implants international No. 4, 2021

Cover / Editorial / Content / The Implant Protection Plan (I.P.P.) - Innovative implant and periodontal maintenance protocol / The role of metallic nano- and microparticles in peri-implantitis / The Stable Tissue Concept / Sinus augmentation and simultaneous implant placement using one-stage Sandwich Technique / Alveolar deficiency management in maxillary lateral incisor agenesis / Immediate functional implants in the aesthetic zone of a heavy smoker / Fine dentistry and creative engineering go hand in hand / Manufacturer news / 50 plus one years into the future - An anniversary congress for German implantology / News / Imprint

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issn 1868-3207 • Vol. 22 • Issue 4/2021

implants
international magazine of oral implantology

research
The Implant Protection Plan

case report
The Stable Tissue Concept

events
50 plus one years into the future

4/21

[2] =>

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[3] =>

editorial

|

Dr Rolf Vollmer
First Vice President and Treasurer of DGZI

50 years of DGZI—a strong indicator
for European dental implantology
In celebration of the 50-year anniversary of the German
Association of Dental Implantology (DGZI), its third Future
Congress for Dental Implantology was held in Cologne in
Germany in early October. Owing to coronavirus-related
travel and other restrictions imposed by governments
worldwide, we had to celebrate our anniversary with a
delay of one year, but this did not hinder its success in any
way. We can proudly look back on a beautiful and worthy
celebration of half a century of European implantology
and a multifaceted, exciting congress. All in all, this oneof-a-kind event did full justice to the unique occasion.
As the oldest implantological expert society in Europe,
celebrating 50 years of our existence was truly a milestone for us. We used the special event in Cologne as an
occasion to reflect on the incredible developments that
dental implantology has undergone in the past 50 years
since our foundation by the visionary group led by Prof.
Hans Grafelmann. DGZI has accompanied and helped
to shape these developments from their very beginnings
until today. Moreover, through our anniversary congress,
we have succeeded in providing a visionary outlook of
what future implantology might offer in five to ten years
from now in terms of new clinical techniques and new
approaches to implantology in general.
We can proudly say that our valued guest speakers were
indeed the who’s who of European implantology and

contributed greatly to the scientific programme. Against
this background, I would like to express my most sincere
gratitude to the presidents and board members of the
German Society for Implantology (DGI), the German
Society of Oral Implantology (DGOI) and the other specialist societies who accepted our invitation to address
our congress participants and delivered truly insightful
lectures. Despite the undoubtedly competitive situation
between the various professional associations, the 2021
event in Cologne revealed something quite important:
on certain topics and in certain situations, those at the
forefront of German—and on a broader scale of course
European—dental implantology are united in their vision
of the future orientation of implantology. This is a strong
indicator for us!
In this spirit, I would like to extend warm and friendly
greetings to you and wish you enjoyable reading of
the last issue of this anniversary year of implants—
international magazine of oral implantology, as well as
a reflective time ahead of the Christmas season!
Sincerely yours,

Dr Rolf Vollmer

4 2021

03

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| content
editorial
50 years of DGZI—a strong indicator for European dental implantology 03
Dr Rolf Vollmer

research
page 20

The Implant Protection Plan (I.P.P.)

06

Drs Tiziano Testori, Giordano Bordini & Matteo Basso

The role of metallic nano- and microparticles in peri-implantitis

14

Dr Ioannis Papadimitriou

case report
page 30

The Stable Tissue Concept

20

Dr Kai Zwanzig

Sinus augmentation and simultaneous implant placement

24

Drs Fernando Duarte, Carina Ramos, Paulo Veiga & Marco Infante da Câmara

Alveolar deficiency management in maxillary lateral incisor agenesis

30

Dr Federico Berton
page 42

Immediate functional implants in the aesthetic zone of a heavy smoker 32
Dr Dr Branislav Fatori & Dr Inge Schmitz

interview
Fine dentistry and creative engineering go hand in hand

34

An interview with Dr Kai Zwanzig and Ric Donaca

news

Cover image courtesy of
Argon Dental / www.argon-dental.de
issn 1868-3207 • Vol. 22 • Issue 4/2021

implants

4/21

manufacturer news

38

news

48

events
50 plus one years into the future

international magazine of oral implantology

42

Dr Georg Bach

about the publisher
imprint

research

The Implant Protection Plan

case report

The Stable Tissue Concept

events

50 plus one years into the future

04

4 2021

50

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[1] Wen et al. J. Periodont. 2019, 1, 734.
[2] Schmitt et al. Clin Oral Implants Res. 2013, 24, 576.
[3] Kloss et al. Clin Oral Implants Res. 2018, 29, 1163.
[4] Solakoglu et al. Clin Implant Dent Relat Res. 2019, 21, 1002-1016.
[5] Kloss et al. Clin Case Rep. 2020, 8, 5.
References available at: www.biohorizonscamlog.com/references_minerossa
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[6] =>

| research

The Implant Protection Plan (I.P.P.)
Innovative implant and periodontal maintenance protocol
Drs Tiziano Testori, Giordano Bordini & Matteo Basso, Italy

Introduction
The last 30 years of world dentistry have undoubtedly
been characterised by the exponential growth of implantology, which has gone from being a discipline in
the hands of a few experts “to being a field of treatment
at many dental practices. There are several reasons for
this increase: firstly, surgical and prosthetic techniques
have been simplified over the years, repeatable protocols being certified by decades of literature, reducing
costs for the patient and limiting invasiveness and postoperative discomfort. In addition, many patients want an
aesthetic and functional restoration by means of fixed
implant prostheses as their first choice, rather than resorting to solutions such as removable prostheses or
fixed prostheses on natural teeth involving the prosthetic

“... modern implantology
is trying to address the
possibility of guaranteeing a
clinical result that endures
over time ...”
preparation of healthy teeth. Ultimately, it should not be
under-estimated that implantology has also increased
because it represents a source of income for the economic balance sheet of many healthcare facilities that
have decided to specialise in this field. However, the implementation of an oral implant rehabilitation, be it a single tooth or a complex solution, cannot and must not
today represent the end point either for the patient or
for the dentist and his or her team. Nowadays, thanks
to our knowledge, we have no difficulty in achieving
implant-based rehabilitation even in cases of severe
bone atrophy using regenerative techniques.
The critical point that modern implantology is trying to
address, not always successfully, is the possibility of
guaranteeing a clinical result that endures over time.

06

4 2021

To achieve this ambitious goal, it is crucial to design
an effective and feasible implant and periodontal maintenance protocol. We know that home maintenance
around implants can be more difficult than around
natural teeth because the techniques and instruments
to be used, in many clinical cases, are inevitably different from those used for natural teeth. In addition, we
may be confronted with the typical pathologies of implants, represented by mucositis and peri-implantitis,
subtle pathologies that are difficult to control and
whose differences from gingivitis and periodontitis we
have learnt about.1 According to studies on the prevalence of peri-implant disease,2 45% of patients show,
after an average of nine years, signs of mild periimplantitis and 14.5% medium to severe. In recent times,
we have gained knowledge about oral biofilm, discovering that the biofilm changes in its characteristics when
a pathology is established and that some pathologies,
such as mucositis and peri-implantitis, are characterised by a repetitiveness in the type of pathogenic
microorganisms present.3 Implant maintenance protocols, however, have not evolved alongside knowledge,
sometimes only introducing new instruments or technologies, such as laser therapy or phototherapy, and
some new antiseptic principles.

The concepts of periodontal and
peri-implant eubiosis and dysbiosis
One of the key points for the long-term success of a
patient rehabilitated with implants, which is no different
from that of a patient treated for periodontal disease,
is to establish a correct programme of supportive therapy and periodic follow-up that includes differentiated
recalls based on an analysis of risk factors and consequent classification into risk categories. The literature
and our decades of clinical experience have shown
that patients with treated periodontal disease are at
risk of having setbacks and developing a new disease
process.4 Thus, the implant patient or the periodontal
therapy patient should not and must not be considered a patient who after treatment, however successful, can return to being normal and be low risk. Based
on this scientific and clinical evidence, we can begin
to plan the future of our therapies, starting with the
biological basis of the problem and the new assump-

[7] =>

[8] =>

| research

implant protection plan

SUPPORTIVE THERAPY CLINICAL CHECKLIST
Name and Surname

Date

FOLLOW-UP

RISK ASSESSMENT
STAGE
STAGE
STAGE
STAGE

I A
II A
I B/C
II B/C
III A
IV A
III B/C
IV B/C

TYPE 0
TYPE 1

EVERY 2 MONTHS

EVERY 4 MONTHS

EVERY 3 MONTHS

EVERY 6 MONTHS

TYPE 2
TYPE 3

CLINICAL CHECKLIST

Full-mouth plaque score (FMPS) < 25%
Full-mouth bleeding score (FMBS) < 25%
Presence of periodontal pocket depth ≥ 5 mm
Clinical signs of mucositis

Clinical signs of peri-implantitis

YES
NO

YES
NO

YES
NO

YES
NO

YES
NO

YES

Tooth mobility

NO

Significant risk factor modification

Better

Worse
Adequate

Patient compliance

Not adequate
YES

Is this follow-up frequency appropriate for the patient?

However, when a pathological process of either periodontitis or peri-implantitis occurs, the oral biofilm
changes and a picture of dysbiosis5 of the oral microbiota emerges, there being a change in the relationships between the present species and that can trigger
an immune and inflammatory response. It is precisely
the inflammation created by the bacterial trigger that
feeds and often maintains the dysbiosis itself, leading
to chronicity of the condition. This alteration in the balance leading to the onset of disease is affected by many
variables or risk factors which can affect the patient’s
clinical situation at several levels.6 There is a solid body
of literature on the most important risk factors for periodontal disease, drawn from many clinical trials and a
smaller number of longitudinal studies.7, 8 This has made
it possible to identify some of these factors as being
strongly correlated with periodontal disease and, at
least regarding the current state of research, to suggest for others a correlation whose nature has yet to
be validated in detail.9–14

NO

New follow-up
frequency:
________________

1
Fig. 1: Operational checklist for maintenance sessions.

Risk factors include some that are modifiable and others
that are not. Among the most important modifiable factors are smoking, stress and diabetes, which we know
cannot yet be eliminated but is treatable and therefore
modifiable. Among the non-modifiable factors is genetic
predisposition, a generic and imprecise term that refers
to a host’s ability to modulate the quality of the immune
and inflammatory response differently and thus favour
the onset of disease. Other risk indicators whose correlation with implant and periodontal disease has yet to
be fully clarified include obesity, metabolic syndrome,
hypertension, cardiovascular disease, and osteopenia/
osteoporosis.

A cooperative patient–professional plan
tions linked to a more accurate knowledge of the oral
microbiota.
The oral microbiota is the set of microorganisms that live
and coexist in the oral cavity. It should be distinguished
from the concept of oral microbiome, which is the collective genomes of the microorganisms present. The
microbiota is made up of more than 700 different bacterial species, as well as numerous other microorganisms,
and in a healthy state it is in perfect balance with the
host, causing no harm and providing numerous benefits through the predigestion of food, antibacterial action,
and the secretion of enzymes. This state of equilibrium
is called “eubiosis”. It is important to emphasise that
a eubiotic microbiota may also contain species that are
considered pathogenic but which as part of a balanced
biofilm are not capable of inducing pathology. Thus, the
mere presence of periodontopathogenic species or
implant pathogens is no longer considered a sign of pathology, as it was in the past; they can at most be considered risk factors to which more attention should be paid.

08

4 2021

Once the biological bases currently considered valid
for a more scientific and modern understanding of periimplant pathologies have been clarified, other much more
practical and organisational aspects of maintenance
need to be investigated. First of all, not all patients are
the same: the selection of a good candidate for periodontal treatment or implant therapy should always be
made a priori, excluding those patients in whom the risk
factors described, or even who display an unsuitable
propensity and attitude regarding adhering to the practitioner’s requests and prescriptions (patients defined as
having a low degree of cooperation or compliance), are
not considered satisfactory. Sometimes it is not possible to select only ideal candidates, and even these, in the
course of their lives, may suffer a disease setback if not
properly motivated and followed up. Although a number
of periodontal and peri-implant risk assessment tools
have existed for years to assist clinicians in setting up
the most suitable maintenance programme possible,15, 16
there is no uniformity even among the most experienced

[9] =>

research

professionals.17 Furthermore, the patient undergoing
implant and periodontal rehabilitation often requires a
guarantee of duration of treatment, a need which goes
far beyond what medicine can offer but to which, nowadays, we cannot fail to provide a satisfactory answer.

implant protection plan

THERAPEUTIC ALLIANCE
IMPLANT/PERIODONTAL SUPPORTIVE THERAPY PLANNING

The aim of this scientific contribution is to suggest a protocol, the implant protection plan (IPP), that establishes
a therapeutic alliance between the treating dentist, the
dental hygienist and the patient at the end of the active
phase of periodontal or implant therapy. The IPP protocol provides for a shared maintenance pathway which
starts with the initial assessment of the patient and periodic re-evaluations, which are not an end in themselves
or a mere collection of clinical data, but determine actions and changes in the dental professional’s attitude
or that of the patient in order to optimise the periodontal and implant prognosis. The patient himself or herself
should feel involved in the IPP, share its purpose and not
play a passive role (Figs. 1 & 2).

