ceramic implants international No. 1, 2023

ceramic implants international No. 1, 2023

Cover / Editorial / Content / Clinical success rate of two-piece zirconia dental implants / Immediately placed two-piece zirconia implant with customised healing abutment in the maxillary molar region / Magneto-dynamic site preparation for zirconia implants: A dry, cold and minimally invasive protocol / Modern workflow of immediate zirconia implant surgery utilising dynamic navigation: case studies and benefit analysis / Looking for a ceramic solution / Full-arch maxillary rehabilitation using Y-TZP protheses on ceramic implants—18 month follow up / Interview: Discover the latest in ceramic implantology at the EACim’s 2023 congress in France / Events / Manufacturer news / News / Imprint

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issn 1868-3207 Sondernummer • Vol. 7 • Issue 1/2023

ceramic

1/23

implants

international magazine of ceramic implant technology

research

Clinical success rate of two-piece
zirconia dental implants

case report

Magneto-dynamic site preparation
for zirconia implants

news

First long-term study on two-piece
zirconia implants published

[2] =>

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[3] =>

editorial

Titanium versus
zirconia? Osteoimmunology in
implantology
Titanium and zirconia are the two primary materials used in dental implantology. While both materials have been used successfully for many years,
there is still a debate about which one is better. Titanium has been the
traditional choice for dental implant surgery for over 40 years. However,
there are some concerns with the use of titanium implants. One growing
concern is that dissolved titanium particles induce inflammatory reactions
not only in the superficial margin but also around the bony bed of the
titanium implant. Specifically, the inflammatory cytokine tumour necrosis
factor-alpha (TNF-) is expressed in the adjacent bone. The transition from
TNF--induced local inflammation after placement of titanium implants
to a chronic stage of “silent inflammation”, that is, low-grade chronic inflammation, could be a cause of apparently unexplained medical conditions, and this neglected area of consideration is investigated in osteoimmunology. Osteo-immunology, however, is an emerging field, but has
already provided valuable insight into the mechanisms of bone growth,
development and regeneration, as well as the role of the immune system
in these processes. In the context of implantology, osteo-immunology is
important because the success of dental implants depends on the ability
of the implant to integrate with the surrounding bone tissue. When a foreign material such as a dental implant is introduced into the body, the
immune system reacts to it. This immune response can be beneficial, as
it can help to promote the integration of the implant with the surrounding
bone tissue. However, if the immune response is too strong, it can lead
to chronic inflammation and potentially contribute to implant failure. By
understanding the interactions between the immune system and bone
tissue, researchers can develop better implant materials and techniques
that minimise the risk of inflammatory responses and improve the longterm success of dental implants.

Dr Johann Lechner, Germany
Integrative Oral Medicine and Osteoimmunology
Founder of the International College of Maxillomandibular Osteoimmunology
Author details

Multiple studies have proved that zirconia implants induce little to no
peri-implant tissue inflammation and allow for high levels of epithelial attachment. Thus, in recent years, these ceramic implants have gained significant traction as a viable alternative to traditional titanium implants. They
offer numerous advantages, including superior biocompatibility, enhanced
aesthetics and excellent mechanical properties.
In conclusion, the choice between titanium and zirconia implants ultimately
depends on the individual patient. While titanium implants have been the
traditional choice, zirconia implants are becoming increasingly popular.
Yours,
Dr Johann Lechner

implants 1 2023

[4] =>

| content
editorial
Titanium versus zirconia? Osteoimmunology in implantology

03

Dr Johann Lechner

research
Clinical success rate of two-piece zirconia dental implants
page 24

06

Dr Joseph Sarkissian & Minehli Kamarzar

case report

Immediately placed two-piece zirconia implant with customised
healing abutment in the maxillary molar region

12

Dr Alexandre Marques Paes da Silva

Magneto-dynamic site preparation for zirconia implants: A dry,
cold and minimally invasive protocol
page 32

18

Dr Franco Giancola

Modern workflow of immediate zirconia implant surgery utilising
dynamic navigation: case studies and benefit analysis

24

Dr Daniel Madden

Looking for a ceramic solution

30

Dr Olivier Chéron

page 44

Full-arch maxillary rehabilitation using Y-TZP protheses on
ceramic implants

32

Dr Rodrigo Gomes Beltrao

interview
Discover the latest in ceramic implantology at the EACim’s 2023
congress in France

38

An interview with Dr Fabrice Baudot

events

Cover image courtesy of Zircon
Medical Management/PatentTM
www.mypatent.com
issn 1868-3207 Sondernummer • Vol. 7 • Issue 1/2023

ceramic

5th Group & Experts Meeting at IDS 2023

42

Zeramex congress in Zurich: Exciting insights into metal-free
implantology

44

news
manufacturer news

46

news

48

1/23

implants

international magazine of ceramic implant technology

about the publisher
imprint

research

Clinical success rate of two-piece
zirconia dental implants

case report

Magneto-dynamic site preparation
for zirconia implants

news

First long-term study on two-piece
zirconia implants published

04

implants 1 2023

50

[5] =>

STRAUMANN®
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ABUTMENTS

A0022/en/B/01

04/23

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* references on www.straumann.com/ceramichealing-abutments

→ Contact your local Straumann
representative or visit:
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[6] =>

| research

Clinical success rate of two-piece
zirconia dental implants
Dr Joseph Sarkissian & Minehli Kamarzar, USA

With the recent development of mechanically improved
and clinically versatile zirconia implants, their clinical use
over the past several years has become more widespread globally. Although zirconia implants currently represent a niche market, their popularity worldwide is growing rapidly.1 Studies show that zirconia implants offer
many advantages over metal implants, including aesthetics, greatly reduced plaque retention and incidence of
peri-implantitis, lower accumulation of surface biofilm
compared with titanium implants, outstanding biocompatibility, and a degree of osseointegration and softtissue response that is superior to that of titanium dental
implants.2–5 Owing to the white colour of zirconia implants, they do not exhibit the unsightly metallic grey
shadowing under the gingival tissue as do titanium implants. This fact alone imparts a significant aesthetic advantage of zirconia over metals as a material choice for
dental implants. Zirconia has a very high hardness scale,
is a strong insulator, is not electrogalvanic and does not
corrode. Overall, zirconia implants provide an excellent
aesthetic and biocompatible alternative not only for today’s health-conscious patients but for mainstream dentistry as well.
This article reports on a study involving only one of the many
zirconia dental implant models offered by Z-Systems.
Specifically, the clinical performance of all Z5c implants
placed in our dental practice between January 2016 and
July 2022 will be presented.

The Z5c is a two-piece implant system which has an implant with a flared platform intended to be at tissue level
and an abutment which is cemented into an internal access hole in the middle of the platform. The proprietary
Zirkolith process and SLM (Surface Laser Modified) technology used in the production of all Z-Systems’ implants
were introduced in 2009.6
All Z5 implants are made from TZP-A Bio-HIP. The hot
isostatic pressing (HIP) process results in a material
which has a far greater flexural strength than titanium.7
The laser modification of the surface increases the surface area, facilitating excellent osseointegration and tissue response. The tissue-level design of the implants allows for preparation of both the abutment and the

implants 1 2023

3
Fig. 1: Z5c implant after the four- to six-month healing period and preparation and exposure of the implant margins with the Waterlase prior to
cementing the abutment. Fig. 2: Abutment cemented and prepared prior to
scanning. Fig. 3: IPS e.max CAD crown milled with CEREC and cemented
on the same day.

[7] =>

The only scientifically proven
two-piece zirconia implant system
First long-term study offers
groundbreaking results*

Only we can make it
The patented production process, in which
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before sintering, creates two unique product
features:
• No process-induced micro-cracks
• Ideal surface topography for hardand soft-tissue adaptation

* Brunello G, Rauch N, Becker K, Hakimi AR, Schwarz F, Becker J. Two-piece zirconia implants in the
posterior mandible and maxilla: A cohort study with a follow-up period of 9 years. Clin Oral Implants
Res. 2022 Dec;33(12):1233-1244. doi: 10.1111/clr.14005. Epub 2022 Oct 31. PMID: 36184914.

The New Standard
Long-term oral health: Patent™ has
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[8] =>

| research
margins. The most desirable attribute of the tissue-level implant
is that it does not interfere with the highly vulnerable biological
zone between the alveolar crest and the gingival surface.

Materials and methods
Of the 110 implant cases, 74 were performed in female patients
and 36 in male patients. The final cases included in the study
were a cohort of 73 patients, 47 female patients and 26 male
patients.
All the surgeries followed a semi-guided protocol. A CBCT scan
was obtained, and a surgical guide was made using various
methods. The surgical guides were intended and designed to be
used for the initial osteotomy with a pilot drill to a depth short of
2 mm of the projected depth. In most cases, a flapless or conservative papilla-sparing flap design was used. A radiograph
with a guide pin was taken to confirm and modify depth and angulation after the initial osteotomy. Bone threading was performed except in sites of D3 and D4 bone quality. All the implants
were placed within 1 mm of the gingival level; however, most
were placed either at or slightly below gingival level. Only implants of 4 and 5 mm in diameter and lengths of 8, 10 and 12 mm
were used, depending on the osseous anatomy. The placement
torque ranged from 25 to 35 Ncm.
4

All the patients were required to wear a protective Essix appliance 24/7, even while eating, for two months. The Essix appliances were made on a preoperative model with a vacuum forming
unit using Essix A+ or PLUS Plastic (Dentsply Sirona) of 1 mm
thickness. The implant sites were blocked out to prevent any
contact during wear. The healing times ranged from three to six
months.
After healing, testing for successful osseointegration was carried out with a torque test at 20 Ncm. After the internal access
hole had been thoroughly decontaminated and primed, the
abutments were cemented with a dual-polymerising resin cement, such as PANAVIA SA Cement Universal (Kuraray Noritake
Dental) or RelyX Unicem (3M). After placement of the abutment,
a Periotest reading (Medizintechnik Gulden) was obtained. Fully
integrated implants exhibit a Periotest value of between –0.5 and
–7.0, a higher negative number indicating stronger integration.

5
Fig. 4: Failing endodontically treated maxillary incisor planned
for extraction and immediate replacement with a Z5c implant.
Fig. 5: Radiograph of the implant after immediate placement.

implants 1 2023

The abutment and implant shoulder were typically ground and
shaped with a fine, red-striped diamond bur to conform to the
contours of the gingiva and create adequate abutment angulation, taper and clearance. The implant margins were prepared
and exposed with the Waterlase (BIOLASE) prior to cementing
the abutment. The crowns were made in-house on the same day
with CEREC technology from either IPS e.max CAD (Ivoclar) or
Lava Ultimate materials (3M). Their occlusion was designed with
less intensity than on the rest of the dentition. The crowns were
cemented with the same dual-polymerising resin cement used
for the abutments. The implants were typically followed up every
six months during the recall appointments, and Periotest values
were taken (Figs. 1–21).

