» dccuracy is what I want. dnd Primescan is my answer. « Martin Wohanka, Hardware Engineer Primescan Engineered for superior performance. Innovation requires commitment to ambition: Primescan sets new standards in dental technology, making scanning more accurate, faster and easier than ever. It is engineered to enable all kind of treatments, from single tooth to full arch. Due to the innovative Smart Pixel Sensor, Primescan processes more than 1.000.000 3D points per second and therefore produces highly accurate and photorealistic data with great dimensional depth – even for very steep surfaces. With Primescan, intraoral scanning is as accurate as never before. Enjoy the scan. Learn more at: dentsplysirona.com/primescan
4 RESTORATIVE Dental Tribune Middle East & Africa Edition | 2/2019 Overcoming the myths of bulk ﬁll composite materials Bulk ﬁll composite materials were introduced for restorations more than a decade ago; however, many dentists were reluctant to try them due to the limitations and performance of earlier bulk ﬁlling materials. By 3M Oral Care In addition, most dentists were trained to use incremental filling materials that require a layering technique in order to minimize stress/shrinkage; achieve proper ad- aptation and eliminate voids; and achieve proper depth of cure. Be- cause of this, many dentists find it difficult to trust or incorporate bulk fill materials that seemingly contra- dict their training. Older composite resin chemistries feature monomers that need to be layered in 2 mm increments to mini- mize shrinkage. This traditional lay- ering technique requires more steps and means dentists spend more time working in a patient’s mouth. Using a traditional layering tech- nique requires multiple steps of packing, layering, and curing, which could increase the potential for voids and/or poor adaptation with each layer. The amount of time that this layering technique requires could also increase the potential to intro- duce contamination from blood or saliva. “Since the introduction of bulk fill materials, a significant amount of technology has been dedicated to ad- dressing shrinkage stress, but depth of cure issues persisted for some time,” says 3M Advanced Product Development Specialist Tim Dun- bar, Ph.D. “Significant advances in materials science and chemistry in the past decade enable more trans- lucent composites that allow curing light to penetrate to a depth of 5 mm with low shrinkage stress.” 3M™ Filtek™ One Bulk Fill Restora- tive is designed for the posterior so dentists don’t need to sacri- fice wear resist- ance, strength up to 5 mm 1 mm 2 mm 2 mm and handling. It also has opacity equivalent to many typical univer- sal composite materials used today, so dentists don’t need to sacrifice esthetics while working quickly and efficiently. Unfortunately, despite the great ad- vances made over the last few years, myths about bulk fill materials con- tinue to persist. Let’s take a closer look at the science of Filtek One Bulk Fill Restorative – and break down the myths of bulk fills. MYTH 1 Bulk ﬁll materials are not aesthetic enough (too translucent). In the past, bulk fill materials needed a rela- tively high amount of translucency (low opacity) in order to fully cure in a 4-5 mm in- crement. The concept is quite simple – if the composite needs to cure all the way through 4-5 mm of material, then it needs to allow the light to penetrate to a greater degree. In the decade or so since the introduction of the first bulk fill composites, the field of materials science has exploded. Research and development efforts in the past 5-10 years have yielded bulk fill composites that no longer require a choice between fast and effective depth-of-cure and esthetics. 3M de- signed Filtek One Bulk Fill Restorative with unique optical properties and improved opacity to provide the simplicity of one-step placement up to 5 mm, without compro- mising esthetic results. 3M leveraged its nanotechnology expertise to increase opacity without reducing depth of cure. In its cured state, Filtek One Bulk Fill Restorative has a higher opacity than other leading bulk fill restoratives, resulting in im- proved esthetics. 3M’s nanofiller technology also provides superior wear resistance and excellent polish retention. MYTH 2 It’s necessary to layer bulk ﬁll materials in order to minimize stress/shrinkage. Stress is the amount of force exerted on a tooth due to polymerization shrinkage as it cures. This stress can break the adhesive bond, crack enamel and allow leakage at the margins. The amount of stress is deter- mined by the shrinkage of the material and its stiffness. 3M™ Filtek™ One Bulk Fill Restorative ex- erts less or equivalent stress on a tooth than some common incrementally placed uni- versal composites, because it uses two new resin components to reduce polymerization stress. One resin component is an addition-frag- mentation monomer (AFM). During polym- erization, the central group can fragment to relieve stress and the fragments can then re- polymerize in a lower stress state. The other resin component is aromatic ure- thane dimethacrylate (AUDMA). Because this is a larger monomer than found in tra- ditional dimethacrylates, it limits the num- ber of shrinkage zones. This helps reduce the amount of shrinkage and stress that occurs during polymerization. 1 2 Without AFM With AFM Traditional Dimethacrylate AUDMA MYTH 3 It’s necessary to layer ﬁlling materials in order to achieve proper adaptation and eliminate voids. For many decades, the incremental place- ment of composite has been the prevailing technique, in part because this was thought to minimize the potential for introducing voids. However, studies have shown that the opposite is true when compared to using an effective bulk fill composite. Extruding 3M™ Filtek™ One Bulk Fill Restor- ative material out of its newly designed unit dose capsule creates the necessary condi- tions for shear thinning. This means the vis- cosity of the material temporarily decreases and the material flows into the cavity prep, resulting in excellent adaptation, as well as fewer defects (voids). In an in-vitro simulated operatory test with 79 dentists, restorations placed with Filtek One Bulk Fill Restorative in 5 mm deep class II cavities had fewer defects compared to res- torations made using incrementally placed composites. MYTH 4 A bulk ﬁll placed in a 5 mm increment won’t achieve the proper depth of cure. Methacrylate-based dental composites have the ability to achieve a very high depth-of- cure, but this has often come at the price of lowered opacity/esthetics (see myth 1). In order to achieve a high depth-of-cure while maintaining a tooth-like opacity, we must look at the interaction of light between the filler particles and the matrix. If the optical properties (refractive index) of the filler and matrix do not match closely, light is scattered within the composite re- sulting in higher opacity. This will limit the depth of penetration of the curing light to effectively enable bulk curing. If the optical properties match closely, light penetrates more effectively without the scattering re- sulting in more translucency. This will allow for greater penetration of the curing light and allow for bulk curing. Traditionally, this resulted in more translucent restorations. stages at which the material looks opaque and translucent. The end result is a compos- ite with the depth-of-cure required for bulk placement, and a final opacity that is closer to the natural tooth. 3M™ Filtek™ One Bulk Fill Restorative uti- lizes the science described above to achieve a uniform cure even at the bottom of 5 mm cavity, without sacrificing esthetics. “We have data and peer-reviewed literature that indicate 3M’s bulk fill materials work as intended,” says Senior Technical Service Engineer Joe Edgington. “Bulk fills have been around for 10 years and many concerns and challenges have been worked out thanks to advances in materials science and chemis- try.” “With fewer defects, fewer voids, less chance of contamination, and less time than univer- sal composites, dentists can make quality restorations with 3M’s bulk fill composites,” adds Dunbar. By manipulating the base chemistry that controls this behavior, we can control the For more information, contact your 3M Oral Care sales representative. Refractive index does not match Refractive index does match Incoming light Incoming light The innovative component of the ﬁrst resin is an addition-fragmentation monomer (AFM). The unique feature of this resin is that, during polymerization, the central group can fragment to stress. The fragments can then re- polymerize lower stress state. relieve in a AFM The other resin component is aromatic urethane dimethacrylate (AUDMA). Because it’s a larg-er monomer than found in traditional dimethac- rylates, it limits the number of shrinkage zones. That helps reduce the amount of shrinkage and stress that occurs during polymerization. AUDMA If the ﬁller and the resin DO have matching optical properties (bottom diagram), as is the case with 3M™ Filtek™ One Bulk Fill Restorative, then the light will not be signiﬁcantly bent, and the light will be successfully transmitted through the materials, which increases the material’s depth of cure.
6 mCME Dental Tribune Middle East & Africa Edition | 2/2019 Intraoral welding and lingualised (lingual contact) occlusion: a case report mCME articles in Dental Tribune have been approved by: DHA awarded this program for 1 CPD Credit Points CAPP designates this activity for 1 CE Credits By Dr Luca Dal Carlo, Dr Franco Ros- si, Dr Marco E. Pasqualini, Dr Mike Shulman, Dr Michele Nardone, MD, Dr Tomasz Grotowski and Dr Shel- don Winkler Intraoral welding was developed by Pierluigi Mondani1 of Genoa, Italy, in the 1970s to permanently connect submerged implants and abutments to a titanium wire or bar by means of an electric current (Fig. 1). The cur- rent is used to permanently fuse the titanium to the abutments in milli- seconds, so the heat generated does not cause any pathology or patient discomfort. If possible the implants are placed without flaps. The titanium wire or bar is bent and aligned passively to the contour of the labial and lingual surfaces of the implants before ap- plying the electric current to perma- nently connect titanium implants. The technique follows a strict sur- gical and prosthodontic protocol, which includes using a number of implants as close as possible to the number of teeth to be replaced, achieving primary stability by en- gaging both cortical plates (bicorti- calism), immediate splinting of the implants utilizing intraoral welding and immediate insertion of a fixed provisional prosthesis with satisfac- tory occlusion. The technique pro- vides for immediate loading and does not jeopardize the integration process.2 Although intraoral welding has been used successfully in Europe, especial- ly Italy, for many years, it has yet to achieve everyday use in the United States. Members of the Italian affiliate of the American Academy of Implant Prosthodontics, NuovoGISI, have long and successful experiences with immediate loading of maxil- lary implants connected together by intraoral welding.2 By inserting the prosthesis with ad- equate retention and stability the same day as the surgery, patient complaints and discomfort can be avoided or substantially reduced. The instantaneous stability that re- sults from the splinting can reduce the risk of failure during the heal- ing period. Intraoral welding can also eliminate errors and distortions caused by unsatisfactory impres- sion making, as the procedure is per- formed directly in the mouth. Intraoral welding can fulfil a great need for business and socially active persons, as the surgical and prostho- dontic procedures are accomplished on the same day. Patients can leave the dental office with a stable, esthet- ic and retentive prosthesis. ÿPage 7 mCME SELF INSTRUCTION PROGRAM CAPPmea together with Dental Tribune provides the opportunity with its mCME – Self Instruction Program a quick and simple way to meet your continuing education needs. mCME offers you the flexibility to work at your own pace through the material from any location at any time. The content is international, drawn from the upper echelon of dental medicine, but also presents a regional outlook in terms of perspective and subject matter. Membership Yearly membership subscription for mCME: 1,100 AED One Time article newspaper subscription: 250 AED per issue. After the payment, you will receive your membership number and allowing you to start the program. Completion of mCME • • • • • • • • mCME participants are required to read the continuing medical education (CME) articles published in each issue. Each article offers 2 CME Credit and are followed by a quiz Questionnaire online, which is available on www.cappmea.com/ mCME/questionnaires.html. Each quiz has to be returned to firstname.lastname@example.org in three months from the publication date. A minimum passing score of 80% must be achieved in order to claim credit. No more than two answered questions can be submitted at the same time Validity of the article – 3 months Validity of the subscription – 1 year Collection of Credit hours: You will receive the summary report with Certificate, maximum one month after the expiry date of your membership. For single subscription certificates and summary reports will be sent one month after the publication of the article. Fig. 1. Schematic drawing of Mondani intraoral solder unit Fig. 2. Preoperative panoramic radiograph of 50-year-old cauca- sian woman Fig. 3. Nonrestorable teeth visible after removal of the patient’s pros- thesis Fig. 4. Eight titanium one-piece implants are inserted. Fig. 6. Panoramic radiograph after 90 days suggests complete integration Fig. 5. Immediate stabilization of the eight implants and two additional implants previously inserted in the posterior regions, by welding each implant to a 1.5 mm supporting titanium bar Fig. 8. Lower implants welded together intraorally Fig. 7. Healthy gingiva was observed after 90 days Fig. 10. Seven-year follow-up radiograph shows satisfactory pres- ervation of bone surrounding all of the implants The answers and critiques published herein have been checked carefully and represent authoritative opinions about the questions concerned. Articles are available on www.cappmea.com after the publication. For more information please contact email@example.com or +971 4 347 6747 FOR INTERACTION WITH THE AUTHORS FIND THE CONTACT DETAILS AT THE END OF EACH ARTICLE. Fig. 9. Three-tooth mandibular ﬁxed prosthesis Fig. 11. Intraoral photograph of the deﬁnitive prosthesis shows healthy gingiva
Dental Tribune Middle East & Africa Edition | 2/2019 ◊Page 6 mCME 7 The flapless technique, first pro- posed by Tramonte3, can be per- formed when the bony crest is wide and an adequate amount of attached gingiva is present. The technique al- lows for uneventful healing, a reduc- tion of postsurgical inflammation and only moderate inconvenience for the patient, who can eat efficient- ly the same day. Provisional prosthesis and tooth arrangement During the surgical session a tem- porary resin prosthesis is inserted. Occlusal plane height must be cor- rect. A lingualized (lingual contact) scheme of occlusion is recommend- ed. The upper anterior teeth are best arranged without any vertical overlap. The amount of horizontal overlap is determined by the jaw re- lationship. A vertical overlap for ap- pearance can be used, provided that an adequate horizontal overlap is in- cluded to guard against interference within the functional range.4 Lingualized (lingual contact) occlusion Lingualized (lingual contact) occlu- sion maintains the esthetic and food penetration advantages of anatomic teeth while maintaining the me- chanical freedom of nonanatomic teeth. Among the advantages of a lingualized occlusion are occlusal forces centered over the ridge crest in centric occlusion, masticatory force is effectively transferred more “lingual” to the ridges during work- ing side excursions, the “mortar and pestle” type of occlusion minimizes the occlusal contact area provid- ing for more efficient food bolus penetration and elimination of the precise intercuspation that can com- plicate the arrangement of anatomic denture teeth. Lingualized occlusion also prevents cheek biting by holding the buc- cal mucosa off the food table by eliminating occlusal contacts on the maxillary buccal cusps, minimizes occlusal disharmonies created from errors in jaw relationships, denture processing changes and settling of the denture base, and simplifies set- ting of denture teeth, balancing the occlusion and any subsequent oc- clusal adjustment procedures.5 Clinical report A healthy 50-year-old caucasian woman presented for treatment at the office of one of the co-authors (LDC) with a mobile, painful, 12-tooth semiprecious alloy-ceramic fixed prosthesis (Fig. 2). The prosthesis was removed and all of the remain- ing abutment teeth were found to be nonrestorable with extraction in- dicated (Fig. 3). After removal of the retained teeth, eight titanium one- piece implants were inserted in one session (Fig. 4). Immediate stabilization of the eight implants and 2 additional implants that were previously inserted in the posterior regions was achieved by welding (Acerboni Intraoral Weld- ing Unit, Casargo, Italy) each implant to a 1.5 mm supporting titanium bar (Acerboni, Casargo, Italy), which previously had been bent to fit pas- sively on the palatal mucosa (Fig. 5). A provisional resin prosthesis was inserted, which provided an accept- able vertical dimension and lingual contact occlusion. Oral hygiene pro- cedures were demonstrated to the patient and reviewed at all future ap- pointments. After 90 days, a panoramic radio- graph suggested complete integra- tion (Fig. 6) and a healthy mucosa was observed. (Fig. 7). The definitive full-arch gold-ceramic maxillary prosthesis was inserted, which great- ly pleased the patient and her family. In the lower arch, the right first and second bicuspids were extracted and implants placed in the first bicuspid and first molar regions. The implants were welded together intraorally (Fig. 8), followed by the fabrication and cementation of a three-tooth fixed prosthesis (Fig. 9). A 7-year follow-up radiograph (Fig. 10) shows satisfactory preserva- tion of bone surrounding all of the implants. An intraoral photograph of the definitive prosthesis shows healthy gingival tissue (Fig. 11). References 1. Mondani PL, Mondani PM. The Pierliugi Mondani intraoral electric solder. Principles of development and explanation of the solder using syncrystallization. Riv Odontostom- atol Implantoprotesi. 1982;4:28-32. 2. Rossi F, Pasqualini ME, Dal Carlo L, Shulman M, Nardone M, Winkler S. Immediate loading of maxillary one-piece screw implants utilizing intraoral welding: a case report. J Oral Implantol (in press). 3. Tramonte, S. A further report on intraosseous im- proved drive screws. J Oral Implant Transplant Surg. 1965;11:35-37. 4. Winkler S, ed. Essentials of Com- plete Denture Prosthodontics. 3rd implants with ed. Delhi, India: AITBS Publishers; 2015. 5. Lang BR, Lauciello FR, McGivney GP, Winkler S. Contemporary Com- plete Denture Occlusion, revision 4. Amherst, NY: Ivoclar Vivadent, 2012. Editorial note: This article was originally published in implants – the international maga- zine C.E. of oral implantology, Issue 2/2015. Dr. Luca Dal Carlo and Dr. Franco Rossi are in private practice in Venice, Italy. Dr. Marco E. Pasqualini is in private prac- tice in Milan, Italy. Dr. Mike Shulman is in private practice in Clifton, N.J., and adjunct associate profes- sor at the School of Oral Health Sciences, Kingston, Jamaica. Dr. Michele Nardone is with the Ministry of Public Health, Rome, Italy. Dr. Sheldon Winkler is adjunct professor at Midwestern University College of Dental Medicine, Glendale, Ariz., and School of Oral Health Sciences, Kingston, Jamaica. Dr. Tomasz Grotowski is in private practice and professor at the School of Minimally Invasive Implantology, Szczecin, Poland. AD 14th edition CAD/CAM & Digital Dentistry Conference Madinat Jumeirah Conference Centre | Dubai | UAE Final Programme Day 4 | 42 April 2049 WhatsApp Enquiry +971 50 2793711 09:00 - 09:45 | Prof Tim Joda, Swtizerland Dual Presentation: Monolithic Implant Reconstructions – The Keystone to Advances in CAD/CAM Technologies 43:45 - 44:45 | Dr Jan Paulics, Sweden Mastering the Art of Digital Impressions 09:00 - 09:45 | Vincent Fehmer, MDT, Switzerland Dual Presentation: Monolithic Implant Reconstructions – The Keystone to Advances in CAD/CAM Technologies 44:45 - 45:30 | Dr Dimitris Strakas, Greece Lasers - Cutting Edge Technology for the Modern Dentist 09:45 - 40:30 | Dr Bart Vandenberghe, Belgium Pitfalls in 3D CBCT Imaging 46:00 - 46:45 | Lt Dr Nawaf Al-Dousari, Kuwait Custom Made Artistic Smile (Mix of CADCAM & Press) 40:45 - 44:30 | Prof Goran Urde, Sweden Implant Dentistry “It was Better Before” 46:45 - 47:30 | Dr Daz Singh, UK Aesthetically Focused Multi-Disciplinary Treatment Planning with Aligners 44:30 - 42:45 | Dr Martin Lebeda, Czech Republic Aesthetics with CEREC – Design of Digital Wax–Up, Guided Implant Surgery, No–Prep Veneer Case 47:30 - 48:00 | Dr Eduardo Mahn, Chile How to Choose the Most Appropriate CAD/CAM Material for Modern Indications Final Programme Day 2 | 43 April 2049 09:00 - 09:45 | Dr Manol Ivchev, Bulgaria 3D Function in Occlusion – A Key for Orthodontics 44:45 - 45:00 | Dr Isabelle Savoye, Belgium The Full Digital Orthodontic Patient and the 3D Application 09:45 - 40:30 | Prof Tim Joda, Switzerland Complete Digital Workﬂow for Single–Unit Implant Restorations 40:30 - 44:45 | Dr Hao-Wei Tsao, Taiwan Clinical Application in Chair–side CAD/CAM 44:30 - 42:00 | Dr Munir Silwadi, UAE Restoration of Endodontically Treated Teeth with Chair Side Partial Crowns 42:00 - 42:45 | Dr Adam Nulty, IDDA, UK FULLYDIGITAL: Prosthetic Driven Implant Planning 45:00 - 45:45 | Dr Anoop Maini, UK Cost Eﬀective Chairside Dentistry Utilising a Fully Open Platform 46:45 - 47:00 | Germen Versteeg, NL +1000 Digital Dentures Later. A Huge Improvement in Quality and How it Changes your Business Model 47:00 - 47:45 | David Claridge, IDDA, UK Scanomics – The Economics of Intraoral Scanning Accreditation: DHA 12.75 CME CAPP designates this activity for 14 CE Credits www.cappmea.com/digital-dentistry-2019-conference