Name and Surname

The first step in implementing the protocol is to assign
a periodontal or peri-implant risk profile. The dentist
determines a specific risk class on the basis of systemic and local risk factors, the presence or absence
of implants (patient with only natural teeth, patient with
natural teeth and implants, or patient with only implants)
in order to plan the frequency and manner of individualised maintenance therapy. The assessment of the
risk profile is therefore divided into a periodontal profile,
if the patient still has natural teeth, and a periodontal
framework in order to combine the two classifications
into a single patient risk class assignment. Assigning a
prognostic risk for a patient who has a partial natural
dentition is a process that requires cross-referencing
anamnestic information and elements from the objective examination and interpreting this data through
prognostic assessment. It is necessary to include in the

Date

INITIAL ASSESSMENT

1-YEAR ASSESSMENT
RISK CATEGORY

RISK CATEGORY
STAGE
STAGE
STAGE
STAGE

I A
II A
I B/C
II B/C
III A
IV A
III B/C
IV B/C

FOLLOW-UP

The protocol also includes an operational checklist with
all the factors that the hygienist has to check during the
session. This tool is designed to monitor the clinical
situation and alert the dental practitioner to any worsening of the patient’s clinical condition compared with
the baseline and to make consequent adjustments to
the current supportive therapy (e.g. shortening recall
times; Fig. 3).
The true innovation is to ensure that the patient does
not have to give up compliance because, in return for
a personalised maintenance programme set out in a
contract signed by both parties, he or she will be guaranteed specific treatments or interventions, such as
prosthetic replacement treatments, without any financial cost should any biological problems occur, but only
if he or she has complied with the maintenance sessions
agreed with him or her beforehand.

|

TYPE
0

6 months
4 months

TYPE
1

4 months

TYPE
2

TYPE
3

6 months

3 months
4 months

2 months
3 months

TYPE 0

STAGE

TYPE 1

STAGE

TYPE 2

STAGE

TYPE 3

STAGE

PATIENT COMPLIANCE

Medium/High
Low

Low
Medium

FOLLOW-UP

TYPE
0

6 months
4 months

TYPE
1

4 months

High
Low
Medium

TYPE
2

High
Low
Medium
High

I A
II A
I B/C
II B/C
III A
IV A
III B/C
IV B/C

TYPE
3

6 months

3 months
4 months

2 months
3 months

TYPE 0
TYPE 1
TYPE 2
TYPE 3

PATIENT COMPLIANCE

Medium/High
Low

Low
Medium
High
Low
Medium
High
Low
Medium
High

2
Fig. 2: Programming of periodontal and implant maintenance sessions.

analysis the patient’s medical and dental history, oral
and extra-oral radiographs and the main periodontal
variables (plaque index, bleeding on probing, probing
depth, recessions, furcation involvement, pathological
tooth mobility, bone profile) and to give the patient the
correct periodontal disease diagnosis (in terms of stage
and grade).18
Today, there are several tools and algorithms that
help us to plan the correct timing of maintenance sessions and, indirectly, to predict the patient’s prognosis.
It should also be pointed out that some of these collected variables, besides having a greater relative weight
(odds ratio) than others in influencing prognosis, offer
more information as indicators of disease progression.
The most important of these are smoking, diabetes and
a history of periodontitis.
In a recent review of the scientific evidence supporting
periodontal maintenance p
 lanning, the following was
19
emphasised:

4 2021

09

[10] =>

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implant protection plan

THERAPEUTIC ALLIANCE
FIRST VISIT: RISK ASSESSMENT

Name and Surname

Date

IMPLANT EVALUATION
TYPE 0 PATIENT

TYPE 1 PATIENT

TYPE 2 PATIENT

TYPE 3 PATIENT

Implant patient

Implant patient

Implant patient

Implant patient

• Absence of tooth loss due
to periodontitis

• Absence of tooth loss due
to periodontitis

• History of tooth loss due
to periodontitis

• History of tooth loss due
to periodontitis

• No risk factors

• Risk factors:

• No risk factors

• Risk factors:

Smoking

Smoking

Stress

Stress

Diabetes

Diabetes

Other__________________

Other__________________

PERIODONTAL EVALUATION
NOT TO BE FILLED IN FOR EDENTULOUS PATIENTS
FRAMEWORK FOR STAGING:
INTERDENTAL CAL* AT
SITE OF GREATEST LOSS
RADIOGRAPHIC
BONE LOSS
PERIODONTITIS
ASSOCIATED TOOTH
LOSS

I

II

III

IV

STAGE I

STAGE II

STAGE III

STAGE IV

1-2 mm

3-4 mm

≥ 5 mm

≥ 5 mm

Coronal third
(> 15%)

Coronal third
(15-33%)

Extending to the middle third
of the root or beyond

Extending to the middle third
of the root or beyond

No tooth loss
from periodontitis

No tooth loss
from periodontitis

Tooth loss from periodontitis
≤ 4 teeth

Tooth loss from periodontitis
≤ 5 teeth

GRADE A

GRADE B

GRADE C

Evidence of no loss
over 5 years

< 2 mm over 5 years

≥ 2 mm over 5 years

*Clinical Attachment Loss

FRAMEWORK FOR GRADING:

Longitudinal data
(radiographic bone loss
or attachment loss)

Direct
evidence of
progression

PRIMARY
CRITERIA

GRADE
MODIFIERS

Indirect
evidence of
progression

A

B

C

Percent bone loss/age

< 0.25

0.25 - 1.00

> 1.00

Case phenotype

Heavy biofilm deposits
with low level of destruction

Destruction commensurate
with biofilm deposits

Destruction disproportionate
to biofilm deposits

Smoking

Non-smoker

< 10 cigarettes/day

≥ 10 cigarettes/day

Diabetes

Normoglycaemic with or without
prior diagnosis of diabetes

HbA1c < 7,0%
in diabetes patient

HbA1c ≥ 7,0%
in diabetes patient

Risk Factors

3
Fig. 3: Assignment of risk class.

1) In healthy patients or those with mild forms of periodontal disease, stable clinical conditions can be maintained with six-monthly recalls. In patients with medium
and severe forms of periodontal disease, the scientific evidence suggests a maintenance protocol with
a greater frequency, varying in the literature from two
to four months.
2) Data from retrospective studies shows that the proportion of residual affected sites (residual periodontal
pockets with bleeding on probing) is an important variable in planning the frequency of visits. The efforts of
health professionals should aim precisely at reducing
these sites with disease both during the active phase of
therapy and during supportive therapy.
Less prolific in the literature are systematic reviews and
longitudinal studies on implant patient retention and prevention of peri-implantitis. However, as peri-implantitis
shares many risk factors with periodontal disease, it
is intuitive that implant patient maintenance planning

10

4 2021

will also have many common variables to consider.20–22
However, the key to the prevention of peri-implantitis
lies in the prevention of peri-implant mucositis. As reported by Jepsen et al., control of modifiable risk factors—smoking and bleeding on probing of residual
dentition—is crucial in controlling mucositis.23 Monje et al.
in a meta-analysis on the impact of maintenance in the
prevention of peri-implantitis emphasise the critical role
of a history of periodontal disease as modifying the incidence of mucositis and peri-implantitis.24 Numerous
works identify plaque control, bleeding on probing,
smoking and diabetes as the most important biological
variables to consider.25, 26
Having to classify, not a random sample of patients,
but a subcategory (patients with previous periodontal
disease and patients with implant restorations) with a
higher intrinsic risk,4 we decided to maximise the importance of the above-mentioned variables, set very strict
cut-off values and establish rather tight recall intervals.
Patients are thus divided into four classes of increasing
risk, which are re-evaluated by the treatment team on
a yearly basis with total transparency and in dialogue
with the patient.
It is much more effective to plan this phase for the duration
of one year (12 months from the date of initial planning),
as achieving good compliance and correct use of home
oral hygiene instruments often requires several months
and several professional recall sessions, during which
time positive reinforcement by the hygienist and dentist
will contribute to progressive improvement. The patient
himself or herself is actively involved in this decisionmaking phase, promptly informed of his or her risk status
and encouraged to excel in protecting the investment he
or she has made during the active phase of therapy.
The patient is motivated to scrupulously follow the
instructions of the hygienist, who has the authority to
suggest to the dentist after an observation period of
one year a different maintenance protocol according to
the degree of compliance demonstrated by the patient
and the clinical results obtained. This patient–hygienist
synergy has a twofold objective: it raises the status of
the hygienist, who, in the eyes of the patient, becomes
a professional figure empowered to propose a different treatment plan to the dentist; and it motivates the
patient to follow the hygienist’s therapeutic indications,
which, if put into practice, will save the patient both
time, because by spacing out the recalls the patient will
come to the practice fewer times, and economic resources, since reducing the maintenance sessions will
reduce the costs. The tangible saving of time and money
is an important motivating factor for most, if not all, patients
and is far more motivating than a generic invitation to
follow clinical indications, which are often under-estimated
and experienced by the patient as an imposition.

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Finally, the IPP protocol is an important instrument of
patient loyalty and involvement, similar to other contracts that patients sign every time they buy tangible goods and want to protect an investment. In this
specific case, the patient protects his or her own oral
health, which, as we know, also has repercussions for
systemic health,27, 28 an aspect that is increasingly clear
from the literature and becomes a motivational lever

“The therapeutic alliance
involving the dentist,
the dental hygienist and the
patient is the cornerstone of
long-term success ...”
for patients to take care of their restorations. As mentioned, patients increasingly demand a form of guarantee for the professional service in which they have
invested time and financial resources. It is universally
accepted, including by legislation, that in many areas of
medicine we cannot offer absolute guarantees similar to
the purchase of material goods. The IPP protocol represents, in our opinion and experience, a realistic and
professional response to patients’ demands for a guarantee that does not increase the risk of free prosthetic
remakes because, by reviewing patients according to a
tight and individually modulated recall schedule, mucositis can be intercepted and treated effectively before it
becomes peri-implantitis.
The protocol also allows the practitioner to have a
powerful communication weapon should a clinical
problem occur in patients who have refused the IPP.
In this regard, it is advisable to write down any refusal
in the medical record and have it countersigned by the
patient. Clinical experience over the past 40 years has
shown us that patients usually lose track of time and
think that they have been out of treatment for a few
years when in reality many more years have passed and
the patient has never shown up for his or her scheduled appointments. Having recorded even the nonacceptance of the PPI protocol allows the practitioner
to demonstrate his or her diligence and protects him
or her from possible medicolegal proceedings that
patient appear increasingly willing to bring in the event
of failure. We are convinced that, by protecting the
patient from biological problems that may occur, we
are fulfilling our professional duty in an ethical manner
and protecting ourselves by demonstrating our com
petence and diligence.

12

4 2021

Conclusion
The aim of establishing the IPP protocol is to help the
dental team to assign a future risk profile designed
specifically for the periodontal and implant therapy, not
neglecting the many variables that contribute to the
prognostic assessment but giving maximum emphasis
to those that evidence suggests are the most relevant.
The therapeutic alliance involving the dentist, the dental
hygienist and the patient is the cornerstone of long-term
success, there being a continuous flow of communication between the parties and periodic feedback to
recalibrate the most appropriate times and methods for
continuing to maintain health.
In its essence, the IPP protocol represents a modern
and innovative approach to the patient that is aimed
at: (1) effectively motivating the patient, who perceives
real and tangible benefits; (2) building patient loyalty,
because the practitioner offers protection that many
other practitioners do not offer, thinking it too risky for
the practice; (3) raising the professional profile of the
hygienist, who becomes a key player in maintaining
the results achieved by the dentist through treatment;
and (4) protecting the dental practitioner from possible
medicolegal proceedings, especially in those patients
with inconsistent compliance.

Author details

Literature

about the author
Dr Tiziano Testori is head of the implant dentistry and oral rehabilitation
section of the IRCCS Galeazzi Institute
in Milan in Italy. He is an adjunct professor in the Department of Biomedical,
Surgical and Dental Sciences of the University of Milan and an adjunct clinical
assistant professor in the Department
of Periodontics and Oral Medicine at the
University of Michigan School of Dentistry in Ann Arbor in the US.
He obtained his MD in 1981, his DDS in 1984 and a specialty
qualification in orthodontics from the University of Milan in 1986.

contact
Dr Tiziano Testori
ttestori@umich.edu

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| research

The role of metallic nano- and
microparticles in peri-implantitis
Dr Ioannis Papadimitriou, Germany
Dental implantology has become a fundamental com
ponent of oral rehabilitation and is closely associated
with prosthetic therapy. The aim of both implantology and
prosthetics is to replace a lost natural tooth and to achieve
restitutio ad integrum. To attain this goal, attempts have
been made with different materials and techniques for
many centuries. In the last few decades, metal implants
in particular have established themselves extremely suc
cessfully as an alternative to purely prosthetic therapies;
however, the extent to which these may have a negative
impact on the organism and the reasons for which they
can lead to inflammatory reactions must be examined
more closely.1, 2
In the middle of the twentieth century, Brånemark’s
Gothenburg research group first researched the bio

compatibility of different materials with bone and has
since triggered an uninterrupted upswing in dental im
plantology. It was found that implants made of pure
titanium have the ability to heal in the bone without any
signs of inflammation or rejection. Brånemark defined this
process as osseointegration, which includes all elements
of biocompatibility, a bio-inert material and bioactivity.1, 3
The term “biocompatibility” defines materials that have
no negative effects on living organisms. This is extremely
important with implants, as they remain in the living tissue
for a long time. Implant materials must also be bio-inert,
which means that no toxic substances may be released
from them over time. Bioactivity involves the creation of a
chemical bond between the implant and the surrounding
tissue.1, 3 Since Brånemark was able to demonstrate these
properties of pure titanium, it is now the material of first

1a

While natural teeth develop simultaneously with perio
dontal tissue to form a functional unit, endosteal implants,
being artificial, are made of inorganic material, for which
no artificial periodontium has yet been found. This consti
tutes a weak point regarding later peri-implant inflamma
tion.4, 5 The morphological differences between a natural
tooth and a titanium implant cause implants to be more
prone to inflammation.32 Overall, metals have good me
chanical properties, but their susceptibility to corrosion
and their possible release of metal ions and consequently
the sensitisation of the organism represent disadvan
tages. Therefore, collar-shaped stable soft tissue around
the implant protruding into the oral cavity is essential for
long-term success of an implant, including the prosthetic
restoration. The healing processes after implantation can
only start from a vital bone.6, 7

Periodontitis and peri-implantitis
Biofilm is mandatory for the development of periodontitis.
The bacteria from this infiltrate the periodontal tissue,
resulting in inflammatory reactions and subsequent irre
versible tissue damage. Risk factors such as nicotine and

1b

Figs. 1a & b: Clinical peri-implantitis.

