DT Asia Pacific No. 10, 2015

Anxiety provoking scale develloped / Asia News / Data security: How not to become the next Ashley Madison / World News / Interview: “We are now able to enter the second phase of expansion” / Mandibular body reconstruction with a 3-D printed implant / High viscosity ionomers / Implant Tribune Asia Pacific Edition

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DTAP1015_01_Title 14.10.15 11:26 Seite 1

DENTAL TRIBUNE
The World’s Dental Newspaper · Asia Pacific Edition
www.dental-tribune.asia

Published in Hong Kong

Vol. 13, No. 10

INTERVIEW

A MOSAIC

SPECIAL TRIBUNE

How Ivoclar Vivadent’s new office
in Indonesia it will influence the
company’s position and business strategies in the Asia Pacific
region.
” Page 9

Clinical case describing the numerous individual pieces that
make up the treatment plan for
restoring a badly abraded dentition.
” Page 14

Read all about the latest development and trends from the field
of dental implantology in our
special section included in this
edition.
” Page 17

Anxiety provoking scale developed
By DTI
HONG KONG: Dental anxiety is a
major hindrance in the provision
of dental care. Although it is known
that fear of the dentist is closely related to patients’ past experiences
in the dental setting, only limited
scientific research on the actual
causes of dental anxiety is available. Now, researchers have developed a Dental Anxiety Provoking
Scale (DAPS) that measures the degree to which anxiety is triggered
by certain dental stimuli.
For the study, the participants,
460 male and female students recruited from two universities in
Hong Kong, answered a questionnaire including a 73-item measure
of dental anxiety-provoking stimuli.
The factor analysis established seven
factors for the DAPS, namely, dental
check-up, injection, scale and drill,
surgery, empathy, perceived lack of
control, and clinical environment.
In a sub-group of 160 participants,
injections and surgical treatment,
in particular, were identified as

In addition, the researchers found
that perceived dentist behaviour

had an impact on the expression
and development of dental fear,
indicating that the dentist–patient
relationship is strongly related to
patients’ feelings of safety and control during treatment.
The researchers concluded that
their DAPS covers a broad spectrum of patients’ individual dentistry-related anxiety and may also
function as a further assessment

DENTSPLY International and
Sirona Dental Systems have entered
into a definitive merger agreement
and will operate under the name of
DENTSPLY SIRONA in the future. Both
companies will retain their respective
headquarters. The current DENTSPLY
head office in York will serve as the
new company’s global headquarters,
while the international headquarters
will be located in Salzburg.

to supplement initial screening.
This may allow the identification
of patients with higher dental fear
so that the causes of their dental
fear can then be addressed.

Upon close of the transaction,
Jeffrey T. Slovin, current president
and CEO of Sirona, will serve as CEO
of DENTSPLY SIRONA and will be a
member of the board of directors.
Bret W. Wise, current chairman and
CEO of DENTSPLY, will assume the
position of executive chairman of
the newly founded company. In their
respective positions, they will collaborate in executing the corporate
strategy and in integrating the companies and their respective corporate
cultures.

The study, titled “Development
of a Dental Anxiety Provoking
Scale: A pilot study in Hong Kong”,
was published in the September
issue of the Journal of Dental
Sciences.

Together, the companies expect
to generate a net revenue of about
US$3.8 billion (€3.4 billion) and adjusted EBITDA of more than US$900
million (€796 million), excluding the
incremental benefit of synergies.

Injections and surgery provoke highest dental anxiety.

anxiety-provoking events. Although
it was not a statistically significant
finding, female respondents showed
relatively higher anxiety regarding
injection, surgery, and scale and drill,
while male respondents showed
relatively higher anxiety regarding
perceived lack of control, empathy,
and dental check-ups.

Mega-Merger

Extractions
cost Australia
millions

Associate Professor Supatra Thongrungkiat (left), Deputy Dean for Finance and
Assets at Mahidol University, and Associate Professor Passiri Nisalak from the
Faculty of Dentistry opening Thailand’s ﬁrst dental museum.

Job prospects

Caries inhibition

Dentist and orthodontist are
among the top ten highest paying
jobs in the US, the 2015 Jobs Rated
report by CareerCast has revealed.
The profession of dentist was rated
the fifth best paid job with a median annual salary of US$146,340,
followed by orthodontist at No. 7
with a median annual salary of
US$129,110.

A new method that uses specifically formulated, non-staining
silver particles to arrest caries and
render teeth more resistant to
decay has been developed by researchers at the University of
Otago in Australia. The technology
could help preserve caries-infected
teeth and prolong the life of dental
fillings in the future.

A new study conducted at the
University of Western Australia has
shown that prophylactic removal
of third molars costs the Australian
health system more than half a
billion Australian dollar a year. In
addition, the researchers found
that between A$420 and A$513 million (US$309 and 377 million) could
be saved annually if Australia
adopted guidelines comparable to
the UK.
The UK National Institute for
Health and Care Excellence generally recommends that asymptomatic impacted third molars not
be operated on because there is
no reliable research to suggest that
this practice benefits patients, and
surgery is linked to adverse health
effects, including pain, nerve damage and infection.

Distinguished by innovation
Healthy teeth produce a radiant smile. We strive to achieve this goal on a daily basis. It inspires
us to search for innovative, economic and esthetic solutions for direct filling procedures and
the fabrication of indirect, fixed or removable restorations, so that you have quality products
at your disposal to help people regain a beautiful smile.

www.ivoclarvivadent.com
Ivoclar Vivadent AG
Bendererstr. 2 | FL-9494 Schaan | Liechtenstein | Tel.: +423 / 235 35 35 | Fax: +423 / 235 33 60

[2] =>

DTAP1015_02_HealthAtlas 23.03.16 17:23 Seite 1

ASIA NEWS

Dental Tribune Asia Pacific Edition | 10/2015

FDI releases second edition
of Oral Health Atlas
factors and inequalities in oral
health, as well as oral disease prevention and management. Moreover, it
aims to ensure that oral health is
granted higher priority on the global
health and development agendas.
Written for national dental associations, health organisations, industry
professionals and the general public,
the atlas provides them with the
means to address policymakers, governments and local authorities based
on sound facts so that they can better
advocate for change in oral healthrelated policies, Williams said.
According to the atlas, only about
two-thirds of the world’s population
have access to adequate oral health
care, even though oral disease, particularly tooth decay, is among the
most common human diseases.
“Untreated tooth decay is the most
common health condition of chil-

IMPRINT
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Torsten OEMUS
GROUP EDITOR/MANAGING EDITOR DT AP & UK:
Daniel ZIMMERMANN
newsroom@dental-tribune.com
CLINICAL EDITOR:
Magda WOJTKIEWICZ
ONLINE EDITOR:
Claudia DUSCHEK
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DESIGNER:
Franziska DACHSEL

Dr Habib Benzian (left) and Prof. David
Williams, editors-in-chief of the second
edition of the Oral Health Atlas.

INTERNATIONAL EDITORIAL BOARD:
Dr Nasser Barghi, Ceramics, USA
Dr Karl Behr, Endodontics, Germany

By DTI
BANGKOK, Thailand: The FDI World
Dental Federation has released the
second edition of its Oral Health Atlas
at the Annual World Dental Congress
(AWDC) in Bangkok in Thailand.
Titled The Challenge of Oral Disease
—A Call for Global Action, it aims to
AD

Dr George Freedman, Esthetics, Canada
Dr Howard Glazer, Cariology, USA
Prof. Dr I. Krejci, Conservative Dentistry, Switzerland
Dr Edward Lynch, Restorative, Ireland
Dr Ziv Mazor, Implantology, Israel
Prof. Dr Georg Meyer, Restorative, Germany
Prof. Dr Rudolph Slavicek, Function, Austria
Dr Marius Steigmann, Implantology, Germany

Benzian and Williams discussing the new publication with WDD Editor Daniel Zimmermann, DTI, during the launch event.

serve as an advocacy resource for all
oral health care professionals and
recommends strategies to address
the global challenge of oral disease.
At the launch event held at the
Bangkok International Trade and Exhibition Centre, Dr Habib Benzian and
Prof. David Williams, the publication’s
editors-in-chief, presented the new
edition of the atlas and spoke with DTI
group editor Daniel Zimmermann
about the contents of the book and the
global challenge of preventing oral
disease and implementing adequate
oral health care worldwide.
The first edition of the Oral Health
Atlas, titled Mapping a Neglected
Global Health Issue, was released at
the FDI 2009 AWDC in Singapore and
highlighted the extent of the problem of oral disease worldwide. The
second edition of the atlas provides
an update of the global health challenge and reflects on policies and
strategies that address the burden
of oral disease, such as tooth decay,
periodontal disease and oral cancer,
Benzian pointed out.
The book summarises the key oral
health issues based on the latest
available information from various
international sources, Benzian and
Williams explained, including the
impact of oral disease, major risk

dren across all countries, recently
confirmed by the Global Burden of
Disease Study looking at the burden
of 281 diseases and conditions”, said
Benzian. “Children with severe untreated tooth decay are impacted in
their growth, have frequent episodes
of pain, miss days in school and
have a generally lower quality of life,”
he continued. They also usually have
the lowest access to oral health
care and preventive services, added
Williams. Therefore, the two editorsin-chief hope that the second edition
of the Oral Health Atlas will most
of all serve as an advocacy tool
for institutions, policymakers and
dental associations in their effort to
improve access to oral health care
worldwide.
The compilation of the new
edition of the Oral Health Atlas was
supported by the Hong Kong Dental
Association and the FDI’s Vision
2020 oral health initiative. The
book content includes chapters and
data from 30 contributors, and was
reviewed and edited by the two
editors-in-chief.
The atlas can be downloaded free
of charge from the FDI website and
will be translated into the FDI’s official languages of French and Spanish.
These versions will be available
electronically in early 2016.

Published by DT Asia Pacific Ltd.
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responsibility for the validity of product claims,
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[3] =>

DTAP1015_03_News 14.10.15 09:09 Seite 1

ASIA NEWS

Dental Tribune Asia Pacific Edition | 10/2015

New dental school opens in Malaysia
By DTI
KUALA LUMPUR, Malaysia: With the
completion of the new dental faculty
building on Sungai Buloh Campus,
Universiti Teknologi MARA (UiTM) is
now operating the largest dental centre in the country. The RM73.8 million
(US$17.1 million) project, which was
launched seven years ago, houses
Malaysia’s first sterilisation and dental supply centre and will allow treatment of up to 500 patients per day.

The new building unites academic,
clinical and administrative facilities
for both undergraduate and postgraduate dentistry students. The faculty’s
state-of-the-art facilities are expected
to deliver high-quality education and
training for staff and students alike.
As reported online by Astro Awani,
the new building houses operating

theatres, wards, a radiology unit, as
well as the first sterilisation and dental supply centre in Malaysia. Of the
16 clinics included in the faculty, two
specialise in treating persons with
disabilities.
During a press event held to celebrate the completion of the new facilities on 1 September, UiTM Vice Chan-

competent and professional dentistry graduates to allow for the
provision of the best services to the
community.

cellor Tan Sri Prof. Sahol Hamid Abu
Bakar stressed that the faculty’s clinics
will offer dental care services to people
from all walks of life. “When fully operational, we estimate some 205 patients
can be treated at any one time, with
400 to 500 patients per day,” he said.

The UiTM’s Faculty of Dentistry
was founded in 2006. Collectively,
the university offers more than 300
academic programmes and has over
40,000 students on its main campus
and 80,000 throughout the country.

He further expressed his hope that
the new campus will produce more

English is the sole language of
teaching.
AD

2016
WOHD
campaign
launched

LIFELIKE ESTHETICS –
EFFICIENTLY PRESSED

By DTI
BANGKOK,Thailand:Since 2013, World
Oral Health Day (WOHD) has sought
to spread the key message of good oral
health being relevant to general
health among the public worldwide.
The new campaign, launched last
month at the National Liaison Officers’ Forum at the FDI Annual World
Dental Congress (AWDC) in Bangkok,
will offer more tools and applications
than ever to help dental associations
around the world to promote this important event, FDI Executive Director
Enzo Bondioni said.
In addition to the customisable
poster application first introduced in
February, this year’s campaign will be
supported by a promotional video featuring individually recorded messages
from dental professionals around the
world explaining why they think good
oral health is important. For this, attendees of the AWDC in Bangkok were
invited to visit the WOHD stand on the
second floor in the Bangkok International Trade and Exhibition Centre to
have their message recorded. Individual messages can also be sent to the organisation via e-mail. The best of these
will be included in the final product.

