DLI Plus

Vol. 2, No. 1 – February 2010

DLIPlusV2N1:Layout 1 2/9/2010 4:38 PM Page 1


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Palmeri Publishing

4EditorialEttore Palmeri, MBA, AGD, B.Ed., BA

6Shape and Surface DesignAndreas Piorreck, MDT

Don’t Fear Demanding Patients! Part IMarkus Stang, MDT

CE Credit Test 1 .................................................................................. 33CE Credit Test 2 .................................................................................. 34

Contacts

dental labor international plus – Vol. 2 No. 1 – February 2010 3

Contents and Contacts

12Zircon is not Always the SameShahab Esfarjani, MDT

28

22

Customized AbutmentsJosé de San José González, MDT


Ettore Palmeri, MBA, AGD, B.Ed., BA

ContactsEditorial

Let’s plan to leave a mark. We are in the midst of the holiday season and

I am sitting here in my home study as I amwriting this editorial for the February issue

of Dental Labor International Plus. I am enjoying myespresso and I am thinking how to structure mythoughts. At the same time I am trying to listen to whatArianna, my four and half year old daughter, is doingin the play room. My wife, Bahar, has gone out boxing-day shopping; Tommy Hilfiger, had a sale and despitemy warnings about crowds and false advertising, shehas ventured out.

I catch myself day dreaming and I refocus on the jobat hand. Mostly, I am thinking of about the importanceof having a vision and setting up the objectivesnecessary to achieve success in life and in business. Imust admit, though, it is not easy.

I realize that the bigger I dream, the more ourorganization grows, the more challenges I face as anindividual and as a team.

My mission in life is very simple. I want to helpdental professionals become extraordinary and theirbusinesses more successful by providing cutting edgeeducation in a different format. In turn, we can allmake the world a better place. This is not just abusiness to me, it is my vocation. But, the higher Ireach, the more I get tested. Sounds familiar?

But challenges are good. We grow when we facethem. The leaders among us smile in the face ofadversity. They know that life tests all of us, however,only the strong get to sing their heart song.

So, as we face 2010, I commit to embrace all thechallenges it will bring. I will consciously keep my eyesfocused on my mission. Because, I know this worldbelongs to dreamers like you and me.

In the end, it will not be important if we win everybattle. What is important is that we make a differenceto our world, and that is good enough for me.

Contacts

4 dental labor international plus – Vol. 2 No. 1 – February 2010

Editorial


Mail orders to: Palmeri Publishing Inc., 35-145 Royal Crest Court, Markham, ON L3R 9Z4 CanadaPhone orders: 905.489.1970 Fax orders: 905.489.1971 or order online at www.spectrumdialogue.com

Aesthetics and Techniques for New Materials

Achieving success for the Dental Team

This admirable and clear text is updated and enriched byan interesting and vast iconography which originated fromthe enthusiasm of two competent men who are experts in theirprofessions.

The cooperation between the two authors, dental technicianPaolo Smaniotto and Dr. Alexander Beikircher, has been afortunate one. Both have always managed to give theirprofessions a cultural impulse, seeking and finding, both in Italyand all over the world, renovating sources and worthy teachers,from whom they have drawn knowledge, advice and exchangeof ideas.

After so much effort, they have become cultural referencepoints over the last few years thanks to their conferences andbooks, now crowned by this valuable text.

This text is the keeper of decades of professional activity andconstant updating, thanks to which the authors have beenable to find a balanced mixture between theoretical conceptsand practical applications.

They have proposed recent topics of modern dentistry anddental techniques, comparing them with consolidatedmethodologies. They have also been able to elaborate anddescribe fortunate personal intuitions, further enrichingtheir work.

Through detailed descriptions, the authors have constantlyunderlined the fundamental importance of teamwork;premises to achieve success in the challenging prosthodonticsector are persistently pointed out in every chapter:competence, updating, good materials, adequate instrumentsbuy, more importantly, commitment, great responsibility,mutual respect and deep sense of collaboration.

This book represents the ‘future oriented state-of-the-art’, andI am confident that readers, neophytes and expertprosthodontists will derive many lessons from reading andconsulting the ‘Smaniotto - Beikircher’.

AuthorsPaolo Smaniotto, MDTDr. Alexander Beikircher

$179.00214 pages, 11.5 x 9.5 inches

“Attention is

the teacher of

every detail”


The initial situation was an insufficient bridgerestoration region 13 to 23 (Fig. 1). This restorationwas about one year old. The patient came to us

requesting an aesthetic enhancement: he disliked the color,the insufficient length of the anterior teeth and the factthat the restoration did not blend in with his natural teeth.He requested a new bridge. We decided on a Vita A2 veneerto give it a bright and natural characteristic without an age-based individualization in terms of color.

We chose Keramicgold P6 (manufactured by Goldquadrat)as the alloy. We did not use zirconium dioxide for thisrestoration due to the long span of the bridge. The facing wasdone with the refractory ceramic EX-3 manufactured by theJapanese company Noritake (Fig. 2).


Rationality and Efficiency

Shape and Surface DesignAndreas Piorreck, MDT

High quality, efficiency and rationalityshould not be in contradiction witheach other. Manual skills are stillessential when it comes to the designand the aesthetic result of a restoration.This is true even in times ofCAD/CAM supported fabrications.Designs created with rotary tools arestill an essential part of any restorationfabrication. We will demonstrate howeasy it is to use the Noritake MeisterPoint Set for the fabrication of aestheticrestorations.

Keywords: shape, ceramic, morphology,grinding, grinding tool, ceramic facing

Fig. 1: Initial state before the treatment. Notice the length of tooth 23. Itresulted in an uneven occlusal surface. Age of restoration: about one year


A wax-up helped us to determine the aestheticaspect and was the basis for the transformation inceramic afterwards. The metal-ceramic EX standsout due to its natural appearance. Figure 3 showsthe dentine core with a margin of enamel material,which guarantees a uniform distribution in theincisal third. The enamel compounds are appliedvery sparingly with this particular ceramic; theyhave the characteristics of an effect compound. An internalstain firing to individualize the dentine core was not necessary.Now we can finish the tooth shape with Luster material. TheseLuster materials reproduce the natural opalescence andfluorescence of enamel and are an important part of theNoritake EX-3 ceramic set. Figure 4 shows the prepared bridgeready for the final shaping. We should always aim for anaccurate modellation to avoid unnecessary rework.

