digital international No. 2, 2023
Cover
/ Editorial
/ Content
/ Dentsply Sirona, FDI and Smile Train deliver first-ever global protocols for digital cleft treatment
/ Artificial intelligence in dentistry
/ Researchers use generative artificial intelligence to design realistic dental crowns
/ AI may assist in dental implant surgery, localising mandibular canals
/ Is digital dentistry the solution to the sustainability dilemma?
/ Net-zero emissions in dentistry—achievable goal or greenwashing?
/ Aspen Dental’s digital denture transformation - An interview with Eric Kukucka
/ “It is the combination of the many improvements in detail that are advancing implant dentistry today” - An interview with Dr Michael R. Norton
/ Modern workow of immediate zirconia implant surgery utilising dynamic navigation: case studies and benet analysis
/ Screw-retained restoration of a maxillary first molar and second premolar
/ Comprehensive dental rehabilitation with a digital workflow: - A case study
/ Digitally planned highly aesthetic restorations
/ Chairside fabrication of a nano-ceramic hybrid composite endocrown for a severely damaged molar after endodontic treatment
/ Digital workflow for dental offices and laboratories— where are we now? - An interview with Niels Plate from Dentsply Sirona
/ Manufacturer news
/ Could placing attachment over authenticity be the reason behind dental burn-out?
/ International events
/ Submission guidelines
/ Imprint
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[1] =>
issn 2193-4673 • Vol. 4 • Issue 2/2023
digital
international magazine of digital dentistry
opinion
Is digital dentistry the solution to
the sustainability dilemma?
case report
Comprehensive dental rehabilitation
with a digital workflow
industry news
Digital workflow for dental offices
and laboratories—where are we now?
2/23
[2] =>
[3] =>
editorial
|
Magda Wojtkiewicz
Managing Editor
IDS 2023—simply the best!
After the turbulence of the COVID-19 pandemic, the
dental industry is back on form! The best proof of this
was the global meeting of the dental community at the
largest trade show and dental business summit—the
International Dental Show (IDS). Despite the many economic and political issues presently facing the world,
IDS 2023 achieved pre-pandemic attendance levels—
120,000 visitors—and massive participation by clinicians,
members of the dental team, educators, manufacturers
and distributors while showcasing a vast variety of
products and equipment.
Koelnmesse in Cologne in Germany was the centre of
the dental universe for tens of thousands of participants
during a full week in March, often with a crush of people
trying to pass through the crowded aisles for a glimpse
of new products and technology. The halls were full of
visitors watching hands-on demonstrations and presentations delivered by clinicians, laboratory technicians,
dental hygienists and industry partners representing
1,788 exhibitors from 60 countries.
Like pre-pandemic editions of IDS, seeing everything that
one might wish to see in the multiple halls was impossible.
One thing was abundantly clear: there was a major
emphasis on innovation and digital solutions focusing
on the expanding world of 3D printing, design software,
CAD/CAM chairside devices, materials with excellent
physical and aesthetic properties, cloud solutions and
artificial intelligence (AI) technology. The innovations presented at IDS were stunning, and the number of new digital
solutions on display was almost beyond imagination!
Naturally, the overall feedback from the exhibitors was
very positive. Fred Freedman, vice president of member
services at the Dental Trade Alliance and president of
International Dental Manufacturers, stated: “IDS is the
largest and best international dental meeting in the world.
The 2023 IDS can be summed up in one sound bite:
IDS is back. With the enormous crowds and thousands
of international distributors and visitors, this is a must for
all US manufacturers and companies looking for new
international business.”
The success of this year’s IDS allows us to look to the
future development of the dental industry with great
optimism.
Sincerely,
Magda Wojtkiewicz
Managing Editor
2 2023
03
[4] =>
| content
editorial
IDS 2023—simply the best!
03
news
Dentsply Sirona, FDI and Smile Train deliver first-ever
global protocols for digital cleft treatment
page 06
page 22
06
opinion
Artificial intelligence in dentistry
08
Researchers use generative artificial intelligence
to design realistic dental crowns
14
AI may assist in dental implant surgery, localising mandibular canals
16
Is digital dentistry the solution to the sustainability dilemma?
18
Net-zero emissions in dentistry—achievable goal or greenwashing?
20
interview
Aspen Dental’s digital denture transformation
22
“It is the combination of the many improvements in detail
that are advancing implant dentistry today”
26
case report
Modern workflow of immediate zirconia implant surgery
utilising dynamic navigation: case studies and benefit analysis
page 36
30
Screw-retained restoration of a maxillary first molar and second premolar 36
Comprehensive dental rehabilitation with a digital workflow: A case study
40
Digitally planned highly aesthetic restorations
46
Chairside fabrication of a nano-ceramic hybrid composite endocrown
for a severely damaged molar after endodontic treatment
52
industry report
Cover image courtesy of
EduardTanga/Shutterstock.com
2/23
issn 2193-4673 • Vol. 4 • Issue 2/2023
digital
Digital workflow for dental offices and laboratories—
where are we now?
60
manufacturer news
64
practice management
Could placing attachment over authenticity be the reason
behind dental burn-out?
68
international magazine of digital dentistry
meetings
International events
about the publisher
opinion
Is digital dentistry the solution to
the sustainability dilemma?
case report
Comprehensive dental rehabilitation
with a digital workflow
industry news
Digital workflow for dental offices
and laboratories—where are we now?
04
72
2 2023
submission guidelines
73
international imprint
74
[5] =>
simply.TRIOS 5
Hygienic by design for minimal risk of crosscontamination. Smaller and lighter than ever for
next-level ergonomics. And a ScanAssist engine
with intelligent-alignment technology that makes
precision scanning effortless, every time.
Intraoral scanning that
simply makes sense
[6] =>
| news
As part of its sustainability strategy, “BEYOND: Taking action for a brighter world”, Dentsply Sirona entered a three-way partnership with Smile Train and
FDI World Dental Federation in 2022 to improve the quality of and access to oral healthcare, specifically cleft care, globally. (Image: © Dentsply Sirona)
Dentsply Sirona, FDI and Smile Train
deliver first-ever global protocols
for digital cleft treatment
By Dental Tribune International
Dentsply Sirona, the world’s largest manufacturer of
professional dental products and technologies, in partnership with Smile Train, the world’s largest cleft-focused
organisation, and FDI World Dental Federation, the global
voice of the dental profession, have recently announced a
major milestone in the push to advance global cleft care.
Together, they have developed the first global standard
protocols for digitalised cleft treatment. The protocols are
expected to improve the accuracy and efficacy of current
treatments significantly by providing dental professionals
with a comprehensive digital clinical approach across all
stages of care.
The workflows outlined in the protocols contain a wealth
of information to guide dental practitioners in their work
and enable best practice. The protocols encompass
treatment in the case of pre-surgical infant orthopaedics,
mixed dentition, permanent dentition and oral rehabilitation. Each option features a remote monitoring and oral
health component.
“These protocols will help bring health and opportunity to countless children worldwide,” FDI President Prof. Ihsane Ben Yahya
said in a press release. “It took an incredible amount of research
and effort to put these workflows together,” she continued.
06
2 2023
To aid application of the available information and details, an
interactive tool was created that will help dental professionals
navigate through the different stages of care.
“The new protocols set the bar for the evolution of digital
cleft care, leveraging technology that will ensure access to
high-quality care for marginalised communities, and reduce
the burden of care for the cleft community,” commented
Susannah Schaefer, president and CEO of Smile Train.
In addition, the three organisations have developed a clinical
education course that aims to provide cleft professionals
worldwide with additional in-depth training on digital cleft
care protocols and to support them as they integrate digital
technologies into their treatment plans.
The partnership builds on an ongoing global partnership between
Dentsply Sirona and Smile Train, which funded more than 730 cleft
surgeries in the first year of collaboration. “Together with Smile Train
and FDI, we are working to advance the future of cleft care and go
BEYOND for children with clefts worldwide,” added Erania Brackett,
chief marketing officer and head of sustainability at Dentsply Sirona.
“The launch of these new global protocols is an enormous step
forward on that journey, integrating high-quality digital, more
sustainable technologies and workflows into cleft care.”
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| opinion
Artificial intelligence in dentistry
Dr Miguel Stanley, Portugal
For those who have been paying attention to the latest
news in the technology space, you will most certainly
have noticed that OpenAI recently launched ChatGPT, a
new artificial intelligence (AI) chatbot. It is amazing to see
how this technology works and how quickly it can do incredibly complex tasks and have virtually all the information
that is online at your disposal in a matter of seconds.
I had to test it multiple times and try to force it to make a
mistake on the information that I wanted, but this machine
learning technology is really powerful.
For example, I asked it to write me a song around a specific theme and asked for the chords I liked best, and in
less than 10 seconds, I had a song that I could easily play
on the guitar. I even asked it to write this article quoting
articles and giving examples of application of AI in medicine, and the result was quite complete, but naturally as
the applications of AI in dentistry are still few and of little
relevance, naturally there was little information it could
combine and use in an intelligent way. As such, the result
was somewhat interesting, but not what I was looking for.
That is not to say that in a year or two when the bot can
obtain more information online, and there are more cases
and documentation, the technology will not be able to be
even better.
08
2 2023
If ChatGPT is asked things for which a great deal of information is already available, the responses are simply
amazing, and the scary thing is that the bot is still learning.
It learns with every question and with every answer. It is
going to revolutionise the way we search for information
and the way we learn, and certainly many jobs are at risk
with this technology. As a rule, I am not a person who is
afraid of technologies, but if we look at the automobile
industry, which used to rely almost entirely on people,
all tasks are now mainly done using robots. The work of
cashiers at the supermarket can also already be 100%
automated. There are already platforms for lawyers
and legal articles written by AI programs and translated
almost instantly. It is all quite impressive.
Our dental business has three main components:
– diagnosis and treatment plan;
– execution of treatment; and
– daily management of the clinic.
Of course, I am simplifying here. We all know that it is
far more detailed and that there are many more factors
at play than these, but I think that these are the main
areas in the day-to-day running of a modern dental prac-
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| opinion
tice. Where might AI have an immediate impact on these
specific areas?
Diagnosis and treatment plan
There are already several online platforms available to
help in diagnosis. Of course, they are not perfect, but
they are already able to very quickly through a panoramic
radiograph or CBCT scan segment all the teeth and identify problems such as caries, endodontics and missing
teeth. Some of these platforms also assist the dentist
incredibly quickly in preparing a treatment plan beyond
diagnosis. We are still in the early days of this technology,
but I believe that within a very short time the application of
AI in the diagnosis and treatment planning of our patients
will be the norm, and for those who work for insurance
or large dental groups, it will almost be a requirement.
The advantages implicit in this technology are that we
can often miss small details because we might be looking
at more complex problems in our patients’ mouths and
for example miss a small cavity between two teeth or
because we do not have the requisite amount of time in our
initial appointment to look at everything or are focused
on the primary reason the patient came to us and might
overlook broader aspects. This technology will help mitigate
error incredibly in this very important process when we
are diagnosing a patient for the first time or re-evaluating
our case after a few years. We all know that our eyes can
10
2 2023
sometimes deceive us. Here this technology will play an
incredibly powerful role in helping to analyse CBCT scans
and radiographs, and I believe that intra-oral scanners
and laboratory scanners will also be a part of this process,
as well as the various software programs available for the
dental laboratory.
AI will also play a predominant role in the preparation of
a treatment plan, as well as in the sequence of treatments
to be performed, making sure that the right methods are
in place. Depending on the technology used, the software will serve the clinic or the patient. Different groups
may create AI programs according to their various goals,
such the promotion of biomimetics or all-on-four or aesthetic treatment. This means that programs are going
to be trained to prompt a specific outcome by whoever
programmed them. AI software does only what it is programmed to do, so whoever creates these AI programs
can set whatever parameters they want.
Imagine an AI program available to the patient through
which the patient could influence the dentist’s treatment
plan and the materials used. The second the dentist
presents the treatment plan based on his or her diagnosis,
the patient would be able to ask for that report and
enter it into the program on his or her smartphone and
instantly critically analyse whether the dentist’s goal is
financial only rather than the pursuit of optimal treatment.
This program might enable instant recommendations
[11] =>
opinion
from nearby clinics that can perform the same type of
treatment at a lower cost and with greater proficiency
because they have better means and materials to do so.
It appears that soon all this information will be available
to everyone, not just dentists.
in developing a treatment plan and that the sequencing
of treatment steps is done according to the principles of
biology and mechanics, based on a deep understanding of
what is possible and tangible, in order to achieve longevity and success for the dentist and of course the patient.
That is why I have been warning for some time in my lectures and at international conferences that this is a very
good time to start investing in quality and to be as ethical
as possible in our professional conduct, because sooner
or later there will be technological entities controlling the
way we work. It is going to be very difficult to deceive your
patients, and we all know that there are many today who
practise dentistry that is not congruent with current science
and clinical evidence in order to save time or money.
It will certainly be very interesting to see the evolution of
all these technologies in our industry.
Just like we have been doing with clear aligner treatment
for over 18 years, this whole process has to be validated
by a human, the dentist—who of course is sovereign at
the end of the day! If he or she changes the treatment
plan, however, the AI program will inform the patient
of this change immediately, giving the patient the opportunity to ask why. If things go wrong in the future,
AI programs will certainly give patients the means to engage
with their dentists. This will have legal implications, and
I believe will make life more difficult for some but easier
for others.
Personally, I think that this is great! Since the beginning
of my career, I have been putting myself on the side of
the patient and not on the side of the industry. I practise
empathy every day when I have a patient in front of me.
I am sure that every patient in the world wants the same
thing: good treatment performed with the best materials,
painlessly and with care and that lasts a lifetime with high
aesthetics. Of course, this magic formula does not exist,
but surely the incredible tension that exists between
patients and the industry will dissipate if we have a technological referee in our midst.
Execution of treatment
We all know that there are patients with unrealistic expectations who have a very complicated phenotype and
want complex mouth treatments that are unachievable.
An AI program will be able to immediately mediate in the
conversation by introducing an objective examination
so that the dentist can have more tools to demonstrate
the facts of the case based on science and to support a
challenging explanation to the patient and, by the same
token, so that the patient will have extra support to ensure
that he or she is not being misled and that the dentist
is not trying to sell something outside of the necessary
scope, in defence of the patient’s oral health and wallet.
I think that it will be an incredible help to many.
Of course, clinics that practise dentistry without regard
to quality and ethics should be very concerned about
these new technologies. I think that this mediation is
something that is missing in our industry. I have already
been working with companies and been helping some
of them, learning from them and trying to ensure that
decision-making and implementation are based only on
ethics, science and clinical evidence.
To summarise, I think that AI will provide an incredible
means to improve the effectiveness of diagnoses and
treatment plans, making the process much safer for
everyone involved, and to ensure that no step is forgotten
|
I believe that this will be an area explored more by robotics
than by AI. There are already robots that can place
dental implants remotely with incredible precision, and
naturally they will be controlled by AI in the future. For
now, we can be assured that, at least for the next few
years, the art of taking care of our patients’ mouths will
still be very manual, and here dentists play a leading role.
I believe that, if we are smart and use the time saved in
creating the treatment plans and diagnoses by AI, we can
use that time to invest more time in our patients. Certainly,
there will be clinics that will quickly fill those hours with
more patients, but as you know I am a strong advocate
of Slow Dentistry (slowdentistry.com), and I believe this is
how we will secure our future. The human touch is going
to be the major differentiator. I believe that we have to
focus on the human side of our art because in the future
the dentists who create the best relationships with their
patients will be more successful.
Patients will surely want to be sure that their dentist is
doing things right, and we all know that working in a
hurry is very difficult. There are more and more young
dentists in the business. Experience takes years to acquire, and it is imperative to give young people adequate
time to be able to do their jobs well. I even believe that
there will be an AI program that will be able to measure
what the optimal time is for performing each task with
quality and that will inform the patient that the average
optimal time for a Class I restoration on a molar is
35 minutes, for example, and that fitting a dental dam
for treatment is essential.
Regarding the execution of treatment, I think that AI will
play a very relevant role in the selection of materials and
technologies to use. Here it is easy to understand how.
When the AI program compiles the treatment plan,
it will be able to analyse all materials available quickly and
2 2023
11
[12] =>
| opinion
determine the best material for each step in the treatment to be executed, helping the dentist to select the
materials more carefully for his or her treatment. This will
also help laboratories avoid materials not congruent with
the long-term success of the treatment being performed.
Each time, the dentist or dental technician does not
accept the recommendation provided the AI, the patient
will be warned.
Consider blockchain technology, a digital ledger in which
transactions made in a cryptocurrency are recorded
chronologically and publicly. This data is distributed
across a network of computers and cannot be changed
without verification and approval via time-stamp. This
means that the security of these assets does not rely on
a third party, heralding a significant decentralisation of
power over information.
All the information that we acquire from our patients, for
example via radiographs, intra-oral scans, CBCT scans
and photographs, belongs to the patient. I believe that
every time that information is shared with entities outside
the clinic, the patient will be notified via an AI program.
Imagine, for the groups that send crowns to be manufactured in China or India or anywhere for that matter,
the patient will be notified that his or her file has been sent
abroad. Of course, this is no problem at all if the dentist
has informed his or her patient that he or she will be doing
this to lower costs, but it will be difficult to explain this to
the patient if he or she has been given a guarantee that
the crown will be manufactured in Portugal, for example.
This demonstrates that ethical care will be facilitated by
default in the dental industry and in the health business
in general in the future, thanks to AI and the associated
technologies.
Daily management of the clinic
We all know the difficulties we have managing in complex schedules. I believe that AI will play a major role in
supporting the day-to-day management of our clinics.
The following are some areas where I believe that AI will
very quickly be of great use to us:
– stock management;
– calculation of dental professionals’ commissions;
– invoicing;
– legal documentation for patients;
– patient conflict management; and
– improving communication between departments.
Nowadays, all these tasks require endless hours of
human resources day in and day out throughout the year,
at great cost to clinic owners. Yet it is difficult to include
redundancies in these tasks, and there are many possibilities for error. All these errors come at a great cost
as well. Surely, it will be incredibly welcome for practice
12
2 2023
owners, insurers and all those involved in managing
practices to have support that can enable them to reduce
error and increase efficiency.
