s e l l i n g N o b e A c t i l v e ® a n d N o b e l P a r a l l l e ™ C C i m p l a n t s . GMT 60588 GB © Nobel Biocare Services AG, 2019. All rights reserved. Nobel Biocare, the Nobel Biocare logotype and all other trademarks are, if nothing else is stated or is evident from the context in a certain case, trademarks of Nobel Biocare. Please refer to nobelbicare.com/trademarks for more information. Product images are not evident from the context in a certain case, trademarks of Nobel Biocare. Please refer to nobelbicare.com/trademarks for more information. Product images are not evident from the context in a certain case, trademarks of Nobel Biocare. Please refer to nobelbicare.com/trademarks for more information. Product images are not evident from the context in a certain case, trademarks of Nobel Biocare. Please refer to nobelbicare.com/trademarks for more information. Product images are not evident from the context in a certain case, trademarks of Nobel Biocare. Please refer to nobelbicare.com/trademarks for more information. Product images are not necessarily to scale. Disclaimer: Some products may not be regulatory cleared/released for sale in all markets. Please contact the local Nobel Biocare sales office for current product assortment and availability. For prescription use only. Caution: Federal (United States) law restricts this device to sale by or on the order of a licensed dentist. See Instructions For Use for full prescribing information, including indications, contraindications, warnings and precautions. a v a i l a b l e f o r t h e O n 1 ™ B a s e T h e n e w X e a l s u r f a c e i s n o w a n d t h e M u l t i - u n i t A b u t m e n t . i T U l t r a i s a v a i l a b l e o n o u r b e s t W e ’ v e n o w e n t e r e d t h e M u c o i n t e g r a t i o n ™ e r a . s u r f a c e c h e m i s t r y a n d t o p o g r a p h y t o o p t i i m z e t i s s u e i n t e g r a t i o n a t e v e r y l e v e l . o f a p p l i e d a n o d i z a t i o n e x p e r t i s e . F r o m a b u t m e n t t o i m p l a n t a p e x , w e h a v e i r e m a g i n e d I n t r o d u c i n g X e a l a n d i T U l t r a – t w o n e w b r e a k t h r o u g h s u r f a c e s d e r i v e d f r o m o u r d e c a d e s S u r f a c e c h e m s t r y c e i l l s c a n ’ t r e s s t . i

Clinical MastersTM | issue 2020 | Contents CONTENTS Editorial Brendan Day TRIBUNE CME Global knowledge, delivered by world-class faculty in prime locations Clinical Masters™ Program in Esthetic and Restorative Dentistry Article Dr. Didier Dietschi Bioesthetic dentistry— a modern teaching array that embraces all aspects of esthetics and dental biomechanics, or how to restore smiles and function with conservative, often no-preparation, techniques Article Dr. Galip Gürel, Dr. Braulio Paolucci, Dr. Georgi Iliev, Dr. Dimitar Filtchev & Adriano Schayder The art of a personalized smile design Program The next level—Dr. Gürel Study Club Istanbul, Turkey Article Dr. Miguel Stanley Toxic dentistry? INTERVIEW Dr. Stavros Pelekanos Program Mastering contemporary prosthodontics Athens, Greece | Munich, Germany Faculty Favorites Clinical Masters™ Program in Advanced Implant Esthetics Program Anatomical surgery course with cadaver lab Brescia, Italy Article Dr. Giovanna Perrotti The changes social media has brought to businesses and how we interact with social media 03 06 08 16 24 28 32 34 36 38 42 Program INTERNATIONAL COURSES AT THE LAKE COMO INSTITUTE Lake Como, Italy | Paris, France 46 Program gIDE Master Clinician Program in Implant Dentistry 48 4 Clinical Masters™ Program in Modern Concepts in Restorative Dentistry Profile FRADEANI EDUCATION AT THE ACE INSTITUTE Pesaro, Italy 50 Article Dr. Mauro Fradeani & Dr. Federico Emiliani Do conservative and prosthetic restorations really represent a solution for carious disease? The answer to this question lies in the DMF index and in salivary analysis 52 Clinical Masters™ Program in Endodontics Profile Endo Inn–advanced training in endodontics Oslo, Norway Program Endo Inn–advanced training in endodontics Oslo, Norway INTERVIEW Dr. Gianluca Plotino Article Dr. Hugo Sousa Dias Management of intracanal separated instruments: A clinical case report Program Courses to share our passion for teaching and endodontics Athens, Greece | Brașov, Romania | Lisbon, Portugal | Porto, Portugal CLINICAL MASTERS™ TESTIMONIALS Clinical Masters™ Program in Periodontics and Restorative Dentistry INTERVIEW Dr. Giovanni Zucchelli Article Dr. George Goumenos The use of connective tissue graft for the treatment of multiple recession defects Program Ten days of mastering soft-tissue surgery Athens, Greece INTERVIEW Dr. Daniel Edelhoff & Dr. Otto Zuhr INTERVIEW Dr. Peter Wöhrle REGISTRATION FORM IMPRINT | about the publisher 58 62 66 68 74 76 78 82 86 88 92 94 96

Clinical MastersTM | issue 2020 | Presentation TRIBUNE CME Global knowledge, delivered by world-class faculty in prime locations The concept of the Tribune CME (contin- uing medical education) programs is based on a blended learning approach. Tribune CME’s mission is to deliver com- prehensive, advanced hands-on training in leading edge dentistry on a global scale through: – Intensive face-to-face clinical educa- tional sessions and practical training, conducted at specialized state-of-the art training facilities of prominent fa- culty members, in locations across the world. – Extensive self-study opportunities via a sophisticated e-learning platform, as well as ongoing support, live mentoring sessions with experts and peers via our webinars, premium online video train- ing on demand and the opportunity to collaborate with peers and the Tribune CME faculty. The result is an unmatched opportunity for dentists to achieve their most ambi- tious goals for professional development and their practice’s success. Programs are offered in: recognized by the American Dental As- sociation (ADA) and provide ADA CERP credits. ADA CERP is a service offered by the ADA to assist dental professionals in identifying quality providers of continu- ing dental education. “Tribune CME’s mission is to deliver comprehensive, advanced hands-on training in leading edge dentistry on a global scale.” • Esthetic and Restorative Dentistry • Advanced Implants Esthetics • Endodontics • Modern Concepts in Restorative Dentistry • Periodontics and Restorative Dentistry Upon successful completion, participants receive a Tribune CME certificate, which is also endorsed by the educational insti- tutions associated with Tribune CME. Personal branding opportunities: Tribune CME graduates may make use of the Cli- nical Masters™ Program logo to promote themselves and their practice both online and in print. Tribune CME programs are FIND US ON FACEBOOK! www.facebook.com/TribuneCME 6

Clinical MastersTM | issue 2020 | Esthetic and Restorative Dentistry | Article Bioesthetic dentistry— a modern teaching array that embraces all aspects of esthetics and dental biomechanics, or how to restore smiles and function with conservative, often no-preparation, techniques • biofunctional posterior adhesive resto- rations (direct, semidirect and indirect techniques); • conservative (interceptive and resto- rative) treatment of tooth wear; • anterior veneering techniques; and • BEF (better, easier, faster) digital dentistry (this program starts in 2021). Bioesthetics is the key philosophy of this education center. Bioesthetics refers to the comprehensive integration of biol- ogy and biomechanics (or biomimetics) into treatment planning, giving priority to conservative, often no-preparation, adhesive techniques. On the esthetic level, embracing the natural teeth and appearance of the smile, rather than uti- lizing stereotypes, is another key element of our teaching. We actually consider that finding individualized solutions to each patient’s needs and expectations rather than applying a standardized treatment approach is a crucial factor in performing dentistry on a high quality and ethical lev- el. This thinking process is deeply imple- mented across all topics covered in our programs. Educators and their objectives Teaching at Edudentinternational offers general and more specialized practition- ers a global overview of evidence-based protocols in the aforementioned domains and provides the information necessary for delivery of the highest level of dental care to their patients. The strength of Edudentinternational programs lies in both the excellence of clinical teaching and a strong scientific background, following a modern evidence-based practice phil- osophy. In fact, at Edudentinternational, Dr. Didier Dietschi Dr. Pascal Magne Dr. Didier Dietschi Edudentinternational, Geneva Smile Center, Geneva, Switzerland; senior lecturer in the Department of Cario- logy and Endodontics, School of Den- tistry, University of Geneva, Switzerland; adjunct professor in the Department of Comprehensive Care, Case Western Reserve University, Cleveland, U.S. Dentistry has undergone major develop- ments over the last several decades, ow- ing to a series of breakthroughs, starting with prevention and risk factor-oriented therapies, then adhesion and implantol- ogy. This has undoubtedly changed the way we treat our patients; for instance, preventive measures and implementa- tion of dental coaching instead of de- cay-oriented treatments will help future generations to maintain their dentition at a much healthier level so that the need for complex treatments will finally drop. However, in parallel, patients’ expec- tations and needs have evolved toward esthetics and metal-free, tooth-colored restorations, while modern times have made life more active and demanding. As a consequence, the incidence of formerly infrequent pathologies has risen tremen- dously; for instance, tooth wear (erosion and attrition) and cracked teeth have be- come common dental emergencies and requests for comprehensive treatments. In short, the modern dental practice is under high demand for ultimate esthetics while having to respond in parallel to chal- lenging biomechanical conditions. There is no doubt that the profession now has to adapt to these new tasks and implement its global competence in modern treat- ment concepts and clinical protocols. The courses at Edudentinternational are consequently focused on some of the most current topics in dentistry, covering the following in depth: • anterior freehand bonding (anterior composite restorations in all their variations); 8

Clinical MastersTM | issue 2020 | Esthetic and Restorative Dentistry | Article strict we have abolished classical (and declin- ing) scientific evidence-based concepts (using merely scientific data), which have proved too often to be dis- connected from clinical reality or simply are relevant to another environment. Academic, social and private environ- ments largely differ from each other. Our teachers are both acclaimed clinicians and scientists. The scientific and clinical director of Edudentinternational pro- grams is Dr. Didier Dietschi (PhD, Academisch Centrum Tandheelkunde Amsterdam, Netherlands; DMD, Univer- sity of Geneva, Switzerland), who teaches at the University of Geneva and Case Western Reserve University. Edudent- international is privileged to benefit from the cooperation of Dr. Pascal Magne (DMD and PhD, University of Geneva), who runs the program on anterior veneering techniques. Dr. Magne is an associate professor of esthetic dentistry at the Herman Ostrow School of Dentist- ry of the University of Southern Califor- nia, Los Angeles, U.S. Education center and location The education center is located at the Geneva Smile Center, a group practice where Dr. Dietschi works (www.geneva- smilecenter.ch). The center is ideally lo- cated close to the iconic water fountain, the Jet d’Eau, and within walking distance to all hotels, shops and restaurants in downtown Geneva. The very popular old town is only 10 minutes from the Geneva Smile Center and can be conveniently reached on foot to discover its many bou- tiques, galleries, bars and restaurants. The center comprises a lecture room and dedicated workshop area. All work- stations are equipped with ZEISS mi- croscopes and provide attendees with a comfortable environment and complete instrumentation to perform all proce- dures. For participants, the concept is to arrive with a smile, strong motivation and their hands in their pockets, everything else being provided by the center. At the demonstration station, the microscope has 4K visual capability and a special light 10 Figs. 1–6 Figs. 7–12

Clinical MastersTM | issue 2020 | Esthetic and Restorative Dentistry | Article Case 2 (Figs. 14–18): A typical example of a no-preparation smile rehabilitation using composite in a young patient (16 years old) after unsuccessful ortho- dontic space closure to treat lateral incisor aplasia. 12

Clinical MastersTM | issue 2020 | Esthetic and Restorative Dentistry | Article Case 4 (Figs. 24 & 25): Before and after views of both maxillary and mandibular arches after interceptive treatment of tooth wear, using a no-preparation approach and freehand composite placement. new demands. Composites and adhesive techniques have thus become the foun- dation of modern restorative dentistry, owing to tremendous improvements in material mechanical performance, wear resistance and esthetic potential. Com- posite resins are currently used in a broad range of situations, including the treat- ment of initial decay to the restoration of extensive and serial cavities, including the esthetic and functional rehabilita- tion of patients with severe tooth wear. However, polymerization shrinkage of the resin matrix and in-mouth material application are still crucial issues (even with bulk filling technology) that impose certain limitations on the use of direct techniques. Therefore, restorative op- tions such as semidirect, CAD/CAM (chairside or in-laboratory) and indirect techniques have to be considered for large and deep cavity configurations or nonvital teeth. The lecture thus provides an overview of decision criteria for the treatment of posterior teeth with direct or luted restorations. The choice of material in consideration of tooth biomechanical status has to be discussed with reference to special bio- mechanical conditions such as cracked tooth syndrome and nonvital teeth. Actually, optimal restorative scenarios rely on proper evaluation of the residual tooth structure quality (vitality or nonvi- tality), pulpal status (symptom absence, pain on pressure, sensitivity to cold, or pulpitis) and crack extent in order to assess which material, preparation ap- proach and restorative technique is to be applied. New, improved concepts related to tooth preparation and cavity lining, as well as luting procedures, are presented in this program, and these lead to a simplification of clinical pro- cedures and superior results in indirect restorations. 3. Conservative (interceptive and restor- ative) treatment of tooth wear Tooth wear represents a frequent pathol- ogy with multifactorial origins. Behavioral changes, an unbalanced diet, and various medical conditions and medications in- ducing acid reflux or influencing salivary composition and flow rate trigger tooth erosion. Awake and sleep bruxism, which nowadays are widespread functional dis- orders, induce attrition. It has thus be- come increasingly important to diagnose early signs of tooth wear so that proper preventive and, if needed, interceptive and restorative measures can be taken. Such disorders have biological, functional and esthetic consequences. After a com- prehensive clinical evaluation, treatment objectives, such as a proper occlusal and anatomical scheme, as well as a pleasing smile line, are usually set on models of anterior teeth or a full-mouth wax-up, depending on the severity of tissue loss. Based on the new vertical dimension of occlusion set on the articulator, combi- nations of direct, semidirect and indirect restorations (using composite resins or monolithic high-strength ceramics) can help to reestablish proper anatomy and function. The use of adhesive and ultra- conservative techniques has proven its potential, in particular for the treatment of moderate to advanced tooth wear. A modern approach to treating tooth wear involves specific and detailed treatment planning that considers etiology, risk factor control and the biomechanical status of each tooth to be treated. The program on tooth wear reviews re- cent knowledge and clinical concepts related to preventive measures, various forms of early restorative interventions (using adhesive techniques) and restor- ative options (usually more complex and leading to a more extensive treatment approach). Their respective potential to restrict ongoing tissue destruction and to restore function and an attractive smile in the long run is explored through 20 years of clinical experience and re- lated literature (modern evidence-based dentistry). 14

