CAD/CAM international No. 2, 2024
Cover
/ Editorial: CAD/CAM innovations transforming dental laboratories
/ Content
/ Resurgence and consolidation in Europe’s dental prostheses and digital dentistry markets: A report on market recovery, growth drivers and industry trends by Donna Santos & Kamran Zamanian
/ Industry news. DS Core for laboratories; Nobel Biocare presents dentistry's first navigated photogrammetry; New 3Shape Dental System
/ “Thinking cloud native has raised the bar” An interview with Dentsply Sirona’s Manfred Müller and Niels Plate
/ Digitalisation for the conventional and analogue dentist: Ten key points, The change is easier and less complicated than you think by Dr Fernando Gérman
/ Predictability of the CAD/CAM workflow in today’s aesthetic cases by Dr Paola Ochoa
/ Same-day dentistry: Replacement of two PFM crowns with zirconia restorations by Dr Frank Heldenbergh
/ Biocompatibility of CAD/CAM biomaterials for bone tissue engineering application by Dr Katharina Pippich et al.
/ Work–life balance—a lifestyle more than a goal by Jerko Bozikovic
/ Manufacturer news: R5, redefining milling and grinding
/ International events
/ Submission guidelines
/ Imprint
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[1] =>
issn 1616-7390 • Vol. 15 • Issue 2/2024
international magazine of dental laboratories
interview
“Thinking
cloud native
has raised the bar”
case report
Predictability of the
CAD/CAM workflow in
today’s aesthetic cases
feature
Work–life balance—
a lifestyle more than a goal
2/24
[2] =>
Anatomically shaped ,
individualised PEEK gingiva
formers and impression posts
Do you want to reduce patient times and increase patient comfort?
The individual PEEK gingiva formers and impression posts support a convenient
patient-oriented workflow. The anatomically designed emergence profile offers
aesthetic and functional advantages in immediate implantations, with the
preservation of the surrounding hard and soft tissues.
Features
Patient-specific emergence profile
Made of biocompatible PEEK
Can be ordered individually or from the same
dataset as a “gingiva former + impression post set”
camlog.com/en/products/cadcam
The individual DEDICAM PEEK gingiva formers and impression posts are offered for the
CAMLOG®, CONELOG®, iSy®, CERALOG® and BioHorizons® implant systems. Only open
impression posts can be ordered for BioHorizons®. DEDICAM® services are not available
in all countries. Please ask your local Camlog / BioHorizons® representative if you have
access to our CAD/CAM services.
DEDICAM®, CAMLOG®, CONELOG®, iSy® and CERALOG® are registered trademarks of
CAMLOG Biotechnologies GmbH. BioHorizons is a registered trademark of BioHorizons.
All rights reserved. Not all products are available in all countries.
[3] =>
editorial
|
Magda Wojtkiewicz
Managing Editor
Shaping the future:
CAD/CAM innovations transforming
dental laboratories
In this issue of CAD/CAM magazine, we dive into the
transformative impact of CAD/CAM technologies on
dental laboratories and explore how these advancements
are redefining the workflow and precision of laboratory-
based dental solutions. In light of digital dentistry becoming an essential element in both laboratories and
dental offices we bring you insights into how innovation
in this area is streamlining processes, enhancing collaboration and pushing the boundaries of what is possible
in the field of dental prosthetics.
This issue presents a close look at recent developments
in Europe’s dental prostheses and digital dentistry markets, showcasing how consolidation and growth in these
areas are driving change. In these segments, industry
competitor Dentsply Sirona is leading the charge with
DS Core, a cloud platform crafted specifically to enable
smarter workflows and seamless collaboration for dental
professionals. Nobel Biocare’s new FastMap technology
also represents a leap forward, introducing dentistry’s
first navigated photogrammetry tool for unprecedented
accuracy in digital implantology.
In our interview with Manfred Müller and Niels Plate from
Dentsply Sirona, we discuss the company’s vision of a
cloud-native future and how it is setting new benchmarks for laboratory capabilities and efficiency. Complementing this, Dr Fernando Gérman’s user report provides practical guidance on how conventional dental
practices can benefit from digitalisation, offering valuable
tips for dental professionals aiming to enhance their
collaboration with laboratories.
We also present case reports that demonstrate the
reliability and adaptability of CAD/CAM workflows, including Dr Paola Ochoa’s work on aesthetic cases and
Dr Frank Heldenbergh’s insights into same-day zirconia
restorations. These reports exemplify how CAD/CAM
technology enables more predictable outcomes in diverse
clinical scenarios.
In this issue, we also feature an article on cutting-edge
research into CAD/CAM biomaterials. In their investigations,
Dr Katharina Pippich and her team tested the bio
compatibility of these for applications in bone tissue
engineering—an area of future growth in restorative and
reconstructive dentistry.
I hope that this issue of CAD/CAM magazine serves
as a comprehensive guide for your laboratory’s journey
into the digital era, offering the latest tools, insights and
innovations to help you enhance your practice and
improve patient outcomes.
Sincerely,
Magda Wojtkiewicz
Managing Editor
CAD/CAM
2 2024
03
[4] =>
| content
editorial
Shaping the future:
CAD/CAM innovations transforming dental laboratories
03
news
© 3Shape
Resurgence and consolidation in
Europe’s dental prostheses and digital dentistry markets
05
page 14
industry news
DS Core for laboratories: Open cloud platform offers laboratory-focused
features for efficient collaboration and smart workflows
10
Nobel Biocare presents dentistry’s
first navigated photogrammetry with FastMap
12
New 3Shape Dental System
boosts productivity for dental laboratories
14
page 24
interview
© Creative Cat Studio/Shutterstock.com
“Thinking cloud native has raised the bar”
16
An interview with Dentsply Sirona’s Manfred Müller and Niels Plate
user report
Digitalisation for the conventional and analogue dentist:
Ten key points
20
page 42
case report
Predictability of the CAD/CAM workflow in
today’s aesthetic cases
24
Same-day dentistry:
Replacement of two PFM crowns with zirconia restorations
28
research
Biocompatibility of CAD/CAM biomaterials
for bone tissue engineering application
32
Cover image courtesy of
sunlight19/Shutterstock.com
issn 1616-7390 • Vol. 15 • Issue 2/2024
2/24
feature
Work–life balance—a lifestyle more than a goal
42
manufacturer news
46
international magazine of dental laboratories
meetings
International events
48
about the publisher
interview
“Thinking
cloud native
has raised the bar”
case report
Predictability of the
CAD/CAM workflow in
today’s aesthetic cases
submission guidelines
49
international imprint
50
feature
Work–life balance—
a lifestyle more than a goal
04 CAD/CAM
2 2024
[5] =>
[6] =>
© Hyejin Kang/Shutterstock.com
| news
The European dental prostheses market is set to experience an increase in value, primarily propelled by the rising demand of the ageing population.
Resurgence and consolidation in
Europe’s dental prostheses
and digital dentistry markets
A report on market recovery,
growth drivers and industry trends
Donna Santos & Dr Kamran Zamanian, Canada
When COVID-19 affected the European dental
prostheses and digital dentistry markets—including in
countries such as Austria, Belgium, France, Germany,
Italy, Luxembourg, the Netherlands, Portugal, Scandinavia,
Spain, Switzerland and the UK—the market value declined by more than 30%.1, 2 Both markets have since
stabilised, nearly reaching pre-pandemic levels in 2023
after experiencing a surge in demand in 2021 and
2022.1, 2 This surge was driven by the reopening of
numerous dental practices, the resumption of regular
dental services.
is aged 65 or older, a figure projected to reach around
30% by 2050.5 According to Eurostat population sta
tistics, Germany has the largest population aged 65
and over in Europe, followed by Italy and France.6 The
Robert Koch Institute, a key public health authority in
Germany, reported that this demographic is expected
to grow by 29% by 2030.7 Based on WHO records, the
European countries with the highest proportion of elderly
people, showing significant growth from 2015 to 2022,
include Portugal, Austria, Italy, Spain, Germany, and
France.8
Population in Europe
Periodontal disease and edentulism
The growth of the dental prostheses market is primarily
being driven by the ageing population, who are more
commonly affected by edentulism and periodontal
disease.3, 4 Currently, an estimated 20% of Europeans
Another factor influencing the demand for dental
prostheses is the prevalence of periodontal disease.
Among European countries, Italy has the highest prevalence of periodontal disease among people aged 15
06 CAD/CAM
2 2024
[7] =>
news
|
and over (18.2%),9 while Germany ranks first for in
dividuals aged 15 and over, at 27.4%,10 followed by
Portugal at 18.4%11 However, periodontal disease
prevalence in the ageing population has significantly
decreased in countries like France and Germany, tempering overall demand for dental prostheses. In terms
of edentulism, the Netherlands has the highest percentage among those aged 20 and over, at 16.8%,
followed by Portugal at 13.1%.12
Growth of the dental prostheses
and digital dentistry markets
Despite improvements in oral health, the European dental
prostheses market is projected to grow modestly each
year to an anticipated valuation of €18 billion by 2030.2
Among the market segments, crowns and bridges are
expected to show the fastest growth compared with inlays, onlays, veneers and dentures. As modern dentistry
continues to shift towards digitisation, driven by stable
demand for dental prostheses, the use of CAD/CAM
and specifically 3D-printing technology is anticipated
to soar.15
The expansion of CAD/CAM technology is likely to contribute significantly to the growth of digital dentistry,
and projections indicate a market valuation exceeding
€2 billion by 2030.16 The CAD/CAM device market is
expected to lead this growth, followed closely by the
3D printer market.
Prevalence of edentulism and severe periodontal disease by country in
Europe in 2019.13, 14 (Source: © iData Research)
Consolidation of dental laboratories
and clinics
In digital dentistry, dental laboratory and clinic consol
idation is a major driver of growth alongside the strong
demand for dental prostheses. Consolidation has increased access to capital for small and medium-sized
laboratories, including in-house laboratories within
clinics, enabling them to integrate digital workflows.
Total dental prostheses and total digital dentistry markets in Europe between 2020 and 2030. (Source: © iData Research)
CAD/CAM
2 2024
07
[8] =>
| news
Some noteworthy mergers and acquisitions involving
pan-European consolidators between 2021 and 2023
include:
– Oakley Capital: On 10 August 2023, Oakley Capital,
a leading pan-European private equity investor, acquired the laboratory operations of European Dental
Group, a pan-European provider of oral care services. Having achieved rapid expansion of its European clinic platform and concurrently established a
European laboratory business, the company made
the strategic decision to separate and divest its laboratory operations, including Excent, Flemming and
Artinorway Group. This translates to a network of
5,000 clinics supported by 70 laboratories throughout Europe.
– Colosseum Dental Group: In August 2021, the pan-
European Colosseum Dental Group, which is part of
Jacobs Holding, acquired Curaeos, which had 186 dental
clinics and 54 dental laboratories across Europe. This
strategic move enabled Jacobs Holding to enhance its
global presence, comprising 800 clinics and a team
of over 13,000 professionals. During the same year,
Colosseum further expanded its international footprint
by acquiring Mirò Dental Medical Center in Italy, adding
19 clinics to its portfolio. In June 2022, Colosseum
continued its growth with the acquisition of Kliniek
Tandheelkunde Sneek, a provider of dental services in
the Netherlands.
– Corus Dental: In August 2022, Corus Dental, a pan-
European dental laboratory consolidator headquartered
in Barcelona in Spain, strengthened its influence in the
dental prostheses market in Scandinavia through the
acquisition of Nordentic, a notable industry participant
in the dental prostheses market in the region. This
strategic move expanded Corus Dental’s portfolio to
63 laboratories and over 1,500 employees, enabling
the company to cater to the needs of over 12,000 dental
practices across Europe.
– Avedon Capital Partners: Avedon Capital Partners
acquired Ketterling Dental-Technik in June 2023.
Avedon is a private equity investor catering to small
to medium-sized companies located in Belgium, the
Netherlands, Luxembourg and Germany. In 2019,
Avedon teamed up with Maxident, Crossmill, Hamm
Dental and B u. T Dentaltechnik to form the DELABO.
GROUP. In an effort to increase its reach in the dental
industry, the DELABO.GROUP acquired a number of
dental laboratories in Germany from January 2022
to April 2023. These include Dental Labor Kanzler +
Trompeter, Gerling Dental-Labor, Huiss Dental-Labor
and Dental-Labor Schiewe in January 2022, followed
by Keller Dental-Labor in March 2022, Hans Plewe laboratory in April 2022, Walsdorff Zahntechnik in August
2022, Hesse Dentallabor in September 2022, Reitt &
Meyer Labor in January 2023 and BIEMADENT Zahntechnisches Labor in April 2023.
08 CAD/CAM
2 2024
Aside from these consolidations, there were significant
merger and acquisition activities involving notable participants in the dental industry in Europe from 2021
to 2023. Sun European Partners, United Clinics,
Dentalum Group, Adagia Partners and Bencis Capital
Partners were among the entities involved in these
transactions.
Closing thoughts
The European dental prostheses market is set to experience an increase in value, primarily propelled by the rising
demand of the ageing population. However, this growth
is being tempered by the continuous efforts of each
country to improve its dental hygiene, resulting in relatively modest market growth. Conversely, digital dentistry
is expected to experience robust growth, predominantly
fuelled by the shift to digitisation and increased use of
digitally fabricated dental prostheses. Additionally, the
ongoing consolidation of dental laboratories and clinics
is set to have a substantial impact, notably increasing demand, especially in markets such as CAD/CAM devices,
including 3D printers. These consolidation activities are
expected to provide expanded access to capital funds
for small to medium-sized dental laboratories and inhouse dental laboratories, thereby playing a significant
role in reshaping the dynamics of the dental prostheses
and digital dentistry markets.
