digital international No. 1, 2020
Cover
/ Editorial
/ Content
/ Digital dentistry in daily practice
/ The integration of CAD/CAM into dental school curricula
/ Digital workflow versus conventional approach in aesthetic dentistry
/ A new smile in one day
/ The copyCAD
/ Immediate post-extraction implants in the anterior maxilla
/ Digital workflow with a metal-free surgical guide and zirconia implant
/ Treatment of an edentulous space with a digital workflow
/ Digitally fabricated bulb obturator
using virtual data and 3D printing
/ Manufacturer news
/ Dental startups are harnessing artificial intelligence
/ Practice management
/ Meetings
/ Submission guidelines
/ Imprint
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[1] =>
issn 2193-4673 • Vol. 1 • Issue 1/2020
digital
international magazine of digital dentistry
trends & applications
Digital dentistry in daily practice
case report
Digital workflow versus conventional
approach in aesthetic dentistry
feature
Dental startups are harnessing artificial intelligence
1/20
[2] =>
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Technologies, LLC in the United States and/or other countries. Nobel Biocare, the Nobel Biocare logotype and all other trademarks are, if nothing else is stated or is evident
from the context in a certain case, trademarks of Nobel Biocare. Please refer to nobelbiocare.com/trademarks for more information. Product images are not necessarily
to scale. All product images are for illustration purposes only and may not be an exact representation of the product. Disclaimer: Some products may not be regulatory
FOHDUHGUHOHDVHGIRUVDOHLQDOOPDUNHWV3OHDVHFRQWDFWWKHORFDO1REHO%LRFDUHVDOHVRIФLFHIRUFXUUHQWSURGXFWassortment and availability. For prescription use only. Caution:
Federal (United States) law restricts this device to sale by or on the order of a licensed clinician, medical professional or physician. See Instructions For Use for full prescribing
information, including indications, contraindications, warnings and precautions.
[3] =>
editorial
|
Dr Scott D. Ganz
Editor-in-Chief
digital is here!
What a great way to start off 2020! You might have noticed: our new name is digital! How great is that? It was
a necessary change to encompass everything that we
do today, to provide a platform for an exchange of ideas
among the finest clinicians, researchers, educators, and
much more, a platform that reflects the state-of-the-art
in dentistry today. As I like to start many of my own presentations, there is a danger when we are bound by 2D
concepts, when we truly live in a 3D world. Digital allows
us all to communicate globally with a universal language
that connects us all, the general practitioner, restorative
dentist, surgical specialist, prosthodontist, paediatric
dentist, orthodontist, oral and maxillofacial radiologist,
dental laboratory technician, auxiliaries, and more.
Digital represents the evolution from the analogue modalities of Dr G.V. Black as incorporated in the curriculum
of every dental school worldwide to perhaps unforeseen
technological advances of today that have dramatically
changed how we deliver care to our patients. Digital allows us to capture the intra-oral condition of a patient’s
occlusion without costly impression material, to visualise the result on a high-resolution LCD computer monitor
and to utilise sophisticated software tools to diagnose,
plan treatment and virtually simulate a smile design—
to the amazement of our patients. Digital then allows
us to virtually produce state-of-the-art CAD/CAM restorations with new and improved materials, a long way
from the lost wax method of casting metal for metal–
ceramic crown and bridgework. Digital allows a patient
with malpositioned teeth to see a computer-driven simulation of how his or her teeth can be moved into the cor-
rect functional and aesthetic positions and then through
rapid prototyping 3D printing modalities achieve these
results with a series of wearable aligners.
Digital represents tremendous advances in the assessment of patients’ individual and unique anatomy through
cone beam computed tomography (CBCT) to diagnose
potential pathology, to appreciate proximity of vital structures when planning for dental implants, to assess temporomandibular joint disorders, to plan for third molar
extractions and bone grafting, and much more. The ability to then merge the data sets of a CBCT scan and an
intra-oral scan enhances the clinician’s diagnostic capability to fabricate static surgical guides, or as the foundation for dynamic navigation, greatly improving implant
placement based upon a truly restoratively driven plan.
Can we imagine placing implants without 3D imaging
today? Digital finally allows for a seamless platform for
the clinician to communicate and interact with the dental laboratory technician, who is crucial to changing the
quality of life of our patients.
How can we be educated on our new universal language? Within the pages of this first issue of 2020, you
will find articles by some of the best and brightest that
illustrate these concepts, helping us to move from the
constraints of two dimensions into the unlimited potential of the 3D world. Enjoy our first issue of digital in 2020!
Respectfully,
Dr Scott D. Ganz
Editor-in-Chief
1 2020
03
[4] =>
| content
editorial
digital is here!
03
Dr Scott D. Ganz
trends & applications
Digital dentistry in daily practice
16
Dr Edouard Lanoiselée
page 22
education
The integration of CAD/CAM into dental school curricula
10
Brendan Day
case report
Digital workflow versus conventional approach in aesthetic dentistry
14
Dr Florin Lazarescu
A new smile in one day
22
Dr Gustavo Harfagar
page 34
The copyCAD
26
Dr Yassine Harichane
Immediate post-extraction implants in the anterior maxilla
30
Drs Gian Battista Greco & Danilo Alessio Di Stefano
Digital workflow with a metal-free surgical guide and zirconia implant
34
Dr Saurabh Gupta
Treatment of an edentulous space with a digital workflow
38
Prof. Heinz Kniha, Thomas Lassen & Dr Kristian Kniha
page 52
special report
Digitally fabricated bulb obturator using virtual data and 3D printing
42
Dr Tariq Saadi
manufacturer news
48
feature
Dental startups are harnessing artificial intelligence
52
Jeremy Booth
Cover image:
LuckyStep | Shutterstock.com
1/20
issn 2193-4673 • Vol. 1 • Issue 1/2020
digital
practice management
“As dental coaches, we are servants in a noble profession”
56
An interview with Kirk Behrendt
international magazine of digital dentistry
meetings
Nobel Biocare Global Symposium 2020 postponed to early 2021
58
about the publisher
trends & applications
Digital dentistry in daily practice
case report
submission guidelines
60
international imprint
62
Digital workflow versus conventional
approach in aesthetic dentistry
feature
Dental startups are harnessing artificial intelligence
04
1 2020
[5] =>
[ DIGITAL ]
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now or visit www.straumann.com.
A0019/en/A/00 03/20
[6] =>
| trends & applications
Digital dentistry in daily practice
Dr Edouard Lanoiselée, France
How can a patient’s treatment be optimised? How
can both speed and efficiency be increased without
sacrificing quality? These questions are constantly
being asked in our practices. Our patients’ demands
are becoming increasingly advanced in terms of aesthetic and functional results, yet they have ever less
time to dedicate to treatments. We now have a great
deal of equipment at our disposal that enables this
optimisation. Many of these tools are digital and as
such allow us to digitise our patient files in order to
transfer as much information as possible to the prosthetic laboratory. This information can thus be prioritised and streamlined to be processed in the laboratory by the appropriate people in the respective
field (modelling, ceramic coating, etc.). In this effort to
Fig. 1
centralise information, colour is a complex area that
requires extensive resources in terms of information.
It is usually assessed in the chair by means of comparison of the patient’s teeth to one or more shade
guides. This reading is influenced by many factors,
and results can be significantly affected by surrounding interference (brightness of the room, bright colour
of lipstick, etc.), making it particularly subjective.1, 2
Dental photography is now considered an excellent
way to convey colour information. It requires the prosthetist to use a shade guide as a reference to ensure that the information is as objective as possible.
Working with dental photography, however, increases
working time, as the prosthetist has to perform map-
Fig. 2
Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig.
Fig. 67
Fig. 87
Figs. 1 & 2: Initial situation: teeth #22 and #23 required restoration. Fig. 3: Colour reading sheet on the tooth to be treated. Fig. 4: Colour reading sheet
on the contralateral tooth. Fig. 5: Translucency, detailed (pixel by pixel) and 9 parts shade mappings. Fig. 6: Optical impression. Fig. 7: Reduction control.
Fig. 8: Optical impression of the preparation (with TRIOS 4, 3Shape).
06
1 2020
[7] =>
trends & applications
Fig. 9
Fig. 10
Fig. 12 Fig. 1
|
Fig. 11
Fig. 13
Fig. 9: Modelling of the restoration (with Dental System, 3Shape). Fig. 10: The veneer, ready to be seated in the patient’s mouth. Fig. 11: Seating of the final
restoration under dental dam isolation. Fig. 12: Final situation immediately after removal of the dental dam. Fig. 13: Check-up at four months.
ping based on the information obtained from the photographs. Moreover, cameras are sensitive to shade
variations, depending on the colour temperatures
predetermined by the camera, which can skew this
reading.3 To counter this problem, spectrophotometers are currently the best tools we have to objectify
a result. They work by emitting calibrated light which,
depending on the reflection registered, enables a colour reading to be taken. This reading is unaffected by
environmental factors that could potentially skew its
results (lipstick, colourful clothing, unsuitable lights,
etc.).4, 5
Some models allow a photograph to be taken with
mapping of the tooth, which enables the prosthetist to be guided more effectively in the process of
creating the prosthesis. The sheet is then stored on
the software and can be processed and archived in
a patient file. The Rayplicker (Borea) is a device that
allows the practitioner to record all the information
collected and communicate it to the prosthetic laboratory. The laboratory sheet can be sent via a secure
portal and reprocessed by the prosthetic laboratory.
This flow enables the form to be marked as reviewed
by the laboratory, in order to monitor the progress of
the treatment from the practice. Most shade guides
on the market are referenced, making the work easier
for the laboratory.
Clinical case
The patient attended the practice for replacement
of the restoration on tooth #23, which she found un-
sightly. The clinical examination revealed the presence of a composite restoration on the vestibular surface of tooth #23 with a stained joint, as well as the
presence of early carious lesions on the neighbouring teeth (Figs. 1 & 2). After discussing treatment options with the patient, it was decided on composite
restorations for the carious lesion and a veneer for
tooth #23. However, there was a constraint that made
this case more difficult: the patient had to go abroad
for three months and needed the work to be done
within ten days of accepting the treatment.
The first step in the treatment was registering the colour, performed using the Rayplicker. A reading was
taken of the tooth to be restored and of the contralateral tooth (Figs. 3 & 4). This double reading would
give the prosthetist information not only on the tooth
to be restored but also on the overall integration of this
tooth. The readings were sent to the laboratory via a
secure server. The important information for creating
the restoration is centralised on this sheet: translucency, detailed mass mapping and the shade guide
values (Fig. 5).
As the treatment did not require any modification of
shape, it was decided to use the initial situation as a reference for the laboratory, and an optical impression was
taken, which would guide the laboratory in the design of
the veneer (Fig. 6). A reduction guide was then made with
silicone and the tooth was prepared (Fig. 7). The thickness would be checked at the end of preparation with this
key, which enables the ceramic thickness, the homogeneity and the homothety of the preparation to be checked.
1 2020
07
[8] =>
| trends & applications
rehydrated and the periodontal tissue that had been
pushed in when the dam was put in place had resumed its original position (Fig. 13). It was evident that
the restoration had integrated well.
The use of digital techniques means that it is now
possible to create simple and reproducible protocols. If the practitioner or prosthetist encounters difficulties, these can be analysed and resolved quickly.
While shape can now easily be checked by the practitioner, colour is one of the crucial points to master
during procedures. Spectrophotometers such as the
Rayplicker now offer a simple, fast and effective solution. The secure platform facilitates interaction between the practice and the prosthetic laboratory, as
well as confirms receipt of documents, centralises information and provides the option of enhancing the
content with photographs clarifying the surface qualities and characterisations required for the integration
of the prosthesis. All these elements combined deliver
qualitative and rapid results in line with patients’ expectations.
Fig. 14
Editorial note: A list of references is available from the
publisher.
Fig. 14: Spectrophotometer Rayplicker developed by BOREA.
The optical impression of the preparation was then
performed (Fig. 8). To do this, tooth #23 was erased
on the initial impression and then the area was registered. This would enable the impressions to be
merged easily in the laboratory to control the modelling process. All the information was then sent to the
laboratory (shade sheet and optical impression). In
both cases, the files were sent via a secure portal with
the option of verifying receipt by the dental surgeon.
The veneer was then modelled in the Dental System
software (3Shape; Fig. 9) and then printed in burnout
resin on a 3D printer. It was then processed conventionally using the pressed ceramic technique, as the
fineness of the veneer is not easily compatible with a
machining technique (Fig. 10).
After curettage and sealing of the lesion on tooth #22,
the veneer was placed with a try-in paste (Fig. 11).
The patient confirmed the result, and then the veneer
was glued on to the tooth. Only light-polymerised glue
(G-CEM veneer, GC) is used for this—the advantage
of this type of glue is the longer working time and
therefore the management of excess glue, which is
easier to remove. After thorough polishing, the dental
dam was removed and a final polish was performed
(Fig. 12).
The patient was seen again at four months, when she
returned from abroad for a check-up. The teeth were
08
1 2020
about
Dr Edouard Lanoiselée graduated
from the Faculty of Dentistry of the
University of Nantes in France and later
obtained a master’s degree in medical
sciences. He worked as a university
hospital assistant at the teaching and
research centre of the Nantes university
hospital in the prosthetic department.
He is the coordinator of the aesthetic
dental restoration university degree at the University of Nantes
and a consultant to the implantology department of Nantes university hospital. Dr Lanoiselée is a CAD/CAM specialist and a
partner at a general dental practice in Nozay in France.
[9] =>
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Follow Dentsply Sirona Implants
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[10] =>
| education
The integration of CAD/CAM into
dental school curricula
By Brendan Day, DTI
By this point, the benefits of employing digital technologies in the dental practice and laboratory have been well
documented. CAD/CAM was developed for commercial
use in the 1980s at the University of Zurich in Switzerland
by Prof. Werner H. Mörmann and Dr Marco Brandestini,
and its usefulness for creating dental restorations and
orthodontic appliances has grown in the decades since,
as has its reputation. FDI World Dental Federation, the
principal representative body for more than one million
dentists worldwide, went so far as to issue a policy statement in 2017 declaring that it supports “the research and
development of CAD/CAM dentistry to improve the quality
of the final product and allow for cost reduction”.
