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Two Crowns One Milling Machine

This is a lesson in chairside efficiency for all CAD/CAM users. Traditionally, you would be forced to prep two teeth and impress them both at same time, but with digital dentistry, you can break the case up and do it in segments, as if they are two separate patients involved.

In this particular case, the restorations were designed, milled, and seated in a single appointment.  To speed things along, only the second premolar was addressed; it was prepared, imaged, designed and milled.  While milling, the second molar was prepared.

After the tryin, they were chrystalized and seated at the same time.  Leveraging preparation time with mill time of multiple units can greatly increase efficiency at chairside.  See the following videos to pick up on all the details of the case.

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CASE SET UP FOR PREMOLAR SCAN IN MEDIT

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REMAINING TOOTH STRUCTURE AFTER REMOVAL OF PREVIOUS RESTORATION AND PREPARATION REFINEMENT

PREMOLAR DESIGN IN EXOCAD

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REMAINING TOOTH STRUCTURE AFTER PREVIOUS CROWN REMOVED AND THE PREPARATION REFINEMENT

CASE SET UP FOR MOLAR IN MEDIT

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MOLAR DESIGN IN EXOCAD

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TRY-IN OF EMAX PREMOLAR

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TRY-IN OF EMAX MOLAR

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SEAT OF PREMOLAR AND MOLAR EMAX CROWNS

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IMMEDIATE POST OP X-RAYS

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Korolation with Medit i500

One of the greatest advantages of digital impressions is the ability to copy a pre-existing condition.  This has a lot of benefits, one of which is that the patient will not notice a difference in the new restoration vs. the old one.  For this to happen with the medit i500, you need an extra image catalog box.  Rumor is that this will be available in the near future.  Since we only have the upper and lower jaws, and the buccal bite to imagine into (and scanbody catalog boxes), what you can simply do is treat the case as if they are two separate patients.

Create a new patient, and scan the preop condition and save the case.  Once processed, you can export the case file in OBJ, PLY, or STL format.

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You can then launch a second case, where you take the opposing, the prepared arch, and the buccal bite images. You can download the Korolation OBJ case files and design along. Just remember, in exocad, the upper and lower arches from “patient #2″ will automatically articulate with each other, but you will have to manual import the preop scan and merge the prepped model and the pre-op models.

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Once you import in the pre-op condition, you can manually relate the models to each other by identifying common landmarks between the two models. After you perform alignment, you can then click on “Best fit matching”. The color scheme in exocad is a great guide in letting you know how well you have articulated the models together.

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The more blue you see in the Korolated models, the more reliable your stitch is and you can be assured of greater accuracy in your final restoration.

 
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Agents Carrie Johnson and Carol BarberLamb (C2 Carrie Times Carol)

 

Happy Hump Day! We might be in your area! It’s going to be a crazy month! Here’s the 411! WE ARE SHOWING THE WORLD HOW MUCH WE LOVE DIGITAL DENTISTRY! C2 will be traveling to Utah this weekend for a show on Saturday….
North Carolina & South Carolina Sunday & Monday!
Send us a PM if would like a demo! #mediti500 #c2style #welovedigitaldentistry
Grady Dix Armen Mirzayan Frank Weinstein Carol BarberLamb

Posted by Carrie Mcnabb Johnson on Wednesday, October 10, 2018

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Clinical Reasons to use Digital Impressions

There are many clinical advantages to taking digital impressions over traditional ones. Some of these concepts you may not appreciate until you are a user.

We break these down into the following categories:

  • digital impressions / models can be edited
  • digital impressions can be captured independent of time comstraints
  • Sequencing of image acquisition is irrelevant
  • Occlusion and contacts require minimal effort and give predictable results

 

EDITING IMPRESSIONS AND MODELS

 

INDEPENDENT OF TIME

 

SEQUENCING FREEDOM

 

PREDICATABLE CONTACTS AND OCCLUSION

For single unit restorations, all you need to really capture, besides the margins, are the contacts of the adjacent teeth and the occlusal surface of the opposing teeth that will make contact with the restoration.

