issn 2193-4673 • Vol. 4 • Issue 2/2023 2/23 digital international magazine of digital dentistry opinion Is digital dentistry the solution to the sustainability dilemma? case report Comprehensive dental rehabilitation with a digital workflow industry news Digital workflow for dental offices and laboratories—where are we now?

editorial | Magda Wojtkiewicz Managing Editor IDS 2023—simply the best! After the turbulence of the COVID-19 pandemic, the dental industry is back on form! The best proof of this was the global meeting of the dental community at the largest trade show and dental business summit—the International Dental Show (IDS). Despite the many eco- nomic and political issues presently facing the world, IDS 2023 achieved pre-pandemic attendance levels— 120,000 visitors—and massive participation by clinicians, members of the dental team, educators, manufacturers and distributors while showcasing a vast variety of products and equipment. Koelnmesse in Cologne in Germany was the centre of the dental universe for tens of thousands of participants during a full week in March, often with a crush of people trying to pass through the crowded aisles for a glimpse of new products and technology. The halls were full of visitors watching hands-on demonstrations and presen- tations delivered by clinicians, laboratory technicians, dental hygienists and industry partners representing 1,788 exhibitors from 60 countries. on the expanding world of 3D printing, design software, CAD/CAM chairside devices, materials with excellent physical and aesthetic properties, cloud solutions and artificial intelligence (AI) technology. The innovations pre- sented at IDS were stunning, and the number of new digital solutions on display was almost beyond imagination! Naturally, the overall feedback from the exhibitors was very positive. Fred Freedman, vice president of member services at the Dental Trade Alliance and president of International Dental Manufacturers, stated: “IDS is the largest and best international dental meeting in the world. The 2023 IDS can be summed up in one sound bite: IDS is back. With the enormous crowds and thousands of international distributors and visitors, this is a must for all US manufacturers and companies looking for new international business.” The success of this year’s IDS allows us to look to the future development of the dental industry with great optimism. Like pre-pandemic editions of IDS, seeing everything that one might wish to see in the multiple halls was impos sible. One thing was abundantly clear: there was a major emphasis on innovation and digital solutions focusing Sincerely, Magda Wojtkiewicz Managing Editor 03 2 2023

simply.TRIOS 5 Hygienic by design for minimal risk of cross- contamination. Smaller and lighter than ever for next-level ergonomics. And a ScanAssist engine with intelligent-alignment technology that makes precision scanning effortless, every time. Intraoral scanning that simply makes sense

Go further with DS OmniTaper™ implant system Take your greatness to new heights. DS OmniTaper™ implant system is an intuitive, dependable and scalable solution, allowing you to go further and do more for your patients. – Pre-mounted TempBase for immediate restorations and efficient workflows – OsseoSpeed® surface for more bone, more rapidly – Conical EV connection and harmonized prosthetics for streamlined efficiency To learn more about the newest member of the EV Implant Family – visit dentsplysirona.com/ds-omnitaper or talk to your representative. Follow Dentsply Sirona for the latest in implant dentistry dentsplysirona.com/implants

TRULY CONICAL PRECISION Fully Fully guided! guided! CONELOG® PROGRESSIVE-LINE conical performance 1, 2 at bone level long conus for reduced micromovements superior positional stability in comparison to other conical systems 1,2 easy positioning with excellent tactile feedback easy positioning with excellent tactile feedback integrated platform switching supporting the preservation of crestal bone [1] Semper-Hogg, W, Kraft, S, Stiller, S et al. Analytical and experimental position stability of the abutment in different dental implant systems with a conical implant–abutment connection Clin Oral Invest (2013) 17: 1017 [2] Semper Hogg W, Zulauf K, Mehrhof J, Nelson K. The influence of torque tightening on the position stability of the abutment in conical implant-ab- utment connections. Int J Prosthodont 2015;28:538-41 CONELOG (R) is a registered trade mark of Camlog Biotechnologies GmbH. It may however not be registered in all markets. VISIT OUR WEBSITE!

opinion | from nearby clinics that can perform the same type of treatment at a lower cost and with greater proficiency because they have better means and materials to do so. It appears that soon all this information will be available to everyone, not just dentists. in developing a treatment plan and that the sequencing of treatment steps is done according to the principles of biology and mechanics, based on a deep understanding of what is possible and tangible, in order to achieve longev- ity and success for the dentist and of course the patient. That is why I have been warning for some time in my lec- tures and at international conferences that this is a very good time to start investing in quality and to be as ethical as possible in our professional conduct, because sooner or later there will be technological entities controlling the way we work. It is going to be very difficult to deceive your patients, and we all know that there are many today who practise dentistry that is not congruent with current science and clinical evidence in order to save time or money. It will certainly be very interesting to see the evolution of all these technologies in our industry. Just like we have been doing with clear aligner treatment for over 18 years, this whole process has to be validated by a human, the dentist—who of course is sovereign at the end of the day! If he or she changes the treatment plan, however, the AI program will inform the patient of this change immediately, giving the patient the op- portunity to ask why. If things go wrong in the future, AI programs will certainly give patients the means to engage with their dentists. This will have legal implications, and I believe will make life more difficult for some but easier for others. Personally, I think that this is great! Since the beginning of my career, I have been putting myself on the side of the patient and not on the side of the industry. I practise empathy every day when I have a patient in front of me. I am sure that every patient in the world wants the same thing: good treatment performed with the best materials, painlessly and with care and that lasts a lifetime with high aesthetics. Of course, this magic formula does not exist, but surely the incredible tension that exists between patients and the industry will dissipate if we have a tech- nological referee in our midst. We all know that there are patients with unrealistic ex- pectations who have a very complicated phenotype and want complex mouth treatments that are unachievable. An AI program will be able to immediately mediate in the conversation by introducing an objective examination so that the dentist can have more tools to demonstrate the facts of the case based on science and to support a challenging explanation to the patient and, by the same token, so that the patient will have extra support to ensure that he or she is not being misled and that the dentist is not trying to sell something outside of the necessary scope, in defence of the patient’s oral health and wallet. I think that it will be an incredible help to many. Of course, clinics that practise dentistry without regard to quality and ethics should be very concerned about these new technologies. I think that this mediation is something that is missing in our industry. I have already been working with companies and been helping some of them, learning from them and trying to ensure that decision-making and implementation are based only on ethics, science and clinical evidence. Execution of treatment I believe that this will be an area explored more by robotics than by AI. There are already robots that can place dental implants remotely with incredible precision, and naturally they will be controlled by AI in the future. For now, we can be assured that, at least for the next few years, the art of taking care of our patients’ mouths will still be very manual, and here dentists play a leading role. I believe that, if we are smart and use the time saved in creating the treatment plans and diagnoses by AI, we can use that time to invest more time in our patients. Certainly, there will be clinics that will quickly fill those hours with more patients, but as you know I am a strong advocate of Slow Dentistry (slowdentistry.com), and I believe this is how we will secure our future. The human touch is going to be the major differentiator. I believe that we have to focus on the human side of our art because in the future the dentists who create the best relationships with their patients will be more successful. Patients will surely want to be sure that their dentist is doing things right, and we all know that working in a hurry is very difficult. There are more and more young dentists in the business. Experience takes years to ac- quire, and it is imperative to give young people adequate time to be able to do their jobs well. I even believe that there will be an AI program that will be able to measure what the optimal time is for performing each task with quality and that will inform the patient that the average optimal time for a Class I restoration on a molar is 35 minutes, for example, and that fitting a dental dam for treatment is essential. To summarise, I think that AI will provide an incredible means to improve the effectiveness of diagnoses and treatment plans, making the process much safer for everyone involved, and to ensure that no step is forgotten Regarding the execution of treatment, I think that AI will play a very relevant role in the selection of materials and technologies to use. Here it is easy to understand how. When the AI program compiles the treatment plan, it will be able to analyse all materials available quickly and 11 2 2023

O r t R e h o d o s t o r n t i c s a t i v e D e n S t l e e p u r e s I m p l a n t Simplify workflows and expand your practice NEW DEXIS IS 3800 Expand your treatment offerings DEXIS™ IOS Solutions seamlessly integrates into your dental workflow, helping you to simplify processes, increase productivity, and facilitate practice expansion. Say hello to more time for what really matters — your patients. Find out more at dexis.com © 2023 Dental Imaging Technologies Corporation. All rights reserved; DXIS00275 /RevA dexis.com | 888-88-DEXIS

opinion | 2 3 Fig. 2: Researchers make use of generative AI to design personalised dental crowns. Fig. 3: Natural tooth (left) compared with tooth tailored by generative AI (right). The generative AI-designed crowns had the lowest 3D discrepancy, closest cusp angle and similar occlusal contacts compared with natural teeth. In lithium silicate, the AI-designed crowns were found to have an expected lifespan similar to that of natural teeth. According to the researchers, the other two methods of designing dental crowns produced crowns that were either too large or too thin and failed to reach the same lifespan as that of natural teeth. “This demonstrates that [the algorithm] could be utilised to design personalised dental crowns with high accuracy that can not only mimic both the morphology and bio- mechanics of natural teeth, but also operate without any additional human fine-tuning, thus saving additional costs in the production process,” added senior researcher Dr James Tsoi, an associate professor in dental materials science at the university. “Many AI approaches design a ‘lookalike’ product, but I believe this is the first project that functionalises data-driven AI into real dental application. We hope this smart manufacturing technology will be the stepping stone for driving Industry 4.0 in dentistry, which is vital to meet the challenges of an ageing society and lack of dental personnel in Hong Kong,” Dr Tsoi stated. Clinical trials for using the generative AI for dental crowns are underway. Additionally, the researchers are working to expand the applicability of the tool to other dental pros- theses, such as partial and complete dentures. Editorial note: The study, titled “Morphology and mechanical performance of dental crown designed by 3D-DCGAN”, was published online in the March 2023 issue of Dental Materials. Fig. 4: The HKU Dental Materials Science research team: (from left) co-investigator postdoctoral fellow Dr Hao Ding, principal investigator Dr James Kit Hon Tsoi, and PhD candidate Ms Yanning Chen. 4 15 2 2023

