The International Journal of Dental Technology · 2020-01-14 · On top of that, people will go to...

The International Journal of Dental Technology

From head to toeSuccessful and affordable approach to a fixed full-arch implant caseWolfgang Sommer, Master Dental Technician

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Heraeus Kulzer Nordic ABFlorettgatan 18254 67 HelsingborgSwedencara-service@kulzer-dental.comwww.cara-kulzer.com

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2 dental dialogue VOLUME 11 07/2010 ©

From head to toeThis article presents an approach that results in a successful fixed implant-supported restoration while keep-ing cost down to a minimum without sacrificing quality and premium aesthetics. With today’s manufacturingtechniques, dental technicians can break new ground in a way that benefits the dentist and the dentaltechnician, but above all the patient.

Wolfgang Sommer, Master Dental Technician, Mönchengladbach (Germany)

Successful and affordable approach to a fixed full-arch implant case

Category

Product-related case study

Key words

• Aesthetics• CoCr framework• Fixed restoration• Reduced-labour

implant case

Implants – pros and cons

The 50–65 age group accounts for thelargest share of implant-supported restora-tions. This is in part due to the fact thatteeth will often fail at that age and needto be replaced. In most cases, these pa-tients will have been treated with bridgesor telescope work at age 30–45. Then af-ter 10–20 years in situ, the remainingabutment teeth will often be diagnosedas not salvageable, with the patient requir-ing a complete denture. Another factor isthat many patients below the 50–65 agegroup do not have the financial means toafford implants and the correspondingrestorations. On top of that, people willgo to great lengths these days to »stayyoung« and to look vital and healthy.The demand for fixed dental restorationsis high, and most patients expect to re-ceive implants. Disillusionment often fol-lows once the patient sees the cost esti-mate. Not everyone can afford expensivedesigns with eight or more implants,bone augmentation and high-quality su-perstructures. If you reduce the numberof implants to six or even four, possible

superstructures will be removable or elsea non-segmentable bridge – with abouttwelve to fourteen units in one piece.Every dental technician with some expe-rience knows that casting such a restora-tion process is a challenge, to say the least– whether in a non-precious or high-goldalloy. In addition, patients with completedentures usually exhibit severe verticalbone loss, and the superstructures mustcompensate for this by providing a fairlybulky anatomical base. There are someways to compensate for the distortionthat large-span frameworks can be sub-ject to, but all of them – for example elec-troplated mesostructures – are labour-in-tensive and costly. Even if you do cometo terms with the problem of frameworkdistortion after firing, the result will be anexpensive design with significant outlaysfor surgical/implantation work, not tomention the cost of precious alloys.But in the age of computer-aided designand manufacturing, new avenues areopening up for us. We dental technicianstend to fear being replaced by a machineor a computer at some as yet undefinedtime in the future. While no one will be

able to moderate this fear, we must notoverlook the fact that computer-aidedmanufacturing techniques offer new op-portunities we should take advantage of.I would like to present a case where thelatest in laser-sintering technology madeit possible to realize a fixed maxillarybridge on six implants without expensiveabutments or costly precious alloys – andwith relatively little effort. At the sametime, this design sacrificed neither wear-ing comfort nor aesthetic appearance.

Implant insertion andimpression

The patient presented with hopeless max-illary crowns and bridges. All remainingteeth had to be extracted and the patientsupplied with a complete denture as an in-terim replacement. The implants wereinserted using the navigated placementtechnique with a surgical guide from theNobelGuide system (Fig. 1). After sixmonths, an open-tray impression of thesituation was taken. The dentist splintedthe impression post to achieve primary sta-bility within the impression (Fig. 2).

dd T E C H N I Q U E

VOLUME 11 07/2010 © dental dialogue 3

Fig. 3 To secure the set-up on a resin base in the mouth, it isattached to at least one implant.

Fig. 4 The aesthetic appearance is checked directly on thepatient. This also shows how much bulk must be replaced.

Aesthetic try-in

The maxillary cast was aligned in the ar-ticulator using a facebow transfer to ob-tain an exact occlusal plane for setting upthe anterior teeth. For the bite index, abase with a bite wall made of tray materialwas attached to a reworked impressionpost; its only purpose was to serve as abite index for the aesthetic try-in. Thisphase is crucial for a perfectly sized su-perstructure; it is the only way to properlyaccount for both the aesthetic and thephonetic aspects of the case. Nothing isleft to chance.

