issn 2193-4673 • Vol. 1 • Issue 1/2021 1/21 3D printing international magazine of dental printing technology interview “3D printing in dentistry is much more than just a new technology” case report A fully digital workflow in implant and restorative dentistry trends & applications Printing clear aligners in-house—how accessible is it?

editorial | Dr George Freedman Editor-in-chief 3D printing: Revolution in dentistry 3D printing has arrived in dentistry. Like with the other great paradigm shifts of the past 50 years in the profession (cosmetic dentistry, implants and diagnostics), major ad- vances are very apparent on the near horizon. The needs are many, the technologies numerous, the applications almost unlimited and the potential open-ended. Just like cosmetic materials and techniques brought aesthetic restorative dentistry into the hands of every practitioner, 3D printing promises to bring functional and artistic con- trol of the restorative process into the chairside setting. The digital transformation of dentistry, including CBCT, intra-oral and extra-oral scanning, milling of ceramic and composite materials, and robotic implant placement, is firmly established. Stereolithography, first developed in the 1980s, was soon followed by additive manufacturing, the deposition of ma- terial in increments. Dental applications are more recent. 3D printing has been utilised for rapid prototyping and modelling for more than a decade. The size and cost of the earlier printers meant that they were limited to larger lab- oratories. The most recent desktop printers have a much smaller footprint, are easily affordable for the single prac- titioner, communicate with existing software platforms and offer high levels of precision with a wide range of materials. The documented, wide-ranging 3D-printing applications can be grouped by treatment category: – Fixed prosthodontics: Permanent and provisional indirect restorations (crowns, onlays, inlays, bridges) and permanent monobloc direct restorations can all be custom-fabricated chairside within minutes of scanning the preparation. – Removable prosthodontics: Both complete and partial dentures, including digital occlusal design, are deliver- able within hours. – Implant dentistry: 3D printing of surgical guides has facilitated ideal implant positioning. Biomimetic custom 3D-printed bone implants replace missing segments, minimising stress transfer to the remaining bone. – Orthodontics: Aligners, designed using CBCT data and artificial intelligence extrapolation of tooth move- ment over time, are 3D-printed. – Endodontics: The pioneering 3D-printed endodontic access guide, utilising CBCT data, translates pre- surgical planning into clinical success. – Maxillofacial surgery: Custom-designed bone grafts and fixation plates expedite both the surgical proce- dure and the healing process. – Periodontics: 3D-printed guides that relieve and retract gingival margins offer aesthetic gingival correction. Soft-tissue printing is currently in the research phase. Current 3D printers are fully capable of managing the great demand for temporary, transitional, and perma- nent restorations and appliances and of achieving the clinical excellence required by the dental profession. Consequently, there has been a growing acceptance of this transformative technology. Increasingly, 3D printing is viewed as an industry game-changer and a forecast of the future direction of the dental practice. 3D-printing techniques and procedures are high-quality, high precision, accurate and significantly lower in cost than conventional treatment options. Dentists save money: many desktop printers cost between US$3,000 and US$10,000, and dental 3D-printing materials cost pennies per tooth. Patients save money, by the elimina- tion of intermediate procedures and transportation costs. Treatment is faster, typically same-day services. 3D-printing techniques include stereolithography, fused deposition modelling, selective laser sintering, powder binder printing, photopolymer jetting, electron beam melting and direct light processing. Welcome to 3D printing! Welcome to the future of dentistry! Dr George Freedman Editor-in-chief 3D printing 1 2021 03

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industry | Fraunhofer IWS in Dresden, told Dental Tribune Inter- national (DTI): “One of the main objectives of ATeM is to in- crease the technology readiness levels of current research activities in dentistry, for example by introducing novel ma- terials or by integrating additional functionalities; another important goal is the transferral of these to companies —especially to small and medium-sized enterprises— in order to make the new products readily available for clinical practice.” New functionalities in dental prostheses In the dental field, Fraunhofer scientists are investigating new areas of application for 3D printing in dental pros- thetics. “There is great potential in the use of innovative materials and the integration of additional functionalities in dental prostheses to increase the wearing comfort for the patient,” Brückner commented in a press release. When asked about the properties and functionalities that were being investigated, Brückner said: “The main purpose is to provide dental components with new function- alities, to improve their aesthetic appearance and to opti- mise present fabrication routes.” For example, new func- tionalities can be achieved through intelligent implants. He explained: “For this purpose, sensors for certain bio- markers are integrated into dental components during the manufacturing process. These can then provide information to the dentist regarding the healing progress or the occurrence of complications.” Fraunhofer IWS mentioned some of the applications that are being investigated in the dental field, stating that advancements in additive manufacturing could al- low for faster treatment and the printing of significantly more complex dental implants immediately after the oral cavity is scanned using an intra-oral scanner. Additive processes could also be harnessed in order to combine metal and plastic materials for improved aesthetics, and the production of dental prostheses could also be made faster and more efficient, both in terms of treatment costs and resources. Tailoring orthodontic appliances to patients and streamlining manufacturing Developments in additive manufacturing could also en- able orthodontic treatment time to be reduced and brack- ets to be individualised for patients. Brückner explained: “For visible orthodontic components, such as brackets, a targeted multi-material composite design might enable the combination of functionally optimised internal struc- tures, which could bear the mechanical load, with a patient-specific aesthetic external design. In this way, a significantly improved aesthetic appearance of the orthodontic appliances could be achieved, which is es- pecially desirable in the anterior region.” Dentists well know that many dental products are still manufactured using a number of manual steps. Additive manufacturing already allows for the partial substitution of what can be expensive and time-consuming tasks, and ad- vancement in 3D-printing processes could lead to greater savings of resources in the dental practice and laboratory. The institute explained, for example, that it is examining established process chains for the production of dental components in order to identify possibilities for the seam- less integration of 3D-printing technologies. Brückner com- mented: “A major focus is on the end-to-end digitalisation of the process chain from data collection—for example, using an intra-oral scan—through manufacturing to appli- cation. As a result, waiting times and costs for complex dentures could be significantly reduced for the patient.” Investigating innovative materials and data acquisition The project is a collaboration between the Fraunhofer IWS in Dresden, the Fraunhofer Institute for Machine Tools and Forming Technology IWU in Chemnitz in Ger- many, and the Faculty of Mechanical Engineering and the Center for Advanced Manufacturing Technologies at Wroclaw University of Science and Technology in Poland. This network of partners implicates a wide range of ad- ditive technologies, including stereolithography or fused filament fabrication, for example, which can be used to process a wide range of polymers that offer a significantly better aesthetic appearance in the oral cavity than metals do—particularly in visible areas. Brückner explained that metals, however, play an im- portant role in many load-bearing applications, such as implants or prostheses, and that various processes are available for metal-based additive manufacturing. “For example, even challenging materials can be processed into highly complex, near-net-shape components. Binder jetting also enables the production of complex compo- nents, and unlike other powder bed-based processes, no support structures are required, and good surface qualities can thus be achieved in the process,” he said. In addition to materials that are well established in the den- tal field, such as titanium-based and cobalt-chromium- based alloys, the scientists at ATeM are also investigating innovative materials that offer, for example, better wear- ing comfort for the patient, a reduced risk of plaque ad- hesion or the integration of sensor technologies which could be used to facilitate increased data acquisition. Additive manufacturing processes are already highly dig- italised; however, scientists at ATeM are aiming to further optimise them in order to incorporate a seamless inte- gration of these processes into digital data acquisition in dentistry. Brückner explained: “For example, dental res- torations can be built up directly based on the data of an 3D printing 11 1 2021 11

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industry | 3 Fig. 3: 3D-printed temporary bridge made of VarseoSmile Temp. (Image: © BEGO) technology. He stated: “What makes 3D printing the technology of the future is the commitment of the pro- fessionals who work tirelessly to improve and elaborate the existing printing techniques and to explore and ex- ploit new possibilities. As far as SprintRay is concerned, 3D printing will be future-proof.” 3D-printing applications in dentistry Some of the 3D-printing technologies that are currently available and used in the dental industry include digital light processing, selective laser melting, stereolithography and fused deposition modeling. All areas of dentistry are covered by 3D printing, including printed study models, surgical guides, metal frameworks, dental pros- theses, temporary crowns and bridges, permanent restorations, occlusal splints, aligners, and removable dentures. Prof. Markus Blatz, who is chair of the Department of Preventive and Restorative Sciences and assistant dean for digital innovation and professional develop- ment at the University of Pennsylvania School of Dental Medicine in Philadelphia, US, previously told DTI that he believes 3D printing to be the future of restoration fabrication in dental laboratory technology and that it is likely to be used for all types of materials and res- torations. In a previous interview with DTI (CAD/CAM 1/2021), prosthodontist Dr. Ryan C. Lewis noted: “3D printing has changed the way that we produce surgical guides. 3D printers have become so accurate and inexpensive that any dentist can now afford to have them in his or her office and print surgical guides as well as casts for diagnostic purposes or aligners at a relatively low cost.” He added that going back to traditional dentistry would have a significant impact on costs, efficiency, quality of work, and ability to communicate with surgeons and dental technicians. The advantages of 3D printing over CAD/CAM technology 3D printing, or additive manufacturing, consists of add- ing material. In contrast, milling is a method that involves subtracting material. Labor told DTI that additive manu- facturing is more cost-effective than subtractive computer- aided manufacturing and explained that it produces less waste. Additionally, 3D printing is highly accurate, faster for many indications and offers increased pro- duction efficiency since the user can produce printable solutions in volume. Finally, Labor stated that additive manufacturing boasts consistency, which is crucial for successful product fabrication. He explained: “3D-printing technology has proved to be more accurate and more consistent in replicating consistency when mass-producing. When using the analog way of fabricating dental apparatus, you can never replicate a process with exactitude, and we all know how important consistency is in pro- duction.” Investing in new technology is a way of reaching and establishing high standards of patient care. As Patrick Thurm, the managing director and general manager for Europe at SprintRay noted, dentists and laboratories are currently seeking efficient solutions for their practices and their patients post-pandemic, and a 3D printer, such as the one from SprintRay, could be a great asset to dental practices, laboratories and patients. 3D printing 15 1 2021 15

