Excellent provisionals from digital technology

Laboratory fabricated provisionals have always presented challenges - the need for chairside additions, relining with limited material thickness, and insufficient material choices all inhibit optimal esthetics and strength. Denture teeth bonded together with acrylic are esthetic, but usually do not offer long-term strength. Light-cured composites are a possibility; however, they can be difficult to reline and even harder to add-to or modify chariside. The best compromise has been processed acrylic, until now.

With the use of CAD/CAM technology, ROE is now offering provisional restorations fabricated from a special dense, porosity-free polymethylmethacrylate commonly called PMMA, which is fabricated in our industrial milling machines. Technicians use our powerful CAD system to design ideal anatomy and contours with materials much stronger than hand-mixed acrylic. The benefits extend beyond strength and contours. Using our CAD/CAM system we can digitize a diagnostic wax-up and superimpose it over a study cast. This process allows us to maintain beneficial contours and precisely duplicate a patient-approved diagnostic work-up. Due to the strength of the material, we are able to mill single-unit shells and even full-arch bridges as thin as 1/2mm. Once the milling is complete we characterize the units with stain and, when needed, customize with layering materials, particularly when incisal translucency is requested.

SureTempTM        $32 per unit

Efficient All-On-4 Conversions

The All On 4 Immediate Hybrid Technique is becoming an increasingly popular restoration. ROE has been closely involved in this process from the very beginning and provides complete restorative support from surgical guidance and in-office lab support to the final hybrid design and fabrication. Typically, the final restorative process is a five- or six-appointment sequence, preliminary impressions, final impression, a bite registration and fit verification, tooth try-in, a bar try-in, and seating. We have developed a new streamlined process that eliminates half of these original steps.

This technique requires one of two approaches. One option has the dentist perform a pick-up impression of the provisional, and articulate the master casts in the office. The second option requires the doctor to send the picked-up provisional to the lab to be mounted and finished, leaving the patient without the provisional for 2-3 days. Alternatively, arrangements could be made to have the patient bring the records to the laboratory to expedite the process to one day or less.

To complete the pick-up, long open-tray screws must be used. Also, if the pick-up impression is compromised during the separation procedure, an alginate study cast must be captured so we can duplicate the set-up. If you are interested in more information on this technique, Joe Ambrose CDT (ext 303) will be happy to discuss it with you, or may simply request the Modified All on 4 Technique sheet.

Digital Impressions Now Affordable !

What would you pay for a digital impression machine? Over the past several years we’ve had countless conversations with dentists on this particular question. Until now most doctors agree the technology is here to stay but the price is too high, and they prefer to ‘stick with conventional impressions’. We would like to introduce True Definition Scanner, a $11,995, second generation, digital impression scanner from 3M.

3M is not new to the digital impression market. Its first generation scanner, the Lava COS, was very effective. However, the company has made several improvements that involve hardware changes, resulting in a totally a new machine. The new scanner offers an ergonomic, cleansable, stainless steel wand that is simply tapped with the index finger to power. The wand is smaller than any other on the market, close in size to an intraoral camera, and scans with a smooth, flowing motion. The system is controlled by a touchscreen monitor. The size of the overall scanner is smaller than the previous version, offering more mobility in the office. We are very pleased with the software update, which is open-source, allowing our laboratory the ability to import directly into our iRis digital workflow. Although a powder is still necessary, a very light dusting is all that is required.

This new scanner uses the same “3D-in-motion” process as the last version, which captures video-scans and allows simultaneous viewing on the monitor. Wicher J. van der Meer, (Assistant Professor, Department of Orthodontics, University of Groningen, The Netherlands)  et al conducted an independent study published in August of this year in Plos One. In this in vitro study, implant abutment replicas were scanned on full arch models. The files were imported into an industrial reverse-engineering software called Rapidform for comparative measuring. In a controlled environment, the scans were performed by an experienced dentist following the manufacturer’s scan-protocols. They concluded that this scanning technology is 3x more accurate than the other two scanners on the market. To request a demonstration in your office please contact Alan Banks ext 306.