Editorial note: Please scan the QR code for
the list of references.
about
Donna Santos is a research analyst
at iData Research, specialising in the
dental industry. She is responsible
for spearheading research projects on
dental prostheses and digital dentistry.
She has years of experience as a
marketing analyst and has a bachelor’s
degree in engineering and a
postgraduate diploma in data analytics.
Dr Kamran Zamanian is the
CEO and founding partner of
iData Research. He has spent over
20 years working in the market
research industry, focused specifically
on medical devices used to
support the health of patients
all over the globe.
[9] =>
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stated or is evident from the context in a certain case, trademarks of Nobel Biocare. Please refer to nobelbiocare.com/trademarks for more information. Product images
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[10] =>
| industry news
DS Core for laboratories: Open
cloud platform offers laboratory-
focused features for efficient
collaboration and smart workflows
Dentsply Sirona
Today, thousands of laboratories globally use DS Core.
From receiving orders to securing case data, DS Core
gives dental laboratories the ability to get closer to their
customers in dental offices. Laboratories now have
access to the same easy-to-use ordering and collaboration tools as dentists do, and the new DS Core Light
subscription for laboratories offers additional capabilities, such as storing all order and design files in the
cloud and digitally interacting with dentists who are not
yet using intra-oral scanning technology.
The DS Core open platform unlocks the power of digital
dentistry for dental laboratories and practices alike,
supporting easy order acceptance, communication
of design proposals with the dentist in real time and
seamless integration of data into the laboratory’s
preferred software—and that’s just the beginning!
Dentsply Sirona has now introduced new DS Core
functionalities for laboratories, enhancing seamless
collaboration with the dental practices they serve.
Clear overview with the revamped
dashboard; new collaboration and sharing
possibilities
The dashboard has been enhanced to elevate order
management. Orders and media are now listed under
client and patient names for quick and easy access to
the relevant information. Another new feature is the
ability to outsource jobs to other laboratories or even
DS Core Create and retain all the original job details
and files. This is useful when working with production
partners or managing temporary staff bottlenecks.
“For me, DS Core is an efficiency gain because I can
find everything I’m looking for in one place—from intra-
oral scans and X-rays to my orders and correspondence,” said Devaughn Fraser, director of Highland
Dental Laboratory in Canada. “The potential is vast:
10 CAD/CAM
2 2024
with this digital step forward, practices and labs are
now digital neighbours—no longer limited by distance,
time or file types. All information and communication
is centralised—no need to check seemingly endless
portals, e-mails, text messages and file transfer services. All information now cohabitates happily under
one roof.”
The DS Core Light subscription is a newly launched
option that provides two important additional functions. It gives users 1 TB of storage space and enables
laboratories to store order and design files. Another
very special capability is that DS Core Light allows laboratories to bring their partner dentists who have not
yet transitioned to digital workflows into their digital
processes. Digitised models of physical impressions
and design proposals can be shared with dentists
via DS Core even if they are not yet DS Core users.
Once dentists start using intra-oral scanners to take
impressions, they can send their orders via the
DS Core platform.
DS Core empowers the dental team
Since its launch, DS Core has inspired many users
around the world. As an open ordering and collaboration solution, it connects dentists and dental tech
nicians in a broad network for efficient collaboration.
DS Core supports numerous data formats (DXD, STL,
PLY, OBJ and DCM), enabling nearly all dentists to
send data to the laboratory, regardless of the digital
devices they use. The data input can easily be viewed
by the laboratory partner via a web browser—without
needing to install special software, giving dental technicians the freedom to choose the laboratory software
they use to design or fabricate their appliances.
“Dentistry is a team sport, and dental labs are an
essential part of the dental care team. That’s why we
[11] =>
industry news
are continuously developing DS Core to enable the
dental care team to advance with confidence and
play together effectively. The latest updates are specifically for dental labs,” said Max Milz, group vice
president of connected technology solutions at
Dentsply Sirona. “With DS Core, dental labs can efficiently work together with practices using digital impressions, designs and even X-ray data, supported
by real-time chat functionalities. DS Core is a single
channel for exchanging many types of data securely,
which is a huge improvement compared to the usual
|
fragmented communication channels used today
and a significant step towards a new era of connected
dentistry.”
Andreas Frank, executive vice president and chief business officer at Dentsply Sirona, said: “At Dentsply Sirona,
we partner with dental professionals to advance our
shared vision of transforming dentistry. We are committed to enhancing patient outcomes and supporting
practice success. DS Core positions our customers to
advance with confidence on all fronts.”
“For me, DS Core is an efficiency gain because
I can find everything I’m looking for in one place—
from intra-oral scans and X-rays to my orders
and correspondence.”—Devaughn Fraser,
director of Highland Dental Laboratory in Canada
CAD/CAM
2 2024
11
[12] =>
| industry news
Demonstration of X-Guide with FastMap navigated photogrammetry at Nobel Biocare’s booth at the European Association for Osseointegration congress
in Milan in Italy. (Image: © Nobel Biocare)
Nobel Biocare presents dentistry’s first
navigated photogrammetry with FastMap
Nobel Biocare
Navigated photogrammetry opens the door to a new
dimension of prosthetic design for full-arch implant-borne
restorations. Nobel Biocare recently launched the new
FastMap navigated photogrammetry system, which
offers enhanced capabilities in precise measurement
and maintenance of implant positions for full-arch
restorations.
Employing dedicated software and scan bodies, FastMap
allows dental professionals to measure and maintain the
true position of implants and abutments relative to the
preoperative prosthetic plan and the patient’s anatomy.
This relationship is preserved during navigated procedures
through the use of a patient tracker, which is registered
preoperatively to ensure alignment throughout the procedure. In contrast to this capability, basic photogrammetry
and physical conversions create a continuity gap, disrupting this crucial relationship.
FastMap enables the tracking of scan body locations
while capturing platform-to-platform positions. It allows
for the creation of a conversion-free, passive-fit CAD/CAM-
produced provisional restoration that can be placed directly on to abutments. The scan bodies are interchangeable at any implant or abutment location with the same
connection interface, and there is no need to correlate
a scan body identifier to a specific implant or abutment location within the software. FastMap works with
all Nobel Biocare multi-unit abutments as well as a
12 CAD/CAM
2 2024
variety of abutments from other manufacturers, including
Astra Tech MultiBase EV abutments, Neodent GM Mini
abutments, BioHorizons multi-unit abutments and
BIOMET 3i Low Profile abutments.
The system works with three or more scan bodies per
jaw, providing flexibility for various clinical scenarios.
If one of the scan bodies is damaged, FastMap allows
dental professionals to easily replace it with a single new
scan body without affecting other scan bodies.
With X-Guide dynamic navigation, a single device is used
for both implant placement and photogrammetry, and
no additional scanner hardware is required for surgery.
The scanning device is conveniently suspended above
the patient, eliminating the need for a handheld device
during data capture.
FastMap integrates with established workflows of major
CAD/CAM software solutions, allowing dental professionals to work with a variety of service providers and laboratories. It has an open workflow and is compatible with
various 3D printers and milling devices, offering export
options in STL and PLY format, which can be used with
the most common prosthetic design software, including
exocad.
To discover the benefits of X-Guide dynamic navigation with
FastMap, visit www.nobelbiocare.com/en-int/fastmap.
[13] =>
New
release
out now
3Shape
Dental System 2024
Your design workflows have never been easier
10 x faster 20 x faster
case management*
case reload *
*Data/references for substantiation available upon request from 3Shape.
Read more about
the latest update at
3shape.com/dentalsystem
[14] =>
| industry news
With Dental System 2024, case management speeds are up to ten times faster and case reload speeds up to 20 times faster, making this the most extensive
and innovative upgrade in recent years. (Image: © 3Shape)
New 3Shape Dental System boosts
productivity for dental laboratories
3Shape
Global digital dentistry innovator 3Shape has announced the release of Dental System 2024. This latest
upgrade introduces a significant boost in speed for the
Dental System software and case management workflows. Through features such as faster case reloads and
workflows powered by artificial intelligence (AI) that minimise repetitive tasks, Dental System 2024 promises dental
laboratories heightened productivity and streamlined
operations.
Upgrading to 3Shape Dental System 2024 is available
at no additional cost for 3Shape LabCare subscribers.
Dental laboratories are encouraged to contact their
3Shape resellers for guidance on updating via their
3Shape dongle or purchasing the software.
“3Shape Dental System 2024 is a true collaboration
between dental technicians and our development team.
Together, we’ve crafted numerous enhancements that
make designing and production workflows more flexible
and efficient. We urge technicians to upgrade their
Dental System software right away to experience these
improvements,” said Dr Rune Fisker, senior vice president
of product strategy at 3Shape.
14 CAD/CAM
2 2024
Highlights of the new 3Shape Dental System include the following:
– Enhanced workflow efficiency: New automation tools
eliminate routine tasks, making case management up to
ten times faster and case reloads up to 20 times quicker
compared with previous software versions. AI-driven
features handle occlusal plane positioning, segmentation and annotation placement, supporting workflows
with gypsum models, impressions and intra-oral scans.
– Optimised removable partial denture workflows: Quality
control functions have been added, enabling tolerance
checks with the distance map function. The quality
control suite, accessible directly after the design stage,
ensures production readiness. Technicians can also
digitally adjust removable partial denture teeth to minimise post-production adjustments.
– Simplified handling of complex cases: Upgraded multibite functionality allows easy switching between jaw
positions during the design process. The new memory
bite function supports multiple bite positions per case,
enabling quick jaw alignment and design adjustments.
More information about the new software can be found
at www.3shape.com.
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[16] =>
| interview
Talking technical (left to right): DTI’s Jeremy Booth in conversation with Manfred Müller, vice president of software engineering and user experience at
Dentsply Sirona, and Niels Plate, the company’s head of equipment research and development and launch management.
“Thinking cloud native
has raised the bar”
An interview with Dentsply Sirona’s
Manfred Müller and Niels Plate
Jeremy Booth, Dental Tribune International
The launch of Primescan 2 in September was one small
step for Dentsply Sirona and one giant leap for digital
dentistry. It being the first cloud-native intra-oral scanning
solution on the market, dental professionals are curious
about the benefits of the device and the broader impli
cations of intra-oral scanning that is powered by the
DS Core cloud platform. Dental Tribune International
spoke with two of the leading technical minds behind
Primescan 2—Manfred Müller, vice president of software
engineering and user experience, and Niels Plate, head
of equipment research and development and launch
management—and learned that it opens the door to
a number of new possibilities.
16 CAD/CAM
2 2024
Mr Müller, Mr Plate, how were you involved in the
development of Primescan 2?
Müller: The project goes back further than one might
think. It was years back that we assessed our portfolio
and asked how we could make it future proof. This was
around the time that DS Core was getting started.
From a user perspective, DS Core consolidates
everything on to one platform, and this has become
the future standard for devices at Dentsply Sirona.
Primescan 2 is the first cloud-native device that
aligns with this target environment and that has been
developed for it.
[17] =>
interview
Plate: Manfred and I worked on Primescan 2 from
the start. It was clear that software was central to this
product, and so we had a dedicated software team.
Nonetheless, we worked very closely together to integrate the hardware and the software into one product.
In terms of hardware, there was advancement in optics,
and we made the sleeve smaller and slimmer in comparison to Primescan; however, we focused on being able
to compress the data and send it to the cloud and,
of course, on logging into the Wi-Fi network and establishing the link between the camera and the internet.
Primescan 2 is wireless, so we also had to move the battery into the device and think about charging. This was
quite a substantial change but not as comprehensive as
the changes on the software side, where we moved into
an entirely new territory. The whole team was behind it,
because we considered that the move into the cloud
was overdue.
What are the immediate implications of these
changes?
Müller: It was a complete renovation, from the ground up,
of the software stack that we have. This has formed the
foundation for the next decade, also considering the
constant maintenance that software typically requires.
What we have achieved is the development of a device
on which the software does not age; it is always kept
fresh. This is really important, and I think it provides the
biggest advantage for the customer. Customers will
never have an old product.
Plate: By keeping the software fresh in the cloud,
instead of asking the customer to download updates
for the device or the hardware, we have removed much
of the complexity for the customer. Traditional devices
—a scanner connected to a laptop, for example—
will at some point require a new version of Windows,
and the laptop will become outdated and need to
be replaced. We have simply put it in the cloud and
generated a comprehensive platform where everything
is always fresh.
What can you tell us about the user experience
design that has gone into Primescan 2?
Müller: Basically, at Dentsply Sirona, user experience
design is a functional organisation of one team led by
one person, which extends to various other areas, such
as hardware design, equipment and platform software.
A key goal was to have one user interface, and I think this
was realised quite satisfactorily.
Plate: It is a modern user interface that is closer to
consumer software. It is not made by the mechanical
engineer who places a button on a touch screen; rather,
it is closer to the experience that we expect when using
a mobile phone or driving a Tesla. With user interface
and user experience design, there is always feedback
|
“The ultimate vision with
DS Core is that clinicians
only have end user devices
in the practice.”
—Manfred Müller,
Dentsply Sirona
from users, and this is natural because different people
use the product differently. The important thing is that
we can constantly update the user interface and user
experience, based on how the product is used, and this
is really a great opportunity.
