issn 2193-4673 • Vol. 1 • Issue 3/2020 3/20 digital international magazine of digital dentistry case report Overdenture solutions for today’s economy trends & applications Virtual reality and orthodontics: A new patient experience news Artificial intelligence-based analysis of dental radiographs saves time in patient care

editorial | Dr Scott D. Ganz Editor-in-Chief COVID-19 times Here we are in the autumn of 2020 in a situation that most of us would never have dreamed would happen. Our offices were closed for weeks and months owing to the global pandemic that has dramatically changed the way that we live, socialise, travel, interact, shop, eat, educate others and ourselves, and practise our profes- sion. Major and minor meetings and hands-on work- shops have been cancelled or postponed indefinitely. For many, the everyday practice of dentistry has been limited in many ways, including the need for extra per- sonal protective equipment and enhanced infection control necessitated by the aerosol spread of the potent virus. Of course, this affects the clinicians who practise dentistry, our staff, dental laboratory technicians, indus- try suppliers, local and regional sales representatives, and many other people. To summarise, SARS-CoV-2 has influenced every aspect of our lives, becoming the new normal for everyone, as I indicated in our previous issue. This is now several months later, and we are perhaps in the middle of a strong second or even third wave of infections. Regrettably, in many regions of the world, the response to SARS-CoV-2 has become political, many leaders not accepting the recommendation of scientists who traditionally have been evidenced-based truth- tellers. If there is one saving grace, it is our experience and understanding of technology and the tools that can help us survive this time of the pandemic with a little less pain—and this is especially true for the readership of digital. Most of our educational venues have gone “virtual” – meaning that many of us are spending more and more time in front of our computer screens. We are now rou- tinely interacting with our colleagues, associates, family members and others using remote communication tech- nology on our computers or our incredible smartphones, which have become a universal means of instant global communication. Fortunately, in our profession, our digi- tal workflows are already in place: we are used to send- ing and receiving files or interacting with a computer simulation, assessing a digital radiograph or CBCT scan, and working with software applications to review, plan and design treatment plan objectives. Within the con- fines of the current COVID-19 limitations, it has become apparent that those with enhanced digital skills will have a distinct advantage. As always within the pages of this current edition of digital, you will find interesting articles, concepts, clinical applications and much more from some of the brightest minds and most talented clinical practitioners and edu- cators in our profession. Please enjoy this latest offering while staying safe, practising social distancing, washing hands and wearing masks to protect those around you. Let us all do our very best to get through these difficult times of managing our professional and private lives with the anticipation that life will return to a pre-COVID-19 existence of normality, sooner than later. Dr Scott D. Ganz Editor-in-chief 3 2020 03

2D & 3D exams MAC Compatible 75µm High resolution image up to 50% dose reduction 1 MINUTE implant planning report o compromise with 3D image quality IT'S TIME FOR TRUE LOW DOSE CBCT DE GÖTZEN® A company of ACTEON® Group Via Roma, 45 21057 Olgiate Olona VA ITALY Phone +39 0331 376760 Fax +39 0331 376763 E-mail : info@acteongroup.com www.acteongroup.com

interview | by not only providing new and fascinating content but also delivering it in a way that has not been seen before. What was new for attendees of EAO Digital Days who were used to the traditional format? First of all, the programme was broadcast in the eve- nings, allowing participants to easily enjoy the shows after work. Secondly, the event was not just a compilation of webinars; it mirrored the complete structure of a scien- tific conference in a virtual environment. Eight different channels provided abstract sessions, e-poster sessions, virtual exhibition booths, sponsors’ lounges and EAO membership lounges that attendees could choose from. And thirdly, our flagship channel, Channel 1, broadcast the core scientific content and was structured like a TV show, running from 7:00 p.m. to 11:30 p.m. CET during the first four evenings. This channel presented focus sessions that provided clinical and practical knowledge, guided by a moderator, and expert question sessions that, in addition to providing expert knowledge, offered the possibility of audi- ence interaction. The real heart of each of the four evenings was the prime time debates in which a group of experts gathered and discussed certain topics. Short “champion” stories told by scientists and clinicians lightened up the eve- nings, which were concluded by a late-night show featuring an eminent person from the implant dentistry community. What were some of the topic highlights? EAO Digital Days focused on three major areas. Firstly, we wanted to show the great potential of digital implant dentistry, but also its limitations. In order to do so, we discussed fully guided versus dynamic navigation and how to use digital data in complex interdisciplinary cases. Based on this discussion, the relevance to the relationship between practitioners and patients was demonstrated, and it was evaluated whether patients appreciate the improvements associated with digital implantology. A second area of innovation that was addressed is bio- “The real heart of each of the four evenings was the prime time debates” technology, including the latest developments in bio- active and anti-infective implant coatings and the prog- ress that bioprinting has made in tissue repair and reconstruction in deficient areas. In addition, we took on some of the ongoing controversies about implant placement in growing individuals and the combination of teeth and implants in prosthetic treatment concepts. And finally, we showed live soft-tissue repair surgeries, which were presented directly from the operating rooms and discussed by our expert guests in the studio. The EAO is an important association for implantolo- gists and periodontists. Apart from moving the EAO congress to an online event, how is the EAO handling the SARS-CoV-2 pandemic, and how are you support- ing your members in these challenging times? The EAO is committed to our members, and since all of them are affected by this pandemic, we try to provide sup- port on different levels. We have offered expert knowledge on the management of dental offices and the treatment of patients under COVID-19 circumstances in a recent “Just Ask” session that is available online. Furthermore, we have devoted €50,000 for European research on the development of a vaccine against the virus in a crowdfund- ing approach. On the Friday of EAO Digital Days, we ded- icated one session to an update on the management of daily work under conditions of COVID-19 and discussed matters such as protection measures. Editorial note: More information about EAO Digital Days can be found at digitaldays.eao.org. 3 2020 07

Digital Implant Workflow Streamlined collaboration for your treatment team From data capturing, planning and guided surgery to the final restorative solutions, with the Digital Implant Workflow from Dentsply Sirona you have all the support you need to save time, deliver predictable results and provide your patients with the best possible care. Follow Dentsply Sirona Implants dentsplysirona.com/implants

case report | 6 7 8 Fig. 6: Panoramic view of the planned implant in the SMART Guide software. Figs. 7 & 8: Zoomed-in view of the planned implant in the SMART Guide software. develop a treatment plan based on the patient’s needs and anatomical suitability rather than on a specific implant manufacturer’s product lines. Thus, the ideal guidance system can be adapted to a variety of implant brands and types, offering recommendations that are patient-centred rather than product-centred. The SMART Guide Technology System (dicomLAB Dental) provides complete case analysis and preparation shortly after imaging, enabling immediate treatment planning for any type of implant placement. It is possible to set the implant length in 0.5 mm increments and the diameter in 0.1 mm increments. The surgical protocol of the 9 10 11 12 Fig. 9: Digital tooth set-up visualisation in the SMART Guide software. Fig. 10: Implant for fractured tooth #24 planned. Fig. 11: Planned implant in 3D visuali- sation in the SMART Guide software. Fig. 12: SMART Impression Tray visualisation in the SMART Guide software. 3 2020 11

