implants international No. 4, 2023
Cover
/ Editorial
/ Content
/ Immediate placement and loading of ceramic implants in the aesthetic region: One-year follow-up—two case reports
/ Extreme maxillary bone reconstruction with CERASORB Bioactive—a case report
/ A fully guided digital workflow for predictable implant planning and placement
/ Biocompatibility of CAD/CAM biomaterials for bone tissue engineering application
/ Revolutionising implant dentistry - The Penguin II ISQ device as an example of progress
/ Events
/ Manufacturer news
/ Imprint
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[1] =>
issn 1868-3207 • Vol. 24 • Issue 4/2023
implants
international magazine of oral implantology
case report
A fully guided digital
workflow for predictable
implant planning and
placement
research
Biocompatibility of
CAD/CAM biomaterials
for bone tissue
engineering application
industry
Revolutionising implant dentistry
4/23
[2] =>
[3] =>
editorial
|
Dr Georg Bach
President of the DGZI
A great congress
in Hamburg
Dear colleagues and friends,
We are looking back on a fantastic DGZI annual congress!
Once again, the venerable Hanseatic city of Hamburg
proved to be a good venue for the DGZI—a significantly
increased number of participants, a consistently excellent atmosphere that ran like a golden thread through the
two content-packed days and an extremely interesting
programme—all of which is very pleasing! The oldest
European implantology society will have very fond memories of Hamburg and would like to thank everyone involved—it really has been a pleasure.
My own highlight was our many foreign guests and partners, that we were finally able to welcome back to our
annual congress after the coronavirus pandemic.
I will remember for a long time the cheerful discussions
with the large Japanese delegation on the eve of the congress. In addition to the enhanced travel opportunities
for the representatives of our foreign partners, we were
also able to get the expert exams back on track in Hamburg and award our young colleagues the much-desired
qualification “made in Germany”.
Another high point was the presentation of the Implant
Dentistry Award. The outstanding papers submitted in
advance by young female scientists were so impressive
that the award ceremony was “spoilt for choice”. Congratulations to the two award winners once again!
So you see, I came back from Hamburg with a whole
package of positive emotions and I’m certainly not the
only one! And as we all know, the next congress is just
around the corner—next year we’ll be moving to the
Rhineland, where the big DGZI family will be meeting in
Düsseldorf.
Enjoy reading the implants magazine!
Yours,
Dr Georg Bach
President of the German Association of
Dental Implantology
4 2023
03
[4] =>
| content
editorial
A great congress in Hamburg
03
Dr Georg Bach
case report
page 6
Immediate placement and loading of ceramic implants in the
aesthetic region: One-year follow-up—two case reports
06
Drs Alexandre Marques Paes da Silva, Dennis de Carvalho Ferreira,
Thamires Alves Silva, Mayla Kezy Silva Teixeira,
Daniel de Moraes Telles & Eduardo José Veras Lourenço
Extreme maxillary bone reconstruction with
CERASORB Bioactive—a case report
16
Drs Fernando Duarte & Carina Ramos
page 16
A fully guided digital workflow for predictable implant
planning and placement
20
Dr Beat R. Kurt
research
Biocompatibility of CAD/CAM biomaterials for bone
tissue engineering application
24
Dr Katharina Pippich, Dr Katharina Hast, Adem Aksu,
Stefanie Grom, Dr Tobias Wolfram, Frank Reinauer,
Dr Dr Andreas Fichter, Dr Dr Achim von Bomhard
page 20
industry
Revolutionising implant dentistry
34
events
Implantology as a teamwork—Implantology is a teamwork!
36
Dr Georg Bach
news
manufacturer news
41
about the publisher
imprint
Cover image courtesy of
TK @ www.oemus.com
issn 1868-3207 • Vol. 24 • Issue 4/2023
implants
4/23
international magazine of oral implantology
case report
A fully guided digital
workflow for predictable
implant planning and
placement
research
Biocompatibility of
CAD/CAM biomaterials
for bone tissue
engineering application
industry
Revolutionising implant dentistry
04
4 2023
42
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[1] Semper-Hogg, W, Kraft, S, Stiller, S et al. Analytical and experimental
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a conical implant–abutment connection Clin Oral Invest (2013) 17: 1017
[2] Semper Hogg W, Zulauf K, Mehrhof J, Nelson K. The influence of torque
tightening on the position stability of the abutment in conical implant-abutment connections. Int J Prosthodont 2015;28:538-41
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[6] =>
| case report
Immediate placement and
loading of ceramic implants in
the aesthetic region: One-year
follow-up—two case reports
Drs Alexandre Marques Paes da Silva, Dennis de Carvalho Ferreira, Thamires Alves Silva,
Mayla Kezy Silva Teixeira, Daniel de Moraes Telles & Eduardo José Veras Lourenço, Brazil
In the late 1990s, yttria-stabilised zirconia (Y-TZP) emerged
as a versatile and promising material with wide applicability in implant dentistry. Among the advantages of this
material, its white colour and opacity stand out, these
properties allowing it to mimic the appearance of natural
teeth. Owing to its mechanical properties, mainly the ability to withstand high masticatory loads, zirconia has been
used not only for creating restorations but also for the
manufacture of ceramic implants.1
Y-TZP implants, in addition to being resistant and aesthetic, are highly biocompatible implants, have low affinity
for bacterial plaque, are capable of stimulating osteogenic cells during the osseointegration process and
boast corrosion resistance and radiopacity.2 These characteristics have made these ceramic implants a possible
substitute for titanium implants in oral rehabilitation,
achieving predictable and reliable results.3 The aim of the
1
Fig. 1: Situation on initial clinical examination.
present study is to report two clinical cases of ceramic
implantation in the aesthetic region using a surgical and
prosthetic approach free of metal.
Case reports
2a
2b
Figs. 2a & b: CBCT image showing the vertical root fracture.
06
4 2023
The patients were referred to one private clinical centre in
Rio de Janeiro in Brazil with the need for extraction and
immediate placement and loading of single implants in
the aesthetic region. In order to carry out the correct
planning and diagnosis, the patients were asked to undergo a CBCT scan, a periapical radiograph and intraoral photographs. The patients were non-smokers and
were in good general health, without any systemic condition. Although the patients had good plaque control,
they underwent supragingival scaling and root planning.
This study was submitted to the ethics committee of the
Universidade do Estado do Rio de Janeiro and approved
(No. 5.598.463). The patients were previously invited to
participate in and informed about the study and signed
informed consent to participate, and all ethical aspects
were followed.
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© 2023 Dental Imaging Technologies Corporation. All rights
reserved; DXIS00275 /RevA
dexis.com
[8] =>
| case report
Case 1
A 66-year-old female patient who was a smoker
presented with the main complaint of a broken anterior tooth. On clinical examination, it was noted
that the maxillary left lateral incisor had a metalceramic crown with a partially displaced cast metallic core (Fig. 1). The CBCT examination showed
the presence of a vertical root fracture due to recurrent caries (Fig. 2). Given the clinical and radiographic situation, the proposed treatment was the
extraction of the tooth in question, followed by immediate placement of a ceramic implant and immediate restoration with a crown.
3
The extraction was performed atraumatically with the
aid of periotomes and forceps and a 3.75 × 13.0 mm
two-piece ceramic implant (Zi, Neodent) was placed
in the fresh alveolus (Fig. 3). The insertion torque
was 35 Ncm, and this primary stability allowed for
immediate loading. It should be noted that the implant was placed according to the manufacturer’s
recommendations at the level of the bone crest, and
the gap was filled with bone substitute (maxresorb,
botiss biomaterials; 0.5 cm2 of 0.5–1.0 mm; Fig. 4).
A 4.5 × 5.0 × 2.5 mm (regular) zirconia abutment
(Zi CR abutment) was seated (Fig. 5), and a provisional restoration was made with light-polymerising
composite resin and cemented on the abutment
(Fig. 6). At the end of the surgical procedure, a radiograph was taken (Fig. 7).
4
The three-month postoperative period was uneventful, and after this period, the patient returned
to begin the final prosthetic phase. The final prosthesis was fabricated from monolithic zirconia using
a digital workflow (Virtuo Vivo intra-oral scanner,
Straumann; Figs. 8 & 9) and cemented on to the
abutment with a dual adhesive cement (RelyX U200,
3M; Fig. 10). After 12 months of follow-up, the periapical radiograph showed the stability of the bone
(Fig. 11).
5
After cementing the crown, it was observed that a
new crown was needed for the adjacent tooth, the
maxillary left central incisor, owing to the discrepancy in colour and dental anatomy. This prosthesis
was also fabricated from monolithic zirconia using
a digital workflow (Fig. 12) and cemented onto the
prepared tooth with a dual adhesive cement (RelyX
U200; Fig. 13).
6
Fig. 3: Placement of the Zi implant. Fig. 4: Filling of the gap with bone grafting material. Fig. 5: Cemented zirconia abutment. Fig. 6: Immediate post-op situation with
the provisional crown cemented.
08
4 2023
Case 2
A healthy 70-year-old female patient presented
with the main complaint of toothache in the region
of the maxillary left lateral incisor. Upon clinical examination, it was noted that the tooth had a metal–
ceramic crown and had not undergone endodontic
[9] =>
case report
7
8
9
11
13
|
10
12
Fig. 7: Post-op radiograph. Fig. 8: Scan body in position for
intra-oral scanning. Fig. 9: Intra-oral scan. Fig. 10: Cementation of the final zirconia crown. Fig. 11: Periapical radiograph showing stability of the bone after 12 months. Fig. 12:
Intra-oral scan of the maxillary left central incisor for a new
crown. Fig. 13: Situation at conclusion of the case.
4 2023
09
[10] =>
| case report
Like in the previous clinical case, the extraction was performed atraumatically, and curettage and cleaning of the
fresh alveolus was performed. After that, a 4.3 × 13.0 mm
two-piece ceramic implant (Zi) was placed to an insertion
torque of 45 Ncm (Fig. 15). A 4.0 × 5.0 × 2.5 mm (narrow)
17° angulated zirconia abutment (Zi CR abutment) was
seated (Fig. 16), and a provisional restoration was made
with self-polymerising resin and cemented on to the
abutment (Fig. 17). At the end of the surgical procedure,
a radiograph was taken (Fig. 18).
The three-month postoperative period was uneventful,
and after this period, the patient returned to begin the final prosthetic phase. The final prosthesis was fabricated
from lithium disilicate (IPS e.max, Ivoclar Vivadent) using
an analogue workflow with impression material (additioncured silicone, Yller) and cemented on to the abutment
with a dual resin cement (RelyX U200; Fig. 19). Prior to
cementation, the health of the peri-implant tissue around
the ceramic implant was observed, as was the maintenance of the soft tissue, including the mesial and distal
papillae (Fig. 20). After 12 months, the patient returned
and a radiograph was taken, on which the maintenance
of the bone around the implant was observed (Fig. 21).
14
Fig. 14: CBCT image showing periapical periodontitis.
Discussion
treatment. The CBCT scan showed the presence of an
endodontic lesion of greater than 5 mm, and the patient
wanted the tooth extracted (Fig. 14). Given the clinical
and radiographic situation, the proposed treatment was
tooth extraction, immediate placement of a ceramic implant and immediate restoration with a 17° angulated
abutment and a provisional crown.
