Dr. Mike Kelliher takes you through a few essential design techniques using the newest version of PlanCAD Easy v5.85 for 2017.
Hi, This is Mike Kelliher - a little video that I did called “Design in 2017” ... Basically just kind of an update of how I’m doing basic design. It’s the bread and butter of everything, the things that we do every day - a single, simple crown and to be able to do these efficiently and effectively is something that will help all of us to be a little more quick and get better results.
So some of the tools that I'm using, I’m using differently now than I would have used a couple years ago. There's some new additions to the software I think people find that help things. v5.85 has a couple new things particularly the color but also changes of how you can fine-tune the bite. So I thought I'd show you a few of those little things and how those can be helpful for you. Also the materials - we have a whole host of new materials have been added in the past 6 months or so. … Just a quick look at those, how those might be helpful, what kind of category as those materials fall into. Not a really deep dive into the science on them but just a little bit about each of those materials and then where you might find them useful in your practice. So hopefully you'll find this helpful even if someone has been doing this for a while I think you'll find a nugget or two here of use and for someone who is just getting started I think it's a good starting point is this is the basis of what we do. This is a very important part to get right. All of the workflows for bridges or implants or veneers all come off of understanding how to do a basic simple design. So hopefully you find this useful and enjoy it!
Okay so starting with v5.8 we had a lot of different materials added into our software. Traditionally, we just had the Ivoclar materials and a few things from 3M but we've had some things added in from Vita that have changed things a little bit, even a GC material that’s been added. So essentially we look at our materials we've got a couple categories. The first category are glass ceramics. So that's your eMax, your Empress, also Vida Suprinity, the Vita Mark II and the Vita TriLux Forte.
So the new ones into the system in that category - we're all familiar with eMax and Empress and what they can do - although there’s one little thing with eMax I'll show you in a bit that's different - but the Suprinity, this one I'm not all that familiar with this is a newer material. It’s supposed to be a competitor with the eMax. I have not had a lot of - any experience with it at all. I have not seen a lot of data on it is either so that one I’d kind of leave.
The Vita Mark II has been around for a long time. That's been in other systems before. You can think of that one as very similar to Empress in terms of strength characteristics, etchable ceramics, similar deal.
The TriLux Forte is you can kind of think of that one as very analogous to Empress multi - similar materials in terms of strength and also this one has the similar kind of deal with the gradation in color in the block.
So those are your Ceramics. These are your etchable materials you can put in the oven and all things we’re normally used to doing.
The next kind of [category] or [classification] or materials that we have are resins. Of course, Telio CAD is a temporary resin we've had for a while. This is for making temporary crowns and bridges and all kinds of stuff but that's been around for a bit.
The kind of newer ones are the Vita Enamic, Cerasmart, and Lava Ultimate we’ve had for a while. These are meant as long term materials for definitive restorations. The lava ultimate we've had around for a while. We know there have been some issues with that. Originally it was indicated for full crowns. 3M has pulled that indication because we have a lot of debonding issues.
Cerasmart and Enamic are still indicated for full crowns. How I'm using these guys right now, I would say, is carefully. I'm using them in just partial coverage situations. One of the things you'll notice with these materials they're not as aesthetic as the ceramics. They were only polished so then you can obviously stain them in the same way you can stain a ceramic. You can put some surface stains on there but they don't I think they're going to last all that long. So these I would be cautious with. Also, the way you treat the surfaces of these for bonding is different. Like Lava Ultimate you're only going to sandblast that. Cerasmart and Enamic they say you can etch but also can be sandblasted as well.
Again these are not glass ceramics in total so they're they're handled differently. So make sure you read the manufacturer's instructions for each of these materials if you're planning to use them on how they're supposed to be bonded. That's a real important thing to do with these guys but I'd say use them with caution. I would stay limit them to partial coverage. The big advantage of these guys is that they don't have to go through the oven to be fired so they can be just millled, polished and inserted. So now they can, I think, have some you utilization in our software for a partial coverage restoration. So something to be aware of it and take a look at.
One of the kinds of lost materials we have is this BOB acrylic. For those not familiar - this is just a clear acrylic block that you can use and what this is for is if you want to do say a Gold Crown you can go ahead and scan and design in the software, mill it in the BOB acrylic, and then just send that your laboratory they can just put a sprue on that, cast it and they'll send you back the Gold Crown. So it saves you a little bit of a fee for the laboratory to wax this crown up and generate models and all that sort of thing.
