issn 2193-4673 • Vol. 1 • Issue 2/2020 2/20 digital international magazine of digital dentistry case report Dental Anatomical Combinations— smile design harmony trends & applications Full-arch implant considerations— Innovations in the digital workflow with the iJIG practice management Ten guiding principles as we recover from COVID-19

editorial | Dr Scott D. Ganz Editor-in-Chief Our new world In January, it appeared that the new year would start off very promising: 2020 was to be a great year of inno- vation, learning and prosperity in the dental industry. It was during that month that many of us became aware of something happening in China, an evolving epidemic caused by a new coronavirus strain. We were still going to events, travelling around the globe and busy in our practice of dentistry. In January, I had the honour of presenting at a major meeting in Istanbul in Turkey, where we were still shaking hands, hugging and sitting shoulder to shoulder listening to our col- leagues present their work from the podium. At the end of January, the International Digital Days inaugural meeting was held in Paris in France—a wonderful and successful venue, plenty of vendors and products demonstrated, high-level presentations delivered by speakers from many different parts of the globe, and hands-on workshops too! There were also dinners with our colleagues, friends and corporate partners all in close proximity within the crowded restaurants. We went on planes, trains and automobiles; it was part of our everyday world. And then Europe started to notice that the virus was spreading. Within a few weeks, the McCormick Place convention centre in Chicago was transformed from one of the largest event halls in the US to a hospital to care for people ill with COVID-19. The same happened to the Javits Center in New York City and many others in the US and around the globe. The dental industry has been hard hit owing to our constant exposure to aerosols generated from intra-oral procedures. However, we in the dental industry are resilient, resourceful and innovative. Brilliant minds set to work immediately to help with the lack of certain supplies crucial to containing the spread of the virus, using the technology that we know so well, digital. We should be so proud of our industry for its ingenuity in producing 3D-printed face mask frames to help seal off the face from exposure, in response to the severe shortage of personal protective equipment, even offering free STL files for downloading, and 3D-printed nasopharyngeal test swabs, which are needed to col- lect samples, designed by clinicians and laboratory tech nicians fluent in CAD software. There are innovative designs for 3D-printed face masks with snap-on HEPA filters or specially fabricated suction devices to reduce exposure to aerosols. In the US, one of our largest dental meetings, the Chicago Dental Society Midwinter Meeting, was held in late February, and there were thousands of partic- ipants at the various associated meetings located all around the heart of the windy city, one of which was a highlight for me: LMT LAB DAY, where digital is a major focus of an event held always at the Hyatt hotel. After long daily sessions, the bars were full at night, as were the great restaurants of Chicago. Then our world suddenly changed and came to a screeching halt. Our new normal has redefined countries, cities, states, towns and populations across the globe. We will come out of this better and stronger. We are seeing an entirely new aspect of the power of technology and the new digital workflow that we rely on today and highlight in our publication. Stay safe, stay strong, stay healthy and keep innovating! Respectfully, Dr Scott D. Ganz Editor-in-Chief 03 2 2020

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case report | – Calm or stable: smoothly rounded square dental shapes, weak dominance (current symmetry), hor- izontal incisal edge and 3D rectilinear or standard dental positioning on the arch. Case presentation The patient had short teeth and was not happy with the narrow buccal corridors and the yellowish colour of her teeth (Figs. 2a–d). Aesthetic analysis and Rebel Simplicity Aesthetic design can be challenging for dentists. Rebel (Visagismile) is a recent digital previsualisation 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 – visualise the final aesthetic 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 members and to create a 3D visualisation of the case in the patient’s mouth. The digital project will be tested and approved 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 transfer- ring all the necessary information 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. Single central incisor mock-up and intra-oral digital scanning A composite mock-up is performed on one (or two) of the central incisors in order to identify the incisal edge position vertically and the position of the facial surface buccolingually (Fig. 3). This is no different from creating any direct mock-up; however, the greatest advantage of creating this mock-up for Rebel is that the dentist does not need to concern himself or her- self with the perfect design of this mock-up, meaning that he or she does not need to choose the shape of 3 Fig. 3: Once the mock-up on the central incisor has been completed, it should be digitally scanned. It can be scanned with any intraoral scanner that can produce an STL file. Most intra-oral scanners convert the 3D scan into an STL file automatically. However, if the dentist does not have an intra-oral scanner in the dental practice, an analog impression of the upper jaw (preferably with the direct mock-up done on the central incisors) is taken and sent to the nearest dental laboratory that owns a scanner (laboratories that work with a CAD/CAM machine will have a digital scanner). The dental technician can digitalise this impression for the dentist and upload the STL file to Rebel, in order to complete the order via a provided link. the tooth (square, triangular, rounded, etc.), the angula- tions of the axes of the teeth, surface texture, etc. These details of the smile design will be provided by the Rebel artificial intelligence-based software, according to the facial analysis and the personality of the patient. Therefore, this will allow any dentist at any level to start working with mock-ups and end up with high-level wax-ups. If the dentist does not wish to make a mock-up, then he or she can alternatively write down the additional length that would be needed to be added to the central incisors vertically, and the volume on the facial aspect (e.g., 0.3 mm thicker facially). In that case, the dentist can easily relate the existing length of the teeth to the upper lip position with the help of a periodontal probe. This information should be noted (the additional length that is needed to be added to the central inci- sors vertically and the volume on the facial aspect e.g., 0.3 mm thicker facially) and included in the file that will be sent to Rebel. Full-face photographic protocol The software requires five full-face photographs for facial analysis and classification of the patient and for relation of the 3D intra-oral digital scan to the facial 09 2 2020

