Implant Tribune UK No. 2, 2014

Flapless MIMI® implantation using the two-piece implant shuttle preventing physiological bone loss / Fabrication of a customised implant abutment using CAD/CAM: A solution specific to each clinical case / Treatment options for peri-implantitis

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Table of contents

Flapless MIMI® implantation using the two-piece implant shuttle preventing physiological bone loss
11 - 16 view
Fabrication of a customised implant abutment using CAD/CAM: A solution specific to each clinical case
17 - 18 view
Treatment options for peri-implantitis
19 - 20 view

Implant Tribune
Implant Tribune

Implant Tribune

Flapless MIMI® Implementation

Perio-implantitis

Customised implant abutment

Using the two-piece implant shuttle

What are the treatment options?

By Theirry Lachkar

pages 11-16

pages 19-20

pages 17-18

Flapless MIMI® implantation using the two-piece
implant shuttle preventing physiological bone loss
Armin Nedjay discusses Flapless implants
Fig 1

Fig 2

Fig 3

Sulcus 0,2 - 0,5 mm
Epithelial attachment
about 1 mm

Dentogingival
Connective tissue attachment complex

Biological
width

about 1 mm

Fig. 1: Implant on the right: Physiologically speaking, bone loss has been considered as
inevitable, and some traditional implants are frequently associated with bone loss.
Fig. 2: The epithelial attachment in natural teeth and the one in osseous implants have
many features in common, but there are also differences between them. The connective
tissue fibers adjacent to the implant are in parallel with the longitudinal axis of the
implant, which is different from the biological structures around natural teeth5-8. There
are no nerve and vessel structures adjacent to the implant surface; the tissue is similar to
scar-like tissue and differs from periodontal tissue, which is connected to the tooth and
alveolar bone.
Fig 3: Soft tissue consists of the sulcus, the gingival epithelium, and the connective tissue
attachment. Their vertical height of 3 mm is called the biological width. A biological
cuff-like barrier protects healthy implant surfaces/sites from apical migration of bacteria. Hard and soft tissue, mineralized connective tissue (alveolar bone), soft connective tissue and junctional epithelium serve as a protective barrier. Bacterial migration
into the periodontal and periimplant soft tissue in the sulcus area causes an apical
migration and destruction of soft and hard tissue, which can lead to an attachment
loss9-11. Poor dental hygiene or the iatrogenic detachment of the periosteum with a flap
reflection and/or an implant exposure can cause injury to soft tissue, which can lead to
periimplantitis.

ccording to valid scientific criteria for a successful implant treatment, bone loss after one-year
loading is considered as inevitable1. Thus, the implantation is defined as successful when crestal
bone loss does not exceed 2mm
after one-year loading time and
0.2mm annually thereafter.
With more than 22,000 successful implantations with immediately restored and loaded
implant systems, the author describes solutions that have been
successful in preventing physiological bone loss. With respect
to Tarnow’s findings concerning

bone loss2-4, the author has suggested that the periosteum preserving MIMI® procedure with
implants that have an integrated
Platform-Switching design and
that can achieve primary stability
has a proper potential to prevent
physiological bone loss. Since
bone loss can be evidenced if animplant is uncovered, it is also
recommended to avoid implant
exposure.
Implant Design & Physiological Bone Loss
Most traditional implant systems
have a conventional platformmatched implant-abutment connection. External and internal

connections can have an impact
on the hard and soft tissue interface. Long-term studies have
shown that the peri-implant bone
level is established apically from
this platform-matched implantabutment connection (Bullon
1999). If the implant, surrounded by bone, heals with its cap
screw in bone until its exposure
and if the cap screw is removed
by means of ostectomy and replaced with a healing cap, a bone
remodeling process starts after
exposure. This can lead to a periimplant bone defect (Fig. 1, implant on the right).
Micro-gap
The micro-gap is located between the implant body and abutment. It has been considered as
a disadvantage of two-piece implants. If the micro-gap is too big,
as is the case with many conventional two-piece implant systems
and due to loading of the implantabutment connection, there is a
high risk of bacterial contamination of the micro-gap and implant
body. This can lead to bone loss.
X-ray images of some twopiece implant systems (eg ITI),
which are connected to the
oral cavity, have shown that the

biological vertical distance between the micro-gap and the
implant-bone contact area is
2mm, regardless of how deeply
the implant is inserted in bone
(Hermann 1997, 2000 and 2001).
Tarnow2-4 has demonstrated in
his studies 2000 and 2003 that the
micro-gap expands horizontally
by about 1.4mm, which is similar
to the effect in case of a periodontal defect. Tarnow recommends
that the minimum distance between two implants should be
3mm to protect bone and interimplant papillae.
Platform Switching
Implants with a Platform-Switching concept have a proper potential to prevent bone loss15,16. The
diameter of the healing abutment
is narrower than the diameter of
the implant platform/shoulder.
In this way, the implant-abutment connection is not platformmatched. Dental implant systems
such as the Champions (R)Evolution® (Fig. 17 & 18), Ankylos®
and Astra Tech® have an integrated Platform-Switching design
and an internal cone that is long
enough and that has an optimal
angle. In addition, the geometry
of the implant-abutment connection is the same for all implant

