Cover / Editorial / Content / The added value of the pterygoid implant in the management of edentulous patients / Restoring anterior aesthetics with two-piece zirconia implants / Resective peri-implantitis therapy with implantoplasty in Crohn’s disease / Interdisciplinary approach for a missing maxillary incisor / Immediate or delayed loading in the fully edentulous maxilla / Industry / Manufacturer news / Events / Imprint
Cover
1 - 1 viewEditorial
3 - 3 viewContent
4 - 4 viewThe added value of the pterygoid implant in the management of edentulous patients
6 - 10 viewRestoring anterior aesthetics with two-piece zirconia implants
12 - 14 viewResective peri-implantitis therapy with implantoplasty in Crohn’s disease
16 - 21 viewInterdisciplinary approach for a missing maxillary incisor
22 - 27 viewImmediate or delayed loading in the fully edentulous maxilla
28 - 31 viewIndustry
32 - 35 viewManufacturer news
36 - 37 viewEvents
38 - 40 viewImprint
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[1] =>
issn 1868-3207 • Vol. 24 • Issue 2/2023
implants
international magazine of oral implantology
case report
Restoring anterior aesthetics
with two-piece zirconia implants
Resective peri-implantitis
therapy with implantoplasty
in Crohn’s disease
industry
Economic success in the
implantology market in Germany
2/23
[2] =>
© MIS Implants Technologies Ltd. All rights reserved.
REVOLUTION
IN A BOX!
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Every MIS C1 implant is now supplied with XD Single-Use drills. These single-use drills are designed
for optimal implant-drill compatibility and high initial stability, while ensuring safe and simplified
procedures. Learn more about MIS at: www.mis-implants.com
[3] =>
editorial
|
Dr Rolf Vollmer
First Vice President
and Treasurer of DGZI
Implantology in
the team
Dear colleagues and friends,
At the very beginning of oral implantology at the end of
the sixties and beginning of the seventies of the past century, it was already clear that implantology is a team effort,
and this is just as relevant today.
The challenges of the early days are certainly very different from those of the present time, and the associated
tasks for the team are just as varied. Whereas in the past
the focus was on insecurities regarding a successful implantation, today completely different requirements such
as technical conditions, patient expectations or the digital
workflow are coming to the fore.
Therefore, I am pleased to invite the international implantological community on behalf of the DGZI to this year’s
52nd Annual Congress in Hamburg on 6 and 7 October.
The event will take place this time under the motto “Implantology in the team”, the focus will be on the dentist, his
practice team, and the dental technician. The congress
offers a unique international platform for the exchange of
expertise, experience, and best practices. Traditionally, at
the beginning of the congress we will look into the future
and offer our young DGZI friends a podium. Regarding
the scientific programme, we have also succeeded not
only in attracting renowned speakers, but also in setting
up a programme that covers the entire range of facets of
dental implantology. Naturally, the popular “Table Clinics”
will not be missing either, a format with a unique possibility of directly imparting expert information in small groups
and direct implementation of what has been learnt.
Especially in recent years, the annual congress of the
DGZI has been established as an important, international
scientific and practice-relevant event.
In addition to the scientific programme, the host city of
Hamburg offers a rich culture, a picturesque landscape
and excellent gastronomy. Take the opportunity to network and explore this impressive city!
We are looking forward to meeting you again and to a
vivid collegial interchange.
Yours,
Dr Rolf Vollmer
First Vice President and Treasurer of DGZI
2 2023
03
[4] =>
| content
editorial
Implantology in the team
03
Dr Rolf Vollmer
case report
page 6
The added value of the pterygoid implant in the management
of edentulous patients
06
Dr Henri Diederich
Restoring anterior aesthetics with two-piece zirconia implants
12
Dr Saurabh Gupta
Resective peri-implantitis therapy with implantoplasty in
Crohn’s desease
16
Lucas A. Greilich, Dr Mischa Krebs, PD Dr Maximilian Moergel
Interdisciplinary approach for a missing maxillary incisor
page 22
22
Dr Tran Hung Lam
research
Immediate or delayed loading in the fully edentulous maxilla
28
Drs Yassine Harichane, Rami Chiri & Benjamin Droz Bartholet
industry
Economic success in the implantology market in Germany
32
Andreas Halamoda
“Clean” medical products
page 38
35
news
manufacturer news
36
events
Cheers to new beginnings: celebrating oral tissue regeneration
Cutting edge science and innovation
38
40
about the publisher
imprint
Cover image courtesy of Fotona d.o.o.
www.fotona.com
issn 1868-3207 • Vol. 24 • Issue 2/2023
implants
2/23
international magazine of oral implantology
case report
Restoring anterior aesthetics
with two-piece zirconia implants
Resective peri-implantitis
therapy with implantoplasty
in Crohn’s disease
industry
Economic success in the
implantology market in Germany
04
2 2023
42
[5] =>
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■ natural tissue and color structure8
■ rapid and complication-free healing of soft tissue4, 6, 7, 9
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Before use, physicians should review all risk information, which can be found in the Instructions for Use attached to the packaging
of each NovoMatrix™ Reconstructive Tissue Matrix graft. NovoMatrix™ is a trademark of LifeCell™ Corporation, an AbbVie.
©BioHorizons. All rights reserved. Not all products are available in all countries.
[6] =>
| case report
The added value of the pterygoid
implant in the management of
edentulous patients
Dr Henri Diederich, Luxembourg
Pterygoid implants were first proposed by Linkow in
1975, and the method was first described by French
maxillofacial surgeon J.F. Tulasne in 1992.1,2 Tulasne and
Tessier were the first to describe the technique for implant placement in the pterygoid plate. Pterygoid implants are relatively long and specifically manufactured
with the characteristics of the pterygoid region in mind.3
The pterygoid implant enables rehabilitation in the posterior maxilla in cases of poor and limited bone quantity
as well as the presence of the maxillary sinus when such
cases cannot be treated with standard implants.4–6 Expertise and a thorough understanding of the anatomy of
the posterior maxilla are crucial for successful placement of pterygoid implants. The pterygoid implant placement method has been previously documented in the
literature.7
The following case studies showcase the use of pterygoid implants to restore function in patients with edentulous jaws. The pterygoid implant employed in this case
series is a new generation of pterygoid implant, designed
by the author in collaboration with the Swiss company
TRATE. It is a one-piece tissue-level conical implant with
compressive threads and undergoes a surface treatment with hydroxyapatite and tricalcium phosphate. The
implant neck has a wide thread profile, providing compression in areas of low bone density, such as the maxillary tuberosity. Its pointed, self-tapping apex ensures
strong anchorage when inserted.3,8 The pterygoid implant ranges from 16 to 26 mm in length, ensuring that
the implant apex engages the cortical bone of the medial wall of the pterygoid plate 9 and is 3.5 or 4.5 mm in
diameter.
1
Case presentations
2
Fig. 1: Case 1—panoramic radiograph of the patient at presentation. Fig. 2:
Radiograph of the patient after bridge delivery.
06
2 2023
Case 1
A 45-year-old female patient sought to have missing teeth
on the right side of her upper jaw replaced (Fig. 1). Owing
to the narrow width of the upper jaw ridge, conventional
implant options were not feasible. The patient also had a
history of chronic sinus infection and did not wish to undergo a sinus lift procedure. To rehabilitate her missing
teeth, ROOTT C3516m, C3514m and C3520mp implants
were placed in positions #18, 15 and 14. The procedure
was performed under local anaesthesia after flap elevation, and a 2.5 mm pilot drill was used to prepare all three
osteotomies. The implants were loaded after a threemonth delay, and a screw-retained metal–ceramic bridge
[7] =>
case report
|
3
6
4
5
Fig. 3: Case 2—panoramic radiograph of the patient at presentation. Figs. 4 & 5: Traditional implant options were not feasible owing to the narrow ridge.
ROOTT C3016ms implants were placed in positions. Fig. 6: Radiograph of the patient after bridge delivery.
7
9
8
Fig. 7: Case 3—panoramic radiograph of the patient at presentation. Fig. 8: Placement of pterygoid implant into the maxilla. Fig. 9: Radiograph of the patient
after bridge delivery.
2 2023
07
[8] =>
| case report
was seated 14 days after impression taking with screwed
impression copings (Fig. 2).
Case 2
The next case involved a 64-year-old female patient who
sought to have missing teeth on the right side of her upper jaw replaced (Fig. 3). The patient had extensive maxillary sinus pneumatisation and a narrow alveolar ridge.
Owing to her history of chronic sinus infection, a sinus lift
procedure was not a desired option. Traditional implant
options were not feasible owing to the narrow ridge.
ROOTT C3016ms implants were placed in positions #15
and 14 (Figs. 4 & 5). The patient received an immediate
temporary bridge constructed at the chairside after the
surgery (Fig. 6). Three months after the surgery, impressions were taken with screwed impression copings, and
a screw-retained metal bridge was seated three weeks
later.
Case 3
In a similar case, a 54-year-old female patient sought a
solution for missing teeth on the right side of her upper jaw
(Fig. 7). ROOTT C3514m, C3008ms and C3520mp implants were placed in positions #18, 15 and 14 (Figs. 8 & 9).
