Analog vs CAD/CAM: The patient has the choice!

Monday morning in Austria’s capital Vienna: Nineteen dental technicians from various countries and one dentist from the Czech Republic meet at Ivoclar Vivadent’s International Center for Dental Education (ICDE) for a special kind of showdown. They have followed the invitation of the dental company to participate in an unusual event. Under the slogan “One aim, three solutions”, they are set the task to provide the same patient with a restoration using three different treatment approaches. What will the result be? Share the thrill with them and see which one will come out on top! 
Analog vs CAD/CAM: The patient has the choice!
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The competition

Restoration of a live clinical case with three different approaches: that’s the challenge set to the 20 participants of the “Train The Trainer” event in the city on the Danube. Basically, the participants will be divided into three teams – and into three different approaches, which all pursue the same treatment goal:
  • analog (technical),
  • digital (technical),
  • digital (clinical).
Which team will finish their task first? Which team will win? What will the result look like? At this stage, we know only one thing: at the end the patient will decide which restoration she wants to wear. After all, she will be the one who needs to be happy with the final restoration in the long run. She will be able to decide freely as to which restoration she likes best, wholly independent of the manufacturing method used to develop the restoration. You could say that she is actually the most important person on this day.

IPS e.max for all three groups

All three teams will use the products from Ivoclar Vivadent. The restoration that is accomplished completely chairside will be milled from IPS e.max CAD and finalized by the dentist. The dental technicians using digital technologies will produce a conventional CAD/CAM-supported restoration. The dental technicians using analog methods will create a restoration using IPS e.max Press
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A challenging task

The task is far more challenging than it may appear at first. This is because materials such as IPS e.max CAD or the highly translucent IPS e.max ZirCAD can be processed in a range of methods: monolithic, ground in an anatomically reduced shape or milled. The same applies to IPS e.max Press, which can be pressed in full or reduced anatomical contour and then stained or veneered, or a combination of all of these options. This sounds versatile and that’s exactly what it is. And it is also an impressive presentation of the universal all-ceramic product portfolio of Ivoclar Vivadent. Even though things may look complicated at this stage, the solution at the end will be straightforward… 

Dr Petr Hajný, dentist based Prague in the Czech Republic, carried out the preparation on the patient. 
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Sound preparatory work

Dr Petr Hajný, dentist from Prague, has a central part in this competition. It was him who did all the preparatory work on the patient in the run-up to this thrilling day. It’s his patient and his preparation that will be at the centre of attention at the showdown between the teams. 

The competition is held at Ivoclar Vivadent’s ICDE facilities in Vienna/Austria.
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The highly motivated team and the event organizers
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Gernot Schuller, Managing Director Austria & Eastern Europe of Ivoclar Vivadent AG, welcomes the participants of the “One Aim – three Solutions“ Train The Trainer (TTT) event in the lecture room at ICDE Vienna.
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Martina Jakob, Head of Marketing & ICDE for Austria and Eastern Europe, presents the agenda of the three-day event. In line with the course schedule, the participants will be allowed to start working on their projects from 10 o’clock onwards, following a case presentation and discussion.
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Before the clinical case is presented, Hannes Meischl, Technical Trainer of ICDE Vienna, briefs the participants on the process of the dental technician work and the materials and equipment available to them. 
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The initiator

Hannes Meischl

Hannes Meischl

Hannes Meischl is a dental technician. He has been working as a trainer at the ICDE of Ivoclar Vivadent in Vienna since January 2016.
His career as a dental technician began in 2000, when he commenced his occupational training at the dental laboratory of Christian Smaha in Vienna. After having completed his final exams, he continued to work at the laboratory.
His further career path saw him working as field sales representative for three years and he worked at two more practice laboratories before he joined Ivoclar Vivadent. 
Hannes Meischl

Hannes Meischl

See complete profile
Hannes Meischl is a dental technician. He has been working as a trainer at the ICDE of Ivoclar Vivadent in Vienna since January 2016.
His career as a dental technician began in 2000, when he commenced his occupational training at the dental laboratory of Christian Smaha in Vienna. After having completed his final exams, he continued to work at the laboratory.
His further career path saw him working as field sales representative for three years and he worked at two more practice laboratories before he joined Ivoclar Vivadent. 

The participants

Next, get to know the participants of the competition and find out what method and material they used.

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Alen Alić, dental technician

Analog

Full-contour crowns using IPS e.max Press MT BL4. Minimal cut-back by 0.2 to 0.5 mm. Veneering using various IPS e.max Ceram materials and shade effects using IPS Ivocolor.

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Andras Varadi, dental technician

CAD/CAM

Full-contour crowns using IPS e.max CAD LT A2. Buccal cut-back. Veneering using various IPS e.max Ceram materials.

