digital international No. 4, 2021

Cover / Editorial / Content / The COVID-19 practice manager 2021: Four steps to con dence—Part 4 / Teledentistry: A bridge between present and future / “Digital technologies are fundamentally changing the dynamics of our industry” - An interview with master dental technician Stephan Kreimer / Amann Girrbach goes “shareside” / Full-arch rehabilitation with lithium disilicate secondary crowns luted on to the primary framework / The use of autologous tooth structure as adjunct grafting modality for full-arch dental implant rehabilitation / Delayed immediate implant placement and direct soft-tissue management / Restorative simplicity for a challenging case with limited space / “It was easy to turn off the pain”— Patient receives dental implant under self-hypnosis / News / Industry / Meetings / Submission guidelines / Imprint

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issn 2193-4673 • Vol. 2 • Issue 4/2021

digital

international magazine of digital dentistry

interview

“Digital technologies are fundamentally
changing the dynamics of our industry”

case report

Restorative simplicity for a challenging case

industry

Extension of Ceramill CAD/CAM workflow

4/21

[2] =>

© MIS Implants Technologies Ltd. All rights reserved.

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ZEN

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PEACE OF MIND WITH PERSONALIZED DIGITAL DENTISTRY. MAKE IT SIMPLE
The MGUIDE system features user friendly software to ensure accurate planning and an open design template that allows
for a greater field-of-view and irrigation for easier implant placement. Learn more about the MGUIDE and MIS at:
www.mis-implants.com

[3] =>

editorial

Dr Scott D. Ganz
Editor-in-Chief

Signs of recovery
As we approach the last month of 2021, we can reflect on how our lives have changed during the global
pandemic. Regardless of where you live in the world,
SARS-CoV-2 has had a profound impact on daily life,
including various levels of personal restrictions: wearing
masks, social distancing, vaccine mandates, decline in
travel and in-person meetings, and a large population of
people working remotely. While it appears that the world
is slowly making progress against this devasting virus
and its variants, we are not yet there. In our world of dentistry, many events have been postponed or cancelled,
and some have gone remote or are a hybrid mix of both
in-person and remote sessions. The largest international
dental event in the world, the International Dental Show
held every two years in Cologne in Germany, was pushed
back from its usual time in March until September, and
both the vendor participation and overall attendance
were significantly lower. The good news is that the event
did happen; within the new restrictions of travel and vaccine status, new products were showcased, educational
courses were held, and vendors and clinical colleagues
were finally able to meet face to face.
The 107th annual meeting of the American Academy of
Periodontology, held in Miami in the US, was a success,
as was the 103rd annual meeting of the American Association of Oral and Maxillofacial Surgeons recently held
in Nashville in Tennessee in the US. This past weekend,
the American Academy of Implant Dentistry held its
70th annual conference in Chicago in the US and celebrated

a record 63 diplomates awarded at the event. These
meetings were successful despite being hindered by a
lack of international attendance due to imposed travel
restrictions. Clearly, there is a pent-up need for in-person
meetings, continuing education, large and small symposiums, live-surgery training, hands-on workshops, etc.
These are all signs that our industry is slowly recovering,
albeit to a new normality.
Perhaps one of the most encouraging signs was the
amazing success of the Digital Dentistry Society Global
Congress, which was held in beautiful Lake Como in Italy
earlier in November. Over 750 clinicians descended on
the Villa Erba international congress and exhibition centre
in Cernobbio to learn from international experts speaking
on all aspects of digital dentistry at an incredible venue
made possible by the generous support from industry
sponsors. All participants were required to show their
green pass, proof of vaccination or negative recent PCR
test to enter the facility with their masks. Despite these
limitations, the participants—from around the globe—
were happy to be there to take part in this event. The
signs are there, we are moving in a positive direction and
hopefully the past is behind us. Please enjoy our new
issue of digital magazine as we look forward to a very
successful 2022 season and return to normality with
renewed energy and spirit.
Dr Scott D. Ganz
Editor-in-Chief

4 2021

[4] =>

| content
editorial
Signs of recovery
Dr Scott D. Ganz

03

practice management

The COVID-19 practice manager 2021: Four steps to confidence—Part 4 06

Chris Barrow

Teledentistry: A bridge between present and future
Dr Carlo Fornaini
page 06

10

interview

“Digital technologies are fundamentally changing the dynamics of our industry” 12
An interview with master dental technician Stephan Kreimer

Amann Girrbach goes “shareside” 		

An interview with Dr Wolfgang Reim, CEO of Amann Girrbach

16

case report

Full-arch rehabilitation with lithium disilicate secondary crowns
luted on to the primary framework
page 36

18

Joaquín García Arranz (Quini), Dr Ramón Asensio Acevedo & Oscar Jiménez Rodríguez

The use of autologous tooth structure as adjunct grafting modality 		
for full-arch dental implant rehabilitation
24
Drs Scott D. Ganz & Isaac Tawil

Delayed immediate implant placement and direct soft-tissue management 30

Dr Haki Tekyatan

Restorative simplicity for a challenging case with limited space
Dr Fernando Rojas-Vizcaya & Jose de San Jose Gonzalez

36

feature
page 56

“It was easy to turn off the pain”—					
Patient receives dental implant under self-hypnosis
Franziska Beier

38

news

Study highlights how artificial intelligence can be used for detection of caries 42
Brendan Day

Apple’s iOS 14 shakes up digital dental brands
Jeremy Booth

44

industry

3Shape Unite—the platform connecting the digital dots in dental clinics 46
Claudia Duschek

Cover image courtesy of
Frunze Anton Nikolaevich/Shutterstock.com
4/21

issn 2193-4673 • Vol. 2 • Issue 4/2021

digital

international magazine of digital dentistry

MODJAW: A next-generation digital dentistry solution
48
Extension of Ceramill CAD/CAM workflow—digital solutions lead the way
into the dental practice
50
Clinical advantages of KATANA Zirconia YML as related to an external
organisation’s test results
52

meetings

DS World 2021: Latest innovations, product launches 			
and partnership announcements

56

Iveta Ramonaite

Registration for 2022 Midwinter Meeting is now open
International events

about the publisher

interview

“Digital technologies are fundamentally
changing the dynamics of our industry”

submission guidelines
international imprint

case report

Restorative simplicity for a challenging case

industry

Extension of Ceramill CAD/CAM workflow

04

58
60

4 2021

61
62

[5] =>

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© Sergey Nivens/Shutterstock.com

| practice management

Time management—there simply do not seem to be enough hours in your day.

The COVID-19 practice manager 2021:
Four steps to confidence—Part 4
Chris Barrow, UK

In the first part of this series, we looked at the characteristics of great leadership and how this applies in the
role of practice manager. In the second part, we looked
at management and the checklist of systems required to
run a modern-day dental business. In the third part, we
talked about teamwork: what makes an ideal team player
and an ideal team, and how does the practice manager
keep the right people?
In the concluding part of this series, I will be looking at
extreme self-care, making sure that the best possible version of you can turn up for work (and arrive home again!).
I set the scene by running through what has inevitably
become a series of present-day challenges:
– time management—there simply do not seem to be
enough hours in your day;
– task management—when you get to the end of the day,
you rarely get to the end of the list;

06

4 2021

– energy management—you are living in what seems to
be a perpetual state of exhaustion;
– attention management—everyone wants a piece of
you and a variety of digital channels are used to try and
grab your attention.
Sound familiar? I want to share some insights about each
of these challenges that have helped me (and those I care
for) to navigate the pandemic.

Time management
It has been suggested that time management is a myth,
that we all have 24 hours in the day and the choice as
to what we do with them. That sounds very harsh when
you have a family to raise and bills to pay. I am lucky to
be at an age when my five children have left the nest,
and believe me, I recognise my good fortune (if you
see what I mean), but I also remember long years of

[7] =>

© Pixel-Shot/Shutterstock.com

struggling to make ends meet, come a boom or bust
economy.
To anyone caring for others at home as well as at work
during the pandemic, I can only offer my admiration. I do,
however, want to make a point about boundaries, about
learning to say NO to situations, things and people that
are unhealthy for you.
People are not designed to work a 50- to 70-hour week
or to take on the stresses of everyone else as well as
their own—that kind of high-energy level of operation
can only be sustained for short periods before you
burn out. My business coach, Rachel Turner, likens
this to a revolution counter on a car engine, asking two
questions:
1. How long do you operate with your revolution counter
in the red zone?
2. How do you get your revs back down again?

Task management—when you get to the end of the day, you rarely get to
the end of the list.

Or
– yoga
– meditation
– high-quality reading
– running/cycling/swimming/walking
– music?

The answer to the second question can reveal much.
Do you use:

Task management

– alcohol
– caffeine
– sugar
– low-quality TV
– shopping

Philosopher and guru Wayne Dyer famously observed
that “nobody in a cancer ward ever wished they had
spent more time at the office”. You get the point. That
list of yours is endless—there will be no end to it, and
it will outlive you. So, you must learn to do the best you

4 2021

07

© LightField Studios/Shutterstock.com

Energy management—you are living in what seems to be a perpetual state of exhaustion.

[8] =>

| practice management
reasonably can and accept that what is left over will either
get done by somebody else or never get done. You cannot
work eight days a week or 27 hours a day.
Task management is another myth—there is only priority
management. One of the first modern-day books on
time management, The Time Trap by Alec MacKenzie,
suggested the following:
– Make a list every day.
– A, B, C the list.
– Do the As first.
Simple enough but profound and timeless.
I am a list person—my life is a list—and I keep that list
nowadays on the cloud and synced to every device I own.
Do not try managing your list; simply manage your priorities (and often other people’s—that can be the hard
part)—back again to strong boundaries and saying NO.

Energy management
I use a simple mnemonic with my clients, SNEF:
– Sleep. Read Matthew Walker’s book Why We Sleep.
I did in 2019, and it changed my approach to the
subject. Without adequate and appropriate sleep, we
cannot function at high revs for any sustainable period.
– Nutrition. I do not do diets and am a happy carnivore,
but I do ensure that my nutrition is healthy and balanced. COVID-19 introduced me and my wife to meal

kit company HelloFresh, and we remain committed
clients.
– Exercise. Aerobic exercise has been a backbone of
my life since the mid-1990s. Nowadays, I am a retired
marathon runner after countless injuries, but I have
taken up cycling and taken to it, both indoors and
outdoors. Having two hunt, point and retrieve dogs
helps as well.
– Fun. Despite everything the world throws at us, I have
always regarded a healthy sense of humour as being
a prerequisite of happiness (and the best version of that
is the ability to laugh at oneself—which I do most days).
Fun can be quality entertainment, great company or
a mini-adventure.

Attention management
This is a modern-day phenomenon that seems to have
crept up on us in the Internet age. There is a lot of online
talk at the moment of the difference between synchronous and asynchronous communication.
Synchronous communication happens when messages
can only be exchanged in real time. It requires that the
transmitter and receiver are present in the same time
and/or space. Examples of synchronous communication
are phone calls or video meetings via platforms like Zoom
and Microsoft Teams. Another example of synchronous
communication is that tap on the door (or the shoulder),
followed by “I know you said not to be interrupted, but...”.
In this case, the transmitter is someone who wants your
help (or to dump his or her load) and the receiver is you.

Attention management—everyone wants a piece of you and a variety of digital channels are used to try and grab your attention.

4 2021

[9] =>

practice management

Focus on you; become incredibly selfish, so that you can best serve those who need you.

Asynchronous communication happens when information can be exchanged independent of time. It does not
require the recipient’s immediate attention, allowing him or
her to respond to the message at his or her convenience.
Examples of asynchronous communication are e-mails,
online forums, collaborative documents and communication via platforms like WhatsApp, Slack and Asana.
Another example of asynchronous communication is you
taking yourself off to get some privacy—whether that is
working from a local coffee shop or at home—frankly,
just hiding from the synchronous stuff so that you can get
your own work done or find the time and space to think.

really is a genuine emergency—and there are very few of
them), and so if you want my attention you either have to
book a slot with my business manager, Phillippa (my synchronous communication guardian), or send me an asynchronous message, and I will answer it when I am able to.

Here is what COVID-19 did to us regarding attention
demands:

My advice to anyone who is in a management position is
simple and stark (and I am paraphrasing the late, great Thomas
Leonard, father of modern coaching): become incredibly
selfish, so that you can best serve those who need you.

1. increased the amount of synchronous communication we
are expected to be available for, so that we risk burn-out
2. added pressure to treat asynchronous communication
as if it were synchronous: the ping of an incoming
message that we delude ourselves into thinking requires our immediate attention when it does not
3. decreased the amount of asynchronous communication that we allow for ourselves so that we do not
suffer burn-out.
I am going to give away one of my big secrets of success:
I ruthlessly minimise my availability for synchronous communication. This is going to sound terribly pompous (and
I am sorry), but NO, I have not got a minute (unless it really,

In summary, my advice is to:
1. create boundaries around your time;
2. prioritise your tasks;
3. conserve your energy; and
4. protect your attention.

about
Chris Barrow has been active as
a consultant, trainer and coach to the
UK dental profession for over 24 years.
His main professional focus now
is through his Extreme Business
company, providing coaching and
mentorship to independent dentistry
around the world via face-to-face
meetings, a workshop programme
and an online learning platform.

4 2021

[10] =>

| practice management

Teledentistry: A bridge between
present and future
By Dr Carlo Fornaini, France and Italy

The COVID-19 pandemic has dramatically and totally
changed all medical clinical practices. The aims of limiting
physician–patient contact and reducing hospitalisation
have become major concerns, pushing researchers to
find novel ways to perform medical care.1
The new field called “telemedicine” has achieved great
importance, and today it can be used in several medical specialties:
– Store-and-forward telemedicine, common in the medical fields of dermatology, radiology and pathology,
makes it unnecessary for the medical practitioner to
meet in person with a patient because patient information such as medical images or biosignals can be sent
to the specialist as needed after it has been acquired
from the patient.2
– Remote monitoring, also known as self-monitoring or
self-testing and extensively used in the management
of chronic diseases such as cardiovascular disease,
diabetes mellitus and asthma, uses a range of technological devices to monitor the health and clinical
symptoms of a patient remotely.3
– Real-time interactive services can provide immediate
advice to patients who require medical attention, utilising

10

4 2021

for this purpose several media, including the phone
and the Internet, followed by an assessment similar to
one conducted during face-to-face appointments.4
The term “teledentistry”, first used in 1997 when Cook
defined it as “... the practice of using videoconferencing
technologies to diagnose and provide advice about
treatment over a distance,”5 is a new area of dentistry that
integrates electronic health records, telecommunications
technology, digital imaging and the Internet, in order to
improve access to care for patients in remote settings.
It allows specialists located many miles away to make
a diagnosis and recommend treatment options and/or
referral for patients who, otherwise, would find it difficult
to see them.6
In the field of oral and maxillofacial surgery, it has been
reported that diagnostic evaluation of impacted teeth
using teledentistry is as efficient as real-time patient assessment. Similarly, it has been shown that screening for
dental caries in children using teledentistry is comparable
with traditional techniques such as tactile and visual dental examinations. In the field of endodontics, teledentistry
has been successfully used to identify root canal orifices
and periapical lesions of anterior teeth.7

[11] =>

© Alliance Images/Shutterstock.com

practice management

|

A recent study at Newcastle Dental Hospital’s Paediatric
Dentistry New Patient Service recently demonstrated
that teledentistry can be used for numerous applications
in paediatric dentistry, including initial triage, remote
assessment, reinforcement of oral disease prevention,
implementation of initial management and building of
rapport to maximise safety and minimise inconvenience
for both parent and child.12 Another study showed that
including a teledentistry consultation in the standard care
provided to patients in an eating disorder day hospital
could be beneficial, notably for screening for particular
pathologies and preventing dental erosion.13
In conservative dentistry, remineralisation treatment
which offers the advantage of being non-invasive, is increasingly being used as a minimal intervention treatment
in managing incipient enamel caries, and a solution of
38% silver diamine fluoride (SDF) has been reported as
an effective treatment for caries arrest.14 Therefore, it
is possible to think that the treatment of small carious
lesions may be performed at home with SDF application
supervised by a remote follow-up.

