issn 1616-7390 • Vol. 11 • Issue 1/2020 1/20 CAD/CAM international magazine of dental laboratories interview Advantages of a digital workflow industry report New paradigm in aesthetic restoration education CAD/CAM can be an incredible teaching tool

editorial | Magda Wojtkiewicz Managing Editor Dear readers, I have the great pleasure of introducing our new CAD/CAM international magazine of dental laboratories, which aims to be one of the primary sources of information for dental laboratory owners and dental technicians. This is the first publication in Dental Tribune International’s portfolio focused mostly on dental technicians and their needs. In the era of rapid changes and transition from a conven- tional to a digital workflow in dental offices and laboratories, it is crucial to stay updated with the latest technologies. Nowadays, dental technicians need to be more involved in what dentists are doing. Whether managing an in- house laboratory working intimately with the dentist and patient or owning a larger laboratory organisation and consulting over the phone or in person, the dental tech- nician’s role is now, more than ever, that of an integral partner with the dentist to achieve the best results for the patient. procedures such as guided surgery, implantology and full-mouth rehabilitation. Digital technology has helped to break down the separation of dental offices and den- tal laboratories by involving technicians in all aspects of the dental treatment workflow. This rapid change in the dental field will continue and will have an increasing impact on the industry and its struc- ture. Soon, CAD/CAM will be supporting every single department within the laboratory and digital technology will create even more collaboration with dentists. Inside this issue of CAD/CAM, you will find articles about advantages of the digital workflow, computer- aided treatment planning, matching the CBCT scan and virtual wax-up, the latest CAD/CAM software develop- ments and much more. I hope you will find our magazine informative and that it will encourage you to continue to learn about and embrace the digital reality. As the role of the dental technician continues to change, so too does the need to acquire specific knowledge and skills. Dental technicians need to broaden their knowledge. Owing to omnipresent digital technology, many technicians are involved in treatment planning and Sincerely, Magda Wojtkiewicz Managing Editor CAD/CAM 1 2020 03

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industry report | Fig. 5 Fig. 6 Fig. 7 Fig. 8 is to condition the marginal tissue using the BOPT by Dr Ignazio Loi (Fig. 4). fitted crowns, the interproximal spaces would be further reduced after the definitive restoration. For the BOPT, the vertical preparation of the abutment has a finishing line that extends into the gingival sulcus. The temporary conditioning of the tissue induced by the provisional prosthesis allows us to modify the level of the gingival parabolas to a certain extent (Fig. 5). Healing of the tissue one month after the initial periodon- tal treatment was significant (Fig. 6). The role of the pro- visional restoration, appropriately realigned, is crucial for obtaining healthy soft tissue around future restorations. The conditioning of the tissue was achieved by means of the provisional restoration, which modified the level and shape of the marginal tissue. Once filled with correctly The correct management of the provisional restoration is crucial for the healing of the tissue. The placement of a provisional restoration before the periodontal ther- apy allowed us to create the right environment for com- plete healing. At the same time, the vertical preparation allowed us to gradually condition the marginal gingival tissue by shortening or lengthening the provisional resto- ration as necessary (Fig. 7). One of the advantages of a vertical preparation is that tak- ing the final impression is easy, because the absence of a horizontal finishing line greatly simplifies the procedure (Fig. 8). However, the BOPT also requires the taking of an Fig. 9 Fig. 10 CAD/CAM 1 2020 09

industry report | Fig. 17 Fig. 18 Figure 16 shows the clinical situation one year after ce- mentation, performed with PANAVIA V5 (Kuraray Noritake Dental): the marginal tissue was in a good clinical condi- tion, with no signs of inflammation or bleeding. The BOPT allowed us to optimise the level of the gingiva without resorting to periodontal surgery, while the shape of the new crowns made it possible to close all the interproximal spaces for an optimally aesthetic result. the restoration, even though the initial situation appeared to be particularly unfavourable (Fig. 17). Compared with the previous prostheses, the incisal re- duction allowed not only for the optimisation of the func- tional phase by reducing the overbite, but also made it possible to achieve more natural aesthetics, the contour of the incisal margins following that of the lower lip. The brightness of the restorations (thanks to the use of a particularly translucent zirconia) combined with the shape of the incisors, greatly improved the aesthetics of Figure 18 demonstrates the excellent aesthetic proper- ties of KATANA Zirconia UTML and the perfect integration of the prostheses in harmony with the pink tissue. about Francesco Ferretti received his dental technician degree from L’istituto E. De Amicis in Rome in Italy. In 1992, he began working with Prof. Mario Martignoni and a year later with the Oral Design centre founded in Rome by master ceramist Willi Geller and became a partner. In 1999, he returned to working on his own and enrolled at the University of Rome Tor Vergata. In 2001, he founded Estech Dental Studios, in cooperation with Pentron for technical training and consulting. He taught prosthetics at the Gabriele d’Annunzio University of Chieti–Pescara from 2002 to 2005, has taught the perfection of prostheses at the University of Naples Federico II since 2006 and is a consultant to the San Raffaele hospital in Milan, all three in Italy. He is interested in metal-free prosthetics, has published articles in Italian and American journals and has participated as a speaker at numerous conferences in Italy. He is a member of the European Society of Cosmetic Dentistry, Associazione Nazionale Titolari di Laboratorio Odontotecnico [Italian national association of dental laboratory owners] and Gruppo Italiano per la Ricerca Applicata in Scienze Biomediche [Italian group for applied research in the biomedical sciences]. Dr Marco Nicastro obtained his degree in dentistry and dental prosthetics from the Sapienza University of Rome in 1989. Since the beginning, he has been interested in prosthetic restorative dentistry and treating aesthetic problems. From 1990 to 1996, he attended Prof. Martignoni’s studio, where he developed his prosthetic knowledge. From 1993 to 1998, he cooperated as a lecturer with the Oral Design centre in Rome, giving lectures and courses on aesthetic restoration either in Italy or in other countries. In the same period, he expanded his experience in aesthetics, attending training courses at the University of Geneva in Switzerland. Since 1993, he has been cooperating with Ferretti in the organisation of courses and conferences, paying particular attention to metal-free methodology. He practises prosthetic and aesthetic restorative dentistry in Rome. He has published his work in Italy and other countries and given national and international lectures on aesthetic restorations. He is one of the founders and an active member of the Gymnasium Interdisciplinare CAD/CAM, a certified member and vice president of the European Society of Cosmetic Dentistry, an active member of the Società Italiana di Odontoiatria Conservatrice [Italian society of conservative dentistry] and a partner of the Italian Academy of Prosthetic Dentistry. CAD/CAM 1 2020 11

