32012

i s sn 1868-3207 Vol. 13 • Issue 3/2012

implantsinternational magazine of oral implantology

| researchRehabilitation of a complex case with zirconium dental implants

| case reportImmediate implantation in the anterior maxilla

| industry reportCAD/CAM-based restoration of an edentulous maxilla

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editorial _ implants I

I 03implants3_2012

_Dental implantology has experienceda substantial change in the last 25 years. The treatmentspectrum has been significantly expanded; simultaneously, our patients’ expectations and demandsin implant treatment have developed disproportionately. In addition, implant dentistry now is alsoan integral part of everyday dental practice. In spite of the growing importance of oral implantol-ogy, most dentists receive their education in implant dentistry after graduation with only little em-phasis on the complexity and risks of implant treatment. Providing our patients with quality implanttreatment motivates us to give the best our profession has to offer. This does however not imply thatour treatments must be perfect to 100 per cent, since perfection such as this does not exist in thepractice of implant dentistry. Instead, we must strive to achieve the best we can do for our patients.We need to work either as individuals or as members of a team to assure that implant treatment issafe, effective, and aesthetically acceptable. We can all play a part in providing quality dental implanttreatment by being there for the patient with skills that are attained by proper education, experience,and counsel from those who have gained the necessary skills, knowledge, and judgment.

For 42 years, DGZI has organized its annual conferences in order to inform about scientific in-sights and “truths” established by research and evidence-based clinical observations. Not only fornovice clinicians is attaining the proper education a continuing process, but it is also an ongoing en-terprise for the highly experienced clinician. New developments occur with each passing day. There-fore, providing the best we can do for our patients and profession becomes an impossible task if wekeep our blinders on and persist in our practice as we did yesterday. As early as the beginning of the1990s did DGZI begin to administer an examination for particularly qualified colleagues, allowingthem to both revise and prove their knowledge and skills to the advantage and the safety of their pa-tients. The Curriculum Implantology was established as a systematic education for the newcomersas well as for the experienced implantologist. Some thousand colleagues have since passed the ed-ucation successfully. A subsequent master studies postgraduate program can be attended addi-tionally for more theoretical skills. In addition, a specialist and German board (GBOI) internationalexamination was established by DGZI for clinicians who want to have their theoretical and practi-cal experience tested by an international examination board. One of this year’s DGZI highlights willbe our International Annual Meeting in Hamburg from 5 to 6 October titled “Quality Oriented Im-plantology—Ways to Long-Term Success”. Complex situations in dental implantology and the digi-talization of surgery and prosthetics are discussed, along with a periimplantitis special session anddiscussion. Take your chance and register for the meeting as well as the German board and special-ist examination. You can request more information from our central office in Düsseldorf (Tel. +49 211 1697077). I invite you all to join us and enjoy Hamburg where it is most beautiful, di-rectly located on the Elbe River—at the heart of the harbour! Indulge in new culinary creations andan unforgettable atmosphere, combining state-of-the-art scientific meeting with maximum relax-ation. Sincerely Yours,

Dr. Rolf Vollmer1st Vice president of DGZI

To know when to do!To know when not to do!

Dr Rolf Vollmer

I content _ implants

04 I implants3_2012

I editorial

03 To know when to do! To know when not to do!| Dr Rolf Vollmer

I research

06 Rehabilitation of a complex case withzirconium dental implants| Dr Andrea Enrico Borgonovo et al.

12 Impression and registration for full-archimplant dentures| Dr Gregory-George Zafiropoulos

20 Time-saving debridment of implants with rotating titanium brushes| Dr Dirk U. Duddeck et al.

I case report

24 Immediate implantation in the anterior maxilla| Dr Nikolaos Papagiannoulis et al.

I industry report

28 Fixed full arch metal-free prosthesis on four SHORT®

implants| Dr Mauro Marincola et al.

32 CAD/CAM-based restoration of an edentulous maxilla| Arnd Lohmann

I business news

36 Conical internal connections will fuel growth in dental implant market| Dr Kamran Zamanian et al.

I news

38 Manufacturer News

48 News

I education

40 Master of Oral Medicine in Implantology

| DGZI

41 Celebrating the Triumph of Osseointegration

| Frederic Love

I meetings

35 International events 2012

42 National Osteology Symposium in Bonn

| Verena Vermeulen

44 “Quality-oriented implantology”

| DGZI

I about the publisher

50 | imprint

page12 page 20 page 24

page 28 page 32 page 42

Cover image* courtesy of Implant Direct,

www.implantdirect.com

Original Background: ©antishock

Artwork by Sarah Fuhrmann, OEMUS MEDIA AG.

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I research

Fig. 1_Pre-op clinical view.

Fig. 2_Pre-op radiograph.

Fig. 3_Preparation of implant site.

_Introduction

For several decades, dental implants have largelybeen used for the rehabilitation of completely andpartially edentulous ridges with success. For this rea-son, implant dentistry has been the object of numer-ous investigations to further improve the effective-ness of this kind of device.1, 2 Titanium is the materialmost often utilised for dental implants because of itsfavourable properties, such as its biocompatibility.3, 4

However, aesthetic concerns may arise when restor-ing anterior teeth owing to the grey colour of thismetal.

For this reason, new techniques and materialswere developed to achieve better aesthetics, such asceramic (zirconium) abutments5, 6 and metal-freerestoration.7, 8 These prosthetic devices have alreadyachieved assessable results. There are, however, somesituations, resulting from a thin gingival biotype or in-correct tri-dimensional implant positioning, in whichzirconium abutments and crowns are not able to ob-tain optimal aesthetics.9, 10

Many authors11 have attempted to solve theseproblems by coating titanium dental implants withwhite material such as ZrO2 and Al2O3. While the pop-ularity of coating has increased, its use has remainedcontroversial. Concerns have been raised owing toproblems such as the dissolution and cracking ofcoatings, as well as the separation of coatings frommetallic substrates, a phenomenon referred to as “delamination”.

For the same purpose, Al2O3 implants have beentested in various clinical studies since the 1970s. Theywere commercialised in France, Germany, Japan andthe USA. Among them, Tubingen implants are proba-bly the most well known ceramic implants.12These im-

Rehabilitation of a complex case withzirconium dental implantsAuthors_Dr Andrea Enrico Borgonovo, Dr Marcello Dolci, Dr Rachele Censi, Dr Oscar Arnaboldi,

Dr Virna Vavassori & Prof Carlo Maiorana, Italy

06 I implants3_2012

Fig. 3

Fig. 2

Fig. 1

research I

plants were soon abandoned because of frequent im-plant fractures, mobilisation, loss of osseointegrationand peri-implant bone loss. Most of these problemsprobably occurred owing to the inadequate mechan-ical characteristics of Al2O3.13, 14

More recently, ZrO2 has been introduced to den-tistry for its good mechanical properties and high bio-compatibility, combined with excellent aesthetics.While ZrO2 has been largely used and documented inprosthetic dentistry, only few studies have reportedclinical experiences with zirconium implants.15, 16

The aim of this article is to present a five-year fol-low-up study of a complex implant-prosthetic reha-bilitation with ZrO2 dental implants.

_Case report

A 55-year-old male patient presented with partialedentulism in the left maxilla in regions 21 to 26 at theDepartment of Oral Surgery at the Dental Clinic at theUniversity of Milan. The patient was in general goodhealth and a non-smoker. However, lately he had hadfinancial difficulties that had led to him taking inade-quate care of his oral health and consequently losingteeth. After professional hygiene and oral hygiene in-structions, the patient was re-evaluated for an im-plant-prosthetic rehabilitation. His edentulism wascomplex owing to the lack of numerous teeth and be-cause the alveolar process had undergone moderateresorption. Yet, it was sufficient to insert four dentalimplants. There was no need for an augmentationprocedure and the predictable level within the gingi-val marginal profile was not considered a problem be-cause of the patient’s low smile line (Figs. 1 & 2).

After a diagnostic wax-up, the surgical guide wascreated. A mucoperiosteal flap was raised with a ver-tical releasing incision distal to tooth 1.2. Four one-piece yttria-stabilised ZrO2 (YSZ) implants (whiteSKY,bredent) were inserted. Two 4 x 12 mm implants were

positioned in regions 2.1 and 2.3, and two 4.5 x 12 mmimplants in regions 2.5 and 2.6 (Fig. 3). After the im-plant sites had been prepared, implant insertion wasperformed using a surgical contra-angle handpieceand then a dynamometric key, at a maximum torqueof 40 N. The fixtures were screwed in until the sandedsurface reached the bone crest level, leaving the pol-ished part untreated at transgingival level. A heterol-ogous bone graft (Bio-Oss, Geistlich Pharma), to-gether with a double layer resorbable membrane (Bio-Gide, Geistlich Pharma), was positioned on the im-plant placed in region 2.1 because of the thin corticalwall and to reduce bone resorption. A sinus lift wasperformed using Summers’ osteotome technique toinsert the implant with an adequate length (12 mm)in region 2.6 (Figs. 4–7). The flaps were sutured withnon-absorbable 4.0 monofilament (Premilene, B.Braun).The removable partial denture was adapted in order to avoid any contacts with the implants.

The patient was prescribed a soft diet, antibiotictherapy with 1 g amoxicillin and clavulanic acid (Lab-oratori Eurogenerici) every eight hours for seven daysand a 0.2 % chlorhexidine mouth rinse (Corsodyl,GlaxoSmithKline) twice a day for 15 days. The patientattended a follow-up visit ten days later. The sutureswere then removed and the implant stability waschecked. The supra-gingival portion of the one-piecezirconium implant was minimally prepared withETERNA burs (bredent) to achieve parallelism of theimplant axes. Then the partial denture was replacedwith a temporary acrylic resin bridge to enhance soft-tissue healing and guide the gingival profile (Fig. 8). Inthe temporary phase, particular attention was givento occlusion to ensure centric contact that was as lightas possible and to avoid contacts in eccentric move-ments.

After four months, the temporary bridge was re-moved. Implant stability, probing depth and gingivalhealth were examined. Furthermore, the occlusal sur-face of the temporary restoration was modified and

Fig. 4_Sinus lift using Summers’

osteotome technique in region 2.6.

Fig. 5_The four implants are

positioned.

I 07implants3_2012

Fig. 4 Fig. 5

I research

Fig. 6_Occlusal view of the implants.

Fig. 7_Post-op radiograph.

Fig. 8_The acrylic resin temporary

bridge is placed.

Fig. 9_Clinical view of the

all-ceramic ZrO2 bridge five years

after surgery.

the implants were loaded. Six months after surgery,the YSZ implants were definitively restored with aZrO2 bridge. A light-pink ceramic layer was applied tothe marginal areas of regions 2.1 to 2.3 to better sup-port the upper lip and limit the width of the interden-tal space (Fig. 9).

Follow-up appointments were scheduled for sixmonths after prosthesis delivery and thereafter oncea year. Periodontal indices were measured and stan-dardised periapical radiographs were obtained. Theplaque index and bleeding on probing scores were 1,except at the last follow-up. No implants had probingdepth values of less than 5 mm. Mobility was not pres-ent at any site. No pain (spontaneous or on percus-sion) or paraesthesia was reported. From baseline to

five years after surgery, radiographical evaluation ob-served the absence of peri-implant radiolucency andno implant exhibited marginal bone resorption at anyfollow-up (Figs. 10 & 11).

_Discussion

Titanium dental implants have proved to be highlysuccessful in replacing missing teeth. Several studieshave demonstrated the successful osseointegrationof this material and its use for restoration in patientswith partial or total edentulism.17 In recent years, nu-merous studies have focused on the development ofimplant surfaces to ensure better and faster osseoin-tegration and to re-establish masticatory function ina shorter period.18, 19 Although excellent results havebeen obtained in the maxillary anterior region by sev-eral clinicians, aesthetics remains a challenge for im-plant dentistry.

Titanium implants are of a grey colour, which canshine through gingival tissue, particularly in thin bio-types or in patients with a high smile line. Moreover, itmust be considered that soft tissue around dental im-plants may shrink or develop gingival recession, orthat peri-implantitis may occur, thus compromisingthe overall treatment outcome, particularly if treat-ment entails an aesthetic region.

In recent years, several solutions to this problemhave been proposed. Various authors have suggestedplacing implants 3 to 4 mm apical to the cemento-enamel junction or free gingival margin of adjacentteeth, considering that soft-tissue margins aroundimplants tend to re-establish a biological width.20 Im-plants positioned too far apically in an attempt to es-tablish appropriate biological width can cause gingi-val recession.21 Gingival recession may also develop inthin gingival biotypes because these tissues are moresensitive to trauma and inflammation. For these rea-sons, surgical approaches such as connective tissuegrafts have been suggested to augment tissue thick-ness and improve peri-implant aesthetics.22, 23 How-ever, these techniques are not always completely pre-dictable from an aesthetic point of view. Moreover,morbidity of the donor site and patient discomfortmust also be taken into account. Other authors24 haverecommended colouring the implant neck, thuschanging the optical appearance of peri-implant mu-cosa. For the same reason, a great number of investi-gations have been conducted on tooth-coloured im-plants. Various ceramics have been tested as coatingmaterial, such as ZrO2 and Al2O3.13, 26 However, even ifthe studies conducted in the 1990s showed better re-sults than earlier investigations, these implants didnot have adequate mechanical properties for long-term loading27 or required large diameters that wereincompatible with use in the anterior region with lim-

08 I implants3_2012

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Fig. 7

Fig. 8

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I research

10 I implants3_2012

ited space.28 Consequently, the indications for theseimplants were limited and they were withdrawn fromthe market.

More recently, YSZ has been utilised for dental im-plants. This new generation of ceramic implants ex-hibits good mechanical properties, combined withgood optical properties and high biocompatibility. Infact, YSZ has a flexural strength similar to titaniumand a textural strength similar to stainless steel.29

A number of animal studies have demonstratedgood osseointegration.30, 31 In further studies,32 thesame authors have demonstrated osseointegrationstability after a long-term loading period. Scarano33

analysed the bone–implant interface in rabbit tibia,and observed neither fibrous tissue nor inflammation,with good bone-to-implant contact (68 %). Similarresults were obtained in monkeys by Kohal.34

In another study, the same author compared stressdistribution in YSZ implants and titanium implants,and observed similar stress distribution patterns.35

Sennerby36 studied the effect of varying surfaceroughness on extraction torque and bone-to-implantcontact with YSZ implants compared with titaniumimplants six weeks after implant insertion. The resultsdemonstrated that when surface roughness was en-hanced, the two materials exhibited similar behaviour.Other studies37, 38 have confirmed that a treated YSZimplant surface provides good osseointegration at alltimes and after a long-term loading period.

