digital international No. 2, 2022
Cover
/ Editorial
/ Content
/ Dental sales a mixed bag as war and supply dif culties bog down pandemic recovery
/ GDC reveals continuing impact of COVID-19 on UK dentistry
/ Preferences for fixed restorations and resulting impact on the US and European overdenture markets
/ “The future is digital, and I want women not only to participate in the future but also to actively shape it” - An interview with Eva-Maria Meijnen
/ “At age 37, CEREC advances the restorative capabilities of dentists as never before” - An interview with Prof. Werner H. Mörmann and Dr Cord F. Stähler
/ Experiences of and successes achieved with Zolid zirconia How a dental material developed to become a game-changer — An interview with Falko Noack, Prof. Bogna Stawarczyk & Atsushi Hasegawa
/ Efficient production of a zirconia overdenture
/ Digital implant planning in combination with a conventional prosthodontic workflow
/ Implant replacement of congenitally missing incisors using a surgical guide fabricated in-office
/ How clean do sterile implants have to be? - Analysis and clinical relevance of factory-related contaminations
/ Digital dental shade measurement: Practical applications with a state - of-the-art colorimeter
/ The real cost of an analogue impression, compared with a digital one
/ Review of Aoralscan 3 The latest intra-oral scanner by SHINING 3D — the best low-cost intra-oral scanner?
/ Manufacturer news
/ International events
/ Submission guidelines
/ Imprint
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[1] =>
issn 2193-4673 • Vol. 3 • Issue 2/2022
digital
international magazine of digital dentistry
interview
“The future is digital,
and I want women to actively shape it”
trends & applications
Digital dental shade measurement
case report
Digital implant planning in combination
with a conventional prosthodontic workflow
2/22
[2] =>
KATANA Zirconia
YML
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EMPOWER YOUR DENTAL LAB
DISCOVER NEXT EVOLUTION MULTI-LAYERED
This innovative raw material combination of highly translucent zirconia with high strength will empower
your dental lab. “KATANA™ Zirconia” YML delivers efficiency, clarity, simplicity and precision in handling
without compromising the quality of the outcome!
Visit kuraraynoritake.eu/katana-zirconia-yml for more details on KATANA™ Zirconia Yttria Multi-Layered.
BORN IN JAPAN
Kuraray Europe GmbH, BU Medical Products, Philipp-Reis-Str. 4, 65795 Hattersheim am Main, Germany, +49 (0)69-30 535 835, dental.eu@kuraray.com, www.kuraraynoritake.eu
[3] =>
editorial
|
Dr Scott D. Ganz
Editor-in-Chief
Fast, faster, fastest...
It is difficult to believe that at one time clinicians lectured
using 35 mm slides in a Kodak Carousel projector, first
using one screen, then two projectors and two screens,
and then some clinicians would use three projectors
and three screens, all with static images taken with an
analogue camera. Of course, this all changed when
the graphical user interface became available with the
Windows operating system and software like Microsoft
PowerPoint was introduced. The problem then became
how to move the analogue slides to digital. Many of us
either used a service bureau or bought a dedicated slide
scanner to digitise the 35 mm slides. For those of us fortunate enough to have one of the first laptop computers,
we could take the hundreds of 35 mm slides imported
into PowerPoint and leave the slide carousels at home!
This was certainly not a fast process for most, but we
were so impressed with the imagery that speed was not
an issue.
At the beginning, when the practice of dentistry began to
go digital, we were all amazed when objects appeared
on a computer screen which could be rotated, sized and
enlarged for better viewing. Of course, the technology
was not always fast, and the images on the screen may
not have reacted with great speed, but it was fascinating!
Many clinicians started out with an intra-oral digital camera which could be used to capture images of patients’
oral cavities in the hopes of educating patients about their
oral condition. We could even create physical prints from
the intra-oral screenshots and then technology continued to evolve with the introduction of intra-oral scanners
which would capture 3D images of teeth and adjacent
structures. These first intra-oral scanners introduced
clinicians to the use of digital technology in dentistry—
a major advance for certain! Computed tomography has
been used for dental applications since the mid-1980s,
but did not reach mainstream US until after the introduction of CBCT scans, starting after the turn of the century.
We could then take data from the intra-oral scanner and
merge that data with the data set from the CBCT scan
to relate the placement of implants to the actual position
of the planned restoration, and we could take the next
step to export the final implant plan for CAD/CAM or
3D-printing a surgical guide.
All these innovations have taken years for clinicians to
embrace, and we are still at the tip of the iceberg in terms
of global use of technology. While this is happening, most
of the marketing strategies have been to promote the
fastest intra-oral scanner or the fastest 3D printer or immediate loading of implants to achieve faster treatment
outcomes. A word of caution: digital dentistry is dependent on sound principles of restorative and surgical dentistry, so although fast may be important, we should not
move so fast that we may lose the foundation of proper
diagnosis and treatment planning. Sometimes, it is OK if
a scan takes 30 seconds longer—if it provides the necessary information to achieve the best treatment outcomes
for our patients.
Please take a moment to enjoy this latest edition of
digital to learn current concepts and modalities that
will enhance your practice of dentistry.
Dr Scott D. Ganz
Editor-in-Chief
2 2022
03
[4] =>
| content
editorial
Fast, faster, fastest...
Dr Scott D. Ganz
03
industry
Dental sales a mixed bag as war and supply difficulties bog down pandemic recovery 06
Jeremy Booth
GDC reveals continuing impact of COVID-19 on UK dentistry
Brendan Day
page 14
10
Preferences for fixed restorations and resulting impact
on the US and European overdenture markets
12
Daniel Sussman & Dr Kamran Zamanian
interview
“The future is digital, and I want women not only to participate
in the future but also to actively shape it”
14
An interview with Eva-Maria Meijnen
page 28
“At age 37, CEREC advances the restorative capabilities
of dentists as never before”
18
An interview with Prof. Werner H. Mörmann and Dr Cord F. Stähler
Experiences of and successes achieved with Zolid zirconia
How a dental material developed to become a game-changer
An interview with Falko Noack, Prof. Bogna Stawarczyk & Atsushi Hasegawa
22
case report
Efficient production of a zirconia overdenture
28
Digital implant planning in combination
with a conventional prosthodontic workflow
30
Implant replacement of congenitally missing incisors
using a surgical guide fabricated in-office
36
Mathias Berger
page 46
Dr Mats Wernfried Heinrich Böse & Andrea Rosinski
Drs Sean Meitner & Gregori M. Kurtzman
research
How clean do sterile implants have to be?
Dr Dirk U. Duddeck
42
trends & applications
Digital dental shade measurement: Practical applications
with a state-of-the-art colorimeter
Dr Jordi Manauta, Dr Walter Devoto, Daniele Rondoni, Dr Anna Salat,
Prof. Zsolt M. Kovacs & Prof. Angelo Putignano
Cover image courtesy of
Chesky/Shutterstock.com
2/22
issn 2193-4673 • Vol. 3 • Issue 2/2022
digital
international magazine of digital dentistry
practice management
The real cost of an analogue impression, compared with a digital one
Dr Naren Rajan
industry report
56
manufacturer news
meetings
62
Dr Ahmad al-Hassiny
about the publisher
“The future is digital,
and I want women to actively shape it”
submission guidelines
international imprint
trends & applications
Digital dental shade measurement
case report
Digital implant planning in combination
with a conventional prosthodontic workflow
04
2 2022
54
Review of Aoralscan 3
International events
interview
46
64
65
66
[5] =>
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Zolid-Webinars:
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Tel +43 5523 62333-105
www.amanngirrbach.com
Q
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UI
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[6] =>
| industry
© ThongdenStudio/Shutterstock.com
Dental sales a mixed bag as
war and supply difficulties bog down
pandemic recovery
By Jeremy Booth, Dental Tribune International
Dental companies may have expected a widespread
ebbing away of the SARS-CoV-2 pandemic to bring them
out of the financial woods. However, the resulting supply
chain crisis has choked the world’s ports, and the war in
Ukraine has caused consumer price indexes and inflation
to soar. Owing to these factors, the first quarter of this
year arguably provided a stiffer operating environment
than that of two years ago, and economic headwinds
appear to have finally caught up with clear aligner therapy.
The first quarter was a challenge for the dental giants
Dentsply Sirona, Align Technology, Envista Holdings and
the Straumann Group—the latter being the strongest performer during the three-month period ended 31 March.
Sales of clear aligners appeared to be unshakeable at
the beginning of the pandemic, but this idea was contradicted by minimal—albeit, symbolic—consecutive dips
for the world’s largest clear aligner manufacturer. Align
had recorded six consecutive quarters of sequential
revenue growth prior to the first quarter of this year, when
total sales of US$973.2 million (€914.0 million) represented a 5.6% decline compared with the prior quarter.
In a webcast call with analysts, Align Technology President
and CEO Joseph Hogan listed three factors that had
resulted in a challenging quarter: the continued impact of
the COVID-19 pandemic, particularly the strict measures
in place in China; a difficult economic environment driven
by inflation, waning consumer confidence and supply
chain disruptions; and fallout from the war in Ukraine.
06
2 2022
Hogan explained that industry data showed a decrease
in orthodontic demand. He said: “[The] data from about
700 ortho practices, covering more than 1,000 orthodontists across 1,600 locations in the United States and
Canada, showed weakening underlying patient demand
trends in the first quarter for both adult and teens and
across wires and brackets and clear aligner products.”
Hogan added that new patient visits in North America
during the period were down by 7.6% year on year.
Dentsply Sirona navigating troubled waters
Dentsply Sirona’s revenue for the first quarter was down
6.1% year on year. In the first quarter of 2021, the company topped one billion in sales, and a year later, this
had decreased to US$965 million. Operating income of
US$93 million represented a decline of 39.5%.
Dentsply Sirona reported preliminary earnings with the
US Securities and Exchange Commission and did not
submit a Form 10-Q. The company was therefore not
in compliance with the listing rules of the Nasdaq stock
exchange, where its stock is listed under the XRAY ticker
symbol, and was given a period of 60 days to detail the
steps it will take to regain compliance. Dentsply Sirona
said in a statement in mid-May that it was unable to file
its Form 10-Q owing to a pending investigation into its
use of incentives to sell products to distributors in the
third and fourth quarters of last year. It received a filing of
delinquency from Nasdaq.
[7] =>
INTRODUCING
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Follow Dentsply Sirona for
the latest in implant dentistry
dentsplysirona.com/implants
[8] =>
| industry
These events follow an April leadership reshuffle at the
dental giant that included the unceremonious dismissal of
Donald Casey as board member and CEO of the company
and the appointment of John Groetelaars as interim CEO.
Groetelaars said that it had been a challenging quarter,
ending with a disappointing result. He said that US sales
had been weaker than in the prior quarters and that
COVID-19 restrictions in China, supply chain issues and
disruptions resulting from the war in Ukraine were hampering the manufacturer. Dentsply Sirona earns roughly
5% of its revenue in China.
Barbara Bodem, the company’s interim chief financial officer, noted that currency exchange rates and increased investments in research and development had contributed to
the drop in operating income. “We attribute approximately
60% of the year-over-year decline to the transitory macro
challenges of foreign exchange, inflationary pressures, and
the impact of COVID in China,” Bodem told analysts, noting
that earnings per share for the first quarter were US$0.52
versus US$0.72 in the comparable period last year.
“Dental companies faced
a difficult economic
environment during the first
quarter of this year.”
Straumann Group outperforms
Straumann reported revenue of CHF589 million (€573
million), a year-on-year increase of more than 25% compared with the CHF469 million that it banked for the same
period last year. Straumann’s sales increased by double digits (on an organic basis) in all regions where it
operates, and its sales grew most quickly in the Latin
America region.
In Latin America, Straumann’s sales for the quarter
increased by 56.1% to reach CHF39.3 million. Sales
of CHF267.2 million for the Europe, Middle East and
Africa region represented an increase of 24.7%, and
those for North America—at CHF170.1 million—were up
by 23.2%. Sales for the Asia Pacific region amounted
to CHF112.3 million, and this represented Straumann’s
narrowest regional growth margin of 21.7%.
Straumann said in its results that patient volumes had
remained strong in most countries during the threemonth period, except in China, where local lockdowns
to contain the spread of SARS-CoV-2 had interrupted
patient flow.
08
2 2022
CEO Guillaume Daniellot commented that digital solutions, led by intra-oral scanners, had helped sales, and
the company attributed some of its success during the
quarter to a strong performance from its dental support
organisation business in North America and to sales of
premium dental implants in the region. In Latin America,
orthodontic sales grew rapidly and sales of the Straumann
Virtuo Vivo intra-oral scanner drove revenue growth.
Sales growth in China was constrained by COVID-19
lockdowns, Straumann said, but the impact of this had
been partially compensated for by strong sales in fellow
Asia Pacific markets Japan and Australia and expansion
in India. “Across the region, premium implants and orthodontics contributed strongly to the overall performance,”
the company said.
Envista leads way to differentiated portfolio
and remains upbeat on dental
During the quarter, Envista further aligned its portfolio
with faster-growing segments of the dental industry. In
January, it completed the sale of its KaVo treatment unit
and instrument business to Planmeca and announced
that it would purchase Carestream Dental’s intra-oral
scanner business.
The company’s revenue from the first quarter amounted
to US$631.4 million and represented a year-on-year increase of 5.4% in core sales growth. Sales of specialty
products and technologies were US$397.1 million, compared with US$366.5 million in the first quarter of last
year, and sales of dental equipment and consumables
decreased to US$234.3 million from US$246.1 million.
Operating profit for these two segments during the period
showed little year-on-year change, being US$70.3 million
and US$45.5 million, respectively.
CEO Amir Aghdaei said in Envista’s earnings announcement that the company had performed well in what
had been a “challenging macro environment” and that
it had made progress towards its goal of transforming
its portfolio and building a strategically differentiated
dental company. “With the closing of the acquisition of
Carestream Dental’s intra-oral scanner business, we
have now added a suite of world-class scanners and
software solutions that further differentiate our portfolio
and support our vision of digitising, personalising, and
democratising dental care,” Aghdaei said.
Signalling the company’s ongoing optimism about the
dental sector, Envista announced in May that it would
acquire Osteogenics Biomedical, a leader in the development of regenerative solutions for periodontists, oral and
maxillofacial surgeons, and clinicians involved in implant
dentistry. The transaction is expected to close in the
third quarter of this year.
[9] =>
Soft tissue augmentation
NovoMatrix®
Reconstructive Tissue Matrix –
the next generation material
NovoMatrix® Reconstructive Tissue Matrix is an acellular dermal matrix
derived from porcine tissue intended for soft tissue applications. The proprietary
LifeCell™ tissue processing is designed to maintain the biomechanical integrity of the tissue,
which is critical to support tissue regeneration.
Indications
Localized gingival augmentation to increase keratinized tissue (KT) around teeth and implants
Alveolar ridge reconstruction for prosthetic treatment
Guided tissue regeneration procedures in recession defects for root coverage
Product features
Consistent thickness (1 mm)
Pre-hydrated
Controlled source
www.biohorizonscamlog.com
Before use, physicians should review all risk information, which can be found in the Instructions for Use attached to the packaging of each NovoMatix®
Reconstructive Tissue Matrix graft. NovoMatrix® is a registered trademark of BioHorizons. They may not be registered in all markets.
©BioHorizons. All rights reserved. Not all products are available in all countries.
Bone tissue augmentation
MinerOss® A
The allograft for outstandingly
fast bone remodeling [1]
The scientific evidence shows that allografts are the second best option to patient‘s
own bone compared to other bone substitutes. [2]
Benefits of MinerOss® A human bone substitute [1, 3–5]
Optimal osteoconductivity
Fast graft incorporation
Complete remodeling potential
www.biohorizonscamlog.com
[1] Wen et al. J. Periodont. 2019, 1, 734.
[2] Schmitt et al. Clin Oral Implants Res. 2013, 24, 576.
[3] Kloss et al. Clin Oral Implants Res. 2018, 29, 1163.
[4] Solakoglu et al. Clin Implant Dent Relat Res. 2019, 21, 1002-1016.
[5] Kloss et al. Clin Case Rep. 2020, 8, 5.
References available at: www.biohorizonscamlog.com/references_minerossa
MinerOss® is a trademark of BioHorizons®. BioHorizons® is a registered trademark of BioHorizons.
They may not be registered in all markets. ©BioHorizons. All rights reserved. Not all products are available in all countries.
[10] =>
© BalanceFormCreative/Shutterstock.com
| industry
GDC reveals continuing impact
of COVID-19 on UK dentistry
RE
DT
By Brendan Day, Dental Tribune International
As the statutory regulator for all dental professionals
across the UK, the General Dental Council’s (GDC’s)
main aim is to maximise patient safety and promote confidence in the provision of dental services. Recently, the
GDC published a pair of surveys that measured the impact of COVID-19 in 2021 on dentists and dental patients,
respectively. The findings of these surveys indicate that,
though UK dentistry has begun to return to normal, major
hurdles still exist across a number of areas.
