issn 1868-3207 Sondernummer • Vol. 7 • Issue 1/2023 1/23 ceramic implants international magazine of ceramic implant technology research Clinical success rate of two-piece zirconia dental implants case report Magneto-dynamic site preparation for zirconia implants news First long-term study on two-piece zirconia implants published

Titanium versus zirconia? Osteo- immunology in implantology Titanium and zirconia are the two primary materials used in dental implan- tology. While both materials have been used successfully for many years, there is still a debate about which one is better. Titanium has been the traditional choice for dental implant surgery for over 40 years. However, there are some concerns with the use of titanium implants. One growing concern is that dissolved titanium particles induce infl ammatory reactions not only in the superfi cial margin but also around the bony bed of the titanium implant. Specifi cally, the infl ammatory cytokine tumour necrosis factor-alpha (TNF-␤) is expressed in the adjacent bone. The transition from TNF-␤-induced local infl ammation after placement of titanium implants to a chronic stage of “silent infl ammation”, that is, low-grade chronic in- fl ammation, could be a cause of apparently unexplained medical condi- tions, and this neglected area of consideration is investigated in osteo- immunology. Osteo-immunology, however, is an emerging fi eld, but has already provided valuable insight into the mechanisms of bone growth, development and regeneration, as well as the role of the immune system in these processes. In the context of implantology, osteo-immunology is important because the success of dental implants depends on the ability of the implant to integrate with the surrounding bone tissue. When a for- eign material such as a dental implant is introduced into the body, the immune system reacts to it. This immune response can be benefi cial, as it can help to promote the integration of the implant with the surrounding bone tissue. However, if the immune response is too strong, it can lead to chronic infl ammation and potentially contribute to implant failure. By understanding the interactions between the immune system and bone tissue, researchers can develop better implant materials and techniques that minimise the risk of infl ammatory responses and improve the long- term success of dental implants. Multiple studies have proved that zirconia implants induce little to no peri-implant tissue infl ammation and allow for high levels of epithelial at- tachment. Thus, in recent years, these ceramic implants have gained sig- nifi cant traction as a viable alternative to traditional titanium implants. They offer numerous advantages, including superior biocompatibility, enhanced aesthetics and excellent mechanical properties. In conclusion, the choice between titanium and zirconia implants ultimately depends on the individual patient. While titanium implants have been the traditional choice, zirconia implants are becoming increasingly popular. Yours, Dr Johann Lechner editorial | Dr Johann Lechner, Germany Integrative Oral Medicine and Osteoimmunology Founder of the International College of Maxillo- mandibular Osteoimmunology Author details implants 1 2023 03

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The only scientifically proven two-piece zirconia implant system First long-term study offers groundbreaking results* Only we can make it The patented production process, in which all surface-machining steps are carried out before sintering, creates two unique product features: • No process-induced micro-cracks • Ideal surface topography for hard- and soft-tissue adaptation * Brunello G, Rauch N, Becker K, Hakimi AR, Schwarz F, Becker J. Two-piece zirconia implants in the posterior mandible and maxilla: A cohort study with a follow-up period of 9 years. Clin Oral Implants Res. 2022 Dec;33(12):1233-1244. doi: 10.1111/clr.14005. Epub 2022 Oct 31. PMID: 36184914. The New Standard Long-term oral health: Patent™ has redefi ned implant success in the latest long-term studies. Learn more at: www.mypatent.com/scientifi c-studies Zircon Medical Management AG | Switzerland | Phone: +41 44 552 84 54

research | 6 8 10 12 7 9 11 13 Fig. 6: Occlusal view of the implant after immediate placement. Fig. 7: Occlusal view of the same implant after five months of healing, ready to be restored. Fig. 8: Same implant after laser exposure of the margins, abutment cementation and preparation for a CEREC-milled crown. Fig. 9: Same implant after receiv- ing the final crown on the same day. Fig. 10: Implant ready to be scanned, demonstrating excellent tissue response after ideal margin exposure and emergence profile creation performed on the same day with the Waterlase. Fig. 11: Same implant restored on the same day with a CEREC-milled IPS e.max CAD crown. Fig. 12: Implant replacing a maxillary second premolar after four months of healing, demonstrating excellent tissue healing and no foreign-body response. Fig. 13: Same implant after laser margin exposure and removal of the abutment access hole seal. implants 1 2023 09