Design

The Noritake Meister-Point-Set (Fig. 5) was especially designedfor the shaping of ceramic facings. It consists of dense sintereddiamond grinding tools, of which each guarantees long wearand durability. These grinding tools combine a high grindingperformance with the ability to create an ergonomic design.The polishing material Pearl Surface by Noritake incombination with mechanical polishing lets you achieve perfectsurfaces and a natural looking result.

Fig. 5: Noritake Meister-Point-Set


Fig. 2: Body and enamel core ready for the first dentine firing Fig. 3: Completion of the build-up with Luster compound

Fig. 4: Firing result ready for finishing

Fig. 6: Corrective adjustments of the contact points



Fig. 7: Marking of the pontic

I start with the contact points adjustment. For thisstep the elongated grinding tools are used; they aredesigned for this kind of work with their shape and

lateral f lanks (Fig. 6). Next, I place the bridge anddesign the pontic with a lenticular grinding tool DP 08(Figs. 7 and 8).

Fig. 8: Pontic reduction with a lenticular grinding tool

Fig. 9: Contouring of the palatal surfaces with DP 08 Fig. 10: With the help of the lenticular grinding tools the contouring inthe approximal surface is a breeze

Fig. 11: Even delicate structures can be created easily in thepalatal area.

Fig. 12: In order to achieve a tridimensionaleffect, the approximal surfaces need to becontoured



Fig. 13: Length adjustment with the DP 10 tool

Fig. 14: Marked surface structure

Fig. 15: My tools for the surface design: UP 71, DP 05,DP 01, DP 02

Fig. 16: Carbide bur for enamel fractures

Fig. 19: Applying of vertical structures

Fig. 17: Creating the vertical texture

Fig. 18: Creating and rounding off of the vertical structures

Morphology

Figures 9 to 13 show my approach for thecreation of a natural morphology. Differentkinds of grinding tools can be used. It isimportant to create a tridimensional toothshape; the contouring of the approximalsurfaces with the proper grinding tools is amust (Figs. 10 and 12).



The surface design isan important step whenfabricating an aestheticrestoration. It is oftennoticeable in seminarsthat this subject isoverlooked. Only withan appropriate age-basedsurface design can arestoration be integratedharmoniously in itssurroundings. With thehelp of a few tools and acouple of tricks, it ispossible to achieve asurface that is identicalto that of natural teeth(Figs. 13 to 20).

I use the Noritake Detail Checker (Figs. 21and 22) to check the created surface details.The Detail Checker enables me to noticesurface detail and color clearly before the glazefiring; it contains an oily substance, whichburns completely without leaving any residue.The surface texture should be a little thickerat this point.

After the glaze firing and the mechanicalpolishing, we finalize the surface texture andthe gloss level. The thick surface texture isvery noticeable for a 50 year old patient andhas to be corrected. After the glaze firing wepolish with Pearl Surface polishing material(Figs. 23 to 25).

Fig. 20: The Noritake Meister Cones are the ideal device for thereconstruction of perikymata

Fig. 21: Surface detail verification with the Detail Checker

Fig. 22: Noritake Detail Checker

Fig. 23: The result after the glaze firing Fig. 24: Mechanical polishing with Pearl Surface material



Conclusion

With the use of basic means an efficient andeconomic result is guaranteed. The NoritakeMeister-Point-Set allows us to create the shapeand surface structures of a ceramic facing withlittle effort. The result is an aesthetic pleasingceramic restoration. In combination with thepolishing material Pearl Surface and a mechanicalpolishing, it is possible to easily achieve theutmost aesthetic reproduction of natural effectspresent in natural surfaces (Figs. 26 to 28).

Acknowledgment:

The clinical images were done with the kind assistance of Dr.Kathleen Berger, Saxonia-Klinik Leipzig.

• CE Credit Test 1 on page 33

About the Author

Andreas Piorreck, MDTContact:Avantgarde Dentaltechnik GmbHStöhrerstraße 3b04347 LeipzigTel. 0341-6964043Email: [email protected]

Fig. 26: Before…Fig. 25: The Pearl Surface Set

Fig. 27: …and after

Fig. 28: A pleasingresult



The patient, whose case we are documenting,introduced herself with the following words:“Good day, are you the person who will do my

teeth? You must know that I do not want beautiful teeth;I prefer my teeth to be crooked! Do you understand whatI mean? I do not want to be beautiful; I prefer to beunique because that is me: I am unique and my teethshould be unique as well.”

Good Planning with a Special Touch

Don’t FearDemanding Patients! Part IMarkus Stang, MDT

“That is a very difficult patient” is acommon excuse when a restorationis doomed to fail in spite ofintensive efforts or it does not meetthe patient’s expectations. Why aresome patients so hard to please? Ishe/she too demanding? Was poorplanning the reason or maybe theinflux of information could notkeep up with the currentfabrication process? There might becountless reasons but one thing issure, the reason for failure does notlie with the patient. In this article,Markus Stang points out ways inwhich even sophisticated patientscan be satisfied because specialdemands require special methods!

Keywords: CAD/CAM, frameworkdesign, ceramic, long-term prosthesis,mock-up, facing, wax-up

Fig. 1: This patient has the highest standards: most of her teeth are missingbut she requests a fixed prosthesis



Findings

Large interdental spaces from 22 to 13 aswell as 16 and 36, minimal spacing, a patientwith very high standards and very detailedwishes (Figs. 1 to 3). In the mandibula wedecided on a zirconium oxide bridge and inthe maxilla we preferred a fixed restoration aswell. Due to the large interdental space thedentist chose a solid gold alloy.

Case History

The patient had already lost some teeth at anearly age and had since then receivedtreatments with fixed restorations. So far onlyone bridge was satisfactory. However, it had tobe removed since yet another abutment toothwas lost. We used this bridge as a guideline(Figs. 4 and 5).

The patient insisted that none of theprevious dental technicians ever dared to placecrooked teeth in the gap. We decided to acceptthe challenge!

