Bill Atkission, Owner of Bella Vita Dental Designs

	Bella Vita Dental Designs has predominantly been a crown and bridge lab since we first opened our doors back in 1989. Now with the digital age upon us providing so many new and efficient workflow and restorative options, I’m always looking to expand my techniques as well as my lab offerings. So when the reality of digital dentures was presented to our industry, I was immediately intrigued. What better way to advance my position as a full-service partner to my clients than to add digital dentures to our roster of services? We’ve actually been a fully digital crown and bridge lab for 12 years, so the idea of digital dentures was really the next logical step.

	In the beginning of 2018, Dentsply Sirona contacted my lab with a proposition I couldn’t resist - they wanted Bella Vita Smiles to become one of the first four labs to offer Dentsply Sirona Digital Dentures. This was way too exciting to turn down. Shortly after, we made our way to Dentsply Sirona headquarters in York, Pennsylvania, to be trained as a Certified Dentsply Sirona Digital Denture lab (

	First and foremost, your clients don’t have to be a digital office or even own a digital scanner to receive beautiful digital dentures from your lab. Dentsply Sirona Digital Dentures can accommodate anyone who’s interested in providing beautiful, well-fitted dentures via a simplified workflow. Labs can either scan models and mill in-house with the inLab

 MC X5, or simply scan and let Dentsply Sirona and AvaDent take care of the rest. Either way, you can count on the same premium Dentsply Sirona materials.

	Digital dentures can drastically eliminate numerous patient appointments while also providing financial benefits to your clients by using that extra chair time for other procedures instead of numerous try-ins. In fact, the Dentsply Sirona Digital Denture process saves your clients up to six office visits when compared to traditional methods. This is truly a one-to-one digital denture; from the patient’s digital scan to final denture, you can rest assured that the result will be an exact representation.

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	Once we were fully trained and certified, we quickly contacted some select accounts to see who would be interested in doing our first set of digital dentures. One of our local dentists was the first to jump at the chance. Before any work was done, I explained to my doctor that this procedure is unlike the traditional denture process, and that the patient will not experience typical results. 

	The patient, a current denture wearer, loved his existing dentures (i.e. size and shape of teeth) but wanted a better fit due to the fact that he was tired of having to use over-the-counter liners.

	I was prepared to offer beautiful, esthetically-pleasing dentures while providing a perfect fit and a truly reliable prosthesis through the Dentsply Sirona Digital Denture method in collaboration with my doctor and AvaDent.

	The first step was for the doctor to send a traditional physical impression over to us. Accepting a digital scan is currently in the works, but for now our lab accepts physical impressions. When sending a digital denture case to the lab, we recommend that the doctor uses the Wagner Tray for custom impression taking for fully edentulous patients (

). This eliminates the need for a custom tray fabricated by the lab, and it saves an appointment for both the doctor and patient.

	The Wagner Tray provides the same benefits as a lab-fabricated custom tray but is ready in just minutes. Moreover, Wagner Trays are formed from an exclusive thermoplastic shape-retaining material called Wagner Compound.

	For this particular patient, we used his existing denture as a custom tray by taking a wash impression inside, and then checked to ensure the midline and vertical dimension of occlusion were correct before the scanning procedure.

	The doctor simply poured the impression material straight into the intaglio surface of the denture and took an impression. For this specific case, the office contacted us for a morning pick up so that we could deliver the original denture back that same afternoon. 

	Once received, we scanned the impression with the inEos

 X5 scanner. Because we didn’t want to distort the wash impression, we scanned the intaglio surface first (

). Since this was a reference denture, this was mainly the only change since the patient loved the lip support, size and shape of his current denture. We scanned the palatal side for reference to create the try-in denture (

), and then we let AvaDent choose the best mold shape and size.

