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oralhealth
w w w. o r a l h e a lt h g r o u p. c o m
LABS
SPRING 2016
SURVIVING
IN THE
DIGITAL
WORLD
FALL 2015
• oralhealthLABS
www.oralhealthgroup.com
OHLabs Spring16.indd 1
1
16-03-28 9:13 AM
The power of this
Packed into this
Because we’re not born with robotic arms
MADE EASY FOR YOU
To make dental scanning easy, we could have built the
world’s first automatic, clearance controlled high-speed
bionic appendage. Instead we packed it all into our new
CS 3600 to make acquiring digital impressions easier for you.
Explore more at
carestreamdental.com/CS3600
or by calling 855.762.2291
© Carestream Health, Inc. 2016. 13744 CAN CS 3600 0315
13744 CAN Oral Health Lab Ad; April 2016.indd 1
3/15/2016 12:34:06 PM
16-03-28 9:13 AM
2:34:06 PM
contents
6
4
Editorial
Survival Of The Fittest
What Business
Are You In?
5
News
Smile of the Year Contest
Sirona’s 7th inLab Summit
10
Foundation for
Effective Collaboration
Photographic Communication Between
Dentist and Dental Technician
12
14
The Screwmentable
CASE STUDY
Multidisciplinary
Digital Dentistry
Advantages of Digital Smile Design
EDITORIAL DIRECTOR
Catherine Wilson
(416) 510-6785
[email protected]
EDITORIAL ASSISTANT
Jillian Cecchini
(416) 442-5600, ext. 3207
[email protected]
ART DIRECTOR
Carolyn Brimer
PRODUCTION MANAGER
DENTAL GROUP ASSISTANT
Karen Samuels
(416) 510-5190
[email protected]
Kahaliah Richards
(416) 510-6777
[email protected]
CIRCULATION
SENIOR SALES MANAGER
MANAGING DIRECTOR
Melissa Summerfield
(416) 510-6781
msummerfield@oralhealth
group.com
Mary Garufi
(416) 442-5600 ext. 3546
[email protected]
Tony Burgaretta
(416) 510-6852
[email protected]
VICE PRESIDENT
DENTAL MARKETPLACE – CLASSIFIED
ASSOCIATE PUBLISHER
Jim Glionna
Karen Shaw
(416) 510-6770
[email protected]
Joe Glionna
PRESIDENT
Hasina Ahmed
(416) 510-6765
[email protected]
ORAL HEALTH LABS IS A SUPPLEMENT TO ORAL HEALTH
SPRING 2016
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editorial
SURVIVAL OF THE FITTEST
As Bob Dylan wrote, “The times they are a-changin’”. This often quoted lyric holds true to dentistry and dental laboratories today. We as dentists have seen many changes over the years to materials and techniques, none in my humble
opinion as dramatic as the advent of the digital age of dentistry. More and more dentists are embracing digital technologies and employing them in their offices. Yes the use of digital radiography is probably most
prevalent, but how about the use of digital impressioning systems? There are multiple companies at every
major dental convention on the trade show floor wanting us to buy their digital impression scanners whether
it is Trios, iTero, Planmeca, Cerec, E4D and so on. More and more dental offices are embracing these systems
as times goes by as the gold standard for dental impressions. These scanners truly are amazing in that they
now are bringing dentistry to the patients quicker (if one chooses to use in office milling such as Cerec or E4D)
and much quicker via the internet delivery of our impressions to our labs. Within
seconds the labs can start working on our cases, or can they? Do they possess the
ability to utilize this technology in their facilities or do they have to “farm out” our
impressions elsewhere to be able to work on our cases? Do they wish to go through
the painstaking process and monetary commitment to keep up with the ever-changing advancements in dentistry? These are the kinds of issues that we as the dental
profession are encountering on a daily basis.
We all have choices to make within our own practices. Is there anything wrong
with maintaining our course using the tried and true methods that have been very
successful in dentistry since the age of the dinosaur? We have used amalgam as a
very successful material forever, but recognize that there are safer and better ways
to restore teeth. Our patients too have had a large say in what THEY wanted inside their mouths due to the
information that was made available in public places like magazines, newspapers, and the Internet. So we as
dentists evolved our materials to suit the public’s wants and desires.
Dental labs have been able to help dentists restore teeth for decades by fabricating restorations of either
metal or ceramics. Dental materials for indirect restorations are evolving daily. There are so many new materials available that not only rival the old PFM restoration, but actually far exceed them in terms of durability,
strength and esthetics. Most of these materials involve some sort of digital technology. With all these new
materials and technologies available, the question is, will your lab be equipped to evolve with the times that
are definitely changing? In my mind, survival of the fittest is the best way to define this. Dental laboratories
that are willing to evolve with our new technologies will survive, but ones that maintain the tried and true,
unfortunately will become extinct like the dinosaur.
Les Rykiss, DMD
Dr. Rykiss maintains his private practice in Winnipeg, MB.
He is a graduate of the University of Manitoba as well as
a graduate and Mentor at the Nash Institute for Dental
Learning in Charlotte, N.C. He has his Fellowship with
the International Academy for Dental Facial Esthetics,
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oralhealthLABS •
an associate Fellowship from the World Clinical Laser
Institute, and is a member of the ASDA and CAED. He
teaches, lectures, and writes articles on restorative, cosmetic dentistry, and hard and soft tissue laser use.
SPRING 2016
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news
Tetra Dynamics Dental Laboratory Presents
Smile of the Year Contest
Tetra Dynamics, a MircoDental Dental Laboratory, introduced their Smile of the Year contest. The lab
believes smiles matter and are constantly witnessing how great dentistry is able to transform people’s
lives. Tetra Dynamics Smile of the Year celebrates the positive impact that cosmetic dentistry
has on patients around the world.
To be eligible for the contest, a doctor must have a patient that has benefitted from
a Tetra Dynamics smile makeover (already restored). Restorations include all-ceramic, implants, partial and complete dentures. Doctors must complete and submit the
required entry form and photographs by June 30th, 2016.