Prefabricated denture teeth are set up ona new resin base, which must be attachedto at least one implant to secure the set-up in place within the mouth (Fig. 3). Atthis point, rather than being distracted bydetails, the technician should pay atten-tion to basic aspects such as phonetics,the sagittal alignment of the teeth, themidline of the face and the height and lev-el of occlusion of the anterior teeth. Theshade and shape of the teeth are still ofno consequence at this time. A lip shield,

as often used when trying in a completedenture in order to keep an eye on thepositions of the implants, should also bedispensed with. At the aesthetic try-in,we want to – and can – show the patientwhat the treatment result could look like,so we should restrict ourselves at thisstage to what is feasible to implement inthe final restoration (Fig. 4). Otherwisewe would make life unnecessarily diffi-cult for ourselves and raise false expecta-tions in the patient.

Framework design

A bite rim based on the set-up is made onthe master cast, and the set-up is removed.This is where one becomes aware just howmuch bulk must be replaced (Fig. 5).Special auxiliary parts are needed for theresin “wax-up”. First, an I-Flex is screwedonto the implant analogues, although thissimply serves for proper orientation of theactual modelling aids (Figs. 6 and 7).

The Access Guides are placed on the I-Flex,where they can be individually aligned (upto an angle of 20 degrees). The outer di-

ameter of the modelling aids representsthe inside diameter of the future screw ac-cess hole. Based on bite rim, all modellingaids are aligned to match the aesthetic set-up (Figs. 8 and 9). Figure 9 nicely showshow the modelling aids on the I-Flex candiverge.

To avoid spending hours on a laboriousresin build-up, the bite rim is filled withlight-curing tray material, repositionedon the model with the modelling aidsand polymerized (Figs. 10 and 11). Thearea from the implant platform to the be-ginning of the set-up is added later by thesoftware and does not need to be con-structed. Everything is reinforced byadding Pattern Resin on the palatal as-pect. Guided by the bite rim, the resin iscut back, a tooth at a time, to make roomfor the future veneer (Figs. 12 to 15). It isnot necessary to provide reinforcing spotsas for structures made of high-gold alloys.Now this may sound as if the modellationtask were a breeze – put everything intothe bite rim, cut back and finish. But un-fortunately this is not the case. You reallyhave to concentrate, always have the end

T E C H N I Q U E dd

Fig. 1 Navigated implant placement using the Nobel-Guide system.

Fig. 2 An impression is madeof the splinted implants.

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result in mind and consistently check theremaining space after each grinding stepand sometimes even add some materialhere or there. This process may well takemore than half a day. The modellation it-self does not need to be separated and re-splinted to achieve a passive fit; it is merelya scanning template. Once the “wax-up” iscompleted, everything is carefully wrappedand sent to Heraeus Kulzer in Sweden.

Laser melting and CAD/CAM

First, the model is scanned with just theanalogues in place (Figs. 16 and 17). Thenthe wax-up is attached, and a second scanis performed. The software then calculatesthe data, determining the parts that aremissing between the ball joint and theresin wax-up material. The essence of thelaser melting process is easy to explain:

Based on the scanned data, base-metal al-loy powder is additively built up using a bymelting it with a laser beam until the en-tire framework is completed. After thisprocess, the framework is placed in amilling machine and the platform aspectsand screw holes are milled. This processis patented by Heraeus Kulzer. When Iwatch this process it still feels a bit futuris-tic; we could never have dreamt of any-


Fig. 5 Not until the set-up has been removed does it become evident how muchbulk has been loss and must be replaced.

Fig. 6 This modelling aid (left) definesthe final screw hole.

Fig. 7 The Access Guides are placedon the I-Flex, ...

Figs. 8 and 9 ... which only serve to align the modelling aids individually and as in-dicated by the bite rim.

Figs. 10 and 11 The modelling aids, which had been kept in place with a bit of wax, are secured in place with light-curing traymaterial.

10 11

7 98

5 6


thing like this at the time I set out to be-come a dental technician. At that time, alaser beam was still a weapon in a sci-fifilm, not a tool a dental technician woulduse. “May the Force be with you!”