opinion | by high pressure or mixing with a catalyst. It is also known as stereolithography, and commonly referred to as SLA. 2. Laser sintering with both for metals and thermoplas- tics is an additive manufacturing process that be- longs to the Powder Bed Fusion family. A laser selec- tively sinters the particles of a polymer powder, fusing them together and building a part, layer by layer. It is known as selective laser sintering and commonly referred to as SLS. Laser sintering is very expensive, with high maintenance costs, but delivers amazing results. 3. Extrusion is a 3D printing process that uses a contin- uous filament of a thermoplastic material. It is known as fused filament fabrication or fused deposition modeling and commonly referred to as FDM. This technology is based on feeding a modelling filament through a heated nozzle, and printing layer by layer. While very affordable, FDM’s accuracy and service quality are quite limited with respect to dental appli- cations. Various companies utilise differing photopolymerisation technology categories: 1. SLA—Stereolithography printing exposes the liquid resin to a laser light source. 2. LFS—Low force stereolithography can be described as SLA’s successor. It uses a flexible tank and linear illumination to polymerise liquid resin. 3. DLP—Digital light processing exposes the liquid resin to a DLP projector light source. 4. LED—New technology that uses LED instead of laser light sources for the additive manufacturing of metal parts and optimises 3D metal printing. However, the underlying principle is the same: a polymer- ising light hardens the resin to a solid-state layer by layer. DLP or LED techniques offer faster results, while SLA and LFS modes provide smoother and finer details, but the process is significantly slower. There are numerous dental applications for 3D printing.2 In fact, there are many applications that are not possible without 3D printing (aligner thermoforming models, indi- rect bonding trays). 3D printing can enhance traditional techniques such as surgical guides, custom impression trays, diagnostic models, splints, restorative models, and provisionals. And there are novel 3D printing opportunities such as full dentures and permanent indirect and direct restorations. In my daily practice, I find many situations where 3D print- ing allows me to offer existing services more predictably and rapidly. Currently available options include provi- sional crown and bridge restorations, inlays, onlays and veneers. The ability to print splints represents a tremendous ad- vantage; a reliable inhouse splint can be completed in a single appointment whereas sending the case to a dental laboratory is far less efficient and much more ex- pensive. The routine use of rapidly printed surgical guides improves the patient’s perception of surgical procedures, speeds treatment, and assists in predictable results for every case. In-house 3D printing reduces the waiting time before surgeries.3 In the past, it was extremely difficult to treat fully eden- tulous patients with significant bone loss. Ultimately, the limitations of dentist–technician communications made the process long and tedious, and results were often less than satisfactory. It was also frustrating that during this time-consuming ordeal the patient had no access to pro- visional dentures. 3D-printed full dentures, available the same day, offer a practical solution to both patient and dentist. Scanner, 3D printer and an in-house technician are the ideal. As with any new technology, 3D printing has a learn- ing curve. It is highly recommended that the practitioner begins with simpler procedures, and then tackles more complex ones as experience and confidence are accu- mulating. 3D-printing technology is a game changer in the dental industry that will greatly influence and modify patient treatment in the years to come. 3D printing, taken together with CAD/CAM and CBCT, creates a comprehensive shift to digital dentistry, a trend that is rapidly redefining the dental profession. Editorial note: A list of references is available from the publisher. This article originally appeared in Oral Health Magazine, and an edited version is provided here with permission from Newcom Media. about Dr Florin Lăzărescu owns a private dental practice in Bucharest in Romania and in his work focuses on aesthetic dentistry with an emphasis on all-ceramic and implant restorative procedures. He is the author of numerous publications on dentistry, and he is the editor of and a contributing author to the Romanian book Incursiune în Estetică Dentara (Immersion in Esthetic Dentistry, Society of Esthetic Dentistry in Romania, 2013)— republished in English as Comprehensive Esthetic Dentistry (Quintessence, 2015) and in Chinese (Qiuntessence China, 2017). He is editor-in-chief of Dental Tribune Romanian Edition. Dr Lăzărescu is the president of the European Society of Cosmetic Dentistry and a founding member and director of the Society of Esthetic Dentistry in Romania. 3D printing 1 2021 17

opinion | 4 5 Figs. 1 & 2: Dental technology impresses with its wide range of materials and the prosthetic restorations fabricated from them. IDS 2021 demonstrated new options and attractive business models. (Images: © Koelnmesse/IDS Cologne/Harald Fleissner) Figs. 3–5: The variety of materials and processing techniques in the dental laboratory is enormous: gold, non-precious alloys, ceramics, CAD/CAM and manual working techniques. (Images: © Koelnmesse/IDS Cologne [Figs. 3 & 4]/Christian Ehrensberger [Fig. 5]) Fig. 6: A procedure with high potential: 3D printing of special dental resins. (Image: © BEGO) or complete denture or are even fabricated in one piece through this technique. Furthermore, mock-ups can be printed from try-in resins. In implantology, a drilling template ensures that the surgeon locates the optimum position and angle deter- mined during planning. Printed orientation templates with separate cranial and caudal sections help during exter- nal sinus lift: blood vessels that run through the access are protected. In endodontics, printed orientation templates make it easier to locate a root apex for resectioning. In ortho- dontics, high precision is achieved with positioning trays (indirect bonding trays). The positions of the brackets are initially planned virtually, and the brackets then have to be cemented precisely in the correct position in the patient’s mouth. The template printed from resin provides additional security in this regard. the latter, for example, can prove useful in situations where the dentist requires assistance or when an instru- ment fails, if a 3D printer is available and the necessary digital infrastructure is in place and so on. Why not simply print several copies of the required instrument accord- ing to a blueprint? This works for simpler aids anyway. A holding device for a bag of isotonic saline solution, for example, can be printed quickly and precisely for a den- tal unit as described by Dawood et al.1 This demonstrates above all that 3D printing stimulates the creativity of all involved! Reference 1. Dawood A, Marti Marti B, Sauret-Jackson V, Darwood A. 3D printing in dentistry. Br Dent J. 2015 Dec;219(11):521–9. doi: 10.1038/ sj.bdj.2015.914. Erratum in: Br Dent J. 2016 Jan 22;220(2):86. about The basic strength of 3D-printed objects lies in their pos- sible implementation as one-offs or as a small series— Christian Ehrensberger is a dental journalist from Frankfurt am Main, Germany. 6 19

interview | 2 Fig. 1: Master dental technician Stephan Kreimer believes that digital technologies such as 3D printing will help establish new standards of care in dentistry and create new business models. Fig. 2: Stephan Kreimer bought his first 3D printer back in 2016 and has significantly scaled up digital production in his dental laboratory ever since. I was betting strongly on innovative technologies such as CNC milling and 3D printing and closed collabora- tions with leading manufacturers, including 3Shape and Formlabs. Smartly combining the passion for aesthetics and craftsmanship, which is inherent to our industry, with the enormous potential of digital technologies is definitely the way forward. Your dental laboratory has eagerly adopted digital technologies into its workflow. Could you tell us more about it and discuss some of the digital solutions you are using? It has been a journey. We started as a conventional den- tal laboratory and have been operating with traditional workflows for over 30 years. In 2009, we adopted our first CAD software but outsourced all of our digital produc- tion to service providers. Things changed quickly when we invested in our first 3D printer, a Formlabs Form 2, in 2016. At the time, the system was not optimised for dentistry, but it was clear that it had great potential. Within the less than five years since then, most of our customer base has adopted intra-oral scanners and we scaled our digital production capabilities significantly. Today, we use an imes-icore milling machine and multiple 3D printers that run almost 24/7 and work with both 3Shape and exocad. Around 70% of our customers send us digital impressions. How did you integrate digital technologies, including 3D printing and CAD/CAM, into your laboratory? It was definitely through trial and error. Especially in the early days, which was just a few years back, 3D printing was not well optimised for a dental workflow. Interfaces to materials, software and other workflow requirements “Combining the passion for aesthetics and craftsmanship, with the enormous potential of digital technologies is definitely the way forward.” have not been coordinated well between different man- ufacturers. This has led to the formation of a highly ac- tive international community of dental technicians who exchange through social media what they have learned. Personally, I’ve learned a lot from my peers around the world, and I’m equally giving back to the community 3D printing 1 2021 21

