CDOCS - Blog

SEO vs. GEO: What Every General Dentist Needs to Know to Get Found Online

2026-03-23T18:06:50Z

If you've ever Googled your own practice and wondered why you're not showing up, you're not alone. For years, the answer to "how do I get more patients online?" has been one thing: SEO — Search Engine Optimization. But that landscape is shifting, and there's a new strategy dentists need to know about called GEO — Generative Engine Optimization. Don't let the tech jargon throw you off. This is actually pretty straightforward once you break it down, and understanding the difference could be a game-changer for your practice growth.

SEO: The Foundation You Probably Already Know (a Little)

SEO is the process of making your website show up higher when someone types something into Google — like "family dentist near me" or "teeth whitening in Charlotte." When done well, a potential patient sees your practice near the top of the search results, clicks your website, reads about your services, and hopefully books an appointment.

The key building blocks of good dental SEO haven't changed much: a well-structured website, consistent contact information across the web, strong Google Business Profile, positive patient reviews, and content that answers the questions your patients are actually asking. Google ranks practices based on three main things — proximity (how close you are to the searcher), relevance (does your content match what they're looking for?), and prominence (are you trusted and well-reviewed?).

If you haven't nailed these basics yet, that's where to start. Reviews alone can account for up to 15% of your local Google ranking. Every five-star review isn't just good for your ego — it's working for you around the clock.

GEO: The New Game in Town

Here's where things get interesting. More and more patients aren't just typing into Google anymore. They're asking AI assistants — ChatGPT, Google Gemini, Perplexity, even Siri — questions like "Which dentist near me takes Delta Dental and is open on Saturdays?"

And instead of returning a list of ten links for the patient to scroll through, these AI tools spit out one answer. A single recommendation. If that's not you, the patient never even knew you existed.

That's where Generative Engine Optimization comes in. GEO is about making sure AI-powered platforms can easily find, understand, and recommend your practice. It's less about keyword density and more about being a clear, credible, well-documented source of information that AI can confidently surface when a patient asks.

Think of it this way: SEO gets you on the list. GEO gets you the answer.

What This Means for Your Practice — Practically Speaking

You don't have to choose between SEO and GEO. You need both. Here are the most important things to focus on right now:

Keep your Google Business Profile squeaky clean. Your name, address, phone number, hours, and services should be accurate and updated consistently everywhere online. AI tools pull from this data heavily when forming recommendations.
Write content the way your patients talk. Instead of a generic "Services" page, think about building FAQ-style content that directly answers conversational questions — "What happens during a root canal?" or "How much does a dental cleaning cost without insurance?" AI assistants are specifically looking for content structured around natural questions and direct answers.
Collect reviews consistently — and make them detailed. AI systems weigh reviews heavily when deciding who to recommend. A patient leaving a review that mentions specific services ("Dr. Smith did my crown in one visit and it was painless") gives AI more useful data to work with than a generic five-star rating.
Make sure your practice is mentioned on reputable third-party sites. Healthgrades, Zocdoc, Yelp, and even local news or community blogs help AI systems understand that you're a legitimate, well-regarded provider in your area.
Don't abandon traditional SEO. About 80% of AI-generated search results still pull from websites that already rank well on Google. Your SEO foundation directly feeds your GEO visibility.

The Bottom Line

The way patients find a dentist is changing fast. They're still Googling, yes — but they're also asking AI, using voice search, and expecting instant, specific answers. Practices that adapt now will have a significant edge over competitors who are still playing the old game.

You don't need to become a digital marketing expert overnight. But you do need to be aware that the rules are evolving. A well-optimized Google Business Profile, helpful patient-focused content, a steady stream of reviews, and accurate information across the web — these aren't just good SEO habits anymore. They're the building blocks for showing up in the AI-powered future of patient search.

And in a world where the AI might give one name to a patient in pain at 11pm on a Sunday — make sure that name is yours.

Dr. Shivi Gupta Named CDOCS Faculty Chair

2025-12-09T04:04:12Z

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CDOCS is proud to announce the appointment of Dr. Shivi Gupta as its new faculty chair. A practicing dentist, educator, and global thought leader in CAD/CAM and CBCT technology, Dr. Gupta will guide CDOCS faculty in delivering world-class education to dental professionals through hands-on workshops and online learning.

With 23 years of clinical experience, Dr. Gupta has dedicated her career to advancing digital dentistry. At her private practice in San Diego, California, she has pushed the boundaries of CAD/CAM technology, using it to its fullest potential across crowns and bridges, implants, smile design, and orthodontics.

“Dr. Gupta’s leadership embodies the spirit of CDOCS,” Dr. Dan Butterman, Chief Dental Officer of CDOCS, said. “Her expertise in CAD/CAM and digital workflows, combined with her ability to inspire and mentor clinicians, makes her the ideal leader to help our members elevate their practice and deliver better dentistry to their patients.”

Beyond her practice, Dr. Gupta has served as a resident faculty member with CDOCS, a KOL speaker and beta tester for Dentsply Sirona, a product consultant for leading dental companies, and an advanced trainer for Patterson Dental. Her lectures and training programs have reached clinicians across the globe.

“Appointing Dr. Gupta as faculty chair reflects our commitment to staying at the forefront of digital dentistry,” Ingo Zimmer, Chief Strategy Officer and General Manager of CDOCS, said. “Her vision and experience align perfectly with our mission to empower clinicians with innovative, practical education that drives long-term success in their practices.”

For Dr. Gupta, this role represents both a professional milestone and a personal passion.

“I am honored to step into this role and help shape the future of digital dentistry education at CDOCS,” Dr. Gupta said. “My career has been dedicated to showing how technology can transform patient care. As faculty chair, I look forward to working with our outstanding educators and members to expand knowledge, build confidence, and continue pushing the limits of what’s possible in digital dentistry.”

Dr. Gupta is a graduate of the University of Manitoba, Canada, and completed her Advanced Education in General Dentistry residency at the University of Texas Health Science Center in San Antonio. Her deep clinical knowledge, combined with years of industry collaboration, has made her a respected voice in digital dentistry and an invaluable part of the CDOCS community.

Her appointment as faculty chair underscores CDOCS’s commitment to excellence and innovation, ensuring its members have access to the most advanced, practical, and transformative dental education available today.

The Practice Building Secret That Doesn't Involve CE: The Fall/Holiday Patient Letter

2025-11-26T10:10:07Z

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I recently found myself sitting in Level 4, catching up with one of our mentors before class. We were talking about the holidays, specifically how closing our offices during the Christmas season sometimes frustrates patients who expect us to be open until December 31st at 11:59 PM.
I shared something I've been doing for the entirety of my 18 years of practice ownership - something that has become coveted by our patients: my fall/holiday letter.

Beyond Clinical Proficiency
As a clinical instructor here at CDOCS for the last 18 years, and as a dentist who takes 75–100 hours of CE every year outside of the classes I teach, I recognize that becoming proficient at the procedures we perform is vital to career success.
However, I honestly don't think technical proficiency is the most important thing that dictates the success of your practice.
I learned a profound lesson many years ago from my father, who was a gifted clinical dentist. He told me that to run a truly successful practice, we need to understand that patients are looking for mainly two things from us. He instructed me to:

Learn how to talk and connect with my patients on a personal level before I ever look in their mouth.
Learn how to give a great injection.

As he explained, patients ultimately want to know, "Were they nice to me and did they hurt me?" You strive to become a great technical dentist because you want to give them the best clinical dentistry you can perform, but patients don't know what a great dentist truly is. Most patients just want to know that you are kind, attentive, and that you make the procedure comfortable.
The Cornerstone of Connection: The Holiday Letter
I took this lesson to heart as an associate and continued it into my practice ownership. I want to share the practice building tip that has become one of the cornerstones my patients look forward to: the holiday letter.
Every year, around the middle of October, I craft a letter to my dental family of patients. I even refer to them that way, starting the letter by saying, "To my wonderful dental family of patients."
I follow a simple template that ensures I cover three critical areas:

1. The Opening Paragraph: Personal Connection
The opening is always about me, my family, and my team. I talk about what my kids and family have been up to. I talk about celebratory milestones my team has achieved, such as engagements, weddings, births of children, or new members we have added (by name) whom they will be introduced to when they visit the office. This creates a deep connection right out of the gate between us and the patients. I sometimes even include cool adventures some of the team may be doing over break to create talking and connection points for their next visit.
2. The Middle Paragraph: Clinical Trust
This section is always about what types of CE or technology we have added to the practice to keep us on the forefront of clinical dentistry in our area. For example, this year we sent one of our associates to learn to do All-on-X cases in-house, surgically and restoratively, so patients can now stay in-house if they are in need of that treatment or know people who are. This subtly reinforces our clinical excellence.
3. The Closing Paragraph: Practice Management & Call to Action
The final paragraph addresses the business side. I remind them that their benefits are ending at the end of the year and to utilize them ASAP so they don't lose them. I also let them know that we are closing from Christmas Eve until the beginning of January to allow our hard-working team some time to recharge their batteries.
We remind them that since we are closing, if they have kids coming home for break, they need to make their cleaning appointments immediately as those spots will fill. I also remind them that our doctor schedules fill with bigger procedures as we get to the end of the year, so finding time to fit things they may need becomes less likely the longer they wait.
I end by thanking them for being wonderful and loyal patients whom we consider family. I tell them that we are always looking for more great patients similar to them, so please let their friends and family know about us, or feel free to leave reviews on Google or Yelp to help others looking for a dentist in our area choose us.

The Power of Emotional Connection
When I was a small, four-chair practice with 1,000 patients, we would type this up on MS Word, print them on beautiful holiday or fall stationary, and physically sign them along with my team. We are now a much larger, 17-operatory practice with well over 5,000 patients, so this has become more cost-prohibitive; we now just email it to them. My Office Manager has a background in graphic design, so she creates a beautiful background and sends it out.
This letter has become such an important staple that:

My patients thank me for sending the letter (email) after it goes out. They come in and always compliment me that they feel so connected to our practice.
When I send the letter out a little later than normal, they will ask or even call into the office wondering if the letter is still going out.

Learn to connect with your patients emotionally. Ask about them and their families when they come in. Write down in your exam notes things they like to do in their spare time, as well as life events coming up in the future. At the next visit, I will ask them how the Beyoncé concert was, or how their Alaskan cruise was that they had been saving up for over the years to take their entire family. They won't believe you remember.
This connection leads to trust, which then leads to case acceptance. Make your patients part of your family. Share a piece of your heart. It will fulfill you personally and be one of the biggest reasons for the growth of your practice!

CDOCS Expands into Canada

2025-09-08T11:11:59Z

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Already known worldwide for setting the gold standard in digital dentistry education, CDOCS is expanding its reach north of the border.

Dental professionals will soon have access to hands-on workshop training and advanced learning opportunities at the Dentsply Sirona Academy & Showroom Canada, located just outside Toronto.

“Expanding to the Dentsply Sirona Academy in Canada marks an important milestone in our mission to make the highest level of digital dentistry education more accessible worldwide,” Ingo Zimmer, Chief Strategy Officer and General Manager of CDOCS said. “This new location allows us to bring our world-class faculty, hands-on workshops, and innovative learning environment to an even greater number of clinicians.”

With established locations in Scottsdale, Arizona and Charlotte, North Carolina, CDOCS continues to be the trusted destination for dentists who want to sharpen their skills, embrace innovation, and deliver the very best patient care.

"Dentists can expect the same renowned CDOCS workshop experience at our new Canadian campus, featuring hands-on, expert-led instruction that’s proven to deliver practical, ready-to-implement techniques and predictable workflows,” Dr. Dan Butterman, Chief Dental Officer at CDOCS said. “The Dentsply Sirona Academy in Toronto will give clinicians the tools and training they need to confidently elevate their practices."

Official dates for hands-on workshops at the new campus will be announced in the near future.

Long-Term CDOCS Member Named to Resident Faculty

2025-07-28T07:07:26Z

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We’re excited to announce that Dr. Anthony Ponzio has officially joined the CDOCS Resident Faculty!

A longtime member of the CDOCS community—13 years and counting—Dr. Ponzio brings a deep passion for digital dentistry, a sharp eye for technology integration, and a teaching style that blends clinical excellence with humor, humility, and heart.

“I am very excited to join the CDOCS faculty and get to work with all of the great teachers and friends that I have gotten to know over the years,” Dr. Ponzio said. “I can't wait to work with doctors and their team members to share what I’ve learned, help them grow their CEREC skill set, and hopefully increase their enjoyment of this journey through the crazy world of dentistry.”

A LEADER IN DIGITAL INTEGRATION AND EDUCATION

Dr. Ponzio is a 2004 graduate of the University of Illinois College of Dentistry and currently practices in Oak Park, Illinois. He serves as Clinical Director for P1 Dental Partners, a DPO with offices throughout the Midwest, where he leads innovation in practice systems and digital workflows.

With more than a decade as a CEREC Basic and Advanced Trainer, Dr. Ponzio has worked with dentists and teams across the globe to elevate their use of digital tools—always with a focus on improving the patient experience and driving productivity. He’s served as CDOCS Visiting Faculty and previously taught at Midwestern University’s College of Dental Medicine, where he helped integrate CAD/CAM into the dental school curriculum.

At CDOCS, his focus will be teaching the 90-Minute Crown Appointment with Chairside CAD/CAM hands-on workshop.

"My teaching philosophy has always been about keeping things fun and light, and creating a safe and open environment for attendees to ask questions and make sure they leave with tools they can use in their practices right away," Dr. Ponzio said.

FUN FACTS

CDOCS members already familiar with his approachable, high-energy teaching style will appreciate these fun Dr. Ponzio facts:

What’s your guilty pleasure snack you hope your patients never find out about? Peanut Butter Monster Mix and Garrett’s Popcorn

What’s your go-to karaoke song? “Baby Got Back” by Sir Mix-A-Lot (and yes, he’s performed it at weddings and dental meetings)

You’re stuck on a deserted island … but you have to keep doing dentistry. What 3 things are in your emergency dental kit? CEREC, Electric Handpiece, Spade Proximator Set

What’s the most unexpected thing a patient has ever said while in the chair? I had an 80 year old woman in the chair, and when reviewing her medical history she had marked that she used recreational marijuana. I asked her how often she smoked and she said "only when I drink." I then asked her how often she drank, and she replied "Every day!" I almost fell out of my chair.

Please join us in welcoming Dr. Ponzio to the CDOCS Resident Faculty—we’re thrilled to have him on board!

Welcoming Dr. Varisha Parikh to CDOCS Resident Faculty

2025-06-02T09:09:01Z

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CDOCS is proud to welcome Dr. Varisha Parikh as the newest member of our Resident Faculty.

Dr. Parikh is a private practice prosthodontist based in Los Angeles, California. She earned her dental degree from the Arizona School of Dentistry and Oral Health and completed her advanced specialty training in Prosthodontics at UCLA, where she now also serves as a clinical instructor in the Advanced Prosthodontics Residency Program.

With a practice deeply rooted in digital workflows for complex rehabilitation, Dr. Parikh brings a strong clinical perspective on how technology can transform both patient outcomes and practice efficiency.

“I’m grateful to be part of the CDOCS Resident Faculty team—a group of educators and clinicians who lead with purpose, innovation, and heart,” Dr. Parikh said.

As a respected speaker and mentor, Dr. Parikh is passionate about creating learning environments that are hands-on, collaborative, and clinically relevant.

“To contribute in this space—where learning is collaborative, curiosity is encouraged, and authenticity is embraced—is truly meaningful,” she said. “It’s an opportunity to share my experience, continue growing as a clinician, and help shape the future of dentistry in a way that feels both purposeful and personal.”

We’re thrilled to welcome Dr. Parikh to the CDOCS community and can’t wait for our members to learn from her expertise, energy, and dedication to elevating digital dentistry.

Bonded - A CDOCS Podcast: Episode 4 Preview: Dickey Bumps

2025-04-14T08:08:15Z

Episode 4: Dickey Bumps

New Faculty, Familiar Vibes: Vishal Sharma Joins the CDOCS Family on “Bonded”.

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In the latest episode of Bonded, the CDOCS podcast that brings dental professionals together through real conversations and shared experiences, hosts Dr. Meena Barsoum and Dr. Rich Rosenblatt welcome a fresh face to the faculty — Dr. Vishal Sharma.

Vishal, the newest member of the CDOCS teaching team, joins the episode with energy, humor, and insight, sharing stories that highlight both the triumphs and tribulations of modern dental practice. From his whirlwind travel delays to the everyday curveballs of running a practice, Vishal keeps things real — and relatable. You’ll hear tales that will have you laughing one moment and nodding in agreement the next. Beyond the anecdotes, the episode dives deep into the themes that matter most: mentorship, continual professional development, and the powerful role of digital technology in transforming dental practices. Vishal shares how these elements shaped his own journey and how he hopes to inspire others on theirs.

A proud Canadian, Vishal reflects on his roots and the importance of building strong relationships in the dental community. Whether it's with patients, colleagues, or mentors, that human connection is central to his philosophy — and it shows in every story he tells. This episode of Bonded isn't just about introducing a new faculty member — it's about welcoming a kindred spirit into the CDOCS family. The camaraderie between Meena, Rich, and Vishal is infectious, and their shared passion for dentistry, education, and laughter shines through from start to finish.

Tune in to hear about:

The challenges and rewards of becoming a CDOCS faculty member
How mentorship fuels growth and confidence in clinical practice
Funny moments from the operatory that every dentist can relate to
The evolving role of digital dentistry in expanding possibilities
Why relationships — not just restorations — are at the heart of dentistry

Catch the full episode wherever you listen to podcasts, and get to know Dr. Vishal Sharma — a teacher, a storyteller, and now, a proud part of the CDOCS journey.

Stay Curious. Stay Bonded.

Where to Listen:

Spotify
YouTube
CDOCS

A Case of HPV / Squamous Cell Carcinoma of the Oropharynx as Seen from a CBCT

2025-04-11T09:09:57Z

HPV is the leading cause of oropharyngeal squamous cell carcinoma. The CDC states that HPV is the most common sexually transmitted infection in the United States. Of the more than 100 types of HPV, about 40 types can spread through direct sexual contact to genital areas, as well as the mouth and throat. Oral HPV can be transmitted to the mouth by oral sex or in other ways.

Many people are exposed to oral HPV in their life. About 10% of men and 3.6% of women have oral HPV, and oral HPV infection is more common with older age. The age of diagnosis of HPV squamous cell carcinoma starts in males and females at about 30 years old and peaks between 60-69 and then starts decreasing after that. Most people clear HPV within 1 to 2 years, but HPV infection persists in some people.

HPV can infect the mouth and throat. It usually takes years after being infected with HPV for cancers to develop in the oropharynx. This includes the back of the throat, including the base of the tongue and tonsils. HPV oropharyngeal cancer is thought to cause 60% to 70% of oropharyngeal cancers in the United States. HPV is not known to cause other head and neck cancers including those of the larynx, lip, nose or salivary glands. HPV related oropharyngeal cancer is the eighth most common cancer in men.

There is a difference between HPV positive oropharyngeal cancer and HPV negative cancer. HPV negative cancer is usually caused by tobacco and alcohol factors. HPV positive oropharyngeal cancers tend to be more responsive to treatment.

Symptoms include a long-lasting sore throat, earaches, hoarseness, swollen lymph nodes, pain on swallowing and unexplained weight loss. Some patients have no symptoms.

The overall 5-year survival rate in patients with oropharyngeal cancer is about 52%. However, prognosis for HPV positive survival rate is >80% whereas HPV negative patients have a survival rate of <50%. With more than 13,000 new diagnoses of throat cancer each year in the US, the disease has surpassed cervical cancer as the most common cancer with HPV.

A 46-year-old male patient of mine presented to the clinic with chronic sore throat. He had been having issues with it for about 2 years and had been seen by an ENT physician. He had fallen and down some stairs recently and a lump was noted by a massage therapist. He was examined and was dismissed as having a hematoma due to the trauma. He had been a patient of mine for many years coming regularly for routine dental restorative issues and hygiene appointments. He presented to the clinic with left posterior base of the tongue swelling, left tonsillar swelling, chronic throat pain, submandibular swelling and weight loss. He hadn’t felt well for a while. He had recently been to his primary care physician who also dismissed it as viral. The PCP tested for strep throat twice but both times results were negative. Palpation of the left neck region revealed a swollen submandibular lymph gland about the size of a quarter with mobility. Intraoral examination revealed a left sided red and swollen tonsillar pillar area and unusual swelling at the base of the tongue. It was difficult to visualize due to the swelling and his gag reflex. Low level laser therapy was applied to the area using a Lightwalker Twin Light erbium/yag and ND/yag Laser utilizing both mediums on a twice weekly basis.

He returned two weeks later with continued discomfort. The patient noticed more swelling in the cervical lymph node area. We continued Nd/yag low level laser therapy twice weekly for about 3 weeks as the patient stated that things were getting better but was still feeling some pain on his neck and jaw. A recent CBCT revealed asymmetry of the left side of the lower oropharynx near the epiglottis.

He was immediately referred to the ENT office for further evaluation. I sent the ENT office a snap shot of a recent CBCT and an intraoral photo. The physician’s assistant saw the patient and dismissed my snapshot of the CBCT and photo but took a biopsy of the left tonsillar fossa.

The biopsy came back positive stage IV HVP squamous cell carcinoma. Due to the extent of the carcinoma, surgical intervention was ruled out and a combination of chemotherapy and radiation was instituted to try to shrink the carcinoma.

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Image 1 - Intraoral photo of the lesion at the base of the tongue

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Image 2 and 3 - Cross sectional and axial view from CBCT 8 years ago

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Image 4 and 5 - Cross sectional and axial view from 1 year ago showing pathology

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Image 6 and 7- Cross Sectional and axial view several months after chemo and radiation therapy

The patient seems to be doing well after treatment. A biopsy was recently performed which nicked the carotid artery and required ligation of the artery to stop the bleeding. The biopsy was clear of any carcinoma.

In retrospect, continued sore throat and swelling should have been a red flag followed up by his PCP. However, I am glad we were able to discover this lesion and refer quickly to save this gentleman's eating and swallowing functions and his life.

John Rothchild, DDS.

Bonded - A CDOCS Podcast: Episode 3 Preview: The Green Bubble

2025-04-08T08:08:43Z

Episode 3: The Green Bubble

We’re back with Episode 3 of the CDOCS Bonded Podcast, and this one is a must-listen for anyone passionate about dental education, mentorship, and the evolution of clinical practice through digital innovation.

Titled "The Green Bubble," this episode features an engaging conversation between your hosts Dr. Meena Barsoum and Dr. Rich Rosenblatt and their special guest, Dr. Sean Sharp—a passionate educator and practitioner who brings a refreshing perspective on what it means to grow in dentistry today.

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What's Inside the Green Bubble?

Dr. Sharp opens up about his personal journey through the world of dental education and shares the unique challenges that come with teaching technical dental courses. He sheds light on the rewarding (and sometimes tough) realities of shaping the next generation of dentists, emphasizing the pivotal role that mentorship plays in bridging the gap between classroom learning and real-world application.

The episode also dives into the exciting ways digital dentistry has transformed Dr. Sharp’s private practice. From workflow efficiencies to patient outcomes, his story is a great example of how embracing technology can lead to significant professional growth.

Whether you’re a seasoned clinician, a dental educator, or just starting out in the field, there’s something in this episode for you. It’s honest. It’s insightful. It’s a great reminder of how staying connected to mentors, colleagues, and innovation keeps the passion for dentistry alive.

Tune in to Episode 3 – “The Green Bubble” on your favorite podcast platform and join the conversation.

CDOCS
Spotify
YouTube

Stay curious. Stay bonded.

Addressing Esthetic Implant Complications: A Reflection on a Recent Case

2025-04-07T08:08:42Z

Lately, I've seen an increase in esthetic implant complications in my practice. Some are referred from other clinicians, while others are my own cases, like a recent 7-year follow-up after an immediate implant placement. This case highlights the importance of proper soft tissue management in the esthetic zone.

In immediate implant placement, techniques like the socket shield and connective tissue grafting are now considered essential. These weren’t applied in this case, leading to soft tissue recession despite the buccal bone plate remaining intact. Soft tissue management is crucial, as recession can occur even with stable bone structures.

The treatment approach for such complications depends on the implant's 3D position and typically involves autogenous soft tissue grafting. These procedures are vital to restore tissue health and esthetics.

Later this year, we’ll be offering a specialized surgical implant complications course at CDOCS, where we’ll cover soft tissue grafting, socket shield techniques, and strategies for managing esthetic zone complications. This hands-on, in-person course will equip clinicians with the latest techniques to prevent and address complications.

Farhad

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Faculty and our member doctors post dental cases to our CDOCS discussion board daily. Join CDOCS today for full access.

Take a workshop with Dr. Boltchi

Achieving Predictable Results in Guided Implant Surgery

Hard and Soft Tissue Grafting in Digital Dental Implant Dentistry

Bonded – A CDOCS Podcast: Episode 2 Preview: Sasquatch

2025-04-02T10:10:14Z

Episode 2: Sasquatch

The journey of innovation continues with the second episode of Bonded: A CDOCS Podcast! Join hosts Dr. Meena Barsoum and Dr. Rich Rosenblatt as they sit down with Dr. JF Levesque to discuss his transformative journey into digital dentistry.

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In this episode, Dr. Levesque shares his experience transitioning from traditional methods to a fully digital workflow. He provides valuable insights into how cutting-edge tools like Primescan and Primeprint have revolutionized his practice, making workflows more efficient and enhancing patient care. Listeners will also hear firsthand how he seamlessly integrated these technologies into his team, ensuring a smooth and successful adoption process.

Whether you're considering making the switch to digital or looking to refine your current approach, this episode is packed with inspiration and practical advice from a clinician who has embraced the future of dentistry.

Where to Listen

Tune in to Bonded - A CDOCS Podcast, available right here on the CDOCS Website, Spotify and YouTube.

Maximizing Clear Aligner Efficiency with Attachments

2025-03-28T10:10:44Z

Clear aligners have transformed orthodontic treatment, offering a discreet and comfortable way to achieve beautifully aligned teeth. While the aligners themselves are powerful, their effectiveness is significantly enhanced by one key feature—attachments. These small composite additions provide essential grip and force application, allowing aligners to move teeth with precision. Let’s explore three critical movements where attachments make a world of difference.

1. Rotations: The Power of a Couple

One of the biggest challenges with clear aligners is rotating cylindrical teeth, such as premolars and canines. This is where the biomechanical concept of a “moment of a couple” comes into play. By strategically placing beveled attachments, we create two opposing forces that generate an efficient rotational movement.

For instance, if a premolar is rotated distally, a facially placed attachment with the bevel oriented distally, combined with a lingually placed attachment with the bevel oriented mesially, creates the necessary force couple. This precise placement enhances the aligner’s ability to achieve controlled and predictable rotations, reducing the number of refinements needed.

2. Extrusions: Lifting with Precision

Extruding teeth—bringing them down into the correct position—can be challenging with clear aligners due to the lack of inherent vertical force. Attachments serve as anchor points that allow aligners to generate the necessary vertical pull.

A gingivally beveled rectangular attachment is often used to create an extrusion-friendly surface. This attachment allows the aligner to grasp and guide the tooth downward with each aligner change. Whether addressing a deep bite or improving smile esthetics, strategically placed attachments ensure that extrusion movements occur efficiently and with long-term stability.

3. Translations: Moving with Control

For bodily movements, such as closing spaces or shifting incisors, attachments are crucial for applying uniform force across the tooth surface. Without attachments, the aligner may struggle to generate enough force to bodily move a tooth rather than tipping it.

A vertical rectangular attachment placed at the center of the crown serves as a force distributor, helping the aligner exert consistent pressure across the tooth. This ensures controlled translation, reducing the risk of unwanted tipping and improving overall treatment precision.

Conclusion: Small Details, Big Impact

Attachments may be small, but their impact on clear aligner treatment is enormous. They turn aligners from passive trays into powerful tools capable of achieving complex movements with predictability and efficiency. By understanding how to leverage attachments for rotations, extrusions, and translations, one can maximize treatment success and deliver stunning smiles with confidence.

For patients, these tiny additions may be unnoticeable, but they make all the difference in ensuring faster, more effective, and more beautiful results.

To learn more about clear aligners from Dr. Shah, visit our orthodontic course pages and register for a hands on workshop today!

Clear Aligner Excellence for Dentists and Their Teams (Part 1) workshop.

Clear Aligner Excellence for Dentists and Their Teams (Part 2) workshop.

Introducing Bonded – A CDOCS Podcast: A New Conversation in Dentistry

2025-03-18T11:11:44Z

At CDOCS, we’re always looking for new ways to educate, inspire, and connect with the dental community. That’s why we’re thrilled to introduce Bonded – A CDOCS Podcast, a brand-new way to engage with leading voices in dentistry. Hosted by Dr. Rich Rosenblatt and Dr. Meena Barsoum, Bonded brings candid conversations, expert insights, and personal stories straight to your ears.

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Episode 1:

In our inaugural episode, Meena and Rich introduce themselves and share their passion for dental education. They also welcome special guests Dr. Shivi Gupta and Dr. Kanchan Jindal for an engaging discussion which includes Dr. Gupta's daughter.

This podcast isn’t just about clinical skills—it’s about the relationships that shape our careers, the power of learning together, and the ways technology continues to transform the way we practice.

Click here to watch the first video.

Where to Listen

Bonded – A CDOCS Podcast is available now on the CDOCS website, Spotify and YouTube. Whether you’re in the office, on your commute, or winding down at home, tune in to be part of the conversation.

We can’t wait to share this journey with you. Subscribe, listen, and let’s get bonded!

New DS Core Features - General and Core Plan

2025-02-14T13:01:29Z

CDOCS is excited to share the latest updates to DS Core software from Dentsply Sirona, bringing enhanced features and improvements to elevate your digital dentistry experience.

New DS Core General Features

Visualization of 3rd Party Radiographic Files

DS Core now supports viewing radiographic files from Carestream, Planmeca, and Morita directly within the DS Core viewer. Users can access the same powerful tools available for DS radiographic files to enhance their viewing experience.

Additionally, users can upload multiple single-slice DICOM (.dcm) files from a folder or a single multi-slice DICOM file (.dcm). These files can be stored alongside other patient records, shared with colleagues, or included in lab orders for streamlined collaboration.

Note: This feature is not intended for diagnostic purposes.

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Media Library Improvements

Navigating a patient's media library is now more efficient with enhanced filtering options. Users can filter by file type and date, allowing them to quickly locate specific records.

Date Filter: Select a range or use the "older than" option for targeted searches.
File Type Filter: Options include digital impressions, intraoral radiographs, CBCT scans, design files, and more.
Improved File Identification: Original file names are now displayed alongside timestamps, simplifying organization.
Primescan 2 Scan Deletion: Users can now delete Primescan 2 scans like other files, except those linked to treatment scans.

Availability Notice: Deletion of Primescan 2 scans will be available starting February 24th.

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Bulk Download of Patient Files

Managing patient data is now easier with bulk download functionality. Users can download patient media through:

The All Actions button in the patient's media library (for a single patient)
The Patient List (for multiple patients)
The Practice Profile (for all patient media)

Once requested, DS Core prepares the files, which may take up to 24 hours. Users will receive an email and in-app notification when the files are ready for download.

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New DS Core Plan Features

CEREC SW 5.3.2 Connected with DS Core

The latest version of CEREC SW 5.3.2 now allows users to upload bridge case designs to DS Core, enabling centralized management of end-to-end manufacturing tasks. This integration ensures all necessary information is included for seamless manufacturing. Additional updates include: • DI & CAD/CAM Connector Included: The installer now includes the DI & CAD/CAM Connector, removing the need for a separate download. • Windows 11 and Graphics Compatibility: Enhanced support for Windows 11 24H2 and the latest NVIDIA graphic card drivers.

Availability Notice: The update will roll out via AutoUpdate starting February 19th.

Note: This feature requires InLab CAM SW connected with DS Core and a DS Core Standard Subscription or higher.

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New DS Core Make Features

Enhanced Email Notifications

Labs will now receive more informative email notifications when an order is received, improving communication and workflow efficiency. The updated emails include:

Sender's contact information
Comments and special instructions
Desired delivery date
Printable order sheet for documentation

Additionally, emails for accepted orders now contain more relevant details, improving order tracking and management.

Users can manage email notification preferences under the User Profile Settings in the Notification Tab.

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These new DS Core updates improve usability, efficiency, and workflow integration, ensuring a seamless experience for dental professionals and labs alike.

For more in depth videos on DS Core as well as other digital dentistry products join CDOCS or speak to one of our customer success managers today by calling 877.295.4276 or email at membership@cdocs.com

5 Secrets to Undetectable Chairside Anterior Restorations

2025-01-06T09:09:28Z

There are five major factors that go into perfecting the final outcome of your anterior restorations: design, anatomy, line angles, texture and, of course, shade. As an expert dental technician, I know if even one of these are off, you will instantly notice something isn’t quite right.

While creating a seamless blend can be tough, here are my five secrets that will have you creating realistic anterior restorations without having to send them to the lab.

1. Perfect the Design: Aim for an Identical Twin

Design is crucial and can make or break your case. Every embrasure needs to match perfectly, as even the slightest discrepancy is easy to spot. The width and overall dimensions of the ceramic must align with the contralateral tooth, even if the actual measurements don’t match exactly. This is where the use of line angles will trick the eye, making it appear as though the tooth is the same size.

[video:Perfect_the_Design.mp4]

2. Match the Anatomy with a Simple Dry and Scrub

As attendees in my “Lab-Quality Chairside Restorations: Mastering Stain and Glaze for Dentists and Their Teams” hands-on workshop learn, anatomy of the restoration needs to mirror the surrounding teeth. Check this by drying the surrounding teeth & scrubbing them with articulating paper. This helps to define the facial anatomy and depressions, allowing replication on the ceramic. After identifying the anatomy on the adjacent tooth, scrub the articulating paper on the ceramic and mimic the indicated depressions.

[video:Match_the_Anatomy.mp4]

3. Manipulate Line Angles for Flawless Symmetry

When symmetry isn’t perfect, you can make the restoration appear symmetrical by adjusting where the light hits through manipulation of the line angles. This is a powerful technique to ensure the restoration has the appearance of symmetry.

[video:Manipulate_Line_Angles_for_Flawless_Symmetry.mp4]

4. Nail the Texture for a Natural Look

Texture is incredibly important and can elevate or diminish the overall outcome of the restoration. Natural teeth don’t usually have a super shiny, glassy finish, but have more of a matte surface.

If you create a beautiful design and anatomy within the design but then apply a thick glaze, you risk losing all the fine detail you worked so hard to achieve. Sometimes a glaze with a honey-like consistency, which gives a highly glazed finish, is what the case needs, especially when matching other ceramics.

Other times, you need to mimic the natural texture of a tooth. This can be done by simply applying a thinner glaze and control the application amount to highlight the anatomy and blend the restoration more naturally. If after firing you find the glaze is too heavy, brush over it lightly with a Meisinger polisher to soften the finish while still preserving the underlying colors.

[video:Nail_the_Texture_for_a_Natural_Look.mp4]

5. Shade Match to the Highest Value

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Finally we come to shade, which is arguably the most important aspect.

Even if your line angles or design are slightly off, people may not notice, but if the shade is wrong, it will stand out. The key to shade matching is finding the highest value in the tooth you are matching.

For example, a patient may primarily be an A3.5 but near the incisal edge, the value could be A1. If you mill the A3.5 shade, the restoration will never match. You cannot increase value like you can decrease value. In this case, I would mill an A1 and use colors to lower the value where needed.