research | 20 21 Fig. 20: Radiograph of the same implant after four months of healing. Fig. 21: Bitewing radiograph of the crown after cementation. Maxilla (44 implants) Mandible (66 implants) Tooth no. No. of implants Tooth no. No. of implants 18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 – 2 6 6 5 2 – 2 1 – 1 4 8 7 – – 38 37 36 35 34 33 32 31 41 42 43 44 45 46 47 48 – 7 22 6 3 1 – – – – – 2 4 18 3 – Table 3: Number of implants placed in the maxilla and mandible.* * Includes failed implants. implant failure, such as immediate implantation, bone quality, low vitamin D3 levels, bruxism, prediabetes, smoking and patient cooperation in wearing the protec- tive devices. It is common to expect higher success rates among younger populations. Regardless of age, how- ever, careful case selection combined with the highly bio- compatible nature of zirconia, as well as the improved health status of the current ageing population, suggest that age should represent only a small determinant of im- plant success. Similarly, implant failure in relation to sex and tooth specificity in our study was not statistically re- liable, owing to the low number of failures reported. serve as a viable alternative. The population demand for aesthetic and biocompatible implants is constantly rising. More studies are highlighting the allergies to titanium.8 Dentists are encouraged to acknowledge the risk factors of all implants on one hand and the biocompatibility, sci- ence, workflow and encouraging success rates of zirco- nia implants on the other. Dentists are also encouraged to embrace them as an alternative to satisfy rising de- mand in a modern ageing population which has a higher standard of living and therefore higher expectations re- garding aesthetics and biocompatibility. about the author Dr Joseph Sarkissian studied micro- biology at the University of Alabama in the US and then attended the dental school of the University of Göttingen in Germany, graduating in 1989. Over the next eight years, he practised dentistry on the Mediterranean island of Cyprus. During that time, he trained in homeop- athy, abandoned the use of amalgam and expanded his knowledge of the biological aspects of dental therapy. In 1998, he moved to Los Angeles and received his li- cence to practise in California in the US. He owns a state-of-the- art biological dental practice in Glendale in California. Dr Sarkissian is a member of the International Academy of Oral Medicine and Toxicology, World Clinical Laser Insti- tute, International Academy of Biological Dentistry and Medicine, and International Association for Orthodontics. Literature Dr Joseph Sarkissian Conclusion contact This clinical survey, along with many others in the litera- ture, proves that zirconia implants exhibit high success rates comparable to those of titanium implants and can Dr Joseph Sarkissian drs@sarkissiandds.com www.sarkissiandds.com implants 1 2023 11

case report | safe option with predictable results, but this does not pre- vent tissue shrinkage.8,9 Nevertheless, when this is com- bined with alveolar ridge preservation procedures, post- extraction tissue loss can be significantly reduced.10 To preserve the transgingival profile immediately after ex- traction, the socket sealing abutment technique was proposed.11 This technique also allows for primary wound closure and protects the alveolar clot and biomaterial particles underneath.12 The aim of this case report is to demonstrate the use of a two-piece ceramic implant sys- tem and a custom healing abutment to replace the max- illary right first molar and review the clinical and radio- graphic situation after ten months of follow-up. Case presentation This study was submitted to the ethics committee of the State University of Rio de Janeiro in Brazil and ap- proved under No. 5.598.463. The patient was invited to participate in and informed about the study and signed informed consent to participate, and all ethical require- ments were met. The patient, a 60-year-old woman, was referred to a private clinical study centre in Rio de Janeiro complaining about pain at the first molar on the right side of the upper jaw. The patient was a non-smoker and in good general health, but reported having type 2 diabetes, which was however well controlled. To carry out the correct planning and diagnosis, a CBCT scan was obtained (Fig. 1). The radiographic examination showed unsatisfactory end- odontic treatment and the presence of periapical peri- odontitis. According to the patient, the tooth had already undergone endodontic retreatment, but without suc- cess. Thus, the decision to extract and replace the tooth was taken. 2 4 3 5 6 Fig. 2: Pre-op situation before sectioning of the roots. Fig. 3: Socket preparation. Fig. 4: GZi implant. Fig. 5: Placement of the implant Fig. 6: Final bone-level position of the implant. implants 1 2023 13

case report | In addition, a bone substitute material (0.5 cm3 of 0.5– 1.0 mm maxresorb granules, Straumann) was used to fill the gaps between the fresh socket walls and the external face of the implant (Fig. 7). A PEEK abutment was se- lected, and a customised healing abutment was made using light-polymerised flowable resin (Fig. 8). It was not necessary to use a suture to close the surgical wound. At the end of the surgery, a radiograph was taken (Fig. 9). The three-month postoperative period was uneventful. The customised healing abutment was carefully re- moved, and conventional impressions were taken with a putty and medium-bodied addition-cured silicone us- ing the closed-tray technique. A provisional crown was made with self-polymerising resin and seated. It re- mained in the patient’s mouth until the day of cementa- tion of the definitive crown. It is important to highlight that the gingival emergence profile was carefully copied using light-polymerised flowable resin (Figs. 10–12). A lithium disilicate crown was manufactured and ce- mented on to the prosthetic abutment with adhesive cement (Figs. 13–18). After cementation of the definitive crown, the stability of the marginal bone level was observed on the final radio- graph in relation to the immediate postoperative radio- graph. The patient has been followed up periodically for the last ten months, and there have been no complica- tions to date. At the end of the treatment, she was asked to rate her degree of satisfaction with the aesthetic results of the treatment according a visual analogue scale and selected “very satisfied”. Discussion To our knowledge, this is the first ten-month follow-up clinical report on the use of this two-piece zirconia im- plant system in the molar region using a customised healing abutment. According to a European Federation of Periodontology consensus report, peri-implant soft-tissue health is an important criterion for implant success.14 In the present study, after ten months of follow-up, seven of them under occlusal loading, the soft tissue around the ceramic implant appeared healthy and to be of a natural colour. It should be noted that the use of a customised healing abutment favoured the maintenance of the soft- and hard-tissue architecture around the ceramic implant, as previously reported in another study, which used PEEK healing abutments seated on titanium implants replacing posterior teeth.15 Studies on animals have shown that the osseointegra- tion potential of zirconia is comparable to that of titanium implants.13,16 The implant in this case achieved osseointe- gration during the first three months, and no bacterial plaque adhering to the surface of the implant or pros- thetic abutment was observed during the follow-up 13 14 15 16 17 Figs. 13 & 14: Clinical views of the healthy peri-implant tissue free of in- flammation. Fig. 15: Lithium disilicate crown. Figs. 16 & 17: Clinical views of the definitive crown. implants 1 2023 15