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interview | However, other countries are catching up quickly, as the benefit of reduced production costs, time to market and patient satisfaction are valid in every market. What impact did the COVID-19 pandemic have on the dental 3D-printing market and on your company in particular? The beginning of the pandemic was an unprecedented time for all of us. However, many dental professionals 3D printing 1 2021 25 Recently, we have welcomed several dentists, ortho- dontists and dental laboratories to our showroom and have spread our message in webinars and online. We are proud to be working with dental key opinion leaders who quickly adapted our solutions into their practices and laboratories. We work with leading dental distributors across Europe and have attracted a great amount of dental and non- dental talent to join us in our journey to provide friction- less dental workflow solutions. The best feedback we have received was from a dentist, who commented that our product was providing the “experience as if Tesla and Apple had built a 3D printer together”. Our customer support has also received very positive feedback. 3D-printing systems were introduced to dentistry about two decades ago. However, the technology has been rather costly. Do you think that more dental laboratories and practices will consider 3D printers in the near future now that new companies are entering the market and offering more affordable solutions? All dental practices, laboratories and even patients can benefit from 3D printing. It offers frictionless integra- tion with intra-oral scanners and digital workflows, fast in-house production for many indications, and efficient treatment workflows. It boasts rapid development, with many innovations in material for an even broader range of indications. Needless to say, 3D printing also allows for faster delivery of solutions to the patient, and invest- ing in our solution is affordable for practices and smaller laboratories. Based on your experience, which have been the quickest countries in Europe to adopt 3D-printing technology, and in which countries has the develop- ment been rather slow? In general, countries with a higher rate of digitisation of laboratory scanners, intra-oral scanners and chairside dentistry are adopting the technology faster, and at the moment, these countries are Germany, Italy and Spain.

What exactly can be printed and with which mate- rials? We are able to print a broad range of applications and materials. All kinds of models can be printed, including aligner models and die models and study models, and our portfolio includes biocompatible dental applica- tions such as occlusal guards/splints, permanent and temporary crowns and bridges, surgical guides, indi- rect bonding trays, denture bases/teeth, and wax-ups. We have a wide range of high-quality SprintRay res- ins, but also a broad range of validated and certified materials available from other 3D-printing resin man- ufacturers. Users are free to choose from either range of materials. The majority of dental impressions are still fabricated using conventional methods. What developments do you foresee in the coming years in this field? We are expecting a fast growth and adoption rate in intra-oral scanners and dental technology, despite the pandemic. By purchasing a SprintRay 3D printer, the users of intra-oral scanners and CAD/CAM technology are able to offer solutions that further accelerate the fast adoption of intra-oral scanning for their patients. Cost efficiency, speed and usability are key advantages of 3D printing. The material used is the most important factor for innovation in the upcoming fields. More and more indications can be printed already, and more are coming in the near future. If one has an intra-oral scan- ner, there is no reason why one should not invest in a 3D printer. Do you think that 3D-printing technology could replace milling systems in the long run? Yes and no. Yes, because printing is cheaper and faster for many indications, and no, because materials such as ceramics and metals will always have their place in dentistry. I believe that milling and printing will go hand in hand. interview | 27

interview | 2 Fig. 2: Thomas Kwiedor has more than four decades of experience in the dental industry. We pioneered this 3D-printing process with metal powder for the dental sector, making the CAD-supported, fully automated production of crown and bridge frameworks possible early on. For us, milling is only a kind of bridging technology, which is why we have at all times resisted the temptation to offer milling machines for decentralised production. Over the last two decades, we have invested heavily in the development of customised solutions for dental 3D printing, not only with metal powder but also with res- ins and ceramic-filled hybrid materials, in order to enable users to produce a wide variety of dental restorations. What do you regard as the advantages of 3D print- ing over milling, which you described as a kind of bridging technology? Today, 3D printing already offers the possibility of quickly and inexpensively producing, for example, aesthetic crowns for temporary and permanent retention in the patient’s mouth. 3D printing is superior to subtractive or milling techniques not only because of freedom of design but also because of efficiency, as it is much more resource- effective. Compared with milling, the investment costs for 3D-printing technology are also significantly lower. Already today, there are powerful 3D printers on the market that require only a fraction of the usually high five- or even six-figure acquisition costs for milling units. 3D printing is therefore suitable for all users who want to produce high-quality dental restorations with contempo- rary and future-oriented technologies while keeping in- vestment costs low and thus avoiding the risk of a bad investment. This is particularly relevant as technologies are developing ever more rapidly and becoming obsolete after only a few years. Last year, BEGO caused a sensation in the 3D print- ing area by introducing VarseoSmile Crown plus. What are the performance features of 3D-printed restorations made out of this material? VarseoSmile Crown plus is the world’s first ceramic- filled hybrid material for the 3D printing of permanent restorations. It has been given 510(k) clearance by the U.S. Food and Drug Administration and fulfils all the requirements for a Class II medical device. Restorations made of VarseoSmile Crown plus are characterised by high aesthetics, a low ageing and discoloration ten- dency, and high patient comfort. VarseoSmile Crown plus is offered in seven shades according to the proven VITA classical shade system. The high bond strength of the material with luting composites prevents de- cementation and thus reduces the risk of secondary caries formation. Renowned universities and institutes have tested the long-term performance of 3D-printed restorations made of VarseoSmile Crown plus and confirmed the ex- cellent properties of the material. The results of these studies are available for download from our website (https://www.bego.com/3d-printing/materials/varseosmile- crown-plus/scientific-studies/). In what aspects are 3D-printed crowns made of VarseoSmile Crown plus superior to milled crowns made of hybrid ceramics? Here again, the main issue is efficiency. Thanks to full integration into the digital workflow and low material costs, a permanent crown can be printed with a material input of about US$2 and, depending on the printer, in significantly less than an hour! Patients thus receive direct, permanent restorations in just one session. These resto- 3D printing 1 2021 29

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interview | 3D printing is a powerful technology on its own, but the real impact comes from the people who use it. We see new 3D printing applications all the time, whether they are born of necessity or innovation. That is why Formlabs is committed to increasing access to powerful digital technology. What are some of the criticisms of dental 3D printing, and do the benefits offered by using 3D printing out- weigh the associated risks? Ten years ago, the biggest problem with 3D printing was the prohibitively high cost of a printer. Luckily, with the success of manufacturers such as Formlabs in the mar- ket, printers are more affordable, more reliable and easier to use than ever before. Now, the only risk lies in having false expectations. A 3D printer is a piece of equipment, and learning to use a desktop unit like the Form 3B is easy, but it does take some time. Those who choose to adopt digital technol- ogy should embrace the learning curve, ask for advice from their peers and seek out professional development opportunities. Moving forward, 3D printing needs to overcome the den- tal industry’s skepticism about novel printing materials and applications such as printed dentures and perma- nent restorations. Manufacturers like Formlabs need to be proactive about teaching experts and validating new technology in the industry in order to achieve a mindset shift. But it will eventually happen. We have already seen it many times in the dental industry. Implants, zirconia, intraoral scanners, chairside milling and many other ma- terials and technologies overcame the initial skepticism. I am glad to be part of the movement that is leading and revolutionising digital dentistry. Georgio Haddad, dental strategic partnerships and initiatives lead at Formlabs, a 3D-printing technology developer and manufacturer. (Image: © Georgio Haddad) “3D printing is a powerful technology on its own, but the real impact comes from the people who use it.” Editorial note: The Formlabs Dental webinar, titled “Revo- lutionizing digital dentistry with 3D printing—accessible solutions and new applications,” is available on demand at www.dtstudyclub.com. Registration is free of charge. Formlabs’ Form 3B printer. (Image: © Formlabs Dental) 3D printing 1 2021 33

interview | 2 Fig. 2: Riccardo Molinelli, SHINING 3D’s regional sales manager for the Europe, Middle East and Africa region. (Image: © DTI) different business units have application for both scan- ning and 3D printing. What is the company offering to dental profes- sionals? We began developing dental scanners around 2012. We are proud to look back to our very first product, which was a desktop scanner for a dental laboratory, and to compare it with what we see around us here at our IDS booth—a full suite of digital solutions for both dental clinics and dental laboratories. Over the years, we have developed more powerful and better-performing desk- top scanners, and we have also developed and launched 3D printers and our intra-oral scanning solution. The company is exhibiting two new products at IDS: Aoralscan 3 and AccuFab-L4D. What should dental professionals know about these new products? The first thing that I would say is that we can think about these two products either as stand-alone solutions or as a bundled solution that has been developed specif- ically for a dental clinic. That does not mean that the L4D printer cannot be used in the laboratory. However, from our point of view, this is an ideal 3D printer for use with the intra-oral scanner in order to cover the needs of dentists. There is a series of different reasons behind this. Firstly, the footprint and design of the unit are ideal for clinics, where space is often limited. Furthermore, all of the possible applications that the printer is equipped for—such as printing crowns, orthodontic models and surgical guides—make it an ideal choice for dental clin- ics. One additional point I would like to stress is that the printer is an open system. This means that, if the den- tist is already familiar with third-party materials, we can integrate those third-party materials into our 3D printer without any limitations. We just saw a demonstration of the Aoralscan intra- oral scanner. How have dental professionals at IDS reacted to it? Aoralscan is something that we are very proud of. We have worked on this technology for several years, and what we see being demonstrated here at the booth is the result of our constant investment in research and development and in product improvements. This intra-oral scanner comes with a lot of nuances, both from the hardware and software point of view. The previous generation remains an excellent product, but what I can say about the new scanner at the end of this four-day exhibition is that we have received extremely positive feedback from users from all around the world. We have had excellent feedback with regard to the scan- ning speed, the precision of the data collected, and the multiple applications and options that can be covered by this brand-new device. The company has a global network. What are the ad- vantages of this for dental clinics and laboratories? We have a sales network that covers five continents and three offices. Our headquarters is located in Hangzhou in China, and we have offices in San Francisco in the US, and in Stuttgart in Germany. The greatest benefit of this structure is that, for technical support and sales support, our customers know that there will always be somebody to assist them. What we do on a daily basis is to support dentists and laboratories all over the world. Fortunately, we can also rely on the wonderful support of our dealers around the world. It is a matter of cooperation, and we are very satisfied with the partnerships that we have and the advantages that they bring for our customers. 3D printing 1 2021 35