The winning doctor and his/her patient will be part of a professional photo shoot
in San Franciso. Airfare, transportation, meals, up to four-nights hotel and a $500 gift
card for both the patient and the doctor will be included. This is a wonderful opportunity to
experience a photo shoot production with a professional team of stylists, makeup artists and photographer. All prizes are awarded in exchange of image usage rights. The prizewinner may be featureE in
a variety of marketing projects including videos, ad campaigns, and on the company website. Winning
doctors will also receive digital copies of selected photo shoot images. The winner will be selected on
August 1st, 2016.
For more information about Tetra Dynamics’ Smile of the Year contest, visit www.teradynamics.
com/tetra-dynamics-smile-of-the-year.
Sirona’s 7th inLab® Summit
Dentsply Sirona, The Dental Solutions Company, announced its 7th inLab Summit. The inLab
Summit will take place at Harrah’s New Orleans
Hotel on April 15th and 16th, 2016. The twoday summit includes powerful educational sessions and hands-on courses presented by laboratory professionals that translate directly to
your lab.
Hundreds of lab technicians are expected to
attend this year’s inLab Summit in order to
learn about the most current industry topics
centered on all aspects of inLab CAD/CAM
technology in a powerful educational environment among like-minded colleagues and professionals. With a non-stop schedule containing an
outstanding roster of educational opportunities, the inLab Summit is set to provide the
most beneficial CAD/CAM training along with
the richest networking opportunities available.
Over 30 breakout sessions and hands-on
workshops are scheduled throughout the summit where attendees will have multiple opportunities to work alongside expert inLab users
on a multitude of specific applications and techniques relevant to everyday restorative requests, as well as unique laboratory situations.
All courses and workshops are designed to provide participants with increased knowledge and
skills in order to maximize their own production, efficiency, and financial benefits using the
inLab system.
All attendees will be provided up to nine CE
credits for attending the inLab Summit. For
more information and to register for the
inLab Summit in New Orleans, please visit
www.inLabevents.com.
SPRING 2016
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WHAT
BUSINESS
ARE
YOU
IN?
By George Cowburn
As an established dental lab, you are proud of your
workmanship and expertise. Over the years, you have built
a reputation for quality and service, and you have a solid,
long-term relationship with key local professionals.
But the flood of new technology is worrying –
“How can I ever keep up with it all?”
George Cowburn, D.D., began researching
digital dental solutions in 2003 while studying
denturist technology at the Northern Alberta
Institute for Technology. He went on to cofound
one of the largest denture clinics in Western
Canada. For the last five years, Cowburn has
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been dedicated to researching and developing digital treatment workflows. This passion for
digital solutions was fully realized with the launch
of Perfit Dental Solutions, a company dedicated
to facilitating the adoption of digital technology
in the dental industry.
SPRING 2016
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I
n our last article in Oral Health Labs’ Fall 2015 edition,
we looked at how digital dentistry is slowly crossing
the adoption cycle chasm. Digital dentistry has been
slow in coming, largely because the learning curve for
new methods and tools is steep indeed. Given their
professional responsibility for patient care, dentists have every reason to be measured and thoughtful in adopting new
methods; “Sorry, that didn’t work” is not what patients are
willing to hear. A lab can test ideas and procedures on models
to refine and perfect their methods before bringing them to
market, but dentists are not afforded this opportunity. Until
digital workflows are quick, easy and reliable, digital dentistry
will continue to be a gently flowing stream of gradual change.
Dental labs in contrast already have digital tools and workflows, which are quick, reasonably straightforward and highly
reliable. The change is and will be an overwhelming tsunami
flooding the entire landscape. Labs are being forced to decide
to head for higher ground or retire. A recent survey showed
by 2020, over one-third of labs plan to sell off their equipment
or sell their business to a competitor or lab group.
RIDERS ON THE STORM
Dental labs are responsible for producing whatever the dentist
requires. The dentist needs results, and is less concerned with
how those results are achieved. Three-dimensional printing
versus milling a model is irrelevant to most dentists; they just
want the restoration to fit.
There is therefore, no limit on the pace of technology adoption in dental labs — new ideas can be very rapidly adopted.
How can smaller labs deal with this situation?
Historically, full service labs did it all but with the heavy
equipment investments in newer workflows, labs are forced
to outsource, and often with a twinge of regret. “We really
should be able to do that.” Unless you are a very large lab with
deep pockets, most labs simply can’t continue to provide every service in house.
As the waters of change rise, labs can’t stay moored to the
old dock. The only way to survive is to cut loose and become
a rider on the storm.
SERVICING THE DENTIST BEST
As a lab, you have an intimate relationship and understanding
of what your doctors want. With a bit of training, that design
skill can be transferred from physical design to software driven design. CAD can become your core area of expertise.
Large milling operations have the benefit of economies of
scale. They can buy many machines and have extra capacity
available when inevitable breakdowns occur. They can invest
in researching efficiencies in manufacturing and optimize it
over hundreds and thousands of cases. Missteps are surviv-
able as they bring in and test out new machines and procedures and recover from their failure without going under.
As the technology matures, it may make sense to bring milling in house. Milling centres recognize and support this evolution. They leverage their knowledge and expertise to empower smaller labs to enter the milling business. What they stand
to lose in market share, they regain in providing support services, affordable materials and, most importantly, they can
step in to fill orders if the local mill has an issue. This allows
smaller labs to gain experience with digital workflows without
significant capital outlay and risk while providing reliable
products of exceptional quality for reasonable costs. These
milling companies are also riders on the storm, intelligently
navigating a sea of change.
SO WHAT BUSINESS ARE YOU IN?
The dental lab industry is now becoming a computer technology industry.
Google is one of the most successful computer technology
companies in the world. Eric Schmidt, Google’s former CEO,
summed it up well: “Be a damn good router.”
From a dentist’s perspective, what matters is quality, timeliness and cost.
So let’s walk through the digital production process. First
and foremost, you have to support dental staff in learning
what data they need to provide you with in order for you to
achieve mutual success. A recent survey of labs showed one in
four of impressions received from dental offices are unacceptable. Working with poor inputs makes high quality products
impossible to achieve.
