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Intra Oral Scanners, How Good are They

Traditional impression materials have served dentists and their patients quite well for decades. Does it make sense to replace the goop with microchips? Is the new technology better? Will the added expense be more cost effective in managing the continued pressure on dental fees?

Manufacturers and distributors all believe intraoral scanners should be in every practice. Of course, that’s their job. But dentists who have adopted the technology are universally pleased, reporting better accuracy, faster seat times, and in some cases, lower lab fees. But, let’s be clear. Those are subjective opinions. Below are some of the facts about intra oral scanners and their advantages.

Accuracy

One way to measure the advantages is accuracy. Intraoral scanning is consistently better when it comes to accuracy than are impression materials. That is not because PVS and poly ether aren’t good materials. They are. It is because intraoral scans are more consistently accurate in quadrants by eliminating the variables inherent to traditional impressions. Using strict research protocol, good impression materials provide errors of about 35 microns. In contrast, Pradies et al, reported scan results in 2015, showing “an average error of 18 – 30 μm for a single tooth and less than 40 to 60 μm error measured over the restoration and neighboring teeth and pontic areas, up to 7 units.” They also found that for a 4 unit bridge, the length error was less than 100 microns. However, accuracy declines when scanning a full arch. Testing showed that mean error for a full arch was 100 – 140 μm, indicating a good measure of unreliability.

There are many intraoral scanners to choose from. Deciding on which one might be as simple as feel, newly updated advances, ease of use, or ancillary costs. However, based on research, accuracy shouldn’t be a differential in most cases. Researchers at the University of Ohio tested three intra-oral scanners, 3M LAVA True Definition, 3Shape Trios and Cadent iTero, found similar accuracy, and showed that “digital intra-oral scanner impressions can be used for fabricating accurate short-span screw retained implant supported fixed dental prosthesis with a misfit range of 12.40 to 90.20 m.”

Implant Applications

Dental implant restorative is a growth area for dentistry minimally impacted by dental insurance. Intraoral scanners have become increasingly useful for implant diagnosis as planning becomes more digitized. In Lee et al’s report from 2015, 36 patients had a single missing molar replaced with an implant. “Of the 36 patients, 6 required contact adjustments, 7 required occlusal adjustments, and 3 required a gingivectomy around the implant to completely seat the restoration. Chair time for adjustments did not exceed 15 minutes.” Clearly, IOS and accompanying implant related technology [in the lab setting] provide better accuracy than building cases on stone models, plaster mountings, and resin-based adjuncts.

Tracking and Managing Occlusion

Another, but rather unexplored advantage of intraoral scanning technology is tracking and managing patient occlusion. In 2014, Meireles et al, looked into occlusal wear tracking: “Eight extracted teeth were etched with acid for different times to produce wear and scanned with an intra-oral optical scanner. Computer vision algorithms were used for alignment and comparison among models…Results demonstrated that it is possible to directly detect sub millimeter differences in teeth surfaces with an automated method with results similar to those obtained by direct visual inspection.”

The ROI

One thing to keep in mind is, chair time is expensive. If IOS can cut chair time and the cost of traditional impression materials, the investment might be worthwhile. However, there is a balance to consider because not all situations easily lend themselves to the current state of the art. Some clinicians have acquired lasers to help control the challenges gingival tissue presents.

As with all things, when considering an intra oral scanner, we need to avoid biases, do our homework, and keep an open mind.

ceramir kit

A new Cement Perfect for Zirconia and More

Ceramir Crown & Bridge (Doxa) is a new, unique category of permanent cement that might be the best suited cement available for zirconia. Additionally, it has been shown to chemically form hydroxy apatite on the surface of tooth structure, integrating the cement to the tooth, photo below, hence the description, “bioactive.”

ceramir dentin integration

What is Ceramir C&B?

Ceramir C&B is a hybrid composition of Calcium Aluminate and glass ionomer, that when combined with its liquid, undergoes an acid-base reaction similar to hydraulic cements.