Large Print Size & 4K Resolution 192*120mm printing size and 4K resolution satisfy the demands of users for effi ciency and details. Reliable Performance High quality optical module with long-life components. Multiple Material Options SHINING DENT covers a wide range of materials for dental 3D printing applications. Unparalleled Accuracy Print accuracy reaches as high as ±50μm consistently. The AccuFab-L4D is a large-format dental 3D printer de- veloped completely in house by SHINING 3D to make 3D printing solution more accessible to everyone. Smart layout planning with one-click printing makes it easy to get started with 3D printing. The short learning curve and the ease of use make AccuFab-L4D the perfect companion for effi cient and easy dental 3D printing. Exceeding Expectations: SHINING 3D strives to enable dental labs and clinics all over the world to go fully digital and experience a new level of dentistry!

possibility of same-day replacements and improved compatibility with fixed appliances for hybrid treatments. “The ability to provide aligners on the same day or even in the same week is huge. Our busy adult clientele love it,” Kaltschmidt explained. She said that integrating 3D print- ing is inevitable once a practice has begun using intra- oral scanners and that doing so has allowed Bellevue to take control of its workflow. “3D printing has allowed us to be in control of our own workflow, and with that, the possibilities are endless. We are able to provide aesthetic treatment options for our patients and keep the cost down by not accruing large laboratory fees from third-party companies. This includes in-house clear aligners, lingual braces and hy- brid treatment using a combination of both. 3D printing has truly changed the way we practice,” Kaltschmidt said. “We’re so used to next-day delivery with Amazon and other services, why should straightening teeth be any different?” Riolo asked in a press note. “Orthodontists have the technology and clinical expertise to expedite care in ways that major corporations cannot deliver. This is why we decided to adopt these technologies early on.” “The investment for orthodontists and dental profes- sionals to get started (with a 3D printer) can be any- where from $500 to $20,000 or more,” Kaltschmidt said. where from $500 to $20,000 or more,” Kaltschmidt said. where from $500 to $20,000 or more,” Kaltschmidt said. “Technology is advancing so quickly, and the cost of 3D “Technology is advancing so quickly, and the cost of 3D “Technology is advancing so quickly, and the cost of 3D printers will continue to come down. Our advice for those printers will continue to come down. Our advice for those printers will continue to come down. Our advice for those interested in getting started with 3D printing is to spend interested in getting started with 3D printing is to spend interested in getting started with 3D printing is to spend less on the printer and invest more time into refining your less on the printer and invest more time into refining your less on the printer and invest more time into refining your digital workflow. You will begin to notice the differences digital workflow. You will begin to notice the differences digital workflow. You will begin to notice the differences when you go from analog to digital.” when you go from analog to digital.” when you go from analog to digital.” l l l l l l l l l l m m m m m m m m m m o o o o o o o o o o c c c c c c c c c c . . . . . . . . . . k k k k k k k k k k c c c c c c c c c c o o o o o o o o o o t t t t t t t t t t s s s s s s s s s s r r r r r r r r r r e e e e e e e e e e t t t t t t t t t t t t t t t t t t t t u u u u u u u u u u h h h h h h h h h h S S S S S S S S S S / / / / / / / / / / n n n n n n n n n n k k k k k k k k k k e e e e e e e e e e k k k k k k k k k k e e e e e e e e e e e e e e e e e e e e b b b b b b b b b b © © © © © © © © © © i i i i i i i i i i “Orthodontists can definitely brand their own aligners and they absolutely should,” Kaltschmidt continued. “The product you design and manufacture in your office as an orthodontist is a superior product in the end, and you should package and brand your aligners to reflect that. In-house aligners give the practitioner full con- trol over workflow, time to delivery, trim line and choice of aligner materials.” Last year, Riolo and Kaltschmidt founded the Tooth Movement 3D-printing educational community in order to share their expertise on using 3D-printing technology for orthodontic applications like clear aligner therapy. Kaltschmidt said that demand from within the dental community for the limited courses on offer has been significant and that she and Riolo have worked mostly with orthodontists, members of the treatment team and recent graduates. “Many residents do not have any expo- sure to 3D printing while in their schooling,” she pointed out. trends & applications | Manufacturers are bullish on adoption of 3D printing in dentistry Advancements in 3D-printing technology have seen the quality of desktop models for dentistry climb while costs have fallen. According to Dr Baron Grutter, who owns a dental prac- tice in Kansas City, being able to offer clear aligner treat- ment at a lower cost has improved case acceptance at his practice for a product that is known for its high earn- ing potential. Grutter was an early adopter of 3D-printing technology in the dental practice and has manufactured his own clear aligners in-house for some time. He told the “Orthodontists have the technology and clinical expertise to expedite care in ways that major corporations cannot deliver”— Dr Christopher Riolo, Bellevue Orthodontics manufacturer SprintRay in its Practice Insights series last year that a return on the investment of a 3D-printing work- flow can be made by selling as few as three or four cases. Growing demand for this technology from dentists is being met by companies manufacturing solutions that are tailored to a number of dental applications, including making clear aligners. Manufacturers predict that sales will climb this year and that integrated digital workflows will make the technology even more accessible. Lee Kwang Min, vice president of the Korean 3D-printer manufacturer Carima, told the online trade journal 3D Printing Industry in 2019 “[2020] will be a full-scale dig- ital dentistry year. The emergence of a variety of 3D scan- ning solutions with an affordable price range, which has been an obstacle to the spread of digital dentistry, will re- place the milling machines in the market and, furthermore, (will accelerate) the rapid adoption of 3D printers.” Min said that he expects that a collaborative approach between individual manufacturers of 3D printers, software and scanners will act to increase the accessibility and adop- tion of the technology by dentists. 3D printing 1 2021 39

trends & applications | ment plan to the company’s technicians, who then create customised brackets and trays. The system uses ceramic material that is specially formulated for 3D printing, but which is otherwise virtually identical to that used in injection-molded brackets. The founder of the company, Dr Alfred Griffin III, told Dental Tribune International that the digital workflow resembles that used in clear aligner therapy. “LightPlan is the proprietary treatment software developed by LightForce that enables mass-customised braces,” he said. “Doctors have complete control over every aspect of the treatment plan and can utilise a simple cloud- based interface for adjustments and approvals.” “Our treatment plans are unique to each individual patient and largely follow the clear aligner workflow,” Griffin con- tinued. “Where our technology diverges is when the ortho- dontist uploads the patient’s scan to our LightPlan soft- ware, which enables the doctor to adjust the teeth virtually in order to create a perfect smile and bite for that unique patient, enabled by automatically designed braces.” Griffin explained that the LightPlan software generates bracket files, which are then printed at LightForce’s central- ised manufacturing plant in Cambridge. The brackets are then delivered to the orthodontist’s office about a month later. Increased personalisation using digital tools LightForce says that orthodontists should “move teeth, not brackets.” LightForce aims to provide treatment for malocclusion, which is as individual as each patient is. “A person’s lips, jaws, teeth and smile are individual, and it’s important to customise the tools that impact his or her face,” Griffin ex- plained. “3D printing provides the ideal solution for patients, as it allows for customisation and uses modern technology to address an age-old problem. We’ve found 3D printing to be the best solution for orthodontic applications because it enables complete personalisation for each patient—it can print complex geometries, in this case unique tooth mor- phology that would otherwise be unavailable to patients.” He added: “On the one hand, we believe that the days of bracket prescriptions are numbered; on the other hand, we welcome the days of ‘tooth prescriptions’ for mass-customised appliances like aligners and 3D-printed brackets that can adapt to achieve a desired final tooth position for that unique patient.” Griffin said that, in the future, he expects that there will be a rapid expansion of 3D-printing technology within the dental industry. LightForce Orthodontics was founded in 2015. Over the last five years, Griffin and his team have undertaken extensive research and development for what is now the company’s eponymous treatment platform. No one could have predicted that the 2020 launch of the bracket system would take place in the midst of a global pan- “Our treatment plans are unique to each individual patient and largely follow the clear aligner workflow.” demic, but it seems that the outbreak of SARS-CoV-2 has not hampered the company’s plans. “In light of the ongoing pandemic, technology that reduces in-person dental visits is crucial not only for patients but also for the orthodontists and their teams that are caring for them,” Griffin said. Hundreds of orthodontists throughout the US are already providing treatment using LightForce brackets. Griffin said that the company will use its newly acquired funds to fur- ther develop its technology and product offerings and to scale its operations in order to meet what he called a recent surge in demand for more efficient dental technologies. The funds were raised in a Series B funding round that was led by investors Tyche Partners, Matrix Partners and AM Ventures. 3D printing 1 2021 41