IPS e.max PRESS MULTI
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Furthermore, a smartphone game
is in development that will be available for iPhone and Android platforms later this year, Bondioni said.
Originally held in September, WOHD
is now celebrated on 20 March every
year. In addition to public awareness
campaigns and sponsored oral healthrelated events, the FDI’s member national dental associations, schools,
companies and other groups worldwide celebrate the day with individually organised events to inform people
everywhere in the world about oral
health issues and the importance of oral
hygiene. Last year saw over 100 countries around the world participating
in the effort. As a highlight, the campaign’s key message was broadcast to
the world via the giant NASDAQ screen
in Times Square in New York in the US.

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www.ivoclarvivadent.com
Ivoclar Vivadent AG
Bendererstr. 2 | 9494 Schaan | Liechtenstein | Tel.: +423 235 35 35 | Fax: +423 235 33 60

[4] =>

DTAP1015_04_Haque 14.10.15 09:09 Seite 1

OPINION

Dental Tribune Asia Pacific Edition | 10/2015

Data security: How not to become the
next Ashley Madison
By Naz Haque, UK
be transferred to a country or territory outside the EEA (European
Economic Area) unless that country or territory ensures an adequate level of protection for the
rights and freedoms of data subjects in relation to the processing of
personal data.” As a dental practice,
you should reconsider if you are using a commercial e-mail provider
to liaise with your patients, and
determine whether your website
communication tools and feedback portals are compliant and if
not ensure your designated data
policy controller addresses this as
a priority. Here in the UK, the ICO
can issue monetary penalty notices,
requiring organisations to pay up
to £500,000 for serious breaches
of the DPA occurring on or after
6 April 2010. Clients at Dental Focus
expect us to take care of online
compliance and provide guidance
on keeping up to date and resolving
these issues. Make sure your data
is secured and protected before it is
too late.

At the heart of the relationship between a dentist and a patient lies
trust and respect. Recent events,
such as the Sony or, more currently,
the Ashley Madison breach, have
brought to public awareness the importance of securing one’s data. Data
security and governance is a very
tricky area. I must make it clear I am
not a lawyer, but I am a highly experienced information technology professional with a good understanding
of data protection and other relevant
legislation. All interpretations provided here are my own.
Even if a dental practice has not
embraced the digital age and all
records and correspondence are
ink and paper based, the practice
still has a number of responsibilities regarding data security. As dental practices collect patient details,
they must register with the Information Commissioner’s Office
(ICO) here in the UK. Dental records
must be stored safely and securely
for a number of years (up to six
years for the National Health Service; NHS) and kept for a maximum
of 30 years (Department of Health).
Records must also be disposed of in
a policed manner to avoid fines.
What about dental practices who
have embraced digital? Data is
accessed in two situations, storage
and movement, the same as physical records are. This also means that
there are the two situations in which
data can be compromised in the
digital world. Dental practices have
an obligation to ensure patient data
is backed up, recoverable (in case
of disasters), secure and protected.

This applies during both storage
and movement. If you are using
one of the popular industry patient
management systems, such as
EXACT (Software of Excellence), it
should have features to support this
in place; liaise with your account
manager to verify this.
The next area of concern then is
movement of data. This can be via

e-mail, online referral tools or portals, feedback platforms or devices,
and your website. E-mail is not a secure medium, and communication
with patients about their medical
history or medical circumstances
using this platform raises potential
issues. The service provider you use
for your e-mail could also be inadvertently making you breach data
security rules. For example, if you

are using one of the popular USbased organisations for e-mail,
such as AOL, Hotmail and Gmail,
and liaise with your patients via
this e-mail platform, you have to
consider where the e-mails are being stored; most likely on servers
outside your own country.
The UK’s Data Protection Act
states that “personal data shall not

Naz Haque, aka
the Scientist, is
Operations Manager at Dental
Focus. He has a
background in
mobile and network computing,
and has experience supporting
a wide range of blue-chip brands, from
Apple to Xerox. As an expert in search
engine optimisation, Naz is passionate
about helping clients develop strategies
to enhance their brand and increase the
return on investment from their dental
practice websites. He can be contacted at
naz@dentalfocus.com.

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[5] =>

DTAP1015_05_Aligners 14.10.15 09:09 Seite 1

Dental Tribune Asia Pacific Edition | 10/2015

WORLD NEWS

Clear aligners more
beneﬁcial than braces
By DTI
MAINZ, Germany: In recent years,
clear aligners have become a
favourable treatment alternative
in orthodontics to fixed orthodontic appliances (FOA). However,
there are few studies about the effects of aligner treatment on oral
hygiene and gingival condition.
A team of German researchers has
now compared the oral health status, oral hygiene and treatment
satisfaction of patients treated
with FOA and the Invisalign
aligner system. They found that
Invisalign patients have better
periodontal health and greater
satisfaction during orthodontic
treatment.
To date, the majority of patients,
particularly during childhood and
adolescence, are treated with FOA.
However, these appliances tend to
complicate oral hygiene and thus
interfere with patients’ periodontal health. Moreover, treatment
with FOA is not very popular in
adult orthodontics for aesthetic
reasons. Therefore, other orthodontic techniques have been developed to improve aesthetics and
simplify oral hygiene procedures.
An alternative to FOA is clear aligners, which are discreet and have
the advantage of being removable
during oral hygiene and eating or
drinking. The use of clear aligners
has increased greatly in the last
decade, one prominent example
being Invisalign, produced by
Align Technology since 1999.
However, only a limited number of
studies have compared the effects
of Invisalign and FOA on oral hygiene, the researchers from the
Johannes Gutenberg University of
Mainz pointed out.
Their study included 100 patients who underwent orthodontic
treatment, divided equally between
FOA and Invisalign, for more than
six months. The researchers performed clinical examinations
before and after treatment to
evaluate the patients’ periodontal condition and any changes.
Furthermore, a detailed ques tionnaire assessed the patients’
personal oral hygiene and dietary
habits, as well as satisfaction with
the treatment. All of the patients
received the same oral hygiene
instructions before and during
orthodontic treatment. This included the use of toothbrush, dental floss and interdental brushes
three times daily.
The data analysis showed no differences between the two groups
regarding periodontal health and
oral hygiene prior to the orthodontic treatment. However, the
researchers observed notable
changes in periodontal condition
in both groups during orthodontic

treatment. They found that gingival health was significantly
better in patients treated with
Invisalign, and the amount of
dental plaque was also less but not

significantly different compared
with FOA patients.
The questionnaire results
showed greater satisfaction in

05
patients treated with Invisalign.
Only 6 per cent of the Invisalign
patients reported impairment of
their general well-being during
orthodontic treatment, compared
with 36 per cent of the FOA patients. Other negative effects that
also were significantly higher
in FOA patients included gingival irritation (FOA: 56 per cent;
Invisalign: 14 per cent), being kept
from laughing for aesthetic reasons (FOA: 26 per cent; Invisalign:
6 per cent), having to change

eating habits during orthodontic
treatment (FOA: 70 per cent;
Invisalign: 50 per cent), and having to brush one’s teeth for longer
and more often (FOA: 84 per cent;
Invisalign: 52 per cent).
The researchers concluded
that orthodontic treatment with
Invisalign has significantly lower
negative impacts on a patient’s
condition than treatment with
FOA, both with regard to gingival
health and overall well-being.
AD

[6] =>

DTAP1015_06_Branemark 14.10.15 09:10 Seite 1

WORLD NEWS

Dental Tribune Asia Pacific Edition | 10/2015

“We need to stay open-minded
to new crazy ideas”
An interview with Dr Rickard Brånemark, Sweden
The concept of osseointegration has
been applied to dental implants for
several decades. As an orthopaedic
surgeon and engineer, Dr Rickard
Brånemark has continued the work
of his famous father by adapting
the concept to the treatment of amputees. In an recent interview with
Dental Tribune at the EAO congress
in Sweden, Brånemark explained
the benefits and future possibilities of osseointegrated amputation
prostheses.
Dental Tribune: Dr Brånemark, could
you please give an outline of the
development of osseointegrated
prostheses?
Dr Rickard Brånemark: The work
started by my father was the foundation of what we do in ortho-

paedics today. Using his concept,
I developed new treatments for
amputees based on osseointegrated
implants, which I have been performing for about 25–30 years now.
Since 1998, I have mostly worked
with my own companies, namely
Brånemark Integration, the dental
company I started with my father,
and Integrum, which does all the
development for orthopaedic osseointegration. However, we now also
have multinational collaborations
with universities in Gothenburg,
Vienna, San Francisco and Chicago,
and hopefully also Göttingen in the
near future. As the Swedish implant
system has recently been approved
by the US Food and Drug Administration (FDA) for the treatment of

Dr Rickard Brånemark

amputees, I am currently establishing an orthopaedic osseointegration centre in San Francisco and am
working closely with the US Department of Defense, which has many
soldiers with amputations and is
thus very interested in supporting
our work.

Stays where you need it.

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The main advantage of our
approach compared with our competitors is that they have to use
wireless technology because they
do not have the means to bring
wires out of the body owing to the
risk of infection. However, we have
this fantastic osseointegrated implant to use as a conduit so that
the wires can pass through the
implant system. Similar to a fibreoptic Internet connection, the wired
connection in a robotic arm is much
better, stable and robust.
We have already successfully
treated one patient. However, our
research is still in the early phase,
but I think we could do amazing
things in the future.

Stability or flowability? The new Honigum Pro material is a
champion in both disciplines. Thanks to its patented material
structure, Honigum Pro flows when and where it needs to
flow – under pressure. And that’s all! Due to its stability there

prosthesis, which helps us to direct
the prosthetic device in a much
better way and provides feedback.
This is extremely important for
truly restoring function.

is no annoying run-off or drips. With high-precision
Honigum Pro, even the smallest areas are reliably reached
and the finest details accurately reproduced. Honigum Pro
is also particularly well suited to implant impressions.
www.dmg-dental.com

What do you consider the main
challenges of this treatment?
Anchoring something to the
bone is the core of osseointegration
technology and that is a fairly robust
technology we have proven in millions of dental implants. However,
in orthopaedics, we face additional
challenges. There are, for example,
no materials available today that
are strong enough to withstand
20–50 years of high physical activity.
Therefore, we have developed and
continue to develop new materials
and surfaces that better withstand
the higher loads.
Another important concern is the
mucosal area and skin penetration,
which is maybe even more challenging. We are working with a concept
very similar to the old Brånemark
protocol and the bone-anchored
hearing aid in that we have a smooth
surface that is not an attachment.
There are many groups working
with attachments and, as far as
I know, all have failed, especially in
the orthopaedic field.
However, just like with every
surgical procedure, the outcome
largely depends on the skills of the
surgeon too.
For the last six years, you have also
been using osseointegration in conjunction with implanted electrodes.
Could you tell us more about this
programme?
Yes, we are also developing the
next generation of amputation
prostheses. In addition to the osseointegrated implant, we are able
to attach electrodes to muscles and
nerves to have a brain-controlled

Do you think that osseointegrated
prostheses could potentially replace
traditional prostheses in the future?
This treatment would not apply
to amputations of the lower leg as
a result of poor circulation caused
by diabetes or vascular diseases
related to smoking. Such patients
constitute about 90 per cent of the
amputee population. However, the
younger population who have been
in road or war accidents or who have
musculoskeletal tumours, which
are more likely to occur in younger
patients, will be candidates for this
treatment.
If the technology continues to be
as promising as it appears now, the
majority of patients will opt for it—
just like they now have the choice
between dentures or fixed dental
implants, which are much better
for the patient. There will be a shift,
but this will take some time. The
introduction of dental implants
took about 17 years; similarly, this
shift could take another ten to
20 years. However, receiving FDA
approval and having the system in
use by the military could definitely
speed up the establishment.
Overall, this treatment offers
many alternatives to conventional
treatments. However, there is often
too much conservatism in the dental and medical fields when it comes
to innovations, but I think we need
to stay open-minded to new crazy
ideas. This research shows what
might be possible in the future.
We might be able to restore sensory
function of a non-existing limb,
creating good artificial sensation.
It also shows that the dental and
the medical professions should
work more closely together. As one
can see, there are many synergies
that could be drawn from the fields
of dental and orthopaedic research
in our case. The idea of translation
of knowledge was also the original
idea of the EAO, which has now
become a purely dental meeting.
This is a pity because we have to collaborate more, but maybe there will
be more cross-disciplinary presentations and meetings in the future.
Thank you very much for the interview.

