Over the past 10 years, digital dentistry

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Digital dentistry for private practice Dr. Dean C.

significant contribution to our profession. It has allowed the clinician better diagnostic techniques and allowed us to view the head and neck area from a different vantage point.

But which systems are best for your practice? The real answers lie in the training of these high-tech software and milling machines.

1 Digital dentistry for private practice Dr. Dean C. Vafiadis reviews the significant contribution of digital dentistry to implant procedures for better diagnostic techniques and implementation Over the past 10 years, digital dentistry has made a significant contribution to our profession. It has allowed the clinician better diagnostic techniques and allowed us to view the head and neck area from a different vantage point. 1,2 We have broadened our diagnostic capabilities from using cone beam CT scans of the bony architecture to milling restorations for placement in a one-visit protocol. But which systems are best for your practice? The real answers lie in the training of these high-tech software and milling machines. The good news is that all the manufacturers and laboratories have made an educational and financial commitment to help clinicians make the right decision. Intraoral impressions with in-office milling The first question to ask for your specific clinical private practice is, What kind of digital platform do I want to have? Does your office have the space to house a milling machine, and do one-visit restorations fall into your specific patient demographic? If so, then your choices are the CEREC Omnicam system (Sirona Dental Systems, New York) the NEVO-E4D (Planmeca E4D, Richardson, Texas), and the Carestream CS 3500 system (Carestream Dental LLC, Atlanta, Georgia). These scanning and milling technologies Educational aims and objectives This article aims to discuss the various options and benefits regarding digital technologies available to dentists who provide implant procedures. Expected outcomes Implant Practice US subscribers can answer the CE questions on page XX to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: Realize the various benefits of intraoral impressions with and without in-office milling. Identify various software programs available to facilitate implant placement. Recognize the possible uses for CBCT imaging in the implant process. Recognize how merging information in digital STL files and DICOM files can facilitate sharing data with the dental laboratory. have made multiple upgrades that make scanning and milling possible within minutes and a total patient-specific restoration, even an anterior central veneer or crown, from scanning to insertion in under 90 minutes. 3 The ceramic material by Ivoclar Vivadent and 3M that is available has also been upgraded and provide very lifelike natural esthetics, good enough for even anterior central incisors (Figures 1-3). This comes with a large financial investment from the clinician, but the financial plans that are available can make this decision a comfortable and affordable 6-year payout. The laboratory costs, materials, and supplies used with conventional impressions will be huge savings for the Figure 1: e.max CAD-block high-translucent material (Ivoclar Vivadent, Amherst, New York) Dean C. Vafiadis, DDS, is a program director of the Full Mouth Rehabilitation CE course at NYU College of Dentistry (NYUCD). He has been on faculty at NYUCD since He currently practices in New York City, New York, where he is the president of the New York Smile Institute a multi-specialty practice for esthetics, CAD/CAM, and implant dentistry. He currently uses CEREC, TRIOS, E4D, and 3M True Definition Scanners in his office. He has lectured around the world and has given over 300 all-day courses on esthetics, implants, and CAD/CAM technologies. Figures 2 and 3: Right central incisor CAD/CAM one-visit treatment fractured, prepared, scanned, designed, and milled within 90 minutes 46 Implant practice Volume 9 Number 1

practice. In most offices and clinics, the savings will offset some of the cost of the payment. For example, a $120,000 investment over 6 years may average around $2,000 per month.

In addition, the savings of time and the second appointment will pay for the initial financial investment over the course of the year.

When looking at the office s financial profit and loss columns, the practice saves thousands of dollars over the course of the 5-year payout.

Although the technology is constantly changing, the scanners are still useful and will probably need upgrades every 2-3 years.