Case 4
A 34-year-old female patient presented with missing teeth
in her right upper jaw (Fig. 10). A similar treatment approach was taken to that used in the previous cases, involving the placement of ROOTT C3512m, C3508m and
C3520mp implants in positions #18, 15 and 14 (Fig. 11).
Case 5
A 54-year-old female patient sought to have her complete
denture replaced with a fixed solution, without undergoing extensive surgical procedures such as bone grafting
or sinus lift (Fig. 12). Owing to her narrow alveolar ridge,
it was decided to use standard one-piece tissue-level implants and pterygoid implants for rehabilitation of the upper jaw. The procedure was performed under local anaesthesia after flap elevation. A 2.5 mm pilot drill was
used for preparation of all the osteotomies. ROOTT
C4520mp implants were placed in positions #18 and
28, ROOTT C3016ms implants with short necks were
placed in positions #13, 12, 22 and 23, and a ROOTT
C3522mp implant was placed in position #24 (Fig. 13).
Early loading was carried out with a temporary denture
fabricated at the chairside (Fig. 14). After five days, the key
was tried in. One week later, a trial of the metal frame was
done, and a further week later, an aesthetic trial was conducted. At the fourth appointment, the metal–resin denture was screwed in (Fig. 15). The patient left the clinic
with a fixed solution without having to undergo extensive
surgical procedures.
10
Discussion
11
Fig. 10: Case 4—panoramic radiograph of the patient at presentation.
Fig. 11: Radiograph of the patient at the completion of treatment.
08
2 2023
These case reports demonstrate the use of pterygoid implants for restoration of the maxilla in various cases. With
this approach, atrophic jaws could be rehabilitated without the need for additional surgical procedures such as
sinus lift and bone grafting.1 The use of pterygoid implants
allows for the resolution of many cases that cannot be
managed with standard implants within a short period, effectively solving the patients’ problem of edentulism.3,6,8,10–12 The high success rates of pterygoid implants
in patients with minimal bone levels and minimal complications make them an attractive option for treating such
patients.6,13,14
[9] =>
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[10] =>
| case report
12
13
14
15
Fig. 12: Case 5—panoramic radiograph of the patient at presentation. Fig. 13: Healed situation after pterygoid implant placement in the maxilla. Fig. 14: Radiograph of
the patient at the completion of treatment. Fig. 15: Clinical photograph of the patient at the completion of treatment.
about the author
contact
Dr Henri Diederich
+352 621 144664
hdidi@pt.lu
Literature
10
2 2023
Dr Henri Diederich
Dr Henri Diederich is a highly accomplished dentist with
over 35 years of experience. He received his doctorate
in dentistry from the Free University of Brussels (ULB)
in 1985, after which he established his own successful
dental clinic in Luxembourg. As a Sworn Expert at the
Luxemburgish Court of Justice, Dr Diederich has gained
a reputation as a leading authority in legal dentistry. He
is also the founding member and President of the Implantoral Club Luxembourg and President of the Open Dental
Community. In addition to his extensive involvement in professional organisations,
Dr Diederich has also held the position of Maître de stage at the University of Nancy, France, and is responsible for regular training seminars for the management of
implantation in atrophied bone at Queen Mary University in London. Dr Diederich
is a renowned international lecturer and has published numerous papers on immediate loading in atrophied bone. He is the inventor of the CF@O protocol and
the Hybrid Plates HENGG-1/4, for which he holds patents (Nr 93019 and 93186).
His memberships in various professional organisations, including ICOI, DGOI,
BDIZ EDI, DGZMK, and BAFO, attest to his dedication and expertise in the field
of dentistry.
[11] =>
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[12] =>
| case report
Restoring anterior aesthetics with
two-piece zirconia implants
Dr Saurabh Gupta, India
Zirconia implants are one of the newest and most exciting developments in dental implantology. Multiple
studies have proved that zirconia implants induce little to
no peri-implant tissue inflammation and allow for high levels of epithelial attachment. Additionally, these implants
look more natural; hence, they provide improved aesthetics. Furthermore, they do not have metal components,
which makes them ideal for people with metal sensitivities and patients who would prefer their implants to be
metal-free.1–3
with a thicker gingival biotype, will have less bone over
the implant on the facial aspect of the ridge. The result,
like with a thin gingival biotype, will be a shadow over the
underlying implant that hampers the aesthetic result and
does not blend with the adjacent tissue around the natural teeth.4–7 In the following, a clinical case is described to
demonstrate the use of two-piece ceramic implants in the
anterior aesthetic zone to avoid this aesthetic difficulty.
Aesthetics around natural teeth can be challenging under
normal circumstances. When teeth are to be replaced
with implants, especially in the aesthetic zone, gingival
tissue can complicate the desired results. In a patient
with a thin gingival biotype, the grey of a titanium implant
will show through, leading to a darker gingiva overlying
that area and decreasing the aesthetics of the patient’s
smile. A patient who has had a missing anterior tooth for
a period, resulting in resorption of the facial plate even
A 44-year-old male patient presented to our office to
learn about options for replacement of his failing maxillary
central incisors after undergoing partial root canal therapy. He also complained of greyish gingiva around the
endodontically treated teeth and desired a metal-free
solution (Figs. 1 & 2). Photographs of his teeth when smiling were taken to assess the overall aesthetic risk of the
case. Treatment options were then discussed with the
patient. After reviewing the options, the patient chose to
have the endodontically treated teeth extracted and replaced with two-piece zirconia implants and metal-free
crowns.
Case presentation
Surgical procedure
The guidelines for zirconia implant placement in the anterior zone and the drilling protocol specified by the manufacturer (Zeramex XT, Dentalpoint) were followed. It is
important to note that implant sites must be prepared adequately to prevent excessive implant insertion torque
and that the use of a bone tap is necessary. Both the
vertical and transverse insertion depth of the zirconia implant are important for prosthetic success. The implant
can be placed between 1.6 and 0.6 mm supra-crestally
because the neck section (0.6 mm) is smooth. The insertion depth is determined by the height of the gingiva and
the existing bone around the adjacent teeth.
1
2
12
Fig. 1: Initial situation. Fig. 2: Initial radiograph.
2 2023
[13] =>
case report
3
|
4
Fig. 3: After atraumatic extraction of teeth #11 and 21. Fig. 4: Immediate placement of Zeramex XT implants.
After atraumatic extractions and laser curettage, twopiece zirconia implants (4.2 × 12.0 mm) were placed in
sites #11 and 21 under local anaesthesia, cover screws
were placed and the sites closed to allow for healing
(Figs. 3 & 4). After 72 hours, the PMMA temporary crowns
were inserted (Fig. 5).
Angulated abutments (15°), also made of alumina-toughened zirconia like the implants, were placed on the implants with Zeramex XT VICARBO screws (Figs. 7–9).
This screw, which is made of longitudinal carbon fibre
strands and moulded slightly larger than the internal aspect of the implant, allows absorption of the forces of
mastication and provides a hermetically sealed connection. A digital impression was taken for the fabrication of
the final crowns (Fig. 10). Zirconia crowns were cemented
to the abutment heads with glass ionomer cement to provide natural aesthetics. Instructions were given for maintenance and periodic recall (Figs. 10–12).
After a four-month healing period, the second-stage surgery was performed with a 940 nm diode laser, the cover
screws were removed and healing abutments were
placed for a period of two weeks. Reduced inflammation
of the peri-implant soft tissue was noted, demonstrating
excellent biocompatibility and host response (Fig. 6).
Discussion
Owing to rising complications observed in some clinical
situations involving the use of titanium dental implants
and the growing incidence of peri-implant mucositis and
peri-implantitis affecting both the short- and long-term
Fig. 5: PMMA temporary crowns placed one week after surgery. Fig. 6: Healing after four months. Fig. 7: Example of a Zeramex XT implant, abutment
and VICARBO screw (metal-free solution).
5
6
7
2 2023
13
[14] =>
| case report
8
9
10
11
Fig. 8: Angulated zirconia abutments in position. Fig. 9: Four-month post-op radiograph. Fig. 10: Zirconia crowns in situ, lateral view. Fig. 11: Zirconia crowns
in situ, frontal view.
survival rates of titanium dental implants, the development of alternative materials to address these has been
pursued. Zirconia has been shown to have similar osseointegration success to titanium, offer a soft-tissue response that is superior to that of titanium and have less
of an affinity for plaque collection compared with titanium
surfaces.
Also, the peri-implant soft tissue around titanium and zirconia abutments has been shown to have colour differ-
ences compared with the soft tissue around natural
teeth, and the peri-implant soft tissue around zirconia has
been demonstrated to have a better colour match to the
soft tissue than titanium. This can be extrapolated to the
aesthetics of the colour of the implant itself. Zirconia implants can be used in aesthetic situations, the white
shade of the implant eliminating any potential for darkening of the gingival tissue and providing a more natural final
aesthetic result than is possible with titanium implants.
Long-term studies are necessary to continue to evaluate
the effectiveness and success rates of two-piece zirconia
implants.
Literature
contact
Dr Saurabh Gupta
+91 9916 203455
saurabh@iaoci.com
Fig. 12: Radiograph of implants and final crowns.