The literature shows that titanium implants have achieved
excellent and predictable results over the last decades,
are biologically tolerable and exhibit excellent mechanical
properties. However, it is important to point out that titanium implants have aesthetic disadvantages, especially
when placed in patients with a thin gingival biotype in the
anterior region. Ceramic implants avoid the metallic shadow
of the implant or abutment under the tissue.4
15
16
17
Fig. 15: Placement of the Zi implant. Fig. 16: Cemented zirconia abutment. Fig. 17: Immediate post-op situation with the provisional crown cemented.
10
4 2023
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[12] =>
| case report
Over the years, ceramic materials have been the subject
of investigation and clinical application as a potential alternative to titanium, and increasingly, zirconia has stood
out as a promising alternative.5 Among its beneficial
properties is its colour, which is similar to that of natural
teeth, making this material especially relevant in the aesthetic region,6 which we observed in the present study.
This similarity enables adequate light transmission at the
critical interface between the marginal gingival tissue and
prosthetic components.6
With the development of CAD/CAM, this high-strength
ceramic is becoming the first choice for restoration of implants in the aesthetic region.7 In addition to its aesthetic
advantages, monolithic zirconia has several excellent
mechanical characteristics, such as high fracture toughness, resistance to fatigue, high flexural strength, significant corrosion resistance and radiopacity,8 strengthening
its viability for use for a range of restorations, from single
crowns to complete dentures, supported on implants in
the anterior and posterior regions.9 In both regions, zirconia crowns have shown high survival rates.10
In Case 1, a digital workflow was employed, and a monolithic zirconia crown was fabricated, whereas in Case 2,
an analogue workflow was followed, and a lithium disilicate crown was fabricated. In both cases, satisfactory
aesthetics were achieved; however, the possibility of performing a digital workflow, in addition to being more accurate regarding the final result, reduces the number of
adjustments and is more comfortable for the patient.7
Biologically, zirconia provides reduced plaque build-up
and excellent hard- and soft-tissue integration, equivalent
to that of titanium.11 In the current literature, studies show
that zirconia implants present similar or even better results regarding these measures when compared with ti-
19
18
Fig. 18: Post-op radiograph.
tanium implants.12,13 Furthermore, zirconia, like titanium,
is a biocompatible material and favours the health of the
peri-implant soft tissue,14 as was observed after 12 months
of follow-up in the two cases reported here. In Case 2,
we observed the health of the soft tissue around the ceramic implant, particularly the collagen fibres present in
the region.
Initially, ceramic implants were predominantly one-piece
implants.15 These single-body implants have reduced
20
Fig. 19: Cementation of the final lithium disilicate crown. Fig. 20: Healthy soft tissue around the implant.
12
4 2023
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[14] =>
| case report
plants placed in the aesthetic region in two patients, who
were followed up for 12 months. The soft and hard tissue
were maintained over the follow-up period.
The Zi two-piece ceramic implant system used in the two
cases described proved to be a safe and reliable alternative in oral rehabilitation of the aesthetic region. Further
studies will need to be carried out to confirm our findings,
and the cases presented here will continue to be monitored.
Literature
about the authors
Dr Alexandre Marques Paes da Silva is a lecturer in the department of prosthodontics of the faculty of dentistry at the Universidade do Estado do Rio de Janeiro in Brazil. He can be contacted
at xandemps@gmail.com.
21
Fig. 21: Final radiograph.
prosthetic versatility, since there is no possibility of angling the prosthetic component, which may be critical in
the aesthetic region.16 However, these single-piece implants have the advantage of having a transmucosal
abutment as part of the implant unit, thus avoiding the
presence of an implant–abutment micro-gap and nullifying the micro-movements between the abutment and the
implant.17 There are few studies on single-piece ceramic
implants with long follow-up periods, and most of them
have a low sample size.18
In order to address the limitations of single-piece implants, a separate implant body and abutment were designed, thus providing greater prosthetic options. Twopiece zirconia implants have been found to have high
success rates, similar to those found in titanium implants.19 Zirconia abutments are widely used in regions
with high aesthetic demand, presenting high biocompatibility and mechanical resistance.20 In the present study,
it was decided to use a two-piece implant in order to have
more prosthetic options, and Case 2 required the use of
an angulated abutment owing to the positioning of the
bone. In this case, it would have been difficult to use a
one-piece implant without the need for abutment preparation.
Conclusion
The main objective of this case report was to present the
clinical and radiographic performance of ceramic im-
14
4 2023
Dr Dennis de Carvalho Ferreira is a lecturer in the microbiology
department of the faculty of dentistry at the Universidade Estácio
de Sá in Rio de Janeiro in Brazil.
Dr Thamires Alves Silva has a position in the faculty of dentistry at the Universidade Federal Fluminense in Niterói in Brazil.
Dr Mayla Kezy Silva Teixeira is a lecturer in the department of
prosthodontics of the faculty of dentistry of the Universidade do
Estado do Rio de Janeiro in Brazil.
Dr Daniel de Moraes Telles is a full professor in the department
of prosthodontics of the faculty of dentistry of the Universidade
do Estado do Rio de Janeiro in Brazil.
Dr Eduardo José Veras Lourenço is an associate professor in
the department of prosthodontics of the faculty of dentistry of the
Universidade do Estado do Rio de Janeiro in Brazil.
contact
Dr Alexandre Marques
Paes da Silva
+55 21 997905289
xandemps@gmail.com
Dr Alexandre Marques
Paes da Silva
[15] =>
© MIS Implants Technologies Ltd. All rights reserved.
REVOLUTION
IN A BOX!
TM
FULL PROCEDURE IN EVERY IMPLANT PACKAGE. MAKE IT SIMPLE
Every MIS C1 implant is now supplied with XD Single-Use drills. These single-use drills are designed
for optimal implant-drill compatibility and high initial stability, while ensuring safe and simplified
procedures. Learn more about MIS at: www.mis-implants.com
[16] =>
| case report
Extreme maxillary bone
reconstruction with CERASORB
Bioactive—a case report
Drs Fernando Duarte & Carina Ramos, Portugal
Ossifying fibroma is classified as, and behaves like, a
benign bone neoplasm. It is often considered to be a
type of fibroosseous lesion. This bone tumour consists of
highly cellular, fibrous tissue that contains varying amounts
of calcified tissue resembling bone, cementum or both.1
Owing to the presence of both bone and cementum-like
tissue in ossifying fibromas, these lesions are described
using the terms “ossifying fibroma”, “cementoossifying
fibroma” and “cementifying fibroma”.2 Nonetheless, the
consensus is that these three terms describe the same
underlying type of lesion.3,4
In most cases, ossifying fibroma is slow-growing, but it is
occasionally aggressive, particularly its juvenile subtypes. Additionally, its growth is usually concentric, and it
is well demarcated from the adjacent bone. Some lesions
may grow to become massive, causing considerable
aesthetic and functional deformities. Clinically, ossifying
fibroma is usually asymptomatic and is often found accidentally in routine dental examinations.
Ossifying fibroma predominantly affects the facial bone,
most commonly in the mandible, where it arises apical to
the premolars and molars and superior to the mandibular
canal.2 Among the other cranial and facial bones, the
periorbital, frontal, ethmoid, sphenoid and temporal
bones are also relatively common sites of this tumour.4,5
1a
1b
Figs. 1a–c: Initial orthopantomography and computed tomography.
16
4 2023
Ossifying fibroma most commonly occurs in patients in
the second to fourth decades of life, although it may arise
in children and adolescents, as well as in older adults.2 It
shows a predominance among females.6
Classification
In 1968, Hamner et al. analysed 249 cases of fibroosseous jaw lesions of periodontal membrane origin and
classified them.7 In 1973, Waldron and Giansanti reported
65 cases (of which 43 had adequate clinical histories and
radiographs) and concluded that this group of lesions
was best considered a spectrum of processes arising
from cells in the periodontal ligament.6 In 1985, Eversole
et al. described the radiographic characteristics of central ossifying fibroma, and two major patterns were noted,
expansile unilocular radiolucencies and multilocular configuration.8,1
In 1971, the World Health Organization (WHO) suggested
the classification of cementum-containing lesions into
four types: fibrous dysplasia, ossifying fibroma, cementifying fibroma and cementoossifying fibroma.2 In a subsequent WHO classification, benign fibroosseous lesions of
the oral and maxillofacial regions were divided into osteogenic neoplasms or non-neoplastic bone lesions, the former category including cementifying ossifying fibroma.2
1c
[17] =>
case report
2a
2b
2c
3a
3b
3c
|
Figs. 2a–c: Clinical aspect of first quadrant bone defect. Figs. 3a–c: Rectangular osteotomy in the chin area.
However, the term “cementifying ossifying fibroma” was
simplified to “ossifying fibroma” in the 2005 WHO classification system.9
Radiographic features
In a study by Liu et al. the radiographic characteristics of
the tumour showed two patterns: cystic lesions (either
unicystic or multicystic) and mixed-density lesions. The
predominant radiographic features of ossifying fibroma
are a round or oval well-defined, expansile mass with a
corticated border and a variable degree of internal radiopacity.1
The internal aspect of these lesions can be granular, resembling fibrous dysplasia, and they may have a thin, radiolucent periphery, representing a fibrous capsule. This
can result in the expansion of the outer cortical plate of
bone. The density of these lesions is mixed, and the internal structure may be a mixture of radiolucent and radiopaque tissue.1 Radiographically, ossifying fibroma most
frequently appears as a well-defined mixed radiolucent
and radiopaque lesion.
Differential diagnosis
The differential diagnosis includes benign mixed radiolucent and radiopaque neoplasms, and the diagnosis is
determined by the clinical and radiographic behaviour.2
The differential diagnosis depends on the degree and
pattern of internal radiopacity. In many cases, CBCT images are helpful for diagnosing these lesions.2 A diagnosis of fibrous dysplasia or periapical osseous dysplasia
may be considered, and occasionally, a diagnosis of cementoblastoma.
Fibrous dysplasia refers to the replacement of normal
bone with fibrous tissue containing foci of immature woven bone. Although fibrous dysplasia shows poorly defined
expansion, the general shape of the involved bone is maintained. In contrast, ossifying fibroma displays tumour-like,
concentric expansion.2
However, periapical osseous dysplasia is often multifocal, whereas ossifying fibroma is not. A wide sclerotic
border, as well as a more undulating expansion, is more
characteristic of the slow-growing periapical osseous
dysplasia. The epicentre of periapical osseous dysplasia is located at the apex of the tooth, within the alveolar
process.
Bone reconstruction
The treatment of choice for an ossifying fibroma is
resection, requiring subsequent bone reconstruction.
CERASORB Bioactive (curasan) is a bioactive synthetic,
porous, biocompatible ceramic material made for filling,
bridging and reconstruction of bone defects and augmentation of the atrophied alveolar ridge. This fully resorbable material provides the potential to increase bioactivity.10 This new material with phase-pure betatricalcium phosphate technology is doped with silicate to
enhance its mechanical stability and offers high opencelled porosity of approximately 75% for immediate start
of osseointegration and is completely resorbed after four
to six months.