Also, the quality of the dentistry improves due to better preparation, margination, and the reduction of remaking impressions or remaking crowns because of quality control of the clinician and more

Intraoral impressions without inoffice milling Due to the cost of scanning and in-office milling, some clinicians have decided that simply scanning will save them the cost of making a restoration and

2 practice. In most offices and clinics, the savings will offset some of the cost of the payment. For example, a $120,000 investment over 6 years may average around $2,000 per month. But the lab costs saved may be around $1,000 per month, and the supplies and materials savings may be $300. In addition, the savings of time and the second appointment will pay for the initial financial investment over the course of the year. The one-visit in-office CAD/CAM financial model will definitely save the clinician the cost of labs, materials, provisionals, trays, and countless hours of saved appointments. When looking at the office s financial profit and loss columns, the practice saves thousands of dollars over the course of the 5-year payout. In addition, this provides the patient with a one-visit dental experience. 4 The good news is after the unit is paid off, the financial gains really manifest to the bottom line of the practice. Although the technology is constantly changing, the scanners are still useful and will probably need upgrades every 2-3 years. Asking for this and cost differentials of trade-in packages ahead of time is a good idea. Also, the quality of the dentistry improves due to better preparation, margination, and the reduction of remaking impressions or remaking crowns because of quality control of the clinician and more accurate occlusal reduction. Intraoral impressions without inoffice milling Due to the cost of scanning and in-office milling, some clinicians have decided that simply scanning will save them the cost of making a restoration and avoiding the goopy mess of regular PVS impression materials, which is what patients always complain about. Enter the intraoral scanners: 3Shape TRIOS (3Shape Dental, Warren, New Jersey); 3M True Definition scanner (3M ESPE Dental, St. Paul, Minnesota); itero scanner (Align Technologies, San Jose, California). All these allow accurate impressions for any restoration, posterior, anterior, and full arch. Although there are other scanners available and more being manufactured in Europe and Asian markets, these have not yet made it into the U.S. market (Figures 4-5). A recent article was published that made a very detailed comparison with 10 different intraoral scanners but could not give a definitive answer as to which, if any, were better than another. 4 The orthodontic community has readily adapted the itero due its collaboration with Invisalign. They can very abruptly take impressions and merge the files with the orthodontic software to create models and treatment plan for the orthodontic patient. But the others are soon to follow that digital orthodontic model. The accuracy of these new scanners is unprecedented, and the integration with the laboratory component has never been easier. The 3Shape TRIOS scanner is one of the fastest scanners available. It is easily integrated into any dental office. In single-provider dentists, group practices, or dental clinics, it can quickly be used for any restoration. In addition, the staff can be trained to take the intraoral impressions for diagnostic models, final impressions, and full arch impressions. Can you imagine that you could take a full arch impression to restore a full arch of restorations, a digital occlusal record in MIP position, and a counter scan in under 4 minutes? This is the average setting time of most PVS impressions. Then within 7 working days, you can have copings or even final restorations made at the highest level of accuracy and ready for delivery. One of the main advances in digital dental technology has been made possible by using printed models or stereolithography (SLA), instead of stone casts. Figures 6A-6D are examples of a printed model. The printed models have been shown to accuracy levels of microns, can be printed in less than 10 minutes, and with zero expansion, unlike dies and stone casts. This allows the technicians to really adapt the margins, interproximal contacts, and occlusal relationships on the computer monitor and deliver close to perfect restorations in any type of material, whether it be ceramo-metal, CONTINUING EDUCATION Figures 4 and 5: 3Shape TRIOS scan of full lower arch of preparations and interocclusal record for all ceramic CAD/CAM crowns Figures 6A-6D: 6A: TRIOS SLA model with 6 procelain veneers. 6B: Virtual LAVA COS scan then converted to SLA model. 6C: Digital TRIOS design of crown No. 4 and central No. 8. 6D: TRIOS SLA model with central incisor Volume 9 Number 1 Implant practice 47

Figures 7A-7B: 7A: Digital design of abutment on screen.

plan) (blueskybio.com, 3D software, Grayslake, Illinois) lithium disilicate, zirconia/feldspathic, or even gold crowns for the purist.