Let us consider an example. Imagine a healthcare
group that has one dentist. This dentist works in three
different clinics and, at the end of the month, is remunerated based on a calculation of the treatment activities performed. It is necessary for an accountant or an
account manager to confirm all the facts described and
entered into the system by the dentist. Now, the healthcare group must confirm that the dentist has indeed
performed these tasks, but how can it know whether
he or she has done them well? How can it be sure that
he or she has not made a mistake? An AI program used
by the clinic management could very quickly go through
the radiographs, the photographs, the clinic’s and dentist’s e-mails, all communication between the parties
involved, the stock record for the materials removed
from the stock for the treatment, the chair time allocated
for the treatment and the laboratory workflow around
the treatment and calculate immediately whether in fact
what the dentist claims to have done was in fact done
and done well. Naturally, the dentist will feel more secure
because his or her entire effort will be validated and
confirmed by management, and his or her payment will
be effected without problems.
The problem arises if the dentist has not been correct in
his or her conduct, because the AI program will quickly
warn both parties of an error and help correct it to the
benefit of both parties. Surely no dentist will want to be
paid for work he or she did not do, and no organisation
will want to pay for work not done. Certainly in the future
there will be a discussion about whether organisations
should pay for poorly performed work, but that is another
discussion for another time.
I think that AI may make things more difficult for some but
also much easier for others. We are still a long way from
seeing all this happening, so do not become worried just
yet. It is important, however, to keep an eye on how things
are developing because it is not a matter of whether it will
happen but when.
contact
Dr Miguel Stanley
Rua Dr. António Loureiro Borges 5
1º Andar Arquiparque
Miraflores
1495-131 Algés
Portugal
info@whiteclinic.pt
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[14] =>
| opinion
Researchers use generative
artificial intelligence to design
realistic dental crowns
By Iveta Ramonaite, Dental Tribune International
CAD/CAM technology has greatly improved the productivity of dental prostheses but still has its drawbacks
when it comes to the design of crowns. Using an artificial intelligence (AI) learning method, researchers from
the Faculty of Dentistry at the University of Hong Kong
have created an algorithm for personalised dental crown
design of high accuracy to produce crowns that resemble
the morphology and biomechanics of natural teeth.
According to the researchers, the CAD/CAM workflow
has significantly improved dentistry, but is still labourintensive and time-consuming, particularly because
of the need for customisation for each patient, despite
CAD software using a tooth library to assist in generating prosthetic designs, and it generates health and environmental hazards during the 3D-printing and milling processes.
CAD/CAM remakes are often necessary because of marginal misfits, and design can affect the biomechanical
performance and thus the fatigue lifetime of the crown.
For this reason, a means of crown design that addresses
these issues is needed.
In the study, the researchers trained the algorithm
on 600 sets of digital casts of mandibular second
premolars and their adjacent and antagonist teeth and
tested it on an additional 12 sets of data to generate
12 crowns. They then compared the natural second
premolars with the designs created by their algorithm,
using CEREC software and by a technician using a
CAD program. They looked at morphological parameters of 3D similarity, cusp angle, and number and
area of occlusal contact points. They also subjected
the designs realised on computer in lithium disilicate to
biomechanical fatigue simulations based on physiological
occlusal force.
“During the training process, natural teeth morphological
features were learned by the algorithm, so that it can
design dental crowns comparable to a natural tooth—
both morphologically and functionally,” lead author
Dr Hao Ding, a postdoctoral fellow in applied oral
sciences and community dental care at the university,
said in a press release.
Fig. 1: Project co-investigator Dr Hao Ding and the design of a tooth crown using generative AI.
1
14
2 2023
[15] =>
opinion
|
2
3
Fig. 2: Researchers make use of generative AI to design personalised dental crowns. Fig. 3: Natural tooth (left) compared with tooth tailored by generative AI (right).
The generative AI-designed crowns had the lowest
3D discrepancy, closest cusp angle and similar occlusal
contacts compared with natural teeth. In lithium silicate,
the AI-designed crowns were found to have an expected
lifespan similar to that of natural teeth. According to the
researchers, the other two methods of designing dental
crowns produced crowns that were either too large or
too thin and failed to reach the same lifespan as that of
natural teeth.
“This demonstrates that [the algorithm] could be utilised
to design personalised dental crowns with high accuracy
that can not only mimic both the morphology and biomechanics of natural teeth, but also operate without any
additional human fine-tuning, thus saving additional costs
in the production process,” added senior researcher
Dr James Tsoi, an associate professor in dental materials
science at the university.
“Many AI approaches design a ‘lookalike’ product,
but I believe this is the first project that functionalises
data-driven AI into real dental application. We hope this
smart manufacturing technology will be the stepping
stone for driving Industry 4.0 in dentistry, which is vital to
meet the challenges of an ageing society and lack of
dental personnel in Hong Kong,” Dr Tsoi stated.
Clinical trials for using the generative AI for dental crowns
are underway. Additionally, the researchers are working
to expand the applicability of the tool to other dental prostheses, such as partial and complete dentures.
Editorial note: The study, titled “Morphology and
mechanical performance of dental crown designed by
3D-DCGAN”, was published online in the March 2023
issue of Dental Materials.
Fig. 4: The HKU Dental Materials Science research team: (from left) co-investigator postdoctoral fellow Dr Hao Ding, principal investigator Dr James Kit Hon Tsoi,
and PhD candidate Ms Yanning Chen.
4
2 2023
15
[16] =>
| opinion
AI may assist in dental
implant surgery,
localising mandibular canals
Franziska Beier, Dental Tribune International
Studies have shown that artificial intelligence (AI) can
recognise structural patterns in medical imaging data.
However, in dental and maxillofacial radiology, only a
few studies have used AI to locate mandibular canals.
Knowing their exact location is a prerequisite for dental
implant planning. Until now, dental professionals have
had to examine radiographs to locate the mandibular
canal, a potentially complex and time-intensive process. A recent study from Finland has now tested the
use of an AI-based model for this purpose and found
that it locates canals in 3D radiographs quickly and
precisely.
Localisation of the canal in CBCT images is complicated
by anatomical variations in the course and shape of the
canal according to individual and ethnicity. To avoid compression or other surgical complications, a safety margin
of 2 mm above the mandibular canal is recommended
in implantology. Precise knowledge of canal position is
also important for various other oral and maxillofacial
surgical procedures, such as jaw surgery or removal of
third molars.
Researchers from Aalto University in Espoo, Planmeca
and the Finnish Center for Artificial Intelligence (FCAI)
developed a deep learning system and trained it
with 3D images rendered with CBCT. The database
consisted of images from five different CBCT scanners
from four vendors and patient cohorts of two ethnicities;
869 Finnish patients (79%) and 234 Thai patients
(21%).
The performance of the deep learning system was
clinically evaluated by comparing its results with those
of four experienced dental and maxillofacial radiologists. The model accurately segmented the man-
Researchers in Finland have created an artificial intelligence-based model that locates the mandibular canals quickly and precisely. (Image © Alex Mit/Shutterstock.com)
16
2 2023
[17] =>
opinion
|
CBCT images showing overlaid expert and deep learning system segmentations. Every image on each column is annotated by the same expert, shown in red,
the deep learning system annotation is shown in green and overlap is shown in yellow. (Image: © 2022 Järnstedt et al., licensed under CC BY 4.0, no changes)
dibular canal and performed better overall than the
radiologists. In addition, it showed promising generalisability with regard to new CBCT scanners and
ethnic groups.
“When a huge amount of data is fed to the neural network
and the location of the mandibular canal is marked in it,
it learns to optimise its own internal parameters. The neural
network resulting from this learning quickly finds the
mandibular canal from the individual 3D data input,” said
co-author Vesa Varjonen, vice president of research and
technology at dental equipment manufacturer Planmeca,
which is based in Helsinki.
Planmeca to integrate the model
in its imaging portfolio
For Planmeca, a Finnish family business and one of the
world’s leading equipment manufacturers in health technology, the collaboration with FCAI and Tampere University
Hospital means significant new business potential.
“Digitality and AI used in imaging equipment are important for us. We will integrate the neural network model
developed in this research into our imaging software.
This will improve the usability and performance of our
equipment,” said Varjonen.
“In clinical assessments, experts went through the results
produced by the model and discovered that in 96%
of the cases they were fully usable in clinical terms.
We are highly confident that the model works well,”
commented co-author Jaakko Sahlsten, a doctoral
researcher at Aalto University.
Model for orthognathic surgery
“The collaboration arose from the needs of experts
practising clinical work and from seeking ways to help
their everyday work. A lot of time can be saved by using
artificial intelligence in patient treatment planning,” said
Varjonen in a press release.
“I see artificial intelligence as a very powerful tool that
physicians and other experts can use when making their first
assessments or to get alternative opinions. The challenge
with deep learning models is that we cannot give definite
grounds as to why the model reaches a specific outcome.
Further research is needed to increase the explainability and
transparency of the models,” concluded Sahlsten.
“Tampere University Hospital provided us with extensive
and versatile clinical materials produced with several
3D-imaging devices. The data was divided at random
and part of it used for training the neural networks and
part of it isolated for testing and validating the designed
method,” said Sahlsten.
In addition, the collaborative research project developed a
neural network model for orthognathic surgery. “The model helps
to identify landmarks in the skull area for correcting malocclusion
and planning jaw alignment surgery,” said Varjonen.
Editorial note: The study, titled “Comparison of deep
learning segmentation and multigrader-annotated mandibular canals of multicenter CBCT scans”, was published
on 3 November 2022 in Scientific Reports.
2 2023
17
[18] =>
| opinion
Is digital dentistry the solution to
the sustainability dilemma?
Dr Les Kalman, Canada
I think we can agree that dentistry is not the most
environmentally friendly profession. Just take into consideration the number of single-use materials such as
plastics, stone and plaster, barrier protection, and, of
course, personal protective equipment. Are they all
necessary to maintain the standard of care and appropriate infection control? Now, consider the steps in a
typical analogue workflow for an indirect restoration.
The impression is taken, boxed up, sent by vehicle to
the laboratory and poured up. The crown is fabricated
and sent back to the clinic, again by vehicle. Is this sustainable? I believe that we have tools at our disposal
that can help improve the workflow and the environmental footprint.
© M-SUR/Shutterstock.com
The evolution of digital dentistry has had a significant
impact on the dental profession. The acquisition of
digital intra-oral impressions, scanned impressions
and models has improved efficiency, accuracy and
the clinical workflow. But what about sustainability?
18
2 2023
Is taking an analogue impression and sending it to a
laboratory by vehicle more environmentally damaging
than sending a file digitally? The digital method would
immediately reduce carbon dioxide emissions; however, it would be necessary to consider the sourcing of
all the materials and the fabrication of all the components required for the digital transfer based on the total
cumulative energy demand throughout the life cycle of
a product.
What impact does digital design have on sustainability?
The analogue workflow would require impressions, casts,
registration and an articulator to design and develop the
prosthesis. The storage of models must also be considered.
This requires physical space and utilities compliant with
regulatory requirements. Digital design has a completely
different workflow, allowing image capture, cloud storage,
visualisation and planning on a device, all done remotely.
It also provides a simple approach for design modifications and remakes.
[19] =>
opinion
What impact can the output or fabrication of dental
prostheses have on sustainability? Initially casting required investing, melting and significant finishing and was
heavily reliant on materials and time. Milling provides an
accurate and predictable workflow but has limitations on
design and sustainability.
How does additive manufacturing (AM) or 3D printing
fit into the equation? There are a multitude of AM processes that provide accurate and efficient prostheses in
plastic (resins), metals and ceramics (zirconia and lithium
disilicate). These approaches can create any geometry
and typically offer superior accuracy and improved
sustainability. Additionally, recent research has quantified
that the AM workflow is more sustainable than conventional fabrication pathways. A further advantage is that
prostheses made digitally offer impressive physical
properties.
The possibility of bypassing digital design by using
indirect onlay restorations has also been explored.
This would be a novel approach that could save an enormous amount of time, money and resources. And this is
just the beginning, since artificial intelligence is already
having an impact on diagnosis and treatment planning,
and virtual and augmented reality are being used for
education and training. Another factor to be considered
is the developing metaverse.
However, digital dentistry comes with a significant
caveat: the user must have an excellent understanding
of its applications and limitations in a clinical setting.
After all, digital dentistry provides another set of tools
in the dentist’s toolbox. Clinicians must know which
tool to use and when. For example, there was a
recent report of a clinical full-arch implant case which
included a bone reduction guide and a guide for
implant placement. Both were acquired through a fully
digital workflow. Unfortunately, during the surgical
session, neither guide fitted well, and the clinician
had to detour to a free-hand approach. Kudos to
the clinician for realising the errors, but what an
unnecessary environmental impact and waste of
time and money!
I have heard similar stories where the implant surgical
guides did not fit intra-orally owing to the patient’s limited
mouth opening—another unfortunate situation in which
digital dentistry was improperly used.
The last scenario I will highlight concerns a clinician
who bought a 3D resin printer to complement his
intra-oral scanner. In this case, all patients received a
diagnostic scan and printed models for educational
and marketing reasons. Is this an appropriate use of
digital dentistry? How does this reflect sustainability?
What happens to those models when the patients
|
have no use for them? Are they recyclable? This
scenario reminds me of that meme where a gaspowered generator is being used to charge an
electric vehicle.
“Digital dentistry provides
another set of tools
in the dentist’s toolbox.”
If we collectively strive for dentistry to have improved
sustainability, we must consider the entire picture.
Here are a few recommendations for implementing digital
dentistry as related to sustainability:
– consider the clinical workflow and assess how
sustainability can be improved without compromising
the standard of care;
– understand and follow the fundamentals and principles
of digital dentistry. It is merely a set of tools to improve
the workflow;
– be curious and explore new technologies;
– be critical. For example, consider whether a fully guided
case is essential;
– consider a hybrid or fused workflow, combining the
best aspects of analogue and digital, until there is a
strong grasp on predictable digital workflows; and
– exercise the Rs: recognise, reduce, recycle, repurpose,
rethink and rejoice!
Digital dentistry is a strong technological tool that
can help dentistry become more sustainable. However,
dental professionals have to ask the right questions,
perform due diligence and make appropriate decisions
that benefit patients and the planet.
about
Dr Les Kalman is an educator and
medical device researcher focusing on
additive manufacturing and software.
He is a fellow of the Academy of
Osseointegration, American College
of Dentists and Academy for
Dental Facial Esthetics and a diplomate
of the International Congress of
Oral Implantologists. He is the recipient
of an Alumni of Distinction Award from the Schulich School of
Medicine and Dentistry at Western University in London
in Ontario in Canada and a CES Innovation Awards honouree.
2 2023
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[20] =>
© jantsarik/Shutterstock.com
| opinion
Net-zero emissions in dentistry
—achievable goal or greenwashing?
By Jeremy Booth, Dental Tribune International
“Net zero” has become one of the buzzwords of the climate crisis, and experts consider the emissions reduction
strategy to be the current gold standard in sustainable business practice. Dental manufacturers have touted net-zero
commitments, and there is a push to decarbonise oral care
services and individual clinics. Does a net-zero commitment
represent a zero-sum game, or does it add up for dental
companies and the dental professionals that they serve?
Net zero differs from carbon neutrality. It considers all
emissions that are attributable to an entity, including those
resulting from the supply chain and other processes that
occur outside of direct operations. Carbon neutrality can
pertain only to carbon dioxide emissions from specific business operations. On the one hand, becoming carbon neutral means striking a balance between emitting carbon and
having it absorbed from the atmosphere via carbon sinks—
natural systems, such as the ocean and forests, that absorb
more carbon that they emit. Emissions made in one sector
can be offset by reducing them in another, and certification
and international standards exist to verify carbon neutral
claims. Corporate net-zero targets, on the other hand, can
be backed by the Business Ambition for 1.5 °C scheme and
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2 2023
its Corporate Net-Zero Standard, which requires companies to make long-term, holistic commitments that are in line
with the latest climate science and the 2015 Paris Agreement.
Crucially, polluters who commit to the scheme may not
simply offset their emissions into the ether; rather, they are
required to actively and substantially decarbonise their
entire value chain and offset any emissions that remain.
The Science Based Targets initiative (SBTi), which governs
the scheme, does not permit companies to make net-zero
claims until they have committed to and achieved a long-term
net-zero target.
Henry Schein, the US healthcare giant whose dental business is one of the world’s largest, is the only major dental
company that has committed to the Corporate Net-Zero
Standard. Henry Schein signed up to the Business Ambition
for 1.5 °C scheme in late 2021, from which date the company has 24 months to set short- and long-term net-zero
targets for review by the SBTi. Henry Schein’s targets must
account for its Scope 3 emissions, which are those that
the company does not produce but for which it is indirectly
responsible, and must aim for substantial carbon dioxide
reductions and net-zero emissions by 2050 or sooner.
[21] =>
opinion
“We recognise that with our global environmental footprint and
unique position within an ecosystem of relationships with suppliers and business partners, we are uniquely positioned to be
a driving force for sustainability in the healthcare supply chain,”
Stanley M. Bergman, CEO and chairman of the board at
Henry Schein, commented at the time in a press release.
Of the more than 4,800 companies that have joined the
initiative, 2,538 have made science-based targets and
1,779 have made a net-zero commitment.
Align Technology, whose mainstay is the manufacture
and global distribution of clear aligner trays, says on its
website that it is investing in energy efficient buildings and
employee transportation in order to reduce emissions.
Align thus far provides no data about its emissions or
concrete plans to reduce them.
In its 2021 Sustainability Report, Envista Holdings quantified
its operational emissions (Scope 1 and Scope 2) and said
that it intended to assess and review its Scope 3 emissions.
Envista, which was spun off as a new dental company in 2019,
said at the time that identifying an environmental target,
such as net-zero standard, was an area of priority for the
young company. Dentsply Sirona also announced in 2021 its
ambition to reach net-zero carbon emissions (Scopes 1–3) by
2050. The company said that its target is “in line with globally
recognised standards” but did not detail which standards or
whether its commitment was binding.