Then the practice has to learn how to send you digital image
files, along with clear and precise instructions. This too is a
new skill, and you want to be a supportive part of the learning
process, to train the office to efficiently route information to
you.
Then you want to manage and monitor every step of the
production process. The dentist’s instructions should be interpreted by a design expert, preferably one with knowledge of
the subtle preferences of the specific client. In an ideal world,
the proposed design would be reviewed and approved by the
doctor, or patient, before proceeding to manufacturing. In the
event the client isn’t satisfied, redesigning a virtual case is far
easier and less costly than remaking physical work.
The manufacturing process may have several steps, depending on the product required. At every step, progress is logged
and tracked, so that you, and your client, know precisely what
stage the work is at. Expectation is the mother of disappointment; allowing transparency is a highly effective way of managing expectations. At a minimum, you must be a damn good
router.
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IS IT ENOUGH TO BE A DAMN GOOD ROUTER?
It is entirely possible for a modern lab to be nothing more than
a router.
After building and renovating several clinics, we see similarities between the dental lab industry and the construction
industry. Any homeowners can choose to be their own general
contractor, and manage the whole process. But a homeowner
who does that ends up spending an enormous amount of time
chasing after contractors and managing the project schedule.
“The drywaller didn’t show up again, now I have to rebook the
painters and figure out how to get the project back on schedule
so it doesn’t affect the move-in date.”
With dental labs, the situation is far more complex, because
there is an ever-changing suite of technologies to choose between. Dentists are seldom interested in assessing emerging
technologies – they just want the restoration to consistently
fit, look good and be affordable; how it came into existence is
of far less concern. It becomes your responsibility to pick the
right solution to provide a product of good value and uncompromising quality – as their general contractor.
The more change and upheaval there is in the dental industry, the more value a router will have. New solutions and efficiencies are being discovered every day and good routers are
always on top of the latest developments, and know when to
adopt them.
FORGING THE GOLDEN HANDCUFFS
Traditional dental labs employ people in departments and
simpler tasks are done by regular technicians, who become
experts in a relatively limited set of tasks. But the success of
a lab commonly relies on a few highly skilled ‘star performers’,
who have a deeper understanding of the overall picture.
In a digital workflow environment, these ‘star performers’
will have a different set of skills which are not yet part of any
school program and cannot be hired ‘off the street.’ Persons
with the interest and ability to become experts in dental lab
workflow management and automated production will be few
and far between.
You absolutely must retain these key employees. Forging
“golden handcuffs” is essential: create an environment where
employees have it so good that they could never consider
leaving.
Part of the solution may be financial; some labs offer high
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oralhealthLABS •
wages, bonuses, profit sharing, shares in the company, or additional benefits and holidays.
Research continually shows that the most effective incentives are not financial. The key to success is developing a culture that people want to be a part of, and one that fits the new
business model. If your people are happy, processes will flow
smoothly, dentists will be pleased, and patients will be well
cared for.
THE RIGHT DESIGN
Computer Assisted Design (CAD) is a function that likely fits
well with your current lab’s skill set. This is the most critical
component of the digital process in the lab’s control, so quality is key.
Many five axis mills produce great results, but the product
is only as good as the design. Mistakes in the virtual world
aren’t significant issues until they’re milled and become real
problems.
In CAD design, a culture of quality is critical. A new technology is always suspected, and the results will have to be even
better than the conventional state of the art to convince skeptics.
Once you have talented CAD experts in-house, utilize them
to train others. This skill set will be ever more valuable, and it
is essential that you manage your dependency on the star performers that your competitors will be seeking to lure away.
Many of our best technicians are retiring, so we must mentor
a new generation.
Companies are now specializing exclusively in CAD and
work closely with milling companies to deliver integrated solutions. If you have weaknesses in CAD, try sending a couple
test cases to outsourced CAD companies and evaluate the results.
THE BRAINS OF YOUR BUSINESS
Irrespective of your labs position in the industry, you need to
have a solid process management system in place.
Implementing a new software system is always challenging,
but offers efficiencies. The sooner these efficiencies are realized the more significant impact they can have on your business. Being digital-ready sooner means that by the time the
digital market really opens up, you’re more than ready for it.
Digital data transfer rules are reasonably new. We’ve had
SPRING 2016
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cars for a hundred years and every driver is familiar with the
rules of the road. The new information highway is not as well
understood by the people who navigate its lanes. To communicate with dental professionals, you should utilize a system,
which is PIPPA/HIPPA compliant.
The software you choose will literally become the brains of
your business. You either need integration with your lab management software or an all-in-one solution. Here are some
things to consider:
Is there a client portal where they can quickly log
in and see all communication and files sent? This
will save you phone calls to see where cases are.
Web based cloud-data solutions are generally
preferable to those in which the software and data
are stored on your own machine – which must then
be backed up and secured.
Is there invoicing and integration to accounting
programs such as quickbooks? This will save you
time and money. Your bookkeeper and accountants
will thank you.
Can it streamline and sort information more efficiently? Software solutions, such as CAPzilla and LabStar, have the ability to acquire information, such as
the patient’s name, directly from the 3Shape files,
reducing the time and error inherent in double entry.
Does my software meet my current and long term
needs? This is perhaps the most important question,
as switching systems is always challenging. Make sure
you choose a software vendor that has a long-term
vision and the ability to adapt with the industry.
These are stormy seas of change – but if you cut free and
ride on the storm, these will be the winds of opportunity!
SPRING 2016
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dental photography
Foundation for
effective collaboration
Photographic communication between dentist and dental technician
Prof. Dr Daniel Edelhoff,
Munich/Germany
In addition to a bite registration,
facebow transfer and impressions,
intraoral and extraoral photos form
the most important key in the
communication between dentist
and dental technician.
Adequate photographic equipment is
an indispensable tool for the teamwork
between dentist andtechnician
T
he importance of photographic communication is particularly
significant if the dentist and dental technician collaborate
with each other from distant locations and have to fulfil demanding esthetic and functional requirements. Photos are
not only used for the initial transfer of information to conduct an esthetic and functional analysis on the basis of a wax-up, but they also
play a significant part in many other steps of the restorative process,
such as in the clinical evaluation of the proposed restoration (mock-up)
and in the shade selection of the toothand preparation.
