implants international No. 4, 2018

Cover / Editorial / Content / Dental extraction: What else? / Prevention 0: The best way to prevent peri-implant disease? / Full-arch implant rehabilitation / Industry / Innovate, educate, inspire / Mini in size, high in standard / Manufacturer News / Events / News / Imprint

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issn 1868-3207 • Vol. 19 • Issue 4/2018

implants

international magazine of oral implantology

research

Prevention 0: The best way
to prevent peri-implant disease?

case report

Full-arch implant rehabilitation

events

1st Future Congress sets new standards

4/18

[2] =>

GC Implants:
Quality derived
from tradition

www.gctech.eu

[3] =>

editorial

Dr Rolf Vollmer
First Vice President and Treasurer of DGZI

We are ready for the future
Dear colleagues,
Our last Annual Congress, which took place under the
motto “Visions in Implantology”, has shown that there is
an ongoing development and significant progress in the
field of dental implantology, in particular when it comes
to digitalisation. For instance, the accuracy of bone-supported drill templates is constantly improving, whereas
the amount of planning deviations is decreasing. Yet, we
would be well advised to maintain a critical stance towards our own ambitions. In addition, we should always
reassess the large amount of available information, obtained through modern radiology for example, in a critical
and realistic fashion. The number of medical mistreatment cases does not decrease as a mere consequence
of having a large amount of information and scientific data
at our disposal and it would be unwise to believe that.
Specialists working in the field of dental implantology, as
well as courts are currently dealing with an increasing
number of malpractice cases and bad treatment results,
which is obviously a global issue. A couple of years ago,
Dr Dennis Tarnow complained about the fact that sixty
per cent of his new patients, already having implants,
were attending his clinic to receive follow-up treatments.
It is not without reason that we are facing an increasing
number of patients suffering from peri-implantitis today.
So-called peri-implantitis classifications are being introduced at the moment and respective new treatment methods are being proposed by the various scientific associations. Our colleagues who are working in this field deserve
the highest praise and our utmost respect. Let’s have a
closer look at various cases that are being published.
I personally believe that many cases of peri-implantitis
are home-grown or lie within the responsibility of the implantologists. To show all of these different cases in their

entirety would go far beyond the scope of this editorial,
so let’s just name some of the main causes of peri-implantitis: risky implantations in regions with low bone volume, disregard of both the periodontal conditions and
underlying general illnesses, disregard of the therapeutic
indication or inaccurate positioning, disregard of already
established principles and guidelines, inadequate prosthetic care, remaining excess cement, and insufficient
education of the implantologist, only to name a few. With
regard to aetiology, there are no statistically significant
studies yet, and thus further research is urgently needed.
Please consider that there is no technology capable of
replacing the human brain and of considering all the vital
factors that are necessary to achieve the best possible
treatment results for our patients. The fact remains that
medical mistreatment has to be avoided by all possible
means. In addition, I would argue that a good medical
education is the key to preventing mistakes and thus the
key to success.
There is a new DGZI educational programme for the
entire practice team, which is about to be launched. It
features a modern training for dental technicians and
can be requested at our office in Düsseldorf, Germany.
We will be happy to provide you with personal advice
and to forward special requests to the respective heads
of department.
With this in mind, I remain with best regards and wish
you a Merry Christmas and a peaceful new year.
Yours,

Dr Rolf Vollmer

4 2018

[4] =>

| content
editorial
We are ready for the future

03

Dr Rolf Vollmer

research
Dental extraction: What else?
page 14

06

Prof. Mauro Labanca, Dr Ernesto Amosso,
Dr Giuseppe Galvagna & Prof. Luigi F. Rodella

Prevention 0: The best way to prevent peri-implant disease?

14

Prof. Magda Mensi, Timothy Ives & Dr Gianluca Garzetti

case report
Full-arch implant rehabilitation
page 24

18

Dr David García Baeza

industry
Peri-implantitis therapy

24

Dr Fernando Duarte & Dr Gregor Thomas

Quality seal for dental implants

28

Dr Dirk U. Duddeck
page 44

Connection between periodontal and peri-implant health emphasised 30

interview
Innovate, educate, inspire

32

Mini in size, high in standard

36

events
Cover image:
CONELOG® system by CAMLOG
www.camlog.com
issn 1868-3207 • Vol. 19 • Issue 4/2018

implants

Essential guide for clinical practice in implant dentistry

42

1st Future Congress sets new standards

44

4/18

news

international magazine of oral implantology

manufacturer news

38

news

48

about the publisher

research

Prevention 0: The best way
to prevent peri-implant disease?

case report

Full-arch implant rehabilitation

events

imprint

1st Future Congress sets new standards

04

4 2018

50

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[6] =>

| research

Dental extraction: What else?
Prof. Mauro Labanca, Dr Ernesto Amosso, Dr Giuseppe Galvagna & Prof. Luigi F. Rodella, Italy

The decision-making process leading to a dental extraction has changed a great deal in the history of dentistry. We have moved from the concept of elimination
of the infective source to one of bone preservation and
regeneration of the alveolus. With the advent of modern drugs and the collaboration between different medical specialties, today we can consider extraction to be
a totally safe procedure for the patient,1 even though it
should be deferred as much as possible in favour of the
increasingly advanced techniques of restoration, recovery or regeneration.
When, unfortunately for the patient, extraction is indicated, how is this situation managed? And what is the deci-

sion tree to which we can refer today? This type of therapy,
which is often under-estimated but of relevance to every
single dental specialty, and especially important for general
practitioners, is too little considered but is of great importance for the patient in the present and the future (Fig. 1).

Anaesthesia
Anaesthesia is the initial phase of any dental treatment.
Often poorly evaluated by the operator, it plays a key
role—for more than only clinical reasons—in ensuring
greater compliance on the part of the patient. The patient
will, in fact, judge the work of his or her dentist almost exclusively on the basis of the pain suffered: first in the

Decision tree of extraction
Anaesthesia
Tooth extraction
Bleeding management
Treatment plan

Reconstruction:
implant, bridge

No treatment

Bone
grafting

Alveolus
management

Bone
grafting

Nothing
decided yet
Bone
grafting

Site closure
SUCCESS

Post-op pain management
Post-op complications

· Damaged adjacent teeth
· Nerve injury
· Etc.

Fig. 1

Dry socket

Complication treatment

4 2018

Alveolus
management

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| research
injection phase, then with regard to the pain felt during
the operation and perceived after any type of treatment.
It is, therefore, essential that a topical anaesthetic is
used to make the injection phase as least unpleasant
as possible and that the injection is performed by applying the right pressure, so as not to overstretch the tissue
(a cause of pain in itself) and in the right anatomical site
(Figs. 2 & 3). Moreover, the recommended injection time
is 1 ml/minute. Nevertheless, 84 per cent of dentists inject 1.8 ml in 20 seconds or less.2 A compound suitable
for the planned intervention must be used in terms of duration of its action and, therefore, of effectiveness, paying
attention also to the quantity of vasoconstrictor present
and the overall patient condition.
As far as the compound to be used is concerned, the
absorption time and the duration time must, of course,
always be carefully considered, and this must not be
arbitrary, but linked to the type of extraction planned, in
order to always have the most adequate pain coverage
not only during the operation but also in the immediate
postoperative period.
Articaine is one of the most recently developed local
anaesthetic drugs available to dentists worldwide and the
most widely used local anaesthetic in Europe. Articaine
is closer to physiological pH and therefore its onset is
quicker. Owing to its higher lipo-solubility, articaine is a
potent dental anaesthesia molecule, and it has a longer
duration than lidocaine owing to its higher protein binding. Being both an amide and an ester, its degradation
starts as soon as it reaches the bloodstream, its metabolism is quicker and, therefore, it is safer to use. It has the
lowest systemic toxicity, which is why it can also be used
during pregnancy.
Lidocaine is one of the most widely used anaesthetics
even though there are several other compounds of comparable efficacy; these drugs differ in terms of pharmacokinetic parameters.

cations. For instance, that might contribute to the onset
of dry socket, which could possibly result from an excessive vasoconstriction induced in the area of the intervention along with other possible factors.

Extraction and management of the alveolus
After having carried out adequate anaesthesia, the
tooth or root can be extracted as planned. And obviously,
as indicated, the dentist’s choice regarding the treatment
of the post-extraction alveolus will reflect what needs to
be done in the site involved in the extraction.
After extraction, dimensional and aesthetic changes to
the oral tissue occur. For this reason, it is important to
contextualise the procedure (if it is not urgent) within a
broader treatment plan.
The reasons for an extraction can be numerous. According to the directives of the Società Italiana di Chirur
gia Orale ed Implantare (Italian Society for oral and
implant surgery), the indications that lead to the decision
to extract a tooth are as follows:
–– the presence of ongoing dental caries that has led to a
widespread destruction of the dental crown, affecting
the gingival margin and making it impossible to recover
the element;
–– irreversible apical lesions;
–– serious periodontal disease with non-reversible alveolar bone loss;
–– fractured roots;
–– orthodontic treatment;
–– dysodontiasis of the third molars;
–– management of infectious loci in patients having to undergo radiation therapy;
–– immunodepressed patients;
–– patients having to undergo treatment with bisphosphonates or anti-coagulants of the latest generation; and
–– impacted teeth or continued presence of primary teeth
in the mouth.

For long procedures, bupivacaine is the most logical
choice for its long anaesthetic duration in soft tissue,
although, according to some studies, it is also the most
painful during injection.3–6

Once the extraction has been carried out, it will then
be possible to opt for:
1. an immediate regenerative treatment;
2. a delayed regenerative treatment; or
3. no treatment.

It should be remembered that the presence of a va
soconstrictor is often fundamental not only for good
control of haemostasis, but also and above all to antagonise the vasodilatory effect induced by any local anaesthetic. Inadequate use of the vasoconstrictor can make
a simple extraction complex if the haemostatic effect is
not induced. Indeed, the administration of a high concentration of vasoconstrictor (with the local anaesthetic)
if used in an inappropriate manner (for example with an
intraligamentous procedure) can create severe compli

The preservation of the alveolar process after a dental
extraction is recommended to preserve the bone’s volume and the soft tissue over it and to simplify the subsequent rehabilitation. It has been widely illustrated in the
literature that, every time a dental extraction is carried
out, a restructuring of the bone takes place in the site of
extraction, leading to a decrease in volume, accompanied by qualitative and quantitative changes that affect
the result of a prosthetic rehabilitation, especially if it is the
anterior zone that is affected, which is further impacted

4 2018

[9] =>

research

by the significant aesthetic changes.7, 8 It should be remembered that, with the extraction of a tooth, the periodontium is eliminated and with it the rich vascular network that characterises it. The supply of blood and lymph
is essential for the turnover of the gingival cells and of the
periodontal ligament itself, and even if to a lesser extent,
it also contributes to the nourishment of that portion of
bone close to it. Another determining factor for bone resorption is the surgical technique that is adopted during
extraction; indeed, if a full-thickness flap is raised, the
blood supply in the external cortex is interrupted, inducing a remodelling of the affected area.

Fig. 2

We should stress that the alveolar bone is a structure
that is closely linked to dental survival, and it undergoes
important changes where the latter is absent. There are
numerous studies that show that the greatest reduction in
bone volume occurs mainly in the first three months, continuing in lower percentages in the first year after surgery.
In the first six months, the volumetric variation is quantifiable as 3.80 mm in width and 1.24 mm in height, with
displacement of the crestal profile by two-thirds with respect to the original position.7–13
Based on an analysis of correlation, the vestibular thickness of the bone wall of less than 1 mm has been identified as a critical factor associated with the extent of bone
resorption. The thin-walled bone phenotype shows significant bone resorption with mean bone loss of 7.5 mm
compared with the thick-walled bone phenotypes, with
a predicted loss of 1.0 mm.

