ceramic implants international No. 1, 2018

ceramic implants international No. 1, 2018

Cover / Editorial: Ceramic implants—current state of discussion / Content / From peri-implantitis to implant disease - Will terminology and definitions change? / Analogous therapy for guided regeneration of lamellar bone tissue / Individual CAD/CAM abutments on ceramic implants / Aesthetic restoration in the incisal region / Immediate placement in the maxillary aesthetic zone / Change is mandatory for extraordinary results / Ceramic implants in anterior dental restoration / Manufacturer news / Clear trend towards metal-free reconstructions / A shift to “well-care” / “The future of implantology — ceramics and biology” in Hamburg / News / Imprint

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issn 1868-3207 Sondernummer • Vol. 2 • Issue 1/2018

ceramic

1/18

implants

international magazine of ceramic implant technology

research

Guided regeneration
of lamellar bone tissue

case report

Immediate placement
in the aesthetic zone

interview

Clear trend towards
metal-free reconstructions

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[3] =>

editorial

|

Georg Isbaner
Editorial Manager

Ceramic implants—
current state of discussion
Dear Readers,
When the idea for this magazine was first presented
at the IDS 2017, it was not yet foreseeable that in the
months leading up to the first publication in fall 2017 the
developments of the ceramic implant market would yet
be speeding up. Numerous dental businesses were introducing new or newly acquired ceramic implant systems. The first publication of ceramic implants—international magazine of ceramic implant technology thus
occurred in a highly sensitive environment and consequently received much attention.
If one is closely following the discussions regarding
ceramic implants of the past months and years—may it
be by reading, among others, this magazine or by participating in the specialist congresses e.g. in San Diego,
USA (IAOCI), Constance, Germany (ISMI) or at the diverse ITI sessions—certain topics have become especially prominent:
On one hand material and processing characteristics
are concerned—taking into account the monoclinic and
tetragonal phases of zirconium dioxide (ZrO2)—defining the mechanical and prosthetic capacities of the implant body. As implant material ZrO2 can resist extreme
loading forces in the tetragonal phase (compared to the
monoclinic phase) and its high biocompatibility makes it
an ideal dental material. However, owing to its tremendous stiffness in comparison to titanium it is also prone
to fractures at the load limit—as has been noticed in
the past. This consequently has an influence on the design (production), application and the characteristics of

one-piece and two-piece (screw-retained or cemented)
implant systems. Thus we are reaching the second discussion topic: One-pieced or two-pieced?
The advantage of one-piece ZrO2 implants is the absence of a micro-gap. The experts however recommend
—and here the opinions and methods still widely differ—
to forego a possible prosthetic follow-up processing by
grinding the implant head as it can impair the surface characteristics (tetragonal > monoclinic). Thus, naturally also
the indication area is restricted, as the surgically best position does not necessarily lead to the most reasonable
prosthetic solution.
According to the experts, also with two-pieced, screwretained systems, owing to the material solidity of ZrO2
and in case of faulty design, there is a risk of fractures
or loosening at the implant–abutment connection. Manufacturers of the newest two-piece systems are, however, stating that these risks have been overcome as
the design was adjusted accordingly and no significant
disadvantages in comparison to two-piece titanium implants have to be feared. Further the prosthetic diversity
of two-piece ZrO2 systems, especially when combined
with thorough digital planning, makes it possible to join
the necessary prosthetic solution with the surgically reasonable position of the implant. Overloading and faulty
functionality including the presumed fracture risk can
be avoided in advance. The newest generation of bonelevel ZrO2 systems is closing important indication gaps
in comparison to titanium systems.
Yours, Georg Isbaner

implants 1 2018

03

[4] =>

| content
editorial
Ceramic implants—current state of discussion

03

Georg Isbaner

research
From peri-implantitis to implant disease
page 10

06

Dr Franz-Jochen Mellinghoff, M.Sc., PhD

Analogous therapy for guided regeneration of lamellar bone tissue

10

Dr Karl Ulrich Volz, Prof. Dr Dr Ralf Smeets, Dr Martin Chares,
Dr Stefan König MSc., Dr Dominik Nischwitz, Dr Alexander Neubauer,
Sabine Hutfilz, ZÄ Clara Esquinazi & ZA Paul Kilanowski

case report
Individual CAD/CAM abutments on ceramic implants
page 40

16

Dr Frederic Hermann

Aesthetic restoration in the incisal region

24

Dr Michael Gahlert

Immediate placement in the maxillary aesthetic zone

26

Dr Saurabh Gupta & Dr Sammy Noumbissi

industry
page 44

Change is mandatory for extraordinary results

30

Ceramic implants in anterior dental restoration

32

Dr Franz-Jochen Mellinghoff, M.Sc., PhD

interview

Cover image courtesy of Straumann AG
www.straumann.com

Clear trend towards metal-free reconstructions

40

A shift to “well-care”

44

events
“The future of implantology—ceramics and biology” in Hamburg

46

news
manufacturer news

36

news

49

about the publisher
imprint

04

implants 1 2018

50

[5] =>

“ For me, biological dentistry and the
use of ceramic implants are important
milestones in dentistry.“
Dr. Alexander Neubauer, Tittling
“The opportunities for a dentist to make a positive contribution to patient health in this ﬁeld, are truly
enormous. In addition to the courses themselves, work shadowing Dr. Volz and his live procedures was
always a great experience and proved really impressive. The idea of the concept being implemented in
their own dental practices was very popular with patients right from the start. Courses in the areas of
stress management, practice management and nutrition also contributed to holistic training and personal
development that I wouldn’t want to miss out on“.

SDS Swiss Dental Solutions AG
Konstanzerstrasse 11 · CH-8280 Kreuzlingen
info@swissdentalsolutions.de
swissdentalsolutions.com

[6] =>

| research

From peri-implantitis
to implant disease
Will terminology and definitions change?
Dr Franz-Jochen Mellinghoff, M.Sc., PhD, Germany

Current demographic prognoses show that the proportion of elderly (population of 60 and above) will increase strongly in all developed and underdeveloped
countries worldwide by 2050 (Fig. 1). This naturally results in an increasing stress on the global health system.
One of the stressors that dentists can focus on is dental
health, specifically regarding implants (Table 1).
Millions of dental implants made from titanium are inserted annually worldwide. They are especially used for
the elderly, in order to rebuild the functional and aesthetic
purposes of teeth after partial or total loss. Implant therapy
has therefore developed into a procedure which allows
very demanding dentures in faster and cheaper ways.

Implantological developments
With the development of titanium implants from 1965
to 1990 there was a wave of excitement and hope among

both dental practitioners and patients in need. This technology was new, fascinating, and incredibly profitable.
Unfortunately, in the excitement to apply this new technology the much needed research on the still unknown side
effects began to diminish and the focus quickly turned to
treatment diversification and profit.
Fast forward 52 years to present day and we now see
that implants can lead to some form of bodily reaction
presented as infection. These infections are described as
mucositis and peri-implantitis. It can be observed that the
implant disease starts with mucositis and progresses towards a status of peri-implantitis and can even progress
as far as to result in complete implant loss.
Recently it has been shown, that these problems of
inflammation increase especially with titanium implants
that have been inserted over a longer period of time.1 The
majority of respondent US implantologists reported that

Least developed countries
2 000

Less developed regions, excluding Least developed countries
More developed regions

Millions

1 500

1 000

500

1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 2013 2015 2020 2025 2030 2035 2040 2045 2050

Fig. 1: Population aged 60 or above by development region. (Source: United Nations: World Population Aging 2013)

implants 1 2018

[7] =>

[8] =>

| research
2013

Inserted
implants

Inhabitants

Inserted implants/
population (%)

Brazil

2,552,822

201,009,622

1.27

USA

1,805,011

316,668,567

0.57

Italy

959,124

61,482,297

1.56

Germany

795,243

81,147,265

0.98

South Korea

773,492

48,955,203

1.58

Spain

630,028

47,370,542

1.33

Japan

496,287

127,253,075

0.39

France

389,115

65,951,611

0.59

Russia

285,001

142,500,482

0.20

China

269,917

1,349,585,838

0.02

Switzerland

231,311

22,457,336

1.03

Canada

203,952

34,568,211

0.59

the Netherlands

142,843

16,805,037

0.85

UK

133,131

63,395,574

0.21

Australia

89,050

22,262,501

0.40

Austria

86,327

8,221,646

1.05

ing towards titanium intolerance playing a
decisive role in patient condition.8 As studies were able to show, zirconium dioxide
reduces that risk because ceramic, unlike
titanium particles, do not provoke significant secretion of messenger substances
for osteolytic processes.9

Could ceramic implants be the
(new) “next best thing”?
After a rough beginning, with frequent
material breakages and very limited numbers of suppliers, ceramic implants are becoming increasingly more present in the
field of dental solutions. More and more,
informed consumers are demanding treatment options which are holistic and thus
considering the body as a whole. To date,
there is very little data of known implant
disease regarding ceramic implants—not
a bad start but will this data change? And
if so, when, how, and by how much?
The now realised success with twopiece and specifically the new bone-level
ceramic implants will lead to much greater
use of ceramic implants, as a wide range
of indications can be covered, that were
until now reserved to titanium implants.

Conclusion

In summary there could be a change of
focus turning from peri-implant disease to
implant disease. Bringing more focus to the
Sweden
67,484
9,119,423
0.74
implant disease in general medicine will give
us a chance to investigate this phenomenon
Total:
9,987,893
more seriously. This is a task for all particTable 1: Overview of inserted implants by nation. (Source: Süddeutsche Zeitung [Uhlmann 2016], Press office DGI,
ipants in the field of implantology because
KZBV, dental industry)
knowledge about implant disease could
lead to widespread unLiterature
certainty in our patients
the prevalence of peri-implant mucositis and peri-implanand we need to be well informed in
titis in their practices is as high as 25 per cent. They esorder to properly advise them.
timated that there is an even higher proportion within the
general US population.
Portugal

77,755

10,799,270

0.72

Regarding this study and the fact that there is no proven
therapy for this detrimental process, when consulting the
published success rates it becomes obvious that more
often than would be expected it results in implant loss.
According to relevant literature, we can take 10 per cent
as a minimum value for implant losses over the years.2–7
Even though aetiology is multifactorial and could not
be clarified acceptably, there is a lot of evidence point-

08

implants  1 2018

contact
Dr Franz-Jochen Mellinghoff
M.Sc., PhD
Pfauengasse 14
89073 Ulm, Germany
Tel.: +49 731 62158
jochen.mellinghoff@dr-mellinghoff.de
www.dr-mellinghoff.de

Author details

[9] =>

www.tavdental.com

info@tavdental.com

[10] =>

| research

Analogous therapy for guided
regeneration of lamellar bone tissue
Dr Karl Ulrich Volz, Prof. Dr Dr Ralf Smeets, Dr Martin Chares, Dr Stefan König MSc., Dr Dominik Nischwitz,
Dr Alexander Neubauer, Sabine Hutfilz, ZÄ Clara Esquinazi & ZA Paul Kilanowski, Germany & Switzerland

Regarding bone formation, the regeneration
Literature
of lost bone substance follows indisputable biological laws. The creation of cavities through
so-called space makers in combination with the
building of a blood clot within, has been a wellknown procedure for guided bone regeneration
for a long time. Due to growth factors in platelet-derived alphagranula there is a fast incrementation of blood vessels in the blood clot, followed by a fast
bone regeneration through callus formation.1–3 Herewith,
the osseoinductive characteristics of the periosteum or
the Schneiderian membrane can have a positive impact
in addition. This form of bone formation leads to a histologically highly vascularised Havers’ bone morphology in
the long term and is functionally superior to regenerated
bone, formed by bone substitution materials, especially
regarding the response behaviour by induced pressure.
The new SDS sinus implant of the series “bone growing
implants” supports the so-called form of callus bone formation4, 5 with its specific macro geometry based on the
tent pole/sunshade principle, creating a stable and voluminous cavity (bio container) kept open over the necessary
time scale, so that by waiving bone substitution material
new biological bone of highest quality can be generated.

Objective
The aim of our work has been to develop a
reliable surgical procedure without secondary
materials for augmentation, which creates suitable bone in the sinus maxillaris evaluated quantitatively and qualitatively in which dental implants can be anchored with high predictability.
Besides a significant reduction of surgical risk
as well as postoperative complications, and
thus surgical stress for the patient, a substantial cost saving can be achieved for the patient.

they show a disc-like and preferably wide plateau for extensive and risk limited support concerning perforations of the Schneiderian membrane. Simultaneously, there should be created
a peri-implant cavity kept open over the required time for creating a bioactive container. In
it an entirely autologous and blood clot initiated
bone formation should take place, which should
lead to Havers’ bone morphology in the long term (Fig. 1).

