Inv. No. 337-TA-1091
`
`CX-1 500
`
`Allgn-1091_00163479
`
`Align EX. 2009
`3 Shape V. Align
`
`IPR2019-00160
`
`0001
`
`Inv. No. 337-TA-1091
`
`
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`CX-1500
`
`Align Ex. 2009
`3Shape v. Align
`IPR2019-00157
`
`0001
`
`

`

`l~) L~~II·<E ~)Ef\l[)lf\IC~ )l()tJF{
`
`() () LJ F1
`
`L~~ i\ E1 (~) F1 i\ ~T~· () F\ 't
`
`rovvheaci hioh!y recorr~rr~ends
`
`90-second facebow is practical enough for every case.
`
`Transfer with precision to our Artex Articulators.
`
`Essential for ensuring patient-specific functional esthetics.
`
`Align-1 091_00163480
`
`0002
`
`

`

`esthetic Dentistry
`
`TECHNOLOGY AND TRENDS IN THE FIELD OF
`AESTHETIC DENTISTRY
`VOLUME 5 ISSUE 4 • FALL zoo6
`
`Contents * Fall 2006
`
`·1
`
`6
`
`C~~O\./er Story·/Colleen Cornelius
`Getting the Smile of My Dreams
`
`1\iouth/Dick Barnes
`Stepping Over Dollars to Get to the Nickels
`
`9 Case Analy~,i~Jjames Downs
`48 Hours
`
`'12 Secrets
`Success/joe Wi llardsen
`You Must Choose Wisely
`
`16 Scit'IKe &
`nolosv/Robert Kerstein
`Delayed Implant Loa~:fing
`IS llot Products/Tim Mack
`Impressing Your Patients with Digital Technology
`
`1 1
`
`I nsights/T awana Coleman
`Customer Service
`
`About the Cover
`
`After ta!dng a ne1.v farnif),~ portrait] Coffeen Cornelius realized how
`unhappy she was >Pith her smile. Ti-~rn to page 4 to read her account in
`Cover StO!)l.
`
`Aesthetic denl:istry by Dr. james Downs, Denver; Colorado. Aesthel:ic
`re:;!:orution:; by Arrowhead Dental Laboratorv, Sand)-', UT. Cover photo
`by Dirk Doi,!glass Photography. Salt Lake City. UT. fdlrkdoug!ass.wmf.
`
`!"1 ic<dte•ll
`AII'O\'iheaJ Der<tc;! Laborc;tol; • Biof:esea~·ch •
`P:osthetics
`Cera\..'led "'
`c:_a:J~k,;.
`Dr. Dick BaiTJh
`• DC<A Der;L;! Lasze•s • lv~ds1r Vivc,denl
`Industries • Tzeksc:in •
`
`opport:unirie:_;, ~~{.-:rrtoc"t 5cort: i··!e.r;ke.f
`""0'.v'''"i {801) :;/)-/2,}.)
`or eddress (.ht:r;ges. ,;onf:(f,;t Debi ftJ(fns fdev~rnsQJ
`
`Strength, Precision, Esthetics.~@
`
`www.arrowheaddental.com I T: 800.800.7200
`
`For exceptional results~ call Arrowhead Dental laboratory!
`
`aU three!
`
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`Align-1 091_00163481
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`0003
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`

`CtJ\lEH STtJnY
`
`COLLEEN CORNELIUS
`
`I was resigned to s m !ling s moll until I become an \lrr~:nMHead Flo nds~mn Gosmetlc lentistty
`class patient.
`
`L:ke most teenagers, I had braces for a couple of years.
`'vVhen tlley were removed, I loved my new smile. ,ll.fter rligll
`school, I cJicjn't wear rny upper retainG:· cJHiQcJntly, so my new
`smile soon beQan to shrft. \!\lith the stress of college, I noticed
`tr1at my tGeth wGm bGcoming flatter, especially on one side.
`I startecJ to teel lecjges on trlG tJack of rny amenor teetr1-a
`result of grinding. Perplexed, I found myself making an effort
`to smile smaller so people wouldn't notice my gummy gr·in and
`crookmj tootr1.
`A few years later I went to dental school w:th my llusband.
`I finally got an occlusal guard to llelp with the grinding, but I
`ciicjn't cjo anylrlitl(:) cJIScJ to fix rny smHe. My mal rry(:)iem was
`good, and I only r1ad a few one-surface dental fillings. Because
`I didn't havG any cavitiGs or major restorations, I tr1ought that
`cosmetic venGGrs or crovvns woulcJ tJG too ag(:)ressive. I r1acj
`very sensitive upper teeth and was worried that crowns would
`cmate more pain. I resigned myself to a life of smiling small.