Clinical MastersTM | issue 2020 | Esthetic and Restorative Dentistry | Article The art of a personalized smile design Dr. Galip Gürel Private practice in Istanbul, Turkey; visiting professor in the Department of Prosthodontics, College of Dentistry, New York University, New York, U.S. Dr. Braulio Paolucci Private practice in Barbacena, Brazil Dr. Georgi Iliev Assistant professor in the Department of Prosthetic Dental Medicine, Faculty of Dental Medicine, Medical University of Sofia, Bulgaria Dr. Dimitar Filtchev Associate professor in the Department of Prosthetic Dental Medicine, Faculty of Dental Medicine, Medical University of Sofia, Bulgaria Adriano Schayder Certified dental technician at WELL LAB, São Paulo, Brazil Esthetics has become one of the most im- portant outcomes of dental treatments. Regardless of the complexity of the case, patients are seeking better-looking smiles. For many years, we, as dentists or laboratory technicians, have been us- ing all the basic esthetic rules in order to properly create a smile design. These rules should be fundamental to the de- sign. At the end of the treatment, the pa- tients should feel happy. If one can evoke this feeling with a smile design, both the dentist and the patient will be satisfied giving and receiving more than standard, well-aligned teeth. However, the final es- thetic results may often fail to meet the patient’s expectations, owing to a dis- harmony between the smile design and the patient’s identity. Patients’ demands and the level of information needed have driven the profession to question itself regarding the customization of smile de- signs, which if ignored may lead to dissat- isfaction with the esthetic outcome, even though all the esthetic principles and rules which tend to establish standards have been taken into account. The mock-up Visualization of the smile design will have a great impact on the patient’s under- standing of the rest of the treatment. It is much more powerful than only ver- bally explaining what will be done. Prior to initiating any treatment, it is necessary to visualize the desired outcome. It then becomes possible to formulate the steps required to achieve this result. Mock-ups facilitate significant improve- ment in communicating with the patient by showing him or her the potential final outcome of the treatment and allow- ing an easy comparison of the pre- and postoperative situations, and mock-ups allow the clinician to be able to check the functional aspects. Whether it is a case of worn dentition that requires altering the vertical dimension or just a straightfor- ward veneer case, the esthetic plane of occlusion and function will be based on 16

Clinical MastersTM | issue 2020 | Esthetic and Restorative Dentistry | Article Figs. 2a–c: The aim of this esthetic treatment was to enhance the patient’s smile. However, additional to all the esthetic smile design basics, the facial analysis and the personality of the patient should be reflected in this design, in order to create the most natural, minimally invasive, personalized smile design. – Delicate: oval dental shapes, medium dominance, curved incisal edge and standard 3D dental positioning. – Calm or stable: smoothly rounded square dental shapes, weak dominance (current symmetry), horizontal inci- sal edge and 3D rectilinear or standard dental positioning on the arch. The case presentation The patient had short teeth and was not happy with the narrow buccal corridors and the yellowish color of her teeth (Figs. 2a–c). Esthetic analysis and Rebel Simplicity Esthetic design can be challenging for dentists. Rebel (Visagismile) is a recent digital previsualization technique that allows the clinician to: – efficiently design the new smile; – improve the communication between the dental team members involved in the treatment; – obtain better communication and achieve better patient motivation; and – visualize the final esthetic result even before the treatment is started. 3D Rebel smile design plays an important role in the entire treatment planning and will guide the actual clinical treatment. This approach makes it possible to share the treatment plan among team mem- bers and to create a 3D visualization of the case in the patient’s mouth. The digital project will be tested and ap- proved even before starting the actual treatment. Accordingly, it will allow the dentist to present the treatment solution. The Rebel workflow Rebel offers probably the simplest steps for transferring all the necessary infor- mation to the Rebel digital laboratory. These are the three mandatory steps: 1. a single mock-up on a central incisor to be digitally scanned; 2. a full-face photographic protocol; and 3. a simple questionnaire. 18

Clinical MastersTM | issue 2020 | Esthetic and Restorative Dentistry | Article Fig. 5: The optimal tooth shape is determined with the help of the interview. The questionnaire is based on popular psychological tests of personal self- assessment. The first question is an adapted test by Dellinger10 and the other three questions concern personality traits based on the theory and ques- tionnaire by Eysenck and Eysenck.11 The questionnaire is checked by a computer algorithm to classify the patient’s personality. Based on the data from the interview, a software algorithm automatically calculates the temperament as perceived by the patient. The temperament is a combination of strong, dynamic, delicate and calm. After this procedure is done, the dentist and/or the technician will have a full idea of the facial analysis and the personality of the patient. Full-face photograph in rest position This photograph is for the automatic fa- cial recognition process of the software, and part of the new Rebel smile design will be based on this facial analysis of the patient. Technically, it is very important that the forehead and the ears of the pa- tient are visible. If the patient has long hair, it should be held away from the face. It is crucial to keep the head upright (not tilted to the right or left, or up or down), preferably positioning the eyes parallel to the horizon and keeping the lips apart. The software automatically checks the required full-face photograph and sends a message immediately to the dentist if the necessary technical requirements have not been met so that he or she can retake the photograph. Full-face photograph of patient smiling Keep the patient in the same position with the eyes open and parallel to the horizon and the head upright (not tilted to the right or left, or up or down). This time, ask the patient to keep his or her lips apart in a soft smile (if possible, ensure the in- cisal edges of the maxillary incisors are displayed). Photograph of face in 12 o’clock position There are two simple ways of taking this specific photograph. An easy way is to keep the patient in the same position and ask him or her to incline his or her face 45° forward while giving a full smile, tak- ing the photograph so that it shows the relationship to the maxillary central in- cisors and the displayed arch position to the lower lip line. The dentist can also move the patient to a supine position on the dental chair and to the 12 o’clock po- sition, ask him or her to smile fully, and take the photograph from a 45° angle. Full-face photograph with mouth closed and lips retracted The patient should be asked to hold the full-mouth retractors, again keeping the position of the eyes parallel to the hori- zon and his or her head upright (not tilted to the right or left, or up or down), and keeping his or her teeth closed and the occlusal plane parallel to the horizon. Full-face photograph with mouth open and lips retracted The same protocol as for the mouth closed should be repeated, but this time with the teeth (upper and lower jaws) sep- arated. Questionnaire An interview to reveal the character and the personality of the patient is com- pleted through a questionnaire available in the software and gives the dentist the primary and complementary characters of the patient (Fig. 5). The temperamen- tal type of each individual is defined by a unique combination of diverse charac- teristics of the four main temperaments, 20

Clinical MastersTM | issue 2020 | Esthetic and Restorative Dentistry | Article Figs. 7a–d: After the STL file has been 3D-printed (a), the dentist can easily transfer this design to the patient’s mouth by making a silicone impression of the digital wax-up (b). The harder this silicone transfer impression, the more precise this transfer will be, in order to duplicate all the details, such as the line angles that give the ideal shape of the teeth, as well as surface texture. This transfer should be done prior to everything. The dentist should evaluate the new design well before starting the tooth preparation with the APT (Aesthetic Pre-evaluative Temporaries) or as the final mock-up. This way, not only the ideal 3D smile design, but also a great 3D communication opportunity, will be given to the dentist and the patient. The final esthetic design should be approved at this time. Figs. 8a–d: Once the final design has been approved by the dentist and the patient, the dentist can anesthetize the patient and start preparing the teeth through the APT (Aesthetic Pre-evaluative Temporaries). As soon as the teeth have been prepared, it is then the choice of the dentist to continue the case digitally, by taking an intraoral digital scan, or to continue with the conventional analog way. The patient leaves with the provisionals. Back to chairside/3D printing This STL file is then sent to the den- tist via email, ready to be 3D-printed (Figs. 7a–d). Tooth preparation through the Aesthetic Pre-evaluative Temporaries The design of the APT (Aesthetic Pre-evaluative Temporaries). creates a very solid reference for the tooth prepa- ration. With the use of a depth cutter, the dentist can start preparing the teeth through the APT. His or her work will lead to the most minimally invasive tooth preparation (Figs. 8a–d).5, 6 Porcelain laminate veneers are tried-in and after the esthetic acceptance of the patient and the dentist, they are bonded to the teeth under rubber-dam isolation. (Figs. 9a–c). Conclusion The combination of the basic rules of es- thetics together with the reflection of the facial analysis and the personality of the patient in the smile design creates a 22

Clinical MastersTM | issue 2020 | Esthetic and Restorative Dentistry | Program The next level— Visual identity of the smile: Analog versus digital Dr. Gürel Study Club Istanbul, Turkey Course dates Advanced smile design hands-on work- shop: Oct. 16–17, 2020 Venue: the St. Regis Istanbul hotel Dr. Galip Gürel, course director and pre- senter Depending on the nature of the courses, some modules will be run digitally. The courses are continually updated de- pending on the evidence-based changes in dentistry. The nature of our courses, which are limited to 25–30 participants, creates a very interactive atmosphere. Dr. Galip Gürel graduated from the Uni- versity of Istanbul, Dental School in 1981. He continued his education at the Uni- versity of Kentucky College of Dentist- ry, Lexington, U.S., and received his MSc from Yeditepe University, Istanbul. He has been practicing in his own clinic in Istanbul, specializing in esthetic dentist- ry, since 1984. He is a visiting professor at New York University, U.S.; University of Aix-Marseille, France; and Yeditepe Uni- versity. In October 2014, Dr. Gürel received the Irwin Smigel Prize in Aesthetic Dentistry, which is granted biennially by the New York University College of Dentistry to honor the best esthetic dentists in the world for their social contribution, their support for the improvement of esthetic dentistry, their vision and determination, and their ability to present innovative ideas around dentistry globally, and the education they provide to dental health professionals on advanced esthetics, technology and new techniques in gener- al dentistry. 24 Dr. Gürel is the editor-in-chief of the Quintessence magazine in Turkey (Quin- tessence Türkçe). He is the author of The Science and Art of Porcelain Laminate Veneers (Quintessence, 2003), which has been translated into 12 languages. Dr. Gürel has lectured on dental esthet- ics all over the world and given post- graduate lectures on esthetic dentistry. He was the president of the European Academy of Esthetic Dentistry for 2011 and 2012, and is the founder and hon- orary president of the Turkish Academy of Esthetic Dentistry. Dr. Gürel is also a member of the American Society for Dental Aesthetics and American Acade- my of Restorative Dentistry, and an hon- orary diplomate of the American Board of Aesthetic Dentistry. Topics covered in different modules Basic introduction to the APT concept – The story of APT (Aesthetic Pre-evaluative Temporaries) – The story of silicone indexes – The story of preparation using the APT technique – Basic analog workflow for anterior bonded porcelain restorations Video of recorded cases (full-high-definition) – Tooth preparation by Dr. Gürel (video) – Smile design – Mock-up and wax-up – Preparation of silicone indexes in the laboratory or chairside – Analysis of the smile with the indexes – Esthetic pre-recontouring (if needed) – APT – Evaluation of the esthetics using the APT – Evaluation of occlusion using the APT – Evaluation of phonetics using the APT • Tooth preparation using the APT • Using depth cutters • Using extra-fine diamond burs • Finishing the margins • Utilizing loupes and a microscope • Customizing Arkansas stone burs for finalizing gingival margin prepara- tions • Using Sof-Lex paper discs (3M) du- ring preparation – Handling exposed dentin at the time of preparation – Impression taking using retraction cords (if needed) – Provisional restorations (discussion of different techniques depending on different indications)

Clinical MastersTM | issue 2020 | Esthetic and Restorative Dentistry | Program – Treatment options – Opening the vertical dimension of occlusion (restorative dentistry, orthodontics, or a combination of both?) – Details on decision-making – Esthetic mock-up versus functional mock-up – Esthetic plane of occlusion – Defining the exact vertical dimension of occlusion – Customized jig preparation – Kois deprogrammer – Retral contact position versus intercuspal position – Tooth preparation: posterior versus anterior – Adjusting the occlusion – Contact points to keep and not to keep – Chewing motion in functional fine- tuning Istanbul Where to stay The course venue is in the Nişantaşı area, which is within walking distance to Taksim Square. In Taksim, there are many three- or four-star hotels, but if you would like to stay in a stylish hotel, choices include the St. Regis Istanbul, the Stay Nişantaşı (5-minute walk to the venue), the Stay Bosphorus (3,7 km from the venue), 10 Karaköy and Georges Hotel Galata (both 4 km from the venue, a 15-minute taxi drive). What to see If it is your first time in Istanbul, it is time to discover and experience the city—feel, smell and taste it! Istanbul is the connec- tion between East and West, where the ancient and modern cities are side by side. Walk down Istiklal Street from Taksim to Beyoğlu, tasting kokoreç or midye dol- ma on the way. Go to the Blue Mosque and Hagia Sophia Museum and experience the ancient Turkish bath. The Grand Bazaar is not to be missed, and certainly you should not go back home before visiting Ortaköy and walking to Bebek near the Bosporus. pression for the provisional restorati- ons – Making the provisional restorations using the RSVP (Rapid Simplified Ve- neer Provisionals) technique (Cosme- dent, Chicago, U.S.) – Rechecking the provisional restorati- ons for esthetics Live application of the Rebel 3D digital wax-up – The 3D-printed model from Rebel is analyzed. – An impression of the 3D-printed model is taken with a silicone impression ma- terial. – Producing the APT (Aesthetic Pre- evaluative Temporaries) from the sili- cone impression in the patient’s mouth. – Checking the final outcome. Bonding adhesives – Update on dental adhesives – The hybrid layer – Compositions of the adhesive systems – Classifying the adhesive systems in the – Possible postoperative problems – Light sources (important or not) Video of recorded cases on bonding (full-high-definition) – Bonding of porcelain laminate veneers by Dr. Gürel – Removing provisional restorations • Try-in • Whether or not to use a dental dam • Surface treatment of the prepared tooth surface • Surface treatment of the intaglio surface of the porcelain restoration – Seating the porcelain restoration – Bonding the porcelain laminate veneers – Light-activated polymerization (techni- que for minimally invasive margin clean- ing) – Final cleaning (burs or what?) – Checking the esthetics and occlusion Digital versus analog regarding function- al esthetics – Diagnosis – Differentiating bruxism from other most simplistic way types of wear – Total etching versus self-etching – Advantages and disadvantages: when to use which one – Occlusal dysfunction versus a constric- ted envelope – Equilibration 26