Then we get down to our zirconia materials. Now zirconia is one [that has] a lot of popularity over the past five years or so. Very strong material. The thing with it - we can do it - but in order to do a zirconia you have to sinter the material, it's not as simple as firing it and crystallizing like we would with eMax. So you have to have a different oven, a fairly expensive different oven at that and it's not really a one visit procedure. It takes a while for that material to sinter so this is definitely not something you’re going to do in a single visit like you would with some of your other materials. So you want to bear that in mind. My take on zirconia right now for CAD/CAM in office is that it’s really is not worth … spending the money to buy that extra oven, learn how to use the material, work with it, stain it, at all the stuff you have to do, for the few cases that I find that I would want to use Zirconia for - mostly I'm doing this for the longer span Bridges. So for those I'll just go ahead and scan it, you can even design if you want, and then send it to the Dental Laboratory through DDX and they go ahead and mill it and characterize it and send it back to you. If you're designing it the turnaround time can be very quick on these because the lab doesn't have a lot of work to do with it. So that I think is probably the better way to use Zirconia right now but if you're one of those people wants to live on the edge you can grab yourself a sintering oven and get some Zirlux blocks and you can go ahead and do the zirconia in office.
So we get over to version 5.85, two little things ... or two fairly significant things that you'll see. First of all, is the color ... We got a nice stone model here for this case should be fairly easy to mark the margins but just to show you that the color. This is the version 5.85 color. Pretty darn impressive. I mean I was not a big fan of color up until this version I didn’t find that the past version of the color were that useful. This I do find useful. This I could definitely see with a gingival margin here that will help me mark that margin the in the correct place.
Hat's off to the engineers. They've done a nice job here bringing the color along over the last couple versions, and now they're to a point where they've done a nice job and so it's a useful addition to the software.
The other kind of cool thing with the 5.85 is buccal bite alignment. Now we found in the past that a lot of times you’d get over closure of the bite. Now there are some strategies to minimize that from happening, and the big one is to make sure your kind of stopping and starting your scans in the same spot. So in this case on number 14. I start my scans over 14 on the prep start the scans over tooth number 19 for the opposing and then start the buccal bite right over the union of those two teeth and by having them in roughly the same spot you saw less of this over closure issue but you still saw it from time to time.
So what the software engineers have added an automatic bite alignment into the software. Pretty cool. You just basically will go ahead and head hit the letter “A” and it will come in and just refine the bite. This case is pretty close so I don’t think it’s going to do a lot here but if you had one of those cases where it was over closed and the bite was really heavy on one tooth as opposed to the other it'll come in and it will refine that and make that a more even bite. So that's a neat little addition to have in the software. So something you want to take if a try next time you do in a case with the version 5.85.
And then we get over to kind of just our basic design. How I'm designing now versus how I was designing back maybe a couple years ago. First thing I always do is turn these stupid flags off I wish there was a setting to take care that but there's not.
Anyway, we've got basically the same kind of margin. I'm going to go ahead and I’m going to mark my margin with trace. I’ll use sometimes I'll have that the green on it's and sometimes I won't. I’m going to use the stone model as much as I can and I'm not going to try to get this absolutely perfect the first go-round because we're going to jump right to our move margin tool as soon as we get it on a so we try and get this in reasonably close.
And here I may toggle over to the color so I can see just a little bit better where this margin is here. That's something I would have I would have done in regular ice before and then we've got it to that point and then we're just going to go ahead and we're going to get that margin dragged out. When I’m working margins what I'm really looking for here is you can see and you always want to turn and rotate that model so you can really highlight that margin point and I'm looking to make sure I'm on that line that you can see as you rotate the model around. The green can be a help to marking that but sometimes it's good to kind of toggle back and forth, turn that that green line off and get a look at where you are. I even toggle off and on the margin marking itself and just kind of refine that bring it into place. Same thing here. So I'm a little short here. This is a really critical, critical step. You got to get this right. You get this wrong and you get a short crown.
So that's all we're doing there. So that's really not remarkably different than what I’ve been doing in the past but adding the color in is a help.
