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Unlocking the future of digital workflow, new materials, and communication devices
By Pam Johnson and Jason Mazda
If there were a single secret word that would allow access to what the future of dentistry has in store for the next 5, or fewer, years, that password would have to be “technology.” Few, if any, segments of the dental industry have been left untouched by some form of computer-driven science. From caries detection and digital impressioning at chairside to virtual communication and automated manufacturing technology in the laboratory, every diagnostic and restorative phase of dentistry is being enhanced by computer-chip technology.
These rapid technological advancements are not only having a profound impact on the day-to-day routine of dentists and laboratory owners and managers, but they are also reshaping how companies in the dental space both big and small operate within the dental business environment. Once siloed with distinct brands available exclusively through the company or a select distributor, the lines between the big-brand companies continue to blur as even the largest of them finds it necessary to work with one another in order to gain access to new materials and new technologies or strategically expand its product distribution lines. In recent months, Heraeus Kulzer and Dental Wings, Straumann and Amann Girrbach, Sirona and Align Technologies, Dentsply and Renishaw, Shofu and Merz, and Nobilium and EOS all have announced strategic partnerships, distribution agreements, buyouts, or mergers to gain greater footholds in a competitive environment that is forcing companies to change how they do business.
Likewise the explosion of new technologies launched on the market in recent months is forcing dental laboratories to rethink their positions in the marketplace. New product lines have opened up to a digital workflow, new materials may offer a competitive advantage, and improved automated equipment and communication devices will enhance production efficiencies and speed throughput. Also, new concept technologies and materials are breakthroughs for the industry and will impact how restorative products are made and what they are made of in the future.
In March, the editors for Inside Dental Technology attended the International Dental Show (IDS) 2015 and saw many of the new innovations that will be introduced to the US market in upcoming months. In this article, we wanted to provide some perspective for what we saw, what we heard, and what we perceived as trends that will impact the industry for years to come.
Digital Dentures Everywhere
If there is one technology trend that is taking the dental industry by storm, it is finding solutions that will transition the manufacture of full-arch dentures from conventional manual techniques to a digital workflow.
“Many companies offered their own twist on the digital denture solution,” says IDS attendee Chris Brown, BSEE, Manager of Aclivi Consulting/Technical Services in Pinckney, Michigan. “This will be one of the emerging markets available for laboratories and clinicians to use for delivering dentures and removables.”
The process of creating a complete digital solution has encountered several obstacles. The first has been the inability of current digital impressioning technology to digitally capture the necessary landmarks of the edentulous arch to accurately design a well-fitting and functional prosthetic. The second has been the development of open-architecture, non-proprietary CAD software that would provide access for the majority of laboratories owning scanning/CAD technology to participate in a digital workflow. A third obstacle that specifically targets manufacturers of 3D printing technology has been the development of FDA-approved materials for long-term use in the mouth. Also, the problem of setting denture teeth has lingered, which for most processes introduced is still manual. Only two companies currently provide a digital solution. AvaDent has successfully demonstrated the ability to mill a full arch from a single block of FDA-approved material complete with denture teeth, and Heraeus Kulzer with the Pala Digital Denture system uses a proprietary process to finish the final denture.
Central to any solution to the digital removable process is the software. With the introduction of CAM software by 3Shape and exocad, laboratories using CAD technology powered by these two scan/software companies now have or will soon have the ability to digital design full-denture solutions. This breakthrough has spurred manufacturers of milling and 3D printing technologies to develop at least partial solutions for the full digital process. Recently three companies, VITA, Dental Wings, and Dreve, announced they plan to bring together VITA’s expertise in denture teeth, Dreve’s 3D printing capabilities, and Dental Wings’ CAD software in a collaborative effort to develop a digital workflow for full-denture cases. This also shows promise for the future.
For those using subtractive technology, Wieland Dental and Amann Girrbach both announced solutions for milling a complete denture base. Wieland introduced the Zenotec Select Ion mill, equipped with an 8-disc material changer and ionization system that directs ionized compressed air onto the material and tools during the milling process to neutralize the static electricity of particles when milling acrylic materials and producing full-arch dentures, bite templates, try-ins, surgical guides, occlusal splints, and PMMA restorations. CAD design includes a tooth library with sample setups using digital versions of Ivoclar Vivadent and Candulor denture teeth. The denture base is milled from IvoBase CAD PMMA and available in several shades, and the denture teeth are set by hand.