case report | Questionnaire An interview to reveal the character and the personality of the patient is completed through a questionnaire available in the software and gives the dentist the primary and complementary characters of the patient (Fig. 5). The temperamental type of each individual is defined by a unique combination of diverse characteris- tics of the four main temperaments, and therefore, for a precise and practical evaluation, it is necessary to apply a specific questionnaire. personalised, 3D wax-up. For every level of dental prac- tice, reproducible and accessible to all professionals, a concept for smile design customisation was developed by Paolucci3 and Paolucci et al.4 The concept, called “Visual Identity of the Smile,” arose from the association of different knowledge such as aesthetic and functional dental fundamentals, artistic visual language, facial recognition and personality typology. For the objec- tive application of this concept, the Rebel software was developed. As the dentist is about to send the three mandatory files, he or she will also be asked to include for the Rebel digital laboratory, a description of the clinical case regarding any specific designs, such as the buccal corridors and perfect imperfections, and the intensity of the surface texture, or choose some of the optional features provided if needed. When the en- tire Rebel workflow has been completed, the software will guide the dentist to exit, and at a click of a button, the file will immediately be sent to the Rebel digital laboratory via e-mail. Rebel software is able to perform facial reading, person- ality assessment and personal preference evaluation of each patient and convert that information into mathe- matical language. Through pre-programmed algorithms, an initial 2D smile design is created. The software is capable of transforming this 2D smile design into a 3D customised model automatically. The model generation is performed by a custom 3D library, developed specif- ically for Rebel Simplicity. Every model is personalised according to the proposed tooth configuration. Rebel digital laboratory It has a very sophisticated simplicity, owing to a very complex software behind it which enables the den- tist to do the most simplistic, yet most predictable and The Rebel system is actually a virtual laboratory that converts the 2D design into 3D and creates a digital wax-up immediately. The 2D design is created by re- lating the facial perception and the personality of the patient to the smile design, by applying algorithms for 5 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 questionnaire 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. 11 2 2020

case report | computing the optimal combination of the incisal sil- houette, tooth axis, dominance of the central incisors and the combination of individual tooth shapes out of thousands of possibilities. It may sound complicated; however, it is the simplest way of creating one of the best 3D digital wax-ups possible. Rebel employs very sophisticated artificial intelligence- based software with algorithms; however, it provides great simplicity to the end users, the dentists and dental technicians (Figs. 6a–d). Back to chairside/3D printing This STL file is then sent to the dentist via e-mail, ready to be 3D-printed (Figs. 7a–e). Tooth preparation through the Aesthetic Pre-evaluative Temporaries The design of the APT (Aesthetic Pre-evaluative Tem- poraries). creates a very solid reference for the tooth preparation. 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 aesthetic acceptance of the patient and the dentist, they are bonded to the teeth under rubber-dam isola- tion (Figs. 9a–c, page 14). Conclusion The combination of the basic rules of aesthetics together with the reflection of the facial analysis and the personality of the patient in the smile design creates a more natural and personalised smile.7–9 This princi- ple presumes harmony between the smile design and the patient’s personality. However, in the dental prac- tice, its application has been limited owing to the lack of an objective method for assessing the patient personality and incorporating its results into the smile design. Currently, Rebel can help the clinician to provide smile designs that consider patients’ emotions, sense of identity, behaviour and self-esteem. Combining modern digital technologies with the classic treatment rules can be used to achieve predictable aesthetic results. 8a 8c 8b 8d Figs. 8a–d: Once the final design has been approved by the dentist and the patient, the dentist can anesthetise 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 intra-oral digital scan, or to continue with the conventional analog way. The patient leaves with the provisionals. 13 2 2020

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case report | important role, especially for the future definition of the maxillary central incisors (Figs. 1a & b).7–11 In the following case report, I will present an aesthetic reha- bilitation in the anterior with no-preparation veneers, taking into consideration the patient’s expectations for his new future smile and the tooth shape, internal substructure of the veneer due the ceramic layering technique and the external surface appearance of the veneer based on the quality of the veneer texture. The challenge of this case was to realign all the teeth with a new dental anatomical combination to close all the spaces. One of the difficulties experienced in this rehabilitation was moving the distal inclination of the maxillary right central incisor to a regular axial position. Furthermore, soft-tissue conditioning was needed in order to create a new cervi- cal contour.12 Technique Based on the anatomical concepts and facial details, I used a new tooth form classification system, called “Dental Anatomical Combinations”, in order to create the right technical approach in the laboratory.13 This concept aims to help dental professionals produce different tooth anat- omies that extend beyond the standard tooth shapes. The basic principle of this system is the segmentation and recombination of two or even all three of the basic tooth Table 1: Complementary classes.13 forms.13 First, the surface of each tooth form is sectioned into smaller segments; for example, by sectioning the tooth into three different segments, a mesial, distal and incisal segment can be obtained. If necessary, these full seg- ments can be further divided in half, resulting in six half segments: mesial cervical, mesial body, mesial incisal, distal cervical, distal body and distal incisal (Fig. 2).13, 14 To create the final tooth form, the full or half segments can be recombined, creating complementary shape classes (Table 1).13 The class numbering system (1: 3, 1: 2, 1/2 : 3 or 1/2 : 2) indicates which segment was used (the number before the colon signifies whether a full [1] or half [1/2] seg- ment) and with how many basic tooth forms for recom- bination (the number after the colon signifies the number of basic tooth forms [2 or 3]).13 The first complementary class, 1: 3, uses one full seg- ment of each of the three principal tooth forms, resulting 3a 3b Figs. 3a & b: Complementary class 1 : 3. Full tooth segments of all three basic forms are combined.13 17 2 2020

case report | 9a 11 9b 12 10 13 Figs. 9a & b: Ceramic layering. The first effects were brushed directly into the moist ceramic material via infiltration (a). Result after the first firing ready to be worked on three surfaces, making vertical grooves for the staining procedure (b). Figs. 10 & 11: Veneers with vertical grooves, placed on the cast ready for staining under microscope magnification. Fig. 12: Final result after correction baking and glazing. Fig. 13: Teeth with sectioned ceramic masses. An important topic of this aesthetic rehabilitation is the pre- cision of the margins. I would like to explain the difference between the meaning of “emergence profile” and “angle profile”, which are in close connection regarding precision, but they have different specific meanings. The emergence profile concerns the precise relationship between the surface contour of the soft tissue and the facial contour surface of the tooth in its emergence profile that must not be overcontoured compared with the gingival margin. The emergence profile precision thus relates to two areas: the soft tissue and the facial contour of the tooth. The angle profile concerns the relationship in precision between the technical margin of the veneers and the clinical finishing line preparation on the natural tooth in order to decide, under the microscope, the precise fit of the veneer and the suitable emergence angle inclination of the margin, which will determine subsequently the future emergence profile design (Fig. 18). 14 16 15 17 Fig. 14: Manually polished veneers on the model. Figs. 15–17: Accurate finishing line and veneer texture. 19 2 2020