4 2023
17
[18] =>
| case report
Platelet-rich fibrin is a therapeutic blood matrix obtained
by selective centrifugation and acts as an adjuvant in tissue repair. In order to obtain these fibrin matrices for the
case presented in this article, six samples of autologous
blood were collected in 10 mL pure glass dry tubes
(Montserrat) and two blood samples in polystyrene dry
tubes (Greiner Bio-One). These were centrifuged in the
Fibrin System centrifuge (Ortoalresa) according to the
methodological proposal of Duarte de Almeida and de
Oliveira, which uses relative centrifugal force of 200 ×g for
ten minutes to obtain two physical forms of fibrin, a polymeric or solid gel form and a monomeric or temporary
liquid phase form, in a single centrifugation step.11
Clinical case
A 26-year-old female patient attended an oral and maxillofacial surgery consultation at the Clitrofa medical, dental and surgical centre in Trofa in Portugal for bone reconstruction of the maxillary right quadrant. The patient had
been diagnosed with ossifying fibroma. It had been excised with a safe bone margin, and the bone defect was
reconstructed with an autogenous fibula graft in the
same surgery. This had failed after a month owing to
bone exposure. The osteosynthesis plate used in graft
fixation was present.
Anamnesis found no allergies or use of medications. On
extra-oral clinical examination, a normal appearance was
observed. On intra-oral clinical and radiographic exam-
ination (dental panoramic tomogram and CBCT), a massive bone defect was noted in the anatomical areas of
teeth #15–12 (Figs. 1a–2c).
Two vertical and two horizontal osteotomies were performed in the symphyseal and parasymphyseal region
to delimit the bone area to be grafted. This rectangular
osteotomy was performed according to the bone availability evident in the CBCT scan (Figs. 3a–c).
Bone reconstruction was performed by combining this
autogenous bone and CERASORB Bioactive in a 50:50
ratio. The bone grafting material was mixed with the
platelet-rich fibrin to create sticky bone, facilitating handling and application and allowing immediate adhesion
to the defect site. The use of platelet-rich fibrin in the
grafting process allows one to exploit its properties, especially in supporting the inflammatory response, immune response, tissue repair, tissue reorganisation and
angiogenesis.
An EPI-GUIDE membrane (curasan) was used to cover
the grafted site. This is a non-biological, resorbable hydrophilic membrane containing a 3D structure important
for barrier function. Its 3D constructed density gradient is
designed to attract and stabilise fibroblasts and epithelial
cells while allowing permeable nutrients through the membrane. To ensure reliable positioning and fixation of the
membrane, 5 mm Ti-SYSTEM pins (curasan) were used
(Figs. 4a–c).
4a
4b
4c
5a
5b
5c
Figs. 4a–c: Sticky bone and EPI-GUIDE membrane fixed with Ti-SYSTEM 5 mm pins. Figs. 5a–c: Suture with undyed monofilament non-absorbable PTFE 4/0
and non-absorbable nylon 5/0.
18
4 2023
[19] =>
case report
6a
7a
|
6b
7b
7c
Figs. 6a & b: Final computed tomography. Figs. 7a–c: Final clinical aspect of first quadrant bone reconstruction.
The autologous platelet-rich fibrin membranes were
placed over the site to provide an extra-protected environment for bone regeneration in the defect area and to
support new bone growth by presenting a barrier to the
infiltration of soft tissue and promoting the growth of osteogenic cells in the bony defect (Figs. 5a–c). Suturing
was performed with simple sutures using undyed nonresorbable (#4/0 PTFE) and non-resorbable monofilament
suture material (#5/0 nylon; Figs. 6a & b).
contact
Dr Fernando Duarte
+351 252 428960
fduarte@clitrofa.com
The patient underwent systemic antibiotic, analgesic and
anti-inflammatory therapy for eight days. Regarding postoperative care, she was instructed to maintain strict oral
hygiene. The CBCT scan and clinical examination during
the postoperative period of six months showed evidence
of new bone formation (Figs. 7a–c).
Dr Carina Ramos
+351 252 428960
cramos@clitrofa.com
Conclusion
This new biomaterial was developed for resorption and
new bone formation to mimic autologous bone. It shows
superior handling with rapid hydration with the surgeon’s
preferred fluids, including autologous fluids, growth factors and antibiotics for various surgical indications. In this
case report, bioactive silicate coupled with high-porosity
beta-tricalcium phosphate appears to have led to enhanced bone formation. A longer follow-up and case series will be needed to corroborate the encouraging preliminary results of this new biomaterial.
Literature
Dr Fernando Duarte
Dr Carina Ramos
4 2023
19
[20] =>
| case report
A fully guided digital workflow
for predictable implant planning
and placement
Dr Beat R. Kurt, Switzerland
A 62-year-old male patient was referred to my practice
for implant planning and treatment in the maxillary anterior region. The teeth in the maxillary anterior region had
all undergone endodontic therapy, and teeth #11-22 had
received crowns owing to an accident that had occurred
30 years before. The patient reported pain and was conscious that tooth #21 was mobile (Figs. 1a & b).
1a
The first step was to obtain a CBCT scan of the maxillary
arch, which revealed periapical pathology in teeth #12-22
(Figs. 2 & 3). Furthermore, tooth #21 exhibited significant
loss of buccal bone, and a small piece of amalgam was
identified in the bone near tooth #21. After a thorough
analysis of the radiographic findings, a treatment plan
was established to extract teeth #12-22 and perform
ridge preservation to reduce bone loss in the extraction
sites.
1b
2
Figs. 1a & b: Initial situation. Fig. 2: Initial CBCT scan of the maxillary arch.
20
4 2023
[21] =>
case report
3
4a
4b
|
4c
Fig. 3: Initial CBCT scan. Coronal view of tooth #21 showing buccal bone loss. Figs. 4a–c: Digital impressions of the initial situation.
5
6
7
Fig. 5: Intra-oral radiograph after the extractions and ridge preservation. Fig. 6: Intra-oral image with the temporary prosthesis in place. Fig. 7: CBCT scan
of the maxillary anterior region after the extractions.
8a
8b
9
Figs. 8a & b: Digital impressions after the extractions. Fig. 9: Implant planning for all four positions.
10
Fig. 10: Final planning for two implants with merged intra-oral scan and CBCT data.
4 2023
21
[22] =>
| case report
11a
11b
11c
12
Figs. 11a–c: Implant planning and guided surgical guide design. Fig. 12: Intra-oral radiograph of the implants after placement.
22
4 2023
[23] =>
case report
|
During the implant planning phase, we created a preliminary plan using 3D imaging software with a prosthetically
driven implant planning approach (Figs. 9 & 10), and the
plan was exported into surgical guide planning software
for final planning and construction of the surgical drilling
guide (Figs. 11a–c). The implants were planned in all four
positions with the object of identifying the two most optimal and accessible sites for the placement of two implants and the corresponding bridge restoration.
13a
13b
Figs. 13a & b: Intra-oral view of the implants with healing abutments after
placement.
As is routine protocol in my dental practice, we captured
a digital impression of the maxillary and mandibular arches
with the DEXIS IS 3800 intra-oral scanner (Figs. 4a–c),
along with intra-oral photographs to document the initial
oral condition. These digital models were used for the
fabrication of the temporary removable prosthesis.
After completion of the planning and drilling reconstruction, the surgical guide was 3D-printed with a Stratasys
printer using MED610 resin (Stratasys). The two implants
(4.1 x 12.0 mm Straumann Bone Level Tapered, Regular
CrossFit, SLActive, Roxolid) were then placed utilising the
Straumann guided surgery kit for precise guidance. The
remaining piece of amalgam in the bone of tooth #21 was
carefully removed—only a small piece in the gingiva remained (Fig. 12). The buccal bone was again thickened
with EthOss, and the wound was closed with a semisubmerged technique, facilitating proper healing and integration of the implants (Figs. 13a & b).
After a ten-week osseointegration and healing period, the
patient returned for a final assessment of the implant stability using the implant stability quotient measurement.
The subsequent step will involve the completion of the final prosthesis, which will be performed by the patient’s
general dentist. To create the screw-retained monolithic
bridge, a digital impression will be obtained using an intraoral scanner, and the dental technician will also work fully
digitally—as far as possible—for the final prosthesis.
about the author
Dr Beat R. Kurt is a paid consultant for
DEXIS. The opinions presented are those
of Dr Kurt. Dental Imaging Technologies
Corp. is a medical device manufacturer
and does not dispense medical advice.
Clinicians should use their own judgement in treating their patients.
Upon receiving approval from the insurance company for
the proposed treatment plan, all four teeth were extracted. After the extractions, the extraction sockets were
meticulously debrided with EthOss degranulation burs
and filled with EthOss grafting material to promote primary closure and healing of the wound (Fig. 5).
To preserve both the aesthetic and functional aspects for
the patient during the time between extraction of the
teeth and the new bridgework, a temporary removable
prosthesis was fabricated (Fig. 6). The patient’s general
dentist has also been working fully digitally for years, and
the temporary prosthesis was made from a digital impression and printed models.
Two months after the extractions, we obtained a CBCT
scan of the maxilla (Fig. 7) and captured digital impressions using our DEXIS IS 3800 intra-oral scanner (Fig. 8).
These scans were essential for commencing the implant
planning process and creating the surgical guide.
contact
Dr Beat R. Kurt
Winkelriedstrasse 35
6003 Luzern
Switzerland
+41 41 2102474
office@oralchirurgie.ch
oralchirurgie.zahnarzt-luzern.dentist/
Dr Beat R. Kurt
4 2023
23
[24] =>
| research
Biocompatibility of CAD/CAM
biomaterials for bone tissue
engineering application
Dr Katharina Pippich, Katharina Hast, Adem Aksu, Stefanie Grom, Dr Tobias Wolfram, Frank Reinauer,
Dr Dr Andreas Fichter, Dr Dr Achim von Bomhard, Germany
Large bone defects have so far mainly been treated with
autogenous bone grafts. Owing to limited availability and
donor site morbidity, research is ongoing into the development of various bone replacement materials. An advantage of CAD/CAM implants is the possibility of patientspecific engineering. Ceramics and polymers have been
extensively investigated, but not all materials can be produced in a standardised and patient-specific way yet. In
this study, a wide range of materials were investigated, all
of which can be CAD/CAM manufactured and individually
dimensioned in the clean room with standardised techniques using digital light processing, selective laser sintering and fused deposition modelling. The novelty of the materials is the compounding of these, including the special
processing by 3D printing. Eight polymer and ceramic CAD/
CAM materials—poly-L-lactic acid and calcium carbonate,
poly-L-lactic acid and tricalcium phosphate, poly-L-lactic
acid and polyglycolic acid and calcium carbonate, poly-D,
1a
1b
1c
1d
Fig. 1: Scaffold construction (sizes in mm). Scale bars = 1 mm. 3D view (a),
top view (b), side view (c), Cross section (d).
24
4 2023
L-lactic acid and magnesium, poly-D, L-lactic acid, betatricalcium phosphate (β-TCP) and hydroxyapatite, β-TCP
and β-TCP'—were tested to evaluate the cytotoxic effects
on human osteoblasts. Biocompatibility was tested using
a proliferation assay, a cytotoxicity assay, an apoptosis
assay and fluorescence microscopy. The ceramic-based
scaffolds, in particular β-TCP, showed very high cell counts
in the proliferation assay as well as rapidly falling apoptosis rates and offer significant potential for use for patientspecific bone replacement implants.
