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www.ajlobby.com www.ajlobby.com Contents Acknowledgments Preface About the Authors Part One 1.1 The History of CAM/CAM in Dentistry Introduction Dental CAD/CAM Evolution Dental CAD/CAM Today Summary Supplemental Reading 1.2 Digital Scanning and its Applications Introduction Components of Digital Scanners for Dentistry Applications of Digital Dental Scanners CAD/CAM for Occlusal Analysis Summary Supplemental Reading 1.3 Optimizing Preparations & Gingival Retraction for Scanning Introduction Preparation Guidelines for Digital Impressions Tissue Management Summary Supplemental Reading 1.4 Designing Restorations Introduction Restoration Design Digitally Designing Restorations Summary Supplemental Reading 1.5 Materials Optimized for CAD/CAM Introduction Materials for Milled Restorations Materials for Milling Dentures Materials for 3D Printed Restorations Summary www.ajlobby.com Supplemental Reading 1.6 Manufacturing and Milling Technologies Introduction Subtractive Dental CAD/CAM (Milling) Process Selecting Milling Machines Additive Dental CAD/CAM (Printing) Processes Summary Supplemental Reading Part Two 2.1 The Digital Workflow and Its Variations Introduction Interoperability: Closed or Open Architecture File Splitting In-office Same Day Dentistry, Diagnostics & Record Keeping Laboratory Processing Workflow Collaborative Treatment Planning Digital Denture Planning & Fabrication Summary Supplemental Reading 2.2 Role of Cone Beam Computed Tomography Technology in CAD/CAM Basic Principles of CBCT Scanning Technology Principles of CBCT Image Quality Influence of Various Scanning, Reconstruction & Artifacts on Image Quality Principles of CBCT 3D Image Reconstruction Applications of CBCT in the CAD/CAM Workflow & Integration With Other Imaging Modalities Summary Supplemental Reading 2.3 Same Day Dentistry Introduction Challenges Summary Supplemental Reading 2.4 CAD/CAM for Anterior Full-Coverage Restorations Introduction Analog Waxups/Digital Design & Fabrication Completely Digital Diagnostics, Planning, Design & Fabrication Summary Supplemental Reading 2.5 Implant Treatment Implant Treatment Summary Supplemental Reading www.ajlobby.com 2.6 The Application of Digital Technology to Denture Fabrication Introduction Essentials: Clinical Information Needed for Denture Fabrication Current Digital Denture Systems Clinical Procedures in the Digital Denture Workflow CAD/CAM Design & Prototype Manufacture Case Study Summary Supplemental Reading 2.7 The Digital Era of Orthodontics Introduction Understanding Aligner Capabilities & Limitations Digital Orthodontic Aligner Processes Patient Report Moving Forward Summary Supplemental Reading 2.8 CAD/CAM Technology in Dental Education Introduction The Solution: CAD/CAM Technology Student Response to Computerized Preparation Evaluation Clinical CAD/CAM Dentistry in Preclinical Dental Education CAD/CAM During the Clinical Years Summary 2.9 Additional Considerations Overview Summary Supplemental Reading www.ajlobby.com Fundamentals of CAD/CAM Dentistry The American College of Prosthodontists Copyright © 2018 American College of Prosthodontists Education Foundation All Rights Reserved www.ajlobby.com Acknowledgments The American College of Prosthodontists (ACP) acknowledges Dr Jonathan L Ferencz and Dr Nelson R.F.A Silva for their generous contribution of their expertise and content for Fundamentals of CAD/CAM Dentistry The authors wish to acknowledge Henry Schein for their generous support in underwriting the ACP Educational Standards Revision project In addition, we are grateful to Ivoclar Vivadent for their generous grant to help offset the cost of this text We also thank Allison DiMatteo for her tireless efforts in providing editorial assistance All proceeds generated from the book will be donated to the ACP Education Foundation www.ajlobby.com Preface This book is meant to be used as a supplemental learning tool along with the ACP's Digital Dentistry Curriculum The book is structured into fifteen sections, compiled into two main chapters The sections include learning objectives, supporting material, summaries and reading lists The American College of Prosthodontists is working to ensure that prosthodontists are prepared to lead the emergence of digital dentistry in clinical practice To access and view additional resources available, please visit the Digital Dentistry Resources page of the ACP website We hope these learning tools will be instrumental in your Digital Dentistry education www.ajlobby.com About the Authors Dr Jonathan L Ferencz B.S, Rensselaer Polytechnic Institute DDS, New York University College of Dentistry Advanced Education in Prosthodontics New York University College of Dentistry Diplomate American Board of Prosthodontics Clinical Professor of Post-Graduate Prosthodontics New