Biological Principles
Systemic conditions
General ability of the organism to form new bone must
be enhanced prior implant insertion. For this purpose, patients were instructed to set their LDL (Low Density Lipoprotein) below 1,2 g/l and their vitamin D3 level (25-OHCholecalciferol) at greater than 70 ng/ml by following a certain diet and by the intake of a specific vitamin and mineral
nutrients mix (BASIC IMMUNE, SWISS BIOHEALTH AG).
According to the study of Choukroun et al. (2014), the risk
of infection reduces and the bone formation accelerates.6
Local conditions 1
Improvement of the extracellular matrix by creating a
stable cavity formed by the osseous floor of the sinus
and the Schneiderian membrane. Palma et al. (2006)
showed that new bone is formed in contact to the
Schneiderian membrane on a regular basis, also
in mere blood clot areas proving the osteoinductive quality of the maxillary sinus membrane.7
Local conditions 2
Continuity of the circulation in the newly
formed bone. Mammoto et al. (2009) postulate
that the long-term maintenance of regenerated
bone depends in particular on the maintenance
of the bone’s blood circulation.8

Material and method
Modified zirconium dioxide implants of
SDS Swiss Dental Solutions AG, Switzerland, have been used. On the apical end

implants 1 2018

Fig. 1: The two-piece SDS ceramic implant shows a disclike bulge with soft roundings on the apical end, not only
widely supporting the membrane at reduced risk, but also
creating a cavity to the thread.

[11] =>

research

Fig. 2
Fig. 2: The tent pole/sunshade principle has been demonstrated impressively in the publication of Hämmerle et al. (2000).9

The avoidance of secondary materials for bone replacement increases the amount and extent of a highly
vascularised Havers’ bone morphology, which develops
from an initial vascularisation within an autologous blood
clot with subsequent ingrowth of cortical bone transforming to lamellar bone.3
Tent pole/sunshade principle
In 1998, Hämmerle et al. (2000) already have shown
that high volumina of new bone could be created by the
so-called Memfix® system, without the need of bone
block or granular bone graft material.9 The periosteum
has been kept at a distance through a tent pole (Memfix®
screw). In addition, GORE-TEX® membranes have been
placed and fixed on one or more tent poles to protect
and seal the cavity (Fig. 2).
The significance of the periosteum for bone regeneration is now undisputed. Srouji et al. (2009) noted, that the
Schneiderian membrane is periosteum, which produces
all necessary humoral and cellular factors needed for
bone regeneration, like bone morphogenetic protein 2,
only with the presence of a blood clot and without the
existence of calcified structures.10
Further studies show, that the periosteum is an outstanding source for bone forming progenitor cells. Froget et al. (2011) point out the periosteum’s ability of local
angiogenesis.11 Marolt et al. (2015) show the existence of
bone forming stem cells in the periosteum,12 You-Kyong
et al. (2016) conclude:13 “Thus, periosteum-derived cells
can be expected to be a good source for bone regeneration.”
We also know today that no artificial membranes are
necessary. The sealed and cavity stable cover of the periosteum or Schneiderian membrane is sufficient to effec-

tively protect the cavity. This waiver then again lowers the
risk of infection or a dehiscence and reduces the cost of
intervention. The additional insertion of PRF membranes
stabilises the blood clot in the cavity and supports the
bone and tissue regeneration (Fig. 3).14–16
According to the idea of Choukroun and Simonpieri,
which is a further development of the root disc protocol
of Randelzhofer et al. (2016),17 we fixed zirconia discs on
top of SDS ceramic implants when facing extended defects. Complete bone regeneration in the defect could
be achieved with the use of A-PRF (Fig. 4). Asymmetric
bulges on ceramic implants (SDS balcony implant) also
lead to a full bone regeneration by sealing the adjacent
socket and due to the sunshade effect (Fig. 5).

Literature research
Various groups have done intensive research on gen
erating new bone in the maxillary sinus without bone
substitution material:
1. Palma et al. (2006) have shown, that new bone is regularly formed by being in contact with the Schneiderian membrane in mere blood clot areas and thus
showing the osteoinductive potential of the membrane
(“New bone is frequently deposited in contact with the
Schneiderian membrane in coagulum-alone sites, indicating the osteoinductive potential of the membrane.”).7
2. Cricchio et al. (2009) have installed absorbable space
makers and could show, that, almost exclusively in the
combination of simultaneous implant placement, it was
possible to generate bone along the implant surface
(“Histologically there were only minor or no signs of
bone formation in the sites with a space-making device only. Sites with simultaneous implant placement
showed bone formation along the implant surface.”).18

implants 1 2018

[12] =>

| research

Fig. 3
Fig. 3: During a surgery with immediate implant placement, the implants were placed at the desired level of the regenerated bone. The unharmed periosteum
as well as the attached gingiva were fixed over the tulip formed widening (“sunshade principle”) of the SDS ceramic implant, which results in a stable cavity.
The panoramic X-ray shows the final restoration with e.max crowns after only 2.5 months postoperatively with complete bone regeneration at the desired level.

3. Junger et al. (2015) have found out that “bone formation after sinus membrane elevation with or without additional bone grafts starts at the sinus floor and sprouts
into the elevated space along the implant surface”.19
4. Cricchio et al. (2011) have proven that “when the sinus
membrane was elevated, bone formation was a constant finding”.20 Therefore, “an ideal space-making device should be stable and elevate the membrane to ensure a maintained connection between the membrane
and the secluded space”.
5. Sohn et al. (2008) have shown the capacity of new
bone formation in the maxillary sinus after elevating the
Schneiderian membrane and simultaneous insertion of

implants 1 2018

implants into the resulting cavity without using any additional bone substitute.21 “New bone formation without
additional bone graft in the maxillary sinuses revealed
from the clinical, radiographic, and histologic results…”
Summarising the aforementioned studies, it can be
concluded that an optimal one stage result can be
achieved by a bone substitute free insertion of an implant,
whose design is able to lift the Schneiderian membrane
without perforating it, as well as to create a voluminous
and stable cavity. Additionally, this cavity must be kept
stable and sealed against the oral cavity. This led to the
development of the sinus implant.

[13] =>

research

Fig. 4

Fig. 5
Fig. 4: After an internal sinus lift, the implant was stabilised only in the compacta of the maxillary sinus floor. The cavity was filled with A-PRF and the socket
was sealed with a disc abutment in the sense of a sunshade. The defect has fully recovered after four months. Fig. 5: Implant placed in the distal socket of
region #46, covering the medial socket after being filled with A-PRF. Complete regeneration of the hard- and soft-tissue.

Surgical protocol
Preparation of the immune system by adjuvant systemic therapy (adjusting the LDL and D3 levels, see
above) and highly dosed vitamin C infusion as well as
single shots of 600 mg Sobelin and 8 mg Dexametasone i.v. on three consecutive days (–1, day of surgery,
+1). The surgery can be performed in local anaesthesia only.
–– Incision on the maxillary crest with gingival margin cut
at the neighbouring teeth to avoid a vertical incision.
–– Avoidance of incision of the periosteum with the brushing technique by Choukroun et al. (2016) to achieve

tension and movement free coverage in combination
with apical mattress sutures.22
–– Thinning out the vestibular bone in the area of the window with the help of the safescraper (Safescraper®
TWIST, straight) and simultaneous gain of cortical
chips.
–– Usage of piezo surgery (Piezotome Solo F 57 500, Kit
“Extern Sinuslift” F 87 319 Bone Surgery BS1) to
remove the bone window without perforating the

Schneiderian membrane.
–– Elevation of the Schneiderian membrane far to the medial, dorsal and palatal side. This ensures the blood
supply for the cavity23, 24 and secures the sinus implant,

implants 1 2018

[14] =>

Fig. 6
Fig. 6: Result after six months postoperatively. One can observe, that there
could be gained enough satisfactory bone quantitatively and qualitatively.

because there shall not be any tension on the membrane with expulsive forces on the sinus implant.
–– Reinforcement of the membrane with one layer of
A-PRF, insertion of the sinus implant and placement
of the boney lid of the vestibular window on top of the
disc of the sinus implant to enlarge the “shadow effect”. Filling the cavity with more A-PRF membranes
and cortical chips from the Safescraper.

–– Closure of the window with cortical chips, covering
with one or two A-PRF membranes and saliva proof
and tension free wound closure. This is achieved by
a two-layer suturing technique (apical mattress sutures and single button or continuous sutures) with a
monofil, atraumatic suture material, preferably PGC25
(Atramat®). PGC25 shows the lowest bacterial ad
herence rate and therefore significantly minimises the
incidence of stitch canal infection, which is a possible
secondary complication.25, 26

Results
The slight radiopacity due to the cortical chips and the
A-PRF show, that the cavity space was attained and the
bony lid placed on top of the disc of the sinus implant
(Fig. 6). Figure 7 shows an extensive treatment using
SDS ceramic implants and three sinus implants on both
sides. The results of the bone formation after four and
eight months show a perfect situation regarding hardand soft-tissue around the implant (Fig. 8).

Fig. 7: Insufficiently pre-treated maxillary situs, after inserting eight more implants in the maxillary, sinus lift on both sides, bone formation in the front.
Fig. 7

implants 1 2018

[15] =>

16.02.2017

Fig. 8: Significant bone formation already after four months and continuous
improvement after another four months.

Fig. 8

Conclusion
The external and internal maxillary floor elevation using secondary materials for augmentation is a standard
surgical procedure in oral implantology. However, complications such as infections or dehiscences up to total
loss are still a regular problem. Unfortunately, in most
cases “restitutio ad integrum” cannot be expected. The
maxillary sinus floor mucosa as well as the soft tissue
are mostly permanently compromised. On the one hand,
the presented therapy concept allows for a minimally
invasive and atraumatic surgical procedure, which only
uses autologous materials.

21.06.2017

23.10.2017

On the other hand, only highly biologically compatible, metal-free implant materials are inserted. The complication-free processes and the outstanding results up
to date in regard to the clinical, radiological as well as the
bone and soft tissue situation are very positive. This presents a promising alternative for the practitioner. In case of
complication, the worst that could happen in this treatment concept, is falling back to the original condition.
It is now necessary to confirm these results sustainably in regard to patient quantity and observation period
within long-term studies.

Prof. Dr Dr Ralf Smeets
Author details

Dr Martin Chares
Author details

Dr Stefan König
Author details

Dr Dominik Nischwitz
Author details

Dr Alexander Neubauer
Author details

Sabine Hutfilz
Author details

16.02.2017

21.06.2017

contact
Dr Karl Ulrich Volz
Biological Medical & Dental Clinic
SWISS BIOHEALTH AG
Brückenstr. 15
8280 Kreuzlingen, Switzerland
dental@swiss-biohealth.com
www.swiss-biohealth.com

Author details

23.10.2017

[16] =>

| case report

Individual CAD/CAM abutments
on ceramic implants
Dr Frederic Hermann, M.Sc., Switzerland

Full-ceramic systems have been successfully established
in the field of dental technology as well as in oral surgery.1
The necessity of being able to offer patients metal-free restorations has continuously increased in recent years.2 Owing to a genuine two-piece design, the newer generation
of ceramic implants allows for successful restoration concepts similar to titanium implants. The reconstruction of
an edentulous space in the upper jaw with simultaneous,
transcrestal sinus floor elevation by using three CERALOG®
implants will be described in the following case report.

Case presentation
In January 2015, the 42-year-old patient desired a holistic and metal-free reconstruction of the teeth, which were
either missing or in need of restoration (Fig. 1). The bridge
in region #15–17 had been removed by his family dentist a
few years ago and the gap situation had not been prosthetically restored since (Fig. 2). The patient had already gathered restoration information and thus desired his missing
teeth to be replaced with ceramic implants. The assessment of the radiological findings indicated an adequate
bone width with simultaneously reduced bone height,
which was caused by alveolar bone resorption and maxillary sinus pneumatisation. A wide zone of attached mucosa existed in the anticipated area of implant emergence.
The case-related risk classification by means of SAC criteria revealed an A classification (A=advanced; Table 1).
In a preoperation consultation, the patient was informed
in detail about the intended procedure and the possible
risks. The special features of ceramic implants were par-

Fig. 1
Figs. 1 & 2: Initial intraoral situation.

implants 1 2018

Fig. 2

ticularly addressed. On the one hand, the present research situation, the role as a “maverick technology” and
the alternative to titanium implants were addressed, while
the positive biological, immunological and tissue-compatible aspects were discussed on the other hand.
Prior to the surgical procedure, the areas in need of
restoration in the second and third quadrants were restored with full-ceramic bridge reconstructions as well as
with a CAD/CAM-manufactured lithium disilicate crown in
region #14. The prosthetically oriented implant positioning
was digitally planned to achieve the highest clinically possible predictability of treatment success. Thus the three
digitally designed crowns were overlaid with the DVT data
according to the intraoral scanning method (Fig. 3). The
positions, axial alignments and the lengths of the three implants were determined with the aid of planning software
(Fig. 4). Since there is still no guided solution for the implant
system utilised here, an orientation template was made in
the laboratory on the basis of the accumulated planning
data reproducing the anatomical marginal boundary of the
teeth to be replaced as well as the alignments. The template
could be exactly supported by the adjacent teeth (Fig. 5).