Introduction
Bone defects often occur in the context of tumour resection, bone inflammation, malformation or trauma.1 Autogenous bone transplantation continues to be the gold standard for the reconstruction of such defects. However,
bone availability is limited in this case, and not inconsiderable donor site morbidity, including impaired wound
healing, functional limitations, scarring and necrosis, can
occur.2 Research in the field of bone regeneration is
steadily growing.3 Of great interest are biomaterials, which
being bone replacement materials, avoid the creation of
donor sites and the associated complications and which,
owing to their osteoconductive properties and suitable
architecture, represent a viable alternative to autogenous
bone transplantation.4–6 In addition, materials that can be
additively manufactured offer the advantage of being able
to be individually dimensioned according to the defect.
The growing demand requires bone replacement materials to possess improved mechanical and biological properties. An ideal biomaterial is characterised by biocompatibility and is replaced by regenerated new bone after
the healing period. In terms of chemical composition and
architecture, it should mimic the extracellular bone matrix
so that cells can adhere, multiply and differentiate.7, 8 Biomaterials that are very frequently used include ceramics
such as beta-tricalcium phosphate (β-TCP) and hydroxyapatite (HA). Owing to their osteoconductivity and similar
composition to that of bone, they play a crucial role in tissue engineering. In particular, β-TCP has a high degree
[25] =>
research
CC); PDLLA–Mg; PDLLA; β-TCP–HA; and β-TCP and
β-TCP' for biocompatibility using the same methodology.
The compounding of the materials, including special processing by 3D printing, represents an innovation in additive manufacturing. All eight materials were produced by
digital light processing, selective laser sintering or fused
deposition modelling (FDM). Both the respective processes
and the pore structures were optimised accordingly in order to be able to produce comparable scaffolds using all
technologies. This enabled us to objectively compare a
wide range of materials and material combinations.
of solubility and is broken down more quickly, enabling
replacement with new, regenerated bone.9–11 Polymers
such as poly-L-lactic acid (PLLA) or poly-D, L-lactic acid
(PDLLA) have also shown promise in numerous studies.
Their biocompatibility and biodegradability make them
suitable for the regeneration of bone tissue. They have
sufficient mechanical stability, and their modulus of elasticity is closer to that of the natural cortex than ceramic
materials, which are more brittle.12, 13 Composite scaffolds
made of polymer and ceramic are also frequently used
biomaterials in bone tissue engineering and are currently
being investigated clinically. Ceramic and polymer components are combined to achieve good biocompatibility
and stability.14–19 Likewise, PDLLA or PLLA mixed with
calcium carbonate (CC) or magnesium (Mg) is rated as
promising.20, 21 However, the comparability of materials
has been limited by the different methodologies of the
various studies on them, and most studies have only described one group of materials. Previous studies have
shown that certain defined parameters, such as pore
size, pore shape and porosity, in addition to certain defined mechanical properties and biocompatibility, are decisive for cell adhesion and bone ingrowth.22, 23 Thanks to
the 3D construction of a scaffold that is optimal with regard to these parameters, the bone metabolism can be
positively influenced in a targeted manner. However, this
complex construction can only be implemented with difficulty using conventional production techniques, since
parameters such as pore size, porosity and pore distribution cannot be precisely controlled.24 We examined such
materials more closely, all of which can be additively manufactured in the clean room using standardised techniques. In this way, defined construction parameters can
be implemented precisely for a wide variety of materials.
We examined eight different biomaterials of PLLA–CC;
PLLA–TCP; PLLA, polyglycolic acid and CC (PLLA–PGA–
Biomaterials
The scaffolds were manufactured, packaged and then
sterilised with gamma irradiation in cooperation with the
medical technology company Karl Leibinger Medizintechnik
under clean room conditions. All scaffolds were constructed
with a diameter of 12 mm and a height of 5 mm (Fig. 1). In
order to obtain comparable scaffolds, the wall was reduced
in the first step. After an optimisation of the process parameters, sections of the wall were removed in a second
optimisation, thus making the scaffolds permeable to liquids and cells in the edge structures. In a final step, the
pore geometry was enlarged and rotated in order to achieve
greater reproducibility and comparability between the various manufacturing methods (Figs. 2 & 3). The PLLA–CC
scaffolds were manufactured on the FORMIGA P 110 (EOS),
using selective laser sintering technology. The scaffolds
made of PLLA–TCP, PLLA–PGA–CC, PDLLA–Mg and
PDLLA were manufactured using FDM technology on the
ARBURG AKF freeformer 200-3X (ARBURG). To achieve
technical feasibility, technically pure Mg (99.8%, Alfa Aesar)
was used. The β-TCP–HA and β-TCP scaffolds were manufactured using digital light processing technology on the
2a
2c
2b
|
Material and methods
2d
Fig. 2: Scaffold production. Initial state (a), reduction of the wall (b), removal of sections of the wall (c), enlargement and rotation of the pore geometry (d).
4 2023
25
[26] =>
| research
3a
3b
3c
3d
3e
3f
3g
3h
Fig. 3: Examined scaffolds in culture medium. Scale bar = 10 mm. PLLA-CC (a), PLLA-TCP (b), PLLA-PGA-CC (c), PDLLA-Mg (d), PDLLA (e), β-TCP-HA (f),
β-TCP (g), β-TCP' (h).
CeraFab 7500 (Lithoz). For the β-TCP–HA scaffolds, sintering took place between 1,150 and 1,300 °C, and for the
β-TCP between 1,050 and 1,200 °C. Two scaffold types with
different mechanical properties were made from β-TCP
(β-TCP and β-TCP'). To better differentiate between β-TCP
and β-TCP', the flexural strength was determined in a flexural test of the samples. The flexural strength between
β-TCP and β-TCP' increases with increasing sintering temperature. A flexural strength of 68 N/mm² was determined
for β-TCP and of 120 N/mm² for β-TCP'.
Seeding of biomaterials and cultivation
The biomaterials were seeded with human osteoblasts
(PromoCell). Before seeding, the scaffolds were incubated
for 72 hours at 37 °C and 5% carbon dioxide (CO 2) in
standard culture medium (Osteoblast Growth Medium,
PromoCell) to hydrate the scaffold matrix in order to later
facilitate the growth of the cells into the scaffold structure.
In addition, the pores in the medium were de-aerated by
applying a vacuum in a 100 ml syringe. The cells were
amplified in monolayer culture with standard culture medium to a confluence of 80–90% and then passaged.
Cells from the second passage were used. For seeding,
the cells were detached by trypsinisation and resuspended
in standard culture medium to obtain a cell suspension
with a final cell concentration of 2 × 106 cells/ml. One scaffold was placed per well in a 24-well plate. For seeding,
the cell suspension was pipetted on to the hydrated scaffolds. To ensure that the cells were homogeneously distributed, each batch was pipetted from a cell suspension
and vortexed several times in between. For the apoptosis
and proliferation assays, the scaffolds were seeded with
2 × 105 cells, each with a density of 3.54 × 105 cells/cm3.
In order to enable cell adhesion, the seeded scaffolds
26
4 2023
were incubated for 30 minutes at 37 °C and 5% CO2. The
well was then filled with 1 ml of culture medium so that the
scaffolds were covered by medium. During the course of
this, the medium was changed every two days.
Fluorescence microscopy
In order to visually validate the success of culturing after
21 days, the scaffolds were evaluated using a fluorescence
microscope. The scaffolds (n = 2) were seeded with ten
million cells and cultured for 21 days in differentiation
medium (StemMACS OsteoDiff Media, human, Miltenyi
Biotec) and then fixed in 3% formaldehyde. They were
covered in a 24-well plate with a Hoechst staining solution (Hoechst 33342, AppliChem, in phosphate-buffered
saline; 1:2,000) and incubated for 10 minutes at room
temperature, protected from light. They were then transferred to a well filled with phosphate-buffered saline and
viewed there under a fluorescence microscope (BZ-9000
BIOREVO, Keyence) with a DAPI filter.
MTS assay
The number of metabolic cells growing on the scaffold
surface and in the scaffold matrix was estimated using an
MTS assay (CellTiter 96 AQueous One Solution, Promega).
This proliferation assay uses tetrazolium salt, which is
converted by the cells into purple formazan. The amount
of formazan dye produced is directly proportional to the
number of proliferating cells in the sample. Since this assay is not cytotoxic, it is suitable for multiple measurements over long periods. To each scaffold, 200 μl of MTS
assay was added in 1,000 μl of phenol-free medium and
incubated for 1 hour at 37 °C and 5% CO2. The absorption of each sample was then measured three times at
490 nm in a photometer (BioPhotometer plus, Eppendorf).
[27] =>
research
4a
4b
4c
4d
4e
4f
4g
4h
|
Fig. 4: Fluorescence microscopy of the scaffold surface with Hoechst staining solution on day 21 after seeding. Scale bar = 200 μm. PLLA-CC (a), PLLA-TCP (b),
PLLA-PGA-CC (c), PDLLA-Mg (d), PDLLA (e), β-TCP-HA (f), β-TCP (g), β-TCP' (h).
An unseeded scaffold, medium and MTS served as control. To determine the number of cells, a calibration curve
was carried out with human osteoblasts. The samples
were analysed on days 2, 5, 7, 14 and 21 (n = 8).
Apoptosis assay
In order to assess the apoptosis activity of the cells on the
scaffolds, an apoptosis assay (Caspase-Glo 3/7 assay,
Promega) was carried out. A DEVD substrate was used
which, in the presence of the apoptotic enzyme caspase -3
or -7, luciferase and adenosine triphosphate, results in
the luciferase reaction and the production of light. This
luminescence is directly proportional to the apoptosis
activity of the cells. At room temperature, Caspase-Glo
reagent was pipetted in a ratio of 1:1 on to the scaffolds
in the medium. These were then agitated on the plate
shaker (30 seconds, 300–500 rpm) and incubated at
constant room temperature for 45 minutes. The luminescence of each sample was then measured three times in
a plate-reading luminometer (Victor X2, PerkinElmer). The
samples (n = 8) were analysed on days 2, 5, 7, 14 and 21.
To determine the apoptosis activity based on the metabolic cells in the scaffold, the quotient of the apoptosis
value (luminescence) divided by the cell count in the scaffold was generated. With the help of an establishment
experiment, it was shown that the assay is not cytotoxic
and is therefore suitable for a series of measurements
over longer periods. For this purpose, the proliferation
rate of cells incubated with the apoptosis assay was
checked by means of the MTS assay.
Cytotoxicity assay
The cytotoxicity assay was performed according to ISO
10993-5. Extracts of the scaffolds were produced by hy-
drating them in 2 ml of serum-containing culture medium
for 72 hours in order to accumulate potentially cytotoxic
substances in the medium. Human osteoblasts were cultivated in 96 well plates with a density of 1,000 cells per
well and, after addition of the extracts (in the dilutions 100%,
75%, 50% and 25%), incubated for 24 hours. Viability was
assessed with the aid of the proliferation assay (CellTiter 96
AQ ueous One Solution). The extract from ThinCert membranes (Greiner Bio-One), which are considered to be
particularly cell-friendly, served as a negative control, and
100% dimethylsulfoxide (DMSO) was used as a positive
control.
