	According to research, people speak on average 16,000 words per day. Yet among all those words, all too often important details are left uncommunicated. Fortunately, some of these details can be shared through photography.

It has been said that approximately 80 percent of restorative cases are being sent to the lab without any type of patient photography. Also often missing are bite records and facebow registration records. Without this information, the lab technician may be left to guess the best place to mount models on an articulator.

Cover story: Understanding the latest breakthroughs in dental technology

	There are three results that can happen if one guesses where to mount the models:

		the lab tech was really good at guessing and the restoration created on the model fits well

		the dentist will need to use valuable chairtime to adjust the restoration in the mouth

		the restoration will be sent back to the lab to be reworked, causing the dentist and patient both to reschedule their time

Technique: How going digital can revolutionize dental esthetics

	In 2015, Whip Mix introduced new technology into the dental market to help make it easier to capture some of this patient information. The new product is an app called 

, which uses photography taken on a tablet to capture vital patient landmarks that show the relationship between the upper teeth and the patient’s head. This photo with landmarks can then be sent to the laboratory for mounting models on most Denar, Hanau and Whip Mix articulators.

	Head to the next page to learn about this helpful procedure ...

 can be used in the practice for many cases, including esthetic, edentulous and three-plus unit restorations. Max, through photography, will capture the patient’s facial midline, horizontal cant and anterior/posterior angle. 

	Set the tablet parallel to and about 8-10 inches away from the patient’s face. It is recommended that the patient use retractors to give you the most accurate view of the teeth.

Fig. 01 Taking the photograph of the patient.

	Next, line up the patient’s facial midline with the vertical red line, and the horizontal edge of the centrals with the red horizontal line. Click “Arm Auto Capture” to take the photo (

). There will be a two-second delay before the picture is taken.

	To complete the next step, measure the width of the patient’s central in millimeters. This measurement will be used to size the photo that you have taken (

Step-by-step: Creating surgical guides with the digital workflow

	Increase or decrease the size of the photo until the patient’s centrals fit inside the skeleton of the teeth. Press “OK” to save the photo. This step will ensure that the focal point of the camera gives the lab a correct 1:1 ratio from the tablet to the mounting stand.

Fig. 03 Determining the first point of contact and the width of the centrals.

	If mounting the models in centric relation, determine the patient’s first point of contact. Document this on page three (

). The lab will then be able to confirm this contact on the models when they are both mounted. Otherwise, leave blank, and save.

	With these three easy steps, photography and records establishing the relationship between the upper teeth and patient’s head have been captured and saved to be used in mounting the models as well as for patient documentation.

	Having this information in the lab will help ensure that the model is not mounted incorrectly causing the final restorations to be canted, or the midline be off, or both.

Fig. 04 A mounted case that looks right, but isn't.

	This case was mounted from impressions without any photography or records. With the information available, the mounting looks accurate (

	In reality, both the facial midline and mandibular midline are off center. The actual patient’s facial midline is the black line to the left of the frenulum in the pink, and the mandibular midline is between the second and third teeth starting from the left. Imagine how a restoration made from this mounting would fit.

	The dental lab will use the tablet attached to a labstand that should sit on a stable counter that is high enough so the lab technician can sit directly in front of the tablet. The labstand can be attached to the counter if desired for additional stability. The lab technician will look through the image on the tablet, and putting both arms around the tablet, adjust the model on the occlusal stand behind the tablet.

Fig. 05 Using MaxAlign in the lab with a stand.

	The lab will use Max in conjunction with a labstand for mounting the maxillary model (

). While looking through the photo of the patient, the model on the lab stand will also be visible. By moving the blue capture bar from one side to the other, the transparency of both images can be increased or decreased.

	The lab technician will tilt the stand so that the model on the stand is in the exact same position as the teeth are positioned in the photo.

	Fig. 06 The lab uses a model for verifications via the MaxAlign.

	Once the model is positioned correctly on the stand, the lab technician will take a photo of the model for verifications (

). Both the photo of the patient and the photo of the model can then be enlarged to ensure the mounting is accurate.

	The photography and records captured by Max take minutes to do, and may save a great deal of time and stress later if the restoration needs to be reworked.

Q&A: The reality of technology in the modern workflow

	Max is an easy and fun communication tool for both the dentist and the lab to share the needs of the patient, and to document the patient’s case. This information, when received, helps everyone produce great looking and fitting results. Save a thousand words each day with every picture taken by Max.

Articles

Lorena Lighthart, product manager at Whip Mix, explains how the MaxAlign App can improve esthetic results and workflow through digital photography and a tablet computer.