For shade customization, look at the patient’s before photo and intraorally to make sure nothing is missing. After treatment, dehydration from prolonged mouth opening and suction can cause the value of the teeth to increase, so make the shade appear lighter in this situation.

Over time, this process becomes easier and more predictable- it’s really an art. An art that you can master with the proper training and practice. Analyze the colors and replicate what you see, and always remember, you can always refire.

Is Dentistry Draining You? 5 Steps to Fight Burnout and Reignite Your Passion

2024-07-01T10:10:45Z

Burnout in dentistry is on the rise. For most dentists, it's not a matter of if you will experience burnout in your dental career but when.

Survey data from the 2023 ADA Council on Communications Trend Report found that more than 40% of dentists felt defeated, wanted to quit dentistry, or did not want to go to work in the six months leading up to the survey, with these feelings being more common in dentists 44 years and younger.

Furthermore, more than 90% of dentists reported feeling some type of stress about their careers, with middle-career dentists experiencing stress about insurance reimbursement and younger dentists feeling stress about debt, especially student loans.

Does this sound familiar?

Here are the five immediate steps you can take to start combating burnout:

1. Control your schedule

Research indicates that dentists are more stressed when running behind schedule than when dealing with difficult or demanding patients. When evaluating your schedule, reduce less valuable and highly frustrating procedures and instead prioritize high-value and high-energy procedures. Work with your front desk to assist with the scheduling organization, so you’re not shouldering all the weight.

2. Minimize debt

Develop a plan for repayment. Being debt-free is worth it! Routinely pay on any student loans, no matter the amount. Do not make rash money decisions or questionable investments. Obtain input on money matters from the financial and practice experts.

3. Do not isolate - Ask for help

Burnout thrives in isolation. When you’re feeling overwhelmed and discouraged, it’s tempting to withdraw from colleagues, friends, and family. But remember, imperfection is not a sign of weakness; it’s simply part of being human. Everyone faces challenges, and seeking help is a sign of strength, not a character flaw. Asking for help could be by talking to a trusted colleague or mentor, accessing resources and support groups, and even seeking professional help.

4. Engage with the dental community/collegial support

Burnout occurs when your energy is depleted, you don’t have much interest in people, and you don’t really feel like you are very effective at what you do. The opposite of burnout is engagement. Emotional exhaustion is replaced with energy, depersonalization is replaced with involvement, and reduced personal accomplishment is replaced with efficacy. Interacting with dentists who have high energy in dentistry can help inspire that energy in you.

5. Take care of yourself and your family

Establish boundaries with staff and patients by communicating clear expectations about appointment times, after-hours communication and emergency procedures. Make a clean break from work when you leave the office, prioritizing activities that bring you joy and fostering strong social connections through hobbies and time with loved ones. Remember, it's okay to say no sometimes. Focus on what you can control and learn to let go of the rest.

By taking proactive steps like managing your schedule, prioritizing financial wellness, seeking support, and maintaining a healthy work-life balance, you can significantly reduce your risk of burnout and cultivate a fulfilling and sustainable dental career. Remember, dentistry is a rewarding profession, and with some effort, you can ensure it stays that way for you.

4 Ways to Combat Dental Assistant Job Dissatisfaction that You Can Implement Today

2024-03-04T13:01:00Z

According to the Dental Assisting National Board, dental assistant job satisfaction has declined every year since 2016, and currently only 50% feel valued by their employer. Within the last year, feeling under appreciated is now the second highest reason dental assistants are leaving the dental field.

Even with the boosted team member benefits and increased hourly compensation, staff exodus and rising dissatisfaction are near the top of practice owners’ headaches.

There are opportunities for relief. Here are the four things you NEED to be doing to boost your assistants’ morale and job satisfaction.

Offer Ongoing Training and Development: Investing in continuous education and training programs demonstrates a commitment to the professional growth of dental assistants. Providing opportunities to learn new skills and advance their careers not only enhances job satisfaction but also improves the patient experience.
Be Intentional with Your Retention: These efforts are crucial for maintaining practice stability and continuity of care. Don’t be passive. Be direct. Set scheduled time every month with each of your assistants to solicit feedback and then act. Listening to their thoughts and concerns on various aspects of your practice and implementing positive changes based on their input demonstrates a commitment to their well-being and can help cultivate a loyal and motivated team.
Foster a Sense of Ownership and Engagement: Dental assistants may feel frustrated if they perceive their roles as being strictly the dentist’s helper, with limited autonomy and decision-making authority. Now is the time to change that! Dental assistants trained in specialized procedures can enable the practice to expand its service offerings. Whether it's through assisting in advanced treatments like dental implants or expanding their clinical functions, a broader range of services can attract more patients and increase revenue streams. Create opportunities to let them better highlight their worth.
Recognize and Appreciate Contributions: Dentists should acknowledge the hard work and dedication of dental assistants regularly. Every minute of the day is important, but this time will pay off for you, your team and your patients in the long run. Whether through verbal praise, written commendations, or small tokens of appreciation, recognizing their contributions boosts morale and reinforces a sense of value within the team.

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Click HERE to learn more about this limited time offer!

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One action you can take to address all four of these steps is gaining access to CDOCS GO and its Assistant training pathways through CDOCS’ Mentor+ membership. Never before has such high-level assistant training been so easily accessible.

CDOCS GO is a guided online learning platform that offers advanced training for dentists and comprehensive peer-to-peer assistant training on CEREC, Clear Aligners, 3D Printing, Implants, Endodontics and Cone Beam all at no travel cost. These assistant courses are often taught by the assistants of CDOCS’ expert-level faculty, meaning dentists can feel confident knowing the clinical education their assistants are receiving matches what they’re learning in hands-on CDOCS workshops.

Plus, assistants will have the chance to become ‘CDOCS Certified’ in each of the assistant pathway topics and receive a certification for their achievement that can be promoted and hung in the office.

Check out CDOCS GO now to view available dentist courses and assistant training pathways.

"CDOCS Came to the Rescue" - A CEREC Journey

2022-06-06T16:04:13Z

After working with both an Omnicam and a Bluecam, Dr. Rubecca Shahid decided to make the leap and purchase a new Primescan and register for CDOCS Fundamentals of CEREC Dentistry workshop.

"I knew this was a time when I really needed to step up my game and learn what I was missing in this puzzle," Dr. Shahid said. "That's where CDOCS came to the rescue!"

Watch below to hear all of Dr. Shahid's story, including how CDOCS Faculty Member Dr. Dan Butterman not only helped her identify all her issues, but as Dr. Shahid puts it - "he had answers to all my problems!"

[video:CEREC_CDOCS_Experience.mp4]

If you are interested in advancing your CEREC journey than register for our 90-Minute Crown Appointment with Chairside CAD/CAM workshop!

The Updated SureSmile Software Provides Enhanced Workflow and Patient Experience

2022-01-05T09:09:32Z

By Shivi Gupta, DMD
Sponsored by Dentsply Sirona

SureSmile Clear Aligner Therapy is fully integrated with my practice’s digital workflow. My team can collect treatment records efficiently and comfortably for our patients. Within minutes a full mouth digital scan is captured using the Primescan and this digital model is used for patient communication resulting in an increased case acceptance rate (Figure 1). Once the patient has approved treatment the digital scan in uploaded to the SureSmile software through the Case Connect Center on the Primescan. A series of intra- and extra-oral pictures, an optional CBCT or X-rays are also submitted to software that is browser-based and can be accessed from any computer.

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Figure 1 – Assistant Capturing a Full Mouth Digital can with the Primescan

The latest enhancements to the software have simplified and improved the treatment planning process. The dental examination is now completed on a tooth model like what is used in the CEREC software (Figure 2). The model is very intuitive ad we can easily click on teeth we plan for no movement, label teeth that have implants or those that will be extracted.

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Figure 2 – Enhanced Dental Examination

The new prescription process has been the greatest benefit of the recent software update. The older Macros has been replaced with a streamlined prescription (Figure 3). This simplified process enables clinicians to submit cases at a faster rate allowing for quicker turnaround times with patients starting treatment.

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Figure 3 – Streamlined Prescription Process

Where SureSmile really stands out is the excellent initial treatment plan that is designed and sent back from the SureSmile digital lab. The final treatment plan can then be dialed in using the software tools. The updated treatment planning tools are now housed in a favorites tab for easy access. The tooth movement icon on the bottom right of the screen (Figure 4) allows the displacements dialogue box to be toggled on and off. This provides more space to view the model in the patient overview screen.

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Figure 4 – Enhanced Patient Overview Screen

The outstanding initial set up results in fewer refinements and prevents aligner fatigue. Below is a 16 aligner SureSmile case (Figure 5 and 6) that required no refinements and finished on time as planned.

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Figure 5 and 6 – Before and After of 16 Aligner SureSmile Case

The predictability of the SureSmile aligner system allows for shorter treatment times, less chair time and overall greater patient satisfaction.

Shivi Gupta DMD
Scripps Rock Dental
12112 Scripps Summit Drive, San Diego CA 92131
Resident Faculty CDOCS
sgupta@cdocs.com

Full Mouth Rehabilitation

2021-12-08T08:08:12Z

Erin Green DDS
Sponsored By Ivoclar

Treating patients with TMD disorder caused by chronic grinding or clenching can be a challenging and often long process that can take months or even years to correct. Patients often present with severely worn dentition resulting in severe tooth sensitivity. As CEREC® dentists, we are accustomed to and pride ourselves on the ability to provide same-day dentistry. Even when we have a case that requires more than one visit, the case is usually resolved within a couple of days or a week. Occasionally, however, we are presented with a case, such as the one reported here, that requires multiple phases of treatment, with each phase carefully evaluated to ensure a decrease in TMD symptoms and a resolution of tooth sensitivity.

Case Report

The patient is a 45-year-old female with a history of chronic jaw pain and complaining of severe tooth sensitivity. She also was unhappy with the appearance of her worn dentition and very self-conscious of her smile (Figure 1). Past dental treatment to alleviate these issues included multiple nightguard/TMJ splints, therapeutic Botox treatment to relieve jaw pain, topical treatments for tooth sensitivity, and regular use of prescription strength fluoride toothpaste.

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Figure 1: Patient presented to the practice unhappy with her smile and complaining of a history of jaw pain, worn dentition and severe tooth sensitivity. A full mouth rehabilitation was proposed.

After a complete exam, the treatment plan proposed to the patient was a full mouth rehabilitation to restore lost tooth structure and missing teeth and improve the position of her jaw. The first phase of treatment would involve restoring the upper arch to address the patient's primary complaint of an unattractive smile and placing implants in both arches to address lost or missing tooth structure.

Although endentulous site #30 was determined suitable for implant placement, upon closer examination edentulous site #14 was deemed unfavorable due to a lack of restorative space, and it was recommended the site be restored with a 4-unit bridge. Vertical dimension of occlusion would need to be opened 1mm with crowns on upper and lower posterior teeth to ensure optimal esthetic proportions for maxillary and mandibular anterior restorations. Each phase of treatment would require the fabrication of new upper and lower nightguards to prevent grinding and damage to restored teeth.

This four-year treatment process began in July of 2017 with placement of an implant at tooth site #30 and restoration of her upper arch. To gain enough vertical dimension of occlusion to ensure esthetic proportions for the anterior crowns, teeth #4 and #5 were prepped for single crowns and teeth #12-#15 for a bridge. The preparations were scanned and imported to CAD software for design and milling of the full contour crowns (Figures 2 and 3) and 4-unit bridge (IPS e.max CAD, Ivoclar Vivadent). Once the patient approved the new bite, restoration of her worn anterior teeth #6-#11 could be executed. The teeth were prepped, scanned and full-contour crowns CAD designed, milled and seated (Figures 4 and 5) (IPS e.max CAD).

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Figures 2 and 3: To gain enough vertical dimension of occlusion to ensure esthetic proportions for anterior crowns, teeth #4 and #5 were restored with single crowns and a 4-unit bridge on teeth #12-#15.

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Figures 4 and 5: Vertical dimension was achieved to ensure esthetic proportions for crowns on teeth #6-#11.

However, at a later appointment, the patient complained she could not tolerate the 4-unit bridge on teeth #12-#15 and opted instead to restore those teeth with single crowns on teeth #12, 13, and 15 (Figure 6). The single crowns were milled and seated, and implant site #30 restored with a full contour crown, completing the upper arch restoration.

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Figure 6: The 4-unit bridge placed on teeth #12-#15 was replaced with milled single full contour crowns after the patient complained she had difficulty tolerating the bridge.

Over the next couple of years, the patient reported that symptoms of her TMD had remained unchanged and in March of 2021 was ready to initiate treatment of her lower arch.

A Lucia jig was used to capture and restore the patient's centric relation. Her VOD was increased by 1mm. Teeth #18-#21 and #29-#31 were prepped and overlay restorations designed (Figure 7), fabricated (Tetric CAD, Ivoclar Vivadent) and seated.

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Figure 7: Onlays were designed and seated on teeth #18-#21and #29-#31.

In June of 2021, the patient reported she had adjusted well to the new bite, which had decreased her TMD symptoms and lessened her desire to clench and grind her teeth. At that appointment permanent restorations for her lower anterior teeth were initiated. For severely worn lower anterior teeth #22-#27 (Figure 8) veneers were prescribed. The teeth were prepped (Figure 9) and veneers designed, milled and seated. The full arch rehabilitation was completed with replacement of the Tetric CAD overlays on teeth #17-#20 and #29-31. IPS e.max CAD veneers were milled and seated at the approved centric bite position (Figure 10). All restorations were milled of IPS e.max CAD MT shade B1 and cemented with Adhese Vivapen/ Variolink Esthetic combo (Figures 11-14).

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Figure 8: To restore the patient’s worn lower dentition, veneers were prescribed for teeth #22-#27.

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Figure 9: Final veneers were seated on teeth #22-#27.

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Figure 10: The Tetric CAD onlays were replaced with IPS e.max CAD veneers on teeth #17-#20 and #29-#31, completing the restoration of the lower arch.

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Figures 11-14: The full mouth rehabilitation restored the patient’s smile, resolved her tooth sensitivity issue, and continues to decrease her symptoms of TMD.

The patient was thrilled with her new smile and continues to report decreased TMD symptoms and complete resolution of tooth sensitivity.

Connecting the Patient to Financial Assistance

2021-11-30T11:11:22Z

Patient financing made easy with transparent payment options, competitive APRs, and monthly payment plans.

Millions of Americans don't have dental insurance, and for those who do, coverage doesn’t include all dental treatments. Patients deserve a more affordable option than paying out of pocket or using a credit card with a high interest rate, and dental practices deserve to focus on caring for patients, not payments.

LendingClub Patient Solutions is a dental practice’s financing partner. The plans provide budget-friendly monthly payments, removing cost as a barrier and allowing more patients to move forward with their treatment.

Hugh Crean, Senior Vice President at LendingClub, said that financing using their solution also removes the financing burden from the staff. “Any patient questions regarding payment plans are directed to us,” Crean explained. “Providers get paid in 1 to 2 business days from payment plan approval. It’s a win-win for both the provider and the patient.”

The experienced team at LendingClub Patient Solutions is passionate about delivering flexible, transparent plans and supporting them with outstanding service. “Our knowledgeable Customer Care team will take questions from providers and patients by phone, email, or live chat,” shared Crean. “Our team of account managers works with providers to optimize their patient financing strategy.”

Another advantage to LendingClub is multi-disbursement. “We make it easy for surgeons and referring practices to be paid quickly for complex cases,” said Crean. “Practices are paid when the patient’s payment plan is funded, and it’s all done with a single, simple application process.”

Increasing Case Acceptance

Payment plans offered through LendingClub Patient Solutions have the power to increase case acceptance. Often, the patient understands the benefits of the treatment you’ve just outlined, but there’s still hesitancy. Presenting a budget-friendly monthly payment can make the conversation around treatment cost that much more productive. When affordability is no longer an issue, the chances of hearing “yes” are that much greater.

And with LendingClub, patients can check what payment plans they are prequalified for, with no impact to their credit until they select a plan and move forward.

Partnering for Success

It's more important than ever for practices to partner with supportive services like LendingClub Patient Solutions.

“We want providers to be able to grow their practice and help patients afford the necessary dental care they need,” concluded Crean.

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ENROLL NOW
Visit www.lendingclub.com/patientsolutions/ enroll to register your practice with LendingClub Patient Solutions.

FOR MORE INFORMATION:
800.630.1663
www.lendingclub.com/patientsolutions/

Milling and Post-mill Processing of 3M Chairside Zirconia

2021-11-23T12:12:23Z

By Dr. Michael Snider
Sponsored by 3M

In our last article, we dove into zirconia and its structure. We highlighted the properties that allow zirconia to be such a versatile dental restorative material. We also highlighted some of the properties of the 3MTM Chairside Zirconia, and what gives it the unique blend of functional strength and esthetics.

In this article, I would like to discuss the milling and post-mill processing of 3MTM Chairside Zirconia. To begin, the milling process of zirconia is quite a bit different than the grinding process that is used with chairside glass ceramics. The smaller diameter of the carbide burs used in the milling process, compared to the diamond burs used in the grinding process, allows for markedly less overmiling of the intaglio of the restoration. The overmiling phenomenon is highlighted by the images below. The crown was designed to go over a custom abutment. The restoration on the left shows the grinding process using the diamond burs. The restoration on the right shows the milling process using the carbide burs.

[image:Figure_1a_Grinding_Process.png] [image:Figure_1b_Milling_Process.jpg]
Figures 1a & 1b: Grinding vs. Milling Process

The milling process with zirconia is outstanding with the new Primemill from Dentsply Sirona. We have multiple milling options with the Primemill. There is Fast, Fine, and Extra Fine. I find myself using the fast mill option most of the time in practice for single units. However, when I am doing bridges, I usually find myself using the extra fine option. I prefer the extra fine setting for bridges because I can achieve more definition at the embrasures associated with the connectors. The images below compare the fast, fine, and extra fine milling of a single unit of 3MTM Chairside Zirconia.

[image:Figure_2a_Fast_milling_of_3M_Chairside_Zirconia.png] [image:Figure_2b_Fine_milling_of_3M_Chairside_Zirconia.png] [image:Figure_2c_Extra_Fine_milling_of_3M_Chairside_Zirconia.png]
Figures 2a, 2b & 2c: Fast, Fine, and Extra Fine milling of 3MTM Chairside Zirconia

As you can see from the images in Figure 2, there is a difference in the overall occlusal anatomy that is generated from the burs when extra fine milling is used. However, in my practice the ability to fast mill in roughly 5 minutes compared to the anatomy I receive from extra fine milling at 18 minutes is not relevant.

[image:Figure_3a_Mill_time_of_single_unit_at_Fast_Mill_Setting.png] [image:Figure_3b_Mill_time_of_single_unit_at_Fine_Mill_Setting.png] [image:Figure_3c_Mill_time_of_single_unit_at_Extra_Fine_Mill_Setting.png]
Figures 3a, 3b & 3c: Mill times of single unit at Fast, Fine, and Extra Fine Mill Settings

Regardless of the mill speed that is selected, the marginal integrity when milling zirconia is unrivaled. The softness of the material in the green state, combined with the carbide burs make for margins that are pristine. We do not see any chipping at the margin like we can see with some of the other glass ceramics when milling a fine margin.

[image:Figure_4_Margins_of_milled_3M_Chairside_Zirconia.png]
Figure 4: Margins of milled 3M Chairside Zirconia

In my practice, I try to keep the post mill processing of zirconia very simple for my team members. We first use a fine carbide bur to remove the sprue. Next, we use the Blue Twist Polisher from Meisinger to remove any of the superficial scratches left from the milling process. Then, it is important to remove any zirconia dust from the restoration. If any dust is left on the surface of the restoration, it will affect the esthetics of the final product when sintered.

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Figure 5: Removal of Sprue

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Figure 6: Prepolish with Blue Twist Polisher

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Figure 7: Removing the residual zirconia dust from restoration

Once cleaned, the restoration is then sintered in the SpeedFire Oven from Dentsply Sirona. The restoration is always placed occlusal side down. This takes into account the shrinkage that happens during the sintering process. We wouldn’t want our margins dragging against the firing pad as the restoration shrinks during sintering.

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Figure 8: Placement of restoration for sintering

The technology of the SpeedFire Oven is what allows zirconia to now be a chairside restorative material. Before the SpeedFire Oven, the process of sintering zirconia would take multiple hours. Although it was a fantastic material, the long processing time made it useless in a chairside, same day, application. To now be able to sinter this material in roughly 20 minutes is an absolute game changer in chairside dentistry.

[image:Figure_9_Sintering_time_of_3M_Chairside_Zirconia.png]
Figure 9: Sintering time of 3M Chairside Zirconia

In the photo below you can see the importance of the pre-polishing step. The crown on the left was not pre-polished and you can still see the horizontal striations left from the milling process on the buccal cusp. The crown on the right received the pre-polish and will be much easier to complete the post-sintering process.

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Figure 10: Crown without prepolishing step (left) and crown with prepolishing completed (right)

In our practice, most of the single unit posterior 3M^TM Chairside Zirconia are not glazed. We simply polish the restoration and then deliver it to the patient. My go to for final polish is the Yellow Twist Polisher from Meisinger.

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Figure 11: Final Polish of restoration with Yellow Twist Polisher from Meisinger

By using just three simple steps, we can fabricate predictable and esthetic restorations for our patients. I love the simplicity of the armamentarium that my team needs to process a zirconia restoration post-mill. It doesn’t require a lot of burs, glazes, stains, etc. It is just three burs as mentioned previously.

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Figure 12: Armamentarium for Post Mill Processing of 3M Chairside Zirconia

In our practice, we almost exclusively polish zirconia, however glazing is also an option after the sintering process is completed. The restoration is mounted on one of the firing pins included with the SpeedFire Oven and then spray glaze can be added. The glazing cycle is quick, at only around 9 minutes. The key here is to apply a fine, even coat of glaze for the entire restoration. We do not want to see the glaze accumulating and becoming runny on the surface of the restoration.

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Figure 13: Appropriate glaze application (left) versus too much glaze application (right)

3M^TM Chairside Zirconia is a material that offers me the esthetics I want and strength that I need in my posterior restorations. In the case below, the patient presented with a failing amalgam restoration on tooth #3. The decision was made to restore this case with a full coverage restoration. The ability to be conservative with preparations when using 3MTM Chairside Zirconia makes these cases simplistic. In the final image you can see the 3MTM Chairside Zirconia, adjacent to an e.max LT restoration on #4 and a porcelain fused to metal crown on tooth #5.

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Figure 14: Before and After restoration of #3 with 3MTM Chairside Zirconia

Next time, we will discuss the delivery process of 3M^TM Chairside Zirconia for our final article in the series. When to consider bonding the restorations and when to consider conventional cementation. The beauty of this material, especially when partnered with 3M^TM Scotchbond^TM Universal Plus Adhesive and 3M^TM RelyX^TM Universal Resin Cement, is the versatility in delivery options.

The Key to Higher Case Acceptance

2021-11-17T11:11:41Z

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Q&A with Matt Jones, Business Development Manager, LendingClub Patient Solutions

A huge factor in case acceptance is cost, and most of the dental industry is stuck in the mindset that patients won’t pay interest. With the ability to offer better APRs to people with good credit and show patients the APRs they prequalify for with no effect on their credit score, LendingClub stands out from the rest. We recently spoke with Matt Jones, the Senior Business Development Manager at LendingClub Patient Solutions, about why LendingClub is the right choice for any practice.

Q. Why should practices start using LendingClub?

A. LendingClub Patient Solutions is one of the most trusted names in dental financing. We’ve been helping people afford their dentistry since 2007 and currently work with over 23,000 providers nationwide. With some of the most attractive and patient-friendly payment plans on the market, you’ll see more and more patients saying “yes” to optimal treatment.

Q. How is LendingClub a practice builder?

A. Practice growth starts with case acceptance, and presenting affordable payment options plays a key role in that. LendingClub provides a robust suite of payment options. Our big differentiator is our installment loans. In my 15 years of being a consultant in the patient financing industry, the number 1 mistake that I see practices make is relying on no-interest or “interest-free” plans too often. These can be ineffective for larger treatment plans. For example, a $10,000 case is about $834/month with a 12-month no-interest plan, which is not affordable for many patients. The APR for other patient financing companies' extended, or "budget" plans, is usually a flat rate of around 17.90%. LendingClub rewards well-qualified applicants with an APR that’s more in line with their qualifications. Our interest rates can be as low as 4.99% APR and are based on term length and credit standing.

Q. Does LendingClub lead to a production increase, and therefore a revenue increase, in practices?

A. Absolutely. With our industry-leading approval rates, and patient-friendly payment plans, the typical dental practice will see a lift in their overall case acceptance, especially on their largest cases. This will have a major impact on revenue. Plus, patients can generally finance any treatment they are receiving at the dentist’s office. This includes implants, crowns, periodontal treatment, oral surgery, TMJ treatment, cosmetic dentistry, and more.

Q.What are some common concerns about LendingClub and how can they be addressed?

A. We get a lot of questions surrounding our approval rates, but we always assure potential clients that we are as responsible as possible when it comes to approving people for credit. In fact, we consistently get feedback from clients saying that our approval rate is the best they’ve ever had.

One misconception is that it will be a big hassle to get set up on our platform, and that there will be hours of training to get onboarded. Our online enrollment only takes about 5 to 10 minutes to complete, and an orientation typically only takes about 20 to 30 minutes over the phone. The practices we serve are often pleasantly surprised when they realize how quick and easy our application process is.

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The Vantage Point II

2021-11-10T09:09:15Z

The Seminar is over but the recorded session is available here:

[cerecvideo:5286|The Vantage Point II]

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Free Virtual Seminar

December 3 • 2pm EST | 11am PST

Join Dr. Sameer Puri, CDOCS VP of Education, on December 3rd as he hosts The Vantage Point II!

This virtual seminar will discuss the clinical, digital and scientific applications of the esthetic zirconia KATANA from Kuraray Noritake with three prominent clinicians.

The event will also include presentations from Dr. Lynne Thomas, Dr. Robert Winter and Dr. Markus Blatz, as well as an opportunity for the audience questions to be answered during a Q&A and open discussion with each expert.

Click here for the full agenda and to get registered!

Revolutionizing Practices Using Digital Dentistry: Part 3

2021-11-05T09:09:13Z

By Dr. Ahmad Al-Hassiny
Sponsored by Ivoclar

Part I
Part II

Digital dentistry offers us incredible tools for same-day treatment of patients in immediate need and to control every aspect of a case whether it’s a single crown or smile makeover. Not only is a digital workflow more efficient than conventional treatment methods for restoring a patient's function and esthetics, it is also much more accurate. Digitally captured case data can be stored, cloned, shared with other team members very easily and manipulated in ways that conventional methods cannot provide. One of the most significant advantages of digitizing a case is the ability inspect and rotate the captured data, enlarge it and look at all aspects up close, which has a research-proven positive impact on the quality of the preparations and ultimately the fit and function of the final restorations.

Presented here are two cases, quite different in nature, which demonstrate the strength, versatility, and case control that digital dentistry brings to our practice.

Case 1

This case showcases how a trauma patient can be treated immediately in a single visit. This 19-year-old male presented to my practice with severely fractured teeth #7 and #8 (Figure 1) as a result of being assaulted. Unfortunately, he had waited 48 hours before seeking treatment and the exposed pulp required us to perform root canals on both anterior teeth with core build-ups to retain the crowns (Figure 2). The teeth were prepped and the preps scanned. Two full-contour crowns in shade A2 (IPS e.max CAD, Ivoclar Vivadent) were milled, then crystalized, stained, glazed and placed in the mouth (Figure 3). One year later the patient returned for a post-op appointment to ensure the success of the root canal procedure and that the margins had filled in nicely with no inflammation (Figures 4 and 5).

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Figure 1: Blunt force trauma fractured and chipped this 19-year-old patient’s anterior teeth #7 and #8, which were repaired in single visit.

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Figure 2: Patient delay in seeking treatment resulted in root canals on both teeth being needed due to irreversible pulpitis.

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Figure 3: The two full contour IPS e.max CAD crowns immediately after seating.

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Figures 4 and 5: The patient one-year later confirmed marginal integrity of the two crowns and success of the root canal therapy.

Case 2 (Val)

This was one of those situations where the case was not completed in a single visit. However it demonstrates how digital dentistry allows the clinician to efficiently control every aspect of the case from preparation, temporization to final restorations. A 43-year-old woman came to my practice for a smile makeover to repair her chipped teeth and close the diastema between teeth #8 and #9 (Figure 6). Upon examination it was clear that the root canals on teeth #12 and #13 were failing and the pre-molar on her left side was compromised. It was decided to place a 4-unit full-contour zirconia bridge on teeth #11-14 and individual crowns in the esthetic zone on teeth #6, 7, 8, 9, and 10 (IPS e.max CAD, Ivoclar Vivadent). The teeth were prepped (Figure 7), scanned and new restorations created. We then 3D printed a model and filled the putty wash matrix (Figure 8) with a self-cure composite material (Luxatemp Ultra, DMG) to create provisionals for the patient to wear for a week to get feedback on fit, function and color (Figure 9). At the final appointment her comment that the provisionals were too white and didn’t match the rest of her teeth was noted for milling of the final restorations (Figures 10-11). The final restorations were milled and seated in the mouth at that second visit (Figure 12).

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Figure 6: This 43-year-old patient presented with multiple chipped unaesthetic teeth, a large diastema, and failing root canals.

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Figure 7: The patient’s teeth were prepped for a 4-unit zirconia bridge on teeth #11-#14 and single full-contour crowns on teeth #6-#10. The preps were scanned and the bridge and individual crowns created.

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Figure 8: From a scan of the final design, a model was 3D printed and a putty wash matrix used to create provisionals.

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Figure 9: The patient was asked to wear the provisionals for a week to assure fit, function and esthetics of the treatment proposal.

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Figures 10 and 11: The final milled restorations on the model and seated in the mouth.

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Figure 12: The final restorations immediately after seating.

Revolutionizing Practices Using Digital Dentistry: Part 2

2021-10-29T11:11:40Z

By Dr. Ahmad Al-Hassiny
Sponsored by Ivoclar

In Part II of this three-part series, Dr. Ahmad Al-Hassiny shares the workflow processes that maximize his clinical efficiency and profitability as well as helpful tips to ensure success of the single-visit CAD/CAM restoration.

If you missed Part I

Part II

Transitioning a traditional dental practice to a digital workflow offers a unique set of challenges for practitioners steeped in the conventional analog treatment process. Certainly, that was true in our situation here in Wellington, New Zealand where our independently operated clinics would need to make that transition. As one could imagine, the first challenge was the expense of outfitting each of our clinics with CEREC® CAD/CAM systems, let alone all the other intraoral scanners, milling machines, 3D printers we have purchased over the years. This undertaking was an incredibly significant investment, not to mention the inventory of materials each clinic would require. The second major hurdle, and probably the most critical challenge, was the learning curve for our associates and us. However, we all agreed that the expense would be justified and the initiative profitable if we were able to perfect a digital workflow that was efficient, maximized clinical processes, and was streamlined effectively enough to minimize chairtime for patients.

As we undertook our transition, digital technologies matured, as did the millable materials. Modern intraoral scanners are now much faster and more accurate; milling technologies more precise; CAD software more intuitive and user-friendly; and materials much stronger, more predictable, and esthetic. Most importantly, our associates and I worked very hard to master and streamline our workflow processes, which directly impacted the profitability of our practices.

Today, our standard workflow from prep to design and mill for a single crown can be accomplished within 45 minutes or less, and the final crown is seated in an hour to an hour and a half on average. After we prep the tooth, we routinely use retraction cord (Figure 1) to displace the gingiva and ensure an accurate scan of the margins and a dry field of operation to avoid contamination from blood, saliva, or crevicular fluid. We take an intraoral scan using CEREC Primescan for our same-day dentistry and design using CEREC Biogeneric software. Our dental assistants are fully trained to be proficient with using CAD software (Figure 2-3) and do all of our CAD designs with clinician oversight, and approval of the final design, and the design is then sent to the milling machine (Figure 4). Our staff is also trained in all of the post-processing steps, from the crystallization firing process to staining and glazing the final restoration (Figure 5). In the meantime, the retraction cord stays in place so that during the seating of the final crown the fit at the margin is clearly visible and once cemented, excess cement is removed as the cord is removed. Most critical to this process and the profitability of our practices is that while the design, milling, and post-processing is taking place, our clinicians are busy seeing and treating other patients. Single-visit dentistry can be immensely profitable if done well. Now 95 percent of the work that was once sent to the laboratory is completed in-house. This effectively slashed our lab bill by more than 70%.

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Figure 1: Application of a retraction cord around a prepared tooth before scanning displaces the gingiva and ensures an accurate scan of the margins as well as a dry field of operation.

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Figures 2-3: Our dental assistants are fully trained to be proficient with the CAD software and do all of our CAD designs with clinician oversight, which frees me to see other patients during this same-day workflow process.

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Figure 4: Our dental assistants also process and mill same-day restorations.

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Figure 5: My dental assistants also perform post-milling staining, glazing, and crystallizing of the IPS e.max CAD crowns. The Programat CS2 firing furnace allows for the IPS e.max CAD crowns to be fired within 15 minutes.

My advice to colleagues who are thinking of entering this space is not to be afraid of the cost, learning curve, and new workflow processes. We hire new associates steeped in the analog process, and within about two months or less, they are proficient with the CAD/CAM process and workflow. Even if you are doing same-day dentistry already, the key to that transition or perfecting your workflow is immersing yourself in online and in-person learning from those who have mastered the CAD/CAM equipment and digital workflow process.

Also, choose a restorative material that offers the confidence of predictability, flexibility, strength, and esthetics in all areas of the mouth. Here in New Zealand, zirconia is not the typical go-to material, as it is in the States. We need a material that research has shown to have all these characteristics as well as a fracture rate of less than 1%-2%. That’s why we chose IPS e.max. Millions of these restorations have been placed globally, and the research on this material is extensive.

One vital key to success when using CAD/CAM processes is tooth preparation. Above all things, this matters the most. If you under prep or prep poorly, the entire process will be more challenging, slower, and less efficient. I, and many of my colleagues, thought we were masters of tooth preparation until we transitioned to CAD/CAM and could see our preparations on the computer screen. With the ability to examine all aspects of your preparation in 3D, you can see any flaws and make corrections while the patient is in the chair. Using intraoral scanners makes you a better dentist due to the instant feedback you receive about the quality of your preparation.

A critical area that requires attention during tooth preparation for the CAD/CAM process is adequate occlusal reduction. The primary reason for the failure of all-ceramic restorations is inadequate tooth reduction. Depending on the restorative material being used, you need at least 1mm of occlusal reduction to ensure the integrity and durability of that restoration. If you don’t reduce the occlusal to that degree, the software will compensate, and you will either end up with a poorly designed restoration invading minimal thickness or a high spot on the finished crown that risks fracture from occlusal forces.

Without a doubt, the CAD/CAM process is extraordinarily accurate and can be used for a wide range of chairside single visit cases (Figures 6-10). However, the output is only as good as the input. In Part III of this series, I will share some of the clinical cases from a single crown to full quadrant dentistry that we have completed using our same-day dentistry workflow and processes.

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Figure This patient presented with a decoronated tooth, which required emergency same-day treatment.

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Figure 7: CEREC and same-day dentistry enable us to provide treatment modalities that were otherwise not possible in a single visit. Because this patient needed treatment the same day, we decided to keep the root. The post and core were carried out under rubber dam.

