAD/CAM technology. The old adage “what you
don’t know you don’t miss” holds true._

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

_about the author

CAD/CAM

Dr Wally Renne, DMD, is a
2003 graduate of the College
of Charleston and a 2008
graduate of the Medical
University of South Carolina
(MUSC) College of Dental
Medicine. He is active in
undergraduate dental education
and holds a full time faculty position in the department
of oral rehabilitation at MUSC. He is the course
director for CAD/CAM technologies and ceramics
and runs the E4D CAD/CAM clinic at MUSC.
Dr Renne maintains an active general dentistry
practice utilizing both the CEREC AC and E4D
Dentist System. His special interests in patient
treatment include advances in CAD/CAM dentistry,
adhesive dentistry and conservative dentistry.
He is active in dental research and currently
has a patent pending for a new dental adhesive
that is permanently antimicrobial and has
revolutionary bond durability components that
prevent enzyme degradation of the hybrid layer.
This bonding agent may prevent recurrent caries
and bond breakdown in the long term.

[11] => CAD0313_01_Title

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[12] => CAD0313_01_Title

CAD0313_12-15_Schwartz 20.09.13 17:35 Seite 1

I CE article _ litihium disilicate restorations

Using in-office CAD/CAM
technology and lithium
disilicate to fabricate efficient
and predictable restorations
Author_ Dr John C. Schwartz, USA

Fig. 1

Fig. 2

Fig. 1_A preoperative, buccal view
of the patient’s smile revealing
unsightly crown margins
and gold restorations.
Fig. 2_Preoperative occlusal view
of the patient’s unsatisfactory
restorations.

12 I CAD/CAM
3_ 2013

_In today’s fast-paced world, instant gratification is expected to be synonymous with worthwhile results. This also applies to dental treatments.
While there have been many recent technological
innovations specifically for chairside restorations,
dentists have faced complications when mastering
complex and time-consuming protocols.
The E4D Dentist System (D4D Technologies)
eliminates those obstacles by providing outstanding clinical results in a single visit using intuitive,
efficient and state-of-the-art technologies.
The E4D Dentist System’s three-dimensional
software simplifies designing and milling multiple
restorations. This provides dentists with more control over the aesthetic process. The E4D in-office
CAD/CAM system is equipped with a high-speed
intraoral laser scanner for capturing digital impressions, which provides restorations with betterquality fit and function because it incorporates
intraoral digital impressions, traditional impressions and models.
The E4D Dentist System streamlines work for
dentists, who gain the enhanced confidence of

producing reliable restorations for every patient
case. Meanwhile, patients receive both enhanced
and more efficient care with faster treatment
times.
Contributing to efficiency and accuracy is the
E4D design software, which facilitates required
modifications to finalize restorative designs in
record time.
Restorative designs are then sent to the E4D
precision milling unit, which incorporates dual
spindles and diamond burs to efficiently form CAD
materials into restorations that exhibit exceptional fit, maximized strength and lifelike aesthetics.
In fact, restorations fabricated using CAD/CAM
processing have demonstrated less chipping or
fracturing, which enhances the predictability of the
restoration.1
Among the materials that can be processed
chairside with the E4D Dentist System is lithium
disilicate (IPS e.max CAD, Ivoclar Vivadent), which
is available for processing CAD/CAM restorations indicated for placement in the anterior and
posterior.

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Fig. 3

Fig. 5

Fig. 4

Fig. 3_Scan of the patient’s prepared
teeth with margins identified.
Fig. 4_View of the CAD proposals
created utilizing Autogenesis.
Fig. 5_Buccal view of the
CAD proposals.
Fig. 6_Optimization of CAD proposal
to account for occlusion
and contact pressure.
Fig. 7_Optimization of CAD proposal
with model and occlusion in place.
Fig. 6

Fig. 7

The material is also indicated for an assortment
of dental procedures, including partial and full coverage inlays and onlays, thin veneers (0.3 mm) and
implant superstructures. Lithium-disilicate glass ceramic trumps traditional ceramic materials because
of its durability and high flexural strength values.

In-office CAD/CAM restorations (IPS e.max
CAD) were discussed with and agreed to by the
patient. The optical qualities of IPS e.max CAD,
which include a fairly low refractive index, optimal
light transmission and lifelike translucency, would
provide natural appearing and highly aesthetic
restorations.2, 3

_Case presentation
Preparation and digital impression taking
A 55-year-old woman presented requesting
removal of the maxillary left bicuspid and molar
crowns. Their unsightly margins and the gold
restorations were visible in her smile (Figs. 1 & 2),
and the patient had grown weary of their unsettling
and lackluster appearance. Her goal was to whiten
her dull-looking teeth in order to reflect the brighter
colour of her natural anterior dentition.

The existing crown restorations were removed
and the teeth were prepared for IPS e.max CAD
crowns. Preparations included a 2 mm occlusal
reduction and a 1–1.2 mm shouldered margin.
A scan was performed of the patient’s arch and
prepared teeth, and the margins were identified
(Fig. 3).

Fig. 8

Fig. 9

Fig. 8_The internal aspects
of the crowns are cleaned,
etched and silanated.
Fig. 9_Ceramic Etching Gel is applied
for 20 seconds, rinsed with
water and dried. In preparation
for salinating using
Monobond Plus primer.

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Fig. 10

Fig. 11

Fig. 10_The Monobond Plus Primer
was applied with a microbrush
for 60 seconds.
Fig. 11_The preparations are
cleaned and three drops each
of Multilink A&B solution
are mixed in a well.

Digital restoration creation

Cementation

The autogenesis feature in the E4D DentaLogic
intuitive software was used in conjunction with E4D
CAD proposals (Fig. 4), which incorporated images
of the buccal and occlusal aspects (Figs. 5 & 6) and
contact intensity (Fig. 7).

Lithium-disilicate glass ceramic restorations
(IPS e.max CAD) can be traditionally cemented or
bonded adhesively. As a result, any restrictions that
may be presented due to placement or location
within the mouth are eliminated.4, 5

The restorations were designed and then sent
to the E4D milling unit, where lithium-disilicate
hightranslucent (HT) blocks (IPS e.max) were milled.
After completion, the monophasic crowns were first
tried in the patient’s mouth to appraise fit, contour
and anatomical harmony, then crystallized.

The internal aspects of the crowns were cleaned
with Ivoclean and etched with Ceramic Etching Gel.
The Ceramic Etching Gel was applied for 20 seconds,
rinsed with water and dried in preparation for silanating using the Monobond Plus Primer (Fig. 9).

Customization

Fig. 12_Excess Multilink A&B
solution is air blown gently
to remove excess.
Fig. 13_Multilink Automix cement
is loaded into the crowns.

Fig. 12

The restorations were removed from the furnace, then cleaned and dried. To fulfil the patient’s
desired goal of having a more natural coloured smile,
the restorations were appropriately stained and
glazed. The ideal shade stain was placed on the tip of
a hygienic brush and applied to the restorations.
Once staining was complete, the crowns were fully crystallized and fired. The case was ready for seating
using universal cement (Multilink, Ivoclar Vivadent).

Fig. 13

14 I CAD/CAM
3_ 2013

The Monobond Plus Primer was applied with
a microbrush for 60 seconds to the internal surfaces of the restorations to ensure a sound bond
between the restorations and cement, as well as
increase bond strength (Fig. 10). Excess primer was
air dried.
The solution was then applied to the prepared
teeth and allowed to sit for 40 seconds. The Multilink A&B solution (Fig. 11) was air blown gently to
remove excess. Note that the patient’s surrounding gingival tissues may turn white temporarily
(Fig. 12).

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Fig. 14

Next, the internal aspects of the IPS e.max CAD
crowns were loaded with Multilink Automix (Ivoclar
Vivadent) (Fig. 13) and seated on both the maxillary
left bicuspid and molar with slight pressure applied.
The “wave” technique was then used to cure the
excess cement to a gel like state, which enabled easy
removal (Fig. 14).

Fig. 15

By incorporating the essential components of
smile design and accurate scanning, the E4D Dentist
System helps to ensure the accuracy and predictability of resulting restorations.
When milled from highly esthetic lithium-disilicate blocks (IPS e.max CAD), the restorations enable

Fig. 14_The crowns are seated and
the Wave technique used to facilitate
easy cleanup of excess cement.
Fig. 15_Postoperative, buccal view
of the patient’s restored smile,
complete with more natural
looking IPS e.max CAD
lithium-disilicate crowns.
Fig. 16_Postoperative occlusal
view of the final chairside fabricated
E4D restorations.
(Photos courtesy of Dr John C. Schwartz)

Fig. 16

Excess cement was removed from interproximal
and cervical areas using a microbrush, after which
complete polymerization was achieved by curing
from the buccal, lingual and distal aspects.

dentists to provide exceptional treatments tailored
to the patient’s authentic esthetic characteristics._
Editorial note: A complete list of references is available
from the publisher.

_Conclusion
The combination of lithium-disilicate blocks (IPS
e.max CAD) and the E4D Dentist System is a stateof-the-art material and technology solution that
enhances the predictability, aesthetics and ease-ofuse of in-office CAD/CAM procedures. Restorations
completed with this complementary combination
demonstrate excellent fit, function and aesthetics
(Figs. 15 & 16). As a result, dentists can provide
progressive, one-day treatments to patients, eliminating more invasive and time-consuming procedures that can require multiple appointments.

_about the author

CAD/CAM

Dr John C. Schwartz
337 Metairie Road, Suite 302
Metairie, LA 70072
USA
johnschwartz@
drjohnschwartz.com

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CAD/CAM technology:
Setting the standard
and achieving success
Author_ Dr Matthew Krieger, USA

Fig. 1

Fig. 2

Fig. 1_Tooth #2 before.
Fig. 2_Tooth #12 after
(same-day IPS e.max).

16 I CAD/CAM
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_As a full-time general dentist, CAD/CAM
technology is a subject that has been of significant
interest to me. I incorporated CAD/CAM into my
practice more than 10 years ago and have been
a proponent of the technology and its efficiency
ever since.

my decision to switch late in 2010 and have never
looked back. Since then, research and development
in CAD/CAM restorative materials have exploded.
We have a wide variety of material options to
choose from to meet all of our restorative and
aesthetic demands.

I began with CEREC 3, and then graduated to
CEREC 3D. After successfully incorporating 3-D
technology into my practice, I was excited to see
some new faces emerge in the CAD/CAM marketplace. E4D, Itero and Lava COS were all options
to consider for digital capture, but only the E4D
Dentist System and CEREC offered both scan and
mill capability in the office.

My peers routinely ask me about how to use
technology most effectively to cope with rising
costs and lower margins. I often answer by suggesting that they incorporate chairside CAD/CAM
into their practices. I am confident that chairside
CAD/CAM is the future of restorative dentistry, not
only from a clinical perspective, but also in terms
of profitability and marketing.