A push for net zero in health clinics
and services
There is a drive to reach net-zero emissions in individual
dental clinics and health services that provide oral care.
The UK government, for example, passed legislation last
year to deliver a net-zero National Health Service (NHS),
including NHS dental care. The ambitious vision of achieving a
net-zero NHS by 2040 includes an 80% reduction in Scope 1
and Scope 2 emissions by 2032 and slashing Scope 3
emissions by the same figure by 2039. “Our intention for
these targets is to construct the most ambitious, credible
declaration to reach net zero of any national healthcare system in the world,” the health service declared in a report.
A forthcoming article from the Australian Journal of General
Practice, shared with Dental Tribune International (DTI),
showed that non-clinical emissions account for around
40% of total emissions at general medical practices in the
UK and that the remaining 60% is attributable to the clinical
component. The largest sources of non-clinical emissions
were staff travel, at 22.8%, business services, at 22.5%,
and patient travel, at 18.4%.
Dr Richard Yin, co-author of the article and chair for Western Australia of the organisation Doctors for the Environment
Australia (DEA), told DTI: “With energy and transport being
|
a large component of the non-clinical emissions, at least in
Australia, with our vast solar and wind resources and with
our transitioning to electric vehicles powered by renewable
energy, I think the non-clinical emissions can realistically be
substantially reduced. The clinical component, however, is largely
attributable to pharmaceuticals and procurement. As doctors,
we can minimise unnecessary treatments and focus on low
carbon treatment options but it will be necessary to put pressure on supply chains to decarbonise. That is something that
we can advocate for but is also out of our control.”
DEA advocates for a net-zero target for Australia’s healthcare sector, and Dr Yin said that the industry has an urgent
responsibility to decarbonise. “The most important reason
for the profession to take steps and be part of the climate
movement is to be advocates for change,” he emphasised.
Speaking about net-zero targets for individual clinics, Dr Yin said:
“The issue is to define the carbon footprint of a dental
practice and then understand how to reduce it.” Here,
practice owners can engage consultancy services, such as
Glasgow-based Net Zero Dentistry, which market a service
of decarbonisation and offsetting to practice owners.
Earnestly adopted and used, the strength of net zero as
a tool to make dental care and manufacturing more sustainable lies in its focus on proactively reducing emissions
rather than offsetting them and its being backed by climate
science; however, the risks of greenwashing and ineffective
carbon offsets remain. An investigation by news outlets
The Guardian and Die Zeit, together with not-for-profit investigative
journalism organisation SourceMaterial, revealed in January
that the bulk of forest carbon offsets issued by leading
certifier Verra were largely worthless. Rainforest protection
accounts for 40% of the credits that Verra sells, and journalists found that Verra overstated threats to its forest projects
and sold credits that had failed to reduce deforestation.
Washington DC-based Verra, whose clients include Shell,
easyJet and Pearl Jam, disputed the claims.
Dr Yin said that carbon offsets were problematic and could
not be relied upon for decarbonisation. “There is no guarantee
that a tree planted today will be around in 30 years’ time.
The time frame required for us to decarbonise to avoid the
worst of climate impacts requires urgent action this decade.
Nonetheless, buying offsets places carbon on a balance
sheet, and that helps keep it as a cost that has to be addressed,” Dr Yin said.
Currently, no artificial carbon sinks are capable of removing
carbon dioxide from the atmosphere at the scale that would
be necessary to achieve climate goals, and even natural
sinks are struggling to keep pace with perpetual economic
growth. According to the European Commission, global
carbon sinks remove up to 11 Gt of carbon dioxide from the
atmosphere every year, whereas global carbon emissions
totalled 36 Gt even in 2020, when global emissions dipped
owing to the SARS-CoV-2 pandemic.
2 2023
21
[22] =>
| interview
Aspen Dental’s
digital denture transformation
An interview with Eric Kukucka
By Dental Tribune International
The world of removable prosthodontics is rapidly
growing, and Eric Kukucka is one of the foremost experts
in the space. Recently, he made the transition from
private practice to vice president of clinical removable
prosthetics and design technologies at dental service
organisation Aspen Dental. Dental Tribune International (DTI)
spoke with him about his involvement in the development of digital denture technologies, the exciting
advancements in the field of digital dentures and
obstacles to their adoption.
Mr Kukucka, for how long have you been a denturist?
What attracted you to this field?
I’ve been a denturist since 2010, and there were several
factors that initially brought me to this field. Dentures
are a thriving business, so the promise of financial
reward was attractive. I also love being able to work with
my hands. As I grew in my career, I delighted in being
able to give people back their smiles and their quality
of life, and the monetary appeal became secondary.
I quickly learned that there is no greater reward than
being of service to others.
What kick-started your digital denture journey?
About ten years ago, I was working with Ivoclar, which
is a worldwide dental company that produces a range
of products and systems for dentists and dental technicians. I was lecturing for Ivoclar as well as working
on various research and development projects related
to materials for removable prosthetics. In 2014, I was
shown the alpha prototype of the Ivoclar digital denture,
and I was blown away! The product was so impressive
and so disruptive that I knew I wanted to be part of it
right from its infancy.
Being a denturist provided me with the unique perspective of working on the clinical and the lab side, so I was
well positioned to work on the multifunctional validation of the product as we conducted the alpha testing.
Over the years of testing, we implemented many different iterations of workflows, material processes and
manufacturing concepts. This also led to the development of advanced milling technologies able to fabricate a monolithic denture that was both white and pink
in one single uninterrupted manufacturing process.
Development of scanning technology also continued,
and we were able to move from desktop scanners to more
innovative and handheld wireless intra-oral scanners
that could scan not only inside the mouth but also
physical impressions and gypsum models.
Eric Kukucka
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2 2023
[23] =>
interview
During this evolution, I also developed a relationship
with the counterpart that was working with Ivoclar
on the digital dentures, a company named 3Shape.
3Shape produces desktop and intra-oral scanners as
well as dental design software for all types of dental restorations. As part of the collaborative Ivoclar–
3Shape team, I also helped develop scanning strategies for the TRIOS intra-oral scanners, so I’ve been
able to see the journey of digital dentures all the way
from conception through to more widespread use
and to being a valued component in any dental
facility that prides itself on employing the latest technology in the field.
Have these digital denture workflows changed in
the years since?
One of the best features of digital dentures from a training and implementation perspective is that when moving from analogue to digital, the clinical workflow can
remain the same. While there are more efficient workflows that allow for greater flexibility, dental professionals
who are providing removable prosthetic therapy do not
need to change their current workflow when they switch
to digital dentures. The biggest change that comes
with digital dentures is data acquisition, how the data
captured clinically is rendered in the design software,
the manufacturing methodology, and the process that
supersedes it.
However, for those who want to overcome the challenges of conventional workflows, there are various
methods for the delivery of dentures in two appointments
rather than the traditional three to five appointments
that may be necessary with more conventional
methods.
To capture that efficiency, the biggest change we’ve
seen is the process and workflow for immediate dentures. With an intra-oral scanner, dental professionals
can scan the patient’s oral cavity, render a design and
then deliver the dentures at the next appointment when
the teeth are being extracted. This technology has been
revolutionary both on the clinical side and on the lab
side, because we can now digitally visualise where
a patient’s natural teeth were and where the new
teeth will be. This truly provides unparalleled results for
the clinician and the patient.
Another revolution of digital denture technology is the
ability to deliver the final denture at the try-in stage.
In the conventional analogue process, dental professionals
have to perform a wax try-in, where all of the teeth are
individually set in wax. This is a very labour-intensive and
technique-sensitive process that requires extreme care
and is prone to human error as well as material deficiencies, which can result in extensive and expensive corrective measures. In contrast, with digital dentures, you
|
can deliver that same quality—or even higher quality—
dentures for a fraction of the cost to the clinic and in
a fraction of the time at that try-in appointment. Moreover, if the denture isn’t completely correct, making adjustments is efficient, effective and predictable
by applying the changes via the software with a few
keystrokes and mouse clicks.
Today, at our Aspen Dental locations that offer
digital dentures, there is an over 80% success rate
at that denture delivery appointment. Just think:
if you fit 100 dentures a month and 80% of the time
you deliver those dentures successfully, you will
have gained 80 appointments in your schedule that
month. That means new and existing patients aren’t
waiting as long resulting in an increase in more available chair time that can be used to deliver high quality
removable therapy to more patients.
“For dental laboratory
technicians, digital dentures
offer consistency in the
design process and greater
customisation.”
What benefits does the digitalisation of the denture
process bring for the clinician, the dental laboratory
technician and the patient?
First and foremost, the most significant benefit for all
three parties is the ability to electronically preserve
the patient’s initial data acquisition, whether that is a
scan of the teeth, dentures or edentulous oral cavity,
as well as the preservation of the final design file of
the restoration. For the patient, the electronic preservation of that data means that, if a patient loses
a denture, a replacement denture can be fabricated
within 24–48 hours without having to take another impression or come in for any additional appointments.
That’s simply not possible with conventional dentures. In addition, digital dentures have greater retention, stability and strength than dentures produced
in the analogue manner. It’s important to note that
digitally manufactured prostheses have a uniform
thickness feature that provides the patient with true
physiological comfort.
For dental laboratory technicians, digital dentures
offer consistency in the design process and greater
customisation. For clinicians, the improved workflow,
efficiency and accuracy of digital dentures reduce
2 2023
23
[24] =>
| interview
the chair time needed per denture patient. The use
of digital dentures results in fewer postoperative
adjustments, thereby freeing up operating chair time
for clinicians to provide care to a greater number of
patients.
Are there any common obstacles that prevent
dental professionals from adopting and integrating
digital workflows?
Resistance to change applies in every profession, and
the dental industry is no exception. Often, we have reservations about adopting new technologies or techniques
because what we’ve been doing has been working—
that if it isn’t broke, don’t fix it mentality comes into play.
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2 2023
There’s also some resistance to the cost associated
with switching to digital technology as well as the shift
from conventional manufacturing to subtractive or
additive manufacturing, namely 3D printing. I understand that clinicians are hesitant to work with a technology that uses different materials and manufacturing
processes and has financial ramifications. My message
to those clinicians would be to try out the technology
by providing removable prosthetic treatment to a few
patients. Partner with a manufacturing centre or lab that
is skilled in digital dentures and do five, ten, 15 cases
until you are comfortable with the process and can see
the benefits for yourself. Then, it’s much easier to make
that investment.
[25] =>
interview
|
“The biggest change
that comes with
digital dentures is data
acquisition, how the data
captured clinically is rendered
in the design software
and the manufacturing
methodology.”
and knowledge to help shepherd Aspen through the
digital transformation. This was a great opportunity, so
I agreed. I very quickly fell in love with the organisation,
not just because of its commitment to digital technology,
but also because I was able to convey my clinical
knowledge and skills to our dentists through our various
onboarding programmes and learning and development initiatives.
After over a decade in private practice, why did you
choose to join Aspen Dental?
Before I joined Aspen, I was an industry leader lecturing at some of the most prestigious conferences
in the world, as well as publishing articles, working
on various research and development projects and
co-authoring textbooks. I truly valued private practice and loved working in research and development
and, most importantly, treating patients with removable therapy. Fast-forward to January 2021, when
Aspen Dental decided to go digital with its dentures.
Dr Sundeep Rawal, the senior vice president of implant
support at Aspen and a long-time colleague, asked
me to come on board as a consultant to use my skills
I helped establish the curriculum alongside our vice
president of clinical support, Dr Andrew De La Rosa,
and when we first delivered the learning programme,
I asked every dentist in the room how many dentures they
had done in dental school. In the room of 30 dentists,
the average had made just two dentures. That’s when
I realised, in an organisation where we do half a million dentures a year and someone can graduate and
go into an office and do up to 100 dentures a month
with very little experience, I could have an enormous impact on hundreds of thousands of patients
and hundreds of dentists. Our chief clinical officer,
Dr Arwinder Judge, asked me whether I wanted to
make a change and come join Aspen Dental full time
on the clinical team. Without hesitation, I decided to
sell my private practices and join Aspen full time, not
just to help lead the digital transformation, but also
to improve the quality of the removable prostheses
we deliver here at Aspen Dental, irrespective of
whether those are produced digitally or using analogue methods. Ultimately, it was the organisation’s
mission and the clinical support team that attracted
me, but the ability to provide countless dentists, dental technicians and team members with the training
they need to deliver the best possible removable prosthetic experience to patients is what made me fully
commit to Aspen Dental. I am honoured to be part of
the clinical support team here at Aspen Dental and
truly changing the way we deliver care to millions of
patients every year!
2 2023
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[26] =>
| interview
“It is the combination of the many
improvements in detail that are
advancing implant dentistry today”
An interview with Dr Michael R. Norton
By Dental Tribune International
A specialist in implantology, Dr Michael R. Norton
has dedicated a huge part of his life to disseminating
knowledge on implant dentistry by publishing scientific
research, lecturing internationally and offering courses
on the subject. Owing to his enormous contribution
to the field, he is highly respected among his peers
and is considered one of the world’s most renowned
educators and researchers in implant dentistry. In this
interview with Dental Tribune International during the
DS World in Dubai, he spoke about topics such as digitisation and the benefits and limitations of a fully digital
workflow, discussed Dentsply Sirona’s Implant Solutions
World Summit in Athens in Greece this year and talked
about some of the implant systems available on the market,
including the DS PrimeTaper.
Dr Norton, DS World runs under the theme “The
ultimate experience in digital dentistry”. How is the
event living up to this slogan in your opinion?
This is not my first time at a DS World event. The experience gets bigger and better each time. As someone
who has been practising for over 30 years, I always
feel excited when I see dental innovations, especially
in implant dentistry and digital dentistry. I am thrilled to
be here in Dubai and to give a lecture on the evolution of
implants while focusing on the digital implant workflow.
I am looking forward to attending the other sessions,
learning from fellow experts and meeting my peers from
the Middle East region. All that makes this weekend in
Dubai a special experience!
Dr Michael R. Norton is a world-renowned dentist and a dental clinic owner
from the UK who has over three decades of experience in implant dentistry.
(All images: © Dentsply Sirona)
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2 2023
Digitisation has been a trend in dentistry since the
early 1980s. What have been the major achievements of digital dentistry regarding the simplification of workflows and the reduction in the number of technological and software options in dental
practice?
Implants have changed very little over the past
30 years that I have been working with them. An exception is the EV connection, which was first introduced for the Astra Tech Implant System EV in 2014.
[27] =>
interview
|
However, this is now considered a stand-alone feature for the EV family of implants. The design provides
six-position indexing for prefabricated abutments
and seating in any rotational position for non-indexed
abutments. It also offers a one-position-only asymmetric index for digital scanning and restoration with
CAD/CAM abutments.
When we go beyond the implant itself, the evolution
of surgical techniques and digital technology, such as
CBCT, 3D scans and digital impressions, is significant.
It would, therefore, make little sense to single out the
one greatest achievement. Rather, it is the combination
of the many improvements in detail that are advancing implant dentistry today. These include CAD/CAM
technology and 3D printing and how they enable more
efficient workflows and better patient care.
In your opinion as an expert in dental implantology,
what are the advantages of a fully digital workflow
in implant dentistry for the practitioner, the patient
and the laboratory?
Standardised and digital workflows work intuitively
over and over again. It makes a difference not having
to rethink procedures every time. This applies to
other medical disciplines as well. The results become
more predictable and easier to plan. This also includes prosthetics which are produced in the dental
laboratory.
Workflows driven by digital technology can result in
higher accuracy, repeatability of processes and time savings.
The DS PrimeTaper implant system by Dentsply Sirona,
for example, is an illustration of this concept as it can
easily integrate into a digitally driven workflow through
the EV connection. This is beneficial for both the experienced implant practitioner and the clinician who is just
embarking on the implant path.
Digital workflows also offer patient security. From
the perspective of backward planning for restorations,
digital treatment planning allows us to show the patients in advance what the result will look like and how
we will get there. This improves patient acceptance
enormously.
What are the limitations of a digital workflow?
Interesting question! The implants of today are incredibly good. Assuming that success rates are in the 95–99%
range and considering the statistical failure that usually occurs, there is only little room for improvement.
Limitations, therefore, arise not so much from the implant itself but from the individual patient situation—
clinical, ethical and financial. Therefore, it is important
for us as dental practitioners to be constantly curious
and open to learning in order to continuously improve
the care we give to patients.
The DS PrimeTaper offers a superior implant treatment for numerous indications.
Events like DS World are a great opportunity to meet
and learn from various experts and peers. Another
great educational resource is DS Academy’s Dental
Implant Curriculum. It is a fully online, comprehensive
and free tool that aims to inspire dental professionals to
build and develop their clinical knowledge and digital
skills in implant dentistry. I lead one of the courses on
implant design and osseointegration. Whether one is
new to implant dentistry or has had many years of experience, there is a suitable course level with interesting
topics and practical advice.
You were the scientific co-chair of Dentsply Sirona’s
Implant Solutions World Summit this year together
with Dr Tara Aghaloo. What attracted you to take
this position?
I am passionate about dentistry and very interested
in scientific knowledge. After all, the results gained
from the research show me which materials and
methods I can use to treat my patients safely and
with long-term success. By chairing the scientific
programme, Tara and I were able to select what
topics we want to talk about at the summit and also
which researchers or lectures we wanted to listen to.
2 2023
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[28] =>
| interview
That was a great honour and a responsibility that
I am delighted to take on.
Why was this event a must-attend for dental implant
professionals and those seeking to learn more
about Dentsply Sirona’s products and solutions?
What could they expect to take away from the event?
There were three reasons for the importance of the event.
Firstly, we have been presented with a truly challenging
scientific programme. In addition to master classes,
there were presentations by renowned speakers who
talked about their research and experiences. Secondly,
we were dealing with forward-looking topics and technologies that will help us in our daily work. Thirdly, we
did meet face to face again and exchanged ideas on the
best treatment approaches. And a bonus was that the
venue was highly appealing. We did meet at the home
of civilisation, where science began, and had a chance
to network and socialise.
to date with the latest status of treatment concepts—
that is essential for me and a great motivation for my
work in the practice.