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Figure 8: The preparation was scanned using CEREC Omnicam.

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Figure 9: The final crown was designed chairside using CEREC Omnicam.

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Figure 10: The final crown milled from IPS e.max CAD using CEREC MC XL achieved a great shade-match. This otherwise "temporary" fix has been in the patient's mouth for 6 years and counting.

Revolutionizing Practices Using Digital Dentistry: Part 1

2021-10-22T10:10:01Z

In this 3-part series, Dr. Ahmad Al-Hassiny shares how digital dentistry has revolutionized his New Zealand clinics, streamlined workflow efficiencies, and significantly increased profitability.

Sponsored by Ivoclar

Part I

Digital dentistry has transformed our dental practices here in Wellington, New Zealand, and continues to revolutionize the field of dentistry. Even though we are almost 8,000 air miles and 17 hours apart from our colleagues in the US, I am sure our digital journeys share similarities. For us, it has been a 15-year undertaking to transform our five dental clinics from the comfort zone of status quo dentistry to a fully digital workflow. Today, each of our clinics is equipped with a CEREC® system and all the latest materials and technologies the profession offers (Figures 1-3). In fact, we are so passionate about the possibilities of digital dentistry that we opened New Zealand’s first digital dentistry training center where like-minded dental professionals from around the globe gather for live and online courses. Our mission is to ensure dental professionals gain the knowledge and confidence they need to use digital dentistry effectively and efficiently.

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Figure 1: Central Hutt Dental, New Zealand is an eleven-chair dental clinic and one of five clinics established, owned, and operated by the Al-Hassiny family. 

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Figure 2: Our Institute of Digital Dentistry offers the latest clinical and laboratory CAD/CAM equipment from intraoral scanners and laboratory scanners to photogrammetry devices, milling machines, and 3D printers.

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Figure 3: The laboratory at the Institute of Digital Dentistry Laboratory, Naenae Dental Clinic, New Zealand.

That knowledge and confidence we gained from our journey to achieve high-quality same-day restorations has completely changed how we practice dentistry and the perception of our patients on how dentistry is practiced. Our patients are “wowed” by our ability to provide them with single-visit restorations, which has become a significant selling point to families and friends and an enormously profitable and free marketing tool for our practice. Patients love the concept of leaving the practice with a new beautiful, life-like smile (Figure 4-5), or more simply a same-day crown. No more temporaries; no waiting for weeks for the final restorations; and few, if any, final adjustments after seating (Figures 6-9).

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Figures 4-5: This smile makeover involved full coverage crowns for teeth #13-23 milled from IPS e.max CAD in MT B1. The monolithic crowns were stained and glazed to optimize the esthetics.

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Figure 6: This interdisciplinary full-mouth rehabilitation was performed on a patient with severe bruxism-related attrition. Prior to treatment, the patient underwent orthodontic treatment and multiple implant surgeries including a sinus lift.

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Figure 7: Full-contour crowns for teeth #1-#16 were milled from IPS e.max CAD and fitted on a 3D-printed model prior to staining and glazing.

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Figure 8: The final IPS e.max CAD restorations fired, stained, and glazed.

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Figure 9: The patient at a 2-year recall. The IPS e.max CAD crowns were cemented using a resin adhesive, posterior implant-supported crowns followed.

Of course, our journey, like yours, would not be possible without proven technologies and research-based materials that provide the combined trifecta of strength, esthetics, and workflow efficiency. Over the years, we have placed more than 10,000 digitally-driven restorations, 90% of which were fabricated from a single all-ceramic material (IPS e.max^® CAD, Ivoclar Vivadent). Whether a single crown or a quadrant, we rely on materials that provide the highest quality esthetics while maximizing our time, workflow efficiency, and profit, as well as the comfort and convenience of our patients. For example, if we find decay mesial or distal to a crown preparation, which is quite common, we can simply prep the site, restore with an inlay or onlay milled from a complementary material (Tetric^® CAD, Ivoclar Vivadent), and bond both at the same appointment (Figures 10-15).

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Figure 10: This same-day case involved restoring teeth #1-#3 with full-contour crowns and inlays. The patient was experiencing symptoms similar to cracked tooth syndrome.

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Figure 11: During tooth preparation the amalgam fillings were removed, decay excavated, and compromised tooth structure reduced.

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Figure 12: The preparations were scanned and margins deliniated using CEREC Primescan.

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Figure 13: The inlays and full contour crowns designed using CEREC Primescan.

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Figure 14: The inlays were milled from a Tetric CAD block (Ivoclar Vivadent).

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Figure15: This immediate post-op image shows the final seated restorations cemented using resin adhesive cement. The Tetric CAD inlays were polished and the IPS e.max CAD crowns stained, glazed, and crystallized for final esthetics.

Perfecting a digital workflow that is efficient, that maximizes timesaving processes and that increases profitability requires constant tweaking as the field of digital dentistry continues to evolve. In Part II, I will share the workflow processes we have found most efficient and helpful tips and techniques we have incorporated to ensure we provide optimum dental care in a single visit.

Transverse Considerations in Periodontal Attachment Loss

2021-10-06T08:08:09Z

Shalin Shah, DMD, MS

The goals of orthodontic treatment are well established for the sagittal and vertical dimensions in terms of how the teeth and jaws should relate, fit, and work together. Diagnostic and treatment strategies focusing on these dimensions are the topic of many orthodontic symposiums, conferences, and research papers. However, the transverse dimension is often missing from generally accepted and performed patient analyses and discussions. Additionally, well-defined criteria for determining if there is a need for correction based on objective means, instead of subjective, frequently are not used.

As there are treatment goals for the final tooth positions based on sagittal and vertical skeletal dimensions, there must be a set of defined goals for the transverse. For the posterior teeth, these would be to have them upright and centered in the alveolus in addition to being well-intercuspated with proper arch coordination, as shown in Figure 1.

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Figure 1: Posterior Tooth Position

When there is a skeletal transverse discrepancy, oftentimes this is recognized by a posterior dental crossbite. However, many times there is no posterior dental crossbite, but the maxillary posterior teeth are tipped buccally, and mandibular posterior teeth are inclined lingually to compensate for the skeletal disharmony. This compensated dental arrangement opens the patient to a higher likelihood for non-working interferences from plunging palatal cups, centric prematurities, and functional shifts, in addition to placing off-axis forces on the dentition. “Decompensation” which uprights and centers the teeth in the alveolus, then reveals the underlying “skeletal crossbite” and amount of skeletal correction required, as shown in Figure 2.

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Figure 2: Ideal, Compensated, Decompensated Relationship

While it is possible to achieve good uprighting and intercuspation of the posterior teeth in the presence of a skeletal disharmony, a risk of doing so is potential compromise to the periodontium. In an attempt to upright and well-intercuspate the teeth in the presence of a discrepancy, the amount of soft tissue and bone overlying the roots becomes thinner (Figure 3) because the teeth will no longer be centered in the alveolus. In mild discrepancies, the effects of this dental positioning may not pose a concern. However, in severe transverse discrepancies, an attempt to normalize the posterior dentition inclination and intercuspation in light of the uncorrected skeletal disharmony risks root fenestration and clinically obvious attachment loss, as shown in Figure 4.

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Figure 3: Thinner tissue and Bone on Maxillary Tooth

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Figure 4 Root Fenestration and Attachment Loss

Moderate skeletal discrepancies are the most common missed situation using just clinical observation and not an objective analysis. However, a practitioner can gain an appreciation for where an underlying skeletal crossbite is present, in the absence of a dental one, by looking at the inclinations of the mandibular teeth (Figure 5).

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Figure 5 Mandibular Teeth Inclination

In these scenarios the consequences of attempted tooth position normalization, without skeletal correction, and their effect on long-term periodontal viability may not be immediately realized clinically. On debond it may appear that the posterior teeth were corrected with just using brackets, cross-elastics, or expanded archwires. However, because no overt attachment loss was seen during treatment, the practitioner may wrongly assume that no harm was done to the patient or the periodontium is viable and resilient for the long term.

Over time and in a susceptible patient, as stated above, the gingival attachment may be less resilient to normal stresses placed on it due to the reduced bulk of tissue vs. the amount present in a non-compromised patient. There is now a higher risk for mechanically-induced periodontal tissue loss, especially for those patients who may have a thinner tissue biotype at baseline. Therefore, the negative sequelae of loss of attachment and recession may not appear until years or decades later, depending on the patient’s adaptability, periodontal biotype, and genetic makeup².

Welcoming Our Newest Resident Faculty Member

2021-10-04T10:10:29Z

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CDOCS is incredibly proud to welcome Dr. Shivi Gupta as its newest CDOCS Resident Faculty member.

Dr. Gupta, a current CDOCS Mentor, owns a private practice in San Diego, CA with a focus on CEREC and CBCT technology, using these technologies to their fullest potentials for crowns and bridges, implants, smile designs and orthodontics.

She brings nearly two decades of practice experience to our faculty, as well as serving as a beta tester for Dentsply Sirona and an advanced trainer for Patterson Dental. She has also lectured all over the world on CAD/CAM and digital dentistry.

"I was first introduced to CDOCS 12 years ago," Dr. Gupta said. "I immediately knew there was something unique and incredible about this group. I was drawn to the culture and the dynamic community. I am honored to be Resident Faculty at CDOCS, and join my colleagues in delivering exceptional dental education."

Dr. Gupta graduated from the University of Manitoba, Canada and the Advanced Education in General Dentistry residency from the University of Texas Health Center in San Antonio.

For CDOCS, she will be teaching Fundamentals of CEREC Dentistry (CL2) and Implants in the Esthetic Zone (CI5).

Extra Fine Milling Katana STML

2021-09-29T09:09:18Z

Mike Skramstad, DDS
Sponsored by Dentsply Sirona

This patient presented with a RCT tooth that previously had a PFM crown. That crown fractured off and took some of the tooth structure with it.

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Pre-op tooth #14

There was no decay present, excellent oral hygiene, and sufficient tooth structure to make a new buildup and crown for this patient

Since there was no enamel present, the tooth was already prepared for a conventional crown, and we needed to maximize resistance and retention form, a full coverage zirconia crown was chosen. Katana STML was the zirconia we planned to use because the rest of her arch was restored with IPS e.max CAD and we wanted to match the translucency as close as possible.

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Preparation tooth #14

Since we had some extra time allocated for this patient (1 hour and 40 minutes), we also decided to use the Extra Fine Zirconia milling for this case. In addition to the 2.5 CS shaper bur and 1.0 CS finisher, there is a smaller .5mm CS finisher to create extra detailed anatomy and minimize finishing after the manufacturer process.

After anesthetizing the patient with 4% Articaine, the shade was taken for the restoration. It was determined that we would use an A2 Katana STML block. Once the shade was taken, the block information was entered into the Primemill and the touch process was initiated.

After starting the touch process, the patient information and Administration Phase was completed (designating Katana STML Milling for the restoration).

After a bonded buildup was completed, a full coverage restoration was then prepared with appropriate resistance and retention form for a cementable zirconia restoration. We prepped to the gumline with a 1.0mm modified shoulder (Winter Shoulder) and reduced occlusally by 2.0 mm to guarantee the final restoration had nice anatomy and at least 1.0mm thickness. No retraction cord was used in this case.

After prepping the tooth, the lower jaw, upper jaw and buccal bite were recorded with the CEREC Primescan in Acquisition Phase.

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Imaging

The models were processed and the automargination was evaluated. The CEREC Software did an excellent job with the margination and only minor modifications were necessary.

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Auto Margination

The CEREC software gave an excellent initial proposal and only minor adjustments were necessary to the contours, contact or occlusion.

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Proposal Design Phase

After evaluating the proposal, the restoration was brought to the Manufacture Phase and sent to the CEREC Primemill. Since the touch process was completed earlier, the milling began immediately.

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Pretouch Prompt

For this case we used the Extra Fine milling to complete the process. This milling takes substantially longer than the fine or fast milling, but the detail is improved greatly. The total mill time for the Katana STML restoration was 26:59. In most cases, the Extra Fine Milling takes closer to 19 minutes. Since this was such a large restoration, it took longer.

After Extra Fine milling was completed, the restoration was removed from the sprue.

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Extra Fine Katana Mill out of mill

Since the anatomy was excellent with the Extra Fine Milling, no extra detail was required and just a minor prepolish completed in the presintered state.

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Pre-polish Katana before Sinter

The EF milling definitely reduced the amount of time necessary on the presinter work. The restoration was automatically transferred to the CEREC SpeedFire furnace and sintering was completed in 18 minutes.

After Sintering, the functional surfaces were polished using Brasseler Dialite wheels and then stained and glazed in the CEREC SpeedFire furnace.

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Final Stain and Glaze

After glazing and cleaning the restoration, the CEREC Zirconia was cemented conventionally using resin modified glass ionomer.

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Final Restoration Extra Fine Katana STML #14

The total treatment time for this restoration can be broken down in the following way:

Anesthesia, entering the block information in the Primemill, Pre-Touch process, and entering the patient and case information: 6 minutes
Preparing the tooth and tissue management: 9 minutes
Imaging and designing of restoration: 4 minutes
Milling of the restoration: 26:59
Removing restoration from sprue, defining anatomy and prepolish: 2 minutes
Sintering of the restoration: 18:39
Cooling of the restoration: 2 minutes
Post sinter polishing of the restoration and stain/glazing: 5 minutes
Glazing of the restoration: 9 minutes

10. Cooling of the restoration: 2 minutes

11. Cleaning and final cementation of the restoration: 5 minutes

TOTAL treatment time: 1 hour 30 minutes

The final restoration fit excellent and needed no post cementation adjustments whatsoever. The Extra Fine milling certainly extended the time compared to the Super Fast milling, but even with the extra milling time, the total appointment time fell into an acceptable range. The great thing about the Extra Fine Milling is that we have an option to create additional detail if so required for the case.

The CEREC Primemill not only brings speed to the appointment, but also versatility in milling strategies. In this case we chose extra manufacturing time in order to create a restoration with beautiful detail. This especially is useful when doing bridges as it created beautiful embrasures not possible with fine or fast milling.

When required the CEREC Primemill Extra Fast milling can create anatomy not seen before with conventional manufacturing with the MC XL. While this would not represent my daily workflow, the appointment time is still in a very acceptable range to produce an exceptional result. Options are the key.

Dentsply Sirona World 2021

2021-09-27T09:09:05Z

Dentsply Sirona World 2021 did not disappoint! What an incredible three days of education, community and fun in Las Vegas.

We hope all of you that were able to attend in-person and virtually had a fantastic experience and are feeling rejuvenated to continue pursuing great dentistry.

Remember, annual admission to this event comes included as part of our Mentor membership. Let us know if you're interested in becoming a Mentor so you can attend next year's event at no admission charge.

Check out some of our photos from the event, and then we'd love for you to share some of yours!

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Staged Transcrestal Sinus Lift: An Alternative Approach

2021-09-16T11:11:09Z

By Farhad Boltchi, DMD, MS

The sinus augmentation/sinus lift procedure has become an integral and predictable aspect of surgical implant therapy. Traditionally the lateral window sinus augmentation procedure has been regarded as the standard technique to perform this procedure. Although this is a highly successful and predictable technique it is also more invasive and associated with a higher morbidity. The transcrestal sinus lift procedure was developed as a less invasive but still an equally predictable alternative technique for the augmentation of the maxillary sinus. However, this approach is typically limited to simultaneous implant placement and sinus lift scenarios where a minimum residual bone height of 4mm is present. In cases where the residual bone height to the maxillary sinus is less than 3-4mm the lateral window sinus augmentation technique is still regarded as the gold standard. Here we present an alternative minimally invasive staged transcrestal sinus lift technique for cases with minimal residual bone height.

A healthy female patient presented with a missing tooth site #3. Clinical examination revealed a moderate bucco-lingual deficiency and radiographic examination revealed a moderate buccal bone deficiency and a severe vertical bone deficiency due to a significantly pneumatized maxillary sinus (Figure 1). The residual bone height to the maxillary sinus was 1-2mm. The patient was informed of the need for a staged maxillary sinus augmentation/sinus lift procedure to be followed by implant placement 6-7 months later. A surgical treatment plan was devised to attempt the staged sinus lift procedure via a transcrestal approach initially and only resort to a lateral window approach if the transcrestal approach would result in a perforation of the Schneiderian sinus membrane rendering bone graft containment unsuccessful and thus necessitating a lateral window approach to repair the membrane perforation and perform the sinus augmentation procedure. The surgical steps of the staged transcrestal sinus lift procedure were as follows:

1.) Preparation of a full thickness bucco-lingual envelope flap sites #2-4.

2.) Prepare an osteotomy 1mm short of the sinus floor with the final drill diameter (in this case 3.7mm) corresponding to the anticipated implant to be placed (in this case a 4.2mm implant). This step can be performed guided as well.

3.) Use an end cutting transcrestal sinus lift bur with stoppers (Meisinger Crestal Lift Control Kit) to access the sinus floor and cut through the cortical floor of the sinus without perforating the Schneiderian membrane. In this case the 3.8mm Meisinger Crestal Lift Control bur was used.

4.) Prepare the bone graft material. In this case a mixture of a xenograft (Bio-Oss, Geistlich Pharma) and platelet-rich-fibrin (PRF) was utilized.

5.) Insert the bone graft mixture into the osteotomy in increments and lift the Schneiderian sinus membrane via the bone graft mixture with the Densah osseodensification technique (Versah, LLC). In this case the Densah VT3545 bur was used. It is important to perform this step with the Densah bur rotating in the reverse osseodensification mode at 50 RPM and without irrigation. It is also important not to extend the bur more than 1mm into the sinus. In this case this step was performed 10-11 times in increments to slowly lift the sinus Schneiderian membrane approximately 10mm (Figs. 2-3).

6.) Augmentation of the buccal deficiency with a mixture of allograft bone (Maxxeus Cortical Min/Demin Blend) mixed with PRF and overlayered with a long-resorbing membrane (Pericardium).

7.) Primary closure of the surgical flaps with non-resorbable sutures (5.0 Polypropelene).

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Figure 1: Pre-operative CBCT scan images of site #3

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Figure 2: Occlusal view after completion of the staged transcrestal sinus lift procedure

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Figure 3: Periapical radiograph of the staged transcrestal sinus lift procedure

After an uneventful healing period of 6 months a periapical and cone beam CT radiographic evaluation was performed and implant planning was carried out in the SICAT 2.0 implant planning software (Figure 4). The digital implant plan was uploaded to SiCat in Germany for design of a Digital Guide, which was 3D printed in-house. The surgical steps of the second stage surgery were as follows:

1.) Preparation of a full thickness bucco-lingual envelope flap sites #2-4.

2.) Fully guided placement of an Astra EV S 4.2 X 9mm implant (Figure 5).

3.) Minor additional buccal augmentation with a mixture of a xenograft (Bio-Oss, Geistlich Pharma) and platelet-rich-fibrin (PRF) overlayered with a long-resorbing ossifying collagen membrane (Ossix Volumax, Dentsply Sirona) and with a PRF membrane.

4.) Placement of a transmucosal healing cap (Astra EV Healdesign 5 X 4.5) and non-submerged suturing around the healing cap with a non-resorbable suture (5.0 Cytoplast, Osteogenics).

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Figure 4: Second stage implant plan in SICAT 2.0

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Figure 5: Immediate post implant placement periapical radiograph

After an additional uneventful healing period of 3 months an Atlantis IO FLO ScanBody was inserted into the implant and a CEREC Primescan digital impression of the implant was obtained and uploaded to Atlantis. Atlantis designed and fabricated a titanium custom base and the corresponding e.max crown was milled in-house from the core file provided by Atlantis for a final screw-retained implant crown (Figs. 6-8).

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Figure 6: Final periapical radiograph of restored implant

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Figure 7: Final post-operative CBCT scan of restored implant

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Figure 8: Final clinical view of the restored implant

The staged transcrestal sinus lift procedure provides an attractive minimally invasive alternative to the traditional lateral window sinus lift technique. The key to successful implementation of this technique is to maintain the integrity of the Schneiderian membrane to ensure containment of the bone graft. The surgeon must be prepared to resort to a traditional lateral window sinus lift procedure should a perforation of the membrane occur to repair the membrane perforation and augment the sinus at the same time.

What Lies Beneath the Surface?

2021-09-09T17:05:29Z

By Karyn M. Halpern DMD, MS
Sponsored by Ivoclar

A 40-year-old otherwise healthy female presented for an initial exam with a chief complaint of, “I hate the color of my front tooth and would like it fixed”. She reported her tooth had fractured after a fall when she was just thirteen years old. She stated her previous dentist “bonded” it and she has not had it replaced since. She denied any discomfort or sensitivity. Her motivation for treatment was cosmetic as she was self- conscious on how it appeared.

Initial examination and x-ray findings revealed the maxillary left central incisor, tooth #9, had a history of a Class III (MFL) composite restoration as well as a facial composite veneer. The appearance of tooth #9 was very dark in shade and stood out like a sore thumb amongst what would otherwise be a very esthetic smile (Figure 1). A series of both extraoral and intraoral diagnostics photos were taken. The discolored and darker value of #9 appeared to be visible from both the facial and palatal aspects (Figure 2). The value and chroma appeared closest to shade A4 on the Vita shade guide, where the remaining dentition was significantly brighter, A1 (Figure 3).

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Figure 1: Initial presentation with chief complaint of discolored unesthetic previously bonded tooth #9

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Figure 2: Extraoral and intraoral facial and palatal views of initial presentation with very dark tooth #9

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Figure 3: Initial shade and chroma of tooth #9 closest to shade A4

It was noted that there was also some minor incisal chipping present on #8 as well. Patient declined any restorative treatment to #8 and wanted to focus on treating #9 as a single unit.

Treating a single central incisor alone maybe one of the most challenging esthetic treatments a dentist performs.

In this case, the challenges, and potential limitations of what may be able to be accomplished with retreating #9 alone were even more concerning since it appeared so very dark. The questions and concerns were many. Is the tooth nonvital? How dark is the prep going to be? What materials will work best to block it out if necessary? How will I best block out a very dark prep and still mimic the high translucency present in her adjacent teeth? Maybe endo and pre-prosthetic internal bleaching, composite opaquers, or an MO coping?

Although often the most challenging, these cases can also be the most rewarding for both doctor and patient alike. I was up for the challenge and after interviewing the patient at length, I was confident I could manage and meet her expectations.

Since the tooth appeared very dark and had a history of trauma, the patient was referred for an endodontic evaluation prior to proceeding. The endodontist reported that #9 tested vital within normal limits. However, he advised in the event the prep was very dark, he could perform a pre-prosthetic root canal therapy to facilitate internal bleaching.

The patient returned for digital impressions with the Primescan, and the case was sent to the lab technician for a digital diagnostic wax up of tooth #9. A printed model and putty index of the digital wax up were fabricated.

Next, the patient presented for a pre-scheduled “prep and temp” visit. The plan was to remove the previous discolored resin restorations and clinically evaluate what lied beneath it all. Depending on how dark the prep, it would be determined which treatments would be best indicated to lighten as needed. A provisional was planned to allow for any additional treatments to be rendered.

I began to strip the bonding and prep the tooth for a conservative cingulum sparing ¾ crown. Once I removed the bonding, I began to smile to myself underneath my mask. The prep was not dark after all! I was pleasantly surprised. It was actually A1 (Figure 4). The patient was advised, good news, I am not going to need to place a temporary crown after all. No need for pre-prosthetic root canal therapy or internal bleaching. I can make your permanent crown today.

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Figure 4: Prep shade light in value closest to A1 shade

The preparation was completed and scanned with the CEREC Primescan in the usual fashion. The digital diagnostic model was scanned, and the final restoration designed using Biocopy (Figure 5). The final restoration was fabricated with IPS e.max CAD MT A1 for the perfect balance of strength and translucency. Since the prep shade was ideal in value, the MT block (medium transclucency) was selected because it provides a very naturally translucent enamel replacement. Clinical experience has also demonstrated IPS e.max CAD certainly stands the test of time.

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Figure 5: CEREC Primescan digital impressions of printed digital diagnostic of wax up stitched to marginated preparation

Once milled, the line angles, contours and texture were further enhanced using the diamond bur from CDOCS Meisinger Finishing Kit. The twist polishers were then used to pre-polish the restoration (Figure 6).

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Figure 6: CDOCS Meisinger Finishing Kit used to contour and pre-polish the restoration

The IPS e.max crystal glaze and stains were then applied to the crown prior to crystallization.

The blue I1 incisal shade applied lightly on the incisal 1/3 for incisal translucency. Shade 1 applied to the for cervical 1/3 for gingival warmth and characterization to mirror discoloration visible on DF of #8. The white stain was applied framing, mirroring white spots visible on adjacent teeth, and craze lines (Figure 7).

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Figure 7: A hand sketched diagram on a photo of the restoration illustrating where the IPS e.max crystal stains were applied prior to crystallization

The restoration was tried in, and the patient was handed a mirror. The patient was thrilled with the result and could not believe her eyes. I was also honestly surprised in this case and did not anticipate an A1 prep shade (Figures 8 & 9). The restoration was prepared and bonded with NX3 translucent resin cement.

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Figure 8: Before and after treatment retracted view of tooth #9 with bonded IPS e.max CAD MT A1 restoration

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Figure 9: Full face smiling after cementation of IPS e.max CAD MT A1 restoration #9

Managing patient expectations and preparing the patient for both limitations and possible need for additional treatments is always best practice. However, occasionally, you may be pleasantly surprised when there’s light discovered behind the darkness.

The Y’s of Zirconia

2021-08-31T11:11:53Z

Author: Dr. Michael Snider
Sponsored by 3M

In our last article, we discussed a very brief history of the CEREC system, as well as a limited history of the materials that are available for use in the CEREC System. In this article, we are going to discuss one of the biggest influencing materials in the market today: Zirconia.

The zirconia that we all know in our restorative cases, actually starts oﬀ quite diﬀerent. Zircon (ZrSiO4) is the initial silicate mineral that is mined from deposits in Africa and Australia.¹ After the zircon is purified to produce zirconia powder, metal oxides are added to the powder.

Aluminum is then added to prevent water corrosion, yttrium is added to stabilize the tetragonal phase of zirconium.

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Figure 1. Classic “3Y”, High Strength Zirconia

The benefits of zirconia were huge for us as clinicians. We had incredible strength in a monolithic restoration. The necessity to bond as with other high strength glass ceramics was removed. Due to the unique characteristics of how the zirconia restorations are milled and sintered, we had a multitude of options in regard to margin design, prep design, and even conventional cementation. The one thing that was missing was the ability to produce this restoration chairside. Sure, the restoration could be milled in our oﬃce, but the sintering times required for zirconia did not make them suitable for chairside restorations.

All of that changed with the release of the CEREC SpeedFire oven from Dentsply Sirona partnered with the ability to dry mill. The hours previously needed to sinter zirconia restorations was cut down to under 30 minutes. With the technological advances made by Dentsply Sirona, zirconia was now ready for chairside application

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Figure 2. Dentsply Sirona PrimeMill and Figure 3. CEREC SpeedFire Oven

The ability to now produce these restorations chairside was exciting for many of us. But, I still found myself utilizing the high strength glass ceramics because of their superior esthetics. The initial zirconias that most of us were using were 3Y zirconias. They were extremely strong materials, but they had little translucency and looked quite opaque in the mouth.

So what’s the real story with of the “Y’s” in today’s zirconias? Since we have so many options now available to us, let’s go through what the real diﬀerences are. I’m sure you’ve by now heard the terms 3Y, 4Y, and 5Y in reference to zirconia, but what do these terms actually mean?

Let’s begin by discussing why yttria is added to zirconia. We stated early that it helps to stabilize the tetragonal phase of the zirconium. The amount of yttria in the composition of the zirconia directly aﬀects the strength and translucency by adjusting the phase composition. In other words, the more yttria in the composition, the more cubic phase of zirconia in the product.

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Figure 4. Comparison of Monoclinic, Tetragonal, and Cubic zirconias

The tetragonal phase of zirconia is responsible for the strength we all love with zirconia. The tetragonal phase increases strength by hindering crack propagation through phase transformation.²

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Figure 5. Tetragonal Phase, Strength

The cubic phase of zirconia is responsible for the translucency of the material. The cubic phase increases translucency by reducing light scattering and deflection. As the material has less tetragonal phase, there is less refraction of the light at tetragonal boundaries.

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Figure 6. Cubic Phase, Translucency

The 3Y zirconia is going to be similar to the CEREC Zirconia that many of you may have used in the past. With only 3% yttria composition, 90% of the material is in the tetragonal phase and only 10% in the cubic phase. These materials are extremely strong, but not very esthetic.

The 5Y zirconia acts like a completely diﬀerent material. At 5% yttria composition, we have only 45% of the zirconia in the tetragonal phase, and we have 55% of the zirconia in the cubic phase. This material has markedly better esthetics. But, by gaining the increased esthetics, we have lost strength. We have moved from nearly 1400MPa with our 3Y zirconias and are now around 800MPa with our 5Y zirconias.

This is why 3M™ Chairside Zirconia has been unique for me in my practice. This zirconia is a 4Y Zirconia, or we have 4% yttria composition. This composition makes 3M™ Chairside Zirconia the best of both worlds in my practice. I still get the strength that I want from a zirconia restoration being at 1000MPa, but with the increase in yttria, I also get the translucency that I like compared to the 3Y zirconias. 3M™ Chairside Zirconia is a perfect blend of beauty and esthetics.

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Figure 7. 3Y vs 4Y vs 5Y

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Figure 8. Strength Comparison amongst materials with varying yttria compositions.

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Figure 9. Translucency Comparison amongst materials with varying yttria compositions

In our next article, we move back into more clinical applications of 3M™ Chairside Zirconia. We will review the eﬀects of diﬀerent milling speeds on the restoration. We will also discuss the eﬀects of polishing and glazing zirconia restorations; is one preferable over another?

See you soon!

References:

1. Burgess, J. Zirconia: The Material, Its Evolution, and Composition. CompendiOKum. 2018.

2. 3M Internal Data.

Axeos: Favored by Dentists, Loved by Patients

2021-08-19T12:12:36Z

Author: Devan Letemendia

Excellence in diagnosis and treatment planning begins with imaging. Dentsply Sirona's 3D/2D imaging system, Axeos^TM is the newest addition to our lineup of extraoral imaging devices - and it is already making big waves in the dentistry world. Together with trusted dentists and clinicians, we have developed a new CBCT which will allow you and your staff to experience the next level of dental imaging. Axeos delivers clinical confidence, smart connectivity, and an exceptional experience for you, your staff, and your patients.

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Axeos^TM offers benefits for more than just imaging.. With Dentsply Sirona's technology, the device incorporates seamlessly into any digital workflow! Axeos^TM can create a full patient profile with just one scan. No wonder it’s loved by both patients and clinicians everywhere!

Clinical Confidence

Axeos^TM features cutting-edge imaging technology that goes above and beyond the average imaging device. Axeos^TM is the most versatile 3D/2D unit in Dentsply Sirona's line of extraoral imaging units. With a large field of view and outstanding image quality, this machine is perfect for practices with a wide treatment spectrum. The chart below indicates what you can see within each volume.

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Increase clinical confidence with the clearest image possible. The high-definition mode captures with the best resolution, so you can see more details.However, the intelligent low dose feature allows you to take a 3D scan at the dose of a 2D, which is great for post-operative scanning, or young, radiation sensitive patients.

We all know that metal artifacts are often a challenge in 3D imaging, so we created a solution called Axeos^TM MARS that automatically reduces metal artifacts.

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Smart Connectivity

Axeos^TM smoothly integrates into workflows with its state-of-the-art Sidexis 4 software. The timeline function with Sidexis 4 offers an intuitive user interface that allows easy navigation into patient history. Diagnose with confidence while viewing adjacent 2D and 3D patient data simultaneously - all housed in the same program. That means, instead of switching back and forth between windows, you’ll have everything you need to make a clear diagnosis right at your fingertips, saving you valuable time.

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Sidexis 4 integrates seamlessly into your existing office network. Whether it is from Dentsply Sirona or third parties, Sidexis 4 is ready to connect. With easy connection to over 200 practice management software products worldwide, Sidexis 4 + Axeos^TM are designed to fit into any workflow, including specialty practices that focus on Orthodontics, Implantology, Sleep Apnea, or Endodontics.

Exceptional Experience

But Axeos^TM isn’t just favored by dentists. Patients love it, too.

Dentsply Sirona is always searching for new ways to improve patient experience. With Axeos^TM, we’ve achieved the highest level of patient comfort with the automatic patient positioner feature. Add in a quick scan time of only 9.1 seconds and intuitive use, and you have an efficient system that works for clinician and patient.

Not to mention, Axeos^TM can do all this in just one scan. A single scan means a more efficient, tailored appointment for every patient that comes through your office. With Axeos^TM in your practice, it can help lead you to improved patient experiences, healthy smiles, and even more word-of-mouth recommendations.

As a dentist, growing your passion doesn’t just mean having the most advanced technology. To us, real growth means adding systems into your practice that will help your staff and technology work together to provide the best care possible.

Interested in leveling up your practice with the Axeos^TM? Contact your Dentsply Sirona representative, or visit www.dentsplysirona.com to learn more. And don’t forget to ask about the “Upgrade your Diagnostics with Axeos^TM” program, valid through October 31, 2021.

Copy And Mirror Is Ideal For Single Centrals

2021-08-11T10:10:13Z

I have a love/hate relationship with the Copy and Mirror function in the software. For years it was such a promising tool, but I could never get good initial proposals. Today with the 5.2 Software, the Copy and Mirror function is vastly improved, and I find myself routinely using it when matching single central incisors.

This patient presented with a chief complaint of his poorly matching crown on tooth #9. He has a history of trauma to the tooth as a child and this is his third restoration. This crown has been in service for 10 years, but now the patient would like to replace it for his daughters upcoming wedding (figure 1). As you can see in this retracted view (figure 2) the crown has some thickness issues which is causing the stump to show through. He also has staining at the buccal margin and the shape of the restoration is not perfectly symmetrical with tooth #8.

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Figure 1: Pre-op condition

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Figure 2: Retracted view

I explained the esthetic challenges with treating a single central versus the entire smile, mainly the inability to change the shade and overall contours of the remaining teeth. He was fairly insistent that he only wanted to replace tooth #9 so that it would match the length and shape of the existing central #8.

After removing the existing ceramic crown, we designated the restoration as a Copy and Mirror and would restore this with Ivoclar e.max (figure 3). You can see how much of the tooth structure was reduced previously, so I was limited in my material choices (figure 4). With this much ceramic thickness, it would be difficult to control the value and match the translucency of his existing tooth. After drawing my margin, I then have the Copy Line step to circumscribe the contralateral tooth, in this case #8 (figure 5).

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Figure 3: Case Details

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Figure 4: Previous tooth preparation

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Figure 5: Copy line

The initial proposal was spot on (figure 6). I only had to adjust the mesial and distal contacts using the smooth tool and the restoration was ready to manufacture. At this point I like to show the patients the final proposal and explain what they might expect when it’s delivered. In this case we discussed the gingival embrasure and the potential for a black triangle due to the triangular shape of his centrals. Since I used a 2 cord technique to retract the gingiva, due to the depth of his existing preparations, I was comfortable with the likelihood of some gingival rebound to close the space.

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Figure 6: Initial proposal

This case was manufactured using my 4-motor wet/dry MCXL. With the 4 motor milling machines, you have the option of extra find grinding, which produces a finer and truer restoration, with less overmilling and greater anatomical detail. The software will default to fine grinding (figure 7), and once the proper tools are inserted, the extra fine option will be available (figure 8).