When the time was right for me to upgrade to
the newest technology, the E4D Dentist System
by D4D Technologies was just a better fit—literally
and figuratively. The software, support, training
and results were more in line with my practice
goals and vision, and I felt more confident in the
longevity of the hardware. While both systems
can produce high-quality restorations, I felt that
I would be better supported in achieving restorative success with the E4D Dentist System. I made

_Simple economics
Over the last five years, my practice has doubled
in revenue. In 2010 it grew 18 per cent while other
practices were struggling to break even. It consistently produces more than $1 million on a fourday work week, with an average collection rate
of 98 per cent. It maintains an overhead of about
55 per cent and normally attracts more than
30 new patients per month.

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Fig. 3

Fig. 4

I am able to do all of this while participating
with more than 15 preferred provider organizations (PPO), as well as several reduced-fee plans
and two union plans. I attribute the success of the
practice to five key factors (Table 1).

the available materials with same-day CAD/CAM
dentistry?

Although every factor plays a critical role in the
growth and success of a practice, technology has
the most significant impact on my practice’s ability to generate high-quality restorative dentistry in
a more efficient and less stressful way. My practice
utilizes networked office management software
with computers in every operatory, office and
support area.

After I completed some additional clinical
training in CAD/CAM aesthetics, including staining
and glazing IPS Empress and IPS e.max ceramic
(Ivoclar Vivadent), and now the simplified polishing of LAVA Ultimate (3M ESPE), I was surprised
by how easy it was to achieve great aesthetics.
I now find myself tackling the more challenging
cosmetic cases on my own because I have more
control when characterization is done chairside.

In addition to digital radiography, we regularly use intraoral cameras, diode and erbium
lasers and, most importantly, chairside CAD/CAM
technology. Our ability to provide high-quality
dentistry with ease and efficiency relies on the
integration and utilization of all of these different technologies, with CAD/CAM being at the
centre of our restorative treatment appointments.
The decision to purchase and implement new
technology can be challenging. In a PPO practice,
where fees can be as much as 30 per cent lower
than in a fee-for-service office, the decision can
be even more intimidating. With a lower potential
profit margin, added capital expenditures can have
more of an impact on your bottom line.
I considered several factors when choosing to
add CAD/CAM to my technology armamentarium.
Quality, fit and durability of the restorations
were the primary focus of my clinical decision. The
profitability, practical application and return on
my investment were the primary focus of my
business decision.

Would the materials available offer enough variety to handle complicated aesthetic challenges?

The E4D Dentist System also offers the option
to have your restorations designed and/or milled
offsite using the E4D SKY network. For an additional fee, you can actually send your scans to
D4D Technologies to expert designers to have your
designs or milling completed if you choose. This
is a great service for dentists who are new to the
technology, are just getting into more advanced
restorative/cosmetic cases or want to maximize
utilization while still keeping a full schedule.
In addition, the E4D Dentist System (DentaLogic
Version 4.5) can import and export open file for-

Table 1_Five key factors
to practice success.

Five key factors to practice success
Technical skill

Proficiency in clinical, diagnostic and communcation skills for the
practitioner and team

Team

Highly skilled, motivated, well-trained and easily adaptable individuals

Systems

Clear and effective protocol for clinical, administrative and financial
practice management

Marketing

Effective marketing and advertising to generate awareness and new
patients

Technology

Cutting-edge technology to increase efficiency and productivity

_Control and aesthetics
Aesthetics was a significant concern as well.
Would I be able to achieve optimal aesthetics with

Fig. 3_Teeth #8 and #9
pretreatment.
Fig. 4_Immediate
post-treatment
(same-day IPS e.max).

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Fig. 5

Fig. 6

Fig. 5_Teeth #13 and
#14 pretreatment.
Fig. 6_Post-treatment
(CAD/CAM IPS e.max Crowns).

mats (.stl), providing additional options for utilizing a variety of digital services from laboratories
and services through the E4D Sky network.
Not only can it match the esthetics, strength
and durability of traditional indirect restorative
methods, but CAD/CAM technology can also provide a significant and immediate financial advantage over traditional impression-based dentistry.
It allows a dentist to produce and deliver restorations in one visit.
It reduces overhead by eliminating external
fabrication fees and it reduces material costs associated with impressions and provisionalization
as well reducing chairtime.

_Scheduling same-day dentistry
Table 2_The economics
of singlevisit vs. multiple-visit
indirect restorative dentistry.

Every patient visit costs a practice time and
money. Each time a patient is seated we use per-

The economics of single-visit vs. multiple-visit indirect restorative dentistry
Crowns #13, #14

Traditional Restorative
Treatment

CAD/CAM Treatment

Visits (time)

150 min

135 min

Lab cost

$ 250

Materials cost

$ 100

$ 80

Staff cost

$ 40

$ 50

Average PPO fee

$ 1,722 ($861 each)

Production per hour (fee/time)

$ 688.80

$765

Total profit (fee minus cost)

$ 1,372

$1,592

Down time

15 min

45 min*

* During this procedure, Krieger delivered three IPS Empress CAD/CAM crowns and produced an additional $565 in
direct restorative dentistry in his second chair. The total office production for the two-hour time span was $2,157.

18 I CAD/CAM
3_ 2013

ishable goods, expend valuable chairtime, utilize
staff time and must track and manage scheduling.
The average crown delivery visit requires 30 minutes of chairtime and costs a practice more than
$50 in overhead expense.
It is critical to maximize the efficiency with
which you provide dentistry in order to remain
profitable, and one visit is more efficient than two.
The economics of single-visit vs. multiple-visit
indirect restorative dentistry is obvious and impactful.
In addition to an increase in total profit and
hourly productivity, the dentist has 30–45 minutes
of additional down time to produce more dentistry,
provide hygiene exams and perform administrative duties.
Beyond the financial return on investment are
the intangible and immeasurable benefits that
same-day dentistry provides. If a patient does not
need a temporary, he or she is certainly less likely
to call you over the weekend to have the temporary
re-cemented.
If a second visit is not necessary to insert
a restoration, then the potential of cancelling,
changing or not showing for the appointment is
eliminated. This reduces stress and opens up
valuable time in your schedule to produce more
dentistry profitably.

_Marketing same-day dentistry
Whenever I am speaking with dentists or team
members about practice management and increasing production, marketing strategies invariably become a topic of discussion. I usually suggest that the best marketing techniques focus
on addressing the concerns that our patients have
regarding dentistry.

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Fear, money, time and discomfort are common
barriers to dental treatment. CAD/CAM addresses
the issue of time quite well, but for most patients
every dental visit represents time away from work,
family members or other important tasks. By providing same-day restorative treatment you are
saving your patients precious time.
People don’t like going to the dentist. It’s not
personal. It’s just not pleasant. Have you ever had
a colonoscopy? Not a great memory. Now imagine
the thought of a colonoscopy that took not one,
but two visits and required you to “wear a temp
between each visit that may fall out.”
It is much easier for patients to accept treatment if they can fit it into their budget, as well as
into their schedule.
Show patients that you value their time and
that you have made a significant time/money investment in your practice in order to facilitate the
ease and efficiency with which you can provide
treatment, and I will show you a great marketing
strategy.
Not only is time a major deterrent to treatment
acceptance, but so is fear. When patients are told
that they need a crown, these are the thoughts
and images that come to mind: An awful tasting
impression materials or temps that fall out during
an important meeting. Ugly gray lines near the
gum lines around old crowns. Think about how
powerful a marketing tool it is to be able to tell
them that in your practice:
_they don’t need any impressions,
_they don’t have to wear a temp,
_there is no metal under the crown so they won’t
have gray lines,
_and the entire procedure can be done in one visit,
during which they will have 30–45 minutes to
catch up on work, return e-mails or just relax and
watch TV (I have TVs in all of my operatories).
When that patient leaves with a brand new
crown and goes back to work or out with friends,
he (or she) is going to talk about what a wonderful and convenient experience he just had in your
office. “No, I don’t have to go back. My dentist
can do crowns in one day.” That’s how to market
your practice, and that’s the most significant
return on your investment that CAD/CAM has to
offer.
By offering CAD/CAM, you are able to address
two common and significant barriers to treatment acceptance. Same-day dentistry is a power-

ful marketing tool, as well as an effective way
to increase the frequency with which your patients choose to move ahead with restorative
dentistry.
Although the decision to implement new technology into your practice can be stressful and
challenging, reduced productivity due to outdated
technology should be of greater concern.
Make an investment in your office, your team
and your practice, and the results that you see
will far outweigh the financial concerns that are
preventing you from making a huge leap forward
and a difference in your dentistry._

_about the author

CAD/CAM

Matthew Krieger, DDS, is a
1998 graduate of New Jersey
Dental School. He completed
a GPR at Mt. Sinai Hospital in
New York City. He started his
practice in 2003 and built it
into a full-time practice in just
one year. He has consistently
grossed more than $1 million since 2006.
In addition to running a full-time private practice,
Krieger is the founder and CEO of Symposia C.E.,
and he serves as a practice efficiency consultant
with High Performance Dental Consulting.
Krieger maintains more than 500 hours of
C.E. credits and continues to expand his knowledge
in dental practice management.

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I case report _ CAD/CAM lingual orthodontic system

Non-extraction treatment
of a Class II case with a
missing mandibular central
incisor using a CAD/CAM
lingual orthodontic system
Author_ Dr Khaled M. Abouseada, Saudi Arabia
treated with a fixed system and who are looking
for invisible orthodontics. They are also perfect
for patients who are not committed to dealing
with removable aligners. Lingual braces are an
exciting advancement in orthodontic care, and
many patients are thrilled. I would like to present
a brief background on the Incognito lingual
braces system, followed by a discussion of a case
I treated with lingual braces and why I chose this
system.1

Fig. 1

Fig 1_Different Steps of
Manufacturing of Incognito System.