Software programs such as Materialise (Materialise Plymouth, Michigan), Anatomage (Anatomage, San Jose, California) and SIMPLANT (Dentsply, Waltham, Massachusetts), as well as many others, can

With the help of a CBCT scan and a trained laboratory technician, you can virtually look at the surgical plan and print a perfect surgical guide that actually fits within 4 business days.

The digital workflow from surgical guides to final restoration can now be entirely done on the computer screen and verified instantly by a portable mobile device or tablet by the lab or clinician

30 After the implants are healed, it s really simple to fabricate your ideal CAD/CAM patient-specific abutments with digital scanned healing abutments such as Encode (BIOMET 3i, Palm Beach

3 Figures 7A-7B: 7A: Digital design of abutment on screen. 7B: LAVA COS SLA model with two implant crowns Figures 8 and 9: Digital implant design using the CBCT scan and implant software will be used to fabricate ideal digital surgical guide (Blue Sky Bio plan) (blueskybio.com, 3D software, Grayslake, Illinois) lithium disilicate, zirconia/feldspathic, or even gold crowns for the purist. An example of the screen shots used by the 3Shape designer software is shown in Figures 7A-7B. Implants and digital technology Want to place your own implants? Software programs such as Materialise (Materialise Plymouth, Michigan), Anatomage (Anatomage, San Jose, California) and SIMPLANT (Dentsply, Waltham, Massachusetts), as well as many others, can diagnose the best possible placement angle, depth, width size, and type of implant that you desire. With the help of a CBCT scan and a trained laboratory technician, you can virtually look at the surgical plan and print a perfect surgical guide that actually fits within 4 business days. Placement of implants through flapless techniques better preserve the gingival tissues and allow the clinician ideal accuracy within a 100 micron tolerance for surgical placement. The digital workflow from surgical guides to final restoration can now be entirely done on the computer screen and verified instantly by a portable mobile device or tablet by the lab or clinician (Figures 8-11). Figure 10: Surgical printed surgical guide for central incisor implant Figure 11: Surgical guide used for implant No. 30 After the implants are healed, it s really simple to fabricate your ideal CAD/CAM patient-specific abutments with digital scanned healing abutments such as Encode (BIOMET 3i, Palm Beach Gardens, Florida). These have been around since 2004 and have cornered the market on digitally design CAD/ CAM abutment fabrication. 5,6 They are sitespecific and patient- specific. They create ideal contoured and anatomically shaped abutments to replace the root and gingival form of the tooth that has been lost without removing them to take a fixture-level impression (Figures 12-15). For those not using the Encode system from BIOMET, there is a vast choice of scan bodies for all the other implant systems. These are made for each specific implant and size for the specific manufacturer, 48 Implant practice Volume 9 Number 1

Figures 14 and 15: Final CAD/CAM abutments placed and CAD/CAM e.max crowns. Addition of ceramic material was added to contact between No. 28 and No. 29 after radiograph was made.

They have their own scan bodies for their implant line.

com) and Bio-Dent (biodent. com) (Figure 16). These can be scanned for any implant being used and create a custom CAD/CAM abutment for ideal design.

I believe this will be a market that will soon get increase popularity, again only to minimize cost and time (Figure 17).

DICOM is a common file format, allowing utilization of the information between different platforms and manufacturers units.

This allows the laboratories to use open platform information and merge different software within one program (Figure 18). If it sounds like a space-age concept, well, it is.

System, healing abutments (BIOMET 3i, Zimmer/BIOMET, Palm Beach Gardens, Florida) by the U.S. NASA space program for over 15 years.