industry report | ceramics. For the practitioner, it is important to maintain an overview in order to select the optimal material for the indication. Dental ceramics can be broadly divided into ceramics with a glass phase (e.g. silicate ceramics and glass-infiltrated ceramics) and ceramics without a glass phase, the oxide ceramics (e.g. zirconium dioxide). Differences exist in, among other things, the materials’ photo-optical properties and characteristics (e.g. flexural strength and fracture toughness). To perform single-tooth restorations chairside, a high-strength glass-ceramic is often used, such as lithium disilicate ceramic or lith- ium silicate ceramic. To obtain the final strength level of 360–400 MPa, these ceramics are crystallised after milling. There are also pre-crystallised blanks available that only need to be polished. However, in this case, the strength is greatly reduced. For several months, the fam- ily of CAD/CAM glass-ceramics has been augmented with a further class of materials: lithium aluminosilicate ceramics (n!ce, Straumann). Pre-crystallised and high strength aluminosilicate. Its flexural strength is 350 MPa (± 50). Its great advantage is its easy and efficient processing. The range contains blanks in two translucency levels: HT (high translucency) and LT (low translucency). Both trans- lucency levels are available in different shades (Bleach, A1, A2, A3, B2 and B4 of the VITA classical shade guides) and cover a large number of restorative indications in everyday clinical practice. The fully crystallised milling blocks were developed specially to fabricate complete crowns, partial crowns, inlays, onlays and veneers. The blanks are compatible with different block holders for dif- ferent milling machines (Fig. 1). The glass-ceramic blocks can therefore be processed with conventional milling machines and require no investments in additional hard- ware or software. The material can be milled, polished and seated without crystallisation firing. This saves time and effort in daily practice. Individual characterisation is possible if required. Case report In terms of materials science, the n!ce fully crystallised glass-ceramic is a lithium disilicate reinforced with lithium Initial situation The patient wished to have the large-surface amalgam fillings in the upper and lower jaw (Figs. 2a & b) removed Fig. 2a Fig. 2b Fig. 3a Fig. 3b Fig. 3c Figs. 2a & b: The patient desired replacement of the large-surface amalgam fillings in the upper (a) and lower jaw (b) with full-ceramic restorations. Figs. 3a–c: The prepared teeth are readied for intra-oral digitalisation (intra-oral scanning). CAD/CAM 1 2020 13

industry report | and replaced with full-ceramic restorations created with the least possible effort. These were single-tooth res- torations (partial crowns). In the maxillary posterior re- gion, a bridge restoration was indicated, which was pro- duced from lithium disilicate ceramic. All other indirect single-tooth restorations were to be fabricated from n!ce. The material is biocompatible and relatively strong with- out additional crystallisation firing, while featuring natural photo-optical properties. Preparation The aim was a new minimally invasive treatment per- formed within the dental practice. No functional disorders were present and no periodontal abnormalities were identified either. A vitality test was performed on all of the teeth and a positive result was found up to tooth #46. This tooth had undergone root canal therapy. After anaesthesia and fitting of the rubber dam, the amalgam fillings were removed and the teeth were pre- pared in a minimally invasive way for full-ceramic resto- rations (Figs. 3a–c). The restoration guidelines for n!ce are a rounded design, with no angles or sharp edges, and a shoulder preparation with rounded inner edges and/or chamfer. The manufacturer specifies 1 mm as the minimum layer thickness for complete crowns and partial crowns, which was complied with in the prepa- ration. Construction and milling Digital impressions of the situation were captured with an intra-oral scanner. To prevent mirror images or un- desired reflections, the teeth were first dried to the maxi- mum extent. This was followed by bite registration (scan) and importation of the data into the CAD software. The scans were checked and artefacts were removed. After the virtual model calculation and assignment of the jaws with the bite register, the preparation bound- ary could easily be marked and the insertion axis defined with a few clicks. The automated, biogeneric initial sug- gestion of the software was a valuable aid in construct- ing the restorations. Only minor changes were made to the initial suggestion. The restorations were constructed within a short time (Figs. 4 & 5) and the data was trans- ferred to the CAM machine. In the milling preview, the design was finally checked, for example for values be- low the minimum wall thickness. The n!ce blocks were then secured and the restorations were milled (Fig. 6). Milling was performed in the fine mode and took about 25 minutes. Completion After removing the milled restorations from the ma- chine, the milling pins of the blank were removed with a fine-grain arkansas stone. The restorations milled from n!ce showed finely tapered margins and a 1:1 reproduc- tion of the construction. On trial placement in the mouth, the fit was judged as very good. At some sites, the ap- proximal contact points were adjusted as required. Final polishing of the restorations outside the mouth produced a high-gloss finish. For a natural appearance, the n!ce restorations can be polished with a standard polish- ing set for lithium disilicate glass-ceramic. A classical polishing protocol was used in this case—coarse burs, ceramic polisher, zirconium oxide polishing paste (FEGUPOL ZIRKOPOL, Feguramed) and brushes (Fig. 7)— and the restorations were then cleaned in an ultrasonic bath. The complete crowns and partial crowns were then ready to be fitted. An additional crystallisation firing as for comparable materials is not necessary for n!ce. Insertion The insertion of restorations in the mouth was performed with an adhesive under rubber dam isolation. The same adhesive cements used for lithium disilicate can be used for n!ce. Before insertion, the ceramic restorations were cleaned with phosphoric acid (30 seconds). Conditioning of the bonding surface was performed according to the protocol, with 20-second etching with a 5 % hydrofluoric acid gel. After cleaning and conditioning the teeth, final insertion of the restorations was performed (Figs. 8 & 9), and the functional criteria underwent a final check. The two small amalgam fillings in teeth #34 and 35 were re- placed with direct composite fillings. Conclusion In combination with the intra-oral scanner and the chairside CAM machine, n!ce glass-ceramic offers the possibility of fabricating indirect single-tooth restorations easily, safely and comfortably within the dental practice. The lithium aluminosilicate ceramic is supplied in the fully crystallised state; thus, no crystallisation firing is neces- sary. Mill, polish, seat—the procedure described offers high comfort for the patient and high productivity in everyday practice. about Dr Johannes Beiter holds a Master of Science in Periodontology and Implant Therapy and specialises in these fields. Since 2012, he has been a dentist specialising in oral surgery. CAD/CAM 1 2020 15