[9] =>

research

6

7

8

9

10

11

12

13

|

Fig. 6: Occlusal view of the implant after immediate placement. Fig. 7: Occlusal view of the same implant after five months of healing, ready to be restored.
Fig. 8: Same implant after laser exposure of the margins, abutment cementation and preparation for a CEREC-milled crown. Fig. 9: Same implant after receiving the final crown on the same day. Fig. 10: Implant ready to be scanned, demonstrating excellent tissue response after ideal margin exposure and emergence
profile creation performed on the same day with the Waterlase. Fig. 11: Same implant restored on the same day with a CEREC-milled IPS e.max CAD crown.
Fig. 12: Implant replacing a maxillary second premolar after four months of healing, demonstrating excellent tissue healing and no foreign-body response.
Fig. 13: Same implant after laser margin exposure and removal of the abutment access hole seal.

implants  1 2023

09

[10] =>

| research

Fig. 14: Side view of the same implant. Fig. 15: Side view of the same implant after cementation and preparation of the abutment. Fig. 16: Same implant
restored with a CEREC-milled IPS e.max CAD crown on the same day. Fig. 17: Same implant and crown at the three-month follow-up, demonstrating excellent
tissue response. Fig. 18: Immediate implantation and simultaneous grafting after extraction of a mandibular molar. Fig. 19: Occlusal view of the same implant
after four months of healing, demonstrating excellent tissue response.

Results and discussion
Of the 110 implant cases, 104 were successful and six
failed (Table 1), yielding a success rate of 94.5% and a
failure rate of 5.5%. The failure rates according to sex
were not statistically significant. The average time between implantation and removal due to failure of the implants was 7.33 months. Of the six failures, three of them
were delayed, occurring after initial osseointegration and
final restoration of the implant. The follow-up period for
the successful implants ranged from eight months to
seven years, representing the time elapsed from their respective placements to the date of completion of this
study.
In a retrospective analysis of the failures in this study, all
of them had an underlying mitigating circumstance which
increased the risk of implant failure. One case revealed

Months elapsed to failure*
2
6
6
8†
8†
14†

Tooth no.
16
37
46
13
46
37

Sex (M/F)
M
F
F
F
F
M

implants 1 2023

Failure was more common in patients older than the age
of 40 (Table 2; Fig. 22). Owing to the low number of failures, however, the statistical significance of age and site
location (Table 3) could not be determined. Additionally,
there are many other risk factors which may contribute to

Age (years)
55
63
58
76
43
59

Table 1: Variables of failed implants.
*
Average number of months elapsed between implantation and failure was 7.33.
†
Failed after restoration.

elevated blood glucose and cholesterol levels along with
a low vitamin D3 level in a blood test performed in the
months after implantation. One other failure case also
had a low vitamin D3 level. Two other cases had a simultaneous crestal sinus lift and insufficient primary stability
when the implant was placed. One case in an older female patient failed owing to reckless chewing habits and
non-compliance during the period immediately after restoration. Other causes of failure may have been insufficient primary stability (namely an insertion torque of
around 20 Ncm) and epithelial migration into the implant–
bone interface.

Age (years)

Implant success rates

20–29

3/3 = 100%

30–39

10/10 = 100%

40–49

16/17 = 94.12%

50–59

20/23 = 86.96%

60–69

36/37 = 97.30%

70–79

17/18 = 94.44%

80–89

2/2 = 100%

Table 2: Implant success rates according to age.

[11] =>

research

Fig. 20: Radiograph of the same implant after four months of healing. Fig. 21: Bitewing radiograph of the crown after cementation.

Maxilla (44 implants)

Mandible (66 implants)

Tooth no.

No. of implants

Tooth no.

No. of implants

18
17
16
15
14
13
12
11
21
22
23
24
25
26
27
28

–
2
6
6
5
2
–
2
1
–
1
4
8
7
–
–

38
37
36
35
34
33
32
31
41
42
43
44
45
46
47
48

–
7
22
6
3
1
–
–
–
–
–
2
4
18
3
–

Table 3: Number of implants placed in the maxilla and mandible.*
* Includes failed implants.

implant failure, such as immediate implantation, bone
quality, low vitamin D3 levels, bruxism, prediabetes,
smoking and patient cooperation in wearing the protective devices. It is common to expect higher success rates
among younger populations. Regardless of age, however, careful case selection combined with the highly biocompatible nature of zirconia, as well as the improved
health status of the current ageing population, suggest
that age should represent only a small determinant of implant success. Similarly, implant failure in relation to sex
and tooth specificity in our study was not statistically reliable, owing to the low number of failures reported.

serve as a viable alternative. The population demand for
aesthetic and biocompatible implants is constantly rising.
More studies are highlighting the allergies to titanium.8
Dentists are encouraged to acknowledge the risk factors
of all implants on one hand and the biocompatibility, science, workflow and encouraging success rates of zirconia implants on the other. Dentists are also encouraged
to embrace them as an alternative to satisfy rising demand in a modern ageing population which has a higher
standard of living and therefore higher expectations regarding aesthetics and biocompatibility.

about the author
Dr Joseph Sarkissian studied microbiology at the University of Alabama in
the US and then attended the dental
school of the University of Göttingen in
Germany, graduating in 1989. Over the
next eight years, he practised dentistry
on the Mediterranean island of Cyprus.
During that time, he trained in homeopathy, abandoned the use of amalgam
and expanded his knowledge of the biological aspects of dental
therapy. In 1998, he moved to Los Angeles and received his licence to practise in California in the US. He owns a state-of-theart biological dental practice in Glendale in
California. Dr Sarkissian is a member of Literature
the International Academy of Oral Medicine
and Toxicology, World Clinical Laser Institute, International Academy of Biological
Dentistry and Medicine, and International
Association for Orthodontics.
Dr Joseph Sarkissian

Conclusion

contact

This clinical survey, along with many others in the literature, proves that zirconia implants exhibit high success
rates comparable to those of titanium implants and can

Dr Joseph Sarkissian
drs@sarkissiandds.com
www.sarkissiandds.com

implants 1 2023

[12] =>

| case report

Immediately placed two-piece
zirconia implant with
customised healing abutment
in the maxillary molar region
Drs Alexandre Marques Paes da Silva, Dennis de Carvalho Ferreira, Francisco Augusto Horta dos Santos,
Mayla Kezy Silva Teixeira, Daniel Moraes Telles & Eduardo José Veras Lourenço, Brazil

Over the past two decades, the utilisation of metal-free
materials for oral rehabilitation has surged and emerged
as an alternative to titanium in the production of dental
implants.1 Among these materials, yttria-stabilised tetragonal zirconia polycrystal has gained recognition as the
preferred choice for such applications owing to its superior mechanical properties and reduced tendency to accumulate bacterial plaque.2
It is important to highlight that in the aesthetic region
there is a risk of peri-implant tissue recession, which can
cause titanium implants to become visible through the
soft tissue. This is especially problematic in cases where
the biotype is thin, compromising the overall aesthetics
of the restoration.3

1
Fig. 1: Pre-op CBCT scan of the patient.

12

implants  1 2023

Initially, zirconia was primarily used to make one-piece
implants.4 However, this limits the prosthetic options
available, as there is no possibility of adjusting the implant
to the prosthetic component. This is especially concerning in the aesthetic region.5 In contrast, two-piece implants can minimise this problem by providing prosthetic
abutment angulation to improve implant positioning in
certain situations. This can significantly enhance prosthetic versatility.6
In addition to their aesthetic demands and request for
metal-free materials, in recent years, patients have come
to desire a reduction in the number of surgical and clinical
steps.7 To reduce the total treatment time, extraction followed by immediate implantation has proved to be a

[13] =>

case report

safe option with predictable results, but this does not prevent tissue shrinkage.8,9 Nevertheless, when this is combined with alveolar ridge preservation procedures, postextraction tissue loss can be significantly reduced.10 To
preserve the transgingival profile immediately after extraction, the socket sealing abutment technique was
proposed.11 This technique also allows for primary wound
closure and protects the alveolar clot and biomaterial
particles underneath.12 The aim of this case report is to
demonstrate the use of a two-piece ceramic implant system and a custom healing abutment to replace the maxillary right first molar and review the clinical and radiographic situation after ten months of follow-up.

proved under No. 5.598.463. The patient was invited to
participate in and informed about the study and signed
informed consent to participate, and all ethical requirements were met.

This study was submitted to the ethics committee of
the State University of Rio de Janeiro in Brazil and ap-

The patient, a 60-year-old woman, was referred to a
private clinical study centre in Rio de Janeiro complaining
about pain at the first molar on the right side of the upper
jaw. The patient was a non-smoker and in good general
health, but reported having type 2 diabetes, which was
however well controlled. To carry out the correct planning
and diagnosis, a CBCT scan was obtained (Fig. 1). The
radiographic examination showed unsatisfactory endodontic treatment and the presence of periapical periodontitis. According to the patient, the tooth had already
undergone endodontic retreatment, but without success. Thus, the decision to extract and replace the tooth
was taken.

Case presentation

Fig. 2: Pre-op situation before sectioning of the roots. Fig. 3: Socket preparation. Fig. 4: GZi implant. Fig. 5: Placement of the implant Fig. 6: Final bone-level
position of the implant.

implants 1 2023

[14] =>

| case report
Surgical procedure
After local anaesthesia (4% articaine with 1:100,000
adrenaline, DFL), tooth extraction was performed via a
minimally invasive surgical approach. The roots of the first
molar were sectioned and extracted separately using
delicate periotomes to sever the periodontal ligament
and lift the tooth pieces without flap raising (Fig. 2). After

7

8

9

10

11

12

extraction, the alveolus was thoroughly curetted to remove any inflammatory tissue and abundantly irrigated
with saline solution. The recipient site preparation sequence was performed according to the manufacturer’s
recommendations (Zi ceramic implant, Neodent) as described in a previous study (Fig. 3).13 A two-piece yttriastabilised zirconia implant (4.3 × 10.0 mm) was placed into
the socket to a final insertion torque of 45 Ncm (Figs. 4–6).

Fig. 7: After placement of the bone substitute material. Fig. 8: Customised healing abutment in situ. Fig. 9: Post-op radiograph with customised healing
abutment. Fig. 10: Gingival emergence profile carefully copied using light-polymerised flowable resin. Fig. 11: Provisional crown and customised healing
abutment. Fig. 12: Provisional crown in situ.

14

implants  1 2023

[15] =>

case report

In addition, a bone substitute material (0.5 cm3 of 0.5–
1.0 mm maxresorb granules, Straumann) was used to fill
the gaps between the fresh socket walls and the external
face of the implant (Fig. 7). A PEEK abutment was selected, and a customised healing abutment was made
using light-polymerised flowable resin (Fig. 8). It was not
necessary to use a suture to close the surgical wound. At
the end of the surgery, a radiograph was taken (Fig. 9).
The three-month postoperative period was uneventful.
The customised healing abutment was carefully removed, and conventional impressions were taken with
a putty and medium-bodied addition-cured silicone using the closed-tray technique. A provisional crown was
made with self-polymerising resin and seated. It remained in the patient’s mouth until the day of cementation of the definitive crown. It is important to highlight
that the gingival emergence profile was carefully copied
using light-polymerised flowable resin (Figs. 10–12). A
lithium disilicate crown was manufactured and cemented on to the prosthetic abutment with adhesive
cement (Figs. 13–18).
After cementation of the definitive crown, the stability of
the marginal bone level was observed on the final radiograph in relation to the immediate postoperative radiograph. The patient has been followed up periodically for
the last ten months, and there have been no complications to date. At the end of the treatment, she was asked
to rate her degree of satisfaction with the aesthetic results
of the treatment according a visual analogue scale and
selected “very satisfied”.