`Last surrmwr, rny tr1inking tJ~:Jgan to cr1an(:)e. WG took a
`new family picture and when I saw rt, I didn't like it. ~v'ly smile
`didn't look mal and the space next to my turned tootr1 was get-(cid:173)
`till(:) r1uge. I tolcj my rlusiJancj atJout it ancj rKJ saicj rKJ vvanteci
`me to be his patient at Arrowhead's hands-on cosrnetic class
`tr1e next Spr·ing. Because I wouldn't mind having some anterior
`V(-;neers. I t)(-;gan to look forvvarcJ to trlt-} cias.s.
`As the date drew closer, my llusband told me that rny
`case was going to be more difficult than we thought. He
`explaimcj H1at my smile haci a cam. 1\t a minimum. I woulcj
`probably need gingival recontouring.
`When I arrived at Dr. Downs' office, I learned that I would
`tJe ruving a frmectomy, txmy recontouring wiH1 trKJ Waterlase
`laser, gingival recontouring witr1 tr1e Deka laser. and crown
`preps on all of my maxillary teetr:. I was a bit nervous, but when
`I saw tile waxecj up mociels of my new teetr1, my nervousnGss
`was replaced w:th antic:pation.
`We did bone and gingival recontour·ing first. I was shocked
`to fine) Hut uncJGr tile IJonG, I r·:acJ long. p:·Gtty teeth. It vvas
`amazing to see my sm:le even out as the cant was corrected.
`Originally, I simply wanted the space in my smile closed,
`
`Fig 1. Before
`
`Fig. 2 After
`
`so I was blown away with tr1e results of my smile makeover.
`My t~:Jetrl am gorgeous, wr·:ite, ancj straiQrlt. TrKJ gumrny grin is
`gone. My occlusion is more cornfortable than I can remember,
`and my sensitivity is completely gone. I can bite into ice cmam
`ancj cJrink ic~:J water without a stmvv. l'rn simply amazeci at tr1e
`difference this llas made in my l:fe. Ironically, I now r1ave to
`pmctice smiling big, but I love it. Tr1e fir·st time I saw a picture of
`mG witrl my new smile, I coulcjn't r·:elp tJut notice how genuinely
`happy I looked.
`I would like to thank Arrowr1ead for tlleir awesome Elite
`cmwns. wr·:en I tell patimts in our office trlat rny top teetr·: are
`all crowns, they don't believe me because they look so natuml.
`I would also like to thank Dr ... Jim Downs and Dr. Chris Stevens
`for tr·:eir tecrmiques ancj suppo:·t in trKJ r1ancis-on cosmetic
`class. Last. but definitely not least. I want to tllank my hus(cid:173)
`band-----my favorite dentist----for· transforming my smile. Ill
`
`Align-1 091_00163482
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`\V.
`watt,MS.
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`3“
`
`{\cx».
`
`“ca
`
`‘9“Vi:y3.
`
`V./i
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`0005
`
`00163483
`-1091
`IgnAI
`Align-1 091_00163483
`
`0005
`
`

`

`I n the past three weeks I've visited with three den(cid:173)
`
`tists that produce betvveen $200,000-$300,000
`every month. These are solo practices. All three
`told me about the $"100,000 they spent on an in
`office CAD/CAM system to c:-..ave $2,000 a nmnth
`
`on their laboratory bills. They were "jumpinq over
`the dollars to get to the nickels." A productive prac(cid:173)
`tice doesn't have time for a "do--it-yourself kit"
`The three dentists have placed their systems
`on E-Bay with no luck. The units sit in a back closet
`gathering dust. They don't have time tor it because
`they have become too busy doing implants and
`comprehensive cases. They don't even care that
`they wasted their money on CAD/CAM because
`now they are producing many more dollars and
`enjoyinq a much more quality care of treatment.
`If you want to increase your production by
`$200,000 a year or more, picture yourself sitting
`clown to clo an exam. You see that the patient
`is missing a lower first bicuspid. Instinctively you
`think of a three unit bridge. But instead you choose
`an implant as your first tier of care. Imagine that
`you've recently been through a simplified two--day
`intensive traininq proqmm and have a mentor who
`helps you incorporate implants into your practice.
`And because you're a "Barnesified" dentist you
`also present comprehensive dentistry. As a result,
`the patient accepts not only the implant but the ten
`units of crowns that need to be done as well.
`The implant takes only 20 minutes to place
`and the ten units you prepped and temporized
`
`are finished in less than three hours. This type ot
`treatment is not uncommon nor is it out of your
`scope ot treatment. I believe all dentists should be
`placing implants.
