32013

i s sn 1868-3207 Vol. 14 • Issue 3/2013

implantsinternational magazine of oral implantology

| researchRetromolar bone grafts prior to implant placement—Part I

| overviewPeriimplant lesions—causes and treatment options

| case reportGTR and recession coverage in immediate implantation

www.dentsplyimplants.com

DENTSPLY Implants offers a comprehensive line of implants, including ANKYLOS®, ASTRA TECH Implant System™, and XiVE®, digital technologies such as ATLANTIS™ patient-specific CAD/CAM solutions, regenerative bone products and professional development programs.

DENTSPLY Implants is built upon the fundamental values of open-mindedness, a thorough scientific approach, a dedication to long-term clinical evidence and a

strong customer focus. Our current DENTSPLY Friadent and Astra Tech Dental customers can rest assured knowing that the world-class products they know will continue to be supported.

We are confident that dental professionals around the globe will come to recognize DENTSPLY Implants as their new partner of choice for integrated implant solutions, dedicated support and better patient care.

DENTSPLY Implants is the union of two successful and innovative dental implant businesses: DENTSPLY Friadent and Astra Tech Dental*.

DENTSPLY Implants – the new powerhouse in implant dentistry

We invite you to join our journey to redefine implant dentistry.

*DENTSPLY Implants was launched in North America April 2012. Transition to the new business in other geographical locations around the globe will follow.

79571-U

SX-1

212

©

2012

DEN

TSPL

Y IH

Facilitate™

79571-USX-1212 The New Powerhouse_Ad A4_HR.pdf 179571-USX-1212 The New Powerhouse_Ad A4_HR.pdf 1 29.04.13 13:0429.04.13 13:04

editorial I

I 03implants3_2013

The 43rd International Annual Congress of the DGZI takes place in Berlin, Germany –the city that never sleeps and which is always good for a surprise.

As in the previous years, DGZI has compiled a programme which is good for a surprise aswell, although in a strictly implantological sense. It was our task to elicit practical and reliableconcepts to support your individual success, following the motto “from practice—for thepractice”. Our speakers have applied their concepts successfully for many years. Therefore,they will tune in this year’s congress motto “Practice-oriented Implantology” with theirspeeches on Saturday. Our special prosthetic podium supports DGZI’s team spirit, offering asymbiosis of dental and dental technical topics from the perspective of sustainability as theonly way to modern dentistry.

A firework of practice-oriented science will be held on Saturday. Renowned speakers willgive you an update on the state of the art of practice-relevant topics. As has been known formany years, DGZI favours plain language. Following various controversial and refreshing dis-cussions on short implants, mini implants and periimplantitis, this year’s topic is the “All-on-Four Concept—Practice-oriented and science-based?”. We are pleased that Dr Paolo Malo hasaccepted our request to present his concept and arguments during an open discussion. I amlooking forward to hearing the results gained by discussion group and auditorium. Feel freeto join the discussion! DGZI will accept each individual opinion. Furthermore, DGZI scientificadvisory board has launched a scientific study on the All-on-Four Concept at the Universityof Bonn, Germany. Its results will be presented at the 43rd International Annual Congress ofthe DGZI for the first time.

Our international podium will again provide you with a cross section of international sci-ence, since DGZI is known to be the implantological society which has the best network inGermany. Our corporate podiums and the legendary party night at the Wasserwerk, Berlin ti-tled “Lounging, Dining, Clubbing”, will take you on a trip to the adventurous side of Berlin.

I am looking forward to welcoming you at this special weekend, which celebrates the Ger-man unification, at its centre stage in Berlin for the 43rd International Annual Congress of theDGZI.

Yours,

Dr Roland HilleScientific Director

Dear colleagues, Dr Roland Hille

Programme and registration form

I content

04 I implants3_2013

I editorial

03 Dear Colleagues| Dr Roland Hille

I research

06 Retromolar bone grafts prior toimplant placement—Part I| Andreas Sakkas et al.

I case report

14 GTR and recession coverage in immediate implantation| Dr N. Papagiannoulis et al.

I overview

20 Periimplant lesions — causes and treatment options| Dr Georg Bach

26 Fast & Fixed as an alternative treatment in cases of periodontitis profunda | Dr Regina Schindjalova

I industry report

30 The use of the LiteTouch Er:YAG laser in peri-implantitis treatment| Prof. Tzi Kang Peng et al.

36 Safe interdisciplinary navigation| Dr Frank Schaefer et al.

41 Peri-implantitis prophylaxis by sealing implant gaps andhollow spaces | Prof. Dr Dr Claus Udo Fritzemeyer

I news

44 Manufacturer News

47 News

I meetings

49 Nobel Biocare Global Symposium 2013 in New York

| Nobel Biocare

I about the publisher

50 | imprint

page 06 page 14 page 26

Cover image courtesy of Isy by Camlog,

www.camlog.de

Original Background: ©Vadim Georgiev

Artwork by Sarah Fuhrmann, OEMUS MEDIA AG.

page 36 page 47 page 49

Education. Technology. Family.

LI-PB77692E

N

Join the Syneron Dental Lasers Family

The unique fiber-free Er:YAG laserthat has changed the face of laser dentistry

presenting

To learn more about our innovative technology solutions, contact: dental@syneron.com, www.synerondental.com EMEA 2011 Winner

LI-PB77692EN A4 Advertisment 2, LiteTouch award from in print.pdf 1LI-PB77692EN A4 Advertisment 2, LiteTouch award from in print.pdf 1 02.08.13 10:5002.08.13 10:50

I research

Figs. 1 & 2_Exposure of the recipient

site for the graft prior to harvest,

measurement of its dimensions and

the minimal time elapsed between

graft harvest and placement.

Fig. 3_Preoperative situation.

Fig. 4_Mean surgical time of five

minutes for harvesting.

Fig. 5_Inferior osteotomy connecting

the posterior and anterior

vertical cuts.

Figs. 6 & 7_Fixing of the block grafts

after appropriate separation into

smaller parts.

_Introduction

The dental rehabilitation of partially or totally eden-tulous patients with oral implants has become commonpractice with reliable long-term results.1 However, un-favourable local conditions of the alveolar ridge due toatrophy, periodontal disease, trauma sequel, malforma-tion or neoplasia may cause insufficient bone volume,which may complicate the therapy of the masticatoryfunction with dental implants.2 When alveolar ridgeslack the appropriate bone volume, additional surgicalreconstructive procedures are required.

The use of autologous bone grafts with dental im-plants was described originally by Brånemark et al. in1975, and today is a well-accepted procedure in oral andmaxillofacial rehabilitation.3-5 Insertion of an en-dosseous implant requires sufficient bone volume forcomplete bone coverage. Physiologically, an ideal bonegrafting material should provide osteogenicity, os-teoinductivity and osteoconductivity for new bone for-mation. Despite some recent advances in bone-substi-

tute technology, autogenous bone grafts remain the“gold standard” in reconstructive surgeries because oftheir osteoinductive, osteoconductive and non-im-munogenic properties. Guided bone regeneration (GBR)is an alternative technique to onlay grafting for lo-calised alveolar ridge augmentation prior to dental im-plant placement.6, 7 The clinical potential of membranetechniques for bone regeneration was recognised byNyman et al.8 They demonstrated that membranes actas a physical barrier when applied over bone defects,preventing the ingrowth of competing, non-osteogeniccells into the membrane-protected space.7,9 Space pro-vision, such as guided tissue regeneration, was shownto be effective in regenerating new bone on atrophiedalveolar ridge, either vertically or horizontally, with theuse of a membrane. Similar to onlay bone graft, whichalso serves as a space maintainer, GBR may incur simi-lar complications that pertain to the use of onlay graft.Complications related to GBR may come from mem-brane exposure, miniscrew exposure and contamina-tion. Exposed membranes or fixation screws often causelocal inflammation with decreased bone formation.10

Retromolar bone grafts priorto implant placementOutcomes and complications—Part I

Authors_Andreas Sakkas, Carsten Winter, Frank Wilde & Alexander Schramm, Germany

06 I implants3_2013

Fig. 5 Fig. 6

Fig. 2 Fig. 3

Fig. 4

Fig. 1

All trademarks are property of their respective companies. www.implantdirect.eu | 00800 4030 4030

LegacyTM System100% Compatible with Zimmer© Dental

Cover Screw Healing Collar

Legacy™ Implant System Advantages:

Legacy™3 Implant

LegacyTM1 LegacyTM2 LegacyTM3

Industry-Compatible Internal Hex Prosthetic compatibility with Zimmer Dental Screw-Vent®, BioHorizons®

& MIS implants

Surgical Compatibility with Tapered Screw-Vent®No need to change surgical protocol or tools

Three Implant Designs & Packaging OptionsAllows for selection based on price, packaging or thread design

Legacy1: €115 includes cover screw, healing collar & plastic carrier

Legacy2: €130 includes cover screw, healing collar & temporary abutment/transfer

Legacy3: €145 includes cover screw, healing collar & preparable abutment/transfer

Micro-ThreadsReduce crestal stress for improved initial stability

Widest Range of Dimensional OptionsThe entire Legacy system includes seven implant diameters

(3.2, 3.7, 4.2, 4.7, 5.2, 5.7, 7.0mm) & six implant lengths (6, 8, 10, 11.5, 13, 16mm)

All-in-One Packaging includes implant, abutment,

transfer, cover screw & healing collar €145

Standard “V” Threads

Matches Screw-Vent®

Spiral Threads

for Increased Stability

Buttress Threads

for Increased Surface

Dubli

n - 17th-19th October 2013 Implant Direct

VISIT US! Stand S31

Reality Check Zimmer Customers

Straight

ContouredLaboratory

Abutment15° Angled

Contoured

Straight

Snap-On

Gold/

Plastic

Zirconia/Ti

Abutment

Plastic

Temporary

Abutment

Ball

Attachment

GPS™

Attachment AngledStraight

€75 €75 €75 €90 €90 €30 €68 €90 €90 €75 €90€60

Multiple-Unit

w/Cap & TransferAngled

GPS™

Attachment

EU_Legacy3_Implants_313.pdf 1EU_Legacy3_Implants_313.pdf 1 25.07.13 10:4125.07.13 10:41

I research

08 I implants3_2013

The significance of early membrane exposure on the re-generative outcome has been somewhat controversialin guided tissue regeneration and GBR procedures. Sev-eral studies have shown better responses when themembranes remained submerged than when they be-came exposed during healing.11, 12 However, other stud-ies failed to show such differences.13, 14

It must be pointed out that patients affected by par-tial edentulism do not easily accept major surgical pro-cedures that may imply hospitalisation or generalanaesthesia. These disadvantages, together with thefact that dental implants do not demand a large amountof bone, lead to the growing use of autogenous blockbone grafts from intraoral sources rather than from ex-traoral.15-20

The use of the mandible as a donor site is said to beless invasive, to save surgical and anaesthetic time andto be accomplished in the outpatient operatory.13,21,22

Harvesting of bone grafts from the retromolar regionhas been reported several times before.22-26 In the repairof localised alveolar defects, bone grafts from the retro-molar region offer several benefits: a) the proximity ofdonor and recipient sites that reduces operative andanaesthetic time; b) conventional surgical access; andc) making them ideal for outpatient implant surgery.Minimal discomfort and decreased morbidity are alsoreported for this type of bone grafting.27-29 This tech-nique can be combined with impacted third molar ex-tractions.30

The purpose of the present retrospective study wasto evaluate the surgical success and to assess the rate ofcomplications that arise from harvesting retromolarbone grafts in a group of partially edentulous patientsprior to implant placement. We used a two-stage tech-nique. In the first surgical stage, one or more cortico-

cancellous bone blocks harvested from the retromolarregion were fixed with osteosynthesis titanium screwsto the recipient site as onlay grafts to achieve a hori-zontal and/or vertical augmentation of the ridge vol-ume. In the second procedure, three to six months later,the screws were removed and implants were placed. Theresults regarding bone augmentation, donor and recip-ient site morbidity, bone graft stability and resorptionprior to implant placement were recorded during thepostoperative period and healing phase. Complicationsassociated with this procedure mostly involve infection,incision line opening, nerve dysfunction, wound dehis-cence, loss of portion of the bone graft, and graft mo-bilisation (Table 1).31 A short review of the literature ispresented in Table 2.

_Materials and methods

A consecutive retrospective study was conducted onpatients who underwent retromolar onlay bone graft-ing from January 2008 until January 2011. Files of 86 pa-tients (77 males and 9 females) reporting 104 bone graftoperations were reviewed. Patients ranged in age from20 to 58 years (average 37.9 years). From the currentstudy, patients were excluded if their data covered: a)grafting of bone defects caused by tumour resections,osteoradionecrosis and bisphosphonate-associatedosteonecrosis, b) grafting of bone defects in syndromepatients with craniofacial involvement and with con-genital malformations, such as cleft patients, c) graftingof extraction sockets and intraalveolar defects simulta-neously with immediate implant placements and d)augmentations including the application of distractionosteogenesis. Medical history, cause of tooth loss andsmoking status at the time of operation were recorded.All patients underwent primary clinical and radi-ographic examinations and were diagnosed as havingan inadequate quantity of bone for implant placement.

Figs. 8 & 9_Filling of the small gaps

between bone graft and alveolar

crest with corticocancellous bone.

Fig. 10_Periosteal releasing

incisions.

Fig. 11_Orthopantomographic

control to evaluate the outcome of

the surgical procedure.

Fig. 12_Crestal incision and

subperiosteal dissection of the

alveolus, removal of the fixation

screws. Implant site preparation with

guidance from the laboratory-made

splint. Positioning of the implants.

Fig. 7 Fig. 8 Fig. 9

Fig. 10 Fig. 11 Fig. 12

It’s called NobelActive 3.0. This unique implant is the ideal solution for narrow spaces in the anterior region. The drilling procedure is designed to retain as much bone as possible, while the implant body and thread design condenses bone during insertion enhancing ini-tial stability. The sharp apex and cutting blades enable you to adjust the implant position for optimal

restorative orientation. Together with the strong sealed connection and built-in platform shifting, NobelActive 3.0 allows you to safely produce excellent esthetic re-sults. After 45 years as a dental innovator we have the experience to bring you future-proof and reliable tech-nologies for effective patient treatment. Their smile, your skill, our solutions.

Visit nobelbiocare.com/active3

© Nobel Biocare Services AG, 2013. All rights reserved. Nobel Biocare, the Nobel Biocare logotype and all other trademarks are, if nothing else is stated or is evident from the context in a certain case, trademarks of Nobel Biocare. Disclaimer: Some products may not be regulatory cleared/released for sale in all markets. Please contact the local Nobel Biocare sales offi ce for current product assortment and availability. 1 Dental Product Shopper voted NobelActive 3.0 Best Product 2012. (https://www.dentalproductshopper.com/nobelactive-30).

Smaller and stronger.

Maximum material strength and strong sealed connection.

High initial stability and bone preservation.

Safe implant placement in areas with limited space.

For limited spaces

Ø 3

.0 m

m

1

NobelBiocare_A4_implants313.pdf 1NobelBiocare_A4_implants313.pdf 1 23.08.13 11:4523.08.13 11:45

I research

10 I implants3_2013

Figs. 13–18_Crestal incision and

subperiosteal dissection of the

alveolus, removal of the fixation

screws. Implant site preparation with

guidance from the laboratory-made

splint. Positioning of the implants.

Table 3 shows the frequency of causes for the tooth loss.All the patients were informed in advance that bone re-construction might be necessary prior to implant place-ment, since the need to augment the alveolar ridge canbe evaluated correctly using panoramic radiographsonly when there is vertical resorption of the ridge. Con-ventional radiographic examination provides little or noinformation about ridge thickness. Because of this, allthe patients of the study underwent, except a conven-tional panoramic radiograph of the jaws, CT scans re-formatted with Dentscan software. In disagreementwith other authors, we believe that reformatted CT im-ages always provide a precise treatment guide when thedecision to graft or not to graft has to me made in criti-cal cases.32 A total of 104 alveolar segments weretreated: 22 procedures involved the maxilla and 82 themandible. In six of the augmented areas on the maxillaposterior, a Sinus elevation was also performed. Fifteenpatients included in the study were treated in separateprocedures for augmentation of different alveolar sites.Each augmented site was studied. 67 procedures werecarried out under local anaesthesia and 37 under gen-eral anaesthesia. All sites were treated in a similar fash-ion. The number of bone blocks, donor sites and numberof implants inserted in each augmented site were alsorecorded. The choice of donor site, left or right, was de-termined preoperatively, based on defect morphologyand recipient site location. When the augmentation wasplanned in the posterior mandible, a single surgical fieldwas needed, thus reducing patient discomfort. The re-cipient site was healed completely prior to graft surgery.

