A High-Tech, Single-Visit Restorative Solution

INTRODUCTION
Digital dentistry is transforming the way the profession views dental care. With the onset of CAD/CAM, in-office milling systems, and single-visit restorative systems, doctors and patients are changing their expectations when it comes to what it means to deliver and receive great dental treatment. The changes associated with the move to digital dentistry can be both a positive thing and, yet, have its challenges.

For doctors, the move to digital technologies offers opportunities to revamp their practices and offer more treatment to more patients in less time while saving money on dental laboratory bills. Meanwhile, patients are starting to realize that it is possible to receive lab-quality crowns in a single visit. For both groups, digital dentistry represents a new era of possibilities. However, many doctors are still faced with the natural uncertainty that always accompanies this type of evolution within an industry. The onslaught of new technology can lead to concerns about the learning curve, the time investment, the fear of being left behind as the dental industry evolves, and especially the cost required to get on board. It is easy to realize why some doctors still question whether or not to go digital. Then, if they do make the choice to move ahead with integrating these technologies, the challenges they need to overcome are where to begin and how to do it.

Figure 2. Removal of the old amalgam exposed the sound tooth structure below. As shown in this image, there was amalgam-stained dentin in the distal-lingual area.	Figure 3. A composite resin material was used to place a core, serving as a direct base for the new restoration. Then the full-coverage preparation was completed.

An In-Office Single-Visit Digital Option
Thankfully, there are simple solutions available that make the transition process easier. In my experience as a practitioner, the key to successful adoption of digital dentistry lies within selecting a chairside system that combines a simple learning curve with easy-to-use, integrated technology and unparalleled support at every step of the process. To that end, one such option, showcased in this clinical case report article, is the glidewell.io In-Office Solution (Glidewell Laboratories).

The glidewell.io In-Office Solution is a chairside restorative ecosystem that simplifies and streamlines the process of designing, milling, and delivering single-unit restorations in a single visit. The system is made up of cutting-edge components that run the gamut of the restorative process, from the initial scan through milling of the final restoration itself. The glidewell.io In-Office Solution includes the following components:

• iTero Element 2 Intraoral Scanner (Align Technology)
  This scanner creates accurate impressions and seamlessly integrates with the rest of the system for a streamlined workflow.
• fastdesign.io Software (Glidewell Laboratories)
  This easy-to-use software takes advantage of cutting-edge technologies like Glidewell Intelligent Design, which uses artificial intelligence to create informed crown proposals based upon the extensive case library of data at Glidewell Laboratories. This simplifies the process for the user and helps ensure successful results.
• fastmill.io In-Office Mill (Glidewell Laboratories)
  Electric-powered with a small footprint, this in-office milling unit uses lab-tested technology to ensure precise margins and superior fit.

The restorative case shown here is an example of a typical patient case that is ideally indicated for completion using this in-office digital solution.

CASE REPORT
Diagnosis and Treatment Planning
A patient presented with a cuspal fracture and lost marginal integrity on her mandibular first molar (Tooth No. 19) (Figure 1). A missing portion of the old amalgam restoration on the buccal, combined with dental caries and the cuspal fracture, indicated the need for restoration with a full-coverage crown. Due to the patient’s desire for a quick resolution, and the fact that a high-strength option was indicated, a chairside zirconia (BruxZir NOW [Glidewell Laboratories]) would be an excellent material choice. It should be noted that this is the only fully sintered chairside zirconia material available for use at this time.

After the treatment plan was shared with and agreed upon by the patient, the clinical work began.

Figure 4. Preparation for a chairside BruxZir NOW (Glidewell Laboratories) fully sintered zirconia restoration requires only a 0.7-mm minimum reduction. A nonaggressive design for the margin was the correct preparation for this type of restoration. This lateral view shows the occlusal and buccal reduction that was done.	Figure 5. After completing the preparation, a digital impression (iTero Element Intraoral Scanner [Align Technology]) was taken. The process was streamlined, involving a simple scanning of the prep, opposing teeth, and bite and taking just under one minute to accomplish.
Figure 6. As part of the glidewell.io In-Office Solution (Glidewell Laboratories) workflow, the iTero Element scanner automatically converted the scans into a virtual model, which was evaluated from multiple angles and magnifications to confirm the scan and preparation were what was needed before proceeding.	Figure 7. The digital model (shown here in centric occlusion), generated by the iTero Element, provided everything required to evaluate the prep design and restorative parameters. The blue color denotes acceptance of the scan by the iTero Element, allowing the user to rescan areas where more data is needed.
Figure 8. Once the virtual model was finalized, the glidewell.io workflow allowed me to make one of several choices. I could send the file digitally to Glidewell Laboratories so that they could fabricate the restoration, or I could mill a provisional or final restoration directly in the office. Since I was confident in the design of my restoration and wanted to proceed immediately, I went ahead and sent the scan to the fastdesign.io Software (Glidewell Laboratories) to proceed with in-office fabrication of the crown.	Figure 9. The fastdesign.io Software took me through the steps of the design, the first of which involved marking the margin. The built-in margin tool allowed for the creation of an automatic margin line and then to make a few minor adjustments to it, all while viewing the area from multiple angles to ensure accuracy.

