implants international No. 4, 2024

Cover / Editorial / Content / Immediate or delayed loading in the completely edentulous mandible / Torque factor in implant dentistry / Impact of periodontitis on systemic health and on implants / Immediate implant placement and provisional restoration in the aesthetic zone / Maxillary fixed full-arch rehabilitation / Full-arch dentistry with dynamic navigation and photogrammetry / Dentistry innovations through research collaboration / Events / Manufacturer news / News / Imprint

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Table of contents

issn 1868-3207 • Vol. 25 • Issue 4/2024

implants

4/24

© gfx_nazim – stock.adobe.com

international magazine of oral implantology

research

Torque factor in implant dentistry

case report

Maxillary fixed full-arch rehabilitation

industry

Dentistry innovations through
research collaboration

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1 Ratka C. et al. JCM. 2019;8(9):1397. 2 Bosshardt DD. et
al. Clin Oral Invest. 2022;26(4):3735–3746. 3 Zipprich H.
et al. Clin Oral Invest. 2022;26(6):4549–4558. 4 Schlee.
et al. JCM. 2019;8(11):1909. 5 Schlee M. et al. JCM.
2021;10(16):3475. 6 Data on file, GalvoSurge AG.

[3] =>

editorial

|

Dr Georg Bach
President of the DGZI

Insights and innovations in oral
implantology
Dear colleagues!
In this last issue in 2024, we delve into groundbreaking
research and innovative practices that are pushing the
boundaries of dental implantology. The spotlight on critical topics such as the impact of periodontitis on systemic
health, implant stability with torque factor adjustments,
and full-arch rehabilitation in edentulous patients illustrates the magazine’s commitment to connecting emerging science with clinical applicability.
One of the key discussions in this issue is the comparative analysis of immediate versus delayed loading protocols in the fully edentulous mandible. Research by
Drs Harichane, Chiri, and Droz Bartholet offers insight
into the delicate balance between patient satisfaction,
tissue health, and implant longevity, proposing a cautious
approach to immediate loading to mitigate failure risks
while recognising the value in specific clinical scenarios.
Readers will find detailed case studies illustrating fullarch rehabilitations and immediate provisional restorations, emphasising clinical techniques that enhance
both aesthetic outcomes and patient satisfaction. The
case studies by Drs Lopes, Santos, and Guedes underscore the utility of zygomatic implants in addressing
severe bone atrophy, pushing the All-on-4 protocol further with an eye on patient comfort and predictability.
In this issue’s industry section, we explore how digital
workflows and interdisciplinary collaborations are revolutionising implant procedures, from diagnosis through to
final restoration. Advances such as dynamic navigation

systems and real-time photogrammetry are accelerating
the accuracy and efficiency of implant placements, transforming patient outcomes.
Each article in this issue reflects our shared commitment
to pushing the boundaries of what’s possible in implantology. Together, through continued learning and innovation, we can shape a future where treatments are ever
more precise, resilient, and life-changing for our patients.
May these insights inspire you to explore new horizons
in your practice and to contribute to the collective
advancement of our field.
Enjoy reading the magazine!
Sincerely,

Dr Georg Bach
President of the German Association of
Dental Implantology

Dr Georg Bach

4 2024

03

[4] =>

| content
editorial
Insights and innovations in oral implantology

03

Dr Georg Bach

research
Immediate or delayed loading in the completely
edentulous mandible
page 06

06

Drs Yassine Harichane, Rami Chiri & Benjamin Droz Bartholet

Torque factor in implant dentistry

12

Dr Sushil Koirala

Impact of periodontitis on systemic health and on implants

18

Prof. Curd Bollen, Prof. Paul Tipton, Dr Mishel Kocharyan &
Prof. Gagik Hakobyan

case report
Immediate implant placement and provisional restoration
in the aesthetic zone
page 22

22

Drs Luiz Otavio Camargo, Livia Lamunier de Abreu Camargo &
Lucio Kanashiro

Maxillary fixed full-arch rehabilitation

30

Drs Armando Lopes, Diogo Santos & Carlos Moura Guedes

Full-arch dentistry with dynamic navigation
and photogrammetry

34

Dr Emilien Tronc

30 years OEMUS MEDIA
page 30

39

industry
Dentistry innovations through research collaboration

40

events

Cover image courtesy of ClaroNav Inc.
www.claronavdental.com
showing the MicronMapper (see also page 46)

Advancing interdisciplinary exchange in dentistry and
dental technology

43

EAO Congress 2024: Advancing excellence in implant dentistry

44

news
manufacturer news

46

news

48

about the publisher
imprint

04

4 2024

50

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[1] Semper-Hogg, W, Kraft, S, Stiller, S et al. Analytical and experimental position stability of the abutment in different dental
implant systems with a conical implant–abutment connection Clin Oral Invest (2013) 17: 1017.
[2] Semper Hogg W, Zulauf K, Mehrhof J, Nelson K. The influence of torque tightening on the position stability of the
abutment in conical implant-abutment connections. Int J Prosthodont 2015;28:538-41.
CONELOG® is a registered trademark of CAMLOG Biotechnologies GmbH. It may however not be registered in all markets.

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| research

Immediate or delayed loading in the
completely edentulous mandible
Drs Yassine Harichane, Canada, Rami Chiri & Benjamin Droz Bartholet, France

Rehabilitation of complete mandibular edentulism is
considered a clinical challenge in dentistry. Conventional
removable complete dentures have limitations that compromise the patient’s quality of life. The McGill consensus
recommended the mandibular two-implant overdenture
as the standard of care, and it helps improve retention
and masticatory efficiency.
To achieve osseointegration, Brånemark et al. suggested
that implant loading should be done after at least three
months for the mandible and six months for the maxilla.
With scientific research, the healing time has been reduced.
In 2008, the International Team for Implantology consensus meeting set out the following definitions of the loading
protocols (Fig. 1):
· immediate loading: during the first week after implant
placement.
· early loading: between one week and two months after
implant placement.
· conventional or delayed loading: more than two months
after implant placement.
Studies have shown that immediate loading is comparable to delayed loading for fixed prostheses. However, no
consensus exists on the timing of implant loading for
mandibular implant-supported overdentures. Our study
sought to answer the question of whether immediate
loading provides better clinical results compared with
delayed loading for mandibular implant-supported overdentures.

Implant survival
One year of observation is necessary to evaluate the effect
of immediate loading on osseointegration. From analysis
of recent scientific literature, it appears that implants
loaded immediately have a higher failure rate than those
with delayed loading. However, the difference is not statistically significant. Nonetheless, the authors recommend
delayed loading rather than immediate loading.
Implant placement can follow the one- or two-stage surgical protocol (Fig. 2). However, there is no significant difference in terms of early implant loss between the different surgical stages. The placement of implants according

4 2024

1
Fig. 1: Implant loading timeline.

to the one-stage protocol therefore does not seem to
affect either implant or crestal bone loss.
A relevant parameter during immediate loading is the
measurement of insertion torque or implant stability quotient (ISQ). Generally, during multiple restorations, a minimum torque of 20 Ncm is required, but this is not a guarantee of implant survival. Studies that measured ISQ
have reported a significantly greater difference for delayed
loading at three months; however, beyond three months,
no difference was found between immediate and delayed
loading.

Peri-implant soft and hard tissue
The evaluation of soft-tissue indices (plaque index, probing depth, bleeding on probing, etc.; Fig. 3) indicates similar values between immediate and delayed loading at
one year. Crestal bone loss of less than 1.5 mm has been
cited as a criterion for implant survival. It should be noted
that an average of 1 mm of marginal bone loss normally
occurs during the first year and is followed by a loss of
0.2 mm each year. The meta-analyses included did not
find any statistical difference between the two loading
protocols.

Type of attachment
Analysis showed that different types of attachments did
not result in a statistically significant difference between
immediate loading and delayed loading. Furthermore, no
difference was found between splinted and non-splinted
implants (Fig. 4). However, probing depth appeared to be
lower with a ball attachment and delayed loading rather

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| research
than with a bar and immediate loading. This can be
explained by the easier cleaning of the ball, whereas the
bar, being less easily cleaned, can lead to gingival hyperplasia. A single meta-analysis has shown that delayed
loading is preferable with ball or LOCATOR attachments
(Zest).

Number of implants
Most of the studies we included compared two implants
versus four and found no significant differences. During
the initial years of mandibular implant overdenture treatment, four interforaminal implants were used with a
secured bar. Over the years, the use of two implants with
axial or bar-connected attachments has proved to be as
effective as the four-implant bar option. The results of the
meta-analyses included indicate that there is no difference in implant failure or marginal bone loss with immediate or delayed loading when two unsplinted or four
splinted implants are used (Fig. 5). Concerning overdentures supported by one or three implants, the research
is insufficient in quantity and quality to determine statistically significant differences.

Patient’s oral health-related quality of life

discomfort or pain caused by the interference of healing
screws with the existing prosthesis.
From our literature review, no significant difference
between immediate and delayed loading with regard to
patient discomfort, pain or oedema has been reported.
One explanation could be that the procedures were rarely
uncomfortable, the number of patients included was too
small and the questionnaires were not sensitive enough
to detect differences.
The same arguments could be made for patient satisfaction, as most patients were very satisfied with the treatment. The lowest satisfaction score was found for satisfaction with the temporary prosthesis. At one year, studies
have found no difference in patient satisfaction between
immediate and delayed loading protocols (Fig. 6). This
may indicate that patients may have forgotten the procedure over time. Thus, the claimed greater patient satisfaction with immediate loading is not supported by solid
evidence. The patient’s perception of the implant treatment is more dependent on other factors than the loading
protocol. Patients can accept temporary discomfort if they
are convinced that it is essential to obtaining a stable
long-term result.

Patient satisfaction may be associated with the stability
obtained once the patient’s removable prosthesis has
been converted to a fixed implant-supported prosthesis.
Dissatisfaction with delayed loading may be related to

Prosthetic complications and maintenance

Studies have compared immediate and delayed loading
regarding prosthetic complications and maintenance.

Fig. 2: Comparison of the surgical protocols. Fig. 3: Peri-implant tissue measurement indices.

Fig. 4: Comparison of attachment types. Fig. 5: Comparison of number of implants.

4 2024

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| research
a clinically satisfactory result. The role of the practitioner
is to evaluate the risk–benefit ratio in carrying out such
a procedure. The immediate loading protocol has advantages for mandibular implant-supported overdentures;
nevertheless, the potentially higher risk of implant failure
cannot be ignored. Therefore, the patient should be
informed of the risks and benefits beforehand. Arguments such as patient satisfaction and reduction in the
number of treatment sessions with immediate loading are
not sufficiently relevant given the risk of therapeutic failure.

6
Fig. 6: Patient satisfaction timeline.

Editorial note: This article was first published in
issue 10/2023 of Dental Tribune France.

Literature

The main complications reported for immediate loading
included prosthetic fracture and relining. For delayed
loading, attachment displacement, screw fracture and
denture fracture were more common. No differences were
found between the two loading protocols.

Conclusion

10

about the authors
Dr Yassine Harichane holds a DDS,
MSc and PhD and is in private practice
in Canada.

Based on our reading of recent scientific literature, the
following conclusions can be drawn:
· There is no statistically significant difference in implant
failure rate and marginal bone loss between immediate
and delayed loading for mandibular implant-supported
overdentures.
· The risk of early implant loss (before one year) is higher
with immediate loading compared with early loading.
· The available evidence shows no differences in the
health of peri-implant tissue regardless of the type of
attachment, the number of implants or the loading protocol.
· An overall analysis of all the studies included revealed
that no specific attachment type, number of implants
or loading protocol had a significant advantage over
the other.
· Patient satisfaction and oral health-related quality of life
are similar for immediate and delayed loading protocols.
However, with immediate loading, patients restored with
fixed prostheses are more satisfied than those treated
with removable prostheses. However, this difference
does not persist after one year.
· Prosthetic complications and maintenance of mandibular implant-supported overdentures were similar
between delayed loading and immediate loading.
· Further studies are needed to strengthen the evidence
and make firm recommendations on loading protocols. The available evidence recommends early rather
than immediate loading and delayed rather than early
loading.

contact

In summary, immediate loading in the completely edentulous mandible is a scientifically validated protocol. However, many factors must be taken into account to obtain

Dr Yassine Harichane
North Hatley, Canada
yassine.harichane@gmail.com

4 2024

Dr Rami Chiri holds a DDS and is in
private practice in France.