_Adult orthodontic patients insist on aesthetic treatment options that have the least possible impact on their work and life. Clear aligners
are an excellent treatment option that is well
suited to many comprehensive orthodontic treatment plans. You may have already figured out
that case selection is essential, and some movements are more difficult to perform well with
removable aligners.
Incognito lingual braces (3M ESPE) are an ideal
treatment option for adult patients who are best

20 I CAD/CAM
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The Incognito appliance is manufactured
using state-of-the-art CAD/CAM technology.
The first step in the fabrication process is taking
accurate polyvinyl siloxane impressions and bite
registration using polyvinyl siloxane, and then
creating a model in plaster and a diagnostic waxup thereafter (according to my direct instructions). The final model is then sent to me digitally
for feedback, and I can make a series of changes
until I am satisfied with the final result. The final
model is then scanned with a 3-D scanner and the
brackets are designed on the computer.
The bracket and archwire system consists entirely of individualised components. The bracket
bases and bodies, the position of the bracket
body on the bases, the bracket-slot orientation
(ribbonwise), the direction of the archwire insertion (vertical or horizontal) and the archwire
geometry are all individually adjusted to each
tooth, according to malocclusion and the orthodontist’s instructions. Rapid prototyping tech-

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nology is used for the manufacturing of the lingual brackets. The braces are then cast from gold
alloy, mounted in a flexible indirect bonding tray,
and shipped out ready to be bonded. Direct bonding is feasible too, owing to the extended individual bases.
Bending archwires is one of the most difficult
tasks in orthodontics. In this system, computeroperated bending of archwires using robots is
used to manufacture precisely shaped archwires.
Even super-elastic archwires can be precisely
shaped. This helps solve three major problems in
lingual orthodontics:
1. Patient discomfort during the adaptation
phase: The appliance is designed to be as flat
as possible, not much higher than a bonded
retainer; this significantly improves patient
comfort.
2. Difficulties in re-bonding: The customised
bracket base covers the major part of the lingual tooth surface and therefore allows direct
re-bonding without the need for any other
positioning aids.
3. Inaccuracies in finishing: Inaccuracies of the
slots due to production and resulting variation
in torque play are now part of the past, owing
to Incognito. Measuring rates show divergences of not more than 0.008 mm between the
slots. The precisely shaped archwires also make
high-standard finishing easily achievable.2, 3
Figure 1 shows the different steps in manufacturing braces with the Incognito system.
This case report describes the treatment of a
patient with a skeletal Class II malocclusion due to
a retrognathic mandible and protrusive maxilla.
He also had a congenitally missing mandibular
left central incisor. The extraction of a single
mandibular incisor can be employed as a compromise treatment of certain malocclusions if the
end result fulfils the requirements for a healthier
dentition that is functionally and aesthetically
harmonised in relation to the surrounding structures.4 In this case, one of these incisors was
missing so extraction was not necessary.
The Class II malocclusion was corrected by
non-extraction orthodontic treatment with a
CAD/CAM fixed lingual appliance (Incognito).
The Class III molar relationship had not changed
at the end of treatment, but a Class I canine
relationship was achieved and the facial profile
improved owing to improvement in the position
of the mandibular incisor in relation to the mandibular plane, which affects the position of the
lower lip.

Fig. 2

Fig. 3

_Diagnosis and aetiology
The patient was male, aged 23 years and
9 months, and had the chief complaint of crowding of the maxillary and mandibular anterior teeth.
He had Class III canine and molar relationships on
both sides, a 2 mm overjet, a 4 mm overbite, a missing mandibular left central incisor, the maxillary
midline was coincident with the midsagittal plane,
the mandibular midline was shifted to the left, the
maxillary dental arch had about 7 mm of crowding
and lower dental arch had 8 mm of crowding,
excluding the width of the missing mandibular

Fig 2_Extraoral and Intraoral
Photographs Before Treatment
Showing Severe Upper and Lower
Crowding and Retruded Lower Lip.
Fig 3_Final Photographs Show
Normal Overbite and Overjet
Relationship, Elimination
of Anterior Crowding and
Improvement of Facial Profile.

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extraction. The third option was to extract all four
first premolars but this would have affected the
facial profile negatively. After detailed discussion
with the patient, we chose option 2, non-extraction using a lingual appliance.

Fig 4_Pretreatment Cephalometric
Tracing and Measurements.

_Treatment progress
Treatment began with customised, pre-adjusted,
CAD/CAM fixed lingual appliances (0.5588 mm
slots) placed on both the maxillary and mandibular arches using an indirect bonding technique.
Levelling, alignment and expansion of the arch were
achieved using heat-activated, super-elastic, customised wire (14, 16, 16 x 22; and 18 x 25). Detailing
and finishing were performed using 16 x 22 stainless-steel wire and 18.2 x 18.2 Beta III Titanium
Archwire. The total active treatment time was
17 months. Patient compliance was good. For retention, fixed maxillary and mandibular retainers
were provided, as well as an Essix retainer at night.

Fig. 4

incisor, and the maxillary lateral incisors were
in crossbite (Fig. 2). According to cephalometric
analysis, there was a Class II jaw relationship and
normal vertical facial height. The patient was in
good health and his medical history showed no
contra-indications to orthodontic therapy (Fig. 3).

_Treatment objectives
The treatment objectives included correction of
the maxillary and mandibular crowding, improvement of the dentoalveolar and maxillomandibular relationships, improvement of facial aesthetics,
and establishment of a stable occlusion and better
smile.

_Treatment alternatives

Fig 5a–g_Showing Upper and Lower
Initial and Final Comparing Them
to Their Corresponding Set-up.

Fig. 5a

Three treatment options were suggested to the
patient. The first alternative entailed labial orthodontics using either metal or clear brackets. The
second option entailed lingual orthodontics, as the
aesthetic demand was very high for the patient and
clear aligners would not have been able to achieve
the needed results. Both options 1 and 2 were non-

Fig. 5b

22 I CAD/CAM
3_ 2013

_Treatment results
The post-treatment extra-oral photographs
showed general improvement in the facial profile. The post-treatment intra-oral photographs
showed satisfactory dental alignment, Class I canine and Class III molar relationships, and a normal
overbite and overjet. In addition, the maxillary and
mandibular incisors had a normal inter-incisal
angle due to the interproximal reduction in the
maxillary arch. In Figure 4, we can see how accurate the model was compared with the final treatment outcome for both arches. At the end of
treatment, a normal morphological and functional
occlusion was obtained, with anterior guidance
in lateral and protrusive excursions. Class I canine
relationships were obtained on both sides. The
good interdental relationship also provided a wellbalanced facial profile with lip competence.

_Discussion
The treatment objectives were attained with
the non-extraction treatment protocol using a

Fig. 5c

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case report _ CAD/CAM lingual orthodontic system

Fig. 5d

Fig. 5e

CAD/CAM lingual system. Obviously, the results
reflect the effects of not only the proclination of
the mandibular anterior teeth, but also the relief of
crowding in both arches and the accuracy of the
model in reflecting the final result (Fig. 5). We still
had to perform interproximal reduction in the maxillary arch to achieve a normal overbite and overjet,
with the canines in a Class I relationship. Another
treatment option would have been to extract the
maxillary and mandibular first premolars. However,
this was not a favourable treatment alternative
owing to its negative effect on the facial profile.
Performing lingual orthodontic treatment for
each patient in the average orthodontic office is
now a reality. The treatment results are of a high
level, and all our patients may benefit from an invisible appliance. Former problems, such as discomfort, speech alteration, finishing inaccuracies,
and particular tooth anatomy, can be overcome in
this manner.5

Fig. 5f

Fig. 5g

niques. If it is planned carefully and executed properly, incisor extraction can be an effective way of
satisfying a particular set of treatment objectives._
Editorial note: A complete list of references is available
from the publisher.

_about the author

CAD/CAM

_Conclusion

Dr Khaled Abouseada
is a consulting orthodontist
involved in private practice
in Saudi Arabia, Bahrain
and Egypt. He lectures
orthodontics at the Batterjee
Medical College and
Specialized Academy for
Medical Training. He has lectured at many
international dental and orthodontic forums.
He is a certified trainer for CAD/CAM orthodontics
and serves on the editorial board of Dental Tribune
Middle East. He won the I Love My Dentist Award
in 2010–2012 and the MENA Award for
Orthodontic Best Case in 2010–2012.

The key to success in lingual orthodontics in
terms of both professional and patient satisfaction is practice and training. The Incognito system
can be used for all types of malocclusions with
the same precision as labial braces.

Dr Khaled M. Abouseada
Asnani Dental Clinic
P.O. Box 122721
Jeddah 21332
Saudi Arabia

The possibility of incisor extraction should be a
part of every clinician’s portfolio of treatment tech-

khaled@khaledabouseada.com

The extraction of the mandibular incisors constitutes a therapeutic alternative in treating certain anomalies. It is not a standard approach to
symmetrically treating most malocclusions, but
the therapeutic aims must be adjusted in certain
clinical situations to individual patient needs, even
when this means that the final occlusion achieved
is not ideal. The deliberate extraction of a mandibular incisor in certain cases allows the orthodontist
to improve occlusion and dental aesthetics with
minimal orthodontic treatment. In all cases, however, a diagnostic cast is required to predetermine
the occlusal possibilities precisely.6

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I case report _ guided surgery

Immediate restoration in
the edentulous mandible
According to the Maló procedure using the
CAMLOG Guide System and Vario SR abutments
Author_Dr Ferenc Steidl & Sebastian Schuldes, Germany

Fig. 2

Fig. 1

Fig. 1_Initial radiograph.
Fig. 2_Initial clinical situation.
Fig. 3_Scanning template made from
plastic containing barium sulphate.
Fig. 4_Holes drilled through
the radiopaque teeth according
to the prosthetic tooth axis.
Figs. 5a & b_Diagnostics and
implant planning (a) in accordance
with anatomical and prosthetic
requirements (b).

Fig. 3

_The Vario SR prosthetic components for
fixation of implant-supported occlusally screwretained restorations were used in this case to
treat neuropathic pressure-indicated facial pain.
The 66-year-old patient came to our practice for
the first time in May 2010 complaining of persistent
pain in the right mandible. The pain intensified when
the complete mandibular denture was inserted.
However, pronounced pain continued even after
several days of not wearing the prosthesis. The
intensity of the pain varied between 6 and 10 on the
visual analogue scale.

Fig. 4

The following diagnosis was made:
_severe mandibular atrophy;
_crestal position of the bilateral mental foramina;
_chronic neuralgiform facial pain in regions 43 to
45—the trigger point indicated the mental foramen region.

_Treatment planning
The patient had been treated with two onepiece diameter-reduced implants in regions 31

Fig. 5a

Fig. 5b

Fig. 6

Fig. 7

Fig. 8

Fig. 9

Fig. 10

Fig. 11

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case report _ guided surgery

Fig. 12

Fig. 13

Fig. 14

Fig. 15

Fig. 16

Fig. 17

Fig. 18

Fig. 19

and 43, as well as a complete mandibular denture
anchored by ball abutments (Figs. 1 & 2).
After extensive counselling and discussion, we
opted for a temporary fixed mandibular restoration on four implants with simultaneous explantation of the existing implants.
Benefits of the selected restoration concept:
_explantation, implantation and immediate restoration in one sitting;
_a high level of safety owing to 3-D implant planning;
_durable temporary restoration with CAD/CAM
high-performance plastic;
_precision template-guided implantation with the
CAMLOG Guide System;
_high patient satisfaction with fixed screw-retained immediate restoration.

_Pre-implantation planning
Because the existing denture satisfied the basic
aesthetic and functional requirements, the given
situation was reproduced in plastic containing barium sulphate according to backward planning. The
desired prosthetic was fabricated from clear plastic
with a titanium reference pin for the scanning template (Fig. 3). In order to make the prosthetic tooth
axis visible in the CBCT scan, holes were drilled
through the radiopaque teeth in the axis (Fig. 4).
The DICOM data was then read into the
coDiagnostiX implant planning system (Straumann).
Computer-supported analysis offers the possibility
of accurate diagnosis and planning the implants in
agreement with anatomical and prosthetic requirements (Figs. 5a & b). Positioning of the terminal implants at an exact 30-degree angle is a crucial requirement for the success of this treatment (Figs. 6 & 7).