Fig. 2: We have to place 5 pontics in this large interdental space Fig. 3: Limited space complicates our work

Fig. 6: With the patient’s wishes in mind, we created a wax-up in the lab Fig. 7: The position of the teeth was determined by the patient beforehand

Fig. 4: The existing bridge had to be removed because an abutment was missing

Fig. 5: The present restoration was not “crooked enough” according to the patient



Wax-up

The detailed wishes of the patient were recorded, impressionsfor the sit model and the saw model were done, photos weretaken and drawings were created. We set up an appointmentwith the patient for the aesthetic fitting. We wanted topropose shape and positioning of the teeth and discussadditional details.

A wax-up was prepared in the lab according to the patient’sideas (Fig. 6). She gave us precise instructions regarding theposition of each tooth (Fig. 7). The palatal and occlusalsurfaces were designed as close to natural dentition as possibleand aligned harmoniously with the mandibula (Figs. 8 to 10).The tooth shape had to be optimized at the same time. Theentire restoration had to be very unique and have an overall“true to nature” color appearance (Figs. 11 to 13).

Fig. 8: The palatal surfaces were designed to look natural and to befunctional

Fig. 9: The posterior teeth all line up harmoniously

Fig. 10: The artificial teeth seem to “grow” out of the edentulous jaw Fig. 11: The shape of the teeth matches the patient’s overall look

Fig. 12: The marginal line was designed individually, tooth by tooth Fig. 13: It is hard to tell that only a few abutments are left, even from theside view



In order to get a better idea of the spacing situation ofthe overlapping anterior teeth we presented the patientwith a design made of artificialteeth (Fig.19). After getting thepatient’s approval, we transferredthe result in the lab to the wax-up.The following images show thechanges done after the first trialfitting (Figs. 20 to 23).

For the second fitting, we createdan acrylic mock-up of the newsituation (Fig. 24). The patient wasthrilled with our design (Figs. 25 and26) and a happy smile confirmedthat our efforts paid off.

Fig. 14: For the first fitting the wax-up is transferred into acrylic

Fig. 19: We did not want to confuse the patient and evaluated thesituation with the help of a wax-up

Fig. 17: The first fitting reveals that the invisibility of the teeth isunsatisfactory. Tooth 12 is almost covered by the lower lip

Fig. 18: The side view reveals that the entire anterior area is too short, theindividual characteristics are not visible

Figs. 15 and 16: We now have to create details and pay special attention to the parodontal space

The First Fittings

Deep draw foil was used to transfer the anterior area intoacrylic and tried in the mouth as a mock-up (Figs. 14 to 16).At the first fitting appointment the patient was notsatisfied; she found the teeth too short and not crookedenough (Figs. 17 and 18). Even with setbacks like these wehave to stay positive and fix it on the spot to assure thepatient that his/her wishes can be realized perfectly.

Fig. 15 Fig. 16



Fig. 20: The adjustments are transferred into the wax-up Fig. 21: The front is lengthened by 1.5mm and the basic shape of the fourincisors is changed considerably

Fig. 22: The patient emphasized again that the anterior teeth shouldoverlap more and have a more unique look

Fig. 23: The palatal surfaces were adjusted aesthetically and functionally

Fig. 24: The new situation is transferred into acrylic with the help of a deep draw foil

Fig. 25: The visibility of the anterior teeth has improvedsignificantly. The individual characteristics are much morenoticeable

Fig. 26: Despite the prominent positioning of the teeth, we achieved aharmonious lip/teeth appearance



The Prosthesis

Our next step was the fabrication of along-term restoration with the possibilityof making necessary adjustments evenafter a few weeks. We decided on a metalreinforcement. It had to be cost-effectiveyet fit perfectly under the modeled teeth.With these prerequisites in mind, Idecided on a titanium bridge milled withthe Kavo-Everest-System. This way I didnot need to worry about an accurate fitfor this wide-span bridge.

Figs. 27 and 28: The models and each stump are scanned with the Scan-Pro and transferred to thecomputer

Fig. 29: The fabricated mock-up replaces themush-bite as a counter-bite. We spray it withocclusal spray and scan it as well

Fig. 31: All areas that are not part of the wax-up have to be removed

Fig. 30: We get an accurate image of the wax-up in the computer

Fig. 32: This way the individual componentscan easily be faded in and out duringconstruction

Fig. 34: A 3D cross line lets us position thepontics with ease in the specified space

Fig. 33: From the start, the pontics were notperfectly created under the wax

Fig. 35: The pontics can be rotated, bent,moved and their dimension changed

Fig. 36: The wax-up can be opaque ortransparent in color. It helps with theevaluation of individual positions

We started by scanning the modelsand the individual stumps with theScan-Pro (Figs. 27 and 28). I used thealready fabricated mock-up as a counterbite in place of a mush-bite, misted itwith occlusal spray and then scanned itas well (Fig. 29). The result is a perfecttransfer of the wax-up into thecomputer program (Fig. 30).



Figs. 37 and 38: In the cross section view, we can see the position of the ponitc very clearly

Fig. 39: These three different views let useasily look at each pontic

Fig. 41: The connection bars can be finishedin no time with little effort just like the pontics

Fig. 40: The pontic in the posterior area canbe placed effortlessly

Fig. 42: The dimension of the connectors canbe changed in any direction with or without across section design

Fig. 44: Even the individual caps can bechanged in their dimension

Fig. 43: Point-and-click and the selected crosssection is transferred to the other side

In order to properly import the virtual wax-up, allsurrounding areas have to be removed (Figs. 31 and 32). Thisway the individual components are easily faded in and outduring the construction.

Unfortunately, the pontics are not properly constructedunder the wax-up (Fig. 33). With the CAD-software thepontics can be placed effortlessly in the specific situation withthe help of a 3D cross line (Figs. 34 to 36). They can berotated, bent, moved and their dimension changed. In thecross section view the position of the pontic under the wax-up

is clearly visible (Figs. 37 and 38). The three different views ofthe object enabled us to look at every pontic separately (Figs.39 and 40). We were able to work on the pontics and theconnection bars individually (Fig. 41). The dimension may bechanged in any direction and if needed an individual crosssection shape can be determined. The cross sectiondimensions of the connector are always available. The dataand the bar turn red if the predetermined minimumdimension reaches a low point (Figs. 42 and 43). Thedimension of each cap can also be adjusted (Fig. 44).

