Re-think dental implants Patent™ implants mark a new era for dental implants. Its reduced to the maximum approach sets a new standard for simplicity. Zero screws, one revolutionary surface, two components. The implants are made from ceramic (Y-TZP zirconia), available as one- or two-piece and completely customizable. The post is made from high-performance glass fiber. Reduced to the maximum, that’s what Patent™ is all about. www.mypatent.com

| content N 0 0 1 ° 5 3 1 editorial Ceramic implantology in times of a pandemic Georg Isbaner lithium disilicate crown research ZrO2 abutment ZrO2 implant Prosthetic complications after artifi cial ageing Dr Manuel Reinisch, Dr Martin Koller, Dr Elisabeth Steyer, Prof. Karl Glockner, Prof. Norbert Jakse & Prof. Michael Payer page 06 Biological guided bone regeneration and ceramic implants Dr Karl Ulrich Volz, Dr Stephanie Vergote, Dr Rebekka Hueber, Dr Josephine Tietje, Dr Tobias Wilck & Prof. Shahram Ghanaati Quality defi ciencies of sterile packaged implants Dr Dirk U. Duddeck overview Zirconium-dioxide as preferred material for dental implants Profs. Curd M. L. Bollen & Maher Al-Masri page 42 case report Surgical aspects of two-piece ceramic implants Dr Bernard Dahan, DCD The key to optimal implant aesthetics Dr Kunal Shah Immediate restoration with one-piece zirconia implants Dr Kazuhiko Okamoto, Prof. Shuji Ohkawa, Dr David Ashley & Prof. Yung-Tsung Hsu Single-tooth restoration of an upper molar with a ceramic implant Dr Frank Hoffmann Patent™ zirconia implant system Dr Sebastian Horvath page 57 industry Ceramic Excellence Program interview A new solution in the fi eld of digital workfl ows ISMI and IAOCI join forces Ceramic implantology in Europe events A look back at the 9th Annual Congress of the IAOCI Dr Sammy Noumbissi news manufacturer news news about the publisher imprint Cover image courtesy of Institut Straumann AG www.straumann.com issn 1868-3207 Sondernummer • Vol. 4 • Issue 1/2020 1/20 ceramic implants international magazine of ceramic implant technology research Prosthetic complications after artificial ageing case report The key to optimal implant aesthetics interview ISMI and IAOCI join forces 04 implants 1 2020 03 06 10 18 20 24 30 34 40 42 46 54 57 60 62 48 64 66

| research Prosthetic complications after artificial ageing A study with two-piece zirconia implants Dr Manuel Reinisch (lead author), Dr Martin Koller, Dr Elisabeth Steyer, Prof. Karl Glockner, Prof. Norbert Jakse & Prof. Michael Payer (co-authors), Austria Currently, the majority of ceramic implants used are one-piece implant systems, which, however, have some limitations and disadvantages.1, 2 One-piece implants cannot always be inserted in the optimal orientation and require angulation correction to enable prosthetic res- toration. In addition, one-piece implants are subjected to soft tissue and chewing forces immediately after in- sertion. These reasons motivated the development and manufacture of two-piece ceramic implants. Several two-piece ceramic implants are already available on the market, but only limited clinical evidence is avail- able for these systems. Currently, a large proportion of two-piece ceramic implants have a bonded implant–abut- ment connection. While bonded zirconia abutments have promising clinical results,3, 4 there is uncertainty about the long-term stability of the adhesive bond between the implant and abutment and the biological effects of adhe- sive residues in the area of the gingival sulcus. Concerning two-piece screw-retained ceramic implants, in vitro studies showed higher fracture rates compared to two-piece titanium implants or one-piece zirconia im- plants.5 The weak location for increased fracture suscep- tibility is the area directly around the abutment screw. Further studies are needed to indicate the ideal con- nection design for two-piece screw-retained zirconia implants. 1 3 2 4 Manufacturing of the crown: Fig. 1: Zirconia implant inserted instead of missing tooth #21 in an exemplary upper jaw tooth model. Fig. 2: Zirconia implant region #21 fitted with an individualised zirconia abutment. Fig. 3: Lithium disilicate crown after milling. Fig. 4: Lithium disilicate crown after sintering. 06 implants 1 2020