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case report | Initial situation A 53-year-old female patient presented to the office with a fractured left central incisor which had been repeatedly bonded to a ceramic crown (Figs. 1 & 2). Anamneses and examination established good systemic and oral health, a well-balanced occlusion and no smoking habits. Cone beam computed tomography (CBCT) and a periapical radiograph showed external root resorption with very limited insertion into the alveolar bone, insufficient for adequate conventional intra-radicular post placement (Figs. 3 & 4). Considering that the fractured tooth was in the aesthetic zone, the patient re- quested restoration in the safest and fastest way possible. Treatment planning Given the clinical and radiographic situation with the position of the root towards the labial wall and sufficient apical bone, extraction followed by immediate implant placement (Straumann BLX) and immediate restoration was chosen as the treatment option. An immediate tem- porary abutment would be placed and chairside tooth shell pick-up technique for the provisional restoration. Surgical procedure Intra-sulcular incisions were performed to release the mar- ginal gingival fibres to allow a minimally invasive extraction. The socket was carefully cleaned to remove any ligament and debris left. Special attention was given to assessing the alve- olar wall integrity. A distance of 3 mm was observed between the gingival margin and the labial wall margin. Implant bed preparation considered a medium-density bone workflow, starting with the needle drill aimed at the palatal wall to create 5 7 6 8 Fig. 5: Initial osteotomy with needle drill. Fig. 6: Osteotomy with Ø 2.2 mm drill. Fig. 7: 3D confirmation with Ø 2.2 mm alignment pin. Fig. 8: Osteotomy with Ø 3.2 mm drill. an entry point for the next drills, creating an osteotomy that allows for a greater area of implant engagement (Fig. 5). The Ø 2.2 mm pilot drill was used to the respective implant length planned, followed by the use of an alignment pin to check the 3D orientation (Figs. 6 & 7). The Ø 2.8 mm and Ø 3.2 mm drills were used to finalise the osteotomy (Fig. 8). The site was then properly probed to assess for possible wall perforation. A 4 × 14 mm implant was placed, starting with the surgical handle engaging the apical part of the implant, following the same orientation as that of the needle drill and correct- ing the implant direction as it moved within the osteotomy (Figs. 9 & 10). Primary stability (45 Ncm) was achieved at 9 12 10 11 13 Fig. 9: Implant pick-up. Fig. 10: Implant placement with surgical handle. Fig. 11: Final implant position assessment. Fig. 12: Final implant position assessment in relation to gingival margins. Fig. 13: Healing abutment to protect connection. 23 2 2020

case report | 22 24 23 25 Figs. 22 & 23: Fitting assessment of provisional tooth shell. Fig. 24: Screw access open. Fig. 25: Temporary provisional tooth shell in position for pick-up of the temporary abutment. 26 28 27 29 Fig. 26: Temporary provisional tooth shell after pick-up impression taking and emergence profile creation. Fig. 27: Temporary crown seated and polished. Fig. 28: Temporary crown one week post-op. Fig. 29: Periapical radiograph one week post-op. 25 2 2020

case report | 6 9 7 10 8 11 of regions #21, 22 and 25. The patient’s health was appropriate to his age. He was a non-smoker and re- ported suffering from minor heart problem, which had been treated about five years before and for which he took ASS 100 daily. His pre-existing periodontal dis- ease had been continually treated for several decades, but had led to loss of the second molars on both sides of the lower jaw and the first molar in the left lower jaw in 2013. Implantation in region #36 was done in our clinic. In October 2019, his treating dentist extracted teeth #21, 22, 25 and 26 owing to massive loosening, owing to periodontal lesions. The healing process was uneventful. After a healing period of around three months for the extraction sites, we started planning the restoration. For that purpose, we took a CBCT scan (X-Mind trium, ACTEON; position: seated; 80 × 80 mm; 90 kV; 8 mA; 1,128.38 mGy cm2). The evaluation of the situation with the ACTEON Imaging Suite software (Version 5.0; Figs. 1–4) showed signifi- cant vertical bone loss at all examined remaining teeth and the implant in region #11 directly next to one of the implantation sites. The distance measured between the neighbouring structures, tooth #23 and implant #11, was 15 mm. As the implant-to-implant distance should 12 14 13 15 29 2 2020

case report | 22 23 24 cations and one palatal application). Thereafter, we raised a flap at the implantation site, avoiding vestibular periosteal elevation (Fig. 17). The open bone surface was cleaned with diamond-coated rotating burs (degranula- tion kit designed by Dr Efraim Kfir; Strauss & Co.; Fig. 18). intra- oral scan, and the neighbouring structures were firm enough to position and retain a surgical template. As the matching process is significant for the outcome of the surgical procedure, this is the most important step in the entire workflow. With the surgical splint, we started the transfer of the planned implant positions, using the depth preforming drill with a diameter of 2 mm (Astra Tech OsseoSpeed TX implantation kit, Dentsply Sirona) and a penetration depth of around 5 mm (Figs. 19–21). The final depth, as well as the widening of the implant bed, was achieved without the splint (Fig. 22). Two implants (Astra Tech OsseoSpeed TX) were inserted (Fig. 23), and the small bone defect palatal of the collar of the implant in region #22 was restored with self-hardening beta-tricalcium phosphate (GUIDOR easy-graft CLASSIC 400, Sunstar Suisse; Fig. 24) and sutured with a PTFE su- ture (GORE-TEX Suture, P5K17; Gore Medical; Fig. 25). We tried to take the postoperative radiograph as parallel as possible (Fig. 26). Conclusion The outcome of this special case was able to be improved by the use of 3D planning and 3D guided surgery procedures. The re-entry was planned for June 2020. Since we were able to minimise the risk of damaging the neighbouring structures to a large extent, the healing process had been uneventful by the time of writing and the greatest part of the implant surface was covered with native bone, we expected a positive end result. Once one is familiar with the procedure, the workflow of intra-oral scan and CBCT scan capture, followed by planning and construction using ACTEON Imaging Suite can be done very easily and quickly—although guided surgery does have its own risks. The demon- strated case offered good visualisation of all relevant structures. The description of the surfaces of all neigh- bouring structures was sufficient to easily match the 25 26 To improve the already very reliable procedure, it would be great to widen the possibilities of the STL file trans- fer system. Once it is possible to transfer an image of templates of implants in STL format, positioned in a DICOM data set and matched with the anatomy taken with an intra-oral scan, back to a restorative construction software programme like exocad, CEREC or inLab, we would have the possibility of backward planning com- pletely digitally to determine the perfect implant position. contact Dr Henrik-Christian Hollay Albert-Roßhaupter-Straße 94 81369 München Germany info@dr-hollay.de 31 2 2020