14

choice for implants. An alternative to pure titanium is zir
conium dioxide, which also has very good biocompatible
properties. In addition, in medicine, other metals, metal
alloys, polymers and ceramics are used as biocompatible
materials.1, 3 Bone deposition on the titanium implant sur
face, important for osseointegration, was also confirmed
in many studies. Primary stability is achieved through
mechanical blocking.

4 2021

[15] =>

research

Figs. 2a & b: Corrosion on implants and the superstructure. Corrosion of the implant–abutment connection (a). Corrosion of the overdenture prosthesis (b).33

alcohol abuse, as well as systemic disease (e.g. diabetes
mellitus) or even stress, amplify the bacteria migration
into the tissue.6 Peri-implantitis is progressive peri-implant
bone loss with simultaneously inflammable and inflamed
soft tissue. Bacterial infection and biomechanical over
load are considered to be its triggers. Clinically and radio
graphically recognisable destruction is the result, since
the bone is more easily exposed to the inflammatory in
filtrate without a protective periodontal ligament. Since
peri-implantitis is clinically and microbiologically similar to
chronic marginal periodontitis, it is concluded that plaque
can cause peri-implant disease. However, it still remains
to be clarified whether a predisposition to periodontal dis
ease also favours peri-implant inflammation. Neverthe
less, it is recommended that alternative therapies to in
traosseous implants should be preferred in patients with
an increased susceptibility to periodontal disease.6, 8, 9–14
At the 2017 World Workshop on the Classification of
Periodontal and Peri-Implant Diseases and Conditions, periimplantitis was defined as “a plaque-associated patho
logical condition occurring in tissues around dental im
plants, characterised by inflammation in the peri-implant
mucosa and subsequent progressive loss of supporting
bone”. This definition does not take factors such as metal
particles or the cytotoxicity of metals into consideration.
Clinical cases of pronounced peri-implantitis are docu
mented in Figures 1a & b. The purulent secretion from the
peri-implant pockets is noticeable. The soft-tissue cuff is
no longer present, and the loss of bone can be guessed.
There is scientific consensus that periodontitis or periimplantitis is caused by excessive bacterial colonisation of
the gingiva caused by inadequate dental and oral hygiene.
It has been shown that progressive periodontitis occurs
more often in families. Although its origin is multifactorial,
genetic predisposition is important because some genes
have been isolated as risk factors, including the interleu
kin 1 gene, proteinase 3 and cathepsin.15, 16 Nanoparti
cles that gain access to the bone compartment during
implantation through the surgical instruments themselves
and through the implant insertion are increasingly being
researched as a cause and a trigger of peri-implantitis.

However, there is still no clearly defined standard or pro
tocol for the treatment of peri-implantitis. Owing to the
very high recurrence rate of peri-implantitis after one year
despite therapeutic intervention (surgical or non-surgical),
the question now arises of whether metal abrasion par
ticles from the implant surfaces maintain peri-implantitis.
No studies have compared non-surgical measures with
surgical measures.2, 17, 18

Nanoparticles
In the last 20 years, nanotechnology has experienced a
great boom. Particles below 100 nm are referred to as
nanoparticles. They are produced industrially, but also
occur naturally (for example viruses and in volcanic ash
and forest fires). They are characterised by their extremely
large surface in relation to their low mass. Nanoparticles
are mainly made from silicates and various metal ox
ides, including titanium and aluminium oxides. They can
be found, for example, in candies and in many skin care
products, especially sunscreens. Titanium dioxide parti
cles and zinc oxide are used as stabilisers. It was found
that orally ingested titanium dioxide particles are depos
ited in the intestine and in other tissue (peritoneal tissue,
liver, spleen, kidney and heart) without being excreted,
causing epithelial disorders, and chronic damage of the
intestinal cells can be triggered. In the case of intact skin,
evidence of titanium dioxide can only be detected in the
top layer of the epidermal layer.19 Nanoparticles are also
used in medicine. Owing to its higher efficiency and ac
curacy, nanoparticle-based fluorescent marking is indis
pensable in diagnostics and imaging. The use of nano
particles in pharmaceuticals has shown that they have
better bioavailability and effectiveness, fewer side effects
and, above all, reduced organ toxicity.20 Because of these
positive and negative aspects, the question arises as to
whether nano- or microparticles from implants or metallic
instruments lead to an increased risk of peri-implantitis
during implantation. Very little is known about the risks
and translocation of titanium dioxide nanoparticles from
implants or metallic instruments. The existing literature
from 2010 onwards should be examined for references

4 2021

[16] =>

| research

Figs. 3a–d: SEM images of the effect of Streptococcus sanguinis on the titanium surface. Titanium surface in artificial saliva enriched with S. sanguinis. Scale: 100 μm (a)
and without S. sanguinis. Scale: 100 μm (b). Enlarged view of Figure 4a (the arrows show S. sanguinis). Scale: 10 μm (c). Enlarged view of Figure 4c. Scale: 5 μm.24 (d).

to this, because the aspects of particle formation during
implantation have been investigated in more detail only in
the recent last few years.

Titanium properties
The grey colour of titanium is caused by the oxide layer that
forms on the surface immediately after the metal comes
into contact with oxygen and is 2–5 nm thick. This nor
mally very dense and chemically stable oxide layer gives
titanium its biocompatibility and mediates osseointegra

Figs. 4a–d: Detailed images of two implant–abutment connections under
masticatory load.31

4 2021

tion by allowing cellular adhesion molecules to accumu
late. In some cases, however, different types of corrosion
can be observed clinically: pitting, crevice and stress cor
rosion, and erosion (Figs. 2a & b).7, 21, 22 Pitting corrosion
occurs primarily and predominantly at the connection point
between the implant and the abutment, which can cause
crevice corrosion. As a result, a concentration of chloride
ions is created, which lowers the pH in the immediate
vicinity of the implant. Thus, the oxide layer on the titanium
implant dissolves irreparably and cannot renew itself due
to Streptococcus sanguinis. These bacteria form a barrier
to oxygen through a biofilm formed around the implant;
owing to the lack of oxygen, titanium ions and particles are
released from the complex titanium structure. On the one
hand, this inflames the tissue, and on the other hand, the
titanium implant continues to corrode. The saliva, which
can act as an electrolyte, also contributes to the perma
nent damage to the oxide layer because the corrosion is
supported by electrochemical processes in the mouth.23, 24
The extent of damage to the implant surface, which is sig
nificant, is shown in Figures 3a–d.24 In addition, Nakagawa
et al. found in a further study that pure titanium and tita
nium alloys corrode faster owing to the influence of fluo
rides at a low oxygen content, whereas without fluoride
they showed a higher corrosion resistance at the same
oxygen concentration.25 For this, the fluoride concentration
in commercially available toothpastes was considered,
which turned out to be too high and does not protect the
metals from corrosion damage.25

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[18] =>

| research
Metal abrasion during insertion
and its consequences
The original implant surface and shape can be modified
by the insertion procedure. A very deep insertion causes
greater damage to the bone and implant than a less
forced insertion. By torsion and friction of the implant on
the bone, titanium particles are released from the surface
structure of the implant into the already damaged bone
tissue. The size of the released titanium particles varies
between 10 nm and 20 μm. At the sharp edges of the
implant, the entire oxide layer is partially lost as a result
of the insertion. The loss of the oxide layer also depends
on the type of implant.26–28 Martini et al. showed that im
plants coated with fluoro-hydroxyapatite were less sus
ceptible to abrasion during insertion than plasma-coated
implants. Titanium particles released by plasma-coated
implants were found at a distance of 200–250 μm from
the implant surface and prevented neo-osteogenesis.
A deformation of the implant thread can be seen in the
area of the bone, especially in the form of microfractures.
Titanium abrasion can be found both in the peri-implant
mucosa and in the newly formed bone. Titanium particles
have even been detected in organs further away: the liver,
kidneys, lungs and heart.29, 30 In addition to the implant
insertion, the high mechanical loads on the connection
between the implant and the abutment are another factor
that contributes to the release of metallic particles. Com
plete implant failure can also occur as a result. In addition,
micro-gaps can form at the implant–abutment connec
tion, where titanium and metal particles can also loosen.
Microleakage, material wear, material fatigue and screw
loosening are other possible consequences that can result
from the micro-gaps. Microleakage is particularly evident
in hexagonal connections with a loose fit (Figs. 4a–d)
through which—in addition to metal abrasion and
material damage—liquids and bacteria gain entry to the
interior of the implant and cause internal corrosion of
the implant. The microgap movements can be reduced
by a conical connection between the implant and the
abutment.31

Conclusion
At the beginning of the implantology era, the focus was
on the euphoria about solving the problem of osseointe
gration, but in recent years, the question of the reasons
for a shortened lifetime of implants has moved increas
ingly into focus. Peri-implantitis, which sometimes turns
out to be therapy-resistant, was seen as a further indi
cation that, in addition to a lege artis insertion, factors
that lay the foundation for peri-implantitis during insertion
can be responsible for achieving osseointegration. Nanoand microscale titanium and zirconium dioxide parti
cles detach themselves from both the instruments and
the implants during insertion and the surgical, prosthetic
and aftercare phases. They can be detected in bone and

4 2021

other tissue and have only recently been shown to be
cytotoxic. According to the current research, the release
of these particles cannot yet be prevented regardless
of the implant surface. The metal and titanium ions and
particles dispersed into the peri-implant hard and soft
tissue trigger cellular reactions that can be compared to
aseptic chronic inflammation. This can lead to therapyresistant peri-implantitis and thus to failed osseo
integration.
Although these clinically and radiographically visible
peri-implant changes are very similar to periodontitis,
peri-implantitis is not always bacterial. For this reason, the
classic treatment concept for periodontitis cannot gen
erally be transferred to peri-implantitis. A concept for the
treatment of peri-implantitis that is not caused by bac
teria is not yet available. Particle-induced peri-implantitis
is often accompanied by osteolysis, which is clearly not
considered to be bacterial. In such cases, explantation
with thorough lavage of the bone cavity is necessary.
Further investigations are required to determine whether
and to what extent bone regeneration measures need
to be taken. Overall, however, the prevailing opinion is
that metallic nano- and microparticles are of no impor
tance in dental implantology. For this reason, the 2017
World Workshop on the Classification of Periodontal
and Peri-Implant Diseases and Conditions defined periimplantitis without including factors such as metal parti
cles and their cytotoxicity. However, it is expressly advised
that further research regarding metallic nanoparticles is
absolutely necessary owing to their potential danger.

Author details

Literature

about the author
Dr Ioannis Papadimitriou specialised
in oral surgery and holds an MSc in oral
implantology and periodontics from the
German Association of Oral Implantology
and the Steinbeis University in Berlin
in Germany. He is a senior physician at
the department of oral and maxillofacial surgery at the St Lukas hospital in
Solingen in Germany.

contact
Dr Ioannis Papadimitriou
giannis.papadimitriou_4@hotmail.com

[19] =>

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| case report

The Stable Tissue Concept
Dr Kai Zwanzig, Germany

In order to achieve long-term stable results, it is important not to disregard biological principles. Bone and
soft-tissue management should be an integral part of
the portfolio of implantologists, since stable tissue is the
basic prerequisite for implantological success. To this
end, hard- and soft-tissue augmentation must be performed with materials adapted to the situation and indication. Another important factor is the choice of the
implant system, because this can also be decisive for
whether the bone level is maintained. Conical internal
connections are therefore recommended, as they ensure
the necessary stability of the abutment. Many reasons
for bone resorption around implants are described in the
literature. Firstly, implants are often screwed into bone
that is too thin; a circumferential bony layer of at least
2 mm is required to keep an implant stable.1 In addition,
two-piece implant systems usually have the disadvantage that the abutment has some mobility. Twenty years
ago, Hermann et al. were able to prove that it is not
the gap between the implant components that induces
bone resorption, but that this process is caused by
micro-movements between the implant and abutment.2
It is therefore important to select an implant system that
completely eliminates these micro-movements. Numerous studies show that implant systems with tapered
internal connections can avoid such movements.3
However, there are also major differences between

these implant systems. Systems with self-locking tapered connections show the least movement between
implant and abutment, and that is particularly the case
for the Morse taper connection.4 The Morse taper was
developed to secure tool components in the spindle of
a tool. It is characterised by a taper angle of a maximum
of 1.5°, transmitting the torque from the hollow cone of
the operating tool spindle to the shaft of the tool, which
is clamped in it, in a friction-fit manner by static friction
as a result of self-locking.

4 2021

The implant system (K3Pro, Argon Dental) used in the
following case has such an internal connection. These
implants do not show any gap formation in radiographic
analysis, even at the maximum load of 200 N, and do not
exhibit any micro-movements. In this case report, a clinical procedure according to the Stable Tissue Concept is
described.

Clinical case
The patient visited the practice in 2016 after the removal
of tooth #36 elsewhere to have the gap restored with a
dental implant (Fig. 1). A bone defect was visible on the
preoperative radiographic image (Fig. 2). After elevation of
a mucoperiosteal flap and careful curettage of the surgical
site, it became obvious that augmentation was required

[21] =>

case report

(Figs. 3 & 4). Despite the spectacular-looking defect, it
was quite easy to augment. It was a multi-walled defect
confined mesially and distally by two teeth that maintained the bone volume. The regeneration potential was
therefore very high and favoured a prognosis of success.
An implant was placed with high primary stability (Fig. 5).
The author prefers bone grafting materials that resorb entirely and are converted into natural bone. Allogeneic bone
has precisely these desired properties. The grafting material used here (Osteograft, Argon Dental) was human
donor bone prepared by the German Institute for Cell and
Tissue Replacement. The grafting material was prepared
in PRGF (plasma rich in growth factors) matrix (BTI) to
obtain so-called sticky bone.5 Embedded in this clot, the
particulate material adapts well to the defect (Fig. 6). Every
grafting material needs stabilisation to prevent mechanical irritation, that is, it must heal in a completely stable
position. Movement hinders the process of mineralisation, leading either to healing via the connective tissue
or to resorption.6 In this case, stabilisation was ensured
by two things. First, a very rigid membrane was used.
This membrane was a deproteinised thin cortical plate
that becomes very flexible after rehydration. Second,
membranes must always be fixated by pins, screws or
sutures in such a way that movement of the barrier membrane is avoided. In this case, resorbable pins were used
to protect the membrane both buccally and lingually from
dislocating (Fig. 7). When employing an implant with a
fixed tapered connection, like the one used here, it should
be placed sub-crestally.7 In order to facilitate the exposure, no cover screw was used for closure. However, a
membrane support screw with a height of 2 mm was used
to ensure more comfortable handling (Fig. 8).