diameters, so there is a prosthetic line for all implant diameters. With the Platform Switching function, the central position
of the micro-gap is moved to the
implant axis. Through the separation of the micro-gap, which
might risk being contaminated
with bacteria, from the peri-implant bone tissue in the implant
shoulder area, the biological
width is shifted away from bone.
As a rule, an exposure of the
Champions (R)Evolution® implant and a reopening/ injury of
the sensitive biological width are
not necessary. In this way, biological bone loss can be avoided, and
the issue according to Tarnow remains to be discussed, also with
respect to one-piece implants.
Conclusion
Conventional implantation methods have been increasingly questioned13,14. MIMI® is the abbreviation for the Minimally Invasive
Method of Dental Implantation.
One-piece implants and also twopiece implant systems will be ideal for MIMI® if they can remain
bacteria-resistant even if they are
loaded with strong forces.
à DT page 12

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May 2014

ß DT page 11

Fig 4

Fig 5

Fig 6

Fig. 4-6: For the implant site preparation, the conical triangular drills (not twist drills!) are used, which allow for bone condensation. You prepare the bone cavity depth that corresponds to the endosseous implant length, except
if you perform an indirect sinus lift. To ensure periimplant nourishment through the intact periosteum, the 3.0 mm and 3.5 mm-diameter reduced implants are used. The 2.5 mm-diameter implants are only used in individual
cases.

Fig 7

Fig 11

Fig 14

Fig 8

Fig 9

Fig 12

Fig 15

Fig 10

Fig 13

Fig. 7 -13: With conical triangular drills, you prepare the bone
cavity depth that corresponds to the implant length, except if
you perform an indirect sinus lift. For the D1 bone, the twist
drills can also be used. Contrary to what critics might think,
MIMI® surgery is not a “blind procedure”. After each drilling
and preparation with condensers, it is an absolute must to
palpate and check thoroughly in all dimensions by means of a
thin probe. Autologous blood for humidifying the bone cavities
is recommended. Only if primary stability is not achieved with
condensers or diameter-reduced implants, can you insert an
implant with a larger diameter (for example, a 4.5 mm or 5.5
mm-diameter implant).

Fig 16

Fig. 14 - 16: Due to a lack of a Platform-Switching function or a too short or too large cone of many implant systems, for example with diameters of 3.8 mm or 4.1 mm, there is a risk of bacterial migration into the micro-gap. In
studies, a relatively wide gap was observed when certain implant systems were loaded with forces of only 100 N. In such a case, there is a risk of bacterial penetration into the inner thread and outer part of the implant, which
can induce periimplantitis.

Fig 17

ty without deforming or breaking
the outer part and inner thread
and without loosening the abutment during the prosthodontic
phase.

Fig 18

Fig. 17 - 18: By comparison, two-piece implant systems with an optimized cone-implant-abutment connection can be loaded with
strong forces, causing just an extremely small micro-gap or none at all. For instance, this picture shows a 3.5 mm-diameter Champions- (R)Evolution® implant that was loaded with a force of 200 N in a study led by engineer Holger Zipprich. No micro-gap was
observed12.

1) The Shuttle: The two-piece
Champions (R)Evolution® implant system consists of an integrated bacteria-proof “Shuttle”/
Insert, which remains in the
implant for at least eight weeks
post surgery until the final prosthodontic restoration is fit. Dur-

ing the healing phase in the
first weeks, the implant internal
thread will not be contaminated
with bacteria. During implantation, the Shuttle and micro-close
connection protects the internal
thread from contamination with
bacteria, blood or saliva. With
these two-piece implant systems

and also one-piece implants,
there is very little risk of bone
loss. Sufficient primary stability at a torque of at least 35Ncm
is a prerequisite for a successful
implantation17. The implant with
the Shuttle can be inserted at a
torque of up to 70/80Ncm and
achieve sufficient primary stabili-

2) Platform Switching & Optimised Cone Connection: It has
been found that crestal bone loss
can be prevented with implants
with an integrated PlatformSwitching design15,16. In addition,
internal cone connections should
have an angle of 5° to 10°, and
the cone should be long enough
in order to prevent bacterial migration even if, for example, a
3.5mm-diameter two-piece implant is loaded with a force of
200 N12. Since one-piece implant
systems have no micro-gap at all,
they are bacteria-proof as well.
The one-piece implant system

is particularly indicated for the
rehabilitation of four or more
implants/teeth. In order to compensate insertion divergences,
Prep-Caps (zircon or titanium)
can be cemented. The impression can be cast with super hard
plaster (no Laboratory Analogs!)
in the dental laboratory. If done
correctly, the cement will not
be pressed subgingivally so that
there is no risk of periimplantitis because of cement remains
in these one-piece implant PrepCaps (“abutments”).
3) Due to the flapless MIMI® procedure and the fact that a second
or third session is not necessary
(implant exposure, subgingival impression), the biological
width can be formed and is not
disturbed because of a second