Discussion
To our knowledge, this is the first ten-month follow-up
clinical report on the use of this two-piece zirconia implant system in the molar region using a customised
healing abutment. According to a European Federation of
Periodontology consensus report, peri-implant soft-tissue
health is an important criterion for implant success.14 In
the present study, after ten months of follow-up, seven of
them under occlusal loading, the soft tissue around the
ceramic implant appeared healthy and to be of a natural
colour. It should be noted that the use of a customised
healing abutment favoured the maintenance of the softand hard-tissue architecture around the ceramic implant,
as previously reported in another study, which used PEEK
healing abutments seated on titanium implants replacing
posterior teeth.15
Studies on animals have shown that the osseointegration potential of zirconia is comparable to that of titanium
implants.13,16 The implant in this case achieved osseointegration during the first three months, and no bacterial
plaque adhering to the surface of the implant or prosthetic abutment was observed during the follow-up

17
Figs. 13 & 14: Clinical views of the healthy peri-implant tissue free of inflammation. Fig. 15: Lithium disilicate crown. Figs. 16 & 17: Clinical views
of the definitive crown.

implants 1 2023

[16] =>

| case report

18

19

Fig. 18: Final radiograph with the definitive crown. Fig. 19: Radiograph at ten months showing marginal bone stability.

consultations. This is an important finding, since the
adhesion of bacterial plaque is a critical problem and can
be the first stage of peri-implant disease.17 Indeed, studies show less affinity for bacterial plaque on zirconia surfaces compared with titanium surfaces.18 A prospective
clinical study showed that patients who received twopiece zirconia implants had low plaque and bleeding
rates after six years, suggesting healthy peri-implant tissue.19 In this same research, as well as in our study, the
authors observed that the marginal bone levels remained
stable over time.19
Yttria-stabilised zirconia, such as used for the system
employed in the present study, is the material of choice
for the manufacture of ceramic implants, not only because of the aesthetic advantages, but also because it is
a material resistant to corrosion, wear and tear, and especially masticatory forces.20 Another important point
reported in the current study was the high patient satisfaction reported, also found by another study that investigated the performance of zirconia implants.21

about the author
Dr Alexandre Marques Paes da Silva
graduated in dentistry from the former
Universidade Gama Filho in 2005 and
obtained a master’s degree in dentistry
from the Universidade Veiga de Almeida in 2017 and a PhD in dentistry from
Estácio de Sá University in 2020, all in
Rio de Janeiro in Brazil. He is currently
pursuing postdoctoral research in dental
prosthetics with an emphasis on implant dentistry (ceramic implants) at the State University of Rio de Janeiro. He is a member
of the International Team for Implantology and of the International
Academy of Ceramic Implantology. Dr Marques has experience in
dentistry and focuses mainly on immediate placement and loading
in implantology, ceramic implants and oral rehabilitation in atrophic
maxillae.

Literature

It should be noted that, although ten months is a short
follow-up time, there were no clinical, biological or radiographic complications, and both the bone level around
the implant and peri-implant health were maintained.

Conclusion
This clinical case suggests that treatment with this new
two-piece zirconia implant using a customised healing
abutment for soft- and hard-tissue maintenance is a safe
and reliable alternative in oral rehabilitation involving a
posterior tooth. Studies with a higher number of implants
and a longer follow-up time are necessary to confirm our
findings, and the patient involved in this case will continue
to be monitored.

16

implants  1 2023

Dr Alexandre Marques
Paes da Silva

contact
Dr Alexandre Marques Paes da Silva
+55 219 7905289
xandemps@gmail.com

[17] =>

w h i t e

Aesthetic.
Functional.
Safe.

SKY

Mistake and subject to change reserved

TISSUE LINE

ALVEO LINE

Reshaping clinical
and scientific success

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[18] =>

| case report

Magneto-dynamic site preparation
for zirconia implants: A dry, cold
and minimally invasive protocol
Dr Franco Giancola, Italy

Today, dentistry is facing new challenges. Demanding
and fragile patients who require quick, atraumatic and
risk-free treatments are increasingly presenting to our
dental clinics. These patients require immediately loaded
implants even in local situations of bone atrophy and despite precarious health conditions such as diabetes,
heart disease, osteoporosis and other chronic diseases.
Furthermore, the COVID pandemic has made dental care
increasingly complex regarding the management of operating times and the prevention of infections. The use of
minimally invasive procedures in medicine and dentistry
has increased exponentially for reduction in postoperative complications, lower consumption of analgesic and
anti-inflammatory drugs, and shorter recovery time.
To cope with the changing demands and requirements,
biomaterials technology has made significant progress in

recent years. Today, we have zirconia implants that are
very reliable in terms of biocompatibility and resistance.
There are numerous types of dental implants on the market that allow the surgeon to rehabilitate in any clinical
situation. However, the clinical results depend not only on
the material used but also on the general condition of the
patient, on the biological response of the tissue and on
the operative technique.
The patient’s health can be improved through the correction of pathological conditions and the administration of
nutraceuticals that improve the health of the tissue (vitamin D in high dosage, Lithothamnion calcareum, Ganoderma lucidum). The use of platelet growth factors in the
form of membranes or liquids to be infiltrated makes it
possible to reduce discomfort after surgery and stimulates the biological response.
For good implant osseointegration, however, the preparation of the implant site is essential for adequate immediate mechanical retention and stable biological integration over time. Unfortunately, the surgical technique for
positioning implants has remained unchanged over time.
Mucosal flaps are still raised and the implant site prepared using high-speed rotary drills and a water jet for
cooling. The use of drills can lead to overheating of the
tissue and tissue necrosis especially when using metallic
materials that wear. The need for cooling of the rotating
instruments exposes patients and operators to infectious
contamination due to the aerosol cloud that is created
during the operative sessions. Finally, preparation using
drills alters the bone microstructure and removes tissue
that is already very deficient in edentulous conditions.

1
Fig. 1: Correct grip of the Magnetic Mallet handle with one hand.

implants 1 2023

In addition to traditional techniques, today it is possible to
prepare the implant site using magneto-dynamic surgery
with the Magnetic Mallet (Osseotouch), allowing the expansion of the alveolar crest without the use of water jets
and without removing bone tissue. Magnetic dynamic
technology is based on the concept of acceleration with
a short impact time and high force of the pulse, thereby
increasing effectiveness. Through this technology, it is

[19] =>

case report

possible, without the use of irrigation, to easily extract
teeth (ankylosed), perform crestal sinus lift, expand thin
alveolar ridges and prepare implant sites in low-density
bone (Type D3 and D4).
The Magnetic Mallet surgical device is equipped with various inserts, such as for dental extraction, implant site
preparation and regenerative surgery. The device applies
greater force than conventional methods in short time on
a focus point in the area being treated along a central axis
moving up and down. An implant site can be prepared
using only osteotome inserts of increasing diameter.
Plastic bone deformation is facilitated by shock waves
(130 daN in 80 µs) through their tips. The implant site is
created by expanding bone tissue laterally and apically.
No bone tissue is removed. Instead, the tissue is compacted, creating increased density and enabling greater
primary stability.
Magneto-dynamic surgery has several advantages. The
force applied to the inserts is high and brief; therefore, the
intervention is faster and more precise. The handpiece is
operated with one hand (Fig. 1). The movement is only longitudinal; therefore, we will have better operative control
and reduced operational risk. The absence of rotating instruments and lack of irrigation permit cold surgery without
the risk of tissue overheating and infectious contamination.
The ZiBone implant system (COHO Biomedical Technology) has an ideal topography for placement using the
magneto-dynamic technique. The standard ZiBone im-

plant is made in one piece (endosseous and abutment
portions) of highly pure and extremely resistant zirconia.
The cylindrical body and apex’s conical design allow the
implant to achieve high primary stability. The thin threads
on the implant collar increase the contact area and mechanical retention. The broad threads on the implant
body improve primary stability and enhance osseointegration. The sandblasted intraosseous area gives to the
implant a micro- and macro-roughness that favours better tissue integration. In vivo studies have demonstrated
60% bone–implant contact just eight weeks after implant
placement.

Surgical protocol
In the case of an edentulous area with intact tissue, gingival access is created using a tissue punch mounted on
a surgical handpiece rotated at 250 rpm (flapless technique) or by incision and raising of a flap with a zirconia
scalpel. In the case of a compromised tooth, the root is
first extracted using dedicated magneto-dynamic inserts
(EXTR1, 2, 3, 4 and 5). After the cleaning and disinfection
of the alveolus, the best site and inclination are sought for
the preparation of the implant site according to the morphology of the alveolar crest and the condition of the residual bone.
The preparation of the site for the positioning of onepiece implants is achieved using the Black Ruby osteotomes owing to the excellent correspondence of shape
and dimension. The Black Ruby inserts have a double

Fig. 2: Dental panoramic tomogram before surgery. Fig. 3: Initial clinical situation. Fig. 4: Gingival incision using a zirconia scalpel (ZiBone CST-B15).
Fig. 5: Initial osteotomy preparation using a BLK-R1 osteotome. Fig. 6: Placement of the implant into the osteotomy.

implants 1 2023

[20] =>

| case report
taper, a rounded tip and a diamond-like carbon coating
which decreases friction with the tissue and facilitates the
sliding of the instrument into the bone being prepared.
The penetration of the alveolar cortical bone is performed
with the Black Ruby pointed osteotome (BLK-R1) with
force Level 1. The implant site is created by expanding the
bone tissue laterally and apically against the pre-existing
bone. The instrument is slowly advanced through electromagnetic pulses and back and forth movements of the
insert to allow the bone to adapt to the elastic stresses it
has undergone. The osteotomy is progressively widened
by means of a succession of inserts with progressive diameter (BLK-R2, BLK-R3, BLK-R4 and BLK-R5) until the
dimensions compatible with the chosen implant are
reached. The osteotomy is progressively expanded with
the force distributed by the Magnetic Mallet osteotomes
by 1 mm at each pulse. The final diameter of the osteotomy
has to be between 0.5 mm and 1.2 mm under-prepared
depending on the local bone density and the type of implant. In cases where sinus lift or adaptation of the osteotomy is required, standard flat-head inserts (200-F, 300-F
and 330-F osteotomes) can be used. After preparation of
the host site, the implant is first conditioned with the patient’s platelet growth factors and subsequently positioned with a surgical handpiece or impacted with an
adapter mounted on the Magnetic Mallet.

Case presentation
Case 1
A 79-year-old woman with psychiatric disorders, previous femoral fracture due to severe osteoporosis and sequelae of stroke presented for the replacement of a lost
incisor. Considering the general condition of the patient
and the lack of cooperation, it was decided to place the
implant using a minimally invasive protocol (Figs. 2 & 3).
The gingival mucosa was incised using a zirconia scalpel, and a flap was raised (Fig. 4). The penetration of the
alveolar cortical bone was performed using the BLK-R1
insert (Fig. 5). The instrument was made to advance to
the desired depth through magneto-dynamic pulses of
force Level 1 by rhythmic up and down and rotational
movements. The implant was then mounted on a modified adapter and advanced into the prepared alveolus
by the mechanical impulses delivered by the Magnetic
Mallet (Fig. 6). The impact insertion allowed further expansion of the alveolar ridge and greater bone condensation essential for primary stability (Figs. 7–10). At the
end of the treatment, autologous platelet growth factors
were infiltrated via injectable platelet-rich fibrin (i-PRF)
into the peri-implant tissue, which allowed a pain-free
postoperative course; therefore, the patient did not need
analgesics.