You were one of the first clinicians to work with
Dentsply Sirona’s PrimeTaper implant system.
What has your experience with it been like?
I was privileged to place the very first PrimeTaper
implants. My initial experience has been very promising. The implant is easy to insert. This is in part
due to the simplified drilling protocol but even more
due to the apical thread design. The implant proves
to be stable even if the patient’s bone situation is
not optimal. It also shows that immediate implant
placement, including a temporary restoration in
occlusion, works. Digital impression taking, digital
treatment planning, CAD/CAM-supported fabrication of the temporary restorations—all these are
important factors that help to achieve an aesthetic
“Workflows driven by digital technology
can result in higher accuracy, repeatability
of processes and time savings.”
What were you personally looking forward to on the
scientific agenda?
I was looking forward to a programme full of science,
literature, documentation and technology dealing with
particular aspects of the digital dentistry world.
I was very excited about leading the panel discussion with Dr Aghaloo. This was similar to the concept I tried at my Los Angeles meeting for the
Academy of Osseointegration in 2018. It was a great
success, and I think the key to that success was
its spontaneity. Essentially it was a panel of experts
“chewing the fat” over topics of great importance.
I did like to think it was like a chat show where the
audience is listening to a conversation between
celebrities.
The summit was an excellent networking opportunity
for implant professionals. How has this community
influenced your career over the years?
I have worked in my dental clinic in London for 30 years,
specialising in implant dentistry. I have personally
experienced the development of this community and
certainly contributed to it—through my research, association activities, congresses and workshops. To exchange ideas, to show best practices and to keep up
28
2 2023
result already at this stage. From my point of view,
DS PrimeTaper is an asset for any dentist working
with implants.
How does PrimeTaper compare with other implant
systems?
Of course, there are many excellent implants on the
market, and Dentsply Sirona has some of the best in
its portfolio. DS PrimeTaper is a step forward in that
it makes things even easier, faster and therefore more
efficient, both clinically and economically, especially
for immediate extraction and insertion. The treatment
experience for the patient thus becomes better with
an enhanced functional and aesthetic outcome in a
shorter period.
If you had to explain to a colleague why DS PrimeTaper
is a good choice, what would you say? What convinced you about PrimeTaper?
The DS PrimeTaper implant system enables optimised
implant treatment for many indications. It delivers desired primary stability at placement, particularly on an
immediate basis. This new system provides an efficient
handling experience and is supported by a seamless
digital workflow. The results with DS PrimeTaper speak
for themselves.
[29] =>
EXPERIENCE THE ART OF
ESTHETIC
DENTISTRY
21.09. – 23.09.23 | BADEN-BADEN, GERMANY
Explore new perspectives.
Meet world-class experts.
Grow your capabilities.
Join the community.
A0046_1/en/B/00/DIG 05/23
GET YOUR TICKET
[30] =>
| case report
Modern workflow of immediate
zirconia implant surgery utilising
dynamic navigation: case studies
and benefit analysis
Dr Daniel Madden, USA
1
2
Fig. 1: Yomi-Link and fiduciary array. Fig. 2: CBCT of initial situation with link attached.
Dental implant therapy is an integral and growing treatment modality for today’s clinicians. With the advent of
digital workflows dental implant treatment has become
more accessible, faster, safer, and more predictable. All
which can provide a better patient experience and more
idealised final restorations.
As the knowledge of the excellent healing profiles and
popularity of zirconia implants continues to grow, ideal
placement and treatment outcomes of these implants
becomes ever more important.6–9 As such we must look
at designing predictable and repeatable surgeries. Studies have shown adding dynamic navigation resulted in
higher accuracy than the freehand surgical method and
while similar accuracies were found between dynamic
navigation and static guidance for deviations; we will look
at some potential benefits of dynamic guidance using
the Yomi platform (Neocis Inc.) over static guidance in
the digital implant workflow.1–5
30
2 2023
Despite the introduction of CBCT-based planning software and fabrication of static surgical guides, challenges
remain in efficiently and accurately transferring the plans
to surgery. Limitations inherent in the static guide workflow include multiple steps and appointments in fabrication, the risk of poorly fitting guides, and the physical
bulk of the guide impeding surgical site access and visualisation.1–5 Immediate dental implant placement in
conjunction with tooth extraction can require us to be
dynamic in our placement. We as dental surgeons know
that sometimes what we plan on a CBCT and what we
see visually intra-orally, may have us wanting to alter our
plan. Immediate implants have well documented success
rates and navigating anatomical variations and tooth
associated pathologies is essential to their long-term
success.12 Small changes in direction, depth and angulation can be the difference between success with proper
initial stability and the inability to place the implant the
same day. Robotic assistance using haptic boundaries
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|
3a
Figs. 3a & b: Surgical planning for bicortical fixation with placement in
furcal bone.
has been shown to enhance accuracy, precision, and
flexibility across surgical fields.1,2 The Yomi dynamic
navigation platform with haptic feedback allows for small
adjustments in real time and accurate visualisation of
drills into the surgical site. This can be significantly impactful when managing close implant placement to
sensitive anatomical structures of the IAN, drill depth
management in vertical sinus lift augmentation, and assuring immediate implant placement into adequate native
bone. The following case studies will review the digital
workflow of dynamic navigation with Yomi when performing immediate zirconia implant surgery and the perceived
benefits therein.
Case presentations
Case 1
A 60-year-old female presented with history of LANAP
at the periodontist on #3 for a 9 mm periodontal pocket
on the DB one year ago. Upon recall at the periodontist,
the vertical bone defect was non healing, and the tooth
was deemed hopeless. The patient came to our clinic
hoping for extraction and immediate implant placement,
risks and alternatives were given to the patient including
the possibility of inability to place the implant the same
day due to bone anatomy in the area.
Yomi link was attached to her upper left using bite registration and a CBCT was taken with the additional fiduciary arrays attached to the link (Figs. 1 & 2). Surgery was
3b
planned for bicortical fixation with placement in furcal
bone avoiding the defect on distal (Figs. 3a & b). The surgical procedure involved a planned implant depth to the
sinus floor, followed by a gradual increase in depth to perform an internal sinus lift. The extraction was carried out
atraumatically, and the socket was thoroughly cleaned.
Yomi guide arm was then attached to the link and the
landmark verified, ensuring accurate stable navigation.
Under surgeon guidance and robotic assistance the pilot
drill was guided to the surgical site. The osteotomy continued with a drill path and depth that locked once in the
planned position. The osteotomy was completed to the
sinus floor with confirmation of depth via dynamic live
CBCT navigation. Incremental advancement of the drill
depth stop was used to complete the sinus lift. Proper visualisation aided in depth management of the transgingival implant. The implant (2.2_5411, SDS) was placed
2 2023
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4a
4b
to 35 Ncm, and the sockets were subsequently grafted
with allograft (cortical min/demin blend, particle size
.25–1mm), hydrated with i-PRF, and covered with an
A-PRF+ membrane that was sutured in place (Figs. 5 & 6).
The postoperative radiograph showed accurate implant
placement (Fig. 7).
Discussion
Visualisation of the surgical site was crucial in this scenario to prevent a bone defect on the distal and ensure
sufficient native bone around our implant. The plan and
guide path were adjusted in real time for ideal depth
and location to achieve optimum results.
5
4c
Case 2
The patient presented having previously seen an endodontist who deemed the retreatment of tooth 19 nonrestorable. The patient wanted to explore replacement
options, and a comprehensive clinical assessment was
performed, including CBCT and bitewing radiographs.
Multiple periapical radiolucencies were noted, associated with failing root canals of teeth 19, 21, and 27, and
a horizontal root fracture was observed in tooth 29
(Figs. 8a & b). Due to decay and abscess, a failing double
abutted bridge was observed in teeth 21/22-27/28, making full-mouth rehabilitation without implants a poor option (Fig. 9).
6
7
8a
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8b
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9
10a
Treatment plan
A thorough discussion of treatment options, limitations
and risks was reviewed with the patient. Poor long-term
prognosis was given to remaining mandibular teeth except
#30. The patient’s primary concerns were to have no
teeth during healing, not wanting a removable prosthesis,
and to have biologically friendly materials. Delicate consideration was made to design an immediate implant surgery
that provided the patient with a stable temporary restoration and protected our healing implants. One-piece
SDS (Swiss Dental Solutions) implants were chosen for
their variety of diameters and lengths. Posterior teeth 18,
28, 30 were elected to remain in place during the tempo-
10b
12
|
rary healing phase to provide posterior stops for occlusion and to maintain stability of implants and temporary
restoration during healing phase. Pre-surgical planning
was performed using CBCT and Yomi planning software
to parallel all implants (Figs. 10a & b). Preoperative maxillary and mandibular arch scans were taken and sent to
the lab to aid in temp mock-up (Fig. 11).
Surgical Phase
The procedure began with the administration of bilateral
inferior alveolar nerve blocks for anaesthesia, followed
by sectioning and removal of the PFM bridge. The Yomi
link was then attached to the lower left using bite regis-
11
Fig. 4a: Placement of the pilot drill into the surgical site via dynamic live
CBCT navigation. Figs. 4b & c: Osteotomy was completed to the sinus
floor with confirmation of depth via dynamic live CBCT navigation. Fig. 5:
Placement of the ceramic implant (2.2_5411, SDS) to 35 Ncm. Fig. 6: PRF
covering with allograft. Fig. 7: Postoperative radiograph showing accurate
implant placement. Fig. 8a: Initial situation on CBCT showing multiple periapical radiolucencies associated with failing root canals of teeth 19, 21,
and 27. Fig. 8b: Horizontal root fracture in tooth 29. Fig. 9: Failing double
abutted bridge in teeth 21/22-27/28. Figs. 10a & b: Pre-surgical planning
using CBCT and Yomi. Fig. 11: Preoperative maxillary, mandibular and bite
scans to aid in temp mock-up. Fig. 12: Immediate implantation in site #29
using the Yomi robot with haptic controls and locked drill path depth and
angulation.
2 2023
33
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| case report
13
14
Fig. 13: Intra-oral scans of the surgical sites for temporary fabrication. Fig. 14: 3D lab-printed temporary with Flexera-Smile Ultra+ (Desktop Health).
tration, and a CBCT scan with fiducial arrays was taken
for accurate planning. The placement of the link allowed
for complete visualisation of the surgical field between
teeth #22 and 30. A-PRF+ and i-PRF were created using
horizontal centrifugation to aid in healing. Atraumatic
extractions of teeth #29, 27, and 22 were performed initially, followed by the creation of a small crestal incision
and full-thickness flap from teeth #27 to 22. The surgical
sites were degranulated using curettage and degranulation burs, and decontamination ozone therapy was
administered to the sockets using 03 gas and 03 water.
Surgery was then initiated using a lance drill in sites #29,
27, 25, and 24, with osteotomies being incrementally in-
15a
15b
16
17
creased to manufacturer’s recommendations. The orientation of the drills was confirmed intraorally and via dynamic live CBCT navigation. Close proximity to the nerve
was successfully navigated during immediate implantation in site #29 with high confidence using haptic controls and locked drill path depth and angulation with Yomi
robot (Fig. 12). Implants were placed in sites 29, 27, 25,
and 24. The first phase of the surgery was completed in
approximately 90 minutes, and the Yomi link was removed, and the guide arm detached.
The second phase involved the removal of teeth 19, 20,
21, and 22. An attempt was made to connect link to
Figs. 15a & b: Placement of laminar bone sheet into minimally released buccal and lingual flap. Fig. 16: Full arch temp adjusted and seated with temp cement.
Fig. 17: Excellent healing situation seven weeks after surgery.
34
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|
“With the variety of modern digital workflows
choosing a surgical method that is predictable and repeatable
is what we as clinicians must evaluate.”
the the lower right side of the patient’s mouth, utilising
teeth 30 and 28, and implant abutments 29 and 27, but
it was then unsuccessful. Yomi’s traditional workflow
only allows for working on one quadrant of the mouth at
a time, and a new scan and four or more stable teeth are
required to anchor the link on the other side. This has now
been overcome with a new Yomi bone link which would
have been ideal in this case.
Freehand immediate placement and parallelisation of implants (#22, 20, and 19) was possible with the visual aid
of the previous implants. Intra-oral scans of the surgical
sites were made and sent to the lab for temporary fabrication (Figs. 13 & 14). Site #21 had significant bone loss due
to infection and was grafted with allograft and a laminar
bone sheet. The bone sheet was trimmed and placed
into a minimally released buccal and lingual flap and covered with A-PRF+ (Figs. 15a & b). Suturing was completed, and a full arch temp was adjusted and seated with
temp cement (Fig. 16). Seven weeks later, the patient’s
loose temp was removed, cleaned, and recemented. Excellent healing of the soft tissue was shown in Figure 17.
Discussion
Ceramic dental implant placement can be a delicate process, having ideal emergence with one piece dental implants remains one of the biggest challenges and ideal
placement is essential. A fixed drill path and depth combined with Yomi’s surgical flexibility and the dentist’s visualisation during surgery may be one of its advantages over
other guided navigation systems. As patient awareness
grows of different dental materials, zirconia implants with
their excellent healing profiles are poised to continue to gain
attention. Accurate and ideal placement of zirconia implants
is essential in gaining trust of our patients and dental community. With the variety of modern digital workflows choosing a surgical method that is predictable and repeatable is
what we as clinicians must evaluate. The benefits of robotic
assistance point towards Yomi holding its place in the
surgical suite and will likely continue to pave the path forward
in giving patients access to safe, efficient, accurate and
long-lasting zirconia implant therapy.
Editorial note: This article was first published in ceramic
implants international magazine of ceramic implant
technology, Vol. 7, Issue 1/2023.
Please scan this QR code for the list of
references.
about
Dr Daniel Madden received his
Doctor of Dental Surgery from the
University of Minnesota and pursued
advanced studies in implantology and
comprehensive dentistry abroad at the
Radboud University Medical Center
in Nijmegen, the Netherlands.
He has served as adjunct affiliate
assistant professor at Oregon Health
and Science University and is a certified Integrative Nutrition
Health Coach. He has a passion for education and technology
in dentistry, and believes that this leads to a more
comfortable, efficient and pleasurable patient experience.
He offers patients biologic treatment solutions for optimum
oral and whole-body health at Lotus Dental Wellness
in Lake Oswego, Oregon, and his surgical services through
his company Peak Potential Dental at multiple private practice
locations in Oregon and Washington State.
contact
Acknowledgements to Dr Shepard Delong for his guidance
and introduction to ceramic implantology and to Lotus Dental
Wellness, Lake Oswego, Oregon.
Dr Daniel Madden
Lake Oswego, USA in Hood River, USA
www.dentistdanielmadden.com
2 2023
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Screw-retained restoration
of a maxillary first molar and
second premolar
Dr Anthony Bendkowski, UK
1
2
Fig. 1: Initial situation. Fig. 2: Pre-op radiographic assessment.
Introduction
Dental implants are widely accepted as a successful
method for replacing missing teeth. The success of dental implant treatment depends on many factors, such as
implant design, surgical technique, bone quality and patient factors. The aim of this case report is to present
a step-by-step description of the implant treatment and
3
4
restoration of a patient who had undergone extraction of
a maxillary right first molar and second premolar, from
the initial osteotomy preparation to the final restoration.
Case presentation
A 64-year-old female patient presented to our practice
with a heavily restored dentition. Her failing maxillary right
5
Fig. 3: Full-thickness envelope flap and direction indicators after initial preparation with the 2 mm diameter OmniTaper drill. Fig. 4: Placement of the
OmniTaper EV implant in position #15 using the TempBase driver. Fig. 5: Both OmniTaper EV implants placed with the help of the preassembled TempBase
abutments nicely aligned in positions #15 and 16. Implant–abutment connection size of medium indicated in yellow.
36
2 2023
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case report
6
7
10
8
11
|
9
12
Fig. 6: Use of the BoneTrap to augment the small bone fenestration. Fig. 7: Large quantity of autogenous bone collected from the BoneTrap.
Fig. 8: Symbios Xenograft Granules layered over the autogenous bone. Fig. 9: Symbios Collagen Membrane SR trimmed to shape to complete the guided
bone regeneration procedure. Fig. 10: Passive primary closure with PGA sutures. Fig. 11: Post-op radiograph of the implants. Fig. 12: Healing Abutments EV
placed at three months after initial surgery.
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[38] =>
| case report
indicated that there was ample bone depth in the posterior
maxilla to allow for satisfactory implant placement (Fig. 2).
An implant solution was provided using two individual
screw-retained crowns supported by two OmniTaper EV
implants (Dentsply Sirona) and using a digital workflow
with Primescan and Atlantis (Dentsply Sirona).
13
Fig. 13: Atlantis IO FLOs in situ ready for the Primescan digital impression.
Fig. 14: Design of Atlantis abutments and zirconia crowns.
first molar and second premolar had been extracted
by her general dental practitioner (Fig. 1), leaving an
unbounded edentulous area. Radiographic assessment
14
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2 2023
A full-thickness envelope flap was raised with relieving
incisions, and the initial small round guide drill was used
to mark the implant position. The site was enlarged with
OmniTaper drills of different diameters, following the recommended drilling protocol. The initial osteotomy preparation was performed with a 2 mm diameter OmniTaper
drill at no more than 1,500 rpm and with copious external
irrigation with saline according to the surgical protocol
(Fig. 3). An OmniTaper EV 3.8 × 11.0 mm implant was
placed in position #15 using the TempBase driver (Fig. 4).
Both OmniTaper EV implants placed with the help of the
preassembled TempBase abutments nicely aligned in
positions #15 and 16 (Fig. 5).
Next, the large quantity of autogenous bone collected
with the disposable BoneTrap (Dentsply Sirona) during
surgery was used to augment the small bone fenestra-
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case report
15
16
17
18
|
Fig. 15: Well-fitting screw-retained Atlantis CustomBase abutments and zirconia crowns tried in. Fig. 16: Radiograph to verify correct seating of the restorations.