What has been less covered, however, is the role that
CAD/CAM can play in tertiary dental education as both
a teaching aid and a tool for future dentists to experience
in a preclinical setting. In contrast to older dentists who
may have had to learn how to use these technologies
from scratch, today’s dental students are frequently
digital natives, already well versed in using computers by
the time they reach university. As a result, they often have
an increased affinity for the incorporation of CAD/CAM
into their learning experiences.
A 2015 article in Inside Dentistry asserted that 76 per cent
of American dental schools have at least one CEREC unit
from Dentsply Sirona, perhaps the piece of CAD/CAM
equipment most commonly found in dental practices.
However, this level of access to such technology is nowhere near guaranteed, according to a survey that was
the subject of a report by Dental Tribune International in
2017. Most British dentists stated that they did not use
any CAD/CAM equipment in their practices, even though
89 per cent of them admitted that it had a major role to
play in the future of dentistry.
So how has CAD/CAM been integrated into dental school
curricula to this point?
The University of Tennessee College
of Dentistry—a trendsetting school
One of the first dental schools to incorporate CAD/CAM
into its undergraduate curriculum was the College of
Dentistry at the University of Tennessee Health Science
Center in the US. In 2001, the school invested in a CEREC 3
unit from Sirona—having tested five CEREC 2 units the
summer before—and, slowly but surely, let its students
experience at first hand the potential of this digital
technology.
Dr Mojdeh Dehghan, an associate professor and Chair of
the Department of General Dentistry, was one of the chief
drivers of this technological shift. She outlined to Dental Tribune how the dental school’s curriculum integrates
CAD/CAM technology from the very first day of students’
preclinical studies, which allows them to gain a better understanding of what their eventual clinical study will entail.
Fig. 1
Fig. 1: Dr Mojdeh Dehghan, an associate professor and Chair of the Department
of General Dentistry at the University of Tennessee College of Dentistry in the US.
10
1 2020
“Before the end of their first year, our undergraduate
students have not only been introduced to CAD/CAM in
their dental morphology course, they have also undertaken an ‘Introduction to CAD/CAM Dentistry’ course,
where they get to work directly with mannequin teeth that
are already prepared for an onlay and a crown, going
through the whole process of scanning, designing and
milling,” Dehghan says.
[11] =>
education
|
“When they’re exposed to technology like this early on
in their education, especially for this tech-savvy generation, they not only often really enjoy being given the
opportunity to see what they’ll be doing later on but also
are able to reinforce their knowledge of tooth morphology and anatomy that they’ve learned in prior courses,”
adds Dehghan. “It’s the optimal way to integrate technology into the basic science courses and has been a really
successful programme for us.”
Maryland’s father of digital dentistry
Dr Gary Hack is an associate professor at the University
of Maryland School of Dentistry, where he teaches in the
Department of Advanced Oral Sciences and Therapeutics.
Having instructed dental students for more than three
decades now, Hack might be forgiven for not having
stayed up to date with all of the technological developments in dentistry. This, however, couldn’t be further
from the truth, since he was one of the first dental educators in the nation to integrate CAD/CAM devices into
his teaching. At Maryland, Hack’s enthusiasm for modern
dental technology is such that many of his colleagues call
him the university’s father of digital dentistry.
“In the early 2000s, there were some representatives
from Sirona who came to conduct a demonstration at
our dental school,” Hack explains. “At that time, they had
the CEREC Red Cam. I had been teaching a crown and
bridge course for many years at that point, but when
I saw this technology at first hand, I was overwhelmed.
I knew that this was the future of dentistry. I knew that
this would introduce an incredible level of excitement
for the dental students. And I knew about the students’
passion for computers and technology.”
By 2006, Hack had set up ten CEREC Red Cams in the
school’s so-called Dream Room and began integrating
digital dentistry into his classes with immediate effect.
“I was teaching a freshman course on amalgams and
composites, and the general thinking was that you
couldn’t gain any value from scanning amalgam and
composite preparations because they have undercuts,”
he says.
“What I quickly learned, however, was that it was very
easy to scan these. Instead of ten or 15 students gathered
around me and a typodont, failing to really see anything
while I tried to explain about the walls of an intracoronal
preparation, a single scan allowed for me to show everybody all the different elements in a way that was much
easier for them to understand,” Hack adds.
Fig. 2
Fig. 3
Fig. 2: Dr Gary Hack, an associate professor at the University of Maryland
School of Dentistry in the US. Fig. 3: Dr Selim Pamuk, a retired professor who
used to teach at Istanbul University’s Department of Prosthodontics in Turkey.
feedback regarding site preparation. “After 35 years of
teaching, I can tell you that it’s almost impossible to get
ten dentists to look at the same dental preparation and
each come up with the same grade,” he declares.
“Everyone has his or her own bias, his or her own way of
looking at things. However, the computer has no such bias.”
The era of digital natives
When it comes to understanding how to use dental CAD/
CAM technologies, it is clear to educators like Dehghan
and Dr Selim Pamuk that this current generation of
students is much more capable than their predecessors.
“Today, young generations are growing up using smartphones, game consoles and powerful computers from
their childhood onwards,” says Pamuk, a retired professor who used to teach at Istanbul University’s Department of Prosthodontics in Turkey before opening up his
own private practice in the same city.
“Teaching these students everything in a virtual environment is much easier than adapting ourselves to these
changes. They understand how to use technology with
ease, and do it instinctively,” he admits.
Pamuk’s assertions are echoed by Hack, who emphasises
that “there really is no learning curve” for the dentists
of tomorrow. “These students pick it up within minutes,
to a point where they understand it better than I do!” he
remarks. “They grew up with computers and are naturally
drawn to this technology, are passionate about it and are
excited to bring it into their future dental practices.”
Are we moving too fast?
Somewhat surprisingly, Hack asserts that the software
available on certain CAD/CAM devices comes with an
added benefit for students: the provision of unbiased
It can be somewhat easy to argue that, given CAD/CAM’s
increasing influence in the dental world, it should be
1 2020
11
[12] =>
| education
inequalities that continue to exist between and within
different communities.
“A lot of the time, we don’t know exactly where our
students are going to end up working,” Dehghan says.
“They may end up working in public health, in remote
areas, in the military—any number of places that often
have less access to CAD/CAM. This is why we’re exposing them to these advanced technologies while also
ensuring that they learn all of the traditional methods
of impression taking, crown preparation, temporizing
the patient, sending the information to the laboratory,
and so on. CAD/CAM is wonderful, and while it should
be integrated into dental education, it shouldn’t be the
sole method,” she adds.
Dehghan affirms that the initial cost of investing in
CAD/CAM devices and technologies is something that
puts off not just private dental practices but certain
schools as well.
Fig. 4
Figs. 4–7: By 2006, Dr Gary Hack had set up ten CEREC Red Cams in the school’s
so-called Dream Room and began integrating digital dentistry into his classes.
readily and widely employed in dental schools. “More and
more dentistry is surrounded by new digital ‘toys’ that
can make our practices more efficient than ever before,”
claims Pamuk, who is a strong believer in the power of
CAD/CAM.
“Digital dentistry is now a reality, and dental schools and
practices should all be part of this. Dental schools should
change and adapt their curricula accordingly,” he adds.
However, the truth of the matter, according to Dehghan,
is somewhat more complicated given the oral health
Fig. 5
12
Fig. 6
1 2020
It’s a sentiment that Hack readily agrees with. “In my
opinion, all dental schools are, to some degree, struggling with this decision,” he says. “Clearly, they know
that they have to do this, that it is incumbent on them that
they teach their students this technology, since if they
don’t, they are not properly preparing them for their
future practice. Yes, the financial cost can be a barrier,
but this is clearly outweighed by the benefits that come
with integrating CAD/CAM devices into current methods
of teaching,” Hack continues.
There is a way, however, that the financial burden of
CAD/CAM investment can be lessened for dental schools:
partnering with key players in the industry.
[13] =>
education
|
Fig. 7
Industry involvement
in dental CAD/CAM education
The role that industry can play in promoting CAD/CAM
use in dental schools has already been recognised.
Henry Schein, for example, has partnered with the
American College of Prosthodontists Education Foundation since 2018 to create its Digital Dentistry Curriculum
Initiative, which aims to develop new curricula for
American dental schools that incorporate CAD/CAM
technologies into their curricula.
“We believe CAD/CAM technology enhances dentistry
and we are pleased to support this initiative, which will
offer dental students the education and training needed
to effectively apply this exciting technology in their
future work,” said Stanley M. Bergman, chairman of
the board and CEO of Henry Schein, in a press release
announcing the company’s initiative. “By rallying the
industry to ensure that dental students are fully educated on the practice benefits and patient benefits of
digital dentistry, we are helping the dentists of tomorrow succeed.”
Hack sees the relationship between dental schools and
CAD/CAM providers as one that, if executed correctly,
can prove to be essentially symbiotic in nature. “As teachers, we can go back to the manufacturers and tell them
what we would like to see in their evaluation software
and they will work on it,” he explains.
“There is a collaboration between dental school education
and the manufacturers that becomes a win-win situation.
The manufacturers know that, if the students are being
taught digital dentistry, then chances are, when they
get into private practice, they’ll move in that direction,”
Hack adds.
For Pamuk, this association is something that can
ultimately lead to reduced costs and greater access to
CAD/CAM technology for dental schools.
“The industry has to collaborate with dental schools
and research centres, even with private practitioners, in
order to develop digital dentistry and reduce the cost of
equipment,” he says.
“Once the cost has been lowered, digital dentistry will be
more democratic. But for this, close collaboration is needed,
as teaching and learning skills will change completely with
the adoption of digital tools in classrooms,” Pamuk adds.
On the whole, it appears as though the integration of
CAD/CAM into dental school curricula throughout the
world is on the increase. Heidelberg University Hospital
in Germany, Queen Mary University of London in England
and RMIT University in Australia are just a few of the educational institutes that currently offer courses centred on
dental CAD/CAM technologies. Though there are certain
barriers to its widespread adoption, this number looks
set to continue to grow.
1 2020
13
[14] =>
| case report
Digital workflow versus conventional
approach in aesthetic dentistry
Dr Florin Lazarescu, Romania
Digital technologies are becoming ever more present in the daily work of dental clinicians, even if sometimes the digital part of the work is done by the dental
laboratory using CAD/CAM technology. Nowadays, as
dental practitioners, we often ask ourselves which technique we should use—should we trust only new digital
solutions or rather stick to conventional, analogue, techniques? In this article, I seek to answer this question by
presenting the same case treated in a digital and an analogue way.
Every dental practitioner uses common impression materials; we are used to them, they have passed the test of
time and they appear to be predictable. Therefore, many
of us might ask whether digital scanning is reliable and
if so which scanner to choose. My colleagues from the
Iuliu Hatieganu University of Medicine and Pharmacy in
Cluj-Napoca in Romania conducted research on the accuracy of different scanners and milling machines, considering them singularly and in combination (products
both from single manufacturers in combination and from
different manufacturers in combination; Tables 1–5).1
Fig. 1
Fig. 2
Fig. 3
Fig. 4
Figs. 1–4: Initial clinical situation.
14
1 2020
Their research found a median precision of 78.40 μ
for complete in-office systems, of 76.04 μ for additive CAD/CAM systems and of 60.46 μ for laboratory
CAD/CAM systems. When scanners and milling machines from different producers were combined, a
median precision of 49.85 μ was obtained for laboratory systems, while complete in-office systems had a
precision of 78.32 μ and single brand laboratory systems 60.46 μ. The results of this research demonstrate that the precision is very good no matter which
system one uses, that CAD/CAM technology is reliable and that we can count on it in everyday work.
Case report
A 32-year-old female patient came to our clinic for improvement of the aesthetics of her smile. After analysing the initial situation (Figs. 1–4), we recommended
veneers on teeth #14 to 23 and ceramic crowns on
teeth #15 and 16. To optimise the final outcome, it was
decided with the patient to treat this case both ways,
analogue and digital.
[15] =>
case report
|
Table 1: Precision for various CAD/CAM systems according to product.1
System kind
Scanner and milling machine
(product and manufacturer)
Measurement
Precision (μ)
Complete in-office
systems
Lava C.O.S. (3M ESPE)
MVS
46.81
E4D (Planmeca)
MVS
85.98
CEREC 3 MC (Dentsply Sirona)
MVS
102.43
Median precision (μ)
78.40
Additive CAD/CAM
systems
PM100 Dental (Phenix Systems)
MVS
62.60
EOS 3D scanner + EOSINT M 270 (EOS)
MVS
72.60
laser sintering (BEGO Medical)
MVS
92.93
76.04
Laboratory CAD/CAM
systems
Zenotec (Wieland)
MVS
13.78
Decim (Dentronic)
MVS
23.00
NobelProcera (Nobel Biocare)
MVS
30.78
KaVo Everest (KaVo Dental)
MVS
41.50
M5 (Zirkonzahn)
MVS
47.26
DECSY SCAN (Digital Process)
MVS
49.00
CORiTEC 250i (imes-icore)
MVS
53.00
Lava ls (3M ESPE)
MVS
55.68
CEREC inLab (Dentsply Sirona)
MVS
56.10
Gn-l
MVS
66.80
Cercon eye (Dentsply DeguDent)
MVS
66.85
Ceramill Motion 2 (Amann Girrbach)
MVS
71.31
DigiDent (DigiDent Labs)
MVS
75.00
Cynovad Pro 50 (Cybernetic Innovations)
MVS
79.50
E4D (Planmeca)
MVS
90.47
iTero (Align Technology)
MVS
93.13
Compartis (Complete Milling Lab)
MVS
114.70
60.46
MVS = Medium vertical space
1 2020
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[16] =>
| case report
Fig. 6
Fig. 5
Fig. 7
Figs. 5–7: Functional analysis wax-up.