Scope of photographic documentation
To be able to obtain a detailed impression of the clinical situation at
hand, dental technicians should receive a comprehensive photographic
portfolio comprising the following shots:
1. Portrait photo of the patient with the facebow (Fig. 1).
2. Portrait photos showing the patient with relaxed lips, with a light
smile and with a full smile (Fig. 2).
Fig. 1 A portrait photo of the patient with the
facebow in place gives the dental technician valuable information on the position of the bipupillary
line in relation to the occlusal plane.
Fig. 2 A portrait photo showing the patient with a
full smile is used for analysing basic esthetic parameters: 1. centre line, 2. bipupillary line, 3. occlusal
plane. The patient presented in this case shows
asymmetries in the area of the facial midline (4.),
gingival contours and the occlusal plane/buccal
corridor.
2.
3.
2
1
Fig. 3 Frontal view of the upper anterior teeth. An autoclavable black contrastor was used to obtain a more detailed picture of the morphological
structures (Flexipalette, www.smileline.ch).
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oralhealthLABS •
Fig. 4 Frontal view of the upper anterior teeth. To facilitate the analysis
of the internal structures, it may be useful to take an additional picture
using a cross-polarization filter to eliminate all reflections (polar_eyes,
www.finest-dental.de).
SPRING 2016
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2
Fig. 5 Shade selection with a gingival mask including a white balance and
Fig. 6 For fine tuning the intensity of the tooth’s fluorescent level, additional
pictures using a UV light source may be useful and may be referenced with
grey card (modified according to MDT Otto Prandtner). The shade tabs of
shade tabs (fluor_eyes, www.finest-dental.de).
the A-D shade guide may be fitted in the gingival mask and photographed
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stains. It is essential to take a picture of the closest shade
virtually impossible to increase it at a later stage by using
sample (reference shade) together with the remaining denstains. It is essential to take a picture of the closest shade
sample (reference shade) together with the remaining den-
Fig. 9 Professor Edelhoff during intraoral photography
Fig. 7 Various shade samples of the IPS Natural Die Material shade guide
Fig. 7 Various shade samples of the IPS Natural Die Material shade guide
Fig. 8
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tant
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to enable the dental technician to manufacture laboratory
Conclusion
tition.
translucentcolour
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dies
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andcreated,
8).
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(Fig.
9)
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tant
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(Fig.
9)Material)
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tition.
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restorations
are created,
it is alsobetween
imporindispensable
fortechnician
the
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to
the basis
dental
to manufacture
laboratory
anenable
indispensable
basis
for successful
the successful
collaboration
beConclusion
tant to include a die shade guide (IPS Natural Die Material)
the
members
of thecolour
restorative
team
and8).
provides
high levela
dies
in athe
matching
(Figs
7 and
tween
members
of the
restorative
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and
High-quality
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documentation
(Fig.
9)aprovides
provides
to enable the dental technician to manufacture laboratory
of
predictability
with
regard
to
the
clinical
result.
level of predictability
with
regard tocollaboration
the clinical result.
anhigh
indispensable
basis for the
successful
bedies in a matching colour (Figs 7 and 8).
Conclusion
tween
the members of the restorative team and provides a
High-quality
photographicwith
documentation
9) provides
Acknowledgement
high
level of predictability
regard to the(Fig.
clinical
result.
Acknowledgement
Conclusion
an
indispensable
basisOliver
for the
successful
collaboration
be
like
Brix
forfor
providing
the the
dental
lab
II would
would
like to
tothank
thank
Oliver
Brix
providing
dental
High-quality photographic documentation (Fig. 9) provides
tween
the
members
of
the
restorative
team
and
provides
a
pictures.
Acknowledgement
lab pictures.
an indispensable basis for the successful collaboration belevel
regard
to thethe
clinical
result.
I high
would
likeof
topredictability
thank Oliver with
Brix for
providing
dental
lab
tween the members of the restorative team and provides a
pictures.
Reprinted
with
permission.with
Reflect,
2/14.
high
level of
predictability
regard
to the clinical result.
Acknowledgement
Contact details:
I would like to thank Oliver Brix for providing the dental lab
Acknowledgement
pictures.
Prof. Dr Daniel Edelhoff
details:
I would like to thankContact
Oliver Brix
for providing the dental lab
Chief Senior Surgeon, Deputy Chair
pictures.
Policlinic for Dental Prosthetics
Prof. Dr Daniel Edelhoff
Ludwig Maximilian University
Chief Senior Surgeon, Deputy Chair
Contact
details:70
Goethestrasse
Policlinic for Dental Prosthetics
80336 Munich
Ludwig Maximilian University
Contact
Prof.
Dr details:
Daniel Edelhoff
Germany
Goethestrasse 70
Chief
Senior Surgeon, Deputy Chair
[email protected]
80336 Munich
Prof.
Dr Daniel
Edelhoff
Policlinic
for Dental
Prosthetics
Germany
Chief
Senior
Surgeon,
Deputy Chair
Ludwig
Maximilian
University
[email protected]
Policlinic
for Dental
Prosthetics
Goethestrasse
70 SPRING
2016 • oralhealthLABS
Ludwig
Maximilian
University
80336 Munich
Goethestrasse
70
Germany
80336
Munich
[email protected]
Germany
[email protected]
16-03-28
7
11
7
7
7
9:13 AM
THE
Screwmentable
Mike Callaghan, RDT;
Peter McKeon, RDT
12
oralhealthLABS •
I
n an industry that offers so
many options and emerging
products restoratively, many of
us have never heard of one of
the new and extremely useful
phenomenons: the Screwmentable.
What is a Screwmentable? It’s a restoration consisting of an abutment, a
crown and a screw. To many, that
doesn’t sound any different from a
screw-retained restoration, and it
shouldn’t. But here’s where it differs.