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Andreas Wölfle, dental technician

CAD/CAM

Full-contour for teeth 11 to 13 using IPS e.max ZirCAD MT Bleach, full-contour for teeth 21 to 23 using IPS e.max CAD MT A2. Staining and glazing of lithium disilicate parts, infiltration with colouring liquid of zirconia parts prior to the final sintering process. Glazing and staining of both materials using IPS Ivocolor

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Andrej Lukas, dental technician

Analog

Copings pressed from IPS e.max Press MO1, veneering using IPS e. max Ceram Selection. Glaze using IPS Ivocolor.

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Davor Marković, dental technician

CAD/CAM

Full-contour crowns using IPS e.max ZirCAD MT Bleach, infiltration with colouring liquid prior to the final sintering process, glazing and staining with IPS Ivocolor.

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Dr. Petr Hajný, Zahnarzt

CAD/CAM chairside

Full-contour crowns using IPS e.max CAD MT A1. Crystallization, staining and glazing with IPS e.max Crystall. Glaze Paste, Shade and Stains.

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Dragan Stolica, dental technician

CAD/CAM

Full-contour crowns using IPS e.max ZirCAD MT Bleach; infiltration with colouring liquid prior to the final sintering process. Glazing and staining with IPS Ivocolor.

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Florin Raicea, dental technician

CAD/CAM

Frameworks using IPS e.max CAD LT A2 and IPS e.max ZirCAD MT Bleach. Veneering using various IPS e.max Ceram materials and shade effects using IPS Ivocolor.

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Georg Licen, dental technician

CAD/CAM

Full-contour crowns using IPS e.max CAD MT A2 and IPS e.max ZirCAD MT Bleach. Staining and glazing of the lithium disilicate parts, infiltration with colouring liquid of the zirconia parts prior to the final sintering process. Glazing and staining of both materials using IPS Ivocolor.

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Helmut Berger, dental technician

CAD/CAM

Full-contour crowns using IPS e.max CAD A1 and IPS e.max ZirCAD MT Bleach. Infiltration and subsequent characterization using IPS Ivocolor.

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Martin Ebringer, dental technician

Analog

Full-contour crowns using IPS e.max Press MT A2. Minimal cut-back. Veneering using various IPS e.max Ceram materials. Only mechanical polishing, no glaze firing

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Milos Miladinov, dental technician

CAD/CAM

Frameworks using IPS e.max CAD LT A2 and 3 as well as IPS e.max ZirCAD MT Bleach. Full veneering using various IPS e.max Ceram materials and shade effects using IPS Ivocolor.

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Moritz Wenger, dental technician

CAD/CAM

Full-contour crowns using IPS e.max CAD MT A2 and IPS e.max ZirCAD MT Bleach. Staining and glazing of lithium disilicate parts, infiltration with colouring liquid of the zirconia parts prior to the final sintering process. Glazing and staining of both materials using IPS Ivocolor.

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Ondřej Adam, dental technician

Analog

IPS e.max Press MO frameworks for the central incisors and full-contour crowns using IPS e.max Press MT B1 for teeth 12 and 13 as well as 22 and 23. Cut-back of the crowns for the lateral and canine teeth. Individual layering using various IPS e.max Ceram materials.

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Pavel Medar, dental technician

Analog

IPS e.max Press Multi A1 in full contour,  characterization using IPS Ivocolor.

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Richard Koinegg, dental technician

Analog

Full-contour crowns using IPS e.max Press MT B1. Minimal cut-back. Veneering using IPS e.max Ceram Selection materials and shade effects using IPS Ivocolor.

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Stefan Chobota, dental technician

Analog

Full-contour crowns using IPS e.max Press Multi A1. Minimal cut-back. Veneering using IPS e.max Ceram Selection materials and shade effects using IPS Ivocolor.

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Velimir Žujić, dental technician

Analog

Frameworks using IPS e.max Press MT BL4, individual veneering using IPS e.max Ceram materials. Glazing and staining with IPS Ivocolor.

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Vinko Iljadica, dental technician

Analog

Minimally reduced crowns using IPS e.max Press MT BL4. Veneering using various IPS e.max Ceram materials and shade effects using IPS Ivocolor.

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Zsolt Fodor, dental technician

CAD/CAM

Full-contour crowns using IPS e.max ZirCAD MT Bleach. Infiltration with colouring liquid prior to the final sintering process. Glazing and staining with IPS Ivocolor