Five months after insertion, it was found that the band of
keratinised gingiva was to narrow and that movements
from the cheek were transmitted to the alveolar ridge
(Fig. 9). This underpins the importance of the presence
of sufficiently keratinised gingiva.8 Implant exposure was
carried out by means of elevation of an apical flap (Fig. 10).
If locating the membrane support screw is easy, as it
was in this case, in almost all cases no further removal of
bone is necessary (Fig. 11). Upon removal of the screw,
the effect produced by this procedure became visible.
Figure 12 clearly shows the cylindrical chimney that extended the entire length of the membrane support screw
to the transition into the inner cone. This tissue was quite
stiff and immobile. The histological composition would
be interesting to know, since macroscopic evaluation is
rather difficult. The author suspects that this was a complex connective tissue structure with slight mineralisation. For this treatment case, the author had a customised anatomical healing abutment milled, which was
to accommodate the slim design in the apical part so
that the augmented bone did not have to be removed
again (Fig. 13). Owing to the still insufficient amount of
keratinised tissue and lack of soft-tissue thickness, an

4 2021

[22] =>

| case report

autologous soft-tissue graft was taken from the palate
and fixated vestibularly to ensure that there was no movement whatsoever (Fig. 14). The thickness of the tissue
above the implant shoulder also plays an important role;
it should not be less than 3 mm, otherwise bone resorption will occur.9

Prosthetic restoration
Two months after exposure, the prosthetic restoration
was carried out. Since an individual anatomical healing
abutment was used in this case, the implant shoulder
was completely covered by the connective tissue chimney
described (Fig. 15). In order to expose the shoulder, the
entire chimney was removed again with the aid of a sulcus
former so that the impression post could be placed on the
implant shoulder without a gap (Figs. 16 & 17). However,
the entire biologically built structure was destroyed as a
consequence (Fig. 18). At the time of crown installation,
the situation was macroscopically completely free of irritation and healed (Fig. 19). An individually tailored hybrid
abutment made from zirconia was attached to a titanium
adhesive base and placed in the patient, and a lithium
disilicate crown was cemented intra-orally (Fig. 20). The
postoperative radiograph shows the gap-free fit and the
removed bone in the apical region of the abutment (Fig. 21).
Clinically, a perfectly integrated restoration without tissue loss was seen four years after placement (Fig. 22).
The CBCT scan showed that complete remineralisation
of the bone in the interface appeared to have occurred
(Fig. 23).10, 11

Discussion
This procedure, which was very experimental at the time,
has since become the standard procedure in the author’s
practice and is the basis of the Stable Tissue Concept.
The parts required for the Stable Tissue Concept are
now available preassembled. This means that all the
parts, from the anatomical healing abutment to the abutment, have been modified to the required geometry and
matched to each other in such a way that no tissue needs
to be removed in the interface. The impression post no
longer rests on the implant shoulder for reference, but

4 2021

is attached deep in the index of the implant to enable
precise impression taking without being inhibited by the
taper. The implant used here serves as the basis of this
concept. The internal connection with the Morse taper
cone fulfils creates the prerequisite that any movement in
the abutment is eliminated and no bone resorption occurs.
The standard insertion depth of the implant is 2 mm
sub-crestally. Such a procedure is only possible with this
internal connection; it is possible to insert the implant even
deeper without causing any biological complications.
Of course, hard- and soft-tissue augmentation must be
performed in such a way that the biological conditions
for long-term success are created. The augmentative procedure must be adapted to the specific clinical situation.
No matter the case, sufficiently thick soft tissue ensures
that there is little bone resorption. In the author’s practice, the aim is always to generate 4–5 mm of keratinised
gingiva above the implant shoulder.

about the author
Germany-based Dr Kai Zwanzig
studied dentistry at the University of
Münster in Germany and received his
PhD from the same university. He completed a four-year specialisation in oral
surgery. Since 2007, he has been in
private practice together with Dr Bodo
Zwanzig in Bielefeld in Germany, which
he established as a referral practice for
oral surgery specialising in complex implant cases, plastic periodontal surgery, anterior aesthetics and ceramic restorations.
He has authored specialist articles in numerous dental journals.
Author details

contact
Dr Kai Zwanzig
info@praxis-zwanzig.de
www.praxis-zwanzig.de

Literature

[23] =>

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| case report

Sinus augmentation and
simultaneous implant placement
using one-stage Sandwich Technique
Drs Fernando Duarte, Carina Ramos, Paulo Veiga & Marco Infante da Câmara, Portugal

1
Fig. 1: Initial CT scan with coronal and sagittal sections.

Introduction
The posterior sector of the maxilla consists of an extremely thin facial lamina, with the underlying trabecular
bone having a low mineral content. The loss of maxillary
posterior teeth is a typical bone resorption pattern that
implies a decrease in the bone width available at the expense of the labial plate.1 This is the explanation why the
width in the posterior sector of the maxilla decreases at
a faster rate compared to other regions.2 It should also
be noted that the lack of vascularisation accelerates the
phenomenon of bone resorption and initial Class D3 or D4
trabecular bone. Even if it decreases by 60%, however,
the residual ridge is wide enough in the posterior maxilla
for root-form implants. Progressive resorption shifts the
alveolar crest towards the palate at the expense of bone
width.3 The posterior maxilla continues to atrophy until the
entire alveolus is ablated to basal bone. The vestibular
cusp of definitive prosthetic rehabilitation must result from
a balance between aesthetic requirements, biomechanical conditions, and bone availability in moderate to severe
atrophic crests.4

Maxillary sinus resorption
The inner anatomy of the maxillary sinus maintains its
full size while the teeth remain in arch and function, but

24

4 2021

expands when the posterior teeth are lost.1 There is an expansion of the antrum in the inferior and lateral directions,
potentially invading the canine region and even the lateral
piriform sinus. After the loss of teeth, sometimes related
to periapical infectious processes, the amount of bone
available in the posterior region of the maxilla for implant
placement is greatly reduced. This phenomenon is likely
the result of atrophy caused by reduced bone tension due
to lack of occlusal function. Implants placed under the
ungrafted sinus floor are known to stimulate increased
bone formation in the sinus floor. Among the main criteria
for the success of treatment with implants, bone quality
and quantity stand out. In a limited literature review, it can
be seen that, statistically, implants with a height of 10 mm
or less have a 16% lower survival rate than implants with
more than 10 mm in height.5 It is therefore important to
emphasise that, bone height is a factor to consider in
predictability and longevity of implant-supported rehabilitation. In periodontal compromised patients, a phenomenon known as pneumatic trifurcation is frequently
observed, whereby the maxillary sinus extends between
the roots almost to the furca in the area of the first molar.
Tooth extraction leaves 4–5 mm of bone available as a
result of this anatomical peculiarity of the sinus. The limited
vertical dimension further aggravates the problem of the
position of the medialised crest and the already compromised alveolar width. As a general rule, bone quality in

[25] =>

[26] =>

| case report

2a

2b

Figs. 2a & b: Osteotomy by piezoelectric surgery and sticky bone for reconstruction.

the posterior maxilla is worse than in any other intra-oral
anatomical region.6 The bone density of the maxilla is often five to ten times lower than that of the anterior mandible, namely the symphysis and para-symphysis regions.7
Bone mineral density directly influences the amount of
contact between the implant and the bone surface, which
in turn transmits the load to the bone.8 The tension pattern
spreads more towards the apex of the implant in lowdensity bone than in dense bone.9 When tension is excessive, bone loss occurs in the trabecular bone, which
begins in the cervical and may travel throughout the entire
body of the implant. Strategies to increase bone–implant
contact, both surgically and by modification of implant
topography, are being developed.
Bone mineral density is extremely important for the
survival of the implant in function.6 Implants have an
increased risk of failure in conditions of poor mineralisation. Deficient bone structure compromises not only the
primary stability of the implant, but also the ability to support occlusal forces. The absence of cortex on the ridge
crest compromises the primary stability of the implant
and, since the buccal cortical plate is generally very thin
and the crest is relatively wide, it does little to increase
stability. The occlusal forces in the posterior region are
greater than in the anterior region of the oral cavity by
up to five times.10 The maximum occlusal force in the
anterior region varies from 241 to 345 Pa, compared to
the maximum occlusal force in the molar region which
varies from 1,378 to 1,723 Pa.11 Natural maxillary molars

3a

3b

3c

Figs. 3a–c: Intra-op images of bone reconstruction and implant placement.

26

4 2021

have 200% more surface area as well as a significantly
larger diameter than premolars,1 and clearly the combination of the two factors contributes to the reduction in
bone tension. In accordance with the clinically observed
morphology, in the oral cavity, the support of the implant
should be greater in the molar region, thus allowing a
more functional and aesthetic prosthetic rehabilitation.1
It should be noted that the decrease in bone quantity
and quality, as well as the increase in occlusal strength,
should be highly considered aspects in the treatment of
the posterior maxillary region.

Sinus floor approach
Tatum was the first clinician to suggest a crestal approach
to sinus floor elevation and placement of submerged implants.12 The technique, used in thin residual crestal bone,
involved an upfracture into the sinus using a socketforming instrument. A bone graft was placed beneath the
tented sinus membrane. Later, a modified Caldwell–Luc
procedure was developed in which the lateral sinus wall
was infractured and the wall was used to help elevate the
sinus membrane. Autogenous bone was then placed into
the area.13 Since then, a variety of techniques have been
described for augmenting the maxillary sinus floor. Two
general procedures for sinus elevation for dental implant
placement are currently in use: a two-stage technique
using a lateral window approach and a one-stage technique
using a lateral or a lateral from the crest approach.14–17
The decision to use a one- or two-stage technique is
made based on the amount of bone present at the alveolar
crest. Piezoelectric surgery has certain fundamental characteristics that make it safer and more precise than the
instruments (manual and motorised) traditionally used in
this type of surgery. Morphological and histo-morphometric
studies have found that the tissue responds better to
piezo-surgery than to the drill.18, 19 The extreme precision and safety of the method are assured by the following:
a) Micrometric cutting action allows effective cutting
of mineralised structures but is inactive on soft tissue;
b) Absence of macro-vibrations permits better handle

[27] =>

WEBINAR OF THE MONTH
www.zwpstudyclub.de/webinar/we-love-biology-the-stable-tissues-concept-in-daily-practice

CME-Point

Our readers get the opportunity to collect a valuable training point here. Participation is free of charge. To receive the CME point, only registration is required.

TOPIC

We love biology—The Stable Tissue Concept in daily practice
Long-term stable results are what
every dentist should strive for with his
work. Patients trust us and pay a lot
of money when it comes to implantological rehabilitation. Many problems
in implantology are home-made because biological principles are dis
regarded. Bone and soft tissue man
agement should be firmly anchored
in the implantological dentist’s port
folio, as stable tissues are the basic
prerequisite for implantological success. For this purpose, hard and soft
tissue augmentation must be carried
out with materials that are adapted to
the situation and indication. Dr Kai
Zwanzig has been using allogeneic
materials, which are completely ab-

sorbed by the body and thus inte
grated into the organism, with great
success for more than 10 years. An
other important factor is the choice
of the right implant system. The hardware is also a decisive factor in whether
the bone level is maintained. Conical
internal connections are best suited
for this purpose, as they ensure the
necessary stability of the abutment.
But even here there are decisive differ
ences, because not all cones are the
same! With the Stable Tissue Concept
by Dr Zwanzig it is possible to preserve all structures to the maximum,
in which the implant system in partic
ular plays a predominant role. The
self-locking conical inner connection

prevents any movement of the abutment and is absolutely bacteria-proof.
This prevents any micro-movements
that could lead to bone loss and bio
logical com
p lications. In addition,
there is no titanium abrasion, which
can subsequently lead to incompatib ilities. The Stable Tissue Concept
combines state-of-the-art treatment
methods with innovative materials to
generate the best possible treatment
results.

Dr Kai Zwanzig
About the speaker

Registration/ZWP Study Club
In order to actively participate, a free membership in the ZWP Study Club is required. After registering free of charge at www.zwpstudyclub.de, users will receive a confirmation
e-mail and can immediately make full use of the continuing education offer.

Holbeinstr. 29 · 04229 Leipzig · Germany · Phone: +49 341 48474-0 · info@oemus-media.de

[28] =>

| case report

Figs. 4a & b: Autologous fibrin membranes and sutures.

control, thus assuring completely safe access to the most
difficult anatomical zones and high cutting precision;
c) Cavitation with the cooling saline solution that is generated from the characteristic ultrasonic vibrations produces tiny sprayed particles of water that keep the area
cool and free of blood, thus avoiding overheating of the
tissue and allowing optimal intra-operative visibility.

Sandwich Technique

additional membrane. Sticky bone (CERASORB M, curasan;
and platelet-rich fibrin) is placed and compressed in the
posterior (palatal) portion of the bone window. It is easy to
manipulate and accelerates tissue healing and minimises
bone loss during the healing period. Subsequently, the
implant is placed, the existing cervical bone acting as the
primary stability source. Finally, new sticky bone is placed
in the anterior portion (vestibular) and membranes of
autologous fibrin are applied as a cover of the bone graft.