trends & applications | 3a 3b Figs. 3a & b: Cross-sectional images show the planned positions of each implant. The yellow projections reveal the trajectories and positions of the screw access holes as they emerge through the tooth set-up outline (green). The red line represents the coronal portion of the implants and where the bone would be reduced. been developed to enhance the process of delivering both preoperative and postoperative treatment. This current article presents innovations that can improve the workflow essential to improving efficiencies and achieving success with single and dual full-arch implant reconstruction. Diagnostics and surgery A 58-year-old male patient presented with a failing denti- tion. The preoperative intra-oral retracted view illustrated missing, broken, fractured and decayed teeth, plaque and calculus accumulation, as well as severe soft-tissue inflammation (Figs. 1a–c). The patient complained of pain and difficulty chewing and exhibited a reduced vertical dimension of occlusion and hyper-erupted posterior teeth (Figs. 2a & b). The pre-existing intra-oral condition was recorded with impressions and stone casts that were then digitised with a desktop scanner. Additionally, an intra- oral scan (3Shape) recorded the existing occlusion. The patient’s anatomy was fully assessed with 3D imaging technology and interactive treatment planning software. Cone beam computed tomography (Carestream) was essential in order to visualise the periapical pathology ex- hibited by multiple teeth. Utilising the digitised casts, the dental laboratory completed a virtual tooth set-up to es- tablish the correct plane of occlusion, function and aes- thetics. The virtual occlusion was merged with the original tooth set-up to assist in the diagnostic phase of selecting the appropriate implant receptor sites. The dimensions and volume of the alveolar bone, thickness and opacity of the cortical plates, and overall bone density were impor- tant in evaluating each implant receptor site, necessary for initial stability. Cross-sectional images reveal the planned positions of each implant to achieve a screw-retained fixed restoration on seven proposed implants (Figs. 3a & b). The surgical phase was planned to utilise the full-tem- plate guided surgical protocol as described in the first article (CAD/CAM 4/2019) and therefore only summarised here. On the day of surgery, the necessary components included the tooth-borne fixation base with pin guide, an- chor pins, bone reduction guide, osteotomy drill guide, carrier guide and transitional full-arch prosthesis, and var- ious 3D-printed models for both maxillary and mandibular arches (Fig. 4; CHROME GuidedSMILE, ROE Dental Labo- ratory). The fixation base was first secured to the pin guide and then seated on the maxillary teeth. The facial anchor holes were drilled through the guide holes in the metal 4 5 6 Fig. 4: The necessary components included the tooth-borne fixation base with pin guide, anchor pins, bone reduction guide, osteotomy drill guide, carrier guide and transitional full-arch prosthesis, and various 3D-printed models for both maxillary and mandibular arches. Fig. 5: The fixation base was first secured to the pin guide and then seated on the maxillary teeth so that facial anchor holes could be drilled and anchor pins placed through the guide holes of the fixation base. Fig. 6: The carrier guide was used to accurately position the transitional prosthesis so that it could be secured to the implant sleeves with dual-polymerising composite material. 33 2 2020

trends & applications | 11a 12a 11b 12b Figs. 11a & b: The maxillary and mandibular iJIGs were sectioned and held together with a clear vacuum-formed overlay for seating and then intra-oral luting. Figs. 12a & b: Each section of the iJIG was tightened on to the multi-unit abutments and luted together with either flowable composite or autopolymerising or dual-polymerising resin. The first-generation iJIG involved removing the existing tran- sitional prosthesis for digitisation with a 360° scan with either an intra-oral scanner or a desktop scanner. The prosthesis was then reseated to scan the opposing arch and to digi- tally record the bite relationship. The first generation was ad- equate in concept, but very challenging for both the clinician and the dental laboratory technician trying to decipher the images of the cylinders and trajectory of the access holes to align the components. To overcome this difficulty, special iJIG analogues (ROE Dental Laboratory) were developed to accurately capture the positions of the implants and pros- thetic components. The third generation utilised CAD soft- ware to develop digital tooth set-ups with anatomical teeth that were used to compensate for the equilibrated and worn teeth as a result of function during the healing phase. The fourth-generation iJIG is a prosthetic device that was de- signed based on the concept of “see your smile before sur- gery”. With CHROME GuidedSMILE, most patients receive a nearly true-to-form smile simulation and subsequent virtual tooth set-up based on STL files that mimic the simulation. During the planning phase, the implants were positioned based upon the merging of intra-oral scans or digitised stone casts in combination with the transitional prosthetic design exported as an STL file. Therefore, the original im- plant and tooth planning phase rendered an ideal set-up 13a 13b 14 Figs. 13a & b: The iJIG prosthesis was reinserted, and a polyvinylsiloxane impression material was injected via syringe to capture the tissue interface and bite relationship. Fig. 14: A stone model was created from the impression to capture the location of the multi-unit abutments. 35 2 2020

trends & applications | 17 18a 18b Fig. 17: The pre-op condition was captured in colour with an intra-oral scan. Figs. 18a & b: After the healing phase was completed, an intra-oral scan was utilised to record the positions of the multi-unit abutments and the surrounding soft tissue for both maxillary and mandibular arches. arch and bite scans as previously described (Figs. 19a–d). The introduction of the soft tissue aids in the design of the prototype iJIG in establishing the material-to-ridge relationship of the final prosthetic tooth position, tissue contours, cantilevers, etc. The iJIG and resin try-in phase provides the clinician with essential information to deliver a more accurate and predictable definitive restoration. The sixth generation requires the previously described seating procedures. The information was again introduced into the CAD/CAM software (3Shape) to complete the design of the definitive prosthesis, taking into consideration all changes in occlusion and aesthetics (Figs. 20a & b). The lateral views of the virtual design are illustrated in Figures 21a and b. The definitive screw-retained monolithic zirconia restorations were delivered for both arches. The screw access holes were first covered with PTFE tape and then filled with composite (Figs. 22a & b). The definitive pros- theses can be visualised in the retracted views, showing an acceptable functional and aesthetic result (Figs. 23a–c). 19a 19b 19c 19d Figs. 19a–d: Utilising special iJIG scanning analogues attached to the implants, the entire prosthesis was then scanned and digitised extra- orally and merged with the opposing arch and bite scans. 37 2 2020