Dr Benjamin Droz Bartholet holds a
DDS and is in private practice in France.

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| research

Torque factor in implant dentistry
Dr Sushil Koirala, Nepal

Implant systems

Dental implants have revolutionised dentistry, providing a permanent, functional and reliable solution for missing teeth. With advancements in technology, the success
rates and outcomes of implants have become more predictable, solidifying their role in restorative dentistry.

Implants are designed to support the restoration of missing teeth and remain in the jawbone permanently, making
the selection of the right implant system crucial for success. Simplifying the learning and adoption of these systems is essential for long-term practice success.

The practice of implant dentistry should be informed by
the clinical outcomes from a clinician’s own cases based
on long-term records. Clinicians should embrace the role
of practice-based researcher, using their experiences and
documented evidence to help refine implant dentistry into
a more straightforward, predictable and affordable method
of restoring missing teeth.

There are multiple approaches to classification of implant
systems, such as implant design, surface treatment, materials used, implant length and diameter, placement level
and site, prosthetic design, and surgical and restorative
protocols. If you carefully examine the key factors of implant systems based on fundamental biomechanical
principles and core benefits, you will likely find the same
factors that guide my practice.

Numerous implant manufacturing companies around the
world produce a variety of implant designs and suggest different surgical and restorative protocols, each with various
claims. However, many novice practitioners face challenges
in selecting the appropriate implant system and developing
the necessary skills to achieve clinical competency. This often results in an over-reliance on guidance from mentors,
company-backed speakers, marketing materials, social media and financially motivated offers from implant suppliers.

In my 32 years of clinical practice and extensive involvement
in teaching and mentoring in the area of minimally invasive
comprehensive dentistry (MiCD), one of the most challenging questions I frequently encounter from fellow practitioners and trainees worldwide is which implant system
is best and easiest to master. While this question seems
simple, it requires long-term practice-based research and
clinical experience to effectively teach or share skills and
concepts with colleagues in implant dentistry.

To address this issue, leading clinicians worldwide are collaborating to share their long-term research findings, clinical experiences and expert opinions through unbiased,
philanthropic educational platforms. These efforts aim to
support young practitioners and simplify the field of implant dentistry, enhancing affordability and quality of care.

Owing to my passion for sharing and teaching clinical
skills based on my own practice-based research, I have
had the opportunity to work with many like-minded re-

Fig. 1: Interfacial bone remodeling: Insertion torque generates pressure around the surrounding bone of the implant and osteoclastic activities start taking place
with bone resorption. Slowly this resorbed area will be altered by newly formed woven bone, which eventually re-establishes the contact to the implant interface
(secondary biological stability), and will subsequently remodel multiple times toward a lamellar configuration that will support the metallic device throughout its
lifetime. (© Bicon) Fig. 2: Graphic representation of osseointegration pathway of torque-based implant system.

4 2024

[13] =>

research

searchers and academics and well-recognised clinicians
worldwide. This collaboration has given me the opportunity and confidence to use different implant systems and
observe their clinical predictability and long-term success in my own practice. Our group at MiCD Global
Academy has witnessed both successes and failures
across various systems, emphasising the importance of
respecting biology and individual biomechanical adaptation capacity.
Based on these observations, I have proposed a simplified classification for implant systems based on the application or avoidance of the torque factor in implant dentistry. By carefully examining the implant system used in
your practice and how you approach the torque factor,
you can understand the sensitivity of this art and science
during surgical and restorative processes. In this brief article, I will summarise the clinical and scientific facts and
contemporary professional understanding of the torque
factor1–78 that we apply, knowingly or unknowingly, in our
implant dental practice.

|

New classification of dental implant systems
I propose a new classification of implant systems based
on the use or avoidance of the torque factor in implant
placement and prosthesis fixation. This classification aims
to simplify clinical practice, enhance teaching methodologies and support practice-based research in implant
dentistry. By categorising the available systems into two
simple groups, clinicians can more easily choose the appropriate system for their patients, improving outcomes
and streamlining the learning process (Table 1).

Torque-based implant system
The torque-based implant system utilises a threaded design and appropriate torque to place the implant in the
jawbone, following the concept of primary mechanical
stability as the foundation for secondary biological stability, or osseointegration. Primary mechanical stability is
achieved by applying a specific amount of torque to insert
the implant into an under-prepared osteotomy site, creating

Key issues

Torque-based implant system

Torque-free implant system

Implant macro-design

Screw root form

Plateau root form

Healing chambers

None/limited

Well focused and in-built design

Primary mechanical stability

Considered foundation for success

Not applicable

Osteotomy diameter

Smaller than implant diameter

Similar to implant diameter

Preferred implant length

Longer/standard

Shorter (minimally invasive)

Torque application stages

Multiple

Not necessary

Implant insertion torque

Multiple recommendations

Not applicable

Cover screw placement/removable torque

Necessary and based on implant design

Screwless, so not applicable

Healing abutment placement/removable
torque

Necessary and based on implant design

Screwless, so not applicable

Abutment screw placement/removable
torque

Necessary and based on implant design

Screwless, so not applicable

Prosthetic screw placement/removable
torque

Necessary and based on implant design

Screwless, so not applicable

Healing pathway

Interfacial bone remodelling

Intramembranous-like bone remodelling

Healing speed

1–2 µm per day

20–50 µm per day

Primary stability dip phase

Present

Not present

Functional loading protocols

Multiple approach

Single approach

Delayed functional loading (gold standard)

Biological stability dependent

Biological stability dependent

Early functional loading

Possible if primary stability value permits

Not recommended

Immediate functional loading

Possible if primary stability value permits

Not recommended

Table 1: Key issues related to torque factor in implant dentistry. This helps differentiate torque-based and torque-free implant systems, enabling clinicians to
understand the long-term benefits and technique sensitivity of the system they are using or planning to adopt.

4 2024

13

[14] =>

| research

Fig. 3a: Healing extraction socket. Fig. 3b: A torque-based implant (Intra-Lock) was placed with a torque range of 25 Ncm due to the low density of bone at
the time of implant placement (2019), and functional loading was done after four months. Fig. 3c: Bone gain is evident in follow-up X-ray of 2024.

Fig. 4a: Two torque-based dental implants (Intra Lock) were placed (2018) with a torque range of 45–55 Ncm. Fig. 4b: Bone loss was observed (2023) around
implant #46, hence the prosthesis was removed for thorough debridement of the affected area. A new prosthesis with a wider gingival diameter was provided
after two weeks. Fig. 4c: Bone healing noted after one year (2024).

a mechanically stable environment. The primary mechanical stability achieved by such an implant system must
endure the implant stability dip phase of the healing process (Figs. 1–4).

3. High torque during implant insertion can induce tissue
stress, potentially compromising healing. Primary mechanical stability may decrease during the initial healing phase, making immediate and early functional
loading protocols sensitive and often requiring special
measurement tools to confirm stability.
4. Precise torque application demands a high level of surgical skill and experience. Using high-quality, calibrated torque instruments is essential to ensure accuracy. Digital torque wrenches provide precise control,
reducing the risk of human error.
5. Mechanical complications, such as screw loosening and
fracture, and ultimately implant failure may arise from incorrect torque application during the restorative phase.

The general clinical implications of the torque-based implant system are as follows:
1. Primary mechanical stability depends on factors such
as bone density, implant design and the level of torque
application.
2. Assessing the patient’s bone quality is essential before
determining the appropriate torque level. Dense bone
typically requires higher torque, whereas softer bone
necessitates a more conservative approach.

Fig. 5: Intramembranous like bone remodeling: The void spaces left between bone and implant bulk, is referred as healing chambers, will be filled with blood
clot immediately after placement and will not contribute to primary stability. Such healing chambers, filled with the blood clot, will evolve toward osteogenic
tissue that subsequently ossifies through an intramembranous-like pathway. (© Bicon) Fig. 6: Graphic representation of osseointegration pathway of the
torque-free implant system.

4 2024

[15] =>

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Biocare. Nobel Biocare, the Nobel Biocare logotype and all other trademarks are, if nothing else is
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[16] =>

| research

8
Fig. 7: The patient had a history of conventional implant failure, so we decided to place torque-free short implants. (© Bicon) Fig. 8: Three torque-free short
dental implants (Bicon) were placed in the posterior region of the mandibular arch, and the patient was provided with a removable upper denture.

6. Long-term secondary biological stability is often reliable
if primary mechanical stability is successfully achieved
by respecting bone biology and the healing approach.
7. Immediate and early functional loading protocols in
torque-based implant dentistry are becoming popular,
demanding optimal primary mechanical stability and
objective confirmation before seating the prosthesis.

Torque-free implant system
The torque-free implant system avoids primary mechanical stability by keeping the final osteotomy size similar to
the implant diameter. Such implants have built-in healing
chambers that increase the implant surface area, promoting primary biological stability (biologically stable environment) that facilitates faster secondary biological stability. Additionally, such a system incorporates bioactive
surface treatment technology, enhancing the implant’s
ability to bond with bone cells. Since this system does not
rely on primary mechanical stability, there is no primary
stability dip phase during the healing process (Figs. 5–8).

The general clinical implications of torque-free implant
systems are as follows:
1. The gentler approach of placing implants without torque
preserves bone integrity, creating a biologically favourable and stable environment for healing.
2. Placement is less invasive and technically less demanding, potentially reducing surgery time and improving
patient comfort.
3. Patients with poor bone quality or density can benefit
from these innovative solutions.
4. The bioactive surfaces of the implants can accelerate
bone healing and help achieve earlier secondary biological stability.
5. These implants are beneficial in areas with limited bone
volume, where achieving primary stability through torquebased methods is challenging.
6. Since the implant sits passively within the bone, immediate functional loading is not possible, and early loading is not advisable.
7. Implant systems based on torque-free implant dentistry
are suitable for cases with low bone volume and density.

9b
Figs. 9a & b: With the success of torque-free short dental implants, the patient was encouraged to have similar implants placed in the upper arch to avoid
sinus lift and bone graft procedures.

4 2024

[17] =>

Conclusion
As dentists integrate implant dentistry into their practices,
understanding the role of torque and selecting the right
implant system is crucial. Torque-based systems provide
reliable results when precise torque application is achieved,
requiring clinical skill and additional instruments to confirm primary stability for successful immediate or early
functional loading. Torque-free systems offer predictable
results with simplified instruments and are ideal for practitioners who prefer predictable techniques that are less
invasive, often avoiding sinus lift and other grafting procedures.

Lopes
o
d
n
a
m
r
by Dr. A
3

ZYGOMA RETRACTOR
637

Both systems have their place in modern implantology,
each with unique advantages. Recent research and developments indicate that contemporary implant manufacturers are focusing on combining the benefits of both
a mechanically stable environment (tight fit) and a biologically stable environment (healing chambers) in a single
implant through innovative implant design, leading to the
emergence of hybrid implant systems. Only long-term
clinical and practice-based research will determine their
future success.
By leveraging shared knowledge and experience, dentists
can enhance their skills and make implant dentistry more
accessible and rewarding. For further
Literature
learning, explore the MiCD learning station at www.micdglobalacademy.com.

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Zygoma bone retractor

Periosteal elevator

DOUBLE HOOK RETRACTOR
638
638S - slim version
1

7,5mm

Editorial Note: This article first appeared in Implant &
Digital Dentistry—Nepal and is reprinted here with
the publisher’s permission in an edited version.

15mm

Cheek retractor

(like Bishop retractor)

about the author
Dr Sushil Koirala is the founder and
chief instructor of MiCD Global Academy.
He also serves as chairman of National
Dental Hospital Ltd. in Kathmandu, Nepal.
Dr Koirala leads advanced training in
“MiCD Care—Do No Harm Dentistry”
through the Academy of Advanced General Dentistry (AAGD) in Nepal.