This technique recommends 3D bone reconstruction
around the entire body of the implant in cases of elevation of the sinus floor by 4–5 mm and implant placement
in the same stage. The technique recommends that two
vertical osteotomies be performed on the lateral wall of
the maxillary sinus to delimit the bone area to be grafted.
A third inferior horizontal osteotomy is performed according to the bone availability shown on a CT scan and a
fourth superior horizontal osteotomy to delimit the height
of the graft. The bone window produced is reflected into
the maxillary sinus with the intention of functioning as
a ceiling for the grafted area. Whenever possible, it is
advisable to maintain the integrity of the Schneiderian
membrane. If it is eventually perforated during the osteo
tomy or is already perforated, it is necessary to place an

CERASORB M is a resorbable beta-tricalcium phosphate,
pure phase, biomimetic and totally resorbable to fill, join
and rebuild bone defects of small, medium and large
dimensions; as well as to promote bone fusion throughout
the skeletal system. CERASORB M is made of biocompatible synthetic ceramic material with a phase purity of
approximately ≥ 99%.20 CERASORB M granules have a
polygonal shape which allows for better structural adaptation between them, they have an open interconnected
micro, meso and multiporous structure macropores
(about 65%), radiopacity is lower and absorption and remodeling in autologous human bone are achieved more
quickly than with conventional biomaterials. Over the course
of months in contact with vital bone, the CERASORB M
material is resorbed and simultaneously replaced by autol-

5
Fig. 5: Final CT scan with coronal and sagittal sections.

4 2021

[29] =>

case report

ogous bone tissue. As a synthetic and bioactive ceramic
material, CERASORB M has excellent histocompatibility
and absence of local or systemic toxicity. Unlike materials of biological origin, CERASORB M does not present
a risk of infection or allergic reaction, which should be
considered an important advantage.20 Platelet-rich fibrin
is composed of therapeutic blood matrices obtained by
selective centrifugation and acts as an adjuvant in bone
and tissue repair. To obtain the fibrin matrices, autologous
blood samples are collected in dry 10 ml pure glass tubes
(Montserrat) and blood samples in dry polystyrene tubes
(Greiner Bio-One), in a tube ratio of 6:2. They should be
centrifuged in a centrifuge (Ortoalresa), according to the
protocol described by Duarte de Almeida and Alves de
Oliveira,21 which uses a relative centrifugal force of 200 × g
for 10 minutes to obtain two physical forms of fibrin, the
polymeric form or solid gel, and the monomeric or tem
porary liquid form only in one centrifugation step.

Clinical case
A 21-year-old female patient attended the oral-maxillofacial
surgery consultation at Clitrofa medical centre in Trofa
in Portugal for placement of an implant in anatomical
position #15. In the anamnesis, no allergies or use of medications was reported. On extra-oral clinical examination,
no abnormalities were observed. On intra-oral physical
examination, a slight bone depression was noted in position
#15 as a result of dental agenesis. In the CT scan, a sinus
floor of 4 mm in height was detected in position #15, making
the case suitable for a one-stage implant technique—
the Sandwich Technique (Fig. 1). Two vertical osteotomies
were performed on the lateral wall of the maxillary sinus to
delimit the bone area to be grafted. A third inferior horizontal
osteotomy was performed according to the bone availability
shown on the CT scan and a fourth superior horizontal
osteotomy was performed to delimit the height of the graft
10 mm. The bone window produced was reflected into the
maxillary sinus, and the Schneiderian membrane was kept
intact. The use of platelet-rich fibrin in the grafting process
offers the benefits of modelling of the inflammatory response, immune response and tissue repair, tissue reorganisation and angiogenesis. The association with mineral
biomaterials facilitates handling and application and allows
immediate adhesion to the receiving bed (Fig. 2).
The sticky bone was inserted with maximal light compression into the posterior (palatal) portion of the bone window.
Subsequently, the implant (Epikut HE, 4.5 × 10.0 mm;
S.I.N. Implant System) was placed, the existing cervical
bone acting as the primary stability source. More sticky
bone was inserted into the anterior portion (vestibular;
Fig. 3). The autologous fibrin membranes create a protected environment for bone regeneration in the defect
area and support osteogenesis by presenting a barrier to the infiltration (migration) of soft tissue and thus
promote growth of osteogenic cells in the bone defect.

Suturing was performed with simple sutures using nonresorbable thread (#4/0 silk; Fig. 4). The patient underwent
systemic antibiotic, analgesic and anti-inflammatory therapy
for eight days. Regarding postoperative care, the patient
was instructed to maintain strict oral hygiene. After a postoperative period of six months, evaluated by a postoperative
CT scan, there was evidence of new bone formation of 12 mm
in height around the entire implant body and apex (Fig. 5).

Conclusion
Diffuse maxillary sinus remodeling and posterior maxillary
morphology after tooth loss suggest several treatment options. Maxillary sinus graft is an increasingly common procedure in implantology, and the use of resorbable and biomimetic bone regeneration materials, such as CERASORB M,
in combination with platelet-rich fibrin (sticky bone), should
be considered. This technique has a safety, predictability
and longevity character for the rehabilitation of the posterior maxillary sector, and it can be performed alone or in
conjunction with other reconstructive procedures. When
approached and managed properly, the sandwich technique leads not only to bone reconstruction of the posterior
maxilla, but simultaneously to the placement of the dental
implant, with consequent restoration of the orthoalveolar
shape and function between the arches.
Conflict of interest: The authors declare that there is no
conflict of interest regarding the publication of this article.

about the authors

Dr Fernando Duarte
Author details

Dr Carina Ramos
Author details

Dr Paulo Veiga
Author details

Dr Marco Infante da Câmara
Author details

contact
Dr Fernando Duarte
Clitrofa—Centro Médico,
Dentário e Cirúrgico
Trofa, Portugal
+351 252 428960
fduarte@clitrofa.com

Literature

4 2021

[30] =>

| case report

Alveolar deficiency management
in maxillary lateral incisor agenesis
Dr Federico Berton, Italy

1a

1b

Background
The second most common dental agenesis is that of the
maxillary lateral incisors, after agenesis of the mandibular third molars.1 This common agenesis has important
functional and aesthetic impacts for the patient and is
challenging to manage for the dental professional. Several
approaches to address this condition, both for unilateral
and bilateral, have been reported. From least to most invasive, these are (1) the conservative or prosthetic adaptation of the canine to replace the incisor and of the first
premolar for canine function (with or without orthodontic assistance); (2) the orthodontically assisted creation
of space for the incisor and prosthetic replacement with
a fixed prosthesis (employing several approaches); and (3)
the orthodontically assisted creation of space for the incisor and implant-supported fixed rehabilitation; removable
prosthetic rehabilitation can also be used, but only for provisional necessity when a fixed provisional prosthesis cannot be used.2 Although implant-supported rehabilitation
has many advantages, it also has several disadvantages,
such as age constraints, surgical invasiveness, and high
hard- and soft-tissue aesthetic demands, given the location of the incisor in the aesthetic zone. Moreover, early

3a

30

3b

4 2021

2

implant insertion should anticipate the long-term prognosis of the rehabilitation according to the age of the patient.
Finally, incisor agenesis results in a soft- and hard-tissue
deficiency that has to be managed to guarantee an opportune aesthetic result and a long-term prognosis for the
implant rehabilitation. Therefore, implant replacement of a
missing lateral incisor is challenging for the oral surgeon
and the prosthodontist.

Case presentation
An otherwise healthy 21-year-old patient was evaluated
for implant insertion after a careful evaluation of treatment
alternatives. The patient underwent 12 months of fixed
orthodontic therapy for space creation and tooth alignment. Afterwards, the patient wore a removable retainer
until musculoskeletal growth was reasonably complete.
The CBCT scans showed sufficient mesiodistal space but
a width deficiency (Figs. 1a & b). Clinical examination highlighted a generous band of attached gingiva. Therefore,
the treatment plan involved an initial surgery for implant
insertion and bone regeneration, then the positioning of
a healing abutment and soft-tissue augmentation after six
months, and finally the definitive prosthetic rehabilitation.

4

[31] =>

case report

Amoxicillin (2 g) was given as antibiotic prophylaxis before
the surgical intervention. A trapezoidal full-thickness flap
was elevated from tooth #11 to tooth #13. After bone exposure, the implant site was prepared with a combined
approach (piezoelectric and twist drill; Fig. 2). A tapered
implant with a conical connection (3.6 × 12.0 mm; GTB,
Advan) was inserted 1.5 mm below the crest in a palatal
position (Figs. 3a & b). Afterwards, bone-promoting holes were
made in the buccal bone and a cross-linked collagen membrane (Geistlich Bio-Gide, Geistlich Pharma) was secured
with a single palatal pin and two buccal pins positioned
between the roots of teeth #11 and 13. The gap was filled with
deproteinised bovine bone mineral and autologous bone.
After accurate periosteal releasing incisions, primary intention closure of the flaps was gained (Fig. 4). The patient was
prescribed antibiotic and anti-inflammatory therapy (ibuprofen,
every 8 hours; amoxicillin, every 12 hours), together with
a 0.2% chlorhexidine mouthwash, and given instructions on
postoperative care. Postoperative healing was uneventful,
and the sutures were removed after 14 days.

the sufficient bone height and width for primary implant
stability and to provide the requisite bone width to reduce
the risk of facial dehiscence and possible aesthetic impairment and to allow prosthetically driven implant positioning.5
Also the choice of implant was made according to the state
of the art. A position below bone level allows more space
for hard and soft tissues, together with prosthetic management of the crown. Therefore, a conical implant connection
was chosen. The conical connection is reported to have the
least micro-gap with the prosthetic abutment. This seems
to protect the peri-implant bone from resorption.6 Finally, the
minimal roughness of the implant surface (OsseoGRIP)
was chosen according to the expected prognosis of the implant and its position: a good long-term prognosis may be a
benefit of this choice, given the low correlation to peri-implant
pathology and the ease of cleaning7 if exposed to the oral
cavity. In conclusion, an accurate treatment plan, together
with the most updated scientific findings brought to the
clinical setting, facilitates a successful treatment result, for
both the patient and the clinician.

After 6 months, during the uncovering phase, a roll flap
technique was employed to augment the soft tissue and
a leucocyte- and platelet-rich fibrin (L-PRF) membrane
was placed (Fig. 5). After a healing phase of 1 month,
impressions were taken and a cemented fixed lithium di
silicate crown was delivered (Fig. 6). After one year of healing,
besides a physiological remodelling of the peri-implant
bone, the soft and hard tissue remained stable and the
aesthetic and functional results were good (Fig. 7).

about the author

Discussion and conclusion
Prosthetic implant rehabilitation is an effective approach to
the treatment of dental agenesis. However, the correct management of tissue deficiencies is a fundamental factor for
short- and long-term tissue stability and thus final implant
success. L-PRF was chosen in this case to promote softtissue healing and for soft-tissue augmentation given the
presence of a wide band of attached gingiva.3, 4 Therefore,
the more invasive option of a connective tissue graft was not
considered. The easy withdrawal of blood and the reduced
costs of the procedure make L-PRF the procedure of choice
for select cases. The choice of hard-tissue augmentation,
within the context of implant insertion, was made owing to

Federico Berton, DDS, MSc, PhD,
is a dental consultant at the clinic of
maxillofacial surgery and dentistry of
the University of Trieste in Italy and an
oral surgeon at his family’s dental office.
He is a lecturer and tutor at the University
of Trieste and a national councillor on
the board of the Società Polispecialistica
Italiana dei Giovani Chirurghi. He is an
active member of the International Piezoelectric Surgery Academy.
He engages in research in regenerative surgery, implantology
and periodontics and has authored more than 30 scientific
articles in international journals.

Author details

contact
Dr Federico Berton
Adjunct Professor, Department of Medicine, Surgery
and Health Sciences, University of Trieste, Clinica di Chirurgia
Maxillofacciale e Odontostomatologia, Trieste, Italy
+39 040 3992020
fberton@units.it

Literature

4 2021

[32] =>

| case report

Immediate functional implants in
the aesthetic zone of a heavy smoker
Dr Dr Branislav Fatori & Dr Inge Schmitz, Germany

Dental implant placement represents the most cost-
effective and long-term solution for the replacement of
missing teeth and it can be argued that dental implants have
a high average life expectancy. Immediate or early implant
loading procedures are well documented in cases of edentulous sites in the mandible and the maxilla. It is often difficult to obtain good results in the anterior region and it is essential for practitioners to understand the anatomical basis
for and the limitations of implant dentistry in the aesthetic
zone. To achieve satisfactory implant survival rates, it is vital
to have reproducible treatment protocols that reinforce individual expertise and help to achieve high treatment quality.
To this end, the following factors should be taken into consideration: Prior to tooth extraction, immediate loading requires
the careful selection of patients and a high level of p
atient

4 2021

compliance. Immediate loading protocols increase the complexity of treatment planning and the surgical procedure itself. Immediate implant loading should be planned ahead of
tooth extraction and should be limited to clinical situations
that allow for primary stability (> 30 Ncm) and correct prosthetic positioning. Additionally, the procedure can help to reduce bone resorption. However, there can be complications
when carrying out immediate implant loading in the anterior
region. When immediate loading is performed there should
be no indication of inflammation, periodontitis or gingivitis.
Furthermore, a good concept for Antibiosis is necessary and
tooth extraction should be carried out in minimally invasive
fashion. In the anterior region the vestibular lamella should
not be incriminated. Immediate implant placement in combination with immediate loading can lead to a better clinical and
aesthetic treatment outcome. Fixed prostheses on implants
show significantly better results than removable prostheses.

Materials and methods
The 75-year-old male patient was a heavy smoker who
smoked approximately 40 cigarettes per day (Fig. 1). Heavy
smoking can be a contraindication for implant insertion.
There is evidence in the literature pointing to a lower survivability of dental implants in smokers. One possible mechanism by which smoking may affect osseointegration is the
reduced blood flow rate due to increased peripheral resistance and platelet aggregation. Smoking directly affects
osteoblast function. In general smoking is a major risk factor
for implant failure. When smokers are treated with implants
good bone quality is required.

[33] =>

case report

Treatment protocol

Editorial note: During the production of this article
Dr Inge Schmitz unfortunately passed away.

Augmentin was administered as premedication for a
period of one week. After microbiological examination, an
antibiotic was prescribed (Clindamycin Aristo 600, Aristo
Pharma). In addition, the patient was instructed to rinse
with Chlorhexamed (GlaxoSmithKline). Local anaesthesia
was administered with Ultracain D-S forte (Sanofi-Aventis
Deutschland), and 40 mg Dexa-ratiopharm (ratiopharm)
was administered intramuscularly at the same time. The
implants used were OKTAGON DENTAL RATIO implants
(DRS International) with a diameter of 4.1 mm and a length
of 12 mm (Figs. 2 & 3).