Fig. 17: Screw access holes sealed and amalgam in tooth #14 replaced with composite. Fig. 18: Final restorations in situ.
tion (Figs. 6 & 7), and Symbios Xenograft Granules were
layered over the autogenous bone (Fig. 8). Finally, Symbios
Collagen Membrane SR (15 × 20 mm) was trimmed to
shape to complete the guided bone regeneration procedure (Fig. 9). The wound was closed with PGA sutures
(Fig. 10), and radiographic evaluation was performed to
verify the implants postoperatively (Fig. 11). Three months
later, medium Healing Abutments EV were placed
(Fig. 12).
A digital impression using an intra-oral scanner (Primescan)
was then captured using the Atlantis IO FLO for a digital
restorative workflow (Fig. 13). An Atlantis CustomBase
solution, consisting of an Atlantis crown, an Atlantis abutment and an Atlantis abutment screw, was fabricated
for each implant and tried in, and no adjustments were
needed (Figs. 14 & 15). After seating, a radiographic evaluation was performed to verify the final restorations (Fig. 16).
The final restorations showed excellent soft-tissue adaptation and an aesthetic outcome (Figs. 17 & 18). The
patient was extremely satisfied with the outcome of
the treatment and the fixed restorations.
Conclusion
This case report highlights the successful placement
of OmniTaper EV implants in a patient with a heavily
restored dentition. The use of an intra-oral scanner and
impression components for the prosthodontic and technical
digital workflow allowed for precise planning and execution
of the treatment plan. The use of the OmniTaper drill
system allowed for efficient and predictable placement
of the implant.
about
Dr Anthony Bendkowski is an oral
surgery specialist in practice limited
to implant reconstructive surgery with
two clinics in London and Maidstone
in the UK. He has over 30 years of
experience in both the surgical and
restorative management of implant
cases. He is a past president of the
Association of Dental Implantology,
an examiner for the Royal College of Surgeons of Edinburgh
Diploma in Implant Dentistry and a contributor to the
postgraduate dental implant programme at Brighton and
Sussex Medical School in the UK. He is co-chair of Bromley,
Bexley and Greenwich LDC and an honorary consultant
at King’s College Hospital NHS Foundation Trust in London.
He can be contacted at enquiries@theimplantexperts.com.
2 2023
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Comprehensive dental
rehabilitation with a digital workflow:
A case study
Dr Michael Braian, Sweden
Introduction
Digital advancements have revolutionised dentistry, providing efficient, precise dental care.1 Intra-oral scanners
are replacing traditional means of taking impressions,
enabling virtual models for implant placement, orthodontics and prosthodontics, for example.2 Scan bodies
aid in digitising implants, while CAD/CAM improves prosthesis design and fabrication.3 Milling and 3D printing
offer speed, accuracy and complexity in creating dental
prostheses.4 These innovations promise a bright future
for dental professionals and patients.
Case presentation
surgery planning.5 After the extraction, the patient
was provided with appropriate postoperative care instructions, and a healing period was allowed before
proceeding with the next steps (Fig. 1).
Dentures during the healing period
During the healing period of approximately seven
months, the patient was fitted with dentures to replace
the extracted teeth. This temporary solution allowed
the patient to maintain oral function, appearance and
confidence while the extraction sites healed and the
oral tissue was prepared for the implant surgery.6
Extraction of severely decayed teeth
The first step in the patient’s dental rehabilitation involved the extraction of severely decayed teeth. This
procedure was necessary to eliminate the source of
infection and discomfort and to prepare the oral cavity
for the subsequent steps in the rehabilitation process.
The dentures were later used to simplify the guided
Implant surgery
Six implants were placed in the upper jaw, while only
four were placed in the lower jaw (Fig. 2). This decision was based on the patient’s individual needs and
oral anatomy. Studies have shown that the number
of implants required for optimal support and stability depends on various factors, including bone quality
and quantity, implant position and prosthesis design.7
Research suggests that six implants in the upper jaw and
four in the lower jaw are sufficient to provide adequate
support for a full-arch fixed prosthesis, high success
rates and patient satisfaction having been reported.7
Additionally, placing fewer implants can help reduce
surgical time and cost, as well as minimise the risk of
complications associated with placement of multiple
implants. Therefore, this approach was deemed appropriate for this particular patient’s case.
1
2
The integration of digital technologies in dentistry
has brought about significant advancements in dental care.1 This case study presents the comprehensive
dental rehabilitation of a patient utilising a digital workflow involving extraction, provisional dentures, implant
surgery, intra-oral scanning, 3D-printed try-ins and
final monolithic prostheses.
Fig. 1: Severely decayed teeth prior to extraction. Fig. 2: Dental implants placed in the lower jaw.
40
2 2023
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case report
3
|
4
5
6
Fig. 3: Scan bodies in situ for intra-oral scanning. Fig. 4: Splinted scan bodies in the lower jaw. Fig. 5: Intra-oral scan of the implant positions. Fig. 6: Digital
impression of the patient’s oral cavity with scan body alignment in dental CAD software.
Intra-oral scanning and digitisation
After the implant surgery, intra-oral scanning was performed using scan bodies from the implant manufacturer, Straumann. This process accurately digitised the
position and orientation of each implant in the patient’s
mouth. For the lower jaw, Luxatemp (DMG) was used
to splint the single-use scan bodies, simplifying the
intra-oral scanning process by providing additional geometrical landmarks in an area with fewer natural reference points (Figs. 3–5). Intra-oral scanning has become
an indispensable tool in modern dentistry, providing
detailed and accurate digital impressions of patients’
oral cavities and replacing the traditional methods of
impression taking.2 Recent research has investigated
the accuracy of intra-oral scanners for full-arch implant
cases and shown promising results.8 One study found
that intra-oral scanners were comparable to conventional impressions in terms of accuracy and precision
when used for full-arch implant cases and offered advantages such as reduced material and labour costs
and faster turnaround times.9
Additionally, the use of geometrical landmarks, such
as via scan bodies and splinting materials, can further enhance the accuracy and reproducibility of
intra-oral scanning (Fig. 6).10 The digital workflow is
particularly advantageous in implant dentistry, as it
allows for improved communication and collaboration
between dental professionals, laboratories and patients, as well as provides a more streamlined and
efficient treatment process.
3D-printed try-ins
After the digitisation of the implants, two sets of
3D-printed try-ins were fabricated for both jaws.
The first set, the validator set, was designed with gaps
between the implant positions (Fig. 7). These gaps
allowed for the detection of tension when the validator
was seated, fractures occurring in the small gaps if
tension was present. This step ensured that the final
prostheses would fit accurately and comfortably without undue stress on the implants or surrounding tissue
(Figs. 8–10). The validators had the same design as
the second set of try-ins, the only difference being
that the validators were cut between the implants
using a virtual disc cutter and the attachment function in exocad software. It is crucial to ensure that
the titanium bases or bar is firmly seated within the
validator, which can preferably be achieved using resin
cement. The validator should be retained with the
same torque as the manufacturer recommends for
the final restoration.
The second set of try-ins was used to check various factors,
including aesthetics, occlusion, vertical dimension of
occlusion (VDO), hygiene capability, phonetics and function.
One important consideration is to avoid using the
OptraGate retractor (Ivoclar) when checking the bite.
The retractor affects muscular activity and could negatively impact the validation process. These final try-ins
closely resembled the final prostheses and were used to
make any necessary adjustments before fabricating the
final prostheses (Figs. 11 & 12).
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7
8
9
10
Fig. 7: 3D-printed validator try-in with gaps between implant positions. Fig. 8: Seating of the validator try-in in the patient’s mouth. Fig. 9: Validator try-in seated
in the patient’s mouth. Fig. 10: Adjusted validator try-in without fractures in the lower jaw.
In this case, the validator did not break, and we did not
need to make any changes to the validator. If a fracture
is present, the practitioner needs to identify and locate
the source of the misfit. He or she should then attach
the broken segments with composite, remove the val-
idator and sent it back to the laboratory for precision
scanning. If the operator has to change the occlusion
or adjust anything on the try-in, a new intra-oral scan
will have to be taken so that the technician can adjust
accordingly.
11
12
13
14
Fig. 11: Final try-ins in CAD software. Fig. 12: The patient wearing the final try-ins. OptraGate was used to simplify the photography process. Fig. 13:
CAD of the lower jaw prosthesis. Fig. 14: Try-in of the lower jaw prosthesis.
42
2 2023
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case report
15
17
|
16
18
Fig. 15: CAD view of the designed prosthesis in the context of the patient’s smile. Fig. 16: Cementation of the Elos Accurate Hybrid Base H Non-Engaging
bases with PANAVIA V5 and CLEARFIL CERAMIC PRIMER PLUS. Fig. 17: The final prosthesis on the day of delivery. Fig. 18: Final prostheses of monolithic
KATANA Zirconia YML, stained using CERABIEN ZR FC Paste Stain. The dark gingiva spots were stained with the shade Red, the light pink surfaces with
the shade Pink and the highlights with the shade Salmon Pink.
19
20
21
22
Fig. 19: Final prostheses, right side view. The cervical parts were stained with the shade Cervical 2, the incisal two thirds of the anterior teeth with the shade
Grayish Blue and the mamelons with the shade Mamelon Orange 1. Fig. 20: Final prostheses, left side view. Fig. 21: Final maxillary prosthesis, occlusal view.
Fig. 22: Final mandibular prosthesis, occlusal view.
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Both the validators and the try-ins were made on
titanium bases from the manufacturer. Furthermore,
it is possible to use the validators as both a validation of fit and for all other checks, removing the need
for two different sets. The same procedure is possible for bridge base constructions, minimising the
de-cementation risk of titanium bases.
Fabrication of the final prostheses
Once the validators and try-ins had been successfully checked, the final prostheses were fabricated
using the same features and specifications as those
of the try-ins. This step ensured that the final prostheses would accurately represent the validated try-ins,
providing a comfortable, functional and aesthetically
pleasing result for the patient. In this step, it is important
“The integration of
digital technologies
in dentistry has significantly
improved the efficiency,
precision and
outcomes of dental
treatments [...].”
to use a material that has the aesthetic features and
material properties for manufacture of the full anatomy as a monolithic restoration.11 Studies have shown
that monolithic zirconia prostheses exhibit high
fracture resistance and excellent long-term clinical
performance, making them a suitable material choice
for full-arch fixed implant-supported prostheses.12
A fully digital workflow requires the user to validate
intra-orally and then adjust the initial CAD accordingly
and verify that whatever is designed is shown as close
as possible in the manufacturing process (Figs. 13 & 14).
If the technician has to add veneering material or
in any other way change key morphological parts
of the restoration, the digital workflow will be less
reliable.
In this case, the final prostheses were fabricated using
monolithic KATANA Zirconia YML (Kuraray Noritake
Dental). This high-quality material offers excellent
strength, durability and aesthetics for dental restorations. The staining process was performed using
CERABIEN ZR FC Paste Stain (Kuraray Noritake Dental)
to achieve a natural appearance and blend seam-
44
2 2023
lessly with the patient’s existing dentition. PANAVIA V5
in the shade Opaque and CLEARFIL CERAMIC
PRIMER PLUS (both Kuraray Noritake Dental)
were used to cement the bases (Elos Accurate
Hybrid Base H Non-Engaging compatible with
Straumann Standard and Standard Plus 4.8 mm
diameter, regular neck implants; Elos Medtech;
Figs. 15–22).
Conclusion
This case study demonstrates the successful application of a digital workflow in a comprehensive
dental rehabilitation involving extraction, provisional
dentures, implant surgery, intra-oral scanning,
3D-printed try-ins and final monolithic zirconia
prostheses. The integration of digital technologies
in dentistry has significantly improved the efficiency,
precision and outcomes of dental treatments, resulting in enhanced patient care and satisfaction.
As technology continues to advance, it is expected
that digital dentistry will continue to evolve, offering
even greater possibilities for dental professionals
and patients alike.
Editorial note: Please scan this QR code
for the list of references.
about
Dr Michael Braian has dedicated
his entire professional life to the field
of prosthetic dentistry. He began
his dental technology education at
Malmö University in Sweden in 1999
and has since graduated as both a
dental technician and dentist. In 2018,
he defended his doctoral thesis in
digital dentistry. For the past 15 years,
Dr Braian has focused exclusively on digital solutions in dentistry.
In 2014, he fulfilled his dream of starting a private practice,
where he works as both a dentist and dental technician, allowing
him to oversee the entire process from start to finish in all
patient cases. He has won several awards for his pedagogical
skills and is constantly engaged in expanding his knowledge
in the field of prosthetic dentistry. Dr Braian is the founder of
the Swedish organisation for computer-aided digital dentistry
SWECADD. He can be contacted at info@SWECADD.se.
[45] =>
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| case report
Digitally planned
highly aesthetic restorations
Atsushi Hasegawa & Dr Yusuke Takayama, Japan
and aesthetically convincing if essential components of
modern dental technology are combined with the expertise
and experience of both the dentist and dental technician.
Case presentation
A 37-year-old female patient presented to Dr Takayama’s
dental practice requesting correction of the colour and
shape of her anterior teeth and treatment of her gingivitis.
Her tooth #23 had been extracted when she was at
school, and gingival recession was visible in this region.
When she first came to us, she had already received a
bridge from tooth #21 to tooth #24 and crowns in regions
#11 and 12. Especially the shape of the bridge did not
meet her aesthetic demands (Figs. 1 & 2).
Planning and pretreatment
The given circumstances meant that no labial space
was available for layering porcelain. It was thus decided
to treat the patient with monolithic restorations made of
the highly translucent and polychromatic zirconia Zolid
Gen-X Multilayer (Amann Girrbach) and to undertake
partial orthodontic treatment of the labially inclined and
crowded mandibular anterior teeth.
1
Aesthetic intuition, creativity and technical expertise—
these are just a few relevant factors for implementing
high-quality restorations. Choosing the right material is
also of key importance for accurate fitting. This patient case
illustrates how restorations can be functionally effective
2
3
In addition, correction of the gingival margin was to be carried out before starting the restorative treatment. Owing to
the gingivitis and missing tooth #23, the gingiva in the region
had receded considerably. This was corrected by surgery
in order to later achieve a natural gingival margin (Figs. 3 & 4).
4
Figs. 1 & 2: Initial situation. Bridge from tooth #21 to tooth #24 with a pontic in region #23 and crowns on teeth #11 and 12. Figs. 3 & 4: Soft- and hard-tissue
management with soft- and hard-tissue grafting.
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5
6
|
7
Fig. 5: Orthodontic treatment of the mandibular anterior teeth. Fig. 6:
Situation after surgery for gingival margin correction. Fig. 7: Teeth #12, 11,
21, 22 and 24 prepared for restoration. Fig. 8: Artex facebow transfer.
After these pretreatments (Figs. 5 & 6), the teeth were
prepared for restoration by the dentist (Fig. 7).
The perfect fit right from the start
The use of a facebow (Fig. 8) is considered essential to
show the individual relationship of the patient’s condyles
and occlusal plane. This ensures subsequent realisation
of patient-friendly occlusal concepts on the Artex articulator (both virtual and physical, Amann Girrbach).
The classic model work used the Model Management
System workflow (Amann Girrbach). Afterwards, the
models were mounted on the Artex CR articulator using
the Artex facebow record (Fig. 9) and digitalised using the
Ceramill Map 600 scanner (Amann Girrbach). The CAD
was done using the Ceramill Mind CAD software. One of
the major advantages of the Ceramill system is that both
analogue and digital workflows can be employed using
the same concept (Figs. 10 & 11).
The setting of the Artex articulator (condylar inclination
and Bennett angle) was average (sagittal condylar inclination of 35° and transversal condylar inclination of 10°).
For incisal inclination, a custom incisal guide table was
9
10
13
8
chosen to set at 35°, the left wing at 0° and right wing at
30°, owing to the shallow anterior overbite and the right
canine being natural dentition (Fig. 12).
When designing anterior restorations, it is necessary to
consider not only aesthetics but also occlusion. The goal
is to achieve an occlusal scheme in which the posterior
teeth prevent excessive contact of the anterior teeth in
the maximal intercuspal position and the anterior teeth
disengage the posterior teeth in all mandibular excursive
movements. For this reason, when the anterior region is
in occlusion, it is an important area that guides the mandible and controls both protrusive and lateral movements.
In this case, since one canine was a pontic, tooth #24 was
also involved to reduce the load on the pontic and to control
the lateral movement (Figs. 13 & 14).
11
14
12
Fig. 9: Mounting the model using the Artex facebow. Fig. 10: Ceramill Artex virtual articulator. Fig. 11: Ceramill Artex physical articulator. Fig. 12: Setting of
all function parameters on the Ceramill Artex. Fig. 13: Static occlusion registration. Fig. 14: Dynamic occlusion registration.
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16
15
17
Fig. 15: Smile design with Ceramill M-Smile. Fig. 16: Ceramill M-Smile, oblique view. Fig. 17: CAD-design based on pre-op data.
Virtual reality—Ceramill M-Smile brings
restorations to life
Designing a restoration with the Ceramill M‐Smile module
creates possibilities not available to technicians in the
analogue workflow. References, such as the pupillary
line and midline, previously difficult to make out with an
analogue articulator and models are now easy to see, and
it is even possible to use the patient’s smile for the design
(Fig. 15).
18
19
20
21
22
23
Fig. 18: Observation of the centreline without facial orientation. Fig. 19: The balance between the shape and size of the tooth is important to achieve a good aesthetic result. Fig. 20: Matching
the midline of the facial profile. Fig. 21: Matching the midline and the lip line. Fig. 22: Design of the crown for tooth #12. Fig. 23: Design of the dental bridge for tooth #21 to tooth #24.
48
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|
It has to be considered that Ceramill M-Smile uses
2D images. Therefore, it is not advisable to use it for determining the crown labial contour or for the lip support
design. In order to sufficiently design these aspects,
designs from provisional restorations (preoperative scan
data) are useful, as the position of the incisal edges and
the contour of the labial aspect can be adjusted with reference to the provisional restorations (Figs. 16 & 17).
