Dental Tribune South Asia No. 2, 2023

One step closer to nature: Occlusal concepts and sophisticated aesthetics in digital dentistry / Interview of Drs. Sheetal Potnis & Vivek Patni. “Favex maxillary expander is patient-centric rather than appliance-centric”: / AI & ML for real time pathology detection in dentistry / Enamel hypomineralisation: Study points to drugs commonly used in children / 3D-printing start-up promises 100-fold reduction in print times

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Table of contents

DENTALTRIBUNE
The World’s Dental Newspaper · South Asia Edition

Published in India

www.dental-tribune.com

Maxillary expander

AI & ML

“Favex maxillary
expander is
patient-centric
rather than
appliancecentric”

AI & ML for real
time pathology
detection in
dentistry

Enamel defects

3D printing

Enamel
hypomineralisation:
Study points to
drugs commonly
used in children
” Page 6

” Page 4

02/23
3D-printing start-up
promises 100-fold
reduction in print
times
” Page 7

” Page 8

One step closer to nature: Occlusal
concepts and sophisticated
aesthetics in digital dentistry
teeth from the vertical pressure
and the anterior protects the
posterior teeth from the lateral
pressure. Occlusion being highly
diverse, it is one of our roles as
dental technicians to understand
this complex mechanism of
movement and the pathway of
the temporomandibular joint
(mandibular movement) and
dentition (occlusal compass) and
reect it in the daily work of the
production of prostheses.
Uniting the functional and
aesthetic considerations
Figs. 1a & b: Natural waxing-up technique (a) by dental technician Dieter Schulz and sequential functional occlusion (b) by Prof. Rudolf
Slavicek.

By Atsushi Hasegawa, Japan
A dental restoration is not
just an aesthetic restoration;
it must fulfil many more
requirements and integrate
perfectly into the existing
system. In this article, I discuss
function and the way to a highly
aesthetic, functional and very
natural tooth restoration.

My philosophy
The goal of dental technicians
is to produce restorations which
are harmonised in terms of the
natural teeth and mandibular
movement.
Restorations
should be incorporated into
the body without inhibiting
existing functions and satisfy

the functions of mastication
and pronunciation. To achieve
the purpose of restoration,
it is necessary to deeply
analyse and understand the
temporomandibular joint with
mandibular movement and
skeletal form and the anatomical
shape of each tooth. There is a
functional correlation between
mandibular movement and

Figs. 2a & b: Initial situation with severe peri-implantitis.

the anatomical shape of the
individual tooth. This interaction
is an important basic concept
for the reconstruction of the
masticatory organs. By the dental
technician understanding and
implementing such a concept, the
anterior and the posterior teeth
maintain their harmony in the
static and dynamic positions. The
posterior protects the anterior

A 50-year-old female patient
with severe peri-implantitis came
to our laboratory with the desire
for a functional and aesthetic
restoration (Figs. 2a & b). Our treatment plan was to address the
severe peri-implantitis, to place
new implants and, ultimately, to
improve the overall aes-thetics.
For the implementation of the
treatment plan, our first step
was complete occlusal reconstruction with Zolid FX Multilayer (Amann Girrbach), except
for the mandibular anterior teeth.
It is important to collect as much
patient information as possible
for such an extensive occlusal reconstruction. Therefore, we used
the CADIAX system (GAMMA
Medizinisch-wissenschaftliche
Fortbildungs-GmbH) to obtain
the jaw movement data. The facebow transfer data, in combination with the Artex CR (Amann
Girrbach) and the CADIAX data,
is necessary to reproduce the jaw
movements with the virtual articulator (Figs. 3a & b).
During
the
design,
I
concentrate on a few key points,
which I finally check with the

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virtual articulator. The most
important points are the occlusal
supporting surfaces, such as the
posterior tooth areas, which are
important for support during
intercuspation and stabilisation
of the vertical dimension.
They protect the joints from
compression and the anterior
teeth from overloading.

Figs. 3a & b: Extensive patient data was obtained using the facebow and transfer to the Artex CR.

Figs. 4a & b: The virtual articulator is filled with CADIAX data.

Figs. 5a & b: 2D and 3D images, combined with the design, are the perfect base for recreating the patient situation.