case report | 20 24 28 31 21 25 22 26 23 27 Fig. 20: Preparation. Fig. 21: START long drill. Fig. 22: The first drill goes in with the spoon to stabilise the drill. Fig. 23: The first drill with its spoon. Fig. 24: Inserting the first drill through the surgical guide after the START drill. Fig. 25: The second drill with its spoon. Fig. 26: Inserting the second drill. Fig. 27: The third drill with the corresponding spoon. The remainder of tooth #24 was extracted. In order to avoid any complications due to residual bacteria or possible periapical or periradicular infection, a two- month healing time was set. After the initial healing, a CBCT scan was taken and an intra-oral impression of the patient was taken with a custom-made plastic impres- sion tray and C-silicone. This is the SMART Guide simple CBCT protocol. This approach has some limitations, as the superimposition of the CBCT scan on to the silicone impression requires the presence of a minimum of eight sound teeth as reference points on the dental arch to be treated. The silicone impression must be scanned with an extra-oral scanner for the digital superimposition of the CBCT scan on to the impression. Another option is to use an intra-oral scanner. The same limitations regarding sound teeth apply, however. The reference teeth must be sound or restored with metal-free restorations; any metal restorative components, such as amalgam fillings, porcelain-fused-to-metal crowns or bridges, or metal posts, interfere with the CBCT data acquisition. After the CBCT scan of the patient and the scanned impression had been completed, both data sets were uploaded, without patient-identifying information, to SMART Cloud. The SMART Guide centre then checked the quality of the images. In cases in which the patient is completely edentulous or there are not enough metal-free, sound or restored teeth to provide the required minimum eight reference points, the double CBCT scan technique can be em- ployed. This procedure entails taking an initial impression 29 32 30 33 Fig. 28: After the preparation, the implant drills are used up to the last drill needed. Figs. 29–33: Implant insertion. 3 2020 13

case report | Once the SMART Guide centre has prepared the case, the operator receives a notification e-mail or text. This is typically within approximately 4 hours after successful data upload. The practitioner then downloads the patient data to the practice computer on which the SMART Guide software has previously been installed. It is now possi- ble to plan the optimal positioning (location, angulation, depth and diameter) of the implant, considering the im- plant properties (length, diameter and shape; Figs. 4–8). In the current example, the replacement of the extracted maxillary left first premolar with an implant and an im- plant-borne crown is demonstrated. The software makes it possible to visualise the bone, the soft tissue and the intra-oral impression taken of the patient. The software then suggests a crown shape, which assists with the planning of the implant angulation and the ideal emer- gence profile of the restorative crown. The recommended shape considers the anatomical properties of the adja- cent and opposing teeth and the soft-tissue condition. In cases in which screw-retained crowns are planned, this process is essential in ensuring proper location for optimal angulation and access to the retention screw (Figs. 9–12). Once the planning phase has been completed, it is pos- sible to ask for a treatment plan review by a contracted expert implant specialist on the SMART Guide system who is able to mentor the practitioner. This approach offers confirmation of treatment approach and direction prior to any surgical steps. For those who are less experienced in treat- ment planning, this is an invaluable safeguarding service. A comprehensive pre-planning service (that begins imme- diately after data upload) is also available. In all cases, however, the final decision is always at the discretion of the operator. Further planning and mod ifications are always possible before the SMART Surgical Guide is ordered. A short time after it is ordered, the printed surgical guide arrives at the practice. It is a good idea to sterilise it in an autoclave. Along with the printed surgical guide, the operator is provided with a specific surgical protocol for the planned implant (Figs. 13–19). During the actual implant placement surgery, the sequence that is recommended on the attached drilling protocol chart should be followed. The surgical kit of the SMART Guide system consists of drills 20.0 mm, 24.0 mm and 28.0 mm in length, each with a diameter of 2.0 mm, 2.5 mm, 3.0 mm and 3.5 mm (Figs. 20–27). The final drilling step is done with the final core drill of the selected implant system, to the proper depth and dia meter to ensure perfect implant placement. The final implant drill can also be used without the surgical guide, since the direction and depth of the bone prepara- tion will already have been pre-established with the SMART Guide. The bony housing will already have been prepared to a size which almost matches that of the intended implant (Figs. 28–43). Conclusion The SMART Guide Technology System offers a versatile implant placement guidance system that can be adapted to most implant brands and types, making implant surgery patient-centred (rather than product-centred), more predictable and more efficient. about Dr Mark Antal is an assistant professor at the Faculty of Dentistry of the University of Szeged in Hungary. After earning his DMD, he specialised in operative dentistry and oral surgery, completing internships at Martin Luther University Halle-Wittenberg in Germany and Boston University and New York University in the US. He previously served on the Education Committee of FDI World Dental Federation and is an honorary lifelong member of the International Association of Dental Students. He is a member of the Magyar Esztétikai és Restauratív Fogászati Társaság (Hungarian Association for Aesthetic and Restorative Dentistry) and the MAGYAR FOGORVOSOK IMPLANTOLÓGIAI TÁRSASÁGA (Hungarian Dentists Society of Implantology). A graduate of McGill University in Montreal in Canada, Dr George Freedman maintains a private practice limited to aesthetic dentistry in Toronto in Canada. He is adjunct professor of dental medicine at Western University of Health Sciences in Pomona in California in the US and a visiting professor and director of the MClinDent programme in restorative and cosmetic dentistry at BPP University in London in the UK. He is the author or co-author of 14 textbooks, his most recent being Contemporary Esthetic Dentistry (Elsevier, 2012), and of more than 800 dental articles and numerous webinars. He serves on the editorial team of REALITY and is the international editor-in-chief of Dental Tribune. He lectures internationally on aesthetic restorative dentistry, adhesion, composites, implants, oral health maintenance, porcelain veneers, 3D printing and other dental technologies. Dr Freedman is a regent and fellow of the International Academy for Dental-Facial Esthetics and a diplomate and chair of the American Board of Aesthetic Dentistry. He is a founder and past president of the American Academy of Cosmetic Dentistry and a founder of the Canadian Academy for Esthetic Dentistry and the International Academy for Dental- Facial Esthetics. Dr Freedman is a recipient of the Smigel Prize in Aesthetic Dentistry (New York University College of Dentistry). 3 2020 15

case report | 7a 8a 7b 8b all straight, in order to support a fixed full-arch prosthesis (Fig. 4). The provisional prosthesis was produced prior to the implant placement. The surgical guide was printed to perform a static guided surgery. Treatment planning Using coDiagnostiX (Dental Wings), we could see that there was enough bone into which to place the im- plants (Fig. 5), apart from two regions that would need bone grafting (Fig. 6). Six straight positioned implants were planned with an adequate cross-arch distribution to support the masticatory forces and avoid cantilevers (Figs. 7a & b). The Straumann BLX implants would be placed using a surgical guide (Figs. 8a & b), and the pro- visional prosthesis would be screwed on to the implants just after the surgery as part of the immediate loading protocol. 9 12 10 11 13 3 2020 17