What I am doing differently is with orientation. Of course orientation normally popup only at the beginning for new cases but this is a case I designed before so we're not going to see that but I used to be really fastidious about making sure this orientation was absolutely perfect at the stage everything lined up exactly right. I'm not so much anymore and the reason is because we have the plan tab right now and I used to go ahead tell you to bring your green ghost tooth in here get everything all lined up perfectly. We don't do that anymore.
So I just take a quick over and over head look is that lined up? Are these central grooves lined up pretty good? Yep. OK good. Look at it from the buccal is everything in reasonable alignment? Yes, it is and I'll just lock orientation. That's all I'm going to do with it. Then in the plan tab, I'll go ahead and take care of any fine-tuning. This is again the orientation of the proposal tooth, the ghost tooth here is going to come from your orientation but we have the ability to really fine-tune this very easily.
So we got these three tools in the plan tab. You’ve got move, resize, rotate. I’ll always start with resize - get the size close. We don’t want it necessarily touching but I want it relatively close. Then I’m going to use the move tool to get things in shape and you can see here I've got this is a little bit crooked I've got this marginal ridges up too high, this one may be about right maybe a little bit low and maybe it's a little bit over-rotated to the buccal. Now we have this fantastic rotate tool here so I can go through it I can fix that very easily and the old days of trying to fix this in the margin tab was very, very difficult you have to keep going back and forth back and forth. This is very simple and I can get this lined up pretty well and get myself in good alignment. Again the goal here with our designs to both make them look nicer and to get them done quickly is to not disturb the anatomy that's in the library. If we have to go back and do additional stuff with the library tooth then we will slow our design down and we won't get as nice a design. So that's kind of the idea, try to keep this as minimal in terms of our changes as possible.
That's pretty good I like that.
The other thing I'm always looking to do is have the outline of the proposal match as close to the outline of the prep as I can cuz that will minimize how much twisting and turning that the software has to do. That's why we run into such trouble when we're designing implants. There’s a very skinny margin on the abutment and a very large tooth that's why we have to do some additional things to make that. But that looks pretty good so … I’m going to go right ahead and go to design. We’re going to let autogenesis do its thing from here.
OK as you can see, we’re given a pretty good starting point. Everything is looking reasonably good so what that means is we can skip our incremental change tools. Any time we can I minimize our tool sets the better.
One other thing I’m going to show your real quickly here is something I've always kind of done for at least past few years anyway. … If you have a nice preparation, something similar to what I got here where you got a nice millimeter or so of a shoulder or champfer a nice smooth rounded off internal angles, I will bring this little tool here is our spacer for settings. OK. This is the axial. I'm always going to bring this axial into .06 tightens that up. Gives you a little better mechanical retention. The occlusal doesn't matter as much cuz that's not adding mechanical retention but you could move in if you wanted as well and the margin ramp. This is kind of one of the most misunderstood parts of the software - what the margin ramp basically means is how much porcelain is in contact with the margin. And if you got about a millimeter margin, the .5 or half millimeter seems to work really well. Helps to make you have a nice tight margin in here. So … these are kind of my default settings. At the end of this video I'll show you how to set these so that you don't have to keep coming [back]. Because if you change them one time in here they won't stick but there's a way to make them stick that I'll show you.
So we got that we're all good there. Now I'm going to go to my tools. Again minimizing the tool set. So I’m going to start with rubber tooth and I always start the same way every time and you know this is how I do it you may find ways that you like that work better but I just find a way and stick with it but I find that I always like to come in and deal with all these little conavities that the software tends to leave around the tooth and get those pulled out and we'll see those both on the buccal in the lingual and also in the contacts. So nice little spot there that's a little bit under contoured and I'll bring those out. So I get those done first.
Then I’m going to start working on my contacts. Now you can see here we got a very point contact here this isn’t how we want it. Now the natural tendency is you're going to from this point you're going to pull with rubber tooth and try to close a contact. What happens if you do that though is you end up with a very high contact and what I like to do after I finish these restorations get them out of the mill is to kind of round over this edge so we have a nice easy place for the floss to slide through - more natural anatomy. I don't want to have the contact really sharp and high. Kind of like how this old restoration is on this tooth. So what I'm going to do is I'm going to start closing those contacts from below the context.
So rubber tooth and again when I'm using rubber tooth it’s all littls small moves it’s not one big move it wants. And I’m going to go ahead and close that contact that way. Same thing here. I'm going to come from underneath and close that contact. I will do just a little bit here because of shape of adjacent tooth but now you see that's been closed. We got a pretty good contact. I may just come back and do just a little bit more. And now those contacts are closed but they're not - they're closed in a more anatomical position when we refine the contacts I'll show you what's going on there.