With a Screwmentable, we at the Lab
pre-cement the crown to the abutment
creating a one-piece restoration. All
that is left to be done is to screw the
abutment (through the access hole in
the crown) down and then place composite over the screw access hole to
hide the area. Voila, we have the
Screwmentable!
Here’s why this solution
should be considered. First
of all, it is very cost effective
as it not only allows the use
of stock or Ti base abutments, but it saves chair
time as it arrives to the practice already cemented into one
piece, leaving a clean and smooth
surface that will be sub gingival. The
Screwmentable also alleviates the worry about cement entrapment as the lab
pieces the crown and the abutment together, and as such, a spinoff is that it
therefore helps prevent peri implantitis
that excess cement may cause. Finally,
moving forward, there is the ease of
future access and retreiveability should
the screw become loose or the cement
erode. In both cases, unlike with a cement-retained restoration, there is no
need to try and find the mesostructure
of the abutment below because the
screw access hole is available. All that
would need to be done is one of two
options. Drill out the composite cover
and either tighten the screw, or remove
the Screwmentable and re-cement
chairside, or in more complicated situations, return to the lab for cementation.
Screwmentables can be used for a
wide variety of restorations including
Full Contour and Layered Zirconia,
PFM’s and e.Max. Of note, as with all
implant procedures, we would recommend that the master model be saved
at the practice in case of potential micro movements or any unforeseen complications arising down the line. Should
you have any question, concerns or
comments please feel free to call or
email us at Shaw Laboratories.
416-977-0700 / info-toronto@shawlab
group.com.
SPRING 2016
16-03-28 9:13 AM
SPRING 2016
• oralhealthLABS
13
16-03-28 9:13 AM
case study
MULTIDISCIPLINARY
DIGITAL DENTISTRY
ADVANTAGES OF DIGITAL SMILE DESIGN: A CASE STUDY
By:
Amarjit Rihal,
DMD, FICD, FPFA;
Tim Dumore DMD, BSc, MSc,
FRCD(C), DipABO, FICD, FPFA;
Les Rykiss DMD, FIADFE
Amarjit Rihal obtained his DMD
degree from the University of Manitoba, Faculty of Dentistry, in 1995.
His professional interest has involved
all aspects of implant and CAD/CAM
dentistry. He has additional training in
both hard and soft tissue grafting as
well as placing and restoring implants.
In addition to implantology, Dr. Rihal
has acquired expertise in CAD/CAM
14
oralhealthLABS •
T
he prevalence of impacted cuspids is
approximately one to two percent of
the population. For those individuals with impacted cuspids who seek
orthodontic treatment, they can expect more complicated mechanics and increased
treatment time. There is a similar prevalence of
cases with peg lateral incisors. These situations
also present challenges for the orthodontist and
the restorative dentist alike. One solution for peg
laterals with poor prognosis can be substitution
of the cuspids into the lateral incisor position.
With proper management, a very acceptable
result is often possible. Of course, CL II management in non-growing patients presents challenges in treatment as well, with a need to consider
upper bicuspid extraction or surgical correction
of a skeletal discrepancy to achieve an acceptable
result. This case report presents an interesting
patient presentation that combines all of these
considerations.
based prosthetic dentistry, involving
numerous CAD systems and materials. Utilizing his CEREC ac and InLab
system he has designed over 2000
restorations. He presently is a partner
in a large group practice in Winnipeg,
MB and serves on the boards of the
Manitoba Dental Association and the
National Dental Examination Board.
He has newly be elected to the Com-
mission on Dental Accreditation of
Canada. He was also a part time clinical instructor at the University of Manitoba Faculty of Dentistry and is a fellow of the Pierre Fauchard Academy
and International College of Dentist.
Tim Dumore has practiced orthodontics in Winnipeg since graduating from the orthodontic residency at
SPRING 2016
16-03-28 9:13 AM
Case Study
This patient presented in January 2010 to the
orthodontist with a chief concern that the
"cuspids need to be brought down" and that
he wanted to address his front teeth that had
been traumatized in a hockey accident three
years prior. Diagnostic records were obtained
in March; five days prior to the records, he fell
and traumatized 22. Figures 1 and 2 shows
patient’s full smile and retracted anterior
view.
Upon initial examination, our findings
showed an increased vertical jaw relationship.
This was due to the posterior rotation of the
mandible and contributed to the open bite
tendency and a class II malocclusion. His
open bite was compounded by factor of his
central incisors as seen in Figure 3.
Figure 3 shows impacted cuspids 13, 23,
pegged lateral incisors, supernumerary tooth
between 22-24 as well as severe maxillary
crowding and moderate mandibular arch
crowding.
Fig. 1
Fig. 2
Fig. 3
University of California, San Francisco
in 1998. He has a special interest in
interdisciplinary treatment and is codirector of the Winnipeg Progressive
Dental Study Club, a chapter of the
Seattle Study Club. His practice places a significant focus on technology,
with early adoption of digital radiographs and CBCT, intra-oral scanning,
and 3D printing. He has been a part-
time clinical instructor at the University of Manitoba Faculty of Dentistry
Graduate Orthodontic program for
sixteen years. In 2013, he was invited to be a member in the Schulman
Study Group.
Les Rykiss maintains his private practice in Winnipeg, MB. He is a graduate
of the University of Manitoba as well as
a graduate and Mentor at the Nash Institute for Dental Learning in Charlotte,
N.C. He has his Fellowship with the International Academy for Dental Facial
Esthetics, an associate Fellowship from
the World Clinical Laser Institute, and
is a member of the ASDA and CAED.
He teaches, lectures, and writes articles on restorative, cosmetic dentistry,
and hard and soft tissue laser use.
SPRING 2016
• oralhealthLABS
15
16-03-28 9:13 AM
sponsored case study
Fig. 4
Restorative Phase
The cuspids and peg lateral incisors were prepared for
CAD all ceramic crowns with the supra gingival margins
on enamel. Figure 6 shows prepared teeth and uneven
proximal spacing.
After the preparations were complete, it was necessary
to take a normal digital photograph of the patient smiling
to be imported to our Sirona Inlab design software. Note
that the patient’s facial midline was not coincident with
his mandibular dental midline as seen in Figure 7.