The CoCr framework

After about five days, the laser-sinteredframework will be delivered to the labo-

ratory. Since I was very sceptical aboutthe fit of such a massive part over such awide span, I immediately checked the fitof the superstructure. I carefully placedthe superstructure on the analogues with-out screwing it down. The frameworksurprised, pleasantly, with its perfect pas-sive fit. Not even the Sheffield test coulddisturb the framework giant. I had ex-pected problems, had removed and re-

placed, unscrewed and rescrewed theframework several times, but it still fittedperfectly without fail. This is when I re-alized that I could never have cast a frame-work of this quality (Figs. 18 and 19).I had mentioned earlier that the model-ling aids could be individually realignedby up to 20 degrees can be aligned andsimultaneously represent the screw hole.But how would one tighten the screw


Figs. 16 and 17 The scanned “wax-up”.

Figs. 12 to 15 The wax-up is cut back a tooth at a time to obtain the space needed for veneering.

12 13

14 15

16 17


through an angled channel? HeraeusKulzer has come up with a solution. Boththe screw head and the screwdrivers aredesigned such that the screws can betightened at the required angle, up to 20degrees (Figs. 20 and 21). The frame-works fabricated in Sweden have to be on-ly slightly revised for veneering. I pay a littlemore attention, however, to the supragin-gival aspects (Figs. 22 to 25).

Framework try-in

Before adding the ceramic veneer, theframework is tried in intraorally. This is

absolutely necessary because a large ob-ject like cannot simply be remade just likethat if it does not fit after all. Before evensending the framework for laser sintering,it is advisable to “index” the implant im-pression and to try this in. Only if the X-ray control confirms a perfect fit shouldthe framework be fabricated. So why didwe drop this step in the case reportedhere? Dr Bernd Quantius, the treating den-tist, is a highly experienced implantolo-gist with whom I can be absolutely surethat the impressions are correct and thereare no problems (Fig. 26).

The framework try-in session was usedfor an additional aesthetic and occlusioncheck (Fig. 27). In the process we noticedthat somewhat larger central incisorswould match the patient’s physiognomyrather well. Especially in fashion and ad-vertising photography, models often havelarge, prominent central incisors. Theyrepresent a current ideal of beauty andsuggest vitality and success. The prereq-uisite for this, of course, is sufficient space.I made sure implemented this ideal thelab immediately after the try-in. In orderto achieve a slightly more natural appear-ance, the lateral incisors were shortened


Figs. 18 and 19 The framework madein Sweden using thelaser melting processseats absolutely pas-sively on the cast.

Figs. 20 and 21 The screw can bescrewed in at anglesup to 20 degrees.

Figs. 22 to 25 After finishing, theframework presentsitself at its best –non-precious metalcan be so beautiful!

18 19

20 21

22 23

24 25


a bit and turned distally slightly (Figs. 28to 29). I feel a strong sense of responsi-bility when making decisions about toothshapes and positions. If there are no rel-evant photos from the patient’s past orthe testimony of remaining teeth to relyon for orientation, the only thing thatremains is the usual parameters for com-plete dentures. But even minusculechanges to the incisal edges may result ina greatly altered appearance. Meeting pa-tients’ high expectations requires the ex-perience of the technician.

Veneering preparations

In the laboratory, the platform aspects ofthe framework are first covered with wax,then the framework is sandblasted with110-μm aluminium oxide. After sand-blasting I started wondering about whatwould happen to the oxide on the surfacefacing the implant. Normally these wouldcontact the abutments, which never seethe inside of the ceramic furnace. To pre-vent this sensitive area from oxidizing, wetherefore add Oxide Stop NPM for non-

precious metals. It is true that coveringthese areas before firing is a bit of extrawork, but it does make sense because Ido not want to sandblast these areas. Un-fortunately, Oxide Stop NPM could notbe removed with steam, as I had been ac-customed with from Oxide Stop PM forprecious metals. But since the oxide stoplayer is very thin, it could simply be leftin place during all firing cycles (Fig. 30).


Fig. 26 The radiograph docu-

ments the perfect fitof the framework.

Fig. 27 Once again, theaesthetic result ischecked at the frame-work try-in. As the im-plant shoulders are located subgingivally,a mild anaestheticwas used at thepatient’s request.This is why the lipappears to be droop-ing a bit on the left.

Figs. 28 and 29 After the try-in,

corrections weremade according to

the patient’s wishes.