Analogue approach
We started with dental impressions taken with common
materials. Next, the facebow registration was taken and
sent to the dental laboratory together with the impressions. The dental technician then prepared the wax-up
and analysed it in an articulator (regarding occlusion and
functional movements; Figs. 5–7). The first important observation in this case was the overjet distance. In order to
achieve a perfect bite, I would have recommended double veneers (buccal and palatal) from teeth #12 to 22. An
analogue approach allows fabrication of double veneers,
and it is a common procedure, but a digital approach
using a CAD/CAM chairside system does not permit this
solution, or makes it complicated (double scanning is
necessary and is possible only after cementation of one
of the parts of the veneers, palatal or buccal).
A mock-up was done, followed by guided tooth preparation through the mock-up in order to have a mini-
mally invasive procedure. Next, we analysed the central incisor (CI) length and ratio, visibility of the anterior
teeth in different lip positions (at rest, during smiling
and during functional movements), levels of the fixed
gingiva and zenith points. If necessary, based on this
mock-up, we can perform gingival surgery in order to
achieve a highly aesthetic final result.
According to many studies, resin–enamel bonds are
reliable and durable. The presence of the enamel at
the preparation margin offers a perfect seal against
the ingression of oral fluids and bacteria. When the
cavity margins are bonded to enamel, bonds to dentine are more durable (even a simplified, more hydrophilic adhesive may survive because of the protective
effect of bonded enamel against the diffusion of water
across the bonded interface).2–4
The greater the difference between acid solubility of
enamel periphery and prism core, the stronger the
Table 2: Precision for laboratory CAD/CAM systems of different producers.1
Scanner and milling machine
(product and manufacturer)
Measurement
Precision (μ)
TRIOS (3Shape) D900 + RXD5 (Röders)
MVS
19.80
Dental Wings DW-5-140 (Dental Wings) + D40 (Yenamak)
MVS
29.25
Lava C.O.S. (3M ESPE) + Mori Seiki (DMG MORI)
MVS
48.00
TRIOS (3Shape) D900 + DNM500 (SMT)
MVS
51.50
TRIOS (3Shape) D900 + Zanotec (Wieland)
MVS
60.16
iTero (Align Technology) + E4D milling machine (Planmeca) MVS
68.50
Dental Wings 3D (Dental Wings) + DC 40 (Yenadent)
71.80
MVS
Median precision (μ)
49.85
16
1 2020
[17] =>
case report
Fig. 8
Fig. 9
Fig. 10
Fig. 11
|
Figs. 8–11: Microscopic views of acid etching of the enamel surface, prisms cut longitudinally and transversally, displaying the three acid etching patterns.5
bond is. Resin tags up to 25 μ in length and 6 μ in diameter are formed into microporosities of the conditioned
enamel, providing a long-lasting bond by mechanical interlocking (the mean values of tensile and shear stress
are 20–25 MPa, higher than the surface tension after
polymerisation shrinkage of the composite resin [16–
18 MPa]; Figs. 8–11).5, 6–8
While enamel is predominantly mineral, dentine is a vital
tissue. Permeability of the dentine depends on the diameter of the dentinal tubules. The smear layer extends
1–10 μ into the initial part of the dentinal tubules. The
smear layer is in direct proportion to the grain size of the
bur. The smear layer has a weak bond to the underlying
dentine. Micro- and nano-leakage phenomena still pose
major theoretical and clinical challenges (Fig. 12).5, 9–11
Owing to minimal preparation, restricted to the enamel
surface, local anaesthesia was not necessary in this
case. Vitality of all teeth was maintained. Because of the
necessity of closing the overjet, a slightly palatal prepa-
ration was performed (Figs. 13–15). The ceramic preparations were no thicker than 0.5 mm, and because of the
minimal thickness of the ceramic restorations, a try-in
paste was used in order to determine which cement to
use (Figs. 16–19).
Digital approach
An intra-oral scan of the initial situation was performed
(Primescan, Dentsply Sirona) and sent to the dental laboratory. Initially, we planned to scan the wax-up previously
prepared in a conventional (analogue) way and to use
these references for the final preparations. However, the
software of the scanner could not match the teeth from
the wax-up model and from the oral cavity, so we had to
repeat the scanning and manually prepare the aesthetic
modelling. The aesthetic modelling is time-consuming,
and this has to be taken into consideration when choosing between a digital and conventional approach. In the
digital chairside approach, all work is done in the dental
office (Fig. 20).
1 2020
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[18] =>
| case report
Table 3: Median precision according to scanner type.1
Scanner type
Measurement
Median precision (μ)
Intra-oral
MVS
81.25
Model
MVS
75.32
Table 4: Median precision according to system type.1
Fig. 12
Scanner type
Measurement
Median precision (μ)
In-office
MVS
78.40
Laboratory single brand
MVS
60.46
Laboratory composed
MVS
49.85
If one wants to keep the workflow digital only, a virtual
wax-up can be performed as well (3D-printed model),
followed by a mock-up and the aforementioned aesthetic analysis. Guided enamel preparation is done
through the mock-up in order to conserve as much
tooth structure as possible.
Definitive ceramic restorations with a thickness of
0.3 mm were milled. They were sent to the dental laboratory for staining in order to achieve better aesthetics. For a highly aesthetic result, staining or the cutback technique in the dental laboratory is mandatory.
A try-in paste was used in order to observe the transparency of the tooth structure (Figs. 21–24).
Patient’s choice
The patient was asked to choose one of the sets of
ceramic restorations (Figs. 25–31). From a clinical and
Fig. 12: Microscopic view of demineralised dentine and penetration of the
hybrid layer into dentinal tubules.5
technical point of view, both sets of restorations were
perfect, both were adapted, functional movements
were present for both and both were highly aesthetic.
The patient chose veneers and crowns prepared using conventional techniques; her choice was totally
subjective, since she did not know which set of restorations had been produced with the digital approach
and which with the analogue procedures.
Conclusion
Are we able to follow a digital workflow for a major
dental rehabilitation? In my opinion, yes; however,
some learning is necessary, and in many cases, analogue and digital methods should be combined.
We can conclude the following:
– Both fully digital and fully analogue treatments are possible and give great aesthetic results, bearing in mind
that staining and the cut-back technique is mandatory.
– Thickness of definitive restorations can vary between
0.3 and 0.5 mm for both approaches.
– Precision is perfect for both approaches.
– The double veneer technique is not possible when
using the digital approach.
Table 5: Median precision and range according to system type.1
18
Scanner type
Measurement
Median precision and range (μ)
In-office
MVS
78.32 (39.60–161.40)
Laboratory single brand
MVS
60.46 (13.78–114.70)
Laboratory composed
MVS
49.85 (19.80–71.80)
1 2020
[19] =>
case report
Fig. 13
Fig. 14
Fig. 16
Fig. 15
Fig. 17
Fig. 18
Fig. 19
Fig. 20
Fig. 22
|
Fig. 21
Fig. 23
Fig. 24
Figs. 13–15: Minimally invasive preparation. Figs. 16–19: Final analogue ceramic restorations. Fig. 20: Digital modelling. Figs. 21–24: Final digital ceramic
restorations.
1 2020
19
[20] =>
| case report
Fig. 25
Fig. 26
Fig. 27
Fig. 28
Fig. 29
Fig. 30
Figs. 25–31: Final results of the analogue and digital approach.
about
Fig. 31
The future belongs to the digital approach certainly.
My recommendation is to allow dental practitioners a
period of learning in which to integrate digital and analogue methods, to start with minor cases and gradually progress towards fully digital and/or full-mouth
rehabilitation.
Editorial note: A list of references is available from the
publisher.
20
1 2020
Dr Florin Lazarescu owns a private
dental practice in Bucharest in
Romania and in his work focuses on
aesthetic dentistry with an emphasis
on all-ceramic and implant restorative
procedures. He is the author of numerous publications on dentistry, and he is
the editor of and a contributing author
to the Romanian book Incursiune în
Estetica Dentara (Immersion in Esthetic Dentistry, Society of
Esthetic Dentistry in Romania, 2013)—republished in English
as Comprehensive Esthetic Dentistry (Quintessence, 2015) and
in Chinese (Qiuntessence China, 2017). He is editor-in-chief of
Dental Tribune Romanian Edition.
Dr Lazarescu is the president of the European Society of
Cosmetic Dentistry and a founding member and director of the
Society of Esthetic Dentistry in Romania.
[21] =>
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[22] =>
| case report
A new smile in one day
Dr Gustavo Harfagar, Chile
Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Introduction
Digital workflows can improve our treatment results. In this
report, a multidisciplinary patient treatment is presented,
focusing on the chairside workflow and the use of n!ce
ceramic material (Straumann). Nine successful chairside
restorations (six in the aesthetic zone) are described. The
teeth and implants were prepared and scanned during
the morning, and the final restorations were placed the
same day. The patient received her new smile in a much
shorter time than with traditional protocols, and this was
a key driver in her decision to accept the treatment plan
exclusively with Straumann digital solutions.
Procedure
Initial situation
Treatment planning
After cause-related therapy (oral hygiene instructions,
prophylaxis and dental fillings), the patient was ready
for the surgical phase. This would include mucogingival
surgery in the second sextant in order to improve the
pink aesthetics and the placement of dental implants in
the posterior region.
A generally healthy 51-year-old female patient visited our
clinic requesting a new smile. On extra-oral and intra-oral
After the soft tissue had healed, the restorative phase
would begin. In the second sextant, the old crowns
Fig. 6
Fig. 7
22
examination, she was found to have a medium smile
line with fixed restorations and multiple recessions in
the aesthetic zone, carious lesions, inflammation, plaque
and missing teeth at positions #16, 25, 26, 36 and 45
(Figs. 1–5).
1 2020
Fig. 8
[23] =>
case report
Fig. 9
Fig. 10
Fig. 11
Fig. 12
Fig. 13
would be removed and the teeth prepared for the new
n!ce crowns following the Straumann chairside workflow.
Surgical procedure
The five planned implants (Straumann Standard Plus;
diameter: 4.1 mm, length: 8.0 mm, regular neck, Roxolid,
SLActive) were placed in positions #16, 25, 26, 36 and
45 in one surgical phase. Provisional crowns were placed
for all the implants.
The multiple recessions in the aesthetic zone were
treated with a tunnel technique using a connective tissue
graft taken from the palate. This surgery was performed
by Dr Enrique Javer (Figs. 6–8).
Prosthetic procedure
When all the implants had osseointegrated, the posterior remaining teeth were prepared for crowns,
and in the same session, a digital impression was
taken with the new Straumann Virtuo Vivo intra-oral
scanner.
|
On the same day, after confirmation of fit, all crowns were
placed and cemented. With the new vertical dimension,
the mandibular premolars, canines and incisors were
adjusted with IPS Empress Direct composite (Ivoclar
Vivadent).
After a further intra-oral scan, a new smile was designed using Straumann CARES Visual. A 3D model
printed with the Straumann P30 3D printer was used
for the digital wax-up. Photographs were taken to register all the details needed for the final design of the
restorations.
At the next appointment, the patient came to the clinic
early in the morning. All the old crowns were removed,
and teeth #24, 25 and 34 were prepared for crowns.
Intra-oral data was acquired with Virtuo Vivo, and a
photograph of the patient’s face was taken.
Using the Straumann CARES Visual software, all the
posterior crowns were designed and then milled with
the Straumann CARES C series chairside milling machine.
STL files of the digital wax-up and prepared teeth and
the patient’s photograph were uploaded to Straumann
CARES Visual, and the crowns were designed. After
25 minutes, all the crown designs were sent for milling
with the C series milling machine. On completion of the
milling process, all the crowns were placed for a final fit
check (Figs. 9–13).
Fig. 14
Fig. 15
1 2020
23
[24] =>
| case report
Fig. 16
Fig. 18
Fig. 17
Fig. 19
Fig. 20
The fit was confirmed, and only minor adjustments were
needed at the contact points. The crowns were removed
from the patient’s mouth and polished by hand using
OptraFine (Ivoclar Vivadent; Figs. 14 & 15). All the
crowns were cemented using IPS Ceramic Etching Gel
(Ivoclar Vivadent) according to the Ivoclar Multilink
protocol (Figs. 16–21).
Treatment outcome
The patient was very happy with the functional and
aesthetic result, as well as the short treatment period.
She finally received her new smile in a much shorter time
than expected, and this was a key driver in her decision
to accept our treatment plan.
about
Fig. 21
24
1 2020
Dr Gustavo Harfagar graduated
with a BSc from the University of Chile
in Santiago and then went to dental
school at Universidad Mayor, also in
Santiago. He completed his studies in
implantology at the same university.
For ten years, he was an assistant
professor in the department of prosthodontics at the school of dental medicine
of Universidad del Desarrollo in Santiago, Chile and a visiting
professor at the postgraduate school at the same university.
In 2016, he attended the ITI Education Week at Harvard School
of Dental Medicine and Tufts University, both in Boston in the US.
He returned to Harvard School of Dental Medicine for
a continuing education course on digital restorative dentistry
in 2017. In the same year, he was named director of the digital
restorative dentistry programme at Universidad del Desarrollo.
He gives lectures on digital dental technologies both nationally
and internationally. Dr Harfagar has his own practice and twelve
years of experience working in aesthetic and implant dentistry.
[25] =>
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[26] =>
| case report
The copyCAD
Dr Yassine Harichane, France
Introduction
Preparation
Nature has always captivated us with its beauty. Whether
it is a landscape, a sunset or the intricate details of a leaf,
one marvels at natural aesthetics. The goal of an artist is
to copy nature in every medium: painting, sculpture, music, photography. It is easy to see parallels in dentistry.
