issn 2193-4673 • Vol. 3 • Issue 1/2022 1/22 digital international magazine of digital dentistry interview Digital dentistry trends for 2022 case report Digital workflow for partially edentulous mandible feature Why does dental practice design matter?

editorial | Dr Scott D. Ganz Editor-in-Chief Tools of the trade What are the essential ingredients of the provision of state-of-the-art care to patients? While this may be very general and difficult to quantify, is there a general con- sensus on what technology is important for a variety of practice scenarios? Let us consider the process from the beginning, diagnosis and treatment planning. Many clinicians made the transition from analogue to digital radiographs many years ago. Yet, many are still using film for periapical and/or panoramic radiographs, creating a static image from which to make treatment decisions. Digital radiography has many features, but perhaps most important is the ability to interact with individual images regardless of the software application that is utilised. A static film is viewed as it is on a light box. It is not pos- sible to change the contrast, brightness or sharpness or to zoom in to an area of interest as we can with a digital image on an LCD computer screen. The ability to interact is the key concept to understand. It is the interaction that helps expand the clinician’s insight and vision in order to diagnose and assess a patient presentation accurately. now play a major role in most dental offices. Portability has become important for many applications, including digital radiography and now the ever-growing popularity of intra-oral scanners, which require a powerful computer to function properly. Therefore, we are no longer tied to one operatory with either digital radiography or intra-oral scans. The only exception within our digital workflow, especially for those placing dental implants, is the CBCT device, which requires its own space within an office en- vironment. The use of digital radiography, intra-oral scan- ning and CBCT provides clinicians with the necessary digital information to diagnose and plan treatment prop- erly. The issue however is not the physical equipment or the software that is available; it is the individual clini- cian’s ability to assess, interact and interpret the unique patient data so that treatment recommendations can be presented to the patient. Therefore, while we have differ- ent tools of the trade, it is the essential knowledge base that helps us understand what the data represents and how to use that data for the benefit of our patients. As technology has evolved, so have the intra-oral sen- sors that capture the images and there have been leaps in computing power to process the data with advanced graphics hardware and software. Desktop computing has remained important for most clerical everyday prac- tice management, but has been largely supplanted by the portable and very powerful laptop computers which Please enjoy the latest online or print issue of digital, which always contains useful information for clinicians of all levels. Take time to interact! Dr Scott D. Ganz Editor-in-Chief 1 2022 03

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news | explained that practitioners could begin by asking more questions about how manufacturers of certain types of equipment arrived at their conclusions and what the impli- cations might be for their patients. “Be aware regarding what the technology says it can deliver and what the results are, and if it is not clearly improving care, then remove it,” added Dr Ducret. “The chain of responsibility is also critical. In the case of a malpractice event, the question is, who will be held responsible? Before implementing these tools, one needs to know where responsibility lies,” continued Dr Mörch. Additionally, the researchers noted in the study that sharing data could help create more transparent and understandable technology from which everyone from the patient to practi- tioner and manufacturer could benefit. “It is pretty simple to say, but sharing data and the benefits is challenging in real- ity,” admitted Dr Ducret. However, he continued: “There are many questions around data security and intellectual prop- erty (IP), but the point we wanted to make is to try and reduce the time, expertise and energy currently used to make prog- ress in the field, as it clearly lacks sustainability. We want to encourage a type of dentistry that does not try and promote again and again a novel solution by starting from zero, and there are ways to collaborate without losing IP, not only in the field of research but also within industrial groups.” Along with transparency and education, there are other serious ethical questions around the development of new technology that need to be considered, the researchers said. One of these is about the collection of patient data that could then be used to develop new algorithms and sold back to patients in the form of a new procedure or piece of technology. “I think people are not aware the way current AI solutions are developed, and dentists need to be respon- sible for telling patients what might be done with data that is collected,” noted Dr Ducret. AI has the potential to revolutionise dentistry in far greater ways than it has done so far. However, according to the researchers, the question is how this new technological era should be optimised in order to provide the best oral healthcare possible. “In our paper, we try to highlight some questions that those in the field may need to discuss in the coming years. For now, we do not have a perfect solution, but peo- ple need to think about it,” said Dr Ducret. Adding to that sentiment, Dr Mörch noted, “Right now the technology requires a high level of knowledge, and if insufficient effort is put into the training of practitioners and researchers, we will end up with a field that is illiterate regarding the equipment they are using. We should know and be responsible for all the techniques we promote, use and teach in healthcare.” The researchers believe the question of whether industry, practitioners and patients can come together to find a way to integrate AI in a safe and sustainable manner is one of the most critical challenges facing dentistry today. If it is not addressed soon, they are concerned that the sacred doctor– patient relationship could one day be damaged beyond repair. Editorial note: The study, titled “Artificial intelligence and ethics in dentistry: A scoping review”, was published on 21 June 2021 in the Journal of Dental Research. “In the case of a malpractice event, the question is, who will be held responsible?” —Dr Carl-Maria Mörch, researcher m o c . k c o t s r e t t u h S / b e g _ y l i l o t a n a © Artificial intelligence is revolutionising dentistry in amazing ways, and researchers believe it is time for a set of ethical guidelines to be developed to help dentists with this transition. 1 2022 07

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news | and the clear aligner trays were made of ClearX v.1.1 material in the two thicknesses 0.8 mm and 1.0 mm. The forces delivered were quantified using an ortho- dontic measurement and simulation system (OMSS). They found that the 4D-printed aligners were capable of achieving significant tooth movement within the range of 2.5 mm ± 0.5 mm, with little variation between the two thicknesses. In the OMSS simulations, it was found that the range of maximum forces delivered varied according to the different temperatures tested (37 °C, 45 °C, 55 °C) but that they were all within the range of acceptable physiological orthodontic forces, as re- ported by the literature. In contrast to other studies, the researchers found that using a thicker aligner had no effect on the generated force except at the higher temperature of 55 °C. The authors highlighted a number of limitations to the study, such as its focus on the isolated movement of a single tooth and not on a complex clinical case and the fact that it did not account for intra-oral conditions and factors such as humidity and salivation. They con- cluded, however, that the 4D aligner was capable of moving teeth using biocompatible orthodontic forces. “[...] practitioners still report some drawbacks to aligner use.” They wrote: “Although orthodontic aligners have been studied in several aspects and great progress was done in orthodontic treatment by aligners, practitioners still report some drawbacks to aligner use.” They explained that these drawbacks included the limited movement achieved by single aligner trays, which necessitated changing regimes. They concluded: “Therefore, we believe that if a method could be applied to decrease the number of the aligners per treatment, together with a method to accelerate the biological movement of the teeth, that would be a quantum leap in the field of orthodontics.” Editorial note: The study, titled “Potential application of 4D technology in fabrication of orthodontic aligners”, was published online on 28 January 2022 in Frontiers in Materials. 1 2022 11 m o c . k c o t s r e t t u h S / w q y n e g v E © i

