T he room was filled with tension and excitement as the lights were slowly dimmed in the auditorium. The next 2 hours offered a glimpse of the future ofdentistry. The topic was something out ofa scie nce- fict ion nove l, and it inst ille d in the audience a sense of awe, wonder, and just a touc h of fear . As the auditor ium lights came up, everyone sat in stunned si- lence as they contemplated all the possibil- ities offered by the presenter: dentistry go- ing digital. That presentation was given more than 20 years ago by one of digital dentistry’s pioneers, Francois Duret, on the applica- tion of computer-assisted design/computer- assisted manufacturing (CAD/CAM) tech- nology for res torative dent istr y . While it took sli ghtl y longer than anti cipated to inte grate into the dai ly practi ce of den- tistry, the new millennium seemed to in- clud e the catalys ts for change in digi tal dentistry, as more than 10 different CAD/CAM systems have now been introduc ed as solutions for restorative dentistry. Dentistry has cautiously welcomed this influx of technology that was promised so long ago . Bas ed on tec hnology adopted from aerospace, automotive, and even the watch-making industry, this technology is now being accepted due to its advantages of increased speed, accuracy, and efficiency without a compro mise in quality . Today’ s chairside and laboratory-based CAD/CAM systems, such as Procera (Nobel Biocare), Lav a (3MESP E),Cerco n (DE NTS PL Y Cer am- co), CEREC (Sirona), and E4D (D4D Tech- nologies), just to name a few, are being used to desi gn and manu fact ure metal, alumina, and zirconia frameworks, as well as all-cera mic and composite full-contou r crowns , inla ys, and vene ers . All the res- torations manufact ured in this way may be stronger, fit better, and have the possibility to be as or more aesthetic than rest ora- tions fabricated using traditional methods . REDEFINING ROLES AND RELAT IONSHIPS The pri mar y role of the dentist, dental team member , and dental technici an in indire ct resto rative dentist ry is to copy perfectly all functional and aesthetic pa- rameters, as defined by nature, into a re- storative solution. It is an architect-builder relations hip. Througho ut the entire restor- ative process —fr om the init ial consulta- tion thro ugh trea tment planning, pro vi- sio nali zati on (if need ed), and final plac e- ment—the communication routes between the clinician and the laboratory technician require a complete transfer of information. This includes any informatio n pertainin g to existing, desired, and realistic situations and expectations, to and from the clinical environment. Functional componen ts, oc- clusal parameters, phonetics, and aesthetic require ments are just some of the essential types of information that are necessary for the technician to successfully complete the fabrication of excellent functional and aes- thetic restorations. The primary and conventional tools ofcommunic ation between the denti st and the technician are photo graphy , writt en doc umentation, and impres sions of the patient’s existing dentition, clinical prepa- rations, and opposing dentition. From this information, models are created and mount- ed on an articulator that simulates the jaw movements of the mandible. As res tora tive dent istr y evol ves into the digital world of image capture, comp ut- er design, and creation of dental restora- tions through robotics, our perceptions and defi niti ons of the dent al labo rato ry must also evolve. First, in order to fully under- stand this concept, we must clearly define what a laboratory is. At first thought, we might say that a labo rato ry is the place where dentists send patient impressions , whic h the laborato ry then pro cess es into restorations to be sent back to the dentist for adjustment and delivery . This defini- tion does seem to fit well with the tradi- tional concept of a dentist-la boratory work- flow. However, just as the Internet has for- ever changed the landscape of communica- tion through related computer technology, the possibility of using CAD/CAM restora- tion files electronically has provided the catalyst for a signif icant change in the 112 RESTORATIVE T h e E v o l u t i o n o f D i g i t a l De n t i st r y an d t h eD i g i t a l D e nt a l Tea m Edward A. McLaren, DDS Lee Culp, CDTSherri White, RDA Figure 1. Dental operatory with a clinical CAD/CAM unit. Figure 2. The D4D Dentist System. DENTISTRY TODAY • SEPTEMBER 2008 conti nued on page 114
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thetized and in the chair, try-in forproximal and marginal fit can be
completed chairside with assur-
ance. Once the restorations are
verified and adjusted, conventional
ceramic stain and glaze techniques
can be used, if needed. If desired,
with minimal training required,
the restorations can be aesthetical-
ly enhanced by the addition of sub-
tle colors (stains) and glaze appli-
cation using an appropriate glaz-
ing oven in the dental office (Fig-
ure 12). The ceramic chosen for
this case was Empress CAD Multi-
blocks. These ceramic milling blocks
were designed to offer optimal aes-thetics by offering varying de-
grees of color and translucency
designed into the block. This was
created to mimic the appearance of
dentin and enamel as well as the
polychromatic nature of natural
dentition (Figure 13).