The incorporation of the Calcium Aluminate gives it several unique properties that separate it from conventional GIC’s. After 3-4 hours of setting time, Ceramir C&B changes its pH from a very mild acid to a base of pH of ~ 8.5. Mild, lasting alkalinity allows continuous formation of apatite when adjacent to phosphate containing solutions of dentin. Additionally, the alkalinity of its dense matrix fixes the glass ionomer structure to help prevent the ionomer glass from continuously leaking over time. Below, we see hardened hydroxy apatite in the surface of the cement.

ceramir 50 micron cbs

Alkalinity also helps with pulpal compatibility. Histological data shows that even at a minimum distance from the pulp, there is virtually no irritation resulting in inflammation.

Ceramir C&B relies on the mode of hydration by its key component, Calcium Aluminate, and the ionic bond of the GIC to bond to the tooth. That means, etching enamel or dentin and using a bonding agent isn’t needed. Moreover, its hydrophilic nature makes the material insensitive to oral fluids, while its alkalinity helps prevent bacterial growth and sensitivity.

According to Johanna Engstrand, et al, Ceramir C&B’s properties are unique. “Zinc phosphates are too acidic and do not contribute with Ca ions. Resin-based materials are not alkaline, and do not show extended ion leakage. Glass ionomers have an ion leakage but are acidic and cannot induce HA formation on its surface.”

Published by the American Ceramic Society, 2010

Author, Hermansonn, et al

“Ceramir C&B has a 2 minute working time, and a setting time of 4-5 minutes. Its film thickness is 15 microns. Its compressive strength at 24 hours is 160 MPa, similar to many resin-based cements, such as Rely x Unicem (157 MPa) but far greater than Rely x Luting’s (96 MPa). However, after one month, the bioactive nature of Ceramir C&B boosts its compressive strength to 200 MPa.”

Unlike RMGIs that expand as much as 4% and then contract, and resin cements that shrink as much as 4% then expand. Ceramir net change is essentially zero: “Expansion of Ceramir C&B is at most, 0.4%, and is due to the free growth of hydrated crystals associated with the formation of apatite. However, bulk expansion, measured as expansion pressure was recorded to be zero.”

Bacteria Resistant and virtually no Microleakage

Ceramir C&B is the only cement with the necessary components to form HA. Zinc phosphates are too acidic and have no free Ca ions. Resins aren’t alkaline and don’t provide ion leakage to the extent required to form HA. RMGI ion leakage is acidic and therefore, can’t initiate HA formation on dentin.

One advantage of Ceramir alkalinity is its antibacterial properties. Secondary caries caused by a wide variety of bacteria is a major concern for all. Jiang, in 2011, conducted a resazurin test on Rely x™ Unicem, Ketac™ Cem Aplicap™ (RMGI), Harvard zinc phosphate, and Ceramir® C&B cements for their antibacterial (S. mutans) properties. After different time periods, up to 10 days, Ceramir C&B with its calcium aluminate showed the strongest antibacterial properties, while the RMGI showed none. The other cements have only slight antibacterial properties. The strong showing of Ceramir is due to its initial pH 5.4 ending at pH 8.5.

Another important attribute of Ceramir C&B cement is a lack of microleakage. Because the process of forming HA creates a nearly insoluble barrier intimately integrated with dentin, Ceramir cement was reported in 2015 by Jefferies, et al, to have only minimal microleakage, and far less than the tested GI and RMGI: “There was no evidence of marginal gap occlusion for the three conventional control cements, whereas both bioactive, surface apatite-forming cements demonstrated occlusion of the artificial marginal gaps.”

Ceramir margins alone

The photos, left, described by Jefferies:

“Artificial margin gaps at 8 months of incubation in phosphate buffered saline: upper left photomicrograph is Fuji I (glass ionomer material), ∼110 μm gap; upper right is Rely X Luting Cement (resin-modified glass ionomer), ∼80–100 μm gap; lower left ProRoot MTA (calcium silicate/Portland cement-like hydraulic cement), ∼100 μm gap; and lower right Ceramir Crown & Bridge (calcium aluminate/glass ionomer cement), ∼300 μm gap. Cement material is positioned above the gap space, whereas dentin segment is below the artificial gap.”