Figure 10. The next stage of the design process required identification of the occlusal and buccal aspects of the tooth preparation. This ensured that the proposed restoration would be correctly oriented over the site.

Clinical and Digital Workflow Protocols
The first step in the treatment process was to remove the old amalgam restoration (Figure 2). After administering local anesthesia, removing the old amalgam restoration, and completing the removal of all caries, a composite resin (CLEARFIL DC CORE PLUS [Kurarary Noritake Dental]) core build-up was placed, and a full-coverage preparation was completed (Figure 3). BruxZir NOW requires only a conservative 0.7-mm minimum reduction, which allowed for the preservation of the majority of the remaining tooth structure (Figure 4).

Next, an intraoral scan was done using the iTero Element 2 Intraoral Scanner (Figure 5). Once the scan was completed, it was loaded into the fastdesign.io Software, and the BruxZir NOW crown was fabricated with the fastmill.io. (The digital workflow steps are shown and described in Figures 6 to 17.)

Figure 12. The shape and contours of the presented design proposal looked accurate. I made a few slight alterations to the cusps and occlusion using the intuitive editing tools in fastdesign.io. In total, the design process took less than 5 minutes from the acceptance of the scan to the completed proposal.

Figure 14. BruxZir NOW zirconia milling blocks, which are pre-shaped in cylindrical form, are fully sintered and require no post-processing or oven time once milled. They are easily loaded into the fastmill.io unit when a restoration is ready to mill.

The finished restoration was tried in for fit (Figure 18) and then delivered using a bioactive luting cement (Ceramir Crown & Bridge [Doxa Dental). This cement allows for the efficient and reliable cementation of high-strength zirconia restorations without the need for special cleaners or ceramic primers. The occlusion was checked, and no adjustments were needed.

The patient was out the door with the job done within a one-hour window. Needless to say, she was thrilled with the outcome (Figure 19), knowing that the durability of the BruxZir NOW zirconia would ensure a long-lasting result. As her clinician, I was thrilled to have solved this restorative case so successfully using a single-visit digital solution.

Figure 17. The milled restoration, once removed from the fastmill.io unit, required only the removal of the sprue before being ready to deliver. Although not required, I gave the restoration a quick polish to give it the look that I desired.	Figure 18. At this stage of the process, the patient was called back to the chair and the crown was tried in. No adjustments were needed as the fit, interproximal contacts, and occlusion were excellent.

Figure 19. The patient was extremely pleased with both the look and feel of her new single-visit BruxZir NOW crown.

CLOSING COMMENTS
Whenever someone asks me why glidewell.io is my system of choice, the response revolves around some key points that are based upon my own clinical experience with digital dentistry, which now spans more than a decade. From my perspective, the investments of time, effort, and money that were required to implement these new technologies have paid off exponentially. In comparison to other systems on the market, glidewell.io requires a much lower initial investment and, even more importantly, provides a much quicker positive return on the investment. The ability to deliver high-strength restorations in a single visit has expanded my practice, improved the options for patient care, and resulted in increased revenues and cost savings. Users of glidewell.io report a 65% reduction of their dental laboratory bills within the first 5 months of use. In addition, the support of Glidewell Laboratories that comes along with integrating the glidewell.io In-Office Solution into a dental practice makes the transition period so easy that I would encourage any dentist to explore it.

Dr. Jones received his DDS from the Virginia Commonwealth University School of Dentistry, where he has held adjunct faculty positions since 1976. He maintains a private practice in Richmond, Va. Dr. Jones has been a member of Align Technology’s speaker team since 2002, published numerous articles on digital dentistry, and recently founded Mobile Imaging Solutions (scans4you.com). Dr. Jones belongs to several dental associations and is a master of the AGD. He can be reached via email at perry@drperryjones.com.

Disclosure: Dr. Jones reports no disclosures.

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