_Surgical protocol

Stage 1 surgery

The bone harvesting procedure was performed us-ing a standardised surgical technique. The anaesthesiaof all patients was carried out with UltracainTM D-S

(Hoechst Marion Roussel Deutschland, Frankfurt, Ger-many) containing 1: 200,000 epinephrine at the donorand recipient sites. A single shot of 2,2 g amoxicillin andclavulanic acid (Augmentan®, GlaxoSmithKline Con-sumer Healthcare GmbH & Co. KG) or, if penicillin aller-gic, 600 mg Clindamycin (Clinda-saar®, MIP PharmaGmbH) as well as 250 mg Prednisolon (Solu-Decortin®,Merck Pharma GmbH) was administered intravenous topatients a few minutes prior to surgery.

The proposed recipient site for the graft was exposedprior to graft harvest in all cases. In this manner, the di-mensions and morphology of the bony defect weremeasured, and minimal time elapsed between graftharvest and placement (Figs. 1 & 2). Figure 3 presents thepreoperative situation. The recipient site was preparedand recon toured with the Safescraper (C.G.M. S.p.A., Di-visione Medicale META, Italy) by pushing the end of thedevise toward the bone surface and simultaneouslypulling the devise backward. Collection of 2–3 ml ofbone was feasible with a mean surgical time of five min-utes for harvesting (Fig. 4). The collected bone was pre-served in a sterile environment until grafting. To accessthe ramus area, the concavity formed by the border be-tween the ascending ramus and the external obliqueridge was identified and used as a starting point for themucosal incision.

The incision was made medially to the externaloblique ridge and extended mesially toward the buccalaspect of the second molar. Care was taken to ensurethat the incision was not extended too far lingually, pre-venting damage to structures on the lingual aspect ofthe mandible. A mucoperiosteal flap was elevated supe-riorly, exposing the lateral aspect of the ramus. The os-teotomy was carried out with an osteotomy kit forPiezosurgery® (Mectron, Deutschland Vertriebs GmbH)and was started anteriorly to the coronoid process at the

Fig. 17 Fig. 18

Fig. 14 Fig. 15

Fig. 16

Fig. 13

With Roxolid® SLActive® Implants we break

new ground:

p Eliminating invasive grafting procedures

p Increasing patient acceptance

Our new generation of implants provides you

exceptional material strength combined

with excellent osseointegration properties for

greater confidence.

Now available:

p All diameters

p 4 mm Short Implant Line

p Loxim™ Transfer Piece

Discover more benefits on www.straumann.com/roxolid

A Real Breakthrough in Implantology.Roxolid® SLActive® – Setting New Standards, Reducing Invasiveness

AD_ROXILD_SLActive_A4_en_high.pdf 1AD_ROXILD_SLActive_A4_en_high.pdf 1 15.08.13 10:5015.08.13 10:50

I research

12 I implants3_2013

point were adequate bone thickness developed. A microreciprocating saw was used to cut through the cortexalong the anterior border of the ramus medially to theexternal oblique ridge. The anterior vertical cut wasmade in the mandibular body in the molar region with avertical saw. The length of this cut was dependent on thesize requirements of the graft and on the position of theinferior alveolar canal. The posterior vertical cut wasmade on the lateral aspect of the ramus, perpendicularlyto the external oblique osteotomy. The inferior os-teotomy connecting the posterior and anterior verticalcuts was made with a straight saw. This was a shallowcut into the ramus to create a line of fracture (Fig. 5). Athin chisel was gently tapped along the entire length ofthe external oblique osteotomy, and care was taken toparallel the lateral surface of the ramus, so that a frac-ture would occur at a particular level. This level wasmodified to predetermine the size of the corticocancel-lous bone graft. Thus, the splitting of the graft from theramus was completed. The bone block was lifted care-fully to ensure that the inferior alveolar nerve was nottrapped within the graft. The donor area was filled witha collagen cotton sponge for local haemostasis.

The block grafts were then fixed with small-diam-eter titanium osteosynthesis screws (Matrix Midface,Synthes© 2011 NHS Supply Chain) after appropriateseparation into smaller parts (Figs. 6 & 7). Corticocan-cellous bone, collected with the Safescraper, was thenused to fill the small gaps between the bone graft andthe alveolar crest (Fig. 8). In all cases, a collagen mem-brane (Bio-Gide, Geistlich Biomaterials, Wolhusen,Switzerland) was cut appropriately and adapted tocover the defect and extended 2 to 3 mm sideways,being laid over the graft in a saddle configuration. Itwas tucked underneath the palatal or lingual flap tocover the ridge and buccal defect, moistened, andpressed gently to adapt to the underlying bone (Fig.9). Periosteal releasing incisions were made whennecessary to achieve easy closure of the mucosal flapson top of the grafts without tension (Fig. 10). An or-thopantomographic control was performed postop-eratively to evaluate the outcome of the surgical pro-cedure (Fig. 11).

Postoperatively, patients were instructed to rinsetheir mouth with chlorhexidine 0.2 % for two to threeweeks twice a day. After this period, the sutures were re-moved. Removable provisional prostheses were ad-justed generously. Patients were instructed to use theirprostheses for cosmetic appearance and for eatingrather than function for the whole period of healing, i.e.three months. At that time, patients were scheduled forimplant surgery. No antibiotic therapy was continuedafter surgery and patients were instructed to use non-steroidal anti-inflammatory drugs (Ibuprofen®,Docpharm® Arzneimittelvertrieb GmbH & Co. KGaA)only if pain was present.

Stage 2 surgery

After a healing period varying between three to sixmonths after the grafting procedure, clinical and radi-ographic evaluations were performed and implantswere placed in a routine fashion using the special pro-gram for guided implant surgery CoDiagnostiX® (IVSSolutions AG). All patients underwent CT scan before theimplant placement to assess new bone formation andplan the accuracy of the implant position. A crestal in-cision and subperiosteal dissection of the alveolus wereperformed and the fixation screws were removed. Im-plant site preparation was performed with guidancefrom the laboratory-made splint and the implants werepositioned (Figs. 12–18). We used bone-level type tita-nium implants. The most common in use were Strau-mann® Bone Level implants (Institut Straumann AG,Switzerland), followed by Astra® (Astra Tech Inc.) andCamlog® (CAMLOG Vertriebs GmbH, Germany). In total,155 implants were positioned, 39 in the maxilla and 116in the mandible. Three to six months later, the prostheticwork was started.

Clinical appointments were performed after surgeryto evaluate any complication at the donor and recipientsite, such as dehiscence, infection, swelling, sensory dis-turbances or haemorrhage. Graft loss and graft removalwere defined as failure; swelling, wound dehiscence, in-cision line opening, infection with pus or temporaryparesthesia were defined as complications. Buccalnerve damage from incision along the external obliqueridge as well as the damage of inferior alveolar nerve ispossible. Graft incorporation was evaluated followingthe removal of the fixation screws. Statistical analysisincluded descriptive statistics using IBM SPSS Softwarefor Windows. The significance level of p ≤ 0.05 for all sta-tistic tests was definite. The residents of our departmentoperated and followed upon all patients, and the resultswere analysed in percentage and presented in tablesand diagrams._

DisclosureThe authors do not have any financial interests, either directly or

indirectly, in the products listed in the study.

Editorial note: To be continued in im-

plants 4/2013 with results, an exten-

sive discussion and tables. A full list of

references is available from the pub-

lisher.

Andreas Sakkas

Oral Surgeon

Department of Oral and Maxillofacial Surgery, Facial

Plastic Surgery

Military Hospital Ulm and Academic Hospital

University Ulm

Ulm, Germany

Tel.: +49 731 17101701

andreaszfc13@yahoo.gr

_contact implants

AZ_Leyli_Behfar_FAN_A4_EN_PRINT.pdf 1AZ_Leyli_Behfar_FAN_A4_EN_PRINT.pdf 1 22.04.13 13:5022.04.13 13:50

I case report

Fig. 1_Initial situation.

Fig. 2_Preoperative panoramic

radiograph.

Fig. 3_Tooth 11 post-op.

Fig. 4_Tooth 22 post-op.

Fig. 5_Implant insertion tooth 11.

Fig. 6_Implant inserted in tooth 11.

GTR and recession coveragein immediate implantationAuthors_Dr N. Papagiannoulis, Dr E. Sandberg & Dr M. Steigmann, Germany

14 I implants3_2013

Fig. 5 Fig. 6

Fig. 2 Fig. 3

Fig. 4

Fig. 1

_Introduction

Among the difficulties and challenges in immedi-ate implantation, local inflammations of the hard orsoft tissue are major criteria on how we implant. Thebehaviour after implantation, especially of the softtissue, is only predictable when the diagnosis and thetreatment concept are correct. Gum recessions arepotential contra-indications for immediate implantplacement.

Nevertheless, we have to take into considerationthat soft tissue and recession coverage techniquesfunction differently when applied to implants. A cal-culated risk is acceptable if the procedure preventssoft and hard tissue from absorbing, which can leadto compromised aesthetics and an unsatisfied pa-tient.

_Clinical and radiological findings

The patient visited the practice complaining aboutcompromised aesthetics of the anterior maxilla. The firstexamination showed a challenging situation of teeth 11and 22. In the past years, the almost 30-year-old patienthad experienced the whole range of dentistry, includingendodontology, periodontology, and surgical crown ex-tension.

Teeth 11 and 22 were insufficiently restored, withtooth 11 showing a soft tissue recession Miller class 2and tooth 22 showing an apical inflammation. Bleedingon probing was positive in 11 (grade 4), so were percus-sion and mobility in 22. The crown in tooth 11 wasoverextended, probably to cover recession. Crown 22was also overextended, leading to secondary caries. Theperiodontal screening index on 11 was grade 3 with

Join us at EAO Dublin!

Attend the interesting lectures about hard- and soft-tissue augmentations

www.geistlich-pharma.com

LEADING REGENERATION

Thursday, 17 October 2013, 11:00 – 13:00

Visit us at our

booth #G1!

PD Dr. Ronald E. Jung, Switzerland

Hard- and soft-tissue concepts for alveolar ridge preservations

Dr. Daniele Cardaropoli, Italy

The management of soft tissues in post-extractive site and periodontal plastic surgery

More information: www.geistlich-pharma.com/dublin2013

?Ad_210x297_EAO_Dublin_E_Original_57543.pdf 1Ad_210x297_EAO_Dublin_E_Original_57543.pdf 1 08.08.13 10:4908.08.13 10:49

I case report

16 I implants3_2013

Fig. 7_Provisional crown and GTR.

Fig. 8_Tooth 11 post-op.

Fig. 9_Tooth 22 post-op.

Fig. 10_Three weeks post-op.

Fig. 11_Provisional crown on the modell.

Fig. 12_Veneers, biscuit bake.

Fig. 13_Completed provisional crown and veneers.

Fig. 14_Four weeks after re-entry.

Fig. 15_Try-in of zirconium abutment 11.

Fig. 16_Try-in of zirconium abutment 22.

Fig. 17_Zirconium caps in occlusion.

Fig. 18_Tissue quality four weeks after provisional

placement.

Fig. 19_Provisional crown tooth 22 after re-entry.

Fig. 20_Provisional crown tooth 11 after re-entry.

Fig. 21_Veneers and provisional crown placed after

re-entry.

Fig. 22_Try-in of abutment tooth 11.

Fig. 23_Try in of abutment tooth 22.

Fig. 24_Abutments and completed

crowns.

Fig. 7 Fig. 8 Fig. 9 Fig. 10

Fig. 11 Fig. 12 Fig. 13

Fig. 14 Fig. 15 Fig. 16

Fig. 17 Fig. 18 Fig. 19 Fig. 20

Fig. 21 Fig. 22 Fig. 23 Fig. 24

case report I

I 17implants3_2013

Fig. 25_Crowns completed.

Fig. 26_Check-up of teeth 11 and 22

and crowns.

Fig. 27_Three months after insertion

of crowns.

3.5 mm mesially and 4.0 mm distally. The radiologicalcontrol (Figs. 1–4) also shows a discrepancy betweenpreparation and crown modelling in tooth 11. This arti-ficial undercut and the minimized biological width werethe main reasons for the local inflammation.

_Planning

Teeth 11 and 22 were to be extracted. A new crownon 11 would not offer any better aesthetic and func-tional results. Due to the root screw, the root treatmenton 22 was risky and its result was unpredictable. Largercomposite fillings on 12 and 21 compromised aesthet-ics additionally.2-5

The treatment plan included the following steps:1. Extraction of teeth 11 and 22 with immediate im-

plantation and guided bone and tissue regeneration.2. Maryland Bridge as a temporary restoration.3. Veneers on teeth 12 and 21 after implant re-entry.4. Full ceramic crowns on teeth 11 and 22.

_Surgical phase

After extraction of teeth 11 and 22, the ridge wascleaned and disinfected. No injury or perforation of thebuccal lamella was observed. The implant system usedwas tapered, with platform switching and high primarystability. The drill sequence was followed as provided bythe manufacturer but with no irrigation and a low rota-tion of 50 to 70 rpm with maximum torque.10-14

Implants were placed slightly subcrestally so that theapical coronal position was 0.5 mm below bone level. Inregion 11, a 4.1 x 13 mm implant was inserted (Figs. 5-8)and an implant of 4.1 x 10 mm in region 22 (Fig. 9).6-8 Thegap to the buccal plate of 1 mm was augmented with amix of ß-TCP and HA 40 %–60%.9,15No effort was madeto manipulate the soft tissue recession or raise a flap.Cuts in this region would have led to major recessionsbecause of the periodontal situation of the neighbour-ing teeth. For this reason, the recession in tooth 11 wasleft as it was. The crestal part of the extraction socket wascovered with collagen tissue fleece. At last, a piece ofdermis matrix was positioned crestally and slightly buc-cally to improve soft tissue quantity after healing.16-19

The provisional Maryland Bridge was manufacturedwith pontics on 11 and 22 for optimal soft tissue man-agement (Figs. 10–13). Recall appointments were keptfor one, three, seven, 14, 21 and 30 days and afterwardsmonthly.

_Provisional and healing phase

At four weeks postoperatively, the bridge was re-moved and teeth 12 and 21 were prepared to receiveveneers. The soft tissue condition was optimal, with-out inflammation and with full epithelialisation of thewound. With a new temporary restoration, we for-warded soft tissue conditioning. Radiological con-trols were made after each cementation procedure topreclude cement rests and a risk of periimplantitis. Ve-neers were inserted before loading the implant forbetter colour adaptation of the supra-construction,but also after implant re-entry for an optimal emer-gence profile planning.

_Implant re-entry

The re-entry was performed three months postop-eratively with a simple mucoperiosteal flap. The qualityof the soft tissue was good so that a small crestal cut of4 mm was enough to remove the healing screw. Insteadof inserting a gingival former, we decided for a tempo-rary abutment with a composite crown, resulting in ascrew-retained provisional. No risk of cement rests wastaken and the screw-retained temporary crown enabledus to manipulate soft tissue as desired for an excellentaesthetic outcome. The patient received this temporar-ily for four weeks and afterwards impressions weretaken.

_Restorative phase

The veneers were retained four weeks after im-plant re-entry (Figs. 13 & 14, 19–21). At this time, wehad optimal conditions for colour selection and im-pression of the implants with customised implantcopies. At the first abutment try-in (Figs. 15–18, 22 &23) we could see the soft tissue regeneration andforming around the zircon caps. Even the gingivalsurface texturing is evident.

Fig. 25 Fig. 26 Fig. 27

I case report

18 I implants3_2013

The correct abutment and crown insertion (Figs.24 & 25) were controlled with X-rays (Fig. 26). Not onlydid the surgical part lead to such highly aesthetic results,but also the technical part played a crucial role in theaesthetic outcome (Figs. 27–31). The soft tissue situa-tion showed a slight improvement of the papilla ontooth 11 four weeks after loading.