The teeth and soft tissue display details on the macroscopic and microscopic scale that make up all their
beauty. Even the smile has characteristics that define
what is beautiful and what is not. Like an artist, the dentist and the dental technician use all their combined talents to create lifelike restorations. The secret to imitating
nature is in the details of daily practice and hard work.
In this clinical case (Figs. 1 & 2), the patient wanted the
aesthetic aspects of her smile to be improved without
losing unique features she had come to consider as part
of her look and personality. The maxillary anterior teeth
showed caries and defective restorations, but their overall shape was satisfactory and they had a certain charm
despite their defects. Although her premolars did not
have an optimal aesthetic appearance, the patient’s budget limited treatment to the incisors and canines.
Fortunately for dental practices and laboratories, technology has advanced considerably, making the ability to
imitate nature much more achievable while paving the
way for new practical methodologies. Performing a single
restoration on a central maxillary incisor is a challenge,
both technically and artistically. Whether it is a filling, a
crown or an implant, all the skills of the artistic dentist
must come into play because the patient naturally expects a result symmetrical to the contralateral tooth. Using the latest technology, it is as simple as the copy and
paste function one is so accustomed to using on a computer. The dentist has gone from being an artist to a computer scientist with the same optics: copying nature in all
its perfection.
On the basis of a clinical case without the utilisation of an
intra-oral scan, I will demonstrate a workflow with CAD/
CAM technology. This will show that the ability to copy
nature has now become accessible to all practitioners.
Fig. 1
Fig. 2
The first step was to take an impression of the preoperative oral condition. Although the dimensions and appearance did not conform to all the rules of dental aesthetics,
they would be preserved because they had characteristics specific to the patient and they respected the occlusal dynamics. The impression of the teeth can be taken
with an intra-oral scanner. However, the number of dentists who own intra-oral scanners is relatively low. The
current materials allow for a satisfactory physicochemical
impression and remain accessible to all dentists. A polyvinylsiloxane impression was performed in one step and
two viscosities (V-Posil Putty Fast and V-Posil X-Light
Fast, VOCO) to record the initial clinical situation (Fig. 3).
Temporisation
The second step was to prepare the provisional crowns
by copying and pasting the patient’s teeth. After preparing the teeth, the impression is sent to the laboratory,
which will scan and design the provisional crowns. Most
CAD/CAM software possesses this copy and paste function (Fig. 4), so the scan and design processes take less
Fig. 3
Fig. 1: Initial situation, smiling. Fig. 2: Initial situation, frontal view with lips retracted. Fig. 3: V-Posil impression.
26
1 2020
[27] =>
case report
Fig. 4
Fig. 5
|
Fig. 6
Fig. 4: Screenshot of the design software. Fig. 5: Structur CAD disc. Fig. 6: Screenshot of the nesting software.
than 1 hour. The six provisional crowns were then milled
over the course of 1 hour and 30 minutes from a resin
disc suitable for producing long-term provisional restorations (Structur CAD, VOCO; Figs. 5 & 6). Finishing the
provisional crowns—checking the contact points, controlling the occlusion and polishing—required 30 minutes, allowing delivery of the crowns two days after taking the impression. The result obtained was strikingly
natural (Fig. 7) thanks to the material’s aesthetic properties: natural shade, easy polishing and improvable with
characterisation. Concerning the form, the provisional
crowns had an asymmetry that is found only in nature,
being both spontaneous and pleasant. They were temporarily cemented in the mouth to validate the prosthetic
project (Figs. 8 & 9). The material’s biocompatibility clinically allows for a three-year maximum period in which the
crowns can be worn, making it a material perfectly suited
for complex cases, or those requiring periodontal rehabilitation. The material’s composition provides not only excellent resistance to abrasion, but also the possibility of
repair with a compatible composite. In this clinical case,
the provisional crowns were kept in the mouth for one
week—the time needed to prepare the definitive restorations. No defects were observed.
Finalisation
During the last stage, after the functional and aesthetic
validation of the provisional crowns, definitive porcelain
crowns (IPS e.max, Ivoclar Vivadent) were milled also
by copying the preoperative situation from the original scan. The provisional crowns were then removed,
and the underlying teeth were cleaned. After fitting and
validation within the mouth, the definitive crowns were
luted (Futurabond DC and Bifix QM, VOCO; Fig. 10).
The final result was a harmonious smile that did not
distort the features the patient considered to be an important part of her facial personality (Fig. 11).
Discussion
Therapeutic success is measured by dental and periodontal health, as well as by patient satisfaction and
feedback from the healthcare team. The skills of a
caregiver are not limited to making the right diagnosis or defining the ideal treatment plan; technical skills
are essential and mimicking nature is a daily challenge.
Dentistry has come a long way with the introduction
and implementation of digital technologies, becoming
faster and more precise as a result. These tools are
becoming increasingly popular, and many practitioners
are quickly equipping their offices and operatories.
Contrary to what one might think, the acquisition of an
intra-oral scanner for the office is not an absolute obligation for one to take advantage of the digital dentistry
revolution. Digital dentistry, above all, is a concept and
we have just seen that it allows for an unsuspected and
perhaps surprising function: copy and paste.
The advantages of copying and pasting are numerous
and benefit everyone involved: dentist, dental technician and patient. For the dentist, the main advantage
of copying and pasting is obtaining an intuitive result.
On the one hand, the current materials (composite and
porcelain), allow for a natural rendering. On the other
hand, digital technology makes it possible to copy nature with all of her details. The use of computer-generated provisional restorations makes it possible to
validate complex or demanding projects. In the end,
restorations are both functional and aesthetic. They integrate perfectly with the occlusion because no major
changes have been made. In addition, they integrate
with the overall harmony of the face.
For the dental technician, the copy and paste function is part of his or her skill set. On the one hand,
the laboratory scanner can capture every detail of the
dental arch. On the other hand, milling machines can
deliver strictly identical crowns over and over again
as needed. The milling of a provisional disc or block
will therefore validate the therapeutic project before
moving to more expensive materials such as zirconia or lithium disilicate. In the same way, if returned
to the laboratory, the cost will be lower by using a
millable temporary resin. After provisional crowns are
1 2020
27
[28] =>
| case report
Fig. 7
Fig. 8
Fig. 10
Fig. 9
Fig. 11
Fig. 7: Structur CAD provisional crown. Fig. 8: Try-in of provisional crowns. Fig. 9: Smile with provisional crowns. Fig. 10: Porcelain crowns luted with
Futurabond DC and Bifix QM (VOCO). Fig. 11: Final result.
validated, the dental technician only needs to press a button to start producing the definitive crowns in the desired
material.
For patients, digital dentistry is an education on just how
far dentistry has evolved: technological advancements in
clinical procedures are replacing many of those treatments
of their bad childhood memories. It is now possible for the
patient to reclaim the smile of his or her twenties. Better still,
it is possible to copy the child’s juvenile smile and place it in
the deteriorated dental arch of the father. The smile will become a legacy that will be passed down through families.
rials. The author congratulates French certified dental
technician Christophe Giraud for his talent and skills.
The author is grateful to Tom Kershaw and Russ Perlman of VOCO America for proofreading and improving this article.
Conclusion
Technology is making significant progress in dentistry, it
is up to us to appropriate it. The emergence of new tools,
such as intra-oral scanners, and unique new materials, like
millable temporary resins, makes it possible to develop
new therapeutic concepts and procedures. Copying and
pasting is now a part of the dentist’s, and dental technician’s, therapeutic armamentarium. A copycat is an artist
who tries to capture nature in all its glory through painting.
Now, a copyCAD is an artist who can capture nature in all
its perfection through CAD/CAM technology.
Acknowledgements
The author wishes to thank Matthias Mehring of
VOCO for his friendly support and support with mate-
28
1 2020
about
Dr Yassine Harichane graduated
from the Paris Descartes University
and conducted several research there.
He is an author of numerous publications and a member of the Cosmetic
Dentistry Study Group (CDSG) at the
Paris Descartes University in Paris,
France.
[29] =>
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[30] =>
| case report
Immediate post-extraction
implants in the anterior maxilla
The importance of a high-resolution CBCT system
in patient selection
Drs Gian Battista Greco & Danilo Alessio Di Stefano, Italy
Introduction
changes in the alveolar bone cannot be prevented by placing an implant immediately.
Placement of an immediate post-extraction implant in
the aesthetic zone is a sound and well-documented approach.1–3 Yet the success of this procedure calls for careful selection of the candidate patient; if not performed following a precise decision tree, the risk of aesthetic and
prosthetic failure is high.4 Consequent to tooth extraction,
the alveolar process undergoes a well-known sequence of
events leading to progressive bone atrophy.5–7 These 3D
Fig. 1a
Fig. 3a
Fig. 1b
Fig. 3b
Fig. 3c
Immediate implant placement creates a condition that, conversely, may enhance bone resorption and accelerate the
apical migration of soft tissue, mainly on the buccal side.8, 9
These consequences may be prevented only by means of a
careful preoperative diagnosis that involves assessment of
the alveolar bone characteristics at the implant site and positioning the implant accordingly.10, 11
Fig. 2
Fig. 3d
Figs. 1a & b: (a) The initial clinical situation and (b) the intra-oral radiograph taken when the patient presented. Tooth #12, which had been endodontically
treated, had lost its crown because of a traumatic fracture. Fig. 2: The patient provided a CBCT scan obtained at another centre. On this scan, the buccal bone
plate was measured with difficulty because of the background noise and therefore of the lack of sharpness of the scan images. It was found to be approximately
2.4 mm thick. Figs. 3a–d: Implant positioning. (a) The implant site underwent no flap elevation nor any bone or tissue regeneration. (b & c) The implant was
placed according to the manufacturer’s instructions and (d) at bone level.
30
1 2020
[31] =>
case report
Fig. 4a
Fig. 4b
|
Fig. 5a
Fig. 5b
Fig. 6a
Fig. 6b
Fig. 6c
Figs. 4a & b: (a) The implant after placement, occlusal view. (b) Twenty-four hours later, the patient’s own fibrin was visible around the implant.
Figs. 5a & b: Provisional restoration. After taking an impression, a provisional crown was prepared (a) on the cast model and (b) delivered to the
patient approximately 24 hours after the surgery. Figs. 6a–c: Five-month post-op control. (a) The provisional crown. (b & c) Soft-tissue conditioning
was excellent. No buccal resorption was observed.
Some authors suggest routine regeneration of the hard and/
or soft tissue using guided bone regeneration (GBR) and
guided tissue regeneration (GTR) techniques to prevent resorption.12, 13 Some even suggest abstaining from immediate
post-extraction implant placement in the aesthetic area (such
as Quirynen et al.: “When clinicians operate in the aesthetic
zone it may be reasonable to allow soft- and hard-tissue healing before implant surgery to be able to compensate for the
resorption at the buccal site.”14). Yet both the periodontal biotype15, 16 and the initial bone thickness17, 18, 10 may strongly influence buccal bone remodelling after tooth extraction, and
patients presenting with specific anatomical features, that is,
a thick gingival biotype and a high-density and a coronal buccal bone plate that is more than 2 mm thick, show little or no
tendency to alveolar bone resorption.
ment thickness are consequently of paramount importance
when planning immediate post-extraction implant placement
followed possibly by immediate implant loading. Beyond performing a careful clinical examination, the quality of the cone
beam computed tomography (CBCT) scans recorded is crucial in collecting reliable information about the thickness of
the periodontal ligament and of the buccal plate. Accordingly, the surgeon should use devices that provide high-quality, high-resolution scans, possibly measuring bone density
in absolute Hounsfield units.19 Given the small amount of
radiation to which the patient is subjected when undergoing a CBCT examination, this may be safely applied even
when planning the extraction and replacement of a single
tooth.20, 21, 22 The following case illustrates such an approach.
Case report
Additionally, the thickness of the periodontal ligament may
be a predictor of the probability of fracture of the vestibular
bone plate. Precise and reliable information about the gingival biotype, the cortical bone width and the periodontal liga-
A 74-year-old male patient presented at the Dentalnarco dental centre in Trezzano Sul Naviglio in Milan in Italy with a coronal fracture of tooth #12 (Figs. 1a & b). He had already under-
1 2020
31
[32] =>
| case report
Fig. 7a
Fig. 7b
Fig. 8a
Fig. 7c
Fig. 8b
Figs. 7a–c: The definitive crown was delivered to the patient, achieving a highly satisfactory aesthetic outcome. Figs. 8a & b: (a) The CBCT scan taken
after 25 months using a high-quality, high-resolution CBCT device and (b) the initial CBCT scan. The buccopalatal thickness of the alveolar bone process was
unchanged, showing complete preservation of the 3D bone features and confirming the correctness of the treatment plan. The high-resolution CBCT scan
showed no metal artifacts and provided excellent details of the various anatomical parts, allowing accurate measurement.
gone a CBCT examination (using a 6 × 6 cm field of view)
some days before at a different dental clinic (Fig. 2). Examination showed that the fractured tooth, previously devitalised, presented with a reduced ferrule because of the coronal fracture. The periodontal tissue was slightly inflamed
because of marginal gingivitis. No significant pockets were
detected with probing, and the gingival biotype appeared
to be thick and flat. The CBCT scan provided by the patient
showed a residual root of about 16 mm long, no bone defects and no endodontic lesions. The coronal buccal bone
was a 2.0–2.5 mm thick dense cortical plate (Fig. 2).
The patient was first presented with a plan that would involve the orthodontic extrusion of the damaged tooth in order to allow for restoration with a prosthetic crown. The patient refused, however, and the alternative plan presented
would involve extraction of the damaged tooth followed by
immediate implant placement and possible delivery of an
immediate screw-retained provisional prosthesis. Given the
patient’s apparently low risk of bone resorption, this plan did
not call for any GBR or GTR procedures involving connective tissue grafting. The patient provided informed consent.
