by Michael J. Moroni, DDS
The first time my local supply dental representative came
into my office to sell me a CAD/CAM system was
nearly 20 years ago. The one he showed me that day
specifically made crowns. He told me how wonderful
the system was and how it would be able to change my
practice. Of course, I knew that he was just there to sell me something
but I was interested in learning more. In fact, he actually
sat in my dental chair so that I could inspect the full crown that
he had created for his own tooth. Let’s just say, I was not at all
impressed: The margin was open on the mesial, it had no occlusal
anatomy, it was bulky on the buccal and lingual sides, and quite
frankly, the best way I could describe it was that it looked like a
mushroom sitting on a tooth. That was my very first experience
with CAD/CAM dentistry.
After making other technology improvements, eventually, I
decided to take the plunge. Years after my first less than stellar
introduction to CAD/CAM, I began my journey with CEREC. I
became a huge advocate of digital dentistry. This system allowed
me to experience what digital dentistry was capable of achieving.
Having already seen what CAD/CAM could do for my practice,
I was very interested when the new E4D system came out on the
market. I was excited to see what this new system had to offer. It’s
been years now, but my first E4D system was eventually upgraded
a couple of times to my current system, the Planmeca PlanScan.
I quickly converted and easily became a full supporter of this
unique system. Not only does it streamline my dental processes,
but the products that come out of it are of the highest quality. The
machine ended up being much easier to use and every bit as versatile
in terms of the applications for the procedures that I could do
chairside. Also, I really appreciated the system upgrades I was able
to receive with limited expenses on my end.
CAD/CAM dentistry has definitely come a long way. With a
variety of systems available on the market, dentists have more options
to choose the best system. For me, Planmeca PlanScan has advanced
my practice tenfold and I am able to achieve many procedures that
were thought to be impossible when I first started in dentistry. With
an exception of a few cases where I do need to use the lab, I can do
almost everything in-office now. Some procedures that would take
days to complete can now be completed in a matter of hours.
Let’s take a look at several cases completed entirely with
CAD/CAM, depicting the possibilities that can be accomplished
in dentistry today.
Case presentation #1: CAD/CAM anterior bridge
Patient is a 41-year-old male who presented to my office
with a loose Maryland B ridge from teeth #6-#8 , and another
Maryland Bridge placed on #9-#11. Patient had congenitally
missing laterals and had the bridges placed in his 20s. Both
bridges were over 20 years old. Upon clinical and radiographic
examinations, decay was evident surrounding wings of the
bridge on both abutments. On the bridge from teeth #9-#11,
patient had recurrent decay on #11 as well. Patient stated that he
never liked the appearance and would like both replaced (Fig.
1). Patient opted not to have implants placed at edentulous sites
#7 and #10. With the amount of decay present on abutment
teeth, they required full coverage crowns to restore. Bridges
were the preferred treatment plan for this patient. Due to financial
concerns, patient decided to do the bridges individually.
With the in-office CAD/CAM system, it is easy to accommodate
this as we mill in-office. The color stability is better than
when we send it to the laboratory.
Patient was anesthetized and the bridge #6-#8 was scanned
(Fig. 2) to use as a template of what we want the final bridge to
look like and then removed. Full bridge preps on teeth #6 and #8 .
Digital impressions were taken (Fig 3). Designing the bridge was
accomplished with outlining the margins on teeth #6 and #8. The
pontic margin is drawn on the gingiva at tooth site #7 (Fig. 4). The
pre-scanned image of the prior bridge is outlined, individually, for
all three teeth. Once that is done, the pre-scanned image is laid over
the prepared teeth, final adjustments are made, and proposed bridge
is done (Fig. 5). Once proposal was approved, the three-unit bridge
was milled. In this case the material of choice was e.max from IPS
Ivoclar Vivadent (Fig. 6). The bridge is then crystalized in the oven
and then bonded into place.
Several months later the patient returned for bridge #9-#11.
The exact same process was used to restore this area for him (Figs.
7 & 8). The aesthetics and fit of the final restorations are amazing
and the patient was in shock to have such a beautiful looking final
result. His only regret was not doing it sooner in life.
Case presentation #2: anterior veneers
Patient presented into my office because his wife “forced him to”
(how many times have you heard that?). Patient is a 63-year-old male
businessman that had severe wearing of teeth and displayed multiple
fractures and chips on his anterior teeth. He seemed not to care or
even notice the appearance of his anterior teeth, but his wife sure did
and prompted his visit to our office. Please note the initial picture
of how he smiled (Fig. 9), and also his oral condition at the time
(Fig.10). He may not have wanted to get anything done, or may have
been in denial that things needed to be fixed, but his canted and
limited full smile spoke volumes to me. For years he never had a full
smile, being self-conscious about the appearance of his teeth.