_Discussion

The decision to extract the teeth and place implantsimmediately is always a risk. This risk is lowered if we un-derstand why the tooth had to be removed, how biologyworks and what we can or must not do. In this case, aflap raise or papilla raise would have been fatal with re-gard to aesthetics, resulting in unpredictable and majordefects. The implant position slightly beneath the cre-stal bone level is correct, calculating the inevitable lossof crestal height through the former local inflamma-tion. The grafting of the buccal plate gap is also appro-priate and leads to a higher predictability when per-formed with a combination of fast and slow, or slow andnon-resorbable biomaterials.

Platform switching is a useful technique to offer softtissue or hard tissue space to grow and a stable scaffoldfor support. When the system offers real platformswitching, as seen here, hard tissue growing on the re-versely bevelled implant neck prevents crestal bone re-sorption. Especially soft tissue growing and coveringthe implant neck will form a tissue ring around it, pro-tecting the crestal bone from resorption as well. Pros-thetics are as important as the surgical part. They en-compass the final restoration with the emergence pro-file, the proximal contact and margin design, but thetemporary restoration also is crucial for soft tissue

maintenance, management and long-term stability. Ascan be seen from the recall photos four weeks afterloading, the soft tissue fills the proximal gaps if the con-ditions for it are fulfilled. The initial recession is gone andwe created enough soft tissue for good aesthetic re-sults. The tight interdisciplinary collaboration betweensurgeon, technician and restorative dentist finally guar-anteed a satisfactory result and a happy patient.20-25_

Fig. 28_Occlusion.

Fig. 29_Left.

Fig. 30_Right.

Fig. 31_Smile.

Fig. 31Fig. 30

Fig. 29Fig. 28

Dr N. Papagiannoulis

Proaesthetic DentalPraxis für kosm. ZHK und ImplantologieBrückenkopfstr.1/269120 Heidelberg, Germany

Tel.: 06221 9986482Fax: 06221 9986484

www.fsde.com.gr

Dr E. Sandberg

Zahnarztpraxis Dr Sandberg & KollegenLiebigstraße 1160323 Frankfur/Main, Germany

Tel.: 069 97097171Fax: 069 97097272

www.dr-sandberg.de

Steigmann Institute

Bahnhofstraße 6469151 Neckargemünd, Germany

_contact implants

Ritter Implants GmbH & Co. KG | Gruener Weg 32 | 88400 Biberach | GERMANY Fon 0049 7351. 52 925-10 | Fax 0049 7351. 52 925-11info@ritterimplants.com | www.ritterimplants.com

FAX VOUCHER

%YES, I want to save my benefit !Please contact us as soon as possible.I confirm with my address and signature / stamp

Number of Sets (max.10) NAME

STREET VAT-NO.

CITY / ZIP COUNTRY

FON EMAIL

DATE SIGNATURE

Fax 0049 7351. 52 925-11

Founded in 1887 by the German Frank Ritter in

New York, Ritter is one of the oldest prestige

brands of finest dental equipment worldwide.

Due to innovative ideas and a great entrepre-

neurial spirit, Ritter produced the first dental

units already more then 125 years ago.

Today Ritter products are more than ever an es-

sential element in dental practices worldwide.

Users appreciate the Ritter product range for

the high-quality aspects and the reliability -

Made in Germany. Due to their functionality

and user orientated construction, Ritter dental

units contribute constantly to an optimized

workflow of today’s modern dental practices.

In the course of the last years, Ritter has started

to write a new success story with the launch

of an innovative, state of the art implant sys-

tem. The Ritter Implant Ivory Line provides Two

Piece Implants (Implant plus separate Abut-

ment) as the QSI Spiral Implant and TFI Twin

Fissure Implant as well as One Piece Implants

(Implant and Abutment already connected)

called Mono Compress Implant MCI. The system

contains logically reduced and clearly arranged

components of tools and abutments with the

best features for all clinical cases. Due to the

super Nano-Surface, a quick and reliable Os-

seo-Integration is guaranteed. Clever and easy

handling is provided by self-tapping threads

and a coloured system of drills and implants

according to their diameters.

All Ritter Implants and Accessories are made by

high modern CNC manufacturing machines. A

combination of advanced machining and

hand-finishing create the most accurate tools

possible for the marking of ceramic drills.

The Ritter brand stands for high quality, state

of the art technology and innovative pro-

ducts Made in Germany. The credo is to always

provide customers and clients with the best

services and prices combined with the most

comprehensive dental solutions in the market.

More information:

www.ritterimplants.com

_RITTER IMPLANTS SYSTEM_Quality. Flexibility. Innovation.

....ask for your special start offer:

Set price, incl. Implants, Analogs, Transfers

A

butments, Healing Caps and Starter Tool Kit !NEW

Leipzig Fachdental, 06.-07. Sept.Stand-Nr. 4A47

Hamburg ID Nord, 21. Sept. HalleA1, Stand-Nr. G43

Stuttgart Fachdental Südwest, 11.-12. Okt. Stand-Nr. 4B44

Frankfurt ID Mitte, 08.-09. Nov.Stand-Nr. F34

Implant Expo Frankfurt, 29.-30. Nov. Stand 107

Ritter_A4_IM313.pdf 1Ritter_A4_IM313.pdf 1 20.08.13 10:5520.08.13 10:55

I overview

Figs. 1–4_The hygiensation phase:

The hygienisation phase is an

essential treatment step at the

beginning of periimplantitis

treatment. Hard and soft plaque must

be removed from the

superconstruction and at the

transition from gingiva to

superconstruction. To avoid

scratches on the implant surface,

many authors recommend the use of

plastic curettes or curettes with

titanium covered ends. Additional

disinfectant measures, i.e. rinsing

with chlorhexidine digluconate, may

be necessary. Polishing is the final

step in this initial treatment regimen.

Now the patient has to be guided

back to the straight and narrow: He

or she has to be willing and, with

enhanced instructions, also able to

clean the superconstruction

sufficiently. A continuous recall

system guarantees the respective

success monitoring. If the

periimplant lesion is limited to

mucositis, the hygienisation phase

may even be the final step in the

treatment of periimplantitis.

_Introduction

While in the early stages of implantology, issuesconcerning the “healing” of artificial abutment teethwere in the focus of interest, those early complicationshave become rare due to improved implant forms, op-timised minimally invasive diagnostic and surgicaltechniques, and especially because of improved im-plant surfaces.

Instead, “long-term complications” with implantsthat have been osseointegrated for many years, whichare functioning and have developed periimplant infec-tions, have become the focus of interest for dentists/implantologists.

This type of infection on/around the implant, whichcan lead to serious bone loss and, if untreated, will re-sult in the loss of the artificial abutment tooth (andgenerally also in the loss of the superconstruction), isreferred to as periimplantitis.

There are two possible causes:a) Infectious/bacterial (as defined by MOMBELLI, 1987).b) Functional/aseptic, e.g. due to stress phenomena

caused by not observing a balanced proportion ofimplant length/crown length and disregarding seri-ous deficits of the osseous implant site (as defined byJASTY, 1991). Functional/aseptic periimplantitis isusually the exception.

The majority of periimplant infections are of bacte-rial/infectious origin. According to information pro-vided by the only chair holder of dental implantology,Professor Dr Herbert Deppe, a prevalence of up to 15 percent of implants can be expected after 10 years.

Thus, the prevention and treatment of periimplan-titis have now become two of the major tasks in im-plantology. This article will provide information abouttried and tested laser treatments, but also about newtherapeutic approaches with laser light for the treat-ment of bacterial periimplantitis.

Periimplant lesions—causes and treatment optionsAuthor_Dr Georg Bach, Germany

20 I implants3_2013

Fig. 1 Fig. 2

Fig. 3 Fig. 4

overview I

_Treatment of the infectious form ofperiimplantitis

The four-phase treatment schemeMany authors agree on a four-phase regimen for the

treatment of periimplantitis:1) Initial treatment: This initial phase of PI treatment con-

sists of diagnosing periimplant lesions (as early on aspossible), cleaning and hygiene procedures as well asmotivating/instructing the patient suffering fromperiimplantitis.

2) Surgical resective phase: After local anaesthesia andthe creation of a soft-tissue flap, an image of the peri-implant defect (generally with its unique crater-likeform) is taken, the granulation tissue is removed andthe bone is cleaned.

3) Augmentative/reconstructive phase: The primarygoal—although not always achievable—is an augmen-tation which will ultimately lead to a restito ad inte-grum: In this case, as opposed to an augmentation, thepatient’s own bone is not the gold standard; bone sub-stitutes have become established.

4) Recall-Phase: All authors agree in their definition thatrecall is just as important as the actual treatment of aperiimplant infection. If there is no adequate andshort-term recall after the successful treatment ofperiimplantitis, recurrence will be just a matter of time.

_Explantation as a treatment option forperiimplantitis

Explantation would indeed be a “treatment op-tion” if the defect situation proves very difficult forexecuting the above-mentioned regimen or if theosseous lesions are so severe that there is only a pooroverall prognosis for the implant. At times, explan-tation may even be the only choice if it can be as-sumed that, by leaving the implant in place, the in-fection would result in further bone loss that couldprevent implantation at a later time or complicatedaugmentative measures.

_Use of laser light

There is more and more mention of the use oflaser light in both the resective/surgical and the re-call phases primarily. In principle, two types of laserlight applications can be defined:

a) Laser light application without morphologicalchanges on the implant surface and without ab-lative effect: decontamination.

b) Laser light application with abrasive effect: abla-tive treatment (possibly in combination with de-contamination).

4,0 x 5,0mm

4,5 x 6,0mm

5,0 x 5,0mm

6,0 x 5,7mm

6,0 x 5,0mm

5,0 x 6,0mm

www.bicon.de.com

Since 1985

5,0 x 6,0mm 6,0 x 8,0mm 5,0 x 6,0mm 5,0 x 5,0mm

6,0 x 5,7mm

4,5 x 6,0mm

5,0 x 5,0mm

4,5 x 6,0mm

5,0 x 5,0mm

5,0 x 6,0mm

6,0 x 5,7mm

14 Years

6,0 x 5,7mm

14 Years

0 x 5,4

mm0,5

e 1985Sinc

Simple»e 1985

.dte Lporun EociB

1. rtstpuaH reubnehcueB19455

ner nyamreG 56)0(9 4+e nohP

34 002818 mo.cnoic@byanmreg

m om.cde.oncib.www

AD

I overview

Figs. 5–10_Simplified laser-assisted treatment of peri-

implantitis with a pasty bone substitute: The original

clinical image (Fig. 5) already shows the typical symp-

toms of periimplantitis, which are confirmed after the

creation of flaps (Fig. 6). A profound bone defect has de-

veloped around the artificial abutment tooth; the granu-

lation tissue is thoroughly removed (Fig. 7). A pasty bone

substitute (Ostim®) can be applied congruently with the

defect (Fig. 8); the wound is then closed with a suture

(Fig. 9). The last image of this case study (Fig. 10) shows

the two-year check-up, which revealed a stable and

aesthetically pleasing result. Proponents of this proce-

dure (use of a pasty bone substitute) emphasise the sim-

ple application of the bone substitute congruently with

the defect and the advantage of a simplified treatment by

foregoing the membrane (“periosteum is the best mem-

brane”).

Figs. 11–16_Laser-assisted treatment of periimplantitis

with a bone substitute with improved application: The

X-ray shows considerable vertical bone loss which has

already reached the 50 % mark of the coated portion of

the implant mesially. After thorough cleaning of the im-

plant surface, a laser light decontamination (here with

diode laser light—wavelength 810 nm—in cw mode—

20 seconds—1 watt of power) is then performed in pure

decontamination mode, non-ablative. Following applica-

tion of the bone substitute, which is hardened with a bio

linker in such a way that the particles can both be well

applied and adhere to each other (easy-graft®), the

wound is then closed with a saliva-proof suture.

The last image shows the check-up after two years,

fortunately with no clinical problems.

22 I implants3_2013

Fig. 13

Fig. 14 Fig. 15 Fig. 16

Fig. 5 Fig. 6 Fig. 7

Fig. 8 Fig. 9 Fig. 10

Fig. 11 Fig. 12

The proponents of ablative treatment argue that they “kill two birds with one stone”by removing any contamination from the implant surface, by smoothing it and possiblyeliminating any bacteria and microorganisms. The proponents of pure decontamination,on the other hand, point out the risks of unwanted effects on the implant surface, whichwould complicate or might even prevent the re-appositioning of the bone, and the excel-lent long-term results of pure decontamination. In this context, they also accept that, intheir non-ablative form of laser treatment for periimplantitis, the implant surfaces mustbe cleaned with suitable manual instruments prior to laser light application.

_Technique for both of the two treatment options

1. Decontamination without ablative effect or morphological changes on the implantsurface in the sense of a pure decontamination

The term “decontamination” was coined by the Freiburg Laser Research GroupBach/Krekeler and Mall in 1994-1995. They introduced the diode laser to dentistry, whichhad been unknown until then. For decontamination, the diode laser light (810 nm) is ap-plied to the implant surface with the largest possible fiber (usually 600 µm) under contactand with constant movement. The authors from Freiburg indicated a maximum power of1 W and an application time of no more than 20 seconds for the laser light treatment. A30-second waiting period is necessary if there is a need for further laser light applicationon the same implant. In clinical applications, a waiting period of 20 seconds has proven tobe completely sufficient. If an implant shows a surface that is exposed from the bone andthat requires an application of laser light in excess of 20 seconds, the prognosis for thisartificial abutment tooth should be categorised as unfavourable and the periimplantitistreatment considered questionable if not experimental.

Bach/Krekeler and Mall expressly caution against exceeding the time-time values,which would inevitably cause a heat build-up in the implant and in the periimplant bone,and thus lead to destruction. The parameters mentioned by these authors (1.0 W/ max. 20seconds of laser light application) have been impressively confirmed by other authors(Sennhenn-Kirchner et al., Moritz et al.) and/or accepted by the device suppliers and man-ufacturers on the flourishing diode laser market.

Romanos et al. described the option of working with Nd:YAG lasers without changingthe surface. However, there are no long-term and clinical results yet. The above-men-tioned diode laser research group in Freiburg, on the other hand, submitted a ten-yearstudy in 2005, proving a reduction in the recurrence rate from previously 30% (withoutlaser) to now 11% (with diode laser). These authors called for an integration of diode laserdecontamination as a standard procedure into tried and proven schemes for periimplanttreatment. Long-term clinical findings for laser treatment of periimplantitis were alsoachieved with a further wavelength: CO2 (gas) lasers have been used for the treatment ofperiimplantitis since the work of Deppe, Horch and colleagues (university of Munich) wascompleted.

Prof. Dr Herbert Deppe and his co-authors were able to prove that the use of the gaslaser, which had been regarded critically for the treatment of periimplantitis until then, isappropriate here and will later—after the periimplant infection subsides—yield afavourable starting point for the regeneration of the supporting tissue. Deppe suggeststhe use of the CO2 laser in continuous-wave (cw) mode with 2.5 W of power for 10 sec-onds. He works with a scanner and, if necessary, also with a dental powder jet and post-operative application of a membrane. A five-year study (Deppe and Horch, 2005) is alsoavailable.

2. Procedure with ablative effect (laser curettage) and possibly an additional decontam-inating effect– Er:YAG laser: Compared to the laser light decontamination procedure described above,

the ablative laser light procedure uses additional wavelengths: This laser with ablativeeffect used for the treatment of periimplantitis is the Er:YAG laser. This wavelength has

Degradable Solutions AGA Company of the Sunstar GroupWagistrasse 23 CH-8952 Schlieren / Zurichwww.easy-graft.com

Ingenious: Simple handling and accelerated osteocon-duction for long-term volume preservation.

easy

-gra

ft®C

RY

STA

L

bio

nic

sti

cky

gra

nule

s AD

I overview

been successfully used in conservative dentistry formany years and is the only wavelength that has beenscientifically backed, is suitable for practice and canbe used to work on and prepare the hard-tooth sub-stance. The names Keller and Hibst are closely con-nected to the Er:YAG wavelength.

We owe significant scientific studies of the Er:YAGlaser to these two researchers from Ulm, Germany. Inthe past years, Keller and Hibst—after having fully re-searched the treatment of the hard tooth substance—turned their attention to further integrations with theEr:YAG laser, including studies regarding the use of thislaser for the treatment of periodontitis and periim-plantitis. For this, even special chisel-shaped laser lightapplicators were made available. In 2001, Schmelzeisenand Bach confirmed the suitability of the Er:YAG laserfor removing tartar and concrements from the implantsurface without damaging the implant surface. How-ever, this requires a non-contact procedure with a 30 milli-joule pulse and a PRP of 10–30 ppt for a max-imum of 30 seconds.