case report | 21a 21b 22 23 24 with the rachet, and the Straumann surgical torque control device indicated primary stability, measured as being above 35 Ncm, allowing the implants to be loaded immediately (Figs. 14–17). After the implant placement, a small flap was elevated in the regions with pre-planned implant exposure. The screw-retained abutments were screwed on to the implants (Fig. 18). Over the exposed implant surfaces (Fig. 19), we performed guided bone regeneration utilis- ing the Buser concept, placing autogenous bone chips as the first layer in contact with the implant (Fig. 20). Over the autogenous bone, we augmented the volume with a layer of biomaterial (cerabone, botiss biomaterials) 25 27 26 28 3 2020 19

case report | 39 41 43 were created in the printed models, based on the surgical guide (Figs. 29–31). Following the same orien- tation, six holes were created in the provisional pros- thesis (Figs. 32–34). After suturing, we inserted the prosthesis over the implants to capture the final implant positions. With flowable composite, we con- nected the provisional prosthesis with the provisional titanium copings (surgery performed together with Dr Cristiane Juchem; Figs. 35 & 36). The final adaptation was performed chairside, and after some minutes, the restoration was screwed on to the screw-retained abutments. After three months, the temporary res- toration was replaced by the definitive restoration (Figs. 37–44). Treatment outcome Immediate loading in edentulous patients is a well- documented procedure that has similar implant and restoration survival rates to those of delayed loading. The possibility of performing small adaptations to the provisional restoration produced before the surgery is a very good way to compensate for the small deviations that can occur in guided surgery. 42 40 44 about Dr Leandro Soeiro Nunes graduated from the Federal University of Rio Grande do Sul in Porto Alegre in Brazil and specialised in oral and maxillofacial surgery in 2006 at the Universidade Luterana do Brasil in Canoas in Brazil. For his master’s degree, which he undertook at the University of São Paulo in Bauru in Brazil, he evaluated the biological behaviour of biomaterials in sinus lift procedures, and for his doctorate, completed at the Pontifical Catholic University of Rio Grande do Sul in Porto Alegre, he compared the biological behaviour of different implant surfaces. In 2010, he moved to Berne in Switzerland to join the International Team for Implantology (ITI) scholarship programme headed by Prof. Daniel Buser at the University of Bern. Dr Nunes is an ITI fellow, ITI study club director in Porto Alegre and teaches implantology at the Associação Brasileira de Odontologia, seção Rio Grande do Sul (Rio Grande do Sul section of the Brazilian association of dentistry). He also runs his own private practice focused on oral surgery, implant therapies and bone regeneration He can be contacted at leandrosnunes@gmail.com. 3 2020 21

case report | 6 7 Fig. 6: Physics Forceps used for extractions (GoldenDent). Fig. 7: Area grafted and sutured. decay, but also the areas remaining bone for dental im- plant placement (Fig. 3). Since the patient had expressed his concern about cost, our goal was not only to find a treatment modality that would restore aesthetics and function economically in terms of cost, but also to pro- vide a treatment that could potentially be upgraded in the future. Preliminary impressions for immediate dentures were ob- tained using Silginat (Kettenbach), a cost-effective elasto- meric polyvinylsiloxane impression material. Orthodontic retractors were utilised in order to ensure that the patient was accurately biting in centric occlusion when capturing the bite registration with fast-setting Futar bite material (Kettenbach; Fig. 4). Photographs of the patient’s smile and midline were acquired in order to properly inform the dental laboratory (Advanced Implant Dental Lab) of any changes that were desired, including tooth position, tooth size and arch form for the immediate dentures (Fig. 5). All risks, benefits and alternatives were fully described to the patient and any questions fully answered. Upon listening to the various treatment options, the patient decided to have all his remaining teeth extracted and those sites grafted. In the maxillary arch, the patient would be getting a complete denture, whereas in the mandibular arch, he would be getting an overdenture retained by four dental implants. In order to assist the patient with this investment, financing options using a third-party payment option (Alphaeon Credit) were discussed. This consideration was a very important part of facilitating acceptance of his care, since it made the cost of treatment more economical. Once anaesthesia was acquired, we started removing the teeth in the maxillary arch using the Physics Forceps (GoldenDent; Fig. 6). Since the Physics Forceps act like a Class I lever, the only force applied with the beak is on the lingual aspect of the tooth. With the beak positioned at the lingual cervical portion, the soft bumper is placed on the buccal alveolar ridge at the approximate location of the mucogingival junction. While the beak grasps the tooth, the bumper acts as the fulcrum, providing leverage and stabil- ity for the beak. Extraction is accomplished with slight wrist movement rotation in the buccal direction for about 30–60 seconds, depending on the length and curvature of the roots. Once the teeth in the maxillary arch had been removed, any granulation tissue remaining within the sockets was removed using a curette (GoldenDent), and any sharp areas of the alveolar crest were levelled with a bone bur (GoldenDent). OsteoGen plugs (Impladent) were placed in each socket to facilitate bone growth within the sockets over a four- to five-month period for future implant placement if the patient desired. Using resorbable sutures, the OsteoGen plugs were further stabilised and the tissue sutured (Fig. 7). 8 9 10 Fig. 8: Try-in of immediate denture. Fig. 9: Chairside soft denture relining material. Fig. 10: Dispensing SOFRELINER TOUGH (Tokuyama Dental) into immediate denture. 3 2020 23