Sulforhodamine B assay
The sulforhodamine B assay allows conclusions to be
drawn about the number of cells in the osteoblasts growing in the milieu of the scaffolds by measuring protein
quantities. Human osteoblasts were seeded in six-well
plates at a density of 100,000 cells per well. With the help
of ThinCert inserts, the scaffolds were placed in the medium above the cells. It was thereby possible to investigate whether the materials release cytotoxic substances
into the medium over longer periods and to what extent
this affects the number of cells and therefore cell growth.
The cells were fixed with methanol (99%; Carl Roth) on
the measurement days and stored at –80 °C. For staining,
the methanol was removed from the wells, and the cells
were covered with sulforhodamine B staining solution
(1% acetic acid solution and 0.4% w/v sulforhodamine B
sodium salt, Sigma). Incubation was performed for 30 minutes at room temperature with continuous agitation. The
sulforhodamine B staining solution was then removed, and
the fixed cells were washed five times in a 1% acetic acid
solution. The stained cells were dried and, after 24 hours,
4 2023
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dissolved in 2 ml of 10 mM Tris buffer. The absorption of
each sample was then measured three times at 550 nm
in a photometer (BioPhotometer plus). To determine the
number of cells, a calibration curve was carried out with
human osteoblasts. The samples (n = 8) were analysed
on days 2, 5 and 7.
Statistical analysis
The data for the tests performed are presented as
mean ± standard deviation. Statistical analysis was performed using GraphPad Prism 8 (GraphPad Software).
To evaluate the differences between time points and
groups, one-way ANOVA and Friedman Test were performed followed by Dunn’s post hoc multiple comparisons. T-test and Mann–Whitney U test were performed
for significance of viability in cytotoxicity testing. A P value
< 0.05 was considered significant.
Results
Fluorescence microscopy
PLLA–PGA–CC, PDLLA, β-TCP–HA, β-TCP and β-TCP'
showed the highest cell density (Fig. 4).
MTS assay
The initial cell count after seeding was 2 × 105 cells/scaffold. On day 2, the first measurement was performed. The
cell count on day 21 was evaluated in comparison to days
2, 5, 7 and 14. In the group of PLLA-based polymers, the
PLLA–CC scaffold contained 2.77 x 105 (± 0.34 × 105)
cells on day 2. After a slight decrease in cell count on day 5
(2.01 × 105 ± 0.80 × 105) and day 14 (2.36 × 105 ± 0.51 × 105),
5a
5b
5c
5d
5e
5f
Fig. 5: Proliferation assay (MTS assay). Determination of the number of proliferating cells in the scaffolds after two, five, seven, 14 and 21 days (a–f).
Regression lines to determine growth tendency over time (d–f).
28
4 2023
the cell count per scaffold increased to 4.20 × 105 (± 0.63 × 105)
after 21 days (p < 0.05). For PLLA–TCP, the cell count increased until day 7 (8.28 × 105 ± 1.34 × 105), decreased to
3.17 × 10 5 (± 0.93 × 10 5) on day 14 and increased to
4.49 × 105 (± 1.03 × 105) on day 21. The difference in cell
count between day 21 and day 14 was significant (p < 0.05).
For PLLA–PGA–CC, the cell count increased from day 2
(4.37 × 10 5 ± 0.56 × 10 5) to day 5 (3.48 × 10 5 ± 1.16 × 10 5),
day 14 (4.07 × 10 5 ± 0.62 × 10 5) and day 21 (5.74 × 10 5 ±
0.61 × 105; p < 0.05). Overall, the highest values were obtained on day 7 with 10.15 × 105 (± 2.30 × 105) cells. PLLA–
PGA–CC showed the highest cell counts over time in the
group of PLLA-based polymers (Figs. 5a & d). For PDLLA–Mg,
the total cell count decreased from 0.14 × 105 (± 2.25 × 105)
on day 2 to 0.00 × 105 (± 0.26 × 105) on day 21, having only a
temporary slight increase on day 5 (1.44 × 105 ± 0.88 × 105)
and day 14 (0.89 × 10 5 ± 0.66 × 10 5). PDLLA increased
steadily from day 2 (1.67 × 10 5 ± 0.44 × 10 5) to day 5
(2.65 × 105 ± 0.71 × 105), day 7 (4.19 × 105 ± 1.00 × 105), day
14 (4.13 × 105 ± 1.31 × 105) and day 21 (9.39 × 105 ± 1.12 × 105;
each p < 0.05). In the group of PDLLA-based polymers,
PDLLA showed the best results over time (Figs. 5b & e). For
the ceramics, an increase in cell count was observed
in β-TCP–HA on day 21 to 6.54 × 10 5 (± 1.26 × 10 5)
compared with day 2 (3.34 × 10 5 ± 0.68 × 10 5), day 5
(3.22 × 105 ± 1.05 × 105) and day 14 (4.83 × 105 ± 1.01 × 105;
p < 0.05 for days 2 and 5). β-TCP increased steadily from
day 2 (1.67 × 105 ± 0.80 × 105) to day 5 (3.93 × 105 ± 1.75 × 105),
day 7 (5.74 × 105 ± 1.49 × 105), day 14 (5.68 × 105 ± 1.70 × 105)
and day 21 (7.35 × 105 ± 1.43 × 105; p < 0.05 for days 2 and 5).
β-TCP' also showed a significant increase in cell count
on day 21 (7.46 × 105 ± 4.07 × 105) compared with day 2
(1.87 × 105 ± 1.41 × 105), day 5 (5.01 × 105 ± 2.55 × 105) and
day 7 (4.53 × 105 ± 2.62 × 105; p < 0.05). Day 14 showed the
highest value with 8.26 × 105 (± 2.98 × 105) cells (Figs. 5c & f).
In summary, β-TCP–HA, β-TCP and β-TCP' showed the
best results over time, and PDLLA–Mg showed the lowest cell counts.
Apoptosis assay
In order to determine the apoptosis activity in relation to
metabolic cells, the quotient of the apoptosis value (luminescence) divided by the cell count in the scaffold was
generated. The PLLA-based polymers all showed a similar course of apoptosis activity over the observation period. For PLLA–CC, apoptosis activity was significantly
increased on day 2 to 118.57 × 10-5 (± 19.60 × 10-5) compared with days 5, 7, 14 and 21, when the value approached
zero (range: 0.00–5.29 × 10-5; p < 0.05). PLLA–TCP, with a
value of 187.19 × 10-5 (± 32.20 × 10-5), and PLLA–PGA–CC,
with a value of 107.32 × 10-5 (± 21.90 × 10-5), also showed
increased apoptosis activity on day 2 compared with the
other days (p < 0.05; Figs. 6a & d). After initially increased
apoptosis on day 2 (84.15 × 10-5 ± 53.80 × 10-5), PDLLA–Mg
decreased to 1.44 × 10 -5 (± 2.50 × 10 -5) on day 5 and
increased again on day 7 (971.03 × 10-5 ± 1,358.90 × 10-5;
p < 0.05). Subsequently, it remained slightly elevated at
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| research
strong cytotoxic effect of the tested extract, whereas values between 70 and 100% reflect the absence of cytotoxic components. The viability of 50% extract dilutions
was at least as high as that of 100% extracts for all biomaterials, as required by the ISO guidelines.
6a
6b
6c
6d
6e
6f
Fig. 6: Apoptosis assay. L = luminescence. Determination of apoptosis activity
related to cell count on the scaffolds after two, five, seven, 14 and 21 days (a–f).
Regression lines to determine apoptosis tendency over time (d–f).
15.40 × 10-5 (± 9.50 × 10-5) on day 21 (p < 0.05 compared
with day 5). For PDLLA, apoptosis activity was significantly
increased only on day 2 (375.48 × 10-5 ± 25.60 × 10-5) and
then decreased to low values between 0.00 and 7.01 × 10-5
(Figs. 6b & e). All ceramics showed a similar course of
apoptosis activity. On day 2, β-TCP–HA, with a value of
103.52 × 10-5 (± 32.50 × 10-5), and β-TCP', with a value of
129.85 × 10 -5 (± 30.50 × 10 -5), showed significantly increased apoptosis activity compared with days 5, 7, 14
and 21 (0.00–4.79 × 10 -5). Also, β-TCP showed an increased value on day 2 (246.27 × 10 -5 ± 34.90 × 10 -5;
p < 0.05). Furthermore, the curve flattened more slowly
here (Figs. 6c & f). In summary, apoptosis decreased towards zero after having initially increased on day 2 for
PLLA-based polymers, ceramics and PDLLA. For PDLLA–Mg,
apoptosis activity peaked again on day 7 and moderately
increased again after 21 days.
Cytotoxicity assay
The proliferation of human osteoblasts was not affected
by the extracts (100% undiluted extract) of the biomaterials (Fig. 7). Cell growth and metabolism were unchanged
compared with the non-cytotoxic control (negative control). The negative control value was set to 100%. The viability of extracts of PLLA–CC (156%) and β-TCP (151%)
even exceeded that of the negative control. Cells incubated in 100% DMSO (positive cytotoxic control) reflected
the cytotoxic effect of DMSO on viability (5.6 ± 4.8%). The
viability of human osteoblasts cultured in DMSO was significantly reduced compared with the negative control
and the scaffold extracts (p < 0.05). According to ISO guidelines, cell viability in the range of 0 to 50% reflects a
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Sulforhodamine B assay
The initial cell count after seeding was 1 × 105 cells/scaffold. On day 2, the first measurement was performed. After an increase of the cell count of PLLA–CC on day 2 to
4.46 × 105 (± 1.90 × 105), it decreased on day 5 (2.57 × 105 ±
1.60 × 10 5) and remained almost unchanged on day 7
(2.76 × 105 ± 1.01 × 105). For PLLA–TCP, the cell count after day 2 (4.36 × 105 ± 2.63 × 105) decreased to 3.18 × 105
(± 0.97 × 105) on day 5 and to 2.79 × 105 (± 1.49 × 105) on
day 7. PLLA–PGA–CC showed almost constant cell counts,
having a value of 2.38 × 105 (± 0.74 × 105) on day 2 and of
2.20 × 105 (± 0.95 × 105) on day 5. On day 7, there was a
significant increase to 2.84 × 105 (± 0.79 × 105) compared
with day 5 (p < 0.05; Figs. 8a & d). Starting with 3.56 × 105
(± 0.66 × 10 5) on day 2, the cell count of PDLLA–Mg
dropped to 1.45 × 105 (± 0.44 × 105) on day 5 and remained
nearly unchanged (1.52 × 105 ± 0.55 × 105) on day 7. For
PDLLA, a value of 2.61 × 105 (± 0.23 × 105) was observed
on day 2. On day 5, the cell count slightly decreased
(2.06 × 105 ± 0.49 × 105), and it also remained nearly unchanged on day 7 (2.11 × 105 ± 0.39 × 105; Figs. 8b & e). After
day 2 with a cell count of 2.22 × 105 (± 0.37 × 105), β-TCP–HA
showed a slight decrease in cell count on day 5
(1.84 × 105 ± 0.37 × 105). The count increased slightly on
day 7 (2.21 × 10 5 ± 0.52 × 10 5). β-TCP' showed a similar
course, having 3.01 × 105 (± 1.82 × 105) cells on day 2, a
slight decrease on day 5 (2.64 × 105 ± 0.72 × 105) and an
increase on day 7 (3.08 × 105 ± 0.44 × 105) compared with
day 5 (p < 0.05). β-TCP had a cell count of 2.37 × 10 5
(± 0.52 × 105) on day 2, a minimal decrease on day 5
(2.08 × 105 ± 0.47 × 105) and a significant increase on day 7
(6.72 × 10 5 ± 5.88 × 10 5) compared with day 5 (p < 0.05;
Figs. 8c & f). PLLA–PGA–CC, β-TCP and β-TCP' showed
a significant increase in cell count as well as the largest
slope of the regression line over the observation period
(Figs. 8d & f). The other materials showed only insignificant
changes or decreasing cell count.