14
2 2023
Dr Saurabh Gupta
[15] =>
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[16] =>
| case report
Resective peri-implantitis
therapy with implantoplasty in
Crohn’s disease
Lucas A. Greilich, Dr Mischa Krebs, PD Dr Maximilian Moergel, Germany
In 1977, Per-Ingvar Brånemark defined osseointegration as a functional ankylosis of the bone on the surfaces
of titanium implants.1,2 Since then, dental implants have
evolved and now offer most patients a predictable option
for long-term rehabilitation of their masticatory function.
However, despite high healing rates of 90 to 95 per cent,
certain risk factors predispose to peri-implant inflammation with bone resorption (peri-implantitis).3,4 This article
reviews peri-implantitis and describes resective therapy
with implantoplasty in a patient with Crohn’s disease.
The risks that can lead to implant failure can be categorised as either generalised systemic factors or localised
factors. Table 1 provides an overview of these factors.
Prevalence
Peri-implantitis affects a significant number of patients.5
Derks et al. reported the prevalence of peri-implant mucositis to be 19 to 65 per cent and peri-implantitis to be
1 to 47 per cent. The wide variation in the literature is due
to the high degree of variability in the underlying definition
of peri-implantitis, particularly with regard to the type and
extent of bone resorption.6,7
Aetiology
Some of these factors can be influenced by the patient
(e.g. oral hygiene, smoking); others can be avoided by the
clinician through advance treatment planning (e.g. cement
residue, implant position). Still others, however, cannot be
Peri-implantitis is primarily caused by anaerobic oral
pathogens (e.g. T. forsythia, P. nigrescens, A. actinomycetemcomitans, P. gingivalis, T. denticola).8–12 Titanium-
Generalised systemic risk factors
Localised risk factors
Diabetes mellitus
Incorrect implant position
Rheumatoid arthritis
Locally limited oral hygiene ability
Osteoporosis
Keratinised mucosa < 2 mm
Periodontitis
Cement residue
Radiation exposure
Mechanical overload
Antiresorptive drugs
Frequently replaced abutments
Crohn’s disease
Abutment emergence profile too steep (< 30°)
IL-1 polymorphism
Previous implant loss
Poor oral hygiene
Irregular recall schedule
Nicotine abuse
Table 1: Factors that can lead to peri-implantitis.
16
influenced (e.g. osteoporosis, diabetes mellitus). However,
no valid therapy has been established that would result
in complete healing of the progressive bone loss.
2 2023
[17] =>
case report
1
|
2a
Fig. 1: Panoramic radiograph. Bowl-shaped peri-implant bone resorption at
implant 36, less pronounced horizontal bone resorption at implant 37, splinted
crowns on implants 36 and 37. Fig. 2a: Initial situation (photographed indirectly
with a mirror). Narrow keratinised mucosa at sites 36 and 37. Fig. 2b: Ten
seconds after probing with a WHO probe. Bleeding on probing as a sign of an
inflammatory event in combination with radiographic bone resorption > 2.0 mm;
diagnosis of peri-implantitis.
affine S. aureus also appears to play an important role
in the development of peri-implantitis.13 Histological analysis also shows that leukocytes, B cells, and T cells are
significantly increased.14,15
Definitions
In 2017, at the World Workshop in Chicago, USA Schwarz
et al. defined peri-implantitis as a pathological inflammatory condition in the peri-implant soft tissue that induces
progressive bone resorption.16 Bleeding on probing has
been established as a mandatory finding for the diagnosis of mucositis, while radiographic evidence of bone
loss, in combination with clinical signs of inflammation, is
indicative of peri-implantitis.16–20
Untreated mucositis can progress to peri-implantitis.20–22
The distinction is important because mucositis may be
reversible with consistent plaque removal, whereas periimplantitis cannot be brought to long-term healing. Progressive bone resorption subsequently poses a risk of
implant loss.16
In daily clinical practice, the diagnostic problem is to decide when the extent of bone resorption can still be considered bone remodelling or when peri-implantitis must
be assumed. In the absence of baseline radiographs after
implant placement, Sanz and Chapell recommend diagnosing peri-implantitis at 2.0 mm vertical bone loss. If
baseline radiographs are available after implant placement, a more sensitive value may be used. Krebs et al.
compared different definitions of peri-implantitis. They
recommend a threshold of 1.5 mm of radiographic bone
loss in the presence of postoperative radiographs.7
2b
Treatment
Treatment of peri-implantitis can be divided into conservative and surgical approaches; the latter of which may
be regenerative or resective in nature. Derived from periodontology, the core issue is adequate plaque control.12
Plaque reduction is performed with plastic or carbon curettes to avoid damaging the delicate titanium surfaces
with metal curettes.23,24 Other plaque reduction options
include ultrasound, air-abrasive devices, diode lasers, or
antiseptics (e.g. citric acid or chlorhexidine).25–27 Treatment
may be combined with topical or systemic antibiotics.28
The surgical therapeutic approach to peri-implantitis is
derived from that of open periodontal surgery.29 Regenerative therapy approaches form a narrow range of indications, namely those in which (mainly) three-wall defects—which must be sufficiently steep and deep—can
be filled with bone substitute.30 The therapeutic success
of these regenerative measures is largely determined by
whether complete decontamination of the implant surface has been achieved.
Often, however, generalised bone resorption occurs with
successively exposed implant threads. Here, implantoplasty is an option. In this procedure, the contaminated
2 2023
17
[18] =>
| case report
3
4
Fig. 3: Preoperative situation. Hyperaemic peri-implant mucosa with inflammatory changes at sites 36 and 37. Fig. 4: Mobilisation of a mucoperiosteal flap
after a trapezoidal incision. Granulation tissue infiltrating the pronounced bone defect at site 36. Adequate individualised plaque control is no longer possible
for this patient. The exposed, submerged implant threads provide optimal conditions for pathogens.
implant surface is smoothed by ablation of the exposed
implant threads (red diamonds, yellow diamonds, Arkansas stones), making it more difficult for plaque to accumulate.31
It is important not to treat the implant surface with silicone
polishers (“brownie”, “greenie”), as silicone residues in the
peri-implant soft tissue are not biocompatible and can
lead to foreign body reactions and reinflammation.32 Free
titanium particles do not interfere with cellular activity
(based on research to date), but may cause metallic discoloration of soft tissue, which constitutes an aesthetic
compromise.33–35
Case report
Medical history
A 61-year-old female patient was referred to our day clinic
for maxillofacial surgery. She presented with complaints
related to implants placed in 2009. The patient’s medical
history included Crohn’s disease, which had been diagnosed in adolescence and was currently well controlled.
She had been in remission for eight years and was not
taking any medication at the time.
Clinical findings
After clinical examination and evaluation and a panoramic radiograph, peri-implantitis was diagnosed on
the splinted implants 36 and 37 based on clinical bleeding on probing and radiographic bone loss > 2.0 mm
(Figs. 1 & 2). The width of the keratinised mucosa was
less than 2.0 mm on implant 36 and completely lost on
18
2 2023
implant 37. The surrounding free mucosa showed reactive hyperaemic changes with associated oedematous
swelling (Fig. 3).
“In daily clinical practice,
the diagnostic problem is
to decide when the extent
of bone resorption can still be
considered bone remodelling
or when peri-implantitis must
be assumed.”
Treatment
After detailed consultation and explanation, the patient
was scheduled for resective peri-implantitis therapy
by implantoplasty. Under local anaesthesia (Articaine
1:200,000), a strictly marginal incision was made (to preserve the remaining keratinised mucosa) and a trapezoidal flap was elevated with distal relief incisions at
implant 37 and mesial relief incisions at tooth 35 (Fig. 4).
After mechanical decontamination with a curette, an implantoplasty was performed on the exposed implant
surfaces (Fig. 5). The implant threads were removed until
a smooth implant surface was achieved with less risk of
plaque accumulation and recontamination. During an
implantoplasty, it is important to strictly level only the im-
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[20] =>
| case report
5
6
Fig. 5: After decontamination and implantoplasty of implants 36 and 37. The levelling of the implant threads is intended to prevent early recontamination of
the implant surface by pathogens. Leaving the superstructure in place makes an implantoplasty more difficult. Fig. 6: Wound closure. Monofilament sutures
(Monofast; mectron) are used for tension-free and saliva-tight adaptation of the wound margins.
plant threads, so as not to reduce the implant diameter
(risk of fracture). Finally, the surface was polished with an
Arkansas stone. The wound was closed with a 5/0 monofilament suture material (Monofast; mectron) after thorough irrigation with chlorhexidine (Chlorhexamed forte
alcohol-free 0.2%; GSK) and saline solution (Fig. 6).
The patient received postoperative instructions and analgesic therapy (paracetamol 1 g). Sutures were removed
after seven days. The patient was referred back to the
referring general dentist with the request to re-evaluate
the case and to perform regular dental prophylaxis in six
months at the earliest. Further appointments were scheduled at our day clinic for expansion of the keratinised mucosa with a free mucosal graft after healing. Figure 7 illustrates the situation 20 days postoperatively.
Discussion
This case report demonstrates how risk factors (reduced
height of keratinised mucosa, splinted superstructure,
limited hygiene ability, Crohn’s disease) can influence the
development of peri-implantitis.