Benefits of a bone grafting material
Studies conducted on samples of patients who had to
undergo dental extraction have confirmed that the placement of biomaterials in the alveolar site immediately after
extraction, compared with the samples where nothing was
inserted, showed a significant reduction in the reshaping
process, with preservation of the bone volume after healing, validating the concept of ridge preservation.7–14
It has been demonstrated in numerous histological
studies carried out on different samples of bone taken
from sites treated with different types of biomaterials,15, 16
that beta-tricalcium phosphate is one of the few synthetic
materials to be completely resorbable, with no trace remaining one year later in any of the samples examined.
Moreover, an improvement of between 6 and 23 per
cent was observed in the receiving site compared with
the sites treated only with the presence of the coagulum
(Figs. 4–12).13
Recently, in a systematic review, Ten Heggeler et al.
demonstrated that the use of biomaterials in the post-
extraction site resulted in alveolar volume preservation

Fig. 3
Fig. 2: Anaesthesia administered to the alveolar inferior nerve. Fig. 3: Anaesthesia administered to the buccal nerve.

during healing.17 It should also be noted that alveolar sites
filled only with fibrin sponges do not register any significant improvement.
The technique of preserving the extraction site thus
has proved to be effective both in minimising the resorption of the bone tissue and in expanding the bone volume
for subsequent treatment with implants.18, 19
In some situations, when there is no implant or regenerative intervention planned directly after the extraction,
it may be necessary and appropriate to control the haemostasis and the flap closure in an appropriate manner, in order to make the postoperative phase easier and
thereby reduce the risk of infection of the site or the onset of dry socket. The control of haemostasis will be important, but at the same time, it will be essential for the
dentist to verify at the end of the extraction that there is
bleeding in the post-extraction alveolus. In case of a lack
of bleeding, the site must be freshened in order to ensure
the fundamental blood supply necessary for full healing
of the site. A lack of spontaneous bleeding could instead
be prodromal to a dry socket.

Bleeding management and collagen sponges
Several risk factors associated with post-extraction
dental complications, including age, gender, drugs, ex-

4 2018

[10] =>

| research
traction site, smoking, poor oral hygiene and dentist experience, are reported in the literature. Some studies have
suggested that the use of local antimicrobial, anti-fibrinolytic and anti-inflammatory substances at the post-extraction site minimises postoperative complications.

14 days through the action of collagenase and peptidase.21 Sponges or any other material must be placed
carefully in order to prevent excessive compression,
which could cause ischemia and trigger a problem in the
revascularisation (Figs. 13 & 14).

Excessive and uncontrollable bleeding of the alveolus is one of the most common complications and if not
properly treated can lead to severe consequences. In the
decision-making process leading to a dental extraction,
it is therefore important to evaluate the patient’s intake of
anti-coagulant and anti-platelet drugs. The procedures
to be implemented in these patients are well known,
although the risks associated with bleeding are never
completely absent.20

Post-extraction complications

Beyond the obvious need for appropriate suturing of
the flap, it is well known that the insertion of Type I collagen sponges minimises the risk of complications by controlling bleeding, protecting the wound and stabilising the
coagulum. Its resorption normally takes place in 10 to

Among the less serious but certainly more annoying
complications that can arise after a dental extraction is
dry socket. This occurs in very low percentages (one to
five per cent of the cases) and is localised mainly in the
molar region. The aetio-pathogenesis is caused by an in-

Even though in most cases extraction is considered a
non-major surgical operation, the possibility of more or
less significant intra- and postoperative complications,
which may be caused by incorrect procedures on the
part of the dentist or systemic disease of the patient and
which can interfere with the regular healing of the extraction site, should never be under-estimated.

Fig. 4

Fig. 5

Fig. 6

Fig. 7

Fig. 8

Fig. 9

Fig. 10

Fig. 11

Fig. 12

Fig. 4: First case example: fractured tooth #12. Fig. 5: Extraction of tooth #12. Fig. 6: Placement of biomaterial (R.T.R. Cone, Septodont) into the alveolus.
Fig. 7: Biomaterial in situ. Fig. 8: Post-op radiograph showing the biomaterial in situ. Fig. 9: Post-op suture. Fig. 10: Situation after six days. Fig. 11: Suture
removal after six days. Fig. 12: Situation two weeks later: good healing with no interference by the biomaterial.

4 2018

[11] =>

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[12] =>

| research
the presence of a white or greyish pus secretion can be
observed within the alveolus.
A study conducted by Poveda-Roda et al. showed that,
in the case of dry socket, between 43 and 96 per cent of
cases reveal the presence of viridans streptococci, which
is very dangerous, especially for patients with bacterial or
immunosuppressed endocarditis.22

Fig. 13a

Fig. 13b

Fig. 14
Figs. 13a & b: Second case example: teeth #33 and 34 were successfully
extracted. Fig. 14: Haemostatic sponges (Hemocollagene, Septodont) were
inserted into the extraction sites.

flammation of the alveolar bone due to a fibrinolysis process triggered by bacterial contamination, itself caused
by several factors, such as poor oral hygiene, use of anaesthetics with vasoconstrictors often injected by the
intraligamentous technique or the daily use by women of
oral contraceptives.

A common practice to prevent the onset of dry socket,
especially when treating patients with diseases that may
interfere with the normal healing process, entails suturing the edges of the wound or inserting active ingredients into the post-extraction alveolus to reduce the risk
of postoperative infections. It is widely documented in the
literature, that before carrying out any surgical procedure,
the asepsis of the operating area and the instruments
used should be strictly respected, if necessary undertaking a preliminary decontamination of the oral cavity with
0.2 % chlorhexidine.23
In the case of dry socket, Syrjänen and Syrjänen describe the local use of a small dose of Alveogyl, which,
owing to the presence of Penghawar fibres, produces a
soothing effect on the tissue.24 In the nineteenth century,
these fibres, obtained from the fine soft down of certain
ferns, were already being used for their haemostatic effect, producing a discreet result.25 It is also advisable to
use chlorhexidine gluconate sponges for a week, after
careful alveolar curettage.26

Conclusion
Dental extraction has always been considered as a
simple, carefree and minimal procedure. Nevertheless,
this is an important procedure from the patient’s point
of view and from the clinical perspective. It is relevant to
all categories of dentists independent of their specialties and always needs to be properly planned, in order
to avoid risks and to obtain the expected results for a
proper future rehabilitation. Today’s patients expect this
approach from dentists, and they deserve it.

Literature

The patient suffering from dry socket often reports excruciating and persistent pain, unresponsive to analgesics and with a peak in symptomatology after three to
four days.
A local swelling is always associated with swelling of
the local-regional lymph nodes and cutaneous hyperaesthesia, and above all, there is always the presence of
halitosis due to the occurrence of malodorous pus.
The gingiva around the alveolus is relatively swollen
with a smooth and shiny appearance. In severe cases,

4 2018

contact
Author details

Prof. Mauro Labanca
Studio Professor Mauro Labanca
Corso Magenta, 32
20123 Milano, Italy
mauro@maurolabanca.com

[13] =>

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[14] =>

| research

Prevention 0: The best way
to prevent peri-implant disease?
Prof. Magda Mensi, Timothy Ives & Dr Gianluca Garzetti, Italy

The philosophy of prevention in all medical professions
is increasing from a global perspective. In fact, prevention
of chronic non-communicable diseases, the major burden of illness and disability in almost all countries in the
world, has been strengthened in recent years.1 The motivation is to ensure a better quality of life for people and
to reduce public health expenditures.
In dentistry, periodontitis is one of the major chronic
non-communicable diseases. World experts in periodontics and science have published several principles regarding the prevention of periodontal diseases.2
Peri-implantitis is a twenty-first-century version of periodontitis and increasing in occurrence as implant placement is increasing (Figs. 1–3). Like periodontitis, it is a
biofilm-associated pathological condition, but instead of
affecting periodontal ligaments and bone, it is characterised by inflammation in the peri-implant mucosa and
subsequent progressive loss of supporting bone.3 The
main reasons for concerns in this area are an aetiology
in which several risk factors can play a determining role4
and a lack of a gold standard therapy. Primary and secondary preventative measures are really important to
prevent mucositis and peri-implantitis and to avoid recurrences, but there are many details to consider before
placing implants to mitigate iatrogenic problems. There
are many different prosthetic solutions besides implants

Fig. 1a

Fig. 1b

that dental professionals could propose to patients if
consideration is given from the beginning to the entire
situation. Implants may not always be in the best interest of the patient.
For these reasons, every clinician, before placing an
implant, should consider not only patient- and site-specific aspects, but also surgeon, prosthodontist, dental
hygienist and dental technician skills in order to minimise
the possibility of peri-implantitis in the future.
The following should be considered before primary and
secondary prevention, and it is the proposal of the authors that this approach be called “Prevention 0”.

Patient-specific considerations
When deciding to rehabilitate a patient with dental implants, before surgical planning, we have to carefully inform the patient about the characteristics of this procedure. It is important to underline that personal daily
maintenance at home and appropriate compliance regarding follow-up controls and dental hygiene therapies
are effective preventative measures.5 Procedure awareness and compliance are the foundation for success,
but the clinician must also inform the patient about the
impact of systemic disorders (osteogenesis imperfecta,
ectodermal dysplasia, diabetes), medications (bisphos-

Fig. 2

Fig. 3

Figs. 1a & b: Implant in position #14 affected by peri-implantitis: peri-implant probing a) with the prosthetic crown in situ and b) after prosthetic crown
removal. Fig. 2: Radiographic examination of the implant. Fig. 3: Excess resin cement around the implant.

4 2018

[15] =>

Fig. 4a

Fig. 4b

Fig. 4c

Figs. 4a–c: Peri-implant home care with a) AirFloss (Philips), b) X-Floss (ROEN) and c) interdental brush (TePe).

phonates), therapies (radiotherapy in the jawbone), habits (smoking, poor biofilm control) and a history of aggressive periodontitis6 as being relevant risk factors for
peri-implant disease.7

Site-specific considerations
The healing process after tooth loss leads to a variable
reduction of the alveolar process, inducing hard- and
soft-tissue deficiencies. The clinician must evaluate carefully all sites exposed to the following factors, because
they have the potential for major healing deficiencies: loss
of periodontal support, endodontic infections, longitudinal root fractures, thin buccal bone plates, buccal/lingual
tooth position in relation to the arch, extraction with additional trauma to the tissue, injury, pneumatisation of the
maxillary sinus, medications and systemic diseases reducing the amount of naturally formed bone, agenesis
of teeth and pressure from soft-tissue-supported removable prostheses.
Other site considerations relate to anatomical knowledge and in respect to the suitable anatomical structure
of the area (maxillary sinus, inferior alveolar nerve), endo
dontic and periodontal health of adjacent teeth, and
patient phenotype. According to Linkevicius et al. there
is significant evidence that thin soft tissue leads to increased marginal bone loss compared with thick soft tissue around implants.3, 8 Lack of bone has led to the development of various alternative surgical techniques to

Fig. 5a

avoid large bone regenerations or grafts, such as short
implants, tilted implants, pterygoid implants and palatal
implant mesh, with questionable results, but definitely
decreasing the cleanability and maintainability of implants and prostheses.

Dental hygienist skills and devices
This professional figure plays a key role in disease prevention and oral health promotion.9 Dental hygienists
should not limit their activities to being an oral cleaner,
but act as the patient’s dental coach or personal oral
trainer, motivating patients not only in dental habits but
also in lifestyle, for example regarding smoking cessation
and diet. This is a friendly expert who strengthens patient
fidelity to the dental office, even in fearful patients, and
maintains restorative work and rehabilitations undertaken
by the dentist.10
To perform professional care in a minimally invasive
way, wearing loupes and using plaque disclosing agents
and appropriate devices are mandatory, especially if
prosthetic rehabilitation is difficult for the patient to maintain. Correct and periodic biofilm removal should be considered the standard of care for prevention and management of peri-implant disease.11 For this reason, patients
should be motivated and instructed in daily implant maintenance, which should begin before implant placement
and be continued after treatment within a regular, personalised recall regime (Figs. 4 & 5).

Fig. 5b

Fig. 5c

Figs. 5a–c: Professional peri-implant biofilm removal by a) AIRFLOW with erythritol powder (PLUS powder, EMS), b) PERIOFLOW with PLUS powder and
c) with PEEK tip (PI, EMS).

4 2018

[16] =>

| research

Fig. 6

Fig. 7

Fig. 8

Fig. 6: Improper planning led to poor performance. Fig. 7: Careful removal of excess cement after prosthesis cementation using a PEEK tip (PI). Fig. 8: Careful
removal of excess cement with dental floss after prosthesis cementation.