Müller: I think Apple taught the world that good user
interface and user experience design means something. Previously, technical products were not really
designed with the users in mind, and different styles
and approaches were evident. It has since become
a very important topic, and we now have one style,
one approach and one philosophy on how to use
Dentsply Sirona products.
How does being cloud-native change the user
experience?
Müller: First and foremost, the cloud is available everywhere. This is one of the main differences when comparing Primescan 2 with devices that require a dedicated
workstation with a dedicated piece of software that
must be maintained and updated. Thinking cloud-native
has raised the bar in terms of expectations. We expect
that the device will also require less training, at least for
the most common applications, and this will make a big
difference.
Plate: We can also turn your question around and ask
what the dentist would not have to change because of
the cloud-native device. Dentists will not have to change
their ergonomic settings, screen or beloved iPad. They
can use their current clinical set-up without changing
anything. Previously, when buying a new device, users
were basically forced to adapt their workflow to that of
the device. Now, with cloud-native, users can use any
device for screening. If working in the 12 o’clock position
with a PC in the cabin, dentists can simply use that
screen without worrying about cables or connections.
Change is not always perceived as positive, especially
when it comes to changes in the workflow, and we must
consider that dental schools train dentists differently
from country to country, using different protocols. We
know that dentists are perfectionists who never stop
CAD/CAM
2 2024
17
[18] =>
| interview
According to Manfred Müller, the development of Primescan 2 involved a complete renovation of the software stack and resulted in a device that
never needs updating.
developing their workflows, and many do not like to stray
from their preferred methods and protocols. We did
not want to force them to do that, so being cloud-native
also brings convenience!
What exactly are the restrictions on the viewing
device?
Müller: What is important is that, with Primescan 2,
users do not need to consider where they do certain things.
For example, in the past, it was a given that certain equipment was needed for viewing certain file types. This is
just not necessary anymore. Wherever users are, they are
free to access the resources in the cloud using whatever
browser they have. If the hardware can run YouTube,
it can run DS Core. It could be ten years old, so long as
it can run the latest version of Chrome.
Plate: This is also very important when we consider
the patient experience. I had a medical MRI scan last
year, and they gave me a QR code so that I could look
at the image. When I opened the link, I was told to
download a viewer for the software and install it on my
computer. As a private patient, I have to say I’m not
interested in downloading viewer software for viewing
one image. The difference here is DS Core. Patients
can just open the web page and view the image right
away.
18 CAD/CAM
2 2024
How does Primescan 2 align with the vision behind
DS Core?
Müller: The ultimate vision with DS Core is that clinicians
only have end user devices in the practice—no servers,
no high-end computers whatsoever. An iPad or a cheap
Chromebook is completely sufficient. This means that
the clinic could be independent of the physical hardware
environment. Even the server set-up would no longer be
needed, as users would not need to back up the devices.
Dentists currently invest a lot of time and money each
year in servers, and this is unnecessary. I remember
when iCloud was introduced and, suddenly, my photos
were saved and even transitioned with me to another
phone. It was super easy, and the same is true for
DS Core. There is no need to migrate data physically from
one device to another. This is a big difference compared
with the old way of doing things.
What about equipment management in cloud-based
clinical environments?
Plate: This is another big topic. The cloud allows us to
access equipment, if the user allows, in order to analyse
its situation. I believe that three-quarters of challenges
that customers experience can be solved remotely. This
is the best way to answer questions or resolve concerns
with devices, and it means no waiting time or downtime
for the customer. We have all experienced customer
[19] =>
interview
|
Niels Plate pointed out that moving to a cloud-native intra-oral scanner means that clinicians do not have to adapt their existing workflows, ergonomic settings
or devices to the new technology. (All images: © Dentsply Sirona)
hotline scenarios in which the technician cannot connect
to your device. It is very valuable when service personnel
know what the issue is and can easily and quickly resolve it.
With DS Core, this connectivity applies to our whole portfolio, and we are currently connecting one device after
another. This helps us a lot in the area of service and is
also a topic that is very interesting for our dealer partners.
Considering the recent workflow integration between
3Shape and Dentsply Sirona, will users be able to
take advantage of DS Core and Primescan 2 as an
open system?
Müller: That is also an important question. In that context,
what we are also adding to the platform is application
programming interfaces (APIs), which basically means
that others can also create workflows and connect their
solutions to our platform. We will start small, but the idea
has always been to be open. Think about the connection
to patient management systems, to dental laboratories
and so on. We will be opening our system with APIs so
that our programs can easily be integrated into workflows
from other providers.
Plate: Yes, this is another instance where we are breaking
from the past. Dentsply Sirona was previously known to
have a closed system, and that was a necessity to keep
the process slim, smooth and quick. Now, we can do
both and be both. We can be open and can have a very
smooth user experience. We believe that our customers
benefit from this approach, which is why we are com
mitted to working towards an open system. Ultimately,
the goal is to enhance the provision of oral care for dental
professionals.
Lastly, where does cloud-based technology bring us
in terms of the future implementations of artificial
intelligence (AI) in oral care?
Müller: When customers are not restricted by local
hardware, much more AI-based functionality is possible.
This could start from diagnosis and extend to, let’s say,
restorative tasks. I see huge potential in using AI in the
cloud and making it available to everybody without the
need to invest in local equipment. This is one of the biggest opportunities, and I think Dentsply Sirona is very well
positioned to deliver it, given that we have deliberately
parted ways with the old technology. We made the big
decision to go with a different technology stack, to use
a different architecture and to make sure that we are
not carrying the past into the future. When we started
DS Core, what we really did was push “play” on the future.
Primescan 2 is a continuation of our work in this direction,
and the whole team is very excited about it.
All images: © Dentsply Sirona
CAD/CAM
2 2024
19
[20] =>
| user report
Digitalisation for the conventional
and analogue dentist: Ten key points
The change is easier and less complicated than you think
Dr Fernando Gérman, Spain
Technology enabling a digital workflow has transformed dental practice, providing new opportunities to
improve accuracy, efficiency and the patient experience.
For analogue dentists in their 40s and 50s looking to
modernise their practices, the transition can seem challenging at first. However, with tools like the SprintRay
protocol and its intuitive and logical apps, digitalisation
is both accessible and quick to achieve. The integration
of Medit’s digital recording and apps enables optimal
results, streamlining the delivery process and allowing for
efficient outcomes directly within the clinic. In this article,
I cover ten key points for professionals to consider when
deciding whether to adopt this digital technology.
Differences between analogue
and digital processes
The differences between analogue and digital processes
are evident both in the form and in the number of steps
for prosthetic planning and manufacturing.
1. Ease of use of the SprintRay app and protocol
The SprintRay app is designed with an intuitive, protocol-
driven interface that makes it easy to use even for those
with no prior experience with advanced technology.
The platform provides detailed tutorials and ongoing
technical support, allowing for a smooth and seamless
transition and requiring no in-depth technical computer
knowledge.
2. Complete workflow integration
SprintRay enables the integration of all stages of the
dental process, from initial scanning to 3D printing of
prostheses. This unification of the workflow eliminates the
need for manual processes and reduces shipments to the
laboratory, significantly improving operational efficiency.
From the Medit scanner program, the sending of the scan
to the printer can be directly integrated without any prior
steps. Everything is ready to go for the dentist without
experience in digital workflows.
3. Precision and detail in scans
The systems offer impressive accuracy in the scans
obtained, capturing minute details that ensure a perfect
20 CAD/CAM
2 2024
[21] =>
user report
fit of the restorations. This accuracy reduces the need
for subsequent adjustments, improving patient satis
faction and optimising the dentist’s time. With the help of
artificial intelligence, it is possible to obtain the design
of a crown in less than 5 minutes and be ready to print
in 15 minutes.
screen, control bite levels and project the provisional prosthesis design, offers the new digital dentist
a wide range of intuitive and easy-to-use options
that enhance communication and marketing for the
practice.
5. Reduction of human error
Digitalising the workflow minimises human errors common in manual processes. Digital scans eliminate the
possibility of distortion, providing an accurate basis for
prosthetic design and manufacturing.
7. Time- and cost-savings
Implementing digital technology significantly reduces the
time needed to complete complex treatments. In addition, by reducing the practice’s dependence on external
laboratories, the associated costs are reduced, making
the practice more profitable. Obtaining a result in the
same visit allows for immediate patient satisfaction and
acceptance, differentiating the practice from those using
analogue technology. With apps such as Medit ClinicCAD
and the ability to send designs directly to the printer, the
new digital dentist can create a durable provisional bridge
during the same visit.
6. Improved patient communication
SprintRay’s 3D images and digital models facilitate
communication with the patient, allowing him or her to
visualise the treatment plan and better understand the
proposed procedures. This improves patient confidence
and collaboration in the treatment.
8. Continuous training and support
SprintRay offers training programmes and ongoing
support through SprintRay University, ensuring that
analogue dentists can resolve questions and optimise
their use of the technology. This support is crucial for
a successful and smooth transition.
The initial scan in any version of the Medit app, along
with the ability to display dynamic occlusion on the
In the case of Medit, the dental professional can
access various courses and advice, enabling rapid
4. Intuitive apps
The SprintRay app and the Medit scanner app are highly
intuitive, having easy-to-navigate interfaces. This allows
analogue dentists to learn and adapt quickly without facing
the typical barriers associated with adopting new technology.
|
CAD/CAM
2 2024
21
[22] =>
learning and providing valuable support for beginners
with no prior experience. Moreover, auxiliary staff
can quickly learn the scanning techniques, saving
dentists time and money and freeing them up to do
other tasks.
9. Sustainability and energy efficiency—cloud database
Digitalisation of the dental workflow contributes to environmental sustainability by reducing the use of materials
and the generation of waste. SprintRay 3D printers use
biocompatible materials and minimise waste, promoting
greener practices.
Employing an intra-oral scanner allows files to be securely stored in the cloud and in accordance with data
protection laws rather than having to keep models stored
in physical locations. Both in the SprintRay cloud and
in the Medit app, files can be accessed and retrieved to
be used again.
10. Competitive advantage
Adopting technology to support a digital workflow
provides a significant competitive advantage. Patients
are looking for practices that use cutting-edge tech
nology to provide faster and more accurate and comfortable treatments. Modernising the dental practice
can attract a broader and more demanding clientele
but also one willing to pay for a more comprehensive,
faster and more efficient service without long waits for
resolution.
22 CAD/CAM
2 2024
Personal opinion
Transitioning from an analogue to a digital practice can
seem overwhelming at first. However, with tools designed to
facilitate this adoption, such as those offered by SprintRay
and Medit, the benefits far outweigh the initial challenges.
Improved accuracy and operational efficiency and the
ability to deliver a better patient experience are powerful
reasons to consider this transition.
In my opinion, analogue dentists who embrace this technology are not only modernising their practices but also
positioning themselves to deliver a higher level of care.
The key is to take advantage of SprintRay’s intuitive
capabilities and to seek out the ongoing support and
training available. With the right attitude and the right
tools, digitalisation can be a transformative and rewarding
experience for any dental professional.
about
Dr Fernando Gérman is a dental
expert and director of Dentinova Academy,
a regular speaker for SprintRay and a
key opinion leader for CAD-Ray Europe.
He is a graduate of New York University
in the US and is the author of several
research articles on implantology,
3D printing, digital impression taking
and denture fabrication.
[23] =>
[24] =>
| case report
Predictability of the CAD/CAM
workflow in today’s aesthetic cases
Dr Paola Ochoa, Peru
1a
1b
Figs. 1a & b: Intra-oral views with the teeth in maximum intercuspation (a) and separated (b).
Introduction
Although CAD/CAM technology is not new to our pro
fession, its widespread use is increasingly becoming
the norm rather than the exception among dental profes
sionals. However, adopting a fully digital workflow in the
dental practice can be quite challenging for those new
to it. Like with any learning experience, leaving behind
old ways and incorporating new ones requires effort and
perseverance, not just on the part of the dentist but also
on the part of the entire dental team.
Once the new ways have been established and the
necessary learning has been accomplished, the benefits
of having a digital dental practice can be fully enjoyed.
Not only is the patient experience improved, but the
overall standard of care is elevated, as the final outcome
2
becomes more predictable and restorations more pre
cise. This article will demonstrate how the digital work
flow can be used to predictably restore a case where
smile aesthetics and function had been compromised
owing to wear and tooth loss.
Patient presentation
A 45-year-old female patient presented to my clinic with the
chief complaint of small, discoloured teeth and an overall
dislike of her smile aesthetics. Although there were no sig
nificant findings in her medical history, she reported having
a past habit of sucking lemons, which may have partially
explained the enamel wear observed in her maxillary arch
during the clinical examination. She also presented with
an edge-to-edge occlusion with worn incisal edges in both
arches and mild mandibular anterior crowding (Figs. 1a & b).
3
Fig. 2: Digital smile using the Smilecloud Biometrics system. Fig. 3: Different views of the digital wax-up using scanned models in exocad.
24 CAD/CAM
2 2024
[25] =>
case report
|
4
5a
5b
Fig. 4: 3D-printed models of the digital wax-up and the silicone matrix. Figs. 5a & b: Preparations on the exocad model (a). Merging of the mock-up
with the preparations for the final restorations (b).
She had good oral hygiene and sound periodontal
tissue.
Facially, she presented with an average lip length and an
inadequate incisal display at rest. Her smile assessment
revealed an average smile height, a flattened smile curve
and deficient buccal corridors.