Beyond the pandemic, there are several situations where it
is convenient to have a consultation via teledentistry, such
as in the case of geriatric, special needs and oncological
patients who sometimes have difficulties coming to the clinic.8, 9
Whereas several dental clinical treatments can today be
remotely performed, for others, it is possible to hypothesise that, in the future, there will be the opportunity of full
“at-distance” management.
The field of oral medicine is becoming increasingly interesting. By using smartphones or intra-oral cameras,
which are very inexpensive today, it is possible, by sending
images to the specialist, for him or her to make a tentative diagnosis and to decide, for example, whether a
biopsy is necessary. Some studies have demonstrated that
screening for potentially malignant oral disorders using
photo messaging can serve as an effective adjunct and
a potential cost-effective tool in a low-resource setting.10
Moreover, by utilising smartphone-based mobile digital
PCR devices which allow, in a simple way, smartphones
and tablets to be transformed into chemical laboratories,
the research of particular salivary biomarkers in the saliva
will be also possible.11

Tele-orthodontics, a term first used and described by
Squires, may be a cost-effective way to provide care
by reducing expenses, such as transportation for a
consultation with a specialist, and additionally, it may help
general practitioners to screen and/or appropriately refer
potential patients for future orthodontic therapy.15 With
tele-orthodontics it is possible to check tooth movement
and treatment progression using at-home digital photographic technology with a smartphone device and, when
associated with aligner therapy, it allows the patient to
progress through aligner trays independently, which may,
in turn, reduce the number of in-office visits and help
orthodontists monitor treatment progress even when
the patients are at home.16
Teledentistry represents the future of oral health: patients,
doctors and companies will have to make a great effort to
be ready for this important opportunity, which will completely change current ways of performing oral treatment.
Editorial note: A list of references is available from the
publisher.

about
Dr Carlo Fornaini is a researcher at the
Microbiologie Orale, Immunothérapie et
Santé (oral microbiology, immunotherapy
and health) laboratory at the dental
faculty of the Université Côte d’Azur in
Nice in France and at the Group of Applied
ElectroMagnetics of the Department
of Engineering and Architecture
at the University of Parma in Italy.

4 2021

11

[12] =>

| interview

“Digital technologies are
fundamentally changing the
dynamics of our industry”
An interview with master dental technician Stephan Kreimer
By Iveta Ramonaite, Dental Tribune International

Stephan Kreimer is a master dental technician who runs
a dental laboratory in Warendorf in Germany. Since he
developed an interest in technology early on, Kreimer
was always eager to integrate dental technologies into
his workflow. Now, more than a decade later, innovative technologies such as CAD/CAM, CNC milling and
3D printing are shaping his work and offer increased efficiency. In this interview with Dental Tribune International,
Kreimer shares his journey from a conventional to a digital laboratory and weighs up the advantages of investing
in an in-house 3D printer.

1

12

4 2021

Mr Kreimer, when did you first start working in the
dental field, and what led you to a career in dentistry?
Technology has always been an interest of mine. Since
2009, I have been able to combine this interest in technology with dentistry through my education in dental
technology. At the time, my parents were operating a
conventional dental laboratory in Germany that made
little use of digital technologies such as CAD/CAM.
After completing my master’s in dental technology,
I took over as managing director of our family laboratory.

[13] =>

interview

2
Fig. 1: Master dental technician Stephan Kreimer believes that digital technologies such as 3D printing will help establish new standards of care in dentistry
and create new business models. Fig. 2: Stephan Kreimer bought his first 3D printer back in 2016 and has significantly scaled up digital production in his
dental laboratory ever since.

I was betting strongly on innovative technologies such
as CNC milling and 3D printing and closed collaborations with leading manufacturers, including 3Shape and
Formlabs. Smartly combining the passion for aesthetics
and craftsmanship, which is inherent to our industry, with
the enormous potential of digital technologies is definitely
the way forward.
Your dental laboratory has eagerly adopted digital
technologies into its workflow. Could you tell us more
about it and discuss some of the digital solutions
you are using?
It has been a journey. We started as a conventional dental laboratory and have been operating with traditional
workflows for over 30 years. In 2009, we adopted our first
CAD software but outsourced all of our digital production to service providers. Things changed quickly when
we invested in our first 3D printer, a Formlabs Form 2,
in 2016. At the time, the system was not optimised for
dentistry, but it was clear that it had great potential. Within
the less than five years since then, most of our customer
base has adopted intra-oral scanners and we scaled our
digital production capabilities significantly. Today, we use
an imes-icore milling machine and multiple 3D printers
that run almost 24/7 and work with both 3Shape and
exocad. Around 70% of our customers send us digital
impressions.

How did you integrate digital technologies, including
3D printing and CAD/CAM, into your laboratory?
It was definitely through trial and error. Especially in the
early days, which was just a few years back, 3D printing
was not well optimised for a dental workflow. Interfaces
to materials, software and other workflow requirements

“Combining the passion for
aesthetics and craftsmanship,
with the enormous potential
of digital technologies is
definitely the way forward.”
have not been coordinated well between different manufacturers. This has led to the formation of a highly active international community of dental technicians who
exchange through social media what they have learned.
Personally, I’ve learned a lot from my peers around the
world, and I’m equally giving back to the community

4 2021

[14] =>

| interview

3
Fig. 3: 3D-printed dental appliances. (All images: © Stephan Kreimer)

and the manufacturers. Dentistry is at the intersection of
multiple disciplines, and we need to have good communication to make progress.
The rate of innovation in digital dentistry is extremely high.
We now see manufacturers coordinating much better
and creating more accessible ecosystems that are much

To me, dental technology is about combining the best
of two worlds: analogue and digital. We still need and
will continue to need traditional craftsmanship to meet
the high requirements for individualised aesthetics in
complex cases. At the same time, the holistic digital
workflow works well in an increasing number of areas,
enabling significant increases in efficiency while maintaining or improving overall quality. Digital fabrication
in particular enhances production speed and reproducibility.

“We are undergoing a
Dentistry is constantly evolving. What lies ahead for
paradigm shift in dentistry dentistry, and what dental technology is most likely
shape its future?
because digital technologies toIn my
view, we are now at a point where most of the
understands and embraces the vast potential of
are fundamentally changing industry
digital technologies. At the same time, we are just about
move from an early adopter stage to the early majority
the dynamics of our industry.” tostage
when it comes to the adoption of digital technologies.
easier to use. At the same time, most of the potential is
still untapped and will become apparent as we undergo
significant transformations within our industry.
Having worked with digital technology for over a
decade now, what benefits do you see of using dental technology, especially 3D printing, in a dental
laboratory?

4 2021

In Germany, for example, only 15% of dental practices
are using intra-oral scanners, much less than in the US.
However, the trend towards digital impressions is accelerating fast!
We are undergoing a paradigm shift in dentistry because
digital technologies are fundamentally changing the dynamics of our industry. We will see entirely new business
models, and together we will establish new standards of
care. It is an exciting time, and for those who embrace
this change, there will be many opportunities.

[15] =>

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[16] =>

| interview

Amann Girrbach goes “shareside”
By Jeremy Booth, Dental Tribune International

Going digital in dentistry is now more important
than ever. CAD/CAM pioneer Amann Girrbach has a
long history of developing workflow solutions for dental
clinics and laboratories. “We’re experts on both sides,”
said CEO Dr Wolfgang Reim, who spoke in this interview about the company’s new modular Ceramill Direct

Restoration Solution (DRS) and the communication and
case management platform AG.Live.
Dr Reim, what is new regarding Amann Girrbach’s
approach to the overall digital workflow?
The traditional approach to chairside workflows cuts off
the competence of the laboratory from that of the dental technician. This is what we want to avoid. We have
learned a great deal about the challenges at the interdisciplinary interface and have focused on the development of Ceramill DRS in order to offer added value to all
stakeholders. With our new software platform AG.Live,
in combination with the modular DRS, we have combined
clinical and laboratory workflows, thus closing the gap
between the dental practice and the laboratory. As a
result of this process, professionals have more choices
and instant modes of communication, and both sides
can contribute their core competencies in order to provide patients with the best possible restorations. This is
what we call “shareside”—Amann Girrbach’s specific
concept of chairside.
There are two core elements to the new and fully integrated workflow. Firstly, can you tell us more about
the Ceramill DRS?
Ceramill DRS offers dentists and laboratories fully integrated and validated workflows with consistent highestquality restorations and full flexibility. Depending on
the type of collaboration desired, three team workflows
are available in combination with the corresponding
Ceramill DRS modules.
The Ceramill DRS Connection Kit integrates digital impressions taken by the dentist into the digital laboratory
workflow. It consists of a high-performance intra-oral
scanner, the Ceramill Map DRS, and scan software.
It includes a connection to AG.Live, through which all
case data is shared seamlessly and in real time with the
laboratory of choice, and further communication directly
linked to the case can be done online or offline. This eliminates the need for handwritten job sheets and phone
calls and enables same day dentistry for certain restorations with a fast laboratory process.

Dr Wolfgang Reim has been the CEO of Amann Girrbach since 2020.
(All images: © Amann Girrbach)

4 2021

Users can upgrade to the Ceramill Motion DRS production module, and restorations can be designed either
on-site or with the support of the laboratory via AG.Live.
In combination with the Ceramill Therm DRS speed

[17] =>

interview

sintering furnace, a full chairside workflow for a crown in
less than one hour is possible in validated consistency
and at the highest quality level.
The second core element is AG.Live. How does
this platform connect and enable dentists and technicians?
AG.Live offers an infrastructure and patient case management that provides consistency and efficiency and
raises the flow of information to entirely new levels.
It networks laboratories and clinicians both online and
offline for a particular case, displaying, for example,
its process status. For the production process in the
laboratory, machine and material availabilities are visible
and overall task management of the dental fabrication
process is made transparent.
Thus, AG.Live allows dental professionals to keep track
of all activities digitally—from anywhere and at any time.
Furthermore, participants can work and collaborate more
efficiently through this network and better focus on their
strengths and core competencies.
What are the real and tangible benefits of this fascinating solution for dentists and their patients?
There are three main benefits: firstly, the validated 100%
consistency at the highest quality level, independent of
the chosen workflow; secondly, the support of unique
relationships between the dental practice and laboratory
focusing on the best possible treatment of their patients;

Ceramill Motion DRS.

thirdly, the many options for the patient from this one
scalable and validated system—from a single-visit crown
to a full-mouth restoration.
Additionally, the flexibility and speed on offer may lead to
a better experience for the patient and ultimately attract
new patients and more orders for the laboratory.

With its Ceramill Direct Restoration Solution (DRS), Amann Girrbach has extended its integrated digital workflow to the dentist and thus closed the communication gap that existed between the dental practice and the laboratory.

4 2021

[18] =>

| case report

Full-arch rehabilitation with lithium
disilicate secondary crowns luted
on to the primary framework
Joaquín García Arranz (Quini), Dr Ramón Asensio Acevedo & Oscar Jiménez Rodríguez, Spain

Figs. 1a & b: Digital mock-up. Fig. 2: Digital design of the gingiva.

Introduction
Dealing with implant restoration is challenging, and this
process would be impossible if we could not communicate freely between the clinic and laboratory. At the start,
we do not know what type of framework design we will
have to make, nor what the pink and white proportions
will be. The starting point is working as a team, maintaining constant communication through emerging technologies in photography or digital smile design. In a treatment
protocol for complete edentulism with digital design information, we transfer the ratios of white and pink aesthetics to the scanner, turning it into an analogue test
for a first analysis inside the mouth via CAM. When we
know how far we need to go with the case, we select the

type of material that will result in the best outcome, combining materials with appropriate techniques as required
throughout the treatment. The patient’s needs are
always taken into account in pursuit of greater durability
of our prostheses over time.

Case presentation
A patient with inadequate crown and bridgework attended the clinic because several abutment teeth had
failed. Owing to the Class III occlusal pattern and the
small number of remaining teeth with a good long-term
prognosis, we decided on an implant-supported restoration in the maxilla and a combined tooth–implant
restoration in the mandible.

Fig. 3: Mock-up in PMMA with pink and white aesthetics. Figs. 4a & b: Evaluating the integration of the mock-up in the patient’s mouth.

4 2021

[19] =>

case report

Figs. 5a–d: Choice of different definitive materials. Figs. 6a–c: Single-crown design on different framework materials for easy repair.

Today, these technologies are basic tools for approaching
and establishing treatment. We combined digital smile
design and the patient’s photographs, and we entered
them into the GC Aadva Lab Scan’s exocad software.
We merged the patient’s facial contours with the Anteriores Templates Contour Library provided by Jan Hajtó
(Figs. 1a–c). Once the teeth matching the facial features
had been selected, we started to adjust the tooth shapes,
keeping a close eye on length–width ratio, midline, and
labial and pupillary plane. When the white aesthetics had
been finished, we designed the pink aesthetics together
with the implants, taking the anatomical design and the

cleansable basal area into account (Fig. 2). After the
aesthetic design, we sent this digital information to the
CAM software to create a mock-up structure in PMMA.
This can be done by either milling or printing (Fig. 3).
To check the precision, we systematically link our aesthetic mock-up to the implants. We do this by screwing
three implant interfaces to the implants with the correct
occlusion, providing a tripod of accuracy. With constant,
good communication between dentist and laboratory,
we did several aesthetic tests, working to a high degree
of accuracy. In this phase, we need to work precisely and

11a

11b

Fig. 7: Scanning the aesthetic mock-up. Fig. 8: Framework design in GC’s exocad software. Fig. 9: Porcelain-fused-to-metal framework: pink aesthetics with GC Initial MC.
Fig. 10: Single-crown frameworks ready to be pressed. Figs. 11a & b: GC Initial LiSi Press ingot (a). Secondary frameworks pressed in GC Initial LiSi Press (b).

