The speed of advancement in the world of digital technology has made a tremendous impact in dentistry.
The way we look at this advancement is quite important. With the influx of artificial intelligence powered robots, robots may perhaps augment humans by doing the work that humans don’t really want to do. Doing so would free up our time to become more efficient and effective in providing more value to our customers with higher quality products. We will still need a talented ceramist to make the magic happen, because I can assure you that if you settle for mediocrity in your work, then for sure, machines will replace you.
Technology is not only a time saver, but also can be a significant source of profit. As useful as they are, machines cannot do everything; it is still the 20% of the human touch that makes 100% of the difference. As dental professionals, we must always allow the patient to feel and know that technology is only an enhancement and not a replacement of a dental professional’s “personal touch”. The personal touch and how well you and your staff make it happen is an incredibly important element of patient retention and satisfaction. Communication is one of the ways to achieve this.
One of my favourite quotes is “Beauty is in the eye of the beholder, but so is ugliness”. What you or your ceramist might consider beautiful, your patient might consider ugly. That is why it is so important to involve the patient in the process. The patient should always be given options and alternatives so that they can make educated decisions. Make them aware of what the possibilities.
After proper diagnosed, specific tools can be used to support a consistent message between all of those involved The process can be optimized by utilizing the latest technology.
Creating an “illusion of reality” is the task at hand when designing a case. The market is saturated with materials that make this an attainable goal even with monolithic (no ceramic layering) restorations.
To maximize success there are critical tools that need to be used to enhance communication between the dentist, the patient and the dental technician:
- Preoperative models of both arches.
- Preoperative clinical images, A) Smile B) Retracted view with a shade tab of the natural colour shown with it.
- Image of the unprepared teeth with the existing colour shade tab next to them.
- Image of the desired shade tab next to the prepped teeth. The technician must know the shade of the prepared teeth so that the correct material can be used to fabricate the patient’s new smile. When using zirconia, a regular shade guide will not be a true representation of the shade that the zirconia will be. Custom shade guides made with zirconia, by the technician (Figs 1A & 1B) can give the patient the accurate shade to choose from.
- Image and a study model of provisional restoration.
- Image of the patient’s full face, straight on so that the forehead, both eye browns and chin are in the image with NO SLANT.
- Digital impressions or three or more accurate impressions. The reason for 3 impressions is that certain distortions in impression material are very smooth and unrecognizable to the eye until the impression is poured up. Then the technician can compare all 3 impressions for accuracy allowing for the best fit of the restoration.
- A list of the desired expectations of the patient as well as of the dentist.
Printing technology (Figs 2A, 2B) can be used in the lab to save the dentist, the patient and the lab time and money. Almost instantly and affordably, the patient can see what their new smile design will look like. This helps to avoid patient dissatisfaction and If any modifications are needed in the new printed smile, it is as simple as accessing the original digital file, adjusting, modifying and printing another one for try in prior to making the final restorations. It is a definite time-saver.
POP IN SMILES®
The Pop In Smile® is an important tool for communication. The benefit of the Pop In Smile® in the pre-treatment stage is to avoid patient dissatisfaction and enhance communication between the patient and the entire dental team. The patient can not only see, but in additive cases, can also “feel” what their new smile will look like in their mouth. It is very important that who ever will be fabricating the final restorations also make the Pop In Smile – otherwise the look may be very different. And remember, there is no right or wrong in aesthetics, just different opinions and the patient needs to be the one who makes this decision.
The patient in Fig. 3 wanted her smile enhanced. She is a fashion model and Miss Georgia USA winner, 2018. She felt that her teeth were too small for the size of her lips.
The first step is digitally designing her new smile vision and printing the removable Pop In Smile in a tooth shade material. This takes about 30 minutes and then you can get approval of the shape, length and the overall new look from the patient. (Fig. 4) This process is possible when we have more the 0.7 mm and no undercuts.
Solid Monolithic Zirconia
Multiple studies have proven the strength and longevity of zirconia and in certain clinical situations are ideal in transmitting light. They are also able to be highly polished to resist odors, staining and, in solid zirconia, chipping. However, not all zirconia materials are created equal. They are similar to ceramic powders in the fact that they are all purchased from the same manufactures, yet each technician ends up with different outcomes and get paid at different price points. We have come up with a digital solution and concept that creates a signature line with a more consistent, efficient style, while still being able to to keep the aesthetics and adding an excellent value and being able to serve more dentist and their patients.
