Efficient Treatment Planning Using a Digital Workflow

Size: px

Start display at page:

Download "Efficient Treatment Planning Using a Digital Workflow"

Quentin Wheeler
5 years ago
Views:

1 Efficient Treatment Planning Using a Digital Workflow Technologies optimize aesthetics, improve patient care experience Products used Trios (3Shape) Telio CAD (Ivoclar Vivadent) Wieland Zenotec Hybrid Select (Ivoclar Vivadent) by Jonathan L. Ferencz, DDS, FACP Jonathan Ferencz, DDS, FACP, graduated from Rensselaer Polytechnic Institute in 1967 and the New York University College of Dentistry in He then received a certificate in prosthodontics from NYU in Ferencz has been on the faculty at NYU since 1972 and was named clinical professor of postgraduate prosthodontics and certified by the American Board of Prosthodontics in He serves as an adjunct professor of restorative dentistry at the University of Pennsylvania School of Dental Medicine and clinical professor of dental medicine at the Columbia University College of Dental Medicine. He is a past president of the Greater New York Academy of Prosthodontics, the Northeastern Gnathological Society and the American College of Prosthodontists. Ferencz has several published articles and has given more than 300 courses and programs throughout North America, South America, Europe and Asia. His areas of research have included high-strength ceramics, CAD/CAM and complete dentures. Introduction Almost every dentist who treats a patient requiring multiple single-unit indirect restorations either creates chairside provisionals or requests that the laboratory fabricate a shell that the dentist must then reline. In either case, the aesthetic result is usually less than ideal, the fit is poor and the reline material does not match perfectly. Additionally, with each reline, occlusion might require an adjustment because of polymerization shrinkage. These procedures are time-consuming and tedious for both dentist and the patient. Such inconveniences are considered part and parcel of indirect restorative procedures. Patients and dentists have begrudgingly come to accept that multiple appointments are required for taking uncomfortable and unpleasant impressions or, worse yet, remaking them, viewing hard-to-visualize-the-real-thing wax-ups, and placing, removing and replacing temporary restorations... all before the final restorations are even delivered. However, with a digital dental workflow, all of that changes. Imagine only two clinical visits When digital dental for provisionalizing and delivering a technologies are in treatment involving multiple single-unit restorations. While it may have been the practice, they unheard of just five years ago, it s becoming increasingly commonplace improve the clinical throughout dental practices today when intraoral scanners, in-office CAD/CAM workflow, practice and aesthetic high-strength millable efficiency and provisional and definitive restorative materials are used. In fact, when digital overall patient care dental technologies such as these are in the practice, they improve the clinical experience. workflow, practice efficiency and overall patient care experience AUGUST 2018 // dentaltown.com

In the case of an 80-year-old patient who presented with caries on five of his maxillary anterior teeth (Figs.

process. Fig. 1: Preoperative retracted frontal view of the patient s maxillary and mandibular teeth in occlusion. Fig. 2: Preoperative retracted frontal view of the patient s maxillary arch.

Consultation appointment Intraoral scanners eliminate the need for physical impressions and help minimize the

Then, when combined with CAD technology, the intraoral scans can be used to create a digital diagnostic wax-up, which

In this case, the patient was less concerned with aesthetics, but he understood the necessity of treatment based on the

Upon seeing the proposed treatment plan, he accepted the recommendation for full-coverage restorations. Fig.

2 In the case of an 80-year-old patient who presented with caries on five of his maxillary anterior teeth (Figs. 1 5), digital dentistry eliminated previous difficulties with indirect restorative dentistry and simplified the overall process. Fig. 1: Preoperative retracted frontal view of the patient s maxillary and mandibular teeth in occlusion. Fig. 2: Preoperative retracted frontal view of the patient s maxillary arch. Figs. 3 5: Preoperative radiographs revealing caries on teeth #6 through #10. Consultation appointment Intraoral scanners eliminate the need for physical impressions and help minimize the disadvantages associated with conventional impressions such as material costs, remakes, inaccuracies, storage and manual handling. 2 They also relieve patients of the discomfort and time typically required for taking traditional impressions. Then, when combined with CAD technology, the intraoral scans can be used to create a digital diagnostic wax-up, which serves as a virtual tool for treatment planning and patient understanding. In this case, the patient was less concerned with aesthetics, but he understood the necessity of treatment based on the extent of his caries. Upon seeing the proposed treatment plan, he accepted the recommendation for full-coverage restorations. Fig. 6: A preoperative scan was taken with an intraoral scanner (Trios 3Shape). Figs. 7 and 8: While the patient was in the chair, the treatment was designed to illustrate what his restorations would look like. The blue color indicates the original tooth position and white indicates what would change. The patient accepted the treatment plan. dentaltown.com \\ AUGUST