D A In Dr Rune Fisker’s view, 2022 could be a year in which significant shifts and advances occur in the world of digital dentistry. Your article states, simply, “AI is here”. In your view, what will the continued integration of AI enable dental professionals to do? I used to say that AI is coming. Now, I believe it has arrived, but I think we have to understand what defines real AI. It requires a training set and a deep learning network that needs to be trained. In my opinion, there are very few examples of true AI currently being applied in everyday dentistry. And this is where 3Shape stands out. We use “I used to say that AI is coming. Now, I believe it has arrived.” AI for intra-oral scanning, treatment simulation and seg- menting scans as well as for digital dental design through the 3Shape Automate platform. I feel that we are well ahead of many competitors in this integration of AI; however, it’s clear that AI hasn’t reached its full potential yet. What does 2022 hold in store for clear aligners and dentures? Cosmetic dentistry is a clear driver of digitalisation. Clear aligners are leading to an increased uptake in digital dental tools and to the adoption of intra-oral scanners, as a larger, societal emphasis on our appearance continues to be an im- portant factor for the treatments chosen by dental patients. Of course, dentures, which used to be the missing indica- tion in CAD/CAM, are really beginning to grow. In 3Shape’s laboratory system, we had more than three million digi- tal denture cases come through in 2021—the number of full dentures handled increased by 104%, whereas the number of partial dentures increased by 123%, which is an incredible increase from 2020. PRAGUE 26–29 May 2022 4 DAYS OF ENDODONTICS 12 LECTURES 14 HANDS-ON-COURSES register at www.roots-summit.com Tribune Group GmbH is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Tribune Group GmbH designates this activity for 18.5 continuing education credits. This continuing education activity has been plan- ned and implemented in accordance with the standards of the ADA Continuing Education Recognition Program (ADA CERP) through joint efforts between Tribune Group GmbH and Dental Tribune International GmbH.

interview | m o c . k c o t s r e t t u h S / i y k s r o b m a S n a m o R © What is your opinion about giving the responsibility of the colour result to the technician? The responsibility cannot lie in the hands of one person. In the last couple of years, the colour has not been de- cided by the technician, rather by members of our team, either the clinician or the assistant, and with OptiShade, we are able to bypass subjectivity in the way in which our eyes see something. The full team can only be successful if it has a target in sight. If we are able measure colour repeatability, we can reproduce it. Thanks to the versatility of OptiShade, we can finally help the technician to obtain the perfect colour and the clinician to deliver perfect results. What does perception mean to you? Perception in dentistry is incredibly complex to define, but we can say that it is the aspect of the final restoration, cemented in the mouth, positively judged by our eyes and those of the patient. That concept will never change. What counts is a beautiful aesthetic result in the mouth, and digital technology is here to make this happen— in an easier, faster and more predictable way. A digital colorimeter needs to be able to tell its user the colour in a way that can be understood! Is the digital colorimeter difficult to use? No, it is very intuitive. It is possible to start using it straight out of the box. The colorimeter will immediately tell you the shade, and you can select any shade guide from our wide database. It will tell you, of course, the colour “Perception in dentistry is incredibly complex to defi ne, but we can say that it is the aspect of the fi nal restoration, cemented in the mouth, positively judged by our eyes and those of the patient.” coordinates for the software that is able to give you the colour for the restorations. For optimising the measurements like a professional, it takes less than 10 minutes of training, and anyone in the clinic can use it. We can send the technician the mea- surements by e-mail or WhatsApp, in matter of seconds. OptiShade is here to stay, increasing the quality and reliability of our work. Digital colour is the future. Editorial note: Prof. Angelo Putignano is currently head of the department of restorative dentistry and endodon- tics and dean of the school of dentistry at the Università Politecnica delle Marche in Ancona in Italy. He is a found- ing member of the Italian Academy of Esthetic Dentistry (IAED) and an active member of the European Academy of Esthetic Dentistry (EAED). 1 2022 15

interview | m o c . k c o t s r e t t u h S / e M y r r u B © l Dental99’s technology-centric approach to dentistry means that patients are able to book appointments directly through a dedicated app. that you can’t exist as a healthcare provider without offering high-quality services. There have been a num- ber of budget dental brands that have come and gone in Australia, and we don’t want to follow suit, so we have a particular focus on offering quality treatment and deliver- ing patient satisfaction as well as providing an unmatched user experience when it comes to using our app. Whereas price is a significant contributor to patient be- haviour, we also believe Dental 99’s success comes from our ability to offer an excellent dental experience. We are currently developing this aspect of our business and planning to push the boundaries of dentistry through the integration of artificial intelligence and other technologies. Since your bookings are all made through the Dental99 app, have you found that your patients are younger and more digital-savvy than the average Australian dental patient? That’s what we thought was going to happen, but it hasn’t necessarily been the case. Our largest patient bases are 28- to 35-year-olds and 50- to 60-year-olds. Basically, if you can use Facebook, you can use the Dental99 app, and we all know that pretty much all grandparents and parents are able to use Facebook now. So I think this has shifted our thinking because almost every age group has evolved rapidly with the digital age. If you have a patient who needs an implant, a wisdom tooth extraction or a greater level of restorative work done, do you refer them to a specialist? Initially, we generally referred these types of patients to another specialist. Over time, though, enough demand built up on both the patient and clinician side of things to make us realise that we had to begin to offer more major dental services as part of our treatment mix. When the patients form a relationship with the practice, with their clinicians and with the brand, it makes sense that they wouldn’t want to be referred to another clinician for something like root canal therapy. “We’ve built an infrastructure that supports the clinicians and dental team as well as the patients without needing to use a traditional dental model.” Do you think Dental99’s approach is one that could be replicated by other Australian dental practices or even international dental practices? It’s definitely not a model that only fits the Australian den- tal industry, and we’re actually now in the early stages of considering locations and regional cities to which we can expand the Dental99 concept internationally. We built our technology to be able to support 1,000 dental practices, not just 13, and we are presently in the process of investi- gating whether in certain countries, like the US, there’s the right economic and dental climate in which this can work. Editorial note: According to the 2020 Survey of Dental Fees conducted by the Australian Dental Association, a simple filling can cost up to A$275, whereas 9News reported last year that the average dental visit costs approximately A$215. As a result, about two million Australians each year either avoid or delay going to the den- tist because of the financial burden they potentially face. 1 2022 17

case report | 8 9 Fig. 8: Smile design for the production of the temporary restoration. Fig. 9: Temporary restoration in place. specific needs exactly. Others, however, would pre- fer a faster and more standardised path to beauty. For the latter group, Kuraray Noritake Dental has just in- troduced a true all-rounder: KATANA Zirconia YML. This product is based on newly developed raw materi- als with different yttria content integrated into the com- pany’s multilayer colour structure. As a consequence, KATANA Zirconia YML offers colour, translucency and strength gradation throughout the blank, resulting in an unlimited indication range. That sounds promising, but does it really work in the laboratory and clinical environment? Are there any hid- den challenges with regard to design and manufacture? And how beautiful are the outcomes? In order to as- sess the material’s properties in real life and to see how it performs in our hands, we decided to test it clinically in treating a complex case. “KATANA Zirconia YML offers colour, translucency and strength gradation throughout the blank, resulting in an unlimited indication range.” Initial situation and treatment plan This female patient was concerned about the aes- thetics of her maxillary anterior teeth (Figs. 1 & 2). Sev- eral porcelain-fused-to-metal crowns in the anterior 10 12 11 13 Fig. 10: Digital impression taken with the temporary restoration in place. Fig. 11: CAD of the definitive restorations. Fig. 12: Aesthetic assessment of the virtual design. Fig. 13: Functional assessment of the virtual design. 1 2022 19