With traditional impressions, to get predictable results, you should capture both arches completely so when the lab pours up the models, they can properly tripod the casts for accurate relationships between upper and lower arches.  With digital impressions, you can just capture the immediate teeth adjacent to your prep and the opposing and get a very predictable result.  Now, the more data you capture with the digital impressions, the more it will help with designing the restorations.  For example, you can better align the cusp tips in relation to the arch form.

In this video, you can see how there are some “holes” in the model, but they play no role in the final result and its is unnecessary to capture them.  You certainly can if you wish, but the point is that capturing the bite is so much easier for single units with digital than it is for traditional impressions

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What Milling Machine Works with the Medit i500?

This a very common question we get at CAD-Ray.com and it reflects on how little dentists understand about digital impressions and CAD/CAM in general.

“Digital Ready”

It reminds me of a dental conference I want to, fresh out of school, placing orders for our  start-up practice.  As we went to the X-Ray equipment section, one of the first things the representative said to us was that their machines are “Digital Ready”!  We all had good laugh explaining to the rep that the machine had nothing to do with digital X-Rays, the sensors did!

We feel the same way with digital impressions and CAD/CAM platforms when people talk about integration and making sure one “product talks to the another ” and how it all needs to be developed by the same single manufacturer. It’s loaded with a lot of inaccuracies and misrepresentations.

The reality is that every system has its flaws and can have just as much trouble talking to a machine manufactured by the same company! As dentists, we are much smarter with our decision processes now, but it is still a buyer-be-ware landscape.

Here are some basics you should appreciate before committing to a high ticket item. It’s imperative to understand that imaging has little to no impact on milling. These are completely independent processes- let us explain:

You can image (take an intra-oral scan) with system A. Then you can take the data from system A and take it to CAD software of system B.  A lot can go wrong here at this step alone. Simple examples include;

  • The patient name doesn’t come along with the data.
  • Incorrect data may come across with incorrect information- you can have the occlusal relationship look perfect in system A but when it goes to CAD, the bite can be off.
  • You mark your margins in A, but they are distorted in cad software. So you have to make sure this works.

Keep in mind that this can even happen if you stay within a “System A” or “complete system”.  Luckily a lot of this is ironed out already with legacy and legitimate products and competent practitioners.  Now comes the design step. You have a few choices; exocad and 3shape being the leaders.  If exocad does the margin placement and the final restoration from start to finish, a lot of errors are eliminated.

After the design process, comes the nesting and manufacturing. At this step, the milling machine has NO idea what iOS you have used. It’s just data for a restoration that it needs to process.  Ar this most vulnerable step, we need to make sure the CAM software for a particular machine can interpret the design software that did the nesting.  A lot happens here;

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  • How’s the restoration positioned in block?
  • What size block / puck?
  • What materials? What speed? What detail?
  • What are sizes of burs in mill, etc…

Then comes the consideration for your milling needs.

  • You can mill soft ceramics for 15,000$
  • For a little more, you can wet mill emax
  • Cross the 30k barrier with and you can cut zirconia (we do NOT recommend in office zirconia- dumbest thing you can do)
  • Closer to 40k and you can do in house metal custom abutments.
  • Over 40k you can mill roundhouse bridges and you are as much a labtech as a dentist.

The trickiest part of all this is the last step. Making sure the mill has the right cam to talk to design software. This can be a nightmare if you don’t do your homework.

So, with the Medit iOS you can mill to any machine. You can even take it to cerec inlab software and Jump through a lot of hoops to mill with CEREC chair side milling machine. Not worth the headache!

The CEREC chairside mill remains the fastest carver of emax restorations, but it can come at a cost – you need to bulk out the margins so they don’t break off at mill.

 

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Not Enough Clearance? No Problem!