4 2021

[20] =>

| case report

12a

12d

12b

12e

12c

12f

12g

Figs. 12a–g: Light dynamics of natural teeth in direct and indirect light.

consistently before we can continue with the treatment.
All necessary changes were made to clear any doubts
until we achieved the desired integration of the mock-up
into the patient’s mouth and face (Figs. 4a & b).
During the treatment protocol for edentulous patients,
we take the time to evaluate the aesthetic mock-up to
verify what the best obtainable result would be and which
material would be ideal for the definitive restoration:

13a

14a

a conventional porcelain-fused-to-metal (PFM) restoration
or a white material, such as zirconia, combined with metal
interfaces (Figs. 5a–d). For this type of design, there
are many elements that we have to take into account:
the length from the implant to the incisal edge, implant–
restoration ratio, widths of the design, occlusion, etc.
We take great care to ensure that every patient has a
prosthesis customised to his or needs. The restoration

13b

14b

14c

Figs. 13a & b: Light dynamics of natural teeth under fluorescent light. Figs. 14a–c: Layering with GC Initial LiSi.

20

4 2021

[21] =>

case report

16
Fig. 15: Etching and pretreatment of the ceramic surfaces. Fig. 16: Cementation using G-CEM Veneer in Shade A2.

should be durable and, in case of an accident, easy to
repair. Therefore, in some metal–ceramic and in zirconia
restorations, we make single-crown designs on a primary framework (Figs. 6a–c). This enables us to repair
or replace a broken element. In this case, where we had
sufficient length, a change from a Class III to Class I occlusion with a considerable adaptation in the vestibular
direction and long tooth structures in proportion to the
gingiva, we opted for a PFM framework. We scanned
the aesthetic mock-up with the GC Aadva Lab Scan and
determined implant positions with its dedicated scan
flags (Fig. 7).
Thanks to the tilt and swivel unit, 90° angulation and
dual camera system, we were able to scan the basal
side of the mock-up. With the exocad software, we could
make a quick design of the restoration with a proportioned reduction (Fig. 8).
Once the frame structure had been designed, the STL file
was sent to the milling unit to mill the metal framework.
Although our protocol was carried out with rigid splinting
of the impression copings, we still tested the framework’s
passive fit, both on the model and in the mouth.
For layering, we have two different techniques, both with
their advantages and disadvantages:
– pink layering technique with white aesthetic cut-back
technique; and

– pink layering technique with white aesthetic full-contour
painting protocol (as is also shown in the alternative
method section at the end of this article).
GC Initial LiSi Press MT was used for the secondary crown
frameworks. The cut-back technique was used in the anterior area and full-contour frameworks were used in the posterior area. For this technique, we use duplicated secondary
crowns in milled PMMA or wax to fit the emergence profile
correctly while layering the pink aesthetics with GC Initial MC.
After layering the pink aesthetics, we applied a very fine
layer of highly chromatic ceramic (GC Initial MC) on to the
die’s surface (Fig. 9). Once fired, this gives us the major
advantage of being able to create a chemical bond between this feldspar-based ceramic and the future lithium
disilicate secondary single crowns (GC Initial LiSi Press)
that can now still be readjusted before pressing them
(Fig. 10). We use this technique mostly for anterior restorations, leaving the lingual side monolithic with the correct
occlusion and without any protrusive risk of chipping the
ceramic. GC Initial LiSi Press looks very much like natural teeth, enabling excellent integration (Figs. 11a & b).
The best way to understand how the light dynamics of
a material work is to conduct different tests with a natural tooth and play around, not only in direct light but also
in indirect light (Figs. 12a–g) and even under black light or
fluorescent light (Figs. 13a & b). By matching these optical
properties, we can achieve good aesthetic results. GC Initial

Fig. 17: Perfect integration of the pink and white parts after mechanical polishing. Fig. 18: Definitive restoration. Fig. 19: Intra-oral view after treatment.

4 2021

[22] =>

| case report

Fig. 20: Frontal view after treatment. Fig. 21: Radiograph after treatment.

Cementation and bonding protocol

LiSi Press is available in degrees of translucency, from the
most opaque to the most translucent (MO, LT, MT and HT).

The bonding protocol to cement the LiSi Press restorations
on to the surface of the ceramic-covered dies starts by applying hydrofluoric acid to both ceramic surfaces and leaving
it on for 20 seconds. After rinsing and drying, GC CERAMIC
PRIMER II or G-Multi PRIMER (GC) is applied (Fig. 15).

The anterior area is the most aesthetically demanding
area and was veneered using the polychromatic layering
technique using GC Initial LiSi veneering ceramic. This
ceramic is exactly matched to the lithium disilicate framework and ensures a perfect fusion (Figs. 14a–c). Once
the macro- and microtexture surfaces have been finished, we mechanically polish the restoration for perfect
integration with the pink aesthetics.

Shade A2 of G-CEM Veneer (GC) was selected, verified with
G-CEM try-in paste (GC) to check the shade and used
to cement the restorations (Fig. 16). The cement was tack-

26a

26b

Fig. 22: Engineering of the micro- and microtexture of the surface. Fig. 23: Application of the GC Initial Spectrum Stains. Fig. 24: Fitting the GC Initial LiSi Press restoration
on to the zirconia framework. Fig. 25: Highly fluid GC Initial LiSi ceramic is applied to the zirconia framework. Figs. 26a & b: Multi-chromatic layering of gingival structures.

4 2021

[23] =>

case report

27a

27b

Figs. 27a & b: Polished gingiva and teeth, view from two different angles.

polymerised for 1–3 seconds to remove excess material and
then completely light-polymerised for 30 seconds. After completion, the restoration was finished and polished (Figs. 17 & 18).
The finished restoration placed in the mouth showed
good integration (Figs. 19 & 20). The correct implant
seating was verified with a CT scan (Fig. 21). The basal
adaptation was perfect to enable optimal cleaning of the
mucosa. Occlusal fit was checked with active posterior
cusps and canine and protrusive guidance.

Alternative method
In this case, zirconia was used for the primary framework.
Before sintering, the dies were infiltrated with colouring
liquids and fluorescent effects. The secondary complete
anatomical crowns were adjusted to the zirconia framework. After pressing in GC Initial LiSi Press MT, the surface structure (macro- and microtexture) was engineered
(Fig. 22). Here, the aesthetic details were painted on to
the full-contour zirconia restorations using the GC Initial
Spectrum Stains and fixated in the ceramic furnace.
A great advantage of this approach is the ability to continue
firing until the desired colour has been achieved (Fig. 23).
Once the desired colour has been achieved, the surface
is mechanically polished. The inside of the crowns and
the zirconia die surfaces are gently sandblasted with
aluminium oxide. We pay close attention to the correct
fit between the GC Initial LiSi Press restorations and the
zirconia framework (Fig. 24). The most delicate step in this
technique is the placement of highly fluid GC Initial LiSi
ceramic on to the dies’ surface and manoeuvring of the
crowns into their right position, taking the marginal fit and
occlusion into consideration (Fig. 25).
A special firing for overall fusion of the secondary GC Initial
LiSi Press crowns and the primary zirconia framework
is conducted. Once both structures have been fired together, we layer the pink aesthetics with GC Initial Zr-FS.
Multi-chromatic layering between different firing cycles is
performed to reach the desired goal and achieve perfect
gingival adaptation (Figs. 26a & b). The mucogingival surface
is finished and mechanically polished together with the
crowns (Figs. 27a & b), resulting in harmonious integration.

about
Joaquín García Arranz (Quini)
is the founder of the Ortodentis dental
laboratory in Madrid in Spain, director
of the Dental Training Center in Madrid
by Quini and founding partner of the
Fresdental fabrication centre in Alicante
in Spain. He lectures in the master’s
degree programme in implants at the
European University of Madrid and
in the master’s degree programme in prosthetics for dental
technicians at Vericat Formación’s training centre in Madrid.
He is an opinion leader for GC Iberica. He has presented
numerous courses at national and international conferences,
has written articles published in national journals and
is the author of the book Experience Group.
Dr Ramón Asensio Acevedo
holds a DDS from the Alfonso X el
Sabio University in Madrid in Spain
and a master’s degree in aesthetic and
restorative dentistry and a master’s
degree in interdisciplinary aesthetic
rehabilitation, both from the Universitat
Internacional de Catalunya in Barcelona
in Spain. He is in private practice
in Madrid, Barcelona and Toledo in Spain and an assistant
professor in the aesthetic dentistry, endodontics and restorative
dentistry department at the Universitat Internacional de Catalunya.
Oscar Jiménez Rodríguez
is a dental technician specialised
in dental prosthetics. He completed
his studies at the Juan Badal March
institute in Valencia in Spain
and underwent training at the
Giovanni Natile dental laboratory.
He has been in private practice in the
Oscar Jiménez Rodriguez laboratory
since 2011 and is a collaborator in the Dental Esthetic Laboratory
and at the Fresdental fabrication centre in Alicante in Spain.
He has presented numerous courses at the Murcia prosthetic
school, Dental Miv Facilities and GC Iberica on GC Initial ceramics.

4 2021

[24] =>

| case report

The use of autologous tooth structure
as adjunct grafting modality for
full-arch dental implant rehabilitation
Drs Scott D. Ganz & Isaac Tawil, USA

2
Fig. 1: CBCT imaging showing volumetric reconstruction, axial, panoramic and sagittal views. Fig. 2: Panoramic reconstructed view revealing fractured teeth,
residual root tips and failing dentition.

Introduction

left by extraction sockets, or pre-existing concavities.5, 6
It is well understood that substantial bone resorption and
loss of bone volume can occur when extraction sites are
not grafted.7, 8 Avila-Ortiz et al. concluded that “alveolar
ridge preservation is an effective therapy to attenuate the
dimensional reduction of the alveolar ridge that normally
takes place after tooth extraction”.9 The gold standard has
always been autologous tissue harvested from the patient,
but it is not always easy to harvest or readily accessible.
Therefore, most clinicians currently utilise bone and membranes available through tissue banks. However, current
innovations have fortunately provided a new, previously
untapped source of this autologous tissue: the extracted

Full-arch dental implant rehabilitation is a viable treatment choice for patients who are edentulous or who have
teeth that are compromised and in need of extraction.
Regardless of a freehand or fully guided surgical protocol,
treatment outcomes for full-arch implant-supported restorations have helped patients regain proper function, aesthetics and quality of life.1–3 Additionally, the ability to place
implants immediately after tooth extraction has become
a viable treatment modality which can often reduce the
time to delivery of functional restorations.4 However, the
residual alveolar ridge may require grafting to fill defects

Figs. 3a & b: Six implants planned for maxillary arch fixed restoration (a). Five simulated implants with two tilted to avoid the inferior alveolar nerves in the
mandibular arch (b).

4 2021

[25] =>

case report

Figs. 4a–f: Cross-sectional planning for maxillary implants and angled multi-unit abutments.

tooth, which is often readily available when full-arch implant rehabilitation is planned. This current article will
demonstrate that it is possible to provide enough grafting
material volume to fill all residual sockets and concavities
from extracted teeth harvested during immediate implant
placement for a dual-arch surgical procedure.

Case report
A 68-year-old female patient presented with failing den
tition in the maxillary and mandibular arches due to
years of neglect and patchwork dentistry. The patient was
unhappy with the condition of her teeth and was embarrassed to go out in public. She had difficulty chewing
owing to missing and fractured teeth in the maxillary arch,
did not have any posterior mandibular teeth, and did not
have a repeatable bite position. The patient had been to
several dentists, who offered differing treatment plans,
and was very confused regarding potential options to correct the deficiencies to improve her quality of life. Options
that were presented included removable partial dentures,
a maxillary complete denture and a mandibular removable partial denture, and implant-supported removable
and fixed restorations for both arches. The patient wished
to determine whether a fixed full-arch restoration could be
considered for both the maxilla and mandible.
The patient’s medical history revealed hyperthyroidism and
hip replacement within the past five years. Clinical exam-

ination confirmed the diminished condition of the patient’s
dentition, and the need for a thorough 3D assessment of
her existing anatomical presentation and that this could
only be accomplished with a CBCT scan was explained
to the patient. The CBCT scan allowed for the inspection of the anatomy in multiple views and with the digital
tools afforded by the software (Carestream 3D Imaging,
Carestream Dental; Fig. 1). The panoramic reconstruction
served as a scout film to help visualise the condition of the
patient’s dentition (Fig. 2). The maxillary arch exhibited several fractured teeth, several that had undergone previous
root canal therapy, a single crown and a four-unit posterior bridge on teeth #24, 25, 26 and 27. Using the embedded link, the original CBCT scan data was then exported
from the Carestream 3D Imaging software directly to
Blue Sky Plan software (Blue Sky Bio). Blue Sky Plan offers
additional planning and design tools to aid in accurate diagnosis, treatment planning and surgical guide fabrication.
The preliminary plan consisted of placing implants in
strategic positions to support implant-supported fixed
restorations accurately delivered with the implementation
of static, sequential surgical guides (Fig. 3). Each potential
implant receptor site was designated by tooth number
for the maxillary and mandibular arches. Manufacturerspecific simulated implants were then refined within the
cross-sectional images, recording diameters and lengths
in screenshots for the maxilla (Fig. 4) and the mandible
(Fig. 5) utilised during the surgery as colour printouts.

Figs. 5a–e: Implant planning for the mandibular arch with straight and angled multi-unit abutments.

4 2021

[26] =>

| case report
6a

Figs. 6a–d: 3D volumetric reconstruction of the maxilla and mandible (a). The isolated mandibular arch (b). STL surface model merged with DICOM
data with virtual posterior teeth (c). Yellow abutment projections representing screw access channels (d). Figs. 7a & b: Bone reduction guide design (a).
Reduced mandible, nerves and simulated implants with selective transparency (b). Figs. 8a & b: Transparent reduced mandible, five implants and yellow
abutment projections (a). Transparent STL model and virtual teeth (b). Fig. 9: Osteotomy drilling guide seated on the mandible.

When assessing the potential mandibular implant receptor sites, the buccal and lingual cortical plates appeared
to be well defined. However, careful inspection revealed
a deficient density within the intermedullary bone. Yellow
abutment projections represented simulated abutment
trajectories helpful in the determination of screw access
channels within the transitional and definitive prostheses.
It was also possible to place realistic simulated abutments
based on the desired angulation and tissue cuff height
chosen from the implant library within the software. The
planning continued with the examination and manipulation of the 3D reconstructed volume of the mandible
and maxilla (Fig. 6a). Using the isolate function within the
Blue Sky Plan software, the mandibular arch was separated from the maxillary arch, which with the merging of
the intra-oral scanning data helped with the restoratively
driven planning and refinement of implant positioning
(Figs. 6b & c). The implants were then planned with
precise regard for the emergence of the screw access
channels represented by the yellow abutment projec-

tions which extended above the occlusal plane (Fig. 6d).
Once each of the implant receptor sites and the vertical
positions had been validated, the amount of alveolar reduction (after tooth extraction) was determined. A bone
reduction guide was then designed with four anchor pins
for stable fixation to the mandible (Fig. 7a). The various
components of the diagnostic progress can be better
appreciated using selective transparency to visualise
structures based on their density (Fig. 7b). Selective transparency was again utilised to visualise the final location of
the three central straight implants and the two angled implants, clearly indicating the safe proximity to the bilateral
inferior alveolar nerves (Fig. 8a). The translucent STL model
of the mandibular teeth and virtual teeth helped relate
the implant positions to the restorative plan (Fig. 8b). The
sequential osteotomy drilling guide was designed based
upon the parameters of the implant system and guided
drilling kit utilised. The osteotomy drilling guide was to be
secured to the mandible with the same fixation pins as
used for the bone reduction guide (Fig. 9).