A digital impression using Sirona’s Omni cam was taken. As you can see a colour digital 3D rendering of the
patient’s prepared maxilla, mandible and bite was captured into the software. Figures 8 and 9 show occlusal and
anterior scanned images from CEREC’s OmniCAM.
Figure 8 shows preparations from the occlusal view as
well as occlusal contact points. As seen in Figure 9, an
approximated final incisal and maxillary midline position
Fig. 5
Treatment Plan
Due to the complexity and challenges dentally presented
with this case, there are a number of treatment options
that could have been considered. The reality of this case
was that after orthodontics was completed, the case was
presented, and the patient would only be available for
three days. The treatment would need to be completed by
then. This really simplified our restorative treatment plan
options. It was decided that our only choice, given time
constraints, was using Sirona InLab Smile Design software in combination with CEREC (Sirona) CAD/CAM design and in-house milling.
The orthodontist had already decided that restoring 11
and 21 was not feasible due to the poor restorative prognosis and were planned for extraction. As the impacted
cuspids were approaching the central incisors, the cuspids
were erupted in the position of the central incisors post
extraction. The pegged lateral incisors were maintained to
assist with orthodontic anchorage. Figures 4 and 5 show
the final orthodontic position with 13, 23 in the position
of (formerly extracted) 11 and 21.
As you can see, there were tremendous restorative challenges due to asymmetrical proximal spacing, tooth size
discrepancies, and asymmetrical anterior dental midlines.
Due to severe time limitations, we didn't have the ability
to do any pre-preparation wax-ups or diagnostic aesthetic
evaluations.
16
oralhealthLABS •
Fig. 6
Fig. 7
SPRING 2016
16-03-28 9:13 AM
was roughly drawn with pencil and captured by the Omni cam on
the facial surfaces of 31 and 41. This was to help confirm our smile
design is accurate.
Next, preparation margins were identified easily with CEREC’s
auto margination feature as shown in Figure 10.
The next step in our lab component with CEREC software is to
upload the full face smile photo that we took after preparation of
the teeth, and transfer the intercanthi width (far corner of eye to
corner of other eye in mm) to calibrate the photo to the digital
impression as shown in Figures 11 and 12.
The full integration of the digital facial photo and digital impression is shown in Figure 13. The digital impression is guided into
correct position by utilizing the software tools as seen in Figure 13.
Once the integration was completed, the next step is an initial
proposal by the CEREC software for four anterior crowns, 12 to 22.
Fig. 10
Fig. 8
Fig. 11
Fig. 9
Fig. 12
SPRING 2016
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16-03-28 9:13 AM
Fig. 13
Fig. 15
There are many design tools that are used to adjust the
shape, size, length and anatomic form of the restorations.
These tools are very intuitive and as one becomes more experienced with design, their actions become second nature.
Figure 14 shows the final design of the crowns to be superimposed and manipulated on the full facial smile design
photo of the patient (Fig. 14).
This photo can be grabbed and rotated three dimensionally in any direction to illustrate to the patient chairside
(and the dentist) exactly what the 3D crown proposal setup
is (Figs. 15 and 16).
Each restoration can then be altered so that the midlines
are straight and coincident to the facial midlines and the
incisal length positioning can follow the lower lip line. Being
18
oralhealthLABS •
Fig. 14
Fig. 16
able to visualize the final proposal in his own smile was
invaluable to the patient experience. Once the patient
viewed this proposal, it was accepted and the crowns were
milled.
Figures 17 and 18 show the transparent restorations over
the preparations. As one can see, the orthodontic asymmetries of tooth positioning was corrected in our CEREC
crown design. This would not have been possible without
the Smile Design software.
The CAD/CAM ceramic block of choice was Vita’s Tri-Lux
Forte. This block contains four layers of feldspathic porcelain built into the block. This mimics the labour intensive
layering techniques that the lab artists (technicians) do for
ultimate aesthetics. Figure 19 shows the stratified layers of
SPRING 2016
16-03-28 9:13 AM
g. 14
Fig. 17
Fig. 18
Fig. 20
Fig. 19
g. 16
the block, which can be raised or lowered to alter the opacity
and translucency of the milled crown.
Figure 20 shows the untreated freshly milled crowns. Also
visible is the natural chroma progression from gingival to incisal that is built into this block. Some incisal variations and
texture characterizations were cut into the porcelain using a
finishing diamond bur. The patient verified the shade and contours (this time intraorally) and the crowns were treated with
surface glaze, fired in the VITA PM oven and polished for insertion. Figure 21 shows the completed restorations after cementation (with Ivoclar’s Multi-link and a self-etch technique using
a yellow shaded cement, which warmed the overall value of the
restorations), and final polishing of the margins.
Fig. 21
SPRING 2016
• oralhealthLABS
19
16-03-28 9:13 AM
Conta
Fig. 22
Fig. 23
Digital Timeline
As you can recall, the patient presented for the first time
from the orthodontist. At that time, we took facial photos, prepped, and designed the crowns in a matter of two
hours. The crowns were milled the next day for try-in,
finalization, and insertion. This took a total of three
hours. The grand total for this improbable task was completed start to finish in five hours, which included combined chair and lab time. This was an incredible result for
our patient and an incredibly rewarding experience for
the dentist. The true value as a restorative dentist was
shown by our patient’s emotional reaction when seeing
his new smile. This is the true power and versatility of
digital dentistry.
Fig. 24
Conclusion
Final post-operative check of the restorations were done
several months later when the patient returned to town
for a visit , as shown in Figures 22, 23 and 24. Tissue
response and healing were uneventful. This case was only
possible given our timeline with the use of CAD/CAM
dentistry and is a tremendous adjunct to our restorative
practice.
20
oralhealthLABS •
SPRING 2016
16-03-28 9:13 AM
Dental Marketplace
Contact: Karen Shaw • tel: 416-510-6770 • fax: 416-510-5140 • e-mail: [email protected] Toll free: CDA 1-800-268-7742 ext 6770 • Toll free: USA 1-800-387-0273 ext. 6770
Practices & Offices
SOUTHERN MANITOBA —
ORTHODONTIC PRACTICE
WEST KOOTENAYS, BC
Well established practice with solid referral base. Spacious, modern office in
free-standing building. 6+2 ops. Newer
leaseholds. Ample parking with easy
access.