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case report | possible, without the use of irrigation, to easily extract teeth (ankylosed), perform crestal sinus lift, expand thin alveolar ridges and prepare implant sites in low-density bone (Type D3 and D4). The Magnetic Mallet surgical device is equipped with var- ious inserts, such as for dental extraction, implant site preparation and regenerative surgery. The device applies greater force than conventional methods in short time on a focus point in the area being treated along a central axis moving up and down. An implant site can be prepared using only osteotome inserts of increasing diameter. Plastic bone deformation is facilitated by shock waves (130 daN in 80 µs) through their tips. The implant site is created by expanding bone tissue laterally and apically. No bone tissue is removed. Instead, the tissue is com- pacted, creating increased density and enabling greater primary stability. Magneto-dynamic surgery has several advantages. The force applied to the inserts is high and brief; therefore, the intervention is faster and more precise. The handpiece is operated with one hand (Fig. 1). The movement is only lon- gitudinal; therefore, we will have better operative control and reduced operational risk. The absence of rotating in- struments and lack of irrigation permit cold surgery without the risk of tissue overheating and infectious contamination. plant is made in one piece (endosseous and abutment portions) of highly pure and extremely resistant zirconia. The cylindrical body and apex’s conical design allow the implant to achieve high primary stability. The thin threads on the implant collar increase the contact area and me- chanical retention. The broad threads on the implant body improve primary stability and enhance osseointe- gration. The sandblasted intraosseous area gives to the implant a micro- and macro-roughness that favours bet- ter tissue integration. In vivo studies have demonstrated 60% bone–implant contact just eight weeks after implant placement. Surgical protocol In the case of an edentulous area with intact tissue, gin- gival access is created using a tissue punch mounted on a surgical handpiece rotated at 250 rpm (flapless tech- nique) or by incision and raising of a flap with a zirconia scalpel. In the case of a compromised tooth, the root is first extracted using dedicated magneto-dynamic inserts (EXTR1, 2, 3, 4 and 5). After the cleaning and disinfection of the alveolus, the best site and inclination are sought for the preparation of the implant site according to the mor- phology of the alveolar crest and the condition of the re- sidual bone. The ZiBone implant system (COHO Biomedical Technol- ogy) has an ideal topography for placement using the magneto-dynamic technique. The standard ZiBone im- The preparation of the site for the positioning of one- piece implants is achieved using the Black Ruby osteo- tomes owing to the excellent correspondence of shape and dimension. The Black Ruby inserts have a double 2 4 3 6 5 Fig. 2: Dental panoramic tomogram before surgery. Fig. 3: Initial clinical situation. Fig. 4: Gingival incision using a zirconia scalpel (ZiBone CST-B15). Fig. 5: Initial osteotomy preparation using a BLK-R1 osteotome. Fig. 6: Placement of the implant into the osteotomy. implants 1 2023 19

case report | Case 2 A 60-year-old man presented for the removal of a tita- nium dental implant and minimally invasive rehabilitation of the mouth using ceramic implants. The anamnesis found that the patient had Crohn’s disease and an al- lergy to metals. The dental evaluation found severe peri- odontal disease, edentulous areas and peri-implantitis with bleeding deep periodontal pockets in the area of the previously inserted titanium implant (Figs. 11 & 12). Given the patient’s request and pathological conditions, it was decided to perform a targeted periodontal treat- ment, extract the compromised teeth and rehabilitate the mouth using one-piece zirconia implants positioned with the Magnetic Mallet to reduce trauma and preserve residual bone tissue. The extraction of the teeth was performed using forceps (Fig. 13), and the alveoli were first cleaned and then dis- infected using ozone at a concentration of 20 μg/ml. Subsequently, the implant sites were prepared by oste- otomy creation and sinus lift via the crestal route using standard inserts for bone condensation (160-F, 230-F and 300-F osteotomes; Fig. 14). Once the appropriate dimensions of the sites had been reached, the implants were positioned first using a surgical handpiece and then with a manual dynamometric ratchet up to a torque 11 13 16 14 17 12 15 18 Fig. 11: Dental panoramic tomogram before surgery. Fig. 12: Lateral clinical view of the affected area. Fig. 13: Atraumatic extraction of the compromised tooth. Fig. 14: Initial preparation of the socket with a 100-P pointed osteotome. Fig. 15: One-piece implant (ZiBone Zr-I5010) mounted on a surgical micromotor. Fig. 16: Screwing of the implant into the prepared site. Fig. 17: Lateral view of the implants after placement. Fig. 18: Clinical situation the day after surgery. implants 1 2023 21