user report | 3 Fig. 3: High-gloss and transparent splint made of NextDent Ortho Flex. After importing the digital impression scans into the dental CAD software (3Shape), the wizard will guide the operator through the design of the dental splint (Fig. 1). Different parameters can be controlled, and block-out of undercuts is automated. Different design options are achievable, giving the technician and/or clinician options for selecting occlusal guidance etc. Once the dental splint design has been finished, it can be shared directly to a 3D printer. In our dental lab- oratory, we use the NextDent 5100 (3D Systems). The software (3D Sprint, 3D Systems) that controls the printer is very user-friendly and helps with positioning and support of the file. 4 Fig. 4: Special support placement. For printing the occlusal splint, a specialist resin has been developed by 3D Systems called NextDent Ortho Flex (Fig. 2). This resin is optimised for occlusal splints and exhibits excellent mechanical properties, has a transpar- ent appearance and is easy to polish after production. A high-gloss and transparent splint can be achieved by conventional polishing techniques, fine pumice and a lathe, and a high-gloss polishing compound at the final stage (Fig. 3). The unique printing style created for NextDent Ortho Flex provides support placement in such a way that the supports do not touch the occlusal surface (Fig. 4). As a result of this optimised printing style and supports, the dental splint fits the patient’s dentition com- fortably and the bite and occlusion are correct without manual altering. This is a huge step forward in the con- struction of digitally manufactured splints, saving a great deal of time for dental laboratories. The NextDent Ortho Flex resin (Fig. 5) has shown excellent results clinically, as it is more durable because of the specially developed flexibility. This has been confirmed by zero splint failures reported in six months of use. contact Sokratis Gonidis is the owner of Gonidis LAB located in Athens in Greece and is specialised in orthodontics and orthodontic CAD/CAM. He may be contacted at sgonidis@gmail.com. 5 Fig. 5: NextDent Ortho Flex resin. 3D printing 1 2021 43

news | At IDS 2021, exocad announced the release of ChairsideCAD 3.0 Galway, the next generation of its easy-to-use CAD software for single-visit dentistry. Imagine the CADabilities Exoplan 3.0 Galway for implant planning Exoplan 3.0 Galway is a powerful, open and efficient soft- ware package for virtual implant planning. Having over 40 new and over 60 improved features, the new Galway version represents a significant expansion of guided im- plantology possibilities and offers improved integration with exocad’s DentalCAD software. ChairsideCAD 3.0 Galway for single-visit dentistry During IDS, exocad announced the release of ChairsideCAD 3.0 Galway, the next generation of its easy-to-use CAD soft- ware for single-visit dentistry. With this new release, exocad offers dentists design tools for a vast range of indications with a wide choice of integrated devices. The new chairside workflow is highly automated, intuitive and optimised for practice use. In 2021, for the third year in a row, ChairsideCAD was selected for the Cellerant Best of Class Technology Award. ChairsideCAD 3.0 Galway is now available in the EU and other select markets. By exocad, Germany At IDS 2021, exocad, an Align Technology company, pre- sented highlights of its three core products—DentalCAD 3.0 Galway, exoplan 3.0 Galway for implant planning and ChairsideCAD 3.0 Galway for single-visit dentistry. The 360 m² booth was a central meeting point for exocad’s global community at IDS. The trade show offered a rare opportunity for exocad users to meet specialists and developers from the Darmstadt-based software company in person. Visitors could linger at the booth’s dozen soft- ware stations, learn about the 3.0 Galway release’s high- lights and ask exocad’s software experts questions. DentalCAD 3.0 Galway Visitors experienced the 90 new and 80 additionally optimised features of DentalCAD 3.0 Galway. For exam- ple, they had the opportunity to try out the new Instant Anatomic Morphing. This feature automatically adjusts teeth in real time, greatly improving the speed and preci- sion of anatomical tooth placement. Another exciting fea- ture is parametric shape adjustment, which can transform all tooth libraries from a younger to an older anatomy. At another station, on-site experts demonstrated how the Smile Creator module can automatically recognise facial fea- tures using new artificial intelligence-assisted technology. Other demonstrations included: the improved process- ing of bridge connectors and how multiple connectors can now be adjusted simultaneously, the creation of mock-up tooth set-ups and how the software supports virtually prepared models, and virtual tooth extractions. ChairsideCAD: Simple interdisciplinary collaboration between practitioner and dental laboratory is achieved through integration with DentalCAD, exocad’s leading lab software, and exoplan, the software for guided surgery. ChairsideCAD 3.0 Galway now features a dark mode. 3D printing 1 2021 45

news | ratory after virtual surgical planning. The remaining patients each received a prosthesis that was designed by a surgeon and 3D-printed via the in-house laboratory. The researchers fabricated a dental prosthesis using point- of-care 3D printing within 24 hours of the virtual surgi- cal planning session. The time required to generate the in-house 3D-printed prostheses was significantly shorter when compared with dental laboratory-fabricated prosthe- ses, which typically take weeks. Additionally, the procedure was more cost-effective. Whereas the prostheses created by an off-site dental laboratory averaged $617.00, each in-house 3D-printed prosthesis cost an average of $8.34 for resin, and the researchers noted that a full-arch pros- thesis 3D-printed in NextDent Micro Filled Hybrid costs under $50.00. The price includes the costs for the resin and the export fee for Blue Sky Plan, a 3D-printing software. “The study describes a digital workflow to design and 3D-print an immediate provisional dental prosthesis to be placed during jaw reconstruction when using a fibular free flap. This surgery has been called ‘Jaw in a Day.’ Previous methods involved third-party dental laboratories which require additional time, laboratory expertise and are more expensive. Our technique allows surgeon-guided virtual planning, just like we do with the jaw and fibula,” Dr Fayette C. Williams, fellowship director in the Division of Maxillofacial Oncology and Reconstructive Surgery at John Peter Smith Health Network, told DTI. “Creating a 3D-printed dental prosthesis in-house allows more control for the surgeon to create the occlusal scheme. It is also much quicker. I can generate this prosthesis in one day, whereas dental laboratories can take two or more weeks,” he added. According to the researchers, outsourcing dental prostheses to a dental laboratory has previously created a delay in the treatment, which has limited its usefulness to benign condi- tions. In the present study, the digital workflow used allowed for immediate dental restoration for patients with malignant disease. “This time is significant for a patient with cancer waiting to get their surgery to remove their jaw and tumor,” Williams explained. Despite its clear advantages, the re- searchers believe that the digital workflow presented in the study is most suitable for patients with teeth in place pre- operatively that will be removed with their tumor. For more complex cases, it is necessary to familiarise oneself with image manipulation and prosthesis planning. Additionally, the researchers calculated that the total initial cost of a 3D printer and post-processing supplies can reach around $3,000.00, plus additional costs associated with using the software. Editorial note: The study, titled “Immediate teeth in fibulas: Planning and digital workflow with point-of-care 3D printing,” was published on 1 August 2020, in the Journal of Oral and Maxillofacial Surgery. m o c . k c o t s r e t t u h S / n k e k e e b © i l “The time required to generate the in-house 3D-printed prostheses was signifi cantly shorter when compared with dental laboratory-fabricated prostheses (...)” A recent study found that printing dental prostheses for fi bula and implant reconstructions in-house eliminates the additional waiting period before surgery, making the treatment suitable for patients with malignant disease. 3D printing 1 2021 47

case report | 6a 6b Figs. 6a & b: Two 3D-printed templates designed on the digitised model (green): one for the initial drill to section the tooth at the root apex (a) and the second for using sequential guided drills to drill through the root itself (b). “Triangle of Bone” concept and specific instrumentation to achieve successful outcomes.5 The ability to perform the procedures requires care- ful diagnosis, treatment planning and excellent control of the drilling process to ensure that the root fragment will be maintained while maximising implant stability. In many cases, it may also be possible to provide imme- diate transitional restorations when high implant stability is achieved. However, complications can also arise when the root fragment is lost or the implant fails to integrate. It should be noted that PET has mainly been accomplished with a diagnostic freehand method for sectioning roots, osteotomy preparation and implant placement. The cur- rent article describes methods of providing PET proce- dures using full-template guidance based on a thorough appreciation of the existing anatomical structures utilis- ing advanced state-of-the-art treatment planning tools, 3D design software, 3D printing and/or CAD/CAM sur- gical templates. 7a 8a 7b 8b Fig. 7a: A sleeveless guide to accommodate a 2 mm long pilot drill that was used to reach the root apex. Fig. 7b: Removing the guide allowed for inspection of the drill embedded within the tooth. Figs. 8a & b: Using drill guides with long shanks to engage the sleeveless template allowed for sequential and accurate drilling of the tooth and subsequent bone for implant placement. 3D printing 1 2021 49