Clinical MastersTM | issue 2020 | Esthetic and Restorative Dentistry | Article Toxic dentistry? tion and has been an expert for the online education platform DentalXP since 2009. Last year, Dr. Stanley hosted a documen- tary on the new boundaries of dentistry for National Geographic, and he has even given a TED Talk on the future of the den- tal profession. He was nominated one of the top 100 dentists in the world by his peers in 2020. He is married with chil- dren and loves to cook and play his guitar. According to market research company Industry Research, the global dental market is expected to grow at a compound annual growth rate of 5.5% until 2025 and is expected to reach U.S.$37.16 billion by 2025, from U.S.$30.05 billion in 2019.1 These numbers are massive, so massive that it is difficult for me comprehend them, despite having been in the industry for 22 years professionally. The business of dentistry is so complex, so large and so multifactorial, and means so many different things to almost every- one in the industry. It changes from cul- ture to culture and from demographic to demographic. It is even practiced dif- ferently depending on how old you are, what part of the city and country you live in, and what kind of resources you have, let alone your specialization. Yet, this can all be captured in a number. That is very curious. Because the more I learn about the dental industry, the more I see that, in many parts of the world, dentistry is truly and only financially driven. We see the growing trend of the dental service organization business model in the U.S.; it has also had great success in the U.K., Spain, Australia and a few other countries around the world. These service com- panies offer the practitioner the oppor- tunity to relinquish the difficult part of managing a clinic to a financial organi- zation so that he or she can focus mainly on the practice and the art of dentistry. But is this truly happening? Is dental care becoming better as a result of this? It should be. We also still have the classical business model of a privately owned clinic with one or more partners working hard to make a living and dealing with growing competition and staying relevant in the marketplace. We also have dentistry per- formed in hospitals in some countries and the obvious government programs, such as the U.K.’s National Health Service, that are a case study in more ways than one. Dr. Miguel Stanley Dr. Miguel Stanley is the clinical director of White Clinic, based in Lisbon, Portugal, and founded 20 years ago. He is a pas- sionate advocate for high-quality dental care, and his career has consequently been focused on restoring smiles with his interdisciplinary team, using state-of- the-art technology, software and materi- als, according to a strong sense of ethics and in pursuit of minimal invasiveness to better protect his patients. This is the rea- son that he created the No Half Smiles treatment philosophy and Slow Dentistry, both aimed at improving the patient ex- perience and the overall quality of care. Based on his training in implant dentistry, cosmetic dentistry and functional occlu- sion, Dr. Stanley has developed an ad- vanced biological cosmetic dentistry ap- proach to his work that incorporates the full scope of action of modern dentistry. He spends most of his time managing his longtime team and learning about new technologies in dentistry. Dr. Stanley has given over 200 keynote lectures in more than 50 countries, and his lectures are critically acclaimed by dentists of all ages and specialties for the open dialogue and simple and beau- tiful manner in which complex cases are presented. He is the vice president of the Digital Dentistry Society and a member of many implant and cosmetic dentistry societies around the world. He is an am- bassador for the CleanImplant Founda- 28

Clinical MastersTM | issue 2020 | Esthetic and Restorative Dentistry | Article dentists the masses choose. Why? Be- cause of the cost. The public will choose a clinic because of price, location, market- ing and insurance coverage over clinics that have invested in education, technol- ogy, trained dentists and quality proce- dures and that follow gold standard pro- tocols on everything from sterilization to surgical procedures. These are per- ceived as expensive. Thus, fast, affordable solutions—which work wonders in many industries—have pervaded dentistry, and there are many companies and clinics making huge profits off this. I believe that, if there was better informa- tion given to the public, this would end. The mass marketing dentistry to the gen- eral public has not really changed in the last 20 years. Biology and mechanics are the same all around the world, and each mouth reacts the same way to bacteria and trauma and dental treatments in gen- eral. So why is it that the top scientists and clinicians around the world are focused on quality and doing the right thing, and so many in the industry and most of the public are focused on price and quick fix- es? Is it even possible to have it all—fast and cheap and good? I do not know. I, for one, at my clinic have not been able to do this—and I have really tried. Let us consider some things that should be ubiquitous and always in place before seating a patient in the chair: • The clinic should be fully licensed, as well as all the dentists and team mem- bers, according to local law. • The clinic should be equipped for per- forming all basic dentistry protocols, such as radiographs, extractions and fillings. I say this as some clinics do not have radiographic units and do not of- fer panoramic radiographs, let alone CBCT scans, prior to doing a check-up. I find this alarming. How can you do a complete check-up just by looking at the teeth and gingivae? • All rooms should be disinfected, and not just tidied up, before seating a pa- tient. This takes up to 8 minutes in most cases. In some countries, the average time for an appointment is 15 minutes. This seems to leave insufficient time for proper disinfection. This is one of the foundations for my Slow Dentistry movement: Take the required amount of time to disinfect. Proper disinfection cannot be done in a rush. Hands should be properly washed, and all instruments correctly disinfected and properly packed, and then a decent amount of time should be spent explaining to the patient what will done, the costs, the risks, the consequences and other al- ternatives. This time is a fundamental part of the medical aspect of our pro- fession. • Obviously all treatments should be up to date with the latest science and clinical evidence. I am the first person to say that the more I know about dentistry, the less I seem to truly understand why our profession does not have a more relevant role in society, as I believe that our teeth are a major part of our overall health. It took me 20 years to understand some very basic principles, but I guess dentistry is very much like life itself. You know less as you learn more. The truth of the matter is that most den- tists learn biology, biomechanics, dental anatomy, medicine and a huge array of other very important sciences that are then all wrapped up into making us den- tists. That journey is taken by hundreds of thousands of young men and women around the world every year and will re- sult in them joining the roughly 2 million dentists practicing around the globe. Yet, the truth of the matter is that very little connects us all, apart from the fact that we are dentists, because we are individ- uals before we are dentists. And like in politics, religion or sports, we all have our way of seeing the world, and this affects our behavior and our way of thinking and working. But let us get back to basics. What is den- tistry? I have asked this question to den- tists, young and old, around the globe, as I have now lectured in over 50 countries. I truly have met many amazing profes- health, so it is more profitable, and prod- ucts that are an easy sell and fast to com- municate, such as bleaching, veneers and aligners, are in fact way more appealing to the end consumer. But what about a patient with a cyst wrapped around one or more of the teeth involved in a cos- metic treatment that is performed by a well-intentioned practitioner who sees no reason to take a CBCT scan or a panoram- ic radiograph, as it is merely an esthetic treatment? What then? Who is there to protect the patient? To make sure that his or her oral health is protected and en- sured? I have seen in my own office many times in the past two decades patients who pres- ent wearing traditional orthodontic appli- ances and have cavities and active gingivi- tis, yet no time was taken by the previous practitioner to ensure that the mouth was cavity-free and the gingivae were healthy. Why? We will never truly know, but I pre- sume that it would have taken a great deal of time to go into that with some- one who just wanted straight teeth, and moreover, it would have increased the overall cost of treatment. Quite honest- ly, people are playing Russian roulette with their health and smiles, depending on where they go to fix their teeth. The irony is that those who really are best equipped to diagnose and treat patients to the highest level are usually the last 30

Clinical MastersTM | issue 2020 | Esthetic and Restorative Dentistry | Interview INTERVIEW with Dr. Stavros Pelekanos Jeremy Booth & Nathalie Schüller, DTI : Dr. Pelekanos, you are the course direc- tor of the course on mastering contem- porary prosthodontics, which begins in Athens in March. What would you say to dentists who are considering the benefits of taking part in the program? First of all, I would like to thank you for the opportunity for this interview. It was always one of my dreams to organize a comprehensive prosthodontic course from A to Z, something that is not com- mon, as most of the available courses, at least in Europe, have a surgical back- ground. The course covers treatment planning, modern approaches to CR, vertical dimension of occlusion, various occlusal appliances, modern minimally invasive procedures in terms of touching and preparing teeth, restoring endodon- tically treated teeth and implant resto- rations, from single-tooth to full-mouth restorations. I have the honor of being supported in the course by some of the best clinicians in prosthodontics, among them Drs. Ilia Roussou, Andrea Ricci, Francesco Mintrone, Nazariy Mykhaylyuk, Florin Cofar and Daniel Edelhoff. Prosthodontics is considered to be the basic foundation of clinical dentistry. Which of the core steps involved in prosthodontics have changed most dra- matically with the introduction of new technologies into the dental practice? That is true; the prosthodontist is the architect, especially when it comes to full-mouth rehabilitation. Unfortunate- ly, most universities do not provide adequate training in prosthodontics. Moreover, new technologies are de- veloping so rapidly that what students learn today becomes out of date fast, changing after five years. The major steps Dr. Stavros Pelekanos received a DDS in 1991 from the National and Kapo- distrian University of Athens, Greece. In 1993, he obtained a doctoral degree in prosthodontics from the University of Freiburg, Germany. After his prof- essional training, he established a pri- vate practice in Athens specializing in, implantology and esthetic dentistry. In 2002, he was appointed as a full- time lecturer at the Department of Prosthodontics, School of Dentistry, National and Kapodistrian University of Athens, and in 2012 assistant prof- essor in the same department. He is a faculty member of gIDE Institute, Los Angeles, California, U.S., and lec- tures internationally and gives hands- on courses on implants, esthetics and restorative procedures. To date, he has published over 20 articles in peer- reviewed journals and three chapters in books. 32 of In 2008 and 2011, Dr. Pelekanos re- ceived second and first prize at the scientific award competition of the European Academy Esthetic in Madrid, Spain, and Dentistry held Istanbul, Turkey, respectively. Since 2013, he has been an active member of the European Academy of Esthetic Dentistry. His other professional affilia- tions include the International College of Prosthodontics, European Prosthodon- tic Association and Greek Prosthodontic Society. “...the prosthodontist is the architect, especially when it comes to full- mouth rehabilitation.”

Clinical MastersTM | issue 2020 | Esthetic and Restorative Dentistry | Program Mastering contemporary prosthodontics Athens, Greece | Munich, Germany Dr. Stavros Pelekanos, course director Dr. Ilia Roussou, course presenter Prof. Daniel Edelhoff, course presenter Dr. Francesco Mintrone, course presenter Dr. Nazariy Mykhaylyuk, course presenter Dr. Andrea Ricci, course presenter 34 – Occlusal concepts in modern prosthodontics Live demonstration Part I (live patient and hands-on) – Photographic documentation, initial impressions, facebow registration March 7: Dr. Pelekanos and Roussou Theory – Treatment position according to the prosthetic space – Occlusal registration (centric relation or maximal intercuspal position) – Alteration of the vertical dimension of occlusion according to the prosthetic space – Use of anterior deprogrammers and occlusal splints – Diagnosis and treatment sequence for full-mouth rehabilitation – Live demonstration Part II (live patient and hands-on) – Anterior deprogrammer, stabilization appliance, mounting of models in the articulator March 8: Dr. Ricci Theory – Digital smile design and its contribu- tion to prosthodontics (how to become the architect of the smile) 1. Why adopt the digital smile design philosophy? 2. What are the advantages of digital smile design? 3. Interview and photographic documentation 4. Diagnosis of functional and esthetic issues 5. Facially generated treatment planning 6. Conversion of the planning to an STL file for printing This one-year curriculum provides com- prehensive training in the field of prost- hodontics, from clinical evaluation and documentation at the first appointment until the final delivery, including basic steps throughout the treatment. In all sessions, live patient demonstrations and hands-on practice will be performed. At the end of this course, participants should be able to complete a prosthet- ic restoration, from ceramic veneers to full-mouth cases, using updated modern concepts. Course dates Module 1 March 6–8, 2020, Athens, Greece Module 2 May 29–31, 2020, Athens, Greece Module 3 Oct. 4–6, 2020, Athens, Greece Module 4 Oct. 30–31, 2020, Munich, Germany Module 1 March 6: Drs. Pelekanos and Roussou Theory – Concepts of modern prosthodontics (esthetic and functional analysis) – Case analysis (esthetic and functional analysis) – Initial impressions in the analog and digital workflow – Diagnosis and diagnostic procedures – Dental photography (digital case design) – Articulators and facebows: which ones and when to use them Live demonstration Part III – Photographic and video documen- tation (live demonstration) – Design of the new smile (live demon- stration on the iPad app and/or Keynote)

Clinical MastersTM | issue 2020 | Faculty Favorites Some favorites of our faculty MANI D Finders “One of the most common challenges in clinical endodontics is obtaining patency in blocked, calcified or challenging anatomies. D Finder is my key to obtaining success in these cases.” “Photography is my passion and for me, the best way I have to relax and enjoy my free time.” Dr. Hugo Sousa Dias © Dr. Hugo Sousa Dias “I am thrilled about my new channel for sharing my experience, tips and tricks in the world of endodontics.” Dr. Gianluca Plotino © Dr. Gianluca Plotino “What better way to relax than going kitesurfing?” Dr. Stavros Pelekanos © Dr. Stavros Pelekanos 36

Clinical MastersTM | issue 2020 | Advanced Implant Esthetics | Program Anatomical surgery course with cadaver lab Brescia, Italy Prof. Mauro Labanca In 1986 earned his MD from the Univer- sity of Milan, Italy, where he also qualified in dentistry and general surgery. In 2006, he created and directed the first master program in marketing and communica- tions in medicine and private dentistry, at IULM University in Milan. From 2007 to 2013, he was a consultant professor of oral surgery in the department of den- tistry at the Vita-Salute San Raffaele University, Milan. He has practiced oral surgery and implantology since 1992 in his private dental office in Milan’s city center. Since 2001, he has been director of the anatomical surgery course with cadaver lab at the institute of anatomy at the Medical University of Vienna, Austria, and at the institute of anatomy at the University of Brescia, Italy. Since 2008, he has been a consultant professor of anatomy in the department of medicine at the University of Brescia. located Prof. Labanca is co-author of the books Anatomia chirurgica per l’odontoiatria (Elsevier Masson, 2014) and Guida clinica e anatomica alla chirurgia orale (Quin- tessence, 2020), and co-editor of the book Clinical, Neurochemical and Experi- mental Aspects of Orofacial Pain in Den- tistry (Research Signpost, 2010). He has written several scientific articles pub- lished in impacted reviews. He is the author of the DVD Anatomical Approach in Oral Surgery: Guidelines for an Aware Practice (Tueor Servizi, 2019) and author of the DVD Sutures in Dentistry: Materials and Knotting Techniques (ETHICON, 2018). He is an international speaker and key opinion leader for many leading dental companies. In 2009, Prof. Labanca co-founded the Società Italiana Studio Dolore Orofa- ciale [Italian society for the study of oro- facial pain]. At the International College of Dentists (ICD), he is the Regent of the Italy district, Registrar of the European section, and an international Councilor for the international board. Course dates Anatomical surgery course: March 26–28, 2020 Anatomical surgery course: October 22–24, 2020 European Association for Osseointegration master clinician course: March 11–13, 2021 Prof. Mauro Labanca, director and coordinator Prof. Luigi F. Rodella, scientific coordinator 38