4 Figures 14 and 15: Final CAD/CAM abutments placed and CAD/CAM e.max crowns. Addition of ceramic material was added to contact between No. 28 and No. 29 after radiograph was made. Provisional cementation of individual crowns with Temrex (Temrex Corp. Freeport, New York). 3-year postoperative photo such as BioHorizons, Straumann, Ritter, and MegaGen implants. They have their own scan bodies for their implant line. However, because of the high demand from the laboratories, independent companies have fabricated their own scan bodies that are available for each implant system, such as Elos Medtech (elos.com) and Bio-Dent (biodent. com) (Figure 16). These can be scanned for any implant being used and create a custom CAD/CAM abutment for ideal design. Some scanners are allowing clinicians to mill their own abutments, but this requires specific technical abilities that many clinicians are not comfortable with. I believe this will be a market that will soon get increase popularity, again only to minimize cost and time (Figure 17). Merging of digital files Another emerging technology is at the forefront with digital information. That is the merging of digital STL files and DICOM files. DICOM is a common file format, allowing utilization of the information between different platforms and manufacturers units. This allows the practitioner to have a specific scanner, for example, and the lab to have different software and still permit communication between the dentist and lab. This allows the laboratories to use open platform information and merge different software within one program (Figure 18). If it sounds like a space-age concept, well, it is. This has been available only within the past 3 years in the dental market but has been used Figures 12 and 13: 3M True Definition Scanner and 3Shape abutment design software with Bellatek Encode System, healing abutments (BIOMET 3i, Zimmer/BIOMET, Palm Beach Gardens, Florida) by the U.S. NASA space program for over 15 years. The manufacturers have realized the potential to capture all esthetic dentists as well as implant dentists, and to do that, they had to open their software platforms to allow labs to use them with any digital software design system. This allows the lab techs to merge files from various scanners and milling systems to idealize every patient treatment, from implant placement to digital guides, and provisional materials such as polymethyl methacrylate acrylic (PMMA). In addition, with the new digital design systems that are available, the clinician can take a digital impression and fabricate ideal smile design with a printed digital wax-up that is available with the 3Shape software. For example, think about a 10-unit bridge on teeth or implants. The clinician would like to evaluate the placement of abutments, so that interproximal space is available. Utilizing two individual software programs (3Shape and Materialise), the laboratory can merge the scan of the provisional, which is superimposed onto the implant abutments or prepared teeth. Utilizing the provisional, the technician and clinician can review the proposed position of the final porcelain and restorations on a personal device or smartphone and in minutes communicate whether CONTINUING EDUCATION Figure 16: Various types and shapes of scan bodies that are used specifically for each implant manufacturer (Ritter, Glidewell, and Elos scan bodies) Figure 17: CAD/CAM implant crown designed with CEREC. EMAX block has centric access hole Figure 18: Merging of three files intraoral scan (gray), CBCT scan (yellow), and ideal implant placement with diagnostic tooth wax-up (blue and green) to create ideal diagnostic view Volume 9 Number 1 Implant practice 49

Figures 19 and 20: Merged files of CAD/CAM abutment design with provisional intraoral scan overplayed for viewing and quality control. This can be viewed on personal computer or smartphone.