York University College of Dentistry Adjunct Professor of Restorative Dentistry at the University of Pennsylvania School of Dental Medicine Clinical Professor of Dental Medicine at Columbia University College of Dental Medicine Past-president, the Greater New York Academy of Prosthodontics Past-president, the Northeastern Gnathological Society Past-president, the American College of Prosthodontists Dr Nelson R.F.A Silva Professor at Departamento of Operative Dentistry at UFMG, Brazil MSC, Prosthodontics/Biomaterials at University of Sao Paulo, Brasil PhD, Prosthodontics/Biomaterials at University of Sao Paulo/New York University www.ajlobby.com was finalized The file is split to enable fabrication of the zirconia substructure Figure 2.9-5 The zirconia substructure was tried on the stone model Figure 2.9-6 A bonding liner was applied to the zirconia substructure Figure 2.9-7 The substructure was tried onto the stone model with the putty impression/matric in place to demonstrate the build-up of veneering ceramic required Figure 2.9-8 To prepare for pressing the veneer ceramic onto the zirconia framework, an eye dropper was used to apply molten wax Figure 2.9-9 The waxed zirconia framework was then pressed with layering ceramic Figure 2.9-10 The veneered zirconia bridge was tried on the stone model Figure 2.9-11 The restoration was characterized with stains and then glazed Figure 2.9-12 Occlusal and intaglio views of the completed 3-unit bridge restoration Figure 2.9-13 Occlusal and buccal view of the completed restoration following cementation FULL - CONTOUR ZIRCONIA Figure 2.9-14 Here, the same fixed 3-unit bridge will be fabricated differently Based on digital scans of the analog impressions and analog stone models, a full-contour zirconia bridge will be created using CAD software Figure 2.9-15 When the full-contour CAD/CAM zirconia bridge is returned from the laboratory or milling center, it is tried onto the stone model to verify fit Figure 2.9-16 The full-contour zirconia bridge can then be characterized using stains and glazes Figure 2.9-17 Occlusal characterization can also be completed with occlusal tints Figure 2.9-18 View of the finalized full-contour 3-unit zirconia bridge on the stone model Figure 2.9-19 View of the completed restorations in the mouth MILLED ZIRCONIA SUBSTRUCTURE WITH A SEPARATELY MILLED DISILICATE VENEER SHELL BONDED ON TOP Figure 2.9-20 A third approach to creating the same restoration began by digitally scanning the stone model of the preparations to create a digital model with this to mark margins, establish connector and abutment parameters, etc LITHIUM Figure 2.9-21 The CAD software was directed to construct a zirconia framework, and the program generated a design proposal that accounted for the preparations, as well as the opposing teeth The CAD software articulated the restorations with the opposing arch Figure 2.9-22 However, most significant to the design and manufacturing process was the ability of the CAD software to split the file in order to separate the zirconia framework design from the outer lithium disilicate ceramic layer design This would enable the two separate restoration components to be milled simultaneously, but at separate milling facilities and from different materials Figure 2.9-23 View of the milled zirconia framework and the lithium disilicate veneering overlay Figure 2.9-24 The zirconia framework and veneer overlay were tried together to ensure an intimate fit Figure 2.9-25 Intaglio and buccal view of the framework and overlay together Figure 2.9-26 A connecting cement was applied, the lithium disilicate overlay placed, and the entire restoration fired to cure the connecting cement Figure 2.9-27 View of the 3-unit bridge restoration after the lithium disilicate overlay has been cemented onto the zirconia framework Figure 2.9-28 The restoration was further characterized with stains and glaze after firing to cure the cement Figure 2.9-29 Occlusal and intaglio views of the completed restoration Figure 2.9-30 Occlusal and buccal view of the completed restoration in the mouth Additionally, digital files will enable clinicians to maintain baseline patient information regarding tooth structure, underlying bone quality/quantity, fractured teeth, and other conditions for future reference and collaborative treatment planning Among the digital technologies that will shape how dentists monitor patients will be computerized occlusal analysis devices, which could be used in combination with digitally scanned facebows and digital articulation Similarly, other enhancements to intraoral optical scanners are enabling imaging of other aspects of the jaw and entire quadrants, including preparations, adjacent teeth, and opposing teeth The relationship of the upper and lower teeth to each other can also be scanned intraorally, either via