case report | of just 0.4 mm in the anterior and 0.5 mm in the posterior region. A digital impression was then taken with TRIOS 3 (3Shape; Fig. 7). The acquired data was matched with photographs of the patient’s face to design a virtual wax-up (Fig. 8) and mill a temporary restoration in the dental laboratory. The placement of this temporary restoration allowed for an aesthetic and functional assessment as well as a clinical test drive of the planned definitive restorations (Fig. 9). In this set-up, the left first premolar took over the function and shape of the missing canine. The fact that the gingival margin was slightly higher in the re- gion of the right compared with the left central incisor did not bother the patient, so alignment (gingivectomy) was not necessary. 20 Fig. 20: Treatment outcome. The material masked the discolouration of the under- lying tooth structure very well and offered nice trans- lucency in the incisal area (Fig. 20). Production of the definitive restorations A true all-rounder After successful completion of the test drive, a dig- ital impression was taken with the temporary resto- ration in place (Fig. 10). Based on this impression and the information acquired during the test drive, four full- contour crowns, two partial crowns and one bridge were designed (Figs. 11–13). The bridge in the region of the right first premolar to first molar had a small can- tilever pontic to fill the reduced space of the missing first molar. The restorations were milled from KATANA Zirconia YML. Despite the varying levels of flexural strength within the blank, virtual positioning of the restorations in the disc is extraordinarily easy. For the restorations pro- duced in this case, it was only necessary to respect the minimum wall thickness and connector cross section recommended by the manufacturer. When long-span restorations (with more than three units) are planned, half of the connector cross-sectional area needs to be positioned in the lower half of the blank. This is the case if a restoration is placed in the middle of the disc, independent of its size. Finishing Individual textural features were added with hand instru- ments to the restorations before sintering (Figs. 14 & 15). A seamless multilayer structure without transition lines and with a warm body area was obtained. For an even more natural appearance, some individual effects and glaze were added using the CERABIEN ZR FC Paste Stain kit (Figs. 16–19). Treatment outcome Our test project confirmed that KATANA Zirconia YML is a high-quality material with great aesthetic potential and no limits with regard to the indication range. It is surprisingly easy to design and position the restorations in the virtual blank, and after milling, the surfaces are smooth, the margins are sharp and stable, and the fit is accurate. Micro-layering with paste stain is often suffi- cient for lively outcomes. This makes the new KATANA Zirconia YML the material of choice for anyone placing great value on a high level of automation, the standard- isation of laboratory workflows, and efficient and easy procedures. about Dr Marco Valenti is an active member of the Italian Academy of Prosthetic Dentistry (AIOP) since 2006. He was a President of the AIOP Scientific Committee between 2015 and 2016, and is an active member of the International Academy for Digital Dental Medicine (IADDM). Angelo Canale, DT, graduated as a dental technician in 1981. He began his activity as a laboratory owner in 1986 in Rimini in Italy and is a co-author of many publications in Practical Procedures in Aesthetic Dentistry (PPAD), Quintessence of Dental Technology (QDT), The International Journal of Esthetic Dentistry (EJED) The restorations were placed with the PANAVIA V5 adhesive cementation system (Kuraray Noritake Dental). and The Journal of Adhesive Dentistry. Angelo Canale is also a speaker at international conferences. 1 2022 21

case report | tive experiences at times resulted in untreatable aes- thetic complications as well as a few sleepless nights. At the beginning, the restorative process was dominated by time-consuming chairside fabrication of provisional restorations, and there was a high risk of contamination of the surgical site. I learned that these major shortcomings can be over- come when adopting a reasonable digital workflow and soon started utilising a CAD/CAM-fabricated surgical guide as a first step into digitalisation. This was followed by the preoperative fabrication of provisional restorations. As I gained experience in digital methods, I tried to inte- grate all digital methods into my portfolio of problem solvers in order to find suitable treatment options for dif- ferent clinical situations and patient demands. 7 Fig. 7: Planning for implantation via dynamic navigation. A CONELOG SCREW-LINE implant with integrated platform switching was to be placed immediately, slightly below bone level. The following case report could have been finished in different ways, choosing other digital methods. I choose this workflow for several reasons: 4. Digital duplication of the transitional emergence profile is very predictable for the final abutment and crown. Clinical case 1. An intra-oral scanner and CBCT device can acquire digital data directly. 2. Dynamic navigation is an efficient and time-saving method for guided surgery. 3. Digital design and production of immediate resto- rations after implant insertion is more accurate than a surgical guide, as with a guide small deviations from the planned implant position may cause major diffi- culties in placing the prefabricated restoration. A 38-year-old male patient presented to our den- tal clinic seeking therapy for a discoloured central inci- sor which, according to the patient, had increasingly been moving mesially since a trauma 20 years before. The displacement of the tooth towards the midline of the upper jaw had led to closure of an originally existing diastema and caused loss of papilla distal to the central incisor (Figs. 1 & 2). The CBCT scan showed that the tooth 8 11 9 10 12 Fig. 8: Occlusal view after careful tooth extraction. Fig. 9: Occlusal view after immediate implant placement (the insertion post was still in place). Compared with the position of the tooth, the implant was placed in a little more palatal position and in a more distal position to correct the displacement of the tooth after trauma. Fig. 10: Preparation for the intra-oral scan just after implant placement. With the CONELOG scan body, only the position of the implant needed to be captured (as the scan of the complete intra-oral situation had been performed prior to surgery). Fig. 11: A xenograft was used to fill the gap between the implant and the buccal wall. Fig. 12: A healing abutment was placed temporarily to avoid collapse of the soft tissue during the production process of the provisional restoration (about 30 minutes). 1 2022 23

case report | Fig. 13: The digital model imported into 3Shape Dental Manager. Fig. 14: Matching of the CONELOG scan body. Figs. 15 & 16: Selecting a titanium base with a 2 mm gingival height for model-free design. Fig. 17: Emergence profile design. Figs. 18 & 19: The provisional restoration. Symmetry was established between the central incisors. Fig. 20: The crown was fabricated and bonded to the titanium base. had undergone endodontic treatment in the past and suffered external apical root resorption. The buccal wall appeared to be small in width (> 1 mm) but intact (Fig. 3). Based on the clinical symptoms of increased mobility of the tooth, the radiographic findings of a failed endodon- tic treatment and the patient’s willingness to have the aesthetic anterior area restored, it was decided to ex- tract the hopeless tooth and replace it with an implant. The prerequisites were promising. Enough bone volume apically if additional stability was needed through apical anchoring, an intact buccal wall and a thick gingival bio- type supported immediate placement as our first choice. Combined with an immediate provisional restoration, this would help us to maintain the soft-tissue contour in the aesthetic zone. The patient was informed about the risks, the cost and alternatives of the planned procedure and gave written consent. Preparation before surgery Implant selection was made based on the need for inte- grated platform switching and proven effectiveness in pre- serving marginal bone level. I defined the exact 3D position of the chosen implant, and the data acquisition was initiated to prepare for dynamic navigation. Compared with working with a surgical guide—and its fabrication 21 22 Figs. 21 & 22: Provisional restoration in place. Note the preservation of soft tissue. leading to additional cost and delay in the treatment process—dynamic navigation is for us a more effective way to plan and perform surgery in the same clinical visit. A CBCT scan with a fiducial clip was taken for naviga- tion surgery (Fig. 4). A digital model was prepared on the basis of an intra-oral scan before surgery. At the im- plant site, data was erased to enable for rapid capture of the implant position during the surgery (Figs. 5 & 6). The 3D position of the CONELOG SCREW-LINE implant (CAMLOG) was carefully designed in dynamic navigation software before surgery (Fig. 7). Day of surgery The hopeless tooth was carefully extracted atraumatically (Fig. 8). Immediately after the extraction, a CONELOG SCREW-LINE implant of 3.8 mm in diameter and 13.0 mm in length was placed, guided by the navigation system (Fig. 9). Before simultaneous augmentation with biomaterial, the CONELOG scan body (3.8 mm) was placed to capture 23 25 24 26 Figs. 23 & 24: The CBCT scan scan after immediate implantation and restoration confirmed that the 3D position of the implant was as planned. Figs. 25 & 26: Labial and occlusal views after three months. Note the symmetry of the gingival contour. 1 2022 25