Zirconia & Phosphates Don’t Mix

Don’t let phosphates contaminate your zirconia. Phosphates, in the form of phosphilipids, are found in saliva. They are attracted to zirconium oxide and create a reaction that affects ‘bonding’. Phosphilipids cannot be rinsed with water or phosphoric acid, which is actually full of phosphates. Therefore, following a try-in of a zirconia restoration that has contacted saliva, it is recommended that you use a zirconia oxide solution called Ivoclean from Ivoclar. This 20-second process optimizes adhesion by drawing the phosphate groups away from the oxides and leaving a fresh bonding surface for priming and/or cementing.

NEW CAD/CAM Provisionals

Digital dentistry is the hot topic these days in both publications and lectures - and for good reason; it’s the future of dentistry. Hardware technology and software programing are moving forward at a torrid pace and are actually evolving faster than the industry’s ability to absorb. At ROE we work hard to stay current on digital technology, providing our clients industry- leading restorations manufactured to the highest standards. Currently, through our iRis system, we digitally produce over 65% of our products, and every month find better ways to fabricate restorations with this technology. We have been anxious to convert our manufacturing processes because digital technology allows us to produce stronger, more consistent and precise restorations with faster turnaround times, often at a lower cost. We have recently moved the fabrication of our provisional restorations into the digital age with results that you’ll be excited to learn about.

Virtual Diagnostic to be Milled In PMMA

Laboratory fabricated provisionals have always presented challenges - the need for chairside additions, relining with limited material thickness, and insufficient material choices, all inhibit optimal esthetics and strength. Denture teeth bonded together with acrylic are esthetic, but usually do not offer long-term strength. Light-cured composites are a possibility; however, they can be difficult to reline and even harder to add-to or modify chairside. Processed acrylic has traditionally been the best compromise.

 

With the use of CAD/CAM technology, ROE is now offering provisional restorations fabricated from a special dense, porosity-free polymethylmethacrylate commonly called PMMA, which is milled in our industrial milling machines. Technicians use our powerful CAD system to design ideal anatomy and contours with materials much stronger than hand-mixed acrylic.

The benefits extend beyond strength and contours. Using our CAD/CAM system we can digitize a preoperative model or diagnostic wax-up and superimpose it over a study cast. This process allows us to maintain beneficial contours and precisely duplicate a patient-approved diagnostic work-up. Due to the strength of the material we are able to mill single unit shells and even full arch bridges as thin as 1/2mm. Once the milling is complete we characterize the units with stain and, when needed, customize with layering materials, particularly when incisal translucency is requested.

When extra-strong, long-term provisionals are required, these shells can be reinforced internally with a CAD metal substructure. Both the outer shell and the inner reinforcement are fabricated using the same digital technology. Due to the accuracy of the fabrication process, the combined layers can be made thinner than hand-fabricated, metal-reinforced temporaries. We also recently started using alternative reinforcement materials in lieu of cast metal. Fiber reinforcement (FiberForce) and Polyetheretherketone (PEEK) are durable materials with high flexural strength. And, since both are white, they can be easily hidden within the provisional. Our fees for provisional restorations with this technology remain a bargain - just $30 per unit or $65 per unit with either  of the reinforcement options.

SimPlant Master Site

We are announcing that ROE is now a Master SimPlant Site. For you this means that you can not only request scan appliances, surgical guides amd treatment planning session, but also ROE can complete data conversion. We are your turn-key service for SimPlant, BlueSkyBio, iDent, and NobelGuide surgical guides.

Photography Update

During a recent seminar we met Dr. Todd Schoenbaum, Assistant Clinical Professor, UCLA, who works closely with Dr. Ed McClaren. He presented some very interesting updates to dental photography.

Nikon d300s
w/ Adjustable Flash

First, current camera body recommendations are the  Nikon D300S, D7000, and D90 as well as Canon’s 7D, 60D, and the T3i. These cameras offer an ‘ideal balance between resolution, noise and depth of field, and both companies offer excellent flash systems for dental macro photography”.