3 FUNCTION INSTRUMENT
IN ONE HAND

Lip retractor

FULL ARCH RETRACTOR

639
3

contact
Dr Sushil Koirala
National Center for Oral Implantology
and Tissue Regeneration
National Dental Hospital Ltd
Kathmandu, Nepal
drsushilkoirala@gmail.com

Tissue flap retractor

FOUR APPROACHES FOR
UPPER AND LOWER JAW
INCLUDED IN THE DELIVERY.

Tissue flap and Lip retractor.
Rotating mechanism made
of special PTFE plastic for
adjusting the retractor.
Multiple recessed grips
adapt perfectly to the
palm of the hand.

more
information

Neuenkamper Str. 80-86 | 42657 Solingen | Germany
Tel. +49 (0)212 / 81 00 44 | www.carlmartin.de

[18] =>

| research

Impact of periodontitis on systemic
health and on implants
Prof. Curd Bollen & Prof. Paul Tipton, UK, Dr Mishel Kocharyan & Prof. Gagik Hakobyan, Armenia

Introduction
Mouth and health go hand in hand. After all, the mouth is
the entrance gate to our body. Food enters through there
and our teeth are the instruments to chew this food so
that the food components we need can also be effectively
released. There is a need for a healthy mouth, to keep a
healthy body!
After all, infections in the mouth have an enormous impact
on the rest of our general health. Biting and chewing can
continuously force oral bacteria into our bloodstream,
where they move through the body, and can cause
damage in several organs (e.g. kidneys, heart, lungs and
brain).
Thousands of scientific articles have already been published about this topic: on 1 August 2024, there were
3,966 hits combining both topics on PubMed! However,
this phenomenon is still insufficiently known to the public
and even to many dentists and physicians.1
Meanwhile, periodontitis, the severe gum infection that
damages the soft tissue and destroys the tissues that
support the teeth, has been linked to several systemic
diseases. This connection is largely due to the inflammatory nature of periodontitis which is accompanied by
large quantities of highly pathogenic bacteria (eg. Porphyromonas gingivalis, Prevotella intermedia and Fusobacterium nucleatum). These pathogens have farreaching effects beyond the oral cavity because they strongly
trigger the immune response.2
The local consequence is limited to tissue destruction: the
inflammatory response leads to the destruction of gum
tissue, periodontal ligament and alveolar bone.3
The systemic impact of these focal infections is however
often neglected although the scientific literature is very
clear: periodontitis undeniably causes or worsens several
systemic health problems.4
This first article in a series of two, will focus on six key
points about the relationship between periodontitis and

4 2024

systemic diseases. The second article will come up with
six more associations between periodontal disease and
systemic diseases.

1. Cardiovascular disease
Cardiovascular disease (CVD) encompasses a range of
heart and blood vessel disorders, including coronary artery
disease, hypertension, and stroke.
Periodontitis and cardiovascular disease are interconnected
through various mechanisms, involving systemic inflammation, endothelial dysfunction, and shared risk factors.
The inflammation caused by periodontitis can contribute
to the buildup of plaques in arteries (atherosclerosis), leading to heart attacks and other cardiovascular events. Moreover, periodontitis increases the risk of a heart attack by
two times.5 The risk of a stroke or TIA is even three times
higher when periodontitis is present.6 Existing heart problems are also aggravated by the presence of oral infections.
The four main connections between periodontitis and
cardiovascular disease are:
1. Systemic inflammation: periodontitis can cause an
increase in systemic infl ammatory markers like Creactive protein (CRP), which is also linked to atherosclerosis.
2. Endothelial dysfunction: bacteria and inflammatory
mediators from periodontal disease can enter the
bloodstream, leading to endothelial dysfunction, a precursor to atherosclerosis.
3. Bacterial translocation: oral bacteria from periodontitis can enter the bloodstream, contributing directly to
the formation of arterial plaques.
4. Immune response: the immune response to periodontal infection can exacerbate inflammatory processes in
the arteries—chronic inflammation is a key factor in the
development of atherosclerosis.
Cardiovascular disease and periodontitis have several
major shared risk factors: smoking, diabetes, age, genetics and diet.7

[19] =>

research

The obvious link between the two diseases invites
patients and practitioners to some clinical implications:
1. Early screening: regular dental check-ups and periodontal assessments help identify individuals at risk
for CVD.
2. Structured preventive care: good oral hygiene and
periodontal therapy reduces systemic inflammation,
lowering the risk of CVD.
3. Promoting integrated care: serious collaboration
between dental and medical professionals improves
overall patient health outcomes.

2. Diabetes
Diabetes is a chronic metabolic disorder characterised
by high blood glucose levels due to either insufficient
insulin production (Type 1 diabetes) or insulin resistance
(Type 2 diabetes).
There is a bidirectional relationship between periodontitis
and diabetes. Not only are people with diabetes more
susceptible to periodontitis, but periodontitis can also
make it more difficult to control blood sugar levels, thereby
exacerbating diabetes.8 More than 90% of periodontitis
patients are at risk of diabetes. In this bidirectional relationship, both conditions can influence the onset and
progression of the other.
Impact of diabetes on periodontitis:
1. Impaired immune response: hyperglycemia can impair
the immune system, making it harder to fight off bacterial infections in the gums.
2. Increased inflammation: high blood sugar levels
increase the inflammatory response, exacerbating gum
disease.
3. Poor healing: diabetes can slow down the healing process of gum tissue, worsening periodontitis.9
Impact of periodontitis on diabetes:
1. Increased blood sugar levels: chronic inflammation
from periodontitis can increase insulin resistance,
making blood sugar control more difficult.
2. Systemic inflammation: periodontitis can elevate systemic inflammatory markers, which can negatively affect
blood sugar regulation.
3. Complications management: poor oral health can complicate the management of diabetes, leading to a vicious
cycle of worsening health.
In these processes there are three mechanisms of interaction. Both conditions increase the production of
inflammatory cytokines such as TNF-α and IL-6, which
contribute to insulin resistance and tissue destruction.
Furthermore, advanced glycation end-products (AGEs)
which are elevated in diabetes, can accumulate in periodontal tissues, promoting inflammation and tissue damage there.10 Finally, increased oxidative stress in both dia-

betes and periodontitis can lead to further tissue damage
and complications.
Due to this two-way relationship, similar clinical recommendations can be highlighted as for CVD:
1. Screening and monitoring: for diabetics patients regular dental check-ups are crucial to detect and manage
periodontitis early. Whereas for periodontitis patients’
blood glucose monitoring can help identify undiagnosed diabetes or prediabetes.
2. Integrated care: dentists and other healthcare providers should work together to manage both conditions.
Furthermore, educating patients on the importance of
oral hygiene and diabetes control is vital for overall
health.
3. Preventive and therapeutic strategies: regular brushing, flossing, and professional cleanings can help prevent periodontitis. Maintaining optimal blood sugar levels through diet, exercise, and medication can reduce
the risk of periodontal disease. Medications and therapies to reduce inflammation can benefit both conditions.

3. Respiratory diseases
Respiratory diseases include a range of conditions affecting the lungs and airways, such as chronic obstructive
pulmonary disease (COPD), pneumonia, and asthma.
Chronic periodontitis has been linked to an increased risk
of these respiratory conditions. The latter is thought to
occur due to the aspiration of bacteria from the mouth
into the lungs. A similar link has also been demonstrated
with the severity of COVID-19 infections.11
The relationship between respiratory disease and periodontitis involves shared mechanisms such as inflammation and bacterial infection.
The interconnection between both pathologies is based on:
1. Bacterial aspiration: bacteria from the oral cavity can
be aspirated into the lower respiratory tract, leading to
infections such as pneumonia. This is particularly a risk
in elderly patients and those with weakened immune
systems.12
2. Systemic inflammation: periodontitis can increase systemic inflammatory markers (e.g. IL-6, TNF-α) into the
bloodstream, which can exacerbate chronic inflammatory conditions like COPD and asthma.13
3. Immune response: the immune response to periodontal infection can weaken the body’s ability to fight off
respiratory pathogens.
4. Oral hygiene: poor oral hygiene associated with periodontitis can increase the risk of respiratory infections
due to higher levels of pathogenic bacteria in the mouth.
The same clinical recommendations as for periodontitis–
diabetes/CVD are also applicable here: good oral hygiene,

4 2024

[20] =>

| research
regular dental check-ups, interprofessional dental–medical
collaboration and early screening.
The therapy consists of anti-infl ammatory treatments
(managing periodontal inflammation reduces systemic
inflammation and potentially improve respiratory health)
and eventual antibiotic therapy (when the bacterial
infection is significant, targeted antibiotics may be necessary).

4. Pregnancy
Pregnancy is of course not a disease, but it involves significant physiological changes that can influence oral
health. Pregnant women with periodontitis are at a higher
risk of adverse pregnancy outcomes because inflammatory mediators from periodontitis may affect the fetal
environment.
There are three main types of impact from periodontitis
on pregnancy:
1. Preterm birth: periodontitis has been linked to an
increased risk of preterm birth (delivery before 37 weeks).
The inflammatory mediators produced in response to
periodontal infection can enter the bloodstream and
potentially trigger premature labor.14
2. Low birth weight: inflammatory cytokines and bacterial endotoxins from periodontitis can affect the placental function, potentially leading to low-birth-weight
babies.15
3. Preeclampsia: periodontitis has been associated with
an increased risk of preeclampsia, a pregnancy complication characterised by high blood pressure and
damage to other organs, often the kidneys.
Furthermore, there are also three sorts of impact from
pregnancy on periodontitis:
1. Pregnancy gingivitis: increased hormone levels can
cause gums to become more sensitive and prone to
inflammation, known as pregnancy gingivitis. If left
untreated, it can progress to periodontitis.16
2. Exacerbation of existing periodontitis: hormonal changes
during pregnancy can exacerbate existing periodontal
disease due to increased blood flow to the gums and
an altered immune response.17
3. Altered oral hygiene: morning sickness and changes
in diet can lead to increased plaque accumulation, affecting periodontal health.18
The key aspects of these interactions include:
1. Hormonal changes: elevated levels of estrogen and
progesterone. These hormones can enhance the inflammatory response in gum tissues.
2. Immune system alterations: modulated immune
response to accommodate fetal development. These
changes in the immune system can alter the host
response to periodontal pathogens.

4 2024

3. Inflammatory mediators increase: cytokines and prostaglandins produced during periodontal inflammation
can affect pregnancy outcomes.
4. Increased blood volume: enhances tissue sensitivity
and bleeding.
The clinical advice consists of: pre-conception care, regular dental visits, oral hygiene education, professional
cleaning, good oral hygiene practices, nutritional guidance and management of morning sickness.

5. Rheumatoid arthritis
RA is an autoimmune disorder characterised by chronic
inflammation of the joints, leading to pain, swelling, and
eventual joint destruction. There is evidence suggesting
a link between periodontitis and rheumatoid arthritis.
Both share several pathogenic mechanisms and risk factors. The more severe the periodontitis, the more severe
the rheumatism. Specific oral bacteria are responsible
for this.
Emerging evidence suggests a bidirectional relationship
between these diseases.
There are four shared mechanisms between rheumatoid arthritis and periodontitis:
1. Chronic inflammation: both conditions involve chronic
infl ammation driven by an overactive immune response.
2. Cytokine production: elevated levels of pro-inflammatory cytokines like TNF-α, IL-1, and IL-6 are common
in both RA and periodontitis.
3. Genetic predisposition: certain genetic factors, such
as shared susceptibility loci, may predispose individuals to both conditions.
4. Autoimmunity: the presence of autoantibodies like rheumatoid factor (RF) and anti-citrullinated protein antibodies (ACPAs) is common in RA and may be found in
periodontitis patients.
The impact of periodontitis on RA deals not only with
increased inflammation (periodontal infection can exacerbate systemic inflammation, potentially worsening RA
symptoms), but also with bacterial translocation (oral
bacteria, particularly P. gingivalis, can enter the bloodstream and contribute to RA pathogenesis through molecular mimicry and citrullination of proteins).19
Meanwhile, the impact of RA on periodontitis bears with
an altered immune response (the dysregulated immune
response in RA can impair the body’s ability to control
periodontal infections) and the effects of medication
(immunosuppressive medications used to treat RA can
affect oral health, either by increasing susceptibility to
infections or causing dry mouth, which can exacerbate
periodontitis).20

[21] =>

research

Clinical implications comprise again: screening and diagnosis (regular periodontal assessments for RA patients—
individuals with severe periodontitis should be evaluated
for signs and symptoms of RA), integrated care (rheumatologists and dentists should collaborate) and preventive
and therapeutic strategies (oral hygiene, professional dental care and anti-inflammatory treatments).