Crohn’s disease and ulcerative colitis have become more
prevalent in developed industrialised countries in recent
decades, making this condition increasingly relevant for
dentists. In Germany, 322 new cases of Crohn’s disease
are diagnosed per 100,000 inhabitants per year. Patients
in their third and fourth decades of life are the most likely
to develop the disease, although apparently young and
healthy people can also be affected.36
20
2 2023
Crohn’s disease is an inflammatory bowel disease characterised by transmural ulcers of the bowel wall. Unlike
Crohn’s disease, ulcerative colitis can affect the entire digestive tract (from the mouth to the anus). In the dental
office, therefore, close examination of the oral mucosa
should be performed in these patients in order to detect
any lichenoid/leukoplakic changes, lip and gingival swelling, pseudo-polyps or aphthoid/ulcerative lesions (“cobblestones”) at an early stage.37
The disease progresses in phases, being completely
asymptomatic in remission, while patients suffer from
abdominal cramps, diarrhoea, weight loss, vomiting and
fever during an active phase. The disease is treated with
various pharmacological drugs, prescribed according to
a graduated scheme.
Therefore, when examining the patient’s medical history,
the dentist should pay close attention to immunosuppressants (prednisolone, mesalazine, azathioprine, methotrexate) and biologics (infliximab, adalimumab, vedolizumab,
ustekinumab). Given the patient’s chronic inflammatory
bowel disease, non-steroidal anti-inflammatory drugs (ibuprofen, aspirin, diclofenac) should be avoided, as they may
irritate the gastric mucosa and trigger an episode.
In a systematic review, Voina-Tonea et al. identified a statistically significant association between Crohn’s disease
and early implant loss.36 Malnutrition has been implicated
as a cause of impaired osseointegration; autoimmune
inflammatory events may have a direct effect on bone
formation. In addition, possible side effects of long-term
[21] =>
case report
|
cortisone therapy on implant survival are conceivable.
Other known side effects that may directly or indirectly
affect implant survival include hypertension, diabetes mellitus, gastritis type C, osteoporosis, glaucoma, and an increased risk of infection.
Three retrospective studies and one prospective study
were evaluated In the above-mentioned review, although
the studies by van Steenberghe et al. and Alsaadi et al.
were limited by the very small number of participants of
n = 2 and n = 3, respectively.38,39 The extent to which
Crohn’s disease played a specific role in the development of peri-implantitis in the present case remains hypothetical, but must be considered in the search for a
therapy.
Due to the horizontal (site 37) and bowl-shaped (site 36)
bone defect configuration, a regenerative therapy approach was not considered promising (Figs. 1 & 5). Shallow bone defects create extremely poor conditions for
a regenerative therapeutic approach and are difficult to
augment stably over the long term.40,41 To slow down periimplantitis, especially outside the aesthetic zone, a resective therapeutic approach was chosen, which facilitates complete decontamination by “levelling” the implant
threads and makes early recontamination of the implant
surface more difficult.
“In a systematic review,
Voina-Tonea et al. identified
a statistically significant
association between
Crohn’s disease and
early implant loss.”
Removal of the superstructure should always be discussed with the patient and the general dentist prior to
any proper implantoplasty. Leaving the superstructure in
place will make levelling the exposed implant threads
much more difficult and may compromise the result. In
complex cases, it may even be advisable to close the
implants with cover screws and allow them to re-heal
subgingivally after bone grafting. In the present case, the
patient chose not to have the superstructure removed for
economic reasons.
7
Fig. 7: Progress of wound healing after 20 days.
there are factors that are beyond the control of either
the patient or the clinician (Table 1), and despite the best
efforts of both, implants may ultimately have to be explanted.
Note: This article was not funded by any external source.
The authors report no conflicts of interest. The clinical
case presented here is a recent case for which the longterm evaluation (follow-up) is still pending.
contact
Lucas A. Greilich
Burgstraße 2–4, 65183 Wiesbaden, Germany
lucas.greilich@helios-gesundheit.de
Dr Mischa Krebs
Schillerplatz 3, 55232 Alzey, Germany
PD Dr Dr Maximilian Moergel
Burgstraße 2–4, 65183 Wiesbaden, Germany
maximilian.moergel@mkg-burgstrasse.de
Literature
Lucas A. Greilich
Dr Mischa Krebs
Dr Maximilian Moergel
The clinical and radiographic success of peri-implantitis
therapy can only be evaluated retrospectively after several years, and the patient and clinician should be aware
that long-term implant retention depends on many factors. Because peri-implantitis is a multifactorial process,
2 2023
21
[22] =>
| case report
Interdisciplinary approach for a
missing maxillary incisor
Dr Tran Hung Lam, Vietnam
Implant therapy aims to provide patients with a highly
predictable treatment outcome, good long-term stability
of the treatment results and a low risk of complications
during the healing and follow-up phases. The growing
demand for functional and aesthetic restoration of missing teeth has become an important challenge. This is especially true in the anterior zone, as various local risk factors can compromise the predictability of the results.
Therefore, the clinician must carefully examine the patient’s risk profile before establishing the treatment plan.1
The International Team for Implantology recommends immediate implant placement (Type 1) in the presence of
ideal anatomical conditions. This includes (i) a fully intact
facial bone wall with a thick-wall phenotype (> 1 mm) at
the extraction site, (ii) a thick gingival biotype, (iii) no acute
infection at the extraction site and (iv) a sufficient volume
of bone apical and palatal to the socket to allow implant
insertion in the correct 3D position with sufficient primary
stability. When these ideal conditions are not met, it is
suggested to place implants after four to eight weeks of
soft-tissue healing (Type 2). If primary stability cannot be
1
2
3
4
22
5
2 2023
[23] =>
case report
6
7
8
9
achieved after four to eight weeks, the post-extraction
healing period should be extended to allow for partial
bone healing (Type 3).1 Type 4 is the placement of the implant into a fully healed site.2
An adequate amount of bone is needed to be able to
place the implant in an ideal prosthetically driven position.
If adequate bone volume is not available, guided bone regeneration (GBR) techniques should be used for ridge
augmentation before implant placement.3
The following case report describes an interdisciplinary
treatment that included orthodontic therapy, GBR, implant placement and fixed restorations. A fixed orthodontic appliance with ceramic brackets was used to level and
align the teeth and to gain space for implant placement
in a central incisor location. Because of the complexity
of this clinical case, GBR was first carried out with a
non-resorbable membrane and a bovine bone grafting
material, and after six months, an implant was placed.
|
sional restoration. Since then, he had noticed that the
space left by the central incisor was slowly being closed
by the adjacent teeth.
The extra-oral examination revealed a medium smile line
with an impaired mesiodistal proportion of the anterior
teeth. Owing to the limited mesiodistal space at position #21, the provisional restoration looked small and
narrow. Moreover, the anterior teeth were not level, resulting in a reverse smile. For the intra-oral examination, the
provisional restoration was removed. The neighbouring
teeth were mesially tilted (Fig. 1). Since the residual ridge
was atrophic, a severe horizontal ridge defect was apparent, and secondary caries was present in tooth #11 distally (Figs. 2–4). The radiographic assessment (CBCT) revealed a narrow crestal bone width at position #21 and
no local infection (Fig. 5).
Initial situation
The SAC classification assessed the potential difficulty,
complexity and risk of the implant-related treatment. The
case was classified as surgically complex and prosthodontically straightforward (Fig. 6).
A systemically healthy 48-year-old male patient came to
our clinic seeking an aesthetic and functional treatment
for a missing anterior tooth. He reported being a nonsmoker, taking no medication and having no allergies. His
chief complaint was feeling very embarrassed to talk and
smile in public because of his missing tooth. He desired
a fixed restoration and an attractive smile. His dental history revealed the loss of tooth #21 during an accident
over 20 years before. It had been restored with a provi-
After evaluating the patient’s wishes and discussing the
treatment options, it was decided first to perform orthodontic treatment and then GBR and finally to place a
Straumann BLX implant. Straumann BLX implants are
made from the material Roxolid and have the SLActive
surface. These unique properties enable enhanced control over insertion torque to achieve optimal primary stability, which is a fundamental feature in treating this type
of clinical scenario.
2 2023
23
[24] =>
| case report
10
11
12
13
Treatment planning
Treatment would involve the following:
1. provision of oral hygiene instructions and non-surgical
periodontal treatment;
2. digital planning of dental space distribution and aesthetics;
3. restoration of the carious teeth and orthodontic treatment to increase the mesiodistal gap at position #21
and to level and align the smile curve (Figs. 7 & 8);
14
15
16
17
24
2 2023
4. GBR using a non-resorbable membrane and bone
grafting material;
5. membrane removal after six months and implant insertion in a prosthetically driven position;
6. delivery of a screw-retained temporary crown on implant #21;
7. crown preparation and restoration of tooth #11;
and
8. delivery of a screw-retained definitive crown on implant #21.
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[26] =>
| case report
21
22
Surgical procedure
Owing to the limited bone availability, the first step of the
surgical procedure was GBR using a non-resorbable
membrane and bone grafting material. Local anaesthesia
was performed with 2% lidocaine and 1:100,000 adrenaline, and a mucoperiosteal flap with a crestal incision
was raised. The flap was carefully separated from the
bone, and the surgical access confirmed the limited availability of bone (Fig. 9).