intraoral bite registrations or scanning from the buccal aspect This data can then be used to design occlusal surfaces and/or assess uneven wear patterns that could indicate occlusion problems When data from these diagnostic tools is integrated with other biometric findings (e.g., jaw motion trackers, SICAT, Galileos/Sirona) that indicate the presence of stomatognathic disease and dysfunction (i.e., temporomandibular joint disorder), an ideal and comprehensive treatment plan can be developed Because this information is digitally based, it can subsequently be incorporated into restorative and, if need be, surgical planning Further, concepts of using facial scans, combined with CBCTs and intraoral scanning, are also advancing very rapidly, and this approach demands attention for the future Additionally, as additive manufacturing processes evolve and improve for dental applications (i.e., 3D model printing), more cost-effective and efficient approaches for ensuring patient satisfaction and added control over such restorative aspects as contact points, occlusion, and soft tissue architecture will be realized (Figure 2.9-31) Even if dentists and laboratories choose to continue working with models when finalizing restorations, digital technology can still be beneficial by contributing to accurately produced 3D printed model alternatives Figure 2.9-31 View of two distinct soft tissue models, both of which were created from CAD files capable of being split and electronically transferred to different 3D printing facilities Clearly, application and utilization of digital intraoral scanning will increasingly alter traditional dental workflow models Similar to an x-ray machine present in each treatment room, dental offices of the future may include a scanner in each operatory (or portable intraoral scanner carts), and every new patient appointment will include a digital scan as part of the initial evaluation Summary The ongoing enhanced development of CAD/CAM software, milling units, intraoral scanners, and other digital technology will continue to change how dental professionals work and collaborate to deliver consistent and quality treatments As more professionals invest in digital technologies, the potential to improve efficiencies, reduce costs, and contribute to more treatments for patients will increase However, of paramount importance to future developments and the widespread acceptance of CAD/CAM and digital dental technologies will be “plug-and-play” open architectures, as well as more intuitive file splitting capabilities Similar to the evolution of interoperable computers or digital cameras, closed systems will ultimately disappear to enable users to select the equipment of their choice (e.g., scanners, design software, manufacturing techniques, dental materials) For this to occur, file formats and devices will need to be standardized for easy integration Supplemental Reading Att W, Girard M Digital workflow in reconstructive dentistry In: Ferencz JL, Silva NRFA, Navarro JM, eds High-strength Ceramics: Interdisciplinary Perspectives Quintessence Publishing Co, Inc Chicago, IL, 2014: 260–77 Child PL Digital dentistry: Is this the future of dentistry? Dental Economics 2011; 101(10) Duke ES Taking the mystery out of CAD/CAM in dental practice Compend Contin Educ Dent 2004; 25(2): 140–3 Fasbinder D Using digital technology to enhance restorative dentistry Compend Contin Educ Dent 2012; 33(9): 666-8, 670, 672 passim Ganz SD The next evolution in CBCT: combining digital technologies A precise approach to planning dental implant reconstruction enhances accuracy Inside Dentistry February 2012; 9(2) Mehl A A new concept for the integration of dynamic occlusion in the digital construction process Int J Comput Dent 2012; 15(2): 109–23 Olitsky J Digital impressioning: on its way to becoming mainstream Compend Contin Educ Dent 2012; 33(9): 692–3 Pakkala T, Kuusela L, Ekholm M, et al Effect of varying displays and room illuminance on caries diagnostic accuracy in digital dental radiographs Caris Res 2012; 46(6): 568–74 Patel N CAD/CAM and 3-D vision beyond expectations, both clinically and in business Dental Economics 2014 Shull GF An update on CAD/CAM dentistry Dental Learning 2015; 4(2): 1–9 ... College of Dentistry Adjunct Professor of Restorative Dentistry at the University of Pennsylvania School of Dental Medicine Clinical Professor of Dental Medicine at Columbia University College of. .. chairside CAD/ CAM dentistry Inside Dentistry October 2012; 76–81 Helvey GA Zirconia and computer-aided design/computer-aided manufacturing (CAD/ CAM) dentistry Inside Dentistry 2008; 4(4) Patel D CAD/ CAM. .. History of CAM/ CAM in Dentistry Introduction Dental CAD/ CAM Evolution Dental CAD/ CAM Today Summary Supplemental Reading 1.2 Digital Scanning and its Applications Introduction Components of Digital