6. Chronic kidney disease
CKD is a progressive loss of kidney function over time,
which can eventually lead to kidney failure. It is often associated with other comorbidities, such as cardiovascular
disease and diabetes. Periodontitis has been associated
with an increased risk of chronic kidney disease. Inflammatory processes and bacterial infections common to
both conditions might play a role in this connection.
The combination of periodontitis and kidney disease leads
to increased mortality due to the increase in the total
inflammatory burden.
Chronic kidney disease (CKD) and periodontitis are interconnected through shared risk factors, inflammatory mechanisms, and potential bidirectional influences.
The shared mechanisms between these two diseases
are based on:
1. Chronic inflammation: both CKD and periodontitis
involve chronic inflammatory responses. Periodontitis
can contribute to systemic inflammation, exacerbating
CKD.
2. Immune dysregulation: CKD can impair the immune
system, making individuals more susceptible to infections, including periodontal disease.
3. Common risk factors: conditions like diabetes and cardiovascular disease are risk factors for both CKD and
periodontitis.
Periodontitis has a three-way influence on CKD:
1. Systemic inflammation: periodontal infection can
increase systemic infl ammatory markers such as
C-reactive protein (CRP), which can worsen kidney
function.
2. Bacterial translocation: oral bacteria and their byproducts can enter the bloodstream, potentially affecting the kidneys and contributing to the progression of
CKD.
3. Endothelial dysfunction: chronic inflammation from periodontitis can lead to endothelial dysfunction, a factor
in the progression of CKD.21
In the other direction, CKD has a trilateral impact on
periodontitis:
1. Reduced immune function: CKD impairs the immune
response, increasing susceptibility to periodontal infections.

2. Altered oral environment: CKD and its treatments can
alter the oral environment, making it more conducive
to periodontal disease. For instance, reduced salivary
flow can lead to increased plaque accumulation.
3. Medication side effects: medications for CKD, such
as immunosuppressants and antihypertensives, can
affect oral health and increase the risk of periodontal
disease.22
The clinical implications are similar as for the other systemic conditions: screening and diagnosis, integrated care
and preventive and therapeutic strategies.

Summary
The effect of periodontitis is not limited to the oral cavity.
Periodontitis is not only causing tooth loss, but it has also
a far-reaching impact on general health. Periodontopathogens and their toxins are causing harm to different organs
and systems in our body.
Therefore, dentists and all other medical practitioners are
not only responsible for their specific field of training/
interest, but they are all co-responsible for the overall
health of their patients.
It is of utmost importance to not only make patients aware
of the dental–general health connection, but also to sensitise all medical professionals for this link. Therefore, a
holistic medical/dental approach is highly advised.

Literature

Prof. Curd Bollen

contact
Prof. Curd Bollen
Yerevan State Medical University
Yerevan, Armenia
Tipton Training Academy
Manchester, UK
+31 619 130754
curdbollen @me.com

4 2024

[22] =>

| case report

Immediate implant placement
and provisional restoration in
the aesthetic zone
Drs Luiz Otavio Camargo, Livia Lamunier de Abreu Camargo & Lucio Kanashiro, Brazil

The immediate implant placement approach, introduced
decades ago, has established the practice of implant placement in freshly extracted sockets. Indeed, research and
evidence support the assertion that immediate restoration
is at least as effective and safe as delayed restoration.1
Immediate implant placement offers notable benefits, such
as a reduced number of surgical interventions, a shorter
overall treatment duration, and improved aesthetic outcomes. This approach also preserves the existing bone
and gingival structure, contributing to the support of
interdental papillae.2
However, reaching and maintaining optimal gingival aesthetics around implants in the anterior region is a chal-

lenging task. Ensuring sufficient primary stability is a
prerequisite for the success of this approach. The design
of the implant itself is a crucial factor. Recently, the findings from a series of cases indicated that the immediate placement of a novel self-cutting, tapered implant
(Straumann® BLX, Straumann) with immediate provisionalisation through an integrated digital workflow, can
yield reliable functional and aesthetic outcomes when
transitioning compromised single teeth in the aesthetic
zone.3
The Straumann® BLX Implants are made from Roxolid®
material with the SLActive® surface. The use of Roxolid®
material allows the placement of reduced-diameter implants
while ensuring successful osseointegration. Moreover,

Figs. 1 & 2: Chipping of the metal–ceramic crown on tooth #12. Fig. 3: Hopeless tooth #12 after the crown removal. Fig. 4: Gingival inflammation surrounding
the residual root. Fig. 5: CBCT image showing adequate apical bone.

4 2024

[23] =>

case report

the integration of SLActive® surface technology accelerates osseointegration and minimises the healing period.
The following case report outlines a successful treatment
result for a compromised tooth in the aesthetic region,
characterised by a thin gingival biotype. The treatment
involved the utilisation of the Straumann® BLX Implant
System, along with cerabone® and mucoderm® (botiss
biomaterials) with a digital workflow.

Initial situation
A young and healthy non-smoker 25-year-old male patient,
presented at our clinic due to the fracture of his crown on
the upper right lateral incisor. The patient was seeking a
prompt, durable, and aesthetic solution.
The extra-oral examination showed a medium smile line.
On intra-oral examination, a metal–ceramic crown with
chipping on the palatal side was observed on tooth #12
(Figs. 1 & 2).

After removing the crown, there was not enough stump
left. The tooth was listed as hopeless. Additionally, signs
of gingival inflammation around the residual root were
noted (Figs. 3 & 4).
The cone beam computed tomography (CBCT) imaging
revealed that the root was oriented toward the buccal wall
(~1 mm), and there was an adequate amount of apical
bone, making it feasible for an immediate implant placement (Fig. 5).

In terms of surgical classification, the patient was categorised as complex and prosthodontically advanced
based on the SAC classification (Fig. 6).

Treatment planning
Considering the clinical and radiographic observations,
the chosen treatment approach included the immediate
implant placement and subsequent restoration.
The treatment workflow encompasses several essential
steps. Initially, a multifunctional guide will be prepared,
including both the surgical guide and the provisional restoration for optimal outcomes. The hopeless tooth #12
will be extracted. Following the extraction, an immediate
Straumann® BLX Roxolid®, SLActive implant, measuring

Fig. 6: SAC classification of the patient. Fig. 7: Pre-surgical check of multifunctional guide for accurate fit. Fig. 8: Assessment of the distance between
gingival margin and buccal bone wall. Figs. 9 & 10: Implant bed preparation following manufacturer’s instructions. Fig. 11: Placement of the surgical
guide to check proper alignment.

4 2024

[24] =>

| case report

12

13

Figs. 12 & 13: Buccal wall integrity was verified with an implant depth gauge.

14

15

Figs. 14 & 15: The Straumann BLX implant was inserted.

16

17

Fig. 16: The gap is filled with Cerabone® xenograft. Fig. 17: Gingival tunneling followed by placement of botiss mucoderm®.

18

19

Fig. 18: A temporary abutment was placed. Fig. 19: The multifunctional guide was bonded to the temporary abutment with resin.

24

4 2024

[25] =>

case report

3.75 x 12 mm, will be inserted without a flap elevation. To
address the resulting gap, cerabone® will be used, along
with the placement of mucoderm® in the buccal zone. An
immediate temporary abutment will then be applied, along
with a chairside tooth shell pick-up. Next, digital crown
planning will be carried out using the Straumann® CARES
Visual system. Finally, the treatment will conclude with the
delivery of the final screw-retained crown.

Surgical procedure
Prior to the surgical procedure, the individualised and
prefabricated multifunctional guide—designed to serve
both as a surgical guide and a prospective temporary
restoration—was carefully checked in the oral cavity to
ensure a precise fit (Fig. 7). After confirming its proper
position and alignment, a local anesthetic containing 2%
lidocaine and 1:100,000 epinephrine was administered.
Following this, a meticulous extraction of tooth #12 was
performed with the goal of minimising trauma to the surrounding tissues. The socket was then debrided using a
bone curette and irrigated with saline solution to ensure
cleanliness. A thorough evaluation of the gingival margins
was subsequently conducted, revealing a distance of
3 mm between the gingival margin and the buccal wall
margin of the bone (Fig. 8).
Within the Straumann Implant System, all BLX drills are
delivered with a distinct colour code that corresponds to
the specific diameter of the implant. The implant bed
preparation was done following a prescribed sequence,
which included the utilisation of a needle drill 1.6 mm followed by a 2.2 mm pilot drill (blue) and a subsequent
2.8 mm BLX drill (yellow; Figs. 9 & 10), in accordance with
the position determined by the surgical guide. The surgical guide, along with the alignment pin, was employed
to ensure precise depth measurements and the accurate
alignment of the osteotomy’s orientation and position
(Fig. 11).
®

After concluding the drilling procedure according to the
manufacturer’s instructions, the osteotomy was checked
using an implant depth gauge (> Ø 2.1 mm end) for accurate depth measurement, tactile examination of the osteotomy and the verification of the integrity of the buccal
wall (Figs. 12 & 13).
Next, the Straumann® BLX 3.75 x 12 mm implant was
carefully inserted into its final position using the implant
driver, applying a torque of 50 Ncm with the BLX Torque
Control Device for Ratchet. The implant was turned
clockwise during this process (Figs. 14 & 15), achieving
optimal primary stability.
The space between the implant and the buccal wall
was filled with Xenograft cerabone® (botiss biomaterials).
This choice was made due to its sustained graft pres-

Figs. 20 & 21: The subgingival segment was contoured with flowable composite. Figs. 22 & 23: The final prosthesis was created using a digital workflow.

ence, which aids in preserving volume over the long term
(Fig. 16). Subsequently, gingival tunneling was performed,
and mucoderm® (botiss biomaterials) was positioned on
the buccal side with a 5/0 Nylon suture. This was done to
facilitate the gradual growth of bone tissue into the grafted
area (Fig. 17).

Prosthetic procedure
The placement of the BLX implant was done according
to the prosthetic plan (Fig. 18). Subsequently, the multifunctional guide was adhered to the temporary abutment
by injecting flowable resin into the contours (Fig. 19).
Furthermore, the subgingival segment was contoured
with flowable composite in accordance with the slim
concave emergence profile concept, contributing to the
shaping of the gingival tissues (Figs. 20 & 21).
The final prosthesis was manufactured using a digital
workflow. A digital impression was obtained with the
Straumann® Virtuo intra-oral scanner, which accurately
captured the 3D position of the implant, aided by a scan
body attached to the BLX implant (Fig. 22). This process
generated an STL file. Subsequently, we used CARES®
Visual—recognised as one of the dental industry’s most

4 2024

[26] =>

| case report
flexible and powerful CAD/CAM software platforms—for
the design of the crown for tooth #12 (Fig. 23).

check was performed, and oral hygiene instructions were
provided to ensure proper postoperative care.

Subsequently, the Straumann® CARES® C series was
utilised in-house to mill a customised lithium disilicate abutment (Figs. 24–26). This abutment was then
cemented extra-orally to an RB/WB Variobase® using
Multilink® cement (Fig. 27). Following this, a lithium disilicate veneer was adhered to the customised abutment
(Figs. 28 & 29).

Treatment outcomes

The restoration was then positioned and secured by
screwing it in place with a torque of 35 Ncm (Fig. 30).
Afterwards, the access holes were filled with composite
restoration material and Teflon. A thorough occlusion

Four years post-implant placement, a comprehensive
clinical and radiographic assessment revealed favourable
implant stability and the healthy condition of the adjacent
tissues (Figs. 34 & 35).

The patient was very satisfied with the implant placement
procedure and the opportunity to receive a restoration
promptly following the extraction of his anterior tooth
(Figs. 31–33). The patient was enrolled in an annual maintenance programme.

Figs. 24–26: The Straumann® CARES® C series was used to mill a customised abutment. Fig. 27: The abutment was cemented extra-orally to an RB/WB
Variobase®.

