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| content editorial Implantology in the team Dr Rolf Vollmer case report page 6 The added value of the pterygoid implant in the management of edentulous patients Dr Henri Diederich Restoring anterior aesthetics with two-piece zirconia implants Dr Saurabh Gupta Resective peri-implantitis therapy with implantoplasty in Crohn’s desease Lucas A. Greilich, Dr Mischa Krebs, PD Dr Maximilian Moergel Interdisciplinary approach for a missing maxillary incisor Dr Tran Hung Lam page 22 research Immediate or delayed loading in the fully edentulous maxilla Drs Yassine Harichane, Rami Chiri & Benjamin Droz Bartholet industry Economic success in the implantology market in Germany Andreas Halamoda “Clean” medical products page 38 news manufacturer news events Cheers to new beginnings: celebrating oral tissue regeneration Cutting edge science and innovation about the publisher imprint 03 06 12 16 22 28 32 35 36 38 40 42 Cover image courtesy of Fotona d.o.o. www.fotona.com issn 1868-3207 • Vol. 24 • Issue 2/2023 2/23 implants international magazine of oral implantology case report Restoring anterior aesthetics with two-piece zirconia implants Resective peri-implantitis therapy with implantoplasty in Crohn’s disease industry Economic success in the implantology market in Germany 04 2 2023

| case report The added value of the pterygoid implant in the management of edentulous patients Dr Henri Diederich, Luxembourg Pterygoid implants were first proposed by Linkow in 1975, and the method was first described by French maxillofacial surgeon J.F. Tulasne in 1992.1,2 Tulasne and Tessier were the first to describe the technique for im- plant placement in the pterygoid plate. Pterygoid im- plants are relatively long and specifically manufactured with the characteristics of the pterygoid region in mind.3 1 2 Fig. 1: Case 1—panoramic radiograph of the patient at presentation. Fig. 2: Radiograph of the patient after bridge delivery. 06 2 2023 The pterygoid implant enables rehabilitation in the pos- terior maxilla in cases of poor and limited bone quantity as well as the presence of the maxillary sinus when such cases cannot be treated with standard implants.4–6 Ex- pertise and a thorough understanding of the anatomy of the posterior maxilla are crucial for successful place- ment of pterygoid implants. The pterygoid implant place- ment method has been previously documented in the literature.7 The following case studies showcase the use of ptery- goid implants to restore function in patients with eden- tulous jaws. The pterygoid implant employed in this case series is a new generation of pterygoid implant, designed by the author in collaboration with the Swiss company TRATE. It is a one-piece tissue-level conical implant with compressive threads and undergoes a surface treat- ment with hydroxyapatite and tricalcium phosphate. The implant neck has a wide thread profile, providing com- pression in areas of low bone density, such as the max- illary tuberosity. Its pointed, self-tapping apex ensures strong anchorage when inserted.3,8 The pterygoid im- plant ranges from 16 to 26 mm in length, ensuring that the implant apex engages the cortical bone of the me- dial wall of the pterygoid plate9 and is 3.5 or 4.5 mm in diameter. Case presentations Case 1 A 45-year-old female patient sought to have missing teeth on the right side of her upper jaw replaced (Fig. 1). Owing to the narrow width of the upper jaw ridge, conventional implant options were not feasible. The patient also had a history of chronic sinus infection and did not wish to un- dergo a sinus lift procedure. To rehabilitate her missing teeth, ROOTT C3516m, C3514m and C3520mp implants were placed in positions #18, 15 and 14. The procedure was performed under local anaesthesia after flap eleva- tion, and a 2.5 mm pilot drill was used to prepare all three osteotomies. The implants were loaded after a three- month delay, and a screw-retained metal–ceramic bridge

| case report was seated 14 days after impression taking with screwed impression copings (Fig. 2). Case 2 The next case involved a 64-year-old female patient who sought to have missing teeth on the right side of her up- per jaw replaced (Fig. 3). The patient had extensive max- illary sinus pneumatisation and a narrow alveolar ridge. Owing to her history of chronic sinus infection, a sinus lift procedure was not a desired option. Traditional implant options were not feasible owing to the narrow ridge. ROOTT C3016ms implants were placed in positions #15 and 14 (Figs. 4 & 5). The patient received an immediate temporary bridge constructed at the chairside after the surgery (Fig. 6). Three months after the surgery, impres- sions were taken with screwed impression copings, and a screw-retained metal bridge was seated three weeks later. Case 3 In a similar case, a 54-year-old female patient sought a solution for missing teeth on the right side of her upper jaw (Fig. 7). ROOTT C3514m, C3008ms and C3520mp im- plants were placed in positions #18, 15 and 14 (Figs. 8 & 9). Case 4 A 34-year-old female patient presented with missing teeth in her right upper jaw (Fig. 10). A similar treatment ap- proach was taken to that used in the previous cases, in- volving the placement of ROOTT C3512m, C3508m and C3520mp implants in positions #18, 15 and 14 (Fig. 11). Case 5 A 54-year-old female patient sought to have her complete denture replaced with a fixed solution, without undergo- ing extensive surgical procedures such as bone grafting or sinus lift (Fig. 12). Owing to her narrow alveolar ridge, it was decided to use standard one-piece tissue-level im- plants and pterygoid implants for rehabilitation of the up- per jaw. The procedure was performed under local an- aesthesia after flap elevation. A 2.5 mm pilot drill was used for preparation of all the osteotomies. ROOTT C4520mp implants were placed in positions #18 and 28, ROOTT C3016ms implants with short necks were placed in positions #13, 12, 22 and 23, and a ROOTT C3522mp implant was placed in position #24 (Fig. 13). Early loading was carried out with a temporary denture fabricated at the chairside (Fig. 14). After five days, the key was tried in. One week later, a trial of the metal frame was done, and a further week later, an aesthetic trial was con- ducted. At the fourth appointment, the metal–resin den- ture was screwed in (Fig. 15). The patient left the clinic with a fixed solution without having to undergo extensive surgical procedures. Discussion These case reports demonstrate the use of pterygoid im- plants for restoration of the maxilla in various cases. With this approach, atrophic jaws could be rehabilitated with- out the need for additional surgical procedures such as sinus lift and bone grafting.1 The use of pterygoid implants allows for the resolution of many cases that cannot be managed with standard implants within a short period, ef- fectively solving the patients’ problem of edentu- lism.3,6,8,10–12 The high success rates of pterygoid implants in patients with minimal bone levels and minimal compli- cations make them an attractive option for treating such patients.6,13,14 10 11 Fig. 10: Case 4—panoramic radiograph of the patient at presentation. Fig. 11: Radiograph of the patient at the completion of treatment. 08 2 2023