When considering the centreline based on the models,
the axial direction of teeth #11 and 12 suggests setting the
midline along the red dotted line (Fig. 18). With digital design, the feeling for shape and tooth size is lost because,
unlike when looking at a physical model, it is easy to zoom
in and out and rotate. The size of the physical model and
digital model is not the same. This is an important consideration in digital design of anterior teeth (Fig. 19).
The centreline can be determined from the orientation of
the patient’s face. Also, the smile line, which cannot be
referenced in the analogue process, is described by overlapping 2D images (Fig. 16). However, because the centrelines based on the model and on the facial features were
different, design of the individual teeth was very difficult,
especially in the area of the tooth #11 mesial interproximal
emergence profile (green arrow on Fig. 19) as an example.
To improve aesthetics, it was necessary to reduce the
bulk on the labial surface and tilt the tooth axis towards
the lingual side. In such cases, the wall thickness of the
crown must be controlled to ensure strength (Figs. 20–23),
following the manufacturer’s instructions for use.
If there is little space, the preferred restorative material
should always be monolithic. The high strength of zirconia
provides safety and longevity for the restoration. Zolid
Gen-X gives restorations a high level of aesthetics owing
to its natural colour gradient and high translucency.
25
24
Fig. 24: Milling the restorations with Ceramill Matik.
Virtual becomes reality
Once the design process was completed, the restorations
were milled with the Ceramill Matik milling unit (Fig. 24).
As the patient preferred a slightly lighter shade, Zolid Gen-X
in Shade A1 was selected (Figs. 25 & 26).
After milling, the crowns and bridges were reworked with
suitable tools to individualise them (Fig. 27). The Zolid
Green‐State Finishing Kit was used to correct the morphology
of the approximal surface areas (connector areas) and of
26
Fig. 25: Ceramill Zolid Gen-X Multilayer blank discs. Fig. 26: Shade selection according to the patient’s natural teeth in the mandible.
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27
28
Blue-grey
Thin layer of Shade A
Shade A
29
30
Transparent glaze paste
Transparent glaze paste and
a small amount of white
31
32
Fig. 27: Milled restorations. Fig. 28: Sintering process with the Ceramill Therm 3. Fig. 29: Sintered and polished restorations. Figs. 30 & 31: Aesthetic
finishing with ready-to-use Vintage Art Universal paste stains and glazes. Fig. 32: Final restorations on the model. Fig. 33: Cleaning with KATANA Cleaner.
Fig. 34: Cementation of the restorations under the microscope.
33
34
50
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|
35
Fig. 35: Zolid Gen‐X monolithic crowns after cementation in the patient’s
mouth. Fig. 36: Final result in the patient’s natural smile.
the occlusal surface, which were difficult to correct after
sintering. The sintering process was then started (Fig. 28).
After sintering, slight adjustment of the morphology was undertaken using the Zolid Sinter‐State Polishing Kit, including
medium-grade polishing at the end (Fig. 29).
Zolid Gen‐X has a beautiful multilayer graduation and a very
natural look, so it is possible to produce restorations that require
minimal staining. In this case, Vintage Art Universal stains and
glazes (SHOFU) were used. The incisal area was coloured blue‐
grey for transparency. During application, care must be taken
not to make the incisal area too blue. A very thin layer of Shade A
was added over the body area (for colour supplementation),
and the cervical area was coloured darker than the body area
(Fig. 30). At the end, a thin layer of glaze paste was applied over
the surface. As a second layer, glaze paste was mixed with
a small amount of white and layered on the mesial and distal
marginal ridges (Fig. 31). By using Zolid Gen‐X, aesthetic and
functional restorations were produced (Fig. 32).
The typical cementation protocol was followed, but retraction
cord was used and extra care regarding moisture and contamination was taken. Especially the fitting surfaces of restorations can be contaminated by salivary protein during
the try‐in stage and have to be cleaned, for example with
KATANA Cleaner (Kuraray Noritake Dental; Fig. 33). PANAVIA V5
(Kuraray Noritake Dental) resin cement was used. To control
the value, bleach shade cement was chosen. Cementation
was performed under the dental microscope (Fig. 34).
Result
In this case, the position of the teeth limited the thickness of the
crowns and there was no space for ceramic layering. Anterior
bridges involving canines must be strong and aesthetic. In such
cases, Zolid Gen-X is the best material because it offers strength
and aesthetics. In addition, the use of Zolid Gen-X in combination with Ceramill M-Smile in the fabrication of the anterior
monolithic crowns produced a highly aesthetic result (Fig. 35).
The patient had a beautiful smile after cementation of the anterior
monolithic zirconia restorations in her mouth (Fig. 36).
36
about
Atsushi Hasegawa gained his licence
to practise as a dental technician in
1996 and completed postgraduate
studies at Kanagawa Dental University
in Yokosuka in Japan in 1998.
He then worked for 11 years in a dental
laboratory in Tokyo in Japan,
where he acquired specific knowledge
and skills in the field of occlusal concepts.
In 2008, he opened his own laboratory, Organ Dental Lab,
in Chigasaki in Japan. Today, Hasegawa transfers his
knowledge through lectures in Japan and worldwide.
He can be reached through his website, www.organdental.jp.
Dr Yusuke Takayama graduated
from Nihon University in Tokyo
in Japan in 2004. He has been in
private practice since then and opened
his own dental office, Shinyurigaoka
Minami Dental Clinic, in Kawasaki
in Japan in 2016. Since 2019,
he has been a lecturer at
the Dental Arts Academy in Tokyo.
He is a member of the Society of Japan Clinical Dentistry
and Japan Association of Microscopic Dentistry.
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Chairside fabrication of a
nano-ceramic hybrid composite
endocrown for a severely damaged
molar after endodontic treatment
Drs Alejandro Bertoldi Hepburn & Matías Scazzola, Argentina
Introduction
Many authors recommend not using endodontic posts
in the reconstruction of endodontically treated molars,
as they are not necessary for the retention of the restoration or for a better mechanical prognosis.1, 2 For the
restoration of severely damaged endodontically treated
molars, endocrowns made of highly filled nano-hybrid
composites are a valid alternative to conventional
post build-ups and fixed dentures. Compared with
conventional methods, endocrowns offer good aesthetics, better mechanical performance, lower costs
and less clinical time for their fabrication, among other
advantages.3, 4
Endocrown restorations are luted by adhesive cementation using the enlarged pulp chamber and the remaining coronal structure as the most effective retention area.5 This minimally invasive treatment concept
has shown the following advantages in comparison
with the classical post and core approach: preservation of healthy tooth hard tissue, reduced risk of catastrophic failures such as root fractures or perforation
while preparing the post space, lower contamination
of the endodontic system, fewer failures in creating the
necessary adhesive interfaces, no need for excessive
interocclusal space, fewer clinical appointments and
lower costs of treatment.
The longevity of these restorations is similar or even
better than that of conventional restorations on glass
fibre-reinforced composite posts.6, 7 Compared with
the insertion of posts, endocrowns are considered
a more conservative approach that allows easier reintervention and access to root canals and that has
reduced technical steps during fabrication (avoiding
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cementation of the post, creating a core build-up, producing a provisional crown, etc.), reducing treatment
time and costs and the risk of endodontic reinfection.8
This article presents the endodontic retreatment and
coronal restoration of a badly damaged mandibular
molar using a nano-ceramic hybrid composite block for
the fabrication of an endocrown by means of a CAD/CAM
technique.
Case, diagnosis and treatment planning
A 40-year-old male patient came to our endodontics
department at the University of Buenos Aires’ School
of Dentistry in Argentina due to toothache. At the intraoral examination, the restoration on tooth #46 presented with a mesial fracture. The preparation margins
showed a clear marginal gap all around the restoration,
indicating possible microleakage. The massive loss of
dental hard tissue was particularly evident on the lingual side, and on the buccal side, the enamel margin
was discoloured from grey to brown. The interproximal
contact points between tooth #46 and neighbouring
teeth had been lost. Teeth #47 and 45 appeared to be
tipped towards the first molar.
The reason for the spontaneous pain was the endodontically treated tooth #46, which had been previously restored with an amalgam filling. There was also
inflammation in the apical area of the molar evident
from the intra-oral palpation.
In the radiographic examination, the amalgam restoration showed open margins, especially on the mesial
side (Fig. 1). The endodontic treatment was defective:
the root canal preparation appeared to have been inadequate, and both the 3D seal and the working length
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case report
1
2a
2b
|
3
Fig. 1: Radiograph of the pre-op situation showing insufficient endodontic treatment of tooth #46. Additionally, an amalgam coronal restoration with
microleakage was detected. There were also apical lesions evident around both roots. Both neighbouring teeth had migrated towards tooth #46 and closed
the interproximal spaces. Figs. 2a & b: Radiographs of the endodontic treatment. Working length control (a). Check of the extension of the Master gutta-percha
points (b). Fig. 3: Post-op results of the endodontic treatment. A proper 3D seal had been achieved. The working length and sealing had been corrected.
The extra distal root canal had been found, treated and sealed.
were insufficient. A canal in the distal root seemed not
to have undergone any endodontic treatment. Irregular root morphology compatible with hypercementosis
was observed in the apical half of the roots of tooth #46,
showing an increase of volume of a round shape.
A widening of the periodontal space over almost all of
its extent could also be observed. A significant apical
lesion of the distal root and a smaller one of the mesial
root were revealed as well.
The patient was diagnosed with a defective amalgam restoration on endodontically treated tooth #46
with microleakage, acute periapical periodontitis with
spontaneous pain, and a ball-shaped morphology of
both roots (hypercementosis). The tooth required endodontic retreatment and a new coronal restoration.
Endodontic retreatment and immediate fabrication
and insertion of the definitive coronal restoration were
planned to be carried out in the same clinical session.
The clinical situation and the intended therapy were
explained to the patient, and the patient accepted the
therapy recommended.
Timeline of treatment steps
The first step was the endodontic reintervention. After
local anaesthesia, the operative field was isolated with
a dental dam, and a dental dam clamp was placed
around tooth #46. The old amalgam was removed,
taking care to preserve sound tissue. Once the endodontic filling had been reached, remnants of amalgam and cement were carefully removed. The endodontic filling was removed with rotary instruments
for canal shaping and retreatment (ProTaper Universal
retreatment files, Dentsply Sirona). The coronal third
was treated with the D1 file (30/.09), the medium third
with the D2 file (25/.08) and the apical third with the
D3 file (20/.07). An entirely mechanical removal proce-
dure was performed to avoid the use of endodontic
solvents. The non-treated root canal in the distal root
was located and manually prepared with size 15, 20
and 25 K-files. The same files were used for the radiographic check of the working length, which was measured with an apex locator (Fig. 2a).
Once the working length had been determined, the root
canals were prepared and cleaned with the ProTaper
Next system (Dentsply Sirona). This system has three
main files, X1, X2 and X3, with a variable taper. Before
moving to the next file in the sequence, the root canals
were irrigated with a 2.5% sodium hypochlorite solution
(EndoActivator, Dentsply Sirona).
After shaping, irrigation with a 17% EDTA solution was
performed for 1 minute in the root canals, this antibacterial solution being indicated for removal of the
smear layer. Final irrigation was done with a 2.5% sodium hypochlorite solution. The root canals were finally
dried with sterile paper points.
ProTaper Next Conform Fit gutta-percha points
(Dentsply Sirona), matched to the size of the canals prepared with ProTaper Next files, were inserted in each
root canal and checked with an intra-oral radiograph
(Fig. 2b). The root canals were then filled by means of a
lateral condensation technique with cold gutta-percha
and manual spreaders. Accessory gutta-percha points
and an endodontic sealer (ADSEAL, Meta Biomed)
were used as well.
Once completed, the gutta-percha points were cut
manually with a hot instrument. After cleaning the
dentine surface of the pulp chamber floor, a radiographic control was carried out (Fig. 3). The results
were promising. The radiograph showed properly prepared, well-filled root canals, including the canal in the
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4
5
Fig. 4: Situation immediately after root canal filling. Gutta-percha needed to be cut properly. Poor condition of the residual dentine. No longer any enamel on
the distal area. Fig. 5: Large volume of the enlarged pulp chamber. There were undercuts over the lingual wall. The remaining tissue was thin.
critical distal root. In all four root canals, the working
and filling lengths were now well established.
adhesion to the floor of the pulp chamber; hence, this
was done under the microscope (Fig. 6).
After the endodontic retreatment, a great loss of tissue was observed in the coronal part of the molar,
including the loss of enamel in the distal and lingual
sides of the tooth crown, and the residual dentine was
thin and strongly discoloured (Fig. 4). Nevertheless,
the area that would serve for adhesive bonding to
the planned endocrown was large and voluminous.
This space, an enlarged pulp chamber, consisted of
the original pulp chamber augmented by the access
cavity, endodontic instrumentation and iatrogenic
tissue removal (Fig. 5).
Since some excess material had accidentally been left
behind, 1–2 mm of gutta-percha inside each root canal
was removed using the tip of an ultrasonic device
without water cooling and with manual excavators.
Removing excess gutta-percha and cleaning away the
endodontic sealer are important steps for enhancing
The next step was the covering of the floor of the enlarged pulp chamber and its walls with a flowable
composite material in order to close the access to the
root canals, to fill the undercuts and to shape the final
preparation. Pretreatment with total etching using 37%
phosphoric acid of enamel and dentine was carried
out over the enlarged pulp chamber for 15 seconds,
the phosphoric acid was aspirated and the conditioned
surface rinsed for 20 seconds (Fig. 7a). Afterwards,
a universal dual-polymerising adhesive (Futurabond U,
VOCO) was applied to the conditioned surface, which
had been dried off according to the instructions for
use (Fig. 7b). The adhesive was rubbed carefully for
20 seconds and dried for at least 5 seconds with a gentle air
stream for the evaporation of the solvent and remaining
water. Light polymerisation of the adhesive was then
performed for 10 seconds with a high-power LED curing
light (Celalux 3, VOCO).
6a
7a
6b
7b
Figs. 6a & b: Gutta-percha cut by 1–2 mm inside each root canal with an ultrasonic tip and manual excavators. Figs. 7a & b: Etching of the dentine and enamel
with phosphoric acid (a). Application of a universal adhesive after rinsing and drying (b).
54
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case report
8
9
|
10
Fig. 8: Floor of the cavity and undercuts covered and sealed with Rebilda DC. Fig. 9: Polymerising of the core build-up composite with the Celalux 3.
Fig. 10: Cavity shaped, excess material removed and margins smoothed.
Subsequently, a layer of a dual-curing core build-up
composite (Rebilda DC, VOCO) was applied over
the cavity floor and the lingual wall where the
undercuts were present (Fig. 8). The build-up
material was light-cured immediately thereafter
(Fig. 9) and the cavity reshaped (Fig. 10), resulting in
a smooth floor and preparation margins and a voluminous enlarged pulp chamber. The residual tissue,
especially the enamel over the mesial side, could be
preserved.
Owing to the loss of interproximal contact points that
had occurred in the previous years, both teeth #47
and 45 had tipped towards tooth #46, bringing it into
contact with them subgingivally. After their separation
with a thin diamond bur, the appropriate space needed
was recreated to allow proper coronal restoration of
tooth #46. Finishing and polishing reciprocating tips
for the EVA system (KaVo Dental) were used afterwards to smooth and polish the reduced interproximal
surfaces. Immediately thereafter, the dental dam was
removed and retraction cord was placed around the
molar (Fig. 11). A digital impression was carried out
using the CEREC Omnicam (Dentsply Sirona; Fig. 12),
11
12a
capturing the preparation margins of the endocrown
cavity perfectly.
After general design of the restoration, the impression file was transferred to another design program
(exocad) in order to digitally generate the restoration
(Fig. 13). After completion of the digital design of the
endocrown, the file was returned to the CEREC system. Once this had been done, the restoration was
fabricated by milling a block of a highly filled nanoceramic hybrid material (Grandio blocs, VOCO; Fig. 14).
The processing of the composite block took about
10 minutes. Afterwards, a light-curing characterisation material (FinalTouch, VOCO) was applied
to pretreated furrows and fissures (Fig. 15), lightcured and occlusally covered with a packable or
flowable composite (or a mixture) and light-cured.
The endocrown was polished with rubber points and
brushes (Figs. 16 & 17).
During the CAD/CAM of the restoration, the patient
remained in the clinic. Once the restoration had been
finished, it was taken to the clinic, disinfected in alcohol for 3 minutes and tried in the cavity. The fit was very
12b
Fig. 11: Final preparation prior to taking the digital impression, for which retraction cord had been placed. Figs. 12a & b: Margins and various details of
the cavity preparation well captured in the digital impression.
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13a
13c
13b
13d
Figs. 13a–d: Design performed in exocad (a & b). Restoration digitally placed inside the block to support the milling process (c & d).
precise and so was the occlusal relationship, so no
adjustments were done. The restoration covered the
remaining tissue, and the portion inserted in the enlarged pulp chamber was voluminous to guarantee the
retention of the endocrown and protect the residual
dental tissue.
After several try-in tests, the adhesive luting could take
place. For this purpose, the inner surface of the endocrown had been previously roughened through
sandblasting with 50 µm aluminium oxide particles at
100–200 kPa, cleaned using brushes and distilled
water and detergent, rinsed with water and dried with
air stream (Fig. 18a). Thereafter, a silane coupling agent
(Ceramic Bond, VOCO) was applied and let dry for
60 seconds (Fig. 18b). Once again, retraction cord
was placed in the gingival sulcus to displace the free
gingivae and prevent fluids from affecting the adhesive process, and Teflon tape was used to protect the
neighbouring teeth (Fig. 19).
The newly covered cavity was etched with 37% phosphoric acid, rinsed with water, dried and pretreated
with Futurabond U. A dual-curing cementation composite material (Bifix QM, VOCO) was applied to the
endocrown (Fig. 20) so that it could be luted in the
tooth. After application of continuous light pressure,
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2 2023
it was fitted into place correctly. Excess cement was
removed with micro-brushes from the lingual and buccal sides and with dental floss from the interproximal
spaces. The material was then light-cured for 1 minute
from the lingual and buccal sides. The margins were
optimised with finishing diamond burs and polished
with rubber points and brushes. The interproximal
spaces were checked for excess material. The occlusion was checked, and no adjustments were needed
(Figs. 21 & 22).