`The irT1plant tee is $·1 ,200 and the crown is
`approximately $800 plus. Let's say that that par(cid:173)
`ticular patient's adjacent teeth to the space were
`in goocl condition. The bridge would have worked,
`but the implant provides a higher level of dentistrf.
`The patient vvillnow have a replacement that looks
`like a real tooth and is easier to maintain.
`You can do more lor your patients and for
`your practice by learning to place implants. If you
`want to increase your production then it's impor(cid:173)
`tant to learn to do implants. I mean really learn
`HOW to do implants. Don't just take a course just
`to learn about them.
`
`You will increase your production next year by
`$200,000 or more by learning the simple techniques
`and procedures with osseointergraded implants.
`
`2006
`
`Align-1 091_00163484
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`Align-1 091_00163485
`091_00163485
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`

`They vvork and patients want them. You need to develop
`"implant eyes." This new vision vvill help you find at least
`two edentulous spaces a week. That's aiL I know that
`virtually every dentist can find two spaces a week in their
`practice. The math is easy. Two implants a week tor a
`year is 100 implants a year. That's over $100.000. The
`crown on top will bring the other $100,000.
`
`lnm~ina 1~UIS~II [HliVi~i~~ irn~llnllt IJ~~tistP{ t~~ SHill~ Wa1
`~~IJ I~!Hm~tlliHliViiJ~ ~ri1J~~S.
`
`Many ot you are thinking, "Yeah, but I don't see
`two spaces a week in rTIY practice." Well, they're there,
`you just don't see them. One reason is that you haven't
`made it your locus. You simply haven't been looking
`lor them. In the programs that I present throughout the
`world, I talk about this as a scatoma .... ·a blind spot. This
`is the inability to see something based upon past experi·
`ences. The edentulous spaces are there, you just need
`to see your world differently.
`
`Dr .. John Bauer from fv1anslield, Texas is a great
`example ol what can happen to your practice if you
`choose to place implants and think comprehensively.
`Two years ago he attended Dr. Jon Julian's implant
`course and learned about which implant system use.
`He discovered that to get the best results the Ankylos
`system from Dentsply is the implant ot choice.
`At that time. Dr. Bauer was averaging approxi(cid:173)
`mately $60,000 a month. Jon became his mentor and
`he learned to place Ankylos implants easily and suc(cid:173)
`cessfully in just two, 2-day sessions. Since then he has
`placed over 500 implants and his practice produces
`nearly $250,000 monthly in implants and crowns.
`Imagine yourself providing implant dentistrf the
`same way you currently provide bridges. You too can be
`like Dr. Bauer and succeed in placing implants. We've
`definitely moved into a new era in tooth replacement
`and implants are nmv the standard of care for tooth
`replacement It is the best option for your patients and
`vvill quickly move your practice to the next level. l\lmv is
`the time to get started and stop "jumpinq over the dol·
`Iars to get to the nickels!'' IIIII
`
`Align-1 091_00163486
`
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`

`1 t's been a long and product:ve appointment-a grueling,
`I five hour· maxillar-y arch rer1abilitation-----to create a beautiful
`I
`'
`'
`' -
`'
`'
`I
`t''
`'
`'(
`'
`t
`§ srrl::t-3 anc supt~nor runct:ona posH-mor c-;etn. · ou n-; gc-; 11ng
`r1ungry and your eyes are tired. You feel sttess :n your neck,
`a burn in your siloulder blades, and an incr-edible desire to
`visit u--:e tJatilroorn. Tr1e pati~:mt is t!recJ, r1ypoglycmnic, vvoulcJ
`love a trip to the bathroom, and r1as a numb neck, too. But
`
`ratie~t~ ~8~[1 ~X~Innatio~, ~lit !lOt at t~~ L~~t ~f
`t~eir LOmf~rt
`
`now is the best time to finalize your bite relationship, review
`contours, stJicJct silacJGs, trKJ srztJ of u--:e c~:mtmi incisms, test
`for phonetics, and decide on how mucl: translucency will work
`best----right? Wrong!
`fJatients m~:Jcj explanation. tJut not at tr1e cost of tr1eir
`comfott. Dentists today are tesponsible for form, function, and
`health, but more importantly, aesthetic outcome. If you're not
`in tune w:H1 you:· pati~:mt ancJ Hlcl latJoratory, you rnay IJe recio(cid:173)
`ing tl:e case for aesthetic reasons even rf tl:e clinical outcome
`is perfect.
`/\tter initial milatJilitation. most cJentists will not see tr1e
`patient again until trte placement appointment. At that t:me the
`dentist----and the lab technician----are hoping and praying that
`u--:e castJ :s exactly wrut u--:e patient citJsires. A critical step :n
`which confirmation of the provis:onal teetrt has been lost as an
`instrument of communication for the dental technician.