These promising results led a still limited numberof authors to test ZrO2 implants on humans. The firstfew clinical studies are quite recent. Among these,Blatsche and Voltz39 observed 98 % osseointegrationin 66 implants in 34 patients in a period of betweentwo and five years. Kohal and Klaus40 reported the sta-bility of an YSZ implant in a fresh extraction socketwith a graft material after loading. Oliva et al.41 re-ported one-year results for 100 YSZ implants with twodifferent surfaces, in some cases combined with bone

augmentation and sinus lift procedures. Within thisobservation period, the authors reported a 100% sur-vival rate and a 98 % success rate in terms of absenceof bleeding on probing, signs of inflammation, mobil-ity and radiolucency. Similar results (93 % success)were reported by Mellinghoff42 in a one-year follow-up study on 189 implants in 71 patients. These stud-ies suggest that YSZ implants exhibit a good rate ofosseointegration.

Improvements in zirconium surface characteris-tics will probably lead to interfacial biomechanicalproperties comparable to treated titanium surfaces inthe future. Compared with titanium, plaque adhesionto zirconium surfaces is very limited because nochemical or physical bonding between ZrO2 andplaque occurs.43 This is an important feature for long-term survival.

These findings, together with the good mechani-cal properties characteristic of zirconium implants,are encouraging. However, further histological andclinical studies are needed to investigate long-termsuccess and stability.

_Conclusion

In conclusion, it can be stated that it is logical touse a ceramic material for the aesthetic regions. Zir-conium dioxide is particularly suitable, since it offerstissue friendliness and a resistance comparable to ti-tanium. Its increased tensile strength, superior me-chanical properties, unsurpassed integration with tis-sue and aesthetic appearance, as well as the possibil-ity of easy fabrication of the prosthetic restoration,may well result in partially YSZ becoming the mostcommonly used material in implant dentistry for aes-thetic regions.

This case report has demonstrated that YSZ im-plants offer a successful rate comparable to titanium,with a higher aesthetic performance in the anteriorregion. For this reason, the authors recommend theutilisation of YSZ implants in cases like the one in thisarticle._

Figs. 10 & 11_Periapical radiographs

five years after surgery.

Dr Virna Vavassori

University of Milan

Dental Clinic

Postgraduate School of Oral Surgery

Via della Commenda 10

20122 Milan

Italy

virna.vavassori@hotmail.it

_contact implants

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I research

Fig. 1a_Full denture in situ.

Fig. 1b_Duplicate (DentDu) of the

interim denture.

Fig. 1c_Trial of the DentDu.

Fig. 2a_Placement of the DentDu in

the articulator.

Fig. 2b_Pick-up impression system.

On the left: titanium impression post

(placed on the implant). On the right:

plastic impression sleeve (will be left

in the impression).

_Introduction

Usually, a full denture is delivered following toothextraction or implant insertion of a fully edentulousarch. A denture is usually used until the final restora-tion is performed. A well-designed full dentureshould fulfill the following criteria: 1) correct verti-cal height and maxilla-mandibular relationship; 2) accurate occlusion; 3) appropriate choice of teethwith regard to shape, length, width and position; 4)adequate lip support and 5) proper function and aes-thetics to meet the patient’s expectations. The finalrestoration should fulfill or surpass these require-ments. Obtaining a correct impression and accu-rately evaluating the interocclusal relationship (e.g.,interocclusal distance, occlusal recording and deter-

mination of the exact position of the placed im-plants) are often challenging and time-consumingtasks.1

The aim of the current report is to present an im-pression and registration technique that allows thetransfer of the interocclusal relationship, occlusalrecording and esthetics that were initially applied toproduce a full denture as a template for the recon-struction of the final full-arch implant.

_Materials and Methods

Following multiple extraction of a non-salvage-able rest dentition and the placement of six dentalimplants in positions #4, #5, #6, #11, #12,# 13, a fulldenture was fabricated. After the extraction sites hadhealed and denture sores were eliminated, the func-tion and esthetics of the denture was optimized. Ifnecessary, angulations, shape and color of the den-ture teeth and the shape of the denture base werecorrected (Fig. 1a). The resulting denture was used bythe patient until the final restoration was delivered.For the final restoration of the maxilla, an implant-

Impression and registration for full-archimplant denturesAuthor_Prof Dr Gregory-George Zafiropoulos, Germany

12 I implants3_2012

Fig. 2a Fig. 2b

Fig. 1b

Fig. 1c

Fig. 1a

research I

retained denture with telescopic crowns as attach-ments was planned.

After the implant was uncovered, the denture wasmodified to allow sufficient space for the healingabutments. A duplicate of the denture (DentDu) wasmade out of clear resin (Paladur, Heraeus, Hanau,Germany, Fig. 1b). A trial of the DentDu was per-formed and minor occlusal discrepancies were cor-rected (Fig. 1c). Bite records were taken in centric oc-clusion with modeling resin (pattern resin®, GC, Al-sip, IL; Fig. 1c), using the casts of the original denture.Afterwards, the DentDu was placed in an articulatorand a controlling of the occlusion was made (Fig. 2a)with the bite records. A pickup transfer system con-

sisting of a titanium impression post and a plastic im-pression sleeve was employed (Dentegris, Duisburg,Germany, Fig. 2b). The DentDu was carefully modifiedby creating internal clearance in the area of the im-plants so that it could be applied as an individualizedcustom tray. This permitted it to be fully seated whenthe impression posts were in place. Impressions weregenerated by a polyether material (Impregum, 3MESPE, St. Paul, MI). During this process, the DentDuwas kept in centric occlusion using the bite records(Fig. 3a).

The titanium impression posts were connectedwith the implant analogues and with the plastic im-pression sleeves (Dentegris), which were embedded in

Fig. 3a_Taking the impression with

the DentDu. The bite records were

used to determine the exact position.

Fig. 3b_Fabrication of the master

cast.

Fig. 3c_Placement of the cast into

the articulator using the bite

registrations.

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Fig. 3a Fig. 3b Fig. 3c

I research

the impression material (Fig. 3b). A master cast wasthen fabricated and articulated with the help of thebite records (Fig. 3c, Figs. 4a & 4b).

Customizable abutments (Dentegris) were takento fabricate the implant abutments. Parallelism, an-gulation, position and shape of the implant abut-ments were determined using a silicon key fabri-cated from a matrix of C-silicone (Zetalabor, Zher-mack SpA, Badia Polesine, Italy, Fig. 5). The dentistand the dental technician relied on two alternativesfor customized abutments selection: 1) UCLA cus-tomizable abutments (UCLA, Dentegris) for castingwith a gold alloy (for example, Portadur P4, Au 68.50%, Wieland, Pforzheim, Germany, Fig. 6a) or 2) plat-inum-iridium customizable abutments (PTIR, Den-tegris) for casting with a chromium cobalt (CrCo) al-loy (for example, Ankatit, Anka Guss, Waldaschaff,Germany, Fig. 6b).

After casting, the customized implant abutmentswere grinded, polished and served as the basis for the

fabrication of electroformed pure-gold copings witha thickness of 0.25 mm (AGC Galvanogold, Au >99.9 %, Wieland, Fig. 6c).2-4 The framework was thenconstructed via CAD/CAM. To ensure proper func-tioning of the framework, a plastic mock-up and atemporary fixed denture (TFD) were milled (ZENO-PMMA, Wieland). The customized implant abutments,the electroformed copings, the mock-up and the TFDwere delivered by the dental laboratory for the nextclinical session.

The abutments were transferred, positioned on theimplants and torqued to 35 Nm using a resin transferkey (pattern resin, GC; Figs. 7a-b). From this point on,the customized abutments remained fixed in order toavoid any possible inaccuracies. The electroformedcopings were placed on the implant abutments (Fig.7c). The mock-up was placed over the electroformedcopings and the occlusion was checked with the biterecords (Figs. 8a-b). A final impression with a poly-ether impression material (Impregum, 3M ESPE) wastaken with electroformed copings. The mock-up wasfurther set up and used for the fabrication of a new(final) master cast. After the impression was taken,the TFD was fixed on the implant abutments usingtemporary cement (TempBond, Kerr, Orange, CA). Itwas then left in place until the delivery of the finalrestoration (Fig. 8c).

The new master cast was articulated with the helpof the gold copings and the mock-up. The metalframework was milled (here: Titanium Zenotec TI,Wieland, Fig. 9a). The veneering of the superstructurewas made using a light-cured indirect ceramic poly-mer (Ceramage, SHOFU, Menlo Park, CA, Figs. 9a-d).The electroformed gold copings were fixed in themetal framework using a self-curing compomer ce-ment (AGC Cem, Wieland, Fig. 10).

The above-described procedures can be also per-formed in cases in which a fixed denture was plannedfor the rehabilitation of the full-arch (Figs. 11a & 11b,Figs. 12a-c) and in cases where part of the naturaldentition is periodontally stable and can be applied asabutments. In these cases, the immediate full denturecan be designed as a cover denture. From this cover

14 I implants3_2012

Fig. 6a Fig. 6b

Fig. 6c

Fig. 4b

Fig. 5

Fig. 4a

Fig. 7a

Fig. 7b

Fig. 7c

Fig. 4a_Master cast.

Fig. 4b_The master cast is placed

into the articulator.

Fig. 5_The customized implant

abutments are fabricated using a

matrix of C-silicone.

Fig. 6a_Gold customized abutments.

Fig. 6b_Chromium cobalt (CrCo)

customized abutments.

Fig. 6c_Electroformed gold copings.

Figs. 7a & 7b_The customized

abutments are mounted on the

implants using a transfer key.

Fig. 7c_Electroformed gold

copings in situ.

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I research

Figs. 8a & b_Brial of the mock-up.

Fig. 8c_Temporary fixed

denture in situ.

Figs. 9a-d_Final telescopic crown

retained implant denture, palatal;

(Fig. 9a), anterior teeth (Fig. 9b),

right side (Fig. 9c), left side (Fig. 9d).

Fig. 10_Placement of the

electroformed copings

into the frame.

denture, a DentDu could be fabricated and furtherused as described above (Figs. 13a-c).

Porcelain is a possible material for veneering offixed-denture frameworks. If the angulation of theimplants does not allow for taking impressions in theabove-described way and an open-tray impression ispreferable, fenestrations can be fabricated into theDentDu (Fig. 14).

_Discussion

The reconstruction of the fully edentulous archwith implant-retained dentures necessitates thor-ough planning and a precise and passive fit of thesuprastructure. A previous study demonstrated thata passive fit between the implant superstructure andthe underlying abutments is essential for the long-term success of the implant prosthesis.5 To achieve apassive fit, an accurate positioning of the implantreplicas in the master cast must be assured. The im-pression technique and the splinting of the implantcopings are factors which may contribute to errors inthe final positioning of the implant analogs, thusleading to inaccuracies in the fit of the final super-structure.5-10 Furthermore, the angulation or proxim-ity of the implants may inhibit proper seating of theimpression copings and/or caps, which may also havea detrimental effect on the registration of the implantposition.11

The precise recording of the maxillo-mandibular,e.g. interocclusal, relationship is a prerequisite forachieving proper occlusion and a successful treat-ment outcome.1,10 The initially delivered denture al-lowed for the correction of the interocclusal relation-ship, tooth shape and color and angulations duringthe entire healing period. In this way, the patient wasable to acclimatize to the function and esthetics of thedenture. In the method described in this report, an ac-curate impression and recording of the full denturewas achieved by using a duplicate as a custom tray forthe impression. Therefore, it was not necessary to re-peat all the steps usually needed for recording the in-terocclusal relationship, e.g. wax-up, etc., at the timeof the fabrication of the final restoration.

If an open-tray impression is preferred, only minorchanges to the procedure are necessary. This methodis based on a previous publication.12 In cases such asthis, it is advisable to fabricate two DentDus. The im-pression can be taken by the first DentDu ; the secondDentDu is used for the remaining steps. Customizedabutments are applied instead of a bar, galvano cop-ings allow a precise transfer coping, and secondarytelescopes as well as different technologies are em-ployed for the transfer of implant positions and forthe construction of the superstructure.

Customized implant abutments allows for betterangulations and shape, for improved occlusal force

16 I implants3_2012

Fig. 8b Fig. 8cFig. 8a

Fig. 9a

Fig. 9b

Fig. 9c

Fig. 10Fig. 9d

research I

transmission from the crown to the implant and thebone, and also for facilitating the fabrication of an es-thetically pleasing implant-supported denture. Waysin which abutment design contributes to improvedesthetics include changes in the location of the crownand changes in the dimension and/or form of therestorative platform.

Additionally, features of the abutment design con-tribute to the health and dimensional stability of thesoft tissue. Current attempts to objectively define im-plant-restoration esthetics have focused on periim-plant mucosal parameters.13,14 The introduction of theUCLA abutment provided a custom solution for im-plant restorations. This direct-to-implant restorationconcept provided adaptability. Through waxing andcasting, the height, diameter and angulations can beaddressed in order to provide a wide range of clinicalsolutions for problems associated with limited inte-rocclusal distance, interproximal distance, implantangulations and related soft tissue responses.15

The customized implant abutments served as pri-mary telescopes, and the electroformed copingsserved as secondary telescopes in cases where a re-movable denture with telescopic crowns was used asthe attachment. Electroformed gold copings are as-

sociated with several advantages, in conjunction withboth removable and fixed restorations. The galvano-forming and electroforming process yielded a pre-cisely-fitted secondary coping for the implant abut-ment with a gap of only 12–30 µm. The gold electro-formed coping saves space and is made of high-qual-ity material.2-4 Using gold copings for the impressionallows for the exact transfer of the form, angulationsand position of the inserted customized implantabutments.

With the help of the milled mock-up, the future fitof the CAD/CAM fabricated framework can be evalu-ated and necessary changes in the shape of therestoration and occlusion can be made. Making thesechanges on the mock-up was easier and less time

Figs. 11a & b_A case of fixed implant

retained denture for the maxilla

full-arch rehabilitation: trial of the

mock-up (Fig. 11a) and the milled

temporary fixed denture is placed on

the abutments (Fig. 11b).

I 17implants3_2012

Fig. 11a Fig. 11b

Please contact Claudia Jahn

c.jahn@oemus-media.de

AD

[PIC

TUR

E: ©

SU

KIY

AKI]

consuming than making them on the metal frame-work itself, and it was then possible to transfer themdirectly to the final framework. Furthermore, themock-up almost “splinted” the electroformed goldcopings during the impression, allowing for the exacttransfer of the abutment position. At the same time,the vertical height and interocclusal relationshipwere recorded. The delivery of a milled temporaryrestoration permitted a slow and non-progressiveloading of the implants, which then leads to bone re-modeling.16 Abutments were left in place aftermounting. Combined with the fabrication of a newcast, this further decreased the risk of inaccuraciesduring the transfer process.