Dr Dr Branislav Fatori
Author details

Dr Dr Branislav Fatori has more than
four decades of experience in implantology. In addition to his German doctoral
degree, he holds a second doctoral
degree from the University of Belgrade
in Serbia. He was trained at prominent
clinics around the globe and has worked
as a consultant for expert societies and
implant manufacturers.

The criteria of Albrektsson and Buser et al. were applied
in the follow-up examinations. These criteria for implant
success are frequently cited and generally accepted.
According to them, implant success is defined by the
absence of persistent subjective complaints, including
pain, foreign body sensation and/or dysaesthesia, the absence of recurrent peri-implant infection with suppuration,
the absence of mobility, continuous radiopacity around
the implant and the possibility of a prosthetic restoration.
The healing process of the implants was good in the case
described.

Dr Inge Schmitz has worked at the
Institute of Pathology of the Ruhr University Bochum in Germany since 1990.
Her main interests were implantology,
stents, electron microscopy and osteology.
She studied biology at the Ruhr University
Bochum and completed her PhD at the then
University of Essen in Germany in 1989.

Discussion

There is evidence that immediate loading protocols
demonstrate high implant survival rates and could be recommended with caution in certain clinical situations. The
use of implants in smokers may influence failure rates in the
form of postoperative infections and marginal bone loss.
Therefore, our results should be interpreted with caution.

Dr Inge Schmitz
Author details

about the authors

Postoperative care

The literature frequently reports high survival rates for the
immediate loading of fixed full-arch maxillary prostheses
supported on three or four implants or on multiple basal
implants (Figs. 4 & 5).

contact
Dr Dr Branislav Fatori
Essen, Germany
+49 201 82188890
info@fatori.de
www.fatori.de

4 2021

[34] =>

| interview

Fine dentistry and creative
engineering go hand in hand
An interview with Dr Kai Zwanzig and Ric Donaca

Many problems in implantology are self-made because biological principles are disregarded. Bone and
soft-tissue management should be firmly anchored in
the implantologist’s portfolio, as stable tissues are the
basic prerequisite for implantological success. With
the new Stable Tissue Concept from Dr Kai Zwanzig,
it is possible to preserve all structures to the maximum, in which the implant system in particular plays
a paramount role. The new K3Pro product line from
Argon Dental offers the best prerequisites for this. In
this interview, Dr Kai Zwanzig and Ric Donaca, Managing Director of Argon Dental, discuss the advantages
of this system.
Dr Zwanzig, please describe your motivation to
personally commit to the new implantology concept “Stable Tissue”.
Dr Kai Zwanzig: I love teeth. My patients love their
teeth. If a tooth cannot be preserved, I am not satisfied
with “tooth replacement”. And no colleague, no dental
technician and no patient should be satisfied with
“replacements”. The focus of my medical practice is

Fig. 1: Dr Kai Zwanzig (left) and Ric Donaca, Managing Director of Argon Dental.

4 2021

to take into account the entire biology surrounding a
healthy tooth, set in healthy soft tissue and stable bone.
Nothing else should apply to lasting implantological
success. Why do the majority of implant manufacturers
pay so little attention to these scientifically quantifiable
biological factors of the healthy tooth, forcing me to work
around the considerable design-related problems of
their systems—which I locate in a professionally driven
“faster, simpler, more productive”—with all my skills?
It is time to commit to a new value orientation in implantology and to pave the way for it. This can only be done
hand in hand with an industry partner who ticks similar
boxes and is prepared to continue to substantially improve a good product. I have known and appreciated
Argon for ten years now.
Mr Donaca, your K3Pro implant system is considered by insiders to be particularly innovative and
proven at the same time. Why is that?
Ric Donaca: The principle of our conical implantabutment connection—a particularly long cone of 3.1 mm
with such strong friction that micromovements are excluded, no bacterial colonisation of the
implant interior can take place and a
loaded retaining screw is basically obsolete thanks to the friction lock—comes
from mechanical engineering and was
adapted for implantology in my early
days in the 1980s.
It is not a pseudo-cone with a flat angle, which actually only corresponds to
a phase for sealing between the implant
and abutment, but does not prevent
movement and continues to load the
screw. As a result, the force fit equals
the solidity of a monolithic implant, with
all the dental advantages of a two-piece
system. The innovation lies in the development of a practical prosthetic handling of this special connection, which
allows easy try-in, precise height of
the crowns even without butt joint
and defined forces. But this, too, is now
proven.

[35] =>

interview

“It is time to commit to
and pave the way for
a new value orientation
in implant dentistry.”

Fig. 2: The K3Pro+ Implant System from Argon Dental.

Your system grew into an extended family over
the years with numerous prosthetic options, different thread designs, many lengths and diameters, and last but not least, complete digitisation.
How did the further evolution with Dr Zwanzig come
about?
Ric Donaca: As an innovation advocate in the context
of allogeneic transplants and a strong voice of the young
guard of German implantologists, Kai’s word has always
carried a lot of weight in our company. The sustainable
bone and gingiva preservation thanks to K3Pro and
the special aesthetics due to subcrestal positioning are
a well-known and scientifically proven strength. But in
addition to these qualities, Kai immediately recognised
the optimisation potential of the system in the aspect of
the biology of mucosal and bone regeneration, which
we had previously paid little attention to. This is grumbling at a very high level, but the end result shows that it
was worth the effort. With K3Pro, we are talking about
what is undoubtedly the most minimally invasive, anatomically optimised and tissue-friendly titanium implant
on the market.
Dr Zwanzig, please describe the Stable Tissue
Concept to our readers.
Dr Kai Zwanzig: It is not a product alone that is in the
foreground, but a philosophy. An implantological overall view that brings all aspects—surgical and prosthetic
challenges and procedures, indication and anatomy,
implant system used and specific patient wishes—
into harmony. The ultimate goal is patient satisfaction.
This takes into account aesthetics—beautiful teeth and
not “dentures”—and sustainability. A beautiful, reliably
healthy implant for a lifetime! Colleagues who adopt this
philosophy will also be on the winning side economically. Of course, this also requires questioning outdated,
partly industry-driven methods and habits, as well as the
willingness to change paradigms. Even for the complicated case, it is always true that you have to have the

perfect end result in front of your mind’s eye. I always
create bone if it is required for this, but I always think of
the soft tissue first. I have to question what will harm the
soft tissue and consistently sort this out: Any implant
design with cortical pressure is likely to irritate the bone,
which can lead to recession. It does not matter whether
the emergence profile is wide or narrow, with or without
a platform switch, polished or surface-treated margin.
It should be noted that implants with a short taper
must have thickenings to cope with peak loads (often at
the shoulder) due to the unfavourable load distribution,
which is surgically disadvantageous.
Good results are possible with bone level implants
without a cortical anchorage thread, but only with strict
adherence to the so-called three-millimetre rule, which
states that one must have at least 3 mm of stable gingiva over the bone and implant shoulder to seal the
implant. This requires a high effort in soft tissue surgery.
And even then, a predictably good long-term result is
only possible if the load distribution of the prosthetics is
perfectly balanced. Tissue-level implants and a perfect
final result, on the other hand, are ruled out from the
outset because of the unsatisfactory aesthetics and
have long been out of date.
Mr Donaca, what is the solution?
Ric Donaca: A subcrestally placed implant is the solution, with a shoulder that slopes down toward the abutment exit and is completely surface-treated according
to the OsteoActive principle, inviting the bone to seal
it permanently during regeneration. This is because,
thanks to the stable long cone, the implant not only remains tight, but the abutment also remains absolutely
motion-free. And thus bone and soft tissue remain permanently stable, there is no longer any bacterial point of
attack. The long-term results prove us right, but I would
like to emphasise that this is only possible if an implant
such as the K3Pro is optimised for subcrestal use in

4 2021

[36] =>

| interview
every respect. This principle opens up every conceivable option for prosthodontists thanks to the subcrestal
implant position. Narrow, particularly tissue-friendly
emergence profiles are clearly the trend.
Dr Kai Zwanzig: From a scientific point of view, it should
be added that studies have shown the following: It is not
so much the microgap with the bacterial pumping effect
in the implant–abutment connection that is problematic, but rather the constant movement between abutment and implant, however minimal. The objective for
bone and gingiva preservation is to completely eliminate
this movement. This has been achieved with K3Pro—
hence my personal commitment to this philosophy with
full conviction. As a friend of biological dentistry, I must
not forget that thanks to this principle, no titanium oxide
abrasions are released and the organism is not gradually
contaminated with them.

“The practical handling with
complete preservation of the
biology of bone and soft
tissue is in the foreground.”
So what is the innovation that came out of the
collaboration?
Dr Kai Zwanzig: By exploiting the entire as yet undiscovered biological potential of K3Pro. We proceeded
step-by-step. I let my first cases heal in the classic closed
subcrestal way and regretted having to “search” for the
cover screw in the tissue when uncovering it. With the
use of the high cover and membrane fixation screw of
2 mm height, everything changed. I was thrilled with the
stable bone and tissue channel that formed completely
over the implant shoulder, and so this became my personal standard protocol. The goal was not only to take
the impression and gingival design directly through this
tissue channel of unique biology, but also to have the
abutments precisely pick up this geometry, thus providing the maximum stable support of the bone over the
entire length of at least 2 mm. This was unique among
all implant systems known to me and also takes into account recent scientific findings that lengths of 8 to 9 mm
are completely sufficient and only in immediate implantations more bone should be grasped apically due to
the alveolar anatomy.
Ric Donaca: For this we had to extend all the im
pression posts, gingiva formers, scanposts and, above
all, the abutments to an emergence length of 2 mm.

4 2021

In addition, with regard to the transfer aids, we switched
from a butt-joint principle on the implant shoulder to
impression-taking purely via indexing by means of a
hexagon and depth stop in the implant, because at this
stage the cone fit is not yet desirable; practicable handling with complete preservation of the biology of bone
and soft tissue is paramount. This is how the new prosthetic line of the K3Pro was developed within the framework of the Stable Tissue Concept—it stands for one
millimeter more. Quite a challenge for the engineer.
Dr Zwanzig, is it difficult for implanting people who
are changing over to this new system to adjust to it?
Dr Kai Zwanzig: It always takes conviction to decide
to fundamentally change learned techniques. With regard to the 2 mm subcrestal positioning, experience in
implantology is of course an advantage. But thanks to
Argon’s optimised instrumentation and optional digital
planning in the full-guided procedure, the changeover
is easy. As soon as you have gotten rid of old habits of
placing the implant supra- or equicrestally and instead
place it deep and leave it to biology with the high healing screw, you immediately recognise the superiority of
this concept. Such reliable and rapid o
sseointegration is
unparalleled! Especially with immediate implant placement. Uncovering, gingiva shaping, transferring or
scanning is extremely simple, since the dimensions of
this healing screw already specify the appropriate components. Only the gingival height needs to be determined. My technicians are delighted with the innovative
model analog, which completely eliminates the handling disadvantages of a friction-fit tapered connection
and makes prosthetic work as easy as with a butt fit.
And last but not least, there are our courses under the
sign of the Stable Tissue Concept: At Argon in Bingen
or at my place in Bielefeld.

Dr Kai Zwanzig
Author details

contact
Argon Dental
Bingen, Germany
info@argon-dental.de
www.argon-dental.de

Argon Dental
Company details

[37] =>

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for implants—international magazine of oral implantology

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issn 1868-3207 • Vol. 22 • Issue 4/2021

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network and beneﬁt from a
wide reach and high level of
awareness

4/21

international magazine of oral implantology

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or contact Mrs Janine Conzato:
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Phone: +49 341 48474-147

issn 1868-3207 Sondernummer • Vol. 5 • Issue 2/2021

ceramic

2/21

implants

international magazine of ceramic implant technology

research
The Implant Protection Plan

case report
The Stable Tissue Concept

research
Room for improvement

events

case report
Restoring aesthetics in the mandible

50 plus one years into the future

events
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[38] =>

| manufacturer news
Argon Medical

Perfect and aesthetic
mucosal stability
The preservation of tissue is essential for long-term implantological
success in terms of aesthetics and function alike. Our K3Pro and
the new K4Pro have always been optimised for subcrestal insertion, so the optimum biological width can always be maintained.
The implant with its anatomically designed shoulder is reliably
sealed by vital bone. Science and practice determined
that strict adherence to a 3 mm minimum rule is a basic
prerequisite for the application of the zero bone loss
concept and thus the sustainability of implantological success. Users of crestally placed
implants face the problem that a minimum
3 mm thick gingiva must be present
for this protective mucosal sleeve to
remain stable. Users of the subcrestal
K3Pro and K4Pro are always on the
safe side here. Argon Dental is again
significantly increasing the range of
indications. New components with identical
emergence profiles for healing, impression
taking, laboratory and prosthetics allow
for the first time 2 mm subcrestal insertion with gingival heights of 1, 2 or 3 mm.
The unique biology created by this subcrestal philosophy of healing
remains untouched after surgery. Healing screws and abutments,
impression posts and abutments precisely matched to the respective insertion depth and gingival height function in unison like a
first-class orchestra. The results are unparalleled, and the unique
systematic approach to application makes it easy for new users.

The new DS PrimeTaper is a demonstration of science and art in
harmony. Its innovative design enables predictable, secure placement across the widest range of bone densities. DS PrimeTaper
is a self-tapping implant with a tapered design and progressive
self-cutting threads that have been crafted to cut quickly and
engage without excess torque, the result is immediate installation
stability. A simple drilling protocol ensures excellent control and
supports the workflow. Lasting performance is further enhanced
by the unique MicroThread design that provides long-term biomechanical bone stimulation, improved aesthetics and lasting satisfaction for both patient and clinician. Building on Astra Tech Implant
System’s proven reputation for fast, predictable osseointegration,
the DS PrimeTaper OsseoSpeed surface bonds with more bone,
more rapidly. The outcome is long-term bone care and stability that
outperforms the competition at both 1- and 5-year intervals (Norton MR,
Astrom M. Int J Oral Maxillofac Implants 2020; 35:1099–111).