Clinical MastersTM | issue 2020 | Advanced Implant Esthetics | Program DAY 2 DAY 3 08:30–11:30 | Dissecting room – Completion of the procedures of the 09:00–14:00 | Dissecting room – Completion of the procedures of the previous day 11:30–12:30 – Description of the anatomy of the previous day – Dissection of the extraoral regions 14:00–16:30 – Control of arterial bleeding and techni- ques for hemostasis – Prevention and management of failures – Nerve damage and pain management in dentistry 16:30–17:00 Closure of the course and award presentation For more information: www.maurolabanca.com Contact: mauro@maurolabanca.com Program DAY 1 09:00–10:00 – Presentation of the faculty and tutors, introduction to the course and instruc- tion on the behavior to be observed in the dissecting room – Instruction on how to use the material made available to participants upper jaw 12:30–13:00 – Description of the surgical techniques applicable to the upper jaw: elevation of a flap, elevation of the maxillary sinus by crestal access with osteotomes and elevation of the sinus via a vestibular approach, elevation of the nasal floor, reconstruction of atrophic areas, ridge expansion, and suturing 14:00–18:00 | Dissecting room – Execution of the surgical techniques described in the previous session (par- ticipants will carry out autonomously, under tutorial guidance, all interven- tions via a surgical approach, but the areas of risk will be pointed out by ana- tomy specialists) 10:00–11:00 – Description of the anatomy of the lower jaw 11:00–11:30 – Description of the surgical techniques applicable to the lower jaw: elevation of a flap, placement of implants in areas of high esthetic areas, harvesting of bone from the chin, lateralization of the infe- rior alveolar nerve, harvesting of bone from the mandibular ramus, filling of defects with biomaterials and covering them with membranes, and suturing 11:30–18:00 | Dissecting room – Execution of the surgical techniques described in the previous session (parti- cipants will execute autonomously, un- der tutorial guidance, all interventions via a surgical approach, but the areas of risk will be pointed out by anatomy spe- cialists) 40

Clinical MastersTM | issue 2020 | Advanced Implant Esthetics | Article The changes social media has brought to businesses and how we interact with social media Dr. Giovanna Perrotti Dr. Giovanna Perrotti received her DDS and postgraduate degree in orthodontics from the University of Milan, Italy. Until 2018, she was head of the department of orthodontics and pediatric dentistry at the University of Milan and of the de- partment of technology for health at the IRCCS Galeazzi Institute School of Den- tistry, Milan. She is a visiting professor in the orthodontics program at the Univer- sity of Milan and a senior lecturer in the advanced course in oral implantology at the IRCCS Galeazzi Institute School of Dentistry; the course in rehabilitation therapy and reconstructive surgery in implantology at the University of Milan; the advanced course in implantology at the University of Genova, Italy; and the master’s degree in digital dentistry pro- gram at the University of Insubria, Italy. Since 2016, she has been CEO of Lake Como Institute, where she coordinates international courses and training in oral surgery and implantology, under the su- pervision of the founder and main lectur- er, Prof. Tiziano Testori. She is a co-author of the book 3D Im- aging and Dentistry: From Multiplanar Cephalometry to Virtual Implant Sur- gery Planning (Quintessence, 2016), and has also co-written books on esthetics in implantology and guided surgery and immediate loading in the esthetic zone. Perrotti is an active member of the Digital Dentistry Society and serves on the scientific committee of Dental Cadmos. 42

Clinical MastersTM | issue 2020 | Advanced Implant Esthetics | Article Image: ©shutterstock_1185354412. I myself work and spend many hours daily cultivating the social garden to promote the products of the company I represent. The products of my company are training courses in oral surgery and implantology. I have been part of it since its birth, when its founder wanted to create a center of reference for implantology studies and research, for those practicing in this spe- cialty of dentistry. At the beginning, courses were given an- nually and included hours and hours of lessons, and students were aware that the training journey required long hours of practice, discipline and dedication. The circle of people was small, and word of mouth was almost the only marketing and advertising medium for acquiring partic- ipants. Thirty years later, we have totally revolu- tionized the communication system be- cause needs have changed. The courses are aimed at providing practical solutions for immediate realization. I would like to share some considerations for solutions in the form of questions. • Can we replace direct contact between those who sell and those who buy, using only the web? • What is the penetration index of an ad- vertising campaign in terms of return on investment and how effective is an advertising campaign in terms of my in- vestment? Today, we are probably already so satu- rated with information of similar content that the end user has become confused and finds it difficult to make decisions. By “the web,” I mean search engines, which are a great encyclopedia of answers and have certainly revolutionized the way we obtain information, but the web has now become a great showcase of spon- sorships, and with the struggle between keywords and clicks, the advancement of a product is guaranteed. So how does the user distinguish quality? How does he or she choose from among the first ten hits on the first page of search results? Ran- domly? Most likely the user has learned to trust that position indicates quality. Great- er visibility equals greater probability of finding the best product. But with the data we can acquire today, the rela- tionship between people and the way in 44

Clinical MastersTM | issue 2020 | Advanced Implant Esthetics | Program INTERNATIONAL COURSES AT THE LAKE COMO INSTITUTE Lake Como, Italy | Paris, France Lake Como Institute boasts internation- ally recognized faculty in the field of im- plant dentistry and experts in other disci- plines of modern dentistry. The institute’s mission is to deliver meticulous diagnosis, treatment and comprehensive manage- ment of complex cases. A team of high- ly dedicated professionals work in close collaboration to achieve the best possi- ble outcome for the patient. Didactics is combined with scientific and clinical research and is applied with an interdis- ciplinary teamwork enriched by constant co-operation. Our philosophy is not to reach an 80% success rate, but to add the 20% that makes the difference. Clinical excellence is based on protocols and attention to detail, the two most important factors for achieving long-term results. With this winning philosophy, combined with 35 years of clinical experience, we are proud to offer innovative courses that will allow you to provide better, more com- prehensive treatments for your patients. Course dates Live surgeries: Immediate loading of dental implants, maxillary sinus augmen- tation, perio-implantology—soft-tissue management: May 15–16, 2020 Anatomical and surgical training with workshop on human cadaver: July 8–10, 2020 Live surgery seminar: An evidence-based educational path in maxillary sinus augmentation—the lateral and crestal approach: Sept. 25–26, 2020 Maxillary sinus surgery: Lateral and crestal approach, alternatives in the treatment of atrophic maxillae: Oct. 1–3, 2020 Drs. Tiziano Testori, Marco Esposito, Gabriele Rosano, Bernard Lazaroo and Jean F. Gaudy, course presenters Live surgeries: Immediate loading of dental implants, maxillary sinus augmen- tation, perio-implantology—soft-tissue management Lake Institute, Lake Como, Italy Presented by Drs. Testori and Esposito This course is only for those attending the Faculty of General Dental Practice (UK), Royal College of Surgeons of England. Course coordinator: bfornoni@fgdp.org.uk Anatomical and surgical training with workshop on human cadaver Université de Paris, Faculté de médecine, fifth floor, 45 rue des Saints-Pères, 75006 Paris Presented by Drs. Testori, Rosano, Lazaroo and Gaudy Details to be announced on the website. 46

Clinical MastersTM | issue 2020 | Advanced Implant Esthetics | Program gIDE Master Clinician Program in Implant Dentistry Dr. Sascha Jovanovic, U.S. Dr. Giacomo Fabbri, Italy Dr. Egon Euwe, Italy Next sessions in Advanced implant surgery and esthetic implant prosthodontics November 25–29, 2020 Florence, Italy Drs. Sascha Jovanovic & Francesco Mintrone February 17–20, 2021 Zurich, Switzerland Drs. Sascha Jovanovic, Giacomo Fabbri & Roland Glauser June 30 – July 3, 2021 Dubrovnik, Croatia Drs. Sascha Jovanovic & Egon Euwe September 20–25, 2021 Santa Monica, California, U.S. Drs. Sascha Jovanovic, Egon Euwe, Francesco Mintrone, Giacomo Fabbri, Joseph Kan & Jaime Lozada gIDE originated this year-long learning format and curriculum 13 years ago. More than 2,000 practitioners of implant and esthetic dentistry have advanced their understanding and proficiency in placing and restoring implants in this evidence- based, comprehensive program taught by world-class faculty. This one-year pro- gram is offered concurrently in North America, Australia, China and Vietnam, in addition to Europe. LEARN & PRACTICE – Place an implant predictably. – Preserve bone. – Maintain soft tissue correctly. – Achieve optimal esthetics. – Achieve a team approach with your patients and colleagues. – Diagnose your case. – Treatment plan. – Graft bone. – Diagnose and treat complications. – Manage and document your case from diagnosis to delivery. For more information: gidedental.com/master-clinician Contact: info@gidedental.com Dr. Jaime Lozada, U.S. Dr. Joseph Kan, U.S. Dr. Francesco Mintrone, Italy Dr. Roland Glauser, Switzerland 48

Clinical MastersTM | issue 2020 | Modern Concepts in Restorative Dentistry | Profile FRADEANI EDUCATION AT THE ACE INSTITUTE Pesaro, Italy share operative and educational models founded on evidence and experience, giving constant attention to technologi- cal innovation. Through a complete didactic portfo- lio, Fradeani Education offers a wide range of educational hands-on programs, in both Italian and English, covering all aspects and levels of prosthodontics and implant dentistry. Customized one- to 12-day courses can be organized for private groups upon request, either in Italy or abroad. www.fradeanieducation.com ACE Institute The ACE Institute is an advanced contin- uing education center established in 2000 by Dr. Mauro Fradeani and locat- ed in the historical center of Pesaro. Over the years, the facility has become a highly renowned research center for all dentists wishing to expand their clinical knowledge, progress in their profession- al skills and remain updated on scientific developments. It can accommodate up to 30 participants for theoretical and hands-on courses. It offers 18 laboratory stations, and high-quality professional audiovisual equipment allows an immersive experience in the world of dentistry for participants. Simultaneous interpreting can be arranged upon request. www.maurofradeani.it/ace_institute Fradeani Education Fradeani Education is the name of the educational project founded by Dr. Mauro Fradeani together with Drs. Leonardo Bacherini, Tiziano Bombardelli, Stefano Gori and Roberto Turrini, all of whom are talented and motivated lecturers with several decades of ex- perience in lecturing both in Italy and worldwide. The project’s mission is to Dr. Mauro Fradeani After graduating in medicine and surgery in 1979, Dr. Mauro Fradeani completed a specialization in dentistry at the then University of Ancona (now the Università Politecnica delle Marche), Italy, in 1983. He was a visiting associate professor in prosthetics at the Louisiana State Uni- versity Health Sciences Center New Orleans, U.S., from 1999 until 2008. Dr. Fradeani is founder and director of the ACE Institute, a highly advanced training center based in Pesaro and home to Fradeani Education, an educational project developed together with a group of expert lecturers that aims to promote a model of excellence in dentistry world- wide. He runs his private practice in Pesaro limited to prostheses on natural dentition and implants. He is the author of the two-volume book Esthetic Rehabilitation in Fixed Prostho- dontics (Quintessence, 2004 and 2008), which has been translated into 12 lan- guages. He served on the editorial board of Practical Procedures and Aesthetic Dentistry and is presently associate edi- tor of the International Journal of Esthetic Dentistry and serves on the editorial advi- sory board of the Journal of Esthetic and Restorative Dentistry. He was president of the European Academy of Esthetic Dentistry in 2003/2004 and of the Acca- demia Italiana di Odontoiatria Protesica in 1999/2000. 50

Clinical MastersTM | issue 2020 | Modern Concepts in Restorative Dentistry | Article Do conservative and prosthetic restorations really represent a solution for carious disease? The answer to this question lies in the DMF index and in salivary analysis Dr. Mauro Fradeani graduated in medicine and surgery in 1979, and completed a specialization in dentistry at the then University of Ancona (now the Università Politecnica delle Marche), Italy, in 1983. He is founder and director of the ACE Institute, a highly advanced training center based in Pesaro and home to Fradeani Education, an educational project developed together with a group of expert lecturers that aims to promote a model of excellence in dentistry worldwide. He runs his private practice in Pesaro limited to prostheses on natural dentition and implants. Dr. Federico Emiliani graduated in dentistry in 2009 from the University of Rome Tor Vergata, Italy, and opened his first clinic in Rome in the same year. He has since then attended several courses in Italy and abroad on prosthodontics, implant dentistry, adhesion and complex rehabilitation. From 2009 to 2013, he collaborated at various clinics all over Italy and, in 2013, opened his second dental office, in Frosinone, Italy. He currently practices in both of his private clinics. Dr. Emiliani teaches Fradeani Education courses, and in 2018, he was appointed a speaker in the master’s degree program in digital dentistry organized by the University of Rome Tor Vergata and headed by Prof. Claudio Arcuri. Dr. Emiliani lectures mainly on digital esthetic treatment plan- ning in fixed prosthodontics and the use of modern applications for guided esthetic rehabilitation. We often mistakenly give the term “caries” to the cavities that form in a tooth in response to the demineralizing action of bacteria and acids. In reality, the term should be used to indicate the disease that attacks the surface of the teeth and that manifests with different signs, including cavitated lesions and carious lesions.1, 2 The distinction between pathology and its signs is very important. If we talk about “periodontitis,” for example, we look for signs of this pathology, which are high probing depths, bleeding, plaque, loss of attachment, mobility, recession, furcation involvement and loss of teeth. The con- trol of these factors is really important, but the therapy to address periodontitis is aimed at eliminating bacterial biofilm, removing calculus, and controlling home hygiene and lifestyle, which are the caus- es of the disease itself. What therapy addresses the causes of caries? Does eliminating demineralized tissue and performing conservative res- torations or endodontic therapies rep- resent a true resolution of the disease? Certainly, the elimination of carious lesions is fundamental to halt the pro- gression of the lesions but performing a restoration does not address the di- sease. The therapy of any pathology must aim to address the causes, not the consequences, through the inclusion of protective factors. Yet, the majority of clinicians often limit treatment to elimi- nating cavities and take no other action to address the underlying causes of the disease. As is known, caries is a pathology with a multifactorial etiology, in which bac- teria, diet, quality of saliva, oral pH, and the patient’s lifestyle, hygiene and health play a fundamental role. The introduc- tion of fluoride, calcium and phosphate 52