[3] =>

United Kingdom Edition

intervention (exposure). During
surgery, the periosteum, which
nourishes peri-implant bone on
the long-term, can be preserved.
Peri-implant bone nourishment
shall be ensured. The minimally
invasive implantation method
has proven beneficial to the periosteum18-23. In this way, the supracrestal bone/bone’s sensitive
outer membrane connection can
be protected. The peri-implant
bone is almost completely nourished by the histological, doublelayered bone membrane, which
is richly supplied with blood
vessels and nerve fibres: the inner cambium layer (Stratum
osteogenicum) is rich in cells.
It is composed of stem cells (osteoblasts!!), ensuring bone regeneration, as well as of nerves and
blood vessels. The outer fibrous
layer (Stratum fibrosum) is connective tissue, which is not cellrich but rich in collagen fibers.
The Sharpey’s fibers, which pass
from the outer layer through the
inner layer, are embedded in the
Substantia compacta of the bone
and secure the periosteum to

Apical deviations of 500 μm have
been observed24. Implants for at
least four implants/teeth that will
be splinted (including fixed, prepared teeth that are positioned
mesially from the implants) can
be immediately loaded with a
final implant-supported restoration within the first 14 days post
surgery. Current studies have
demonstrated good treatment
outcome with regard to stable
soft and hard tissue conditions after immediate restoration – also
in conjunction with immediate

Implant Tribune 13

May 2014

implantation. This success rate is
comparable to the one obtained
in conventionally loaded implants three to six months after
implantation25-31. In addition, immediately restored/loaded and
delayed loaded implants showed
similar bone-implant interface
contact rates28. In addition, a
biologically optimised surface
enhances bone cell regeneration19,32.
With these techniques, the
risk of physiological bone loss

can be reduced or even eliminated. Currently, Tarnows theory
that there should be a distance
between the implants of at least
3mm is controversial. DT
Bibliography
1) Zarb GA, Albrektsson T.: Towards optimized treatment
outcomes for dental implants. J
Prosthet Dent. 1998 Dec;80(6):63941.
2) Tarnow, D. P. and R. N. Eskow
. Preservation of implant esthetics: soft tissue and restorative con-

siderations. J Esthet Dent 1996.
8:12–19.
3) Tarnow DP, Cho SC , Wallace
SS: The effect of inter-implant
distance on the height of interimplant bone crest. J Periodontol
2000; 71:546-549
4) Tarnow, D. , N. Elian , and P.
Fletcher . et al. Vertical distance
from the crest of bone to the height
of the interproximal papilla between adjacent implants. J Periodontol 2003.
à DT page 14

‘The peri-implant
bone is almost completely nourished
by the histological, double-layered
bone membrane’

the bone. The iatrogenic detachment of the periosteum can lead
to poorly nourished bone after
weeks, months or years. Consequently, an iatrogenic mucoperiosteal flap is not recommended.
However, if the gingival thickness
is 4 mm or more, crestal incisions
(also flapless) can be performed.
The peri-implant, gingival
structures and the periosteum,
which nourishes bone, remain
intact. Physiological bone loss is
very unlikely to occur. Current
studies and clinical findings over
16 years have shown that the
periosteum preserving flapless
MIMI® method is very beneficial18-23.
Drilling templates have not
always shown to be particularly
accurate to perform MIMI®. On
the one hand, the diameter of the
Champions® implant is not congruent with the diameter of the
conical triangular drills.
On the other hand, studies
have compared virtually planned
implant positions using current
DVT-based
navigation-guided
templates with achieved implant
positions, also involving the use
of drills with diameters congruent with the implant diameters.

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Birmingham

Manchester

London 2 Devonshire Place, London W1G 6HJ
Manchester Mansion House, 3 Bridgewater Embankment, WA14 4RW
Birmingham 2nd Floor, Varsity Medical Centre, 1a Alton Road, B29 7DU

London

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14 Implant Tribune

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Fig 19

Fig 21
Fig 20

Fig 23

Fig 22

Fig 25

Fig 30

Fig 35

Fig 26

Fig 27

Fig 31

Fig 28

Fig 32

Fig 36

Fig. 19 - 24: When inserting the implants using the flapless and
periosteum preserving MIMI® method, we drill the bone cavity
transgingivally at a rotation speed ranging from 50 – 250 rpm
with the conical triangular drills, depending on the bone density.
In most cases, this is done without water cooling. The cylindrical
drills are additionally used to prepare the D1 and D2 bone. For
preparing the soft D3/D4 bone, it is sufficient to use the conical triangular yellow drill and special bone condensers. After each step,
the bone cavity must be checked with the thin BCC (Bone Cavity
Check) probe. While avoiding bone overheating, a two-piece Champions (R)Evolution®, which is equipped with an Insert/Shuttle, can
be inserted at a torque ranging from 40-60 Ncm without deforming or breaking the inner thread and the thin titanium part (for
instance, a 3.5 mm-diameter implant has an approx. 0.4 mm-thick
outer part). Sufficient primary stability can be achieved.