opinion | CBCT images showing overlaid expert and deep learning system segmentations. Every image on each column is annotated by the same expert, shown in red, the deep learning system annotation is shown in green and overlap is shown in yellow. (Image: © 2022 Järnstedt et al., licensed under CC BY 4.0, no changes) dibular canal and performed better overall than the radiologists. In addition, it showed promising gen- eralisability with regard to new CBCT scanners and ethnic groups. “When a huge amount of data is fed to the neural network and the location of the mandibular canal is marked in it, it learns to optimise its own internal parameters. The neural network resulting from this learning quickly finds the mandibular canal from the individual 3D data input,” said co-author Vesa Varjonen, vice president of research and technology at dental equipment manufacturer Planmeca, which is based in Helsinki. “In clinical assessments, experts went through the results produced by the model and discovered that in 96% of the cases they were fully usable in clinical terms. We are highly confident that the model works well,” commented co-author Jaakko Sahlsten, a doctoral researcher at Aalto University. “The collaboration arose from the needs of experts practising clinical work and from seeking ways to help their everyday work. A lot of time can be saved by using artificial intelligence in patient treatment planning,” said Varjonen in a press release. “Tampere University Hospital provided us with extensive and versatile clinical materials produced with several 3D-imaging devices. The data was divided at random and part of it used for training the neural networks and part of it isolated for testing and validating the designed method,” said Sahlsten. Planmeca to integrate the model in its imaging portfolio For Planmeca, a Finnish family business and one of the world’s leading equipment manufacturers in health tech- nology, the collaboration with FCAI and Tampere University Hospital means significant new business potential. “Digitality and AI used in imaging equipment are import- ant for us. We will integrate the neural network model developed in this research into our imaging software. This will improve the usability and performance of our equipment,” said Varjonen. Model for orthognathic surgery In addition, the collaborative research project developed a neural network model for orthognathic surgery. “The model helps to identify landmarks in the skull area for correcting malocclusion and planning jaw alignment surgery,” said Varjonen. “I see artificial intelligence as a very powerful tool that physicians and other experts can use when making their first assessments or to get alternative opinions. The challenge with deep learning models is that we cannot give definite grounds as to why the model reaches a specific outcome. Further research is needed to increase the explainability and transparency of the models,” concluded Sahlsten. Editorial note: The study, titled “Comparison of deep learning segmentation and multigrader-annotated man- dibular canals of multicenter CBCT scans”, was published on 3 November 2022 in Scientific Reports. 17 2 2023

opinion | What impact can the output or fabrication of dental prostheses have on sustainability? Initially casting re- quired investing, melting and significant finishing and was heavily reliant on materials and time. Milling provides an accurate and predictable workflow but has limitations on design and sustainability. How does additive manufacturing (AM) or 3D printing fit into the equation? There are a multitude of AM pro- cesses that provide accurate and efficient prostheses in plastic (resins), metals and ceramics (zirconia and lithium disilicate). These approaches can create any geometry and typically offer superior accuracy and improved sustainability. Additionally, recent research has quantified that the AM workflow is more sustainable than conven- tional fabrication pathways. A further advantage is that prostheses made digitally offer impressive physical properties. The possibility of bypassing digital design by using indirect onlay restorations has also been explored. This would be a novel approach that could save an enor- mous amount of time, money and resources. And this is just the beginning, since artificial intelligence is already having an impact on diagnosis and treatment planning, and virtual and augmented reality are being used for education and training. Another factor to be considered is the developing metaverse. However, digital dentistry comes with a significant caveat: the user must have an excellent understanding of its applications and limitations in a clinical setting. After all, digital dentistry provides another set of tools in the dentist’s toolbox. Clinicians must know which tool to use and when. For example, there was a recent report of a clinical full-arch implant case which included a bone reduction guide and a guide for implant placement. Both were acquired through a fully digital workflow. Unfortunately, during the surgical session, neither guide fitted well, and the clinician had to detour to a free-hand approach. Kudos to the clinician for realising the errors, but what an unnecessary environmental impact and waste of time and money! I have heard similar stories where the implant surgical guides did not fit intra-orally owing to the patient’s limited mouth opening—another unfortunate situation in which digital dentistry was improperly used. The last scenario I will highlight concerns a clinician who bought a 3D resin printer to complement his intra-oral scanner. In this case, all patients received a diagnostic scan and printed models for educational and marketing reasons. Is this an appropriate use of digital dentistry? How does this reflect sustainability? What happens to those models when the patients have no use for them? Are they recyclable? This scenario reminds me of that meme where a gas- powered generator is being used to charge an electric vehicle. “Digital dentistry provides another set of tools in the dentist’s toolbox.” If we collectively strive for dentistry to have improved sustainability, we must consider the entire picture. Here are a few recommendations for implementing digital dentistry as related to sustainability: – consider the clinical workflow and assess how sustainability can be improved without compromising the standard of care; – understand and follow the fundamentals and principles of digital dentistry. It is merely a set of tools to improve the workflow; – be curious and explore new technologies; – be critical. For example, consider whether a fully guided case is essential; – consider a hybrid or fused workflow, combining the best aspects of analogue and digital, until there is a strong grasp on predictable digital workflows; and – exercise the Rs: recognise, reduce, recycle, repurpose, rethink and rejoice! Digital dentistry is a strong technological tool that can help dentistry become more sustainable. However, dental professionals have to ask the right questions, perform due diligence and make appropriate decisions that benefit patients and the planet. about Dr Les Kalman is an educator and medical device researcher focusing on additive manufacturing and software. He is a fellow of the Academy of Osseointegration, American College of Dentists and Academy for Dental Facial Esthetics and a diplomate of the International Congress of Oral Implantologists. He is the recipient of an Alumni of Distinction Award from the Schulich School of Medicine and Dentistry at Western University in London in Ontario in Canada and a CES Innovation Awards honouree. 19 2 2023

opinion | “We recognise that with our global environmental footprint and unique position within an ecosystem of relationships with sup- pliers and business partners, we are uniquely positioned to be a driving force for sustainability in the healthcare supply chain,” Stanley M. Bergman, CEO and chairman of the board at Henry Schein, commented at the time in a press release. Of the more than 4,800 companies that have joined the initiative, 2,538 have made science-based targets and 1,779 have made a net-zero commitment. a large component of the non-clinical emissions, at least in Australia, with our vast solar and wind resources and with our transitioning to electric vehicles powered by renewable energy, I think the non-clinical emissions can realistically be substantially reduced. The clinical component, however, is largely attributable to pharmaceuticals and procurement. As doctors, we can minimise unnecessary treatments and focus on low carbon treatment options but it will be necessary to put pres- sure on supply chains to decarbonise. That is something that we can advocate for but is also out of our control.” Align Technology, whose mainstay is the manufacture and global distribution of clear aligner trays, says on its website that it is investing in energy efficient buildings and employee transportation in order to reduce emissions. Align thus far provides no data about its emissions or concrete plans to reduce them. In its 2021 Sustainability Report, Envista Holdings quantified its operational emissions (Scope 1 and Scope 2) and said that it intended to assess and review its Scope 3 emissions. Envista, which was spun off as a new dental company in 2019, said at the time that identifying an environmental target, such as net-zero standard, was an area of priority for the young company. Dentsply Sirona also announced in 2021 its ambition to reach net-zero carbon emissions (Scopes 1–3) by 2050. The company said that its target is “in line with globally recognised standards” but did not detail which standards or whether its commitment was binding. A push for net zero in health clinics and services There is a drive to reach net-zero emissions in individual dental clinics and health services that provide oral care. The UK government, for example, passed legislation last year to deliver a net-zero National Health Service (NHS), including NHS dental care. The ambitious vision of achieving a net-zero NHS by 2040 includes an 80% reduction in Scope 1 and Scope 2 emissions by 2032 and slashing Scope 3 emissions by the same figure by 2039. “Our intention for these targets is to construct the most ambitious, credible declaration to reach net zero of any national healthcare sys- tem in the world,” the health service declared in a report. A forthcoming article from the Australian Journal of General Practice, shared with Dental Tribune International (DTI), showed that non-clinical emissions account for around 40% of total emissions at general medical practices in the UK and that the remaining 60% is attributable to the clinical component. The largest sources of non-clinical emissions were staff travel, at 22.8%, business services, at 22.5%, and patient travel, at 18.4%. Dr Richard Yin, co-author of the article and chair for West- ern Australia of the organisation Doctors for the Environment Australia (DEA), told DTI: “With energy and transport being DEA advocates for a net-zero target for Australia’s health- care sector, and Dr Yin said that the industry has an urgent responsibility to decarbonise. “The most important reason for the profession to take steps and be part of the climate movement is to be advocates for change,” he emphasised. Speaking about net-zero targets for individual clinics, Dr Yin said: “The issue is to define the carbon footprint of a dental practice and then understand how to reduce it.” Here, practice owners can engage consultancy services, such as Glasgow-based Net Zero Dentistry, which market a service of decarbonisation and offsetting to practice owners. Earnestly adopted and used, the strength of net zero as a tool to make dental care and manufacturing more sus- tainable lies in its focus on proactively reducing emissions rather than offsetting them and its being backed by climate science; however, the risks of greenwashing and ineffective carbon offsets remain. An investigation by news outlets The Guardian and Die Zeit, together with not-for-profit investigative journalism organisation SourceMaterial, revealed in January that the bulk of forest carbon offsets issued by leading certifier Verra were largely worthless. Rainforest protection accounts for 40% of the credits that Verra sells, and journal- ists found that Verra overstated threats to its forest projects and sold credits that had failed to reduce deforestation. Washington DC-based Verra, whose clients include Shell, easyJet and Pearl Jam, disputed the claims. Dr Yin said that carbon offsets were problematic and could not be relied upon for decarbonisation. “There is no guarantee that a tree planted today will be around in 30 years’ time. The time frame required for us to decarbonise to avoid the worst of climate impacts requires urgent action this decade. Nonetheless, buying offsets places carbon on a balance sheet, and that helps keep it as a cost that has to be ad- dressed,” Dr Yin said. Currently, no artificial carbon sinks are capable of removing carbon dioxide from the atmosphere at the scale that would be necessary to achieve climate goals, and even natural sinks are struggling to keep pace with perpetual economic growth. According to the European Commission, global carbon sinks remove up to 11 Gt of carbon dioxide from the atmosphere every year, whereas global carbon emissions totalled 36 Gt even in 2020, when global emissions dipped owing to the SARS-CoV-2 pandemic. 21 2 2023