`
`After you rehabilitate a large anterior segment or full arcl:,
`have tile patient retur·n within 48 hour-s to refine and define
`s~:weral issues. Tr1e patient will tJG restecj ancJ can tell you if trKJ
`occlusion is off, pl:onetics are altered, or if tl:e contouts of the
`teeth are acceptable.
`
`A simple checklist will rtelp you be cettain of trte out(cid:173)
`come and will show patients your attention to detail. 'vVhen
`rny patients return tor u--:eir 4.3-rlOLJr retimrnmt appointments, i
`review rny checki:st whicl: includes occlusion, prtonetics, cen(cid:173)
`tr-al incisors (75-80), contours, and shade.
`
`If tooth positron is be:ng altered (in most cases), I check
`for discrepancies in both vertical and anterior poster·ior posi-(cid:173)
`tions. looking tor tr1e ortilop~:Jcjic position ot trKJ jaw JOints.
`Typ:cally, you can alter vertical position 2-3 millimeters w:thout
`stimulating muscular activity. But if you alter the anterior pos-(cid:173)
`ttJrio:· position just a quarter rn:ilirnet~:Jr, muscular st:mulation
`occuts. Lateral crtanges inttoduce torque, wrtich results in
`pitch, roll, and yaw relations. If one side is not contacting in
`cemnc occlusion, trltJ patient will torqutJ up tile cJef:cient sicj~:J to
`contact the oppos:ng arch within 24 rtours, causing muscular
`dysfunction -- SPA.SM.
`S~:Nenty percent of rleaciadlcJS are contractecj types
`associated witrt malocclusions. Having the patient back within
`48 hours can save you from turning a non-symptomatic patient
`:mo a syrnptornatic pati~:mt
`Have the patient relax his or her muscles by using a tens(cid:173)
`ing unit for 30 minutes. Tensing tile muscles of mastication
`proviciGs increa.seci !Jioocj tiovv, n-;rnovc-;s toxins (lactic ac:cj)) anci
`releases adhes:ons in the muscle so tl:at trtere is an :ncrease
`in range of motion. ,ll.fter· a four--to-six hour session in the chair,
`Hlcl pat:em rnay experienc~:J post-op~:J:-ative swelling ancJ tru(cid:173)
`isms. The tensing unit is a great thetapeutic instrument to telax
`m uscies so t!lat a true trajectory of function and toot!l contact
`can tJG ~:waluat~:JcJ for acijustrnent. OnctJ patients ftJGI H1at trKJy
`are simultaneously contacting bi-laterally, it's time to stop.
`
`Evaluation ot tile F-poim ancJ :ncisal cJCJQe position can
`fine-tune pl:onetics to an acceptable position. In an upright
`
`Align-1 091_00163487
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`

`position, r·:ave tr1e patient count tmm 40 to 50 rapicJiy. Look at
`u·1e maxillary incisal edge and its relationship to the lower lip.
`Upon saying ~~F!l sounds~ if the centra! incisors ern bed into the
`lower lip, tile lengtr1s of tile incisms at·G too lon(:).
`I\CJJust trKJ
`incisal GdgG on 8-9 by a quartm of a m!llimetGr at a ttmG until
`the patient is _iust barely touclling the lower lip.
`r'iext, r1ave trKJ patient count from m-70 mpicJiy. Watcr1
`and listen for a proper "S" sound made by tile maxillary incisors
`and tile mandibular incisors. Are tlley clinging into eacll other
`or is til ere GxcGssive space lxJtvvGE'Jrl trKJrn? Acjjust IJy recJucinQ
`tr1e lingual tncline of thG upper teetr1 and la.blal surfacG of tr1e
`lower teeth, or add composite to the incisor to establisr1 an
`acceptatJIG "S" souncj.
`
`l!J lw )m:!:B)Shll ~~ l~!J)ffWtiL !l~~tiSlP1 t!Hltl~1, l~B ~~~tal
`[Jmf~))i!Hltll ~~r,~~ tll ~~ r:mnmitt~~ tll m~r,ti~~ til~
`[Jatir,llf) \No Ill~ amJ ~Bsirr,s.
`
`Central incisor wtth lengtil percentage (75-80)-Evaluate
`the patient's head type. If their type is bracllocepllalic---·80
`pGrcGnt, rrwsoceprlalic-7.3 pc;t·cmt ancJ cjolioceprlalic -75-78
`percent, you decide on the widtil and length of the central inci(cid:173)
`sors and let tr1e lab establisll the proper golden pmportion.
`
`This is the best way to develop an eye for an overall aes(cid:173)
`thetic appearance of teeth. The anatomy of teeth can make you
`a woncJerful artist. LGam how to sr·:apcJ ancJ slencierize, espe(cid:173)
`cially canines! Att.entton to detail at trlis point is time well spent.
