Lab Tribune Middle East & Africa No. 5, 2016
Minimally invasive prosthetic treatment with various ceramic materials / 3Shape CAD/CAM in a major Dental Lab
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www.dental-tribune.me
Published in Dubai
September-October 2016 | No. 5, Vol. 6
Minimally invasive prosthetic
treatment with various
ceramic materials
By Dr Marko Jakovac, Croatia, and
Michele Temperani, Italy
In cases where a full mouth reconstruction is required, it is essential to
follow a systematic procedure and
use carefully coordinated materials.
The following case study describes
the treatment of a patient with tooth
agenesis.
New materials and innovative techniques for modern esthetic and minimally invasive dentistry are coming
to the market every day. As a result,
patient-focused treatment protocols
are continuously improving. If complex treatment is indicated, however, personal aspects in addition to
the functional and esthetic requirements of the patient need to be addressed – for example, psychological
stress or financial constraints.
In this article, we will explore the
possibilities of providing minimally
invasive treatment, taking these factors into consideration.
Case study
Fig. 1: Patient with hypodontia: portrait
picture of the initial situation. A total of
fourteen teeth were missing in the upper
and lower jaw.
The twenty-three-year-old patient
showed severe hypodontia (tooth
agenesis) with a total of 14 missing
teeth (Fig. 1). Seven teeth were missing in both the upper and the lower
LIFELIKE ESTHETICS –
EFFICIENTLY PRESSED
jaw. Severe hypodontia of this kind
usually results in a very low vertical dimension of occlusion. In some
cases, it disturbs the chewing function. At the beginning of this type
of treatment, psychosocial aspects
have to be taken into consideration.
In the present case, the patient did
not smile during the first appointment, and he covered his mouth
with his hand when he spoke. Due
to the financial constraints of the
young candidate and his fear of an
operative intervention (treatment
with implants), it was decided to pursue a conventional prosthetic treatment approach. According to the
treatment plan, the upper anterior
teeth would be restored by means of
an all-ceramic bridge and the lower
anterior teeth with lithium disilicate
veneers. The decision was taken to
treat the posterior teeth with metalceramic restorations.
IPS e.max PRESS MULTI
®
THE WORLD’S FIRST POLYCHROMATIC PRESS INGOT
• Monolithic LS2 restorations showing a lifelike shade progression
ÿPage 2
amic
all cer need
u
all yo
• Exceptional combination of strength, esthetics and efficiency
• For crowns, veneers and hybrid abutment crowns
• Coordinated with high-precision Programat press furnaces
• Maximum cost effectiveness in the press technique
www.ivoclarvivadent.com
Ivoclar Vivadent AG
Bendererstrasse 2 | 9494 Schaan | Liechtenstein
Tel.: +423 235 35 35 | Fax: +423 235 33 60
Fig. 2: Anterior Lucia jig for the evaluation of the centric relation
Fig. 3: Capturing a protrusive bite record with Virtual CADbite
[2] =>
2
lab tribune
Dental Tribune Middle East & Africa Edition | 5/2016
◊Page 1
Clinical examination
treatment planning
and
The first part of the oral rehabilitation process involved a clinical examination in which the facial and
dental conditions were analyzed.
This investigation showed a substantially reduced vertical dimension of
occlusion. The patient was missing
14 permanent teeth. Furthermore,
several deciduous teeth were still in
place. Tooth 36 had been destroyed
by caries, making its extraction inevitable.
In order to provide the dental technician with the information required
for waxing up a restoration, details
related to the vertical dimension
of occlusion and facebow records
must be supplied in addition to the
impression. If the vertical dimension
of occlusion needs to be increased,
the correct centric position has to be
evaluated first. In this case, an anterior Lucia jig made of a thermoplastic material was used as a registration aid (Fig. 2). A facebow was used
to establish the relationship of the
maxillary jaw to the horizontal reference plane or bipupillary line. In the
fabrication of extensive restorations,
the protrusive and the laterotrusive
positions have to be recorded in order to make any necessary adjust-
ments in the articulator. An addition
silicone, for example, Virtual® CADbite can be used for this purpose.