How to: How a tablet computer can help with esthetics

Implantology is one of the biggest growth areas in dentistry. The CEREC

 systems are an ideal way for dentists and laboratories to work closer together to create added value for their services. Dentsply Sirona’s CEREC and inLab systems continue to support dentists and dental lab technicians with their implantology cases. 

	To simplify the process, the two softwares work together to facilitate a joint workflow between the dentist and lab. This step-by-step case shows how we used the 

 for a completely digital fabrication of an implant surgical guide.

Related: Understanding's Sirona's game-changing digital solutions

With CEREC Guide 2 and inLab SW 15, Dentsply Sirona provides dentists and laboratories the technology needed to expand their offering to include guided surgery. This will allow more doctors to safely place implants. Using these softwares, the clinician can communicate data with inLab SW 15 owners for fabrication of surgical guides without analog models or impressions. 

Technique: How technology makes global collaboration a reality

	The CEREC and inLab 15 SW integrate seamlessly, allowing a laboratory to create a precise surgical guide using implant data from the doctor’s implant planning.

	Head to the next page to go step-by-step ...

Optical impressions (a digital scan) of the case were obtained by the doctor using 

 A virtual tooth (digital wax-up) was designed for the patient using the CEREC 4.4 software.

 The virtual wax-up design was imported as a *.ssi file and sent to the 

 (cone beam computed tomography) reading workstation.

 The CBCT scan was acquired using Dentsply Sirona Galileos.

The GALILEOS CBCT scan provides 3D diagnostic imaging for comprehensive dentistry and diagnostics.

The *.ssi file from the digital wax-up was integrated within the GALILEOS implant software.

The virtual wax-up was then integrated into the CBCT scan. 

Integrated implant treatment planning software allows the clinician to virtually plan implant placement in 3D.

A cross-sectional image showing the integrated CAD/CAM virtual restoration with the planned implant.

A volumetric analysis of comprehensive implant planning.

The implant sleeve system was modified to the CEREC Guide 2 for guided surgery.

A comprehensive implant plan was exported to the laboratory’s inLab SW 15 via a completely digital workflow.

A view of the inLab SW 15 importation of a comprehensive implant plan. 

 was selected as the definitive material for the surgical guide milling. 

The lab then trimmed the digital model for the design of the implant surgical guide directly in the software.

Parameters were set for specific fit and thickness of the surgical guide.

Sleeve and design tools for the surgical guide are also available to the inLab SW 15 technician. 

An automatic proposal of the surgical guide was then displayed in the inLab SW 15 with various tools available to modify the design (i.e. addition, removal and integration of viewing windows).

Positioning of surgical guide within the inCoris PMMA material disc using inLab SW 15.

A sample of the inCoris PMMA guide disc before milling.

The laboratory was then able to produce a completed milled surgical guide using the inLab MC X5 milling machine.  

Removal of surgical guide from milled disk.

The clinically seated surgical guide for guided surgery.

This step-by-step technique from Dr. Neal Patel and Marina Caponigro, MDT shows how digital tools from Sirona Dental can be used to create incredible surgical guides.

Technique: An integrated surgical guide workflow

	We rely on digital advancements and technology as an integral part of our own day-to-day lives, and the rapid advancement of digital technology for the dental industry means that we can’t ignore it in our professional lives either. 

	Since our lab began accepting digital scan files more than six years ago, we have seen firsthand how digital scan files can improve dentist/lab communication, contribute to overall increases in efficiency, and enable better accuracy. More and more dentists are beginning to adopt digital scanning technology, and the results we’ve seen in our lab make it clear that this is a technology that has numerous benefits to dentists, labs and patients. At D&S Dental Laboratory, the integration of digital technology is key to our success. It enables easier client communication, more efficient workflows and better overall results. 

With traditional impressions, there is more time and energy involved in the process before we may detect an issue. When our lab encounters an issue with a digital scan, we can quickly call the dentist and email them the scan file. Then, we simply point out in real time where any details are missing from a scan, and we can get the final product to our customers quicker. When we communicate with our dentists about the benefits of digital scanning, time-savings is certainly a popular topic.

	To that end, we make it a top priority to utilize a digital workflow for as many steps as possible. Our lab can receive digital scan files from customers in minutes, allowing us to avoid spending time pouring up a mold and scanning it into the system, as we must do with traditional impressions. Increased efficiencies in workflows and less chance of error benefit both the lab and the dentist. 

	With digital scanning, our remake percentage is less than 0.5 percent, which is a huge advantage. We have extreme confidence in scan files, enough so that we often are able to utilize model-less workflows. Currently, our lab is around 98 percent digital, and it’s extremely efficient for us. We can use state-of-the-art technology for our clients, and we can offer the best possible product at the best possible price. With digital comes consistency and confidence, and it’s something that allows our lab to perform at the highest level possible. 