10
Fig. 7: Implant impacted in the implant site by means of a Magnetic Mallet device at force Level 1. Fig. 8: Final position of the one-piece ZiBone implant.
Fig. 9: Frontal view after implant placement. Fig. 10: Dental panoramic tomogram after surgery.

implants 1 2023

[21] =>

case report

Case 2
A 60-year-old man presented for the removal of a titanium dental implant and minimally invasive rehabilitation
of the mouth using ceramic implants. The anamnesis
found that the patient had Crohn’s disease and an allergy to metals. The dental evaluation found severe periodontal disease, edentulous areas and peri-implantitis
with bleeding deep periodontal pockets in the area of
the previously inserted titanium implant (Figs. 11 & 12).
Given the patient’s request and pathological conditions,
it was decided to perform a targeted periodontal treatment, extract the compromised teeth and rehabilitate
the mouth using one-piece zirconia implants positioned

with the Magnetic Mallet to reduce trauma and preserve
residual bone tissue.
The extraction of the teeth was performed using forceps
(Fig. 13), and the alveoli were first cleaned and then disinfected using ozone at a concentration of 20 μg/ml.
Subsequently, the implant sites were prepared by osteotomy creation and sinus lift via the crestal route using
standard inserts for bone condensation (160-F, 230-F
and 300-F osteotomes; Fig. 14). Once the appropriate
dimensions of the sites had been reached, the implants
were positioned first using a surgical handpiece and
then with a manual dynamometric ratchet up to a torque

Fig. 11: Dental panoramic tomogram before surgery. Fig. 12: Lateral clinical view of the affected area. Fig. 13: Atraumatic extraction of the compromised tooth.
Fig. 14: Initial preparation of the socket with a 100-P pointed osteotome. Fig. 15: One-piece implant (ZiBone Zr-I5010) mounted on a surgical micromotor.
Fig. 16: Screwing of the implant into the prepared site. Fig. 17: Lateral view of the implants after placement. Fig. 18: Clinical situation the day after surgery.

implants 1 2023

[22] =>

| case report

Fig. 19: Dental panoramic tomogram after treatment.

Case 3
A 56-year-old dental phobic woman presented to our
clinic for aesthetic smile rehabilitation. The clinical and
radiographic evaluation found widespread dental caries
and apical granulomas associated with devitalised teeth
(Figs. 20–22). Patients who are attentive to natural therapies and very sensitive to pain want to quickly improve
their dental aesthetics without putting their health at risk.
It was therefore decided to proceed with the extraction of
the compromised teeth using a minimally invasive technique and placement of zirconia implants in the same
session.

of 35 Ncm (Figs. 15–17). At the end of the treatment, the
peri-implant tissue was infiltrated with i-PRF and the patient underwent a session of systemic ozone therapy at
a concentration of 30 μg/ml. The patient returned the
next day for the positioning of provisional prosthesis and
reported that he had not taken any analgesics, having
had no pain (Figs. 18 & 19).

The extraction of the compromised teeth was performed
first gently to detach the periodontal ligament and then
more decisively to complete the dislocation of the tooth
root. We worked on the mesial and distal sides not to
damage the thinner and more delicate vestibular cortical
bone. We continued with the cleaning and disinfection of
the alveoli using ozone at a concentration of 20 μg/ml. The
implant sites were prepared using standard osteotomes

Fig. 20: Dental panoramic tomogram before surgery. Fig. 21: Frontal view at the first dental visit. Fig. 22: Occlusal view of the affected arch. Fig. 23: Initial osteotomy preparation with a 100-P pointed osteotome. Fig. 24: Subsequent preparation with a 230-F osteotome. Fig. 25: One-piece zirconia implants (ZiBone
Zr-I5010) correctly positioned. Fig. 26: Occlusal view after surgery. Fig. 27: Dental panoramic tomogram after surgery.

implants 1 2023

[23] =>

case report

gery had less pain and little postoperative discomfort;
therefore, they did not need to take analgesics and their
healing was quicker.
The positioning of implants using the Magnetic Mallet
also has advantages for the dentist, as it is faster, more
precise and more efficient. The absence of drills and irrigation leads to a lower risk of infectious contamination,
avoids bone overheating and saves bone tissue in the
case of thin alveolar ridges. The ZiBone one-piece implants adapted perfectly to the implant sites prepared
using the Black Ruby inserts. Magneto-dynamic surgery
represents a good alternative to traditional osteotomy
preparation using rotary drills.
28
Literature

Fig. 28: Cementation of the resin prosthesis the day after surgery after preparing the abutment teeth.

for bone condensation to the chosen size (Figs. 23 & 24).
After the surgery, a systemic ozone therapy session was
performed at a concentration of 30 μg/ml, and periimplant infiltration was performed with i-PRF to reduce
postoperative discomfort and promote healing of damaged tissue to ensure primary stability. The one-piece zirconia implants were inserted to a torque of 35 Ncm to
ensure primary stability (Figs. 25–27). The following day,
all the teeth of the maxillary arch were prepared, and a
resin prosthesis was positioned (Fig. 43).

Discussion
The aim of this article is to demonstrate an alternative way
to place zirconia implants into poor-quality bone in fragile
patients. In bone that is less dense, Magnetic Mallet osteotomes increase the density around the implant. In the
cases reported in this article, the implant sites were prepared by use of osteotomes which compressed the
native bone and by cortical sinus lift as reported by the
literature. These surgical procedures, supported by data
from several experimental studies, resulted in faster and
greater bone apposition compared with conventional
drilling. The Magnetic Mallet site preparation increased
the bone–implant ratio in early phase placement, enhancing primary stability of the implant and expediting
bone healing.

Conclusion
The use of the Magnetic Mallet in poor-quality bone (Types
D3 and D4) and in fragile patients can make zirconia implant surgery safer, more predictable, faster and more comfortable for patients. The surgery improves tissue healing
and long-term implant survival. All the patients treated
with ZiBone implants placed with magneto-dynamic sur-

about the author
Dr Franco Giancola is serving as a specialist in Ceramic Implantology and Guided
Regenerative Surgery at DENTZIA Clinic
in Barcelona since September 2022. He
is registered with the Valencia College of
Official Dentists and Stomatologists and
the Barcelona College of Physicians. Dr
Giancola is also a Director of Health and
Freelance specialist in Immunocompatible
Implantology, Ozonotherapy and Regenerative Medicine at the Domus Medica European Ceramic Implantology Clinic in San Marino
since October 2018.
Dr Giancola’s previous experience includes working as a Chief of
Ceramic Implantology and Autologous Regenerative Surgery at
Nuova Villa Claudia and Villa Mafalda in Rome. He also worked
at SALVATOR MUNDI International Hospital in Rome as a Chief of
Ceramic Implantology and Biological Dentistry. He has undergone
training and received certification in various areas of expertise, including Ceramic Implantology, Guided Regenerative Surgery, Ozonotherapy, and Regenerative Medicine.

contact
Dr Franco Giancola

Dr Franco Giancola
+39 388 0913583
+34 657 610406
www.implantosofia.com
www.ceic.eu

implants 1 2023

[24] =>

| case report

Modern workflow of immediate
zirconia implant surgery utilising
dynamic navigation: case studies
and benefit analysis
Dr Daniel Madden, USA

1

2
Fig. 1: Yomi-Link and fiduciary array. Fig. 2: CBCT of initial situation with link attached.

Dental implant therapy is an integral and growing treatment modality for today’s clinicians. With the advent of
digital workflows dental implant treatment has become
more accessible, faster, safer, and more predictable. All
which can provide a better patient experience and more
idealised final restorations.
As the knowledge of the excellent healing profiles and
popularity of zirconia implants continues to grow, ideal
placement and treatment outcomes of these implants
becomes ever more important.6–9 As such we must look
at designing predictable and repeatable surgeries. Studies have shown adding dynamic navigation resulted in
higher accuracy than the freehand surgical method and
while similar accuracies were found between dynamic
navigation and static guidance for deviations; we will look
at some potential benefits of dynamic guidance using
the Yomi platform (Neocis Inc.) over static guidance in
the digital implant workflow.1–5

24

implants  1 2023

Despite the introduction of CBCT-based planning software and fabrication of static surgical guides, challenges
remain in efficiently and accurately transferring the plans
to surgery. Limitations inherent in the static guide workflow include multiple steps and appointments in fabrication, the risk of poorly fitting guides, and the physical
bulk of the guide impeding surgical site access and visualisation.1–5 Immediate dental implant placement in
conjunction with tooth extraction can require us to be
dynamic in our placement. We as dental surgeons know
that sometimes what we plan on a CBCT and what we
see visually intra-orally, may have us wanting to alter our
plan. Immediate implants have well documented success
rates and navigating anatomical variations and tooth
associated pathologies is essential to their long-term
success.12 Small changes in direction, depth and angulation can be the difference between success with proper
initial stability and the inability to place the implant the
same day. Robotic assistance using haptic boundaries

[25] =>

case report

3a
Figs. 3a & b: Surgical planning for bicortical fixation with placement in
furcal bone.

has been shown to enhance accuracy, precision, and
flexibility across surgical fields.1,2 The Yomi dynamic
navigation platform with haptic feedback allows for small
adjustments in real time and accurate visualisation of
drills into the surgical site. This can be significantly impactful when managing close implant placement to
sensitive anatomical structures of the IAN, drill depth
management in vertical sinus lift augmentation, and assuring immediate implant placement into adequate native
bone. The following case studies will review the digital
workflow of dynamic navigation with Yomi when performing immediate zirconia implant surgery and the perceived
benefits therein.

Case presentations
Case 1
A 60-year-old female presented with history of LANAP
at the periodontist on #3 for a 9 mm periodontal pocket
on the DB one year ago. Upon recall at the periodontist,
the vertical bone defect was non healing, and the tooth
was deemed hopeless. The patient came to our clinic
hoping for extraction and immediate implant placement,
risks and alternatives were given to the patient including
the possibility of inability to place the implant the same
day due to bone anatomy in the area.
Yomi link was attached to her upper left using bite registration and a CBCT was taken with the additional fiduciary arrays attached to the link (Figs. 1 & 2). Surgery was

planned for bicortical fixation with placement in furcal
bone avoiding the defect on distal (Figs. 3a & b). The surgical procedure involved a planned implant depth to the
sinus floor, followed by a gradual increase in depth to perform an internal sinus lift. The extraction was carried out
atraumatically, and the socket was thoroughly cleaned.
Yomi guide arm was then attached to the link and the
landmark verified, ensuring accurate stable navigation.
Under surgeon guidance and robotic assistance the pilot
drill was guided to the surgical site. The osteotomy continued with a drill path and depth that locked once in the
planned position. The osteotomy was completed to the
sinus floor with confirmation of depth via dynamic live
CBCT navigation. Incremental advancement of the drill
depth stop was used to complete the sinus lift. Proper visualisation aided in depth management of the transgingival implant. The implant (2.2_5411, SDS) was placed

implants 1 2023

[26] =>

| case report

4a

4b

to 35 Ncm, and the sockets were subsequently grafted
with allograft (cortical min/demin blend, particle size
.25–1mm), hydrated with i-PRF, and covered with an
A-PRF+ membrane that was sutured in place (Figs. 5 & 6).
The postoperative radiograph showed accurate implant
placement (Fig. 7).
Discussion
Visualisation of the surgical site was crucial in this scenario to prevent a bone defect on the distal and ensure
sufficient native bone around our implant. The plan and
guide path were adjusted in real time for ideal depth
and location to achieve optimum results.