WhatsApp Enquiry +971502793711 08–09 November 2019 InterContinental Hotel DFC, Dubai, UAE Dental Hygienist Seminar Training at the Exhibition Poster Presentation ORGANISED BY www.cappmea.com/aesthetic
10 INDUSTRY Dental Tribune Middle East & Africa Edition | 2/2019 2019 AEEDC show hailed a success for Beverly Hills Formula By Beverly Hills Formula Once more, oral care experts Bev- erly Hills Formula were the stand out brand at this year’s AEEDC in Dubai. Each year, the Irish based company takes the trip to the three-day long exhibition, ensuring their bold and eye-catching branding helps them to attract thousands to their stand. The brand maintains a strong pres- ence at the exhibition show, which gives the team a valuable opportu- nity to access and engage with den- tal professionals and stockists in this region, showcasing their impressive portfolio of oral care products. Currently retailing in UAE, Jordon, Lebanon, Oman, Qatar, Kuwait, Bah- rain, Iran and Saudi Arabia, interest in the range of products has always been huge and unsurprisingly this year was no different. Already a mar- ket leader in the Middle East, the Irish based company have been ex- panding rapidly, thanks to their wide range of products that have truly made a difference to people’s lives. It is more than just bold packaging that has attracted a loyal fan base across the globe - the brand has de- veloped truly ground-breaking and fascinating scientific formulations Beverly Hills Formula booth for each product ensuring they are low abrasive yet perform at the high- est level. Whether it’s real gold parti- cles, or first to market activated char- coal, they have set the precedent for superior and safe teeth whitening in the comfort of one’s home. This year saw the brand showcase their two hugely successful ranges – The Professional White Range and the Perfect White Range. The Professional White range in- cludes Black Pearl whitening tooth- paste, Pink Pearl Sensitive Whitening Toothpaste, Award-Winning Pre- cious Pearl Enamel remineralising toothpaste and Fresh Pearl Mouth- wash, as well as a Professional White Teeth Whitening Kit. The Perfect White Family Consists of the infamous Perfect White Black, Perfect White Gold, Perfect White, Perfect White Sensitive, Perfect White Black Sensitive and Perfect White Black Mouthwash. Joining them were their most recent prod- ucts - Perfect White Optic Blue, Per- fect White Gold Mouthwash and the Perfect White Whitening Kit. Following on from the success of their hero product Perfect White Black, the brand has developed their most intriguing product yet, repli- cating their award-winning activated charcoal formulation into a whiten- ing kit, which is set to be released this year and is highly anticipated by both consumers and profession- als alike. The Perfect White Black Whiten- ing Kit contains 28 charcoal infused strips as well as a whitening pen. Activated Charcoal, found in both their toothpaste and mouthwash, is known for its love of tannins and makes for an excellent tooth stain re- mover. The innovative Pen works as an express touch up service, helping to remove the build-up of plaque. The Activated Charcoal Whitening Strips offer professional dental whit- ening in 5 simple and easy to use steps that only takes 30 minutes. Thanks to years of dedicated scien- tific research, Beverly Hills Formula’s cutting-edge products are often are on the receiving end of highly pres- tigious awards. They may be a small company, but their ranges certainly command huge attention – they are confident they are the best in the business, and it is difficult to disa- gree. Beverly Hills Formula team New milling machines for the digital age PrograMill: digital manufacturing of highly aesthetic restorations By Ivoclar Vivadent AG Ivoclar Vivadent is introducing four new milling machines which, to- gether with the innovative materials and coordinated processes offered by the new Ivoclar Digital product portfolio, fulfil the exacting stand- ards of modern dental laboratory and clinical technology. PrograMill One: the new benchmark PrograMill One is the world’s small- PrograMill: new milling machines shape the digital future est 5-axis milling machine. It com- bines industrial manufacturing quality with high precision and modern design. In the innovative 5-axis turn-milling technique, the workpiece rotates around the tool. The feed remains constant; the tool never leaves the block. This ensures short milling times and minimal tool wear. Various validated process- ing strategies are available for differ- ent materials and indications. The machine’s wireless capabilities allow it to be operated from any location with the help of a spe- cial app for tablets and smartphones. The optical status display shows the current status of the machine. PrograMill One is coordinated with the scanners and design solu- tions from 3Shape. The unit has been developed for mill- ing IPS e.max in par- ticular. PrograMill PM7: dynamic flagship machine for laboratories PrograMill PM7 is capable of mill- ing a large variety of materials in a wet and dry state. It is suitable for a wide spectrum of indications. The 5-axis milling process is controlled by means of an integrated PC with a touch-screen monitor. The material and tool changers work in unison so that the fabrication process proceeds independently and without inter- ruption. The centralized manage- ment of the contents of the material changer and the tool magazine en- sures that the correct milling strat- egy is used. An ionizer reduces the cleaning requirements when PMMA materials are processed. All in all, the PM7 offers a future-proof solution for manufacturing prosthetic resto- rations. PrograMill PM3/PM5: economical and precise PrograMill PM3 and PM5 are de- signed for wet-grinding and dry- milling procedures. They are ca- pable of processing a wide range of materials for many indications. The fully automatic materials man- ager checks the compatibility of the tools and milling strategies. The tool changer ensures consistent, unin- terrupted manufacturing. The in- tegrated 8-disc material changer of PrograMill PM5 allows you to accom- plish several milling jobs involving different materials and indications at the same time. Individual machin- ing strategies offer short process times for the respective restorations. Comprehensive range of accessories A comprehensive range of accesso- ries supplements the new machine portfolio. It comprises software pro- grams, a common base station, in- novative colour-coding to ensure the reliable handling of materials as well as a wide range of tools and special attachments. IPS e.max® is a registered trademark of Ivoclar Vivadent AG. For more information contact: Ivoclar Vivadent AG Bendererstrasse 2 9494 Schaan/Liechtenstein Tel.: +423 235 35 35 Fax: +423 235 33 60 E-mail: firstname.lastname@example.org Web:www.ivoclarvivadent.com
THE EVMLUTIMN MF PRMPHYLAXIS CMMBI touch AIRPMLISHING AND ULTRASMUND IN MNE UNIT easy switch from supra to subgingival air-polishing by a simple click subgingival perio air-polishing tip – flexible, soft and anatomically adjustable to the periodontal pocket more than 40 inserts for scaling, perio, endo and prosthetics soft mode: the ultra-gentle scaling for sensitive patients V I S I T U S ! BOOTH O/P HALL . www.mectron.com www.we-love-prophylaxis.com
14 RESTORATIVE Dental Tribune Middle East & Africa Edition | 2/2019 A clinical case using the Palodent® V3 Sectional Matrix System Adjacent teeth damaged by dental bur By Prof Dr A. Lussi Bern, Switzerland Objective Cutting and finishing approximal preparations with conventional in- strumentation and methods may produce iatrogenic damage in ad- jacent tooth surfaces which subse- quently requires restoration. The objective of this investigation was to determine the occurrence of iat- rogenic damage and whether, under everyday working conditions in den- tal practice, such damage could be re- duced significantly by using an alter- native method and instrumentation designed especially for the purpose. Method Dental practitioners were asked to take impressions of teeth sched- uled for Class II amalgam restora- tions. One group (control) prepared the teeth with conventional rotary instrumentation (n = 71), while the test group used a new method and instrumentation (n = 63). These comprised a set of files, a rightangle handpiece with reduced stroke, 36 fixed (rotation-locked) positions for the files and a cylindrical bur with a recessed front-end cutting surface. Damage to the adjacent teeth was as- sessed under a stereomicroscope. Results Using conventional methods, all ad- jacent tooth surfaces showed dam- age, often exposing deep layers of dental tissues. There was a clinical and statistically significant reduc- tion of incidence and severity of iat- rogenic preparation trauma in the test group. Conclusion It appears that conventional ap- proximal box preparation results in significant damage to adjacent tooth surfaces. With the system tested, damage to adjacent tooth surfaces during preparation of proximal boxes can be significantly reduced. This should have an impact on the subsequent rate of restoration for the adjacent surfaces. 1 Palodent® Plus was re-branded to Palodent® V3 in 2015. For more information contact: Dentaply Sirona 21st Floor, The Bay Gate Tower Business Bay, Al Sa’ada Street Dubai, United Arab Emirates Tel.: +971 (0)4 523 0600 Web: www.dentsplysirona.com/en E-mail: MEA-Marketing@dentsplysirona.com Insert Palodent® V31 WedgeGuard before starting preparation WedgeGuard protects adjacent tooth during preparation Remove plate from WedgeGuard, wedge remains Initial Case. Proximal caries on the distal area of the ﬁrst lower molar. Insertion of the Palodent® V3 WedgeGuard before tooth preparation. Cavity preparation and the Palodent® V3 system in place. Palodent® V3 WedgeGuard showing damage caused to the WedgeGuard (and not the adjacent tooth) after tooth preparation. AD IDS 2019 Hall : 10.2 Booth: V15 Temporary crown & bridge material Less than 5 min. processing time Strong functional load Perfect long-term aesthetics Excellent biocompatibility Kaltpolymerisierendes provisorisches Kronen- und Brückenmaterial, Paste-Paste-System Material provisório polimerizável a frio para coroas e pontes, sistema pasta-pasta 50 ml cartridge / mixing tips Made in Germany 0482 Glass ionomer luting cement High level of adhesion Highly biocompatible, low acidity Continuous fluoride release Precision due to micro- fine film thickness Translucency for an aesthetic result Light-curing micro-hybrid composite Applicable for various indications and all cavity classes High translucency and a perfect colour adaption Polishable to a high gloss Excellent physical properties for durable fillings High filler content Packable consistency (also available as Composan LCM flow) Dental Material GmbH 24537 Neumünster / Germany +49 43 21 / 5 41 73 Tel. +49 43 21 / 5 19 08 Fax eMail email@example.com Internet www.promedica.de
The perfect duo BRILLIANT EverGlow® & ONE COAT 7 UNIVERSAL BRILLIANT EverGlow is a universal submicron hybrid composite of the latest generation and a true all-round material. It has been developed with special focus on high, long-lasting gloss and shade aesthetics and handling convenience. Meeting highest requirements for “brilliant” anterior and posterior restorations, it is the ideal modern ﬁ lling material. ONE COAT 7 UNIVERSAL is a light- cured, one component bonding agent used eﬀ ortlessly, for all adhesive restoration techniques. The outstanding shear bond strength ensures excellent adhesion to enamel and dentine. Dietmar Goldmann P +41 71 757 54 40 firstname.lastname@example.org everglow.coltene.com | www.coltene.com 9 1 2 0 . 1 9 4 4 0 0
16 DIGITAL DENTISTRY Dental Tribune Middle East & Africa Edition | 2/2019 Digital workﬂow and application of PRF and ozone therapy in oral rehabilitation By Dr Miguel Stanley, Dr Ana Paz, Dr Catarina Rodrigues & Dr Diogo Mendes, Portugal There are numerous technologies that simplify the daily work, such as intraoral, extraoral and face scan- ners, CBCT (cone beam computed tomography) with a low radiation dose, and software processing and production, better known as CAD/ CAM (computer-aided design/com- puter-aided manufacture), which to- gether with new aesthetic materials and prototyping tools (milling ma- chines and 3-D printers) are radically transforming dental medicine. This case report has the aim of present- ing an example of prosthetic digital workflow, with the integration of several technologies that help us achieve treatment success. Introduction The digital revolution has changed the world and dental medicine is no exception. We live in the digital era: we have the materials and tech- niques that allow us to develop a to- tally digital workflow, allowing den- tal medicine to grow to a new level, becoming faster and more efficient, when combined with scientific and clinical knowledge. Clinical case In November 2017, a 39-year-old fe- male patient came to an initial ap- pointment at White Clinic owing to tooth pain (tooth #16). A clinical and radiographic examination were per- formed, including a periapical radio- graph, CBCT scan (Carestream 9500, Carestream Dental), and intra- and extraoral photographs (Figs. 1–3). In the clinical and radiographic eval- uation, it was observed that tooth #16 presented an invasive cervical resorption at the mesiobuccal root. The treatment plan established was dental extraction with immediate implant placement. The tooth had been previously re-treated endodon- tically and restored with a definitive ceramic crown. Due to the current situation of the tooth, although the protocol in White Clinic is to pre- serve teeth, it had indication for im- mediate extraction. Also due to the lack of time, our digital team was not able to produce a surgical guide for the implant placement. Therefore, the treatment plan, included a sur- gical phase and a digital prosthetic phase. The surgical treatment phase started with extraction of tooth #16, fol- lowed by excision of the root cyst and alveolar curettage (Figs. 4a & b). For good disinfection of the alveolus, ozone therapy (Ozone DTA, Apoza) was applied (Fig. 4c), taking into ac- count the antimicrobial action of ozone, which prevents the develop- ment of the inflammatory process, favouring cellular recovery and consequently improving the post- operative healing. Once the alveolus had been disinfected, the implant bed was prepared with a sequence of implant drills from the AnyRidge surgical system (AnyRidge Surgical Kit, MegaGen; Fig. 4d). The bone de- fects were filled with a bone xeno- graft of porcine origin (Gen-Os, Os- teoBiol), mixed with i-PRF (injectable platelet–rich fibrin; PRF process by Choukroun; Figs. 5a & b). Afterwards, bone densification was performed through a sequence of Densah drills (Densah Burs, Versah; Fig. 6a). This type of drill allows the clinician to perform a bone densification pro- cess. Once the implant bed had been pre- pared, a 7 × 10 mm implant (Any- Ridge) was placed. After placement, the ISQ (Implant Stability Quotient) was measured with a stability meter (Mega ISQ, MegaGen), and the value was 72. According to the ISQ scale, this represents high stability (Fig. 6b). A 10 × 7 mm healing screw (Any- Ridge) was placed, along with a plug of A-PRF (advanced platelet–rich fibrin; PRF process by Choukroun) in order to accelerate the healing process, and sutured with 4/0 poly- propylene (Hu-Friedy; Figs. 7–10). After the surgical procedure, the White Clinic postoperative protocol was applied: application for eight minutes of the ATP38 laser (Swiss Bio Inov), based on the principle of Low Level Laser Therapy that acts on the cellular metabolism and provides a better and faster postoperative heal- ing. The patient was instructed to use a 0.2% hyaluronic acid gel (Gengigel, Ricerfarma) and 0.1% hyaluronic acid mouthwash (Gengigel First-aid, Ricerfarma) for one week after sur- gery, with the goal of accelerating the healing process. One week after surgery, the sutures were removed, ozone was used to disinfect the area around the implant, and the ATP38 was applied for eight minutes to pro- mote healing. In March 2018, four months after the surgery, the prosthetic phase was Fig. 4a Fig. 4b Fig. 4c Fig. 4d Fig. 1a Fig. 1b Fig. 2 Fig. 3 started. An impression was taken with an intraoral scanner (CS 3600, Carestream Dental) using scan bod- ies for an impression at the implant head (MegaGen; Figs. 11a & b). The in- formation was sent to the Anatomic Lab, where a crown was designed us- ing a CAD programme. After the de- sign of the crown had been finished, the information was sent to a milling machine (Amann Girrbach) and the crown was milled (Fig. 12). One week after the preparation, the definitive crown in monolithic zirco- nia was attached and the occlusion tested using T-Scan technology (Tek- scan; Figs. 13a–c & 14). Discussion The main success indicator for den- tal implants is primary stability, which is one of the prerequisites for achieving osseointegration.1 This is affected by factors such as bone quantity and quality, surgical place- ment procedure, and implant shape and coating.2 This stability can be measured with a device that analyses the resonance frequency of the implant after its placement. The software converts the received hertz waves to a nu- merical value called ISQ on a scale ranging from 1 to 100. The manu- facturer’s instructions suggest that a stable implant has an ISQ higher than 65 and an unstable implant less than 50.3 However, these values dif- fer from one author to another. Nowadays, we have several options that can help us achieve a successful rehabilitation with implants. One of them is the use of a fibrin membrane rich in platelets (PRF). This has the ability to reduce the healing period and improve bone regeneration. The use of PRF as a covering membrane allows rapid epithelisation of the site surface and represents an effective barrier against the penetration of ep- ithelial cells within the bone defect.4 Öncü and Alaaddinoglu evaluated the impact of implant coating with L-PRF (leukocyte– and platelet–rich fibrin).5 The stability of the implant was measured by ISQ.5 The use of L- PRF in the implant insertion resulted in statistically significant ISQ values that continuously increased over time. Boora et al. reported early bone remodelling around implants coated or not with L-PRF at the insertion.6 Implants coated with L-PRF showed 50% less initial bone loss after both one and three months, respectively.7 Nowadays, centrifugation protocols have been optimised, called the low speed concept of centrifugation, re- sulting in A-PRF and i-PRF. These new protocols seek to obtain a greater number of platelets, in order to in- crease the healing capacity, and leu- cocytes, therefore also increasing the regenerative capacity.8 Furthermore, positive effects on bone regeneration and implant sur- gery have been suggested when PRF is applied. Given its ease of prepara- tion, low cost and biological proper- ties, PRF can be considered as a reli- able treatment option.7 Although the application of PRF during implant placement or for the treatment of peri-implant defects is quite recent, several studies have already shown clinical benefits, such as higher ISQ values and marginal bone resorp- tion.7 Another technique that has proven to be an asset in the success of oral rehabilitation with implants is ozone therapy. This ozone-based tool has an antibacterial effect resulting from the oxidative action on cells, dam- aging the cytoplasmic membranes of certain organisms, such as bacte- ria, viruses, fungi and parasites, with- out, however, the ability to damage healthy human cells.9,10 Thus, ozone has the following advantages: ac- celerates the healing of soft tissue (increases the rate of physiological healing), controls opportunistic in- fec- tions, reduces scarring time after extraction (forms a pseudomem- brane over the alveolus and protects it from physical and mechanical ag- gression) and aids in bone regenera- tion.10–12 The literature suggests that the post-extraction socket must be prepared conventionally and dis- infected with ozone for about 40 seconds, followed by placement of the implant. In this way, we avoid infections and improve bone regen- eration.10,13 A further study showed that in ozone-treated implants there was regeneration of periodontal cells similar to those around natural teeth.10, 14 In modern digital dentistry, the four basic phases of work are image ac- quisition (through scanning), data preparation/processing (through CAD software), production (CAM sys- tems), and clinical application on pa- tients.15 The dental preparation can ÿPage 18