Discussion
Despite promising advances in tissue engineering, the
treatment of large bone defects is still a challenge.25 An
optimal biomaterial should be biocompatible and have
controllable biodegradability and architecture and optimal mechanical properties.26 An interconnected pore
system, porosity and optimal pore size are required, although opinions differ on this.27, 28 In general, however, a
pore size of over 300 μm is favoured.29 We chose a pore
diameter of 800 μm to allow osteogenesis, fluid exchange
and subsequent vascularisation. While a complex scaffold design is difficult to implement using conventional
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techniques, additive manufacturing processes allow for
individual implant production.24, 30, 31 This enables us to
both individually adapt the scaffold shape to a bone defect and to construct the microscopic scaffold architecture. We evaluated the biocompatibility of various additively manufactured biomaterials using a proliferation,
apoptosis, cytotoxicity and sulforhodamine B assay and
were thereby able to objectively evaluate and compare a
wide variety of materials and material groups. In the proliferation and apoptosis assays, multiple measurements
could be made over longer periods owing to the lack of
cytotoxicity of the assays. This also has the advantage of
better comparability and fewer inaccuracies. TCP–HA is
becoming an increasingly important biomaterial in bone
tissue engineering. Owing to its similarity to the mineral
phase of bone, HA plays an important role in cell adhesion and proliferation and, along with tricalcium phosphate,
is one of the most frequently used ceramics.32–34 In vivo
studies have also shown that the combination of TCP–HA
induces bone formation.35–37 In this study, β-TCP–HA
showed a significant increase in the number of cells
growing on the scaffold over 21 days, but the cell count
on days 14 and 21 was lower than that of β-TCP and
β-TCP'. The apoptosis activity of β-TCP–HA was significantly increased on day 2 compared with the other days;
over time, it decreased to zero. Initially increased apoptosis activity was observed in all the materials and is most
likely explained by the trypsinisation and the passage
when seeding the scaffolds. After day 2, hardly any cells
were in apoptosis, evidence of the cell compatibility of the
scaffold. Compared with pure β-TCP, the quotient of the
apoptosis value divided by the cell count was significantly
lower for the TCP–HA on day 2. Woo et al. describe suppressed cell apoptosis through the addition of HA to
composite scaffolds.38 This is in line with our results. In
the cytotoxicity test in accordance with ISO 10993-5, the
growth of the osteoblasts was not impaired by the scaffold extract either. The sulforhodamine B assay evaluated
the number of osteoblasts that grew in the scaffold extract in the immediate vicinity of the scaffold for seven
days. Good results were demonstrated here; the regression line had a positive gradient. However, the total number of cells was even higher for pure β-TCP and β-TCP'.
Despite very good biocompatibility and low apoptosis
values, TCP–HA showed somewhat poorer results than
β-TCP and β-TCP' with regard to cell proliferation and
growth behaviour. β-TCP is one of the most used biomaterials. Its osteoconductivity, rapid degradability and similarity to the composition of bone make it suitable for bone
tissue engineering.10, 11 This has also been shown by numerous in vivo studies. For example, Kondo et al. successfully implanted β-TCP into femur bones in the rat model.39
The brittleness of the material usually makes it difficult to
adapt to the individual,40 but this is no longer necessary
owing to the possibility of individual construction using
additive manufacturing processes. Since, depending on
the dimensions, classic fixation of ceramics with screws
|
is not possible, alternative fixation techniques are necessary (e.g. a cage). Both β-TCP and the mechanically improved β-TCP' with higher flexural strength showed a significant increase in cell count from day 2 to day 21. In
addition, both (with PDLLA) achieved the highest cell
counts on days 14 and 21 compared with all other materials and therefore better cell proliferation. While β-TCP'
showed a twofold drop in cells during the process, the
growth curve of β-TCP demonstrated a consistent upward trend. After initially elevated values (day 2) for β-TCP
and β-TCP', apoptosis activity decreased towards zero.
On day 2, the quotient of the apoptosis value divided by
the cell count of β-TCP was significantly increased compared with β-TCP' and TCP–HA. This agrees with the results of the proliferation assay, in which β-TCP had the
lowest cell count among the ceramics on days 2 and 5,
as the cells increasingly went into programmed cell death.
However, the number of cells then rose steadily to very
good values. Osteoblast proliferation was not negatively
influenced in the cytotoxicity assay by the extract of
β-TCP or β-TCP', also indicating good biocompatibility. In
7
Fig. 7: In vitro cytotoxicity of 100% undiluted extract. Human osteoblasts
cultivated in control extract (negative control = dotted line, 100%) or undiluted scaffold extract all showed high viability. The viability of osteoblasts
cultivated in dimethylsulfoxide (positive cytotoxic control) was significantly
reduced compared with the scaffold extracts (p < 0.05).
the sulforhodamine B assay, we observed a higher cell
count on day 7 for β-TCP and β-TCP' compared with
TCP–HA; for β-TCP', this difference was significant.
Compared with all the materials, they also showed the
best results here, having a regression line gradient of
67.5 (β-TCP) and 23.2 (β-TCP'). With regard to cell proliferation and growth behaviour, β-TCP and β-TCP' showed
the best results in the ceramic scaffolds group. PLLA–CC
was recently described in the literature as a bone replacement material.20 CC has a beneficial effect in bone
4 2023
31
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8a
8b
8c
8d
8e
8f
Fig. 8: Sulforhodamine B assay. Determination of the cell count of osteoblasts
growing in the scaffold environment after two, five and seven days (a–f).
Regression lines to determine growth tendency over time (d–f).
tissue engineering, as extracellular calcium enhances osteogenic gene expression and promotes bone regeneration.41 CC was mentioned earlier as a suitable filler for polyester, because its pH-stabilising effect buffers the acidic
degradation of polylactides.42 In this study, PLLA–CC
showed a significant increase in cells growing in the scaffold from day 2 to day 21, but the cell count was slightly
lower than that of the other PLLA-based scaffolds at all
measurement times. Apoptosis activity was significantly
increased initially (day 2) and decreased towards zero
over time, indicating the long-term cell tolerance of the
scaffold. The increased apoptosis activity is probably related to differences in the degradation kinetics and initial
water absorption of the polymeric scaffold systems. Different proteins also play a role as deposits on the scaffolds. In the cytotoxicity test, the growth of the osteoblasts was not impaired by the scaffold extract either. In
the sulforhodamine B assay, the cell count on day 7 was
not significantly different from that of the other PLLA scaffolds. However, the curve showed the smallest regression line gradient among the PLLA scaffolds. Gayer et al.
described good cell compatibility of PLLA–CC, but there
is no possibility of comparison with other materials.20 In
this study, PLLA–CC demonstrated overall good biocompatibility. In comparison with the poly-L-lactides
PLLA–TCP and PLLA–PGA–CC, however, the latter can
be assessed as even more promising in terms of cell proliferation and growth behaviour. Composite scaffolds
made from PLLA–TCP are frequently used biomaterials
in bone tissue engineering.14–18 The aim is to overcome
the shortcomings of the individual materials by combining PLLA and TCP. On the one hand, TCP counteracts
32
4 2023
the acidic environment that results from the breakdown
of polylactide. On the other hand, the combination of
PLLA and TCP improves the mechanical properties of a
scaffold.32, 43 We observed a non-significant increase in
cells growing in the scaffold from day 2 to day 21; the increase from day 14 to day 21 was significant. The cell
count over time was higher than for PLLA–CC, but lower
than for PLLA–PGA–CC. For PLLA–TCP, the apoptosis
activity was significantly increased on day 2, and over
time, it also decreased to zero. The results in the cytotoxicity test reflected the absence of cytotoxic components.
In the sulforhodamine B assay, the cell count on day 7
was not significantly different from that of the other PLLA
scaffolds. However, the cell counts fell again after an increase on day 2, and the regression line showed a slightly
lower gradient than PLLA–PGA–CC did. PLLA–PGA–CC
in this composition has not yet been described in the literature as a bone replacement material. PLLA is already
widely used in tissue engineering for the regeneration of
bone tissue.44–47 PGA is a less hydrophobic polymer with
a relatively rapid degradation rate.48 The co-polymer
PLLA–PGA has been described for bioresorbable bone
fixation in the form of screws, plates or orbital floor reconstruction plates.49–52 There is also information on the
good biocompatibility of the composite of poly (lacticco-glycolic) acid (PLGA) and CC, but not on PGA–CC or
PLLA–PGA–CC.53 As a co-polymer of PGA, PLGA has
similar properties in some cases. In our investigations,
PLLA–PGA–CC showed a significant increase in cell metabolism from day 2 to day 21. The cell count of the osteoblasts growing on the scaffold was significantly increased
on all measurement days compared with the other PLLAbased scaffolds, with the exception of PLLA–TCP on
days 5 and 7. After initially increased values (day 2), the
apoptosis activity decreased over time to zero, which is
desirable. Furthermore, PLLA–PGA–CC sometimes showed
the lowest quotient of the apoptosis value divided by the
cell count compared with all the other materials, indicating good cell compatibility. In the cytotoxicity test too, the
scaffold extract did not impair the growth of the osteoblasts.
When evaluating the cell count in the sulforhodamine B
assay, the cell count on day 7 was about the same as
for the other PLLA scaffolds. However, PLLA–PGA–CC
was the only material here that showed a significant increase in cell count over the course of the experiment
and the largest gradient of the regression line. With regard to cell proliferation, growth behaviour and apoptosis
activity, PLLA–PGA–CC showed the best results in the
group of poly-L-lactides. PDLLA–Mg in this composition
and Mg in this processing method have not yet been described in the literature. Mg is believed to have great potential in bone tissue engineering because of its biodegradability and its ability to promote new bone formation.
In addition, the modulus of elasticity of Mg is comparable
to that of cortical bone.54–58 The problem, however, is the
rapid corrosion of Mg, which can lead to a loss of structure and the release of degradation products.59 The rate
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of degradation of technically pure Mg is much faster than
that of alloys such as WE34 which are already in clinical
use. Because the degradation rates are significantly lower,
these alloys also show very good biocompatibility, but
other elements are also present here, for example rare
earth elements that are not found in technically pure Mg.
Our intention was to generate a polymeric matrix around
the Mg material to create a polymer–metal composite to
reduce the degradation rate of metallic Mg and thereby
improve biological effects such as cell compatibility. Our
results showed a comparatively low number of cells on
the scaffolds. This was also confirmed by our electron
microscopic examinations on day 21 (ongoing study).