5

Case 2
The patient presented having previously seen an endodontist who deemed the retreatment of tooth 19 nonrestorable. The patient wanted to explore replacement
options, and a comprehensive clinical assessment was
performed, including CBCT and bitewing radiographs.
Multiple periapical radiolucencies were noted, associated with failing root canals of teeth 19, 21, and 27, and
a horizontal root fracture was observed in tooth 29
(Figs. 8a & b). Due to decay and abscess, a failing double
abutted bridge was observed in teeth 21/22-27/28, making full-mouth rehabilitation without implants a poor option (Fig. 9).

6

7

26

4c

8a

implants  1 2023

8b

[27] =>

case report

10a

Treatment plan
A thorough discussion of treatment options, limitations
and risks was reviewed with the patient. Poor long-term
prognosis was given to remaining mandibular teeth except
#30. The patient’s primary concerns were to have no
teeth during healing, not wanting a removable prosthesis,
and to have biologically friendly materials. Delicate consideration was made to design an immediate implant surgery
that provided the patient with a stable temporary restoration and protected our healing implants. One-piece
SDS (Swiss Dental Solutions) implants were chosen for
their variety of diameters and lengths. Posterior teeth 18,
28, 30 were elected to remain in place during the tempo-

rary healing phase to provide posterior stops for occlusion and to maintain stability of implants and temporary
restoration during healing phase. Pre-surgical planning
was performed using CBCT and Yomi planning software
to parallel all implants (Figs. 10a & b). Preoperative maxillary and mandibular arch scans were taken and sent to
the lab to aid in temp mock-up (Fig. 11).

10b

Surgical Phase
The procedure began with the administration of bilateral
inferior alveolar nerve blocks for anaesthesia, followed
by sectioning and removal of the PFM bridge. The Yomi
link was then attached to the lower left using bite regis-

Fig. 4a: Placement of the pilot drill into the surgical site via dynamic live
CBCT navigation. Figs. 4b & c: Osteotomy was completed to the sinus
floor with confirmation of depth via dynamic live CBCT navigation. Fig. 5:
Placement of the ceramic implant (2.2_5411, SDS) to 35 Ncm. Fig. 6: PRF
covering with allograft. Fig. 7: Postoperative radiograph showing accurate
implant placement. Fig. 8a: Initial situation on CBCT showing multiple periapical radiolucencies associated with failing root canals of teeth 19, 21,
and 27. Fig. 8b: Horizontal root fracture in tooth 29. Fig. 9: Failing double
abutted bridge in teeth 21/22-27/28. Figs. 10a & b: Pre-surgical planning
using CBCT and Yomi. Fig. 11: Preoperative maxillary, mandibular and bite
scans to aid in temp mock-up. Fig. 12: Immediate implantation in site #29
using the Yomi robot with haptic controls and locked drill path depth and
angulation.

implants 1 2023

[28] =>

| case report

Fig. 13: Intra-oral scans of the surgical sites for temporary fabrication. Fig. 14: 3D lab-printed temporary with Flexera-Smile Ultra+ (Desktop Health).

tration, and a CBCT scan with fiducial arrays was taken
for accurate planning. The placement of the link allowed
for complete visualisation of the surgical field between
teeth #22 and 30. A-PRF+ and i-PRF were created using
horizontal centrifugation to aid in healing. Atraumatic
extractions of teeth #29, 27, and 22 were performed initially, followed by the creation of a small crestal incision
and full-thickness flap from teeth #27 to 22. The surgical
sites were degranulated using curettage and degranulation burs, and decontamination ozone therapy was
administered to the sockets using 03 gas and 03 water.
Surgery was then initiated using a lance drill in sites #29,
27, 25, and 24, with osteotomies being incrementally in-

15a

15b

creased to manufacturer’s recommendations. The orientation of the drills was confirmed intraorally and via dynamic live CBCT navigation. Close proximity to the nerve
was successfully navigated during immediate implantation in site #29 with high confidence using haptic controls and locked drill path depth and angulation with Yomi
robot (Fig. 12). Implants were placed in sites 29, 27, 25,
and 24. The first phase of the surgery was completed in
approximately 90 minutes, and the Yomi link was removed, and the guide arm detached.
The second phase involved the removal of teeth 19, 20,
21, and 22. An attempt was made to connect link to

Figs. 15a & b: Placement of laminar bone sheet into minimally released buccal and lingual flap. Fig. 16: Full arch temp adjusted and seated with temp cement.
Fig. 17: Excellent healing situation seven weeks after surgery.

implants 1 2023

[29] =>

the the lower right side of the patient’s
mouth, utilising teeth 30 and 28, and
implant abutments 29 and 27, but it
was then unsuccessful. Yomi’s traditional workflow only allows for working
on one quadrant of the mouth at a time,
and a new scan and four or more stable
teeth are required to anchor the link on
the other side. This has now been overcome with a new Yomi bone link which
would have been ideal in this case.
Freehand immediate placement and parallelisation of implants (#22, 20, and 19)
was possible with the visual aid of the
previous implants. Intra-oral scans of the
surgical sites were made and sent to the
lab for temporary fabrication (Figs. 13 & 14).
Site #21 had significant bone loss due
to infection and was grafted with allograft
and a laminar bone sheet. The bone
sheet was trimmed and placed into a
minimally released buccal and lingual flap
and covered with A-PRF+ (Figs. 15a & b).
Suturing was completed, and a full arch
temp was adjusted and seated with
temp cement (Fig. 16). Seven weeks
later, the patient’s loose temp was removed, cleaned, and recemented. Excellent healing of the soft tissue was
shown in Figure 17.

Discussion
Ceramic dental implant placement can be
a delicate process, having ideal emergence with one piece dental implants remains one of the biggest challenges and
ideal placement is essential. A fixed drill
path and depth combined with Yomi’s
surgical flexibility and the dentist’s visualisation during surgery may be one of its
advantages over other guided navigation
systems. As patient awareness grows of
different dental materials, zirconia implants with their excellent healing profiles
are poised to continue to gain attention.
Accurate and ideal placement of zirconia
implants is essential in gaining trust of our
patients and dental community. With the
variety of modern digital workflows choosing a surgical method that is predictable
and repeatable is what we as clinicians
must evaluate. The benefits of robotic assistance point towards Yomi holding its
place in the surgical suite and will likely
continue to pave the path forward in giving
patients access to safe, efficient, accurate
and long-lasting zirconia implant therapy.

case report

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Acknowledgements to Dr Shepard Delong
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implantology and to Lotus Dental Wellness,
Lake Oswego, Oregon.

about the author
Dr Daniel Madden received his Doctor of Dental Surgery from the
University of Minnesota and pursued advanced studies in implantology
and comprehensive dentistry abroad at the Radboud University Medical Center in Nijmegen, the Netherlands. He has served as adjunct
affiliate assistant professor at Oregon Health and Science University
and is a certified Integrative Nutrition Health Coach. He has a passion
for education and technology in dentistry, and believes that this leads
to a more comfortable, efficient and pleasurable patient experience.
He offers patients biologic treatment solutions for optimum oral and
whole-body health at Lotus Dental Wellness in Lake Oswego, Oregon, and his surgical services
through his company Peak Potential Dental at multiple private practice locations in Oregon and
Washington State.
Dr Daniel Madden

Literature

contact
Dr Daniel Madden
Lake Oswego, USA in Hood River, USA
www.dentistdanielmadden.com

www.zeramex.com
implants 1 2023

[30] =>

| case report

Looking for a ceramic solution
Dr Olivier Chéron, Spain

Initial situation and treatment planning

would be reattached with temporary cement until placement of the final crown on the implant and of the new
bridge.

A 40-year-old patient in good general health came to our
practice wishing to replace the bridge extending from
pontic #24 to tooth #27 and to place an implant in region
#24. An initial digital radiograph and a CBCT scan were
performed to analyse the possibility of placing an implant
in this area (Figs. 1 & 2). The area did not present with any
periapical or intraosseous lesions. The bone width and
height were found to be sufficient for implantation, and
there was no atrophy. A mucous retention cyst was observed in the left maxillary sinus.

Procedure
Prior to the surgery, local anaesthesia was administered.
Once the gingival flap had been raised, the drilling protocol was followed according to the manufacturer’s recommendation for Type D2 bone: initial drill, tapered drills of
increasing diameter (2.0, 3.5, 4.3 mm), countersink drill
and bone tap (Fig. 3). The implant (4.3 × 10.0 mm) was
placed to a final torque of 45 Ncm (Fig. 4) and then a Zi
cover screw was placed (Fig. 5). After suturing had been
completed, the old bridge was temporarily cemented in
place.

After the initial evaluation, it was decided to replace the
bridge from tooth #25 to tooth #27 and to place a Zi implant (Neodent) in the region of tooth #24. The old bridge

Fig. 1: Radiograph of the initial patient situation. Fig. 2: CBCT scan of the initial situation regarding tooth #24. Figs. 3a–e : Drilling according to protocol
using a 2.0 mm diameter tapered drill (a), a 3.5 mm diameter tapered drill (b), a 4.3 mm diameter tapered drill (c), a countersink drill (d) and a bone
tap (e). Figs. 4a & b: Placement of the Zi implant.

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case report

Prosthetic restoration
After three months, a secondary surgery was carried out
to place a Zi healing abutment (4.5 × 2.5 mm). Fifteen
days after the second surgery, the Zi implant scan body
was seated and an intra-oral scan taken (Figs. 6 & 7). The
final crown was seated over the Zi base. The crown and
a new bridge were placed, and the occlusal adjustments
were performed (Figs. 8 & 9).