Fig. 6_Positioning of the terminal
implants at an exact 30-degree angle.
Fig. 7_View with the superimposed
radiopaque components.
Fig. 8_The scanning template was
converted into a drilling template.
Fig. 9_Preparation of the cast
for model implantation.
Fig. 10_The insertion posts
in the required cam alignment
with the screw-retained
laboratory analogues.
Fig. 11_Laboratory analogues
placed into the cast.
Fig. 12_The cast with
screw-retained straight
Vario SR abutments.
Fig. 13_The Vario SR abutments
with the Vario SR titanium caps.
Fig. 14_Digitised cast situation.

Fig. 20

Fig. 21

Fig. 22

Fig. 23

Fig. 24

Fig. 25

Fig. 26

Fig. 27

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I case report _ guided surgery

Fig. 28

Fig. 29

Fig. 30

Fig. 31

Fig. 32

Fig. 33

Fig. 34

Fig. 35

Fig. 15_Desired prosthetic situation
superimposed over the cast situation.
Fig. 16_The CAD restoration was
created with DentalDesigner.
Fig. 17_The second molars
were omitted.
Figs. 18 & 19_CAM of the restoration
(Fig. 18) using a tooth-coloured
PMMA blank (Fig. 19).
Fig. 20_Detailed preparation
of the occlusal surfaces.
Figs. 21 & 22_Aesthetic
customisation using
gingiva-coloured plastic,
basal (Fig. 21) and labial (Fig. 22).
Fig. 23_Adequately sized bonding
gap for intra-oral bonding.
Fig. 24_Explantation of the one-piece
diameter-reduced implants.
Fig. 25_The explants.

_Fabrication of the drilling template
and immediate restoration

and 13 show the Vario SR abutments and Vario SR
titanium caps on the cast.

The position of the implant determined during
3-D implant planning was transferred to the drilling
template in the dental laboratory using the gonyX
coordinate table. The guiding sleeves with depth
stops from the CAMLOG Guide System were precisely bonded on to the scanning template, thereby
converting the scanning template into a drilling
template (Fig. 8).

A laser scanner was then used to digitise the cast
(Fig. 14). In order to simplify the CAD of the immediate restoration, it made sense to superimpose the
desired prosthetic situation defined by backward
planning over the existing situation (Fig. 15). The
design was created with DentalDesigner (3Shape;
Figs. 16 & 17). After a suitable milling strategy had
been determined, the data was transferred to a fiveaxis milling machine. A tooth-coloured PMMA blank
was used as the material of choice (Figs. 18–20).

In order to fabricate the immediate restoration, a
model was required. Corresponding cavities were
incorporated into the cast (Fig. 9). The CAMLOG
Guide insertion posts were then used to insert the
laboratory analogues into the cast (Fig. 10). It was
important here to position the insertion posts with
the screw-retained laboratory analogues according
to the required cam alignment Fig. 11). Figures 12

In contrast to traditionally fabricated temporary
solutions, CAM-fabricated immediate restorations distinguish themselves by their high resistance to fracture. This property is an important technical requirement
for complication-free function of the restoration. In
order to achieve pleasing aesthetics, gingiva-coloured

Fig. 36

Fig. 37

Fig. 38

Fig. 39

Fig. 40

Fig. 41

Fig. 42

Fig. 43

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case report _ guided surgery

plastic was used (Figs. 21 & 22). Careful polishing is
required to keep plaque deposits as low as possible.
The bonding gap around Vario SR titanium caps should
be sized for tension-free intra-oral bonding (Fig. 23).

_Surgical procedure
The one-piece diameter-reduced implants were
explanted (Figs. 24 & 25). The drilling template was
secured using four osteosynthesis screws (Fig. 26).
These provided adequate stability and safety for
guided implantation. In order to correctly align
the insertion posts, corresponding markings were
milled into the CAMLOG Guide guiding sleeves in
the laboratory (Fig. 27).
Implantation was flapless using the CAMLOG
Guide System gingival punch (Fig. 28). The implant
bed was prepared accurately with the CAMLOG
Guide System and depth referenced with drills of ascending lengths in an intermittent drilling technique
(Fig. 29). After a central implant had been inserted,
a terminal implant was inserted (Fig. 30). The second
centrally positioned implant was then placed and
the second terminal implant thereafter (Figs. 31–34).

_Seating the immediate restoration
After removing the CAMLOG Guide insertion
posts, the Vario SR abutments were inserted at
20 N cm (Figs. 35 & 36). The Vario SR titanium caps
were shortened to the required length, placed on the
Vario SR abutments and mounted with the Vario SR
prosthetic screw (Fig. 37). The immediate restoration fabricated pre-implantation could then be
bonded in the mouth tension-free (Figs. 38–41).

_about the authors

cosmetic
dentistry

Dr Ferenc Steidl obtained
his degree in dentistry in 1996
from Friedrich Schiller
University in Jena in Germany.
He subsequently undertook
specialist training in oral
surgery in Bietigheim-Bissingen
and at Diakonie Hospital
in Schwäbisch Hall in Germany. He has been
practising implant dentistry since 1997. In 2001,
he qualified as a specialist in oral surgery through
the Baden-Württemberg Federal Chamber of
Dentists (LZK) in Germany. He is a member of
the German Society of Dental, Oral and
Craniomandibular Sciences (DGZMK), German
Federation of Oral Surgeons (BDO), German
Association of Oral Implantology (DGI), Academy
of Oral and Maxillofacial Surgery (AGKi), German
Society of Periodontology (DGP), and Central German
Association for Dental Implantology (MVZI).
In 2008, he became a fellow of the European Board
of Oral Surgery (European certification). Dr Steidl
works at a group practice for maxillofacial surgery
in Sömmerda and Bad Frankenhausen in Germany.
Praxis Dr Ferenc Steidl
DRK Manniske Krankenhaus
An der Wipper 2
06567 Bad Frankenhausen
Germany
Tel.: +49 3634 317387
info@praxis-steidl.de
www.dr-steidl.de

_Discussion
The procedure demonstrated here, which follows
the All-on-4 technique taught by Paulo Maló from
Lisbon, led to the complete disappearance of the
severe facial pain about two months post-operatively.
The immediate prosthetic restoration was highlighted
in particular in the patient’s evaluation. This resulted in
an immediate improvement in mastication, speech
function, food intake and quality of life. Remission of
neuralgiform symptoms protracted over two months
after seating of the fixed prosthesis and corresponding
load relief of the mental foramen.
This case illustrates the failure of a numberreduced implant treatment concept in the advanced
atrophied mandible and the potential of purely
implant-supported prostheses to avoid pressureinduced neuropathies. The mandibular restoration
was converted into a removable bar-retained superstructure (Figs. 42 & 43)._

Sebastian Schuldes, MDT,
undertook dental technician
training from 1991 to 1995,
and qualified as a master dental
technician in 1999. In 1999
and 2000, he pursued continuing
education for business
administration in trade. In 2004,
he helped establish the Cercon technology centre.
He obtained a Master of Science degree in 2008.

Fig. 26_Fixation of the drilling
template using four
osteosynthesis screws.
Fig. 27_The fixed drilling template.
Fig. 28_Gingiva punching.
Fig. 29_Implant bed preparation
with the CAMLOG Guide form drill.
Fig. 30_Positioning of one central
and one terminal implant.
Figs. 31 & 32_Implant bed
preparation and insertion
of the final implant.
Fig. 33_All four SCREW-LINE
implants CAMLOG Guide
in the defined final positions.
Fig. 34_Detailed view of the
precisely maintained cam alignment.
Figs. 35 & 36_The Vario SR
abutments were inserted (Fig. 35)
at 20 N cm (Fig. 36).
Fig. 37_The Vario SR titanium caps
were shortened according
to the prosthetic unit.
Fig. 38_Check of the tension-free
seating of the immediate restoration
on the Vario SR titanium caps.
Fig. 39_The surgical procedure
was stress-free and controlled.
Fig. 40_A dual-hardening luting
composite (combo.lign, bredent)
was used for intra-oral bonding
of the immediate restoration.
Fig. 41_A final photograph
of the immediate restoration
in the mandible.
Fig. 42_The final restoration was
milled from a zirconium oxide bar.
Fig. 43_The final
mandibular restoration.

Dental-Labor Schuldes
Johann-Sebastian-Bach-Str. 2
99817 Eisenach
Germany
Tel.: +49 3691 203950
info@zahn-neu.de
www.zahn-neu.de

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I case report _ guided surgery

Bridge construction in the
anterior region of the maxilla
Author_Dr Steffen Wolf, Germany

Fig. 1

Fig. 2

_Initial situation

_Procedure

A 67-year-old patient presented to the dental
practice for consultation on implant placement.
The anamnesis revealed some specific conditions,
particularly an allergy to dental metals.

Treatment planning

At this time, prosthetic restoration in the area
to be reviewed consisted of an insufficient crown
in the anterior region with an attachment monoreducer-combination denture. Significant loosening of the abutment teeth in the anterior region was
found. Post and cores that had already loosened
several times were found in the insufficiently filled
root canals, probably due to monoreducer leverage
(Fig. 1).
The prognosis for conservative restoration was
thought to be extremely poor.
During the consultation, the patient expressed
a preference for an implant solution. The patient
also specified a cost limit.

Fig. 4

Fig. 5

28 I CAD/CAM
3_ 2013

Fig. 3

For optimum assessment of the initial situation
and subsequent treatment planning, after assessing
the clinical situation, a dental panoramic tomogram
diagnosis with intra-operative assessment of the implant site was favoured as method of choice (Fig. 2).
This would take into account the minimally invasive
therapeutic concept of surgical augmentation. Treatment would involve the extraction of non-conservable
teeth and the immediate placement of a Straumann
Bone Level implant in the region. Two implants were
to be inserted in the premolar region. We planned to
expand bone with the bone spreading technique and
to use two Straumann Standard Plus Narrow Neck
CrossFit implants (NNC) made from Roxolid implant
material if the transverse bone at the site was compromised. Prosthetic restoration was to fulfil the requirements for an allergy-free dental prosthesis. The prosthetic construction was to be manufactured with the
Straumann CARES System in the in-house laboratory.