The quotient of the apoptosis value divided by the cell
count was significantly increased in particular on day 7
compared with the other materials. The high value can be
explained by the low cell count on the scaffold, and of
these few cells, a large percentage were found to be in
apoptosis. The high apoptosis levels are consistent with
the low cell counts. In the sulforhodamine B assay too,
the cell count was lower than that of the other materials,
and the regression line decreased with a slope of –4.5. In
contrast to this, osteoblast proliferation was not negatively influenced by the extracts, suggesting low cytotoxicity. Tavares et al. reported a lack of cytotoxicity of composite scaffolds to which Mg was added in the cytotoxicity
test in accordance with ISO 10993.60 This illustrates how
important it is to test the material itself and not only to test
an eluate produced from it, as here the effects of the scaffold architecture and other interactions are neglected.
PDLLA–Mg showed less favourable results in this study
compared with the other PDLLA-based materials. When
looking at all the materials together, the other materials
also performed better. This is presumably primarily due
to the release of degradation products59 and gas formation and was to be expected for pure Mg. It can be assumed that the slowdown in degradation, which we
wanted to achieve with the composite material formulation, had occurred to an insufficient degree. However, we
were able to show that the additive production of Mgbased implants using FDM technology is technically feasible. Further work is necessary to develop other material
formulations that allow optimal degradation kinetics of
technically pure Mg with a cell biologically compatible release of degradation products in order to fully exploit the
material’s potential for bone tissue engineering. PDLLA
has been frequently described as a biomaterial.42, 61–63 In
this study, the cell count of the osteoblasts growing on
the scaffold increased steadily up to day 21 and was significantly higher than that of the other PDLLA-based scaffolds on days 5, 7, 14 and 21. After initially strongly increased values (day 2), apoptosis activity decreased
towards zero over the course of the experiment. In the
cytotoxicity test too, the growth of the osteoblasts was
not impaired by the scaffold extracts. In the evaluation of
the cell count in the sulforhodamine B assay, the cell
count on days 5 and 7 was significantly increased com-
|
pared with PDLLA–Mg. In addition, PDLLA showed the
most significant regression line gradient within the poly-D,
L-lactide materials. With regard to cell proliferation, growth
behaviour and apoptosis activity, PDLLA showed the
best results in the group of poly-D, L-lactides. We evaluated the biocompatibility of the various additively manufactured biomaterials in the clean room and therefore had
the opportunity to objectively evaluate and compare the
different materials. The novelty of the materials is the
compounding of these, including the special processing
by 3D printing, to produce comparable scaffolds. Looking at all the materials together, the ceramic-based scaffolds proved to be the most promising. They showed the
highest cell counts in the proliferation assay. They can be
considered non-cytotoxic when used in vitro, and the
apoptosis activity strongly decreased over the measurement period. β-TCP and β-TCP' exhibited particularly
good results, showing the steepest growth curves in the
sulforhodamine B assay. Among the poly-L-lactides,
PLLA–PGA–CC performed best in terms of cell proliferation, growth behaviour and apoptosis activity. In the poly-D,
L-lactide group, PDLLA showed the best results. The
comparatively lowest cell counts and highest apoptosis
values were observed for PDLLA–Mg. Further studies to
improve the materials are planned, as these materials
also demonstrated very promising properties that should
be used for tissue engineering. A study is currently being
carried out with regard to the behaviour of the materials in
vivo.
Acknowledgement
This work was supported by the German Federal Ministry
of Education and Research within the project “Establishment of industry-in-clinic platforms for the development
of innovative medical devices” (grant number: 13GW0248).
References
Dr Katharina Pippich
contact
Dr Katharina Pippich
Department of Maxillofacial Surgery
Technical University of Munich
Ismaninger Straße 22
81675 Munich, Germany
katharina.pippich@mri.tum.de
4 2023
33
[34] =>
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| events
Implantology as a teamwork—
Implantology is a teamwork!
Need to see more
Dr Georg Bach, Germany
pictures?
Just scan the code.
“Implantology is teamwork—no ifs and buts!”—this was
the opening statement by Dr Georg Bach, President of
the German Association of Dental Implantology (DGZI), at
the 52nd International Annual Congress, which took place
in Hamburg on 6 and 7 October. What was true at the
beginning of oral implantology in the late 1960s/early 1970s
is just as valid today—if not more so. Reason enough for
the DGZI, as the oldest European specialist society, to
place this year’s congress under the motto “Team”: while
the first day of the congress focused on 25 table clinics
and two surgical tutorials, Saturday was entirely dedicated to science: 50 renowned speakers delivered outstanding scientific presentations to over 350 participants.
The annual congress was completed by the oral hygiene
day and seminars for practice teams as well as by a large
adjoining dental exhibition featuring a three-dozen selected, “hand-picked” industry partners.
Future podium/young generation DGZI
A first highlight was offered to the participants at the very
beginning of the congress with two remarkable lectures
with completely different directions, but which together
drew a clear picture of the future options of implantology,
even of dentistry as a complete discipline. Just a few years
ago, AI was not yet a topic in dentistry—this has completely
changed at a rapid pace. Therefore, Prof. Dr Falk Schwendicke set the bar high right at the start of the congress with
his presentation “Artificial intelligence in dentistry—benefits
for the entire team?”. As a leading specialist in AI in den-
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tistry, Prof. Schwendicke stated that the prerequisites for
AI are based on the availability of digital data and the development of new algorithms. Dentistry, however, is one of the
difficult sectors for AI: on the one hand, due to the smaller
amount of digital data compared to other fields and, on the
other hand, due to the complexity of the matter, which requires many experts. Schwendicke sees major areas of
application for AI in dental radiology (caries identification/
recognition of anatomical structures, etc.) and in periodontology (e.g. periodontal staging). Schwendicke concluded
his lecture with a glimpse into the future: based on an increase in the availability of digital data by a factor of 23 in
the last ten years (“data explosion”), everyday data will
therefore also gradually be used for medical AI applications, which will be beneficial for personalised medicine.
The Swiss speaker duo Dr Malin Strasding and MDT Vincent Fehmer, who presented “Collaboration 2.0—a concept for success in everyday practice and laboratory
work”, fully lived up to the congress motto. They introduced the Geneva concept—starting with digital diagnostics and digital treatment planning, followed by digital
implantation and digitally supported dental technology.
The crucial advantage of digital treatment planning is the
predictable result for both, the patient and the dentist.
The intensity of the subsequent panel discussion and
the number of questions posed by congress participants
confirmed that the three speakers were exactly the right
choice for this podium.
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OP tutorials
It is already a tradition at DGZI congresses to present certain topics in more detail using animated images: a broadcast of surgical tutorials enabled congress participants
and DGZI members to experience a unique insight into
the work of renowned colleagues—and all in HD quality!
The event kicked off with a spectacular start given by
Dr Dr Markus Schlee, who spoke on the topic “Update
augmentation—is autologous bone still the gold standard?”. From the very first minute of Schlee’s presentation, it was obvious that this topic is also his main discipline. During his lecture, the Forchheim-based periodontist
and implantologist discussed numerous patient cases.
The speaker’s conclusion: “Autologous bone has never
been the gold standard, but today we do have material
alternatives!”
In the second surgery tutorial, Dr Paul Schuh and MDT
Bastian Wagner presented their reflections on “Digital disruption. Planning—surgery—restoration—is everything digitally possible?”. Again, a clear credo: “Communication
between dentists and dental technicians is of crucial importance for the success of treatment.” The speaker duo
presented their jointly developed concept for synoptic
patient care and ultimately fully agreed with the statements of the previous speakers: “Implantology is teamwork—and the interface between dental technology and
dentistry is extremely significant here!”
DGZI Implant Dentistry Awards in three
categories
The DGZI Implant Dentistry Award, which went this year
to Dr Diana Heimes from Mainz for her work on a vestibuloplasty using a collagen membrane, was embedded in
the two surgical tutorials. Second place stayed in the
Hanseatic city of Hamburg and went to Dipl.-Ing. Sandra
Fuest from the research group led by Prof. Dr Dr Ralf
Smeets. Alongside the congress theme, the DGZI also
presented for the first time a team award, which went to
the Schoebel and Reuleke dental practice in Hanover.
Table clinics
The table clinics were set up as round tables in the style
of banquet seating instead of the usual parliamentary
seating facing the stage and were an unusual view for
some congress participants. At these tables, demonstrations on a wide variety of special implantology topics took
place in three stages. Each exhibiting company had been
provided with a table and engaged speakers to provide
the demonstrations. The discussions and exchanges that
took place immediately after the demonstrations proved
to be very informative and the format was once again very
well received by both congress participants and industry
partners.
Second congress day—the “science day”
While the first day of the congress had a strong practical
orientation, the following day focused on the scientific aspects. Based on a review of current trends, the focus here
was also increasingly on the question: “How will implantology of the future be?”
The Saturday programme thus offered scientific overview
lectures on all relevant areas of oral implantology, such
as digital implantology and prosthetics, bone and tissue
as well as materials and design.
The DGZI congress organisers once again pursued the
goal of primarily presenting the future in the lectures, which
is why the focus was not on case reports or the presentation of individual studies, but rather on current development directions and visions.
4 2023
37
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| events
ber of leukocytes, the concentration of fibrin and in the
centrifugation protocols. While initial experience was gained
with PRP (platelet-rich plasma) and PRGF (plasma-rich in
growth factor) concentrates, the breakthrough in dentistry
came with the development of the PRF concentrate. This
is characterised by its simple extraction and wide range
of possible applications.
Three thematic blocks captivated the auditorium:
Session 1: Bone and hard-tissue regeneration
When it comes to bone and implant issues, there is only
one expert speaker, and it was he who took the microphone: Prof. Dr Dr Peer Kämmerer with his lecture “Bone
lost—don’t despair!”. “I have a little coup de main planned
for you,” said Kämmerer, who dedicated the first part of
his presentation to patient-specific factors that can reduce the success of oral implantation. In this regard, the
use of antidepressants and proton inhibitors had proved
to be detrimental to implant success.
The second part of his presentation addressed the options for augmentation. If all materials are available, simple defects can best be augmented using a membrane.
For more complicated dehiscence defects, the Mainzbased oral surgeon recommends the combination of autologous bone and bone substitute materials as well as
the use of PRF (platelet-rich fibrin) and a membrane.
The lecture given by Prof. Dr Dr Daniel Rothamel, who investigated the question “Blocks, shells, granules: which
makes sense for bone augmentation?” was an ideal addition to the first presentation on the second day of the
congress. Implantology can be very simple, although it
can also be complicated from time to time, said Rothamel
in his opening remarks. In complex cases, the oral and
maxillofacial surgeon recommends not only looking at the
defect alone, but also at its surroundings: “Stability and
rest” were defined by him as the most important prerequisites for the success of augmentation. Numerous excellently documented case studies underpinned Rothamel’s
explanations.
Afterwards, Dr Torsten Conrad presented the concept
developed by Prof. Dr Dr Dr Shahram Ghanaati on blood
concentrates as mediators for promoting wound healing
in oral medicine and asked: “Which role does PRF play?”.