| case report 12 14 13 15 Fig. 12: Case 5—panoramic radiograph of the patient at presentation. Fig. 13: Healed situation after pterygoid implant placement in the maxilla. Fig. 14: Radiograph of the patient at the completion of treatment. Fig. 15: Clinical photograph of the patient at the completion of treatment. about the author Dr Henri Diederich is a highly accomplished dentist with over 35 years of experience. He received his doctorate in dentistry from the Free University of Brussels (ULB) in 1985, after which he established his own successful dental clinic in Luxembourg. As a Sworn Expert at the Luxemburgish Court of Justice, Dr Diederich has gained a reputation as a leading authority in legal dentistry. He is also the founding member and President of the Implan- toral Club Luxembourg and President of the Open Dental Community. In addition to his extensive involvement in professional organisations, Dr Diederich has also held the position of Maître de stage at the University of Nan- cy, France, and is responsible for regular training seminars for the management of implantation in atrophied bone at Queen Mary University in London. Dr Diederich is a renowned international lecturer and has published numerous papers on im- mediate loading in atrophied bone. He is the inventor of the CF@O protocol and the Hybrid Plates HENGG-1/4, for which he holds patents (Nr 93019 and 93186). His memberships in various professional organisations, including ICOI, DGOI, BDIZ EDI, DGZMK, and BAFO, attest to his dedication and expertise in the field of dentistry. contact Dr Henri Diederich +352 621 144664 hdidi@pt.lu Literature Dr Henri Diederich 10 2 2023

| case report Restoring anterior aesthetics with two-piece zirconia implants Dr Saurabh Gupta, India Zirconia implants are one of the newest and most ex- citing developments in dental implantology. Multiple studies have proved that zirconia implants induce little to no peri-implant tissue inflammation and allow for high lev- els of epithelial attachment. Additionally, these implants look more natural; hence, they provide improved aesthet- ics. Furthermore, they do not have metal components, which makes them ideal for people with metal sensitivi- ties and patients who would prefer their implants to be metal-free.1–3 Aesthetics around natural teeth can be challenging under normal circumstances. When teeth are to be replaced with implants, especially in the aesthetic zone, gingival tissue can complicate the desired results. In a patient with a thin gingival biotype, the grey of a titanium implant will show through, leading to a darker gingiva overlying that area and decreasing the aesthetics of the patient’s smile. A patient who has had a missing anterior tooth for a period, resulting in resorption of the facial plate even 1 2 12 2 2023 with a thicker gingival biotype, will have less bone over the implant on the facial aspect of the ridge. The result, like with a thin gingival biotype, will be a shadow over the underlying implant that hampers the aesthetic result and does not blend with the adjacent tissue around the natu- ral teeth.4–7 In the following, a clinical case is described to demonstrate the use of two-piece ceramic implants in the anterior aesthetic zone to avoid this aesthetic difficulty. Case presentation A 44-year-old male patient presented to our office to learn about options for replacement of his failing maxillary central incisors after undergoing partial root canal ther- apy. He also complained of greyish gingiva around the endodontically treated teeth and desired a metal-free solution (Figs. 1 & 2). Photographs of his teeth when smil- ing were taken to assess the overall aesthetic risk of the case. Treatment options were then discussed with the patient. After reviewing the options, the patient chose to have the endodontically treated teeth extracted and re- placed with two-piece zirconia implants and metal-free crowns. Surgical procedure The guidelines for zirconia implant placement in the an- terior zone and the drilling protocol specified by the man- ufacturer (Zeramex XT, Dentalpoint) were followed. It is important to note that implant sites must be prepared ad- equately to prevent excessive implant insertion torque and that the use of a bone tap is necessary. Both the vertical and transverse insertion depth of the zirconia im- plant are important for prosthetic success. The implant can be placed between 1.6 and 0.6 mm supra-crestally because the neck section (0.6 mm) is smooth. The inser- tion depth is determined by the height of the gingiva and the existing bone around the adjacent teeth. Fig. 1: Initial situation. Fig. 2: Initial radiograph.

| case report 8 10 9 11 Fig. 8: Angulated zirconia abutments in position. Fig. 9: Four-month post-op radiograph. Fig. 10: Zirconia crowns in situ, lateral view. Fig. 11: Zirconia crowns in situ, frontal view. survival rates of titanium dental implants, the develop- ment of alternative materials to address these has been pursued. Zirconia has been shown to have similar osse- ointegration success to titanium, offer a soft-tissue re- sponse that is superior to that of titanium and have less of an affinity for plaque collection compared with titanium surfaces. Also, the peri-implant soft tissue around titanium and zir- conia abutments has been shown to have colour differ- ences compared with the soft tissue around natural teeth, and the peri-implant soft tissue around zirconia has been demonstrated to have a better colour match to the soft tissue than titanium. This can be extrapolated to the aesthetics of the colour of the implant itself. Zirconia im- plants can be used in aesthetic situations, the white shade of the implant eliminating any potential for darken- ing of the gingival tissue and providing a more natural final aesthetic result than is possible with titanium implants. Long-term studies are necessary to continue to evaluate the effectiveness and success rates of two-piece zirconia implants. Literature contact Dr Saurabh Gupta Dr Saurabh Gupta +91 9916 203455 saurabh@iaoci.com Fig. 12: Radiograph of implants and final crowns. 14 2 2023