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Figure 7: Fine Grinding default

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Figure 8: Extra Fine Grinding option

Upon starting the manufacturing job, you may notice the time to be almost twice as much for extra fine (figure 9). However, after the touch process is complete, this time often shrinks down to a more realistic amount. In this case we started with 19:29 and after the touch process we were down to about 13:49 with extra fine grinding.

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Figure 9: Grinding times

Our shade selection prior to starting was A2-MT. The patient decided to inform me as we were placing the block in the milling machine that he also wants to whiten and wants to make sure his new crown will whiten along with his teeth! So, we decided to increase the value and jump to an A1-MT and allow him to bleach his teeth to match the color.

Here are the 2 week follow up photos (figure 10). You can see the slightly higher value on #9 and the black triangle still present (figure 11). Typically, I wait at least 6-8 weeks for full tissue maturation so I will continue to follow him and post the final photos in a few months once his bleaching has settled in and the tissue rebounds to close the space (figure 12).

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Figure 10: Two week follow-up

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Figure 11: Slight interproximal space

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Figure 12: Pre-op vs post-op

CERASMART® 270 and G-CEM ONE™- A Winning Combination

2021-08-04T10:10:18Z

By Karyn M. Halpern DMD, MS

Patient Presentation

A 45-year-old healthy male presented for a hygiene visit and exam without complaints. After a clinical and radiographic examination, large distal proximal caries was observed adjacent to a failing occlusal-lingual resin restoration on tooth #3. In addition, tooth #2 was diagnosed with both occlusal-lingual pit and fissure caries as well as mesial proximal decay (figures 1 and 2, below).

Upon being shown and advised of the findings, it was recommended to restore the large lesion on tooth #3 with a single-visit CEREC® onlay and restore the smaller lesion on tooth #2 with a direct resin restoration.

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Figure 1: Tooth #3 failing occlusal-lingual resin and large distal recurrent decay

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Figure 2: Radiographically evident proximal caries on tooth #2 mesial and #3 distal

Technique

The failing resin restoration on tooth #3 was removed, and the extensive distal decay was excavated. The remaining undermined and thin distal lingual cusp was prepared for cuspal coverage. Caries detector was applied to assist in verification of complete caries removal (figure 3, below). The pit and fissure caries on tooth #2 was removed, as well as the decay on the mesial wall that was accessed directly. G-aenial™ Universal Flo flowable composite was used to restore #2 mesial, occlusal-lingual, and was also placed on the pulpal floor of the preparation of tooth #3.

As with all CEREC® restorations, the key to success comes down to the preparation. For a partial coverage onlay, the preparation must have draw with no undercuts, especially in the interproximal box. The internal line angles should be round and smooth, with straight exit walls on the interproximal.

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Figure 3: Onlay Preparation tooth #3 and application of caries detector to assist in caries removal

After the composite restoration on #2 and the preparation on #3 were complete, the lower jaw, upper jaw and buccal bite were recorded using the CEREC® Primescan in the Acquisition Phase. The virtual models were created and the margins on the virtual preparation were created using the auto margin finder crown using the CEREC® 5.2 software (Figure 4). Once the design was completed, the onlay restoration was fabricated using a CERASMART® 270 A2 LT block with Dentsply Sirona’s MCXL. It mills quickly and predictably without any marginal chipping (figure 5). It also saves time since no firing is needed.

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Figure 4: Margination using auto margin finder

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Figure 5: Milled margins without any marginal chipping

Once milled, the sprue was removed. The restoration was then trial seated, verifying margins were closed and the contact was checked with floss. The restoration was then characterized using the OPTIGLAZE™ Color red-brown stain in the occlusal fissures followed by a clear coat of OPTIGLAZE™ Color.

To deliver the onlay for final placement, G-CEM ONE™ self-adhesive resin cement was used in “Adhesive cement mode” by combining it with G-CEM ONE™ ADHESIVE ENHANCING PRIMER (“AEP”). AEP accelerates the chemical cure of the cement to allow for optimal bonding. It allows for extremely easy cleanup which makes it even more advantageous.

Once bonded into the tooth, the restoration margins blend seamlessly with the surrounding tooth structure (Figure 6, below).

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Figure 6: Occlusal view of final seated CERASMART®270 A2 LT restoration #3 after cementation

Advantages

This clinical case demonstrates how predictably and efficiently a partial coverage CEREC® onlay can be designed, fabricated, and placed in a single visit using CERASMART® 270 and G-CEM ONE™ resin cement. CERASMART®270 mills beautifully without chipping and saves significant chairside time, as no firing is needed. It can be characterized easily with OPTIAZE™ Color to match existing esthetic or simply polished and placed. When combined with G-CEM ONE™ with AEP, the result is a strong and esthetic restoration that blends seamlessly with the surrounding tooth structure.

Why I Use LendingClub Patient Solutions

2021-07-20T11:11:44Z

Why I Use LendingClub Patient Solutions

A simple, transparent, and flexible way to finance patient care and increase case acceptance

Kathy Schweiger

As the office manager for Glen Gallimore, DDS, for the past 13 years, Kathy Schweiger understands that patients can sometimes struggle to pay for the dental treatment they desperately need. Here, Schweiger shares how LendingClub Patient Solutions offers these patients a no-nonsense way to move forward.

Kathy has been a professional in the dental field for over 20 years, having graduated from San José City College in 1992. Throughout her career, Kathy’s emphasis has always been on providing great patient care and excellent customer service. She has worked as a dental and oral surgery assistant, a front- and back- office lead, an office manager for 702DENTIST, and as the director of dental implant treatment for Nevada Oral and Facial Surgery.

Why I Use LendingClub Patient Solutions

Dental treatment can be expensive, which makes it difficult for patients to receive the care they need. In our office, many patients need help with financing, especially when it comes to full-mouth treatment plans or any procedure over a few thousand dollars.

If a patient is not financially able to proceed with treatment, LendingClub Patient Solutions gives them options to space out the payments in a way that fits their budgets and makes treatment more affordable. It allows them to more easily say "yes" to treatment, which helps boost our case acceptance rate.

Support That's A Step Above

The customer service is excellent at LendingClub and we’ve never had an issue with them. Our representative is always accessible and we never get sent to an answering machine when we call. And, if an answer to our question is ever unclear, they will immediately resolve it. This service is accessible for patients as well, which is a huge bonus. Usually, it takes very little convincing to get patients on board with LendingClub because they know we are being transparent about their financing options.

Helping Patients See the Difference

I always let patients know the key differences between LendingClub and other popular financing companies. I tell them that both companies offer an interest-free promotional period. With LendingClub, if the loan isn't paid during the promotional period, you pay interest on the remaining balance. However, other companies may tack on interest from the very beginning, despite advertising an interest-free period.

LendingClub works like a traditional loan or mortgage where the financial obligation is part interest and part principal, right from the beginning. There's no loan origination fee like other companies have, so to me, there really is no comparison with the competition. Whenever I explain this, patients always choose to go with LendingClub.

The funds are usually deposited to our practice the very same day. If once in a while the deposit is not available immediately, the LendingClub service team always tracks it down and resolves the issue.

Financing That Boosts Production

Using LendingClub at our practice has led to a definitive production increase, which of course translates into a revenue increase. While we pay a fee to offer LendingClub to our patients, it's worth it because it allows more patients to move forward with treatment while we build up our practice.

3 PERKS OF LENDINGCLUB PATIENT SOLUTIONS:

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FOR MORE INFORMATION:

800.630.1663

https://www.lendingclub.com/trypatientsolutions

Dentsply Sirona World is BACK in Las Vegas!

2021-07-14T07:07:08Z

Are you ready for the Ultimate Dental Experience? Dentsply Sirona World 2021 is happening at the Caesars Forum in Las Vegas, Sept. 23-25!

The best part … CDOCS Mentors’ admission ($1,995 value) is INCLUDED with their membership!

What is Dentsply Sirona World?

Dental professionals from all across the world gather for this must-attend event to experience engaging speakers, informative continuing education sessions and innovative technologies. It is a true celebration of dentistry.

Who attends Dentsply Sirona World?

If you work in the dental industry, then the Ultimate Dental Experience is for you!

Dentists, specialists, hygienists, dental technicians, industry experts, office managers and more make up the conference’s diverse population.

Attendees are dental professionals who care about the growth of their practice or business. Become a part of the brilliant people who influence and shape the ever-changing landscape of dentistry.

Speakers and Tracks

Click to see all the educational tracks and the first set of speakers in each.

Entertainment

It wouldn’t be a true celebration without some quality entertainment, and DS World is bringing it this year.

Click to see who has already been announced, and more entertainment announcements will be coming soon.

Ready to Register?

If you’re already a CDOCS Mentor, simply click and follow the instructions.

Not a Mentor? Want free admission? Simply click to let us know you’re interested in becoming a Mentor.

Primescan Biocopy - A Valuable Resource

2021-07-07T10:10:15Z

e.max has been the main restorative material in my practice for in office CEREC® restorations for a decade. This report documents a mandibular anterior veneer case that illustrates the superior quality of fit, esthetics and ease of use with this material. Even though I am constantly solicited with new materials, I find myself maintaining at least a 75 % use of e.max for crowns, onlays, veneers, 2–3-unit fixed bridges and implant restorations. My first experience with CEREC was creating a single unit crown during a CEREC ACCEPT program. Having no technical nor clinical experience with the digital production of in office restorations I fabricated a crown that I glazed in Scottsdale and cemented onto my patients’ first premolar the very next Monday at my Brooklyn N. Y. office. This crown was designed and milled after scanning a stone die that my local lab had poured and used to fabricate a PFM crown. The esthetics, marginal fit and the ability to have control of the process sold me immediately and was the impetus for my transition into a fully integrated digital practice. I was able to compare this crown against the lab fabricated PFM and found that there were many advantages to being able to produce in office restorations. I was able to control the morphology, occlusion and esthetics with increased proficiency, all while speeding up production and improving the quality of my restorations. No longer dependent upon a lab to create all my restorations saved me the turnaround time, reduced lab fees and the cost of impression materials immeasurably.

What began as mostly single unit restorations has expanded into producing Implant crowns, bridges and multiple unit cases. Having control of occlusion, contour and esthetics elevated my ability to produce high quality restorations in a timely manner that satisfies or exceeds patient expectations in an extremely high percentage of my cases. Over the years these restorations have performed exceptionally well in function with a nearly 100% success rate.

A Valuable Design Option-BIOCOPY

Having restorations replaced multiple times due to porcelain fracture, recurrent decay and endodontic failures led this patient on a multi-year treatment plan. Porcelain fractures occurred because of inadequate occlusal clearance and clenching. I diagnosed and presented him with a full mouth rehabilitation years ago, but he declined because he had his dentition restored more than once prior to becoming our patient. Many of his existing restorations have since failed and were replaced with crowns. Multiple teeth became hopeless and required implant tooth replacements. For more than a year lower anterior veneers would de-bond and be re-bonded during emergency visits. Porcelain incisal wear throughout the mandibular anterior segment, marginal ledging and recession of the gingival tissues exposed tooth structure, creating triangular spaces that became food traps. While travelling out of the state on a business trip the # 25 veneer popped off again. This incident convinced him to have teeth # 22-26 treated along with # 28. It took this embarrassing occurrence for him to finally agree to their replacement. (fig. 1)

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Figure 1: Pre-operative condtion of lower veneers #s 22-26 and crown # 29.

The case was challenging due to his occlusion and the narrow mesial distal incisor widths. I planned to utilize the Biocopy Design Mode feature in Chairside software as the blueprint and basis for the final design albeit with modifications to enhance the outcome. I captured a digital impression with Primescan of the existing dentition in a Biocopy folder. I selected e.max as the material to manufacture his veneers because these restorations in my experience are esthetic, strong in function and produce a superior marginal fit that seal the underlying tooth structure and prevent recurrent decay. (fig. 2-3)

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Figure 2: Digital impression of existing mandibular dentition (Biocopy) for use in design of new restoration morphology and occlusion.

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Figure 3: Intraoral photo of prepared teeth 22-26.

I sectioned the existing porcelain veneers and modified the preparations. The first modification made was to provide 1.5mm of incisal reduction and the second was to extend the mesial and distal preparations inter-proximally towards the lingual of each tooth. Tooth # 22 was already prepared for a crown, so this preparation was extended apically to gain additional coverage of the cervical margins. Retraction paste was injected into each sulcus and left on the teeth for about 90 seconds rinsed off to adequately expose each margin. Primescan captured these margins quickly with incredible detail. The opposing arch and bite were optically impressed completing all the necessary information needed to design and manufacture the case. Temporization was quickly accomplished with a putty matrix and Luxatemp bisacrylic in a B1 shade, bonded onto the preps in one piece. I use ExciTE F which is a light-curing, fluoride releasing, single-component total-etch adhesive. One difference is I do not etch the teeth and rely on the primer to retain these provisionals along with wrapping the material inter-proximally to provide mechanical retention. I rarely have provisionals detach between the impression and the insertion visit when using this technique. This shade was lighter than adjacent teeth but would only remain in place for about 1-2 weeks.

The scans moved from the Acquisition Phase to the Model Phase where each preparation was marginated. The Biocopy model was then used to outline any usable information in the preoperative morphology that could be helpful in the initial design phase of the newly proposed restorations. I made use of the grid feature to create an even incisal plane and improve the occlusion. I sent my scans to a digital lab to print dies and mount upper and lower models for me to make any necessary final adjustments of the milled restorations prior to their crystallization and insertion. (figs. 4-7)

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Figure 4: Model phase of digital impression being marginated.

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Figure 5: Margination Completed 22-26, 28.

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Figure 6: Margination completed and checking clearance after design.

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Figure 7: Occlusal Clearance.

This case is a good example of how using the Biocopy feature can make the fabrication and insertion of CADCAM restorations effortless, requiring little to no adjustments during the insertion phase. Providing enough interocclusal space was an important factor in developing fracture resistant restorations. The provisionals remained in place without any issue and once removed I was able to bond in the five anterior restorations using Ivoclar’s Variolink esthetic light plus resin material. The restorations were etched with 9.5% hydrofluoric acid for 15 seconds then silanated. The teeth were treated with a total etch technique prior to luting each e.max restoration. This is a permanent light curing or dual curing luting composite that is easy to use and maintains shade stability over time. The shade selected for these restorations was MT B1. This displays a higher value, with a medium transluscency, which blended in well with the existing dentition. This case documents how these monolithic ceramic blocks can be processed in office with efficiency and high quality to satisfy even demanding restorative situations. (figs. 8-15)

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Figure 8: Copy line # 26.

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Figure 9: Using Biocopy as a Reference for Designing Restorations.

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Figure 10: Designing restorations using grid (controlG), ready for mill.

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Figure 11: e.max blue phase restorations milled and fitted on printed model.

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Figure 12: Final Design of Restorations Ready to Mill.

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Figure 13: Milled e.max on model, checking occlusion prior to crystallization phase.

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Figure 14: Glazed and finished e.max restorations ready for insertion.

A 9-month recare visit documented no change in the appearance of these veneers and a favorable the tissue response to the new ceramic material as compared to the original presentation. I have total confidence that these restorations will remain esthetic and function for years to come. (figs. 16-18)

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Figure 16: Veneers #s 22-26 Bonded with variolink esthetic high value before separation.

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Figure 17: Occlusion immediately after cementation of 22-26 and 28 e.max restorations.

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Figure 18: 9 month recare visit 22-26, 28 e.max restorations.

Case Study: Six single-unit anterior crowns featuring KATANA™ multilayered Zirconia material

2021-06-30T12:12:53Z

Sponsored by Kuraray

Patient Presentation

An 80-year-old male presented with what he considered to be unattractive teeth due to failing composite bondings that chipped away over time, creating unsightly patches (Figure 1). Specifically, the patient stated he wanted younger-looking teeth and was tired of having the composites replaced every few years, and therefore desired an esthetic and lasting solution. Furthermore, upon clinical examination and evaluation of radiographs, a diagnosis of recurrent decay was established on teeth #s 6 through 11.

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Figure 1: Pre-op photo of teeth #s 6-11.

Material

A multilayered translucent material, KATANA™ Zirconia STML (Kuraray Noritake), was chosen to restore the patient’s teeth as it provides optimal strength and esthetics without the need for external stains. The multilayered block consists of four layers of zirconia in graduated shades, including an enamel layer, two transition layers and a body (dentin) layer. This material requires approximately 8 to 10 minutes milling time (dry milling) per unit in the CEREC® MC XL milling chamber, and 30 minutes sintering in the CEREC SpeedFire.

Treatment Steps and Technique

Step 1: Preparation

Teeth #s 6 through 11 were prepared as minimally as possible to accept KATANA™ Zirconia STML crowns (Figure 2). The CEREC Biojaw function, along with CEREC Biocopy, morphology and positioning tools were used to design the restorations in an effort to keep the size of the teeth similar to the patient’s existing teeth, but with improved morphology. Additionally, it was decided to add more incisal embrasures, as the patient was unhappy with the flat, worn down look of his natural teeth.

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Figure 2: Preparations ready for digital scans.

Step 2: Scanning

The following scans were captured: Upper Biocopy, lower jaw and buccal bite. A preparation scan was also taken in the upper jaw after preparing the teeth with crown preps (Figures 3 & 4).

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Figure 3: Scan of crown preps with gingival margins delineated.

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Figure 4: Buccal preps scan.

Step 3: Designing

After an initial proposal was received with the Biogeneric Individual method, the Biojaw method was utilized to generate a design that was identical to the Biocopy in terms of length and width, but also satisfying the patient’s want of better shaped and younger-looking teeth. A shape was chosen that provided more incisal embrasures to avoid getting the flat, worn-down look of the incisal edges (Figure 5).

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Figure 5: Biogeneric crown proposals.

Step 4: Milling

Each unit was milled in the MC XL, which was used for its ability to dry mill Zirconia. The “Fine” milling parameter was chosen as this case was not “same-day seating” so time was not an issue. That said, each of the six restorations required about 8 to 10 minutes total milling time.

Step 5: Firing

The restorations were fired in the CEREC SpeedFire for approximately 30 minutes.

Step 6: Glazing

The inherent multilayer shading of the KATANA™ material produces a natural shade gradient, resulting in no need for additional stains. A light coating of Indenco Spray Glaze was applied to each restoration to impart a natural luster.

Step 7: Cementation

The intaglio of each restoration was sandblasted with alumina powder as a mechanical etchant, and then rinsed and dried thoroughly in preparation for cementation. Next, following manufacturer’s instructions for use, CLEARFIL™ CERAMIC PRIMER PLUS (Kuraray Noritake) was applied to the intaglio of each restoration, followed by PANAVIA™ V5 Tooth Primer to each tooth prep, and lastly PANAVIA™ V5 Cement to the intaglio of each restoration prior to final seating.

Conclusion

The patient was extremely happy with the final results as it met all his desires of uniform, younger-looking teeth with no patchwork (Figure 6). From a clinician’s point of view, I enjoyed working with a material that was easy to mill, along with high strength and excellent esthetics right out of the milling chamber.

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Figure 6: Post-op view of seated KATANA™ Zirconia STML crowns.

The Vantage Point: Free Virtual Seminar

2021-06-25T09:09:24Z

This event was hosted in the past.

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Join CDOCS VP of Education, Dr. Sameer Puri on July 23rd as he hosts The Vantage Point! This virtual seminar will discuss the clinical, digital and scientific applications of the esthetic zirconia Katana from Kuraray Noritake through three distinctive viewpoints.

Dr. Gerald Chiche will discuss the clinical applications of esthetic zirconia in the mouth, indications, contraindications as well as cementation protocols. He will share a clinical case featuring the material.

Dr. Michael Skramstad will discuss the digital applications of Katana using the CEREC technology. How to design a multi-unit restoration taking into consideration things such as pontic size, span as well as connector dimensions needed for success.

Dr. Nate Lawson will then discuss the scientific basis of Katana and how the material has performed in the laboratory as well as in vivo. He will compare Katana zirconia to other commercially available zirconias on the market.

The presentations will be followed up with a round table discussion and an opportunity for the audience to ask questions.

Click here for the full schedule and to reserve your spot!

Restoring Implant Bridges with CEREC® and Atlantis

2021-06-23T11:11:10Z

There are multiple workflows for restoring implant supported bridges with CEREC. The CEREC Chairside software and TiBase workflow is a good option for restoring single implant crowns, but this workflow is much more labor intensive for restoring bridges. This is the typical CEREC TiBase workflow for implant bridges:

Scan the retainer implants with a Dentsply Sirona ScanPost
Design individual split restorations for each implant
Mill only the abutments
Bond each abutment to a TiBase
Bring the patient back to insert the abutments and re-scan in the mouth
Treat the abutments as teeth and design a conventional bridge

The Atlantis workflow allows for the retainer implants to be similarly scanned but using an Atlantis IO FLO ScanBody. The scans are sent via the Connect software to Dentsply Sirona Implants. On the prescription, the clinician can request to make the abutments parallel in order to have a passively fitting bridge. A core file is then returned to design and manufacture the bridge. This workflow involves less appointments and results in an excellent fitting bridge. These are the steps in the typical Atlantis workflow for implant bridges:

Scan the retainer implants with an IO FLO and send via Connect to Atlantis (Dentsply Sirona Implants)
Request parallel abutments and approve design
Open core file, design, and manufacture a conventional bridge
Seat abutments and bridge

This case involved a failing bridge from #18-21 (images 1 and 2). Both #18 and #21 were non-restorable. The patient had an Axeos CBCT Scan and an optical scan with CEREC 5.1.2 Chairside software. Teeth #19, 20, and 21 were virtually extracted from the model (image 3), and implants were planned in SICAT 2.0 software at positions #19 and #21 (Image 4). The restorative plan was to fabricate a three-unit bridge from #19 to #21. Two CEREC Guide 3 surgical guides were fabricated to ensure proper implant placement (image 5). The bridge was sectioned, leaving #18 in place to help support the surgical guides (image 6). Tooth #21 was extracted, and implants were placed at sites #19 and #21 (image 7 and 8). Tooth #18 was then extracted. IO FLO ScanBodies were placed and imaging was done to fabricate custom healing abutments for implants #19 and #21 (image 9). The stock healing abutments were screwed into the implants, and sutures were placed (image 10). The IO FLO scan was sent to Dentsply Sirona Implants. The prescription for the custom healing abutments was submitted on the Atlantis Weborder site, and a design was ready to approve within a few hours (image 11). The custom healing abutments arrived two days later. When the patient returned for the one-week post op, the stock healing abutments were replaced with the custom healing abutments.

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Image 1. Pre-op radiograph of failing bridge #18-21

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Image 2. Pre-op bridge

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Image 3. Optical scan of pre-op bridge virtually extracting #19-21

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Image 4. Implant planning in SiCat 2.0 implant module

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Image 5. Designed and milled surgical guide

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Image 6. Bridge sectioned and removed

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Image 7. CG3 surgical guide for position #19

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Image 8. Guided ostetomy for implant #19

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Image 9. IO FLO scan at time of surgery for custom healing abutments

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Image 10. Completed surgery with stock healing abutments

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Image 11. Atlantis designed custom healing abutments

The advantage of the custom healing abutments is to develop perfectly contoured tissue during the initial healing process. After the implants integrate, there is an option to alter the healing abutment design in order to create the final abutments using the same contours. This eliminates the need for imaging after healing. In this case, however, the decision was made to have the patient return for new imaging. At ten weeks post-surgery, the implants were imaged with IO FLOs for the final abutments. The file was sent to Dentsply Sirona Implants via the Connect 5.1 software. A prescription was filled out on Atlantis Weborder requesting parallel titanium abutments with concave emergence and tissue support for implants #19 and #21 (image 12). An insertion guide was also requested to ensure the abutments were placed in the correct position.

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Image 12. Atlantis designed final abutments

A few hours later, the core file was ready. The model, with abutments #19 and #21 virtually placed, was imported into the CEREC Chairside 5.1 software (image 13). A three-unit zirconia bridge was designed and manufactured (image 14). On delivery, the custom healing abutments were removed, the final abutments were torqued into position with the aid of the insertion guide, and the zirconia bridge was cemented with RMGI cement (images 15-18). There was no need for anesthetic and almost no tissue blanching. Due to precise digital imaging of the gingiva with a Primescan, the final abutment contours were a perfect match of the custom healing abutment contours.

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Image 13. Core file of virtually placed abutments

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Image 14. Designed bridge #19-21 from core file

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Image 15. Insertion guide with abutments and milled Zirconia bridge

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Image 16. Abutments seated and torqued with insertion guide

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Image 17. Final titanium abutments #19 and #21

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Image 18. Final cemented bridge #19-#21

The Atlantis workflow produced perfectly contoured and parallel titanium abutments, without having to fabricate the abutments chairside or bond them to a TiBase. As an added bonus, the core file that was included with the abutments allowed for the final bridge to be designed and fabricated without having to place or scan the abutments intraorally. The Atlantis workflow not only produces a precise fitting implant bridge, but it saves valuable time for both dentist and patient.

Versatility in the CEREC® World Today

2021-06-15T13:01:51Z

Sponsored by Ivoclar

I had the amazing opportunity to witness eight smile transitions in a single day. Eight unique, life changing moments for both the doctors and the patients. While I wish I could share in detail all of the stories that were entrusted to us from the patients, I am excited to share a few of the cases from novice CEREC users to experienced users, and the wide variety of treatment options that were possible through today's technology and IPS e.max CAD. These cases were not done by my hands, but I could not be prouder of the work that was done. As a long-time user of Ivoclar Vivadent products, I was excited to partner with them and I appreciate the amazing support in donating the materials for this cause. The cases that were done involved multiple types of restorations, all IPS e.max, from crowns, to bridges, to implants as e.max offered incredible versatility in these cases while also demonstrating the strength and beauty that we were looking for.

Cathleen

When I first met Cathleen and asked her what a new smile would mean to her, she told me that she was looking for confidence to smile again and not be embarrassed. She has had an incredible life journey and a new smile would represent the person she has become, not the person she once was.

Cathleen had veneers placed on her upper and lower anteriors 20 years ago which started to break and fall off (Figure 1). She was not in a position to get them fixed and the exposed dentin started to cause pain. She presented with edentulous areas on the upper right and lower left, leaving her with little chewing surface in the posterior regions. The treatment plan is to establish her smile line first, and then she will be receiving implants in the posterior and the remainder of necessary treatment.

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Figure 1. Before retracted photo.

A digital wax up was completed for the full mouth, but for the purposes of this phase of treatment, fabricating crowns for #6-11, we also had a digital wax up for only the upper anterior teeth #6-11 done so that the wax-up and the remaining teeth would stitch together in Biogeneric Copy (Figure 2). With the software updates today, using the Biogeneric Copy design mode is easier than ever before, allowing for efficiency in these large cases (Figure 3). The six crowns were milled out of IPS e.max, shade A2 MT, contoured, glazed and stained. The hand contouring is what can really set a case like this apart, knowing the anatomy and defining the line angles a touch more than what the mill can do (Figure 4). The stain and glaze system used was IPS e.max CAD Crystall. Fluo glaze was utilized, and the stains were shade 1 for gingival warmth, shade I 2 for translucency and shade Creme for the framing (Figure 5).

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Figure 2. Digital wax up provided from a lab and printed from SprintRay Pro.

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Figure 3. BioGeneric copy "stitch" of design and wax up.

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Figure 4. Anatomy of anterior teeth for contouring post mill.

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Figure 5. Stain pattern used to give natural appearance to restorations.

After the crowns were fired, the teeth were isolated using an Optragate and bonded in. To prepare the restorations, Monobond Etch and Prime was scrubbed into the intaglio surface for 20 sec, let rest for 40 sec and then rinsed. This one-step system to prepare the restorations is just one more advancement for simplicity and efficiency in chairside cases. One of my favorite tools for rinsing crowns chairside is the Etch-Ease Holding System as shown in Figure 6. This is fantastic for preventing restorations from getting sucked into the high vac when removing any surface cleaner from crowns or veneers. The teeth were prepared by scrubbing in the Adhese Universal Vivapen bond for 20 sec, air drying until there is no movement of bond, light cured for 10 seconds and then bonded on the crowns. Tack cure for 3 seconds each side, remove excess, and fully cure.

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Figure 6. Etch-Ease Holding System for removing surface cleaners to intaglio surface of crowns.

There is so much magic in cases like this not only for the patient with their new smile, but for the doctor as well, with the knowledge that she created that smile with her own hands. This case was done by Dr. Kirsten Andrews and when she delivered this case, there was not a dry eye in the room (Figure 7). I recently saw Cathleen for a post op visit and to prepare her for her next section of treatment and I am proud to say that she just can’t stop smiling (Figure 8).

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Figure 6. Dr. Kirsten Andrews post delivery of the crowns.

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Figure 8. Before and after smile photo.

Felicia

Nothing breaks my heart more than when a young patient covers their mouth when they speak because they are so embarrassed by their smile. Felicia presented with decay on every tooth, and on almost every surface of every tooth (Figure 9). She hated her smile, and it had gotten to the point where she was just overwhelmed by the amount of appointments and the cost. Although I was really excited about the change and impact we could do for this case, when I first saw her, I knew a huge challenge would be her bite. With that much overclosure and “tight bite”, it is evident that she has a restricted envelope of function which could be a source of the fractured teeth. Personally, I think “tight bites” are one of the largest challenges we face in reconstruction.

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Figure 9. Initial before smile photo with heavy decay and stain present on every tooth.

The teeth were prepped but the patient was warned of the potential need for root canal therapy due to rotation and decay. A digital wax up was also done as a map and guide for the case. The doctor practiced prepping the case on a 3D model to ensure enough reduction would be done (Figure 10). We also discussed reducing the lowers to help create more space. Cases like this are perfect for use of the articulator function in the chairside software to minimize the interferences and potential problems. The articulation function can be found and turned on in the Administration screen as seen in Figure 11. I do not normally check the box to “Use Articulation for initial proposal” because it can load the system down too much. After I finish the design, I do check the Occlusal Compass to look for interferences and modify the design as necessary (Figure 12). This is a fantastic tool to minimize post-operative complications and does not take a lot of extra time.

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Figure 10. 3D wax up, practice preps, and original 3D model printed on SprintRay Pro.

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Figure 11. Administration screen of how to set up articulation feature.

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Figure 12. Articulator function within chairside software.

The crowns milled were e.max A2 MT and was characterized minimally with IPS CAD Crystall e.max stains and Fluo glaze. I2 was used for the translucency and Crème for the framing of that translucency (Figure 13). The restorations were bonded as described in the case above using Variolink Esthetic resin cement. This case was beautifully done by Dr. Jacquie Angell and her team. As you can see in Figure 14, the patient was incredibly excited and grateful about her new smile and looking forward the rest of her treatment. What an incredible transformation and service for this patient (Figure 15).

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Figure 13. Minimal stain and glaze pattern with natural effect of e.max.

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Figure 14. Initial reaction of the reveal of her new smile.

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Figure 15. After smile photos of e.max crowns #6-11, shade A2 MT.

Tina

Tina presented with edentulous areas in the posteriors in all quadrants and a large abscess on tooth #10. The bone defect from the infection was so large that it made the possibility for an implant in that site difficult. The tooth was extracted and grafted four months prior to her anterior teeth being restored (Figure 16). Teeth #s 6, 7, 8, 9 and 11 all had recurrent decay present with large fillings. Tina wanted the confidence to smile again, and we began her treatment plan with the upper anterior restorations to start this process. The plan was for single unit restorations on #s 6, 7, 8, and a 3-unit bridge from #9-11. A digital wax up was completed with only the anterior upper 6 mocked up so that the models would stitch. Originally when we discussed what the patient was looking for with her new smile, she had mentioned that she wanted her existing diastema closed, but when it came time to the prep day, she had changed her mind wanting to keep that character trait (Figure 17). What I love about this case in particular is that the dentist who restored the case did not have much experience with CEREC. However, because the new software and hardware is so user-friendly, she had no problem navigating this case and executed it beautifully.

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Figure 16. Initial retracted photo.

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Figure 17. 3D printed models from the SprintRay Pro of original scan, preps and digital wax up.

The design method for this case was Biogeneric Copy (Figure 18), but as mentioned before, the doctor had to open up the diastema. This can be done by using the group function, selecting #8 and #9, and then selecting the anatomical 2D tool to evenly open the gap between the centrals (Figure 19). The suggested connector size for an e.max bridge is 12 mm squared which was achieved by using the Anatomical Connector design and then extending the connector on the lingual surface as much as the bite would allow. The crowns and bridge were milled with e.max blocks, shade A2 LT, as e.max bridge blocks are only available in LT. The crowns and bridge were contoured by hand and then characterized using IPS e.max CAD crystal stains and glaze. The connectors of the bridge were distinguished using shade 1 to give the illusion of slight staining and separation of the teeth. The stain, shade Creme, was used for slight craze lines giving the teeth a natural appearance appropriate for the age of the patient. The translucency was highlighted by using a mixture of shades I1 and I2 and then that was framed with the shade white stain at the incisal edges and 1/3 of the way down on the mesial and distal marginal ridges as shown in Figure 20. After the ideal characterization was achieved, an Optragate was placed, and the restorations were bonded in using Variolink Esthetic resin cement.

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Figure 18. Original BioCopy design from digital wax up with diastema closed.

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Figure 19. Design using Shape > Anatomical 2D tool after grouping #8 and 9 for symmetrical modification of the centrals.

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Figure 20. Staining and glazing pattern using IPS e.max CAD stains and Fluo Glaze.

When this case was delivered, I am not sure who was truly more excited, Tina or Dr. Michelle Falbo, which is who restored this gorgeous case (Figure 21). Dr. Falbo had limited experience with CAD/CAM in the past and was not truly convinced of the capabilities of the CEREC, especially with anterior restorations. This was not an easy case to begin with, having spacing discrepancies and mixing bridges and single unit crowns in the treatment, but she executed it beautifully and is now a true believer of CEREC and same day delivery. The patient was thrilled with her new smile and looking forward to the next steps of establishing her posterior occlusion with implants and single unit restorations.

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Figure 21. Patients initial reaction to her new smile.

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Figure 22. After retracted photo of same day delivery. E.max crowns #6, 7, and 8. E.max 3-unit bridge from #9-11, shade A2 LT.

Crystal

Crystal presented with uneven diastemas and spacing on her upper anterior teeth with an edentulous space for #11 (Figure 23). An implant was placed six months prior to this treatment phase and is ready to restore. She did not want to go through orthodontics, but she did want to fix the gaps in her teeth and get rid of the decay. The challenge is the uneven spacing right and left of the midline, and also the canted midline. This is a perfect case for a digital wax-up to provide more ideal proportions and allow the patient to see where the case can go (Figure 24).

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Figure 23. Initial smile photo showing uneven diastemas from left to right side and edentulous space #11.

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Figure 24. Digital wax up showing roadmap of possibilities

What I love about using e.max is the versatility of different types of restorations. The implant crown and the single unit restorations can all be done with one material, which gives a more natural result. What is great about CEREC is you can do multiple restoration types at once, meaning you can select crowns and the implant crown in the same file (Figure 25). The plan for imaging purposes is to prepare the restorations first, making sure the margins are clear, the preps are smooth, and the substructures are all similar to allow for a more natural appearance of multiple restorations in the smile (Figure 26). The next step is to remove the healing cap and image the prepped teeth in the Upper Jaw folder, and then place the ScanPost in for #11 and scan this into the ScanBody Upper folder. Scan the lower jaw and Buccal Bite as normal and start to design the case (Figure 27).