Surgeon skills
Nowadays, especially in Italy, a new professional figure has appeared: the implantologist, who is a graduate dentist, generally a co-worker, and goes to different
dental offices or clinics and mainly places implants, often
without sufficient expertise in periodontal and prosthetic
fields. That means, in some cases, implant mispositioning, resulting in reconstructive and maintenance problems. In order to avoid fabrication of specific prosthetic
parts, unrestored implants and surgical interventions to
remove or reposition them in favourable prosthetic positions, this surgical intervention should only be performed
by an elite clinician.7 This is an expert dentist with the
necessary surgical skills to manage both soft and hard
tissue (before and after implant placement) perfectly and
with adequate expertise in the prosthetic field to allow
a prothesis-guided implant surgery and, subsequently,
a functioning, not overloaded, patient-tailored, cleanable
and aesthetically pleasant rehabilitation.

Prosthodontist skills
Skilled clinicians know that there is no such thing as
a gold standard prosthesis, but every patient needs a
tailored rehabilitation, which takes into consideration his
or her resources and requirements and which has to be
planned before surgical intervention. After data collection
and decision planning regarding the numbers of implants
requested, Toronto versus overdenture, cemented versus screwed work, with a motivated and aware patient,
the surgical and prosthetic work with careful load management can start.12 Only careful and considerate planning can prevent poor outcomes (Fig. 6).

Prosthesis fabrication and cementation
Dental technicians should work in direct contact with
prosthodontists in order to create aesthetically pleasant,
patient-tailored and comfortable cleaning spaces. After
dental hygienist instruction and training, patients should be

4 2018

able to clean their prostheses daily with minimal effort to
maintain healthy mouths.13 Another important factor associated with clinical signs of peri-implant disease is excess
cement.14–17 To avoid excess cement, restoration margins
should be located at or above the peri-implant mucosal
margin; otherwise, excess cement must to be removed.18
Despite world literature demonstrating an increased
interest in excess cement as one of the key factors in
aetio-pathogenesis of peri-implant disease, a standard
protocol guiding clinicians in this delicate removal procedure is still needed. From the authors’ point of view, the
cementation procedure requires time, attention, loupes
and meticulousness. For these reasons, an accurate
protocol, dependent on cement composition, should be
published (Figs. 7 & 8).

Conclusion
Implant rehabilitation provides a therapeutic alternative
that is more similar to natural teeth than other alternatives. Nevertheless, while an implant-supported prosthesis can be a permanent successful solution, it lasts only if
carefully planned with the patient, properly surgically performed, correctly loaded, and conLiterature
stantly maintained by the patient and
the dental professionals. Successful
results can be achieved only by an
expert, patient-centred dental team.

contact
Prof. Magda Mensi, DDS
Department of Medical and Surgical
Specialties, Radiological Science and
Public Health
University of Brescia
Brescia, Italy
magdamensi@gmail.com

Author details

[17] =>

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| case report

Full-arch implant rehabilitation
Dr David García Baeza, Spain

Introduction
An implant-supported restoration is a good alternative
to conventional complete prostheses for patients with
edentulism. This treatment has been performed successfully in recent years and constitutes a high-value
clinical reality.
Oral implantology has undergone great advances in
recent years, as it allows lost teeth to be replaced with
a high degree of satisfaction on the functional and aesthetic level. A partial or total loss of teeth affects not only
facial aesthetics but also vital functions, like chewing and
phonation. A prosthodontic rehabilitation with a high suc-

A hybrid prosthesis consists of a cast metal framework
covered by acrylic, which supports artificial fixed teeth.
The original design of the hybrid prosthesis (fixed-removable) was developed by Swedish researchers using
the two-stage endosseous implant system developed
by Per-Ingvar Brånemark. The prosthesis consisted of a
gold alloy framework attached to the copings of the implants, and on this framework conventional acrylic resin
denture teeth were secured with acrylic resin.2
The factors that determine the type of implant-supported restoration for a completely edentulous patient
are the amount of space from the bone to the occlusal
plane (prosthetic space) and the lip support. The prosthetic space needed for a hybrid prosthesis is a minimum of 11 mm and a maximum of 15 mm, with lip support given by the bone structures. When a space of
10 mm or less is available and there is lip support, a porcelain-to-metal restoration is suggested. When there is
more than 15 mm of prosthetic space and absence of lip
support, a type of implant-supported overdenture restoration is recommended, which will give the lip support
not provided by the bony structures of the patient.1 Cox
and Zarb described the treatment of severely resorbed
completely edentulous maxillae with a hybrid prosthesis
using a metallic structure with acrylic and artificial teeth,
with prosthetic spaces larger than 15 mm.3

Fig. 1

An incorrect adaptation between metal structures and
implants can cause bone loss and failure of osseointegration, which is clinically decisive. It is generally accepted in the literature that the passive fit of a prosthesis
is required for maintenance and long-term success of an
implant treatment. In addition, the literature has implied
that incorrect adaptation of metal structures is a decisive
and significant factor, causing mechanical and biological
complications. The loosening of both the prosthesis and
the abutment screws and even the fracture of various
system components have been attributed to the lack of
adjustment and adaptation of the prosthesis.

Fig. 2
Fig. 1: Frontal view of the initial patient situation. Fig. 2: Intraoral view of the
initial situation.

cess rate can be obtained for this type of patient. The
prosthetic options for rehabilitating an edentulous patient
with dental implants are divided into two categories: fixed
and removable restorations.1

4 2018

In this article, the clinical case of a patient with a completely edentulous maxilla and advanced periodontal dis-

[19] =>

case report

Fig. 3a

Fig. 4a

Fig. 3b

Fig. 4b

Figs. 3a & b: After extractions: a) Frontal and b) occlusal view. Figs. 4a & b: Healing abutments: a) Frontal and b) occlusal view.

ease in the mandible is presented. The patient’s mandible
was rehabilitated with a hybrid prosthesis on six implants.
The implant-supported prosthetic treatment that was performed to restore the patient’s aesthetics and functionality, thereby improving his quality of life, is described step
by step, as is the preparation process of the prosthesis.

with Class II and III mobility, which made it very difficult to
chew (Figs. 1 & 2).

Case presentation

The proposed treatment plan for the patient was to extract the mandibular teeth and rehabilitate the lower arch
using implants and a fixed prosthesis to maintain the same
feeling as with his natural teeth. In addition, it was decided
to replace the complete denture of the upper arch.

A 68-year-old patient presented to our facility with a
complete maxillary mucosa-supported denture, with
which he was relatively comfortable. He had all of his original teeth on the lower arch, but with very advanced periodontal disease, which had caused him a loss of support of more than 80 per cent. These teeth presented

Normally, when teeth are extracted from a complete
arch and an immediate restoration is placed, it creates
a problem of adaptation for the patient, especially in the
mandibular area. To help the patient during this period of
healing and osseointegration of the implants, it is recommended to place two provisional implants.

Fig. 5

Fig. 6

Fig. 7

Fig. 5: SR Abutments at gingival level. Fig. 6: Impression taking with closed-tray copings. Fig. 7: Preliminary impression.

4 2018

[20] =>

| case report

Fig. 8

Fig. 9

Fig. 10

Fig. 11
Fig. 8: Rigid metal tray impression taking: Fixing with plaster. Fig. 9: First step of final impression taking. Fig. 10: Final impression. Fig. 11: Master model.

Once the extractions had healed, six Aadva tapered
implants (GC Tech.Europe) of 4 mm in diameter and
10 mm in length were placed in the position of the molars, first premolars and central incisors (Figs. 3a & b).
The bone quality and quantity were good, and once
the expected osseointegration time had passed, transitional abutments were placed. In this case, two abutment diameters were used, narrower (SR Abutment of
3.8 x 2.0 mm, GC Tech.Europe) for the incisal and premolar areas, where there was less inserted gingival tissue, and wider (SR Abutment of 4.3 x 2.0 mm) in the posterior area (Figs. 4 & 5).

Fig. 12

Before beginning with the prosthetic phase, there was
a waiting period for the tissue to mature. For this, an
impression was taken with closed-tray copings, which
is very simple, but does not give a very exact model
(Figs. 6 & 7). This was subsequently used to make a rigid
impression tray that was made of metal and was secured
with plaster to only one of the implants (Fig. 8).
Once the rigid impression tray was placed in the
mouth, open-tray copings were then used and they were
splinted to the structure with a special plaster mixture;
once this had hardened, everything was registered with

Fig. 13
Fig. 12: Lateral radiograph taken with lead foil on the old denture for radiographic evaluation. Fig. 13: Fox plane test.

4 2018

[21] =>

case report

a polyvinylsiloxane impression (Figs. 9 & 10). This technique yields a very reliable master cast, ensuring a very
good structure fit (Fig. 11).
Once the final model with the different analogues was
ready, the planning started. First, the old complete maxillary
denture was analysed. In this type of case, it is very useful
to perform a lateral analysis, thus photographs and radiographs were taken. A step that differentiates our technique
from other dentists’ is that a narrow lead foil strip is placed
on the maxillary and mandibular central incisors. This provides extra information to see the relationship between the
position of the anterior teeth and the bone (Fig. 12).

Fig. 14

With the lateral radiographs, the situation of the transitional
abutments can be visualised, which is very important, as all
the manipulation based on the different tests that need to
be done will be carried out far from the head of the implant.
Once the fulcrum points and the inclination of the maxillary incisors for lip support had been analysed, the new
upper arch was designed in order to give the patient a new
occlusal plane and a new incisal position. The Fox plane
helped us to obtain the correct plane and then we used
the Kois Bow for the cranial-maxillary reference (Fig. 13).
Once the models had been placed in the articulator
and the parameters taken from the patient, the laboratory
technician began to make a set of test teeth from wax for
both the upper and lower arches so that the correct fit
could be assessed, including the patient’s occlusion and
aesthetics (Figs. 14 & 15).
As Figures 16 to 19 show, the upper arch was narrower
than the lower one because those teeth were lost much
earlier, which meant that, for correct functioning of the
complete maxillary prosthesis while chewing, the posterior areas were to be placed at a crossbite. That way, the
axis of force when chewing food would fall on the alveolar
process and not displace the prosthesis.
Once confirmed that everything worked properly, the
next step was constructing the metal structure that would
be closely linked to the wax tooth design (Figs. 20 & 21). This
was once again checked with the teeth in position to give a
last confirmation before the final manufacturing. At that time,
confirmation of the modifications made could be carried out
again by using the lead foil strip, as well as confirmation of the
occlusion, in case there was any variation (Fig. 22).
Subsequently, the final prostheses were made. The
maxillary one was made as wide as possible in the posterior area so that it would be as stable as possible, and
the mandibular one was placed on implants. Confirmation and small adjustments had to be performed in the
mouth to counterbalance the small misalignments that
normally occur in manufacturing (Figs. 23–25).

Fig. 15

Fig. 16a

Fig. 16b

Fig. 16c
Fig. 14: Panadent articulator phase. Fig. 15: Wax test confirming smile parameters. Figs. 16a–c: Wax try-in: a) Left, b) right and c) frontal view.

Discussion
The treatment of a completely edentulous patient with
an oral restoration on implants begins by discussing
treatment expectations, followed by an accurate clinical

4 2018

[22] =>

Fig. 17

Fig. 18a

Fig. 18c

Fig. 18b

Fig. 17: Models in final position. Figs. 18a–c: Models in the articulator.

evaluation. Thus, a detailed intraoral and extraoral examination are performed following a work plan to help
in the diagnosis. This includes studying patient photographs and radiographs, which have evolved remarkably
in recent times, using models on a semi-adjustable articulator and following the protocol for the design of a
proper prosthetic restoration on implants, choosing from
overdentures, or hybrid or fixed prostheses. The choice
will depend on what the dentist plans using a multifunctional guide—tomographic/surgical/prosthetic—for implant placement and a suitable type of oral restoration.

Bidra and Agar proposed a classification system for
edentulous patients for using implant-supported fixed
prostheses, classifying them into four classes according
to the following factors:
1. amount of tissue loss;
2. position of the anterior teeth in relation to the location
of the residual ridge;
3. lip support;
4. smile line; and
5. need for prosthetic material for gingival colouring (pink
acrylic).4

Rehabilitation with implant-supported hybrid prostheses is a fixed treatment in completely edentulous jaws
where the prosthetic space is 11 mm or 15 mm,3 but
where the need for lip support for prosthetic restoration
is not a determining factor.4 An implant-supported hybrid
prosthesis can be a questionable alternative treatment
when a fixed restoration of porcelain and metal does
not meet the patient’s requirements for a
esthetics, good
phonetics, proper oral hygiene and oral comfort.5, 6

Class I includes patients who require gingiva-coloured
prosthetic material such as pink acrylic to obtain aesthetic tooth proportions and optimal prosthetic contouring to attain adequate lip support. Class II patients
require pink acrylic only to obtain aesthetic tooth proportions and for prosthetic contouring. Lip support is
not a consideration, since the difference in lip projection with or without any prosthesis is generally insignificant. Class III contains patients who do not require gin-

Fig. 19a

Fig. 20
Figs. 19a & b: Final wax test. Fig. 20: Aadva software: Structural design.