Clinical procedure

11
Fig. 10: Pre-op retracted view. Fig. 11: Mandibular extractions.

4 2021

The patient presented with a collapsed bite due to missing, mobile and fractured teeth, which severely affected
her ability to masticate food, resulting in embarrassment
and a diminished quality of life (Fig. 10). After a thorough
review of the diagnostic process, the treatment plan was
presented and accepted by the patient for maxillary and
mandibular implant-supported fixed restorations. At the
request of the patient, one long procedure was scheduled
to be completed under sedation administered by a dental

[27] =>

anaesthesiologist. Once the patient had been sedated,
bilateral mandibular blocks were accomplished with 2%
lidocaine with 1:100,000 adrenaline and 4% articaine. The
remaining mandibular teeth were extracted using periotomes, elvatomes, and forceps (all TBS Dental), and all
the sockets were thoroughly debrided and then irrigated
with 0.12% chlorhexidine gluconate (Fig. 11). Many of the
extracted teeth were free of decay, root canal therapy or
fillings, and therefore it was elected to utilise the patient’s
own teeth to fabricate autologous grafting material for use
in both maxillary and mandibular arches. The process of
harvesting grafting material from tooth structure has been
successfully reported in the literature and has become a
great source of autologous tissue when teeth are to be
extracted and grafting is required.
When teeth are to be extracted, often the extraction sites
and implant receptor sites will require some type of grafting to manage the resultant anatomical defects and bony
concavities. Currently, most bone grafting is dependent
on tissue banks to supply us with bone in a bottle in various shapes, sizes and formulations. While these products are essential to have on hand, when teeth are to
be extracted, perhaps an alternative concept would be
to use the autologous material from enamel and dentine to serve as grafting material to fill defects and augment the surgical sites. As many of our patients present
with a failing dentition due to alveolar bone loss, dentine
grinding has gained popularity as an important ancillary
method to gain significant volumes of grafting material,
especially when patients are to undergo full-arch dental implants.10–12 One such innovation is the Smart Dentin
Grinder (KometaBio; Fig. 12a). Once the remaining mandibular teeth had been extracted and evaluated, a diamond bur in a high-speed handpiece was used to clean
the tooth roots and areas of the enamel, removing all
debris, soft-tissue tags, fillings and decay. The teeth were
then dried and placed in the single-use sterile chamber
attached to the Smart Dentin Grinder (Fig. 12b). The
grinding process was timed for 3 seconds, followed by
a 10-second sorting process, and was repeated until the teeth were sufficiently ground, and the particles
were separated and sorted by size within the cannister
and collection drawers. The particle size ranged from
250–1,200 μm as collected in two separate drawers
(Fig. 12c). The volume of autologous particulate mate-

12a

12b

12c

Figs. 12a–c: Smart Dentin Grinder and extracted teeth (a). Teeth in the cutting chamber (b). Large and small particle sizes sorted into two drawers (c).

rial was impressive at approximately 5–6 cm3 of grafting
material generated from the extracted teeth. According
to the recommended cleansing protocols, the grafting
material was transferred from the top and bottom drawers
to a sterile dish. The entire volume of grafting material was
then covered with the dentine cleanser solution and left
covered for 5 minutes. The material was then dehydrated
with a sterile gauze. This liquid cleansing process effectively rendered the dentine particulate bacteria-free without harming the collagen, bone morphogenetic proteins
and growth factors imbedded in the dentine. A phosphate-buffered saline was then used to neutralise the
pH levels, followed by dehydrating with a sterile gauze and
a repeat of the rinsing process, and saved for later use
as needed in both the maxillary and mandibular arches.
The entire process can range from 8 to 10 minutes
and is usually completed by a trained auxiliary.
A full-thickness mucoperiosteal flap was elevated from the
approximate areas of tooth #46 to tooth #35 and carefully reflected to expose the alveolar ridge. A bone reduc
tion guide was placed over the site and fixated with four
anchor pins. The bone was then reduced to the planned
vertical height with rongeurs and flattened with carbide
burs in a straight handpiece (Alveoplasty Kit, Meisinger
USA). Based upon the 3D planning, the 3D-printed osteotomy drilling guide was designed to fit over the reduced
bone and fixated in the same holes as the bone reduction guide (Fig. 13). The fixation pins were of two different lengths and secured the resin guide to the mandible
(Fixation Kit, ROE Dental Laboratory). The osteotomies
were prepared with sequential guided drills for accuracy, and five implants (Helix Grand Morse, Neodent)
were placed approximately 2 mm subcrestally (Fig. 14).
Although the implants all exhibited moderate insertion
torque, the intermedullary bone density within the mandibular implant receptor sites was poor, as previously

Fig. 13: Surgical guide fixated to the mandible. Fig. 14: Five implants placed as planned. Fig. 15: Dentine graft covering socket defects.

4 2021

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| case report

Fig. 16: Surgical guide fixated to the maxillary arch for guided drilling protocols. Fig. 17: Implant delivered through the guide. Fig. 18: Fully template-guided
implants were placed.

noted during the diagnostic phase. Each implant was
then objectively tested for stability using resonance frequency analysis, and implant stability quotient (ISQ) values were recorded (Osstell IDx, Osstell). The ISQ values
confirmed the initial CBCT assessment of the mandibular bone, and a decision was made to bury the implants
and leave them covered for approximately 2–3 months
to provide sufficient opportunity and time for the implants
to fully integrate within the mandibular bone prior to loading. Each subcrestally placed implant received a 2 mm
cap screw to fill the coronal osteotomy site. All the residual tooth sockets and any defects or concave areas
were then filled with the dentine grafting material (Fig. 15).
Two 20 × 30 mm collagen membranes (MaxxMem, Community Tissue Services) were then draped over the
grafted site and stabilised with deep horizontal mattress
sutures. Closure was then achieved with continuous and
interrupted sutures using #4/0 thread (VICRYL, Ethicon).
A similar procedure was completed for the maxillary arch.
After local infiltration of anaesthetic agents, all remaining
root tips and teeth were atraumatically extracted and all
sockets thoroughly debrided. A full-thickness mucoperiosteal flap was elevated from approximately the area of
tooth #16 to tooth #26 to expose the residual alveolar ridge.
Once the bone had been reduced, an osteotomy drilling
guide was fixated to the maxillary arch (Fig. 16). Osteo
tomies were then prepared, and six Helix Grand Morse
implants were placed through the guide (Figs. 17 & 18).
The stability of each implant was objectively measured,
and the ISQ values were found to be below the threshold
for immediate loading. Therefore, the maxillary implants
were buried in a two-stage protocol. To preserve the width
and height of the residual alveolar ridge, the extraction
sites were all filled with the grafting material gleaned from
the teeth extracted from the mandibular arch (Fig. 19a)
and covered with large 20 × 30 mm collagen membranes
(Fig. 19b). The immediate postoperative panoramic radiograph showed the placement of five implants for the mandibular arch and six for the maxillary arch (Fig. 20). The
classic radiolucent appearance of fresh extraction sites
was not evident, as each had been filled with the dentine
grafting material. Small, round radiolucent holes could
be visualised in the mandibular arch from the four fixation
screws. The 2D panoramic reconstructed view is some-

4 2021

what distorted and thus the true trajectory of each implant
cannot be accurately appreciated. It was the original plan
that the right and left most distal tilted implants would
receive 30° angulated multi-unit abutments at the appropriate tissue cuff height once the implants had been uncovered and after osseointegration had been confirmed.
The patient was then brought out of sedation and allowed
to recover until she was fully coherent and ambulatory.
Immediate complete dentures were then delivered to the
patient after soft-tissue relining had been accomplished
to improve fit. Postoperative instructions were provided to
the patient orally and in writing. The procedure was well
tolerated, and the patient was subsequently followed for
suture removal and healing progress.

Discussion
When full-arch implant restoration is contemplated for
patients who are partially dentate, immediate extractions
will be required. Many will require extractions of perfectly
intact teeth and roots, which can provide an excellent
source of autologous grafting material. These extraction
sockets may leave significant voids in the bony architecture of the remaining alveolar ridge. As it is recommended that implants should be planned with 3D imaging acquired through CBCT scans, the diagnosis should
also include an assessment of where the teeth will be
extracted and what type of bony defects will be left after extraction. When implants are planned to be placed
directly within fresh extraction sockets, often there is a
gap on the buccal wall, which can be filled with grafting
material to help preserve the bony housing. In other areas,
the entire sockets can be filled to reduce potential for
volumetric shrinkage of the ridge over time. The current
case presentation illustrated the effectiveness of utilising
an innovative device to grind extracted teeth to produce sufficient graft volumes required during the surgical
phase of full-arch implant rehabilitation. Calvo-Guirado
et al. found that, after processing with the Smart Dentin
Grinder, “0.25 gr of human teeth produced 1.0 cc of
biomaterial” and that the “chemical composition of the
particulate was clearly similar to natural bone”.13 The present case illustrated immediate extraction and immediate
implant placement for a delayed loading protocol with

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case report

19a

19b

Figs. 19a & b: Implants and residual sockets (a). Collagen membrane placed over the graft site (b). Fig. 20: Post-op panoramic radiograph showing the
implants and grafted sites.

autologous dentine grafting material, which can also be
used for immediate loading protocols when appropriate.

Conclusion
Full-arch implant-supported restorations can be either
fixed or removable overdentures. Regardless of the proposed treatment modality, when extractions are required,
it is recommended that grafting be an integral and
necessary part of the surgical procedure. The use of
autologous tissue generated from the patient’s own teeth
has many advantages, including:
1.
It represents a biocompatible material and is not
recognised as a foreign body.
2. It has almost the same composition as bone, comprised of higher density hydroxyapatite and Type I
collagen fibre.
3. Dentine and enamel are tougher than cortical bone
and therefore provide an excellent scaffold and hence
osteoconductivity.
4.
Dentine contains good amounts of morphogenetic
proteins and growth factors that aid in the regeneration process to form new bone relatively quicker than
most grafts; hence, it is osteoinductive.
5. A single tooth, dependent on the type, can produce
anywhere between 0.5 cm3 and 2.5 cm3, providing an
ample amount of grafting material.
6. Autologous dentine does not require a secondary harvesting site and therefore eliminates morbidity, risk and
pain associated with that secondary procedure.
7. Cost related to purchasing bone grafting material from
tissue banks is reduced.
While dentine grafting can be especially useful with fullarch implant-supported restorations, additional uses can
include conventional socket preservation, onlay grafting,
sinus augmentation, creating sticky bone with plateletrich fibrin and partial extraction (socket shield),14 like any
other available grafting material. Patients are also pleased
that their own cells are being used to enhance the healing process. More research, especially long-term studies
and follow-up, is recommended to quantify the benefits
of this adjunct modality to provide autologous grafting
material for patients in need.

Editorial note: A list of references is available from the
publisher. This article originally appeared in Dentistry
Today in October 2021, and an edited version is provided
here with permission from Dentistry Today.

about
Dr Scott D. Ganz received his
specialty certificate in maxillofacial
prosthetics and prosthodontics, and
this led to his focus on the surgical and
restorative phases of implant dentistry
and his subsequent contribution
to 15 implant-related textbooks.
He is a fellow of the Academy of
Osseointegration, a diplomate of the
International Congress of Oral Implantologists, US ambassador
of the Digital Dental Society, president of the US branch of
the Digital Dentistry Society and a co-director of Advanced
Implant Education. Dr Ganz is on the teaching staff of the
Rutgers School of Dental Medicine in Newark in New Jersey
in the US and maintains a private practice in Fort Lee in
New Jersey. He can be reached at drganz@drganz.com.
Dr Isaac Tawil received his DDS
from the New York University College
of Dentistry and has a master’s
degree in biology from Long Island
University, both in the US. He is a
fellow of the International Congress of
Oral Implantologists and the Advanced
Dental Implant Academy, a d iplomate
of the International Academy of
Dental Implantology and a co-director of Advanced Implant
Education. He has received recognition for outstanding
achievement in dental implants from the Advanced Dental
Implant Academy, as well as the President’s Volunteer Service
Award for his volunteer work in places such as Honduras,
Tijuana in Mexico, the Dominican Republic, China and Lima
in Peru. Dr Tawil lectures internationally on advanced dental
implant procedures using the latest technology and teaches
live surgery seminars in his office and abroad, as well as
hands-on courses globally. He maintains a general private
practice in New York, where he focuses on implant therapy.
He can be reached at tawildental@gmail.com.

4 2021

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| case report

Delayed immediate implant placement
and direct soft-tissue management
Dr Haki Tekyatan, Germany

4
Fig. 1: Initial clinical situation of tooth #12. Fig. 2: Radiograph of tooth #12
showing failed endodontic treatment with the dislocated post restoration and
deep complicated fracture. Fig. 3: Gentle detachment of marginal gingiva
and periodontal ligament fibres using periotomes. Fig. 4: Atraumatic extraction
of the tooth and the fractured fragment.

In the case of implant planning, the preservation of
soft tissue and bone is essential for functional and aesthetic long-term success. There are now various different
techniques and materials available. The timing of implant
insertion and soft-tissue shaping play a crucial role, as
do the measures taken in advance of the planned therapy. A targeted strategy can generate favourable conditions before implant placement. In this context, the use
of bone grafting materials in combination with intravenously collected autologous platelet concentrates (I-PRF
and A-PRF) has become increasingly important in recent
years. With this “biologisation” of specially developed
bone grafting materials for alveolar management, stable
preservation of the extraction socket and the bone can
be expected while promoting wound healing. The greatest loss of bone and, as a result, soft tissue occurs in the
first 12 months after tooth extraction. In the literature, loss
rates of up to 60% are reported.3 In this regard, Tan et al.