Figs. 28 & 29: A veneer was adhered to the abutment. Fig. 30: The restoration was positioned, and the access hole was filled with composite and Teflon.

4 2024

[27] =>

the future of oral health

more at epitome.inc

[28] =>

| case report

Figs. 31–33: A happy patient with final outcome. Figs. 34 & 35: At the four-year follow-up, implant stability and healthy tissues were observed.

The final outcome resulted in health maintenance in the
hard and soft tissues.
Adequate primary stability is a prerequisite to enable
this type of treatment. The implant design plays an
important role in this context. In my clinical experience,
the Straumann® BLX implant offers the ideal properties for these clinical situations. At the same time, the
SLActive ® surface has an impact on the early osseointegration of immediately restored implants.

Authors’ testimonial
Reaching and maintaining optimal gingival aesthetics
around implants in the anterior region is a challenging
task. One of the main characteristics of immediate implant
placement and provisionalisation is its effectiveness in
the aesthetic outcome, preserving the existing bone and
gingival architecture.

contact
Dr Luiz Otavio Camargo
Sao Paulo, Brazil
luizotavio@me.com
www.clinicaadc.com.br

4 2024

Literature

about the authors
Dr Luiz Otavio Camargo holds both a
Master’s and PhD in prosthodontics from
the University of São Paulo, Brazil. He
serves as the Director of the ImplanTeam
project in São Paulo and has a private
practice specialising in oral rehabilitation
and implantology. Additionally, Dr Camargo is an ITI Fellow and a sought-after
speaker.
Dr Livia Lamunier de Abreu Camargo
is an ITI Member and currently a Master’s student in dental implants at the
University of Guarulhos in Brazil. She
is also a member of the ImplanTeam in
São Paulo.

Dr Lucio Kanashiro is an ITI Fellow
with a Master’s in Prosthodontics from
the University of São Paulo. He is also
a member of the ImplanTeam in São
Paulo.

[29] =>

SAVE T

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DATE!

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BLOOD
CONCENTRATE DAY
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[30] =>

| case report

Maxillary fixed full-arch
rehabilitation
Drs Armando Lopes, Diogo Santos & Carlos Moura Guedes, Portugal

The use of zygomatic implants inserted in immediate
function through the extra-maxillary technique presents
a viable solution for patients with insufficient bone volume
in the maxilla. This article presents a clinical case of an
upper maxillary implant-supported fixed rehabilitation in
a woman with atrophic maxilla, employing the All-on-4
hybrid concept. This rehabilitative approach offers numerous advantages over alternative therapeutic strategies,
including enhanced predictability, increased simplicity,
and a superior success rate.

Introduction
The use of zygomatic implants has become a good treatment alternative for the rehabilitation of the severely atrophic maxilla,1–3 eliminating donor graft site morbidity, and
reducing the overall cost of surgical and prosthetic treatment while maintaining excellent patient satisfaction outcomes.4,5
There is generally a low frequency of complications reported
in the literature with the use of zygomatic implants: the
most prevalent complication seems to be sinus infections,1,2,6–10 followed by mechanical complications10,11 and,
to a smaller degree, functional complications.12,13 This
group of complications may have a connection to classi-

1
Fig. 1: Pre-operative orthopantomogram.

30

4 2024

cal surgical techniques for inserting zygomatic implants.14
For example, the internal technique15 consists in the
insertion of the zygomatic implant intra-sinus, with a
potential increased probability of sinus complications
and a bulky prosthesis caused by the palatal emergence.
The extra-maxillary surgical technique aims to overcome
these limitations, by placing the zygomatic implant extramaxillary (external to the maxillary sinus before anchoring in the zygomatic bone, covered only by soft tissue
along its lateral maxillary surface)16 providing the preservation of the Schneiderian membrane and a decreased
vestibular-palatine width of the prosthesis due to the
more crestal emergence of the zygomatic implant. The
aim of the present case report is to describe the shortterm outcome of a fixed prosthetic rehabilitation of the
atrophic maxillae supported by standard and zygomatic implants placed through the extra-maxillary surgical technique.

Case report
A 64-year-old Caucasian woman has been under our care
since 2004, following the successful placement of an
All-on-4 implant in the mandible (Fig. 1). She had been
completely edentulous in the upper arch for over 30 years
and expressed a strong motivation to undergo surgical

[31] =>

case report

intervention to restore her upper jaw. Her primary objectives
were to secure fixed prosthetic teeth and to restore both
masticatory function and aesthetic appearance (Fig. 2).
The proposed treatment plan entailed total rehabilitation of
the upper jaw with the All-on-4 hybrid technique and was presented in February 2024. The surgical procedure in the upper
jaw began with a mucoperiosteal incision performed along
the crest of the ridge, slightly palatal (in each quadrant) from
the region corresponding to the second molar to the canine.
Relieving incisions were done in the first molar area to access
the corresponding zygomatic bone. Full thickness flap reflection was performed, and the flap was stabilised using a full
arch retractor (Carl Martin) exposing the inferior edge of the
zygomatic bone and the insertion of the masseter fascia in
the zygomatic arch (distal limit). A second retractor, the
zygoma retractor (Carl Martin) was used to access the
zygomatic bone body and reflect the soft tissues in this higher
level (Fig. 3). The zygomatic implant site was then prepared
using a round bur as posterior as possible on both sides, to
reduce the cantilever to a minimum. This was followed by
2.9 mm drill (Nobel Biocare), a depth indicator to verify the
correct length of the implant, and drills of 3.5 mm, 4.0 mm,
and 4.4 mm (Nobel Biocare) used sequentially. During preparation, the soft tissues were reflected and protected, with particular attention being paid to the base of orbit to prevent
damage to its contents.
One zygomatic implant (Nobel Zygoma 0˚, Nobel Biocare)
measuring 5 mm in diameter and 42.5 mm in length was
placed with an insertion torque of > 50 Ncm in each quadrant
in the position of the second premolar (Fig. 4). To compensate for the slope of the implants, 45°/6 mm angulated abutments were used (Multi-Unit Abutment, Nobel Biocare) with
a torque tightened at 30 Ncm.17 Two straight implants (Nobel
Speedy Groovy, Nobel Biocare) measuring 3.3 mm in diameter and 11.5 mm in length were placed with an insertion
torque > 50 Ncm in the anterior region (13 and 21) and two
straight abutments of 3 mm (13) and 2 mm (21) were used
(Multi-Unit Abutment, Nobel Biocare) with a torque tightened
at 25 Ncm (Fig. 5). The flap was repositioned and sutured
(4/0 silk; B. Braun Medical; Fig. 6).
The patient’s existing PEEK denture was captured directly in
the mouth and converted into an immediate fixed prosthesis.

Fig. 2: Intra-oral preoperative occlusal photograph of the maxilla. Fig. 3: Intra-oral
photograph capturing the inferior view of the zygomatic bone. Fig. 4: Intra-oral
occlusal photograph demonstrating the placement of a 42.5 mm zygoma implant at
0˚ in the second quadrant, with flap retraction supported by a zygomatic retractor
and a full arch retractor (Carl Martin). Fig. 5: Intra-oral occlusal photograph displaying implants and abutments positioned according to the All-on-4® hybrid protocol. Fig. 6: Intra-oral occlusal photograph following suturing.

4 2024

[32] =>

| case report

7

8

Fig. 7: Intra-oral occlusal photograph of the provisional fixed prosthesis post-delivery. Fig. 8: Extra-oral smile photograph showcasing the provisional fixed
prosthesis after delivery.

The provisional bridge was finished in the dental laboratory and delivered to the patient’s mouth 90 minutes
after the surgery ended, achieving immediate function
(Figs. 7 & 8).
On day ten post-operation, the patient was seen in the
follow-up clinic for removal of sutures; the wound was
noted to be healing well and a system for patient followup at two, four and six months post-surgery was established (Fig. 9).

Discussion
The present clinical case reports the short-term outcome of a fixed prosthesis supported by immediate
function zygomatic implants inserted extra-maxillary with
45-degrees angulated abutments in conjunction with
standard implants for the rehabilitation of a severely
atrophic maxillae, with high success rates for prosthesis,
implants, and abutments. This concept of rehabilitation

9
Fig. 9: Post-operative orthopantomogram.

32

4 2024

has several advantages over other therapeutic strategies,
namely bone grafts: higher predictability, more simplicity,
higher success rate, higher patient comfort and aesthetics, and the possibility of immediate function through provisional low-cost prostheses.6,18,19 The biggest advantage
of applying the All-on-4 extra-maxilla hybrid technique
over other techniques lies in the high success rate it can
achieve, in contrast to bone grafting techniques (from
iliac crest, for example). Using extra-long implants placed
externally anchored into the maxilla and zygomatic bone
allowed overcoming the anatomical limitations posed, thus
opening a new approach to use fixed implant-supported
rehabilitation in extreme situations.6,20
The importance of planning in advance the rehabilitation
of totally edentulous cases with implants must be stressed:
whether carried out pre-surgically (using anamnesis, clinical examination and imaging), surgically (through nonguided or guided surgery—static or dynamic) or postsurgically (using an appropriate follow-up regimen).

[33] =>

Conclusion
This case study illustrates that the All-on-4 hybrid concept is a viable treatment option for patients with significant atrophy in the upper jaw. Despite the challenges
posed by extensive bone loss, this innovative approach
enables effective rehabilitation, providing patients with a
functional and aesthetically pleasing
Literature
solution. The All-on-4 protocol utilises
only four strategically placed implants
to support a complete arch of prosthetic teeth, which minimises the need
for bone grafting and other invasive
procedures.

about the authors
Dr Armando Lopes graduated from the
University of Lisbon in 2003 and joined
MALO CLINIC in 2004 as Director. He
specialises in oral surgery and implant
rehabilitation, particularly in MALO CLINIC
and All-on-4 protocols. He holds a Master’s (2013) and PhD (2019) from the
University of Granada and has published
several scientific works.
Dr Diogo Santos specialises in oral surgery, implantology, and periodontology.
He has contributed to multiple scientific
articles and book chapters on implant
technologies and holds an Integrated
Master’s Degree in Dental Medicine.

Dr Carlos Moura Guedes graduated
from the University of Lisbon and earned
an Advanced Studies Diploma from
Granada University. He is the National
Clinical Director at MALO CLINIC and a
lecturer in Prosthodontics at the University of Lisbon, specialising in Oral Rehabilitation and Esthetic Dentistry.

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[34] =>

| case report

Full-arch dentistry with dynamic
navigation and photogrammetry
Dr Emilien Tronc, France

Nowadays, an increasing number of patients are coming to our office with cases of implant failure, whether biological or aesthetic. Recovering from these situations is
often complex, as a second failure is not an option. It is
crucial to identify the causes of the initial failure and to use
all the tools available today to perform both from a surgical and prosthetic perspectives.
How can we find a sustainable solution without incurring
significant new costs of care? We will explore this through
a common case, where a new workflow allows us to
address these challenges effectively.

Case presentation
Our patient is a 61-year-old female business owner who
was referred to us due to discomfort with her upper
implants, which she finds aesthetically unappealing. She
places a high priority on her appearance and is determined to avoid any period without teeth.

The patient reports no systemic diseases, allergies, or
medications.
The clinical examination reveals a marked loss of vertical
dimension and a collapse of soft tissues and lips, although
the upper lip remains intact (Figs. 1a–c). A high smile line
is evident, exposing substantial crown height and showing noticeable offsets at the necks of teeth #11 to #22 in
comparison to adjacent teeth.
Intra-orally, the patient has two cemented implantsupported bridges in the maxilla, spanning teeth #12
to #15 and #23 to #26. All other remaining teeth are
crowned, except for teeth #18 and #28. In the mandible,
an implant-supported bridge extends from teeth #35
to #37, and a substantial tooth-supported bridge spans
from #44 to #48 (Figs. 2a–c). Clinical examination of the
gingiva reveals signs of erythema and inflammation, with
edematous and purulent areas, suggesting active periodontal disease as well as peri-implant disease.

Fig. 1a: Initial expression with a closed, natural smile. Fig. 1b: Relaxed open mouth smile. Fig. 1c: Full, confident smile showcasing unaesthetic implants. Fig. 2a:
Left quadrant—side view of dental implants and restorations. Fig. 2b: Front view of dental work. Fig. 2c: Right quadrant—opposite side view of dental implants
and restorations.