In most cases, this type of material
produces faster and more accurate
results than wax. When wax is used
for bite-taking, the patient has to be
shown how to move into the protrusive or laterotrusive position. Experience has shown that it is easier to let
the patients produce these movements of their own accord and stop
them when they arrive at the “right”
position (Fig. 3). Virtual CADbite is
injected while the teeth are in this
closed position.
Wax-up and mock-up
The following minimum documentation was required for the fabrication of the wax-up: precision impressions of the upper and lower
jaw, a facebow transfer record, a
centric bite record in wax with the
predetermined vertical dimension
of occlusion, portrait pictures of the
patient as well as close-up pictures
of the situation when the patient is
smiling. This information was used
to build up the restoration in wax
and bring the teeth into their ideal
functional and esthetic position.
Furthermore, the occlusal plane and
the Spee’s curve were adjusted (Fig.
4). For the purpose of checking the
laboratory work intraorally, a mockup of the wax-up was made (Telio®
CS C&B) (Fig. 5). All the functional
and esthetic parame ters were then
checked in the patient’s mouth.
This stage of the treatment is very
important for many reasons. Patients are given the opportunity
to actively participate in designing
their new smile, which is a very motivating experience. In addition, the
functional wax-up, the maximum
intercuspation, the new vertical dimension and the protrusive and laterotrusive movements can be tested
in a realistic situation. Moreover, the
mock-up serves as a model for the
provisional restoration. Therefore, it
should be produced with the highest
of accuracy. Once the patient is completely satisfied with the proposed
result and the mock-up fulfils all the
clinical criteria, the actual treatment
can begin.
Preliminary treatment
At present, the preparatory measures for minimally invasive procedures and the topic of tooth preparation are receiving a lot of attention.
Nevertheless, there are some other
aspects that should not be neglected.
For example, the properties of the
materials used strongly influence
the result. State-of-heart materials
are offering increasingly sophisticated solutions. Before using any
new materials, it is important to
learn more about the application
recommendations of the manufacturer. Excellent planning and a carefully crafted mock-up will reduce the
preparations needed for the fabrication of the final restoration. With the
help of the mock-up, for example,
the teeth can be suitably prepared
for veneers or even crowns. The use
of optical appliances such as dental
loupes and microscopes also makes
work easier and more accurate.
In the present case, the teeth were
first cleaned very thoroughly. The
necessary extractions were performed and one tooth was endodontically treated. Then the teeth were
prepared and readied for the prosthetic treatment (Figs 6 and 7). The
long-term temporary was fabricated
using CAD/CAM equipment. Therefore, the wax-up was digitized with
the help of a laboratory scanner. This
information provided a basis for the
computer-aided design of the provisional. The CAD/ CAMfabricated
provisional made of tooth-coloured
composite (Telio CAD) also served
as a test object or blueprint during
the healing process. Its function and
esthetics were closely examined and
adjusted in detail (Fig. 8).
Fabrication of the permanent
restoration
Fig. 4: Wax-up: ideal functional and esthetic position and adjusted occlusal plane and Spee’s curve
Fig. 5: Mock-up fabricated with the help of the wax-up for the intraoral examination of the functional and esthetic components
Fig. 6: The prepared upper anterior teeth
Fig. 7: The prepared lower anterior teeth
Fig. 8: The CAD/CAM-fabricated long-term provisional (Telio
CAD) in the mouth
Fig. 10: Metal-ceramic posterior bridge (IPS Style); all-ceramic
upper anterior bridge (IPS e.max Ceram); veneers on the lower
anterior teeth (IPS e.max Press)
Fig. 12a: The permanently placed restoration in the mouth …
Fig. 9: The CAD/CAM-fabricated framework on the model of the
upper jaw
Fig. 11: Upper anterior restoration after placement with an esthetic luting composite (Variolink Esthetic DC)
Fig. 12b: … and a portrait picture of the
patient.