case report | 18 19 20 Fig. 18: Chairside hard denture relining material TOKUYAMA REBASE II (Tokuyama Dental). Fig. 19: Immediate post-op retracted view. Fig. 20: Retracted post-op smile view. guide, the next layer, which was the implant surgical guide, was placed over it (Fig. 14). Using the MGuide Set (MIS Implants Technologies), the drilling sequence for four Seven (MIS Implants Technologies) dental implants was initiated. This computer-based planning system enhances both accuracy and effectiveness for a more ideal implant placement procedure. The drills in the MGuide kit are designed with built-in stoppers to allow precision preparation and placement to the planned depth and positions without the need for keys. The four 3.75 × 13.00 mm Seven dental implants (Fig. 15) were torqued to the desired depth at approximately 50 Ncm. Once the implants had been fully inserted, four 5 mm high Zest LOCATOR attachments (Zest Dental Solutions) were inserted within the implants using the Zest tool. Using a torque wrench with the appropriate adapter, the Zest LOCATOR attachments were tightened to 30 Ncm (Fig. 16). The internal aspect of the dental implants having been sealed, bone grafting putty material (GoldenDent) was injected into any remaining voids in the bone (Fig. 17). Using resorbable sutures, primary closure was accom- plished around the locations of the implants. In order to avoid tearing the sutures during the pick-up procedure of the Zest housings, small strips of C-fold towel were used to cover any exposed areas of the sutures. Since the bone had been levelled with the guide, there were no interferences detected between the denture base and attachments in the anterior portion of the immediate denture. Using TOKUYAMA REBASE II chairside hard denture relining material (Tokuyama Dental; Fig. 18), the female components of the Zest LOCATOR attach- ments would be picked up. Since this material is free of methyl methacrylate, it does not have a strong odour or taste, and it generates very minimal heat. The first step in the pick-up process was to brush on a thin coat of TOKUYAMA REBASE II adhesive included in the TOKUYAMA REBASE II kit into the area of the over- denture attachments. This would enhance the chemical retention between the denture base and the hard relining or pick-up material. KY lubricant was applied to the sur- rounding surfaces of the denture to prevent unwanted adherence of excess material. Once the powder and liquid of TOKUYAMA REBASE II had been mixed, the material was placed into a plastic dispensing syringe and injected into the internal anterior portion of the man- dibular immediate denture as well as on to the receptor attachments. The prosthesis was held in position by the patient bit- ing in centric occlusion (Fig. 19). After approximately 3 minutes, the overdenture with the incorporated reten- tion caps was removed and any excess material was removed with a trimming bur. The bite of the maxillary immediate denture with soft relining opposing the man- dibular overdenture was verified and any interference eliminated (Fig. 20). Conclusion As we see more and more patients presenting with dental issues requiring full-mouth rehabilitation, we need to offer a variety of different treatment modalities to accommodate their aesthetic and functional needs in addition to fitting their budget. Overdentures are a great treatment option for these patients, and they can later be upgraded to fixed restorations with additional dental implant therapy. about Dr Ara Nazarian maintains a private practice in Troy in Michigan in the US with an emphasis on comprehensive and restorative care. He is a diplomate of the International Congress of Oral Implantologists.. He has conducted lectures and hands-on workshops on aesthetic materials, grafting and dental implants throughout the US, Europe, New Zealand and Australia. 3 2020 25

trends & applications | Dr Lucio Lo Russo, University of Foggia’s School of Dentistry. (Image: © 3Shape) Germen Versteeg, denturist. (Image: © 3Shape) Using digital dentures also puts more power into the hands of the patients. Versteeg said: “The patients them- selves are in charge of their aesthetics, and they can discuss the aesthetics with the help of 3D simulations.” Versteeg noted that fabricating a new denture is fairly uncomplicated, since it only involves creating a 3D pic- ture of the patient, simulating a new smile and scanning the mouth with an intra-oral scanner, such as 3Shape’s TRIOS. He went on to explain that people used to find wearing dentures quite off-putting. However, since it is a necessity rather than a choice, Versteeg believes that people should wear dentures with confidence: “So why can’t we make it a sexier thing, something to be proud of?” Endless possibilities For those thinking about transitioning to a fully digital production workflow, Versteeg explained that 3Shape software is highly sophisticated. Whether one wants to work with dental models, intra-oral scanners or impres- sions, all these and more options are already in the soft- ware. “You have the flexibility to work in your own way,” Versteeg commented. Additionally, the software pos- sesses older tools, making the transition so much smoother for more conservative dental professionals. When using a digital workflow, a completely new denture can be made in two to three appointments. This saves time compared with fabricating dentures in a conventional analogue way and consequently boosts patient comfort. Another clear advantage of using digital dentures is reproducibility. Versteeg explained that, when a patient loses a denture or wants to improve the previous one, the denturist has the option of quickly accessing the software, where the back-ups of all CAD/CAM denture designs are saved, and printing or mailing a new denture in very little time. What 3Shape brings to the table When talking about his experience with using 3Shape denture software, Versteeg explained that both parties benefit from the cooperation. The dental laboratory pro- vides input and points out the improvements that need to be made in the software or in the workflow, and 3Shape immediately considers the laboratory’s needs and con- stantly updates the software. As he noted, 3Shape spe- cialises in IT, and dental laboratories perform clinical work, which means that both parties need to give feedback and exchange information that will help improve software quality and increase laboratory productivity. “The great thing about 3Shape is that they listen to the end user. And I think that’s something that makes them really stand out from all other companies,” Versteeg explained. Go all the way To make the most of the digital workflow and to truly benefit from it, Versteeg encouraged dental professionals to take the leap and go fully digital from the very beginning. As he highlighted, digital dentures are already being used today, and with every passing day, those who still have not adopted a digital workflow are falling further behind the technology. “Even in more developed countries, there are millions of edentulous people who have limited access to oral treatments for biological or financial reasons. We still need effective and efficient rehabilitation of edentulous patients that is focused on their functional needs and favours access to treatment,” Russo noted. “Digital technologies applied to removable prosthodontics have the potential to make such treatments affordable for these patients and also profitable for oral healthcare providers,” he concluded. 3 2020 27

trends & applications | 7 8 Fig. 7: A facial pre-op view is shown of teeth #12 and 11 prior to preparation for full-coverage ceramic restorations. The teeth had excessive palatal wear due to occlusal considerations thinning and weakening the remaining tooth structure. Fig. 8: The preparations are shown after the #00 and 1 retraction cords are in place. dibular tori, etc.). Some patients also just do not do well with a mouth full of gloop that takes several minutes to set. A discussion of digital scanning and traditional impression taking techniques follows. Restorative margin placement is dictated by the restorative material chosen Current aesthetic materials allow the restorative margin to be located supra-crevicularly (above the gingival tissue), equi-crevicularly (at the free gingival margin) or intracrevic- ularly (in the gingival sulcus). Porcelain-fused-to-metal crowns are typically more aesthetic with intracrevicular margin placement. All-ceramic restorations can often be placed at the free gingival margin, or in the case of con- tact lens porcelain veneers, slightly supragingivally, which is the ideal location for dentine and enamel bonding procedures. It is important to remember that an optical scanner cannot see through the gingival tissue or through fluid (haemorrhage or crevicular fluid) in the sulcus. The optical scanner must clearly see the restorative margin as well as the tooth or root surface just apical to the margin to create an accurate master die. Digital impression ac- curacy therefore requires appropriate tissue management and retraction. Tissue management for optical scanning is the same as for conventional impressions The digital scanning workflow makes it convenient to scan the opposing arch while the anaesthetic is setting in. Depending upon the number of teeth, or types of resto- rations that are planned, a quadrant or full-arch scan is indicated. Once the preliminary preparation data has been entered into the patient’s record, the software instructs the operator which views are required. After completing equi-crevicular or intracrevicular tooth preparation, the soft tissue surrounding the preparation must be retracted, or deflected away from the margin, such that there is no fluid contamination in the sulcus prior to the scanning process. There are several ways to accomplish this task. Two-cord tissue retraction A two-cord impression technique is utilised for master impressions for full-coverage (circum-coronal) and facial veneer restorations (both intracrevicular and equi-crevicular margins). First, a #00 cord (Ultrapak, Ultradent Products) is packed around each preparation margin, starting from the lingual area proximal to the facial, then back through the remaining proximal area to the lingual area. The ex- cess cord at both lingual ends is trimmed, and the ends 9 10 Fig. 9: A view of the scanned impression of the preparations from the facial aspect. Note the amount of retraction present, for clear visibility of the root surfaces of the prepared teeth. Fig. 10: This lateral view is shown after the image was rotated to evaluate clearance between the preparation and opposing incisal edges. 3 2020 29