[7] =>

©MIS Corporation. All Rights Reserved

MORE BONE Where it Matters Most...

Find out more about the new V3 Implant at: www.V3-implant.com

[8] =>

[9] =>

DTAP1015_09_Interview 14.10.15 09:10 Seite 1

Dental Tribune Asia Pacific Edition | 10/2015

BUSINESS

“We are now able to enter the second
phase of expansion”
An interview with Jörg Brenn and Christian Brutzer, representatives of Ivoclar Vivadent in Asia
developed to such an extent that it
is now self-sustaining and can be
entirely managed by local talent.
This allows us to use valuable resources in other markets. We are
extremely lucky to have someone
like Jörg Brenn, who has 25 years of
work experience in the region.

In the presence of 100 guests and
partners from South East Asia, dental manufacturer Ivoclar Vivadent
recently opened a new marketing
office in Indonesia. Located in the
western province of Banten, the office is intended to provide marketing support on both clinical and
technical products to business partners in the region. The former general manager of Ivoclar Vivadent
China, Jörg Brenn, will head the new
operations. At the recently held
FDI Annual World Dental Congress in
Bangkok in Thailand, Dental Tribune
had the opportunity to speak with
Brenn and Global Region Head
Asia/Pacific Christian Brutzer about
the new venture and how it will
influence their company’s position
and business strategies in the Asia
Pacific region.
Dental Tribune: With the new office
in Indonesia, your company has
recently extended its marketing
network to South East Asia. What
was the incentive behind setting up
a regional hub there?
Jörg Brenn: Besides having a large
number of dentists and dental laboratories, Indonesia remains one of
the fastest growing markets in the
entire Asia Pacific region. However,
this was only one of the reasons for
setting up an office there. We also
decided to go to Indonesia because
of the unique economic circumstances. Most of our competitors
are still operating from Thailand
or Singapore, so we decided to do
something completely different.
The new office is based in the
suburb of Tangerang (not in downtown Jakarta), which is very close
to the airport. This means we can
offer excellent connections for
visitors from South East Asia who
want to participate in our training
programmes, for example.

Jörg Brenn (left) and Christian Brutzer (centre) in talks with DTI Group Editor Daniel Zimmermann.

our knowledge, it is also the first
training centre that a foreign manufacturer has set up in the country.
Since we have highly trained personal on-site, we will be able to offer
support to our clients and part-

and have full access to the Ivoclar
Vivadent information network.
How does the new operation in Indonesia fit into your overall business
strategy for the Asia Pacific region?

thought-out steps. This strategy
helped us to get through the financial crisis in 2008/2009 largely
unharmed. As the markets in Japan,
Korea, China and India have become established, we are now able

“Asia is still growing more dynamically
than any other market in the world...”
ners—something unprecedented
in Indonesia. Our staff will be regularly trained at our head office

Brutzer: When we developed
our road map for Asia, we decided
to implement it in small, well-

to enter the second phase of expansion and to venture into new
territories. China, particularly, has

Christian Brutzer: Some years
ago, Jakarta and Indonesia as a
whole were certainly a secondary
choice in terms of accessibility and
logistics. Now, however, one can
reach all important hubs in the
region and beyond from there.
The country also boasts a domestic market potential that is far
higher compared with countries
like Singapore.
You mentioned that you will be offering educational programmes in
Indonesia. How and in what courses
will dentists be able to participate?
Brutzer: Ivoclar Vivadent is a system provider. This includes education, which we are now able to offer
through the new International
Centre for Dental Education (ICDE)
in Indonesia. It is on the same level
as our ICDEs in Shanghai and
Osaka, for example. According to

What challenges does the market in
Indonesia pose compared with China?
Brenn: Indonesia is at the point
of development where China was
15 years ago. There is a similar optimistic spirit, even though it is on
another level and has different
characteristics. One can really feel a
great deal of energy in the country,
which may be fuelled by the new
president, whose ideas have provided inspiration for many. While
there remains much to be done,
one can clearly see the economy
moving forward. For example,
many Indonesians went to Singapore for dental treatment in the
past, but now the country has so
many excellent clinics and dental
practices that there is no longer
any need for patients to go abroad.
This has given the dental business
in Indonesia greater strength and
higher autonomy.
What are the prospects for Ivoclar
Vivadent’s business in the region?
Brutzer: The market in Asia is
still growing more dynamically
than any other market in the world,
even more than Latin America. In
some countries, like China, we are
currently experiencing deflation
owing to previous efforts by the
government there to slow down
growth. Naturally, this had an effect
on dental services and the demand
for materials and systems. However, we envision the private sector
constantly expanding and this development will give us completely
different opportunities in the years
to come. We are seeing similar developments currently in India.
As usual, we have adopted a
middle- and long-term strategy in
South East Asia. This means that
we did not enter the market expecting to know everything in just
a few months. It will take some time
to understand the environment.
Fortunately, we are able to address
a market like Indonesia with
enough resources to accelerate
that process. Our approach is based
on sustainability.
Brenn: After a year of preparation and observing the market, we
are already seeing a positive development in Indonesia. We now
know more than ever what huge
opportunities this market offers
for our business.

Christian Brutzer and Jörg Brenn celebrating the opening of Ivoclar's new SEA ofﬁce with local staff members.

Thank you very much for the interview.

[10] =>

DTAP1015_10-11_Kazemi 14.10.15 09:11 Seite 1

TRENDS & APPLICATIONS

Dental Tribune Asia Pacific Edition | 10/2015

Mandibular body reconstruction
with a 3-D printed implant
By Dr Saeid Kazemi, Reza Kazemi, Sita Rami Reddy Jonnala & Dr Ramin S. Khanjani, Sweden
topography of the surrounding
structures. Thanks to the available
technology and material, now it is
possible to 3-D print such intricate
designs with above-standard accuracy and minimum technical
glitch. The result is the highest fit
of precision always craved for by
maxillofacial surgeons to complement their skilful incisions.

Case presentation

Fig. 1: One-of-a-kind mandibular implant as reconstruction for the missing mandible body.—Fig. 2: Replica of the patient’s
skeleton. Missing mandible body replaced with a ﬁbula graft.

Nowadays, no aspect of human life
seems to have been left untouched
by the ever-expanding digital technology. Particularly in scientific
fields, digitalisation has working
wonders during the past few years,
to the degree that it is even difficult
to imagine going back to the ordeal
of analogue methods and putting
up with their vagaries. A remarkable blessing of digital technology,
among others, is the exceptional
precision and high control over the
measurements, never possible to
obtain through any of the preceding
methods. There is no surprise then
that it has the strongest appeal to
the fields of knowledge and practice
wherein precision is amongst the
most critical element of success.

Hot spot for digital
technology
With a lot of technical sensitivity
at its heart, the dentistry can easily

be viewed as a hot spot for implementing digital technology to
achieve the most-wished precision. Indeed, the digital technology has already gained a stable
foothold in dentistry and there is
an ongoing shift towards embracing digital systems into the dental
practice. Predictably, the majority
of the advertised technologies and
services are geared towards routine
dental procedures. On the other
hand, the most significant advancements have been witnessed
in an area which falls only within
the experience of specialists; it is
the domain of maxillofacial surgery where tailoring the treatment
plan to the unique conditions of
the patient is the key to success.
Here the state-of-the-art digital technology comes in handy to fully customise the treatment by taking the
slightest details into consideration
and reflecting that into the surgical
and restorative solutions.

Though the successful reconstruction of any human structure is
justifiably a challenge, the stakes
are even higher when the oral and
maxillofacial area is affected. In this
latter case, care must be taken to retrieve function in conjunction with
restoring aesthetics. Oftentimes,
even the second objective might
take precedence. As such, the significance of precision and adaptability
to the existing structures for the
maxillofacial implants cannot be
overemphasised. Fortunately, with
the advent of 3-D digital designing
and additive manufacturing a fully
satisfactory treatment is no more
a remote possibility.
The virtual environment of 3-D
software accommodates full inspection of the surgical area from
multiple angles. It also facilitates
designing and adjustment of the
form of the future implant with
much ease and with respect to

Since its inception, DRSK Company has been committed to explore potentials for incorporation
of the digital and computer science
into the dental field by devising
innovative solutions. With 3-D services being a major activity of DRSK,
the company has been approached
for 3-D designing the maxillofacial
implants of different kinds and
successfully accomplished them.
All these 3-D designed implants are
highly customised and feature great
accuracy and therefore satisfy both
surgical and mechanical standards.
Patient case
One such recently carried out project that merits further elaboration
is the design and manufacture of
one-of-a-kind mandibular implant
(Fig. 1) for reconstructing the missing
mandible body (Fig. 2). The patient,
a young man, had lost the entire
mandible except for the rami after
being severely injured in a blast. Over
the years, the patient had undergone
several surgeries with little improvements achieved. In point of fact, one

consequence
of those surgeries was the
formation of fibrous scar tissues
which, as will be explained in the
following, exacerbated the situation
and restricted the chance for an
effective treatment.
At the time the surgical team
contacted DRSK, the patient had
already received a graft taken from
his fibula. Owing to the extent of
structure loss, the graft alone failed
to yield the anticipated results.
Needless to say, the ultimate goal
of the treatment was to improve the
aesthetics and retrieve the function
of the reconstructed jaw by a prosthetic treatment and giving the
patient a chance to experience an
almost normal mastication once
more. However, the form and size of
the grafted bone could not provide
the required support for prosthetic
structures such as dental fixtures.
Eventually, the surgical team decided to seek assistance from DRSK
and use its 3-D services expertise
to design and manufacture an ad
hoc mandibular implant that fully
complies with the patient’s unfavourable conditions and enables
the complementary prosthodontics

Fig. 3: Left and right segments of the implant were designed to be placed and screwed over the corresponding ramus.—Fig. 4: At the front, left and right segments of the implant met and dovetailed into each other.—
Fig. 5: A temporary or surgical middle piece was designed to be placed over the left and right sections at the surgical session.—Fig. 6: The middle piece should hold two pieces in place at the front.—Fig. 7: The prosthetic,
permanent middle section.—Fig. 8: After the healing period: Insertion of the prosthetic component with unscrewing und removing of the surgical middle part.—Fig. 9: Insertion of the prosthetic middle section,
carrying the teeth.—Fig. 10: Fixation of the prosthetic middle section.

[11] =>

DTAP1015_10-11_Kazemi 14.10.15 09:11 Seite 2

Dental Tribune Asia Pacific Edition | 10/2015

TRENDS & APPLICATIONS

3-D printing
As the designing procedure finished, the designed implant had
to be manufactured and delivered
to the surgical team. All three pieces
were 3-D printed in Titanium Grade 5
using EBM technology. Also before
installing the implant, patient’s
facial skeleton needed to be reproduced in a plastic material. It was 3-D
printed by means of SLS technology.
This replica was produced in order
to give the surgeon a better idea of
the surgical site and therefore facilitate the surgical process.

treatment. The overall shape of the
implant and its relation with other
anatomic structures, including the
grafted bone and the soft tissue were
all fleshed out and requested by
the surgical team. One stipulation
of the surgical team was to keep
the previously grafted fibula. They
considered it as a safety measure in
event of implant’s failure.
The design solution
One big challenge to carry out
this particular project was to design the implant in such a way that
it can be easily seated in the correct
position. There were two major impediments to a one-piece implant
solution. First of all, the implant
was intended to be mounted over
the remaining parts of the patient’s
jaw, i.e. his two rami. To achieve the
maximum anchorage from the
rami, those parts of the implant
connecting them were supposed to
adapt to their external anatomy.
Since the rami converge to the
front, the same was expected from
the corresponding implant design.
However, such designing choice
would have made the matters complicated for surgical placement
of the implant. What’s more, the
fibrous tissues resulting from the
previous surgeries have dramatically reduced the patient’s ability
to open his mouth. Therefore,
DRSK 3-D design team had to cross
out the one-piece implant solution.
Eventually by taking different limitations into account and after
consulting with the surgical team
and receiving their endorsement, it
was decided to make the prosthesis
in three pieces.
Each of the two larger left and
right segments of the implant was
designed to be placed and screwed
individually over the corresponding ramus (Fig. 3), while at the front
they met and dovetailed into each
other (Fig. 4). A third part then had
to be placed over the two pieces
at their interface, embrace both
and hold them together securely
(Figs. 5 & 6). This way the whole
thing turned into a unified structure.
Excellent fit with 3-D designing
The success of the proposed design was to a large extent reliant on
obtaining an excellent fit for each
piece. This is the reason why the
role of 3-D design and manufacture
was so essential in this procedure.
The parts of the right and left sections that meet the rami had to
be exactly adapted to the form
of their corresponding anatomic
structures. Each of them had to be
formed in such a way that can fold
over the edges of the ramus and
embrace it enough for a proper
support. Using 3-D design as well
guaranteed the perfect contacts
between three pieces which otherwise might have been an area of
concern for a design of this nature.
Given the necessity for including
a prosthetic solution and considering the patient’s limited mouth
opening, the most feasible solution
was to incorporate the artificial
teeth into the structure of the