For more information, please contact
[email protected]
ph: 604-220-4830
www.HEAPSandDOYLE.com
VANCOUVER, BC
Successful Prosthodontic practice. Vendor willing
to stay on for longer term transition. Beautiful office
with great views. 2+1ops. Strata unit available
for purchase. Contact Ruth at 604-220-4830 or
[email protected]
Successful practice in smaller Southern BC
community. Associate buy in available. Spacious
office with 5 ops. Nicely decorated with dedicated
staff. 1600 active patients. Currently on a four
day week. Great lifestyle!
Call Ruth at 604-220-4830
[email protected]
TORONTO N.E.
Part time general practice and condo
for sale. Owner retiring. 2 ops located in
professional and commercial building.
Toronto N. East.
Contact Mrs. Nguyen 647-999-0475
Email: [email protected]
COBOURG, ON
OSHAWA, ON
Busy dental office looking for a full or part
time associate. No evenings or weekends and new graduates are welcome.
Associate must be competent in root
canal therapy.
For more information please call:
905-372-6251 or
e-mail: [email protected]
SOUTHWESTERN ONTARIO
Chaudhry Corporation is looking for
dental associates for multiple practices in their southwestern Ontario
offices. Part time and full time available depending on location.
Please send resume to
[email protected] or
you can call Heather at 519-732-0920
OSHAWA, ON
Looking for a part time associate asap
in an Oshawa office. Shifts are Tuesdays 1-9, selected Wednesdays 9-1,
every other Friday and every other
Saturday. We prefer an associate with
minimum 2 years experience. We are a
large office with the potential of more
working hours in the future.
E-dental: [email protected]
TORONTO, ON
Busy and expanding downtown
family clinic is looking for a
general dentist, periodontist,
implant specialist and a part
time orthodontist.
Please fax your resumes to
416-538-8422 or email to
[email protected]
Associateships
EXCELLENT ASSOCIATE
OPPORTUNITY
Associateships
Progressive growing family practice
in Oshawa is looking for an energetic,
friendly, ambitious, caring individual
for a part time associate position. For
Thursday, Friday and alternating Saturdays starting in April.
Please forward your resume to
[email protected]
BRADFORD, ON
Part-time associate needed for our Holland Square Dental Clinic, Monday’s,
Thursday’s and Friday’s weekly. The
clinic is 8 years old and has a wonderful staff that care about the community
as a whole. We prefer a minimum of 2
years experience.
Please send your resume to
[email protected] Attn: Denise.
EDMONTON, AB
Great opportunity for a motivated associate
with some experience. $80,000-$100,000 per
month, in a beautiful office with new equipment and a great team. Current associate is
moving to another province. Potential of earning up to 45% and longterm buy-in for the
right candidate. Experience is an asset but
not required.
Please email:
[email protected]
THOMPSON, MB
Westwood dental clinic in Thompson, MB team looking for experienced
dentist full time or part time. Decent
income plus accommodation .
E-mail: [email protected]
NEWMARKET, ON
Seeking Part-time associate for
Monday and Wednesdays for our
busy practice in Newmarket.
Please email resume to:
[email protected]
GRANDE PRAIRIE, AB
Full time associate dentist required
for busy family practice. Looking
for highly motivated associate.
Our practice includes the latest in
technology (IOC camera, digital
x-rays, paperless etc.). Large existing patient base. Current associate
moving, team in place to help.
[email protected] 780-538-2992.
MULTIPLE LOCATIONS
IN ONTARIO
Exciting full and part time associate opportunities available for Barrie, Mississauga,
Stoney Creek, Etobicoke and Scarborough.
We are also looking for an orthodontist.
SPRING 2016
• oralhealthLABS
21
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Associateships
MULTIDISCIPLINARY
DENTAL CLINIC IN
BURLINGTON REQUIRES:
Oral & Maxillofacial Surgeon
1 – 2 days per month to start.
Orthodontist P/T
This is an excellent opportunity in a
well established, dynamic, privately
owned practice, maintaining Type A
facility permit, with 9 ops, 5 hygienists & 2 f/t dentists.
Please email CV to
[email protected]
SOUTHWESTERN
ONTARIO
We are a family dental office looking for
a periodontist available to work once or
twice a month.
Please reply to: [email protected]
TORONTO, ON
Full time dental associate needed immediately for busy group practice in downtown Toronto. Seeking dentist who is
comfortable with a fast paced environment. Excellent earning potential.
Please forward your resume to:
[email protected]
OTTAWA, ON
Modern Ottawa area 5 op. clinic with
growth potential in need of an associate. We are well established and use the
latest tech. The ideal candidate must be
dynamic, passionate and enthusiastic.
Reply: [email protected]
Great opportunity of mentorship & partnership. Beautiful new office. We offer IV, GA,
nitrous & conscious sedation. Ideal opportunity for someone seeking a balanced lifestyle.
Email: [email protected]
WHITBY, ON
GTA/HAMILTON/GUELPH, ON
Part time associate position for friendly
office in Whitby. Experience a must. Great
staff and relaxed environment.
[email protected]
PT/FT associates required. Family practices
looking for family dentists to grow with our
teams. Minimum 2 years experience required.
Please send your resume to
[email protected]
Large group practice(s) seeking self motivated dentists who
enjoy above average remuneration. Positions available in
great established locations in Calgary, Medicine Hat, Regina
and surrounding communities that are all within driving distance to airports. Progressive and established clinics with
strong patient base and excellent support structure. Shifts
available for minimum 4 days on, 4 days off allow the right
individual an opportunity to enjoy life and be very productive.
Remuneration to be greater of guaranteed income, or percent
collections. Experience with kids, surgery, endo and sedation an asset. Mentorship and buy-in opportunities available
to right candidates.
Email resume in confidence to: [email protected]
CORNWALL, ON
Part-Time position available in sophisticated office with excellent staff and
team environment. Must be compassionate and maintain the highest quality
standard of care for all patients.