Fig. 6

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case report _ guided surgery

Fig. 8

Fig. 9

Fig. 7

Fig. 10

Surgical procedure
Owing to the impaired vasoconstriction, adrenaline-free local anaesthetic was administered pretreatment with one subsequent injection during the
operation. Extraction of the central and left lateral
incisors was without complication. A central crestal
incision was made with little crestal bone denudation and no relief incision. The anticipated reduction
of the transverse bone then became clearly visible,
and bone spreading was performed and two NNC
implants were placed (Fig. 3). The insertion sites in
the region of both left premolars were prepared
by manually shaving the bone until an even bone
plateau had been created. The autologous bone
chips gained here were later used for bone augmentation in the left central incisor area.
Once the implant sites had been carefully prepared by means of bone spreading (Fig. 4) and the
final implant cavities drilled, the prepared bone
was meticulously examined with a bulbous probe
and gauges from the Straumann surgery set. The
two NNC implants were then inserted into the
controlled, intact bony structures (Fig. 5). An NNC
SLActive implant of 3.3 mm in diameter and 14 mm

Fig. 13

Fig. 11

Fig. 12

in height was inserted in the region of the first premolar, and the 3 mm reduced-height NNC healing
cap was used for both the implant seal and for primary soft-tissue conditioning. We decided to use an
NNC SLActive implant of 3.3 in diameter and 12 mm
in height and the matching 3 mm closure screw for
the region of the second premolar.
Once this stage of the operation was complete,
restoration of the alveolar bone in the central anterior region was performed. The immediate implantation of a Straumann Bone Level implant of 4.1 mm
in diameter and 10 mm in height fitted with the
0.5 mm Regular CrossFit Connection closure screw
was then performed. The walls of the alveolar bone
were undamaged, and there was primary implant
stability. As a sufficient amount of autologous bone
chips had been gained from maxillary crest levelling
in the premolar area, this was used as a volume filler
for bone augmentation. The distance between the
body of the implant and the wall of the alveolar bone
that required augmentation was 1–2 mm. Vertical
bone augmentation was performed, and there was
a slight overlap owing to a platform switch at the
implant shoulder. Restoration of the alveolar bone
around the lateral incisor was performed using

Fig. 14

Fig. 15

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I case report _ guided surgery

Fig. 16

Fig. 17

a collagen matrix. Suture closure in the area of the
anterior implant resulted in complete coverage of
the augmentation area. The closure screw lay only
minimally exposed approximately 3 mm below the
mucogingival tissue. Soft-tissue closure at the NNC
closure screw supported transgingival healing of
the implant (Fig. 6). Intra-operative haptic assessment of the various fixations of the implant insertion aids was easily possible (Fig. 7). In order to
assess post-operative treatment success with regard to adequate peri-implant bone coverage in
particular, a control CBCT scan was taken to verify
the correct implant–bone relation. This meant additional augmentation measures could be safely
dispensed with (Fig. 8). Perioperative medication
included antibiotic endocarditis prophylaxis. The
patient was also given post-operative pain medication for one day.
Prosthetic restoration
Following integration of a provisional denture
and a complication-free healing period, individualised gingival architecture was then created in the
anterior region. In order to facilitate continued
wearing of the provisional denture during the
gradual process of soft-tissue conditioning, our
dental laboratory prepared and shortened a Regular CrossFit Connection temporary abutment with
hard polymer plastic, individualised to the area of
the soft-tissue profile (Figs. 9–11). The impression
for the incisor abutment was taken with a gingiva
former in place on the basis of a Regular CrossFit
Connection impression post to match the individual impression post. The NNC implants were
incorporated into the impression (Fig. 12) with the
ready-made NNC impression posts. On account
of the patient’s allergy and in consideration of
the aesthetic aspect, in addition to titanium abutments (Fig. 13) it was decided to use a zirconiabased bridge framework with ceramic veneering
(Figs. 14 & 15). The titanium abutments and zirconia bridge were designed virtually using the
Straumann CARES Scan CS2 scanner in our own
dental laboratory and the framework was made
at the Straumann Milling Center in Leipzig.

30 I CAD/CAM
3_ 2013

Fig. 18

Because of the inter-occlusal distance, an anatomically formed zirconia occlusal surface was used,
which was optimally prepared with the Straumann
CARES System processing software during the
construction phase. In consideration of the aesthetic
aspect, the individualised veneering was mostly
in the vestibular region (Figs. 16 & 17). A postoperative radiographic control confirmed correct
positioning of the prosthetic components (Fig. 18).

_Conclusion
The patient was extremely satisfied with both the
result and the cost–benefit relationship. Appropriate design of the emergence profile, the titanium
abutment and the zirconia bridge entirely fulfilled
the aesthetic requirements in the visible areas.
In the event of later loss of the second molars, the
patient wishes to undertake prosthetic restoration
of the ensuing end gap situation. As shown here,
in cases of compromised bone and in consideration
of the aesthetic zone and CAD/CAM elements of
different materials, the use of NNC implants can
lead to very positive results._
The prosthetic restoration was made by David Szymanska,
MDT (laboratory).

_about the author

CAD/CAM

Dr Steffen A. Wolf attained
his Doctor of Dentistry degree
in 2000 from the Department
of Oral and Maxillofacial
Surgery at the Freie
Universität Berlin headed
by Prof. B. Hoffmeister.
Since 2000, he has worked in
his own private practice in Halberstadt in Germany.
He received a Master of Science degree in
Oral Implantology in 2010 from the DGI.
praxis@zahnimplantate-wolf.de
www.zahnimplantate-wolf.de

[31] => CAD0313_01_Title

CARES ® X-Stream™

The complete implant-based single-tooth
prosthetic restoration in 1 step:
1 scan, 1 design and 1 delivery

Straumann® CARES ® X-Stream™ is a new solution-driven functionality providing a one-step single-tooth prosthetic solution.
Enhance your productivity and profitability with only one scan, one design, associated with an excellent component fit.

More on: www.straumann.com/CARES8

RZ_STRMN_CARES_8.0_X-Stream_A4.indd 1

11.04.13 13:50

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I feature _ interview

Dentures produced using
3-D printing versus
casting and milling
turing, such as metal laser melting and powderbased plastic laser sintering. With rapid manufacturing methods, you can select the most functional
and affordable dental prosthetic solution based on
your customer’s needs, be it crowns and bridges,
frameworks, primary and secondary structures, or
implant superstructures.
_Can you give us an idea of the process of creating dental restorations from metallic powders using
additive manufacturing technology?

Fig. 1
Fig. 1_Tailor-made dental
technologies: Master Dental
Technician Dieter Spitzer offers
traditional manufacturing along
with CAD/CAM methods,
such as laser melting of metals
for dental restorations.
All images courtesy of Concept Laser
GmbH, Lichtenfels, Germany.

_Non-precious metal alloys are enjoying increased demand in dental technology. Additive manufacturing with laser melting ensures the uniformity
and accuracy of ceramic-veneered, non-precious
metal restorations created from powder using laser
energy. Are the traditional manufacturing processes
of dental technicians, such as casting and milling,
making a comeback? CAD/CAM magazine spoke
with Master Dental Technician Dieter Spitzer of
Unicim, a manufacturer of dental restorations based
in Berschis in the Swiss canton of St. Gallen, Switzerland.
Digital process networking is linking dentists,
laboratories and dental manufacturers more closely
than ever and putting everyone involved under pressure to act. The entire process chain, from impression
taking to prosthetic restoration, is undergoing a
dynamic transition—a trend away from casting and
toward digital additive manufacturing.
_ CAD/CAM: Mr Spitzer, you refer to Unicim as a
digital production centre. What do you mean by that?
Dieter Spitzer: Unicim combines traditional production methods with digital CAD/CAM manufac-

32 I CAD/CAM
3_ 2013

Once the 3-D CAD data is complete, the support
structures are set up using data-processing software. Various software solutions are available for
this purpose. One of the most common is CAMbridge, which requires licence fees. Alternatively,
there is AutoFab Mlab, which is licence-free and
allows you to assign specific measurements. With
Concept Laser’s systems, the customer is able to
choose freely and is not bound by any software. The
processed data is transmitted to the machine via the
network or USB port and the construction job is
started. With this process, you can finish a project
fully automatically overnight. Once complete, the
components are removed from the building board
and refinished. After manually removing the support
structures, the surface is then micro-blasted with
aluminium oxide, and the crown edges are thinned
down in the case of bridges.
_Will milling and casting soon be a thing of the
past in dental prosthetics?
Milling and casting will remain part of the standard repertoire of dental laboratories for training
and application. Additive manufacturing options
will offer many advantages in the future and reduce
production risk enormously. Unfortunately, they are
still far too rarely seen in practice by dentists and
dental technicians. Some of this has to do with the
old school mentality of doing everything manually.
The dental laboratory of the future will be more of

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feature _ interview

a hybrid: milling and casting where desirable but
with additive manufacturing as a top alternative.
“Add on versus take away,” I like to call it. In summary,
the casting process, from the cast object to the finished product, is usually very time-consuming and
can lead to distortion, especially with large-span
restorations. With additive technology, we achieve
contour accuracy more easily than with milling. Our
workplaces in dental technology are also cleaner
thanks to CAD/CAM: less dust, bonding agent, glue,
and outgassing. Ultimately, the deciding factor is
quality. Compared with casting and milling, additive
printing processes are creating entirely new ways of
thinking in terms of production, workflow and the
products themselves.

Fig. 2_Non-precious titanium alloys:
Mlab cusing R from Concept Laser
at Unicim.

_How are these changes expressed?
We need to look at different levels here. First is
the transition from manual craftsmanship to highprecision, high-accuracy industrial CAD/CAM production. Milled non-precious metal restorations
have significant disadvantages owing to material
consumption: high production costs and system-related lower quality in terms of fit and shape retention.
During casting, we also encounter disadvantages in
terms of low material density, mould costs, production time and rework. Nearly all of these disadvantages disappear with laser melting. By using proven
materials like remanium star CL and rematitan CL
from Dentaurum with our Mlab cusing R, we have
been very satisfied with the quality of our systemmanufactured products. In the case of large-volume
restorations, any excess tension that arises can be
alleviated through subsequent heat treatment, thus
avoiding any potential distortion. Of course, the same
applies to cobalt–chromium alloys or titanium.
_You mentioned changes to the products. What
changes were you referring to?
I’m quite optimistic. I’ll describe a couple of them.
First, the geometric flexibility of prostheses is enabling a new way of looking at shapes or functions.
In the future, imagine restorations with channels
into which medications can be fed. The dentist or
orthodontist can provide treatment, and the patient
will not have to deal with temporaries. The second
major change is the selective density of a component made possible by the process. Thus, for example, not only can bridges with more than ten sections
be manufactured in a one-step process tension-free,
but they can also be increasingly applied in heavily
utilised areas, such as cantilevers, edges or brace
elastics. In model casting, that is not always an easy
problem to solve. Geometric freedom is a genuine
plus for us, as it opens up new possibilities for restoration design. For example, brace elements can be