trends & applications | 23a 23b 23c Figs. 23a–c: The definitive maxillary and mandibular prostheses as seen in the retracted views, showing an acceptable functional and aesthetic result. protocol, a screw-retained definitive restoration was com- pleted. It was not until a digital workflow and the advent of CAD/CAM software and milling machines that the analogue wax-up was then digitised to create a virtual design and STL file for fabrication of full-arch monolithic zirconia res- torations. To enhance the digital workflow, the evolution of the time-saving iJIG device was presented. As previously described, immediate loading of dental implants for full-arch reconstruction offers many advan- tages over delayed treatment alternatives, but it does require a prefabricated prosthesis at the time of surgery. For the purposes of this article series, the transitional restorations were all digitally designed and produced with a nearly true-to-form smile simulation for delivery via a stackable guide system at the time of surgery. The current iteration of the iJIG manages the small dif- ferences from the original transitional restoration to the desired definitive restoration with an accurate and time- saving innovation. The iJIG can potentially reduce restorative time to three visits. The iJIG is compatible with most im- plant systems, including those of MegaGen, Nobel Biocare, BioHorizons, Neodent, Zimmer Biomet (former Biomet 3i implants), Straumann, Hiossen, Thommen Medical and Keystone Dental. Other systems, which include those of Zimmer Biomet (former Zimmer implants), Implant Direct, CAMLOG, Dentsply Sirona (Astra Tech Implant System), MIS Implants Technologies, Straumann and Paltop, require specific original equipment manufacturer multi-unit abut- ment replicas in order to accurately scan the prosthesis. The present case study required bone reduction to achieve the necessary restorative space for the completion of suc- cessful dual full-arch FP-3 prostheses, utilising the CHROME GuidedSMILE concept with advanced digital workflows. The same full-template guided protocols have also been demonstrated in cases where preservation of the alveolar and interproximal bony architecture was desired, which resulted in an FP-1 prosthetic (pink-free) design, or when zygomatic implants were to be used to support a fixed res- toration necessitated in the severely atrophied maxillary arch. More research and additional multicentre studies will help in understanding the long-term success of these innovative surgical and restorative protocols. Editorial note: This article originally appeared in Dentistry Today in January 2020, and an edited version is provided here with permission from Dentistry Today. Disclosures: The authors report no disclosures. contact Dr Scott Ganz received his specialty certificate in maxillofacial prosthetics/ prosthodontics from the University of Texas MD Anderson Cancer Center in Houston in the US, and this led to his focus on the surgical and restorative phases of implant dentistry and his subsequent contribution to 15 implant-related textbooks. He is a fellow of the Academy of Osseointegration, a diplomate of the International Congress of Oral Implantologists (ICOI), US ambassador of the Digital Dentistry Society, President of the US branch of the Digital Dentistry Society and a co-director of Advanced Implant Education (AIE). Dr Ganz is on the faculty of the Rutgers School of Dental Medicine in Newark in New Jersey in the US and maintains a private practice in Fort Lee in New Jersey. He can be reached at drganz@drganz.com. Dr Isaac Tawil received his DDS from the New York University College of Dentistry and has a master’s degree in biology from Long Island University, both in the US. He is a fellow of the ICOI and the Advanced Dental Implant Academy, a diplomate of the International Academy of Dental Implantology and a co-director of AIE. He has received recognition for outstanding achievement in dental implants from the Advanced Dental Implant Academy, as well as the President’s Volunteer Service Award for his volunteer work in places such as Honduras; Tijuana, Mexico; the Dominican Republic; China; and Lima, Peru. Dr Tawil lectures internationally on advanced dental implant procedures using the latest technology and teaches live surgery seminars in his office and abroad, as well as hands-on courses globally. He maintains a general private practice in New York, where he focuses on implant therapy. He can be reached at tawildental@gmail.com. 39 2 2020

interview | Fig. 2: So far, 41 patients have been treated with the IPS Implants Preprosthetic. Fig. 3: Dr Björn Rahlf (left) and Prof. Nils-Claudius Gellrich at the clinic for oral and maxillofacial surgery at the Hannover Medical School in Germany. Fig. 4: IPS Implants Preprosthetic can be individually adapted to each patient, since the framework structure and the post length can be individually adapted to the defect situation. Our initial goal was to be able to guarantee prostheses after six to 12 weeks. Today, we can even offer immediate care on the day of outpatient treatment. Although this means that the planning phase for the implant is somewhat more intensive, the time for invasive clinical procedures for the patient has become significantly shorter. Rahlf: Also important to mention is that our patients are spared a major operation in which bone is usually trans- planted from their iliac crest or the fibula to the jaw, be- cause these operations often result in complications. With the IPS, we can operate independently of the bone volume because the bone does not necessarily have to be situated where conventional implants would be placed. Instead, we can analyse the existing bone structure, which de- termines the implants, and we can have the posts emerge from the bone where they are needed for the prosthetic solution. Soft tissue must, nevertheless, be transplanted in many cases, for example to ensure the unrestricted movement of the lips. However, this is not a problem, as the human body has sufficient soft tissue and this transplantation is not very difficult to perform. Gellrich: The clinic’s cooperative partner is the KLS Martin Group, a globally operating medical technology company based in Tuttlingen in Germany. IPS Implants Preprosthetic is a registered trademark. KLS Martin now also offers the digital interface to prosthetic solutions. How many patients have received the IPS so far? Rahlf: The first time we considered this idea was in 2014; the first treatment followed in 2015, and the current num- ber of patients is 41. However, some of them have received more than one IPS, which means that we have placed a total of 45 implants. Gellrich: We treat sick patients, patients who are often also undergoing irradiation and patients with congenital malformations—meaning all of them have poorer medical preconditions. However, so far, over a period of more than five years, none of the implants has failed. I hope that, with this method, we will also be able to show that, for example, even very old people can still live for many years with a high load capacity and chewing comfort. The oldest patient we treated was 91 years old and the youngest 19. Is the IPS implant currently only available in your clinic? Rahlf: We organised an event where we showed other university professors in Hanover how the method works. We have also been to international congresses and have presented the method at these. The demand is great, and some colleagues have already planned and implemented their first major cases. Gellrich: In Germany, colleagues are now slowly starting to use the method, some of them at a clinic in Kassel. We also have guest students who come from other clinics to watch live operations at our hospital. Are there clinical studies on your implant application available? Rahlf: We have already published a clinical study1 that de- scribed the kind of system it is and how it works. In a current follow-up study2, we have been investigating whether the quality of life of our patients was improved by the IPS implant. Would you like to add anything else? Gellrich: To avoid any misunderstandings, I would like to emphasise that the IPS, contrary to some misconceptions, is not a reinvention of the old subperiosteal implants that were used from the 1930s or 1940s up until the 1970s. The great difference is that subperiosteal implants were an alternative to normal implants at that time; however, this does not apply to our implant solution. Firstly, the indication is different, and secondly, subperiosteal implants were not functionally stable at any time. The IPS implant, however, is a functionally stable anchorage that a normal implant restoration could never achieve in a comparable form in one of our patients, even under the ideal conditions of a perfect bone graft. It is a line extension in implant dentistry, an individual sup- plement, not a replacement, and certainly not in compe- tition with conventional implants. We consider it a useful addition for a specific patient group. Editorial note: A list of references is available from the publisher. 41 2 2020