Upon preparing the second molar for full cuspal coverage, the lack of clearance necessitated a refining the preparation. The great part of digital dentistry is that you don’t have to take a whole new impression.
You can just selectively crop out the area that needs refinement, protect the areas you are satisfied with, and fill in the areas that are missing data. You can see how this case was managed in this video and how the final buccal bite was captured. We always recommend that you capture the bite at the last step so that you can verify clearance through the camera itself.

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WATCH THE DESIGN AND IN OFFICE MILLING OF THIS RESTORATION

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Crisp Margins that Pop Out!

It was a long struggle to find margins with the Omnicam and after 4 years it was sold. The margin definition and resolution never reached an acceptable level. After seeing margins from high resolution scans by the Medit and defining them in exocad, it completely validated that we shouldn’t settle for anything less than the highest standard. This is an scan performed on a upper second molar with tough access, replacing a failing crown.

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Download STL
Download OBJ
Download PLY

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LAST X-RAY IS IMMEDIATE POST OP- EXCESS CEMENT WAS REMOVED AFTER FILM CHECK

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Premolar Onlay Captured in High Resolution Mode

This article demonstrate how a case be set up while the patient is being anesthetized. While waiting for it to take effect, your team can scan the opposing arch, the arch to be prepared, and even the buccal bite. You can see how that is set up in first video. Notice how we crop out the tooth to be prepared so that the software doesn’t get confused between the preop and prep stages.

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Once the tooth is prepared, the premolar is imaged back into the arch form in high resolution mode. This mode comes in handy for picking up the enamel that is exposed at the cavosurface margins. Some intra-oral imaging systems struggle with picking up the detail in these situations.

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You can see how clearly discernible the margins are in this preview. Feel free to download the case data at the end of the article. Please note that areas that are not critical for the restoration design were essentially ignore as they play no significant role in the desired outcome.

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Download STL
Download OBJ
Download PLY

 

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exocad DentalCAD and exocad Chairside (CS)

What is Exocad?

  • Exocad is a powerful software that can import any STL, OBJ, or PLY file from any digital impression system, design a restoration, and fabricate it by outputting to either a milling or printing machine.  This is a very simplified explanation and CAD-Ray will guide you through the process.

What is the difference between Exocad DentalCAD and Exocad Chairside (C.S) ?

  • Exocad DentalCAD is utilized by over 35,000 users worldwide and is a very powerful software that allows you to design and fabricate a wide range of restorations, ranging from single units to bars and removable dentures.  It may be overkill or intimidating to a dentist or for chair-side, so the alternative is the C.S. platform.  Be aware that the DentalCAD system has many add-on modules that the C.S. version does not, as you can see in the attached table
Add-On Module Exocad DentalCADExocad Chairside (C.S.)
Bite Splint ModuleYesYes
Provisional ModuleYesYes
TruSmile TechnologyYesYes
Custom abutmentsYesComing Soon
Screw-retained bridgesYesNo
Standard barsYesNo
Complex barsYesNo
Create physical modelsYesNo
Bite Splint ModuleYesNo
Full denturesYesNo
Partial framework designYesNo
Virtual ArticulatorYesNo
Smile DesignYesNo
Jaw Motion ImportYesNo
DICOM ViewerYesNO

 

What are the pricing and software options for Exocad DentalCAD?

SOFTWARECAD-FLEX CAD-PERMANENT
Price$2600$5000
PERPETUAL Yearly Maintenance Fee$1500N/A
Software still functions if you opt out, but no new features will be added
OPTIONAL Yearly Fee for UpdatesN/A
Software stops functioning without yearly fee.		$1200
For continuous software updates
Implant Restorative Module$500 / Year (Perpetual)
FDA regulations mandate yearly updates		$ 1200 one time purchase with yearly optional $450 updates
Provisional Module$250 / year (Perpetual)$600 one time purchase with yearly optional $150 updates
Bite Splint Module$350 / year (Perpetual)$ 1200 one time purchase with yearly optional $450 updates
Implant PlanningComing SoonComing Soon

 

What are the pricing and software options for Exocad Chairside C.S.?