18 ◊Page 16 DIGITAL DENTISTRY Dental Tribune Middle East & Africa Edition | 2/2019 Fig. 5a Fig. 5b Fig. 6a Fig. 6b Fig. 7 Fig. 8 Fig. 9 Fig. 10 Fig. 11a Fig. 11b Fig. 12 Fig. 13a Fig. 13b Fig. 13c Fig. 14 Fig. 15a Fig. 15b Fig. 15c Fig. 15d Fig. 15e be scanned outside the oral cavity, on the plaster model, or inside the oral cavity by an intraoral scanning system.16 Optical impressions have several ad- vantages over conventional impres- sions. Among them, the most im- portant is the reduction of patient stress and discomfort. Moreover, they are time-efficient and can sim- plify clinical procedures for the den- tist, especially for complex impres- sions (in patients with undercuts and/or in oral implantology, when multiple implants are present). In addition, optical impressions elimi- nate plaster models, saving time and space, and allow for better commu- nication with the dental technician. Finally, optical impressions improve communication with patients and are therefore a powerful marketing tool for the modern dental clinic.17, 18 Regarding accuracy as compared with conventional impressions, opti- cal impressions are equally accurate for individual restorations or three- to four-unit bridges on natural teeth and on implants. Conversely, con- ventional impressions still appear to be the best solution currently for long-span restorations, such as fixed full prostheses on natural teeth and implants (with a higher number of prosthetic abutments).17 Signifi- cant differences in trueness have been found among different optical impressions. For each scanner, the trueness was higher in a partially edentulous model than in a fully edentulous model.19 Conversely, the disadvantages of using optical impressions are the difficulty in detecting deep margins in prepared teeth and in the case of bleeding, the learning curve, and the purchasing and maintenance costs.17 Nowadays, we also have the possibil- ity to superimpose the information related to the teeth and gingivae, received from the intraoral scan, over the bone-related information acquired with CBCT. It is therefore possi- ble to plan the optimal posi- tioning of implants with software to guide the surgery. Planning data is transferred to a surgical template that can be physically fabricated in various ways and with different ma- terials. This guide will help the sur- geon correctly position the implants without needing to raise a flap.18 After obtaining the digital model, we proceed to the preparation of the virtual part through the CAD soft- ware that defines the geometry of an object, while CAM programming directs the fabrication process.20 The CAD/CAM process eliminates cur- rent conventional processes, such as the melting and subsequent manip- ulation of the material after the me- chanical working of the same. Pieces made by the CAD/CAM process have a more precise fit compared with conventional methods for dental prosthetic manufacture.21 The main concern with CAD/CAM restorations lies in the marginal fit. However, nowadays CAD/CAM parts show an adaptation with gaps of only around 40 μ.16, 22, 23 Conclusion The use of new technologies in den- tistry, such as the application of PRF, ozone therapy and intraoral scan- ners, has contributed significantly to the success of rehabilitation with dental implants, reducing the time for implant placement and for their restoration. Editorial note: A list of references can be obtained from the publisher. This article was originally published in CAD/CAM international magazine of digital dentistry, Issue 3/2018. Dr Miguel Stanley Rua Dr. António Loureiro Borges, ed. 5, 1o Andar Arquiparque Miraﬂores 1495-131 Algés, Portugal Phone: +351 21 396 2727 email@example.com
20 DIGITAL DENTISTRY Dental Tribune Middle East & Africa Edition | 2/2019 Revolutionary Technology in Additive Manufacturing – by 3D Systems By 3D Systems NextDent™ 5100 by 3D Systems, a high-speed 3D printer – powered by Figure 4™ technology helps den- tal laboratories and clinics redefine their workflow to achieve improved accuracy, repeatability and produc- tivity with lower total cost of opera- tion. When used in conjunction with the company’s robust portfolio of certified NextDent materials, dental labs and clinics are able to address the broadest range of indications from a single printer available today. This plug-and-play solution inte- grates with the industry’s state-of- the-art intra-oral scanning and soft- ware solutions delivering a much more precise result than available with manual production. The ben- efits of the NextDent 5100 solution extend to the patient – reducing the time required to produce orthodon- tic and prosthodontic devices, and the number of office visits needed to complete treatment. This end-to-end solution combining materials, tech- nology, software and services will help dental labs and clinics bridge from traditional methods to a digital workflow, revolutionizing their busi- ness. “With 3D Systems’ NextDent solu- tion, dental laboratories and clinics are now able to produce dental devic- es at dramatically increased speed- up to 4X faster than other available solutions - while reducing material waste and capital equipment ex- penditure as well as reliance upon milling centres,” said Rik Jacobs, vice president, general manager, dental, 3D Systems. “Benefits also extend to the patient by reducing the time it takes to produce prosthodontics and orthodontics, as well as the number of required office visits.” This new solution is already dem- onstrating its ability to truly revolu- tionize the dental workflow. “The NextDent 5100 is the fastest dental 3D printer I’ve ever seen, with accuracy and precision that result in extremely fine detail,” said Adrienne Slevin, director of education and technology, Dental Arts Laborato- ries (a NextDent 5100 beta test site). “I’ve also found it very simple to use. The 3D Sprint™ software is so robust - it handles objects that none of my other printers will accept. The post- processing is equally simple and straightforward.” Dental Arts Laboratories has been able to achieve print speeds more than 4X faster than comparable printers – completing print runs for some indications in as little in 28 minutes. 3D Systems’ 3D Sprint software, which is bundled with the NextDent 5100, provides Dental Arts Laboratories with a complete CAD optimization and print manage- ment tool, helping to more efficient- ly produce dental devices. The NextDent 5100 is powered by 3D Systems’ proprietary Figure 4™ tech- nology, which facilitates high-speed 3D printing of dental devices and fix- tures. The printer is compatible with industry-leading, intra-oral scan- ning and dental software solutions, delivering more precise results than conventional manual production 3D Printed Denture base using NextDent™ biocompatible material using NextDent™ 5100 AD techniques. This end-to-end digital workflow also provides higher and more predictable uptime, with a significant reduction in risk for the operator. 3D Systems is also providing 18 new NextDent materials for an unprec- edented total of 30 different options. All NextDent materials are biocom- patible and CE-certified to cover a broad range of dental applications for lab managers, dental technicians, dental prosthetic technicians and clinical prosthodontists and ortho- dontists. “As of this week, we’re shipping the NextDent 5100 for Dental. I’m pleased with how it has performed through the testing phases, and that dental labs and clinics are seeing the power of 3D printers redefine digital dentistry,” said Vyomesh Joshi, pres- ident and chief executive officer, 3D Systems. “With the addition of these printers, 3D Systems offers the in- dustry’s widest range of regulatory- approved 3D printing materials and technologies that allow dental labs and clinics of every size to improve their customer service and competi- tiveness with more accurate dental devices, delivered faster than ever before.” For further information, please contact: 3D Middle East, 3D Systems Distributor Suite 3204 Prism Tower, Business Bay, P. O Box 28820, Dubai, UAE Tel: +971 4 443 3853 Email: firstname.lastname@example.org Web: www.3d-me.com Why occlusion matters? By Vivek Gupta, UK Occlusion is the cornerstone of suc- cessful dentistry, however, it also is perhaps the most misunderstood subject in dentistry. Why do restora- tions done with occlusal understand- ing last the test of time, whilst a lack of occlusal understanding causes iat- rogenic damage to patients? 90% of the patients have occlusal disease, so learning the Principles of Occlusion and about Occlusal As- sessments will allow you, as a den- tist, to begin to treat occlusal disease, confidently and competently. Understanding the language of oc- clusion and the schools of thought that exist will allow you to fully in- tegrate the 5 principles of occlusion into your daily dentistry. Knowing the theory of levers will al- low delegates to explain clearly and logically to patients such that con- sent given is informed and patients are educated correctly about occlus- al disease. Allowing them to make informed and legally correct choices, whilst allowing the clinician to prac- tice defensive but correct dentistry. Large VH and HV slides, when to treat and when to refer is funda- mentally important. Understanding how this works and how these can be used to treat patients will reduce treatment or restoration failure. Knowing when to use splint ther- apy, types of splints and duration and protocol of treatment will allow you to provide excellent care for all your patients bringing a whole new area of treatment available for your patients. PURE SIMPLICITY NEW CHIROPRO IMPL ANTOLOGY motor system NEW CHIROPRO PLUS IMPL ANTOLOGY motor system ORAL SURGERY motor system Control your entire implant and oral surgery motors using a single rotary knob. The new Chiropros from Bien-Air Dental have been designed around a single philosophy : simplicity. WWW.BIENAIR.COM VISIT US ! MARCH 12-16, 2019 – COLOGNE, GERMANY – HALL 10.1 STAND H050 J051 Bien-Air Dental SA Länggasse 60 Case postale CH-2500 Bienne 6 Switzerland Tel +41 (0)32 344 64 64 email@example.com www.bienair.com
ZirCAD MT Multi The most esthetic high-strength, multi-translucent1 zirconia All ceramic, all you need. 1 Composed of different material classes www.ivoclarvivadent.com Ivoclar Vivadent AG Bendererstr. 2 | 9494 Schaan | Liechtenstein | Tel. +423 235 35 35 | Fax +423 235 33 60
24 ◊Page 22 DIGITAL DENTISTRT Dental Tribune Middle East & Africa Edition | 2/2019 tern was subsequently secured in the slot of the IPS Multi investment ring base. The position of the sprues was checked with the help of the IPS Sprue Guide (Fig. 11). The shade pro- gression within the crown can be adjusted as required. For example, if the incisal portion should be more pronounced, the Wax Pattern is sim- ply moved downward on the invest- ment ring base (max. 2 mm). The preheating, pressing and divestment steps were carried in the customary way and in line with the instructions of the manufacturer. Finishing The pressed restorations can be ad- justed if desired in order to accentu- ate certain individual characteristics. In the present case, the unglazed restorations were tried in the pa- tient’s mouth before the stains and glaze firing. At this stage, most of the clinically important properties were clearly recognizable: tooth axes, suit- able pressure on the adjacent soft tissue (e.g. papillae and gingival con- tour), harmony of the lip line and in- cisal edges as well as the symmetry of the crowns. The patient was satisfied with the optimised lengthtowidth ratio of the teeth. The main aim now was to reproduce this situation with utmost precision. The inter-occlusal record was sent to the laboratory in order to minimize the work involved in the adjustment of the occlusion. The surface texture of the IPS e.max Press Multi crowns was created with suitable grinding instruments be- fore the glaze firing cycle. The resto- rations were then characterized with IPS Ivocolor stains (copper, white and anthracite) and glazed. The crowns were manually polished to the de- sired brilliant sheen (Fig. 12). Placement The excellent collaboration of the dentist, dental technician and the patient paid off: The restoration was swiftly placed in the practice without having to make any further adjust- ments. The clinical situation which was created on the model and with the help of provisional restorations could be successfully reproduced in the permanent restoration (Fig. 13). The patient and the dental team were highly satisfied with the result. The entire treatment process was straightforward and efficient. Result One month later, the teeth and gums looked beautiful and healthy without any inflammation (Figs 14 and 15). Digital workflows minimize efforts but maximize aesthetics. The possibility of replicating the subgingival contours of the provi- sional crowns allowed a variety of modifications to be made during the treatment process. The IPS e.max Press Multi material itself offers an impressive array of aesthetic prop- erties. If a restoration requires even more individualised characteristics, the incisal area can be built up with IPS e.max Ceram layering materials (cut-back technique). The presented process shows that the traditional press technique combined with CAD/CAM methods offers a wide va- riety of benefits and provides a basis for new and innovative applications. The discovery of further creative uses involving a combination of these two techniques is only a ques- tion of time. Heal Dental Clinic 309, Gangseo hillstate shopping center 242, Gangseo-ro, Gangseo-gu Seoul, South Korea E-mail: firstname.lastname@example.org Fig. 13: IPS e.max Press Multi restorations immediately after placement Fig. 14-15: Result after one month in situ The abutment teeth were separated and the margins and contours were adjusted (Figs 6 to 8). This approach allowed the shape of the provisional crowns to be exactly replicated. We focused on recreating the subgingival contours, which sup- port the oral soft tissue, so that the restorations would not have to be individually adjusted in the dental office. The crowns were milled from a dimensionally stable wax disc. ProArt CAD Wax yellow was used in the present case (Figs 9 and 10). This material is specially designed for use with IPS e.max Press. The smooth surfaces of the wax ensure precision results and high accuracy of fit. The material burns out without leaving any residue. Up to this point, it was possible to reduce the manual work to a minimum. Spruing and pressing In the next step, the wax crowns were reproduced with a pressed ceramic (IPS e.max Press Multi). For the investment procedure, the milled wax crowns were attached to a special prefabricated precision wax component (IPS Multi Wax Pat- tern). At this stage, it is important to make sure that the attachment joint is not too thick and that it is aligned with the labial surface. This helps to accentuate the unique shade gra- dations of the material. The wax restoration attached to the Wax Pat- Reliable planning for an optimal workﬂow By Dentsply Sirona Part of creating an optimal work- flow involves the ability to reliably plan for variables that differ with each patient. 3D imaging gives the clinician the ability to view ana- tomical structures not seen in two- dimensional images. The following case study involving a male patient in need of a restoration shows the advantages of utilising 3D imaging and an integrated digital workflow. Methods In this case, an Orthophos SL 3D from Dentsply Sirona was used for both panoramic and DVT scans. Digital impressions of the patient were taken with a CEREC camera and implant planning took place within the Galileos Implant software. For guid- ed surgery, the team used CEREC Guide 2 milled in-house at their dental laboratory on an inLab MC X5 milling machine. Case Study A 52-year-old male patient pre- sented to our practice with gap in the area of teeth 45-47. He wanted this area restored. We used the Or- thophos SL 3D to take a panoramic scan for planning purposes. The patient opted for a treatment plan involving the insertion of two implants and then an implant- supported bridge. Digital imaging, combining DVT with CEREC optical impressions were used to plan the implant surgery in Galileos Implant software. The software creates an implant proposal as well as enables planning of the alignment of the prosthetic. The ability to plan and perform virtual surgery allowed the team to maximise safety and minimize risk. CEREC Guide 2 was chosen in the treatment plan and then milled in our practice to use during surgery. An additional DVT image was made in the Orthophos SL’s Low Dose Mode as a check post-implantation. Hybrid abutments on ti-base for the final restoration were chosen. Summary Reliable planning makes for an ef- ficient treatment while helping to minimize risk. 3D imaging is an im- portant part of creating a solid plan and the integrated digital workflow offered by using the Orthophos SL along with relevant planning soft- ware saves time for the practitioner and is also efficient for the patient by reducing the number of times he/she has to come to the practice. For more information contact: Dentaply Sirona 21st Floor, The Bay Gate Tower Business Bay, Al Sa’ada Street Dubai, United Arab Emirates Tel.: +971 (0)4 523 0600 Web: www.dentsplysirona.com/en E-mail: MEA-Marketing@dentsplysirona.com Matching of Orthophos SL 3D data with the prosthetic proposal in Gali- leos Implant. Prosthetic alignment of the implant in planning. By means of a low-dose recording, the implant was checked three-di- mensionally.