Fig. 11: Final prosthesis shown over the patient’s model.

mandibular implant. As described
above, during the surgical procedure and after screwing left and
right pieces over the rami, the two
overlapping front ends of left and
right parts were fully fixed in place
by adding the middle segment.
The idea for the final design was
to include the artificial teeth as part
of this middle section.
However to eliminate the risk of
any force or pressure that would
have compromised the success of
the surgery, a temporary or surgical middle piece was designed to be
placed over the left and right section at the surgical session (Fig. 5).
The function of this piece was simply to hold two pieces in place at the
front (Fig. 6) before being replaced
with the prosthetic, permanent
middle sections (Fig. 7).
The prosthodontic component
On the surgical team’s recommendation, the mandibular dentition included in the design of the
middle section only comprised ten
teeth including incisors, canines
and premolars on both sides (Fig. 7).
Due to the size of third surgical
piece and its function of uniting
the other two sections, only incisors and canines are in contact
with the interconnecting surface
of the middle part. So when the
middle prosthetic piece is seen independently, the premolars look
unsupported in the manner of a
cantilever bridge.
However, after insertion of this
enfolding middle part over the
overlapped arms of left and right
pieces, the premolars become
tightly in contact with left and right
sections; this prevents any destructive lever function from taking
place. Again such close contact has
only been enabled by the accuracy
of 3-D designing and the following
3-D print procedure.
The particular design of arms
of left and right pieces, which collectively form the body of the
mandible, is also worthy of note.
These arms feature a 90 degree
twist in the approximate area of
molars. In this way they can adopt
to both the thinner posterior part
which is anchored over the ramus
and the frontal part that required

a broader width for carrying the
teeth. Such twist also offered a solution for the relative lack of space
in the posterior part of the mouth.
This curve can as well bolster the
physical resistance of the mandibular implant to the mechanical
pressures.

After the healing period, the
time comes for insertion of the
prosthetic component. At this
stage the surgical middle part will
be unscrewed and removed (Fig. 8)
and the prosthetic middle section,
carrying the teeth, will be inserted
(Fig. 9) and fixed in place (Figs. 10
& 11). After checking the occlusion
the patient’s bite is to be registered.
The sizes of the teeth have to be
adjusted accordingly. As the next
step, a layer of porcelain should
be added to the teeth to finalise
the prosthetic phase and thereby
the treatment process.

Summary
In brief, the 3-D design has paved
the way for devising unorthodox,
novel surgical and prosthodontics
solutions, as exemplified by the
case presented in this article. Such
alternative solutions could not be
achieved through traditional technology with the same level of accuracy, which is essential for achieving
the desired outcome. The 3-D designing and 3-D printing therefore have
infinitely widened the scope of
maxillofacial surgeries by expanding and improving the potentials
for customisation. Hence, it is now of
utmost importance for maxillofacial
surgeons to get further familiar with
areas of application of these empowering tools and learn about opportunities for enlisting its assistance.

Dr Saeid Kazemi
is the CEO of
DRSK, a Swedish
company specialised in implantology and
3-D services.
He can be contacted at drsk@
drsk.com.
AD

[12] =>

DTAP1015_12_Elizari 14.10.15 09:12 Seite 1

TRENDS & APPLICATIONS

High viscosity ionomers
Amalgam alternatives in the posterior section
By Dr José Ignacio Zalba Elizari, Spain
This article discusses a treatment approach change in the Minimal Intervention model, where high viscosity
glass ionomers present some advantages that position it as the restorative material of choice in the posterior section for all patients, especially
for those with high risk of caries including children, older people, periodontal patients and patients on
medication.

requirements of functional feasibility, biostability, biocompatibility
and sterility.

serving as protection for the pulp.
Proper adhesion will help prevent
microleakage by isolating residual
bacteria from nutrients, reducing
its metabolic activity, thus stopping
the progress of demineralisation,
while the calcium, phosphorous
and fluoride ions available in the
ionomer will increase remineralisation. The ultimate in MI models
involves greater conservation of

No restorative material can replace enamel and dentin perfectly,
and therefore preserving these
must be of the utmost importance
in any treatment plan. Aware of the
situation, the profession has developed new techniques and dental

Dental Tribune Asia Pacific Edition | 10/2015

leased from the material, forming
a union between both. A degree of
adhesion is also produced between
the groups of carboxylic acid and
the dentin collagen.

end up being more economical in
the work process, which makes them
of more interest in the current climate where it is not only about doing
it well, but less expensively too.

The first restorative glass ionomer aesthetically accepted was the
Fuji II (GC Europe, Netherlands),
which showed better physical properties than previous materials.
Since then, the basic composition
of these materials has improved
and we can now say that its aesthetic condition is suitable for the
posterior section or areas where
aesthetic requirements are not
paramount. After polishing, and
with the aim of improving this
characteristic, the coat or layer has
been developed, which is placed on

There is strongcontroversy on the
potential health impacts caused by
the use of amalgam, which started
long ago when some members of
the scientific community raised
doubts about its effectiveness and
safety regarding the effects on animals and humans of the mercury
contained in amalgams that have
been used for several decades in
various odontological applications.
All this requires rethinking and even
more so now that we have more biocompatible materials with a high
success rate when it comes to resolving the requirements of restoring
teeth using current MI working
models. The team at the dental clinic
itself suffers the greatest risk of contamination when handling it, since
it causes mercury to be released into
the surgery environment.

Clinical case—Fig. 1: Initial situation
with dental caries.—Fig. 2: Opening
of the cavity.—Fig. 3: Application of
the material (Equia Fil) all at once.—
Fig. 4: Modelling after 150 seconds.—
Fig. 5: Application of the nano-ﬁlled
varnish.—Fig. 6: Result after light
curing 20 seconds.

the surface of the material making
it more visually appealing and protecting it from water for proper
maturation, increasing its aesthetic
and physical properties.

Black’s classification of cavities
was used in dentistry for treating
dental caries for much of the last
century, and lesions have therefore
been treated by removing the diseased tissue from the tooth along
with a healthy portion as well. That
past reality fit the techniques and
material available at the time, primarily amalgam.

materials that adequately restore
existing lesions and may prevent
secondary caries from developing.
Glass ionomers were introduced
into this search in dentistry several
years ago, which, due to the development of their characteristics, gives
them great advantages over other
restorative materials.

dental tissue, since we know the side
effects of removing the tooth mechanically.

Changes in the treatment approach and the development of
adhesive materials led to progress
in dentistry. Minimal Intervention
has changed the traditional model
where treatment of caries does not
just involve a mechanical approach,
but also requires a biological approach, made possible by less invasive techniques; therefore the
biocompatibility of the materials
requires greater attention.
Biomaterials are, by definition,
any materials that take on the
functions of the tissues in natural
organs, capable of imitating the
properties of the tissue as far as
possible in its biological environment. Biomaterials must meet the

Glass ionomers have undergone
numerous changes with the aim of
improving their clinical properties.
The advances in these high viscosity
materials offer a better alternative
as restorative material than amalgam in the posterior section. The adhesion of the glass ionomer to the
dental structure is less susceptible
to the loss of healthy dental structure, even recovering affected
dentin. Therefore these restorative
materials end up being safer and
more indicated in minimal intervention dentistry. Research suggests that glass ionomers used to fill
extensive lesions will facilitate the
remineralisation of affected (demineralised) dentin at the bottom of
the cavity once the infected dentin
has been taken away, additionally

The setting reaction of the glass
ionomer is an acid-base reaction
between the polyacrylic acid and the
glass base: the acid attacks the glass
particles, causing Ca, Al and F ions
to be released. The F ions are incorporated into the matrix, and can be
spread among the structure surrounding the tooth and in the salvia.
Fluoride toothpastes can be a source
of this ion for the glass ionomer.
The release of fluoride provides anticaries qualities that are strongly indicated in all patients, but with special attention to those most at risk to
caries (children, older people, those
taking medication, etc.) and in periodontal patients (exposed roots).
The adhesion is the result of a
change in ions between the tooth
structure and the cement. The polyacrylic acid in the glass ionomer
attacks the tooth surface, releasing
calcium and phosphate ions that reprecipitate along with the calcium,
phosphate and aluminium ions re-

The physical properties of glass
ionomers are important in the
context of minimal intervention
techniques. Like all water-based cements, they are relatively sensitive
to water and loads for 24 hours after
their placement, until they are fully
matured. With proper control of the
procedure, they have demonstrated
adequate duration in areas of normal load. There is sufficient bibliography to ensure that glass ionomers
may be used as definitive material
in Class I, II and V restorations.
The latest publications have even
indicated that high density glass
ionomers can be used in Class II under stress where the isthmus is less
than half the intercuspal distance.
Its low sensitivity to the technique (encapsulated ionomers), as it
is a material that is placed all at once,
tolerates moisture when it is handled, and its ease of use in modelling
or removal of excesses makes it well
suited to the conditions required for
day-to-day use in dental surgeries.
As Dr Karl-Heinz Friedl demonstrated, these are materials that are
more economically efficient than
traditional ones (amalgam and
composite), and they ultimately

Up to now, the restorative material that is closest to nature is glass
ionomer (EQUIA, GC Europe), which
is a mineral. We could say that
EQUIA is in itself a new restoration
concept involving two materials: a
next generation high viscosity glass
ionomer (Equia Fil), with a translucency and aesthetic hitherto unseen
in this type of material, and a nanofilled varnish (Equia Coat) that not
only buffs the material easily, but
also protects it as it matures.
With this new restoration technology, we have the huge advantage
of being able to fill a cavity all at once
and carry out very quick restoration,
which results in an economical
restoration that is at the same time
aesthetic. Another added benefit
typical of ionomers as explained before, is that it is not necessary to isolate the area, so we will have better
adhesion in fillings where it is difficult to get an adequate dry area.

Conclusion
Minimally invasive restorative
models, combined with the demand
for more aesthetic, biocompatible
and lower cost materials, are causing current direct restorative minimal intervention dentistry to move
away from amalgam in order to
find new systems based on glass
ionomers as the material of choice
in the posterior section. In addition,
this new restorative concept is a perfect alternative for any patients who
reject composites for financial reasons or in those situations where the
isolation required for a composite
may not be attainable.
Editorial note: This article was originally
published in GACETA DENTAL 212, March 2010

Dr José Ignacio
Zalba Elizari is a
specialist in minimally invasive
dentistry. He is
currently working as a dentist
at Zalba dental
clinic in Pamplona in Spain.
Zalba can be contacted at consulta@
capdental.net.

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[14] =>

DTAP1015_14_16_Kersting 14.10.15 09:49 Seite 1

TRENDS & APPLICATIONS

Dental Tribune Asia Pacific Edition | 10/2015

A mosaic of numerous individual pieces
Treatment plan for restoring a badly abraded dentition
By Dr Jan Kersting & Alexander Miranskij, Germany

Fig. 1: Reduced vertical dimension of occlusion. The photograph shows the well-developed masseter muscle on both sides of the face.—Fig. 2: Customised occlusal appliance raising the vertical dimension by approximately 2.5 mm (splint therapy).—Fig. 3:Wax-up incorporating the vertical dimension evaluated via the occlusal appliance.—Fig. 4:Wax-up rendered in composite by means of a silicone matrix.—Fig. 5: Composite occlusal veneers adhesively cemented to the tooth structure without any prior preparation.—Fig. 6: Sequential preparation for the permanent restoration by maintaining the vertical dimension of occlusion.—Fig. 7: Bite
taking after the preparation of teeth #36, 46 and 43.—Fig. 8: Prepared mandibular teeth.