7a
6
Smile design and treatment planning
Dental photography and the digital smile design asso
ciated with it are key tools in the treatment planning
process of any aesthetic case. A browser-based smile
design software program (Smilecloud Biometrics) was
used to determine the patient’s ideal tooth size, shape
7b
Fig. 6: Final lithium disilicate restorations. Figs. 7a & b: Pre-op (a) and post-op frontal views
of the patient’s smile (b).
CAD/CAM
2 2024
25
[26] =>
| case report
8b
8c
8a
Figs. 8a–c: Final views of the aesthetic outcome.
and proportions (Fig. 2). Interestingly, this software
uses artificial intelligence to couple the smile design with
a search engine of natural tooth morphologies called a
biometric library. This allows the dentist and the patient
to visualise not one but several potential aesthetic
outcomes. The program also provides the user with
STL files of the chosen tooth forms for further use.
After the patient had approved the smile design simulation,
the STL files were imported into dental CAD software
(exocad), where they were merged with the patient’s intra-
oral scan (iTero Element 2, Align Technology) to create
a 3D digital wax-up (Fig. 3). Somewhat similar to a conven
9a
9b
9c
tional wax-up over a cast model, in the digital version, the
tooth shapes are adapted to fit the patient’s natural teeth,
gingivae and occlusion. In the case presented here, it was
deemed necessary to open the vertical dimension to pro
vide space for the reconstruction of the occlusal surfaces.
After completion of the digital wax-up, the models were
then printed on a stereolithographic 3D printer (Form 2,
Formlabs). These printed models are physical replicas
of the initial smile design carried out in the smile design
software and can be used to fabricate a conventional
putty matrix. A polyvinylsiloxane impression was taken
of the 3D-printed model (Fig. 4).
9d
Figs. 9a–d: Full-face views demonstrating the predictability of the digital workflow. Initial situation (a). Digital mock-up (b). Physical mock-up (c).
Final restorations (d).
26 CAD/CAM
2 2024
[27] =>
case report
10a
|
10b
Figs. 10a & b: Pre-op (a) and post-op intra-oral views with the teeth in maximum intercuspation (b).
The mock-up serves as a clinical simulation of the outcome, thus allowing assessment of the aesthetics, function and phonetics. It can be inserted into the patient’s
mouth very easily using a self-polymerising resin
(e. g. Luxatemp, DMG). An additional benefit of the mock-up
is that it can be used as a guide for minimal tooth preparation. With the mock-up still in place in the patient’s
mouth, a depth cutter bur was used to provide enough
space for the future restorations while preserving the
maximum amount of tooth structure.
Preparation, impression and cementation
Because of the need to increase the vertical dimension
and restore both the facial and palatal surfaces, the
decision was made to restore teeth #13-23 with full veneers,
teeth #16, 15, 14, 24 and 25 with veneerlays and tooth #27
with an overlay. Tooth #26 had previously been replaced
with an implant-supported crown. In the mandibular
arch, tooth #36 was replaced with an implant-supported
crown, tooth #46 was restored with a crown and the worn
edges of the mandibular anterior teeth were restored with
direct composite—the patient agreed to have these teeth
restored with veneers in the future for maximum strength
and aesthetics.
As previously described, minimal preparation was achieved
using the mock-up as a guide. The iTero Element 2 intraoral scanner was used to take digital impressions of both
arches. Subsequently, the STL files were imported into
the exocad software and merged with the previous digital
wax-up (Figs. 5a & b).
The restorations were milled in lithium disilicate from
IPS e.max CAD blocks in the MT BL4 shade (Ivoclar;
Fig. 6). The restorations were cemented following the
manufacturer’s recommendations after confirming marginal fit and obtaining the patient’s approval during a trial
insertion. This involved conditioning the ceramic with
a 5% hydrofluoric acid for 20 seconds and applying a
layer of silane to the etched surface (Monobond Plus,
Ivoclar) after rinsing and drying. The tooth substrates
were treated with a 35% phosphoric acid and rinsed
for 20 seconds, and a layer of universal adhesive was
applied to the dried surfaces (Scotchbond Universal,
3M ESPE). The full veneers, veneerlays and onlay were
adhesively luted using a light-polymerising resin luting
agent (RelyX Veneer Cement, 3M ESPE) and photoactivated for 20 seconds with a high-power curing light
(VALO, Ultradent Products). The decision to use a photoactivated cement was made to ensure both complete
polymerisation through light exposure as well as chromatic stability and was justified by the thickness (< 1 mm)
and medium opacity of the restorations. The excess cement was removed, occlusal adjustments were made
and a removable acrylic appliance was made for the protection of the final restorations. The patient was satisfied
with the result (Figs. 7a & b, 8a–c).
Conclusion
The digital workflow allows for high predictability of the
aesthetic outcome, as the final restorations can be made
to match the digital wax-up with better precision than with
the analogue method (Figs. 9a–d, 10a & b). The learning
process involves all the dental team members, including
the dental laboratory, as good communication is still
critical for treatment success.
Editorial note: This article originally appeared in Oral Health
Magazine, and an edited version is provided here with
permission from Newcom Media.
about
Dr Paola Ochoa graduated at the top
of her class from Cayetano Heredia
University in Lima in Peru in 2006.
She has a degree in occlusion and
oral rehabilitation from the Universidad
Científica del Sur in Lima and has
received extensive training in Brazil and
the US. She is the co-founder of the
Infinity dental clinic and of the Infinity
Institute for Advanced Dental Learning in Lima. Dr Ochoa
is a member of the American Society for Dental Aesthetics
and a diplomate of the American Board of Aesthetic Dentistry.
In her work, Dr Ochoa employs an interdisciplinary, facially
driven and minimally invasive philosophy and utilises digital
tools for the planning and communication of all her cases.
CAD/CAM
2 2024
27
[28] =>
| case report
Same-day dentistry:
Replacement of two PFM crowns
with zirconia restorations
Dr Frank Heldenbergh, France
1
2
Fig. 1: Initial clinical situation. Fig. 2: Situation after removal of the existing restorations.
Introduction
The advancements in zirconia in contemporary
dentistry allow for a wider range of applications, in
3
Fig. 3: Shade determination using a shade tab. A2 was the appropriate shade.
28 CAD/CAM
2 2024
cluding in the anterior region, and for chairside pro
duction using dedicated CAD/CAM systems. Even
without a cutback, KATANA Zirconia Block (STML),
combined with CERABIEN ZR FC Paste Stain (both
[29] =>
case report
|
4
Fig. 4: Virtual models of the patient’s teeth with the newly designed crowns, revealing the space available for a slight retraction.
“In the present patient case, the materials were
chosen to replace old porcelain-fused-to-metal (PFM) crowns
on the maxillary central incisors.”
Kuraray Noritake Dental), offers an extremely satis
factory aesthetic solution.
In the present patient case, the materials were chosen to
replace old porcelain-fused-to-metal (PFM) crowns on
the maxillary central incisors. The planned treatment was
in accordance with the patient’s wishes and carried out
in a single appointment.
Case presentation
The patient asked for a replacement of the existing
crowns on the two maxillary central incisors. The PFM
restorations had been in place for about 30 years (Fig. 1).
She desired aesthetic improvements and slight reposi
tioning of these two teeth.
5
Fig. 5: Designing of the two crowns.
CAD/CAM
2 2024
29
[30] =>
| case report
healthy, and there was no bleeding. The only uncertainty
was whether the existing crowns had been cemented on
to inlay cores or whether they were Richmond crowns.
A preliminary silicone impression was taken as a pre
cautionary measure. In case something unexpected
prevented the new crowns from being bonded during the
session, it would then be possible to produce temporary
crowns easily.
Treatment
Using a diamond bur, followed by a tungsten carbide bur,
the existing crowns were removed, revealing that they
were indeed Richmond crowns. Because the anatomy of
the intra-radicular posts clearly contraindicates an attempt
to remove these posts, it was decided to trim the crowns
to transform them into inlay cores rather than risk further
damage. The corono-peripheral preparations were re
worked at the same time. One of the major challenges
was related to the necessity of masking the metal of the
transformed coronal-radicular reconstructions. Luckily,
the space available was sufficient to accommodate com
plete zirconia crowns of a significant thickness (Fig. 2).
The target shade of the crowns was chosen in consulta
tion with the patient (Fig. 3).
6
7
Fig. 6: Milled crowns in the CAD/CAM blocks. Fig. 7: Crowns in the furnace
after staining and glazing with liquid ceramics.
Treatment plan
In agreement with the patient, it was decided to perform
the entire procedure in one appointment: removal of the
existing crowns, digital impressions, production and
bonding of the new restorations. The periodontium was
Subsequently, impressions were taken using an intra-oral
scanner, the virtual models were checked and the crowns
designed, considering the patient’s request to have her
two incisors slightly retracted (Figs. 4 & 5). The two
crowns were milled from KATANA Zirconia Block 14Z in
Shade A2 (Fig. 6). A quick reminder: unlike lithium disili
cate, zirconia prosthetic parts cannot be tried in imme
diately after milling, as they are around 20% larger than
their final size after sintering. Final sintering was per
formed within about 18 minutes in the SINTRA CS fur
nace (Shenpaz Dental). After this process, the crowns
may be tried in to check their fit, shape, shade and optical
integration.
For finishing of the restorations, various options are avail
able. In this case, we decided not to limit ourselves to
mechanical polishing of the prosthetic parts, as zirconia
does not fluoresce like natural teeth do. To add fluores
cence as an optical feature, the surface was lightly
stained and glazed with CERABIEN ZR FC Paste Stain
(Fig. 7).
8
Fig. 8: Selected cementation and try-in system.
30 CAD/CAM
2 2024
After firing, the two crowns were tried in again using a
try-in paste corresponding to the chosen resin cement
system (PANAVIA V5, Kuraray Noritake Dental). In this
way, the final appearance was simulated to validate
the shade of the cement. The intaglio surfaces of
the crowns were then sandblasted before applying
CLEARFIL CERAMIC PRIMER PLUS (Kuraray Noritake
Dental) as the restoration primer. The prepared teeth
were treated with KATANA Cleaner to decontaminate the
[31] =>
case report
9
10
|
11
Fig. 9: Crowns immediately after placement. Fig. 10: Aesthetically pleasing result. Fig. 11: Patient’s smile at a recall after four months. Fig. 12: Great optical
integration. Fig. 13: Natural surface texture contributing to the successful outcome. (Photos 11–13: © Emmanuel Charleux)
surface of proteins in saliva and possibly blood, yielding
clean surfaces ideal for bonding.
After thorough rinsing and drying, PANAVIA V5 Tooth
Primer (containing MDP monomer for bonding with
the hydroxyapatite and metal of the preparation) was
applied according to the manufacturer’s instructions
(Fig. 8). Subsequently, PANAVIA V5 Paste was applied
into the first crown, which was then seated, followed
by brief light polymerisation, excess removal and
final light polymerisation from all sides. The procedure
was then repeated for the second maxillary central
incisor.
12
The result instantly satisfied the patient, both in terms
of aesthetics (adaptation, position of the new crowns,
mimicry) and the comfort provided (Figs. 9 & 10).
At a recall after four months, the soft-tissue conditions
were ideal, and the patient was happy with the outcome
(Figs. 11–13). The selected zirconia had good optical
properties, masking of the metal posts was successful
and the natural surface texture contributed to an aesthetic overall picture. The retracted position of the teeth
was also perceived positively by the patient, and the
comfort and function were excellent.
Discussion
Although lithium disilicate has so far been considered
the material of choice for prosthetic work in the anterior
region, zirconia is nowadays proving to be an extremely
satisfactory alternative from every point of view: milling,
strength, aesthetics, assembly—among other things,
no hydrofluoric acid is required for bonding.
KATANA Zirconia Block (STML) with a multilayered colour
structure in a single 4Y-TZP zirconia block, combined
with CERABIEN ZR FC Paste Stain, offers a remarkable
solution. This applies to treatments involving the replacement of existing crowns as well as first-line treatments
with less invasive preparations (vertical preparation) than
those required by other types of ceramics.
13
about
Dr Frank Heldenbergh earned his
DDS from the University of Reims
Champagne-Ardenne in France in
1988. Passionate about prosthetics,
he specialised further as a prosthetics
resident at the university’s dental faculty
from 1990 to 1992. He joined the board
of the Académie de Dentisterie Adhésive
(academy of adhesive dentistry, serving
Reims, Champagne-Ardenne and Picardy) in 1999 and now serves
as vice president. Well known for his expertise in ceramic veneers,
inlays and onlays, Dr Heldenbergh supervised practical work
at the Société Odontologique de Paris (Paris odontological society)
from 2000 to 2018 and at the annual dental meeting of the
French Dental Association from 2000 to 2016. His commitment
to innovation led him to pursue a degree in CAD/CAM from
Paul Sabatier University in Toulouse in France in 2022,
underscoring his dedication to advancing his dental practice.