_Conclusion

The method described here can be used for full-arch restorations with both fixed and removable im-plant supported dentures. Accurate impressions canbe accomplished and occlusion, vertical dimensions,as well as implant positions can be transferred while

facilitating the full-arch restoration process. In addi-tion, this technique resulted in a reduction of the re-quired chair time

Disadvantages of this technique lie in the fact thatthe quality of laboratory technician’s work meetshigher demands than usual, and that the clinician alsoneeds to acquire some additional skills. Further disad-vantages of this method include the need for a highlyqualified technical lab and higher technical costs rel-ative to those associated with prefabricated titan im-plant abutments.

To date, this method has not been applied in con-junction with immediate implant loading. However,dentists and patients have come to expect this level ofrehabilitative accuracy, precision, long-term successand aesthetics._

Editorial note: A complete list of references is available

from the publisher.

I research

Figs 12a–c_A case of fixed-implant

retained denture for the maxilla

full-arch rehabilitation, rigth site

(Fig. 12a), anterior area (Fig. 12b),

left site (Fig. 12c).

Figs. 13a–c_Impression of a case

with natural dentition (teeth #11 and

#12) and implants. Master cast in the

articulator with a duplicate of the

over-denture in place (Fig. 13b).

Gold copings fixed on the remaining

teeth #11 and #12 and customized

implant abutments mounted on the

implants (both of them served as

primary telescopes, Fig. 13c).

Fig. 14_DentDu modified for open-

tray impression technique.

18 I implants3_2012

Prof Dr Gregory-George Zafiropoulos

Blaues Haus

Sternstr. 61

40479 Düsseldorf, Germany

zafiropoulos@blaues-haus-duesseldorf.de

www.blaues-haus-duesseldorf.de

_contact implants

Fig. 13b Fig. 13c

Fig. 12b Fig. 12c

Fig. 13a

Fig. 12a

Fig. 14

Visit nobelbiocare.com/active3

© Nobel Biocare Services AG, 2012. 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.

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NActive 3.0 A4 IMPLANTS.pdf 1NActive 3.0 A4 IMPLANTS.pdf 1 02.07.12 11:3902.07.12 11:39

I research

Fig. 1_Mounted titanium brush

(PeriBrush™, Tigran Technologies).

Fig. 2_The titanium brush was

designed to match the implant

architecture.

_Introduction

The mechanical debridement of implants as partof peri-implantitis therapy is time-consuming andtedious. The use of rotating brushes with titaniumbristles can result in significantly shortened treat-ment times. Compared with mechanical curettage,they ensure a gentler and more even treatment ofthe exposed portions of the thread.

Despite—or because of—the success story of oralimplantology, peri-implantitis, associated with sig-nificant bone loss, is on the rise. A meta-analysisperformed by Berglundh et al. in 2002 (which in-cluded periimplant mucositis) showed that the inci-dence of periimplant disease for different implantsystems was between 5 and 8 per cent.1 In fact, theprevalence of periimplantitis alone is assumed to bebetween 10 and 20 per cent today.2, 3 The biologicalresponse to the implant and the implant’s ability tointegrate with the surrounding tissue are deter-mined by the structure of the implant surface.Roughened implant surfaces to enlarge the bioac-tive surface are a clinically proven method and havebeen accepted by all manufacturers as the basis for

successful osseointegration of their implants.4, 5 Ad-vanced periimplantitis invariably leads to bone lossand, hence, to the exposure of implant surfaces, in-cluding threaded parts. One of the most frequentlydiscussed topics in oral implantology today is thatof finding the right treatment approach in this situ-ation. In cases with pocket depths of more than 6 mm, surgical access followed by mechanicalcleaning and decontamination of the exposed por-tions of the thread is certainly an option. Followingbone loss, the implant surface is generally coveredby concrements, necrotic bone and inflammatorytissue. Proper debridement thus requires mechani-cal cleaning of the implant surface to remove con-crements and granulomatous tissue.

This mechanical debridement is generally per-formed by specific curettes. The vertical movementsof these curettes, which have only limited contactwith the implant thread, are not very efficient. Itstands to reason that rotationally symmetrical,screw-shaped structures like those of most con-temporary implants are more rapidly and moreevenly debrided with rotary instruments (Fig. 1). Ro-tating brushes are capable of adapting more closely

Time-saving debridmentof implants with rotatingtitanium brushesAuthors_Dr Dirk U. Duddeck, Dr Viktor E. Karapetian & Dr Andrea Grandoch, Germany

20 I implants3_2012

Fig. 1 Fig. 2

Fig. 3_Implant following mechanical

debridement using a curette

(light microscope, ×20).

Fig. 4_Implant following mechanical

debridement using the titanium brush

(light microscope, ×20).

Fig. 5_Implant surface before treat-

ment (SEM, x100).

Fig. 6_Implant surface after curetting

(SEM, x100).

Fig. 7_Implant surface after

debridement using the titanium brush

(SEM, x100).

Fig. 8_Implant surface after

debridement using the titanium brush

(SEM, x200).

research I

to the architecture of the implant. In a previousstudy6 we have analyzed the effect of rotating tita-nium brushes (PeriBrush™, Tigran Technologies; Fig.2) on different types of implant surfaces. Implantswith an anodized surface and implants with a tita-nium-blasted surface were examined with a scan-ning electron microscopic (SEM) and with a KeyenceVHX 600 before and after treatment with a single-use rotating titanium brush as well as before and af-ter curetting. For the purposes of this study, thebrush was inserted into an angled hand piece andheld against the implant while rotating at 300 to 600rpm. Only minimal pressure was applied, becauseexcessive pressure can bend the titanium brushesand reduce the cleaning effect. Under the light mi-croscope, the traces of curettage are clearly visible(Fig. 3), whereas the treatment with the rotatingbrush results in only barely discernible damage tothe implant surface. The brush has an even, slightlysmoothing effect on the implant surface (Fig. 4). Thisis confirmed by the corresponding SEM images(Figs. 5–8).

The topographic effect of the rotating brush onthe implants surface and on the brush itself is di-rectly correlated with the horizontal load/force andthe duration of the treatment. In the actual study“Clinical parameters for the use of rotating titaniumdebridement brushes” we analyzed the surface ef-

fects of different loads/forces between 10 and 60 g/ 0.1-0.6 N on the surface of sandblasted and acidetched implants.

Four implants were fixed at the apex in PatternResin, GC. The Pattern Resin plate with the implantin the middle was fixed in a turning machine andcarefully turned down until a complete rationalsymmetry with the centered implant was achieved(Fig. 9). Two screws fixed the Pattern Resin plate withthe centered implant on a motor driven plate of alu-minum (Fig 10).

To ensure the different horizontal loads/forcesonto the KaVo angel piece and therefore on the ro-tating PeriBrush, a spring based construction(spring steel wire) with defined distances of impres-sion under load was used. The spring length showsa linear correlation to the load/force as seen in Fig-ure 11.

Fixed in an angle piece (KaVo), the Tigran™ Peri-Brush™ transfers a defined horizontal load/force onthe implants surface according to the predefinedlength of the spring. The angle piece works with ad-ditional rinsing at 600 rpm and has been applied ver-tically against the implant at an angle about 20–30degrees, so that the bristles make contact with thecircular side of the implant and also clean in be-

I 21implants3_2012

Fig. 3 Fig. 4

Fig. 5 Fig. 6 Fig. 7 Fig. 8

I research

Fig. 9_Turning machine with

centered implant.

Fig. 10_Spring based horizontal load

and overview of the lab situation.

Fig. 11_Spring length shows a linear

correlation to the load/force.

Fig. 12_Tigran™ PeriBrush™

before use.

Fig. 13_Brush after load/force of

20g/0.2N for 60 sec.

Fig. 14_Brush after load/force of

60g/0.6N for 120 sec.

Fig. 15_Clinical case exhibiting

pronounced periimplantitis.

Debridement is effected within 60

seconds under continuous saline

irrigation.

tween the threads (Fig. 11). The round aluminumtable rotated at 20 rpm (clinical measured averageturns with the rotating device around the implant).

Samples of the Tigran™ PeriBrush™—before andafter use—and dental implants with sandblasted-acid-etched titanium surfaces before and after thetreatment with rinsing were investigated by scan-ning electron microscopy (SEM) after differentloads/forces and treatment time. The load/force of20 g/0.2 N for 60 seconds is the suggested and rec-ommended normal treatment case and 60 g/0.6 Nfor 120 seconds of treatment time, as this load/forceis the suggested worst case scenario.

SEM analysis confirmed the gentle polishing ef-fect to the implant surface with all loads/forces inthis study. Loads/forces of more than 60 g/0.6 N and120 sec of treatment time (worst case) results in mi-nor damage to the brush—caused by an uncon-trolled vibration with a “slip-off” of the brush thus

bending, but not rupturing the fine titanium bristles(Figs. 12–14).

Another advantage of the PeriBrush, beyond thegentler and more effective cleaning of the implant sur-faces, is the significantly shortened treatment time. Theimplant surfaces can be cleaned within a few secondsunder continuous irrigation with sterile saline solution(Fig. 15)._

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

22 I implants3_2012

Dr Dirk U. Duddeck

Dr Viktor E. Karapetian

Dr Andrea Grandoch

Interdisciplinary Policlinic for Oral Surgery and ImplantologyDepartment of Oral and Maxillofacial Plastic Surgery, University of CologneHead: Prof Dr Dr Joachim E. ZöllerKerpener Straße 6250937 Köln, Germany

dirk.duddeck@uk-koeln.de

_contact implants

Fig. 9 Fig. 10

Fig. 11

Fig. 15Fig. 14Fig. 13Fig. 12

April 12–13, 2013Rom, Italy I Sapienza Università di Roma

Giornate RomaneImplantologia senza limitiScientific Chairman

Prof. Dr. Mauro Marincola/RomProf. Dr. Andrea Cicconetti/Rom

SpeakersProf. Dr. Hans Behrbohm/Berlin I Prof. Dr. Andrea Cicconetti/Rom I Prof. Dr. Dr. RolfEwers/Wien I Prof. Dr. Mauro Marincola/Rom I Prof. Dr. Marcel Wainwright/Düssel-dorf I Prof. Mauro Labanca/Mailand I Priv.-Doz. Dr. Dr. Steffen G. Köhler/Berlin IDr. Georg Bayer/Landsberg am Lech I Dr. Vincent J. Morgan, DMD/Boston I Dr. MariusSteigmann/Neckar gemünd I DDr. Angelo Trödhan/Wien I Dr. Ulrich Volz/ Meersburg

Organzier I OEMUS MEDIA AGHolbeinstraße 29 I 04229 Leipzig, Germany I Tel.: +49 341 48474-308 I Fax: +49 341 48474-390 I event@oemus-media.de I www.oemus.com

implants 3/12

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I case report

_Introduction

Endodontic and periodontal problems, such as sur-gical complications, often place before the professionalthe dilemma of choosing between tooth preservationand extraction. Correctly performed root planing usu-ally leads to soft-tissue recession. In cases of tooth mo-bility, periodontal surgery can improve the situationonly in the short term. Tooth loss eventually follows af-ter some months or years, not to mention the aestheticdisadvantages of flap elevation and tissue excision af-ter periodontal surgical treatment. Similar outcomesare predicted for teeth following endodontic treatment,particularly if they show complications or have under-gone root resection. The combination of endodonticand periodontal problems, as with periodontal-en-dodontic lesions, endangers the tooth, as well as thebone and the anatomy of the jaw. Lesions such as thesecan result in severe defects, hampering any subsequenttreatment with prostheses.1

The question one ought to be asking is whether atooth in the aesthetic zone should be treated until alltreatment options have been exhausted or whether theextraction of this tooth at the right time could increasethe success and aesthetic outcome of the implant treat-ment. The extraction of a tooth in the aesthetic zone im-mediately solves the inflammation problem, but the dif-ficulties only begin at this point. There are many aspectsto take care of in order to achieve aesthetic success.Analysis of hard and soft tissue, the implant system,time of implantation, flap design and closure of the area,implant position, implant dimensions, temporary treat-ment and prostheses are all factors that influence thetreatment outcome massively.

_Case history

A 34-year-old female patient visited our practicetwo years ago, with complaints about her maxillary cen-tral incisor (tooth #21). The tooth had been treated en-dodontically eight years before. Five years later, thetooth had been retreated owing to complaints and shehad undergone root resection a year later. Afterwards,an intra-radicular post and a metal ceramic crown hadbeen placed.

At the time of the patient’s first visit, the tooth wasmobile, bled from the periodontal gap during brushingand caused pain, resulting in headaches. Consideringthe extended period for which the patient had beenstruggling with this tooth, a quick and effective decisionhad to be made.

_Findings

There were no general pathological findings. Clini-cally, we found a Grade I mobility in tooth #21, a mobilecrown on tooth #21, and a bleeding on probing score of3. The sulcus probing depth was 2 to 3 mm. The verticalpercussion test was negative at this point (Fig. 1). Therest of the teeth exhibited no pathological findings.

Immediate implantation inthe anterior maxillaPlanning in reverse

Authors_Dr Nikolaos Papagiannoulis, Dr Olaf Daum, Dr Eduard Sandberg & Dr Marius Steigmann, Germany

24 I implants3_2012

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

Fig. 2a Fig. 2b

case report I

The radiological control showed sufficient root fill-ing. The crown was not optimally placed and the intra-radicular post was of insufficient length and diameter(Fig. 1). Our initial suspicion of inflammation at the rootproved negative following a second X-ray.

_Treatment focus

The replacement of the intra-radicular post and anew crown did not seem to be sufficient treatment.Owing to the caries under the crown, the crownlengthening necessary to establish adequate biologi-cal width and the patient’s complaints regarding thisregion, any further effort to preserve this tooth madeno sense to us. The aesthetic outcome was anotherreason to promote tooth extraction. Any further con-servative therapy would have resulted in aesthetic de-ficiencies. The patient also desired an efficient solutionthat would put an end to the problems in this region.Furthermore, the adjacent teeth only had small fillingsat the palatal surface and it would have been a pity tohave to prepare them for prosthodontics. Also for thisreason, the patient rejected prosthodontic treatmentof the adjacent teeth.2-5, 7

Our decision was to extract the tooth and imme-diately place an implant in order to support the softtissue, influence bone remodelling and offer a tem-porary tooth replacement without a flipper.6,3,7,8,9,10,1

As the maxillary anterior region is an aestheticallysensitive region, we planned for an immediate im-plantation with simultaneous guided bone regener-ation (GBR).11,12 As for the prosthesis, we selected abiocompatible metal-ceramic crown for financialreasons.

_Treatment plan

Professional tooth cleaning and patient instruction

As a standard procedure, the patient received pro-fessional tooth cleaning before implantation in orderto achieve optimal hygiene conditions. He also re-ceived behaviour and hygiene instruction and was en-couraged to follow a good oral hygiene routine.