case report | gery had less pain and little postoperative discomfort; therefore, they did not need to take analgesics and their healing was quicker. The positioning of implants using the Magnetic Mallet also has advantages for the dentist, as it is faster, more precise and more efficient. The absence of drills and irri- gation leads to a lower risk of infectious contamination, avoids bone overheating and saves bone tissue in the case of thin alveolar ridges. The ZiBone one-piece im- plants adapted perfectly to the implant sites prepared using the Black Ruby inserts. Magneto-dynamic surgery represents a good alternative to traditional osteotomy preparation using rotary drills. Literature about the author Dr Franco Giancola is serving as a spe- cialist in Ceramic Implantology and Guided Regenerative Surgery at DENTZIA Clinic in Barcelona since September 2022. He is registered with the Valencia College of Official Dentists and Stomatologists and the Barcelona College of Physicians. Dr Giancola is also a Director of Health and Freelance specialist in Immunocompatible Implantology, Ozonotherapy and Regenerative Medicine at the Do- mus Medica European Ceramic Implantology Clinic in San Marino since October 2018. Dr Giancola’s previous experience includes working as a Chief of Ceramic Implantology and Autologous Regenerative Surgery at Nuova Villa Claudia and Villa Mafalda in Rome. He also worked at SALVATOR MUNDI International Hospital in Rome as a Chief of Ceramic Implantology and Biological Dentistry. He has undergone training and received certification in various areas of expertise, in- cluding Ceramic Implantology, Guided Regenerative Surgery, Ozo- notherapy, and Regenerative Medicine. 28 Fig. 28: Cementation of the resin prosthesis the day after surgery after pre- paring the abutment teeth. for bone condensation to the chosen size (Figs. 23 & 24). After the surgery, a systemic ozone therapy session was performed at a concentration of 30 μg/ml, and peri- implant infiltration was performed with i-PRF to reduce postoperative discomfort and promote healing of dam- aged tissue to ensure primary stability. The one-piece zir- conia implants were inserted to a torque of 35 Ncm to ensure primary stability (Figs. 25–27). The following day, all the teeth of the maxillary arch were prepared, and a resin prosthesis was positioned (Fig. 43). Discussion The aim of this article is to demonstrate an alternative way to place zirconia implants into poor-quality bone in fragile patients. In bone that is less dense, Magnetic Mallet os- teotomes increase the density around the implant. In the cases reported in this article, the implant sites were pre- pared by use of osteotomes which compressed the native bone and by cortical sinus lift as reported by the literature. These surgical procedures, supported by data from several experimental studies, resulted in faster and greater bone apposition compared with conventional drilling. The Magnetic Mallet site preparation increased the bone–implant ratio in early phase placement, en- hancing primary stability of the implant and expediting bone healing. Conclusion contact The use of the Magnetic Mallet in poor-quality bone (Types D3 and D4) and in fragile patients can make zirconia im- plant surgery safer, more predictable, faster and more com- fortable for patients. The surgery improves tissue healing and long-term implant survival. All the patients treated with ZiBone implants placed with magneto-dynamic sur- Dr Franco Giancola +39 388 0913583 +34 657 610406 www.implantosofia.com www.ceic.eu Dr Franco Giancola implants 1 2023 23

case report | 3a Figs. 3a & b: Surgical planning for bicortical fixation with placement in furcal bone. has been shown to enhance accuracy, precision, and flexibility across surgical fields.1,2 The Yomi dynamic navigation platform with haptic feedback allows for small adjustments in real time and accurate visualisation of drills into the surgical site. This can be significantly im- pactful when managing close implant placement to sensitive anatomical structures of the IAN, drill depth management in vertical sinus lift augmentation, and as- suring immediate implant placement into adequate native bone. The following case studies will review the digital workflow of dynamic navigation with Yomi when perform- ing immediate zirconia implant surgery and the perceived benefits therein. 3b Case presentations Case 1 A 60-year-old female presented with history of LANAP at the periodontist on #3 for a 9 mm periodontal pocket on the DB one year ago. Upon recall at the periodontist, the vertical bone defect was non healing, and the tooth was deemed hopeless. The patient came to our clinic hoping for extraction and immediate implant placement, risks and alternatives were given to the patient including the possibility of inability to place the implant the same day due to bone anatomy in the area. Yomi link was attached to her upper left using bite regis- tration and a CBCT was taken with the additional fidu- ciary arrays attached to the link (Figs. 1 & 2). Surgery was planned for bicortical fixation with placement in furcal bone avoiding the defect on distal (Figs. 3a & b). The sur- gical procedure involved a planned implant depth to the sinus floor, followed by a gradual increase in depth to per- form an internal sinus lift. The extraction was carried out atraumatically, and the socket was thoroughly cleaned. Yomi guide arm was then attached to the link and the landmark verified, ensuring accurate stable navigation. Under surgeon guidance and robotic assistance the pilot drill was guided to the surgical site. The osteotomy con- tinued with a drill path and depth that locked once in the planned position. The osteotomy was completed to the sinus floor with confirmation of depth via dynamic live CBCT navigation. Incremental advancement of the drill depth stop was used to complete the sinus lift. Proper vi- sualisation aided in depth management of the transgin- gival implant. The implant (2.2_5411, SDS) was placed implants 1 2023 25