4 2021

were able to show in a systematic review that six months
after extraction there is a horizontal bone loss of 29–63%
and a vertical bone loss of 11–22%. The transverse bone
loss was found to be higher than the vertical bone loss.12
This was also confirmed by Araujo and Lindhe in their animal studies. They found that the greatest changes to the
alveolar process in the area of the buccal wall occurred
within three to six months after tooth extraction.2 In implant dentistry, these are limiting factors in daily practice.
However, it is crucial to have sufficient hard and soft tissue both in quantity and in quality to achieve the goals of
implant therapy.5
Preventive interventions can aid in counteracting bone
loss and resorptive processes in order to preserve hard
and soft tissue.7 In this regard, alveolar stabilisation is
a method performed during or after tooth extraction to
minimise external resorption of the alveolar process, preserve bone, and promote and support bone formation
within the extraction socket.6 Various terms are used for
this in the literature, such as alveolar ridge preservation
(for three- or two-walled defects), socket preservation
(for circularly intact alveoli), socket seal technique and
alveolar preservation. The aim of these methods is to fill
the fresh extraction socket with a bone grafting material
and to achieve stabilisation of the alveolar walls.9 In this
regard, the use of bone substitute materials biologised
with platelet-rich plasma (I-PRF and A-PRF) is described
in the literature as a successful means to preserve bone
and soft tissue and to support the healing process.8, 11
In the following case report, socket preservation with
CERASORB Foam (curasan) and I-PRF (IntraSpin, BioHorizons Camlog), obtained according to the Low Speed
Centrifugation Concept (LSCC) of Prof. Shahram Ghanaati,
was performed after extraction of tooth #12.15 Similar
cases were reported by Palm et al. and Al-Nawas et al. in
the past.13, 14 The implant was positioned and inserted six
weeks later on the basis of external planning (DEDICAM,
CAMLOG) and using a surgical guide with depth stop
(CAMLOG Guide System). An intra-oral scan (Medit i500,
Kulzer) was performed intra-operatively, and the first surgical phase concluded with submerged healing. During
this period, a new type of healing abutment was fabricated entirely from PEEK material. After a healing pe-

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case report

Fig. 5: Biologisation of the -tricalcium phosphate collagen matrix CERASORB Foam
with I-PRF. Fig. 6: Insertion of the biologised CERASORB Foam into the extraction
socket. Fig. 7: Gentle adaptation of the easily mouldable CERASORB Foam to the
alveolar walls with slight material compression. Fig. 8: Crestal covering and sealing of
the augmentation material using a compressed A-PRF plug. Fig. 9: Stabilisation and

fixation by means of cross-suturing. Fig. 10: Temporary restoration of the gap with
an interim prosthesis. Fig. 11: Radiographic control of the augmentation site. Note
the almost structurally identical distribution of the bone grafting material throughout
the extraction socket.

riod of three months, this PEEK healing abutment was
used directly after implant exposure in order to shape
the peri-implant soft tissue optimally and atraumatically
in a few treatment steps. Finally, the prosthetic restoration was realised with a ceramic-veneered CAD/CAMfabricated crown.

placed. In the case described here, the alveolar bone
could be preserved in all directions. The decision was
made in favour of delayed immediate implant placement
and the use of a bone regeneration material that is rapidly
resorbed and quickly incorporated into the autogenous
bone.

Case report

Socket preservation was performed with a -tricalcium
phosphate collagen matrix (CERASORB Foam), which
was biologised in advance with I-PRF (platelet-rich fibrin
concentrate; Fig. 5). In its hydrated, biologised state, the
collagen matrix can be excellently shaped and adapted
to the alveolar walls under as little compression as possible (Figs. 6 & 7). The augmentation site was covered
crestally and sealed with a compressed A-PRF plug
(Fig. 8). The site was then stabilised by means of
cross-suturing (Fig. 9). Tight covering using the socket
seal approach and a tissue punch was not necessary
in this context. The gap was temporarily restored with
an interim prosthesis, which was designed as a pontic in order to shape the soft tissue (Fig. 10). Lastly, a
control radiograph was taken, and the optimal defect
filling and almost structurally identical distribution of
the matrix could be noted on the radiograph (Fig. 11).
After the treatment, irritation-free, stable and, above all,
pain-free healing was observed. As a result, planning
for implant placement by means of CBCT (Orthophos
XG 3D, Dentsply Sirona) could be carried out after only
three weeks (Figs. 12 & 13). To achieve optimal 3D axial
positioning of the implant in the vertical, mesiodistal and

A healthy 55-year-old female patient presented to the
practice with an unsalvageable tooth #12. Clinically, the
oral situation was unremarkable. The patient reported
that the crown was loose and that it rotated slightly. She
also reported pain on biting. The radiographic evaluation
revealed that the tooth had been endodontically treated
and restored with a metal post. Dislocation of the post and
core with the crown and a deep fracture were detected,
and the patient was informed accordingly (Figs. 1 & 2).
A few days later, tooth #12 was extracted gently and
atraumatically with the aim of preserving the alveolar walls
as far as possible. Special periotomes and instruments
(KLACK set, Geistlich Biomaterials) were used for this
purpose (Figs. 3 & 4). Since an implant restoration was
planned in this case, it was decided in advance, and
together with the patient, that appropriate measures for
bone preservation should be taken. The condition of the
alveolus after extraction is an important criterion for deciding which treatment protocol should be used, that is,
which bone grafting material with which resorptive properties should be used and when the implants should be

4 2021

[32] =>

| case report

Fig. 12: Evaluation of 3D diagnostics showed sufficient stable bony conditions in all directions. Fig. 13: Clinical situation before implant placement. Figs. 14 & 15:
Planning of the surgical guide (CAMLOG Guide), vertical and ventral views.

orovestibular directions, the CBCT/DICOM data sets
were sent to an external planning centre (DEDICAM) via
a secure channel and a surgical guide (CAMLOG Guide,
SMOP, Swissmeda) was fabricated (Figs. 14 & 15).
An implant (CAMLOG PROGRESSIVE-LINE, CAMLOG;
diameter: 3.8 mm; length: 13.0 mm) was chosen which
would ensure sufficient high primary stability owing to
its progressive thread design.
Six weeks after extraction and socket preservation, implant insertion in region #12 was performed under local
anaesthesia. A crestal incision was made, and a flap was
reflected in a minimally invasive manner. The surgical
guide was put into position, and then the guide system
and the 3.8 mm drill set (CAMLOG) were used to prepare
the osteotomy in several steps to the planned length of
13 mm. Finally, guided implant placement was performed
to a torque of 25 Ncm (Figs. 16–18). After final positioning of the implant (Fig. 19), the insertion post was removed and a PEEK scan body (CAMLOG) with the same
diameter of the implant (3.8 mm) was inserted (Fig. 20).
The implant and the jaws were then scanned intraoperatively (Medit i500 and Medit Link software, Medit) to
verify the position of the inserted implant (Figs. 21a & b).
After scanning, the scan body was removed, the healing
abutment was installed, the surgical site was tightly
sutured for submerged healing and a dental panoramic

4 2021

tomogram (Orthophos XG 3D) was taken (Figs. 22a–c). During
the healing phase of the implant, the scans were further
processed for further planning (Fig. 23). The objective was
to shape the soft tissue and to fabricate the definitive restoration in as few steps and as effectively as possible.
Experience has shown that it is important to minimise
insertion and extraction torque in order to protect and
stabilise the peri-implant hard and soft tissue. This is essential for achieving long-term implant success, which, in
the present case, was realised on the basis of the treatment protocol followed.
After an irritation-free healing phase of three months, the
hard- and soft-tissue conditions were considered stable, and therefore the implant was exposed under local
anaesthesia. Since the soft-tissue situation was considered quantitatively sufficient, the incision was made crestally. In collaboration with the external planning service
centre (DEDICAM), a novel healing abutment was fabricated from PEEK during the healing phase and subsequently inserted. This one-piece healing abutment does
not require further processing, thereby minimising possible sources of error and potential contamination (Fig. 24).
The soft tissue was modelled in the coronal direction by means of a suspension suture, and the wound
margins were fixed to the adjacent teeth by means of
vertically modified backsuture (Fig. 25). Finally, a con-

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case report

16

18

|

17

19

20

Figs. 16–18: Ventral and crestal views of the inserted surgical guide and guided implant placement in region #12. Fig. 19: Final position of the implant in
region #12. Fig. 20: Insertion of the PEEK scan body.

trol radiograph was taken, and the interim prosthesis
was adapted to the new situation (Fig. 26). With the customised healing abutment and the corresponding emergence profile, the soft tissue was entirely shaped within
three weeks, and within the healing period. No further
treatment steps, impressions or other measures were
necessary. Not only is the treatment protocol shortened

21a

22a

in this way, but the soft tissue is also protected from
stress. The healing abutment is not radiopaque; thus,
its position cannot be checked on radiographs at present. However, the correct position of the fixation screw is
clearly visible. In this case, the focus was on the implant
itself, the bone and tissue regeneration, and the control of the healing of the implant site after three months.

21b

22b

22c

Figs. 21a & b: Determination of the final implant position by means of intra-oral 3D scanning. Figs. 22a–c: Different views: buccal view (a), vertical view (b),
maxilla segmented on to the planned restoration (c). The emergence profile of the healing abutment was matched to a virtual crown and designed accordingly
(3Shape CAD software).

4 2021

33

[34] =>

| case report

Fig. 23: Dental panoramic tomogram after implant placement in region #12 and post-op control at three months. Fig. 24: Healing abutment made of PEEK.
Fig. 25: Inserted individual healing abutment and fixation of the peri-implant mucosa. Fig. 26: Periapical radiograph for radiographic control of the implant in
region #12. Fig. 27: Vertical view shows the individually shaped mucosa immediately before the installation of the definitive superstructure. Fig. 28: Buccal view
of the definitive crown in region #12. Fig. 29: Radiographic control of the implant in region #12 after installation of the definitive crown.

There was homogeneous and continuous bony healing
of the implant site throughout (Fig. 26).
After a healing period of nearly three months, the definitive restoration of the implant in region #12 was carried
out. A fully-veneered zirconia crown was fabricated in a
CAD/CAM procedure. The customised zirconia abutment
was bonded to the titanium base. The crown was then
cemented onto the abutment. Following the final restoration, a final radiographic control was taken. Since the
crown was placed immediately after customisation, further aesthetic remodelling of the approximal peri-implant
mucosa is to be expected over time. Overall, a nonirritant, aesthetically pleasing and satisfactory result was
achieved (Figs. 27–29).

Conclusion
Restoration in the anterior region is one of the greatest
challenges in implant dentistry. The demands and expectations of patients regarding the aesthetic zone are
very high.4, 7, 10 In order to meet these expectations and to
achieve an aesthetically predictable and prognostically
reliable aesthetic long-term result, it is vital to ensure the
preservation of the soft tissue. Extensive augmentation
of the bone and soft tissue should be avoided if possible,
and the tissue should not be put under stress after implant placement.1 Preventive, predictable and minimally
invasive measures aid in preserving bone and soft tissue. In the present case, implant surgery in the aesthetic
zone was successfully carried out by means of a gentle
extraction technique, alveolar management adapted to
the situation using -tricalcium phosphate collagen ma-

4 2021

trix (CERASORB Foam) biologised according to LSCC,
delayed implant placement, as well as direct soft-tissue
management after exposure using a prefabricated customised healing abutment. The case demonstrates how
adequately sized and contoured hard and soft tissue for
implant restoration in the aesthetically relevant zone can
be achieved in preventive and efficient treatment steps
that are kept as short as possible.
Editorial note: This article was first published in
implants—international magazine of oral implantology,
Vol. 22, Issue 3/2021.

about
Dr Haki Tekyatan is a
Germany-based dentist who specialises
in implant dentistry and maxillofacial
surgery. He is currently in private
practice in the German city of Simmern.

contact
Dr Haki Tekyatan
Simmern, Germany
info@dr-tekyatan.de
www.dr-tekyatan.de

[35] =>

[36] =>

| case report

Restorative simplicity for a
challenging case with limited space
Dr Fernando Rojas-Vizcaya & Jose de San Jose Gonzalez, Spain & Germany

Initial situation and treatment planning

Crown Abutment (Dentsply Sirona) was planned to be used
to restore the appearance and function of the missing tooth.

A 40-year-old male patient with a missing mandibular right
lateral incisor and grafted area requested restoration with a
dental implant. The challenge with this type of restoration is the
limited space available and the proximity of the adjacent teeth.
The clinical evaluation revealed the limited space (Fig. 1), and
the periapical radiograph taken before the treatment showed
both the grafted area into the bone and the limited space (Fig. 2).
The treatment plan involved conventional implant placement
using an OsseoSpeed EV implant (Dentsply Sirona) and immediate provisionalisation using a Temporary Abutment EV
(Dentsply Sirona), and for the definitive restoration, an Atlantis

Implant placement
In the first step of implant placement, the biological aspects
according to the 3A-2B rule were evaluated using a surgical
guide (Fig. 3). The first drilling position was marked to obtain 2B and to create the osteotomy angulation using the
Precision Drill EV (Dentsply Sirona). The angulation was confirmed and the implant depth of the osteotomy was prepared
with the Twist Drill EV (Dentsply Sirona; Fig. 4). The depth of
the osteotomy was verified using the Implant Depth Gauge

4 2021

[37] =>

case report

EV (Dentsply Sirona; Fig. 5). Implant placement was then
performed with an OsseoSpeed EV 3.6 implant of 11 mm
in length (Fig. 6). The remaining interproximal bone was
expected to provide support for the interproximal papillae.
The periapical radiograph taken immediately after implant insertion confirmed that the implant had no contact with the
adjacent roots (Fig. 7). Thereafter, an implant-level impression
was taken using the Implant Pick-up Design EV (Dentsply
Sirona), a self-guiding impression component that engages
into the implant, in order to obtain the information regarding
the implant’s position (Fig. 8). The Temporary Abutment EV
was modified in the shoulder area to avoid contact with the
interproximal bone and to allow for a correct fit (Fig. 9). Using
a dental dam, the immediate temporary restoration was
fixed with acrylic resin (Fig. 10). After fixation, it was removed,
finished, polished and repositioned with finger-light force.

Definitive prosthetic restoration
The patient was called in for an appointment one week after surgery. At that point, the fit of the temporary restoration
was considered satisfactory (Fig. 11). Figure 12 shows the
digital planning for the Atlantis Crown Abutment in zirconia
with correct space for ceramic layers. The definitive restoration was produced in the dental laboratory with a view to
creating harmony with the adjacent teeth (Fig. 13). Space for
the interproximal papillae was created. The screw-retained
abutment with lingual access can be seen in Figure 14. The
provisional restoration was replaced with the definitive one
(Fig. 15). The subgingival portion of the abutment provided
soft-tissue support, and space for the interproximal papillae was created. The Atlantis Crown Abutment was torqued
to 25 Ncm (Fig. 16). The lingual screw access hole was
first covered with filling material (PTFE) and after that with

a composite. Afterwards, another radiograph was taken of
the implant with the definitive Atlantis Crown Abutment in
place (Fig. 17). In Figure 18, the final outcome with the definitive restoration can be seen, showing the correct soft-tissue
contour and the filling of the interproximal space. Also, the
ceramic perfectly mimicked the colour of the adjacent teeth.
Editorial note: This article was first published in implants—
international magazine of oral implantology, Vol. 22, Issue 3/2021.

about
Fernando Rojas-Vizcaya, DDS, MS,
graduated from the University of North
Carolina at Chapel Hill, USA, where he
completed a three-year postgraduate
qualification in prosthodontics and a
one-year scientific research fellowship
in dental implants in the prosthodontics
programme. He currently collaborates with
the university as an assistant professor.
He also studied oral medicine and oral implantology at the Complutense
University of Madrid in Spain and completed a programme in
oral surgery at the Gregorio Marañón university hospital in Madrid.
His research is focused on the development of protocols in oral
implantology, complete rehabilitation and virtual treatment using
new digital technologies. He maintains a private practice limited to
prosthodontics and dental implant treatment in Castellon in Spain.

contact
Dr Fernando Rojas-Vizcaya
Clínica Dental Fernando Rojas Vizcaya, Castellon, Spain
+34 964 257200
www.prosthodontics.es

4 2021

[38] =>

| feature

1

“It was easy to turn off the pain”—
Patient receives dental implant
under self-hypnosis
By Franziska Beier, Dental Tribune International

Physically lying in a dentist’s office but mentally
walking barefoot through a mountain river—that is how
a patient successfully received a dental implant under
self-hypnosis without any anaesthesia. The patient, who
underwent such a procedure for the first time under these
conditions, was very satisfied with the result and reported
that he felt hardly any pain during the procedure.