Figs. 6a & b: Beautiful surface results after manual surface treatment.

Based on this information, I
consider the natural waxing-up
technique
and
sequential
functional occlusion to be
particularly suitable. With the
virtual articulator, I control
all the jaw movements in all
directions (Fig. 4). The canines
are important because they
protect the posterior teeth from
overloading. The guiding angle of
the canine should be coordinated
with
the
craniomandibular
system and should not affect
the posterior teeth. The anterior
teeth are important for speech,
for function with the lips and, of
course, for aesthetics—a natural
smile. To recreate the original
patient situation, I use 2D and 3D
images for excellent orientation
(Figs. 5a & b).
With the Ceramill Motion 2
(Amann Girrbach), I obtain satisfactory milling results, but if
I want to achieve more surface
structure with higher aesthetic
results, I treat the surfaces manually. I select my tools carefully
because it is essential to avoid
chipping, cracking and contamination of the zirconia during this
procedure (Figs. 6a & b). The manual surface treatment produces
beautiful small details and morphologies for a natural appearance. These include perikymata
and transverse ridges, which are
needed for anterior teeth morphologies.
After sintering, I obtain
the perfect basis for the finish
(Figs. 7a & b). The occlusal
contacts are polished by hand
before glazing. For a natural
shine, I finally set the last accents
with staining and glazing. From
my point of view, the greatest
advantage of Zolid FX Multilayer
is that I can produce the digitally
designed
form
precisely.
Especially in these complex cases,
I want as little post-processing as
possible (Figs. 8a & b).
Finally, I would like to have
canine guidance with no disturbing contacts in laterotrusion and
protrusion. These movements are
reproduced correctly in the same
way as I designed them in virtual
Artex CR (Figs. 9a & b). The coordinated workflow from the manual articulator to the virtual
articulator is simply ingenious
and facilitates my daily work.
This only works successfully if

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the manufacturer coordinates both the articulator and the
CAD/CAM system, which has
been done successfully for these
products.

Figs. 7a & b: The surface structure can still be seen after sintering.

Function is a major part of
my daily laboratory life, and I
am very thankful that the virtual
implementation of function
in combination with effcient
materials makes my work much
easier. From my point of view,
zirconia, especially Zolid FX
Multilayer, is ideal, as it combines
high aesthetics with strength
(Figs. 10a & b). Zirconia also has
disadvantages; for example, if
the crown is incorrectly stressed,
this can lead to periodontitis or
problems with preparation or
the condyles. Therefore, our job
as dental technicians requires
that we consider occlusion and
function.
I would like to thank my
clients who provide me with
exciting work every day.
Editorial note:
This article was published in
digital—international magazine of
digital dentistry vol. 3, issue 3/2021.

Figs. 8a & b: For a natural shine, I set the accents with staining and glazing.

About:

Atsushi Hasegawa

Figs. 9a & b: The perfect occlusal surfaces and canine guidance control during jaw movement.

Figs. 10a & b: Highly aesthetic and functional result.

Atsushi Hasegawa gained
his licence to practise as a
dental technician in 1996 and
completed postgraduate studies
at Kanagawa Dental University
in Yokosuka in Japan in 1998.
He then worked for 11 years in
a dental laboratory in Tokyo in
Japan, where he acquired specific
knowledge and skills in the field
of occlusal concepts. In 2008,
he opened his own laboratory,
Organ Dental Lab, in Chigasaki
in Japan. Today, Hasegawa
transfers his knowledge through
lectures in Japan and worldwide.
He can be reached through his
website, www.organdental.jp.

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Interview

02/23

“Favex maxillary expander
is patient-centric rather than
appliance-centric”:
Interview of Drs. Sheetal Potnis & Vivek Patni

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Favex is a patient-centric maxillary expander developed by Drs. Vivek Patni and Sheetal Potnis. (Photo: Dr. Vivek Patni)