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Figure 25. Administration page of multiple types of restorations at once.

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Figure 26. Prepped teeth #6-10 prior to implant impression.

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Figure 27. Acquisition screen of CEREC for cases with multiple types of restorations such as implants and crowns.

Due to the placement of the implant, there was not enough room to do a custom abutment and crown, so a screw-retained crown was the only option for same day delivery. The access hole was on the incisal facial edge which was not ideal. One way to fix this would be move all of the restorations more buccal which would move the access hole more lingual, but because of the existing spacing this also would have made the teeth larger which was not ideal (Figure 28). We compromised on the access hole being visible and honestly the patient was so grateful for her new smile, she didn’t even notice the access hole. Another option would have been to have a custom abutment fabricated outside of the CEREC workflow, but this was not within the realm of our capabilities for this day.

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Figure 28. Occlusal screenshot of design with access hole of screw-retained crown on facial insical.

To minimize the illusion of wide teeth, youthful anatomy was designed into the wax up, meaning that the central lobe and mesial and distal depressions were distinct. The trick is not having it so prominent that the patients find it annoying but breaking up the light helps the teeth not look so wide (Figure 29). After the characterization was complete, the crowns were seated first using Variolink Esthetic and the implant crown was seated last. The TiBase was seated outside of the mouth by sandblasting the TiBase and priming the metal with Monobond Plus. The screw retained crown was prepared with Monobond Etch and Prime, rinsed and then Multilink Hybrid Abutment Opaque cement was used to bond the TiBase to the crown. It needs to sit for 7 minutes prior to seating it. The implant crown was torqued to the value given by the implant company.

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Figure 29. After retracted photo with youthful anatomy.

The midline is straight, the diastemas are closed and the patient is so excited for her new smile. Dr. Katie Kennedy wanted the challenge of mixing an implant crown into the process of a smile design case and she did a magnificent job at creating the illusion of a more even smile with a natural looking result.

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Figure 30. After smile photo of e.max crowns #6, 7, 8, 9, 10 and screw retained implant crown #11, shade A1 LT.

Conclusion

As dentists, we always strive to do ideal dentistry but sometimes there are real life situations that prevent it. I would have loved to see all of these cases go through orthodontics, make sure all of the decay is removed and restored and have every patient be on an ideal hygiene schedule, but these are patients who have life circumstances that prevent it. I am honored that these patients allowed us into their lives. They gave us the opportunity to take them one step closer to building the confidence to change their life situations, and that is what this is all about. We do have plans to deliver the rest of the needed treatment if they choose to let us but for now, I appreciate the dedication and time that these doctors gave and the impact they made by giving these women hope again. How fortunate are we, that we have the capabilities to do this chairside with IPS e.max and CEREC!

Orthodontics and CEREC ®

2021-06-09T12:12:24Z

Intro: Interdisciplinary dental care is a staple of both the Spear Education and CDOCS core philosophies and, with the ongoing advances in CEREC technology, delivering comprehensive treatment has never been easier. Now more than ever, patients expect efficient and predictable restorative solutions, and these expectations can be routinely delivered with some creativity. The following case is a demonstration of how out-of-the-box thinking can be combined with our CEREC technology to create an entirely new smile for our deserving patient.

Case study: The patient presented with severe anterior wear necessitating indirect restorations; however, the resulting segmental supra eruption of the maxillary and mandibular incisors had reduced the inter arch space, therefore there was not adequate restorative space. (Fig. 1: Pre-operative condition)

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Figure 1

To better communicate the restorative challenges to the patient, the Spear Facially Generated Treatment Planning (FGTP) templates where superimposed over the patient's smile using Keynote (Macintosh) presentation software. (Fig. 2: FGTP templates)

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Figure 2

When viewing the prospective smile design plan, it became obvious that segmental orthodontic intrusion of the upper and lower incisors would be necessary to gain the necessary restorative space to treat the anterior teeth. The patient was then referred to the orthodontist and the orthodontic intrusion plan was finalized. Orthodontic brackets were bonded, and wires were pre-bent to achieve the necessary intrusion as guided by the FGTP templates. After several months or active treatment and several additional months of stabilization, the orthodontic movements were complete. (Fig. 3: Orthodontic progression)

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Figure 3

Before removing the brackets, though, the dentition was imaged with Primescan and the CEREC software was then used to design prepless anterior overlays to test drive the occlusion and phonetics. (Fig 4: Anterior overlay design)

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Figure 4

Next, Tetric CAD (Ivoclar) overlay restorations were milled on the MCXL in shade A3 and were then bonded to the intruded maxillary and mandibular incisors. (Fig. 5: Anterior overlays)

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Figure 5

Once the esthetics, function, and phonetics were approved by the patient, the orthodontic brackets and wire were finally removed, The Tetric CAD overlay provision restorations were then used as a Biocopy image for the design of the final restorations. (Fig. 6: Biocopy image)

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Figure 6

Next, the bonded overlays were then used as a preparation guide for the adequate reduction prior to the final refined veneer preparations. (Fig. 7: Final preparations)

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Figure 7

The initial restorative Biocopy proposal was then improved using the software’s design tools to create ideal anterior form. Final veneer restorations for teeth #7-10 and 23-26 were then milled from Ivoclar e.max MT A3.5 and were adhesively bonded to create the final smile makeover. (Fig. 8: Final post-op smile)

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Figure 8

Summary: Using a combination of traditional orthodontic techniques and progressive digital technology, a difficult restorative case was made predicable and relatively straightforward thanks to use of Spear FGTP concepts to predict the outcome before the case was ever started, by beginning with the end point in mind, a clear pathway to the final smile design can be followed.

Sometimes We Just Can’t Be Ideal

2021-06-03T11:11:32Z

The Spear Facially Generated Treatment Planning workshop I took early in my career had a massive impact on the amount of comprehensive dentistry I can now see and diagnose and present to my patients. Often the initial discussion I need to have with patients is either orthodontics or periodontal surgery. Using various smile design techniques to describe the possibilities to patients can only go so far. We can’t force a patient to follow the right sequence and often times we have to make compromises to achieve a stable and healthy dentition. I present to you Greg.

Greg came to my practice initially in 2013 as a new patient. We captured our standard new patient documentation - photos, scans, 3D imaging, etc. (Fig 1 - Smile), (Fig 2 - Lip at Rest), (Fig 3 - retracted anterior). I showed Greg his outlived composite bonding on his incisors, and the crowding, supereruption and malocclusion. I created a detailed presentation on what orthodontic treatment could do - positioning the teeth in a more ideal location, making the restorations more conservative and balancing the gingival heights and contours.

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Figure 1

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Figure 2

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Figure 3

Fast forward to 2021 - I have now presented the same comprehensive treatment option to Greg 16 times - think 2 periodic exams each year. My team would joke about how much time I would spend discussing this case knowing without a doubt he will decline ortho like he has for the last 8 years. But today he presents with a slight change in his dentition. The large composite bonding on his centrals is failing and the anterior radiographs we captured today are showing recurrent decay and we now need to make a restorative decision before the situation gets worse (Fig 4 - Anterior PA images).

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Figure 4

One option is to deliver new composite buildups and attempt to bond the teeth again. Another option is to restore the teeth with porcelain. Here in lies the challenge - the malocclusion leaves the centrals and laterals in different facial planes (Fig 5 - Occlusal View). Surprisingly Greg was interested in improving the appearance of his anterior teeth, however he declined orthodontics with a very colorful emphasis on “no”. We decided to restore his 4 incisors with porcelain restorations, and I captured a full arch scan with the Primescan and sent it to my lab technician Bill Marais at Disa Dental Studio (Fig 6 - STL files of existing arches).

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Figure 5

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Figure 6

Today I am delivering my chairside anterior restorations by using digital wax-ups from a master ceramist like Bill. It creates a much more predictable scenario and expedites my design time, improving the esthetic outcomes. Bill sends me a digital file of the wax-up (Fig 7 - STL of Wax-up) which I can either print and scan as a Biocopy or use inLab and import the original STL to design the case. However, the same issue arises, how do I know where to end my reduction? If you look at Greg’s tooth position in relation to his wax-up, some teeth are purely additive, and some will be purely reductive. I still want to be conservative with my preparations, so I need some form of guidance. We use guides for Implants and Endo, why not use a guide for anterior preparations? One technique is to roughly prepare the teeth, and then transfer the wax-up and perform depth cuts through it. Another technique is to use a merged wax-up file that can seat passively over the unprepared teeth (Fig 8 - Merged Wax-Up). I simply fabricate a Copyplast matrix of this merged model, after I 3D print it in my office (Fig 9 - Seated Copyplast of Merged Wax-Up, note it’s passively seating). I can then transfer that merged wax-up using any bisacryl material (Fig 10,11 - Transferred Wax-Up).

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Figure 7

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Figure 8

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Figure 9

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Figure 10

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Figure 11

From here, I can easily perform my depth cuts through the wax-up and finalize my preparations (Fig 12 - depth cuts through transfer, note tooth #10 will be purely additive). Once the preparations are complete (Fig 13 - Final Preps), I can use inLab to merge my prep STL with my wax-up STL (Fig 14 - Final Design). Note the wax-up from the lab required some gingival contouring or crown lengthening, which unfortunately the patient declined (Fig 15 - Biocopy, note the apical positioning of the ideal gingival margins).

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Figure 12

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Figure 13

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Figure 14

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Figure 15

After grinding the restorations, printing a model and contouring the ceramic to refine the line angles and anatomy, the restorations are seated (Fig 16 - Seated Restorations 7-10). You can see the compromise we were left with, gingival asymmetry and the obvious crowding and malocclusion on the lower arch. However, we left him with a comfortable bite and tight contacts that he can now floss and maintain better than before. (Fig 17 - Final Smile) (Fig 18 - Retracted Smile), (Fig 19, Before/After). Now all we need to do is convince him to trim his mustache a bit so we can see his beautiful new smile!

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Figure 16

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Figure 17

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Figure 18

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Figure 19

While it’s always best practice to recommend ideal comprehensive dentistry, sometimes our patients just won’t do it. Ultimately, we can still provide an esthetic, biological and functional improvement while knowing the compromises in advance.

Join us on the CDOCS Summer $500 Tour

2021-05-27T10:10:29Z

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Come rock out at our hands-on workshops in Scottsdale or Charlotte and earn $500 towards some summer fun!

It’s part of our incredible CDOCS Summer $500 Tour, where you get a $500 gift card if you attend back-to-back workshops over four days with us from now through September. *

Email courses@cdocs.com or click HERE to schedule a time to speak to one of our Education Advisors to take advantage!

While you can attend ANY two CDOCS workshops over the four days to qualify for the offer, we thought we might help give you some suggested options to make the most out of our curriculum.

CAD/CAM

9/26-9/29 Scottsdale: Anterior Esthetics with CEREC (CL4) & Comprehensive Restorative Care with a Digital Workflow (CL5)

CONE BEAM

9/16-9/19 Charlotte: Cone Beam Basic Training (CB1) & Advanced Cone Beam Diagnostics (CB2)

IMPLANTS

8/26-8/29 Charlotte: Hard and Soft Tissue Grafting in Digital Dental Implant Dentistry (CI3) & Digital Full Arch Dental Implant Therapy (CI4)

9/16-9/19 Charlotte: Fundamentals of Guided Implant Surgery with Cone Beam (CI1) & Advanced Surgical Guided Implant Dentistry (CI2)

ORTHO

8/26-8/29 Charlotte: Fundamentals of Clear Aligner Therapy (CO1) & Clear Aligner Therapy in Advanced Cases (CO2)

9/9-9/12 Charlotte: Fundamentals of Clear Aligner Therapy (CO1) & Clear Aligner Therapy in Advanced Cases (CO2)

9/9-9/12 Scottsdale: Fundamentals of Clear Aligner Therapy (CO1) & Clear Aligner Therapy in Advanced Cases (CO2)

9/16-9/19 Scottsdale: Fundamentals of Clear Aligner Therapy (CO1) & Clear Aligner Therapy in Advanced Cases (CO2)

ENDO

9/9-9/12 Charlotte: Fundamentals of Endodontic Therapy (CE1) & Advanced Concepts in Endodontics Therapy (CE2)

Again, email courses@cdocs.com or click HERE to schedule a time to speak to one of our Education Advisors to take advantage!

*Offer only applies to new workshop registrations now through Sept. Must register for both workshops before attending first workshop to qualify. Must attend both workshops by Sept. 30 to qualify. Offer subject to change. Offer cannot be transferred, exchanged for cash. Other restrictions may apply.

New Infrastructure Needed, Bridge Replacement

2021-05-25T13:01:01Z

By Gregory Mark, DDS
Sponsored by Kuraray

All patients have unique cases with various solutions, but some have the opportunity to boost their confidence without worrisome procedures. This treatment applied to one patient in specific. This patient presented a failing bridge between teeth #29-31 due to secondary decay. She was an average dental patient, having medical history within normal limits, and a dental history revealing multiple restorations.

The ideal treatment plan for this patient was to remove the existing bridge, remove the secondary decay, and fabricate a new zirconia bridge. The step-by-step procedure was done using local anesthesia. First, the existing bridge made of PFM (Porcelain Fused Metal) was removed and the secondary decay was excavated. To prepare for the crowns, a CEREC Omnicam was used to scan the patient and forward the digital imaging file via CEREC Connect to the InLab software.

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Figure 1: Removable dies and model digitally designed and printed.

As we all know, restorations need manual touch and precise materials to accentuate anatomy. Therefore, the crowns were developed using KATANA STML Zirconia for the final restorative material for several reasons: this restorative material had a near identical shade, exemplified the needed strength, and was extremely easy to work with.

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Figure 2: Secondary occlusal anatomy carved prior to sintering and staining.

With this material, the InLab software designed a bridge milled with an MCX5 milling unit. When the final product bridge was milled, it was placed in a Vita Zirconia oven to sinter for 8 hours. In order to bring more vitality to the restoration, and stain and glaze was utilized and additionally a diamond paste to polish the bridge.

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Figure 3: Stain and glaze was utilized and additionally a diamond paste to polish the bridge.

The patient returned the following week for the final steps of the procedure. The temporary bridge was removed, and the final cementation of the restoration was conducted.

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Figure 4: Buccal view post cementation.

After the fitting, the patient examined the esthetic look and occlusal feel, extremely satisfied with the results. Finally, x-rays and photos were taken, and an overall happier patient was achieved.

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Figure 5: Buccal view post cementation.

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Figure 6: Occlusal view post cementation.

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Figure 7: BW post cementation.

Knowing More About Photo-Chemical Etching

2021-05-18T10:10:57Z

One of the fabrication processes used in producing intricate dental implants is a method called photochemical machining or etching. Photochemical etching is a non-conventional machining method wherein the process does not involve cutting tools. Photographic and chemical techniques are used to remove material from the workpiece to shape the final product. The process involves exposing the workpiece to a special chemical solution and selectively corrode defined areas. These areas are defined through photoresist imaging.

Fundamental Steps of Photochemical Etching

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1. Preparation for the Photo-tool Plotting.

The pattern used for this process is designed using CAD software that will be converted to the appropriate format needed for printing. The pattern is printed on a photographic film, in the form of a diazo or silver halide film, by a photoplotter or a laser imaging system. Common compensation factors affect the photo-tool dimensions; these are the etch factor, the temperature, and the humidity variations.

2. Preparing the Workpiece

The work part will be cut and cleaned prior to loading it in for the etching process. It is important to ensure that there should be no contaminants on the metal surface for successful adhesion of the photoresist. The parts may be cleaned by two methods (mechanical and chemical). Mechanical cleaning involves the application of a degreasing solution and subjecting it to a certain form of scrubbing. On the other hand, in chemical cleaning, the work part is suspended into a degreasing solution made up of combining mild acids and agents. Most fabrication shops prefer chemical cleaning methods because of their minimal damage applied to the work part.

3. Photoresist Processing

Photoresist Coating

Photoresists are usually set down on the surface of the work part. These can withstand the strong effects of the etching solution, leaving behind a masked and defined image. The photo-tool is responsible for protecting and exposing the desired photoresist regions. This compound exposure to UV light makes it either soluble or insoluble (depending on what was used) to the developer agent.

Below are the different classifications of photoresists:

● Classification according to the type of image produced (Positive Photoresist and Negative Photoresist)

● Classification according to chemical structure (Photopolymer, Photodecomposition, and Photocrosslinking)

● Classification according to form (Dry Film and Liquid or Wet Film)

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Soft Bake (90°C to 110°C)

The next process, after applying the photoresist material, is “soft baking.” This is done to heat, vaporize, and release residual solvents. This process should be supervised to avoid high evaporation, causing bubbles and voids within the photoresist. Additionally, a low evaporation rate might inhibit the necessary evaporation of the residual solvents, which will result in a film formation on the surface.

Exposure

Before proceeding with this process, it is vital to ensure proper alignment of the photo-tools in a multi-layered pattern. After everything has been set, the work part may now be subjected to exposure. The exposure process is where the photo-tool image will be relayed to the work part with the photoresist. This is typically done with wavelengths less than 400nm (Ultra-violet rays). Different techniques are used for exposing the photoresist, and these are through contact exposure, proximity exposure, projection, direct laser imaging, and electron beam.

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Post Exposure Bake (110°C to 120°C)

This process involves thermally catalyzing the chemical reactions, which completes the photoreaction initiated by the Ultraviolet light exposure.

Developing

This process is made to remove unnecessary parts of the photoresist, leaving behind the desired pattern on the work part.

Hard Baking (120°C)

This process adds to the physical stability of the workpiece to withstand the etching process.

4. Etching Proper

This is when the unnecessary materials are subtracted from the work part to form it into the desired shape. Etching can be classified into two main types, namely, wet etching and dry etching.

Wet Etching

This method uses liquid chemicals to erode the unprotected part. It starts with oxidizing components through hydrogen peroxide or nitric acid. Next is the oxidized part's dissolution using chemicals like hydrofluoric acid, phosphoric acid, and hydrochloric acid. Finally, the dissolved oxidized substrate is removed from the part, ensuring a homogenous solution in contact.

Dry Etching

This method relies on high-velocity gaseous ions in removing and corroding the material. The collision of ions with the part is responsible for removing the material in one direction only, removing the undercut problems arising from wet etching.

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5. Photoresist Removal or Stripping

After the desired shape has been created, the photoresist materials are removed. This process can be made with two methods: by using solvents and by using combustion. Solvents have the ability to break down the structure of the photoresist layer, and oxygen combustion, on the other hand, can deal with materials that are not easily removed by chemical agents.

8 Exercises to Ease That Dental-Related Neck and Back Pain

2021-05-10T10:10:11Z

Protect ya neck. Okay, so maybe not all of you are Wu-Tang clan fans, but that doesn’t mean they don’t have some good advice. Incorrect posture shortens more careers in dentistry than just about anything else. If you look at the literature the prevalence of neck and back pain is rampant in dentistry, with most studies showing rates in the 75+% or higher. Dentistry has been listed as one of the most detrimental professions for your health due the musculoskeletal dysfunction associated with it.

Proper treatment position is key to a long career in dentistry. However, it is not always possible to maintain proper posture for everything that we do. The average human head weighs approximately 11-12lbs. However, once we break the vertical plane the weight increases drastically. Add into the weight loupes, head lights and now face shields the weight just keeps adding more and more stress to an already strained system.

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The best thing is to keep proper ergonomics, but as was stated earlier, this isn’t always possible. Luckily, with some good maintenance exercises the damage can be lessened and if caught early enough reversed. The most common areas that are affected are the neck, back, shoulders and hips for all dental professionals. Wrists and hands are at more risk for hygiene due to repetitive stress injury, commonly known as carpal tunnel syndrome. For the sake of this article, we will focus mainly on the neck and some shoulder mobility.

The exercises can be done before or after working, or for that matter both. The goal of these exercises is getting the specific area moving. It is not about getting a “workout” from the exercises. With that in mind, when using bands, it is not about how much weight you are pulling. You only need enough to have a sense of resistance. This gives you enough to activate the muscle and stabilize the joint you are working on. Remember the idea is to get the proper movement, not fatigue the muscle.

Here are the eight exercises:

• Do the first five three times a day in the order listed below.

• The last three can be done either before or after work, or both if you need it.

Exercises:

RETRACTION / CHIN TUCK

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CERVICAL EXTENSION

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CERVICAL ROTATION

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SHOULDER ROLLS

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UPPER TRUNK ROTATIONS – UTR

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Rows with Theraband

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Shoulder Extension with Theraband

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Shoulder Shrugs with TBand

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Trying to maintain good posture is of course the first goal but if that is not possible there are ways to reduce the strain and stress on the body. By performing these exercises on a regular basis, you can help reduce any damage done through poor posture. With regular maintenance you can slow down the progression of cervical and thoracic spinal issue and the corresponding shoulder impingements that most dental professionals suffer from.

Interdisciplinary Case Report

2021-05-04T14:02:11Z

Anthony Ramirez, DDS, MAGD

e.max Completes This Dream

I incorporated the surgical phase of implant dentistry over a decade ago with my investment of an in-office Cone Beam imaging system and becoming proficient in computer assisted implantology. Implant dentistry is an all-encompassing discipline that requires expertise in maxillofacial radiology and anatomy, Cone Beam CT interpretation, oral surgery, periodontal regeneration, advanced digital implant planning and prosthodontics, both removable and fixed. Without this additional skill set and post graduate training I simply could not deliver the results that my patients deserve. Couple this with the in-office technologies of CEREC® Primescan and CBCT allowed us to gain control of the technical processes necessary to manage and produce the surgical and restorative phases of treatment at one location.

The following will describe a case that required multiple dental disciplines to replace missing maxillary lateral incisors with fixed tooth replacements. This case is emblematic of how being able to control the surgical and restorative processes within a digital workflow can raise the level of how we practice dentistry. We need to recognize how clinical dentistry has become intertwined with digital technologies to synergistically assist us in providing enhanced diagnosis with safe and predictable treatment outcomes. A healthy 46-year-old patient who has lived for over 30 years with missing bilateral maxillary incisors desired a fixed solution to his problem. He dreamed of the day when he no longer had to look in the mirror and see his missing lateral incisors. The existing acrylic partial denture replacing these incisors along with missing upper right molars and premolars was a poor compromise at best that was becoming increasingly difficult to tolerate. He was ready for a change and was mentally, and financially prepared for what would become a life changing experience.

Our first visit included a clinical assessment of the existing maxillofacial anatomy and an advanced radiographic evaluation employing 3D imaging. Intra-oral photographs were taken and after reviewing his medical history we discussed his desires for a fixed replacement of these teeth. His recollection as to how he lost these teeth was that after five years of difficult orthodontic therapy they simply fell out. The patient was only interested in replacing the missing lateral incisors at this time and would be satisfied with a unilateral flexi partial replacing # 2, 3 and 4. Various options were communicated for the posterior teeth which could be considered in the future. He presented with a high smile line and desired fixed natural appearing teeth. Restoring a high esthetic risk patient can be our most challenging anterior case type. A dynamic smile assessment revealed a full display of this patients’ dentition which exposed anywhere from 3-5mm of gingival tissue with a thick biotype. I diagnosed this case to be complex, requiring extensive bone regeneration, possibly with multiple grafts and informed this patient of the risks, timeline and complexity of his case. Being able to communicate our patient's problems in the third dimension always breaks down barriers to case acceptance as the information gleaned via a CT scan is invaluable for both planning and educating the patient. Only with a full understanding of the challenges associated with these complex cases can a viable solution be planned and executed to our satisfaction.

Co-Discovery and Informed Consent

The treatment plan was developed and presented during our first visit, a direct benefit of having these digital technologies at our fingertips. After reviewing his 3D imaging, it was apparent that we needed to begin his therapy by augmenting the severely deficient bilateral alveolar ridge sites. The existing removable partial denture would serve as a provisional prosthesis while the grafts mature. These cases can be treated in a variety of ways including using block graft, particulate layered composite bone grafting techniques and or ridge splitting. The gingival tissue was thick, keratinized and both sites were devoid of infection which would preclude the need for any adjunctive subepithelial connective tissue grafting. Thick keratinized tissue is required to prevent gingival marginal changes that may occur after implant placement due to thin tissue. The existing alveolar bone volume decreased as we tracked the bone from the crest to its apical termination but appeared to be amenable for regeneration. The goal was to replace these two missing lateral incisors with fixed, esthetic and fully functioning tooth replacements. Without the integrated workflow this process can become disjointed and not as streamlined when working the analog world and with multiple clinicians. These methods also reduce the number of visits necessary to restore our implants by controlling abutment design and tooth morphology with in-office technology. We reviewed the 3D images together and discussed the risks associated with his case. The possible complications were communicated so that the patient could make an informed decision and proceed with treatment. (figs. 1-3)

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Figure 1: Initial presentation of missing teeth #7 and 10

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Figure 2: Close up views edentulous sites #7 and 10

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Figure 3: Pre-op CBCT imaging and virtual implant #7 with deficient bone site

Regenerating Bone Volume

The patient presented for his first surgical appointment premedicated with Amoxicillin 500 mg. Three carpules of 4% Articaine with 1/100,00 epinephrine was administered producing profound anesthesia which lasted throughout this visit. I chose to regenerate these sites with buccal bone grafts, using MinerOss Blend, a 50/50 mixture of cortical and cancellous mineralized bone allograft. Full thickness flaps exposed the underlying boney defects, and the alveolar bone was prepared with intermedullary bone preparations (decorticated) to initiate bleeding bone. Angiogenesis connects the existing tissue with the bone grafts and carry the cells and growth factors to the sites necessary to accelerate bone growth leading to regeneration. I utilized 2CC of the mineralized freeze-dried allograft, particle size 500um to 1000um. The bone grafts were covered with Bio-Gide non-cross linked collagen membranes using a double membrane technique and the areas were sutured with primary closure. I modified his acrylic partial to avoid contacting the surgical sites. The patient tolerated this surgery well and was dismissed with post-op instructions to continue antibiotic therapy for five days, 1 tablet tid and rinsing twice a day with .12% chlorhexidine. Ibuprofen 600mg was prescribed to be taken one tablet every 8 hours as needed for pain. I followed this patient closely for three months and healing was uneventful. (figs. 4-5)

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Figure 4: Exposed bone defect site #10

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Figure 5: Bone regeneration surgery completed

Integrating Technologies for Implant Planning

I obtained a Cone Beam CT scan after 12 weeks to evaluate the result of his bone grafts and began digital implant planning. The Dicom file was loaded into Simplant software and virtual teeth were placed to help formulate a prosthetically driven implant plan. 3D imaging is helpful to produce the proper 3D position for the virtual implants and help create the foundation for a computer assisted surgical guide. The regenerated bone volume appeared adequate to receive 4.2 x 10.5mm tapered internal implants. These fixtures were placed virtually, and my implant plan was digitally transferred to Simplant to design and produce a SAFEguide for guided surgery. The advantages of implant planning in this manner are twofold, we learn immediately if our previous regeneration treatments were successful and can prepare for the next phase of treatment within the 3D software, giving us the necessary information to facilitate the production of a surgical guide. (figs. 6-8)

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Figure 6: #7 Simplant implant plan with a 4.2x10.5mm implant and surgical guide design

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Figure 7: #10 Simplant implant plan with 4.2x10.5mm fixture

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Figure 8: Simplant screenshot of virtual teeth and labial bone augmentation of #7 and 10

Guided Implant Surgery

Our patient was premedicated with amoxicillin 500mg in preparation for his implant surgery. There are studies that have shown this regimen lessens early implant failures. The surgical sites were anesthetized with 4% Articaine with 1/100,00 epinephrine. The SAFEguide tooth borne surgical guide was well fitting and stable. We gained a good volume of bone which was accessed through mini flaps. The osteotomies for # 7 and # 10 were prepared through the guide. I noted that the bone was soft, D3 D4 in density but the implants were torqued in sufficiently to gain stability, a pre-requisite for Osseo-integration. I anticipated uncovering the 4.2 x 10.5 mm tapered implants after 12 weeks. Upon follow up I obtained an updated cone beam and discovered apical fenestrations, so I accessed these areas via trapezoidal flaps and added additional bone to both sites. This unexpected complication set the restorative phase of treatment back a couple of months, but the results were favorable after 6 weeks verified with 3D imaging. The cross-sectional views show improved apical coverage of both implants and the tissue appeared healthy. (figs. 9-13)

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Figure 9: 4.2x10.5mm tapered implant #7

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Figure 10: 4.2x10.5mm tapered implant #10

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Figure 11: Post-op revised bone graft implant #10

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Figure 12: #7 xsectional Sidexis 3D view post bone regeneration prior to restoring

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Figure 13: #10 xsectional Sidexis 3D view post bone regeneration prior to restoring

Restorative Workflow

Uncovering was performed through tissue punch access through the surgical guide. I temporized with PEEK prefabricated abutments and Luxatemp crowns. A printed model with acrylic denture teeth replaced #s 7 and 10 which was used to create an omnivac shell as a blueprint for the provisionals. Osstell ISQ values were obtained indicating high stability (any value 70 or higher) and provided objective confirmation that these implants were ready to be restored. Osstell ISQ values are taken at different times to determine when the implants were biologically stable and provides supporting documentation for our clinical decision to move forward with the restorative phase of treatment. The results were good, and the final optical impression would be obtained after the gingival tissue healed and our emergence profile could be optimally managed. (figs. 14-18)

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Figure 14: Primescan optical impression of site specific IO Flo scan bodies capturing fixture level impression

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Figure 15: Atlantis design reviewed and accepted

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Figure 16: Model phase derived from Atlantis .dxd core file used to design and manufacture e.max crowns

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Figure 17: Osstell ISQ values for # 7 Implant indicating successful osseo-integration. Note the 49 value was caused by bone interfering with the digital reading, revalued at 74 same visit

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Figure 18: Osstell ISQ values for # 10 implant indicating successful ooseo-integration

The CEREC digital workflow to fabricate Atlantis abutments is, in my opinion, the ideal way to produce CAD/CAM custom abutments that are efficient, productive, functional and economical. The manufacture of a screw-retained or cementable implant crown and Atlantis abutments comes with a significant cost savings. Routinely a 25-40% reduction in cost as compared to the dental lab. In addition, I can review the design and make any necessary changes to achieve an optimal outcome. This case is illustrative of such a restorative outcome. An optical scan of the site-specific IO Flo scan body for the implant was captured and digitally transferred through the CEREC Connect Case Center to the Atlantis lab. A materials reference guide is available for the clinician to review and decide which abutment is appropriate for a particular implant site. I chose to utilize a zirconia abutment and selected shade 20 used for midrange shades in the VITA shade guide, i.e. A2. At least 1.5mm of occlusal clearance and 1 mm of axial wall depth provides adequate space for restorative strength. The gingival chamfer margins would be placed .5mm subgingivally in the labial, mesial and distal positions. The lingual margin would be at the gingival crest. The cement margins would be easy to clean at the insertion visit by placing the margins at these levels. I requested a core file which was downloaded into CEREC before the Atlantis abutment was delivered to my office and used for the design and manufacture of the e.max crowns. These restorations are milled, stained and glazed by my assistant before the abutments arrive at the office, usually a two-day turnaround. Much faster than the local lab turnaround times. The Atlantis lab always includes an insertion jig with these kinds of abutments to make the insertion visit a non-event. An accurate Primescan impression is key to capture the IO Flo scan bodies seated into the implant registering the correct implant position in situ. Both abutments were torqued in to 30 ncm and their access holes covered with Teflon tape and resin. The abutments were seated with little effort and the e.max crowns were cemented onto the abutments completing the restorative phase of treatment. A slight reduction in the uneven incisal edge on # 8 was the final enhancement to this case. The CEREC digital workflow facilitates this restorative process to a point where no occlusal adjustments were necessary during the insertion visit. Implant protected occlusion is built into the occlusion to avoid any physiological overload of masticatory forces during function. Esthetic and functionally demanding cases can easily be incorporated into our CEREC chairside workflow with these approaches. The optical properties of e.max are consistent and when the proper block shade and translucency is selected, these lithium disilicate ceramics produce a natural, esthetic, well-fitting and biocompatible restoration. (figs. 19-22)

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Figure 19: Peri-implant tissue at restorative visit

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Figure 20: e.max crowns completed and fitted prior to insertion visit

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Figure 21: Zirconia abutments and e.max crowns

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Figure 22: Insertion jig during installation of # 10 zirconia Atlantis abutment

Success is determined by clinical and radiographic post loading evaluations. The patient was seen two months after his restorative visit and remarked that he loved the look and feel of his new teeth. Success will include healthy keratinized gingival tissue, no bleeding upon probing and minimal sulcular depths. His surgery maintained all papillae which added to the natural looking esthetic result. The use of zirconia Atlantis abutments enhanced the e.max crown which reflected light as well as his adjacent natural dentition. It is important to monitor the crestal bone levels over time which should exhibit minimal or zero bone remodeling ensuring a healthy and optimally functioning dental implant. (figs. 23-29)

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Figure 23: #10 zirconia Atlantis abutment

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Figure 24: Right side view post op loading

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Figure 25: Left side view post op loading

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Figure 26: Definitive emax implant crown # 7 cemented onto Zirconia Atlantis abutment

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Figure 27: Definitive e.max implant crown # 10 cemented onto Zirconia Atlantis abutment

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Figure 28: Completed e.max restorations

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Figure 29: A happy confident smile

Control of the Process Leads to Success

Only with a full understanding of the challenges associated with these complex cases can a viable solution be planned and executed to our satisfaction. Preparing to succeed before any treatment is performed with advanced 3-dimensional implant planning, a direct benefit of our in-office digital technologies. Being in control of all the processes to treat both the surgical and restorative phase of implant dentistry has been a practice builder leading to securing case acceptance during our patient's initial visit. Technology goes hand in hand with clinical skills to empower the clinical side of the practice by opening new avenues for expanded services. The goal is to replace missing teeth in a safe, predictable and streamlined approach while providing long lasting solutions. In this case, replacing two missing teeth with fixed tooth replacements changed our patient's life. His priceless smile displays a newfound confidence, derived from both functionality and esthetic appearance, that will serve him throughout his life. Note how the light is reflected off both his natural teeth and restorations to provide a natural blended appearance. A predetermined game plan preceded our efforts to improve the foundation for implants and precipitated a straightforward restorative case

CDOCS LIVE: An Event for the Entire CDOCS Community

2021-04-27T08:08:59Z

For the first time ever, CDOCS is gathering its entire community for three hours of engaging clinical education, live engagement with some of the best minds in dentistry and special access to incredible offers.

It’s CDOCS LIVE, an online event where admission is included for all CDOCS members. And there’s only one way to be involved - Be there on May 14, starting at 1 p.m. ET/10 a.m. PT.

“This has never been done,” CDOCS Vice President Dr. Sam Puri said. “It’s an opportunity for our whole community to come learn together, laugh together and grow both personally and professionally together.”

Come chat with your peers, ask questions and enjoy five unique clinical lectures from the CDOCS faculty on CAD/CAM, Cone Beam, Ortho, Endo and Implants.

“This is our way of giving back to those who make CDOCS truly special – its members,” Dr. Puri said. “This is going to be a fun three-hours and we hope all of you will join us.”