5 Figures 19 and 20: Merged files of CAD/CAM abutment design with provisional intraoral scan overplayed for viewing and quality control. This can be viewed on personal computer or smartphone. Final implant restorations completed utilizing this technique shows proper facial contour and lip support that was worked out in the provisional phase before porcelain was placed onto frame to continue or fine-tune the proposal. So with one image, the clinician can see the preparations or abutments, evaluate the frame to be milled, and see the final restorative position, all at the same time, and looking at exact occlusal contacts to be designed (Figures 19-20). This has been a dream of many of us for years finally, a program that lets us see everything in one view, accurately and clearly to all members of the restorative and surgical team. Diagnostically, this is an amazing breakthrough, especially for quality control. Using these programs, the labs can now design and fabricate restorations, surgical guides, partial and complete dentures, working smile designs, frames, and arches without depending on one certain scanner or software system. The dentists are free to make the best decision for their practices and not worry about their favorite labs purchasing software from the same company. This allows the laboratories to deliver excellent restorations regardless of the scanning system and platform that are provided. This gives a long awaited freedom to the clinician and maximizes efficiency for the labs. Of course, time for the patient and clinician is reduced as well as the cost of fabrication. Many people ask, Why this massive change in the dental world? This all began when the cost of gold and precious metals reached record highs, and the cost of making a dental restoration was becoming prohibitive. Add labor costs to this, which account for a large percent of lab costs, To keep costs down, CAD/CAM technology allows high precision while allowing the lab to keep fees down and still generate a profit for the lab. This began a wave of corporate decisions from every dental company to create a digital platform within their business model. A rampant change in the profession also followed that utilized high-strength ceramics Digital technology reference sites 3M True Definition Scanner: 3Shape TRIOS Scanner: Align Technologies / itero Scanner: BIOMET 3i, Zimmer/Biomet Co. Bellatek Encode System: Carestream CS 3500 scanner: Planmeca / E4D Technologies / NEVO scanner: Sirona / CEREC Omnicam: Materialise 3D Software: and materials that have allowed the low- as well as high-income practices to deliver excellent restorations for their patients. Like all things, change equals growth in different areas, and we have seen the collaboration of corporations, laboratories, and clinicians, where patients will finally benefit from this amazing and ever-changing technology. We must also give credit to the wonderful touchscreen phones and computers that have influenced all of our lives. It s not difficult to realize that they would eventually infiltrate the medical and dental profession. What is the future? How much better can it be? Let s think about what we do every day, and how we can make it better. Take, for instance, and extraction of a single tooth. This treatment is performed every day all around the world. What if we could scan the tooth and the root before extraction and have a duplicate root form of the exact shape and size ready at the time of surgery? In addition, what if it was made out of titanium and a high-grade surface texture with lateral side screws that could engage bone? How would the tissue response be to that surgical site? How would the loads be transferred with the exact anatomy of the root for that patient? Basically, every scenario of every procedure we do can be performed digitally. The ideas are only paralleled with one s imagination, and my prediction is that our young dental professionals will push the envelope even more to where no one has gone before. As always in technology, we are faced with the decision to be the first, follow a friend, or wait and see which is the best choice. It seems clear that regardless of the platform one chooses, it will no doubt impact the practice, the employees, and the overall patient experience. Digital dentistry is here, and it s exciting. Sometimes you have to jump right in and swim! IP REFERENCES 1. Birnbaum NS, Aaronson HB, Stevens C, Cohen B. 3D digital scanners: a high-tech approach to more accurate dental impressions. Inside Dentistry. 2009;5(4): Fasbinder D. Using digital technology to enhance restorative dentistry. Compend Contin Educ Dent. 2012;33(9): , 670, Logozzo S, Franceschini G, Kilpelä A, Caponi M, Governi L, Blois L. A comparative analysis of intraoral 3D digital scanners for restorative dentistry. The Internet Journal of Medical Technology. 2008;5(1). Internet Scientific Publications. Accessed January 15, Mitchem C. Why Digital Impressions? Dent Economics. 2012;102(1):32, 54, Vafiadis D, Goldstein G. Single visit fabrication of porcelain laminate veneer with CAD/CAM technology: a clinical report. J Prosth Dent. 2011;106(2): Ramsey CD, Ritter RG. Utilization of digital technologies for fabrication of definitive implant-supported restorations. J Esthet Restor Dent. 2012;24(5): Vafiadis, DC. Computer-generated abutments using a coded healing abutment: a two year preliminary report. Pract Proced Aesthet Dent. 2007;19(7): Implant practice Volume 9 Number 1

Soft Tissue Transfer Utilizing Digital Impressions of Anterior Implants

Soft Tissue Transfer Utilizing Digital Impressions of Anterior Implants Pacific Coast Society for Prosthodontics Anchorage, Alaska June 28, 2013 Kenneth F. Hinds DDS Traditional(Analog) ImpressionTechnique