Fig. 2

made much finer while retaining sufficient mechanical properties. These new options also increase the
longevity of dental products. In casting or milling, we
have to deal with cost, material waste and lower
material density; in casting especially, we have oversized dimensions and much lower material densities.
With cast restorations, breakage is always an issue.
But it does not have to be that way. Another benefit
is the ability to create combinations through module
or multicomponent construction methods. Base elements implanted into the jawbone are used as primary structures. An additively manufactured foundation element is then put into place as a secondary
structure, on to which a secure, durable veneer such
as HeraCeram is applied. Another aspect relates to
new materials, such as non-precious metal titanium.
_Titanium is hard and biocompatible.
Titanium is the ideal material for allergy sufferers,
for example. In combination with laser melting and
veneering, we can maximise its biological benefits.
From a visual standpoint, titanium restorations offer
a risk-free silver-grey lustre. Manufacturers of nonprecious metal alloys have spread pseudoscientific
criticism regarding the aesthetics of titanium. Lowdose fluoride in toothpaste or mouthwash, for example, has no impact on appearance. We cannot
deny the reality that titanium has not only caught up
with non-precious metal alloys in importance, but
also surpassed them. This is precisely why, in 2012,
Unicim invested in an Mlab cusing R system for titanium applications from Concept Laser, which allows
us to process reactive titanium material in a closed

CAD/CAM
3_ 2013

I 33

[34] => CAD0313_01_Title

CAD0313_32-34_Spitzer 20.09.13 17:16 Seite 3

I feature _ interview

Fig. 3

Fig. 4

Fig. 3_Crowns and bridges
manufactured using laser
melting technology.
Fig. 4_Cast parts manufactured
with LaserCUSING.

system. The unit can be used with dental materials
certified under the German Medical Devices Act,
such as rematitan CL from Dentaurum. Because of
the high amount of material waste, milling-based
processing of titanium is too expensive and casting
is highly impractical.
_What are some of the problems that arise in the
casting of titanium?
The reaction of titanium with oxygen causes
the formation of an alpha-case layer on the outside.
This leads to embrittlement of the surface and must
be removed. If not removed, it can lead to problems
with the adhesion of veneering. With LaserCUSING,
no alpha-case layer forms. This makes laser melting
with titanium powder excellent for processing. The
very fine-grained microstructure of the laser-fused
parts of this titanium alloy allows greater firmness
than with conventional castings. The dentist receives a high-performance, long-life alternative
that is easy to work on and more affordable than
a precious metal solution. Finally, dentists and patients can benefit from a quality product that is both
durable and natural in appearance.
_How does titanium compare in terms of price?
The price of the Dentaurum titanium powder
we use is currently around €595 per kilogram; a
four-unit bridge weighing 4 g thus costs €2.40 in
material alone.
_Why has laser melting been so slow to catch on
in the dental industry?
The reasons for this are many. The process is relatively new, so the learning curve is long. The fact that
the quality of laser-fused products is better than
conventionally manufactured dental restorations

34 I CAD/CAM
3_ 2013

remains largely unknown. Its reputation continues
to be tarnished by ignorance or misconceptions.
Keep in mind, too, that dental technician training
takes four years in Switzerland, and theoretical instruction is slow to incorporate new technologies.
In addition, Swiss dental laboratories are very small.
The Association of Swiss Dental Technicians estimates that there are some 1,200 centres, many of
which operate with just one or two people. Therefore, investments in laser melting are carefully considered. Unicim, as a digital production centre, acts
as a service provider to other laboratories. Right now,
I see it as an outsourcing area while we wait for it
to take hold in the market.
_What is the position of dentists regarding this issue?
Interest is undoubtedly growing, not least because it is impossible to ignore the technical, timesaving and affordability benefits. But we also need
to look at the process chain. In order to prepare the
data for manufacturing, it must be in STL format.
STL data from different scanners can be processed
using the CAMbridge or AutoFab Mlab data-processing software available from Concept Laser.
Nowadays, conventional dental impressions form
the basis for CAD data. The accuracy of the data depends on the preciseness of the work performed the
dentist. Higher accuracy is essential. A high-quality
intra-oral scanner costs about CHF20,000. If we had
complete data migration from the dentist to the
dental laboratory, we would be one step further. In
the long term, however, that is unavoidable. Quality
assurance and documentation needs will make
open, manufacturer-independent data transfer an
increasingly critical requirement. Especially in terms
of affordability, the topic of laser melting is becoming more important.
_Thank you for the interview._

[35] => CAD0313_01_Title

6 Months Clinical Masters Program

in Implant Dentistry
12 days of intensive live training with the Masters
in Como (IT), Maspalomas (ES), Heidelberg (DE)

Live surgery and hands-on with the masters
in their own institutes plus online mentoring and
on-demand learning at your own pace and location.
Learn from the Masters of Implant Dentistry:

Registration information:
12 days of live training with the Masters
in Como, Heidelberg, Maspalomas + self study

Curriculum fee: € 11,900

contact us at tel.: +49-341-48474-302 / email: request@tribunecme

(€ 900 when registering, € 3,500 prior to the first session, € 3,500 prior to the second session, € 4,000 prior to the last session)

Collaborate
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100

ADA CERP
C.E. CREDITS

Tribune America LLC is the ADA CERP provider. ADA CERP is a service of the American Dental Association to assist dental professionals
in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors,
nor does it imply acceptance of credit hours by boards of dentistry.

[36] => CAD0313_01_Title

CAD0313_36-37_Straumann 20.09.13 17:16 Seite 1

I industry news _ Straumann

Experience business solutions
with Straumann CARES
customized prosthetics solutions

Fig. 1

Fig. 2

Fig. 1_CARES® customized solutions.
Fig. 2_CARES® zerion® zirconium dioxide.
Fig. 3_CARES® metal frameworks.
Fig. 4_CARES® crowns and bridges.
Fig. 5_The new CARES® zerion® LT
(Low Translucency) shades for
framework constructions.
Fig. 6_CARES® abutment,
zirconium dioxide (ZrO2).
Fig. 7_CARES® abutment, titanium (Ti).
Fig. 8_CARES® Variobase™
Abutment, zerion®.

Fig. 3

_The market for dental restorations presents
a broad variety of prosthetic offerings. Yet customers experience constant challenges to make
the right choice when it comes to fulfilling their
primary product needs of high efficiency, cost
effectiveness and long-term reliability. Thanks to
the trustworthy relationship with dental clinics and
laboratories for close to 40 years, Straumann has
learned very well what matters to them and their
business. Straumann is committed to adapting its
service and products to the clinical and professional
needs.

Fig. 4

36 I CAD/CAM
3_ 2013

Straumann CARES customized solutions deliver
dental professionals all they will need in their practice
or laboratory (Figs. 1–4). With CARES X-Stream they
have a service that provides an implant-based singletooth prosthetic restoration in only one step: they
do 1 scan, 1 design and receive 1 delivery.
Invested on their customers’ behalf, Straumann
constantly develops and improves its portfolio,
namely of zirconium dioxide (zerion) for:
_High precision milling to deliver very detailed and fine
morphology and smooth surfaces;

[37] => CAD0313_01_Title

CAD0313_36-37_Straumann 20.09.13 17:16 Seite 2

industry news _ Straumann

I

Fig. 5
Fig. 6

_Ease of use by simply polishing the delivered restoration to finalize the zerion HT crown or bridge;
_Conquering demanding cases thanks to the shade
diversity. Simple characterization can be efficiently
applied to create a beautiful and individualized result.

_Work with confidence—
customized, aesthetic,
reliable original Straumann solutions

_Low design complexity: direct placement on implants
(no additional abutment needed), allows treating
patient-specific emergence profiles with full design
control;
_High quality through original Straumann connection;
_Biocompatible and corrosion resistant;
_Each framework is milled completely from one block
of material ensuring homogeneous and predictable
quality._
Fig. 7

Ensuring a perfect harmony of design, Straumann
abutments are engineered for an original and precisely attuned fit on Straumann implants. The proven
clinical long-term success explains why “Once you
go Straumann, you never go back”—simply because
Straumann’s exceptional quality delivers more!
Straumann CARES customized abutments provide the
foundation for exceptional restorative results

_contact

CAD/CAM

Institut Straumann AG
Peter Merian-Weg 12
4002 Basel, Switzerland
www.straumann.com
Fig. 8

The high design flexibility combined with the high
standards of precision make the CARES customized
abutments an outstanding benefit for practitioners
and dental technicians alike (Figs. 6–8):
_Customized shape and patient-specific emergence
profile;
_Validated long-term performance due to the original
Straumann connection;
_Optimized path of insertion thanks to the design
flexibility to adjust angulations;
_High convenience in the restoration procedure
thanks to an accurate design allowing time saving
and cost efficiency;
_Control over the cement gap.
Moreover CARES abutments blank size enlarged
more than 20 per cent to increase design options and
9 new zerion LT (Low Translucency) shades available
for CARES Variobase abutments.
Straumann CARES Screw-retained bridges and bars
offer an excellent solution in challenging cases
CARES Screw-retained bars deliver a finished and
ready-to-use strong mechanical connection capacity
without compromising the biological benefits of the
implants:

Original Straumann Bone Level
Implant-Abutment Connection

Mechanical Aspects _Transfer of force load on taper screw
and conical connection to implant
surface and bone evenly

Example of a flat non-original Bone
Level Implant-Abutment Connection

_Limited force load distribution to
connection and limited engagement
_Increased stress to flat top screw

_Reduction of micro movements while _The abutment only sits on the narrow
controlling the micro gap through
implant shoulder: Limited sealing of
a conical, tight sealing connection
the implant-abutment connection
_Increased possibility of soft tissue
impingement
Surgical aspect

_Lateral mastication forces are absorbed _Lateral mastication forces are absorbed
by the inner connection, reducing
by the screw thereof resulting in increased
excessive loading of the screw
danger of screw breakage.
_Consideration of the biological distance _The flat implant connection can have an
with a horizontal off set between
effect by over lapping the biological
micro gap to bone
distance of the micro-gap
_Typical Bone Control Design feature
 The Bone Control Design feature of the
of the Straumann Bone Level implant
Straumann Bone Level implant isn’t respected

CAD/CAM
3_ 2013

I 37

[38] => CAD0313_01_Title

CAD0313_38_3Shape 20.09.13 17:17 Seite 1

I industry news _ 3Shape

3Shape releases CAD solution
for post and core restorations
ratory technicians simply insert Scan
Posts in the model before scanning.

_Sophisticated design tools

_3Shape, the provider of 3-D scanners and
CAD/CAM software solutions for the dental industry, has launched its CAD solution for post and
core restorations, which includes dedicated post
and core intra-oral scanning with 3Shape TRIOS
and unique CAD design workflows in Dental System 2013. 3Shape’s Post and Core solution utilises
special scanning capabilities, 3Shape Scan Posts,
and sophisticated software tools for reliable capture, and optimally shaped and functional post and
core designs. The solution saves time by allowing
laboratory technicians to design all layers in a single
digital workflow.