to the specific gingival situation generated a great deal of very positive feedback. This interest, combined with the fact that the demand for digital solutions is already very great, made it possible for us to achieve an even better start than we expected. Customers and users with whom we have long-standing, close relationships natu- rally knew about our project at an early stage and were involved in product and process optimisation. Not only did they support us in this project, but they also con- firmed that there will almost certainly be great demand for the new competence centre in future. The word “future” brings us to the next question. Will the digital workflow at Zeramex offer even more options in future? Are you already working on fur- ther developments in the Zeramex Digital Solutions department, and if so, what form will these take? Hunn: I thought you might put this question to me [laughs]. Indeed, there are product enhancements that are already in development and, in some cases, almost completed. In the near future, the competence centre will certainly provide users with innovations as well as enhancements of existing products. Of course, I cannot yet tell you ex- actly what these will be. In addition to the product, deliv- ery times are an issue. We are already working intensively on offering the customer shorter delivery times as soon as possible. The aim is that, in future, Zeramex Digital Solutions products will be received by the customer within two days of placing the order. Mr Hölldampf, you are the laboratory manager at Geiger Dentaltechnik, one of the longest estab- lished machining centres in southern Germany and a close partner of Zeramex. In 2000, your labora - tory was the first in Germany to use 3M ESPE to im- plement a pilot project for milling zirconium dioxide with CNC machines which operated on a CAD/CAM basis. What can you tell us about this material, the machining process and your experience with it? Hölldampf: Yes, that was very exciting back then. Zirco- nium dioxide was still in its infancy, and when 3M, then ESPE, came to us to test this new process, we were ini- tially quite sceptical about whether it would work. In the test phase, we realised that the material zirconium di- oxide was unique and functioned really well and that it would, therefore, be possible to do quite a lot with it. Of course, zirconium dioxide has its pitfalls, and there are a few things to consider when preparing and machining it. At the end of the day, zirconium dioxide is a ceramic. This means that you have to carefully investigate factors like stability values, connector cross sections for bridges and the creation of the correct substrate for subsequent veneering ceramics. There are many factors that come into play. Extremely precise processing must be ensured over all the manufacturing steps. In the past, full-ceramic restorations were really only possible using pressed ce- ramics or the hot isostatic pressed variant. Milling in the interview | green state, however, was a complete innovation. This new approach was gentle on the material, the machine and the milling tool. In addition, it was possible to achieve much more detailed and precise results. It is said that stability is still an issue with zirconium dioxide. You have been working with this material for over 20 years. What is your opinion about its stability? Hölldampf: Zirconium dioxide is a very hard material. If we take a gold crown for comparison, it is much more for- giving in terms of chipping. This is because gold is much more malleable than ceramic. For the ceramic process, this means that an absolutely perfect impression is re- quired in advance. If uncertainties are already present in the impression, this can lead to inaccuracies, and there is a risk of parts of it breaking off. Since pressure cannot be used to apply zirconium dioxide restorations, a per- fect fit must be assured. A gold matrix is more forgiving. Because zirconium dioxide is such a hard material, the product has to be extremely precise and a perfect fit, as I said. The fit is the absolutely crucial. In the further course of machining, it is also important to process it carefully without pressure and with the right cooling. Especially in the area of the geometry of implant connections, it is important to use extremely stable ceramic material. The pressure on a natural tooth is simply very different from that on an implant. An implant is firmly anchored in the bone and allows practically no further movement. Are there still problems with fitting with zirconium dioxide, and does this require a lot of reworking? 2 Fig. 2: Peter Hölldampf is the laboratory manager at Geiger Dentaltechnik, one of the longest established machining centres in southern Germany. 43 2 2020

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manufacturer news | Comprehensive solutions for guided surgery New drill kit for placement of conical connection implants As part of the company’s continuing effort to offer comprehensive solutions for guided surgery in all clinical scenarios, MIS Implants Technologies this spring released its new MGUIDE kit for 16 mm conical connection drills used in implant placement procedures. The new kit has already been implemented in MSOFT, the MIS software used for guided procedure planning, and is offered through an automatic update. This new offering extends the existing solution for this implant length. The kit includes all drills for a complete procedure, as well as a marking drill, which is intended for extraction sites. In addition, the kit offers both standard- and narrow-sleeve drills. Orit Kario, MIS digital solutions product manager, highlighted the marking drill, explaining: “It was designed for this specifi c kit and enables drilling within sockets, providing an added value in immediate place- ment procedures within extraction sites.” The drill’s design allows drilling through the socket wall. www.mis-implants.com 4 5 is modular and is composed of three macro modules: Ortho Studio, Dental Restoration and Smile Creator, which itself consists of the 3D Denture Guide and Digital Mockup modules. Dental Restoration (Fig. 3) Simple and intuitive, it allows you to create dental restorations of up to 16 units, providing real-time feedback and control of all the modelling operations. Easy to use by both laboratories and dental practices, and em- ployed in combination with the Maestro 3D dental scanner, it is a complete solution that helps laboratories and dental practices to enter the digital era. Thanks to the union of the Ortho Studio mod- ule, the Dental Restoration module and the Smile Creator module in a single software programme, it is possible to exploit these com- bined functionalities within an intuitive and integrated workfl ow. Ortho Studio (Fig. 2) This well-known orthodontic software allows you to create study models and virtual set-ups to produce clear aligners, among other things. 3D Denture Guide (Fig. 4) The software guides and assists the user in positioning artifi cial teeth, in order to build a printable guide to create a prosthesis for an edentulous patient. Digital Mockup (Fig. 5) This module helps dental technicians and dentists to conduct highly aesthetic restorative treatments based on the smile desired by the patient. www.maestro3d.com 47 2 2020