The patient underwent thorough professional cleaning four
days before surgery. Antibiotic prophylaxis (amoxicillin and
clavulanic acid, Augmentin, GlaxoSmithKline; 2 g 1 hour
before surgery and then every 12 hours for eight to ten
days) was initiated, and the patient was subjected to mouth
rinsing with 0.2% chlorhexidine (Corsodyl, GlaxoSmithKline)
32
1 2020
and given instructions to continue this for two weeks after
surgery. Nimesulide (100 mg; Aulin, Roche) was also administered 1 hour before surgery. The surgical area was
anesthaetised using 40 mg/ml articaine hydrochloride with
1:100,000 epinephrine. No flap was elevated. The root was
extracted atraumatically (Fig. 3a).
After probing the socket walls to check their integrity, a cylindrical 3.75 × 17.00 mm implant (Aries, IDI evolution) was
placed (Figs. 3b–d, 4a & b). The maximum torque at insertion was 55 Ncm. After connecting a pick-up impression
coping to the implant, an impression was taken with elastomeric impression material. The dental technician used this
to prepare a cast and manufacture a screw-retained provisional crown (Fig. 5a). A screw-retained healing abutment
was then connected to the implant, and the patient was
dismissed.
Approximately 24 hours later, the provisional crown was
connected (Fig. 5b). After checking all the interproximal
contacts and unloading all the static and dynamic occlusal contacts, the retaining screw was tightened at 15 Ncm.
The patient underwent no anaesthesia for this. He was advised to abstain from biting hard food with his incisors for
eight weeks.
Five months later, the provisional prosthesis was removed
and placed on the hard- and soft-tissue cast used for its
manufacture. As no changes were observed involving either
the soft tissue (Figs. 6a–c) or the interproximal contacts, a
[33] =>
case report
definitive cement-retained prosthesis was manufactured
using a commercial titanium abutment and a metal–ceramic crown. The abutment was connected to the implant
by tightening the retaining screw to 25 Ncm, using a torque
wrench, and the definitive prosthesis was connected using
a temporary cement (Figs. 7a–c). Radiographs were taken
and they confirmed a good fit of the prosthetic components
and preservation of the peri-implant bone level.
Twenty-five months later, the patient presented asking to
have his mandibular arch rehabilitated. Consequently, a
new set of CBCT scans was obtained, and this enabled
assessment of the peri-implant bone levels at position #12
(Fig. 8a). The CBCT examination was performed using a
high-resolution CBCT device (X-Mind trium, ACTEON) with
a 12 × 8 cm field of view. This system employs an acquisition and reconstruction algorithm that ensures a uniform
and high-quality image on all visual axes, and the system
employs 3D software with advanced functionalities. The
high-quality CBCT scans made it possible to assess the
peri-implant alveolar bone at position #12 with a very high
degree of precision. They showed complete preservation of
the alveolar bone, in both the buccopalatal dimension and
the apicocoronal dimension when compared with the initial
CBCT scan (Fig. 8b). This result confirmed the suitability of
the preoperative treatment plan proposed to the patient.
Discussion
Patients like the one described here represent the ideal candidates for immediate implant placement without elevation
of a flap or performance of any tissue regeneration procedures. Such patients (i.e. those with both a thick, flat periodontal biotype and more than 2 mm of thick cortical bone
plate) are seldom encountered, as the association between
gingival thickness and type and bone thickness is low.23, 24
Identifying such relatively rare cases spares the patients
longer, more expensive surgical procedures that do not offer any additional benefits but do increase morbidity.
In the presented case, a careful preoperative diagnosis
made it possible to develop an adequate treatment plan.
This spared the patient additional surgeries, possible infective complications, worse postoperative progress and additional costs. A misdiagnosis that called for additional procedures, such as bone grafting, to preserve the alveolar bone
from resorption could have increased the risk of bone resorption as a result of disconnecting the periosteum25 and,
according to the outcome actually observed, would have
meant overtreating the patient.
This case thus underscores the importance of a correct
preoperative diagnosis. As this must be based on objective and precise data, using high-quality, high-resolution
CBCT devices such as the X-Mind trium system to acquire
high-definition scans can make a significant difference; the
higher the quality of the scans, the greater the diagnostic
power of the surgeon will be.
|
The difference between scans with high and low background noise, and thus different sharpness, may be easily appreciated by comparing the initial CBCT scan provided by the patient in the present case, which allowed
assessment of the thickness of the buccal bone plate
only with great difficulty, to that taken after 25 months.
In the latter, virtually no metal artifacts can be observed
and all the anatomical elements surrounding the implant,
that is, the alveolar cancellous and cortical bone layer,
the soft tissue and the empty spaces, could easily be
distinguished and their dimensional parameters carefully
measured. This confirms that high-quality, high-resolution CBCT devices are a necessary tool for gaining reliable information and identifying sound, proper therapeutic alternatives.
Conclusion
When planning immediate post-extraction implant placement in the aesthetic zone, a proper preoperative diagnosis is essential. Thick and flat gingival biotype patients
who have more than 2 mm of buccal bone may be safely
rehabilitated without elevating flaps or performing other
procedures aimed at preserving the alveolar bone. Under certain conditions, it may be possible to immediately
load the implant. Conversely, misdiagnosis may expose
the patient to additional discomfort, expense and overtreatment. Using only high-quality, high-resolution CBCT
devices can help to prevent such misdiagnosis.
Editorial note: A list of references is available from the
publisher.
about
Dr Gian Battista Greco graduated
from the University of Trieste in Italy
in 2000. In 2007–2008, he completed a biennial master’s degree in
prosthetics and implantology at the
University of Milan in Italy under the
direction of Dr Stefano Gracis. He is
in private practice in Trezzano Sul
Naviglio at the Dentalnarco dental
centre, of which he is co-owner, and concentrates his activity mainly in the field of prosthetics and implant prosthetics.
He is the author of scientific publications and has lectured at
national and international courses and conferences.
contact
Dr Gian Battista Greco
Via Leonardo da Vinci 40
20090 Trezzano sul Naviglio, Italy
Phone: +39 02 4427540
E-mail: gianbattistagreco@libero.it
1 2020
33
[34] =>
| case report
Digital workflow with a metal-free
surgical guide and zirconia implant
Dr Saurabh Gupta, India
In recent years, ceramic implants have become an
attractive and reliable alternative to titanium implants.
With the advancement of digital implant dentistry and increasing use of metal-free surgical guides, there should
be reliable guided surgery options available to place such
implants.1–3 There are different kinds of surgical guide
Fig. 1a
Fig. 1b
Fig. 2a
Fig. 2b
Fig. 2c
34
designs available in the current market. The ideal guide
should be produced defect-free; should offer precision,
a perfect fit and high primary stability; and should aid exact reproduction of the planning.4 Furthermore, the surgical guide should be robust and thus not be affected by
transport, storage and sterilisation. In addition, the guide
design should allow clear visual inspection and easy irrigation. Finally, the use of this guided system should not
lead to an increase in the cost of the operation.5–8 Companies manufacturing guided systems for dental implant
placement offer surgical guides of almost similar design:
they are tooth-, mucosa- or bone-supported, and mostly
made out of resin, and drilling and implant holes are
placed within the body of the guide itself. These drilling
holes usually receive metal sleeves of various diameters
to guide successive drills.9, 10 In this case report, we used
a metal-free fully guided system (2ingis) for the placement
Figs. 1a & b: Missing tooth #36. Figs. 2a–d: Digital planning with SMOP
software.
Fig. 2d
1 2020
[35] =>
Fig. 3
Fig. 5
Fig. 4
Fig. 6a
Fig. 7a
Fig. 6b
Fig. 7b
Fig. 3: Stabilisation of guide. Fig. 4: Implant placement. Fig. 5: Ideal position of implant. Figs. 6a & b: Immediately post-op (a); seven days post-op (b).
Figs. 7a & b: CBCT scan.
of a ZiBone zirconia dental implant (COHO Biomedical
Technology) for missing tooth #36 (Figs. 1a & b).
Planning phase
The manufacturing of the surgical guide was done using
CAD/CAM technology. The design of the guide was first
worked out on a computer with CAD software (SMOP,
Swissmeda) after the DICOM and STL files had been uploaded (Figs. 2a–d). Guide stability by dental supports
was sought preferentially. Finally, the surgical guide was
printed in try-in resin using a NextDent 3D printer (3D
Systems).
Surgical phase
During the surgical phase, flapless surgery was performed and the specific surgical kit (2ingis) was used
along with the instruction manual provided. It included a
contra-angle handpiece (W&H) with guide forks of different lengths (depending on the patient’s mouth opening,
the edentulous span and the depth of drilling). It also has
depth wedges, a ring with two arms (to be inserted into
the guide tubes in the same way as for the drilling guide
fork) to guide the implant holder during manual placement of the implant, a metal trephine to cut the gingival tissue, and zirconia drills which allow flattening of the
bone crest and performing of the initial drilling (pilot drill),
respectively. Zirconia drills were then used for the rest of
the drilling sequence, using depth wedges when necessary. The instruction manual was followed, which listed
the drills needed throughout the surgery phase. With the
surgical guide remaining in place, the implant was placed
with the contra-angle handpiece in the planned site with
good primary stability, and the desired torque of 35 Ncm
was achieved (Figs. 4–6b).
Prosthetic phase
The provisional restoration was prepared and fixed soon
after intra-oral scanning (TRIOS, 3Shape) of the abutment part of the zirconia implant (Fig. 8). The crown was
1 2020
35
[36] =>
| case report
Fig. 8
Fig. 9
Fig. 10
Fig. 11
Fig. 12
Fig. 13
Fig. 8: Provisional restoration. Fig. 9: Twelve weeks post-op. Fig. 10: Intra-oral scan. Fig. 11: Monolithic crown. Fig. 12: Final crown in situ. Fig. 13: Final
radiograph.
kept out of occlusion, and strict instructions were given
to the patient. The osseointegration process was successful, and the implant was planned for restoration using a permanent monolithic zirconia crown (3M) after
12 weeks (Fig. 9). The TRIOS intra-oral optical scan was
retaken with the provisional restoration seated (Fig. 10).
The final monolithic crown was then designed, milled
and prepared according to a completely digital workflow
(Fig. 11). The crown’s intaglio surface and the implant’s
abutment surface were cleaned and primed with a coating of Z-Prime Plus (BISCO) and was later cemented with
a self-adhesive resin cement (3M ESPE). Extra cement
was carefully removed using dental floss soon after the
final crown had been cemented. The occlusion of the
crown was checked with articulating paper. The patient
was well satisfied with the treatment procedure with
respect to both form and function (Figs. 12 & 13).
Conclusion
In conclusion, the metal-free surgical guide stands out
from other guided systems and appears to be a significant advancement in the field of guided implant surgery. In this case report, the wide-open design of this
guide allowed unrestricted irrigation and visual control
under conditions comparable to those of surgeries performed without surgical guides. There was no friction
of the zirconia drills on the surgical guide, which would
have damaged it or contaminated the drilling hole with
sleeve particles torn from the guide. This metal-free
36
1 2020
guided system seems to be ideal for placement of zirconia dental implants.
Editorial note: A list of references is available from the
publisher.
about
Dr Saurabh Gupta is an oral and
maxillofacial surgeon from India. He is
a private practitioner working as Clinical Director at the Digital Dental Design
Clinic & DVG’s lab (3M authorized) in
India. He is Education Director/Board
Member of the International Academy
of Ceramic Implantology (IAOCI) and
part of the Zirconia Implant Research
Group (ZIRG) in the US. In addition, he is a fellow and an
ambassador for the Clean Implant Foundation in Germany. At
present, he is involved in many research studies on zirconia
implant materials and digital dentistry.
contact
Dr Saurabh Gupta, BDS MDS
Oral and Maxillofacial
Surgeon, India Board
of Director, IAOCI, USA
Phone: +91 9916 203455
saurabh@iaoci.com
[37] =>
[38] =>
| case report
Treatment of an edentulous space
with a digital workflow
Two-piece ceramic implants in the aesthetic zone
Prof. Heinz Kniha, Thomas Lassen & Dr Kristian Kniha, Germany
More and more dentistry students, individuals working
in dental care, dental science and dental technology, as
well as university lecturers, are now encountering modern zirconia implants. The subject of zirconia implants not
only polarises patients, but is also hotly debated at international congresses and in respected scientific publications. Irrespective of this, the amount of evidence-based
in vivo data concerning zirconia implants continues to
grow. On the one hand, the ceramic surface allows a
very pleasing aesthetic result to be achieved, especially
in the soft-tissue region. Studies with a follow-up period
of three years have shown that hard tissue remains stable
Fig. 1
and that there is even a statistically significant enlargement of the interdental papillae.1–3 On the other hand,
an experimentally induced mucositis study has shown
that titanium implants prompt a greater inflammatory immune response to plaque accumulation with regard to
specific inflammatory markers (interleukin-1 beta values,
total bacterial count and sample volumes of Tannerella
forsythia and Prevotella intermedia).4, 5 These clinical insights into zirconia implants lead us to hope that the risk
of peri-implantitis too can be minimised with the lower
incidence of mucositis. Initially, single-piece zirconia
implants were restored with cement-retained prostheses.
Fig. 8
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 1: Radiographs showing root fillings and post-and-cores in teeth #12, 21 and 22. Fig. 2: Visible scarring after apicectomy and dark-coloured gingiva in
region #11. Fig. 3: Secondary caries in the hopeless abutment teeth. Figs. 4–6: Immediate implantation of two-piece zirconia implants in regions #12, 11, 21
and 22. Figs. 7 & 8: An intra-op digital impression of the two-piece implants was taken.
38
1 2020
[39] =>
case report
Now, two-piece implants allow screwed connections
between the prosthesis and implants. The following case
describes the clinical application of two-piece zirconia
implants in an extensive anterior reconstruction in combination with digital procedures.
Patient case
Baseline
This is a clinical case of a 34-year-old healthy woman.