	Fig. 3                                                                                                 Fig. 4

	We sent this and some other information such as photos, tooth mold, occlusal scheme, tooth angulation, rugae type, etc. through the online AvaDent dashboard (

). The dashboard allows you to relate all things that comprise each case so that your lab and AvaDent can work as a team to create the best digital denture for your patient. Photos of the case are key, as they show the face structure and midline position between the eye and nose. These are a bit more crucial for fully edentulous cases, but photos are always a useful added tool for any case. Real palatal rugae mimicking current patients’ rugae can also be implemented in the palatal surface, along with frenum relief and other added functions like a post palatal seal. All of this information and more can be sent through the AvaDent dashboard.

	Once AvaDent has been given the order, it takes approximately 48 hours to receive the initial try-in design. Labs will also receive a digital 3D mockup that can be moved and enlarged, and notes can be made and sent to the lab regarding any changes. A new 3D mockup can be sent along with those changes (

	Fig. 5                                                                                                    Fig. 6

	At this time, it’s best to thoroughly discuss the 3D preview and changes with the doctor; this collaborative effort between you and your client is the best way to receive the greatest printed try-in results. The more time spent examining this phase, the better the 3D printed try-in will be. What you see in the digital preview is exactly what you will receive (i.e. lip support, frenum, etc.)

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	The design was then printed with our in-house 3D printer, providing a full monolithic denture for the try-in (

).
	One of the great benefits of this process is that there’s no longer a need to move teeth around; if there are any adjustments to be made, they’re made right on the denture. (i.e. if the mid-line needs to be moved, increased lip support, frenums to be relieved, etc.). You can also make as many notes as possible and can then incorporate any changes to the final denture.

	                    Fig. 7                                                                                 Fig. 8

	Once the try-in is returned, we’ll re-scan any and all adjustments, re-adjust the teeth if needed and AvaDent will send another 3D mockup to the lab.

	                         Fig. 9                                                                                      Fig. 10

	Once the doctor reviews and approves the final prosthesis, we receive the final file back from AvaDent, mill only the intaglio side of the new denture out of the Lucitone 199 (

), add premium Portrait IPN teeth with HIPA acrylic (

), and finish the denture so that it’s ready for delivery (

	               Fig. 11                                                                                 Fig. 12

	When taking advantage of Dentsply Sirona Digital Dentures, a pre-pressed Lucitone 199 puck is used, which means less residual monomer so that the chances of a patient having any allergic side effects are greatly reduced (

). In addition, no stone is needed, so the ratios of water to stone for your model, or monomer to polymer for traditionally packing a denture, are nonexistent!

	Fig. 13                                                                Fig. 14

	What’s more, the 3D printed try-in offers that extra comfort - there are no teeth set on a wax rim that can move or shift through transit from your office to the lab, resulting in an ill-fitted denture. Get ready to impress your clients and patients with the best esthetics and fit you’ve ever experienced (

Articles

How Dentsply Sirona Digital Dentures are raising the bar for perfectly-fitted prostheses.


How to create well-fitted, esthetic dentures using a simple digital workflow

	Dentistry is fortunate enough to have access to a wide selection of chairside CAD/CAM monolithic blocks, ranging from the first feldspathic block introduced back in 1991 to more recent advances in zirconia chairside milling technologies.

As dental professionals, we have witnessed a general increase in chairside monolithic block mPa strength over the years yet, many times, at the expense of esthetics. For example, we have an extremely strong material like zirconia but with less than desirable esthetics, or sometimes even more disappointing, an esthetically-pleasing restoration with low to moderate strength.

	Fortunately, industry professionals have been working hard to address these issues and over the years have made significant improvements by marrying strength and esthetics. The best example of this that I’ve seen to date has been with 

 (Dentsply Sirona), a pressable material offered exclusively to dental labs that satisfies both strength and esthetics while clinically displaying a beautiful blending effect with surrounding teeth known as the “chameleon effect,” as seen by its natural opalescence, translucency and fluorescence.

	I had been milling chairside with Celtra DUO for most cases for approximately two years before I recently requested Celtra Press from my lab partner. What a pleasant surprise! Celtra Press provides a natural vibrancy while reducing the “greying effect” often seen in similar materials due to high translucency without enough opacity. Celtra Press uniquely brings together the best of both worlds: strength and esthetics, and not having to compromise a bit on either.