18
Afterwards, GBR was performed using the bovine material cerabone (botiss biomaterials) for bone grafting. In
addition, a non-resorbable membrane to prevent non‐
osteogenic tissue from interfering with bone regeneration
was used (Fig. 10).
19
The patient was advised to follow a soft diet and use ice
packs on the area for the first 48 hours. Moreover, the
postoperative prescription included rinsing with an antiseptic solution (0.2% chlorhexidine for 1 minute twice a
day for one week), an analgesic (600 mg ibuprofen up to
four times a day as required) and an antibiotic (500 mg
amoxicillin three times a day for five days).
Two weeks later, at the suture removal appointment, the
patient reported no complications with healing. The patient returned six months after surgery for a follow-up
evaluation. Healing had continued to progress well, and
oral hygiene was good. Furthermore, there was an adequate mesiodistal gap at position #21 for implant placement, thanks to the orthodontic treatment (Fig. 11).
20
26
2 2023
[27] =>
case report
23
The implant placement was planned. After local infiltration anaesthesia, the area was reopened with a fullthickness flap for membrane removal. The bone morphology and dimensions were assessed and found to be
optimal for implant insertion (Fig. 12).
A 3.75 × 12.00 mm Straumann BLX implant was selected
(Fig. 13). The surgical bed was prepared, and the implant
was placed in a prosthetically driven position following
the manufacturer’s instructions (Fig. 14). Next, the mucoperiosteal flap was adapted and closed with interrupted
sutures, achieving primary closure (Fig. 15).
At the suture removal appointment, since healing had
been uneventful, the fixed appliance was removed, and
a screw-retained temporary restoration was delivered
(Figs. 16 & 17). A periapical radiograph was taken to assess the correct fit of the restoration (Fig. 18).
Prosthetic procedure
Twenty weeks after implant surgery, the papillae were
well formed and osseointegration of implant #21 had
been achieved. Crown preparation of tooth #11 was performed (Fig. 19). The Straumann regular base Variobase
and zirconia coping obtained by a CAD/CAM procedure
for the final restoration of the BLX implant were placed
(Fig. 20).
The final implant restoration was performed, and a lithium
disilicate crown was placed on tooth #11 (Fig. 21). The
soft and hard tissue demonstrated a natural contour
(Fig. 22). The occlusion was checked, and oral hygiene
instructions were reinforced.
The patient was involved in an annual maintenance programme in which soft and hard tissue were evaluated
and oral hygiene instructions reinforced. The radiographic control after three years showed good maintenance of the peri-implant bone (Fig. 23).
|
24
Treatment outcomes
The outcome met our patient’s expectations. In addition,
the hard and soft tissue were well maintained over time
(Fig. 24). At the three-year follow-up visit,
the patient said that the treatment had Literature
greatly affected his life, restoring his confidence and self-esteem. Encouraged
by his new smile, he had begun smiling
far more than he ever had and everyone in his social circle had noticed.
about the author
Dr Tran Hung Lam graduated in odontostomatology from the University of Medicine and Pharmacy at Ho Chi Minh City in
Vietnam. He received his PhD and training in fixed prosthodontics and implantology at the dental faculty of Aix-Marseille University in France. He is the
founder of Elite Dental Group and the
THL Academy.
Dr Tran is vice dean of research and international affairs at the
Faculty of Dentistry at Van Lang University in Ho Chi Minh City.
He is president of the Ho Chi Minh City Society of Dental Implantology, an International Team for Implantology (ITI) fellow, an ITI
study club director, chair of the ITI’s Vietnam section and a fellow
of the International College of Dentists.
contact
Dr Tran Hung Lam
Dr Tran Hung Lam
drtranhunglam@gmail.com
elitedental.com.vn
2 2023
27
[28] =>
| research
Immediate or delayed loading in
the fully edentulous maxilla
Drs Yassine Harichane, Rami Chiri & Benjamin Droz Bartholet, France
Although scientific and technical advancements have
been made in the field of dentistry, there are still many
patients who are either partially or fully edentulous. Edentulism has a negative impact on both dental and general
health, leading to physical problems like inability to eat
normally and mental health issues such as a decrease
in self-esteem.
offer them a maxillary implant solution that is supported
by scientific research? Can patient management be improved by modifying implant placement and loading
protocols? These are the two questions we will aim to
answer with the aid of recent scientific literature.
Oral implantology has made tremendous progress, allowing patients to have clinical outcomes similar to
natural dentition. Implant-supported prostheses provide
edentulous individuals with daily satisfaction, enabling
them to enjoy food and social interactions. When a single
tooth or multiple teeth are lost, fixed solutions are suggested, whereas in the case of complete edentulism, the
patient can choose between an overdenture or a fixed
complete denture on implants.
In implant surgery, considering anatomical obstacles is
crucial. Regarding the maxilla, the nasal cavity and maxillary sinuses pose challenges, while in the mandible, the
inferior alveolar nerve and mental foramen can be problematic (Fig. 1). The two areas also differ regarding bone
density, the maxillary bone usually being less dense than
that of the mandible. To overcome anatomical obstacles
like the maxillary sinus, either axial implants can be placed
after sinus lift or zygomatic implants can be placed to bypass the obstacle (Fig. 2). Many implant designs have
been developed to provide satisfactory primary anchorage, regardless of bone density.
The McGill consensus statement recommends an overdenture supported on two implants as the first choice for
the edentulous mandible. Numerous protocols describe
technical aspects of implant surgery and prosthetic restoration, whether in immediate or delayed loading. While
the McGill consensus statement considers a conventional tissue-supported denture for the maxilla to be
problem-free, some patients may wish for a more comfortable solution to improve their dental health. Can we
1
Surgical steps
Brånemark’s work in oral implantology established success criteria that have become standard in implant practice. Scientific research has enabled advancements in
oral implantology, such as immediate placement after
extraction procedures for single or multiple teeth in both
the maxilla and mandible.
2
Fig. 1: Maxillary anatomical obstacles. Fig. 2: Maxillary prosthesis on axial and tilted implants.
28
2 2023
[29] =>
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[30] =>
| research
While the McGill consensus statement recommends an
overdenture on two implants for the mandible, there is no
established consensus for the maxilla. This is due to the
heterogeneity of results and the difficulty of conducting
systematic reviews on the subject. However, Malò et al.
have pushed the clinical boundaries of maxillary implant
treatment with the All-on-x procedure (Fig. 3), which is
demanding but effective and satisfying for patients.
Digital workflows have also improved surgical protocols
through static guides and dynamic navigation (Fig. 4).
Static guides involve planning the implant position in
software and reproducing it in a surgical guide, while
dynamic navigation allows for real-time adjustments
based on CBCT imaging during surgery, providing greater
precision.
Prosthetic steps
Brånemark initially recommended allowing several months
for implants to heal, but current literature supports the
possibility of immediate loading, whether for a single
implant or multiple implants in the maxilla or mandible
(Fig. 5). Research has validated immediate loading in fully
edentulous maxillae, whether using conventional or zygomatic implants, with high success rates. However, certain conditions need to be considered.
3
This accelerated-care approach has prevented patients
from experiencing disabling edentulism and has been
shown to improve their overall satisfaction and oral healthrelated quality of life. Studies have found that implantsupported overdentures can improve the general wellbeing of edentulous patients and that fixed implant prostheses are even more effective (Fig. 6).
The effectiveness of immediate loading of implants is
comparable to that of delayed loading, although the evidence is not strong enough to make a definitive clinical
recommendation. Studies have shown that there is no
statistically significant difference in survival rates between immediate and delayed loading of implants and
prostheses. However, it is worth noting that early implant
failure in the maxilla is quite common, half of the failing
implants being lost within the first six months. This is often
attributed to poor bone quality of the mandible.
Patients may be more satisfied with a functional fixed
prosthesis regardless of the time of loading, but there is
limited evidence to support this. Prosthesis instability may
also contribute to differences in loading times. For example, one study showed no difference in patient satisfaction between immediate and delayed loading after three
Fig. 3: All-on-4 and All-on-6 prostheses. Fig. 4: Surgical guide and dynamic
navigation.
30
2 2023
4
[31] =>
research
5
|
6
Fig. 5: Implant loading timeline. Fig. 6: Patient satisfaction timeline.
months, although patients in the delayed-loading group
had relined provisional restorations. At 12 months, patient
satisfaction levels were similar, suggesting that the perception of the prostheses does not change much over
time. Studies have shown that patients have an excellent
level of satisfaction with immediate loading, and the protocol is generally well tolerated with careful preoperative,
perioperative and postoperative management.
bar overdentures are also effective and well tolerated
by patients. Patients seem to be at least as
satisfied with immediate loading, and clinical Literature
complications may be comparable to those of
delayed loading. The choice of immediate loading should be based on the practitioner’s expertise in providing such treatment and on patient selection.
Recent research has expanded the indications for zygomatic implants, which offer sufficient primary stability, but
may still be susceptible to lateral forces that can cause
implant fracture. This is particularly problematic in clinical
cases in which the maxillary fixed prosthesis opposes
natural mandibular dentition. One possible solution is to
use a hybrid prosthesis on a bar.
about the authors
Marginal bone loss data indicates a loss of 1.67 mm for
the maxilla after ten years, regardless of the type of implant used. However, a more pronounced loss was observed around implants supporting acrylic prostheses
than those supporting ceramic prostheses, beginning at
the fifth year of follow-up. This underscores the importance of surface polishing to reduce plaque build-up
when using acrylic prostheses.