Notice in Figs 5A & B we removed a failing implant retained bridge that was made with a metal frame and cemented single crowns with pink composite for tissue. This is a very popular treatment done today. The main issues with using plastic in the mouth is that plastic is porous easily retains plaque, stains and odors as you can see.
A full arch implant supported prosthesis cannot be removed by the patient. And since the patient is physically unable to access the concavities of the intaglio surface if a ridge lap design is done. The surface touching the tissue has to be as flat as possible.
Fig. 6A shows an improper design that is unclean-sable by the patient will eventually lead to failure.
Fig. 6B shows the smoothness of how the intaglio surface should be designed for optimal results.
When zirconia is highly polished and no ceramic is layered (except for the pink tissue), it will resist plaque and staining. Even the juncture of a minimal cutback in the the zirconia can stain.
Optimizing the aesthetics of solid zirconia after it has been milled and is in the “green state” (Fig. 7) when it is very soft, makes contouring and surface texture an easy possibility this is also the time for colouring the effects for characterization.
After the zirconia has been sintered at a high temperature for 9–16 hours and cooled, pink porcelain is then added to create the illusion of soft tissue (Fig. 8A).
In the hands of the right technician, the monolithic option is common and can be completely life-like in appearance as shown in Fig. 8B.
The process and protocol in fabricating large implant bridges is important to follow. If any step is missed or done wrong, the cost of redo is expensive and frustrating. If the impressions are not accurate and a verification easy bar jig was not provided, the implant bridge will break, because as strong as zirconia is, it is still very brittle before cementation and seating.
Taking a correct and highly accurate Index/impression is one of the keys to success. We recommend using Easy Bars and luting them together with either Duralay or a low shrinking composite for the most accurate impressions as shown in Fig. 9. Done the correct way, these EasyBar impressions are always precise.
It is essential to ensure the proper planning and a collaborative effort pre surgery so the proper space and vertical dimension will allow for the proper thickness thus creating a stronger final zirconia hybrid. (Fig. 10) Placing at least four and no more than seven implants also allow the distribution of forces to be optimal.
For most of our clients the first step after the healing with the conversion in place is a new design based on the patient’s likes and dislikes and a new occlusion scheme with printed PMMA (temporary) try in with pink wax for tissue.
The three steps to start our transformation is our “All In One” process are as follows: (Fig. 11)
- Connect the Easy Bars to titanium cylinders with duralay ensuring to capture the intaglio ridge with the light body material. (no tray is necessary with this system).
- Duplicate the conversion in a retainer box with light body and hard body.
- Take a bite registration.
- Take pictures of the conversion that can be super-imposed on exocad software during the laboratory designing phase.
You can watch videos of this full process at www.adar.net
After all the models have been mounted in articulation and all the data scanned and digitized wand then be super-impose the scanned data as well as pictures for a reference to create a new digital smile design with all the modification that are needed from the conversion dentures. (Figs. 12 A,B,C,D)
After printing the final new design from STL files, (Fig. 11) pink wax is added to simulate the gingiva for a try in process. New photos should be taken to insure the tissue is harmonious with the new smile.
After the try in and the adjustment to the bite and the intaglio ridge are made, the lab will then make the changes to the STL file and mill it in solid, high strength zirconia followed by manual shaping and texturizing Fig. 13 and then infusing the colour prior to final sintering. (As shown in previous example Fig. 7)
The final solid zirconia dual arch with all the details and the human touch to re-create a natural smile for our patient is shown in Fig. 14. Fig. 15 is a portrait sent to us from our patient who was very grateful and influential in spreading the word about the value of his life changing transformation and the power of a smile.
Savanah Miles Cover Case
The case that was selected for the cover of this Journal, truly demonstrates the impact that digital technology along with the human touch can transform patient’s lives in meaningful ways.
Savanah was competing for the Ms.Teen, USA but had to first win the title as of Miss. Teen Georgia, USA.
She was beautiful with a dynamic stage presents. She had small teeth with spacing and excessive soft tissue. Fig. 16
Our vision was to give her a more balance and attractive “power smile” to help her get the Miss Teen, USA title as she had dreamed of since she was a little girl.
