issn 1616-7390 • Vol. 12 • Issue 2/2021 2/21 CAD/CAM international magazine of dental laboratories case report The copyCAD 2: Complete success for a complete denture interview “Digitalisation brings the patient to the dental laboratory with 24/7 availability” industry news Empower your dental laboratory

editorial | Magda Wojtkiewicz Managing Editor Embrace changes and welcome challenges We are witnessing various technological breakthroughs transforming dentistry and the growth opportunities of digital dental solutions. Digital technologies are finding more and more applications in dentistry and becom- ing as useful and common in dental offices as in dental laboratories. The use of digital dental technologies has steadily in- creased in recent years, but the COVID-19 pandemic has accelerated it and undoubtedly contributed to the role played by digital solutions in dentistry and certainly their perception. Now more than ever, the benefits of digital solutions and emerging technologies are appre- ciated. Many dental practitioners and dental laboratory owners have realised that the conventional approach to dentistry is not sufficient to manage patients or of- fices. The possibilities offered by digital dentistry, such as diagnostic and restorative procedures, and especially CAD/CAM technology, are transforming the speed, quality and efficiency of dental procedures and fast becoming indispensable. Moreover, digitalisation is not limited to chairside and laboratory procedures. Digitalisation also means col- lecting, transforming and storing data. Digital dentistry generates a great deal of data, which has to be properly managed and protected. This might be challenging and requires improving conventional ways of storing infor- mation and adopting more complex data management, and the pandemic is certainly reinforcing e-transformation here as well. The integration of technology in our lives is changing patients’ expectations of how healthcare should be delivered. Almost unlimited access to information can be a blessing and a curse. More so than before, patients desire fast, accurate and complete treatment in the same way as they obtain other services, unfortunately often without understanding of biology. More patients than before expect that online or phone consultations can solve their health problems, and this can be quite limiting to treatment possibilities, especially in the case of dentistry. With so much transformation going on, it is necessary to learn to embrace changes and welcome challenges. Digitalisation offers enormous possibilities of develop- ment, and while it is not always easy to adapt to these changes, especially since they often arise in many areas at once (chairside and laboratory procedures, and patient and practice management), it can help dental practitioners and dental technicians to be more accu- rate and more efficient. Sincerely, Magda Wojtkiewicz Managing Editor CAD/CAM 2 2021 03

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industry | Total sales revenue at SDC for the quarter was $174.2 million, an increase of 62.7% year over year, and the company completed just over 90,000 unique aligner shipments, compared with 57,136 in the second quarter of last year. Align Technology posts $1 billion in sales Staying with orthodontics, leading clear aligner maker Align Technology fared better than SDC during the quarter, as it continued to break its own earnings records. The company sold $841 million worth of clear aligner trays during the period—a year-over-year increase of 181.9%—and its imaging systems and CAD/CAM ser- vices revenue was $169.8 million, a 214.7% year-over- year increase. Total sales therefore topped $1 billion for the first time. Compared with the first quarter of this year, the company’s clear aligner and imaging services rev- enue streams were up 11.6% and 20.0%, respectively. Clear aligner volume for the second quarter increased by 200.0% year over year to reach 665,600 cases, and clear aligner volume for teenagers increased by 156.3% to reach 181,000 cases. A look at the company’s regional figures shows that dentists in most regions provided Invisalign treatment to more patients in the second quarter of this year than they did in the quarterly periods before the pandemic. In the Americas region, case volume was up 260.7% year over year. International shipments were up 149.2%, and those in the Europe, Middle East and Africa region (EMEA) were up 265%, led by Iberia, the UK and Italy. In the Asia Pacific region, clear aligner volume increased by 50%, led by Japan, China, Australia and New Zealand. Straumann remarks on improved patient volumes in 2021 The results of another international player, Straumann Group, will give readers an impression of the state of global dental markets. In the EMEA region, total sales of CHF 230 million (€212.7 million) represented a 102% year-over-year increase, which Straumann credited to sales of premium and challenger implant brands, its orthodontics business, and strong sales in Germany, Iberia, France, the UK and Turkey. Straumann’s organic sales growth in North America decreased by 42% during the second quarter of 2020; this year, it increased by 135% to reach CHF 152 million. Sales in the Asia Pa- cific region rebounded by 63% in the period to reach CHF 103 million. In Latin America, where Brazil is the largest contributor to regional revenue, CHF 31 million in sales represented a year-over-year increase of 174.4%. Straumann’s total revenue for the second quarter was CHF 516 million. This represented a year-over-year in- crease of around 92%—in the comparable period last year, Straumann’s total revenue of CHF 248 million was down nearly 40%. The company published a half-yearly report at the close of the second quarter, and in the report, the company said that dental practices had been operating with “healthy patient flows throughout the first half of 2021”. “With the exception of Latin America, which is still in the eye of the storm, all of our regions report that more than 85% of dental practices are open”—Guillaume Daniellot, CEO Straumann Group Guillaume Daniellot, Straumann CEO, reminded analysts in a conference call: “When we held our last media con- ference three months ago, our industry was in lockdown. COVID-19 had cut our monthly revenue by 70%, and we were initiating measures to reduce our headcount and cost base in preparation for the economic recession that the pandemic is expected to trigger.” He added that the situation on the day of the latest media conference (12 August 2021) was more positive. “With the exception of Latin America, which is still in the eye of the storm, all of our regions report that more than 85% of dental practices are open. Correspondingly, between 85% and 100% of our facilities are open and our sales team are operating at similar levels. In short, both we and our cus- tomers are back to business.” Envista optimistic about continued recovery Sales at Envista Holdings in the second quarter were $740.1 million, an increase of 104.4% year over year. The close of the period marked four consecutive quar- ters of growth for Envista’s premium implant business— which achieved 90% core sales growth in the three- month period ended 30 June. Envista CEO Amir Aghdaei said during the company’s earnings call that Envista had seen solid demand for its infection prevention business, owing to the fact that en- hanced disinfection protocols are now the new normal. Aghdaei said: “We’re excited about the opportunities for a new CaviWipes 2.0 product. It features a two-minute universal contact time, shows efficacy against a broad CAD/CAM 2 2021 07

Although the majority of dental impressions are still fab- ricated using conventional methods, it is expected that the number of prostheses fabricated using these meth- ods will decrease over the coming years. This decrease will give way to an increased use of digital technolo- gies such as CAD/CAM for producing dental prosthe- ses. Whereas dental prosthetic procedures in the past used to take several dental visits, it is now possible to complete dental treatments within the same day using chairside CAD/CAM systems. This flexibility and the in- creased efficiency provided by digital technologies are likely to accelerate its market growth over the coming years. The global COVID-19 pandemic has had a significant impact across the European dental prosthetics and dig- ital dentistry markets. Within the digital dentistry market, CAD/CAM materials have sustained the hardest hit owing to the pandemic. As elective dental procedures were postponed during the peak months of the pandemic, the ability of manufacturers to sell CAD/CAM blocks and discs was substantially reduced, leading to a drop in market revenue. Furthermore, the market for CAD/CAM systems led by companies such as Dentsply Sirona, 3Shape, Amann Girrbach, Ivoclar Vivadent, Straumann, Carestream and Envista declined over the last year owing to the suspension of major dental exhibitions, such as EXPODENTAL (in Spain). The COVID-19 pandemic has also had an impact on the dental 3D-printing market. Although market growth slowed during the early onset of the pandemic, the sales of 3D printers are increasing rapidly now that the pan- demic is getting closer to being stabilised. In addition, digital technologies, such as 3D printers and intra-oral scanners, offer better control of contamination risk, and this has already started to drive sales and will continue to do so in the near future. There has been an increasing trend towards the adoption of 3D printing and intra-oral scanners in digital dentistry, and Scandinavian countries and Portugal have been the most aggressive countries in Europe to embrace the new technologies. Rapidly improving technology and enhancements in materials are expected to boost market growth in these areas. Moreover, growth in these areas is likely to slow down the milling system market. In the past few years, there has been a surge of com- petitors, such as Formlabs, in the dental 3D-printing market space. These have introduced several affordable solutions, thereby depressing the average selling price (ASP) of prosthetics. Other notable competitors in this space are 3D Systems, Stratasys, Asiga, Rapid Shape, EnvisionTEC, among many others. The demand for better quality and reliability continues to increase, stabilising the ASP over the foreseeable future, thereby driving the market value potential of dental 3D printers. Overall, it is expected that the European digital dentistry market and the dental prosthetics market will continue to grow considerably over the foreseeable future. The increased sales of intra-oral scanners and dental 3D printers along with a rising elderly population are expected to drive the growth of the dental prosthetics and digital dentistry market in Europe. With improvements in technology offering better reli- ability, it is likely that the demand for digital technologies in dentistry is going to be higher than in the past. Furthermore, better safety and infection control offered by digital technologies is likely to drive their adoption in the future. Ultimately, the European digital dentistry mar- ket is expected to grow at a cumulative growth rate of 13.6% between 2020 and 2027, with the total market value reaching €1.4 billion ($ 1.7 billion). about Dr Kamran Zamanian is CEO and founding partner of iData Research. He has spent over 20 years working in the market research industry with a dedication to the study of dental implants, dental bone grafting substitutes, prosthetics, as well as other dental devices used in the health of patients all over the globe. CAD/CAM 2 2021 11