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Full Mouth Reconstruction with Medit i500

To see this case presented in webinar fashion click on the image and enter the members area for much greater detail and information

Pre-existing restorations that warranted replacement with an increase in vertical dimension.

Pre-existing restorations that warranted replacement with an increase in vertical dimension. The upper and lower arch were captured with the medit I500 and articulated together with enough clearance to accommodate new restorations and to restore the patient to an ideal tooth position.

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This video shows how the vertical dimension was captured with cotton rolls blocking out the tongue and the dark oro-pharynx, which usually spell trouble for an IOS

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The digital models were then imported into a third party software where a library of tooth morphologies are available for the clinician to choose from.

Once the appropriate library is chosen, the digital wax ups are performed. In the subsequent photos you can see the transparent overlay of the wax-ups to the original position of the existing dentition

 

Once the case is designed to the ideal vertical dimension then multiple shells can be fabricated for treatment. The wax up model can be uniformly reduced by .5mmm’s circumferentially and a temporary shell can be designed. Once the teeth are prepared, these shells can be relined and seated onto the preps.

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PREP AND TEMPS

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How was this done? Watch this video of how the case was imaged over a 4 hour time span in multiple segments

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FIRST VERTICAL DIMENSION
The initial vertical dimension was greater than desired and the tooth shape was too bulky in appearance.

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ADJUSTED TEMPORARIES AND NEW VERTICAL DIMENSION
Over the course of a few appointments, the vertical dimension was reduced and the temporaries were adjusted to the patient’s desires. The new upper and lower arch were captured with the Medit i500 and the jaws were related to each other.

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This was then imported into exocad where the prepped arches from a few weeks prior were force matched to the new bite

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After the upper jaw was related to the temps, the same was done with the lower arch. Great care was taken to make sure the arches were properly related to each other throughout the process

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CASE DESIGNS

The case was designed by CADENT BESSA, and the models were printed by Burbank Dental Lab with Carbon Printers. There restorations were milled and cut back and layered by Burbank Dental Lab

IMAGES OF PRINTED MODELS

 

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IMMEDIATE POST-OP PHOTOS AND VIDEO WITH IPHONE CAMERA

 

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ONE WEEK POST-OP RADIOGRAPHS / CEMENT CHECK

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Settings for Meditlink Scanning

 Video 1Video 2Video 3Video 4Video 5
High Resolution ScanningNoNoNoNoYes
Automatic Noise FilteringYesYesNoYesYes
Show Unreliable DataYesNoYesNoNo

 

Video 1- Show Unreliable Data and Automatic Noise filtering (High Resolution Scan off)

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Video 2- Use Automatic Noise filtering / Do Not Show Unreliable Data and High Resolution Scan off)

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Video 3- No Automatic Noise-filtering / Show Unreliable Data

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Video 4- Do Not Show Unreliable Data and Do Not Use High Resolution Scanning / Use Auto Noise Filtering

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Video 5- Do Not Show Unreliable Data / Use Automatic Noise Filtering and High Resolution Scan

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The Toughest Scan of All

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Denture Duplication with the Medit i500 for Guided Implant Planning and Surgery

When planning for guided surgery in edentulous patients, it is important to have the final vertical dimension and tooth position determined. Ideally, a denture duplicate should be used with proper radiographic markers.