Fig. 37 Fig. 38



Fig. 45: The finished construction under theopaque wax-up

Fig. 47: The finished construction withoutwax-up

Fig. 46: The finished construction under thetransparent wax-up

Figures 45 to 47 show the finished construction with andwithout the scanned-in modellation.

The titanium bridge can be placed on a blank by itself.Any unused space is saved on the computer and lets us milladditional bridges or crowns on the same blank in thefuture (Fig. 48). The computer helps with the cutting task as

well, except for a few bars the machine cuts the bridge aftercompletion from the blank, therefore reducing the finishingtime! Conclusion: with little effort we achieve a custom-fitframework (Figs. 49 to 51).

The deep draw foil can be placed on the finishedframework (Fig. 52). The tedious cutting and grinding of

Fig. 48: The position of the titanium bridge on theblank is saved on the computer so that additionalbridges or crowns can be milled in the future

Figs. 49 and 50: With a little effort, we created a custom-fit titaniumframework. The tedious cutting and grinding of sprues is therefore eliminated

Fig. 51: The same result on the unsawn model, a perfect fit, no distortions,no bubbles

Fig. 52: The deep draw foil can easily be placed on the finished framework

Fig.49

Fig.50



Fig. 54: In the second step, the dentine was reduced and individualized

sprues is therefore eliminated. The over pressing of theframework with tooth colored acrylic specially designed forprostheses is now a breeze (Fig. 53).

In the second step, the dentine is reduced andindividualized (Fig. 54). A second pressing with transluscentacrylic finalizes the procedure (Figs. 55 and 56). We payspecial attention to the edentulous jaw section during thefinishing process of the long-term prosthesis. Usually weencounter an epithelia resilience of up to 1.2mm in theanterior maxilla but not in this case. The gingiva section inthe anterior interdental space is very tight and is attachedfirmly to the jawbone. The marginal run of the fiveconnecting units has been designed uniquely and shouldintegrate harmoniously even under poor conditions. Weslightly outlined the run border on the cast model. Withthe help of the long-term prosthesis the anterior gingiva areacan be molded uniquely. After a three months wear of theprosthesis a significant improvement is noticeable: themarginal anterior teeth area has perfectly molded itself intothe gingiva (Figs. 57 and 58).

…to be continued in the next issue.


Fig. 53: Opaquer was applied to the framework and pressedwith a special tooth colored acrylic for prostheses

Figs. 55 and 56:An additionalpressing withacrylic lets therestorationappear verynatural even atthis stage

Fig. 57: The wear of the long-term prosthesis should form a thin sulcus inthe edentulous jaw portion

Fig. 58: After a three months wear of the long-term prosthesis: a noticeableimprovement!

About the Author

Markus StangContact:Carl-Orff Str. 1569214 EppelheimTel.: 0151 14183352Email: [email protected]

Fig.55

Fig.56


TRICKS and HINTSAuthor: Gérald Ubassy, 216 pages, 10” x 12”, hard cover with over 1000 photographs. Price: $259.00 plus S&H. For more information please visit www.spectrumdialogue.com

SURFACE TEXTURES - The Theory of Surface MarksAuthor: Giuseppe Spina, 96 pages, 8 3/8” x 9 3/8”, glossy hard cover with full colour images. Price: $99.00 plus S&H.For more information, visit www.spectrumdialogue.com

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ESTHETIC GUIDE BOOKAuthor: Luke S. Kahng, 60 pages, 9” x 11”, hard cover with full colour images.Price: $99.00 plus S&H.For more information, visit www.spectrumdialogue.com

THE INCISAL EDGE: The Strong Point in the Expression of an IncisorAuthor: Attilio Sommella, 176 pages, 8” x 10”, glossy hard cover with full colour images. Price: $139.00 plus S&H.For more information please visit www.spectrumdialogue.com

ANATOMY FROM NATUREAuthor: Luke S. Kahng, 62 pages, 11” x 9” x .5”, hard cover with full colour images. Price: $99.00 plus S&H.For more information, visit www.spectrumdialogue.com

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AESTHETIC & RESTORATIVE DENTISTRYAuthor: douglas A. Terry, DDS, 770 pages, 8.5” x 12”, glossy hard cover with full colour images. Price: $330.00 plus S&H.For more information please visit www.spectrumdialogue.com

Mail orders to: Palmeri Publishing Inc., 35�145 Royal Crest Court, Markham, ON Canada L3R 9Z4Phone Orders: 905. 489.1970 • Fax Orders: 905. 489.1971 • Online Orders: www.spectrumdialogue.com



CAD/CAM – Intelligent Outsourcing

Zircon is not Always the SameShahab Esfarjani, MDT

In the meantime CAD/CAM generatedzirconium restorations are a standardfeature at many dental laboratoriesworldwide. In coming years the wax knifewill be replaced more and more by the PCmouse, however the dental technician's taskof designing dental prostheses in an idealmanner will remain the same. ShahabEsfarjani has been working with thematerial zirconium dioxide since 2002 andhas gained a great deal of experience withthis material by processing almost 1900units. He places a particular emphasis onthe natural aesthetics of his work.

Keywords: CAD/CAM, Outsourcing,Quality assurance, Scanner, Software,Processing, Zirconium dioxide

Why Zircon?

Metal ceramics are a sound basis for aesthetic restorations,regardless of whether they are used for individual teeth orbridges. We have achieved excellent results with them overmany years. But times change. The divide between patientswho can afford high-quality prostheses and those who canonly draw upon health insurance has grown considerably.One can increasingly see that the requirements and desires ofpatients have changed in the field of aesthetic dentistry.Many patients wish to have an aesthetic, pleasant smile, notonly at work. Such results cannot be achieved withconventional metal ceramics, since they are not transparentand can therefore not be used to copy the naturalcharacteristics of teeth, such as translucency, opalescence ornatural anisotropy, just to name a few. In addition to thesefacts, the price of alloys has increased considerably, whichmeans one has to select and calculate the material carefully.

What is Zircon?