case report | 4 5 Fig. 4: Virtual denture before gingiva carving. Fig. 5: Virtual denture after gingiva carving. First dental appointment (30 minutes) First, the denture is relined with a hard composite-based material (Ufi Gel hard C, VOCO; Fig. 2). The material allows an extension of the edges of the prosthesis for better retention. An adjustment of the occlusion can be done at this time in order to have a homogeneous distri- bution of the contacts and the absence of interference. The patient is photographed with the complete denture in the mouth to control the height of the lower third of the face, the support of the lips, the inclination of the occlu- sal plane and the aesthetics of the smile (Fig. 3). During this session, it is possible to scan the relined prosthesis with an intra-oral scanner in order to be able to return the denture to the patient during the session. The digital impression can accurately record the surface and upper surface of a prosthesis with impressive precision. If the practitioner does not have an intra-oral scanner, it is al- ways possible to send the denture to a dental technician who owns a laboratory scanner. A digital or physical im- pression of the antagonistic arch and of the occlusion is also sent to the dental laboratory. Dental laboratory (two to three days) The dental technician receives digital files of the denture, antagonist and occlusion. It is possible to make all the changes by working on virtual models (3Shape Dental 6 8 7 9 Fig. 6: Virtual model segmentation. Fig. 7: STL files of the base and the prosthetic teeth. Fig. 8: 3D-printed base and milled teeth with supports. Fig. 9: 3D-printed base and milled teeth without supports. CAD/CAM 2 2021 13

case report | 13 14 Fig. 13: Patient’s smile. Fig. 14: Final situation. Discussion All dental disciplines benefit from digital advancements. The removable prosthesis is no exception thanks to the contri- butions of the digital impression and milling but especially of 3D printing. Indeed, it is possible to copy a removable prosthesis in great detail and add improvements. These changes can be minimal, such as the tooth shade or the prosthetic tooth anatomy, or major, such as the correction of the occlusal plane inclination or a sagging of the lower third of the face by wear of the prosthesis or bone atrophy. Everybody benefits from a denture digital copy. The prac- titioner benefits from digital technology by integrating a workflow for the removable prostheses. Working time is reduced to two short clinical sessions when the pa- tient already has a denture. Communication with the lab- oratory is optimised and patient satisfaction is visible. Producing complete removable prostheses becomes a simple, fast and profitable task. The dental technician also benefits from this digital work- flow. By copying the existing prosthesis, he or she can spend less time on the setting and more time on fine ad- justments and creativity. By manipulating virtual models, validation of the prosthetic project by electronic commu- nication with the practitioner is feasible and much faster. By using 3D printing, dental technician will be able to rationalise his or her production line and delegate time- consuming and unrewarding tasks to machines. The results are reproducible and allow easy and quick fabrication of a replacement prosthesis if the denture is lost or destroyed. The patient is the main beneficiary of the digital copy and paste technique. Many patients with removable prosthe- ses have often been disappointed by the end result, par- ticularly in terms of aesthetics if the smile to which they were used was not restored. This feeling is all the stron- ger when it comes from those around them and confirms that the change is visible and noticeably unsightly. With copying of their dentures, patients can be sure of get- ting their smiles back in their original form but with the changes they have always wanted: whiter teeth, natural alignment and stronger retention. When the procedure is completed in just two straightforward sessions, patient expectations will be greatly exceeded. Conclusion The fabrication of a removable prosthesis has long been considered a difficult task. Indeed, the dentist–prosthetist duo have to follow tedious steps while often taking care of elderly patients. Digital dentistry has brought a wind of change by making it fast, efficient and profitable. CAD/CAM tools allow, after just one short clinical ses- sion, copying and delivery of an existing denture, after 3D printing, in record time back to the patient in an even shorter clinical session. The patient will be delighted with this experience at the dentist’s practice because he or she will rediscover his or her smile literally and figuratively. Duplicating a complete denture requires ordinary tech- nical skills; duplicating the positive emotions felt by a patient requires extraordinary human skills. Disclosure The author did not report any disclosures. Acknowledgements The author wishes to thank the VOCO team for their friendly and material support. The author is grateful to certified dental technician Kim Hannawald and certified dental assistant Karen Vrignon for their skills. contact Dr Yassine Harichane graduated from the former Paris Descartes University in France and conducted a number of research projects there. He is an author of numerous publications and a member of the cosmetic dentistry study group at the University of Paris. He can be contacted at yassine.harichane@gmail.com. CAD/CAM 2 2021 15

case report | those who consider these steps will have a fast and easy surgery with great results and good long-term stability of the dental implants (Figs. 4 & 5). Similarly, choice of 4 5 6 7 Fig. 4: Surgical procedure, placement of implants. Fig. 5: CT scan after the surgical insertion of the four implants. Fig. 6: Result immediately after surgery. Fig. 7: Alpha-bridge: initial temporary design. CAD/CAM 2 2021 17 3 and an old bridge in the lower jaw were failing owing to periodontal disease and massive bone loss (Fig. 2). The patient wished to be able to smile again with confidence and to have a fixed, functional and aesthetic treatment. We captured initial panoramic images and decided to restore both jaws with the All-on-4 surgical protocol with immediate loading of the dental implants. The treatment of each All-on-4 case starts with image capture (Fig. 3) and planning of the definitive restoration. In this phase, we talk very intensely with the patient to see what problems he or she had in the past and what wishes he or she has for his or her future restoration. In this first phase, we also take the initial impressions, the facebow and bite registration of the initial situation, the height registration, digital panoramic images and CBCT scans in order to plan the surgery and prosthetic steps of the case. Implant placement In this case, we used the All-on-4 technique to restore the edentulous upper jaw. On the CT scan we captured before the surgery, we saw that the patient had very thin bone in the maxilla. Our initial plan was to start with bone augmentation of the maxilla and then proceed later with placement of dental implants. In our first consultation with the patient, he made clear that he was not willing to undergo bone augmentation surgery. He wanted a solution without bone augmentation and with the least possible amount of surgery. After a review of the bone situation in the maxilla, we decided to implement the All-on-4 approach with the NobelSpeedy Groovy implant system (diameter: 4.0 and 3.3 mm; Nobel Biocare) to solve this case. The surgery is a very important part of this protocol. There are certain steps that need to be fulfilled to es- tablish an ideal situation for the prosthodontist and for the dental technician, including during diagnostics and planning, bone and soft-tissue remodelling, implant placement, restorative and aesthetic space creation, placement of multi-unit abutments and suturing. Only

case report | 10 11 Fig. 10: CAD of the definitive restorations. Fig. 11: Finished milling result of the substructures made from Ceramill PEEK White. 12 13 Fig. 12: Finished milling result of the zirconia crowns made from Zolid FX Multilayer. Fig. 13: Zolid FX Multilayer crowns ready for the anterior veneering. CAD/CAM 2 2021 19

case report | 17a 17b Figs. 17a & b: The final result and a happy patient. As preparation for the gingival veneering, the PEEK sub- structure is sandblasted with 50 μm particles under 2 bar pressure and cleaned afterwards using dry air. In the second step, we apply the primer visio.link (bredent) and light-polymerise the layer for 5 minutes. Afterwards, the crowns are cemented using a resin-based cement on the PEEK substructure and covered in addition by composite opaquer. The gingiva is veneered using GC GRADIA (GC), which is a composite-based veneering material. We cover the ceramic margin of the crowns and the visible PEEK parts with the veneering composite. The contact points on the patient’s gingiva are kept in PEEK and polished to a high gloss (Fig. 16). If we think into the future, this type of restoration offers fur- ther great advantages. This type of restoration can easily be repaired in comparison with a monolithic zirconia res- toration, for example. If there is chipping or fractures of the crowns, the stored data of the CAD construction can be retrieved and the broken part can simply be re-milled. After sintering, the dentist can remove the damaged crown and cement the new one to the PEEK structure. In the end, the key to success is good teamwork be- tween all interfaces, in this case between the surgeon, the prosthodontist and the dental technician. Of course, the selection of the right material is also important. about The patient was extremely happy with the final result (Fig. 17). The definitive restoration perfectly corresponded to his facial attributes and had great function. Our digital proto- col gives us the advantage of being able to design, see and test the envisioned result in the very early begin- ning of treatment. This is extremely important in today’s dentistry, as we can precisely adjust every aspect of the planned definitive restoration. Our protocol also benefits the patient. The patient is in- volved in the planning at a very early stage and can make aesthetic changes together with the prosthodontist before the definitive restoration is started. Thanks to this method, we can avoid unwanted surprises and stress with the definitive restoration for both the dentist and the patient. Drs Ivan Miletic (middle) and Stanko Miletic (right) are in private practice at Dental Center Miletic in Zagreb in Croatia. Visit them at www.dental-miletic.com. Pavel Metelka (left) is a dental technician at Dens Technika in Brno in Czech Republic. CAD/CAM 2 2021 21

