At this point in time in anyone’s dental career, few have not yet heard of the revolutionary trend in the operatory called CEREC.
Utilizing CAD/CAM technology, the machine boasts an amazing ability to accurately produce an esthetic restoration in several minutes. Due to computer reconstruction and fabrication, the process utilizes less time, money, and energy than traditional methods. But this technology has not made our lab technicians obsolete. In fact, the in-office CAD/CAM machines are only the beginning. What the dental industry is now experiencing is an explosion of new technology in the laboratory arena providing faster case completion with better results. Computer Aided Design is leaking into every aspect of our practice and has become an unstoppable tide of change.
In The Office
With more than 20 years of development, Sirona’s CEREC 3D has a proven track record, placing itself into a category all its own. Restorations are predictable and there is a huge number of materials available from manufacturers such as Ivoclar Vivadent and 3M ESPE. Vident and Ivoclar have also released multicolored blocks allowing for natural transitions from cervical areas to the translucent occlusal. But CEREC’s unique market position has also made it the one to beat. D4D Technologies has done extensive work developing their own in-office system, the Evolution 4D. This company manufactures the image acquisition side, the software that creates the restoration, and the machine that does the milling.
Even newer than the Evolution 4D are several companies working on release of just the camera or acquisition end of the process. Brontes 3D, Cadent, and Densys 3D are developing intraoral cameras which will be able to take accurate 3D “Digital Impressions” of teeth. Dentalcompare was the first to break the news back at the ADA convention in 2006 with Dr. Paul Feuerstein that 3M had aquired Brontes 3D. Dr. Fuerstein noted the significance that one of the largest impression material companies in the world has recognized the value of this technology.
What this represents is a complete change in our daily appointments and the way we communicate with our lab. Right now the process is to take a gagging impression, sterilize the impression, ship it to the lab, pour up the model in stone, trim the model, pindex the model, trim the die, and only then can the lab technician begin making the restoration. With digital scanners, as well as the CEREC system, you can take a digital impression (a 3D picture of the tooth) email it to a lab, and they can immediately begin fabrication. For those who grow faint at the price tag of in-office systems, these scanner-only systems could make CAD/CAM transitions easier and more widespread than ever. While the restoration is still completed by the lab, rather than in-office, the digital impressions negate the need for physical impressions and shipping, and, many say, provide more a more accurate starting point than a physical impression.
Down At The Lab
Once that digital impression reaches the lab, there is an enormous range of materials that can be used. Wax blocks can be milled using CAD/CAM technology, and cast using traditional “lost wax” techniques. Machines such as the Invision DP 3D from 3D Systems Corporation can even “Print” the wax up with a proprietary light cured resin material. This allows traditional cast restorations such as bridges, inlays, onlays, and PFM’s to be made in a fraction of the time.
Zirconia copings can be manufactured quickly using design software and milling machines such as KaVo’s Everest, Sirona’s MC XL, Nobel’s Procera, and 3M ESPE’s Lava. Zirconia is incredibly strong and is an amazing alternative to cast gold copings and bridge frameworks. Layered over with porcelain, these restorations have all the benefits of all-porcelain restorations and eliminate the need for a thick layer of opaque porcelain that deadens the look of a PFM. Zirconia manipulation is virtually impossible without CAD/CAM technology. Your lab is now able to quickly deliver a better restoration than ever before.
Implants, Ortho and Beyond
CAD/CAM technology in dentistry may have gotten its start on the single tooth, but it has progressed far beyond that. A main driving force behind that is Cone Beam Computed Tomography. These systems include Imaging Science International’s i-CAT, Kodak/Imtec’s Iluma, and the Galileos from Sirona. These volumetric CT scans create amazing detailed 3D images that offer incredible imagery and diagnostics. From these scans, laboratories can create CAD/CAM surgical stents to aid in 3-dimensional placement of an implant. CADImplant is one such company that combines hardware, software planning based on a CT image and computerized drilling service to manufacturer your surgical guide.
Companies such as Nobel Biocare are utilizing this type of imaging to virtually treatment plan cases using multiple implants. NobelGuide allows you create a surgical guide, place the implants, and place the final denture, abutment or bridge in the same appointment. 3i has a new system called Encode. This system allows you to take an impression or scan of just the healing cap itself. The healing cap has all the specifics of implant type and position to allow a participating lab to fully fabricate a custom abutment made from gold or zirconia.
CAD/CAM technology is creating a huge wave in orthodontics as well. Systems such as eModel and OrthoCAD eliminate the need for stone models. All model diagnostics can be done onscreen, and OrthoCAD allows you to virtually place brackets on teeth. Approve the the setup, and the company will send you a clear tray with the brackets in place already. All you have to do is bond them on. Dolphin Image and Management services even has a module which can utilize 3D scans with extraoral photographs to create a high resolution digital model of a patient that has all soft and hard tissue structures…with digital “skin” layered over all of it. Think of the technology they used to make “The Matrix”, and orthodontic diagnostics.
In the future, it may even be possible to use that technology to create digital surgical simulations for orthodontics or for reconstructions from accidents. Imagine seeing your patient two years into the future with orthodontic work completed, including tooth movement or bone changes.
What It All Means
The question at hand is whether these technologies represent the next entry in a long line of dental vaporware, or this is the inception of the practice of tomorrow. Benefits such as reduced overhead, reduced development cycle, and improved materials give way to better business profitability. Better materials give way to better and better prognosis, giving rise to better clinical results. CAD/CAM has begun to leak into every aspect of our practice. The better question may not be about CAD/CAM’s sticking power, but when you will begin to take advantage of it. It is a tide that at some point will envelope you as a clinician and propel you to the next level of dentistry whether you expect it or not.