Clinical MastersTM | issue 2020 | Modern Concepts in Restorative Dentistry | Article Risk Low Salivary test Antibacterial (CHX/xylitol)* Fluoride Radiograph frequency (months) Control frequency (months) Sealant CPP-ACP† Optional (especially if first visit) F‡ toothpaste twice/day Bitewing (24–36) 6–12 Recom- mended Moderate Recom- mended (assess compliance) Xylitol (6–10 g/day) 2 chewing gums 4 times/day for 5–15 min maximum High Requested 0.12% CHX mouthwash for 60 s before bedtime for 1 week/month Xylitol (6–10 g/day) 2 chewing gums 4 times/day for 5–15 min maximum 1% CHX gel in tray, 5 minutes/day for 14 days, before Phase 2 0.005% F mouthwash once/day F varnish professional initial application, before Phase 2, then after any recall F toothpaste 2,500 ppm 3 times/day 0.005% F mouthwash 1–2 times/day F varnish professional 1–3 applications, before Phase 2, then after any recall 12,500 ppm F gel before bedtime once a day F toothpaste twice/ day Bitewing (18–24) 4–6 Yes Not requested (optional in case of root hypersensitivity) Not requested (optional in case of root hypersensitivity) 3–4 Yes CPP-ACP paste 1–2 times/day Bitewing (6–18), until risk changes 3 Yes CPP-ACP paste 1–2 times/day Bitewing (6), until risk changes Extreme Requested 0.12% CHX mouth- wash for 60 s before bedtime for 1 week/month Xylitol (6–10 g/day) 2 chewing gums 4 times/day for 5–15 min maximum 1% CHX gel in tray, 5 minutes/day for 14 days, before Phase 2 F toothpaste 2,500 ppm 3 times/day 0.005% F mouthwash 1–2 times/day F varnish professional 1–3 applications, before Phase 2, then after any recall 12,500 ppm F gel before bedtime once a day * CHX = chlorhexidine; † CPP-ACP = casein phosphopeptide-amorphous calcium phosphate; ‡ F = fluoride. Table 1: Guidelines to be adopted for patients older than 6 years old at risk of caries, based on the level of risk: low, moderate, high and extreme.4 54

Clinical MastersTM | issue 2020 | Contents To encourage an increase in the amount of saliva, it is important to drink plenty of water. Another effective suggestion is the use of xylitol chewing gum (sever- al times per day, for a maximum of 5 to 15 minutes each time) and the controlled eating of fruit, in particular kiwis, oranges and blueberries. These kinds of fruits help increase the quantity of saliva, but must be eaten in small quantities only because of their acidity, which can be dangerous for the enamel. Acidity (pH) The saliva sample collected with the pre- vious test can be used to measure the pH. It is possible to place a few drops of saliva on a special testing paper and compare the resulting color with a specific refer- ence color scale. Figure 4 shows the basic salivary test kit for measurement of pH, examination of the amount of stimulated saliva and buffer capacity. A pH of higher than 6.8 is considered normal and a pH of lower than 5.8 is con- sidered a high risk factor.1 A pH that is frequently below this level can promote, in addition to the increased risk of for- mation of carious lesions, the onset of enamel erosion and consequent exposure of dentin areas. Modern minimally inva- sive prosthetic restoration techniques allow us to exploit adhesion to the residu- al enamel to restore patients with erosion problems, avoiding losing further healthy tooth substance.9 But it is good to con- sider this aspect even after restoration, as a constant presence of acidity can result in problems of infiltration of the pros- thetic restoration. of this aspect is another important factor of the CAMBRA method.5 There are tests that, by analyzing saliva samples on specific paper, give us an idea of the buffer capacity in just a few min- utes and give us an indication of the spe- cific risk level of the patient so that we can put in place appropriate measures to change this important aspect and lower the risk of developing carious lesions. In the presence of risky pH values or a low buffer capacity, the patient will naturally have a greater risk of developing caries, owing to the prolonged acidity of the oral environment after meals.2, 8 When testing detects these problems, one or more of the following modification factors could be recommended to the patient: 1. Use toothpaste containing bicarbona- te. 2. Rinse with water, or with water and bicarbonate, at the end of a meal in order to counteract the acidity and improve the buffer capacity. 3. End the meal with a protective food, such as aged cheese. 4. Use buffer substances after meals. There are commercially available bi- carbonate and hyaluronic acid sprays able to improve the buffer capacity. For reliable results, it is important to per- form salivary tests at least 2 hours after the last meal and the last home oral hy- giene. It is also important that the patient has not taken antibiotics in the two weeks prior to testing. We also advise patients not to smoke, drink or use mouthwash in the previous 2 hours. Buffer capacity Buffer capacity is a measure of the ability to counteract a pH change brought about by the addition of a certain amount of a strong acid or a strong base. Owing to the presence of bicarbonates, saliva is a buff- er system that corrects the acidity of the oral cavity after food intake. If the buffer capacity of the saliva is good, the resis- tance of the oral environment to the for- mation of caries will be high. The analysis Conclusion In the fight against caries, the goal of cli- nicians must not be focused only on per- forming conservative or prosthetic res- torations, but must include the execution of specific protocols for controlling the causal factors of the disease, as well as educating the patient that, in order to ad- dress caries, it is not enough to eliminate carious lesions; rather, it is fundamental to change his or her lifestyle radically.1, 3, 5, 6 The CAMBRA method allows us to cus- tomize caries care, based on individual risk analysis, and to develop a suitable prevention plan for each patient, with the aim of avoiding the onset of new carious lesions and reducing the risk of marginal infiltration of conservative and prosthet- ic restorations. Saliva is one of the main controlling factors in patients at high risk of developing caries, and it is the dentist’s duty to recommend to the patient the most suitable strategies to improve saliva quality and its protective properties. References 1. Featherstone JD. The science and practice of caries prevention. J Am Dent Assoc. 2000 Jul;131(7):887–99. doi: 10.14219/jada.archive.2000. 0307. 2. Young DA, Featherstone JD, Roth JR. Curing the silent epidemic: caries management in the 21st century and beyond. J Calif Dent Assoc. 2007 Oct;35(10);681–5. 3. Featherstone JD. Prevention and reversal of dental caries: role of low level fluoride. Com- munity Dent Oral Epidemiol. 1999 Feb;27(1): 31–40. doi: 10.1111/j.1600-0528.1999.tb01989.x. 4. Divaris K. Predicting dental caries outcomes in children: a “risky” concept. J Dent Res. 2016 Mar;95(3):248–54. doi: 10.1177/0022034515620779. 5. Featherstone JD, Domejean-Orliaguet S, Jenson L, Wolff M, Young DA. Caries risk assess- ment in practice for age 6 through adult. J Calif Dent Assoc. 2007 Oct;35(10):703–7, 710–3. 6. Sammarco G, Manfrini F. Analisi del paziente cariorecettivo e metodiche mini-invasive. 54° quaderno. Amici di Brugg; 2011. p1-106. 7. Jenson L, Budenz AW, Featherstone JD, Ramos-Gomez FJ, Spolsky VW, Young DA. Clinical protocols for caries management by risk assessment. J Calif Dent Assoc. 2007 Oct;35(10): 714–23. 8. García-Godoy F, Hicks MJ. Maintaining the integrity of the enamel surface: the role of dental biofilm, saliva and preventive agents in enamel demineralization and remineralization. J Am Dent Assoc. 2008 May;139 Suppl:25S–34S. doi: 10.14219/jada.archive.2008.0352. 9. Fradeani M, Barducci G, Bacherini L, Brennan M. Esthetic rehabilitation of a severely worn dentition with minimally invasive prosthetic procedures (MIPP). Int J Periodontics Restorative Dent. 2012 Apr;32(2):135–47. 56

Clinical MastersTM | issue 2020 | Endodontics | Profile Endo Inn—advanced training in endodontics Oslo, Norway Endo Inn Endo Inn was established to provide ad- vanced training in endodontics. Its aim is to introduce to both general dental prac- titioners and specialists the latest tech- nology in the specialty of endodontics in order to meet the essential biological re- quirements for predictable and success- ful outcomes. Our new center has five areas: a lecture room with capacity for 40 participants, a workshop room with capacity for 12 par- ticipants, a lunchroom, a secretary’s room and a dressing room with 30 lockers. In the workshop room, participants are ac- commodated at individual workstations designed and produced by Dentsply Sirona. All units have their own microscopes with high-definition cameras connected to individual monitors. The units are well equipped and all have motors (high- and low-speed), two suctions systems and ultrasonics. The master workstation has two microscopes, a ZEISS EXTARO 300 (Carl Zeiss Meditec) and a FreeVision 3D (JADENT). During the courses, both con- ventional radiography (Kodak) and cone beam computed tomography (Morita) are used for treatment planning and to check the outcome of each participant’s treatment. The lunchroom provides a large space for lunch and learn lectures, as well as a space for meeting and mingling during social and scientific events. The room has a wireless 60 in. 4K TV for lectures and meetings. At Endo Inn, dental practitioners can choose between three types of courses according to their schedules and levels of interest. The core course is divided into three modules. The first module intro- duces modern microscopic endodontics in primary endodontic treatment. The second module is dedicated to nonsur- gical endodontic retreatment. The third module covers microsurgical endodon- tics. During all modules, 3D-printed teeth and extracted teeth are used for train- ing so that participants can understand and navigate the complex internal root canal anatomy. These are implanted into models attached to a frasaco phantom Dr. Gilberto Debelian received his DMD from the University of São Paulo, Brazil, in 1987. He completed his specialization in endodontics at the University of Pennsylvania School of Dental Medicine, Philadelphia, U.S., in 1991, where he re- ceived the Louis I. Grossman student award in endodontics. He completed his PhD studies on endodontic microbiol- ogy at the University of Oslo, Norway, in 1997, for which he earned two scientific awards, from the European Society of Endodontology and the Norwegian Den- tal Association, respectively, also in 1997. Dr. Debelian taught in the endodontic program at the University of Oslo as a clinical instructor and associate profes- sor from 1991 to 2001. He was an adjunct visiting professor in the postgraduate program in endodontics at the Universi- ty of North Carolina at Chapel Hill, U.S., from 2006 to 2015. He is an adjunct visiting professor in the postgraduate program in endodontics at the University of Pennsylvania. He maintains a private practice limited to endodontics and is the director of the advanced endodontic microscopy center Endo Inn in Oslo. He has written seven chapters in books on endodontics, one book on endodontics, and more than 80 scientific and clinical papers. 58

Clinical MastersTM | issue 2020 | Endodontics | Profile The accommodation is within walking distance of Endo Inn. www.sagahoteloslo.com/saga-apartments/ Cochs Pensjonat is a guesthouse behind the Royal Palace and near Bogstadveien street, the best shopping street of Oslo. It is within walking distance of Endo Inn. Tripadvisor Certificate of Excellence Citybox is centrally located and low- priced but modern, offering guests sim- ple and stylish rooms. www.citybox.no Tripadvisor 2019 Travelers’ Choice Comfort Hotel Grand Central, housed in an historic railway building, is located right in the center of the newly opened Østbanehallen food court and in the vicinity of the Oslo Opera House and the main shopping district of Karl Johans gate. www.comfort-grand-central.hotels-in- oslo.com Hotel Continental, one of Norway’s oldest hotels, has a prime location and classy design, making it an optimal choice. It neighbors the national theatre and houses the famous cafe Theatercaféen. It is also located close to the National- theatret metro station, only one stop from the Majorstuen metro station to get to Endo Inn. www.hotelcontinental.no Tripadvisor 2019 Travelers’ Choice THE THIEF, a cutting-edge lifestyle bou- tique hotel with exceptional cuisine, is located in Tjuvholmen, thief islet, where world-class architecture and art are at home. It boasts a beautiful view over the Oslofjord and a very enjoyable spa. www.nordicchoicehotels.com/hotels/ norway/oslo/the-thief/ Tripadvisor 2019 Travelers’ Choice Where to eat There are a variety of restaurants in Oslo. In the summer, the Aker Brygge area is a winner. With a beautiful view of the Oslofjord, you can choose between fresh Norwegian salmon, shrimps and lobsters, sushi, burgers and pizza. Vippa is a food court with eateries and fancy cocktail bars in an industrial area by the harbor called Vippetangen. Den Glade Gris is a pub-like cafe specializ- ing in pork-based dishes—the house spe- cialty is slow-grilled pork knuckle. www.dengladegris.no Having opened in 1874, the Grand Café has a long history of famous guests, among them the playwright Henrik Ibsen, who ate there daily, and the painter Edvard Munch. The kitchen being open to view, patrons can look on while the culinary team produces Nordic dishes with international influences. The restau- rant boasts an extensive wine cellar. www.grandcafeoslo.no MADU, located in the First Hotel Grims Grenka, uses modern techniques with classic food to bring together its concept of elevated comfort food, serving a con- temporary Nordic menu. 26 North Restaurant & Social Club is a res- taurant inspired by the Nordic countries and their culinary treasures where guests can enjoy locally sourced products from the region in a stylish and relaxed atmos- phere. www.26north.no 60

Clinical MastersTM | issue 2020 | Endodontics | Program Endo Inn—advanced training in endodontics Oslo, Norway Course dates Module 1: February 27–28, 2020 August 31–September 2, 2020 Module 2: June 25–26, 2020 Module 3: May 14–16, 2020 Guest lecture: May 28–29, 2020 Dr. Gilberto Debelian, course director Dr. Edmar Oya, course assistant Module 1: Advanced primary endodontic treatment—two-day advanced hands-on course February course presented by Dr. Debelian (in English) August/September course presented by Drs. Debelian and Oya (in Portuguese) In this immersion course, participants will be updated on new biological and tech- nical concepts and procedures for pre- dictable outcomes. Participants will learn the complexity of the internal root canal anatomy and understand the way to clean and disinfect the root canal system effi- ciently and predictably. All participants will be trained using individual micro- scopes on simulated 3D teeth, extracted teeth and phantom head models. Both 2D radiographs and cone beam comput- ed tomography (CBCT) will be used to as- sess all information before and after the treatment is completed. All procedures will be demonstrated by Dr. Debelian with an operating microscope and a new 3D camera that transmits to participants’ individual 2D and 3D monitors. 62 Highlights: – Ergonomics and the use of the operat- ing microscope: The first phase of this course is to teach each participant how the microscope should be used ergo- nomically, in relation to the upper and lower jaws. Ergonomic chairs to use for dental microscopy are provided to each participant. – Access cavity: Participants will be trained on minimally invasive access cavity preparation techniques and efficient techniques to find hidden second mesiobuccal canals in maxillary molars. – Scouting and glidepath techniques: Participants will be able to practice following demonstration about nego- tiating obliterated and complex root canals using hand files and nickel- titanium (NiTi) rotary scouting in- struments will be demonstrated and participants will be able to practice. – Shaping: Training on the most advanced NiTi adaptive rotary instruments for ef- ficient 3D root canal cleaning and disin- fection will be offered. – Cleaning/irrigation: A comprehensive and evidence-based irrigation protocol will be discussed and demonstrated, using all teeth treated during the course. – Obturation material and techniques: New premixed bioceramic materials for obturation of the root canals will be demonstrated. A cold hydraulic bio- ceramic root filling technique and a continuous wave condensation tech- nique will be demonstrated and prac- ticed. – Radiographic and CBCT analysis: At the end of the course, all teeth treated by the participants will be individually analyzed with a 2D radiographic tech- nique. The teeth treated on the phan- tom head models will be individually analyzed with CBCT technology. The two-day program provides the following: • 17 hours of theoretical lectures and hands-on practice; • an individual workstation and individual instruments and devices for each par- ticipant; • a customized microscope for each participant (ZEISS or Global) with a high-definition camera and individual monitors; • 3D microscopic demonstration; • all instruments and materials used during the course; • scrubs for each day; • lunch and refreshments during coffee breaks. Module 2: Nonsurgical endodontic re- treatment—two-day advanced retreat- ment hands-on course Presented by Dr. Debelian (in English) In this course, participants will be updat- ed on biological concepts and technical procedures for post-treatment endo- dontic diseases. Clinical decision-making strategies will be discussed regarding when a retreatment or surgical approach should be applied for optimal outcomes. All participants will be trained using individual microscopes on simulated 3D teeth, extracted teeth and phantom head models. Both 2D radiographs and CBCT will be used to assess all informa- tion before and after the treatment is completed. All procedures will be demon- strated by Dr. Debelian with an operating microscope and a new 3D camera that transmits to participants’ individual 2D and 3D monitors. Highlights: – Access cavity: Training on minimal- ly invasive access cavity preparation techniques and efficient techniques to