Dr Yassine Harichane holds a DDS,
MSc and PhD and is in
Dr Yassine Harichane
private practice in France.
Dr Rami Chiri holds a DDS and is in
private practice in France.
Conclusion
Dynamic navigation is a promising technique that allows
for precise implant placement in fully edentulous patients.
Zygomatic implants are a reliable and predictable option
for maxillary rehabilitation.
The existing literature provides limited evidence on the
comparative efficacy of immediate versus delayed loading of implants. Evidence supports the effective use of
immediate loading for fixed complete dentures without
the need for augmentation. Immediate loading and fixed
hybrid restorations are the most commonly used methods for their rehabilitation. However, delayed loading and
Dr Benjamin Droz Bartholet holds
a DDS and is in private practice in
France.
2 2023
31
[32] =>
| industry
Economic success in the
implantology market in Germany
What role does the choice between two-piece
implants with conical and non-conical internal
connections play?
Andreas Halamoda, Germany
Since the first dental implant consensus conference a
good 40 years ago, the development of modern implantology has been impressive, both scientifically thanks to
the discovery of the biocompatibility of the titanium surface and economically: the number of dental implants
placed in Germany has risen from 400,000 per year
around 20 years ago to an estimated 1.3 million today—
and the upwards trend is stable. Over the years, not only
has an independent, innovation-driven industry developed, but also established global competitors in the
dental industry want to participate in this solid market.
In Germany, there are currently more than 200 independent endosseous implant systems, an unusually high
number are approved and accordingly many national and
international suppliers are vying for the favour of the dental profession. There is no doubt that the German market
is a key market in which every market participant wants
to succeed, particularly in order to succeed globally. It is
not easy for dentists to find their way around the selection
of implant systems on offer, especially as the pricing of
the products varies greatly. The same applies to the effort
that suppliers put into the publication of studies, advertising, customer care and training events.
Unsurprisingly, the market is dominated by a manageable
number of established providers, who are well known by
the public thanks to extensive marketing and are often
owned by listed companies. In addition, there are the
smaller, often independent manufacturers who are characterised by their innovative spirit rather than advertising
presence and large field service organisations. There are
also numerous outsiders who are known neither for exceptional presence and pricing nor for innovation and
customer proximity. Their market share is small.
The role of innovative spirit for success
In dental implantology, besides one-piece systems and
the still young ceramic implant systems, the group of
two-piece titanium implants has established itself as the
dominant one on the market because it is the most versatile. Among their numerous further developments over
the decades, the (not so recent) invention of the conical
internal connection between implant and abutment is
certainly the most significant innovation, dividing the
market roughly into conical and non-conical internal
connection implant systems. Some of the large established providers do offer a conical internal connection
implant, some do not. Many of them offer both.
With the conical internal connection, the aim is to mitigate
or even eliminate the system-inherent weaknesses of the
rightly popular two-piece implant systems. These concern primarily the enormous mechanical stress on the
connecting screw between implant and abutment and in
the gap between these two parts triggered by masticatory forces, which can promote bacterial colonisation of
the interior of the implant when positioned subgingivally.
Conical internal connection designs aim to seal this gap
or relieve the abutment screw, ideally achieving both.
32
2 2023
[33] =>
industry
Dental professionals’ needs
Implant manufacturers must always be aware of limited
time and limited staff, even in established and successful
practices. Accordingly, dentists want lean and easily reproducible processes, especially with regard to teamwork, but without compromising quality. This does not
apply only to implantology. While the differences in surgery between conical and non-conical internal connection systems are minor, they are sometimes clear when it
comes to implant exposure and impression taking.
Non-conical internal connection implants are usually
placed crestally or supragingivally, which is advantageous for quick and easy exposure and impression taking. For implants with a conical internal connection, more
care is required, especially in the correct positioning of
the impression aids. The special features of optional subcrestal insertion, not recommended for non-conical internal connection implants, must also be taken into account.
At the time of restoration, the differences become greater:
the butt joint or joint connections of non-conical internal
connection systems enable, for example, a clear determination of the correct height for single crowns without
the abutment screw being necessary at this point. With
many conical internal connection systems, press fit with
the connection screw is first required to determine the fit
and occlusion in order to seal the implant and establish
the correct fit of the crown. Special unscrewing instruments are often required here to make the extra work
easier for the dentist.
Dental technicians too want standardised procedures in
order to work economically and avoid mistakes. Furthermore, a diverse selection of abutments is required
for modern and sustainable implant prostheses. Conical
internal connection implant systems gained a poor reputation among dental technicians in this respect, as the
|
prostheses are considered to be limited and the press
fit between abutment and laboratory analogue on the
model is considered to be a hindrance. However, many
innovative conical internal connection systems now provide dental technicians with the tools to enable them to
work as efficiently as with the butt joint. In particular,
consistent digitalisation in the fabrication of dental restorations has led to impressive prosthetic possibilities in
recent years—and this now applies equally to both designs.
Preventing complications
The enormous increase in the number of implants placed
in Germany over the years automatically brought with it a
significant increase in the number of high-risk patients
treated. A decisive indicator of the predictability of longterm implant success is therefore whether an implant
has the necessary design prerequisites to prevent periimplantitis. With non-conical internal connection systems, it is inherent in the design that some play remains
between implant and abutment, which inevitably results
in micro-movements and gap formation. These factors
are not suitable for preventing gingival recession and
bone resorption in the case of subgingival implant positioning. Good results are nevertheless possible, but only
if the surgeon pays the utmost attention to sufficient tissue volume, especially mucosa of at least 3 mm thick,
which can seal the micro-gap from bacterial intrusion.
High surgical effort is unavoidable in many cases.
Conical internal connection implant systems score points
in the long term with their tightness and are accordingly
more forgiving of tissue deficits. If the construction is designed to completely eliminate micro-movements between abutment and implant, subcrestal positioning is
possible and thus a bony seal can form around the implant shoulder, providing the best conditions for stable
soft tissue.
2 2023
33
[34] =>
| industry
Complications include loosening or even fracture of the
abutment screw. No one wants regular visits from their
patients just to tighten or even replace the screw. It is inherent in the system of non-conical internal connection
implants that the screw always has to cope with the force
of the connection, and thus complications are latent. With
conical internal connection systems, it is worth taking a
closer look at the individual details. Especially a large
Morse taper can significantly relieve the abutment screw
by creating strong self-friction between implant and abutment.
Patients’ needs
The patient’s desires are ultimately a combination of perfect aesthetics, sustainability and tolerability, as the implantological solution has been recommended to him or
her as the best for his or her case. Aesthetically, conical
internal connection implants are usually at an advantage,
as they are always placed crestally or subcrestally. However, non-conical internal connection systems can also
deliver convincing results, provided they are positioned
subgingivally, unlike tissue-level implants, and, for example, with a polished shoulder to allow soft tissue on top
and bone underneath.
34
be achieved if this abrasion is eliminated. It is apparent
that the conical internal connection has an inherent advantage here, since it avoids micro-movements.
Market development
The coming years will be characterised by numerous further developments of conical internal connections—
which makes sense, because this principle is the more
recent one. The much respected large established providers will also present innovations in this area, and thus
the market share of conical internal connection systems
will continue to increase, but will also soon reach a point
where both designs converge in market share. Because
of the efficient prosthetic restoration and the simpler
workflow, non-conical internal connection systems will
retain their supporters. The key to success will be keeping up to date with customers’ wishes and responding to
these. Customers will succeed in finding exactly the
product that suits their philosophy, owing to the enormous diversity of the German implant market that becomes apparent upon closer inspection.
about the author
For the patient, the sustainability of the implantological
restoration means not only the best possible prevention
of peri-implantitis but also, of course, a high degree of
tolerance with the aim of achieving the most biological
solution possible. While it is up to the dentist to carry out
careful patient selection and, in case of suspicion, to test
for titanium intolerance, the implant manufacturer of a
two-piece system can positively influence the long-term
result with its individual design approach to the abutment
connection. This is because micro-movements of the
abutment in the implant involuntarily result in abrasion of
titanium particles, which permanently enter the human
organism unnoticed. This must be separated from possible intolerance to titanium surfaces.
Andreas Halamoda has been Key Account Manager for the German-speaking
markets at a medium-sized German implant manufacturer since 2012. He is
also responsible for the areas of training
courses with external speakers and internal staff training. He advocates demandoriented sales and holistic customer
care, starting with the surgeon, continuing with the prosthetic dentist and ending with the dental
technician.
The extent and effects of this titanium abrasion are the
subject of initial studies, but it can already be said that
highly biological solutions with titanium implants can only
Andreas Halamoda
+49 1511 2697915
andreas.halamoda@gmail.com
2 2023
Andreas Halamoda
contact
[35] =>
industry
|
“Clean” medical products
1
After the “Astra Tech EV” by Dentsply Sirona was awarded
already this March, the coveted seal for Trusted Quality has
now been given to two other implant systems: The renowned
implants, “SuperLine” by Dentium and “INVERTA” by Southern Implants are now welcomed into the family of certified
clean implants. The scientifically based seal of quality, which
underlines the first-class surface purity of dental implants, is
only awarded by the CleanImplant Foundation’s Scientific
Advisory Board after a rigorous peer-reviewed analysis and
testing process.