First clinical appointment With patient acceptance of the treatment plan, CAD/CAM technology can be used to easily design and fabricate provisional and definitive

2 Provisional restorations serve as the basic template for the definitive restorations and ensure their predictability by confirming the design of the occlusion,

9: The teeth were prepared for full-coverage restorations, retracted and scanned, after which the patient took a break while remaining in the dental office. Fig.

Fig. 14: Based on the original design and preparations, a set of provisional restorations was milled in the office from a PMMA material puck (Telio CAD, Ivoclar Vivadent)

15: The provisional restoration was cut from the puck, trimmed and polished. Fig. 16: The patient was brought back into the operatory for provisional try-in.

the prepared teeth as a final crown would. Fig.

3 First clinical appointment With patient acceptance of the treatment plan, CAD/CAM technology can be used to easily design and fabricate provisional and definitive restorations. 2 Provisional restorations serve as the basic template for the definitive restorations and ensure their predictability by confirming the design of the occlusion, structure and shape of the proposed restorations. 3 Fig. 9: The teeth were prepared for full-coverage restorations, retracted and scanned, after which the patient took a break while remaining in the dental office. Fig. 10: Incisal view of the preparations. Fig. 11: The scanned preparations were articulated with the opposing teeth. Fig. 12: Alternate view of the scanned preparations. Fig. 13: The original restoration design created during the consultation appointment was superimposed over the scanned preparations. Fig. 14: Based on the original design and preparations, a set of provisional restorations was milled in the office from a PMMA material puck (Telio CAD, Ivoclar Vivadent) in a dry mill (Wieland Zenotec Hybrid Select, Ivoclar Vivadent). As many as 30 units can be manufactured from one millable puck at a time. Fig. 15: The provisional restoration was cut from the puck, trimmed and polished. Fig. 16: The patient was brought back into the operatory for provisional try-in. No adjustments were required to the margins, occlusion or aesthetics; the mill copied and manufactured the original patient-approved design, and it fit as precisely on the prepared teeth as a final crown would. Fig. 17: The provisional was temporarily cemented and the patient was given an opportunity to test-drive what is essentially a dynamic mock-up for a week or so to verify that aesthetics, speech and function were acceptable. The patient could experience exactly what his teeth would be like in final restorations. In this case, the patient called to report that he loved the provisionals and didn t want to change anything there was no need for him to return to the practice. 32 AUGUST 2018 // dentaltown.com

Show your work in Dentaltown! If you ve got a case you think might be a great study for Show Your Work, email editor Sam Mittelsteadt: sam@dentaltown.com.

Fabrication of final restorations With computer-aided manufacturing (CAM) technology, lithium disilicate blocks (e.g., IPS E.

The monolithic properties of machinable lithium disilicate also contribute to its high aesthetics.

5 Although lithium disilicate achieves high aesthetics without the need for layering, 6 it can be layered, stained and glazed for more individualized characterization and anterior restorations. 7 Fig.