Fig 24

Fig 37

Fig 33

Fig 38

Fig 29

Fig 34

Fig. 25 - 29: The bacteria-proof platform-switched Shuttle (see Fig. 11 and
„2“), which is set in the implant cone,
is restored with a Gingiva-Clix. The
Gingiva-Clix is made from white biocompatible WIN!, and it is available in 6
combinations of heights and dimensions.
During the bone remodeling phase within
8 weeks following surgery, the GingivaClix stays on the Shuttle. After 8 weeks,
the Gingiva-Clix is removed, and with
this particular Clix type, the gingiva is
shaped irritation-free. An impression post
is transgingivally set in the Shuttle and
manually screwed…

Fig. 30 - 34: The Impression Coping is
set. After making the impression and the
supraconstruction, the Shuttle, which
is connected to the implant, is removed
with the Shuttle Extractor. The Shuttle is
removed for the first time, while the screw
remains uncontaminated. After removing the Shuttle, the Abutment (ICA zircon
abutment) is screwed seal-tight, preventing
bacterial migration. Finally, the crown is
cemented and fit.

Fig. 37: View of the implant in Tooth site 14: when the Shuttle was
removed from the implant, the inner thread and the exterior wall of the
Champions -(R)Evolution® remained intact and was not contaminated
with bleeding, saliva and bacteria.
Fig: 38: After removing the Shuttles, the Abutments for Ball-Head are
screwed with the Insertion Aid that is also used for one-piece Champions®.
Fig. 39 - 40: The Shuttles are removed from the implants (without local
anesthesia because the treatment, including the impression, is performed
supragingivally).

Fig 39

Fig. 35 - 36: After removing the small implant/Shuttle connecting screw, you can easily
remove the Shuttle from the Champions-(R)Evolution® with the Shuttle-Extractor. This
procedure is performed either about 8 weeks after implantation (transition between
Primary Osseointegration Stability and Secondary Osseointegration Stability) in many
cases or immediately after the insertion of the implants like in this case.

Fig 40

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74:1785–1788.
5) Berglundh T, Lindhe J, Ericsson I, Marinello CP, Liljenberg
B, Thomsen P. : The soft tissue
barrier at implants and teeth.
Clin Oral Implants Res. 1991 AprJun;2(2):81-90.
6) Buser, D., Weber, H.P., Donath,
K., Fiorellini, J.P., Paquette, D.W.,
Williams, R.C.: Soft tissue reactions to non-submerged unloaded
titanium implants in beagle dogs.
J Periodontol 1992;63:225-235
7) Abrahamsson, I., Berglundh,
T., Wennstrom, J. , Lindhe, J.: The
peri-implant hard and soft tissues
at different implant systems. A
comparative study in the dog. Clin
Oral Implants Res 1996;7:212-219
8) Abrahamsson, I., Berglundh, T.,
Moon, I.S. , Lindhe, J.:Periimplant
tissues at submerged and non-submerged titanium implants. J Clin
Periodontol 1999;26: 600- 607
9) James RA, Kelln EE.: A histopathological report on the nature
of the epithelium and underlying
connective tissue which surrounds
oral implants. J Biomed Mater
Res. 1974;8(4 Pt 2):373-83.
10) Ericsson, I., Persson, L.G.,
Berglundh, T., Marinello, C.P.,
Lindhe, J, Klinge, B. : Different
types of inflammatory reactions
in peri-implant soft tissues. J Clin
Periodontol 1995;22:255-261
11) Tillmanns HW, Hermann JS,
Cagna DR, Burgess AV, Meffert
RM: Evaluation of three different dental implants in ligatureinduced peri-implantitis in the
beagle dog. Part I. Clinical evaluation. Int J Oral Maxillofac Implants 1997;12:611-620
12) Zipprich H (Universität
Frankfurt am Main): Überprüfung der konischen Implantat/
Abutmentverbindung des Champion (R)Evolution® Systems mit
3,5mm, 4,0 und 4,5mm Durchmessern auf Bakteriendichtigkeit auf
Belastung mit 0N, 175N und 200
N auch im Vergleich mit anderen
Implantat- Systemen, Mai-November 2012, noch nicht veröffentlicht
13) Chen ST, Beagle J, Jensen SS,
Chiapasco M, Darby I. Consensus statements and recommended
clinical procedures regarding surgical techniques. Int J Oral Maxillofac Implants 2009; 24 Suppl:
272-278.
14) Crespi R, Capparè P, Gherlone
E, Romanos GE: Immediate occlusal loading of implants placed
in fresh sockets after tooth extraction. Int J Oral Maxillofac Implants. 2007 Nov-Dec;22(6):955-62
15) Telleman G, Raghoebar GM,
Vissink A, Meijer HJ.: Impact of
platform switching on inter-proximal bone levels around short
implants in the posterior region;
1-year results from a randomized
clinical trial. J Clin Periodontol.
2012 Mar 29. doi: 10.1111/j.1600051X.2012.01887.x.
16) Romanos GE, Nentwig GH:
Immediate functional loading
in the maxilla using implants
with platform switching: fiveyear results. Int J Oral Maxillofac Implants. 2009 NovDec;24(6):1106-12
17) Esposito M, Cannizzaro G,
Soardi E, Pistilli R, Piattelli M,