industry report | Fig. 4 Fig. 5 Fig. 6 Fig. 7 Fig. 8 Fig. 9 Fig. 10 Fig. 11 CAD/CAM 1 2020 17

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industry report | Fig. 6 Fig. 7 Figs. 6 & 7: Successful placement of the implant. for maximum precision (Figs. 3–5). For tooth #12, we decided to fabricate a thin-walled IPS e.max ceramic restoration (Ivoclar Vivadent). Thanks to digital planning and a carefully fabricated surgical guide, the implant was placed successfully, even though the anatomical conditions appeared to be less than advantageous. We achieved a torque of 30 Ncm and attached a healing abutment to the implant (Figs. 6 & 7). Three months after the implant placement operation, the osseointegration of the implant fixture was com- pleted. A temporary crown was fabricated on the im- plant from a VITA ENAMIC multiColor block to support the formation of soft tissues (Figs. 8–10). We improved the original design on the Straumann superstructure with gum contouring. On tooth #12, crown lengthening was performed with an electrocoagulator (Figs. 11–13). Once the formation of the soft tissues was complete, tooth #12 was minimally prepared for the ceramic crown with the help of a surgical microscope. After the prepa- ration, the teeth were scanned in order to digitally design a custom abutment and crowns (Figs. 14–19). The final smile design was planned digitally together with the patient. For the implant structure, we chose an individual zirconium abutment screw with a ceramic fac- ing and a fully anatomical Empress crown (Figs. 20 & 21). Fig. 8 Fig. 9 Fig. 10 Figs. 8–10: Temporary crown was installed to support the formation of soft tissues. The ceramic facing concealed the excessive brightness of the zirconium, and we were able to achieve the desired colour. Thanks to the digital workflow, we managed to fulfil the wishes of the patient. (Figs. 22–24). Conclusion With digital technologies, the entire implant workflow can be completed in the dental clinic, from planning to fabrication of the restorations. Digital planning in- creases the reliability of the implant treatment and helps the dentist to succeed in the operation. Digital tools allow achieving the maximum functional and aesthetic result even in combined operations in which an im- plant placement and ceramic restoration are performed simultaneously. Fig. 11 Fig. 12 Fig. 13 Figs. 11–13: Crown lengthening was performed on tooth #12. CAD/CAM 1 2020 21