The baseline showed a splinted bridge extending from
tooth #12 to tooth #22, where tooth #11 had been replaced with a bridge unit. Radiographs showed root fillings
and post-and-cores in teeth #12, 21 and 22 (Fig. 1).
Scarring after apicectomy and dark-coloured gingiva in
region #11 were noted (Fig. 2). Clinically, there was a
loosened bridge with secondary caries in the hopeless
abutment teeth (Fig. 3). The procedure was explored
with the patient and the various treatment options were
discussed. The patient wanted a permanently fixed restoration for which the healthy adjacent teeth in positions #14 and 13 should not be ground down. With this
in mind, to close the gap, four zirconia implants restored
with screw-retained crowns with palatal screw access
holes was agreed with the patient. The patient exhibited
excellent oral hygiene. All conditions for immediate im-
|
plantation with immediate treatment (without immediate
loading) were met.
Surgical procedure
A pickup impression was taken so that chairside temporary restorations could be produced after the implantation. First, teeth #12, 21 and 22 were extracted atraumatically. After tooth extraction, the situation was not
inflamed and there was sufficient bone available to allow immediate implantation of two-piece zirconia implants (PURE implants, with the ZLA surface, Straumann)
in regions #12, 11, 21 and 22 while maintaining primary
stability (Figs. 4–6). This was achieved with a minimally
invasive approach via a marginal incision without vestibular release. Scan bodies allowed an intraoperative digital impression of the two-piece implants to be taken
(TRIOS 3, 3Shape; Figs. 7 & 8). The digital data set was
then sent via the Internet to the laboratory to produce
temporary crowns.
Prosthetic restoration
Wound closure was performed with single interrupted
sutures. All scan bodies were shortened and transformed into provisional telescopic solutions. The temporary crowns were made with Luxatemp (DMG ChemischPharmazeutische Fabrik) based on the existing pickup
Fig. 9
Fig. 10
Fig. 11
Fig. 12
Fig. 13
Fig. 14
Fig. 15
Fig. 16
Fig. 17
Figs. 9–12: The temporary crowns, which were made based on the existing pickup impression, were provisionally cemented to the anchoring elements.
Figs. 13–17: Clinical situation at the second appointment seven days after the implant surgery. The dental restorations were produced by the Thomas Lassen
dental laboratory.
1 2020
39
[40] =>
Fig. 18
Fig. 19
Fig. 20
Fig. 21
Fig. 22
Fig. 23
Fig. 24
Fig. 25
Fig. 26
Figs. 18–22: Another digital impression of the intra-oral situation was taken. Fig. 23: The definitive implant prostheses. Figs. 24–26: The radiographic and
clinical situation six weeks post-op.
impression. These were then provisionally cemented to
the anchoring elements with Temp-Bond (Kerr Dental,
Figs. 9–12). During the cementing process, it was essential that no material was pressed into the periodontal gap.
Postoperative radiographic follow-up was performed in
line with the cementation protocol (Fig. 11). The temporary restorations were taken out of occlusion, and the
patient was instructed not to bite off food with her incisors
in the next three months, but rather to spread the masticatory force to the posterior region.
All the dental restorations were produced by the Thomas
Lassen dental laboratory (Figs. 13–17). The sutures were
removed as standard on the seventh day postoperatively.
In the same appointment, the chairside temporary restorations were replaced with aesthetically high-quality
temporary restorations made of composite in the form
of a crown block. Provisional bonding was achieved with
Temp-Bond on the screw-retained zirconia mesostructures. After a total healing phase of three months, there
was a significant harmonisation of the soft-tissue situation. Another digital impression of the intra-oral situation
was taken so that the final crowns could be produced
(Figs. 18–22). The CAD/CAM-supported workflow allows
simple and time-saving procedures using modern materials. The definitive implant prostheses consisted of
screw-retained customised CAD/CAM-milled zirconia
frameworks which were bonded with the angled Variobase
abutments in the laboratory and then veneered (Fig. 23).
The radiographic and clinical situation six weeks after
implantation showed stable bone progression and irritation-free, pale membranes (Figs. 24–26).
Conclusion
Two-piece zirconia implants allow reliable anterior reconstruction with predictable outcomes. The individual
40
1 2020
soft-tissue conditioning can start directly after implantation. The digital workflow in particular supports the optimum shaping of the peri-implant soft tissue with ceramic
materials and accelerates interdisciplinary processes. It
is evident that there is an increase in the size of the interdental papillae in the first three years. For this reason, the
interdental spaces should be physiologically designed
from the outset as part of the prosthetic treatment.
Editorial note: A list of references is available from the
publisher.
about
Prof. Heinz Kniha is a Munich-based
oral surgeon working in a joint practice
together with Dr Karl Andreas Schlegel.
He is highly specialised in implant dentistry and is an internationally prominent
figure in research on zirconia implants.
He studied dentistry and human medicine at the Friedrich-Alexander-University Erlangen-Nürnberg and University
Hamburg, and completed his education as a specialist in maxillofacial surgery under the supervision of Prof. Dieter Schlegel
at the Medical Center of the University of Munich. Today, being
the author of many scientific articles, he is frequently invited to
lecture at dental conferences on an international level.
contact
Prof. Dr Dr Heinz Kniha
Arnulfstraße 19 (Renaissancehaus)
80335 Munich, Germany
Phone: +49 89 590686990
www.prof-kniha-kieferchirurgie.de
[41] =>
[42] =>
| special report
Digitally fabricated bulb obturator
using virtual data and 3D printing
Dr Tariq Saadi, UAE
Introduction
Computer-assisted digital planning has become an important diagnostic and therapeutic tool in modern dentistry. Digital technologies related to imaging and manufacturing provide the clinician with a wide variety of
treatment options. Additive manufacturing (3D printing)
technology offers a simple and predictable means of fabricating dental prostheses.1
This case report presents the rehabilitation of a patient
who had undergone a hemi-maxillectomy. This clinical
case describes the digital workflow using an intra-oral
Clinical case
Clinical history
A 65-year-old patient with squamous cell carcinoma of
the maxillary left alveolar process presented to our clinic
two months post-surgery. According to her medical report, she had undergone left hemi-maxillectomy, left
neck dissection and a split-skin graft harvested from her
left thigh for the lining of the maxillary defect (Fig. 1).
Clinical examination
There was a significant limitation in her mouth opening, owing to radiation and surgical scar contracture, a
stiff oral aperture and difficulty in stretching of the lips.
Intra-oral examination revealed the surgical removal of
the entire upper left jaw, including the premaxilla, maxilla, and hard and soft palate. The dissection extended
to the nasal septum, and there was communication between the oral cavity and nasal cavity (Fig. 2a). For two
months after the surgery, the patient had worn a medicated gauze pack covering a flat acrylic plate retained by
metal clasps (Fig. 2b).3
Fig. 1
Chief complaint
The post-surgical maxillary defect had resulted in hyper-nasal speech, leakage of fluid into the nasal cavity
and impaired masticatory function.4 Trismus, xerostomia,
mucositis, tissue ulceration and gingival bleeding were
Fig. 2a
Fig. 1: Initial situation with missing maxillary left dentition. Fig. 2a: Mirrored
intra-oral view revealing a surgically removed left maxilla, extending up to
the nasal septum. Fig. 2b: Used medicated gauze and flat acrylic plate with
metal clasps.
Fig. 2b
42
digital impression, 3D facial scanning, and cone beam
computed tomography (CBCT) volumetric data to create
a digital (3D) virtual model of the dentition, defect area,
and soft and hard tissue for this patient. 3D printing technology was used to manufacture a resin obturator prosthesis (a hollow bulb with a removable partial denture).2
1 2020
[43] =>
special report
Fig. 3a
Fig. 3b
Fig. 4a
Fig. 4b
|
Fig. 3c
Fig. 3a: Intra-oral digital impression of the right maxilla. Fig. 3b: 3D facial scan. Fig. 3c: CBCT image. Fig. 4a: Acquired 3D data placed into one software
program: facial, CBCT and intra-oral scan data. Fig. 4b: Merged digital data using the Dental System software.
side effects of the patient’s postoperative chemoradiotherapy (adjunctive treatment).
Dental assessment
The absence of a dental prosthesis had resulted in both
functional disability and cosmetic disfigurement.2, 4 The
fabrication of a dental prosthesis like a bulb obturator and denture is essential for oral functions such as
speech, swallowing and mastication, and for esthetics.5
Limited mouth opening (microstomia)3 commonly leads
to difficulties in taking conventional impressions even
when using custom-fabricated trays. The reduced
mouth opening hinders conventional dental treatment,
and so alternative procedures have to be considered
in order to overcome these challenges when managing the case.
Digital technology creates opportunities for enhancing
the fabrication and delivery of a maxillofacial prosthesis.5 Digitised data of any object can be obtained from
various sources, such as CBCT, 3D facial and 3D intra-oral scans (digital impressions).
Data collection phase
Digitising this patient was initiated with an intra-oral
digital impression (TRIOS 3, 3Shape). Utilising the intra-oral scanner allowed for successful capture of the
right maxilla and remaining dentition, even with the
limited mouth opening (Fig. 3a).6, 7 A facial scanner
(Bellus3D) was then utilised to digitise the patient’s face
(Fig. 3b).8
A CBCT unit (GiANO HR, NewTom) was capable of producing high-quality 3D diagnostic images in submillimetre resolution with a short scanning time, low radiation
exposure, and minimal distortion, capturing the maxillofacial hard and soft tissue accurately (Fig. 3c).9, 10
Data integration phase
The representation of a 3D virtual patient requires the
successful superimposition of the data collected on
the 3D structures: (1) the DICOM format derived from
the CBCT scan; (2) the STL and PLY formats derived
from the intra-oral scan; and (3) the OBJ format derived from the facial scan. showing colour and texture information.11 The key to linking the different files
was to identify common reference points as constant
landmarks within the same software in all three data
acquisitions, to allow for predictable superimposition,
in order to create a 3D virtual patient (Fig. 4a).11 In this
case, all the data was integrated using the Dental System software (3Shape; Fig. 4b). The superimposition
of data from the CBCT, intra-oral and facial scans and
the creation of the virtual patient allow for better diagnosis, treatment planning and communication with
the patient, the laboratory and other professionals involved in the treatment.11
Treatment plan
The goal of treatment for this patient was to restore
a barrier between the oral cavity and the structures
above it.12 Owing to the complexity of this case and
the difficulty in inserting and removing the obturator, the decision was made to fabricate13 a detachable obturator to overcome this problem.14 The plan
1 2020
43
[44] =>
| special report
Fig. 5a
Fig. 5f
Fig. 5b
Fig. 5c
Fig. 5g
Fig. 5d
Fig. 5h
Fig. 5e
Fig. 5i
Fig. 5a: First step in fabrication of the removable partial denture. Fig. 5b: Digital maxillary left dentition acquired by mirroring the data gathered from the right
maxilla. Fig. 5c: Complete digital maxillary dentition. Fig. 5d: Digital maxillary left teeth virtually extracted. Fig. 5e: Digital maxillary dentition with artificial left
alveolar ridge. Fig. 5f: Digital maxillary dentition with denture borders. Fig. 5g: Digital maxillary dentition with designed maxillary left teeth. Fig. 5h: Digital
maxillary dentition with an artificial left alveolar ridge and left teeth. Fig. 5i: Final removable partial denture design for printing.
was to fabricate a hollow bulb and a removable partial
denture as a transitional solution for this patient, until the surgical site had healed completely and patient
was prepared, physically and emotionally, for any further surgical and restorative care that might be necessary.15
Digital denture fabrication
Digitalisation of intra-oral data enables design and fabricate of dentures without trays or conventional impressions.16 A digital workflow using design software and a
3D printer was simplified to produce a partial denture
quickly, easily and cost-effectively:
1. Denture fabrication began by importing the patient’s
digital data (CBCT, intra-oral and facial scan data)
into Dental System to create a 3D virtual patient
(Figs. 4a & b).
2. A digital artificial substructure for the left maxilla was
required to allow for setting up of the virtual teeth
(Fig. 5a). The upper right jaw intra-oral scan data was
inserted into Meshmixer software (Autodesk), and the
copy and mirror tools were used to create a digital upper left jaw in the mirror image of the acquired data of
the right side of the jaw (Fig. 5b).17
Fig. 6a
Fig. 6b
Fig. 7a
Fig. 7b
Prosthetic phase
Fig. 6a: Milled teeth (milled using the CORiTEC 140i, imes-icore). Fig. 6b: Printed denture. Fig. 7a: 3D image from CBCT data. Fig. 7b: Segmented hard and
soft tissue using 3D Slicer software.
44
1 2020
[45] =>
special report
Fig. 8
Fig. 11a
Fig. 12b
Fig. 9a
Fig. 9b
Fig. 11b
Fig. 13a
|
Fig. 10
Fig. 12a
Fig. 13b
Fig. 8: Digital maxillary dentition and the segmented CBCT data uploaded to Meshmixer software. Fig. 9a: Obturator fabricated using the Meshmixer software.
Fig. 9b: Hollow obturator. Fig. 10: Initial obturator design. Fig. 11a: Printed hollow bulb obturator. Fig. 11b: Top side of the obturator. Figs. 12a & b: Definitive
prosthesis. Fig. 13a: Mirrored digital maxillary left dentition using CBCT data. Fig. 13b: Complete digital maxillary dentition using CBCT data.
3. A complete maxillary digital arch was obtained by joining both sides together.
4. The new data was imported into Dental System
(Fig. 5c), and virtual teeth extractions were done to remove the teeth from the mirrored left side (Fig. 5d).
5. An artificial alveolar ridge was created to allow for setting of the new virtual teeth (Fig. 5e).
6. The design process continued by creating a denture
border, denture base and retentive clasps (Figs. 5f–i).
7. The final design was printed on a 3D printer (NextDent 5100, 3D Systems) using a denture resin material, and the acrylic teeth were milled (CORiTEC 140i,
imes-icore; Figs. 6a & b).