Clinical MastersTM | issue 2020 | Endodontics | Program Day 1 (12:30–18:30): Theory The concept of “endodontic retreat- ment” • Where do the bacteria cause apical periodontitis? • Where are the typical places for bacte- ria to form biofilms? Removal of biofilms and gutta-percha root filling materials • Why do gutta-percha root fillings have MTA obturation in retreatment (perfora- tion repair) • Comparisons of clinical properties and root canal preparation between gutta-percha and MTA as a root filling material. Predictable techniques for MTA obtura- tion • Predictable and minimally invasive in- strument retrieval. • Psychological principles underlying to be removed in retreatment? planning instrument retrieval. • What is the most efficient technique • Diagnosis and treatment planning for for removing root fillings? broken file removal. • Presentation of the new Terauchi ultra- sonic sharpener. Irrigation • Irrigation protocol during retreatment. • What is the most efficient technique for irrigating the canal? • Concepts of broken file removal. • Two key preparation techniques. • Two predictable removal techniques. • Case reports. Day 2 (9:00–17:00): Live demonstration and hands-on practice Management of ledged canals • How do you prevent ledge formation? • What are the predictable and practical • All the topics discussed in the theory session will be demonstrated and prac- ticed during the workshop. techniques for bypassing ledges? • Seats are limited to 12 participants. instruments and devices for each participant; • a customized microscope for each participant (ZEISS or Global) with a high-definition camera and individual monitors; • 3D microscopic demonstration; • all instruments and materials used during the course; • scrubs for each day; • lunch and refreshments during coffee breaks. Guest lecture: Endodontic retreatment and instrument retrieval—theoretical and hands-on course Presented by Dr. Yoshi Terauchi Initial root canal therapy does not always result in healing, for a multitude of rea- sons. Failure to adequately disinfect the root canal system may result in a lack of healing. Bacteria may remain after initial treatment because of areas that were inaccessible to instrumentation and irri- gation. Causes of treatment failure may include a lack of tooth isolation; inade- quate cleaning, shaping and irrigation; and incomplete obturation. In addition, iatrogenic accidents such as separated instruments and ledge formation can be a problem leading to failure, because of the inability to disinfect the canal system apical to these obstructions. In retreat- ment, those mishaps that can negatively impact the treatment outcome should be properly managed. Therefore, in this theoretical and hands-on course, predict- able techniques to best manage those mishaps will be presented and demon- strated. During the workshop, particip- ants will have the opportunity to be trained by master endodontist Dr. Yoshi Terauchi on retreatment and minimally invasive techniques for retrieving sepa- rated instruments. 64

Clinical MastersTM | issue 2020 | Endodontics | Interview INTERVIEW with Dr. Gianluca Plotino “The importance of the prac- tical sessions and the inter- action between the teacher and the participants is still of utmost importance and should be maintained.” Dr. Gianluca Plotino received his degree in dentistry in 2002 from the Università Cattolica del Sacro Cuore in Rome, Italy, and completed his PhD there in 2009. He maintains a private practice special- izing in endodontics and restorative dent- istry in Rome. Dr. Plotino has been awarded several international prizes, published more than 100 articles in scientific, peer-reviewed journals, 2 textbooks and has contrib- uted to numerous chapters in reputable textbooks. He gives lectures and pre- sents courses across the world. He is a certified member of the European Soci- ety of Endodontology, an international member of the American Association of Endodontists, and an active member of the Italian Academy of Endodontics, the Italian Society of Endodontics and the Italian Society of Conservative Dentistry. Nathalie Schüller, DTI: Dr. Plotino, we meet again one year later. Then we spoke about and presented your endodontic bucket list course. Your goal was to offer a different format, a wish list for participants of materials and devices you use in your clinic daily that are best suited for each case. Are you satisfied with the results? The bucket list course was very successful and presented all over the world. It was really appreciated, as it was built based on the needs of the participants and this was very clear to everybody who attend- ed this course. After this success, an idea came to me for a new project, which is to try to give everybody the possibility of following my courses and my projects with a different format. Therefore, at the end of 2019, I launched “endo channel”. Indeed, you announced in December the launch of “endo channel” by Gianluca Plotino, a new ambitious project. Can you tell me all about it? This is my own endodontic channel, available on www.endo-channel.com, a place where I can talk about my work and what I think about endodontics, without filters or commercial influence, a place to share my pleasure of speaking about endodontics and what I have learned, my secrets. It will be structured in two parts, a main program with courses (in general 2-hour courses), webinars, etc. The second part will feature interviews with colleagues about hot topics of the moment, as well as advice and feeds with information I will provide on specific topics. The reason I created “endo channel” on the web is because I do not much like to communicate through social media channels such as Facebook or Instagram for my professional endeavors. I prefer to keep those for my social activities in my private life and do not post profes- sional information there. For anything related to my work, my passion about endodontics, I prefer to communicate in a more scientific manner, such as writing articles in scientific literature or publish- ing interviews in important magazines like Clinical Masters™ or writing books. 66

Clinical MastersTM | issue 2020 | Endodontics | Article Management of intracanal separated instruments: A clinical case report Introduction According to Lambrianidis, a great vari- ety of foreign objects (fragments of the whole range of instruments used in root canal instrumentation, e.g. fragments of ultrasonic tips and fragments of irrigation needles) may be found in the root canal, compromising cleaning and shaping pro- cedures and thus having a potential im- pact on the treatment outcome.1 These foreign objects may be largely attribut- ed to iatrogenic errors, and fracture is an undesirable and troublesome incident during root canal therapy or retreatment that frustrates both practitioners and patients. Endodontic instruments are the foreign objects most frequently found in the root canal; a literature review revealed a prevalence of retained fractured instru- ments at between 0.7% and 7.4% of teeth undergoing root canal therapy.1, 2 This mishap can happen even to experienced clinicians following the most appropri- ate preventive measures and may occur in both anterior and posterior teeth, but it is most frequently reported in molars, having similar rates for the maxilla and mandible.1 The vast majority of instru- ment fracture occurs in the apical third of the root canal.3 A study from the endodontics graduate program at the University of Pennsylvania, Philadelphia, U.S., conducted between 2000 and 2004, found that the probability of file fracture in the apical area was estimated to be 33 and six times greater than in the coronal and middle thirds of the root canal, respectively.4 Several factors have been implicated in the failure of root canal instruments, and they have been grouped into four main categories, namely, operator-related, anatomy-related, instrument-related and technique-/use-related:1 – Operator-related: Skill, proficiency, judgment – Anatomy-related: Access cavity, root canal anatomy – Instrument-related: Material, design, manufacturing process and errors – Technique-/use-related: Motor’s operating parameters, instrumenta- tion technique, reuse and sterilization, irrigants. The endodontic management of a frac- tured instrument within the root canal is a difficult process that requires train- ing, experience and knowledge of the methods and techniques that can be used. It is a time-consuming and chal- lenging procedure often associated with anxiety for both clinician and patient and has variable success rates.1 According to Lambrianidis, the best management of instrument fragments during root canal therapy is retrieval, in order to enable sufficient debridement and obturation of the root canal system.1 At present, there is no standardized pro- cedure for safe and consistently success- ful instrument fragment removal. In each case, the chances of success should be balanced against potential complications. There are four treatment options for managing fractured instruments: – no intervention; – nonsurgical management; – surgical management; and – tooth extraction.1 When the clinician decides to manage a clinical case of a separated instrument, it is important to take into consideration that all procedures include the risk of additional errors that may eventually jeopardize the prognosis of the tooth, and the clinician should continuously re-evaluate the progress of management procedures, and consider alternative Dr. Hugo Sousa Dias graduated with a DDS from University Fernando Pessoa, Oporto, Portugal, and completed his postgraduate program in endodontics at the University of Lisbon, Portugal. He was director of the Master in Endodon- tics clinical residency program at the Foramen Dental Education, Oporto, until 2018. He runs a practice limited to endo- dontics in Oporto and gives side-by-side training courses adapted to the clinician’s needs while training with patients. Dr. Dias is co-author of a chapter in the book The Root Canal Anatomy in Perma- nent Dentition (Springer, 2018), has pub- lished in a number of scientific journals, and gives lectures and courses around the world. He is the founder of the Por- tuguese Group for Endodontic Study (study club), and a member of the Euro- pean Society of Endodontology and the Sociedade Portuguesa de Endodonto- logia [Portuguese endodontic society]. 68

Clinical MastersTM | issue 2020 | Endodontics | Article Fig. 4: Modified size 3 Gates–Glidden bur creating a staging platform. Fig. 5: Radiograph after removal of the coronal part of gutta-percha and creation of a staging platform. Fig. 6: Schematic representation of a staging platform. Figs. 7a & b: SONICflex quick 2008 L with a size 25 Endo clean tip, creating a space around the coronal part of the separated instrument. 70

Clinical MastersTM | issue 2020 | Endodontics | Article Fig. 13: Radiograph after removal of the fragment. Fig. 14: Obturation with a bioceramic sealer. tion to the root canal curvature, and to estimate its size and length; • redefining the access cavity to allow better visualization and unobstructed manipulation; • keeping the staging platform, created with a modified Gates–Glidden bur, centered in order to allow better visu- alization of the fragment and the sur- rounding dentinal root canal walls; • placing PTFE tape over other exposed orifices in multicanal teeth in order to prevent dislodgment of the fragment into another root canal; • maintaining constant visualization using magnification during management ef- forts; • taking frequent working radiographs during the retrieval procedure in or- der to check the level of retrieval and amount of dentin loss; • using copious irrigation to remove all debris and dentin chips, followed by thorough drying of the canal to facilita- te perfect vision; • using sonic energy in addition to ultra- sonic energy to create space around the fragment (around 2 mm deep) and thereby avoid a secondary fragment fracture (with SONICflex quick 2008 L and size 25 Endo clean tips or with SONICflex 2003 L with Micro Files Type D)—touch the coronal part of the separated instrument with a sonic tip in Figs. 15 & 16: Radiograph after obturation. ration was made. The patient was referred to her dentist for the permanent coronal restoration. At a follow-up visit after six months, the tooth was asymptomatic (Fig. 17). Discussion The intracanal fracture of endodontic files with the possible retention of frag- ments in the root canal is an unwanted complication in everyday clinical practice. Fragment removal is time-consuming and technically difficult to perform and might jeopardize the outcome of the endodon- tic treatment. To improve the success of the file retrieval technique, most of the time, a combination of techniques is needed, and there are certain common steps to follow: • conducting a radiographic examination with more than one angulation or with a cone beam computed tomography scan, to confirm the presence of the fragment, to reveal its location in rela- 72

Clinical MastersTM | issue 2020 | Endodontics | Program Courses to share our passion for teaching and endodontics Athens, Greece | Brașov, Romania Lisbon, Portugal | Porto, Portugal Totally or partially calcified canals present a constant challenge in clinical endodon- tics. Negotiating obliterated canals can range from difficult to nearly impossible. The risk of procedural accidents, such as perforation and instrument separation, is high. However, under the magnification provided by a dental operating micro- scope and with the correct armamen- tarium, the whole procedure of dealing with obliterated, blocked, ledged and hidden canals can become very predict- able. Complete root canal space block- age associated with apical periodontitis is relatively rare. This course is designed to help the clinician deal predictably with challenging cases of partial or diffuse calcification in endodontics and blocked and hidden canals. Learning objectives At the end of this course, the participant should: – have an understanding of the problem of calcification; – have an understanding of the mechanisms of iatrogenic blockage and ledging; – be able to perform the most common techniques for managing calcified canals; – be able to perform the most common techniques for managing iatrogenic blockage and ledges; – be able to negotiate second mesiobuccal and middle mesial hidden canals; – be able to perform a new technique with specially designed files to pene- trate through calcified canals; and Separated instruments retrieval course (EndoCowboy technique) Instituto Português de Endodontia of Dr. Rui Pereira da Costa Presented by Drs. Hugo Sousa Dias and Dennis Köhrer Registration: www.rpcendo.com/endocowboy Topics – Nature of instrument fracture – Appropriate diagnosis and treat- ment planning for broken instrument removal – Importance of magnification for dealing with cases of separated instruments (operating microscope) – Preparing the canal for broken instrument removal – Dislodging and removal of fractured instruments – Principles for the use of ultra-sonic technique in retrieval of separated instruments – Principles for using EndoCowboy technique (Köhrer Medical Engineer- ing) in retrieval of separated instru- ments (from coronal to apical) – Hands-on microscopic training (on extracted teeth or 3D models) on removing separated instruments Learning objectives At the end of this course, the participant should: – have improved treatment planning skills related to file retrieval situations; and – be able to deal with separated – be able to perform static and dynamic instruments. guidance techniques for pulp canal obliteration. Course dates Microscope simulation course—canal blockage, second edition: June 6–7, 2020, Athens, Greece Drs. Antonis Chaniotis, course director | Dr. Hugo Sousa Dias, course presenter Microscope simulation course—canal blockage (small version course): December 18, 2020, Brașov, Romania Drs. Antonis Chaniotis | Dr. Hugo Sousa Dias, course presenters Separated instruments retrieval course (EndoCowboy technique): July 11, 2020, Lisbon, Portugal Dr. Hugo Sousa Dias, course director | Dennis Köhrer, course presenter Microscope simulation course—canal blockage Presented by Drs. Hugo Sousa Dias and Antonis Chaniotis 74