case report | 9 10a Treatment plan A thorough discussion of treatment options, limitations and risks was reviewed with the patient. Poor long-term prognosis was given to remaining mandibular teeth except #30. The patient’s primary concerns were to have no teeth during healing, not wanting a removable prosthesis, and to have biologically friendly materials. Delicate consid- eration was made to design an immediate implant surgery that provided the patient with a stable temporary resto- ration and protected our healing implants. One-piece SDS (Swiss Dental Solutions) implants were chosen for their variety of diameters and lengths. Posterior teeth 18, 28, 30 were elected to remain in place during the tempo- rary healing phase to provide posterior stops for occlu- sion and to maintain stability of implants and temporary restoration during healing phase. Pre-surgical planning was performed using CBCT and Yomi planning software to parallel all implants (Figs. 10a & b). Preoperative max- illary and mandibular arch scans were taken and sent to the lab to aid in temp mock-up (Fig. 11). Surgical Phase The procedure began with the administration of bilateral inferior alveolar nerve blocks for anaesthesia, followed by sectioning and removal of the PFM bridge. The Yomi link was then attached to the lower left using bite regis- 10b 11 12 Fig. 4a: Placement of the pilot drill into the surgical site via dynamic live CBCT navigation. Figs. 4b & c: Osteotomy was completed to the sinus floor with confirmation of depth via dynamic live CBCT navigation. Fig. 5: Placement of the ceramic implant (2.2_5411, SDS) to 35 Ncm. Fig. 6: PRF covering with allograft. Fig. 7: Postoperative radiograph showing accurate implant placement. Fig. 8a: Initial situation on CBCT showing multiple peri- apical radiolucencies associated with failing root canals of teeth 19, 21, and 27. Fig. 8b: Horizontal root fracture in tooth 29. Fig. 9: Failing double abutted bridge in teeth 21/22-27/28. Figs. 10a & b: Pre-surgical planning using CBCT and Yomi. Fig. 11: Preoperative maxillary, mandibular and bite scans to aid in temp mock-up. Fig. 12: Immediate implantation in site #29 using the Yomi robot with haptic controls and locked drill path depth and angulation. implants 1 2023 27

D A case report | Zeramex XT The two-piece all-ceramic implant system Get to know the proven all-ceramic implant system with the unique metal- free Vicarbo® screw that counteracts tensile and bending forces. - 98% success rate - Low risk of inflammation - Perfect red-white aesthetics - Biocompatible Made in Switzerland - since 2005 the the lower right side of the patient’s mouth, utilising teeth 30 and 28, and implant abutments 29 and 27, but it was then unsuccessful. Yomi’s tradi- tional workflow only allows for working on one quadrant of the mouth at a time, and a new scan and four or more stable teeth are required to anchor the link on the other side. This has now been over- come with a new Yomi bone link which would have been ideal in this case. Freehand immediate placement and par- allelisation of implants (#22, 20, and 19) was possible with the visual aid of the previous implants. Intra-oral scans of the surgical sites were made and sent to the lab for temporary fabrication (Figs. 13 & 14). Site #21 had significant bone loss due to infection and was grafted with allograft and a laminar bone sheet. The bone sheet was trimmed and placed into a minimally released buccal and lingual flap and covered with A-PRF+ (Figs. 15a & b). Suturing was completed, and a full arch temp was adjusted and seated with temp cement (Fig. 16). Seven weeks later, the patient’s loose temp was re- moved, cleaned, and recemented. Ex- cellent healing of the soft tissue was shown in Figure 17. Discussion Ceramic dental implant placement can be a delicate process, having ideal emer- gence with one piece dental implants re- mains one of the biggest challenges and ideal placement is essential. A fixed drill path and depth combined with Yomi’s surgical flexibility and the dentist’s visuali- sation during surgery may be one of its advantages over other guided navigation systems. As patient awareness grows of different dental materials, zirconia im- plants with their excellent healing profiles are poised to continue to gain attention. Accurate and ideal placement of zirconia implants is essential in gaining trust of our patients and dental community. With the variety of modern digital workflows choos- ing a surgical method that is predictable and repeatable is what we as clinicians must evaluate. The benefits of robotic as- sistance point towards Yomi holding its place in the surgical suite and will likely continue to pave the path forward in giving patients access to safe, efficient, accurate and long-lasting zirconia implant therapy. Acknowledgements to Dr Shepard Delong for his guidance and introduction to ceramic implantology and to Lotus Dental Wellness, Lake Oswego, Oregon. about the author Dr Daniel Madden received his Doctor of Dental Surgery from the University of Minnesota and pursued advanced studies in implantology and comprehensive dentistry abroad at the Radboud University Med- ical Center in Nijmegen, the Netherlands. He has served as adjunct affiliate assistant professor at Oregon Health and Science University and is a certified Integrative Nutrition Health Coach. He has a passion for education and technology in dentistry, and believes that this leads to a more comfortable, efficient and pleasurable patient experience. He offers patients biologic treatment solutions for optimum oral and whole-body health at Lotus Dental Wellness in Lake Oswego, Oregon, and his surgical services through his company Peak Potential Dental at multiple private practice locations in Oregon and Washington State. Dr Daniel Madden Literature contact Dr Daniel Madden Lake Oswego, USA in Hood River, USA www.dentistdanielmadden.com www.zeramex.com implants 1 2023 29