`Check for overhanging and rough acr-ylic on tr1e provisionals,
`cJspecially trKJ facial marQitlS of trKJ anterior tGGtrl. n·:en::; is notrl(cid:173)
`ing worse than having your patient return witil apically lifted
`margins exposing root surface. Can you spell "R .. E-P-R-E-P?"
`
`OncG completecj witr·: trlE'J contouring pr1ascJ, polisil every(cid:173)
`wrlere again and ask rf tr1ere are any rough spots. Use a smile
`catalog to select the appearance tr1at your· patient desires.
`Take an impression of tr1e provisionals to sGncJ to tile latJ with
`your case.
`
`f\lcJxt, review trKJ colm mapping of trKJ teGtrt Fill out trKJ
`laboratory prescript:on in front of the patient Start by evaluat(cid:173)
`ing the sllade of tr1e provisionals. I usually use A1 sr1ade, but
`trKJ paticmt may want to go I!QrltGr. CrKJck for tile wrliterKJss in
`the pat:ent's eye (Sclera). Tile two dist:nct features of a face are
`eyes and smile. Create the contrast needed for tllese features
`to stancJ out toQcJHlcJI-.
`Start witr1 the ging:val silade selection f:rst, followed by
`tile middle upper body third, then tile main dominate shade
`in tr1e mici to incisal om-r·:alf to two-Hlit·cJs of tr1e tootrL Finisr1
`with a milky translucency of 1 to 1.5 mm of the incisal edge.
`An example of tllis usinQ a chmmascope shade Quide would
`tJc-;: i 1 0 gingiva! I 040 upp(-;r tf·lirci I 0~30 rr1ain tJociy 'Nith a lotJeci
`milky translucency incisal edge of 1 mrn. All along, tr1e tootr1
`becomes lighter· in shade as it progresses casually to the incisal
`mJQe. Decicie surface texture ancJ any occlusal stain.
`Within reason, the pat:ent should deterrnine ilow wrrite
`tile teetll sllould be. But I find tr1at patients rarely complain of
`QoinQ too ligr·:t. tJut trKJY cio re~w;t not goinQ ligr1t enougr1.
`Following th:s outline will create certainty mt only for the
`dentist and patient, but fm the lab tecr1nician as well. To be
`succcJssful in cosmetic cjmtistry tocjay, trKJ cJental professional
`needs to be committed to meeting tr1e patient's wants and
`desires. CJthervvise tf-1e dentist rnust be prepared for reprepping
`trKJ case at HlcJir Gxpcmse for aesthetic masons.
`
`James C. Downs received his D.lv1.D. degree Jfi·om Tufts Univer(cid:173)
`sity School of Dental Medicine. He is an expert in comprehen(cid:173)
`sive restorative treatment by completing numerous full-month
`reconstruction cases. He maintains an aesthetic, _f<unily .. oriented
`practice in Denver, Colorado.
`
`Align-1 091_00163488
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`60163490
`Align-1 091_00163490
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` \Rxxmm‘x
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`00163491
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`

`after pictures can be your lab tecrmician catalog.
`Two recent easelS cimnonstrate r1ow cjifferent tecrmician
`styles can affect outcome. In both situations (photos 1 & 3), the
`patients were not ilappy witr1 their restorations. The relation-(cid:173)
`sr·dp IJetwtJtJn tile cJoctor ancj tile patitJnt sutfemcj tx;cause of
`the compromised results. Botr1 patients dec:ded to leave the:r
`doctor and have a new doctor redo their mstorations. Once the
`new cioctor removecj trltJ mstorations, r1eJ cJiscovtJrecJ that the
`bond was good and the preps were acceptable. Tr1e reason
`thtJstJ castJs tailed was because the first doctor did not use a
`cornpetemt latJ. TrltJ latJ failecJ to get trKJ p:·oper information ancj
`therefore delivered an unacceptable product Tile new doctor
`only ilad to select a quality lab and communicate effectively to
`switcJ1 eJacll patimt from a cJtJsperateJ situation to a tJtJautitul,
`comfortable smile (photos 2 & 4).
`
`Quality without Compromise
`To avoicj similar situations. you must cr1oose your latJ
`wisely. If you skimp on quality, it will cost you more in the long
`run. Make sure the lab mquires tr1e proper tools to get the smile
`JUSt :·igr·:t. n·:ey sr·:ouicj QivtJ you a dleJckiist of evtJr'ytr·dnQ ti1ey
`will need to Qet started. Tllis cllecklist :s preliminary, so expect
`the lab to ask for models, photos, different bite 1'8Qistmtions.