Many different therapeutic components combine to produce a treatment solution that focuses on both
functional and aesthetic parameters.
However, the different pieces have to
be carefully matched in order to obtain
a satisfying, long-lasting result. A wellstructured treatment plan is requisite,
particularly in extensive restorative
procedures. Continuous interaction
and communication between the
practitioner and the dental technician
throughout the treatment and the patient’s confidence in these specialists
represent important components in
the process of restoring the aesthetics
and function of the patient’s dentition.

When the patient consulted our
practice for the first time, he had
severely worn anterior and posterior
teeth. He was of a strong build and had
been participating in competitive
sports for many years. His facial muscles were exceptionally pronounced
(Fig. 1). Dental professionals are increasingly faced with cases demonstrating this type of pathological loss
of tooth structure today. Causes include erosion (demineralisation of
the teeth without the involvement
of micro-organisms), attrition (physiological or pathological occlusal
contacts) or abrasion (mechanical
processes and bruxism).

In addition, materials play a pivotal role. In this regard, the highstrength lithium disilicate glassceramic IPS e.max Press (Ivoclar
Vivadent) offers excellent physical
and aesthetic characteristics, making
it the ideal choice for many indications. Apart from its high strength,
the material has a very attractive
appearance, allowing exceptionally
aesthetic results to be achieved, even
if space is limited.

Preoperative
considerations
The patient originally presented to
the dental practice to have a carious
lesion in tooth #46 repaired. Owing
to the obvious dysfunction of his jaw,
we explained to him the medical importance of undergoing a suitable treatment. In order to achieve the longterm success of the treatment, we first

had to realign the physiological vertical occlusion. Therefore, we needed to
establish the cause of the destruction,
as this significantly influences the
treatment planning and the choice of
the materials to be used in the process.
In many cases, wear is caused by
a number of different factors. Here,
the strenuous physical activity of the
patient appeared to be the main contributor to the loss of tooth structure.
We devised a minimally invasive treatment plan, which was discussed with
him. All the necessary patient details
were recorded. Owing to the extensive
loss of vertical occlusion, the patient’s
physiognomy had changed dramatically. His facial features were asymmetrical and his smile was crooked.
The corners of his mouth were not
properly aligned. Contrary to aesthetic guidelines, the curve of the
lower lip was not parallel to the upper
incisal edge. The incisors had been so
severely abraded that they no longer
formed an upward curve. Furthermore, the lower lip drooped on the
right side. The patient reported that he
often clenched his teeth, especially

during physical exertion. He also
complained of tenseness of his jaw
muscles.

Planning phase
The initial diagnosis involved the
evaluation of intra-oral and extraoral photographs and a clinical functional analysis. In addition, study
models were assessed. A diagnostic
wax-up based on a digital aesthetic
analysis (Digital Smile Design according to Dr Christian Coachman) gave
us essential information about aesthetic aspects, the vertical dimension
of occlusion, the occlusal design and
bite elevation. The existing structures
were rebuilt in wax using an additive
method, and the physiological state
was restored. In this case, the wax-up
was used not simply to evaluate the
initial situation and guide the treatment process, but also as a communication device. The wax-up allowed
the patient to visualise the treatment
result. Furthermore, the model gave
him the motivation to persevere in
pursuing the challenging and timeconsuming treatment goals.

In the first part of the treatment,
the patient was fitted with a customised occlusal appliance. The aim
of the splint therapy was to restore
the physiological bite of the patient.
Before the appliance was fabricated,
a comfortable physiological rest position was evaluated. Furthermore,
a 2.5 mm increase in the vertical dimension was required (Fig. 2). Several
days after the splint had been placed,
the patient reported that he felt comfortable with the old-but-new vertical dimension of occlusion. He wore
the appliance for three months, during which time he did not experience
any functional problems. The muscles relaxed quite visibly.
The occlusal situation that could
be established with the appliance
was stabilised by treating the patient
with long-term temporary restorations. We decided to provide him
with non-invasive occlusal veneers
made of composite, which would be
adhesively cemented in the lower
jaw. For this purpose, the study models were set up in the articulator in
the arbitrary hinge axis position on

Fig. 9: Occlusal veneers modelled in wax according to conventional wax-up principles.—Fig. 10: The successively waxed-up restorations were recreated exactly in ceramic (IPS e.max Press).—Figs. 11 & 12: The occlusal
veneers were placed with the adhesive technique, and the mandibular anterior teeth were built up with composite. The restorations blended in smoothly with the remaining dentition. Owing to its strength,
lithium disilicate can withstand high masticatory forces.—Fig. 13: The ultrathin anterior veneers were applied to pressed frameworks (cut back). (see next page)

[15] =>

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[16] =>

DTAP1015_14_16_Kersting 14.10.15 09:13 Seite 2

TRENDS & APPLICATIONS

Dental Tribune Asia Pacific Edition | 10/2015

Fig. 14: The ultrathin anterior veneers were applied to pressed frameworks (cut back).—Figs. 15 & 16: The restorations in situ showed a lifelike interplay of colour. A well-structured treatment plan and high-strength
ceramic restorations enabled the dental team to adjust the vertical dimension of occlusion of the patient and improve his appearance quite dramatically.

the basis of a functional analysis.
The anticipated final situation was
waxed up according to the diagnostic set-up (Fig. 3). The waxed-up
restorations were recreated with
composite and the help of a clear
silicone matrix (Fig. 4). The occlusal
veneers were then completed. In the
process, we paid particular attention
to functional and morphological
principles. Next, the veneers were
adhesively cemented in the patient’s
mouth and the functional parameters were checked. This temporary
restoration represented a decisive
step in the treatment procedure and
a significant component in achiev-

ing a lasting result. The patient could
not be expected to wear the occlusal
appliance continuously for 24 hours.
The long-term temporaries, however, enabled the movement patterns to be optimally established,
since they were cemented in place
(Fig. 5).
The situation stabilised over the
next three months and the patient
indicated that he felt very comfortable. The temporaries did not show
any signs of wear and the patient
was pain-free. The time had come
for the final treatment phase to
begin.

We had carefully assembled all
the strategic pieces up to this point.
At this stage, the success of the permanent restoration would depend
completely on the preparation technique. Neither the horizontal nor
the vertical maxillomandibular relationship could be disturbed. The
sequential preparation phase started
with the occlusal veneers. In the first
step, teeth #36, 46 and 43 were prepared (Fig. 6), and three-point support was established. Subsequently,
the maxillomandibular jaw relationship was recorded (Fig. 7), and teeth
#33 to 37, as well as #44 to 47, were prepared according to minimally inva-

.
Dr

K ris h n a

sive principles. This is currently the
acceptable standard in aesthetic and
functional restorative treatment, as
it corresponds to the requirements
of patient-oriented and responsible
dentistry. The patient’s teeth showed
a number of cervical lesions (damaged fillings and untreated wedgeshaped lesions). As a result, the
preparation strategy was adjusted to
take these lesions into account. First,
the damaged fillings were replaced
with composite (Tetric EvoFlow,
Ivoclar Vivadent), then the now intact fillings and the wedge-shaped
lesions were included in the enamel
preparation and sealed with the occlusal veneers. We ensured that the
preparation margins were located in
the enamel and were free of composite (Fig. 8). We decided not to prepare
or build up the teeth with composite
in the lower anterior jaw.
After the impressions had been
taken, the study models were fabricated and mounted in the articulator
in relation to the horizontal plane.
Before the final mandibular restoration was completed, we discussed the
aesthetic and functional reconstruction of the maxillary anterior teeth
(veneers for teeth #13 to 23) with the
patient. We helped the client to visualise the anticipated result by building
up the teeth in wax. The teeth acquired a distinctive shape and a suitable length. The wax-up was used to
fabricate a mock-up, which was tried
in by the patient. He was extremely
pleased with what he saw and was
completely satisfied with the veneer
solution. Nevertheless, he wanted our
assurance that we would not grind any
healthy tooth structure unnecessarily. State-of-the-art materials that can
be cemented with adhesive methods
enabled us to fulfil his wish. In this
case, we used ultrathin lithium disilicate veneers, which we bonded to
the healthy tooth structure for longlasting results.

Fabrication of the
ﬁnal restorations
High strength was a priority in the
posterior dentition. Therefore, fullcontour restorations (monolithic)
were fabricated with IPS e.max Press
(Figs. 9 & 10). The occlusal veneers
were produced in wax according to
customary methods. The restorations
were created in ceramic using the
press technique and then prepared
for adhesive cementation. The teeth
were conventionally prepared according to the requirements of the adhesive technique. For the permanent
cementation of the restorations, we
used a dual-curing luting composite
(Variolink II, Ivoclar Vivadent).

The teeth in the lower jaw were
built up with a highly aesthetic composite resin (Tetric EvoCeram, Ivoclar
Vivadent; Figs. 11 & 12). The maxillary
anterior teeth (#13 to 23) were prepared by removing a minimal
amount of tooth structure. A model
was produced and then the veneers
were fabricated with IPS e.max Press
HT ingots (high translucency). The
pressed veneers were cut back and
customised with a veneering ceramic
(IPS e.max Ceram, Ivoclar Vivadent;
Figs.13 & 14). In the layering process, we
strove to achieve a lifelike appearance
and therefore paid a considerable
amount of attention to this step.
With the help of gold powder, we
were able to produce a lifelike surface
texture. We polished the restorations
manually. All the parties involved
were impressed with the result after
the adhesive cementation of the
restorations. The inclined all-ceramic
restorations showed excellent fit and
physiological function. As a result, a
very natural-looking appearance was
achieved (Figs. 15 & 16). A lifelike interplay of colour was observed within
the veneers.

Conclusion
A well-coordinated treatment plan
composed of many pieces, like a mosaic, is required in situations where
complex restorative treatment, including bite elevation, is necessary.
In the process, it is important to treat
patients responsibly and inspire
them with the required confidence.
Careful deliberation is particularly
important in the establishment of
the physiological bite elevation. In the
case described, a non-invasive strategy
was devised to re-establish a stable
vertical dimension. The teeth were
ground for the preparation of the final
restoration only after a suitably long
temporary phase (occlusal veneers
made of composite) and stabilisation
of the bite elevation.

Dr Jan Kersting
is a dentist at
Dr Roland Ritter
dental practice
in Nuremberg in
Germany. He can
be contacted at
j a n ke r s t i n g @
t-online.de.

Alexander Mi ranskij is a dental technician at
dentalmanufaktur
nürnberg in Nuremberg in Germany.
He can be contacted at mail@
dentalmanufakturnuernberg.de.

[17] =>

DTAP1015_17-18_Buchmann 14.10.15 09:14 Seite 1

IMPLANT TRIBUNE
The World’s Implantology Newspaper · Asia Pacific Edition
www.dental-tribune.asia

Published in Hong Kong

A time shift link

Vol. 13, No. 10

are manufactured as strew splints in
a dimension of 1.5 mm with extension
limited to the first molars.

a) Anatomy: Treated severe periodontitis usually displays clinical stability with further drawbacks around
implant supported bone at buccal

Clinical practice emphasizes a
time-tested planning with (i) removal
of severely compromised teeth,
(ii) periodontal therapy securing the
residual dentition, supplemented by
(iii) microsurgical revision of deep
intrabony pockets prior to implant
placement to safeguard inflammation (Figs. 3 & 4). Implant planning
resides tentatively. A final quotation
will be drawn after completion of

muscels (M. temporalis, M. masseter) and the temporomandibular
joints (M. pterygoideus medialis
und lateralis) with focus of tension,
induration and pain pressure.
2. Osteopathic examination of craniocaudal dysfunctions: initiated
by body statics (inclined position),
(mis-) posture, walk (activity) etc.
should exclude somatic sources.
If applicable supportive therapy.
If applicable, manual osteopathic
treatment to improve physiologic
function, i.e. body alignment, symmetry and support homeostasis
that has been altered by somatic
dysfunctions.4
3. Carefull reduction of prominent
protrusive contacts (front) and slid-

How implant planning affects periimplant diseases
By Rainer Buchmann1, 2, Daniel Torres-Lagares2, Guillermo Machuca-Portillo2
1 University of Düsseldorf, Germany; 2 University of Seville, Spain
Implants are becoming increasingly
popular with low-cost offers promoting this development. The number
of customers preferring implants to
customary restorations is expanding.
The variety of client demands, individual settings, treatment options and
risks related to inflammation and bone
damage following implant treatment
advocate evident, comprehensible and
durable solutions.