38

4 2021

It all started when the patient, Tomas Schröck, a hypnotherapist with his own practice in Leipzig, asked his dentist, Dr Nico Lindemann, co-owner of a dental practice
Dr Lindemann, Kurtz-Hoffmann and colleagues in Leipzig,
whether he would be willing to support him in a selfexperiment: an implant surgery performed under selfhypnosis without any analgesics or anaesthesia.

[39] =>

feature

“Even though I had been involved with hypnosis before,
owing to the patient’s desire for self-hypnosis, I would
have to hand over the responsibility of pain elimination
solely to him. On the one hand, I was optimistic that it
would work. On the other hand, I wondered whether
I could trust him enough so that the procedure could be
performed properly as planned,” Lindemann told Dental
Tribune International.
When asked about his motivation for the self-experiment,
Schröck said that he primarily wanted to raise awareness
of hypnosis and demonstrate what can be achieved.
Especially for patients afraid of dental treatments or with
drug intolerances, self-hypnosis can be a very helpful
enabler of treatment without fear or substantial pain.
He was also curious and wanted to try out on himself
what he had been teaching his patients for years.
“During self-hypnosis, one assumes both the role of
hypnotist and the person being hypnotised and gives
oneself corresponding stimuli. At first glance, this may
seem contradictory. However, once one understands how
hypnosis works, it becomes clearer,” Schröck explained.
It is assumed that everyone experiences trance states
several times a day, often without realising it. Schröck
gave the example of monotonous car journeys, during
which the mind drifts off into everyday thoughts and the
journey thus quickly passes. The same applies to hobbies, where time flies by. These moments, in which much
occurs automatically via the subconscious, are everyday
trances. This ability can be used for self-hypnosis. Individually selected memories or images are trained until

2
Fig. 1: Dr Nico Lindemann operating on Tomas Schröck, who was under self-hypnosis. Fig. 2: Tomas Schröck started practising his self-hypnosis technique
several times a day six weeks before the operation. (All images: © Tomas Schröck)

4 2021

[40] =>

| feature

3
Fig. 3: Before the operation, Tomas Schröck tested his pain sensation with the help of a vascular clamp.

they function largely automatically and only a few stimuli
from the consciousness are necessary.

tive pain tend to be mutually exclusive in my world,” he
explained.

For his procedure, Schröck employed a memory of
walking barefoot through an ice-cold mountain lake.
“I chose this memory for two reasons. The feet are
physically furthest away from the mouth and thus from
the site of surgery, and I associate a strong feeling of
euphoria with this memory. Euphoria and fear or nega-

He continued: “The art of self-hypnosis is to consciously
self-regulate oneself on one level in order to have unconscious experiences on another level. That means you
are not switched off or entirely passive in self-hypnosis.
As soon as I became too aware of what was happening in my mouth, I directed my attention back to my

4
Fig. 4: A single implant was placed in the mandible.

40

4 2021

[41] =>

feature

5
Fig. 5: The team paid close attention to the patient’s body signals during the operation.

resource place in the mountain stream.” For the most
part, Schröck only felt greatly diminished pain during
the operation.

In retrospect, I was even a little surprised at how quickly
it went, and how easy it was to turn off the pain,” Schröck
explained.

Keeping an eye on bleeding behaviour
and hand signals

He failed only to control the bleeding to a level less
than one would expect without anaesthesia. “There
are enough studies and case vignettes in which sim-

“The team was slightly nervous before the operation,”
Lindemann said. All eventualities during the procedure—for example, what would happen if the patient did
experience severe pain—were considered by the dental
team in advance, so the nervousness quickly dissipated
once the operation had begun. When asked to what
extent the team supported the patient during the procedure, Lindemann replied: “We created a very calm and
relaxed environment. In addition, we agreed on signals
that the patient should give us in case he felt pain or he
needed a break to get back into a deep enough state
of hypnosis.”
During the placement of a single implant with minor osseous augmentation in an open procedure in the mandible
with subsequent suture closure, the dental team had to
pay particular attention to the bleeding behaviour, which
differs from that under vaso-constriction.

“As soon as I became too
aware of what was happening
in my mouth, I directed
my attention back to my
resource place in the
mountain stream.”

A matter of trust

ilar things have been proved. Unfortunately, in the heat
of the moment, I forgot to focus on that too.” However,
he plans to work on that aspect in the subsequent
operation, during which the cover screw will be removed.

Although the hypnotherapist was convinced that his
self-experiment would succeed, he harboured some
doubts. In the run-up, he asked himself whether he
would really manage to concentrate for the entire duration of the surgery. “I am very satisfied with the result.

According to Lindemann, the mutual trust between the
patient and the team made it possible to fully concentrate on the operation. He concluded: “I am grateful for
my great team and for the trust that our patient placed
in me.”

4 2021

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| news

Study highlights how artificial
intelligence can be used
for detection of caries
By Brendan Day,
Dental Tribune International

A study from researchers at Charité—Universitätsmedizin Berlin has sought to measure the impact that artificial intelligence has on the ability of dentists to detect caries.

Though artificial intelligence (AI) is being increasingly
integrated into a variety of dental products and services,
the body of literature evaluating its perceived benefits is
scarce. To help rectify this, researchers from Charité—
Universitätsmedizin Berlin have recently published the
results of a randomised controlled trial they conducted.
These results demonstrate that AI can increase the
diagnostic accuracy of dentists.
Artificial intelligence technologies are steadily being adopted by dental practices aiming to digitise and streamline their workflows. From initial consultations, diagnosis

4 2021

and treatment planning through to surgical procedures
and postoperative care, a range of dental tasks can now
be augmented by the various AI solutions that have been
developed in recent years.
The performance of these AI-powered tools in medical
and dental settings, however, has rarely been tested in
clinical trials. As a result, the real impact of AI on the
decision-making and diagnostics processes of dental
practitioners remains somewhat unknown. This lack of
clarity can carry over into decisions regarding available
courses of treatment and their advantages.

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examined with the assistance of this AI tool, whereas the
other ten were not.
According to the study authors, their hypothesis—that
dentists using AI would be significantly more accurate
than those not using AI—proved to be partially correct.
In their discussion, they noted that “using AI significantly
increased dentists’ sensitivity, especially on enamel caries lesions, but did not greatly alter specificity; on more
advanced lesions AI did not impact on accuracy at all”.
They stated that it was likely the AI was more helpful in
situations where changes between images were miniscule, and that it played a lesser role when carious developments were significant and relatively easy to notice.

“Gathering evidence to better
evaluate the benefits that
AI can deliver dentists is at
the core of what we do.”—
Prof. Falk Schwendicke
“Our results demonstrate that combining the AI model
performance with human expertise can reach accuracies
which are beyond those of the AI itself (...) or the human
experts on their own,” the authors wrote.

MAD_Production/Shutterstock.com

It was also noted, however, that using the AI software led
to an increased likelihood of the dentists deciding to use
invasive restorative therapy to treat the carious lesions.
“In this sense, using an AI support to improve sensitivity
may increase the risk of type I errors and overtreatment,”
the authors remarked, adding that it could be beneficial
for the dental industry to provide evidence-backed treatment recommendations for lesions of various depths.
In their view, this would ideally lead to “better, not necessarily more invasive care”.

The research team thus commenced a trial using
dentalXrai Pro, a software program that allows dental
practitioners to analyse radiographs based on AI. The
dentalXrai Pro project was co-founded at Charité by
Prof. Falk Schwendicke, head of the Department of Oral
Diagnostics, Digital Health and Health Services Research,
and has since been spun off into a start-up simply titled
dentalXrai.

Prof. Schwendicke confirmed that further studies regarding
the dentalXrai Pro software are already being planned.

The AI-utilising software was employed by the 22 participating dentists to support their detection of caries on
20 bitewing images randomly chosen from a pool of 140.
Of the 20 images analysed by each dentist, ten were

Editorial note: The study, titled “Artificial intelligence for
caries detection: Randomized trial”, was published online
on 14 October 2021 in the Journal of Dentistry, ahead of
inclusion in the December 2021 issue.

“We are already planning on examining a different sample cohort using the updated version of this software that
will be available early next year,” he told DTI. “Gathering
evidence to better evaluate the benefits that AI can deliver
dentists is at the core of what we do,” he explained.

4 2021

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| news

Apple’s iOS 14 shakes up
digital dental brands
Jeremy Booth, Dental Tribune International
In the past, key steps in maintaining one’s privacy might
have entailed drawing the curtains after dark, planting a
hedge or shredding documents that contained personal
information. Nowadays, in a world increasingly ruled by
digital data, privacy begins with not opting in. Privacy
changes in the 14th major release of Apple Inc.’s mobile
operating system, iOS, have made it more difficult for
companies to track users’ virtual activities and caused
headaches for marketing departments—including those
at leading digital dental brands.
Apple’s iOS 14 has significantly raised the bar for Internetbrowsing privacy. The tech giant’s new application
tracking transparency (ATT) measures were launched
with iOS update 14.5 and went live in April this year.
Crucially, users are now required to actively opt in in order
to share their device’s identifier for advertisers (IDFA)—
a random identifier that Apple assigns to its products—
with the websites and apps that they use. Before the
update, users were required to actively opt out. Apple
has effectively closed the faucet that allowed user-related
data to flow freely to those who sold adverts online.

4 2021

The changes have hammered social media platforms such
as Facebook (which commissioned academic research
that found that they represented an “anti-competitive
strategy disguised as a privacy-protecting measure”)
and resulted in challenges for the scores of companies
that rely heavily on online advertising to inform consumers about their products, including digital dental brands.
But are Internet users opting in?
This flow of data from IDFAs was sizable—picture N
iagara
Falls—and extremely lucrative for all parties, bar those to
whom the data pertained. This fact was not lost on users,
if current opt-in rates are anything to go by.
US-based mobile apps analytics company Flurry surveyed
user privacy choices from two billion mobile devices and
found that users opted out in 96% of cases and that just
a quarter of users had agreed when presented with an
ATT opt-in prompt. The worldwide opt-in rate was 25%
and the US rate was 17%, according to Flurry, whose
data related to the period between April and August this
year. When the data was published, around half of users

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had either not been exposed to the prompt or deactivated
such prompts in their device settings, and Flurry estimated that the ultimate tally of opt ins would be around
21%—a number “too small to support robust u
ser-level
targeting and attribution”.

Commenting on the “iOS effect”, Katzman highlighted
that changes in the conversion funnel (digital lead tools
that result in sales) required a re-optimisation and retargeting “because you really can’t follow these people
around the Internet”.

Flurry wrote that it was time to move forward without
IDFAs and proclaimed the time of death of the individual-
level identifier as August 2021.

Kyle Wailes, SDC’s chief financial officer at the time, commented in a media release that, together with pandemic
headwinds, the “Apple privacy changes earlier this year
have presented significant challenges to digitally native
brands such as SmileDirectClub”.

Digital-native dental brands forced
to pivot on the back foot
Digital dental brands are proliferating, and many of them
reach consumers in the same way that their treatment
does: largely via virtual means. This is particularly the
case for companies that offer partially or primarily remote
treatments, such as clear aligner therapy, and the CEO
of Align Technology, Joseph M. Hogan, confirmed that
the privacy changes had been felt by the company.
He told analysts in late October that the company had
registered some impact from iOS 14; however, he played
down the significance of the privacy changes for the
company’s brand marketing. “The thing is, there’s a lot
of other media you can pivot to in order to find those patients,” he said. Hogan confirmed that Align had needed
to adjust its marketing strategy, but suggested that the
changes may result in lasting impacts. “I wouldn’t discount [the impact of the changes] in any way, in the sense
of that change being material in some sense in the near
future.”
David Katzman, chairman and CEO of remote clear
aligner treatment provider SmileDirectClub (SDC), was
more candid. In early November, he reminded analysts
that SDC had called out the privacy changes as representing a problem for digital-native brands.
“In the past three months, there have been no fewer than
20 companies noting this change as a substantial headwind in (the second and third quarters),” Katzman said.
“Facebook and Snapchat’s earnings last month reinforced just how material this change has been to their
business. Similar to all of these companies, the privacy
changes required us to pivot quickly to different lead
strategies,” he explained.
A large portion of SDC’s marketing budget was previously spent on advertising on Facebook’s platforms, and
this had a high rate of conversion into sales. Now, the
company is spending at least part of those funds elsewhere. “We’ve not only been shifting marketing spend
away from these platforms to more TV, but we’ve also
changed our lead strategy,” Katzman explained. “We are
now focused on higher funnel leads to more efficiently
and effectively drive long-term growth.”

“Privacy changes in the
14th major release of Apple Inc.’s
mobile operating system, iOS,
have made it more difficult
for companies to track users’
virtual activities...”
A step forward for big tech
and a challenge for marketers
The privacy changes that came with iOS 14 represent
a positive step for the tech industry, according to
Nishat Mehta, chief product officer at media analytics
and marketing research company IRI.
Writing in Forbes in November, Mehta said that raising the
bar for data collection had provided marketers with a new
challenge. He wrote: “The new privacy rules, by design,
reduce the amount of information marketers can collect
from third-party sources and thereby create new hurdles
for marketers who have relied on that data to reach target
audiences with relevant, effective marketing messages.”
Providing advice to marketers, Mehta said that first-party
customer databases have been undervalued and could
be further exploited. He explained that companies could
further invest in existing customer relationship management systems, e-mail subscription lists and followers on
social media. Engaging with social media influencers and
working together with retail and distribution partners are
further strategies that he recommended to help marketers
adapt to the new data landscape.
“Finally, an efficient marketing strategy—in today’s
post-iOS 14 landscape and beyond—includes constant,
accurate measurement so marketers can validate which
marketing investments are driving the strongest results,”
Mehta wrote.

4 2021

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| industry

With 3Shape Unite, dental professionals have the opportunity to harness the power of an app store and connect easily with world-leading companies and laboratories.

3Shape Unite—the platform connecting
the digital dots in dental clinics
By Claudia Duschek, Dental Tribune International
In October, 3Shape launched 3Shape Unite. The new open
platform brings world-leading dental companies, solutions
and laboratories together and will allow dental professionals
to manage all their cases seamlessly and efficiently.
During the launch event, Dr Rune Fisker, senior vice
president for product strategy at 3Shape, introduced
the new platform, describing it as the greatest effort and
investment in the company’s history. More than 100 people

have been working on this project for the past three years.
He explained that 3Shape had recognised that the main
problem with digitised dentistry was that, although a wide
range of tools were available, these remained rather isolated
in use. 3Shape Unite aims to provide an unprecedented
connection of digital tools, offering users freedom of
choice, unrestricted access to their preferred products and the flexibility to easily switch between different
brands’ and manufacturers’ solutions.