`eJtc., to create tile successful outcome you cJesire.
`
`Checklist for Wise Solutions
`• Maxillary arch witil hamular notciles and mandibular
`impressions (suQgest tr·:ese IJe takem in polyvinyl for
`accuracy and duplicate casts) Outline cast to desig-
`nate vvhere tissue contouring is needed. Be sure to get
`a very accurate) irnpmssion of (:)urn tissueJ! It vvill save a
`lot of time :n the temporary phase of treatment.
`• Smile design from either· patient mock-up m smile
`cataloQ. Magazines are also i1elpful. Ti1is is trKJ first line
`of commun:cat:on.
`• Elite registration (a r1ar-d acrylic bite reQistration will help
`mountinQ protJimns ancJ minimizeJ tecr1nician error)
`• Stick bite with horizontal and vertical components
`
`• Photograpils (see samples)
`• sr·drntJasrli vertical measurements (Qumline to QumlintJ
`or CEJ to CEcl)
`After mceiving tr1e completed cilecklist, a good lab will
`fatJricate tile wax-up ancj other necessa:'y items to tltJQin tmat(cid:173)
`ment The diagnostic wax-up can llelp you plan your case and
`get tr1e patient's acceptance. It is very important that the lab
`takes eJxtra care in manaQHlQ tissutJ rKJiQhts ancj contours in
`the wax-up and temporary matrices. Clear marg:ns and clean
`lines are a sign of good lab work and will save tile doctm later
`rleJacjacJKJS.
`The degree of treatment success wiH depend on the
`accuracy of information the doctor supplies to the lab. /-'-.qual(cid:173)
`ity, corrlprer·:ensive latJ will provicJtJ trKJ follovving items:
`• Wax-up
`• Pmp-guide
`• Surgical stint (surgical ternpiateJ)
`• Ternpomry rnatnx
`• Transfer bite (used when chanQing vertical)
`• TissutJ contours ma:·kmJ on casts
`• Laboratory cr1aractenzation guides (such as tr1e Elite
`Characterization Guide from Arrowhead l..aboratory)
`it you vvant to keep costs to a rninimum. fincj out you:·
`lab's srlipping policy and carrier. Shipping back and forth can
`add up hundreds of doHars for just one case.
`BucJgt~t, of course-;, plays a roit~ in cr1oosing a latJ. But: if
`you focus on tr1e price per unit, tllen all your lab work is going
`to be expensive. Remember that usinQ a good lab is less
`tJxpensivtJ tr1an rescJKJcJulinQ trltJ patimt m recjoing tr·:e case.
`While choosing a good lab isn't an exact science, know(cid:173)
`inQ you r1ave communicated proper·ly, used the correct tools,
`ancj cJevcJiopmJ a Qoocj :·tJiationship witr1 tr1e patiemt will rKJip you
`avoid lab frustration. iii~
`
`.Joseph Wiilardsen is a graduate ofLoma Linda University
`School of Dentist1y. His expertise in marketing and aesthetic
`dentist-r; has allowed him to maintain a succesiful cosmetic and
`neuromuscular practice in Las Vegas, Nevada.
`
`Photos 1-2 and 3-4 show referenced before-and-after photos. Photos 5-12 reflect other photos you should send to your lab.
`
`Align-1 091_00163492
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`Align-1 091_00163493 39436100.1901.QA
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`lay
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`Cases with implants and Natura! Teeth
`
`aturai teetrr move rnore tllan implants because the
`periodontal ligament is so resilient. In mixed implant--(cid:173)
`natura!
`tootr1 occlusal scrKJmGs,
`tr1is movcJrmJnt
`discrepancy mGans an irnplant prosthesis, wrlich moves signrfi(cid:173)
`cantly less, can interfere
`with tile natura! teeth
`completely depress(cid:173)
`ing into the periodon(cid:173)
`tal ligament. Tlli:m:Jtore,
`trre irnplant prostheSIS
`receives most of
`tf-1e
`occlusai forces,
`To
`minimize
`excessive implant pros-
`trKJsis force, tr1e occlu-
`sal scheme can include
`time
`a quantifiable
`cielay, such tr1at trKJ natura! teeth occiucje tJefore trKJ implant.
`Natural teeth move 1n a two-stage process. The f1rst stage
`is the intrasocket stage, during whicrr a tooth moves within the
`perioc)ontal ligament 1. Tr1e seconcj staQG is an elastic cjeforma(cid:173)
`tion of the alveolar bone 1. it IS dunng the lntrasocket stage that
`most tootrr movement occurs under occlusal loading.
`~~on-motJiiG post~:Jnor tGGtrl cjepress into tr1eir periocjontal
`l1gament fibers about 28 microns verticaHy and 56-75 microns
`later·ally. Anter·ior teeth move from 90·- i 10 microns''.