4 2018

Fig. 19b

[23] =>

Fig. 21

Fig. 22

Fig. 23a

Fig. 23b

Fig. 24

Fig. 25

Fig. 21: Anterior view, final test. Fig. 22: Lead foil test for the new design. Figs. 23a & b: Final restorations: a) Lateral and b) frontal view. Fig. 24: Final
smile. Fig. 25: Final restoration.

giva-coloured prosthetic material. Class IV is assigned
to patients who may or may not require pink acrylic,
depending on the result obtained after surgical intervention.4 Following this classification, the patient in this report
was determined as Class II.
The fabrication of hybrid dentures in patients with adequate interocclusal space provides the dentist with several advantages regarding the aesthetic appearance, including replacement and decrease of soft-tissue support
owing to the bulkiness of the metal substructure and in
the height of crowns compared with a metal-supported
porcelain prosthesis. In addition to these aesthetic advantages, hybrid prostheses work as shock absorbers,
reducing load forces on implants.7
The success rate of implant-supported hybrid prosthetic treatments is high, as demonstrated by a systematic review published in 2014, which included 18 studies
for evaluation. In a period of five to ten years, high survival rates of 93.3–100 per cent for the prostheses and
of 87.9–100 per cent for the implants were found.8
In a retrospective study evaluating the main complications after rehabilitation with an implant-supported hybrid prosthesis, it was observed that the main complication was mucositis, which affected 24 per cent of the
cases, followed by problems with the prosthetic screws
in 13.7 per cent of the cases, including thread wear or

loss, and the same percentage was found for fracture
of the prosthetic teeth or prosthesis detachment. These
problems were related to an incorrect record of vertical
dimension, inadequate occlusion or a lack of passive fit
of the metallic structure. Another problem encountered
concerned the access to the entrance holes of the prosthetic screws (7.8 per cent).9

Conclusion
A lower jaw hybrid restoration is a good option for the
rehabilitation of an edentulous mandible, and it should
be included in the treatment options when evaluating a
patient, as it improves aesthetics, functionality and proprioception. It is furthermore easy to clean, requires less
prosthetic maintenance, and can be
Literature
removed at any time and repaired at
a very low cost.

contact
Author details

Dr David García Baeza
CIMA private dental practice
Laguna Grande 4
28034 Madrid, Spain
clinica@cimadental.es

4 2018

[24] =>

| industry

Peri-implantitis therapy
Using resorbable bone replacement material
Dr Fernando Duarte, Portugal & Dr Gregor Thomas, Germany

Peri-implantitis is one of the medical challenges of the
21st century. Implantologists and periodontists around
the world are consistently searching for reliable and
implementable therapy solutions. The authors presented
their preferred protocol of peri-implantitis treatment in this
clinical case using a biomimetic bone replacement material and a resorbable collagen membrane.
Peri-implantitis is defined as a local lesion which is
associated with bone loss around an osseointegrated implant, whereas peri-implant mucositis is a reversible inflammatory change in the mucosa surrounding the implant.
Peri-implant mucositis is diagnosed by probing, that is
followed by bleeding. The mucositis is often not classified as severe and also not taken seriously by the patient.
Based on various examinations, prevalence for peri-implantitis varies significantly between 2 and 58 per cent of
all implants (Koldsland et al.). According to a Cochrane
report published in 2011, there is insufficient evidence for
known peri-implantitis treatments. More research in this
field thus needs to be conducted (Esposito et al.).
The authors experience regarding their preferred protocol for peri-implantitis treatment is presented step by step
in the following clinical case. The Implacure® (MedTech
Dental AG) peri-implantitis set and a regenerative, biomimetic bone replacement material (CERASORB® M,
curasan AG) were used to replace the lost bone.

Surgical protocol
1. Formation and mobilisation of a mucoperiosteal flap
to achieve unconstrained access to the defect area.
If possible, the superstructure should be removed.
2. Careful curettage of the infected area, thorough removal of all soft-tissue adhesions on the bone.
3. Decontamination of the implant surface using various burs: both the apical part, that later will come into
contact with the bone replacement material, as well
as the crestal part, that later will be in contact with
mucosa have to be cleaned.
4. Dressing of the entire exposed bone surfaces with
sterile gauze and moistening of the gauze with sterile saline solution in order to improve its adhesion to
the bone.
5. Application of a gel comprised of 37 % phosphoric
acid and 2 % chlorhexidine onto the entire exposed
implant surface in order to eliminate all remaining
biofilm.
6. After two minutes, the gel is thoroughly rinsed off
with saline solution and the gauze is removed.
7. Dressing the entire implant surface in sterile gauze.
The gauze is subsequently soaked with a sodium
hyaluronate/piperacillin/tazobactam solution, letting
it set for five minutes.
8. Removal of the gauze.
9.
The bone replacement material is blended with a
sodium hyaluronate/piperacillin/tazobactam solution
and autologous blood taken from the defect area
or PRP in a sterile container and inserted into the
affected area without pressure. The defect area is
subsequently covered with a resorbable collagen
membrane which was previously soaked in antibiotic
solution.

Fig. 1

Fig. 2

4 2018

10. Re-adaption of the flap and suturing.

[25] =>

industry

Fig. 3

Fig. 4

Fig. 5

Fig. 6

Fig. 7

Fig. 8

Case presentation

burs (Fig. 4). Chemical debridement of the surface with
subsequent antibiotic impregnation was performed
(Figs. 5 & 6).

A 59-year-old patient presented to the practice complaining about minor exudate at his dental implants in
the anterior region (Fig. 1). Probing revealed a deep
circular pocket around the implants during the initial
examination. Mobility of the implants was, however, not
detected. As suspected, the radiographic examination
confirmed an advanced peri-implantitis at the recently
placed implants (Fig. 2).
In accordance with the described protocol, a mucoperiosteal flap was created in order to obtain full access
to the severe four-wall defect (Fig. 3). The implant surface was mechanically cleaned with diamond-coated

|

After completion of the preparatory steps, the bone replacement material consisting of phase-free beta-tricalcium phosphate—which offers optimal conditions for osseous remodelling owing to its micro-, meso- and macropores—was inserted as previously described (Fig. 7).
Finally, the surgical area was covered with the bioresorbable membrane, and the flap was re-adapted with
interrupted sutures in order to achieve a complete and
impermeable wound closure (Fig. 8). The radiograph
taken immediately after surgery showed the filled defect

4 2018

25

[26] =>

| industry
The decontamination of the implant surface proves to
be the crucial step in all proposed treatment approaches.
The complex topography of modern implants offers ideal
conditions for bacterial growth. The decontamination of
these surfaces sometimes seems impossible, particularly if non-surgical treatment is pursued. There are diverse options for surface decontamination. Anti-infective
treatments with chlorhexidine, tetracycline, metronidazole, citric acid, laser and photodynamic application help
in disinfecting the implant. Mechanical debridement with
titanium, plastic or steel curettes, implantoplasty or powder jet should remove the biofilm. Most clinicians select a
combination of these therapies assuming that as a result
surface decontamination can successfully be obtained.
Fig. 9

Fig. 10

(Fig. 9). Good osseous consolidation at the enamel-cement junction of the adjacent teeth could be seen on the
follow-up radiograph taken 24 months later (Fig. 10).

Discussion
While improved oral hygiene and professional cleaning
prove to be very effective in treating periodontitis, peri-implant lesions do not react correspondingly. This does not
mean that good oral hygiene and professional tooth cleaning are redundant as peri-implantitis prevention. However,
conservative therapy proves to be inefficient once peri-
implantitis has developed. Non-surgical approaches by
means of laser or powder jet show moderate results. Systemic chemotherapy and mechanical debridement have
also largely been without success.1–3 The use of photodynamic therapy has also proven to be unsuccessful. In summary, it can be said that non-surgical therapy approaches
are not suitable for reliably treating peri-implantitis.1, 4
Surgical treatment seems to be only the promising therapy approach. A surgical resection treatment is, however,
only partially effective. In 2003, Leonhardt stated that
surgical and antimicrobial treatments were successful in
more than half of the cases for a period of five years. In
2008, Heitz-Mayfield et al. were able to demonstrate that
using an antimicrobial protocol with surgical access via
mobilisation of a flap stopped the progression of peri-
implantitis in 90 per cent of the cases over a period of
one year, while the bleeding on probing persisted in more
than 50 per cent of these cases.5
Unfortunately, not all cases of peri-implantitis are suitable for regeneration. The crater shape with four walls
does not typically occur in implants with thin fascial and
lingual walls. In some of these cases the defect is associated with a complete loss of the surrounding bone crest,
which turns regenerative measures into an unpredictable
treatment alternative.

4 2018

Implantoplasty ensures a complete decontamination
of the implant surface, there are, however, four essential
concerns: heat generation, accumulation of residue of
milled material in the surrounding tissue, damage to the
implant surface and impairment of the implant structure.
Heat generation can be contained through careful and
abundant irrigation, and an adapted bur selection. Some
authors presume that milling residue has not been clinically verified in rejection reactions. Reducing the microand macro-roughness of the implant surface has mainly
proven advantageous in preventing bacterial colonisation. The required abrasion thickness on the implant is
ultimately not a decisive factor for reduced stability.6, 7

Conclusion
The existing scientific findings and the clinical experiences obtained with the presented system, thus allow
the conclusion that the protocol proves to be a successful and understandable method for the sanitation of periimplant defects, when lost bone substance is simultaneously regeneratively replaced. The fully synthetically produced, biomimetic beta-tricalcium phosphate granulate
has proven to be successful in this treatment. By means
of a restitutio ad integrum it is possible to return the weakened implant site not only mechanically, but also biologically, to a functional condition, which is the prerequisite
for a successful long-term sanitation.
Literature

contact
Author details

Dr Fernando Duarte, DDS, M.Sc.
Clitrofa Clinic
Avenida de Paradela, 626
4785-248 Trofa, Portugal
fduarte@clitrofa.com

[27] =>

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[28] =>

| industry

Quality seal for dental implants
More safety for patients and practitioners
Dr Dirk U. Duddeck, Germany

Impurities on sterile-packaged implants, in particular
organic particles from the production or packaging pro-

cess (Figs. 1–3), are highly suspected of being responsible for incomplete osseointegration of dental implants or
even loss of bone in the early healing period.
Four consecutive studies over a period of more than
ten years conducted in close cooperation with the University of Cologne and the Charité–University Medicine
Berlin, both in Germany, have shown that neither CE
(French: Conformité Européenne) marking nor U.S. Food
and Drug Administration clearance can provide a reliable

Full-size high-resolution SEM image 500x (digitally composed of 360 single SEM images)

Fig. 1
Fig. 2

Fig. 3

Fig. 1: Massive organic pollution on sterile packaged implant (SEM mapping at 500x). Fig. 2: Organic particles on the implant thread (SEM image at 500x).
Fig. 3: Organic particles with antimony on the implant shoulder (SEM image at 500x).

28

4 2018

Photos: © www.cleanimplant.com

Dr Michael Norton, former president of the Academy
of Osseointegration, summed up a problem of the implant market, stating “Dentists have to rely on the word
of manufacturers and the FDA or CE marks to feel sure
that the implants they are using are being manufactured
to a standard one would expect of an implantable dental
device. Sadly, this is often not the case.”

[29] =>

Fig. 4: blueSKY implant (bredent; SEM mapping at 500x).

indication of the cleanliness of dental implants. Scanning electron microscopy (SEM) imaging and elemental
analysis (EDS) of more than 250 dental implants from
over 200 brands were used to establish one of the largest, most comprehensive databases in implant dentistry.
Recent analyses in 2018, revealed a continually growing
number of implants with severe pollution, compared with
previous reports. Areal pollution and particles containing iron, copper, chromium, nickel, tungsten and sulphur,
and large quantities of stainless-steel particles, as well as
remnants of polytetraﬂuoroethylene and other signiﬁcant
organic contaminations, give cause for concern.