Digital hollow bulb fabrication
The conventional fabrication of an obturator is a complex
task that requires multiple scheduled appointments and
involves a maxillofacial surgeon, prosthodontist and dental laboratory technician.5, 18, 19, 20 Modern digital technology, including CBCT and 3D printing, opens up the possibility of manufacturing maxillofacial prostheses more
efficiently and cost-effectively:21, 22
1. A 3D image of the maxillary defect and the remaining
maxilla was compiled from the CBCT scan (Fig. 7a).23
2. The images were imported into 3D Slicer software for
3D processing of the DICOM images and building of an
anatomical virtual model.
3. 3D Slicer software was utilised for hard and soft tissue
segmentation and preparation of an STL file (Fig. 7b).
4. The data obtained from 3D Slicer was processed and
then uploaded to Meshmixer (Fig. 8). Meshmixer was
utilised to design the digital obturator to fit within the
defect borders and extensions (Figs. 9a & b).24 The
weight of the obturator was minimised by reducing the
thickness of the walls and hollowing its internal aspect
(Fig. 10).
5. The digital bulb obturator was 3D-printed (NextDent 5100 and NextDent Denture 3D+ resin material,
3D Systems; Figs. 11a & b).
Prosthesis delivery
The two-piece maxillary detachable obturator required
a retentive element to facilitate the easy insertion and
removal of the prosthesis (Figs. 12a & b).13 Magnets
were added to retain the prosthesis and assist in easy
orientation and placement of the denture.14 The obturator bulb housed one part of the magnet using autopolymerising acrylic resin. The other magnet was embedded into the inner surface of maxillary denture in
the proper position to the opposite magnetic pole in the
bulb during the try-in session.14 A soft denture relining material (Bisico Softbase, Bisico Bielefelder Dentalsilicone)
was used on both components to achieve a more intimate
fit to the soft tissue and to ensure the magnets would re-
1 2020
45
[46] =>
| special report
main completely isolated from the oral environment when
the bulb and denture of the obturator were in place.
The patient was educated on how to insert and remove the
prosthesis and instructed on oral hygiene and self-maintenance. Follow-up visits every two weeks for further assessment and a new reline were indicated owing to rapid
soft tissue changes that occur during the wound healing
process.15, 25
Future steps
Based on 3D digital data, patient-specific reconstructions
(custom-made implants) can be produced as a definitive
solution.26 In close collaboration with the maxillofacial surgeon and prosthodontist, the design can be modified,
customised and fabricated utilising 3D printing material to
achieve better aesthetics and function to enhance patient
satisfaction (Figs. 13a & b).27
Conclusion
Dentistry has entered a new era where 3D virtual treatment
planning, design and fabrication are common and affordable. The thought process on how to treat our patients has
changed. We can now predictably have a prosthesis fabricated using CAD/CAM technology without the need for
conventional impressions and fabrication techniques.
The digital revolution is changing dentistry, and the impact
of new 3D image acquisition devices such as CBCT devices, intra-oral scanners and facial scanners is already influencing the dental field.28 At the same time, CAD/CAM
software and innovative fabrication procedures, including
3D printing and milling, are transforming the way we treat
our patients, making those previously difficult manual tasks
easier, faster, cheaper and more predictable.11 Nowadays,
digital design, including 3D virtual planning, and fabrication of a provisional or definitive prosthesis can be accomplished with a concise workflow with predictable aesthetic
and functional outcomes.1, 29
Editorial note: A list of references is available from the
publisher.
Declaration of patient consent
The author certified that all appropriate patient consent
forms were obtained.
46
about
Dr Tariq Saadi is a medical director
and general dental practitioner in a
dental facility in the UAE. Dr Saadi
focuses on the digital workflow in
cosmetic and implant dentistry. His
vision is that digital technologies
will dramatically change the world
of dentistry; therefore, he decided
in 2015 to transform his work completely from analogue to digital. He invested in digital intra-oral scanners, 3D facial scanners, 3D printing, CAD/
CAM software, milling machines and CBCT. He believes that
digitally driven dentistry is what we need today to fulfil patients’ expectations of dental treatments.
Conflicts of interest
There are no conflicts of interest. There was no financial
support or sponsorship.
contact
Acknowledgements
The author would like to thank Dr Farag Edher, Royelle
Mejia, Paul Andrada, Lovelyn Baslan and Ruby Policarpio; their help was of tremendous value.
Dr Tariq Saadi
Phone: +971 50 293 9550
E-mail: dr.tariqsaadi@hotmail.com
Instagram: dr_tariqsaadi
1 2020
[47] =>
Welcome to
MasterClass.Dental
Online classes taught by the world’s best doctors
directly from their practice
OBSERVE
DISCUSS
YOUR CASE
ON DEMAND
ALL DEVICES
GUARANTEED
www.MasterClass.Dental
[48] =>
| manufacturer news
New grinding and milling unit
CEREC Primemill makes excellence easy
the selected material and machining option. The tools are outfitted with colour codes according to the material to be processed
and are therefore easy to distinguish. Each tool also contains a
small RFID tag that can be read by an integrated scanner in the
CEREC Primemill. The machine informs the user about the tool’s
status and when it should be replaced. The new user guidance
makes it even easier to delegate the operation of the machine.
Fig. 1: CEREC Primemill: fast fabrication speed, excellent quality and easy
to handle.
CEREC has taken another big step forward with the introduction
of CEREC Primemill, a brand-new grinding and milling unit from
Dentsply Sirona. Fabricating chairside restorations is about to get
easier and significantly faster. Thanks to state-of-the-art technology, a wide range of restorations can now be manufactured
with greater speed and outstanding results. Together with CEREC
Primescan and CEREC Software, CEREC Primemill forms a modern set-up for achieving predictable results with a completely new
chairside experience—for both the user and patient.
CEREC Primemill, Dentsply Sirona’s new grinding and milling
machine, ensures the production of impressive restorations with
precise margins and a very smooth surface, thanks to the highspeed set-up with two spindles and four motors. CEREC Primemill
features a powerful 7 in. touch interface, an integrated camera
for scanning material blocks with compatible data matrix codes
and a radio-frequency identification (RFID) scanner for reading
tool information. It also works with a wide range of materials. The
new design offers significantly smoother operation.
“CEREC Primemill is a real game changer in the whole workflow,”
said Dr Gertrud Fabel, a dental practitioner in Munich in Germany
and key opinion leader for Dentsply Sirona. “Everything works
significantly faster than before, the quality of the restorations is
convincing owing to the very fine margins and smooth surfaces,
and handling is more than simple: the team can provide perfect
support and thus accelerate the entire workflow to make it even
more pleasant for the patient.”
For additional convenience, material blocks with compatible data
matrix codes can be scanned with the integrated camera. With
this, the block information, including type, size, colour and zirconia enlargement factor, are recorded. The unit’s LED light strip
also informs the user about the unit’s status, including a moving
blue progress bar, which changes to green when the manufacturing process is finished. In addition, the interface guides the user
through routine maintenance procedures and thus facilitates the
easy upkeep of CEREC Primemill.
More aesthetic, faster and simply excellent
With CEREC Primemill, restorations, especially those made of zirconia, can be milled even faster thanks to new tools and improved
technology. The time required to fabricate a zirconia crown has
been reduced by more than half: it can be cut from around 10–
12 minutes to as little as 5 minutes using the new super-fast mode.
The results speak for themselves. Using newly developed,
very fine tools (0.5 mm) in the extra-fine milling mode, the unit
achieves a high level of detail for occlusal fissures as well as interdental areas on bridges, enabling users to achieve predictable,
first-class results.
Superior chairside experience
The entire CEREC system takes on a new dimension with CEREC
Primemill. For those customers who now want to step into the
chairside CAD/CAM world and want to use CAD/CAM technology
in their practice, the all-new CEREC gives them a full system with
great flexibility for reliable results. Users who are already suc-
Guided operation for
maximum convenience
When developing the new CEREC Primemill, special attention was
paid to its user-friendliness: the large touch interface guides the
user through all workflow processes. Each workflow step is displayed in order and shows, for example, which tools are used for
48
1 2020
Fig. 2: Familiar usage of the touch interface. Easy and guided processes
speed up the workflow.
[49] =>
manufacturer news
|
cessfully using CEREC in their practices will appreciate the new
level of speed and high level of quality and convenience provided
by CEREC Primemill.
“It was important for us to create real added value with CEREC
Primemill, both for the CEREC newcomer and for those who have
been passionate CEREC users for years,” explained Dr Alexander Völcker, group vice president of CAD/CAM and orthodontics
at Dentsply Sirona. “We have noticeably increased the process
speed while delivering outstanding restoration results. The variety
of applicable materials leaves nothing to be desired and operation
the unit has never been easier. The complete system does not
require any data imports or exports. All processes are coordinated
with one another and fully validated for an excellent and seamless
chairside experience.”
Owing to various certification and registration periods, not all products
are immediately available in all countries.
Dentsply Sirona
www.dentsplysirona.com
Fig. 3: The renewed CEREC system. CEREC Primemill has proved to be a
real game changer.
implant solutions for edentulism
MIS introduces the LOCKiT,
an affordable, long-term, quality solution
MIS Implants Technologies has released its new LOCKiT advanced anchoring system for implant-supported overdentures.
With life expectancy on the rise and an ever-growing ageing
population effected by edentulism, there is a significant need
for simple and affordable long-term solutions. The system was
developed to answer these needs, while maintaining an uncompromising level of quality and patient comfort.
The LOCKiT system was designed with customisable levels of
retention, features a concave emergence profile and anodised
colour-coding for easy identification during the workflow, and is
available for MIS internal hexagon and conical connections in all
platforms, narrow, standard and wide. The abutment is coated
with anti-wear material and is strengthened above the threads,
which enables maximum durability. The plastic caps exhibit excellent resistance to abrasion over time and have a predictable and
consistent retention level.
Tali Jacoby, implants product manager, explains: “We are attentive to the needs of our customers and looked for a solution
that would include everything in a single package—a compact
and convenient kit.” In order to get it right, “we considered the
doctors who currently use a parallel product and made sure
to incorporate full compatibility for the components. This way,
they can use our solution with their own existing tools and accessories.” In order to provide an advantage when it comes to
aesthetics, the LOCKiT was designed to reduce the height of
the attachment for endosseous implants. The
1.5 mm height of the attachment makes this
one of the shortest on the market, providing
a convenient and aesthetic solution for the patient.
With an extended range of components, the system enables
restoration of a non-parallel implant of up to 20° of angulation. This adds up to an extensive 40° of divergence between
two implants and delivers maximum versatility for the clinician.
MIS Implants Technologies
www.mis-implants.com
1 2020
49
[50] =>
| manufacturer news
Content sharing platform from Straumann
New StraumannPLAY series outlines digital workflows
Straumann has launched the second season of StraumannPLAY. The season focuses on digital workflows, and in it,
Dr Hugo Madeira, founder of the advanced implantology clinic
Clínica de Implantologia Avançada in Lisbon in Portugal, takes
the audience on a five-part journey in digital dentistry.
Digital workflows offer dental professionals accuracy and reliability and save a considerable amount of time. For patients,
this means higher levels of comfort. In the new StraumannPLAY season, Dr Madeira delves into how dental professionals can manage these workflows and discusses the essential tools for successful treatments. Each 10-minute episode
provides a glimpse into a specific topic, such as intra-oral
scanning or the perfect smile. The first episode of Season 2
examines the rapid adoption of the intra-oral scanner in prac-
50
1 2020
tices in order to replace conventional impressions or models.
The next episodes are “Implant planning and guided surgery”,
“Designing and printing the surgical guide”, “How to plan a
smile” and “Prosthetic design and milling”.
StraumannPLAY, which is created by peers for peers, was
launched as a means of sharing content on dentistry and
beyond. The platform meets a growing need and interest in
easily accessible content and formats. It is ideal for mobile
devices when on the go. Season 1, titled “Digital for your dental practice”, was a major success, registering close to 3,000
views—and counting.
Episodes of StraumannPLAY can be viewed at www.straumann.com/play.
[51] =>
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[52] =>
| feature
Dental startups are harnessing
artificial intelligence
By Jeremy Booth, DTI
A new wave of startup companies are developing artificial intelligence solutions for dentistry. (Image: Zapp2Photo/Shutterstock)
Artificial intelligence (AI) has broken free from the pages
of science fiction to become fact. Machines and software
that can think and learn are now a reality and a wave of dental startups are developing new AI-assisted technologies for
dentists. So what are some of the youngest companies in
the industry hoping to achieve? And how can they bring their
AI solutions from the drawing board to the dental practice?
Most readers will have first been introduced to AI as the
fodder of fiction in comic books, novels or films screened
on late-night television. AI typically impressed but usually
came with the ominous caveat of potentially outsmarting
its creators. The murderous Hal 9000 computer in Stanley
Kubrick’s 1968 film 2001: A Space Odyssey is just one
example in a litany of bad introductions to AI. Nowadays,
science has caught up with science fiction. Around 16,000
peer-reviewed scientific papers are published in the
AI field each year, and smart software has proven its worth
in applications spanning a range of fields from the automotive industry to health care. According to dental startups,
AI has the potential to make a big impact in dentistry in areas
such as diagnostics, smile design and treatment monitoring.
These companies are focusing on research and development and obtaining the funding that will help them to make
AI a part of daily business in dental practices.
52
1 2020
Getting smart with medical imaging
Medical imaging is a valuable source of information in
diagnostics and quick advances in the segment mean
its availability may grow to outstrip the capacities of medical specialists. Tasking machine learning algorithms with
lightening the workloads of doctors and dentists need not
be seen as a compromise.
A systematic review and meta-analysis, published by
the Lancet Digital Health on Sept. 25, 2019 compared
the performance of deep learning—a type of AI—with that
of health care professionals in the detection of diseases
using medical imaging. Based on a review of 14 studies
conducted between 2012 and 2019, the review found
that the diagnostic performance of deep learning models was equivalent to that of health care professionals.