– “Er:YAG—threshold” for PI treatment: The researchgroup around Frank Schwarz (Düsseldorf, Germany)was finally the one who determined the “thresholdvalue” that today is generally considered binding for

ablative treatment of periimplantitis using an Er:YAGlaser (irrespective of device and manufacturer): 13.1 J/cm². Different values can cause thermal or me-chanical damage. If Er:YAG light is applied correctly,however, it leaves a clean, homogenous and intactimplant surface.

– Er,Cr:YSGG laser: First experiences were also gainedwith the latest laser wavelength, the Er,Cr:YSGG laserthat was introduced to dentistry in the treatment ofperiimplantitis. The names Henriot and Ritschel(Hamburg, Germany) especially come to mind in thiscontext. They described multiple uses of theEr,Cr:YSGG laser, more widely known as Biolase, insoft-tissue surgery and in hard tissue. The respectivelong-term experience and multi-centric studies areyet to be confirmed.

_Summary

There are two options for using laser light in thetreatment of periimplantitis:

Pure decontamination, non-ablativeFor this application, diode lasers with a wavelength

of 810 nm and CO2 gas lasers have gained acceptance.Solid scientific data and long-term studies are availablefor this form of diode laser light application which,however, requires conventional cleaning of the implantsurface prior to the laser light application.

Ablative, possibly with additional decontaminating effect

Er:YAG laser and the Er,Cr:YSGG laser are availablefor this application. They can remove concrements andtartar from the implant surface without changing itsoriginal morphology. However, strict and limiting pa-rameters must be observed with respect to perform-ance and time. Regarding clinical and long-term expe-rience, the ablative procedure has not yet reached thelevel of the purely decontaminating diode and CO2

lasers._

24 I implants3_2013

Figs. 17–22_The hopeless case—

the explantation: When looking at

the initial clinical diagnosis (Fig. 17),

only its unfavourable aesthetics

might be noticeable. However, after

creation of a soft-tissue flap, the

“true extent of the horror” (Fig. 18)

becomes visible: the defect extends

all the way to the area of the implant

apex. In particular, there is no bone

left buccally (Fig. 19). Periimplantitis

treatment does not appear very

promising because of the extent of

the osseous lesions. The artificial

abutment tooth has to be removed,

i.e. explanted (Fig. 20), leaving a

profound defect. An augmentation is

carried out to facilitate a new

implantation at a later time, and a

membrane is inserted (Fig. 21),

followed by a saliva-proof suture

(Fig. 22).

Dr Georg Bach

Rathausgasse 3679098 Freiburg/BreisgauGermany

Tel.: 0761 22592Fax: 0761 2020834

doc.bach@t-online.dewww.herrmann-bach.de

_contact implants

Fig. 17 Fig. 18

Fig. 19 Fig. 20

Fig. 21 Fig. 22

International annual congress of the DGZI

FAX REPLY // +49 341 48474-390

Please send me further information on the

43rd International annual congress of the DGZIon October 4–5, 2013, in Berlin, Germany.

Office Stamp

Implants 3/13

"Practice-Oriented Implantology"

October 4–5, 2013//Berlin, Germany//Hotel Palace Berlin

Congress President//Prof. Dr. Dr. Frank Palm/DEScientific Director//Dr. Roland Hille/DE

Silver Sponsor:Gold Sponsor: Bronze Sponsor: DOWNLOADPROGRAMME AND

REGISTRATION FORM

Introduction

In the last few years, the Fast & Fixed therapy con-cept has proven itself an effective alternative treat-ment to conventional tooth implantation methods.This is especially true for patients who suffer from thesevere effects of periodontitis profunda, i.e., the loss ofall teeth, as shown in the case of a 44-year-old patientwhich is described below.

The Fast & Fixed method has emerged as an effi-cient treatment concept, especially when immediateimplants are inserted at an angle. With that method,implantation is possible even in cases of bone loss. It

saves time and expenses, while at the same time offer-ing the patient safety of treatment. The survival rate ofthose implants is between 93.7 per cent and 99.6 percent.1,2

Studies that have examined the long-term survivalof implants set at an angle and loaded immediately areespecially interesting in this context. By looking at atime frame of ten years, it was proven that patientswith reduced bone material can certainly profit fromimmediate implantations, in which the implants areset angularly. A loss rate of 2.9 per cent and, therefore,a success rate of 97.1 per cent were observed.3

The Fast & Fixed method also compares favourablywith delayed loaded implants. A large-scale study con-ducted in 2006 did not find significant differences be-tween the two treatment methods when it comes torates of healing and long-term success.2

However, when it comes to implants, it is importantto always make sure that primary stability can beachieved, supported by well-fitting implants, so thatsafe healing and good load-bearing capacity of artifi-cial teeth can be guaranteed. It is also important thatthe patient brings the proper conditions for an angu-lar, immediate implantation: For complete treatmentof the jaw he/she should be toothless (teeth may be ex-tracted just before implantation begins). The implan-tologist should be experienced with regard to themethod, and pre-operative diagnostics should haveeliminated any possible risk factors.

Digital volume tomography is the best method forpre-operative diagnostics because the images aremore precise and allow a better planning prior to im-plantation. Especially in cases of bone loss, this is of ex-traordinary importance so that a decision can be made

I overview

Figs. 1a-h_Pre-operative

radiological views.

Fast & Fixed as an alternativetreatment in cases ofperiodontitis profunda Author_Dr Regina Schindjalova, Varna, Bulgaria

26 I implants3_2013

Fig. 1a Fig. 1b Fig. 1c

Fig. 1d Fig. 1e Fig. 1f

Fig. 1g Fig. 1h

overview I

I 27implants3_2013

Figs. 2a–e_Images taken with digital volume tomography.

Fig. 2a Fig. 2b

Fig. 2c Fig. 2d

I overview

whether or not an implantation is possible. With theproper planning software, actual preparations can be made virtually. For instance, in our clinic we use Co-Diagnostix.

Case presentation

A 44-year-old female patient suffered from peri-odontitis profunda and came to our clinic with the spe-cific wish of not wanting dentures under any circum-stances—even as a temporary solution. All her teethwere extremely loose. Nutrition for her was limited tosoft foods.

The plaque control report of our clinical examina-tion showed optimal oral hygiene. The last profes-sional cleaning had taken place six months ago. An ad-ditional professional cleaning was not performedsince no improvements could be expected and no con-cretions would enter the mouth during extractions.

Concretions were found subgingivally and approx-imally, which the patient could not remove in spite ofall her best oral hygiene efforts because they were lo-cated too deeply to be reached by a toothbrush or den-tal floss. Looseness of her teeth was between 2 and 3,but mostly at 3. Bone loss had taken place equally inthe upper and lower jaw.

Further diagnostic examinations were conductedvia digital tomography. Digital tomography preciselyillustrates available space, nerve placements and to-pography of the jaw cavity. With this examinationmethod it could be determined that the patient’s teethcould not be saved.

Use of the Co-Diagnostix software facilitated de-tailed planning for the positioning of the implants andthe necessary sinus lift of the right upper jaw. Highestprecision planning was made possible by the three- dimensional images and precise data gained by the useof digital volume tomography in pre-operative exam-inations.

Diagnostic findings were confirmed during sur-gery: Natural fastening of the teeth in the upper andlower jaw was no longer possible. The teeth were ex-tracted.

After the extraction of teeth in the upper jaw, fourimplants were set at an angle of 17 degrees—regio 14,12, 22, 24. In regio 26, one implant was inserted at a 35degree angle. Afterwards we began a sinus lift proce-dure in the right upper jaw. Through a window in thefacial bone wall we detached and lifted the Schneidermembrane from the sinus floor, the mesial and distalwalls of the jaw cavity. The resulting space gave us theopportunity of anchoring endosseous implants by fill-

28 I implants3_2013

Figs. 3a & b_Co-Diagnostix

Planning Software: Showing where

to place implants.

Figs. 4a–d_Loss of tooth attachment

shown during surgery.

Fig. 2e

Fig. 3a

Fig. 3b

Fig. 4a

Fig. 4b

Fig. 4c

Fig. 4d

overview I

I 29implants3_2013

ing areas of the jaw with the bone replacement mate-rial Allograft made by Zimmer Dental. The implant inregio 16 was inserted at an angle of 35 degrees and fas-tened bicortically. The biological material Allograft wasstabilised with the addition of a Bio-Gide membranemade by Geistlich.

After extraction of the teeth in the lower jaw andsmoothing of the jaw tissue, implants in regio 35 and45 were set at a 35 degree angle, and implants in regio32 and 42 were set at a 0 degree angle. All implants—in the upper and lower jaw—were provided with abut-ments and prosthetic caps.

Prior to surgery, plaster models had been made. Ad-ditionally, the dental laboratory prepared a mock-up ofthe bite pattern, affixing synthetic teeth for the upperand lower jaws. This way, instead of taking a rough tra-ditional bite pattern with silicone and an individualtray after the operation, a more effective and innova-tive method was used. Right after surgery, the pros-thetic caps were powdered, and the prepared mock-ups with synthetic teeth were affixed.

Advantages of this method: The base of the bitemock-up is used as an individual tray to show the den-tal technician the position of the gums. This is very im-portant for making the base of the bridge. Using thesynthetic teeth, the dental technician can determineand document the relation of the jaws, bite height,chewing-, central- and laugh lines, as well as shapeand length of teeth for manufacturing the permanentdental prostheses.

This method allows the lab technician to beginmaking a long-term temporary solution. At the sametime, this also results in enormous savings of time forthe doctor and the dental technician. For the patient,there is one important advantage: A feeling of addi-tional confidence. As in our case, the patient was ableto see what her future prostheses would look like, mak-ing her feel more secure.

Conclusion

The Fast & Fixed therapy concept represents an in-teresting new development which has established it-self in the last few years as a solution for toothless jaws.

This method makes a firmly seated and biome-chanically supportive solution possible within 24hours of implantation surgery. This was of special im-portance to our patient because she did not want re-movable dentures and preferred a fixed solution. Fin-ishing her synthetic teeth the following day was madepossible by the fact that no infection of the tissue waspresent on the day of surgery. The jaw bone was intactand was still of good quality, so that primary stability

could be warranted. What made the Fast & Fixedmethod interesting in this case was the fact that therewas only limited bone density available, so that onlyangled insertion of the implants could lead to the de-sired success. Additional support was necessary in theright upper jaw which was obtained with the use ofbone replacement material.

Bite impressions made prior to surgery saved thedoctor additional time. The bite mock-ups are madeexactly according to each patient’s individual needs,thereby making the dental technician’s work fast andefficient. The permanent prostheses are much easier tomake since relation of the jaws, bite height, chewing-,central- and laugh lines, as well as shape and length ofteeth had already been determined when making themock-ups. Therefore, preoperative bite impressionsand mock-ups represent an ideal addition to the Fastand Fixed method._

Fig. 5_Stabilisation with BioGide

Membrane.

Figs. 6a & b_Finished

implantation in the upper and lower

jaw, with soft tissue sutured.

Fig. 7_Post-op radiographs of the

maxilla and mandible.

Fig. 8_Post-op fixed bite mock-up of

the maxilla and mandible, checking

occlusion for balance.

Fig. 9_Fixed long-term temporary

solution with synthetic teeth made by

Ivoclar, upper and lower jaw,

24 hours after surgery.

Dr Regina SchindjalovaDentaprime-ZahnklinikSt. Constantine Resort St. 27, No. 19006 Varna, Bulgaria

content@dentaprime.com

_contact implants

Fig. 5

Fig. 6a

Fig. 6b

Fig. 7

Fig. 8

Fig. 9

I industry report

Fig. 1_Periapical radiograph of a

dental implant with bone loss

of > 3 mm.

Fig. 2_Implant site prior to

measurement (implant

suprastructure still in place).

Pus discharge is evident.

_Introduction

With oral implantology experience its Renais-sance, the growing incidence of peri-implantitisworldwide today is point of interest for both scientistsand clinicians. Peri-implantitis is a disease of inflam-matory nature which leads to the loss of the implantwhen left untreated.11,24 The aetiological factors ofperi-implantitis are very similar to periodontitis.2,24

Different treatment modalities for the inflammatorysoft tissue and bone lesions in peri-implants havebeen proposed—antibiotics, antiseptics, mechanicaldebridement, and surgical procedures have beensuggested, depending on the grade of the clinical andradiographic manifestations.6,7,10,16,17

Treatment modalities such as scaling and rootplaning, used to treat roots with periodontitis, cannotbe used in the same way on the threaded and reten-tive implant surfaces. The rough implant surface pro-vides bacteria with shelter, unapproachable to con-ventional mechanical removal.23 Conventional treat-ment procedures like closed peri-implant pocket de-bridement have shown limited success7,10 whereasthe treatment of peri-implantitis using open-flapprocedures has shown more promising results.17 Al-though the improved access to the implant surface

with open procedures can be seen as a fact, cliniciansmeet the same problems as encountered with openperiodontal therapy. The decontamination of the re-tentive implant surface is much more complicatedthan the decontamination of a plane root surface.23

The instruments used in periodontal treatment aretoo large to clean an implant surface from bacteriaand any metal to metal contact during mechanicaldebridement has the potential to damage the implantsurface.12,13 The common antiseptic therapy seems tobe effective against bacterial biofilm in in vitro condi-tions.5 In addition, the local antibiotics used as an ad-junct therapy to mechanical debridement has beenadvocated and shown to reduce bleeding on probingand probing pocket depth in patients with peri-im-plantitis,16 but there are no data supporting the effectof antibiotics on the decontamination of implant sur-faces and more specifically the endotoxin elimina-tion.10,16,18

Currently, there are no clinical studies or case se-ries documenting successful regenerative proce-dures in periimplant bony lesions after conventionaltreatment. Some case series demonstrated limitedbone fill after GBR procedures.6 Another treatmentmodality that may offer an advantage over tradi-tional mechanical treatment is the use of lasers.25,26

The use of the LiteTouchEr:YAG laser in peri-implantitis treatmentAuthors_Prof. Tzi Kang Peng, Taiwan & Prof. Georgi Tomov, Bulgaria

30 I implants3_2013

Fig. 1 Fig. 2

Studies have demonstrated that the treatment with an Er:YAG laser has a bactericidaleffect.8 Er:YAG laser treatment can debride the implant surface effectively and safelywithout damaging.31,35 Much better clinical results have been reported for Er:YAG lasertreatment compared with non-surgical mechanical debridement.15,27,31,35

_Aim

The aim of the (present study) intercontinental research led by Syneron was to as-sess the clinical outcomes of an open-flap procedure performed with conventionalmechanical therapy (CMT) or laser-assisted surgical treatment (LAS) with the novelLiteTouch Er:YAG laser (Syneron Dental Lasers) in patients with implants and a diag-nosis of peri-implantitis.

_Materials and methods

The design was a single-masked, randomized six-month clinical intervention trialwith two groups of patients diagnosed with peri-implantitis. The ethics committeesof Cheng Hsin General Hospital, Taipei, Taiwan, and the Faculty of Dental Medicine,Plovdiv Medical University, Bulgaria, approved the study. Written consent was ob-tained from all enlisted patients. Patients were enrolled if they presented with at leastone dental implant with bone loss of > 3mm around the implant identified on intra-oral radiographs (Fig. 1), and with a PPD of > 5mm with bleeding and/or pus discharge(Fig. 2) on probing. The study was conducted between September 2010 and August2011 at the Cheng Hsin General Hospital and Plovdiv Medical University‘s Faculty ofDental Medicine. The following general criteria were used to exclude subjects from thestudy:

_subjects having taken medications likely to cause gingival hyperplasia within onemonth prior to baseline examination;

_subjects receiving regular periodontal maintenance treatment or having undergoneany sub-gingival cleaning less than twelve months prior to baseline examination;

_subjects received peri-implantitis surgery of any type prior to baseline examination;_subjects with clinically significant chronic illness (diabetes mellitus, compromised

heart condition, rheumatism, joint replacement) requiring antibiotic prophylaxis;_subjects having undergone systemic cancer therapy and/or radiation therapy at any

time; _subjects taking or having taken bisphosphonates;_subjects having taken antimicrobials, steroids or non-steroidal anti-inflammatory

drugs within one month prior to baseline examination;_pregnant or lactating women;_subjects engaged in excessive tobacco or alcohol intake or drug abuse.

Sixty-eight patients with a total number of 128 implants were included consecu-tively over a period of one year.