interview | During this evolution, I also developed a relationship with the counterpart that was working with Ivoclar on the digital dentures, a company named 3Shape. 3Shape produces desktop and intra-oral scanners as well as dental design software for all types of den- tal restorations. As part of the collaborative Ivoclar– 3Shape team, I also helped develop scanning strat- egies for the TRIOS intra-oral scanners, so I’ve been able to see the journey of digital dentures all the way from conception through to more widespread use and to being a valued component in any dental facility that prides itself on employing the latest tech- nology in the field. Have these digital denture workflows changed in the years since? One of the best features of digital dentures from a train- ing and implementation perspective is that when mov- ing from analogue to digital, the clinical workflow can remain the same. While there are more efficient work- flows that allow for greater flexibility, dental professionals who are providing removable prosthetic therapy do not need to change their current workflow when they switch to digital dentures. The biggest change that comes with digital dentures is data acquisition, how the data captured clinically is rendered in the design software, the manufacturing methodology, and the process that supersedes it. However, for those who want to overcome the chal- lenges of conventional workflows, there are various methods for the delivery of dentures in two appointments rather than the traditional three to five appointments that may be necessary with more conventional methods. To capture that efficiency, the biggest change we’ve seen is the process and workflow for immediate den- tures. With an intra-oral scanner, dental professionals can scan the patient’s oral cavity, render a design and then deliver the dentures at the next appointment when the teeth are being extracted. This technology has been revolutionary both on the clinical side and on the lab side, because we can now digitally visualise where a patient’s natural teeth were and where the new teeth will be. This truly provides unparalleled results for the clinician and the patient. Another revolution of digital denture technology is the ability to deliver the final denture at the try-in stage. In the conventional analogue process, dental professionals have to perform a wax try-in, where all of the teeth are individually set in wax. This is a very labour-intensive and technique-sensitive process that requires extreme care and is prone to human error as well as material deficien- cies, which can result in extensive and expensive cor- rective measures. In contrast, with digital dentures, you can deliver that same quality—or even higher quality— dentures for a fraction of the cost to the clinic and in a fraction of the time at that try-in appointment. More- over, if the denture isn’t completely correct, mak- ing adjustments is efficient, effective and predictable by applying the changes via the software with a few keystrokes and mouse clicks. Today, at our Aspen Dental locations that offer digital dentures, there is an over 80% success rate at that denture delivery appointment. Just think: if you fit 100 dentures a month and 80% of the time you deliver those dentures successfully, you will have gained 80 appointments in your schedule that month. That means new and existing patients aren’t waiting as long resulting in an increase in more avail- able chair time that can be used to deliver high quality removable therapy to more patients. “For dental laboratory technicians, digital dentures offer consistency in the design process and greater customisation.” What benefits does the digitalisation of the denture process bring for the clinician, the dental laboratory technician and the patient? First and foremost, the most significant benefit for all three parties is the ability to electronically preserve the patient’s initial data acquisition, whether that is a scan of the teeth, dentures or edentulous oral cavity, as well as the preservation of the final design file of the restoration. For the patient, the electronic pres- ervation of that data means that, if a patient loses a denture, a replacement denture can be fabricated within 24–48 hours without having to take another im- pression or come in for any additional appointments. That’s simply not possible with conventional den- tures. In addition, digital dentures have greater reten- tion, stability and strength than dentures produced in the analogue manner. It’s important to note that digitally manufactured prostheses have a uniform thickness feature that provides the patient with true physiological comfort. For dental laboratory technicians, digital dentures offer consistency in the design process and greater customisation. For clinicians, the improved workflow, efficiency and accuracy of digital dentures reduce 23 2 2023

interview | “The biggest change that comes with digital dentures is data acquisition, how the data captured clinically is rendered in the design software and the manufacturing methodology.” and knowledge to help shepherd Aspen through the digital transformation. This was a great opportunity, so I agreed. I very quickly fell in love with the organisation, not just because of its commitment to digital technology, but also because I was able to convey my clinical knowledge and skills to our dentists through our various onboarding programmes and learning and develop- ment initiatives. I helped establish the curriculum alongside our vice president of clinical support, Dr Andrew De La Rosa, and when we first delivered the learning programme, I asked every dentist in the room how many dentures they had done in dental school. In the room of 30 dentists, the average had made just two dentures. That’s when I realised, in an organisation where we do half a mil- lion dentures a year and someone can graduate and go into an office and do up to 100 dentures a month with very little experience, I could have an enor- mous impact on hundreds of thousands of patients and hundreds of dentists. Our chief clinical officer, Dr Arwinder Judge, asked me whether I wanted to make a change and come join Aspen Dental full time on the clinical team. Without hesitation, I decided to sell my private practices and join Aspen full time, not just to help lead the digital transformation, but also to improve the quality of the removable prostheses we deliver here at Aspen Dental, irrespective of whether those are produced digitally or using ana- logue methods. Ultimately, it was the organisation’s mission and the clinical support team that attracted me, but the ability to provide countless dentists, den- tal technicians and team members with the training they need to deliver the best possible removable pros- thetic experience to patients is what made me fully commit to Aspen Dental. I am honoured to be part of the clinical support team here at Aspen Dental and truly changing the way we deliver care to millions of patients every year! 25 2 2023 After over a decade in private practice, why did you choose to join Aspen Dental? Before I joined Aspen, I was an industry leader lec- turing at some of the most prestigious conferences in the world, as well as publishing articles, working on various research and development projects and co-authoring textbooks. I truly valued private prac- tice and loved working in research and development and, most importantly, treating patients with remov- able therapy. Fast-forward to January 2021, when Aspen Dental decided to go digital with its dentures. Dr Sundeep Rawal, the senior vice president of implant support at Aspen and a long-time colleague, asked me to come on board as a consultant to use my skills

interview | However, this is now considered a stand-alone fea- ture for the EV family of implants. The design provides six-position indexing for prefabricated abutments and seating in any rotational position for non-indexed abutments. It also offers a one-position-only asym- metric index for digital scanning and restoration with CAD/CAM abutments. When we go beyond the implant itself, the evolution of surgical techniques and digital technology, such as CBCT, 3D scans and digital impressions, is significant. It would, therefore, make little sense to single out the one greatest achievement. Rather, it is the combination of the many improvements in detail that are advanc- ing implant dentistry today. These include CAD/CAM technology and 3D printing and how they enable more efficient workflows and better patient care. In your opinion as an expert in dental implantology, what are the advantages of a fully digital workflow in implant dentistry for the practitioner, the patient and the laboratory? Standardised and digital workflows work intuitively over and over again. It makes a difference not having to rethink procedures every time. This applies to other medical disciplines as well. The results become more predictable and easier to plan. This also in- cludes prosthetics which are produced in the dental laboratory. Workflows driven by digital technology can result in higher accuracy, repeatability of processes and time savings. The DS PrimeTaper implant system by Dentsply Sirona, for example, is an illustration of this concept as it can easily integrate into a digitally driven workflow through the EV connection. This is beneficial for both the expe- rienced implant practitioner and the clinician who is just embarking on the implant path. Digital workflows also offer patient security. From the perspective of backward planning for restorations, digital treatment planning allows us to show the pa- tients in advance what the result will look like and how we will get there. This improves patient acceptance enormously. What are the limitations of a digital workflow? Interesting question! The implants of today are incredi- bly good. Assuming that success rates are in the 95–99% range and considering the statistical failure that usu- ally occurs, there is only little room for improvement. Limitations, therefore, arise not so much from the im- plant itself but from the individual patient situation— clinical, ethical and financial. Therefore, it is important for us as dental practitioners to be constantly curious and open to learning in order to continuously improve the care we give to patients. The DS PrimeTaper offers a superior implant treatment for numerous indications. Events like DS World are a great opportunity to meet and learn from various experts and peers. Another great educational resource is DS Academy’s Dental Implant Curriculum. It is a fully online, comprehensive and free tool that aims to inspire dental professionals to build and develop their clinical knowledge and digital skills in implant dentistry. I lead one of the courses on implant design and osseointegration. Whether one is new to implant dentistry or has had many years of ex- perience, there is a suitable course level with interesting topics and practical advice. You were the scientific co-chair of Dentsply Sirona’s Implant Solutions World Summit this year together with Dr Tara Aghaloo. What attracted you to take this position? I am passionate about dentistry and very interested in scientific knowledge. After all, the results gained from the research show me which materials and methods I can use to treat my patients safely and with long-term success. By chairing the scientific programme, Tara and I were able to select what topics we want to talk about at the summit and also which researchers or lectures we wanted to listen to. 27 2 2023