| case report Resective peri-implantitis therapy with implantoplasty in Crohn’s disease Lucas A. Greilich, Dr Mischa Krebs, PD Dr Maximilian Moergel, Germany In 1977, Per-Ingvar Brånemark defined osseointegra- tion as a functional ankylosis of the bone on the surfaces of titanium implants.1,2 Since then, dental implants have evolved and now offer most patients a predictable option for long-term rehabilitation of their masticatory function. However, despite high healing rates of 90 to 95 per cent, certain risk factors predispose to peri-implant inflamma- tion with bone resorption (peri-implantitis).3,4 This article reviews peri-implantitis and describes resective therapy with implantoplasty in a patient with Crohn’s disease. The risks that can lead to implant failure can be catego- rised as either generalised systemic factors or localised factors. Table 1 provides an overview of these factors. influenced (e.g. osteoporosis, diabetes mellitus). However, no valid therapy has been established that would result in complete healing of the progressive bone loss. Prevalence Peri-implantitis affects a significant number of patients.5 Derks et al. reported the prevalence of peri-implant mu- cositis to be 19 to 65 per cent and peri-implantitis to be 1 to 47 per cent. The wide variation in the literature is due to the high degree of variability in the underlying definition of peri-implantitis, particularly with regard to the type and extent of bone resorption.6,7 Aetiology Some of these factors can be influenced by the patient (e.g. oral hygiene, smoking); others can be avoided by the clinician through advance treatment planning (e.g. cement residue, implant position). Still others, however, cannot be Peri-implantitis is primarily caused by anaerobic oral pathogens (e.g. T. forsythia, P. nigrescens, A. actinomy- cetemcomitans, P. gingivalis, T. denticola).8–12 Titanium- Generalised systemic risk factors Localised risk factors Incorrect implant position Locally limited oral hygiene ability Keratinised mucosa < 2 mm Cement residue Mechanical overload Frequently replaced abutments Abutment emergence profile too steep (< 30°) Diabetes mellitus Rheumatoid arthritis Osteoporosis Periodontitis Radiation exposure Antiresorptive drugs Crohn’s disease IL-1 polymorphism Previous implant loss Poor oral hygiene Irregular recall schedule Nicotine abuse Table 1: Factors that can lead to peri-implantitis. 16 2 2023

| case report 3 4 Fig. 3: Preoperative situation. Hyperaemic peri-implant mucosa with inflammatory changes at sites 36 and 37. Fig. 4: Mobilisation of a mucoperiosteal flap after a trapezoidal incision. Granulation tissue infiltrating the pronounced bone defect at site 36. Adequate individualised plaque control is no longer possible for this patient. The exposed, submerged implant threads provide optimal conditions for pathogens. implant surface is smoothed by ablation of the exposed implant threads (red diamonds, yellow diamonds, Arkan- sas stones), making it more difficult for plaque to accu- mulate.31 implant 37. The surrounding free mucosa showed reac- tive hyperaemic changes with associated oedematous swelling (Fig. 3). It is important not to treat the implant surface with silicone polishers (“brownie”, “greenie”), as silicone residues in the peri-implant soft tissue are not biocompatible and can lead to foreign body reactions and reinflammation.32 Free titanium particles do not interfere with cellular activity (based on research to date), but may cause metallic dis- coloration of soft tissue, which constitutes an aesthetic compromise.33–35 Case report Medical history A 61-year-old female patient was referred to our day clinic for maxillofacial surgery. She presented with complaints related to implants placed in 2009. The patient’s medical history included Crohn’s disease, which had been diag- nosed in adolescence and was currently well controlled. She had been in remission for eight years and was not taking any medication at the time. Clinical findings After clinical examination and evaluation and a pan- oramic radiograph, peri-implantitis was diagnosed on the splinted implants 36 and 37 based on clinical bleed- ing on probing and radiographic bone loss > 2.0 mm (Figs. 1 & 2). The width of the keratinised mucosa was less than 2.0 mm on implant 36 and completely lost on “In daily clinical practice, the diagnostic problem is to decide when the extent of bone resorption can still be considered bone remodelling or when peri-implantitis must be assumed.” Treatment After detailed consultation and explanation, the patient was scheduled for resective peri-implantitis therapy by implantoplasty. Under local anaesthesia (Articaine 1:200,000), a strictly marginal incision was made (to pre- serve the remaining keratinised mucosa) and a trape- zoidal flap was elevated with distal relief incisions at implant 37 and mesial relief incisions at tooth 35 (Fig. 4). After mechanical decontamination with a curette, an im- plantoplasty was performed on the exposed implant surfaces (Fig. 5). The implant threads were removed until a smooth implant surface was achieved with less risk of plaque accumulation and recontamination. During an implantoplasty, it is important to strictly level only the im- 18 2 2023