In the laboratory, technicians align the
captured Scan Posts and allow the software to calculate positions and depths
automatically. By first designing the anatomy layer and applying dedicated post
and core modelling tools, technicians can
create optimally shaped and functional
post and core designs that are matched to the clinical case and ready for manufacture through wax
print and cast, milling, or laser sintering.
Frédéric Rapp, director of the Crown Ceram
dental laboratory in France, said: “In combination
with TRIOS, 3Shape’s Post and Core design software
gives us a fast and easy way to model optimally
shaped and robust post and core restorations. The
full digital workflow makes it very easy to design
parallel post and cores, or work with cases involving
multiple posts.”

_All types of post and core cases
_3Shape patented Scan Posts for use
in clinics and laboratories
3Shape has developed special Scan Posts (patent
pending) to facilitate the accurate capture of a
post and core’s position and depth. Scan Posts are
approved for both intra-oral use in the clinic and
for model scanning in the laboratory. Scan Posts
are autoclavable, and come in various shapes and
sizes to support drill systems from major suppliers.

_Flexible input: uses scans from TRIOS
and from dental laboratory scanners
3Shape’s Post and Core solution can be used with
3Shape TRIOS digital impressions and 3-D scans
of gypsum models. Dentists with 3Shape TRIOS can
kick-start post and core cases in the clinic by capturing and sending highly reliable images to the
laboratory for direct designing. A special dual-scan
workflow using 3Shape Scan Posts ensures accurate
capture of the true depth and position of the root
canal. If gypsum models are the input source, labo-

38 I CAD/CAM
3_ 2013

Laboratories can design post and core cases for
standard crowns, single-piece retained crowns, and
anatomical single-piece retained crowns that are
cut back for veneering.
3Shape’s Post and Core design solution is fully
functional in Dental System 2013 and with 3Shape
TRIOS. 3Shape Scan Posts are available to both
dental clinics and laboratories through 3Shape
distributors. Please contact your local 3Shape representative for details and purchase information._

_contact
3Shape A/S
Holmens Kanal 7
1060 Copenhagen K
Denmark
www.3shape.com

CAD/CAM

[39] => CAD0313_01_Title

[40] => CAD0313_01_Title

CAD0313_40_Schuetz 20.09.13 17:33 Seite 1

I industry news _ Schütz Dental

From veneers to bridges:
Zirconia reinforced composite
The elasticity module of
this material is 3.050 MPa
which is lower than the one
of zirconium dioxide. This
fact and the optional facing
with composite prevents
from any chipping.

Fig. 1

Fig. 2

Fig. 3

Fig. 4

Fig. 1_Milling blank.
Fig. 2_Final restoration veneered
with dialog Occlusal.
Fig. 3_13-unit unveneered
long-term denture (polished).
Fig. 4_Individual Table-Tops using
dialog Vario Chroma Flow.

_Schütz Dental presents a new material combining high performance acrylics and zirconium
dioxide. Tizian Zirconia Reinforced Composite
blanks enables you to produce temporary restorations of up to 16 units and even lets you complete
final restorations of up to 3 units. These restorations stand out thanks to their outstanding
antagonist and TMJ friendly properties. These
bionic qualities derive from the moderate Vickers
hardness and corresponding elasticity module.
Milling blanks (available in two heights) fit in the
98 millimeter open system holder and are suited
to dry-milling.

If you’re looking for a
veneering material for final
restorations, the specially
developed composite, dialog Occlusal from Schütz
Dental, comes highly recommended. Cases which
where faced with this composite make convincing
results thanks to its fantastic translucence, homogeneity and plaque-resistance. Tizian Zirconia Reinforced Composite blanks
come in a range of five
tooth colours.
Thanks to the excellent
physical properties, this material is ideal for use
on patients with CMD or Bruxism (Fig. 4). When
working on implants, the elasticity of the system
works as a buffer. This reduces the pressure on the
implants and the bone structure.
The chemical formula is free of TEGDMA and
Bisphenol A. This makes the material biocompatible with a lot of potential for the future._

_contact
This material (Fig. 1) is suitable to produce
final restorations up to three-unit bridges. This
bridges might even expand to the posterior region. This adds to its suitability for final crown
structures as well as fully anatomical crowns,
inlays, onlays and veneers. This material can also
be used for implant cases and long-term temporaries for up to a whole arch and lasting for up to
two years of wear (Figs. 2–3).

40 I CAD/CAM
3_ 2013

Schütz Dental GmbH
Dieselstr. 5-6
61191 Rosbach
Germany
export@schuetz-dental.de
www.schuetz-dental.com

CAD/CAM

[41] => CAD0313_01_Title

2013 - 2014

ALL EVENTS ACCREDITED BY

UPCOMING EVENTS

MIDDLE
EAST
Centre for Advanced Professional Practices (CAPP) is an ADA CERP Recognized Provider. ADA CERP is a service
of the American Dental Association to assist dental professionals in identifying quality providers of continuing
dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply
acceptance of credit hours by boards of dentistry.

5th DENTAL - FACIAL COSMETIC INTERNATIONAL CONFERENCE
Joint Meeting with

American Academy of Implant Dentistry, 2nd Global Conference
JUMEIRAH BEACH HOTEL
08-09 NOVEMBER 2013
DUBAI, UAE
www.cappmea.com/aesthetic2013

DENTAL TECHNICIAN FORUM part of IDEM SINGAPORE 2014
in cooperation with Koelnmesse
SUNTEC INTERNATIONAL CONVENTION & EXHIBITION CENTRE
05-06 APRIL 2014
SINGAPORE
www.idem-singapore.com

CAD/CAM & DIGITAL DENTISTRY INTERNATIONAL CONFERENCE
9th EDITION
09-10 MAY 2014
DUBAI, UAE
www.cappmea.com/cadcam9

4

4

4 th IRAQI DENTAL REUNION ANNUAL CONFERENCE
Breaking New Opportunities in cooperation with
The 5th International Healthcare Exhibition & Conference Serving Iraq
MAY 2014
ERBIL IRAQ

36 th ASIA PACIFIC DENTAL CONGRESS 2014
Event Supporter

17, 18, 19 JUNE 2013
DUBAI, UAE
www.apdentalcongress.org

T: +971 4 3616174 | F: +971 4 3686883 | M: +971 50 2793711 | E: info@cappmea.
f
fo@cappmea.
com | www.cappmea.com
M: +971 55 1128581 | E: deyanov@capp-asia.com | www.capp-asia.com

[42] => CAD0313_01_Title

CAD0313_42-44_Nobel 20.09.13 17:18 Seite 1

I industry news _ Nobel Biocare

Nobel Biocare announces
new digital workflow
and new regenerative
product at Global
Symposium in New York
_Announcement of new fully integrated
digital workflow

_Nobel Biocare welcomed more than 2,000
attendees to the famed Waldorf Astoria New York
for the exclusive and sold-out Nobel Biocare Global Symposium 2013, which was held from 20 to
23 June. Over 100 world-famous researchers, scientists, clinicians and academics took the stage to
share their insights and perspectives on how to provide better treatment to more patients. The exciting
programme, prominent guests and historic location
provided the ideal platform for announcing Nobel
Biocare’s new digital workflow and latest regenerative product, and for the inauguration of the
Foundation for Oral Rehabilitation (FOR).
“We are making continued improvements in efficiency and at the same time we continue to invest significantly in our future,” said Richard Laube,
Nobel Biocare CEO. “Our Nobel Biocare Global
Symposium in New York is one of these investments
and sold out months ago. The establishment of
FOR is another clear example, as well as our efforts
in innovation with the launching of our exciting
new products and solutions.”

42 I CAD/CAM
3_ 2013

With a strong focus on patient safety and treatment efficiency for dental professionals and their
patients, Nobel Biocare is developing a seamless
workflow, from patient diagnostics and treatment
planning to surgery and later also prostheses, all
efficiently and digitally connected through Nobel
Biocare’s secure online network, NobelConnect.
The next step, previewed at the symposium, continues to build on the individual strengths and
expertise of the treating team by digitally linking
NobelProcera laboratory technicians and NobelClinician users.
Starting with diagnostics and treatment planning in NobelClinician software, the highly accurate surface model obtained with the secondgeneration NobelProcera 2G Scanner can now be
included at any stage of treatment through fully
automated and precise smart fusion technology.
This enables even better representation of intraoral tissue for diagnostics and planning. Furthermore it reduces (procedural) treatment costs and
shortens treatment time by allowing CT/CBCT
scans to be taken at the first patient visit, offering
clinicians a truly flexible way of working.
Radiographic guides, specific markers and scan
protocols are no longer necessary. A decision on
guided surgery can be taken at any stage. Fully
automated, precision-fitted surgical templates
are generated at the click of a button using the
integrated surface scan and planned implant

[43] => CAD0313_01_Title

CAD0313_42-44_Nobel 20.09.13 17:18 Seite 2

industry news _ Nobel Biocare

positions. In addition to the fully guided traditional approach, NobelGuide now offers options for
guided pilot drilling. The decision on the position,
orientation and depth of the first drill during implant site preparation is one of the most crucial
steps. The NobelGuide pilot drill template helps to
solve this challenge and enables clinicians to finish
the surgery using their existing freehand techniques. All surgical templates can be visualised
immediately in NobelClinician and ordered online,
and are delivered ready for use.
The iPad-operated drilling unit OsseoCare Pro
truly sets a smarter standard in safety and efficiency, and is seamlessly linked to NobelConnect.
This allows the secure transfer of digital plans from
NobelClinician directly to the intelligent device for
freehand surgery or guided surgery options—all
immediately and neatly documented in automated
clinical reports. After the surgery, patient-specific
data is exported back to NobelClinician and stored
in the fully encrypted NobelClinician file for later
reference.
Able to run on both Windows and Mac OS X,
NobelClinician is continuously expanding its user
base. With the recently introduced volume rendering technique, a patient’s anatomy can be
evaluated more easily before surgery. The innova-

tive NobelClinician Communicator iPad app allows
for review of NobelClinician plans together with
the patient to understand the proposed treatment
better. The app, available from the Apple App
Store, is aimed at increasing treatment acceptance
and securely links through NobelConnect to any
iPad.
A predictable restorative outcome is assured
through the design of individualised prostheses
in NobelProcera software. The software is directly
linked to the global network of NobelProcera production facilities for the manufacture and delivery
of functional and natural-looking dental restorations designed to last a lifetime.

_New regenerative product
to be added to Nobel Biocare’s products
and solutions portfolio
Nobel Biocare recently entered the field of regenerative solutions with a new membrane, creos
xeno.protect, which it will offer in selected European markets. A biodegradable collagen membrane, creos xeno.protect is for dental use in guided
bone regeneration and guided tissue regeneration
procedures. It creates a favourable environment
for bone regeneration in the defect area by preventing the migration of undesired cells from the

CAD/CAM
3_ 2013

I 43

[44] => CAD0313_01_Title

CAD0313_42-44_Nobel 20.09.13 17:18 Seite 3

I feature _ interview
surrounding soft tissue and allowing the ingrowth
of osteogenic cells. The first results demonstrated
excellent revascularisation behaviour and tissue
compatibility, combined with an extended barrier
function. The membrane furthermore offers excellent handling properties, with a minimal size
increase when hydrated, as well as easy repositioning and unfolding. The official launch date will
be advised at a later date.