CAD/CAM
2 2024
31
[32] =>
| research
Biocompatibility of CAD/CAM
biomaterials for bone tissue
engineering application
Dr Katharina Pippich, Katharina Hast, Adem Aksu, Stefanie Grom, Dr Tobias Wolfram, Frank Reinauer,
Dr Dr Andreas Fichter, Dr Dr Achim von Bomhard, Germany
Large bone defects have so far mainly been treated with
autogenous bone grafts. Owing to limited availability and
donor site morbidity, research is ongoing into the development of various bone replacement materials. An advantage of CAD/CAM implants is the possibility of patientspecific engineering. Ceramics and polymers have been
extensively investigated, but not all materials can be produced in a standardised and patient-specific way yet. In
this study, a wide range of materials were investigated, all
of which can be CAD/CAM manufactured and individually
dimensioned in the clean room with standardised techniques using digital light processing, selective laser sintering and fused deposition modelling. The novelty of the materials is the compounding of these, including the special
processing by 3D printing. Eight polymer and ceramic CAD/
CAM materials—poly-L-lactic acid and calcium carbonate,
poly-L-lactic acid and tricalcium phosphate, poly-L-lactic
acid and polyglycolic acid and calcium carbonate, poly-D,
1a
1b
1c
1d
Fig. 1: Scaffold construction (sizes in mm). Scale bars = 1 mm. 3D view (a),
top view (b), side view (c), Cross section (d).
32 CAD/CAM
2 2024
L-lactic acid and magnesium, poly-D, L-lactic acid, betatricalcium phosphate (β-TCP) and hydroxyapatite, β-TCP
and β-TCP'—were tested to evaluate the cytotoxic effects
on human osteoblasts. Biocompatibility was tested using
a proliferation assay, a cytotoxicity assay, an apoptosis
assay and fluorescence microscopy. The ceramic-based
scaffolds, in particular β-TCP, showed very high cell counts
in the proliferation assay as well as rapidly falling apoptosis rates and offer significant potential for use for patientspecific bone replacement implants.
Introduction
Bone defects often occur in the context of tumour resection, bone inflammation, malformation or trauma.1 Autogenous bone transplantation continues to be the gold standard for the reconstruction of such defects. However,
bone availability is limited in this case, and not inconsiderable donor site morbidity, including impaired wound
healing, functional limitations, scarring and necrosis, can
occur.2 Research in the field of bone regeneration is
steadily growing.3 Of great interest are biomaterials, which
being bone replacement materials, avoid the creation of
donor sites and the associated complications and which,
owing to their osteoconductive properties and suitable
architecture, represent a viable alternative to autogenous
bone transplantation.4–6 In addition, materials that can be
additively manufactured offer the advantage of being able
to be individually dimensioned according to the defect.
The growing demand requires bone replacement materials to possess improved mechanical and biological properties. An ideal biomaterial is characterised by biocompatibility and is replaced by regenerated new bone after
the healing period. In terms of chemical composition and
architecture, it should mimic the extracellular bone matrix
so that cells can adhere, multiply and differentiate.7, 8 Biomaterials that are very frequently used include ceramics
such as beta-tricalcium phosphate (β-TCP) and hydroxyapatite (HA). Owing to their osteoconductivity and similar
composition to that of bone, they play a crucial role in tissue engineering. In particular, β-TCP has a high degree
[33] =>
research
CC); PDLLA–Mg; PDLLA; β-TCP–HA; and β-TCP and
β-TCP' for biocompatibility using the same methodology.
The compounding of the materials, including special processing by 3D printing, represents an innovation in additive manufacturing. All eight materials were produced by
digital light processing, selective laser sintering or fused
deposition modelling (FDM). Both the respective processes
and the pore structures were optimised accordingly in order to be able to produce comparable scaffolds using all
technologies. This enabled us to objectively compare a
wide range of materials and material combinations.
of solubility and is broken down more quickly, enabling
replacement with new, regenerated bone.9–11 Polymers
such as poly-L-lactic acid (PLLA) or poly-D, L-lactic acid
(PDLLA) have also shown promise in numerous studies.
Their biocompatibility and biodegradability make them
suitable for the regeneration of bone tissue. They have
sufficient mechanical stability, and their modulus of elasticity is closer to that of the natural cortex than ceramic
materials, which are more brittle.12, 13 Composite scaffolds
made of polymer and ceramic are also frequently used
biomaterials in bone tissue engineering and are currently
being investigated clinically. Ceramic and polymer components are combined to achieve good biocompatibility
and stability.14–19 Likewise, PDLLA or PLLA mixed with
calcium carbonate (CC) or magnesium (Mg) is rated as
promising.20, 21 However, the comparability of materials
has been limited by the different methodologies of the
various studies on them, and most studies have only described one group of materials. Previous studies have
shown that certain defined parameters, such as pore
size, pore shape and porosity, in addition to certain defined mechanical properties and biocompatibility, are decisive for cell adhesion and bone ingrowth.22, 23 Thanks to
the 3D construction of a scaffold that is optimal with regard to these parameters, the bone metabolism can be
positively influenced in a targeted manner. However, this
complex construction can only be implemented with difficulty using conventional production techniques, since
parameters such as pore size, porosity and pore distribution cannot be precisely controlled.24 We examined such
materials more closely, all of which can be additively manufactured in the clean room using standardised techniques. In this way, defined construction parameters can
be implemented precisely for a wide variety of materials.
We examined eight different biomaterials of PLLA–CC;
PLLA–TCP; PLLA, polyglycolic acid and CC (PLLA–PGA–
Biomaterials
The scaffolds were manufactured, packaged and then
sterilised with gamma irradiation in cooperation with the
medical technology company Karl Leibinger Medizintechnik
under clean room conditions. All scaffolds were constructed
with a diameter of 12 mm and a height of 5 mm (Fig. 1). In
order to obtain comparable scaffolds, the wall was reduced
in the first step. After an optimisation of the process parameters, sections of the wall were removed in a second
optimisation, thus making the scaffolds permeable to liquids and cells in the edge structures. In a final step, the
pore geometry was enlarged and rotated in order to achieve
greater reproducibility and comparability between the various manufacturing methods (Figs. 2 & 3). The PLLA–CC
scaffolds were manufactured on the FORMIGA P 110 (EOS),
using selective laser sintering technology. The scaffolds
made of PLLA–TCP, PLLA–PGA–CC, PDLLA–Mg and
PDLLA were manufactured using FDM technology on the
ARBURG AKF freeformer 200-3X (ARBURG). To achieve
technical feasibility, technically pure Mg (99.8%, Alfa Aesar)
was used. The β-TCP–HA and β-TCP scaffolds were manufactured using digital light processing technology on the
2a
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2b
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Material and methods
2d
Fig. 2: Scaffold production. Initial state (a), reduction of the wall (b), removal of sections of the wall (c), enlargement and rotation of the pore geometry (d).
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3a
3b
3c
3d
3e
3f
3g
3h
Fig. 3: Examined scaffolds in culture medium. Scale bar = 10 mm. PLLA-CC (a), PLLA-TCP (b), PLLA-PGA-CC (c), PDLLA-Mg (d), PDLLA (e), β-TCP-HA (f),
β-TCP (g), β-TCP' (h).
CeraFab 7500 (Lithoz). For the β-TCP–HA scaffolds, sintering took place between 1,150 and 1,300 °C, and for the
β-TCP between 1,050 and 1,200 °C. Two scaffold types with
different mechanical properties were made from β-TCP
(β-TCP and β-TCP'). To better differentiate between β-TCP
and β-TCP', the flexural strength was determined in a flexural test of the samples. The flexural strength between
β-TCP and β-TCP' increases with increasing sintering temperature. A flexural strength of 68 N/mm² was determined
for β-TCP and of 120 N/mm² for β-TCP'.
Seeding of biomaterials and cultivation
The biomaterials were seeded with human osteoblasts
(PromoCell). Before seeding, the scaffolds were incubated
for 72 hours at 37 °C and 5% carbon dioxide (CO 2) in
standard culture medium (Osteoblast Growth Medium,
PromoCell) to hydrate the scaffold matrix in order to later
facilitate the growth of the cells into the scaffold structure.
In addition, the pores in the medium were de-aerated by
applying a vacuum in a 100 ml syringe. The cells were
amplified in monolayer culture with standard culture medium to a confluence of 80–90% and then passaged.
Cells from the second passage were used. For seeding,
the cells were detached by trypsinisation and resuspended
in standard culture medium to obtain a cell suspension
with a final cell concentration of 2 × 106 cells/ml. One scaffold was placed per well in a 24-well plate. For seeding,
the cell suspension was pipetted on to the hydrated scaffolds. To ensure that the cells were homogeneously distributed, each batch was pipetted from a cell suspension
and vortexed several times in between. For the apoptosis
and proliferation assays, the scaffolds were seeded with
2 × 105 cells, each with a density of 3.54 × 105 cells/cm3.
In order to enable cell adhesion, the seeded scaffolds
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were incubated for 30 minutes at 37 °C and 5% CO2. The
well was then filled with 1 ml of culture medium so that the
scaffolds were covered by medium. During the course of
this, the medium was changed every two days.
Fluorescence microscopy
In order to visually validate the success of culturing after
21 days, the scaffolds were evaluated using a fluorescence
microscope. The scaffolds (n = 2) were seeded with ten
million cells and cultured for 21 days in differentiation
medium (StemMACS OsteoDiff Media, human, Miltenyi
Biotec) and then fixed in 3% formaldehyde. They were
covered in a 24-well plate with a Hoechst staining solution (Hoechst 33342, AppliChem, in phosphate-buffered
saline; 1:2,000) and incubated for 10 minutes at room
temperature, protected from light. They were then transferred to a well filled with phosphate-buffered saline and
viewed there under a fluorescence microscope (BZ-9000
BIOREVO, Keyence) with a DAPI filter.
MTS assay
The number of metabolic cells growing on the scaffold
surface and in the scaffold matrix was estimated using an
MTS assay (CellTiter 96 AQueous One Solution, Promega).
This proliferation assay uses tetrazolium salt, which is
converted by the cells into purple formazan. The amount
of formazan dye produced is directly proportional to the
number of proliferating cells in the sample. Since this assay is not cytotoxic, it is suitable for multiple measurements over long periods. To each scaffold, 200 μl of MTS
assay was added in 1,000 μl of phenol-free medium and
incubated for 1 hour at 37 °C and 5% CO2. The absorption of each sample was then measured three times at
490 nm in a photometer (BioPhotometer plus, Eppendorf).
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4a
4b
4c
4d
4e
4f
4g
4h
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Fig. 4: Fluorescence microscopy of the scaffold surface with Hoechst staining solution on day 21 after seeding. Scale bar = 200 μm. PLLA-CC (a), PLLA-TCP (b),
PLLA-PGA-CC (c), PDLLA-Mg (d), PDLLA (e), β-TCP-HA (f), β-TCP (g), β-TCP' (h).
An unseeded scaffold, medium and MTS served as control. To determine the number of cells, a calibration curve
was carried out with human osteoblasts. The samples
were analysed on days 2, 5, 7, 14 and 21 (n = 8).
Apoptosis assay
In order to assess the apoptosis activity of the cells on the
scaffolds, an apoptosis assay (Caspase-Glo 3/7 assay,
Promega) was carried out. A DEVD substrate was used
which, in the presence of the apoptotic enzyme caspase -3
or -7, luciferase and adenosine triphosphate, results in
the luciferase reaction and the production of light. This
luminescence is directly proportional to the apoptosis
activity of the cells. At room temperature, Caspase-Glo
reagent was pipetted in a ratio of 1:1 on to the scaffolds
in the medium. These were then agitated on the plate
shaker (30 seconds, 300–500 rpm) and incubated at
constant room temperature for 45 minutes. The luminescence of each sample was then measured three times in
a plate-reading luminometer (Victor X2, PerkinElmer). The
samples (n = 8) were analysed on days 2, 5, 7, 14 and 21.
To determine the apoptosis activity based on the metabolic cells in the scaffold, the quotient of the apoptosis
value (luminescence) divided by the cell count in the scaffold was generated. With the help of an establishment
experiment, it was shown that the assay is not cytotoxic
and is therefore suitable for a series of measurements
over longer periods. For this purpose, the proliferation
rate of cells incubated with the apoptosis assay was
checked by means of the MTS assay.
Cytotoxicity assay
The cytotoxicity assay was performed according to ISO
10993-5. Extracts of the scaffolds were produced by hy-
drating them in 2 ml of serum-containing culture medium
for 72 hours in order to accumulate potentially cytotoxic
substances in the medium. Human osteoblasts were cultivated in 96 well plates with a density of 1,000 cells per
well and, after addition of the extracts (in the dilutions 100%,
75%, 50% and 25%), incubated for 24 hours. Viability was
assessed with the aid of the proliferation assay (CellTiter 96
AQ ueous One Solution). The extract from ThinCert membranes (Greiner Bio-One), which are considered to be
particularly cell-friendly, served as a negative control, and
100% dimethylsulfoxide (DMSO) was used as a positive
control.
Sulforhodamine B assay
The sulforhodamine B assay allows conclusions to be
drawn about the number of cells in the osteoblasts growing in the milieu of the scaffolds by measuring protein
quantities. Human osteoblasts were seeded in six-well
plates at a density of 100,000 cells per well. With the help
of ThinCert inserts, the scaffolds were placed in the medium above the cells. It was thereby possible to investigate whether the materials release cytotoxic substances
into the medium over longer periods and to what extent
this affects the number of cells and therefore cell growth.