Fig. 30 In order to prevent oxida-tion in the precision firing area,the appropriate Oxide Stop is ap-plied in the appropriate placesahead of firing.

26 27

28 29


Bonding and opaquer

After the oxide firing, the oxide layer isremoved using radiation with 110-μmaluminium oxide and the framework isthen steam-cleaned. To ensure a safebond with the ceramic material, GC Ini-tial IN Metalbond bonding agent is ap-plied to the remaining surfaces. This ma-terial comes pre-mixed in syringes and isapplied in a thin covering layer (Fig. 31).It narrows the CTE gap, and even a singlelayer provides a warm shade for the frame-work, to the point where one would hard-ly guess that there is a non-precious alloybeneath (Fig. 32). Neither bubbles norcracks were formed in the ceramic mate-rial during any of the firing cycles. I attrib-ute this to the homogeneity of the alloy,but above all to the good bond achievedby the bonding agent. As a first opaque layer I apply a powderopaque for a wash firing. For the second

firing I work with paste opaque, as it isapplied more easily. This paste opaqueis mixed with scattered Fluo Crystalsthroughout, which ensures a certain levelof fluorescence in the depth of the opaque.I use only minimum staining in the gin-gival area (Fig. 33). For the third firing Isimply fill the spaces between the crystalswith paste opaque. This technique invari-ably produces a uniform thin opaque lay-er, as can be seen from the fired result inFigure 34.

Stress-free veneering

An extensive restoration should not bebuilt up free-handedly in one piece withall the masses at once, as it frequentlyhappens that too much incisals and trans-parents are applied for the first firingand the shrinkage turns out more pro-nounced than expected. As a conse-quence, more incisals are added for the

second firing, only to find that dentine ismissing and the shade has become muchtoo bright – and then an attempt is madeto replace the chroma with stain. To pre-vent this from happening, it is better tobuild up the veneer in multiple smallersteps to retain full control over the shapeand shade throughout the entire process.I have been using GC Initial dental ce-ramics for several years now and contin-ue to be impressed by their versatility. Ibegin with a thin layer of fluorescent den-tines 92 and 91, which are very intenselyfluorescent and have an intense shadewhile at the same time covering theframework silhouette well(Figs. 35 and36). Interdentally, some IN 46 createsmore depth.

I am not so keen on using a bite rim forthe build-up, but in a case like this one itwould be silly not to transfer the shapeand position one has worked so hard to


Fig. 31 GC Initial IN Metalbond bonding agent is appliedto the remaining surfaces to ensure a safe bond with theceramic material,

Fig. 32 The bonding agent narrows the CTE gap, andeven a single layer provides a warm basic shade for theframework.

Fig. 33 For the opaque layer I apply paste opaquemixed with scattered Fluo Crystals. Fig. 34 The result after firing: no trace of the framework.

Fig. 35 Fluorescent dentine 91 and 92 before ... Fig. 36 ... and after firing.


obtain. The bite rim is slightly isolated,filled with a pure dentine and replacedon the framework with a little pressure(Figs. 37 to 39). As I had only preparedthe anterior teeth for the second aesthetictry-in, the posterior teeth still have to bebuilt up in dentines. In order to reserveenough space for the incisal, everythingis cut back slightly (Figs. 40 and 41), andthe bridge pontics are completed withgingivals GM 23 and GM 24. In this state,

the dentine layer is fired at 900 °C (Fig.42). From that point on, a cooling periodof one minute is provided.At this point I can pretty accurately judgewhether I still have to add or cut back anydentine. For the next firing I focus strictlyon the gingiva. The somewhat more red-dish GM 24 or the more intense GM 36is used to line the interdental spaces andcovered by GM 23 gingival. The gingivalmargin area is slightly brightened with

GM 35, reminiscent of slightly less per-fused gums. Some effects may also beadded using a bit of blue or white stain(Fig. 43). This layer is again fired at 900 °C(Fig. 44). The dentin is now slightly over-fired, but at this point this does not hurt.Now I can assess the relationship betweentooth size and the tissue to be replacedand cut the dentine back a bit more ifneeded to accommodate the incisals andtransparents.


Figs. 37 to 39 The bite rim is filled with pure dentine and replaced on the framework with slight pressure.

Fig. 40 To reserve enough space for the incisal, ... Fig. 41 ... everything is cut back slightly.