Second, it is suggested that “advanced users... attach polarizing film over the flash units to reduce glare, adjust specular reflection, and provide a deeper and clearer image of the anterior dentition.”

We posted an article written by both doctors on the smile page of our website. The article offers several more suggestions including specific settings for full face and close-up shots.

Due to the signing of the Federal Health Reform Bill, in 2013 a 2.3% an excise tax will be assessed on the sale of all medical devices in the United States, this includes dental equipment and dental prosthetics. Unlike most taxes, this tax is assessed regardless of a company’s profitability, leading to a burden on the balance sheet. This tax will increase costs to all medical and dental providers. The government offers the argument that the marketplace will be expanded by 32 million people through mandated healthcare. This is of little consequence to the dental industry that is primarily on the outside looking in on ‘healthcare’, while still subject to the excise tax.

New Zirconia Wear Study

Zirconia is one of the most studied materials in dentistry, especially since the development of the monolithic option. Manufacturers insist that wear to opposing dentition is similar to enamel, provided that restorations are highly-polished. Furthermore, many dentists contend that individual crowned teeth in balanced occlusion should not spontaneously supererupt because of wear to the opposing teeth. Rella Christiansan’s TRAC Research group has released preliminary results of a 7-year full-contour zirconia wear study which supports both of these claims.  The study seeks to measure the amount of wear zirconia and other monolithic restorations exhibit invivo. After one year, the “very promising” results show that zirconia “mimics” natural dentition.

Emax Update

A recent major upgrade to our Sirona InLab design software has enhanced our emax restorations. One of the new features includes the ability to design multiple units simultaneously, which provides increased control. This update also allows us to communicate with E4d customers and Cerec dentists who are using version 4.0. Digital impressions allow us to deliver lower cost restorations much quicker.

Adding to a Pontic - Troubleshooting

Have you ever returned a case to the laboratory with these instructions “The bridge looks and fits great  and fits the model, but please add porcelain under the pontic”? This phenomenon may be due to the pontic site deforming during the impression taking process. Anesthesia and packing cord often causes inflammation in the pontic site which can lead to an inaccurate representation of the tissue site in the final impression. When developing pontic sites with provisional restorations, it is suggested that an additional impression of the pontic site be captured immediately following provisional removal, but prior to packing cord for the final impression. Please indicate this is a “pontic impression”.

AlginZ Ultra - A Step above Alginate

A few newsletters ago we mentioned an affordable and stable alternative to alginate called Alginot. Another cost-effective impression material that warrants consideration is AlginX Ultra,  from Dentsply. According to surveyed dentists, AlginX is extremely stable, produces more detail and allows multiple pour-ups. The impressions are dimensionally stable for up to 14 days, comes in  spearmint flavor, and offers quick working time. These benefits make this product a real thumbs up.

Comfort H/S Update - New Improved!

Have you ever heard the old saying, “You can have it done right, inexpensive or fast, pick two”. As consumers, this applies to many of the products we purchase, though it is rare to realize all three attributes in one product. Due to recent improvements in our Comfort Splints, we think we have the exception. The appliances are fabricated in just two laboratory days, cost only $59, and are better than ever. The clarity, thickness and bite improvements we made in recent weeks will be evident in each case you receive.

THE Twin Clasp Technique

Waxed Up Crown

Cast Clasp Replica

Having to send a patient’s partial denture to the laboratory while a crown is being fabricated to fit within the existing partial has always been a major inconvenience and disappointment to patients. Many years ago we introduced the Twin Clasp Technique to eliminate this frustrating problem. Over time this technique has proven to be quite successful. The next time a patient complains about giving up their partial denture, we encourage you to give it a try. Here is the technique:

1. Prior to tooth preparation be sure to observe the seating of the partial. Success of this technique is dependent upon a positive and accurate seat of the partial after the tooth is prepared.