| case report 5 6 Fig. 5: After decontamination and implantoplasty of implants 36 and 37. The levelling of the implant threads is intended to prevent early recontamination of the implant surface by pathogens. Leaving the superstructure in place makes an implantoplasty more difficult. Fig. 6: Wound closure. Monofilament sutures (Monofast; mectron) are used for tension-free and saliva-tight adaptation of the wound margins. plant threads, so as not to reduce the implant diameter (risk of fracture). Finally, the surface was polished with an Arkansas stone. The wound was closed with a 5/0 mono- filament suture material (Monofast; mectron) after thor- ough irrigation with chlorhexidine (Chlorhexamed forte alcohol-free 0.2%; GSK) and saline solution (Fig. 6). The patient received postoperative instructions and anal- gesic therapy (paracetamol 1 g). Sutures were removed after seven days. The patient was referred back to the referring general dentist with the request to re-evaluate the case and to perform regular dental prophylaxis in six months at the earliest. Further appointments were sched- uled at our day clinic for expansion of the keratinised mu- cosa with a free mucosal graft after healing. Figure 7 il- lustrates the situation 20 days postoperatively. Crohn’s disease is an inflammatory bowel disease char- acterised by transmural ulcers of the bowel wall. Unlike Crohn’s disease, ulcerative colitis can affect the entire di- gestive tract (from the mouth to the anus). In the dental office, therefore, close examination of the oral mucosa should be performed in these patients in order to detect any lichenoid/leukoplakic changes, lip and gingival swell- ing, pseudo-polyps or aphthoid/ulcerative lesions (“cob- blestones”) at an early stage.37 The disease progresses in phases, being completely asymptomatic in remission, while patients suffer from abdominal cramps, diarrhoea, weight loss, vomiting and fever during an active phase. The disease is treated with various pharmacological drugs, prescribed according to a graduated scheme. Discussion This case report demonstrates how risk factors (reduced height of keratinised mucosa, splinted superstructure, limited hygiene ability, Crohn’s disease) can influence the development of peri-implantitis. Crohn’s disease and ulcerative colitis have become more prevalent in developed industrialised countries in recent decades, making this condition increasingly relevant for dentists. In Germany, 322 new cases of Crohn’s disease are diagnosed per 100,000 inhabitants per year. Patients in their third and fourth decades of life are the most likely to develop the disease, although apparently young and healthy people can also be affected.36 Therefore, when examining the patient’s medical history, the dentist should pay close attention to immunosuppres- sants (prednisolone, mesalazine, azathioprine, methotrex- ate) and biologics (infliximab, adalimumab, vedolizumab, ustekinumab). Given the patient’s chronic inflammatory bowel disease, non-steroidal anti-inflammatory drugs (ibu- profen, aspirin, diclofenac) should be avoided, as they may irritate the gastric mucosa and trigger an episode. In a systematic review, Voina-Tonea et al. identified a sta- tistically significant association between Crohn’s disease and early implant loss.36 Malnutrition has been implicated as a cause of impaired osseointegration; autoimmune inflammatory events may have a direct effect on bone formation. In addition, possible side effects of long-term 20 2 2023

| case report Interdisciplinary approach for a missing maxillary incisor Dr Tran Hung Lam, Vietnam Implant therapy aims to provide patients with a highly predictable treatment outcome, good long-term stability of the treatment results and a low risk of complications during the healing and follow-up phases. The growing demand for functional and aesthetic restoration of miss- ing teeth has become an important challenge. This is es- pecially true in the anterior zone, as various local risk fac- tors can compromise the predictability of the results. Therefore, the clinician must carefully examine the pa- tient’s risk profile before establishing the treatment plan.1 The International Team for Implantology recommends im- mediate implant placement (Type 1) in the presence of ideal anatomical conditions. This includes (i) a fully intact facial bone wall with a thick-wall phenotype (> 1 mm) at the extraction site, (ii) a thick gingival biotype, (iii) no acute infection at the extraction site and (iv) a sufficient volume of bone apical and palatal to the socket to allow implant insertion in the correct 3D position with sufficient primary stability. When these ideal conditions are not met, it is suggested to place implants after four to eight weeks of soft-tissue healing (Type 2). If primary stability cannot be 3 4 22 2 2023 1 2 5

| case report 10 12 14 16 11 13 Treatment planning 4. GBR using a non-resorbable membrane and bone grafting material; Treatment would involve the following: 1. provision of oral hygiene instructions and non-surgical 5. membrane removal after six months and implant in- sertion in a prosthetically driven position; periodontal treatment; 6. delivery of a screw-retained temporary crown on im- 2. digital planning of dental space distribution and aes- plant #21; thetics; 7. crown preparation and restoration of tooth #11; 3. restoration of the carious teeth and orthodontic treat- ment to increase the mesiodistal gap at position #21 and to level and align the smile curve (Figs. 7 & 8); and 8. delivery of a screw-retained definitive crown on im- plant #21. 15 17 24 2 2023

| case report 18 19 20 26 2 2023 21 22 Surgical procedure Owing to the limited bone availability, the first step of the surgical procedure was GBR using a non-resorbable membrane and bone grafting material. Local anaesthesia was performed with 2% lidocaine and 1:100,000 adren- aline, and a mucoperiosteal flap with a crestal incision was raised. The flap was carefully separated from the bone, and the surgical access confirmed the limited avail- ability of bone (Fig. 9). Afterwards, GBR was performed using the bovine mate- rial cerabone (botiss biomaterials) for bone grafting. In addition, a non-resorbable membrane to prevent non‐ osteogenic tissue from interfering with bone regeneration was used (Fig. 10). The patient was advised to follow a soft diet and use ice packs on the area for the first 48 hours. Moreover, the postoperative prescription included rinsing with an anti- septic solution (0.2% chlorhexidine for 1 minute twice a day for one week), an analgesic (600 mg ibuprofen up to four times a day as required) and an antibiotic (500 mg amoxicillin three times a day for five days). Two weeks later, at the suture removal appointment, the patient reported no complications with healing. The pa- tient returned six months after surgery for a follow-up evaluation. Healing had continued to progress well, and oral hygiene was good. Furthermore, there was an ade- quate mesiodistal gap at position #21 for implant place- ment, thanks to the orthodontic treatment (Fig. 11).