EXPERIENCE THE ART OF ESTHETIC DENTISTRY .. – .. | BADEN-BADEN, GERMANY Explore new perspectives. Meet world-class experts. Grow your capabilities. Join the community. GET YOUR TICKET / I G D / / B / n e / _ A

case report | 3a Figs. 3a & b: Surgical planning for bicortical fixation with placement in furcal bone. has been shown to enhance accuracy, precision, and flexibility across surgical fields.1,2 The Yomi dynamic navigation platform with haptic feedback allows for small adjustments in real time and accurate visualisation of drills into the surgical site. This can be significantly im- pactful when managing close implant placement to sensitive anatomical structures of the IAN, drill depth management in vertical sinus lift augmentation, and as- suring immediate implant placement into adequate native bone. The following case studies will review the digital workflow of dynamic navigation with Yomi when perform- ing immediate zirconia implant surgery and the perceived benefits therein. 3b Case presentations Case 1 A 60-year-old female presented with history of LANAP at the periodontist on #3 for a 9 mm periodontal pocket on the DB one year ago. Upon recall at the periodontist, the vertical bone defect was non healing, and the tooth was deemed hopeless. The patient came to our clinic hoping for extraction and immediate implant placement, risks and alternatives were given to the patient including the possibility of inability to place the implant the same day due to bone anatomy in the area. Yomi link was attached to her upper left using bite regis- tration and a CBCT was taken with the additional fidu- ciary arrays attached to the link (Figs. 1 & 2). Surgery was planned for bicortical fixation with placement in furcal bone avoiding the defect on distal (Figs. 3a & b). The sur- gical procedure involved a planned implant depth to the sinus floor, followed by a gradual increase in depth to per- form an internal sinus lift. The extraction was carried out atraumatically, and the socket was thoroughly cleaned. Yomi guide arm was then attached to the link and the landmark verified, ensuring accurate stable navigation. Under surgeon guidance and robotic assistance the pilot drill was guided to the surgical site. The osteotomy con- tinued with a drill path and depth that locked once in the planned position. The osteotomy was completed to the sinus floor with confirmation of depth via dynamic live CBCT navigation. Incremental advancement of the drill depth stop was used to complete the sinus lift. Proper vi- sualisation aided in depth management of the transgin- gival implant. The implant (2.2_5411, SDS) was placed 31 2 2023

case report | 9 10a Treatment plan A thorough discussion of treatment options, limitations and risks was reviewed with the patient. Poor long-term prognosis was given to remaining mandibular teeth except #30. The patient’s primary concerns were to have no teeth during healing, not wanting a removable prosthesis, and to have biologically friendly materials. Delicate consid- eration was made to design an immediate implant surgery that provided the patient with a stable temporary resto- ration and protected our healing implants. One-piece SDS (Swiss Dental Solutions) implants were chosen for their variety of diameters and lengths. Posterior teeth 18, 28, 30 were elected to remain in place during the tempo- rary healing phase to provide posterior stops for occlu- sion and to maintain stability of implants and temporary restoration during healing phase. Pre-surgical planning was performed using CBCT and Yomi planning software to parallel all implants (Figs. 10a & b). Preoperative max- illary and mandibular arch scans were taken and sent to the lab to aid in temp mock-up (Fig. 11). Surgical Phase The procedure began with the administration of bilateral inferior alveolar nerve blocks for anaesthesia, followed by sectioning and removal of the PFM bridge. The Yomi link was then attached to the lower left using bite regis- 10b 12 11 Fig. 4a: Placement of the pilot drill into the surgical site via dynamic live CBCT navigation. Figs. 4b & c: Osteotomy was completed to the sinus floor with confirmation of depth via dynamic live CBCT navigation. Fig. 5: Placement of the ceramic implant (2.2_5411, SDS) to 35 Ncm. Fig. 6: PRF covering with allograft. Fig. 7: Postoperative radiograph showing accurate implant placement. Fig. 8a: Initial situation on CBCT showing multiple peri- apical radiolucencies associated with failing root canals of teeth 19, 21, and 27. Fig. 8b: Horizontal root fracture in tooth 29. Fig. 9: Failing double abutted bridge in teeth 21/22-27/28. Figs. 10a & b: Pre-surgical planning using CBCT and Yomi. Fig. 11: Preoperative maxillary, mandibular and bite scans to aid in temp mock-up. Fig. 12: Immediate implantation in site #29 using the Yomi robot with haptic controls and locked drill path depth and angulation. 33 2 2023

case report | “With the variety of modern digital workflows choosing a surgical method that is predictable and repeatable is what we as clinicians must evaluate.” the the lower right side of the patient’s mouth, utilising teeth 30 and 28, and implant abutments 29 and 27, but it was then unsuccessful. Yomi’s traditional workflow only allows for working on one quadrant of the mouth at a time, and a new scan and four or more stable teeth are required to anchor the link on the other side. This has now been overcome with a new Yomi bone link which would have been ideal in this case. Freehand immediate placement and parallelisation of im- plants (#22, 20, and 19) was possible with the visual aid of the previous implants. Intra-oral scans of the surgical sites were made and sent to the lab for temporary fabrica- tion (Figs. 13 & 14). Site #21 had significant bone loss due to infection and was grafted with allograft and a laminar bone sheet. The bone sheet was trimmed and placed into a minimally released buccal and lingual flap and cov- ered with A-PRF+ (Figs. 15a & b). Suturing was com- pleted, and a full arch temp was adjusted and seated with temp cement (Fig. 16). Seven weeks later, the patient’s loose temp was removed, cleaned, and recemented. Ex- cellent healing of the soft tissue was shown in Figure 17. Discussion Ceramic dental implant placement can be a delicate pro- cess, having ideal emergence with one piece dental im- plants remains one of the biggest challenges and ideal placement is essential. A fixed drill path and depth com- bined with Yomi’s surgical flexibility and the dentist’s visu- alisation during surgery may be one of its advantages over other guided navigation systems. As patient awareness grows of different dental materials, zirconia implants with their excellent healing profiles are poised to continue to gain attention. Accurate and ideal placement of zirconia implants is essential in gaining trust of our patients and dental com- munity. With the variety of modern digital workflows choos- ing a surgical method that is predictable and repeatable is what we as clinicians must evaluate. The benefits of robotic assistance point towards Yomi holding its place in the surgical suite and will likely continue to pave the path forward in giving patients access to safe, efficient, accurate and long-lasting zirconia implant therapy. Editorial note: This article was first published in ceramic implants international magazine of ceramic implant technology, Vol. 7, Issue 1/2023. Please scan this QR code for the list of references. about Dr Daniel Madden received his Doctor of Dental Surgery from the University of Minnesota and pursued advanced studies in implantology and comprehensive dentistry abroad at the Radboud University Medical Center in Nijmegen, the Netherlands. He has served as adjunct affiliate assistant professor at Oregon Health and Science University and is a certified Integrative Nutrition Health Coach. He has a passion for education and technology in dentistry, and believes that this leads to a more comfortable, efficient and pleasurable patient experience. He offers patients biologic treatment solutions for optimum oral and whole-body health at Lotus Dental Wellness in Lake Oswego, Oregon, and his surgical services through his company Peak Potential Dental at multiple private practice locations in Oregon and Washington State. contact Acknowledgements to Dr Shepard Delong for his guidance and introduction to ceramic implantology and to Lotus Dental Wellness, Lake Oswego, Oregon. Dr Daniel Madden Lake Oswego, USA in Hood River, USA www.dentistdanielmadden.com 35 2 2023

case report | 6 7 8 9 10 11 12 Fig. 6: Use of the BoneTrap to augment the small bone fenestration. Fig. 7: Large quantity of autogenous bone collected from the BoneTrap. Fig. 8: Symbios Xenograft Granules layered over the autogenous bone. Fig. 9: Symbios Collagen Membrane SR trimmed to shape to complete the guided bone regeneration procedure. Fig. 10: Passive primary closure with PGA sutures. Fig. 11: Post-op radiograph of the implants. Fig. 12: Healing Abutments EV placed at three months after initial surgery. AD THE GLOBAL DENTAL CE COMMUNITY REGISTER FOR FREE DT Study Club – e-learning community www.dtstudyclub.com @DTStudyClub Tribune Group is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry.This continuing education activity has been planned and implemented in accordance with the standards of the ADA Continuing Education Recognition Program (ADA CERP) through joint efforts between Tribune Group and Dental Tribune Int. GmbH.

case report | 15 17 16 18 Fig. 15: Well-fitting screw-retained Atlantis CustomBase abutments and zirconia crowns tried in. Fig. 16: Radiograph to verify correct seating of the restorations. Fig. 17: Screw access holes sealed and amalgam in tooth #14 replaced with composite. Fig. 18: Final restorations in situ. tion (Figs. 6 & 7), and Symbios Xenograft Granules were layered over the autogenous bone (Fig. 8). Finally, Symbios Collagen Membrane SR (15 × 20 mm) was trimmed to shape to complete the guided bone regeneration proce- dure (Fig. 9). The wound was closed with PGA sutures (Fig. 10), and radiographic evaluation was performed to verify the implants postoperatively (Fig. 11). Three months later, medium Healing Abutments EV were placed (Fig. 12). A digital impression using an intra-oral scanner (Primescan) was then captured using the Atlantis IO FLO for a digital restorative workflow (Fig. 13). An Atlantis CustomBase solution, consisting of an Atlantis crown, an Atlantis abut- ment and an Atlantis abutment screw, was fabricated for each implant and tried in, and no adjustments were needed (Figs. 14 & 15). After seating, a radiographic eval- uation was performed to verify the final restorations (Fig. 16). The final restorations showed excellent soft-tissue ad- aptation and an aesthetic outcome (Figs. 17 & 18). The patient was extremely satisfied with the outcome of the treatment and the fixed restorations. Conclusion This case report highlights the successful placement of OmniTaper EV implants in a patient with a heavily restored dentition. The use of an intra-oral scanner and impression components for the prosthodontic and technical digital workflow allowed for precise planning and execution of the treatment plan. The use of the OmniTaper drill system allowed for efficient and predictable placement of the implant. about Dr Anthony Bendkowski is an oral surgery specialist in practice limited to implant reconstructive surgery with two clinics in London and Maidstone in the UK. He has over 30 years of experience in both the surgical and restorative management of implant cases. He is a past president of the Association of Dental Implantology, an examiner for the Royal College of Surgeons of Edinburgh Diploma in Implant Dentistry and a contributor to the postgraduate dental implant programme at Brighton and Sussex Medical School in the UK. He is co-chair of Bromley, Bexley and Greenwich LDC and an honorary consultant at King’s College Hospital NHS Foundation Trust in London. He can be contacted at enquiries@theimplantexperts.com. 39 2 2023