By Dr. Rajeev Chitguppi,
Dental Tribune South Asia
It took five years of research
for Drs. Vivek Patni and Sheetal
Potnis to develop Favex – a
maxillary expander appliance
that is versatile, indigenously
developed, and manufactured.
This
interview
explores
the journey of their latest
innovation
Rajeev Chitguppi: Congratulations on creating the Favex
maxillary expander. Let‘s start
from the basics. What’s a skeletal maxillary expander?
Sheetal Potnis: In orthodontics, maxillary expansion is a century-old modality to gain space.
Orthodontists frequently expand
the maxilla to correct certain
types of malocclusion. The expansion is usually done during
the growing age when the palatal suture has not matured. Over
a period, the side effects of tooth-borne expanders have been
noted. Also, the limitation that
expanders don’t work without
accompanied surgical intervention in grown-up patients reduces the utility and acceptance
of these appliances. These shortcomings led to the development
of mini screw-assisted rapid palatal expanders.
What is the basis of your appliance design?

Vivek Patni: Dr. Benedict
Williams has detailed the best
anchorage sites as the T Zone
concept, which formed the basis
of our design. Reading between
the lines, we realized it’s all
about the anchorage sites where
screws are inserted. We studied
those sites and published a related paper in 2017 in the Journal
of APOS.

on a patient’s needs rather than
modifying his treatment plan to
fit an appliance.

What were the issues you
felt or faced with other existing
designs of expanders?
Sheetal Potnis: There are
several schools of thought, and
each considers a particular expander design to be better. We
thought of designing an appliance that followers of any school
of thought could use. The orthodontist has the freedom to decide
the design of the appliance based

What problems has the innovation addressed?
Sheetal Potnis: The treatment planning should be patient-centric rather than appliance-centric, and our design addresses this principle very well.
Another practical issue we solved
was to limit the requirement of
additional equipment and tools
to be used along with the appliance that could otherwise make
the treatment expensive. Since
we already have ‘FavAnchor’ - a
popular orthodontic implant system available in many orthodontic offices, it made perfect sense
to design an appliance to be used
with the same inventory. Being
an indigenously manufactured

Fig.1 Bone-bone anchored
designThe support arms can be
temporarily bonded with
composite to stabilize the
expander for TAD insertion and
cut off afterwards

Fig.2 Bone-bone anchored
designThe support arms can be
temporarily bonded with
composite to stabilize the
expander for TAD insertion and
cut off afterwards

appliance further makes it affordable. Another point is that
most adult patients may not have
anyone available to activate the
appliance or may not be keen to
have someone for activating it for
various reasons, including hygiene. So we also ensured that the
appliance is very easy for the patient to self-activate.
How long did it take the innovation from a concept design
into a marketable product?
Vivek Patni:: The development of a commodity is a game of
patience and diligence. Usually,
it takes years to convert an idea
into a product. We worked on a
few design versions after doing
basic research and kept on making alterations as needed. We
struggled for 4 to 5 years to get
to the final marketable product

Fig.3 Bone- tooth anchored
design: Only 2 anterior TADs
and support of molars

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About:

Fig.4 Bone- tooth anchored
design: 2 anterior TADs 2
posterior TADs and support of
molars

from the budding idea of creating an expander.
Have you published your research?
Sheetal Potnis: Yes, we have
published it in the Journal of
Indian Orthodontic Society in
Nov 2022.
Have you received any feedback from other experts or colleagues?

Fig.5 Bone- tooth anchored
design: 4 anterior TADs and
support of molars

Vivek Patni: Senior orthodontic researchers from India as
well as abroad have appreciated
the design philosophy in personal communications. Experienced clinicians have given positive and encouraging results of
patients treated with Favex.
What are your next-level
plans?
Vivek Patni: Next, we will
take feedback from the users
for any improvements needed,

Fig.6 Bone- tooth anchored
design: 4 anterior TADs 2
posterior TADs and support of
molars

which we will learn only after
more and more people start
using the appliance - this is common with every product. iPhone
is now in the 14th version, so it’s
a continuous process. We would
also make newer appliances to be
used with FavAnchor driver and
implants to make it a one-stop solution for any implant-based Orthodontics.

Dr. Sheetal Potnis: Orthodontist,
Prof and HOD, Sinhgad Dental
College, Pune

Fig 1a: Pretreatment intraoral view showing severe transverse and anteroposterior
jaw discrepancy.