The main benefit of the new 3Shape Unite platform is its simplicity, providing an intuitive customer experience. (All images: © 3Shape)

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4 2021

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industry

“For dentists, 3Shape Unite simply and openly connects them to the right dental partners and makes digital dentistry easy, end to end,” said Jakob Just-Bomholt, CEO of 3Shape.

On the new platform, 3Shape CEO Jakob Just-Bomholt
said: “3Shape Unite is a tremendous launch for 3Shape!
It brings to life our historic vision of giving dentists freedom and open options. It is digital dentistry united under
one platform. From labs and treatment solution partners
to managing patient care, 3Shape Unite creates workflows that just flow.”

Leading the way for the future
of the dental clinic
Aiming at making digital dentistry more straightforward
and accessible, 3Shape opted for an app-based approach in the development of Unite—very similar to
modern smartphones. Fully integrated with the awardwinning TRIOS intra-oral scanner, the Unite platform and
apps deliver an intuitive user interface, including a simplified laboratory order form with built-in chat and bestin-class workflow between the dental practice and over
1,000 laboratories; integrations with more than 50 clear
aligner providers and patient management systems as
the key cornerstone of Unite; and easy access to patient
data and images.
“3Shape Unite is going to be the go-to dental platform,
enabling treatment planning and execution in just a few
clicks,” Just-Bomholt added. In fact, Unite provides the
interface for the entire treatment—from the initial scan
to completion. With absolute integration between TRIOS
and all partner apps, there is no need to switch platforms
or to save or transfer files during the workflow. Included
free of charge with every TRIOS, the Unite platform gives
practitioners the freedom to effortlessly manage and
expand their digital dentistry offering via an ever-growing
built-in app library, Unite Store.
For dental laboratories, 3Shape Unite provides a platform
and directory for them to become more visible to dental
practices, market their services with a profile they create

and take advantage of an optimised order workflow with
practices.
In order to provide a truly open and united platform,
3Shape has joined forces with some of the leading companies in the dental industry: Henry Schein, Ivoclar Vivadent
and the Straumann Group. The partnership enables
3Shape Unite users to directly access optimised, integrated digital solutions from these founding partners.
Guillaume Daniellot, CEO of the Straumann Group, said
that the rationale behind the company’s involvement in this
project is to provide “frictionless access to Straumann
solutions and services—be it our ClearCorrect clear
aligner treatment, implant surgical planning or an overall
Smile in a Box treatment, or any other prosthetic solution
from the Straumann Group”.
Diego Gabathuler, CEO of Ivoclar Vivadent, which has
collaborated with 3Shape for ten years already, added
that “the fit with Unite is perfect, as we can integrate our
smart systems and workflows in a new platform where
customers can access everything in one place”.

Global launch in 2021
The platform will be available globally in mid-December
2021, Fisker announced.
Dental professionals can access the 3Shape Unite platform from their PCs and TRIOS MOVE via a software
update that requires no additional hardware. In the long
run, Unite will replace other 3Shape platforms, such as
3Shape Communicate and Dental Desktop.

More information about and an interactive demonstration
of 3Shape Unite are available at www.3shape.com.

4 2021

[48] =>

| industry

1
Fig. 1: MODJAW strongly believes that using 4D data from the Tech in Motion device brings more than just beautiful smiles. It brings, first and foremost, healthy
and long-lasting ones. (All images: © MODJAW)

MODJAW: A next-generation
digital dentistry solution
By MODJAW, France
4D dentistry is driven by the idea that both static and
dynamic parameters should be considered in order
to enable complete diagnostics and bespoke restorations. Having a 4D dentistry concept, French company
MODJAW introduces a new way of entering patients’
reality using true jaw motion and dynamic occlusion, in
addition to 3D modelling.
MODJAW started to emerge on the digital dentistry scene
in March 2019, when the company introduced a new
digital dentistry solution for real-time jaw motion called
MODJAW Tech in Motion.

How does it work?
Inspired by the animated movie industry, the device allows dentists and orthodontists to record the real-time
jaw motion of their patients and to create their dynamic
digital twin. MODJAW’s unique platform can aggregate
2

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industry

all patient data, including 3D models, 4D movements,
and CBCT and facial scans. It then creates a digital
“clone” or exact virtual replica of the patient. This solution is the realisation of the company’s strong belief that
both static and dynamic data should be considered when
treating a patient.

For diagnostics...
Using MODJAW and the recommended software, dental professionals can evaluate patients clearly and accurately during the diagnosis stage. Recording an animated
dental arch in real time provides a broad and objective
view of the patient’s problem. Within a few minutes of
recording, all static and dynamic parameters are obtained, and occlusal guides, unilateral occlusal contact,
tooth wear, malocclusion or temporomandibular joint
disturbances can be detected.

...and building treatment plans
The data provided by MODJAW is used in the treatment
phase to completely personalise the dental treatment.
Considering the complex reality of every patient in
motion is not a luxury, it is a must-have in order to
be able to offer fully fitting treatments. It covers everything in simple to complex cases, including adhesive
and removable prostheses, implants, and orthodontics.

|

One of its flagship features is that users can select a
new vertical dimension from a record and apply previously recorded kinematics with just a few clicks. This is
especially useful in eroded situations where space for
the restoration is required.
The solution is open and designed to make data accessible to all dental technicians. All static data is provided
in STL file format, so it is compatible with all CAD software. For example, plans, arches in specific locations,
hinge axes and constellations can all be transferred
directly. The motion data from MODJAW in an XML
file format is easily integrated with exocad software.
The company is working on integration with other
CAD/CAM software such as the products available
from 3Shape.
Also, in light of the ongoing COVID-19 crisis, it is vital
to reduce patient visits to the dental office to the absolute minimum. In other words, efficiency needs to be
increased, and absolutely all patient data must be fetched
at the first visit, including mandibular movements. Then
any dentist beginning a treatment will be able to predict
the outcome.

www.modjaw.com

3
Figs. 2 & 3: With the 4D dentistry concept, MODJAW introduces a new way of entering your patients’ reality using true jaw motion and dynamic occlusion,
in addition to 3D modelling.

4 2021

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| industry

Ceramill Direct Restoration Solution (DRS). The new digital workflow from Amann Girrbach has been designed to enable interdisciplinary future-oriented
collaboration and streamlined production processes that enable same-day dentistry. (All images: © Amann Girrbach)

Extension of Ceramill CAD/CAM
workflow—digital solutions lead
the way into the dental practice
By Amann Girrbach, Austria
With its Ceramill Direct Restoration Solution (DRS),
Amann Girrbach has extended its integrated digital workflow to the dentist and thus closed the communication
gap that existed between the dental practice and the laboratory. The new digital workflow from Amann Girrbach
has been designed to enable interdisciplinary futureoriented collaboration and streamlined production processes that enable same-day dentistry.
In this process, both partners contribute their core competencies in order to provide patients with definitive and functional prostheses in a more timely and less complicated way.
The delivery of smaller units is possible on the same day,
depending on the local distance between the two partners.
Depending on the type of collaboration that is desired,
three team workflows are available in combination with
the corresponding Ceramill DRS Kits. In each case, the
central basis of these workflows is AG.Live, a new digital
platform that provides the infrastructure and patient case
management procedures to support a level of consistency

4 2021

and efficiency that was previously unattainable. As such,
AG.Live takes communication and collaboration between
the practice and the laboratory to an entirely new level.

Virtual platform AG.Live creates freedom,
more efficient processes
and greater customer proximity
With AG.Live, Amann Girrbach has started the largest
digitisation offensive in the company’s history. This webbased portal for collaboration between laboratories and
dentists offers comprehensive digital services at all levels. For example, AG.Live is a central tool for digital case
management, networking, infrastructure, material management and support services. It is also a knowledge
database that will gradually replace the company’s previous C3 customer portal.
On the one hand, the platform networks machines and
materials in the laboratory, thereby simplifying processes
and increasing quality and reproducibility. On the other

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hand, the greatest advancement is that AG.Live connects
the growing global network of dental professionals who
are operating digitally. This bridges the interdisciplinary
gap between dentists and dental technicians and facilitates future-oriented cooperation. Furthermore, within
this network of optimised and new partnerships, participants can focus on their strengths and better position
themselves on the market.

Extending the digital Ceramill CAD/CAM
workflow to the dentist
The Ceramill DRS Connection Kit is the basic entry-level
option, with which dentists and laboratories can already take full advantage of digitisation. It consists of a
Ceramill Map DRS intra-oral scanner, the associated
scan software and the connection to AG.Live. Any order
data, including all the required information, can therefore
be shared with the laboratory seamlessly and in real time
via AG.Live. This eliminates the need for handwritten job
sheets and conventional impressions. All that is necessary is the physical delivery of the restoration to the dental practice, and this is possible on the same day in cases
of simple restorations. Such timely delivery can lead to
a better dental experience for the patient and could ultimately attract new patients to the practice and generate
more orders for the laboratory.
If the preferred material is zirconia, the High-Speed
Zirconia Kit, consisting of Zolid DRS zirconia and a corresponding Ceramill Therm DRS sintering furnace, can
optimally support the laboratory in fabricating straightforward zirconia restorations on the same day.

In an additional step—which can provide patients with their
prostheses even faster—the system in the dental practice
can be upgraded at any time with the Ceramill DRS Production Kit. This allows simple restorations to be fabricated in the
practice and placed in the patient’s mouth in a single session.
All Ceramill DRS Kits are currently available for preordering within Germany, and the High-Speed Zirconia Kit
is already available to laboratories. Early bird DRS users
benefit from particularly close support from the DRS
specialists at Amann Girrbach. For further information
and to pre-order, visit www.ceramill-drs.com.

Free online presentation about the
innovative Ceramill DRS
In this online presentation, Amann Girrbach explains why it
places the dental laboratory at the centre of the prosthetic
workflow and ensures the highest possible quality and
patient satisfaction through close integration and digital
exchange with the dentist. Even with the basic version, the
Ceramill DRS Connection Kit and the link to the AG.Live
digital platform, the practice and laboratory can connect
in a unique manner and take full advantage of the benefits of digitisation. The presentation also explains interdisciplinary collaboration for restorations in a single session
or on the same day, using the upgrades to the Ceramill
DRS Production Kit and the DRS High-Speed Zirconia Kit.
The full presentation can be accessed, free of charge,
in various languages from Amann Grirrbach website,
https://academy.amanngirrbach.com/en/webinar/ceramilldrsthe-roi-of-digital-transformation/3606.

The Ceramill Direct Restoration Solution enables dental practitioners and technicians to work as an interdisciplinary and future-oriented team and makes
same-day prosthesis fabrication possible.

4 2021

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| industry

Clinical advantages of KATANA
Zirconia YML as related to an
external organisation’s test results
By Kuraray Noritake Dental, Japan

1

Introduction
Kuraray Noritake Dental is a manufacturer with a long
history and wealth of experience in the field of producing dental materials, including bonding agents,
cements and ceramics. The all-ceramic restorations
market, including that for zirconia products, has been
growing rapidly around the world since the beginning
of the 2000s. In response to this trend, we have established an integrated production system that can be
used to manufacture a wide range of dental zirconia
products in-house, from powder to discs.
When we develop new zirconia products, we carefully analyse the characteristics of dental zirconia that

52

4 2021

are actually demanded by users in the clinical setting,
and based on the results of our analysis, we craft new
products with these clinically needed characteristics.
In our first efforts, we focused on developing a dental zirconia that would have a natural tooth colour after sintering. We launched KATANA Zirconia, our first
dental zirconia product to span all the VITA classical
A1–D4 shades, in 2007, and in 2013, using our original
manufacturing method, we launched KATANA Zirconia
Multi Layered, a multilayered zirconia product that
produces smooth colour gradations like those of natural teeth, avoiding sharp colour transitions between
layers. Then, in 2015, we released KATANA Zirconia
Ultra Translucent Multi Layered and Super Translucent
Multi Layered (STML). We are one of the pioneering

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manufacturers of dental zirconia, and as such, we
are committed to continuing to deliver excellent highly
aesthetic dental zirconia products to the dental market
now and into the future.
Recent advancements in dental technology have made
it possible to use zirconia as a prosthetic material
across a wide variety of dental applications, from large
implants, where great mechanical strength is required,
to treatment in the anterior region, where aesthetics
are of the utmost importance. The material characteristics needed, however, differ from one case to another.
Many dental zirconia suppliers respond to these therapeutic requirements by offering various types of dental
zirconia that feature different levels of mechanical and
aesthetic properties. This requires dentists and dental technicians in clinical settings to select, from a wide
range, the type of zirconia that will be the most appropriate for treating the specific case. This means that it
is necessary for each clinic to keep in stock many types
of dental zirconia materials with different characteristics
in order to meet the requirements of the wide variety of
possible case parameters.
Several dental material manufacturers have responded
to these circumstances by offering dental zirconia disc
products that have combinations of multiple layers
with different levels of translucency and mechanical
strength. They claim that these products make materials available that can be used to fabricate a wide
range of restorations. These products, however, can
have serious shortcomings. Some require laborious
manufacturing work, tailored to the fabrication of
the particular restoration. Others do not include the
required high-strength zirconia layer that makes it possible to fabricate a bridge. These products, therefore,
may provide no assurance of providing the mechanical
strength recommended by the International Organization for Standardization for the manufacture of certain
restorations.
A market need arose for dental zirconia products that
could be used easily and safely for the fabrication of
a wide range of restorations. In response to this need,
at Kuraray Noritake Dental, we have developed and
released KATANA Zirconia Yttria Multi Layered (YML),
a new type of dental zirconia material that provides
the blend of excellent performance variables of the
KATANA Zirconia multilayered series (Fig. 1). With its
well-balanced performance, YML is indicated for the
fabrication of a wide range of restorations, from large
ones requiring great mechanical strength to anterior
crowns that require a high level of translucency. In this
article, we will describe YML’s features and the technology behind it. We will also present comparative data
on YML and a similar competing product collected
by Dr Masanao Inokoshi, an assistant professor in the

Department of Gerodontology and Oral Rehabilitation
at Tokyo Medical and Dental University’s Graduate
School of Medical and Dental Sciences in Japan.

Features of this product
and the technology behind it
Short sintering time
YML can be baked satisfactorily in a short period,
thanks to our innovative technology. In addition to
the conventional sintering schedule of about 7 hours
and even the 90-minute schedule, we have also made
it possible to shorten the sintering time further, to a
remarkable 54 minutes. (The material is removed
from the furnace at 800 °C and can be used for up to
three-unit bridges.)