Clinical MastersTM | issue 2020 | Testimonials CLINICAL MASTERS™ TESTIMONIALS “I was looking for specialized training in instrument removal tech- niques and microapical microsurgery. It was with no doubt a very enriching experience totally adapted to me. I was able to specifically address the points I wanted to improve and learn. The theoretical content was very clear and thorough. In practice, I had the opportu- nity to apply all the concepts in patients, always with the support of Dr. Hugo Sousa Dias. I strongly recommend this training.” Dr. Joana Oliveira Monteiro After the Clinical Masters™ courses each year, we ask participants about their experience of the programs and presenters. This is their feedback for this new edition of the Clinical Masters™ magazine. Clinical Masters™ Program in Endodontics This year offered by Dr. Hugo Sousa Dias in Athens, Greece | Brașov, Romania | Lisbon, Portugal “Excellent training! Personalized teaching with Dr. Sousa Dias has undoubtedly changed my clinical practice. I had the opportunity to choose the topics to be addressed in the Side by Side program and in all the modules I received clinical practice directly on patients! Even after completing the training, Dr. Sousa Dias remains available to answer any questions. I strongly recommend not only for those who already have some clinical practice but for those who are starting in the world of endodontics.” Dr. Cláudia Pires “After completing my master’s degree, I was looking for training in the field of endodontics that would allow me to feel confident in my clinical practice. I was looking for something that would help me to clarify doubts I had and consolidate my knowledge in prac- tice. I found the Side by Side training course and had the oppor- tunity to put in practice all the knowledge I had acquired with the most current clinical evidence, and apply it on patients, in a totally individualized program adapted to my needs. It was definitely a great choice that I would choose to do again.” Dr. Elisa F. Carreiro Martins ‘elevates’ your mind, “He is not just a surgeon; he ‘only’ makes surgery and more! He ‘cuts’ through your fears, ‘implants’ some ideas and ‘closes,’ waiting for the seeds to flourish. He touches each and every attendee in a subtle way, giving you what you need, even though you may not have known you needed it. After you attend his course, your tech- nique will surely improve, and you will have more self-confidence, become more empathetic, show more respect for and awareness of your patient and the med- ical act. He is a human, he is a teacher, and the reason why, after you meet him, you have to change, become a better ver- sion of yourself, because he is inspiring. You see this in his team as well, so willing to help, to share everything they know, happy to give to others! You will not be a mere participant; you will become a part of the family, taking home with you not only a better knowledge of human anatomy and surgical procedures, but a better knowledge of the human soul and the feeling that you are a special hu- man yourself. Thank you and your team for everything!” Dr. A.N. 76 “Three days of hard work on anatomical preparations but so much excitement. I have found a team as competent and tightknit as efficient. The relationship with the tutor was one to one and this made the work very smooth. The anatomy room was transformed into an operating theater with both surgical and recovery equipment that made possible many hours of tutorials. My interest was not in gaining experience in dissection, but in practicing using a reference. I loved the concept of this course; the schedule was very strict but the friendly approach and the good humor made it, without a doubt, an enjoyable experience. I strongly recommend the course to young dentists and also to those who, like me, have a few years of experience in dental surgery. I can say that it is a completion to a medical practice that changes every day.” Dr. S.M. Clinical Masters™ Program in Advanced Implant Esthetics This year offered by Prof. Mauro Labanca in Brescia, Italy (anatomical surgery course with cadaver laboratory) “This course truly amazed me. It struck me due to the very accurate organi- zation, the material made available and the state-of-the-art equipment; we were able to use the PIEZOSURGERY touch device of the latest generation, handpieces and more. The room in which the course was held was perfectly equipped, and we worked on fresh human specimens without any kind of un- pleasant smell. The work is carried out in total peace, and the environment is really friendly; the tutors are very competent and always available. I have been working for 25 years and have to say that a course like this can give you that input needed to improve and perhaps to review things that you may have lost after so many years of activity.” Dr. E.C.

Clinical MastersTM | issue 2020 | Periodontics and Restorative Dentistry | Interview INTERVIEW with Dr. Giovanni Zucchelli Dr. Giovanni Zucchelli is profes- sor at the University of Bologna in Italy and president elect of the Ital- ian Academy of Osseointegration. He specializes in the treatment of complex periodontal and peri- implant cases and in the esthetic rehabilitation of gingival tissue around natural teeth and implants, applying the avant-garde proce- dures he himself devised. Zucchelli also offers courses at his private in Bologna and speaks practice regularly at major international congresses. Furthermore, he is an active researcher and regularly gives presentations internationally. He has published several books fo- cusing on periodontal plastic sur- gery. OMNIPRESS & Nathalie Schüller, DTI: Dr. Zucchelli, how would you describe yourself? What would you like people to know about you? Dr. Zucchelli: Most probably that what really made me choose this type of life was a desire to be a little different. I was small as a child, and this might have been the reason that I wanted to be different. I don’t mean better, rather I wanted more to think outside the box and try to think by myself without being too influenced by others. I am grateful to my mentors who introduced me to different topics while I was learning. They taught me how to lecture, to present and to do research. From that time, I decided not to look any more at the past and not to look so much at what had been done before, but rather to try to be innovative. So, did this come from your mentors or was it from your own personality? This is my personality. I am not happy to repeat things over and over; I always try if possible, to to improve. In order to do better, you have to add to what you have already done to see if you can improve. The one positive thing I think I have done in my life is that I have tried to innovate, and not repeat what others have already done, rather, improve what has been done and to add my own input. Sometimes I have succeeded and at other times I have not—that is life—but even if you succeed in improving even a small thing, I think it is good, and maybe, people appreciate that you are always trying to give them something new, something from yourself. We all have dif- ferent talents and I think that is one of mine. I try to communicate what I know, what I have learnt, and the feedback I re- ceive from dentists tells me that I have succeeded in sharing with them. How did a career in dentistry come about for you? My father was a nephrologist, and in my youth, I was not so keen on studying. After finishing high school, I had a dis- 78 Image: OMNIPRESS cussion with him and asked him what he thought I should do. He told me that, since I did not want to study so much, I could become a dentist. For him, as a medical doctor, he thought that my becoming a dentist would allow me to make a de- cent living. He considered that dentistry was for people who were smart enough but not sufficiently intelligent to become medical doctors. I think that caused my conflict from the beginning. I always have had to prove something to myself. So, it is an incentive to push myself, but on the other hand, I have a tendency to never be completely satisfied. If you always want something more, once you get it, you find you need something new. Why soft tissue? What appeals to you in periodontics that you decided to make it your specialty? Soft tissue is what people see; they don’t see bone. I want to be appreciated and make people understand what I do. I am always afraid of things happening to what I can see rather than afflictions that are

Clinical MastersTM | issue 2020 | Periodontics and Restorative Dentistry | Interview Indeed, my next book is almost finished. I feel a need to write when I think some- thing is missing and my focus is really always the same topic: soft-tissue man- agement around the implant. It tends to be considered as a procedure done only to improve an outcome that can be achieved with bone augmentation. I think it is exactly the opposite. By increasing the soft-tissue thickness and by improv- ing the soft-tissue management, you can usually avoid bone augmentation and at the same time you are able to achieve the best esthetic outcome. This is the sub- ject of my book—how far we can go with soft-tissue management to reduce the need for bone augmentation. It is some- thing which, at least in my opinion, is not as critical for esthetic success. Are you talking about soft-tissue man- agement before implant placement or after placement as well? The book is about soft-tissue man- agement before, during or after im- plant placement, if the surgeon did not do it when placing the implant, and in that case, what you are able to do to im- prove the esthetic appearance of an im- plant that has already been placed. The first book, Mucogingival Esthetic Surgery, was an incredible success, maybe because very few dentists do mucogingi- val surgery. The great story, however, is that now mucogingival surgery is not only to treat recession, it is, I think, a work philosophy. You can apply it to recession problems, restorative work and implan- tology. I can say that my first book gave me great satisfaction because, although not linked to a company, there was a great demand for it and it indicated to me that people appreciate the need for what I am doing. You will be the next President of the Italian Academy of Osseointegration (IAO). What is your vision and goal in accom- plishing this new mission? My goal is to make dentists who place implants appreciate and understand how soft-tissue management is critical. For many years, we focused on gaining a deeper understanding of osseointegra- tion and bone augmentation, but most clinicians don’t understand the potential of soft-tissue management. My objective is to include soft-tissue management in implant therapy, thereby indicating the need to understand the importance of periodontics in placing implants for an optimal outcome. “For many years, we focused on gaining a deeper under- standing of osseointegration and bone augmentation, but most clinicians don’t under- stand the potential of soft- tissue management.” I agree that at implantology congresses one still hears a lot about osseointegra- tion but not so much about soft-tissue management. True, only recently did we start hearing about soft-tissue management. I think it is another challenge to make implan- tologists consider soft tissue more. I love to speak with women in the many places around the world where implan- tology and periodontal therapies are carried out mainly by women. When you speak to them, you find that they are much more sensitive to soft-tissue management then men. I am not sure why, maybe because of the esthetic aspect. I refer to esthetics also when speaking about function. I think that, by improving the soft tissue, the patient can maintain better hygiene and, of course, will be happy with the successful esthetic outcome. What advice would you give young peri- odontists? I would advise them to study a lot, learn as much as they can and, once they have a good background, try to think for themselves. They should not continually re-evaluate what has already been done because it is easy. It is easy to publish today something that was published in the past, but to come up with an origi- nal article is very hard. If you only speak about the past, it is difficult to advance. I would like them to try to think a little more biologically. I had the good fortune to gain this type of experience when I attended the Department of Periodon- tology at University of Gothenburg in Sweden under the chairmanship of Prof. Jan Lindhe. The emphasis there was very biologically focused; everything was justified biologically more than scientifi- cally. Science deals in numbers; biological concepts exist and will be the same for- ever. So, you should not try to do some- thing because someone told you to do it; you should try to understand why you are doing it, and if you don’t understand, then don’t try it. I think that the problem is that many are afraid to question themselves and rather do something because someone else said they should. Dr. Zucchelli: Yes, this is the problem of young people. Of course, it is difficult, and my students are often confused when I tell them to do something in a certain way and somebody else tells them to do it in another way. This is the reason that they need the knowledge to think for themselves and evaluate the different options. 80

Clinical MastersTM | issue 2020 | Periodontics and Restorative Dentistry | Article The use of connective tissue graft for the treatment of multiple recession defects Dr. George Goumenos Dr. George Goumenos graduated from the School of Health Sciences, Depart- ment of Pharmacy of the National and Kapodistrian University of Athens, Greece, with a BScPharm in 1982 and from the School of Dentistry of the same Univer- sity, with a DDS in 1988. He graduated from Tufts University School of Dental Medicine, Boston, U.S., where he obtained his Certificate in Periodontology in 1990 and his MSc in 1991. He received a doctoral degree in 1998 from the National and Kapodistrian University of Athens’ School of Dentistry. He is a faculty member of gIDE and has been a clinical instructor at the Depart- ment of Periodontics of the National and Kapodistrian University of Athens since 1991. Dr. Goumenos has been in private practice since 1992 and is the director of Periocare Goumenos in Athens, a clinic that is devoted to periodontics, esthetic dentistry and implantology. He has published several articles to date and lectures both nationwide and inter- nationally. His main interests are the bio- logy of oral tissue and its management in periodontal and implant reconstruc- tive plastic surgery. Dr. Goumenos was announced a diplomate of the American Board of Periodontology in 1996. He is a member of the American Academy of Periodontology, European Federation of Periodontology and European Associa- tion for Osseointegration. According to the American Academy of Periodontology glossary, “periodontal plastic surgery” is defined as the surgi- cal procedures performed to correct or eliminate anatomical, developmental or traumatic deformities of the gingiva or alveolar mucosa.1 More recently (2001), the American Academy of Periodontol- ogy gave a new definition for periodon- tal plastic surgery that includes all the surgical techniques aimed at the resto- ration of the morphology, and the po- sitioning and the quantity of soft tissue surrounding teeth and implants. “Gingival recession” is defined as the marginal displacement of the gingiva api- cal to the cementoenamel junction, and the denudation of the root as a result of the loss of attachment of the periodon- tal apparatus.2 The main indications for root coverage procedures are increas- ing recession, esthetic demands, root hypersensitivity, root caries lesions and cervical abrasions. Gingival recession is a serious concern both functionally and esthetically. The surgical technique of choice depends on several factors, each having their advantages, disadvantages, indications and contraindications. The clinician should choose from among the various surgical protocols available by selecting the least traumatic technique for the patient. In 1985, Langer and Langer described the use of a subepithelial connective tissue graft technique for covering of gingival recession in single and multiple adjacent teeth.3 They described a tech- nique in which the graft was covered by the overlying partial-thickness flap. Modification of their technique was the use of the full-thickness flap to cover the subepithelial connective tissue graft as described by Nelson4 and the enve- lope technique described by Raetzke.5 The concept of Raetzke’s technique was the positioning of the connective tissue graft between the overlying flap and the underlying periosteum without any incisions of the buccal flap, through an envelope that was designed intra-sulcu- larly. This was referred to as the treat- ment of single recessions and was the in- troduction of the tunneling procedures and their modifications that followed, for the treatment of multiple adjacent recessions. In 1994, Allen proposed a modification of Raetzke’s technique, de- scribed as the tunnel or supraperiosteal envelope technique, for treatment of multiple adjacent gingival recessions.6 In 1999, Zabalegui et al. described their concept for the tunneling procedures, extending the partial-thickness prepara- tion up to the papillae,7 while in 2002, Azzi et al. included also the papillae in the preparation, improving the flap mo- 82

Clinical MastersTM | issue 2020 | Periodontics and Restorative Dentistry | Article Fig. 6: The free gingival graft. Fig. 7: The free gingival graft. Note the white color and rough appearance of the connective tissue at the right of the graft compared with the left where the epithelium had not been removed yet. Fig. 8: De-epithelialized free gingival graft being dehydrated with the exudate of A-PRF. Fig. 9: Determining the orientation of the graft. Fig. 10: Positioning of the graft inside the tunnel with the help of two mattress sutures at the proximal edges of the graft. Fig. 11: The double-crossed suturing technique with 6/0 polypropylene sutures. Fig. 12: The double-crossed suturing technique with 6/0 polypropylene sutures, occlusal view. Fig. 13: Placement of the A-PRF membrane for coverage of the donor site, kept in place with horizonal mattress sutures using 4/0 d-PTFE sutures. 84