| research B fractured after 1,123,200 cycles. All specimens in both groups had grinding facets. In group A grinding facets had an over- all mean appearance of 639,360 ± 200,106 cycles with no significant differ- ence (p > 0.05) to group B with 483,840 ± 208,800 cy- cles (Fig. 14). None of the samples showed cracks, fractures or decementa- tions of the crown. ° 5 3 1 Conclusions and clinical implications 13 Of course, long-term, clinical, randomised tri- als are one of the best ways to generate reliable data. But it is necessary to implement preclinical study de- signs that simulate clinical conditions before clinical trials are conducted. Thermomechanical loading of implants, group 1 group 2 Fig. 14: Incidence of grinding facets during dynamic loading in the chewing simulator. 100% 90% 80% 70% 60% 50% 150 k 300 k 450 k 600 k 750 k 900 k 1,050 k 1,200 k k … 1,000 Chewing simulation cycles group 1 group 2 Fig. 15: Survival rates for the different cementation methods. 08 implants 1 2020 l i l s e c y c n o i t a u m s g n w e h C i 1,000,000 900,000 800,000 700,000 600,000 500,000 400,000 300,000 200,000 100,000 0 X X about the author N 0 0 1 Fig. 13: Dynamic loading setup. ZrO2 implant ZrO2 abutment lithium disilicate crown abutments and crowns of- fers a suitable method for this. Within the limitations of this preclinical trial it can be concluded that CAD/ CAM-fabricated anterior monolithic lithium disilicate crowns mounted on two- piece screw-retained zirco- nia implants should provide sufficient resistance at least up to five years of intra-oral forces. Regarding prosthetic complications, there was no statistical difference be- tween using an adhesive resin composite com- pared to a resin-modified glass ionomer cement for crown cementation. It can be assumed that different manufacturing meth- ods or design properties of two-piece screw-retained ceramic implants lead to variable fracture behaviour un- der load. A generalisation for two-piece screw-retained ceramic implants does not yet seem to be possible. Fur- ther studies are needed. Literature Dr Manuel Reinisch studied medicine and is now a student in the last year of dentistry at the Medical University of Graz. He is a member of the Euro- pean Society for Ceramic Implantology (ESCI). In addition, he is doing a mas- ter’s degree in medical ethics and the master’s programme in implantology and periodontology at the Medical Uni- versity of Vienna. contact Dr Manuel Reinisch Medical University of Graz Division of Oral Surgery and Orthodontics Department of Dental Medicine and Oral Health Billrothgasse 4 8036 Graz, Austria manuel.reinisch@stud.medunigraz.at Author details

| research Biological guided bone regeneration and ceramic implants The first of a two-part series Dr Karl Ulrich Volz, Dr Stephanie Vergote, Dr Rebekka Hueber & Dr Josephine Tietje, Switzerland; Dr Tobias Wilck & Prof. Shahram Ghanaati, Germany dioxide heals absolutely inert, shows as high a bone-to- implant contact as titanium does and achieves genuine osseointegration.13–19 In the case of titanium, abrasion occurs with high fric- tion when the implants are inserted, and as a result of the process of (bio)corrosion, titanium dioxide particles are released into the surrounding hard and soft tissue, activating macrophages.20–28 This activation leads to the aforementioned release of TNF- and interleukin-1, which results in local reactions and chronic systemic in- flammation (silent inflammation). The activation of os- teoclasts triggers bone resorption in the sense of peri- implantitis.29 Since zirconium dioxide does not corrode, macrophage activation with this material is probably not expected. Bone resorption around ceramic implants oc- curs rarely, but is mainly caused by very high insertion torques. This has a particularly fatal effect with ceramic implants, as they are poor thermal conductors. The fric- tional heat generated on the implant’s surface during in- sertion is not conducted to its core. Therefore, the ce- ramic implant from Swiss Dental Solutions, developed by Dr Karl Ulrich Volz, is designed in such a way that all friction and stability are obtained from the apical part, and its deep and aggressive thread makes it impossi- ble to overheat the cortical bone if the drilling protocol is applied correctly. In the crestal part of the bone, the last drill, the counter- sink, is used for overextended preparation, thus avoid- ing any pressure of insertion in this sensitive and less vascularised area.30 The aggressive apical thread allows the implant to be re-torqued to > 35 Ncm in more than 80 % of cases in the case of connective tissue healing. In such cases, the implant will osseointegrate with more than 95 % certainty, since the very thin layer of connec- tive tissue between the implant and the bone will differ- entiate back to bone owing to the inertia of the material. This understanding of the physical, biological and immu- nological properties of zirconium dioxide is very import- ant when one considers bone reconstruction measures. In general, the need for such measures has significantly Fig. 1: Overextended implant bed preparation allows the growth of de novo bone, inter alia by a high rate of cellular migration. BMPs = bone morphogenetic proteins; GFs = growth factors; VEGF = vascular endothelial growth factor. Ceramic implants consist of high-performance ce- ramic zirconium dioxide. As the material is present in its oxide state, it no longer reacts chemically,1 does not ex- hibit free-binding electrons and is inert.2 Temperatures above 2,600 °C or the application of hydrofluoric acid are necessary to change the material. The low affinity with plaque, the lack of thermal and electrical conductivity, and the resistance to corrosion are great benefits of zir- conium dioxide over titanium.1–8 While titanium stimulates the release of TNF- and interleukin-1 and apparently osseointegrates the implant towards chronic inflamma- tion with a type of encapsulation, these messenger sub- stances are not activated during the healing process of zirconium dioxide. Brånemark assumed that titanium implants achieve true non-reactive osseointegration. Today, we know that this is not the case.1, 9–12 Zirconium 10 implants 1 2020