_Clinical measurements

The measurement scale used in this study was constructed in order to obtain quan-titative measurement data:

_PPD at four sites per implant (mm);_presence/absence of BOP at the implant (four sites/implant), graded as follows: _no bleeding, (1) point of bleeding, (2) line of blood and (3) drop of blood;_bone loss (in mm on segment radiographs).

The PPD and BoP measurements were taken using a color-coded plastic periodon-tal probe (Kerr). All clinical measurements were obtained after removing the supra -structures. Intraoral standardized radiographs of sites of interest were obtained atbaseline and at six months. Holders were used for standardization purposes. Radi-

AD

I industry report

Fig. 3_Removal of plaque biofilm

and granulation tissue using

the LiteTouch Er:YAG laser with its

1.3 x 1.4 mm sapphire tip.

Fig. 4_The periapical radiograph

revealed peri-implantitis with bone

loss of > 5 mm (a). The abutment

was removed and surgical treatment

using the LiteTouch laser was

performed. Bone grafting with a

biomembrane followed the laser

treatment (b). The periapical

radiograph revealed bone

regeneration after six months (c).

ographs were analyzed by two of the study investi-gators after previous calibration.

_Hygiene phase (non-surgical phase)

Before treatment, the suprastructures were re-moved and the baseline measurements were taken.The goal of the initial phase was the reduction of asmuch tissue inflammation as possible. The patientmoved on to the support phase once signs of im-provement and reduction of inflammation had beenobserved. In case of persisting bleeding and pus dis-charge, a surgical procedure was planned. For thissurgical phase, fifty-one of all sixty-eight patientswith a total number of 100 implants were random-ized with a lottery assignment.

_Surgical phase

If there was no significant improvement after thenon-surgical phase (in the second week), a surgicalintervention was planned (surgical phase). Surgicalintervention was indicated in cases in which the con-ditions around the implant had failed to improve af-ter the initial phase, but plaque control was ade-quate, and there was a need to retain the contami-nated implant. The supraconstruction of the im-plants was removed in order to gain access and topreserve as much soft tissue as possible to cover thearea after surgery. Patients were randomly assignedto one of the two treatment regimens.

_Conventional mechanical therapy (Group I)

Infiltration local anesthesia was used during treat-ment. The first incision was an internal gingivectomy,directed towards the bony ridge, which separates theperi-implant tissue from the mucosal flap. The flap wasthen raised to the level of the bony ridge, gaining ac-cess to the entire implant surface. The granulation tis-sue around the implant was carefully removed withsharp curettes and the implant surface was inspectedfor calculus deposits. The implant surface was thencarefully cleaned using an ultrasonic device at low set-tings (PI tip, Piezon® ultrasonic unit, EMS). The PI tip wasplaced and used for approximately 60 seconds aroundthe implant, ensuring coverage of the full circumfer-ence of the implant. Chemical debridement with atetracycline solution was performed after ultrasoundcleaning. In addition, bone augmentation was per-formed when required (21 patients; Bio-Oss, GeistlichPharma; Dembone). During the study, all subjects re-ceived individualized oral hygiene instructions.

_Laser-assisted surgical treatment (Group II)

Under local anesthesia, gingivectomy and the sep-aration of the peri-implant tissue from the mucosawere performed. The flap was raised to the level of thebony ridge, gaining access to the entire implant sur-face. The granulation tissue around the implant wasremoved with the LiteTouch Er:YAG laser (Fig. 3). Tip ofchoice was 1,300 micron, noncontact mode (distancebetween end of the tip and target tissue = 1.5mm). Ifcalculus deposits were found, the implant surface wasthen carefully cleaned with laser. Decontaminationwith a non-contact, defocused Er:YAG laser was per-formed by systematically moving the laser tip alongthe surface. The area was rinsed with a sterile saline so-lution. Bone augmentation was performed when nec-essary (19 patients; Bio-Oss and Dembone with orwithout an absorbable biomembrane). The tips andsettings used during treatment are given in Table 1.

_Postoperative Instructions

The patients were prescribed clindamycin 150mgx 50 tabs to avoid infection. They were also givenibuprofen 800mg x 15 tabs for pain. Patients were in-structed to rinse with chlorhexidine 0.2%, starting thenext day, for two weeks three times a day, and were ad-vised to maintain good oral hygiene.

_Support phase

The goal of the support phase was to maintainlong-term treatment results. Regular examination ofthe soft tissue, plaque control, radiographs and minor

32 I implants3_2013

Fig. 4a Fig. 4b Fig. 4c

Fig. 3

industry report I

local treatments were performed, based upon the re-call interval. If there was a recurrence of minor in-flammation around an implant, the antibacterial peri-odontal treatment was repeated.

_Statistical methods

A statistical software package (SPSS) was used forthe statistical analysis. Statistical significance was de-fined by a p-value of < 0.05. A change in PPD was de-fined as the primary outcome measure. The secondaryoutcome measure was a change in bone height. Thedata was also analyzed using independent t-tests forcontinuous variables with a normal distribution (equalvariance not assumed; PPD, changes in bone height)and using the Mann-Whitney U-test for non- para-metric data (BoP, suppuration) and a chi-squared test.

_Results

At baseline, a point of bleeding was found at 4.2%of all implant surfaces, a line of blood at 47.6% and adrop of blood at 56.9% of the sites. Statistical analy-sis failed to demonstrate baseline differences in BoPbetween different implant surfaces (p = 0.85). At sixmonths, no evidence of bleeding was found in 81% ofthe implants in the LAS group and in 59% of the im-plants in the CMT group. The decrease in BoP was sig-nificant in both study groups (p < 0.001). Statisticalanalysis demonstrated differences in changes in BoPbetween the study groups (p < 0.001). The mean PPDreduction in the CMT and LAS groups was 0.8mm (SD± 0.5) and 1.7mm (SD ± 1.3), respectively, with meanchanges in bone height (loss) of -0.5mm (SD ± 0.6) and-0.1mm (SD ± 0.2), respectively (S) (Table 2). The pro-portional changes in bone height between baselineand six months, assessed from radiographs and de-fined at the implant level, are presented in Table 3. Apositive treatment outcome, PPD reduction of >4mmand gain or no loss of bone were found in 59% of theCMT and 81% of the LAS groups, respectively (S). Allsubjects completed the study, and no implants werelost.

_Discussion

In modern oral implantology, lasers have a consid-erable spectrum of clinical application. The literaturedata revealed that different laser wavelengths areused on peri-implant tissues: treatment of peri-im-plant mucositis, treatment of infrabony defects, re-moval of peri-implant hyperplastic overgrowth tissue,preparation of bone defects for GBR.3,4,22,28,29 Unlikemechanical decontamination methods, which cannotfully adapt to the irregularities on the surface of an im-plant, lasers can irradiate the whole surface, reachingareas that are too small to receive mechanical instru-mentation. Recent in vivo studies have analyzed theoutcome of peri-implantitis treatment using Er:YAGlasers1,21,27,31 and CO2 laser.3,28,29 Many of these studiesshowed promising short-term results (less than sixmonths), but report no long-term follow up. In thepresent study, differences in the reduction of BoP sixmonths after treatment were found between LAS andCMT groups. While oral hygiene had improved greatlyand no plaque was found at the treated implants, alarge proportion of the im-plants in the CMT group con-tinued to exhibit BoP at the six-month post-treatment assess-ments. In the present study,BoP was graded to distinguishthe severity of inflammationand approximately 14% of theimplants in the LAS and 41% inthe CMT groups presented withbleeding, which was consistentwith other data.30 The reason-able explanation for these re-sults is the quality of deconta-mination of the implant surfaceprovided by the treatment ap-proaches evaluated. Contami-nants such as bacteria and theirby-products, calculus, andgranulations should be re-moved without modifying the

Table 1_Tips and settings used

during laser treatment.

Table 2_Proportional changes in PPD

between baseline and six months,

defined at the implant level based on

the mean value of changes at four

sites/implant.

Procedure Hard tissue/soft tissue

Contact/non-contact

Laserenergy(mJ)

Pulsefrequency(Hz)

Tip diameterx length (mm)

Waterspraylevel

Releasing incision of the flap

Soft tissue Contact 200 35 0.4 x 17 5–6

Granulation tissue ablation

Soft tissue Non-contact 400 17 1.3 x 14 6

Bone remodelling

Hard tissue Non-contact 300 25 1.3 x 19 8

Implantdecontami nation

Hard tissue Non-contact 150 45 1.3 x 17 6

Decortication for GBR technique

Hard tissue Non-contact 300 25 1.3 x 19 8

I 33implants3_2013

PPD changes CMT (%) LAS (%)

Decrease (mm)

> 4 1.2 37.4

3.1–4.0 7.9 35.0

2.1–3.0 14.0 7.9

1.1–2.0 35.4 12.1

0.1–1.0 1.7 4.2

Unchanged (mm)

0.0 29.2 1.4

Increase (mm)

0.1–1.0 7.9 0.0

1.1–2.0 1.2 0.0

2.1–3.0 1.0 0.0

3.1–4.0 0.0 0.0

I industry report

Table 3_Proportional changes in

bone height between baseline and

six months, defined at the implant

level based on the mean value of

changes in mesial and distal bone

height.

implant surface and with re-spect to surrounding soft tis-sues. Numerous methods forthe decontamination of im-plant surfaces have been sug-gested, either alone or in var-ious combinations, as part ofthe surgical treatment ofperi-implantitis. The litera-ture data revealed that meth-ods as cleaning with metalcurettes and impropriate ul-trasonic tips or irradiationwith Nd:YAG laser can dam-age the implant surface andcould compromise the resid-ual implant stability.9,20 Air-

powder abrasive units are often recommended for thesurgical treatment of peri-implantitis. A recent studyaimed at evaluating the influence of different air-abra-sive powders on cell viability at biologically contami-nated titanium dental implant surfaces revealed thatno surface treatments led to mitochondrial cell activityvalues comparable to the sterile control group.33 Citricacid application and sandblasting have also been rec-ommended.18 However, implant decontamination us-ing sandblasting units have been associated with riskssuch as soft tissues damage and emphysema.34

Er:YAG lasers are seen as the most promising newtechnical modalities of treating failing dental implants,since their performance of tissue ablation is accompa-nied by a high bactericidal and detoxification effect.26,32

When considering the use of Er:YAG lasers in the treat-ment of peri-implantitis, there are some crucial pointswith clinical importance. Power settings are variable,and the clinician must also choose a setting that will ef-fectively disinfect the implant while not damaging thesurface. A narrow range of power settings (100mJ/ perpulse) was described in the literature.21,27,30,31,32 Onlyone study used a higher power setting of 120mJ perpulse.1 The frequency was set at 10Hz for each of thementioned studies, however, neither the distance fromwhich the laser was applied, nor the time of applicationto each implant was stated. In the present study, thesettings used for implant surface decontamination are150mJ/45Hz, at non-contact mode and constantmovement. Another important point is the interactionbetween laser light and metal surfaces. This interactionis mainly determined by the degree of absorption andreflection. With a reflectance capacity of about 71%,19

titanium implant surfaces do not absorb irradiation.Consequently, there is no increase in temperaturewhich could damage the implant surface. Several in-vestigations have reported on the promising ability ofthe Er:YAG lasers in implant surface debridement with-out producing thermal side-effects on implant surfaceand adjacent tissues.14,35 Treatment of peri-implantitis

using Er:YAG laser therapy has been investigated beforeand appears to result in a more effective reduction inbleeding around implants than surgical debridementwith hand instruments and sub-gingival application ofchlorhexidine.1,27,30,31 Irradiation with this specificwavelength seems to have a bactericidal effect on pe-riodontopathic bacteria and remove bacterial biofilm.However, in order to treat the implants with the laserdevice in the present study, the suprastructures wereremoved, allowing the access to the implant surfaces toimprove. Thus, the results of the present study are lim-ited to implants where the suprastructures can be re-moved during treatment.

_Conclusion

Among lasers used in the field of dentistry, theEr:YAG laser seems to possess the characteristics mostsuitable for peri-implantitis treatment because of itsability to ablate both soft and hard tissue, as well as bac-terial biofilm and calculus, without causing thermaldamage to the adjacent tissues and implant surfaces.The decontamination effects of Er:YAG laser are alsobeneficial regarding peri-implantitis pathogenesis. Inthe present study, the use of the LiteTouch Er:YAG laserhas been proposed for the treatment of peri-implanti-tis and the results indicate that the laser-assisted sur-gical therapy may lead to significant clinical improve-ments such as BoP and PPD reduction as well as a gainin clinical attachment. From a clinical point of view,these results advocate the Er:YAG laser as an alterna-tive treatment modality to conventional mechanicaltherapy._

With the collaboration of Dr Ke, Dr Yu, Dr Lu , Taiwan;Dr Kenny Chiu, Hong Kong; Drs Kanbayashi, Takahashi,Ikeda & Kamiya, Japan.

For more information about the LiteTouch™—thefiber-free Er:YAG laser, please visit: www.synerondental.com

Editorial note: A list of references is available from the publisher.

34 I implants3_2013

Prof. Tzi Kang Peng DDS, MS, PhD, FICDProfessor and Chair of the Department of DentistryCheng Hsin General HospitalTaipei, Taiwan

Assoc Prof. Georgi TomovDDS, MS, PhDAssociate Professor and Chair of the Department ofOral Pathology, Faculty of Dental MedicineMedical University of Plovdiv, Bulgaria

_contact laser

Radiographic changes

in bone height

LAS (%) CMT (%)

Decrease (loss in mm)

1.1–2.0 12.2 35.4

0.1–1.0 37.1 39.5

Unchanged (mm)

0.0 29.3 4.2

Increase (gain in mm)

0.1–1.0 17.4 12.5

1.1–2.0 4.9 2.1

2.1–3.0 7.1 6.3

Towards Innovative Proceduresand Technique in Dental Implantology

United Arab Emirates—Dubai

Atlantis The Palm

From 31 October to 2 November 2013

StampI hereby accept the terms and conditions of the 8th DGZI Congress.

Date

Signature

Fax this form to+97126289833

E-mail this form toreg@dgzi-agic.ae

I hereby register the following person for the 8th DGZI Congress from October 31 to November 2, 2013, in Dubai, United Arab Emirates (Please fill out this form):

Note: For online registration please visit www.dgzi-agic.ae, for further inquiries please contact 0097126355527.

First name: Title: ❑ Dr ❑ Prof. ❑ Mr. ❑ Mrs.Last name:

Office phone: E-Mail:Fax:

Institution: Adress/P.O. Box:

Registrationfees*

Early BirdBefore September30, 2013

September 30,2013, to October 29,2013

ON-SITE

❑ Dentists US $ 500 US $ 550 US $ 600

❑ Students &Interns

US $ 400 US $ 450 US $ 500

❑ DGZI members

US $ 300 US $ 350 US $ 400

Payment Details: Money transfer (or bank deposit)Abu Dhabi Islamic Bank: 1-56686-9; IBAN: AE-31-050-0000000015668699Beneficiary: success Steps Seminars & Conference LLC

*Fees include: Congress Lectures, Access to exhibition hall and 3 days lunch at Atlantis The Palm Hotel, Dubai.

Silver Sponsor:

Dr Gernot Wimmer Dr Khaled Abdel-Ghaffar Dr Mario H. Rodriguez Dr Mazen Tamimi Dr Michael Payer Dr Ramy Fahmy

Dr Nicole M. Geha Dr Mohamed Moataz Dr Amr Abdel Azim Prof. Nabil Barakat Dr Rainer Valentin Dr Rolf Vollmer Dr Vedat Bankaoglu

Dr Martin Lorenzoni Dr. Nadim Aboujaoude Dr Martina Vollmer Dr Roland Hille Dr Suheil M. Boutros Dr Werner Zechner

I industry report

Fig. 1_Current clinical cases as

examples for inadequate 3-D

diagnostics and manual placement:

a) Implants in the third quadrant and

the region of tooth 47 are impacted

completely; those in the regions of

teeth 37 and 47 have penetrated the

mandibular nerve canal. These

image sections show orthogonal

alveolar ridge sections through the

centres of the implants.

b) Implants in the regions of teeth 35

and 45 have been fully inserted into

the mental foramen. The mandibular

nerve has a lesion in region 46.

_Introduction

Every day we hear about new curative proceduresand their successful application in therapy. The newmedia broadcast information about medical per-formances worldwide instantly to wide sections ofthe population. This environment places greater de-mands on us, the operators, to meet our patients’ in-creasing expectations for high quality.