Implantation
The crestal incision was made after performing successful infiltration anaesthesia with preceding surface anaesthesia. It was carried out in a slightly palatally oriented
manner and continued paramarginally vestibular around
tooth #18. No distal vertical relief incision was made, in
order not to reduce the blood supply in the flaps. After the

[17] =>

case report

low risk

moderate risk

high risk

1. health status

good

treated

bad

2. smoking (p/day)

0–10

> 10

3. oral hygiene/compliance

good

moderate

bad

4. periodontal status

good

moderate

bad

5. aesthetic demands

low

moderate

high

6. level of the smile line

low

moderate

high

7. gingival biotype

thick

moderate

thin

8. infection

chronical

acute

9. distance bone to contact point

< 5 mm

5.5–6.5 mm

> 7 mm

10. restorative status of the neighbour teeth

11. width of the gap

single > 7 mm

single < 7 mm

> 2 teeth

12. soft tissue condition

intact

reduced

defect

13. bone volume

no defect

horizontal defect

vertical defect

14. time of surgery

late

early

immediate

15. loading time after surgery

> 2 months post-op

1 weeks – 2 months

immediate

restored

Table 1: Assessment of medical findings and risk classification by means of SAC criteria.

Fig. 4

Fig. 3

Fig. 5

Fig. 3: 3-D planning: overlay of datasets. Fig. 4: Planning visualisation. Fig. 5: Try-in of the drilling template.

preparation of the mucoperiosteal flap, the position of the
implant was marked on the bone using the triangular drill
and orientation template.

technique. The axes of the drilled hole were examined with
the aid of directional indicators and the implant site was
expanded according to the surgical protocol (Figs. 6–8).

In the next step the pilot drill holes were created reaching
slightly beneath the maxillary sinus floor, as in the following
step the sinus floor was to be elevated using the osteotome

The indirect technique for augmenting the sinus floor
through the drill holes was for the first time described
by Tatum in 1986 and modified by Summers in 1998 on

implants 1 2018

[18] =>

| case report

Fig. 6

Fig. 7

Fig. 8

Fig. 9

Fig. 10

Fig. 11

Fig. 6: Definition of the implant positions. Fig. 7: Paralleling pin. Fig. 8: Red extension drill. Fig. 9: Minimally invasive osteotome-aided sinus lift in region #17.
Figs. 10 & 11: Application of collagen fleece beneath the Schneiderian membrane.

the basis of the osteotome technique.3–5 A systematic review of specialised literature revealed that this approach
is predictable, and has low incidence for intraoperative
as well as postoperative complications.6 The fracture of
the sinus floor beneath the drill holes was initiated with
an osteotome (Stoma) according to the implant diameter
(Fig. 9). With the aid of the Piezon technology and specifically angled miniature sinus curettes, the Schneiderian
membrane stayed always in touch with the bone and was
carefully lifted under visual control (surgical microscope).
Collagen fleece (PARASORB, RESORBA) was inserted
through the drill holes in region #16 and 17 and carefully
applied over the implant site in order to prevent a perforation of the Schneiderian membrane (Figs. 10 & 11).
Thread cutting was performed to avoid overheating
the bone while inserting the zirconium dioxide implants,
which have lower thermal conductivity than titanium implants (Fig. 12). The implants (CERALOG® Hexalobe,
CAMLOG) of 8 mm in length were inserted manually at a
controlled maximum torque of 35 Ncm and a maximum
insertion speed of 15 /min (Fig. 13). The design of the
connection was optimally adapted to zirconium dioxide.
The power transmission occurred radially with the insertion device. A predetermined breaking point in the device shields against an excessively high-torque value and
therefore against excessive pressure which could initiate
fractures in the implant or necrosis in the bone (Table 2).
The design of the implants utilised here was beneficial to the existing low bone height, thereby preventing
the possibility of slipping into the maxillary sinus. Zirco-

implants 1 2018

nium dioxide implants are manufactured in a ceramic injection-moulding (CIM) process obtaining a dual surface.
The surface texture in the neck region is less coarse than
in the enossal region favouring soft tissue apposition,
whereas the surface in the enossal region is optimised
for osseointegration. The implants were inserted about
0.5 mm supracrestally and primary stability was achieved
at 25 Ncm (Fig. 14). After the insertion of the implants, the
collagen fleece was situated apically like a screen above
the implants in region #16 and 17, which were protruding two to three millimetres into the sinus floor. A blood
clot formed in the created cavity favouring regeneration
into stable bone through the formation of growth factors
during implant healing.7 The intraosseous, periodontal
bone defect in region #18 was filled with a pure phase
beta-tricalcium phosphate (Fig. 15).
Mixed with patient blood taken from the surgical site the
porous synthetic granulation can be easily applied. After
about six to nine months the material regenerates into stable cortical bone. After sealing the implants with the cover
cap made of polyether ether ketone (PEEK), tension-free
wound closure was performed with two mattress sutures
and multiple simple interrupted sutures (Fig. 16). Further,
a radiographic control image was taken (Fig. 17).8 The patient left the practice with a renewed reference regarding
postoperation behaviour focusing on care and non-strain.
Suture removal was performed during the two-week
check-up showing well and irritation-free wound healing.
The patient appeared six months later for implant exposure. The implants in region #15 and 16 were exposed

[19] =>

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www.WITAR.de

[20] =>

| case report

Fig. 14

Fig. 12

Fig. 13

Fig. 15

Fig. 16

Fig. 17

Fig. 18

Fig. 12: Thread cutting. Fig. 13: Implant insertion in region #17. Fig. 14: Implants inserted at 0.5 to 1.0 mm supracrestally. Fig. 15: Guided bone regeneration
(GBR) of intraosseous periodontal bone defect. Fig. 16: Tension-free wound closure. Fig. 17: Postoperative radiographic control image. Fig. 18: Six-months
post-op exposure surgery.

with a stab incision, the cover cap was removed and the
PEEK gingiva former was screwed on with the aid of a
holistic screw for shaping the gingiva. The soft tissue
around the implant in region #17 was pre-prosthetically
thickened by preparing a mucosa flap and shifting it into
vestibular direction. This shaping with a 2.5 mm high gingiva former was also performed without any additional
suture being necessary (Fig. 18).

Definitive restoration
The implants and the jaw situation were moulded for
the production of individual definitive full-zirconium dioxide abutments. For taking the impressions according to
the open tray technique the gingiva formers were screwed
off and the PEEK impression posts were inserted. Some
practice is necessary to control the exact fit during the
subsequent radiographic control image, since the material is only marginally radiopaque (Figs. 19 & 20).
The master model with a removable gingival mask was
produced in the laboratory. Scan posts were screwed on
and the morphology of the implant as well as the gingiva
was digitally recorded. The data compiled from the wax-up
was merged with the model data, and three individual abutments were designed in consideration of material thicknesses and the anatomical coronal-emergence profiles.

implants 1 2018

Six days after order placing, the laboratory received
the CAD/CAM-manufactured abutments. The design of
the internal connection was adapted to zirconium dioxide and ensured an optimal distribution of the forces involved. Owing to the limitations of milling radii the full-
zirconium dioxide abutments (DEDICAM®, CAMLOG)
were made with platform switching. The abutments were
screwed on in the laboratory and the subgingival parts
were checked for hygienic capability (Fig. 21).
Another important step was the reliable prosthetic
crown restoration. For this purpose, prototypes were
made from polymethyl methacrylate by 3-D printing on
the basis of already existing STL datasets. The occlusion, contact points, hygienic capability as well as shape
and aesthetics can be checked intraorally during a prototype try-in with these cost-effective synthetic crowns.
Owing to the integrated platform switching and the occlusal structure height, the coronal emergence profile in
region #16 could not be optimally aesthetically solved
(Figs. 22 & 23). As zirconium dioxide has a lower accumulation of plaque and the subsequent hybrid-abutment
crown would be easy to clean in this area, this situation
was assessed as clinically acceptable.9,10 Owing to consistent prosthetic backward planning, the zirconium dioxide crowns—which are to be buccally veneered
later—could be made with an integrated occlusal screw

[21] =>

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Die Zukunft der Implantologie –
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[22] =>

| case report
manufacturing process known as CIM. Adapted to the
soft-tissue cells, the neck region exhibits a roughness
with an average roughness value of 0.5 micrometres and
the enossal region exhibits a roughness of 1.6 micrometres. As a result, outstanding osseointegration properties
can be attained.11,12

Fig. 19

Fig. 20

Fig. 19: Lateral view of impression posts. Fig. 20: Radiographic control image.

access channel. After crown finalisation, they were adhesively attached to the abutments in order to produce
one-piece fully anatomical hybrid-abutment crowns. The
hybrid-abutment crowns were inserted into the mouth
with titanium screws at a torque of 25 Ncm after function
and aesthetics had been controlled.
Cement residues have been repeatedly discussed in
literature as being the cause of an emerging mucositis or peri-implantitis. This risk was eliminated with the
screw-retained solution. The screw access channels
were initially filled with sterile Teflon tape and then sealed
with methacrylate-free composite (Fig. 24).
During follow-up appointments at one and six weeks
after the insertion of the full-ceramic implant restoration
the soft tissue proved to be stable and irritation-free. The
osseointegrated ceramic implants and the osseously regenerated periodontal defect mesial of region #18 were
apparent on the radiographic control image (Fig. 25). The
patient was very satisfied with the holistic rehabilitation of
his oral situation.

Discussion
The patient demand for ceramic implant restorations
is undisputedly increasing.2 The aesthetic and health-
related needs of patients should be considered in the
treatment concept. In doing so, clinically proven systems
provide us with certainty. A dual surface roughness without mechanical finishing is created through the modern

Fig. 21

Fig. 22

Abutments made of the high-performance polymer
PEKK are offered as a standard for two-piece implants.
In medical technology, the material is used in areas with
high load levels. PEKK is biocompatible and has a great
degree of strength. Because of the chemical composition and ductility these abutments cover the entire implant platform, including the circular slanting bevels. A
uniform choice of materials is guaranteed with the option of individual, CAD/CAM-manufactured full-zirconium
dioxide abutments. Owing to the milling geometry, the
full-zirconium dioxide abutments can only be made with
integrated platform switching. The choice of abutment
used for the reconstruction should be defined during the
implant positioning, as the abutments influence the vertical position of the ceramic implant.
When setting the PEKK abutment on the shoulder,
the implant platform should be placed between 0.5 and
1.5 mm supracrestally. In case of thick gingiva (> 3 mm),
supracrestal placement is possible with zirconium dioxide
abutments. However, owing to platform switching a slightly
subcrestal or epicrestal positioning is advantageous for
the prosthetic emergence profile if adequate bone supply
is available (Table 2). The connection is secured with the
aid of a titanium screw or a holistic gold screw, which does
not have any connection to the oral environment when
embedded in the overall construction. Today, the genuine
two-piece design of the implant system offers similar
treatment procedures as with titanium implants.
For successful treatment therapy 3-D planning by means
of DVT datasets has become established in the dental
practice. The optimal prosthetically oriented position of
implants can be determined through a template-guided
or template-oriented surgery and the digitally designed
reconstruction. After successful osseointegration, the
intraoral structures can be scanned or conventionally
moulded. With the aid of a laboratory scan and the open
STL datasets the abutments can be designed and com-

Fig. 23

Fig. 21: Abutments on the model. Fig. 22: Try-in of the abutments. Fig. 23: Occlusion control and adaptation of prototypes.

implants 1 2018

[23] =>

case report

Thermal
conductivity

The insertion device for Hexalobe® implants is equipped with a predetermined breaking point, which:
– prevents excessive torque and excessive load,
Predetermined breaking point
– breaks with excessive load, and
– prevents damage on the implant.

Primary stability/
protocol

The drilling protocol depends on bone quality.
– CERALOG® has no self-tapping thread

Pre-tapping a thread is strongly recommended in case of hard bone (D1/D2).
The following torques have to be noted: – maximum torque of 35 Ncm, and
– maximum speed of 15 /min.

Positioning

Individual DEDICAM® full-zirconium dioxide abutment: owing to the integrated platform
switching, the implant should
be positioned epicrestally.

0.7 mm

The PEKK abutments completely contain the platform’s
circular bevel. The implant
can be placed supracrestally
between 1.5 and 0.5 mm.

