issn 2193-4673 • Vol. 3 • Issue 2/2022 digital international magazine of digital dentistry 2/22 interview “The future is digital, and I want women to actively shape it” trends & applications Digital dental shade measurement case report Digital implant planning in combination with a conventional prosthodontic workflow

editorial | Dr Scott D. Ganz Editor-in-Chief Fast, faster, fastest... It is difficult to believe that at one time clinicians lectured using 35 mm slides in a Kodak Carousel projector, first using one screen, then two projectors and two screens, and then some clinicians would use three projectors and three screens, all with static images taken with an analogue camera. Of course, this all changed when the graphical user interface became available with the Windows operating system and software like Microsoft PowerPoint was introduced. The problem then became how to move the analogue slides to digital. Many of us either used a service bureau or bought a dedicated slide scanner to digitise the 35 mm slides. For those of us for- tunate enough to have one of the first laptop computers, we could take the hundreds of 35 mm slides imported into PowerPoint and leave the slide carousels at home! This was certainly not a fast process for most, but we were so impressed with the imagery that speed was not an issue. At the beginning, when the practice of dentistry began to go digital, we were all amazed when objects appeared on a computer screen which could be rotated, sized and enlarged for better viewing. Of course, the technology was not always fast, and the images on the screen may not have reacted with great speed, but it was fascinating! Many clinicians started out with an intra-oral digital cam- era which could be used to capture images of patients’ oral cavities in the hopes of educating patients about their oral condition. We could even create physical prints from the intra-oral screenshots and then technology contin- ued to evolve with the introduction of intra-oral scanners which would capture 3D images of teeth and adjacent structures. These first intra-oral scanners introduced clinicians to the use of digital technology in dentistry— a major advance for certain! Computed tomography has been used for dental applications since the mid-1980s, but did not reach mainstream US until after the introduc- tion of CBCT scans, starting after the turn of the century. We could then take data from the intra-oral scanner and merge that data with the data set from the CBCT scan to relate the placement of implants to the actual position of the planned restoration, and we could take the next step to export the final implant plan for CAD/CAM or 3D-printing a surgical guide. All these innovations have taken years for clinicians to embrace, and we are still at the tip of the iceberg in terms of global use of technology. While this is happening, most of the marketing strategies have been to promote the fastest intra-oral scanner or the fastest 3D printer or im- mediate loading of implants to achieve faster treatment outcomes. A word of caution: digital dentistry is depen- dent on sound principles of restorative and surgical den- tistry, so although fast may be important, we should not move so fast that we may lose the foundation of proper diagnosis and treatment planning. Sometimes, it is OK if a scan takes 30 seconds longer—if it provides the neces- sary information to achieve the best treatment outcomes for our patients. Please take a moment to enjoy this latest edition of digital to learn current concepts and modalities that will enhance your practice of dentistry. Dr Scott D. Ganz Editor-in-Chief 03 2 2022

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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 applications. 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 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 registered trademark of BioHorizons. They may not be registered in all markets. ©BioHorizons. All rights reserved. Not all products are available in all countries. Bone tissue augmentation MinerOss® A The allograft for outstandingly fast bone remodeling [1] The scientifi c evidence shows that allografts are the second best option to patient‘s own bone compared to other bone substitutes. [2] Benefi ts of MinerOss® A human bone substitute [1, 3–5] Optimal osteoconductivity Fast graft incorporation Complete remodeling potential www.biohorizonscamlog.com [1] Wen et al. J. Periodont. 2019, 1, 734. [2] Schmitt et al. Clin Oral Implants Res. 2013, 24, 576. [3] Kloss et al. Clin Oral Implants Res. 2018, 29, 1163. [4] Solakoglu et al. Clin Implant Dent Relat Res. 2019, 21, 1002-1016. [5] Kloss et al. Clin Case Rep. 2020, 8, 5. References available at: www.biohorizonscamlog.com/references_minerossa MinerOss® is a trademark of BioHorizons®. BioHorizons® is a registered trademark of BioHorizons. They may not be registered in all markets. ©BioHorizons. All rights reserved. Not all products are available in all countries.

industry | those working purely in private dentistry (78% compared with 63%). In addition, approximately 35% stated that they believed their income would remain lower than pre-pandemic levels over the next year. Patients continue to face issues of access “Dental professionals continue to rise to challenges posted by the pandemic [...]” For a snapshot of the general public’s attitudes towards COVID-19 and its impact on dentistry, the GDC commis- sioned the Community Research company to carry out independent research. An online survey that explored attitudes about patient safety and dental visit frequency, among others, was filled out by 2,389 members of the public, spread across England, Wales, Scotland and Northern Ireland. Some of the findings reinforced the widespread notion that UK dentistry is dealing with challenges at a systemic level in providing adequate care for patients. Though most individuals who wanted a dental appointment had been able to secure one, 22% reported being unable to book an appointment since August 2020. A higher proportion of young people and individuals of Asian or Black ethnic backgrounds stated that they had expe- rienced difficulties in accessing dental services, indi- cating that the pandemic had continued to exacerbate oral health inequalities in the UK. Meanwhile, around one-quarter of respondents said that they were still hes- itant about visiting a dental practice owing to concerns about COVID-19. “Dental professionals continue to rise to the extra- ordinary challenges posed by the pandemic, but these findings point towards a system being overstretched,” said Stefan Czerniawski, executive director of strategy at the GDC, in a press release. He added: “Many of the most pressing and wide-reaching challenges highlighted in this research, such as access to services, health inequalities and pressure on professionals, will require attention and effort from everyone right across dentistry. While some of these are areas outside of the GDC’s direct control, we will use this evidence to inform all our work and share the insights with our partners to support those broader efforts to address these problems.” REGISTER FOR FREE DT Study Club – e-learning community AD 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 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 instruc- tors, 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.

market, other minor competitors exist, such as the Smileloc system. Naturally, the fixed attachment market not only benefits from a steadily increasing rate of adoption but also from being tied to the fastest growing segment within the overdenture market. A shifting landscape for the implant bar market Like the attachment market, the implant bar market is also undergoing substantial changes that will affect it in both the short and long term. The first such change relates to the market’s competitive landscape. The implant bar market can be broken down into implant bars manu- factured by dental laboratories and those manufactured in independent milling facilities. Traditionally, there was a near-even split between dental laboratories and milling facilities in the US; however, dental laboratories command a significantly higher share of the market in Europe, par- ticularly in Italy, Spain and Portugal. Recently, the growing use of CAD/CAM technology has increased efficiency in the milling process and decreased the cost. Hence, smaller dental laboratories are now able to produce their own implant bars inexpensively, substantially increasing their share of the implant bar market. The competition between milling facilities and dental laboratories, in addition to the increased efficiency and cost savings of CAD/CAM technology, have combined to place downward pressure on implant bar prices across the US and Europe. As CAD/CAM technology becomes more accessible, an increasing number of dental labo- ratories have begun in-house manufacturing of implant bars. The increased efficiency of this process has caused the cost per implant bar to decrease. Whereas dental laboratories and CAD/CAM milling facilities are interested in maintaining their profit margins, reduced costs pres- ent an opportunity to capture greater market share. As a result, the price of implant bars has been decreasing while the use of CAD/CAM technology increases. This is expected to reach a plateau as the implant bar market becomes saturated with CAD/CAM milling. These price reductions also have an impact on the pricing of splinted overdentures such as fixed-hybrid overdentures and re- movable implant bar overdentures, since the implant bar is a key component of these overdentures. Another current trend within the implant bar market regards the materials being used in their fabrication. Implant bars in both the US and Europe are primarily fab- ricated with titanium, cobalt chromium or, occasionally, gold. In the US, the use of titanium has been most pop- ular whereas in Europe, cobalt is used more often. Both titanium and cobalt chromium have benefits. Cobalt has been used in dentistry for decades and is a very strong, biocompatible material with high corrosion resistance. Titanium is also a very strong and corrosion-resistant 2 material. Where titanium distinguishes itself, however, is through its lightweight nature, elasticity and superior biocompatibility. In the implant bar market, titanium has been gaining considerable popularity, mostly owing to its biocompatibility. Germany, Scandinavia, Austria, Switzer- land and the Benelux region have paved the way in the use of titanium in Europe. Cobalt chromium still com- mands a significant unit share of the implant bar market in France, the UK, Italy, Spain and Portugal, but titanium is expected to become the dominant implant bar material in these countries over the next decade (Fig. 2). Closing thoughts In summary, shifting patient preferences towards fixed- restorations and the widespread adoption of CAD/CAM technology has led to significant changes in the over- denture market. Whereas the future may be uncertain, iData Research forecasts indicate that this market is expected to experience substantial growth over the next five to ten years across Europe and the US. This will be spearheaded by remarkable growth within the fixed- hybrid overdenture, implant bar and fixed attachment markets. about Daniel Sussman is a research analyst at iData Research. He develops, writes and models syndicated and custom research projects for various medical device industries. To date, he has published the company’s European gastrointestinal endo scopic devices report as well as its US and European dental overdentures series. 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. 13 2 2022 © iData Research Inc.