It is increasingly less feasible for a “universal ge-nius” to perform complex dental medical therapyalone—consistent interdisciplinary cooperation hasbecome essential. Diagnostics and therapy strategiesare necessary and increasingly extensive prerequi-sites which must be carried out prior to the actualmanual dental procedures. Advance planning of ther-apeutic measures as well as the continuous use oftreatment procedures and working instructions withregard to a quality management system form the ba-sis for successful complex oral rehabilitations.

Three-dimensional imaging procedures, uponwhich dental diagnostics and implant navigation arebased, are an important component. Navigation pro-

cedures are considered established methods in im-plantology. Although they have been in use for almost20 years, colleagues continue to disagree about themvehemently even today. Comments range from “noneed” and “won’t work anyway” to “I cannot do with-out them”.

For 3-D diagnostics and implant planning, meet-ing the requirements by processing and evaluating 3-D radiographic data is essential. In dentistry, cone-beam computed tomography is increasingly used asthe source for 3-D radiological image data.

In its guidelines 2005: Cone-beam computed to-mography (CBCT)—S1—Recommendation and 2012:Indications for implantological 3-D radiographic di-agnostics and navigation-guided implantology—S2kguideline, DGZMK (German Society of Dental, Oraland Craniomandibular Sciences) debates this topicfundamentally. Not only are the technical principles,prerequisites and indications summarised and com-mented on, but they also discuss the currently feasi-ble results when using navigation-guided implanta-tion. The few in vivo data available show that devia-tions of 2.4 mm in 2005 at the implant tip appear to

Safe interdisciplinarynavigationAuthors_Dr Frank Schaefer, Dr Dagmar Schaefer, Dr Mike C. Zäuner & Master Dental Technician Jürgen Sieger

36 I implants3_2013

Fig. 1a Fig. 1b

industry report I

have deteriorated to 4.7 mm in the 2012 S2K guide-line. This also applies to deviations in the implant axeswhich have deteriorated from 4 degrees (2005) to 9.8 degrees (2012). In comparison, the deviations inthe position of the implant tips decreased in the in vitro studies cited (2005: 6 mm; 2012: 2.5 mm), asdid the deviations in the implant axes (2005: 11 de-grees; 2012: 7.9 degrees).

These data show that all current types of 3-D nav-igation surgery are considerably better than manualimplant placement without 3-D diagnostics but donot represent a reliable basis for an exactly plannedprocedure as demanded by the increased expecta-tions placed on modern forms of medical therapy(Figs. 1a & b).

There is a multitude of causes of these deviations:Firstly, as described in detail in these publications,only a minimal amount of in vivo and in vitro data isavailable. Secondly, there are numerous options forerrors due to working stages not always being carriedout consistently and co-ordinately. It is even more im-portant that all those involved follow standardisedprocedures: The prosthodontist, surgeon, dental

I 37implants3_2013

Dentist

Dental technician

Radiologist/Dentist

Dentist

Dentist

Dental technician

Dental technician

Dentist

Dental technician

anatomic impression

planning template

image processing/diagnostics

set implant positions

transposition planning data

drilling template

implant insertion

CT/radiograph model-scan (stl)

Fig. 2_The procedures for navigation-guided implant

placement using a template.

Please contact Claudia Jahn

c.jahn@oemus-media.de

AD

[PIC

TUR

E: ©

SU

KIY

AKI]

I industry report

technician, radiologist, where relevant and, of course,the patient. The CTV system provides conveniently forthis type of cooperation in planning and carrying outtreatment, including the documentation of the re-sponsibilities, concise treatment counselling with thepatient and, last but not least, success evaluation.

_Error analysis

Errors during 3-D-based navigation-guided im-plant placement may have a multitude of causes. As

in all error analyses, one must differentiate betweencoincidental and systematic errors. It can be seenfrom the principal procedure for template-guidednavigated implantation (Fig. 2) and from the numberof its sub-stages and different persons involved thaterrors can—and do—occur in this working process.When analysing errors, it must be kept in mind thatnavigated implant surgery involves planning and op-erating within the range of millimetres or even below.In addition, errors during the sub-stages may havegrave consequences for the ensuing stages. It istherefore advisable to analyse precisely and developprocedures for avoiding these errors.

Errors with the longest-lasting consequenceshave turned out to occur during impression-taking ofthe jaw planned for implant placement, when takingthe 3-D radiograph as well as when retransferring theplanned virtual implant position to the model or sur-gical navigation template.

The quality of the 3-D radiographic dataset is de-pendent on the image-taking procedure selected, beit CT, CBCT or truncated CBCT. Also, regardless of themachine used, all radiographs are subject to the lawsof optics and exhibit distortion, interference and dif-fraction phenomena. Apart from that, the image maybe blurred if the patient moves while it is taken. Theactual pixel size in the image sensor of the unit alsohas an effect, as does the algorithm used for recon-structing the image in the X-ray machine. Last but notleast, correct setting of the parameters and position-ing the patient properly in the machine are also deci-sive for the quality. Assuming that the impression ofthe jaw was taken correctly and the planning tem-plate was fabricated properly, incorrect positioning ofthe template in the patient’s mouth during image-taking also leads to far-reaching planning and trans-fer errors. Errors during and due to 3-D image-takingare always coincidental and therefore irreparable –which rules out compensating for them with diag-nostics and planning.

Once the radiograph has been taken with an X-raymachine, which is subject to quality managementbased on the (German) radiation act, during the fol-lowing image-processing, often too little attention ispaid to retaining the information included in the pri-mary image data. These processes are often not ade-quately certified and mostly do not comply with theradiation act. In addition, a loss of detail/structural in-formation is thoughtlessly taken into account.

The difference between the patient’s positionwhen the radiograph was taken and the actual modelof the jaw is especially crucial for retransferring thevirtual implant positions to the model of the jaw. Re-transferring with the various compensation mecha-

38 I implants3_2013

Model mesh with z-level-cut. Rendered model with virtual (inside X-ray-date-file) plannedimplants.

Stl-data (mesh) in connection with picture of alveolarridge cut and plannes implants with abutments.

Stl-data (rendered) in connection with picture of alveolarridge cut, z-level-picture, planned implants including abut-ments an rd reconstructed channel of N. mandibularis.

Figs. 3a–b & 4a–b_A selection of

the options for merging the optical

scan of the model with

3-D radiological planning data.

Figs. 5a–d_Merging the optical scan

of the model (red) with an aesthetic

set-up (green) using 3-D radiological

planning data.

Fig. 3a Fig. 3b

Fig. 4a Fig. 4b

Fig. 5a Fig. 5b

Fig. 5c Fig. 5d

industry report I

nisms (e.g. CeHa implant [X1;X2]™, coDiagnostiX[gonyX ]™ etc.) may also be a considerable source oferror for the transfer process. Intraoperative errorsmay also occur: an incorrectly placed surgical naviga-tion template will certainly lead—in case of specificnavigated implant placement—to malpositioning ofthe implants, thus possibly resulting in inadvertent,unplanned injury to the adjacent structures. Malpo-sitioning of implants may also occur if the “half-guide” (only the pilot drilling is navigated) procedureis employed. As far as this is concerned, “full-guide”procedures appear safer but may be limited in theirapplicability. This excerpt of errors is a possible expla-nation for the relatively high inaccuracy of proce-dures used to date as documented in the above-men-tioned DGZMK guidelines.

_Further development

The CTV system follows different paths, based oncomprehensive theoretical and clinical evaluation, inorder to attain interdisciplinary cooperation and reli-able planning with only minimal toleration of errors.Use of the CTV system allows coincidental and there-fore unforeseeable errors to be identified and, wher-ever feasible, systematic errors to be compensatedfor.

The quasi-analogue image processor developedfor the CTV system is relatively tolerant where qualityand alignment of the primary radiographic datasetare concerned. It permits any image sections in 3-Dcubes to be created with no limitations to angles, dis-tances and locations. These images reproduce im-pressive details and structures as do plain images,calculated panoramic tomographs and calculatedteleradiographs. The operator is provided with theusual “analogue” image quality.

But the same applies here, too: The quality of theprimary dataset and the density of the information itcontains is decisive for the 3-D diagnostic and plan-ning options. In addition, the CTV system merges datafrom an optical scan of the planning template, modeland/or wax-up/aesthetic set-up and/or drilling tem-plate with the 3-D radiographic planning dataset(Figs. 3-5). This fully automatic matching processdiscovers and compensates for coincidental errors inimages (Figs. 6 & 7).

Regarding bone availability and prosthesis posi-tioning, the planning positions can thus be deter-mined more comprehensibly and exactly. When us-ing this method, the emergence profile can alreadybe estimated accurately during prosthetic (pre)plan-ning. The surgical navigation template can also befabricated based on STL datasets. When this templateis then matched with image planning, the (virtual)

planning positions can be checked for correct align-ment with the sleeve positions in the template priorto placement. Starting with optical and radiologicaldigital data, the entire planning and fabricationprocess is digitized from one single base without fur-ther interim stages, which eliminates inaccuracies

Figs. 6a–b & 7a–d_An example of

error recognition – checking and

determining the gingival contours on

the planning radiographs using the

scan of the model.

Figs. 8a–d_The gingiva or tooth

structures are recognised

automatically when the radiological

planning data are matched to the

model of the jaw or wax-up.

I 39implants3_2013

Fig. 6a Fig. 6b

Fig. 7a

Fig. 8a Fig. 8b

Fig. 8c Fig. 8d

Fig. 7b Fig. 7c Fig. 7d

Gingiva line after matching withmodel.

Tooth line after matching withwax up.

Determined height of gin-giva in X-ray planning (pink).

Out of implant planningresulting position of the drill.

Yellow line: real line ofgingiva on basis of scannedmodel—sleeve below gin-giva!

Source of error: arte-facts in CT-scan due toprecious metal containingrestoration (z-level-cut).

Yellow line: automatically reconstructed line of gingiva on basis of model scan.

I industry report

encountered with conventional methods involvingtransferring virtual positions to the actual model.

The CTV system provides for reliable postoperativeexamination once the implants have been placed.This means that unerringly precise congruency isachieved between planning dataset and postopera-tive 3-D radiological dataset for comparing the ac-tual implant positions with the planned positions. Itis irrelevant whether the planning and controldatasets stem from the same machine (Figs. 8 & 9).This enables the user to check for success at an earlystage as well as analyse the cause of any errors whichmay occur. This should lead to errors being avoidedlong-term (learning effect).

Of course, the CTV system can generate compre-hensive and custom expandable, forensically de-pendable case documentations at the push of a but-ton. They can be stored as PDF files, printed and/orforwarded. The use of RFID chips integrated into themodel of the jaw ensures that the CTV system storesa complete documentation of the responsibilities aspart of the total process (Fig. 10).

_Conclusion

The combination of radiological and optical dataand simultaneous integration of CAD/CAMprocesses enables errors to be identified at an earlystage and, together with suitable compensationmeasures, leads to a much better match betweenplanning requirements and outcome. The numerousoptions for combining images create optimum con-ditions for interdisciplinary understanding as well asexplaining the therapy strategy to the patient in aplausible and understandable manner. The indica-tions of this new technique range far beyond mereimplant planning and can be used in-house withouthaving to purchase costly special equipment andtransfer units._

40 I implants3_2013

DiagnosisPreplanning

Realisation ofplanning positions

DefinitePlanning

Planning Doctor Dental-Lab.

Doctor

Radiologist

Dental LabDigital release of

planning data by RFIDSaving of transfer-red data by RFID—digital sealing of the

case (data)

Figs. 9a–h_Clinical success—The

condition after transgingival

navigated implant placement (2012).

Fig. 10_Matching to check for

success—left: The 3-D radiological

planning (blue implant) was made

congruent with the model (red),

wax-up (green) and 3-D image

post-operatively (eclipsed by the

virtual implant); right: Matching

planning, postoperative radiograph

with the gingival contours from the

model of the jaw (2012).

Fig. 11_Documentation of the

responsibilities for the total

process—below: RFID Reader,

model base with RFID chip,

customised Ident Keys for the

RFID Reader.

Dr Frank Schaefer

PraxisHaarbergstr. 2199097 Erfurt, Germany

Tel.: 0361 4230713 PraxisSoft@web.de

_contact implants

Fig. 9a Fig. 9b Fig. 9c Fig. 9d Fig. 9e Fig. 9f

Fig. 9h Fig. 9h

Clinical status after insertion im-plants—screwing parts (Strau-mann).

Clinical status immediatly afteroperation.

Review of success: left – planning target; right – result.

Fig. 10

industry report I

I 41implants3_2013

Fig. 1a_Peri-implantitis, clinically.

Fig. 1b_X-ray of peri-implantitis.

_Introduction

In the last decades, implantology has emerged asone of the most innovative enrichments in the field ofdentistry. Considerable increase is expected in the fu-ture. Compared to earlier preprosthetic methods, en-dosseous implantology is a simple treatment thatusually is not very stressful for the patients and offersmany advantages, e.g. the physiological transfer ofchewing forces into the bone, which—under certainconditions—even generates renewed bone growth.

Against this background, implantology with allits prosthetic treatment varieties is considered anestablished method. One of the most common andmost feared complications occurring in implantol-ogy is peri-implantitis (Figs. 1a & b), which usuallyleads to implant loss when it remains untreated.

Initially, the periimplant tissue disease mani-fests itself as mucositis with progressive bone lossat the implant area, as described by Albrektsson etal.1 The reasons for this disease pattern are complex,and various hypotheses about the development ofperi-implantitis were proposed, amongst them in-sufficient oral hygiene, lack of fixed gingiva, and/oroverstressed implants. These putative triggeringfactors contradict the statements of well-knownimplantologists, "An absence or insufficient widthof keratinized gingiva is not linked aetiologically tothe development of gingivitis and peri-implantitis"or "The functional strain placed on an implant can-not be solely held responsible for progressive boneloss“.8,17 That means that additional pathologic in-fluences, which trigger and sustain the progress ofthe disease, must exist next to these ostensiblecauses.

Therapies reach from improved basic hygiene toantibiotics and disinfectant inserts into periimplant

pockets up to ultrasound treatments and lasercurettage of inflamed tissues.4,8 The main attention,however, should not be placed on therapy, but ratheronto an efficient prevention of peri-implantitis.

_Gaps and hollow spaces of assembled implants

It is a fact that assembled implants contain hol-low spaces, which can be minimised but not pre-vented even by the most meticulous production. Be-cause threads also hold gaps, the contamination ofimplant interiors with germs originating from theoral cavity is inevitable.2,11

Re-infection from an implant cannot be ruledout. On almost every assembled implant we noticeda putrid smell of its content, which was extractedwith a cotton tip. In 1996 we initiated examinationswhich confirmed the assumption that gaps and hol-low spaces in interior implants were contaminatedwith germs, which matched the germ spectrum ofan interdental smear.4,5 9,12,14,15

Implant interiors in their dimensions, positionand size are easily recognised by construction draw-ings, cross sectional shapes and X-rays, and so it be-

Peri-implantitis prophylaxisby sealing implant gaps andhollow spaces Author_Prof. Dr Dr Claus Udo Fritzemeier, Germany

Fig. 1a Fig. 1b

I industry report

42 I implants3_2013

comes clear that hardly any assembled implant isactually excluded from those facts.7

Of course, these considerations apply to screwedsuperstructures as well. Cemented superstructuresseem to be sealed at first by the fastening cement,but everyone knows the smell that emerges whencement is drilled from crown and bridgework and gives evidence of germs permeating here aswell.

The access paths of germs into the implant inte-rior are easily comprehendible, and we were able toprovide evidence by taking light and electron mi-croscopic exposures of a used implant (Fig. 2). Thepaper "Implant Component Compatibility“ by Binonet al. confirms this matter quite impressively.3 Theresults showed that the macroscopically good fit re-

vealed severe flaws under electron microscopic ex-amination.

Furthermore, the capillary forces and micro mo-tions18 between implant and abutment promotethe exchange of infectious material, for which salivais a good vehicle. Figure 3 shows the proportion ofthe gap located between implant and abutmentcompared to an erythrocyte.7 In order to make thedimensions even more clearly, the randomly chosengerms shown are also matched to an erythrocyte ex-actly to scale.13

_Peri-implantitis through re-infectionfrom an implant

The implant is contaminated with germs fromthe oral cavity as soon as it is opened for placementof the insertion tool. Germ growth starts immedi-ately after fastening the locking screw, unless theimplant interiors were previously treated with a ma-terial for sealing and combatting germs.