The GDC commenced research on the impacts of
COVID-19 on oral health and dentistry back in August
2020, the key findings of which it published in December that same year. This second set of surveys was conducted in the same period in 2021 and, according to the
regulator, aimed to capture how the perceptions of dental
professionals and the general public towards dentistry
had continued to evolve throughout the pandemic.
To better understand the impact of COVID-19 on dental
professionals in 2021, the GDC commissioned Pye Tait
10
Consulting to conduct an online survey of 2,168 respondents, six focus groups with 39 total participants and five
further in-depth phone interviews. One of the key findings of its research was that the well-being of UK dental
professionals is markedly lower than that of the general
population. Based on dental professionals’ rating of their
happiness on a scale of 0 (not at all happy) to 10 (completely happy), the mean average happiness score was
found to be 5.2. The average anxiety score on a scale of
0 (not at all anxious) to 10 (completely anxious) was 5.6.
In comparison, a survey conducted by the Office of
National Statistics found that the average happiness
score in the UK in 2020/2021 was 7.31 and the average
anxiety score was just 3.31.
From a financial perspective, the effects of the pandemic
continued to be felt by many dental practices: 69% of
respondents said that their income had decreased
compared with pre-pandemic levels, significantly higher
proportions of National Health Service or mixed public–
private dental practices reporting reduced incomes than
2 2022
Tribune Gr
s, nor do
Tribune Gr
[11] =>
industry
those working purely in private dentistry (78% compared
with 63%). In addition, approximately 35% stated that
they believed their income would remain lower than
pre-pandemic levels over the next year.
Patients continue to face issues of access
For a snapshot of the general public’s attitudes towards
COVID-19 and its impact on dentistry, the GDC commissioned the Community Research company to carry out
independent research. An online survey that explored
attitudes about patient safety and dental visit frequency,
among others, was filled out by 2,389 members of the
public, spread across England, Wales, Scotland and
Northern Ireland.
Some of the findings reinforced the widespread notion
that UK dentistry is dealing with challenges at a systemic
level in providing adequate care for patients. Though
most individuals who wanted a dental appointment had
been able to secure one, 22% reported being unable
to book an appointment since August 2020. A higher
proportion of young people and individuals of Asian or
Black ethnic backgrounds stated that they had experienced difficulties in accessing dental services, indicating that the pandemic had continued to exacerbate
|
“Dental professionals continue
to rise to challenges posted
by the pandemic [...]”
oral health inequalities in the UK. Meanwhile, around
one-quarter of respondents said that they were still hesitant about visiting a dental practice owing to concerns
about COVID-19.
“Dental professionals continue to rise to the extraordinary challenges posed by the pandemic, but these
findings point towards a system being overstretched,”
said Stefan Czerniawski, executive director of strategy at
the GDC, in a press release.
He added: “Many of the most pressing and wide-reaching
challenges highlighted in this research, such as access to
services, health inequalities and pressure on professionals,
will require attention and effort from everyone right across
dentistry. While some of these are areas outside of the
GDC’s direct control, we will use this evidence to inform all
our work and share the insights with our partners to support
those broader efforts to address these problems.”
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Tribune Group and Dental Tribune Int. GmbH.
[12] =>
| industry
Preferences for fixed restorations
and resulting impact on the US and
European overdenture markets
© iData Research Inc.
Daniel Sussman and Dr Kamran Zamanian, Canada
1
In recent years, patient preferences for fixed restorations have driven significant growth in both the US and
European fixed-hybrid overdenture markets. This trend is
particularly pronounced in the US, where patient awareness has also been a significant factor in recent years.
Though it was slowed momentarily by the COVID-19 pandemic, this market has made a full recovery and is set to
experience single-digit growth moving forward.
Fixed-hybrid overdentures are full-arch restorations that
use an implant bar into which the dentist screws the denture prosthesis and, therefore, they cannot be removed
by the patient. This makes them similar to natural teeth
and eliminates much of the hassle of regular maintenance.
As a result, the proportion of patients seeking a fixed-
hybrid restoration has soared across the US and Europe
despite their premium price tag. During the pandemic,
there has been a rise in demand for more affordable
12
2 2022
options such as implant-supported overdentures, but
the fixed-hybrid overdenture market has now recovered
and, as can be seen in Figure 1, is set to grow steadily
in the coming years.
Fixed attachments gaining ground
The growth of the fixed-hybrid overdenture market as well
as that of the total overdenture market has had a positive
impact on both implant bar and attachment markets.
In 2016, Zest Dental Solutions launched its Locator F-Tx
fixed attachment system. This system operates as an alter
native to screws and cement, and has created significant
value in the attachment market. Zest’s fixed attachment
system has experienced significant growth, as the system has been used to secure an increasing number of
fixed-hybrid overdentures. Whereas Zest Dental Solutions’
Locator F-Tx currently dominates the fixed attachment
[13] =>
© iData Research Inc.
market, other minor competitors exist, such as the
Smileloc system. Naturally, the fixed attachment market
not only benefits from a steadily increasing rate of adoption
but also from being tied to the fastest growing segment
within the overdenture market.
A shifting landscape
for the implant bar market
Like the attachment market, the implant bar market is
also undergoing substantial changes that will affect it
in both the short and long term. The first such change
relates to the market’s competitive landscape. The implant
bar market can be broken down into implant bars manufactured by dental laboratories and those manufactured
in independent milling facilities. Traditionally, there was
a near-even split between dental laboratories and milling
facilities in the US; however, dental laboratories command
a significantly higher share of the market in Europe, particularly in Italy, Spain and Portugal. Recently, the growing
use of CAD/CAM technology has increased efficiency
in the milling process and decreased the cost. Hence,
smaller dental laboratories are now able to produce their
own implant bars inexpensively, substantially increasing
their share of the implant bar market.
The competition between milling facilities and dental
laboratories, in addition to the increased efficiency and
cost savings of CAD/CAM technology, have combined to
place downward pressure on implant bar prices across
the US and Europe. As CAD/CAM technology becomes
more accessible, an increasing number of dental laboratories have begun in-house manufacturing of implant
bars. The increased efficiency of this process has caused
the cost per implant bar to decrease. Whereas dental
laboratories and CAD/CAM milling facilities are interested
in maintaining their profit margins, reduced costs present an opportunity to capture greater market share. As
a result, the price of implant bars has been decreasing
while the use of CAD/CAM technology increases. This is
expected to reach a plateau as the implant bar market
becomes saturated with CAD/CAM milling. These price
reductions also have an impact on the pricing of splinted
overdentures such as fixed-hybrid overdentures and removable implant bar overdentures, since the implant bar
is a key component of these overdentures.
Another current trend within the implant bar market
regards the materials being used in their fabrication.
Implant bars in both the US and Europe are primarily fabricated with titanium, cobalt chromium or, occasionally,
gold. In the US, the use of titanium has been most popular whereas in Europe, cobalt is used more often. Both
titanium and cobalt chromium have benefits. Cobalt has
been used in dentistry for decades and is a very strong,
biocompatible material with high corrosion resistance.
Titanium is also a very strong and corrosion-resistant
2
material. Where titanium distinguishes itself, however,
is through its lightweight nature, elasticity and superior
biocompatibility. In the implant bar market, titanium has
been gaining considerable popularity, mostly owing to its
biocompatibility. Germany, Scandinavia, Austria, Switzerland and the Benelux region have paved the way in the
use of titanium in Europe. Cobalt chromium still commands a significant unit share of the implant bar market
in France, the UK, Italy, Spain and Portugal, but titanium
is expected to become the dominant implant bar material
in these countries over the next decade (Fig. 2).
Closing thoughts
In summary, shifting patient preferences towards fixed-
restorations and the widespread adoption of CAD/CAM
technology has led to significant changes in the over
denture market. Whereas the future may be uncertain,
iData Research forecasts indicate that this market is
expected to experience substantial growth over the next
five to ten years across Europe and the US. This will be
spearheaded by remarkable growth within the fixed-hybrid
overdenture, implant bar and fixed attachment markets.
about
Daniel Sussman is a research analyst
at iData Research. He develops, writes
and models syndicated and custom research
projects for various medical device
industries. To date, he has published the
company’s European gastrointestinal
endoscopic devices report as well as its
US and European dental overdentures series.
Dr Kamran Zamanian is CEO and
founding partner of iData Research.
He has spent over 20 years working in the
market research industry with a dedication
to the study of dental implants, dental
bone grafting substitutes, prosthetics,
as well as other dental devices used in
the health of patients all over the globe.
2 2022
13
[14] =>
| interview
“The future is digital, and I want
women not only to participate in the
future but also to actively shape it”
An interview with Eva-Maria Meijnen
By Franziska Beier, Dental Tribune International
Female leaders are still under-represented in many fields,
and dentistry is no exception. This situation inspired
Dental Tribune International (DTI) to talk to Eva-Maria
Meijnen, co-CEO of a growing clear aligner business
based in Berlin in Germany. In conversation with DTI, she
spoke about what drives her professionally, how diversity
can benefit a business, the importance of celebrating
women’s achievements more and future endeavours for
her company.
Ms Meijnen, could you please tell us about your
professional background? What did you do before
you became co-CEO at PlusDental?
I have always had a passion for technology and innovation—wanting to understand in detail how things work
and how I can help make them work even better. This has
been reflected in my academic and professional choices.
I have a degree in industrial engineering from the Karlsruhe
Institute of Technology. After graduating, I began my professional career at Siemens introducing new manufacturing and supply chain concepts following the lean management approach. I absolutely loved its rather simple
but important core principle: always put the customer in
the centre and optimise holistically, not at the cost of one
party but rather creating a win–win situation. After two
years, I joined Porsche Consulting, the expert consultancy on lean management, as a senior consultant in order
to gain more experience in different companies and
industries. In 2009, I joined engine manufacturer MTU,
where I first set up an internal consultancy and then held
various management positions.
What sparked your interest in PlusDental?
I believe that technology and digitisation hold immense
potential for the healthcare sector in general and for the
dental sector in particular—the potential to offer modern
Eva-Maria Meijnen joined PlusDental shortly after it was founded at the end
of 2017. She was appointed chief operating officer at the beginning of 2019
and co-CEO in December of the same year.
Eva-Maria Meijnen
[15] =>
interview
|
Eva-Maria Meijnen in the PlusDental office in Berlin. Presently, more than 50,000 patients have received treatment with the company.
and improved treatments at reduced costs to more patients. It was this purpose that I found irresistible and
that made me end my corporate career and join a ninemonth-old start-up.
I first came across the invisible aligner product through a
friend who had returned from working in the US. I immediately noticed that something was different about her.
Her demeanour had changed completely; she seemed to
have much greater self-confidence and a new charisma.
She told me that she had undergone an aligner treatment
in the US and that she had felt much more comfortable
in her skin ever since. Two things in particular struck me.
Firstly, the fact that something as small and barely visible as an aligner can have such an enormous impact on
one’s life and, secondly, that this fantastic product was
hardly known in Germany and was affordable for even
fewer people.
Weeks later, I met Lukas Brosseder, a good friend of
mine and a serial entrepreneur. He told me about this
new company he was going to found, a company that
had the vision to bring the invisible aligner product and a
new digital treatment concept to Germany. So, it’s probably no surprise that I wanted to be part of this journey.
“I care about creating
a company that shapes
the future of dentistry.”
You share the leadership position with two other
colleagues. What is your specific area of responsibilities within the company?
We are all co-CEOs and, whereas each one of us has
his or her own field of responsibility, we take all important
and strategic decisions together.
I am responsible for our medical team, our operations,
finance, customer relations, sales and human resources.
One milestone of which I am particularly proud is the setting up of our own production of aligners and retainers
in our Berlin dental laboratory. From our treatment plans
to our products, everything is 100% made in Germany.
You are aiming to reach unicorn status for PlusDental
this year, which would make you the first woman in
Germany to co-lead a company with such a status.
2 2022
15
[16] =>
| interview
Brand ambassador Bruce Darnell (left) and Eva-Maria Meijnen in the PlusDental flagship clinic in Berlin.
Please tell us more about this endeavour. What
drives you?
Change is amazing—this is exactly what drives me personally and PlusDental as a company. Our goal is not only
to digitise and modernise dentistry, but also, and above
all, to democratise it. We want more people to have access to innovative and affordable dentistry that meets the
highest medical standards. I’m really passionate about
empowering people to change the things that they are
not happy with.
16
Fifty per cent of the population is female; however, we are
heavily under-represented in all areas where important
decisions are made and our future is shaped. I believe it
is time to change that. We should celebrate every woman
who makes it to the top and make sure that many others
will follow in the same path.
I don’t personally care about the evaluation of my company and even less about unicorn status. I care about
creating a company that shapes the future of dentistry.
A relevant and large company that has the scale to make
a significant difference.
How do you evaluate the importance of role models?
Role models are both an important source of inspiration
and proof of what’s possible. I think it’s very important to
have role models that speak to you in different areas of
life. It can be someone from your immediate environment,
a scientist, an entrepreneur or a fictional character from
a book, show or movie. Role models can inspire and
empower girls and young women greatly by showing
them that the sky’s the limit.
You have been accused of exploiting your role as a
female leader for PR purposes. How did you respond
to that and how can we move towards a culture where
women’s achievements are celebrated more?
Contrary to a LinkedIn comment accusing my leadership
claim of being femwashing, I was promoted to the position of co-CEO purely on the basis of my hard work and
the results I delivered. Instead of discussing semantics,
it is vital to focus on the really important issues, such as
supporting as well as empowering more women on their
professional journeys.
In your opinion, how can gender equality benefit
a company or other structures?
I believe that diversity in any form is beneficial for a company. When different backgrounds and perspectives come
together, it automatically forces you to look at things from a
different point of view and to step outside your comfort zone.
This is the best foundation for being truly creative and successful, as in this way you gain new insights and are much
more willing to challenge the status quo. Also, you are much
less prone to strict group thinking. I have noticed this in my
own teams as the best ideas have come from diverse teams.
2 2022
[17] =>
interview
In addition, there’s another interesting and noticeable
side effect. A company that’s genuinely diverse has
a strong pull effect as it automatically attracts diverse
employees, making it a key factor in the competition for
the best talents. Great business ideas can be duplicated
to a certain extent, but great teams cannot.
I am proud that we have such a diverse team composed
of members coming from more than 50 different nations.
Fifty per cent of our employees are female, and this is true
at all leadership levels.
Based on your own experiences, what do we need
to change in society in order to enable more women
to reach the top?
It is never just one thing when it comes to changing
society. A key aspect for me is education. Already as
children we often encounter outdated stereotypes like
“technology and maths are only for boys”. Let’s inspire
and motivate all children alike to try out new things without any limitations. My parents have always encouraged
me and taught me to remain curious, open-minded and
brave. They brought me up having the awareness that
everything is possible. The future is digital, and I want
women not only to participate in the future but also to
actively shape it. To this end, they need to believe and
be confident that they can do anything they set their
minds on.
I also believe that schools play a decisive role. Young
girls should be given the chance to try out different
things from an early age, and we should use formats that
go beyond the classic way of teaching subjects such
as maths. Technology-related subjects such as coding,
machine learning and environmental technology should be
included more often into the regular school schedule.
Coding, for instance, is easy to learn, and it fosters analytical thinking in a manner that is playful and low threshold.
In addition to encouraging new approaches in school
education, it’s very important to promote entrepreneurship
in general and inspire young women to help shape the
technology scene and the digital future within their own
companies. This is the case with “Makers of Tomorrow”,
an initiative of the German Chancellery to encourage and
inspire university students to start their own businesses.
It’s in an online course format and consists of ten master
classes given by different start-up CEOs and their founders. I’m very proud to be part of this project by providing
a master class.
Besides education, I have seen many talented women
in my generation stepping down when they started a
family. They took over the majority of family and care
work and reduced their working hours for years, even
after their parental leave was over. It is, of course, each
person’s personal decision how to combine career
|
“The focus for us remains
on further digitising
high-quality dentistry
and making it accessible
to even more people.”
and family planning. My husband and I decided that
we will share everything 50/50. We both continued
working full-time and took care of our home and family together. I would not have been able to follow my
career plans without equally sharing all responsibilities
with my husband. From my experience, this set-up is
still an exception.
The tooth models that serve as the basis for manufacturing each step of the
aligner treatment are 3D-printed. (All images: © PlusDental)
What are your ideas and plans for PlusDental and the
oral healthcare sector in the future?
The focus for us remains on further digitising high-quality
dentistry and making it accessible to even more people.
Accordingly, we want to continue to constantly improve
our processes without compromising accuracy and quality.
We are also considering expanding our current medical
services to include new dental areas such as more advanced aligner treatments and adding new products to
our portfolio such as whitening, prophylaxis and artificial
dentition. Furthermore, we want to strengthen our presence in our current markets and also internationally. No
matter where we are, we want to offer modern dentistry
that people can afford.
Editorial note: This interview was conducted before it
was announced on 20 May that PlusDental is to become
part of the Straumann Group.
2 2022
17
[18] =>
| interview
“At age 37, CEREC advances
the restorative capabilities
of dentists as never before”
An interview with Prof. Werner H. Mörmann
and Dr Cord F. Stähler
By Jeremy Booth, Dental Tribune International
technology officer at Dentsply Sirona, about the history
and future of the one-and-only CEREC.