So after I got my contacts all squared away then I'm going to go ahead and go check occlusion. So two clicks and again you haven't changed any of my tool in here I'm going to go ahead and I'm going to use a rubber tooth. I'm going to rotate the tooth around and I was going to use rubber tooth to to bring that in. You can you slice plane to do this but I find this works out pretty well. You just have to kind of find an angle to rotate the tooth so you're pulling in the right direction and this will speed you up a lot adding in, coming in and clicking on that slice plane take some time. I can still do a really nice job of this without bringing in slice plane but if you want to you can that will work too. But you can see now I’ve got a pretty good set of occlusion there.
So I'm going to look at the material thickness and we got good thickness here. I’ve used some prep checks to go ahead and give me - I’m just going to thicken that out a little bit - I use prep checks to make sure I have good clearance. Prep check is - Common Sense Dental makes them. They are small little rubber tabs that are 1.5. You can get them a 1.5, 1 and 2 mm thicknesses and it will leave a little mark on the preparation. Put it in between the tooth and the preparation and when the patient bites down it’ll leave a little mark if you're under-reduced so I'll go ahead and use those. Ivoclar has changed the indications of the material though and you can actually use a millimeter of thickness now and you'll be fine. So in the past if I saw a lot of yellow down and in these grooves I would have spent some time coming in and trying to bring that up and kind of thicken that material up. It ends up taking time. It also reduces how nice the anatomy look so you know I don't do that anymore and it does help out to make things look better.
So there were pretty good shape and terms our shape of that restoration Looking from the sides everything looks pretty good. Maybe a little tweak or two here. Again I'm still in rubber tooth, I haven’t changed anything. Now I will change my tools. I'm going to go ahead and I'm going to check my proximal contacts and that's too heavy but you see how anatomically that’s in a really good spot. I’ll just switch over to smoother. Full influence and I’ll just kind of and I'm going … moving this around. Get this down to a little bit of aqua in there and again same thing here. I’m a little heavy in here. Bring that down so I get some dark blue with just a little bit of that aqua color there and that's pretty good. You see how that nice and broad that contact is. That's going to work out nicely and if you wanted to you can turn off the coloring and you could just kind of do a little smoothing of the overall proposal and that will help to keep the mill from going in to try and to mill all those irregularities out.
So that's it we've got a finished proposal that's ready to go to the mill.
I will go and show you on the settings... how we can get rid get those spacer settings set so they stay as they were. So we have to close out of the case here and where you’re going to do that is in the settings tab right here you can go ahead and change those and so we double click on that and it’ll bring up this CAD/CAM in progress business again. OK so now from here you can go ahead and you can make changes to a bunch of things but what we're going to be looking at here is the margin ramp so I’m going to set that at .5 and the spacer setting we're going to move this into .06. If you wanted to move the occlusal down you could a little bit as well and if you hit save then those defaults are now saved into your settings. That's what it will come out every single time so you won't have to go back and change that at all.
So anyway so that's kind of a little bit of a new update of design 2017. How I'm doing things. Hopefully, you found a few little tidbits in here that will help you to get your designs done a little bit quicker and easier and you know we'll be looking for you online. Hopefully, you can post your cases and we'll see some interesting work.
Thank you for listening.
Dr. Michael Kelliher earned a Bachelor of Arts in Biology from the University of Massachusetts and went on to graduate from Boston’s Tufts University School of Dental Medicine in 1993 – where he received the Robert R. Andrews award for student research, and presented his original research at several national dental meetings.
Dr. Kelliher runs a general dental practice, Flagship Dental Group, in Longmeadow, MA, with a focus on restorative and CAD/CAM dentistry. He was a very early adopter of E4D, and incorporated the technology into his practice back in 2009.
He serves as an administrator and clinical mentor on LearnDigitalDentistry.com, acts as an administrator on Dental Town, and assists as a moderator for the E4D forums. Whether he’s online, at a study club, or at a lecture, Dr. Kelliher enjoys sharing his experiences in order to help everyone reach their potential with digital dentistry.
He is married with two children, and plays an active role in his community by serving on school committees and coaching youth sports.