The cells were fixed with methanol (99%; Carl Roth) on
the measurement days and stored at –80 °C. For staining,
the methanol was removed from the wells, and the cells
were covered with sulforhodamine B staining solution
(1% acetic acid solution and 0.4% w/v sulforhodamine B
sodium salt, Sigma). Incubation was performed for 30 minutes at room temperature with continuous agitation. The
sulforhodamine B staining solution was then removed, and
the fixed cells were washed five times in a 1% acetic acid
solution. The stained cells were dried and, after 24 hours,
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dissolved in 2 ml of 10 mM Tris buffer. The absorption of
each sample was then measured three times at 550 nm
in a photometer (BioPhotometer plus). To determine the
number of cells, a calibration curve was carried out with
human osteoblasts. The samples (n = 8) were analysed
on days 2, 5 and 7.
Statistical analysis
The data for the tests performed are presented as
mean ± standard deviation. Statistical analysis was performed using GraphPad Prism 8 (GraphPad Software).
To evaluate the differences between time points and
groups, one-way ANOVA and Friedman Test were performed followed by Dunn’s post hoc multiple comparisons. T-test and Mann–Whitney U test were performed
for significance of viability in cytotoxicity testing. A P value
< 0.05 was considered significant.
Results
Fluorescence microscopy
PLLA–PGA–CC, PDLLA, β-TCP–HA, β-TCP and β-TCP'
showed the highest cell density (Fig. 4).
MTS assay
The initial cell count after seeding was 2 × 105 cells/scaffold. On day 2, the first measurement was performed. The
cell count on day 21 was evaluated in comparison to days
2, 5, 7 and 14. In the group of PLLA-based polymers, the
PLLA–CC scaffold contained 2.77 x 105 (± 0.34 × 105)
cells on day 2. After a slight decrease in cell count on day 5
(2.01 × 105 ± 0.80 × 105) and day 14 (2.36 × 105 ± 0.51 × 105),
5a
5b
5c
5d
5e
5f
Fig. 5: Proliferation assay (MTS assay). Determination of the number of proliferating cells in the scaffolds after two, five, seven, 14 and 21 days (a–f).
Regression lines to determine growth tendency over time (d–f).
36 CAD/CAM
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the cell count per scaffold increased to 4.20 × 105 (± 0.63 × 105)
after 21 days (p < 0.05). For PLLA–TCP, the cell count increased until day 7 (8.28 × 105 ± 1.34 × 105), decreased to
3.17 × 10 5 (± 0.93 × 10 5) on day 14 and increased to
4.49 × 105 (± 1.03 × 105) on day 21. The difference in cell
count between day 21 and day 14 was significant (p < 0.05).
For PLLA–PGA–CC, the cell count increased from day 2
(4.37 × 10 5 ± 0.56 × 10 5) to day 5 (3.48 × 10 5 ± 1.16 × 10 5),
day 14 (4.07 × 10 5 ± 0.62 × 10 5) and day 21 (5.74 × 10 5 ±
0.61 × 105; p < 0.05). Overall, the highest values were obtained on day 7 with 10.15 × 105 (± 2.30 × 105) cells. PLLA–
PGA–CC showed the highest cell counts over time in the
group of PLLA-based polymers (Figs. 5a & d). For PDLLA–Mg,
the total cell count decreased from 0.14 × 105 (± 2.25 × 105)
on day 2 to 0.00 × 105 (± 0.26 × 105) on day 21, having only a
temporary slight increase on day 5 (1.44 × 105 ± 0.88 × 105)
and day 14 (0.89 × 10 5 ± 0.66 × 10 5). PDLLA increased
steadily from day 2 (1.67 × 10 5 ± 0.44 × 10 5) to day 5
(2.65 × 105 ± 0.71 × 105), day 7 (4.19 × 105 ± 1.00 × 105), day
14 (4.13 × 105 ± 1.31 × 105) and day 21 (9.39 × 105 ± 1.12 × 105;
each p < 0.05). In the group of PDLLA-based polymers,
PDLLA showed the best results over time (Figs. 5b & e). For
the ceramics, an increase in cell count was observed
in β-TCP–HA on day 21 to 6.54 × 10 5 (± 1.26 × 10 5)
compared with day 2 (3.34 × 10 5 ± 0.68 × 10 5), day 5
(3.22 × 105 ± 1.05 × 105) and day 14 (4.83 × 105 ± 1.01 × 105;
p < 0.05 for days 2 and 5). β-TCP increased steadily from
day 2 (1.67 × 105 ± 0.80 × 105) to day 5 (3.93 × 105 ± 1.75 × 105),
day 7 (5.74 × 105 ± 1.49 × 105), day 14 (5.68 × 105 ± 1.70 × 105)
and day 21 (7.35 × 105 ± 1.43 × 105; p < 0.05 for days 2 and 5).
β-TCP' also showed a significant increase in cell count
on day 21 (7.46 × 105 ± 4.07 × 105) compared with day 2
(1.87 × 105 ± 1.41 × 105), day 5 (5.01 × 105 ± 2.55 × 105) and
day 7 (4.53 × 105 ± 2.62 × 105; p < 0.05). Day 14 showed the
highest value with 8.26 × 105 (± 2.98 × 105) cells (Figs. 5c & f).
In summary, β-TCP–HA, β-TCP and β-TCP' showed the
best results over time, and PDLLA–Mg showed the lowest cell counts.
Apoptosis assay
In order to determine the apoptosis activity in relation to
metabolic cells, the quotient of the apoptosis value (luminescence) divided by the cell count in the scaffold was
generated. The PLLA-based polymers all showed a similar course of apoptosis activity over the observation period. For PLLA–CC, apoptosis activity was significantly
increased on day 2 to 118.57 × 10-5 (± 19.60 × 10-5) compared with days 5, 7, 14 and 21, when the value approached
zero (range: 0.00–5.29 × 10-5; p < 0.05). PLLA–TCP, with a
value of 187.19 × 10-5 (± 32.20 × 10-5), and PLLA–PGA–CC,
with a value of 107.32 × 10-5 (± 21.90 × 10-5), also showed
increased apoptosis activity on day 2 compared with the
other days (p < 0.05; Figs. 6a & d). After initially increased
apoptosis on day 2 (84.15 × 10-5 ± 53.80 × 10-5), PDLLA–Mg
decreased to 1.44 × 10 -5 (± 2.50 × 10 -5) on day 5 and
increased again on day 7 (971.03 × 10-5 ± 1,358.90 × 10-5;
p < 0.05). Subsequently, it remained slightly elevated at
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15.40 × 10-5 (± 9.50 × 10-5) on day 21 (p < 0.05 compared
with day 5). For PDLLA, apoptosis activity was significantly
increased only on day 2 (375.48 × 10-5 ± 25.60 × 10-5) and
then decreased to low values between 0.00 and 7.01 × 10-5
(Figs. 6b & e). All ceramics showed a similar course of
apoptosis activity. On day 2, β-TCP–HA, with a value of
103.52 × 10-5 (± 32.50 × 10-5), and β-TCP', with a value of
129.85 × 10 -5 (± 30.50 × 10 -5), showed significantly increased apoptosis activity compared with days 5, 7, 14
and 21 (0.00–4.79 × 10 -5). Also, β-TCP showed an increased value on day 2 (246.27 × 10 -5 ± 34.90 × 10 -5;
p < 0.05). Furthermore, the curve flattened more slowly
here (Figs. 6c & f). In summary, apoptosis decreased towards zero after having initially increased on day 2 for
PLLA-based polymers, ceramics and PDLLA. For PDLLA–Mg,
apoptosis activity peaked again on day 7 and moderately
increased again after 21 days.
Cytotoxicity assay
The proliferation of human osteoblasts was not affected
by the extracts (100% undiluted extract) of the biomaterials (Fig. 7). Cell growth and metabolism were unchanged
compared with the non-cytotoxic control (negative control). The negative control value was set to 100%. The viability of extracts of PLLA–CC (156%) and β-TCP (151%)
even exceeded that of the negative control. Cells incubated in 100% DMSO (positive cytotoxic control) reflected
the cytotoxic effect of DMSO on viability (5.6 ± 4.8%). The
viability of human osteoblasts cultured in DMSO was significantly reduced compared with the negative control
and the scaffold extracts (p < 0.05). According to ISO guidelines, cell viability in the range of 0 to 50% reflects a
strong cytotoxic effect of the tested extract, whereas values between 70 and 100% reflect the absence of cytotoxic components. The viability of 50% extract dilutions
was at least as high as that of 100% extracts for all biomaterials, as required by the ISO guidelines.
Sulforhodamine B assay
The initial cell count after seeding was 1 × 105 cells/scaffold. On day 2, the first measurement was performed. After an increase of the cell count of PLLA–CC on day 2 to
4.46 × 105 (± 1.90 × 105), it decreased on day 5 (2.57 × 105 ±
1.60 × 10 5) and remained almost unchanged on day 7
(2.76 × 105 ± 1.01 × 105). For PLLA–TCP, the cell count after day 2 (4.36 × 105 ± 2.63 × 105) decreased to 3.18 × 105
(± 0.97 × 105) on day 5 and to 2.79 × 105 (± 1.49 × 105) on
day 7. PLLA–PGA–CC showed almost constant cell counts,
having a value of 2.38 × 105 (± 0.74 × 105) on day 2 and of
2.20 × 105 (± 0.95 × 105) on day 5. On day 7, there was a
significant increase to 2.84 × 105 (± 0.79 × 105) compared
with day 5 (p < 0.05; Figs. 8a & d). Starting with 3.56 × 105
(± 0.66 × 10 5) on day 2, the cell count of PDLLA–Mg
dropped to 1.45 × 105 (± 0.44 × 105) on day 5 and remained
nearly unchanged (1.52 × 105 ± 0.55 × 105) on day 7. For
PDLLA, a value of 2.61 × 105 (± 0.23 × 105) was observed
on day 2. On day 5, the cell count slightly decreased
6a
6b
6c
6d
6e
6f
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Fig. 6: Apoptosis assay. L = luminescence. Determination of apoptosis activity
related to cell count on the scaffolds after two, five, seven, 14 and 21 days (a–f).
Regression lines to determine apoptosis tendency over time (d–f).
(2.06 × 105 ± 0.49 × 105), and it also remained nearly unchanged on day 7 (2.11 × 105 ± 0.39 × 105; Figs. 8b & e). After
day 2 with a cell count of 2.22 × 105 (± 0.37 × 105), β-TCP–HA
showed a slight decrease in cell count on day 5
(1.84 × 105 ± 0.37 × 105). The count increased slightly on
day 7 (2.21 × 10 5 ± 0.52 × 10 5). β-TCP' showed a similar
course, having 3.01 × 105 (± 1.82 × 105) cells on day 2, a
slight decrease on day 5 (2.64 × 105 ± 0.72 × 105) and an
increase on day 7 (3.08 × 105 ± 0.44 × 105) compared with
day 5 (p < 0.05). β-TCP had a cell count of 2.37 × 10 5
(± 0.52 × 105) on day 2, a minimal decrease on day 5
(2.08 × 105 ± 0.47 × 105) and a significant increase on day 7
(6.72 × 10 5 ± 5.88 × 10 5) compared with day 5 (p < 0.05;
Figs. 8c & f). PLLA–PGA–CC, β-TCP and β-TCP' showed
a significant increase in cell count as well as the largest
slope of the regression line over the observation period
(Figs. 8d & f). The other materials showed only insignificant
changes or decreasing cell count.
Discussion
Despite promising advances in tissue engineering, the
treatment of large bone defects is still a challenge.25 An
optimal biomaterial should be biocompatible and have
controllable biodegradability and architecture and optimal mechanical properties.26 An interconnected pore
system, porosity and optimal pore size are required, although opinions differ on this.27, 28 In general, however, a
pore size of over 300 μm is favoured.29 We chose a pore
diameter of 800 μm to allow osteogenesis, fluid exchange
and subsequent vascularisation. While a complex scaffold design is difficult to implement using conventional
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techniques, additive manufacturing processes allow for
individual implant production.24, 30, 31 This enables us to
both individually adapt the scaffold shape to a bone defect and to construct the microscopic scaffold architecture. We evaluated the biocompatibility of various additively manufactured biomaterials using a proliferation,
apoptosis, cytotoxicity and sulforhodamine B assay and
were thereby able to objectively evaluate and compare a
wide variety of materials and material groups. In the proliferation and apoptosis assays, multiple measurements
could be made over longer periods owing to the lack of
cytotoxicity of the assays. This also has the advantage of
better comparability and fewer inaccuracies. TCP–HA is
becoming an increasingly important biomaterial in bone
tissue engineering. Owing to its similarity to the mineral
phase of bone, HA plays an important role in cell adhesion and proliferation and, along with tricalcium phosphate,
is one of the most frequently used ceramics.32–34 In vivo
studies have also shown that the combination of TCP–HA
induces bone formation.35–37 In this study, β-TCP–HA
showed a significant increase in the number of cells
7
Fig. 7: In vitro cytotoxicity of 100% undiluted extract. Human osteoblasts
cultivated in control extract (negative control = dotted line, 100%) or undiluted scaffold extract all showed high viability. The viability of osteoblasts
cultivated in dimethylsulfoxide (positive cytotoxic control) was significantly
reduced compared with the scaffold extracts (p < 0.05).
growing on the scaffold over 21 days, but the cell count
on days 14 and 21 was lower than that of β-TCP and
β-TCP'. The apoptosis activity of β-TCP–HA was significantly increased on day 2 compared with the other days;
over time, it decreased to zero. Initially increased apoptosis activity was observed in all the materials and is most
likely explained by the trypsinisation and the passage
when seeding the scaffolds. After day 2, hardly any cells
were in apoptosis, evidence of the cell compatibility of the
scaffold. Compared with pure β-TCP, the quotient of the
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apoptosis value divided by the cell count was significantly
lower for the TCP–HA on day 2. Woo et al. describe suppressed cell apoptosis through the addition of HA to
composite scaffolds.38 This is in line with our results. In
the cytotoxicity test in accordance with ISO 10993-5, the
growth of the osteoblasts was not impaired by the scaffold extract either. The sulforhodamine B assay evaluated
the number of osteoblasts that grew in the scaffold extract in the immediate vicinity of the scaffold for seven
days. Good results were demonstrated here; the regression line had a positive gradient. However, the total number of cells was even higher for pure β-TCP and β-TCP'.