case report | 3 4 5 6 Fig. 3: Scan bodies in situ for intra-oral scanning. Fig. 4: Splinted scan bodies in the lower jaw. Fig. 5: Intra-oral scan of the implant positions. Fig. 6: Digital impression of the patient’s oral cavity with scan body alignment in dental CAD software. Intra-oral scanning and digitisation After the implant surgery, intra-oral scanning was per- formed using scan bodies from the implant manufac- turer, Straumann. This process accurately digitised the position and orientation of each implant in the patient’s mouth. For the lower jaw, Luxatemp (DMG) was used to splint the single-use scan bodies, simplifying the intra-oral scanning process by providing additional geo- metrical landmarks in an area with fewer natural refer- ence points (Figs. 3–5). Intra-oral scanning has become an indispensable tool in modern dentistry, providing detailed and accurate digital impressions of patients’ oral cavities and replacing the traditional methods of impression taking.2 Recent research has investigated the accuracy of intra-oral scanners for full-arch implant cases and shown promising results.8 One study found that intra-oral scanners were comparable to conven- tional impressions in terms of accuracy and precision when used for full-arch implant cases and offered ad- vantages such as reduced material and labour costs and faster turnaround times.9 Additionally, the use of geometrical landmarks, such as via scan bodies and splinting materials, can fur- ther enhance the accuracy and reproducibility of intra-oral scanning (Fig. 6).10 The digital workflow is particularly advantageous in implant dentistry, as it allows for improved communication and collaboration between dental professionals, laboratories and pa- tients, as well as provides a more streamlined and efficient treatment process. 3D-printed try-ins After the digitisation of the implants, two sets of 3D-printed try-ins were fabricated for both jaws. The first set, the validator set, was designed with gaps between the implant positions (Fig. 7). These gaps allowed for the detection of tension when the validator was seated, fractures occurring in the small gaps if tension was present. This step ensured that the final prostheses would fit accurately and comfortably with- out undue stress on the implants or surrounding tissue (Figs. 8–10). The validators had the same design as the second set of try-ins, the only difference being that the validators were cut between the implants using a virtual disc cutter and the attachment func- tion in exocad software. It is crucial to ensure that the titanium bases or bar is firmly seated within the validator, which can preferably be achieved using resin cement. The validator should be retained with the same torque as the manufacturer recommends for the final restoration. The second set of try-ins was used to check various factors, including aesthetics, occlusion, vertical dimension of occlusion (VDO), hygiene capability, phonetics and function. One important consideration is to avoid using the OptraGate retractor (Ivoclar) when checking the bite. The retractor affects muscular activity and could neg- atively impact the validation process. These final try-ins closely resembled the final prostheses and were used to make any necessary adjustments before fabricating the final prostheses (Figs. 11 & 12). 41 2 2023

case report | 15 17 16 18 Fig. 15: CAD view of the designed prosthesis in the context of the patient’s smile. Fig. 16: Cementation of the Elos Accurate Hybrid Base H Non-Engaging bases with PANAVIA V5 and CLEARFIL CERAMIC PRIMER PLUS. Fig. 17: The final prosthesis on the day of delivery. Fig. 18: Final prostheses of monolithic KATANA Zirconia YML, stained using CERABIEN ZR FC Paste Stain. The dark gingiva spots were stained with the shade Red, the light pink surfaces with the shade Pink and the highlights with the shade Salmon Pink. 19 21 20 22 Fig. 19: Final prostheses, right side view. The cervical parts were stained with the shade Cervical 2, the incisal two thirds of the anterior teeth with the shade Grayish Blue and the mamelons with the shade Mamelon Orange 1. Fig. 20: Final prostheses, left side view. Fig. 21: Final maxillary prosthesis, occlusal view. Fig. 22: Final mandibular prosthesis, occlusal view. 43 2 2023

case report | 5 6 7 Fig. 5: Orthodontic treatment of the mandibular anterior teeth. Fig. 6: Situation after surgery for gingival margin correction. Fig. 7: Teeth #12, 11, 21, 22 and 24 prepared for restoration. Fig. 8: Artex facebow transfer. After these pretreatments (Figs. 5 & 6), the teeth were prepared for restoration by the dentist (Fig. 7). The perfect fit right from the start The use of a facebow (Fig. 8) is considered essential to show the individual relationship of the patient’s condyles and occlusal plane. This ensures subsequent realisation of patient-friendly occlusal concepts on the Artex articu- lator (both virtual and physical, Amann Girrbach). The classic model work used the Model Management System workflow (Amann Girrbach). Afterwards, the models were mounted on the Artex CR articulator using the Artex facebow record (Fig. 9) and digitalised using the Ceramill Map 600 scanner (Amann Girrbach). The CAD was done using the Ceramill Mind CAD software. One of the major advantages of the Ceramill system is that both analogue and digital workflows can be employed using the same concept (Figs. 10 & 11). The setting of the Artex articulator (condylar inclination and Bennett angle) was average (sagittal condylar incli- nation of 35° and transversal condylar inclination of 10°). For incisal inclination, a custom incisal guide table was 8 chosen to set at 35°, the left wing at 0° and right wing at 30°, owing to the shallow anterior overbite and the right canine being natural dentition (Fig. 12). When designing anterior restorations, it is necessary to consider not only aesthetics but also occlusion. The goal is to achieve an occlusal scheme in which the posterior teeth prevent excessive contact of the anterior teeth in the maximal intercuspal position and the anterior teeth disengage the posterior teeth in all mandibular excursive movements. For this reason, when the anterior region is in occlusion, it is an important area that guides the man- dible and controls both protrusive and lateral movements. In this case, since one canine was a pontic, tooth #24 was also involved to reduce the load on the pontic and to control the lateral movement (Figs. 13 & 14). 9 10 13 11 14 12 Fig. 9: Mounting the model using the Artex facebow. Fig. 10: Ceramill Artex virtual articulator. Fig. 11: Ceramill Artex physical articulator. Fig. 12: Setting of all function parameters on the Ceramill Artex. Fig. 13: Static occlusion registration. Fig. 14: Dynamic occlusion registration. 47 2 2023

case report | It has to be considered that Ceramill M-Smile uses 2D images. Therefore, it is not advisable to use it for de- termining the crown labial contour or for the lip support design. In order to sufficiently design these aspects, designs from provisional restorations (preoperative scan data) are useful, as the position of the incisal edges and the contour of the labial aspect can be adjusted with ref- erence to the provisional restorations (Figs. 16 & 17). When considering the centreline based on the models, the axial direction of teeth #11 and 12 suggests setting the midline along the red dotted line (Fig. 18). With digital de- sign, the feeling for shape and tooth size is lost because, unlike when looking at a physical model, it is easy to zoom in and out and rotate. The size of the physical model and digital model is not the same. This is an important consid- eration in digital design of anterior teeth (Fig. 19). The centreline can be determined from the orientation of the patient’s face. Also, the smile line, which cannot be referenced in the analogue process, is described by over- lapping 2D images (Fig. 16). However, because the centre- lines based on the model and on the facial features were different, design of the individual teeth was very difficult, especially in the area of the tooth #11 mesial interproximal emergence profile (green arrow on Fig. 19) as an example. To improve aesthetics, it was necessary to reduce the bulk on the labial surface and tilt the tooth axis towards the lingual side. In such cases, the wall thickness of the crown must be controlled to ensure strength (Figs. 20–23), following the manufacturer’s instructions for use. 24 Fig. 24: Milling the restorations with Ceramill Matik. Virtual becomes reality Once the design process was completed, the restorations were milled with the Ceramill Matik milling unit (Fig. 24). As the patient preferred a slightly lighter shade, Zolid Gen-X in Shade A1 was selected (Figs. 25 & 26). If there is little space, the preferred restorative material should always be monolithic. The high strength of zirconia provides safety and longevity for the restoration. Zolid Gen-X gives restorations a high level of aesthetics owing to its natural colour gradient and high translucency. After milling, the crowns and bridges were reworked with suitable tools to individualise them (Fig. 27). The Zolid Green‐State Finishing Kit was used to correct the morphology of the approximal surface areas (connector areas) and of 25 26 Fig. 25: Ceramill Zolid Gen-X Multilayer blank discs. Fig. 26: Shade selection according to the patient’s natural teeth in the mandible. 49 2 2023