| research Immediate or delayed loading in the fully edentulous maxilla Drs Yassine Harichane, Rami Chiri & Benjamin Droz Bartholet, France Although scientific and technical advancements have been made in the field of dentistry, there are still many patients who are either partially or fully edentulous. Eden- tulism has a negative impact on both dental and general health, leading to physical problems like inability to eat normally and mental health issues such as a decrease in self-esteem. Oral implantology has made tremendous progress, al- lowing patients to have clinical outcomes similar to natural dentition. Implant-supported prostheses provide edentulous individuals with daily satisfaction, enabling them to enjoy food and social interactions. When a single tooth or multiple teeth are lost, fixed solutions are sug- gested, whereas in the case of complete edentulism, the patient can choose between an overdenture or a fixed complete denture on implants. The McGill consensus statement recommends an over- denture supported on two implants as the first choice for the edentulous mandible. Numerous protocols describe technical aspects of implant surgery and prosthetic res- toration, whether in immediate or delayed loading. While the McGill consensus statement considers a conven- tional tissue-supported denture for the maxilla to be problem-free, some patients may wish for a more com- fortable solution to improve their dental health. Can we offer them a maxillary implant solution that is supported by scientific research? Can patient management be im- proved by modifying implant placement and loading protocols? These are the two questions we will aim to answer with the aid of recent scientific literature. Surgical steps In implant surgery, considering anatomical obstacles is crucial. Regarding the maxilla, the nasal cavity and max- illary sinuses pose challenges, while in the mandible, the inferior alveolar nerve and mental foramen can be prob- lematic (Fig. 1). The two areas also differ regarding bone density, the maxillary bone usually being less dense than that of the mandible. To overcome anatomical obstacles like the maxillary sinus, either axial implants can be placed after sinus lift or zygomatic implants can be placed to by- pass the obstacle (Fig. 2). Many implant designs have been developed to provide satisfactory primary anchor- age, regardless of bone density. Brånemark’s work in oral implantology established suc- cess criteria that have become standard in implant prac- tice. Scientific research has enabled advancements in oral implantology, such as immediate placement after extraction procedures for single or multiple teeth in both the maxilla and mandible. 1 2 Fig. 1: Maxillary anatomical obstacles. Fig. 2: Maxillary prosthesis on axial and tilted implants. 28 2 2023

| research While the McGill consensus statement recommends an overdenture on two implants for the mandible, there is no established consensus for the maxilla. This is due to the heterogeneity of results and the difficulty of conducting systematic reviews on the subject. However, Malò et al. have pushed the clinical boundaries of maxillary implant treatment with the All-on-x procedure (Fig. 3), which is demanding but effective and satisfying for patients. Digital workflows have also improved surgical protocols through static guides and dynamic navigation (Fig. 4). Static guides involve planning the implant position in software and reproducing it in a surgical guide, while dynamic navigation allows for real-time adjustments based on CBCT imaging during surgery, providing greater precision. Prosthetic steps Brånemark initially recommended allowing several months for implants to heal, but current literature supports the possibility of immediate loading, whether for a single implant or multiple implants in the maxilla or mandible (Fig. 5). Research has validated immediate loading in fully edentulous maxillae, whether using conventional or zy- gomatic implants, with high success rates. However, cer- tain conditions need to be considered. This accelerated-care approach has prevented patients from experiencing disabling edentulism and has been shown to improve their overall satisfaction and oral health- related quality of life. Studies have found that implant- supported overdentures can improve the general well- being of edentulous patients and that fixed implant pros- theses are even more effective (Fig. 6). The effectiveness of immediate loading of implants is comparable to that of delayed loading, although the evi- dence is not strong enough to make a definitive clinical recommendation. Studies have shown that there is no statistically significant difference in survival rates be- tween immediate and delayed loading of implants and prostheses. However, it is worth noting that early implant failure in the maxilla is quite common, half of the failing implants being lost within the first six months. This is often attributed to poor bone quality of the mandible. Patients may be more satisfied with a functional fixed prosthesis regardless of the time of loading, but there is limited evidence to support this. Prosthesis instability may also contribute to differences in loading times. For exam- ple, one study showed no difference in patient satisfac- tion between immediate and delayed loading after three Fig. 3: All-on-4 and All-on-6 prostheses. Fig. 4: Surgical guide and dynamic navigation. 3 4 30 2 2023

| industry Economic success in the implantology market in Germany What role does the choice between two-piece implants with conical and non-conical internal connections play? Andreas Halamoda, Germany Since the first dental implant consensus conference a good 40 years ago, the development of modern implan- tology has been impressive, both scientifically thanks to the discovery of the biocompatibility of the titanium sur- face and economically: the number of dental implants placed in Germany has risen from 400,000 per year around 20 years ago to an estimated 1.3 million today— and the upwards trend is stable. Over the years, not only has an independent, innovation-driven industry devel- oped, but also established global competitors in the dental industry want to participate in this solid market. In Germany, there are currently more than 200 indepen- dent endosseous implant systems, an unusually high number are approved and accordingly many national and international suppliers are vying for the favour of the den- tal profession. There is no doubt that the German market is a key market in which every market participant wants to succeed, particularly in order to succeed globally. It is not easy for dentists to find their way around the selection of implant systems on offer, especially as the pricing of the products varies greatly. The same applies to the effort that suppliers put into the publication of studies, adver- tising, customer care and training events. Unsurprisingly, the market is dominated by a manageable number of established providers, who are well known by the public thanks to extensive marketing and are often owned by listed companies. In addition, there are the smaller, often independent manufacturers who are char- acterised by their innovative spirit rather than advertising presence and large field service organisations. There are also numerous outsiders who are known neither for ex- ceptional presence and pricing nor for innovation and customer proximity. Their market share is small. The role of innovative spirit for success In dental implantology, besides one-piece systems and the still young ceramic implant systems, the group of two-piece titanium implants has established itself as the dominant one on the market because it is the most ver- satile. Among their numerous further developments over the decades, the (not so recent) invention of the conical internal connection between implant and abutment is certainly the most significant innovation, dividing the market roughly into conical and non-conical internal connection implant systems. Some of the large estab- lished providers do offer a conical internal connection implant, some do not. Many of them offer both. With the conical internal connection, the aim is to mitigate or even eliminate the system-inherent weaknesses of the rightly popular two-piece implant systems. These con- cern primarily the enormous mechanical stress on the connecting screw between implant and abutment and in the gap between these two parts triggered by mastica- tory forces, which can promote bacterial colonisation of the interior of the implant when positioned subgingivally. Conical internal connection designs aim to seal this gap or relieve the abutment screw, ideally achieving both. 32 2 2023