Thank you for speaking with us, Prof. Mörmann.
Could you tell us how you came up with the idea for
CEREC?
Prof. Mörmann: In 1979, a very intense discussion in
dentistry arose about a possible health risk from the mer
cury component of amalgam, the then standard material
for treating carious defects in molar teeth. Dentists began
to systematically replace amalgam fillings with compos
ites, and patients liked the more aesthetic tooth-coloured
fillings. However, these caused new problems: the large
resin-based posterior fillings leaked from the beginning
because of polymerisation shrinkage, causing pain and
secondary caries. As a lecturer and researcher, I felt
compelled to seek a solution.
1
2
Fig. 1: CEREC pioneer Prof. Werner H. Mörmann. Fig. 2: Dr Cord F. Stähler
is chief technology officer at Dentsply Sirona. (Images: © Dentsply Sirona)
CEREC was launched in 1985 as the first complete
CAD/CAM system for the fabrication of dental resto
rations. Astoundingly, nearly four decades later, CEREC
remains the sole solution of its kind and is used by
dentists the world over, including by the youngest pro
fessionals, who would be hard pressed to swap their
iPads for Macintosh Xls. CEREC founders, Prof. Werner
H. Mörmann and electrical engineer Dr Marco Brandestini,
unveiled the system to a bewildered profession, and
many dentists insisted that digital technology had no
place in oral healthcare. Dentsply Sirona, however,
quickly recognised its potential, partnered with the inven
tors and became instrumental in the system’s develop
ment. Dental Tribune International had the honour of
speaking with Prof. Mörmann, who recently celebrated
his 80th birthday, and with Dr Cord F. Stähler, chief
18
2 2022
The solution was to have the filling fabricated quickly
outside the mouth and to bond it to the tooth as an inlay.
However, conventional inlay procedures using ceramic or
metal were laborious and time-consuming, and it was
clear that new technology would be needed to solve the
problem. Around this time, the accessibility of computers
was increasing, and their potential fascinated me. That
was when the idea came to me that dentists could
produce inlays by themselves using digital technology:
3D-scanning the tooth, for example, and designing the
inlay and having it formed quickly from a block of aes
thetic material directly in the practice. This brought ce
ramics to the forefront of interest because the material
was very similar to tooth structure physically, biologically
and aesthetically. Using ceramics, however, required a
completely new manufacturing technique as well as
a new clinical concept. The rest is history!
The development of the CEREC system was not quite
straightforward. What setbacks did you experience
and how were they overcome?
[19] =>
interview
|
3
Fig. 3: Prof. Werner H. Mörmann (left) developed the CEREC system in the early 1980s together with electrical engineer and close friend, Dr Marco Brandestini.
Prof. Mörmann: I had a technical solution in mind that
would integrate data acquisition, design and form grind
ing into a small mobile unit. The solution needed a
monitor and had to be a practical device that could be
used chairside by the dentist. Dr Marco Brandestini, an
electrical engineer and a good friend of mine, was also
enthusiastic about the idea and saw it as a technical
challenge for himself. Our first functional model of a
form grinding machine actually self-destructed when the
grinder sank into the ceramic!
The solution was to use cylindrical plunge grinding along
the mesiodistal inlay axis with a diamond-coated grinding
wheel and a water turbine as the drive. This worked
quickly at the chairside, but the occlusal surface was flat
and dentists had to shape the fissures and cusps manu
ally by themselves after bonding. I am extremely pleased
that inlays made in this way still work after 25 years
or more. This solution—together with many clinical
studies—confirmed that the clinical concept was viable.
The full story of the technical and clinical emergence
of the CEREC method is rather long, but those who
are interested can download it free of charge from
moermanncerecstory.com, in English or German.
Dr Stähler, as CTO at Dentsply Sirona you are well
versed in all matters relating to CEREC. How important has the system become for the company?
Dr Stähler: Dentsply Sirona and CEREC have been in
separably linked for many years. In 1985, when CEREC
was launched, digitalisation in dentistry was still in its
infancy, and scepticism and reservations about it were
prevalent.
As a company, however, Dentsply Sirona always believed
in this idea and demonstrated its perseverance from the
very beginning. Engineers from our company were in
constant exchange with Prof. Mörmann and Dr Brandestini,
and with CEREC users. Together, the parties continued
to develop the system and to set new standards in digital
dentistry.
Today, the system is mature, and the quality of the clinical results are unquestionable. CEREC has had a huge
impact on us as a company and continues to do so.
Digital is now part of our DNA: we think, we act, and we
live digitally.
How would you describe the current significance of
CEREC in dentistry?
Dr Stähler: CEREC, as a system, is a fixed force in the
market. The all-new CEREC includes Primescan and
the CEREC Primemill, and it is now easier for an even
wider circle of practitioners to decide how this modern
digital technology can be used quickly and economically
in individual dental practices.
The individual components of CEREC, including the
scan, the software, the milling and grinding machine and
the material block, are optimally coordinated to provide
a seamless workflow. Digital chairside dentistry is now
faster, easier and more reliable than ever before. It has
reached a new level of quality, and this provides for a
noticeably more comfortable treatment experience for
the patient.
The use of 3D scanners is increasing dramatically.
Where does the Primescan fit into the CEREC
system?
Dr Stähler: We developed intra-oral scanning in the
context of CEREC and, by doing so, established a market
for the technology. Today, we see the use of intra-oral
2 2022
19
[20] =>
| interview
4
Fig. 4: Innovative and fully integrated CEREC system.
scanning and digital impressions growing beyond chair
side and encompassing all areas of dental treatment;
first and foremost with clear aligners, but also in the daily
interaction with laboratories. Here, we see our market-
leading and patient-benefiting precision and speed as
key advantages. We will continue to drive single-visit
dentistry, but we will also use our experience of dozens
of years in chairside for all other applications, especially
in the cooperation with dental laboratories.
Prof. Mörmann, are you surprised that new applications for CEREC are still being discovered?
Prof. Mörmann: Not at all! I said a few years ago that the
intra-oral scanner has the potential to scan the complete
oral situation for diagnosis during practically any dental
examination. To name just one example, scans can also
be done by dental assistants. In any case, as a treatment
method, CEREC still offers plenty of scope for further
developments. These could relate to any of the steps,
including data acquisition, form grinding, milling tech
nology and materials.
While we are on the topic of new developments,
Dr Stähler, what can you tell us about the latest
upgrades of the Connect and CEREC software?
Dr Stähler: The latest upgrade of the Connect and
CEREC software is upgrade 5.2, and it has provided
users with new functionalities and even better perfor
mance. Patient communication has also been improved
20
2 2022
through a new visualisation step in the model phase. It is
now possible to view the model directly without resto
ration selection. Primescan users also benefit from these
updates, and new firmware makes the intra-oral scanner
faster and extremely stable while giving users access to
new workflows and even better usability.
How do these developments benefit dentists?
Dr Stähler: Owing to its improved firmware, Primescan
can now generate more 3D data points per second than
ever before. With software generation 5.2, the scanning
speed and scan stability have doubled. For clinicians
working with Primescan in their practices, these improve
ments in firm- and software result in more efficient work
flows and even greater reliability and they also provide
a more comfortable patient experience.
CEREC is the best example of Dentsply Sirona’s pioneer
ing of digital dentistry. Using CEREC, we are building
a digital platform that brings together all stakeholders
and devices and the intention is that new technologies
and existing equipment can be seamlessly integrated
into the workflow. By doing that, we can help dentists to
focus on providing patient care and we can give patients
a much better and smoother experience.
What drives upgrades to CEREC? Is it advancements
in technology or changes in dental treatment and
patient preferences?
[21] =>
interview
Prof. Mörmann: Foremost are the expectations of the
patient. Whether he or she needs the perfectly aesthetic
blending in of a single anterior tooth or a full rehabilitation
of the dentition, the patient wants to have the treatment
done with efficiency and the results of the restoration
need to be pleasing and clinically and aesthetically dura
ble. Upgrades have led to the perfection and expansion
of the application of the CEREC method, and the system
itself has also benefited from advancements in technol
ogy. These developments go hand in hand. For example,
I expect that the large number of digital CEREC resto
ration designs worldwide could be analysed using artifi
cial intelligence in order to develop assistance systems
that would further improve restorative work.
Dr Stähler: I agree, and I would add that the driving force
behind innovation is the sum of many factors. Dentists
and dental technicians wish to treat and care for patients
in the best possible way, and our goal is to support them.
Our focus on digital technologies has made dental treat
ment more accurate and more pleasant for patients, and
it has resulted in workflows in laboratories being safer,
more cost-efficient and more predictable.
Our success in developing solutions that meet the needs
of dentists worldwide is the result of a competitive spirit
and talented employees who are committed to product
innovation and high-quality service and training. Improv
ing clinical outcomes, workflows and patient satisfaction
is a driving force in our daily efforts, and we are continu
ally investigating ways in which we can redefine the limits
of what is possible. As you see, it is not just about
technology; it is also about attitudes and emotions.
What do you think the future holds for digital dentistry and how will CEREC compete with other
advancements, such as 3D printing?
Dr Stähler: Digital technologies will always offer benefits.
Diagnostics and planning can be implemented in a timesaving manner, and the patient can find out very quickly
which treatment options are available and what the results
will be. The treatment itself is also faster. The keyword here
is single-visit dentistry and, ultimately, this will lead to even
greater cost-efficiency for dental practices. The CEREC pro
cedure, which includes digital impressions and chairside
manufacturing of restorations, plays an important role in this.
A 3D printer could be a useful addition to the portfolio for
use in applications in which milling and grinding ma
chines do not always provide an optimum result—such
as in the use of composites. I believe that 3D printing is
ready to take centre stage; it is ready to become a part
of the daily workflow for clinics and laboratories alike.
So, watch this space!
However, CEREC and 3D-printing technology are not
mutually exclusive. They complement each other per
|
fectly in digital practices and laboratories. I am certain
that 3D printing will be used alongside CEREC for a long
time to come and that both technologies will have their
specific use cases.
Prof. Mörmann: Anyone who is involved with digital
technology knows: never say never. Forty years ago, we
would never have dreamed of all the things that are now
possible with CEREC. In this respect, as we consider the
future, all dental professionals can look forward to being
part of a very exciting process of development.
“Forty years ago,
we would never have
dreamed of all the things
that are now possible
with CEREC.”
Finally, Prof. Mörmann, what gives you the most
satisfaction as the inventor of CEREC?
Prof. Mörmann: For me, it is the fact that the method, as
it is today, is more fascinating than ever. It has increased
the enjoyment of restoring teeth, be it with single inlays,
onlays, overlays of any form and size, half and full crowns,
endocrowns, veneers, anterior and posterior crowns,
tabletops, implant crowns, quadrant treatments, threeand four-unit bridges or complex full-mouth rehabilitations.
Restorations are automatically generated with individual
biogeneric occlusal morphology using habitual bite or
virtual functional registration. Drilling templates can be
fabricated. To sum up, CEREC provides dentists with a
vast choice of high-tech, highly aesthetic ceramic, hybrid
ceramic and composite restorative block materials with
suitable strength.
Everything runs smoothly, quickly, easily and with high
precision: the scanning, the restoration design and the
machining. And the result is first fit, at the margins as
well as at proximal and occlusal contacts. We are talking
about a system that was launched in 1985. To me, this
represents an awesome and truly fantastic success, and
for this, I would like to thank the developers at Dentsply
Sirona! It is wonderful to realise how many colleagues
around the world are successfully using CEREC in their
practices and providing patients with excellent clinical
care. Without a doubt, at age 37, CEREC advances the
restorative capabilities of dentists as never before.
Editorial note: The name CEREC is derived from Chairside Economical Restoration of Esthetic Ceramics and
also from the initial letters of ceramic reconstruction.
2 2022
21
[22] =>
| interview
Experiences of and successes
achieved with Zolid zirconia
How a dental material developed to become a game-changer—
An interview with Falko Noack, Prof. Bogna Stawarczyk & Atsushi Hasegawa
By Amann Girrbach
Fifteen years ago, Amann Girrbach was one of the first
companies to manufacture and sell zirconia blanks for
the production of dentures. This was followed five years
later by the launch of the Zolid brand: for the first time,
users were offered CAD/CAM blanks that enabled excellent
aesthetic results without requiring complex veneering
processes. Since then, the company has continuously
developed its materials and manufacturing processes
and has gained numerous faithful customers. In this interview, Falko Noack, vice president of research and development at Amann Girrbach; Prof. Bogna Stawarczyk,
scientific director of materials science of the outpatient
department of dental prosthetics of Ludwig-MaximiliansUniversität München in Germany; and Atsushi Hasegawa,
owner of the Organ Dental Lab in Chigasaki in Japan,
discuss the advantages of zirconia as a dental material,
the developments over the past years and possible future
challenges.
the zirconia blank production and the application-side
supervision of initial verified processing methods, such as
copy milling, were highly exciting projects—we were able
thereby to generate immensely important basic knowledge. Since its introduction, zirconia has virtually gone
through the roof. There is hardly another material that has
undergone such amazing development. All issues on the
manufacturing side, including the now almost exclusively
CAM-based processing, correct sintering management
and veneering, are to be considered verifiably resolved.
In the aesthetic field too, zirconia has exhibited a steep
performance curve and can thus, by virtue of increased
translucency and enhanced colour properties, also be
used monolithically. The long-term clinical results provide
evidence of very good suitability and an excellent survival rate for the greatest variety of fixed indications. On
the production side, enormous development has taken
place: the production area for our blanks has increased
20-fold compared with the initial set-up and has been
continuously upgraded with cutting-edge technology. By
now, we are one of the five largest worldwide producers
of dental zirconia blanks (Fig. 1).
“Certainly the most important
innovation was Ceramill ZI,
What, specifically, were the most important innovaour first self-developed
tions in this context?
Noack: Certainly the most important innovation was Ceramill ZI,
zirconia blank.”
our first self-developed zirconia blank. With this material,
Mr Noack, you were already interested in zirconia
and its applications as a student in the course of your
university studies and became more intensely so in
the past 15 years in the scope of your work at Amann
Girrbach. How were the beginnings, and how have
things developed in all these years?
Noack: Even during my studies at university, zirconia appeared to me to offer an ideal alternative to the dental materials that existed at the time. However, issues with verified
processing and limited usability constituted strongly limiting
factors. When I was given the opportunity after completing
my studies to address these issues at Amann Girrbach,
I was immediately enthusiastic. The establishment of
22
2 2022
we have achieved the goal of being able to offer the production of maximum widespan restorations in a secured
manner—that was a fundamental innovation. The development of Ceramill Zolid was essential too: we were looking for enhanced aesthetics and greater translucency at
the time (Fig. 2). To this end, some manufacturers took
the approach of increasing the sintering temperatures—
which, as we know today, was indeed the simpler approach, but also the riskier one from a materials science
point of view. Together with our longstanding development partner and exclusive raw material supplier Tosoh
Corp. in Japan, we, in the scope of intense cooperation,
successfully developed our first translucent material that
does not require an increase of the sintering temperature.
Moreover, the aesthetic zirconia materials Zolid FX Multilayer
[23] =>
interview
|
1
Fig. 1: The zirconia blanks are produced exclusively in Austria.
and Zolid Gen-X Multilayer, which, by virtue of their translucency and colour gradients, are used monolithically in
a wide variety of ways for fixed dentures, also constituted
important innovations (Figs. 3 & 4). The last major innovation of the more recent past is surely Zolid DRS, a material
that can be sintered in 20 minutes with the aid of the corresponding sintering furnace, Ceramill Therm DRS. Just
the shortening of the sintering time from formerly 8 hours
to less than one-sixteenth of that, if nothing else, shows
the advances that could be achieved through ongoing
development.
Prof. Stawarczyk, in the scope of your work as
scientific director, you have been involved in the
assessment of materials from Amann Girrbach a
number of times. Do you remember the beginnings
of your expertise on zirconia as well as subsequent
developments?
Prof. Stawarczyk: Yes, I remember it well: I assessed the first
zirconia discs for Amann Girrbach at a very early stage, and
I appreciate how much knowledge and work are involved.
I’m all the more glad to see how successful zirconia has become and what standing Amann Girrbach has achieved today.
We have examined almost every zirconia modification of
Amann Girrbach at our department and have an excellent
knowledge of the materials. Our most recent joint project
was the development of a high-speed sintering furnace
with appropriate zirconia—which has been on the market
since last year. This development was implemented in
the scope of a cooperation project funded by Zentrales
Innovationsprogramm Mittelstand—a federal programme
that aims to foster the innovative capacity of small to
medium-sized enterprises—based on the knowledge we
had jointly gained over many years.
What is your assessment of the future of zirconia in
dental applications, and what are the research focuses?