Mastership Programme Lasers in Dentistry Certiﬁcation Course From Aachen Dental Laser Center & RWTH International Academy - RWTH Aachen University & CAPP Prof. Dr. med. dent. Norbert Gutknecht DDS, MS, PhD Germany Dr. Dimitris Strakas DDS, MSc, PhD Greece Dr. Miguel Rodrigues Martins Priv.-Doz. Dr. rer. medic. DDS, MSc, PhD Portugal Rene Franzen Germany One-year clinical specialisation course for selected wavelengths DUBAI AACHEN Group 7 Registration Open Pathway to German Masters 84 CME & Daily Hands-on Module 1 | 23-26 October 2019 (4 days) | Laser Safety, Laser Devices and Diode Lasers Laser Safety Ofﬁcer course | e-learning | Laser technique (Diode lasers) | High power Diode lasers (clinics) | Scientiﬁc background and clinical indications | Skill training every day of every clinical indication | Patient treatments (demonstrations) Hands on: Pigmentation on soft tissue, gingivectomy and gingivoplasty, frenectomy, ﬁbroma removal, crown lengthening, depigmentation, endodontic procedure- canal irradiation performed on sheep heads | Patient treat- ments (demonstrations) Module 2 | 11-14 March 2020 (4 days) | Module Erbium Lasers Laser Safety Ofﬁcer course | e-learning | Laser technique (Diode lasers) | High power Diode lasers (clinics) | Erbium Lasers (clinics) | Laser technique (Erbium lasers) | Er:YAG and Er,Cr:YSGG | Scientiﬁc background and clinical indications | Skill training every day of every clinical indication | Patient treatments (demonstrations) Hands on: Preparation in enamel and dentine, generation of a retentive surface, canal decontamination, apicectomy, soft-tissue cut with short pulses, soft-tissue cut with long pulses, open curettage, crown lengthening and bone preparation performed on sheep heads. | Patient treatments (demonstrations) Module 3 | 13-16 December 2020 (4 days) | Combined Wavelengths Therapy Concepts & Mastership Exams Laser therapy concepts with the use of 2 diﬀerent wavelengths | Written multiple-choice exam | Oral Exam (presentation of 5 patient treatments cases with diode or Erbium lasers) | Graduation Ceremony, after successful completion of an examination at RWTH Aachen University | 600 hours total workload | Over the complete course duration: case documentation & discussions The programme targets dentists who would like to specialise in certain wavelengths. Over the course of one year, participants are taught fundamental physical and technical knowledge, and how to recognise primary, secondary, and tertiary indications on 12 attendance days split into 3 modules held over 3 educational blocks. This programme concludes with an ofﬁcial certiﬁcate of RWTH Aachen University, and is oﬀered in collaboration with the RWTH Aachen International Academy, the post graduate education wing of the University.. +971 528423659 | email@example.com www.cappmea.com/laser
THE COMPACT MAKES ABIG CHANGE To help any user of air driven handpieces c o n v e r t t o e l e c t r i c a n d e n j o y t h e f u l l b e n e ﬁ t s o f i t s h i g h f u n c t i o n a l i t y. A b i g c h a n g e i n t r e a t m e n t e n v i r o n m e n t i s brou ght with only a minor addition to the current equipment in your off ice. E L ECT R IC M IC ROMOTO R U P G R A D I NG SYS T EM *NLZ E with Endo Function
34 DIGITAL DENTISTRY Dental Tribune Middle East & Africa Edition | 2/2019 VISIT SINTEREX AT 14TH CAD/CAM & DIGITAL DENTISTRY EXHIBITION DUBAI, UAE 12-13 APRIL 2019 DHA successfully saves patients jaw using 3D printing Experts from Dubai Health Authority, PHC Dental Center, and Rashid Hospital have combined with 3D printing healthcare startup Sinterex, to save the jaw of a patient who had an aggressive tumor. By Sinterex DUBAI, UAE: Experts from Dubai Health Authority, PHC Dental Cent- er, and Rashid Hospital have com- bined with 3D printing healthcare startup Sinterex, to save the jaw of AD =C4A=0C8>=0;4=C0;G7818C8>=5A820 4TH INTERNATIONAL TRADE SHOW FOR THE DENTAL SECTOR IN AFRICA HYATT REGENCY HOTEL IN COOPERATION WITH MORROCAN ASSOCIATION OF ORO-DENTAL PREVENTION www.idea-africa.com a patient who had an aggressive tu- mor. The patient, a 17 year old girl in high school, was admitted to hospital af- ter discovering she had a large, fast growing tumor of the right jaw. Dr Khaled Ghandour, Maxilofacial Sur- geon at DHA, said that the patient was diagnosed with Ossifying Fibro- ma, a particularly aggressive form of tumor, which meant that the right side of the jaw had to be removed. It was at this stage that Sinterex be- came involved. Sinterex is a UAE based start-up specializing in cus- tomized 3D printed healthcare products. Managing Director, Julian Callanan, explained that given the aesthetic implications and complex- ity of the case, it was critical to use digital planning and 3D printing to create a patient specific solution. The workflow started with the pa- tients CT scan, which was segmented and converted into a 3D printed physical model. This model allowed Dr Khalid Ghandour, and his team of surgeons, to visually inspect the patient’s situation and to develop a treatment plan. After finalizing the treatment plan, Sinterex 3D printed a Surgical Guide, which was fitted to the patient in the operating theatre to ensure that the surgeons drilling, and cutting are guided with preci- sion. Finally, a patient specific im- plant was 3D printed in bio-compati- ble medical grade Titanium. Dr Khaled Ghandour stressed the importance of utilizing 3D printing in medical care by saying; In maxil- lofacial surgery we are working in an area where both aesthetics and func- tion are important and operating conditions challenging. 3D printing models helps us better visualize the patient’s situation, whilst 3D print- ing Surgical Guides and Patient Spe- cific Implants allows us to translate plans into reality. Dr Mohammad Al Redha, Director of the Department of Organiza- tional Transformation at the DHA said that that this is just one further example of how the DHA has suc- cessfully used 3D printing. Other recent examples include 3D printing a prosthetic leg, removing a cancer- ous growth from a patient’s kidney referencing a 3D model, and saving the life of a patient suffering with cerebral aneurysm. Dr Al Redha said that the DHA is planning to further utilize 3D print- ing in medical care in line with the Dubai 3D printing strategy – a unique global initiative that aims to exploit technology for the service of humanity and promote the status of the UAE and Dubai as a leading hub of 3D printing technology by 2020. For further information, please contact: Sinterex Jebel Ali Industrial Area Tel: +971 48 855 759 E-mail: firstname.lastname@example.org
Dental Tribune Middle East & Africa Edition | 2/2019 INTERVIEW 35 LOS 1965 Interview: "Motivation and team work were the main reasons for the success and continuity of the LOS over the years." By Kinga Mollov, DTMEA The Lebanese Orthodontic Society (LOS) is one of the oldest dental societies in the Mid- dle East. Kinga Mollov from Dental Tribune Middle East & Africa had the pleasure to in- terview Dr Mona Sayegh Ghoussoub, Presi- dent of the Lebanese Orthodontic Society. Dr Mona, could you please brieﬂy intro- duce LOS and what the Society does? Founded in 1965 in Beirut, Lebanon, the Leba- nese Orthodontic Society (LOS) is one of the oldest dental scientific societies in the Middle East. Four orthodontists were instrumental in its conception: Drs. Pierre Rizkallah, Edgard Debbaneh, Frédéric Maalouf and Alexandre Khoury. Today, the LOS is a member of the Arab Or- thodontic Society, a corresponding member of the European Federation of Orthodontics and an affiliate organisation of the WFO. It has currently 250 affiliated members who are orthodontic specialists and practice ortho- dontics exclusively. Moreover, it contributes actively to the development and progress of orthodontics in Lebanon through the or- ganization of one main meeting per year, as well as many seminars. Since 1993, several renowned orthodontists have participated in LOS meetings and seminars, including Drs. Robert Ricketts, Roberto Justus, Athanasios Athanasiou, Ravindra Nanda, in addition to many others. Working closely with the Lebanese universi- ties, the LOS supports the development of the specialty in Lebanon by furthering the continuing-education of its members and by encouraging the development of scientific re- search in orthodontics. In October 2001, the LOS hosted the 5th Arab Orthodontic Meet- ing in Beirut, during which the first directory of Arab orthodontists was released. The LOS also hosted the first meeting of French-speak- ing orthodontists in Beirut in February 2005. Most recently, Beirut was the site of the 11th Arab Orthodontic Meeting and 12th Lebanese Orthodontic Congress in November 2013. In 2016, the Golden Jubilee of the LOS was cel- ebrated during the 3rd Francophone Meet- ing CIFO (Collège Inter-Universitaire Franco- phone en Orthodontie) in Beirut. The LOS is active since 1965. Could you please tell us how far has the Society come since then? Motivation and team work were the main reasons for the success and continuity of the LOS over the years. A few motivated and experienced orthodontists instigated the So- ciety at the start with the ambition of better structuring the profession and keeping the orthodontists informed on latest advance- ments and techniques in the orthodontic field. Then it was leaded for many years by an orthodontist of talent Professor Pierre Riz- kallah who braved all difficulties to maintain the subsistence of this institution. He was organising Scientific Meetings and seminars regularly inviting international and local speakers. The goal of the succeding LOS presidents was to keep on with the progress initiated and build more regional and international con- nections with other dental and orthodontic societies. The LOS participation in lots of in- ternational events all over the world as well as organising many conventions in Lebanon helped in establishing good relationships Dr Mona Sayegh Ghoussoub, President of the Lebanese Orthodontic Society (LOS) with other orthodontists and dental profes- sionals at the scientific and human levels. Dr Mona, you have joined the Lebanese Orthodontic Society as President in 2018. Could you please share with us your expe- rience so far? The experience has been rewarding and worthy. My participation as a LOS member at the beginning, then part of the executive board and chair of the scientific committee later helped me greatly in progressing as LOS President with a background at the scientific, logistic and relational aspects. Since the start, the objectives were well-defined and ap- proved by the newly elected board and com- mittees involved in the good administration of the Society. Motivating orthodontists to subscribe to the LOS was one of the main goals to allow inter- action and to keep them within the educa- tional path. Interdisciplinary seminars with eminent speakers are organised on regular basis conferring different topics in relation with orthodontics. Working hand in hand with other orthodon- tic Societies such as the Tunisian, the ATREO “Association Tunisienne de recherche et d’études en orthodontie”, in two joint Meet- ings was successful and thriving. The first one took place in June 21-23, 2019 in Beirut and the second in December 14-16, 2019 in Tunis where colleagues shared their knowledge and consolidated friendships. In February 21-24, 2019, the 13th Saudi Arab Society Meeting was held jointly with the 14th Arab Orthodontic Society Conference in Jeddah and was at a high international level. All Arab Orthodontic Societies’ Presidents including Lebanon were present to exchange experience and coordinate together. It is important to emphasise that all previous and upcoming LOS achievements are owed to the team-work and efforts made by the preceding Presidents and Committees; and as the American Author Helen Keller quoted: “Alone we can do little; together we can do so much”. What was the main goal you would like to achieve by the end of your presidency when you joined LOS? In fact, while progressing in the work at the LOS, not only one but many fundamental goals seemed to be of major importance. If I must choose one, it would be to place the LOS in a leading and front position internationally by enhancing and supporting scientific research and publications. LOS can contribute actively to connect Lebanese or- thodontists with other orthodontic organisations and institutions to at- tain this aim. The LOS is annually organising many events, could you give us more information about the up- coming one? The 17th LOS Annual Meeting en- titled "Overcoming Challenges in Orthodontics" will take place in June 20-22, 2019- Beirut, in addition to further programmed events. International distinguished speak- ers will participate at this event to share their knowledge and experi- ence with the Lebanese orthodon- tists. As this meeting is planned to be of a high scientific level, not only Lebanese but also orthodontists from all nationalities are invited to join in order to combine efforts and plan for future collaborations. All information concerning LOS ac- tivities are regularly displayed and updated in the LOS website (www. leborthosoc.com). Thank you for the interview and time Dr Mona. Looking forward to welcoming you in Dubai, 12-13 April 2019 for the 14th CAD/CAM & Digi- tal Dentistry Conference. AD www.idem-singapore.com BOOK YOUR SPACE NOW THE LEADING DENTAL EXHIBITION AND CONFERENCE IN ASIA PACIFIC MEETING CONFERENCE EXHIBITION 24 - 26 April 2020 Suntec Singapore Over 500 Exhibitors from 41 Countries 13 National Pavilions Network with close to 9,000 Attendees World Class Conference Programme & Workshop Sessions SECURE EARLY BIRD RATES FOR YOUR EXHIBITION SPACE! Endorsed by Supported by Held in Organised by Sales (International) Koelnmesse Pte Ltd Mr. Aaron Ann T: +65 6500 6725 E: email@example.com Singapore Dental Association
From British Academy of Restorative Dentistry DUBAI 2019-2021 Prof. Paul Tipton,UK Specialist in Prosthodontics President, British Academy of Restorative Dentistry Prof. Edward Lynch, UK The University of Warick, Coventry Prof. Göran Urde, Sweden Director Futurum Clinic PhD, Lond, MA, BDentSc, TCD, FDSRCSEd, FIADFE, FDSRCSLond, FASDA, FACD Program Director P.G Education Dept. of Materials Sci. & Tech. Prof. James Prichard, UK BDS (ULond), MSc(ULond), LDSRCS (Eng), MFGDP (UK) FIADFE (USA) Dr. Malcolm Riley, UK BDS (Lon), LDS RCS(Lon), FDS RCS(Lon), MRD(Ed), FDS RCS(Ed) Dr. Matthew Holyoak, UK, BDS, Dip Rest Dent (RCS Eng), MSc (Rest Dent) Dr. Timothy Eldridge, UK BDS Birm Clinical Director myFACE Dr. Adam Toft, UK BSc (Hons), BDS (Hons), MFGDP (UK), MMedSci (Rest Dent), Dip Aesth (BARD) FBARD PGCertEd (Sheﬃeld) Dr. Ash Rayeral, UK BDS MFGDP(UK) MSc (Aesthetic and Restorative Dentistry) Dr. Adam Nulty, UK BChD MJDF RCS Eng PGCert MSc (Dist.) MAcadMEd Group 5 Pathway to UK 210 CME & Daily Registration Open Masters Hands-on Certificate | 4 Modules | 15 Days Module 1 | 19-21 September 2019 | Prof. Paul Tipton & Dr. Adam Toft & Dr. Ashish Rayarel Treatment Planning in Advanced Restorative Dentistry | The Principles of Occlusion in Advanced Restorative Dentistry | Tooth Preparation in Advanced Restorative Dentistry Module 2 | 20-23 November 2019 | Prof. Paul Tipton & Dr. Matthew Holyoak & Dr. Adam Toft & Dr. Ashish Rayarel Minimally Invasive Veneer Preparations | Master the Art of Composites Part 1 - Adhesion Composites & Anterior Composite Restorations | Master the Art of Composites Part 2 - Composite Veneers | Master the Art Composites Part 3 - Posterior Composites Module 3 | 19-22 February 2020 | Prof. Paul Tipton & Prof. James Prichard & Dr. Adam Toft & Dr. Ashish Rayarel Enhance Your Expertise in Endo Part 1 | Enhance Your Expertise in Endo Part 2 | Occlusal Examination | Emax & Zirconia Anterior & Posterior Restorations Module 4 | 08-11 April 2020 | Prof. Paul Tipton & Dr. Malcolm Riley & Dr. Adam Toft & Dr. Ashish Rayarel Bridge Design | Aesthetic Perio Connective Tissue Grafting | Aesthetic Perio Crown Lengthening | Modern Post and Core Techniques Diploma | 4 Modules | 15 Days Module 5 | September 2020 | Prof. Paul Tipton & Dr. Adam Toft & Dr. Ashish Rayeral Bridge Preparation Techniques | Articulator selection in Restorative Dentistry | Porcelain Inlays & Onlays | Veneer Cementation Techniques Practical Module 6 | November 2020 | Prof. Paul Tipton & Mr. Gary Jenkinson & Dr. Adam Toft The Art & Science of Aesthetic Dentistry Part 1 & Anterior Diagnostic Waxing | The Art & Science of Aesthetic Dentistry Part 2 & Posterior Diagnostic Waxing | TMD, It's Diagnosis and Treatment | Adhesive Bridge Preparation Techniques Module 7 | February 2021 | Prof. Paul Tipton & Prof. Edward Lynch & Dr. Adam Nulty & Dr. Adam Toft & Dr. Ashish Rayeral Minimally Invasive Dentistry | Digital Dentistry Workﬂow & Photography Principles, Hardware and Storage Part 1 & 2 Module 8 | May 2021 | Prof. Göran Urde & Dr. Timothy Eldridge & Dr. Adam Toft & Dr. Ashish Rayeral Implant Prosthodontics Part 1 & 2 | Botox & Dermal Fillers – A Dental Facial Aesthetics Part 1 & 2
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N L Y A L S O N O F E S SI O R T A L P D E N PUBLISHED IN DUBAI www.dental-tribune.me March-April 2019 | No. 2, Vol. 9 Minimally invasive root canal shaping – A new protocol By Dr Bogdan Moldoveanu, Roma- nia Minimally invasive—the most well- known oxymoron in dentistry—is probably nowadaysconsidered the new standard of care in almost every field of dental medicine, but more so in endodontics. Despite improved oral and dental health, the demand for endodontic treatment and resto- rations remains high among individ- uals with relatively complete denti- tion and dental awareness.1 The need for adequate endodontic treatment is most likely one of the driving forces behind all the improvements that have reached practitioners in recent years. The use of nickel-tita- nium (NiTi) rotary files in root canal preparation is one of those improve- ments and has provided a reduction in the frequency of procedural errors and the time required for chemome- chanical preparation in relation to manual files.2 Shaping is considered a crucial phase in root canal therapy because it not only is aimed at removing remain- ing pulp tissue, microorganisms and debris, but should also create the preconditions for effective irriga- tion and obturation.1, 3, 4 These tasks should be accomplished without altering the diameter and position of the apical foramen or excessively Fig. 1 Fig. 2 weakening the root in any part. New instruments have been introduced every year, each claiming to be bet- ter than the previous one and hav- ing the ability to provide a better outcome. Regardless of any com- mercial interests, with regard to root canal shaping, from the aspect of the success of endodontic treatment, it is very important to maintain the original form of the canal as far as possible while the root canal is being gradually enlarged from the apical to the coronal region.3 The need for successful endodontics has probably set the stage for a new generation of rotary files, made with heat-treated NiTi. The various ther- momechanical procedures and the improvement in composition of the alloy that is used in manufacturing NiTi files are aimed at improving the flexibility of NiTi files.5–7 Improved flexibility of NiTi files would mini- mise the intracanal irregularities, such as canal transportation, and would ensure an increase in the suc- cess of root canal therapy. One of the most well-known instru- ments when it comes to heat-treated rotary files are the HyFlex CM files (COLTENE). The controlled memory (CM) wire made with a thermally treated NiTi alloy, owing to the austenite/martensite transforma- tion, has a stable martensitic mi- crostructure at body temperature.8 Therefore, the structure of HyFlex CM enables significant fatigue resist- ance, ease of bending and the ability to return to its original shape when heated above the transformation temperature.9 Recently, COLTENE has introduced a new type of file, the 20/05 EDM (the preparation file), which comes as a muchneeded addition to the already existing EDM shaping system. Hy- Flex EDM instruments (COLTENE) are manufactured using the tech- nique of electrical discharge ma- chining and are the first endodontic files to be made with this method.10 Electrical discharge machining can be used in manufacturing all types of conductive materials (e.g. metals, alloys, graphite and ceramics) of any hardness at high precision levels.11 This manufacturing process uses spark erosion to harden the surface of the NiTi file, resulting in superior fracture resistance and improved ÿPage A2 Fig. 3 Fig. 4 Fig. 5 Fig. 6 Fig. 7 Fig. 8
A2 ◊Page A1 ENDO TRIBUNE Dental Tribune Middle East & Africa Edition | 2/2019 Fig. 9 Fig. 10 Fig. 11 Fig. 12 Fig. 13 Fig. 14 Fig. 15 Fig. 16 cutting efficiency. HyFlex EDM NiTi files are manufactured using CM al- loy technology just like the HyFlex CM NiTi files. HyFlex EDM 25 has a taper that changes throughout the file shaft and a 0.25 mm apical di- ameter. Throughout the file shaft, HyFlex EDM 25 has three different cross sections: quadratic in the apical third, trapezoidal in the middle third and almost triangular in the coronal third.12 The other HyFlex EDM files (10/05 and 20/05) have a single taper of 0.05 throughout the working part. The purpose of this case report is to present a new protocol that uses only three files in order to reach an optimum result, sacrificing a mini- mal amount of dental structure. One of the most important things that a clinician can focus on is be- ing open-minded to question the paradigms of our profession. In time, some paradigms can become a false “standard of care” to those who blindly follow statements that are not supported by valid information. Adherence to some ideas promoted in the virtual or actual professional environment may ruin the balance of accurate knowledge, leading both clinicians and researchers to un- derstand things solely from their perspective, for it seems evident to them that there is no other way to be. This is what we have come to know as the settlement of the paradigm.14 One of the most well-known para- digms in endodontics concerns the instrumentation of curved root ca- nals, for which it is believed that the use of a #25 file in the apical portion fulfils all of the cleaning and shap- ing objectives of root canal therapy. The idea behind this theory is mostly centred around what can happen if one over-instruments the root ca- nal. Failures such as deviations, per- forations and zipping may have a higher rate of occurrence when one enlarges the apical diameter beyond a #25 file.15–17 However, when one is treating a tooth exhibiting signs and symptoms of periapical periodon- titis, further enlargement by hand files might be required, since it ap- pears that the minimum instrumen- tation size needed for penetration of irrigants to the apical third of the root canal is a #30 file.18 Case report The patient who is the focus of our discussion came to our office report- ing intense pain in response to hot and cold stimuli in the left maxilla (Fig. 1). He described the pain as be- ing spontaneous at times and that in order for it to subside administration of anti-inflammatory medication was required. Upon examination, an accurate diagnosis was established of symptomatic irreversible pulpitis affecting tooth #27. The patient had had the tooth prepared for a crown sometime in the last 60 days (Fig. 2), but unfortunately the treatment was not completed for unknown reasons. Caries seemed to be absent; there- fore, a minimally invasive approach was planned. Most likely, the pathol- ogy was caused by either trauma or an iatrogenic event. After isolation of the tooth (Fig. 3), an access cavity was created using high- speed diamond burs and ultrasonic tips (Figs. 4–8). Pre-flaring in the coronal and middle thirds was done with the HyFlex EDM 25 instrument (at a torque of 4 Ncm and a speed of 500 rpm). It is a proven fact that pre- flaring allows an increase in the in- strument size that binds in the root canal, irrespective of the discrepancy between the size of the file and ana- tomical diameter.19–21 Afterwards, ca- nal scouting was performed using an ISO size 10 stainless-steel K-file up to working length. Upon estab- lishing the working length, with the help of an apex locator, the 10/05 EDM file (glide path file) was used up to working length (at a torque of 3 Ncm and a speed of 300 rpm). Subse- quently before finishing the prepara- tion with the 25 EDM file, the 20/05 EDM (preparation file) was used to full working length (at a torque of 3 Ncm and a speed of 400 rpm). At this point, the working length was con- firmed again with an ISO size 20 NiTi K-file. Root canal shaping was com- pleted with the 25 EDM file, which was inserted to full working length (at a torque of 3 Ncm and a speed of 400 rpm; Figs. 9–12). This recommended shaping proto- col also has the benefit of extruding less debris outside the root canal, thus improving the patient’s qual- ity of life after the completion of the therapy. Dentinal and pulp tissue debris, microorganisms and irrigat- ing solutions may extrude into per- iradicular tissue during the prepa- ration of root canals,22 thus causing complications such as postoperative pain, inflammation/infection and flare-up, and possibly delaying the healing process.23 The instruments in such an order are also very well suited for maintain- ing the anatomy of the root canals. The HyFlex EDM 25 file determines slightly less transportation at every level and in most cases stays a little more centred compared with other instruments available.24 Using the HyFlex EDM instruments as opposed to the HyFlex CM ones is no random choice. HyFlex CM files are manufactured via a grinding pro- cedure. Grinding procedures during the production of NiTi files cause the formation of irregular areas, such as pits, fissures and metal folds.25 Being subjected to huge flexural and tor- sional forces, the instruments need to be resistant and the surface of the file must not change throughout the therapy. According to a study by Uslu et al., the surface of used HyFlex EDM files was found to be statisti- cally significantly rougher than that of used HyFlex CM files.25 The surface properties of HyFlex EDM files, when compared with those of HyFlex CM files, were better retained after use for severely curved root canal prepa- ration. The sequence proposed in the pre- sent article is easy to use, easy to learn and highly versatile. One may adapt it to different cases, be it a se- verely curved mesial root of a man- dibular molar or a highly calcified canal in a mandibular central incisor. Following several easy steps, but re- specting the order in which the files must be used, success is just around the corner. After chemomechanical treatment, the root canals were filled using a single-cone filling technique (ROEKO Guttapercha Points and ROEKO Gut- taFlow bioseal, both COLTENE), and the access cavity was sealed using composite materials (Figs. 12–16). Conclusion Living in a world full of endodontic opportunities, it is important that the clinician use all the means availa- ble to provide the best quality of care for patients. Hopefully by applying this particular sequence in root canal therapy, the clinician can achieve the task more easily and in a much safer manner. Editorial note: A list of references is available from the publisher. This article was originally published in roots – international magazine of endodontics, Issue 3/2018. Dr Bogdan Moldoveanu He gained his DMD from the Iuliu Hațieganu University of Medicine and Pharmacy in Cluj-Napoca in Romania and then a Master in Clinical and Surgical Microendodontics from the University of Turin. He is a visiting professor at the Uni- versity of Turin and at the Iuliu Hațieganu University. He practises in Cluj-Napoca, focusing mainly on surgical and non-sur- gical micro-endodontics. Dr Moldoveanu is the CEO of the educa- tional platform Endodonție Cu Pasiune [endodontics with passion] and an opin- ion leader for COLTENE. He is a certiﬁed member of the Italian Academy of Endo- dontics and of the European Society of En- dodontics, and an international specialist member of the American Association of Endodontists. He can be contacted at email@example.com.