case report | “By using digital methods reasonably, mistakes can effectively be avoided.” After surgery Approximately 30 minutes after surgery, the healing abutment—which was intended to prevent collapse of the soft tissue—was removed and the provisional crown was fixed in the patient’s mouth (Figs. 21 & 22). A CBCT scan captured after immediate implantation and restoration confirmed that the implant had been placed correctly in the planned 3D position (Figs. 23 & 24). Fabrication of final crown Three months after surgery, the labial gingival contour of both central incisors was symmetrical (Figs. 25 & 26). The patient wanted the diastema to be closed with the final restoration. As the provisional restoration had pre- served the soft-tissue contour, we considered it unnec- essary to recapture the implant position and emergence profile. We used the immediate implant scan and provi- sional restoration design, adopting the data, to design the final restoration accordingly (Figs. 27 & 28). To close the diastema and to minimise the lack of soft tissue, we marginally increased the mesiodistal dimen- sions of both the restoration on the implant and the contralateral central incisor. To increase the gingival vol- ume, a veneer was planned for the other central incisor (Figs. 29 & 30). A titanium base-supported customised final abutment was created to maintain the emergence profile, and the crown and automatic cut-back were designed to accom- modate the zirconia mesostructure (Figs. 31 & 32). The customised abutment was placed and the mesial area of the right central incisor prepared, based on a silicone impression (Figs. 33 & 34). The final implant-borne res- toration and the veneer on the right central incisor were placed (Figs. 35 & 36). Conclusion Experience is important but not always reliable. By using digital methods reasonably, mistakes can effec- tively be avoided. It is not always about the digital equip- ment you own; it is about thinking differently, assessing a challenge from an alternate angle. It is the desire to start digitalising your workflow, step by step, perhaps starting with one small step at the beginning but with the mindset of doing more. In this manner, I am con- vinced you will explore the digital world and find it more and more beneficial. 33 35 34 36 Figs. 33 & 34: The final abutment in place and preparation for the veneer. Figs. 35: Labial view of the restorations in place. Note the symmetry of the two incisors. Figs. 36: Radiographic view after three months. Note the perfect integration of the CONELOG implant and bone growing over the implant shoulder. It proves that the perfect design of the outer geometry and connection and the availability of comprehensive digital workflow com- ponents are crucial for the final results of an immediate placement protocol in the aesthetic zone. Although the case presented can be classified as a routine example of our daily work, we have significantly changed the path we use to treat our patients in comparison with several years ago. With that in mind, I hope I can take you on the journey and share the positive impact this development can have on more complicated cases in the near future. about Dr Gang Chen is the director of U-dental implant centre and U-dental implant training centre in Shenzhen in China. He received his PhD in oral and maxillofacial surgery from Peking University in China and since then has focused on restoring implant cases efficiently using digital techniques. He has been a visiting dentist at Implant and Prosthetic Department of Tuebingen University in Germany and Okayama University’s dental school in Japan and holds certification in implantology from the European Association for Osseointegration. Dr Chen spends almost half of his time giving training and lectures on how to perform digital dentistry and aesthetic treatments on international level. He is the vice president of the Chinese association of aesthetic dentistry and a committee member of the Chinese society of oral cosmetic dentistry and Chinese society of oral implantology in Guangdong. 1 2022 27

case report | 8 11 9 12 10 13 Figs. 8–13: Model editing, different options. favourite with dental practitioners. This article presents a unilateral distal extension edentulous case restored with multiple implants with a special focus on using Aoralscan 3 in the restoration phase of treatment. This case was prepared in cooperation with the West Hospital of Hangzhou Dental Hospital. 14 16 18 15 17 19 Figs. 14–17: Customised abutment design. Figs. 18 & 19: Prosthetic restoration design. 1 2022 29

case report | 24 25 Figs. 24 & 25: Try-in of the definitive dental restoration. scan bodies in place should be captured from the buccal or lingual side for ease. Data on the contralateral teeth was then acquired using Aoralscan 3 (Figs. 5–7). When data collection is com- pleted and confirmed, it is sent to the dental laboratory through SHINING 3D’s dental cloud platform. “The use of Aoralscan 3 allowed the collection of accurate 3D data from the patient’s mouth in only a few minutes.” The data is imported into 3Shape software for model editing (Figs. 8–13). It is important to choose the cor- responding data format on SHINING 3D’s dental cloud platform according to the design software you prefer to use. The software allows the design of customised abut- ments (Figs. 14–17) as well as prosthetic restorations (Figs. 18 & 19). The definitive restoration was fabricated using CAD/CAM technology (Fig. 20). It was fitted and adjusted on the printed model (Figs. 21 & 22). After the final abutments had been installed in the mouth (Fig. 23), the definitive restoration was tried in (Figs. 24 & 25). Postoperative radiographic examination showed that the position of the restoration was accurate, the approximal contact was good and the occlusion was stable (Fig. 26). Conclusion The whole process of this implant case adopted a fully digital workflow from impression taking to restoration. The use of Aoralscan 3 allowed the collection of accurate 3D data from the patient’s mouth in only a few minutes. This improves the efficiency of diagnosis and the chair- side treatment process and greatly reduces problems such as time-consuming, tedious working procedures, silicone rubber deformation and transfer movement, which leads to inaccurate data. The cloud transmission function and digital processing flow not only further en- sure the accuracy of the implant model and restoration, but also greatly shorten the production time. The treat- ment is more efficient and comfortable, and patients are more satisfied. 26 Fig. 26: Post-op radiograph. about Dr Qingsheng Chen has a master’s degree in implant dentistry and is an associate chief physician and director of the oral implant department at the Hangzhou Dental Hospital’s branch in Chengxi in China. He serves on the Chinese Stomatological Association’s restoration committee and aesthetic restoration committee. He is the standing director of Chinese association of aesthetic dentistry and has won numerous prizes in various national implant competitions. 1 2022 31

case report | The dual-scan protocol was used to visualise bone, soft- tissue thickness and denture position in the Simplant soft- ware (Dentsply Sirona). Four DS PrimeTaper EV 3.6 mm diameter implants were planned according to the posi- tion of the patient’s denture, and four Multibase abutments (Dentsply Sirona) were visualised accordingly (Fig. 3). Prior to surgery, intra-oral scans of the edentulous upper jaw and dentate lower jaw were performed. The existing denture was used first as a surgical guide and then as a provisional prosthesis, after removing the palate (Fig. 4). Immediately after implant placement (Figs. 5–10), abut- ment position was registered with an intra-oral scan (Fig. 11). The provisional prosthesis was prepared from the existing denture (Figs. 12 & 13) and then the Atlantis BridgeBase was designed (Fig. 14). Eight weeks after implant placement, the soft tissue had healed well (Fig. 15) and was ready for try-in of the Atlantis BridgeBase with a printed wax-up (Fig. 16). The wax-up was later copy-milled in zirconia (Fig. 17). The definitive prosthe- sis consisting of the Atlantis BridgeBase and zirconia was placed eight weeks after implant placement (Fig. 18). about 11 13 12 14 Fig. 11: Intra-oral scan of the abutment position, antagonists, provi- sional prosthesis and jaw relation for the manufacturing of the definitive prosthesis. Fig. 12: Seating surface of the provisional prosthesis. Fig. 13: Provisional prosthesis in place. Fig. 14: Design of the Atlantis BridgeBase. Dr Mischa Krebs is in private dental practice, Dr. Krebs & Kollegen, in Alzey in Germany. Alexander Müller works in a private dental laboratory, Müller & Edelhoff Dentallabor, in Wörrstadt in Germany. 15 17 16a 16b 18 Fig. 15: Healed soft tissue eight weeks after implant placement. Figs. 16a & b: Try-in of the Atlantis BridgeBase without (a) and with a printed wax-up (b). Fig. 17: Definitive prosthesis consisting of an Atlantis BridgeBase and zirconia. Fig. 18: Definitive prosthesis seated eight weeks after implant placement. 1 2022 33