Fig 1b: Post expansion

Fig 2a: Pretreatment intraoral view showing severe transverse and anteroposterior
jaw discrepancy

Fig 2b: Post expansion

Dr. Vivek Patni, Orthodontist,
Former Professor and PG Guide,
MGM Dental College & Hospital,
Mumbai

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AI & ML for real time pathology
detection in dentistry

The AI empowered computer vision platforms can detect various potential conditions in a radiograph, which are difficult to spot on routine checks. (Photo: Second opinion/
hellopearl website)

By Dr. Sahithi Kolli,
Dental Tribune South Asia
Artificial Intelligence (AI)
has been pivotal in refining
diagnostic
accuracy
and
revolutionizing care. Of all
the applications that AI can
provide us, real-time pathology
detection software is the one
that is taking a spot recently in
most dental clinics.
In dentistry, what was
once thought impracticable is
now possible with the help of
technology. All this has been
possible through the introduction
of artificial intelligence and
machine learning in healthcare
[1]. Recent advancements in
computing
infrastructure,
machine learning (ML), and
digitized data collecting have
allowed AI applications to spread
into fields previously regarded to
be domains of human expertise.
These improvements in the
field of dentistry have promised
increased quality of life and
improved decision-making [2].
X-rays
are
the
most
important part of developing
an ideal treatment plan for
the patient. The real-time
pathology detection software
integrated into the radiology
system helps dentists identify
various dental abnormalities

Real-time pathology detection software from Second Opinion

in patients‘ radiographs. Since
dental radiology is a regular
part of a patient’s experience,
the impact of AI through this
detection software can be greatly
appreciated by the dentist and
the patients [3].
Since the fine interpretation
of the X-rays is the first step in
providing quality patient care,
the adoption of this AI technology
and machine learning will help
you to deliver the necessary care.
One of the fast-growing
companies
that
provide

artificial intelligence solutions
in dentistry is Pearl. Pearl’s AI
through
detection
software
offers a “Second opinion”
platform which is the leading
product today. The second
opinion by Pearl is a computer
vision platform that can detect
various potential conditions
in a radiograph. It can detect
pathologies like incipient caries
or early signs of radiolucency,
which are difficult to spot on
routine checks. This radiologic
detection system is trained

to detect bone loss, calculus,
crowns, fillings, root canals,
caries, periapical radiolucencies,
widened periodontal ligaments,
and many more.
It was noted that Pearl is using
machine learning to analyze
radiographs, helping insurance
companies to identify if the same
X-ray was used for more than one
patient and if the recommended
procedure
was
necessary.
Pre-processors for generative
adversarial networks improve
images so that radiologic analysis
can be carried out even when are
deteriorated, overexposed or
underexposed, or have digital
artifacts.
Computer
vision
segmentation models distinguish
individual teeth and supporting
structures, which can give
localizing information on the
type and severity of detected
problems. To determine the size
of anatomical structures and the
extent of deterioration, detection
and segmentation capabilities
work together in the Second
opinion platform.
The integration of such
software options into the clinical
workflow and receiving the
advantages of dental AI support
help in creating a healthy
environment where patients
get the optimum care. These

technologies make it easier
for the dentist to interpret the
X-rays, which helps in better
communication and education of
the patient.
References:
1. Machoy ME, SzyszkaSommerfeld L, Vegh A, Gedrange
T, Woźniak K. The ways of using
machine learning in dentistry.
Adv Clin Exp Med. 2020
Mar;29(3):375-384. doi: 10.17219/
acem/115083. PMID: 32207586.
2. Nguyen TT, Larrivée N,
Lee A, Bilaniuk O, Durand R.
Use of Artificial Intelligence
in Dentistry: Current Clinical
Trends and Research Advances.
J Can Dent Assoc. 2021 May;87:l7.
PMID: 34343070.
3. Fatima A, Shafi I, Afzal H,
Díez IT, Lourdes DRM, Breñosa
J, Espinosa JCM, Ashraf I.
Advancements in Dentistry with
Artificial Intelligence: Current
Clinical
Applications
and
Future Perspectives. Healthcare
(Basel). 2022 Oct 31;10(11):2188.
doi: 10.3390/healthcare10112188.
PMID:
36360529;
PMCID:
PMC9690084.

