N L Y A L S O N F E S SI O O R T A L P N E D PUBLISHED IN DUBAI www.dental-tribune.me September-October 2021 | No. 5, Vol. 11 New study reafﬁrms Astra Tech Implant System and the OsseoSpeed surface as superior in marginal bone maintenance By Dentsply Sirona For the first time, a meta-analysis looks at how three premium brands’ implant surfaces influence marginal bone maintenance. According to the study, OsseoSpeed is the best, and the difference is statistically signifi- cant. Dr Michael R. Norton, who co-au- thored the study1 with statistician Mikael Åström, was triggered to do this meta-analysis for two reasons. First of all, he was surprised that no meta-analysis had evaluated dif- ferences in marginal bone loss due to different surface modifications among currently marketed pre- mium brands, although the type of surface might be crucial. Premium implants are proven to be superior The second reason stems from the findings of a published article by Dr Dirk Duddeck et al.2, comparing pre- mium implant surfaces to look-alike implants. Their conclusion favours premium implant surfaces as these are free of foreign materials and backed by reliable clinical documentation. The authors found that copycat implants had impurities such as organic resi- dues and traces of iron or aluminum and, apart from case reports, no solid clinical documentation. In the recently published meta- analysis, Dr Norton points out that the above is likely to affect osseointe- gration and marginal bone mainte- nance. This may cause peri-implant infections and compromised func- tion when using cheaper clones. All premium surfaces are good. OsseoSpeed is better So, Dr. Norton knew that premium implants are better at maintain- ing the bone but wanted to know if the premium ones are equal. To answer this, he and Mikael Åström performed a meta-analysis of the entire body of literature concern- ing OsseoSpeed (Dentsply Sirona), TiUnite (Nobel Biocare), and SLA/ SLActive (Straumann). According to Michael Norton, the results send a broad message and bring good news to Dentsply Sirona. “All three have remarkably little bone loss; however, the facts are the facts. We did the statistical analy- sis on a prospective basis, in other words, we did not know what the outcome would be. It shows a sta- tistically significant difference be- tween the amount of bone loss, and OsseoSpeed is the best of the lot,” says Michael Norton. OsseoSpeed is significantly better – and offers higher predictability The mate-analysis includes over 11,000 implants from 113 articles, and the key takeaways include: • OsseoSpeed had, on average, the least marginal bone loss in both 1-year (-0.29 mm) and 5-year (-0.35 mm) follow-ups. There was a statistically sig- nificant difference between OsseoSpeed and TiUnite and SLA/SLA Active in both 1-year and 5-year follow-ups. In the 5-year follow-up, there was no statistically significant difference between TiUnite and SLA/SLA Active. OsseoSpeed offers more pre- dictable outcomes with less variation around the mean and less spread. • • • Delivering the best possible func- tional, biologic and aesthetic out- comes In the study’s conclusion, Dr Norton and Mikael Åström state that Osse- oSpeed demonstrates superior mar- ginal bone levels—which is vital to achieving the best possible function- al, biologic and aesthetic outcomes over the long term. That the OsseoSpeed surface per- forms so well comes as no surprise to Michael Norton. “The company was clever enough to patent the use of titanium di- oxide particles as the grit-blasting medium, which meant that no con- taminants were introduced onto the surface,” says Michael Norton. It all started in 1990 and in the ear- ly days of 2021, it is clear that the OsseoSpeed surface is still the im- plant surface to beat. References 1. Michael R Norton, Mikael Åström. The Influence of Implant Surface on Maintenance of Marginal Bone Levels for Three Premium Implant Brands: A Systematic Review and Meta-analysis. Int J Oral Maxillofac Implants. Nov/Dec 2020;35(6):1099- 1111. 2. Dirk U Duddeck, Tomas Albrekts- son, Ann Wennerberg, Christel Lars- son, Florian Beuer. On the Clean- liness of Different Oral Implant Systems: A Pilot Study. National Library of Medicine (Online). J Clin Med. 2019 Aug 22;8(9):1280. doi: 10.3390/jcm8091280. For further information, please contact: Dentsply Sirona 21st Floor, The Bay Gate Tower, Business Bay, Al Sa’ada Street Dubai, United Arab Emirates Tel.: +971 (0)4 523 0600 Web: dentsplysirona.com/en E-mail: MEA-Marketing@dentsplysirona.com