Extraction

The tooth extraction was performed as carefully aspossible and the socket was decontaminated withchlorhexidine solution and tetracycline for ten min-utes. Although mobile, the periodontal fibres wereseparated with a periotome. The tooth was mobilisedwith the same instrument until an atraumatic post ex-traction was possible. Together with the tooth, wemanaged to remove the apical cyst without needing toscale the socket. Careful inspection of the socket wallswas necessary to prevent inflamed tissue affecting theGBR. There was also no perforation of the buccal plate(Fig. 1).9, 13

_Implantation and guided bone regeneration

The implant we selected for this case was the inter-nal hex Laser-Lok implant (BioHorizons), which is ta-pered with microgrooves at the implant neck. Our aimwas to achieve maximal bone adaptation to the crestalportion and soft-tissue adaptation to the implantneck.14, 15, 10, 17-19 We used a periodontal probe to inspectthe socket. The socket was rinsed again with chlorhexi-dine solution before proceeding with the implantation.Apart from the final drilling, the drill sequence was per-formed with water irrigation. The last drilling was per-formed at 40 rpm/min and maximum torque in order todecrease the risk of ridge injury.

The gap width was 10.5 mm in the mesial-distal di-rection and 6 mm from the inner ridge in the oral-vestibular direction. The crestal thickness of the ridgewalls was 0.5 to 1 mm (Figs. 2–4).6, 7, 9 Therefore, we de-cided to use a 4.6 mm implant with a length of 12 mm.Simultaneous to the implantation, we performedguided bone augmentation in order to fill the gap be-tween implant and ridge and to influence bone remod-elling during implant healing. The gap between the im-plant and buccal bone plate was 1.4 mm. Combined withthe augmentation material (allograft using maxgraft,botiss) in this gap and on the buccal plate, we plannedto preserve at least 2 mm buccally after bone remodel-ling.

One third of the implant was inserted. Augmentationfollowed and then we inserted the implant com-

I 25implants3_2012

Fig. 3a Fig. 3b

Fig. 4a Fig. 4b

Fig. 5bFig. 5a

I case report

pletely.20, 6 In this way, we were ensured augmentationof the entire ridge and not only the crestal portion.For GBR, we used autologous bone extracted with abone scraper (to preserve living osteoblasts) andnon-resorbable hydroxyapatite (cerabone, botiss)for 3-D stability. The implant was placed sub-cre-stally at 1.5 mm in order to prevent under-coveredgeowing to bone resorption, which is inevitable follow-ing tooth extraction.21 Although the implant-neckdesign guarantees soft-tissue adaptation, we se-lected this kind of implant placement, since wefeared unpredictable bone behaviour after so manyyears of continuous endodontic and inflammatoryproblems in this region.

Another advantage of this implant system is theall-in-one abutment, which supports positioningcontrol and reverse planning for the prosthodontictreatment as an insertion aid. The implant was placedaccording to the best surgical position and the pros-thetic position. A second all-in-one abutment wasshortened to a length of 2 mm and used as a coverscrew in order to achieve optimal soft-tissue support(Figs. 5 & 6). In this manner, we conditioned the softtissue to form the final desired emergence profile.

Owing to the mild but unpredictable inflammationin region 21, we decided against a flap and primaryclosure of the operating area. The soft tissue wasraised buccally in order to place a pericardium mem-brane (Jason, botiss). The membrane covered the

whole ridge up to the palatal wall, where it was se-cured between the gingiva and crestal ridge using a 4-0 Supramid horizontal mattress suture (S. Jackson).We placed a collagen fleece over the membrane toprevent proteolytic resorption of the exposed mem-brane. The fleece was secured with a 5-0 PROLENEcriss-cross suture (ETHICON, Fig. 7).

Temporary crown

Temporary treatment of the gap was crucial. Freegranulation of the extraction wound resulted in ahigh risk of soft-tissue dehiscence. In order to fill thegap, to support and form soft tissue, and to rehabili-tate the patient aesthetically, we trimmed the ex-tracted tooth to form a pontic and attached it withflowable composite (Tetric EvoFlow, Ivoclar Vivadent)to the adjacent teeth. After soft-tissue coverage ofthe ridge, we attached a Maryland bridge to optimiseaesthetics. The papilla support was perfect and theoutcome until implant exposure was stabilised. Thesutures were removed four weeks post-operativelyand two weeks after the Maryland bridge had been at-tached, without having to remove it (Figs. 5, 6, 8 & 9).

Healing phase

During the healing phase, we followed a frequentrecall pattern of one, two, three, four, eight, twelveand 16 weeks. In addition to hygiene instructions, thepatient was informed about the importance of thecontrol appointments. During the healing phase,there were no complications, inflammation or com-plaints from the patient.

Exposure

The implant was uncovered after 14 weeks. Owingto sufficient soft-tissue thickness on the labial side,we decided to uncover with a tissue punch. The tissuepunch was 1 mm thick. The operation resulted in asoft-tissue height of 3 mm crestally up to the implantneck. The papillae were maintained, and labially the

26 I implants3_2012

Fig. 6a Fig. 6b Fig. 6c

Fig. 7a Fig. 7b Fig. 8a Fig. 8b

Fig. 9 Fig. 10

case report I

I 27implants3_2012

contours of the bone and the soft tissue were harmo-nious and at optimum level aesthetically. These find-ings ensured a highly aesthetic outcome (Figs. 10 &11).

Pre-prosthetic phase

At this point, we decided against a healing abutment.Assuming that implant transfer, abutment and healingabutment have the same emergence profile, we fabri-cated the final abutment after impression and insertedit with a temporary resin crown (Trim, Bosworth). Thetemporary crown had exactly the same form as the finalcrown and conditioned the tissue for the time needed tofabricate the final crown (Fig. 12).

Prosthetic phase

Two weeks after uncovering the implant, we per-formed the final crown fitting. The abutment length was5.5 mm and the crown retention part had a length of 4.5 mm. The crown length was 8.5 mm and the distancebetween approximal contact and crestal bone was 4 mm(Fig. 13). The patient was pleased with the aesthetic out-come.

Recall appointments for clinical and radiologicalcontrol took place at one week, as well as six, 12 and 18months. At each appointment, stable conditions in thecrestal bone and in the soft tissue were exhibited. At the24-month follow-up, no recessions or clinical or radio-logical crestal bone resorption was apparent.

_Discussion

Nowadays, we know that osseointegration worksand we know how it works. We can also achieve pre-dictable and repeatable results. The correct implant po-sition is crucial for long-term success, and is both a sur-gical and a prosthetic parameter. No matter how wellimplants are inserted, grafted or osseointegrated, if theangulation and position are not beneficial for the pros-thesis, the outcome will be neither aesthetic nor durable.The clinician must first decide where to place the abut-ment and decide upon the emergence profile before heperforms the surgical part. As implantology becomes anincreasingly important treatment option, osseointe-gration and a firm bite, as well as functional stability,aesthetic and long-lasting results, are more frequentlydemanded by the patients.

A crucial question has to be asked: now that aes-thetics is becoming increasingly important, how muchsense do conservative treatments make in cases such asthe one described here? Is it better to extract a toothcausing ongoing problems at the right time, rather thantrying to preserve it and losing bone and soft tissue?When we wait for too long, we lose bone and soft-tis-sue aesthetics and limit our implantological treatmentoptions. In this case, extracting the tooth was the cor-

rect choice, as was placing the implant immediately.Seeking to influence bone remodelling by augmenta-tion was also a good decision. Using an all-in-one abut-ment as a cover screw and scaffold for the soft tissuewas also the only way to achieve an aesthetic outcome.

All these aspects, as well as correct positioning, pros-thesis and recall, are factors that must be planned be-fore surgery. Reverse planning is very important. If theplanning is correctly structured, the surgical part entailsonly a drill sequence, especially when using computerguidance. Patients do not only want to eat with theirteeth, but they want them to look good for a long time.This can only be achieved if we choose the right systemfor each patient, customise our operating protocol ac-cording to each individual situation, decide first wherewe want to place the abutment for perfect prostheticsand then manipulate the soft tissue without a scalpel.We can preserve the crestal bone by both adequate sur-gical bone treatments and soft tissue.

Each technique works well within its specific rangeof indication. The correct decision with regard to whichtechnique to use, when and for which patient is the keyto success. In addition, collaboration between surgeon,prosthetic specialist and technician is necessary toachieve the desired result._

Dr Nikolaos Papagiannoulis

Heidelberg Clinic for plastic and cosmetic surgery proaestheticBrückenkopfstraße 1/2, 69120 Heidelberg

Tel.: +49 6221 6461-0Fax: +49 6221 6460-20www.proaesthetic.de

_contact implants

Fig. 11a Fig. 11b

Fig. 12 Fig. 13a Fig. 13b

I industry report

_Introduction

The concept of having only four SHORT® implantsfor the support of a fixed full arch non-metallic pros-thesis (Trinia™), a CAD/CAM fiber reinforced resin, wasfirst executed in 2010. The clinically based results per-formed in three different implant dentistry centersare showing clinical success because of Trinia’s inher-ent mechanical and clinical properties. Another fac-tor were the 360 degrees of universal abutment posi-tioning provided by the Implants Locking Taper con-nection (Bicon®), which gives the opportunity to usethe Trinia™ prosthesis to orient and seat the abut-ments in the well of the implants. The Trinia frame-work may be covered with either customized poly-ce-ramic indirect composite material or by conventionaldenture teeth and resin.

In the following case presentation, we want toshow how short implants have been successfully usedto restore severely atrophic mandibles without theuse of difficult bone augmentation procedures andcomplicated prosthetic suprastructures in the pastdecade.

_Material and methods

Bicon Dental implants (Bicon LLC, Boston, MA,USA) were used for the reconstruction of the case,combined with a CAD/CAM fiber reinforced resinframework (Trinia™) and conventional denture teethand resin prosthesis. Bicon implants can be charac-terized by their special macro-structure, including aroot-shaped design with wide fins called plateaus, bya sloping shoulder and by a well which holds the abut-ment post by means of a Locking Taper connection.1

The plateaus are of particular importance for thebiomechanical performance, allowing SHORT® im-plants with a wide diameter to be used in any positionin the oral cavity. Their insertion into the osteotomy,which has been prepared using atraumatic drills ro-tating at 50 rpm, is executed by using mechanicalpressure. The countless micro-retentions created on

Fixed full arch metal-freeprosthesis on fourSHORT® implantsAuthors_Dr Mauro Marincola, Italy, Dr Vincent J. Morgan, USA, Angelo Perpetuini & Stefano Lapucci, Italy

28 I implants3_2012

Fig. 3 Fig. 4Fig. 2

Fig. 1

industry report I

the surface of the fin edges with the walls of the os-teotomy ensure primary stability of the implant in theimplant site. Furthermore, the wide spaces betweenthe plateaus avoid vertical compression on the bonewalls and rapidly collect the clotted blood, allowingrapid bone formation without the classicmacrophagic and osteoclastic processes of bone re-sorption taking place. Thus well defined bone isformed, with haversian canals and blood vesselswhich enable continuous bone remodelling aroundthe implant/bone contact surface. This ensures stabil-ity of the implant in any situation involving biome-chanical stimulus.2

The sloping shoulder is vitally important for thepreservation of crestal bone after implant osseointe-gration and for implant function. The Bicon implantdesign offers platform switching with a neck whichconverges from the widest diameter of the firstplateau, to 2 or 3 mm towards the crestal zone (con-verting crest module). In our patient, we used im-plants 5 mm in diameter, but the space taken up atcrestal level is only 3 mm. This ensures bone augmen-tation above the neck, also because the implant isseated at least 1 mm below the crest during the firstsurgical stage. This allows the above structures, suchas the crestal bone, periosteum and epithelium, togrow around the hemispherical base of the abutmentand to give sufficient space for maintenance and thegrowth of the papillae.

Another important factor for obtaining long-termcrestal bone stability is the bacterial seal within theconnection between implant and abutment. If crestal

bone maintenance and the formation of papillae canonly be achieved when the implant is placed in a sub-crestal position and by platform switching at the levelof the implant neck, it is also true that this situationcan only be accomplished if the connection is her-metically sealed from bacterial infiltration. Withoutthis feature, the placement of a sub-crestal implantwithout a bacterial seal would result in the rapidspread of pathogens around vital structures, crestalbone, periosteum and epithelium. The result would bebone resorption well below the original crestal bonelevel.

Bicon’s locking taper is a design feature ensuringcrestal bone level maintenance around an implantwith a convergent sloping shoulder placed subcre-stally.3 The Locking Taper is a precise connectionformed by cold welding out of two surfaces of thesame material which are brought into close contactwith pressure. In this way, the oxidation layers—formed both on the abutment post and on the surfaceof the implant well—are detached.4, 5 The prostheticcomponents (one-piece titanium abutments madefrom the same surgical grade titanium alloy as the im-plants) ensure maximum mechanical resistance andoptimum biocompatibility. The subgingival hemi-spheric base geometry is ideal for the stability of peri-implant connective tissues.

The abutments are connected to the implant wellby means of a post, which is 2 mm, 2.5 mm or 3 mm indiameter. Implants which are 3.0 mm and 3.5 mm indiameter are suitable for 2 mm posts, while implantsof a diameter of 4.5 mm, 5 mm or 6 mm match with

I 29implants3_2012

Fig. 5 Fig. 6 Fig. 7

Fig. 8 Fig. 9 Fig. 10

I industry report

abutments with a 3 mm post. All of the abutmentposts have diameters or emergence profiles of 3.5, 4.0,5.0 or 6.5 mm, suitable for allowing a natural anatom-ical shape of the soft tissues. Abutment diameters aretherefore independent of implant diameters, whichmeans that any implant may host the four differentabutment emergence profiles. The different emer-gence profiles start from the 2 mm , 2.5 mm or 3 mmposts, placed at crestal bone level. The geometry of theabutments provides for platform switching even at aprosthetic level, which is of vital importance in the or-ganization of the connecting tissue and the epitheliallayer.

The supraperiosteal space involved in the shift fromthe connecting post diameter (2–3 mm) to the diame-ter of the abutment hemisphere (3–6.5 mm), allows athicker and denser connecting tissue to form, resultingin the optimal preservation of the papilla. In the fol-lowing case, all the selected abutments have a 3 mmpost, as they must connect to the 3 mm wells of the 5.0x 6.0 mm implants. Abutment post heights, inclinationsand diameters are selected in the laboratory in accor-dance with the position of the implants relative to theanatomy of the alveolar ridge.

Trinia is a CAD/CAM multidirectional fiber rein-forced resin material, which despite its leight weight iscapable of withstanding occlusal forces.

_Case report

A 52-year-old male patient, presenting a severelycompromised mandibular bone, was treated with theplacement of four short implants. Two SHORT® im-plants (4.5 x 8 mm) were placed bilaterally at the canineregion and two ULTRA SHORT® implants (4 x 5 mm)were bilaterally located at the first molar region (Fig. 1).The implants were placed in a two-stage surgery andthey were uncovered after a healing period of threemonths (Figs. 2 and 3).