Clinical MastersTM | issue 2020 | Periodontics and Restorative Dentistry | Program Ten days of mastering soft-tissue surgery Athens, Greece The mastering soft-tissue surgery curric- ulum involves four modules, which are as follows: Module I: Contemporary soft-tissue sur- gery: From flap design to wound closure Presented by Drs. Goumenos and Burkhardt This module covers topics such as wound healing mechanisms, the basic principles of periodontal microsurgery, flap design, suture materials and suturing techniques. Module II: Soft-tissue quantity and quality enhancement around teeth and implants Presented by Drs. Zucchelli, Rasperini and Goumenos In this module, soft-tissue grafting tech- niques (free gingival grafts, connective tissue grafts and soft-tissue substitutes) will be demonstrated. Module III: The defective ridge after extraction: Prevention and treatment strategies for predictable esthetic restorations around teeth and implants Presented by Drs. Zuhr, Goumenos and Stimmelmayr This module will present socket sealing techniques and the palatal pedicle flap. Module IV: Management of esthetic fail- ures and complications in implantology Presented by Drs. Euwe and Goumenos This module will examine the etiology of esthetic failures and demonstrate the surgical protocols for their resolution. For more information: www.omnipress.gr Contact: info@omnipress.gr Dr. George Goumenos, program director Dr. Egon Euwe, program director Dr. Rino Burkhardt, program presenter Dr. Michael Stimmelmayr, program presenter Course dates Module I: Feb. 14–15, 2020 Module II: May 8–10, 2020 Module III: June 25–27, 2020 Module IV: Oct. 17–18, 2020 The achievement of a stable postoper- ative outcome from both an esthetic and a functional perspective is the goal of everyday dentistry. The mastering soft-tissue surgery curriculum aims to render the application of surgical tech- niques more user-friendly and help den- tists achieve more predictable and effec- tive results. Trainees will gain a solid foundation of knowledge on the biology of wound heal- ing and receive comprehensive training in the basic surgical principles and soft-tis- sue surgical techniques through: • scientific and clinical presentations; • clinical videos; • hands-on training; and • live surgical procedures. Dr. Giovanni Zucchelli, program presenter Dr. Giulio Rasperini, program presenter Dr. Otto Zuhr, program presenter 86

Clinical MastersTM | issue 2020 | Periodontics and Restorative Dentistry | Interview INTERVIEW with Dr. Daniel Edelhoff and Dr. Otto Zuhr Image: OMNIPRESS Dr. Daniel Edelhoff is director and chair of the department of prosthodontics sciences and dental material at the Ludwig-Maximilians- Universität in Munich in Germany. He is a member of the German society of oral and maxillofacial surgery [Deutsche Gesellschaft für Mund-, Kiefer- und Gesichtschirurgie] and the German society for prosthetic dentistry and biomaterials [Deutsche Gesellschaft für Prothetische Zahnmedizin und Biomaterialien. DGPro]. He is vice presi- dent of the Association of dental technology [Arbeitsgemeinschaft Dentale Technologie], a member of the advisory board of the DGPro, a member of the American Academy of Esthetic Dentistry and an International College of Dentists Fellow. 88 Dr. Otto Zuhr is a specialist in periodontics and runs a private office together with Dr. Marc Hürzeler in Munich in Germany dedi- cated to periodontics and implant dentistry. Zuhr is an associate professor in the depart- ment of periodontics at Goethe University in Frankfurt am Main in Germany. He has written several refereed scientific articles in the fields of periodontics and implant den- tistry and is the author of Plastic-Esthetic Periodontal and Implant Surgery (Quintes- sence, 2012). His research activities are focused on oral soft-tissue wound healing and reconstruction. With more than 25 years of clinical experience and teaching practice, he has become a proven expert in his field well beyond European borders.

Clinical MastersTM | issue 2020 | Periodontics and Restorative Dentistry | Interview more. I had always been interested in understanding how material behaves, so I chose to do my thesis in the field of dental material science. This was the main reason, to acquire more knowledge for prosthodontics. What motivates you? Dr. Zuhr: It is a general attitude. If you want to progress, you need to have a goal and my goal has always been to make things better for the patient. I also have always believed in working in a team and have never had the experience of working alone. Being part of a team is not always easy, just like every human relationship is not always easy. But at the end, teamwork can be very inspiring, stimulating and mo- tivating to advance care for our patients— this has always been my driving force. Dr. Edelhoff: For me, it is the same—the team—and Otto, of course. I am curious to know what he is doing, what his tech- nique is, what surgical options we have and how we can improve the treatment of our patients and simplify it, making it easier for us but still with the goal of re- taining the same level of quality. I have a very good team in Munich, con- sisting of very smart, self-driven people. I give them a lot of freedom and this in- creases their creativity. The head of the dental lab in our department holds 22 patents! I like this. When we talk, we both have ideas and feed from one another. An interdisciplinary approach seems to be a recurring theme nowadays. Some people have difficulty going outside of their comfort zone to collaborate with others. Do you believe it is something uncommon today? Dr. Edelhoff: I would say it is not new, but the patient, especially, benefits from it, and I do as well, because in collaborat- ing, I get so much inspiration from Otto or from my dental technicians, who have very interesting ideas, and from gen- eral practitioners also. A lot of good ideas come from them and I learn from them all constantly. One needs a functioning network. Dr. Zuhr: The biggest issue is whether or not you are open-minded. You need to know what other disciplines can do. If you don’t, you cannot offer it to your patients. You are both teachers and therefore in your own ways defining or sculpting the future of dentistry. What do you focus on giving your students and what do you wish them to have when they graduate in order to become well-rounded practi- tioners? Dr. Edelhoff: I always tell them to stay cu- rious. I give myself as an example. When I graduated, I had a feeling that I knew nothing. I could do simple cases but did not understand the whole connection be- tween the different specialties very well or the chronology of treatment. There- fore, one needs sessions where one can discuss and exchange ideas. It is a question of character, personality. Some will only focus on money and I would not like to be a patient of such a dentist. Otto and I have similar personalities. We are sort of perfectionists. I would do some treatments free of charge, only to gain more experience. For me, it has to do with passion, curiosity about something new, developing something or a new idea. Do you think you manage to give your students all of this? Dr. Zuhr: I think you can open their minds and motivate them to continue expand- 90 ing their knowledge and improving their manual skills. Our profession is not so easy. On the one hand, you might be the most skilled professional, the best surgeon in the world, able to do every- thing with your hands. However, if you are lacking the fundamental knowledge and thus every second decision that you take for your patients is wrong, few of your patients will really benefit from your manual dexterity. On the other hand, you might be the brightest, smartest person in the world, know everything and make the right decision for your patients every time, but if you cannot transfer this knowledge with your manual skills to the patient’s mouth, hardly any patients will benefit from your knowledge. Patients need both from us: profound knowledge and manual skills. This is not a reason to be frustrated; it is actually the beauty of our profession. It is a journey that never ends. If you think “That’s it, I’m good enough now”, it’s over; there is no more space for improvement. That is the mindset that I want to commu- nicate to my students. Dr. Edelhoff: To motivate the young stu- dents, I always tell them that it is a very motivating and passionate profession, because you, as a clinician, achieve tech- nical success and what you give to your patients can have such a great impact on their lives.

Clinical MastersTM | issue 2020 | Interview INTERVIEW with Dr. Peter Wöhrle comes and patient experience and with more streamlined, scientifically proven protocols. What challenges do they need to solve on a daily basis? How can they advance their skills and practice implant dentistry at the highest level? At the Global Symposium 2020, you can gain practical knowledge to improve treat- ment success and skills with a mix of hands-on sessions, discussions and presentations from many experts. What are the key topics that attendees can expect? The program is truly diverse because, as every clinician knows, we are faced with countless different indications and treat- ment options. Immediate function and esthetic outcomes are central topics covered in numerous sessions. Other topics of interest include hard- and soft- tissue regeneration, treatment planning, managing complications, extreme cases and ceramic implants. And, of course, digital dentistry is fundamental to the future of our field, so we cover this topic across many sessions as well. But most importantly, the scientific prin- ciples upon which these solutions are based are presented in a logical and con- vincing way. How can the sessions help clinicians grow their practices? The patient experience is at the center of what we do. A positive patient experience is probably the most effective way to raise patient awareness and increase exposure and thus profile for the practice. Deliver- ing predictable esthetic outcomes, com- bined with shorter time-to-teeth, is para- mount in today’s market place. Therefore, these treatment approaches are reflect- ed in many of the sessions. What I always find exciting about Nobel Biocare symposia are the debuts of inno- vative new solutions that have real po- tential to improve the way we can treat patients and subsequently make an indi- Dr. Peter Wöhrle received a DMD and MMedSc (oral biology) from Harvard School of Dental Medicine, Boston, U.S., in addition to a specialty certif- icate in prosthodontics and a specialty certificate in implant dentistry. Prior to his studies in Boston, he completed a four-year dental technician program in Switzerland. At Harvard, he worked with others on developing the concept of immediate loading with Brånemark implants. Later, he applied these prin- ciples to the single tooth and the con- cept of immediate tooth replacement. He lectures worldwide and in his prac- tice in Newport Beach, California, U.S., focuses exclusively on dental implants. After the success of the Nobel Biocare Global Symposium a few months ago, Wöhrle will be a speaker and moderator at the upcoming Global Symposium 2020, on April 16–18, in Las Vegas in the U.S. One of a few doctors worldwide with formal specialty training in the inter- related areas of implant surgery, implant prosthodontics and dental implant tech- nology, here he provides insight into what implant professionals can expect from this world-class event. Dr. Wöhrle, what inspired this event and what can dental professionals expect when they attend? What motivates us is helping dental im- plant professionals around the world treat more patients better with improved out- 92 The symposium has been postponed to early 2021. A new date will be com- municated as soon as it is available. On April 16 to 18, Nobel Biocare will host a series of virtual educational sessions made available to all that had registered to the symposium. vidual practice stand out from the rest. This year is no exception. Can you tell us about the panel of speakers? It’s a diverse group of experts from differ- ent specialties, from both clinical practice and scientific research, many of whom have been world-renowned for many years. What I find really exciting, though, is that the next generation of experts are taking part in this symposium. They have already excelled in implant dentistry and are bringing a new approach and perspec- tive to the field. This is your chance to experience the future leaders in implant dentistry. How is this symposium different from previous symposia? Today, Nobel Biocare cooperates close- ly with the other Envista companies, all of which will be joining Nobel Biocare in Las Vegas. This time, attendees will expe- rience an even bigger range of solutions, including the latest equipment from KaVo Kerr and clear aligners from Ormco. like discovering the For you personally, what do you like most about taking part in the Nobel Biocare Global Symposia? latest I always cutting-edge innovations from Nobel Biocare. But on a personal level, it’s ex- tremely rewarding to network with other dental professionals. I learn so much from the experiences of my colleagues; we compare the challenges we have to deal with and share different opinions about this exciting and rapidly evolving market. It can be challenging for a lot of practi- tioners and technicians to find the time to interact with their peers, but don’t underestimate how much you can learn from networking and socializing. I find this such a valuable part of the sympo- sia experience.

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Clinical MastersTM | issue 2020 | Imprint IMPRINT | about the publisher Publisher and Chief Executive Officer Torsten R. Oemus Managing Editor Nathalie Schüller n.schueller@dental-tribune.com Contributing Editors Brendan Day Jeremy Booth Chief Content Officer Claudia Duschek Design Ralph Schüller www.ralph-schueller.com Copy Editors Sabrina Raaff Ann-Katrin Paulick Education & Event Manager Sarah Schubert s.schubert@dental-tribune.com Executive Producer Gernot Meyer g.meyer@dental-tribune.com Advertising Disposition Marius Mezger m.mezger@dental-tribune.com Media Sales Managers International Melissa Brown m.brown@dental-tribune.com Western Europe Hélène Carpentier h.carpentier@dental-tribune.com Key Accounts Matthias Diessner m.diessner@dental-tribune.com North America Maria Kaiser m.kaiser@dental-tribune.com Eastern Europe Barbora Solarova b.solarova@dental-tribune.com Contributors Dr. Rino Burkhardt, Switzerland Dr. Antonis Chaniotis, Greece Dr. Gilberto Debelian, Norway Dr. Didier Dietschi, Switzerland Dr. Daniel Edelhoff, Germany Dr. Federico Emiliani, Italy Dr. Marco Esposito, Italy Dr. Egon Euwe, Italy Dr. Giacomo Fabbri, Italy Dr. Dimitar Filtchev, Bulgaria Dr. Mauro Fradeani, Italy Dr. Jean F. Gaudy, France Dr. Roland Glauser, Switzerland Dr. George Goumenos, Greece Dr. Galip Gürel, Turkey Dr. Georgi Iliev, Bulgaria Dr. Sascha Jovanovic, U.S. Dr. Joseph Kan, U.S. Dr. Dennis Köhrer, Germany Dr. Mauro Labanca, Italy Dr. Bernard Lazaroo, France Dr. Jaime Lozada, U.S. Dr. Francesco Mintrone, Italy Dr. Nazariy Mykhaylyuk, Ukraine Dr. Edmar Oya, Norway Dr. Braulio Paolucci, Brazil Dr. Stavros Pelekanos, Greece Dr. Giovanna Perrotti, Italy Dr. Gianluca Plotino, Italy Dr. Giulio Rasperini, Italy Dr. Andrea Ricci, Italy Dr. Luigi F. Rodella, Italy Dr. Gabriele Rosano, Italy Dr. Ilia Roussou, Greece Adriano Schayder, Brazil Dr. Hugo Sousa Dias, Portugal Dr. Miguel Stanley, Portugal Dr. Michael Stimmelmayr, Germany Dr. Tiziano Testori, Italy Dr. Peter Wöhrle, U.S. Dr. Giovanni Zucchelli, Italy Dr. Otto Zuhr, Germany International Office Dental Tribune International GmbH Holbeinstr. 29 04229 Leipzig, Germany T +49 341 48474-302 F +49 341 48474-173 General requests: info@dental-tribune.com Sales requests: mediasales@dental-tribune.com www.dental-tribune.com Printed by Löhnert Druck Handelsstraße 12, 04420 Markranstädt, Germany Copyright Regulations All rights reserved. © 2020 Dental Tribune International GmbH. Reproduction in any manner in any language, in whole or in part, without the prior written permission of Dental Tribune International GmbH is expressly prohibited. Dental Tribune International GmbH makes every effort to report clinical information and manufacturers’ product news accurately but cannot assume respon- sibility for the validity of product claims or for typographical errors. The publisher also does not assume responsibility for product names, claims or statements made by advertisers. Opinions expressed by authors are their own and may not reflect those of Dental Tribune International GmbH. 96

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