CleanImplant Trusted Quality Seal –
Five step approach
STEP 1
Neutral
sampling of 5
implants
3 implants are ordered ex-factory +
2 implants of the same type are provided via mystery shopping from
practices.
STEP 2
Unpacking and
scanning under
clean room
conditions
All 5 collected samples are carefully
unboxed, mounted, and scanned in
a clean room environment according
to Class 100 US Fed. 209, Class 5
DIN EN ISO 14644-1.
STEP 3
Externally
audited
process of
analysis
SEM imaging and elemental analysis
(EDS) are performed according to
DIN EN ISO/IEC 17025 accreditation
process (competence of testing and
calibration laboratories) with
external audits and multi-annual
re-assessments.
STEP 4
Full-size and
high-resolution
SEM images
A special full-size, high-resolution
SEM image—digitally composed of
more than 360 single SEM images
in a magnification of 500x—always
shows the implant surface from
shoulder to apex.
STEP 5
Peer-review
process
Two members of the Scientific
Advisory Board independently
review the comprehensive report of
analysis and sufficient clinical
documentation or multi-annual
PMCF studies (Post-Marketing
Clinical Follow-up) of the analysed
implant type showing survival rates
of more than 95% for the device or
device family.
© CleanImplant Foundation
3
Fig. 1: SEM image SuperLine implant—Dentium. Fig. 2: SEM image
INVERTA implant—Southern Implants. Fig. 3: Dr Dirk U. Duddeck placing
an implant on the sample holder of the scanning electron microscope.
Every quality award is valid only for two years and has
to be renewed after this period. Currently, the following
implant systems also carry the “Trusted Quality Seal”:
Kontact S (Biotech Dental), whiteSKY (bredent group),
UnicCa (BTI Biotechnology Institute), (R)evolution and
Patent/BioWin! (Champions-Implants), In-Kone (Global D),
ICX-Premium (medentis medical), AnyRidge and BLUEDIAMOND (MegaGen), T6 (NucleOSS), Prama (Sweden &
Martina), SDS 1.2 and SDS 2.2 (Swiss Dental Solutions).
Other testing and analysis results are pending.
Moreover, CleanImplant “Certified Production Quality” awards
were received by the CeramTec Group and Komet Custom
Made as contract manufacturers of ceramic implants.
More and more dentists are supporting the CleanImplant
Foundation. Certified as “CleanImplant Certified Dentists”,
they pass on the trust they gained in the products to their
patients and referring dentists.
contact
CleanImplant Foundation CIF GmbH
Berlin, Germany
+49 30 200030190
info@cleanimplant.org
www.cleanimplant.org
© Wlad74/Shutterstock.com
“This award is an objectively transparent proof that colleagues are using a residue-free medical device for their
patients by manufacturers who implemented the highest
quality standards,” explains Dr Dirk U. Duddeck, Founder
and Head of Research at CleanImplant. To obtain this
valid, objective proof, a so-called “five step approach”
was established in cooperation with the eight-member
Scientific Advisory Board:
2
2 2023
35
[36] =>
| manufacturer news
Dentsply Sirona
Introducing DS OmniTaper Implant System—
the newest member of the EV Implant Family
The DS OmniTaper Implant System is an innovative solution that combines the proven technologies of Dentsply Sirona’s EV Implant Family with new features that deliver efficiency and versatility. Unique to the implant system is an intuitive drilling protocol for reduced chair time and a
pre-mounted TempBase for immediate restorations and efficient workflows.
The DS OmniTaper Implant System is the newest member of the EV Implant Family, alongside
Astra Tech Implant System and DS PrimeTaper Implant System. The EV Implant Family offers
surgical flexibility to cover virtually every indication. All three implant systems deliver biologically
driven implant designs for natural aesthetics and lasting bone care, have one connection for restorative clarity, and are optimised for a seamless fit with digital dentistry workflows.
Like the rest of the EV Implant Family, the DS OmniTaper Implant System features the OsseoSpeed
implant surface and the conical EV connection that provides access to the harmonised and comprehensive EV prosthetic portfolio for restorative flexibility and immediate chairside solutions.
Dentsply Sirona, Sweden
+46 31 3763000
www.dentsplysirona.com
Fotona
Advancing dental laser technology
Fotona’ss LightWalker is a revolutionary dental laser system, incorporating
state-of-the-art technologies that redefine the industry. With 20 W of power,
2 wavelengths, 5 pulse durations, and 4 special pulse modalities, LightWalker offers dentists an unparalleled range of clinical applications.
The precision and improved ablation efficacy of LightWalker’s patented
QSP mode make it invaluable for hard tissue treatments, debonding
veneers, orthodontic brackets, dental aesthetics, and surgery, addressing various challenges with a single solution.
Practitioners are thrilled by the efficacy of the LightWalker’s SWEEPS
mode in endodontic cases, witnessing the power of bubbles in cleaning
narrow root canal spaces, removing smear layer, debris, and biofilm.
Moreover, SWEEPS extends its benefits beyond direct laser therapy,
enabling non-invasive, non-surgical removal of biofilm and calculus in
periodontal and peri-implant therapy.
The laser’s innovative SMOOTH mode expands the horizons of dental
practices, allowing them to offer Fotona’ss cutting-edge aesthetic and
anti-snoring laser therapies. With treatments like SmoothEye®, LightWalker 3D®, LipLase®, and NightLase®, dental practices can attract
new patients, fulfilling patient expectations with a wide range of
non-invasive options that can enhance revenue and profitability.
Embrace the future of dental laser technology with Fotona’ss LightWalker, empowering dentists with unparalleled versatility for enhanced patient care.
Fotona d.o.o., Slovenia
(+386) 1 5009100 ∙ www.fotona.com
36
2 2023
[37] =>
manufacturer news
|
bredent medical
Improved osseointegration thanks to the bone growth concept
The design of implants plays a crucial role
in implant treatment, as it can contribute
to optimal osseointegration. That’s why
bredent has equipped its implants with a
backtaper that provides more space for
bone and soft tissue to attach.
Implant design helps to minimise risks and
maximise chances of success in implant treatment. Especially at the passage point from bone
to soft tissue, a functioning interplay of several
factors is required to achieve long-term stable results.
When designing bredent implants, attention is paid to
ensuring that they meet the requirements for optimal
healing in the jaw according to the bone growth concept. Therefore, most of bredent’s implants have a backtaper: this crestal
slope provides more space for bone and soft tissue to attach.
The backtaper is an advancement of the platform
switch concept. With the platform switch, soft tissue is given more space to attach to the surface by
reducing the abutment diameter in relation to the
implant diameter. However, different results were
obtained in clinical studies on the effectiveness of
the platform switch, as the design can lead to cortical
bone stresses and thus bone resorption processes.
A backtaper, such as those found in bredent implants,
does not affect the mechanical stability of the implant body,
reduces friction with cortical bone, and provides more space for
bone and soft tissue to attach. Bone growth on the backtaper of
bredent’s copaSKY implants was confirmed in a recent clinical
multicenter study.1 The effect is supported by a microstructure of
the surface in this area, as found in copaSKY implants, which is
ideal for attaching connective tissue as well as bone.
bredent medical GmbH & Co. KG, Germany
info-medical@bredent.com
www.bredent-medical.com
1
Ghirlanda, G.; Kazak, Z.; Vasina, M.; Neugebauer, J. (2022). 3 years follow up of
ultrashort implants with back-taper design placed at different crestal position:
EAO Poster 2022.
Neugebauer, J.; Kistler, S.; Frank, I.K.; Kistler, F.; Dhom, G. (2022) Krestale Knochenneubildung durch ein Konzept des mikrostrukturierten Backtapers: BDIZ EDI konkret
04/2022, 54–57.
Taheri, M.; Akbari, S.; Shamshiri, A.R.; Shayesteh, Y.S. (2020). Marginal bone loss
around bone-level and tissue-level implants: A systematic review and meta-analysis.
Annals of Anatomy – Anatomischer Anzeiger, 231, 151525.
Straumann
Straumann® Emdogain® and Labrida BioClean™—
a strong team to master regeneration and maintenance
Similar to a natural tooth, plaque-forming bacteria can build up on
the base of dental implants, resulting in an inflammation of the
surrounding soft and hard tissue. Improving dental and periodontal health conditions is a worldwide need and our mission and
ambition. Labrida BioClean™ is a medical device designed for
effective cleaning of osseointegrated dental implants and/or teeth
with pocket depths ≥ 4 mm. Removal of plaque-forming bacteria
from the infected dental implant/tooth surface is the first step
in biofilm management. Straumann® Emdogain®/Straumann®
Emdogain® FL is a unique gel containing enamel matrix derivatives. This mixture of natural proteins forms a matrix that stimulates certain cells involved in the healing process of
soft and hard tissues. Adding Straumann®
Emdogain®/Straumann® Emdogain® FL to cleaned tooth or implant surfaces can improve the clinical outcome of the procedure.