“We are actually talking about autologous platelet concentrates,” said Conrad, which however differ in the num-
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4 2023
The final evolutionary step is the i-PRF, which is characterised by a liquid matrix. Reducing the centrifugal power
increases the number of available cells that can have a
biologising effect. The advantages of the procedure, which
could also be referred to as “guided open wound healing”,
are the avoidance of covering small defects, the minimisation of the wound margins, the avoidance of periosteal
incision and the protection of the mucogingival line.
The panel discussion with the speakers concluded a very
interesting and insightful morning session.
Session 2: Prosthetic concepts between
basic and high-end
The second session focused on the tension between
“high-tech or rather simple” and included three presentations with very different approaches, which nevertheless
complemented each other perfectly.
Dr Peter Gehrke made a plea for simple prosthetic restoration concepts and spoke about “Maximum safety with
minimum effort: How much implant prosthetics is really
necessary?”. He made it clear: “Minimal effort does not
automatically mean using old techniques—quite the opposite: the new digital options support us in our goal to a
significant extent.” The aim must be to establish simple
standard concepts in terms of material, effort, and insertion techniques.
Dental technician Oliver Beckmann and dentist Stefan
Friedrich showed a completely different perspective describing the “implant-prosthetic high-end” and talking
about template-guided bone ridge reduction and simul-
[39] =>
taneous template-guided insertion of implants in the edentulous mandible. A beneficial lecture delivered by practitioners for practitioners: dental technicians and dentists
demonstrated the high level of cooperation that is possible in the dental practice—even for highly complex applications.
The speaker duo has considerable experience in the fabrication and application of templates for bone ridge reduction and subsequent implant placement. The fundamental
prerequisite is that both partners are thoroughly familiarised with the complex planning material and that there is
close coordination before and during the application as
well as a subsequent re-evaluation. “Communication is
the key!” underlined dental technician Oliver Beckmann.
The prosthetics session concluded with a presentation
by Dr Peter Randelzhofer, speaking about his expertise
in immediate implant placement in the aesthetic zone. Very
few speakers have gained as much experience in this demanding field as the Bavarian implantologist. Thus, Randelzhofer was able to open his almost infinite treasure chest
of experience and present fascinating case studies. Even
cases in which the initial conditions were far from ideal were
solved by immediate implant placement. However, according to Randelzhofer, “the absolute consideration of biological concepts is essential, everything else leads to failure!”
Session 3: All about ceramic implants and
toxicological aspects
The congress ended with one more true highlight: three
renowned speakers highlighted the topic of ceramic implants and toxicology in all its aspects and demonstrated
the extraordinary level of development that has now been
achieved in this area.
Prof. Dr Dr Michael Gahlert is the author of numerous
studies on ceramic implants. Dr Dr Stefan Röhling excerpted the most important findings from this broad
knowledge and was able to provide lasting proof of the
effectiveness of this category of materials. A recently published meta-analysis was also presented and explained
by the renowned Munich implantologist: its results show
that the bone and soft-tissue behaviour of ceramic implants is not only equal to that of titanium, but even superior in some points.
With his “Update soft tissue around implants”, Dr Alexander Müller-Busch complemented Gahlert’s presentation
with further scientific facts and long-term experience. At
the same time, he agreed with the previous speaker in his
assessment that ceramic implants are on a par with titanium implants in terms of reliability and safety and that
they also have considerable advantages in terms of periimplant soft tissue.
Dr Elisabeth Jacobi-Gresser has been active in the field
of immune-related research on implants for many years.
The pathoimmunological effects of titanium and zirconium oxide implants were an important part of her fascinating presentation. It is thanks to Jacobi-Gresser’s work
that numerous scientific studies have shown that zirconium oxide implants are clearly superior to titanium implants in a certain number of cases.
The 52nd International Annual Congress of
the DGZI—a brief conclusion
At this year’s DGZI congress in Hamburg, participants were
once again able to experience a unique and innovative
training event. However, there was more: due to the different perspectives of science, practice, politics and industry, an exciting level of interaction was achieved.
The DGZI once again entered new territory with its attempt
to explore the urgent matter of what implantology will look
like in five or perhaps ten years’ time and what the political
and economic framework conditions will be like by then.
“Hamburg was a great venue for the
DGZI, many thanks to the Hanseatic
city,” DGZI President Dr Georg Bach
summed up.
DGZI
Dr Georg Bach
contact
Dr Georg Bach
doc.bach@t-online.de
www.herrmann-bach.de
4 2023
39
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| events
ITI International Team for Implantology
All about the patient: The ITI World Symposium 2024
The ITI World Symposium is back and better than ever: more than 50 world renowned speakers will
present at the world’s largest scientific implant dentistry event in Singapore from 9–11 May 2024.
Building on its previous highly successful online edition, the ITI World Symposium 2024 once
again puts patients at the centre of the action. Over three days, the more than 4,000 participants
will experience real patients and their stories on stage. The speakers will discuss various
treatment options based on the latest scientific evidence. But it does not stop there: world class
clinicians will provide commentary on exclusively recorded clinical procedures live on stage.
“With our unique, patient-centred programme structure, we aim to combine practical, clinical
insights with the discussion of scientific findings,” explains ITI President Charlotte Stilwell. “We
ran a survey in our community last year to identify the topics of currently greatest relevance,
and these form the core of our scientific programme: soft-tissue management, GBR/bone augmentation, immediate implants, peri-implantitis and the digital workflow.” ITI members as well
as early registrations will benefit from significant discounts.
ITI International Team for Implantology · worldsymposium.iti.org
German Association of Dental Implantology (DGZI)
40
4 2023
tor to the demonstration of innovations and their implementation in daily practice. Renowned speakers will cover the entire
spectrum of modern implantology in their lectures. Table clinics from manufacturers and suppliers of implants, membranes,
and bone replacement materials, as well as a separate congress for the implantological team will complete the programme.
Enjoy two content-rich and instructive training days and enjoy
the beautiful Rhineland city of Düsseldorf. Stay tuned for more
details coming soon!
OEMUS MEDIA AG
Holbeinstraße 29 · 04229 Leipzig · Germany
+49 341 48474-308 · Fax: +49 341 48474-290
event@oemus-media.de · www.oemus.com
www.dgzi-jahreskongress.de
© OEMUS
The 2023 annual congress of the German Association of Dental Implantology (DGZI) has barely taken place and the organisers are already working tirelessly on the 2024 event. The
53rd International Annual Congress of DGZI will take place on
8–9 November at the Hilton Hotel Düsseldorf. Participants will
experience as always a congress that sets the course for the
future, raises new questions and provides answers, and also
shows new paths in the interaction between participants,
speakers and the industry. This content-related approach will
also be reflected in the congress programme and the innovative organisational concept.
Specifically, this means sharpening the profile of the congress
as a joint event for practitioners, dental assistants, and dental
technicians. The congress will offer strategy lectures, broadcasts of surgical tutorials and table clinics as well as highquality scientific lectures, which will particularly take into
account the information needs of implantologists in private practice. Table clinics
and an exhibition concept, which is also an
integral part of the programme, will play a
more important role. Communication between all those involved in the congress
will be a key factor on both days.
The aim of the congress is to offer firstclass practical training at the highest level
and to build a bridge between the latest
scientific insights from the university sec-
© OEMUS
© Lukasz Dro/Shutterstock.com
Continuing education at its best:
The 53rd International Annual Congress of DGZI
[41] =>
manufacturer news
|
CaviTAU
The fourth dimension of dental implantology
CaviTAU—The groundbreaking invention for radiation-free, highly
effective and safe measurement of jawbone density.
A new chapter in dental diagnostics has begun and its name is
CaviTAU. This innovative jawbone density meter represents a
breakthrough invention that takes jawbone density measurement
to a new level. With CaviTAU, dentists can now measure jawbone
density radiation-free, in a highly effective and safe way.
Imaging with a simple 2D X-ray is not thorough enough to diagnose
harmful changes in the jawbone. Bone densitometry using DVT is
also too inaccurate in the jaw region, as it cannot always accurately image Fatty Degenerative Osteonecroses.
With CaviTAU this problem is a thing of the past. The instrument
uses state-of-the-art ultrasound technology that allows precise
measurement of jawbone density without the need for radiation.
This non-invasive method is not only safe for the patient, but also
extremely effective and accurate.
Another advantage of CaviTAU is its efficiency. Measurements can
be taken quickly and easily, which is beneficial for both the dentist
and the patient. The results are displayed immediately, which allows an immediate assessment of
the jawbone condition, and supports
sound treatment planning.
The reliability of CaviTAU makes it a valuable tool in the dental
office. The thorough measurements enable the dentist to make
accurate diagnoses and create individualised treatment plans.
This is especially crucial for implantation and other oral surgical
procedures, as accurate knowledge of jawbone density is essential for the success of these procedures.
In addition to accuracy and safety, CaviTAU also has the advantage
of patient convenience. The non-invasive and painless nature of
ultrasound measurement ensures a comfortable patient experience. This is especially important in minimising patient anxiety and
fear and increasing confidence in the treatment process.
CaviTAU undoubtedly has the potential to revolutionise dental
diagnostics. Radiation-free, highly effective and safe measurement of jawbone density enables improved patient care and supports dentists in providing high-quality treatments.
Digital Dental & Healthcare Technology, Germany
www.cavitau.de
Fotona
Redefining dental laser technology
Fotona’s LightWalker is a revolutionary dental laser system with 20 W of power, two wavelengths, five pulse durations and four special pulse modes, offering an unparalleled range of
clinical applications.
Practitioners are thrilled by the LightWalker’s SWEEPS mode for its efficacy in endodontics,
witnessing the power of bubbles in cleaning narrow root canal spaces, removing the smear
layer, debris and biofilm. SWEEPS also enables non-surgical removal of biofilm and calculus
in periodontal and peri-implant therapy.
The LightWalker’s patented QSP mode makes it invaluable for hard-tissue treatments,
debonding of veneers and orthodontic brackets, dental aesthetics and surgery. With the
laser’s SMOOTH mode, dental practices can even perform a wide range of cutting-edge
aesthetic and anti-snoring laser therapies, thus attracting new patients and revenue.
Embrace the power of LightWalker’s unmatched versatility.
Fotona, Slovenia
www.fotona.com
The articles in this category are provided by the manufacturers or distributors
and do not reflect the opinion of the editorial team.
4 2023
41
[42] =>
| about the publisher
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implants
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implants—
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implantology is published in cooperation
with the German Association of Dental
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congress.eao.org/milan/en/
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[43] =>
53
RD
INTERNATIONAL
ANNUAL CONGRESS
OF DGZI
IMPLANTOLOGY
SAVE THE
DATE
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89 NOVEMBER 2024
DÜSSELDORF
[44] =>
June 13–15, 2024
Inspiration, confidence and passion
Implant Solutions World Summit is coming to you in Miami,
Florida, USA, in 2024 – are you ready for inspiration, confidence
and passion delivered?
On June 13–15, you will discover cutting-edge science and the
latest innovations in implant solutions, digital dentistry and
bone regeneration and enjoy the company of world-renowned
speakers, colleagues and friends.
Join world-leading experts in implant dentistry
Implant Solutions World Summit is an exclusive, state-of-the-art
congress focused on science and implant dentistry. In Miami,
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Register now
dentsplysirona.com/worldsummit
#ImplantSolutionsWorldSummit
Follow Dentsply Sirona for
the latest in implant dentistry
dentsplysirona.com/implants
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