interview | Eva-Maria Meijnen in the PlusDental office in Berlin. Presently, more than 50,000 patients have received treatment with the company. and improved treatments at reduced costs to more pa- tients. It was this purpose that I found irresistible and that made me end my corporate career and join a nine- month-old start-up. I first came across the invisible aligner product through a friend who had returned from working in the US. I imme- diately noticed that something was different about her. Her demeanour had changed completely; she seemed to have much greater self-confidence and a new charisma. She told me that she had undergone an aligner treatment in the US and that she had felt much more comfortable in her skin ever since. Two things in particular struck me. Firstly, the fact that something as small and barely visi- ble as an aligner can have such an enormous impact on one’s life and, secondly, that this fantastic product was hardly known in Germany and was affordable for even fewer people. Weeks later, I met Lukas Brosseder, a good friend of mine and a serial entrepreneur. He told me about this new company he was going to found, a company that had the vision to bring the invisible aligner product and a new digital treatment concept to Germany. So, it’s prob- ably no surprise that I wanted to be part of this journey. “I care about creating a company that shapes the future of dentistry.” You share the leadership position with two other colleagues. What is your specific area of responsi- bilities within the company? We are all co-CEOs and, whereas each one of us has his or her own field of responsibility, we take all important and strategic decisions together. I am responsible for our medical team, our operations, finance, customer relations, sales and human resources. One milestone of which I am particularly proud is the set- ting up of our own production of aligners and retainers in our Berlin dental laboratory. From our treatment plans to our products, everything is 100% made in Germany. You are aiming to reach unicorn status for PlusDental this year, which would make you the first woman in Germany to co-lead a company with such a status. 15 2 2022

In addition, there’s another interesting and noticeable side effect. A company that’s genuinely diverse has a strong pull effect as it automatically attracts diverse employees, making it a key factor in the competition for the best talents. Great business ideas can be duplicated to a certain extent, but great teams cannot. I am proud that we have such a diverse team composed of members coming from more than 50 different nations. Fifty per cent of our employees are female, and this is true at all leadership levels. Based on your own experiences, what do we need to change in society in order to enable more women to reach the top? It is never just one thing when it comes to changing society. A key aspect for me is education. Already as children we often encounter outdated stereotypes like “technology and maths are only for boys”. Let’s inspire and motivate all children alike to try out new things with- out any limitations. My parents have always encouraged me and taught me to remain curious, open-minded and brave. They brought me up having the awareness that everything is possible. The future is digital, and I want women not only to participate in the future but also to actively shape it. To this end, they need to believe and be confident that they can do anything they set their minds on. I also believe that schools play a decisive role. Young girls should be given the chance to try out different things from an early age, and we should use formats that go beyond the classic way of teaching subjects such as maths. Technology-related subjects such as coding, machine learning and environmental technology should be included more often into the regular school schedule. Coding, for instance, is easy to learn, and it fosters analy- tical thinking in a manner that is playful and low threshold. In addition to encouraging new approaches in school education, it’s very important to promote entrepreneurship in general and inspire young women to help shape the technology scene and the digital future within their own companies. This is the case with “Makers of Tomorrow”, an initiative of the German Chancellery to encourage and inspire university students to start their own businesses. It’s in an online course format and consists of ten master classes given by different start-up CEOs and their found- ers. I’m very proud to be part of this project by providing a master class. Besides education, I have seen many talented women in my generation stepping down when they started a family. They took over the majority of family and care work and reduced their working hours for years, even after their parental leave was over. It is, of course, each person’s personal decision how to combine career interview | “The focus for us remains on further digitising high-quality dentistry and making it accessible to even more people.” and family planning. My husband and I decided that we will share everything 50/50. We both continued working full-time and took care of our home and fam- ily together. I would not have been able to follow my career plans without equally sharing all responsibilities with my husband. From my experience, this set-up is still an exception. The tooth models that serve as the basis for manufacturing each step of the aligner treatment are 3D-printed. (All images: © PlusDental) What are your ideas and plans for PlusDental and the oral healthcare sector in the future? The focus for us remains on further digitising high-quality dentistry and making it accessible to even more people. Accordingly, we want to continue to constantly improve our processes without compromising accuracy and quality. We are also considering expanding our current medical services to include new dental areas such as more ad- vanced aligner treatments and adding new products to our portfolio such as whitening, prophylaxis and artificial dentition. Furthermore, we want to strengthen our pres- ence in our current markets and also internationally. No matter where we are, we want to offer modern dentistry that people can afford. Editorial note: This interview was conducted before it was announced on 20 May that PlusDental is to become part of the Straumann Group. 17 2 2022

interview | 3 Fig. 3: Prof. Werner H. Mörmann (left) developed the CEREC system in the early 1980s together with electrical engineer and close friend, Dr Marco Brandestini. Prof. Mörmann: I had a technical solution in mind that would integrate data acquisition, design and form grind- ing into a small mobile unit. The solution needed a monitor and had to be a practical device that could be used chairside by the dentist. Dr Marco Brandestini, an electrical engineer and a good friend of mine, was also enthusiastic about the idea and saw it as a technical challenge for himself. Our first functional model of a form grinding machine actually self-destructed when the grinder sank into the ceramic! The solution was to use cylindrical plunge grinding along the mesiodistal inlay axis with a diamond-coated grinding wheel and a water turbine as the drive. This worked quickly at the chairside, but the occlusal surface was flat and dentists had to shape the fissures and cusps manu- ally by themselves after bonding. I am extremely pleased that inlays made in this way still work after 25 years or more. This solution—together with many clinical studies—confirmed that the clinical concept was viable. The full story of the technical and clinical emergence of the CEREC method is rather long, but those who are interested can download it free of charge from moermanncerecstory.com, in English or German. Dr Stähler, as CTO at Dentsply Sirona you are well versed in all matters relating to CEREC. How import- ant has the system become for the company? Dr Stähler: Dentsply Sirona and CEREC have been in- separably linked for many years. In 1985, when CEREC was launched, digitalisation in dentistry was still in its infancy, and scepticism and reservations about it were prevalent. As a company, however, Dentsply Sirona always believed in this idea and demonstrated its perseverance from the very beginning. Engineers from our company were in constant exchange with Prof. Mörmann and Dr Brandestini, and with CEREC users. Together, the parties continued to develop the system and to set new standards in digital dentistry. Today, the system is mature, and the quality of the clini- cal results are unquestionable. CEREC has had a huge impact on us as a company and continues to do so. Digital is now part of our DNA: we think, we act, and we live digitally. How would you describe the current significance of CEREC in dentistry? Dr Stähler: CEREC, as a system, is a fixed force in the market. The all-new CEREC includes Primescan and the CEREC Primemill, and it is now easier for an even wider circle of practitioners to decide how this modern digital technology can be used quickly and economically in individual dental practices. The individual components of CEREC, including the scan, the software, the milling and grinding machine and the material block, are optimally coordinated to provide a seamless workflow. Digital chairside dentistry is now faster, easier and more reliable than ever before. It has reached a new level of quality, and this provides for a noticeably more comfortable treatment experience for the patient. The use of 3D scanners is increasing dramatically. Where does the Primescan fit into the CEREC system? Dr Stähler: We developed intra-oral scanning in the context of CEREC and, by doing so, established a market for the technology. Today, we see the use of intra-oral 19 2 2022

interview | Prof. Mörmann: Foremost are the expectations of the patient. Whether he or she needs the perfectly aesthetic blending in of a single anterior tooth or a full rehabilitation of the dentition, the patient wants to have the treatment done with efficiency and the results of the restoration need to be pleasing and clinically and aesthetically dura- ble. Upgrades have led to the perfection and expansion of the application of the CEREC method, and the system itself has also benefited from advancements in technol- ogy. These developments go hand in hand. For example, I expect that the large number of digital CEREC resto- ration designs worldwide could be analysed using artifi- cial intelligence in order to develop assistance systems that would further improve restorative work. Dr Stähler: I agree, and I would add that the driving force behind innovation is the sum of many factors. Dentists and dental technicians wish to treat and care for patients in the best possible way, and our goal is to support them. Our focus on digital technologies has made dental treat- ment more accurate and more pleasant for patients, and it has resulted in workflows in laboratories being safer, more cost-efficient and more predictable. Our success in developing solutions that meet the needs of dentists worldwide is the result of a competitive spirit and talented employees who are committed to product innovation and high-quality service and training. Improv- ing clinical outcomes, workflows and patient satisfaction is a driving force in our daily efforts, and we are continu- ally investigating ways in which we can redefine the limits of what is possible. As you see, it is not just about technology; it is also about attitudes and emotions. What do you think the future holds for digital den- tistry and how will CEREC compete with other advancements, such as 3D printing? Dr Stähler: Digital technologies will always offer benefits. Diagnostics and planning can be implemented in a time- saving manner, and the patient can find out very quickly which treatment options are available and what the results will be. The treatment itself is also faster. The keyword here is single-visit dentistry and, ultimately, this will lead to even greater cost-efficiency for dental practices. The CEREC pro- cedure, which includes digital impressions and chairside manufacturing of restorations, plays an important role in this. A 3D printer could be a useful addition to the portfolio for use in applications in which milling and grinding ma- chines do not always provide an optimum result—such as in the use of composites. I believe that 3D printing is ready to take centre stage; it is ready to become a part of the daily workflow for clinics and laboratories alike. So, watch this space! fectly in digital practices and laboratories. I am certain that 3D printing will be used alongside CEREC for a long time to come and that both technologies will have their specific use cases. Prof. Mörmann: Anyone who is involved with digital technology knows: never say never. Forty years ago, we would never have dreamed of all the things that are now possible with CEREC. In this respect, as we consider the future, all dental professionals can look forward to being part of a very exciting process of development. “Forty years ago, we would never have dreamed of all the things that are now possible with CEREC.” Finally, Prof. Mörmann, what gives you the most satisfaction as the inventor of CEREC? Prof. Mörmann: For me, it is the fact that the method, as it is today, is more fascinating than ever. It has increased the enjoyment of restoring teeth, be it with single inlays, onlays, overlays of any form and size, half and full crowns, endocrowns, veneers, anterior and posterior crowns, tabletops, implant crowns, quadrant treatments, three- and four-unit bridges or complex full-mouth rehabilitations. Restorations are automatically generated with individual biogeneric occlusal morphology using habitual bite or virtual functional registration. Drilling templates can be fabricated. To sum up, CEREC provides dentists with a vast choice of high-tech, highly aesthetic ceramic, hybrid ceramic and composite restorative block materials with suitable strength. Everything runs smoothly, quickly, easily and with high precision: the scanning, the restoration design and the machining. And the result is first fit, at the margins as well as at proximal and occlusal contacts. We are talking about a system that was launched in 1985. To me, this represents an awesome and truly fantastic success, and for this, I would like to thank the developers at Dentsply Sirona! It is wonderful to realise how many colleagues around the world are successfully using CEREC in their practices and providing patients with excellent clinical care. Without a doubt, at age 37, CEREC advances the restorative capabilities of dentists as never before. However, CEREC and 3D-printing technology are not mutually exclusive. They complement each other per- Editorial note: The name CEREC is derived from Chair- side Economical Restoration of Esthetic Ceramics and also from the initial letters of ceramic reconstruction. 21 2 2022

interview | 1 Fig. 1: The zirconia blanks are produced exclusively in Austria. and Zolid Gen-X Multilayer, which, by virtue of their trans- lucency and colour gradients, are used monolithically in a wide variety of ways for fixed dentures, also constituted important innovations (Figs. 3 & 4). The last major innova- tion of the more recent past is surely Zolid DRS, a material that can be sintered in 20 minutes with the aid of the cor- responding sintering furnace, Ceramill Therm DRS. Just the shortening of the sintering time from formerly 8 hours to less than one-sixteenth of that, if nothing else, shows the advances that could be achieved through ongoing development. Prof. Stawarczyk, in the scope of your work as scientific director, you have been involved in the assessment of materials from Amann Girrbach a number of times. Do you remember the beginnings of your expertise on zirconia as well as subsequent developments? Prof. Stawarczyk: Yes, I remember it well: I assessed the first zirconia discs for Amann Girrbach at a very early stage, and I appreciate how much knowledge and work are involved. I’m all the more glad to see how successful zirconia has be- come and what standing Amann Girrbach has achieved today. We have examined almost every zirconia modification of Amann Girrbach at our department and have an excellent knowledge of the materials. Our most recent joint project was the development of a high-speed sintering furnace with appropriate zirconia—which has been on the market since last year. This development was implemented in the scope of a cooperation project funded by Zentrales Innovationsprogramm Mittelstand—a federal programme that aims to foster the innovative capacity of small to medium-sized enterprises—based on the knowledge we had jointly gained over many years. What is your assessment of the future of zirconia in dental applications, and what are the research focuses? Prof. Stawarczyk: Since its introduction, zirconia has been on the dental market as 3Y-TZP material, then since 2015 as 5Y-TZP and since 2017 as 4Y-TZP. Thus, work on the pro- cessing of this material has been ongoing for years. Faster sintering of this material has been achieved while preserv- ing good mechanical properties, thus enabling savings in terms of valuable work time. Through the various modifi- cations, the material has furthermore become more and more enhanced aesthetically. The colouring recipes are continually optimised, and the aesthetic aspect is always compared to that of silicate ceramics. The various mod- ifications are increasingly combined within a blank in order to achieve good aesthetics along with high-quality mechanical properties. At the moment, in my opinion, the focus is on considering the system as a whole, which also includes the CAD/CAM processing and the positioning of the discs in the software. All in all, innovators are seeking to automatise processes more and more and to employ artificial intelligence in this field as well. 23 2 2022

E U E W N E N V H Y B R ID THE LEADING DENTAL EXHIBITION AND CONFERENCE IN ASIA PACIFIC NEW DATES: 7-9 OCTOBER 2022 MARINA BAY SANDS SINGAPORE www.idem-singapore.com Connect with us Endorsed by Supported by Held in Organised by IDEM Singapore IDEM Singapore idem.sg @IDEMSingapore Singapore Dental Assocation

case report | 4 6 8 5 7 9 Fig. 4: Bar with individualised gingival areas. Fig. 5: Placement of the central incisor crowns on the bar. Fig. 6: Occlusal screw access hole in the finished overdenture. Fig. 7: Overdenture ready for try-in. Fig. 8: Intra-oral try-in of the aesthetic overdenture. Fig. 9: Final situation. biological complications, the overdenture should not be unbreakable; instead, the replacement of single units should be easily manageable. Owing to an excellent fit on the implants (Fig. 8), it was possible to fix the overdenture with the screws immedi- ately, to close the access holes with composite and then to discharge the patient (Fig. 9). Two-part denture design The solution was a two-part design consisting of a milled bar with a gingival area and tooth abutments (Fig. 1) and of single crowns. The material of choice for the bar was KATANA Zirconia HTML PLUS (Kuraray Noritake Dental), which has a uniform flexural strength of 1,150 MPa throughout the disc, and the single crowns were milled from KATANA Zirconia YML, which offers natural trans- lucency and strength gradation. Whereas a monolithic design was selected for the posterior crowns, the six crowns for the anterior region received a micro-cutback for aesthetic micro-layering with CERABIEN ZR porcelain (Kuraray Noritake Dental). Customisation of the anterior crowns (Fig. 2) was performed with the internal stains Cervical 1, Grayish Blue, Dark Grey and A+. The finish- ing layer on the incisors was created using LT0 materials mainly, as well as some CCV-3 on the cervical area and LT Natural on the mesial and distal lobes. On the canines, LT1 was used instead of LT0. The posterior crowns were merely finished with liquid ceramics (CERABIEN ZR FC Paste Stain, Fig. 3). After checking of the fit of the crowns, the gingival areas of the bar were individualised using CERABIEN ZR tissue porcelain (Fig. 4). Subsequently, the crowns were luted to the zirconia abutments (Fig. 5), leaving screw access holes in aesthetically uncritical positions (Figs. 6 & 7). Conclusion This patient case is a good example of how important it is to respect the patient’s background, age and specific demands when producing dental restorations. Thanks to the great variety of restorative materials with different mechanical and optical properties available, it is possible to create suitable prostheses for virtually every patient. However, for this purpose, it is important to stay up to date regarding new products launched and techniques developed. This way, it is often even possible to create beautiful and durable solutions in a simplified and efficient procedure such as micro-layering on innovative zirconia with a high aesthetic potential. contact Mathias Berger Laboratoire Berger 14 Rue Professeur Deperet 69160 Tassin-la-Demi-Lune France www.berger-ceramiste.com 29 2 2022

Owing to the temporomandibular joint discomfort and compromised residual teeth, care was taken to plan an adequate number and position of dental implants. During the discussion with the master dental technician (MDT), Andrea Rosinski of Dental-Concept Berlin, it was decided to place one implant in region #13, one implant in region #23 and one implant in region #36 to achieve satisfactory function and aesthetics. Consequently, the prosthetic treatment goal was defined with a conventional wax-up and mock-up (Fig. 7). The mock-up helped to manage the patient’s expectations regarding her new smile in close consultation with the MDT. 7 Fig. 7: Conventional mock-up after conventional wax-up using transfer splints and provisional material (Luxatemp Star, DMG). A digital wax-up and mock-up would have been an option; however, a conventional way of working without additional digital equipment was chosen to elaborate the possibilities of combining new and established techniques. Furthermore, the MDT is highly specialised in this type of workflow and the equipment required for a digital wax-up and mock-up was not 8 9 Fig. 8: Digital planning of the implant position in region #23 based on the CBCT scan. Fig. 9: CBCT scan matched with the STL data set of the maxillary situation model (displayed in brown). Matching was done by selecting three corresponding points on the CBCT scan and model data sets. Like in this case, fine adjustments by the implantologist are sometimes necessary. 31 2 2022

case report | 13 15 14 16 Fig. 10: CBCT scan with additionally matched STL data set of the maxillary wax-up (displayed in purple). Scanning the mock-up after minor adaptations would also have been possible. Fig. 11: Alignment in region #23, respecting the imported wax-up data set. A 3.8 × 11.0 mm CAMLOG SCREW-LINE Promote plus implant (CAMLOG) was chosen. Occlusal screw retention was aimed for. The implant and drill sleeve are shown in yellow and the safety cylinder in orange. Fig. 12: Pre-op construction of the drilling guide for fully guided implant placement in regions #13 and 23. The drilling guide is shown in yellow. Fig. 13: Pre-op try-in of the drilling guide. Colour-coded drill sleeves indicate the diameter of the implant to be placed. Fig. 14: Intra-op occlusal view after fully guided implant placement. The occlusal stops of the screw-mounted insertion posts define the final implant position. Trying to insert the implant deeper than planned leads to loss of primary stability and thus should be avoided. Fig. 15: Intra-op occlusal view after removal of the insertion posts and insertion of the respective cover screws. Fig. 16: Panoramic radiograph of the situation with the healing abutments in place. available. This may also represent a problem among practi- tioners broadly regarding implementation of digital workflows. SMOP (Swissmeda; Figs. 8–10). This ensured ideal alignment of the implants regarding function and aesthetics (Fig. 11). Therefore, the first step was digitalisation of the situation model and prosthetic treatment goal. Matching with the CBCT data set was performed in the planning software Subsequently, a drilling guide was designed and deliv- ered by the manufacturer (Fig. 12). Guide sleeves for a fully guided implant placement protocol were inserted. 17 19 18 20 Fig. 17: Intra-oral occlusal view of the upper jaw before impression taking. The impression was taken with an individual tray using the double- thread technique and polyether materials. Fig. 18: Definitive maxillary restorations by Andrea Rosinski. Fig. 19: Intra-oral occlusal view of the lower jaw before impression taking with an individual tray using the double-thread technique and polyether materials. Fig. 20: Bite registration of the lower jaw with the aid of a back bite registration plate attached to the previously restored upper jaw. After fine adjustments, registration was carried out with a registration material (LuxaBite, DMG). 33 2 2022

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case report | 5a 5b Figs. 5a & b: Light-polymerised resin placed over the cleats (a) and additional resin placed over the adjacent teeth (b) to create the diagnostic guide to be utilised during the CBCT scan. is angled too far to the facial aspect, creating restorative challenges in the aesthetic zone. Case 3D evaluation by CBCT provides greater information on the dimensions of the edentulous site to allow implant planning and utilisation of a flapless technique while en- suring that the osteotomy does not create a dehiscence and the implant when placed is surrounded by bone. A guided approach to osteotomy preparation allows a flapless approach for implant placement, making healing for the patient easier and less traumatic. Additionally, an osteotomy is planned that is ideal for the site’s osseous anatomy, simplifying the restorative aspect of treatment and yielding a natural aesthetic end result of replacing the congenitally missing incisor. The article will discuss a case wherein replacement of bilateral congenitally missing lateral incisors was planned utilising a diagnostic guide for a CBCT scan, virtual planning of the implants and correction of the guide for a surgical guide fabricated in-office. The accuracy of this technique has previously been described regarding the accuracy of the geometric approach to guided surgery in an in vitro model.3 A 17-year-old female patient presented for consulta- tion on replacement of the bilateral missing maxillary lateral incisors with implants (Fig. 1). The patient had undergone orthodontic treatment and the roots of the canines and central incisors bilaterally were parallel, providing spacing for possible implant placement. Examination noted that a facial defect on the ridge was present at both lateral sites related to the lack of devel- opment of permanent lateral incisors and loss of the primary lateral incisors prior to orthodontic treatment. Evaluation of the preliminary radiographs confirmed ad- equate space between the roots of the canine and cen- tral incisor to accommodate a narrow-diameter implant while maintaining the recommended distance between the natural root and implant on the mesial and distal sides (Fig. 2). Components of the Guide Right system (DePlaque) would be utilised to create the diagnostic guide to be used for the CBCT scan and the subsequently corrected surgical guide that would be utilised for osteotomy creation (Figs. 3a–c). Preliminary impressions were taken and casts fabricated. 6a 6b 7a 7b Figs. 6a & b: The right lateral incisor site viewed in cross section in the planning software (a). An angle correction of 6° measured in the software was made to the planned implant positioning based on the anatomy (b). Figs. 7a & b: The left lateral incisor site in the tangential view showing that no linear correction was needed (a). Cross- sectional view showing that an angular correction of 6° to the palatal would be required (b). 37 2 2022

case report | 11a 11b Figs. 11a & b: The cleat on both guide sleeves covered in primopattern gel (a) and primotec splint resin adapted to the palatal side of the cast (b). (Fig. 7b). No offset would be necessary on the left site. Like with the bilateral site, because of the facial–palatal width of the ridge at mid-height crestally and apically, ridge augmentation would be required at or prior to the time of surgical placement of the implant. extension on to the buccal aspect of the teeth creates a guide that will be stable intra-orally during osteotomy preparation. The URPs were removed from the cast, allowing removal of the surgical guide from the cast (Fig. 12b). On the cast, an offset guide post (0.5 mm) was placed into the right site and a straight (no offset) guide post placed into the left site (Fig. 8). A URP was placed over both guide posts, and the cast was coated with meta- touch (primotec) to prevent the resin that would be added for fabrication of the surgical guide from adhering to the cast (Fig. 9). A 3.9 mm guide sleeve was placed over both URPs, the cleat positioned to the palatal side of the cast (Fig. 10). Like with fabrication of the diagnostic guide, primopattern gel was placed over the cleat on each guide sleeve (Fig. 11a) and then a 2.5 cm length of primotec splint resin was applied to the palatal side of the cast (Fig. 11b). The splint resin was adapted to the cleats and palatal and occlusal/incisal aspects of the adjacent teeth on the cast to create the surgical guide and then light-polymerised (Fig. 12a). Coverage of the occlusal/incisal aspect of the adjacent teeth with slight The patient presented for the surgical appointment, and the consent forms were reviewed and signed by the patient’s parent. Local anaesthetic was administered to the sites in the buccal vestibule and palatally. A #15 scal- pel blade was utilised to make an incision from the mid- facial aspect of the right central incisor in the sulcus and continued to the mesial aspect of the distal papilla of the canine, and a full-thickness flap was elevated to expose the facial aspect of the ridge at the right lateral incisor site (Fig. 13a). The cortical plate was perforated at multiple points at the facial ridge defect with a surgi- cal bur. An OsteoGen Block (Impladent) was hydrated with the INFUSE XX SMALL KIT (Medtronic), hydrated with 0.7 ml sterile water, divided into halves and placed over each defect on the facial aspect of the ridge (Fig. 13b). OsteoGen is a bioactive, resorbable non-ceramic cal- cium apatite crystal that is similar to human bone and is 12a 12b Figs. 12a & b: The primotec splint resin adapted to the adjacent teeth, covering their occlusal/incisal surfaces to aid in stabilising the surgical guide when inserted intra-orally (a). The light-polymerised surgical guide (b). 39 2 2022

case report | 16a 16b 17a 17b Figs. 16a & b: Radiograph of the direction indicator placed into the right lateral incisor site after use of the initial 1.5–2.2 mm tapered drills (a) and radiograph following implant placement after the healing abutment was inserted on to the implant (b). Figs. 17a & b: Radiograph of the direction indicator placed into the left lateral incisor site after use of the initial 1.5–2.2 mm tapered drills (a) and radiograph following implant placement after the healing abutment was inserted on to the implant (b). Fig. 18: The virtual planned position cross section of the right lateral incisor overlaid on to the cross section of the actual implant placement, demonstrating clinical replication of virtual planning with the surgical guide. Fig. 19: The virtual planned position cross section of the left lateral incisor overlaid on to the cross section of the actual implant placement, demonstrating clinical replication of virtual planning with the surgical guide. contact Dr Sean Meitner graduated from Marquette University in Milwaukee in the US after completing a tour of duty in the US Navy, completed his certificate and board examinations in periodontics at Eastman Institute for Oral Health at the University of Rochester in New York in the US and remains a part-time clinical professor in the Department of Periodontology and Dental Implant Surgery at the university. He has been in private practice in periodontics for more than 30 years in Pittsford in New York and is the developer of the Guide Right protocol. He can be reached at swmeit4@gmail.com. Dr Gregori M. Kurtzman is in private general dental practice in Silver Spring in Maryland in the US. A former assistant clinical professor at the University of Maryland, he has earned fellowships in the Academy of General Dentistry (AGD), American Academy of Implant Prosthodontics, American College of Dentists, International Congress of Oral Implantologists (ICOI), Pierre Fauchard Academy, Association of Dental Implantology and International Academy for Dental-Facial Esthetics; masterships in the AGD and ICOI; and diplomate status in the ICOI and the American Dental Implant Association. He has been listed as one of Dentistry Today’s leaders in continuing education since 2006. He can be reached at dr_kurtzman@maryland-implants.com. 18 19 space that can be coordinated with the osseous anatomy. Corrections can then be made in in-office fabrication of the surgical guide that will be created on the cast used to create the diagnostic guide. Congenitally missing lateral incisors pose challenges due to the limited facial–palatal dimensions of the ridge related to lack of development that would normally occur with tooth development at the site. CBCT planning allows cross-sectional viewing of the intended site to assess whether the width of the ridge will allow implant placement or supplemental grafting will need to be per- formed. Often in lateral sites with congenitally missing teeth, insufficient width is present, and grafting will need to be performed either in conjunction with implant placement or as a precursor to implant site osteotomy preparation. The case presented involved a ridge that would not allow initial implant stability at the sites, necessitating osseous grafting to improve the ridge di- mensions and site healing before implant site prepara- tion could be performed. The corrected surgical guide allowed planning in order to position the implant ideally for the anatomy, taking into consideration the triangle of bone in the premaxilla. Editorial note: A list of references is available from the publisher. 41 2 2022

research | 3 Fig. 3: Factory-related contamination of entire implant threads (Ritter Implants). Full-size SEM image of the implant electronically compiled from hundreds of single images at 500× magnification using the material contrast technique (back-scattered electron mode). to depict details at high magnification without pixelation, up to 600 individual SEM images must be electronically stitched together in high resolution for these comprehen- sive overview images. The resulting SEM image in material contrast provides a detailed overview and allows the quantitative detection of individual particles (Fig. 3). Identification of impurities Energy-dispersive X-ray spectroscopy (EDS) provides information about the exact elemental composition of an impurity and thus provides hints about its origin. When fast electrons hit the sample surface, X-rays are emitted inter alia. The energy of these X-rays is characteristic of each chemical element present in the sample or contam- inant. The energy and the number of X-ray quanta emitted in this way are measured over a defined time and output as an EDS spectrum. Time-of-flight secondary ion mass spectrometry (ToF-SIMS) provides even more precise information about the chemical composition of an impurity. The method provides informa- tion on the atomic and molecular structure of the upper- most monolayers of a substrate on an analysis area of 500 × 500 µm2 with sensitivity in the parts per million range and a lateral resolution of up to 100 nm. Comparison of the spectra with known substances allows precise material determination of the respective contamination (Fig. 4). Too many implants of inferior quality In a study from 2017 to 2020, the CleanImplant Foundation, a non-profit organisation based in Berlin in Germany, ana- lysed sterile-packaged implants from various manufac- turers. In cooperation with Charité—Universitätsmedizin Berlin in Germany, a total of 14 ceramic implant systems and 86 implant systems made of titanium and its alloys were examined under the SEM. The protocol of analysis used in this quality assessment study was published in a 2019 pilot study by Duddeck et al.4 The samples were examined for contaminants under the SEM in a testing laboratory accredited according to the DIN EN ISO/IEC 17025:2018 standard. For the study, the implants were unpacked in a particle-free environment (Class 5 clean room according to the DIN EN ISO 14644-1 standard) and subsequently scanned in the same clean room to exclude any laboratory interference with the test samples. To an unexpected extent, that is, in more than one-third of the samples examined, the analysis revealed factory-related residues and contamination. SEM imaging identified not only carbonaceous contaminants in significant quantities (Fig. 5) but also foreign metals such as chromium, iron, tungsten, nickel, copper and tin. Implants made of titanium and zirconium dioxide were affected, regardless of price, market position, size of the manufacturer or production location. Subsequent to the SEM/EDS analysis, selected contaminated implant samples were additionally exam- ined by a detailed ToF-SIMS analysis. Polysiloxanes, that is, synthetic polymers (Fig. 6), thermoplastics and residues of dodecylbenzene sulphonic acid were found on the implant surfaces. This cytotoxic surface-active chemical is one of the most aggressive components in many cleaning agents and is classified as a hazardous substance. Clinical relevance In particular, organic carbonaceous foreign materials have been associated with initial bone loss or even peri-implantitis in the literature.5 Increased osteoclast activity associated with a possible foreign-body reaction, resulting in peri-implant bone resorption, could be the cause.6 Exposure to foreign particles induces macrophages to secrete tumour necrosis factor-␣, interleukin-1␤, inter- leukin-6 and prostaglandin E2, which in turn stimulates the differentiation of osteoclast precursors into mature osteoclasts. This response would explain clinically striking bone loss during the initial healing phase or the early onset of peri-implantitis. All particles found in the study 43 2 2022

research | Sum of: Ti+, TiO, TiO2 Polysiloxan 6 Fig. 6: Time-of-fl ight secondary ion mass spectrometry detection of polysiloxane on a titanium implant. practitioner: he or she usually does not know whether the implant system of his or her choice has already been contaminated at the factory. This is because information or warnings about possible foreign particles that could cause peri-implantitis or about residues of cleaning agents is not provided on the implant packaging or on the package insert. 7 Fig. 7: Signifi cant plastic material (polyacetal) on the shoulder of a ceramic implant (vitaclinical, VITA Zahnfabrik) from abrasion from the packaging. Unfortunately, implant systems do not have consistent, comparable quality, as summarised in 2020 by Dr Norton, a past president of the Academy of Osseointegration, in an opinion piece in the British Dental Journal that is well worth reading.11 The use of factory-contaminated implants not only may lead to inferior clinical outcomes but also carries the risk of legal implications. The problem of possible factory-related contamination concerns not only implants made of titanium or titanium alloys but also ceramic implants, as scientists from the universities of Gothenburg, Malmö and Berlin impressively described in a study published in 2021.12 The bottom line of the study is that just because the material of ceramic implants is white does not necessarily mean that they are clean (Fig. 7). Suppose a clinician chooses a ceramic implant as a metal-free alternative and it has been demonstrably con- taminated by packaging residues across batches. In that case, he or she is, unwittingly, doing a disservice to pre- cisely those patients who place great value on particularly biocompatible materials in their bodies. In a remarkable article decades ago, Wahl and Tuschewitzki employed an apt term for factory contamination of dental implants: they referred to it as “sterile dirt”.3 Conclusion The placement of foreign metals and packaging residues or cleaning agent residues in the osseous site of an im- plant can lead to an uncontrolled foreign-body reaction, resulting in bone recession and even the loss of implants. Contamination of sterile-packaged dental implants can be largely avoided by the manufacturer. However, if individual manufacturers, when asked, say that they consider the amounts of foreign particles found on their products to be harmless according to their own judgement, it would be appropriate for them either to scientifi cally verify this or to warn users and patients accordingly. Editorial note: List of references is available from the publisher. This article was fi rst published in implants—international magazine of dental implantology, Vol. 23, Issue 2/2022. about Dr Dirk U. Duddeck studied biology and dentistry and specialised in oral implantology. He is a guest researcher at Charité—Universitätsmedizin Berlin and founder and head of the non-profi t organisation CleanImplant Foundation, both in Berlin in Germany. contact Dr Dirk U. Duddeck, +49 30 22187237 duddeck@cleanimplant.org, www.cleanimplant.org 45 2 2022

trends & applications | linked to artistic skills and a deep knowledge of the materials and their specific instruments, such as shade guides. Common do-it-yourself (DIY) strategies have been pro- posed throughout the years, in order to optimise the use of stock shade guides. For example, adding an increment of pink composite gives the shade guide a more realistic context, making the sample look more like a real tooth emerging from the gingiva (Fig. 1). Although this does not solve the core issue of stock shade guides, it slightly helps focus attention on the full tooth. However, this hack has had limited success. Commercial pink shade guide holders of various brands have been proposed to this end, but they are easily fabricated by any clinician with acrylic resin. 3 Another DIY method aiming to optimise stock shade guides and increase shade matching precision is trim- ming of the cervical and incisal portions (Fig. 2), leaving only the area where the shade is more even through- out the surface. This eliminates all distractions in shade matching, as for many people, the translucent mass in the incisal area and the opaquer cervical area are dis- tracting rather than helpful. This area trimming makes the shade samples look more like they are of solid shades. This hack not only has had limited success but also gives rise to other problems, one of which is that the useful area of shade reference, which is the centre of the shade guide, is significantly decreased. Personalised shade guides are easy to self-manufacture using the same materials as those used for the actual intra-oral restoration. These have been proposed as the ultimate solution, but have several problems. The first problem is not related to the shade guide itself but to the end user. Self-fabricating several samples is time- consuming for most users, especially if one considers Fig. 3: Two-layer personalised shade guide. This makes composite layering more predictable, but has limitations and some problems. the high number of sample combinations required for a functional sample set, explaining the success of stan- dard shade guides such as the VITA shade guide, which require little to no handling before use. Making a perfect personalised shade guide (bubble-free, of adequate thickness and of uncontaminated composite) requires skill and experience, regardless of the personalised shade guide system used, to obtain perfect shade cor- respondence with the stock shade guide and to avoid discrepancies with the definitive restoration (Fig. 3). The personalised shade guide tends to be of different thickness compared with that of the actual restoration, changing the real shade and perceived shade greatly, and thus obtaining poor shade matching for both ce- ramic and composite restorations (Fig. 4). Furthermore, personalised shade guides lack context, since there is no gingiva or neighbouring teeth, changing the optical appearance. 4 Fig. 4: Thickness of the personalised shade guide compared with ideal thickness in an intra-oral restoration. The thickness is not matched optimally. 47 2 2022

trends & applications | located in the yellow–red and bright area and is very low on chromaticity, touching the neutral axis in almost all of its spectrum. This space is composed of very light beige pastel colours. Rizzi et al. outlined the human dental colour sub-space.1 They found that the best colour difference formula that behaves the most isotropically and uniformly along all axes of this sub-space was the formula ΔE94.1 For digital colorimetry, knowing the content and boundaries of the dental colour space precisely makes the design of the machinery, calculations of layering and ceramic mixing, calibration of the shade measuring devices and hardware specifications more specific. OPTISHADE StyleItaliano 8 Nowadays, it is easy to determine dental shade in a few seconds with a very compact and portable device, OPTISHADE StyleItaliano (Smile Line), and in an incredi- bly easy way that is not dependent on the clinician’s skills. Learning how to use the device is easy and can be done by the dentist, the assistant or the technician, simplifying the work of every member of the team. The OPTISHADE StyleItaliano colorimeter was launched in 2021 specifically for dental application. It works with Apple devices via an app and can be disinfected (Fig. 9). Its high precision (ΔE94: 0.2–0.4) and accuracy in shade measurement in the L*a*b* and L*C*h colour spaces allow for real-time cross-checking of data with several preloaded shade guides, such as the VITA classical A1–D4 shade guide and VITA Toothguide 3D-MASTER. Fig. 8: When graphically located in the full L*a*b* colour space, the dental colour space looks like a small irregular-shaped bean. In an era in which communication is crucial, this device exploits the complete sharing capability of modern mobile devices. In a matter of seconds, it is possible to measure the shade of a tooth and communicate the shade measurement to others, all with the safety and stability of the Apple platforms. Shade matching by replicating the same scenario When we have an accurate and reliable method for shade matching, we should obtain the same numer- ical values when measuring the same subject. Our task consists of repeating the same scenario for 9 Fig. 9: The OPTISHADE StyleItaliano dental colorimeter provides accurate and precise shade measurements. The external camera attaches to Apple devices. 49 2 2022