Implant Tribune 15

May 2014

Ramakrishnan T, Ambalavanan
Corvino V, Felice P.: Posterior
N: The efficicacy of flapless imatrophic jaws rehabilitated with
plant surgery on soft-tissue proprostheses supported by 6 mmfile comparing immediate loadlong, 4 mm-wide implants or by
ing implants to delayed loading
longer implants in augmented
implants: A comparative clinical
bone. Preliminary results from
study. J Indian Soc Periodontol,
a pilot randomised controlled
2010 Oct;14(4):245-51
trial. Eur J Oral Implantol. 2012
20) Al-Juboori MJ, bin AbdulrahaSpring;5(1):19-33.
man S, Subramaniam R, Tawfiq
18) Chen ST, Darby IB, Reynolds
OF: Less morbidity with flapless
EC, Clement JG. Immediate imimplant. Dent Implantol Update,
plant placement postextraction
2012 Apr;23(4):25-30
without flap elevation. J Periodon21) Müller CK, Thorwarth M,
tol 2009; 80:163-172.
The membrane you can trust_Layout 1 15/10/2013 13:10 Page 1
Chen J, Schultze-Mosgau S: A lab19) Ravindran DM, Sudhakar U,

Aug;26(4):760-7.
23) Tsoukaki M, Kalpidis CD,
Sakellari D, L Tsalikis, Mikrogiorgis G, A. Konstantinidis: Klinische,
radiologische, mikrobiologische
und immunologische ImplantatErgebnisse nach chirurgischem
Zugang mit oder ohne Lappenbildung: eine prospektive randomisierte kontrollierte klinische
Studie, Clin Oral Implants Res.
18. Juni 2012. doi: 10.1111/j.16000501.2012.02503.x.
24) Dreiseidler T, Tandon D,

oratory study comparing the effect of ridge exposure using tissue
punch versus mucoperiosteal flap
on the formation of the implantepithelial junction. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod. 2012 Jan 25
22) Mueller CK, Thorwarth M,
Schultze-Mosgau S.: Histomorphometric and whole-genome expression analysis of peri-implant
soft tissue healing: a comparison
of flapless
and open surgery. Int J Oral Maxillofac Implants. 2011 Jul-

à DT page 16

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The membrane
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www.bio-gide.com
1

Schwarz F et al. Clin. Oral Implants Res.

;

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16 Implant Tribune

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May 2014

ß DT page 15

Kreppel M, Neugebauer J, Mischkowski RA, Zinser MJ, Zöller
JE.: CBCT device dependency
on the transfer accuracy from
computer-aided
implantology
procedures. Clin Oral Implants
Res. 2012 Sep;23(9):1089-97. doi:
10.1111/j.1600-0501.2011.02272.x.
Epub 2012 Jun 11.
25) Zafiropoulos GG, Deli G, Bartee BK, Hoffmann O. a case series
using two different implant designs. J Periodontol 2010; 81:604615.Single-tooth implant place-

Fig 41

Fig 44

tions. J Oral Maxillofac Surg
2009; 67:89-107.
28) Linares A, Mardas N, Dard M,
Donos N.: Effect of immediate or
delayed loading following immediate placement of implants with
a modified surface. Clin Oral Implants Res 2011; 22:38-46.
29) Atieh MA, Payne AG, Duncan
WJ, Cullinan MP.: Immediate restoration/loading of immediately
placed single implants: is it an
effective bimodal approach? Clin
Oral Implants Res 2009; 20:645-

ment and loading in fresh and
regenerated extraction sockets.
Five-year results:
26) Mura P. Immediate loading
of tapered implants placed in postextraction sockets: Retrospective
analysis of the 5-year clinical outcome. Clin Implant Dent Relat Res
2010.
27) Block MS, Mercante DE,
Lirette D, Mohamed W, Ryser M,
Castellon P.: Prospective evaluation of immediate and delayed
provisional single tooth restora-

Fig 42

Fig 45

Fig 46

Fig 51

Fig 47

Fig 48

Fig 49

Fig. 47 - 49: After eight weeks, when – independent of bone type – the transition of all Champions® from Primary Osseointegration
Stability to Secondary Osseointegration Stability can be assured, we remove the Gingiva-Clix and the small screw from the Insert/
Shuttle and screw the metal impression posts in the Insert/Shuttle. In this case, we prepared Tooth 45, which was then provided
with a crown. The impression can be made without removing the Insert/Shuttle from the implant and without contaminating the
implant with saliva. The impression of this two-piece implant system is made transgingivally or supragingivally. Implant exposure and anesthesia are usually not necessary.

Fig 52

Fig. 50 - 52: After taking X-rays, we fixed the white impression copings on the metal impression posts and made a
closed impression.

Fig 56

J Periodontics Restorative Dent.
2012 Feb;32(1):29-37
32) Glauser R, Ruhstaller P, Windisch S, Zembic A, Lundgren A,
Gottlow J, et al.: Immediate occlusal loading of Branemark
System TiUnite implants placed
predominantly in soft bone: 4-year
results of a prospective clinical
study. Clin Implant Dent Relat Res
2005;7 Suppl 1:52-59.