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Enamel hypomineralisation:
Study points to drugs commonly
used in children

As many as 20% of children worldwide are estimated to suffer from dental enamel defects, a poorly understood condition that researchers in Brazil think may be linked to antiinflammatory drugs. (Image: BeautifulPicture/Shutterstock)

By Jeremy Booth,
Dental Tribune International
SÃO PAULO, Brazil: Dental
enamel defects (DEDs) are
estimated to affect around 20%
of children worldwide, and
instances such as the fracturing
of children’s teeth as a result of
mastication are of great concern
to clinicians. A recent study
conducted by researchers at
the University of São Paulo has
found that anti-inflammatory
drugs commonly prescribed
to children may be associated
with the poorly understood
condition.
Researchers
from
the
Ribeirão Preto Dental School
and School of Pharmaceutical
Sciences at the university studied
the effects of non-steroidal antiinflammatory drugs (NSAIDs) on
the biomineralisation of enamel
in male mice. Extracted teeth that
had been treated with the NSAIDs
celecoxib and indomethacin for a
period of 28 days were found to

have decreased levels of calcium
and phosphate and lower mineral
density, and they fractured more
easily. Crucially, the researchers
found in the teeth alterations in
the proteins that are important
for enamel biomineralisation
and cellular differentiation. The
findings, the researchers wrote,
alluded to the possibility that
NSAIDs may have a causal effect
in the development of DEDs.

“Hitherto we’ve been
totally in the dark”
– Dr Francisco PaulaSilva, University of
São Paulo
An article by the São Paulo
Research
Foundation
about
the research noted that the
researchers’ curiosity had been
piqued by the fact that DEDs
occur within the first years of
life, when sickness and high fever
are frequent. “These diseases are

typically treated with NSAIDs,
which inhibit the activity of
cyclooxygenase [COX] and reduce
production of prostaglandin,”
corresponding
author
Dr
Francisco
Paula-Silva,
an
associate professor of paediatric
dentistry at the university, told the
foundation. “However, COX and
prostaglandin are known to be
physiological for dental enamel,
and we therefore wondered
whether these drugs interfered
in the normal formation of this
structure,” he added.
“Right now, the study at least
offers us a clue to the identity of a
new player that may be involved
in the development of DEDs.
Hitherto we’ve been totally in the
dark,” Dr Paula-Silva said.
The researchers now plan to
conduct a clinical study in order
to confirm the results. “We’re
going to analyse the medical
history of the children with
DEDs and their use of these
drugs, and we’ll set up a clinical
study that will correlate the two

datasets to see if the same thing
happens to humans. If so, we
can make recommendations on
which drugs shouldn’t be used
for which patients. We can also
help work out an appropriate
treatment protocol in future,” Dr
Paula-Silva told the foundation.
The study, titled “Enamel
biomineralization under the
effects of indomethacin and
celecoxib non-steroidal antiinflammatory
drugs”,
was
published online in Scientific
Reports on 22 September 2022,
ahead of inclusion in an issue.
From the editor‘s desk:
Enamel hypomineralisation
is a common condition that
affects the development of dental
enamel in children.
It occurs when the enamel
layer of the teeth does not develop
properly, resulting in weaker,
more porous and discolored teeth
The condition can be caused
by a number of factors including
genetics, environmental factors

such as illnesses or dietary deficiencies during the |development of the teeth, and certain medications.
The symptoms of enamel
hypomineralisation
include
white spots or discoloration on
the teeth, increased sensitivity to
hot and cold temperatures, and
increased risk of cavities.
In severe cases, the affected
teeth may also become chipped
or broken.
Treatment options for enamel
hypomineralisation depend on
the severity of the condition and
may include fluoride treatments,
dental sealants, and restorative
procedures such as bonding or
crowns.
Early detection and treatment
are important in order to prevent
further damage to the affected
teeth. Regular dental check-ups
can help to identify the condition
and ensure that appropriate
treatment is provided.