The researchers noted that AI models have become more
accurate in diagnosing diseases in the last few years,
hinting at the possibility of a continued improvement that
may see AI models outperform medical professionals in
diagnostics in the near future.
AI in dentistry is now a reality, and both the literature and
the practice show a broad application. From digital smile
[53] =>
feature
|
graphs. The tool—a decision support platform—seeks to
improve the reliability of using this staple of diagnostics
while also speeding up what can be a time-consuming
process for dentists.
Schwendicke told DTI that the treatment application
for using AI to screen digital radiographs varies widely,
improves accuracy and saves time.
“We help dentists detect dental pathologies, such as
caries, apical lesions, periodontal bone loss; and plan for
restorations like crowns, implants and fillings quicker
and more accurately—up to 40 per cent higher accuracy—thereby allowing them to make better treatment
decisions for their patients. As well, multiple tests with
dentists have shown that our product supports dentists
in reducing the time spent on documentation of dental
radiographs by 50 per cent.” Schwendicke added that
the platform has also had a positive effect on patient relations. “All dentists have confirmed that the use of our
product enables them to have a more transparent and
trustworthy communication with their patients,” he said.
DentalXr.ai is a new startup company based in Berlin that
will be begin business in the fourth quarter of this year.
Numerous dentists in Germany have tested the company’s product and dentalXr.ai is currently running a beta
test with a broader dentist population. After receiving
the CE marking product certification, dentalXr.ai plans
to launch its product in Europe in the first half of 2020.
design through to cutting drug prices, visualizing a patient’s pain in real time during treatment and detecting
oral cancer, the question is no longer whether but how
dentists and dental technicians can harness this technology. The range of reasons that they should be interested
in AI include improving patient care, streamlining workflows and increasing revenues. The Canadian startup
Denti.AI, for example, is using cloud-based AI to interpret
dental images for diagnostics using machine learning
algorithms. Denti.AI’s promise to customers, according
to company information, is to increase revenue per patient while addressing problems related to quality assurance and liability.
Dental startups are leading the way
The recent Charité BIH Entrepreneurship Summit 2019 in
Berlin, Germany, focused on global trends in health care,
including AI. Jurors selected a pitch by Dr. Falk Schwendicke, Deputy Director of the Department of Restorative
and Preventive Dentistry at Charité—Universitätsmedizin
Berlin and Chief Medical Officer of the dental startup
dentalXr.ai, as the winner in the digital category. Schwendicke and his colleagues have focused on digital radiography to develop a tool that helps dentists to diagnose,
document and make decisions based on digital radio-
According to Schwendicke, in order to gain acceptance
among dentists, newly introduced AI technologies, such
as the decision support platform, need to deliver what
they promise. If they can do this, then the potential in the
practice is considerable.
“At the beginning, it will be important for us to deliver
our value proposition—better diagnostic decisions in less
time—to dentists with our initial product. In the future,
we see the potential to move from AI-assisted diagnostics for numerous dental pathologies to AI-based prognostics supporting dentists in making the best and most
informed treatment decisions at any given time. Given
our access to substantial longitudinal datasets—radiographic data, patient data, claims data—and our outstanding network of renowned dentists from the Charité
and many other clinical partners worldwide, we are in the
best position to create the maximum value for dentists.”
Funding will bring AI
into more dental practices
VideaHealth says AI is the future of dental care and can
help dentists detect dental diseases earlier and more
reliably. The Cambridge, Massachusetts-based dental startup spun out of the Massachusetts Institute of
1 2020
53
[54] =>
| feature
Technology (MIT) in 2018 after two years of research
into how AI can improve dental care. It says its product
VideaDetect can identify up to 25 per cent more dental
diseases than the average dental practitioner and that
it collaborates with dentists around the world to continuously improve its algorithms.
VideaHealth has partnered with dental organizations
to bring its AI-assisted diagnostics to dental practices
across the U.S., and a recent cash injection will help
the startup company to make an even bigger impact.
A September U.S. Securities and Exchange Commission filing showed that the 1-year-old company raised
$5.4 million in equity through reported investment
by Zetta Venture Partners, Pillar and the MIT-affiliated
Denta V.
After the funding round, VideaHealth CEO Florian Hillen
told TechCrunch that dental practitioners are proving
more receptive to automation technologies than other
health care professionals are. He explained that dentists
perform multiple roles within their practices and therefore
see technologies like image recognition software not as
a threat but as a something that can increase efficiency.
“AI in radiology competes with the radiologist,” Hillen told
TechCrunch. “In dentistry we support the dentist to detect diseases more reliably, more accurately, and earlier.”
VideaHealth will reportedly use the funds to increase its
team and conduct further research and development.
published online by the Angle Orthodontist journal in
March. The study compared tooth movement calculated
by the software using intraoral video scans taken by patients with actual tooth movement data gathered during
practice visits using plaster models. The researchers
found only a negligible average difference between the
movements calculated by the app—those for intercanine and intermolar varied on average by 0.17 mm and
–0.02 mm, respectively. The researchers concluded not
only that the in-office and software measurements were
equivalent within 0.5 mm but also that the at-home intraoral scans done by patients were just as good as those
done in the practice by clinicians.
The Straumann Group announced in April 2018 that
it had invested in the French company. At the time,
Marco Gadola, CEO of the Straumann Group, said the
company’s technology and its mobile applications would
change dentistry. “Our investment in DM provides us
with a proven orthodontics tracking system and access
to artificial intelligence technology. It also secures an
innovative partner with the expertise to develop further
leading-edge solutions in our field.”
The agreement gave Straumann distribution rights to
the company’s technology and an unspecified stake in
Dental Monitoring.
The future of AI in dentistry
remains unwritten
From startup to major player
The Paris-based orthodontics technology specialist
Dental Monitoring is no longer a startup because it has
a range of products that have successfully found their
markets. Founded in 2015 and now employing over
200 staff members in Europe, the U.S. and Asia, the
company is an example of how AI-oriented startups can
quickly have an impact of scale on dental care.
Dental Monitoring has three AI-powered solutions for
dentistry. SmileMate is a mobile app-driven system that
analyses the oral cavity to identify a rage of oral, dental
and orthodontic conditions. The company’s DM Vision
solution uses AI to generate simulations of future smiles
as the outcome of potential treatment. The third solution
is Monitoring, which helps patients to photograph their
own teeth at set intervals using a smartphone. The app
crops the photographs and organizes them by date and
angulation and helps to streamline the treatment experience for patients and minimize practice visits.
The company’s claims of helping dentists to provide
treatment that is more efficient are backed up by science. Researchers from Virginia Commonwealth University in Richmond, U.S., investigated the company’s
smartphone-based orthodontic treatment app in a study
54
1 2020
AI has experienced several “winter” periods. The most
notable of these was between 1974 and 1980 and
between 1987 and 1993, when the thread of progress was lost and funding and research initiatives for
AI technologies went cold. The level of research and
development currently being invested indicates a strong
resurgence period for AI, particularly in health care.
Obtaining funding is crucial for AI startups in dentistry,
but the industry’s thirst for new technologies means
that cash is available. Established dental companies,
meanwhile, will be keeping a close eye on the potential
of new AI solutions.
Is AI a panacea for streamlining dental care? This remains to be seen, because the technology’s ultimate impact rests also on future developments. As the American
professor of cognitive science Dr. Douglas Hofstadter
wrote in 1979, the “AI effect” tells us that the definition
of AI is constantly evolving. He continued: “[Once] some
mental function is programmed, people soon cease
to consider it as an essential ingredient of ‘real thinking.’” Hofstadter quoted the prominent computer scientist Larry Tesler, who said: “Intelligence is whatever
machines haven’t done yet.” If Tesler was right, in the
future, AI may be used in dentistry in ways we have not
yet considered.
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[56] =>
| practice management
“As dental coaches, we are
servants in a noble profession”
An interview with Kirk Behrendt, founder and CEO of ACT Dental. By Iveta Ramonaite, DTI
As dental coaches, we are servants in a noble profession.
I’m so grateful for the opportunities that have led me here.
Our tagline “better practice, better life” rings true every
day. We’re so excited to be doing purposeful work, truly
helping to change people’s lives.
In your experience, what are some of the biggest
management mistakes that dental practices make?
The biggest mistake that a dental practice can make
isn’t a tactical decision; instead, it involves thinking. It’s
not really the problems themselves that matter, but rather
how the team looks at those problems. Dentists limit
themselves with thoughts like “I have to practice in an
insurance-only environment” or “I purchased this business,
so I need to run it as it was always run.” These aren’t
actual problems once you sit down and decide how
you want your business to operate.
Kirk Behrendt is founder and CEO of ACT Dental, a practice performance
coaching company that helps dental practices increase their profitability.
(Image © Kirk Behrendt)
Dental consulting and coaching services provide
advice on dental management and marketing and
help dentists grow their practices. Just recently, Dental
Tribune International spoke with Kirk Behrendt, founder
and CEO of ACT Dental, about his experience as a
dental coach. In this interview, Behrendt talks about
some common mistakes in dental practice management
and discusses the role that social media and continuing
education play in dentistry.
Mr Behrendt, could you tell us something about
yourself and about what prompted you to found
ACT Dental?
I fell into the dental profession by accident. I worked for a
few dental labs after graduation and this experience lit my
fire for the dental profession. I love people and I’ve always
wanted to be a teacher, so I wanted to create value for the
people in this awesome profession. I spent a few years
at a consulting firm, where I had a ton of fun and became
one of the top sales representatives. It was actually when
I saw the movie Jerry Maguire that I realised that I could
do this on my own. I grew ACT Dental one client at a time,
and here we are, 23 years later.
56
1 2020
The most catastrophic scenario for a dentist is waking
up to realise that the practice isn’t being run in the way
he or she wants to run it. People go into dentistry for a
reason, and part of that reason is often the flexibility it
affords you outside of work. It’s up to you to create the
practice you have envisioned and to build the perfect
team.
Social media is an integral part of the digital age.
How can dental professionals effectively use social
media to build their dental practice?
Like it or not, your online presence is something patients take into consideration when choosing a dentist.
They are seeking out your digital footprint. Regardless of
whether you participate, they are making assumptions
about you and your practice based on what they find
on the internet. Authenticity is critical to building a strong
social media presence. If there’s a misalignment between what’s on your social media and what’s on your
“The biggest mistake that
a dental practice can make
isn’t a tactical decision;
instead, it involves thinking.”
[57] =>
practice management
site or in your office, people will pause. Telling your own
story and using your own images will help to build trust
between you and your patients before they even set
foot inside your office.
What role does continuing dental education play in
ensuring high standards of care in dentistry, and
what opportunities are open to dental professionals who want to engage in continuing professional
development?
Continuing education is crucial to the future of dentistry.
Once you assume you know it all, you’re dead. It’s important to keep learning, to keep thinking and to keep
challenging yourself. Dentists must continually refine their
thinking both in order to learn about changes in the field
and to keep growing personally and professionally.
|
“Authenticity is critical to
building a strong social media
presence.”
Fortunately, there are now more opportunities than
ever for continuing education in a variety of formats.
We’re no longer constrained by time and geography.
Webinars, virtual conferences and online courses are
all easily available. But continuing education can also be
as simple as creating a Facebook group with your colleagues to share the latest news and to ask each other
for help. Dentistry is a profession of passionate lifelong
learners, and the opportunities are endless.
1 2020
57
[58] =>
| meetings
Owing to the current COVID-19 crisis and resulting travel restrictions, Nobel Biocare has decided to reschedule its 2020 Global Symposium. It will take place
at a later date and in a new location. (Image: No-Mad/Shutterstock)
Nobel Biocare Global Symposium
2020 postponed to early 2021
After careful consideration and monitoring of the ongoing spread of the virus SARS-CoV-2, Nobel Biocare
has decided to postpone its 2020 Global Symposium,
which was originally scheduled for 16–18 April in Las
Vegas in the US. The symposium is now scheduled for
early 2021. The company will communicate the new
date and location as soon as details are available.
The unprecedented circumstances presented by
COVID-19, the increasing health and safety concerns,
as well as the current travel restrictions, have made it
impossible to hold a global event like the Nobel Biocare
Global Symposium at this time. The company believes
that this decision is in the best interests of the health,
safety and well-being of its customers, employees and
business partners.
For those who have already registered, registrations will
be automatically transferred and will become valid for the
58
1 2020
2021 event. In case participants wish to cancel their
attendance, Nobel Biocare has relaxed its original cancellation policy and will refund registration fees in full.
The company urges participants who have already
made travel arrangements to expedite hotel and flight
cancellations.
Nobel Biocare remains committed to helping dentists advance at every level. Because education is an essential
tool in achieving this goal, the company will host a series
of virtual educational sessions from 16 to 18 April and
make them available to all those who had registered for
the symposium. Details about access to these virtual educational sessions will be communicated soon.
Interested parties can find more information at www.
nobelbiocare.com/international/en/nobel-biocare-global-symposium, contact their local customer service teams
or write to symposium.lasvegas@nobelbiocare.com.
[59] =>
[60] =>
© 32 pixels/Shutterstock.com
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1 2020
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[61] =>
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62
1 2020
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/ Digital dentistry in daily practice
/ The integration of CAD/CAM into dental school curricula
/ Digital workflow versus conventional approach in aesthetic dentistry
/ A new smile in one day
/ The copyCAD
/ Immediate post-extraction implants in the anterior maxilla
/ Digital workflow with a metal-free surgical guide and zirconia implant
/ Treatment of an edentulous space with a digital workflow
/ Digitally fabricated bulb obturator
using virtual data and 3D printing
/ Manufacturer news
/ Dental startups are harnessing artificial intelligence
/ Practice management
/ Meetings
/ Submission guidelines
/ Imprint
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