1.5 mm

The use of a profile drill is recommended in epicrestal placement.
– controlled expansion of the implant bed in the crestal region

Prosthetic portfolio

Literature

Components for crown and bridge restoration:
– PEKK (straight and angled)
– DEDICAM® abutment

Table 2: Factors to be noted for the insertion of CERALOG® implants.

missioned via the DEDICAM® production service. The
material-dependent exact milling data are only stored in
the CAM production. After a controlled sintering process
lasting over three days, a precise fit to the internal config-

uration of the implant is attained. Subsequently fully anatomical crowns or crown frameworks are produced in
a dental laboratory or by means of a production service
provider and individually veneered by dental technicians.
Currently the prosthetic portfolio for two-piece ceramic
implants is still limited, thus the indications for restoration
with fixed crowns or smaller bridge reconstructions are
still limited. Prosthetic components for removable restoration concepts will be available in the near future.

Conclusion

Fig. 24

In summary, it can be stated that two-piece ceramic
implants are a safe and biologically interesting alternative
to existing titanium implants and represent a sensible addition to the implantological treatment spectrum of a dental practice. Thus, in order to reach clinical success with
metal-free implants it is important to determine correct
indications and to properly consider the ceramic-specific
properties.

contact

Fig. 25
Fig. 24: Lateral view of the inserted implant crowns. Fig. 25: Radiographic
control after insertion of the final prosthetics. The regenerated intraosseous
defect in region #18 mesial has to be noted.

Dr Frederic Hermann, M.Sc.
TEAM 15 – Dental Practice
Poststr. 15
6300 Zug, Switzerland
info@team15.ch
www.team15.ch

Author details

implants 1 2018

[24] =>

| case report

Fig. 1a

Fig. 1b

Fig. 3

Fig. 4

Fig. 6

Fig. 7

Fig. 2a

Fig. 2b

Fig. 5

Fig. 8

Figs. 1a & b: Initial clinical situation overview. Figs. 2a & b: Initial clinical situation of (a) tooth #12 and (b) tooth #22. Fig. 3: Lip-smile-line. Fig. 4: Former
Maryland bridges. Fig. 5: Provisional aesthetic restoration with internal suspension clip. Fig. 6: Provisional restoration in situ. Fig. 7: One-piece ceramic
implants prior to prosthetic placement. Fig. 8: Occlusal view.

Aesthetic restoration
in the incisal region
Michael Gahlert, Germany

Dr Michael Gahlert is a fellow of the International Team
for Implantology (ITI) and has been specialising on the
development and placement of ceramic implants. In this
case report the aesthetic restoration of two maxillary incisors with ceramic implants is presented in detail. Dr
Gahlert was supported by Otto Prandtner, dental technician at Dental Plattform and Dr Reza Saeidi Pour, prosthodontic specialist of the Dr Seehofer dental clinic, both
from Munich, Germany.

tion and thus regularly had to be reglued. Consequently,
the patient was not satisfied with this solution anymore
(Figs. 1–4).

Case presentation

In a thorough consultation, the patient was extensively
informed about available restoration options and she decided for one-piece ceramic implants (PURE Ceramic,
Straumann Group). In a first step a provisional aesthetic
restoration with an internal clip was produced and could
be integrated immediately after the former bridges had
been removed (Figs. 5 & 6).

A 28-year-old female patient attended the practice
with the desire to have her incisors, which by nature did
not exist, replaced with implants. The patient had until then been wearing Maryland bridges. However, in the
past years they had repeatedly been falling out of posi-

In the following implantological procedure autologous
bone material was simultaneously buccally accumulated.
The teeth of the provisional restoration were hollowed in
order to prevent them from touching the freshly inserted
one-piece ceramic implants (Figs. 7 & 8).

implants 1 2018

[25] =>

case report

Fig. 9

Fig. 12

Fig. 14b

Fig. 10

Fig. 11

Fig. 13

Fig. 14a

Fig. 15a

Fig. 15b

Fig. 16

Fig. 9: Gingival displacement. Fig. 10: Fitted plastic temporary copings. Fig. 11: Shortened temporary copings. Fig. 12: Final chairside provisional restorations
on laboratory implant analogues. Fig. 13: Chairside provisional restoration in situ. Figs. 14a & b: Definitive restorations. Figs. 15a & b: Final state of (a) tooth
#12 and (b) tooth #22. Fig. 16: Lip-smile-line with final restoration. Fig. 17: Patient portrait with lip-smile-line.

After a healing period of three months the implants
were prepared for the provisional crowns. In order to do
so the peri-implant gingiva had to be displaced with retraction threads. Excess gingiva was removed with an
electrotom on the palatinal side (Fig. 9).
Industrially produced temporary copings (Straumann
Group) were then put on the implant fixture and shortened accordingly (Figs. 10 & 11). This so-called snap-on
method facilitates the prosthetic handling and is also
used for taking impressions with appropriately prefabricated impression caps.
The prosthetic teeth that had been removed from the
provisional restoration were in a further step glued onto

the caps and transferred to the chairside provisional restoration. After forming the pink aesthetics, the definitive
impressions were taken and the full-ceramic crowns
were produced. Finally, the restorations were placed
using glass ionomer cement (Ketac™ Cem, 3M ESPE)
as definitive mounting material (Figs. 12–14).

Conclusion
Ceramic has become a material of choice when dental implants are concerned. Especially as the teeth to be
restored were located in the aesthetic zone the patient’s
decision for ceramic implants proved to be the correct
choice producing a satisfying outcome for practitioner
and patient (Figs. 15–17).

contact
PD Dr habil. Dr med. dent. Michael Gahlert
Hightech Research Center of Cranio-Maxillofacial Surgery
Department of Biomedical Engineering
Author details
University of Basel, Switzerland

Fig. 17

Private Dental Clinic
Theatinerstraße 1
80333 Munich, Germany
www.drgahlert.com

implants 1 2018

[26] =>

| case report

Immediate placement
in the maxillary aesthetic zone
Dr Saurabh Gupta, India & Dr Sammy Noumbissi, USA

This particular case report details the immediate replacement procedure of a previously unsuccessfully
endodontically treated maxillary central incisor with a
one-piece zirconia implant. Atraumatic extraction of the
incisor was followed by a curettage procedure to remove
any fragments of peri-apical granuloma.
Immediate placement of the implant (one-piece ZiBone
zirconia, COHO) with good primary stability was accomplished and the implant was then restored with a zirconia
crown four months later. The follow-up after a year found
effective osseointegration with optimum function and form.

Case presentation
The patient was a 36-year-old woman, who came for
a dental check-up because she was suffering from pain

in the left maxillary anterior tooth area. The pain, according to her, was sudden at the start and it worsened upon
biting. The clinical examination of tooth #21 revealed inflammation, pain on percussion and fractured tooth at the
cervical margin.
The tooth had been endodontically treated three years
before and had not gone through rehabilitation earlier.
Radiographic examination showed a fractured crown
that had minor root resorption with an associated periapical infection (Figs. 1a–c). There was presence of sufficient bone width and height as was radiographically
and clinically verified. The poor prognosis for endodontic retreatment was explained to the patient and she requested more conclusive treatment. It was then decided
that the tooth needed to be removed and immediately be
replaced with a one-piece zirconia implant.

Fig. 1a

Fig. 1c

Fig. 2

Fig. 1b

Fig. 1a: Pre-op clinical photograph of tooth #21. Fig. 1b: CBCT scan. Fig. 1c: Radiograph of tooth #21. Fig. 2: Extracted tooth #21.

implants 1 2018

[27] =>

case report

Fig. 3a

Fig. 4

Fig. 3b

Fig. 3c

Fig. 5

Fig. 6b

Fig. 6a

Figs. 3a–c: One-piece ZiBone zirconia implant (Ø 4.0 mm, length 12.0 mm). Fig. 4: Healing state after four months. Fig. 5: Restoration of tooth #21 with a
zirconia crown. Figs. 6a & b: One-year post-op situation and radiograph.

Surgical procedure
Thorough ultrasonic scaling and maintenance were done
before extraction and placement of the implant. Under local anaesthesia with lidocaine (Lignox, Indoco with adrenaline of 1:200,000) atraumatic extraction of tooth #21 was
performed with the use of a periotome (Fig. 2). In-depth
debridement of the extraction socket was performed using
bone curettes for the removal of granulation tissue.

taking 400 mg of metronidazole and 500 mg of amoxicillin t.i.d. for five days, as well as three days of paracetamol.
Removal of the sutures was done after seven days, at
which time the wound was seen to be healing well.
Impressions were taken four months later and the zirconia crown was subsequently seated on the implant that
had replaced tooth #21 (Fig. 4). Crown occlusion was confirmed with articulating paper of 12 μ in thickness (Fig. 5).

The next procedure was the preparation of the osteotomy sites using a pilot drill and verification followed with
the use of direction indicators. Consecutive drilling was
then performed all the way to the last implant dimension and one ZiBone zirconia implant (Ø 4.0 mm, length
12.0 mm) was placed in region #21. Primary stability was
accomplished at approximately 35 Ncm (Figs. 3a–c).

The postoperative review one year later showed that
there was no indication of mobility, bone loss, peri-implant laceration or paraesthesia. Furthermore, there was
no indication of inflammation of the soft tissue (peri-implant) surrounding the site (Fig. 6).

Then, particulate bone grafting material was placed
with the objective of filling the gap between the tooth
socket and implant. The implant was secured in place
using a Geistlich Bio-Gide collagen membrane (Geistlich
Biomaterials) and the region was sutured with 3/0 black
silk suture thread. It was decided to place the crown at
a later stage. The immediate postoperative radiograph
showed a parallel and properly placed implant.

Considerations for using zirconia implants include the
material’s aesthetic advantages: no galvanic reaction and
lower risk of inflammation in comparison to the accidental
introduction of titanium particles to the osteotomy site.1–3

For postoperative home care, instructions involved
tooth-brushing, rinsing with 0.12 % chlorhexidine, and

Discussion

After 20 years, there is evidence suggesting that zirconia-based implants are highly biocompatible, in addition
to having advantageous physical properties. Further evidence has shown that zirconia has the ability to withstand
sustained loads, which implies that zirconia implants are
also suitable for replacing posterior teeth.4

implants 1 2018

[28] =>

| case report
In this case, metallic implants were not desired by the
patient, and for that reason, the single-piece zirconia
implant was decided on.5, 6 The absence of a micro-gap
with one-piece implants in comparison to two-piece implants guarantees minimum microleakage and minimal
bacterial colonisation, which may otherwise possibly
result in bone loss.7
Conventional protocols for implant placement, as well
as loading in areas with periapical infection, means several months of delay in the implant procedure after extraction, to effectively avoid infecting the surfaces of the
implant.8 Nevertheless, occurrence of unintentional bone
loss is possible while waiting for lesion resolution; this
may compromise function and aesthetics. The amount
of resorption of crestal bone after tooth extraction can
extend to 23 per cent in six months, which may compromise the soft- and hard-tissue structure. Systematic review results advocate that it is possible to place implants
in sites with periapical and periodontal infections.9, 10
This case entailed the performance of exhaustive surgical debridement before placement of the dental implant. Guided bone regeneration (GBR) was performed
as well, for filling of the socket–implant gap. These
steps were followed based on the evidence provided by
Waasdorp et al.’s systematic review.11
A randomised multicentre controlled trial observed no
clinical variances in complications, implant survival and
changes in the marginal bone levels when placing single
implants early, conventionally or immediately.12
A meta-analysis and systematic review that studied the
procedures for immediate placing and loading/restoring single implants in frontal maxillary regions provided
inspiring outcomes of over 97.9 % and 99.0 % implant
survival rates, respectively.13
Both prospective and retrospective studies have been
performed, and they supported the immediate placement of implants even in areas with periapical pathology.
A reflective analysis (67.3 months of follow-up) of 418 immediately placed implants displaying periapical pathology established an increasing 97.8 % survival rate14.
Another reflective study compared the survival rates
of immediate implants placed in sites with and with no
periapical pathology. Among the 922 implants, 285 were
implanted into sockets with periapical radiolucencies
(19.75 months of follow-up).15 The survival rates of the control and study groups were at 97.5 % and at 98.7 %, respectively, which happened to be statistically insignificant.
Remarkably, a statistically greater degree of failure has
been found for implants placed next to retained teeth with
periapical lesions. In a prospective clinical controlled trial

28

implants  1 2018

by Siegenthaler et al. in which 13 immediate implants
were implanted in areas that exhibited periapical pathology and 16 immediate implants were placed in healthy
areas, there was no difference observed between radiographic and clinical parameters.16 Primary stability was
achieved for both groups.
Jung et al. placed immediate implants into areas both
with and with no periapical pathology and reported a
100 % survival rate five years after the placement.17 It is vital to keep in mind that studies like these have emphasis
on the elimination of pathology both chemotherapeutically
and mechanically while supporting GBR wherever it is
required.
Surfaces of zirconia implants tend to accumulate less
bacteria in comparison to titanium surfaces. This could
avert an inflammatory gingival reaction that could aggravate an existing periapical lesion. Reduction in the bacteriological load promotes the biological width formation
and mucosal closure that could thwart any apical bacterial colonisation.18–21

Conclusion
The immediate placement of a zirconia implant could
well benefit areas of existing periapical infection, provided that the infected site undergoes a thorough surgical debridement and GBR is used if necessary, and there
is adequate antibiotic coverage and sufficient postoperative maintenance.
Editorial note: The authors disclosed
that they have no financial or other
competing interests.