Prof. sr. Ivipa Anip, Phs, ssS Croatia sr. Franpespa Ideo, ssS Italy sr. Pierre Maphtou, ssS, MS, Phs, FICs ProTaper® designer Franpe Dr. Vaibhav Garg, MDS Dr. Vaibhav Garg, MDS Dr. Vaibhav Garg, MDS Dr. Vaibhav Garg, MDS Dr. Vaibhav Garg, MDS Dr. Vaibhav Garg, MDS Dr. Vaibhav Garg, MDS Dr. Vaibhav Garg, MDS Dr. Vaibhav Garg, MDS Dr. Vaibhav Garg, MDS Dr. Vaibhav Garg, MDS Dr. Vaibhav Garg, MDS Dr. Vaibhav Garg, MDS Dr. Vaibhav Garg, MDS Dr. Vaibhav Garg, MDS Dr. Vaibhav Garg, MDS Dr. Vaibhav Garg, MDS Dr. Vaibhav Garg, MDS Dr. Vaibhav Garg, MDS Dr. Vaibhav Garg, MDS Dr. Vaibhav Garg, MDS India India India India India India India sr. Clifford Ruddle, ssS, FACs, FICs ProTaper® designer USA Dr. Hadi Alamri, BDS, MSC, F.R.C.D.(C) Dr. Hadi Alamri, BDS, MSC, F.R.C.D.(C) Dr. Hadi Alamri, BDS, MSC, F.R.C.D.(C) Dr. Hadi Alamri, BDS, MSC, F.R.C.D.(C) Dr. Hadi Alamri, BDS, MSC, F.R.C.D.(C) Dr. Hadi Alamri, BDS, MSC, F.R.C.D.(C) Dr. Hadi Alamri, BDS, MSC, F.R.C.D.(C) Dr. Hadi Alamri, BDS, MSC, F.R.C.D.(C) Dr. Hadi Alamri, BDS, MSC, F.R.C.D.(C) Dr. Hadi Alamri, BDS, MSC, F.R.C.D.(C) Dr. Hadi Alamri, BDS, MSC, F.R.C.D.(C) Dr. Hadi Alamri, BDS, MSC, F.R.C.D.(C) Dr. Hadi Alamri, BDS, MSC, F.R.C.D.(C) Dr. Hadi Alamri, BDS, MSC, F.R.C.D.(C) Dr. Hadi Alamri, BDS, MSC, F.R.C.D.(C) Dr. Hadi Alamri, BDS, MSC, F.R.C.D.(C) Dr. Hadi Alamri, BDS, MSC, F.R.C.D.(C) Dr. Hadi Alamri, BDS, MSC, F.R.C.D.(C) Dr. Hadi Alamri, BDS, MSC, F.R.C.D.(C) Dr. Hadi Alamri, BDS, MSC, F.R.C.D.(C) Dr. Hadi Alamri, BDS, MSC, F.R.C.D.(C) Dr. Hadi Alamri, BDS, MSC, F.R.C.D.(C) Dr. Hadi Alamri, BDS, MSC, F.R.C.D.(C) Dr. Hadi Alamri, BDS, MSC, F.R.C.D.(C) Dr. Hadi Alamri, BDS, MSC, F.R.C.D.(C) Dr. Hadi Alamri, BDS, MSC, F.R.C.D.(C) Dr. Hadi Alamri, BDS, MSC, F.R.C.D.(C) Dr. Hadi Alamri, BDS, MSC, F.R.C.D.(C) Dr. Hadi Alamri, BDS, MSC, F.R.C.D.(C) Dr. Hadi Alamri, BDS, MSC, F.R.C.D.(C) Dr. Hadi Alamri, BDS, MSC, F.R.C.D.(C) Dr. Hadi Alamri, BDS, MSC, F.R.C.D.(C) Dr. Hadi Alamri, BDS, MSC, F.R.C.D.(C) Dr. Hadi Alamri, BDS, MSC, F.R.C.D.(C) Dr. Hadi Alamri, BDS, MSC, F.R.C.D.(C) Saudi Arabia Saudi Arabia Saudi Arabia Saudi Arabia Saudi Arabia Saudi Arabia Saudi Arabia Saudi Arabia Saudi Arabia Saudi Arabia Saudi Arabia Saudi Arabia Saudi Arabia Saudi Arabia Dr. Alla Dobryshyna Dr. Alla Dobryshyna Dr. Alla Dobryshyna Dr. Alla Dobryshyna Dr. Alla Dobryshyna Dr. Alla Dobryshyna Dr. Alla Dobryshyna Dr. Alla Dobryshyna Dr. Alla Dobryshyna Dr. Alla Dobryshyna Dr. Alla Dobryshyna Dr. Alla Dobryshyna Dr. Alla Dobryshyna Dr. Alla Dobryshyna Dr. Alla Dobryshyna Dr. Alla Dobryshyna Dr. Alla Dobryshyna Dr. Alla Dobryshyna Russia Russia Russia Russia Russia Russia Russia Russia sr. Filippo Santarpangelo, ssS Italy sr. Erip Matlakala, BsS, sip Odont. South Afripa sr. Beth samas, ssS, MS USA sr. John West, ssS, MSs ProTaper® designer USA sr. Ivan Herrera, MS Mexipo ProTaper® Behind every case is a story of passion “For more than 20 years, ProTaper® instruments have been part of my daily practice at university and in my private practice. They have improved and accelerated my work and increased the number of satisfied patients. For me, there is only ProTaper.®” Prof. Dr. Ivica Anic, Croatia Millions of ProTaper® files sold in 158 countries, used by thousands of clinicians, taught in hundreds of universities worldwide. Proven innovation that’s still shaping the future of endodontics. Share your ProTaper® story with #ProTaperStories and visit dentsplysirona.com/endodontics
B2 ◊Page B1 LAB TRIBUNE Dental Tribune Middle East & Africa Edition | 2/2019 Fig: 6. The denture base was injection moulded and thenreduced to create space for creating soft tissue customisations. Figs: 7 and 8. The completed upper denture distinguishes itself through its characterizations with gingival composite and phonetically aligned teeth. Fig: 9. Model cast denture in the lower jaw with an open periodontal design (self-cleansing). Figs: 10. Completed dentures on the upper and lower jaw models. Figs: 11. Upper and lower dentures in situ. The customized pink and white esthetic effects make the dentures look very natural – the teeth look as though they have grown from the gums like natural teeth. Figs: 12. Upper and lower dentures in situ. The customized pink and white esthetic effects make the dentures look very natural – the teeth look as though they have grown from the gums like natural teeth. Figs: 13 and 14. View of the lips with inserted dentures in function. tures are locked into place in the mouth with the help of six clasps. If the patient should lose another tooth, the denture can be easily ex- tended. Special care was taken to en- sure that the model cast framework featured an open periodontal design to facilitate self-cleansing. The SR IvoBase® system was used for transferring the maxillary wax- up into resin – a system that cou- ples efficiency with reliability. The injection procedure offsets the chemical shrinkage of the resin dur- ing polymerization. High-strength PMMA-based IvoBase was used for the manufacture of the denture base. The waxed-up dentures were invested and the sprues attached. Af- ter the moulds had been cast and the wax boiled out from the plaster, the flask and the denture teeth were pre- pared for the application of the den- ture base material with the injection moulding technique. The predosed denture base material was mixed and filled into the injector together with the flask. The appropriate pro- gram was selected and the injection process started. The accuracy of fit on the plaster model was ideal on the first try; reworking was minimal. A try-in of the setup in the oral cavity helped to verify the arrangement of the anterior teeth established in wax stage by stage. The patient was able to speak and laugh without any dif- ficulty. She was pleased with her new set of teeth already at this stage. Customising the denture base The denture base was reduced – similar to a cut-back – for individual veneering to make the dentures look as discreet and natural-looking as possible (Fig. 6). The soft tissue (pink) aesthetics of the denture base could now be designed with a vari- ety of shades to resemble the natural gums. With its comprehensive range of gingiva shades, the light-curing SR Nexco® lab composite is well suited for reproducing soft tissue character- istics. The material is easy to process due to its exceptional properties. It is optimally matched to the IvoBase denture base materials. Generally, key anatomical features should be borne in mind when char- acterizing soft tissue parts to achieve a lifelike reproduction. For instance, keratinized gingiva has a light pink colour because less blood normally flows through it. By contrast, the mucogingival areas receive a far larg- er supply of blood (dark red) and are interspersed with fine blood vessels. Given the versatile range of gingiva shades, SR Nexco offers abundant possibilities for creating customised characterizations in these cases. The interplay of convex and concave surfaces in the area of the alveoli Figs: 15 and 16. The patient with her dentures. New quality of life and stability and subtle stippling effects lend three-dimensionality and depth to the gingiva and these characteristics were reproduced with the help of the paste-like materials. Although they looked already very natural, the anterior teeth were additionally slightly customised using SR Nexco – a step that in this case was motivated by the high aesthetic ambitions of the dental technician (who, just to remind you, is the grandson of the patient). Step by step, the complete upper denture was given a natural look with the help of the light-curing lab composites. Final polymeriza- tion was followed by mechanical polishing (Figs 7 and 8). The model cast denture for the lower jaw was also completed (Figs 9 and 10). The result The patient was impressed with her new upper and lower dentures right away. Once inserted, their natural and highly aesthetic effect became even more apparent (Figs 11 and 12). This effect can be attributed, among other things, to the micro- and mac- ro-texture of the anterior teeth and the vibrant interplay of shades be- tween the teeth and gingiva. The har- monious interaction between the white and pink aesthetics is impres- sive. With the dentures in situ, the functional, aesthetic and phonetic parameters were again verified (Figs 13 and 14). The preliminary work was worth it. The dentures met all the re- quirements. The patient was happy and relieved that her grandson had mastered the double challenge so well. In her own words, she discovered a whole new zest for life (Figs 15 and 16). Her tooth replacements offer her a much more satisfying situation than her own “old” teeth did in the past few years. Not only is she able to speak and eat again without impedi- ment but she can also laugh again with all her heart. She has received positive feedback from her circle of friends and acquaintances and that has encouraged her even more. My grandma’s quality of life has im- proved considerably and she feels much more positive about life. She is now interested in meeting up with friends again and become involved in the social life around her. Summary Processing technologies that enable restorative treatments customised to the needs of the individual pa- tient are increasingly becoming es- tablished in complete denture pros- thetics. For instance, digital methods allow the fabrication of solid“basic” dentures using relatively little ef- fort. Alternatively, these basic appli- cations can be supplemented with high-quality materials combined with – as cherry on top – a manual layering technique (gingiva) to cre- ate highly aesthetic results. Irrespec- tive of economic aspects, the basic functional and static parameters always remain the same. Every com- plete denture ought to restore full functionality. Sound knowledge and experience in complete denture prosthetics provide the basis for achieving this. Erwin Eitler, Dental Technician Zahnmanufaktur Zimmermann und Maeder AG Hirschengraben 2 3011 Bern, Switzerland www.zmdental.ch For further information, please contact: Ivoclar Vivadent AG Bendererstrasse 2 FL-9494 Schaan Web: www.ivoclarvivadent.com
B4 LAB TRIBUNE Dental Tribune Middle East & Africa Edition | 2/2019 Driving innovation forward For more information about Dentsply Sirona Lab portfolio please contact your local representative Dentsply Sirona 21st Floor, The Bay Gate Tower Business Bay, Al Sa’ada Street Dubai, United Arab Emirates Tel.: +971 (0)4 523 0600 Web: www.dentsplysirona.com/en E-mail: MEA-Marketing@dentsplysirona.com single surrounding detail, which includes being completely recep- tive and having a comprehensive, up-to-date understanding of our production, quality assurance, prod- uct management, and even logistic teams. In R&D you need constant cu- riosity, great communication skills and inventive thinking. How does science, clinical studies, and research all ﬁ t under the Dent- sply Sirona Lab name? Can you pro- vide a little background on what goes into testing a product before it actually goes into development, and ultimately goes to market? Due to the fact we are working in the medical devices market, we fulfi ll a great number of demands for testing and design control processes. For ex- ample, when developing a new ma- terial for dentistry we need to look at the biocompatibility as well as risk management starting from the production process, to the user, all the way to the end result — our pa- tients. Besides proving and surpass- ing all requirements from applicable standards, we also want to know how our customers accept the workfl ow of the product. Before we launch, we take a close look at how it fi ts into the actual workfl ow of real-life den- tal laboratories, and we then start additional vigorous clinical testing after the launch as well. We include our customers quite early on in this process to allow us to react to their outcomes and feedback, and then be able to improve the product within the development timeline. concerns and ongoing daily chal- lenges. What makes Dentsply Sirona unique is that the entire workfl ow is shown, and it can be linked to other work- fl ows and combined into an inte- grated solution. When it comes to the prosthetic treatment of an implant using an abutment and full ceramic crown, for example, Dentsply Sirona Lab is the right partner for laboratories. But the treatment workfl ow as a whole starts from the earlier stage of diagnostics and the implantologi- cal treatment, and ends with the res- toration fi nally being cemented or screwed in place. For this purpose, Dentsply Sirona and its Imaging, Implants, and Restorative business create integrated workfl ows for both dentists and dental laboratories. One of your roles within Dentsply Sirona is to constantly provide ma- terial innovations that expand lab offerings to their dentist clients, while improving their workﬂ ow. How do you gather the informa- tion needed to improve upon these offerings? We use groups of our core custom- ers, labs and dentists. Sometimes the most effective feedback comes from our labs and dentists who are eve- ryday partners because they know their ideal workfl ow routine, and are able to communicate their emerging Can you tell us a little about Celtra® Press, the newest material for labo- ratories? What was the industry missing (doctor, labs, and patients) that this material now offers? Celtra® Press has signifi cantly im- proved the workfl ow in the lab by being easier to press (with excel- lent fl owability) and excluding the time-consuming and dangerous use of hydrofl uoric acid to get rid of the reaction layer. Despite this, it is the reaction layer. Despite this, it is stronger than other pressable high- stronger than other pressable high- strength glass-ceramic materials on strength glass-ceramic materials on the market. Therefore, Celtra® Press the market. Therefore, Celtra® Press provides a simpler workfl ow in the provides a simpler workfl ow in the lab, the dentist receives a robust ma- lab, the dentist receives a robust ma- terial with a very good fi t and easy terial with a very good fi t and easy polishability, and the patient abso- polishability, and the patient abso- lutely loves the natural looking aes- lutely loves the natural looking aes- thetics and beauty of his or her new thetics and beauty of his or her new teeth. What do you foresee Dentsply Si- What do you foresee Dentsply Si- rona off ering in the near or distant rona off ering in the near or distant future as far as material advance- future as far as material advance- ments? We will soon present a new genera- We will soon present a new genera- tion of CAD/CAM material, hand in tion of CAD/CAM material, hand in hand with the lab material combin- hand with the lab material combin- ing Celtra® Ceram porcelain that is ing Celtra® Ceram porcelain that is suitable for every all ceramic case. suitable for every all ceramic case. We are also planning further ma- We are also planning further ma- terial improvements on other terial improvements on other material sectors coming material sectors coming very soon! By Dentsply Sirona As the Director of Research and De- velopment at Dentsply Sirona Lab, Markus plays a central role in terms of our innovation pipeline. He is the person who drives new product developments, for example, innova- tive materials such as Celtra® Press. Thanks to his expertise, great com- munication skills and inventive thinking, Markus understands our customers’ needs and turns them into new and smart product ideas. His work philosophy refl ects Dent- sply Sirona’s unique positioning by always laying out the whole pic- ture of the workfl ow. He is working closely together with other Dentsply Sirona business units to generate valuable links to related workfl ows. This means that you can benefi t from thought out end-to-end solu- tions, and subsequently benefi t from tangible improvements in your daily work. In this interview, Markus explains the various facets of his work as well as the secret behind real innovation. Tell us a little about your role as Director of Research & Develop- ment? What are some of your daily endeavors and/or challenges? A typical day for me is full of review- ing the statuses of all running prod- uct development projects, anticipat- ing and identifying what obstacles or surprises (sometimes positive, sometimes negative) there are or might be, and how we can manage all of these things in order to either meet existing timelines and dead- lines or to be able to start new pro- jects which are fi tting in the overall portfolio of the company. For the development team, one needs an open ear to absorb every Interview: “We deﬁ nitely passed a tipping point for 3-D printers” By Brendan Day, DTI Powered by 3D Systems’ proprietary Figure 4 technology, the NextDent 5100 is a high-speed dental 3-D printer designed to save time for both patient and practitioner. Den- tal Tribune International spoke with Rik Jacobs, dental vice president and general manager at 3D Systems; Se- bastiaan Cornelissen, CEO of Cordent and Core3dcentres; and Dr Michael Scherer, an American prosthodon- tist, about the NextDent 5100 and future trends in dentistry. Is the NextDent 5100 designed speciﬁ cally with the dental lab in mind, or can it be used in a dental practice as well? Rik Jacobs: Essentially, I designed this product to be used by both labs and clinicians with success. Sebastiaan Cornelissen: We found that the most important thing was to have a system that can incorpo- rate multiple machines and multiple materials if necessary. This fl exibility was the main feature that we were looking for, and the NextDent 5100 delivers this. Dr Michael Scherer: For a clinician like myself, there’s been an embrace of 3-D printing in recent years. How- ever, it’s always been the lower-cost models that have been prioritised. With the multiple materials and extremely fast printing that the NextDent 5100 offers, I think that clinicians can now offer a realistic chairside solution for patients. What are the beneﬁ ts of the Next- Dent 5100 for dental labs? Cornelissen: In the dental lab, you have similar time pressure issues to a dental practice. You need to be able to produce things fast, in multiple colours and often in large quanti- ties. To be frank, these are all easily achievable with this printer. Often, a dentist will send some scans to us so that we can quickly create a smile design for the dentist to print a mock-up of in his or her offi ce. Though we are based in the Nether- lands and have clinicians working with us from Germany, the Next- Dent 5100 allows for this entire pro- cedure to be conducted in less than 2 hours. What has the feedback been since the launch of this printer? What have customers most liked about it? Jacobs: What was important for us, besides what these gentlemen have already mentioned, was that the printer have a high level of accuracy. With ten years of experience in the 3-D dental printing industry, I’ve learnt that a lot of printers work fi ne in the beginning but lose their ac- curacy over time. When 3D Systems acquired my company, we decided to make sure that our printer would work without issue, day in and day out, for at least three years. Flexibil- ity, speed, accuracy and, ultimately, affordability of the machine and the materials—these, along with train- ing and ongoing support from our outstanding resellers, are the foun- dations of the NextDent 5100. We got a lot of feedback from users of this printer, like Michael and Se- bastiaan, and thankfully, our R & D team in San Diego really listened to what they asked for, what the mar- ket asked for. I think this is what our company should always do: listen carefully to our customers and de- liver what they need and want. Are software updates included? Jacobs: Automatically. As long as the user is connected to the Internet, he or she will be able to have the latest updates automatically downloaded to the printer. It’s predicted that, within three to ﬁ ve years, more than 50 per cent of dental labs globally will have an in-house 3-D printer. What, in your opinion, is driving this growth? Jacobs: Well in 2018, we defi nitely passed a tipping point for 3-D print- ers here at 3D Systems. Thanks to easier registration, certifi cation, im- proved ease of use, and a range of other factors, it has become much more achievable to integrate a 3-D printer into one’s daily workfl ow. Scherer: Clinicians are now expect- ing dental labs to be digital and to have printing capabilities. It’s no longer a case of whether a lab will take your fi les, but rather if they print themselves or still outsource it. That’s how fast 3-D printing has grown in dentistry.