C3 ◊Page C2 memories or images are trained until they function largely automatically and only a few stimuli from the con- sciousness are necessary. For his procedure, Schröck employed a memory of walking barefoot through an ice-cold mountain lake. “I chose this memory for two rea- sons. The feet are physically furthest away from the mouth and thus from the site of surgery, and I associate a strong feeling of euphoria with this memory. Euphoria and fear or nega- tive pain tend to be mutually exclu- sive in my world,” he explained. He continued: “The art of self- hypnosis is to consciously self- IMPLANT TRIBUNE Dental Tribune Middle East & Africa Edition | 5/2021 regulate oneself on one level in order to have unconscious experiences on another level. That means you are not switched off or entirely passive in self-hypnosis. As soon as I became too aware of what was happening in my mouth, I directed my attention back to my resource place in the mountain stream.” For the most part, Schröck only felt greatly diminished pain during the operation. Keeping an eye on bleeding behav- iour and hand signals “The team was slightly nervous before the operation,” Lindemann said. All eventualities during the pro- cedure—for example, what would happen if the patient did experience severe pain—were considered by the dental team in advance, so the nerv- ousness quickly dissipated once the operation had begun. When asked to what extent the team supported the patient during the procedure, Lindemann replied: “We created a very calm and relaxed environment. In addition, we agreed on signals that the patient should give us in case he felt pain or he needed a break to get back into a deep enough state of hypnosis.” During the placement of a single im- plant with minor osseous augmen- tation in an open procedure in the mandible with subsequent suture closure, the dental team had to pay particular attention to the bleeding behaviour, which differs from that under vaso-constriction. A matter of trust Although the hypnotherapist was convinced that his self-experiment would succeed, he harboured some doubts. In the run-up, he asked him- self whether he would really manage to concentrate for the entire dura- tion of the surgery. “I am very satis- fied with the result. In retrospect, I was even a little surprised at how quickly it went, and how easy it was to turn off the pain,” Schröck ex- plained. He failed only to control the bleed- ing to a level less than one would ex- pect without anaesthesia. “There are enough studies and case vignettes in which similar things have been proved. Unfortunately, in the heat of the moment, I forgot to focus on that too.” However, he plans to work on that aspect in the subsequent opera- tion, during which the cover screw will be removed. According to Lindemann, the mu- tual trust between the patient and the team made it possible to fully concentrate on the operation. He concluded: “I am grateful for my great team and for the trust that our patient placed in me.” Graphene coating that releases antibacterial acid prevents formation of bioﬁlm on dental implants By Franziska Beier, Dental Tribune International GOTHENBURG, Sweden: Biofilm for- mation on dental implants is a major challenge for dental professionals. It causes patients great inconvenience and entails considerable costs. Now, by covering a graphene-based mate- rial with bactericidal molecules, re- searchers from Chalmers University of Technology in Gothenburg have developed a novel material designed to prevent infections. A variety of drugs and molecules with antibacterial properties are available on the market; however, for them to be used in the body, they first have to be attached to a material which can be challenging and labour- intensive to produce. First author Dr Santosh Pandit from the Depart- ment of Biology and Biological Engi- neering at Chalmers explained in a university press release: “Graphene offers great potential here for inter- action with hydrophobic molecules or drugs, and when we created our new material, we made use of these properties. The process of binding the antibacterial molecules takes place with the help of ultrasound,” said Pandit. The researchers covered graphene material with usnic acid, which shows—according to previous stud- ies—good bactericidal properties. In addition, it has been tested for its resistance to the pathogenic bacteria Staphylococcus aureus and Staphylo- coccus epidermidis, which are known to cause biofilm formation on medi- cal implants. The