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case report | expectations play a fundamental role, we proceed with the intra-oral examination. Hygiene and periodontal health are checked, and if required, a session for calculus de- bridement, motivation and instruction is scheduled. Nor- mally, the first radiographic examination performed is an intra-oral radiograph for a single tooth (Fig. 1) or a den- tal panoramic tomogram if the need for a more exten- sive treatment is suspected. In the same session, both dental arches are scanned with an intra-oral scanner and the bite is registered. A simple photographic sequence is followed: 1. Full frontal view intra-oral photograph (Fig. 2). 2. Detailed photograph of the single arch, possibly with a black mirror to contrast the teeth (Fig. 3). 3. Photograph of laterolateral detail of the tooth and gin- gival profile (Fig. 4). 4. Full-face photograph with maximum gingival exposure (Fig. 5). 5. Full-face photograph of a spontaneous smile (Fig. 6). 6. Photograph of the full face at rest. This sequence allows one to view immediately the pres- ence of orthognathic and periodontal issues (Figs. 1 & 2), to evaluate the biotype (Figs. 2 & 3) and to estimate aes- thetic challenges, like tooth colour, tooth texture, soft tissue/lip exposure and position of the incisal edge/lip (Figs. 2 & 4–6). The 3D intra-oral scan is extremely helpful for determining orthodontic alignment of the teeth and in our protocol replaces an occlusal and/or 12 o’clock pho- tograph in most cases. “There can be different ways of treating a disease, but there can be only one correct diagnosis.” Dr Morton Am- sterdam, 1974. When anamnesis, intra-oral examination and preliminary radiographs are sufficient to conclude that the tooth in question cannot be preserved, it needs to be decided what the optimal timing for extraction and a CBCT scan is and how to provide for a temporary tooth replacement. Also, the timing of implant placement is es- sential and the operator must choose between immedi- ate, early or delayed placement in the fresh extraction socket. Will there be a (potential) need for bone augmen- tation and/or a soft tissue graft? In short, our policy is the following: in case of acute inflammation that cannot be effectively treated in a way that an infection of the future implant site will be prevented, we will proceed with ex- traction. A temporary fixed etch and bond or removable prosthesis can be used to guarantee acceptable aes- thetic comfort to the patient. In these cases, a CBCT scan will be taken after extraction so that the most detailed im- age of the socket anatomy can be obtained. Since a pro- visional solution has been provided for, there is no need for very early implant placement. Timing is now based on the expected period needed for the infection to be elim- inated and the risk of loss of volume by the collapse of tissue. Normally, the implant is placed four to six weeks after the extraction. Another reason for delayed implant placement can be the need for healed soft tissue in order to facilitate proper wound closure to protect, for example, bone substitutes and membranes when bone augmen- tation is necessary. Additionally, if the patient is suffering Fig. 5 Fig. 6 CAD/CAM 1 2020 25

case report | software that comes with the CBCT X-Mind trium device, STL files can be matched and aligned with the 3D bone volume, thus giving the opportunity to plan the future im- plant position taking into account the shape and posi- tion of the future crown (Figs. 10a & b). In accordance with the prosthetic procedure preferred, cemented ver- sus screw-retained, CAD/CAM-fabricated versus manual layering and the type of material to be used, all the infor- mation for the final treatment plan is available, on which decisions can be made regarding GBR, connective tissue graft and timing of implant loading. Case report The female patient, aged 47 and a non-smoker, was in good general health. She performed regular oral hygiene and had good periodontal health. The patient experi- enced increasing mobility of the maxillary left central inci- sor and complained about compromised aesthetics due to the extrusion and progressive migration of the tooth in a buccal direction. The incisor had been treated with a crown at a preadolescent age after a violent trauma. The intra-oral radiograph showed incomplete root devel- opment and evidence of a root canal therapy suggesting a strip perforation though no signs of periapical lesions were present. The shape of the crown was not symmetri- cal in relation to the triangular shape of the maxillary right central incisor, but had a wider and rectangular profile. Minor general gingival recession had led to the presence of a tiny inter-dental space. The marginal gingiva was reddened, and the central papilla was not symmetrical. Fig. 9 Probing depths were within 2 mm for both the right and left central incisors and the radiographic mesial and dis- tal bone peaks were of a regular height. The photographic aesthetic evaluation showed that it would be very difficult to obtain symmetry in tooth shape and have good-looking and healthy soft tissue support at the same time. The patient’s maximum smile exposed the gingival contours. In such cases, it may be wise to consider also the possibility of altering the anatomy of the contralateral tooth with, for example, a ceramic veneer and discuss outcomes with the patient before finalising Fig. 10a Fig. 10b Fig. 10c CAD/CAM 1 2020 27

case report | Fig. 22 Fig. 23 surgery time and eliminate unpredictable factors inherent in immediate loading, a removable temporary prosthetic tooth was produced in advance. Surgery Local anaesthesia was performed with 2 % mepivacaine with 1:100,000 adrenaline. Preventative antibiotic therapy with amoxicillin (1 g, b.d. for five days) was prescribed, aided by use of a 0.2 % chlorhexidine mouthrinse three times a day for one minute. The tooth was extracted and the sulcular epithelium removed with diamond burs. The milled surgical template (Figs. 12 & 13) served as a guide for the first 2 mm diameter pilot drill (Fig. 14). Thus, the planned depth, position and angulation of the osteotomy were obtained. The drill sequence was completed free- hand, using tapered 3.0 and 3.4 mm drills. A Neoss Pro- Active Tapered Implant of 4 mm in diameter and 13 mm in length was inserted flush with the mesial/palatal/distal bone, motor driven up to a torque of 50 Ncm and then with a manual wrench (Fig. 15). The correct position of the internal hex was verified by checking the references on the implant driver, which ideally points in the buccal direction. Resonance frequency analysis with Penguin- RFA (Integration Diagnostics Sweden) determined an ISQ value of 73/76. At this stage, a Neoss Esthetic Healing Abutment with a ScanPeg was connected to the implant (Fig. 16). A flap was then raised after a vertical incision of the frenulum and the expected buccal exposure of the implant neck was evident. Autogenous bone harvested from the drills was positioned directly on the implant sur- face (Fig. 17), followed by a bone substitute on top of it and on the buccal cortical bone (Fig. 18). This material was covered with a resorbable membrane (Fig. 19). The mobilised flap was then repositioned by rotating it coro- nally and fixed with single sutures (Fig. 20). The remov- able partial denture was adapted and delivered (Fig. 21). An immediate postoperative CBCT scan of 60 x 60 mm was performed, and it confirmed a perfectly centered implant position (Figs. 22 & 23). Intra-oral scan Eight days after surgery, the patient reported that heal- ing was uneventful and the prosthodontist removed the stitches. It has become the author’s standard proto- col to perform an intra-oral scan for implant position in this same session (Figs. 24 & 25). The specific and Fig. 24 Fig. 25 Fig. 26 CAD/CAM 1 2020 29