The breeding conditions—warmth, humidity andsupply—enable bacterial growth and fungal coloni-sation in an ideal manner, so that re-infection ofperiimplant tissues via the gaps leading outwards isgiven. Regardless of which treatment of this impor-tant area around the implant is applied, it will alwaysremain short-lived.

_Development and efficacy of GapSeal®

In order to counteract these re-infections, we de-veloped a material based on a highly viscous siliconematrix and a bactericidal disinfectant in 1996. An-tibiotics would not be sufficiently intensive or ef-fective in a low dose. Moreover, they would con-tribute to sensitisation and the development of re-sistance. Afterwards we employed the so-calledsplit-mouth technique to test the material againstwhite Vaseline and determine the required admix-ture of disinfectant.15

The sealing material thymol has bactericidal,virucidal and fungicidal properties. It belongs to themicrobiologically very effective materials, but islargely harmless to humans. Its disinfecting effect isabout 30 times higher than that of phenol, but thy-mol has only a quarter of its toxicity. It also does notcause allergies.10,16 The material met its purpose asgap and interior sealant more than satisfactorilyand was subsequently named "GapSeal®“ (Fig. 4).6

For the split-mouth studies, GapSeal® was ap-plied to the right sides of the implants, and Vaselineto the left sides. During this clinical comparison, theVaseline turned out to be thoroughly contaminated,

Fig. 2

Fig. 3

Fig. 4

Fig. 2_Used implant randomly

chosen, on which the marked area

was light and electron

microscopically examined (Brand is

unnamed intentionally).

Fig. 3_Gap situation between

implant and abutment compared to

an erythrocyte with a diameter of 7 µ

(1 µ = 10-6 m), 745 times enlarged.

The randomly chosen germs are

depicted true to scale and compared

to an erythrocyte.

Fig. 4_Sterilisable GapSeal®

applicator with GapSeal® carpules.

industry report I

I 43implants3_2013

while GapSeal®-treated implants usually providedno evidence of germ growth. This is proven by thefollow-up examinations, each of which was con-ducted six months afterwards.

The number of germs (CFU = colony formingunit) at each pertaining implant was determinedthrough serial dilution, followed by counting theCFU’s on the incubation plates. This process enableda definite determination of germs contained in eachinterior implant smear.15 We were able to prove thematerial's efficacy by conducting follow-up exami-nations between 1996 and 2000 and do not want toabstain from using GapSeal® ever since. These stud-ies finally showed a statistically significant reduc-tion in peri-implantitis in more than a third of all im-plants sealed with GapSeal®.15

_Application

Implant interiors can be sealed with GapSeal®immediately after inserting and removing the inser-tion tool, thereby eliminating the prospective peri-implantitis inducing the re-infection factor. For thispurpose, the carpule must be inserted into the ap-plicator at first, and the closing cap needs to be re-moved. It is recommended to bend the cannulaslightly around the applicator shaft according to thefilling situation. Excess material gushing from theimplant when the closure cap is screwed in indicatesa good filling situation (Fig. 6).

The material is delivered in sterile blister packsand the applicator is autoclavable to warrant steril-ity. In case the implant is treated with GapSeal® at alater point, thorough cleansing of the interiorspaces with alcohol is recommended. Furthermore,

it is advised to fill the hollow spaces of screwed su-perstructures with GapSeal®. During implant re-en-try at recalls, it is advisable to renew old material,which may be rinsed out with xylene or alcohol.GapSeal® is very stable; it retains its qualities in ce-mented works over years, and requires neither ex-change nor replenishment.

_Results and discussion

Peri-implantitis is the most feared complicationoccurring in implantology, especially once the im-plant therapy with appropriate prosthetics is com-pleted. Suggestions regarding the treatment exist inample variations and are also put into practice.However, it seems to be more reasonable to preventthe causes for peri-implantitis, which certainly orig-inate to a large percentage from re-infection out ofimplant gaps and hollow spaces. The possibility ofgerm colonisation in implant interiors exists andshould be taken seriously. Attempts to combat re-infection have been described in specialised litera-ture for years. Now GapSeal® with its sixteen yearsof clinical experience offers a truly effective preven-tion against peri-implantitis._

Editorial note: A list of references is available from the pub-lisher.

Fig. 6_Use of applicator and

carpules.

Prof. Dr Dr Claus Udo Fritzemeier

Im Winkel 5

40627 Düsseldorf, Germany

friham@fritzemeier.eu

_contact implants

I manufacturer news

44 I implants3_2013

The new Swish™ Angled OverdentureAbutments feature a compact, one-pieceangled base with screw-receiving headdesigned for reduced vertical height.Available in 15° and 30° for 4.8 mm plat-forms, these abutments simplify treat-ment of fully edentulous jaws by achiev-ing parallelism when implants are in-clined. With an industry-standard internaloctagon connection, 4.8 mmD AngledOverdenture Abutments are compatiblenot only with the SwishPlant™ and SwishPlus™ butalso with Straumann®Tissue-Level implants — offer-

ing Straumann customers a whole new way to treatfully edentulous patients. The Angled OverdentureAbutments package includes a one-piece angledbase with screw-receiving head, Duo-Grip™ fixa-

tion screw, transfer and comfort cap.

Implant Direct Europe AG

Hardturmstrasse 161

8005 Zurich, Switzerland

info@implantdirect.eu

www.implantdirect.de

Two of the largest international clinical studies per-formed to date demonstrated good clinical perform-ance of Straumann Bone Level implants. Evaluatingmore than one thousand implants in Europe, the US andAustralia, both studies reported high implant survivalrates of more than 98% with practically no bone lossaround the implants. The findings are considerably bet-ter than values reported in a comprehensive review ofpreviously published studies with other implants. Oneof the studies, a large ‘non-interventional study’ (NIS)was conducted in Europe and the US, evaluating a totalof 908 implants in 538 patients at more than a hundreddental practices in six countries. It revealed an implantsurvival rate of 98.5% after one year, the bone level re-maining stable in the majority of cases. The investiga-tors concluded that treatment with Straumann BoneLevel Implants yielded successful outcomes in ‘real life’conditions. The new studies add to the wealth of strongclinical evidence backing the Straumann den-tal implant system and thus provide verygood reasons for patients and dentists toinsist on Straumann implants ratherthan undocumented alternatives.

Institut Straumann AG

Peter-Merian-Weg 12

4052 Basel, Switzerland

info@straumann.com

www.straumann.com

Straumann

A new level of confi-dence for patientsand dentists

In addition to the traditional surgical sutures made ofsilk, polyester and absorbable PGA, Omnia expands itsoffer of surgical sutures by introducing the new gen-eration. Omnia PTFE sutures are soft, biologically in-ert and chemically non-reactive. Main features ofPTFE sutures are a great fluency of the thread alongthe tissues and a strong knot holding. Its material ishighly tolerated in the oral cavity. Furthermore, PTFEsutures are optimal to limit inflammation, bleedingand other collateral effects which may occur duringthe soft tissue approximation. The sutures are avail-able in different combinations of diameter and lengthwith different kinds of needles. Omnia PTFE suturescan be applied in any implant, periodontal and bone

graft surgery, where the usage of amonofilament suture with low bacterial adhesion isrecommended. PTFE sutures are available in conven-ient boxes of twelve pieces each

Omnia S.p.A.

Via F. Delnevo, 190sx

43036 Fidenza (PR), Italy

Tel.: +39 0524 52745

info@omniaspa.eu

www.omniaspa.eu

Omnia

PTFE surgical sutures

Aesthetic treatment results are extremely important topatients. A key factor for success is the condition of thesoft tissue. Many dentists take the opportunity to opti-mise soft tissue immediately after an extraction bysewing a tissue punch from the palate into the newsocket. However, graft removal from the palate ispainful and creates a second wound. By using aGeistlich Mucograft® Seal collagen matrix instead ofautologous soft tissue, the dentist spares the patientpain and surgery time. The 8 mm disk is made of thesame proven material as Geistlich Mucograft® colla-

gen matrix and displays the same properties. It pro-tects the graft and creates soft tissue that matches per-fectly the colour and texture of its surroundings.Geistlich Mucograft® Seal is sewn over an extractionsocket that has been filled with Geistlich Bio-Oss® Col-lagen during a ridge preservation procedure. An un-damaged buccal bone plate is a prerequisite for this.Products from Geistlich Biomaterials are marketedonly after they have been scientifically tested and havedemonstrated clear clinical value. An international ad-visory board, under the direction of Prof. Mariano Sanz,

Spain, assessed thenew product. The ex-perts’ opinion wasthat ridge preservation incombination with Geistlich Mucograft® Seal is a pre-dictable approach.

Geistlich Pharma AG

Bahnhofstrasse 40,

6110 Wolhusen, Switzerland

www.geistlich.ch

Geistlich

Seal for good soft tissue outcome

Implant Direct

New Swish™ Angled Overdenture Abutments

Manufacturer News

manufacturer news I

I 45implants3_2013

One vision, two companies and many years of re-search conducted to the patented, revolutionary,natural, atelo-peptidized and lyophilized bovinebone graft composite “Hypro-Oss”. After intensiveresearch and development, medical researchers ofBioimplon and polymer chemistry engineers real-ized the breakthrough: A bone graft substitute, whichpotentially reduces or eliminates the need for auto-grafts. In January 2013, the patented bone graft sub-stitute “Hypro-Oss” was formally presented. It com-bines scaffolding properties with biological ele-ments to stimulate cell proliferation, differentiationand osteogenesis. The atelo-peptidized Hypro-Osswas processed with a special lyophilization technol-

ogy, avoiding any heating of the material for pre-serving the natural bio-elements, which conductcomplete new bone formation in just 14 weeks.

The Hypro-Oss has also strong hydrophilic proper-ties, optimal cell adhesion, blood absorption, excel-lent handling and high biocompatiblity because ofthe atelo-peptidation and lyophilization. The natural,crystalline structure and optimal porosity guaran-tees long-term dimensional stability. Thanks to theatelo-collagen, it has powerful hemostatic and bac-teriostatic properties.

There are no swelling or hematoma complicationsafter sinus lifting or surgical procedures according tomany clinicians’ observations.

Bioimplon GmbH

Friedrich-List-Str. 27

35398 Gießen, Germany

Tel.: +49 641 68681123

Fax: +49 641 68681124

info@bioimplon.de

www.bioimplon.de

Bioimplon

Innovative lyophilized bovine bone graft

www.omniaspa.eu

OMNIA S.p.A.Via F. Delnevo, 190 - 43036 Fidenza (PR) ItalyTel. +39 0524 527453 - Fax +39 0524 525230

VAT. IT 01711860344 - R.E.A. PR 173685 Company capital € 200.000,00

OMNIA S.p.A.Via F. Delnevo, 190 - 43036 Fide

39 0524 527453 - Fax +3711860344 - R.E.A

capital € 20

You are n°1!don’t be satisfied with a second choice, Pick up Omnia irrigation system!

AD

Planmeca’s 3-D X-ray unit range now offers a combination ofthree different 3-D data. With just one unit, the user can acquire apatient CBCT image, 3-D face photo and 3-D model scan, andcombine these data in one software suite. A virtual patient is cre-ated for different clinical needs.

3-D model scanning: Planmeca is proud to introduce a new im-aging mode to its Planmeca ProMax® 3D X-ray units. The imag-ing mode is designed for scanning impressions and plaster casts.Impressions are automatically inverted to digital casts and in-stantly stored in the Planmeca Romexis® software in standardSTL format. For orthodontic purposes, the STL data can be furtheranalysed in the Planmeca Romexis® 3D Ortho Studio module. TheRomexis database stores all digital casts together with other pa-tient images. The 3-D model scans can also be utilised in orthog-natic surgery planning and for follow-up of the patient’s treatment progress.

Planmeca ProFace®: Planmeca ProFace® is a unique 3-D face photo systemavailable for the whole Planmeca ProMax 3D family. Designed to fulfil the mostdiverse diagnostic needs of today’s maxillofacial and dental professionals, thesystem generates both a 3-D face photo and a CBCT volume in just one imaging

session. The 3-D photo can also be acquired sepa-rately in a completely radiation-free process.

Planmeca ProMax® 3D family: The Planmeca ProMax3D family is an intelligent, all-in-one X-ray unit rangedesigned to obtain complete information on patientanatomy in the minutest detail. The units provide digi-tal panoramic, extraoral bitewing, cephalometric, and3-D CBCT imaging, 3-D face photos and now also 3-Dmodel scans. The wide selection of volume sizes al-lows optimising the imaging area according to a spe-cific diagnostic task. All patient images are conve-niently processed in a single software suite, PlanmecaRomexis.

Planmeca Vertriebs GmbH

Walther-Rathenau-Str. 59

33602 Bielefeld, Germany

info@planmeca.de

www.planmeca.com

Planmeca

Three types of 3-D data with one Planmeca unit

I manufacturer news

46 I implants3_2013

Syneron Dental Lasers,provider of innovative hard &soft tissue dental laser tech-nologies, has been selectedamong the winners of the inter-national Red Dot Award, forproduct design in the Scienceand Medicine Category. Thisyear, a jury of international ex-perts evaluated over 4,700 en-tries from 54 countries within19 different products cate-gories against key criteria including the degree of in-novation, ergonomics, durability and ecologicalsoundness. The awards were presented on July 1stat Aalto Theater in Essen, Germany.

The Red Dot jury selectedLiteTouch as the award win-ner because of its innovativefiber-free laser delivery tech-nology. Thanks to miniatur-ization of Syneron DentalLasers’ laser technology, thewhole power generator is in-corporated within the Laser-in-Handpiece™ mechanism.This innovative solution mim-ics the feel of the turbine drill,

yet incorporates laser-unique benefits: micro sur-gery, quicker healing, minimal invasive treatments and higher acceptance of patients to dental treat-ments.

Researches in the implants and surgery field sug-gested that bone surgery with LiteTouch™, whencompared to the mechanical drill, may enhancebone regeneration by increasing the amount ofgrowth factors present in stemcells. In addition Lite-Touch™ has been reported to be used successfullyin implant therapy and for the treatment of periim-plantits.

Syneron Dental Lasers

Tavor Building, Industrial Zone

20692 Yokneam Illit, Israel

dental@syneron.com

www.synerondental.com

Syneron Dental Lasers

Red Dot Design Award in the Life Science and Medicine Category

Numerous international experts are gathering tohost a lecture series on the topic “Optimizing Im-plant Therapy” at the first Lindhe Symposium inOctober in Beijing, China. The topics covered atthe symposium are as diverse as the field of im-plantology itself: from the planning of treatments,over functional and aesthetic aspects, to chal-lenging situations during patient treatment.

Renowned speakers — such as Lyndon Cooper(USA), Ye Lin (China), Stefan Hassfeldt (Germany)and Jan Lindhe (Sweden) himself — ensure thepresentation of interesting, evidence-based conclusions on different treatment procedures inimplant dentistry. The objective of the event is toprovide participants with new ideas for optimalpatient care. The symposium is organized byPeking University, in association with the Univer-

sity of Gothenburg. This event is a supplement tothe successful symposium in Gothenburg, Swe-den, which is held every three years in honour ofJan Lindhe, a noted scholar and scientist in thefield of periodontology and implant dentistry. Itwas founded in 2006 and is organised by theSahlgrenska Academy at the University ofGothenburg. The Satellite Symposium in Chinawill take place from October 26–27 in the Friend-ship Palace Hotel, Beijing.

DENTSPLY Implants is sponsor of the symposium.

More information and registration: www.janlindhesatellitesymposium.com

DENTSPLY Implants

www.dentsplyimplants.com

DENTSPLY Implants

First Jan Lindhe Satellite Symposium in China

The 22ndAnnual Meeting of the Eu-ropean Association for Osseointe-gration (EAO) will take place inDublin and Ireland from 17–19 October 2013, with the theme“Preparing for the Future of Im-plant Dentistry”.

Nearly 70 speakers and more than 3,000 delegatesfrom around the world are expected to participate inthe congress. The Sunstar Foundation is sponsoringthe Breakfast Symposia on Friday, October 18,7.45–8.45 am where Prof. Dr Dr Engelke, UniversityGöttingen, will be lecturing about „Alveolar RidgePreservation using Endoscopically assisted RootEnucleation in Anterior Maxillary Extraction Sites“.As a silver sponsor Sunstar will present their prod-ucts at the commercial exhibition which runsthroughout the period of the congress. Visit them atbooth no. S32 and learn more about the innovativeproduct range.