Literature

contact
Dr Saurabh Gupta
Oral & Maxillofacial Surgeon & Implantologist
IAOCI Educational Director
Bangalore, India
Tel.: +91 9916203455
saurabh@iaoci.com
Dr Sammy Noumbissi
DDS, MS, PA
International Academy of 
Ceramic Implantology
801 Wayne Avenue, Suite #G200
Silver Spring, MD 20910, USA
sammy@iaoci.com

Author details

Author details

[29] =>

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[30] =>

| industry

Change is mandatory
for extraordinary results
Revital Shabtai, VP Marketing, TAV Dental

It is true, titanium was the gold standard in oral implantology for many years, however time is changing and
so are our patients’ needs and demands. High aesthetic
standards and increasing incidences of titanium sensitivities along with a rising demand for metal-free reconstructions have led to the search for an alternative material.
Zirconia implants were introduced into dental implantology as an alternative to titanium implants (Figs. 1a–c).
Zirconia seems to be a suitable implant material because of its tooth-like colour ensuring high aesthetic results, excellent mechanical properties, osseointegration

Fig. 1a

Fig. 1b

Fig. 2a

Fig. 2b

and clinical advantages superior to titanium implants
(Figs. 2a–d).
When it comes to innovation in implant dentistry, new
technologies like patient-customised CAD/CAM abutments, drill guides and digital treatment planning have
been implemented. When it comes to dental implants,
there are those who believe that research has come to
the end of the road. We think different, we think zirconia
implants are the new road the market is going to take
(Figs. 3a–c). New improvements and advancements will
drive value to our customers.

Fig. 1c

Fig. 2c

Fig. 2d

Figs. 1a–c: Tooth #46 three months after implant placement, screw-retained restoration with monolithic zirconia crown. Figs. 2a–d: Tooth #11: Two-piece
zirconia implant with cemented zirconia crown.

implants 1 2018

[31] =>

industry

Fig. 3a

Fig. 3b

|

Fig. 3c

Fig. 3a: Tooth #35: Immediate implant placement after tooth extraction. Radiograph of the day of surgery. Figs. 3b & c: Situation after four months.

As our focus is to create immense value with our zirconia implants, we are committed to bring innovation to
the dental market and to substantially improve the treatments of patients world wide through continuous advancements. This is why we are soon launching a new
generation of zirconia implants, designed by a highly professional team, manufactured by high-end CIM technology, resulting in state-of-the-art products. FDA approval
is expected soon.
Let us together redefine implant dentistry for the benefit of the patients.

All figures: © Dr George Pamborides, DMD at Nicosia
Dental Clinic, Associate Fellow AAID, IAOCI member

contact
TAV Dental
Shlomi, Israel
Tel.: +972 4 9808615
info@tavdental.com
www.tavdental.com
AD

!
w
e
N imp l ant

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R o o t h s c r ew a
w it nte r n al
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n
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co

Strong. Aesthetical. Metal-free.
Two-piece, reversibly screw-retained

100% metal-free

Strong connection with VICARBO® screw

An innovation from Switzerland based on 10 years of experience in the development of ceramic implants.
www.zeramex.com

[32] =>

| industry

Ceramic implants in
anterior dental restoration
Dr Franz-Jochen Mellinghoff, M.Sc., PhD, Germany

Initial situation
A 39-year-old female patient of good general health
attended our practice for a consultation. She came from
a small town approximately 70 km from our practice and
had found out beforehand via the Internet which dentist in the area offered ceramic implants. The patient was
prepared to make the long trip to reach us because she
was worried that the apicectomy proposed by her own
dentist would once again involve introducing new foreign material (sealing material for the apical closure of

Fig. 1

the root canals) into the bone. She had thus decided on
having the root-filled teeth and associated metal-ceramic
crowns, as well as the periapical granulomas, removed.
She clearly and unequivocally communicated her desire
for ceramic implants.
In our practice, particular importance is attached to
an informative initial consultation with new patients. Expectations of both patient and therapist—the “shared
therapeutic vision”—should be addressed in this consultation. The patient in this case was looking for very

Fig. 2

Fig. 3

Fig. 4

Fig. 5

Fig. 6

Fig. 1: Initial situation. Fig. 2: An evaluation of the CBCT scan shows adequate conditions for inserting ceramic implants. Fig. 3: Extracted lateral incisors.
Fig. 4: Implantation of Straumann PURE Ceramic Implant (diameter: 3.3 mm; length: 12.0 mm). Figs. 5 & 6: Radiographs showing the two ceramic implants
inserted into the prepared alveoli.

implants 1 2018

[33] =>

industry

good function, a high level of aesthetics and well-tolerated materials. Our expectations were constructive cooperation covering a comprehensive history, very good
diagnostic options, and high-quality surgical and dental technology products. All of these are integrated in
a programme of oral hygiene management developed
for implant patients. Planning involves detailed explanation of the intended treatment, photographs, models and
radiographs (Fig. 1).

After being given an explanation and time for consideration of the various options, the patient decided on extraction of teeth #12 and 22. We selected immediate implantation for the restoration of regions #12 and 22. Good
experiences with this method allowed us to suggest the
prospect of a shorter treatment period and a high-quality aesthetic outcome to the patient. After evaluation of
the CBCT scan, we were able to meet her request for the
provision of ceramic implants (Fig. 2).

Therapy schedule

Surgical procedure

The patient’s dental chart revealed full dentition, partly
restored with resin composite filling materials. Teeth #12
and 22 had been crowned after endodontic treatment.
The patient complained of problems in the maxillary region between teeth #13 and 23. Pain on pressure was reported in response to digital pressure (thumb and index
finger) in the apical region of teeth #12 and 22, differing
clearly from the adjacent regions. A clinical diagnosis of
suspected apical osteitis was made and was confirmed
in the radiograph and cone beam computed tomography
(CBCT) scans subsequently taken.

The two lateral incisors were removed using a Benex
extractor (Helmut Zepf Medizintechnik; Fig. 3). This procedure reduced the risk of alveolar damage, particularly damage to the vestibular alveolar wall. The alveoli
were freed from the inflamed apical tissue by means of
intensive curettage. Two monotype, reduced-diameter
Straumann PURE Ceramic Implants of 3.3 mm in diameter and 12.0 mm in length were implanted using a surgical drill template (Fig. 4). The two ceramic implants could
then be inserted into the prepared alveoli at a torque of
35 Ncm (Figs. 5 & 6).

Fig. 7

Fig. 8

Fig. 9

Fig. 10

Fig. 11

Fig. 7: Chairside temporisations. Fig. 8: Long-term temporary restorations. Figs. 9 & 10: The impression for permanent crowns was taken using a single tray
with polyether and impression caps compliant with the system. Fig. 11: Crowns manufactured on the basis of milled zirconium dioxide copings veneered with
feldspathic ceramics.

implants 1 2018

[34] =>

| industry
Fig. 12

Figs. 12–14: Secure outcome after cementation with glass ionomer cement.
Figs. 15–17: Periodontal situation after two and a half years. Fig. 18: Patient
satisfied with the outcome; further development will be recorded.

After suturing, impression posts were used to take an
impression in order to create long-term temporary restorations. Chairside temporisations were used until these
were ready (Fig. 7). With the long-term temporary restorations, the patient was able to go to work and her ability to communicate was not restricted in any way either
(Fig. 8). The healing process was problem-free.

Prosthetic procedure
Fig. 13

Fig. 14

The impression for the permanent crowns was taken
using a single tray with polyether and impression caps
compliant with the system (Figs. 9 & 10). The crowns
were manufactured on the basis of milled zirconium dioxide copings veneered with feldspathic ceramics (Fig. 11).
Cementation with glass ionomer cement produced a secure outcome (Figs. 12–14). Treatment was completed
by a functional test.

Fig. 15

Treatment result
The outcome of the treatment met the planned specifications in terms of both aesthetics and function. The minimally invasive extraction meant that both hard- and softtissue were preserved to the maximum extent possible.
Comparison of the periodontal situation after two and a
half years on the basis of photographs and radiographs
indicated a very good long-term prognosis (Figs. 15–17).

Conclusion
Fig. 16

Fig. 17

The patient asked for a non-metal prosthetic implant. As
a result of the limited spatial conditions, ceramic implants
with a diameter of 3.3 mm were selected. The detailed
planning and its implementation meant that it was possible to achieve a more than satisfactory outcome for the
patient, the practice and the dental laboratory (Fig. 18).
The patient decided to remain in our oral health programme despite the additional travel involved. This meant
that we would be able to record further developments.

contact

Fig. 18

implants 1 2018

Dr Franz-Jochen Mellinghoff
M.Sc., PhD
Pfauengasse 14
89073 Ulm, Germany
Tel.: +49 731 62158
jochen.mellinghoff@dr-mellinghoff.de
www.dr-mellinghoff.de

Author details

[35] =>

Senior Premium Partner

Premium Partner

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[36] =>

| manufacturer news
SDS Swiss Dental Solutions

Ceramic implant forms with osteogenic functionality
While SDS ceramic implants were being applied routinely at
the Swiss Biohealth Clinic of Dr Volz, the experience and
knowledge that were gained there led to the development
of a new kind of implant. The improved biocompatibility
of zirconium dioxide implants, together with the bone- and
soft-tissue growth associated with it have provided new
options for implantation wherever pronounced oval alveoli need to be treated, or multiple rooted teeth must be
replaced. To this end, the implant ranges “oval” and “balcony” were developed, available in different diameters
and lengths, both as single pieces and in two parts, and
which were able to optimally close the alveoli, especially
with emergency implantations.
The new SDS “sinus implants” (Fig.) were developed specifically for sinus lifting. Due to the increased biocompatibility of ZrO2, bone growth is

also optimally exploited for this indication. In the apical area
of the sinus implants, a plate is introduced, which on
the one hand spares damage to the Schneiderian
membrane upon sinus lifting, and on the other forms
a large cavity under the plate due to an umbrella
effect. The actual implant serves as a tent pole in this
cavity, which creates optimal conditions for inward
bleeding and the bone regeneration which results from
this. Bone graft material is not necessary in almost all
cases. The sinus implants are also available in various
diameters and lengths.
SDS Swiss Dental Solutions AG
Zollstr. 8
8280 Kreuzlingen, Switzerland
www.swissdentalsolutions.com

Straumann

PURE Ceramic Implant System
Nothing is more winning than a light-hearted and happy smile.
With the PURE Ceramic Implant System even very demanding patients can smile with confidence according to the principle “Discover natural PURE white. Love your smile.”
With this implant system, dentists can grant their patients the
best aesthetic, natural and solid treatment. Patients will benefit from all the highly aesthetic advantages of a natural ceramic
implant—ivory-coloured like a natural tooth root and even in cases
of thin gingiva biotypes not shining through. No compromises on
aesthetics, reliability or the most natural choice of material are
necessary. Further they can rely on high-performance zirconia
ceramic material being even stronger than the gold standard,
grade 4 titanium implants.

implants 1 2018

The Straumann® PURE Ceramic Implant System is the result of
more than 12 years of relentless research and development until the ceramic implants complied with the company’s premium
quality standards. Swiss quality and precision, strength, clinical success and flexible treatment protocols are combined in an
innovative solution that helps dentists meet the needs of their
patients.
Institut Straumann AG
Peter Merian-Weg 12
4052 Basel
Switzerland
www.straumann.com

[37] =>

manufacturer news

CAMLOG

Metal-free aesthetic restorations from implant to crown
CAMLOG’s full range of ceramic implants and prosthetic components supports metal-free aesthetic restorations from the implant
to the crown. CERALOG implants offer high predictability and
exceptional aesthetic properties. The
range includes ivory-coloured one- and
two-piece zirconia implants and reversible screw-retained abutments.
In the application they are close to
the common standard of titanium
implants. Outstanding features of
the system are the biocompatibility
of the high-performance material,
the reversibility of the screw-retained
prosthetic components and the
achievement of highly aesthetic restorations. CAMLOG has established a close interface to DEDICAM and thus to individual CAD/
CAM prosthetic solutions. The expansion of the

product range opens new patient-oriented treatment options
for clinicians. Once again emphasizing the company’s innovative strength.