Planning
Early Decision Making
Early implant decision making
comprises anatomical, functional
and economic issues:

Digital imaging 3-D
Digitization means information
and safeness. The generation of a DVT
in early implant planning harbors
three vantages:
• Commitment: The expenses of
120–180 euro depending to extent,
area of analysis and institute display
a motivational factor ensuring consent with the treatment plan. Young
patients and IT employees ask for
the benefit of 3-D imaging during
the first or second visit of implant

Fig. 1: Severe periodontitis, residual inﬂammation and bacteremia. Poor hygienic capability, comfort and esthetics with furcation caries.—Fig. 2: Drawn-out expectation period in advanced periodontal disease
at # 15, 16 with horizontal alveloar bone resorption at assigned implant site.—Fig. 3: Surgical access to deep intrabony periodontal pockets securing the residual dentition and safeguarding inﬂammation prior to
implant placement following completion of non-surgical periodontal therapy.—Fig. 4: Microsurgical revision using a vascular pedicle ﬂap to maintain interdental papillae and augment resting periodontal pockets
with autogenous bone. Usage of Osteora (antiinﬂammatory) or Emdogain, if applicable.—Fig. 5: Relaxation appliance in the maxilla with a frontal plateau to decompensate age and use related bite reduction
prior to ﬁnal implant planning.—Fig. 6: Advanced horizontal alveolar bone atrophy in the mandible with small ridge, vestibular sloping plateau, proximity to n. alveolaris and small keratinized gingiva.—Fig. 7:
Securing implant planning (implant length, positioning, diameter and surgery) by DVT review (Cranium Bonn, Germany, 2014).—Fig. 8: Interimplant distances of 7 mm at front and premolar sites with 11 mm in
molars to safeguard vascularization and periimplant damage, assigned from prosthodontics. Surgery: Dr G. Kochhan.—Fig. 9: Inadequate implant bone support with vestibular bony defect following tooth loss
due to traumatic crossbite relationship in the left upper maxilla.—Fig. 10: Promotion of perfusion and healing by micro-invasive implant surgery with implant abutment insertion into vascularized blood-supplied
alveolar bone.—Fig. 11: Sinus elevation # 26 with implant placement prior to periimplant enlargement.—Fig. 12: Free gingival graft in situ prior to suturing.—Fig. 13: Unstable periimplant gingiva with poor hygiene
capability, persistent inﬂammation # 34 and chronic sensitivity.—Fig. 14: Unobtrusive healing for 8 weeks posttherapy with functional relief by enlargement and periimplant stabilization.—Fig. 15: Long-cone
implantoprosthetic abutments undergo no self-cleaning frequently initiating periimplant sensitivity.

Safeguarding implant treatment
commences with careful tooth removal, pre-implant treatment and
implant planning respecting four key
issues:
1. Early decision making to ensure
implant bone support with limited
number of implant placements.
Sound tooth removal to protect
bone loss by intraalveolar root dissection.
2. Accuracy of implant diagnosis and
implant placement by 3-D visualization (DVT) of implant surgical
access.
3. Minimal surgical involvement
with short and low diameter implants while restricting augmentation to prosthetic relevant settings.

plates or interapproximal sites by
inflammation (Figs. 1 & 2).1
b) Function:Following untreated periodontal diseases or tooth removal,
shifting of single tooth initiates
due to myofunctional imbalance.
By loss of front-canine equilibration, a group side shift emerges with
further bite reduction as result of
age and misusage.2
c) Dues: Periodontal therapy of severely compromised teeth with
bone loss > 50 % often results in
a later date implant treatment that
doubles dental efforts and bills.
Economic issues should downregulate this strategy.
d) Oral comfort:Stability, oral hygiene
and esthetics become fostered
by timely implant placement and
optimized implant prosthetics.

functional relief and 3-D digital evaluation of the implant bone anatomy.
Functional decompensation
Fully and partially edentulous patients frequently reveal a bite reduction by usage (wear) with loss of frontcanine equilibration and a resulting
left and right grouped pemolar and
molar side shift.3 Dysfunction and
habits (pressing, grinding etc.) promote further damage. In severe periodontitis, group side shift accelerates
disease progression, impedes post
therapy healing and weakens alveloar
bone assigned for later implant placement. Early implant planning includes following key issues:
1. Inspection of the oral cavity comprises evaluation of the mastication

ing bars during laterotrusion on the
operating side.
4. Placement of a relaxation appliance
in the maxilla (overbite and deep
bite in the mandible) for functional
decompensation with a frontal
plateau allowing a front-canine
equilibration and temporary relief
in molars by vertical release of 1 mm
(Fig. 5).
The primary objective is the decompensation of use-related dysfunctions to achieve relief, vascularization and mineralization of the
alveolar bone prior to implant placement. Subsequent realization of the
issues 1–4 ensures dispenses of the
habitual use patterns after four to six
weeks wearing. Due to hygiene and
stabilization, the intraoral appliances

planning to safeguard and minimize
surgical implant placement.
• Anatomy: Additional information
about vicinity to N. alveolaris, extent
of sinus maxillaris and anatomical
septa, characteristics and mineralization of implant bone (following
tooth removal) and implant positioning related to adjacent teeth
(Figs. 6 & 7). However, inclined DVT
readings result in measurement
errors up to 1 mm.5, 6
• Precision: The benefit of a timeintense 3-D implant evaluation is
a more precise, controlled and riskreduced planning, and eases surgical
implant placement. These advantages should be utilized by all dental
health care providers, even with
longterm clinical expertise even those
with long-term clinical expertise. »

[18] =>

DTAP1015_17-18_Buchmann 14.10.15 09:14 Seite 2

IMPLANT NEWS

18
« If you are not a DVT owner, oral
surgeons (specialists) and diagnostic
radiology clinics are appropriate
contact addresses. Regard: For the
intended 3-D image, always allocate
the exact DVT area, details and viewer
suitable for your PC software. The expenses both of the DVT and the digital
analysis and evaluation are subjects
to private cash.

A slight subcrestal position of the
implant is advisable as drilling endpoint.12 To ensure healing, a primary
fixation of the implant is mandatory
for all implant types (cylindrical,
root-formed etc.), bone quality and
anatomical localization. The authors
strongly discourage from further
„screwing“ to avoid ongoing tissue
injury of the implant-bone-interface.13

Interimplant distance
If an implant is placed adjacent to a
tooth, the interdental papilla remains.
If two implants are inserted side by
side, the supracrestal biological width
and the papilla as result disappear, independent of the implant type used.7
The effects of implants with platform
switching, concave abutments, micromachined neck or implant abutment
micro-movements onto the stability
of crestal bone and soft tissues are
limited to subclinical notice.8, 9 The
interimplant distances primarily follow prosthetic requirements of the
residual dentition.10 From anatomy,
the present rules occur:

Periimplant tissue (volumen)
Due to alveolar bone defects resulting from tooth removal, periodontitis
or dysfunction, the conditions of periimplant keratinized gingiva around
implants are not adequate.14 Safeguarding implant planning and surgery, the additional dues of soft tissue
surgery to enlarge periimplant gingiva should be implemented into the
quotation:

1. Minimal distance between singlerooted teeth incl. premolars: 7 mm.
2. In molars interimplant distances
of at least 11 mm (Fig.8).
For appropriate implant placement according to prosthetics, the
local bone anatomy is often inadequate, especially in patients with
cross-bite or long-term periodontal
damage etc. (Fig. 9). If the clinical
setting implicates deficient implant
bone support, 3-D digital imaging of
alveolar bone including individualized implant positioning with diameter-reduced implants is allocated.
Note: Prior to surgery, calculate additional efforts, extent and expenses of
alternative augmentation, bone grafting or allogeneic bone grafts including
pedicle flap surgery and infection due
to soft tissue advancements.

Implant placement
Perfusion
Maintenance of vascularized implant bone is indispensable to avoid
further periimplant damage as result
of spongious bone tissue injury during implant surgery (early implant
failures). Within implant insertion,
bleeding of cortical bone following
drilling is a necessary requirement
for uneventful healing and integration of the implant into surrounding
tissues (Fig. 10).11 The following step
by step procedure has been proven
effective:
a) Utilization of keen pilot und multiuse tapping drills (renew early,
otherwise high drilling forces and
danger of deviation from drilling
axis occur).
b) Intermitted implant bed preparation under permanent cooling with
0.9 % saline.
c) Prior to implant placement, wait
until implant bed has been replenished with blood.
d) Wetting of implant surface with
blood prior to implant insertion.
e) Limited rotation speed < 800 r.p.m
during implant bed preparation,
hand implant placement with
torque key, max. 10–30 Nm, if
applicable.

shrinkage and further scar formation.
Periimplant thickening is limited to
individual patients with esthetic
needs in the upper front of the maxilla. Shortcomings following healing,
scar formation, normal biologic resorption and failing of long-term
stability are usually compensated by
individual prosthetic abutments and
ceramic crowns with a wide periimplant shoulder.
Short and diameter-reduced
implants
The usage of short implants
< 9 mm demands minimalization of
surgery. Implant placement and healing are customer-friendly. However,
micro-incision surgery requires additional efforts by 3-D imaging (DVT)
during planning and sensitiveness
in clinical realization. Evidence-based

Periimplant Therapy
Step

Defect
(PD in mm)

Treatment

≤ 3 mm

Oral Hygiene + IMP Cleaning

≤ 4–5 mm

CHX 0.2 %, Er:YAG

≥ 6 mm

Systemic Antibiotics

≥ 8 mm

Implant Removal/Regenerative Therapy

Table I: Key treatment issues to combat periimplant damage, to a large extent being
prevented by early and carefull implant planning.

Surgical Reentry
1. Removal of suprastructure (screw-fixed).
2.Horizontal alveolar ridge incision with vertical mucoperiostal flap reflection.
3. Intrabony defect curettage.
4. 0,2 % CHX irrigation, Er:YAG-decontamination.
5. Stimulation of spongious bleeding plus autogenous bone grafts
for defect fill and reconstruction.
6. Close, tension-free defect closure, no functional implant loading.
7. Systemic antibiotics.
Table II:Surgical revision of advanced periimplant bony defects is limited to single clinical
settings due to the time and extent of surgery and additional patient expenses.

Enlargement:
Initially, implant planning (not
to forget cast models) and implant
placement. During implant insertion
into local bone, enlargement of periimplant gingiva with a ridge incision
1–2 mm orally is usually adequate.
In lateral augmentation in the
maxilla, periimplant enlargement is
frequently mandatory as result of
flap advancement to cover the defect.
During healing and prior to implant
exposure, vestibuloplastic surgery
with free autogenous gingival graft
from palate at implant site in a separate visit (Figs. 11 & 12). In individual cases and edentulism in the
mandible, periimplant enlargement
with Edlan Mejchar-Vestibuloplastic
surgery to create attached mucosa by
a pedicle flap with adequate esthetics
prior to implant placement. Also, to
achieve soft tissue protection following implant insertion (Figs. 13 & 14).
Thickening:
To safeguard implant placement
and protect against periimplant diseases, an adequate periimplant width
is more needed than soft tissue thickness. Following thickening by free
autogenous soft tissue grafts from the
palate or roll flap, loss of periimplant
dimension is anticipated due to

clinical data for short and diameterreduced implants are inconsistent
and industry-driven. Biomechanical
research underestimates the functional adaptive capacity of implant
bone.15, 16 In clinical practice, vertical
alveolar bone loss is the most frequent
demand:
Mandible:
1. Advanced alveolar bone loss in premolars and molars (numerous).
2. Proximity to N. alveolaris.
Maxilla:
1. Close anatomical relationship to
sinus maxillaris.
2. Atrophied or edentulous maxilla
following longterm appliance of
removable dentures.
Horizontal alveolar bone defects,
as result i.e. of longstanding periodontitis, are compensated surgically
during implant placement to avoid
extended implanto-prosthetic abutments susceptible for recurrent soft
tissue infection (Fig. 15). Fixed implanto-prosthetic restorations of the
partially endentulous mandible are
achieved with axially screwed, uncemented and unlocked crowns to
improve hygiene and avoid further
damage by cementing and periimplantitis. Integration in clinical

Implant Tribune Asia Pacific Edition | 10/2015

practice is successful with focus on
tissue biology and both renunciation
from mechanical dentistry and interlocking theories.
Diameter-reduced (< 4 mm), small
implants (minis) allowing transgingival healing. According to their
material properties (fracture) and
restricted implanto-prosthetic indications and compatibility, Minis are
limited to individual applications in
multimorbid subjects with edentulous mandible, enhanced risk for
surgery i.e. advanced diabetes mellitus or hematopoietic diseases and
handicaps for oral hygiene.17