Prof. Stawarczyk: Since its introduction, zirconia has been
on the dental market as 3Y-TZP material, then since 2015 as
5Y-TZP and since 2017 as 4Y-TZP. Thus, work on the processing of this material has been ongoing for years. Faster
sintering of this material has been achieved while preserving good mechanical properties, thus enabling savings in
terms of valuable work time. Through the various modifications, the material has furthermore become more and
more enhanced aesthetically. The colouring recipes are
continually optimised, and the aesthetic aspect is always
compared to that of silicate ceramics. The various modifications are increasingly combined within a blank in
order to achieve good aesthetics along with high-quality
mechanical properties. At the moment, in my opinion, the
focus is on considering the system as a whole, which also
includes the CAD/CAM processing and the positioning of
the discs in the software. All in all, innovators are seeking
to automatise processes more and more and to employ
artificial intelligence in this field as well.
2 2022
23
[24] =>
| interview
“With Amann Girrbach,
everything is included [...]—
from the material to
the CAD/CAM system.”
2
Fig. 2: Bridge from tooth #13 to tooth #16 (infiltrated, reduced frame for
tooth #13, vestibular reduction for tooth #14 and 15, monolithic and painted
for tooth #16) made by Amann Girrbach from Zolid White, its first Zolid blank,
developed in 2012.
Mr Hasegawa, you have been using zirconia from
Amann Girrbach since 2011. From the point of view
of the user, how have work procedures and methods
changed in the course of recent years with the use
of zirconia?
Hasegawa: An essential aspect is the switch from analogue to digital. When we started using the Amann Girrbach
CAD/CAM system several years ago, we were still working a lot with manually produced wax-ups. Today, it is
possible without any problems to shape even the fine
details digitally; thus, we work entirely digitally. In the field
of materials too, much has developed; from opaque to
highly translucent properties, a wide range of materials
have become available. For fully veneered restorations,
we in some cases still use opaque materials such as
Ceramill ZI like in the past. In this way, we produce a
high brightness value, which gives the restoration a certain natural appearance from inside. We also use these
materials to cover discoloured stumps or metallic structures such as abutments. In the anterior tooth area, we
use the more translucent and thus more aesthetic materials and normally veneer the frame. In this way, the
colour can be better controlled and adapted ideally to
the residual dentition. If the entire anterior is renewed,
then highly translucent materials such as Zolid FX Multi
layer also permit us to perform monolithic fabrication, as
in such cases the colouration by the residual dentition
plays a less important role. This makes the process considerably faster and more efficient. In the lateral tooth
3
Fig. 3: Zolid Gen-X is the newest generation of Zolid blanks and an all-rounder, designed for a wide variety of indications.
24
2 2022
[25] =>
[26] =>
| interview
and will thus in future be predominant are increasingly
becoming evident. From a manufacturer’s point of view,
the constantly increasing statutory and thus documentary obligations and requirements that have to be met
are also certainly challenging. However, we perceive
these requirements as something very positive, as they
contribute to the enhanced safety of the medical device
and thus also to greater safety for patients.
about
4
Fig. 4: Crowns for teeth #13–23 (monolithic, painted and glazed) fabricated
by certified dental technician Atsushi Hasegawa from Zolid Gen-X—a material for all indications thanks to its excellent properties.
area as well, we work a lot with monolithic restorations.
These are considerably less vulnerable to chipping or
general material failure.
Why have you opted for materials from Amann
Girrbach for more than 11 years now?
Hasegawa: The primary reason is that with Amann Girrbach,
everything is included in a consistent system—from
the material to the CAD/CAM system. Such a workflow
greatly facilitates our work. Another factor which is very
important to us is that Amann Girrbach operates in an
evidence-based manner. This means that we know
that the durability and reliability of the zirconia products
have been confirmed in studies by independent testing
institutions.
What do you expect in future from industry with
regard to zirconia and its processing?
Hasegawa: I think that we can expect developments in
the field of 3D printing. Another helpful feature would
be shade determination, such as via eLAB or Matisse,
prior to the sintering process in order to already know
the shade result prior to sintering. This could perhaps in
future be effected via coloured fluids.
In conclusion, Mr Noack, where do you, from a manufacturer’s point of view, currently see the greatest
challenges in connection with zirconia?
Noack: In my opinion, the issues on the application side can
be considered resolved from the technical point of view.
The challenge currently is to maintain an overview in view
of the numerous products offered. Basically, I see a light
at the end of the tunnel here though, since those zirconia generations which feature multifunctional usability
26
2 2022
After working for about eight years
in the dental technology field, during
which he specialised primarily in fixed
and removable prosthodontics and
implant prostheses, Falko Noack
undertook dental technology studies
at the Osnabrück University of Applied
Sciences in Germany. In the course
of his studies, he worked on various
projects at the university in the fields of metallography and
material testing of dental materials. The topic of his diploma
thesis was the development of a process chain for the
manufacturing of a pre-sintered zirconia blank. He went on
to apply his practical and technological knowledge in research
and development at Amann Girrbach, particularly in the field
of materials development and CAD/CAM technology.
Prof. Bogna Stawarczyk studied
dental technology at the Osnabrück
University of Applied Sciences in
Germany after completing her dental
technician training. Later, she obtained
an MSc in dental technology at
the University for Continuing Education
Krems in Austria, and she
completed her doctorate in 2013 at
Ludwig-Maximilians-Universität München (LMU Munich) in
Germany on the topic of long-term stability of CAD/CAM resins.
In 2015, she completed her habilitation in the field of experimental,
dental, oral and maxillofacial medicine, with a focus on biomaterials,
and was appointed to her current position. She was appointed
extraordinary professor at LMU Munich in 2020.
Atsushi Hasegawa acquired his
dental technician licence in 1996, and
this was followed by a postgraduate
course of studies at Kanagawa Dental
University in Yokosuka in Japan in
1998. He subsequently worked for
11 years at a dental laboratory in
Tokyo in Japan, where he acquired
knowledge and skills in the field of
occlusion concepts. In 2008, he established his own laboratory
in Chigasaki in Japan. Today, he imparts his knowledge
in lectures in Japan and worldwide.
[27] =>
EDITION
W E
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EXHIBITION AND CONFERENCE
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[28] =>
| case report
Efficient production of a
zirconia overdenture
Mathias Berger, France
1
2
Fig. 1: Sintered bar milled from KATANA Zirconia HTML PLUS. Fig. 2: Drawing of chroma map for micro-layering in the anterior region.
Every patient is unique. Patients’ specific backgrounds,
functional needs and aesthetic demands need to be respected in any prosthodontic treatment plan. However, the
importance of an individual treatment approach increases
with the number of teeth to be replaced. After all, the impact
of the restorations on facial aesthetics and on the patient’s
quality of life is never greater than when all the teeth are
missing. Fortunately, adequate dental materials and techniques are available for a patient-centred, individual approach, no matter what challenges need to be overcome.
A patient with bruxism
In the present case, an elderly male patient with bruxism
was in need of a new maxillary denture. Since the
placement of five implants in the maxilla, he had had
no proprioception in this jaw. This lack of sensation had
an impact on the overdenture to be produced: material and design needed to be carefully selected in a way
that it would withstand uncontrolled masticatory forces.
As technical complications are easier to address than
Fig. 3: Finished crowns with individual, age-appropriate shade effects on the sintered bar.
28
2 2022
[29] =>
case report
4
5
6
7
8
9
|
Fig. 4: Bar with individualised gingival areas. Fig. 5: Placement of the central incisor crowns on the bar. Fig. 6: Occlusal screw access hole in the finished
overdenture. Fig. 7: Overdenture ready for try-in. Fig. 8: Intra-oral try-in of the aesthetic overdenture. Fig. 9: Final situation.
biological complications, the overdenture should not be
unbreakable; instead, the replacement of single units
should be easily manageable.
Two-part denture design
The solution was a two-part design consisting of a milled
bar with a gingival area and tooth abutments (Fig. 1) and
of single crowns. The material of choice for the bar was
KATANA Zirconia HTML PLUS (Kuraray Noritake Dental),
which has a uniform flexural strength of 1,150 MPa
throughout the disc, and the single crowns were milled
from KATANA Zirconia YML, which offers natural translucency and strength gradation. Whereas a monolithic
design was selected for the posterior crowns, the six
crowns for the anterior region received a micro-cutback
for aesthetic micro-layering with CERABIEN ZR porcelain
(Kuraray Noritake Dental). Customisation of the anterior
crowns (Fig. 2) was performed with the internal stains
Cervical 1, Grayish Blue, Dark Grey and A+. The finishing layer on the incisors was created using LT0 materials
mainly, as well as some CCV-3 on the cervical area and
LT Natural on the mesial and distal lobes. On the canines,
LT1 was used instead of LT0. The posterior crowns were
merely finished with liquid ceramics (CERABIEN ZR FC
Paste Stain, Fig. 3).
After checking of the fit of the crowns, the gingival areas
of the bar were individualised using CERABIEN ZR tissue
porcelain (Fig. 4). Subsequently, the crowns were luted
to the zirconia abutments (Fig. 5), leaving screw access
holes in aesthetically uncritical positions (Figs. 6 & 7).
Owing to an excellent fit on the implants (Fig. 8), it was
possible to fix the overdenture with the screws immediately, to close the access holes with composite and then
to discharge the patient (Fig. 9).
Conclusion
This patient case is a good example of how important it
is to respect the patient’s background, age and specific
demands when producing dental restorations. Thanks
to the great variety of restorative materials with different
mechanical and optical properties available, it is possible
to create suitable prostheses for virtually every patient.
However, for this purpose, it is important to stay up to
date regarding new products launched and techniques
developed. This way, it is often even possible to create
beautiful and durable solutions in a simplified and efficient
procedure such as micro-layering on innovative zirconia
with a high aesthetic potential.
contact
Mathias Berger
Laboratoire Berger
14 Rue Professeur Deperet
69160 Tassin-la-Demi-Lune
France
www.berger-ceramiste.com
2 2022
29
[30] =>
| case report
Digital implant planning in
combination with a conventional
prosthodontic workflow
Dr Mats Wernfried Heinrich Böse & Andrea Rosinski, Germany
1
2
Fig. 1: Panoramic radiograph of the initial situation. Fig. 2: Preoperative situation, frontal view.
Introduction
It is expected that the trend towards digitalisation will
continue within dentistry.1 For practising dentists, this may
give rise to the question of economic efficiency and the
consideration of which aspects of a workflow can be advantageously digitised first. Implementing digitalisation in a
specific clinical case should always be analysed according
to the question of how digitalisation can improve existing
workflows for both the practitioner and the patient. This
analysis may also be influenced by the experience of the
dentist and his or her team in using specific techniques.
However, the correct 3D placement of a dental implant is one
of the most important prerequisites for long-term treatment
success.2 It can reduce the risk of possible technical and
biological complications. Therefore, specific options within
digital dentistry for the placement of implants in a prostheti
cally driven way should be implemented whenever possible.
Applying implant planning software is an example of this and
can be chosen independently of the following treatment steps.
In my opinion, digitalisation within dentistry is a great tool.
However, it does not inevitably simplify everything, but
enables more predictable outcomes. It does not always require investments in costly equipment. Sometimes a smart
combination of new possibilities and proven techniques
add value to an individual case and experience. The following clinical case is intended to illustrate this.
Clinical case
3
4
5
6
Figs. 3 & 4: Preoperative situation, occlusal views. Figs. 5 & 6: Preoperative
situation, lateral views.
30
2 2022
A 72-year-old female patient presented to the Department
of Prosthodontics, Geriatric Dentistry and Craniomandibular Disorders at Charité–Universitätsmedizin Berlin. The
pretreating dentist had referred her with a view to the expected complexity of the case. She required extensive
prosthetic rehabilitation (Figs. 1–6) and had discomfort in
her left temporomandibular joint. Her expectations of the
treatment result were high, and she wanted to be restored
with single crowns and fixed dental prostheses only.
After three months of therapy with an adjusted splint in
the lower jaw to adjust the occlusal height and centric
condylar position, prosthetic rehabilitation was planned.
[31] =>
Owing to the temporomandibular joint discomfort and
compromised residual teeth, care was taken to plan an
adequate number and position of dental implants. During
the discussion with the master dental technician (MDT),
Andrea Rosinski of Dental-Concept Berlin, it was decided
to place one implant in region #13, one implant in region
#23 and one implant in region #36 to achieve satisfactory
function and aesthetics. Consequently, the prosthetic
treatment goal was defined with a conventional wax-up
and mock-up (Fig. 7). The mock-up helped to manage the
patient’s expectations regarding her new smile in close
consultation with the MDT.
7
Fig. 7: Conventional mock-up after conventional wax-up using transfer splints
and provisional material (Luxatemp Star, DMG).
A digital wax-up and mock-up would have been an option;
however, a conventional way of working without additional
digital equipment was chosen to elaborate the possibilities
of combining new and established techniques. Furthermore,
the MDT is highly specialised in this type of workflow and the
equipment required for a digital wax-up and mock-up was not
8
9
Fig. 8: Digital planning of the implant position in region #23 based on the CBCT scan. Fig. 9: CBCT scan matched with the STL data set of the maxillary
situation model (displayed in brown). Matching was done by selecting three corresponding points on the CBCT scan and model data sets. Like in this case,
fine adjustments by the implantologist are sometimes necessary.
2 2022
31
[32] =>
| case report
10
11
12
32
2 2022
[33] =>
case report
13
14
15
16
|
Fig. 10: CBCT scan with additionally matched STL data set of the maxillary wax-up (displayed in purple). Scanning the mock-up after minor adaptations would also have
been possible. Fig. 11: Alignment in region #23, respecting the imported wax-up data set. A 3.8 × 11.0 mm CAMLOG SCREW-LINE Promote plus implant (CAMLOG) was
chosen. Occlusal screw retention was aimed for. The implant and drill sleeve are shown in yellow and the safety cylinder in orange. Fig. 12: Pre-op construction of the drilling
guide for fully guided implant placement in regions #13 and 23. The drilling guide is shown in yellow. Fig. 13: Pre-op try-in of the drilling guide. Colour-coded drill sleeves
indicate the diameter of the implant to be placed. Fig. 14: Intra-op occlusal view after fully guided implant placement. The occlusal stops of the screw-mounted insertion
posts define the final implant position. Trying to insert the implant deeper than planned leads to loss of primary stability and thus should be avoided. Fig. 15: Intra-op occlusal
view after removal of the insertion posts and insertion of the respective cover screws. Fig. 16: Panoramic radiograph of the situation with the healing abutments in place.
available. This may also represent a problem among practitioners broadly regarding implementation of digital workflows.
SMOP (Swissmeda; Figs. 8–10). This ensured ideal alignment
of the implants regarding function and aesthetics (Fig. 11).
Therefore, the first step was digitalisation of the situation
model and prosthetic treatment goal. Matching with the
CBCT data set was performed in the planning software
Subsequently, a drilling guide was designed and delivered by the manufacturer (Fig. 12). Guide sleeves for a
fully guided implant placement protocol were inserted.
17
18
19
20
Fig. 17: Intra-oral occlusal view of the upper jaw before impression taking. The impression was taken with an individual tray using the double-thread technique
and polyether materials. Fig. 18: Definitive maxillary restorations by Andrea Rosinski. Fig. 19: Intra-oral occlusal view of the lower jaw before impression taking
with an individual tray using the double-thread technique and polyether materials. Fig. 20: Bite registration of the lower jaw with the aid of a back bite registration
plate attached to the previously restored upper jaw. After fine adjustments, registration was carried out with a registration material (LuxaBite, DMG).
2 2022
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[34] =>
| case report
21
Fig. 21: Definitive mandibular restorations of lithium disilicate and multilayer
zirconia by Andrea Rosinski.
After preoperative try-in of the guide (Fig. 13), the implants
(CAMLOG) were placed as planned (Fig. 14). The drilling guide
and screw-mounted insertion posts were removed, and the
implants were left to heal for three months (Fig. 15). After
uncovering, the implants were supplied with prefabricated
healing abutments for an additional two weeks for softtissue management. A panoramic radiograph of the situation with the healing abutments in place was taken (Fig. 16).
A combination of digital—in this case utilisation of implant planning software—and conventional techniques
can lead to highly satisfactory results. The restoration of
the edentulous sites of regions #13 and 23 demanded
a detailed consultation with the MDT. A conventionally
manufactured wax-up and mock-up were helpful to
integrate the patient’s expectations and the functional
and aesthetic demands when planning the treatment.
Malpositioning of dental implants (especially in regions
#13 and 23) could have led to compromised prosthodontic results, additionally risking long-term results. This was
avoided by consequent utilisation of backward planning.
Apart from the SMOP fee for planning and manufacturing of the guide, there was no need for any investments
in additional digital technology for treatment implementation or equipment for performing part of the treatment
steps digitally. Therefore, this workflow is easy to implement for any practitioner and has little additional cost for
the patient, resulting in a predictable outcome.
24a
24b
22
23a
23b
25
Figs. 22–24b: Different views of all the restorations in place. Fig. 25: Final radiograph. Remnants of the cementing adhesive were removed after the radiograph was taken.
After the additional healing period, impressions were
taken with an open-tray technique and polyether impression
materials (Impregum and Permadyne, 3M ESPE; Fig. 17).