Discussion
Alternative treatment options would have been either fabricating a new bridge for tooth #24 to tooth #27 or placing
two implants in regions #24 and 26, restoring these with
crowns and restoring teeth #25 and 27 with crowns. I
however chose the treatment solution described because the patient had wished for a ceramic solution already years ago. He had opted for being fitted with a
bridge as he did not want a titanium implant. The patient
thus approached our practice looking for a ceramic solution.
In this case, the clinical indications for the ceramic implant system employed required strictly following the surgical drilling protocol recommended by the manufacturer,
in order to achieve primary stability and to avoid the
stress of screwing into the ceramic. The mentioned procedure requires more attention in positioning and the surgical procedure.

about the author
Dr Olivier Chéron is an implantologist
specialising in treatment with ceramic
implants and has employed a therapeutic approach based on biological dentistry since 2006. He is co-founder of
the Equilibria dental clinic in Barcelona
in Spain. Dr Chéron is the European
Academy of Ceramic Implantology’s
ambassador for Spain and co-director
of the International Team for Implantology’s Barcelona study
club. He is also a member of AFNOR.

contact
Dr Olivier Chéron
drcheron@equilibriadental.com
www.equilibriadental.com

Dr Olivier Chéron

9
Fig. 5: Zi cover screw in situ. Fig. 6: Radiograph after three months. Fig. 7:
Intra-oral scan of the situation with the scan body in situ three months after
implant placement for prosthetic assessment. Fig. 8: Final situation with the
crown and bridge in situ. Fig. 9: Final radiograph.

implants 1 2023

[32] =>

| case report

Full-arch maxillary rehabilitation
using Y-TZP protheses on ceramic
implants—18 month follow up
Dr Rodrigo Pohlmann, Dr Rodrigo Gomes Beltrão, Cristine Finco, Dr Vinicius Dutra & Marcos Chevarria, Brazil

Nowadays, ceramic materials are increasingly used in
the dental field. Ceramic implants, which can be successfully included in different treatment workflows and indications, are today considered reliable thanks to the development of new surfaces, innovative materials and enhanced
clinical protocols.
The demand for such metal-free solutions is continuously
growing, and there is increased scientific evidence available owing to the growing desire for metal-free treatments and a natural, highly aesthetic appearance, as well
as to meet the needs of patients with metal hypersensitivities.
Scientific publications have shown promising preclinical
results of ceramic implants and a favourable response of
peri-implant tissue thanks to significantly reduced biofilm
formation.1 For example, a prospective clinical study reported a 100 per cent survival rate for ceramic implants
and a marginal bone loss of 1.2 ± 0.76 mm after seven
years.2 In addition, a systematic review from 2022 found
that all-ceramic restorations supported by ceramic implants
demonstrated promising survival rates over a medium‐term
observation period.3

The extra-oral examination revealed a smile that slightly
exposed the gingiva. The cervices of crowns #12 and 23
were visible. A central diastema was present, and the absence of the maxillary premolars, right molars and left molars was noted (Fig. 1). The intra-oral examination showed
missing teeth in the mandible too. The periodontal examination revealed generalised tooth mobility, clinical attachment loss, inflammation, deep periodontal pockets,
plaque and bleeding upon probing (Fig. 2). Furthermore,
the CBCT examination before treatment showed vertical
and horizontal bone loss, periapical lesions and bilateral
sinus pneumatisation in the upper jaw (Fig. 3).

Treatment planning
The clinical and radiographic examination indicated that
the prognosis for the maxillary teeth was not favourable,
and all were considered hopeless.
After discussing various treatment options with the patient
and considering her wishes, it was decided on full-arch
rehabilitation with yttrium tetragonal zirconia polycrystal
(Y-TZP) prostheses with ceramic implants.

The following case report describes immediate implant
placement followed by an immediate restoration protocol
using the Straumann PURE Ceramic Implant for the fullarch rehabilitation of the maxilla.

Initial situation
A healthy 63-year-old female patient came to our clinic
seeking dental treatment for her upper jaw. She reported
being a non-smoker and having no relevant medical history or allergies. Her chief complaint included aesthetic
and functional issues. She had generalised dental pain
and mobile teeth that did not allow her to eat properly and
affected her quality of life. Moreover, she was dissatisfied
with the shape, distribution and colour of her maxillary
teeth. She also requested an immediate fixed metal-free
solution.

implants 1 2023

[33] =>

case report

|

3

4

5

implants  1 2023

33

[34] =>

| case report
The main steps for the treatment workflow were the following:
1. oral hygiene instructions, restoration of caries and
periodontal treatment in the lower jaw;
2. digital assessment and planning in coDiagnostiX
(Dental Wings);
3. positioning of the first surgical guide to define the
positions of the anchor pins based on a toothsupported guide;
4. full-arch extractions of the hopeless teeth in the maxilla;
5. use of two surgical guides for ridge reduction, and
drilling protocol stabilisation to enhance the 3Dposition of the implants;
6. immediate placement of Straumann PURE Ceramic
implants in positions #16 (4.1 x 10 mm), 13 (4.1 x 12 mm),
11 (4.1 x 12 mm), 21 (4.1 x 12 mm), 23 (4.1 x 12 mm),
and 26 (4.1 x 10 mm);
7. seating of PEEK temporary abutments for the provisional prosthesis; and
8. final prosthetic restoration with screw-retained protheses on implants.
The patient received oral hygiene instructions as part
of the cause-related therapy. The lower jaw was periodontally treated, and cavities were restored. Given the

implants 1 2023

patient’s financial constraints, it was decided to proceed first with treating the upper jaw, maintaining the
periodontal health of the lower jaw until the second
phase, when one-piece ceramic implants would be
placed.
The treatment planning was defined by full-arch extractions with a guided procedure for ridge reduction
and implant placement.
The 3D wax-up model was uploaded to coDiagnostiX
to define the amount of ridge reduction and the optimal
prosthetically driven 3D implant position (Figs. 4 & 5). The
three-guide sequence was drawn to create the perfect
ridge contours. The surgical planning was exported to
the laboratory to create the perforations in the provisional
prosthesis based on the implant positions (Figs. 6 & 7).

Surgical procedure
The surgery was performed under intravenous sedation.
Before surgery, the surgical guides were checked for
proper fit. The first guide was used to define the position
of the anchor pins, and this was based on the toothsupported guide (Fig. 8).

[35] =>

After atraumatic extractions of the teeth that could not be
saved, a full-thickness mucoperiosteal flap was raised with a
crestal incision to remove inflammatory tissue and access the
bone ridge. The anchor pin marks were located to insert the
second guide for ridge reduction (Figs. 9 & 10).
The goal of bone reduction in the case of failing dentition is
to improve the alveolar ridge profile and create the planned
inter-arch space. The ridge was reduced with a bur using
the pre-planned guide contours to achieve the intended interarch space for optimal prosthetic dimensions. The third guide
was fixed on this guide to drive the implant site preparation
and placement. The Straumann surgical cassette was used,
and the manufacturer’s instructions in the full Straumann
technique guide were followed (Fig. 11).
These implants were selected for their design and surface
characteristics, which enable excellent primary stability to be
achieved in extraction sockets and soft bone. Since the primary stability of all the implants was between 40 and 45 Ncm,
immediate loading could be performed using the PMMA premilled provisional prosthesis and Straumann PURE temporary abutments (Figs. 12–15).

A VITA CAD-Temp temporary cylinder abutment was attached
to each implant with a multi-unit abutment screw. Next, the
provisional prosthesis was seated, a passive fit on the abutments was achieved and the occlusion was checked. Since
the provisional prosthesis was passively adapted and the
occlusion was fine, acrylic resin was used to join the abutments to the prosthesis. Finally, the screws were tightened
to 25 Ncm.
Detailed postoperative instructions were given on oral hygiene and the avoidance of extreme loading when chewing.
A liquid diet was recommended for the first two days and
only soft food for 30 days thereafter.

The suture removal appointment was scheduled for two
weeks postoperatively. Healing was found to be uneventful
(Fig. 16).

Final restorative procedure
After four months, the patient had adjusted very well to the
new prosthesis and was eager to move forward with the treatment plan (Fig. 17). The soft-tissue contours were exactly as
digitally planned (Fig. 18). Implant healing was outstanding,
and osseointegration had been achieved.
Therefore, a conventional impression was taken to deliver
Y-TZP restoration in three parts for optimal load distribution
(Figs. 19 & 20). Straumann PURE Ceramic abutments were
used. The occlusion was checked, and no further adjustments were needed (Figs. 21 & 22). Clinical examination at
the 18-month follow-up indicated excellent maintenance of
the treatment (Fig. 23).

13
14

implants 1 2023

[36] =>

| case report

15

16

17a

17b

18

19

20

21

23

36

implants  1 2023

22

[37] =>

Conclusion
The outstanding health of both hard and soft tissue was achieved thanks to prudent clinical selection, good planning, accurate 3D implant positioning and an appropriate treatment protocol. These were essential for the treatment success and
outstanding aesthetic outcome, which met the patient’s requirements.
Straumann PURE Ceramic two-piece implants allow clinicians to use zirconia implants not only for single-tooth cases but also as a reliable solution for multiple
teeth, treatment in the posterior zone and challenging clinical situations. Correct
planning with coDiagnostiX is essential for achieving successful results by placing
the implant with Straumann Guided Surgery.

Literature

☢ Radiation-free

about the authors
Dr Rodrigo Pohlmann has been practising dentistry in his clinic
for 26 years in the state of Rio Grande do Sul, Brazil. As a specialist
in dental prosthesis and implant dentistry, he became acquainted
with ceramic implant dentistry at the first IAOCI congress in San
Diego, USA and then encouraged this philosophy in Brazil. In addition to applying ceramic implantology in his private clinic, he is now
dedicated to coordinating a postgraduate course in implantology in
Rio Grande do Sul, Porto Alegre, where case studies documented
by students disseminate this new and already important practice
among academics. Within a team of ceramic implant experts, Dr Pohlmann experiences in
practice the benefits already demonstrated by scientific research.
Dr Rodrigo Gomes Beltrão graduated in dentistry from the Federal University of Rio Grande do Sul in Porto Alegre, Brazil in 2001.
After pursuing his master’s degree specialising in oral and maxillofacial surgery at the Pontifical Catholic University of Rio Grande
do Sul in 2003, he got his PhD in dentistry (oral and maxillofacial
surgery) at the same alma mater in 2009. He has been an advanced surgical implant trainee at UCLA, USA and received a post
graduate degree in digital dentistry.
Dr Beltrão is CEO of the BeEasy School, Innovation Advisor at
Biolab3D, a founding member of ABICeram Brazil as well as an ITI member. He has a private practice in Porto Alegre, Brazil and also works as an adjunct professor in the master’s
programme of dentistry at the Porto Alegre campus.
Dr Rodrigo Pohlmann

contact
Dr Rodrigo Gomes Beltrão
rodgBeltrão@gmail.com

Dr Rodrigo Gomes Beltrão

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[38] =>

| interview

Discover the latest in ceramic
implantology at the EACim’s
2023 congress in France
An interview with Dr Fabrice Baudot, scientific leader of the EACim, France

The European Academy of Ceramic Implantology (EACim)
is an independent organisation established to share expertise and skills in the practice of ceramic implantology
in order to promote the field. On 10 June, the EACim is
holding a congress in Paris with an impressive line-up of
international speakers. ceramic implants had the opportunity to have a conversation with Dr Fabrice Baudot, scientific leader of the EACim, to find out more.

fascinating new studies showing long-term clinical results
on zirconia implants without peri-implantitis. If zirconia
implants offer a way to prevent peri-implantitis, they
would be a very important tool for any dentist. I also expect to have valuable interaction with my peers who already use or are about to start using zirconia implants.
There are always some tips and tricks to pick up at a congress like this.

Dr Baudot, you are one of the founding members of
the EACim. Why is it important to have an organisation specifically for ceramic implants?
In 2018, when the EACim was founded, ceramic implants
were not getting enough attention at the larger congresses, such as the European Association for Osseointegration’s annual scientific meeting and EuroPerio.
We wanted to create a forum where ceramic implants
were in focus to ensure that dentists could join to learn
more about current research and have a chance to exchange experiences with their fellow dentists.

How can dentists register for the congress?
I would recommend first becoming a member of the
EACim via our website. That will give the dentist a favourable rate for the congress, some other activities free of
charge and of course access to the EACim website,
where a lot of interesting information is made available. I
would highly recommend joining the EACim to keep up
to date with ceramic implantology. Dentists can find out
more about registering for the congress at eacim-ceramicimplantology.com.