Results
The endodontic retreatment and endocrown restoration of a badly damaged molar were carried out in
a single clinical session. Postoperative clinical photographs and radiographs verified the results of the treatment: the molar recovered its anatomical forms and
thus its function.
The endocrown restoration and the build-up material
occupied the enlarged pulp chamber completely;
the access to the root canals was thus closed hermetically. The margins of the endocrown also showed an
adequate seal. The tight seal of the restoration will play
a crucial role in the long-term results of the endodontic
treatment.
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case report
14
|
15
Fig. 14: Milling of the block in the milling machine. Fig. 15: Application of white stains to characterise the colours of the restoration.
Regarding the endodontic retreatment, the preparation and seal of the root canals were appropriate,
a suitable 3D seal was achieved and the working
length was corrected. Also, the previously untreated
root canal in the distal root was properly prepared and
sealed (Fig. 23).
The microscope-assisted cleaning of the gutta-percha
and endodontic sealer are expected to enhance the
adhesion over the floor of the cavity.1 The quality of
the coronal restoration is at least as important for periapical health as the quality of the endodontic treatment
itself.9
Discussion
In one clinical session, the badly damaged tooth #46 was
endodontically retreated and restored with an endocrown
fabricated chairside by means of CAD/CAM technology.
This combination is both time- and money-saving.
In the case of endodontically treated teeth, several
advantages result from carrying out the definitive
coronal restoration in the same session as the postendodontic treatment of the root canals.10 It ensures a
better coronal seal and increases the success of the
endodontic treatment. Moreover, the time between
the root canal filling and the coronal restoration should
be as short as possible to avoid root canal recontamination.11 Better mechanical protection is provided to
residual tissue from the very beginning of the process if a definitive restoration is inserted in the same
session. In fact, the probability of dislodgement of the
definitive restoration is much lower compared with
that of a provisional one. The final function of the tooth
is restored from the very beginning of the process,
16
17
The radiographically diagnosed hypercementosis
of tooth #46 was a factor with no therapeutic consequences. This hyperplastic formation of radicular
cementum could have arisen from irritation of infected
root canals and/or by the hyperactivity or hypoactivity
of the tooth root due to dysfunctional occlusal forces
associated with the defective anatomy of the old
restoration.
Fig. 16: Occlusal surface of the finished endocrown. Fig. 17: Inner surface of the endocrown. Note the extensive portion for bonding in the enlarged pulp
chamber preparation of the molar.
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18a
18b
19
Figs. 18a & b: Inner surface of the endocrown after sandblasting with aluminium oxide particles, followed by cleaning of the surface with distilled water and
detergent (a). Application of Ceramic Bond (b). Fig. 19: Tooth ready for the adhesive pretreatment with Futurabond U. Teflon tape protecting the neighbouring
teeth and retraction cord placed.
subsequently offering greater comfort to the patient.
Patients normally appreciate having the process finished in just one clinical appointment although it is a
longer session.
The material of choice for this endocrown was a
prepolymerised highly filled nano-ceramic hybrid
composite. Together with lithium disilicate-reinforced
glass-ceramics, feldspathic ceramics and polymerinfiltrated feldspathic ceramics (hybrid ceramics), highly
filled nano-hybrid composites are considered among
the most suitable for the fabrication of endocrowns.
Case reports and clinical studies have shown additional advantages of the fabrication of endocrowns with
nano-ceramic hybrid composite like the one used for this
case: the greater elasticity results in higher absorption
of mechanical stress and thus higher protection of
weakened tooth tissue.8, 12, 13
Compared with a conventional provisional indirect
restoration made of regular composite inserted and
20
21
polymerised over a plaster model, an industrially
polymerised highly filled nano-ceramic hybrid composite
such as Grandio blocs used in this case shows
better physical and mechanical properties13 and features a higher degree of polymerisation. The higher
degree of polymerisation reduces water absorption
and degradation in the oral environment. A restoration made from Grandio blocs is expected to have
a higher fracture resistance, no chipping fractures
and no deformation (because it is prepolymerised).
Compared with analogue procedures, the CAD/
CAM approach adds precision to the final restoration.12
The cavity preparation is also a sensitive aspect
when working with endocrowns. Butt joint occlusal margins are preferred, and axial reduction is not
recommended.2, 4 Some recent investigations have
suggested that butt joints implemented with 20° bevels
are more effective than flat butt joints.14 In this case,
no axial reduction was performed.
22
Fig. 20: Cementation of the restoration with Bifix QM after acid etching, rinsing and drying of the tissue and core build-up composite and application of Futurabond U.
Fig. 21: After placement of the restoration and removal of excess adhesive cement and polishing of the margins and the surface. Fig. 22: After polishing
of the occlusal surface. The gingivae had been injured and needed to heal.
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[59] =>
case report
|
Subgingival preparation margins must be accessible,
and this can be achieved, among other methods,
by placing retraction cord before taking conventional
or digital impressions. No contact should be present
between the cavity and the adjacent tooth. The occlusal space should be adequate as well and have been
carefully checked previously.12
According to various studies, the adhesion protocol
when cementing the restoration is also crucial.
The dentine of an endodontically treated tooth and
especially the dentine of the root canal and of the
floor of the pulp chamber might represent an altered
substrate, offering lower adhesive power.15 Clinically,
tooth #46 had become brown and translucent because
several years had passed since the tooth had lost its
vitality. Research indicates that dentine in this condition
might have modified collagen (lower density collagen
with short and cut fibres). This could negatively affect
the adhesive technique when depending exclusively
on the collagen fibre–adhesive–hybrid layer. Dentinal
tubules should be open in order to generate resin tags
and compensate for the loss of adhesion due to the
poor quality of the collagen.16
In this clinical situation, by the time the restoration
process had started, the dentinal tubules were open,
endodontic treatment having just been completed
and before the adhesive post-endodontic treatment.
Here, it was important not to use rotary instrumentation for removing the excess gutta-percha, as
this would have generated a secondary smear layer.
This is more difficult to dissolve, the usual smear layer
being associated with plasticised gutta-percha and
endodontic sealer.17 Thus, for such cases, the use of
ultrasonic tips and hand instrumentation is preferable for removing excess gutta-percha. Excess endodontic sealer should also be carefully removed with
alcohol or a detergent substance using micro-brushes
or sponges (e.g. Pele Tim, VOCO). Carrying out totaletch conditioning using a 35–40% phosphoric
acid gel after removing gutta-percha and sealer
excess will also help keep the dentine clean and its
tubules open.
Conclusion
Performing the restoration immediately after endodontic
treatment ensures a better and immediate coronal
seal, ensures immediate protection of the sound tissue, saves time, and offers comfort and confidence
to the patient and the clinician. Endocrowns made of
the highly filled nano-ceramic hybrid composite Grandio
blocs represent a new alternative for treating badly
damaged teeth, especially molars, while freeing the
dentist from the use of root posts. In vitro and clinical
studies as well as clinical experience with this material
23a
23b
Figs. 23a & b: Radiographs before (a) and after (b) treatment, showing
dramatic differences. The endodontic treatment had been corrected and
the restoration was well adapted and shaped. The interproximal relationships
had been re-established through the anatomy of the endocrown. There were
no gaps between the restoration and the endodontic filling. The sealing of the
endodontic treatment was complete and tight.
are promising. These endocrowns represent a less
invasive and better mechanical option compared with
posts and crowns.
Editorial note: Please scan this QR code
for the list of references.
about
Dr Alejandro Bertoldi Hepburn
is an associate professor at the
endodontics department of the
University of Buenos Aires’ School of
Dentistry in Argentina and a lecturer
in postgraduate prosthodontics at the
Universidad Del Desarrollo’s dental
school in Concepción in Chile.
Dr Matías Scazzola
is an assistant professor
at the endodontics department
of the University of Buenos Aires’
School of Dentistry in Argentina.
2 2023
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[60] =>
| industry report
Digital workflow for dental
offices and laboratories—
where are we now?
An interview with Niels Plate from Dentsply Sirona
© Dentsply Sirona
By Magda Wojtkiewicz, Dental Tribune International
In an interview with Dental Tribune International at IDS, Niels Plate spoke about the present and the future of digital technologies in dentistry.
During the 2023 International Dental Show (IDS),
Dental Tribune International talked to Niels Plate, group
vice president of digital devices and equipment at
Dentsply Sirona, about the present and the future of
digital technologies in dentistry.
Why should dental professionals go digital—and why
would you recommend it?
I think that many dental professionals are already digital to
some extent, whether they know it or not, because
often they have very simple intra-oral cameras, which just
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2 2023
take photos of the teeth, integrated into their treatment
centres that take digital images. Many dental professionals have digital radiographic units too, and now many
dentists also have 3D scanners, which are all digital.
Why should they go digital? Generally, this improves the
treatment outcome and increases the efficiency of the
practice. At the moment, in dentistry particularly, but also
in many other industries, the key bottleneck is labour:
we don’t have enough dentists or assistants or receptionists or lab technicians. So all over the industry, there is a
[61] =>
|
© Koelnmesse
industry report
Dentsply Sirona presented interactive events, exciting digital experiences and live demonstrations at IDS.
severe shortage of qualified people. Digital helps people
to become more efficient, to produce reproducible results and to get better clinical outcomes, but also to focus
on the core of the job, and this means the patient and
the clinical result.
I can give one very simple example, the documentation
of our new Primeprint Solution. It automatically documents each print and allows the dentist to simplify data
storage in one PDF file. All necessary data can be summarised in one PDF file, which the dentist can then use
to fulfil his legal obligations, eliminating the need to take
any notes, to have any records and to do anything manually; all the work is done automatically. This is exactly
what I mean. This is work which is a waste of qualified
time for the dentist or assistant. This is where we can
help.
What are the latest digital devices and equipment
Dentsply Sirona is showcasing at IDS 2023?
Dentsply Sirona is showcasing many new products at
IDS, but let’s go through them in the sequence they were
introduced. The first one is the Axano. It’s a dental chair,
but of course, it’s much, much more, because it is built
to ideally support the individual way of working of each
dental professional. What does that mean? It means that
as a dentist you can use three settings, but you can
basically individualise the whole workflow according to
your requirements, working style, training and working
preferences. This helps to save time. By presetting the
dental chair regarding how you do an endodontic treatment or how you do a restoration, you don’t need to set
the value each time, allowing you to work fluently without
taking your hands off the patient because all the functions of the dental chair can be controlled by foot. This
allows you to switch smoothly through your preset
menus. Of course, Axano has many other excellent
features, like a massage function for the patient, but the
most important is that it combines an efficient workflow
with ergonomics.
The next product Dentsply Sirona is showcasing at IDS
is the Primeprint 3D-printing system. This is our first
“Digital helps people
to become more efficient,
to produce reproducible
results and to get
better clinical
outcomes (...).”
2 2023
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[62] =>
© Koelnmesse
| industry report
Trade show attendees experienced the digital universe at Dentsply Sirona’s booth.
3D printer, and it was very important for us to have a fully
digitalised workflow offering a complete solution for the
dentist.
Primeprint Solution runs mostly automatically, employing
a robotic arm that handles the printed object. It uses the
patented cartridge system to keep the printed object enclosed so that no chemical fumes reach the user. The
user then switches over to the post-processing unit by
pressing a button, and that again proceeds fully enclosed
and completely automated, producing the final washed
object. Primeprint Solution is designed for all the common dental applications, which start with models, then
also night guards, splints, surgical guides, temporary
restorations and mock-ups.
But there is another product I’d like to mention, Primescan
Connect, which is a version of Primescan, our highperforming intra-oral scanner now available in a laptop
configuration. The laptop version was requested by many
markets. This feature makes the workflow easier and
more ergonomic.
Primeprint Solution and Primescan Connect—are connected to DS Core, our cloud-based solution that provides up to 15 TB of cloud storage. Of course, DS Core
can connect all services and data, including radiographs,
clinical photographs and case files, and dentists can
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share all the data with some clicks or access it from
wherever they are. This data can be safely shared with
partners, with labs and with the patient. In the future, DS
Core will provide further solutions, because the possibilities of its use will continue to evolve.
Here at Dentsply Sirona’s IDS booth all presented devices are connected to DS Core.
Is Primeprint Solution designed exclusively for dental offices, or can it also be used in dental labs?
Our first intention with Primeprint was to have a chairside solution, but it is designed for both dentists and
dental technicians, depending on the size and set-up
of the dental lab. For a very big lab, then I would say
that a more industrial type of product would be needed,
but for the typical family-owned dental lab in Germany,
Primeprint is a very good solution. The biggest advantage of Primeprint is that it is fully automatised, so it
can run the entire printing process, including postprocessing, and safely deliver the final printed product,
providing a chairside solution. This device meets so
many high standards that you could even put it in your
living room.
What role does education play in transitioning dentistry to digital, and how is Dentsply Sirona fulfilling
this role?
[63] =>
industry report
Education is very important to Dentsply Sirona and I think
we have all learned during the COVID-19 pandemic
that we can also digitalise education a little bit more.
Dentsply Sirona offers education programmes through
the Dentsply Sirona Academy. In our many international
education centres around the world, the largest being in
Charlotte in North Carolina in the US and in Bensheim in
Germany, we provide the knowledge, skills and inspiration. Among the clinical educational material available
on our academy platform, we have just published
on-demand curricula.
We also offer more and more digital content on various
platforms, like YouTube, where dental practitioners can
get quick training on subjects of interest, especially on
topics related to digital, or when they just want to get instructions on how to do something, how to maintain a
device or how to use certain functions. All this information
is available online.
I believe that this is the way forward, because that is
exactly how we behave in our non-professional lives.
When I needed to change the battery in my car key, what
did I do? I opened YouTube and searched for a video on
how to do that. I didn’t open the instruction manual;
I found the information online.
Dental professionals also search for information in this
way, and Dentsply Sirona is ready to provide them with
the answers they are looking for where they are looking
for it. Apart from that, we are putting a huge focus on user
experience.
The use of digital technology is a growing trend.
What do you think the next five to ten years will bring
in terms of new products or workflows?
Yes, I think that in the coming years the use of digital technology will still be a growing trend.
What we are now seeing is that digitalisation is moving
quicker and quicker, producing a huge amount of data,
and this will make it mandatory to move things into the
cloud, same as we saw with office software or in many
other industries. Moving to the cloud will give us not only
unlimited storage but also unlimited computing power,
which then, of course, will enable things like artificial intelligence in support of the dentist. I would expect then
bigger breakthroughs in diagnostics to help the dentist
to do an initial diagnosis and create a treatment plan to
solve the problem identified.
I think that design of dental restorations will be much
more automised and that these services which are still
done manually will become more and more generic.
This technology, called biogeneric, is already known to
CEREC users, but will evolve and become define a new
standard way of working. Today, you can imagine that
|
automation will move further and further and reduce the
need for the dentist to amend the final design, making
results reproducible.
I believe that another important area is outcome simulation. A very important part of dentists’ work is communicating with their patients about the outcome of the treatment planned. We can see that very well at the moment
for aligner treatments. A number of companies offer an
outcome simulator, which shows patients how their teeth
will look after aligner treatment. Of course, this has to
be transferred to other treatments to enable dentists to
show patients’ their smiles after treatment and give them
a treatment choice.
“Moving to the cloud
will give us not only
unlimited storage but also
unlimited computing power,
which then, will enable things
like AI support (...).”
The last area I would like to mention is equipment
efficiency to keep everything well maintained and to
increase uptime and reduce downtime. Treatment
management and remote servicing are other areas which
we are actively working on. We can see the first results in
DC Core already today, and this will reduce service costs
significantly. We will increase the number of cases for
which we can fix any issue remotely, without sending a
service engineer to the dental practice, which means that
the dentist can continue working. We will enable bigger
structures, like dental service organisations, to manage
their fleet and make sure that all their facilities are running
and service their dentists well.
That is in a nutshell what I expect, but of course, there
is much more. But there is also a natural limit to what
can be done in a certain amount of time.
Editorial note: More information about the products can
be found at dentsplysirona.com.
2 2023
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[64] =>
| manufacturer news
Next-generation digital impression solution
3Shape’s TRIOS 5 Wireless intra-oral scanner
digital impression taking smoother and faster. Significantly, because of
its new scanner tip design, TRIOS 5 does not need calibration.
Simply hygienic—
a new standard in patient protection and infection control
TRIOS 5 reimagines intra-oral scanner design. The scanner is
hygienically sealed up to its battery inlet, leaving no cracks or
crevices in which contaminants may collect. A sapphire glass window
encloses the autoclavable tip to create a sturdy microbial barrier
between the patient and the scanner. Additionally, single-use body
sleeves cover the entire area touched by the dental professional
to reduce the risk of cross-contamination. These changes make
TRIOS 5 especially easy to clean and disinfect.
TRIOS 5 complies with the US Food and Drug Administration’s
most recent hygiene requirements for dental devices and has
received market clearance from the agency.
Since its release in late 2022, 3Shape’s TRIOS 5 Wireless has won
Best New Imaging Product in DrBicuspid’s 2023 Cuspies Awards,
IOS of the Year in the Institute of Digital Dentistry’s 2022 Intraoral
Scanner Awards and High Technology Launch of the Year in the
Dentistry magazine’s 2022 Dental Industry Awards. It is clear that
both the industry and dental professionals recognise the nextgeneration digital impression solution for its ease of use, ergonomics
and hygienic design.
Dr Austin Vetter, a US dentist, recently purchased his second
TRIOS 5 Wireless. He commented: “3Shape has unlocked the key
to happiness for me in dentistry. With their scanners and software,
I feel like we can achieve anything.”
Simply ergonomic—30% more compact body design
TRIOS 5 Wireless is 20% smaller and 30% lighter than the previous
scanner model. The scanner, battery and tip weigh only 300 g.
With a sleek, pen-grip design, TRIOS 5 houses an improved battery
that scans for up to 66 minutes on a single charge. Its simple two-button
operation makes capturing scans quick and easy, and the wand can
also be used as a remote control to navigate the software.