A unique feature of Amann Girrbach’s denture milling solution is the elimination of trimming the denture teeth by hand. The ridge lap surfaces of the teeth can be adapted to the alveolar ridge in the CAD software and then, using a special denture tooth holder designed for use in the Ceramill Motion 2, the denture tooth surfaces can be trimmed via milling technology. The Amann Girrbach system uses Heraeus Kulzer’s Pala denture teeth and a specialized denture tooth holder developed by Heraeus Kulzer for use in the Ceramill Motion 2. Eventually, Amann Girrbach plans to incorporate other tooth lines into the workflow for a wider range of customization and esthetics.
Straumann also showcased a prototype of an in-house denture milling unit although it is too early for any further information. The company has also made a big play for providing laboratories with in-house production capabilities, which will be covered later in this article.
Several 3D printing solutions are also forthcoming from companies such as Bego, Stratasys, and Valplast. Bego introduced a 3D-printed solution that will be available in the fourth quarter of this year for printing a denture try-in combined with conventional denture fabrication techniques once the try-in is approved. Stratasys also had on display a printed full-denture try-in in color and complete with teeth produced by the company’s new Objet Dental Selection printer. Also, Valplast announced plans to release a full-denture solution later this year, which will feature a new library of denture teeth, plus printing and milling solutions for the final prosthetic.
3D Printing Technologies
Additive manufacturing is a technology that is being watched very closely by many major industries around the world due to the scalability of the technology as well as the promise of new materials that target specific industries. Still in its infancy in dentistry, 3D printing is beginning to show its versatility and advantages.
This year a milestone was achieved by the introduction of Stratasys’ new Objet Dental Selection printer. Using inkjet-style print heads, this new printer can produce a single job in multiple colors and shades of color as well as in multiple textures or multiple jobs requiring a combination of colors and textures. This makes it possible to print clear plastic jaw models with high-definition tooth, root, and nerve anatomy directly from CBCT scans using 3Shape software or print hard models with gingiva-colored soft tissue-like material for evaluating accurate function of implant restorations.
For smaller, less complex 3D printing needs, several companies introduced small-footprint devices. Whip Mix introduced a line of compact printers, the smallest of which was the size of two oversized Rubix’s cubes. Though they are not yet available on the US market, Vice President of Sales and Marketing Anne Steinbock indicated they would be introduced in the near future. Called Veriprint, this technology builds in multiple layers in stacks up to 7 cm in height. Three models were on display: the Veriprint 100 for printing wax patterns, temporaries, and ginigival masks; the 200 for printing wax patterns, drill guides, models, implant trays, temporaries, and gingival masks; and the larger 300 for orthodontic appliances.
Among the new 3D printing companies entering the dental arena was California-based Asiga with its Pico 2 and Pro75 FreeForm SAS (Slide and Separate) technology. This desktop printer produces minimal support material that has to be removed for its printed wax pattern crowns, bridges, partials, inlays, and onlays. In March, the French company Prodways opened a distribution and support center in Minneapolis, Minnesota for its industrial-sized ProMaker L series printers. Well-established in other industries, Prodways utilizes MOVINGLight®, a proprietary technology based on moving the build material and UV LED curing technology simultaneously for high-resolution precision models, wax patterns, and other complex structures in a variety of hybrid materials.
Keep your eye out for a company called Carbon3D. This company was not at the IDS but has developed what it calls CLIP technology, which is said to “grow” parts instead of printing them layer-by-layer. CLIP stands for continuous liquid interface production and uses the interaction of UV light and oxygen to continuously grow objects from a pool of resin. The process is said to offer unprecedented quality and much greater speed than current technologies.