case report | 2a 2c 2b 2d Figs. 2a–d: The aim of this aesthetic treatment was to enhance the patient’s smile. However, additional to all the aesthetic smile design basics, the facial analysis and the personality of the patient should be reflected in this design, in order to create the most natural, minimally invasive, personalised smile design. direct messages, and when it comes to creating smile designs, dentists must consider the unity of the whole, which means bringing the biology, structure, function and aesthetics together with a fifth element, personal- ity. Personality is the quintessential part here, because the other four elements are traditionally laid to balance it like a keystone. Through the large number of smile design elements, such as incisal edge, dominance of central incisors, tooth axis and shape, as well as subelements such as morphological details of each tooth, it is possible to establish, based on the dental scientific literature, which should be determined by the facial typology and which could visually represent the unique personality of each patient, beyond his or her personal preferences and expression of his or her will. The combination of lines generates the most basic forms, transferring to them their own expressions. Thus, the vertical rectangle expresses strength by the pre- dominance of the vertical element on the horizontal, the triangle dynamism, the oval delicacy, the square stabil- ity and immobility with the balance between its vertical element and horizontal one. These basic shapes can be observed in the facial contour as well as in the incisors’ shapes and 3D configuration of the dental arrangement, thus the incisal silhouette. The visual language knowledge applied to the main ex- pressive elements of smile design, such as dental shape, incisal edge, interdental ratio or dominance of central inci- sors, and 3D positioning of the teeth in the arch, determines four smile design types with primary expression (Fig. 1): Visual language Each type of line or shape has a specific emotional meaning.1 Lines represent the most basic elements of visual language. Horizontal lines, because they con- form to gravity, express stability, passivity and calm- ness, while vertical lines represent the movement of the point against gravity, expressing strength and power, just as inclined lines arouse the sensation of instabil- ity, tendency to movement and dynamism. Curved lines are associated with delicacy, sensuality and the feminine gender.2 – Strong: composed mainly of rectangular dental shapes, strong dominance of the central incisors and canines over the lateral incisors (radial symmetry), as well as plane incisal edge and rectilinear 3D dental positioning on the arch from an occlusal view. – Dynamic: triangular or trapezoidal dental shapes, standard dominance, inclined incisal edge and an- gled 3D dental positioning on the arch. – Delicate: oval dental shapes, medium dominance, curved incisal edge and standard 3D dental positioning. CAD/CAM 2 2021 23

case report | 4a 4b 4c 4d 4e 4f Figs. 4a–f: The forehead and the ears of the patient should be visible. It is crucial to keep the head upright (not tilted to the right or left, or up or down). The eyes should preferably be positioned parallel to the horizon. relation of the 3D intra-oral digital scan to the facial features. The following are the five full-face photograph types needed (Figs. 4a–f). I. Full-face photograph in rest position This photograph is for the automatic facial recognition process of the software, and part of the new Rebel smile design will be based on this facial analysis of the patient. Technically, it is very important that the forehead and the ears of the patient are visible. If the patient has long hair, it should be held away from the face. It is crucial to keep the head upright (not tilted to the right or left, or up or down), preferably positioning the eyes parallel to the horizon and keeping the lips apart. The software automatically checks the required full-face photograph and sends a message immediately to the dentist if the necessary technical requirements have not been met so that he or she can retake the photograph. II. Full-face photograph of patient smiling Keep the patient in the same position with the eyes open and parallel to the horizon and the head upright (not tilted to the right or left, or up or down). This time, ask the patient to keep his or her lips apart in a soft smile (if possible, ensure the incisal edges of the maxillary incisors are displayed). III. Photograph of face in 12 o’clock position There are two simple ways of taking this specific photograph. An easy way is to keep the patient in the same position and ask him or her to incline his or her face 45° forward while giving a full smile, taking the photograph so that it shows the relationship to the maxillary central incisors and the displayed arch position to the lower lip line. The dentist can also move the patient to a supine position on the den- tal chair and to the 12 o’clock position, ask him or her to smile fully, and take the photograph from a 45° angle. IV. Full-face photograph with mouth closed and lips retracted The patient should be asked to hold the full-mouth retractors, again keeping the position of the eyes paral- lel to the horizon and his or her head upright (not tilted to the right or left, or up or down), and keeping his or her teeth closed and the occlusal plane parallel to the horizon. V. Full-face photograph with mouth open and lips retracted The same protocol as for the mouth closed should be repeated, but this time with the teeth (upper and lower jaws) separated. CAD/CAM 2 2021 25

case report | 6a 6c 6b 6d Figs. 6a–d: Rebel 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 thanks to the visualisation of the final aesthetic result even before the case has started. By the same token Rebel will enhance the predictability of the entire treatment and guide the actual clinical treatment. This approach allows the sharing of the treatment plan with team members and creates a 3D visual perception of the case in the patient’s mouth. The digital project will be tested and approved before the actual treatment starts and allows the dentist to present the treatment solutions. 7a 7b 7c 7d 7e Figs. 7a–e: After the STL file has been 3D-printed (a), the dentist can easily transfer this design to the patient’s mouth by making a silicone impression of the digital wax-up (b). The harder this silicone transfer impression, the more precise this transfer will be, in order to duplicate all the details, such as the line angles that give the ideal shape of the teeth, as well as surface texture. This transfer should be done prior to everything. The dentist should evaluate the new design well before starting the tooth preparation with the APT (Aesthetic Pre-evaluative Temporaries) or as the final mock-up. This way, not only the ideal 3D smile design, but also a great 3D communication opportunity, will be given to the dentist and the patient. The final aesthetic design should be approved at this time. CAD/CAM 2 2021 27

case report | The Rebel concept, which can be applied very easily and rapidly, can help the dentist or ceramist to achieve this goal in the most simplistic, practical and per- sonalised way. The authors’ clinical experience shows a minimum of 80% success in the acceptance of the final smile design treatment. Finally, before any further investigation and research is done, if the result by applying this technique does not satisfy the patient owing to the subjectivity of the matter, the dentist can about always make minor alterations in order to adopt this design according to the patient’s desires. Editorial note: A list of references is available from the publisher. This article was first published in the Clinical Masters magazine, vol. 6, issue 2020. Dr Galip Gürel Private practice in Istanbul, Turkey; visiting professor in the Department of Prosthodontics, College of Dentistry, New York University, New York, US Dr Dimitar Filtchev Associate professor in the Department of Prosthetic Dental Medicine, Faculty of Dental Medicine, Medical University of Sofia, Bulgaria Dr Georgi Iliev Assistant professor in the Department of Prosthetic Dental Medicine, Faculty of Dental Medicine, Medical University of Sofia, Bulgaria Dr Braulio Paolucci Private practice in Barbacena, Brazil Adriano Schayder Certified dental technician at WELL LAB, São Paulo, Brazil 9a 9b 9c Figs. 9a–c: In the same way, the laboratory can produce these veneers dig- itally by milling or using pressable ceramics or utilising feldspathic veneers. In this case, the material chosen was the IPS e.max Press pressable ceramic (Ivoclar Vivadent), after one-third incisal cut-back and feldspathic porcelain applied on top with the micro-layering technique and bonded to the teeth. CAD/CAM 2 2021 29