After definitive restoration of the idealised maxilla with
lithium disilicate (IPS e.max, Ivoclar) and multilayer zirconia
(Eos, Orodent; Fig. 18), the lower jaw impression was
taken (Fig. 19). Bite registration was performed step by step
and subsequently checked with a bite registration plate
(Fig. 20). The definitive mandibular prosthetic restorations
were manufactured from lithium disilicate and multilayer
zirconia and seated and a final panoramic radiograph taken
(Figs. 21–25).
Conclusion
This case demonstrates that predictable functional and
aesthetic restoration with implant-retained prostheses is possible even without costly investments in digital equipment.
34
2 2022
Editorial note: A list of references is available from the publisher.
about
Dr Mats Wernfried Heinrich Böse
completed his dentistry degree at the
University of Münster in Germany.
In 2021, he completed the European
Association of Dental Implantologists’
(Bundesverband der implantologisch
tätigen Zahnärzte in Europa) specialty
training in implantology and received
his doctoral degree on the topic of root
analogue implants from Charité–Universitätsmedizin Berlin in
Germany. He previously worked in private practice in Essen
in Germany and in Berlin and has been a dentist and research
assistant at Charité in the Department of Prosthodontics,
Geriatric Dentistry and Craniomandibular Disorders since 2019.
[35] =>
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[36] =>
| case report
Implant replacement of c ongenitally
missing incisors using a
surgical guide fabricated in-office
Drs Sean Meitner & Gregori M. Kurtzman, USA
1
2
Fig. 1: Bilateral congenitally missing maxillary lateral incisors with associated facial osseous defect on the ridge. Fig. 2: Radiograph of the maxillary anterior
demonstrating the root positions adjacent to the edentulous spaces at the missing lateral incisors.
Introduction
Replacement of congenitally missing lateral incisors can
pose challenges that can lead to clinical complications.1
These are related to several factors, including angulation
of the premaxilla (triangle of bone)2 and depression of
the facial plate due to lack of development related to the
missing permanent tooth. Traditional radiographs lack
the information necessary to understand the anatomy in
3a
3b
3c
the facial–palatal dimension, and this can lead to dehiscence of the facial aspect of the implant when placed
freehand using a flapless technique. A flap can be elevated prior to osteotomy preparation so that visualisation
of the osseous anatomy can be achieved, allowing the
osteotomy to be angled to prevent dehiscence. Clinically,
freehand, non-guided site preparation has the risk that
the practitioner may overcompensate for the facial defect
and angle of the premaxilla, creating an osteotomy that
4
Figs. 3a–c: Components of the Guide Right system. Guide posts (a). Guide sleeves (b). The 3.85 mm tapered depth stop drills (c). Fig. 4: Guide posts
inserted into the pilot holes created in the edentulous sites on the cast and 2 mm id x 2.4 mm od x 8 mm L thin-walled guide sleeves placed over the posts,
the cleat positioned on the palatal side. URP = upper removable part.
36
2 2022
[37] =>
case report
5a
|
5b
Figs. 5a & b: Light-polymerised resin placed over the cleats (a) and additional resin placed over the adjacent teeth (b) to create the diagnostic guide to be
utilised during the CBCT scan.
is angled too far to the facial aspect, creating restorative
challenges in the aesthetic zone.
3D evaluation by CBCT provides greater information on
the dimensions of the edentulous site to allow implant
planning and utilisation of a flapless technique while ensuring that the osteotomy does not create a dehiscence
and the implant when placed is surrounded by bone.
A guided approach to osteotomy preparation allows a
flapless approach for implant placement, making healing
for the patient easier and less traumatic. Additionally, an
osteotomy is planned that is ideal for the site’s osseous
anatomy, simplifying the restorative aspect of treatment
and yielding a natural aesthetic end result of replacing the
congenitally missing incisor.
Case
A 17-year-old female patient presented for consultation on replacement of the bilateral missing maxillary
lateral incisors with implants (Fig. 1). The patient had
undergone orthodontic treatment and the roots of the
canines and central incisors bilaterally were parallel,
providing spacing for possible implant placement.
Examination noted that a facial defect on the ridge was
present at both lateral sites related to the lack of development of permanent lateral incisors and loss of the
primary lateral incisors prior to orthodontic treatment.
Evaluation of the preliminary radiographs confirmed adequate space between the roots of the canine and central incisor to accommodate a narrow-diameter implant
while maintaining the recommended distance between
the natural root and implant on the mesial and distal
sides (Fig. 2).
The article will discuss a case wherein replacement of
bilateral congenitally missing lateral incisors was planned
utilising a diagnostic guide for a CBCT scan, virtual
planning of the implants and correction of the guide for
a surgical guide fabricated in-office. The accuracy of this
technique has previously been described regarding the
accuracy of the geometric approach to guided surgery
in an in vitro model.3
Components of the Guide Right system (DePlaque) would
be utilised to create the diagnostic guide to be used for the
CBCT scan and the subsequently corrected surgical guide
that would be utilised for osteotomy creation (Figs. 3a–c).
Preliminary impressions were taken and casts fabricated.
6a
7a
6b
7b
Figs. 6a & b: The right lateral incisor site viewed in cross section in the planning software (a). An angle correction of 6° measured in the software was made
to the planned implant positioning based on the anatomy (b). Figs. 7a & b: The left lateral incisor site in the tangential view showing that no linear correction
was needed (a). Cross-sectional view showing that an angular correction of 6° to the palatal would be required (b).
2 2022
37
[38] =>
| case report
a stabiliser for the diagnostic guide when inserted intraorally, and these were light-polymerised (Fig. 5b). The
guide posts were removed from the sleeves, completing
the diagnostic guide. The diagnostic guide was inserted
intra-orally, and a CBCT scan was taken to evaluate the
ideal placement of the implant platform in relation to the
osseous anatomy.
8
Fig. 8: An offset guide post (0.5 mm) placed into the right site and a straight
(no offset) guide post placed into the left site on the cast.
A hole was made in the cast at the planned implant sites
with a 2.38 mm drill in a laboratory handpiece, placing
each in the ideal prosthetic position centred in the edentulous site at the estimated position and trajectory based
on the orientation to the tooth mesial and distal to the
missing tooth. A diagnostic guide post was inserted into
the hole in the cast, and a 2 mm guide sleeve was placed
over the post with its retention element (cleat) oriented
to the palatal aspect (Fig. 4). A two-piece guide post upper
removable part (URP) with cap was positioned over the
2 mm guide post and then a 2 mm guide sleeve was placed
on the URP. This narrower 2 mm guide sleeve provided
more accuracy for the radiographic diagnosis. The palatal
and occlusal surfaces of the cast were lubricated to prevent
resin adherence when the guide was fabricated. A lightpolymerised resin (primopattern LC gel, primotec) was expressed on the cast over the cleat (Fig. 5a), and primosplint
resin (primotec) was placed on the adjacent teeth to create
9
The patient returned for a CBCT scan with the diagnostic
guide. The guide was inserted intra-orally and the CBCT
taken. The scan was imported into the implant planning
software (Carestream). The metal sleeve is visible on
the scan and its radiolucent centre length allows a trajectory to demonstrate the facial–palatal orientation
of the implant if the long axis or position of the original sleeve has been used to guide the implant drills in
creating the osteotomy. CBCT tangential and cross-
sectional views at both sites were evaluated in the
planning software.
The right lateral incisor site, based on the site dimensions,
would accommodate a tapered bone-level implant
(3.3 mm × 12.0 mm, Roxolid, SLActive; Straumann). It was
noted that an offset of 0.5 mm and an angle correction of
6° to the palatal aspect would be necessary (Figs. 6a & b).
Additionally, owing to the facial–palatal width of the ridge
at mid-height crestally and apically, ridge augmentation
would be required to eliminate a dehiscence at the time
of surgical placement of the implant.
Evaluation of the left lateral incisor site also determined
that an implant of the same type and specifications would
be accommodated by the site. The tangential view determined that no linear correction was needed (Fig. 7a), but
in the cross section, it was determined that an angular
correction of 6° to the palatal aspect would be required
10
Fig. 9: The upper removable part inserted on to the guide posts at each site and the cast coated with metatouch lubricant to prevent resin sticking to the cast
during fabrication of the surgical guide. Fig. 10: A 3.9 mm guide sleeve inserted over the upper removable part (URP), the cleat facing palatally.
38
2 2022
[39] =>
case report
11a
|
11b
Figs. 11a & b: The cleat on both guide sleeves covered in primopattern gel (a) and primotec splint resin adapted to the palatal side of the cast (b).
(Fig. 7b). No offset would be necessary on the left site.
Like with the bilateral site, because of the facial–palatal
width of the ridge at mid-height crestally and apically,
ridge augmentation would be required at or prior to the
time of surgical placement of the implant.
extension on to the buccal aspect of the teeth creates
a guide that will be stable intra-orally during osteotomy
preparation. The URPs were removed from the cast,
allowing removal of the surgical guide from the cast
(Fig. 12b).
On the cast, an offset guide post (0.5 mm) was placed
into the right site and a straight (no offset) guide post
placed into the left site (Fig. 8). A URP was placed over
both guide posts, and the cast was coated with metatouch (primotec) to prevent the resin that would be
added for fabrication of the surgical guide from adhering
to the cast (Fig. 9). A 3.9 mm guide sleeve was placed
over both URPs, the cleat positioned to the palatal side
of the cast (Fig. 10). Like with fabrication of the diagnostic
guide, primopattern gel was placed over the cleat on
each guide sleeve (Fig. 11a) and then a 2.5 cm length of
primotec splint resin was applied to the palatal side of
the cast (Fig. 11b). The splint resin was adapted to the
cleats and palatal and occlusal/incisal aspects of the
adjacent teeth on the cast to create the surgical guide
and then light-polymerised (Fig. 12a). Coverage of the
occlusal/incisal aspect of the adjacent teeth with slight
The patient presented for the surgical appointment, and
the consent forms were reviewed and signed by the
patient’s parent. Local anaesthetic was administered to
the sites in the buccal vestibule and palatally. A #15 scalpel blade was utilised to make an incision from the midfacial aspect of the right central incisor in the sulcus
and continued to the mesial aspect of the distal papilla
of the canine, and a full-thickness flap was elevated to
expose the facial aspect of the ridge at the right lateral
incisor site (Fig. 13a). The cortical plate was perforated
at multiple points at the facial ridge defect with a surgical bur. An OsteoGen Block (Impladent) was hydrated
with the INFUSE XX SMALL KIT (Medtronic), hydrated with
0.7 ml sterile water, divided into halves and placed over
each defect on the facial aspect of the ridge (Fig. 13b).
OsteoGen is a bioactive, resorbable non-ceramic calcium apatite crystal that is similar to human bone and is
12a
12b
Figs. 12a & b: The primotec splint resin adapted to the adjacent teeth, covering their occlusal/incisal surfaces to aid in stabilising the surgical guide when
inserted intra-orally (a). The light-polymerised surgical guide (b).
2 2022
39
[40] =>
| case report
13a
13b
14a
14b
Figs. 13a & b: The defect at the right lateral incisor site exposed by elevating
a flap in the area and bleeding points (a). An osseous graft placed to fill the
defect to be even with the adjacent ridge contours (b). Figs. 14a & b: The
defect at the left lateral incisor site exposed by elevating a flap in the area and
bleeding points (a). An osseous graft placed to fill the defect to be even with
the adjacent ridge contours (b).
carried by a bovine collagen created from the Achilles
tendon, allowing adaption to the defect as a malleable
material.4, 5 INFUSE, a recombinant bone morphogenetic
protein-2, has been shown to enhance the maturation
of the graft it is combined with, accelerating guided
bone regeneration with an increase in graft–bone contact.6–8 Combination of the two materials allows maintenance of the grafted space as host angiogenesis occurs
and stimulation of conversion to host bone. The graft is
placed in enough volume to be equal to the ridge contour of the adjacent teeth. The procedure was repeated
on the left incisor site (Figs. 14a & b). The flaps were
closed with #6/0 nylon sutures in an interrupted pattern
and the patient dismissed.
The patient returned four months after the graft placement, and a CBCT scan was taken to evaluate the graft
and ridge contours in cross section (Figs. 15a & b). Local
anaesthetic was again administered into the buccal vestibule and palatal aspects of the ridge at both planned
surgical sites. The surgical guide that had previously
been fabricated in-office was inserted intra-orally. A flapless surgical approach would be utilised. A 2.2 mm depth
stop drill for the 3.9 mm guide sleeve of the appropriate length for the implant that was planned at each site
was run through the surgical guide to depth. The surgical guide was removed, and a 2.0 mm direction indicator (DePlaque) was placed into each osteotomy and a
periapical radiograph taken to confirm the planned osteotomy in relation to the adjacent teeth (Figs. 16a & 17a).
The surgical guide was reinserted intra-orally, and the
osteotomies were enlarged with consecutive 1.5–2.2 mm
tapered depth stop drills of increasing lengths—6.0, 8.0,
10.0, 11.5, 13.0 and 15.0 mm—and then the next largerdiameter drill series was repeated with 2.0–2.8 mm
depth stop drills and finally a 2.8 mm diameter drill was
taken to 15.0 mm. The extra length was used to accommodate the 3 mm depth of the soft tissue using a flapless
protocol. The two implants were placed utilising the guide
sleeves to position them. The guide was removed, and
2 mm healing abutments were placed on both implants.
A periapical radiograph was taken of both sites to document the depth and direction of the osteotomy prior to
implant placement in relation to the adjacent teeth as well
as the depth of the osteotomy in relation to the ridge crest
(Figs. 16b & 17b). The patient was dismissed to allow for
implant osseointegration.
A post-surgical CBCT scan was taken and imported into
the planning software. The virtual planned implant cross
section was overlaid on to the cross section at the right
lateral incisor to verify that the surgical guide had been
able to achieve the planned position in relation to the
osseous anatomy (Fig. 18). Both the planned position of
the right lateral incisor and actual implant position were
identical, demonstrating that the in-office surgical guide
was accurate regarding the virtual planned position.
Additionally, the facial aspect of the ridge where the
graft had been placed eight months prior demonstrated
sufficient thickness of bone for long-term implant main
tenance. Evaluation of the left lateral site made similar
findings, demonstrating the accuracy of the surgical
guide in replicating the virtual planning (Fig. 19). Implant
healing and integration were complete, and the restorative phase of treatment could be initiated.
Conclusion
15a
15b
Figs. 15a & b: CBCT scan four months after grafting. Cross-sectional views
to verify the contour of the ridge at the planned implant sites: right lateral site
(a) and left lateral site (b).
40
2 2022
CBCT scans increase the information available when
planning implant placement by views that are not provided with traditional 2D radiographs. Utilisation of a
diagnostic guide to take the CBCT scan increases the
accuracy in the implant planning software, as it provides
references to where the implants may be placed in the
[41] =>
case report
16a
16b
17a
|
17b
Figs. 16a & b: Radiograph of the direction indicator placed into the right lateral
incisor site after use of the initial 1.5–2.2 mm tapered drills (a) and radiograph
following implant placement after the healing abutment was inserted on to the
implant (b). Figs. 17a & b: Radiograph of the direction indicator placed into
the left lateral incisor site after use of the initial 1.5–2.2 mm tapered drills
(a) and radiograph following implant placement after the healing abutment was
inserted on to the implant (b). Fig. 18: The virtual planned position cross section
of the right lateral incisor overlaid on to the cross section of the actual implant
placement, demonstrating clinical replication of virtual planning with the surgical
guide. Fig. 19: The virtual planned position cross section of the left lateral
incisor overlaid on to the cross section of the actual implant placement,
demonstrating clinical replication of virtual planning with the surgical guide.
contact
18
19
space that can be coordinated with the osseous anatomy.
Corrections can then be made in in-office fabrication of
the surgical guide that will be created on the cast used
to create the diagnostic guide.
Congenitally missing lateral incisors pose challenges
due to the limited facial–palatal dimensions of the ridge
related to lack of development that would normally
occur with tooth development at the site. CBCT planning
allows cross-sectional viewing of the intended site to
assess whether the width of the ridge will allow implant
placement or supplemental grafting will need to be performed. Often in lateral sites with congenitally missing
teeth, insufficient width is present, and grafting will
need to be performed either in conjunction with implant
placement or as a precursor to implant site osteotomy
preparation. The case presented involved a ridge that
would not allow initial implant stability at the sites,
necessitating osseous grafting to improve the ridge dimensions and site healing before implant site preparation could be performed. The corrected surgical guide
allowed planning in order to position the implant ideally
for the anatomy, taking into consideration the triangle
of bone in the premaxilla.
Editorial note: A list of references is available from the
publisher.
Dr Sean Meitner graduated from
Marquette University in Milwaukee in the
US after completing a tour of duty in
the US Navy, completed his certificate
and board examinations in periodontics
at Eastman Institute for Oral Health
at the University of Rochester in
New York in the US and remains a part-time
clinical professor in the Department of
Periodontology and Dental Implant Surgery at the university.
He has been in private practice in periodontics for more than
30 years in Pittsford in New York and is the developer of the
Guide Right protocol. He can be reached at swmeit4@gmail.com.