CDOCS LIVE • May 14 • 1 p.m. ET/10 a.m. PT

CDOCS MEMBERS: To view the event’s agenda and register, click

NON-CDOCS MEMBERS: You must be a CDOCS member to attend this event. To join CDOCS and view the event’s agenda, please click

Pre-Extraction Bone Grafting

2021-04-27T08:08:21Z

The treatment of the hopeless teeth in the esthetic zone remains very challenging due to the pre-existing anatomical limitations. Out of the various available treatment options one strategy which can be employed is that of pre-extraction bone grafting illustrated by the following case report.

A healthy female patient presented with a maxillary left central incisor with advanced external resorption and a very deficient alveolar ridge anatomy (Figures 1-3). Although the tooth was deemed to have a hopeless prognosis it was asymptomatic. A decision was therefore made to perform a minimally invasive pre-extraction bone grafting procedure via a lateral tunneling approach using a cortical mineralized/demineralized blend allograft (Maxxeus Cortical Min/Demin Blend Allograft) mixed with platelet-Rich Fibrin and overlayered with a long-resorbing highly cross-linked collagen membrane (Ossix Volumax) (Figure 4). Six months after the bone grafting procedure a CBCT scan and a CEREC optical impression scan were obtained and the corresponding digital data were uploaded to the Dentsply Sirona Azento portal to obtain a guided implant surgery treatment plan. The post bone grafting CBCT scan revealed a radiographically well consolidated bone graft and adequate augmentation of the previously deficient alveolar ridge (Figure 5). An implant treatment plan was devised through the Dentsply Sirona Azento workflow (Figure 6) and the Azento surgical guide was then utilized to place an immediate implant (Astra EV 3.6S X 13mm implant) at the time of tooth extraction in a minimally invasive flapless approach (Figure 7). The post implant placement CBCT scan revealed an implant accurately placed within the augmented alveolar ridge in accordance with the guided implant surgery plan (Figure 8).

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Figure 1: Pre-operative clinical presentation of tooth #9

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Figure 2: Pre-operative periapical radiograph of tooth #9 with external resorptive lesion

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Figure 3: Pre-operative CBCT scan of tooth #9 with deficient ridge anatomy

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Figure 4: Pre-extraction bone grafting via lateral tunneling approach

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Figure 5: Six months post bone grafting CBCT scan of tooth #9

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Figure 6: Dentsply Sirona Azento implant treatment plan site #9

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Figure 7: Occlusal view of immediate implant placement site #9

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Figure 8: Post implant placement CBCT scan site #9

The pre-extraction minimally invasive bone grafting technique employed in this case allowed the augmentation of the deficient alveolar ridge prior to extraction of the hopeless but asymptomatic tooth. This strategy can be used in certain cases to allow the patient to maintain the natural tooth with a guarded or hopeless prognosis while the bone graft is healing. Implant placement can then follow with a minimally invasive immediate implant placement technique. A major advantage of this workflow is that it avoids the need for the oftentimes challenging provisionalization during the prolonged period of bone graft healing. Furthermore, this workflow results in minimal disruption of the delicate gingival architecture in the esthetic zone thereby significantly enhancing the final esthetic outcome.

Determining Vertical Dimension for Worn Dentition Case

2021-04-19T14:02:11Z

One of the most difficult and misunderstood aspects of comprehensive dentistry is how to address the severely worn dentition. The patient who has worn their teeth so severely that both esthetics and function have been significantly compromised. We all want to help these patients, but we need a place to start. How do we determine what that starting point is? Can we open up vertical dimension or do we need to recommend orthodontics, crown lengthening, or all of the above? In this brief article and case study, we will discuss one method to determine a restorative position that “might” work.

A patient presented into my office with the chief complaint that he had lost tooth #7 and was interested in an implant to replace the tooth. During the exam we noticed the extensive attrition and erosion present and significant loss of vertical dimension (Figures 1 and 2). After reviewing the clinical situation with the patient, he was interested in at least exploring the options to restore his bite. However, at this point we cannot definitely tell the patient what options are available, we need to collect some information and diagnostically work up the case to determine what is possible.

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Figure 1: Preop closed.

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Figure 2: Preop open.

Before the patient left that day, we took a full series of photographs and an upper and lower scan of his teeth with the CEREC® Primescan. I had a suspicion that I would have the ability to lengthen his teeth and open his vertical dimension based on his lip at rest photo (Figure 3). How much I would need to open the vertical I did not know at this point.

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Figure 3: Lip at rest.

So here is an effective technique that can be used to determine a starting restorative position.

Step 1: Build up the upper and lower central incisors to correct proportions (in composites). I personally will start with the upper central incisors and create an ideal shape that establishes proper lip at rest tooth display. Once the uppers are done, I will mock-up the lower central incisors (Figure 4). These mock-ups do not have be perfect, but just establish a tooth position “base-line”

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Figure 4: Composite Mockup on 8,9,24,25 Open.

Step 2. Have the patient close their teeth. This is new proposed vertical dimension... At this new position the patient should only be hitting on the central incisors. Anterior contact with no posterior contact should help the patient's condyle's seat and help them into a CR position. Using a Leaf Gauge with this anterior contact can also help the patient move into CR (Figure 5)

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Figure 5: Composite Mockup on 8,9,24,25 closed.

Step 3: Having the patient in the new CR position with the anterior mock-ups holding this position (or you can hold via bite registration material), take the double buccal bite image to relate the upper and lower arch in the new vertical dimension.

Step 4: Lastly, before you remove the composite mock-ups, scan them in the Biocopy Folders with the Primescan.

Now that you have gathered all the information, you can tell the patient you will comprehensively mock-up the case (via digital wax-up) to see what is possible. We can schedule the patient for a second consult to discuss and finalize the plan.

Using inLab 20, we imported all the information gathered with the Primescan and did a full digital wax-up. Once completed, the wax was 3D printed and Copyplast templates were made to transfer the wax-up to the patients mouth and determine if this restorative position was going to work out.

Using Copyplast and Bis-Acryl, we transferred the wax-up to the mouth and the patient was quite pleased with the plan (Figures 6 and 7). This definitely created value for the patient to move forward with treatment and complete the case. Over the next month or so the entire case was completed using zirconia (Figure 8).

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Figure 6: Waxup transfered in BisAcryl Closed.

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Figure 7: Waxup transferred in BisAcryl Open.

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Figure 8: Final Result Zirconia.

Understanding how to address wear cases can be a daunting task. However, always remember that you simply need a starting point. The best way that I think about it is that esthetics is always the goal. Start with making the shape of the tooth ideal and try to develop function around that. Sometimes (like this case) you can do it entirely restoratively by increasing vertical dimension. Other times, building the tooth to the ideal position will result in 7mm tooth display at rest position... but that tells up important information in how to restore the case. That is, in many wear cases, orthodontics and/or crown lengthening is required.

The Chairside Zirconia Revolution: The Evolution of Choice

2021-04-14T10:10:40Z

Dr. Michael Snider
Sponsored by 3M

As I was sitting down yesterday to begin a standard appointment for a single unit restoration, I was struck by how far we have come in such a short time. Everyone has their own, unique “CEREC® journey”. Whenever I speak to a group of doctors considering integrating the CEREC technology into their practice, I always joke that it’s the gateway drug for digital dentistry. First, you’re getting a CEREC system for single unit posteriors. Next thing you know, you’re becoming an expert on materials, bonding systems, and incorporating CBCT (cone-beam computed tomography) technology into your practice.

My journey is no different. When I began practicing in 2009, I joined a practice that had a Redcam in the corner collecting dust. Although the Redcam may have left a lot to be desired, my patients and I loved it. They, just like me, were engaged instantly by the technology. Regardless of the hurdles that had to be crossed, I always found myself reaching for the CEREC instead of impression material. We were placing VITA Mark II and Empress restorations on *gasp* second molars. I had no idea at that time how many other materials would be coming to the CEREC ecosystem!

In 2010, I upgraded to the Bluecam and also added the necessary armamentarium to be able to produce e.max restorations in office. What a difference! I remember thinking how great the automatic image capture with the Bluecam was compared to having to use the footpedal on my Redcam. Being able to produce same-day, high strength ceramics became our standard workflow. The Bluecam, my Powder Meister™, and e.max were a game-changing combination for my practice.

When the Omnicam was released at CEREC 27.5 Meeting, I couldn’t wait to have the newest technology in our practice. Color Scanning?!?! No Powder?!? Every time the acquisition technology has improved, there has been a litany of materials that has followed as well.

The release of the “nano-ceramic” or “hybrid” ceramics changed the way many of us practice. The fine milling capabilities of these materials for partial coverage restorations, along with the speed of fabrication, allowed inlays and onlays to become common place in many practices.

Over the years, we have continued to have improvement in acquisition. Yes, the Primescan is amazing. I would wager that anyone that has used the Primescan would never give it back for their Omnicam or Bluecam. But, I don’t know if anything has done as much for bringing CAD/CAM into general dentistry offices more than the ability to manufacture zirconia restorations chairside.

When the announcement of the SpeedFire was released, I honestly did not see a use for it in my practice. We had years of success with high strength ceramics and hybrid ceramics. Why did I need the ability to do zirconia restorations in my practice? My how this has changed.

The early zirconias were strong, but they were some of the least esthetic restorations that I had ever produced with my CEREC system. I could appreciate the conservative preps and the ease of cementation, but I just could not get past the appearance of the restorations intraorally.

As with everything else in our CEREC world, we have seen continual improvement in the esthetics of chairside zirconia. With the introduction of materials like 3M™ Chairside Zirconia, I have found myself reaching for those white zirconia blocks more frequently than my beloved purple ones.

The 4-Y composition of the 3M Chairside Zirconia has provided excellent clinical results with a unique blend of esthetics and strength. The 4-Y structure provides 1000 mPa in flexural strength, but also allows me to deliver a restoration that I am happy to see on recall. It doesn’t have the opacity that we see with other “high strength” zirconia.

Something that I didn’t realize was a stress until we began doing more zirconia was the ease of delivery. We were used to bonding ceramics for years, but there is nothing like the ease of conventional cementation. The release of 3M™ RelyX™ Universal Resin Cement has made this a mindless process in our practice.

To say that the excess cement clean-up has been improved is an understatement. But, more importantly to me clinically, was the improvement in radiopacity. We always take bite wing radiographs after delivery of any restoration. I always like to make sure I have adequate cement clean up. 3M™ RelyX™ Ultimate Adhesive Resin Cement was not radiopaque enough for me, not to mention I could never get it cleaned before it was set. The new 3M RelyX Universal is a dramatic improvement, and if you haven’t given it a try you should. This resin cement and its associated 3M™ Scotchbond™ Universal Plus Adhesive has become our standard in office. The bonding agent can be used with virtually all direct and indirect restorations. The resin cement can be used both as a standalone, self-adhesive cement and as an adhesive cement when combined with the bonding agent. It can be used with hybrid ceramics, glass ceramics, and zirconias.

So back to the case that I was starting…

Not every case we do in the office is a full mouth rehab. We spend a lot of our time doing routine single unit dentistry and this case is a perfect example.

The patient presented with an existing zirconia crown that had been fabricated in a traditional analog fashion. As you can see from the preoperative radiograph, there was a significant overhang on the distal. We explained the need for replacement of the restoration to the patient, and she agreed.

[image:Figure_1_Preoperative_radiograph.jpg]
Figure 1. Preoperative radiograph.

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Figure 2. Preoperative condition.

The patient was anesthetized. We had so many materials before we began prepping that we could pick from for the final restoration. As I mentioned earlier, around 15 years ago my choices would have been limited to the likes of VITA Mark II or Empress, and years ago we would have used one of those materials and found it esthetic and predictable. But the process and the requirements of preparation and bonding were not so forgiving. Fast forward to today, where we now have the ability to select from multiple zirconias or other high strength ceramics. In this case, we selected 3M Chairside Zirconia for its conservative preparation guidelines and for its esthetics.

After removal of the restoration, you can note the inflammation present in the retromolar pad from the large distal overhang of the previous restoration.

[image:Figure_3_Removal_of_Existing_Restoration.jpg]
Figure 3. Removal of Existing Restoration.

After the preparation was completed, 3M™ Astringent Retraction Paste was used for tissue retraction and hemostasis. I really like this product for preparing the tissue before scanning. The small tip on the compule allows me to place the material exactly where I want it, deep into the sulcus, where it’s tough to get to with other similar products that have larger application tips. With a smoothed prep using fine diamonds and carbide round burs to finish the margin, even subgingival, we can appreciate a nice ring of enamel that will make margination a breeze in the software.

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Figure 4. 3M™ Astringent Retraction Paste

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Figure 5. Final Preparation.

Delivery of zirconia restorations is stress free with 3M RelyX Universal Resin Cement and 3M Scotchbond Universal Plus Adhesive. The bonding agent does not require curing on the prep before delivering the final restoration. This removes the possibility of cured resin pooling, which can prevent full seat of the restoration. The bond strengths provided by RelyX Universal Resin Cement actually allows for delivery of the restoration with just the cement if the restoration has adequate mechanical retention form¹. I believe adequate isolation is still a must, even with these improved products. In the image of the bond application, you can see the Isolite in place. The cleanup of RelyX Universal is so simplistic. Unlike other bonding resin cements, the excess can be removed after a simple tack cure without any effort whatsoever.

[image:Figure_6_Application_of_Scotchbond_Universal.jpg]
Figure 6. Application of Scotchbond Universal.

[image:Figure_7_Cement_Cleanup.jpg]
Figure 7. Cement Cleanup.

I love the way the tissue responds to zirconia, when the restoration is well fitting. Anytime we deliver an indirect restoration in the practice, we always take a post-operative bitewing. The lack of radiopacity was one reason I did not use the RelyX Ultimate cement in the past. The radiopacity has been greatly improved with RelyX Universal. Now I can make sure any cement interproximally is thoroughly cleaned before the patient leaves the office. Me and my hygienists, both hate finding cement hanging out interproximally months later on recall.

In the two radiographs below, you can appreciate the cement and then its subsequent removal.

[image:Figure_8_Excess_Cement_Interproximally.jpg]
Figure 8. Excess Cement Interproximally.

[image:Figure_9_Thorough_Cleanup_of_Cement.jpg]
Figure 9. Thorough Cleanup of Cement.

[image:Figure_10_Preoperative_Radiograph.jpg]
Figure 10. Preoperative Radiograph

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Figure 11. Initial Presentation

[image:Figure_12_Postoperative_Radiograph.jpg]
Figure 12. Postoperative Radiograph

[image:Figure_13_Delivered_final_restoration.jpg]
Figure 13. Delivered final restoration

The final restoration was a great improvement over the previous ill-fitting restoration. For CEREC users, these are the type of restorations that have become commonplace in all of our practices. What we take as commonplace is still impressive to many patients. Due to the continual improvements to materials and CEREC technology, I think it will continue to be so.

With so much interest in chairside zirconia restorations, I’m looking forward to the next article in this series where we discuss the “Y?” when it comes to 3Y, 4Y, and 5Y zirconias.

References
¹ RR#133 3M Resin Cement Bond Strength to Multiple Substrates. (dentaladvisor.com)

New Dates Added

2021-04-13T09:09:36Z

New Dates Added!

There are now even more opportunities for you to learn this year from our top-notch faculty in either Scottsdale, AZ or Charlotte, NC! Take a look at the new dates below and then head over to our Hands-On Workshops page or email courses@cdocs.com to get registered!

Fundamentals of CEREC Dentistry

June 3-4, 2021 (Charlotte, NC)

Provisionalizing and Restoring Implants with CEREC

July 22-23, 2021 (Scottsdale, AZ)

October 14-15, 2021 (Charlotte, NC)

November 18-19, 2021 (Scottsdale, AZ)

Anterior Esthetics with CEREC

September 16-17, 2021 (Scottsdale, AZ)

Charlotte October 16-17, 2021 (Charlotte, NC)

November 20-21, 2021 (Scottsdale, AZ)

Comprehensive Restorative Care with a Digital Workflow

July 24-25, 2021 (Scottsdale, AZ)

October 14-15, 2021 (Charlotte, NC)

Advanced CEREC Software Mastery

August 5-6, 2021 (Scottsdale, AZ)

October 16-17, 2021 (Charlotte, NC)

Fundamentals of Guided Implant Surgery with Cone Beam

June 24-25, 2021 (Charlotte, NC)

July 22-23, 2021 (Charlotte, NC)

Advanced Surgical Guided Implant Dentistry

June 26-27, 2021 (Charlotte, NC)

July 24-25, 2021 (Charlotte, NC)

Hard and Soft Tissue Grafting in Digital Dental Implant Dentistry

October 14-15, 2021 (Charlotte, NC)

Digital Full Arch Dental Implant Therapy

June 3-4, 2021 (Scottsdale, AZ)

October 16-17, 2021 (Charlotte, NC)

Implants in the Esthetic Zone

June 5-6, 2021 (Scottsdale, AZ)

Fundamentals of Endodontic Therapy

July 22-23, 2021 (Charlotte, NC)

October 21-22, 2021 (Charlotte, NC)

Advanced Concepts in Endodontics Therapy

July 24-25, 2021 (Charlotte, NC)

October 23-24, 2021 (Charlotte, NC)

Fundamentals of Clear Aligner Therapy

July 15-16, 2021 (Scottsdale, AZ)

September 9-10, 2021 (Scottsdale, AZ)

September 16-17, 2021 (Scottsdale, AZ)

October 21-22, 2021 (Scottsdale, AZ)

December 9-10, 2021 (Scottsdale, AZ)

Clear Aligner Therapy in Advanced Cases

July 17-18, 2021 (Scottsdale, AZ)

September 11-12, 2021 (Scottsdale, AZ)

September 18-19, 2021 (Scottsdale, AZ)

October 23-24, 2021 (Scottsdale, AZ)

December 11-12, 2021 (Scottsdale, AZ)

Cone Beam Basic Training

June 24-25, 2021 (Charlotte, NC)

September 16-17, 2021 (Charlotte, NC)

Advanced Cone Beam Diagnostics

June 5-6, 2021 (Scottsdale, AZ)

June 26-27, 2021 (Charlotte, NC)

September 18-19, 2021 (Charlotte, NC)

October 16-17, 2021 (Charlotte, NC)

New Technologies and 3D Imaging — “The Virtual Microscope”

2021-04-07T10:10:24Z

Dental technologies are constantly being developed, and each clinician must decide which innovations best fit their individual practice needs. I pride myself being on the “leading edge” of technology but not the “bleeding edge” of technology. This entails that I implement products that have been researched with scientific evidence and are proven as clinically viable. As an endodontic specialist, patients have higher expectations when visiting my practice, so I feel the need to go above and beyond to provide quality treatment. Three technologies in particular — magnification/illumination, 2D digital imaging, and 3D CBCT imaging have improved my diagnostic, patient-education and clinical skills to help to keep our practice ahead of the curve. This will continue to build our reputation as local experts to assist our referring dentist in a team approach in providing the highest quality of care to our community.

A good microscope with powerful illumination is imperative technology for endodontists. I personally invested in a microscope (Global) in 2004. It has been repeatedly shown in the research that the dental operating microscope allows practitioners to locate anatomy at a far greater rate than the unaided eye. This in turn allows one to be minimally invasive during the root canal procedures, which eventually benefits the referring dentist to have greater amount of tooth structure to restore and better serving the patient overall. When microscopy was introduced in the 1990s, clinicians were resistant to using it and challenged its expense and increase in better outcomes. Now, microscopy has evolved to be one of our standards of care and very few specialists could work without.

[image:Figure1.png]

The same concept is true with other types of technology. Many dental practices have evolved from using traditional film, to 2D digital radiography to 3D CBCT. Each time, the view of the anatomy becomes appreciably more detailed.

Because endodontics necessitates capturing a fair amount of radiographs, endodontists appreciate 2D digital imaging because it emits a lower amount of radiation than traditional film radiography.. Studies have shown that capturing one view of a tooth garners only a limited percentage of information, but both a straight-on view and an angled view results in a greater amount of details. Also, in a digital format, quick access to the data also results in more efficient use of time. During endodontic treatment, I may need a check radiograph to see if I am in the proper length for a root canal, or if I am in the proper orientation for access, and my digital system helps me to quickly capture that type of image. For these “check” radiographs, sensor holders in the shape of paddles that allow the rubber dam to stay on while taking this image and not breaking the sterilization protocol.

[image:Figure2.jpg]

I like the features in Sidexis and the ability to incorporate the SiCat Endo suite into my platform , I can switch between 2D and 3D images, and I don’t have to open up different software. This type of workflow ease is essential in streamlining the patients experience in and out of the chair.

3D technology allows for very thorough treatment planning. While I do not take a 3D scan on every patient, 3D images will be captured when we feel the benefit outweighs the risk to the patient. Some examples of this would be for as a failing root canal, a presurgical consultation, to determine an odontogentic or non-odontogenic lesion, or if the source of the patient’s chief complaint is not obvious on the 2D radiograph. Some other uses for CBCT are when I sense complicated anatomy, resorption, perforations, or instrument failures.

The 3D imaging software also allows me to take measurements which I then use in conjunction with my microscope to located difficult anatomy in a conservative manner. Also, I can be more modest when using a CBCT during treatment planning. The technology helps me confirm when not to treat certain “hopeless” teeth. Before implementing 3D imaging, I would have had to open up the tooth or have done an irreversible procedure only to discover that tooth could not be saved.

It is interesting to note that “when looking at preoperative image with CBCT … 62% of operators changed their treatment plan” because they receive more information.¹ Treatment changes when one has the full knowledge to create a more thorough treatment plan.

[image:Figure3.png]

Patients also benefit from seeing their images. I have a monitor on the foot rest of the patient’s chair that I use to show both 2D and 3D images. When they see their images in conjunction with my explanation, patients understand the problem and why they need a certain procedure. Case acceptance goes up tremendously when a patient is actively involved in their own health care.

Here is some advice before adding 3D technology to your office. Learning to use a CBCT is not difficult, but check to make sure that proper training is incorporated into the cost of the machine. Look for a company that has a good track record when it comes to service and standing behind the product they sell you. There is a learning curve so stick with it and get help from mentors when needed. Also, choose a brand within ALARA (as low as reasonably achievable) for radiation standards. If you are uncomfortable with reading CBCT images or suspect an anomaly, send the scan to an oral radiologist.

Endodontists are notorious for being early adopters of technology. I can’t believe that it has been 12 years since I began using 2D digital radiography. As with my other technologies, my investments continue to pay back over the years in better diagnostics and more efficient treatment methods. When patients see these high quality imaging methods and realize that their endodontist is investing in better patient care, the reputation boost will supersede your monetary return.

¹ Ee J, Fayad MI, Johnson BR. Comparison of endodontic diagnosis and treatment planning decisions using cone-beam volumetric tomography versus periapical radiography. J Endod. 2014;40(7):910-916.

These Workshops Changed the Way I Look at Teeth

2021-04-02T13:01:06Z

There were two reasons Dr. Richard Rosenblatt decided to come to the Charlotte CDOCS campus for four days and attend both Ortho workshops back-to-back, he wanted to find out more about SureSmile and to help a newly hired associate learn and grow.

“We created a growth plan for our office this year, and one of the major ways we want to grow is increasing our aligner therapy cases,” Dr. Rosenblatt said. “I thought it would be an easy way for my associate to be productive at such an early stage in her career.”

Both were quickly impressed by Dr. Shalin Shah, the instructor for all CDOCS Ortho workshops, and his curriculum. All CDOCS workshops allow doctors to go from training to treatment in just a few days.

“When we got back to our practice Monday, we understood which cases to choose for a successful outcome, which cases to avoid and how to talk to patients to help them better understand why this treatment is beneficial,” Dr. Rosenblatt said.

It didn’t take long for Dr. Rosenblatt to put what he learned into practice. His first patient on the Monday after his workshops didn’t necessarily have any pressing issues but was retiring in a year and wanted to address any concerns before losing her insurance.

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“Coming back from the Ortho course, I immediately started looking at the teeth differently,” Dr. Rosenblatt said. “I told her there were some old amalgams and some fracture lines on them that we will likely need to replace. I also asked her if she noticed that her lower front teeth had an angled edge and were much more worn compared to the edges on either side of those two lower front ones.”

The patient agreed to take photos, a scan and an x-ray of her jaw so she could get a free rendering of how clear aligners could help her.

“The conversation was so easy,” Dr. Rosenblatt said. “I have such a better understanding of what I should be looking for and now can share that with my hygiene team so they can start the conversation before I even see the patient.”

Dr. Rosenblatt is confident this patient will move forward with the treatment and believes the SureSmile software will be a game-changer for his practice.

He highly recommends attending both Ortho workshops, Fundamentals of Clear Aligner Therapy and Clear Aligner Therapy in Advanced Cases, back-to-back over four straight days in either Scottsdale or Charlotte.

“If you are thinking of adding aligner therapy to your office or have been "doing aligners" for years, but maybe only a case a month or every other month, these classes are a can't miss,” Dr. Rosenblatt said.

Did you know a single ortho case a week can add $4,000 in production revenue to your practice? Click HERE to learn more and register for your next workshop today.

iJIG Method for Fixed Hybrid Prosthesis using the CEREC Primescan, Digital Imaging

2021-03-31T10:10:20Z

Dr. Douglas Smail, Dr. Sabita Smail, and Chelsea Herr; East Hudson Oral & Maxillofacial Surgery, Troy, New York

For a fixed hybrid prosthesis, before the age of digital dentistry, fabrication of the master cast followed by the final prosthesis 3-4 months after the implants were integrated consisted of a tedious and time-consuming analog process, requiring much coordination between practitioners along with a lab technician. This process included well-choreographed steps beginning with an initial impression to make a custom tray which would be used at the following appointment. After receiving it from the lab, this open or closed custom tray would then be used to take an impression of the prosthetic impression posts attached to the implants for the lab to fabricate the verification JIG. Along with this impression, the dentist would also have to take a lower impression to verify the occlusal bite and record the facebow transfer along with the bite registration at the appropriate vertical dimension (Figure 1).^1,6 An esthetic try-in of the verification JIG would then be done at the next appointment to confirm the smile line of the denture (may need to be sectioned and luted together with GC Resin if it does not fit passively). With the approval of both the patient as well as the practitioner, all materials would be sent back to the lab for the final fabrication of the prosthesis.¹ In total, these 3 appointments could take up to 4 weeks to complete.

[image:Mag_Article.jpg]
Figure 1. Facebow transfer materials and procedure.⁶

For the digital workflow using the CEREC Primescan (Dentsply Sirona), an iJIG is fabricated in one appointment as opposed to the three appointments for the analog verification JIG. Not only is the iJIG method faster but also allows for more precise imaging of the transitional fixed hybrid, resulting in fewer fit alterations with the ability to capture the edentulous ridge (Figure 2). This is done with a scan of the upper/lower denture in the mouth along with the bite followed by the removal of the provisional for the scanning of the placed scan bodies on the denture, maxillary or mandibular arch, and gingival mask. This process can be completed for both or just one arch depending on what the patient needs. All virtually constructed images are then sent via Sirona Connect to the lab for the fabrication of the iJIG. This allows the lab technician to be in direct contact with the restorative dentist for the try-in phase of the prosthesis. Once this is complete, the patient returns to have a try-in appointment of the iJIG.

[image:Mag_Article_1.png]
Figure 2. Edentulous ridge of maxilla (a) and mandible (b) captured using the CEREC Primescan.

Case Study:

A 60-year-old male presented with chief complaint; “I don’t want to keep fixing my teeth anymore and I want to have a fixed denture on the upper and the lower.” Primescan imaging was done of his upper and lower dentures as well as the ridge along with a bite registration and CBCT to determine if the patient had enough bone for implants. All data was sent to the lab to plan for his fixed hybrid prosthesis. A WebEx was scheduled with his surgical and restorative team which included the surgeon, restorative dentist, PRD from the surgeon’s office, and the lab technician. (All data collected at this first appointment as well as surgical planning can be seen below.)

A Chrome GuidedSmile type prosthesis was the resulting treatment seen below (Pre-operative to post-operative radiographs for 60-year-old male dual arch, fixed arch prostheses. [Picture of the prosthesis in place.])

[image:Mag_Article_2.png]
Pre-operative CBCT.

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Initial scans using the CEREC Primescan.

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Chrome GuidedSmile treatment plan.

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Intra-operative CBCT.

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Post-operative CBCT.

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Post-operative conversion with interim prostheses present.

In short, the CEREC Primescan has enabled many advances for not only practitioners but also patients, reducing chair time and overall expense. Because of the high acuity achieved using the CEREC Primescan, it has been recognized that fewer revisions are needed in order to achieve a satisfactory result compared to the lengthy process associated with the analog verification JIG method. Below, a breakdown is provided for the number of appointments needed in the analog workflow (three appointments) compared to the digital CEREC Primescan iJIG workflow (one appointment). In total, the digital iJIG method saves two one-hour appointments.

Comparison of analog verification JIG to iJIG method using the CEREC Primescan.

Appointment 1

Analog Impressions/Stone Models

3 to 4 months after implants are placed, the final prosthesis workflow is started.
Take models to have lab fabricate a custom open tray:

1. Take an impression of upper/lower and bite
2. Remove denture and take impression of maxilla/mandible
3. Take clinical photos (7)
4. Send impressions to lab for custom open tray

CEREC Primescan Digital Workflow

1. Maxilla

a. scan upper denture with scan bodies in
b. scan gingival mask
c. scan of the upper with denture in

[image:Mag_Article_8.jpg]

2. Mandible

scan lower denture with the scan bodies
scan gingival mask
scan the lower denture in the mouth

[image:Mag_Article_9.jpg]

3. Take a bite registration of the upper and lower (VDO)

[image:Mag_Article_10.png]

4. Send materials to the lab with clinical photos.

*Records vertical dimension, accounts for soft tissue texture, and replaces the verification JIG as well as becomes the first esthetic try-in all while creating a working model for occlusion.

Appointment 2

Analog Impressions/Stone Models

Custom tray received from lab and is loaded.

Remove denture
Screw open tray analog copings onto implants in the mouth
Take open tray impression
Complete implant fixed level impressions
Buy impression posts before the next appointment

(LAB) Send materials to lab for master cast to be fabricated and initial jaw relations.

(LAB) Analog is then sent to the lab to make the initial cast for the fabrication of the verification JIG to confirm the accuracy of the initial impression and jaw relation record.

CEREC Primescan Digital Workflow

Clinician receives iJIG from lab. This is placed in the mouth to verify passive fit and serves as the final impression.

[image:Mag_Article_11.png]

Appointment 3
Analog Impressions/Stone Models

Verification JIG is sent back to dentist for confirmation of jaw records.

1. Establish ideal anterior tooth length, lip support, occlusal plane, VDO, and midline along with facebow transfer and bite registration

Take an impression of mandibular arch
All materials sent back to the lab

If the verification JIG does not fit accurately and seat passively:

JIG is sectioned, screwed onto the implants and reconnected with GC Pattern Resin from which a new master cast is made (same when fabricating a denture)
Establish ideal anterior tooth length, lip support, occlusal plane, vertical dimension, and midline along face bow transfer and bite registration recorded at the vertical dimension of occlusion

6. Impression of the mandibular arch

(LAB) All materials sent back to the lab, casts are mounted and diagnostic wax-up completed of the teeth as well as the soft tissue for the fabrication of a simple bis-arcyl try-in prosthesis (an alternative approach is to place denture teeth representing the desired tooth form and soft tissue on the verification JIG). This is done to establish the desired anterior and posterior tooth position, occlusal plane, and vertical dimension as well as the occlusion (like a wax try-in for a complete denture).

(LAB) Lab fabricates a new provisional prosthesis to accommodate any changes that need to be made.

If no changes are made, the bis-acryl try-in prosthesis can be used for the provisional prosthesis (this requires direct communication with the lab so that the bis-acryl prosthesis is fabricated appropriately).

Appointment 4
Analog Impressions/Stone Models

Clinician receives verification JIG from lab.

Acknowledgements
This article was a collaborative effort with the National Director for MicroDental Laboratories, Chuck Genco.

References

Dichter, Darin, D.M.D, Spear Faculty and Contributing Author. Conventional complete denture fabrication in 9 steps. Spear, October 21, 2015.
Genco, Chuck. National Director, Clinical Technology Solutions of MicroDental Laboratories. MicroDental Laboratories.
The iJIG, CHROME GuidedSmile and GuidedSmile Components. ROE Dental Laboratory. Retrieved from https://www.roedentallab.com/products/chrome-guidedsmile/chrome-guidedsmile-components/chrome-ijig/#records
Winters, Bob, D.M.D, Spear Faculty and Contributing Author. Steps for fabrication of an implant-supported prosthesis. Spear, March 19, 2018.
CAD/CAM Titanium Bar/Acrylic Denture. Hybrid Denture Protocol. Haupt Dental Lab Inc.
Ledger, Dave St., (February 23, 2016). 9 Steps to a Facebow Transfer. Spear Education. Retrieved from https://www.speareducation.com/spear-review/2016/02/9-steps-to-a-facebow-transfer

My 15-Year Journey With Lithium Disilicate

2021-03-26T11:11:23Z

Tony Hatch, D.D.S.
Sponsored by Ivoclar

Our journey as dentists is one of lifelong learning as we continue our mission to improve our patient's quality of life and restore the natural function and esthetics of their smiles. It is an evolutionary journey to uncover the technologies and materials that work best in our hands and afford us reliability, efficiency and restorative peace of mind that we are providing our patients with the best care the profession has to offer.

As a CEREC® dentist, I have kept pace with the rapid technological advancements in the machinery and software as well as in the latest material developments in order to expand the versatility of restorative indications and treatments now possible for in-office dental care as well as improve the life-like esthetics and restorative efficiency and durability that patients expect and demand. For the past 15 years I have used and prescribed the IPS e.max family of millable materials to restore my patients in-house and in the laboratory. From single monolithic crowns, 3-unit bridges and custom implant abutments to combination and full mouth cases, the IPS e.max family of materials have evolved along with the technology to cover all these indications and more to ensure seamless esthetics, predictability and reliability in restorative dentistry.

In this article, I want to share five cases that illustrate my personal journey of professional growth over the years and best demonstrate the versatility that advancements in technology and millable materials have brought to the dental practice.

Strength and Durability

Bob was my very first case using IPS e.max CAD and is an example of the durability and strength of the material. Bob was a lifelong bruxer, a parafunctional habit that had resulted in the loss of teeth in the posterior and compensatory eruption of his mandibular anterior teeth (Figure 1). I knew that to reestablish vertical dimension of occlusion (VDO) and alignment of the upper and lower teeth, I would need to open his VDO by placing crowns on teeth #21-#28 (Figure 2 and 3).

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Figure 1: A life-long bruxer, this patient presented with lost teeth in the posterior and compensatory eruption of lower anterior teeth.

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Figure 2: Pre-op image of the patient’s vertical dimension of occlusion.

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Figure 3: Reestablishing the patient’s vertical dimension of occlusion by placing crowns on teeth #21-#28 balanced his occlusion.

However, in 2007 the range of esthetic all-ceramic materials available for the milling of chairside restorations was limited and most did not possess the flexural strength that would withstand the forces of bruxing. The exception was IPS e.max CAD lithium disilicate, a high strength lithium disilicate all-ceramic with a flexural strength of 360-400 MPa. The milled IPS e.max CAD crowns placed on teeth #21-#28 balanced his occlusion (Figure 4) and are still in full function today…14+ years later.

[image:4.png]
Figure 4: Post-op photo of the eight IPS e.max CAD crowns milled in-office and placed on teeth #21-#28 to balance the patient’s occlusion, all of which are still in function 14 years later.