case report | In contrast, the conventional methods of ceramic fabrication have been described as time-consuming, technique-sensitive and unpredictable owing to the many variables, and thus CAD/CAM may be a good alter- 9a native for both dentists and laboratories.3 CAD/CAM may also reduce the fabrica- tion time of high-strength ceramics by up to 90%.1 Furthermore, industrially fabricated blocks are more homogenous, with mini- mal flaws, and CAD/CAM restorations have been found to compare favourably with other restorative options.4, 5 As far as optical properties and CAD/ CAM are concerned, the fact of com- plex optical illusion phenomena in ante- rior aesthetics cannot always be met with monochromatic aesthetic materials with- out the need for final characterisation by a dental technician. In order to overcome such aesthetic disadvantages of a mono- chromatic restoration, multichromatic ce- ramic blocks have been developed to cre- ate a 3D layered structure. These ceramic blocks offer a gradient of chroma from the cervical to the incisal areas that replicate dentine and enamel in the same block.6–8 The aim of this case report is to compare the analogue versus the digital workflow on ten ceramic veneers in the maxilla, in terms of aesthetic outcome, length of procedures and technical sensitivity for both the dentist and the dental technician. 8a 9b 10 12a 13 8b 9c 11 12b 14 Fig. 8a: Mock-up silicone index. Fig. 8b: Intra-oral photograph of the mock-up. Fig. 9a: Preparation through the mock-up. Fig. 9b: Check of the preparation depth, with the use of the silicone guide, palatal aspect. Fig. 9c: Final preparation of the teeth. Fig. 10: Analogue impression with polyvinylsiloxane. Fig. 11: Digital impres- sion with TRIOS. Fig. 12a: Digital planning of the provisional restorations. Fig. 12b: Provisional restorations intra-orally (Telio CAD). Fig. 13: Analogue workflow (refractory dies, built-up veneers, adjustments, staining/ glazing). Fig. 14: Digital workflow (3D printed model, CAD/CAM veneers, adjustments, staining/glazing). 15a 15b 15c Fig. 15a: Feldspathic veneers with try-in paste. Fig. 15b: CAD/CAM veneers with try-in paste. Fig. 15c: First quadrant feldspathic veneers and second quadrant CAD/CAM veneers simultaneously with try-in paste. CAD/CAM 2 2021 31

case report | about Dr Stavros Pelekanos graduated School of Dentistry, National and Kapodistrian University of Athens in Greece and received Doctoral promotion Dept. of Prosthodontics, School of Dentistry, Albert-Ludwigs University of Freiburg, Germany. He was a clinical instructor, Dept. of Prosthodontics, School of Dentistry, National and Kapodistrian University of Athens from 1994–2001. He has published many scientific articles and abstracts, one chapter in a book, and received 2nd prize at the scientific award competition of the EAED in Madrid, Spain, 2008. Dr Pelekanos is in private practice in Athens (AthinaSmile, www.athenasmile.gr) with emphasis on prosthodontics, aesthetic dentistry, pre-prosthetic periodontology and implantology. He is Asst. Professor, Dept. of Prosthodontics, School of Dentistry, National and Kapodistrian University, Athens. Dr Michalis Diomataris received his DDS in 2009 from the University of Athens Dental School, Greece. In 2017 he received his master specialty from the postgraduate programme of Operative Dentistry of the University of Athens. Since 2011, he is supervisor in the education of the undergraduate dental students, in the contemporary principles of aesthetic and restorative dentistry. In 2013 he received the first award of a national competition between the postgraduate students of Operative Dentistry of the national Dental Schools, presenting a case with the topic of “class IV restoration of a maxillary central incisor”. Since 2014, he is a member of the team of Stavros Pelekanos’ Dental Clinic—AthinaSmile, in Athens, Greece, practising in aesthetic and restorative dentistry and prosthodontics. Michalis Papastamos completed his studies in 1983 and ever since he is active on the dental field. Since 1989 he is the owner of the “Dental Aesthetic” dental laboratory, which is specialised in aesthetic restorations. He attends seminars of well established dental technicians and dentists in Greece and abroad, investing in the upgrading of his knowledge and educational level. Moreover, he organises and delivers seminars and demonstrations himself and has participated, in collaboration with Greek and foreign dentists, in complete live dental rehabilitation programmes, being in charge of the dental part. He cooperates with the dental school of the National and Kapodistrian University of Athens, in the field of Prosthodontics. 18a 18b Fig. 18a: Subjective comparison criteria per step between analogue and digital workflows. PVS = polyvinylsiloxane. Fig. 18b: Laboratory duration per step between analogue and digital workflows. PVS = polyvinylsiloxane. of the central incisors between the two sets. Adhesive pro- cedures followed (Figs. 16a–f), and final intra-oral and extra- oral photographs were captured one week later (Figs. 17a–e). Results Intra-oral digital scanning is a perfect alternative clinical procedure compared with the conventional impression technique. The digital planning and mock-up procedure is a powerful communication tool for the dentist, although special skills in using computer software are required. Re- garding the laboratory workflow, most of the analogue pro- cedures require more time (refractory dies, built-up veneers, adjustments), except the staining/glazing (Figs. 18a & b). Although the aesthetic outcome of the feldspathic veneers was subjectively chosen in this case, the analogue workflow is much more demanding. The digital approach, because of the reduced difficulty, speed, complexity and patient dis- comfort, tends to be preferable (Figs. 18a & b). Conclusion Knowledge and application of virtual smile design proce- dures, coupled with innovative dental laboratory technol- ogies, allow dentists to diagnose, plan, create and deliver aesthetically pleasing new dental compositions. Further- more, advances in CAD/CAM technology have catalysed the development of aesthetic veneer restorations with in- dustrially produced materials possessing superior bio- mechanical properties and good aesthetics. CAD/CAM 2 2021 33

3 Fig. 3: Dental professionals who would like to join the tour have to register online on the Ivoclar Vivadent website in advance. (All images: © Ivoclar Vivadent) A roaming showcase with a strong focus on education From September 2021 to early 2022, dental professionals across Europe will have the opportunity to learn first-hand from some of the most experienced experts in the dental field, reconnect with their peers and explore Ivoclar Vivadent’s innovative workflows. With at least three sessions for each two-day event, the tour will have a strong education compo- nent—something that “has been and will remain a priority for Ivoclar Vivadent to support our customers,” Frank confirmed. The Live Experience Tour is Ivoclar Vivadent’s platform for unveiling its latest products, software and services this year. “The new products will be launched within the matching workflow, as we believe that products need to be optimised within a dedicated workflow to enable our customers to achieve the highest aesthetics and efficiency,” Frank said. At each tour stop, product presentations will be complemented by interactive educational sessions and products for custom- ers to test, such as milling machines, scanners and printers. “While products remain at the core of our workflows, we are taking the bigger picture into account, linking them to the other important factors in the work of our customers,” Frank clarified. “Ivoclar Vivadent has always considered itself as a vital link between the dental practice and the laboratory. The presentations and educational sessions therefore are also aimed at fostering collaboration between the two entities.” Among other topics, the following will be in focus: – direct filling therapy with the Tetric line of four coordi- nated composites and 3s PowerCure, an innovative blue phase curing light system for intra-oral polymerisation; – CAD/CAM chairside treatment with the recently launched PrograScan intra-oral scanners and Programat CS6 fur- nace, supporting fast crystallisation of IPS e.max CAD; – the combination of pressing and printing with the re- cently launched Programat furnaces and PrograPrint PR5 3D printer; and Frank further revealed that one highlight of the tour will be the global launch of two new products—one for dentists in the adhesion product portfolio and the other for dental laboratories in the zirconia restoration range. Tour participants will learn about a number of updates, in- cluding the latest version of IvoSmile with CAD integration, for which they will receive an annual licence. The right locations for a safe experience and intimate atmosphere In order to safeguard the health and safety of its customers, Ivoclar Vivadent has worked closely with local experts at each location. The company has also chosen its tour stop locations wisely to provide enough space for a pleasant and relaxing atmosphere that will allow excellent network- ing opportunities. Frank summarised: “The Live Experience Tour is the chance to meet in person again, not only with the wider Ivoclar Vivadent team, including product developers and sales representatives, but also with other dental profes- sionals for business and informal conversation while enjoy- ing great food and drinks in unique locations. Most impor- tantly, each tour stop will be a chance for our customers to share their feedback and wishes with Ivoclar Vivadent as we strive to constantly improve our products and services for the benefit of the user. We can’t wait to catch up with our customers all over Europe.” The number of participants per event is limited and in- advance registration is mandatory. However, at least three time slots per city will be offered. While safety protocols will be adapted to local regulations, wearing of face masks will be required in all indoor areas and all participants will be asked to provide a SARS-CoV-2- negative test. – the Ivotion denture system, which offers a complete digital manufacturing process, allowing laboratories to create top-quality removable dentures. More information about the different tour stops and the respective programmes, as well as the registration form, can be found at www.ivoclarvivadent.com/live-experience. CAD/CAM 35 2 2021 35