Fig. 43 Then the gingivals are applied ...Fig. 42 The dentine was fired at 900°C.

Fig. 44 .. and fired

48

48

48


I then begin applying the transparentsand incisals. A thin layer of CLF is (clear-ly) applied to the entire vestibular surfaceto mimic the sclerotic dentine. On theflanges I add a bit of the TM 01 transpar-ent. The margin is created in an incisaland the rest of the incisal area is built upby alternating yellow TM 04 and opales-cent TO. Since the patient already worea bridge with a rather unobtrusive build-up in the mandible, I deliberately createdno “virtuoso” mamelons. Many patientswant their teeth to have idealized shapesand shades. Therefore, an individualbuild-up may well fail in the case of full-arch restorations, so I save this for single-tooth restorations.The gingival aspect is built up togetherwith the transparents and incisals (Figs. 45and 46) using the same materials as forthe first firing. This task can be approachedsomewhat playfully, as the natural gingivais very diverse. Simply take up three dif-ferent masses with the brush at once andplace them where you feel like. This will

create a degree of naturalness. Thanks tothe previous well-controlled dentinebuild-up, subsequent layers shrank onlyslightly (Fig. 47).But let me come back to the frameworkfor a moment. Whenever I create a simi-lar restoration with a precious-alloyframework, my adrenaline shoots upeach time I return then superstructure tothe cast after firing. Usually, there wouldbe some distortion as early as after thefirst firing. The laser-sintered non-pre-cious framework does not twist a bit dur-ing the entire firing sequence. This givesyou a serene feeling while veneering. After a few adjustments, I then checkwhether I have matched the predeter-mined shade. At this point it is still easyto modify the chroma – something thatis impossible later. Incidentally, I only usethe bite rim for the first dentine layer. Forsubsequent firings this type of build-upwould be far too cumbersome. All move-ments on the articulator are replicatedand evaluated.

For the correction firing I use the yellowCT 22 cervical in the cervical region,which is a fairly good match for the A2shade. Incisally, the line angles are builtup in EOP 2 opal incisal. Final shape ad-justments are made with TM 04 and amix of 58 incisal and TN (neutral trans-parent, diffuse). More different materialsare not required for this type of annularshade build-ups. The gingival areas Icomplete with GM 23 and the papillaewith GM 35. If more pronounced effectsare desired, for example to mimic less per-fused areas, the heavily pigmented whiteEO 15 occlusal incisal should be used(Figs. 48 and 49). Even sporadic patchesof dentine give a nice effect, representingslightly more yellowish areas.

The result of the correction firing sug-gests that thanks to the controlled incre-mental build-up, fewer adjustments arerequired (Figs. 50 and 51). The entiresurface is smoothed with a White Everubber wheels, removing residual micro-


Figs. 45 and 46 The gingival aspect isbuilt up together withthe transparents andincisals

Fig. 47 After firing, therelationship betweentooth size and the tissue to be replacedcam be easilyassessed. Thanks tothe previous well-controlled dentinebuild-up, the layersshrank only slightly.

45 46

47


porosities as far as possible. To get a niceand well-defined surface structure, I useold, worn diamonds. My template is acast with natural examples. The gingivalceramics I like to leave pretty much alone. A few little spots that still need someshape correction are added ahead of theglaze/correction firing using clear CLW(Fig. 52). For the glaze firing, I use onlya little liquid and paint on slight inter-proximal enamel discolorations and sub-tle cracks. This firing cycle – if ceramicmaterial was added – uses a heating rateof 100 degrees per minute and a shortholding time of 10 to 20 seconds. Be-cause of the rapid heating, nothing ischanged in the actual build-up; only the

surface is compacted. To the basal sur-faces I add a thin layer of glaze, makingthis area easy to clean with Superfloss forthe patient

The completed restoration

The most exciting moment for a dentaltechnician is when a finished restorationcomes out of the furnace and you canwatch its final appearance materialize oncooling with every second. The OxideStop is removed with 50-μm glass beadsat no more than 1.5 bar of pressure. Theremaining subgingival metal is finishedand polished. The places where ceramicswas applied during the glaze firing are

slightly polished again. The slight un-evenness on the gingival aspect I leaveuntouched, since it corresponds to thenatural state (Figs53 to 62). A prelimi-nary try-in after the first firing was dis-pensed with in this case because the pa-tient lived a long distance away and all thekey parameters of the bite and aestheticshad therefore been checked in advance.