`
`Fig. 1 Before
`
`lrnplants depress 5 rnicrons vertically and 12-66 m1crons
`laterally2. Because of this movement discrepancy vvllen natural
`teetr-·1 anci implants occlucje sirnultaneousiy, tr·1e natural teGtrl
`are "stopped" on the way into the1r periodontal ligament f1bers
`by trre immovable implant prosthesis. Trre implant prosthesis
`trKm recGives the majority of trlG occlusal forces. Tl1is pr·~e­
`nomenon will affect the long-term prostrresis integrity, implant
`integration, and supporting bone level stability.
`tootr1 occlusal
`in mixecJ
`implant-natural
`Tr1erefore,
`scrremes, it is best if the implant prostllesis occludes after the
`natural teeth. This gives the natural teeth enough elapsed time
`to cj~:Jpn::;ss partway into Hlcl periocjontal liQament fiiJers anci
`beg1n to meet alveoiar housing resistance before the implant
`prosthesis occludes. Tllis time delay3 must be kept sllort (less
`trun .4 seconcJs) fo1· trKJ implants to occlucje at aiL
`In a ciinical report by Stevens4
`, it was demonstrated tllat
`by applyinQ the time delay principle to implants supporting a
`cjistal extGnsion implant prostrKJsis, prim mcJioQmpr·:ic t)(JrlfJ
`loss was regenerated around the implants a few months after
`t!le tirne deiay \vas estabiisiled.
`Estat)lisr·:inQ a time cJelay is a precise occlusal acjjustrnc;nt
`that requires patience and cl1nical tnal. The operator srrould
`fir·st cmate implant prosthesis and natural tooth loadinQ time
`simultanGity, tr·1en (:)entry I~:JssGn tr·1e occiusal contacts on trKJ
`implant prostheSIS so that a trlin layer of occluding matenal is
`20
`
`Fig. 2 Eariiest tooth and implant prosthesis occlusal contacts (A) at .122 sec; The natural tooth depression into the periodontal ligament results in a
`.force increase (B) at .189 sec; The end of intrasocket tooth movement with teeth at maximum .force (C) at .281 sec; The .first significant implant pros(cid:173)
`thesisforce increase (0) at .396 sec; moderateforceful occlusal contacts on the implants (E) at .530 sec. Time delay is approximately ·4 seconds.
`
`Align-1 091_00163494
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`CERAMED
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`Align-1 091_00163495
`Align-1091_00163495
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`rnpress:on rnat~:Jnals rl<WtJ QtaCJuaily evolveci since tr·:eir
`introduction 100 years aQo, but the overall irnpression
`process ilas remained mlativeiy static. The chaHenQes fac··
`inQ tr·:e mstomtive c)entist are well knovvn. W:H1 conwJntional
`:rn press:or:-takinQ,
`• Approximately 36 percent of dentists
`re-take
`impressions u··:ree or more t:rn~:Js p~:Jr rnonH1. *
`• Or: avetage 36 percent must te-appoint patients for
`impression taking at least once per month."
`• At ltJast 15 perc~:mt ot cases mquire f:vtJ rninuttJs or
`rnme adjustment time at seating.*
`
`~m~ fmm v~itls, rmlls, t~al~, ml~ tr[lir:al wm~ i!ltmm~t ir1
`r:~nventi~~al imiHB~~i~n taKi~~ met~o~s{ t~~ t~re~-~~m~11si~nal
`ima~~ all~ws oe~tists vis~alilati~n ~~11~r ~~f~m ar:~iev~o.
`
`Advances in d:gital :magir:g science can now address the
`underlyinQ pr-oblems of conventional impressions. Cadent, Ud.,
`recently laurdlcJCJ Cacjmt :Tero'"~, a cJigital irnpmssion system
`wl:ich offers dentists and labomtones a technology-dr:ven
`impression procedure far· superior to conventionai methods.
`TrKJ iT~:Jro system is tJasecj on 3-0 optical scanning
`technology. Oent:sts find taking impressions witl: :Tero to be
`
`r1:gr·:iy intu:tive. Tr1ere are no sp~:Jcial tooH1-prepamtion Quicje(cid:173)
`lines and coating of the teeth is unnecessary. Following voice
`prompts, the dentist or assistant takes several, split-second,
`opticai scans of HlcJ tar(:)et a:·tJa ancj trKJ opposinQ arcr1 \rvitrl
`a hand-held wand. The scanning sequence concludes w:th a
`bite registration scan. With eacil scan, iTem software captures
`1 DO,OOO c)ata points allowinQ :Tero to present a 3-0 mncJering
`comprised of more tl:an 1.5 rnillion measutements.