Institut Straumann AG, Switzerland
+41 61 9651111
www.straumann.com
2 2023
37
[38] =>
| events
© Osteology Foundation
Cheers to new beginnings:
celebrating oral tissue regeneration
The 2023 International Osteology Symposium, held in
Barcelona from 27 to 29 April, was a resounding success,
bringing together 2,400 participants from 80 countries.
Over 100 world-renowned speakers and international experts from research and practice explored the latest advances in the field of oral tissue regeneration on the occasion of the Osteology Foundation’s 20th anniversary.
Founding Partner Geistlich and Gold Partners Dentsply
Sirona, BioHorizons Camlog, botiss biomaterials, and
Straumann also offered the attendees truly impressive
hands-on opportunities to experience special techniques
and materials. For those who missed out on the highly
sought-after workshop seats, an exclusive pre-congress
session in oral tissue regeneration was offered.
Getting hands-on and exploring
new techniques
Opening of the regenerative marathon
The event kicked off with the symposium’s workshop
programme, an early highlight and with the fully booked
Osteology workshops covering a comprehensive range
of topics: from modern techniques in soft-tissue management using autologous and substitute materials, to reconstructive procedures for peri-implantitis defects, and
the latest in minimally invasive periodontal regeneration
and recession coverage around teeth and implants—this
symposium delivered it all.
Frank Schwarz, Vice President of the Osteology Foundation opened the congress officially together with the scientific chairs Pamela K. McClain and Istvan Urban on Friday morning. They set the stage for what promised to be
an unforgettable marathon of highlights.
Over the course of the following two days, attendees got
to enjoy a variety of lectures, panel discussions and interactive round-table discussions addressing all aspects of
oral tissue regeneration: different strategies of hard- and
soft-tissue augmentation around teeth and implants, prevention and management of complications and errors, as
well as the all-time hot topic of peri-implantitis. These areas of interest were complemented by lectures about innovative technologies, blood products for tissue augmentation and regenerative approaches in interdisciplinary dentistry.
Bringing theory to life: Live surgery
The programme boasted two remarkable live surgeries
performed by none other than the esteemed Istvan Urban and Sofia Aroca. They provided a unique and rare
opportunity for attendees to witness these masters of
oral tissue regeneration in action, as they performed
complex procedures in real-time.
© Osteology Foundation
38
2 2023
Urban’s and Aroca’s exceptional skills, precision, and expertise were on full display, as they shared their knowl-
[39] =>
AD
edge and experience with the audience in an immersive and
interactive setting.
Further highlights of the programme included:
– The research networking day and poster exhibition for
young researchers including research and audience
awards.
– A case session with six outstanding cases competing for
the Osteology Case Award.
– A lively debate on the treatment of intact and compromised
extraction sockets, with a focus on immediate versus delayed implant placement.
– Proceedings from the Osteology DGI SEPA consensus
workshop.
– Osteology partner sessions from the AAP and SEPA.
– A practice-oriented wrap-up session “Oral Regeneration
in a Nutshell”, covering various sub-topics.
– A jubilee evening as a platform for networking and exchange—celebrating oral tissue regeneration.
SUBSCRIBE NOW
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international magazine of ceramic implant technology
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international magazine of oral implantology
research
Clinical success rate of two-piece
zirconia dental implants
BESTELLUNG AUCH
ONLINE MÖGLICH
case report
case report
Magneto-dynamic site preparation
© Osteology Foundation
Restoring anterior aesthetics for zirconia implants
with two-piece zirconia implants
Resective peri-implantitis
therapy with implantoplasty
in Crohn’s disease
news
First long-term study on two-piece
zirconia implants published
industry
Economic success in the
implantology market in Germany
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The 2023 International Osteology Symposium was a true celebration of the Foundation’s 20th anniversary. It was a testament to the Foundation’s unwavering commitment to advancing oral tissue regeneration. The jubilee edition of this
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[40] =>
| events
Cutting edge science and innovation
From 8 to 10 June, the Dentsply Sirona Implant Solutions
World Summit 2023 took place in Athens, Greece where
science has its origins. Inspired by connection and future
innovation, the event delivered immersive experiences to
inspire and feed attendees’ passion for implant solutions.
Implant professionals from around the world who are passionate about elevating the dental industry and improving
the quality of implant treatments and care for patients convened for three days of knowledge exchange, inspiration,
and networking. They have been able to discover the latest
innovations in implant solutions, including the EV Implant
Family, digital dentistry, and bone regeneration. The summit’s state-of-the-art educational programme was developed together with the scientific chairs—Dr Tara Aghaloo,
USA and Dr Michael Norton, UK, and the programme
chairs—Steve Campbell, UK; Dr Malene Hallund, Denmark; Dr Mark Ludlow, USA; Dr Stijn Vervaeke, Belgium;
and Dr Martin Wanendeya, UK and featured 50 world-renowned speakers from 12 countries with inspiring main
stage presentations, hands-on workshops, and break-out
tracks on topics such as aesthetics and the digital dentistry ecosystem, half of them being new presenters at a
Dentsply Sirona event.
The CLOUD session explored the new digital universe
and its power to transform patient journeys from diagnosis to final treatment, with perspectives from two clinicians (Dr Martin Wanendeya, UK and Dr Stefan Vandeweghe, Belgium) and one lab technician (Steve Campbell,
UK), a live demo, and a look at the advantages for clinicians and labs.
Meanwhile, the BATTLE session featured debates from
two clinicians on a hot clinical topic, moderated by Dr Mark
Ludlow, USA with the winner decided by the audience. In
the first battle Dr David Barack, USA and Dr. Rodrigo
Neiva, USA debated about biomaterials vs. implant selec-
© Dentsply Sirona
Dentsply Sirona Implant Solutions World Summit 2023
tion. Battle two considered full arch digital vs. full arch analog, with Dr Mischa Krebs, Germany going head-to-head
with Dr Gary Jones, USA.
“The Implant Solutions World Summit attracts some of the
brightest and most passionate minds in implant dentistry,”
said Dr Malene Hallund, oral and maxillofacial surgeon and
Dentsply Sirona Key Opinion Leader. “The programme
dives deep into all the latest developments in our field while
challenging pre-existing ideas and assumptions. I know
that attendees will walk away feeling excited and inspired
for what the future holds.”
Attendees could visit the Inspiration Hub exhibition area
spread across two floors. Participants gain hands-on experience with Dentsply Sirona’s comprehensive implant
portfolio and digital workflow. Dentsply Sirona’s premium
EV Implant Family—DS PrimeTaper Implant System, DS
OmniTaper Implant System, and Astra Tech Implant System—were on display, as well as OSSIX regenerative solutions, DS Signature Workflows, and the cloud-based DS
Core platform.
Moreover, the Implant Solutions World Summit featured
two social evenings for attendees to network with peers
and enjoy the best Athens has to offer.
© Dentsply Sirona
40
2 2023
“Peer to peer education is vitally important for our Implant
Solutions community and we are thrilled to bring implant
professionals together from around the world to explore
the latest innovations and science transforming implant
dentistry” said Tony Susino, Group Vice President, Global
Implant Solutions at Dentsply Sirona.
[41] =>
DGZI
„Implant Dentistry
Award“ 2023
CALL FOR POSTERS!
On the occasion of the 52nd International Annual
Congress of the DGZI on October 6 and 7, 2023 in
Hamburg, the DGZI will again present its "Implant
Dentistry Award". Prizes will be awarded for scientific
work in the form of posters, which will be published internet-based in a Digital Poster Presentation.
DGZI will pay the congress fee and the conference
fee for the obligatory participation in the congress. The posters will be presented digitally only, no
other form of submission is possible.
Scan QR code now or visit
dgzi-2023.dpp.online/landing
and submit abstract digitally!
CLOSING DAT
E:
15. 8. 2023
[42] =>
| about the publisher
Congresses, courses
and symposia
Imprint
International
Esthetic Days
21–23 September 2023
Baden-Baden, Germany
www.estheticdays.com
30th EAO annual
scientific meeting
28–30 September 2023
Berlin, Germany
www.eao.org
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implants
international magazine of oral
implantology is published in cooperation
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[43] =>
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Cover
1 - 1
view
-
Editorial
3 - 3
view
-
Content
4 - 4
view
-
The added value of the pterygoid implant in the management of edentulous patients
6 - 10
view
-
Restoring anterior aesthetics with two-piece zirconia implants
12 - 14
view
-
Resective peri-implantitis therapy with implantoplasty in Crohn’s disease
16 - 21
view
-
Interdisciplinary approach for a missing maxillary incisor
22 - 27
view
-
Immediate or delayed loading in the fully edentulous maxilla
28 - 31
view
-
Industry
32 - 35
view
-
Manufacturer news
36 - 37
view
-
Events
38 - 40
view
-
Imprint
42 - 42
view
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/ Editorial
/ Content
/ The added value of the pterygoid implant in the management of edentulous patients
/ Restoring anterior aesthetics with two-piece zirconia implants
/ Resective peri-implantitis therapy with implantoplasty in Crohn’s disease
/ Interdisciplinary approach for a missing maxillary incisor
/ Immediate or delayed loading in the fully edentulous maxilla
/ Industry
/ Manufacturer news
/ Events
/ Imprint
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