case report | 6 7 8 Fig. 6: Positioning guide. Fig. 7: Maxillary bone levelling foundation guide. Fig. 8: Maxillary implant surgical guide. A CBCT scan and panoramic radiograph using the CS 8100 3D (Carestream Dental; Fig. 3) were taken to accurately capture the information needed to prop- erly plan the treatment for this case that would ensure the most ideal outcome, especially since the patient had discussed how unhappy she was with her exist- ing gummy smile. Using the CS 3D imaging software (Carestream Dental), dental implants were virtually planned in key positions to biomechanically support a full-arch fixed hybrid restoration in the maxillary arch (Fig. 4). To further develop the treatment plan, diagnostic model impressions were taken using Silginat polyvinylsiloxane impression material (Kettenbach), poured up and for- warded to the dental laboratory. These models were then mounted on an articulator (Stratos 100, Ivoclar Vivadent) for further analysis in order to meet the pa- tient’s aesthetic and functional needs. Financing options using a third-party payment option (LendingClub) were discussed with the patient to make this treatment as affordable as possible within her bud- get. This discussion was a very important part of facili- tating acceptance of her care, since it made the cost of treatment more feasible. Dental) software, integrating it with the digital photo- graphs and analogue models. A virtual online integra- tive meeting with the dental laboratory (Pittman Dental Laboratory) allowed for a comprehensive review of the assembled digital and clinical information to formulate an optimal prosthetically driven treatment plan that would fulfil the necessary requirements for aesthetics, form and function. Within a short amount of time, the den- tal laboratory had fabricated all the necessary guides for positioning, levelling, drilling and implant placement, in addition to the PMMA provisional restoration and back-up dentures (Fig. 5). In my practice, I have found that utilising surgical guides in implant dentistry increases the predictability of treat- ment outcomes as well as makes the procedure ex- tremely efficient. In the past, implant placement routinely took place freehand, but this approach heightened the risk of damage to anatomical structures and lengthened the duration of the surgery. I personally feel that sur- gical guides give clinicians more confidence in accu- rately placing implants in any type of case, whether it is a single unit or full-mouth rehabilitation. Precision surgery reduces stress, decreases liability and leads to a better outcome for the patient. A 3D virtual treatment plan was further developed from our planning with the CS 3D imaging (Carestream The implants that would be utilised for this case were Touareg-OS dental implants (Adin Dental Implant Systems). The Touareg-S and Touareg-OS spiral implants 9 10 Fig. 9: Guided surgery dental implant kits. Fig. 10: Touareg-OS dental implant (Adin Dental Implant Systems). 1 2022 37

case report | were tightened into the Touareg-OS dental implants to 30 Ncm, followed by temporary cylinders to 15 Ncm. Any residual areas around the implants or in the sockets were grafted with a mineralised and demineralised cor- tical bone grafting material (GoldenDent) to optimise the area for regeneration. The maxillary provisional restoration was tried in to ver- ify a passive fit over the temporary abutments. Once fit had been confirmed, trimmed dental dam pieces (COLTENE) were placed to avoid the restoration (Fig. 11) locking on during the relining procedure with REBASE III FAST hard relining material (Tokuyama Dental). After the material had polymerised, the imme- diate provisional restoration was removed and excess material was removed with the Torque Plus laboratory handpiece (Aseptico) and an acrylic bur (Komet). Once trimmed and polished, the provisional restoration was seated and tightened with a torque wrench to 15 Ncm (Fig. 12). The access openings were filled in three- quarters of the way with PTFE tape, followed by Cavit filling material (3M ESPE). A few days later, the patient returned for her postoper- ative appointment with very little discomfort, swelling or bruising. She was very pleased with her new maxillary fixed provisional restoration. The occlusion was further checked and adjusted to confirm that there were no interferences in lateral or protrusive movements. Four months later, the patient presented for impres- sions for the definitive restoration. Using a heavy- and light-bodied polyvinylsiloxane material (Panasil, Ketten- bach) in a stock tray, an open-tray impression was taken of the maxillary arch using transmucosal impres- sion posts (Adin Dental Implant Systems; Figs. 13 & 14). From this impression, the dental laboratory fabricated a PMMA try-in of the proposed maxillary restoration for try-in and evaluation. Once tried in, the restoration was evaluated for midline, incisal edge and smile line. The occlusal record was ac- complished using Futar Fast bite registration material (Kettenbach). Within several weeks, the definitive resto- ration (monolithic zirconia on a titanium frame) was com- pleted and delivered to the dental practice (Figs. 15 & 16). When the patient returned, the hybrid restoration was inserted and torqued to the manufacturer’s suggested settings (Figs. 17–19) and the access openings were sealed with PTFE, followed by composite. The patient was instructed on how to clean and maintain her dental restoration. In addition, we reviewed the im- portance of scheduled professional cleaning and overall oral health habits. With her enhanced look, the patient was motivated to care for her investment (Fig. 20). 19 20a 20b Fig. 19: Post-op panoramic radiograph. Figs. 20a & b: Pre-op (a) and post-op facial view (b). Conclusion When patients present to the dental practice in need of a full-mouth dental implant rehabilitation, they want the treatment performed and delivered in a short amount of time and preferably in one location. Utilising CBCT surgical guides, dental practitioners can provide pros- thetically driven treatment that is as effective and predictable as possible. In conclusion, with the proper training and appropriate materials, dental practitioners can provide extraction, grafting, implant placement and fixed provisional restorations within one appointment at one location. 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. 1 2022 39