Most interesting this year is the introduction of a laser milling technology unveiled by Dental Wings. Instead of using burs to grind a block of ceramic, polymer, or glass material, this new “milling” concept uses laser ablation technology. Very high-intensity laser pulses are used to vaporize small amounts of material with each pulse and with extreme precision. A built-in scanner compares what is being milled to the CAD design to ensure that the restoration meets the quality-control standards of the design. Currently, the unit can produce inlays, onlays, crowns, bridges, and veneers. The advantages of this technology beyond the “closed loop” quality-control process are that no after-market costs such as additional burs, cutting coolant, or compressed air are needed to operate. Because the laser beam is one-tenth the diameter of the smallest known CAM bur, the technology can produce restorations with features and resolution not possible with CNC manufacturing.
In terms of milling technology, the most surprising is the play both Heraeus Kulzer and Straumann are making for the in-house milling arena. Lying dormant on the digital landscape and fixed side of dental technology for many years, Hereaus Kulzer came to life this year with its Pala Digital Denture platform and the introduction of the Cara DS scanner 3.2 and Cara DS mill 2.5. The company also announced plans to distribute the Dental Wings DLMS laser milling unit. The compact scanner is plug and play with an integrated PC and software. It allows scanning multiple teeth simultaneously as well as selective scanning of the gingiva, wax-ups, and check bites. The Cara DS mill on display is a small-footprint device with no further information available, but the unit did have a denture base mounted inside, if that is any indicator of its versatility.
Straumann has strayed from its centralized production-only stance and partnered with Amann Girrbach to make its play into providing laboratories with in-house milling technology. Although the milling units will first be introduced in central Europe starting in the fourth quarter of 2015, the company plans to expand distribution to other regions. Called the CARES® M Series, the 5-axis milling unit is a wet/dry mill for producing a range of prosthetics from inlays, onlays, veneers, and single crowns to bridges and screw-retained restorations. Supported by CARES Visual software and scanning technology, the mill will be offered with the new CARES desktop scanner for laboratories entering the digital workflow or as a standalone for laboratories already equipped with a scanner.
Among the other notable new milling technologies or advancements are Zirkonzahn’s two new milling units. The M4 is designed with an extra-large milling area to handle the processing of 10 models out of large specialized resin blocks. The new M6 unit incorporates a robotic “arm” for the automatic changing of up to 14 material blanks or 49 milling tools. Both will be available to the market soon.
Zimmer introduced the Zfx Inhouse 5-axis wet/dry mill, which it calls the new industrial standard in compact size. It is suitable for milling various materials from zirconia, ceramic, and composite to PMMA, wax, cobalt chrome, and titanium.
Schutz Dental unveiled the Tizian Cut 5.2 milling machine, a compact tabletop unit that it says can mill nearly all materials that are used in dental technology with its wet and dry options. Schutz calls the machine “extremely future-proof” due to its digital workflow integration.
“The smaller, compact 5-axis mills that mill everything are exciting,” says IDS attendee Jessica Birrell, CDT, who owns Capture Dental Arts in Saratoga Springs, Utah. “As a smaller laboratory, if we are going to invest in a mill, we want it to do as much as possible.”
Newest in Material Technology
Two years ago the big story on new material introductions was the launch of millable lithium silicates by VITA, Glidewell, and Dentsply. This year it was the introduction of pressable lithium disilicates from Shofu, Zubler, and the Chinese company Upcera. Shofu’s Vintage LD pressable system boasts 400 MPa and four levels of translucency and comes complete with Vintage LD porcelain and LF stains.
Zubler’s conceptPress lithium disilicate is billed by the company as the most stable on the market at 420 MPa. Offered in three opacities and three pellet sizes, the press system is supported by DC Ceram 9.2 layering porcelain and the Vario Press 300.e furnace, specially designed to process lithium disilicate ceramics.
Anaxdent in partnership with Cendres+Metaux will be the exclusive distributor of a breakthrough new material in the US called Pekkton® ivory. This next-generation high-performance polymer has a compressive strength of 246 MPa and offers shock-absorbing characteristics similar to that of human bone, making it optimal for use in implant dentistry. Pressable and millable, this new highly biocompatible material offers myriad long-term solutions for crown and bridge frameworks and implant-supported restorations.