After scanning and digitally designing a smile with Exocad software, we could not print a removable Pop In Smile® so we printed the model of the new smile and fabricate a silicone index (Fig. 17) with light body and hard body to reproduce the detail of our new design.
After the trying in the silicon index to ensure the fit, the dentist injected Luxatemp material in the silicon mold and “pops” it in the patients mouth. (Fig. 18)
After removing the silicon index, the patient can see her new smile vision with the PopInSmile. (Fig. 19)
After hearing the patients input, the dentist now has a guide in how much soft tissue to sculpt with the laser. (Fig. 20)
The dentist used depth cutter burs to create tooth reduction using the Pop In Smile as a guide and cutting through it.
After removing the PopInSmile (Fig. 21) you can see that the natural teeth were not touched, making this a prep-less case and ensuring that there is plenty of room to fabricate a beautiful smile. We confirm this by placing the removed PopInSmile with the reduction grooves on the pre-op model. (Fig. 22)
After the preps are finalized and the final impressions are taken the silicon index was used to fabricate the temporaries that will be exactly the same smile as we proposed with our PopInSmile. (Fig. 23)
After digitizing the preps we used the same .stl file for a reference for our final veneer design to ensure that we will deliver the final PrepLess veneers look just like the vision and then milled them with e.Max blue blocks MT OM2 . (Fig. 24)
After shaping and texturizing the blue block veneers contact points are then checked on a solid model making the final delivery easy for the dentist. (Fig. 25)
The next step is to clean them well and use the support tray to crystalize the blue blocks where, making the strength higher and bringing out the real colour. (Fig. 26)
After final glaze and polishing we check the final fit to make sure all the contact points (Fig. 27) are perfect before the final delivery.
The MT ingot has a nice translucency and picks up colour from the plaster stone as it does with natural tooth structure. (Fig. 28) Notice the difference in tooth length and tissue harmony
creating a more confident and powerful smile from using a conservative treatment with monolithic restorative solution. (Figs 29 & 30)
There are several things that are necessary for achieving aesthetics and ensuring that the patient can achieve proper oral hygiene. Proper diagnostic records containing existing conditions, specific pictures of the face, the occlusion, bone and soft tissue landscape and the patient’s desires for the final outcome are all components of an outcome that will ensure a happy patient.
The use and knowledge of different materials, depending on the case will also add to success.
However, one of the most important aspects of success is collaborating with like-minded team members who also understands that the “patient’s desires” are the key. High standards and a clear vision of what is possible will exceed your patient’s expectations. Nothing should ever be “good enough” It is essential to not become complacent because of technology.
It is our responsibility to bring life to our dentistry.
And our happy paying patients will become your messengers of hope to many other new patients and this will bring you more happy paying patients. Testimonials from your patients will drive your social media marketing and scale your business to serve more people. (Fig. 31)
Oral Health welcomes this original article.
Acknowledgements: A special thank you to the collaborating clinicians who believe in high-quality dentistry, fighting mediocrity, and becoming part of the team at Adar Dental Laboratory in sharing what is possible in CAD/CAM digital dentistry. The author would like to thank Dr Charlie Cooper, Atlanta GA for the case in 3, 4 and 16-30.
Dr Josh Branco, Las Vegas, NV case 6-8B.
Dr Brad Fulkerson, Amesbury, MA case 11-15 and 31.
Thank you also to the team at Adar Dental who looks forward (most the time) to working long, crazy hours, not only in doing cases, but inventing new ideas and products and and chasing the dream of affordable esthetics to share with the world. And to all of our partner dentists who become certified “Partners in Dental Excellence“ with LHDDS and Ibur Biosytems! Our lifelong committment is to be a beacon of hope in providing you and your patients with the best value and quality in solid monolithic implant hybrid restorations and smile designs with crowns and veneers to provide our patients a better version of themselves!
About the Author
Pinhas Adar is known internationally in the field of esthetic ceramic restoration as well as CAD/CAM technology. Founder of Adar Dental Laboratory and Adar Success Academy. Originally studying at Ort Yad Shapiro in Tel Aviv, Israel, completing his internship with Will Geller in Switzerland and then returning to Israel to complete his Masters degree in dental technology. He has over 44 years of experience in all phases of dental technology and has spent these years studying the principles of Smile Design and the impact of the psychological effects on patients. He has a private practice in Atlanta, GA.
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