case report | Fig. 34 Fig. 35 Fig. 36 Fig. 37 material where necessary until the prosthodontist and the patient felt an optimal result had been achieved. Transfer of the profile A new intra-oral scan sequence was performed. First was the scan of the full arch with the temporary crown in place. The provisional was then removed from the mouth and screwed on to an implant replica fixed to a stable support with wax. The second scan revealed in 360° the modi- fied shape of the temporary crown, including the gingival profile (Fig. 33). These files can be easily matched in the CAD software when the technician designs the definitive crown (Figs. 34–36). If a monolithic material is used, the technician may copy the entire shape of the temporary. When a support is needed that will be layered with ceramic afterwards, at least the gingival profile can be duplicated in a reliable way. Fig. 38 Fig. 39 Fig. 40 CAD/CAM 1 2020 31

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case report | Fig. 2a Fig. 2b Fig. 3a Fig. 3b Figs. 2a & b: Initial dental status: right side (a) and left side (b). Figs. 3a & b: Frontal (a) and occlusal view (b) of the study models after extraction of teeth #41, 31 and 32. ture (RPD) with insufficient stability, in combination with chronic pain affecting the mandibular anterior teeth area. She asked for a comprehensive treatment and was not prepared to accept being edentulous at any stage of the treatment. The patient was a non-smoker and—with the help of antihypertensive (Candecor comp. 32 mg/12.5 mg, TAD Pharma) and anti-coagulant medication (quick 30, Marcoumar)—in good general health. The dental status showed acceptable oral hygiene and some teeth with Grade III mobility (teeth #41, 31, 32, 18 and 28) and local periodontal problems, including hori- zontal bone loss (teeth #42, 41, 31, 32, 33, 18, 17, 27 and 28). Teeth #42 and 33 were healthy and not mobile. The alveolar crest in the lateral mandible area showed clin- ically a wide shape with thick keratinised mucosa. The initial panoramic radiograph revealed stable crestal bone Treatment step Product Manufacturer CBCT PaX-Uni3D Virtual implant planning 3Diagnosys VATECH 3DIEMME Implants CAD CAM Provisional FDP Final FDP ELEMENT RC (4.5 x 9.5 mm) Thommen Medical exocad M1 Wet Prefabricated titanium abutments CAD/CAM cobalt–chromium framework Composite veneering and teeth CAD/CAM cobalt–chromium framework Composite veneering and teeth exocad Zirkonzahn Thommen Medical Sintermetall (Zirkonzahn) SR Nexco Paste (Ivoclar Vivadent) Sintermetall (Zirkonzahn) SR Nexco Paste (Ivoclar Vivadent) Table 1: Material and software used for the planning and realisation of the treatment. CAD/CAM 1 2020 37

case report | Fig. 6a Fig. 6b Fig. 6c Figs. 6a–c: Occlusal view showing CAD of the provisional FDP framework (a) and close-up views from the interface between the CAD framework and the prefabricated titanium abutments (b & c). phylactically one hour prior to surgery. This treatment continued for five days (1 g of amoxicillin and clavulanic acid twice a day). Prior to the start of surgery, the patient rinsed with 0.2 % chlorhexidine for one minute. Local anaesthesia was induced using a 4 % articaine solution with 1:100,000 adrenaline. The two-step approach entailed the flapless, guided insertion of four posterior implants (ELEMENT RC, 4.5 x 9.5 mm; Thommen Medical), using the first sur- gical template, which was tooth- and mucosa-sup- ported (Fig. 8a). The template was then removed and teeth #42 and 33, which had supported the guide, were extracted. Thereafter, the second surgical tem- plate was positioned and stabilised on the four poste- Fig. 7a Fig. 7b Fig. 7c Fig. 7d Figs. 7a–d: CAD/CAM model with the prefabricated titanium abutments (a), CAD/CAM cobalt–chromium framework (b) and composite veneered provi- sional FDP (c & d) before bonding to the abutments. rior implants with the help of specific abutments and the same anchor pins (Fig. 8b), thus allowing guided placement of implants (ELEMENT RC, 4.5 x 9.5 mm) in positions #42 and 33 immediately after the extractions. All the implants were inserted at a torque of 35 Ncm and had good primary stability. CAD/CAM 1 2020 39