COHO Biomedical Technology

WITAR

The next generation of implants

Biocompatible ceramic implant

COHO recognizes that nowadays patients are not
satisfied merely with the function of restorations
but also demand aesthetics. With this in mind, a
completely aesthetic solution for implant treatments was developed: ZiBone ceramic implants
for both function and aesthetics, ceramic drills
for cutting efficiency and reducing heat generation and our milling centre for producing fixed
temporary and Zirconia ceramic prostheses ensuring accurate fit. Zirconia is a material of choice
in terms of aesthetics, biocompatibility and mechanical properties.
All of our products must go through stringent quality
control to make sure that they perform according
to specification and patient safety requirements.
ZiBone ceramic dental implants were approved
by U.S. FDA, CE and TFDA. Their cylindrical body
and conical tip design enables them to achieve the
highest possible primary stability. The fine neck thread
increases the bone contact area and initial stability. Threads in the
implant body and wide pitch design provide stability and promote
osseointegration.

Metal-free, biocompatible and aesthetic: Ceramic implants have
gained popularity among dentists and patients. Building upon this
trend, WITAR offers a new AWI implant system for transgingival
healing. With this, the company promises an implant treatment that
is safe, cost-efficient and simple. The two-piece system that has
been developed and patented recently is made from Y-TZP ceramic
and offers a reliable and easy handling. Treatment steps had been
optimised for an increased safety and biocompatibility. At the same
time, treatment costs and time could be reduced.
The implant system consists of nine two-piece ceramic implants
that are available in three different diameters (3.9, 4.5, 5 mm)
and lengths (8, 10, 12 mm). With this, the system is indicated
for all bone classes. Additionally, the one-piece AWI implant is
available in two sizes (10, 12 mm) with a diameter of 3.9 mm
and can be used in the anterior mandible. Four full-ceramic
abutments of which two are straight and two are angled by
15 degrees, belong to the system as
well. Furthermore, the system includes a sterilisation box, surgical
tray with milling machines made from
ATZ high-performance ceramics, and
turning tools.

COHO Biomedical Technology Co., Ltd.
No. 21 Dafeng Street, Luzhu District
Taoyuan City 33860, Taiwan
www.zibone.com

WITAR Consulting GmbH
Rodenkirchener Straße 148
50997 Cologne, Germany
www.witar.de

CAMLOG Biotechnologies AG
Margarethenstr. 38
4053 Basel
Switzerland
www.camlog.com

[38] =>

TAV Dental

State-of-the-art zirconia dental products
TAV Dental offers both one-piece and two-piece screw-retained
zirconia implants. The passion behind developing zirconia implants is to meet nowadays patient’s needs, which are more
health conscious and have higher aesthetic demands than ever
before. As Oded Ben Shabat, TAV Dental CEO, stated: “If today
you can have zirconia implants at a competitive price with the
same osseointegration, the same stability together with all clear
clinical advantages such as soft tissue integration and low plaque
adhesion, why should a doctor still buy titanium implants.” TAV
Dental will soon launch a new generation of zirconia implants

designed by a highly professional team, manufactured by highend CIM technology and thus resulting in state-of-the-art products, that will be supported by CAD/CAM restoration. “We are
very excited about the release of this new generation of implants
and we are expecting to receive the regulatory approvals soon,”
stated Oded Ben Shabat.
TAV Dental
Shlomi, Israel
www.tavdental.com

Dentalpoint

Bolt-in-tube—the simple and strong ceramic connection
ZERAMEX® XT abutments are screw retained. The key component of the
connection is the VICARBO® screw which acts as a bolt by firmly
fixing the abutment to the implant. It is a fitting screw and safely
absorbs occlusal forces. Thanks to its soft surface, the screw precisely conforms to the thread profile of the ceramic implant upon
tightening.
The abutments are available in straight and angular versions. All
abutments are fitted with a “four merlon”-platform which offers
four positioning options. The VICARBCO® screw seals the implant
hole, and thus prevents the exchange of potentially bacteriologically
contaminated liquids between implant and oral cavity caused by
micromovement. The ZERAMEX® XT implant offers high prosthetic
flexibility as it is placed supracrestally with a variable placement
depth ranging from 0.6 to 1.6 mm.
Dentalpoint AG
Bodenäckerstr. 5
8957 Spreitenbach
Switzerland
www.zeramex.com

implants 1 2018

[39] =>

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[40] =>

| interview

Clear trend towards
metal-free reconstructions
Dr Stefan Röhling is a fellow and speaker of the International Team for Implantology (ITI) specialising on zirconia implant research. Georg Isbaner, editorial manager of
ceramic implants interviewed Dr Röhling (Fig. 1) on his
experience with ceramic implants, scientific research insights, market developments and perceived treatment
chances and challenges with zirconia implants in comparison to titanium implants.
Ceramic dental implants have already been known
since their introduction in the late 1960s. However,
titanium and titanium alloys are still the material of
choice for most dental professionals. What do you
assume to be the reasons?
Titanium or titanium alloy implants are a reliable, scientifically well-investigated and popular treatment option

Fig. 1
Fig. 1: Dr Röhling at the IAOCI World Congress 2017 in Miami, USA.

implants 1 2018

today, especially as the development from machined to
micro-roughened titanium implant surfaces has constantly improved their clinical performance. The first ceramic implants were made of alumina and were clinically
in use until the early 1990s. Based on poor biomechanical properties alumina could never be considered a
reliable alternative to titanium. The first generation of
zirconia implants was introduced at the beginning of
the 2000s. Since then, manufacturing processes have
constantly been improved to produce high-strength
micro-rough zirconia implants with reliable biomechanical properties.
In summary, since the 1960s different materials were
used for the fabrication of ceramic implants and various
generations of zirconia implants have been rolled out

[41] =>

interview

since the beginning of the 2000s. Many dental professionals are not aware of this fact and attribute the poor
clinical performance of alumina implants in general to
“ceramic implants”. It is important to realise that zirconia
is a completely different material and that zirconia implants of the latest generation show similar clinical outcomes as titanium implants.
When it comes to the scientific evidence, what do
we know and where do we need to know more about
ceramic implants?
Experimental studies have shown that zirconia implants of the newest generation have the ability to withstand oral forces and that artificial aging does not have
any significant effect on the biomechanical long-term
stability. Moreover, zirconia implants when compared
to titanium implants show a similar capacity to integrate in bone as well as in soft tissue. In comparison to
titanium or other metals, significantly reduced bacterial
biofilm formation and reduced peri-implant soft tissue
inflammation has been reported for zirconia. Clinically,
survival rates of more than 95 per cent were reported
for one-piece zirconia implants of the latest generation
for investigation periods of up to five years. However,
meta-analyses investigating clinical outcomes are limited to follow-up periods of only one year. Thus, a longterm status as known from titanium implants is currently not yet available. Moreover, only few clinical data
is obtainable regarding the performance of two-piece
zirconia implants.
Zirconium, zirconium dioxide and zirconia: What are
the differences?
Zirconium is a pure metal characterised by a metallic
bond and metal properties (e.g. free electrons and electrical conductivity). Zirconium dioxide, also called zirconia, is an oxide ceramic consisting of zirconium, oxygen
and other supplements (e.g. yttria). Using ionic bonding,
these different elements are firmly interconnected in a
crystal lattice building a new class of material. Based on
the characteristics of the ionic bond, there are localised
electrons indicating typical ceramic properties like no
electrical conductivity for zirconia.
Zirconium dioxide is one of the toughest dental materials that exist. Can you explain in more detail what
its capabilities are and what it means for the dental
application, especially as implant material?
Compared to other ceramics, zirconia shows superior biomechanical properties like high fracture toughness and bending strength, giving zirconia implants the
ability to withstand oral forces. In this context the “fracture toughening mechanism” of zirconia is very important. This mechanism can be considered as a self-healing process and describes the transition from a fracture
proof tetragonal zirconia phase into a more fragile monoclinic zirconia phase. This tetragonal to monoclinic transi-

Fig. 2a

Fig. 2b

Fig. 2e

Fig. 2c

Fig. 2d
Fig. 2a: Initial clinical situation after non-surgical peri-implantitis pre-
treatment. Fig. 2b: Radiograph showing evident peri-implant bone loss.
Fig. 2c: Clinical situation at implant placement (PURE Ceramic Implant
Monotype, Straumann) four months after implant removal and subsequent
augmentation with autogenous bone. Fig. 2d: Clinical situation four weeks
after cementation of definitive crown. Fig. 2e: Radiographic control at delivery of definitive crown.

implants 1 2018

[42] =>

| interview

Fig. 3a

Fig. 3c

Fig. 3b

Fig. 3d

Fig. 3e

Fig. 3a: Initial clinical situation: Secondary root caries and longitudinal fractures in teeth #11 and #21 (implant location according to WHO). Fig. 3b: Clinical
situation at implant placement eight weeks after tooth extraction. Two-piece zirconia implant (PURE Ceramic Implant, Straumann) with metal transfer piece.
Fig. 3c: Clinical situation five months after implant placement. Delivery of definitive crown. Fig. 3d: Clinical situation at delivery of definitive screw-retained
crown. Fig. 3e: Radiographic control at delivery of definitive crown.

tion is associated with a volume expansion which inhibits
the propagation of mechanically induced micro-cracks in
the material structure. Interestingly, uncontrolled implant
surface treatment or grinding procedures might induce
premature phase transformation, probably reducing the
fracture toughening mechanism.
What medical indications do you recognise as the
most suitable for ceramic implants?
In my opinion, there are no specific indications or
contraindications for ceramic implants. Especially in
the anterior region, ceramic implants might provide
advantages over metal implants regarding pink and
white aesthetics. Moreover, patients who do not want

“One-piece implants
are the most natural and
biological way to replace
missing teeth.”
to be treated with metal implants, periodontally compromised patients and patients who have made bad
experiences with titanium implants (e.g. implant loss
caused by peri-implantitis) are highly relevant indication
groups (Figs. 2a–e).

implants 1 2018

Regarding the surgical protocol and prosthetics how
do ceramic implants differ from titanium implants?
In general, the surgical steps for placing zirconia implants do not differ from the protocols for titanium implants. While two-piece ceramic implants can be surgically handled similar to two-piece titanium implants,
several special features should be considered when
using one-piece implants.
Firstly, implant placement must be performed prosthetically driven to guarantee a correct implant axis.
Further, only transgingival healing protocols might be
applied and especially when implant placement was
combined with bone augmentation procedures, overloading during the early healing phase has to be avoided,
e.g. by protective stents or specifically adapted temporary prostheses. On the restorative side, there are less
flexibilities for one- and two-piece ceramic compared to
titanium implants.
In this respect, how important is the digital workflow
when placing ceramic implants?
Especially when using one-piece ceramic implants, an
adequate pre-surgical planning is evident since there are
less possibilities on the restorative side to correct the
implant axis and angulation compared to two-piece implant designs. Consequently, the digital workflow represents a very important tool for a serious backward
planning in order to avoid incorrect implant positioning
and angulation.

[43] =>

interview

What are the benefits of a one-piece and a two-piece
ceramic implant system?
In my opinion, one-piece implants are the most natural and biological way to replace missing teeth. Since
the abutment is an inherent part of the implant body,
there are no micro-gaps on the abutment level. However, avoiding implant overloading during the early healing phase might be a challenge in larger edentulous
or completely edentulous spaces. On the restorative
side, there are less possibilities to correct a wrong implant axis whereas the prosthetics can only be cement-
retained.
Regarding two-piece ceramic implants, the abutments
and prosthetics can be cement- as well as screw-retained whereas a reliable screw-retained connection is
still considered as a technical challenge for the manufacturers. Since individual abutments can be fabricated,
there is more flexibility on the restorative side for twopiece compared to one-piece ceramic implants.
What is the general patient awareness? Do they
already know and explicitly ask about ceramic
implants?
In dentistry, there is a clear trend towards metal-free
reconstructions. In one of our latest studies we have
found out that four times more patients would favour
ceramic over titanium implants and that more than
50 per cent of the patients would even accept higher
ceramic implant treatment costs. Obviously, without
having detailed knowledge about dental implants, tooth-
coloured ceramic implants are more attractive to patients
than metal-coloured titanium implants. This fact has to be
considered in the clinical daily routine. More and more
patients will ask for ceramic implants and dental professionals must be prepared and informed to be able to give
sound answers (Figs. 3a–e).
Nowadays more and more companies are offering
ceramic implants. How do you decide for a system,
what is important for you?
The ceramic implant market has become quite confusing because of the many different generations of zirconia implants having been rolled out since the beginning of the early 2000s. The most critical factor is that
not every zirconia implant system that is currently commercially available has been scientifically investigated.
When deciding for an implant system, it must be mandatory that the offered zirconia implant and respectively
the implant surface have been scientifically investigated in preclinical and clinical studies. These experimental data must not be exclusively based on internal
test series from the manufacturers but should mainly
be collected in independent scientific investigations.
Moreover, implant companies must apply strict quality
controls with regard to the manufacturing processes of
zirconia implants.