What kinds of activities does the EACim arrange?
Our congress is our flagship event for 2023, but we are
also arranging seminars that are more interactive where
participants can come learn from experienced users.
There is one on 23 September in Brussels.
There seems to be a very strong French connection
in the organisation. Do dentists need to speak French
to participate?
No, not at all. For the congress, there will be simultaneous
interpretation into English, and the same goes for the
workshops. We have ambassadors in various European
countries, such as Germany, Spain, Italy, Greece, Portugal and Luxembourg, so we aim to attract dentists from
all over Europe.

about the interview partner
Dr Fabrice Baudot is a French dentist
specialised in periodontics and implantology. He currently leads a practice that
focuses on laser-assisted microsurgery.
His therapeutic approach is always based
on minimally invasive surgery. Dr Baudot
is frequently invited to speak at international dental conCongress registration
ferences, and he is
the author of numerous scientific publications. In addition, he is the scientific leader
and one of the founding members of the European Academy of Ceramic Implantology.
Dr Fabrice Baudot

What are your expectations of the congress in Paris?
We will have many prominent international speakers on
stage who will present new research and clinical applications of ceramic implants. I am convinced that there will
be many interesting subjects covered. There are some

implants 1 2023

contact
Dr Fabrice Baudot
+33 499 060 060
dr.baudot34@orange.fr

[39] =>

[40] =>

| events
ITI International Team for Implantology

All about the patient: The ITI World
Symposium 2024
The ITI World Symposium is back and better than ever: More than 50 worldrenowned speakers will present at the world’s largest scientific implant dentistry event in Singapore from 9 to 11 May 2024. Building on its previous
highly successful online edition, the ITI World Symposium 2024 once again
puts patients at the centre of the action. Over three days, the more than
4,000 participants will experience real patients and their stories on stage. The
speakers will discuss various treatment options based on the latest scientific
evidence. But it does not stop there: world class clinicians will provide commentary on exclusively recorded clinical procedures live on stage.
“With our unique, patient-centred programme structure, we aim to combine
practical, clinical insights with the discussion of scientific findings”, explains
ITI President Charlotte Stilwell. “We ran a survey in our community last year
to identify the topics of currently greatest relevance, and these form the core
of our scientific programme: soft tissue management, GBR/bone augmentation, immediate implants, peri-implantitis and the digital workflow.”
Registration for the ITI World Symposium opens early April. ITI members as
well as early registrations will benefit from significant discounts.
ITI International Team for Implantology
worldsymposium.iti.org

International Society for Metal Free Implantology

“Ceramic Implants meets Aesthetics” in May in Munich

Under the theme “Ceramic Implants Meets Aesthetics”, ISMI invites you to its 7th Annual Meeting on 5 and 6 May 2023 at the
H4 Hotel Messe Munich. The programme is available online and as
a printed programme booklet. Renowned experts and practitioners
from home and abroad will discuss practical experiences and current trends in the use of ceramic implants, as well as biological
aspects of metal-free implantology, with participants on both congress days. Parallel to the ISMI Annual Meeting, and with some
joint podiums, the anniversary congress of the German Society for
Cosmetic Dentistry e.V. (DGKZ) will take place.
The two-day event begins on Friday with an interdisciplinary session on the topic: Zirconium dioxide in general dentistry and implantology—where are we and what perspectives are there?
Other offerings on the first congress day include the SDS Pre-

Congress Symposium incl. Live-OP, Table Clinics, and a course on
the topic: production and obtaining of autologous blood concentrates. The ISMI WHITE NIGHT—this time as a get-together in the
exhibition area—ends the first congress day in a relaxed atmosphere. Saturday will be all about exciting talks from science and
practice.

Details and registration

OEMUS MEDIA AG
www.ismi-meeting.com

[41] =>

EACim Seminar
September 23, 2023
BRUSSELS

The
prosthesis
on zirconia
implants

Simultaneous
translation in English
and in French

ƧƧȲƵƮǞɈƊɈǞȌȁªXðXßƊƧƧƵȯɈƵƮ‫׀ׄـٶ‬ɐȁǞɈȺ‫ف‬

PROGRAM
Event open to all:
EACim members and non-members

Moderator : Prof. SELENA TOMA
09:00 - 10:30 :

Pascal EPPE (Belgium)
The zirconia implant, a preventive
strategy for peri-implantitis

10:30 - 11:00 :

Break

11:00 - 12:30 :

Dr Fabrice BAUDOT (France)
Evolution of prosthetic concepts
on zirconia implants.
Biomimetic reconstructions

12:30 - 14:00 :

Lunch - Buffet

Moderatorr : Pierre DELMELLE
14:00 - 15:30 :

Prof. Marcel WAINWRICHT (Germany)
(ǞǏ˛ƧɐǶɈƧƊȺƵȺǞȁȺɐȲǐƵȲɯƊȁƮȯȲȌȺɈǘƵɈǞƧ
rehabilitation with zirconia implants.
How to solve them ?

15:30 - 16:00 :

Break

16:00 - 17:30 :

Marc NACAR (Belgium)
XȁɈƵȲƵȺɈȌǏƮǞǐǞɈƊǶ˜ȌɩǞȁ
prosthetic management
on ceramic implants

RATE
Registration fee : 180 euros (Lunch included)
ٌ Iª00ȲƵǐǞȺɈȲƊɈǞȌȁ‫ٶ‬ǏȌȲƊǶǶ0!ǞǿǿƵǿƦƵȲȺǞȁ
2023
ٌ §ȲƵǏƵȲƵȁɈǞƊǶȲƊɈƵׁׂ‫ٶٿ׀‬ǏȌȲ²w(ǿƵǿƦƵȲȺ
(in order of contribution 2023)
ٌ §ȲƵǏƵȲƵȁɈǞƊǶȲƊɈƵׁׂ‫ٶٿ׀‬ǏȌȲ² §ǿƵǿƦƵȲȺ
(in order of subscription 2023)

LOCATION
HÔTEL LE PLAZA
Adolphe Maxlaan 118/126
1000 Brussels

ORGANISATION: EACim
Partner :

INFORMATIONS & REGISTRATION : eacim-ceramic-implantology.com

[42] =>

| events

5 Group & Experts Meeting
at IDS 2023
th

Discussing the traceable connection between
packaging and implant contamination

“We’re so happy for the positive reactions and feedback
for our global initiative at this year’s IDS,” summarises
Dr Dirk U. Duddeck, founder and head of research of
the non-profit CleanImplant Foundation (CIF), and continues: “The interactions at the world’s leading exhibition
for the dental industry have proven that more and more
dentists and implant manufacturers are increasingly
sensitised towards the problem of factory-contaminated
implants”. For its 5th iteration, this year’s CleanImplant
Group & Experts Meeting was the largest to date, with
over 50 guests attending, from manufacturers’ representatives to project partners.

Partner of industry and science
“With more than 135,000 subscriptions from dental professionals on Social Media, we understand the CleanImplant Foundation’s role as a partner of industry and

42

implants  1 2023

science,” Dr Duddeck further states. The invited speakers, including physicist Dr Birgit Hagenhoff, Managing
Director of Tascon GmbH and visiting professor at the
University of Münster, and Prof. Dr Patrick R. Schmidlin,
Head Division of Periodontology at the University of Zurich (Switzerland), along with Dr Duddeck emphasised
the worrisome lack of binding industry standards for
implant surface cleanliness. Providing a reference for
patients and practitioners, the consensus-based quality
guideline for implant surface cleanliness was established in 2017 by the scientific advisory board of the
non-profit organisation, as the industry faces increasing
backlash over lacking quality levels.
An expert in surface analysis, Dr Hagenhoff outlined
the various kinds of detectable contaminations. Using
ToF-SIMS analysis, a direct correlation between packaging and surface contamination could be confirmed, most

[43] =>

events

recently even on a sterile-packaged ceramic implant
revealing cell-toxic residues on the implants’ surface.
Joining online from Zurich, Prof. Schmidlin in his lecture
criticised the fact that only the osseointegration rates
are considered as a success parameter of implantation,
an incomplete standard overdue for reconsideration. The
far more relevant indicator of success is the attachment
of the soft tissue to the implant. However, this process
can be affected by impurities on the implant’s surface.
Unveiling the causal effects of the matter, a recently initiated in-vitro study by the University of Zurich in cooperation with the CleanImplant Foundation investigates the

effects of different chemically identified factory-related
implant contaminants on bone and soft tissue. “This
study will provide answers to the question of a connection between implant surface contaminants on the one
hand and previously unexplained early implant failures
and poor osseointegration on the other”, adds Dr Duddeck.

On-site SEM analyses of implant surfaces
A high-resolution scanning electron microscope (SEM),
provided by Thermo Fisher Scientific, was installed at
the CleanImplant booth to demonstrate the analysis
process of implant surfaces to the numerous spectators live at this year’s IDS. Dentists brought sterile packaged implants from their practices to have them analysed directly. As expected, the revelations from the SEM
analyses’ visualisations caused either relief or shock, as

“Providing a reference for patients and
practitioners, the consensus-based quality
guideline for implant surface cleanliness
was established in 2017 by the scientific
advisory board of the non-profit organisation,
as the industry faces increasing backlash over
lacking quality levels.”

dentists found their implants intended for use on patients to carry significant contaminations. Dr Duddeck
and his team continued to educate and inform about
the extent and potential consequences of factory-related
contamination of dental implants. At the same time, implant types that have proven batch-spanning particlefree implant surfaces have been awarded the foundation’s “Trusted Quality” seal and received praise and
mention by the quality initiative for guidance and trust
for practitioners.

contact
CleanImplant Foundation
www.cleanimplant.org

implants 1 2023

[44] =>

Fig. 1: Located directly on the Zurichberg, the venue offered a picturesque setting for exciting lectures and informative discussions about Zeramex implants.

Zeramex congress in Zurich:
Exciting insights into
metal-free implantology
Swiss ceramic implant producer Dentalpoint offered
the possibility for an in-depth exploration of the innovative world of metal-free implantology at the Zeramex congress in combination with picturesque views of the
Zurichberg. The congress highlighted why implants made
of high-performance ceramic might by now be setting
their very own standards.
Dentalpoint, the Swiss technology leader in metal free,
two-piece ceramic implants invited to its Zeramex congress “The Future: natural, white and digital” at the
Zurichberg from 31 March to 1 April 2023. The combination of scientific presentations and practical insights met
a very high resonance. With 100 participants the congress was fully booked.
High biological compatibility, low plaque affinity and excellent red-white aesthetics have led to ceramic implants
now being highly valued in dentistry. The interest of practitioners has been increasing continuously owing to the
growing number of clinical studies and the convincing
results achieved in practice. Zeramex focuses on maximum user-friendliness with its completely metal-free,
two-piece and reversible screw-retained Zeramex XT implant system.