What’s happening to Dentistry, Why, and What to do about It

There was a time when people would say, “All you need to do is hang your shingle, and you’ll have it made.” Nobody predicted today’s exorbitant cost of a dentist’s “shingle” and the smaller ROI it now brings. The story of old has crumbled, and as the Brazilian lyricist and author, Paulo Coelho suggests, we need to tell a new story to bridge the gap between that which is, and that which should be.

 Facts: What is Happening

Private practice dentists, and those supporting them, are losing revenues. Outside interests, mainly insurance companies and DSOs (dental service organizations), are forcing changes to benefit themselves at the expense of the other 90% of the dental industry and sometimes, the patients they serve.

Outsider influence has raised the cost of a dental education to as much as $400,000, while its value has in many cases, plummeted. Sky high debt and inadequate education has made entering private practice upon graduation, largely impractical, and supports the growth of DSO practice models. Meanwhile, insurance companies are lowering the number of procedures performed and their reimbursements. This has caused average annual income for dentists to drop 22%, from 2009 to 2014, currently sitting at the 1995 income level. This has caused each private practice to lose annual revenues in excess of $100,000. If that amount were invested each year for 15 years, a 45 year old dentist would earn about $30,000 per month at retirement (5% annual growth, before taxes).

Facts: Why this is Happening

Dentists and their organizations have allowed these changes to occur, and in some cases, supported them. Good clinicians see patients as people who need care. Outsiders see them as the headwaters of the revenue stream, and the earnings they bring as low hanging fruit in a fragmented industry with no barriers. Influencing the mass market in ways that individual dentists can’t, consumers naturally form attitudes and beliefs shaped by outsider messages and brands.

Below is a link to typical DSO information being distributed. Individual dentists need to confront this  with an equally powerful, but more complete, rendition:

Wisconsin Dental Board Legislation

We are not opposed to DSO practice management services. Neither is state dental board oversight. Like us, state dental boards are interested in protecting patient welfare in all practice models, as they do now only in private practice settings, or, supposed to. The linked article provides no proof to support assertions that DSOs routinely save patients money over private practices. Further, complaints filed  by several state attorneys general would assert otherwise. Unfortunately, nobody is calling this out, publicly. We intend to on the grounds that patients deserve protection in all practice settings.

DSOs have the right to exist, but not the right to practice dentistry without a license. If they are not practicing dentistry without a license, why should they care about falling under state dental board regulation? 

Why is the DSO lobby opposed to that?

Why is no one in the public spotlight asking that question?

How is being regulated by state dental boards anti competitive?

 The Response: Take Action or Do Nothing

Trends from doing nothing are clear, and personal losses (above) astronomical. The question is, “What can we do?” The obvious first step is to organize. Only when organized will newly competitive opportunities surface.

If you are a dentist, laboratory owner, distributor, or manufacturer, now is the time to get busy.  The same mass marketing tools being used against us could be working for us. Together, we can take advantage of everything the internet offers (including social media marketing), and add public relations, pressure legislators and regulatory agencies, and develop new business models in direct competition for market influence, including insurance.

To change the trend line, we need to pull in one direction, for one purpose: Educate and attract consumers as informed patients. The good news is, consumers only want the truth, something traditional care is in the best position to provide. More good news: Accomplishing this is easier than in the past. Research shows that consumers want genuine information they can trust. No patient deliberately chooses to be misled or mistreated, yet it happens daily to hundreds, perhaps thousands while the industry remains silent. Ethical care is a key marketing advantage, but only if we make it one.

Great stories untold die in obscurity.

We have a great story to tell,

But only if we are willing to tell it.

 

“We believe big visions need big stories to match…We believe in the power of collaborative community, and the choices you can always make to change your story. We believe in messages that make people feel inspired and connected to something greater. We are truth-seekers teaching a new paradigm of story.Michael Margolis, CEO and founder, Get Storied

 This is Our Story to Tell

Through professional marketing and a consumer website, OPT-In Dental Advantage is the only dental organization telling the story about the value of traditional dental care and the dentists who provide it. We employ professionals for website SEO, SEO support for our members’ web pages, bi monthly consumer blogs with SEO, and more recently, a national public relations campaign, managed by Braithwaite Communications, to brand the image of traditional dental care and present our story to consumers, nationally.