case report | 35 Fig. 35: Zolid Gen‐X monolithic crowns after cementation in the patient’s mouth. Fig. 36: Final result in the patient’s natural smile. the occlusal surface, which were difficult to correct after sintering. The sintering process was then started (Fig. 28). After sintering, slight adjustment of the morphology was under- taken using the Zolid Sinter‐State Polishing Kit, including medium-grade polishing at the end (Fig. 29). Zolid Gen‐X has a beautiful multilayer graduation and a very natural look, so it is possible to produce restorations that require minimal staining. In this case, Vintage Art Universal stains and glazes (SHOFU) were used. The incisal area was coloured blue‐ grey for transparency. During application, care must be taken not to make the incisal area too blue. A very thin layer of Shade A was added over the body area (for colour supplementation), and the cervical area was coloured darker than the body area (Fig. 30). At the end, a thin layer of glaze paste was applied over the surface. As a second layer, glaze paste was mixed with a small amount of white and layered on the mesial and distal marginal ridges (Fig. 31). By using Zolid Gen‐X, aesthetic and functional restorations were produced (Fig. 32). The typical cementation protocol was followed, but retraction cord was used and extra care regarding moisture and con- tamination was taken. Especially the fitting surfaces of res- torations can be contaminated by salivary protein during the try‐in stage and have to be cleaned, for example with KATANA Cleaner (Kuraray Noritake Dental; Fig. 33). PANAVIA V5 (Kuraray Noritake Dental) resin cement was used. To control the value, bleach shade cement was chosen. Cementation was performed under the dental microscope (Fig. 34). Result In this case, the position of the teeth limited the thickness of the crowns and there was no space for ceramic layering. Anterior bridges involving canines must be strong and aesthetic. In such cases, Zolid Gen-X is the best material because it offers strength and aesthetics. In addition, the use of Zolid Gen-X in combi- nation with Ceramill M-Smile in the fabrication of the anterior monolithic crowns produced a highly aesthetic result (Fig. 35). The patient had a beautiful smile after cementation of the anterior monolithic zirconia restorations in her mouth (Fig. 36). 36 about Atsushi Hasegawa gained his licence to practise as a dental technician in 1996 and completed postgraduate studies at Kanagawa Dental University in Yokosuka in Japan in 1998. He then worked for 11 years in a dental laboratory in Tokyo in Japan, where he acquired specific knowledge and skills in the field of occlusal concepts. In 2008, he opened his own laboratory, Organ Dental Lab, in Chigasaki in Japan. Today, Hasegawa transfers his knowledge through lectures in Japan and worldwide. He can be reached through his website, www.organdental.jp. Dr Yusuke Takayama graduated from Nihon University in Tokyo in Japan in 2004. He has been in private practice since then and opened his own dental office, Shinyurigaoka Minami Dental Clinic, in Kawasaki in Japan in 2016. Since 2019, he has been a lecturer at the Dental Arts Academy in Tokyo. He is a member of the Society of Japan Clinical Dentistry and Japan Association of Microscopic Dentistry. 51 2 2023

case report | 1 2a 2b 3 Fig. 1: Radiograph of the pre-op situation showing insufficient endodontic treatment of tooth #46. Additionally, an amalgam coronal restoration with microleakage was detected. There were also apical lesions evident around both roots. Both neighbouring teeth had migrated towards tooth #46 and closed the interproximal spaces. Figs. 2a & b: Radiographs of the endodontic treatment. Working length control (a). Check of the extension of the Master gutta-percha points (b). Fig. 3: Post-op results of the endodontic treatment. A proper 3D seal had been achieved. The working length and sealing had been corrected. The extra distal root canal had been found, treated and sealed. were insufficient. A canal in the distal root seemed not to have undergone any endodontic treatment. Irregu- lar root morphology compatible with hypercementosis was observed in the apical half of the roots of tooth #46, showing an increase of volume of a round shape. A widening of the periodontal space over almost all of its extent could also be observed. A significant apical lesion of the distal root and a smaller one of the mesial root were revealed as well. The patient was diagnosed with a defective amal- gam restoration on endodontically treated tooth #46 with microleakage, acute periapical periodontitis with spontaneous pain, and a ball-shaped morphology of both roots (hypercementosis). The tooth required end- odontic retreatment and a new coronal restoration. Endodontic retreatment and immediate fabrication and insertion of the definitive coronal restoration were planned to be carried out in the same clinical session. The clinical situation and the intended therapy were explained to the patient, and the patient accepted the therapy recommended. Timeline of treatment steps The first step was the endodontic reintervention. After local anaesthesia, the operative field was isolated with a dental dam, and a dental dam clamp was placed around tooth #46. The old amalgam was removed, taking care to preserve sound tissue. Once the end- odontic filling had been reached, remnants of amal- gam and cement were carefully removed. The end- odontic filling was removed with rotary instruments for canal shaping and retreatment (ProTaper Universal retreatment files, Dentsply Sirona). The coronal third was treated with the D1 file (30/.09), the medium third with the D2 file (25/.08) and the apical third with the D3 file (20/.07). An entirely mechanical removal proce- dure was performed to avoid the use of endodontic solvents. The non-treated root canal in the distal root was located and manually prepared with size 15, 20 and 25 K-files. The same files were used for the radio- graphic check of the working length, which was mea- sured with an apex locator (Fig. 2a). Once the working length had been determined, the root canals were prepared and cleaned with the ProTaper Next system (Dentsply Sirona). This system has three main files, X1, X2 and X3, with a variable taper. Before moving to the next file in the sequence, the root canals were irrigated with a 2.5% sodium hypochlorite solution (EndoActivator, Dentsply Sirona). After shaping, irrigation with a 17% EDTA solution was performed for 1 minute in the root canals, this anti- bacterial solution being indicated for removal of the smear layer. Final irrigation was done with a 2.5% so- dium hypochlorite solution. The root canals were finally dried with sterile paper points. ProTaper Next Conform Fit gutta-percha points (Dentsply Sirona), matched to the size of the canals pre- pared with ProTaper Next files, were inserted in each root canal and checked with an intra-oral radiograph (Fig. 2b). The root canals were then filled by means of a lateral condensation technique with cold gutta-percha and manual spreaders. Accessory gutta-percha points and an endodontic sealer (ADSEAL, Meta Biomed) were used as well. Once completed, the gutta-percha points were cut manually with a hot instrument. After cleaning the dentine surface of the pulp chamber floor, a radio- graphic control was carried out (Fig. 3). The results were promising. The radiograph showed properly pre- pared, well-filled root canals, including the canal in the 53 2 2023

case report | 8 9 10 Fig. 8: Floor of the cavity and undercuts covered and sealed with Rebilda DC. Fig. 9: Polymerising of the core build-up composite with the Celalux 3. Fig. 10: Cavity shaped, excess material removed and margins smoothed. Subsequently, a layer of a dual-curing core build-up composite (Rebilda DC, VOCO) was applied over the cavity floor and the lingual wall where the undercuts were present (Fig. 8). The build-up material was light-cured immediately thereafter (Fig. 9) and the cavity reshaped (Fig. 10), resulting in a smooth floor and preparation margins and a volu- minous enlarged pulp chamber. The residual tissue, especially the enamel over the mesial side, could be preserved. Owing to the loss of interproximal contact points that had occurred in the previous years, both teeth #47 and 45 had tipped towards tooth #46, bringing it into contact with them subgingivally. After their separation with a thin diamond bur, the appropriate space needed was recreated to allow proper coronal restoration of tooth #46. Finishing and polishing reciprocating tips for the EVA system (KaVo Dental) were used after- wards to smooth and polish the reduced interproximal surfaces. Immediately thereafter, the dental dam was removed and retraction cord was placed around the molar (Fig. 11). A digital impression was carried out using the CEREC Omnicam (Dentsply Sirona; Fig. 12), capturing the preparation margins of the endocrown cavity perfectly. After general design of the restoration, the impres- sion file was transferred to another design program (exocad) in order to digitally generate the restoration (Fig. 13). After completion of the digital design of the endocrown, the file was returned to the CEREC sys- tem. Once this had been done, the restoration was fabricated by milling a block of a highly filled nano- ceramic hybrid material (Grandio blocs, VOCO; Fig. 14). The processing of the composite block took about 10 minutes. Afterwards, a light-curing character- isation material (FinalTouch, VOCO) was applied to pretreated furrows and fissures (Fig. 15), light- cured and occlusally covered with a packable or flowable composite (or a mixture) and light-cured. The endocrown was polished with rubber points and brushes (Figs. 16 & 17). During the CAD/CAM of the restoration, the patient remained in the clinic. Once the restoration had been finished, it was taken to the clinic, disinfected in alco- hol for 3 minutes and tried in the cavity. The fit was very 11 12a 12b Fig. 11: Final preparation prior to taking the digital impression, for which retraction cord had been placed. Figs. 12a & b: Margins and various details of the cavity preparation well captured in the digital impression. 55 2 2023

case report | 14 15 Fig. 14: Milling of the block in the milling machine. Fig. 15: Application of white stains to characterise the colours of the restoration. Regarding the endodontic retreatment, the prepa- ration and seal of the root canals were appropriate, a suitable 3D seal was achieved and the working length was corrected. Also, the previously untreated root canal in the distal root was properly prepared and sealed (Fig. 23). The microscope-assisted cleaning of the gutta-percha and endodontic sealer are expected to enhance the adhesion over the floor of the cavity.1 The quality of the coronal restoration is at least as important for peri- apical health as the quality of the endodontic treatment itself.9 Discussion The radiographically diagnosed hypercementosis of tooth #46 was a factor with no therapeutic con- sequences. This hyperplastic formation of radicular cementum could have arisen from irritation of infected root canals and/or by the hyperactivity or hypoactivity of the tooth root due to dysfunctional occlusal forces associated with the defective anatomy of the old restoration. In one clinical session, the badly damaged tooth #46 was endodontically retreated and restored with an endocrown fabricated chairside by means of CAD/CAM technology. This combination is both time- and money-saving. In the case of endodontically treated teeth, several advantages result from carrying out the definitive coronal restoration in the same session as the post- endodontic treatment of the root canals.10 It ensures a better coronal seal and increases the success of the endodontic treatment. Moreover, the time between the root canal filling and the coronal restoration should be as short as possible to avoid root canal recontam- ination.11 Better mechanical protection is provided to residual tissue from the very beginning of the pro- cess if a definitive restoration is inserted in the same session. In fact, the probability of dislodgement of the definitive restoration is much lower compared with that of a provisional one. The final function of the tooth is restored from the very beginning of the process, 16 17 Fig. 16: Occlusal surface of the finished endocrown. Fig. 17: Inner surface of the endocrown. Note the extensive portion for bonding in the enlarged pulp chamber preparation of the molar. 57 2 2023