Clinically, the prosthetic treatment began with animplant level transfer impression by inserting with onlyfinger pressure a green impression post with its corre-sponding acrylic sleeve into the 3.0 mm implant well,

prior to recording their position by making an implantlevel impression with any conventional impressionmaterial (Fig 4). Upon the removal of the full arch im-pression, green impression posts were removed fromthe implant wells and inserted into an implant analogof the same color before inserting them into their cor-responding acrylic sleeves within the impression.

Prior to the pouring of a stone model, a resilientacrylic was applied around the impression posts to sim-ulate a soft tissue contour in the stone model. The stonemodelwas used for the fabrication of a wax bite rim torecord the occlusal registrations. After articulation ofthe models, appropriate abutments with the largestpractical hemispherical base were selected and in-serted into their corresponding implant analogs withinthe stone model. Their prosthetic posts were thenmilled parallel to one another (Fig. 5).

The model with the milled abutments was used tofabricate a light cured resin bar and denture tooth setup for an intra-oral confirmation of the arranged teeth.Once the denture set-up had been clinically approved,a facial occlusal silicone mask was initially formed overthe denture wax set up. Prior to forming the lingual sil-icone mask, indexing or alignment grooves were placedin the facial occlusal mask. After fabrication of the lin-gual mask, grooves were cut into the stone model toprevent the subsequent entrapment of air, when acrylicwas poured into the silicone flask through anterior cut-away or aperture in the lingual mask. Prior to the re-moval of the wax denture tooth set up from the stonemodel, the facial lingual extent of the wax denturetooth set up on the alveolar ridge was marked on thestone model with a pencil.

After the removal of the denture teeth and wax fromthe resin bar, the teeth were cleaned and linguallyroughened or modified prior to being facially glued tothe facial occlusal silicone mask with cyanoacrylateglue. An uneven thin application of clear resin was thenapplied to the cervical area of the teeth on the mask toachieve an aesthetic stratification of the gingival den-ture resin. The facial occlusal mask and the resin barwere then repositioned on the model to confirm the ap-propriateness of their contours relative to each other

30 I implants3_2012

Fig. 12 Fig. 13Fig. 11

industry report I

and particularly to the cervical gingival area of the in-tended teeth. If necessary, the resin bar may be modi-fied by adding wax or by reducing it with a bur. Prior toits being sprayed and digitally scanned, the space be-tween the resin bar and the ridge area between the pen-cil lines on the model is filled with a putty material, sothat the milled framework can be in contact with thesoft tissue of the edentulous ridge (Fig. 6).

After the model with the milled abutments and theresin bar were separately sprayed and scanned, theTrinia fiber resin bar was digitally designed on the com-puter with a minimum thickness of 7.0 mm through-out, an abutment clearance of 30 microns for cementand with a maximum cantilever extension of 21.0 mm.If necessary, the milled Trinia framework may have beenjudiciously reduced manually.

After cleaning the milled Trinia framework with al-cohol, it was placed onto the milled abutments to eval-uate and, if necessary, modify the marginal adaptationof the framework to the abutments and to the alveolarridge of the model. The ridge side of the frameworkshould be convex without any concavities. Addition-ally, the Trinia framework was used to confirm both thepath of insertion of the prosthesis and the sequence ofinsertion of the milled abutments on the model. Afterthe sequence and path of insertion were confirmed, thefacial, occlusal and lingual masks were repositioned onthe model and attached together with cyanoacrylateglue (Fig. 7).

A thin mix of denture resin was poured into the sil-icone flask through the anterior cutaway or aperture inthe lingual mask. Final polymerization was achievedwhile the silicone flask and models were under hot wa-ter, with an air pressure of 3 bars. After polymerization,the Trinia prosthesis was removed from its siliconeflask, then finished and polished in a conventionalmanner. Clinically, after the removal of the temporaryabutments from the implant wells, at least two milledabutments were incompletely inserted into the pros-thesis. If necessary, they were stabilized with an appli-cation of Vaseline, prior to their being transported tothe mouth and inserted into the well of their implant(Fig. 8). The loosely fitting abutment facilitated its in-sertion into the well of the implant (Fig. 9). Once theabutment was initially seated, the prosthesis was re-moved for the definitive seating by tapping directlyonto the titanium abutment. This seating process wascontinued until all of the abutments were definitivelyseated (Figs. 10 to 12).

Alternatively, an abutment could have been initiallybe loosely seated in the well of the implant, prior to theprosthesis being used to orient and seat the abutmentin the well of the implant. Final or temporary cementa-tion was achieved by first applying Vaseline over the

ridge area of the prosthesis to facilitate the removal ofany extraneous cement. Only a minimum of cementwas applied to the bores in the Trinia framework beforeinserting the prosthesis in the mouth. The extraneouscement was blown away with an application of air un-der the prosthesis. The occlusion was evaluated and ad-justed (Figs. 13 & 14).

_Conclusion

Regardless of which type of material will ultimatelybe used to cover the Trinia framework, it was essentialto have an anterior diagnostic positioning, wax rim, orarrangement of the intended teeth prior to the fabrica-tion of the Trinia CAD/CAM framework.

In our clinical case, Meyor composite denture teethwere used for the final prosthetic to assure a good bio-mechanical force distribution around the four SHORT®implants. The follow-ups of our patients treated withthe described technique was showing a good gingivalresponse and no marginal bone loss around the plat-form switched implant neck of the SHORT® or ULTRASHORT® implants (Bicon Dental Implants) used in ourcase presentation and in 60 other cases treated in threedifferent Implant Dentistry Centers.

This technique of a fixed prosthesis on only fourshort implants deserves a clinical, long term, evidence-based study because of its low costs and reduced treat-ment time with minimum morbidity and good patientresponse._

Editorial note: A complete list of references is available

from the publisher.

I 31implants3_2012

Prof Dr Mauro Marincola

Via dei Gracchi, 285I-00192 Roma, Italy

mmarincola@gmail.com

_contact implants

Fig. 14

I industry report

Fig. 1_Orthopantomogram post

insertion of the XiVE TG implant.

Fig. 2_The Friadent MP abutments

transfer the working level from the

edge of the bone to a

supragingival level.

_Introduction

There is probably no other treatment method thatturns our patients’ quality of life for the better so crit-ically and predictably as the restoration of the eden-tulous jaw using implantsupported dental replace-ments (Alfadda et al., 2009). An implant-based, tele-scopic bridge should be viewed as the treatment ofchoice for the rehabilitation of an edentulousmandible (Abd El-Dayem et al., 2009). This is the con-clusion drawn from the results of an investigation byEitner and his colleagues in 2008, especially inanatomically difficult situations, in which an implant-supported superstructure guarantees an adequateprosthetic rehabilitation. Visser et al. showed in 2009that the implant-supported restoration of the eden-tulous maxilla also represents a proven and effectivetreatment method with predictable success.

_Connection elements

Various anchoring elements such as bars, doublecrowns and a variety of prefabricated connection el-ements for the replacement of teeth have been dis-cussed in the past (Alfadda et al., 2009; Eitner et al.,

2008). A bar connection and telescopic crowns are fa-vored for the edentulous maxilla, since, in contrast toflexible connections, these can prevent the denturefrom tilting. Which of these two connection types isto be preferred, however, seems unclear. Implantssupporting telescopic crowns exhibit a reduced sulcusfluid rate, which is interpreted as a sign of a slight in-flammation of the periimplant tissues. This, however,as Eitner and his colleagues showed, does not lead toa reduced rate of implant loss in comparison with im-plant-supported bars, even over a longer period. Bar-retained, implant-supported superstructures, on theother hand, are significantly less prone to repair, withthe result that, according to the working party underEitner, no alternative restoration can be identified asto be preferred. In each case, following extensivetreatment, the patient treated expects—for him, froma financial and, above all, an emotional point of view—a substantially uncomplicated, mechanically“maintenance-free” rehabilitation. In this respect,restoration using a bar-retained, removable super-structure resembling a bridge is, for us, the first choice.As a matter of principle, we include two interlockingmechanisms to improve the wearing comfort. Thisprevents a reduction in the retention of the removable

CAD/CAM-based restoration of an edentulous maxillaAuthor_Arnd Lohmann, Germany

32 I implants3_2012

Fig. 1 Fig. 2

industry report I

I 33implants3_2012

unit caused by abrasion. Furthermore, the interlock-ing gives the patient the important feeling of confi-dence, since unwanted loosening of the restoration isprecluded.

_Materials

Individually milled bars are usually cast in achrome-cobalt or gold alloy. A recent option is thecentral CAD/CAM fabrication of virtually designed barconstructions in accordance to a model scan. This fab-rication variant has numerous advantages: on the onehand, the tension-free fit of the bar on the implants isnot affected by the shrinkage of the metal caused bycooling. On the other hand, it is possible to manufac-ture the bar from titanium, which may result in a re-duction in gingival inflammation (Abd El-Dayem et al.,2009), since there is a better attachment of the tissueshere. The team under Abd El-Dayem further concludesthat both advantages together, the absolutely ten-sion-free fit of the bar and the material itself, couldlead to even less peri-implant bone resorption, whichfurther improves the long-term prognosis.

_Case presentation

A 73-year-old woman, a non-smoker with an un-remarkable medical history, was given six implantswith two milled bars as anchoring elements. FiveXiVE S plus implants were inserted during a simulta-neous sinus floor elevation and were allowed to healsubmerged over six months. When the implant was

uncovered, a vestibular graft was performed with anapical transposition flap. Due to the less favorablebone volume in region 16, an additional XiVE TG plusimplant was inserted subsequently for the purposesof the procedure and was immediately loaded (Fig. 1).The impression for the fabrication of the CAD/CAMbars was made four weeks later on the MP abutmentsinserted during this consultation (Figs. 2 & 3).

The advantage of the Friadent MP abutments is thetransfer of the working level from the implant shoul-der—that is, the crestal edge of the bone—to asupracrestal plane. Hence, the apposition of the mar-ginal tissues on the abutment components is not af-fected by try-ins and other treatment steps. Further-more, a simple visual check of the bar seating can bemade. Figure 2 shows the patient’s condition prior toimpression making, with inserted Friadent MP abut-ments. The model fabricated using the MP analogsand a XiVE TG implant analog was sent to theDENTSPLY Scan Center with the temporary construc-tion. The option of displaying and masking variousstructures, such as the soft tissues, the dentalarrangement, the implants and the bar construction,allows a simplified check of the construction proposal(Figs. 4a–4d). This is adjusted to the practitioner’spreferences as required. Galvanic bar latches aremanufactured on the titanium CAD/CAM-fabricatedbars, embedded in the openings for the slide axles. Thetertiary structure is cast from a chrome-cobalt alloy.In order to guarantee a tension-free fit for the sup-ported metal base, this was cemented to the bar

Fig. 3_Functional impression with

FRIADENT MP impression abutments

Figs. 4 a–d _Screenshots of the

virtual bar construction with

various overlays.

Fig. 5_Working model with bars,

bar slides, tertiary structure and

inserted slides.

Fig. 3 Fig. 4a Fig. 4b

Fig. 4c Fig. 4d Fig. 5

I industry report

Fig. 6_Titanium bars in situ.

Fig. 7_The metal base was

cemented intraorally.

Fig. 8_The finished tertiary structure

with open slides.

Fig. 9_Frontal view of the finished

superstructure.

Fig. 10_The incorporated restoration

in the patient’s mouth; excellent

translucence of the selected dentition

(Genios, DENTSPLY DeTrey).

Fig. 11_OPG for the follow-up;

stable conditions almost two years

after incorporation of the prosthetic

restoration.

latches in the patient’s mouth. The Genios dentition(DENTSPLY DeTrey) was transferred to the manufac-tured framework (Figs. 5–8). The final restoration wasadjusted to the patient’s mouth and inserted (Figs. 9& 10). The dentition showed excellent translucency.On follow-ups 27 months after the implant insertionand 21 months after the incorporation, the tissueconditions were stable (Fig. 11). The crestal bone levelwas still located on the implant shoulder. No resorp-tion was observed.

_Conclusion

Because of its good primary stability, even in mar-ginal situations, the XiVE implant system is applicablein an augmentation of the maxillary sinus with simul-taneous implant placement. Where there is little re-maining bone volume, the prerequisite for this is aclassic, submerged healing phase without pressure.The option of relocating the connection level to anepigingival level following uncovering reduces therisk of a deterioration of the bone in the region of theimplant shoulder due to manipulation. CAD/CAM fab-rication of the bar constructions markedly improvesthe fit of these constructions, which a practitioner

who has used this new technique will immediatelyrecognize. Together with the use of titanium as thecomponent material, the tension reduction repre-sents a further advance in the reproducible retentionof marginal bone. Furthermore, the bar constructionwith latches restores the desired level of security andhence vitality to the patient.

Editorial note: A complete list of references is available from

the author.

34 I implants3_2012

Dr Arnd Lohmann, MSc

Ostpreußische Str. 928211 Bremen, Germany

Tel.: +49 421 443868

mail@zahnarztpraxis-dr-lohmann.dewww.zahnarzt-dr-lohmann.de

_contact implantsFig. 9 Fig. 10

Fig. 11

Fig. 7 Fig. 8Fig. 6

Dr Arnd Lohmann got hisLicensure in Hamburg, Germany, in 2002 and workedas assistant doctor in Oral andMaxillofacial Surgery from 2002to 2003. In 2003 he completedhis dissertation. He has focusedon Oral Implantology since 2003

and completed his Master of Science in Oral Implan-tology in 2007. He is a member of the German Societyof Oral Implantology (Deutsche Gesellschaft fuer OraleImplantologie, DGOI), the German Association of Dental Implantology (Deutsche Gesellschaft fuer Zahnaertzliche Implantologie, DGZI) and the GermanAssociation of Oral Implantology (DeutscheGesellschaft fuer Implantologie, DGI). He works in a partnership and medical practice with Dr RainerLohmann in Bremen, Germany

_about the author implants

International events

meetings _ events I

I 35implants3_2012

2012

AAID 61st Annual Meeting Washington, DC, USA3–6 October 2012www.aaid-implant.org

42nd International Congress of DGZIHamburg, Germany5–6 October 2012www.dgzi-jahreskongress.de

ADF 2012 Conference and Trade Exhibition Paris, France27 November-1 December 2012www.adf.asso.fr

7th CAD/CAM & Computerized DentistryInternational ConferenceSingapore, Singapore6–7 Oktober 2012www.capp-asia.com

BDTA Dental Showcase 2012London, United Kingdom4–6 October 2012www.dentalshowcase.com

3rd Congress of the European Society of Microscope DentistryBerlin, Germany4-6 October 2012www.esmd.info

World Dental Show 2012Mumbai, India5–7 October 2012www.wds.org.in

Dental World 2012Budapest, Hungary11–13 October 2012www.dentalworld.hu

Expodental Milan 2012Milan, Italy18–20 October 2012www.expodental.it

NorDental – Dental Exhibition and CongressLillestrom, Norway11–13 October 2012www.npg.no

Dental-Expo St. Petersburg 2012 International Dental ForumSt Petersburg, Russia30 October–1 November 2012www.dental-expo.com

I business news

Implants with internal conical

connection like the NobelReplace CC

shown in this picture have become

more popular, according to iData

Research. (Photo courtesy of Nobel

Biocare, Switzerland)

_Introduction

The dental implant and bone graft substitute mar-ket is the most rapidly advancing segment of dentaltechnology, and leading competitors in this marketmust consistently develop new products supported byresearch from scientific and academic organizationsto remain competitive. Recent cases have demon-strated that when companies lose a segment of sup-port from the scientific community, their marketshares tend to suffer significantly.