Despite very good biocompatibility and low apoptosis
values, TCP–HA showed somewhat poorer results than
β-TCP and β-TCP' with regard to cell proliferation and
growth behaviour. β-TCP is one of the most used biomaterials. Its osteoconductivity, rapid degradability and similarity to the composition of bone make it suitable for bone
tissue engineering.10, 11 This has also been shown by numerous in vivo studies. For example, Kondo et al. successfully implanted β-TCP into femur bones in the rat model.39
The brittleness of the material usually makes it difficult to
adapt to the individual,40 but this is no longer necessary
owing to the possibility of individual construction using
additive manufacturing processes. Since, depending on
the dimensions, classic fixation of ceramics with screws
is not possible, alternative fixation techniques are necessary (e.g. a cage). Both β-TCP and the mechanically improved β-TCP' with higher flexural strength showed a significant increase in cell count from day 2 to day 21. In
addition, both (with PDLLA) achieved the highest cell
counts on days 14 and 21 compared with all other materials and therefore better cell proliferation. While β-TCP'
showed a twofold drop in cells during the process, the
growth curve of β-TCP demonstrated a consistent upward trend. After initially elevated values (day 2) for β-TCP
and β-TCP', apoptosis activity decreased towards zero.
On day 2, the quotient of the apoptosis value divided by
the cell count of β-TCP was significantly increased compared with β-TCP' and TCP–HA. This agrees with the results of the proliferation assay, in which β-TCP had the
lowest cell count among the ceramics on days 2 and 5,
as the cells increasingly went into programmed cell death.
However, the number of cells then rose steadily to very
good values. Osteoblast proliferation was not negatively
influenced in the cytotoxicity assay by the extract of
β-TCP or β-TCP', also indicating good biocompatibility. In
the sulforhodamine B assay, we observed a higher cell
count on day 7 for β-TCP and β-TCP' compared with
TCP–HA; for β-TCP', this difference was significant.
Compared with all the materials, they also showed the
best results here, having a regression line gradient of
67.5 (β-TCP) and 23.2 (β-TCP'). With regard to cell proliferation and growth behaviour, β-TCP and β-TCP' showed
the best results in the ceramic scaffolds group. PLLA–CC
was recently described in the literature as a bone replacement material.20 CC has a beneficial effect in bone
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tissue engineering, as extracellular calcium enhances osteogenic gene expression and promotes bone regeneration.41 CC was mentioned earlier as a suitable filler for polyester, because its pH-stabilising effect buffers the acidic
degradation of polylactides.42 In this study, PLLA–CC
showed a significant increase in cells growing in the scaffold from day 2 to day 21, but the cell count was slightly
lower than that of the other PLLA-based scaffolds at all
measurement times. Apoptosis activity was significantly
increased initially (day 2) and decreased towards zero
over time, indicating the long-term cell tolerance of the
scaffold. The increased apoptosis activity is probably related to differences in the degradation kinetics and initial
water absorption of the polymeric scaffold systems. Different proteins also play a role as deposits on the scaffolds. In the cytotoxicity test, the growth of the osteoblasts was not impaired by the scaffold extract either. In
the sulforhodamine B assay, the cell count on day 7 was
not significantly different from that of the other PLLA scaffolds. However, the curve showed the smallest regression line gradient among the PLLA scaffolds. Gayer et al.
described good cell compatibility of PLLA–CC, but there
is no possibility of comparison with other materials.20 In
this study, PLLA–CC demonstrated overall good biocompatibility. In comparison with the poly-L-lactides
PLLA–TCP and PLLA–PGA–CC, however, the latter can
be assessed as even more promising in terms of cell proliferation and growth behaviour. Composite scaffolds
made from PLLA–TCP are frequently used biomaterials
in bone tissue engineering.14–18 The aim is to overcome
the shortcomings of the individual materials by combining PLLA and TCP. On the one hand, TCP counteracts
the acidic environment that results from the breakdown
of polylactide. On the other hand, the combination of
PLLA and TCP improves the mechanical properties of a
scaffold.32, 43 We observed a non-significant increase in
cells growing in the scaffold from day 2 to day 21; the increase from day 14 to day 21 was significant. The cell
count over time was higher than for PLLA–CC, but lower
than for PLLA–PGA–CC. For PLLA–TCP, the apoptosis
activity was significantly increased on day 2, and over
time, it also decreased to zero. The results in the cytotoxicity test reflected the absence of cytotoxic components.
In the sulforhodamine B assay, the cell count on day 7
was not significantly different from that of the other PLLA
scaffolds. However, the cell counts fell again after an increase on day 2, and the regression line showed a slightly
lower gradient than PLLA–PGA–CC did. PLLA–PGA–CC
in this composition has not yet been described in the literature as a bone replacement material. PLLA is already
widely used in tissue engineering for the regeneration of
bone tissue.44–47 PGA is a less hydrophobic polymer with
a relatively rapid degradation rate.48 The co-polymer
PLLA–PGA has been described for bioresorbable bone
fixation in the form of screws, plates or orbital floor reconstruction plates.49–52 There is also information on the
good biocompatibility of the composite of poly (lactic-
8a
8b
8c
8d
8e
8f
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Fig. 8: Sulforhodamine B assay. Determination of the cell count of osteoblasts
growing in the scaffold environment after two, five and seven days (a–c).
Regression lines to determine growth tendency over time (d–f).
co-glycolic) acid (PLGA) and CC, but not on PGA–CC or
PLLA–PGA–CC.53 As a co-polymer of PGA, PLGA has
similar properties in some cases. In our investigations,
PLLA–PGA–CC showed a significant increase in cell metabolism from day 2 to day 21. The cell count of the osteoblasts growing on the scaffold was significantly increased
on all measurement days compared with the other PLLAbased scaffolds, with the exception of PLLA–TCP on
days 5 and 7. After initially increased values (day 2), the
apoptosis activity decreased over time to zero, which is
desirable. Furthermore, PLLA–PGA–CC sometimes showed
the lowest quotient of the apoptosis value divided by the
cell count compared with all the other materials, indicating good cell compatibility. In the cytotoxicity test too, the
scaffold extract did not impair the growth of the osteoblasts.
When evaluating the cell count in the sulforhodamine B
assay, the cell count on day 7 was about the same as
for the other PLLA scaffolds. However, PLLA–PGA–CC
was the only material here that showed a significant increase in cell count over the course of the experiment
and the largest gradient of the regression line. With regard to cell proliferation, growth behaviour and apoptosis
activity, PLLA–PGA–CC showed the best results in the
group of poly-L-lactides. PDLLA–Mg in this composition
and Mg in this processing method have not yet been described in the literature. Mg is believed to have great potential in bone tissue engineering because of its biodegradability and its ability to promote new bone formation.
In addition, the modulus of elasticity of Mg is comparable
to that of cortical bone.54–58 The problem, however, is the
rapid corrosion of Mg, which can lead to a loss of structure and the release of degradation products.59 The rate
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| research
of degradation of technically pure Mg is much faster than
that of alloys such as WE34 which are already in clinical
use. Because the degradation rates are significantly lower,
these alloys also show very good biocompatibility, but
other elements are also present here, for example rare
earth elements that are not found in technically pure Mg.
Our intention was to generate a polymeric matrix around
the Mg material to create a polymer–metal composite to
reduce the degradation rate of metallic Mg and thereby
improve biological effects such as cell compatibility. Our
results showed a comparatively low number of cells on
the scaffolds. This was also confirmed by our electron
microscopic examinations on day 21 (ongoing study).
The quotient of the apoptosis value divided by the cell
count was significantly increased in particular on day 7
compared with the other materials. The high value can be
explained by the low cell count on the scaffold, and of
these few cells, a large percentage were found to be in
apoptosis. The high apoptosis levels are consistent with
the low cell counts. In the sulforhodamine B assay too,
the cell count was lower than that of the other materials,
and the regression line decreased with a slope of –4.5. In
contrast to this, osteoblast proliferation was not negatively influenced by the extracts, suggesting low cytotoxicity. Tavares et al. reported a lack of cytotoxicity of composite scaffolds to which Mg was added in the cytotoxicity
test in accordance with ISO 10993.60 This illustrates how
important it is to test the material itself and not only to test
an eluate produced from it, as here the effects of the scaffold architecture and other interactions are neglected.
PDLLA–Mg showed less favourable results in this study
compared with the other PDLLA-based materials. When
looking at all the materials together, the other materials
also performed better. This is presumably primarily due
to the release of degradation products59 and gas formation and was to be expected for pure Mg. It can be assumed that the slowdown in degradation, which we
wanted to achieve with the composite material formulation, had occurred to an insufficient degree. However, we
were able to show that the additive production of Mgbased implants using FDM technology is technically feasible. Further work is necessary to develop other material
formulations that allow optimal degradation kinetics of
technically pure Mg with a cell biologically compatible release of degradation products in order to fully exploit the
material’s potential for bone tissue engineering. PDLLA
has been frequently described as a biomaterial.42, 61–63 In
this study, the cell count of the osteoblasts growing on
the scaffold increased steadily up to day 21 and was significantly higher than that of the other PDLLA-based scaffolds on days 5, 7, 14 and 21. After initially strongly increased values (day 2), apoptosis activity decreased
towards zero over the course of the experiment. In the
cytotoxicity test too, the growth of the osteoblasts was
not impaired by the scaffold extracts. In the evaluation of
the cell count in the sulforhodamine B assay, the cell
count on days 5 and 7 was significantly increased com-
40 CAD/CAM
2 2024
pared with PDLLA–Mg. In addition, PDLLA showed the
most significant regression line gradient within the poly-D,
L-lactide materials. With regard to cell proliferation, growth
behaviour and apoptosis activity, PDLLA showed the
best results in the group of poly-D, L-lactides. We evaluated the biocompatibility of the various additively manufactured biomaterials in the clean room and therefore had
the opportunity to objectively evaluate and compare the
different materials. The novelty of the materials is the
compounding of these, including the special processing
by 3D printing, to produce comparable scaffolds. Looking at all the materials together, the ceramic-based scaffolds proved to be the most promising. They showed the
highest cell counts in the proliferation assay. They can be
considered non-cytotoxic when used in vitro, and the
apoptosis activity strongly decreased over the measurement period. β-TCP and β-TCP' exhibited particularly
good results, showing the steepest growth curves in the
sulforhodamine B assay. Among the poly-L-lactides,
PLLA–PGA–CC performed best in terms of cell proliferation, growth behaviour and apoptosis activity. In the poly-D,
L-lactide group, PDLLA showed the best results. The
comparatively lowest cell counts and highest apoptosis
values were observed for PDLLA–Mg. Further studies to
improve the materials are planned, as these materials
also demonstrated very promising properties that should
be used for tissue engineering. A study is currently being
carried out with regard to the behaviour of the materials in
vivo.
Acknowledgement
This work was supported by the German Federal Ministry
of Education and Research within the project “Establishment of industry-in-clinic platforms for the development
of innovative medical devices” (grant number: 13GW0248).
Editorial note: This article was first published in
implants—international magazine of oral implantology,
Vol. 24, Issue 4/2023.
Please scan the QR code for the list of references.
about
Dr Katharina Pippich
Department of Maxillofacial Surgery
Technical University of Munich
Ismaninger Straße 22
81675 Munich, Germany
katharina.pippich@mri.tum.de
[41] =>
dental-tribune.com
dtstudyclub.com
E-newsletter
For 20 years,, Dental Tribune
International has been at the
forefront of dental media, education,
and events, shaping the global
landscape of dental knowledge
dissemination. With a presence
in over 90 countries,
countries Dental
Tribune International stands as
the world’s largest dental
network, connecting profesThe global voice in essential dental media
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commitment to providing
essential information to the dental
community is unwavering. Since our
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2003, Dental Tribune International
has flourished into
a powerhouse.
Our integrated approach merges print,
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milestone, we proudly
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Together, Dental Tribune International and OEMUS MEDIA bring forth over
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14
15
innovation, quality, and service excellence.
Celebrating 20 years of
16
Interview
Prof. Phoebus
Madianos discloses
tendees can look
what atforward to at
this year’s
EuroPerio.
News
The European
Federation of
Periodontology
has made sustainab
ility a central
EuroPerio10.
focus of
» page 4
EFP welcomes
attendees
to EuroPerio1
0 in Copenhage
More
© Marina Datsenko/Shutter
than 130
to present on advancespeakers from over 30 countrie
s
s in periodontics
and implant dentistr
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terstock.com
Products
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to see and
try out the most
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» pages 17–20
“We aim to insp
ire excellence
during this yea
r’s EuroPerio”
Holger Essig, chief
marketing
n
An interview with
stock.com
officer of BioHoriz
THE GLOBAL DENTAL CE COMMUNITY
Organised by
the European
Periodontology
Federation of
As dental profession
(EFP), EuroPeri
dontics and implant
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held from 15
o10 is being
up for EuroPerio
dentistry and
to 18
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10, Dental Tribune world gear
their conhagen in Denmark June at Bella Center Copenother dental
reached out to
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discigress in periodon . EuroPerio, the leading conchief marketin
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[42] =>
© Creative Cat Studio/Shutterstock.com
| feature
Work–life balance—
a lifestyle more than a goal
Jerko Bozikovic, Belgium
Why is it that so many people struggle to find
balance in their life and work? Why is it that it feels
like time flies and we cannot get half of the things we
intended to done? Why is it that we sometimes feel
like we’re constantly playing catch-up while life goes
on around us?