usnic acid was successfully in- tegrated into the surface of the gra- phene material, and the researchers observed that the usnic acid mol- ecules were released in a controlled and continuous manner, thereby preventing the formation of bio- films on the surface. “This is an es- sential requirement for the method to work,” explained Pandit. Pandit added that the results show that the method for binding the hy- drophobic molecules to graphene is simple. “It paves the way for more effective antibacterial protection of biomedical products in the future. We are now planning trials where we will explore binding other hy- drophobic molecules and drugs with even greater potential to treat or pre- vent various clinical infections,” he continued. The study, titled “Sustained release of usnic acid from graphene coat- ings ensures long term antibiofilm protection”, was published on 11 May 2021 in Scientiﬁc Reports. A new approach for patients on direct oral anti-coagulant medication Fig. 1: The reduced size of position #14. Figs. 2a & b: Dental panoramic tomogram (a) and periapical radiograph (b) prior to implant placement. Fig. 2a Fig. 2b By Dr Stefan Grümer & Melissa Yüce, Germany Implant placement is a surgical procedure employed in accord- ance with the individual wishes of patients. It can often be avoided by choosing conventional, non-surgical alternatives. In particular, in cases of patients with haemorrhagic di- athesis or patients undergoing anti- coagulant therapy with direct oral anti-coagulants (DOACs), the risk of undesired side effects, with even life-endangering consequences, nec- essarily led to a strict selection of patients who are suitable for dental implants. A new laser- supported ap- proach in implantology for patients undergoing anti-coagulant therapy has been developed by the Aachen Institute for Continuous Medical and Dental Education in coopera- tion with the Clinic for Cardiology, Pneumology, Angiology and Inter- nal Intensive Medicine of the RWTH Aachen University hospital in Ger- many. Case presentation Nowadays, the number of implants placed in patients with a higher average age and in medically com- promised cases is rising. Particularly cases of patients undergoing DOAC therapy, with the advantage of no need to permanently control the coagulation parameters, are rising significantly. Despite the advice of cardiologists not to stop or interrupt the medication, these patients often request implants. In addition, for only two DOACs does an antagonist drug exist. For three other DOACs, there is no antagonist drug yet, lead- ing to an increase in possible postop- erative complications. Nevertheless, among this group of patients, the demand for implants is rising as well. To fulfil these wishes while following the advice of the cardiologist, a new transgingival, nearly blood-free sur- gical protocol has been developed. The following case describes this pro- ÿPage C4
Dental Tribune Middle East & Africa Edition | 5/2021 IMPLANT TRIBUNE C4 ◊Page C3 Fig. 3: The initial osteotomy for the implant being performed with the pilot drill. Figs. 4a & b: The guide for a conventional rotating soft-tissue punch with a central guide pin matching the pilot drill hole (a). The laser handpiece used (b). Fig. 4a Fig. 4b mensions. If the bone width appears critical, a 3D radiograph is highly rec- ommended to evaluate the amount of bone in the third dimension. Laser treatment and implant insertion After local anaesthesia, the initial osteotomy for the implant was per- formed with a pilot drill (locator drill; Fig. 3). A guide for a conventional ro- tating soft-tissue punch with a cen- tral guide pin that matched the pilot drill hole was placed in situ as an outline guide for the blood-free laser punch procedure (Figs. 4a & b). The laser unit used was an Er,Cr:YSGG laser operating at a wavelength of 2,780 nm (Waterlase iPlus, BIOLASE). The laser was set to the parameters shown in Figure 5. After the laser incision, the punched tissue was re- moved with a curette (Figs. 6a & b). Thereafter, following the drill proto- col of the implant system placed, a ProActive Tapered implant of 4 mm in diameter and 13 mm in length (Neoss) was inserted to a 32 Ncm torque (Figs. 7 & 8). The healing abut- ment was inserted to 15 Ncm. Slight pressure on the surrounding tissue is important, for which the diameter of the healing abutment should be at least 1 mm larger than the punch di- ameter. In this case, the tissue punch diameter was 4.3 mm and the heal- ing abutment was 5.5 mm in diame- ter (Fig. 