4 2024

[35] =>

case report

3
Fig. 3: Panoramic radiograph along with CBCT slides.

Radiographic findings further underscore these concerns,
showing attachment loss characterised by angular defects
and cratering around the maxillary implants, which were originally placed in 2017 (Fig. 3). A CBCT scan was conducted
to analyse implant positioning and evaluate the remaining
peri-implant bone structure, revealing additional details
pertinent to the patient’s periodontal and implant health.

Treatment plan
We noted the patient’s clinical complexity, with multiple
compromised teeth and implants requiring extensive reconstruction and healing. To improve local conditions, we began
periodontal treatment. During reevaluation, we assessed
the prognosis of both teeth and implants based on their
response to therapy and the patient’s enhanced plaque
control, all while considering her aesthetic priorities.
Temporary solutions were proposed to help the patient
retain her teeth, accommodating her professional commitments. We informed her that management of quadrant four would follow maxillary treatment, as the mandible showed positive response to periodontal therapy,
with maintenance every three months.
The maxillary treatment plan was deferred until reevaluation. Teeth #16, #17, and #27 were considered nonconservable due to periodontal issues. Significant bone
loss in the vestibular area and the three-dimensional
positioning complicated the aesthetic preservation of
implants in sectors one and two.
Although there were no indications for extraction, teeth
#11 and #22 presented aesthetic challenges. The patient
expressed fixed solutions over removable prosthetics.

We evaluated the option of implant removal and tooth
extractions, followed by placement of new implants and
bone grafting; however soft-tissue quality and inadequate residual bone height made complicated predictable outcomes challenging.
Given the complexity of the case, we opted to use Navident dynamic navigation for precise implant placement
and MicronMapper photogrammetry for the prosthetic
phase. These technologies ensure optimal accuracy and
predictability, ultimately enhancing the aesthetic outcomes
we aim to achieve for the patient.
Final treatment plan:
· Step 1: Remove implants and extract teeth #16, #17,
and #27; prepare teeth #11, #18, #21, #22, and #28;
place a temporary PMMA bridge. Plan for soft-tissue
thickening in three to four months.
· Step 2: Conduct bilateral sinus grafting via a lateral
approach, with 2D/3D augmentation scheduled for six
months afterwards.
· Step 3: Place eight implants; extract teeth #11, #18,
#21, #22, and #28; place a functional bridge on the
implants six months later.
· Step 4: Final placement of a definitive bridge.

Implementation of the treatment plan
Temporisation
Prior to the first surgery, the patient visited the clinic to
gather necessary data for her temporary bridge. Photographs were taken to assist in bridge design, and a
digital wax-up was requested. Once received, the waxup and optical impressions were sent to the prosthetist to fabricate a PMMA bridge with teeth #11, #18,

4 2024

[36] =>

| case report

4b
Fig. 4a: Left quadrant—navigated piezo surgery and saw cut. Fig. 4b: Right quadrant—navigated piezo surgery.

#21, #22, and #28 as abutments, ensuring thickened
pontics.
We recorded the vertical dimension based on the maxillary wax-up and requested a 3D impression of the mandibular model for splints and composite injections for
teeth #34 to #38 and #45 to #48.
All prosthetics and implant abutments were removed. At
the extraction sites, A partial thickness flap was created
while a full-thickness flap from teeth #11 to #22 facilitated
implant removal with a left-handed wrench. Most extractions
were straightforward, except for tooth #23, which required
additional bone surgery. The partial thickness flaps also
provided stabilisation for a connective tissue graft.
Postoperative bone remodeling
Two months later, a CBCT scan showed insufficient volume after the removal of the implant and tooth extractions,
necessitating remodeling of the maxillary sinus and horizontal augmentation.
Piezo surgery was employed to elevate and remove the
last implant at site 23, thereby creating a cavity to prevent
titanium contamination.

Horizontal ridge augmentations were performed following sinus grafts. Sutures were placed and the PMMA provisional bridge was repositioned. The patient is scheduled for follow-up appointments at 15 days, one month,
and three months and has diligently adhered to postoperative recommendations.
Implant and prosthetic phase
On the day of the implant surgery, we made a crestal incision positioned palatally, minimising elevation to avoid
disrupting the previously grafted area. The access provided was adequate for implant placement using navigated guided surgery with Navident EVO, which offered
real time tracking of the bone drills along all steps of placing the osteotomy. Using dynamic navigation allowed for

5b
Figs. 5a & b: Navigated implant surgery.

The use of navigated surgery with the Navident EVO system provided precise control and improved access to the
sinus windows, ensuring optimal positioning of the graft
material. This was possible by first planning the accurate
position of the cut in the bone, then executing according
to the plan with precise navigation of the piezo blade. The
Navident EVO’s advanced tracking technology allowed
for real-time adjustments, enhancing the accuracy of the
procedure (Figs. 4a & b).

4 2024

[37] =>

case report

Fig. 6: Printed model with scan bodies. Fig. 7: Photogrammetry software showing scan progress. Fig. 8: Photogrammetry software showing scan and accuracy.

accuracy checks, precise axis management, and optimal
placement of the implants while preserving crestal bone
for placing definitive abutments.
We utilised Straumann BLC conical implants to achieve
maximum primary stability and anchorage in the native
bone, with the exception of sites 16 and 26. All implants
were placed at torque levels exceeding 30 Ncm and we
recorded the Implant Stability Quotient (ISQ) values ranging from 15 to 25 to confirm the torque during placement,
with most values surpassing 70, except for site 14, which
recorded 60.
Definitive SRA abutments with a gingival height of 3.5 mm
were subsequently screwed in. Healing caps were placed
while we managed the soft tissues, utilising the papilla
rotation technique to bring gum tissue between each
abutment, which was sutured to the palatal fl ap. We
intentionally retained the residual teeth before and after
implant placement to:
· Facilitate precise patient registration to use the Navident dynamic navigation system.
· Ensure alignment of implants with the preoperative
impression where the wax-up of the functional bridge
was placed (Figs. 5a & b).

erative and postoperative impressions. Our goal was to
provide thorough information and accurate recordings to
the prosthetist, aiding in the fabrication of a prosthesis
that fits passively. Initially, we incorporated only the first
six implants in the provisional bridge.

Illustration of the workflow
The workflow carried out in the mouth is demonstrated
using a printed model with analogues as no intra-oral
photos were available (Figs. 6–8).
The lab technician gathers all this information in exocad
software to complete the design of the new provisional
bridge, ensuring it adheres to the previous design and
occlusion of the original provisional bridge. The file is then
sent back to the office for 3D printing of the provisional
bridge in resin. This printing process takes 30 minutes,
followed by an additional 20 minutes of postprocessing.
The bridge is subsequently sandblasted with 50-micron
alumina and cleaned with steam. Finally, a primer is
applied before a light finish is done (Figs. 9a & b).
Ultimately, the provisional bridge, engineered for a passive fit, is placed one hour and 30 minutes after surgery,

Photogrammetry using MicronMapper
The photogrammetry software uses scan bodies to capture implant positions with precision down to 20 microns.
This level of accuracy is essential for achieving a true passive fit, significantly reducing risks like screw loosening
and implant stress—factors crucial for long-term patient
outcomes. By minimising manual adjustments and eliminating the need for verification jigs, MicronMapper enables
clinicians to deliver faster, more consistent results with
fewer patient visits.
We then placed the scan bodies to obtain a soft tissue
optical impression. A second impression was taken with
MicronMapper using photogrammetry to generate an
STL file, which could be combined with both the preop-

Fig. 9a: Individual crowns, and printed provisional bridge. Fig. 9b: Side perspective, highlighting the contour and alignment.

4 2024

[38] =>

| case report
with occlusion resembling that of the previous provisional
bridge.
This immediate passive fit not only improves comfort but
also saves time, reduces the risk of complications, and
minimises the need for rework, facilitating better integration with the underlying structures (Figs. 10a & b).
The patient is scheduled to return for postoperative
follow-up appointment at 15 days, one month, and again
at three months.

Follow-up treatment plan

10a

The functional bridge will be kept in place for a minimum
of six months to give the patient sufficient time to plan
and complete her mandibular treatment (posterior sectors) before proceeding with the construction of the definitive bridge with the referring practitioner (Figs. 11a & b).

Conclusion
Today, the patient requires comprehensive treatment,
including periodontal care, aesthetics, occlusion as well
as surgical and prosthetic precision.
10b
Fig. 10a: Passive fitting prosthesis after new bridge and implants are placed
(one month). Fig. 10b: Passive fitting prosthesis after new bridge and implants are placed (three months).

The use of nano-filled ceramic resin transforms these
temporary bridges into a functional, long-term bridge that
can be modified or replaced in a very simple way, helping
to reduce overall treatment costs for the patient.
Effective planning for each case is crucial to the success
of our therapies and should be paired with efficient tools
to be as reproducible and predictable as possible.
Special thanks to Dr Valentini, who greatly contributed to the success of this
case study.

about the author
Dr Emilien Tronc is a specialist in
periodontology, oral surgery, full-mouth
rehabilitation, and digital workflow integration. Based in France, he holds several advanced degrees, including the
European Diploma in Oral Implantology
from the University of Corsica.

11a

contact
11b
Fig. 11a: Pre-treatment image of patient with full confident smile, and unaesthetic implants. Fig. 11b: Post-treatment final result of restored implants
and bridge.

4 2024

Dr Emilien Tronc
La Roche-sur-Foron, France
+33 6 37860900
emilien.tronc@gmail.com

Literature

[39] =>

30 years OEMUS MEDIA

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lebrates three
OEMUS MEDIA AG ce
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e, the upcoming
To mark this mileston
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ories on our team.
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Introducing the implants team

Dr Alina Ion
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Dr Alina Ion is a knowledgeable dentist with a sharp eye for
detail and a wealth of experience in the dental world. Here at
our publishing house, she directs a range of national and international publications, sharing the latest breakthroughs and research
in dentistry and implantology with professionals around the globe.
With her years in the dental industry, Alina has an insider’s understanding of the field’s challenges and innovations, particularly in implantology. Her expertise and dedication make her
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implants

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39

[40] =>

| industry*

Many of Planmeca’s innovations have been born through
joint research and close collaboration with research institutions and universities. Research collaboration also allows Planmeca to observe the development of emerging
technologies and gain in-depth understanding of their
potential applications.
The company has always strived to explore forwardthinking ideas and bring them into practice. This culture
of discovery has allowed it to continue to evolve and to
always stay one step ahead. Planmeca has been the first
in the field of dentistry to introduce several groundbreaking innovations that have been tested with scientific
rigour and proven to make a difference.
Of course, development is a never-ending process.
Products are never truly finished and there is also an
infinite need for new solutions. A strong dedication to
research allows the company to push the limits of technology and to open entirely new doors to improvement.
After all, much of what is routine today was once considered impossible.
As the largest family-owned company in dentistry, Planmeca is in a fortunate position that has allowed it to adopt

4 2024

a long-term perspective characterised by an enduring
and unusually strong commitment to research and development.
This R&D commitment has helped to create an openminded environment that is very stimulating for those with
a deep passion for innovation. The culture of discovery
encourages in-house researchers to think beyond current limitations and to explore the potential of emerging
technologies and future trends.

Game-changing innovations drive dentistry
forward
New technologies and treatment concepts drive the field
forward and improve the standard of care. Many of the
most influential ideas have been formed as a collaborative effort.
Planmeca’s close cooperation with leading dental universities, research organisations and other companies has
indeed paved the way for several game-changing dental
innovations. While technological breakthroughs are often
impressive on their own, their value is ultimately derived
from the real-world benefits they offer.

* The articles in this category are provided by the manufacturers or distributors and do not reflect the opinion of the editorial team.

Dentistry innovations through
research collaboration

[41] =>

implants—international magazine of
oral implantology

issn 1868-3207 Sondernummer · Vol. 8 · Issue 1/2024

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The company has an extensive history of working together with academic and clinical experts to make sure
that research ideas are transformed into tangible products and solutions that make a difference. One of the
best known examples is the proprietary Planmeca Ultra
Low Dose™ algorithm, the leading and scientifically
proven method for acquiring CBCT images at low effective patient doses without compromising the image
quality.