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3D-printing start-up promises 100fold reduction in print times

Using a relatively new type of additive manufacturing process called volumetric 3D printing, Vitro3D claims they are able to print objects such as clear aligners up to one hundred
times faster than other methods. (Image: Nomadneshot/Shutterstock)

By Anisha Hall Hoppe,
Dental Tribune International
BOULDER,
US:
After
raising an astounding US$1.3
million (€1.24 million) in a seed
funding round, Vitro3D will
take its place as a commercial
rival in the increasingly
competitive
3D-printing
market. A start-up grown out
of the University of Colorado
Boulder and the Colorado Life
Sciences Incubation Program,
Vitro3D offers revolutionary
improvements to traditional
3D printing and claims to be
able to 3D-print pieces up to 100
times faster than is done using
existing methods.
Should the company be able
to make good on its claims, its
process would take additive
manufacturing to a whole
new level, making the current
printing speed of nearly every
other 3D-printing solution on
the market virtually obsolete.
By utilising a cartridge-based
design, there is no resin handling

involved. The company also
states that the goal is to design
parts that require far less postprocessing than is currently
necessary in production, and this
applies to the printing of dental
aligners as well as the scaffolds
used in tissue engineering.
Though these seem to be lofty
goals, if Vitro3D is successful in
expanding the current capabilities
of volumetric printing, the entire
dental 3D-printing market would
be turned on its head. The plan is
to continue to tackle both speed
and detail to ensure accuracy is
always maintained. Doing so
would mean production times
across a number of industries
would be reduced.
Dr Camila Uzcategui, CEO of
Vitro3D, attributes the company’s
proprietary
volumetric
3D-printing
technology
to
specific algorithms, carefully
designed hardware and material
science knowledge. She says
that, because the company is
now funded, it can “demonstrate

the power of [its] revolutionary
3D-printing
technology,
which offers the potential
to change the way complex
structures, including intricate
custom medical products, are
manufactured”.
Currently, methods such
as digital light processing and
stereolithography are at the
forefront of dental 3D printing,
but Vitro3D promises that its
new technology will be even
faster. Volumetric printing is
completed incredibly rapidly
because the printed object
is not built layer upon layer.
Instead, the printer uses images
projected from various angles to
solidify the object within a liquid
suspension. The entire printed
object is essentially formed all at
the same time. Because the object
is created by the intersection
of lasers, it does not require the
supports that are traditionally
needed in 3D printing, and the
resulting surface can be much
smoother and the accuracy even
better. Additionally, it saves a

significant amount of time in
post-processing. The separate
machines and products dedicated
to post-processing make up a
large portion of revenue for most
3D printer companies. However,
as other firms are already able
to produce millions of aligners
with cheap materials, it might
take a considerable time for even
the fastest technology to take
hold, given potentially higher
costs related to transitioning
methodology, equipment and
materials.
Vitro3D
promises
print
times of under 1 minute owing
to precisely controlled structure
and mechanics, which also
results in less waste. Only time
will tell whether this latest entry
into the field will prove able to
compete against the currently
dominating companies such as
Align Technology, which, from
2021, has produced over 700,000
clear aligners per day. Vitro3D
has also not specified whether
it intends to be a centralised
producer of aligners like Align

or offer printing solutions for
laboratories or offices.
From the editor‘s desk:
3D printing technology has
been used in dentistry since
the early 2000s. Initially, it was
mainly used for creating models
of teeth and jaws for planning
and training purposes.
In recent years, the technology
has advanced, allowing for the
creation of customized dental
implants, bridges, and crowns.
Additionally, 3D printing
has also been used to fabricate
orthodontic
appliances
and
dentures.
The benefits of 3D printing
in dentistry include improved
accuracy and precision, faster
production times, and reduced
costs. The use of
3D printing in dentistry is
still evolving and holds great
promise for the future of dental
care.

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[cover] => Dental Tribune South Asia No. 2, 2023

[toc] => Array ( [0] => Array ( [title] => One step closer to nature: Occlusal concepts and sophisticated aesthetics in digital dentistry [page] => 1 ) [1] => Array ( [title] => Interview of Drs. Sheetal Potnis & Vivek Patni. “Favex maxillary expander is patient-centric rather than appliance-centric”: [page] => 4 ) [2] => Array ( [title] => AI & ML for real time pathology detection in dentistry [page] => 6 ) [3] => Array ( [title] => Enamel hypomineralisation: Study points to drugs commonly used in children [page] => 7 ) [4] => Array ( [title] => 3D-printing start-up promises 100-fold reduction in print times [page] => 8 ) ) [toc_html] =>

Table of contents

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