2. Prepare the tooth and retract the tissue.

3. Inject heavy-bodied polyether or one-step polyvinyl around only the prepared tooth, making sure the entire margin is captured.

4. Fully seat the partial into its proper position ensuring the clasp around the prepared tooth is imbedded into the impression material. Do not allow the clasp to be totally covered - wipe off any material to expose the exterior of the clasp. The object is to register the tooth surface of the clasp, rest and minor connector. Covering the entire clasp will render this technique ineffective.

5. Allow the material to set under the clasp without occlusal contact.

6. Remove the partial and clasp impression from the mouth. The small impression will most likely be removed with the partial. Separate the impression from the partial without altering it in anyway.

7. Perform your normal C&B impression procedure without the partial in place.

8. Capture a study model impression with the partial in place.

9. Send us the clasp impression (in an old ROE crown box or baggy so it will not be lost), regular C&B impression, bite, opposing model, study model, and work authorization indicating the Twin Clasp Technique has been used.

10. At the laboratory we use the twin clasp impression to wax and cast a clasp assembly that mimics the existing partial. The new crown is fabricated to fit within the duplicate clasp.

An alternative approach, albeit inconvenient to the patient, is to send the partial to us so we may record the clasp location for you. This process requires two laboratory days.

Zirconia Cementation Update

The generally accepted practice of conventionally cementing monolithic ceramic restorations is clinically efficient and is the most popular method of placing our all-zirconia TLZ, BruxZir, and lithium-disilicate eMax restorations. In a recent edition of Inside Dental Technology, however, Dr. Ed McLaren takes issue:  “The problem is that these cements are much more soluble than resin-based cements. If, over time, the cement solubilizes and fails, exposing the glass cement to saliva, the restoration can undergo hydrolytic degradation which weakens the material.” He recommends bonding these restorations, particularly in situations where the preparation is non-retentive. Dr. Russell Giordano, Boston University Goldman School of Dental Medicine, an authority on dental materials agrees. It has been established that bonding almost doubles the load and increases resistance to failure. Low pressure, sandblasting the interior of the restoration at the laboratory with alumina, and the use of primers, such as AZ Primer (Shofu Dental Corporation), Clearfil™ Ceramic Primer (Kuraray), Metal/Zirconia Primer (Ivoclar Vivadent), and Z-Prime Plus® (BISCO), significantly improve adhesion. Recently, The Dental Advisor gave Bisco’s Z-Prime Plus a 5-Star rating and claimed that it doubles zirconia bond-strength. Z-Prime is a priming agent that enhances the adhesion between zirconia and composite resin cements, in both self-cure and light-cure modes.

Based on what we’ve recently learned about the effects of primers, therefore, we recommend their use on both full-contour zirconia and porcelain fused-to-metal restorations, particularly with minimally retentive preparations.

Komet ZR Intraoral Zirconia Adjustment Kit

ROE now offers a special kit for intraoral adjustment of full-contour zirconia and lithium disilicate restorations. The new, diamond-interspersed, ZR Flash Polishers are designed to re-glaze hi-strength ceramics simply,  once seating adjustments are complete.  These slow-speed points and cups complement Komet’s excellent long-lasting adjustment burs.

Call our customer service team to place an order. The kit comes in a sleek stainless steel block and is available for $85.

Lucia Jig - Anterior Nightguard

Anterior nightguards have become very popular appliances. The minimally-invasive design is comfortable and unobtrusive and does not affect the airway. Also, coverage is usually limited to the incisors, which minimizes a patient’s biting force, clenching and bruxing. These devices are  commonly prescribed to patients who suffer from migraines and TMJ pain.

ROE’s anterior nightguard is called the Lucia Jig ($119). To order, simply send maxillary and mandibular casts and a maximum protrusive measurement. To capture this measurement, ask the patient to push his or her jaw forward, and measure the horizontal distance from the lower incisal edge to the upper incisal edge. The appliance requires 3 days in the laboratory and modified designs are available based upon your specific needs.