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The patient and her case

Name: Sandra Rammah

Country: Austria

Sandra is a young woman living in Vienna/Austria. She has been wearing restorations on her central incisors that have been shown esthetic shortcomings. Sandra is no longer happy with this situation. When she was offered the opportunity to have her restorations redone in the course of the TTT competition she agreed to participate.
Sandra has also agreed that teeth 12 and 13 as well as 22 and 23 can be involved in the intervention to achieve an esthetically harmonized integration. So, the three competing teams – analog labside, CAD/CAM labside and CAD/CAM chairside – are given the task to create all-ceramic restorations for the teeth 13 to 23 within the given time frame.
After the existing crowns had been removed from teeth 11 and 21, it was noted that tooth 11 had been provided with a metal post build-up. To reduce the variation in shade, Dr Hajný masked the preparations with an opaquer in the run-up to the event.
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Dr Petr Hajný briefs the participants on the clinical case and the challenges involved. Sandra should receive all-ceramic restorations from teeth 13 to 23.
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Ivoclar Vivadent offers a large portfolio of materials - the range of choices and combination possibilities is likewise large. Here, the choice may be easiest for the analog group because it will centre on IPS e.max Press and the ingot versions appropriate for the case in question. The CAD/CAM labside team will have to consider various options such as monolithic and individually coloured zirconia restorations (IPS e.max ZirCAD MT).
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The creative phase

After the participants have been sufficiently informed about the patient case and the task at hand, they are ready to go. The three teams – analog labside, digital labside and digital chairside – get down to the work with high motivation. They must not squander any time, as the clock is ticking.
Ready, steady, go: At 10 o’clock sharp the participants are given access to the models of the live patient case. The models include a diagnostic model of the temporarily restored upper jaw including a silicone key, a model of the prepared upper jaw with detachable segments and a lower jaw model.
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Group 1: Analog labside

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The group of technicians using analog methods (here: Velimir Žujić, Vinko Iljadica and Alen Alić, from the right) get started right away. They inspect the models and begin with the initial esthetic planning.

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With the technicians working in analog, most can be seen from the outside, due to the large number of working steps. Among other steps, they prepare the dies for the modelling procedure and trim the silicone walls (on the left: Alen Alić; on the right: Stefan Chobota).
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In terms of time, the race is neck-to-neck. While the digital team is milling and grinding the first crowns, the analog team is spruing the first manually contoured crowns for the press procedure (here: Velimir Žujić).
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Is this part of analog dental technology or simply a must for the design of a restoration that meets the needs of the individual patient? Fact is that virtually every participant uses the portray pictures they have been given of the patient for their analysis.
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Alen Alić – like many other participants in the competition – uses the opportunity to take a picture of the patient with the dies in situ.
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The fully contoured crowns, reduced crowns and frameworks are invested, placed in the pre-heating furnace, pressed, divested and further processed in the classic way. Overall, this is a procedure that the participants can do well and that quickly leads to the desired results.
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In view of the large number of individual manual working steps that the analog group has to do, it is hard to imagine that all this could be done completely digitally by the push of a button.
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Although everybody is working intently on their project, there is time for fun. The participants crack a joke now and again and keep each other in good spirits. Velimir Žujić (on the right) is joking with his Croatian compatriots Vinko Iljadica and Alen Alić.
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Manual refinement technique: Velimir Žujić sprinkles dentin powder on an IPS e.max Press framework coated with IPS Ivocolor Mixing Liquid allround. This results in a wash that enhances the bond and provides a sound foundation for the subsequent layering procedure.
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The press technique can also be an efficient option if the restorations are pressed in almost full contour and then customized with subtle accents using a modicum of layering material. As only a small amount of layering ceramic is applied, hardly any shrinkage occurs and the result is easily predictable.
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Representatives of the analog group in particular try to get the most from the materials of the IPS e.max system. Here, the incisors are being layered in full contour on IPS e.max Press MO frameworks.
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Checking the length and position of the all-ceramic crowns in the articulator. The marking on the wax-up serves as guideline. Many dental technicians find it difficult to imagine how these steps could be visualized using a purely digital method.
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Analog version of the try-in: what has initially been seen just as a bit of silliness actually provides already quite a good initial impression.

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Ondřej Adam is absorbed in his job. He veneers the upper incisors completely in an effort to reproduce the transparent margin of the mandibular anterior teeth. The picture shows the result after the first firing.
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Group 2: Digital labside

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The labside CAD/CAM group retrieves the digitized situation and creates a case: this means it defines the software to be used and the teeth to be restored (here Davor Marković).
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High-octane industriousness prevails in the training lab of the ICDE Vienna. The technical CAD/CAM division can be seen in the foreground.
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Individual members of the CAD/CAM group gather around the workstation frequently to discuss the manufacturing strategies to be employed.
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This is the workstation of Milos Miladinov, who has chosen to use a digital workflow on this course. You can see six IPS e.max CAD LT A2 frameworks and three IPS e.max ZirCAD MT Bleach zirconium oxide frameworks.
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Irrespective of whether they use an analog or a digital method: if the participants have chosen a non-monolithic route, they will have to use a manual layering procedure and perform various firing processes to complete the restorations.
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From digital to manual: Some technicians of the CAD/CAM group have chosen to use the monolithic method. However, every so often they are doubtful whether or not they will be able to hold their own in a direct comparison with the analog group. We will see at the end of the competition if their doubts are justified.
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Andreas Wölfle, member of the CAD/CAM team, is working intently on his project. The software allows him to check the scanned temporary and virtual wax-up by superimposing the two structures.
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You may have thought otherwise, but the CAD/CAM team does more than only look at a screen. There are plenty of manual working steps and there is plenty of fun. In the end of the day, it’s not about the method but it’s about creating restorations that are indistinguishable from the natural dentition.
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Mission accomplished: Helmut Berger has managed to correctly align his virtual construction with the image of the patient to check the length and position of the teeth.
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Analog camera found at the work station of Milos Miladinov, a representative of the CAD/CAM team. He loves conventional technologies and products even if he is an avid user of digital technologies in many parts of his life.
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Group 3: Digital chairside