The final prosthetic phase started
after the long-term temporary had
been worn for an adequate period
of time. Before impression-taking,
the teeth were prepared again and
polished. It is very important to
transfer the vertical dimension of occlusion and the information about
the tooth-to-tooth relationship from
the provisional to the final restoration with great care. The “crossmounting” technique is suitable for
this purpose. This method entails
first making a bite record of the prepared teeth in the upper and lower
jaw. Subsequently, a second record is
taken of the provisional restoration
in the upper jaw and the prepared
teeth in the lower jaw. A third record
is captured of the prepared teeth in
the upper jaw and the provisional
restoration in the lower jaw.
The dental technician required the
following minimum information
in order to fabricate the restoration:
precision impressions of the upper
and lower jaw, precision impressions
of the provisionals, a facebow transfer record and three bite records
(“cross-mounting”), and recent portrait pictures of the patient wearing
the provisionals as well as photos of
the patient smiling.
The aim at this stage was to “copy”
the shape and occlusal plane of
the provisionals and to accurately
transfer this information to the final restoration. For this purpose, the
master casts were placed in the articulator after the “cross-mounting”
process. Since the final situation had
been successively attained by means
of the provisionals, the frameworks
could be fabricated relatively easily.
As a result of using the CAD/CAM
approach, the final restoration
could be visualized, modified and/
or duplicated with the assurance
that all the design guidelines would
be observed. The Wieland Precision
Technology (WPT, Naturns, Italy)
milling centre was responsible for
fabricating the frameworks for the
metal-ceramic restorations in the
posterior region as well as the zironcium oxide framework for the upper
anterior teeth (Fig. 9). The framework
was tried in to confirm the correct fit
of the restoration. Most of the inac-
curacies that usually occur are due to
errors made during impression taking, casting or model fabrication. The
veneers for the lower teeth were also
made with the assistance of digital
technology. They were subsequently
pressed with lithum discilicate glassceramic (IPS e. max®).
The metal frameworks were veneered with the new PFM system IPS
Style®. It allowed us to achieve the
desired natural-looking, translucent
shade without having to sacrifice
on brightness. The IPS Style ceramic
offers a major advantage in that it
can be optimally combined with IPS
e.max Ceram. As a result, the veneers
on the metal frameworks could be
optimally adjusted to the bridge in
the upper jaw. After the first bake,
the restoration was tried in. At this
stage, the need for smaller adjustments of the ceramic was identified.
Subsequently, the restorations were
glaze fired and polished. The veneers
were completed by firing on a thin
layer of IPS e.max Ceram A1, followed by a thin glaze layer (Fig. 10).
Before the restorations were seated,
the teeth were cleaned and a rubber
dam (OptraDam® Plus) was placed.
Luting composites such as Variolink® Esthetic are suitable for the
placement of this type of restoration.
This cement exhibits excellent adhesive properties and clinically beneficial characteristics such as easy
removal of excess and long-term
shade stability. The system offers
an additional advantage in that the
shades of the dual-curing (DC) and
the light-curing (LC) luting composite are the same. The DC cement is
used for crowns and bridges (Fig. 11)
and the LC cement for veneers. Furthermore, we used Monobond® Etch
& Prime to condition the veneers
(adhesive cementation). After gentle
sandblasting, the zirconium oxide
and metal-ceramic restorations were
prepared for placement by applying
Monobond Plus. Glycerine gel (Liquid Strip) was applied in order to prevent the formation of an inhibition
layer. The final result completely
satisfied all the parties involved. The
situation which was established during the treatment phase was exactly
transferred to the final restoration
(Figs 12a and b).
Conclusion
In extensive cases, it is particularly
important to develop a well thoughtout plan including all the treatment
steps, which needs to be carefully
followed at all times. In the described
case, various ceramic materials were
cleverly combined to produce a harmonious result. Excellent communication between the dentist and the
dental technician together with wellcoordinated state-of-the-art materials systems provided the basis for
this highly satisfactory outcome.