Dr Gregori M. Kurtzman is in private
general dental practice in Silver Spring in
Maryland in the US. A former assistant
clinical professor at the University of
Maryland, he has earned fellowships
in the Academy of General Dentistry
(AGD), American Academy of Implant
Prosthodontics, American College
of Dentists, International Congress
of Oral Implantologists (ICOI), Pierre Fauchard Academy,
Association of Dental Implantology and International Academy
for Dental-Facial Esthetics; masterships in the AGD and ICOI;
and diplomate status in the ICOI and the American
Dental Implant Association. He has been listed as one of
Dentistry Today’s leaders in continuing education since 2006.
He can be reached at dr_kurtzman@maryland-implants.com.
2 2022
41
[42] =>
| research
How clean do sterile implants
have to be?
Analysis and clinical relevance of factory-related
contaminations
Dr Dirk U. Duddeck, Germany
The initial phase of the biological response to a placed
implant is primarily determined by the implant’s surface
characteristics. The properties of any implant surface
are an essential factor of its non-irritant integration into
surrounding tissue structures.1 Undisturbed osteoblast
proliferation and osteoblast differentiation at the implant
surface depend decisively on the microstructure of the
surface.2 Since the 1980s, however, there have also been
growing demands for flawless cleanliness of the implant
systems used.3 In this context, it is a logical step not only
to look at current analytical techniques but also to take
a critical look at the clinical significance of avoidable
contamination on brand-new sterile-packaged implants.
for the analysis of particulate and film-like contaminants
on sterile-packaged dental implants. Back-scattered
electrons from the implant surface have typical energy
of up to 10 keV. The intensity of these signals depends
on the average atomic number of the sample material
in focus. Compared with titanium or zirconium, heavier
elements, such as iron or nickel, show more intense back
scattering so that corresponding image areas appear
bright (Fig. 1). In contrast, locations with lighter elements,
such as carbonaceous plastic particles, are displayed
darker than areas with titanium or zirconium (Fig. 2).
Imaging in the material contrast mode of a scanning
electron microscope (SEM) has proved to be very useful
The image generated by the back-scattered electron
detector thus allows conclusions regarding the distribution of foreign materials or elements in the imaged
section of the implant surface. For a valid assessment
of the particle load of an implant, a SEM image of the
entire implant should always be acquired. In order
1
2
SEM imaging
Fig. 1: Metal particle of iron, chromium and nickel on the surface of a titanium implant (Adin). SEM 2,500× magnification. Fig. 2: Numerous organic particles
on the entire implant shoulder (OCO Biomedical). SEM 500× magnification.
42
2 2022
[43] =>
research
|
3
Fig. 3: Factory-related contamination of entire implant threads (Ritter Implants). Full-size SEM image of the implant electronically compiled from hundreds
of single images at 500× magnification using the material contrast technique (back-scattered electron mode).
to depict details at high magnification without pixelation,
up to 600 individual SEM images must be electronically
stitched together in high resolution for these comprehensive overview images. The resulting SEM image in material
contrast provides a detailed overview and allows the
quantitative detection of individual particles (Fig. 3).
Identification of impurities
Energy-dispersive X-ray spectroscopy (EDS) provides
information about the exact elemental composition of an
impurity and thus provides hints about its origin. When
fast electrons hit the sample surface, X-rays are emitted
inter alia. The energy of these X-rays is characteristic of
each chemical element present in the sample or contaminant. The energy and the number of X-ray quanta emitted
in this way are measured over a defined time and output
as an EDS spectrum.
Time-of-flight secondary ion mass spectrometry (ToF-SIMS)
provides even more precise information about the chemical
composition of an impurity. The method provides information on the atomic and molecular structure of the uppermost monolayers of a substrate on an analysis area of
500 × 500 µm2 with sensitivity in the parts per million range
and a lateral resolution of up to 100 nm. Comparison of
the spectra with known substances allows precise material
determination of the respective contamination (Fig. 4).
Too many implants of inferior quality
In a study from 2017 to 2020, the CleanImplant Foundation,
a non-profit organisation based in Berlin in Germany, analysed sterile-packaged implants from various manufacturers. In cooperation with Charité—Universitätsmedizin
Berlin in Germany, a total of 14 ceramic implant systems
and 86 implant systems made of titanium and its alloys
were examined under the SEM. The protocol of analysis
used in this quality assessment study was published in
a 2019 pilot study by Duddeck et al.4 The samples were
examined for contaminants under the SEM in a testing
laboratory accredited according to the DIN EN ISO/IEC
17025:2018 standard. For the study, the implants were
unpacked in a particle-free environment (Class 5 clean
room according to the DIN EN ISO 14644-1 standard) and
subsequently scanned in the same clean room to exclude
any laboratory interference with the test samples. To an
unexpected extent, that is, in more than one-third of the
samples examined, the analysis revealed factory-related
residues and contamination. SEM imaging identified not
only carbonaceous contaminants in significant quantities
(Fig. 5) but also foreign metals such as chromium, iron,
tungsten, nickel, copper and tin. Implants made of titanium
and zirconium dioxide were affected, regardless of price,
market position, size of the manufacturer or production
location. Subsequent to the SEM/EDS analysis, selected
contaminated implant samples were additionally examined by a detailed ToF-SIMS analysis. Polysiloxanes, that is,
synthetic polymers (Fig. 6), thermoplastics and residues of
dodecylbenzene sulphonic acid were found on the implant
surfaces. This cytotoxic surface-active chemical is one of
the most aggressive components in many cleaning agents
and is classified as a hazardous substance.
Clinical relevance
In particular, organic carbonaceous foreign materials
have been associated with initial bone loss or even
peri-implantitis in the literature.5 Increased osteoclast
activity associated with a possible foreign-body reaction,
resulting in peri-implant bone resorption, could be the
cause.6 Exposure to foreign particles induces macrophages
to secrete tumour necrosis factor- , interleukin-1 , interleukin-6 and prostaglandin E2, which in turn stimulates
the differentiation of osteoclast precursors into mature
osteoclasts. This response would explain clinically striking
bone loss during the initial healing phase or the early
onset of peri-implantitis. All particles found in the study
2 2022
43
[44] =>
| research
Independent test procedure provides
safety for dentists
4
Fig. 4: Time-of-flight secondary ion mass spectrometry instrument (tascon).
appear to have survived the wet chemical cleaning procedures in the manufacturing process or contaminated the
implant in the handling and packaging process. Especially
foreign particles with a size of 0.2–7.2 µm are classified as
pro-inflammatory.7–9 If they detach from the surface during
the insertion of the implant, macrophages take up the
particles by phagocytosis and subsequently release proinflammatory cytokines. The result is an expanding zone
of soft-tissue damage and inflammation.6
All implants examined in the recent quality assessment
study, including those significantly contaminated, showed
the CE mark on the packaging or carried the U.S. Food and
Drug Administration logo for marketing clearance on the
US market. With the introduction of a worldwide quality
seal for clean implants, the “Trusted Quality” mark, the
CleanImplant Foundation addressed this issue years ago.
Criteria for implants that are largely free of foreign particles
were defined in a guideline in 2017 and published as
a consensus paper involving renowned scientists such
as Prof. Tomas Albrektsson, Prof. Ann Wennerberg,
Prof. Hugo de Bruyn, Prof. Florian Beuer, Prof. Jaafar Mouhyi,
Dr Michael Norton, and Dr Luigi Canullo.10 These scientists also form the foundation’s scientific advisory board,
which ultimately decides on the awarding of the abovementioned quality seal. For the testing procedure of an
implant system, a total of five samples are included.
A maximum of three implants are obtained from the respective manufacturer and at least two implants from
implantology practices. This procedure ensures random
selection during sampling and reliably prevents the acquisition of potentially specially treated test samples. The independent and thorough analysis of the samples must be
renewed every two years in specially accredited testing
laboratories. The same protocol of analysis described in
the Journal of Clinical Medicine in 2019 is to be applied.4
Before the seal can be awarded, proof of a multi-annual
survival rate of at least 95% must be provided for the respective implant system, as well as proof of the absence of
a significant number of particles. The results of the analysis
and the sufficiently reliable clinical documentation of a system are always checked independently by two members of
the scientific advisory board in a peer-review process and
compared with the requirements of the guideline. Not until
all criteria are met can an implant system be awarded the
seal for a period of two years. To date, the following systems have been awarded the foundation’s “Trusted Quality”
seal after rigorous peer review (in alphabetical order):
AnyRidge and BLUEDIAMOND (MegaGen), blueSKY
(bredent medical), CONELOG (CAMLOG), ICX-PREMIUM
(medentis medical), In-Kone (Global D), Kontact S (Biotech
Dental), NobelActive (Nobel Biocare), Patent/BioWin!
(Zircon Medical/Champions), Prama (Sweden & Martina),
SDS1.2 and SDS2.2 (SDS Swiss Dental Solutions), T6
(NucleOSS) and UnicCa (BTI). Other implant systems are
currently undergoing the testing process of the foundation.
Discussion
5
Fig. 5: Carbonaceous particles (polysiloxanes) on a titanium implant at the
implant apex of a titanium implant (T3, ZimVie). SEM 500× magnification.
44
2 2022
The evaluation of the CleanImplant quality assessment
study revealed both light and shadow with regard to the
current quality level and sustainable quality control of
dental implants. This creates a problem for the careful
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|
Sum of:
Ti+, TiO, TiO2
Polysiloxan
6
Fig. 6: Time-of-flight secondary ion mass spectrometry detection of polysiloxane on a titanium implant.
practitioner: he or she usually does not know whether
the implant system of his or her choice has already been
contaminated at the factory. This is because information or
warnings about possible foreign particles that could cause
peri-implantitis or about residues of cleaning agents is not
provided on the implant packaging or on the package insert.
metal-free alternative and it has been demonstrably contaminated by packaging residues across batches. In that
case, he or she is, unwittingly, doing a disservice to precisely those patients who place great value on particularly
biocompatible materials in their bodies. In a remarkable
article decades ago, Wahl and Tuschewitzki employed
an apt term for factory contamination of dental implants:
they referred to it as “sterile dirt”.3
Conclusion
The placement of foreign metals and packaging residues
or cleaning agent residues in the osseous site of an implant can lead to an uncontrolled foreign-body reaction,
resulting in bone recession and even the loss of implants.
Contamination of sterile-packaged dental implants can be
largely avoided by the manufacturer. However, if individual
manufacturers, when asked, say that they consider the
amounts of foreign particles found on their products to be
harmless according to their own judgement, it would be
appropriate for them either to scientifically verify this or
to warn users and patients accordingly.
7
Fig. 7: Significant plastic material (polyacetal) on the shoulder of a ceramic
implant (vitaclinical, VITA Zahnfabrik) from abrasion from the packaging.
Unfortunately, implant systems do not have consistent,
comparable quality, as summarised in 2020 by Dr Norton,
a past president of the Academy of Osseointegration,
in an opinion piece in the British Dental Journal that is
well worth reading.11 The use of factory-contaminated
implants not only may lead to inferior clinical outcomes
but also carries the risk of legal implications. The problem
of possible factory-related contamination concerns not
only implants made of titanium or titanium alloys but
also ceramic implants, as scientists from the universities
of Gothenburg, Malmö and Berlin impressively described
in a study published in 2021.12 The bottom line of the study
is that just because the material of ceramic implants is
white does not necessarily mean that they are clean (Fig. 7).
Suppose a clinician chooses a ceramic implant as a
Editorial note: List of references is available from the publisher.
This article was first published in implants—international
magazine of dental implantology, Vol. 23, Issue 2/2022.
about
Dr Dirk U. Duddeck studied biology
and dentistry and specialised in oral
implantology. He is a guest researcher
at Charité—Universitätsmedizin Berlin
and founder and head of the non-profit
organisation CleanImplant Foundation,
both in Berlin in Germany.
contact
Dr Dirk U. Duddeck, +49 30 22187237
duddeck@cleanimplant.org, www.cleanimplant.org
2 2022
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| trends & applications
Digital dental shade m
easurement:
Practical applications with
a state-of-the-art colorimeter
Dr Jordi Manauta, Dr Walter Devoto, Daniele Rondoni, Dr Anna Salat, Prof. Zsolt M. Kovacs &
Prof. Angelo Putignano, Italy/Hungary/Spain
many others. In a nutshell, colour is psychophysics. Misinterpreted colour science concepts and their incorrect
application are often found in the dental literature. It is
often difficult to explain complex colour science concepts
relevant to the dental field using easily understandable
words. In the following pages, we will try to translate
some of these concepts to more easily understandable
language.
Dental shade determination is very important and requires extreme precision in measurement, computing
and execution; in other words, the definitive restoration
has to be perfect to the eye of the clinician, technician
and patient. This task can be done digitally or analogically.
1
Fig. 1: VITA classical A1–D4 shade guide with the pink additions to improve
its contextuality and increase its efficiency in shade matching.
Introduction
In its vast complexity, colour science embraces physics, mathematics, geometry, measurement, perception,
chemistry, optics, art and human psychology, among
Shade determination by eye is, for obvious reasons, the
most commonly used shade taking method among clinicians. Despite this, the scientific community seems not
to appreciate it, owing to its lack of objectivity, as several factors can affect the way we perceive dental shade.
However, it has the advantage of being the ultimate
means of judging dental shade regardless of the shade
determination method used, since what matters the most
is the appearance of the definitive restoration in place.
Despite being available for more than 30 years, digital shade determination methods only became popular
when their measurements found application in clinical
and laboratory situations. Without digital shade determination having a true benefit in clinical outcome, dentists
and technicians have tended to rely on shade determination by eye.
Dental shade guides
2
Fig. 2: VITA classical A1–D4 shade guide with the cervical and incisal
portions trimmed.
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2 2022
For a very long time, stock shade guides have been the
first resource for dental shade determination, and for
several reasons, there has always been an excuse to
improve them or a hack to make them more reliable.
The VITA classical A1–D4 shade guide (VITA Zahnfabrik)
has always been the default whenever other methods
have not worked. VITA shade matching has always been
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trends & applications
|
linked to artistic skills and a deep knowledge of the
materials and their specific instruments, such as shade
guides.
Common do-it-yourself (DIY) strategies have been proposed throughout the years, in order to optimise the use
of stock shade guides. For example, adding an increment
of pink composite gives the shade guide a more realistic
context, making the sample look more like a real tooth
emerging from the gingiva (Fig. 1). Although this does
not solve the core issue of stock shade guides, it slightly
helps focus attention on the full tooth. However, this hack
has had limited success. Commercial pink shade guide
holders of various brands have been proposed to this
end, but they are easily fabricated by any clinician with
acrylic resin.
Another DIY method aiming to optimise stock shade
guides and increase shade matching precision is trimming of the cervical and incisal portions (Fig. 2), leaving
only the area where the shade is more even throughout the surface. This eliminates all distractions in shade
matching, as for many people, the translucent mass in
the incisal area and the opaquer cervical area are distracting rather than helpful. This area trimming makes the
shade samples look more like they are of solid shades.
This hack not only has had limited success but also gives
rise to other problems, one of which is that the useful
area of shade reference, which is the centre of the shade
guide, is significantly decreased.
Personalised shade guides are easy to self-manufacture
using the same materials as those used for the actual
intra-oral restoration. These have been proposed as the
ultimate solution, but have several problems. The first
problem is not related to the shade guide itself but to
the end user. Self-fabricating several samples is timeconsuming for most users, especially if one considers
3
Fig. 3: Two-layer personalised shade guide. This makes composite layering
more predictable, but has limitations and some problems.
the high number of sample combinations required for a
functional sample set, explaining the success of standard shade guides such as the VITA shade guide, which
require little to no handling before use. Making a perfect
personalised shade guide (bubble-free, of adequate
thickness and of uncontaminated composite) requires
skill and experience, regardless of the personalised
shade guide system used, to obtain perfect shade correspondence with the stock shade guide and to avoid
discrepancies with the definitive restoration (Fig. 3).
The personalised shade guide tends to be of different
thickness compared with that of the actual restoration,
changing the real shade and perceived shade greatly,
and thus obtaining poor shade matching for both ceramic and composite restorations (Fig. 4). Furthermore,
personalised shade guides lack context, since there is
no gingiva or neighbouring teeth, changing the optical
appearance.
4
Fig. 4: Thickness of the personalised shade guide compared with ideal thickness in an intra-oral restoration. The thickness is not matched optimally.
2 2022
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[48] =>
| trends & applications
5
6
Fig. 5: The L*a*b* colour space. L = light–dark, a– = green; a+ = red; b– = blue; b+ = yellow. L = light–dark and L*C*h* color space where L = light–dark,
C = chroma, h = hue expressed in degrees. Fig. 6: Graphic representation. (albeit highly inaccurate) for didactical purposes, of the colour mixture of the
L*a*b* dimensions to obtain a dental shade (i.e. A3).
Why switch to digital colorimetry?
It is impossible to precisely transfer complete information about shade using words because the perception
of even a very specific shade differs between people.
Digital colorimetry has many advantages compared with
the visual method:
– clear and objective language;
– context of neighbouring structures;
– every high repeatability;
– simplicity in obtaining measurements; and
– ease of standardisation.
7
Fig. 7: Matching the reference shade against the sample shade.