Fig. 41-43: The initial situation in the 4th quadrant
shows concave parts and alveolar structures that were
not completely ossified. Tooth 23 could not be preserved,
so the model cast prosthesis was widened by Tooth 23 in
the maxilla. After the patient had received a periodontal
treatment and had been informed about possible therapy
solutions, the patient opted for a fixed implant-supported
restoration in the sites 46 and 47. We provided the patient with a passive-fitting restoration. Tooth 45 was also
provided with a crown. In this way, the patient was able
to “feel” his implants.

Fig 43

Fig. 44 - 46: The patient was treated under anesthesia (UDS forte). He was given 600 mg
Ibuprofen. With the yellow, black, white and blue drills, we drilled in the D1/D2 bone at a
maximum rotation speed of 250 rpm. Then, we checked the bone cavity quality with the BCC
(Bone Cavity Check) probe. Then, we inserted the Champions (R)Evolution® implant with
the Insert/Shuttle, which had been fixed on the implant at a torque of only 10 Ncm Ex Works,
at torques ranging from 40 to 60 Ncm. In most cases, the Shuttles remain aleo loco. Then, we
set Gingiva-Clix on the Champions®-Insert/Shuttle immediately after an X-ray check. The
Gingiva-Clix, which are made from biocompatible WIN! serve as transgingival healing caps.
They are available in a combination of six widths and heights.

Fig 50

659.
30) Crespi R, Capparé P, Gherlone
E, Romanos GE : Immediate versus delayed loading of dental implants placed in fresh extraction
sockets in the maxillary esthetic
zone: a clinical comparative study.
Int J Oral Maxillofac Implants.
2008 Jul-Aug;23(4):753-8
31) Crespi R, Capparè P, Gherlone
E, Romanos G.: Immediate provisionalization of dental implants
placed in fresh extraction sockets using a flapless technique. Int

Fig 53

Fig 54

Fig 55

Fig. 53 - 55: The abutments are chosen. Then, the final prosthodontic restoration is fabricated. When fitting
the prosthodontic restoration, the Gingiva-Clix are removed, and the Inserts/Shuttles are removed from the
implant for the first time. With a Pattern Resin key, you can set the abutments in the 9.5° Champions inner
cone and screw them at a torque of 30 Ncm.

Fig 58

Fig 57

Fig. 56 - 58: After closing the abutment screws with Cavit, the crowns can be fixed with ImplantLink semi (company Detax, Champions- Liga).

Fig 59

Fig 60

Fig. 59: This figure shows 8 placed 3.5 mm-diameter and 10 mm-diameter Champions
(R)Evolution® implants, which were inserted transgingivally using the flapless MIMI®
method. The bone cavity depth corresponded to the implant length. After each drilling
and step, the bone cavity was checked in all dimensions. After taking X-rays, the Insert/
Shuttle was removed, and the implants were immediately restored with Ball-Head
Abutments to fix the prosthesis in the maxilla. Because of the gentle, patient-friendly and
periosteum preserving keyhole and flapless MIMI® method, which is indicated in at
least 80% of the cases, you hardly see any bleeding and open wounds. With this method,
swelling, pain, and hematomas following an implantation are now a thing of the past in
many cases. However, even if this technique might be quite easy to learn, it is not always
suitable for beginners in Implantology. In order to apply the MIMI® method successfully,
it is necessary that the dentist has enough experience in Implantology and that he/she has
considerable manual dexterity.
Fig. 60: This 99 year-old patient from Munich (patient at risk) was the oldest patient
worldwide who was treated with implants using the flapless MIMI® method. In June
2011, this lady was provided with four implants to support a full prosthesis in the mandible. Under local anesthesia, surgery lasted about 20 minutes, and the preparation of the
restoration and matrices in the dental laboratory took about 2 hours. Two hours following surgery, she was able to eat an apple strudel. Two years later, she was still satisfied
with her implants and did not experience any pain.

[7] =>

United Kingdom Edition

May 2014

Implant Tribune 17

Fabrication of a customised implant abutment using
CAD/CAM: A solution specific to each clinical case
Dr Thierry Lachker describes an implant case

he multiplicity and sophistication of the offering in the field of prosthetic elements in implantology
allow the practitioner to make a
choice appropriate to the clinical particularities of each case. If
the practitioner chooses a standard implant abutment, the dental technician will have to make
adjustments, which implies considerable losses in precision and
time. Moreover, with such abutments it is difficult to create an
anatomical emergence profile
because it cannot be modified
and the base of the abutment
cannot be changed. This observation is equally applicable
to the angulation, which might
even be selected by default.
A customised abutment created with CAD/CAM is the most
accurate and simplest solution
for an optimal result. The abutment is individually designed in
order to ensure the homothety of
the thickness of the materials and
therefore the overall strength of

‘A customised abutment created with
CAD/CAM is the
most accurate
and simplest solution for an optimal
result’
C

CMY

the prosthesis. The dental technician has in this case maximum
freedom in terms of design in order to create an abutment with
the optimum emergence profile
and angulation. In this manner,
the abutment is specifically designed and fabricated for each
patient.
Titanium has been established in dental implantology as
the reference material owing to
its biomechanical properties and
its biocompatibility. Today, we
are able to benefit from over 40
years of clinical and experimental experience in implantology.
Customised abutments can be
fabricated from titanium, zirconia or hybrid materials, such as
a combination of titanium and
zirconia, which in certain clinical circumstances improves the
aesthetics of the visible areas
while respecting the requirements of biocompatibility and
biomechanics.