	Celtra Press also has a natural vitality that I haven’t seen before in other materials. The two areas that always concerned me when using comparable materials were marginal chipping and, as mentioned, the greying effect in anterior restorations. With Celtra Press I can polish or re-contour the margins without chipping the restoration, and its chameleon effect assures a natural looking restoration. Moreover, Celtra Press can be either bonded or cemented. Celtra Press fills a definite void in my restorative cases that’s been there for years: it’s a highly esthetic material with exceptional strength.

	Case Presentation: by Dr. William Claytor

	Patient presented with chipped, worn and discolored teeth #8 and #9. Teeth #10 and #11 had PFM crowns placed approximately 15 years prior. The challenge we faced was to not only match the fifteen-year-old crowns on #10 and #11, but to blend #8 and #9 as far as shape, hue, value and saturation (Figs. 1-2).

	Due to these esthetic and strength challenges (i.e., dark stump shade, tight inter-occlusal space, retention) that this case presented, my plan was to place two Celtra Press crowns ordered, designed and created from my lab.

 Omnicam (Dentsply Sirona) I created a digital impression of the case and then sent the image over to my lab partner directly through Sirona Connect. Using a digital communication system as opposed to sending a physical model provides so many advantages: superior accuracy and stability of the impression, immediate feedback from my dental lab technician and, moreover, I am able to make any preparation adjustments while the patient is still in the chair.

	I used a shoulder preparation, preserving as much enamel as possible for retention (Fig. 3).

	I also sent pre-op photos of the un-prepped and prepped teeth along with the corresponding shade tabs for enamel and stump abutment shades to help my dental lab technician evaluate the case pre-operatively in order to lessen potential issues such as the restorations being too translucent or too opaque (Figs. 4-5).

	Here is the beautiful crisp, clear image sent over that shows the case that we received at the lab. The image was sent through the Sirona Connect portal, and was scanned with Dentsply Sirona’s OmniCam by the doctor. Using my inLab (Dentsply Sirona) software, I was able to view the image and start to work on designing the restoration with the “edit restoration” function. This particular image shows the complete facial view with all upper and lower opposing contacts, and in occlusion (Figs. 6-7).

Once the design of the restorations was complete, I was able to send an image of the final proposal in complete facial occlusion view to the doctor for approval (Fig. 8).

	An up-close image of the final restorations ready to mill can be seen in Figure 9, and a lingual and incisal view of the restorations can be seen in Figure 10.

	Here at the lab, I was able to do a model-free pressing of full contour, monolithic restorations due to the fact I had a great scanned image. The restorations were designed using my inLab software, and then I was able to mill the wax puck on my inLab MC X5. I then sprued and invested the restorations with Celtra Press investment and then pressed using Celtra Press ingots.

	Once I received the restoration back, I bonded the restorations with Calibra Ceram Adhesive Resin Cement and 

 universal dental adhesive (Dentsply Sirona).

	The fit was extremely accurate and I had minimal adjustments. The chameleon effect was readily apparent and mimicked the surrounding teeth. The new crowns on #8 and #9 blended extremely well with their surroundings (Figs. 11-12).

	The patient was extremely pleased with the results. He was happy with the fit, feel and the look of his new smile. The nicest compliment a dentist can receive is when the patient is completely satisfied. The natural opalescence, translucency and fluorescence that Celtra Press offers are what make a tooth appear natural in the mouth. Celtra Press is a revolutionary material that provides consistent, reproducible and predictable outcomes as far as esthetics, strength, handling and vitality. Using Celtra Press results in a “win-win-win” situation for the patient, dental lab technician and dentist.

One clinician’s perspective on Celtra Press.

How to Create Strong Restorations With Excellent Esthetics

How to create strong restorations with excellent esthetics

	This was a case that I worked on for a very special patient-my own sister. The patient had a complicated dental history and has worn a removable denture for a very long time. Thankfully, she has a dental professional in the family and came to learn that she now had options for a more stable, permanent and beautiful smile.