9). The definitive restoration is shown in Figure 10. Discussion After three months of healing, the implant can be loaded and the super- structure can be installed. Following the protocol described, 143 implants have been inserted during the last three years. The retrospective analy- sis of this method showed postop- erative haemorrhage with the need for additional intervention for ten of these. Seven of the ten appeared dur- ing the first 30 implantations. After finding the right relation between size of the tissue punch and size of the healing abutment (diameter and height), only three cases of postop- erative haemorrhage were en- coun- tered. The main precondition for this kind of treatment is a sufficient amount of bone in the implant site. Any augmentative procedures more demanding than a punch technique to gain 1–2 mm in the neck area of the implant are not compatible with the protocol described. In cases of re- duced horizontal bone volume, case suit- ability for the laser-supported protocol should be evaluated by 3D radiography. The postoperative evaluation by the Clinic for Cardiol- ogy, Pneumology, Angiology and Internal Intensive Medicine showed no negative effects on the general health of the patients treated. This protocol is officially recommended by the clinic. Conclusion The use of laser in this delicate zone of soft tissue and bone of the implant site is very beneficial and does not harm the bone (or soft tis- sue) through high temperatures or carbonisation. In addition, the posi- tive effect of biostimulation leads to quicker and better healing by accel- erating the fibroblast activity around the implant. Of course, the primary benefit for patients is the reduction of the general risk of blood clotting and thrombosis, which can possibly cause seizures or strokes during the interruption of anticoagulant thera- py, and such interruption is no long- er essential with this laser-supported protocol. Editorial note: This article was originally published in implants—international maga- zone of oral implantology vol. 22, issue 2/2021. About the author Dr Stefan Grümer, MSc, is a specialist in implantology and laser dentistry. In 2013, he was appointed clinical director of the ﬁrst academic teaching clinic in dentistry in Germany accredited by RWTH Aachen University. He is the head of clinical educa- tion in the MSc in lasers in dentistry pro- gramme at RWTH Aachen University. In addition, he is a member of the board of directors of the German Society for Laser Dentistry and the International Society for Laser Dentistry. Fig. 5: The laser settings. cedure in general and points out dif- ferences in relation to conventional treatment. Clinical and radiographic situation A 62-year-old male patient with moderate general health attended the prosthetic consultation. His medical history revealed that he had had three bypasses between 2014 and 2016 and signs of anginal attacks. Also, there were periodically recurring events of sinus arrhyth- mias. For a duration of three years, he had been on dabigatran etexilate (Pradaxa), which is a direct thrombin inhibitor. He was slightly overweight and a non-smoker. Upon intra-oral examination, restoratively and pros- thetically rehabilitated dentition and missing teeth #14, 27 and 35 were noted, and it was observed that posi- tion #14 had reduced in size (Fig. 1). The patient maintained good oral hygiene. The panoramic radiograph revealed an apically compromised tooth #47 with furcation involve- ment and good bone structure in positions #14 and 35 (Figs. 2 & b). The patient was thoroughly informed regarding the treatment options. He asked for an implant replacement for tooth #14 and possibly, at a later stage, for tooth #35. After an explana- tion about the medical compromis- es regarding a surgical intervention and after consulting the cardiologist regarding the DOAC therapy, it was mutually decided not to interrupt medication with Pradaxa and to opt for transgingival, laser-supported implant surgery in position #14. The initial bone contours showed a suffi- cient amount of bone in all three di- Fig. 6a Fig. 6b Fig. 7 Fig. 8 Fig. 9 Fig. 10 Figs. 6a & b: Removal of the punched tissue with a curette (a). The tissue removed with the punch (b). Fig. 7: The implant placed. Fig. 8: Periapical radiograph immediately after implant insertion. Fig.9: Slight anaemia was vis- ible around the healing abutment, demonstrating the pressure on the surrounding tissue required to prevent post-op haemorrhage. Fig. 10: The deﬁnitive restoration.