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2 2022
The L*a*b* colour space overcomes language barriers, enabling anyone to easily communicate shade and
shade differences (Fig. 5). The L* axis runs from light
to dark, 100 being white and 0 black. The a* axis runs
from red to green, a positive value indicating red and
a negative value green. The b* axis runs from yellow to
blue, a positive value indicating yellow and a negative
value blue.
When graphically located in the full L*a*b* colour space,
the human dental colour space looks like a small
irregular-shaped bean (Figs. 6–8). This sub-space is
extremely important for our profession. It is mainly
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trends & applications
|
located in the yellow–red and bright area and is very low
on chromaticity, touching the neutral axis in almost all of
its spectrum. This space is composed of very light beige
pastel colours.
Rizzi et al. outlined the human dental colour sub-space.1
They found that the best colour difference formula that
behaves the most isotropically and uniformly along all
axes of this sub-space was the formula ΔE94.1 For digital
colorimetry, knowing the content and boundaries of the
dental colour space precisely makes the design of the
machinery, calculations of layering and ceramic mixing,
calibration of the shade measuring devices and hardware
specifications more specific.
OPTISHADE StyleItaliano
Nowadays, it is easy to determine dental shade in a
few seconds with a very compact and portable device,
OPTISHADE StyleItaliano (Smile Line), and in an incredibly easy way that is not dependent on the clinician’s skills.
Learning how to use the device is easy and can be done
by the dentist, the assistant or the technician, simplifying
the work of every member of the team.
The OPTISHADE StyleItaliano colorimeter was launched
in 2021 specifically for dental application. It works
with Apple devices via an app and can be disinfected
(Fig. 9). Its high precision (ΔE94: 0.2–0.4) and accuracy
in shade measurement in the L*a*b* and L*C*h colour
spaces allow for real-time cross-checking of data with
several preloaded shade guides, such as the VITA
classical A1–D4 shade guide and VITA Toothguide
3D-MASTER.
8
Fig. 8: When graphically located in the full L*a*b* colour space, the dental
colour space looks like a small irregular-shaped bean.
In an era in which communication is crucial, this device
exploits the complete sharing capability of modern
mobile devices. In a matter of seconds, it is possible to
measure the shade of a tooth and communicate the
shade measurement to others, all with the safety and
stability of the Apple platforms.
Shade matching by replicating
the same scenario
When we have an accurate and reliable method for
shade matching, we should obtain the same numerical values when measuring the same subject. Our
task consists of repeating the same scenario for
9
Fig. 9: The OPTISHADE StyleItaliano dental colorimeter provides accurate and precise shade measurements. The external camera attaches to Apple devices.
2 2022
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[50] =>
| trends & applications
10
Fig. 10: Scene reproduction in practical application.
every measurement; in other words, shade should be
measured using a device that has minimal discrepancy
in its measurements (intra-device precision) and minimal discrepancy compared with other devices of its
kind (inter-device precision), with the same background and centring and positioning, with the teeth
clean and hydrated, and with no external light contamination.
11a
11b
11c
11d
11e
11f
Fig. 11a: Same tooth, same surface (clean), same time frame, same positioning, same device, same background. Shade difference: 0.12. Reliable measurement. Fig. 11b: Same tooth, same surface (clean), *different time frame, same positioning, same device, same background. Shade difference: 0.29. Reliable
measurement. The asterisk indicates the parameter critical to the reliability of the measurement. Fig. 11c: Same tooth, same surface (clean), *different time
frame, same positioning, *different device, same background. Shade difference: 0.31. Reliable measurement. The asterisks indicate the parameters critical
to the reliability of the measurement. Fig. 11d: Same tooth, same surface (clean), same time frame, same positioning, same device, *different background.
Shade difference: 1.89. Unreliable measurement. The asterisk indicates the parameter critical to the reliability of the measurement. Fig. 11e: Same tooth, same
surface (clean), same time frame, same positioning, same device, *different background. Shade difference: 0.89. Unreliable measurement. The asterisk indicates the parameter critical to the reliability of the measurement. Fig. 11f: Same tooth, *different surface (not clean), same time frame, same positioning, same
device, same background. Shade difference: 2.32. Unreliable measurement. The asterisk indicates the parameter critical to the reliability of the measurement.
50
2 2022
[51] =>
trends & applications
12a
12b
12c
|
12d
Fig. 12: Ceramic layering predictions: desired shade (a), substrate (b), raw restoration (c), restoration integrated with the substrate (d).
With these simple parameters, it is possible to reproduce the scene accurately and obtain a reliable shade
measurement (Fig. 10). The user should be able to easily
recreate the same scene. When measurements are taken
from the same subject, the resulting values must fall
under a 0.4 ΔE94 threshold. If measurements with higher
values are obtained, it is necessary to analyse what may
have gone wrong in the standardisation process, such as
the tooth background, device positioning, tooth cleaning
or tooth hydration level (Figs. 11a–f).
13
Fig. 13: Obtaining a good shade match for the integrated restoration.
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[52] =>
| trends & applications
14a
14b
Fig. 14a: Failed anterior crown. Fig. 14b: Acrylic temporary restoration.
Digital ceramic mixing and layering predictions
Among the applications for OPTISHADE are ceramic
layering and mixing predictions, composite layering recipe
calculations, bleaching tracking and material quality
control, to mention just a few. To make the system more
versatile, OPTISHADE is compatible with an integral
ceramic mixing and layering system (Matisse) in such
a way that the personalisation and shade matching of
the aesthetic restorations and ceramic prosthetic work
reach perfection.
One of the greatest challenges in dental shade is the
integration of the single-unit anterior restoration. This
has been demonstrated to be very reliable when done
with precise mathematical computation, particularly with
ceramic mixing and layering.
For the best outcome of ceramic mixing and layering software predictions, it is essential to use a high-precision
shade matching device. OPTISHADE has been demonstrated to be the best for this application. Two perfect
shade measurements must be provided (Fig. 12):
– Desired shade: This is the target shade. It is calculated from the nearby healthy teeth or nearby attractive
restorations.
– Substrate shade: This is the shade of the prepared tooth
to which the restoration will be cemented. Since this
may modify the final shade of the restoration, it must
be considered.
15
16
17
Fig. 15: Desired shade (neighbouring tooth). Fig. 16: Measurement of the
shade of the maxillary lateral incisor. Fig. 17: Taking the shade of the
prepared tooth into account.
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2 2022
With all this information, it is possible to calculate several layers of a restoration that, together with the stump,
will generate a final shade. The raw restoration, that is,
before integration and in-context try-in, has a different
appearance from the desired shade. It is out of context
and thus without the influence of the substrate. With the
raw restoration, it is possible to modify the unfavourable
substrate to be very similar or equal to the desired shade.
The shade of the raw restoration is calculated mathe
matically, in order to obtain the right layers and opacities
to balance the chromatic change that will occur when the
restoration and substrate are integrated. The integrated
restoration, that is, the restoration seated on the substrate in the mouth, whether permanently cemented or
attached with a try-in agent, must have the desired shade
as a final result or at least be very close to it (Fig. 13).
Single anterior crown: A clinical case
Probably the application where digital shade determination stands out and is the most useful is in the creation
of single aesthetic crowns in the anterior region. In this
[53] =>
trends & applications
Substructure
|
Dentine receipes Skin enamel
(aprismatic enamel)
Substructure material
IPS e.max Press HO 0
Thickness of framework
0.3 mm (cervical area)
0.3 mm (middle area)
0.3 mm (incisal area)
Cervical area
Cervical area
IPS e.max Ceram
IPS e.max Ceram
D3 x3
Power Incisal 2
IPS e.max Ceram
PB L4 x6
Mamelon salmon x1
Instructions
Stain the framework by making changes to
red (a*) or yellow (b*)
Estimated required staining
Δa* = 1.77; Δb* = 11.03 (cervical area)
Δa* = 2.28; Δb* = 7.61 (middle area)
Δa* = 1.09; Δb* = 1.53 (incisal area)
Estimated required staining with
VITA Toothguide 3D-Master
2M1 (cercival area)
1M1 (middle area)
OM1 (incisal area)
18
Middle area
Middle area
IPS e.max Ceram
IPS e.max Ceram
CT orange x1
Power Incisal 3
IPS e.max Ceram
White-blue x1
Incisal area
Incisal area
IPS e.max
IPS e.max Ceram
Opal Effect 4 x2
Power Incisal 3
IPS e.max Ceram
D C1 x3
Table 1
Fig. 18: Shade selection of the different regions in Matisse. In red, the three regions of the desired shade (dentinal shade). In blue, the three regions of
the preparation shade. Table 1: Ceramic mixing strategy for a perfect personalised recipe. The numbers in blue indicate the units for mixing, where a unit is the
minimal amount of ceramic to be mixed. Units can be large or small as long as all the units are the same. Use of a quality ceramic portioner is recommended.
clinical case, the crown on implant #11 had failed mechanically and aesthetically (Fig. 14a). The ideal situation
for such a case is to restore it in a single try, without the
technician ever seeing the patient and of course avoiding
any kind of repetition. This can be achieved by providing the OPTISHADE measurements of the desired shade
and the stump shade (Fig. 14b).
nologies mentioned in this article, besides being precise,
are now more user-friendly, allow easy sharing and saving of data, are more universal and do not require any
hardware updates.
The desired shade in this case was found in the neighbouring
tooth. It is important to have the measurement done with
the temporary restoration seated and the tooth perfectly
hydrated (Fig. 15). The shade of the maxillary lateral incisor
was also measured (Fig. 16). The teeth in the same arch
might look similar or even identical, but they are generally
of different shades. The shade of the stump has to be taken
into consideration, using an individual measurement that
is included in the calculations for the restoration (Fig. 17).
The OPTISHADE shade measurements are uploaded to
Matisse, and these, along with the type of restoration,
are crucial for planning a perfect raw restoration (Fig. 18).
Thereafter, the ceramic is mixed according to a perfect
personalised recipe provided by Matisse (Table 1). The
definitive crown showed very good integration (Fig. 19).
This was achieved in only one attempt.
Conclusion
Digital shade determination removes the subjectivity of
the eye. As long as the measurement is correctly taken,
the colorimeter cannot be fooled like the human eye can.
Communication using numbers is the most precise way
to define a shade. With precise data, we can calculate
ceramic mixing, layering and much more. The new tech-
19
Fig. 19: Definitive crown.
contact
Prof. Angelo Putignano is currently
head of the department of restorative
dentistry and endodontics and dean of
the school of dentistry at the Università
Politecnica delle Marche in Ancona in Italy.
He is a co-founder of the StyleItaliano
community. He can be contacted at:
infocourses@styleitaliano.com.
2 2022
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[54] =>
| practice management
The real cost of an analogue impression,
compared with a digital one
Dr Naren Rajan, USA
Digital dentistry is a major cost, and a sound investment
is dependent on realistic return on investment (ROI) planning. What sort of offset costs can be achieved? Can you
match your ROI with patient care?
Thousands of dentists have already put intra-oral scanning equipment through its paces—day in and day out.
I’ve been asked to reflect on the following question: was
it worth spending the money when you bought into digital
impression technology?
There is no extra laboratory work that needs to be done
before the end of the day, no racing to the UPS or the
FedEx box. We noticed that right away, and that is one of
the prime advantages of moving to intra-oral scanning for
a dentist who is not currently doing so.
The bulk of savings is in laboratory
turnaround time
The second thing is the improvement in turnaround time
with the laboratories. Before, we would routinely wait for
two full weeks for a restoration to come back to our office.
The dental office is based on the East Coast of the US, but
often we use laboratories on the West Coast.
Now, if I scan, say, on a Monday morning, the restoration
arrives on Wednesday morning for that model. For our
routine procedure, which is between one and three units,
we produce all of them without any physical models.
Fig. 1: Comparison of polyvinyl cost versus scanner cost. The cost saving
reflects the saving on polyvinyl only. It does not include staff time, staff
efficiency, shipping savings or increased revenue due to higher case acceptance. This cost offset calculation is just an example. Please contact your
local 3Shape reseller for financing options.
The financial impact of digital impressions
on my business
I think that from a financial standpoint, for restorative dentistry, the greatest advantage was the efficiency of utilising
our team members in the office. Many obligated duties for
managing the physical impressions were essentially gone
overnight! Before, we were taking impressions all day long,
and there was a team member whose responsibility was
to disinfect the impressions and manage the prescription
slips, the shipping, the return date, pouring the opposing
models and whatnot. Simply not having to do that directly
equates to a significant savings because we can now
manage that team member’s time more efficiently. That
team member can move on to the next patient.
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2 2022
Taking advantage of the digital workflow in that way has really helped the efficiency of our practice and our business.
I shared that feedback a couple of years ago with 3Shape
when the company was working on the ROI calculator:
that is the bulk of the financial savings that I can attribute to
the TRIOS. These financial benefits can be gained by any
dentist within the first couple of months.
What growth to expect after starting
with intra-oral scanning
I know that our clinic has grown every year since we have
introduced this technology and that there is a component
of the incorporation of this technology that is part of that
growth. I share that information with dentists in my area.
I could figure out percentages for my own clinic, but I can
tell you from patient visits that I think we are more productive actually. I am working more days now, coming out of
the pandemic, but prior to the pandemic, I was working
fewer clinical days but producing more revenue than I had
in the previous years.
My most enjoyable year in practice was 2019, prior to
the current world difficulties, when we really were firing
on all cylinders by incorporating this technology. We were
doing at least one to two reconstructive cases digitally per
month, and it was a very enjoyable way to practice and
it was profitable.
[55] =>
© Robert Plociennik/Shutterstock.com
Using the technology goes far beyond just an impression
replacement when you look at the ROI calculator, but even
if the dentist is only focused on acquiring the TRIOS as
an impression replacement, it can be asserted that buying
a TRIOS will save him or her money.
My experience with offsetting costs
when purchasing my dental 3D scanner
In my one-dentist clinic, I was spending about US$500 or
US$600 a month on polyvinyl impression material prior
to buying a scanner. When I bought my first scanner, the
TRIOS 2, I think the payment on the scanner was US$700
or US$800 a month. Thus, there was already a cost offset
from not having to buy the polyvinyl (Fig. 1). A dentist considering acquiring the technology has to figure out what
it is going to cost per month, because most dentists are
going to finance it through their reseller. The subscription
cost also needs to be added on top of that.
In some cases, the dentist may be spending a few dollars
more on his or her TRIOS investment, initially at least. However, this does not consider the cost savings of the time benefits that I mentioned, the savings from utilising the team with
greater efficiency, rather than spending payroll on a team
member pouring models and making UPS labels and things
like that. When the dentist first introduces the scanner, it is
almost a one-to-one transfer, and I do not think it will cost the
dentist any extra to move to this technology, but then as he
or she really starts utilising it and leveraging the other tools
that are included, that is when he or she will really start to see
many of the advancements and the savings—the true ROI.
The time you spend as a dentist
is a key cost factor
If I was looking at this afresh, it would be difficult to imagine that
buying this piece of technology would save me US$100,000,
practice management
|
US$200,000, US$300,000. However, from the experience that I
have had, I know that it has saved me money and that it has helped
grow my practice and my reputation in the dental community.
How my team adjusted
to the new impression technology
My dental assistant is over 60, and she has been in dental
assisting for 40 years. She was able to pick up this technology within the first couple of months. She manages the
calibration and the 3Shape Dental Desktop platform, she
handles the management of case orders on a daily basis,
and she can copy and edit orders and things like this. She
was able to learn how to use the system, and she is a more
experienced person with a vast analogue background.
It is very easy to use and share data. When patients come
in, we will take the smile design photographs, and I will bring
these into TRIOS Smile Design and see whether the gingival
levels are where we want them or see whether the crowns are
where we want them. I take screenshots of this or short videos
and send these to the orthodontist. The orthodontist is always
pleased with the level of data I provide and with the level of
communication with patients enabled by this technology.
about
Dr Naren Rajan, who graduated with
honours from Rutgers School of Dental
Medicine in Newark in New Jersey
in the US, is a leader in the education
of digital techniques in dentistry
and lectures nationally on the topic.
In practice for over 15 years, Dr Rajan
focuses on incorporating digital techniques
into all aspects of general practice. He
believes in finding the best combination of traditional techniques
and cutting-edge advancements to improve patient outcomes.
2 2022
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[56] =>
| industry report
Review of Aoralscan 3
The latest intra-oral scanner by SHINING 3D—
the best low-cost intra-oral scanner?
Dr Ahmad al-Hassiny, New Zealand
There are no loading screens between each scanning stage
during the scanning workflow, making the workflow fast
and efficient. Very brief processing occurs when switching
between jaw scans, but this is barely noticeable. Instead,
the majority of the processing occurs after all scans have
been completed. This final post-processing took about
3–5 minutes for most cases, which is about average across
all scanners, on our high-performance laptop.
Scanner size and ergonomics
Aoralscan 3 is super-ergonomic and a huge improvement
on the Aoralscan 2. It fits comfortably in the user’s hand
and has a narrow scanning tip that makes it enjoyable to
scan with.
1
2
Figs. 1 & 2: Aoralscan 3 is one of the smallest scanners on the market.