We invite dental professionals and companies to join us in making the advantages of traditional dental care known, and preferred. Please help our voices to be heard through stories consumers want and need to hear. Contact us today.

Please visit our website, OPT-In Companies, or call us at 855-321-OPTN (6786). It’s time to be a part of the solution.

Nacera hi res logo

Is this the next Generation Zirconia: Results, Part 2

This may look like an ad, but it really isn’t. We are all simply very excited about a company that promised both strength and esthetics in zirconia, and delivered what they promised. So, read on, and if you agree, you’ll have a new tool to help your practice, your lab, and your patients. And one more thing. The company, Nacera US, is the only company helping private practitioners and dental labs become more competitive. To us, that is important.

A few months ago, a new zirconia from Germany came our way for testing called, Nacera. This is an update to an article we published last month on the experience of two lab members. We pointed out that Nacera claimed to be a higher grade of 1400 MPa zirconia purity with more translucency and improved esthetics. We determined after a few months of testing that the esthetics was better than any 1400 MPa full contour zirconia we had seen, with the potential to rival lithium disilicate, but stronger. In the photo below, you can see the unusual vitality that this full strength zirconia provides.

Roberto U Molar


There are two molars in this photo, one a finished full contour zirconia, the other, a newly sintered full contour zirconia. All samples in the photo are Nacera zirconia. The finished Nacera molar, provided by Roberto Rossi, MDT, was only lightly stained.

OPT-In lab members working with Nacera have commented on the improved margin accuracy and how true the shades are. That is not the case for all zirconia brands. Another aspect of Nacera zirconia is purity. Some brands have impurities that form pits on the surface during finishing, and also risk areas of weakness, internally. Other brands are naturally weaker and unpredictable because of faster and less thorough compression during compaction. We know better about Nacera.

To see a short video about Nacera manufacturing, click the below. When it ends, click it off or it will continue to other topics.

Nacera Video

This month, we visited the Nacera factory in Dortmund, Germany. The parent company, Doceram, is actually an industrial engineering company that routinely designs parts to meet sub micron tolerances. They then manufacture parts in zirconia  and test them to make certain those same tolerances have been met. This same precision approach is applied to dental zirconia, with constant testing and measuring. In fact, they test each zirconia batch, individually, and then measure each separate individual zirconia disc prior to packaging, printing the measurements on the label. Nothing is left to chance.

Visit Nacera US at Chicago Lab Day, Booth L-22

For information on Free Hands-on and Lectures, visit

Nacera US

The one word that kept surfacing during our visit was, Certainty. Dentists can now offer patients both strength and esthetics without paying more. However, if the need arises, a Certified Nacera Lab can also deliver the highest level esthetics when only veneered zirconia will meet a patient’s needs.

Ant Germano Rossi

Germano Rossi produced these outstanding results by veneering Nacera zirconia copings  with ceraMotion® (Dentaurum). CeraMotion® is used as a very thin, colored paste with a built-in glaze. When applied, it stays in place and finishes with only one bake. The thickness of the veneered surfaces are 1 mm or less.

Nacera US is a dental company. Dedicated to patients, dentists, and dental labs, Nacera US offers “best products” suitable for all dentists and dental labs who care about dentistry, regardless of the markets and patient budgets they serve.

We tested it, in fact, our lab members and their dentists are testing it daily. They, also, have come to the conclusion that What’s Inside Matters. That’s why OPT-In is proud to be a Nacera partner.

If you would like to try Nacera for your patients, contact us for a Certified Nacera Lab referral that fits your practice. Each was trained in November in how to consistently obtain the very most from Nacera. Having Certainty is always good. Having Nacera Inside takes Certainty to a higher level.

Almost forgot…the pink in the bottom photo, that too is Nacera!

Visit Nacera US for more information

Contact OPT-In for a Nacera Certified Lab