case report | of CAD/CAM were used to remedy the loss of vertical di- mension of occlusion (VDO), as well as the associated aes- thetic and temporomandibular joint (TMJ) impairments. Case presentation In 2015, a 47-year-old male patient presented complain- ing of pain in the TMJ. He also had an aesthetic request, since part of the veneer on one of the maxillary cen- tral incisors had broken off (Figs. 1–3). The clinical and radiographic analysis (Fig. 4) indicated a loss of VDO and tooth substance due to bruxism. Digital intra-oral photographs were taken of the frontal view under retraction and from the occlusal and lateral perspectives. Further photographs were also taken using a digital single-lens reflex camera (frontal, lateral and 45°). A diagnostic impression of both jaws was pro- duced with an intra-oral scanner (Carestream 3500). The maximum intercuspal position was determined intra- orally using the Carestream 3500 intra-oral scanner, and the new vertical dimension of occlusion (VDO) was obtained by opening the virtual articulator to the desired width in the CAD/CAM software. The dynamic documentation protocol of the DSD was used. Videos were recorded with a smartphone from four different calculated angles to achieve harmoni- ous facial symmetry for the smile: a frontal video of the smiling face with and without the lip and cheek retrac- tor, a profile video, a 12 o’clock video and an anterior occlusion video perpendicular to the occlusal level without a mirror. Four supplementary videos were recorded for the func- tional, structural and facial analysis: a consultation as to the patient’s expectations, a 180° phonetic video, an intra-oral functional video and intra-oral structural video with lip and cheek retractor (Fig. 5). The information was transmitted to the DSD laboratory. The main goal of the DSD technique is to combine the photographs from 5 6 Fig. 5: DSD protocol: image of patient smiling wearing a lip and cheek retractor. Fig. 6: Motivational mock-up made of bis-acryl (Structur 3). the three views (occlusal, frontal and 12 o’clock) with a digital ruler in order to recreate the correct smile pro- portions by means of a video analysis (smile frame). The smile frame was then created as follows, taking the facial symmetry into account: digital facebow, form and position of the smile curve, determination of width using the recurring aesthetic dental proportion, tooth length proportions, gingival margin papillary curve, vermilion border and jaw curve. The 2D proportions of the smile were converted in the CAD software into a digital 3D simulation model. The resulting 3D file in STL format was transmitted to a printer, which created the model with the new design. It was then used to produce a matrix made of bis-acryl (Structur 3, VOCO) for the motivational mock-up (Fig. 6). The vertical dimension (VD) was increased in the new model, and for this reason, the patient tested the mock-up over the course of two weeks to ensure that the new VDO met his expectations. The bite trial showed no stability problems, and the patient was happy with the result. As such, there was no need for further deprogramming of the occlusion and defi- nition of a new centric relation. The patient felt com- fortable with this new VD and experienced no pain in 7 8 Fig. 7: Two years later, prior to treatment (2017). Fig. 8: No preparation of the posterior teeth and minimal preparation of the mandibular anterior teeth. Teeth #11–13 and 21–23 had already been prepared. CAD/CAM 2 2021 37

case report | STL file with virtual models produced in the laboratory (Anatomic Lab). These 3D models (V-Print model, VOCO) were created in a 3D printer (SolFlex 650, VOCO). The final veneers and crowns were digitally prepared using the Ceramill Mind design software (Amann Girrbach) and produced in a milling machine (Ceramill Motion 2, Amann Girrbach) from machinable lithium disilicate ceramic blocks (VITABLOCS TriLuxe forte for Ceramill Motion 2, Amann Girrbach; Fig. 10). After confirming the marginal seal and the visual proper- ties through trial insertion, a lip and cheek retractor (OptraGate, Ivoclar Vivadent) was placed in the pa- tient’s mouth. The abutment teeth and ceramic veneers and crowns were prepared in accordance with the manufacturer’s recommendations: The ceramic surface was prepared with 50 µm aluminium oxide and for 20 seconds with 5 % hydrofluoric acid. It was then rinsed for 20 sec- onds before being treated with 37 % phosphoric acid (Total Etch, Ivoclar Vivadent) and 96 % alcohol in order to be cleaned and finally conditioned for 20 seconds with silane (Monobond Plus, Ivoclar Vivadent). The crowns (#11–13 and 21–23) and veneers (#14–17, 24–27, 31–37 and 41–47) were secured to the abut- ments using a light-cured resin adhesive (Futurabond U and Bifix QM, VOCO). A high-performance LED light- curing device (Celalux 3, VOCO) was used for poly- merisation (Figs. 11 & 12). Excess luting material was removed, and the occlusion was adapted and checked with the T-Scan technology (Tekscan). A removable acrylic resin splint was used to protect the final restorations. The final restorations were checked after six months. The restorations were still stable and showed no signs of fracture (Figs. 13–15). The patient also reported that he no longer suffered from headaches with the new VDO. Conclusion Thanks to dental technological developments, fully dig- italised treatment is possible, which can solve prob- lems such as a loss of VDO successfully. However, fur- ther clinical studies are necessary in order to achieve reliable results as regards the digital work process compared with conventional techniques in the event of a loss of VDO. The functionality of permanent resto- rations must also be assessed in the long term. Editorial note: A list of references is available from the publisher. 15 Fig. 15: Panoramic image at the end of treatment. contact Dr Miguel Stanley White Clinic Rua Dr. António Loureiro Borges 5 Arquiparque 1º Andar Miraflores 1495-131 Algés Portugal Dr Inês Miguel White Clinic Rua Dr. António Loureiro Borges 5 Arquiparque 1º Andar Miraflores 1495-131 Algés Portugal Dr Ana Gomes Paz White Clinic Rua Dr. António Loureiro Borges 5 Arquiparque 1º Andar Miraflores 1495-131 Algés Portugal Dr Christian Coachman Well Clinic Rua Bento de Andrade, 116 Jd. Paulista São Paulo—SP 04503-010 Brazil CAD/CAM 2 2021 39

trends & applications | “I stand behind AI because I am always looking for ways to improve the quality of the work I do.” diagnostic consensus on any given tooth. They also produced widely divergent full-mouth treatment plans, ranging in cost from US$300 to US$36,000. These inconsistencies can be attributed to factors such as differences in training, experience and state of mind— but whatever the cause, it’s quite clear that even the most experienced clinician is inconsistent—AI is not. Once trained, computer vision systems for diagnostics will perform the same job the same way every time. They are consistent above all else. Because a computer vision di- agnostic system’s intelligence is so narrowly focused, its performance is unaffected by the preconceptions, bias or fatigue that affect even the most expert human radiol- ogist. This makes them ideally suited to providing prac- titioners with chairside diagnostic second opinions— validation that delivers cascading benefits that have an impact on everything, including treatment planning, pa- tient trust, insurance claim approvals and medical liability. Of course, these systems are also very fast. In just a few seconds, a computer vision system can deliver diagno- ses on thousands of radiographs. Although that kind of Dr Stanley, in your Osstell ISQ Symposium lecture, you spoke about different applications of AI in den- tistry. Could you please explain how AI is enhancing different aspects of dental care and what the bene- fits for dental professionals and their patients are? Patient care begins with diagnosis, and in dentistry, di- agnosis starts with radiographs. Computer vision AI has proved a potent dental diagnostic tool—and diagnostic consistency is the source of much of AI’s potency. That’s because dentists have an unfortunately large consistency deficit. Many will be familiar with a 1997 Reader’s Digest story written by an investigative journalist who visited 50 different dentists across the US over four months, showed them each the same radiographs of his teeth, and received 50 different diagnoses and treatment plans. That experience has been validated in numerous stud- ies over the years, including one recently by the Dental AI Council, in which 136 dentists reviewing the same full-mouth radiographs never delivered better than 50% Dr Kyle Stanley CAD/CAM 2 2021 41