Argon Medical, Germany
+49 6721 30960
www.argon-medical.com

Dentsply Sirona, Sweden
+46 31 376-3000
www.dentsplysirona.com/en/explore/implantology/ds-primetaper.html

Dentsply Sirona

The perfect union of
form and function

curasan

Maximum flexibility with CERASORB® Foam
CERASORB® Foam is a multiporous composite material for bone
augmentation consisting of collagen and resorbable bioceramics. The
use of phase-pure -tricalcium phosphate with regular interconnecting porosity and primary particle size results in the degradation of the
biomaterial simultaneous to bone formation. The shapeable variant of
the CERASORB® Foam with low density allows plastic deformation
and can be individually adapted to the defect. CERASORB® Foam is
miscible with blood and I/A-PRF at a ratio
of 1:1, producing an ideal kneadable mass
for filling bone defects. The multiporosity
of the granules embedded in the collagen
helps bone to grow in faster. Blood components and body fluids can permeate

4 2021

the bone regeneration material unhindered and rapidly to accelerate
osseous integration, vascularisation, and resorption. Due to the specific
composition of CERASORB® Foam, a high degree of volume stability
is achieved even after degradation of the more rapidly resorbable
collagen, while high radiographic density is maintained. In addition to
the round granule form, which has only interconnecting micropores,
CERASORB® Foam consists of polygonally broken -tricalcium
phosphate with micro-, meso- and macropores with a pore size up to 500 μm.
curasan AG, Germany
+49 6027 40900-57
www.curasan.de

[39] =>

manufacturer news

|

Fotona

Ultimate mobility,
style & performance
TBR Dental

Giving you confidence
in implantology
The Z1 implant, combining a titanium body and a zirconia collar, offers
the advantage of being a tissue-level implant as well as using materials
optimised for the tissues with which they are in contact. Tissue-level
implants require only one surgery, which saves time for the practitioner
and is also more comfortable for the patient. Moreover, it allows a healing of the soft tissues of first intention as well as a simultaneous healing
of the hard and soft tissues, thus saving treatment time and improving
final aesthetic. Its titanium body, combined with its sandblasted and
etched surface, allows a good integration of the implant into the bone
and also provides it good mechanical properties. The transgingival zirconia collar reduces bacterial colonisation compared to titanium thus
protecting the bone from bacterial infiltration.1 In addition, the adhesion and proliferation of fibroblasts is improved, leading to a strong
attachment between the soft tissues and the zirconia collar, ultimately
leading to an optimal aesthetic result. This last item is accentuated by
the zirconia colour that is similar to the one of natural teeth, which will
avoid the greyish colouring of the gingiva.2 Discover the Z1 implant
to combine the advantages of a tissue-level
Literature
implant and a transgingival zirconia collar!

Fotona’s award-winning SkyPulse dental
laser is widely recognised as a uniquely
versatile tool in dentistry, and implantology is no exception. SkyPulse’s highprecision Er:YAG laser is perfect for the
treatment of peri-implantitis, including the removal of granulomatous tissue from inflamed surfaces and
direct implant decontamination. In addition,
SkyPulse’s high-performance diode laser allows for highly effective soft-tissue procedures
with simultaneous coagulation
and disinfection, as well as
tissue regeneration, making it
perfect for applications in oral
surgery. For those interested
in a more compact solution,
Fotona also offers the hand-held
XPulse diode laser that is ideal
for a wide range of soft-tissue
procedures, plus innovative new
treatment possibilities such as
the revolutionary EmunDo Photothermal & Photodynamic Therapy,
which treats both periodontitis and
periimplantitis with the aid of a
unique photosensitive activator.

TBR Dental Group
24, impasse René Couzinet
31500 Toulouse, France
www.tbr.dental

Fotona d.o.o., Slovenia
+386 1 5009100
www.fotona.com

MIS

Single-use, procedure-ready drills
MIS presented its latest innovation at the DS World event in Las Vegas. MIS XD are single-use, sharp, sterile,
procedure-ready drills, delivering a complete procedure in every implant package. These single-use drills are
designed for optimal implant-drill compatibility and high initial stability, while ensuring safe and simplified
procedures. Using sharp drills in every drilling procedure prevents drill wear and deformation. Their sterility
eliminates the need for post-surgery sterilisation and reduces the risk of cross-contamination and infection.
MIS XD are always compatible with the implant shape and dimensions. The drills are designed for depth
control, providing more visibility and confidence in the drilling procedure. Single-use drills allow for a simple
and quick procedure while eliminating cleaning, re-sterilisation, and the management of drill replacement.
MIS XD will be available with the MIS C1 and MIS SEVEN implants from December 2021 in the US Market.
MIS Implants Technologies, Israel
info@mis-implants.com
www.mis-implants.com

4 2021

39

[40] =>

| manufacturer news
BioHorizons Camlog

The next generation soft-tissue augmentation material

When choosing a biomaterial, there is a strong demand in clinical
practice for predictable outcomes. For over 20 years, LifeCell, a
leading global medical technology company, has developed innovative products for use in a wide range of applications. BioHorizons
Camlog expands its soft-tissue portfolio to bring NovoMatrix, an
innovative soft-tissue augmentation material. NovoMatrix is an
acellular extracellular dermal matrix consisting of tissue-engineered
porcine material. It is a breakthrough in xenogeneic processing
ensuring a structurally intact, undamaged scaffold that supports
cell and microvascular ingrowth. The proprietary tissue processing
allows for rapid revascularisation, cell repopulation and minimal
AD

inflammation. NovoMatrix comes pre-hydrated and ready to use
and offers a true alternative to autogenous soft-tissue grafts and
current products on the market. The NovoMatrix indications include
guided tissue regeneration procedures in recession defects for root
coverage, localised gingival augmentation to increase keratinised
tissue (KT) around implants and natural teeth, and alveolar ridge
reconstruction for prosthetic treatment.
Camlog Biotechnologies GmbH, Switzerland
+41 61 5654100
www.biohorizonscamlog.com

[41] =>

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[42] =>

| events

50 plus one years into the future
An anniversary congress for German implantology
Dr Georg Bach, Germany

“Everything had been perfectly prepared, but the
little matter of a virus got in the way”—with this opening statement, the congress president of the German
Association of Dental Implantology (DGZI) opened the
third Future Congress for Dental Implantology, which
took place on 1 and 2 October in Cologne in Germany.
Indeed, last year’s 50th anniversary congress, which
was planned to be held in the founding German city
of Bremen, fell victim to the coronavirus. However,
DGZI made a virtue of necessity and celebrated its
50th birthday in the 51st year of its existence—with
50 speakers and about 250 participants (the coronavirus-related regulations did not allow for more). The
focus on the first congress day on the Friday was on
75 table clinics, the livestreaming of two surgeries into
the conference hall and a highly regarded digital poster
presentation. The Saturday was all about science:
renowned speakers—the who’s who in German implantology—presented outstanding scientific lectures,
rounded off with courses for practice staff and a huge
dental exhibition with 25 hand-picked industry partners.

Future-oriented congress structure
In terms of content, the course of events and the
structure of the congress, Europe’s oldest professional
society deliberately and unquestionably succeeded in
breaking new ground, even in its 51st year of existence.
The organisers aimed at realising a congress that was
future-oriented, even in its organisation, featured attractive content and allowed the presentation of new points
of view. Undoubtedly as a consequence of the coronavirus-related restrictions, the congress was somewhat
smaller than in previous years. “We are pleased that so
many participants came despite the pandemic, but we
naturally would have appreciated even greater participation numbers,” said DGZI vice president Dr Rolf Vollmer.
“Our overriding focus is on a structural reorientation
and, above all, quality.” Dr Arzu Tuna, the DGZI vice
president who represents the younger generation of
implantologists, added: “The reactions of our colleagues and their feedback show that we have taken
the right path!”

1
Fig. 1: The DGZI board members: Dr Rainer Valentin, Prof. Gyula Takacs, Oliver Beckmann, Dr Navid Salehi, Dr Rolf Vollmer, Dr Elisabeth Jacobi-Gresser,
Dr Georg Bach and Dr Arzu Tuna (from left).

42

4 2021

[43] =>

events

Fig. 2: Dr Georg Bach leads the participants in his opening lecture through half a century of dental implantology. Fig. 3: Prof. Ralf Smeets, Prof. Knut A. Grötz,
Dr Georg Bach, Prof. Daniel Grubeanu and Prof. Bilal Al-Nawas (from left). Fig. 4: Dr Armin Nedjat (right) receives from Dr Georg Bach the honour for his father
Dr Manutschehr Nedjat as a long-standing member of the DGZI. Fig. 5: Dr Georg Bach in conversation with Prof. Knut A. Grötz (left) and Prof. Bilal Al-Nawas (right).

Future Podium
The congress set off with a bang: three lectures with (at
least on paper) completely different orientations painted
a clear picture of the future options for our special field
as well as for dentistry as a whole. The DGZI president,
Dr Georg Bach, spoke about triumphs and tragedies
in implantology, reflecting first on the founding of DGZI
51 years ago in Bremen. At that time, the new professional association collectively identified providing knowledge transfer in the field of implantology and promoting
this then still young discipline as its core mission, and it
focused on cooperation with other professional societies
and collaboration with dental laboratories. By means of
two patient cases, Dr Bach, who is an oral surgeon from
Freiburg in Germany, demonstrated that it is undoubtedly possible to achieve successful results with implants
that last for decades, based on the incredible progress
that has been made over the past five decades.

Prof. Shahram Ghanaati, a true expert in the field of biological dentistry, spoke next. His lecture on the use of
autologous blood concentrates kicked off with a surprising
statement: “Forget all classifications of biological materials
in terms of their origin etc. What matters is the individual
immune response.” Prof. Ghanaati presented six studies
and evaluated them with regard to their relevance to daily
implantology practice. By means of excellently documented case studies, the Frankfurt-based oral surgeon,
who leads a surgical oncology department at Goethe
University, demonstrated how valuable the use of plateletrich fibrin (PRF) membranes can be, particularly in socket
preservation, and how this can achieve faster and more
biological wound closure and, consequently, significantly
improved healing. Prof. Ghanaati recommends thorough
filling of the socket with PRF. Moreover, he sees hybrid
materials as a promising future treatment option. He concluded by giving dental professionals one task: “You need
to learn how to draw blood quickly and gently!”

The ideals and goals of DGZI today are still the same
as in 1970. In order to be prepared for the next years of
DGZI, the society is consistently focusing on continuing
education and knowledge transfer, specifically aimed at
the younger generation of dentists and dental technicians. Collegial and constructive cooperation with other
implantological societies is another goal of DGZI for the
coming years.

At the Center for Dental Medicine of the University Hospital
Freiburg, Prof. Katja Nelson has been working in translational implantology for quite some time and has acquired
in-depth knowledge in this field over the past two decades, particularly in terms of digital approaches. Against
this background, the first take-home message of her
lecture surprised some participants: “When patients
demand implant treatment, it’s not enough to send them

4 2021

[44] =>

| events

7
Fig. 6: The winners of the Implant Dentistry Award 2021 around Dr Arzu Tuna. Fig. 7: The speakers at the MUNDHYGIENETAG 2021: Prof. Thorsten M. Auschill,
Prof. Nicole B. Arweiler, Prof. Mozhgan Bizhang and Prof. Stefan Zimmer (from left). Fig. 8: Prof. Daniel Grubeanu (left) and Dr Wolfgang Jakobs. Fig. 9:
The table clinics on Friday afternoon: a wide variety of implantology topics were discussed at 25 tables. Fig. 10: Impression of the well-attended table
clinics on Friday afternoon. Fig. 11: From left: Katrin Wolters (DGZI secretariat), Dr Torsten Hartmann (DGZI managing director and member of the company
management of OEMUS MEDIA AG) and Katrin Mielke (DGZI secretariat).

directly for a CBCT scan. A thorough clinical examination
remains irreplaceable.” For Prof. Nelson, defining clear
rules and adhering to them is a basic prerequisite for
successful implant surgery. She then moved on to digital
dentistry, paying special attention to data collection as
the basis for creating dental restorations with the highest accuracy of fit. “You can do a lot with a CBCT scan
and a digital scan,” she said. According to Prof. Nelson,
segmentation is followed by manipulation of the data set.
Thereafter, Dr Bach summarised one of the central messages of the three introductory lectures as follows: “Today,
we are able to do a lot, but frankly, we have to be able to
do a lot.” As part of the first round of the panel discussion, both Prof. Nelson and Prof. Ghanaati emphasised
that the safe application of their preferred procedures requires an intensive and time-consuming training phase.

Live surgeries
Now it was time to put what had been learned into practice or, rather, to see it put into practice: multi-channel
livestreaming of surgical operations into the conference
hall enabled the participants to gain a unique and fascinating insight into the work of renowned practitioners—
in high definition. Live surgeries are a tradition at DGZI
congresses. In introducing this novel format, DGZI broke
new ground in continuing education at the time. Hamburg-based specialist Dr Jan Klenke carried out the first
surgery, which involved an elaborate recession coverage
with an acellular dermal matrix using the tunnel technique.
Owing to the dual site (donor and recipient) morbidity, periodontal recession coverage employing autologous graft
harvesting is not that frequently used these days. However, Dr Klenke proposed a novel therapeutic approach:
with the insertion of an acellular dermal matrix, postoperative morbidity is significantly minimised, since there is
no need to harvest an autologous connective tissue graft.

4 2021

In the second livestreamed surgery, German Society of
Oral Implantology President Prof. Daniel Grubeanu from
Trier in Germany presented his ideas, approach and experiences in relation to immediate restoration concepts
by means of a quite challenging patient case in which an
unsalvageable tooth #23 had to be extracted. Immediate
implant placement with immediate loading was planned,
and he detailed this step-by-step, including planning, implant placement and placing the temporary prosthetic
restoration. For this purpose, the extracted tooth was
shortened and hollowed out and then converted into a
soft-tissue stabilising crown. It was impressive to see that
the soft tissue was supported in such a way (also using
a PRF membrane) that there was no post-traumatic loss
whatsoever. His approach was unquestionably techniquesensitive and complex, but the treatment result proved
the appropriateness of his procedure.