case report | Prosthetic restoration After three months, a secondary surgery was carried out to place a Zi healing abutment (4.5 × 2.5 mm). Fifteen days after the second surgery, the Zi implant scan body was seated and an intra-oral scan taken (Figs. 6 & 7). The fi nal crown was seated over the Zi base. The crown and a new bridge were placed, and the occlusal adjustments were performed (Figs. 8 & 9). Discussion Alternative treatment options would have been either fab- ricating a new bridge for tooth #24 to tooth #27 or placing two implants in regions #24 and 26, restoring these with crowns and restoring teeth #25 and 27 with crowns. I however chose the treatment solution described be- cause the patient had wished for a ceramic solution al- ready years ago. He had opted for being fi tted with a bridge as he did not want a titanium implant. The patient thus approached our practice looking for a ceramic solu- tion. In this case, the clinical indications for the ceramic im- plant system employed required strictly following the sur- gical drilling protocol recommended by the manufacturer, in order to achieve primary stability and to avoid the stress of screwing into the ceramic. The mentioned pro- cedure requires more attention in positioning and the sur- gical procedure. about the author Dr Olivier Chéron is an implantologist specialising in treatment with ceramic implants and has employed a therapeu- tic approach based on biological den- tistry since 2006. He is co-founder of the Equilibria dental clinic in Barcelona in Spain. Dr Chéron is the European Academy of Ceramic Implantology’s ambassador for Spain and co-director of the International Team for Implantology’s Barcelona study club. He is also a member of AFNOR. contact Dr Olivier Chéron Dr Olivier Chéron drcheron@equilibriadental.com www.equilibriadental.com 5 6 7 8 9 Fig. 5: Zi cover screw in situ. Fig. 6: Radiograph after three months. Fig. 7: Intra-oral scan of the situation with the scan body in situ three months after implant placement for prosthetic assessment. Fig. 8: Final situation with the crown and bridge in situ. Fig. 9: Final radiograph. implants 1 2023 31

case report | 3 4 5 implants 1 2023 33

After atraumatic extractions of the teeth that could not be saved, a full-thickness mucoperiosteal flap was raised with a crestal incision to remove inflammatory tissue and access the bone ridge. The anchor pin marks were located to insert the second guide for ridge reduction (Figs. 9 & 10). The goal of bone reduction in the case of failing dentition is to improve the alveolar ridge profile and create the planned inter-arch space. The ridge was reduced with a bur using the pre-planned guide contours to achieve the intended inter- arch space for optimal prosthetic dimensions. The third guide was fixed on this guide to drive the implant site preparation and placement. The Straumann surgical cassette was used, and the manufacturer’s instructions in the full Straumann technique guide were followed (Fig. 11). These implants were selected for their design and surface characteristics, which enable excellent primary stability to be achieved in extraction sockets and soft bone. Since the pri- mary stability of all the implants was between 40 and 45 Ncm, immediate loading could be performed using the PMMA pre- milled provisional prosthesis and Straumann PURE tempo- rary abutments (Figs. 12–15). A VITA CAD-Temp temporary cylinder abutment was attached to each implant with a multi-unit abutment screw. Next, the provisional prosthesis was seated, a passive fit on the abut- ments was achieved and the occlusion was checked. Since the provisional prosthesis was passively adapted and the occlusion was fine, acrylic resin was used to join the abut- ments to the prosthesis. Finally, the screws were tightened to 25 Ncm. Detailed postoperative instructions were given on oral hy- giene and the avoidance of extreme loading when chewing. A liquid diet was recommended for the first two days and only soft food for 30 days thereafter. The suture removal appointment was scheduled for two weeks postoperatively. Healing was found to be uneventful (Fig. 16). Final restorative procedure After four months, the patient had adjusted very well to the new prosthesis and was eager to move forward with the treat- ment plan (Fig. 17). The soft-tissue contours were exactly as digitally planned (Fig. 18). Implant healing was outstanding, and osseointegration had been achieved. Therefore, a conventional impression was taken to deliver Y-TZP restoration in three parts for optimal load distribution (Figs. 19 & 20). Straumann PURE Ceramic abutments were used. The occlusion was checked, and no further adjust- ments were needed (Figs. 21 & 22). Clinical examination at the 18-month follow-up indicated excellent maintenance of the treatment (Fig. 23). 10 11 12 13 14 implants 1 2023 35

D A Conclusion The outstanding health of both hard and soft tissue was achieved thanks to pru- dent clinical selection, good planning, accurate 3D implant positioning and an ap- propriate treatment protocol. These were essential for the treatment success and outstanding aesthetic outcome, which met the patient’s requirements. Straumann PURE Ceramic two-piece implants allow clinicians to use zirconia im- plants not only for single-tooth cases but also as a reliable solution for multiple teeth, treatment in the posterior zone and challenging clinical situations. Correct planning with coDiagnostiX is essential for achieving successful results by placing the implant with Straumann Guided Surgery. Literature about the authors Dr Rodrigo Pohlmann has been practising dentistry in his clinic for 26 years in the state of Rio Grande do Sul, Brazil. As a specialist in dental prosthesis and implant dentistry, he became acquainted with ceramic implant dentistry at the first IAOCI congress in San Diego, USA and then encouraged this philosophy in Brazil. In addi- tion to applying ceramic implantology in his private clinic, he is now dedicated to coordinating a postgraduate course in implantology in Rio Grande do Sul, Porto Alegre, where case studies documented by students disseminate this new and already important practice among academics. Within a team of ceramic implant experts, Dr Pohlmann experiences in practice the benefits already demonstrated by scientific research. Dr Rodrigo Gomes Beltrão graduated in dentistry from the Fed- eral University of Rio Grande do Sul in Porto Alegre, Brazil in 2001. After pursuing his master’s degree specialising in oral and maxil- lofacial surgery at the Pontifical Catholic University of Rio Grande do Sul in 2003, he got his PhD in dentistry (oral and maxillofacial surgery) at the same alma mater in 2009. He has been an ad- vanced surgical implant trainee at UCLA, USA and received a post graduate degree in digital dentistry. Dr Beltrão is CEO of the BeEasy School, Innovation Advisor at Biolab3D, a founding member of ABICeram Brazil as well as an ITI member. He has a pri- vate practice in Porto Alegre, Brazil and also works as an adjunct professor in the master’s programme of dentistry at the Porto Alegre campus. ☢ Radiation-free ultrasonic analysis of bone marrow health 🔎🔎🔎🔎 leads to a successful implant treatment Author details ORDER NOW: shop.cavitau.de CONTACT: info@cavitau.de Dr Rodrigo Pohlmann Dr Rodrigo Gomes Beltrão MORE INFORMATION: www.cavitau.de contact Dr Rodrigo Gomes Beltrão rodgBeltrão@gmail.com