case report | 3a 3b 3c 3d Figs. 3a–d: Maxillomandibular occlusal records and final wax-up on master casts (a & b) and the new set of acrylic dentures on the master casts and close-up (c & d). ing have the capacity to facilitate diagnosis, treatment planning and surgical procedures significantly and there- fore provide treatments in a more predictable and efficient way.5, 6 In particular, surgically advanced procedures like full-arch reconstructions may significantly benefit from these advantages, which may reduce chair time and invasiveness for the patient.5, 7 Access to digital technologies may be hindered by finan- cial and time constraints, as well as by a steep learning curve that has been associated with such technologies.8, 9 Recently, digital workflows have become available as part of an outsourced service: Smile in a Box (Straumann). This may help practitioners using conventional workflows readily benefit from the advantages of digital technologies without first having to overcome the hurdles associated with their first-time access. This case report describes a successful immediate conversion of a conventional com- plete denture into an immediate full-arch restoration by applying an outsourced fully digital workflow provided by Smile in a Box. The application of a Straumann Pro Arch protocol, combined with Smile in a Box, allowed us to readily access a fully digital workflow that could efficiently be integrated into our conventional prosthetic workflow, providing a highly satisfying clinical result. Initial situation sented in our clinic complaining of unsatisfactory man- dibular denture retention and associated problems, including poor speech and masticatory function, specif- ically related to his mandibular denture. Clinical exam- ination revealed a round to knife-edge mandibular ridge form and adequate vertical but inadequate horizon- tal bone availability specifically in the posterior aspects (Fig. 1).10 The diagnostic panoramic radiograph revealed a mandib- ular arch presenting with a moderate atrophy of Class III–IV and a fair volume of relatively dense cortical bone of Type 1–2 present in the inter-foraminal area (Fig. 2). The patient had well-controlled Type 2 diabetes and well-controlled hypertension. No systemic or local risk factors or contra-indications that would have excluded the patient from implant treatment were identified. After a thorough discussion about the various treatment options and their advantages and limitations, the patient expressed his preference for an implant-supported man- dibular restoration combined with a new conventional complete maxillary denture. Treatment planning A 65-year-old completely edentulous male patient re- stored with conventional acrylic complete dentures pre- The treatment strategy included the determination of the maxillomandibular relationship, occlusal vertical di- mension and tooth position using conventional complete 4 5 Fig. 4: Transparent radiographic template on master cast before modification. Fig. 5: Transparent radiographic template after modification with radiopaque fiducial markers in preparation for the dual CBCT scans. 1 2022 41

case report | 9a 9b 9c 10a 10b 10c Figs. 9a–c: Positioning of the mandibular pin guide in occlusion with the opposing transparent radiographic template. An occlusal record was used to further stabilise the mandibular pin guide in the correct position. Figs. 10a–c: Fixation of the BLX surgical guide. Specifically, the plan involved prosthetic restoration from the first molar to the first molar supported by four inter-foraminal BLX Roxolid SLActive implants (Straumann) consisting of two anterior 3.75 × 12.00 mm implants in positions #42 and 32 and two 4.75 × 12.0 mm implants in positions #45 and 35. Inclination of the posterior implants by 17° increased the antero-posterior spread and helped to reduce the distal prosthetic cantilevers, obviating the need for any augmentative procedures (Fig. 6).13 The planned surgical templates consisted of a combi- nation of a pin guide for pin fixation and a surgical guide for implant placement. Both guides were supported by crestal mucosa and four anchor pins in positions #46, 43, 33 and 36 (Fig. 7). Surgical procedure Surgery was carried out under local infiltration anaes- thesia. Proper seating and positioning of the mandibu- 11a 11b 11c 12a 12b 12c Figs. 11a–c: Osteotomy preparation (position #32). Access preparation using a mucosal punch (a). Flattening of the alveolar crest using a milling cutter (b). Pilot drilling with a 2.2 mm diameter pilot VeloDrill (c). Figs. 12a–c: Finalisation of the osteotomy and implant placement (position #32). Final drilling with a 2.8 mm diameter VeloDrill (a). BLX Roxolid SLActive 3.75 × 12.00 mm implant (Straumann) (b). Implant placement using a motorised handpiece (c). 1 2022 43

case report | 16a 16b 16c Figs. 16a–c: Delivery of the immediate provisional restoration on the day of surgery. Prosthetic procedure The surgical procedure was directly followed by imme- diate provisionalisation, involving installation of screw- retained abutments to a torque of 35 Ncm and then try-in and pin fixation of the provisional restoration (Fig. 13). An optimal fit of the pre-manufactured provisional res- toration with the prosthetic emergence profiles of the implant restoration was achieved. Next, titanium cop- ings were adjusted in length to suit the contours of the provisional restoration and mounted on the im- plant restoration. Subsequently, the provisional res- toration was mounted, secured with anchor pins and fixed to the titanium copings using flowable composite (Figs. 14 & 15). Treatment outcomes Optimal results were achieved in terms of functionality and aesthetics thanks to the digital pre-planning (Fig. 16). There was satisfactory occlusal fit with the maxillary complete denture, and no adjustments were required. The patient showed optimal immediate phonetic and functional adaptation to the new provisional restoration and reported that he was very pleased and satisfied with the aesthetic and functional result of the immediate provisional restoration. Discussion The presented case illustrates the conversion of a man- dibular conventional complete denture into an implant- supported fixed full-arch restoration using Straumann Pro Arch and Smile in a Box. Conversion of the exist- ing restoration included the delivery of a new set of stable conventional dentures after re-establishing the maxillomandibular relationships and occlusal vertical dimensions by conventional laboratory workflows. Smile in a Box facilitated quick and easy access to a digital workflow, providing the associated advantages of precise prosthetically driven implant planning, guided flapless implant placement and immediate restoration.6, 8 The outsourced workflow could be perfectly integrated into our existing clinical and prosthetic set-up. Key suc- cess criteria that contributed to a seamless integration of the outsourced workflows and an optimal result for the patient included appropriate and accurate data collec- tion and communication with the Smile in a Box team. This allowed for straightforward definition and approval of the virtual planning models based on the visualisa- tions from coDiagnostiX and CARES Visual provided by the team. Efficient communication with the team also ensured that all other critical factors related to immediate implant placement and immediate restoration were appropriately addressed, without having to overcome the initial learning associated with digital techniques.8 Conclusion The application of Smile in a Box to a Straumann Pro Arch protocol allowed for convenient and seamless ac- cess to a digital workflow for the immediate conversion of a conventional complete denture into a fixed full-arch restoration. about Dr Keng Mun Wong is managing director of T32 Dental Group in Singapore, where he focuses on all areas of restorative care, including aesthetic dentistry, full-mouth reconstruction, and fixed, removable and implant prosthodontics. In 2005, he founded T32 Dental Academy, a centre dedicated to educating, motivating and stimulating dental professionals and sharing knowledge. He is an affiliate assistant professor at the University of Washington in the US and a visiting senior lecturer at the National University of Singapore. Dr Valerie Tey graduated with BDS and MDS degrees from the National University of Singapore, where she is a part-time tutor. She holds membership in prosthodontics of the Royal College of Surgeons of Edinburgh and is a fellow of the Academy of Medicine, Singapore. 1 2022 45

case report | 4 5 Fig. 4: Calibration of the Navident device. The tracers and camera are shown. Fig. 5: Intra-op view of the software. the combination of the prepared guide, tracking markers and dynamic tracking of the camera, the dentist can see the actual position of the drill and its angulation with a lag of 0.3–0.5 seconds on the computer screen. According to avail- able data, the accuracy of the equipment is 0.1 mm and 1°, which is significantly better than CAD/CAM-fabricated guides for endodontic treatment. It must be considered that the ac- curacy of the procedure may differ depending on the clinician. Case 1 A 36-year-old female patient came to the dental office with discoloration and pain of the maxillary right first incisor (Fig. 1). In the medical history taking, she reported a trauma approx- imately 15 years earlier. During the radiographic examination in the office of her general dentist, PCO was revealed. She was referred for a CBCT scan and endodontic treatment. During the consultation, the CBCT scan was performed with the 9000 C 3D with a voxel size of 0.1 mm (Carestream). The CBCT scan revealed a highly calcified pulp chamber and an almost invisible trace of the root canal (Fig. 2). The patient was informed about the new, beneficial technol- ogy which can help to preserve additional tooth structure during treatment. Before the treatment, the CBCT scan was uploaded to the software and the virtual guide was planned (Fig. 3). This is one of the most important parts of the protocol because during the treatment the Navident software tracks the handpiece and shows the correlation between the clinician’s work and the already planned guide. If the depth or direction is missed on the guide, there is a very high risk of root perforation. During the clinical procedure, the jaw tracker was placed on the patient’s teeth and fixed with impression material. Registration of the patient’s tooth position and calibration of the CBCT scan was performed with the help of the wand tool. The drill tag was attached to the handpiece, and the calibration of the handpiece and drill was performed with the calibration tool (Fig. 4). After all the registration and 6a 8a 6b 8b 7a 9a 7b 9b Figs. 6a & b: First stage of the access cavity creation (a). CBCT check, sagittal plane (b). The axis of the access cavity was visible. Figs. 7a & b: Hand fi le scouting of the canal orifi ce. Figs. 8a & b: Final preparation (a). The size of the access cavity and of the root canal orifi ce was checked with the #80 hand plugger (b). Figs. 9a & b: Drying the canal before obturation. 1 2022 47