Expanded Indications

Cindy presented to my practice needing a crown to restore the recently placed implant on maxillary tooth #11 (Figure 5). Both the angulation of the implant and the location of the site in the esthetic zone necessitated use of a custom abutment and non-screw-retained crown to achieve the proper emergence profile and esthetics the case demanded (Figure 6). Prior to 2014, restoring an implant site with a custom abutment necessitated outsourcing the design and milling of the abutment to a dental laboratory, which is costly, or using a prefabricated abutment, which most always lacked the proper support, emergence profile, and contour required for an esthetic outcome. When Ivoclar Vivadent, in conjunction with Sirona Dental Systems, developed the IPS e.max CAD Abutment Solution in 2015, the system enabled clinicians like me to design mill, and place abutments (Figures 7 and 8) and corresponding restorations in the practice (Figures 9 and 10).

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Figure 5: Patient presented needing a crown placed on an implant site #11.

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Figure 6: Esthetic concerns and angulation of the implant necessitated a custom abutment and secondary crown.

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Figure 7: In-office milled IPS e.max CAD custom abutment and crown ready for assembly on the titanium base.

[image:8.png]
Figure 8: The milled custom abutment crown with titanium base ready for seating.

[image:9.png] [image:10.png]
Figures 9 & 10: Seated custom abutment crown exhibiting proper emergence profile and seamless esthetic integration.

Tried and True

With attention laser focused on the dental implant as the gold standard for replacing lost dentition, the time-tested three-unit bridge is often forgotten and even considered substandard by many clinicians as a valid restorative solution. However, there are still a large number of cases where the 3-unit bridge is a better solution whether the primary concern is cost, extent of osseous surgery or in some cases a better esthetic solution.

A case in point was a patient who presented to my practice with a 17-year-old, 3-unit PFM bridge on teeth #11-#13 (Figures 11 and 12). Although an implant for tooth #12 and crowns on teeth #11 and #13 was suggested to the patient, she immediately declined, expressing a desire for a quicker option that did not require surgery. Fortunately, IPS e.max CAD #32 block provided me with a solution that would meet her demands. I was able to prep and provisionalize her teeth on a Tuesday and deliver and seat the final highly esthetic milled bridge two days later (Figures 13 and 14). She left the practice a very happy and satisfied patient.

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Figures 11 & 12: The patient presented to the practice with a 17-year-old PFM 3-unit bridge. An implant solution was presented to the patient but was rejected. She wanted a quick solution that did not involve surgery.

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Figures 13 & 14: A highly esthetic in-office IPS e.max 3-unit bridge was milled in-house and seated two days later to meet the patient’s demands.

A Unique Solution

A number of teenagers with congenitally missing laterals who are undergoing orthodontic treatment have presented to the practice wearing Hawley retainers with a debonded denture tooth meant to bridge the gap until an implant can be placed which in some cases could be 5+ years. I began offering these patients a bonded IPS e.max CAD single wing Maryland bridge to replace the missing lateral. The solution requires no anesthesia, no temporaries, and can typically be milled from an IPS e.max CAD #14 block in the same amount of time as a single crown. This long-term solution has become so popular in my area that other local dentists are now referring their young patients to me for treatment.

Tina’s case is a perfect example of how a chairside solution can be easily and quickly provided for our young patients. Tina presented to the practice congenitally missing lateral #10 (Figure 15). She was adamant she did not want, “a retainer with teeth on it”. In a short, two-and-a-half hours I was able to mill a cantilever bridge for #10-#11 (Figure 16) and have her back to the orthodontist for a final retainer impression (Figures 17 and 18).

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Figure 15: Young patients undergoing orthodontic treatment for congenitally missing laterals often present with Hawley retainers where the denture tooth meant to bridge the gap has debonded.

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Figure 16: An in-office solution is to mill and bond a single wing Maryland bridge. 

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Figure 17: The IPS e.max CAD cantilever bridge solution can be milled in two hours and placed with no anesthesia.

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Figure 18: The IPS e.max CAD cantilever bridge is a long-term solution for orthodontic patients and shown here 3 years later.

Full Mouth Reconstruction

When faced with a complex full mouth cosmetic reconstruction case, it is reassuring to work with a material that spans all indications from veneers to implant crowns and that takes the guesswork out of matching different types of materials from zirconia to all-ceramic. The wide range on indications covered by the IPS e.max family of materials allows an abutment crown next to a veneer, which is next to a three-quarter crown with the knowledge that all restorations will seamlessly match in shade and esthetics.

Tim presented to the practice while still undergoing orthodontic treatment (Figure 19). His goal at the end of orthodontic and restorative treatment was to achieve a broad esthetic smile. He was missing his two maxillary lateral incisors and lower premolars, which would be restored with implant crowns (Figure 20). His smile makeover included seven full contour crowns, four implant crowns, and 12 veneers all fabricated in the laboratory using the IPS e.max family of materials (Figures 21-22). His goal was achieved using only a single restorative material

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Figure 19: The patient presented to the practice during orthodontic treatment to consult on a smile makeover when the orthodontic treatment was concluded.

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Figure 20: The patient was missing his two maxillary lateral incisors and lower premolars, which would be restored with implant crowns.

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Figures 21-22: In all, seven full contour crowns, four implant crowns (two of which were screw-retained and two with custom abutments) along with 12 veneers restored the patient’s smile. All 22 restorations were fabricated from the IPS e.max family of materials. Working within a family of restorative materials that covers all indications takes the esthetic guesswork out of full-mouth reconstruction cases.

Rediscovering a Passion for Dentistry

2021-03-25T15:03:31Z

When Dr. Laura Godwin came home from her practice each day, she could tell that something was missing. Something was off. To put it bluntly, she was bored.

“I just got stuck doing stuff we were taught in dental school,” Dr. Godwin said.

After years of practicing, becoming complacent can be a common occurrence for many dentists, and one Dr. Godwin needed help escaping.

The solution came in the form of attending a CDOCS workshop and the Dentsply Sirona Clinical Accelerator Program.

“It’s amazing how much I learned in one weekend and how much more excited it made me,” Dr. Godwin said. “I just feel more passionate again about what I do.”

Watch her story now and see how learning to place implants has helped rejuvenate her excitement for dentistry.

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Find your passion. Register for an upcoming CDOCS workshop today.

CBCT Shines a Light on Every Day Diagnosing and Treatment Planning

2021-03-19T10:10:37Z

Dan Butterman, DDS

One of the most valuable tools we have available for diagnosing and treatment planning is CBCT imaging. It can be very difficult to diagnose what you can’t see, and it is impossible to treat what you don’t diagnose. CBCT imaging shines a light on otherwise difficult diagnoses and asymptomatic pathology.

In my practice, 3D imaging is not only necessary for implant planning, but also for routine diagnoses. My full series of radiographs consists of bitewings and a scan with the Axeos 3D CBCT. The scan is instrumental for a comprehensive patient exam. The Axeos gives me the complete diagnostic package, including larger fields of view and low dose scans.

The larger field of view enables me to visualize the patient’s airway, maxillary sinus, and TMJ. The low dose scan, which has a similar radiation dose to a 2D image, gives me an accurate post op analysis of treatment such as implant placement and endodontic therapy. Implants and root canals can fail for a variety of reasons. In today’s litigious society, it’s a good idea to have a 3D post op confirmation of proper implant placement and endodontic obturation.

Whether you’re contemplating incorporating the Axeos or another CBCT in your practice, here are a few examples of how the technology will pay off for you and your patients on a daily basis:

The patient presented with gross caries on tooth #3. While the periapical radiograph shows no definitive evidence of periapical pathology, the CBCT tells a different story: there is a lesion associated with tooth #3 infiltrating the maxillary sinus.

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Periapical radiograph of gross caries tooth #3

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CBCT slice visualizing palatal root lesion infiltrating the maxillary sinus
The patient presented with a fracture line through the central fossa of tooth #2. The periapical radiograph is inconclusive, but the CBCT demonstrates the extent of the fracture and the fact that tooth #2 is non-restorable. (figs 2 A-D)

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Intra oral picture and bitewing of fractured tooth #2

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2D Periapical radiograph of tooth #2

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Cross sectional view of CBCT demonstrating extent of vertical fracture and sinus lesion

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Extracted tooth #2 with vertical fracture
The patient presented for a second opinion of tooth #18. Based on the periapical radiograph, which shows a radiolucency on the distal root, the patient was scheduled for an endodontic re-treatment of tooth #18. The CBCT shows that the presumed radiolucency is actually the mandibular canal superimposed on the distal root. The CBCT also shows that the true pathology is a vertical fracture and that tooth #18 is non-restorable.

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Periapical radiograph of tooth #18 showing increased radiolucency at distal root. Cross sectional CBCT view of tooth #18 showing normal distal root PDL with the position of the mandibular canal

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Axial and Tangential CBCT view showing fracture and mid root lesion
Low dose scan for evaluating post endodontic obturation.

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Cross Sectional Low Dose CBCT view confirming 3D endodontic obturation of all canals
Low dose scan to confirm implant position after guided surgery.

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Cross Sectional Low Dose CBCT View confirming proper implant placement based on plan
Low Dose scan to evaluate post op implant placement in the anterior.

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2D periapical pre-op and post- op implant placement at site #8

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Low Dose Axeos scan reconstructed 3D view

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Cross Sectional Low Dose CBCT view confirming post op implant placement in relation to the buccal plate
Routine scan demonstrating possible airway issues in a patient that reports poor sleep.

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Airway analysis view in SiCat 2.0 Airway module

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Airway analysis view with soft tissue in SiCat 2.0 Airway module

These cases are every day examples of the benefits of taking a routine CBCT scan in place of a full series of periapical films. We no longer have to “watch” and wait for a tooth with vague symptoms to become an issue. With CBCT we can accurately evaluate the tooth before it blows up. A CBCT scan also gives us a better understanding of tooth’s prognosis before treatment is initiated. Upon completion of treatment, a low dose scan gives us confirmation that endodontic therapy and implant placement were performed successfully.

Improving Patient Communication

2021-03-15T16:04:15Z

A Focus on Interdisciplinary Care and Case Acceptance

Dr. Tyler E. Nelson, DMD, MD and Gretchen Adcock

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By putting ourselves in the shoes of our patients, we can easily see the comfort and trust our patients have developed with their general dentists. This rapport is strengthened as patients share life’s milestones when they return every six months for recall visits. From confidence-boosting cosmetic services, implant cases and orthodontic care, to face and mouth reconstruction from traumatic accidents, our patients rely on our expertise. Patients depend on our clinical knowledge as well as our recommendations and relationships with our specialist partners.

We all have experienced it: the patient’s uneasy reaction when they hear that they have to leave our office and work with the specialist. To us it seems simple; we work with our colleagues on a daily basis. We participate within our dental community in educational meetings and events, which builds our trust in the specialist. But, to the patient who we have referred, their feelings are often very different. Immediately, their minds are flooded with thoughts of uncertainty and questions regarding the value of treatment vs. the cost. Our patients’ thoughts focus on the time, pain, and money regarding the procedure they need. The question often becomes, how can we overcome this disparity in attitudes towards our professional network of referrals? How can we proactively focus on interdisciplinary care while maintaining high case acceptance?

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Oral surgeon, Dr. Tyler Nelson, DMD, MD, says, “Even though it is a health care setting, the patient is still a ‘consumer.’ When working with a case that requires a combination of expertise from the general dentist and specialist, it is our job to be able to explain and provide understanding on all aspects of treatment. It’s a multi-part process, and they are relying on us to be the experts.” When it comes to how you relate with patients, it’s not how much you know about their teeth that will make them want to schedule treatment. It’s how much you care and try and understand their concerns. Communicating with empathy, through careful word choice, tone of voice, and body language, can be very reassuring and help the patient feel comfortable with their decision.

Dr. Nelson further explains, “I believe a key component to success for case acceptance is providing education to my staff and the offices I work with. Having the same vocabulary and understanding of the procedure, from the general dentist’s office to my office, shows that there is a high level of cooperation amongst our teams. Coordination of their care between offices builds trust and therefore inherently creates value for the patient. If a patient does not understand the value of the proposed treatment, they will not move forward with the process.”

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The most successful practices have systems in place that include training in and around patient financing strategies. “Presenting payment plans helps to attribute value to the treatment. Showing the patients a way to afford the deserved treatment reiterates the fact that the treatment has value and will contribute to their overall health,” says Dr. Nelson. We live in a society where the average American doesn’t have the resources to pay for an unexpected expense of around $1,000.² We also know that about half of Americans say they’ve skipped or put off dental care because of costs.³ These alarming statistics show that patients are looking for a means of affordability. Patients are looking for budget-friendly monthly payment options. By the utilization of patient financing strategies, we can help to facilitate a means of affordability for the everyday patient.

“My recommendation is to focus on patient communication and ascribe value to the services you and the specialists provide. Reinforce the motivation for treatment by utilizing the same interdisciplinary vocabulary amongst offices. Educate yourself, teams, and offices you work with so that you are able to communicate the clinical value in an honest, believable way,” says Dr. Nelson.

¹ Based on data on file, applications placed from July 2020 through January 2021. Bankrate.com. https://www.bankrate.com/credit-cards/current-interest-rates/. Accessed February 2021.

² Bankrate.com. Most Americans don’t have enough savings to cover a $1K emergency/ https://www.bankrate.com/banking/savings/financial-security-0118/. Accessed February 2021.

³ DiJulio B, Kirzinger A, Wu B, and Brodie M., Kaiser Family Foundation Data Note: Americans’ Challenges with Health Care Costs. https://www.kff.org/health-costs/issue-brief/data-note-americans-challenges-health-care-costs/. Dated June 2019. Accessed February 2021.

⁴ Titan Web Agency. Top 20 Dental Industry Trends in 2021 & What They Mean to Practice Growth. https://titanwebagency.com/blog/dental-industry-trends/. Updated December 2020. Accessed February 2021.

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Welcome to Our New Digital Magazine

2021-03-15T16:04:11Z

Sameer Puri, DDS

In 2007, a few of us were sitting at dinner when the CEO of our company at the time, Mr. Imtiaz Manji, came up with an idea for the cerecdoctors.com Magazine. You see, we used to be cerecdoctors.com, focusing on just CEREC education, and the magazine was to be a print version that would be sent out quarterly, highlighting the trends with the CEREC system. Almost 13 years and 50 issues later, it came time to update our beloved magazine, a publication that the entire team put a tireless effort into making a great resource for all.

While the concept of the magazine is still valid and on point, in this day and age, the realities around us mean that we need to adapt to the new digital world. This sounds funny from a company that is focused on digital education and technology; a digital company that has been printing a magazine for over a decade. Sometimes, however, it’s difficult to leave the old ways behind.

A print magazine just didn’t make sense for the new CDOCS. With an expanded curriculum of ortho, endo, implants, and cone beam, in addition to all the CEREC courses, a print magazine just wasn’t going to deliver our goal of delivering education and information anymore.

So, with this, we kick off the new CDOCS Digital Magazine. Hardly a magazine, but more of a digital resource for our community. Our goal is to provide the same engaging, informative, and educational content, only in a digital manner. By going digital, we can bring information more rapidly, more targeted to what our audience wants, and be absolutely at the forefront of innovations and technology that our manufacturing partners bring.

Each launch of a new version of CEREC was timed with the release of the CDOCS magazine; our digital version will be no different. Anytime new product innovations are introduced, we will write about them here. Each time a new procedure is discovered as a more efficient way of doing something, we will share it with you here. Anytime relevant information needs to be shared with our community, we will scribe it here.

Our goal is to make this digital magazine interactive, informative and, as I mentioned, educational. We want to ensure that when you read these pages, you are energized, informed, and enthusiastic about the content that you have just learned about.

The faces behind the scenes remain the same; our editor is still the ever-capable Dr. Mark Fleming who will ensure that all the content that's published here meets our rigorous standards.

In the coming weeks and months, we will be sharing new products, techniques, and innovations in the dental world, but also all the new features that we are planning on bringing to this website.

We started our small, little company way back in the day in 2006. We have evolved into so much more and really the last 10 or so years are when we caught our stride. We are proud of what we have accomplished over the years and are more grateful than ever that you have taken time from your busy lives to join us and participate in our community. We look forward to serving you for the next 15 years and thank you for allowing us to be a small part of your dental lives, whether it be on our two campuses, in our online community, or in interaction with our social media. We thank you for your support and look forward to serving you in the future.

New Find a CDOCS Doctor Map

2021-02-11T08:08:25Z

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New Feature
Find a CDOCS Doctor Map

Introducing our new ‘Find a CDOCS Doctor’ referral map. Anyone can now access this map to find a CDOCS doctor in their area.

If you’d like to be included in this map, all you have to do is complete your CDOCS member profile, including the updated Digital Dentistry Profile section. Once your entire profile is complete, you will appear on the map.

To complete your profile:

Click below on Manage My Account (You may be prompted to login).
Make sure all of your information is correct and filled out (Contact Information, Mailing Address, About Your Practice and Your Digital Dentistry Profile)
- In the Your Digital Profile section, please select or write "N/A" or "None" if it does not apply to you
Please consider adding a Short Bio and a Curriculum Vitae to share more about yourself and your expertise.
- NOTE: Please click the orange question mark in this section and find the template that we have provided.
- Before updating your Curriculum Vitae, please remove any text in the field or it will show up in your profile once saved.
Once complete, click Update Your Profile button at the bottom of the page.

Manage My Account

Integration of CEREC inLab and 3D Printing: Maximizing Same-Day Opportunities

2021-01-12T13:01:03Z

CEREC design tools are widely used in many dental practices.

As CAD/CAM technology continues to develop, dentists are taking advantage of its integration with 3D printing to maximize efficiency in their practices. It saves dentists time and money while attracting patients and adding valuable services.

Drs. Joseph Faber and Jeffrey Kay are partners in an emerging DSO that currently has 7 locations and have fully integrated CEREC same-day technology in all of their practices. They currently leverage inLab design software and SprintRay to create as many same-day opportunities for their patients as possible. They’re hosting a webinar on Thursday, January 14th to discuss this integration and how it can work in your dental practice.

Course Objectives:

-Provide an overview of where SprintRay fits into our interoffice workflow

-Help clarify if CEREC inLab is the right software for you

-Demonstrate the simplicity of using CEREC inLab and SprintRay

-Demonstrate how you can utilize CEREC inLab and SprintRay five times in one single case

For more information, and to RSVP (THIS EVENT IS OVER)

In-office dental 3D printing helps improve the efficiency of forward-thinking practices all over the world. By leveraging existing technologies such as CEREC inLab, 3D printing enables better responsiveness to patient needs, significantly reduces manufacturing times, and opens up new treatment options. SprintRay products make it easy to bring digital dentistry and 3D printing together in your practice.

Dentists - Your Covid-19 Vaccine Questions Answered

2021-01-04T12:12:28Z

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As the Covid-19 vaccination process begins, I'm sure many of you have questions about how and when the vaccine will be available to dentists.

The American Dental Association has put together a comprehensive state-by-state vaccination regulation guide that can help answer your particular questions, including the vaccination groups for dentists in each state and if dentists are allowed to administer the vaccine.

Click here to get your answers

Another Way We are Here To Help During These Times

2020-03-18T16:04:00Z

We will be doing FREE Webinars to help you and your team through these times. The schedule is after this video explaining how CDOCS.com is here for YOU!

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Registration links are attached for each meeting along with a brief description.

Monday March 23, 2020
- Efficient Posterior Crown Design – Learn how to optimize your crown preps for maximum efficiency and productivity
  - Dr. Mike Skramstad – 12:00 Noon PDT
Monday March 23, 2020
- Digital Implant Workflows – Learn about a complete digital workflow for replacing single teeth with implants
  - Dr. Dan Butterman – 1:00PM PDT
Tuesday March 24, 2020
- Overview of the new SureSmile 7.6 Software. – Learn the nuances of the new SureSmile 7.6 software and how it significantly improves the workflow
  - Dr. Meena Barsoum – 12:00 Noon PDT
Implant Restorative Design with CEREC – Learn ideal workflows for chairside implant design and fabrication.
- Dr. Mike Skramstad 2:00PM PDT
Wednesday March 25, 2020
- Anterior Design with CEREC – Dr. Mike Skramstad will show you tips and tricks for designing your anterior restorations with CEREC
  - Dr. Mike Skramstad – 12:00 Noon PDT
Immediate vs. Delayed Implants – Dr. Doug Smail will discuss the advantages and disadvantages of each technique for placing implants
- Dr. Doug Smail - 1:00PM PDT
Thursday – March 26, 2020
- Addressing the Failing Implant – What to do when you realize your implant is failing? Dr. Farhad Boltchi will address the proper protocol for handing these situations
  - Dr. Farhad Boltchi – 3:00PM PDT
Friday March 27, 2020
- SICAT 2.0 – Software Update Overview – Learn all the new features of the new SICAT 2.0 software and its indications for use
  - Darin O’Bryan -12:00 Noon PDT

Crown Lengthening #9 by Solea Laser

2020-02-06T10:10:48Z

Crown Lengthening (Closed) #9 performed by Timothy Anderson, DDS

This procedure includes the removal of both soft tissue and bone. It demonstrates Solea’s precision, minimal bleeding and very fast healing.

Case Summary: A 60-year-old female patient presented to the practice with complaints about the appearance of her front crown. After full consultation, it was determined that she was not only unhappy with color/contour of the existing crown, but also the gingival architecture that framed her smile. The patient had a defective restoration on tooth #8 PFM with asymmetry of the gingival zenith on the tooth #9, but did not want to undergo an invasive gum surgery. Therefore, the clinical objective was to obtain an esthetic restoration and gingival architecture on the tooth #9 utilizing a non-invasive closed crown lengthening surgical approach with Solea. The full coverage restoration on tooth #8 and partial coverage on teeth #7,9,10 were prepped immediately following the crown lengthening

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Technique Used: To start, a gingivectomy was performed on tooth #9 to ablate the gingiva to desired height. The dentist used Solea utilizing the 1 mm spot size with cutting speed between 20-40% and 20% mist to remove the excess tissue. The bone was then sounded with a period probe to determine the amount of crestal bone that needed to be reduced to ensure adequate biologic width. The alveolar bone reduction was completed by directing the laser beam down the long axis of the tooth (slightly towards the tooth) using the 0.5 mm spot size with cutting speed between 20-40% and 100% mist. Sulcus depth was checked periodically to verify how much bone had been removed. Once adequate probing depth had been achieved, the teeth were then prepped and temporized. 1 carpule of 4% articaine with 1:100K epi was used during this treatment as 4 teeth were prepped for crowns at the same time.

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Solea Advantage:

With traditional methods (e.g., a scalpel and sutures) the entire surgical procedure would have been a separate 60 min visit, compared to under 10 minutes with Solea.
This case highlights Solea’s exceptionally clean surgical cutting with predictable, rapid healing and minimal bleeding.
The dentist was able to perform this procedure in-house rather than refer it out.
The patient was thrilled not only with the esthetic outcome, but also the speed and lack of the more invasive “traditional surgical approach” needed to complete the procedure.

Results: Solea’s precision enabled complete control of the tissue and the outstanding clinical results. The procedure was finished quickly and there was almost no bleeding. With Solea, the crown lengthening and tooth preparations could be completed in a single visit. This allowed for proper tissue healing around temporaries, fewer appointments for the patient, and less chair time for the clinic. The patient noted no post-op discomfort. She said that the final restoration and process exceeded her expectations.

Anterior CEREC Veneers with Esthetic Crown Lengthening by Solea Laser

2020-01-29T13:01:10Z

Anterior CEREC Veneers with Esthetic Crown Lengthening Using Solea

performed by Dr. Jeffrey Rohde

This procedure demonstrates precision, minimal bleeding and very fast healing.

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Case Summary: A 43-year-old female patient presented to the practice for her regular check-up. Patient has had chipping and various composite repairs for over two decades. She was unhappy with her smile and the way her teeth looked. The oral evaluation of the patient indicated that teeth #7,8,9,10 had discrepancy in the size of the teeth. The “Golden Proportion” was disrupted due to variable interproximal bonding, chipping on incisal edges, and widely variable height to the gingival contour of those teeth. The dentist advised a mix of esthetic gingival contouring and esthetic crown lengthening to correct variations in gingival height as well as porcelain veneers to restore the maxillary central and lateral incisors. The clinical objective was to reduce gingival height to improve esthetics in placement of veneers.

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Technique Used: The treatment plan included diagnostic wax up, surgical guide fabrication (to show the height of reduction), crown lengthening using Solea, prep for veneers, fabrication of provisional crowns (to test out esthetic design and function). CEREC veneers were made using Ivoclar’s eMax. While performing the crown lengthening procedure, the dentist utilized Solea with the 1.25 spot size, 8 ml/min mist, and 40% cutting speed. He easily transitioned from soft tissue to bone by simply varying the pressure on Solea’ s footpedal. The procedure time was 4-5 minutes with Solea, whereas the average procedure time doing traditional flapped crown lengthening would be at least 45-60 min.

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Solea Advantage:

No flap and no sutures were needed for this case, incredible precision of Solea made this procedure minimally invasive.
Blood-free preparation, clear surgical site, and no charring of tissue.
No heat transferred to bone causing unpredictable healing.
Reduced procedure time to 4-5 minutes compared to approximately 45-60 minutes with traditional tools.
Patient experience was improved compared to using traditional tools, and approach was minimally invasive resulting in faster healing (in under 1 week) and minimal discomfort in gingival tissue.

Results: Without Solea, this case would have been sent to a specialist for traditional crown lengthening that involves heavy local anesthesia, raising a flap, use of a drill creating heat and friction, and placement of sutures. The healing time would have been a minimum of 6 weeks. If a diode was used, it would not have been able to remove bone, and the tissue would have been left charred and ragged. The dentist was able to utilize multiple technologies (Solea and CEREC) for improved clinical results and patient experience than any traditional method.

Gingivectomy and restoration on tooth #8 by Solea Laser

2020-01-21T09:09:36Z

Gingivectomy and restoration on tooth #8 performed by Joshua Weintraub, DDS

This case demonstrates how Solea can be used to ablate both hard and soft tissue with no anesthesia, no bleeding, and fast healing.

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Case Summary: A 67-year-old male, who has been a long-time patient of the practice, presented for his follow-up appointment. The oral evaluation revealed the recurrent subgingival decay on tooth #8 DFL (Class III/V combination) under an old composite restoration. The clinical objective was to restore #8 while performing a gingivectomy to access subgingival decay. Total procedure time from start to finish was less than 30 minutes.

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Technique Used: No topical anesthetic or injectable anesthetic were used for this procedure. To start, a gingivectomy was performed to enable removal of the subgingival decay and achieve a clean margin for proper restoration. Next, the old composite and recurrent decay were removed with Solea. The removal of gingiva was performed using the 1 mm spot size with cutting speed between 30-50% with 20% mist. This took less than a minute and did not require anesthetic. The 1 mm spot size with cutting speed between 30-60% with 100% mist was used for removing the decay and old composite. The enamel was beveled with a diamond bur. Finally, the tooth was restored. The entire procedure was completed blood-free (the slight redness on the ‘Restored’ photo was caused by the finishing bur at the gingival margin).

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Solea Advantage:

The treatment was completed without anesthetic, was blood-free, and completed in less time compared to traditional approach.
The soft tissue healed extremely rapidly due to the minimally invasive precision of Solea.
The patient experience was enhanced due to not being injected with anesthesia, avoiding post-operative pain, and a shorter appointment time.

Results: With other instruments, the patient would require an injection in the maxillary anterior region – one of the most uncomfortable places to receive an injection, regardless of dentist’s skill level. This procedure would have likely taken much longer to complete with traditional instruments and techniques, compared to under 30 minutes with Solea. Time savings were achieved without the need to inject the patient and then wait for the patient to become numb. In addition, rapid and easy management of the soft tissue saved time. The patient was excited to avoid the shot, possible post-op pain, and hours of numbness after the appointment.

Deep Troughing for Margin Isolation #5 - Solea Laser

2019-12-04T10:10:46Z

Deep Troughing for Margin Isolation #5 performed by Timothy Anderson, DDS

This case demonstrates how Solea easily enables virtually blood-free soft tissue procedures without anesthesia resulting in better digital impressions for CEREC restorations.

[image:Pre_op.jpg]

Case Summary: This patient of record presented to the practice with a failing restoration and recurrent decay on tooth #5. The patient stated that he really disliked being numb and wanted to avoid the injection. As can be seen radiographically and in the pre-op photo, the distal restoration was significantly subgingival. No anesthetic was used during the treatment.

[image:Before_Troughing.jpg]

[image:After_Troughing.jpg]

Technique Used: The existing composite and decay were removed using Solea. The tooth was prepared for an Emax crown with the Meisinger CEREC Doctors prep kit. Solea was then used to remove adequate tissue for imagining in a clean, bloodless field. No cord was needed and the troughing took less than 15 seconds. The final scan was taken with the CEREC Omnicam. The restoration was designed with CEREC 4.6 Chairside software. The crown was milled, stained and glazed. Crown was then bonded with Variolink Esthetic.

[image:Prep.jpg]

[image:Prep2.jpg]

[image:Example_of_margin_scanned_with_a_two_cord_technique.jpg]

[image:Same_tooth_Scanned_after_Solea_Margin_Isolation.jpg]

[image:Post_op.jpg]

Solea Advantage:

Solea enabled the dentist to perform this treatment anesthesia-free.
With Solea, the procedure was completed in less than 15 seconds compared to several minutes traditionally.
Solea’s ability to precisely and virtually blood-free trough gingiva allowed for an effortless perfect scan.
The dentist delivered an impeccable patient experience including not administering anesthetic, a shorter appointment time, and increased patient comfort post operatively.

Results: The key to a successful CEREC same-day restoration is the ability to have smooth clear margins with separation at the time of scanning. Traditional methods, like retraction cord in a single or two-cord technique, increase procedure time and don’t always deliver predictable outcomes. Solea’s unparalleled precision enabled the dentist to sculpt the tissue for restorative excellence and immediately proceed with definitive restoration. Thus, the Solea and CEREC combination allows for the simplified same day dentistry.

Crown Lengthening (Clinical) #14 by Solea Laser

2019-11-14T13:01:40Z

Crown Lengthening (Clinical) #14 performed by Timothy Anderson, DDS

This case highlights Solea’s exceptionally clean and precise cutting of soft and osseous tissue that enhances the CEREC’s same day dentistry workflow.

[image:Pre_op.jpg]

Case Summary: A 62-year-old male patient presented to the practice with very deep decay to the level of the alveolar crest. Tooth #14 required clinical crown lengthening to restore with a crown. With Solea, performing the surgery and placing the definitive restoration on the same day was possible.

[image:Flapped_Before_Removing_Osseous_Tissue.jpg]

[image:Osseous_Tissue_Removed.jpg]

[image:Immediate_Post_op_crown_inserted.jpg]

Technique Used: To start, the existing amalgam was removed with a carbide bur. Caries was then removed utilizing Solea. A full coverage crown preparation was completed using Meisinger CEREC Doctors prep kit and an electric handpiece, and some minor troughing was performed to expose margins for a final scan without the need for retraction cord. An Emax crown was designed utilizing the CEREC 4.6 Chairside software and fabricated. Crown lengthening was performed during milling and glazing. A minimally invasive flap was reflected with a periosteal elevator. There was minimal tooth structure coronal to osseous crest on the distal and distal-lingual surfaces. Solea was used to remove and sculpt osseous tissue until there was 2 mm of tooth structure coronal to the bone. Positive bony architecture was maintained. Solea provides unsurpassed precision and clear visualization allowing removal of bone without iatrogenic damage. The final restoration was inserted with SpeedCem Plus self-adhesive resin cement. A single 4-0 chromic gut suture was placed.

[image:6_weeks_post_op.jpg]

[image:inserted_crown_14.jpg]

Solea Advantage:

Solea’s remarkable precision and improved visualization allowed for removal of osseous tissue without iatrogenic damage.
Solea enabled complete control of soft and osseous tissue resulting in a very fast and minimally invasive surgical procedure (completed in under 10 minutes with only minimal bleeding).
The Solea and CEREC combination allowed the dentist to finish the entire treatment, crown lengthening and the crown itself in the same visit – a true “crown in a day”.
The dentist was able to perform this procedure in-house rather than refer it out.
The patient was thrilled not only with the esthetic outcome but the speed, comfort, and efficiency, at which the treatment was completed in one visit.

3 Year Anterior Recall

2019-10-10T09:09:21Z

Just wanted to share a 3 year recall on one of our earlier anterior cases. Patient finally allowed me to replace an old existing PFM. What was interesting about this case is the spacing was not the same and we informed the patient of the challenge. She did not want to pursue ortho, so we had to mask the discrepancy with contouring. Overall, I think it turned out well and the material has held up great over the last 3 years. Again, if you are not doing anteriors, get yourself to Level 4 in Scottsdale or Charlotte to get some training.

This was Vita Triluxe done with 1 fire.

Initial:

[image:1initial.jpg]

Immediate Delivery:

[image:2immediate.jpg]

3 year Recall:

[image:4fullshot.jpg][image:3upclose.jpg]

Tom

Katana STML: Posterior Workhorse

2019-09-06T21:09:58Z

Hey All,

It's been a while since I've posted anything. Long summer and trying to get back at it. I think for all of us on here, we are thankful for technology and the constant evolution of materials and digital dentistry.

This case I'm sharing is something that all of us see each day. How I approach this today is different than I would have approached this pre SpeedFire and pre-Katana. I simply love the fit of Zirconia and the anatomy right out of the mill. I can be much more conservative with my margin preprations and edge stability of Zirconia during milling is wonderful. The other reason I do a lot of chairside zirconia and Katana is that I love the ability to cement on those deep margins or those patients where it is really difficult to isolate and bond well. (I will say that Kuraray-Noritake does not advocate cementing Katana STML with RMGI) To make myself feel better on these cases where I am not bonding Katana, I am making sure my fissure height on my design is 1.20mm or greater.

So here is a case that I just did. Tooth #30 had gold onlay that came off.

[image:Katana_STML_Posterior_002.jpg][image:Katana_STML_Posterior_003.jpg]

I tend to choose a shade that is one shade darker than I am shooting for. In this case, I wanted to match the shade of the occlusal 1/2 of tooth #29. I felt like that was A1 so I choose A2 Katana STML.

[image:Katana_STML_Posterior_004.jpg]

Deep recurrent decay that I removed and built back up to ideal.

[image:Katana_STML_Posterior_005.jpg]

It does take extra time but I do think there is significant improvement in esthetics with a Katana crown that has been glazed versus polish only. In this case, I pre-polish my crowns before I sinter them. Post sinter, I lightly air abrade the crown to take away the surface tension so the glaze will adhere uniformly. In this case, I choose to use Empress Stain and Glaze and fire on P4.

[image:Katana_STML_Posterior_006.jpg][image:Katana_STML_Posterior_007.jpg][image:Katana_STML_Posterior_008.jpg]

I schedule all of my crowns for 2 hours so this isn't really a huge deal for me to spend the extra time for a glaze fire. I tell the patients it will be about a 45 minute wait. During this time I am doing another procedure. I haven't received a complaint from a patient. But our team does prep all patients before they schedule to expect to be at the office for 2 hours.

Overall I'm quite happy with the final results and esthetics. I know there are some that don't have a SpeedFire and doing Katana is not possible, but for those of you that do, I think Katana is a wonderful material and I am using it more and more.

One of those cases that meant a lot...

2019-09-03T16:04:01Z

This is just one of those cases that meant a lot to me. This women walked in my practice looking for a third or fourth consult for her front teeth. She was celebrating 1 year of being cancer free after undergoing pretty severe chemo and radiation with low survival rates. She beat the odds but her teeth suffered. She had something to smile about now and wanted her teeth to reflect that. She hated her smile and I was so grateful that she chose me because I wanted to be a part of her story.

