CAD/CAM Dentistry: Exploring the Possibilities by Michael J. Moroni, DDS


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 individual preferences.

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 anterior tooth

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.



Conclusion

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.

Dr. Moroni graduated with his DDS from Case Western Reserve University in Cleveland, Ohio. He completed his dental residency at the Cleveland Clinic. In 1999, he moved to Colorado where he opened his private practice. Dr. Moroni is committed to quality care and has taken over 200 hours of continuing education yearly with emphasis in cosmetic dentistry. He originally started using CAD/CAM technology with CEREC in 2007. Unique in his field, Dr. Moroni is one of the only dental practitioners who utilizes both the CEREC and NEVO PlanScan systems presently in his private practice. He belongs to many professional organizations.

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