meetings | ucts—will certainly fall short of a physical event. Thus, instead of trying to recreate these factors, our team will focus on creating new experiences within the digital event. One advantage of the online event will be that attendees will be able to view and review conference sessions multiple times at their own learning pace. We will strive to introduce new ways for our attendees to engage and for exhibitors to feature their products and solutions. Participants can look forward to connecting with their peers through live chats, discovering new products and interacting with our exhibitors in order to under- stand how these solutions would assist them in their practices. Taking the limitations into consideration, we made a conscious decision on our side to offer basic participation in the digital event free of charge to all our loyal IDEM exhibitors and to fully refund the participation fee for the physical event. What are the greatest challenges in putting the on- line event together, and how does the organisation process differ from planning a live event? As you can imagine, we have spent the last two years planning for IDEM 2020; thus, changing at the last moment to building an online event is not without its challenges. Creating a digital event is also new for our team, yet we are embracing the experience. As many factors are considered when choosing a digi- tal platform to host an event as when choosing a phys- ical venue. The choice of convention centre can make or break a physical event, and in the same way, it was important to ensure that our digital system could sup- port the event in order to provide a positive experience throughout. Some other key considerations were the suitable showcasing of our exhibitors’ products and ser- vices, and the provision of content accessible to anyone, anywhere at an affordable price. To meet these requirements, an important change we have made in order to build a positive experience for IDEM 2020 participants is to have the digital event run for two months instead of the usual three days. This will allow everybody to access the conference sessions and explore the exhibition at their own pace and convenience. These changes to the organisation and format of IDEM are also reflected in our marketing approach, which we have shifted to focus on the flexibility and interactivity of the online platform. Thousands of working hours go into planning a large and prestigious event like IDEM. How did the change from a live event to an online version affect you and the organisation team personally? Naturally, we were disappointed not to deliver the event we had planned. We had spent a lot of time considering how to bring a fresh approach to IDEM 2020, and we were excited about introducing several new additions and changes to the usual format. One such change, for example, was to have workshops conducted on the exhibition floor. Although we were unable to host the conference and exhibition in April as planned, we are grateful that we made the decision to move to a digital platform. Our primary purpose is to serve the dental community by providing learning and networking opportunities, and we are still able to achieve this in a reasonable way through our digital event. We are immensely grateful to the exhib- itors, speakers and attendees who continue to support and demonstrate their commitment to IDEM. “Dentistry as a profession may have to adapt by learning to conduct business in a new way.” The SARS-CoV-2 pandemic has changed the world. What do you think are the long-term effects on the dental industry? There are still so many unknowns about SARS-CoV-2, and dentistry as a profession may have to adapt by learning to conduct business in a new way. While hygiene and sanitation has always been a priority, it is now of paramount importance. There will be more emphasis on infection control and the implementation of these measures across different levels. Continuing education in dentistry will still be essential. As event organisers, it is important for us to continue to adapt in order to deliver relevant content in a timely manner and in various formats, such as online events. The new measures in practice and the restrictions relating to international travel may also be the norm for some time. For the IDEM organising team, even as we plan to bring the event back to its physical format in 2022, we will con- tinue to stay abreast of these challenges and seek to find convenient ways to ensure that our community is heard and can flexibly participate in the learning programmes. We stand ready, as always, to support the needs of the dental community. Editorial note: More information on the event can be found on the official IDEM website: www.idem-singapore.com 49 2 2020

meetings | “Our mission is to advance side by side with dental professionals” – Irin Maier, director of clinical affairs and education, Nobel Biocare Looking to the future of dental education after the COVID-19 pandemic, speaker Dr Sascha Jovanovic, who was one of the first to provide Web-based dental train- ing programmes back in 2003, commented: “It is a very tough time, but we will get out of it, and hopefully the world will be a better place. Looking at online education and training, a lot of us will re-evaluate it. We are going to test how much of the training and education, and the transfer of research, will be possible online. I think it’s going to go far. I do webinars, and we have an online education library and use it constantly for our students. I think our world will be different, our training and educa- tion will be different and meetings between doctors will be different.” The previous Global Symposium was held last summer in Madrid in Spain and involved more than 1,000 partic- ipants. For the 2020 virtual edition, the programme was shortened and included seven live sessions and sev- eral on-demand webinars over two science focus days. Participants had the opportunity to raise questions and further discuss with experts several topics, including guided and navigated treatment planning, implant treat- ment success in the aesthetic zone, soft-tissue grafting, and management of treatment complications. Thanks to the on-demand viewing functionality, more dental profes- sionals and members of the dental team can benefit from these presentations. Irin Maier, director of clinical affairs and education at Nobel Biocare, said: “Our mission is to advance side by side with dental professionals. Their interest and their active participation and excellent feedback on clinical and product topics, show that there is grow- ing interest in advancing in the implant treatment journey, and achieve better patient outcomes. The interactive comments and remarks we have received will guide us in our efforts towards continuous im- provement, science-based innovations and first-class educational tools.” Dental webinars from this symposium are still available free and on-demand on the Nobel Biocare website. 51 2 2020 The 2020 Nobel Biocare Global Symposium, which was originally scheduled to take place from 16 to 18 April in Las Vegas in the US, was conducted online on 16 and 17 April instead. (Image: © Nobel Biocare) educational courses and events at any stage of the im- plantology journey, from novice to expert, are provided through various learning platforms around the world. The comprehensive courses are delivered by industry- leading experts, covering everything, including diag- nosis, treatment planning, and surgical and prosthetic processes. “This digital experience proves that implantology profes- sionals are extremely keen to learn. Maybe we should see it as an advantage that they have the time to attend educational webinars when normally they would be inun- dated by patient appointments,” commented Dr Alessandro Pozzi, a specialist trainer in digital dentistry solutions, on the currently required shift to online education. “In my own sessions, hundreds of clinicians have been building their skills in the DTX Studio suite implant and prosthetic software and increasing their confidence in its daily use. These are valuable tools for clinicians and hygienists at every level, to treat more patients better,” he added.