case report | 18a 18b 19a 19b 20a 20b 20c 21a 21b Figs. 18a & b: CBCT check, sagittal plane. The axis of the access cavity was visible for both teeth. Figs. 19a & b: Drying the canal before obturation (a). The final shape of the access cavity (b). Figs. 20a–c: Obturation with gutta-percha (a & b) and the control radiograph (c). Figs. 21a & b: Occlusal check (a) and the control radiograph of the composite seal (b). confirm that the access cavity and the root canal prepa- ration had the same angulation, parallel to the long axis of the root, and remained in the centre of the root (Fig. 13). Case 2 A 30-year-old female patient presented to the dental clinic complaining of constant pain of the left central incisor. Moreover, the patient was unhappy with the aesthetics of both incisors and had a history of trauma (Fig. 14). CBCT examination was performed with the 9000 C 3D (Fig. 15). The CBCT scan revealed a periapical lesion around the left central incisor and PCO for 12 mm from the incisal edge. The root of the left incisor was approximately 5 mm shorter than the root of the right incisor, which could indicate api- cal inflammatory root resorption. Moreover, PCO was pres- ent in the right central incisor up to 12 mm from the incisal edge, and an irregular shadow in the central area of the root was present. This image could indicate internal resorption. There was no lesion in the periapical area. In both teeth, the size of the canals in the periapical area were narrower than the typical size of the canals in the central incisors. Before the treatment, the CBCT scan was uploaded to the software and the virtual guide was planned (Figs. 16 & 17). All the registration and calibration procedures were per- formed in the same manner as the previous case. The access cavity was performed with the EndoGuide bur with the aid of the software. After reaching the depth of drilling on the prepared guide, another CBCT scan was performed to check the accuracy of the access cavity (Fig. 18). The CBCT scan revealed that the angulation of the access cavity was suitable but that the depth was insuf- ficient. The EndoGuide drill and Navident were used one more time to reshape the access cavity. After gaining pa- tency in the canal, the #10 K-file was used to establish the working length. The canal in the right incisor was shaped with Endostar E3 Azure up to size 40/.04, and the canal in the left incisor was shaped up to size 45/.04. In both canals, the irrigation protocol was performed with 5.25% sodium hypochlorite and 40.0% citric acid. Both solutions were activated with EDDY sonic tips, and sodium hypochlo- rite was additionally activated with elements free for intra- canal heating. The canals were dried with paper points (Fig. 19) and obturated with warm gutta-percha using the continuous wave technique, and a control radiograph was performed (Fig. 20). Finally, the composite sealing was performed and the occlusal check was done (Fig. 21). Conclusion Although dynamic navigation in endodontics is a very new and uncharted technology, the three teeth with massive PCO in these case reports proved that it offers very promising utility for endodontists. This technology requires further in- vestigation, but it appears that it could help many clinicians to treat teeth with PCO and perform non-surgical retreat- ment with a better outcome. Moreover, using this technology in preparing constricted access cavities appears to be very promising in terms of the survival of the treated teeth thanks to preserved tooth structure such as peri-cervical dentine. Therefore, digital solutions like Navident should be used more often in endodontics to gather more data and create a new standard for treating teeth with PCO in the future. contact Dr Bartlomiej Kara´s MAXDENT Ul. Hallera 53/2 53–325 Wrocław Poland kontakt@bkaras.com 1 2022 49

have to design smiles. At the end of the day, we are art- ists. So, without a doubt, a dental clinic should reflect the values, principles and ethos of the team. The White Clinic is, for me, much like its name, which is why the lab coats and the white boards need to be very clean and very simple. As you said, dental clinics have always been asso- ciated with something uncomfortable, so even in my very first clinic, my goal was always to create very wel- coming spaces. In some clinics, you will notice that dentists or busi- ness owners want to maximise space in order to fit in as many treatment rooms as possible. I think, based on my treatment philosophy of Slow Dentistry, that seeing fewer patients a day offers a higher quality of service. Consequently, I do not want a full waiting room or packed corridors. It is, therefore, important for me to create an environ- ment with a serene, comfortable high-tech ambience. It is as important for the clinic as refreshing, updating and upgrading the technology we use is. We can up- date the reception area and the front desk by some- thing as simple as giving the walls a new coat of paint or changing the furniture and decorations. Cleanliness is, of course, very important to me as well. feature | “I think, based on my treatment philosophy of Slow Dentistry, that seeing fewer patients a day offers a higher quality of service.” What were the points you considered vital for the design of the White Clinic? Design for me, very much like architecture, is all about function. Form follows function. It must be functional. If you are trying to build a clinic in a pre-existing space like an old building, where, for example, you cannot knock walls down, it is very difficult to create a work- flow around the existing architecture or to design your floor plan according to the ideal workflow. It is easier to build from scratch in an open space, where the architecture can and should follow the workflow and the patient’s journey. 1 2022 51

feature | dental chairs. It all reflects our minimalistic approach to our work. We do not have anything to hide, and therefore we do not embellish with fancy decoration. The way that my team works, the service and technology we offer, is what people come for, and the clinic is just a backdrop for that. Since we are not trying to hide anything, we do not need to embellish anything either, and I think this is a strong message that the patients appreciate and understand. Dr Stanley, is there anything you would like to add? I think that, especially because of this pandemic, moving forward, one wants a waiting room that is not overcrowded, where people feel they are not sitting on top of one another. People need to be aware of the cleanliness as well. Many people overlook bathrooms, which are, to me, incredibly important. That is where people understand the intimate workings of cleanliness. Having a very clean bathroom with attractive soap, towels and light- ing is essential because it is an important reflection on the clinic. patients to understand. This, in turn, is shown in our approach to treating them. The overall appearance of the clinic sends out the message that we care about the details, and I think that is the most important thing that dentists want their I think that this should shine through every single bit of decoration and design. 1 2022 53

REGISTER FOR FREE DT Study Club – e-learning community THE GLOBAL DENTAL CE COMMUNITY THE GLOBAL DENTAL CE COMMUNIT Y THE GLOBAL DENTAL CE COMMUNIT Y THE GLOBAL DENTAL CE COMMUNIT Y THE GLOBAL DENTAL CE COMMUNIT Y webinars / live operations / online CE events / CE credits www.dtstudyclub.com @DTStudyClub Tribune Group is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry.This continuing education activity has been planned and implemented in accordance with the standards of the ADA Continuing Education Recognition Program (ADA CERP) through joint efforts between Tribune Group and Dental Tribune Int. GmbH.