case report | 15a 15b 15c Fig. 15a: The base template was designed to seat firmly on the adjacent teeth, incorporating buccal and lingual hexagonal offsets to engage the different drill guide inserts. Figs. 15b & c: Separate inserts were fabricated for the initial drill guide to reach the root apex to accommodate sectioning, followed by a second guide for final osteotomy drilling and implant placement. fully appreciate the trajectory through the clinical crown (Blue Sky Plan, Blue Sky Bio). It is important to visualise the root fragment that will remain in order to properly sim- ulate the position of the implant in the alveolus (Fig. 3b). The apical portion of the implant can be positioned to gain stability in host bone using the Triangle of Bone. It is important to note that a cross-sectional slice may only be 0.125 mm in thickness based on the CBCT ac- quisition, and therefore all images in all views must be visualised to confirm the plan. Utilising 3D segmentation (separating objects by density values), it is possible to define each root and further assess the simulated posi- tion of the implant with a sagittal cut through the 3D re- constructed volume (Fig. 4). The ability to export volumes in STL format allows these objects to be edited and utilised in other software appli- cations, such as Meshmixer (Autodesk). The STL file of the root image was imported into Meshmixer, and the root was virtually sectioned using Boolean difference to mimic the crescent shape for PET (Fig. 5a). The apical portion of the simulated implant can then be positioned so as not to touch the root fragment while engaging in host bone for stability (Fig. 5b). Planning with such precision is predicated on the acqui- sition of a satisfactory CBCT scan with a proper field of view and the incorporation of occlusal surface data STL files of the arch form, digitised through either an intra-oral scan or a desktop scanner imported into the software. Two 3D-printed templates were then designed on the accurate digitised surface model, one for the initial drill to section the tooth at the root apex and the second to use sequential guided drills to drill through the root itself (Fig. 6). A 2 mm pilot drill, which was long enough to reach the root apex with the tooth-borne surgical guide in place, was utilised with a sleeveless guided approach (Fig. 7a). Removing the guide allowed for inspection of the drill through the tooth (Fig. 7b). Using guided drills with long shanks in a sleeveless guide allowed for sequen- tial and accurate removal of the tooth and subsequent bone beyond the apex of the natural tooth root (R2Gate, MegaGen; Fig. 8). The cylindrical tooth preparation/oste- otomy resulted in the desired crescent shape to provide space for the implant (Fig. 9). The root was then sectioned mesiodistally using specialised drills (Root Membrane Kit, MegaGen) and the palatal section removed. Utilising 16a 16b Figs. 16a & b: The accuracy of the implant and template design allows for true restoratively driven planning combined with CAD/CAM applications for the design and fabrication of a patient-specific abutment and transitional restoration. 3D printing 1 2021 51

case report | 26a 26b 26c 26d Figs. 26a–d: The prefabricated CAD/CAM abutment and transitional crown (a). A post-op periapical radiograph confirmed successful sub-crestal placement of this platform-switched design (b). The abutment in place (c). The soft-tissue contours were excellent; no sutures were required for the transitional restoration (d). the template, the implant was placed into the osteotomy using the correct implant carrier to achieve full-template guidance and stability measured using resonance fre- quency analysis (RFA) to obtain the implant stability quo- tient (ISQ; Fig. 10). tooth-borne guide); (2) a pilot drill guide for the root apex (APEX STACK); (3) a crescent-shaped guide for shaping root fragments (PET Shaper STACK); and (4) a guide for osteotomy drilling and placing the implant through the guide (Surgical Guide STACK; Fig. 11). The concept of drilling through the root is not new and has been reported in the literature.8 Using guided meth- ods for the socket shield technique has also been re- ported using a CAD/CAM-fabricated template.9 However, the ability to use technology to plan and execute a fully guided procedure for a PET, socket shield technique and root membrane technique illustrates additional method- ology to aid clinicians in successful outcomes. The first concept described the use of two separate templates, one for separating the root at the apex and the second for drilling through the tooth and placing the implant. Continuing the evolution, we present a second option, which does not require the removal of the base template, but has inserts to allow for the different drills and angulation required for the PET technique: the stack- able tooth-borne guide. The new technique has four separate components: (1) a base template (stackable Case report A 62-year-old male patient presented with a hopeless prognosis for a post fracture in the left central incisor requiring extraction (Figs. 12a & b). The preoperative peri- apical radiograph revealed an existing implant support- ing a metal–ceramic restoration for the adjacent region #11 (Fig. 13). The CBCT (CS 9600, Carestream Dental) cross-sectional image revealed a favourable preoperative condition relating to the trajectory of the endodontically treated root to the alveolus for a PET procedure (Fig. 14a). Using the native Carestream 3D Imaging software, a simulated implant and abutment projection was posi- tioned within the available bone to avoid the root frag- ment (Fig. 14b). The final positioning of the implant, as determined by the restorative requirements, and design and fabrication of 27a 27b Figs. 27a & b: The post-op CBCT scan axial view revealed the intact crescent shape of the root membrane (a), as outlined in red in facial to the opaque implant position (b). 3D printing 1 2021 53

case report | (AnyRidge, MegaGen) was facilitated by the R2Gate surgical carrier for full-template guidance at the appropri- ate torque values (Fig. 23). Depth control and rotational positioning were accurately confirmed with the notch indicated on the template to correspond with the inser- tion tool (Fig. 24). The initial plan was for immediate extraction, immediate placement and immediate restoration. Therefore, it was essential to measure the implant’s stability with an objec- tive technology, RFA, which provides an ISQ value util- ising an implant-specific SmartPeg (Osstell; MEGA ISQ, MegaGen). The baseline ISQ value (76) confirmed suf- ficient initial stability to place an immediate restoration (Fig. 25). The prefabricated CAD/CAM abutment was then secured to the implant, and a postoperative peri- apical radiograph confirmed successful sub-crestal placement for this platform-switched design (Fig. 26a). The transitional acrylic restoration was then placed and examined for any occlusal interferences (Fig. 26b). It was important that the restoration be out of occlusion to avoid premature forces that could complicate inte- gration. The soft-tissue contours were excellent, and no sutures were required, since no flap was raised (Figs. 26c & d). After a period of eight weeks, the im- plant stability was measured to be at 80 ISQ, confirming that the integration process had continued to progress successfully and that the implant was ready for the de- finitive restoration. An intra-oral scanner and scanning abutment were then utilised to capture the position of the implant and soft-tissue emergence profile. The post- operative CBCT scan revealed the intact crescent shape of the root membrane (Figs. 27 & 28). The definitive restoration was then delivered and exhibited excellent retention of the soft-tissue profile (Figs. 29 & 30). Conclusion PET, root membrane and socket shield concepts have gained popularity as the techniques have been refined and their efficacy proved in published long-term stud- ies. The purpose of retaining the root is to maintain the periodontal ligament attachment to the bony walls of the socket in order to prevent subsequent resorption and loss of tissue volume which often occurs after tooth ex- traction. PET has been proved to preserve bundle bone and tissue volume with and without immediate implant placement, yet this minimally invasive treatment modal- ity is highly technique-sensitive and may result in com- plications if proper protocols are not followed. Therefore, a complete understanding of the 3D anatomical presen- tation is essential for preliminary diagnosis, treatment planning and execution of the procedure. The present article has described two alternatives that maximise the diagnostic phase using state-of-the-art CBCT imaging and planning software to provide full-template guidance with a new stackable tooth-borne guide with specific in- serts for the root preparation as well as the osteotomy preparation and delivery of the implant. As with most techniques, further clinical trials are recommended to provide additional long-term data to validate these treat- ment modalities. Acknowledgement: The authors would like to thank Dr Barry Kaplan of Morristown in New Jersey in the US for his expertise and assistance in the preparation of this article. Editorial note: This article originally appeared in Dentistry Today in September 2020, and an edited ver- sion is provided here with permission from Dentistry Today. A list of references is available from the publisher. about Dr Scott D. Ganz received his specialty certificate in maxillofacial prosthetics and prosthodontics, and this led to his focus on the surgical and restorative phases of implant dentistry and his subsequent contribution to 15 implant-related textbooks. He is a fellow of the Academy of Osseointegration, a diplomate of the International Congress of Oral Implantologists (ICOI), US ambassador of the Digital Dental Society, president of the US branch of the Digital Dentistry Society (DDS) and a co-director of Advanced Implant Education (AIE). Dr Ganz is on the teaching staff of the Rutgers School of Dental Medicine in Newark in New Jersey and maintains a private practice in Fort Lee in New Jersey. He can be reached at drganz@drganz.com. Dr Isaac Tawil sits on the Digital Dental USA Society Board of Directors, and is a diplomate of the International Academy of Dental Implantology, the IADFE, a fellow of the Advanced Dental Implant Academy, and the ICOI. He is one of Dentistry Today’s Top Leaders in CE, a faculty member of the Osseodensification Academy, Brighter Way educational director (Phoenix, Arizona), and digital director of Guided Smile. Dr Tawil is an ambassador of MegaGen International Network of Education and Clinical Research, a member of MINEC USA and an ambassador for the Slow Dentistry initiative. A recipient of the Pierre Fauchard award and the Presidential Service Award for outstanding achievements in dentistry. He is the founder and co-director of Advanced Implant Education, a partner in TBS instruments, and Universal Shapers LLC, and a new product consultant for dental industry. Dr Tawil has held main podium sessions and workshops globally and maintains a private practice in Brooklyn, New York. He can be reached at iketawil@mac.com. 3D printing 1 2021 55