	The patient no longer wanted the partial denture that she had basically learned to live with for many years; she wanted a “fixed” solution. Teeth #s 3, 4, 8, 9 and 13 were to be prepped and were our only abutments. (

	Fig. 1                                                                                               Fig. 2

	My initial thought was to fabricate two bridges but I did not trust so few abutments and the multiple pontic spans. The doctor and I decided that a round house bridge (full upper restoration) was our best plan for success.
	It’s important to note that my referring doctor is not a 

 doctor nor a digital doctor in any sense, as I’m sure many of us still have quite a few of these traditional clients. I am, though, indeed an inLab

-using laboratory and all of my restorative solutions are produced using the latest laboratory equipment from Dentsply Sirona.

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	The doctor sent us a physical pre-op model with an opposing model and the bite registration so we could create a full temporary for the patient to wear while her new smile was being prepared. After doing the model work, the maxillary model was prepped here at the lab. The case was mounted and then scanned with the inEos

X5. Using inLab SW (software) 16, we designed the temporary free-hand with no wax up for a bio-copy, and then milled the temporary out of a multi-layered PMMA puck. The patient was then able to test drive her new smile for a couple weeks. (

	Fig. 3                                                                                                    Fig. 4

	The only change that we gathered was needed from the patient was to shorten the front four restorations about 1 mm. (

) We later received the final traditional impressions along with a face-bow. We did the model work and articulated on the Hanau

	Fig. 5                                                                                                  Fig. 6

	We then milled a second temporary with the necessary adjustments to use as biocopy in the 

). The case was set-up in the administration function (

) and was scanned into the SW using the inEos X5 (

	                                  Fig. 7                                                                                  Fig. 8

	We finished scanning the upper, lower, buccal bite and bio-copy (

) and the bio-copy stitched extremely well (

	                                                           Fig. 9                                                                                     Fig. 10

) and then set the model axis to use the virtual articulator in the SW in order to check any excursive and protrusive movements (

	Fig. 11                                                                                                Fig. 12

	Especially with large jobs, it is especially important to meticulously set the model axis and individual jaw line in order to create perfectly harmonious occlusions (

). I let the inLab SW auto trim my dies and then auto mark them, but I always double check to see if any edits are needed before moving forward (

	Fig. 13                                                                                        Fig. 14

	Next, we set the insertion axis or, as I think of it, the “bur axis,” which is the direction the bur will need to be in in order to mill the bridge with no undercuts that may cause a less-than-perfect seating of the bridge (

	Fig. 15                                                                                                  Fig. 16

	Although I used a bio-copy, I did not call this “bio-copy” in the administration step. Rather, I chose the biogeneric individual option instead, and I used the bio-copy as a guide to get my width, length and placement of each unit while allowing me to use the SW to choose the style of the restorations.

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	Next, I checked the spacer and other parameters according to the type of material being used as well as keeping the doctor’s specifications and preferences in mind (

	Fig. 17                                                                                               Fig. 18

	The positioning step is very important to ensure all restorations are perfectly situated. Taking some additional time and care to position and size the restorations will result in a better design proposal. By not checking the adapted proposal box, the SW will provide me with the ideal positioning as I set it, as opposed to adapting it to the mandibular arch (

	In the edit restoration stage, my bridge design is set exactly like it was displayed in my positioning step (

). For this particular case, I chose a full contour zirconia with cut backs on teeth #s 6 to 11 in order to layer those six labials to give it a more natural, lifelike look. The zirconia we chose was 

 VM9 porcelain. I did the cut backs in the inLab SW so it would mill ready to layer (

	Fig. 19                                                                                              Fig. 20

	We milled on the inLab MC X5 along with another case (

). After cutting out of the block but before sintering, I used 

 shading liquids to help enhance the body and look after layering (

	Fig. 21                                                                                                Fig. 22

	Here is the finished case before sending it back to the dentist (

	Fig. 23                                                                            Fig. 24

	Fig. 25                                                                   Fig. 26

	As you can see from the picture, the patient was extremely happy with her permanent smile and so was the doctor.

	Fig. 27                                                                                                  Fig. 28

How one technician used his inLab system (Dentsply Sirona) to make a digital solution from analog dental information.