I can think of many more “Why is it” questions. Do these
resonate with you—or with your team? Why is it that we
can or cannot reach a state of work–life balance?
42 CAD/CAM
2 2024
Maybe it is because the terminology is wrong. “Work–life
balance” implies that work is not part of life. It might be
more accurate to look at what we do, how we feel and
how we invest our time, energy and focus in work and in
life. And is there a large difference? And why? Or why not?
Work is love in action
Many years ago, I heard the saying “Work is love in action”.
This changed my whole perspective on work. Before that,
[43] =>
feature
|
have been their passion for their work, their dedication to
their patients, their commitment to their teams and their
aim to strive for excellence. Would we not call that love
too in a sense? And if this is love too, how should we
then create balance? Is it that we give too much of it, that
we do not know when to stop giving to others and start
giving to ourselves? Do we have balance in that? And do
we have balance in the love, the energy, the time we give
to our teams and patients compared with what we give to
our families and friends? Interesting food for thought.
Signs of a disbalanced work and life
Many of the challenges in these current times can be
physical, mental, emotional and spiritual. The body always tells us when something inside of us is off, but so
do our heart, our thoughts and our sense of something
greater in life. Experiencing chronic disturbances like little
sleep, poor eating habits, addictions, challenging relationships with a great deal of emotional struggle, negative
thought patterns or recurrent questions like “Why am
I doing this?” “Who is this all for?” “What about me?” are
very good indicators of the need to take some time off
and reflect. Gain some distance from your life to observe,
feel and analyse.
it felt more that work was something I had to do to get
what I needed (money) to do the things I really liked in my
free time. In truth, though, I never saw work as a burden;
it was always about connecting with people, enjoying my
time, using my talents and competences. So, in reality, it
had always been about love, only I never saw it that way.
So how do you see your work? I have met many orthodontists in the past 11 years since I started collaborating
with Align Technology, and common points among them
I take this approach quite regularly, several times a year,
to see where I am at, what I am doing, what I need and
how I feel. This summer, I spent five days in the woods in
Belgium with 475 men, including a subgroup of 50 entrepreneurs and leaders. We had over 100 workshops to
choose from to work on ourselves over these five days.
The camaraderie, the dedication to learning, growing,
healing, letting go, forgiving, re-examining one’s life,
accompanied by laughter, tears, insights, support of
one another, was very inspiring. We all went home with
a deeper sense of who we are and what we want in life.
This sort of activity provides food for one’s mind, heart,
body and soul.
Solutions—what can we do?
Do you create these moments for reflection in your life,
whether it is sitting still for 15 minutes a day or spending
a few days in nature? What else do you do to seek
balance, insights, growth?
“Experiencing chronic disturbances like little sleep,
poor eating habits, addictions, challenging relationships
with a great deal of emotional struggle,
negative thought patterns (...) are very good indicators
of the need to take some time off and reflect.”
CAD/CAM
2 2024
43
[44] =>
| feature
Here are a few concrete questions to explore that will help
you create a more balanced work life:
© inspiring.team/Shutterstock.com
– Consider your work framework:
· What is expected of you and of others regarding roles,
responsibilities and tasks?
· Is the structure of who does what clear?
· Can you let go and delegate?
· Do you and your team have the necessary skills in
communication, time management, stress management, clinical knowledge and other relevant areas to
deal with everyday situations and challenges?
· What is your desired time frame for your availability to
your patients, your team, your family, your friends and
yourself?
· How reachable do you want to be outside of working
hours by your teams and patients (smartphone, e-mails,
messages)? And has this been clearly communicated
to them?
– Consider your leadership style:
· Do you find it easy to delegate?
· Do you find it easy to trust others?
· Do you take enough time to train new people?
· Do you take enough time to have meetings (one to one
and in a group) to check in with your teams, not only
on work-related topics but also on personal matters?
·A
re you a good listener?
·D
o you communicate clearly?
44 CAD/CAM
2 2024
– Consider your framework for me time, family time and
friend time:
· Do you bring work back home?
· Do your friends and family know what they can expect
from you in terms of time and focus, or do you keep
changing this to prioritise work?
· Can you turn off your work mindset and be fully present with yourself and your loved ones?
If you feel that you have some growth potential in any of
these areas, you can start changing them today—not everything all at once but in micro-steps. Rather than putting too much on your plate, start by setting goals that are
achievable and do not take too much time and energy.
For demonstration, consider these examples of microsteps in areas needing change:
– Do you want to have a healthier morning routine? Do not
immediately reach for your smartphone on waking up and
spend 15 minutes scrolling. Instead, sit up in bed, take ten
deep breaths and visualise how you would like your day go.
– Do you want to have a healthier breakfast routine? Do
not wake up and immediately get your coffee. Get up,
drink a glass of water or even a glass of warm water
with some olive oil and a squeeze of lemon—it will activate your liver and other organs to start working and
detoxing—and then drink your coffee 20 minutes later.
[45] =>
|
© Natalya Bardushka/Shutterstock.com
feature
– Do you not want to bring work back home? Instead
of allowing yourself to work for an extra 2 hours from
home after work every day, reduce this by 15 minutes
per day, giving you this amount of free time. Continue
to reduce it week after week by 15 minutes until you
reach an amount of time for working from home that is
acceptable to you, maybe 30–45 minutes rather than
the 2 hours it used to be.
Be creative! You know what you can do—and make it
feasible. If something is feasible, it is much less likely that
you will fail.
Include your team
Your team might feel overwhelmed from time to time or
that there is a lack of structure or an imbalance. In August,
I was in New Zealand to speak at the ANZ Align Orthodontist Forum. Another speaker at the event shared the
following very significant statement: “Everybody’s time is
as important.” By that, he meant that everybody wanted
to be able to go home on time, have a family life, do hobbies and sports, and have me time, including himself.
With that in mind, he had organised a meeting with his
team explaining this viewpoint and asked a very vulnerable
question: “My private time is as valuable as yours, and
I have noticed that it is not in balance. How can you help
me so that we can all end our working day together?”
Asking this of his team made them aware of his inner
challenges in this regard, and they all started looking
for solutions. Some took on more responsibilities, some
became more proactive and some came up with creative
ideas, and within a few weeks, they all ended work at the
same time, and his working day truly came to an end the
moment he left the clinic. I found this very inspiring.
So, what will you do to make sure that the following
questions do not keep burdening you?
– Why is it that so many people struggle to find balance
in their life and work?
– Why is it that it feels like time flies and we cannot get
half of the things we intended to done?
– Why is it that we sometimes feel like we are constantly
playing catch-up while life goes on around us?
I am convinced that we have so many answers inside of us;
we just need to stand still from time to time to reflect on,
observe, think about and feel what we want to do and
where we want to go. I wish you a wonderful journey in
discovering and balancing your work and life!
Editorial note: This article was first published in
aligners— international magazine of aligner orthodontics,
Vol. 3, Issue 2/2024.
about
Jerko Bozikovic is a specialist
in communication skills, emotional
intelligence, time and stress
management, leadership, and change
management. He is fascinated by
human behaviour and finds working
with people on personal development
to be a daily challenge and blessing.
He speaks seven languages and has
offered his training courses in four languages since 2001.
He embraces and embodies the motto “Love the life you live;
live the life you love.” He can be contacted via LinkedIn.
CAD/CAM
2 2024
45
[46] =>
| manufacturer news*
1
Fig. 1: R5—a highly automated milling and grinding machine for wet and dry machining in dental technology.
R5—maximum automation for perfect restorations
The R5 from vhf camfacture’s HIGH END CLASS is a highly
automated five-axis milling and grinding machine that processes
all materials commonly used in dental technology. Thanks to
its groundbreaking technologies, changing between wet and dry
processing can be done on the fly—enabling continuous operation
around the clock, thanks also to a tenfold disc changer.
The R5 is an extremely compact, high-end machine. Its DIRECTDISC
Technology, a patent-pending loading system for discs, is particularly innovative, allowing the discs to be loaded single-handedly
in a matter of seconds. The working chamber’s drying system with
DIRECTCLEAN Technology, also patent-pending, makes it possible
46
2a
to quickly switch between wet and dry machining. The R5 can
process up to ten discs or 60 blocks or abutments non-stop.
There is barely any material in use in a dental laboratory today
that the R5 cannot process. For instance, it can wet-grind glass-
ceramic and wet-mill titanium. Materials like cobalt–chromium
alloys, zirconia and PMMA can all be dry-milled. The R5 can
process discs up to a thickness of 40 mm, ideal for manufacturing
monolithic dentures. For wet machining, the built-in 5 l tank only
needs to be filled with clean water and does not require any grinding
additives. When dry-machining synthetic materials, a built-in
ioniser reduces the particles’ disruptive static charge.
* The articles in this category are provided by the manufacturers or distributors and do not reflect the opinion of the editorial team.
Redefining milling and grinding in dental laboratories and practices
[47] =>
manufacturer news*
|
2b
Figs. 2a & b: Whether wet-grinding (a) or dry-milling (b), the R5 can handle both modes without elaborate refitting, enabling the fabrication of every imaginable
appliance, model or component on one machine. The patent-pending working chamber’s drying system makes it possible to quickly switch between the two modes.
* The articles in this category are provided by the manufacturers or distributors and do not reflect the opinion of the editorial team.
The R5 is equipped with first-class German-engineered technology from
vhf, guaranteeing that all users will benefit from true-to-the-original
restorations that fit perfectly. A repetition accuracy of the linear axes
of ± 0.003 mm and a sturdy body made of solid cast aluminium ensure
the highest level of precision and minimal vibration, and a powerful
high-frequency spindle, reaching speeds of up to 80,000 rpm, completes tasks in the shortest possible time. The components have been
carefully designed to work together in perfect harmony, making the
R5 one of the fastest machines on the market.
Despite having a small footprint, the machine weighs an impressive 150 kg. As a result, it offers a level of machine rigidity that
meets even the highest demands, yet space for it can easily be
found in any laboratory.
Like all other vhf machines, the R5 is also completely open in every
sense of the word. Data can be imported in the standardised
STL format into the provided DENTALCAM software, and when
selecting discs, blocks and abutments, the R5 can be used with
materials from any manufacturer.
www.vhf.com
3
Fig. 3: The R5 is also ideal for manufacturing monolithic dentures of up to 40 mm
in thickness, such as from Ivoclar Vivadent’s Ivotion disc. Fig. 4: The automatic disc
changer can be loaded without using any tools in a matter of seconds, and once loaded,
the machine can process up to ten discs non-stop. (All images: © vhf camfacture AG)
47
4
[48] =>
| meetings
International events
160th Chicago Dental Society
Midwinter Meeting
26–30 November 2024
Paris, France
www.adfcongres.com
20–22 February 2025
Chicago, US
www.cds.org/midwinter-meeting
Greater New York
Dental Meeting 2024
ICOI
Winter Implant Symposium
1–4 December 2024
New York, US
www.gnydm.com
20–22 February 2025
New Orleans, US
www.icoicampus.org
São Paulo International
Dental Meeting—CIOSP
International Dental Show—
IDS 2025
22–25 January 2025
São Paulo, Brazil
www.ciosp.com.br
25–29 March 2025
Cologne, Germany
www.english.ids-cologne.de
DS World Dubai 2025
2–3 February 2025
Dubai, UAE
www.dentsplysirona.com
AEEDC 2025
4–6 February 2025
Dubai, UAE
www.aeedc.com
48 CAD/CAM
2 2024
EuroPerio11
14–17 May 2025
Vienna, Austria
www.efp.org/europerio/
europerio11
Nobel Biocare Global
Symposium 2025
30 May–1 June 2025
Las Vegas, US
www.nobelbiocare.com/
en-int/global-symposium-2025
© 06photo/Shutterstock.com
ADF 2024
[49] =>
|
© 32 pixels/Shutterstock.com
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CAD/CAM
2 2024
49
[50] =>
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international magazine of dental laboratories
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50 CAD/CAM
2 2024
[51] =>
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480.2041_en_01 | Approved for global use.
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/ Industry news. DS Core for laboratories; Nobel Biocare presents dentistry's first navigated photogrammetry; New 3Shape Dental System
/ “Thinking cloud native has raised the bar” An interview with Dentsply Sirona’s Manfred Müller and Niels Plate
/ Digitalisation for the conventional and analogue dentist: Ten key points, The change is easier and less complicated than you think by Dr Fernando Gérman
/ Predictability of the CAD/CAM workflow in today’s aesthetic cases by Dr Paola Ochoa
/ Same-day dentistry: Replacement of two PFM crowns with zirconia restorations by Dr Frank Heldenbergh
/ Biocompatibility of CAD/CAM biomaterials for bone tissue engineering application by Dr Katharina Pippich et al.
/ Work–life balance—a lifestyle more than a goal by Jerko Bozikovic
/ Manufacturer news: R5, redefining milling and grinding
/ International events
/ Submission guidelines
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