Simply effortless—intelligent alignment technology during scanning
TRIOS 5 introduces the all-new ScanAssist engine with intelligent
alignment technology to ensure precise scanning. ScanAssist optimises
the scan to remove misalignment and distortion in 3D models. Haptic
feedback and an LED ring also guide the user during scanning to make
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Digital dentistry at your fingertips—powered by 3Shape Unite
TRIOS 5 Wireless, like all 3Shape TRIOS scanners, includes the
3Shape Unite platform free of charge. 3Shape Unite connects
dentists online to over 75 seamlessly integrated dental companies,
treatment solutions and practice management systems and more
than 8,000 laboratories. The user can connect to treatment partners
simply by clicking on their respective apps.
TRIOS owners can also take advantage of the free, clinically approved
3Shape intuitive engagement apps that are included with the scanner.
These include the TRIOS Treatment Simulator and TRIOS Smile Design
apps with tooth whitening simulation, TRIOS Patient Monitoring and
TRIOS Patient Specific Motion for jaw tracking. These engagement
apps help dentists to boost treatment acceptance.
TRIOS 5 service agreement for peace of mind
When it comes to protecting dentists’ investment, TRIOS 5 Wireless
offers two TRIOS service agreement options that dentists can
sign up for. TRIOS Care, which is included free for the first year,
provides personal instruction, training, unlimited support, drop
coverage and express replacement if the scanner is damaged.
Alternatively, dental professionals can switch to TRIOS Only after
their first free year of TRIOS Care. TRIOS Only is a scan-ready free
service agreement with no monthly costs.
For additional information, visit 3Shape website.
www.3shape.com/TRIOS5
[65] =>
manufacturer news
|
DEXIS IOS Solutions expands its portfolio and ecosystem
New end-to-end digital workflows for dental practitioners
DEXIS IOS Solutions is pleased to announce the expansion of its
portfolio and ecosystem through new digital end-to-end workflows. The new and enhanced workflows are designed to align
with the objective of DEXIS IOS Solutions to support dental practitioners in accelerating their workflows, resulting in increased
productivity and an improved patient experience. To reinforce
this objective, DEXIS IOS Solutions is focused on three crucial
principles: ease of use, productivity and practice expansion.
Practitioners can now easily expand their range of services
through aligner and denture treatments, as well as in-house printing,
offering their patients personalised and innovative care.
The new prescriptive workflows are being developed concurrently
with ongoing innovations in the broader portfolio of Envista
Holdings Corp., beginning with a new orthodontic workflow in
combination with Ormco’s Spark clear aligners that enables practices to
easily add aligner therapy to their treatment options. A new patient
engagement app within DEXIS IS ScanFlow enables practitioners
to show patients a simulated outcome of their orthodontic treatment, enabling them to visualise the treatment outcome chairside.
Integrated digital transfer of the data sets to the Spark software
streamlines the process, facilitating prompt treatment.
“By further integrating DEXIS IOS Solutions into the broader Envista
offerings, we are providing dentists with the solutions they need to provide
exceptional and personalised care for their patients. We are committed
to helping dental practitioners improve patient outcomes and grow their
practice through digital innovation,”
said Amir Aghdaei, president and CEO of
Envista.
DEXIS IOS Solutions
has also collaborated with
S p r i n t R a y ’s
3D-printing ecosystem for definitive ceramic crowns to simplify
in-office printing and make same-day restorations a reality.
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[66] =>
| manufacturer news
SprintRay Cloud Design leverages
artificial intelligence to streamline the
design of crowns, appliances and surgical guides within minutes. Practitioners
can scan their patients with any DEXIS
intra-oral scanner and upload the data set
directly from either DTX Studio Clinic or
IS ScanFlow to the SprintRay portal, eliminating the need to manually select files,
enter redundant patient information and
design the restoration or appliance.
“By combining DEXIS intra-oral scanners with
SprintRay’s ecosystem, dental practitioners can
offer same-day delivery of crowns and appliances, increasing
their productivity by completing more procedures in a shorter
amount of time,” said Aghdaei. “Offering same-day restorations
can give practitioners a distinct competitive advantage, as patients
often prefer the convenience of single-visit appointments, enabling
dental practitioners to expand their services and attract patients
seeking fast and convenient dental treatment.”
To further enhance the capabilities of the DEXIS IOS Solutions
portfolio, IS ScanFlow (Version 1.0.9) now includes a denture
scanning workflow that streamlines the treatment planning process
by combining the capture of the bite registration and prosthesis
along with the edentulous and denture scans, eliminating the
manual process of matching and aligning data sets by the laboratory.
The software also provides embedded scan tips to optimise and
simplify the edentulous data acquisition.
In addition, DEXIS IOS Solutions is introducing the
IS 3800 wired scanner, which offers the same
high-speed performance as the awardwinning IS 3800W wireless scanner. The
IS 3800 wired scanner is highly ergonomic
and weighs just 190 g without the cable,
making it one of the lightest intra-oral
scanners available. It complements the
IS 3800W scanner, which weighs only 240 g
and is the lightest wireless intra-oral scanner in
the industry.
The latest DEXIS IOS Solutions innovations
provide dental practitioners with access to
intuitive technology that simplifies and streamlines
treatment, thereby boosting productivity. With an extended ecosystem and diverse range of new treatment options, practitioners
can partner with Envista for access to prescriptive end-to-end
workflows or opt for open workflows, which enable collaboration
with their preferred laboratory or manufacturer. The new workflows further align with Envista’s intention to digitise, personalise
and democratise dental care, supporting dental practitioners in
the provision of optimal patient care through enhanced productivity
and predictability of treatment.
For more information about DEXIS IOS Solutions’ products and
services, visit our website.
www.dexis.com
An innovative implant solution
Introducing DS OmniTaper Implant System—
the newest member of the EV implant family
The DS OmniTaper Implant System is an innovative solution that
combines the proven technologies of Dentsply Sirona’s EV implant
family with new features that deliver efficiency and versatility.
Unique to the implant system is an intuitive drilling protocol for
reduced chair time and a pre-mounted TempBase for immediate
restorations and efficient workflows.
The DS OmniTaper Implant System is the newest member of the
EV implant family, alongside the Astra Tech Implant System and
DS PrimeTaper Implant System. The EV implant family offers surgical flexibility to cover virtually every indication. All three implant
systems deliver biologically driven implant designs for natural aesthetics and lasting bone care, have one connection for restorative
simplicity and are optimised for a seamless integration into digital
dentistry workflows.
Like the rest of the EV implant family, the DS OmniTaper Implant
System features the OsseoSpeed implant surface and the conical
EV connection that provides access to the harmonised and
66
2 2023
comprehensive EV prosthetic portfolio for restorative flexibility
and immediate chairside solutions.
www.dentsplysirona.com
[67] =>
register at www.roots-summit.com
ROOTS SUMMIT IS
COMING TO ATHENS
THE GLOBAL DENTAL CE COMMUNITY
Tribune Group GmbH is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or
endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Tribune Group GmbH designates this activity for 18.5 continuing education credits. This continuing education activity has been planned
and implemented in accordance with the standards of the ADA Continuing Education Recognition Program (ADA CERP) through joint efforts between Tribune Group GmbH and Dental Tribune International GmbH.
[68] =>
| practice management
Could placing attachment over
authenticity be the reason behind
dental burn-out?
Dr Huthaifa AbdulQader, Switzerland
Human beings have a need to emotionally bond with
others and to be their authentic selves. In psychology,
these are considered basic survival needs. Infants’ attachment to their mothers improves children’s chances
of survival, and gut feeling informs adults about danger.
Attachment means connection, belonging, loving and
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being loved. Authenticity is the capacity to be in touch
with ourselves and to be able to express and manifest who
we are in our relationships and social interactions.
There is always an inherent fear in moving towards our
authenticity. Ever since our childhood, we have been
[69] =>
practice management
|
our attitudes by detaching ourselves from our behaviours. Only then will the answer come to us.
© Peakstock/Shutterstock.com
Suppressing ourselves in the presence of certain people
is a habit picked up in childhood. We unconsciously
think: “If I am authentic, nobody will like me”. These
habit energies are automatic behaviour patterns that
dictate many of our daily interactions and life decisions,
despite our desire to think rationally. Unless we train
ourselves to confront and change these behaviour
patterns, the same habits will remain.
through various traumatic experiences which caused
us to subconsciously be afraid to express and manifest our authentic selves. Our mind unconsciously pulls
us towards a safe zone by compromising our own
needs in return for social validation. Without recognising, confronting, understanding and accepting this
fear, our need for attachment will always be chosen
over our need for authenticity, and later there will be an
inevitable price to pay.
In situations when we keep suppressing our emotions
for the sake of attachment, we may ask: “Why am I still
acting that way?” This is not an actual question; rather,
it is a statement that implies a feeling of unworthiness.
It is a statement because we subconsciously know of
our self-doubt. It is a self-accusation of lack of unconditional self-worth. Another way to ask the same question is:
“Why am I really pretending to be that way?” By doing
so, we shift our awareness towards compassionate
curiosity. In situations that pressure us to repress our
authentic selves, we need to compassionately question
According to renowned addiction expert Dr Gabor
Maté, addiction is not a choice that we make, nor is it
a disease that we inherit; it is an attempt to solve
a problem. Dr Maté has said: “Pleasure is necessary
for life, however we often lack pleasure in our lives
unless we turn to means that make us temporarily forget about our problems.” Similarly, tendencies to numb
pain, discomfort and the fear of alienation signal the
existence within us of issues which we try our best
to keep at arm’s length. In order to understand and
resolve why we crave pleasure, why we lack comfort
and why we are in pain, we have to look deeper within
ourselves and that can only happen by slowing our life
tempo down. These factors almost always have their
roots in childhood experiences that resulted in compensation through addiction to substances or through
personality patterns, such as seeking validation,
approval and praise from others.
In psychology, burn-out is defined as a state of physical
and emotional exhaustion. It can occur when we experience long-term stress in our job or when we work
in a physically or emotionally draining role. The Slow
Dentistry Global Network teaches that, by treating an
appropriate number of patients per day while implementing its four cornerstones, all dental practices can
achieve a stress-free experience and a painless treatment and all dental practitioners can protect themselves from physical burn-out. However, this does not
necessarily prevent emotional exhaustion. The daily
exposure to a high volume of emotional stressors will
eventually result in dental professionals becoming
unconsciously overwhelmed, anxious or depressed.
The constant exposure to the pain and suffering of patients eventually leads to compassion fatigue, which is
a combination of emotional exhaustion, depersonalisation
and reduced personal accomplishment.
The three main components of stress are:
1) the stressor, which is the external event;
2) the processing apparatus, which is our unconscious
interpretation of the external event; and
3) the physiological response, which is the internal
reaction to the external event.
2 2023
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[70] =>
© mahiruysal/istockphoto.com
| practice management
The components that play the most significant role in
weathering stress in dental practices are our own subconscious beliefs and interpretations. Dental stress is
interpreted subconsciously to the extent that we keep
unconsciously suppressing ourselves in taking on the
emotional burdens of our patients and for the sake
of attachment, desiring to be accepted, loved and
respected; and by doing so, we stay disconnected
from our true selves. We stress ourselves in the clinical
environment to the extent that we actually make ourselves sick. In that way, ultimately, burn-out can teach
us a lesson.
The whole point of this article is for readers to become conscious of the root cause of burn-out. Burnout is not inevitable. However, if you do suffer from
emotional exhaustion, rather than seeing it as a calamity to battle against, see it as an opportunity to learn.
What we have been learning, over and over again, is
that we have never been ourselves. Burn-out indicates
the need to come back to our authentic selves. Unless we as healthcare providers begin to set healthy
boundaries and prioritise self-care, this condition will
continue to persist and affect our job satisfaction and
commitment.
Patient selection is an aspect of ethical dental care
that is misunderstood and misapplied. By refusing to
treat patients who do not align with the set of values
and codes of conduct of their dental practice, dental
professionals can avoid many of the factors that
contribute to emotional burn-out. The Slow Dentistry
Global Network introduces the concept of personal
congruence as a tool to navigate through almost all
challenges and difficulties that dental professionals
may face throughout their careers.
Personal congruence is developed over time, and
the less it is practised, the more confusion and dissonance creep into our relationships with our team
members and patients. It exposes areas of misalignment between our values and our behaviours, thus
serving as a compass for maintaining our well-being.
By coming to know ourselves, we are able to be ourselves—that is why heightened self-awareness is one
of the most important personal skills that every dental
professional is advised to nurture.
Self-awareness requires vulnerability, and for most
of us, being vulnerable is challenging and uncomfortable. So why is it difficult to be vulnerable? The
“The biggest stresses in human beings are emotional ones.
The biggest stressor of all is trying to be who you’re not.”
—János Hugo Bruno Selye, endocrinologist
70
2 2023
[71] =>
|
© Andrea Piacquadio/pexels.com
practice management
Latin word “vulnerare” means “to wound”. Because
our wounds are too raw to confront, we cover up
our vulnerability by using compensatory mechanisms that keep our hearts closed. This emotional
unavailability prevents us from learning how to
practise self-love.
Our childhood traumas have caused many wounds
which have forced us to put on personality layers in
order to protect us from further wounds. These traumas are not events; they are the wounds that we
sustain inside of us which cause us to suppress our
true emotions. The good news is that our authentic
selves are never lost; we can recover our authentic
selves in the same way that people recover after being
sick. To recover means to find something, and when
something is found, it means that it was never lost in
the first place.
Our recovery must come first
so that everything we love
in life does not have to come last
Human functioning is shaped by formative experiences, and we have trouble understanding
those whose formative experiences are different
to our own. All of us live on the same spectrum of
human emotions; some may feel down for a period
and snap out of it afterwards; others may fall into
deep depression and see the world through different lenses.
Those who have never experienced depression may
never be able to relate to those who have, and they
“Only when compassion
is present will
people allow themselves
to see the truth.”
—A.H. Almaas
may become judgemental of them. Nobody should
be a passive recipient of everybody else’s care. We
need to regain our sense of agency, to actually look
at our behaviours, our patterns and our dynamics
and be courageous, open and curious enough to
detach ourselves from them in order to start our own
journey of healing. Let us start by asking ourselves:
“Why am I still numbing myself? Do I really need to
tolerate that patient’s attitude? Am I really still that
infant, a young child who needs to choose attachment over authenticity?” Only then will the answers
come to us.
about
Dr Huthaifa AbdulQader
General secretary of the Slow Dentistry Global Network
www.slowdentistryglobalnetwork.org
2 2023
71
[72] =>
| meetings
International events
Dentsply Sirona World 2023
36th Int’l Dental ConfEx
CAD/CAM Digital
& Oral Facial Aesthetics
21–23 September 2023
Las Vegas, USA
www.dentsplysirona.com/
en-us/lp/ds-world.html
27–28 October 2023
Dubai, UAE
https://cappmea.com
72
2 2023
Formnext 2023
24–27 September 2023
Sydney, Australia
www.fdiworlddental.org/
world-dental-congress-2023
7–10 November 2023
Frankfurt, Germany
www.formnext.mesago.com
EAO-DGI Joint Meeting
GNYDM 2023
28–30 September 2023
Berlin, Germany
www.congress.eao.org/en
24–29 November 2023
New York, USA
www.gnydm.com
ICOI World Congress
ADF 2023
28–30 September 2023
Dallas, USA
www.icoi.org
28 November–2 December 2023
Paris, France
https://adfcongres.com
ESCD Annual Meeting
ROOTS SUMMIT
5–7 October 2023
Wrocław, Poland
www.escdonline.eu/wroclaw-2023
9–12 May 2024
Athens, Greece
www.roots-summit.com/en
© 06photo/Shutterstock.com
FDI World Dental Congress
[73] =>
|
© 32 pixels/Shutterstock.com
submission guidelines
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We can run an unusually long article in
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In short, we do not want to limit you in
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An abstract of your article is not required.
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In addition, please note:
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Questions?
Magda Wojtkiewicz
(Managing Editor)
m.wojtkiewicz@dental-tribune.com
2 2023
73
[74] =>
| international imprint
Imprint
Publisher and Chief Executive Officer
Torsten R. Oemus
t.oemus@dental-tribune.com
Editor-in-Chief
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International Administration
International Headquarters
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All rights reserved. © 2023 Dental Tribune International GmbH. Reproduction in any manner in any language, in whole or in part, without the prior written permission of Dental Tribune International GmbH is
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Dental Tribune International GmbH makes every effort to report clinical information and manufacturers’ product news accurately but cannot assume responsibility for the validity of product claims or for typographical
errors. The publisher also does not assume responsibility for product names, claims or statements made by advertisers. Opinions expressed by authors are their own and may not reflect those of Dental Tribune
International GmbH.
74
2 2023
[75] =>
Partners
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Acc.1249_en_01
[76] =>
Explore 1,000s of apps
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)
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/ Editorial
/ Content
/ Dentsply Sirona, FDI and Smile Train deliver first-ever global protocols for digital cleft treatment
/ Artificial intelligence in dentistry
/ Researchers use generative artificial intelligence to design realistic dental crowns
/ AI may assist in dental implant surgery, localising mandibular canals
/ Is digital dentistry the solution to the sustainability dilemma?
/ Net-zero emissions in dentistry—achievable goal or greenwashing?
/ Aspen Dental’s digital denture transformation - An interview with Eric Kukucka
/ “It is the combination of the many improvements in detail that are advancing implant dentistry today” - An interview with Dr Michael R. Norton
/ Modern workow of immediate zirconia implant surgery utilising dynamic navigation: case studies and benet analysis
/ Screw-retained restoration of a maxillary first molar and second premolar
/ Comprehensive dental rehabilitation with a digital workflow: - A case study
/ Digitally planned highly aesthetic restorations
/ Chairside fabrication of a nano-ceramic hybrid composite endocrown for a severely damaged molar after endodontic treatment
/ Digital workflow for dental offices and laboratories— where are we now? - An interview with Niels Plate from Dentsply Sirona
/ Manufacturer news
/ Could placing attachment over authenticity be the reason behind dental burn-out?
/ International events
/ Submission guidelines
/ Imprint
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