trends & applications | dressing the ways that AI is going to have an impact on the dental workflow. And as AI continues to prove its value, there will be increasing pressure on every kind of enterprise operating within the web of dental business operations to adopt new methods and processes spe- cifically tailored to serve AI systems and maximise the production of data from which the AI can draw insights to drive efficiency, consistency and quality across every aspect of dentistry. The COVID-19 pandemic has made digital solutions even more important for dentistry. Have you noticed an increase of AI usage in the dental community since the onset of the pandemic? Certainly. With many dental offices closed, many of the practice owners I saw went from working in their prac- tices to working on them—looking for efficiencies and developing a more open mind towards technologies, including AI, as well as towards teledentistry. What would you tell dental professionals who are still hesitant to jump on the AI bandwagon? Whether we want to accept it or not, AI is already here— and it is absolutely certain to play a critical role in the future of dentistry. Those people who don’t want to jump on the bandwagon tend to be people who view it as a threat or who think they are infallible or perfect at their jobs. The “infallible” dentists cannot be swayed, but to those who view it as a threat, I would start first by saying that I come from a family of dentists, and I would never stand behind anything that would jeopardise our liveli- hood. I stand behind AI because I am always looking for ways to improve the quality of the work I do—and AI will allow me to do that. It is not taking away my livelihood. If anything, it is making me a better dentist—someone my patients should put more trust in, because the work I do is being assisted by a device that prevents me from making mistakes that every human is subject to making. And that’s really the key: AI is an assistive tool. It’s not doctor versus AI. It is doctor together with AI. By work- ing together, we get better. I like to compare it to intelli- gent cruise control in modern cars: it will help keep you in the lane, it may tap your brakes if you’re distracted and approaching a stopped car too fast, but you hold the steering wheel and you have the final say when it comes to where you’re going and what route you take to get there. And along the way, AI will help limit your liability, build your patients’ trust, and help you do more and better dentistry. Together with two partners, you have founded your own company—named Pearl—which specialises in AI solutions for dental professionals. What is your role within the company, and how do your products sup- port dental professionals in their everyday practice? At Pearl, I am the chief clinical officer. What this means is that I am the dental brain on the team. When products are being created, I make sure they are clinically sound and make sense for the business of dentistry. I also manage a team of doctors who help annotate images that help train AI models. In addition, I represent the company when in- terfacing with members of the dental community, speak- ing to doctors, group practice owners and office staff on podcasts, at conferences and in person. Pearl has an array of products which serve different industry con- stituents: Practice Intelligence is our clinical performance management solution, Claims Review and Pearl Protect “We can expect AI to touch every aspect of dentistry.” are our solutions for the insurance market, Smart Margin and Prep Assess serve practices and dental laboratories with efficiencies within the restorative fabrication work- flow, and Second Opinion is our patient-facing radiologi- cal assistive software, which is set to launch in the EU as we await FDA approval in the US. We also have an edu- cational tool which is beginning to be deployed at various dental schools. Even though AI is already widely used in dentistry and many other aspects of our daily life, surely we have not exploited its full potential yet. In your opinion, what can dental professionals look forward to in the years to come? We can expect AI to touch every aspect of dentistry. In the future, all diagnoses and treatment planning will be assisted with AI, but more importantly our treatment plans will become increasingly individualised. What this means is that two people with the same diagnosis could get different treatment plans based on their genetics, musculature, bacteria flora, bone density, tooth shape and any other input that we can measure. We can also expect to see AI helping to make dentistry more predictive and, therefore, more preventive. Is there anything else you would like our readership to know? Those that know me from social media (@drkylestanley) know that I am a huge proponent of fostering mental health within dentistry. People rarely mention it, but I be- lieve AI will have a real benefit in that area, because it will decrease liability, increase consistency of diagnosis and treatment planning, and tackle many of the mundane tasks that contribute to doctor decision fatigue in our industry. It is a pleasure for me to be able to help introduce new technology that may help reduce dentist burn-out and create a better future for this great profession. CAD/CAM 2 2021 43

interview | m o c . k c o t s r e t t u h S / I N R G O T O F © What are some of the challenges and advantages associated with this? The individual components that I have already men- tioned usually work excellently. The weak point lies more in the interfaces and in the further processing of the acquired data in the software. For example, it makes no sense to generate precise data if it cannot be converted 1:1 into the CAD software. The data compat- ibility of different systems in the laboratory and practice is one of the greatest challenges for me; however, this can certainly be mastered. Ultimately, the advantages of digital technologies outweigh the disadvantages. These advantages include more precise and more ef- ficient reporting, analysis and diagnosis, which will be supported by artificial intelligence in the future. This facilitates treatment planning with accurate selection of the restoration material, virtual try-ins and real clinical “test drives” with direct communication both within the restorative team and with the patient. For open ques- tions and multidisciplinary collaboration, online expert platforms would be desirable in order to produce syn- ergistic results. We often hear that digitalisation can lead to improve- ment in dentistry. What does improvement mean to you and how can digitalisation get us there? Apart from the already mentioned advantages of bet- ter information exchange and communication, digitalisa- tion results in safer planning, the use of higher quality “The data compatibility of different systems in the laboratory and practice is one of the greatest challenges for me; however, this can certainly be mastered.” standardised manufactured materials with higher bio- compatibility, better precision (such as with milled poly- mers), better time-saving and better reproducibility. The new manufacturing possibilities have already brought us many interesting new classes of materials that are otherwise not available in the analogue world. Digital pa- tient records make important data available much faster. We live in a high-performance culture today, and time has become a very precious commodity. As already mentioned, there are new digital possibilities in com- munication that will reduce analogue contact times with patients. This is to be welcomed against the background of the pandemic, but in the longer term, we must not displace empathy from our treatment concept. Thank you for the interview. CAD/CAM 2 2021 45

tive walls, disinfection facilities, mandatory face masks and distancing will provide a safe experience at the booth for both our employees and visitors. We are also working closely with the organiser Koelnmesse to comply with the necessary hygiene requirements. What can IDS visitors expect at the exocad booth? Our booth will be the meeting point for the exocad community. After all, IDS provides one of the few oppor- tunities for users to engage in direct, personal exchange with our software specialists and developers, who are also looking forward to engaging with customers. Getting direct feedback from users motivates and inspires them to improve and enhance our products even further. Exocad has three core products: DentalCAD, ChairsideCAD for single-visit dentistry and exoplan for implant planning. New features for individual software products are planned, as well as some surprises, which we can’t reveal just yet. Exocad’s Booth A020 in Hall 3.2 will be the meeting point for the exocad community at IDS 2021. In addition, exocad will use the IDSconnect platform to interactively attract online visitors. Offering such an online option is, of course, a new challenge, but we have already had a very positive experience with our hybrid congress, exocad Insights 2020. “We will have 12 different software demo stations with plenty of space between them.” What do you personally expect from IDS 2021? I think that many dental technicians and dentists are looking forward to attending IDS in order to see col- leagues and their contacts at companies in person again. I expect an amazing event and a great atmosphere. Of course, IDS will be different this year than before, but one thing remains: we will definitely see many new products in Cologne. CAD/CAM 2 2021 49

4 8 5 6 7 9 10 Figs. 4 & 5: Simple and reliable bite scan procedure with fully automated software alignment. Fig. 6: Milled zirconia crown seated on the equally enlarged 3D-printed model. This allows accurate controlling of the contact points and occlusion. Fig. 7: Colouring liquids are used on the green state zirconia just before sintering. This will give the definitive restoration a very lifelike effect. Figs. 8 & 9: Zirconia restoration directly after sintering. Some additional staining was done with GC Initial Lustre Pastes and Spectrum Stains for the final touch. Fig. 10: GC offers a wide portfolio of ceramic materials for different clinical and economic considerations, such as cost and ease of processing. scanner first and created my own list of requirements for myself and my own wish list to make an educated selec- tion. As it turns out, my list was easily covered by the ability and features of the ALS2, and it even has features that I did not realise that I needed until I had the oppor- tunity to try them, such as the hybrid scanning feature. The new ALS2 is an absolute workhorse, featuring speed, accuracy and high definition, as well as some pretty amazing additional features, and it is absolutely the right choice for my lab. What are the main benefits of the ALS2 in your daily routine? For sure, one of the main features, the accuracy of 4 µm according to ISO standards, is a big advantage for my daily work. On top of that, the speed of 22 seconds per arch is very impressive. With this software, you experience a fully flexible scan flow generating open STL or PLY files. The full articulator scan possibility, for which multiple articulator types are already included in the system, is also an asset for my daily routine. The ability to scan an impression and the model and merge the scans accurately within the scan software, known as hybrid scanning, is also possible with the ALS2. This is the most unique feature of the device. Could you explain from your perspective the hybrid scan flow? Hybrid scanning is a unique workflow that combines an impression scan with a model scan. This allows us to work on a model without having the need to section it or ditch the dies and therefore avoids us introducing errors during scanning and keeps the true and accurate information. This workflow allows for predictable contact points and a perfect occlusion and allows us to design with the soft-tissue information in place for an optimal emergence profile. All this leads to reduced work time, less model prep and less scanning, and it is as predict- able and accurate as the conventional flow. Why and how does the hybrid scan workflow bring value to your practice? I mostly use this technique on subgingival preparations and especially on vertical (biologically oriented prepara- tion technique) preparations, as there is always a high risk of destroying the impression margin when pour- ing these cases, rendering a second pour impossible. Hence, by scanning the impression first, I have this infor- mation saved before even casting the model. I have also used this technique to design post and cores. How do you make use of digital techniques in your lab? Every case I do involves some sort of digital workflow, whether it is scanned intra-orally or not. The ALS2 is simply another tool and an integral part of my workflow. I always choose to have the best possible tools at my disposal, as this allows me to offer the best work that I am capable of. By using a mix of digital and analogue techniques on every case, I can create a much more predictable outcome while optimising the aesthetics and function through my years of hands-on experience. about Stephen Lusty qualified in Cape Town in South Africa. Since 2008, he has been running his laboratory in Cornwall in the UK, specialising in aesthetic dentistry. His passion for the art of dentistry is what drives him to continue to strive for perfection. He works closely with his clients, seeing patients for custom shade matching and finishing. CAD/CAM 2 2021 51