trends & applications | 15 16 Fig. 15: The restoration of teeth #11 and 12 after cementation are shown with a black background to highlight characterisation placed by the ceramist. Fig. 16: A retracted full frontal view of the case in centric occlusion after cementation. In some cases, retraction cord can also be used to displace tissue tags that may be left from laser troughing (Figs. 1–6). Digital scanning of the prepared tooth Digital scanners can quickly scan half-arch and full-arch cases by video streaming. Most enable the practitioner to view the scan in real time to ensure that all critical areas are covered and the segments can be stitched together. The digital software allows the dentist to review, in 3D, the case upon scan completion prior to sending the informa- tion to the laboratory. In fact, the software indicates criti- cal area occlusal clearance of the prepared tooth. Should there be inadequate space for an optimal restoration, the dentist can make immediate corrections and re-scan, and the software will correct the virtual model. This eliminates the need for reduction copings and/or additional patient visits. The entire scanning process for the average case takes about 2 minutes from start to finish (Figs. 7–16). A comparison of digital scanning and conventional impression taking The rapid advent of impression scanning technology has not resulted in an equally rapid decline of conventional impression materials. The main roadblocks, common to all new technologies, are cost and return on investment. The typical full-arch conventional impression (heavy- bodied tray material and injectable light-bodied) costs approximately US$10. Most associated procedural costs (model work, pouring, duplicate dies, etc.) are included in the laboratory per unit fee. Digital scanners can cost US$20,000 or more and often generate additional pro- cessing fees that are passed along to the dentist and the laboratory for the convenience of creating each digital model. The advantages of digital models include that they are not made of dental stone. Digital models are milled to a consistent accuracy; there is no possibility of inaccuracy due to improper powder–water mix ratios (dental stone), chipping or abrasion of the dies, etc. The digital image can be manipulated in 3D to preview all aspects of the prepared arch, the opposing arch and the model in occlusion. If further reduction for restorative material clearance is needed, the preparation can be corrected immediately and the scan updated. Many scanning clini- cians promote the digital technique as less invasive for the patient (no mouth full of gloop during the impression, or gagging). Each dentist must determine individually whether the benefits offset the cost. A well-made con- ventional impression including all preparation margins and emergence profiles can yield a quality definitive res- toration in the hands of an excellent dental technician. Last but not least, there can be no comparison between the artistic ability of a skilled ceramist and the programming of milling machines to create the high levels of anatomical and occlusal detail. In many cases, occlusal anatomical detail and ideal occlusion are sacrificed for the speed and lower cost of monolithic milled restorations. Again, the choice is up to the individual dentist, but these are points to consider. Some practitioners prefer milled substructures with custom anatomical characterisation placed with powder and liquid by the ceramist. Another option on the horizon is an in-office tabletop device that scans a conventional impression and converts it to digital data which can then be transmitted online to the laboratory. This may prove to be a less expensive means of integrating digital workflow with conventional impression methods. Only time will tell. Editorial note: This article originally appeared in Oral Health Magazine, and an edited version is provided here with permission from Newcom Media. about Dr Robert A. Lowe graduated magna cum laude from the then Loyola University School of Dentistry in Chicago in the US in 1982. He maintains a private practice in Charlotte in North Carolina in the US and publishes and lectures internationally on aesthetic and restorative dentistry. Dr Lowe can be reached at boblowedds@aol.com. 3 2020 31

trends & applications | the patient to visit the dental office from his home, where he can visualise the front desk, admire the treatment rooms or view the cleanliness of the sterilisation room (Fig. 5). The aim is to offer a virtual visit of the practice to allow the patient to choose a quality clinic, as well as familiarise himself with the space before his first appointment. Once physically seated in the chair, the patient can wear the VR headset during the treatment and visualise a restful environment of his choosing. From here on, it is solely a matter of preference, as the patient might enjoy the beach, a VR video of Honolulu, or maybe even climbing a mountain. Any VR video is acceptable, as long as it achieves its pur- pose: calming the patient during a treatment session. Thus, everything becomes less tense, and the patient is relaxed. This might also be convenient for the dentist, as he can then execute whatever treatment is necessary as quickly and efficiently as possible. Convincing the patient to undertake an orthodontic treat- ment is one thing, convincing him to follow the relevant recommendations is another. Obtaining patient compliance is not easy, especially in the case of younger patients. Furthermore, dentists have an unfortunate notorious asso- ciation with pain and suffering, which might induce anxiety in a patient. Again, VR can be applied here to divert the attention of the most dynamic patients. Another aspect worthy of mention regarding the benefits is the intellectual retention of instructions on hygiene procedures, for exam- ple, which might be dependent on support. It is plausible to assume that verbal instructions on hygiene may be for- gotten once the patient has left the clinic. Most orthodontic practices provide only leaflets, but few patients retain these or follow their recommendations. A VR video featuring the practitioner or team members might have a much greater impact on follow-up care at home. The message could be pre-recorded and viewed on demand by the patient. The aims of this format is that it can provide different intellec- tual integration between information, which is connected to a stream of visual and auditory stimuli. The clinician might wish to promote the patient retaining the provided informa- tion in an easier way to achieve greater clinical success. For example, youngsters might remember their favourite movie line by heart, as opposed to information provided by their dentist. This is because it demands less of youngsters to remember words that are connected with pictures. For the health practitioner, VR may yield an unexpected, but welcome, advantage in terms of professional education (Fig. 6). Many of us have not been able to attend a confer- ence on the other side of the world for logistical reasons. In the near future, it will be possible to attend an ortho- dontic congress and listen to international speakers while sitting comfortably at home. Similarly, the demonstration of a new therapeutic technique will be easier with a VR video rather than plunging into a detailed explanation in an article without any illustration. The trainer can record his or her procedures with a 360° camera to allow the student 5 6 to learn through immersion the technical movements and ergonomics of the technique being taught. It would be an understatement to claim that VR provides an alternative to conventional styles of learning. Although it is far from perfect, it allows a wider spread of knowledge and a totally immersive pedagogy. VR is changing the way we work, learn and treat our patients. We have seen over time an evolution of orthodontic care by improving patient comfort. We are not just dealing with a set of teeth fixed into a bone mass appended to a skull, but with a person whose positive experience will inevitably lead to clinical success. Similarly, orthodontic education has evolved over time, since the transmission of knowledge is no longer done with a Kodak Carousel slide projector, but with sophisticated presentation software, incorporating photographs and clinical videos. VR is paving the way to a higher degree of evolution regarding how to understand our environment, whether it is an environment of care or work. As with tourism or cinema, VR offers many opportuni- ties in the field of health. Orthodontics is entering into a 360° revolution focused on the patient experience. Acknowledgements The author reports no conflicting interests. He would like to thank Dr Eren Cicek for the proofreading and kind support. Editorial note: This article was first published in the ortho— international magazine of orthodontics, volume 2, issue 2/2017. about Dr Yassine Harichane graduated from the Paris Descartes University and conducted several research there. He is an author of numerous publications and a member of the Cosmetic Dentistry Study Group (CDSG) at the Paris Descartes University in Paris, France. 3 2020 33