“The enamel layer is
composed of the same
zirconia material as KATANA
Zirconia STML, which is
highly acclaimed for its
excellent translucency.”
Excellent translucency and great mechanical strength
A YML disc consists of four layers: one enamel layer and
three body layers. The enamel layer (35% of the total
thickness: 750 MPa) is composed of the same zirconia
material as KATANA Zirconia STML, which is highly
acclaimed for its excellent translucency. The three
body layers (1,000 MPa, 1,100 MPa and 1,100 MPa—
three-point bending test according to ISO 6872:2015)
that lie below the enamel layer are made from a new
type of zirconia material. The first body layer is an intermediate layer that has the desirable translucence of
STML. It includes, however, a well-balanced combination of translucency and mechanical strength suitable
for the treatment of cases which demand these notable characteristics, such as those requiring bridges.
The second and third body layers provide the high level of
mechanical strength of KATANA Zirconia High Translucent
Multi Layered, suitable for the fabrication of large restorations, along with an improved level of translucency.
With its well-balanced combination of translucency
and mechanical properties, provided by taking advantage of multiple zirconia materials, YML is a product
that meets the demand for highly aesthetic products.
It is suitable for the fabrication of the whole range of
restorations, from single crowns to bridges.

4 2021

[54] =>

| industry
Multilayer gradation
Kuraray Noritake Dental released our first multilayered
zirconia product in 2013. Subsequently, the company
launched zirconia products very much appreciated
for their smooth colour gradation, much like that of
natural teeth. We use our own innovative pressing
method to manufacture YML. It smooths the change
of colours between layers, which provides the desirable feature of a very smooth and natural colour
transition.

sintering shrinkage of zirconia materials requires delicate
control, it is not difficult to understand that shrinkage
control is even more difficult when different zirconia
materials are combined into one disc. If the shrinkage
rates of the layers of a zirconia disc differ, the restoration
will necessarily be deformed during shrinkage. Many
users voiced particular concerns about dimensional
stability when they were asked about using zirconia

Reduced deformation after sintering
In general, dental zirconia shrinks during the sintering
process by about 20% in 2D (50% in volume). If shrinkage
cannot be controlled adequately, it becomes difficult
to fabricate restorations that fit precisely on to complicated abutments or into margin lines. The shrinkage of
zirconia materials varies subtly from one production lot
to another, even when the same raw material is used.
We appropriate raw material control, such as raw material crushing, using different sintering shrinkage rates
for different production lots. In view of the fact that the

“When we developed YML,
Kuraray Noritake Dental kept
in mind that the fabrication
guide must be practical,
as well as easy.”
discs (which require high precision) for the fabrication
of implants. Kuraray Noritake Dental has an integrated
production system that is used to manufacture zirconia
products in-house, from the design and manufacture
of zirconia powder as a raw material to final products,
thus making it possible for us to control the shrinkage
rate of zirconia with great accuracy. For this reason, we
are able to use zirconia materials with stably controlled
shrinkage rates to manufacture YML, even though it
consists of multilayers made up of different zirconia
materials. This minimises deformation of restorations
after shrinkage.

Results of a verification of the
physical properties of YML and a review
of its clinical advantages

To verify the physical properties of YML, the translucence,
mechanical strength and crystalline structure of YML
and IPS e.max ZirCAD Prime (Ivoclar Vivadent) were
analysed and compared with one another at the Tokyo
Medical and Dental University. This paper focuses
especially on data on the translucency and mechanical
strength, among the physical properties examined, of
each product.
Data collected at Kuraray Noritake Dental
on the relative translucency of YML and Prime
Total light transmittance (illuminant: D65; test specimens
with a diameter of 30 mm and a thickness of 1 mm)
of raw material in YML’s enamel layer (no colouring
agent) was 49%, and the same was found for Prime’s
enamel layer.

4 2021

[55] =>

industry

Regarding the layers beneath the enamel, such as
the transition and body layers, YML was found to be
more translucent than Prime. It can be concluded that
YML is sufficiently translucent even beneath the layers
beneath the enamel layer. This makes it possible to
fabricate prostheses with natural tooth colours when
used in combination with an enamel layer that is suitably
adjusted to provide the optimum colour.
The translucency of Prime was significantly higher
than that of YML when a comparison was made at the
enamel layer (Fig. 2). This is probably because Prime
contains almost no pigment in the enamel layer, in order
to bring out the brightness (whiteness) of the zirconia
itself. By contrast, YML contains some pigment so that
the product can deliver an optimal level of brightness
in the clinical setting. It thus seems that the addition of
pigments leads to a difference in translucency between
YML and Prime.
The enamel layer of YML had a significantly greater
bending strength than that of Prime (Fig. 3). However,
when the bending strength of the body layers was
compared, Prime’s body layer was the strongest. The
three YML body layers had bending strength values of
more than 850 MPa (four-point bending test according
to ISO 6872:2015), and there were no significant differences in bending strength between Prime’s body layer
and YML’s three body layers.
The results revealed that, while YML has small differences in bending strength among the enamel layer
and the three body layers, Prime has clearly different
levels of bending strength between the body layer and
the other two layers. YML’s body layers (including the
intermediate layer) have such a high level of mechanical strength that it is quite feasible to use it to fabricate
highly reliable prostheses.

Layered design concept
The guide for fabricating large restorations using
YML states the requirement that at least 50% of the
connector cross section should be positioned in the
lower part of the disc (Fig. 4). This means that generally
you can meet the requirement of the guide by positioning the restoration at the centre of the disc’s four layers.
In fabricating restorations using zirconia discs available in the market, it may sometimes be complicated
to position the restoration as specified in the guide or
to position the piece as specified by the guide, making
it difficult to fabricate a highly aesthetic restoration that
makes use of the enamel layer’s better translucency.
When we developed YML, Kuraray Noritake Dental
kept in mind that the fabrication guide must be practical, as well as easy. That is why YML was designed
with a sufficiently thick enamel layer that permits a high
level of aesthetics for any type of restoration that might
be fabricated.

Conclusion
KATANA Zirconia YML is our new zirconia disc product,
and it features a well-balanced combination of mechanical strength and aesthetics. It has been developed
using our innovative zirconia manufacturing technology,
as well as by bringing together the essence of the development and production technology of multilayered zirconia discs. We hope that YML will be one of the options
of choice for zirconia materials available to dentists and
dental technicians who need to use multiple zirconia
materials for various applications or who have concerns
about the mechanical strength and aesthetic properties
of the zirconia materials they are currently using.
www.kuraraynoritake.eu

4 2021

[56] =>

| meetings

DS World 2021 had something to offer for everyone interested in endodontics, implantology and sustainable dentistry.

DS World 2021:
Latest innovations, product launches
and partnership announcements
By Iveta Ramonaite, Dental Tribune International
From 23 to 25 September, dental professionals had
the opportunity to immerse themselves in the world of
dental technology and innovation, all thanks to this year’s
Dentsply Sirona (DS) World, which took place in Las Vegas.
As expected, the event attracted thousands of participants, both in person and online, and featured major
announcements, product releases, informative continuing
education sessions and innovative technologies.

and included Don Casey, the CEO of Dentsply Sirona,
Dr Terri Dolan, vice president and chief clinical officer at the
company, as well as key dental experts Drs Dan Butterman,
John West, and Shivi Gupta. During the conference,
Gupta and Butterman gave presentations on the digital
restorative workflow and the digital implant workflow,
respectively, whereas West discussed new endodontic
solutions and Dolan focused on sustainability.

For the first time, visitors to DS World were able to join the
hybrid event either on-site at Caesars Forum in Las Vegas
or virtually via livestream and on demand. After each
day full of educational opportunities, the attendees were
also able to take some time out and enjoy musical and
comedy performances.

Discussing this year’s developments, Casey reminded
the attendees that Dentsply Sirona is the first digitally
native implant company, and that “the future is digital
for Dentsply Sirona”. He commented that the company
has had many software enhancements throughout the
year and is “on a new products’ roll”, in line with its mission
to transform dentistry and empower dental professionals
by offering innovative dental solutions.

The event reached 7,000 registered participants in total.
The attendees were offered over 150 hours of clinical
education, and the topics were presented by more than
100 expert speakers from all around the globe. On Friday,
24 September, participants were able to join the DS World
press conference, which was streamed live from Las Vegas

56

4 2021

Key highlights
During the event, the company announced the launch of
DS PrimeTaper, an advanced implant system; ProTaper Ultimate

[57] =>

endodontic file, the latest addition to the ProTaper family;
and a restage of the company’s implant business, which will
now include three signature workflows. Additionally, the company released its sustainability report and set environmental
goals for the upcoming years. Sustainability was a major
keyword at the event, and the company also announced a
new hub dedicated to sustainability on its website.
“The world is facing major environmental, social and economic challenges, and all sectors need to step up and
play their part,” Casey said in a press release. “As a global
leader in dentistry, Dentsply Sirona has a responsibility to
go above and beyond to create a more sustainable future—
empowering not only our employees, but our customers,
partners and peers to take action with us,” he continued.
Another major announcement was about a five-year partnership agreement with Smile Train, a non-profit organisation and charity that provides corrective surgery for
children with cleft lips and palates. The partnership is
planned to improve oral health globally and to help children and families affected by cleft lips and palates build
a brighter future. A $5 million (€4.3 million) donation to the
organisation was also announced.
“Our partnership with Smile Train will help children around
the world gain access to cleft treatment and offer them the
chance to live a happy and healthy life. By also focusing

World press conference speakers. From left: Don Casey, Dr Dan Butterman,
Dr John West, Dr Shivi Gupta, Dr Terri Dolan and Marion Par-Weixlberger.

on global treatment standards and best practices, donating innovative technology, and supporting the training and
development of local healthcare professionals, the partnership will have an empowering impact on communities
and will provide access to the best possible cleft care,
for years to come,” Jorge Gomez, chief financial officer
and head of Dentsply Sirona’s sustainability program
“Beyond”, explained in a press release.
Needless to say, the event organisers complied with
applicable state and local mandates as well as with the
requirements of the venues, and the attendees were
required to wear face masks indoors at all times.

4 2021

[58] =>

| meetings

Registration for 2022
Midwinter Meeting is now open
By Dental Tribune International
Like myriad other events, the 156th Midwinter Meeting
was a virtual one. However, the Chicago Dental Society
(CDS) has recently announced that its 157th Midwinter
Meeting will return to an in-person format and that reg-

istration for the February meeting is now open. The renowned dental meeting will be held at McCormick Place
West in Chicago on 24–26 February.
“The Midwinter Meeting has a rich tradition of debuting
the latest scientific information and cutting-edge products to dental professionals for more than 156 years,”
CDS President-elect Dr Thomas Schneider said in a
press release. “After more than a year of virtual meetings,
events and social gatherings, we’re very excited to return
to the traditional in-person format for the 2022 Midwinter
Meeting, ‘A Dental Tradition.’ We deeply missed the
camaraderie and reconnection with old friends and colleagues and can’t wait to be back in person at McCormick
Place,” he continued.
The Midwinter Meeting is renowned for attracting the
premier speakers in dentistry from across the country.

[59] =>

meetings

“The February 2022 event
will offer attendees access
to over 250 courses.”
So far, more than 350 vendors have booked their
places for next year, including many first-time exhibitors.
The exhibition floor, which spans more than 270,000
square feet, will feature the latest products in dental innovation, and the attendees will be able to engage in special events that will provide fun networking experiences.
These include the new Brews & Bargains happy hour and
receptions for new dentists and dental students.
“CDS dentists are essential health care workers, and
as such, we’re on the frontlines battling infection daily,
long before the COVID-19 pandemic and long after,”
Dr Schneider noted. “Much like our commitment to our
patients, the health and safety of attendees, vendors
and staff is our top priority,” he added.
Owing to the ongoing COVID-19 pandemic, the 2022
Midwinter Meeting will feature enhanced health and
safety measures. According to CDS, the organization is
working closely with McCormick Place and will follow all
federal, state and local health and safety requirements in
effect in February.

The February 2022 event will offer attendees access
to over 250 continuing education-accredited courses
taught by renowned clinicians and leaders in dental
education, and dentists and their teams will have the
opportunity to benefit from the latest practice management solutions and evidence-based clinical knowledge.
According to CDS, courses can be purchased a la carte,
or for CDS members and their dental teams, as a lecture
package for $270 (€233) per person.

Finally, CDS strongly encourages all attendees to be fully
vaccinated before attending the Midwinter Meeting and
noted that everyone attending the event will be required to
wear a mask, regardless of vaccination status. Additionally,
attendees will be required to sign a COVID-19 waiver.
More information about the 2022 Midwinter Meeting can
be found online: www.cds.org/midwinter-meeting.

4 2021

[60] =>

| meetings

International events

1–3 February 2022
Dubai, UAE
https://aeedc.com

The British Dental C
 onference &
Dentistry Show

24–26 February 2022
Chicago, USA
www.cds.org/midwinter-meeting

13–14 May 2022
Birmingham, UK
https://birmingham.dentistryshow.co.uk

ICOI—
Winter Implant Symposium

EAS—
The 2nd Spring Meeting

17–19 March 2022
Atlanta, USA
www.icoi.org/events

May 2022
Oporto, Portugal
www.eas-aligners.com

BDIA—Dental Showcase 2022

17th IDEX Istanbul 2022

25–26 March 2022
London, UK
www.dentalshowcase.com

26–29 May 2022
Istanbul, Turkey
https://cnridex.com

16–17 April 2022
Tokyo, Japan
https://www.gcdental.co.jp/
100thsymposium

4 2021

25–28 April 2022
Moscow, Russia
https://en.dental-expo.com/
dental-salon-en

157th Chicago Dental Society
Midwinter Meeting

The 5th International Dental
Symposium

60

Dental Salon 2022

AAID—
Annual Conference 2022
21–24 September 2022
Dallas, USA
www.aaid.com

© 06photo/Shutterstock.com

AEEDC—International
Dental Conference
and Arab Dental Exhibition

[61] =>

|
© 32 pixels/Shutterstock.com

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4 2021

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[62] =>

| international imprint

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4 2021

[63] =>

3Shape TRIOS

A digital
experience that
feels just right.

“

For me, going
digital has been
a magical ride.
Dentist, Hellerup, Denmark

Your digital experience should make you smile.
So we’ve partnered with more than 20,000 labs and made it
easy for you to find the one you want. Just pick a lab, take an
impression, and send it off. It’s fast, easy, and hygienic.1 Plus
TRIOS® scanners fit perfectly in your hand and make scanning
a pleasure. Patients will prefer comfortable digital impressions,
too.2 And the TRIOS Care service agreement for this proven
product includes unlimited technical support, and much more.
Explore more at 3Shape.com

1. A Look at Infection Prevention in Dental Settings (Barenghil, et al. 2019).
2. 80% of studies (4 of 5) show patients choose digital impressions over conventional (Chandran et al. 2019).

[64] =>

Dentsply Sirona does not waive any right to its trademarks by not using the symbols ® or ™. 32671944-USX-2106 © 2021 Dentsply Sirona. All rights reserved

Digital Implant Workflow

Streamlined collaboration
for your treatment team
From data capturing, planning and guided surgery to the final restorative solutions,
with the Digital Implant Workflow from Dentsply Sirona you have all the support you need to
save time, deliver predictable results and provide your patients with the best possible care.
www.dentsplysirona.com

Follow Dentsply Sirona

dentsplysirona.com

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[cover] => digital international No. 4, 2021

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Table of contents

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