2 HYGIENE TRIBUNE Dental Tribune Middle East & Africa Edition | 2/2019 “You are not healthy without good oral health” Interview: By Dental Tribune MEA/CAPPmea Could you please give us a short introduction of yourself and the organisation? I am Kathryn Kell and I am the Pres- ident of FDI World Dental Federa- tion. We are based in Geneva, Swit- zerland and in the organisation, we represent over a million dentists worldwide. We have around 200 members and we have about 130 members that are membership organisations. For example, I am a member of the American Dental Association—they are a member of FDI. The United Arab Emirates is a member of FDI. Those are the mem- bership organisations, but then, in addition, we have other interna- tional organisations as affiliate and supporting members that are also very involved with us. For instance, the International As- sociation of Dental Research, the American Dental Education Asso- ciation and several honorary mem- ber organisations, such as the In- ternational College of Dentists, the Academy of Dentistry International and the Pierre Fauchard Academy are some of our other members. We really have a great international group of people in our organisa- tion. I have been involved with FDI my- self for many years. At one stage, I was the Chair of the Congress and Education Committee, which was why I was previously in Dubai at the last couple of meetings. So, I am rather familiar with this meeting and it is really great to be back here again and see the changes. Can you tell us a little bit about how you are partnering with the industry? You mentioned it now, text under photo 3M is also a partner. Previously— I remember last year—we also partnered with other industry players. How important is that for you and what is the scale that you use to evaluate who should be the partner and how to grow the part- nership? W we say “partners” we really are partners, because without our part- ners we would not be able to do anything, really. As a dentist my- self, in my office, if I do not have equipment and if I do not have the right materials, I am not going to be able to practice. It is the same thing with FDI if we do not have a com- mitment to each other. And that is what we look for: really strong AD Be a part of something extraordinary. 4–8 September 2019 Moscone Convention Center 3 DAYS OF EXHIBITION SCIENTIFIC PROGRAMME 5–7 SEPTEMBER 2 HALF DAYS (4, 8 SEPT) & 3 FULL DAYS (5-7 SEPT) MORE THAN 1,300 STANDS 200 WORLDWIDE SPEAKERS 40,000 M2 OF EXHIBITION SPACE MORE THAN 30,000 PARTICIPANTS Abstract submission deadline 1 April 2019 Early-bird registration deadline 30 April 2019 www.world-dental-congress.org programmes where we can work together. At 3M, we had “Smile Around the World” with 3M and we had a really great, successful project in China last year. So, now we are looking forward to doing more. And you are also doing that in In- dia and Brazil, right? Yes, that was also in the past project. What about here in the Middle East? In the Middle East, we actually need to start developing some programmes. We have a Middle East Education Committee and we have a person who is based in Leba- non actually, Wunir Dumed, who puts on educational programmes around the Middle East and North Africa. Could you share a little bit about the vision you have, 2020? What is that all about? Vision 2020 is our advocacy pro- gramme. Again, we have advocacy for our members, but we also ad- vocate for oral health around the world and we do this by working with the World Health Organisation and other United Nations agen- cies. I recently did a presentation in CIOSP in São Paulo, Brazil a few days ago on the Minamata conven- tion. Basically, people are looking at what other materials we are going to be using in the future. We know the future are composites, glass ionomers and some things we are looking for you to still develop. We are very excited about some of the new things that we know you are going to be coming out with in the next few years, too. We went to the 3M headquarters in the Minneapolis St Paul area and we talked to their research team about some of the things that they can do to help develop materials that can be used in countries where even their water supply is limited—you cannot really use the water—they do not have air, they do not have the tools required to do effective glass ionomers in composites. I think if we all work together and look at how we can develop new to having a big celebration in Cairo. The Egyptian Dental Association and the Egyptian Dental Senate are working hard to put something ex- citing together for us. Along with Vision 2020, we have a new definition of “oral health”, but we have spoken about that before. Now, we are in our next stages: we are going to look at measurement tools, we are going to do surveys and the surveys are going to be global surveys, so that we can actu- ally see what type of dental diseases are out there and which countries have more issues with caries, for example. Whereas other countries may have more issues with peri- odontal disease. This way we can ac- tually get a focus on where we want to go with our vision. And then, eventually, we will develop projects that will be the next step. How can companies or individu- als, who are not directly involved in the World Oral Health day, par- ticipate? How is that something that we can begin? We really hope that everyone—all companies in our industry—would like to join us and be a part of this initiative. They can certainly do that. Companies can help celebrate with some of their dental organisa- tions. So, there is a way to get in- volved. Is there anything else you would like to share with our listeners— the readers of the Middle East dental community? Our vision is to lead the world to optimal oral health and that is what we want to do. It would be a big thing if the people in the Middle East can work with their govern- ments to put together good pro- grammes that would benefit the public. We really want to bring oral health into all of healthcare, all of health- care policies and anything you can do to bring oral health care into the health arena, in policies, in your governments. This can be very helpful. “You are not healthy with- out good oral health”—that is an- other message we want to convey. materials that will really work in some of these countries, that would help us in the long run. And for the region now, one of the main goals, especially for the UAE and the Dubai Health Authority, is to get rid of caries. Caries preven- tion is a big goal. How do you see FDI working with those kinds of entities? Have you already begun doing some activities with them through world oral health care? World oral health is one of the things we do at Prevention, but I cannot stress enough how preven- tion is the key, because if we do not have caries and if we do not have periodontal disease to deal with, then we are in. Then we do not have oral cancer and the things that go along with oral cancer, such as to- bacco and alcohol consumption. Then you know you are going to prevent all these other problems from happening. I think, if any- thing, FDI stresses prevention. And this year, in March, can we expect anything special here for World Oral Health Day? I am actually going to be back in Cairo on March 20th to celebrate World Oral Health Day. I will be there, and we are looking forward Dental Tribune MEA speaking with Dr Kathryn Kell, the President of FDI World Dental Federation
4 HYGIENE TRIBUNE Dental Tribune Middle East & Africa Edition | 2/2019 One PLUS one equals three! Combined, EMS AIRFLOW PLUS powder and the EMS AIRFLOW Prophylaxis Master delivera unique, one-of-a-kind, clinically proven, evidence-based solution to peri-implantitis and more By E.M.S. One of the true standout dental products launched at the biennial In- ternational Dental Show in Germany in 2017 is the EMS AIRFLOW Prophy- laxis Master air polishing system and with it, the crystallisation of a much- needed solution to keeping implants and perio pockets clean. In the last 18 months, the EMS AIRFLOW brand has taken the world by storm. Suddenly, specialists, dentists and dental hygienists and therapists have a single go-to solution for im- plant maintenance and pocket re- generation. As well as prophylaxis, EMS AIRFLOW is even replacing more invasive, technique-sensitive procedures like root planing. Apart from the slick, retro look and cutting edge Swiss engineering of the EMS AIRFLOW Prophylaxis Master air pol- ishing system, the real key to its suc- cess is a symbiotic relationship with EMS AIRFLOW PLUS powder. Based on Erythritol, the patented micro- sized particles of EMS AIRFLOW PLUS have been clinically proven as highly effective time and again at removing biofi lm without damage to implant or tissue. An unexpected benefi t for EMS of the micro-sized particles of AIRFLOW PLUS means that only an EMS air polisher unit can dispense the pow- der. Trying to use AIRFLOW PLUS with a non-EMS air polisher is noth- ing short of problematic, resulting, for instance, in over-dispensing of powder and clogging. Periodontists and hygienists using the air polishing system have lik- ened it to anyone that had a PC and thought it was the same as a Mac. Like a Mac, once you try the AIR- FLOW solution, you immediately understand the difference. AIRFLOW PLUS powder was devel- oped in-house by EMS. We were ea- ger to know more, so we spoke with Marcel Donnet, the EMS Powder Technology Research Group Leader in Nyon, Switzerland and posed the fi ve most common questions dental professionals ask about EMS PLUS powder. Fig. The Guided Bioﬁ lm Therapy protocol. Figs: The EMS AIRFLOW Prophylaxis Master and AIRFLOW PLUS powder. Marcel, ﬁ rstly what is a powder en- gineer and what led you to this role at EMS? We come in contact with powders on a regular basis, never the wiser. Upon closer inspection, we will real- ise that powders are very complex and its behavior is neither like a solid nor a liquid (despite it, in fact, being a solid). As a result, making a powder is actually complex. A specifi c university tract does not exist for powder engineers; one must pursue a combined educa- tional plan consisting of chemical and material engineering. I received my Bachelor’s degree in chemical en- gineering; I then pursued a Master’s degree and fi nally attained my PhD from a material science department which had a laboratory working ex- clusively with powders. Whilst conducting my doctorate studies, I had the opportunity to complete a lot of high-end research on powders. This placed me in the perfect posi- tion to one day work at EMS: here we have to master the powder from the production to the mouth of the patient! Air polishing has always just been seen as a hygiene product for stain removal and we’ve all heard stories of salty and gritty tasting powders. What are some of the recent ad- vances in prophylaxis powders? When I joined EMS in 2005, air pol- ishing did not rank highly in terms of non-cosmetic usage. Today, AIR- FLOW is the new trend, the product of the future, and most in our indus- try attempt to imitate it. The shift came about, because we undertook advanced research. This research al- lowed the development of new ap- plications, better understanding of past issues and highlighted the ad- vantages powders offer. For example, the fi rst advancement made was EMS AIRFLOW PERIO pow- der, which was less abrasive than pre- vious powders and therefore allowed a fully new application: cleaning bio- fi lm in shallow pockets. This turned the powder from being cosmetic to becoming a treatment solution for the periodontist. This was a huge paradigm shift! Due to this success, we developed the EMS PERIOFLOW nozzle, which allows you to easily clean biofi lm inside deep pockets. Treating deep pockets became another success story thanks to its effi ciency, espe- cially in terms of treatment time and patient comfort. The shift from solely cosmetic application to an im- portant and effective tool for patient care was complete. This paradigm shift was formally recognised when EMS received the PLURADENT in- novation prize in 2007. The prize is signifi cant because it’s based on user questionnaires at dental trade shows over a full year. It’s the voice of thou- sands of end users. From there, our innovative journey progressed and led to the new EMS AIRFLOW PLUS powder, which com- bines the advantages of a supragingi- val and subgingival powder in one. The EMS AIRFLOW PLUS powder is unique and patented. However, it was only part of the success story. This unique, fi ne powder required a bespoke delivery system, the AIR- FLOW Prophylaxis Master. The EMS AIRFLOW Prophylaxis Master was launched in Australia last year and is the “enabler” of GUIDED BIOFILM THERAPY [GBT], the systematic, evidence-based solution for dental biofi lm management developed by EMS. GBT refers to the clinical proto- col for selectively removing the bio- fi lm that forms on hard structures of the mouth, such as teeth, resto- rations and removable appliances including dentures, using a colour disclosing technique to assist, so as to maintain and promote good oral, gum and teeth health over time. How did you come up with the idea of using Erythritol as an ingredient for the AIRFLOW PLUS powder and what else distinguishes AIRFLOW PLUS powder from other powders on the market? Innovation requires constant change and improvement. Developing a new product takes time and today, we’re developing the new products of tomorrow. When one new product fi nally comes on the market, we’re already working on the next generation. Based on this philosophy, when we released AIRFLOW PERIO powder, we were already searching for a new powder with hopefully even better characteristics. This research led us to the group of materials known as “polyol”, which are non-sugar sweet- eners. From this group, Erythritol was chosen because the powders are chemically stable and do not cause a reaction with the body. In addition, it is impervious to humidity and tastes good. The powder has been optimised by means of various tests: we revealed that this material has low abrasivity, allowing subgingival usage, but also high effi ciency, mak- ing it ideal for supragingival usage. So in the end, this material in the form that we are manufacturing it has unique balanced properties with low abrasivity and high effi ciency. Therefore, AIRFLOW PLUS is the only powder you need for more than 90% of clinical cases. It really is a universal powder. different dental materials is one of our main research focuses. We strive to offer the safest and the most effi - cient method for removing biofi lm to our end users, hence the advent of Guided Biofi lm Therapy (GBT). The GBT protocol is a scientifi cally validated method which instructs professionals on how to properly perform prophylaxis using our pow- ders and devices. We left no stone unturned. Guided Biofi lm Therapy calls for the clini- cian to: 1. Assess the current health of the pa- tient’s teeth; 2. Disclose biofi lm with a disclosing agent as it is the only guaranteed way to see existing biofi lm; 3. Motivate patients by showing them their dental biofi lm; 4. AIRFLOW the gingiva, tongue, pal- ate and supra and subgingivally up to 4mm; 5. PERIOFLOW pockets sized 4-9mm; 6. PIEZON pockets 9-10mm; 7. Check to ensure all biofi lm is re- moved and accurately diagnose car- ies; and 8. Recall patients for continued oral and overall health. These steps ensure the safety of pa- tients, implant surfaces and soft tis- sues. What happens to the powder in a patients’ mouths after treatment - does it dissolve? EMS focuses on developing solu- tions with the long-term, systemic health of patients in mind, therefore all our powders are highly biocom- patible and soluble. AIRFLOW PLUS powder dissolves in the patient’s mouth right after treat- ment ensuring there is no inhalation to the lungs. For more information contact: There are concerns that air polish- ing powders can damage soft tis- sues and implant surfaces. Is the AIRFLOW PLUS powder safe to use on all surfaces? The question of powder damaging E.M.S. Electro Medical Systems S.A. Ch. de la Vuarpillière 31 1260 Nyon - Switzerland Tel: +41 22 994 26 60 Mob: +41 79 569 12 14 Web: http://www.ems-company.com Web: http://www.ems-dent.com
D2 IMPLANT TRIBUNE Dental Tribune Middle East & Africa Edition | 2/2019 Incorporating CAD/CAM solutions for full-mouth dental implant reconstructions By Dr Ara Nazarian, USA Patients facing the loss of their natural dentition have more treat- ment options than ever before. The traditional complete denture, once the standard of care for the fully edentulous patient, is slowly but surely giving way to ﬁxed full-arch implant restorations as their supe- rior stability, function and aesthetics become more well known. Further, prosthetic materials have advanced in leaps and bounds, and monolithic zirconia can now be milled for ﬁxed full-arch indications. By moving be- yond acrylic and its vulnerability to wear, chipping, stains and fracture, this adds long-term durability to the qualities that make the ﬁxed implant prosthesis the ultimate re- storative option for fully edentulous cases. Owing to the versatility of dental CAD/CAM technology and the mate- rial properties of monolithic zirco- nia, high-strength restorations can be fabricated for the fully edentulous patient in various conﬁgurations. For example, because of its ﬂexural strength of up to 1,465MPa, BruxZir Solid Zirconia (Glidewell Laborato- ries) can be milled into thin layers and maintain the high level of dura- bility for which the material has be- come known. This allows for the fab- rication of restorations ranging from the monolithic zirconia full-arch implant prosthesis, which resembles a screw-retained hybrid denture in form, to cementable prostheses that attach to custom abutments in the manner of traditional crown and bridge work. While the screw-retained monolithic zirconia full-arch implant restora- tion has grown increasingly popu- lar in recent years, the cementable alternative is well suited for many patients. When sufﬁcient hard and soft tissue are present, prostheses can be designed that emerge di- rectly from the gingiva, creating the aesthetics and feel of natural denti- tion. Additionally, the use of custom abutments to support a cementa- ble full-arch bridge allows for low- proﬁle restorations with minimal faciolingual width. This is appealing to many patients and can indicate a ﬁxed solution in cases of limited ver- tical clearance. Cementable monolithic zirconia im- plant prostheses can be fabricated in various designs as described by Dr Carl Misch’s prosthodontic classiﬁca- tions.1 While they are most common- ly indicated in ﬁxed prosthesis (FP) 1 and 2 cases, in which the prosthetic teeth rise from the gingivae like natural teeth, they can also be used in FP3 cases, where the monolithic prosthesis includes pink gingival ar- eas in order to reconstitute the soft tissue.1 Whichever prosthesis type is indicated, the precision of dental CAD/CAM technology and versatil- ity of full-contour zirconia allow the entire restoration to be milled from a sin- gle block of the material, adding to the overall strength. All of these prosthesis types afford bone preservation, improved den- tal function, psychological beneﬁts and enhanced quality of life associ- ated with ﬁxed implant prostheses, which come the closest to natural dentition of all restorative options.2,3 The use of custom abutments for this type of restoration—and all ce- mentable prostheses for that mat- ter— is essential, as it allows for the creation of margins that are gingival or just slightly subgingival, enhanc- ing crown retention, cervical soft- tissue margins and the ﬁnal emer- gence proﬁle.4,5 The precision and ﬂexibility in prosthetic positioning allowed for by custom abutments also make it easier to achieve a pas- sive ﬁt for the restoration and correct for divergent angulation of implants. The following case report features a full-mouth reconstruction via ce- mentable full-arch BruxZir bridges over Inclusive Titanium Custom Fig. 1: Pre-op retracted view. Fig. 2: Pre-op retracted view without denture. Fig. 3: Proposed treatment of maxillary arch. Fig. 4: Proposed treatment of mandibular arch. Fig. 5: Dentofacial analysis of proposed implants in maxillary arch. Fig. 6: Dentofacial analysis of proposed implants in mandibular arch. Abutments (Glidewell Laboratories). The treatment protocol for this type of restoration will be illustrated, as well as the general parameters for de- termining whether this solution is indicated for the individual patient. Standard denture technique, digital treatment planning and CAD/CAM technology were used to achieve an excellent result in an aesthetically challenging case. Case presentation A female patient in her mid-ﬁfties presented for treatment with an edentulous maxilla and grossly de- cayed, hyper-erupted mandibular dentition (Figs. 1&2). The patient was a heavy smoker, had not seen a dentist in several years, and was not taking proper care of her re- maining teeth owing to pain and discomfort. The patient’s maxillary denture had increasingly become loose-ﬁtting since losing her teeth nearly a dec- ade prior. Her desire for a restoration that felt and functioned more like natural teeth led her to my practice, where she could undergo the surgi- cal and prosthetic phases of treat- ment under one roof. Intra-oral and ÿPage D3 Fig. 7: Surgical guide for maxillary implants. Fig. 8: Surgical guide for mandibular implants. Fig. 9: Placement of maxillary surgical guide. Fig. 10: Paralleling pins placed. Fig. 11: Hahn dental implant being inserted. Fig. 12: Healing caps placed.