RESTORATION
PLACEMENT
Next, the internal surfaces of the
stained and glazed ceramic res-
torations were etched with 5% hy-
drofluoric acid (IPS Ceramic Etch-
ing Gel [Ivoclar Vivadent]) for
one minute, rinsed thoroughly, anddried. A silane-coupling agent
(Monobond-S [Ivoclar Vivadent])
was then placed for one minute
onto the internal surfaces and
then lightly air-dried. A self-cur-
ing (chemical-curing), resin-based
luting cement (Multilink Automix
[Ivoclar Vivadent]) was selected for
final cementation. A&B primer was
mixed vigorously and scrubbed
onto all preparation surfaces. The
restorations were loaded with theappropriate shade of cement and
were seated to place; excess was
removed. The occlusal contacts
were checked and harmonized in
static occlusion, and excursive path-
way freedom was verified. Minimal
adjustments were needed due to the
correct capture and alignment of the
bite registration data.
The finished restorations, which
were designed and created by the
team effort of the author and co-
a ut ho rs w it ho ut t he a id o f a n
impression, were found to be in
functional and aesthetic harmony
(Figure 14). They were completed
in one appointment.
CONCLUSION
The dental profession currently
regards CAD/CAM technology as
just a machine that fabricates
full-contour ceramic restorations
or frameworks. Digital dentistry
and the digital den-
tal team represent a
totally new way to
diagnose, treatment
plan, and create func-tional aesthetic res-
torations for our pa-
tients in a more pro-
ductive and efficient
manner. CAD/CAM
dentistry will only
further enhance the
dentist-technician-
assistant relationship
as we move together
into this new era of
patient care.
Automation has
been slow in coming
to dentistry, and al-
though new equip-ment has been in-
troduced to make
our jobs easier, we
still create complex
dental prosthetics us-
ing old techniques.
And, even though
the “lost wax” tech-
nique is still a reli-
able method of fab-
rication, there will
come a day in the
near future when all
frameworks and full
anatomical crowns
will be designed ona computer. Only
then will we truly
realize the wonder
and awe of dental
CAD/CAM technolo-
gy that was intro-
duced to the profes-
sion so long ago.!
References
1 . Ot to T, S chn eid er D .Long-term clinical resultsof chairside Cerec CAD/ CAM inlays and onlays:a ca se se rie s. I nt J .Prosthodont . Jan-Feb2008;21 (1): 53-59.
RESTORATIVE
Dr. McLaren graduated Phi Beta Kappa andmagna cum laude from the University ofRedlands. He received his dental degreefrom the University of the Pacific School ofDentistry, where he graduated OmicronKappa Upsilon, and received his specialtycertificate in prosthodontics from UCLASchool of Dentistry. He maintains a privatepractice limited to prosthodontics and aes-
thetic dentistry in which he does all of hisown ceramics. He is the director of theUCLA Center for Esthetic Dentistry and is thefounder and director of the UCLA MasterDental Ceramist program. He is an associateprofessor in the biomaterials and advancedprosthodontic department. He is also anadjunct assistant professor at the Universityof Oregon Dental School. He can be reachedat [email protected].
Mr. Culp owns Mosaic Studios and is directorof technology and innovation at the DawsonAcademy. He maintains an active teachingschedule at these and other postgraduateteaching centers focusing on reconstructiveand aesthetic dentistry. He is the editor-in-
chief of Spectrum and associate Teamwork . He is also on the editoriaPractical Procedures and Aesthetic DCompendium , and Inside Dentistry .accredited member and currently whis fellowship for the American AcaCosmetic Dentistry. He had beentributor to 4 dental books, includingter in Dr. Peter Dawson’s book FOcclusion: From TMJ to Smile Desi
a resource/inventor for many of the mproducts, and techniques used in and holds numerous patents. Hereached at [email protected].
Ms. White is a lead registered dentant and accomplished chairsiddesigner (CDD) at a top-producinoffice, which she joined in 1998. Aftetial training with the E4D Dentist CCAD/CAM System in 2007, she was become a consultant with D4D TechShe is proficient in all aspects equipment and has successfully designed, and milled more than 160E4D full- and partial-coverage crocan be reached at white.sherri@gma