EACim Seminar September 23, 2023 BRUSSELS The prosthesis on zirconia implants Simultaneous translation in English and in French PROGRAM Moderator : Prof. SELENA TOMA 09:00 - 10:30 : Pascal EPPE (Belgium) The zirconia implant, a preventive strategy for peri-implantitis 10:30 - 11:00 : Break 11:00 - 12:30 : Dr Fabrice BAUDOT (France) Evolution of prosthetic concepts on zirconia implants. Biomimetic reconstructions 12:30 - 14:00 : Lunch - Buffet Moderatorr : Pierre DELMELLE 14:00 - 15:30 : Prof. Marcel WAINWRICHT (Germany) rehabilitation with zirconia implants. How to solve them ? 15:30 - 16:00 : Break 16:00 - 17:30 : Marc NACAR (Belgium) prosthetic management on ceramic implants Event open to all: EACim members and non-members RATE Registration fee : 180 euros (Lunch included) 2023 (in order of contribution 2023) (in order of subscription 2023) LOCATION HÔTEL LE PLAZA Adolphe Maxlaan 118/126 1000 Brussels ORGANISATION: EACim Partner : INFORMATIONS & REGISTRATION : eacim-ceramic-implantology.com

events | recently even on a sterile-packaged ceramic implant revealing cell-toxic residues on the implants’ surface. Joining online from Zurich, Prof. Schmidlin in his lecture criticised the fact that only the osseointegration rates are considered as a success parameter of implantation, an incomplete standard overdue for reconsideration. The far more relevant indicator of success is the attachment of the soft tissue to the implant. However, this process can be affected by impurities on the implant’s surface. Unveiling the causal effects of the matter, a recently initi- ated in-vitro study by the University of Zurich in cooper- ation with the CleanImplant Foundation investigates the “Providing a reference for patients and practitioners, the consensus-based quality guideline for implant surface cleanliness was established in 2017 by the scientific advisory board of the non-profit organisation, as the industry faces increasing backlash over lacking quality levels.” effects of different chemically identified factory-related implant contaminants on bone and soft tissue. “This study will provide answers to the question of a connec- tion between implant surface contaminants on the one hand and previously unexplained early implant failures and poor osseointegration on the other”, adds Dr Dud- deck. On-site SEM analyses of implant surfaces A high-resolution scanning electron microscope (SEM), provided by Thermo Fisher Scientific, was installed at the CleanImplant booth to demonstrate the analysis process of implant surfaces to the numerous specta- tors live at this year’s IDS. Dentists brought sterile pack- aged implants from their practices to have them anal- ysed directly. As expected, the revelations from the SEM analyses’ visualisations caused either relief or shock, as dentists found their implants intended for use on pa- tients to carry significant contaminations. Dr Duddeck and his team continued to educate and inform about the extent and potential consequences of factory-related contamination of dental implants. At the same time, im- plant types that have proven batch-spanning particle- free implant surfaces have been awarded the founda- tion’s “Trusted Quality” seal and received praise and mention by the quality initiative for guidance and trust for practitioners. contact CleanImplant Foundation www.cleanimplant.org implants 1 2023 43