| industry Complications include loosening or even fracture of the Complications include loosening or even fracture of the abutment screw. No one wants regular visits from their abutment screw. No one wants regular visits from their patients just to tighten or even replace the screw. It is in- patients just to tighten or even replace the screw. It is in- herent in the system of non-conical internal connection herent in the system of non-conical internal connection implants that the screw always has to cope with the force implants that the screw always has to cope with the force of the connection, and thus complications are latent. With of the connection, and thus complications are latent. With conical internal connection systems, it is worth taking a conical internal connection systems, it is worth taking a closer look at the individual details. Especially a large closer look at the individual details. Especially a large Morse taper can significantly relieve the abutment screw Morse taper can significantly relieve the abutment screw by creating strong self-friction between implant and abut- by creating strong self-friction between implant and abut- ment. ment. Patients’ needs Patients’ needs The patient’s desires are ultimately a combination of per- The patient’s desires are ultimately a combination of per- fect aesthetics, sustainability and tolerability, as the im- fect aesthetics, sustainability and tolerability, as the im- plantological solution has been recommended to him or plantological solution has been recommended to him or her as the best for his or her case. Aesthetically, conical her as the best for his or her case. Aesthetically, conical internal connection implants are usually at an advantage, internal connection implants are usually at an advantage, as they are always placed crestally or subcrestally. How- as they are always placed crestally or subcrestally. How- ever, non-conical internal connection systems can also ever, non-conical internal connection systems can also deliver convincing results, provided they are positioned deliver convincing results, provided they are positioned subgingivally, unlike tissue-level implants, and, for exam- subgingivally, unlike tissue-level implants, and, for exam- ple, with a polished shoulder to allow soft tissue on top ple, with a polished shoulder to allow soft tissue on top and bone underneath. and bone underneath. For the patient, the sustainability of the implantological For the patient, the sustainability of the implantological restoration means not only the best possible prevention restoration means not only the best possible prevention of peri-implantitis but also, of course, a high degree of of peri-implantitis but also, of course, a high degree of tolerance with the aim of achieving the most biological tolerance with the aim of achieving the most biological solution possible. While it is up to the dentist to carry out solution possible. While it is up to the dentist to carry out careful patient selection and, in case of suspicion, to test careful patient selection and, in case of suspicion, to test for titanium intolerance, the implant manufacturer of a for titanium intolerance, the implant manufacturer of a two-piece system can positively influence the long-term two-piece system can positively influence the long-term result with its individual design approach to the abutment result with its individual design approach to the abutment connection. This is because micro-movements of the connection. This is because micro-movements of the abutment in the implant involuntarily result in abrasion of abutment in the implant involuntarily result in abrasion of titanium particles, which permanently enter the human titanium particles, which permanently enter the human organism unnoticed. This must be separated from possi- organism unnoticed. This must be separated from possi- ble intolerance to titanium surfaces. ble intolerance to titanium surfaces. be achieved if this abrasion is eliminated. It is apparent be achieved if this abrasion is eliminated. It is apparent that the conical internal connection has an inherent ad- that the conical internal connection has an inherent ad- vantage here, since it avoids micro-movements. vantage here, since it avoids micro-movements. Market development Market development The coming years will be characterised by numerous fur- The coming years will be characterised by numerous fur- ther developments of conical internal connections— ther developments of conical internal connections— which makes sense, because this principle is the more which makes sense, because this principle is the more recent one. The much respected large established pro- recent one. The much respected large established pro- viders will also present innovations in this area, and thus viders will also present innovations in this area, and thus the market share of conical internal connection systems the market share of conical internal connection systems will continue to increase, but will also soon reach a point will continue to increase, but will also soon reach a point where both designs converge in market share. Because where both designs converge in market share. Because of the efficient prosthetic restoration and the simpler of the efficient prosthetic restoration and the simpler workflow, non-conical internal connection systems will workflow, non-conical internal connection systems will retain their supporters. The key to success will be keep- retain their supporters. The key to success will be keep- ing up to date with customers’ wishes and responding to ing up to date with customers’ wishes and responding to these. Customers will succeed in finding exactly the these. Customers will succeed in finding exactly the product that suits their philosophy, owing to the enor- product that suits their philosophy, owing to the enor- mous diversity of the German implant market that be- mous diversity of the German implant market that be- comes apparent upon closer inspection. comes apparent upon closer inspection. about the author Andreas Halamoda has been Key Ac- count Manager for the German-speaking markets at a medium-sized German im- plant manufacturer since 2012. He is also responsible for the areas of training courses with external speakers and inter- nal staff training. He advocates demand- oriented sales and holistic customer care, starting with the surgeon, con- tinuing with the prosthetic dentist and ending with the dental technician. Andreas Halamoda contact The extent and effects of this titanium abrasion are the The extent and effects of this titanium abrasion are the subject of initial studies, but it can already be said that subject of initial studies, but it can already be said that highly biological solutions with titanium implants can only highly biological solutions with titanium implants can only Andreas Halamoda +49 1511 2697915 andreas.halamoda@gmail.com 34 2 2023