case report | served (Fig. 16). The patient was very pleased with the aesthetic and functional outcome. Thus, the performed treatment was successful, and it showed stable results without complications or the need for maintenance ser- vice after the first year. Discussion The use of CAI software in the preoperative virtual 3D implant planning allowed for guided and immediate im- plant placement, and proved to be especially beneficial in the mandibular full-arch case presented. While there are some studies that have investigated outcomes of im- mediately loaded implants placed in edentulous patients using computer-aided, template-guided surgery to sup- port an FDP,25 only few case reports are available in the literature that describe the entire workflow, the patient’s state in detail and the usage of guided surgery templates with subsequent immediate loading.3, 4 The considerably more complex combination of immediate implant place- ment and immediate loading required a high level of organisation between the implantologist and technician, minimising the required compliance of the patient. Pozzi et al. reported excellent results with CAD/CAM cross- arch zirconia bridges on immediately loaded implants placed with computer-aided, template-guided surgery.26 Several investigators have presented analyses of recent studies in this context, elaborating on the factors that in- fluence accurate implant placement but also the com- parable outcome of the restorations after guided im- plant placement.15, 20, 21, 27–31 In the present case report, two CAD/CAM surgical templates were combined in this partially dentate patient, with extraction of teeth #42 and 33 and immediate implants performed in a sequenced order. The first scanner-based template was tooth- and mucosa-supported, enabling a higher template stability and thus more accurate guided osteotomies and implant placement. Four posterior implants were placed with this approach, allowing support of the second surgical tem- plate after extraction of teeth #42 and 33. The stability on these four points was high, as the implants in posi- tions #42 and 33 showed a torque value of 35–40 Ncm each. The placement of the subsequent two anterior im- mediate implants was thus perfectly guided. Different factors contributed to this insertion torque, such as the depth of the planned implant position in a more apical area than the extraction site, the minimally invasive tooth extraction, the macroscopic implant geometry and the osteotomy protocol with a smaller drilling diameter compared with the implant diameter (as proposed by the company), the accurate performance of the single steps in the pre- and intra-operative phases, and the bone den- sity in the anterior mandibular area. The prefabricated provisional FDP was prepared to connect the abutments to the FDP intra-orally, which was easily performed, given the accurate implant positions. With this approach, the Fig. 13a Fig. 13b Fig. 13c Fig. 13d Figs. 13a–d: CAD/CAM-fabricated one-piece cobalt–chromium framework before (a & b) and after veneering with composite (SR Nexco Paste, Ivoclar Vivadent), that is the final FDP (c & d). passive fit of the FDP was maximised, the clinical chair- side efforts (in terms of abutment connection and occlu- sal adaptations) were minimal and the predictability was very high compared with the various limitations and prob- lems reported in a recent review.32 The preoperative communication between the dentist and the technician during the decision-making and plan- ning phase was essential for concise timing in the clinic, ensuring the highest surgical and prosthodontic perfor- mance accuracy in this particular case. Therefore, up-to- date software and hardware, as well as the knowledge of how to apply the specific products, were required. This CAD/CAM 1 2020 41

special | Fig. 4 Fig. 5 Fig. 4: Titanium abutment screwed on to the implant. Fig. 5: Determination of the basic shade with the VITA Linearguide 3D-MASTER. Layering procedure The zirconia coping was virtually designed, milled, sintered and fitted. An initial wash firing with VITA VM 9 EFFECT LINER (VITA Zahnfabrik) was a crucial step in adding a fluorescent layer to the non-fluorescent zirconia coping. The liner also provided reliable bonding to the framework. The firing temperature should be 50° higher than that of normal dentine firing. VITA VM 9 BASE DENTINE 3M3 (VITA Zahnfabrik) with a higher chroma was used in the cervical area to mask this critical area and to mask the lifeless and greyish appearance of the titanium abutment. EFFECT CHROMA 4 (yellow; VITA Zahnfabrik) was then applied with a deeper orange in the interdental areas with a mixture of EFFECT CHROMA 5 (golden rod) and 6 (sun- flower; VITA Zahnfabrik) to enhance the masking effect. For the incisal third area, a higher value was selected with 3M2. To create the ridges, the bluish EFFECT ENAMEL 9 mixed with ENAMEL LIGHT (VITA Zahnfabrik) was chosen (Figs. 6a–f). The synergy of these three basic components is essential for the incisal edge: colour, enamel and translucency. VITA VM 9 ENAMEL LIGHT and EFFECT ENAMEL 9 were layered to create a bluish accentuation and replicate natural aesthetics. In addition, VITA INTERNO 2 (sand) and 4 (orange; VITA Zahnfabrik) were added to replicate the character- istics of the contralateral tooth. VITA INTERNO ceramics played an important role in increasing fluorescence and natural warm colour effects with internal characterisation. These characterisations should always be arranged ir- regularly for a natural appearance. To achieve a contrast, BASE DENTINE was layered on to the palatal side of the incisal edge. During contouring, the ceramic mixture must remain creamy and stable to achieve an efficient and Fig. 6a Fig. 6b Fig. 6c Fig. 6d Fig. 6e Fig. 6f Figs. 6a–f: Master dental technician Patrick Rutten at work (a). Layering of the dentine core (b). Creation of the mamelons (c). Layering of the enamel (d). Characterisation with INTERNO (e). Result after the first dentine firing (f). CAD/CAM 1 2020 45