All-On-4 Support

If you are currently restoring or thinking of becoming involved with All-On-4 type cases ROE can be of tremendous service to you. During the past several years we have supported countless dental offices with every step in the process from case-planning and surgical-guidance to chairside denture-conversion the day-of-surgery (Ohio only). For the surgical appointment, we visit the office with all the tools and materials necessary to convert and finish the provisional or final hybrid.

Today, all the major implant brands have a variation of All-On-4: Zimmer - RevitalizeTM, Astra – Uni-For-FixedTM, and 3i - DIEM®2. We support all these systems, as well as Straumann and Thommen, who offer components suited for the protocol.

Can you detect a midline discrepancy?

According to a study published in the Journal of Esthetic Dentistry, which evaluated the perceptions among dentists, orthodontists, and lay people on a variety of esthetic discrepancies, a maxillary midline deviation of 4 mm was necessary before orthodontists rated it significantly less esthetic than the others. However, general dentists and lay people were unable to detect even a 4-mm midline deviation. Conversely, when the midline angulation deviated only 1mm, all three groups noticed. As a team, it is important that we pay particular attention to ensure the angulation of the midline is perpendicular.

Cosmetic Acrylic Mock-up

A diagnostic wax-up is a great tool when discussing the potential of a new smile.  Wouldn’t it be nice also, in a reproduction of the final restoration, to verify all the critical components of anterior esthetics? This is possible by performing an intraoral, reversible, composite build-up.  This procedure, however, is very time-consuming and may result in a less-than-ideal representation of the desired result. ROE offers a “Mock-Up” service, which enables a patient to try-in and visualize the proposed smile quickly and easily. Both form and function can be evaluated prior to tooth preparation.

A “Mock-Up” is created by duplicating the patient’s study model, fabricating a diagnostic wax-up, and reproducing the result of the wax-up on the master model with a very thin acrylic laminate veneer. This replica of the diagnostic wax-up is then placed clinically with try-in paste, or spot-tacked with temporary cement. This disposable laminate is intended for chairside-presentation and evaluation only, and not recommended to be worn outside the dental office. The total cost of this service is $45 per unit, and includes preparation and temporization matrixes for use at the preparation appointment.

Heraeus Kulzer Mondial Teeth

In our last ROE Reports we wrote about the many exciting changes we’ve made to our implant-supported hybrids and overdentures. One update was the adoption of the Mondial tooth line (Heraeus Kulzer). These premium teeth are ideal for implant prosthetics due to proven, clinical success at both the Malo Clinics and ClearChoice®. New NanoPearl® technology makes these teeth much stronger and more resistant  to wear than PMMA teeth. In fact, an independent study conducted by Tufts University found them to be the #1 wear-resistant tooth. Also, according to Heraeus, there is a true chemical bond to acrylic. These key benefits will increase longevity. It is important to note that the switch to these premium teeth for implant cases does not affect our recently introduced All-in-One pricing. Special shade and mold guides are available through ROE.

All-On-4 Support

When you need support planning and restoring All-On-4 cases, trust ROE. We work with specialists and their referring dentists in Central and Northern Ohio with preplanning, provisional and final restorations, as well as chairside assistance the day of surgery. Below are the implant companies that offer specific All-On-4 type systems. We also perform this procedure using Thommen and Straumann implants.

Nobel Biocare - All-On-4

3i - Diem2

 

Zimmer - RevitaliZe

 Astra Tech - Uni-for-Fixed

 

The fee for this service is $2899. Our comprehensive service includes the provisional denture, the definitive hybrid prosthesis, custom trays, models, special soft-tissue model, articulation, standard and processed bite rim, fit verification jig, set-ups, resets, acrylic finish, one full set of premium teeth, one set of economy teeth, protective night guard, iRis titanium CAD/CAM components, final screws for the bar, analogs. Price excludes in-office technician labor, impression transfers, abutments, shipping and tax.

These fees represent maximum costs for the specified design. Actual fees may be less depending upon processes which may not be required or might be performed clinically. Individual fees will be itemized and billed at the time service is rendered. Prices are subject to change without notice.