trends & applications | ment plan to the company’s technicians, who then create customised brackets and trays. The system uses ceramic material that is specially formulated for 3D printing, but which is otherwise virtually identical to that used in injection-molded brackets. The founder of the company, Dr Alfred Griffin III, told Dental Tribune International that the digital workflow resembles that used in clear aligner therapy. “LightPlan is the proprietary treatment software developed by LightForce that enables mass-customised braces,” he said. “Doctors have complete control over every aspect of the treatment plan and can utilise a simple cloud- based interface for adjustments and approvals.” “Our treatment plans are unique to each individual patient and largely follow the clear aligner workflow,” Griffin con- tinued. “Where our technology diverges is when the ortho- dontist uploads the patient’s scan to our LightPlan soft- ware, which enables the doctor to adjust the teeth virtually in order to create a perfect smile and bite for that unique patient, enabled by automatically designed braces.” Griffin explained that the LightPlan software generates bracket files, which are then printed at LightForce’s central- ised manufacturing plant in Cambridge. The brackets are then delivered to the orthodontist’s office about a month later. Increased personalisation using digital tools LightForce says that orthodontists should “move teeth, not brackets.” LightForce aims to provide treatment for malocclusion, which is as individual as each patient is. “A person’s lips, jaws, teeth and smile are individual, and it’s important to customise the tools that impact his or her face,” Griffin ex- plained. “3D printing provides the ideal solution for patients, as it allows for customisation and uses modern technology to address an age-old problem. We’ve found 3D printing to be the best solution for orthodontic applications because it enables complete personalisation for each patient—it can print complex geometries, in this case unique tooth mor- phology that would otherwise be unavailable to patients.” He added: “On the one hand, we believe that the days of bracket prescriptions are numbered; on the other hand, we welcome the days of ‘tooth prescriptions’ for mass-customised appliances like aligners and 3D-printed brackets that can adapt to achieve a desired final tooth position for that unique patient.” Griffin said that, in the future, he expects that there will be a rapid expansion of 3D-printing technology within the dental industry. LightForce Orthodontics was founded in 2015. Over the last five years, Griffin and his team have undertaken extensive research and development for what is now the company’s eponymous treatment platform. No one could have predicted that the 2020 launch of the bracket system would take place in the midst of a global pan- “Our treatment plans are unique to each individual patient and largely follow the clear aligner workflow.” demic, but it seems that the outbreak of SARS-CoV-2 has not hampered the company’s plans. “In light of the ongoing pandemic, technology that reduces in-person dental visits is crucial not only for patients but also for the orthodontists and their teams that are caring for them,” Griffin said. Hundreds of orthodontists throughout the US are already providing treatment using LightForce brackets. Griffin said that the company will use its newly acquired funds to fur- ther develop its technology and product offerings and to scale its operations in order to meet what he called a recent surge in demand for more efficient dental technologies. The funds were raised in a Series B funding round that was led by investors Tyche Partners, Matrix Partners and AM Ventures. 3 2020 35

news | 2 3 Fig. 2: During his lecture, titled “What a dentist can do with exocad”, Scherer explained how he uses the software in his everyday workfl ow. (Image: © Michael Scherer) Fig. 3: At exocad Insights 2020, Dr Michael Scherer discussed the role of exocad in his combined clinical and laboratory dental practice and how the software can be used in daily clinical practice. (Image: © Monique Mehler, DTI) on to analogue ways? What would you say to them in order to convince them to go digital? The one thing that is interesting about the last couple of versions of exocad is that it has become even more simple to do complex tasks. Before, you would have had to take all these workarounds and use special ways to accom- plish something, but nowadays, especially with the newest version, exocad Galway, so much of that is built into the software already. That is a tremendous enhancement and will make it possible for the average clinician to be able to jump into CAD as well. Certainly, digital design is an intim- idating part of the process for a lot of dentists, and if you can simplify the digital design side as well as streamline it, then many more will jump on board. There are still quite a few dentists who are using analogue workflows, and there is nothing wrong with that. You can still do great dentistry using polyvinylsiloxane impressions and stone models. What these dentists probably do not realise is that, if they send the work out to a technician, he or she is very probably using a digital workflow. So, the question is whether this technology will improve the clinician. Possibly yes, possibly no. What I would ask that clinician is: why wait? The future is now, and without a doubt, the analogue workflow will eventually disappear. Will it be going away rapidly? I don’t think so. As dentists, we tend to be pretty cautious and conservative when it comes to things like that. This is for a good reason, and it is something I would expect. I would want my dentist to be sure and able to say: “Yes, this will work.” In my personal opinion, intra-oral scanning, for example, is beyond having been proved and should be considered part of the standard of care. There are a lot of laboratories using 3D printing and milling, but it is also true that you can do some great dentistry with analogue techniques. For now, the mixed approach will probably be applicable; however, in the near future, it is inevitable that a shift will happen. So, in the clinical environment, you use exocad soft- ware every day. If you had to pick one word to describe the exocad software and what it does for you, what would that be? I don’t know if I can put it into one word, but in one phrase it would be “limitless possibilities”. If you can dream it, you can do it with exocad. Well, maybe “freedom” would be one word for it then. Certainly, the company has used that term before, and I agree. Part of what exocad does is that it allows your software to be free and it allows your mind to be free while using it. When you really start to look at how the software fits into a dental practice, it is streamlined so you don’t have to be too creative with it, and it just works. But if you want to take that next step, you can go ahead and do that because you have the freedom to do so. Are there any limitations you would like to mention or things you would like to see improved? There are always ways to improve. You know, if we ever reach a point where something can no longer be improved, then what is the point anymore? Improvement can occur anywhere and everywhere. The question is: what can be dreamed up next? What it comes down to is that there is a fine line between striving for simplicity and adding new features. The key is a good hybrid blend between simplicity and comprehensiveness, and this is where exocad shines. Digital dentistry is a very fast-paced field. What are your expectations in terms of innovations in the near future? You know, I am not really someone who can predict the future. What I certainly hope for is that we strive to grow more digital and comprehensive and adapt slowly towards that. The real future is the ability to transfer the basic factors of the workflow, starting from scanning over to designing and manufacturing. We find that happening with ChairsideCAD and all the other dentist-directed software from exocad. Clearly, the future is a harmony between clinician and laboratory. 3 2020 37