[image:IMG_5935.jpg]

Major damage from erosion was done to teeth #7-10. The canines also show buccal erosion and pitting on the cusp tips. She has obvious tetracycline staining as well and in her smile we decided to work from #5-12 knowing that she could always add in #4 and #13 at a later date if she wanted.

[image:IMG_5937_1.jpg]

When I am looking at the shape of her teeth, I see that the laterals are a bit wide, I want to lengthen #8 and 9 due to the amount of wear and erosion (meaning I have to pay attention to occlusion here) but I really like the overall shape of her teeth.

[image:IMG_5938.jpg]

I set this up in the computer as Biogeneric Individual, but then manually add a BioCopy Upper folder so that I know where her midline, incisal length papillae are.

[image:JO_002.jpg]

[image:JO_001.jpg]

This is a case I delivered in one appointment and a tip that I have definitely learned over the years is to trust biology. I have a huge fear of black triangles and I know I am not alone. Patients hate the look of having pepper stuck in their teeth and are always asking if we can fix it. It's not an easy task with a tiny bit of composite for natural teeth, and then with crowns, I just used to make these long, broad contacts to avoid it at all costs. The problem with those long, broad contacts is that they just don't look quite right. Now it's this constant struggle in my mind of making sure there is no black triangle and trusting biology to fill in the triangle.

Here is an example of that-

[image:IMG_5946.jpg]

Immediate seat

[image:IMG_5983.jpg]

1 week post op and praying to the papillae gods

[image:papilla_001.jpg]

[image:IMG_6066.jpg]

3 week post op

[image:IMG_5935_1.jpg][image:IMG_6063.jpg]

This was such a fun case for my entire team getting to know this woman who has more courage and strength than I could fathom. She affected every one of my team members in a positive manner and now can't stop smiling. She scheduled to do her lower anteriors in a month and I can't wait. She was an amazing reminder of why I love what I do.

Doc I don’t really smile....

2019-08-22T14:02:36Z

Patient presented wanting his smile fixed. Concerned with the laterals and #5. After 5 years of seeing him finally allowed me to do 7 first. Once he saw it signed up to do 5 and 10 in 2 weeks. When we finished this week he said now he can stop smiling on just one side.

"I'm beautiful!"

2019-08-22T07:07:34Z

Richard has been a patient of mine for the last eight years. He’s 32 years old, single, and an overall great guy. Earlier this year he made a consultation appointment for his front teeth to discuss veneers. When we finally sat down, I asked him what made him decide to move forward with this treatment. He mentioned that he was tired of being single and knew that he needed to do something about his smile if he wanted to feel confident enough to enter the dating scene and find a life-long partner.

[image:Cdocs2.jpg][image:Cdocs1.jpg]

We had a lengthy conversation about what he wanted to be sure I could meet his desire. His request was simple: make is teeth white. Overall, the position of the teeth was good; no ortho or soft-tissue treatment was required. As this was a straightforward case and the patient wished to begin treatment as soon as possible, I elected to begin without a wax-up. While this is not my normal protocol, I felt confident I could deliver and the patient would be happy. A pre-op putty was taken and his teeth prepared.

[image:Cdocs_prep.jpg]

CEREC images were captured and the putty was used to fabricate the provisionals. Even though the temps were the same shape/position prior to preparation, he was quite happy at the fact that his teeth were no longer discolored. Without a wax-up to copy, I decided to send the case to Weston Hatcher and allow him to design it. Weston and I spoke about the case and I let him know what I was looking for regarding facial anatomy (minimal to none), embrasures, etc. The final design was emailed back to me a few days later and the restorations were milled in-office.

[image:Cdocs_design.jpg]

After the congratulations, handshakes, and hugs, I walked him to the front door. When he walked outside, he raised his hands in the air Rocky Balboa style and shouted, “I’m beautiful!” Cases like these make all the tough days hard to remember. I wish the young man well in his social life with his new-found confidence. These restorations are Emax BL4 and were hand polished only. I chose not to add any incisal or cervical characterization as the patient’s primary desire was to have teeth that were simply one color.

[image:Cdocs_final_retracted.jpg][image:Cdocs_side_by_side.jpg]

Straight forward anterior case

2019-08-18T15:03:36Z

This was patient had trauma to #7-9 many years ago, neglected her teeth and presented with gross decay and fractures. She wanted a new smile and insisted on doing this in a single visit. The software did a really good job with biogeneric individual proposals. These are 7-10, Empress Multi A1, polish only. I really prefer to not have the anterior's too glossy, when wet, they look very natural. Since I have 2 mills, the entire treatment was completed in just a few hours.

[image:Screenshot_2019_08_18_16_26_08.jpg]

Tips for Immediate Azento and EV

2019-08-12T11:11:43Z

With all the recent interest in Azento and Astra EV, I thought I'd share a case with a couple of tips to help you avoid a couple of complications I encountered during a procedure.

In this case, the patient was referred for an evaluation with suspicion of a fracture; the referring doc was unable to do find the fracture, and after I looked at her I could not locate it either. [image:1.jpg]

I sent the patient to my excellent endodontist, who after accessing was able to find a fracture on the distal and returned her to me with a hopeless diagnosis for #30. We went through the now routine and simple process of capturing CBCT and CEREC digital impression, and uploading them for Azento case analysis and production. With the available interradicular bone, I opted for an immediate placement. Azento digitally removes the tooth and designs the guide as if it were already extracted. As this patient would be returning to her referring doctor for the final prosthesis, I chose the custom healing abutment solution only. When the patient came in for surgery she looked like this:

[image:2.jpg]

Obviously the guide won't fit with the tooth in place, so the first step is to perform a coronectomy. I will typically use a 557 carbide to undercut the tooth following the gingival contours, first from the buccal and then from the lingual until the clinical crown becomes mobile. My assistant will keep the surgical suction on the occlusal of the tooth to keep it from relocating to new territory in the lung or gut. Once the clinical crown is safely gone, I will use whatever large coarse diamond is on hand (either a large football or an 845KR) to finish it down to where the guide will clear it. Try not nick or abrade the soft tissue too much as you do this.

[image:3.jpg]

I prefer to complete the osteotomy with the roots in place; there are a few excellent threads detailing this process here on the boards. One of the benefits of this is that the distal curve of the mesial root that many mandibular first molars have is obliterated during the drilling process. This particular root is often the cause of difficult or complicated extractions. Once the osteotomy is complete, it's usually a fairly simple process to remove what's left of the roots and then thoroughly curette and irrigate the site with saline. When curetting the socket in cases like this one where there was some periapical pathology, spend as much time as necessary to achieve clean, bleeding walls. Once that is done, the implant is placed through the guide to the appropriate depth and orientation to accommodate the custom healing abutment; remember that one of the benefits of using EV and an Atlantis custom abutment is that the abutment fits only one way, and the guide helps you position the fixture so that it is timed correctly. Once the implant is placed (in this case we achieved approximately 25 Ncm on implant insertion), a good practice to follow is placing a cover screw while grafting the gaps around the fixture so that your graft doesn't occlude the internal aspect of the implant. In this case I used a cortical/cancellous mineralized/demineralized blend allograft, mixed with PRF, to graft the gap. Then I used a PRF "membrane" with a hole punched in the middle to drape over the graft. The hole is there for the healing abutment to go through, but if you undersize the hole you will see the PRF membrane distort as you deliver the abutment through it. The final step here is to suture, and in this scenario I will typically start with a horizontal mattress to pull the buccal and lingual gingiva against the healing abutment and underlying graft as much as possible, then follow with a pair of single interrupted sutures to tuck in the papillae.

[image:4.jpg]

I ended up having to remove the healing abutment after the PA was recorded, as it was clearly not seated all the way. I used the larger bone profiler so I felt confident that was not the issue. Turns out despite the care I took to exclude graft material, one tiny piece migrated into the implant in the short time between cover screw removal and abutment placement. Always double check this as you're moving forward; not fun thinking you're pretty much done and then having to go back. This lead to another minor complication: when I put the healing abutment back on and hand tightened it, the PRF membrane distorted a bit and the implant/abutment complex rotated a few degrees. This is one of the aspects of using the Astra EV that can be technique sensitive; the threads of this fixture are not particularly aggressive. While the bone implant contact is very high in a normal osteotomy, and it is very important to keep the insertion torque value less than 45 Ncm to avoid pressure necrosis, the story is a little different in immediate cases. I used the V drill to finish up the osteotomy as I routinely do in most of my EV cases, and in hindsight this is where I erred. Since the implant is only partly fixed in bone, we need the torque value higher (45Ncm) vs the 20-25Ncm I ended up with after using the V drill. If you place the implant and are exceeding 45Ncm, you can always back it out and alter the osteotomy with the V or X drills, or the A or B drills, depending on the clinical situation. Once the bone is gone, however, there's no easy or predictable way to get that torque value back up. I was concerned that trying to reverse the complex simply to make the healing abutment straight or to make the PRF drape ideal might reduce the stability to where the fixture would fail, so I opted to leave them both.

[image:5.jpg]

The patient healed normally and had no further complications, and the referring dentist had no issues restoring the fixture.

I'm hoping the small errors I made with this fairly routine case can help some of you as you adopt this treatment modality and explore the varied uses of Azento and Astra EV.

Jeremy

Another Azento

2019-08-08T08:08:30Z

I know there has been quite a bit of discussion on the boards in regards to the Azento procedure, costs, etc. But, every time I restore one of these cases I am so impressed.

This patient presented with a symptomatic #19 with existing RCT. I explained to the patient that the root canal was failing and our best solution was to restore the area with an implant.

The PA really didn't communicate the area of infection to the patient.

[image:pa.jpg]

But, this is why I love having the CBCT in the office. The ability for co-diagnosis with the patient is much easier.

[image:Thomas_DeAnna_3D_examination_2_VO3_20180821_093750_Longitudinal.jpg]

[image:Thomas_DeAnna_3D_examination_2_VO3_20180821_093750_Cross_sectional.jpg]

The tooth was extracted and socket preservation was completed with prf, sticky bone, and long term resorbable membrane.

Pt returned 6 months later and was scanned and Azento was used for the planning process.

[image:2019_08_08_9_56_07.jpg]

I really like the design of the guides with Azento that allows for the window on the lingual. Access with the drills when performing the osteotomy is greatly improved.

[image:window.jpg]

The procedure is so slick with the keys being built into the the actual drill. Start to finish this case took around 20 min.

[image:placement.jpg]

The best part of this procedure is the restorative component.

This patient returned this morning. The custom healer was removed and the custom abutment was placed. There was no need for anesthesia or releasing incision as the custom healer and the custom abutment have the exact same emergence profile.

[image:healing_cap.jpg] [image:abutment.jpg]

Using the core file we were able to mill the final restoration before the patient came in to have the final abutment placed. The fit is excellent.

[image:seat.jpg]

The new pricing structure with Azento and the efficiency associated with this procedure, now makes it a no brainer for me.

Some In house anterior work!

2019-07-25T15:03:32Z

Some years ago I kind of desisted to do more than 2-4 anterior or cosmetic cases in the office. For time, results or whatever reason. Since prime scan came out, I started to push its limits and that along with the evolution last years in digital design, 3d printing evolution has encouraged me to do this cases again in the office, with a little help of a DT friend of mine we have been doing this cases lately with very nice results. Saving lots of time and money without sacrificing results.

So basically we take all the data, scans, (prime/3shape) pictures. The digital wax up is done either Inlab or meshmixer. Print for mock up/temp, prep and biocopy (nothing new about that. I also take a quick pvs to finish up contacts and adjustments, also print a resin model. This case was done with empress multi BL3

[image:1.jpg][image:2.jpg][image:3.jpg][image:5.jpg][image:6.jpg][image:4.jpg]

OptiSleep Appliance...A 'How To'

2019-07-22T16:04:59Z

I’ve seen a few posts lately regarding the OptiSleep oral appliance and wanted to give a general overview of how to use the Sidexis software to segment the airway, import the necessary CEREC data, and ultimately order the OptiSleep device.

Once a CBCT volume is obtained, selected the TOOLS tab and then select SICAT SUITE.

[image:Screen_Shot_2019_07_22_at_3_52_31_PM.jpg]

Once on the SICAT AIR page, select the ANALYZE tab. Please note the blue, vertical arrows. The single arrow is used when you wish to segment one airway. If you wish to compare airways, perhaps after treatment with the OptiSleep, use the icon with two blue arrows.

[image:Screen_Shot_2019_07_22_at_3_52_53_PM.jpg]

In this screen, you need to identify the patient’s airway. I selected a spot on the hard palate and double-click to begin the segmentation and then drag my cursor to the bottom left, somewhere on the patient’s spine. Again, double-click to end the segmentation and form a box denoting the patient’s airway. The software will trace out what it believes to be the airway and highlight this in yellow. Just like when we merge CEREC & CBCT data, you will need to confirm that the segmentation is correct before proceeding. If you are satisfied with the tracing, hit OK.

[image:Screen_Shot_2019_07_22_at_3_53_22_PM.jpg]

The software will complete its calculations and you will now see a 3-D model of your patient’s airway, complete with coloring. The parameters for the colors themselves can be adjusted, but that is far beyond the scope of this post. IMPORTANT!! This software cannot diagnose obstructive sleep apnea. This representation is merely a conversation starter with your patient. Only a sleep physician can diagnose your patient with obstructive sleep apnea (OSA).

[image:Screen_Shot_2019_07_22_at_3_53_41_PM.jpg]

Moving forward…

Your patient has OSA and can be treated with an oral appliance. Consent forms are signed, finances secured, and the patient is ready to have an OptiSleep oral appliance fabricated.

Full mouth CEREC images are captured, as well as a bite registration obtained using a George Gauge.

[image:Screen_Shot_2019_07_22_at_3_56_45_PM.jpg]

The patient’s CBCT is opened, and the ORDER tab is selected. There is an icon that resembles teeth and that should be clicked to begin importing the CEREC images.

[image:Screen_Shot_2019_07_22_at_3_57_00_PM.jpg]

Again, similar to the workflow when importing CEREC data into the Galaxis software, you will BROWSE your computer and import the correct CEREC images.

[image:Screen_Shot_2019_07_22_at_3_57_17_PM.jpg]

Both arches will be imported. An order will be created and placed.

[image:Screen_Shot_2019_07_22_at_3_57_32_PM.jpg]

[image:Screen_Shot_2019_07_22_at_3_57_49_PM.jpg]

[image:Screen_Shot_2019_07_22_at_3_58_04_PM.jpg]

I hope this helps and please remember this is a generalized overview of the process. Remember, CEREC Doctors has a wonderful seminar on Airway Prosthodontics if you’re looking to go down this path.

CEREC journey over the last nine years...

2019-07-22T08:08:15Z

Over the last few years as I have become more involved in the CEREC community, I have had the pleasure of being surrounded by some incredibly talented dentists. Often these dentists will show me their cases and I am constantly in awe of what they have accomplished in such a short amount of time using their CEREC. What I love even more is their drive on how to improve their skills even more. My constant push (and often harassment) is to get these doctors to post their cases but posting can be intimidating. I hear over and over the same reasons why doctors won't post cases: "my work isn't good enough", "I don't have anything new to share", "people can be mean in their feedback and I don't want to be bullied", etc... As a CEREC doctor we take a lot of pride in our cases because often we create them with our own hands, so getting feedback feels personal. My point in this post is to show a progression of what you can do if you are vulnerable enough to put yourself out there and try.

Here are some of my early cases starting in 2010. I happen to have a really poor post-op photo of my very first anterior case. I was so proud of this when I first began using my CEREC.

[image:CEREC_over_9_years_001.jpg]

One of the best pearls I got in a class was if you want to improve, start taking pictures of your cases, so I did. The problem was my photography wasn't stellar and I still didn't know what I was looking for to be able to make improvements. These restorations definitely made improvements in each of these patient's smiles, but now when I see these cases...

[image:CEREC_over_9_years_002.jpg]

Jumping ahead a few years, I got involved with the mentor group and started posting cases more often. This case in particular was one that was emotional to my entire team because we watched the physical changes that took place with this patient after we changed her smile. I was so proud of this case. After I posted, Mike Skramstad took the time to photoshop the case on ways I could improve it. My first reaction was nausea and to quite dentistry, but once I could reframe that and understand that he was truly trying to help me improve, it was so much easier to actually see what he was talking about with the photoshopped photos so that the next time I wouldn't make the same mistakes. Now did I cut the crowns off and redo the case? Absolutely not. This patient was thrilled. She could not see the nuances that we can, but what I learned from the feedback was unvaluable to my growth as a dentist. It also became a challenge over the next years to see what cases did or did not need photoshopped .

[image:CEREC_over_9_years_003.jpg]

After case after case after case, I began to actually see the nuances of line angles and color patterns and became much more comfortable with my anterior work as the cases became more repeatable.

[image:CEREC_over_9_years_004.jpg]

Now if a case like this walks in the door, it's not a huge deal to squeeze them in and get a good result for our patients. All of this is because of the constant feedback from this community. It's fun to see how all of us have improved over the last 9 years as technology has changed, materials have changed and how we constantly challenge each other. I wouldn't change my path for anything in the world, but I do hope that it takes others a lot less time than it took me to make restorations look natural ;)

Solea Crown Lengthening #9 - Dr. Joshua Weintraub

2019-07-08T14:02:55Z

[cerecvideo:3364|Solea Crown Lengthening #9 - Dr. Joshua Weintraub]

Please close my gap

2019-07-02T15:03:14Z

This long time patient had been self conscious for years with her diastema and ugly crown/tooth size discrepancy. 14 months of Invisalign and a new crown and 3/4 crown on #9 and she is happy and smiling.

[image:IMG_3612.jpg][image:IMG_3832.jpg]

Prep, Scan and Deliver with the Isolite 3

2019-06-27T13:01:47Z

[cerecvideo:3380|Prep, Scan & Deliver with the Isolite 3]

Prep Scan and Deliver with the Isolite 3 - Watch the Video!

2019-06-17T08:08:56Z

The Isolite 3 dental isolation system gives you the all-important isolation and moisture control you need when performing restorations.

[cerecvideo:3380|Prep, Scan & Deliver with the Isolite 3]

3M™ Chairside Zirconia

2019-06-13T13:01:22Z

Watch our latest Featured Video, 3M™ Chairside Zirconia. 3M™ Chairside Zirconia combines strength and esthetics with a fast sintering time, offering more efficiency in a single-visit appointment.

[cerecvideo:3367|3M™ Chairside Zirconia]

IPS e.max HT-Using the "Grey" crown to your advantage

2019-06-12T23:11:05Z

Inventory. It's a love hate for me. I love to try out new materials and have lots of material choices and have all the shades under the sun.

But as a business owner who is trying to run a successful, profitable practice and set the tone for our doctors, I need to be smart.

When I first started using CEREC, I saw post after post from doctors warning us against using IPS e.max HT. If you do, you will get the dreaded "grey" crown. As many of you have seen, I do a lot of HT in the anterior, for crownlays, and if I'm trying to match a patient with a C-shade. In my eyes, C shades are just a lower value of A shades. Sometimes we just say the tooth is "grey" but on the flip side, we can use this to our advantage. If I see a lower value, C-tones or "greyness" in a tooth, my thought isn't to pick a C-shade, it is simply to use IPS e.max HT.

Here's my rationale. It keeps my inventory simple. As I already stated above, I have a lot of uses for the HT block. One of the other qualities of an HT block is that the value can be dramatically affected by the color of your cement. For a case like this, I can use this to my advantage by understanding the nature of qualities of my block on hand. People have argued that I should just pick a C2 or C3 LT block and that is just easier. I look at it from the other end of the spectrum in that using the HT block kind of bails me out if I don't choose the exact right shade. Let's look at this case.

[image:IPS_e_max_HT_Cases_003.jpg][image:IPS_e_max_HT_Cases_002.jpg]

I put the A3.5 shade tab up just to show the lower value of the teeth compared to the tab

This is a case that I see C-shades and automatically think about HT. I told my assistant that we would be doing A3 HT and that she would be doing the rest. I'm really been trying to train up my team members and not do all my stain and glazing.

[image:IPS_e_max_HT_Cases_004.jpg]

Below are the Pre-Op, Try-In and Delivered Crown. All we had was A2 HT left, so this made my assistants job a little more challenging with staining down this crown to get it to match. I told her to use a little of the e.max "1" stain for the gingival 1/2, some of the I-2 stain for the cusp tips to drop the value down a little more and to add some white to create some craze lines. Overall, she did a good job with the staining. At Try-In, the value was too bright for my tastes though I wasn't trying to match the "darker" canine, I still wanted to lower the value down more. If I had done the C2 or C3 LT block, the different color resin cements wouldn't make too much of a difference. In fact, the thicker your porcelain, the less of a difference the colored cements make. As you can see from the photos, the occlusal of the tooth is relatively unaffected from the Warm + cement.

[image:IPS_e_max_HT_Cases_006.jpg][image:IPS_e_max_HT_Cases_007.jpg][image:IPS_e_max_HT_Cases_008.jpg][image:IPS_e_max_HT_Cases_010.jpg][image:IPS_e_max_HT_Cases_009.jpg]

There isn't anything too incredibly special about this case, but wanted to share some things I've learned about IPS e.max HT and how I use it. I hope this can help others not be intimidated by the block and utilize it when appropriate.

Dan

Multilayer vs Screw Retained implant crowns

2019-06-10T08:08:51Z

My team was asking me when I choose multilayer vs screw retained crowns not long ago. I personally try to do screw retained implant crowns whenever possible, but if I get an implant back that is a little too angled it doesn't make it possible without opening the contact up. I put some slides together for a visual and just thought I would share in case anyone else wants to use them.

*If you are not using your CEREC to restore implants, get down to the level 3 course and learn how! It is your biggest ROI with your investment and once you do it a few times, you quickly see how straight forward it really is.

[image:multilayer_vs_screw_retained_001.jpg]

[image:multilayer_vs_screw_retained_002.jpg]

[image:multilayer_vs_screw_retained_003.jpg]

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Happy Monday everyone!!!

Not too Ugly...CEREC Zirconia Bridge

2019-06-05T12:12:58Z

Fortunately our chairside options for bridge blocks is growing. With Ivoclar Vivadent coming out with some blocks, 3M and Katana Noritake will be releasing there STML bridge block later too. Originally I used to push the limits with IPS e.max bridges with the B32 block. I had one failure with connectors that were adequate 18mm2 but they were short. Now I tend to only do IPS e.max bridges if I am doing an anterior case or a premolar pontic.

So here is a case that I just did with CEREC Zirconia A3 in the medi S block. The challenge with CEREC Zirconia in my opinion is the opaqueness and the high value. For me, I'm always trying to tone that brightness down and give the restoration more depth of color. What has worked well for me is infiltration stains from VITA and then stain and glaze to follow. Here is a lower posterior bridge that I just delivered. After design in the software, I used my infiltration stains and then did 45 minutes drying and sintering cycle.

[image:IMG_3797.jpg][image:IMG_3795.jpg][image:IMG_3796.jpg].

I bought the Zig Detailer Brushes on Amazon for like $5/each.

After the sintering cycle, I fired the case on P4 with Empress Stain and Glaze. I used a bit of Mahogany in the grooves and for the embrasures. A little bit of A shade stain for the gingival aspect. Added very little Incisal 1 (Blue) for the translucency for the cusp tips. And then white to create accents and highlight the other colors. [image:IMG_3798.jpg]

Overall this case isn't perfect, but I think it is a good option for us chairside. As an aside, I did this case in two appointments. Milled the provisional bridge with 2M2 Vita CAD Temp.

[image:IMG_3790.jpg][image:IMG_3789.jpg]

The Azento experience - Streamlining implant workflow at IDS 2019

2019-06-03T13:01:01Z

The Azento experience - streamlining implant workflow at IDS 2019

Azento, the latest digital implant workflow solution by Dentsply Sirona Implants, generated a lot of buzz at the US launch last September at DS World in Orlando, Florida. Now Azento has crossed the Atlantic for the European launch.

Delivering digital workflow in three steps

Jo Massoels, Vice President Global Marketing & Solutions at Dentsply Sirona Implants, revealed the secret behind Azento single tooth replacement: “Many companies are talking about digital workflow, but we really deliver on it with Azento. We truly streamline digital implant workflow in three major steps; scan, approve, treat. And that is unique.”

Clinicians and dental technicians at the booth were eager to discover what’s behind the brand promise of “Outstanding flow. Great results.” They learned about tangible financial and time-saving benefits with Azento which, in parallel, enable consistently excellent results. Based on each patient's digital scans, the clinician receives a precise, customized digital treatment plan and, upon approval, an Azento box for the specific case, containing all the components and instruments necessary to perform a complete implant treatment.

Multiple benefits and fantastic healing results

Dr. Mischa Krebs, an oral surgeon from Alzey, Germany, presented Azento along with Azento ambassadors Dr. Darin O'Bryan and Dr. Daniel Butterman from the United States. According to Dr. Krebs, the benefits of Azento, in addition to its fantastic healing results, are shorter treatment time and fewer appointments for the patient, as well as the logistical advantages that has really helped in his clinic: “We get all the parts delivered in one box, there’s less effort involved in ordering, in maintaining an inventory and so on;it's actually a package of all-round benefits.”

Scan, approve, milkshake treat

Visitors had lots of fun trying out their own, personalized Azento experience of “scan, approve, treat.” After scanning and approving a selfie, they received a custom-made treat in the form of a milkshake with their selfie on top. Many of these treats can still be seen on Instagram with the hashtag #azentoexperience.

Azento becomes available for Astra Tech Implant System and Xive in major European markets in 2019

[image:azento.jpg]

Bio Copy still amazes

2019-05-21T05:05:55Z

This patient has secondary decay under a pfm that is critical to the stability of his partial. Both the crown and partial were done just after the Korean War. He loves his partial. These cases are always my favorite. Think back to how we used to handle this workflow in the analog world. Pick up impression and take the patient's partial away from them for a week. They would then hibernate until we gave it back. The lab crown would never fit to the partial so we become human milling machines and try to adjust to fit. Bend the clasps. Break the clasps. In the end we end up with a barely acceptable outcome and offer to make a new partial. [image:Slide1.jpg][image:Slide2.jpg][image:Slide3.jpg][image:Slide4.jpg]

The most important part of implant planning part 2

2019-05-18T07:07:53Z

Last week I talked about the importance of planning the implant restoration prior to doing surgery, in order to avoid complications.

[image:1.jpg]

I want to take it a step further, it's equally important to export the crown design as an .SSI file and import it into Galileos Implant for planning. This patient has multiple missing teeth, and agreed to implant treatment @#12. If I would have only planned the implant in my CBCT planning software, without regard for the restoration, it would have been a restorative nightmare.

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[image:30.jpg]

[image:40.jpg]

[image:50.jpg]

[image:Screenshot_2019_05_18_08_46_46.jpg]

Crowns on 8 and 9

2019-05-15T12:12:44Z

I posted this case on Facebook yesterday and I thought I would post it here as well.

Patient came to my office (works in the dental field) and was concerned about the wear on 8 and 9.

[image:mike_miscellaneous_new_001.jpg]

Now from first look, it seems as you might be able to be conservative with composite. However, we have to understand "how" the wear was caused... In this case her older lower bridge was a bit too long incisally and causing "pathway wear" on the lingual that also damaged the incisal edge. If you just simply add composite, it's likely not to fix the underlying issue.

The plan was to do full coverage crowns on 8 and 9. Why full coverage crowns? Because I wanted to both lengthen the teeth, restore proper lingual contour, and slightly increase overjet to give her more room to function... we also planned on lowering the incisal edge on the lower bridge

Step #1 was to quickly mockup with composite. We mocked up both the incisal edge and the lingual surface. By doing this, the occlusion was obviously very high... This gave me a roadmap on how much to reduce the lower bridge:

[image:mike_miscellaneous_new_002.jpg]

Here are the preparations and scans with Primescan:

[image:mike_miscellaneous_new_003.jpg]

We chose to do Biogeneric using the "mockup" as a guide... we chose a Vita Morphology in the database. Here is the "biojaw" proposals and final designs:
[image:60323753_10157379138579443_817086531285024768_n.jpg]

[image:60303002_10157379139929443_8759882904554700800_n.jpg]

And here is the final result...Vita Trilux Forte

[image:mike_miscellaneous_new_004.jpg]

the most important part of implant planning

2019-05-13T20:08:05Z

I'm always amazed how often surgeons only look at bone when planning implants and spend little time looking at the future restoration. Carl Misch used to say that no one wants implants, they want teeth. This patient was a second opinion for an implant to replace #11, he was already scheduled for the implant in another office, but his wife is a patient and asked him to see me first. The surgeon told him this was a very straight forward implant case.

The first thing I do on every implant case, even before taking a CBCT, is scan the edentulous site, draw a margin, and get a crown proposal. If I see a problem with the proposal, the patient and I can have a conversation about how to move forward. This patient had plenty of bone for his implant, but he has some choices to make about creating room for the restoration. The point is, we can talk about it before surgery. I'm a firm believer in anything you tell the patient before treatment is an explanation, anything after is an excuse.

[image:Screenshot_2019_05_13_20_49_10.jpg]

[image:Screenshot_2019_05_13_20_49_32.jpg]

[image:Screenshot_2019_05_13_20_49_59.jpg]

Work Flow- RCT, B/U, APC in one Appointment

2019-05-13T05:05:58Z

I've posted about this before, how CEREC can help you complete an RCT, b/u, APC in one appointment, often in under 2 hrs. My last post on this topic only showed the before and after photo; no intermediate steps.

[image:RCT.jpg]

In an effort to explain the process further, I performed the same treatment on tooth number 15 and took photos along the way using my Primescan.

Pre-op radiograph.

[image:pre_op_PA.png]

Here are my steps:

Anesthesia, CEREC images of opposing arch and buccal bite. I capture the buccal bite at this stage as the patient has not lost proprioception in the area.
Place IsoDry and begin preparation of the tooth. I begin with occlusal reduction and then move on to the decay.

[image:1.jpg]

Once I have clean margins and I’m at the pulpal floor, I placed a Tofflemire matrix.

[image:2.jpg]

Build-up complete.

[image:3.jpg]

Final preparation. It took me 25 minutes from the time I picked up the handpiece to this point.

[image:4.jpg]

CEREC images are captured and I have a second assistant design, mill, fire the restoration while I drill through the center of the build-up & complete the RCT.

The beauty of this approach is that simultaneous processes are occurring. By reversing the typical RCT-crown order, I was able to complete treatment in under two hours.

[image:xray_final.png]

[image:CBCT_2.png]

Side note: my CBCT allowed me to visualize the number of canals (no MB2) and and their paths prior to initiating the RCT. I knew prior to starting that the palatal canal did not go to the apex of the root. Had I not seen this ahead of time, I may have thought my obturation was short in my final PA. The power of these technologies cannot be overstated. They have allowed me to provide better, more efficient treatment for my patients in a consistent manner that I never thought possible before.

Fun With Primescan and Atlantis

2019-05-11T06:06:34Z

For those that have been on the fence with Primescan, or have not tried the Atlantis workflow, I thought I would share this fun "real-world" case we just finished recently. These are my favorite types of cases, where we can really make a difference for someone. Patient presents as an 80 year old woman who was wearing an ill fitting partial for awhile and was losing weight because eating was very difficult. She has some significant health issues and was told in Florida that she "could not have implants", which was obviously inaccurate. She saw an oral surgeon who we work with for placement of three implants and he bounced her over to me. Now, there are certainly plenty of other restorative concerns, but we wanted to address the immediate issue and get her back in function. Here is how she presented:

[image:Untitled_2_001.jpg]

You can see in the next pic that she has a tight upper lip that we were fighting with, which made photos a challenge, but it also helped us restoratively because she had a low lip line and there was significant atrophy in the area over time. We debated pink porcelain over longer teeth, but as you will see in the finals it really didn't matter esthetically due to the tight lower lip line. But, most importantly, I love how the Primescan picks up everything, including the metal on her partial:

[image:Untitled_2_002.jpg]

The double buccal bite made sure we were able to get a stable model:

[image:Untitled_2_003.jpg]

Check out the depth of scan, into the implants:

[image:Untitled_2_004.jpg]

So, we placed the IO FLO scanbodies and took our scans:

[image:Untitled_2_005.jpg][image:Untitled_2_006.jpg][image:Untitled_2_007.jpg][image:Untitled_2_008.jpg]

Love how it even captures the clasps-ridiculous. So, we sent the case to Atlantis and had them fabricate the abutments...they were able to parallel everything and send me the plan:

[image:Untitled_2_009.jpg]

I approved the plan and they sent me the abutments and the core file for the bridge-I was able to take that core file and send it via connect off to the lab-so at this point I have not taken a single physical impression or touched a model, but we have abutments and a final fixed partial denture being manufactured. I also remembered this time to order the seating jig from Atlantis-makes life so much easier:

[image:Untitled_2_010.jpg]

So, once the bridge came in from the lab, we had the patient come in. Popped in the seating jig and delivered the abutments in a few minutes-such a smooth process. There was blanching of the tissue but patient was never uncomfortable, and it went away after a few minutes:

[image:Untitled_2_011.jpg][image:Untitled_2_012.jpg]

Delivered the final bridge and we had a very happy patient:

[image:Untitled_2_013.jpg]

She called me the next day all excited about how she went out to dinner with her husband and was able to eat...in the world of Italians, that is priority number one! All kidding aside, it was great to use the amazing technology and Atlantis workflow to tackle a challenging case and help her get healthy. Impressions would have been very difficult, but with Primescan it was unbelievably easy. Now, she is so excited she wants to start addressing the other areas as well...fun times in dentistry for sure!

e.max ZirCAD MT Multi Block

2019-05-10T21:09:43Z

Today was a really great day. I got the opportunity to test out the new e.max ZirCAD MT Multi Block. I had one bridge block and one single unit block so I was patiently waiting for a patient with the proper shade.

[image:IMG_5659.jpg]

This patient presented with a bridge needed from #27-29 and a crown on #30.

[image:IMG_5660.jpg]

Here is the bridge right after being sintered

[image:IMG_5666.jpg]

and at try-in

[image:IMG_5670.jpg]

I decided I wanted to add a little characterization so I added Empress Stain and Glaze

[image:IMG_5672.jpg]

[image:IMG_5690.jpg]

Normally this was not something I would do same day but I scheduled this appointment on a Friday that I wasn't normally working so that I could document everything. She was well aware that there would be some down time. What I didn't quite realize was that the sintering time would 144 min. What to do with 144 extra min?? Why not address the front teeth?

[image:IMG_5645.jpg]

She had a lot of large fillings in the anterior with recurrent decay and she wanted a better smile to boost her confidence. In the 2.5 hrs that we waited for the bridge, we made these using e.max A2 MT blocks

[image:IMG_5684.jpg]

And did this...

[image:IMG_5687.jpg]

I asked her at the seat of the anteriors if she wanted to see them before I bonded them in. She said that she trusted me and wanted a surprise.

[video:IMG_2040.m4v]

Today was a great day and the reason I truly love what I do

CDOCS - Blog

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4. Nail the Texture for a Natural Look

5. Shade Match to the Highest Value

Is Dentistry Draining You? 5 Steps to Fight Burnout and Reignite Your Passion

1. Control your schedule

2. Minimize debt

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4. Engage with the dental community/collegial support

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Full Mouth Rehabilitation

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Primescan Biocopy - A Valuable Resource

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