The European dental implant and bone graft sub-stitute market has been further challenged by recenteconomic instability and the eurozone crisis, whichhas created a consistent demand for lower-cost dental implant products. As a result,many lower-priced competitors havebegun to seize larger market shares inalmost every European market. In manysegments, these competitors are eitherregional or sourced from overseas mar-kets such as Brazil, Korea and Israel. Re-generative products and barrier membraneshave been particularly affected by consumerausterity, as these products are discre-tionary in many cases. However, a grow-ing number of consumers continue todemand high-quality products, guaran-tees of service and scientific improve-ments, which only premium manufac-turers are equipped to offer. Conical in-ternal connections is one such recentinnovation, and currently constitutethe fastest-growing connection typein the dental implant industry.

Many dental implant and bone graftsubstitute companies have looked toexpand their product portfolio or create

new markets while they create package deals to offsetcompetition from rapidly emerging lower-pricedcompetitors. Significantly, many European and UScompanies involved in this market have begun to in-vest in rapidly emerging periphery markets such asTurkey.

Increasing prevalence of conical internal

connections

Dental implants are connected to final abutmentsin one of three ways: internal connections, externalconnections or single-unit devices in which the im-plant and abutment are already attached. Further-more, internal connections have two subsegments:

butt-joint internal connections and conical in-ternal connections. Research has shown that

a lack of intimate fit of the implant in theabutment or movement of the implantcan provide an area for bacterialgrowth. Conventional butt-joint con-nections provide a connection that canresult in micro-movement between the

implant and the abutment, creating apump effect for bacteria into the connection

area. When bacteria are present in the micro-gap, they can cause inflammation, tissuerecession and bone loss. Recent clinicalstudies have demonstrated that, on aver-age, conical connections offer a smallermicro-gap than butt-joint connections,in addition to a greater mechanical levelof stability. As a result, conical connec-tion types have become hugely suc-cessful in the dental implant market,and the majority of leading dental im-plant manufacturers have introducedconical internal connection products.Conical connection types will continueto represent one of the fastest-growingsegments of the dental implant market.

Conical internal connections will fuel growthin dental implant marketAuthors_Dr Kamran Zamanian & Ian van den Dolder, iData Research Inc., Canada

36 I implants3_2012

business news I

Industry leaders identify Turkey as one of the

fastest growing dental implant and final

abutment markets in the world

Turkey is one of the fastest-growing dental implantmarkets, congruent with strong economic growth thatweathered the recession far better than the US andnearly any region in Europe. The technology of dentalimplants in this country has advanced rapidly, as mostof the major players in the European market movedquickly to gain a strong market share in Turkey. Addi-tionally, this market benefits from low labor costs,which adds to the incentive for implant companies toestablish domestic subsidiaries or local distributionpartners, fueling options for consumers. Turkey is alsoa popular destination for dental tourism, especiallyamong patients from more expensive European mar-kets. From 2008 to 2018, the Turkish dental implant, fi-nal abutment and computer-guided surgery market isexpected to grow at a compound annual growth rate of20.4%.

In May 2011, AGS Medikal Ürünleri, the first majorTurkish company to produce dental implants, com-menced operations in the province of Trabzon, on thecoast of the Black Sea. The company was establishedwith an initial 5 million Turkish lira investment. Marketexperts predict that the company will soon be joined byother Turkish dental implant manufacturers that willoffer lower-priced products to compete domesticallyand later internationally with larger implant compa-nies.

EU medical tourism directive will strongly impact

the European dental implant market

The EU directive on cross-border healthcare thatcomes into force in 2013 will have a strong impact onthe European dental implant market. This directive willtarget the medical tourism market, which is significant,as dental treatment procedures account for nearly halfof medical tourism in most major markets. The direc-tive gives patients the right to be reimbursed for treat-ment they receive in other EU countries. This could leadto more Western Europeans traveling to Eastern Eu-rope, including Poland and Bulgaria, which are rapidlydeveloping the quality of the medical services they of-fer.

The UK features one of the highest rates of out-bound dental tourism, as patients are unaccustomed tolarge out-of-pocket costs for procedures, owing to thelegacy of the National Health Service. Whereas rich pa-tients from developing countries used to come to pres-tigious hospitals in the UK and elsewhere for treatment,outbound medical travel from the UK has been grow-ing far faster than inbound over the past decade, as UKpatients are increasingly traveling abroad for lower-cost care. Figures suggest more than 50,000 citizens ofthe UK go abroad for treatment annually. The number

of outbound medical tourists from the UK rose by170% from 2002 to 2009.

Dental implant companies follow success of

conical internal connection

Internal connection types as a whole are becomingincreasingly dominant in the dental implant market.Conical internal connections and butt-joint internalconnections represented 83.4% of implants with an in-ternal connection in 2011. Conical internal connectionsis the fastest-growing segment of the market and ex-pected to increase at a compound annual growth rateof 10.1% by 2018. NobelActive (Nobel Biocare) was oneof the foremost early successes of conical connectiontypes, and was rapidly adopted by consumers owing toclinical results demonstrating its greater stability andsmaller micro-gap between implant and abutment. Themajority of large companies now offer a conical con-nection, as this market is expected to overshadow butt-joint internal connections increasingly owing to thegreater stability and perceived smaller-diameter micro-gap offered by conical internal connections. Many com-panies are combining these connection types with ta-pered shape and surface treatments as the current gen-eration of premium products.

_Additional information

The information contained in this article was takenfrom two detailed and comprehensive reports pub-lished by iData Research (www.idataresearch.net), en-titled "European Markets for Dental Implants, FinalAbutments and Computer Guided Surgery" and "Euro-pean Markets for Dental Bone Graft Substitutes, Den-tal Membranes and Tissue Engineering." For more in-formation and a free synopsis of the above report,please contact iData Research at dental@idatare-search.net.

iData Research is an international market researchand consulting firm focused on providing market intel-ligence for the medical device, dental and pharmaceu-tical industries. Watch its short company movie athttp://www.idataresearch.net/discoveridata.html._

I 37implants3_2012

2008

Conical Internal Connections

External Connections

Butt Joint Internal Connections

Single Unit Devices

Source: iData Research Inc.

Year

Unit Share (%)

2009

2010

2011

2012

2013

2014

2015

2016

2017

2018

I manufacturer _ news

38 I implants3_2012

Manufacturer News

Against the backdrop of new technologies, materi-als and methods, implant-therapy concepts in re-cent years have greatly changed and improved. Thisdevelopment is promoted and accelerated by theclose cooperation of specialists from different dis-ciplines, which is a prerequisite for achieving qual-ity treatment outcomes. The DVD/Blu-ray com-pendium implant prosthetics "Four teams—theirconcepts and solutions," which was presented atthe 4th International CAMLOG Congress in early May2012 in Lucerne, documents the team work in animpressive manner.

"Four teams—their concepts and solutions" is afilm production, which was co-developed by CAM-LOG, a German dental publishing house and four

outs tand-ing, inter-d i s c i p l i n a r yteams of authors in atime period of two years of work.The four volumes of the compendium were pro-duced in HD format and are characterized by theirhigh quality as well as their detailed and precise pic-tures taken from the clinical and laboratory areas.

CAMLOG Biotechnologies AG

Margarethenstrasse 38

4053 Basel, Switzerland

info@camlog.com

www.camlog.com

Camlog

DVD / Blu-ray compendium on implant-supportedrestorations

Omnia offers a complete range of drapes, which aresuitable for different applications and treatments,both for covering operating theatresurfaces and for draping and pro-tecting the patient.

Drapes for patient draping aremade either of absorbent/water-proof, non-woven fabric or Soft-esse®, a fluid-repellent, soft, dra-pable and highly breathable mate-rial for complete protection andcomfort. Their whole surface is wa-terproof and they have fluid controlsystems and self-adhesive areas(self-adhesive U-shaped, hole orside), so as to allow a safe and accurate fixing andenhancing of the range of sterile fields.

To cover the patient, Omnia offers a water repellentmono drape with a triangular opening of 11 x 10 cmand a surrounding adhesive strip which enables tofix the drape onto the chin of the patient. An ad-justable aluminum band that runs along the upper

side of the triangular opening allows its safe posi-tioning on the nose of the patient. To protect the pa-

tient’s eyes from any splash oraccidental injuries, the drapehas a protection windowmade of a transparent mate-rial that also allows an easyand immediate communica-tion between the patient andthe operator, thus avoidingunpleasant panic situations.The large size of the drape of133 x 200 cm makes it partic-ularly indicated for long andcomplicated surgeries, and

the two Velcro strips allow fixa-tion of aspiration tubing.

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Omnia

Surgical patient drapes

Nobel Biocare will host the Nobel Biocare GlobalSymposium 2013 in New York. The event will takeplace from June 20–22, at the Waldorf Astoria in NewYork City. The Symposium’s program will build on No-bel Biocare’s mission "Designing for Life: Today andin the future."—"Designing for Life" is Nobel Bio-care's commitment to helping dentists treat morepatients with better solutions. And it is a commitmentto improving the quality of life of every patientthrough solutions that are designed to deliver fullyfunctional, natural-looking results with the aspira-tion to last a lifetime.

The Nobel Biocare Global Symposium 2013 buildson Nobel Biocare's series of scientific symposiastarted in 2012. The exclusive three-day event,chaired by Professor George Zarb, will bring togetherover 70 of the world's most renowned experts andspeakers in restorative dentistry to discuss key cur-rent and emerging trends as well as techniques andtechnologies shaping the industry's future. The sym-posium will feature a new program format that out-lines treatment workflow from patient presentationto treatment follow-up. Nobel Biocare has pioneeredinnovation in the industry and continues its commit-ment to creative synergy between scholarship andindustry to ensure the best possible dental treatmentjourney for all patients.

Nobel Biocare

P.O. Box

CH-8058 Zurich Airport

Switzerland

info.switzerland@nobelbiocare.com

www.nobelbiocare.com

Nobel Biocare

Global Symposium inNew York City

[PICTURE: ©BOBBY20]

Schütz Dental is now on Facebook! Becoming part of theSchütz Dental community brings many benefits. Userscan find out how colleagues have increased their busi-ness with the IMPLA system and watch free training

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their cases on the Schütz Dental Facebookpage. Register for the IMPLA-Newsletter and

stay up to date: http://sdent.eu/newe

Schütz Dental GmbH

Dieselstr. 5–6

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export@schuetz-dental.de

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manufacturer _ news I

I 39implants3_2012

Dentaurum Implants GmbH and Miele Professionalhave worked together to develop an innovative sys-tem solution for efficient and reproducible machinepreparation. The heart of this development is the tio-Logic© easyClean surgery tray, which enables consis-tent, outstanding machine cleaning and disinfectionresults in both dental practices and in centralizedpreparation centres in hospitals. This not only offershuge savings in time and costs but also significantlyincreased safety for users with the reproducible ma-chine preparation results.

The combination of the innovative grid structure withspecial retaining clips fixes all rotary instruments andaccessory components to hold them in position andto ensure that the instruments are completelycleaned with water and cleaning agent. All drills andaccessory components can be replaced in the cor-rect position in the tioLogic© easyClean tray as theyare used in the implant procedure to remain in thecorrect order at all times throughout the opera-tion.

SMP GmbH of Tübingen, an independent institute spe-cialising among other things in the testing and valida-tion of medical devices, was commissioned to testand validate the cleaning results. The tests were animpressive confirmation of the preparation results ofthe instruments and accessory components in the tio-Logic© easyClean.

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Straumann is launching the cost effective treat-ment option Emdogain 015. The new package sizeallows the benefits of commercially availableenamel matrix derivative to be profited from indaily practice.

Approximately 5 – 10 % of the general populationsuffer from severe periodontitis, a bacterial infec-tion of the periodontium which, in most cases, hasa chronic but painless progression.

Progress in biotechnology has led to ready-to-useproducts containing enamel matrix derivative(EMD). EMD stimulates an accelerated regenera-tion of lost periodontal tissue (gums, jaw bonesand fine fibres).

Emdogain is applied after the surgical revision ofthe gum and bone pockets, and the gum is su-tured. After a couple of weeks, formation of newtissue can be identified.

Straumann Emdogain has been documented inover 400 clinical publications for indications suchas intrabony, furcation and recession defects.

With the new Emdogain 015 package, patientswith smaller defects and patients subjected tobone grafting procedures can profit from fasterwound healing, less pain and swelling due to thewell documented effects of the proteins present inStraumann Emdogain.

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I education

_Since 2003, IMC Münster at Münster Universityhas offered a master degree entitled "Master of OralMedicine in Implantology". This Master Degree is in-ternationally accredited by the “Akkreditierungsrat”in accordance with the “Bologna Criteria”. The courseconsists of a web-based part on the one hand and ahigh amount of practical training on the other.

As the oldest professional non-profit associationin implantology, the German Assocation of Dental Im-plantology (Deutsche Gesellschaft für ZahnärztlicheImplantologie, DGZI) focuses its activities on the con-tinuing education and training of dentists practicingin the field of implantology. The objective of these ac-tivities is the improvement of both quality and qual-ity assurance as well as the safety of therapies in theinterest of patients. Furthermore, they aim at provid-ing factual information on existing therapeutic pos-sibilities of implant-based tooth replacement.

DGZI curriculum graduates can now enroll in the5th "Master of Oral Medicine in Implantology" courseoffered at special conditions and in English at Mün-ster University since 2004. The international courseis based on a cooperation agreement betweenDGZI/GBOI (German Board of Oral Implantology) andIMC Münster University, Germany. It is designed as anin-service training for practicing dentists and offerscontinuing practical, university-level education.

Within the field of dentistry, implantology has in-creasingly emerged as an area of specialization in itsown right. The goal of the post-graduate universitytraining course "Master of Oral Medicine in Implan-tology" for dentists is to provide students with in-depth, application-oriented scientific knowledge andpractical skills in the areas of oral surgery and im-plantology. Its focus is placed on indication, planning,symptoms and surgery, as well as post-operative care,its association with prosthetics, as well as general dis-

eases and other individual disciplines in dental andoral diseases and maxillofacial surgery. The courseparticularly aims at the connection between theoryand practice in the area of invasive surgical proce-dures. Students will be able to offer state-of-the-artoral surgery and implantology, consistent with foren-sic ethical standards.