Top speakers and hands-on workshops Exciting presentations and breakout sessions on metal- free implantology were at the center of the congress. Re- nowned experts of metal-free implantology were offering insights into their extensive experience using ceramic im- plants. Participants had the possibility to get in-depth knowledge of the practical work during the breakout ses- sions at the start of the congress: choosing between ei- ther getting to know the Zeramex XT implant system and its digital workflow or expanding their knowledge in mod- ern patient management and dental photography. After a welcome by Dentalpoint’s CEO Adrian Hunn, the congress presentations were kicked-off by Dr Jens Tartsch, congress president and president of the Euro- pean Society for Ceramic Implantology (ESCI), with a presentation on the role of ceramic implants in modern implantology and their increasing importance in practice. Dr Tartsch’s lecture introduced the range of topics of the two-day congress, reaching from material specifications of zirconium dioxide and application conditions to osse- ointegration and the advantages of two-piece implant systems. Repeatedly at the focus of presentations: The clinical evidence of ceramic implants in implantology practice. The speakers discussed the state of research on ceramic implants and the evidence for their functioning in prac- tice based on their own studies, scientific findings and application experience. It was thus shown that ceramic implants can compete with implants made of titan in many criteria, whereas they are even setting their own standards in other areas such as e.g. the risk of peri- implantitis or red-white aesthetics. events | 3 Fig. 2: During a press conference, CEO Adrian Hunn (third from left) and Sales Director D-A-CH Michael Wierz (second from left) provided insights into the company Dentalpoint and the Zeramex brand. Fig. 3: Dr Marc Balmer (left) presented the latest study results with ceramic implants in 2023 together with Dr Jens Tartsch. Insights into implantology’s future Besides clinical evidence and practical experience with ceramic implants the congress also offered exciting in- sights into important topics connected to implantology. During the lecture of Dr Joseph Choukroun, inventor of the PRF technique, attendees were getting insights into osteoimmunology and gained important points of refer- ence regarding soft-tissue management in implantology, especially with ceramic implants. Dental technician Wolfgang Weisser focused his presen- tation on the role of Zeramex implants in dental technol- ogy showing their diverse possibilities in dental practice. To sum things up Dr Gerd Wirtz gave an outlook into the developments that artificial intelligence means for both practitioners and patients in his keynote speech on the future of medicine. It even inspired a spontaneous presentation of US dentist Dr Shepard Delong, demon- strating how he is supported by a highly modern robot in his implantological work. Well attended presentations followed by lively discus- sions, collegial exchange and lasting learning experi- ences characterised the Zeramex congress. Adrian Hunn, Dentalpoint’s CEO and host of the Zeramex congress was truly satisfied: „During the Zeramex congress we have once again highlighted that implants made of high- performance ceramic will not only have a supporting role in dentistry but will become an essential part of it. The outstanding feedback has proven to us that we are on the right track.” contact Dentalpoint AG Switzerland www.zeramex.com implants 1 2023 45

manufacturer news | Zircon Medical Management The two-piece zirconia implant with long-term studies Patent™ has eliminated the drawbacks of conventional two- piece zirconia implants. Its innovative prosthetic concept per- fectly complements the material properties of zirconia: the cemented glass fibre post, having a dentine-like modulus of elasticity, is able to attenuate masticatory forces and transfer them to the implant in favourable way, ensuring reliable long- term function. Additionally, the patented production process, in which all surface-machining steps are completed before sinter- ing, creates a high endosteal surface roughness (Ra 5,7 μm) that is essential for fast and predictable osseointegration. During the subsequent sintering, any process-induced microcracks are eliminated, maximising fracture resistance. The success of the Patent™ Concept has been proven by science: in the first long- term study on two-piece zirconia implants, integrated Patent™ Implants showed no fractures, healthy soft tissues, stable bone levels, and no signs of peri-implantitis after almost a decade.1 In a preclinical study they demonstrated bone-to-implant contact (BIC) of over 70% after just four weeks of healing, outperforming all implants investigated in similar stud- ies thus far in terms of osseointegration speed.2 Zircon Medical Management AG, Switzerland www.mypatent.com Literature 1. Brunello G, Rauch N, Becker K, Hakimi AR, Schwarz F, Becker J. Two-piece zirconia implants in the posterior mandible and maxilla: A cohort study with a follow-up period of 9 years. Clin Oral Implants Res. 2022 Dec;33(12):1233-1244. doi: 10.1111/clr.14005. Epub 2022 Oct 31. PMID: 36184914. 2. Glauser R, Schupbach P. Early bone formation around immediately placed two-piece tissue-level zirconia implants with a modified sur- face: an experimental study in the miniature pig mandible. Int J Implant Dent. 2022 Sep 14;8(1):37. doi: 10.1186/s40729-022-00437-z. PMID: 36103094; PMCID: PMC9474793. bredent medical High primary stability and aesthetic appearance bredent medical GmbH & Co. KG, Germany info@bredent.com · www.bredent-implants.com The whiteSKY implant system from bredent is among the best - documented zirconia implant systems worldwide. It has not only demonstrated excellent osseointegration and longevity in numer- ous studies but has also proven its efficacy in practice. In fact, the longevity of whiteSKY implants is comparable to that of titanium implants. The whiteSKY implant system offers two different im- plant types: the whiteSKY Tissue Line and the whiteSKY Alveo Line. The narrow whiteSKY Tissue Line implant provides sufficient space for both the hard and soft tissue and ensures an aestheti- cally pleasing appearance with its slightly tapered shape in the sulcus area, transitioning from the gingiva to the implant crown. The whiteSKY Alveo Line, on the other hand, is ideal for immediate loading as it fills the extraction socket. At the same time, it pro- vides the treating doctor with the possibility to individualise the implant according to the specific requirements of the clinical case. Optimal conditions for soft tissue attachment and high me- chanical stability Both the Alveo and Tissue Line implants of the whiteSKY system offer optimal conditions for soft tissue attachment due to their specially designed sulcus surface. The whiteSKY implants are made of hardened zirconia and are one-piece, which gives them particularly high mechanical stability. Thanks to the improved thread design and bone-quality-oriented surgical protocol, the whiteSKY implants achieve high primary stability, making them ideal for immediate loading. Studies have shown that immediate implant placement can improve the bone-implant contact by more than 50 per cent. implants 1 2023 47