4 Show your work in Dentaltown! If you ve got a case you think might be a great study for Show Your Work, editor Sam Mittelsteadt: sam@dentaltown.com. Be sure to include a sentence that sums up why the case is so special to you, to help us review and select the best contenders for publication. Fabrication of final restorations With computer-aided manufacturing (CAM) technology, lithium disilicate blocks (e.g., IPS E.max CAD) are milled into restorations, rather than using traditional pressed processes, to impart monolithic strength to the restorations. 4 Using in-office wet milling technology (e.g., E4D/Planmeca), simple restorations can be completed in one visit, while more complex treatments can be completed much more efficiently. The monolithic properties of machinable lithium disilicate also contribute to its high aesthetics. With a single ceramic block, a full-contour restoration fabrication eliminates the challenges associated with working with different materials. 5 Although lithium disilicate achieves high aesthetics without the need for layering, 6 it can be layered, stained and glazed for more individualized characterization and anterior restorations. 7 Fig. 18: The final approved restoration design was used for milling the definitive restorations. Fig. 19: View of the designed restorations, with color turned off. Fig. 20: The restoration design was superimposed into the scan of the preparations. Fig. 21: Alternative view of the restoration design superimposed onto the preparations, with color turned off, before milling. A 3D-printed model of the preparations was also created for use in making the surface texture and viewing the arrangement of the five monolithic units. Figs. 22 and 23: The monolithic lithium disilicate crowns were stained, glazed and placed onto the printed model and ready for delivery. dentaltown.com \\ AUGUST

Second clinical appointment At the second clinical visit, the provisionals were removed, the preparations cleaned and the final restorations cemented (Figs. 24 and 25).

The final restorations precisely duplicated the proposed and approved treatment plan, which was the basis for the provisional restorations. Fig.

5 Second clinical appointment At the second clinical visit, the provisionals were removed, the preparations cleaned and the final restorations cemented (Figs. 24 and 25). Patient satisfaction was extremely high because there was no need to adjust the color, margins, length or occlusion. The final restorations precisely duplicated the proposed and approved treatment plan, which was the basis for the provisional restorations. Fig. 24: View of the definitive restorations after cementation. Fig. 25: Note the surface texture and color nuance of the final restorations, which were designed identical to the provisionals and originally approved treatment plan. Conclusion There are many different digital dental workflows. Some dentists just starting out with CAD/CAM only scan and send the scans to the laboratory for use in fabricating or manufacturing restorations. Other dentists scan and only manufacture lithium disilicate restorations, which requires a wet mill. Still other dentists, like myself, mill PMMA provisionals (dry mill) and lithium disilicate restorations. Milled PMMA provisionals look and fit better than anything I could have made by hand, and they re much less costly because the mill does the tedious work in 20 minutes. In the past, this took laboratory technicians two to three hours to complete. The patient enjoys the benefit of trying a dynamic mock-up of the treatment design as opposed to a white wax try-in, and everyone in the restorative process experiences an improved clinical workflow and practice efficiency when digital dental technologies are used. References 1. Miyazaki T, Hotta Y, Kunii J, et al. A review of dental CAD/CAM: current status and future perspectives from 20 years of experience. Dent Mater J. 2009;28(1): Fasbinder DJ. Digital dentistry: innovation for restorative treatment. Compend Contin Educ Dent. 2010;31(Spec No 4):2-11; quiz Beuer F, Schweiger J, Edelhoff D, et al. Reconstruction of esthetics with a digital approach. Int J Periodontics Restorative Dent. 2011;31(2): Zimmermann R, Seitz S, Evans J, et al. CAD/CAM and lithium disilicate: an anterior esthetic. Tex Dent J. 2013;130(2): Tysowsky GW. The science behind lithium disilicate: a metal-free alternative. Dent Today. 2009;28(3): Culp L, McLaren EA. Lithium disilicate: the restorative material of multiple options. Compend Contin Educ Dent. 2010;31(9):716-20, 722, Fasbinder DJ, Dennison JB, Heys D, et al. A clinical evaluation of chairside lithium disilicate CAD/CAM crowns: a two-year report. J Am Dent Assoc. 2010;141 Suppl 2:10S-4S. 34 AUGUST 2018 // dentaltown.com

Full-coverage crown restorations on seven maxillary teeth and six mandibular teeth

NYC Prosthodontics Dr. Jonathan L. Ferencz, D.D.S. DISCOVERY. ADOPTION. SUCCESS. dentalproductsreport.com Full-coverage crown restorations on seven maxillary teeth and six mandibular teeth Digital Workflow: