issn 2193-4673 • Vol. 4 • Issue 3/2023 3/23 digital international magazine of digital dentistry research Immediate or delayed loading in the fully edentulous maxilla case report An aesthetic, minimally invasive restoration using a fully digital workflow opinion How to master intra-oral scanning

editorial | Dr Scott D. Ganz Editor-in-Chief Have you noticed? Have you noticed changes in your everyday world since the pandemic? Has the practice of dentistry changed in your region of the world? Have you instituted new protocols for safety or sterilisation or added additional protective equipment for patients and staff? Have you taken extra continuing education courses which deal specifically with pandemic-related issues? The pandemic has had a great impact on the world of dentistry, and it appears that the actual impact differs greatly depending on where you practise. One area that has affected many in the US is the hiring of employees, including front desk personnel, dental assistants, dental hygienists and dental laboratory technicians. This may hold true for urban or suburban areas, where finding the right employee at the right salary can be a difficult task. In many instances, staff will require specific training to learn new skills or to enhance existing ones. This training is an investment for the practice. When there is a shortage of staffing, all aspects of the clinical practice can be affected, and perhaps we have overlooked the impact on the digital workflows that now play a major role in the treatment of patients. When we think of the current digital workflow for any type of dental practice, who is responsible for completing the necessary tasks? Who has been designated for taking intra-oral scans, CBCT scans and digital radiographs and for managing the resin tanks for the 3D printer? Usually, it is not the clinician but one of the trained staff. Is this a serious problem? Ask Dr Roger Levin, one of the most well-known practice management consultants. In an article published in February in Dental Economics, he was quoted as stating: “It’s no secret that dentistry has been dealing with an unprecedented staffing short- age for the past several years, and its effect has been widespread.” “For the first time in dental history,” said Dr Levin, “we are noting numerous practices that have lower production and revenue because they cannot properly staff or hire skilled staff members.” While we at Dental Tribune International continue to present state-of-the-art procedures, protocols and digital technology within our pages, we must also be aware of what is happening within our chosen industry which may have a direct impact on maintaining high standards of patient care and overall practice success. Please enjoy the latest issue of digital. We welcome your comments. Respectfully submitted, Dr Scott D. Ganz Editor-in-Chief 03 3 2023

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Study uses artifi cial intelligence for gingivitis detection By Iveta Ramonaite, Dental Tribune International The applications of artificial intelligence (AI) in dentistry have been widely explored in recent years. However, a recent study is one of the first to employ AI to detect gingivitis, enabling monitoring of the effectiveness of patients’ plaque control. The technology has the potential for improving the early detection and prevention of oral and systemic diseases associated with periodontal disease. In the study, the researchers trained and tested a novel AI model on a data set of over 567 intra-oral photographs of gingiva with varying degrees of inflammation. They found that the AI algorithm can accurately (> 90%) analyse patients’ intra-oral photographs to detect signs of inflammation, such as redness, swelling and bleeding along the gingival margin. pain when their teeth are at the end stage of dental disease, in which tooth loss is inevitable, and only expensive rehabilitative treatments are available.” According to Dr Reinhard Chun-Wang Chau, a clinical research coordinator in restorative dental sciences at the University of Hong Kong, using intra-oral photographs in conjunction with AI technology could allow patients to see which areas they had not cleaned well and seek dental care earlier. The researchers now plan to make the technology accessible to elderly and underserved communities to improve their oral health outcomes and reduce healthcare disparities. Lead researcher Dr Walter Yu-Hang Lam, a clinical assistant professor in prosthodontics at the University of Hong Kong, commented: “Many patients […] only seek dentists to alleviate Editorial note: The study, titled “Accuracy of artificial intelligence-based photographic detection of gingivitis”, was published on 26 April 2023 in the International Dental Journal, ahead of inclusion in an issue. news | m o c . k c o t s r e t t u h S / i Z a t e v S © AD A great scan is just the beginning From TRIOS to patient outcome. Unite everything in between. 3Shape TRIOS gives you accurate scans and an unparalleled scanning experience. 3Shape Unite is the workflow engine that unlocks a world of possibilities with your scan. Learn more at www.3shape.com/unite

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DISCOVER DIGITAL WORKFLOWS at the Zurich Digital Days, Nobel Biocare Dental Experience Center HANDS-ON TRAINING FOR S-ON TRAINING FOR ATADATA DIAGNOSIS DIAGNOSIS DESIGN DESIGN DELIVERY DELIVERY EXPERIENCE DIGITAL SOLUTIONS INCLUDING: Ϩ Dexis™ IOS Ϩ DTX Studio™ ecosystem Ϩ X-Guide™ dynamic navigation Ϩ Sprintray™ 3D printer DISCOVER THE DATES AND REGISTER NOW GMT 85991 GB 2308 © Nobel Biocare Services AG, 2023. All rights reserved. Nobel Biocare, the Nobel Biocare logotype and all other trademarks are, if nothing else is stated or is evident from the con- text in a certain case, trademarks of Nobel Biocare. Please refer to nobelbiocare.com/trademarks for more information.

industry news | CleanImplant “Trusted Quality” seal – Five-step approach STEP 1 Neutral sampling of five implants Batch-spanning random sampling: Three implants are ordered ex factory, and two implants of the same type are purchased via mystery shopping from practices. STEP 2 Unpacking and scanning under clean room conditions All five collected samples are carefully unboxed, mounted and scanned in a clean room environment according to Class 100 FED-STD-209E and Class 5 DIN EN ISO 14644-1. STEP 3 Externally audited process of analysis Scanning electron microscope (SEM) imaging and elemental analysis (energy-dispersive X-ray spectroscopy) are performed according to the DIN EN ISO/IEC 17025 accreditation process (competence of testing and calibration laboratories). The independent test laboratories are regularly monitored in external audits by the accreditation body. STEP 4 Full-size and high-resolution SEM images A special full-size, high-resolution SEM image—digitally composed of more than 360 single SEM images at 500× magnification—always shows the implant surface from shoulder to apex. STEP 5 Peer-review process Two members of the scientific advisory board independently review the comprehensive analysis report and sufficient clinical documentation or multi-annual Post-Market Clinical Follow-Up studies of the analysed implant system showing survival rates of > 95% for the device or device family. Fig. 1: Dr Dirk Duddeck placing an implant on the sample holder of the scanning electron microscope. Fig. 2: Implant sample on the sample holder of the scanning electron microscope. (All images: © CleanImplant Foundation) Table 1: CleanImplant five-step approach. “This award is an objectively transparent proof that col- leagues are using a residue-free implant system for their patients by manufacturers who have implemented the highest-quality standards,” explained Dr Dirk Duddeck, founder and head of research at CleanImplant. To obtain this valid, objective proof, a five-step approach was es- tablished in cooperation with the eight-member scientific advisory board (Table 1). Every award of the quality seal is valid only for two years and has to be renewed after this period. Currently, the following implant systems also carry the “Trusted Quality” seal: Kontact S (Biotech Dental), whiteSKY (bredent group), UnicCa (BTI Biotechnology Institute), (R)Evolution and Patent/BioWin! (Champions- Implants), In-Kone (Global D), ICX-PREMIUM (medentis medical), AnyRidge and BLUEDIAMOND IMPLANT (MegaGen), T6 (NucleOSS), Prama (Sweden & Martina), and SDS1.2 and SDS2.2 (Swiss Dental Solutions). Other testing and analysis results are pending. In addition, the contract manufacturers of ceramic implants, CeramTec Group and Komet Custom Made, received the CleanImplant Certified Production Quality Award. “This award is an objectively transparent proof that colleagues are using a residue-free implant system for their patients.” CleanImplant will be present at the 2023 joint con- gress of the European Association for Osseointegra- tion and German Association of Oral Implantology in Berlin in Germany (booth #C06), where dentists will have the opportunity to check dental implants for cleanliness under a scanning electron microscope on-site. contact More and more dentists are supporting the CleanImplant Foundation. Certified by CleanImplant, they pass on the trust they have gained in the products to their patients and referring dentists. CleanImplant Foundation CIF Berlin, Germany www.cleanimplant.org 15 3 2023

While the McGill consensus statement recommends an overdenture on two implants for the mandible, there is no established consensus for the maxilla. This is due to the heterogeneity of results and the difficulty of conducting systematic reviews on the subject. However, Malò et al. have pushed the clinical boundaries of maxillary implant treatment with the All-on-x procedure (Fig. 3), which is demanding but effective and satisfying for patients.4 Digital workflows have also improved surgical protocols through static guides and dynamic navigation (Fig. 4). Static guides involve planning the implant position in software and reproducing it in a surgical guide, while dynamic navigation allows for real-time adjustments based on CBCT imaging during surgery, providing greater precision.5 Prosthetic steps Brånemark initially recommended allowing several months for implants to heal, but current literature supports the possibility of immediate loading, whether for a single implant or multiple implants in the maxilla or mandible (Fig. 5). Research has validated immediate loading in fully edentulous maxillae, whether using conventional or zy- gomatic implants, with high success rates. However, cer- tain conditions need to be considered.3 This accelerated-care approach has prevented patients from experiencing disabling edentulism and has been shown to improve their overall satisfaction and oral health- related quality of life. Studies have found that implant- supported overdentures can improve the general well- being of edentulous patients and that fixed implant pros- theses are even more effective (Fig. 6).1 The effectiveness of immediate loading of implants is comparable to that of delayed loading, although the evi- dence is not strong enough to make a definitive clinical recommendation. Studies have shown that there is no statistically significant difference in survival rates be- tween immediate and delayed loading of implants and prostheses.6 However, it is worth noting that early implant failure in the maxilla is quite common, half of the failing implants being lost within the first six months. This is often attributed to poor bone quality of the maxilla.2 Patients may be more satisfied with a functional fixed prosthesis regardless of the time of loading, but there is limited evidence to support this. Prosthesis instability may also contribute to differences in loading times. For exam- ple, one study showed no difference in patient satisfac- tion between immediate and delayed loading after three Fig. 3: All-on-4 and All-on-6 prostheses. Fig. 4: Surgical guide and dynamic navigation. 3 4 research | 17 3 2023

case report | 5 6a 6b Fig. 5: Intra-oral view of the mandible showing the partial edentulism and stickers with radiopaque beads. Figs. 6a & b: Implant planning with DTX Studio Implant (a). The vestibular-lingual view highlights the benefits of the radiopaque beads on the stickers for the good combination of DICOM and STL data (b). residual mandibular teeth (Figs. 1 & 2). After clinical and radiographic examination (Figs. 3 & 4), the de- cision to perform a full-mouth fixed rehabilitation with implants was made in agreement with the patient. The combination of DICOM and STL data in the con- text of full or partial edentulism is complicated by the lack of reliable fixed reference points. The solution is to place stickers with radiopaque beads. These beads can be identified both radiographically by their opac- ity and on the optical impression by their volume. This facilitates the combination of the data (Fig. 5). During the planning of implant treatment, DTX Studio Implant software was used (Fig. 6). It was decided to place four implants. The prosthetic design (previously validated in the mouth) can also be digitised in an STP file, and therefore, it can be combined with the STL file of the initial situation. This makes it possible to show the prosthetic design on the bone data, making the planning more functional and biological. At the same time, it is possible to trans- form this prosthetic plan into a provisional prosthesis (DTX Studio Lab) adapted to the planning (perforation of the prosthesis adjacent to the position of the future implants and abutments). This prosthesis had four rods at the level of the intrados for insertion into the bone. After drilling with dynamic navigation (X-Guide, X-Nav Technologies), they enable the prosthesis to be posi- tioned correctly (Fig. 7). The provisional prosthesis was prepared from PMMA and made up with pink composite resin to simulate the gingiva (Fig. 8). 7 Fig. 7: Design of the prosthesis. 21 3 2023

case report | 12 13 Fig. 12: The provisional prosthesis placed on the temporary abutments. Fig. 13: The provisional prosthesis in situ. planning. It offers a visualisation technique for CBCT images of the patient. In addition, 2D image data such as photographic images, radiographic images and sur- face scans may be visualised to bring diagnostic im- age data together. Prosthetic information can be added and visualised to support prosthetic implant planning. For a guided surgery plan, the software can be used for a variety of integrated options: static pilot guides, fully guided surgery or dynamic navigation. The surgical plan, including the implant positions and the prosthetic information, can be exported for the design of dental restorations in DTX Studio Lab. DTX Studio Lab integrates CAD software to render the digital design of a dental restoration. The resulting out- put file of the design can be used for either centralised or localised manufacturing. X-Guide is a dynamic navigation system for 3D real-time guidance of drill positioning with no surgical guide. It is designed to improve the precision and accuracy of the position, angle and depth of the implant. Refer- ence points are tracked and displayed in real time via two cameras that are positioned 60–80 cm above the patient. The display guides the surgeon in drilling in the location according to the DTX Studio Implant plan. Virtual registration of the patient’s anatomy can be done with the X-Mark protocol, meaning no CBCT marker is required for the scan. Three points are marked on the CBCT rendering in X-Guide, and the same three points are marked in the patient’s mouth with a probe tool. For edentulous cases, the EDX patient tracker arm is attached to the patient and clears the lip, and does not interfere during surgery. It is suitable for both flapped and flapless surgery, and different arm designs are available based on the surgeon’s hand- edness. Studies have confirmed better accuracy and less devi- ation from the planned implant positioning, compared with freehand surgery.1, 2 Compared with other tested dynamic systems, X-Guide is three to four times more accurate.3 14 Fig. 14: Radiograph control after placement of the provisional prosthesis. The N1 implant system is suitable for all indications in all bone types and for immediate function and fully digital workflows. It enables productivity and predict- ability through a faster surgical protocol, including site preparation that is less traumatic. Editorial note: This clinical case originally ap- peared in May 2023 in CLINIC No 425, and an edited version is provided here with permission from IS Media/1Healthmedia. Please scan this QR code for the list of references. about Dr Renaud Noharet graduated with a DDS from the Claude Bernard Lyon 1 University in France and holds various university diplomas and certificates of specialised studies in implantology and prosthetics. He is an international lecturer and has a private practice in Lyon focused on implantology and the overall rehabilitation of patients. He is the founder of DCO France Prothèse training institutes. 23 3 2023

case report | Description of the case A 45-year-old female patient attended for restoration of her missing left first molar in the maxilla (Fig. 1a). The patient had no history of smoking or alcohol con- sumption at the time of treatment and did not have any medical conditions that would affect implant therapy. Clinical examination showed a moderate loss of the local buccal convexity and height of the gingival mar- gin (Fig. 1b). The radiographic examination revealed a residual bone height of 5.25–7.10 mm below the maxil- lary sinus (Fig. 1c). These conditions allowed placement of an 8 mm long implant after crestal sinus lift involving osseodensification burs.19 The treatment plan called for restoration of the edentulous site with an implant-supported crown after a one-stage surgery and a transmucosal healing period of ten weeks. The patient signed an informed consent allowing her data to be used for research purposes. Surgical steps After extra-oral disinfection of the surgical site, the patient was instructed to rinse with a 0.12% chlorhexidine solu- tion for 1 minute. Antibiotics were not prescribed either before surgery or afterwards because of the use of laser for local decontamination.20 The osteotomy was prepared according to an osseo- densification crestal sinus lift protocol.19 A 4.2 × 8.0 mm conical connection implant (C1, MIS Implants Technologies) was placed in a slightly sub-crestal position with a 60 Ncm insertion torque. A modified palatal roll flap technique with two intrasulcular incisions involving the adjacent mesial and distal teeth was performed21 with the aim of increas- ing the width of the soft tissue and improving the buc- cal tissue volume. De-epithelialisation was realised with a Er,Cr:YSGG Laser, photon emission at 2.78μm (Waterlase iPlus, BIOLASE) and a gold handpiece with the new Z-type glass MZ6 tip (0.6 × 17.0 mm) using the following parameters: an average output power of 2.5 W, a pulse duration of 60 μs (H-mode), a pulse repetition rate of 50 Hz and a water spray (air: 20%; water: 40%). The graft was rolled under the buccal flap. It was allowed to heal standing against a 4.8 × 4.0 mm anodised concave healing abutment affixed to the implant. The flap was repositioned buccally and sutured with two simple interrupted sutures (5/0 GLYCOLON, Resorba Medical) on the mesial and distal sides. Primary closure of the occlusal gingiva was not intended. The monofilament sutures were removed after five days to promote a healing process of secondary intention. Ten weeks after surgery, the patient returned for an osseointegration check of the implant (Fig. 2a). The usual clinical and radiographic examinations were performed, and it was found that the graft had healed uneventfully 2a 2b 2c 2d 2e 2f Figs. 2a–f: Restoration of the edentulous site. Occlusal view of the implant site with the healing abutment in place at the end of the healing period (a). Health of the soft tissue after removal of the healing abutment (b). Buccal (c) and palatal view (d) of the marginal gingiva at prosthesis delivery. Note the gingival bleaching due to compression by the crown. Buccal (e) and palatal view (f) of the gingiva after relaxation of the bleaching. 25 3 2023

case report | Prosthetic steps The healing abutment was removed to check the health of the gingiva (Fig. 2b) and start the prosthetic steps. An IOS (TRIOS 4, 3Shape) was taken with a scan body affixed to the neck of the implant. The STL file was sent to the dental laboratory for CAD/CAM processing. A monolithic zirconia crown was milled (Roland DGA) and prepared based on the digital design. The crown was cemented on a 1.5 mm high titanium base (Ti-Base; MIS Implants Technologies). The crown with the Ti-Base was screwed in by applying the 30 Ncm torque recommended by the manufacturer. Pressure of the crown on the gingival margin provoked a transient buccal and palatal bleaching (Figs. 2c–f). Merging procedures Before surgery, a CBCT scan was obtained to analyse the local bone features and determine the various anatomical obstacles to be aware of. IOSs were subsequently taken at the various milestones: – before surgery (IOS #0); – at the end of the healing period with the healing abut- ment in place (IOS #1); and – at prosthesis delivery, after pressure on the gingival margin had resolved (IOS #2). The digital merging involved the STL files of the healing abutment, the prosthetic abutment and the crown. These were provided by the manufacturer and the dental labo- ratory, respectively. The digital superimposition sequence was performed with exoplan software (exocad). The mere merging of IOSs, as reported by other authors,6, 7 does not enable measurement of the dimensions of the peri-implant soft tissue (Fig. 3). It is only after merging the IOSs with the STL file of each implant-related component that the height and width dimensions of the gingiva can be read.16–18 First, IOS #0 was merged with the CBCT scan and then with IOS #1 (Fig. 4a). At this stage, the STL file of the healing abut- ment was then merged with these (Fig. 4b). The implant was then added to the file, and the shape of the gingival margin, including the gingival seal, was identified (Fig. 4c). The super- imposition enabled measurement of the height and width of the gingiva at the end of the healing period. After prosthesis delivery, IOS #2 was superimposed on the previous set of IOSs. The STL files of the crown, of the Ti-Base and of the implant were then merged sequentially. This super- imposition enables measurement of the dimensions of the peri- implant soft tissue at the time of prosthesis delivery (Fig. 5). Reading of the vertical and horizontal dimensions of the gingiva Before surgery Reading the height of the gingiva at the crest and on the buccal and palatal sides of the abutment was made 6a 6b 6c Figs. 6a–c: Dimensions (mm) of the gingiva at the end of the healing period. Comparison, before surgery (yellow line) and at the end of healing (green line), of the gingival height (GH) measured at the middle of the crest and on the buccal and palatal sides of the healing abutment (a). Measurement of the GH variables—change in GH (∆H) and GH at the level of the implant neck (GHNeck) on the buccal and palatal sides by the end of the soft-tissue healing. The surgical technique did not increase the GH on the buccal side, and GH on the palatal side decreased slightly. Red lines = the limits of the healing abutment (b). Measurement of GW by the end of healing and of the change in gingival width (∆GW) on the buccal side from before surgery until the end of the healing period. GW was measured at 1 mm (GW1mm) and 2 mm (GW2mm) from the gingival margin and at the level of the implant neck (GWNeck) (c). possible by superimposing IOS #0 and IOS #1 on top of the CBCT scan (Fig. 6a). This helped determine the height of the gingiva at the implant site. At the end of the healing period Merging of the STL file of the healing abutment and of the implant with the IOS superimposition set provided access to the gingival height (Fig. 6b) and width (Fig. 6c) at the end of the healing period. The changes in gingi- val height induced by the flap surgery on the buccal and palatal sides were measured by comparing IOS #0 and IOS #1. The gingival height down to the implant neck was also measured on both sides. Similarly, changes in the gingival width at the end of the healing period were followed at various levels of the healing abutment. 27 3 2023

digital protocol that was very recently published16–18 and that cannot be obtained otherwise. The additional clini- cal effort to gain this data is minor: it requires performing three IOSs and obtaining the STL files of the various items from the manufacturer and the dental laboratory. The preoperative gingival height can be read by merging IOS #0 with the CBCT scan.1–3 Determining gingival height during implant planning is important because this variable can affect how deep the implant should be placed sub-crestally without risking the implant neck being insufficiently surrounded by bone.26, 27 The routine way to measure the thickness of the gingiva is with a periodontal probe on the crest of the ridge after flap elevation;26 however, the actual place to determine the thickness is where the biological width (BW) concept applies, that is, at the emergence of the gingival margin in contact with the healing abutment. Szmukler-Moncler et al. showed that determination of the thickness at the crest does not provide an accurate estimate of the gin- gival thickness measured at the buccal and palatal sides of the healing abutment.28 In the present case, the 2.38 mm measured at the crest suggests that the gingiva is thicker than 2 mm and might be classified as thick.26, 29 However, at the place it should be measured, taking into account the biological width concept, the initial gingival heights on the buccal and palatal sides of the abutment are 1.73 mm and 1.41 mm, and therefore the gingiva should be characterised as thin. Consequently, it makes sense to anticipate crestal bone loss down to at least the implant neck in order to achieve acceptable dimensions of the biological width. At the end of the healing period, it appeared that the modified roll technique did not affect the gingival height; however, it did increase the width of the buccal gingiva significantly. The gain in width was 1.84 mm and 1.73 mm at 1.0 mm and 2.0 mm below the gingival margin, re- spectively, and the overall width reached 4.66 mm and 4.87 mm. Today, this digital protocol is the only way to access these clinical variables in a non-invasive way. Placement of the crown instantly and substantially mod- ified the gingival height by 0.70–1.33 mm on the buccal side and by 0.54–1.44 mm on the palatal side. Pressure on the gingiva was clinically evidenced by bleaching of the buccal and palatal gingiva. Again, only this digital methodology is able to provide such a precise insight into the resulting dimensional changes. One can legitimately assume that this compression of the gingiva might lead to a subsequent rearrangement between the compressed soft tissue and the underlying crestal bone and in turn to bone resorption. After delivery of the crown, the digital superimposition showed that part of the width gained by the end of soft-tissue healing by the time-consuming modified palatal roll technique had vanished. case report | Conclusion The inventive step of the present digital methodology consists of merely merging the IOSs that are typically ob- tained6, 7 with the STL files of the various implant-related items.16-18, 28 This single addition brings about an illuminating difference, as it renders the gingiva transparent, enabling reading of the vertical and horizontal dimensions of the peri-implant gingiva and their changes at every level of the abutment and at every stage of the treatment. This is otherwise unattainable in clinical research. Implementation of this digital workflow in clinical research will help refine the data acquired from protocols and techniques of soft-tissue thickening, providing information on not only the tissue thickness that has been gained but also the entire thickness of the gingiva. Please scan this QR code for the list of references. about Dr Ariel Savion holds an MSc in oral implantology from Goethe University in Frankfurt am Main in Germany, an MSc in laser-assisted dentistry from the RWTH Aachen University in Germany and a mastership certificate in laser dentistry from the World Clinical Laser Institute. He is a board-certified diplomate in oral implantology (International Congress of Oral Implantologists), specialises in microsurgical laser therapy and periodontal plastic surgery, and is a board member of the Microscopic Dental Club. He maintains his own private practice in Rishon LeZion in Israel. Dr Savion can be contacted at savion.clinic@gmail.com. Dr Serge Szmukler-Moncler, DDS, PhD, is a director of research at MIS Implants Technologies in Israel. Dr Roni Kolerman, DMD, is a senior lecturer at the Department of Periodontology of the Maurice and Gabriela Goldschleger School of Dental Medicine at Tel Aviv University in Israel. 29 3 2023

case report | 4 5 base in a pink material which is then bonded to a carded denture teeth or a monolithic or segmented printed tooth material arch. Such systems include the Lucitone Digital Print Denture System (Dentsply Sirona) and the SprintRay High Impact Denture Solution. The development of dedicated digital denture design soft- ware was another groundbreaking innovation. In some cases, commercially available software systems were proprietary suites custom-designed for digital denture fabrication (e.g. AvaDent Connect). Elsewhere in the industry, leading companies like Ivoclar use 3Shape-built specialised modules to extend the capacities of pre-existing dentistry design software. The varied benefits of digital dentures The tech industry favours the word “disruption” to describe paradigm-shifting changes in methodologies—and I’ve been guilty of using it myself. Lately, I find it more productive to shift my focus away from how digital dentures destroy old ways of doing work and instead foreground how digital dentures actively benefit clinicians, patients and laboratories alike. The analogue to digital evolution In 1994, the first digital denture study appeared in the International Journal of Prosthodontics.4 The paper introduced a novel process wherein the authors used a laser scanner to take den- ture impressions and 3D-printed a tooth and base contour jig, which allowed a denture to be fabricated using photopolymer- ising resin. While the ideas in the study were groundbreaking, 3D printing at the time was frankly not mature enough for clinical use, so the emerging digital dentures industry focused instead on CAD/CAM milling. A proof of concept detailing a technique for milling a denture duplicate out of wax was pub- lished in the Journal of Oral Rehabilitation in 1997.5 The first commercial digital denture was not produced until 2011—well over a decade later. Global Dental Science designed and fabricated the device, which it marketed as AvaDent Digital Dentures. AvaDent remains as an authority in the current digital denture system market, alongside options from competitors like Ivoclar Vivadent, Dentsply Sirona, SprintRay, VITA Zahnfabrik (Vita Vionic) and Merz Dental (Baltic Denture System).6 Milled denture manufacturers developed and standardised PMMA pucks to place in computer numerical controlled mills. The first milled dentures still involved a significant amount of technical, hands-on work, as fabricators were able to mill the denture base only; they bonded carded denture teeth into the base one by one. Over time, dental laboratories developed improved systems which allowed a full set of teeth to be milled as a single piece. This piece would then be bonded with a separately milled base and returned to the mill for finalisation (Ivoclar’s oversize milling process). Today, the best milled denture systems fabricate one-piece monolithic dentures. 3D printing is now playing a greater role in denture fabrica- tion owing to its already low cost and impressive scalability. In recent years, the development of novel photopolymers and sophisticated fabrication techniques has lowered the cost of entry to this exciting technology significantly, such that it has become a viable option for working laboratories. Today, properly equipped laboratories can print a denture 6 31 3 2023

case report | 10 11a 11b Using traditional methods and materials, reproducing an existing handcrafted denture within acceptable limits— never mind perfectly—is laborious. As I am sure you know, the final quality of an analogue denture is determined largely by the hand–eye coordination and motor dexterity of the person fabricating it. The risks of human error are significant and unavoidable.8 smile and excessive gingival tooth display (Fig. 3). At the approximate desired VDO, the patient showed adequate inter-arch space and exhibited Prosthodontic Diagnostic Index Class 2 edentulous arches.14 After a thorough ex- planation of all treatment options and their objectives and limitations, the patient consented to treatment of the eden- tulous arches utilising a combination of traditional analogue and digital CAD/CAM techniques. Clinical case Clinical record acquisition An 80-year-old male patient presented for prosthodontic evaluation and replacement dentures (Figs. 1a & b). His existing maxillary and mandibular complete dentures were five years old and lacked retention and stability. The periph- eral border extensions of both the maxillary and man- dibular dentures were under-extended, and there was an extensive increase in vertical dimension of occlusion (VDO; Fig. 2). The patient was not pleased with the appear- ance of his dentures, as they displayed a reverse curve The existing dentures were evaluated for VDO, phonetics, aesthetics and peripheral border extensions. The existing dentures presented with under-extended flanges, which were to be captured during initial border moulding of the functional impression technique. If the existing denture is overextended, it is adjusted accordingly prior to taking the impression. It is important to notify the patient that you will be making modifications to the denture. You have the 12a 13a 12b 13b 33 3 2023

case report | 16a 16b 16c Modifications to the monobloc try-in can be conducted, undergo a wash impression, as described in the first step, and be scanned to assure adequate peripheral seal and intaglio adaptation and either sent back to the laboratory or scanned and the scan sent to the laboratory. The reference denture technique in conjunction with digital technology empowers us with a pathway to establishing a protocol with respect to a viable clinical and technical workflow that cohesively form a relationship that renders high satisfaction for clinicians, technicians and most importantly the patient. Manufacture and delivery Manufacture There are various methods of manufacturing digital dentures as mentioned. The Lucitone Digital Print Denture System offers a complete, validated and approved workflow for producing dentures (Figs. 12a–13c). Smart polymers in the base double in strength in response to body temperature with BAM! (body-activated material) technology, providing double the fracture resistance of commercially available den- ture base materials. The SprintRay High Impact Denture Base and High Impact Denture Teeth materials with NanoFusion, a ceramic-infused resin, offer high resistance to fracture and staining and improved colour stability. Delivery The digital complete dentures were inserted and evaluated for efficacy, fit, form and function (Figs. 14a–c). Minimal adjustments to the intaglio surface were necessary when assessed using “Pressure Indicator Paste (white silicone spray; Keystone Industries).” Occlusion, stability and retention were evaluated and determined to provide superior im- provements compared with the initial situation (Figs. 15–17). Oral hygiene instruction and recall maintenance were discussed with the patient. Conclusion Digital denture workflows are effectively infinite in that multiple ways exist to use digital technology for the design and fabrication of removable dentures. This methodology gives both the clinician and the digital technician all the information necessary to fabricate a removable denture predictably. The ability to digitise such a rich data set is still in its infancy with respect to broad adoption; however, this approach is gaining much traction in the industry. 17 about Please scan this QR code for the list of references. Eric D. Kukucka is vice president of Clinical Removable Prosthetics & Design Technologies at ADMI. He is responsible for the efficacy and high standards in the delivery of removable prosthetics. Through innovation, upskilling denture talent, providing scalable solutions and maintaining strong strategic partners throughout the industry to develop procedures that advance removable prosthodontics at Aspen’s 1,000 + locations. An active researcher, educator, author, and key opinion leader, he helped develop protocols materials used by clinicians around the world. 35 3 2023

case report | 5a 5b 6a 6b 4b 4d 4f 7b 7d 8b 3 4a 4c 4e 7a 7c 8a Fig. 3: Digital impression of the occlusion. Figs. 4a–f: Design in exocad for posterior restoration. Figs. 5a & b: Vertical dimension of occlusion augmentation. Figs. 6a & b: The situation pre- and post-orthodontic treatment. Figs. 7a–d: Direct composite restoration of the mandibular anterior sextant. Figs. 8a & b: Anterior wax-up. 37 3 2023

case report | 15a 15b Figs. 15a & b: Adhesive procedures. 25–27, 34, 35 and 44. A digital impression was taken with the DEXIS IS 3800W intra-oral scanner (Dental Imaging Technologies Corp.) of the increased VDO with the jaws in centric relation and stabilised with a posterior occlusal jig (Fig. 3). The restorations were designed on exocad software (Fig. 4), and lithium disilicate was chosen for their fabrication (Fig. 5). The restorations were bonded adhesively in the patient’s mouth. After the increasing of the VDO, the patient’s anterior occlusion was ideal for restoration of anterior guidance. It was therefore necessary to provide the patient with orthodontic treatment (Fig. 6). After the orthodontic treatment had been completed, the incisal edges of the mandibular incisors were restored directly with composite (Fig. 7). Subsequently, the final aesthetic wax-up of the anterior sextant was completed in order to ulti- mately validate the aesthetic restoration and to guide the minimally invasive preparation of the maxillary crowns (Fig. 8). The final preparation was guided by the mock-up (Fig. 9) and, for the most part, was limited to the interproximal areas (Fig. 10). After that, we took a final digital impression of the anterior crowns after displacement of the gingiva with re- traction cord (Fig. 11). For the digital design, limited reduction of the inferior half of the buccal surface of the monolithic resto- rations was performed in order to allow stratification of porcelain for achieving the best possible aesthetic result (Figs. 12 & 13). Ultimately, the final resto- rations (Fig. 14) were bonded adhesively in the mouth under dental dam isolation (Fig. 15). The patient was followed up several weeks after the cementation (Figs. 16 & 17). 16a 16b Figs. 16a & b: Final extra-oral photographs. about Dr Carlo Massimo Saratti received his DDM from the University of Florence in Italy in 2011. Between 2014 and 2016, he completed the Master of Advanced Studies in Microinvasive Aesthetic Dentistry programme—of which he is now coordinator—at the University of Geneva in Italy. Since September 2016, he has been a senior assistant in the division of cariology and endodontics of the University of Geneva. Dr Saratti is also involved in research on dental materials for restorative dentistry and has published internationally on this subject. Alongside his academic activities, he works in the Geneva Smile Center as a specialist in aesthetic adhesive restorations for single-tooth and full-mouth restoration. 17a 17b 17c Figs. 17a–c: Final intra-oral photographs. 39 3 2023

case report | 5 8 6 9 7 10 Fig. 5: Frontal view showing multiple aesthetic and functional deficits. Fig. 6: Right lateral view showing multiple aesthetic and functional deficits. Fig. 7: Left lateral view showing multiple aesthetic and functional deficits. Fig. 8: Frontal view of the teeth in maximum intercuspation. Fig. 9: Right lateral view of the teeth in maximum intercuspation. Fig. 10: Left lateral view of the teeth in maximum intercuspation. anterior sextants and bilateral posterior quadrants. Severe wear due to attrition with compensatory overeruption of the mandibular anterior alveolar crest had contributed to occlusal plane discrepancies. Irregularities in the curve of Wilson and curve of Spee had resulted in occlusal disharmony and no anterior guidance. Excessive over- bite and overjet and vertical maxillary anterior excess were noted. Other aesthetic deficiencies included a lip line that did not match the smile line and irregular and asymmetrical gingival zeniths, incisal embrasures and incisal edge positions. The patient’s profile view showed a retruded chin and deficient lower facial third height. Increasing the lower facial third height would allow for improved chin prominence and a more youthful appear- ance. This “triangle of youth”, present in people with ideal vertical facial thirds, as described by Gelb, is an inverted triangle from the facial view in which three straight lines connect the most lateral aspects of the right and left cheek bones to the mental protuberance of the chin.4 An aged face is often due to a loss of ideal lower facial third height and a retruded chin, in which from the facial view a triangle can be outlined with a straight line connecting the left and right angles of the mandible to the inferior aspect of the nasal bone.4 The treatment objectives were to restore ideal function and aesthetics by correcting these various deficiencies. When numerous functional and aesthetic challenges are present, one of the first steps in establishing an aesthetic reconstruction is to define the proper plane of occlusion.5 According to Dawson, “the form of the occlusal plane is directly related to specific functional requirements, alignment of teeth in relationship to the arc of closure for best resistance to loading and ease of access for positioning of the food on the occlusal surface”.6 Without a proper plane of occlusion, the remaining features that establish proper form and function are adversely affected. Tooth dimensions and “Without a proper plane of occlusion, the remaining features that establish proper form and function are adversely affected.” embrasures will not be balanced and oriented properly, and an aesthetic outcome will be compromised.7 To restore proper form and function and correct the identified deficiencies, our treatment plan involved full- arch implant-retained prostheses following a predictable and streamlined digital workflow. Clinical protocol Using the NavaGation Synergy Guided Workflow (Absolute Dental Services), the restorative and surgical planning phase began with collaboration between the 11 Fig. 11: Frontal view of centric relation bite registration. 41 3 2023

case report | 16 17 18 19 20 Fig. 16: Maxillary and mandibular key fixation foundation guides made from Flexcera with indexed transitional Flexcera Smile prostheses prior to pick-up. Fig. 17: Complete maxillary and mandibular Flexcera Smile transitional prostheses, one day after surgery. Fig. 18: Occlusal view of the maxillary Flexcera Smile prosthesis. Fig. 19: Occlusal view of the mandibular Flexcera Smile prosthesis. Fig. 20: Full-face retracted view of the centric relation bite registration with Blu-Mousse for the final impression using the acrylic transitional duplicates. “The plan was to place eight maxillary implants and five mandibular implants for full-arch implant-retained zirconia prostheses.” guides accurately and securely to the maxillary and mandibular bone. Implant placement guides were sub- sequently utilised to guide precise implant placement. Eight Straumann Bone Level Tapered Roxolid SLActive Regular CrossFit implants were placed in the maxillary arch (4.8 × 8.0 mm implants in sites #16 and 26, 4.1 × 12.0 mm implant in site #14 and 4.1 × 14.0 mm implants in sites #13, 11, 21, 23 and 24). Five Straumann Bone Level Tapered Roxolid SLActive Regular CrossFit implants were placed in the mandibular arch (4.8 × 12.0 mm implants in sites #36 and 46, 4.1 × 14.0 mm implants in sites #33 and 43, and 4.1 × 12.0 mm implant in site #31). Once the implants had been placed, the implant place- ment guide was removed and Regular CrossFit screw- retained 17° multi-unit abutments were placed using a 3D-printed Flexcera multi-unit abutment aligner guide. The transitional prostheses made from Flexcera Smile were then picked up with a dual-polymerising polymer (Triad, Dentsply Sirona), after placing the temporary 21 22 23 24 25 Fig. 21: Frontal view of the try-in Flexcera Smile final prostheses dupli- cates to assess function and aesthetics. Fig. 22: Occlusal view of the complete maxillary try-in Flexcera Smile duplicate of the final prosthe- sis. Fig. 23: Occlusal view of the complete mandibular try-in Flexcera Smile duplicate of the final prosthesis. Fig. 24: Full-face view of the try-in Flexcera Smile final prostheses duplicates, confirming improved aesthetics and function. Fig. 25: Full-face retracted view of the try-in Flexcera Smile final prostheses duplicates, confirming improved aesthetics and function. 43 3 2023

case report | 39a 38 39b Fig. 38: Full-face retracted view of the completed case. Figs. 39a & b: Before (a) and after profile views (a) showing improved lower facial third proportion and autorotation of the mandible. This NavaGation Synergy guided surgery and pros- thetic protocol eliminates the need for guesswork, verification jigs, occlusal rims and wax set-ups. The final impression duplicates of the transitional prostheses served as both final impression trays and correct ver- tical dimension and tooth position guides. At the sub- sequent visit, prototypes made from Flexcera Smile were tried in and aesthetics, function, phonetics and occlusion were assessed (Figs. 21–25). Adjustments to the gingival embrasures were made to idealise the gingival scalloping and guide papillae fill-in, and a final bite registration was obtained using Blu-Mousse. The final prostheses were fabricated from full-contour solid zirconia (ArgenZ HT+ Multilayer, 1,250 MPa; Argen) and were custom stained and glazed to transition nat- urally with the gingival characterisation (Figs. 26–40). The multi-unit prosthetic screws were torqued to the manufacturer’s recommendations and the access holes sealed with PTFE tape and Filtek Supreme Ultra. A full-coverage maxillary flat plane occlusal night guard was fabricated to be worn indefinitely to reduce and manage occlusal parafunctional forces on the prostheses and implants. Conclusion Digital treatment planning for improved aesthetics and function can be both rewarding for the clinicians and fulfilling for the patient.7 Predictable surgical and prosthetic results are possible with a streamlined digitally guided workflow that eliminates guesswork. The collaboration of the surgeon, restorative dentist and guided surgery specialist in treatment planning enables visualisation of the desired outcome prior to surgery. Numerous aesthetic and functional deficien- cies were addressed and resolved in this patient’s case, 40 Fig. 40: Full-face view of the patient’s new smile. resulting in much improved dental health, function and appearance. The patient and all involved with the case were pleased with the outcome. Editorial note: This article originally appeared in Oral Health Magazine, and an edited version is provided here with permission from Newcom Media. Please scan this QR code for the list of references. about Dr Tyler Wynne received his DDS in 2014 from the University of North Carolina at Chapel Hill Adams School of Dentistry in the US, where he is an adjunct faculty member. He practises general dentistry in Clemmons in North Carolina, is an editorial team member of REALITY Ratings & Reviews and is a scholar of the Dawson Academy. Dr Wynne is a fellow of the International Academy for Dental-Facial Esthetics and Academy of General Dentistry and a member of the American Society for Dental Aesthetics. 45 3 2023

opinion | Table 1: An example of recommended computer requirements (for the Medit i700 intra-oral scanner). Operating system Windows Windows 11 (recommended for 12th Gen or later Intel Core processors) Windows 10, 64 bit MacOS MacOS Monterey MacOS Ventura PC type CPU RAM Laptop Desktop Laptop/desktop Intel Core i7-12700H Intel Core i7-12700H AMD Ryzen 7 5800X M1 Pro (10-core CPU, 16-core GPU) M2 (8-core CPU, 10-core GPU) M2 Pro (10-core CPU, 16-core GPU) Graphics card* NVIDIA GeForce RTX 3070 (VRAM 8 GB or higher) NVIDIA RTX A4000 (VRAM 8 GB or higher) * AMD Radeon is not supported. 32 GB 24 or 32 GB – Some distributors provide excellent training, while others will simply send the scanner to you and that is it.6 You are left to figure out the rest for yourself. Just like any new method or technology, there is undoubtedly required training for and practice using an intra-oral scanner. Although there are countless benefits of digi- tising, it is necessary to realise and appreciate that you need to train yourself on how to use the device proficiently. Thankfully, these days, it is much simpler to learn how to use an intra-oral scanner. Software employing artificial intelligence (AI) helps bridge the gap between new and experienced users, and gener- ally, in my experience of training thousands of dentists on how to use these devices, it should not take more than a month of training to become confident in most day-to-day scanning indications. In saying that, I have seen countless instances of dentists not using scanners correctly, because of either poor understanding of the technology or a lack of train- ing. In this article, I will share some of my tips on how to become proficient in intra-oral scanning based on my personal experience in training dentists on how to take full-arch dentate scans easily within 45 seconds. My personal best is 18 seconds. This is doable for everyone reading; it is just a matter of training and practice. Intra-oral scanning will be the best thing that ever happened to your practice once you become confident in it. You will never look back. The first piece of advice may be self-evident, but is important to mention. Scanners come in two forms, either carts (with built-in PCs), such as CEREC, 3Shape TRIOS MOVE and iTero, or scanners that are used with “The question now is not a matter of whether a clinic should digitise but when and —more importantly—how.” 3 Fig. 3: An example of scanning a patient. Note that both my dental assistant and I are retracting the cheeks. 47 3 2023

opinion | “Current literature shows that full-arch dental impressions can have extremely high accuracy if adequate scanning strategies are used.” outside the mouth and then move into position, you will likely capture an artefact like the lips as you move into position. 6 Fig. 6: An example of double images at the incisal edges. The next tip is scanning strategy. A scanning strat- egy refers to how you move the scanner around the mouth to take a scan. The pathway is almost always the same when followed properly. Although AI soft- ware makes it easier to take a full-arch scan and is more forgiving, following a scanning strategy still has multiple benefits, including ensuring high accuracy and efficiency. Current literature shows that full-arch dental impressions can have extremely high accuracy if adequate scanning strategies are used.7 The typi- cal scanning strategy is as follows: starting on the occlusal surface of the terminal molar and moving across the occlusal surfaces to the opposite side (Fig. 5). A vital piece of advice is to tilt the scanner facially while moving across the incisors to ensure that you capture the incisal edges in their entirety to prevent double images and inaccuracies in this part of the scan (Fig. 6). Once on the occlusal surface of the opposite molar, you simply tilt your scanner lingually/palatally and then continue to capture the tooth surfaces, moving back to the original point you started at, finally tilting over to the facial surface and capturing the last remaining data. When using most intra-oral scanners, it is not critical whether you capture facial or lingual/palatal surfaces after carrying out the occlusal aspect scan of a full-arch scan strategy. Rather a smooth and steady motion is much more important. Carrying out this scanning strategy requires practice and muscle memory. There are no shortcuts. At first you will feel uncomfortable and likely lose your spot many times. With time and repetition, you will be able to do this without looking into the mouth, but rather watching the computer screen to see exactly what you are capturing. Once you feel confident with intra- oral scanning, you should be able to take a full-arch scan easily within 45 seconds. I highly recommend to all clinicians to practise as much as possible when they first acquire a scanner. Practise on models, your staff or even your spouse. You will not get better at intra-oral scanning by keeping the scanner in a cupboard. In summary, these are some of the tricks and tips I teach our associates and the thousands of dentists we train at the Institute of Digital Dentistry, both in our live courses and online. We also have an entire library of online content in which I demonstrate these tips and tricks which you can find on the institute’s website (instituteofdigitaldentistry.com). The first step to becoming proficient in scanning is to accept that this is the best way to take an impression. If you do not believe in the technology, you will not bother learning it. Digital dentistry is the future of dentistry, and you do not want to fall behind. It does take practice, and learning to use a scanner can be frustrating at times, but with perseverance, there is no doubt that you will be fully confident in taking scans within a few weeks of proper training and practice. Please scan this QR code for the list of references. about 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 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. 49 3 2023

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Can haptic training replace using phantom head sim- ulation, or do you think that the two types of training methods should complement each other? Phantom head simulation training for invasive dental pro- cedures must be a core component of the preclinical den- tal curriculum. However, besides the conventional training methods, dental schools should consider incorporating haptic VR simulation devices to facilitate the transition of preclinical students from the simulated dental learning envi- ronment to the clinical setting. You have recently worked on a study that examined dental practice that combined VR haptics and frasaco plastic tooth model preparation exercises. What were the most significant results? The combination of haptic VR technology provided by the Simodont dental trainer with frasaco simulation can successfully meet the learning and teaching needs for tooth preparation. What is the future of haptic technology in dentistry? The future of haptic technology looks bright, as it has the potential to revolutionise a wide range of dental training. In the recent past, haptics helped make things perceptible, for example phone vibration and Rumble Paks in gaming controllers. We now have haptic VR dental trainers, and the sterile + dirty Sterile does not mean clean. Far too many implant systems have concerning residual surface contaminants. Receive quality information about your implant in use. Provide more safety for your patients and avoid negligence claims. interview | A haptic virtual reality Simodont dental trainer. (All images: © Szabolcs Felszeghy) use of artificial intelligence (AI) in dental training is just around the corner. The combination of AI with haptic VR devices would definitely enhance training and engagement, and this could potentially reduce the risk of surgical errors and improve patient outcomes. However, further development and evidence-based clinical validation of haptic VR dental trainers are needed to im- prove engagement and learning outcomes for more dental students around the world. I am convinced that, as the tech- nology continues to advance, it is likely that dental educators will see even more innovative and exciting dental applications of haptic VR technology in the coming years. Editorial note: The study has been accepted for publication in the International Journal of Computerized Dentistry. AD sterile + clean These implant systems were awarded the CleanImplant “Trusted Quality” seal after an unbiased and peer-reviewd quality assessment: AnyRidge – MEGAGEN Astra Tech EV – DENTSPLY SIRONA BlueDiamond – MEGAGEN ICX-Premium – MEDENTIS MEDICAL In-Kone – GLOBAL D Inverta – SOUTHERN IMPLANTS Kontact S – BIOTECH DENTAL Patent – CHAMPIONS IMPLANTS Prama – SWEDEN & MARTINA (R)Evolution – CHAMPIONS IMPLANTS SDS 1.2 – SWISS DENTAL SOLUTIONS SDS 2.2 – SWISS DENTAL SOLUTIONS SuperLine – DENTIUM T6 – NUCLEOSS UnicCa – BTI whiteSKY – BREDENT MEDICAL Visit us at EAO BERLIN! Booth C 06 WE FIGHT DIRTY. Dr. Dirk U. Duddeck, Founder and Head of Research | Dr. Ken S. Serota, Representative North America Join in as a CleanImplant Certifi ed Dentist! More information about this non-profi t initiative: info@cleanimplant.com | www.cleanimplant.com/dentists The independent dental implant quality assessment.

interview | to replace Phenyl-P. The main aim of this project was an improvement of our products’ bond strength for metal alloys and dentine. Among the new adhesive monomers being developed, we decided to use the MDP monomer because it features excellent bonding to tooth structure and metal alloys used in dentistry, as well as superb resis- tance to water. Incidentally, our first products to contain the MDP monomer were PANAVIA EX and the bonding agent CLEARFIL NEW BOND. Where did the name PANAVIA come from? The name is a compound of the Greek word “pan” and the Latin word “via”, meaning “everything” and “way” or “method”, respectively. Consequently, PANAVIA de- scribes a method for bonding everything; it represents our desire to have products launched under the PANAVIA brand recognised as dental materials that can bond to all types of restorations and tooth structure. Would you please tell us the story behind the devel- opment of PANAVIA EX? Back in the early 1980s, it was vital for us to develop new adhesive monomers as part of our project to develop a new resin cement with unprecedented adhesive proper- ties. In this context, we conducted a comprehensive lit- erature search for compounds thought to be involved in adhesion. At the same time, we carried out a variety of R & D activities, including basic research to quantitatively clarify the relationship between the molecular structures of monomers and their adhesive qualities, synthesis trials of various monomers and bond strength tests. Conse- quently, we succeeded in developing the MDP monomer that had the physical properties we were working to ob- tain. After the development of this adhesive monomer, we were finally able to create PANAVIA EX in our laboratory. In early 1982, we completed the first prototype of PANAVIA EX for external evaluation and asked a dental colleague in Japan to evaluate it. He found that the proto- type cement might polymerise too quickly in clinical use. This was due to fact that we had not taken into account the difference between room temperature and intra-oral temperature, which has a huge impact on the polymer- isation time. This mistake made us recognise how im- portant clinical evaluations are during the development of dental materials. To this day, we continue to place great importance on the opinions of clinicians whenever a new material is being developed. What were the key technological features of the PANAVIA EX cementation system? The system had five key features: appropriate film thick- ness, appropriate flow properties, radiopacity, improved bond strength and improved surface polymerisation char- acteristics. At the time that PANAVIA EX was developed, a film thickness of 30 μm or less was desired for luting ce- ments. The largest components we wanted to use in the formulation—the silica filler particles present in our com- posite resin—had a maximum particle diameter of 50 µm. We were able to achieve a film thickness of 30 μm or less by significantly extending the silica grinding time, which made the filler particles much finer. An appropriate paste consistency—a low level of viscosity and good flowability— was achieved by using low-viscosity monomers for PANAVIA EX. In order to make the cement radiopaque, we dispersed radiopaque filler within the powder component. 55 3 2023

interview | improvement, achieving reliable general luting has always been at the forefront of our goals. We believe that the successful evolution of the PANAVIA brand owes a great deal to our continual efforts to obtain a high-strength bond to dentine after chemical polymerisation. provided a strong bond to tooth structure or metal alloys were not widely used. I believe that overseas researchers were interested in the development of PANAVIA EX at a relatively early stage for this reason. How has the R & D department evolved over the years? Initially, our efforts in the development of dental materials had focused on bonding agents and restorative composite resins. PANAVIA EX was just one of our new development projects, and only a few staff members were assigned to that product. After PANAVIA EX was launched in 1983 and gained popu- larity worldwide, our product line-up of resin cements was expanded considerably. Consequently, we increased the number of development staff assigned to resin cements and set up a special development team responsible for the self-adhesive resin cement product line that includes PANAVIA SA Cement Universal. As a result, the size of the staff assigned to resin cements has expanded substantially. How has production changed? When PANAVIA EX was launched in 1983, the product was manufactured exclusively for the Japanese market in a relatively small facility. Today, in order to manufacture all products of the PANAVIA family for the global market, we have automated our production facilities and increased the manufacturing equipment and systems dedicated to producing the resin cement paste. To support our product quality, we have also set up a quality control system that assures that we turn out safe and high-quality products, based on our over 40 years of technical know-how and experience in the production of resin cements. When did external researchers start showing interest in PANAVIA? The development of PANAVIA EX was carried out with the active participation of researchers at a dental college in Japan, involving such activities as performing basic adhesion tests and experimenting with clinical applications using adhesive bridges. At that time, resin cements that What goal do you have in mind as you continue devel- oping the company’s adhesive cements? We have two basic central goals: achieving greater bond strength and delivering easier handling characteristics. I think that the shades of resin cements are also devised in each product in order to realise characteristics that sup- port aesthetic restorations. We have achieved greater bond strength with PANAVIA V5 and easier handling character- istics with PANAVIA SA Cement Universal. We are going to continue to explore the development and introduction of various new technological applications to bring even higher-performance products to market. What is the strength of Kuraray Noritake Dental’s R & D team in your opinion? We conduct R & D activities continuously, focusing on the development of luting materials. In our product develop- ment department, the same person is often responsible for one product category for a long time. For example, I have been engaged in the development of PANAVIA products for most of the time since I joined the company. The result is that each person in the development depart- ment can be said to be an expert in a certain category of products. They leverage the technical knowledge acquired in the past for the development of new products, resulting in entirely new discoveries. Do you have any ideas about what the future of PANAVIA will be? We will continue to focus on the development of even simpler, easier-to-use resin cements suitable for a wide range of applications—products based on the concept of universality. They should allow users to focus more on actual treatment than ever before while, of course, delivering a strong and durable bond between the tooth structure and the restoration. 57 3 2023

industry report | damaging the chemical bond between the silica con- tained in glass-ceramics and the silane coupling agent. Three products covering virtually every need By combining these technologies and constituents in a smart way, we have succeeded in developing a resin cement portfolio that covers virtually every need. With PANAVIA V5, PANAVIA SA Cement Universal and PANAVIA Veneer LC, it is possible to treat a wide vari- ety of cases. The products allow for the luting of various types of restorations and prosthetic appliances and for the placement of posts and produce great outcomes if used according to the instructions for use. It is possible for the dental practitioner to choose the right cement system for treatment according to the case and patient needs from among these three major resin cement products. PANAVIA SA Cement Universal is a simple and easy-handling self-adhesive resin cement. PANAVIA Veneer LC is used for bonding laminate veneers. PANAVIA V5 has the widest range of uses among these three cement systems, covering almost all the intended uses of the other two. Exploring new opportunities The good thing about developing technologies in a company like Kuraray Noritake Dental is that their application is not limited to a certain product or product group. The research and development department always carries out research on how to leverage the benefits of the technologies in other applications. Take, for example, KATANA Cleaner, which was released in 2019. This cleaning agent can be used to remove saliva, blood, temporary cement or other contaminants that can adhere to the surfaces of teeth or prosthetic devices during trial fitting and temporary cementation of a prosthetic device. This unique product has been developed by taking advantage of the surfactant function of the MDP monomer. Conclusion Hence, it is mainly our long-standing knowledge and experience in the development of dental resin cements and adhesive solutions that provides for the excellence of the current PANAVIA portfolio. We know how to improve existing technologies, never stop developing new ones and continuously look for the best way to combine proven and new components to obtain the best possible outcomes. In the steps of the product development procedure, clinical tests are conducted and feedback from dental practitioners is gathered to take into account the extreme conditions found in the oral environment. In the past 40 years, this strategy has proved successful, and we are sure that it will help us develop many other innovative products that offer ideal support to the dental practitioner in striving to improve the oral health of patients. 59 3 2023

manufacturer news | An innovative implant solution Introducing DS OmniTaper Implant System— the newest member of the EV implant family The DS OmniTaper Implant System is an innovative solution that combines the proven technologies of Dentsply Sirona’s EV implant family with new features that deliver efficiency and versatility. Unique to the implant system is an intuitive drilling protocol for reduced chair time and a pre-mounted TempBase for immediate restorations and efficient workflows. The DS OmniTaper Implant System is the newest member of the EV implant family, alongside the Astra Tech Implant System and DS PrimeTaper Implant System. The EV implant family offers sur- gical flexibility to cover virtually every indication. All three implant systems deliver biologically driven implant designs for natural aes- thetics and lasting bone care, have one connection for restorative simplicity and are optimised for a seamless integration into digital dentistry workflows. Like the rest of the EV implant family, the DS OmniTaper Implant System features the OsseoSpeed implant surface and the conical EV connection that provides access to the harmonised and comprehensive EV prosthetic portfolio for restorative flexibility and immediate chairside solutions. www.dentsplysirona.com AD THE GLOBAL DENTAL CE COMMUNITY REGISTER FOR FREE DT Study Club – e-learning community 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.

meetings | All about the patient: The 2024 ITI World Symposium By ITI Foundation The ITI World Symposium is back and better than ever. In Singapore from 9 to 11 May 2024, more than 50 world-renowned speakers will present at the world’s largest scientific implant dentistry event. Building on the highly successful online edition, the 2024 ITI World Symposium will once again put patients at the centre of the action. Over three days, more than 4,000 participants will experience real patients and their stories on stage. The speakers will discuss various treatment op- tions based on the latest scientific evidence. Addi- tionally, world-class clinicians will provide commen- tary on exclusively recorded clinical procedures live on stage. “With our unique, patient-centred programme, we aim to combine practical, clinical insights with the dis- cussion of scientific findings,” explained International Team for Implantology (ITI) President Dr Charlotte Stilwell. “We ran a survey in our community last year to identify the topics of greatest relevance currently, and these form the core of our scientific programme: soft- tissue management, guided bone regeneration/bone augmentation, immediate implants, peri- implantitis and the digital workflow.” Registration for the ITI World Symposium is open at worldsymposium.iti.org. ITI members as well as those who register early will benefit from significant discounts. 63 3 2023

How to send us your work submission guidelines | m o c . k c o t s r e t t u h S / s l i e x p 2 3 © Please note that all the textual compo- nents of your submission must be com- bined into one MS Word document. Please do not submit multiple files for each of these items: · the complete article; · all the image (tables, charts, photo- · · graphs, etc.) captions; the complete list of sources consulted and the author or contact information (bi- ographical sketch, mailing address, e-mail address, etc.). In addition, images must not be embed- ded into the MS Word document. All im- ages must be submitted separately, and details about such submission follow be- low under image requirements. Text length Article lengths can vary greatly—from 1,500 to 5,500 words—depending on the subject matter. Our approach is that if you need more or fewer words to do the topic justice, then please make the article as long or as short as necessary. We can run an unusually long article in multiple parts, but this usually entails a topic for which each part can stand alone because it contains so much in- formation. In short, we do not want to limit you in terms of article length, so please use the word count above as a general guideline and if you have specific questions, please do not hesitate to contact us. Text formatting We also ask that you forego any special formatting beyond the use of italics and boldface. If you would like to emphasise certain words within the text, please only use italics (do not use underlining or a larger font size). Boldface is reserved for article headers. Please do not use un- derlining. Please use single spacing and make sure that the text is left justified. Please do not centre text on the page. Do not indent paragraphs, rather place a blank line be- tween paragraphs. Please do not add tab stops. Should you require a special layout, please let the word processing pro- gramme you are using help you do this formatting automatically. Similarly, should you need to make a list, or add footnotes or endnotes, please let the word process- ing programme do it for you automatically. There are menus in every programme that will enable you to do so. The fact is that no matter how carefully done, errors can creep in when you try to number footnotes yourself. Any formatting contrary to stated above will require us to remove such formatting before layout, which is very time-consum- ing. Please consider this when formatting your document. Larger image files are always better, and those approximately the size of 1 MB are best. Thus, do not size large image files down to meet our requirements but send us the largest files available. (The larger the starting image is in terms of bytes, the more leeway the designer has for resizing the image in order to fill up more space should there be room available.) Also, please remember that images must not be embedded into the body of the article submitted. Images must be submitted separately to the textual sub- mission. You may submit images via e-mail or share the files in our cloud storage (please contact us for the link). Please also send us a head shot of your- self that is in accordance with the re- quirements stated above so that it can be printed with your article. Image requirements Abstracts Please number images consecutively throughout the article by using a new number for each image. If it is imperative that certain images are grouped together, then use lowercase letters to designate these in a group (for example, 2a, 2b, 2c). Please place image references in your article wherever they are appropriate, whether in the middle or at the end of a sentence. If you do not directly refer to the image, place the reference at the end of the sentence to which it relates enclosed within brackets and before the period. In addition, please note: An abstract of your article is not re- quired. Author or contact information The author’s contact information and a head shot of the author are included at the end of every article. Please note the exact information you would like to ap- pear in this section and format it accord- ing to the requirements stated above. A short biographical sketch may precede the contact information if you provide us with the necessary information (60 words or less). · We require images in TIF or JPEG for- mat. · These images must be no smaller than Questions? 6 x 6 cm in size at 300 DPI. · These image files must be no smaller than 80 KB in size (or they will print the size of a postage stamp!). Magda Wojtkiewicz (Managing Editor) m.wojtkiewicz@dental-tribune.com 65 3 2023

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