Zircon is the oldest and most common mineral in theearth's crust. Its age is estimated to be approximately 4.4billion years and it belongs to the silicate group (chemicalformula: ZrSiO4). Its natural colour varies between goldenyellow, red, brown, green and blue up to black (Fig. 1). Itwas discovered by the German chemist Martin HeinrichKlaproth in the year 1789. After years of development andusage in medical science, for example for artificial hipjoints, it is now also used in dentistry. Zirconium dioxide isdistinguished for its excellent material properties:

• CET: 10.2• Density: 5.7 g/cm3• Melting point: 2680 C°• Boiling point: 5000 C°• Flexural strength: 1400 mpa

Fig. 1: Zircon rock



What is Quality?

According to a report of the American Dental Association(ADA), leaded compounds have been detected in fullyceramic dental prostheses and in alloys manufactured inChina. These "grey products" also include, for example,ZrO2 blanks (Fig. 3) without retraceable sources andwithout quality assurance, often even with a fake CE labelor brand signet. Faulty grain structures had causedporosity and shape distortions af ter sintering andsubsequent fractures. This has put the reputation ofzirconium dioxide at stake, and likewise the trust betweenthe dentist, patient and laboratory. The "Geiz ist geil(thrifty is nifty)" mentality has become a trend. To savecosts, materials from indefinable sources are processed.

But how can you protect yourself from cheap materialsand quality risks? The dental practice and dentallaboratory are responsible for quality assurance andclinical and technically perfect restorations, which is whythe usage of brand products should be ensured alreadywhen placing orders. You will not put the patient's healthat risk and will maintain the mutual trust between thedentist, patient and laboratory if these materials areprocessed appropriately.

Trust is Good, Control is Better.?

Quality control centres regularly check the quality of theproducts and subject them to numerous endurance tests,which put them under a greater strain than that caused byeveryday life. Certified products, such as those fromStraumann, are checked regularly by independentinstitutes. In addition, numerous internal qualityassurance and inspection measures are taken to ensurebest-possible reproducible production quality. Thematerial structure is essential for f lexural strength andlong-term durability. Continuity can be ensured only byconstant quality control, up-to-date studies and carefulprocessing.

Processing Step

Powder

Compression

Pre-sintering

Processing

Staining

FinalSintering

Processing Parameter

• CO precipitated (withmost types of powder)

• Mixed oxide process• Grain size (0.07–0.3 μm)• Spray drying and

organic additives

• Axial compression• Pressure (800–3000 bar)• Isostatic compression• Clean room (no faults

due to air pollution)

• Temperature• Duration

• Fluids• Pigments (part of

powder processing)

• Duration• Temperature

(1360 – 1530°C)

Clinical Properties

• Transparency• Strength• Durability• Sintering behaviour• Hydrolytic stability

• Strength• Margin fit• Transparency

• Processability• Margin fit

• Margin fit• Strength• Transparency• Durability

• Strength• Transparency• Durability• Hydrolytic stability

What is the Difference?

There are two types of zirconium oxide:pre-sintered and hipped (HIP = hotisostatically pressed) zirconium dioxide.The pre-sintered type is milled and thenre-sintered again in order to obtain itsfinal density. The HIP material is milledin fully sintered condition. Theproduction process also has a greatinfluence on the quality of the material(Fig. 2). The strength, margin fit,millability, long-term stability andtransparency of the material areinfluenced by:

• Different types of zirconium dioxidepowder

• Compression methods andcompression conditions

• Zirconium dioxide staining procedure• Pre-sintering conditions

Fig. 2: Production process

Fig. 3: Blanks



have to wait on suppliers and milling centres. The marketquickly changed in the following years, the degree ofprecision was improved and the variety of materialsincreased. In other words, our system was now outdated!

With a scanner with up-to-date software, you are alwayson the innovative side and produce reproducible results ofhigh quality, even if you have to rely on suppliers (Fig. 4).

Software and Scanner

I saw the Straumann CAD/CAM scanner at a colleague'spractice. The perfect results and the quick productionpersuaded me to work with this system myself. We are nowable to work with all customary materials: zircon (Fig. 5),aluminium oxide, titan, CoCr alloys (Fig. 6), plastic and glass

Outsourcing

Advantages:

Disadvantages:

• Flexible• Innovative• Low staff and

qualificationrequirements

• Staff motivation• Open for all

customary materials• No system required• No maintenance

and repair costs• Independent from a

technical point of view• Low capital

commitment• Low risk of failure

• Time loss• Shipping costs• Reliability of the

suppliers

In-house Production

• Marketing tool• Independent of

suppliers• Quick in

production• Economic in the

event of highutilisation

• Shipping costssaved

• Very high capitalexpenditure

• Shifting of thepersonnel costs

• System requirement• Low flexibility• Technical risk• Maintenance and

repair costs• Expensive blanks

Why Outsourcing?

The constantly increasing modernisation andmechanization in the field of dentistry alsoconstantly raise more questions: CAD/CAM– yes or no? Which scanner or which copymilling device? In-house production oroutsourcing? What are the decisive criteriafor my decision? The increasing use ofcomputers in the field of dentistry is, ofcourse, fascinating and also a welcomechange from usual day-to-day work. However,staff must be trained for each newaccomplishment.

From my own experience, I can confirmthat new equipment is not always beneficialand does not always increase production.Several years ago I bought a semi-automaticcomplete system. At the time the device wasthe ne plus ultra. However, the indicationswere limited and the frameworks had to bemodelled conventionally first. They werethen clamped into an automatic copy millingdevice, scanned, milled and subsequentlysintered. They did not fit perfectly, whichmeans a great deal of time was spent onsubsequent refitting. The disadvantages areobvious: no time saved at the technician,costs for maintenance of the system (blanks,electricity, milling cutters etc.), limitedindication, limited utilisation of the system.The only advantage was that one did not

Fig. 5: Zirconium framework Fig. 6: Metal framework

Fig. 4: Outsourcing versus in-house production



fibre reinforced polyamide for provisional solutions. Theoperation of this software does not require any great EDPskills. However, one should take the time to receive detailedinstruction in the software. The laser scanning technologyworks extremely precisely and records all surface data of theprepared tooth stumps and the remaining teeth, and thepreparation limit is identified automatically. Parameters suchas the cement gap, ceramic support, wall thicknessreinforcement or porcelain shoulder can be set separatelywithout any difficulty. The convincing software allowsframeworks to be produced with up to 14 elements, primaryparts or customised abutments. The modelled framework canbe modelled and checked from any angle. Regular updateskeep the software up-to-date and the indication width isconstantly extended.