Dental Tribune Middle East & Africa Edition | 2/2019 ◊Page D2 IMPLANT TRIBUNE D3 Fig. 13: Mandibular arch anaesthetised. Fig. 14: Mandibular surgical guide stabilised. Fig. 15: Implants and healing caps with surrounding grafting. Fig. 16: Im- mediate dentures with soft relining. Fig. 17: Maxillary ridge four months post-op. Fig. 18: Mandibular ridge four months post-op. radiographic evaluation indicated sufﬁcient bone volume for full-arch implant therapy. Treatment options were presented to the patient for her edentulous upper arch and non-restorable man- dibular dentition, including vari- ous combinations of ﬁxed and re- movable implant prostheses. This involved a discussion of complete edentulism and its problems, con- sequences and solutions, the effect of tooth loss on oral health, and the differences in stability and function afforded by each treatment option. Dental ﬁnancing programmes were explained, which is an important part of treatment presentation, as it can help make implant therapy fea- sible for patients who cannot cover the entire cost upfront. The patient strongly desired ﬁxed restorations, as she had grown quite frustrated with her removable max- illary denture over the years. In addi- tion, the patient had a pronounced gag reﬂex, making the ﬁxed option optimal because it would free up the palate. An FP 3 prosthesis was required for the patient’s maxillary arch, which had undergone substan- tial bone resorption and gingival re- cession. The tissue contours would also need to be recreated in the man- dible, where bone levelling was re- quired to remove undercuts, create an ideal occlusal table, properly seat a bone-supported surgical guide and establish adequate bone width in which to place the implants. The anatomy of the patient’s ridges called for a cementable solution, as the labiolingual bone volume re- quired that several of the implants be tilted in a manner that would have required access holes too far to the facial aspect if screw-retained prostheses were to be prescribed. This would have been especially problematic for this patient, as ciga- rette smoking tends to darken the composite used to seal the screw ac- cess holes. The patient also desired prostheses that occupied as little faciopalatal space as possible, further indicating a cementable solution. Thus, custom abutments would be utilised to correct the angulation of the implants and support full-arch BruxZir restorations. The monolithic construction of the FP3 prosthesis, in which both the gingival areas and teeth are milled from the same block of solid zirconia, would ensure the longest-lasting restoration possible. The patient returned for the records appointment, where maxillary and mandibular impressions were taken so that immediate temporary dentures could be fabricated for de- livery at the surgical appointment. CBCT scanning was performed using a CS 8100 3D scanner (Carestream Dental) to provide the information needed for virtual treatment plan- ning. The 3-D data obtained from the CBCT scans was used to determine the ideal length, width and place- ment of the implants in the key po- sitions of the patient’s edentulous arches, including the ﬁrst molar, ﬁrst premolar, canine and central incisor regions (Figs. 3–6). From the digital treatment plan cre- ated by 3D Di- agnostix, bone-level surgical guides were produced for the maxilla and mandible (Figs. 7 & 8). The Hahn Tapered Implant (The Hahn Tapered Implant System) was selected for the procedure because the pronounced thread design would help achieve optimal posi- tioning and primary stability. The ta- pered shape and wide range of sizes also simpliﬁed the task of situating the implants in the key positions around the arch. Its conical inter- nal hex connection results in a very stable seal between the implant and prosthesis, which is beneﬁcial for crestal bone preservation and soft- tissue health.3 At the surgical appointment, intra- venous sedation was administered to the patient. The bone-level sur- gical guide was seated over the pa- tient’s maxilla once the tis- sue had been reﬂected, and the ﬁxation pins were tightened (Fig. 9). The implant osteotomies were created following the simpliﬁed surgical protocol of the Hahn Tapered Implant System. Eight implants were placed from second molar to second molar in the maxillary arch (Figs. 10&11). Healing abutments were connected to the implants to help prepare the soft tis- sue for the restorative phase (Fig. 12). Next, the patient’s untreatable man- dibular teeth (Fig. 13) were extracted using the Physics Forceps (Gold- enDent), a ﬂap was reﬂected, and an alveoloplasty was performed. A bone-supported guide was seated in order to control the location and Fig. 19: Inclusive CAD/CAM abutments. Fig. 20: PMMA Smile Composer. Fig. 21: Post-op retracted open-bite view. Fig. 22: Post-op retracted closed- bite view. angulation of the implant osteoto- mies (Fig. 14). As the Hahn Tapered Implants were threaded into place, their deep, sharp threads engaged the walls of the socket sites and helped maintain proper position toward the lingual aspect. Because of anticipated tissue swelling as a result of the bone levelling proce- dure, 5mm high healing abutments were connected to the implants in the lower arch (Fig. 15). The immedi- ate dentures were soft-relined with Mucopren (Kettenbach) to seat over the Hahn Tapered Implant Healing Abutments, the hourglass shape and undercuts of which provided a degree of retention that enhanced dental function for the patient dur- ing healing (Fig. 16). Four months later (Figs. 17 & 18), the healing abutments in the maxillary arch were surgically exposed and the tissue appropriately approximated and allowed to heal. Approximately two to three weeks later, Hahn Ta- pered Implant Impression Copings were seated and closed-tray impres- sions taken with a polyvinylsiloxane material (Panasil, Kettenbach), as was a bite registration (Futar, Ketten- bach). Because the immediate den- tures were well ﬁtting and satisfac- tory to the patient, duplicates were provided to the laboratory to aid the restoration design process. Based on the impressions, the labo- ratory poured and scanned stone models, creating a digital representa- tion of the patient’s arches on which the designs for custom abutments and the cementable restoration were created. Inclusive Titanium Custom Abutments were fabricated with cor- responding PMMA Smile Compos- ers. The patient returned for clinical eval- uation of the prosthetic design. The custom abutments were delivered us- ing laboratory-provided acrylic delivery jigs, which helped ensure proper orientation during seating (Fig. 19). Owing to the precision of the digital design process, the ﬁt of the custom abutments was ideal, es- tablishing margins that were at or a slight distance from the gingival sur- face. This simpliﬁed the removal of excess cement from the margins and illustrates the advantages of CAD/ CAM–produced abutments. The PMMA Smile Composers were seated over the custom abutments, and slight alterations were made to ﬁne-tune the gingival margins, length of teeth, and bite (Fig. 20). A bite registration was taken with the try-in bridges in place. The PMMA Smile Composers were returned to the laboratory along with photographs, the bite regis- tration and instructions for minor modiﬁcations, including lowering the gingival margins of the man- dibular prosthesis and raising the gingival margins of the maxillary prosthesis. The laboratory scanned the adjusted PMMA try-in bridges, made the requested alterations to the prosthetic designs, and milled the ﬁnal prostheses from BruxZir Solid Zirconia. The ﬁnal restoration was delivered at the next appointment and estab- lished accurate ﬁt, function and in- terocclusal relationship (Figs. 21&22). No adjustments were needed for the monolithic zirconia prostheses be- cause of the PMMA try-in process, which captured the precise modi- ﬁcations needed for proper form and aesthetics. Final radiography conﬁrmed complete seating of the BruxZir restoration on the Inclusive Custom Implant Abutments. The pa- tient was extremely happy with the reconstruction of her maxillary and mandibular arches, which restored aesthetics, dental function, comfort and conﬁdence. Conclusion The accuracy of dental CAD/CAM technology and the versatility of prosthetic materials allow practi- tioners considerable ﬂexibility in restoring the edentulous arch. For clinicians who prefer a cementa- ble solution or cases in which bone anatomy precludes a screw-retained prosthesis, the monolithic zirconia restoration over custom abutments excels in restoring the teeth, as well as the hard and soft tissue of the fully edentulous patient. Editorial note: A list of references can be obtained from the publisher. This article was originally published in CAD/CAM international magazine for digital dentistry, Issue 1/2018. Dr Ara Nazarian maintains a private practice in Troy in Michigan in the US with an emphasis on comprehensive and restorative care. He is a diplomate of the International Congress of Oral Implantologists and the founder and Chief Clinical Officer of the Ascend Dental Academy. He has conducted lectures and hands-on work- shops on aesthetic materials, grafting and dental implants throughout the US, Europe, New Zealand and Australia.
Long-term clinical evidence with Ankylos® implants N E WLY P U B LI S H E D R E S U LT S WITH D E NT S P LY S I RO N A I M P L A NT S P RO D U C T S Up to 17 years 18 945 OF CLINICAL RELIABILITY ANKYLOS IMPLANTS A retrospective analysis of Ankylos implants placed in a large patient population showed successful long-term clinical results when using a flapless surgical approach. 7783 patients Implant survival rate after 1 year – 98.5% 5 years – 96.7% 10 years – 93.0% Jesch P, Jesch W, Bruckmoser E, et al. An up to 17-year follow-up retrospective analysis of a minimally invasive, flapless approach: 18 945 implants in 7783 patients. Clin Implant Dent Relat Res 2018;E-pub Feb 15, doi: 10.1111/cid.12593. Abstract www.dentsplysirona.com/implants/science Minimally invasive surgery
E2 ORTHO TRIBUNE Dental Tribune Middle East & Africa Edition | 2/2019 Improving the facial balance in an adult using slow arch development techniques Fig. 2: The Homeoblock appliance. By Dr Derek Mahony, Australia, & Dr Theodore R. Belfor, USA Introduction Anti-ageing is a branch of medicine focused on how to prevent, slow or reverse the effects of ageing, thus helping people to live longer and healthier lives. Recently, however, more evidence-based medicine has led to anti- ageing becoming a multi- billion-dollar industry. In the past few decades, the market for anti-age- ing products and services has grown into a global industry valued at an estimated US$261.9 billion in 2013, up from US$162 billion just five years before, according to BCC Research, a publisher of technology market re- search reports based in Wellesley in the US.1 The recent medical literature and evidence-based medicine show that, as we age, there seems to be a loss of fat volume in some areas of the face, as well as a change in the mor- phology of the facial skeleton. Facial soft-tissue augmentation by injec- tion has become increasingly popu- lar as a minimally invasive option for patients seeking cosmetic facial enhancement. Replacing lost soft- tissue volume allowed for a more comprehensive approach to total fa- cial rejuvenation. It has been demon- strated that orthodontic treatment with an intra-oral orthopaedic den- tal appliance (Homeoblock, Ortho- Smile) increases soft-tissue volume and enhances facial symmetry, pro- ducing soft-tissue changes consist- ent with improved facial esthetics.2 Fig. 3: The pretreatment face, the post-treatment face at six months and nine months, and ﬁnally, a morphometric evaluation of the change. This appliance can be added to the treatment protocol of facial injection to create a relatively non-invasive in- terdisciplinary approach to midface enhancement. With this article, we show how or- thopaedic/orthodontic appliance therapy, in conjunction with the placement of dermal fillers for the reduction of lines/wrinkles and de- pressions in the face, can produce desirable facial soft-tissue enhance- ment. Furthermore, we show that the volumetric changes achieved by this combined treatment approach can produce a desirable result, name- ly a more youthful appearance. Case study A healthy woman in her mid-sixties presented for treat- ment with a strong desire to improve her facial appearance (Fig. 1). Her oral hygiene was good and there was no active periodontal disease. She had head- ache symptoms and clinical exami- nation showed a disc displacement with reduction on her right side, with a maximum jaw opening of 38 mm. Her centre line was displaced 2 mm to the right and lined up when she opened < 10 mm, indicating that she had a mandibular displacement to the same side. A Homeoblock ap- pliance, with a 5 mm bite block on the right side (to decompress her temporomandibular joint), was fab- ricated and delivered (Fig. 2). When she closed on the bite block, her oc- clusion freed up and the muscles realigned the mandible so that her centre line lined up correctly. Her headache symptoms were relieved in three weeks and her maximum opening was improved to 42 mm. The patient continued Homeoblock treatment for nine months. Intra-oral and extra-oral photo- graphs were taken to monitor treat- ment, and 3-D stereophotogramme- try was performed. Extra-oral 3-D digital photographs were taken with a facial capture system (3dMD). A fa- cial capture system (3dMD/Kodak) and stereophotogrammetry were used to generate a clinically accurate digital model of the patient’s facial surface. It uses a technique of stereo- triangulation to identify external surface features viewed from at least two cameras. This approach incor- porates the projection of a unique, random light pattern that is used as the foundation for triangulating the geometry in 3-D. The capture takes < 2 ms per frame. The data is processed and a highly precise < 0.5 mm root mean square of the distance meas- ured is calculated, creating a digital model of the patient that is ready for immediate clinical use. Stereo- photogrammetry for quantifying facial morphology was introduced in a study published in the Journal of Dentistry in 1996.3 It was concluded that “stereophotogrammetry is a suitable 3-D registration method for quantifying and detecting develop- ment changes in facial morphol- ogy”.3 Evaluating the patient’s face over the nine months of Homeoblock treat- ment for her temporomandibular dysfunction showed a change in the morphology of the face (Fig. 3). Mor- phometric analysis was performed by superimposing before and after 3-D images and using finite element modelling. Thousands of triangu- lar reference points were used to establish the change. The blue area indicated no change and the red to orange areas showed an increased di- mension of up to 2.9 mm. We saw an increased volume above and under the eyes, the zygomatic region, the upper lip, and the marionette and pre-jowl areas. From the facial pho- tographs, we could see a reduction in the lines, wrinkles and depressions (Figs. 4 & 5). After nine months, the patient’s fa- cial changes prompted her to go for- ward with injections of dermal fill- ers. She was given 1 ml of Restylane (Galderma) for lip enhancement and two 1.3 cc corrections with Radiesse (Merz Aesthetics) in the pre-jowl and marionette areas and along the inferior border of the mandible, and the inferior and lateral borders of the zygoma (Fig. 6). Results Post-treatment, the patient’s face appeared more youthful with better defined cheekbones and a firmer jaw line. The skin appeared smoother with fewer lines, wrinkles and de- pressions (Figs. 7a & b). Fig. 1 Pretreatment facial and anterior intra-oral photographs (note deep dental overbite). with an increase in structural com- plexity, in association with biological processes.”4 Palatal expansion pre- sumably, switches on osteoblastic genes associated with active boney deposition and concomitant remod- eling of the spatial matrix ensues.”4 In relation to the changes around the eyes, we must recall that the max- illa forms the floor of the orbit and skeletal changes may become ap- parent after expansion;4 specifically, changes in orbital morphology may be reflected on the skin of the face: as the lower eyelids become tighter, the lateral canthus becomes more horizontal; facial width increases, particularly at the zygomatico-max- illary sutures; and the craniofacial form, putatively, not only functions better, but looks more attractive.4 These changes have been docu- mented in children, where palatal expansion is an everyday occur- rence. The current article documents similar changes in a non-growing adult. Combining the results of pala- tal expansion and the placement of dermal fillers, we obtained a very satisfactory improvement in facial aesthetics. Editorial note: A list of references can be obtained from the publisher. This article was originally published in ortho international magazine of orthodontics, Issue 2/2018. Discussion Facial changes related to palatal ex- pansion are clearly outlined in Sin- gh: “The maxillary complex shows a change in size (and/or mass) allied Dr Derek Mahony is a Specialist Orthodontist. He can be contacted at derek.mahony@fullfaceorthodontics. com.au Fig. 4: Morphometric evaluation of the ﬁnal results: ﬁnite element analysis showed increased facial volume with a directional change of almost 4 mm, indicated by the red to orange colour. Fig. 5: Superimposing the red post-treat- ment face over the blue pretreatment face, we can graphically illustrate the volumetric changes that occurred during our treatment. There was an increase in volume in the frontal, supraorbital, infe- rior orbital, zygomatic, nasal base, upper lip, nasolabial depression, and marionette and pre-jowl areas. Fig. 6: Morphological facial changes in the lips, zygoma and jowl area after the placement of 1 ml Restylane and 1.3 cc Radiesse. Note the deeper red to orange colour in the areas where the injections were placed. Figs. 7a & b: Before and after facial photographs.