Upcoming Educational Webinar

Webinar:  Maximizing Computer Guided Surgery for You and Your Patients
(1 CE, no charge)

REGISTER NOW

Presented by: Joe Ambrose C.D.T., Technical Director at ROE Dental Lab
Sponsored by:  Blue Sky Bio
Date:  April 17th, 2012. 9PM Eastern, 8PM Central, 7PM Mountain, 6PM Pacific

COURSE DESCRIPTION: Joe Ambrose C.D.T., the Technical Director at ROE Dental Lab, will present the process and advantages of the "No Scan Appliance" surgical template protocol for your practice and your patients. Mr. Ambrose will present and discuss the tools the dentist and the lab have at their disposal to help ensure phenomenal results surgically and prosthetically including virtual articulation, surgical kits and drill stops. 
COURSE OBJECTIVES: The course objective is to educate dentists about computer guided surgical techniques and procedures that can be advantages to them, their practice and the patient. The course will be presented as an online educational webinar at no cost, provided by Blue Sky Bio, LLC. 1 CE credit will be awarded to attendees within 30 days of course. Treatment plans and surgical images may be presented in the BSP software, slideshow / presentation format or as individual images.  

REGISTER NOW

All.In.One Fixed-Fee Implant Restorations

We are pleased to report that state-of-the-art CAD technology and our tech-savvy team of CAD/CAM technicians enable us to reduce fees and turnaround time on our premium, patient-specific, iRis custom abutment and bar implant prosthetics. We call our simple and straightforward fee structure All.In.One. It is intended to remove the uncertainty surrounding lab fees. These low fees, and our decades of restorative experience, can help you become more efficient and profitable in the restoration of implants   while providing optimal treatment.

 

Fees for fixed restorations are per implant and include the following: special soft-tissue model, analog, articulation, iRis custom abutment, CAD abutment seating jig, and fixed restorations, including noble alloy. Price excludes high-noble alloy, shipping, and tax. Removable fees are per arch and include: custom trays, models, special soft-tissue model, articulation, standard and processed bite rim, fit-verification jig, setups, resets, cast metal or Fiber Force strengthening substructure, acrylic  finish, one full set of premium teeth, one set of economy teeth, protective night guard, iRis titanium CAD/CAM bar on an unlimited number of implants, final screws for bar, analogs, and your choice of standard attachments (e.g., locators, hader clips, era, o-rings, bredent). Price excludes in-office technician labor, impression transfer, transmucosal  and multiunit abutments (usually not required) shipping, and tax.

The fees represent maximum costs for the specified designs (call for new Implant Fee schedule). Actual fees may be lower depending upon processes that may not be required or performed clinically. Individual fees will be itemized and billed at the time service is rendered. All.In.One components are produced by ROE’s preferred suppliers. When original manufacturer parts are requested there will be an increased cost.

iRis abutments and bars featured in our All.In.One service are fabricated on the ULTRASONIC 20, a 5-axis, robotic milling machine capable of 42,000 rpm. The 2.3 ton machine is considered the most stable in its class and is capable of milling both titanium and zirconia from single unit to full roundhouse bridges, as well as implant bar frameworks, all within 10 microns.

Digital Impressions Now for Implants

Offices equipped with digital impression machines (iTero & Lava COS) can now transfer implant position directly to the laboratory via special scan caps. These coded, aluminum, digital-impression posts are seated and thumb-tightened into implants and scanned. With this information ROE creates a virtual implant model for abutment and restoration design. There are several advantages to this service. First, the soft-tissue architecture is precisely captured and used to create ideal emergence and margin placement. Second, digital impressions are received by our laboratory very quickly allowing us to design abutments and restorations earlier, leading to much quicker turnaround time. And third, digital files are imported into ROE’s iRis (intelligent restorative individualized system) to engineer restorations to your specific parameters. Scan caps can be ordered through ROE in both plastic and radiopaque aluminum.