trends & applications | 12a 12b 12c 12d Fig. 12: Ceramic layering predictions: desired shade (a), substrate (b), raw restoration (c), restoration integrated with the substrate (d). With these simple parameters, it is possible to repro- duce the scene accurately and obtain a reliable shade measurement (Fig. 10). The user should be able to easily recreate the same scene. When measurements are taken from the same subject, the resulting values must fall under a 0.4 ΔE94 threshold. If measurements with higher values are obtained, it is necessary to analyse what may have gone wrong in the standardisation process, such as the tooth background, device positioning, tooth cleaning or tooth hydration level (Figs. 11a–f). 13 Fig. 13: Obtaining a good shade match for the integrated restoration. 51 2 2022

trends & applications | Substructure Substructure material IPS e.max Press HO 0 Thickness of framework 0.3 mm (cervical area) 0.3 mm (middle area) 0.3 mm (incisal area) Instructions Stain the framework by making changes to red (a*) or yellow (b*) Estimated required staining ∆a* = 1.77; ∆b* = 11.03 (cervical area) ∆a* = 2.28; ∆b* = 7.61 (middle area) ∆a* = 1.09; ∆b* = 1.53 (incisal area) Estimated required staining with VITA Toothguide 3D-Master 2M1 (cercival area) 1M1 (middle area) OM1 (incisal area) Table 1 Dentine receipes Skin enamel (aprismatic enamel) Cervical area IPS e.max Ceram D3 x3 IPS e.max Ceram PB L4 x6 Mamelon salmon x1 Middle area IPS e.max Ceram CT orange x1 IPS e.max Ceram White-blue x1 Incisal area IPS e.max Opal Effect 4 x2 IPS e.max Ceram D C1 x3 Cervical area IPS e.max Ceram Power Incisal 2 Middle area IPS e.max Ceram Power Incisal 3 Incisal area IPS e.max Ceram Power Incisal 3 18 Fig. 18: Shade selection of the different regions in Matisse. In red, the three regions of the desired shade (dentinal shade). In blue, the three regions of the preparation shade. Table 1: Ceramic mixing strategy for a perfect personalised recipe. The numbers in blue indicate the units for mixing, where a unit is the minimal amount of ceramic to be mixed. Units can be large or small as long as all the units are the same. Use of a quality ceramic portioner is recommended. nologies mentioned in this article, besides being precise, are now more user-friendly, allow easy sharing and sav- ing of data, are more universal and do not require any hardware updates. clinical case, the crown on implant #11 had failed me- chanically and aesthetically (Fig. 14a). The ideal situation for such a case is to restore it in a single try, without the technician ever seeing the patient and of course avoiding any kind of repetition. This can be achieved by provid- ing the OPTISHADE measurements of the desired shade and the stump shade (Fig. 14b). The desired shade in this case was found in the neighbouring tooth. It is important to have the measurement done with the temporary restoration seated and the tooth perfectly hydrated (Fig. 15). The shade of the maxillary lateral incisor was also measured (Fig. 16). The teeth in the same arch might look similar or even identical, but they are generally of different shades. The shade of the stump has to be taken into consideration, using an individual measurement that is included in the calculations for the restoration (Fig. 17). The OPTISHADE shade measurements are uploaded to Matisse, and these, along with the type of restoration, are crucial for planning a perfect raw restoration (Fig. 18). Thereafter, the ceramic is mixed according to a perfect personalised recipe provided by Matisse (Table 1). The definitive crown showed very good integration (Fig. 19). This was achieved in only one attempt. 19 Fig. 19: Definitive crown. contact Conclusion Digital shade determination removes the subjectivity of the eye. As long as the measurement is correctly taken, the colorimeter cannot be fooled like the human eye can. Communication using numbers is the most precise way to define a shade. With precise data, we can calculate ceramic mixing, layering and much more. The new tech- Prof. Angelo Putignano is currently head of the department of restorative dentistry and endodontics and dean of the school of dentistry at the Università Politecnica delle Marche in Ancona in Italy. He is a co-founder of the StyleItaliano community. He can be contacted at: infocourses@styleitaliano.com. 53 2 2022

m o c . k c o t s r e t t u h S / k n n e c o P l i i practice management | t r e b o R © Using the technology goes far beyond just an impression replacement when you look at the ROI calculator, but even if the dentist is only focused on acquiring the TRIOS as an impression replacement, it can be asserted that buying a TRIOS will save him or her money. My experience with offsetting costs when purchasing my dental 3D scanner In my one-dentist clinic, I was spending about US$500 or US$600 a month on polyvinyl impression material prior to buying a scanner. When I bought my first scanner, the TRIOS 2, I think the payment on the scanner was US$700 or US$800 a month. Thus, there was already a cost offset from not having to buy the polyvinyl (Fig. 1). A dentist con- sidering acquiring the technology has to figure out what it is going to cost per month, because most dentists are going to finance it through their reseller. The subscription cost also needs to be added on top of that. In some cases, the dentist may be spending a few dollars more on his or her TRIOS investment, initially at least. How- ever, this does not consider the cost savings of the time ben- efits that I mentioned, the savings from utilising the team with greater efficiency, rather than spending payroll on a team member pouring models and making UPS labels and things like that. When the dentist first introduces the scanner, it is almost a one-to-one transfer, and I do not think it will cost the dentist any extra to move to this technology, but then as he or she really starts utilising it and leveraging the other tools that are included, that is when he or she will really start to see many of the advancements and the savings—the true ROI. The time you spend as a dentist is a key cost factor If I was looking at this afresh, it would be difficult to imagine that buying this piece of technology would save me US$100,000, US$200,000, US$300,000. However, from the experience that I have had, I know that it has saved me money and that it has helped grow my practice and my reputation in the dental community. How my team adjusted to the new impression technology My dental assistant is over 60, and she has been in dental assisting for 40 years. She was able to pick up this tech- nology within the first couple of months. She manages the calibration and the 3Shape Dental Desktop platform, she handles the management of case orders on a daily basis, and she can copy and edit orders and things like this. She was able to learn how to use the system, and she is a more experienced person with a vast analogue background. It is very easy to use and share data. When patients come in, we will take the smile design photographs, and I will bring these into TRIOS Smile Design and see whether the gingival levels are where we want them or see whether the crowns are where we want them. I take screenshots of this or short videos and send these to the orthodontist. The orthodontist is always pleased with the level of data I provide and with the level of communication with patients enabled by this technology. about Dr Naren Rajan, who graduated with honours from Rutgers School of Dental Medicine in Newark in New Jersey in the US, is a leader in the education of digital techniques in dentistry and lectures nationally on the topic. In practice for over 15 years, Dr Rajan focuses on incorporating digital techniques into all aspects of general practice. He believes in fi nding the best combination of traditional techniques and cutting-edge advancements to improve patient outcomes. 55 2 2022