Dental Tribune Middle East & Africa Edition | 2/2019 ORTHO TRIBUNE E3 Indirect bonding: Digital technique vs conventional method By Drs Arturo Fortini, Alvise Cabur- lotto, Elisabetta Carli, Giulia Fortini & Francesca Scilla Smith, Italy One of the peculiar features of straight-wire techniques is the in-built tip, torque and in-out ad- justments in the brackets, which reduces the need for making first-, second- and third-order bends on the arch. It follows that the pre- cision in the positioning of the brackets is of fundamental impor- tance for making the correct ad- justments and for the consequent predictability of the result, thus making bonding one of the most important steps of the whole treat- ment. With direct bonding, there is a high margin of error in bracket positioning, due both to the den- tal professional’s experience and to difficulty with visualisation. The positioning errors that can be made are on the horizontal, verti- cal and mesiodistal axes, and can create the need to reposition the brackets during orthodontic treat- ment, resulting in a waste of time. Over the years, indirect position- ing techniques have been devel- oped to make positioning more precise and to make the procedure as fast as possible. The aim of this study was to compare a new, digi- tally assisted method of indirect bonding (Transfer Bite Leone) with the conventional clear two-tray technique, using the split-mouth method to evaluate the amount of remaining composite around the base of the bracket in both proce- dures. In order to avoid differences due to placement, we used the same dedicated programme for both methods. STL files, obtained from intra-oral arch scanning or stone model scanning, were loaded and processed with the Leone Maestro 3D Ortho Studio software (AGE So- lutions). This digital tool permits the segmentation and width and height measurement of the teeth, and the subsequent determination of the long axis and the average height of the clinical crowns, in or- der to virtually arrange the brack- ets in the correct position. The dentist can later change the posi- tioning height, the torque, the tip and the rotation to obtain an abso- lutely individualised and strategic positioning of the brackets for the case (Fig. 1). Once the ideal position of the brackets had been obtained, we used the Maestro 3D software to obtain a file that allowed the 3-D printing of the model in which, in the left hemi-arch, the brackets were integrated to be able to use it to produce the conventional thermoformed clear trays that would contain the brackets to be placed in the mouth. In the right hemi-arch, using the software, we designed a Transfer Bite that per- mitted precise positioning of the brackets. The Transfer Bite is made of biocompatible material and is produced using a high-precision 3-D printer according to specific parameters. Our split-mouth clinical investiga- tion protocol was accepted by the American Association of Ortho- dontists committee for the table clinics that we presented at the 2017 annual congress in San Diego in the US (Fig. 2). This procedure Fig. 1: Dental studio-Ortho Studio Module. clearly demonstrated the limita- tions of the conventional two-tray technique: inconsistent accuracy, an excess of composite around the base of the bracket that cannot be removed during the bonding step, and difficulty in removing the thermo-printed support (Figs. 3 & 4). The Transfer Bite system with po- sitioning devices was found to be better because it allows the clini- cian to have a complete view of the base of the brackets, optimising the removal of excess composite (Fig. 5). In addition, the Transfer Bite, compared with the thermo- formed trays, has greater stability on the dental arches, with an even better precision result, and aids the dentist in repositioning the brack- ets in a detachment case. Our experience of using the Trans- fer Bite system on 12 patients al- lows us to confirm that this new indirect bonding method is sim- pler, easier and more accurate than the conventional method. Further- more, it proved to be a less opera- tor-dependent technique, allowing even less-experienced clinicians to achieve optimal results. Editorial note: This article was originally published in ortho international magazine of orthodontics, Issue 1/2018. Dr Arturo Fortini is a specialist in orthodontics and in pri- vate practice in Florence in Italy. He can be contacted at firstname.lastname@example.org. Dr Elisabetta Carli is a specialist in orthodontics and in pri- vate practice in Fivizzano in Italy. Dr Alvise Caburlotto is a specialist in orthodontics and in pri- vate practice in Venice in Italy. Dr Giulia Fortini is a specialist in orthodontics and in pri- vate practice in Florence. Dr Francesca Scilla Smith is a specialist in orthodontics at Nova Southeastern University, College of Den- tal Medicine, in Fort Lauderdale in the US. Fig. 2: Indirect bonding though Leone’s JIG and brackets. Figs. 3 & 4: Limitations of the conventional method, such as non-constant accuracy and excess of composite around the base of the attachment. Fig. 5: Leone’s Transfer Bite system. AD What is the ClearSmile Aligner? ClearSmile Aligner employs a series of plastic appliances, called aligners, to gently reposition and align the teeth creating a beautiful new smile. A L I G N E R Made in Dubai supervised by orthodontists in UK www.clearsmilealigner.com www.iasortho.com www.mdentlab.com Tel : 04-332901 Whatsapp +971 557590217 email@example.com
E4 ORTHO TRIBUNE Dental Tribune Middle East & Africa Edition | 2/2019 Happy patient with durable, natural outcome Andy Wallace describes a case that successfully combines ﬁxed orthodontics and bleaching with the strength of composite edge-bonding restorations By Dr Andy Wallace, UK A 49-year-old female attended Bachelors Walk Dental because she was unhappy with the appearance of her upper and lower front teeth (Figures 1a and 1b). She wanted them straightened to create a more attrac- tive smile and was hoping to have removable orthodontic appliances. I explained to the patient that with- out treatment, the malalignment might worsen but there were a range of options she could consider. ‘Instant orthodontics’ could be ac- complished with veneers but this method would require heavy prepa- ration, which could result in signifi- cant damage to the tooth structure and possible loss of vitality. Veneers placed after invasive preparation would probably have a lifespan of less than ten years. She was also ad- vised that her teeth could continue to crowd, even after veneers were fitted. Therefore, retainers might still be required. Orthodontic choices The Inman Aligner, clear aligners or fixed appliances were the options offered to the patient. The Inman Aligner would be a quick and inex- pensive way to correct the incisors, but would have limited success with the canines and gum levels. Clear aligners could potentially re- sult in a similar outcome to fixed braces. They are discrete, but have a longer treatment time and are more expensive. Fixed appliances offered the most potential for improving the aesthet- ics, and could be used to achieve the most controllable and predictable outcome. A full orthodontic and diagnostic assessment was undertaken. The patient had a skeletal I classification, with moderate upper and lower in- Figs 1a and 1b: The patient was unhappy with the appearance of her upper and lower front teeth Figs 2a and 2b: The patient had a skeletal I classiﬁcation, with moderate upper and lower incisor crowding Figs 3a and 3b: The patient opted for ﬁxed braces, using clear brackets Fig 4: After alignment, additional composite bonding would be required Fig 5: A colour change from A1 to BL4 shade was recorded cisor crowding (Figures 2a and 2b). She wanted the final outcome to be as successful and efficient as possi- ble, so opted for fixed braces using clear brackets (Figures 3a and 3b). The patient was made aware that inter- proximal reduction (IPR) was needed to avoid excessive proclination of the incisors. the fixed retainer wires were bonded. To ensure correct positioning during cementation, the retainer wires were fabricated by the laboratory on an acrylic placement jig. Before bond- ing, I checked the passive fit of the retainer and jig. I assessed where the wire was going to sit, then removed both the wire and jig. Permanent fixed and removable re- tainers were also required after treat- ment, as her teeth would continue to move throughout her lifetime. Effective alignment It was clear that the wear on the teeth would result in an irregular incisal edge, once the teeth had aligned. The patient was informed that after alignment, additional composite bonding would be required (Figure 4), using the align, bleach and bond (ABB) protocol, pioneered by Tif Qureshi (Qureshi, 2011). The relative positions of the teeth, lips and face were recorded using Spacewize, the diagnostic dental crowding software developed by In- telligent Alignment Systems (IAS). This calculates the space require- ments and serves as a prescription to the laboratory for the Archwize digital preview. Monocrystalline sapphire brackets were pre-positioned and transferred into indirect bonding trays, ready to be bonded intraorally. The brack- ets were placed in the ideal position outside the mouth to save time and reduce the possibility of any errors during the bonding process. The teeth were isolated and the brackets attached, following standard resin cementation protocols. A series of nickel titanium wires were used, ranging from .012 to .016 to 20 x 20, as the arches aligned. The pa- tient was seen for review at monthly intervals. The teeth were shaped pro- gressively with IPR strips to create the necessary space. IPR of 1.4 mm was carried out on the upper arch and 1.6 mm on the lower arch. Alignment was completed after sev- en months and the patient approved the end result. Whitening and retention Following bracket removal, impres- sions were taken to allow tempo- rary vacuum-formed retainers and bleaching trays to be manufactured. Chairside whitening was completed with Philips Zoom 6% hydrogen per- oxide gel and the Philips Whitespeed lamp. A colour-change from A1 to BL4 shade was recorded (Figure 5). In order to enhance the chairside result, the patient was provided with home- whitening trays and Philips Zoom Daywhite 6% hydrogen peroxide, take-home whitening treatment to use for one week. At the three-week review, the final shade was recorded as BL3/BL4, and The back of the teeth were ‘tickled’ with a bur to roughen and remove some of the outer layer of enamel, which cannot be etched well. At this stage, I sometimes sandblast with aluminium oxide to remove any biofilm and the highly-fluoridated surface layer of enamel. This reduces surface tension, allowing a better etch pattern. The teeth were etched with 37% phosphoric acid etch gel and bonded using Kulzer Ibond Uni- versal. Ibond was used because of its simple bonding protocol. The wires and jig were put back in the mouth and a thin layer of Kulzer Ve- nus Diamond Flow was placed, just deep enough to cover the wire. The composite was light -cured, as per the manufacturer’s instructions. The jig was cut off and more Dia- mond Flow was applied to the rough edges of the wire, followed by further curing. Venus Diamond Flow offers ideal viscosity, making it perfect for the placement of indirect fixed-wire retainers (Figures 6a and 6b). Composite aesthetics and strength The edge-bonding was completed using Kulzer Venus Pearl (Figures 7a and 7b) during the same appoint- ment. The shade was selected from the Venus Pearl shade guide and judged to be between Bleach Light (BL) and Bleach Extra Light (BXL). Tooth preparation using a diamond bur included the removal of unsup- ported enamel and minimal rough- ening beyond the enamel composite interface. Venus Pearl Opaque Light Chromatic (OLC) shade was placed in a triangular section, following the ‘reverse triangle technique’, as described by Tif Qureshi (Qureshi, 2016). The BL enamel shade, with small BXL highlights, was placed in a sin- gle layer. This technique offers an aesthetically pleasing outcome by helping to address irregularities and incisal edge wear, as well as minimis- ing chair time and increasing the strength of the restoration. Both ap- plying a single layer of the opaque dentine shades and the chosen shade of the enamel composite reduces the risk of introducing errors or bubbles. I have been using Kulzer Venus com- posites for a number of years. Venus Pearl lends itself very well to the re- verse triangle technique. The enamel shades are sufficiently opaque to ÿPage E6
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E6 ◊Page E4 ORTHO TRIBUNE Dental Tribune Middle East & Africa Edition | 2/2019 Figs 6a and 6b: Venus Diamond Flow offers ideal viscosity, making it perfect for the placement of indirect ﬁxed-wire retainers Figs 7a and 7b: The edge-bonding was completed using Kulzer Venus Pearl Fig 8: At the three-year recall appointment, only the very slightest loss of shine can be seen Fig 9: The patient was so pleased with the ﬁnal result, she has since recommended several new patients to the practice mask the joins when edge bonding and lengthening teeth. They blend well to the natural enamel and adapt perfectly to the colour of the sur- rounding dentition. Durable result Polishing was completed using the Kulzer Venus Supra Polishing kit. Its extensive silicone range is filled with microfine diamond powder. The pink pre-polishers are effective for removing scratches and creating secondary anatomy, while the grey ones give a great, long-lasting finish. A final lustre was achieved using alu- minium oxide paste on a felt wheel. New vacuum-formed retainers and bleaching trays were fabricated for the new shape of the teeth. They would help to retain the treatment outcome and maintain teeth whit- ening. I recommended three to four days of top-up bleaching, using Philips Zoom Daywhite, three times per year. At the three-month follow-up ap- pointment, I found that the upper retainer wire had debonded. The patient was instructed to wear the re- movable retainer full-time while the laboratory made a new wire. The patient attended the surgery the following week and the new retainer wire was bonded in place. New vac- uum-formed retainers were fabri- cated after approximately two years. The patient continues to be seen every six months for her examina- tion and review. We were both delighted with the ABB treatment outcome. The compos- ite provided a long-lasting, natural restoration. At the three-year recall appointment, the edge-bonding had no chips or appreciable wear. No fur- ther polishing had been undertaken since the original treatment and only the very slightest loss of shine can be seen (Figure 8). At the next appoint- ment, I plan to spend a few minutes re-polishing. The patient has maintained the whit- ening beautifully, using the ‘three by three’ protocol - three days whiten- ing, three times per year. The patient was so pleased with the final result, she has since recom- mended several new patients to the practice (Figure 9). Most have pro- ceeded with similar minimally-inva- sive treatment. Offering alignment, bleaching and bonding is a very ef- fective way of attracting new clients. References Qureshi T (2011) Who needs veneers? Re-thinking the order of smile design planning. J Cosmet Dent 27(1): 86-94 Qureshi T (2016) Technique Tips – Composite Edge Bonding – the Re- verse Triangle Technique. Dent Up- date 43 (1): 95-97 Editorial note: The article was origi- nally published in Dentistry Issue February 2019 Dr Andy Wallace BDS (QUB) MClinDent Prosthodontics (KCL) MFGDP (RCS Eng) Dentist at Bachelors Walk Dental, & Vice President of the ESAO Andrew is a general dentist with special interest in Prosthodontics and Orthodon- tics and accepts referrals for full mouth rehabilitation, treatment of tooth wear, cosmetic dentistry and endodontics. AD Final Programme Ihssan Hamadeh, Syria Round Table Presentation: Gradia Plus: Aesthetics and Functionality Vincent Fehmer, Switzerland Round Table Presentation: Advances in Digital Dentistry – for your daily practice Elie El Khoueiry, Lebanon Round Table Presentation: Perspectives of CAD/CAM Technology Germen Versteeg, The Netherlands Round Table Presentation: Digital Denture Design with 3shape in Combination with 3D Printing on the Nextdent 5100 Axel Dittrich, Germany Round Table Presentation: How many types of zirconia do I need? 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Stanislav Shishkov, Bulgaria Round Table Presentation: How to Prepare Printed Metal for Porcelain 12 April 2019 Madinat Jumeirah Conference Centre | Dubai | UAE Round Table Trainings TABLE 1 TABLE 2 TABLE 3 TABLE 4 TABLE 5 TABLE 6 Session A: 10:00 - 11:30 Session B: 11:30 - 13:00 Session C: 14:00 - 15:30 Session D: 15:30 - 17:00 Session E: 17:00 - 18:30 Session A: 10:00 - 11:30 Session B: 11:30 - 13:00 Session C: 14:00 - 15:30 Session D: 15:30 - 17:00 Session E: 17:00 - 18:30 Session A: 10:00 - 11:30 Session B: 11:30 - 13:00 Session C: 14:00 - 15:30 Session D: 15:30 - 17:00 Session E: 17:00 - 18:30 Session A: 10:00 - 11:30 Session B: 11:30 - 13:00 Session C: 14:00 - 15:30 Session D: 15:30 - 17:00 Session E: 17:00 - 18:30 Session A: 10:00 - 11:30 Session B: 11:30 - 13:00 Session C: 14:00 - 15:30 Session D: 15:30 - 17:00 Session E: 17:00 - 18:30 Session A: 10:00 - 11:30 Session B: 11:30 - 13:00 Session C: 14:00 - 15:30 Session D: 15:30 - 17:00 Session E: 17:00 - 18:30 www.cappmea.com/dtim-2019 Tel: +97143476747 | Mob: +971502793711 | E-mail: firstname.lastname@example.org
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