Augmentation
and revision
Except for sinus floor grafting, the
number of augmentative implant
surgery is declining and confined
to reconstruction following trauma
and tumor by vertical distraction or
individual prosthetic or esthetic settings.18 The indications for surgical
augmentation during implant placement include:
a) Tooth loss in cross-bite settings.
b) Lateral alveolar bone defects (premolars and molars).
c) Modelling of periimplant bone in
esthetically demanding situations
at incisors and canines (emergence
profile).
The authors have recently reported
about the use and implementation
of autogenous bone and spongious
bone chips and their synthetical alternatives in implant surgery in detail.19
The regressive developments of
implant augmentation in clinical
practice implicate direct recommendations for surgical revision of periimplant defects. The following procedure is advisable (Tab. I).20
Mucositis:
• Defect depths ≤ 3 mm: Oral hygiene
and implant cleaning (hygienist).
• Defect depths ≤ 4–5 mm: Additionally 0.2 % CHX, Er:YAG decontamination, if applicable (dentist).
• Defect depths ≥ 6 mm: Periimplant
plus periodontal cleaning, systemic
antibiotics: amoxicilline 500 mg
20 T and Clont 400 mg 20 T, t.i.d for
7 days.
Together with decompensation
by occlusal appliances (mentioned
above), safeguarding by front-canine
equilibration and removal of implanto-prosthetic restoration, the
clinical situation often improves.
The procedure can be easily repeated.
The recommendation to removably
screwfix implant restorations axially
(only premolars and molars) is becoming a strong relevance in the
treatment of periimplant damage.
Periimplantitis:
Advanced periimplant damage
with circumferential angular bone
loss encompasses
• Defect depths ≥ 8 mm: Explantation, surgical revision (if applicable).
In these clinical settings, implant
removal with repeated insertion, aug-

mentation (where appropriate) and
prosthetic restoration following healing is advocated, if the client approves
the treatment. In periimplant damage, the benefit of rapid implant bone
healing following insertion of short
and diameter-reduced implants becomes obvious. In individual, strategically important implant sites, i.e. canine
implant area in edentulism, revision
is emphazised with the following
surgical protocol (Tab. II).21
• Removal of implanto-prosthetic
restoration, if screw-fixed.
• Horizontal ridge incision with a mucoperiostal flap and mesial vertical
extension.
• Curettage of implant bone defect.
• Irrigation with 0.2 % CHX, supplemented by Er.YRG-decontamination.
• Stimulation of bleeding plus autogenous bone grafts for defect fill and
reconstruction, defect coverage with
rotated pedicle soft tissue flap.
• Close, tension-free wound closure,
no functional loading.
• Systemic antibiotics.

Summary
The prevention of periimplant diseases is based on a comprehensive
analysis, evaluation and planning
prior to implant placement. Securing
the residual dentition from periodontal disease, on time removal of
compromised teeth and functional
decompensation with focus on frontcanine equilibration are the key issues during implant planning. Prior
to surgery, DVT diagnostic evaluation
is required if proximity to anatomical structures is anticipated, and
short and diameter-reduced implants are advocated to determine
interimplant distances and safeguard implant treatment. Implant
placement succeeds with minimal
mechanical loading of implant bone
and implementation of perfusion
during surgery. Periimplant enlargement is scheduled during implant
healing, either by free gingival graft
or pedicle flap. Premolar and molar
implant restorations are screw-fixed
axially to ease handling in case of
periimplant damage. The concerted
action of eliminating inflammation,
stabilizing function while minimizing surgery secures implant success,
prevents periimplant diseases and
promotes the reputation of dental
health care providers in the community.
The authors appreciate the encouragement
and support of Dr Gerhard Kochhan, Düsseldorf, in periimplant cooperation.
Editorial note: A list of references is available
from the publisher. This article was published in the 03/2015 issue of implants,
international magazine of oral implantology.

Professor Rainer
Buchmann is a
specialist in periodontics and
preventive dentistry. He works
at a private practice in Düsseldorf in Germany
and holds teaching positions at Heinrich Heine University Düsseldorf and the University of
Seville in Spain. He can be contacted at
info@perioimplant.eu.

[19] =>

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100

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CREDITS

Tribune Group GmbH i is designated as an Approved PACE Program Provider by the
Academy of General Dentistry. The formal continuing dental education programs of this
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[20] =>

DTAP1015_20-21_Gaballah 14.10.15 09:25 Seite 1

TRENDS & APPLICATIONS

Implant Tribune Asia Pacific Edition | 10/2015

Avoiding common problems
in tooth extractions
By Dr Kamis Gaballah, UAE
dental nerve (IDN) is a well-known
complication of surgical extraction of deeply impacted LM3. It
should be acknowledged that this is
not simply a loss of sensation; the
damaged nerve can be responsible
for a number of abnormal sensations, including sharp pain and
abnormal response to stimuli, such
as the perception of a light touch
as a sharp stab. This can have a significant impact on quality of life
for many patients.
Injury to the IDN may occur from
compression of the nerve, either
indirectly by forces transmitted
by the root and surrounding bone
during elevation or directly by surgical instruments, such as elevators. The nerve may also become
transected by rotary instruments
or during extraction of a tooth
whose roots are notched or perforated by the IDN. The risk factors
for IDN injury during extraction
of LM3 are shown in Table I.

The last two decades have seen
significant advances in restorative
techniques and materials for dentistry. The latter, along with community-based preventive measures
that aim to reduce the incidence of
caries, have resulted in many patients living with functional teeth
for a longer period. Yet, extraction of
teeth forms the considerable bulk
of the workload in oral surgeries
owing to several factors, including
the late presentation of patients
with advanced dental disease, the
presence of symptomatic impacted
teeth, such as third molars, and the
need to extract teeth for orthodontic or orthognathic treatment.
The extraction of teeth varies
greatly based on the type of patient
who is undergoing the procedure.
For example, elderly patients with
significant co-morbidities and on
a complex combination of medications as compared with young
healthy individuals render the procedure complicated and require
much more preparation with modifications during and after patient
management. Additionally, extractions can range from a single, fully
erupted tooth with favourable morphology to multiple misaligned,
impacted teeth or teeth with challenging morphology. Local anatomy, such as tooth proximity to
the nerve, maxillary sinus and tuberosity, also plays a significant role.
These variations usually dictate
who is to perform the extraction, as
many general practitioners deal
with less complicated cases of dental extraction in individuals regarded as healthy patients and may
not feel comfortable operating on
medically complex patients.

Complex extraction cases have
been linked to a higher rate of postoperative complications; therefore, a cautious and systematic
approach should be adopted that
includes a detailed preoperative
assessment to predict the potential
difficulties that might arise during
extraction. The documentation of
all complicating risk factors along
with their potential postoperative
morbidities is crucial and should
be included in the informed consent. In the following article, other
useful tips will be provided that are
not usually included in traditional
textbooks or lecture notes to help
general practitioners to perform
safer extractions.

The resistance of hard tissue
should be expected, particularly if
maxillary second and third molars
are being extracted, as the potential for fracture of both the buccal
plate and the tuberosity is relatively common when excessive
force is applied with dental forceps.
Fracture of the tuberosity may produce irregular sharp bony boundaries, significant soft-tissue laceration and potentially an oroantral
fistula. If such risk factors are iden-

During clinical examination, it
has been proven useful to observe
the patient’s build. Tall and muscular individuals tend to have a long
ramus with a higher mandibular
foramen, and this increases the
possibility of failure of the inferior
dental nerve block procedure if the
former is not taken into account
when determining the height of
the injection site. This can be aided
by tracing the inferior dental canal
(IDC) to the mandibular foramen
in the preoperative panoramic
radiograph. The teeth of such individuals may also have longer and
more curved roots and be embedded in highly dense, compact alveolar bone, and thus sectioning of
the teeth may be required to ease
the resistance. Racial differences
should also be taken into account,
as extractions of teeth from individuals of Afro-Caribbean descent
tend to be more challenging owing
to the hardness of their bone and
divergence of roots in their molars.

Preoperative radiographic investigations may include intraoral images, such as occlusal radiographs; panoramic views of the
jaws; and conventional CT or CBCT
scans. It should be noted that riskpredicting signs in radiographs
only indicate that there is an increased risk of nerve damage associated with the extraction of the
corresponding third molar. However, they cannot actually prevent
the nerve injury if the tooth is to be
extracted. The effective strategies
that may avoid or minimise the

dental and the lingual nerve owing
to the nerve block procedure.
This injury may be related to the
pharmacological properties of the
agent itself or the injection technique. Studies have shown that the
lingual nerve is affected approximately twice as often as the IDN,
and one reason for this may be the
fascicular pattern in the region
where the injection is given. It also
appears that about half of patients
feel an electric shock sensation
during injection.
There is a higher incidence of reports of nerve injury after the use of
articaine and prilocaine. Although
the reason for this remains unknown, it has been suggested that
this may be because they are 4 %
solutions, whereas the other commonly used local anaesthetics have
lower concentrations. Others associate the damage with the neurotoxicity potential of 4 % articaine
and 3–4 % prilocaine. Hence, it is
recommended that the use of such
anaesthetics be limited to local infiltration. It has been claimed that
needle contact with a nerve felt by
the patient as an electric shock is
related to injection injury. An obvious explanation is that the possibility of mechanical injury to the
nerve is more likely in the case of
multiple repeated attempts at the
inferior dental nerve block procedure. Therefore, it is crucial that
the operator achieve optimal pain
control with minimal episodes of
injection with minimal doses of
anaesthetic agent.
The surgery should be planned
according to the information obtained from the preoperative assessment process. The procedure
itself should aim to minimise the
manipulation around the IDC.
Both should include the carefully
planned access, tooth sectioning
and elevation techniques. In many
scenarios, the extraction of the

Overall risk factors for IDN injury

Radiographic signs of increased risk of IDN injury

Full bony impactions

Apices of the LM3 located inferior to the lower border of the IDC

Horizontal impactions

Darkening of the root

Use of burs for extraction

Abrupt narrowing of the root

Radiographic risk markers

Interruption and loss of the white line representing the IDC

Clinical observation of the bundle during surgery

Displacement of the IDC by the roots

Excessive bleeding into the socket during surgery

Abrupt narrowing of one or both of the white lines

Patient’s age

representing the IDC most of dentists and surgeons

Table I: Risk factors for IDN injury during LM3 extraction.

tified, tooth sectioning should be
followed by elevation of roots with
dental luxatomes instead of traditional elevators or forceps, which
are known to deliver much higher
force to the alveolar bone.
The indications for the extraction of impacted lower third molars (LM3) have been the subject
of long-standing debate. Surgical
procedures for the extraction of
unerupted LM3 are associated
with significant morbidity. This
includes pain, swelling and the possibility of temporary or permanent
nerve damage, resulting in altered
sensation of the lip, chin, gingiva
or tongue. Damage to the inferior

risk of injury to the IDN can be collectively categorised into two main
sets. The first is the preoperative
workup, which should include
critical assessment of the need to
extract the third molar, clinical
examination and radiographic investigation, and the second is intraoperative measures, including proper
selection of local anaesthetic agent,
the injection technique, modification of the surgical procedure and
measures to reduce the degree of
potential injury to the nerve.
Most literature published in the
last decade has given us sufficient
evidence to suggest a significant
risk of damage to both the inferior

whole tooth may carry an unavoidable risk of injury to the nerve,
therefore intentional retention of
parts of the tooth was proposed via
a planned procedure introduced
around 20 years ago called coronectomy. This is the removal of the
crown of a tooth, leaving the root
in situ. It is merely adopted to avoid
or minimise damage to the IDN.
The rate of complications after
coronectomy is comparable to that
observed after surgical extraction,
except with a significantly low incidence of injury to the IDN.
It should be noted that both sectioning and coronectomy can be
performed with a shorter incision,