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Dr Petr Hajný gets the patient ready for the intraoral digital impression procedure and the removal of the temporary. First, he places an OptraGate.

Once the OptraGate is placed, Dr Hajný enjoys a clear view of the treatment field and can begin with the digital scan of the oral situation. First, he takes a scan of the situation while the temporary is still in place.

Now, Dr Hajný carefully removes the temporary and then takes a scan of the tooth preparations.

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Dr Petr Hajný, the dentist, and his assistant take a scan of the oral situation using an intraoral scanner – such as Trios from 3Shape – which does not require the use of powder. As a user of the chairside workflow, he designs the crowns with the CEREC 4.43 software program and has them ground from an IPS e.max CAD MT A1 blank.
 
Crowns made from IPS e.max CAD MT blocks, after completion of the grinding process
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Asking a colleague for advice … Dr Petr Hajný used to work as a dental technician and he is well aware of the efforts involved in the work of dental technicians. Here, he is asking Czech dental technician Ondřej Adam for some advice. This is followed by classic manual work: Dr Hajný applies subtle surface characterizations to his ground lithium disilicate crowns before he finalizes the restorations in a modified crystallization and glaze firing process. This workflow is the fastest way to manufacture the restorations. He can enjoy the most leisure time.
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Before the IPS e.max crowns can be inserted, the proximal contacts have to be controlled and carefully adjusted. Dr Hajný accomplishes this step tooth by tooth – a skill he acquired when he was trained as a dental technician.
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The decision

The TTT competition is drawing to a close. The excitement among the participants is palpable ahead of the patient’s decision. Which restoration will she choose? In view of the rather large number of restorations, the organizers ask the jury, which includes dental technician Christian Smaha, for help. Together, they pre-preselect six restorations, which they will present to the patient.
 
Dental technician Christian Smaha (in the middle) assists in the pre-selection.
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Gernot Schuller addresses all the participants once more. He thanks everybody for their great effort. And he, too, can hardly wait to see which restoration the patient will choose.
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Before Sandra can make her choice, ICDE trainer Hannes Meischl takes photographs of all the restorations. This makes it easier to compare them.
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And the essence of the story

What can we learn from this unusual competition in Vienna? What conclusions can we draw in retrospect? Do dental technicians and CAD/CAM dentists always keep sight of the essentials? Does it matter which method you choose, how many materials and shades you apply – or is it simply the shape and the surface that have a decisive effect on the overall esthetic appearance? Is it possible that in some cases a (supposedly) simpler restoration is more beautiful? Or is it in the end of the day all about being able to listen – and understand what the patient wants?
 
We have asked ICDE trainer Hannes Meischl about his conclusions from the TTT event:
 
“Both technical teams – analog and digital – were intensely working on the case. None of the groups showed significant advantages in terms of time. Both approaches require a high level of concentration and application to the task.”

“The most important aspect in each case is and will remain the patient. The patient should always be at the centre of attention. In the end of the day, it is the patient who has to be satisfied and happy with the restoration in the long run. For the users, this means that delivering a technically refined piece of work is not the be-all and end-all. They should also take time to talk to their patients and realize their wishes. This is exactly what Martin Ebringer, the winner of the competition, has done.”        

What is the ICDE?

ICDE stands for International Center for Dental Education. They are modern further education and training centres run by Ivoclar Vivadent in several locations. Target groups are dentists, dental technicians and also practice teams.
Ivoclar Vivadent runs 29 education centres around the world. The ICDE at the headquarters in Schaan has an international remit. The other ICDEs – such as the one in Vienna – are regional training centres that provide a view at the local market environments.
ICDEs are usually equipped with course rooms, labs, practice rooms and lecture halls. The centre in Liechtenstein for instance includes a phantom practice and four dental labs where course participants can get hands-on training.
All ICDEs offer continuing education courses and events on the application of products from Ivoclar Vivadent throughout the year. In addition, product-independent events, such as courses on dental photography, are also offered.

Products

The following products were used during the competition held at the ICDE in Vienna.

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