44

implants 1 2023

2

[45] =>

events

Top speakers and hands-on workshops
Exciting presentations and breakout sessions on metalfree implantology were at the center of the congress. Renowned experts of metal-free implantology were offering
insights into their extensive experience using ceramic implants. Participants had the possibility to get in-depth
knowledge of the practical work during the breakout sessions at the start of the congress: choosing between either getting to know the Zeramex XT implant system and
its digital workflow or expanding their knowledge in modern patient management and dental photography.
After a welcome by Dentalpoint’s CEO Adrian Hunn, the
congress presentations were kicked-off by Dr Jens
Tartsch, congress president and president of the European Society for Ceramic Implantology (ESCI), with a
presentation on the role of ceramic implants in modern
implantology and their increasing importance in practice.
Dr Tartsch’s lecture introduced the range of topics of the
two-day congress, reaching from material specifications
of zirconium dioxide and application conditions to osseointegration and the advantages of two-piece implant
systems.
Repeatedly at the focus of presentations: The clinical
evidence of ceramic implants in implantology practice.
The speakers discussed the state of research on ceramic
implants and the evidence for their functioning in practice based on their own studies, scientific findings and
application experience. It was thus shown that ceramic
implants can compete with implants made of titan in
many criteria, whereas they are even setting their own
standards in other areas such as e.g. the risk of periimplantitis or red-white aesthetics.

3
Fig. 2: During a press conference, CEO Adrian Hunn (third from left) and Sales Director D-A-CH
Michael Wierz (second from left) provided insights into the company Dentalpoint and the Zeramex
brand. Fig. 3: Dr Marc Balmer (left) presented the latest study results with ceramic implants in
2023 together with Dr Jens Tartsch.

Insights into implantology’s future
Besides clinical evidence and practical experience with
ceramic implants the congress also offered exciting insights into important topics connected to implantology.
During the lecture of Dr Joseph Choukroun, inventor of
the PRF technique, attendees were getting insights into
osteoimmunology and gained important points of reference regarding soft-tissue management in implantology,
especially with ceramic implants.
Dental technician Wolfgang Weisser focused his presentation on the role of Zeramex implants in dental technology showing their diverse possibilities in dental practice.
To sum things up Dr Gerd Wirtz gave an outlook into
the developments that artificial intelligence means for
both practitioners and patients in his keynote speech on
the future of medicine. It even inspired a spontaneous
presentation of US dentist Dr Shepard Delong, demonstrating how he is supported by a highly modern robot
in his implantological work.
Well attended presentations followed by lively discussions, collegial exchange and lasting learning experiences characterised the Zeramex congress. Adrian Hunn,
Dentalpoint’s CEO and host of the Zeramex congress
was truly satisfied: „During the Zeramex congress we
have once again highlighted that implants made of highperformance ceramic will not only have a supporting role
in dentistry but will become an essential part of it. The
outstanding feedback has proven to us that we are on
the right track.”

contact
Dentalpoint AG
Switzerland
www.zeramex.com

implants 1 2023

[46] =>

| manufacturer news
Dentalpoint

The aesthetic implant

Zirconia, the dental material of
the future, the two-piece design of the implant, the unique
implant–abutment connection,
the conventional and digital
workflow, the outstanding clinical results, and the know-how from
17 years of research and development
are the pillars of success of the Swiss
ceramic implant system Zeramex XT.
The heart of the implant–abutment connection is the VICARBO screw made of
carbon re-reinforced high-performance
PEEK. The principle: the implant made

of zirconium dioxide absorbs the compressive forces, while the
VICARBO screw counteracts tensile and bending forces. The design of the external thread ensures high primary stability and the
microrough and hydrophilic Zerafil surface demonstrates convincing osseointegration with a success rate of 98%.
Studies show decisive advantages of zirconium dioxide over other
materials: it has lower plaque accumulation, lower bacterial adhesion as well as reduced thickness of the accumulated biofilm. It
also contributes to better blood circulation in the peri-implant soft
tissue which results in healthier gingiva and improved aesthetics.
Dentalpoint AG, Switzerland
www.zeramex.com

Straumann

Ceramic Healing Abutments:
the first step to harmonious soft tissue healing
These healing abutments for Straumann bone level implants
enable aesthetics from the day of surgery and offer favourable
conditions for soft-tissue attachment, thereby supporting a
healthy peri-implant environment. Their
well-proven zirconia material helps
surgeons and prosthodontists who
are looking for less plaque attachment (smoother surface compared
to titanium) and they support softtissue healing from the day of surgery.
In general, more favourable soft-tissue
attachment around zirconia than around
titanium can be observed, with blood circulation similar to that around a natural
tooth, as well as a more mature and pronounced soft-tissue integration. This comes
with an ease of use entailing aspiration
security thanks to the integrated screw
and a colour-coding to clearly identify the
corresponding prosthetic platform.

46

implants 1 2023

Institut Straumann AG
Switzerland
www.straumann.com

[47] =>

manufacturer news

Zircon Medical Management

The two-piece zirconia implant with long-term studies
Patent™ has eliminated the drawbacks of conventional twopiece zirconia implants. Its innovative prosthetic concept perfectly complements the material properties of zirconia: the
cemented glass fibre post, having a dentine-like modulus of
elasticity, is able to attenuate masticatory forces and transfer
them to the implant in favourable way, ensuring reliable longterm function. Additionally, the patented production process, in
which all surface-machining steps are completed before sintering, creates a high endosteal surface roughness (Ra 5,7 μm) that
is essential for fast and predictable osseointegration. During the
subsequent sintering, any process-induced microcracks are
eliminated, maximising fracture resistance. The success of the
Patent™ Concept has been proven by science: in the first longterm study on two-piece zirconia implants, integrated Patent™
Implants showed no fractures, healthy soft tissues, stable bone
levels, and no signs of peri-implantitis after almost a decade.1 In
a preclinical study they demonstrated bone-to-implant contact
(BIC) of over 70% after just four weeks of healing, outperforming

all implants investigated in similar studies thus far in terms of osseointegration
speed.2
Zircon Medical Management AG,
Switzerland
www.mypatent.com
Literature
1. Brunello G, Rauch N, Becker K, Hakimi AR, Schwarz F,
Becker J. Two-piece zirconia implants in the posterior mandible and
maxilla: A cohort study with a follow-up period of 9 years. Clin Oral
Implants Res. 2022 Dec;33(12):1233-1244. doi: 10.1111/clr.14005.
Epub 2022 Oct 31. PMID: 36184914.
2. Glauser R, Schupbach P. Early bone formation around immediately
placed two-piece tissue-level zirconia implants with a modified surface: an experimental study in the miniature pig mandible. Int J Implant
Dent. 2022 Sep 14;8(1):37. doi: 10.1186/s40729-022-00437-z. PMID:
36103094; PMCID: PMC9474793.

bredent medical

High primary stability and aesthetic appearance
The whiteSKY implant system from bredent is among the bestdocumented zirconia implant systems worldwide. It has not only
demonstrated excellent osseointegration and longevity in numerous studies but has also proven its efficacy in practice. In fact, the
longevity of whiteSKY implants is comparable to that of titanium
implants. The whiteSKY implant system offers two different implant types: the whiteSKY Tissue Line and the whiteSKY Alveo
Line. The narrow whiteSKY Tissue Line implant provides sufficient
space for both the hard and soft tissue and ensures an aesthetically pleasing appearance with its slightly tapered shape in the
sulcus area, transitioning from the gingiva to the implant crown.
The whiteSKY Alveo Line, on the other hand, is ideal for immediate
loading as it fills the extraction socket. At the same time, it provides the treating doctor with the possibility to individualise the
implant according to the specific requirements of the clinical case.

bredent medical GmbH & Co. KG, Germany
info@bredent.com · www.bredent-implants.com

Optimal conditions for soft tissue attachment and high mechanical stability
Both the Alveo and Tissue Line implants of the whiteSKY system
offer optimal conditions for soft tissue attachment due to their
specially designed sulcus surface. The whiteSKY implants are
made of hardened zirconia and are one-piece, which gives them
particularly high mechanical stability. Thanks to the improved
thread design and bone-quality-oriented surgical protocol, the
whiteSKY implants achieve high primary stability, making them
ideal for immediate loading. Studies have shown that immediate
implant placement can improve the bone-implant contact by
more than 50 per cent.

implants 1 2023

[48] =>

| news
Zircon Medical Management

First long-term study on two-piece zirconia implants published
At IDS 2023, the very first long-term study on two-piece zirconia
implants was presented. In the independent prospective 9-year
study by the University of Düsseldorf, two-piece Patent™ Implants
(Zircon Medical Management) demonstrated that long-term oral
health with dental implants can be achieved. The results after 9 years
of implant function are groundbreaking: no peri-implantitis; high
survival rate; healthy soft tissues (bleeding on probing: 12.9 per
cent; mucosal recession: <1 mm); no implant fractures; stable
plaque indices, pocket depths, and bleeding on probing at 2- and
9-year follow-ups. Marco Waldner, CEO of Zircon Medical, is not
surprised by the study results: “We have been seeing exactly this
for the last 14 years in the practices of our long-standing customers.” The first long-term study of its kind closes a fundamental gap
in research and takes two-piece zirconia implants a giant leap
closer towards scientific and, as a result, clinical recognition. Prof.
Marcel Wainwright, Patent™ user and dental implant specialist,
emphasized during the IDS press conference at which the longterm study was presented: “In order to achieve the results Patent™
Implants have demonstrated in the 9-year study in daily practice,
users must be thoroughly trained and strictly follow the surgical
protocol of the manufacturer.”
Source: OEMUS MEDIA AG

CaviTAU

New insight into an underrecognised entity
Why do implants fail?
Why do more and more
people become chronically ill? Is an undetected
disease “silent inflam
mation of the jawbone”
behind it? Many questions, one modern answer: the digital-quality
determination of bone
density through ultrasound
sonography—CaviTAU ®.
Such, the dentist loca
lises chronic and pathogenetic inflammation CaviTAU® application with LED gel pad and schematic representation of transalveolar sonography.
patterns, cleans them up
in surgical “Jawbone Detox steps” and thus turns from a dentist
over 200 literature citations through all the science behind
into a systemic-immunologically oriented and integrative Oral
CaviTAU®. The book can be ordered online at the website
Physician.
www.icosim.de.
With the newest version of the english book Cavitational
osteonecrosis in jawbone by Dr Johann Lechner, you will
be guided in over 390 pages, with 120 illustrations and
CaviTAU · Germany · +49 89 244154460 · www.cavitau.de

48

implants  1 2023

[49] =>

[50] =>

| about the publisher

Congresses, courses
and symposia
Imprint

CERAMIC

ANTS
IMPL
OF THE ART
STATE

7TH ANNUAL MEETING OF

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Editorial Council
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Oral Reconstruction
Global Symposium

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18–20 May 2023
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ANNUAL MEE TING
OF DGZI
6/7 TH OCTOBER 2023
HAMBURG

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52nd International Annual
Meeting of DGZI
6–7 October 2023
Hamburg, Germany
www.dgzi-jahreskongress.de

3rd JOINT CONGRESS for
CERAMIC IMPLANTOLOGY
13–14 October 2023
Kreuzlingen, Switzerland
www.joint-congress.com

50

implants 1 2023

Copyright Regulations
ceramic implants international magazine of ceramic implant technology is issued three times
a year and is a special edition of implants international magazine of oral implantology — the
first issue was published in October 2017. 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
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Reproductions, including extracts, may only be made with the permission of the publisher. Given no
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liability arising from inaccurate or faulty representation are excluded. General terms and conditions apply,
legal venue is Leipzig, Germany.

[51] =>

[52] =>

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Find out more. Join in and support the charitable initiative.
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🎶

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[cover] => ceramic implants international No. 1, 2023

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