Degradable Solutions AG

Member of Sunstar Group

Wagistrasse 23

Tel.: +41 43 4336260

Fax: +41 43 4336261

www.degradable.ch

Degradable

Preparing for the future of implant dentistry

Congress & presentation

[Website]

I 47implants3_2013

NEWS

While a number of dental laboratories use CAD/CAMtechnology these days, the computer-assisted designand fabrication of inlays, crowns and smaller bridges isnot widely taught at dental schools yet. One of the firstuniversity hospitals in Germany to do so, Jena Univer-sity Hospital teaches dental students to use state-of-the-art digital technology.

The small camera head passes over the teeth withouttouching them to obtain a 3-D digital image, which isdisplayed immediately on the screen. In this way, thepatient is spared the usual biting into an impressioncompound. It is not possible to capture the entiredentition with just a single shot in all three dimen-sions. The dentist scans the teeth by moving thecamera with its finger-sized head in a smooth mo-tion over the teeth at a short distance to create anumber of frames that can be joined to form a com-plete 3-D image.

The entire process is quick. Since the restoration canbe placed immediately, the placement of temporariesand the usual waiting period of several weeks for per-manent restoration are avoided. The camera is veryprecise and captures the opposing teeth, which is nec-essary for establishing good occlusion.

CAD/CAM technology

In dental education

With the playing of the Turkish national anthem andthe handover of the presidential chain of the FDI fromDr Orlando Monteiro da Silva to the president elect, Dr Tin Chun Wong, as only two of the highlights, theFDI Annual World Dental Congress was officiallyopened today at an opening ceremony in Istanbul. Lo-cal flavour was added through performances by Turk-ish percussionist Burhan Öçal and his group, followedby Fire of Anatolia, a dance show that offered a fusionof Anatolian dances, modern dance and ballet.

The audience was addressed by the Turkish Minister ofHealth, Mehmet Müezzinoğlu, who took the opportu-nity to thank the organisers for their great efforts in

hosting another outstanding event in Istanbul. Alreadyon 29 August, thousands of visitors from all over theworld were already swarming around the halls and ex-hibition areas of the Istanbul Congress Center.

In total, more than 12,000 dental professionals attended the four-day event, which has been organ-ised by the Geneva-based organisation and the Turkish Dental Association. There were more than160 lectures and presentations, as well as otherevents related to oral disease prevention and man-agement. In addition, local and global manufacturerspresented their latest products and services at theWorld Dental Exhibition on Level 5.

FDI congress gets off to

A promising startCAMLOG

The ever evolvingworld of implant dentistry

The CAMLOG Foundation will be holding the 5th in-ternational CAMLOG Congress in Valencia from26–28 June 2014 (Spain). The congress will beheld under the motto “The Ever Evolving World of

Implant Dentistry” and promises to be the sym-biosis of science and practice at the highest level.

The case at preceding CAMLOG congresses, thecommittee will once again comprise high-rankingscientific personalities and be presided over byProf. Mariano Sanz (Spain) and Prof. FernandoGuerra (Portugal). True to its motto “The EverEvolving World of Implant Dentistry”, continuousdevelopments in the scientific and practical as-pects of implant dentistry will be taken into ac-count.

Congress participants can expect first-class pre-sentations, which serve to deepen the specialistknowledge of the listeners on the one side, andcontribute toward improving the clinical results inthe daily practice of the dental physicians on theother. Main topics of the congress are the clinicalconcepts and recommendations, and also thecomplexity of multifactorial decision-making inimplant dentistry.

Lectures and discussions will also be addressingcontroversial themes. Attention here will focusparticularly on the implementation of these topicsin daily implant practice. Apart from the top-classprogram of the scientific congress, the location ofValencia itself has a great deal of magnetism.

Due to its location on the Mediterranean and theagreeable climate that goes with it, the thirdlargest city in Spain is highly appealing and offerssomething for all tastes.

CAMLOG Foundation

Margarethenstrasse 38

4053 Basel, Switzerland

Tel: +41 61 5654100

info@camlogfoundation.org

[PICTURE: ©ROBERT KNESCHKE]

NEWS

48 I implants3_2013

The Alliance for a Cavity-Free Future, an internationalgroup of experts that promotes an integrated clinicaland public health effort, has announced a new Euro-pean chapter to bring together experts in dentistry andpublic health to create a collaborative focus for the im-plementation of key changes to dental health practicesacross Europe. One of the alliance’s targets is to enableevery child born from 2026 to stay cavity free during hisor her lifetime.

The alliance, first launched as a global initiative in2010, calls for joint action to challenge leaders andstakeholders in the community to learn the importanceof caries as a disease continuum by recognising thatcavities are preventable and that in the early stagescaries is reversible, and to develop comprehensiveprogrammes for the prevention and management ofdental caries appropriate for individual regions. Find-ings from a new omnibus survey of 4,500 Europeanadults conducted online have highlighted the need forfurther education about dental caries at a public healthlevel. According to 2013 figures from the WHO, dentalcaries affects up to 80 per cent of the world’s popula-tion. European countries have seen a marked im-provement in levels of dental caries over the last 30years; however, in many segments of the population,dental caries remains a significant burden, a study re-vealed in 2008. At a global level, the Alliance for a Cav-ity-Free Future has set three long-term goals. First, by2015, 90 per cent of dental schools and dental associ-ations should have embraced and promoted the newapproach of caries as a continuum to improve dentalcaries prevention and management. Second, by 2020,regional members of the Alliance for a Cavity-Free Fu-ture should have developed and implemented inte-grated, locally appropriate, comprehensive caries pre-vention and management systems and monitoring.Third, every child born from 2026 should stay cavityfree during his or her lifetime.

Further information on the launch of the EuropeanChapter is available at www.family.allianceforacavi-tyfreefuture.org/en/us/whats-new.

European experts unite to

Stop caries

FOR is an independent, international initiative thatunites professionals from various disciplines to im-prove oral health care and support humanitarian lead-ership. Young participants can bene-fit from personal mentorship andsupport in advancing their careers asemerging leaders. The mission of thenew foundation is to achieve effec-tive worldwide patient care through scholarship andhumanitarian engagement. The foundation has threenetwork key areas: Science, Education and Humanity.

“FOR SCIENCE” helps participants stay at the forefrontof innovation and scientific breakthroughs by collabo-rating with leading experts and researchers from var-ious fields. Additionally, a FOR participant becomespart of a leading science- and evidence-based organ-ization at the frontiers of oral rehabilitation.

“FOR EDUCATION” provides an interactive learningplatform; it aims to unite a global community of expertsto provide clinical fellowship, mentorship, and mutual

support to improve the quality of life of patients. Youngprofessionals can interact with mentors and peers forpersonal and professional development and life-long

learning.

“FOR HUMANITY” rec-ognizes humanitarianachievement and initia-

tives. They ensure support for humanitarian projectsand provision of free products for treating patients inneed. FOR welcomes active participation from all dis-ciplines and specialties in the field of oral rehabilitation.FOR will look for shared humanitarian values, activeparticipation, and a mutual commitment to contributeto the ideals of the foundation.

FOR CENTER

Werftestrasse 4, PO Box 2558

6002 Lucerne 2, Switzerland

info@forcenter.org

www.for.org

Nobel Biocare

New foundation to improve oral health care

The medical market and especially thedental market are becoming more andmore globalised. DGZI has perceived agrowing interest of foreign patients to re-ceive a competent treatment from expe-rienced German dentists. Especially pa-tients from the Arabian region and theformer GUS states appreciate qualityand know-how “made in Germany” unduse their stay in Germany for extensivedental treatments. For this reason, DGZI– the practitioner’s dental society for oral implantol-ogy – has decided already four years ago to offer ex-perienced colleagues the opportunity to obtain the in-ternationally acknowledged certificates “Expert inOral Implantology DGZI” and “Specialist in Oral Im-plantology DGZI” of the German Board of Oral Implan-tology (GBOI).

These two international certificates includes proof ofqualified, subject-specific command of English. Thisyear’s GBOI examination will take place Thursday, 3October 2013, on the day before the 43rd InternationalAnnual DGZI Congress from 4 to 5 October in Berlin,

Germany. Participants of the GBOI examination will re-ceive a 20 % discount on the congress fees. For ques-tions or application forms, please contact the DGZIheadquarters.

DGZI Headquarters

Paulusstraße 1

40237 Düsseldorf, Germany

Tel.: 0211 16970-77

Fax: 0211 16970-66

sekretariat@dgzi-info.de

www.DGZI.de

International GBOI examination

Register now!

[PICTURE: ©DOOMU]

meetings I

I 49implants3_2013

_The Nobel Biocare Global Symposium 2013 inNew York saw more than 2,000 dental professionalsfrom around the world come together to explore the lat-est developments in implant dentistry under the theme“Designing for Life: Today and in the Future”.

A varied and unique scientific program held overfour days saw well over 100 leading professionals bringthis theme to life as they imparted their knowledge,shared their experiences and presented the very latestinnovative technology and clinical approaches. Over thecourse of the event delegates were taken through fourcomplete “patient journeys”: Missing Anterior and Pos-terior Single Teeth; Missing Multiple Anterior Teeth;Missing Multiple Posterior Teeth; and Managing the Ter-minal / Failing Dentition—The Transition to Edentulism.

The symposium also offered an introduction to Nobel Biocare’s new fully-integrated digital treatmentworkflow for partially edentulous patients. With the se-cure, online NobelConnect network at its heart, NobelBiocare is developing a seamless workflow which bringstogether the latest innovations at each stage of thetreatment process.

Other innovations were also unveiled at the event.The announcement of the creos™ xeno.protect mem-brane marked the introduction of a new regenerativeproduct to Nobel Biocare’s products and solutions port-folio. Made of biodegradable collagen, the membrane is

easy to handle and creates a favorable environment forbone regeneration whilst preventing undesired cellsmigrating to the treatment site from surrounding softtissue. The official launch date is to be announced in duecourse.

Although the symposium has come to an end thework of the Foundation for Oral Rehabilitation (FOR), in-augurated at the event, is only just beginning. FOR hasbeen established by Nobel Biocare to deliver tangibleprogress across three key sections: FOR Education, FORScience and FOR Humanity. The formal launch of thefoundation saw the presentation of the first “FOR Hu-manity Award” to Goodwill Ambassador for the UnitedNations, Bertrand Piccard for his humanitarian worksuch as with the “Winds of Hope” foundation. ProfessorPer Ingvar Brånemark was also elected as the first Hon-orary Fellow of FOR and Dr. Patrick Henry was presentedwith a lifetime achievement award for his contributionto the industry.

FOR is a global initiative that will expand the reach oforal rehabilitation through knowledge sharing and hu-manitarian efforts, helping ensure the best practice dis-cussed in New York will be implemented to the benefitof patients for generations to come. For those whoweren’t able to join us in New York, the key outtakes fromthe event and the latest developments following thelaunch of FOR will be appearing in the next edition ofNobel Biocare News and at www.nobelbiocare.com._

Nobel Biocare Global Symposium2013 in New York Source_Nobel Biocare

Richard T. Laube, CEO Nobel Biocare

Prof. George Zarb, chairman of FOR

[PICTURE: ©ORHAN CAM]

I about the publisher

50 I implants3_2013

implantsinternational magazine of oral implantology

Copyright Regulations

_implants international magazine of oral implantology is published by Oemus Media AG and will appear in 2013 with one issue every quarter. The magazine and all articles and illustrations therein are protected by copyright. Any utilization without the prior consent of editor and publisher is inad-mi ssible and liable to prosecution. This applies in particular to duplicate copies, translations, microfilms, and storage and processing in electronic systems.

Reproductions, including extracts, may only be made with the permission of the publisher. Given no statement to the contrary, any submissions to theeditorial department are understood to be in agreement with a full or partial publishing of said submission. The editorial department reserves the right tocheck all submitted articles for formal errors and factual authority, and to make amendments if necessary. No responsibility shall be taken for unsolicitedbooks and manuscripts. Articles bearing symbols other than that of the editorial department, or which are distinguished by the name of the author, representthe opinion of the afore-mentioned, and do not have to comply with the views of Oemus Media AG. Responsibility for such articles shall be borne by the author.Responsibility for advertisements and other specially labeled items shall not be borne by the editorial department. Likewise, no responsibility shall be assumedfor information published about associations, companies and commercial markets. All cases of consequential liability arising from inaccurate or faulty representation are excluded. General terms and conditions apply, legal venue is Leipzig, Germany.

Publisher

Torsten R. Oemus oemus@oemus-media.de

CEO

Ingolf Döbbeckedoebbecke@oemus-media.de

Members of the Board

Jürgen Isbanerisbaner@oemus-media.de

Lutz V. Hillerhiller@oemus-media.de

Chief Editorial Manager

Dr Torsten Hartmann (V. i. S. d. P.)hartmann@dentalnet.de

Editorial Council

Prof Dr Dr Frank Palmfrank.palm@klinikum-konstanz.de

Dr Roland Hilledr-hille@t-online.de

Prof Dr Dr Kurt Vinzenzkurt.vinzenz@aon.at

Dr Torsten Hartmannhartmann@dentalnet.de

Dr Suheil BoutrosSMBoutros@aol.com

Editorial Office

Georg Isbanerg.isbaner@oemus-media.de

Claudia Jahnc.jahn@oemus-media.de

Executive Producer

Gernot Meyermeyer@oemus-media.de

Designer

Sarah Fuhrmanns.fuhrmann@oemus-media.de

Customer Service

Marius Mezgerm.mezger@oemus-media.de

Published by

OEMUS MEDIA AGHolbeinstraße 2904229 Leipzig, GermanyTel.: +49 341 48474-0Fax: +49 341 48474-290kontakt@oemus-media.de

Printed bySilber Druck oHGAm Waldstrauch 134266 Niestetal, Germany

implantsinternational magazine of oral implantologyis published in cooperation with the German Association of Dental Implantology (DGZI).

DGZI President

Prof Dr Dr Frank PalmDGZI Central Office Paulusstraße 1, 40237 Düsseldorf, GermanyTel.: +49 211 16970-77Fax: +49 211 16970-66office@dgzi-info.de

www.dgzi.dewww.oemus.com

implantsinternational magazine of oral implantology

I would like to subscribe to implants internationalmagazine of oral implantology (4 issues per year)for € 44 including shipping and VAT for German customers, € 46 including shipping and VAT for customers outsideGermany, unless a written cancellation is sent within 14 daysof the receipt of the trial subscription. The subscription will berenewed automatically every year until a written cancellationis sent to OEMUS MEDIA AG, Holbeinstr. 29, 04229 Leipzig,Germany, six weeks prior to the renewal date.

Last Name, First Name

Company

Street

ZIP/City/County

E-mail Signature

Signature

OEMUS MEDIA AGHolbeinstraße 29, 04229 Leipzig, Germany, Tel.: +49 341 48474-0, Fax: +49 341 48474-290, E-Mail: grasse@oemus-media.de

Reply via Fax +49 341 48474-290 to OEMUS MEDIA AG or per E-mail to grasse@oemus-media.de

Notice of revocation: I am able to revoke the subscription within 14 days after my order by sending a writtencancellation to OEMUS MEDIA AG, Holbeinstr. 29, 04229 Leipzig, Germany.

impl

ants

3/1

3

� Subscribe now!

You can also subscribe via www.oemus.com/abo

Implants_Abo_A4_NEU.pdf 1Implants_Abo_A4_NEU.pdf 1 11.09.13 11:5711.09.13 11:57

Planmeca Oy Asentajankatu 6, 00880 Helsinki, Finland. Tel. +358 20 7795 500, fax +358 20 7795 555, sales@planmeca.com, www.planmeca.com

Find more info and your local dealer www.planmeca.com

33D

Implant planning made easy

Planmeca ProMax® 3D Planmeca Romexis®

Planmeca Romexis® 3D Implant Planning software o ers t e most sop isticated tools for t e needs of modern implantolo y.

• Superimpose surface scan on to CBCT data

• se crown li rary or import patient speci c crown from CA system

• osition t e implant usin realistic implant and a utment li raries

• erify t e implant plan wit eri cation tool

• rder sur ical uide directly from t e software

EDI_0513.pdf 1EDI_0513.pdf 1 16.07.13 15:3516.07.13 15:35