Table 1: Sintering programmes chart.*, †, ‡ Temp 1 Temp 2 Rate of temp increase (°C min) Rate of temp increase (°C min) Temp 3 Rate of temp Temp 4 increase (°C min) Hold time Rate of temp Temp 5 increase (°C min) industry news | 54-minute Room temp 120 °C 1,450 °C 10 °C 1,600 °C – – 20 min –120 °C 800 °C 800 °C 90-minute Room temp 50 °C 1,400 °C 7-hour Room temp 10 °C 1,550 °C 4 °C – 1,500 °C 10 °C 1,560 °C 16 min –50 °C – – – 2 h –10 °C Room temp * The sintering recommendations represent only a guideline; depending on each individual furnace and condition, some adjustments might be necessary. † If the 54- or 90-minute sintering programme is not programmable in your furnace, it is not possible to set the furnace according to one of these schedules. ‡ The material is removed from the furnace at 8,000 °C. A furnace with a configurable KATANA Zirconia YML sintering programme is required. For its development, Kuraray Noritake Dental leveraged its long-standing expertise in dental ceramics and the advan- tages of an end-to-end in-house blank production process, without which it would have been impossible to reach the re- quested quality level. As the material is so well aligned, it was even possible to develop a 54-minute sintering programme that produces equally good results to the proven 90-minute or 7-hour programmes and is the go-to option for all rush cases. With this feature, KATANA Zirconia YML is an all-rounder ma- terial: it offers the highest comfort and security like an SUV, but when it comes to speed, it is in no way inferior to a sports car. Users who have already tested ceramic materials with a strength gradient know that positioning of long-span restorations in the blank can be tricky. What are the rules to be respected when positioning a long-span bridge in a KATANA Zirconia YML blank? Positioning of restorations in KATANA Zirconia YML discs is extraordinarily easy. The reason is that the gap between the lowest flexural strength found in the enamel area and the highest flexural strength found in the lowest body layer is comparatively small. Moreover, the Body Layer 1 that is found adjacent to the enamel layer already offers a flexural strength that is higher than the 800 MPa requested for bridges of four or more units. Consequently, users are on the safe side whenever they place their long-span restorations in the middle of the blank. More specifically, half of the connector cross section needs to be in the lower half of the disc, which is quite different from other materials with strength gradation that allow for connector positioning in the body area only. KATANA Zirconia YML restorations of a maximum of three units may be positioned in any layer. In this context, the fact that the thickness of each layer increases proportionally with the height of the disc comes as a benefit: the enamel layer is large enough to exploit its aesthetic potential in single-unit or small bridge cases. What would you recommend to dental technicians regarding the use of KATANA Zirconia YML in their laboratory or milling centre? I can truly recommend testing KATANA Zirconia YML in the laboratory environment to see how it handles and to assess its potential. The exceptional blank quality, seamless integra- tion of the different layers, ease of positioning and process- ing efficiency are factors potential users need to experience 2 Fig. 2: Positioning of long-span restorations in the middle of the disc. in real life to understand what they mean for their daily work. Similarly, the aesthetic outcomes need to be assessed in the clinical environment for an authentic impression of the natu- ral look and feel obtained. I am sure that KATANA Zirconia YML will be able to convince virtually everyone who wants to empower the laboratory with an easy-to-use, efficient uni- versal zirconia solution that fits virtually every patient’s and every dentist’s needs! Kuraray Noritake Dental knows that dental technicians and practitioners are in need of products that support their striving for simplification, standardisation and increased efficiency so urgently needed in present times. Therefore, our product innovations are all focused on deliv- ering more performance with less effort. KATANA Zirconia YML is the latest addition to a whole series of materials pur- suing this goal. Minimum size if more than half of the cross-section areas are in the bot tom half of the disc (up to 50% height from the bot tom [lower]). Table 2: Minimum connector cross-sections are to be respected during CAD of KATANA Zirconia YML restorations. CAD/CAM 2 2021 53

industry news | Kuraray already offers a broad range of zirconia materials covering virtually every indication. Why did you decide to develop yet another dental zirconia? The KATANA Zirconia series has indeed received high praise and great feedback from the market. Users partic- ularly appreciate the remarkably high strength of HTML, the well-balanced aesthetic and strength properties of STML, and the high translucency of UTML. Although there has been a large increase of zirconia materials in the dental market recently, we have received many requests from our customers for a more universal ma- terial that offers the excellent properties of all variants of KATANA Zirconia in one product. Such a product should allow them to fabricate all kinds of restorations from a single disc, from single crowns to long span bridges, while maintaining high aesthetic and mechani- cal properties for both anterior and posterior restorations. KATANA Zirconia YML is our response to these desires expressed by our customers. What is the main difference between KATANA Zirconia YML and the other available products of the KATANA Zirconia series? All layers of KATANA Zirconia UTML, STML and HTML are produced from the same basic powder composition and therefore offer the same strength throughout the whole blank. Depending on the case-specific requirements, users need to select the most suitable type of material, either a high-strength zirconia or a highly translucent variant. KATANA Zirconia YML is an all-in-one zirconia suitable for all cases: it consists of a high-translucency enamel layer, an intermediate layer offering well-balanced strength, translucency and colour, and a high-strength body layer. The raw materials used for this product were developed and are produced by Kuraray exclusively for YML. This is another milestone in advanced product development for KATANA Zirconia. In general, many dental technicians and specialists do not regard the currently available zirconia materials with an integrated strength gradient favourably, 2 Fig. 2: KATANA Zirconia YML offers well-balanced combination of color, translucency and flexural strength gradation. because the materials seem to be insufficiently strengthened in the incisal area. This can lead to fractures in long-span restorations, especially if they are inadequately positioned within the blank. How carefully did Kuraray focus on these problems and how did it try to solve them in order to stand out from the competition? The current yttria-based multilayer products on the market face complicated limitations in connector posi- tion in large cases, such as full-arch restorations, owing to the lack of an ideal combination of aesthetics and strength. To overcome this challenge, Kuraray devel- oped well-balanced raw materials of high strength and high aesthetics and included these raw materials in the intermediate layer between the enamel and body lay- ers. The result is that, even for long-span restorations, it is very simple to position the connectors thanks to the excellent balance between high strength and high 3 Fig. 3: KATANA Zirconia YML. CAD/CAM 2 2021 55

industry news | 5 Figs. 5 & 6: Even if the restoration margins have been milled to a very thin profile, they still show smooth margins without any chipping. KATANA Zirconia YML. This allows for a reduced inven- tory and significantly shortens working time owing to the possibility of high-speed sintering. The most convincing properties are excellent firing accuracy owing to well-balanced material properties across all layers, the wide range of shades available and the great design flexibility even when designing long- span bridges. Last but not least, the trusted quality of the Katana brand and the label “Made in Japan” are reasons to opt for this new product. All blanks from the KATANA Zirconia series stand out from other dental zirconia materials owing to their particularly fine-grained, densely pressed micro- structure, which is the basis for a superior surface quality and edge stability and the resulting accuracy of fit. What is the secret behind this exceptionally high blank quality? Since we do not know the correlation between marginal stability properties (chipping etc.) and material compo- sitions, structures, etc., it is very difficult to answer this question. It may depend on the structure of the zirco- nia crystals, the raw material itself, the correct strength level after pre-sintering or any other minor factor during the manufacturing process of the disc. All these factors together, of course, are important. We use pigments developed by Katana which have an excellent colour stability without fading even after the final sintering procedure. The particle size is appropri- ately controlled. In addition, our professional colour mix- ing staff, reflecting the opinions of clinically experienced dental technicians both inside and outside the company, have achieved a pigment mixture that shows only a slight change in shade even in cases with different thicknesses. What is your vision with regard to future develop- ments in dental zirconia? Since the introduction of zirconia on the dental market, many significant material advances have been achieved. Today, there are high-strength, low light-transmitting zir- conia materials up to low-strength, high light-transmitting zirconia materials available on the market. Furthermore, there are now also low-strength, high light-transmitting zirconia materials in mixed systems (YML series). Our foremost goal is to develop the ultimate zirconia in the near future, combining both high strength and high light transmission, which breaks the general expectation of a compromise between strength and translucency within zirconia materials. A clear advantage of the KATANA Zirconia series, much praised by Katana’s key opinion leaders, is its colour stability and shade match to the VITA clas- sical shade guide. Can you explain the importance of the in-house addition of additives and colour pig- ments in the form of metal oxides to satisfy the user and distinguish KATANA Zirconia from competitors’ products? 6 CAD/CAM 2 2021 57