The continuing education provided by the DGZIcurriculum is recognized by a reduction of the tuitionfee for the “Master of Oral Medicine in Implantology”course by almost one third of the total costs. The mas-ter course will have a duration of 24 months for DGZIcurriculum graduates.

All conditions outlined in the official examinationregulations of Münster University regarding the"Master of Oral Medicine in Implantology" must befulfilled. This means that written examinations and case documentation must be completed. Case documentation takes place under supervision byDGZI/GBOI and includes the corresponding specifica-tions of indication and documentation regulations(master thesis, defense and expert discussion). A pro-fessor serves as mentor for writing the master thesis._

Master of OralMedicine inImplantologyAuthor_DGZI

40 I implants3_2012

DGZI—Deutsche Gesellschaft für

Zahnärztliche Implantologie e.V.

Feldstraße 80 40479 Düsseldorf, Germany

Tel.: +49 211 1697077Fax: +49 211 1697066

sekretariat@dgzi-info.dewww.dgzi.de

_contact implants

[PICTURE: ©ANDREI SHUMSKIY]

education I

_In 1952, Per-Ingvar Brånemark discoveredthe principles of osseointegration in Sweden. Thirtyyears later, in 1982, the discovery was acknowledgedand his subsequent findings were confirmed at anepoch-making meeting of dental authorities organ-ized by George Zarb in Canada.

Yet another thirty years have now passed, and No-bel Biocare is celebrating both these 30- and 60-years anniversaries in Sweden, Canada, and fourother locations.

Starting the year-long celebration in the home-town of osseointegration—Brånemark’s Gothen-burg—Nobel Biocare broughttogether some of the best-known names in the field onMarch 21–23. The event be-gan with a surprise en-trance from Brånemarkhimself who delivered ad-vice and thoughts for thefuture.

Ulf Lekholm then led ex-perts from Scandinavia andthe far corners of the worldas they exchanged ideasand discussed promisingareas for further explo-ration at this meeting.

Pioneers from the headydays of the Toronto Confer-ence of 1982, such as GeorgeZarb and Ragnar Adell, were honored and otherspeakers reminded participants of how far Per-Ing-var Brånemark, Nobel Biocare and their band of sup-porters have brought osseointegration since thosedays of breakthrough 30 and 60 years ago.

The programs of all five of the remaining NobelBiocare Symposia 2012 celebrate the origins and

evolution of osseointegrationas a practical and trusted treat-ment modality over the last sixdecades. Each program willalso include lectures on recentadvances in treatment, pre-sented from surgical, pros-thetic and laboratory perspec-tives.

Speakers will look towardsthe future as well, presentingcurrent trends and possible fu-

ture developments for bone-anchored restorative dentistry.

Under the common theme “Celebrating 60 yearsof osseointegration and 30 years of internationalacknowledgement” meetings will be held in Rimini,Italy (October 19–20), with the final symposiumplanned for Toronto, Canada (October 19–20)where the international breakthrough for osseoin-tegration first took place._

3rd Nobel Biocare Congress Hamburg,

15 June, 2012.

Celebrating theTriumph of Osseointegration Author_Frederic Love, Nobel Biocare

I 41implants3_2012

I meetings

_One topic, but many facets—the OsteologySymposium “Soft Tissue Special” on 24 March inBonn encompassed a broad range of subjects frombiological fundamentals to clinical practice.

It was the first time for an Osteology Symposiumto be dealing solely with one issue. “Soft tissue man-agement has become more and more important inthe recent years, not only for periodontists” ex-plained Prof Søren Jepsen, Bonn, who chaired theconference together with Prof Wilfried Wagner,Mainz. With conferences on the oral tissue regener-ation having been dominated by techniques forguided bone regeneration for a long time, now thesoft tissue management is taking the spotlight. ProfWagner explained the awakening interest: “Thereare some attractive new biomaterials that could re-place autologous soft tissue grafts for indicationssuch as recession coverage, vestibuloplasty or gainof keratinized tissue. So, with the ‘Osteology SoftTissue Special’ we wanted to provide a comprehen-sive overview on where we stand today on the softtissue management and where we are heading.”Main questions during the lectures were: Whichgrafts lead to good results in which indications?What are the opportunities and limitations of bio-materials as compared to free gingival grafts andconnective tissue grafts, respectively?

_Differences between gingival andperi-implant mucosa

350 attendees joined the one-day symposiumwhich took place in the former Federal German Bun-destag in Bonn. The programme began with a lec-ture from the world-famous periodontist Prof JanLindhe. He described the key differences betweenthe normal gingiva and the peri-implant mucosa.One important difference is the loss of collagen fi-bres in the mucosa due to tooth extraction and theensuing resorption of bundle bone: In the peri-im-plant mucosa, the quantity of blood vessels and fi-broblasts is lower, whereas the amount of collagenis higher. Thus, in many respects, the peri-implantmucosa resembles scar tissue.

_Biomaterials versus autologous grafts

Clinical applications followed the biological fun-damentals. Firstly, Dr Markus Schlee, Forchheim,and Prof Anton Sculean, Bern, presented new dataon the recession coverage. While Dr Schlee focusedon single-recession coverage with the coronally ad-vanced flap (modified Zucchelli technique), ProfSculean demonstrated an advanced technique forcoverage of multiple recessions, the modified tun-nel technique. Both speakers had conducted their

National Osteology Symposium in BonnFully focussed on soft tissue

Author_Verena Vermeulen, Osteology Foundation

42 I implants3_2012

meetings I

own studies in which they compared autologousgrafts with biomaterials such as the porcine colla-gen matrix Geistlich Mucograft®. The matrix is notcross-linked and consists of type-one and type-three collagen. It has a bilayer structure, with thecompact structure providing protection, allowingits usage in both closed and open integrative heal-ing processes. The spongy structure stabilises theblood clot and facilitates the ingrowth of cells andsprouting of blood vessels.

The data Dr Schlee and Prof Sculean presentedshow that autologous grafts and the collagen ma-trix yield comparable results. Although the auto-loguous grafts are the gold standard for recessioncoverage, the advantages of the tissue substitutematerial are obvious: patients profit from reducedpain and swelling because none of their own tissueneeds to be removed and the operation time is dras-tically diminished.

Other speakers also compared autologuousgrafts to tissue substitute materials—for indica-tions like thickening of keratinized tissue, ridgepreservation and vestibuloplasty.

_Plenty of room for practical training

In soft tissue management, therapeutic successstrongly depends on the practitioner’s expertise.Thus it is important for him or her to know the ma-terial well and to practice the application correctly.

The speakers pointed out that the collagen matrixshould best be used in a dry state and should be su-tured carefully, if at all. Four workshops and an in-teractive forum in the afternoon offered plenty ofroom for training, discussions and experiences withnew techniques and materials. At the very site ofearlier political discussions, there were now heateddebates on the importance of "morphotype” in thechoice of therapy and optimal peri-implantitistreatment. There was, however, an agreement whenit came to assessing the symposium: it was a real in-spiration for everyday practice.

The next International Osteology Symposiumwill take place from May 2–4 in Monaco—save thedate!_

I 43implants3_2012

I meetings

“Getting to know current practical and, more impor-tantly, practicable ways of long-term success in im-plantology, that’s what this year’s international annualDGZI Congress is about”, Dr Georg Bach, chair of theboard of DGZI (German Society for Dental Implantol-ogy) summarizes the congress’ motto ‘Quality-orientedimplantology—ways to long-term success’. “Just like inthe previous years, we expect up to 500 participantsfrom more than ten countries worldwide”, he adds.

To fulfil its motto, DGZI, Europe’s oldest scientific so-ciety for implantology, has assembled an extensive pro-gram for dentists and their practice team on 5 and 6 Oc-tober in Hamburg.

“We have been able to acquire renowned interna-tional speakers, covering topics such as soft-tissue andbone management and digital implantology by meansof concepts from implant prosthetics”, Dr Roland Hille(Viersen, Germany), vice president of DGZI and scientific

coordinator of the congress, informs. “Exchange of in-formation with colleagues and practical advice are ofparticular importance to the DGZI”, he continues.

Participants of previous congresses already knowthat international speakers inspire the audience withtheir detailed knowledge on the first congress day. Theyare also ready to answer any questions posed by theiraudience. The organisers also offer simultaneous trans-lation during the international panel discussion. Thesecond congress day is going to be equally exiting whenProf Dr Adnrea Mombelli (Genève University, Switzer-land), Prof Dr Anton Sculean (Bern University, Switzer-land) and Prof Dr Herbert Deppe (Munich University,Germany) face questions during the special podium anddebate on Saturday.

“With periimplantitis, we focus on one of the mostsignificant topics with regard to the long-term successof dental implants”, Dr Hille is convinced. Furthermore,

“Quality-oriented implantology”DGZI Annual Congress in Hamburg

Author_DGZITranslation_Claudia Jahn/Leipzig

44 I implants3_2012

meetings I

early birds will be rewarded if they arrive at theHanseatic city already on Friday morning, since this isthe time when “combined theoretical and demonstra-tional coursed will be held and various topics are dis-cussed. Moreover, we recommend visiting the dentaltrade fair, which presents more than 80 exhibitors, togain direct information on products and their applica-tion or participate in one of the ten company workshopsoffered”.

Lecturer Dr Gregor Petersilka (Würzburg, Germany)will present the state of the art of diagnosis, prognosisas well as surgical and non-surgical periodontitis ther-apy for implantological assistants in his compact semi-nar “Practical Periodontology” on Friday morning. “Bynoon, the practice team will have problems to decidewhich panel to attend”, Dr Hille comments.

While the „Mainpodium“ is held to discuss expertinformation for qualified dental employees (prophy-

laxis, caries, mucosa change, oral cancer prevention,periimplantitis, among others), the GOZ seminarpresents the “most important changes in the GOZ(German Scale of Fees for Dentists) paragraphs, thehandling of new forms and the realization of GOZ-factors including the relevant explanation”, Dr Hilleexplains.

Saturday will be dedicated to a seminar on the pro-fession of sanitation commissioner as well as a semi-nar about the “Vocational training as a quality man-agement official”. A multiple choice test will be held tomeasure the success in learning.

For more information, please download the pro-gramme as well as the registration form viawww.DGZI.de. “DGZI also welcomes attendees onshort notice who can register for the DGZI AnnualCongress directly at Elysee Hotel Hamburg”, Dr Bachadds._

I 45implants3_2012

International annual congress of the DGZI

October 5–6, 2012Hamburg//Grand Elysee

Quality oriented implantology— Ways to long-term success

Silver Sponsor:Gold Sponsor: Bronze Sponsor:

Programme · friday, october 5, 2012

9.00 – 10.30 a.m. 1st PART WORKSHOPS

1.1 Dr. Daniel Ferrari, M.Sc./DEBasics of internal and external sinus lifting using short porous and/or screw implants of the latest generation with identical interior connection(incl. hands-on course)—Part 1

1.2 Dr. Mazen Tamimi/JOImpla—Modern Implants & 3-D Implantology (Workshop in English)

1.3 Dr. Marc Hansen/DE I Dr. Harald Hüskens/DEThe narrow jaw: Update ultrasonic surgery and diameter reduced implants inthe aesthetic zone. Theory and practical training using artificial plastic jaws

1.4 Dr. Urs Brodbeck/CH I Dipl.-Ing. Holger Zipprich/DEBiodenta—implants, prosthetic solutions and intraoral scanning device(incl. hands-on course)

1.5 Study group meeting DGZI

10.30 – 11.00 a.m. Break/Visit of the Dental Exhibition

11.00 a.m. – 12.30 p.m. 2nd PART WORKSHOPS

2.1 Dr. Daniel Ferrari, M.Sc./DEBasics of internal and external sinus lifting using short porous and/or screw implants of the latest generation with identical interior connection(incl. hands-on course)—Part 2

2.2 Prof. Dr. Dr. Knut A. Grötz/DEComplex situations in dental implantology—update augmentation measures

2.3 Prof. Dr. Dr. George Khoury/DESoft tissue management and tuning using cross-linked hyaluronic acid (HA)

2.4 Dr. Mario Kirste/DESocket preservation—the ultimate reference for the successful aesthetic implantation

2.5 Dr. Harald Hüskens/DESoft tissue from the blister—future or already reality?MucoMatrixX—A new era of soft tissue augmentation

12.30 – 1.00 p.m Break/Visit of the Dental Exhibition

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

MAIN PODIUMSimultaneous translation German/English, English/GermanChairmen: Prof. Dr. Dr. Frank Palm/DE, Dr. Roland Hille/DE

1.00 – 1.15 p.m. Opening CeremonyProf. Dr. Dr. Frank Palm/DEDr. Roland Hille/DE

1.15 – 1.45 p.m. Prof. Dr. Dr. Jörg R. Strub/DEEndo or implant?

1.45 – 2.15 p.m Prof. Dr. Thomas Weischer/DELong term implant success in tumor patients— is this really possible?

2.15 – 2.45 p.m Prof. Dr. Werner Götz/DEDr. Rolf Vollmer/DEHeat development during implant site preparation—comparing steel and ceramic twist drills in D1/D2 bone

2.45 – 3.15 p.m Prof. Dr. Dr. Albert Mehl/CHOpportunities of CAD/CAM in implant prosthetics

3.15 – 3.35 p.m Dr. Daniel Ferrari, M.Sc./DEMinimizing the patient’s stress by a specific op management

3.35 – 3.45 p.m Discussion

3.45 – 4.45 p.m Break/Visit of the Dental Exhibition

� INTERNATIONAL PODIUM//4.15 – 6.30 p.m.Simultaneous translation German/English, English/GermanChairmen: Prof. Dr. Amr Abdel Azim/EG, Dr. Mazen Tamimi/JO, Dr. Rolf Vollmer/DE

4.15 – 4.30 p.m. Mohamed Moataz M. Khamis B.D.S., M.S., Ph.D./EGAchieving outstanding results with all ceramic CAD/CAM resto-rations together with dental laser

4.30 – 4.45 p.m Prof. Dr. Suheil Boutros/USTrabecular Metal Technology from Orthopedics to Dental Im-plantology—Early Results of Human Dental Implant Cases

4.45 – 5.15 p.m Dr. Sami Jade/LBBleeding risk following implant surgery in the mandibular symphysis

5.15 – 5.30 p.m Prof. Dr. Shoji Hayashi/JPClinical evidence and current future implant concepts in Yoko-hama clinic of Kanagawa Dental College

5.30 – 5.45 p.m Dr. Osamu Yamashita/JPOral infection control for implantology

5.45 – 6.00 p.m Dr. Tomohiro Ezaki/JPImmediate implant placement on anterior and premolar upper teeth using CT scanning

6.00 – 6.15 p.m Dr. Ramy Fahmy Rezkallah/EGSeeing in to the future—External deception versus internal facts: Cone beam computed tomography revealing the reality

6.15 – 6.30 p.m Discussion

�PROSTHETICS PODIUM//4.15 – 6.30 p.m.Chairmen: Prof. Dr. Peter Rammelsberg/DE, ZTM Christian Müller/DEFor further information on the podiums please refer to www.dgzi-jahreskongress.de

� CORPORATE PODIUM//4.15 – 6.30 p.m.Chairmen: Dr. Rainer Valentin/DE, Prof. Dr. Gerd Volland, M.Sc./DE

For further information on the podiums please refer to www.dgzi-jahreskongress.de

8.00 p.m. Evening Event at „AU QUAI“ Port Hamburg on the river Elbe with live music

Stamp/AdressI hereby accept the terms and conditions of the 42nd International Annual Congress of the DGZI.