How important is the surface of the ceramic implant regarding the overall success when inserting
ceramic implants?
The implant surface is one of the most critical factors
for the achievement of a successful and long-lasting
osseous integration. Owing to optimised manufacturing processes fracture-proof zirconia implants with a
similar surface topography as micro-rough titanium implants can be produced. The development of micro-
rough ceramic implant surfaces, such as the ZLA®
surface (Straumann), must be considered as a main
reason why zirconia implants of the latest generation
have become a reliable treatment alternative showing similar survival rates compared to established
titanium implants.

“Without having detailed
knowledge about dental
implants, tooth-coloured
ceramic implants are more
attractive to patients
than metal-coloured
titanium implants.”
It has been suggested that with ceramic implants,
surgeons can now treat patients that formerly refused to have an implant therapy with titanium implants. Do you agree?
Zirconia implants of the latest generation are a reliable
and reasonable extension of the available treatment range
of dental professionals. Thus, patients that formerly refused implant therapy with metallic titanium implants can
now predictably be treated with ceramic implants.
Dr Röhling, thank you for taking the time to answer
our questions.

contact
Dr Stefan Röhling
ITI Fellow, Senior Oral Surgeon
Assoc. Professor, University of Basel
Röntgenstraße 10
79539 Lörrach, Germany
stefan.roehling@usb.ch

Author details

implants 1 2018

[44] =>

| interview

A shift to “well-care”
Dr Sammy Noumbissi has been practicing implantology
for many years, specialising mainly on the use of ceramic
implants. In 2011, Dr Noumbissi founded the International
Academy of Ceramic Implantology (IAOCI), an organisation dedicated exclusively to ceramic and metal-free alternatives to metal implants. In an interview with Georg
Isbaner, editorial manager of ceramic implants, the IAOCI
founder and president spoke about how he entered
ceramic implant dentistry and how he approaches titanium versus ceramic and future challenges.
Dr Noumbissi, you are one of the leading dentists
in the ﬁeld of ceramic implantology having successfully organised the 7th IAOCI World Congress held in
San Diego, USA, at the beginning of February. What
were the most talked about aspects regarding zirconium dioxide implant systems?
The 2018 congress was very successful and we
reached our highest attendance ever: five continents and
attendees from eighteen different countries were present. This year, three major aspects of ceramic implantology dominated the discussion. Firstly, a recurring theme
among most speakers was the optimisation of patients’
systemic health prior to implant surgery. Implant surgery
requires optimal bone healing for initial implant integration
and long-term success. The important role of Vitamin D,
cholesterol levels, Vitamin C and Vitamin K in bone health
and bone healing among others was widely discussed.
As a second aspect a few of our speakers introduced
more advanced and complex cases with ceramic implants which clearly indicates that the limitations of
ceramic implant applications are gradually disappearing. Thirdly, the correlation between
peri-implantitis, certain systemic health problems and titanium disintegration as a result of
corrosion was presented and supported with
recently published research by Prof. Diane
Daubert of the University of Washington and
Dr Johan Lechner of Munich, Germany.
We came out of this meeting with
the overall understanding that
ceramic implants are a viable alternative for aesthetic,
functional and biological
purposes. However, despite

Fig. 1 Founder of the International
Academy of Ceramic Implantology
(IAOCI) Dr Sammy Noumbissi.

the fact that there is mid-term clinical data available on
various ceramic implant systems, there is still a need for
structured and organised scientific research with ceramic implants.
As it was your seventh IAOCI congress can you
please describe how the discussion around ceramic
implants has changed in comparison to the beginning of your IAOCI activities?
There has been a steady evolution in the perception of
ceramic implants and the discussions around them. In the
early days their ability to integrate, the success rates and
if they were really metal-free were questioned. Another
source of discussion was their macroscopic design which
was one-pieced and limited their range of application.
Many of these concerns have been laid to rest today as
we now have implants on the global market that are not
only two-pieced but also contain metal-free abutment
screws. Today there has been an added focus on the
recipient of the implants and the correlation between
their success and systemic health.
Are there any therapeutic indications for which you
recommend the use of ceramic implants only?
Ceramic implants are a wonderful addition to the options implantologists and patients have in replacing
lost or missing teeth. Like any other medical or dental
modality, ceramic implants are not a panacea and certainly cannot be used exclusively. In terms of indications,
we have seen the use of implants as a preferred method
of tooth replacement grow exponentially. This has led to
exposing a very broad range of individuals to dental implants, however, in return the biological response to these conventional implants has resulted in reevaluating the “biocompatible” label
given to titanium and titanium alloy implants.
We now know from scientific literature that titanium when compared to zirconia ceramic did
not fare as well in terms of aesthetics, plaque retention, epithelial attachment and soft tissue
stability. We also know that ceramic
implants with their unique surface
treatments osseointegrate as well
as titanium coated implants. I believe that ceramic implants when
requested or offered should be
used with consideration given to
the biological factors such as
immunology and, of course,
the dental aspects also. Pa-

Photo: © IAOCI

implants 1 2018

[45] =>

interview

Fig. 2
Fig. 2: Attendees at the 7th IAOCI World Congress in San Diego, USA, on 15–17 February 2018.

tients and dentists who want superior aesthetic results as
well as patients who have a history of allergies and sensitivity to metals are prime candidates for ceramic implants.
In your opinion, what are the ideal properties and
functions of a modern ceramic implant system?
A modern ceramic implant—whether it’s one-pieced
or two-pieced—should be able to function as successfully as any conventional implant. Today, most ceramic
implants do match the flexural strength of metal alloys
although there are some ceramic composites headed to
the market that will address such concerns in a significant
manner. Another important thing is that implants, especially from a prosthetic aspect, need to be versatile, meaning they have to be easily serviceable. I see manufacturers
coming out with screw-retained two-piece ceramic implants now and even metal-free screws, which is exciting.
When do you use a one-piece ceramic implant, and
what are the indications for a two-pieced system?
When I fully entered ceramic implantology, the only
option available in North America where I practice were
one-piece ceramic implants. We managed to treat about
90 per cent of cases that came to our clinic. The greatest challenge was the precise and accurate placement of
the implant as there are very few systems that allow you
to prep their abutment if you are off by a couple degrees.
However, I was able to treat a wide range of cases from
single implants to full-mouth reconstructions.

Drawing from your experience, do you think patients
who oppose titanium implants decide now in favour
of ceramic implant solutions?
Yes, absolutely. In my experience when I discuss treatment with patients and I present the option of a metal-
free implant, I get approximately 93 per cent who would
prefer a metal-free solution and 80 per cent of these
are willing to spend extra to replace their teeth with ceramic implants instead of titanium. The reason for that in
my opinion is that people have become more and more
health conscious and concerned with the type of treatment they are willing to accept. Just look at the proliferation of organic/biologic supermarkets and the rise of
alternative medicine, biological dentistry and integrative
medicine. There is a shift from old fashioned health-/
dental care to what I like to call “well-care”.
What are the future challenges or tasks of ceramic
implant technologies?
Ceramic implants still need to improve in terms of flexural strength, their structural and biological properties
however are far superior to metals. Ceramic implants are
not vulnerable to corrosion, do not release ions in the
host and should be regarded as the most biocompatible dental implant material available today. Continued
research and development are the key, but also close
collaboration with clinicians who see far more and unfortunately report less than researchers.
Dr Noumbissi, thank you very much.

In the last four or five years, having two-piece ceramic implants with cementable or screw-retained abutments has brought options to a whole new level as there
are more options and more flexibility. As I see it I would
recommend using one-piece ceramic implants for single tooth or multiple separate single teeth replacement
mainly in the molar and premolar area. When it comes to
anterior teeth or full arches, although in some cases onepiece implants will work, I prefer a two-piece solution. For
servicing and maintenance, I recommend two-pieced,
screw-retained, and in keeping with the metal-free philosophy using a system that offers a metal-free screw.

contact
Dr Sammy Noumbissi
DDS, MS, PA
Practice limited to Metal-Free
Dental Implantology
801 Wayne Avenue, Suite #G200
Silver Spring, MD 20910, USA
drsammy@milesofsmilesdental.net

Author details

implants 1 2018

[46] =>

| events

“The future of implantology—
ceramics and biology” in Hamburg
On 22 and 23 June 2018 the International Society of
Metal Free Implantology (ISMI) is hosting its 4th Annual
Meeting in the Hanseatic City of Hamburg, Germany.
Participants can anticipate seminars, live surgeries and
an interesting presentation programme.

The 4th Annual Meeting of the International Society of
Metal Free Implantology (ISMI), taking place on the second last weekend of June 2018, will be focused on the
topic: “The future of implantology—ceramics and biology”. International speakers and participants will be discussing practical experience and current trends in the
use of ceramic implants during both congress days at
the EMPIRE RIVERSIDE HOTEL Hamburg.
Also with its 4th Annual Meeting, ISMI, founded in Constance, Germany, in January 2014, is once again intending to set examples in the especially innovative field of
implantology. After a successful inaugural event in 2015
and the international annual congresses 2016 in Berlin
and 2017 in Constance ISMI is now inviting to Hamburg
on 22 and 23 June 2018. The team of speakers at the
ISMI congress will once again include national and
international experts. On Friday, the two-day event will

implants 1 2018

be starting with pre-congress symposia and live surgery
broadcasts via Internet. The ISMI White Night will be the
highlight of the first congress day, offering participants
the opportunity to enjoy culinary specialties in a relaxed
and stylish atmosphere. Saturday will be focused on scientific presentations and again include topics of all fields
of metal-free implantology.
The International Society of Metal Free Implantology
(ISMI) was founded in order to promote metal-free implantology as an innovative and especially visionary path
of implantology. ISMI is therefore supporting its members
with regular further education offers as well as regular expert and market information. ISMI is further focusing on
establishing metal-free treatment concepts of implantology through its public relations efforts in specialist groups
and patient communication. ISMI members will receive a
20 per cent discount on the congress fee.

contact
OEMUS MEDIA AG
Holbeinstraße 29
04229 Leipzig, Germany
Tel.: +49 341 48474-308
event@oemus-media.de
www.oemus.com
www.ismi-meeting.com

[47] =>

T

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16

Die Zukunft der Implantologie –
Keramik und Biologie

4

TH

ANNUAL MEETING OF

BOOK ONLINE /
CONGRESS PROGRAM

4TH Annual Meeting of

22 – 23 June 2018
Hamburg, Germany — EMPIRE RIVERSIDE HOTEL

22./23. Juni 2018 | Hamburg
EMPIRE RIVERSIDE HOTEL

Theme
The future of implantology—Ceramics and Biology

www.ismi-meeting.com

Premium Partner

Premiumpartner

Scientific Director
Dr Karl Ulrich Volz/Kreuzlingen (CH)

PRE-CONGRESS

FRIDAY, 22 June 2018
SYMPOSIUM 

09:30 –12:00

PRE-CONGRESS SESSION

Ceramic, in any case—Why different implant designs are the key
to a successful surgery
Dr Dominik Nischwitz/Tübingen (GER)

Moderation Dr Dominik Nischwitz/Tübingen (GER)

LIVE SURGERY (Live streaming)

Lecture partly in English
(Simultaneous translation)

Bone growing implants—intelligent use of biological laws
As part of the regeneration of dissolved bone, bone regeneration follows irrevocably biological laws. The creation of cavities by so-called spacemakers in
combination with the forming of a blood clot is a long-known procedure for
guided bone regeneration (GBR). This live surgery, combined with a webinar,
introduces an autologous therapy concept for guided regeneration of lamellar
bone tissue which is based on the longstanding tent-pole-sunshade principle
and requires no bone replacement material.
Dr Karl Ulrich Volz/Kreuzlingen (CH)
12:00 –13:00

Break/Visit of the Dental Exhibition

Case presentations
15:30 – 15:55

Dr Manuel Bras da Silva/Dortmund (GER)
Dr Peter Fairbairn/London (UK)
	
A new bioresorbable bone regeneration material for the
augmentation in immediate and delayed loading with
ceramic implants
15:55 – 16:20

Christoph Arlom/Berlin (GER)
14 years of experience with ceramic implants—
possibilities and restrictions—A practice concept

16:20 – 16:45
Dr Robert Bauder, M.Sc., M.Sc./Kitzbühel (AT)
	
Ceramic implants as a successful immunological door
opener for patients with titanium intolerance
16:45 – 17:10

Dr Sammy Noumbissi/Silver Spring (US)

Lecture
in English
	
Treatment planning and Case-Specific Implant System
(Simultaneous translation)