How to create a better, permanent smile

	Completing a 7-unit lower anterior bridge using CAD/CAM scanning equipment requires a variety of detailed steps. Fortunately, today’s modern CAD/CAM systems, such as Sirona’s inLab system, can help speed up and simplify scanning, designing and milling.

The inLab system can assist lab technicians in using their craft skills to the fullest. The complete system is comprised of a series of components that can be used individually or in combination, which helps save technicians save time, gain flexibility and safeguard the future of their dental laboratories.

The inLab system is capable of completing all digitization tasks in the dental laboratory. It combines a very short, highly precise measurement, along with operating flexibility and a variety of functions.

	The patient wanted to replace a lower partial involving the front four lower anterior teeth to a 7-unit fixed bridge.

Using the inLab system’s biocopy feature with anatomic connectors, a bridge is selected for the case.

Sirona’s inCoris ZI material is selected for the zirconia framework material, and porcelain will be stacked using VITA VM9.

The case is ready to be scanned with the initial diagnostic waxup on Sirona’s inEos X5 scanner’s robotic arm (Fig. 1).

 After scanning the waxup for biocopy and scanning the working model, the individual dies are scanned for more accuracy in finding the margins (Fig. 2). 

Check out this video with images of the case presentation ...

The working model and the biocopy waxup are stitched together by the software. The transfer jig is used to aid in stitching two separate models that may not have enough common data to be stitched properly.

After scanning the opposing upper model, scan for the buccal bite.

After arrowing forward, set the model axis-a very important step to help assure proper insertion axis as well as more accurate design proposals.

 Mark the margins (Fig. 3). When marking the pontic margins, use the biocopy of the waxup in the transparent mode to help in placing the margins in the best position for the proposed design.

 Choose each restoration to copy by outlining the restoration area on the biocopy model (Fig. 4).

 After outlining the biocopy, the design is stitched to the working model (Fig. 5). An orange peel look indicates a well-stitched biocopy.

Individually select each restoration and use the reduce function to reduce each restoration uniformly eight-tenths of a millimeter in order to leave adequate support to stack porcelain. The newly reduced bridge with the transparent biocopy model shows the reduction (Fig. 6).

 Adjust the connectors to ensure the proper strength needed for a durable 

 framework (Fig. 7). Figure 8 shows the framework after milling.

 Smooth the sprue and run a cleaning cycle in the porcelain oven to assure all milling liquid as well as other impurities are burned out to provide a clean framework. When cooled, dip the framework into the coloring solution for 15 minutes to achieve a nice base shading to stack porcelain against (Fig. 9).
	
	

 Set the framework into the muffle of the porcelain oven to completely dry for about 20 minutes to assure it will not crack during sintering.

 The support bars aren’t cut-off, but are instead left on to stop the possibility of bridge framework warping during sintering. Figure 10 shows the sintered bridge with support bars cut off and ready to stack porcelain.

 Before stacking to full contour using VM9 porcelain from VITA, it is important to provide a slurry layer of porcelain to add in bonding (Fig. 11).

 The finished 7-unit bridge is ready to seat (Fig. 12).

Conclusion
	Equipped with a full gamut of CAD/CAM components, the inLab system saves time and simplifies the scanning, designing and milling process, resulting in exceptionally accurate and esthetically pleasing end results for complex cases such as a 7-unit lower anterior bridge.

ABOUT THE AUTHOR
	Bill Atkission, owner of 

, Asheville, N.C., has been a crown and bridge technician for nearly 30 years. He attended the Dental Technology Institute in Orange, Calif., and then opened his first sole-proprietorship lab, Bill’s Lab, in 1989. Throughout the years, Atkission has continued to expand his skills to maintain a dental lab with an emphasis on unmatched customer service and offering technology driven products.

 Completing a 7-unit lower anterior bridge using CAD/CAM scanning equipment requires a variety of detailed steps. Fortunately, today’s modern CAD/CAM systems, such as Sirona’s inLab system, can help speed up and simplify scanning, designing and milling.