industry report | 3 4 Figs. 3 & 4: The LED ring shows the scanning and connection status. to fabricate crown and bridge restorations within my clinic with no accuracy problems. The institute tests all scanners on the market and com- pares scans of the same tooth preparation using different scanners. We could not see a significant deviation in ac- curacy when comparing scans taken using Aoralscan 3 to those taken with other IOSs and even a laboratory scanner (using Geomagic Control software). However, there is a clear difference in the detail of the rendered colour scan. The Aoralscan 3 scans are a little less detailed. It is not the worst colour scan rendering we have seen, but it is also not the highest quality (Figs. 7–10). None of this colour data is used in the manufacture of a crown though. The colour rendering is just a nice way to see the scan in a more realistic way and see the gingiva and margins rather than in a single colour. Overall Aoralscan 3 performs very well for various indica- tions, including single crowns, implant scans, edentulous sites and deep preparations (Figs. 11 & 12). We tested full arches, quadrants, metals and edentulous areas, and it did a good job regardless. It also has a 22 mm scanning depth, which can be useful for scanning narrow or deep spaces. Using the scanner properly and controlling the scanning field correctly will result in a good scan. Poor usage will result in poor scans. Just like any other scanner, the operator is the key. One nice workflow feature we liked was that, as soon as the user finishes the bite registration (which is very quickly aligned by the software), the scanner automatically shows a heat map of the occlusion without having to click on a menu. This is very useful and is a great workflow improvement over other IOSs. Software The scanning image fabricated by the Aoralscan 3 soft- ware has a realistic but not lifelike appearance. The scans typically have quite high exposure, even when brightness calibration is carried out, and translucent areas (incisal edges) appear grey sometimes. After a refinement phase of the workflow, the scans are processed. After process- ing, some artefacts are taken care of by the software, and the final images look more realistic. The software that runs Aoralscan 3 is called Dental Launcher. The program is installed by running the app on the USB flash drive with the scanner. The Aoralscan 3 software is easily the best out of all Chinese scanners tested by the institute so far. Frankly, it is better than many scanners on the market. It is very impressive for an affordable IOS. 5 6 Figs. 5 & 6: Examples of scans taken with Aoralscan 3. 57 2 2022

industry report | 11 12 Figs. 11 & 12: Aoralscan 3 handles arches, edentulous sites and metals well. SHINING 3D provides fully fledged cloud-based storage for scans. The user can send cases to anyone with an Aoralscan 3 cloud account. Everything is stored locally, and it is up to the user to move it to the cloud manually. Furthermore, this is the only Chinese scanner that has incorporated multiple scanner apps into the software— a model builder, orthodontic simulator and oral health report—a unique innovation. No other low-cost scanner has this line-up of apps. Orthodontic simulation As many already know, orthodontic simulators create an orthodontic alignment animation after the user has taken full-arch scans. Orthodontic simulation is a fantastic addi- tion to the SHINING 3D software. I am surprised that such a low-cost scanner has this app, as most do not. In fact, most scanners double or triple the cost of Aoralscan 3. The Carestream Dental, Medit, TRIOS and iTero scanners have such simulators. Typically these simulators can be a little hit and miss, but the SHINING 3D version seems to do well. This version is like the Medit ortho simulator but easier to use, requiring just a few clicks and making the entire workflow intuitive. It does have fewer features, however. automated, providing accurate automatic tooth segmen- tation, which was done close to perfect every time we tested it (Figs. 16 & 17). I was most impressed by the tooth set-up carried out automatically as the AI aligned the teeth. The orthodontic simulator even picks up missing teeth cor- rectly, and any refinements needed are done easily. The orthodontic simulator is interactive, but it does not have fully fledged modification tools, because it is intended as a communication tool. The simulations look great and are a powerful motivation tool for patients interested in orthodontic treatment, including aligners—a great addition to the software. Model builder The Aoralscan 3 model builder app, which is called AccuDesign, is another excellent addition to the software (Figs. 18 & 19). It allows the user to quickly and easily design printable 3D models from the scans within a few clicks—fitting for a company that also sells 3D printers. These model files can be created from any scan and are ready for printing. This software is not unique to Aoralscan 3, as a model builder app comes with many scanners, such as Medit i700, iTero, TRIOS and those of Carestream Dental, but Aoralscan 3 is significantly more affordable than those scanners. The Aoralscan 3 ortho simulator is fantastic for what it is. It is a communication tool that works very well and is highly This model builder software is easy to use. Within two to three clicks, the user can have a perfectly printable model. 13 14 Figs. 13 & 14: A number of tools are included, such as undercut analysis and margin tools. 59 2 2022

industry report | component. It is impressive to see these software apps done so well in a low-cost Chinese IOS. Ease of use As with almost every scanner on the market these days, the Aoralscan software does very well at making the workflow straightforward. Ease of use comes from the software that sup- ports the hardware. Overall the software has a level of polish not typically seen in Chinese scanners and is well thought out. Everything works very well, from creating cases and send- ing them to the multiple scanner apps. When using the scanner daily, the workflow is intuitive (Fig. 20). It follows a simple step-by-step progression that is identical for almost every scanner on the market. Anyone familiar with typical intra- oral scanning strategies will be able to use this scanner. The software also presents several on-screen tips during the workflow to help the user learn to scan and perform the workflow correctly (Fig. 21). Overall, it is an excellent scanning experience, especially for beginners. Open or closed architecture Aoralscan 3 is an open-architecture scanner, and the software enables easy export of scans in different formats, including STL, PLY, OBJ and exocad file types. The user will primarily use STL, the most widely accepted scanning for- mat across laboratories and software. One key distinction is that the STL file is not a colour file. Although the scanner scans in colour, the user designs on a monochrome model when exporting in STL and opening in design software. PLY and OBJ files include colour details, and it is great to see these being offered as an export option. The software makes exporting scans straightforward from both the soft- ware and the cloud. Exporting of scans in different file types is done automatically once the case has been completed (Fig. 22). This is stored locally with several additional files. Price 20 21 22 Fig. 20: The software is easy to use and has clear and intuitive buttons. Fig. 21: Scanning tips and tricks pop up throughout the workflow. Fig. 22: Exporting is simple and easy to do after scanning. production quality. It does not feel like a cheap product and is impressive for the cost. It is a very well-performing scanner with great software for under US$11,000. For the full review, please visit https://instituteofdigitaldentistry.com/ ios-reviews/aoralscan-3-scanner-review-the-latest-ios-by-shining-3d. Aoralscan 3 is one of the most affordable scanners. Its recom- mended retail price is US$10,999, but may vary slightly accord- ing to local tax policies and other factors. Prospective buyers are thus advised to check with their local distributor or reseller. about An ongoing cost to be considered is that of the scan- ning heads. Aoralscan 3 has removable and autoclavable scanning heads, providing ideal cross-infection control. This feature has become the norm across the IOS market. The autoclavable scanning heads have a limit of 100 auto- clave cycles at 134 °C, after which they will need to be replaced. Dr Ahmad al-Hassiny is a global leader in digital dentistry and intra-oral scanners, carrying out lectures as a key opinion leader for many companies and industry. He is one of the few in the world who owns and has tested all mainstream scanners and CAD/CAM systems in his clinic. Dr al-Hassiny is also the director of the Institute of In summary, although Aoralscan 3 is an entry-level scanner, it is very impressive. The scanner as a whole has good Digital Dentistry, a world-leading digital dentistry education provider with a mission to ensure dentists globally have easy and affordable access to the best digital dentistry training possible. 61 2 2022

Welcome to IXS™ Scan eXam™ Scan eXam™ One Focus™ OP 3D™ OP 3D™ Pro OP 3D™ Vision Carestream Dental (CS 3600, CS 3700, CS 3800) Until recently, our customers knew us under the brand name KaVo Imaging. KaVo Imaging stands for products and software that have been developed for the most demanding users. Decades of experience from manufacturers such as Gendex, Soredex and Instrumentarium have been combined in this brand. We are very proud that this strong portfolio has been expanded and starts to operate under the DEXIS™ name. DEXIS was found in the mid-1990s by Dr. Manfred Pfeiffer, a German engineer and programmer, who knew that digital x-rays would be the future of dentistry. The DEXIS brand has been the world market leader in the field of digital intraoral X-rays for over 20 years. Today, DEXIS offers a wide range of award-winning digital solutions, from intraoral sensor technology to CBCT and intraoral scanners. Moreover, our products are integrated in our high-end software DTX Studio™ Suite, unifying 2D/3D imaging, diagnostics and planning. dexis.com Discover how DEXIS delivers for you

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