sented for treatment. He had no
Seating a four-unit bridge
particular medical conditions or
on three anatomical implant
any contra-indications concernabutments
ing the placement of implants. In
Clinical DentalTribune_CO_A4_June13.pdf
case
1 17/06/2013 20:03:40
2009, the patient had undergone
A 40-year-old male patient pre-

a sinus lift (an increase of the
maxillary bone volume and the
displacement of the sinus membrane to ensure implant success
by increasing the height of the

available bone) at a hospital prior to the placement of implants
to replace teeth 15–17. The postoperative sequelae (pain, oedeà DT page 18

[8] =>

18 Implant Tribune

United Kingdom Edition

May 2014

ß DT page 17

mas, etc.) resulted in the patient
being entirely opposed to another intervention of this kind on
the opposite side of the mouth.
During an appointment in
October 2011, I was able to persuade the patient to accept implant treatment. I suggested first
removing the three-unit bridge
on teeth 23–25 and then extracting the roots of teeth 23 and 25,
as well as seating of a denture
on the day of the extraction, followed by placement of three implants in regions 23–25, the extraction of tooth 26, and seating
of a four-unit bridge as the final
prosthetic solution.
As the height of the available bone around tooth 26 was
insufficient, I would not place an
implant in that area but a tooth
extension (a sinus lift would otherwise have been essential). The
treatment plan was accepted by
the patient two weeks later, and
teeth 23 and 25 were extracted at
the end of the month.
The patient was seen on
10 January 2012 for implant
placement: two implants (NobelReplace RP, Nobel Biocare)
with a diameter of 4.3mm and
a length of 13mm for regions 23
and 24, and one implant (Nobel-

‘Customised CAD/
CAM prosthetic
elements and abutments respect the
dental anatomy
and allow extremely precise seating
of a bridge on implants’

allow extremely precise seating
of a bridge on implants. Periodontal maintenance is therefore
easier owing to easy access with
a toothbrush because of the predetermined interdental spaces.
The simplicity of the process
saves a considerable amount of
time: no adjustments are necessary, the bridge is seated immediately, the occlusion is usually
ideal, and greater accuracy can
be achieved. In addition, only
two appointments are necessary:
one for impression taking and
another for seating of the bridge.

Replace WP) with a diameter
of 5mm and a length of 10mm
for region 25. Tooth 26 was extracted on the same day without
placement of an implant as already mentioned.
In May 2012, implant-level
impressions were taken (opentray impression technique), and
the patient’s occlusion was recorded using silicone and a bite
tray. Owing to the constraints
related to the angulation of the
implants in regions 24 and 25,
I opted for titanium abutments.
The angle of the implant in region 23 allowed for the insertion
of a titanium–zirconia abutment
for good gingival grip and a better aesthetic result.
Ten days later, two titanium
abutments (ANA. T, Laboratoire
Dentaire Crown Ceram) and
one titanium–zirconia abutment
(ANA. TZ, Laboratoire Dentaire
Crown Ceram) were screwed
onto the implants at a torque of
35N, and sealed with compos-

ite. An adjustment check of the
contact points and of the occlusion was performed, followed by
cementation of a ceramic bridge
with a zirconia framework. A
follow-up visit took place three
days later.
Technique
For this case, it was possible to
use abutments made from different materials according to
the angulation of the implant:
titanium for the pronounced
angulations, and a combination

of titanium and zirconia for the
angulation with no particular
constraints. It would have been
equally possible to use a titanium abutment for the implant
in region 23 but I opted for the
titanium– zirconia abutment to
obtain a better aesthetic result
in the anterior region: brightness, translucency and no visible
metal margin.
Customised CAD/CAM prosthetic elements and abutments
respect the dental anatomy and

Dental technician’s perspective
When the laboratory (Laboratoire Dentaire Crown Ceram) received this case, we were asked
to create three customised anatomical abutments with a titanium interface for an individual
and more precise fit, respecting
the requirements of biocompatibility and biomechanics, and a
coronary part in zirconia for a
better aesthetic result.
Once the moulds had been
cast, we determined that the
considerable angulation of the
implants in regions 24 and 25
and their shallow position in the
tissue posed difficulties regarding the design of titanium–zirconia abutments. However, Dr
Lachkar explained to us that in

this case (ie the patient’s reluctance to undergo pre-implant
surgery) he was forced to place
the implants in the bone available and not necessarily in the
ideal situation according to a
prosthetic plan.
In this case, the titanium interface would have considerably
exceeded the buccal surface and
it would therefore have been
necessary to reduce it. The bonding surface would therefore have
been limited, which would have
resulted in a great loss of mechanical resistance. We thus decided to use a titanium abutment
manufactured from a single
block and specially made to allow
for such substantial angulations
for teeth 24 and 25. For tooth 23,
the implant angle allowed for
a titanium–zirconia abutment,
which was preferred to a titanium abutment for a better aesthetic result. DT

About the author
Dr Thierry Lachkar is a dental
surgeon (Paris Diderot University)
and has been a
practitioner for 15
years. He is a general practitioner
and he works at a dental surgery in
Paris. He has specialist postgraduate
training in conservative dentistry and
in endodontics. He can be contacted
at drlachkar@yahoo.fr.