manufacturer news | Innovation and seamless workflow DS PrimeTaper implant system— perfect union of form and function The new DS PrimeTaper implant system is a demonstration of science and art in harmony. Its innovative design enables pre- dictable, secure placement across the widest range of bone densities. The self-tapping implant has a tapered design and progressive self-cutting threads that have been crafted to cut quickly and engage without excess torque, achieving immediate stability. A simple drilling protocol ensures excellent control and supports the workflow. DS PrimeTaper delivers seamless work- flow integration, efficient handling, enviable aesthetics and lasting bone care. Seamless workflow integration DS PrimeTaper integrates easily into the DS Signature Work- flows—from initial diagnosis and planning, through surgery and temporisation, to definitive restoration—to help reduce treat- ment time. With one-position-only placement, the EV connection is the first implant–abutment connection designed for digital workflows. Its unique design lets the clinician position a patient- specific Atlantis abutment exactly where intended. As part of the DS Implants portfolio, DS PrimeTaper comes with the support and service credentials to match, as well as the legacy of the Astra Tech implant system and seamless workflow integration with the Primescan system. Efficient handling The unique, progressive thread is designed to let the clinician place the implant quickly and shorten the procedure. The implant has three distinct thread shapes: the MicroThread shape on the implant neck conserves the bone and provides long-term mar- ginal bone maintenance, the crestal squared thread shape on the body condenses the bone and the pointed thread shape at the apex cuts into the bone. Together, these variable thread shapes and the pronounced flute design contribute to initial stability and cutting efficiency, linear torque build-up throughout the implant placement for predictable placement and immediate implant stability for all implant cases. Enviable aesthetics Implant dentistry professionals want their patients to look great for years to come, to be able to smile and laugh with confidence. To achieve great-looking restorations, clinicians need the long- lasting performance of the unique MicroThread design that provides long-term biomechanical bone stimulation, enhanced aesthetics and lasting satisfaction for both the patient and the clinician. Lasting bone care Building on the Astra Tech implant system’s proven reputation for fast, predictable osseointegration, the OsseoSpeed sur- face on the DS PrimeTaper implant integrates with more bone more rapidly. The outcome is long-term bone care and stability that outperforms the competition at both one- and five-year intervals.1 The superior marginal bone maintenance of the OsseoSpeed surface is vital to achieving the best possible functional, biological and aesthetic outcomes over the long term. The DS PrimeTaper implant system is the latest innovative addi- tion to the comprehensive DS Implants products and solutions portfolio designed to help practices grow their implant dentistry business and get the best results for their patients. Reference 1. Norton MR, Åström M. The influence of implant surface on maintenance of marginal bone levels for three premium implant brands: a systematic review and meta-analysis. Int J Oral Maxillofac Implants. 2020 Nov/Dec; 35(6):1099–111. doi: 10.11607/jomi.8393. www.dentsplysirona.com/primetaper 1 2022 57

industry news | hand, the greatest advancement is that AG.Live connects the growing global network of dental professionals who are operating digitally. This bridges the interdisciplinary gap between dentists and dental technicians and facil- itates future-oriented cooperation. Furthermore, within this network of optimised and new partnerships, partic- ipants can focus on their strengths and better position themselves on the market. Extending the digital Ceramill CAD/CAM workfl ow to the dentist The Ceramill DRS Connection Kit is the basic entry-level option, with which dentists and laboratories can al- ready take full advantage of digitisation. It consists of a Ceramill Map DRS intra-oral scanner, the associated scan software and the connection to AG.Live. Any order data, including all the required information, can therefore be shared with the laboratory seamlessly and in real time via AG.Live. This eliminates the need for handwritten job sheets and conventional impressions. All that is neces- sary is the physical delivery of the restoration to the den- tal practice, and this is possible on the same day in cases of simple restorations. Such timely delivery can lead to a better dental experience for the patient and could ulti- mately attract new patients to the practice and generate more orders for the laboratory. If the preferred material is zirconia, the High-Speed Zirconia Kit, consisting of Zolid DRS zirconia and a cor- responding Ceramill Therm DRS sintering furnace, can optimally support the laboratory in fabricating straight- forward zirconia restorations on the same day. In an additional step—which can provide patients with their prostheses even faster—the system in the dental practice can be upgraded at any time with the Ceramill DRS Produc- tion Kit. This allows simple restorations to be fabricated in the practice and placed in the patient’s mouth in a single session. All Ceramill DRS Kits are currently available for pre- ordering within Germany, and the High-Speed Zirconia Kit is already available to laboratories. Early bird DRS users benefit from particularly close support from the DRS specialists at Amann Girrbach. For further information and to pre-order, visit www.ceramill-drs.com. Free online presentation about the innovative Ceramill DRS In this online presentation, Amann Girrbach explains why it places the dental laboratory at the centre of the prosthetic workflow and ensures the highest possible quality and patient satisfaction through close integration and digital exchange with the dentist. Even with the basic version, the Ceramill DRS Connection Kit and the link to the AG.Live digital platform, the practice and laboratory can connect in a unique manner and take full advantage of the bene- fits of digitisation. The presentation also explains interdis- ciplinary collaboration for restorations in a single session or on the same day, using the upgrades to the Ceramill DRS Production Kit and the DRS High-Speed Zirconia Kit. The full presentation can be accessed, free of charge, in various languages from Amann Grirrbach website, https://academy.amanngirrbach.com/en/webinar/ceramilldrs- the-roi-of-digital-transformation/3606. The Ceramill Direct Restoration Solution enables dental practitioners and technicians to work as an interdisciplinary and future-oriented team and makes same-day prosthesis fabrication possible. 1 2022 59

Soft tissue augmentation NovoMatrix™ Reconstructive Tissue Matrix – the next generation material NovoMatrix™ Reconstructive Tissue Matrix is an acellular dermal matrix derived from porcine tissue intended for soft tissue appli ca tions. The proprietary LifeCell™ tissue processing is designed to maintain the biomechanical integrity of the tissue, which is critical to support tissue regeneration. Indications Localized gingival augmentation to increase keratinized tissue (KT) around teeth and implants Alveolar ridge reconstruction for prosthetic treatment Guided tissue regeneration procedures in recession defects for root coverage Product features Consistent thickness (1 mm) Pre-hydrated Controlled source www.biohorizonscamlog.com 0 2 0 2 / 6 0 3 0 7 7 . J . X Before use, physicians should review all risk information, which can be found in the Instructions for Use attached to the packaging of each NovoMatix™ Reconstructive Tissue Matrix graft. NovoMatrix™ is a trademark of LifeCell™ Corporation, an Allergan affi liate. ©BioHorizons. All rights reserved. Not all products are available in all countries.

Digital dentistry, simply united! Introducing 3Shape Unite. An open platform that brings together world-leading dental companies, solutions and labs. Manage all your cases with choice and ease, from TRIOS scan to treatment completion. Simply connect to the right partners with app-based efficiency and make digital dentistry easier than ever with 3Shape Unite. 3Shape.com/Unite

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INTRODUCING DS PRIMETAPER™ THE PERFECT UNION OF FORM AND FUNCTION DS PrimeTaper is a demonstration of science and art in harmony. With immediate function and intuitive digital workflows, these unique implants will complement and enhance your expertise. EFFICIENT HANDLING LASTING BONE CARE ENVIABLE ESTHETICS SEAMLESS WORKFLOW INTEGRATION