The ﬁve-step approach

How can the clinician know which implants
are not affected by these impurities? With the
variety of implant systems offered on the market it has
become increasingly difﬁcult for dentists to choose a safe
system for their practice. The CleanImplant Foundation
has set itself the goal of providing exactly this information worldwide. This independent non-proﬁt organisation is supported and controlled by a scientiﬁc advisory
board, which is chaired by renowned scientists and practitioners. In 2017 this board set the criteria for the CleanImplant Trusted Quality Mark. Implant companies and
systems already carrying this seal are MIS V3, MegaGen
AnyRidge, BTI UnicCa, bredent blueSKY (Fig. 4), NucleOSS T6 and NDI Replicate. Other implant systems are
currently in the process of examination.

Objective analysis of dental implants

Step 1: Random sample collection
For the Trusted Quality Mark, ﬁve samples of each implant type
will be collected for thorough analysis using a mixture of mystery
shopping (two samples) and direct factory order (three samples)
to ensure that samples are selected randomly.

The CleanImplant Foundation established a thorough
and accredited testing procedure that guarantees unbiased results for the new global quality seal (see information box “The ﬁve-step approach” on the left).

Step 2: ISO Class 5 cleanroom environment

Practitioners interested in a personalised certificate for
their practice and implant manufacturers who want to
apply for the new quality mark will find more information
and a corresponding newsletter at the project’s website
www.cleanimplant.com.

All implants have to be unpacked and analysed in the scanning
electron microscope under cleanroom conditions according to
ISO Class 5 (DIN EN ISO 14644-1).
Step 3: SEM analysis process accreditation
All collected samples are subjected to the same quality analysis protocol. Laboratories have to prove a quality management
system according to DIN EN ISO/IEC 17025 and undergo regular audits and reassessments by external independent accreditation bodies.
Step 4: Full-size high-resolution SEM imaging
This technique produces approximately 400 single high-resolution SEM images of a single implant sample. Images are digitally
composed to one large image with an extremely high resolution
providing a perfect overview of the implant cleanliness.
Step 5: Peer review process
Two members of the scientiﬁc advisory board independently review the comprehensive report of analysis and correspondent
clinical documentation.

contact
Dr Dirk U. Duddeck
Managing Director
CleanImplant Foundation
Pariser Platz 4a
10117 Berlin, Germany
Phone: +49 171 5477991
duddeck@cleanimplant.com
www.cleanimplant.com

Author details

4 2018

[30] =>

| industry

Connection between periodontal
and peri-implant health emphasised
EuroPerio9 was held in Amsterdam from 20 to 23 June
and was the largest congress to date with more than
10,000 attending. There was great interest in the causes
and successful management of periodontitis and peri-
implantitis. Two new classifications provided answers to
the aetiology. Scientifically based and practice-oriented
presentations demonstrated how to prevent and, if necessary, treat these inflammatory diseases.
Three out of four Swiss patients state that prevention is
the main reason for them to visit the dentist.1 They want
to make sure that their teeth stay in good condition. They
aim to keep previously restored teeth or implants for as
long as possible. However, not all patients are aware of
the fact that dental health also depends on intact periodontal or peri-implant tissue.

Fig. 1

At EuroPerio9, renowned experts presented two new
classifications as the basis for all preventive, as well as
therapeutic measures. They were developed at a workshop conducted by the American Academy of Periodontology (AAP) and the European Federation of Periodontology (EFP) in November 2017: According to the
classification, there is only one form of periodontitis, for
which the treatment is classified into four stages, depending on its severity and complexity.2 As explained
in detail in Amsterdam, current research results indicate
that what was formerly considered aggressive periodontitis cannot be distinguished from chronic periodontitis
by microbiological or immunological criteria. According
to the new diagnostic system, the disease is classified as
chronic, which means that recall treatment is necessary
for the remainder of the patient’s life.

Fig. 2

Periodontal therapy largely unchanged

Fig. 3
Fig. 1: Good individual oral hygiene and professional biofilm management,
e.g. with cups and brushes, helps support periodontal and peri-implant
health. Fig. 2: An air scaler efficiently performs the initial debridement, as
part of initial periodontal therapy. Fig. 3: Implants and superstructures can
be successfully cleaned with ultrasonic devices and special plastic instruments during postoperative care or non-surgical therapy. (Source: © W&H)

4 2018

Every dental examination is based on a detailed medical history combined with targeted diagnostics containing as much detail as possible: The dentist records
systemic risk factors such as diabetes or smoking and
identifies any potentially increased tendency to inflammation3. Hard and soft tissues are examined and periodontal pockets are probed in a screening test according to PSR (Periodontal Screening and Recording). In
case of abnormal findings, the periodontal status is then
recorded and therapy is initiated where necessary. This
treatment begins with professional biofilm management,
by using, for example, rotary cups and polishing com-

[31] =>

industry

pounds (Fig. 1), and comprehensive instructions in oral
hygiene. Sonic or ultrasonic systems remain an effective
alternative or supplement to manual instruments for subgingival debridement and biofilm management (presentation by Prof. Dr Ulrich Schlagenhauf; Fig. 2). Supplementary use of photodynamic therapy, air polishing or local
and systemic antibiotics is not adequately documented
(Prof. Dr Sema Hakki).4 According to Dr Sergio Bizzarro,
improved biomarker diagnostics may lead to an increase
in customised patient therapy in the future.

Primary prevention of inflammations
The key statement of the first classification for peri-implant inflammations is that periodontitis, mucositis and
peri-implantitis are a result of biofilm.5 One has to admit,
however, that therapy is not always successful.6 These
inflammatory diseases need to be prevented before they
occur by means of good oral hygiene and professional
biofilm management.7–9 A practice-based randomised
study found that most patients maintain their peri-implant health by attending recall visits two to four times a
year, regardless of the mechanical means of treatment
that are used.10 The risk of peri-implant inflammation is
significantly higher in periodontitis patients.11 The same
goes for patients who have had initial treatment, but are
not yet included in a recall programme (UPT).12 Good biofilm management and preliminary periodontal treatment
are particularly important preconditions for a planned implantation.

Proper implantation
Implantation and implant restoration are performed
following standard surgical and prosthetic protocols.
High-performance implantology motors combined with
surgical contra-angle handpieces are available for the insertion of the implant. Large volumes of cooling fluids at
low speeds are required to prevent the bone from overheating.13 Once the implant has been screwed to its end
position, its eventual stability can be measured safely and
accurately by utilising resonance frequency analysis (RFA).
A load protocol oriented to the ISQ value prevents the implant from developing micro-movement, thus improving
the prognosis.14 As stated in the consensus document presented at EuroPerio, the potential role of the above-mentioned biological and biomechanical factors in the development of peri-implantitis still requires clarification.5

First probe, then treat
Healthy peri-implant tissue does not show any signs
of redness, swelling or bleeding, neither does it secrete
pus when probed.5 Based on the consensus document,
Prof. Dr Giovanni Salvi explained the importance of reg
ular probing—preferably with a flexible probe, as implant
components often tend to obstruct the procedure.5 In the

case of mucositis or initial peri-implantitis already being
present, the non-surgical removal of hard deposits and
biofilm should be attempted first. For this purpose, ultrasonic power and special instruments designed to protect the implant should be employed (Fig. 3; piezo scaler
Tigon+ with 1I, W&H). In case of no remission, the recall
frequency needs to be increased. However, specific recommendations, applicable to individual cases, are not yet
available in this context.15
According to an unpublished study presented by Prof.
Salvi, the supportive use of photodynamic therapy or
locally applied antibiotics does not significantly reduce
bleeding on probing in patients presenting with mucositis
or initial peri-implantitis. This finding is similar to the one
with periodontitis and, according to a systemic overview,
also applies to subgingival air polishing.6 Professor Stefan Renvert states that whether an implant can remain in
position with peri-implantitis depends on the possibility
of retaining the implant-based prosthesis. Additional factors include the patient’s general health, as well as their
financial resources. Regenerative treatment may be indicated with 3- or 4-wall bone defects. Moreover, an implant can be removed rather atraumatically using piezosurgical instruments.

No implantology without periodontology
In a small symposium presented by the Austrian dental company W&H, oral surgeon and periodontologist
Dr Karl-Ludwig Ackermann explained that he does not
insert implants in affected patients without prior periodontal treatment. This procedure is based on many
years of experience and a clinical strategy, which is
based on the so-called NIWOP-workflow, meaning “no
implantology without periodontology”. This workflow,
developed on the basis of the 11th EFP workshop8, was
impressively confirmed at EuroPerio9. EFP President
Prof. Anton Sculean, who chaired the symposium, stated:
“A large number of implants are being placed these days
and periodontitis has become a major problem. W&H
has recognised this and is pursuing the right strategy,
following the principle of NIWOP.”
Literature

contact
Dental Text & Consultancy Services
Dr Jan H. Koch
Parkstraße 14
85356 Freising, Germany
www.dental-journalist.de

4 2018

[32] =>

| interview

Fig. 1

Innovate, educate, inspire
At the Dentsply Sirona World 2018 in Orlando, USA,
Georg Isbaner, editorial manager of implants, had the
chance to talk to Don Casey, CEO of Dentsply Sirona,
about current challenges, future perspectives and
newest product developments, like the newly launched
Azento.
Mr Casey, you took over the leadership of Dentsply
Sirona in February 2018. In the last couple of years
Dentsply Sirona made huge acquisitions on the dental market and became one of the leading dental
companies in the world. However, the competition is
strong. What are the biggest challenges and how do
you address these challenges?
Right now, our challenges are almost more internal
than external. We are still in the process of bringing all
the Dentsply and Sirona teams together. Going from
still thinking as two organisations to getting it merged
into one focused organisation, is mainly what we have
been doing right now. I have been here seven months
and when I came here initially, I said, the most important thing to do, is to grow and now seven months later
I am still saying, the most important thing we should
do, is to grow. I have a lot more clarity now in terms
of how we grow. In my mind the two biggest areas of
growth for us are new products, as well as getting our
commercial organisation more focused on acting as
one organisation.
There are significant competitors on the market. Ultimately our competitors are also helping to improve the

4 2018

practice of dentistry—thus the level rises. Having good
competitors, makes you better.
You have a strong background in the healthcare industry. How does your experience and knowledge
apply to your job at Dentsply Sirona?
I have been doing healthcare for 34 years. The interesting thing is, there is a couple of things that have always
been consistent whether you are working in vision care,
interventional cardiology or diabetes. Firstly, innovation
is critical and how to focus on the customer needs and
deliver innovation.
The second is globalisation. I have spent my whole life
working at global companies, and we have more than
70 per cent of our employees, as well as of our revenues
coming from outside of the US. Realising that the whole
world does not look like, e. g. Florida (where we are right
now), is very important. Thinking about a customer in a developing market like Thailand, is very different than about
an established dentist in Germany. And even though
Germany and France border each other, the French dentist’s practice is extremely different to the German. So, understanding how you globalise things, is essential.
In all parts of healthcare, I have worked in, the KOLs
are critical. The relationship with these thought leaders
is absolutely essential, because they are the people that
are going to challenge our thinking—whether it is somebody inventing something in cardiology or in molecular
diagnostics, the KOLs are important. So how I look at

[33] =>

Fig. 2
Fig. 1: Dental professionals at the Dentsply Sirona World 2018 in Orlando, USA, could profit of up to 200 breakout sessions. Fig. 2: Don Casey, CEO of Dentsply
Sirona and Georg Isbaner, editorial manager of implants, at the Dentsply Sirona World.

it, innovation, globalisation and KOL management—it is
the same.
There are a lot of interesting things about dentistry, that
are different than in general healthcare. If you look at the
degree of specialisation in dentistry, it is not as high as
it is in other industries. If you take eye care for example
there are ophthalmologists, optometrists and opticians in
every country in the world. Whereas in dentistry you will
find oral surgeons but not every country has specialised
endodontists, not every country has hygienists or people
that do nothing but orthodontics. So, the degree of specialisation is a little different in dentistry globally than what
you might see in other parts of healthcare.
Here in Orlando, Dentsply Sirona is welcoming more
than 4,500 participants mainly from the US but also
from many other countries including Germany. You
even have a Dentsply Sirona Oktoberfest. How big
is the “German identity”—if there is such a thing—in
your company and what might it stand for?
I have said that multiple times publicly, I will say it again:
I actually think we are a German company. A lot of our
really big franchises come from Germany or the D-A-CH
region—if you throw in endodontics for example, which is
located in Ballaigues, Switzerland. There is a huge concentration of our big businesses coming out of this region. In Bensheim, Germany, I have now been able to do
two big town hall events which we call “Under the roof”
and I always refer to Bensheim as the capital of dentistry
for the world, because if you think about digital dentistry,
whether it is the imaging business or the CAD/CAM business it came from Germany.
We tend to think that one of the crown jewels of our
entire enterprise is the fact, that we have a strong Ger-

man heritage—whether it is the engineering, the intimacy
with the customers or the fact that we just built a tremendous clinical training centre in Bensheim. The latter
shows our commitment to that market: we would like to
have 10,000 dental professionals per year do a training in
Bensheim, so they think of Dentsply Sirona as their home
town company.