Other breakthroughs are being made in the research and development of 3D printing materials that can be used for permanent restorations. One that may be coming from Bego sometime in the near future is a crown and bridge framework material. The company’s new Varseo 3D printer currently uses a self-contained cartridge system of eight different resin materials for producing splints, CAD/Cast® frameworks, surgical guides, and try-in denture bases. But tucked away in the company’s press materials was a reference to a “permanent” 3D-printed crown and bridge solution. Upon questioning at the Bego IDS press conference about this material and later at the Bego booth, it was revealed the material is a printable composite that can be layered and is in its second year of in vivo testing. If clinical testing proves positive, this would be the first material produced by 3D printing technology for use in long-term crown and bridge frameworks.
Another permanent 3D-printed breakthrough material this time on the removable side of dentistry was unveiled by Valplast. Not yet on the market, this will be a Class II printable resin material that offers the ability to produce the first permanent denture base directly from 3D printing.
Other notable materials introduced include GC America’s millable CerasmartTM nano-ceramic block, Jensen Dental’s high-translucency Imagine full-contour zirconia with a strength of 769 MPa, Kuraray Noritake’s KATANA ST (Super Translucent) and UT (Ultra Translucent) zirconia as well as multi-layered versions of both, and DT Technologies’ high-translucency CubeX2 with a flexural strength of 720 MPa.
“An exciting twist at IDS was the new zirconia materials being shown and introduced,” Brown says. “The higher translucency zirconia could very well be a game changer. Giving up a little strength in exchange for great translucency likely will be well received.”
Next-Generation Communication Technology
A report on new innovations would not be complete without an update on digital impression scanning technology and devices designed to facilitate communication among team members. Faster, smaller, easier to use are the buzz words for impression scanning technology.
“Digital impression scanners are becoming more affordable, but the product is also improving with innovations such as touchscreen technology,” says IDS attendee Pinhas Adar, CDT, MDT, owner of Adar Dental Network in Atlanta, Georgia. “The result is that in the future there will be a streamlined, digital production workflow available to a wider range of professionals.”
Only one new player surfaced this year, and that was GC Europe with the new Aadva IOS. Not yet available in the US, the open-architecture Aadva features a slim, lightweight handpiece that requires no powder to use and can create a digital impression ready to send directly to the laboratory in under 5 minutes via the Cloud for access by all team members.
3Shape was not shy about unveiling its newest entry the Trios Pod, a combination 3D color digital impression scanner and intraoral camera combined with the company’s tooth shade measurement system. The Trios now comes in a lighter-weight pen-grip design that can plug into any USB port for operation rather than the cart. The scan speed has been increased even further to yield a full arch in under a minute as demonstrated by co-founder Tais Clausen.
Dental Wings’ DWIO impression scanner offers clinicians fast scan speed and keeps their attention on the patient rather than the computer screen to ensure capture accuracy by incorporating a green/red LED on the handgrip to indicate whether the device is capturing data. The curved scan head with its 5 miniature 3D scanners allows less rotation to capture buccal and lingual information. The metal scanner is similar in size, shape, and weight to existing dental handpieces. A further innovation is the no-touch computer screen to prevent cross-contamination in the operatory. The clinician can rotate the scan data and direct all functionality in mid-air without touching the screen.
iTero slimmed down its new intraoral scanner, called the iTero Element, by 40% and decreased the weight for ease of use. The company also revamped the software to be more intuitive. The scan speed has been increased with integration of a new image sensor that also allows color scanning. Align Technology and Sirona Dental also announced a collaborative agreement that allows users of the CEREC Omnicam digital impression scanner and CEREC Ortho Software 1.1 to submit digital impressions to Align for orthodontic therapy.
Other updates include Carestream’s integration of its CS 3500 digital impression scanner with exocad software through its patient browser for exporting scan data to the laboratory complete with color information in an open-file format.
To aid communication between the operatory and laboratory, Sirona introduced the Sirona Connect app for the iPad and iPhone. It allows dentists and technicians to track their orders online. Laboratory owners can receive immediate notification of new cases being submitted to the laboratory. They can review the case in the app and accept it remotely. Whip Mix also introduced an iPad app that aids placement of the arch in the articulator. The dentist takes a facial picture, measures the width of the tooth, and chooses the point of contact. That file is sent to the laboratory, where the technician can line up the model and articulator based on the iPad image of the patient’s mouth.