`Once tile software confirms it has obtained sufficient data,
`a voice prompt :ntorrns Hlcl cjmt:st H1at tile scan is complete. At
`this po:nt, iTero uses advanced image processing tecl:nology
`to compile and display a three-dimensional virtual model.
`Ft-tltl from voic)s, pulls, t~:Jars, anci typicai errors inrlcJrmt in
`conventional impression taking methods, the three-dimensional
`image aHows dentists to see what trtey never have before. This
`real-tirntJ ciisplay lets tile cjentist exam:ne trKJ ma:·gin ancj trltJ
`occlusion as well as rneasure and verify proper occlusal and
`inter·-proxirnal reduction.
`l\fttJr tile cjentist rnaktJs acJjustrnents ancJ approves trltJ
`scar:, the file is uploaded to a Cadent CAD workstat:or: at
`tile partnering labor·atory via wireless internet. The labor·atory
`retrieves Hlcl cJigital file, com(cid:173)
`pletes the digital ditcl:ing pro-
`cess, and designs the coping.
`Cac)ent usGs Hlcl cJatafile
`to rnill models, dies, and sub-
`
`Fig. 1 Machine miiled wax coping designed by Cadent and mam.rfactured for iTero maintains dimensional integ(cid:173)
`rity during extreme temperatures; Fig. 2 Semi-adjustable articulator created for iTero by Cadent. which enables
`the lab and dentist to replicate most jaw movements; Fig. 3 Cadent iTem'"" Digital Impression System.
`
`page 2C'
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`The best choice f()!" esthetic, strong and piaque
`r·esistant crowns
`bridges is ( ··
`fror11 ;\rrov,rhead
`Dentai L.aboratory. t······ ·········
`once again vvas voted by
`your peer·s as the ver-y best r-estor-ative choice. Shouidn't
`be your natur·al choice, too?
`Call today and make ;\rrowhead Dental
`Lab your· tr·ustecl smwce for· accur·ate
`and reliable ( ·
`restorations .
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`www.arrowheaddemal.com
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`ARROWHEAD
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`................................................................................................................................................................. 1~8oo~soo~72oo
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`Call Arrowhead for Captek'" Today!
`
`Align-1 091_00163497
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`0019
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`shaved away. Repeated T-Scan!P' !I analyses reveal whether or
`not H1ere is a cJc-;lay. as vvt-}11 as its cJuration.
`After tile irnplant prostllesis :s seated, bring the occlusal
`contact arrangement in line witr1 the rest of the occlusion so it
`ancJ u--:e neigrlt)(JrinQ ti:JtJtrl are in occlusion. Fi::Jcorcj aT-Scan II
`Full Closure Force Movie5 and play it back to watch for when
`the segmental prostr1esis loads in corn pari son to tr1e natural
`teeH1. If trKJ implants prececj::J tr1e teetr1 tJy mo:·tJ u--:an .25 sec(cid:173)
`onds. maJOr occlusal adjustments are required. If the :rnplants
`ioad sin:ultaneously (less than a .05 second deiay of eitiler
`teeH1 txJfore implants, or implants txJfore ttJtJtrl), or slightly after
`the natural teetr1 (less tl1an . ! second delay), further adjusting
`will establish a definitive implant pmsthesis time delay.
`Mark tr1e implant prosHlcJsis vvitrl Accufilrn11v1 ancj Qently
`shave tile occlusal contact marks.
`Record another Fuli Closure Force Movie. If the delay
`1s close to .3 stJconcJs, trKm stop u--:e occlusal acJJustrnent.s
`as furtller adjustment will take tile prosthesis out of contact.
`The closer to .3 seconds, tr1e better tile cllance the teeth
`\rvill cJ::Jpress siQnificantly in acjvance of trKJ implant se(:)ment
`occlud:ng.
`The figures on page 16 demonstrate how to establish
`a quantifiaiJie tim::J cJtJiay. This force movitJ recorcJing is of a
`maxillary left PFM splint on 3 implants. Tile rema:ning maxillary
`teetr1 are restored witr1 PFM crowns on natur-al teeth (fig. 1 ).
`FiQ. 2 sr1ows five 3-D sequential force plots (A-E) trut
`:llustrate tile desired delayed occlusal result.
`Natural teeth move vertically and horizontally in their
`ptJriocJontal ligament fitJtJrs far mo:·tJ than c)ental implants move
`:n bone. T-Scan II occlusal analys:s can determine tile relative
`time of initial contact of natur-al teetr1 and dental implants so
`that it is possitJicJ to stJparattJ tr1em acco:·cjinQ to wr1en trKJY
`come into occlusal contact. By delaying the implant prosthes:s
`until after· the initial tootll contact occur