Table clinics and the digital poster presentation
For some, it was an unfamiliar sight: instead of the usual
rows of seats facing towards the podium, round tables

[45] =>

events

attention. Presidents and board members of implantological and other professional societies were invited to give
lectures and present the latest trends and visions and their
relevance to clinical practice. The Saturday programme of
DGZI’s annual congress offered scientific overview lectures on all relevant areas of oral implantology, including
digital implantology and prosthetics, bone and soft tissue,
materials and design. The participants were captivated
with presentations on three themes: hard tissue, novel
concepts, and soft tissue and its management.

Session 1: Hard tissue
8

were set out as one would expect for a banquet. Each
exhibiting manufacturing company had been provided with
a table, at which demonstrations on a wide variety of implantological topics were given by invited experts in three
sessions and the arising discussions proved to be very
insightful. This new format was met with high acceptance
on the part of the congress participants and the industry
exhibitors. Another highlight was the online and interactive digital poster presentation, which took place on both
congress days, the poster presenters being available in a
lounge in the exhibition area directly in front of the conference hall. All posters could also be accessed online via
mobile devices. Three prize winners were selected among
the submissions on Saturday morning by Dr Tuna. The
first prize went to Dr Tim Hilgenfeld, a private lecturer from
Heidelberg in Germany, the second prize to the working
group of Prof. Christoph Bourauel, Dr Istabrak Dörsam and
Dr Ludger Keilig, and the third prize to Prof. Ralf Smeets
and Dr Sogand Schäfer’s Hamburg research group.
On the podium, every winner was given the opportunity
to briefly present their awarded work to the audience.

Saturday—the day of science
After the first, quite practice-oriented congress day, the
second day focused on the science of implant dentistry.
Current trends were outlined, but the question “What will
implantology look like in the future?” was given much

The scientific programme of the second congress day was
kicked off by Prof. Knut A. Grötz, president of the Deutsche
Gesellschaft für Implantologie (German society for implantology), who spoke about bone augmentation in locally and
systemically compromised cases. In an exciting overview
of the history of augmentative surgery, Prof. Grötz outlined
how “all past paradigms have been surpassed”. While there
is still an isolated need for iliac crest grafts, their number continues to decrease in favour of local and regional
augmentation. This is made possible primarily by osteosynthetic procedures and devices. Ultimately, the decisive factor is a systematic classification of patients who are
systemically compromised, which, according to Prof. Grötz,
is true of 95–97% of all patients with compromised bone.
Such a classification would enable the choice to be made
against augmentation and in favour of reduced-diameter
and short implants. The credo of Prof. Grötz, who is an oral
surgeon from Wiesbaden in Germany, is that the goal and
key should be personalised implant dentistry.
Prof. Bilal Al-Nawas, director of maxillofacial surgery at the
University Medical Center of Johannes Gutenberg University
Mainz in Germany, demonstrated what has been made
possible over the past 50 years with a view to implants, bone
and soft tissue. In eloquent fashion, he stated, “with implantology, it’s like with the miniskirt: it all returns eventually”.
Indeed, his literature review of publications from the 1970s
proved that at the time there were already techniques available that worked and that satisfied patients. These were

4 2021

[46] =>

| events

Fig. 12: CAMLOG dual leadership: Martin Lugert (left) and Markus Stammen. Fig. 13: A highlight was the digital poster presentation, the winners of which
were awarded prizes on Saturday afternoon.

refined, however, and new options were added. In this context, the focus on titanium as the implant material represented an important step, according to Prof. Al-Nawas. The
1990s were distinguished by the development of new implant systems, some of which are still on the market today.
In the same period, new procedures with predictable results
were established, such as the sinus lift. The years after the
turn of the millennium were characterised by observations
on late complications of implant treatment that are of a biological and technical nature. The speed of osseointegration
was significantly increased by the development of new implant surfaces, and handling of the gingival cuff was significantly improved in implants with platform switching, which
is vital when it comes to the interaction between gingiva and
bone. Prof. Al-Nawas noted that the most recent achievements have included reduced-diameter and extremely
short implants, as well as implants made from zirconia.
Prof. Christian Gernhardt, a university lecturer from Halle
in Germany, continued to push boundaries, introducing
himself as “the preserver of teeth who stands in the way
of implant dentists”. In his lecture, he outlined when tooth
preservation and when implant treatment is the better
choice. Decision-making today is increasingly moving in
the direction of tooth preservation and root canal therapy
mainly owing to new techniques and procedures and
industrial developments in the field of endodontics, he
explained, and the debate around peri-implantitis has
only spurred this on. According to Prof. Gernhardt, root
canal therapy is the treatment of an infectious disease
and the interface between endodontics and medicine
plays a major role in this regard in the sense of individualised medicine. Prof. Gernhardt concluded his lecture
by arguing that “tooth preservation always comes first”.

Session 2: Novel concepts
Following on from his impressive live surgery on the previous day, Prof. Grubeanu once again emphasised the
importance of immediate implant placement in daily
practice as part of his lecture. He stressed that resorptive

4 2021

processes always occur—regardless of way the socket
is filled up. Placement of the implant 1 mm sub-crestally
and in an optimal 3D position is a key prerequisite for this
implantation protocol. Based on Wolff’s postulates from
1892, Prof. Grubeanu asserted that bone must loaded
in order for it to be preserved, substantiating his argument for immediate implant placement and immediate
loading. Excellently documented case studies supported
Prof. Grubeanu’s conclusion: “Immediate loading and immediate implant placement brings joy for both patient and
dentist.” Prof. Smeets then defined risk factors in implant
dentistry and pointed to the need to consider patients’
vitamin deficiencies, metabolic diseases and medications. He reported that 30% of patients have inadequate
vitamin D levels, and he recommends supplementation
ahead of major implant procedures, such as sinus lift.
He also discussed the consequences of taking proton
pump inhibitors—information that was met with great interest on the part of the attendees. Dr Wolfgang Jakobs,
chairman of the Berufsverband Deutscher Oralchirurgen
(professional association of German oral surgeons), subsequently elaborated on his main discipline: anaesthetic
procedures in implantology. Dr Jakobs noted that psychosomatic disorders have increased by over 30% in
recent years, and he provided practical tips on local
anaesthesia in dentistry, current sedation procedures and
general anaesthesia. According to Dr Jakobs, the titrated
administration of midazolam has established itself as the
gold standard for sedation owing to its high level of safety.

Session 3: Soft tissue and its management
The question of material was posed by Prof. Florian Beuer,
who discussed different materials for implant prostheses.
“Very often I see implant-supported restorations with excellent implant placement but only average prostheses,” said
Prof. Beuer, chairman of the Department of Prosthodontics, Geriatric Dentistry and Craniomandibular Disorders
at Charité—Universitätsmedizin Berlin. “That’s really a
shame!” He believes that a remedy can be found in the
continued exploration of material-specific potential, such

[47] =>

events

an example being tooth-coloured materials such as zirconium dioxide, which has proved to be advantageous
in terms of aesthetics and biocompatibility. However, the
pursuit of developing ever more translucent materials
from zirconium dioxide has meant that losses in material
strength have had to be accepted and so only first- and
second-generation zirconium dioxide materials should be
used in the posterior region. According to Prof. Beuer, it
is furthermore impossible to imagine implant prostheses
today without the modern generation of acrylics—especially
since they can be processed in CAD/CAM procedures.
For complex restorations, these new high-performance
acrylics can be put to use successfully.
Subsequently, Prof. Thorsten M. Auschill, a lecturer at the
department of periodontics of the University of Marburg,
posed the question “How do I create optimal tissue conditions?” and in his lecture addressed the topic of soft-tissue
defects in answering this. Right at the beginning of his presentation, Prof. Auschill clarified that untreated periodontitis
and peri-implantitis lead to soft-tissue loss. His lecture
put great focus on recessions and the treatment options
for covering them. DGZI past president Prof. Friedhelm
Heinemann, from the University of Greifswald in Germany,
spoke about implant and prosthetic restorations and their
potential. He began by revisiting an old topic, as he described it in his introductory remarks: bone stability around
the implant. In this context, platform switching plays a
central role, according to Prof. Heinemann, and stability is
enhanced by a taper, because “we have to get away from
the bone!” he explained. However, since the taper carries
a rather high fracture risk and may have aesthetic disadvantages in the maxillary anterior region, Prof. Heinemann
sought to incorporate both taper and platform switching
in one implant system. He received support for this project from the working group headed by Prof. Bourauel, the
results of which led to the development of a product line.
Prof. Heinemann’s presentation was rounded off by the
results of his own randomised controlled trial.
The closing lecture of the 50th DGZI annual congress was
delivered by yet another DGZI past president: Prof. Frank
Palm, who answered the question of how to preserve alveolar bone after tooth extraction. Prof. Palm heads the clinic for
oral and maxillofacial surgery at Klinikum Konstanz hospital
in the city of Constance in Germany and also a large outpatient clinic. He has been known for years as an eloquent
and committed advocate of bone substitutes. His remarks
at the congress were also dedicated to this topic. Prof. Palm
presented a product he co-developed, CERASORB Foam,
which is a beta-tricalcium phosphate foam designed to lead
to the preservation of lamellar bone. In addition, this new
material is particularly beneficial in terms of volume preservation, according to Prof. Palm. Should implant surgery be
performed in such a pretreated bone area, a drilling protocol for soft bone is required. Small, not yet organised betatricalcium phosphate remnants can be left in a site like this.

14
Fig. 14: Transmission of the live operation into the conference hall of the
Future Congress.

A brief summary
At the 50 plus one congress in Cologne, participants
experienced an outstanding and innovative continuing
education event and a worthy anniversary celebration
of the oldest European implantological expert society.
But not only that: by looking at implantology from different angles—science, practice, politics and industry—
a new level of interaction was achieved. By attempting
to address the urgent question of what implantology will
look like in five or perhaps ten years from now and what
the political and economic framework conditions will be
then, new ground was broken on the part of DGZI, whose
members shared the stage with the who’s who in Germanspeaking dental implantology. “We are pleased, grateful and happy about this beautiful anniversary congress
and we are glad that we have taken new paths with our
Future Congress!” said Dr Bach. As a conclusion of the
third Future Congress, it can be stated that, with regard
to the implantological practice of the future, in addition to
scientific and technological aspects, it is primarily a matter of answering strategic questions. DGZI will continue
to work actively on this topic with the aim of demonstrating the importance and appeal of its professional society
in the 50 (plus one) years to come.

50th DGZI Congress
Gallery

Dr Georg Bach
Author details

DGZI
Association details

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

4 2021

[48] =>

| news
CleanImplant Ambassadors’ Summit 2021

Safeguarding the established—Daring the new
On 3 November 2021, members of the scientific advisory board
and ambassadors from 16 different nations met for the second

Members of the scientific advisory board and CleanImplant ambassadors
at the Summit 2021 in Como, Italy.

CleanImplant Ambassadors’ Summit at Lake Como in Italy. The
independent foundation evaluates the quality of implants worldwide in officially accredited testing laboratories and awards its
prestigious trusted quality award for implant types with a particularly clean surface. Prof. Tomas Albrektsson from the Sahlgrenska
Academy in Gothenburg, Sweden, emphasised the necessity
and the requirement that implants must not only be sterile when
delivered from the factory but also free of foreign particles. Prof.
Hugo de Bruyn, University of Nijmegen, Netherlands, presented
interim results of a study analysing the presence of metal particles in the peri-implant sulcus fluid in correlation to the respective peri-implantitis status. Madris Kinard Tomes, data specialist
and former FDA employee, broadcasted live from Pennsylvania
to help interpret the rapidly increasing adverse events of oral
implants. Dr Dirk U. Duddeck, CEO and head of research of the
foundation, summarised the results of a recent comparative
study of more than 100 implants. The participants discussed
strategies for supporting manufacturers delivering uncompromised medical devices and how to defend the foundation against
unjustified legal threads from manufacturers providing implants
of inferior quality.
Source: CleanImplant Foundation

Dr Elisabeth Jacobi-Gresser joins

DGZI board as new education officer
On the day before the 3rd Future Congress and 50th International
With the new election of Dr Quitzke, the DGZI also takes an important
Annual Congress of the DGZI, the annual general meeting took place.
step forward in placing younger dentists in important positions of
In addition to the reports of the various board members and the prethe association and thus ensuring a long-term generational change.
sentation and approval of the budget, elections were held and important board positions were reassigned. Dr Elisabeth Jacobi-Gresser,
Source: DGZI
an oral surgeon from Mainz, was elected the new education officer to the DGZI board. Dr Jacobi-Gresser
has been associated with the DGZI for a long time and
has already been intensively involved in the association’s work in the scientific support of the Lernbuch
Implantologie, the online campus and the continuing
educational programme. The new training officer was also
actively involved in the redesign of the successful implantology curriculum. Dr Jacobi-Gresser was and is the
DGZI delegate to the guidelines conference of material
incompatibility. There was also a change in the position
of the DGZI auditor. The long-standing 1st cash auditor
Dr Uwe Ryguschik was bid farewell and the Hamburg
dentist Dr Marcus Quitzke was elected in his place.
President Dr Georg Bach and the entire board of the
DGZI welcomed the new election of Dr Jacobi-Gresser
and see in the experienced dentist and oral surgeon a
confirmation and the possibilities for further development of the innovative training activities of the DGZI. Part of the new DGZI board (from left): Dr Georg Bach, Dr Arzu Tuna, Dr Elisabeth Jacobi-Gresser and Dr Rolf Vollmer.

4 2021

[49] =>

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[50] =>

| about the publisher

Congresses, courses
and symposia

implants
Imprint

ADI Team Congress 2022

Publisher
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implants

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with the German Association of Dental
Implantology (DGZI).

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4 2021

implants international magazine of oral implantology is published by OEMUS MEDIA AG
and will appear with one issue every quarter in 2021. The magazine and all articles and illustrations
therein are protected by copyright. Any utilisation without the prior consent of editor and publisher
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[51] =>

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[cover] => implants international No. 4, 2021

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