industry news | When the SARS-CoV-2 crisis cleared the international dental calendar, Amann Girrbach created its own virtual trade fair booth: the Digital Dental Show. We needed to act, and so we introduced a number of measures—such as pushing our employees to work from home and initiating a range of activities regarding digi- tal collaboration. In addition, we put our strategic focus on digital transformation of most aspects of doing busi- ness and, for example, introduced the first virtual trade fair booth in our industry with great success. But there are also positive effects from this crisis. We believe that the market penetration of digital workflow processes is now being accelerated. This will tend to sup- port a company like ours and accelerate growth. We are focusing strongly on this aspect through our innovation pipeline and have already invested heavily in two areas: research and development and digital transformation. What do you think the medium- and long-term effects of the crisis will be? Reim: The materials business has proved to be rel- atively stable in the pandemic. However, capital goods have been particularly affected, owing to laboratories being hesitant to make major investment decisions during the crisis. We are noticing a slow recovery concerning capital goods—especially in the German market—and are closely monitoring developments worldwide. We see a significant risk for the future in those countries, however, where patients have to make high out-of-pocket payments for restorations, such as the US. Here, it re- mains unclear as to how much patients will be willing or able to pay for elective restorations, for example, and this will likely affect us negatively for the coming two to three years. “This wider structural change was already underway before the crisis—the pandemic has simply accelerated its development and further paved the way for digital transformation”— Dr Wolfgang Reim, CEO of Amann Girrbach 3 2020 39

industry news | On that note, it must be said that the entire pro duction process in the laboratory of today is already digital, but that laboratories stand alone in this respect. Patient management, as well as the communicative and inter- disciplinary steps in between, is for the most part still handled as it was in the 1960s. The decisive second half of digitisation is still missing, so to speak. It will take several more years before the next steps in this process are taken, but when they are, we will remain at the forefront by supporting our customers on their way through digital transformation with definitive and practical solutions. What advantages does AG.Live offer to your customers? Amann: Strategically, AG.Live is one of the biggest projects that we have ever undertaken. We are striving to solve the conflicting priorities of interdisciplinary end-to-end communication. In addition, we are moving into the areas of e-commerce, customer relationship management, remote support and digital training. We don’t want to create conventional isolated solutions that are then laboriously linked. Instead, we are focused on creating an integrated system that is clear and easy to use for the customer and which brings real added value. Reim: Ultimately, the focus of the entire development is on improving the patient’s restoration and the efficiency of the laboratory. AG.Live will enable us to provide con- sulting services for materials and procedures as well as targeted offers based on user profiles. Perhaps we will be able to tackle these goals as early as 2022. What are your plans for the upcoming IDS, which is scheduled to take place in Cologne in Germany in March 2021? Reim: We have been following the development of the pandemic and IDS closely, and we do not believe that large trade fairs will be possible in the near future. IDS thrives on full stands and personal interactions centred on the products on display at the booth; this is not conceivable under the current circumstances. On top of this, international travel will continue to be limited. Therefore, we have come to the conclusion that our participation in the forthcoming IDS should be can- celled. We nevertheless remain open to the digital offerings of IDS, as our product development pipe- line on the hardware and consumables side is full, and the products are scheduled to be presented in spring. Either there will be a suitable digital platform for this with IDS, or we will use our own digital platform. We can well imagine presenting the products again in the context of a virtual trade fair booth as we did at the beginning of the pandemic, in order to try to simulate the feel of a fair as far as possible. Amann: From our point of view, under the current circumstances, it is not possible to ensure safe and “From our point of view, under the current circumstances, it is not possible to ensure safe and meaningful participation in IDS for the exhibitor”— Patrick Amann, head of marketing at Amann Girrbach meaningful participation in IDS for the exhibitor, nor would our participation be responsible with respect to our customers and employees, as the risk of an infection with SARS-CoV-2 is too high. In addition to new products, we will be breaking new ground next year with non-haptic products as well as digital themes in order to tap into new target groups, so IDS will still be an important event for us. However, I am doubtful that the event organisers can roll out a tech- nically flawless platform offering on such a broad basis for the entire industry. Participation at IDS must also be worthwhile from a financial perspective, and we currently do not see the considerable investment that we make in the fair every two years as being justified in 2021. Even if not a replacement of IDS, but an augmentation, we envisage organising smaller local events with our partners in order to give customers the opportunity to see the innovations on-site and not only on a virtual basis. 3 2020 41

meetings | There were three different types of Total Tech Week sessions each day. Can you tell us a bit more about each of them? Yes, we hosted innovation spotlights, tech talks and partner showcases. During the first session type, 3Shape product experts talked about the latest solutions launched by our company. In addition, they announced upcoming promo- tions and offer tips and ideas to further improve workflows and patient experience. The tech talks were very exciting and engaging sessions in which a panel of experts talked about their experiences with specific solutions, workflows or products, gave tips and tricks on how to achieve better results or be more effi- cient, or explained how to become better at your trade with a certain product or technology. During each talk, attendees had the opportunity to ask the experts questions or bring up any issues they face in their everyday work. 3Shape believes in open systems and works with some of the industry’s major companies to create optimal solutions for dentists and laboratories. During the partner show- cases, some of our key partners presented technologies, solutions and workflows in detail, which can help dentists to deliver quality treatments. Traditional congresses offer participants many oppor- tunities to interact with speakers, peers and industry exhibitors and to try out new products first-hand. With a fully digital event, what measures have been taken to ensure this kind of interaction? In the past, meeting partners, industry professionals and end users has been a great experience, because we learned first-hand about the real challenges that dentists and laboratories face every day. This is important for us, because we can address these challenges when developing new products and solutions. That’s why we wanted to include this interactive element when planning Total Tech Week, and the result was the tech talks I mentioned earlier. The greatest advantage of the tech talks was that our panel members were all users themselves of the technology and therefore were able to answer users’ questions from the point of view of the user. Which 3Shape and partner products were showcased during Total Tech Week? To name just a few, we talked about the latest devel- opments in TRIOS intra-oral scanners and our fastest laboratory scanners to date, the latest Generation Red E scanners. In addition, we presented Dental System 2020’s new all-in-one bridge implant workflow and the new inte- gration with Lab Management System. Lars Christian Lund, senior vice president of corporate business development and marketing at 3Shape. tion that has new features is Implant Studio with the new hint and notification systems. Attendees who were interested in digital orthodontics could learn about the new integration between Generation Red E lab scanners and the Ortho System software, and the latest updates in the Clear Aligner Enterprise so lution. We hosted some great sessions by some of our partners. ClearCorrect showcased a step-by-step guide to getting started with clear aligners using TRIOS and the ClearCorrect function in 3Shape Dental Desktop. Another partner is Ivoclar Vivadent, who gave an overview of the latest in CAD/CAM technologies for chairside applications. Our design partner Full Contour demonstrated how to send orders for implant planning and surgical guide design to Full Contour through a new direct integration in Implant Planner and Implant Studio. What were the highlights of Total Tech Week? We covered a range of interesting topics, like complete denture workflows, augmented reality applications in every - day clinical practice, enhancing patient experience through a digital bonding protocol and much more. These topics were discussed by renowned dental experts such as Erik Kukucka from the Denture Center in the US, Michelle Shippy from Full Contour in the US, Dr Jonathan Ferencz from the New York University College of Dentistry in the US, Dr Lucio Lo Russo from the University of Foggia in Italy and Minh Tran from DentalTechTips in the US. Overall, the event was highly invigorating. For clinics, our experts demonstrated the latest develop- ments in 3Shape TRIOS Design Studio, highlighting even more possibilities in same-day dentistry. Another applica- Until 31 December, all sessions of 3Shape Total Tech Week can be watched on demand at www.3shape.com/en/totaltechweek. 3 2020 43