special | Fig. 10 Fig. 11 Fig. 12 Fig. 13 Fig. 14 Fig. 10: Evaluation before glaze firing. Figs. 11 & 12: Cemented maxillary right central incisor crown intra-orally and periapical radiograph. Fig. 13: Natural and aesthetic smile. Fig. 14: Close-up lateral view of the maxillary incisors. were created with a fine diamond instrument to produce a fluent curvature toward the apex. After the fine-structured feldspathic ceramic had been fired, the subgingival areas were contoured and polished with a rubber wheel to create a smooth and compatible environment for the surround- ing soft tissue. The chipped adjacent tooth was matched in the restoration, although in a different location for a more natural outcome. A vertical crack line was accom- plished with a fine tungsten carbide bur. The technician can place the cracks 2 or 3 mm away from the position on the cor responding neighbouring tooth, since the crack line should be irregular. Final characterisation was achieved with VITA AKZENT Plus EFFECT STAINS (VITA Zahnfabrik) and then fired. I try to create something soft without overdoing it. Make the best, but keep it simple! The goal should be to keep the technique straightforward and to know when a restoration is finished so that time is not wasted and cost goals are met. Consequently, every veneering procedure should be consistently ended at some point. The crown was clinically evaluated before the final glaze firing (Figs. 9 & 10). After evaluation of the aesthetics, function and occlusion, the restoration was finalised in the dental laboratory and definitively cemented (Figs. 11–14). The restoration looked exceptionally natural and integrated harmoniously in the aesthetic zone. Texture and ceramic layering created a highly aesthetic combination of contour and colour. The crown supported the gingival architecture and was thereby able to ac- complish pink aesthetics. The patient was delighted with his new restoration and appreciated the outcome. Thanks to expertise, technical skills, interdisciplinary team- work, and outstanding ceramics, a challenging clinical case was solved in a highly aesthetic manner. Editorial note: This article originally appeared in dental dialogue 5/2016, published by teamwork media. Its edited version has been reproduced here with permission. about Patrick Rutten graduated in dental technology from the Anneessens dental technology school in Brussels in Belgium. After completing his training, he moved to Cologne in Germany to specialise in different milling and ceramic layering techniques. Together with his brother, Luc, he has lectured regularly all over Europe and in Australia, India, Israel, Japan, South Africa, Saudi Arabia, and the US. In addition to regularly writing numerous articles published in international dental journals in the field of aesthetic implantology, he has co-authored several textbooks and the books Implantat Ästhetik (teamwork media, 1999) and Crown—Bridge and Implants: The Art of Harmony (teamwork media, 2006). Together with his brother, he maintains a dental laboratory in Tessenderlo in Belgium dedicated to ceramic restorations and aesthetic implantology. He is an active member of the European Academy of Aesthetic Dentistry and of the International Academy for Digital Dental Medicine. CAD/CAM 1 2020 47

industry | “We will continue to support all the partnerships we have throughout the industry.” How has the announcement of the acquisition been received by the industry so far, and how will it affect your business? Overall, we have received a great deal of positive feedback from our customers and from the users as well. However, there have also been some mixed reactions. The thing that people wondered about most was whether they would be able to continue to purchase our products and whether we would remain as open as we are today. We would like to give everyone who has similar concerns full assurance that we will continue to support all the partnerships we have throughout the industry and that we will still have independence within the Align collaboration to do that. Market research forecasts that the global CAD/CAM market is expected to grow continuously. Do you hope that this will give your company preferential development? In past years, exocad grew faster than the market, and I expect that to continue in the future. There are some parts of the world where, by comparison, we are still a bit under-represented, and I think that, by being acquired by a larger company, we will be able to have more impact. How will the exocad users benefit from the collab- oration? Even though some dentists use our software solutions, most of our users are laboratory technicians. Among other things, they will benefit from further improvements and in- tegration with the installed base of iTero intra-oral scanners. As far as dentists are concerned, there will be extremely interesting solutions for orthodontic restorative purposes, although it is still too early to comment on details in this area. This year, exocad will be celebrating its tenth anniver- sary. In the past, what were the biggest milestones for exocad? And what are you hoping to achieve in the next ten years? The first milestones were the ones we mastered while we were still employees at the Fraunhofer Institute. These included finding major partners from the industry who would sell CAD/CAM systems based on our CAD tech- nology. So far, we have all been very successful with that, and everyone benefited from working together. The next big challenge was geographic expansion. We still are a much smaller company than our competitors, and get- ting a foot in the door in Asia or the US was not that easy. But I am very happy with what we have achieved in that respect. In the US, we have a great team and a signi ficant market share, and in Asia, we are the market leader; we consider these achievements to be major milestones. In assessing the future, I think that, today, even though there are various integrative approaches, we still find a dominance of isolated and non-connected solutions in digital dentistry. So, we have CAD/CAM software, software for guided surgery, an orthodontics solution and so on. And they are not optimally linked, as the cross-disciplinary workflows are quite cumbersome. I think that, in the future, there will be very few platforms across the disciplines that will allow more holistic and digitally supported treatments. This idea is something that fascinates me and could greatly benefit our customers, and this is something we want to build together with Align in the future. “I am very happy with what we have achieved.” CAD/CAM 1 2020 49

manufacturer news | through the intaglio surface of the denture base. After the teeth have been placed in the inLab software, the denture base is designed with the corresponding tooth pockets. A special positioning system is used, which facilitates the subsequent attachment of the acrylic teeth and thus accelerates the posi- tioning and bonding of the teeth. For the individual tooth set-up morphology, shape and occlu- sion can be individually designed after the positioning. This allows specific patient situations to be taken into account or individual tooth shapes to be created. The complete tooth arch can be completely fabricated or, depending on requirements, divided into several segments down to the individual tooth. After the denture has been designed, a monolithic try-in can be fabricated. Staying flexible in production The subsequent manufacturing process can be carried out using various methods; for example, the denture base can be milled out of a blank, such as Lucitone 199 Denture Base Disc from Dentsply Sirona, or manufactured in 3D printing material, such as Lucitone Digital Print 3D Denture Resin. Depending on the tooth set-up selected, the tooth arch or segments are milled out of a disc, or the prefabricated IPN 3D Digital Denture Teeth are used. The inLab system continues to follow the principle of seamless, validated and open connection to suitable manufacturing pro- cesses, whether with inLab MC X5 from Dentsply Sirona or via the optional interface with other suitable production units using the milling or 3D printing processes. Digital dentures with inLab—an option for any preference InLab software offers a fast, simple and reasonably economical entry into digital fabrication and opens up the digital path that suits the dental laboratory best. The new application is integrated into the inLab SW 20.0 removables module. More information can be found at: dentsplysirona.com/digital-denture Owing to various certification and registration periods, not all products are immediately available in all countries. AD