industry news | 3Shape Dental System 2021 offers new and improved digital workflows. (All images: © 3Shape) Leveraging AI for design acceleration Through its use of AI technology, 3Shape Dental System 2021 marks a radical shift in how dental laboratories perform their regular tasks. Tooth segmentation and occlusal plane adjustment are just two of the technician’s responsibilities that can now be conducted by AI tools, whereas lines for both temporary indications and dies are now placed auto- matically during the segmentation step of intra-oral cases. 3Shape Dental System 2021 also offers pre-installed integration with the recently launched 3Shape Automate— the world’s first AI-powered digital dental design platform for single unit monolithic molar and premolar crowns. The speed, consistency and scalability that 3Shape Automate offers make it easier than ever for dental lab- oratories to outsource restorative design when dealing with rushes and to modify these designs to add the technician’s own personal touch. “Our goal is to make every laboratory technician’s job easier,” said Dr Rune Fisker, senior vice president for product strategy at 3Shape. “We spend a great deal of resources working with technicians, listening to them and developing the tools they need to succeed.” “From optimising workflows and the user interface and introducing AI power to open integration with production and laboratory management solutions, partners, libraries and components, Dental System 2021 is a software made for and inspired by dental laboratory technicians,” he added. “We spend a great deal of resources working with technicians, listening to them and developing the tools they need to succeed.” According to Fisker, 3Shape has “already received some extremely positive end-user feedback from dental tech- nicians who have integrated Dental System 2021 into their workflows”. Try 3Shape Dental System 2021 today 3Shape Dental System 2021 is available now—just contact your local reseller or request a demo from 3Shape. Learn more about this and all the other latest updates from 3Shape at the company’s website (www.3shape.com). CAD/CAM 2 2021 59

manufacturer news | exocad New exoplan 3.0 Galway now available At the end of last year, exocad announced the availability of exoplan 3.0 Galway, the latest version of its implant planning software. The new release supports planning of edentulous cases, including design of surgical guides. “We are excited to announce the release of exoplan 3.0 Galway and enthused about the new possibilities it presents for guided surgery,” said Tillmann Steinbrecher, exocad CEO. “Exoplan 3.0 Galway will provide dental practices and laboratories with a digital workfl ow that offers maximum fl exibility and builds on exocad’s mission to make CAD design as easy as using an app on a cell phone.” Exoplan 3.0 Galway is a powerful, open, and effi cient software package for virtual implant planning. Customised surgical guides can be designed using the Guide Creator software module, and then produced on site—in a laboratory, dental practice, or an external production centre. The software comes in a new, modern user interface, inspired by the Google Material Design system. With more than 40 new features, as well as enhancements to over 60 existing functionalities, the Galway release represents a major expansion of capabilities in guided surgery and improved integration with DentalCAD, exocad’s dental CAD software. be freely designed or based on a prosthesis scan; new tools to speed up the entire planning process; improved implant selec- tion dialog; automatic panoramic curve detection; more implant libraries, now with over 500 implant systems and over 8,500 im- plants from more than 80 manufacturers; virtual tooth extraction on optical scans; possibility to easily mark sinus cavity and check if implants are intruding. All exocad solutions are based on the same technical platform with an open architecture, ensuring the seamless functionality of the digital workfl ow: from virtual prosthesis-oriented im- plant planning with exoplan and designing surgical guides with Guide Creator, to planning and producing the implant-supported, temporary, and fi nal restorations with DentalCAD, exocad’s dental CAD software. “As the world’s premier OEM supplier of dental CAD software, we provide the symbiosis of prosthetic and implant planning,” said Steinbrecher. “Users can achieve predictable results in a cost- and time-effi cient manner, which can ultimately result in increased customer satisfaction.” Exoplan 3.0 Galway is now available in the EU and other select markets. Key highlights of exoplan 3.0 Galway include: Planning of eden- tulous cases and design of the respective surgical guides, including necessary tools, such as dual scan protocol, anchor pin placement, and fi xation guide; surgical and fi xation guides can exocad.com exocad.com/exoplan-galway CAD/CAM 2 2021 61

© MIS Implants Technologies Ltd. All rights reserved. © MIS Implants Technologies Ltd. All rights reserved. IT'S SIMPLE IT'S SIMPLE TO FIND YOUR TO FIND YOUR ZEN ZENZEN ZEN ® PEACE OF MIND WITH PERSONALIZED DIGITAL DENTISTRY. MAKE IT SIMPLE The MGUIDE system features user friendly software to ensure accurate planning and an open design template that allows for a greater field-of-view and irrigation for easier implant placement. Learn more about the MGUIDE and MIS at: www.mis-implants.com

How to send us your work submission guidelines | m o c . k c o t s r e t t u h S / s l i e x p 2 3 © Please note that all the textual compo- nents of your submission must be com- bined into one MS Word document. Please do not submit multiple files for each of these items: the complete article; · · all the image (tables, charts, photo- · · graphs, etc.) captions; the complete list of sources consulted and the author or contact information (bi- ographical sketch, mailing address, e-mail address, etc.). In addition, images must not be embed- ded into the MS Word document. All im- ages must be submitted separately, and details about such submission follow be- low under image requirements. Text length Article lengths can vary greatly—from 1,500 to 5,500 words—depending on the subject matter. Our approach is that if you need more or fewer words to do the topic justice, then please make the article as long or as short as necessary. We can run an unusually long article in multiple parts, but this usually entails a topic for which each part can stand alone because it contains so much in- formation. In short, we do not want to limit you in terms of article length, so please use the word count above as a general guideline and if you have specific questions, please do not hesitate to contact us. Text formatting Please use single spacing and make sure that the text is left justified. Please do not centre text on the page. Do not indent paragraphs, rather place a blank line be- tween paragraphs. Please do not add tab stops. Should you require a special layout, please let the word processing pro- gramme you are using help you do this formatting automatically. Similarly, should you need to make a list, or add footnotes or endnotes, please let the word process- ing programme do it for you automatically. There are menus in every programme that will enable you to do so. The fact is that no matter how carefully done, errors can creep in when you try to number footnotes yourself. Any formatting contrary to stated above will require us to remove such formatting before layout, which is very time-consum- ing. Please consider this when formatting your document. Larger image files are always better, and those approximately the size of 1 MB are best. Thus, do not size large image files down to meet our requirements but send us the largest files available. (The larger the starting image is in terms of bytes, the more leeway the designer has for resizing the image in order to fill up more space should there be room available.) Also, please remember that images must not be embedded into the body of the article submitted. Images must be submitted separately to the textual sub- mission. You may submit images via e-mail or share the files in our cloud storage (please contact us for the link). Please also send us a head shot of your- self that is in accordance with the re- quirements stated above so that it can be printed with your article. Image requirements Abstracts Please number images consecutively throughout the article by using a new number for each image. If it is imperative that certain images are grouped together, then use lowercase letters to designate these in a group (for example, 2a, 2b, 2c). Please place image references in your article wherever they are appropriate, whether in the middle or at the end of a sentence. If you do not directly refer to the image, place the reference at the end of the sentence to which it relates enclosed within brackets and before the period. In addition, please note: An abstract of your article is not re- quired. Author or contact information The author’s contact information and a head shot of the author are included at the end of every article. Please note the exact information you would like to ap- pear in this section and format it accord- ing to the requirements stated above. A short biographical sketch may precede the contact information if you provide us with the necessary information (60 words or less). We also ask that you forego any special formatting beyond the use of italics and boldface. If you would like to emphasise certain words within the text, please only use italics (do not use underlining or a larger font size). Boldface is reserved for article headers. Please do not use un- derlining. · We require images in TIF or JPEG for- · · mat. These images must be no smaller than 6 x 6 cm in size at 300 DPI. These image files must be no smaller than 80 KB in size (or they will print the size of a postage stamp!). Questions? Magda Wojtkiewicz (Managing Editor) m.wojtkiewicz@dental-tribune.com CAD/CAM 2 2021 65

The latest generation of temporary restorations Structur CAD FILLED COMPOSITE INSTEAD OF THERMOPLASTIC! Fast and efficient CAD / CAM production of precision-fit temporary restorations Highest quality and aesthetics for prolonged, safe wear – especially suitable for long-term provisional and semi-permanent restorations Excellent edge stability Effortless intraoral as well as extraoral polishing and individualisation No need to use an MMA primer Available as blocks and discs VOCO GmbH · Anton-Flettner-Straße 1-3 · 27472 Cuxhaven · Germany · Freecall 00 800 44 444 555 · www.voco.dental