Bridge Construction

Based on the work for a patient, I will now describe theproduction of a framework for a front teeth bridge from 13to 23 with additional supports 11 and 21. For the automaticidentification of the preparation lines, all stumps below thepreparation edge must be under-chamfered considerably(Fig. 7). The project is then set up with the patient andpractice ID, number of supports, pontic, ceramic support,colour of the framework etc. Once the work has beenscanned (Figs. 8 and 9), the stump and preparation limit arechecked and the push-in direction defined (Fig. 10).

Fig. 7: Initial situation of front dental bridge

Fig. 8: Scanning Data

Fig. 9: Scanning data after automatic preparation identification

Fig. 10: Determining the push-in direction



The software can be used to create a full model within aminimum amount of time (Fig. 11), which is then reduced inorder to obtain a perfect ceramic support (Fig. 12). To avoidsubsequent trouble due to chipping, the frameworks must bedesigned in a hump-supporting manner. The festoons used tosupport the veneer ceramics should also not be forgotten (Figs.13 and 14). This was described very well in the article by KarlChristian Adt (dental labor 3/2009). Finally the connectorsare checked again, and then, the entire data is sent to themilling centre via the Internet (Figs. 15 and 16). At the latest,after 72 hours, you receive the finished work, which is placedon the stumps with ease and fits one hundred percent (Fig. 17).

Fig. 11: Full model Fig. 12: Reduction by the amount of x

Fig. 13: Design of the festoons Fig. 14: Festoon (ceramic support)

Fig. 15: Finished model


Conclusion

My experience and the points I have made in this article haveled me to cooperate with the Straumann CAD/CAMproduction centre in Leipzig. The advantages are obvious tome. The software pays attention to slightest inaccuracies andminimum thicknesses of connectors or caps already duringthe modelling process, which are subject to strong deviationsduring manual production. Human errors are ruled outmore and more by the central production. The millingmachines work completely vibration-free and so precisely thatthe maximum positional deviation is 0.001 mm. We can onlybe reliable and trustworthy if we work precisely atreproducible quality.

Sources:

• Prof Dr D.Edelhoff, CAD/CAM Technologien und innovative Werkstoffe(CAD/CAM technologies and innovative materials). www.dental-online-ommunity.de

• R. Riquier (master dental technician), Ohne Limits – Auswirkungeninnovativer CAD/CAM Systeme (Without limits – effects of innovativeCAD/CAM systems). www.dental-onlineommunity.de

• Ch. Thiesen, U. Heermann, Outsourcing versus Inhouse-Fertigung(Outsourcing versus in-house production). Quintessenz Zahntech2008;34(7):879-883


Fig. 16: Milling machines

Fig. 17: Finished framework on model

About the Author

Shahab EsfarjaniAl dente – Oral Design-Center IdsteinHöhenweg 1065510 Idstein, GermanyTel: +49 (0) 61 26 - 22 71 37Email: [email protected]

After passing his A-levels, Shahab Esfarjani completed a three-year training course as dental technician in Helmstedt in 1984. He then gained practicalexperience at different laboratories, including employment as a dental technician in New Zealand from 1986 to 1989. After successfully attending theschool for master dental technicians in Dusseldorf, he opened the dental laboratory Al dente in November 1993, where he produces ceramic front andside prostheses with the focus on functionality and naturalness. He has been a technical consultant of the companies Servo Dental and WohlwendCeramic AG in Liechtenstein since 1998 (Vision Ceramic). In 2001 his laboratory was renamed "oral design-Center Idstein", which means Esfarjani isone of five oral designers in Germany. He became a consultant of the company Creation Willi Geller International in Switzerland in 2001 too. Hepublishes regularly in scientific journals and holds lectures and courses in India, New Zealand, Iran and the United Arab Emirates. In February 2004he opened a second laboratory in Dubai called "Center Dubai" for aesthetic front tooth restorations and training courses for Willi Geller Creation. Hehas been a member of the international oral design group since 2007. Opening of EDC Esfarjani & Partner Dental Concept in 2009.



The basis for an aesthetic and functional optimal result

Customized AbutmentsJosé de San José González, MDT

Keywords: Abutment, CAD/CAM,Implant Construction, CustomizedAbutment, Set-up, Software

Limitations of Conventional Abutments

The use of prefabricated abutments is often labor intensiveand costly when we deal with difficult cases and when theresult we wish to achieve should have a high level of function,aesthetics and durability. Customized abutments like the onesmade by Atlantis, on the other hand, are designed withoutthe need for grinding and adjusting and even in the mostdifficult cases optimal treatment options are available to us.One particular challenge that we have to face quite often inour daily work in the lab, for example, is an implant that wasnot positioned properly prosthetically because the structure of

the jawbone might have prevented it. In such cases thetechnician is required to find an appropriate prostheticsolution that lets him achieve a good and durable overalltherapeutic result.

The limitations of conventional abutments as illustrated isbased on the case of a patient who received two implantsystems , which had been placed divergently in completelydifferent directions (Fig. 1). In this case castable abutmentswere used. It was possible to create a common insertiondirection for a screw-retained bridge (Fig. 2). This approach,however, is not only costly and time-consuming but alwayscarries the risk of failure due to misfit or miscast. Even with



an apparently perfect fit it can happen thatcontinual applied pressure due to occlusalforce causes problems that lead tounphysiological load increase.

With customized abutments, which werefabricated with the help of modernCAD/CAM technology, we achieve a resultwithout much effort even in difficultconditions. The result meets the intraoralsituation as well as the patient’s generally highexpectations of function and aesthetics. As wedemonstrate in the following examples, it isnot important whether zirconium oxide ortitanium is used or whether the space closureshould be done with single crowns or a multi-unit restoration.

Practical Approach

In the maxilla of our patient three implants in position 13,14 and 16 had been inserted previously (Fig. 5), which weresupposed to receive single crowns with a mesialisation of 16.With the impression taken by the dentist, in this case aclosed impression, an implant model made of dental stonewith a removable flexible gingival analog was fabricated(Fig. 6).