Hours: 2 days per week with growth
opportunities.
STONY PLAIN, AB
Our progressive, paperless & high tech clinic is
looking for an Endodontist and Periodontist. You
will have an eager team to maintain your schedule,
referrals & keep you linked to the region. We are 20
minutes from Edmonton. The ideal candidate will be a
seasoned dentist who focuses on clinical excellence,
patient rapport that is caring and informative, while still
being production motivated. Position is available for
September 2016. Will assist with relocation.
Please email your CV to
[email protected]
OWEN SOUND, ON
GTA – TORONTO, ON
Applications to be forwarded to [email protected]
We are seeking a Pediatric Dental associate for a
well-established G.T.A practice. We provide a full
scope of services, including oral sedation, general
anesthetic, and emergent care for a large patient
demographic. We provide a warm, and family oriented work environment, taking a team approach to
eliminating anxiety for our patients and their families.
Associates will enjoy excellent compensation, and
opportunity for income growth.
If you are committed to the comfort and quality
care of each child like we are, please email:
[email protected]
Full time associate required for multi practitioner, progressive family practice. All facets of dentistry provided to all ages including
E4D, implants, sedation, invisalign, crown and bridge, digital charting and radiography. Pleasant, supportive and well trained staff in
a modern, welcoming environment .
Applicant must be a positive, engaged professional looking for a
permanent position. Enjoy above average earnings, and a professionally fulfilling career while enjoying an enviable relaxed year
round lifestyle on Georgian Bay.
Applicants are required to include references and CV. Those
applicants selected for further consideration will be required for a
working interview. Confidentiality is expected and assured.
22
Full time associate required for Grande
Cache Dental Care, located in the beautiful Rocky Mountains of Alberta. The
successful applicant will be fully booked
from day one. Must be comfortable with
all aspects of general dentistry with special emphasis on diagnostics, restorative, oral surgery and endodontics.
Strong communication skills are essential. No weekends or evenings required.
High gross/net office. Associate can
expect above average remuneration.
Please email to:
[email protected]
VICTORIA, BC
PAEDIATRIC DENTIST
SEEKING FULL TIME GENERAL DENTISTS
AND AN ORTHODONTIST – AB and SK
GRANDE CACHE, AB
oralhealthLABS •
SPRING 2016
16-03-28 9:13 AM
Associateships
OKANAGAN, BC
CALLANDER BAY, ON
Fantastic 5 op state of the art practice with billings 1.3-1.5M. A beautiful
office with natural daylight throughout.
Use only the best equipment while
enjoying fantastic views and a low cost
of living. Superbly managed: fully digital/paperless, very profitable, excellent
staff, efficient bookings & collections.
Room for an associate with tremendous growth potential.
Associate required for busy established practice in Callander Bay.
Multi-disciplinary, supportive, caring
team. Clinic offers advanced dentistry
complemented by specialist services. We are located 3.5 hours north
of Toronto. Located on the shores of
Lake Nipissing, this community offers
a great lifestyle. Year round outdoor
activities including boating, fishing,
snowmobiling, skiing and camping.
Great place to raise a family or to
appreciate the outdoors.
To discuss this opportunity contact
Samantha Simpkin.
Email resumes to
[email protected]
Contact Ron at [email protected]
or (604) 685-9227.
AJAX, ON
Full Time/Part Time Associate wanted for a busy
practice in Ajax. Must be experienced. Great
Opportunity. Must be a graduate of an accredited
North American University.
Please email in confidence to
[email protected]
GTA
Expanding group of dental offices in
the GTA looking for experienced dental
associates to join for PT position.
Mail CV to
[email protected]
MILTON, ON
Associate Required
Part-time Tuesday, Wednesday and
Saturdays (9-2) with potential to
go to full time. The right doctor will
possess experience and ability in
General dentistry. We are a high
energy, fun office. The office is fully
equipped with modern technology
(Cone-beam, Planscan (crowns while
you wait) etc…)
Please email resumes to
[email protected]
20 MINUTES WEST
OF HAMILTON, ON
Associate needed, 3-5 days a week to
replace relocating associate dentist.
Send resumes to
[email protected]
SASKATOON, SK
DOWNTOWN DENTAL requires a fulltime or part-time Associate for our well
established clinic in downtown Saskatoon. This is an excellent opportunity
to work in a newly renovated, modern
dental office with an established patient
base and a great staff. The current
position involves no weekends or evenings.The ideal start date would be fall
2016 – January 2017.
Check us out at
www.downtowndentalsaskatoon.ca
Contact
[email protected]
or 306-664-3555.
Bilingual Dental Associate – Full Time – 3-5 Days per week
Dr. Nicole Brien – Children’s Dentistry
Moncton, NB
www.childrensdentistrynb.ca
A MONCTON DENTIST – SPECIALIZED FOR CHILDREN’S HEALTH
Having been a trusted children’s dentist in Moncton for a number of years, we
are set up to offer on-site hospital procedures so children can receive the most
advanced care in an atmosphere they already know and are comfortable in.
Our staff are friendly and our dental experts will work together to ensure that a
child’s experience with us is positive, fun and educational. In our modern office,
we offer a variety of amenities and age-appropriate sedation techniques for the
more nervous children.
Dr. Nicole Brien – Children’s Dentistry is seeking a General Dentist to join our fastgrowing well-established pediatric practice as a full time associate. The ideal candidate will provide services to children and medically compromised adults from all
over New Brunswick. Mentoring with our Pediatric Dentist and with potential for
future opportunities to work in an OR setting. The successful candidate must have
excellent communication skills and warm personality and sense of humor a plus.
New graduates welcome to apply. Possible prospect of buying into the practice.
Benefits include:
Hours: Mon – Thurs 8:00 am – 4:00 pm & Fri 8:00 am – 12:00 pm
Remuneration – 45% pending
Please forward resume or direct inquiries to Kathy Kirkby 902-489-5514 or
email [email protected]
SPRING 2016
• oralhealthLABS
23
16-03-28 9:13 AM
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