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“In the world of research, it is relatively common for companies and even competitors within the same industry to
participate in the same projects. This also applies to big
players like Philips or Siemens, which have long been involved in joint projects. This is because few companies
can control the entire value chain or achieve significant
results on their own in today’s interconnected world. Collaboration, however, allows achieving beneficial outcomes
to everyone involved,” explains Jukka Kanerva, Senior
Vice President of Planmeca.
The power of research collaboration lies precisely in sharing knowledge and creating synergies among different
stakeholders. Consequently, research collaboration not
only advances Planmeca’s technological development
but also lays the foundation for a sustainable future and
broad expertise.

Promising results in ongoing AI research
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Of course, its research efforts have not ended there. In
fact, Planmeca is involved in numerous ongoing scientific
research projects. Through scientific projects, it even has
the opportunity to collaborate with other technology
companies, such as different sensor manufacturers.

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Several ongoing research projects, in which Planmeca
has been actively involved in the past few years, have
already advanced to the stage of applying for official approvals for the developed solutions. One of them is the AI
Head Analysis project, in which Planmeca, CGI, and HUS
Helsinki University Hospital are collaborating to develop
a diagnostic tool for detecting cerebral haemorrhage
from X-ray images with the help of artificial intelligence.
The project is part of the CleverHealth Network research
ecosystem, which has been formed to facilitate the development of new digital solutions for healthcare.

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“AI Head Analysis is an excellent example of how joint research projects can support the development of innovative solutions, which help improve people’s health and
well-being. While we continue to develop the AI algorithm
within the project, our own product development teams
are already exploring future options for utilising the algorithm in maxillofacial images captured with Planmeca
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[42] =>

| industry*
Hospital and sensor technology company Detection
Technologies. The three-year project is coordinated
by the University of Oulu and has secured a funding of over five million euros from Business Finland.
In the realm of 3D printing, Planmeca plays an
active role within the research consortium cerAM.
This consortium consists of five industrial companies dedicated to studying the 3D printing of ceramics for diverse applications, including developing 3D
printable ceramic crown materials. Tampere University
leads this project, which receives funding from Business
Finland.

The ultimate goal of the project is to provide a tool for
Planmeca Romexis® software, which automatically segments the nerve canal to help dental professionals in implant planning and wisdom tooth extraction. The project
has already produced four scientific papers with conclusive results, for example proving the accuracy of the segmentation against the golden standard provided by four
specialist radiologists. Thanks to Planmeca’s active involvement in steering the research, the AI solution has
been designed to work on any Romexis workstation. The
work now continues to secure the necessary regulatory
approvals for customer use.
Romexis has already been complemented with new tools
for 2D and 3D imaging that harness the potential of artificial intelligence, which have also been developed together with academic and clinical experts. For example,
Romexis Smart utilises scientifically proven Relu AI engine,
which has been developed together with KU Leuven.

Exploring diverse routes of discovery
Besides AI, Planmeca is currently involved in several
other research projects. One of them is TOMOHEAD,
which aims to develop edge cloud computing algorithms
to enhance the calculation efficiency and clinical performance of CBCT imaging. The project revolves around the
edge cloud computing technology developed by Nokia
and also involves Helsinki University, Oulu University

4 2024

Planmeca also collaborates with individual researchers,
including doctoral candidates. Dr Juha Koivisto, Planmeca’s Chief Physicist, has conducted several studies on
lowering the effective patient doses. Dr Koivisto is also
involved in numerous scientific articles based on clinical
studies conducted by customers, assessing the usability
of technology developed by Planmeca.
Currently, Planmeca also has an employee through the
national Postdoc for Companies (PoDoCo) programme,
led by the University of Eastern Finland, working on inverse mathematics to develop iterative CBCT reconstruction. Finnish Research Impact Foundation recently
granted EUR170,000 in funding for the project’s continuation.
“We have not limited our approach to scientific research
and research collaboration. By utilising different channels, we believe we can foster innovation and breakthroughs and also expand our network of expertise and
resources. You never know where the next big idea will
come from. In the end, their results will benefit the users
of Planmeca solutions,” Jukka Kanerva says.

contact
Planmeca Oy
info@planmeca.com
www.planmeca.com

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Another example of Planmeca’s ongoing research collaboration projects also involves leveraging artificial intelligence—this time for locating the nerve canal in the lower
jaw. Taking place within the Finnish Center for Artificial
Intelligence (FCAI), the collaboration involving Aalto University, Tampere University Hospital and Planmeca has
produced a deep learning model to locate the mandibular canal in CBCT images rapidly and accurately. The
model has been trained with anonymised hospital data,
which is remarkably diverse, including annotated CBCT
data from various devices, ethnicities, and surgery cases.

Engaging in various research projects, either as an active
participant or through steering groups, enables Planmeca
to keep updated on entirely new, emerging technologies.
These projects can even extend beyond the realms of
dentistry and medical imaging to areas like optics, photonics, and spectral imaging. For instance, Planmeca is
tracking ongoing research analysing the spectral data of
intra-oral tissues through steering group involvement.
Planmeca also provides equipment and product support
for various research projects.

[43] =>

events

Advancing interdisciplinary
exchange in dentistry and
dental technology
The BEGO Dialogues 2024 in Bremen successfully convened over 200 participants from the fields of dentistry
and dental technology for a vibrant three-day programme.
Featuring 18 renowned speakers and led by expert scientific chairs, the event covered an array of current and
emerging topics. Universities from Halle, Berlin, Frankfurt, Mainz, Munich, and Düsseldorf were notably represented, with distinguished faculty sharing
insights on the latest advancements in the
dental sector. Key discussions centered on
digital implant prosthetics, 3D printing innovations, and cutting-edge prosthetic solutions. Renowned thought leaders from
academia and clinical practice introduced
technologies poised to transform laboratory and clinical workflows, making them
more efficient and effective. Interactive discussion sessions and collaborative case studies further reinforced
the connection between dentistry and dental technology,
providing attendees with practical takeaways and new
perspectives for the future of the industry.

peers. This stylish venue created the ideal backdrop for
collegial exchange, blending inspiration from the day’s
lectures with relaxed, meaningful networking opportunities. Reflecting on the success of the BEGO Dialogues
2024, Scientific Chair Dr Markus Tröltzsch shared, “The
BEGO Dialogues offer a unique platform for interdisciplinary exchange on an equal footing. We are delighted
by the positive feedback and the engaging discussions
that defined this year’s event.”

A memorable networking experience

BEGO GmbH & Co. KG
Bremen, Germany
+49 421 2028-144
congress@bego.com
www.bego.com

A highlight of the event was the evening gathering at the
Old Shipyard, where a warm, welcoming atmosphere
fostered informal conversations and networking among

Once again, the BEGO Dialogues underscored the vital
role of collaboration and networking within the dental
industry. BEGO extends its gratitude to all participants,
speakers, and partners for their dedication and looks
forward to continuing this impactful series in 2026.

contact

4 2024

[44] =>

| events

EAO Congress 2024: Advancing
excellence in implant dentistry
© OEMUS MEDIA AG

Over 4,600 attendees from more than 70 countries
gathered in Milan from 24 to 26 October for an exceptional EAO Congress, themed “Details Make Perfection”.
This year’s programme, thoughtfully curated by the scientific committee, was designed to both inspire and challenge participants, with each day focusing on a specific
theme: The Fundamentals, State of the Art—Certainties,
and Beyond the Limits. Sessions featured the latest
evidence-based practices, delivering practical techniques
that dentists can readily implement in their practices.

© OEMUS MEDIA AG

© OEMUS MEDIA AG

44

4 2024

The congress, as always, provided a unique opportunity
to learn from leading experts in the field. Continuing its
tradition of collaboration with prominent local associations, the EAO partnered with the Italian Academy of
Osseointegration (IAO) and the Italian Society of Periodontology (SIdP). Their invaluable contributions enriched

© OEMUS MEDIA AG

[45] =>

events

|

Among the many highlights, distinguished specialists
shared insights on the challenges and innovations in
implant care, covering topics such as sustainable treatment models, digital advancements, and optimised protocols for complex cases. Workshops offered participants hands-on experience with the latest techniques,
equipping them with practical skills for immediate application.

© OEMUS MEDIA AG

the programme, presenting a comprehensive perspective on the latest advancements in implant dentistry.

Attendees enjoyed cutting-edge presentations, connected with esteemed colleagues from around the world,
and experienced the dynamic ambiance of one of
Europe’s most iconic cities. Meanwhile, an extensive
industry exhibition featuring leading companies in the
field fostered the exchange of the latest materials, techniques, and technologies.
This congress marked the EAO’s second event in Italy in
the past decade, following the successful congress in
Rome in 2014. Milan, with its vibrant culture and cosmopolitan energy, served as an inspiring setting for this
global gathering.

© OEMUS MEDIA AG

For those who could not attend all sessions, a selection
of conference recordings is available on the congress
platform starting 5 November free of charge.

contact
EAO European Association of Osseointegration
Paris, France
+33 1 42366220
info@eao.org
eao.org

© OEMUS MEDIA AG

© OEMUS MEDIA AG

© OEMUS MEDIA AG

4 2024

45

[46] =>

| manufacturer news*

ClaroNav

MicronMapper: Precision redefined for full-arch dentistry

Key Benefits of MicronMapper
• Unmatched precision: Leveraging true photogrammetry,
MicronMapper ensures optimal

passive fit for full-arch cases, allowing clinicians to streamline
workflows and increase reliability.
• Enhanced efficiency: MicronMapper’s data capture integrates into existing workflows, reducing chair time and boosting patient throughput by minimising rework.
• Clear ROI: By cutting down on costly rework and follow-up
appointments, MicronMapper improves operational efficiency,
offering clinics a strong return on investment while elevating
patient satisfaction.
MicronMapper sets a new benchmark in dental
technology, merging precision with operational
ease. For clinics aiming to lead in digital dentistry, MicronMapper is an indispensable tool
for achieving outstanding clinical results
and enhancing the patient experience.
For distribution or purchase inquiries, please contact.
ClaroNav Inc.
info@claronav.com
www.claronavdental.com

Geistlich Pharma

Geistlich receives MDR approval for entire product portfolio
The entire Geistlich product portfolio has been successfully certified according to MDR—well before the official transition period.
The pioneer in medical regeneration thus confirms its claim to
meet the highest quality and safety standards.
As one of the first companies in its field, the regeneration specialist Geistlich has successfully completed the approval process for
its entire product portfolio in accordance with the new Medical
Device Regulation (MDR) of the European Union (EU) 2017/745.
Geistlich thus meets the highest European standards of quality,
safety and performance for medical devices.

For MDR certification, clinical and preclinical evidence as well as
safety and performance data were thoroughly reviewed. Since the
project to achieve certification started in 2017, Geistlich has submitted more than 2,200 documents with almost 40,000 pages and
had its quality management system audited according to MDR.
The entire process required several years of collaboration between
teams from different departments and shows how challenging it is
to obtain MDR approval even for established products. “Without
the solid scientific basis of our products and our high quality standards, MDR certification would not have been possible so quickly,”
says Diego Gabathuler, CEO of Geistlich.
The early MDR certification of all Geistlich products, even before
the official deadline in 2027, underlines the company’s strong
commitment to the highest quality and safety standards. The certification is both proof and an incentive to continue to provide safe
and effective solutions for patients and healthcare professionals,
and to continue to advance the field of medical regeneration.

Geistlich Pharma AG
+41 41 4925555
info@geistlich.com
www.geistlich-pharma.com

4 2024

* The articles in this category are provided by the manufacturers or distributors and do not reflect the opinion of the editorial team.

MicronMapper marks a breakthrough in full-arch dentistry, delivering exceptional accuracy and efficiency through cutting-edge
photogrammetry technology. Having achieved CE mark approval
in September 2024, MicronMapper is now available for European clinics, providing reliable, precise results in complex fullarch implant cases.
Designed to overcome common challenges in restorative dentistry, MicronMapper captures implant positions within 20 microns.
This precision is critical for achieving a passive fit, reducing risks
like screw loosening and implant stress—factors
essential for long-term patient outcomes. By
minimising manual adjustments and eliminating the need for verification jigs, MicronMapper enables clinicians to deliver faster,
more consistent results with fewer
patient visits.