Dr Marko Jakovac
Associate Professor
Department of Fixed
Prosthodontics
School of Dental Medicine
University of Zagreb
Gunduliceva 5
1000 Zagreb, Croatia
jakovac@sfzg.hr
Michele Temperani
Laboratorio Odontotecnica
Temperani
Via Livorno 54\2
50142 Florence, Italy
micheletemperani@gmail.com
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lab tribune
Dental Tribune Middle East & Africa Edition | 4/2016
3Shape CAD/CAM in a major Dental Lab
It was the technicians’ choice
By 3 Shape
The versatility and solution coverage
offered by 3Shape systems has enabled Glidewell to grow and develop
well ahead of its competition by continuously expanding the range of its
products and services. Now all types
of restorations and large orders are
handled digitally each day, with over
50 of 3Shape’s installations covering
every Glidewell department need.
The Results
It has become clear to Glidewell that
their 3Shape solutions are a major
factor in enhancing their business,
and they credit this to the system’s
accuracy, consistency, predictability
and reproducibility of output. Many
incoming orders explicitly express
the condition that they are to be
executed using Glidewell’s 3Shape
systems.
The accuracy of the 3Shape system
enabled Glidewell to introduce 2
highly successful products that are
enjoying explosive market growth
– BruxZir® full Zirconia restorations
and Inclusive® Implant Abutment
applications. No other CAD/CAM
solution contained the powerful design capabilities necessary to morph
the explicit full contour required.
Designs made with 3Shape could be
milled directly without flaws – thus
opening windows to new productivity and profitability with Zirconia
material.
BruxZir® Zirconia soon became the
fastest growing product in the history of the laboratory, and today
Glidewell is making 8000 BruxZir®
restorations per week using 3Shape’s
technologies.
The flexibility of 3Shape as a system
and a company fit perfectly with
Glidewell’s goal to help pioneer the
growth of digital dentistry. Glidewell’s technicians continuously
communicate with 3Shape, giving
feedback regarding their daily challenges, and often seeing direct solution answers in later 3Shape software
releases.
Source: Greg Minzenmayer, Robin
Bartolo, Rudy Ramirez
The Challenge
Glidewell’s proclaimed ambition is
to be a pioneer in the Digital Dentistry Revolution, and, to achieve this,
they know they must work with the
best systems. Investing in a single
CAD/CAM brand was not the important issue for them. Glidewell simply
wanted to use best-of-breed systems
for each service they provided.
With a dampened mood in the
economy, more and more small and
midsized laboratories were looking
for sources of digital technology services in order to remain competitive,
and this opened new business opportunities for full-service labs like
Glidewell. More than ever, it became
imperative to have fast and productive systems that could provide attractive digital services and products
of high quality.
inLab MC X5:
DENTAL LAB
FREEDOM OF CHOICE.
Glidewell develops their own systems and methods for many applications, including abutments,
implants, milling and special materials, and they required flexible and
highly versatile software systems to
support these.
They needed a system that was not
limited – a system that could grow
with them, ensuring that they could
continue bringing their in-house
developed products to the market
while broadening their range of services.
The Solution
Glidewell initiated a technology solution business plan whose goal was
to become familiar with the market’s
flexible CAD/CAM systems. 3Shape
was one of the first to present itself,
but other brands were installed later,
and Glidewell technicians soon became familiar with operating a wide
range of systems.
Despite Glidewell’s readiness to
employ best-systems for different
purposes, 3Shape accuracy, ease of
use and efficiency continued to win
preference in every department. Alternative 3D scanners and software
systems were simply being pushed
aside to make room for 3Shape.
Glidewell’s dental technicians “at the
bench” slowly but surely gravitated
to 3Shape’s solutions for most of
their tasks.
Today, Glidewell Laboratories has
over 50 3Shape DentalSystem™ and
D700 series scanner installations
spread throughout the full areas of
Glidewell’s many departments. In
step with the ever-increasing integration of 3Shape into their workflows, Glidewell has instituted convenient on-line services for other
Dental labs using 3Shape, enabling
them to upload their 3Shape scans
or design files direct to Glidewell for
special processing and production
with Glidewell’s own materials.
Experience new freedom in your lab processes breaking the chains of
former dependencies with inLab and the new 5 axis milling and grinding
unit inLab MC X5. Open for all restoration data, combining the largest
material range and the possibility to machine both wet and dry disks
and blocks – for no limitations to your production. Enjoy every day.
With Sirona.
INLABMCX5.COM
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