Date/Signature

E-Mail:

OEMUS MEDIA AGHolbeinstraße 2904229 LeipzigGermany

Fax this form to+49 341 48474-390

I hereby register the following persons for the 42nd International Annual Congress of the DGZI from October 5-6, 2012 in Hamburg,Germany (Please fill out/tick as appropriate):NOTE: Please note, that you can only participate in one workshop in each part. Please mark your choice.

o � Workshops

o yes o � 1st Part: ___

o no o � 2nd Part: ___Title, Surname, Name, Job Title DGZI-Member Podiums (insert no.)

Evening Event: ____ (Please insert no. of persons)

Note: For further information on the program and the general terms and conditions please refer to www.dgzi-jahreskongress.de

Programme · saturday, october 6, 2012 organisational matters

MAINPODIUMSimultaneous translation German/English, English/German

Chairmen: Prof. Dr. Herbert Deppe/DE, Prof. Dr. Dr. Kai-Olaf Henkel/DE

9.00 – 09.30 a.m. Prof. Dr. Dr. Kai-Olaf Henkel/DEComplications and failures in dental implantology

9.30 – 10.00 a.m. Prof. Dr. Herbert Deppe/DEImplants in organ transplant recipients—is this possible?

10.00 – 10.45 a.m. Prof. Dr. Hans-Peter Weber/USThe digital process chain in implant prosthetics

10.45 – 11.00 a.m. Discussion

11.00 – 11.30 a.m. Break/Visit of the Dental Exhibition

11.30 – 12.00 a.m. Prof. Dr. Anton Sculean/CHInnovative techniques and materials for the defect coverage incases of multiple recessions

SPECIAL PODIUMPeriimplantitis: Explantation or treatment?Presentation: Prof. Dr. Dr. Frank Palm/DE

12.00 – 12.30 p.m. Prof. Dr. Andrea Mombelli/CHEpidemiology of periimplantitis: facts and fiction

12.30 – 1.30 p.m. Diskussion with the Speakers: Prof. Dr. Herbert Deppe/DE Prof. Dr. Andrea Mombelli/CH Prof. Dr. Anton Sculean/CH

1.30 – 2.30 p.m. Break/Visit of the Dental Exhibition

Chairmen: Dr. Georg Bach/DE, Dr. Bernd Quantius, M.Sc./DE

2.30 – 3.00 p.m. Prof. Dr. Peter Rammelsberg/DEThe effects of simultaneously performed augmentation procedures on the implant prognosis

3.00 – 3.30 p.m. Priv.-Doz. Dr. Torsten Mundt/DEMini implants in the edentulous jaw—A multicenter study in German dental centers

3.30 – 4.00 p.m. Prof. Dr. Dr. George Khoury/DEMultifunctional use of hyaluronic acid (HA)— perfect for regeneration management

4.00 – 4.15 p.m. Concluding Discussion

4.15 p.m. General assembly of the DGZI

Venue/AccomodationGrand Elysee Hotel HamburgRothenbaumchaussee 10, 20148 Hamburg, GermanyTel.: +49 40 41412-0, Fax: +49 40 41412-733www.grand-elysee.com

Room Rates„Grand Standard“ Single 125,– € excl. breakfast Double 125,– € excl. breakfastBreakfast 20,– € per Person

ReservationsPlease book directly at the hotel using the keyword: „DGZI 2012“Tel.: +49 40 41412-222, Fax: +49 40 41412-122, E-Mail: reservierung@grand-elysee.comNote: Please inform yourself about possible special deals. It is possible, that cheaper rates can be found on the internet or via booking offices.

Room booking in various categoriesPRIMECON | Tel.: +49 211 49767-20, Fax: +49 211 49767-29info@prime-con.eu | www.prime-con.eu

Congress Fees42nd International Annual Congress of the DGZI(Friday, October 5, to Saturday, October 6, 2012)Dentist/Dental Techninician DGZI-Member 245,– €*Dentist/Dental Techninician Non-member 295,– €*Assistants (with verification) DGZI-Member 120,– €*Assistants (with verification) Non-member 135,– €*Students (with verification) conference charge only*The 1st item is calculated incl. 7% tax in the name and for the account of the DGZI e.V.

Conference Charge 90,– € plus VATThe Conference Charge is to paid by each participant and includes coffee breaks, conference drinks and lunch.

Evening Event at „AU QUAI“ Port Hamburg 69,– € plus VATEnjoy Hamburg, where it is most beautiful. Directly located on the Elbe River— in the heart of the harbor! Pamper yourself with fresh creations and an unforgettable atmosphere.(Price includes dinner, wine, beer, softdrinks, transfer and live music)

Organizer Organization

DGZI e.V. OEMUS MEDIA AGPaulusstraße 1 Holbeinstraße 29, 04229 Leipzig40237 Düsseldorf GermanyGermany Tel.: +49 341 48474-308Tel.: +49 211 16970-77 Fax: +49 341 48474-390Fax: +49 211 16970-66 event@oemus-media.desekretariat@dgzi-info.de www.dgzi-jahreskongress.dewww.dgzi.de www.oemus.com

implants 3/12

NEWS

implants3_2012

Researchers at the German University of Duisburg-Es-sen and the Max Planck Institute for Iron Research inDüsseldorf examined the teeth of two different sharks,the shortfin mako and the tiger shark, in terms of theirstructure, composition and mechanical properties. Theteeth of both sharks were found to have a similar crys-talline composition. According to the researchers, theinterior of shark teeth contains dentine, a softer mate-rial also found in human teeth, while the enamel exte-rior is highly mineralised. Shark teeth contain fluorap-atite, a very hard mineral, which could lead to the con-clusion that they are harder than human teeth, whichcontain hydroxylapatite, a softer mineral, according toDr Matthias Epple, Professor of Inorganic Chemistry atthe university.

However, comparative analyses revealed that thehardness of shark teeth and human teeth was compa-rable, both for dentine and enamel. “This is mainly due

to the micro- and nano-structures of our teeth, in whichcrystals are highly ordered in a special topological ori-entation,” said Epple. The scientists are now continu-ing their research on other shark species. They are hop-ing to recreate their dental structures for the produc-tion of dentures in the future. The study was publishedin the June issue of the Journal of Structural Biology.

Tomorrow’s dentures

Resemble Shark teeth

According to a new Espicom market research report,Understanding Russia’s Regional Health Markets, theprogress in improvement in Russia’s health system isslow. Urban areas, particularly Moscow are of a highquality, but provision in rural areas remains poor.

Russia is the largest country in the world, with a landarea of over 17 million square kilometres, encompass-ing eleven time zones. It has an estimated populationof 142.9 million. Delivering universal high qualityhealth services is a challenge.

Funding is at the heart of Russia’s health improvementplans, and at the beginning of 2011 obligatory medical

insurance contributions increased from 3.1 % to 5.1 %,deducible from salaries. This will raise an additionalR460 billion (US$15.1 billion) over two years and willhelp cover the costs of overhauling, and equipping hos-pitals and polyclinics. The extra funds will also help toprovide a wider range of free-of-charge medical serv-ices. With measures to increase income, however, hascome the challenge of distribution and the recognitionthat, in common with countries such as India andChina, there is a yawning gap between well providedfor cities and the more remote regions.

In 2010, the government introduced the idea of a re-gional healthcare services modernisation scheme thataims to improve quality and availability of medicalservices and raise the profile of the medical profession.The decision to implement the required changes wasdifficult, particularly during a period of economic pres-sure. Healthcare modernisation is well overdue. To putthis into context, over 30 % of hospitals lack a hot wa-ter supply, 8 % do not have a drinking water pipelineand 9% lack drainage.

For further information on the report please visitwww.espicom.com/rrmpr.

Russian healthcare system

Improving but in need of investments

Italian Researchers have found that blood plateletbiomaterial significantly improves the healingprocess after placement of dental implants. In a casestudy, they observed beneficial short- and long-termresults after the replacement of a fractured central in-cisor. In the article, they present a new approach toimproving the outcome of anterior implants by usingblood platelet concentrates. The paper reports on acase study of a 45-year-old female patient who hadfractured an incisor in a sport-related accident. In anItalian private practice, the broken tooth was ex-tracted and an implant inserted. In addition, a bioma-terial of leukocyte- and platelet-rich fibrin (L-PRF)was used.

The scientists observed positive healing of the tissuetwo days after surgery. They found that the materialacts as a bio-membrane that protects the implantfrom the oral environment. It appears to stimulate thegrowth of cells and to accelerate gingival healing andmaturation. After seven days, they found that the gin-gival aesthetic profile was well defined. At sixmonths, they reported a satisfactory final result thatwas still stable and aesthetic after two years. Ac-cording to the researchers, L-PRF is simple, inex-pensive and easy to prepare in only 15 minutes.Thus, it suits the practical needs of daily implant den-tistry, in particular. Moreover, it is free of additives,such as anticoagulant, a substance that prevents theclotting of blood, or chemicals for activation, theysaid.

The project was conducted by researchers at theUniversity of Geneva’s School of Dental Medicine,the State University of New York at Buffalo’s Depart-ment of Restorative Dentistry and the Chonnam Na-tional University’s School of Dentistry in Gwangju,South Korea, in collaboration with two practitionersin Italy and Israel. The study was published in the Aprilissue of the Journal of Oral Implantology.

Healing after implant placement

Stimulated by Biomaterials

48 I

[PICTURE: ©STEPAN KAPL]

[PICTURE: ©LAKHESIS]

[PICTURE: ©ZIMMYTWS]

[PICTURE: ©CHAMILLE WHITE]

I 49implants3_2012

A German company has developed a baseball capaimed at helping dentists prevent back pain. Den-tists usually work in a bent position, which affectsthe back negatively. The cap, inspired by the Africantradition of carrying weight on the head (tallabé),has an integrated ergonomic weight inlay and canbe worn standing up or sitting down.

According to the manufacturer, the effect of the tal-labé is immediately evident. The muscles of thebody begin to coordinate, and the body is encour-aged to adopt an upright and relaxed posture.

Back pain

Stopped by BaselCap for Dentists

Orthognathic surgery, affecting the jaws and face,requires a balancing act in anaesthetic technique.Limiting blood loss, avoiding respiratory depression,and averting postoperative nausea and vomitinglead to optimum patient outcomes. The use of thedrugs propofol and remifentanil are increasing be-cause they can meet these needs; however, patientsmay subsequently experience more postoperativepain.

The journal Anesthesia Progress presents a retro-spective study of 51 patients in a single medical cen-tre. The 21 orthognathic maxillofacial surgery pa-tients in the group receiving intravenous propofoland remifentanil experienced significantly higherpain scores. Anaesthesia for the 30 patients in thecomparison group was maintained with inhalationalagents and longer-acting opioids.

The drug remifentanil is seeing increased use in or-thognathic surgery because its short half-life can fa-

cilitate stable operating conditionswhile avoiding the undesirablepostoperative consequences ofmorphine and other such agents.There is still a need for pain controlin the postoperative period usinglonger-acting opioids that carry agreater potential for adverse ef-fects.

The study was undertaken to ensure that achievingbetter intraoperative conditions did not come at theexpense of patients’ recovery. Variables of compari-son included recovery time, occurrence of nauseaand vomiting, pain scores, heart rate, and opioid doseadministered in the four hours following surgery.

There was a trend toward shorter recovery times inthe group receiving propofol and remifentanil. Themedian recovery time was 65 minutes for this groupand 93 minutes for the inhalation group. However, the

first group reported higherpain scores in the first fourhours following surgery. Nodifferences were found inearly postoperative opioiduse, heart rate, or nauseaand vomiting.

With maxillofacial surgery, postoperative respiratoryand gastrointestinal complications can be danger-ous. While turning to drugs that can reduce theserisks leads to better surgical experiences, it may alsomean increased postoperative pain for patients. Thisstudy takes a first look at this occurrence and may bethe stimulus for future controlled studies.

Full text of “The Effect of Anesthetic Technique onRecovery After Orthognathic Surgery: A Retrospec-tive Audit,” and other articles, Anesthesia Progress,Vol. 59, No. 2, 2012, are available athttp://www.anesthesiaprogress.org/toc/anpr/59/2

Anaesthesia varies in

Orthognathic surgery and recovery

The dental implant and bone graft substitute mar-ket is the most rapidly advancing segment of den-tal technology, and leading competitors in this mar-ket must consistently develop new products sup-ported by research from scientific and academicorganizations to remain competitive. Recent caseshave demonstrated that when companies lose asegment of support from the scientific community,their market shares tend to suffer significantly.

The European dental implant and bone graft sub-stitute market has been further challenged by re-

cent economic instability and theEurozone crisis, which hascreated a consistent demandfor lower-cost dental implant

products. As a result, manylower-priced competitors have

begun to seize larger marketshares in almost every Europeanmarket. In many segments, thesecompetitors are either regional or

sourced from overseas marketssuch as Brazil, Korea and Israel.

Regenerative products and barrier membraneshave been particularly affected by consumer aus-terity, as these products are discretionary in manycases.

However, a growing number of consumers continueto demand high-quality products, guarantees ofservice and scientific improvements, which onlypremium manufacturers are equipped to offer. Con-ical internal connections is one such recent innova-tion, and currently constitute the fastest-growingconnection type in the dental implant industry.

Many dental implant and bone graft substitutecompanies have looked to expand their productportfolio or create new markets while they createpackage deals to offset competition from rapidlyemerging lower-priced competitors. Significantly,many European and US companies involved in thismarket have begun to invest in rapidly emergingperiphery markets such as Turkey. For more infor-mation and a free synopsis of the report, pleasecontact iData Research at dental@idatare-search.net.

Conical internal connections

Fuel growth in dental implant market

[PICTURE: ©NUNO ANDRE]

[PICTURE: ©RIDO]

[PICTURE: ©LASCHON MAXIMILIAN]

I about the publisher _ imprint

50 I implants3_2012

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