case report | Subgingival preparation margins must be accessible, and this can be achieved, among other methods, by placing retraction cord before taking conventional or digital impressions. No contact should be present between the cavity and the adjacent tooth. The occlu- sal space should be adequate as well and have been carefully checked previously.12 According to various studies, the adhesion protocol when cementing the restoration is also crucial. The dentine of an endodontically treated tooth and especially the dentine of the root canal and of the floor of the pulp chamber might represent an altered substrate, offering lower adhesive power.15 Clinically, tooth #46 had become brown and translucent because several years had passed since the tooth had lost its vitality. Research indicates that dentine in this condition might have modified collagen (lower density collagen with short and cut fibres). This could negatively affect the adhesive technique when depending exclusively on the collagen fibre–adhesive–hybrid layer. Dentinal tubules should be open in order to generate resin tags and compensate for the loss of adhesion due to the poor quality of the collagen.16 In this clinical situation, by the time the restoration process had started, the dentinal tubules were open, endodontic treatment having just been completed and before the adhesive post-endodontic treatment. Here, it was important not to use rotary instrumen- tation for removing the excess gutta-percha, as this would have generated a secondary smear layer. This is more difficult to dissolve, the usual smear layer being associated with plasticised gutta-percha and endodontic sealer.17 Thus, for such cases, the use of ultrasonic tips and hand instrumentation is prefera- ble for removing excess gutta-percha. Excess endo- dontic sealer should also be carefully removed with alcohol or a detergent substance using micro-brushes or sponges (e.g. Pele Tim, VOCO). Carrying out total- etch conditioning using a 35–40% phosphoric acid gel after removing gutta-percha and sealer excess will also help keep the dentine clean and its tubules open. Conclusion Performing the restoration immediately after endodontic treatment ensures a better and immediate coronal seal, ensures immediate protection of the sound tis- sue, saves time, and offers comfort and confidence to the patient and the clinician. Endocrowns made of the highly filled nano-ceramic hybrid composite Grandio blocs represent a new alternative for treating badly damaged teeth, especially molars, while freeing the dentist from the use of root posts. In vitro and clinical studies as well as clinical experience with this material 23a 23b Figs. 23a & b: Radiographs before (a) and after (b) treatment, showing dramatic differences. The endodontic treatment had been corrected and the restoration was well adapted and shaped. The interproximal relationships had been re-established through the anatomy of the endocrown. There were no gaps between the restoration and the endodontic filling. The sealing of the endodontic treatment was complete and tight. are promising. These endocrowns represent a less invasive and better mechanical option compared with posts and crowns. Editorial note: Please scan this QR code for the list of references. about Dr Alejandro Bertoldi Hepburn is an associate professor at the endodontics department of the University of Buenos Aires’ School of Dentistry in Argentina and a lecturer in postgraduate prosthodontics at the Universidad Del Desarrollo’s dental school in Concepción in Chile. Dr Matías Scazzola is an assistant professor at the endodontics department of the University of Buenos Aires’ School of Dentistry in Argentina. 59 2 2023

industry report | Dentsply Sirona presented interactive events, exciting digital experiences and live demonstrations at IDS. severe shortage of qualifi ed people. Digital helps people to become more effi cient, to produce reproducible re- sults and to get better clinical outcomes, but also to focus on the core of the job, and this means the patient and the clinical result. I can give one very simple example, the documentation of our new Primeprint Solution. It automatically docu- ments each print and allows the dentist to simplify data storage in one PDF fi le. All necessary data can be sum- marised in one PDF fi le, which the dentist can then use to fulfi l his legal obligations, eliminating the need to take any notes, to have any records and to do anything man- ually; all the work is done automatically. This is exactly what I mean. This is work which is a waste of qualifi ed time for the dentist or assistant. This is where we can help. What are the latest digital devices and equipment Dentsply Sirona is showcasing at IDS 2023? Dentsply Sirona is showcasing many new products at IDS, but let’s go through them in the sequence they were introduced. The fi rst one is the Axano. It’s a dental chair, but of course, it’s much, much more, because it is built to ideally support the individual way of working of each dental professional. What does that mean? It means that as a dentist you can use three settings, but you can basically individualise the whole workfl ow according to your requirements, working style, training and working preferences. This helps to save time. By presetting the dental chair regarding how you do an endodontic treat- ment or how you do a restoration, you don’t need to set the value each time, allowing you to work fl uently without taking your hands off the patient because all the func- tions of the dental chair can be controlled by foot. This allows you to switch smoothly through your preset menus. Of course, Axano has many other excellent features, like a massage function for the patient, but the most important is that it combines an effi cient workfl ow with ergonomics. The next product Dentsply Sirona is showcasing at IDS is the Primeprint 3D-printing system. This is our fi rst “Digital helps people to become more effi cient, to produce reproducible results and to get better clinical outcomes (...).” 61 2 2023

Education is very important to Dentsply Sirona and I think we have all learned during the COVID-19 pandemic that we can also digitalise education a little bit more. Dentsply Sirona offers education programmes through the Dentsply Sirona Academy. In our many international education centres around the world, the largest being in Charlotte in North Carolina in the US and in Bensheim in Germany, we provide the knowledge, skills and inspira- tion. Among the clinical educational material available on our academy platform, we have just published on-demand curricula. We also offer more and more digital content on various platforms, like YouTube, where dental practitioners can get quick training on subjects of interest, especially on topics related to digital, or when they just want to get in- structions on how to do something, how to maintain a device or how to use certain functions. All this information is available online. I believe that this is the way forward, because that is exactly how we behave in our non-professional lives. When I needed to change the battery in my car key, what did I do? I opened YouTube and searched for a video on how to do that. I didn’t open the instruction manual; I found the information online. Dental professionals also search for information in this way, and Dentsply Sirona is ready to provide them with the answers they are looking for where they are looking for it. Apart from that, we are putting a huge focus on user experience. The use of digital technology is a growing trend. What do you think the next five to ten years will bring in terms of new products or workflows? Yes, I think that in the coming years the use of digital tech- nology will still be a growing trend. What we are now seeing is that digitalisation is moving quicker and quicker, producing a huge amount of data, and this will make it mandatory to move things into the cloud, same as we saw with office software or in many other industries. Moving to the cloud will give us not only unlimited storage but also unlimited computing power, which then, of course, will enable things like artificial in- telligence in support of the dentist. I would expect then bigger breakthroughs in diagnostics to help the dentist to do an initial diagnosis and create a treatment plan to solve the problem identified. I think that design of dental restorations will be much more automised and that these services which are still done manually will become more and more generic. This technology, called biogeneric, is already known to CEREC users, but will evolve and become define a new standard way of working. Today, you can imagine that industry report | automation will move further and further and reduce the need for the dentist to amend the final design, making results reproducible. I believe that another important area is outcome simula- tion. A very important part of dentists’ work is communi- cating with their patients about the outcome of the treat- ment planned. We can see that very well at the moment for aligner treatments. A number of companies offer an outcome simulator, which shows patients how their teeth will look after aligner treatment. Of course, this has to be transferred to other treatments to enable dentists to show patients’ their smiles after treatment and give them a treatment choice. “Moving to the cloud will give us not only unlimited storage but also unlimited computing power, which then, will enable things like AI support (...).” The last area I would like to mention is equipment efficiency to keep everything well maintained and to increase uptime and reduce downtime. Treatment management and remote servicing are other areas which we are actively working on. We can see the first results in DC Core already today, and this will reduce service costs significantly. We will increase the number of cases for which we can fix any issue remotely, without sending a service engineer to the dental practice, which means that the dentist can continue working. We will enable bigger structures, like dental service organisations, to manage their fleet and make sure that all their facilities are running and service their dentists well. That is in a nutshell what I expect, but of course, there is much more. But there is also a natural limit to what can be done in a certain amount of time. Editorial note: More information about the products can be found at dentsplysirona.com. 63 2 2023

manufacturer news | DEXIS IOS Solutions expands its portfolio and ecosystem New end-to-end digital workfl ows for dental practitioners DEXIS IOS Solutions is pleased to announce the expansion of its portfolio and ecosystem through new digital end-to-end work- fl ows. The new and enhanced workfl ows are designed to align with the objective of DEXIS IOS Solutions to support dental prac- titioners in accelerating their workfl ows, resulting in increased productivity and an improved patient experience. To reinforce this objective, DEXIS IOS Solutions is focused on three crucial prin ciples: ease of use, productivity and practice expansion. Practitioners can now easily expand their range of services through aligner and denture treatments, as well as in-house printing, offering their patients personalised and innovative care. The new prescriptive workfl ows are being developed concurrently with ongoing innovations in the broader portfolio of Envista Holdings Corp., beginning with a new orthodontic workfl ow in combination with Ormco’s Spark clear aligners that enables practices to easily add aligner therapy to their treatment options. A new patient engagement app within DEXIS IS ScanFlow enables practitioners to show patients a simulated outcome of their orthodontic treat- ment, enabling them to visualise the treatment outcome chairside. Integrated digital transfer of the data sets to the Spark software streamlines the process, facilitating prompt treatment. “By further integrating DEXIS IOS Solutions into the broader Envista offerings, we are providing dentists with the solutions they need to provide exceptional and personalised care for their patients. We are committed to helping dental practitioners improve patient outcomes and grow their practice through digital innovation,” said Amir Aghdaei, presi- dent and CEO of Envista. DEXIS IOS Solutions has also col- laborated with S p r i n t R a y ’ s 3D-printing ecosystem for defi nitive ceramic crowns to simplify in-offi ce printing and make same-day restorations a reality. sterile + dirty Sterile does not mean clean. Far too many implant systems have concerning residual surface contaminants. Receive quality information about your implant in use. Provide more safety for your patients and avoid negligence claims. AD sterile + clean These implant systems were awarded the CleanImplant “Trusted Quality” seal after an unbiased and peer-reviewd quality assessment: AnyRidge – MEGAGEN Astra Tech EV – DENTSPLY SIRONA BlueDiamond – MEGAGEN ICX-Premium – MEDENTIS MEDICAL In-Kone – GLOBAL D Inverta – SOUTHERN IMPLANTS Kontact S – BIOTECH DENTAL Patent – CHAMPIONS IMPLANTS Prama – SWEDEN & MARTINA (R)Evolution – CHAMPIONS IMPLANTS SDS 1.2 – SWISS DENTAL SOLUTIONS SDS 2.2 – SWISS DENTAL SOLUTIONS SuperLine – DENTIUM T6 – NUCLEOSS UnicCa – BTI whiteSKY – BREDENT MEDICAL WE FIGHT DIRTY. Dr. Dirk U. Duddeck, Founder and Head of Research | Dr. Ken S. Serota, Representative North America Join in as a CleanImplant Certifi ed Dentist! More information about this non-profi t initiative: info@cleanimplant.com | www.cleanimplant.com/dentists The independent dental implant quality assessment.