In situ

The day of delivery onset is always excit-ing. Finally you get to see the result ofweeks of intense work in the patient'smouth and you look forward to meetinga satisfied patient for whom you restore


Figs. 48 and 49 Some minor shape

corrections are made ahead of the

correction firing. Thegingival areas are

completed with GM23 and the papillae

with GM 35.

Figs. 50 and 51 The result of the correction firing

shows that thanks to the controlled

incremental build-up,fewer adjustments

are required.

Fig. 52 After finishing, someold, worn diamondsare used that ensure

an attractive and well-defined surface struc-ture. A few spots thatstill need some shapecorrection are added

ahead of the glaze/correction firing using

clear CLW .

48 49

50 51

51


some lost quality of life (Figs. 63 and 64).For large implant-supported designs, thepink/white ratio is particularly importantaesthetically. Figure 65 shows how theshade and contours of the “ceramic gin-giva” were optimally adapted to the gums.It is evident that such a result is difficultto achieve without meticulous prior aes-thetic planning.

Pros and cons

The pros are obvious: The patient re-ceives a highly aesthetic implant-support-ed fixed restoration – and that startingwith as few as four implants. In the ab-sence of abutments, mesostructures andgold, cost decreases significantly. Thereis no distortion of the framework and

no problems during the ceramic firing.The treatment provider can remove therestoration at any time thanks to its beingscrew-retained.

A crucial point seems to be that this typeof restoration enables the dentist and thelaboratory to offer excellent restorativedental treatment to even more patients.


Figs. 53 to 62 The slight unevennesson the gingival aspectis left untouched,since it correspondsto the natural state. Apreliminary try-in afterthe first firing was dis-pensed with in thiscase ...

53

54 55

56



Figs. 53 to 62 ... because the

patient lived at adistance and all the

key parameters of thebite and aesthetics

had been checked inadvance.

57

59

62

58

60

61

Product

BonderCoffeeCamera system- Lens - Flash

Modelling plasterModelling resinNon-precious frameworkVeneering ceramicsGingival mask

Name

GC Initial IN MetalbondmiscellaneousCanon EOS 400DCanon EF 100mm USM Macro LensCanon Macro Twin Lite MT – 24 EXpicodent ImplantatrockPattern Resincara I-Bridge FrameworkGC Initial MCZhermack Gingifast Rigid

Manufacturer/distributor

GC GermanymiscellaneousCanonCanonCanonpicodentGC GermanyHeraeus Kulzer Nordic ABGC GermanyZhermack

Products


We need to create and exploit new op-portunities, especially in financially diffi-cult times, to survive in the market. Thereare admittedly also a few cons: The oc-clusal design options are very limited –nothing for gnathological experts. In a case such as the one described here,where the framework is located subgin-

givally at implant level, removing therestoration destroys the biofilm betweenthe restoration and the soft tissues, whichcould adversely affect the gingiva. If animplant is lost, it is not possible to salvagethe case by installing a new implant. Alltold, this approach is a really good alter-native to other methods in selected cases.

Acknowledgement

I would like to cordially thank Dr BerndQuantius of Mönchengladbach and histeam for the perfect collaboration. It washis initiative that encouraged me to im-plement this type of restoration.


Figs. 63 and 64 The finishedrestoration isexperienced as very successfuldirectly after delivery.

Fig. 65 The gingival aspectexhibits an optimallyadapted shade andnatural texture.

Author’s background

Wolfgang Sommer completed his vocational training as a dental technician in 1989. He then gained experience in the area ofcomplex implant-supported restorations experience at various laboratories and dental surgeries. In 2003 he received the vo-cational degree of Master Dental Technician after passing the requisite examination. Since 2009, Sommer has worked for GCEurope as a consultant in the ceramic field. The same year he founded his own dental laboratory in Mönchengladbach. Hisfocus is on implant-supported restorations and anterior aesthetics.

Address for correspondence

Wolfgang Sommer, M.D.T. • Zahnkreation Wolfgang Sommer • Dahlener Straße 570 • 41239 Mönchengladbach +49 2166 1312891 • [email protected] • www.zahnkreation.de

63 64

64

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