_New NobelProcera abutment will
achieve aesthetics from a new angle

tarian engagement. By promoting oral health care
and humanitarian endeavours, the foundation
seeks to provide on-demand opportunities for
learning, sharing and mentoring for better patient care. Its endowment of FOR demonstrates
the strong emphasis Nobel Biocare places on
training and education, and underscores the
future contributions the company plans to make
to the oral health community. Visit www.for.org
to learn more about FOR and these latest announcements.

_Innovative scientific Nobel Biocare
Precise engineering has been part of Nobel BioGlobal Symposium covers four
care’s heritage since its beginning and the forthcomplete patient journeys
coming NobelProcera Angulated Screw Channel
(ASC) Abutment is another milestone in that history. This new NobelProcera abutment can be
designed with an angulated screw channel, which
allows for a more optimal and aesthetic screw access position. Clinicians were previously limited to
cement-retained solutions in some cases for aesthetic reasons or because of access difficulties;
now they can opt for screw-retained solutions
and experience easy placement and removal options with a screw access hole that can be placed
according to preference.
The concept behind the angulated screw channel is to provide a free choice of screw access position to improve aesthetics (in the anterior region),
enable easier access (in the posterior region) and
provide restorative flexibility with increased treatment options. All this is supported by the new
easy-to-handle Omnigrip interface tool. With the
unique Omnigrip interface, the friction-based
pick-up component of the screwdriver easily connects to the screw. Screw tightening is then possible in all situations, whether the screwdriver is
straight or at an angle. The ASC concept combined
with Omnigrip will be introduced in 2014, starting
with selected NobelProcera abutments.

_Foundation for Oral Rehabilitation
inaugurated at Nobel Biocare
Global Symposium 2013
The official inauguration of FOR took place on
20 June during the Nobel Biocare Global Symposium 2013 in New York. Goodwill Ambassador for
the United Nations Population Fund Dr Bertrand
Piccard was awarded the foundation’s first FOR
Humanity Award in recognition of his Winds of
Hope humanitarian foundation. Prof. P.-I. Brånemark was elected the first FOR Honorary Fellow.
Shaped by leading clinicians and scholars, FOR
aims to build on Nobel Biocare’s long-standing
commitment to science, education and humani-

44 I CAD/CAM
3_ 2013

The Nobel Biocare Global Symposium 2013,
themed “Designing for life: Today and in the future”, was aimed at the dental professional who
wants to acquire the latest science-based knowledge and techniques in implant dentistry. The innovative and insightful programme was designed
to maximise the learning experience. The programme centred on four patient journeys: missing
anterior and posterior single teeth; missing multiple anterior teeth; missing multiple posterior
teeth; and managing the terminal/failing dentition—the transition to edentulism. The attendees
were able to follow each patient journey from
planning to maintenance, including possible complications and how to avoid them. Important clinical themes were also covered, such as minimally
invasive treatment, graftless solutions, immediate
replacement and function, soft-tissue health and
aesthetics. The programme included the most recent information on the key factors for successful
oral rehabilitation, such as diagnosis and treatment planning, surgical and restorative treatment,
and patient follow-up.
Learn more about the latest products, solutions and events on the Nobel Biocare website,
which offers product information, first-user comments, course programmes, an online store for
easy purchase and much more._

_contact
Nobel Biocare
Balsberg
Balz-Zimmermannstr. 7
8302 Kloten
Switzerland
www.nobelbiocare.com

CAD/CAM

[45] => CAD0313_01_Title

CADCAM_Abo_A4_Implants_Abo_A4 20.09.13 14:55 Seite 1

CAD/CAM
digital dentistry

international magazine of

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[46] => CAD0313_01_Title

CAD0313_46-47_Ids 20.09.13 17:19 Seite 1

I meetings _ IDS

IDS 2013
sets new records
Source_Koelnmesse GmbH

_The 35th International Dental Show (IDS)
posted record-setting results when it closed
in the middle of the March 2013 in Cologne.
The world's leading dental trade fair attracted
125,000 trade visitors from 149 countries. That
figure represents an increase of six per cent compared to the previous event. Records were also
set in terms of the number of exhibitors and the
occupied exhibition area.

46 I CAD/CAM
3_ 2013

This year 2,058 companies (+5.3 per cent) from
56 countries presented a wide range of innovations, products and services on 150,000 square
metres of exhibition area (+3.4 per cent). With
68 per cent of the exhibitors and 48 per cent of
the visitors coming fromabroad, the fair was
also more international than ever before. “The
degree to which IDS‘s global attraction increases
from one event to the next is impressive,” said

[47] => CAD0313_01_Title

CAD0313_46-47_Ids 20.09.13 17:19 Seite 2

meetings _ IDS

Dr. Martin Rickert, Chairman of the Executive
Board of the Association of German Dental Manufacturers (VDDI). “Thanks especially to the
trade visitors‘ high level of internationality and
decision-making authority; we expect the positive effects of the fair to continue for the rest of
the business year. We‘re also expecting sustained
growth in the German and international healthcare markets.”
Trade visitors were also highly satisfied with
the event. The visitor survey revealed that 74 per
cent of visitors said they were (very) satisfied
with IDS. What's more, the fair's comprehensive
spectrum of products and numerous innovations
caused 79 per cent of the visitors to rate the product range as either good or very good. In terms of
reaching their trade fair goals, 74 per cent of the
visitors surveyed said that they were satisfied or
very satisfied. Overall, 95 per cent of the visitors

surveyed would recommend a visit to IDS to their
business partners.
“IDS is the top event for the dental market. In
2013, it again drew the attention of the international dental world,” concluded Dr Peter Engel,
President of the German Dental Association (BZÄK).
“Demographic developments will make continuous
updates of healthcare structures necessary, and
they will be dependent on technical advances and
innovative therapies. At the trade fair, the industry
has impressively demonstrated its ability to meet
this challenge. But brainstorming for a (dentally)
healthy future isn‘t required within the dental
sector alone. It also has to come from public policymakers. Germany is at an excellent international
level technically and scientifically, as was demonstrated by this year‘s IDS. However, austerity regulations are making it more difficult for innovations
to make their way to the dentists‘ practices.”_

All images courtesy of
Koelnmesse GmbH.

CAD/CAM
3_ 2013

I 47

[48] => CAD0313_01_Title

CAD0313_48_Events 20.09.13 17:19 Seite 1

I meetings _ events

International Events
2013
IFED 8th World Congress
18–21 September 2013
Munich, Germany
www.ifed-2013.com
ESCD annual meeting
3–5 October 2013
Turin, Italy
www.escdonline.eu
2nd Asia-Pacific Edition
9th CAD/CAM & Digital Dentistry
International Conference
5 & 6 October 2013
Singapore
www.cappmea.com
EAO 2013
16–19 October 2013
Dublin, Ireland
www.eao.org
AAID Annual Meeting
23–26 October 2013
Phoenix, AZ, USA
www.aaid-implant.org

BACD Annual Conference
7–9 November 2013
London, UK
www.bacd.com
5th Dental–Facial Cosmetic
International Conference
8–9 November 2013
Dubai, UAE
www.cappmea.com/aesthetic2013/
10th International DLOAC CAD/CAM
Symposium & EXPO 2013
15–17 November 2013
Garden Grove, CA, USA
www.dloac.org/cadcamexpo
ADF Annual Dental Meeting
26–30 November 2013
Paris, France
www.adf.asso.fr
Greater New York Dental Meeting
29 November–4 December 2013
New York, USA
www.gnydm.com

2014
Imagina Dental 2014
13–15 February 2014
Monaco
www.imaginadental.org
ITI World Symposium
24–26 April 2014
Geneva, Switzerland
www.iti.org
9th CAD/CAM & Digital Dentistry
International Conference
9 & 10 May 2014
Dubai, UAE
www.cappmea.com

48 I CAD/CAM
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[49] => CAD0313_01_Title

CAD0313_49_Submission 20.09.13 17:20 Seite 1

about the publisher _ submission guidelines

submission guidelines:
Please note that all the textual components of your submission
must be combined into one MS Word document. Please do not
submit multiple files for each of these items:
_the complete article;
_all the image (tables, charts, photographs, etc.) captions;
_the complete list of sources consulted; and
_the author or contact information (biographical sketch, mailing
address, e-mail address, etc.).

I

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

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

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

Should you require a special layout, please let the word processing
programme you are using help you do this formatting automatically. Similarly, should you need to make a list, or add footnotes
or endnotes, please let the word processing programme do it for
you automatically. There are menus in every programme that will
enable you to do so. The fact is that no matter how carefully done,
errors can creep in when you try to number footnotes yourself.

Author or contact information
The author’s contact information and a head shot of the author
are included at the end of every article. Please note the exact
information you would like to appear in this section and format it according to the requirements stated above. A short
biographical sketch may precede the contact information
if you provide us with the necessary information (60 words
or less).

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

Questions?
Magda Wojtkiewicz (Managing Editor)
m.wojtkiewicz@dental-tribune.com

CAD/CAM
3_ 2013

I 49

[50] => CAD0313_01_Title

CAD0313_50_Impressum 20.09.13 17:20 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
Magda Wojtkiewicz
m.wojtkiewicz@dental-tribune.com

Europe
Melissa Brown
m.brown@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
Esther Wodarski
e.wodarski@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: Esther Wodarski
Holbeinstr. 29, 04229 Leipzig, Germany
Tel.: +49 341 48474-302
Fax: +49 341 48474-173

Executive Vice President
Finance
Dan Wunderlich
d.wunderlich@dental-tribune.com

Asia Pacific
Dental Tribune Asia Pacific Ltd.
Contact: Tony Lo
Room A, 26/F, 389 King’s Road
North Point, Hong Kong
Tel.: +852 3113 6177
Fax: +852 3113 6199

Printed by
Löhnert Druck
Handelsstraße 12
04420 Markranstädt, Germany

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

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 2013 with four issues. The magazine and all articles and illustrations therein are protected by copyright. Any utilisation without the prior consent of editor and publisher is 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.

50 I CAD/CAM
3_ 2013

[51] => CAD0313_01_Title

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GMT 32595 GB 1306 © Nobel Biocare Services AG, 2013. All rights reserved. Nobel Biocare, the Nobel Biocare logotype and all other trademarks are, if nothing else is stated or is evident
from the context in a certain case, trademarks of Nobel Biocare. 3Shape® and 3Shape Dental System™ are registered trademarks of 3Shape A/S. Product images are not necessarily to scale.
Disclaimer: Some products may not be regulatory cleared/released for sale in all markets. Please contact the local Nobel Biocare sales office for current product assortment and availability.

NB 2G_Openaccess 5.0 Master A4.indd 1

2013-08-06 15.33

[52] => CAD0313_01_Title

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[cover] => CAD/CAM international No. 3, 2013

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