In the next step, we created a set-up consisting of artificialteeth with proper occlusion and articulation, which will serveas the basis for the individual structures later on (Fig. 7). Here,it is very important that the set-up is removable and strongenough to be scannable on the model as well as individually.

The implant model, the articulated set-up and the counter-bite model were afterwards mailed in free-of-charge shipping

Fig. 1: Two implant systems placed divergently in different directions Fig. 2: A time-consuming solution: castable abutments

Fig. 3: Even angle-formingabutments are not anoptimal solution

Fig. 4: The implant position does not matchthe abutment angle

Fig. 5: Three maxilla implants that are supposed to receive single crownsFig. 6: Implant model with removable flexible gingivalanalog



boxes to Astra Tech in Sweden, where the models werescanned and the necessary data recorded with the help of apatented 3D process.

Based on this virtual model, which reproduced thesituation in the patient’s mouth in detail, specialistsdesigned the abutments in their desired form with the aidof the software Atlantis VAD (Virtual Abutment Design).They proceeded in a manner similar to the grinding of atooth by taking the shape of the finished crown anddesigned the abutment accordingly (backward planning).Just how the connection between implant shoulder and

artificial crown matches the conditions in the patient’s jawand to which extent his wishes were meeting his needs isclearly evident in the run of the preparation border as wellas in the overall shape.

The finished virtual model images are sent via email tothe dental technician afterwards for verification. Only ifhe approves the design will the abutment be fabricated(Figs. 8 to 10). In this illustrated example the ceramiccopings were created with the aid of the CAD/CAMsystem and afterwards fitted with a ceramic facing(Figs. 11 and 12).

Fig. 7: Set-up with artificial teeth Fig. 8: Model with prefabricated abutment made of zirconium oxide and matrix

Fig. 9: A custom fit: abutment shape and the run of the preparation border Fig. 10: The custom fit zirconium abutments are ready for the trial fitting

Fig. 11: Ceramic copings fitted with ceramic facing Fig. 12: The finished restoration in the patient’s mouth




Free Choice of Material and Surface Design

Atlantis abutments are uniquely designed and areavai lable not just in z irconium oxide but a lso intitanium. To demonstrate this further: the patient hadfour implants in position 11, 13, 21 and 23 placed in themaxilla for a multi-unit restoration (Fig. 13). Whenconstructing the set-up it is important to pay attention tothe size and shape of the teeth and worry less about the

precisely modeled interdentium (Fig. 14). An abutmentmade of t i t anium is preferable in this case. Thetechnician may chose between a machined and aretentive surface. In this case, we decided to go with theretentive one because the cement bonds better with thiskind of surface (Figs. 15 to 17). Afterwards, a ceramicsupported zirconium framework was created, milled andf inal ly the individual ceramic facing was applied(Figs. 18 to 20).

Fig. 13: Four implants in the maxilla that are supposed to receive a bridge Fig. 14: The set-up

Fig. 15: Titanium abutments Fig. 16: We choose a retentive surface

Fig. 17: The verification of the individual abutments in the model Fig. 18: Model with a ceramic supported zirconium framework and matrix



Conclusion

A modern computer supported design of theimplant prosthetic restoration plays animportant role in the improvement ofaesthetic results. Optimal fit as well as goodmaterial properties and durability areessential preconditions for a perfect result inthe work of any dental technician. The combination offunction and aesthetics turns a technical fabricated implantprosthetic reconstruction into a superior product. TheAtlantis VAD-Software solution provides the possibility ofcreating abutments based on the ideal crown situation, whichconforms to patient-specific requirements. Due to theadjustment of the abutments to the intraoral situation it ispossible to achieve, furthermore, an ideal anatomicalemergence profile. The fact that the Atlantis abutmens areoffered in zirconium oxide, titanium and titanium nitrideand that they are available for all major implant systemsguarantees a high degree of flexibility.

Sources:

• Prof Dr D.Edelhoff, CAD/CAM Technologien und innovative Werkstoffe(CAD/CAM technologies and innovative materials). www.dental-online-ommunity.de

• R. Riquier (master dental technician), Ohne Limits – Auswirkungeninnovativer CAD/CAM Systeme (Without limits – effects of innovativeCAD/CAM systems). www.dental-onlineommunity.de

• Ch. Thiesen, U. Heermann, Outsourcing versus Inhouse-Fertigung(Outsourcing versus in-house production). Quintessenz Zahntech 2008;34(7):879-883


Fig. 19: Fitting of thefinished bridgewith individualceramic facing

Fig. 20: Finished

restoration withgingival analog.

About the Author

José de San José González, MDTGonzález ZahntechnikHauptstraße 4c69469 WeinheimTel: 06201 340013Email: [email protected]

José de San José González, MDT, born 1964, did his dental technician training from 1982 to 1986 at the Strubel-Zahntechnik laboratory. Afterwardshe worked in different departments in various laboratories, for example, as department supervisor and laboratory manager. He received his master’sdegree in 1994 from the Chamber of Trade in Karlsruhe. He started his own business in 1999 in Weinheim on the scenic “Bergstraße”. José de SanJosé González is involved in the training of dental technician trainees at the master school in Karlsruhe. For 15 years he has been a consultant fordentists and dental technicians in the field of functional analysis and communication skills between clinicians and laboratories.


1. Which of these should not be in contradiction with each other?A. Quality, efficiency and rationalityB. Time, rationality and qualityC. Efficiency, rationality and materialsD. Quality, efficiency and time

2. Which skills are still essential for aesthetics?A. Good CAD/CAM equipmentB. Good eye for colourC. Good manual skillsD. Good communication

3. What helped determine the aesthetic aspect?A. A good pre-op modelB. A photographC. A computer imageD. A wax-up of the case

4. What was not necessary in order to individualize the dentine core? A. A try-in of the wax-upB. Internal stain firingC. External stain firingD. Grinding the surface

5. What is considered an important step when fabricating an aesthetic restoration?A. The amount of times the crown is bakedB. The amount of internal stainingC. The amount of external stainsD. The surface design

6. What is the most common excuse for case failure?A. The dentist did not have enough room.B. The patient was very demanding.C. The material selection was wrong.D. The doctor selected the wrong shade.