practice management | 4. Show empathy and give comfort 7. Demonstrate your new processes Some people are likely to lose their jobs as a result of the current pandemic, or at least experience a decline in their income. Therefore, showing empathy is vital. Com- fort your patients like a friend would do. Apart from that, avoid losing loyal patients only because they are not able to afford certain procedures anymore owing to the cur- rent situation. You can minimise this risk by offering pa- tients to prioritise certain dental conditions over others. This should happen in written form, where you need to in- clude the important note that this treatment plan is based on recent findings and will be in place for no more than three months. However, remind them (preferably also in written form) that their dental problems will be likely to de- teriorate further over time. 5. Look at things from a patients point of view Many of you are probably anxious about the likely decline in the number of the cosmetic cases that you would nor- mally have treated in the near future. And yes, the truth is that some people probably will not have the budget for cosmetic surgeries in the months ahead. Many people will reduce their social presence and thus there will not be many opportunities for them to proudly show off treat- ment results and their new smiles to others. Patients will only accept treatment proposals and spend money on them, if they understand these treatments are beneficial to their health (human beings are conscious about their personal health, after all). Hence, start to emphasise the strong link between the immune system and dental health when speaking to pa- tients. Try to see the world from their point of view: how does it feel, after living for so many days in lockdown and self-isolation, to face the daily fear of getting infected and/ or being socially discriminated, if you behave in a wrong way? Wouldn’t you be relieved that your favourite dental clinic implements processes that are aimed at benefitting the health of patients? Furthermore, it is our moral duty to enhance our patient’s health, as well as to communicate this approach to them—not only on a theoretical level, but also practically. 6. Think more digitally Start demonstrating the newly developed processes and rules for your clinic or practice by communicating them to your patients: send newsletters to the patients in your database, produce and post short videos of you and your staff using and applying these new processes and opt for social media channels that have the widest pos- sible reach. Remember—life will go on! My dear colleagues, make this “stay home” period a productive one, since there will now be plenty of time to make all the necessary changes to your clinic’s work- flows and processes. It is important to remember that life will go on after this crisis. However, you need to adapt to and prepare for the post-pandemic era. Be proactive and start designing your own new set of rules. Those who understand this concept are more likely to prosper even- tually. In my next article, I will delve more deeply into the implications the current pandemic has for dentists and their clinics in the future. Until then, remember: this is your time to get ready and prepare for the things to come! For any further questions, information, requests and guid- ance feel free to reach out to dba@yiannikosdental.com. about Dr Anna Maria Yiannikos (DDS, LSO, M.Sc., MBA) is one of the first two women worldwide to have obtained a master’s degree in laser dentistry. She has owned a dental clinic for 30 years now and leads the innovative Dental Business Administration Mastership Course at RWTH Aachen University in Germany. She is an adjunct faculty member of the Aachen Center for Laser Dentistry. I would argue that the more your clinic embraces means of digital dentistry, the more it will thrive! Why? These days, patients will prefer fewer visits to doctors in order to minimise the exposure to possible viral dangers and the risk of getting infected. Hence, digital means such as CAD/CAM systems, or intra-oral scanners and cam- eras, which imply fewer physical patient contact and a more forward-thinking attitude, should be added to your clinic’s armamentarium in order to set your clinic apart and attract new patients even in times of a pandemic. contact Dr Anna Maria Yiannikos Adjunct Faculty Member of AALZ at RWTH Aachen University Campus, Germany DDS, LSO, M.Sc., MBA dba@yiannikosdental.com www.dbamastership.com 53 2 2020

practice management | on that journey. I do not wish to make light of any indi- vidual’s personal or professional challenges, but I do want to remind you that we are wired to win. COVID-19 is undoubtedly the greatest challenge to humanity that I have witnessed in my lifetime, and I am confident that we can and will prevail. 2. Stay calm. When all about you are losing it, leader- ship is about calmly taking control and demonstrat- ing the way forward. Every dental team member has a leadership role, whether it is calming team members or patients, answering the phone, offering virtual con- sultations or meeting patients face to face (at a safe distance or in PPE). Emotion is contagious and your calm demeanour can help all of those around you. 3. Be kind. That may sound cheesy to you, but I have witnessed many random acts of kindness during the pandemic, and people remember the way you show up in times like this. 4. Learn a new routine. During the first weeks of lock- down, what we all had in common was that our ex- isting routines were stolen from us by circumstance. We are creatures of habit, and even though we may have complained about the commute to work, the office hours or other aspects of our pre-COVID-19 life, the fact is that lockdown threw us all into chaos. Some reinvented new lockdown routines quickly; others floundered. Whichever group you found yourself in, return to work is now yet another new landscape, and you will have to develop your new routines quickly and settle in to them. 5. Communicate. The winners in lockdown were those who communicated regularly with patients, team members and clinicians via video calls, newsletters and messages. Just because you are back to work, do not stop! It is essential that you listen to the feed- back on how your dental business is perceived by all concerned; essential that your communities have the opportunity to tell you how they feel; essential that you tell everyone what you are thinking and what is going on. 6. Do not be afraid of giving and receiving feedback. As we all learn the new dance steps, mistakes will be made—and that is OK. That is how we grow. So be open to feedback and be ready to give feedback when you see things that are not right. At the moment, your patients and your team are some of the best consultants you could ask for. 7. Do not be afraid to ask for help. When the COVID-19 dental history book of 2020 is written, I like to think that one of the benefits of this horrible situation will have been the growth in unity of the dental profession, both nationally and globally. Have you ever seen so many free webinars? I hope that continues over the years ahead and that dentists do not disappear back into their former silos. Asking for help is a sign of personal strength and confidence. Membership of trade asso- ciations and other representative bodies has grown. My wish is that this momentum continues into post- graduate education and beyond. 8. Be patient. Dentistry will not be back to how it was before, perhaps ever. However, that indomitable spirit of enterprise that identifies humans will, in my opinion, drive even more experimentation, invention and inno- vation over the years ahead. I believe that we will see a sudden acceleration in digital innovation, in virtual consulting and in the arrival of new procedures, ma- terials and techniques in every aspect of dentistry and patient care. 9. Take time to think. Please do not jump into a new hamster wheel to replace the one you were running in before COVID-19. This is a once-in-a-lifetime op- portunity to start again, knowing what you know now. If you were starting your business again, what would you do differently? Well do it! 10. Seek balance. Back to that once-in-a-lifetime moment— I have had many of my clients use this time to create lists of aspects of their personal and professional lives that they like and dislike. I have asked them to seri- ously consider eliminating the tolerations—the people, things and situations that get in the way of their hap- piness. You can. Over the months ahead, there is a great deal to consider: – financial modelling and forecasting; – marketing for new patients; – the new patient journey; – clinical and non-clinical operational systems; – your team—their structure, roles and responsibilities; – your overall game plan. Each of these is on my task list to consider, decide and execute new versions for my clients that apply to the post- lockdown time and (we hope) post-COVID-19 landscape. I am working with a community of over 120 UK practices, and we are taking that journey together, sharing our ex- periences and collaborating on solutions. Dentistry can no longer be a fragmented collection of small business owners. As I heard on a webinar a few days ago: “We may not all be in the same boat but we are in the same storm”. It is only by staying together that we can enjoy strength in numbers. contact Chris Barrow has been active as a consultant, trainer and coach to the UK dental profession for over 24 years. His main professional focus now is through his Extreme Business company, providing coaching and mentorship to independent dentistry around the world via face-to-face meetings, a workshop programme and an online learning platform. 55 2 2020

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