Aoralscan 3 was released on 12 September 2021. It is an
affordable, scanner-only device, but comes with much better software than most Chinese intra-oral scanners (IOSs)
that the Institute of Digital Dentistry in New Zealand has
reviewed—in fact, better software than many mainstream
scanners too.
Scanning speed
Aoralscan 3 is a high-performance scanner. It is very
fast and provides a smooth scanning experience. It can
be considered one of the best Chinese scanners on the
market. The scanning process is efficient, and the artificial
intelligence (AI) is excellent.
56
The scanner weighs 240 g, making it one of the
lighter scanners on the market. Having dimensions of
281 × 33 × 46 mm, it is one of the smallest IOSs on the
market in 2022 (Figs. 1 & 2).
The scanner has some excellent added benefits, such as
a remote control function built into the scanner using a
motion detector, similar to Medit i700 and TRIOS. The remote control feature is well executed in the software. This
feature enables navigation of the software without touching
the computer, and it is effortless. The user double-clicks
the scanner button to progress through the workflow (jaw
scans) or clicks and holds the button to access a pop-up
menu with four options—“next”, “back”, “delete” or “view
the model”—and choses the desired option by waving the
scanner in one of four directions.
Full-arch scanning
This scanner has impressive scanning speeds, especially
given its very low cost. Considering scanning speed alone,
it competes with much more expensive scanners on the
market, such as Medit i700, TRIOS and iTero. We achieved
full-arch scans easily within 30–35 seconds.
Aoralscan 3 handles full-arch scans very well. It has an impressive scanning speed, impressive AI and an inbuilt fan that
prevents fogging and enables long periods of uninterrupted
scanning. The scanner picks up when it is stopped quickly and
is used with a similar scanning protocol to all other scanners.
It is equipped with intelligent algorithms to make the
scanning process easier and faster. Soft tissue is removed
automatically and accurately, and bite registrations are fast.
The scanner quickly finds its place again when the scanning is paused and restarted.
Accuracy
2 2022
Regarding accuracy, no research exists on Aoralscan 3, as
is the case for most new scanners. The technology is simply outpacing research. I have personally used the scanner
[57] =>
industry report
3
|
4
Figs. 3 & 4: The LED ring shows the scanning and connection status.
to fabricate crown and bridge restorations within my clinic
with no accuracy problems.
The institute tests all scanners on the market and compares scans of the same tooth preparation using different
scanners. We could not see a significant deviation in accuracy when comparing scans taken using Aoralscan 3 to
those taken with other IOSs and even a laboratory scanner
(using Geomagic Control software).
However, there is a clear difference in the detail of the
rendered colour scan. The Aoralscan 3 scans are a little
less detailed. It is not the worst colour scan rendering we
have seen, but it is also not the highest quality (Figs. 7–10).
None of this colour data is used in the manufacture of a
crown though. The colour rendering is just a nice way to
see the scan in a more realistic way and see the gingiva and
margins rather than in a single colour.
The scanning image fabricated by the Aoralscan 3 software has a realistic but not lifelike appearance. The scans
typically have quite high exposure, even when brightness
calibration is carried out, and translucent areas (incisal
edges) appear grey sometimes. After a refinement phase
of the workflow, the scans are processed. After processing, some artefacts are taken care of by the software, and
the final images look more realistic.
5
Overall Aoralscan 3 performs very well for various indications, including single crowns, implant scans, edentulous
sites and deep preparations (Figs. 11 & 12). We tested full
arches, quadrants, metals and edentulous areas, and it did
a good job regardless. It also has a 22 mm scanning depth,
which can be useful for scanning narrow or deep spaces.
Using the scanner properly and controlling the scanning field
correctly will result in a good scan. Poor usage will result in
poor scans. Just like any other scanner, the operator is the key.
One nice workflow feature we liked was that, as soon as the
user finishes the bite registration (which is very quickly aligned
by the software), the scanner automatically shows a heat map
of the occlusion without having to click on a menu. This is very
useful and is a great workflow improvement over other IOSs.
Software
The software that runs Aoralscan 3 is called Dental
Launcher. The program is installed by running the app on
the USB flash drive with the scanner.
The Aoralscan 3 software is easily the best out of all Chinese
scanners tested by the institute so far. Frankly, it is better
than many scanners on the market. It is very impressive
for an affordable IOS.
6
Figs. 5 & 6: Examples of scans taken with Aoralscan 3.
2 2022
57
[58] =>
| industry report
7
9
8
10
Figs. 7–9: The same preparations were scanned on the same day with six different scanners. Fig. 10: Tessellated mesh with all the vertices of the scans
compared. The CEREC Primescan and Medit i700 scans show detail in greater complexity, contributing to a better-rendered result in the colour scan.
The software is modern-looking, easy to use, simplified
and aesthetic and has many excellent features. The software is intuitive and efficient. It offers essential scanner
software functions, such as analysing occlusion or reduction space, editing scans and removing any scanning data.
58
2 2022
It also has extra features not commonly seen in other lowcost scanners, like undercut analysis, margin placement,
scanning coordinate adjustment and direct exocad export
(Figs. 13 & 14). All these features work well and are highly
polished for the most part.
[59] =>
industry report
11
|
12
Figs. 11 & 12: Aoralscan 3 handles arches, edentulous sites and metals well.
SHINING 3D provides fully fledged cloud-based storage
for scans. The user can send cases to anyone with an
Aoralscan 3 cloud account. Everything is stored locally,
and it is up to the user to move it to the cloud manually.
Furthermore, this is the only Chinese scanner that has
incorporated multiple scanner apps into the software—
a model builder, orthodontic simulator and oral health
report—a unique innovation. No other low-cost scanner
has this line-up of apps.
Orthodontic simulation
As many already know, orthodontic simulators create an
orthodontic alignment animation after the user has taken
full-arch scans. Orthodontic simulation is a fantastic addition to the SHINING 3D software. I am surprised that such
a low-cost scanner has this app, as most do not. In fact,
most scanners double or triple the cost of Aoralscan 3.
The Carestream Dental, Medit, TRIOS and iTero scanners
have such simulators.
automated, providing accurate automatic tooth segmentation, which was done close to perfect every time we
tested it (Figs. 16 & 17). I was most impressed by the tooth
set-up carried out automatically as the AI aligned the teeth.
The orthodontic simulator even picks up missing teeth correctly, and any refinements needed are done easily.
The orthodontic simulator is interactive, but it does not
have fully fledged modification tools, because it is intended
as a communication tool. The simulations look great and
are a powerful motivation tool for patients interested in
orthodontic treatment, including aligners—a great addition
to the software.
Typically these simulators can be a little hit and miss, but
the SHINING 3D version seems to do well. This version is
like the Medit ortho simulator but easier to use, requiring
just a few clicks and making the entire workflow intuitive.
It does have fewer features, however.
Model builder
The Aoralscan 3 model builder app, which is called
AccuDesign, is another excellent addition to the software
(Figs. 18 & 19). It allows the user to quickly and easily
design printable 3D models from the scans within a few
clicks—fitting for a company that also sells 3D printers.
These model files can be created from any scan and
are ready for printing. This software is not unique to
Aoralscan 3, as a model builder app comes with many
scanners, such as Medit i700, iTero, TRIOS and those of
Carestream Dental, but Aoralscan 3 is significantly more
affordable than those scanners.
The Aoralscan 3 ortho simulator is fantastic for what it is.
It is a communication tool that works very well and is highly
This model builder software is easy to use. Within two to
three clicks, the user can have a perfectly printable model.
13
14
Figs. 13 & 14: A number of tools are included, such as undercut analysis and margin tools.
2 2022
59
[60] =>
| industry report
15
Fig. 15: Cases are presented in a unique and intuitive way.
Typically, users have to employ other software, such as
Meshmixer, to achieve this. With Aoralscan 3, it is all done
within the software, within a few clicks.
options for the bases. The user can easily choose the thickness
and height and whether the model should be hollow or solid or
have draining holes or not and add text, among other options.
SHINING 3D seems to have taken some inspiration from Medit,
as it has developed software with the same strengths. The
model building process is streamlined and provides several
Chinese scanners have caught up on scanning speed,
but most do not compete on software. This is changing.
The SHINING 3D software is missing only a smile design
16
17
18
19
Figs. 16 & 17: Ortho simulation using Aoralscan 3 is automated and efficient. Figs. 18 & 19: The AccuDesign model builder looks rudimentary but works well.
60
2 2022
[61] =>
industry report
|
component. It is impressive to see these software apps
done so well in a low-cost Chinese IOS.
Ease of use
As with almost every scanner on the market these days, the
Aoralscan software does very well at making the workflow
straightforward. Ease of use comes from the software that supports the hardware. Overall the software has a level of polish
not typically seen in Chinese scanners and is well thought out.
20
Everything works very well, from creating cases and sending them to the multiple scanner apps. When using the
scanner daily, the workflow is intuitive (Fig. 20). It follows a
simple step-by-step progression that is identical for almost
every scanner on the market. Anyone familiar with typical intraoral scanning strategies will be able to use this scanner.
The software also presents several on-screen tips during
the workflow to help the user learn to scan and perform
the workflow correctly (Fig. 21). Overall, it is an excellent
scanning experience, especially for beginners.
21
Open or closed architecture
Aoralscan 3 is an open-architecture scanner, and the
software enables easy export of scans in different formats,
including STL, PLY, OBJ and exocad file types. The user will
primarily use STL, the most widely accepted scanning format across laboratories and software. One key distinction
is that the STL file is not a colour file. Although the scanner
scans in colour, the user designs on a monochrome model
when exporting in STL and opening in design software.
PLY and OBJ files include colour details, and it is great to
see these being offered as an export option. The software
makes exporting scans straightforward from both the software and the cloud. Exporting of scans in different file types
is done automatically once the case has been completed
(Fig. 22). This is stored locally with several additional files.
Price
Aoralscan 3 is one of the most affordable scanners. Its recommended retail price is US$10,999, but may vary slightly according to local tax policies and other factors. Prospective buyers
are thus advised to check with their local distributor or reseller.
An ongoing cost to be considered is that of the scanning heads. Aoralscan 3 has removable and autoclavable
scanning heads, providing ideal cross-infection control.
This feature has become the norm across the IOS market.
The autoclavable scanning heads have a limit of 100 autoclave cycles at 134 °C, after which they will need to be replaced.
In summary, although Aoralscan 3 is an entry-level scanner,
it is very impressive. The scanner as a whole has good
22
Fig. 20: The software is easy to use and has clear and intuitive buttons.
Fig. 21: Scanning tips and tricks pop up throughout the workflow. Fig. 22:
Exporting is simple and easy to do after scanning.
production quality. It does not feel like a cheap product
and is impressive for the cost. It is a very well-performing
scanner with great software for under US$11,000.
For the full review, please visit https://instituteofdigitaldentistry.com/
ios-reviews/aoralscan-3-scanner-review-the-latest-ios-by-shining-3d.
about
Dr Ahmad al-Hassiny is a global
leader in digital dentistry and intra-oral
scanners, carrying out lectures as a
key opinion leader for many companies
and industry. He is one of the few in
the world who owns and has tested all
mainstream scanners and CAD/CAM
systems in his clinic. Dr al-Hassiny
is also the director of the Institute of
Digital Dentistry, a world-leading digital dentistry education
provider with a mission to ensure dentists globally have easy and
affordable access to the best digital dentistry training possible.
2 2022
61
[62] =>
| manufacturer news
New materials for greater aesthetics and cost-efficiency
Ceramill FDS now offers option of milling dental arches
and tooth segments
Amann Girrbach has expanded its Ceramill Full Denture System
(FDS) to include the validated Ivotion materials from Ivoclar and
has updated the Ceramill Mind software accordingly. This allows
even more components to be individually combined in the fabrication of removable complete dentures. Users thus benefit from
greater flexibility as well as time- and cost-efficiency.
The Ceramill FDS offers the industry’s broadest range of options for
fabricating dentures digitally. With the addition of the proven dental
materials Ivotion Dent and Ivotion Dent Multi as well as the impact-
resistant denture base material Ivotion Base, users can now also
mill individual dental arches and tooth segments for the first time—
all within a validated workflow. The pearl structure effect of Ivotion
Dent Multi creates a particularly harmonious colour gradient. The
previous options of milling denture bases or fabricating them via
3D-printing technology and combining them with prefabricated
teeth from leading manufacturers have now been extended to include an aesthetic and cost-effective alternative.
In addition, the Ceramill FDS is distinguished by an end-to-end
digital workflow and the seamless interaction of software and
hardware. In this context, the Ceramill Mind software has been
updated so that all components and materials and the stored gap
dimensions and milling strategies are precisely matched.
“With the expansion of tooth libraries, fabrication possibilities and
design options, the Ceramill FDS offers maximum flexibility. Thanks
to the update, we are now in an even better position to cover different
cost segments, so that individual patient wishes can be optimally
addressed,” said a delighted Maria Stroppe, product manager for
laboratory CAD/CAM software and 3D printing at Amann Girrbach.
www.amanngirrbach.com
[63] =>
Welcome to
IXS™
Scan eXam™
Scan eXam™ One
OP 3D™
OP 3D™ Pro
OP 3D™ Vision
Focus™
Carestream Dental
(CS 3600, CS 3700, CS 3800)
Until recently, our customers knew us under the brand name KaVo Imaging.
KaVo Imaging stands for products and software that have been developed for the most demanding users. Decades of
experience from manufacturers such as Gendex, Soredex and Instrumentarium have been combined in this brand.
We are very proud that this strong portfolio has been expanded and starts to operate under the DEXIS™ name. DEXIS
was found in the mid-1990s by Dr. Manfred Pfeiffer, a German engineer and programmer, who knew that digital x-rays
would be the future of dentistry. The DEXIS brand has been the world market leader in the field of digital intraoral X-rays
for over 20 years.
Today, DEXIS offers a wide range of award-winning digital solutions, from intraoral sensor technology to CBCT and
intraoral scanners. Moreover, our products are integrated in our high-end software DTX Studio™ Suite, unifying 2D/3D
imaging, diagnostics and planning.
dexis.com
Discover how DEXIS delivers for you
[64] =>
| meetings
International events
7–10 September 2022
Vienna, Austria
www.envistaco.com/en
British Orthodontic
Society 2022—
BOS Conference
15–17 September 2022
Birmingham, UK
www.bos.org.uk
Dental World Budapest 2022
13–15 October 2022
Budapest, Hungary
https://dentalworld.hu/dental-world-2022-en
19th ESCD Annual Meeting
21–24 September 2022
Dallas, USA
www.aaid.com
13–15 October 2022
Rome, Italy
https://escdonline.eu
21–24 September 2022
Berlin, Germany
www.dgkfo-vorstand.de
2 2022
7–9 October 2022
Singapore
www.idem-singapore.com/aboutidem
AAID Annual
Conference 2022
German Association
of Orthodontists—
DGKFO Annual Meeting
64
IDEM Singapore 2022
Formnext 2022
15–18 November 2022
Frankfurt am Main, Germany
https://formnext.mesago.
com/events/en.html
EAO 2022
Annual Congress
IDS 2023
29 September–1 October 2022
Geneva, Switzerland
www.congress.eao.org/en
14–18 March 2023
Cologne, Germany
www.ids-cologne.de
© 06photo/Shutterstock.com
Envista Summit
EMEA 2022
[65] =>
|
© 32 pixels/Shutterstock.com
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2 2022
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[66] =>
| international imprint
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66
2 2022
[67] =>
[68] =>
Digital dentistry,
simply united!
Introducing 3Shape Unite. An open platform that
brings together world-leading dental companies,
solutions and labs. Manage all your cases with choice
and ease, from TRIOS scan to treatment completion.
Simply connect to the right partners with app-based
efficiency and make digital dentistry easier than ever
with 3Shape Unite.
3Shape.com/Unite
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/ Editorial
/ Content
/ Dental sales a mixed bag as war and supply dif culties bog down pandemic recovery
/ GDC reveals continuing impact of COVID-19 on UK dentistry
/ Preferences for fixed restorations and resulting impact on the US and European overdenture markets
/ “The future is digital, and I want women not only to participate in the future but also to actively shape it” - An interview with Eva-Maria Meijnen
/ “At age 37, CEREC advances the restorative capabilities of dentists as never before” - An interview with Prof. Werner H. Mörmann and Dr Cord F. Stähler
/ Experiences of and successes achieved with Zolid zirconia How a dental material developed to become a game-changer — An interview with Falko Noack, Prof. Bogna Stawarczyk & Atsushi Hasegawa
/ Efficient production of a zirconia overdenture
/ Digital implant planning in combination with a conventional prosthodontic workflow
/ Implant replacement of congenitally missing incisors using a surgical guide fabricated in-office
/ How clean do sterile implants have to be? - Analysis and clinical relevance of factory-related contaminations
/ Digital dental shade measurement: Practical applications with a state - of-the-art colorimeter
/ The real cost of an analogue impression, compared with a digital one
/ Review of Aoralscan 3 The latest intra-oral scanner by SHINING 3D — the best low-cost intra-oral scanner?
/ Manufacturer news
/ International events
/ Submission guidelines
/ Imprint
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