7. Why did the patient request crooked teeth? A. Because she thought she would be beautiful.B. Because she said she was unique.C. Because she wanted to pay less.D. Because she thought they would be done faster.

8. What did the patient find at first fitting?A. That the teeth were perfect.B. That the teeth were too short and not crooked

enough.C. That the teeth were too long and too crooked.D. That the color was wrong.

9. What is the usual epithelial resistance encountered?A. Up to 2 mmB. 1.5 to 2.5 mmC. Up to 1.5 mmD. Over 3 mm

10. Which alloy was selected as reinforcement?A. Silver palladiumB. High noble alloyC. Metal free restorationD. Titanium alloy

Each article in this continuing education series is worth 0.5 credit from the NBC. To get your Scientific CE credit for this article, circle the correct answers to the questions on the short test below. The correct answers can be found within the text of the article.

Then simply complete the form and submit it to Palmeri Publishing Inc., to receive your credit. It’s that easy!

Questions for: Shape and Surface Design by Andreas Piorreck & Don’t Fear Demanding Patients! Part 1 by Markus Stang

TEST FOR NBC & RDT CREDITSdental labor international plus – Vol. 2 No. 1

Once you have completed the questionnaire, fill out the information below. You can photocopy this form.Then simply complete the form and submit to Spectrum dialogue online at www.spectrumdialogue.com

or by fax to 905-489-1971. It’s that easy!

In order to receive credits, you must be a subscriber to dental labor international Plus.

Subscriber Name: __________________________________________________ Phone #: _______________________________________

Address: ___________________________________________________________________________________________________________

Email: ___________________________________ CDT or RDT #: ________________________ Signature: __________________________



1. HIP refers to ...A. zircon used in hip replacement.B. hot isostatically pressed zirconia.C. hot inverted porcelain.D. soft pre-sintered zirconium.

2. What contaminant has been found in ceramics out of China?A. ZincB. SandC. SiliaD. Lead

3. In the past what was a lot of time lost being spent on?A. Refitting the ill fitting work.B. Setting up the CAD/CAM scanners.C. Doing wax-ups.D. Discussing the case.

4. With exception to EDP skills, what is recommended? A. Receive detailed instruction in the softwareB. Work in an air conditioned environmentC. Good photography skillsD. Good communication skills

5. What is reduced in order to obtain perfect ceramic support?A. The time it takes to scan the model.B. The creation of a full model by CAD/CAM.C. The overall cost of materials.D. The amount of tooth structure removed.

6. What is the particular problem often faced in daily lab work?A. Not enough time allottedB. Improperly positioned abutmentsC. Collapsed bitesD. Controlling material costs

7. How was the set-up created?A. Artificial teeth with proper articulation and

articulationB. By making duplicate wax modelsC. Artificial teeth mounted 1mm out of occlusionD. Heat processed temps

8. In order to be scannable, it’s important for the set-up to be...A. strong and removable.B. strong and non removable.C. painted with silver powder.D. opaque in colour.

9. The Atlantis (VAD) abutments are fabricated by...A. taking the final shape then backward designing

the abutment.B. scaning then selecting a prefabricated product.C. casting a wax milled prototype.D. sending instructions to the lab.

10. The Atlantis abutments are available in...A. all types of gold alloys.B. titanium and zirconium.C. chrome cobalt alloys.D. plastic castable pieces.

Each article in this continuing education series is worth 0.5 credit from the NBC. To get your Scientific CE credit for this article, circle the correct answers to the questions on the short test below. The correct answers can be found within the text of the article.

Then simply complete the form and submit it to Palmeri Publishing Inc., to receive your credit. It’s that easy!

Questions for: Zircon is not Always the Same by Shahab Esfarjani & Customized Abutments by José de San José González

TEST FOR NBC & RDT CREDITSdental labor international plus – Vol. 2 No. 1

Once you have completed the questionnaire, fill out the information below. You can photocopy this form.Then simply complete the form and submit to Spectrum dialogue online at www.spectrumdialogue.com

or by fax to 905-489-1971. It’s that easy!

In order to receive credits, you must be a subscriber to dental labor international Plus.

Subscriber Name: __________________________________________________ Phone #: _______________________________________

Address: ___________________________________________________________________________________________________________

Email: ___________________________________ CDT or RDT #: ________________________ Signature: __________________________



Mail orders to: Palmeri Publishing Inc., 35-145 Royal Crest Court, Markham, ON L3R 9Z4 CanadaPhone orders: 905.489.1970 Fax orders: 905.489.1971 or order online at www.spectrumdialogue.com

Knowledge is the basisSuccess is the result

Modern dental technology - rapid and efficient

Mr. Giezendanner’s “secret” is his wide-ranging knowledgeand techniques for the manufacture of porcelain veneers,developed over many years. These set new standards forquality and precision in the field of dental restorations. Thisvaluable book should be a standard reference work for anydental technician. It contains excellent study material. Abrowse through the images and illustrations in this book willquickly show a wealth of important information, detailedcraftsmanship and practical experience in the very latest indental technology.

Trend researchers have noticed that customers are onceagain looking for value in certain product groups rather thansimply the cheapest price. Customers exhibit dental servicesin their mouths, and therefore usually want the best forthemselves. Therefore, dental technicians need to becomeinvolved in the interaction between provider and patient. Thisis not always simple, but it is a pre-requisite for patient-focused dental work. Dental laboratories must carefullyconsider the potentially disastrous results of a “quick andcheap” approach. Instead, they must choose to focus on ourvalues and strengths, such as:

Quality Precision Timelessness

It is up to the dental technician to accept these challenges, andto take on the responsibilities. An ostrich-like attitude andpassing the buck onto various bodies, policies and associationsare not helpful. In this book, Giezendanner passes on the secretof a beautiful crown to anyone who might be interested in thisexpertise. It is then up to every individual to seize theopportunity to perfect his or her skills, and establish themselveson the market place. “Yes we can” is equally applicable to thedental industry.

AuthorPaul Giezendanner

$69.0088 pages, 9.5 x 8.25 inches

“These days, aesthetics

is called success;

Success these days is

called aesthetics.”



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