“Our recipe at Dentsply
Sirona is going to be: talk to
the KOLs, make sure we are
developing great products
and educate the dental
professionals to use them.”
What is the main focus of the Dentsply Sirona World
2018 event?
Dentsply Sirona has a couple of different important
goals. The first is, the opportunity to launch new products. I am adamant about Dentsply Sirona being the innovation leader in all dentistry over the next decade. We
are launching nine new products over the four days here.
It is a great opportunity for us to launch something where
there is a great number of dental professionals. So, innovation is the first big thing.
The second is clinical education. We have over 100
experts here doing 200 breakout sessions, so the level of
clinical education of this event is unsurpassed, compared
to any kind of trade event that we have seen. We are go-

4 2018

[34] =>

| interview
ing to continue building on that as an important heritage,
because our recipe at Dentsply Sirona is going to be: talk
to the KOLs, make sure we are developing great products and educate the dental professionals to use them.

ing the digital planning for the customer. Dentsply Sirona
will literally take him or her through the five or six steps
needed to actually have a perfect procedure. In my mind
that is the way for successful future innovations.

Another focus, to be honest, is having some fun with
our customers. They work hard and they look at this
event as an opportunity to improve their practice and the
way they approach things clinically. They can learn about
five to six new products and it is actually a great opportunity for them to purchase products—there is usually
some good incentives to do that. If they leave this event
reinvigorated to be great dentists, we think that is terrific.

“If they leave this event
reinvigorated to be
great dentists, we think
that is terrific.”

Looking at your portfolio, it does provide such “single items” as scanners, dental chairs, CEREC systems, implants, etc. How do you turn products into
solutions, as your claim “the dental solutions company” implies?
The biggest opportunity we have about innovation and
delivering on solutions, is to put the customer in the centre. Sometimes you have a product line and the product has been thought out, but actually the customer has
to be put in the middle first—like in backward planning.
Instead of inventing a product and then checking who
wants to buy it, the customers should first be asked the
questions “How can we help you?” and “What procedures are you doing in your office?”. A great example is
our product Azento that we are launching today, which
is a single tooth replacement. It is a classic example of
thinking in procedures and not in single products. It is not
about selling only an abutment, but also about provid-

Right now, Azento is only released for the US market,
but it will be presented internationally at the IDS 2019. You
can combine it with our imaging equipment, CAD/CAM
equipment, implant systems and you can put together
a digital treatment. The predictable clinical outcome is
going to be better, the doctor’s confidence is going to
be significantly higher and that is how we deliver on
solutions.

Fig. 3: Introduction of the newly launched Azento™ system.

4 2018

If we look out at the next couple of years, there is ten
to twelve procedures that are critical across all dentistry.
I am really grateful, that our R&D has realised that when
thinking about a new tooth replacement, the innovation is
not a new enamel but how to improve procedures. That
is how we think about it.
So, instead of thinking about the investment, the dentists think of the solution that is offered for the challenges

[35] =>

EXCEED
they are facing in daily practice. Many
single dentist practices do not really
have the time to create a treatment plan
to do an implant, so what we can do with
Azento, is to give them an unbelievably
sophisticated programming tool that will
help plan the abutment, plan the implant—looking at every angle—and it is
all delivered in one package. We think,
that will deliver a significantly better patient outcome.
Implantology belongs to the driving
forces behind dental innovations.
Dentsply Sirona owns some of the
most established implant systems in
the world. How important is implantology for the future of dental care?
If you were to ask, what are the two biggest trends in dentistry, I would say cosmetic is one of them and if you think about
clear aligners as an example of really delivering a new benefit into the adult market, it
has been done very well.
And then I would actually argue, that
the implant category should be a significant grower just based on demographics. We used to think that 60, 70 or 80 was
very close to the end, now in the US alone
we are going to have 25 million 80-yearolds in 2020—just think how many teeth
they will need. In Japan, we are seeing
a great initiative called 80/20, where
they want to achieve 20 teeth among
all the 80-year-olds by 2020—it is just
a great way to help dentists think about
that. A lot of that development will fall
to the implantologists, they will really
have a tremendous opportunity to engage with patients in a much more holistic way and further there is going to
be more patients. So yes, it is all about
implants.
We have a lot of runway in front of
us, especially with the technology and
equipment side—penetration to CAD/
CAM is probably half as high today as
it will be in the next five to seven years.
If you look at the access people will
have to simple tooth replacement because of the sophisticated imaging that
is now available, it is going to be a very
hot growth area. Also, general dentists
will be able to do some of those procedures.

When talking about the future of oral
health in general, what challenges,
changes and chances lie ahead of us?
Governments have to decide, how
much they want to invest in preventive
oral health as a way of enhancing overall
health, as well as basic dental hygiene.
There has not been much uniformness
in the countries around the world that
are approaching this issue. The data that
I have been seeing from longer term clinical studies absolutely show that if you
improve the overall oral health of a population, you will see benefits five to seven
years later, because oral health is a predictor of general health.
The reimbursement paradigms particularly in Europe about how we should
approach prevention and really improve our overall oral health are going
to be critical. I think it is a great investment for governments to make and if the
governments are not investing as much,
we have to start thinking about how we
can collectively do so as an eco-system.
Whether it’s the manufacturers, the media or the practitioners, we really have
to educate the public that prevention
is a very inexpensive way of preventing
much more expensive outcomes later.
I am really optimistic about the technologies we are bringing out and that we
can help do an even better job of clinically educating dental professionals. I
expect this to be the next big change
in the amount of oral healthcare expenditures that will be seen globally. If the
governments figure that out and step
up—great. If they do not, we are going
to have to do the job of educating the
population.
Mr Casey, thank you very much for
the interview.

contact
Dentsply Sirona –
The Dental Solutions Company™
Sirona Straße 1
5071 Wals/Salzburg, Austria
Phone: +43 662 2450-0
www.dentsplysirona.com

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[36] =>

| interview
“Mini implants can be used in
cases where a conventional
system would be problematic
or the amount of preparation
prior to ﬁtting an implant
would be too high.”

Jan Kielhorn

Mini in size, high in standard
Jan Kielhorn from Öhringen, a town in the Southwest
of Germany, is a dentist specialising in oral
surgery. In this interview, he talks about how
he has extended the spectrum of therapy he
offers, by using mini implants. To him, there
are several convincing arguments for
mini implants offering an alternative to standard implants, especially when a minimally invasive
solution is required. He has
spent the past few months
working with the implant system CITO mini® (Dentaurum
Implants) and thus presents
what advantages these mini
implants have to offer and why
he prefers to use this system
rather than others.

Fig. 1: Cross section of a jaw with CITO
mini® implant and ﬁtting matrix.

4 2018

Mr Kielhorn, why have you chosen to establish mini
implants as part of your treatment concept?
First and foremost, I wanted to offer my patients
as many options as possible when it comes to implants. Mini implants can be used in cases where
a conventional system would be problematic
or the amount of preparation prior to fitting
an implant would be too high. Many patients consult my practice wanting implant rehabilitation but, at the same
time, wanting to avoid extensive surgery. In such cases, I can offer them
comparatively minor surgical intervention by using mini implants.
Which indications warrant the
use of mini implants?
The classic case is when a
complete denture needs fixing, but there is a wide range
of options. A modern implant
system can cover many indi-

[37] =>

What did you find convincing about
CITO mini® implants?
The fact that the system is very similar to modern standard implants, yet
they are one-piece mini implants. Their
characteristics are practically equivalent
to standard implants, and they can be
safely used for the above-mentioned indications.
What exactly are the advantages in
comparison to other mini implants?
Work with a professional kit is important to me—this implant system
offers just that. The implants are delivered in gamma-sterilised double packaging. They can be removed from the
packaging contact-free using an insertion key (PentaGrip) and can then be
inserted either with a manual or a
power-assisted intermediate handpiece.
The self-tapping thread ensures atraumatic implant insertion at a steady insertion torque, as well as high primary
stability. The external geometry of the
implant is cylindrical/conical, so we
can assume a uniform, gentle loading
of the bone avoiding local overloading
and tension peaks that might damage
the bone.

How important is the implant surface
to you?
Very important, since it greatly determines successful osseointegration.
In the case of CITO mini® the implant
surface is inspired by two-piece implant systems. In the osseous region,
the implant surface is blasted, etched
and adapted to the cellular structure
of the bone. In the shoulder region,
the implant is polished favouring gingival apposition. Summarising, it can be
said, that the mini implant I use, can
in many ways be compared to a conventional system. As a user, I have a
professional kit at my disposal which I
can offer my patients as an adequate
alternative to a standard implant—it is
an ideal addition to the daily implantological practice.

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Osgide®
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Tel.: +49 6027 / 40 900 - 0
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Thanks for this interview, Mr Kielhorn.
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r
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Jan Kielhorn
Specialist for oral surgery
Praxis Whiter
Verrenberger Weg 15
74613 Öhringen, Germany
Oehr@whiter.dental
www.whiter.dental

Osbone®

How are the prosthetic components
connected?
By means of a ball abutment—a triedand-tested technique. The abutment
of this one-piece implant serves as a
patrix. Configured O-ring matrices are
offered to fit onto the patrix, thus ensuring a stable connection between

implants and tooth-borne telescopic
restorations. The force needed to remove the denture is similar to that of
a telescopic crown. Another advantage is that depending on the indication and the amount of work that can
be involved, a choice can be made between direct processing (without models or laboratory implant) and indirect
processing (in a laboratory).

Bo Gu
ne ide
Re d T
ge iss
ne ue
ra &
ti
on

cations, for example when the number
of abutments needs to be strategically
increased in order to retain partial dentures. If teeth already display periodontal damage or have undergone endodontic treatment, it makes sense to
insert mini implants, for example if the
dorsal arch is shortened. Mini implants
can help to avoid any lever action on
the terminal abutment teeth. They can
also be used in cases of reduced remaining dentition. Often, only a few implants are required to return stability to
existing dentures. Moreover, mini implants are often used as an intermediate
solution in the course of conventional
implant therapy.

[38] =>

| manufacturer news
Nobel Biocare

Dynamic navigation added to digital workflow
At the 2018 annual scientific meeting of the European Association for Osseointegration (EAO) in Vienna, Nobel Biocare announced the next step in its digital workflow. Being officially
launched there for the European market, X-Guide offers a new
treatment option for same-day surgery, with DTX Studio Implant
(formerly NobelClincian) empowering this system for dynamic
3D navigation. This way, treatment plans from DTX Studio Implant can be instantly delivered to the patient, facilitating a workflow for diagnostics, implant planning and dynamically navigated
implant surgeries. X-Guide then provides lag-free 3D intraoral
guidance of the drill in real time. “With DTX Studio Implant and
X-Guide, clinicians can achieve high precision shorter time-toteeth treatments, including screw-retained provisionalisation
with full three-dimensional control of their implant site preparation and dynamically monitored implant insertion,” Dr. Pascal
Kunz, Vice President Product Management Digital Dentistry at
Nobel Biocare said during the presentation at the company’s EAO
booth. X-Guide is manufactured by X-Nav, an exclusive partner
of Nobel Biocare.
Nobel Biocare Services AG
P.O. Box
8058 Zürich, Switzerland
www.nobelbiocare.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.