register at www.roots-summit.com ROOTS SUMMIT IS COMING TO ATHENS Tribune Group GmbH is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Tribune Group GmbH designates this activity for 18.5 continuing education credits. This continuing education activity has been planned and implemented in accordance with the standards of the ADA Continuing Education Recognition Program (ADA CERP) through joint efforts between Tribune Group GmbH and Dental Tribune International GmbH. THE GLOBAL DENTAL CE COMMUNIT Y

practice management | our attitudes by detaching ourselves from our be- haviours. Only then will the answer come to us. Suppressing ourselves in the presence of certain people is a habit picked up in childhood. We unconsciously think: “If I am authentic, nobody will like me”. These habit energies are automatic behaviour patterns that dictate many of our daily interactions and life decisions, despite our desire to think rationally. Unless we train ourselves to confront and change these behaviour patterns, the same habits will remain. According to renowned addiction expert Dr Gabor Maté, addiction is not a choice that we make, nor is it a disease that we inherit; it is an attempt to solve a problem. Dr Maté has said: “Pleasure is necessary for life, however we often lack pleasure in our lives unless we turn to means that make us temporarily for- get about our problems.” Similarly, tendencies to numb pain, discomfort and the fear of alienation signal the existence within us of issues which we try our best to keep at arm’s length. In order to understand and resolve why we crave pleasure, why we lack comfort and why we are in pain, we have to look deeper within ourselves and that can only happen by slowing our life tempo down. These factors almost always have their roots in childhood experiences that resulted in com- pensation through addiction to substances or through personality patterns, such as seeking validation, approval and praise from others. In psychology, burn-out is defined as a state of physical and emotional exhaustion. It can occur when we ex- perience long-term stress in our job or when we work in a physically or emotionally draining role. The Slow Dentistry Global Network teaches that, by treating an appropriate number of patients per day while imple- menting its four cornerstones, all dental practices can achieve a stress-free experience and a painless treat- ment and all dental practitioners can protect them- selves from physical burn-out. However, this does not necessarily prevent emotional exhaustion. The daily exposure to a high volume of emotional stressors will eventually result in dental professionals becoming unconsciously overwhelmed, anxious or depressed. The constant exposure to the pain and suffering of pa- tients eventually leads to compassion fatigue, which is a combination of emotional exhaustion, depersonalisation and reduced personal accomplishment. The three main components of stress are: 1) the stressor, which is the external event; 2) the processing apparatus, which is our unconscious interpretation of the external event; and 3) the physiological response, which is the internal reaction to the external event. 69 2 2023 m o c . k c o t s r e t t u h S / k c o t s k a e P © through various traumatic experiences which caused us to subconsciously be afraid to express and mani- fest our authentic selves. Our mind unconsciously pulls us towards a safe zone by compromising our own needs in return for social validation. Without recog- nising, confronting, understanding and accepting this fear, our need for attachment will always be chosen over our need for authenticity, and later there will be an inevitable price to pay. In situations when we keep suppressing our emotions for the sake of attachment, we may ask: “Why am I still acting that way?” This is not an actual question; rather, it is a statement that implies a feeling of unworthiness. It is a statement because we subconsciously know of our self-doubt. It is a self-accusation of lack of uncondi- tional self-worth. Another way to ask the same question is: “Why am I really pretending to be that way?” By doing so, we shift our awareness towards compassionate curiosity. In situations that pressure us to repress our authentic selves, we need to compassionately question

l i m o c . s e x e p / o d a u q c a P a e r d n A © i practice management | Latin word “ vulnerare” means “to wound”. Because our wounds are too raw to confront, we cover up our vulnerability by using compensatory mecha- nisms that keep our hearts closed. This emotional unavailability prevents us from learning how to practise self-love. Our childhood traumas have caused many wounds which have forced us to put on personality layers in order to protect us from further wounds. These trau- mas are not events; they are the wounds that we sustain inside of us which cause us to suppress our true emotions. The good news is that our authentic selves are never lost; we can recover our authentic selves in the same way that people recover after being sick. To recover means to find something, and when something is found, it means that it was never lost in the first place. Our recovery must come fi rst so that everything we love in life does not have to come last Human functioning is shaped by formative ex- periences, and we have trouble understanding those whose formative experiences are different to our own. All of us live on the same spectrum of human emotions; some may feel down for a period and snap out of it afterwards; others may fall into deep depression and see the world through dif- ferent lenses. “Only when compassion is present will people allow themselves to see the truth.” —A.H. Almaas may become judgemental of them. Nobody should be a passive recipient of everybody else’s care. We need to regain our sense of agency, to actually look at our behaviours, our patterns and our dynamics and be courageous, open and curious enough to detach ourselves from them in order to start our own journey of healing. Let us start by asking ourselves: “Why am I still numbing myself? Do I really need to tolerate that patient’s attitude? Am I really still that infant, a young child who needs to choose attach- ment over authenticity?” Only then will the answers come to us. about Those who have never experienced depression may never be able to relate to those who have, and they Dr Huthaifa AbdulQader General secretary of the Slow Dentistry Global Network www.slowdentistryglobalnetwork.org 71 2 2023

How to send us your work submission guidelines | m o c . k c o t s r e t t u h S / s l i e x p 2 3 © Please note that all the textual compo- nents of your submission must be com- bined into one MS Word document. Please do not submit multiple files for each of these items: · the complete article; · all the image (tables, charts, photo- · · graphs, etc.) captions; the complete list of sources consulted and the author or contact information (bi- ographical sketch, mailing address, e-mail address, etc.). In addition, images must not be embed- ded into the MS Word document. All im- ages must be submitted separately, and details about such submission follow be- low under image requirements. Text length Article lengths can vary greatly—from 1,500 to 5,500 words—depending on the subject matter. Our approach is that if you need more or fewer words to do the topic justice, then please make the article as long or as short as necessary. We can run an unusually long article in multiple parts, but this usually entails a topic for which each part can stand alone because it contains so much in- formation. In short, we do not want to limit you in terms of article length, so please use the word count above as a general guideline and if you have specific questions, please do not hesitate to contact us. Text formatting We also ask that you forego any special formatting beyond the use of italics and boldface. If you would like to emphasise certain words within the text, please only use italics (do not use underlining or a larger font size). Boldface is reserved for article headers. Please do not use un- derlining. Please use single spacing and make sure that the text is left justified. Please do not centre text on the page. Do not indent paragraphs, rather place a blank line be- tween paragraphs. Please do not add tab stops. Should you require a special layout, please let the word processing pro- gramme you are using help you do this formatting automatically. Similarly, should you need to make a list, or add footnotes or endnotes, please let the word process- ing programme do it for you automatically. There are menus in every programme that will enable you to do so. The fact is that no matter how carefully done, errors can creep in when you try to number footnotes yourself. Any formatting contrary to stated above will require us to remove such formatting before layout, which is very time-consum- ing. Please consider this when formatting your document. Larger image files are always better, and those approximately the size of 1 MB are best. Thus, do not size large image files down to meet our requirements but send us the largest files available. (The larger the starting image is in terms of bytes, the more leeway the designer has for resizing the image in order to fill up more space should there be room available.) Also, please remember that images must not be embedded into the body of the article submitted. Images must be submitted separately to the textual sub- mission. You may submit images via e-mail or share the files in our cloud storage (please contact us for the link). Please also send us a head shot of your- self that is in accordance with the re- quirements stated above so that it can be printed with your article. Image requirements Abstracts Please number images consecutively throughout the article by using a new number for each image. If it is imperative that certain images are grouped together, then use lowercase letters to designate these in a group (for example, 2a, 2b, 2c). Please place image references in your article wherever they are appropriate, whether in the middle or at the end of a sentence. If you do not directly refer to the image, place the reference at the end of the sentence to which it relates enclosed within brackets and before the period. In addition, please note: An abstract of your article is not re- quired. Author or contact information The author’s contact information and a head shot of the author are included at the end of every article. Please note the exact information you would like to ap- pear in this section and format it accord- ing to the requirements stated above. A short biographical sketch may precede the contact information if you provide us with the necessary information (60 words or less). · We require images in TIF or JPEG for- mat. · These images must be no smaller than Questions? 6 x 6 cm in size at 300 DPI. · These image files must be no smaller than 80 KB in size (or they will print the size of a postage stamp!). Magda Wojtkiewicz (Managing Editor) m.wojtkiewicz@dental-tribune.com 73 2 2023

Partners in excellence. United by smiles. Acc.1249_en_01 ClearCorrect®, the Straumann Group’s flagship orthodontic brand, is excited to announce new products and clinical features, an improved digital workflow, added support, and treatment planning services to help doctors treat more complex cases. To become a partner or learn more visit: clearcorrect.com