industry report | 16 18 17 19 The crowns are nested and ready for printing; each ma- terial requires a different amount of light intensity, support size and separation force. The properties of GC Temp PRINT make it incredibly easy to print and leave a perfectly smooth finish. After printing, the crowns are cleaned in iso- propyl alcohol and final polymerisation is performed in the Labolight DUO (GC; Figs. 4–6). I always post-polymerise with the supports on. The mate- rial finishes better after post-polymerisation, and I stand the restorations on the supports to polymerise, giving the light full access to the restoration. The fit directly after polymer- isation is absolutely perfect, which is why I prefer working with printable temporary materials over milled materials. The properties of GC Temp PRINT make it incredibly easy to print and leave a perfectly smooth finish (Figs. 7–9). I control the shape and emergence profile manually, be- cause at the end of the day I am still a dental technician and prefer to give all cases the personal touch. The contouring is finished and the emergence is checked, and if any addi- tion is necessary, I would do this now using GRADIA PLUS (GC). These temporary restorations are now ready for fitting and are a great way of assessing the final shape and shade for the long-term restorations. If all goes well, the same file can be used and manipulated to create the definitive restorations (Figs. 10–12). Stump shades the patient’s mouth. This die is used for colour assessment, while the model material die is used to check the fit. The GC Temp PRINT die is in fact accurate enough to check fit; however, by adding a layer of OPTIGLAZE, I am adjusting the fit surface slightly. I therefore prefer the security of having a second die to double-check the fit of the restoration. The final shades are balanced and controlled through the knowl- edge of what lies underneath the restorations (Figs. 13–15). Function I also use this material to help assess bite and form on larger cases prior to committing to a finish. In these cases, it is not necessary to use OPTIGLAZE color, as the func- tion is what is being assessed. The single crowns can be temporarily bonded on to the framework and then once assessed and adjusted if necessary can be re-scanned back into the software for further processing prior to final- ising (Fig. 16). In conclusion, GC Temp PRINT (Figs. 17–19) has been one of the most exciting additions to the material portfolio in my laboratory owing to its versatility and ease of use, and I now have more time available in my milling machine to al- low it to be more productive with the milling of final pieces of work. GC Temp PRINT is probably the easiest material to print and finish with a very smooth surface by compari- son with some other printing materials. It is incredibly rare to get a misprint using this material. Although the majority of my temporary restorations are now made using this material, this is not the most com- mon use of GC Temp PRINT in my laboratory. I use far more of this material to aid with shade assessment by creating natural colour dies. about When I am producing all-ceramic work from intra-oral scans that will have a degree of translucency, I print two dies to work on, one in regular model material and another in GC Temp PRINT. This die is then shaded using OPTIGLAZE color (GC) to the same shade as the remaining stump in Stephen Lusty qualifi ed in Cape Town in South Africa. Since 2008, he has been running his laboratory in Cornwall in the UK, specialising in aesthetic dentistry. His passion for the art of dentistry is what drives him to continue to strive for perfection. He works closely with his clients, seeing patients for custom shade matching and fi nishing. 3D printing 1 2021 57

case report | be done on CAD software and then manufactured with either 3D printing or traditional CAD/CAM dentistry via mill- ing of the prosthesis. The data from the digital impression is also simply sent over the Internet, significantly reducing the time needed to manufacture the wax-up and prosthesis. In the field of implant dentistry, one of the main advantages of the fully digital workflow is the ability to accurately diag- nose and virtually plan the implant position using the digital surface scan (intra-oral scan) and CBCT data with simplicity. This in turn allows the fabrication of an accurate surgical implant guide that facilitates the placement, in terms of bet- ter angulation and accuracy, of single and multiple implant fixtures using a fully guided surgical approach, creating a simplified, accurate and predictable protocol. For the patient, fully digital workflows in implant treatment planning and surgical workflows have the benefits of re- ducing the number of patient visits for the procedure and allowing the visualisation, planning and even designing of the prosthetic design (CAD) prior to the patient attending for the surgical phase of treatment. The following case study demonstrates a scenario in which a complete digital workflow was utilised in the treatment planning, design, implant fixture placement, and implant and natural tooth restorations to rehabilitate the complete maxillary arch. 4 6a 5 6b Figs. 4 & 5: Radiographic scatter can lead to the inability to mesh the intra- oral surface scan to the DICOM data. Figs. 6a & b: Intra-oral photograph (a) and scan (b). Reference markers are utilised in the CBCT scan to minimise radiographic scatter and recorded in the intra-oral scan. Case report A 79-year-old patient presented with the chief complaints of mobile teeth and occasional discomfort from the areas around his existing maxillary fixed partial prosthesis. His medical his- tory was unremarkable. The clinical and radiographic exam- 7 8 9a 9b Fig. 7: The differential colour map indicating accurate stitching or meshing of the surface scan and DICOM data. Note that the green areas indicate a < 0.50 µm difference. Fig. 8: Better stitching facilitates improved accuracy of implant placement. Figs. 9a & b: Verification of the intra-oral scan (yellow line) by super imposition on to the radiographic marker on the CBCT scan. 3D printing 1 2021 59

case report | 16 17 Figs. 16 & 17: Intra-oral surface scans before and after removal of the original porcelain-fused-to-metal fixed partial prosthesis superimposed on to the CBCT scan. This facilitated the planning of implant placement from a restorative perspective. of the tooth abutments was also completed prior to the acquisition of the subsequent intra-oral scan. Intra-oral scanning of the prepared natural tooth abutments at this phase allows the scans to be utilised for the 3D printing of a surgical guide for fixture placement and a tempo- rary prosthesis prior to the surgical phase of treatment. The confirmed file merge will then create an accurate vir- tual rendering on which the digital planning of the implant placement from a restorative perspective can be performed. There is an extensive library of all major implant brands and guide sleeves incorporated into Implant Studio. A digital BioHorizons implant fixture and the associated digital library were used for the planning of this case. Treatment planning After collation of the information, the initial treatment plan was formulated. It would involve guided surgical placement of implant fixtures in sites #16, 14, 11, 21 and 25. A bone graft was planned for site #11 owing to bony defects, and a two- stage surgical protocol would be utilised during the integra- tion phase for the implants in sites #11 and 21. Immediate provisionalisation of the maxillary arch after implant surgery would be performed with a 3D-printed temporary prosthe- sis manufactured using the Asiga MAX UV 3D printer (Asiga) and GC Temp PRINT resin (GC). A copy of the existing shape and contours of the failing prosthesis would be super- imposed to create a temporary prosthesis that was almost an exact copy. A second phase of provisionalisation after implant integration would allow for soft-tissue development, extraction of tooth #15, and verification of the aesthetics and occlusion, that is, a trial smile. The plan was to deliver this phase of treatment utilising individual temporary resto- rations on implants and natural abutment teeth, 3D-printed using the Asiga MAX UV and GC Temp PRINT. Finalisation of the rehabilitation would be performed with a combina- tion of lithium disilicate-based and monolithic zirconia res- torations on both the natural teeth and implant abutments. 18 19 20 Figs. 18–20: Planning of implant placement. A surgical guide was designed based on the desired implant position (five planned implant fixtures, virtual position and angulation, and planned position of access). 3D printing 1 2021 61

case report | Guided implant surgery and bone grafting phase A flap was raised in regions #11 and 21. This allowed vi- sualisation of the surgical site. The implant fixtures were placed utilising the digitally planned surgical guide and the BioHorizons fully guided surgical protocol (Figs. 25 & 26). Owing to existing bony defects, bone grafting with bovine cancellous particulate was done. This was then covered with a porcine collagen membrane, and primary closure was achieved with PTFE sutures after a relieving incision. Primary stability of the fixtures were then confirmed. Heal- ing abutments were placed on the other implant sites, im- plants #16, 14 and 25. The printed provisional prosthesis was then cemented with GC Fuji TEMP LT (GC; Fig. 27). A delayed healing protocol was employed, and osse- ointegration was confirmed after a period of 16 weeks (Fig. 28). During the healing phase, tooth #24 devel- 29 Fig. 29: Pre-op intra-oral surface scan. oped signs and symptoms of pulpal necrosis. Endodon- tic treatment was initiated and subsequently completed. The treatment plan for the next phase of treatment would be finalisation of the preparations and fabrication of single-unit provisional crowns for teeth #13, 12, 22, 23 and 24. There- after, single-unit implant-retained provisional crowns for 30a 30b 31a 31b 32a 32b 33a 33b 34a 34b 35a 35b 36a 36b 37a–c Figs. 30a & b: Pre-op intra-oral photograph (a) and scan using the Mak optimised scan strategy and spaghetti technique (b). Figs. 31a & b: Pre-op intra-oral photograph before (a) and after removal of the initial provisional splinted prosthesis (b) at the start of surgery to uncover implants #11 and 21. Figs. 32a & b: Surgery uncovering im- plants #11 and 21 utilising a GEMINI diode laser (a). Once completed, the remaining healing abutments were removed and a soft-tissue scan was performed. By utilising the Mak optimised scan strategy and spaghetti technique, an accurate scan can be achieved even in the absence of hard-tissue (tooth) landmarks (b). Figs. 33a & b: Intra-oral photograph (a) and implant soft-tissue scan (b) after uncovering of implants #11 and 21. Figs. 34a & b: Intra-oral photograph (a) and digital cut-out in prepa- ration for intra-oral scan with the use of implant scan bodies (b). Figs. 35a & b: Intra-oral photograph (a). Complete maxillary arch intra-oral scan with the utilisation of 3Shape scan bodies (b). The scanning accuracy was improved and scanning was simplified with the use of the Mak optimised scan strategy and spaghetti technique. Figs. 36a & b: The 3Shape scan bodies in situ, frontal (a) and palatal view (b). Figs. 37a–c: Periapical radiographs to verify the seating of the digital scan bodies. 3D printing 1 2021 63