[9] =>

United Kingdom Edition

Implant Tribune 19

May 2014

Treatment options for peri-implantitis
A look at options for peri-implantitis therapy

T

he idea of creating
a
prosthetic
dental
implant to replace a
missing tooth is certainly not
a new one – in fact, there is
evidence of early civilisations
using dental implants as far
back as 4,000 years ago, when
the Chinese made bamboo
into dental pegs – and 2,000
years ago when the Egyptians
fashioned pegs out of precious
metals. Millions of dental
implants are placed every
year on partially and fully
edentulous patients – most of
which achieve long-term success and do not develop complications.

plants – opting for the invasive
treatment because the patient
requests it, or simply expects
it and is unaware that there
are other non-invasive solutions available that don’t run
the risk of infection.

Awareness among dentists about peri-implantitis is
growing and most are aware
that it is no longer rare – although knowledge of the aetiology of peri-implant diseases

number in coming years, as
studies have shown that occurrence of peri-implantitis
increases with the number
of years that the implant has
been in place .

à DT page 20

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Booming business
The number of dental implant
purchases is on the increase,
with
approximately
five
million being sold annually.
It is a very popular treatment
option for people in Asia,
as well as the Middle East,
in particular, Israel – and
has been rising in popularity the world over since the
modern implant was introduced in the 1970s. Some
dentists now believe that
we are placing too many im-

Cases demonstrating biologic
complications
such
as peri-implantitis and the
less
serious
peri-implant
mucositis, which is often
the precursor to peri-implantitis, look set to increase in

[10] =>

20 Implant Tribune
ß DT page 19

is still work in progress. This
has meant that there is currently no consensus or gold
standard as to how to treat
peri-implantitis, as there is
limited scientific evidence
available to back up either
surgical or non-surgical treatment, or explantation of the
dental implant.
Peri-implant diseases
If peri-implant mucositis is

allowed to develop, it turns
into peri-implantitis, which
can lead to progressive loss of
the supporting bone, and implant failure – and is therefore
much more complex to treat.
Peri-implant diseases are
caused by bacterial infection
and/or biomechanical overload, which cause the inflammation. Patients with existing periodontal disease and
poor oral hygiene habits – and
smokers in particular – are
very susceptible to developing

United Kingdom Edition
a peri-implant disease.
Poor oral health and plaque
control are a big cause of
peri-implant diseases, and often occur due to the patient’s
reticence to clean the area
due to fear of pain or bleeding.
Additionally, the patient may
be unable to brush and floss
properly due to the implant’s
positioning or design increasing bacterial prevalence.
Diagnosis and treatment
It’s important to ensure that

the dental team works together to spot the warning signs
of peri-implant diseases – as
these are often not noticed
until they become more severe – and that each member of staff is knowledgeable about the risk factors,
signs and symptoms in order
to achieve early diagnosis
and intervention. It is also a
good idea to partner with a
periodontist as soon as possible
following
diagnosis.
Evidence suggests that periimplant mucositis can be

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treated effectively if detected
early, and is easily treated
non-surgically. Prevention is
possible with regular monitoring of dental implants, comprehensive periodontal evaluation and proper periodontal
maintenance.
Peri-implantitis can be
treated with mechanical debridement with antiseptics
such as chlorhexidine, or
surgery – or when all other

‘It’s important to
ensure that the
dental team works
together to spot
the warning signs
of peri-implant
diseases’

therapies fail explanation. It
is preferable to try a nonsurgical
treatment
first,
where possible. In terms of
the merit of using antibiotics,
Stefan Renvert et al in 2012
found that the use of antibiotics makes no difference.
Many bacteria are now also
resistant to most antibiotics –
we’re in the era of widespread
antibiotic
and
multi-drug
resistance.
In cases where just an
implant is affected by periimplantitis, a non-surgical
approach can have its merits. For example, scaling and
root planing combined with an
antiseptic such as chlorhexidine digluconate. This has
been clinically proven as an
effective adjunctive treatment
for peri-implantitis and an effective first-line treatment for
periodontal pocketing.
In conclusion, as with all
inflammatory diseases, early
detection and intervention of
peri-implant mucositis and
peri-implantitis is the best
solution – however in cases
that do develop, judge the
merits of a non-surgical approach on a case by case basis
and choose this option where
possible to avoid invasive surgery. More study is needed on
peri-implant diseases; we still
do not know enough about
them and require further research to substantiate emerging claims. DT
Prescribing
for PerioChip
request.

See demonstrations at www.pearldentalsoftware.com
Call us on 0800 027 2406 and get a TRIAL COPY
Prices Exclude VAT

BHA-A4-ad-Mince pie (Dentistry).indd 1

14/02/2014 16:52

May 2014

information
available on

About the author
For more information or to contact
the team behind PerioChip®, email
team@periochip.co.uk or call 0800
013 2333

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[cover] => Implant Tribune UK No. 2, 2014

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Table of contents

[toc_titles] =>

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