A diagnostic wax-up was done to show the patient what was
possible if we restored his teeth. The patient really liked the wax-up,
and approved the aesthetics that it would provide for him in the
final restorations. We took a digital impression of it to mimic what
the wax-up looked like so that we could provide final restorations
identical to the shape and size proposed.
We anesthetized the patient and prepared teeth #5-#12 . The
prepared teeth were scanned and temporized so that the patient
could leave on a business trip. This allowed time on my end to
design and mill the restorations. I drew margins on preps # 5 -# 12
(Fig. 11), and then outlined on the pre-scanned wax-up what areas
I wanted the final restorations to look like, or mimic (Fig.12 ).
Once all restorations were proposed to me, I adjusted and finalized the overall aesthetic look of the case prior to milling (Fig.
13). Once I liked the aesthetics of all the proposed restorations, I
milled all of them in the Plan Mill 40. Next, I stained and glazed
the final restorations and seated them into place. The final bonding
was performed the following way.
For the restorations, the internal surface was etched with 5%
hydrofluoric acid IPS Ceramic Etching Gel for 20 seconds. Then
the surface was rinsed off, etched and Monobond Plus (Ivoclar
Vivadent) was applied, a process that took 60 seconds. I then dried
off all liquid from the inside surface of the restorations.
For the teeth, the prepared area was etched with 35 % phosphoric
acid (Ultradent Products, Inc.) for 15-20 seconds, then the gel was
rinsed thoroughly off with copious amounts of water. With tissue
properly isolated and no bleeding present, Prime & Bond Adhesive
was placed with a microbrush onto prepared teeth, agitating the
tooth surface for 30 seconds. While curing, remember to load the
restorations with cement of choice. Once loaded with cement, place
veneers onto tooth. I usually place the centrals first, then laterals,
then canines, etc. Tack-cure on buccal for one to two seconds to
hold in place. Clear all excess cement from buccal and lingual. Floss
interproximal and final cure all restoration's surfaces for 20 seconds.
Once veneers are seated, final check to make sure all excess
cement or bonding agent has been removed from all surfaces,
including all gingival areas around the teeth. Final occlusal
adjustments are done at this point, according to each doctor’s
Figures 14 and 15 show the patient’s before and after smile.
Case presentation #3: restoring an implant
This 25-year-old female patient presented with a previously
placed implant at tooth site #7. Normally one of the hardest situations
to correct — one lone anterior tooth to match color with
rest of anterior teeth. Historically, not fun for any dentist. To
complicate matters even more, patient was leaving in two days
for a mission trip to Brazil, where she would be for two years. I
used a stock aesthetic abutment that I happened to have in stock
at my office. Scanned the implant and created a crown. See before
picture and after pictures (Figs. 16 & 17).
Case presentation #4: same-day crown on broke
The pinnacle and mainstay of owning a CAD/CAM unit
is the same-day treatment of patients who come in, have a
broken tooth, and leave an hour later with a brand new one.
This particular patient was 72 years old and visiting her family
in Colorado. Her tooth broke off while eating a bagel. She
was distraught and nervous that she had to go the entire vacation
with a broken front tooth. I calmed her down and let her
know that we could fix her tooth and get her looking as beautiful
as ever so that she could continue to have a great time
with her grandkids. She was doubtful. I prepped, scanned,
designed and milled tooth # 7 . See patient before and after
photos (Figs. 18 & 19). Patient was amazed that the crown
was done in a single visit.
Case presentation #5: CAD/CAM crown and onlay
The last case I would like to show is another one that I call a typical
“bill payer” — these cases come in with a fractured tooth, and
then requires either an onlay or a crown to properly restore. Patients
don't want an impression. They don't want to have a temporary in
their mouth for three weeks. They don't want to take an additional
day off work to get the final lab-fabricated crown placed. They want
to have an immediate, final fix to their problem. These are simple,
everyday procedures that come into your office, that you can take
care of and have the patient smiling, and referring to you, as they
leave your office and remember the experience that you gave them.
Figures 20 and 21 show a full-coverage crown and how same-day
dentistry can change the value that patients see in your office. Figures
22-24 show a similar case for an onlay.
I love the versatility and the quality of CAD/CAM. I do
not have any desire to step backward in time to perform traditional
dentistry. Not that there is anything wrong with traditional
dentistry — it got us through a huge span of time. But
the technological advances in the world have not only changed
the way we do business, get our news, social media, etc., it has
also changed the way we practice. CAD/CAM has revolutionized
dentistry and how we can treat our patients. It is truly an
amazing time to be a dentist and provide such exceptional care
for our patients. The future of dentistry is changing, and it will
truly be an amazing experience.