| manufacturer news Dentsply Sirona Introducing DS OmniTaper Implant System— the newest member of the EV Implant Family The DS OmniTaper Implant System is an innovative solution that combines the proven technolo- gies of Dentsply Sirona’s EV Implant Family with new features that deliver effi ciency and versatil- ity. Unique to the implant system is an intuitive drilling protocol for reduced chair time and a pre-mounted TempBase for immediate restorations and effi cient workfl ows. The DS OmniTaper Implant System is the newest member of the EV Implant Family, alongside Astra Tech Implant System and DS PrimeTaper Implant System. The EV Implant Family offers surgical fl exibility to cover virtually every indication. All three implant systems deliver biologically driven implant designs for natural aesthetics and lasting bone care, have one connection for re- storative clarity, and are optimised for a seamless fi t with digital dentistry workfl ows. Like the rest of the EV Implant Family, the DS OmniTaper Implant System features the OsseoSpeed implant surface and the conical EV connection that provides access to the harmonised and com- prehensive EV prosthetic portfolio for restorative fl exibility and immediate chairside solutions. Dentsply Sirona, Sweden +46 31 3763000 www.dentsplysirona.com Fotona Advancing dental laser technology Fotona’s LightWalker is a revolutionary dental laser system, incorporating s LightWalker is a revolutionary dental laser system, incorporating state-of-the-art technologies that redefi ne the industry. With 20 W of power, state-of-the-art technologies that redefi ne the industry. With 20 W of power, 2 wavelengths, 5 pulse durations, and 4 special pulse modalities, Light- 2 wavelengths, 5 pulse durations, and 4 special pulse modalities, Light- Walker offers dentists an unparalleled range of clinical applications. Walker offers dentists an unparalleled range of clinical applications. The precision and improved ablation effi cacy of LightWalker’s patented The precision and improved ablation effi cacy of LightWalker’s patented QSP mode make it invaluable for hard tissue treatments, debonding QSP mode make it invaluable for hard tissue treatments, debonding veneers, orthodontic brackets, dental aesthetics, and surgery, ad- veneers, orthodontic brackets, dental aesthetics, and surgery, ad- dressing various challenges with a single solution. Practitioners are thrilled by the effi cacy of the LightWalker’s SWEEPS Practitioners are thrilled by the effi cacy of the LightWalker’s SWEEPS mode in endodontic cases, witnessing the power of bubbles in cleaning mode in endodontic cases, witnessing the power of bubbles in cleaning narrow root canal spaces, removing smear layer, debris, and biofi lm. narrow root canal spaces, removing smear layer, debris, and biofi lm. Moreover, SWEEPS extends its benefi ts beyond direct laser therapy, Moreover, SWEEPS extends its benefi ts beyond direct laser therapy, enabling non-invasive, non-surgical removal of biofi lm and calculus in enabling non-invasive, non-surgical removal of biofi lm and calculus in periodontal and peri-implant therapy. The laser’s innovative SMOOTH mode expands the horizons of dental The laser’s innovative SMOOTH mode expands the horizons of dental practices, allowing them to offer Fotona’s cutting-edge aesthetic and s cutting-edge aesthetic and anti-snoring laser therapies. With treatments like SmoothEye®, Light- , Light- Walker 3D®, LipLase®, and NightLase®, dental practices can attract , dental practices can attract new patients, fulfi lling patient expectations with a wide range of new patients, fulfi lling patient expectations with a wide range of non-invasive options that can enhance revenue and profi tability. Embrace the future of dental laser technology with Fotona’s Light- s Light- Walker, empowering dentists with unparalleled versatility for en- Walker, empowering dentists with unparalleled versatility for en- hanced patient care. Fotona d.o.o., Slovenia (+386) 1 5009100 ∙ www.fotona.com 36 2 2023

| events Cheers to new beginnings: celebrating oral tissue regeneration n o i t a d n u o F y g o o e t s O © l The 2023 International Osteology Symposium, held in Barcelona from 27 to 29 April, was a resounding success, bringing together 2,400 participants from 80 countries. Over 100 world-renowned speakers and international ex- perts from research and practice explored the latest ad- vances in the field of oral tissue regeneration on the oc- casion of the Osteology Foundation’s 20th anniversary. Founding Partner Geistlich and Gold Partners Dentsply Sirona, BioHorizons Camlog, botiss biomaterials, and Straumann also offered the attendees truly impressive hands-on opportunities to experience special techniques and materials. For those who missed out on the highly sought-after workshop seats, an exclusive pre-congress session in oral tissue regeneration was offered. Getting hands-on and exploring new techniques The event kicked off with the symposium’s workshop programme, an early highlight and with the fully booked Osteology workshops covering a comprehensive range of topics: from modern techniques in soft-tissue manage- ment using autologous and substitute materials, to re- constructive procedures for peri-implantitis defects, and the latest in minimally invasive periodontal regeneration and recession coverage around teeth and implants—this symposium delivered it all. Opening of the regenerative marathon Frank Schwarz, Vice President of the Osteology Founda- tion opened the congress officially together with the sci- entific chairs Pamela K. McClain and Istvan Urban on Fri- day morning. They set the stage for what promised to be an unforgettable marathon of highlights. Over the course of the following two days, attendees got to enjoy a variety of lectures, panel discussions and inter- active round-table discussions addressing all aspects of oral tissue regeneration: different strategies of hard- and soft-tissue augmentation around teeth and implants, pre- vention and management of complications and errors, as well as the all-time hot topic of peri-implantitis. These ar- eas of interest were complemented by lectures about in- novative technologies, blood products for tissue aug- mentation and regenerative approaches in interdiscipli- nary dentistry. Bringing theory to life: Live surgery The programme boasted two remarkable live surgeries performed by none other than the esteemed Istvan Ur- ban and Sofia Aroca. They provided a unique and rare opportunity for attendees to witness these masters of oral tissue regeneration in action, as they performed complex procedures in real-time. © Osteology Foundation Urban’s and Aroca’s exceptional skills, precision, and ex- pertise were on full display, as they shared their knowl- 38 2 2023