The traditional way was to embed radio-opaque material in the denture dupe, CT scan the patient with the denture dupes, and then CT scan the denture dupes themselves. Alternatively, you can scan the denture duplicates with a digital impression system. Here we used flowable composite and spread them through the wax set up and take a 3D X-ray of the patient. We then use those landmarks to merge the data sets between the digitize denture and the markers on the CT Scan

 

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Once the dentures are digitized and merged with the CT data, the cases is analyzed to make sure there are no gaps in between the intaglio of the denture and the soft tissue of the palate and the lower / mandibular ridge

An important concept to keep in mind for these edentulous cases is that you actually need 2 models for each arch. One model is used for tooth positioning and implant design, and the other model is used for stent design. Essentially, you design the stent on the ridge, not the denture dupe

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Virtual Extraction for Implant Planning

One of the biggest hassles in most software is to plan a guided surgery case when the tooth is still present in the arch. Some software will force you to part-take in pylon course handling, gymnastics maneuvers, musical chairs, and multiple imports and exports. The issue revolves around the placement of the sleeve / ring in the design step. Usually you are forced to manipulate the data in 3rd party software and then bring it back with the tooth virtually extracted.

This article is about how you can scan the arches and export the STL, OBJ, or PLY data from the Medit i500 scanner. You can then clone the same case and alter it- namely, you can crop out the tooth that will be extracted in the future. This video shows you how the virtual extraction is performed.

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The multiple data sets are then imported in BlueSkyBio software where there are no limits to the number of models you can bring in. In the following video, you can see how the complete upper arch, the virtually extracted lateral arch model, and the opposing are brought in an merged with the CT Data.

The implant is planned for fully guided procedure and a surgical stent is manufactured on the model that has the virtual extraction. You cannot design a stent correctly with the tooth present in the equation. Open architecture and speedy results are the name of the game now with CAD/CAM dentistry. As you can see, these steps are super fast and easy with the open licensed Medit Scanner

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Download the STL
Download the OBJ
Download the PLY
Download the BSB file and design along

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Digital Impressions for Obstructive Sleep Apnea Appliance

This article documents how to capture upper and lower scans for an oral appliance to treat obstructive sleep apnea. The patient was recently diagnosed with mild sleep apnea with a Home Study Test which revealed quite a lot about his sleeping habits and patterns.

The patient decided to pursue treatment with an oral appliance in lieu of CPAP therapy. Upper and lower impressions were taken, and the occlusal relationship was captured in protrusive and with the vertical dimension set a a tolerable distance. Cotton rolls were used to block out the movement of the tongue which usually interferes with capturing the bite.

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Once the bite is captured, we recommend that you move back to the maxilla and mandible catalog box and take additional images to complete and remaining voids in the model. At the end of the article, you can download in multiple formats to see the meshwork and the data that is rendered from the Medit i500 scanner.

Once the patient adapts to the appliance, a titration study will be conducted to measure the effectiveness of the oral appliance

Download the STL
Download the OBJ
Download the PLY

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Occlusal Guard with Digital Impressions by Medit i500

This is a case imaged for an occlusal guard, wehre the upper arch took only 43 seconds to capture. Afterwads, the lower arch is captured, and then ultimately we move to the dual buccal bite. To get enough clearance, we just have the patient bite down on two cotton rolls and hold that position.

One thing to keep in mind is that when you move from one image catalog to another, some processing is done. What we recommend you do is to actually go back to your upper and lower models and fill in any missing data or correct any artifact you may have captured inadvertently. You can see in the footage how the second molars are corrected and filled in with good information.

Note how

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Download STL of this Case
Download OBJ of this Case
Download PLY of this Case

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Checking Occlusion with Digital and Clinical Landmarks for a Clear Aligner Case

Here’s a clear aligner case where the upper and lower arches were scanned and the buccal bite was taken with the Medit i500 IOS system. Prior to the digital impressions, occlusal markings were made with articualting paper so we can verify the accuracy of the digital bite

In the video, which is sped up, the upper and lower models were corrected when parts of the tongue or cheek were inadvertently incorporated into the models. There are some cool features in the software that allow you to protect areas that you previously captured corrected and areas where you can fill in with new information.

After the models were articulated and the occlusion was verified, the case was exported to BlueSkyBio software for orthodontic planning. You can download the date and design along.

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Download OBJ
Download STL
Download PLY
Download BlueSkyBio Ortho Plan