manufacturer news | Dedicated configuration for any clinic ACTEON X-Mind prime family expands The ACTEON X-Mind prime range has been extended with two new cephalometric configurations, the X-Mind prime 2D-CEPH and the X-Mind prime 3D-CEPH, expanding the fields of applica- tion of the device to orthodontic analysis and improving diagno- sis and treatment planning. The line can now offer a dedicated reference integrated in the ear rod ensure quick and precise patient positioning. Its patented collimation system allows up to 17 different cepha- lometric program selections, including new reduced size modes, which ensure a perfect assessment of the region of interest at the lowest radiation dose. X-Mind prime CEPH continues the tradition of the unmatched ease of use of the X-Mind prime product line, thanks to the user-friendly interface of its virtual control panel, which leads the user through all of its functions in just a few simple steps. The use of a state-of-the-art digital sensor, combined with the high performance of ACTEON Imaging Suite software, ensures superior image quality. configuration for any clinical need, from the most basic pan- oramic image only to the most complete panoramic/CBCT/ cephalometric one, guaranteeing a state-of-the-art implemen- tation of the internal technology and presented in the stylish and compact design which characterises the whole range. Premiered in September 2020, the new CEPH configurations now complete the ACTEON X-Mind prime family and retain the same key concepts of the other members. X-Mind prime devices are designed to fit any environment with their minimalistic and compact design, which, combined with their outstanding ease of operation, provides the operator and patient with the best examination experience available. The unique innovative and effortlessly mounted solution, com- bined with a lightweight framework and a compact footprint, make X-Mind prime CEPH one of the easiest and most complete extra-oral solutions for any dental practice. The new cephalostat, specifically designed for optimising patients’ comfort and stability, and the smart Frankfurt plane www.acteongroup.com 3 2020 45

manufacturer news | Creativity and innovation MIS celebrates 25 years of making it simple This year, MIS Implants Technologies is celebrating its 25th anniver- sary. During these two and a half decades, the company has taken on countless challenges, explored many developments and celebrated numerous breakthroughs. Today, MIS is an established global busi- ness and one of the major competitors on the dental implant market. It all began on a scorching and humid August day in 1995 in the north of Israel, when the two Peretz brothers produced their first implant with a single machine in their workshop, which was actu- ally owned by the bank. Overcoming many technical difficulties, from drilling to design, the young brothers succeeded in selling their first order of 100 implants in November that year. With a close friend as their sales force, and a brand-new Vespa scooter Doron Peretz had won in a lottery give-away, they set out to meet their potential customers and sell their new implant. Within a few years, MIS had gained much experience, as well as new customers in Israel, Turkey, Spain and Portugal, and set its sights on a global market. A global emergence Five years after releasing its first implant, MIS set out into the big world. The young company focused its efforts on a few strategic locations, knocking on every door in Europe. However, this was a very conventional and tough market to crack. Therefore, MIS opened its own distribution channel devoted to the European market. With a new international location and a small team of dedicated sales representatives, the company exhibited at the International Dental Show in Cologne in Germany in 2001. Expansion As MIS grew, expanding from 45 to 165 employees at its head- quarters, so did the market demand for its implants. This growth led to an increase of workspace and machinery between 2005 and 2010. The once sole and by then outdated apparatus was replaced by dozens of state-of-the-art machines for production, as well as inspection and quality control. It was time to move the operation to a much larger location, not far from the original building in a brand-new industrial and technological park. Creativity and innovation With the move to its new facilities and acquisition of new tech- nology from 2010 to 2015, MIS was well on its way to a time of creativity and innovation. The research and development team was looking for innovations that would put the company on the right path towards the goal of simple products that would make a real difference. MIS looked to the market and its customers for an answer, and this led its team to implants with a conical connection, as well as the exciting new world of digital dentistry solutions. While research and development looked for the areas and targets of innovation for the products, MIS was busy transforming the business model as well. The company began moving towards a subsidiary model, establishing localised, regional centres that would provide a dis- tribution and support point of focus for customers around the world. Celebration of expertise After developing, working and thriving for two decades, it was time for the company to invite all its loyal customers, partners and friends to the first MIS Global Conference, in 2011. In this arena too, the MIS spirit set the pace for unforgettable, highly professional and fun conferences, drawing key opinion leaders and guests from all over the globe. Looking ahead to the next 25 years With all the amazing changes and developments which have taken MIS to where it is today, it is the company’s goal to keep the focus on the same basic principles of simplicity, passion for its work, and commitment to its customers, partners and team. The company hopes that the next 25 years will be just as exciting and successful. www.mis-implants.com 3 2020 47

SUBSCRIBE NOW! DTI—international magazine subscriptions I would like to subscribe to: CAD/CAM dental labs 2 issues per year ceramic implants 2 issues per year cosmetic dentistry 1 issue per year digital dentistry 4 issues per year e-paper €5.50 per issue e-paper €5.50 per issue e-paper €5.50 per issue e-paper €5.50 per issue e-paper €10 annual subscription e-paper €10 annual subscription print €15 e-paper €20 annual subscription print €30 annual subscription print €30 annual subscription implants 4 issues per year ortho 2 issues per year prevention 2 issues per year roots 4 issues per year e-paper €5.50 per issue e-paper €5.50 per issue e-paper €5.50 per issue e-paper €5.50 per issue e-paper €20 annual subscription e-paper €10 annual subscription e-paper €10 annual subscription e-paper €20 annual subscription print €46 annual subscription print €30 annual subscription print €30 annual subscription print €46 annual subscription www.dental-tribune.com/shop/ Full Name ZIP | City | Country E-mail Address Credit Card Number | Expiration Date | Security Code Date | Signature Dental Tribune International GmbH Holbeinstr. 29 | 04229 Leipzig | Germany Tel.: +49 341 48 474 302 Fax: +49 341 48 474 173 www.dental-tribune.com info@dental-tribune.com Terms & conditions: Subscriptions will be renewed automatically every year until a written cancellation is sent to Dental Tribune International GmbH, Holbeinstr. 04229 Leipzig, Germany, six weeks prior to the renewal date. All prices include VAT, shipping and handling.