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industry | and user friendliness. The speed at which restorations can now be manufactured represents an economic and a structural value—for dental practices and, above all, for patients. For treatment durations of more than 75 to 90 minutes, renewing anaesthesia is almost always necessary. With the new CEREC workflow, a patient can be treated in only one session without having to receive another local anaesthetic. In terms of accuracy, the newly developed fine tools ensure that fissure details can be very precisely drilled out. Furthermore, when combined with the easy-to-use touch interface, the technology practically eliminates minor errors, such as those that can occur when choosing tools or materials. That’s what “made easy” means to us. After the successful introduction of the Primescan intra-oral scanner last year and now the CEREC Primemill, Dentsply Sirona is staying focused on innovations in chairside dentistry. Is this the area in which you see the greatest development potential? We were pioneers in this area. Today, we are clearly the market leader and will continue to drive chairside technologies forward. In this respect, we adapt to the varying needs of our customers. Many of them don’t want to plunge straight into single-visit dentistry, but would rather get to know the digital process first and continue working with their laboratory. This is why, for instance, we entered into an extensive collaboration with exocad in the area of digital dental workflows last year. Despite the steadily growing range of digital prod- ucts on the market, many dentists remain on the threshold of digitalisation. What is Dentsply Sirona doing to advance the level of digitalisation in den- tistry, and what role do you think dental education plays in this regard? The penetration of digital technologies in dental practices is growing noticeably. Dentistry is currently going through a crucial transition period. We have recently become very strong in this area also, owing to the successful launch of Primescan. However, there is no question of the market being saturated yet. From our perspective, the CEREC system that we have today is more attractive than ever before. Hence our slogan “Now is the time—the all-new CEREC”. We believe that the system has reached a level of maturity that enables an interested user to change his or her practice in a commercially effective way over a relatively short period. Education is of huge importance in this regard. Dentists and dental technicians are people who work with their hands, and they want and need to experience the prod- ucts themselves. Presenting something exclusively on screen can certainly arouse interest. However, we are convinced that it is only through personal experience that interest turns into enthusiasm. That is why events and continuing education courses at which our products “From our perspective, the CEREC system that we have today is more attractive than ever before.” can be experienced first-hand are an important building block for us in winning over customers. Dentsply Sirona sees itself as a full-service provider. How important is the CEREC system in your product portfolio? CEREC is extremely important. The digitalisation of dental practices will influence and advance many other develop- ments in the group as a whole. Our technological advan- tage helps us to tie in other technologies and improve them further. The entry into the CEREC workflow also impacts upon other areas of our work, for example that of materials. Here too, we are constantly making new developments so that the customer can get everything under one roof. What role will CEREC play in the dental practice of the future? This touches on the question of the clinical gold standard of the future. Nowadays, the traditional workflow using conventional impression and laboratory production is essentially the clinically established workflow. However, I believe that this will have to be reassessed in the years to come, especially in light of technological progress. The purely manual workflow can often bring about excellent results, but this is not always true and, above all, does not always happen consistently. The results depend heavily on the practitioner, his or her skills and the way he or she feels on the day. With a digital workflow, these factors only play a minor role. Digitalisation offers great advantages in terms of excellent, predictable results. The estab lishment of a new gold standard must come from clinical practice, however. We are aware that many clinicians are already investigating this. “The purely manual workflow can often bring about excellent results, but this is not always true and, above all, does not always happen consistently.” CAD/CAM 1 2020 57

education | At the school, we’re using digital dentistry solutions for crowns, bridges, veneers, implants and so on, but we now have to integrate it into CBCT imaging and surgical guide printing. I think the current students are getting into dentistry at one of the most exciting times in dental history. I’m passionate about this and want Maryland to be at the forefront of dentistry. Is the learning curve greater for students now that they have to learn these digital technologies? There really is no learning curve. These students pick it up within minutes, to a point where they understand it better than I do! They grew up with computers and are naturally drawn to this technology, are passionate about it and are excited to bring it into their future dental practices. Many of our graduates who apply for jobs working un- der older, more experienced dentists are also already ahead of the rest of the pack as a result of their famil- iarity with digital dentistry. The older dentists might be a little nervous about integrating CAD/CAM technology into their dental practices, but realise that CAD/CAM is none- theless the future of dentistry. Do you think that the price of investing in CAD/CAM tools and technologies can be prohibitive? Let me begin with the private practice. The return on investment is clear: If you buy this technology, it can of- ten pay for itself within a few years as a result of savings. If you mill in-house or simply digitally scan at your prac- tice and still send away to a dental laboratory for fabri- cation, you will be saving money over using conventional techniques. In my opinion, all dental schools are, to some degree, struggling with this decision. Clearly, they know that they have to do this, that it is incumbent on them that they teach their students this technology, since if they don’t, they are not properly preparing them for their future practice. Yes, the financial cost can be a barrier, “I soon became aware that, not only was this CAD/CAM equipment good for same-day dentistry in a private practice setting, but it could also be utilised as an incredible teaching tool.” but this is clearly outweighed by the benefits that come with integrating CAD/CAM devices into current methods of teaching. Is there a role for industry to play in supplementing this classroom learning? My thinking is that, yes, it can play a role. As teachers, we can go back to the manufacturers and tell them what we would like to see in their evaluation software and they will work on it. There is a collaboration between dental school education and the manufacturers that becomes a win-win situation. The manufacturers know that, if the students are being taught digital dentistry, then chances are, when they get into private practice, they’ll move in that direction. CAD/CAM 1 2020 59

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