4 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. Find out more at: pure.straumann.com.
Institut Straumann AG
Peter Merian-Weg 12
4052 Basel, Switzerland
www.straumann.com

[39] =>

manufacturer news

Zest Dental Solutions

Newly improved
attachment system
The LOCATOR R-Tx removable attachment system is the fourth
generation of award-winning patient-removable attachment
systems from Zest Dental Solutions. The new abutment coating
is 30 per cent harder with over 25 per cent greater wear resistance, and nearly 65 per cent reduction in surface roughness.
The narrower coronal geometry of the abutment and the dual engagement of the retention inserts on the outside of the abutment
allow patients to easily align and properly seat their overdenture,
decreasing potential deformation of inserts, which could lead to
premature wear.
The system utilises the standard 0.050 in/1.25 mm hex drive
mechanism and treats up to 30° of angle correction using a single set of redesigned retention
inserts with straightforward
retention values: zero, low,
medium, high. In addition,
all of the necessary components for each individual
case are shipped in one convenient vial.
LOCATOR R-Tx is a better,
simpler, stronger attachment
system and comes with a 100 %
Satisfaction Guarantee to prove it!
Zest Dental Solutions
2875 Loker Avenue East
92010 Carlsbad, CA, USA
www.zestdent.com

Anthogyr

New material
for customised prostheses
Anthogyr is now adding a new ceramic to its line of CAD/CAM
customised prostheses: Sina ML. Highly durable (> 1,150 MPa),
it requires no ceramisation and reduces the risk of chipping. This
multi-layer zirconia combines strength, beauty, and biocompatibility for single and multiple implant- and tooth-supported prosthetic restorations.
With the new Sina ML available in seven shades, Anthogyr expands
the line of zirconia in its catalogue, which includes Sina Z (opaque)
and Sina T (translucent), each available in 16 shades.
In addition, angulated access is available on Simeda® customised
prostheses with an integrated inLink® connection in three different
materials: medical grade V titanium, cobalt-chromium and zirconia. They are also available for Simeda® prostheses on multi-unit
abutments for Axiom® BL, and for Connect+ ® prostheses with
Nobel Biocare® multi-unit abutments.
Anthogyr Group
2237 Avenue André-Lasquin
74700 Sallanches, France
www.anthogyr.com

curasan

New application video: Alveolar management

Application video

In his current video, Dr Marjan Stojanovski from Skopje, Macedonia,
demonstrates how fast and easy an alveolar ridge preservation in
the aesthetic zone can be achieved with CERASORB® Foam.
In the case shown in the video, not only the defect is filled, but for
aesthetic and functional reasons, also the crown of the extracted
tooth was used as a space holder. Thus, allowing the patient to
maintain his daily routine. At the end of the video, the one-day
postoperative situation is documented.
Its versatility and easiness of use make CERASORB® Foam
a product of choice for intelligent alveolar management.
curasan AG
Lindigstraße 4
63801 Kleinostheim, Germany
www.curasan.de

4 2018

[40] =>

| manufacturer news

Planmeca

Your key to a fully digital implant workflow
These days, creating implant plans and taking them to actual surgery is easier than ever before, as the Planmeca Romexis Implant
Guide software supports all the required steps in a fully digital
implant workflow. Everything is controlled and completed with the
same software platform—from imaging and scanning to designing and implant guide manufacturing.
Users can capture all needed CBCT images and intraoral scans,
perform prosthetic-driven implant planning using the software’s
comprehensive implant library, and design a surgical guide with
a few simple clicks.

Romexis is an open software, which means data can be smoothly
imported from other systems and completed guide designs exported in STL format without extra fees. The Romexis Implant Guide
module allows designing 3D printable guides for both single and
multiple implants—or even fully edentulous cases.
Planmeca Oy
Asentajankatu 6
00880 Helsinki, Finland
www.planmeca.com

MIS

Makeathon—An unforgettable experience for all
In June 2018, MIS held its first Makeathon—a two-day brainstorming event for young engineers, doctors, students and thinkers in general. After an introduction from MIS CEO Idan Kleifeld,

familiarising the participants with the mission and vision of the
company, the first day continued with several fascinating and
eye-opening lectures by key speakers, from both the dental world
and outside of it.
After a tour of the production facilities, the participants were divided into groups and started to formulate their ideas and work on
their presentations. Throughout the entire process, the Makeathon
mentors offered advice, vast personal experience and knowledge
on what would work best according to the requirements and
limitations.
On the second day, each group presented their ideas to the
panel of judges. The high-level competition resulted in a thirdplace winner and two teams who tied for first place. Tali Jacoby,
product manager and lead organiser of the event, was extremely
pleased with the outcome, saying “MIS is proud that we can
support young doctors, engineers and students in order to come
up with new and fascinating ideas together. […] This is a fantastic platform for introducing new technologies which are still
unknown to clinics.”
MIS Implants Technologies GmbH
Simeonscarré 2
32423 Minden, Germany
www.mis-implants.com

40

4 2018

[41] =>

Dentsply Sirona

Thousands of dental professionals at Dentsply Sirona World
Attendees experienced a one-of-a-kind conference from 13 to
15 September at the Dentsply Sirona World in Orlando, USA. The
company presented many new products while hundreds of workshops showed dental professionals how to make their work even
easier, faster and safer.
Topics ranged from introductory to expert at the 200 breakout
sessions available within 12 educational tracks. Hands-on sessions provided attendees the chance to learn from industry experts in a collaborative space allowing them to apply and test their
knowledge on the spot. A special highlight was the live surgery,
held during the opening general session. A patient was fitted with

a bridge produced with CEREC SW 4.6 for the already-placed
implants, which had previously had a screw-retained temporary
restoration.
The ultimate objective was for event attendees to leave with ideas
on how to improve their daily work within their practice and to
expand their network of peers.
Dentsply Sirona
Sirona Straße 1
5071 Wals/Salzburg, Austria
www.dentsplysirona.com

MEDENCY

State-of-the-art diode laser technology
The Italian company MEDENCY has been built upon profound
global expertise in the dental market and dental lasers in particular. “Our flagship product PRIMO combines state-of-the-art
diode laser technology with innovation and the experience of
MEDENCY in the dental industry. PRIMO provides a variety of applications and is thus a viable alternative to conventional surgical
methods like electrocautery and the scalpel. Owing to its intuitive interface, the device is easy to use,”
stated the company’s general manager,
Alessandro Boschi.
All products are designed, engineered and manufactured in Italy—
with passion and commitment. “Our
overall mission is to deliver a combination of cutting-edge products,
services and interaction with customers drawing on a wide network of
academic partners,” said Boschi.
The company supports its partners
with tailor-made educational courses
in different countries in order to gain
practical experience in the use of the

system in daily practice. Using dental laser technology has never
been so easy.
MEDENCY Srl
Piazza della Libertà 49
36077 Altavilla – Vicenza, Italy
www.medency.com

4 2018

[42] =>

| events

Essential guide for clinical
practice in implant dentistry
Sixty top scientists from around the world participated
in the 2018 EAO Consensus Conference, which was held
in Switzerland in February. The European Association for
Osseointegration (EAO) has now published an essential
guide for practitioners in the field of implant dentistry. It
provides an accessible summary of the findings from the
2018 conference and shines a light on many challenges
currently facing clinicians.
The EAO Consensus Conference takes place every
three years. During the event, leading experts are invited
to discuss emerging techniques and hot topics in the field
and come up with their recommendations for best practice. Their findings are then published in Clinical Oral Implants Research as a comprehensive, open-access supplement. In order to disseminate the findings and make
them more accessible, the EAO has published its Key
points for clinical practice. The report was written by a
group of dentists who were invited to attend the conference to observe the discussions. It provides a clear
summary of the findings and gives readers key facts to
include in their clinical practice. The topics selected for
discussion during the 2018 EAO Consensus Conference were particularly relevant to clinical practice. Par-

ticipants tackled the themes of drugs and diseases, biological parameters, reconstructions, and biomechanical
aspects. These were broken down into several subtopics
and debated at length. Key points for clinical practice follows the same structure and covers each topic in a helpful question-and-answer format.
The EAO has developed a dedicated microsite to allow
users to explore the report. It has also been translated
into ten languages (English, Spanish, French, Portuguese, German, Italian, Russian, Korean, Japanese and
Chinese), and all editions will be available to download
from the microsite (www.eao.org/mpage/Keypoints). In
addition, a version translated into Swedish will be published in the Journal of the Swedish Dental Association.

contact
EAO Office
38 rue Croix des Petits Champs
75001 Paris, France
www.eao.org

Fig. 1: The drugs and diseases working group at the 2018 EAO Consensus Conference.

[43] =>

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[44] =>

| events

1 Future Congress
sets new standards
st

The DGZI is the most traditional European expert association of dental implantology. Right from the start,
the association has provided decisive impulses without which modern implant dentistry as one of the absolute trend disciplines of modern dentistry would not be
conceivable today. Today, the field of dental implantology undergoes a development in the interplay of practitioners, universities and industry, which was almost unimaginable. In this context, it is important for the DGZI
to stay up to date and constantly face the new challenges of a rapidly developing training landscape. Thus,
not only the competition has become stronger, but also
the members of the DGZI, the participants in the DGZI
congresses and curricula meanwhile set different premises. Efficiency, practical utility and a varied scientific
programme are more and more in the spotlight today.
At a general meeting held prior to the congress, new
DGZI board members were elected. By a large majority,
the Cologne-based dentist Dr Arzu Tuna was elected
as Second Vice President. Her focus is on promoting
young researchers and integrating young colleagues
into the DGZI. Prior to her election as a board mem-

ber, Dr Tuna has worked as member of the jury at both
the DGZI Implant Dentistry Award 2018 and the Poster
Award, which were presented within the context of the
Digital Poster Presentation at the 1st Future Congress.
By electing dental technician Oliver Beckman as new
assessor at the board and, thus, including a young and
engaged in the work of the association, the DGZI was
highlighting dental competence once again. In addition,
the association aims to put an increasingly strong focus
on the collaboration between dentists and dental technicians in the future.
From 28 to 29 September, the DGZI was hosting their
1 Future Congress in Düsseldorf, Germany. The event
was held under the motto “Visions in Implantology” and
its overriding aim was to offer new approaches with a
clear eye on the future. Since there is a decrease in the
number of participants at the congresses of the well-established implantology expert associations, the DGZI had
to come up with something fresh and unique: 250 dental
participants and 120 practice employees were experiencing a forward-looking congress that was both raising
and answering new questions, and pointing to new apst

[45] =>

events

|

Fig. 1
Fig. 1: The DGZI board renewing itself. From left: the recently elected assessor Oliver Beckman and the new Second Vice President Dr Arzu Tuna, Dr Rainer
Valentin, Dr Georg Bach and Dr Rolf Vollmer. Fig. 2: The table clinics, which were occupied up to the last seat.

proaches in interaction with participants, speakers and
industry representatives. The high demands on content
were reflected in an entirely new organisational concept. To sharpen its profile as practical and application-
oriented event, the congress was no longer split into
separate speaking stages, workshops and side pro
grammes. Instead, it was divided into a so-called industry day on Friday, featuring strategy talks, live-surgery

broadcasts and table clinics, and a science-oriented
Saturday. This setup guaranteed that individual demands—especially from implantologists—were met
and satisfied. Both a surgical treatment and a tutorial
held in the Competence Centres of Leipzig and Bad
Oeynhausen were broadcasted live using a fascinating
multi-channel streaming technology, which showcased
the direct implementation of a digital workflow into the

Fig. 2

45

[46] =>

| events

Fig. 3
Fig. 3: The 1st Future Congress of the DGZI aimed to raise new questions.

daily practice. Thus, DGZI members abroad, who were
not able to attend the congress in Düsseldorf, had the
unique opportunity to experience the work of their renowned colleagues. In doing that, the DGZI was breaking new ground once again. By performing a surgery
on the topic of “The iSy way—one click, one scan, one
shift. Minimisation as the key to success”, for instance,
the surgeon trio of Dr Thomas Barth, Christian Barth and
Dr Stefan Ulrici were showing that a minimalist approach
can be effective applied to various aspects of the dental practice—from surgical protocols to the digital workflow. Moreover, Dr Jochen Tunkel from Bad Oeynhausen

 ontributed to the programme by presenting flawlessly
c
documented patient cases and sharing his experiences
regarding the peel technique on Friday morning. Dr Tunkel was excellently presenting explaining the medical
procedure, with his main focus being on its safe and
long-term stable application.
Instead of a parliamentary seating facing the stage,
there were round tables resembling a banquet seating,
which was an unusual sight. At these tables, each of the
exhibiting companies gave demonstrations on a wide
variety of different special topics and the accompanying

Fig. 4: The Japanese delegation visiting the congress, as every year, completing the expert examination.