case report | 45 46a 46b 47 Fig. 45: Immediate post-op photograph of the inserted provisional restorations, frontal view. Figs. 46a & b: Immediate post-op photograph of the inserted provisional restorations, labial view (a) and smile (b). Fig. 47: Immediate post-op photograph of the inserted provisional restorations, palatal view. tissue (Figs. 32 & 33). The implant position scan was there- after taken with 3Shape scan bodies (Figs. 34–37). The cor- responding 3Shape scan body was fixed to the implant, and the seating of the scan body was confirmed radiographically before the scan was completed. The use of 3Shape scan bod- ies allows the laboratory to use different CAD libraries for the specific implant system. This feature remains an advantage that is unique to 3Shape presently. The use of 3Shape’s scan bodies also provided a fast, easy and accurate acquisition of the digital fixture-level impression and the seamless trans- fer of the digital information to the Dental System software (3Shape) for the design process of the planned restorations. All other prosthodontic records, including bite registration and the opposing arch, were also captured with the intra-oral scanner. All the digital data was then sent to the ceramist through the 3Shape Communicate portal for the fabrication of the second set of provisional restorations as planned. Fabrication of the second set of provisional restorations The provisional restorations were printed with GC Temp PRINT and the Asiga MAX UV (Figs. 38–41). BioHorizons temporary cylinders were utilised as the abutments for the implant-retained restorations. The contours of pontic #15 and the provisional restorations for implants #11 and 21 were designed and fabricated to allow the contours to be modified to facilitate the development of the soft tissue. Insertion of the second set of provisional restorations After removal of the splinted provisional restoration, all the abutments were cleaned and tooth #15 was extracted (Fig. 42). All the 3D-printed temporary restorations were cemented utilising a provisional cement (GC Fuji TEMP LT). The provisional implant restorations, fabricated with direct screw access, were torqued to the manufacturer’s recom- mendation (Figs. 43–47). The soft tissue was prosthetically shaped and allowed to heal for a period of three months before finalisation of the rehabilitation with the definitive restorations. Conclusion The case presented illustrates how advances in digital tech- nologies can provide clinicians with the tools for diagno- sis, treatment planning, and execution of dental restorative procedures in a truly transformative way. Simplification of clinical protocols, increased accuracy over conventional analogue techniques, and improved patient comfort and outcomes are compelling reasons for the use of a fully dig- ital workflow in the field of restorative and implant dentistry. about Dr Anthony Mak obtained his dental degree at the University of Sydney in Australia and then went on to complete his postgraduate diploma in oral implantology. He graduated with multiple awards and has worked with some of Sydney’s most renowned practitioners. His interests lie in dental technologies and advances in materials and techniques. He has a unique understanding of CAD/CAM dentistry and currently owns two practices in metropolitan Sydney focusing on comprehensive and implant dentistry. Dr Mak has a thorough understanding of direct versus indirect dental restorations and has lectured internationally on the topics of aesthetic and digital dentistry. He is a sought-after speaker and a key opinion leader for several global dental companies. Dr Andrew Chio graduated as a dentist at the top of his year from the University of Melbourne in Australia in 1995. On graduation, he undertook his dental internship at the Bendigo Base Hospital in Australia before spending the next one and a half years working in a rural hospital in Nepal. He is the principal dentist of Arawatta Dental Centre in Carnegie in Australia and an active member of various dental associations. He is a lecturer and gives advanced hands-on training to dentists in specific areas of restorative dentistry. 3D printing 1 2021 65

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manufacturer news | Quality medical products FREEPRINT—30 high-performance 3D-printing resins DETAX is one of the world’s leading manufacturers of high-quality medical products, including a full range of 3D-printing materials. The FREEPRINT line offers more than 30 high-performance 3D-printing resins for all dental applications. All FREEPRINT medical devices have been certified in accordance with the EU medical device regulation. Certain products, for in- stance FREEPRINT denture and FREEPRINT temp, have already received U.S. Food and Drug Administration clearance. DETAX 3D-printing materials are validated for standard printers and post-curing devices. The validation portfolio currently includes 30 devices and is being expanded continuously (see www.detax.com for the latest validation list). This ensures permanently reproducible printing results and the highest product quality. www.detax.com A small footprint but large capability The new VOCO SolFlex 170 HD printer Whether splints, models, denture bases or surgical guides, additive fabrication with SolFlex 3D printers brings numerous advantages. In addition to reducing material and labour costs, it leads to higher clin- ical quality and consistency throughout the production process. In order to offer optimal solutions, VOCO is continuously expanding its range of printing resins as well as 3D printers. Brand new to the portfolio is the SolFlex 170 HD 3D printer. SolFlex 170 HD With its build platform of 121 × 68 mm, sev- eral objects can be printed in parallel—and that with a space-saving, small printer base. The compact new addition uses a high- definition projector, which realises prints of extremely precise and almost continuous surface structures. With long-lasting DLP ultraviolet technology, the large build area is exposed in its entirety with high precision and reliability, saving time. This means that the desired restorations can be produced quickly on the SolFlex 170 HD, at up to 120 mm per hour. The rigid material vat of the SolFlex 170 HD—the PowerVat—permits practical material storage in the vat, simplifying the handling and enabling further prints at a later time. The material vat is non-wearing and therefore extremely durable. If required, only the cost-effective foils are exchanged. To further facilitate work, the intuitive touch screen can also be operated with gloves. In addition, the standard STL file can be easily transferred to the printer via USB, LAN or Wi-Fi. The SolFlex 170 HD is adjusted per- fectly to all VOCO V-Print printing resins— for precise results. www.voco.dental 3D printing 1 2021 69

manufacturer news | More shining smiles with the help of the AccuFab-L4D New L4D dental 3D printer from SHINING 3D SHINING 3D, a complete-solution provider in digital dentistry, has announced a further addition to its line-up of dental additive man- ufacturing solutions, the AccuFab-L4D. This large-platform L4D 3D printer has been developed to further the popularisation of digital treatment solutions. “SHINING 3D is the full-solution provider helping dentists and dental technicians to effi ciently and effectively conquer digital dentistry. We are happy to announce that, with the AccuFab-L4D, we are able to grant even more fl exibility and versatility to everyone who wants to fully digitalise their dental workfl ow processes,” said Kevin Ping, product manager of the dental line at SHINING 3D. The AccuFab-L4D impresses with a large printing platform while simultaneously convincing with a small and compact body. The simple but modern and lightweight design enables easy and user- friendly operation, providing users at all stages of digital dental experience a smoothening of their respective printing application. Large format and high quality The 192 × 120 mm print layout, with 4K high resolution, meets the needs of dental users for effi ciency and detail at the same time. Minimal investment and maximum upgrade Unlike many large-platform 3D printers, the AccuFab-L4D weighs only 19 kg. The AccuFab-L4D has been designed to become dentists’ and dental techni- cians’ lightweight, com- pact and economical companion, helping them to achieve digi- tal transformation and an upgrade to their workfl ow with minimal investment. User-friendly and easy to operate The AccuWare printing software, independently developed by SHINING 3D, helps the user to navi- gate easily and inde- pendently through the entire digital manufac- turing process from planning to printing. The software is designed to support intelligent layout, one-click support generation and one-click printing, empowering even 3D-printing newbies to confi dently start manufacturing their dental projects in-house. Wide range of materials and applications SHINING DENT, SHINING 3D’s self-developed range of dental 3D-printing materials, provides a wide range of options for a broad array of dental 3D-printing applications. The AccuFab-L4D supports the printing of working models, im- plant guides, orthodontic models and individual trays and other types of professional dental applications, improving the effi ciency of denture making and realising effi cient treatment in one visit. In order to popularise the digital treatment and production pro- cess, the AccuFab-L4D incorporates a number of user-friendly features, including nesting, slicing and equipment maintenance operations. The AccuFab-L4D is designed to make it easy to print even for fi rst timers, thus creating an impactful appeal of 3D-printing technologies in the dental industry. SHINING 3D provides fully integrated 3D digital dental solutions, from obtaining 3D data with 3D scanners for laboratories and intra-oral 3D scanners for clinics, then designing with professional dental CAD software, to printing dental products, including work- ing models, orthodontic models, implant models, surgical guides, wax-ups and partial frameworks. www.shining3d.com 3D printing 1 2021 71

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