Fig. 01 The Lava Plus zirconia disc available from 3M provides another option for labs.

	Beyond the advancements in digital scanning that improve lab efficiency, patient communication and results, new materials in the industry are providing stronger, more flexible and esthetic restoration solutions. Our lab has transitioned from classic 3M Lava™ Zirconia to 3M Lava™ Plus High Translucency Zirconia-utilizing a new generation of zirconia that maintains strength, while providing improved esthetics.

	The unique zirconia powder and shading liquids offer the ability to create highly customized restorations, and the material was recently made available in a disc format for open-source milling (Fig. 1). Now, the Lava Plus High Translucency Zirconia Disc is indicated for full-arch restorations, providing the flexibility that many labs seek.

	The improved esthetics of this material enable labs to choose what works best-either monolithic restorations, or to stack or press porcelain for a traditional layered restoration. The greater level of translucency is made possible by high quality processing of the zirconia to minimize impurities and structural defects. Our lab has found that this high quality processing contributes to fewer problems with fracturing during the milling process.  

	Esthetically speaking, a primary standout aspect of this material is the fact that it matches the VITA® Classical A1-D4 shades, plus two bleached shades. Many materials on the market are becoming more esthetic and offering flexibility-and this combination of coloration possibilities and high material translucency means that labs can achieve outstanding esthetics regardless of whether they are creating veneered or monolithic restorations. 

	The below monolithic crown case was completed by our lab using an all-digital workflow. We utilized scan images from the 3M True Definition Scanner and 3M Lava Plus High Translucency Zirconia for the restorative material. 

	01 | The patient had a large MOD amalgam restoration with recurrent caries. Due to the size of the restoration, its location in the mouth, and the patient’s bruxism, it was determined that treatment with a monolithic Lava Plus zirconia crown would be most appropriate. The amalgam and caries were removed and the tooth was prepared for the crown (Fig. 2).

Fig. 03 A digital scan was captured with the 3M True Definition Scanner.

	01 cont'd | The 3M True Definition Scanner was then used to capture a digital scan of the mouth (Fig. 3).

Fig. 04 The scan and margins were reviewed and approved on the monitor.

	01 cont'd | After reviewing the scan for completion, the prescription was submitted to the laboratory via the 3M Connection Center (Figs. 4-5). 

Fig. 05 The prescription was submitted to the laboratory through the 3M Connection Center.

Fig. 06 Software was used to mark the margins of the crown.

	02 | Once the lab received the scan, software was used to mark the margins (Fig. 6). The scan was then imported into CAD software and the full contour design was created (Fig. 7; below). 

Fig. 08 Crown is milled from a Lava Plus zirconia block.

	03 | The CAM file was calculated by the software and the crown was then milled (Fig. 8). Going forward, new zirconia discs offer another solution for labs.

Fig. 09 The milled Lava Plus crown in its green state.

	04 | Once milling was complete, the block/restoration was removed from the mill and a high-speed fine diamond bur was used to cut the crown from the block. The sprues were smoothed and the green state Lava Plus crown was cleaned to remove any excess dust (Fig. 9). 

Fig. 10 The crown was immersed in dying liquid.

	05 | To stain the crown, a mixture of W3 and A1 Lava Plus shading liquids were applied with a brush to the incisal half of the crown. Color markers were used to track where the incisal shade was placed. The entire crown was then immersed for two minutes in the body shade of Lava Plus shading liquid (Fig. 10). The crown was then carefully removed and excess liquid was blotted from the surface. 

Fig. 11 The crown is placed in a sintering tray and fired.

	06 | The crown was placed on a sintering tray and fired (Fig. 11). Our laboratory has found that Lava Plus zirconia is able to produce consistent results with a fast firing cycle of just four hours, which includes drying and cooling time.  

Fig. 12 A final shade comparison was done after staining and firing.

	07 | After firing was complete, final contouring and characterization were performed, including final finishing of the margins and minor adjustments to interproximal and occlusal contacts. The final shade is confirmed (Fig. 12) and the crown is prepared to be returned to the dentist for final seating (Fig. 13; below).

	The efficient workflow described here is very typical for a case utilizing the 3M True Definition Scanner and Lava Plus zirconia. With a highly accurate digital impression and an esthetic and strong monolithic crown, workflows are simplified for both the dentist and the laboratory. In the end, the patient benefits from a natural-looking restoration that will stand up to wear in the mouth and continue looking great for the long term. 

Steve Daggett, CDT, shows how using a digital workflow, including an intraoral scanner, CAD software and a dental mill, can result in tremendous collaborative and esthetic possibilities.

Digital Esthetics June 2016

How to: How a tablet computer can help with esthetics

Technique: An integrated surgical guide workflow

Technique: How going digital can revolutionize esthetics