SYMPOSIUM 

Introducing CERALOG implant systems—components and indications
Case presentation with regard to the live surgery
Dr Sandra Wagner/Dortmund (GER)
LIVE SURGERY (Live streaming)
Template-supported anatomically inserted soft tissue shaping
Backward planning is indispensable for the successful reconstruction with implants. Apart from the three-dimensional imaging of the jawbone and its adjacent
anatomic structures, virtual implant planning is increasingly used. Based on the
available data, individual CAD/CAM gingiva formers made of zirconium dioxide
are being manufactured in advance to shape the soft tissue in the aesthetic area.
In this live surgery, the two-piece CERALOG implants are being precisely positioned in the aesthetic area by using a drilling template. In addition, individual
healing abutments are being inserted. This treatment option, combined with an
interdisciplinary exchange, leads to a predictable outcome.
Dr Rouven Wagner/Dortmund (GER)
Discussion and questions
Dr Sandra Wagner, Dr Rouven Wagner/Dortmund (GER)
15:00 – 15:30

selection with Ceramic Implants

13:00 – 15:00

Break/Visit of the Dental Exhibition

17:10 – 17:35

Dr Stuart Molloy/Paris (FR)

Lecture
in English
	
How to enhance your office with a full zirconium implant
(Simultaneous translation)

and prosthetic rehabilitation by thinking outside the box

17:35 – 18:00
Dr Armin Nedjat/Flonheim (GER)
	
Why the (R)EvoBio pZircono manages to achieve a change
of paradigm in the MIMI procedure
18:00 – 18:15

Panel discussion
under the direction of Dr Dominik Nischwitz/Tübingen (GER)

Simultaneous translation German/English, English/German
from 19:30

EVENING EVENT | ISMI WHITE NIGHT

MAIN CONGRESS

SATURDAY, 23 June 2018

Scientific leadership/moderation Dr Karl Ulrich Volz/Kreuzlingen (CH)
09:00 – 09:10

Dr Karl Ulrich Volz/Kreuzlingen (CH)
Greeting and opening

[48] =>

ORGANISATIONAL MATTERS
Biological dentistry and ceramic implants
09:10 – 09:40
Dr Dominik Nischwitz/Tübingen (GER)
	
Vitamin D3 and other important micronutritients as a
guarantee for success in osseointegration with ceramic
implants
Prof. Dr Jose Mendonca-Caridad/Santiago
Lecture in English
di Compostela (ES)
(Simultaneous translation)
	
The maxilla and mandible as a major source of toxicity:
surgical and systemic approaches with zirconia implants
09:40 – 10:10

10:10 – 10:40

Dr Carolin Stolzer/Hamburg (GER)
Immunological reaction to titanium implants/
ceramic implants

10:40 – 11:00

Discussion

11:00 – 11:30

Break/Visit of the Dental Exhibition

Science
11:30 – 12:00
Univ.-Prof. Dr Dr Ralf Smeets/Hamburg (GER)
	
Bioactivation of ceramic implants through UV light
and nonthermal plasma—an in vitro and
in vivo study—a new path in implantology?
12:00 – 12:30
Lecture in English
(Simultaneous translation)

Elisa Choukroun/Nice (FR)
Prevention of oxidative stress in surgery

12:30 – 12:45

Discussion

12:45 – 13:30

Break/Visit of the Dental Exhibition

Hard and soft tissue on ceramic implants
13:30 – 14:00
Dr Frederic Hermann, M.Sc./Zug (CH)
Ceramic implants at the focus of soft tissue biology
14:00 – 14:45

Dr Alain Simonpieri/Beausoleil (FR)
Modern approach of full arch immediate loading

14:45 – 15:30

Sabine Hutfilz/Chemnitz (GER)
Sinus lifts with ceramic implants—
according to biological legitimacy

15:30 – 16:00

Break/Visit of the Dental Exhibition

16:00 – 16:45

Dr Karl Ulrich Volz/Kreuzlingen (CH)
Bone Growing Implants

16:45 – 17:15

Dr Alexander Neubauer/Tittling (GER)
The biological treatment concept and ceramic implants—
practical implementation of a new vision

Lecture in English
(Simultaneous translation)

Congress Fees
Friday, 22 June 2018 I Pre-Congress
€ 195 plus VAT
(Participation Pre-Congress Symposia & Session)

Saturday, 23 June 2018 I Main Congress
Dentists

€ 260 plus VAT

Friday, 22 June & Saturday, 23 June 2018
Dentists
Assistants (with verification)
Conference charge* (per days)

€ 420 plus VAT
€ 135 plus VAT
€ 59 plus VAT

ISMI members receive 20 % discount on the congress fee on saturday!

Team programme I Hygiene seminar
Dentists
Helper
Team Price (ZA + ZAH)
Conference charge* (both days, per person)

€ 275 plus VAT
€ 224 plus VAT
€ 448 plus VAT
€ 118 plus VAT

*  The conference charge is to be paid by each participant and includes coffee breaks, conference drinks and lunch.

Evening event I ISMI WHITE NIGHT
In the Au Quai restaurant with conservatory and private terrace!
Friday, 22 June 2018, from 19:30
Price per person

€ 120 plus VAT

The price includes food and drinks.

Venue
EMPIRE RIVERSIDE HOTEL
Bernhard-Nocht-Straße 97
20359 Hamburg | Germany
www.empire-riverside.de
Room booking in various categories
Tel.: +49 211 49767-20 | Fax: +49 211 49767-29
wolters@primecon.eu | www.primecon.eu
Organiser
ISMI – International Society of Metal Free Implantology
Lohnerhofstraße 2 | 78467 Constance | Germany
Tel.: +49 800 4764-000 | Fax: +49 800 4764-100
office@ismi.me | www.ismi.me
Organisation/Registration
OEMUS MEDIA AG
Holbeinstraße 29 | 04229 Leipzig | Germany
Tel.: +49 341 48474-308 | Fax: +49 341 48474-290
event@oemus-media.de | www.oemus.com

oemus media ag
4th Annual Meeting of

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(Please fill out/tick as appropriate):
			
		
 Friday
 Saturday
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CI 1/18

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[49] =>

news

Biofilm research could advance

Development of dental materials
Biofilms are generally regarded as a problem to be eliminated due
to the threats they pose to humans and materials. However, new
research suggests that communities of algae, fungi or bacteria possess interesting properties from both a scientific and technical perspective. These properties could result in the improved creation of
structural templates, including materials for teeth.
All natural materials (whether wood, bone or teeth) have been optimised by evolution over millions of years according to the principle of
adapted stability with the lowest possible weight. Thus, nature provides the blueprints for many technical developments. The structural
complexity of the original material in nature can however often not
be reproduced, as the processes on the nanometer scale are hard to
evaluate and mimic.
Prof. Cordt Zollfrank and his team of researchers at the Chair of
Biogenic Polymers at the Technical University of Munich, Campus
Straubing for Biotechnology and Sustainability, have now presented

Source: Technical University of Munich

Cancer-inducing effects of

Cavitating jets improve

Metal used intraorally

Removal of oral biofilm

US researchers investigated the
possible risk factors for carcinoma in the oral cavity—the
cancer causing effects of alcohol
and smoking have multiply been
researched already and such
consumptions have indisputably
been found to be an important
trigger for oral cancer. Nevertheless, there are numerous cases
in which they are not consumed.
The researchers of the University
of Chicago have thus decided to
investigate, proposing that met© Alex Mit/Shutterstock.com
als used in the mouth as tooth
replacement or during orthodontic
treatments also have cancer-inducing effects.
54 cancer patients with the fitting precondition participated in the
study, of whom 80 per cent had never smoked and 20 per cent only
sporadically. No participant had more than two alcoholic drinks
per week, 80 per cent even consuming a maximum of only one.
All patients had however in one way or another been exposed to
metallic materials in the mouth.
It was found, that 40 patients had received tooth replacements
containing metal prior to being diagnosed with cancer. The study
while determining first indications could, however, not yet prove
a causal connection between cancer of the oral cavity and dental
materials containing metal.

In their recent study, “Removal of oral biofilm on an implant fixture by
a cavitating jet”, Prof. Hitoshi Soyama from Tohoku University and his
team from Showa University searching for better ways for dentists
to remove plaque from implant fixtures compared the effects of a
cavitating jet to the standardly used water jet. With the cavitating
jet, high-speed fluid is injected by a nozzle through water to create
minuscule vapour bubbles, which in collapsing produce shock waves
with sufficient force to remove surface contaminants.
To test the two jets, four volunteers performed no oral care for three
days to allow biofilm to develop. Their fixtures were then cleaned
using both methods, with the Japanese researchers measuring the
amount of plaque remaining at several time intervals.
They found the cavitating jet to be more
effective in removing biofilm from the
rough surface of an implant fixture.
In addition to the water jet’s shear
effect, the cavitating jet produces considerable force when
the bubbles collapse. Both
processes in synergy thus
make the cavitating jet superior when cleaning plaque
off the irregular surface of
dental implants.

a series of biological procedures that use light, heat, speciallyprepared substrates and other stimuli to direct the movement of
microorganisms along specific paths.
The findings make it possible to create tailor-made templates for new
materials with natural structures from the microbes themselves, or
their secretions. The scientists are already applying some of these
methods aiming at profiting of the special properties of red algae to
create long, fine polymer threads that serve as customised templates
for the manufacturing of functional ceramics.

k.com

Source: ZWP online

implants 1 2018

[50] =>

| about the publisher

Congresses, courses
and symposia
Imprint

EuroPerio9
20–23 June 2018
Venue: Amsterdam, Netherlands
www.efp.org/europerio9

Publisher
Torsten R. Oemus
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Customer Service
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Members of the Board
Jürgen Isbaner
isbaner@oemus-media.de
Lutz V. Hiller
hiller@oemus-media.de

4th Annual Meeting of ISMI
22–23 June 2018
Venue: Hamburg, Germany
www.ismi.me

Editorial Manager
Georg Isbaner
g.isbaner@oemus-media.de
Editorial Office
Katharina Rühling
k.ruehling@oemus-media.de

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Executive Producer
Gernot Meyer
meyer@oemus-media.de

Visions in Implantology—
1st Future Congress for
Dental Implantology
28–29 September 2018
Venue: Düsseldorf, Germany
www.dgzi-jahreskongress.de

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EAO Congress 2018
11–13 October 2018
Venue: Vienna, Austria
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Giornate Veronesi
03–04 May 2019
Venue: Verona, Italy
www.giornate-veronesi.info

implants 1 2018

Copyright Regulations
ceramic implants international magazine of ceramic implant technology is issued twice
per year and is a special edition of implants international magazine of oral implantology — the
first issue was published in October 2017. The magazine and all articles and illustrations therein are
protected by copyright. Any utilisation without the prior consent of editor and publisher is inadmissible and
liable to prosecution. This applies in particular to duplicate copies, translations, microfilms, and storage
and processing in electronic systems.
Reproductions, including extracts, may only be made with the permission of the publisher. Given no
statement to the contrary, any submissions to the editorial department are understood to be in agreement
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items shall not be borne by the editorial department. Likewise, no responsibility shall be assumed for information published about associations, companies and commercial markets. All cases of consequential
liability arising from inaccurate or faulty representation are excluded. General terms and conditions apply,
legal venue is Leipzig, Germany.

[51] =>

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CI 1/18

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[52] =>

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) [page_count] => 52 [pdf_ping_data] => Array ( [page_count] => 52 [format] => PDF [width] => 595 [height] => 842 [colorspace] => COLORSPACE_UNDEFINED ) [linked_companies] => Array ( [ids] => Array ( ) ) [cover_url] => [cover_three] =>

[cover] => ceramic implants international No. 1, 2018

[toc] => Array ( [0] => Array ( [title] => Cover [page] => 01 ) [1] => Array ( [title] => Editorial: Ceramic implants—current state of discussion [page] => 03 ) [2] => Array ( [title] => Content [page] => 04 ) [3] => Array ( [title] => From peri-implantitis to implant disease - Will terminology and definitions change? [page] => 06 ) [4] => Array ( [title] => Analogous therapy for guided regeneration of lamellar bone tissue [page] => 10 ) [5] => Array ( [title] => Individual CAD/CAM abutments on ceramic implants [page] => 16 ) [6] => Array ( [title] => Aesthetic restoration in the incisal region [page] => 24 ) [7] => Array ( [title] => Immediate placement in the maxillary aesthetic zone [page] => 26 ) [8] => Array ( [title] => Change is mandatory for extraordinary results [page] => 30 ) [9] => Array ( [title] => Ceramic implants in anterior dental restoration [page] => 32 ) [10] => Array ( [title] => Manufacturer news [page] => 36 ) [11] => Array ( [title] => Clear trend towards metal-free reconstructions [page] => 40 ) [12] => Array ( [title] => A shift to “well-care” [page] => 44 ) [13] => Array ( [title] => “The future of implantology — ceramics and biology” in Hamburg [page] => 46 ) [14] => Array ( [title] => News [page] => 49 ) [15] => Array ( [title] => Imprint [page] => 50 ) ) [toc_html] =>

Table of contents

[toc_titles] =>

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