| events Cutting edge science and innovation Dentsply Sirona Implant Solutions World Summit 2023 From 8 to 10 June, the Dentsply Sirona Implant Solutions World Summit 2023 took place in Athens, Greece where science has its origins. Inspired by connection and future innovation, the event delivered immersive experiences to inspire and feed attendees’ passion for implant solutions. Implant professionals from around the world who are pas- sionate about elevating the dental industry and improving the quality of implant treatments and care for patients con- vened for three days of knowledge exchange, inspiration, and networking. They have been able to discover the latest innovations in implant solutions, including the EV Implant Family, digital dentistry, and bone regeneration. The sum- mit’s state-of-the-art educational programme was devel- oped together with the scientifi c chairs—Dr Tara Aghaloo, USA and Dr Michael Norton, UK, and the programme chairs—Steve Campbell, UK; Dr Malene Hallund, Den- mark; Dr Mark Ludlow, USA; Dr Stijn Vervaeke, Belgium; and Dr Martin Wanendeya, UK and featured 50 world-re- nowned speakers from 12 countries with inspiring main stage presentations, hands-on workshops, and break-out tracks on topics such as aesthetics and the digital den- tistry ecosystem, half of them being new presenters at a Dentsply Sirona event. The CLOUD session explored the new digital universe and its power to transform patient journeys from diagno- sis to fi nal treatment, with perspectives from two clini- cians (Dr Martin Wanendeya, UK and Dr Stefan Vande- weghe, Belgium) and one lab technician (Steve Campbell, UK), a live demo, and a look at the advantages for clini- cians and labs. Meanwhile, the BATTLE session featured debates from two clinicians on a hot clinical topic, moderated by Dr Mark Ludlow, USA with the winner decided by the audience. In the fi rst battle Dr David Barack, USA and Dr. Rodrigo Neiva, USA debated about biomaterials vs. implant selec- © Dentsply Sirona 40 2 2023 l a n o r i S y p s t n e D © tion. Battle two considered full arch digital vs. full arch an- alog, with Dr Mischa Krebs, Germany going head-to-head with Dr Gary Jones, USA. “The Implant Solutions World Summit attracts some of the brightest and most passionate minds in implant dentistry,” said Dr Malene Hallund, oral and maxillofacial surgeon and Dentsply Sirona Key Opinion Leader. “The programme dives deep into all the latest developments in our fi eld while challenging pre-existing ideas and assumptions. I know that attendees will walk away feeling excited and inspired for what the future holds.” Attendees could visit the Inspiration Hub exhibition area spread across two fl oors. Participants gain hands-on ex- perience with Dentsply Sirona’s comprehensive implant portfolio and digital workfl ow. Dentsply Sirona’s premium EV Implant Family—DS PrimeTaper Implant System, DS OmniTaper Implant System, and Astra Tech Implant Sys- tem—were on display, as well as OSSIX regenerative solu- tions, DS Signature Workfl ows, and the cloud-based DS Core platform. Moreover, the Implant Solutions World Summit featured two social evenings for attendees to network with peers and enjoy the best Athens has to offer. “Peer to peer education is vitally important for our Implant Solutions community and we are thrilled to bring implant professionals together from around the world to explore the latest innovations and science transforming implant dentistry” said Tony Susino, Group Vice President, Global Implant Solutions at Dentsply Sirona.

| about the publisher Congresses, courses and symposia implants Imprint Publisher Torsten R. Oemus oemus@oemus-media.de CEO Ingolf Döbbecke doebbecke@oemus-media.de Member of the Board Lutz V. Hiller hiller@oemus-media.de Chairman Science & BD Jürgen Isbaner isbaner@oemus-media.de Chief Editorial Manager Dr Torsten Hartmann (V. i. S. d. P.) hartmann@dentalnet.de Editorial Council Dr Rolf Vollmer info.vollmer@t-online.de Dr Georg Bach doc.bach@t-online.de Dr Suheil Boutros SMBoutros@aol.com Editorial Management Dr. Alina Ion a.ion@oemus-media.de Executive Producer Gernot Meyer meyer@oemus-media.de Product Manager Timo Krause t.krause@oemus-media.de Art Director Alexander Jahn a.jahn@oemus-media.de Designer Aniko Holzer a.holzer@oemus-media.de Customer Service Lysann Reichardt l.reichardt@oemus-media.de Published by OEMUS MEDIA AG Holbeinstraße 29 04229 Leipzig, Germany Tel.: +49 341 48474-0 Fax: +49 341 48474-290 kontakt@oemus-media.de Printed by Silber Druck oHG Otto-Hahn-Straße 25 34253 Lohfelden, Germany implants international magazine of oral implantology is published in cooperation with the German Association of Dental Implantology (DGZI). DGZI DGZI Central Offi ce Paulusstraße 1 40237 Düsseldorf, Germany Tel.: +49 211 16970-77 Fax: +49 211 16970-66 offi ce@dgzi-info.de www.dgzi.de www.oemus.com www.implants.de International Esthetic Days 21–23 September 2023 Baden-Baden, Germany www.estheticdays.com FDI World Dental Congress 2023 24–27 September 2023 Sydney, Australia www.fdiworlddental.org 30th EAO annual scientifi c meeting 28–30 September 2023 Berlin, Germany www.eao.org Copyright Regulations implants international magazine of oral implantology is published by OEMUS MEDIA AG and will appear with one issue every quarter in 2023. The magazine and all articles and illustrations therein are protected by copyright. Any utilisation without the prior consent of editor and publisher is inadmi ssible and liable to prosecution. This applies in particular to duplicate copies, translations, microfi lms, and storage and processing in electronic systems. Reproductions, including extracts, may only be made with the permission of the publisher. Given no statement to the contrary, any submissions to the editorial department are understood to be in agreement with a full or partial publishing of said submission. The editorial department reserves the right to check all submitted articles for formal errors and factual authority, and to make amendments if necessary. No responsibility shall be taken for unsolicited books and manuscripts. Articles bearing symbols other than that of the editorial department, or which are distinguished by the name of the author, represent the opinion of the aforementioned, and do not have to comply with the views of OEMUS MEDIA AG. Responsibility for such articles shall be borne by the author. Responsibility for advertisements and other specially labeled items shall not be borne by the editorial department. Like- wise, no responsibility shall be assumed for information published about associations, companies and commercial markets. All cases of consequential liability arising from inaccurate or faulty representation are excluded. General terms and conditions apply, legal venue is Leipzig, Germany. 52nd International Annual Meeting of DGZI 6–7 October 2023 Hamburg, Germany www.dgzi-jahreskongress.de/en 52ND INTERNATIONAL ANNUAL MEETING OF DGZI IMPLANTOLOGY IN TEAM IMPLANTOLOGY IS TEAM 6/7 TH OCTOBER 2023 HAMBURG 42 2 2023

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