Fig. 4

46

4 2018

[47] =>

events

Fig. 5
Fig. 5: The operation performed by Dr Jochen Tunkel was streamed live, supported by Straumann.

discussions proved to be very insightful. This new format
was accepted very well by both the participants, as well
as the dental exhibitors.
Both the table clinics and the exhibition concept, which
were a spatially integral part of the programme, gave
rise to the significance of the industry. By using modern tools such as the Future Podium, innovative presentation techniques or interactive solutions, the congress
aimed to resemble a congress trade fair. In addition, Digital Poster Presentations (DPP) were yet another highlight of the event: On both congress days, internet-based

Fig. 6: Dr Dr Ralf Smeets presenting his digital poster.

and interactive DPP were held in the DPP Lounge, right
in front of the conference hall, with the posters also being
available on mobile devices. The working group headed
by Dr Dr Ralf Smeets proved particularly diligent and
successful: The Hamburg-based team was awarded
first, second and third place.
With a catering concept based on “flying services” and
without considerable breaks between lectures, live surgeries and table clinics, participants, speakers and industry representatives were given significantly more time
and space to communicate with each other.
The goals of this modification were future orientation,
organisational modernity, content attractiveness and a
new way of presenting perspectives in order to reach a
new level of interaction from the different perspectives
of science, practice and industry. The 1st Future Congress in Dental Implantology was in particular addressing the question of what implantology will look like in five
or maybe ten years. Ultimately, apart from scientific and
technological aspects, it was also about strategic questions with regard to the implantological practice of the
future. In Düsseldorf, the DGZI once again proved its
importance and attraction, also in view of the 50th anniversary of its foundation, which is due to happen in 2020.
The 2nd Future Congress will be held under the theme
“Perio-Implantology: Implants, Bone and Tissue” from
4 to 5 October 2019 in Munich, Germany.

contact

Fig. 6

DGZI Central Office
Paulusstraße 1
40237 Düsseldorf, Germany
sekretariat@dgzi-info.de
www.dgzi.de

4 2018

[48] =>

| news
Dental professionals from around the globe

To gather in Las Vegas next June

Nobel Biocare invites dental professionals from around the globe
to join its upcoming Global Symposium, which will be held from
27 to 29 June 2019 at the Mandalay Bay Hotel and the Convention
Center in Las Vegas. The event will offer a great number of lectures, master classes and hands-on sessions, as well as original
solutions that range from smarter implant designs and site-preparation techniques to new digital solutions designed to further

enhance the patient treatment.
The upcoming event will feature
a change of location and venue.
Significantly expanding in size, it
will welcome up to 3,000 dental
professionals from around the
globe. The scientific committee,
led by Dr Peter Wöhrle from the
US, comprises many renowned
experts in implant dentistry
and oral rehabilitation. The programme will, furthermore, feature
a large number of expert speakers
consisting of world-class researchers, clinicians and laboratory
technicians. Moreover, participants will be given the opportunity
to choose different streams to create an individualised programme
tailored to their own interests and treatment goals. You can now
register for the 2019 Nobel Biocare Global Symposium online.
Source: Nobel Biocare

Future “Simplantology”:

The convergence of evidence and digital innovation
From 18 to 19 October 2018, Alpha-Bio Tec hosted a two-day educational congress for European customers in Monte Carlo, Monaco.
The congress, designed for global dental professionals, was an
opportunity to share implant expertise. In addition, the latest
trends in the implantology market were presented. Dental professionals from around the globe were exposed to various topics
related to advanced 3D imaging and CAD/CAM technologies.
Participants had the opportunity to learn from comprehensive
clinical cases, as well as evidence-based advanced treatments
and techniques. Alpha-Bio Tec also addressed the company’s

core value of “simplantology”, based on the convergence of scientific evidence and digital innovation. Yuval Grimberg, General
Manager at Alpha-Bio Tec, stated in his congress speech that the
company’s focus is on providing dentists with simple solutions
that aim for good aesthetic results. The company is continuously developing products and providing international training
and educational programmes, thus delivering on the demand for
patient-oriented solutions.
Source: Alpha-Bio Tec

[49] =>

news

Researchers trial new protocol for

Management of peri-implantitis
Peri-implantitis is one of the most frequently occurring pathological
conditions that dentists and dental hygienists face. So far, however,
there is no gold standard of treatment, nor randomised clinical trials in
the literature comparing surgical and non-surgical treatment. Italian
scientists have now found promising results with a new non-surgical
protocol in their study, titled, “A new multiple anti-infective non-surgical therapy in the treatment of peri-implantitis: A case series”.
The researchers, led by Dr Magda Mensi, Assistant Professor of Periodontology, Oral Surgery and Implantology at the University of Brescia in Italy, embarked on a pilot study in 2013 to determine whether a
combination of low-abrasion powder, topical antibiotic and curettage
could be more effective against severe peri-implantitis than conventional mechanical debridement. Mensi thus developed the multiple
anti-infective non-surgical therapy (MAINST) protocol and utilised
it on 15 patients with dental implants affected by peri-implantitis.
The patients underwent quarterly maintenance sessions and were
instructed to use personalised home care instruments, like sonic
toothbrushes and floss. “The patients have to be educated in plaque

and calculus removal, motivated
to carry out this maintenance at home,
and show up for their dental sessions. If they
come back only when there is a problem, it will be
too late,” Mensi emphasised.
After 12 months of continued observation, a 4.0 mm reduction in probing pocket depths, an attachment level gain of more
than 3.7 mm and a bleeding on probing rate of only 6.5 per cent
were observed. The implant survival rate was 100 per cent. Mensi
added that the results of the study so far indicate that the MAINST
protocol could become the gold standard of treatment for peri-implantitis. A randomised control study shall validate this hypothesis.
Source: DTI
© Mitand73/Shutterstock.com

Dragonfly-inspired implant design shall

Crestal bone preservation

Prevent post-surgery infection

Researchers from the University of Kentucky, USA, and the University of Dammam, Saudi Arabia, investigated the impact of a
microthreaded neck design in implants on crestal bone preservation, which is essential for implant stability. For the study titled
“Microthreaded implants and crestal bone loss: A systematic
review” 23 articles published between January 1995 and June
2016 and obtained via relevant keyword search on three electronic
databases were analysed.
As a result of the analysation the scientists concluded that the
addition of deeper threads on the implant allowed for greater
stabilisation between the implant and the bone, especially with
weaker bone. Further it was found that less crestal bone was lost
with dental implants that had a microthreaded neck design than
with those with a machined surface or conventional rough surface.
The findings demonstrate that geometry does affect the amount
of stress and strain on the implant, shape may thus contribute to
better primary implant stability.
The researchers recommended additional trials
to evaluate how bone loss might be affected
by different implant types. Furthermore,
they suggested that future studies
should use standardised imaging techniques to evaluate the placement of
implants with a microthreaded neck
design in bone-augmented
sites.

Cell biology researchers are partnering with nanotechnology experts to fight post-surgery infection by creating implants based on
dragonfly wings. Working
c om
ck .
o
t
s
with leading surgeons
t te r
/ S hu
r
e
t
is
and an Australian orthok hm
Tse
©
paedic medical device
company, researchers from the
University of Adelaide and University of South Australia will use nanomodification technology to reduce the
risk of infection after surgery.
The bacteria-destroying qualities of
the dragonfly were first identified by Australian scientists who observed bacteria being killed
on the insects’ wings, characterised by tiny spikes—
nanopillars—of about one thousandth of the thickness of a human
hair. The researchers are thus carrying out diverse experiments to
test whether mimicking the nano-patterns of the dragonfly wing on
implants can kill harmful bacteria that cause infections.
The four-year project could achieve a critical breakthrough in the
global fight against antibiotic resistant bacteria. The researchers
from the Adelaide-based institutions will combine their expertise
to create titanium implants with the dragonfly wing surface while
confirming their safety and testing their bacteria-killing properties.
The new technology could thus be of use in any field where surfaces are subject to high levels of bacteria.

Source: DTI

Microthreaded dental implants promote

Source: The Lead South Australia

4 2018

[50] =>

| about the publisher

Congresses, courses
and symposia

implants
Imprint

AO Annual Meeting
13–16 March 2019
Venue: Washington DC, USA
www.osseo.org/annual-meetings

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

Designer
Sandra Ehnert
s.ehnert@oemus-media.de

CEO
Ingolf Döbbecke
doebbecke@oemus-media.de

Theresa Weise
t.weise@oemus-media.de

Members of the Board
Jürgen Isbaner
isbaner@oemus-media.de
Lutz V. Hiller
hiller@oemus-media.de

Giornate Veronesi
3–4 May 2019
Venue: Verona, Italy
www.giornate-veronesi.info

5th Annual Meeting of ISMI
10–11 May 2019
Venue: Constance, Germany
www.ismi-meeting.com

Chief Editorial Manager
Dr Torsten Hartmann
(V. i. S. d. P.)
hartmann@dentalnet.de
Editorial Council
Dr Rolf Vollmer
info.vollmer@t-online.de

26–28 September 2019
Venue: Lisbon, Portugal
www.eao.org

49th DGZI International
Annual Congress—
Visions in Implantology
4–5 October 2019
Venue: Munich, Germany
www.dgzi-jahreskongress.de

4 2018

Published by
OEMUS MEDIA AG
Holbeinstraße 29
04229 Leipzig, Germany
Tel.: +49 341 48474-0
Fax: +49 341 48474-290
kontakt@oemus-media.de
Printed by
Silber Druck oHG
Am Waldstrauch 1
34266 Niestetal, Germany

Dr Georg Bach
doc.bach@t-online.de

implants

Dr Suheil Boutros
SMBoutros@aol.com

with the German Association of Dental
Implantology (DGZI).

Editorial Office
Georg Isbaner
g.isbaner@oemus-media.de

DGZI
DGZI Central Office
Paulusstraße 1
40237 Düsseldorf, Germany
Tel.: +49 211 16970-77
Fax: +49 211 16970-66
office@dgzi-info.de

Johannes Liebsch
j.liebsch@oemus-media.de
Executive Producer
Gernot Meyer
meyer@oemus-media.de
Product Manager
Timo Krause
t.krause@oemus-media.de

EAO Congress 2019

Customer Service
Marius Mezger
m.mezger@oemus-media.de

international magazine of oral
implantology is published in cooperation

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

Art Director
Alexander Jahn
a.jahn@oemus-media.de

and will appear with one issue every quarter in 2018. The magazine and all articles and illustrations therein are protected by copyright. Any utilisation without the prior consent of editor and
publisher is inadmissible and liable to prosecution. This applies in particular to duplicate copies,
translations, microfilms, and storage and processing in electronic systems.
Reproductions, including extracts, may only be made with the permission of the publisher. Given
no statement to the contrary, any submissions to the editorial department are understood to be in
agreement with a full or partial publishing of said submission. The editorial department reserves
the right to check all submitted articles for formal errors and factual authority, and to make
amendments if necessary. No responsibility shall be taken for unsolicited books and manuscripts.
Articles bearing symbols other than that of the editorial department, or which are distinguished
by the name of the author, represent the opinion of the aforementioned, and do not have to
comply with the views of OEMUS MEDIA AG. Responsibility for such articles shall be borne by the
author. Responsibility for advertisements and other specially labeled items shall not be borne by
the editorial department. Likewise, no responsibility shall be assumed for information published
about associations, companies and commercial markets. All cases of consequential liability arising
from inaccurate or faulty representation are excluded. General terms and conditions apply, legal
venue is Leipzig, Germany.

[51] =>

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A metal-free
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Two-piece design available soon

Contact your local Straumann representative now or visit
pure.straumann.com

[52] =>

KNOWLEDGE

CHANGES

EVERYTHING

Nobel Biocare
Global Symposium
June 27 – 29, 2019, Las Vegas, USA
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Join us for three future-focused days in Las Vegas, featuring expert speakers, master
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[cover] => implants international No. 4, 2018

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Table of contents

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