[47] =>

manufacturer news*

Carl Martin

Zygoma—double hook—full arch retractor

Carl Martin GmbH, based in Solingen, Germany, has collaborated
with Dr Armando Lopes of the MALO CLINIC in Lisbon, Portugal,
to launch a newly redesigned series of retractors. The series was
unveiled at this year’s EAO Congress in Milan, Italy, where it
received significant attention.
“The event was a tremendous success. Our international audience
experienced firsthand the advantages of these innovative instruments at our booth, with Dr Lopes’ live demonstration highlighting
their benefits,” said Junior CEO Philip Holzknecht.
Additional presentations for professionals interested in surgical
and implantological advancements were held at the 53rd International Annual Congress of DGZI in Düsseldorf, the 40 th Annual
Meeting of the BDO in Berlin, and will also be presented at the
38th DGI Congress in Dresden from 28–30 November.

Florian Giesen, Technical Development and Sales at Carl Martin, Dr Armando
Lopes, developer of the retractors, and Philip Holzknecht, Junior Managing
Director at Carl Martin (from left) during the EAO Congress in Milan.

Carl Martin GmbH
info@carlmartin.de · www.carlmartin.de

* The articles in this category are provided by the manufacturers or distributors and do not reflect the opinion of the editorial team.

epitome

Novel dental cleaning device removes biofilm by up to 99 per cent
The “e1” by epitome represents a significant advancement in
dental hygiene technology, diverging entirely from conventional
toothbrushes in both design and function. As the world’s first
autonomous dental cleaning device, e1 was meticulously developed by a high-tech company in Vienna between 2018 and 2024.
This innovative device employs sophisticated artificial intelligence
to conduct a comprehensive analysis of the teeth, subsequently
executing a thorough cleaning in under 60 seconds. Utilising 50
advanced sensors and 14 nano-cameras, e1 accurately detects
biofilm accumulation and effectively targets its removal in a
sequential process. The efficacy of this “intelligent cleaning” protocol has been substantiated through rigorous laboratory testing,
demonstrating a remarkable cleaning efficiency and reach of up
to 99 per cent1 within a mere 30 seconds2 for both the maxillary
and mandibular arches.
Upon completion of the cleaning cycle, users receive an indepth
analysis detailing critical health metrics, including body temperature, heart rate, blood pressure, cortisol levels, and oxygen

saturation, thus promoting an integrated approach to oral and
overall health.
The research and development of e1 involved collaboration with
esteemed experts in the field of biofilm research, including Prof.
Georgios Belibasakis, Dr Reinhard Gruber (Professor of Oral Biology at the University Dental Clinic of Vienna), and Prof. Barbara
Cvikl (Sigmund Freud Private University Vienna).
e1 is available for order through the company’s online shop, and
interested individuals are cordially invited to experience this
groundbreaking product at the pop-up store located at Kohlmarkt 10
in Vienna, Austria.
1
2

Referring to the detected tooth surface.
The cleaning time depends on the jaw structure, tooth alignment,
and the amount of biofilm/plaque.

epitome GmbH ∙ +49 30 22405959
support@epitome.inc ∙ www.epitome.inc

4 2024

[48] =>

| news
Global Consensus for Clinical Guidelines (GCCG)

International experts define standards for
edentulous maxilla treatment
Frank Schwarz emphasised the importance of integrating patient
and clinician perspectives in the GCCG: “Our guidelines aim to be
clinically effective and reflective of patient needs, ensuring that
our recommendations enhance treatments and ultimately improve
patients’ lives.”

During a press conference at the Annual Meeting of the European
Association for Osseointegration (EAO) in Milan, the Global Consensus for Clinical Guidelines (GCCG) was announced. For this
pioneering initiative, the EAO, the International Team for Implantology (ITI), and the Osteology Foundation have joined forces with

© GCCG

“Our guidelines aim to
be clinically effective and
reflective of patient needs,
ensuring that our recommendations enhance
treatments and ultimately
improve patients’ lives.”

Fig. 1: The GCCG involves contributors and associations from around the
world.

the aim of establishing clinical guidelines for the treatment of the
edentulous maxilla. Contributors from around the world and professional organisations have been invited to ensure global relevance. The GCCG uniquely integrates feedback from international
clinicians, researchers, patients, and stakeholders, with the goal
of enhancing patient outcomes.

“Therefore, at the core of the GCCG’s methodology are Patient
Reported Outcome Measures (PROMs) and Clinician Reported
Outcome Measures (CROMs), evaluated through systematic
reviews,” he explained. “What also makes the GCCG unique is that
comprehensive feedback is gathered via tailored Delphi surveys
that have been distributed to a substantial number of clinicians,

“The GCCG represents an innovative, evidence-based approach to
consensus-building in implant dentistry,” explained the scientific
leaders and co-initiators, Frank Schwarz and Hom-Lay Wang.
Engaging a broad spectrum of international experts, patients, and
stakeholders, this initiative contrasts traditional consensus conferences by aiming to create straightforward, practical clinical
workflows that improve outcomes for clinicians and patients alike.
Enhancing treatment through evidence-based guidelines
This first GCCG focuses on the rehabilitation of the edentulous
maxilla, which significantly affects patients’ quality of life. Therefore, by focusing on real-world application, the GCCG seeks to
equip clinicians with actionable, evidence-driven guidelines to
improve treatment outcomes for these patients.

48

4 2024

Fig. 2: Press conference during the EAO Annual Meeting in Milan.

[49] =>

news

|

patients, and public stakeholders. We have undertaken these
extensive efforts to incorporate a wide range of perspectives. The
results from these reviews, surveys, and associated meta-analysis
then form the basis for formulating the actual clinical guidelines,
ensuring their clinical relevance and practicality.”

Many traditional consensus conferences had only regional impact
and did not achieve global recognition and clinical relevance. The
GCCG wants to overcome this by involving contributors and associations from around the world.
The efforts will culminate in a consensus conference in Boston in
June 2025, where over 120 international experts will discuss and
formulate the first global guidelines for the treatment of the edentulous maxilla.
Joining forces to advance clinical practice
Representatives of the three core organisations that have teamed
up to jointly organise the GCCG were also present at the press
conference.
Ronald Jung, President of the EAO and a co-initiator of the GCCG,
underlined the collaborative strength of the GCCG, noting, “The
strength of the GCCG lies in its ability to unite experts from around
the world and create guidelines that will benefit clinicians and

© GCCG

A global collaborative effort
The GCCG draws expertise from around the world, making the
guidelines applicable in various cultural and clinical contexts.
“This is not just about developing another set of guidelines; this is
about reshaping how we approach clinical practice in implantology,” explained Hom-Lay Wang and continued: “By bringing
together voices from all over the world and including both clinicians and patients, we are creating a global framework that will
have a lasting impact on the way we care for patients.”

Fig. 3: Signing of the Memorandum of Understanding.

with our mission of promoting the highest standards of clinical
practice. We believe that by integrating patient feedback and
focusing on evidence-based solutions, the GCCG will deliver
guidelines that have a tangible impact on improving patient care.”
Frank Schwarz, commented on behalf of Christer Dahlin, President
of the Osteology Foundation, who could not attend. He also
emphasised the alignment with their goals: “The GCCG aligns perfectly with the Osteology Foundation’s focus on oral regeneration
and its mission to ultimately improve patient care. Our joint aim in
this collaboration is to create clinical guidelines that directly translate into better treatments for patients.”
With these statements, the leaders highlighted the powerful collaboration in developing globally applicable clinical guidelines.

© GCCG

“By bringing together voices from all over the world
and including both clinicians and patients, we are creating
a global framework that will have a lasting impact on the
way we care for patients.”
patients alike. We are striving to make sure that these guidelines
will be useful across different clinical environments, ensuring better treatment outcomes for patients facing the challenges of edentulism.”
Charlotte Stilwell, President of the ITI, supported this sentiment,
adding, “The ITI is proud to support the GCCG because it aligns

Concluding the press conference with a strong message of unity
and a forward-looking vision, they added that this alliance might
be a starting point for further collaborative efforts and could serve
as a stepping stone for additional activities. “Discussions are
already ongoing,” they said.
Source: Global Consensus for Clinical Guidelines

4 2024

49

[50] =>

| about the publisher

Congresses, courses
and symposia
French Dental Association
Annual Meeting
26–30 November 2024
Paris, France
adfcongres.com/en/homepage/

implants
Imprint
Publisher
Torsten R. Oemus
oemus@oemus-media.de

Designer
Aniko Holzer
a.holzer@oemus-media.de

Board
Ingolf Döbbecke
doebbecke@oemus-media.de

Customer Service
Lysann Reichardt
l.reichardt@oemus-media.de

Lutz V. Hiller
hiller@oemus-media.de

Published by
OEMUS MEDIA AG
Holbeinstraße 29
04229 Leipzig, Germany
Phone: +49 341 48474-0
Fax: +49 341 48474-290
kontakt@oemus-media.de

Torsten R. Oemus
oemus@oemus-media.de

IDS—International
Dental Show 2025

Chief Editorial Manager
Dr Torsten Hartmann (V. i. S. d. P.)
hartmann@dentalnet.de

25–29 March 2025
Cologne, Germany
www.ids-cologne.de

Editorial Council
Dr Rolf Vollmer
info.vollmer@t-online.de
Dr Georg Bach
doc.bach@t-online.de
Dr Suheil Boutros
SMBoutros@aol.com
Editorial Management
Dr Alina Ion
a.ion@oemus-media.de

EuroPerio 11
14–17 May 2025
Vienna, Austria
www.efp.org

Executive Producer
Gernot Meyer
meyer@oemus-media.de

Printed by
Silber Druck GmbH & Co. KG
Otto-Hahn-Straße 25
34253 Lohfelden, Germany

implants—

international magazine of oral
implantology is published in cooperation

with the German Association of Dental
Implantology (DGZI).
DGZI
DGZI Central Office
Paulusstraße 1
40237 Düsseldorf, Germany
Phone: +49 211 16970-77
Fax: +49 211 16970-66
office@dgzi-info.de

Product Manager
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t.krause@oemus-media.de
Art Director
Alexander Jahn
a.jahn@oemus-media.de

www.dgzi.de
www.oemus.com
www.implants.de

ITI Annual Global
Conference
23–24 May 2025
Paris, France
www.iti.org

FDI World Dental
Congress
9–12 September 2025
Shanghai, China
www.fdiworlddental.org

4 2024

and will appear with one issue every quarter in 2024. The magazine and all articles and illustrations
therein are protected by copyright. Any utilisation without the prior consent of editor and publisher
is inadmissible and liable to prosecution. This applies in particular to duplicate copies, translations,
microfilms, and storage and processing in electronic systems.
Reproductions, including extracts, may only be made with the permission of the publisher. Given
no statement to the contrary, any submissions to the editorial department are understood to be in
agreement with a full or partial publishing of said submission. The editorial department reserves the
right to check all submitted articles for formal errors and factual authority, and to make amendments
if necessary. No responsibility shall be taken for unsolicited books and manuscripts. Articles bearing
symbols other than that of the editorial department, or which are distinguished by the name of the
author, represent the opinion of the aforementioned, and do not have to comply with the views of
OEMUS MEDIA AG. Responsibility for such articles shall be borne by the author. Responsibility for
advertisements and other specially labeled items shall not be borne by the editorial department. Likewise, no responsibility shall be assumed for information published about associations, companies and
commercial markets. All cases of consequential liability arising from inaccurate or faulty representation
are excluded. General terms and conditions apply, legal venue is Leipzig, Germany.

[51] =>

REGIST

ER

NOW

www.gio
rnate -vero
nesi.info

GIORNATE
VERONESI

IMPLANTOLOGY

AND GENERAL

DENTISTRY

OEMUS
27‒28 JUNE 2025
EVENT
VILLA QUARANTA VALPOLICELLA (IT) SELECTION

OEMUS MEDIA AG

Holbeinstraße 29 · 04229 Leipzig · Germany · Phone: +49 341 48474-308 · event@oemus-media.de

[52] =>

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[cover] => implants international No. 4, 2024

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