[21] =>

DTAP1015_20-21_Gaballah 14.10.15 09:25 Seite 2

TRENDS & APPLICATIONS

Implant Tribune Asia Pacific Edition | 10/2015

as the amount of bone removal required is minimal, thus minimising the postoperative morbidity.
However, it cannot be performed
in all cases in which the LM3 is close
to the IDC and is certainly contraindicated when the LM3 is decayed
or its roots are associated with
a pathology and should be considered with caution in severely
inclined mesio-angular and horizontal impaction cases. The author
does not recommend distal bone
removal or retraction of the lingual
flap with the intention of protecting the lingual nerve, as these may
increase the risk of damaging the
lingual nerve. It should be emphasised that incision may not extend
beyond the distobuccal aspect of
the tooth.
The other important aspect of
the dental extraction procedure is
the future replacement of the
tooth to be extracted. The current
trend of tooth replacement for
both functional and aesthetic reasons is the placement of dental
implants. The success of this treatment largely depends on the availability of healthy bone in sufficient
volume. Therefore, it is crucial for
the dental practitioner not to compromise the alveolar bone during
extraction of the teeth. Changes
in the alveolar bone ridge after an
extraction are inevitable. After all
dental extractions, bone height
and width always undergo dimensional changes. Bone does not
regenerate above the level of the
alveolar crest, that is, its height
will not increase during healing.
The buccal plate tends to shrink,
shifting the crest of the alveolar
ridge lingually, and often forms
a concavity. Such changes are proportional to the amount of trauma
to the soft and hard tissue during
the extraction.
An additional unfavourable
change that may take place is the
slow remodelling of the bone
formed to fill up the extraction
socket owing to lack of functional
stimulation. The presence of poorly
remodelled alveolar bone may
compromise the stability and
function of the future implant.
Furthermore, studies show that
the stripping and elevation of
mucoperiosteal tissue produce a
higher number of osteoclasts within the alveolar ridge and hence
greater resorption and shrinkage
are seen after the classical surgical
or the traumatic extraction of teeth.
The preservation of alveolar
bone for future implant placement
may be achieved by avoiding
unnecessary bone removal and
stripping of the periosteum during
surgery, as well as performing
a surgical alveolar bone preservation procedure. Bone removal can
be largely avoided or minimised
through modification of the traditional extraction technique.
The first such modification is
the use of dental periotomes and
luxatomes to gently strip the periodontal ligament fibres and widen
the socket without causing cracks
or fracture of the cortical plates,
as commonly encountered when

using dental forceps or the bulky
elevators. The use of such gentle
instruments also eliminates the
need for elevation of mucoperiosteal tissue. However, it should be
noted that the safe use of these instruments requires adequate training and should be encouraged during
undergraduate clinics. Clot stabilisation through light packing of the
socket with collagen sponges may
help to minimise clot dislodgment,
as well as accelerate the healing
process and bone regeneration.

The second strategy is the alveolar bone preservation procedure.
This includes packing the extraction socket with different fillers,
such as osteoinductive or osteoconductive materials, like autogenous, natural or synthetic bone
grafting materials that support
the alveolar socket walls, thus preventing their collapse and shrinkage. It should be noted that this
intervention can only slow down
the post-extraction changes to
improve the success of the dental

21
implant, but cannot stop them
altogether.
Finally, post-extraction care
should include an explanation
of the healing process and potential symptoms encountered
after such procedures. The prescription of medications should
be limited to non-steroidal antiinflammatory drugs in most cases
and imprudent use of antibiotics
or socket dressing should be
avoided.

Educated in the
UK and Ireland,
Dr Kamis Gaballah is currently
a n a s s o c i at e
professor and
senior specialist
in oral and maxillofacial surgery
at the Ajman
University of Science and Technology in
the United Arab Emirates. He can be
contacted at kamisomfs@yahoo.co.uk.

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[22] =>

DTAP1015_22-23_Noumbissi 14.10.15 09:16 Seite 1

TRENDS & APPLICATIONS

Implant Tribune Asia Pacific Edition | 10/2015

“Consumers are pushing dentists
toward metal-free implantology”
An interview with Dr Sammy Noumbissi, founder of the International Academy of Ceramic Implantology
structure and could not survive the
demands of the oral environment.
Then came the use of polycrystals
and in the early 2000s yttria-stabilized zirconia bioceramic emerged
as the material of choice for metalfree intrabony implantation in dental implantology.

A great deal of progress has been made
in terms of materials, techniques and
design of dental implants since the beginnings of modern implantology over
50 years ago. While titanium and titanium alloys have always been in use,
the search for metal-free implantable
materials began in the late 1960s and
early 1970s, and during the last decade,
zirconia has emerged as the most
reliable implantable bioceramic. The
International Academy of Ceramic
Implantology (IAOCI) is an organisation entirely dedicated to ceramic
and metal-free alternatives to metal
implants. It was founded in 2011 by
Dr Sammy Noumbissi, with whom
Dental Tribune had the opportunity
to speak about the mission and vision
of the IAOCI, as well as the state of
ceramic implantology today.

in the host bone and surrounding
tissue as a result of the breakdown
and corrosion of metal alloys in the

In the late 1960s, pioneers in
ceramic implantology and notably
Professor Sami Sandhaus began the

How did you become involved in research on ceramic dental implants?
My interest in ceramic implants
came about in two ways. First, on
a personal level, when I discovered
that the metal fillings and implant
I had in my own mouth were determined to be the source of some
of the health problems I had experienced. Second, on a professional
level, where a few of the patients
to whom I had provided metal
implants returned for check-ups or
more implants, and upon reviewing
their medical and dental history,
it was also determined that the implants were at least in part responsible for the health problems they
were experiencing. I then began to
actively look for alternatives and at

“…reports of titanium and titanium alloy
intolerance have increased and are increasingly
being investigated and demonstrated
in the scientiﬁc dental literature.”
presence of body fluids and the oral
environment in particular. Such
facts have been established and
widely recognized in orthopedics.

search for modern non-metal implantable ceramic materials. However, many of the early ceramic implants were monocrystalline in their

the scientific literature, including
case reports in both medical orthopedics and dental implantology. It
was clear that bioceramics in the last

Dental Tribune: Dr Noumbissi, could
you please provide some background
information on the development of
ceramic implants?
Dr. Sammy Noumbissi: The use of
dental implants to replace teeth has
increased very rapidly in the last
15 or more years. With this increase
in dental implant procedures, the
number of manufacturers has increased too. Also, we have witnessed
the introduction of various alloys of
titanium over time.
Now, just like with any pharmaceutical or medical product, the
increase in demand and changes in
production methods come with
problems and challenges. Although
initially anecdotal, reports of titanium and titanium alloy intolerance
have increased and are increasingly
being investigated and demonstrated in the scientific dental literature. Based on the body of research
available today, this intolerance of
implant alloys can in great part be
attributed to the release of metal ions

Dr Sammy Noumbissi presenting clinical cases at the recent Annual World Dental Congress in Bangkok.

Dr Sammy Noumbissi

two decades had established themselves in both medicine and implant
dentistry as the most bio-inert implantable material available. In 2011,
two colleagues and I decided to create the IAOCI.
What is the primary aim of the IAOCI?
Associations and academies exist
around various types of trades and
industries. The common purpose
of such groups is to organise and
create a supportive environment for
those involved in the respective area.
The IAOCI was created with the same
spirit, not only to organize metalfree implantology but also to provide the profession as a whole with
quality and high-level continuing
implant education on bioceramics
as implantable materials. The IAOCI
is also a resource for the public seeking practitioners who have experience with ceramic implants.
In your opinion, what are the dangers
of metal implants?
Metal and most particularly
titanium implants have been very
successful. Their use has grown
exponentially and with that manufacturers have multiplied, as well
as manufacturing protocols. As a
result, we have observed a steady increase in the alloy elements mixed
with titanium during the manufacturing process. The problems begin
when the metal implant highly alloyed or not, once placed is subjected
to functional stresses, galvanism,
body fluids and the harsh oral environment. The combination of
mechanical, chemical and electrical
events induces cracks and pitting of
the metal, as well as breach in the
oxide layer, and the implant undergoes corrosion attack. The corrosion
attack, which is essentially an oxidation process, leads to the release
of metal ions that studies have
shown to be found in the surrounding bone, lymphatics, spleen, liver
and in some cases crossing the
blood–brain barrier.
What alternatives to metal dental
implants are currently available on
the market?

[23] =>

DTAP1015_22-23_Noumbissi 14.10.15 09:16 Seite 2

TRENDS & APPLICATIONS

Implant Tribune Asia Pacific Edition | 10/2015

Today, the well-researched and
proven alternative material to metal
for dental implants is zirconium
dioxide, also known as zirconia. This
is also a well-proven fact in medical
orthopedics. Zirconia is the crystal
phase of zirconium and as such it
is not a metal. There are different
manufacturing protocols for zirconia
for dental implantation and they all
lead to a variety of polycrystal bioceramics, such as zirconia-toughened
alumina, hot isostatic-pressed zirconia and yttria-stabilized zirconia.
The common and most important
properties of these bioceramics
are inertness in the bone and oral
environment, structural stability,
absence of electrical activity, extremely low plaque retention and
superior aesthetics.
Is the success rate of metal-free implants comparable with that of titanium implants?
In the early days, there were challenges. The materials were monocrystalline with very highly polished
and glassy surfaces, which made the
early implants prone to fracture,
poor attachment of bone-forming
cells and low bone–implant contact.
The manufacturing protocols, design, surface modification techniques and technologies of zirconia
implants have evolved to a point
where bone integration is ensured
and comparable results are obtained.
Are ceramic alternatives the future
of dental implantology?
Every industry projection one
sees about implants signals good
news for the future. Implants are
now and will continue to be widely
accepted by patients and the profession. Both groups agree that this
is state-of-the-art treatment. However, owing to technology, the public
is much more informed about
health issues and therapies. We are
in a similar situation today to that
of Invisalign braces a few years back,
in that consumers are pushing
dentists toward metal-free implantology for the most part. In five years’
time, I believe that the number of
ceramic implants being placed will
double.
Bio-inert materials are the future
of any type of implantable device.
I believe bioceramics have taken
hold and will be around for a long
time because there has been a strong
shift toward providing health care
with the minimum risk and invasiveness over the last few years,
as well as in a way that is more integrated, natural and biological.
Furthermore, manufacturers have
rapidly evolved and adapted the material and implant designs to clinical
needs and demands. We now have
a wide variety of implant designs,
surface microstructures, components
and prosthetic connections, making
ceramic implants applicable to an
extensive range of tooth replacement situations.
Dentists may have concerns about
the reliability of ceramic implants.
How does your organization address
this?
Even within specialties, there is a
need for organized groups because

in today’s world research and application of discoveries are moving
at lightning speed compared with
20 years ago. Therefore, once one
has an environment in which much
of the time and energy is spent
tracking, learning and sharing innovative techniques and materials, members have a forum where
they can obtain the information,
training and skills to deliver the
best of care to their patients in
an evidence-based and organized
manner.

As a matter of fact, our membership has doubled in the last two years
and when prospective or new members are asked why they want to join
or joined the academy, the most
common response is that they are
seeking a forum where they can obtain structured information and
training.
Another frequent reason is that
dentists have had patients challenge
or inform them on the use and occasionally the existence of ceramic

23
implants. Through technology and
the ease of access to information, the
public obtains information faster
than we busy clinicians.
The IAOCI will be hosting its Fifth
Annual Winter Congress in Montego
Bay, Jamaica. What can people expect
from the event?
The theme in 2016 will be the last
decade in ceramic implantology.
We will have 14 speakers from seven
different countries who will share
their experiences with a variety of

ceramic implant systems over the
last ten years. One of our guest
speakers has over 15 years of documented experience with zirconia
implants. We will also have workshops on different implant systems,
ceramic regenerative products and
revolutionary soft-tissue- and hardtissue-enhancing protocols proven
to optimize implant integration and
long-term stability.
Thank you very much for the interview.
AD

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[cover] => DT Asia Pacific No. 10, 2015

[toc] => Array ( [0] => Array ( [title] => Anxiety provoking scale develloped [page] => 01 ) [1] => Array ( [title] => Asia News [page] => 02 ) [2] => Array ( [title] => Data security: How not to become the next Ashley Madison [page] => 04 ) [3] => Array ( [title] => World News [page] => 05 ) [4] => Array ( [title] => Interview: “We are now able to enter the second phase of expansion” [page] => 09 ) [5] => Array ( [title] => Mandibular body reconstruction with a 3-D printed implant [page] => 10 ) [6] => Array ( [title] => High viscosity ionomers [page] => 14 ) [7] => Array ( [title] => Implant Tribune Asia Pacific Edition [page] => 17 ) ) [toc_html] =>

Table of contents

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