| research 4a 16.02.2017 4c 23.10.2017 4b 23.10.2017 4d 05.09.2019 4e 4f Figs. 4a–f: Pre-op panoramic radiograph showing vertical resorption in regions #16 and 26 (a). Panoramic radiograph taken after the prosthetic restoration of all implants in the upper and lower jaws (b). Radiographic control of the first quadrant after implant placement (c). Visible gain of bone in regions #13–16 after an eight-month healing phase (d). Radiographic control of the implants in regions #26 and 27 after 1.5 years (e). Radiographic control of the implants in regions #26 and 27 at the follow-up in 2019 (f). this reason, relieving incisions and periosteal slits should be avoided. Rather an incision in the gingival margin should be made and the brushing technique according to Dr Alain Simonpieri should be employed. The newly built bone described in the case report by Hämmerle and Karring biologically beats every bone block or secondary augmentation material, since it is de novo bone, healthy and well-vascularised lamellar bone. Any filling material in the cavity created in the form of a bone block or granules, of animal or synthetic origin, is an obstacle to angiogenesis, which in turn is a prerequi- site for the formation of bone callus. The same laws ap- ply to the sinus cavity, since the Schneiderian membrane also has an osteoinductive function.33–35 All materials we have placed there over the last 30 years have been used exclusively to keep the Schneiderian membrane at a distance and thus create a mechanically stable cavity. According to the biological laws, this cavity will eventu- ally fill with new bone.36 However, a paradox must also be considered here: the more densely a filler is pack- aged into the raised cavity, the less space there is for angiogenesis. Thus, the goal of any biologically finalised guided bone regeneration (GBR) is to create a mechan- ically stable cavity that should be filled with platelet-rich fibrin (PRF) membranes and blood as carriers of infor- mation, and possibly with autologous bone chips. This is also the basis of the Khoury technique,37 in which the space for the newly formed bone is limited by cortical bone plates and a rapidly resorbable bone substitute 12 implants 1 2020

| research 5a 5c 5b 5d 5e Figs. 5a–e: Pre-op CBCT scan of regions #16 and 15 showing chronic periapical periodontitis in region #15 (a). Intra-op image of regions #16 and 15 (b). Post-op radiographic control of the implants in regions #16 and 15 (c). Implants in regions #16 and 15 prior to prosthetic restoration (d). Radiographic control of the implants in regions #16 and 15 after prosthetic restoration with all-ceramic crowns (e). material is introduced into the cavity, or dispensing bone substitute material, only a blood clot or PRF membranes fill the cavity. In recent years, it has been shown that, especially in the posterior jaw, augmented bone blocks are completely resorbed or partially resorbed up to 2–28 %, which is related to the fact that the bone block itself causally prevents angiogenesis in the cavity it occupies. In the posterior mandible, this problem is particularly evident, since posteriorly from the mental foramen, the blood circulation comes almost exclusively from the central and not from the peripheral. From its central origin, it is almost impossible for the inferior artery to grow thorough the coronal compacta into the bone block.38–45 The con- cept of biological GBR is to create a large hollow space, which should be kept mechanically stable for at least four weeks and should not collapse under the periosteum or the Schneiderian membrane. We have this situation with each immediate implant placement, especially when an aggressive apical thread anchors the implant to the bot- tom and therefore primary stability is achieved over not 6a 6b Figs. 6a & b: Pre-op CBCT scan of regions #16 and 15 showing chronic periapical periodontitis in region #15 and vertical bone loss in region #16 (a). Post-op CBCT scan after a six-month healing phase showing a considerable increase of bone around the implants in regions #16 and 15 (b). 14 implants 1 2020

| research Dr Karl Ulrich Volz Prof. Shahram Ghanaati Dr Tobias Wilck Dr Stephanie Vergote Dr Rebekka Hueber Dr Josephine Tietje only the width but also the length. Ideally, the implant should have a wide tulip, which achieves the largest pos- sible shadow effect and therefore an umbrella effect. Figure 1 explains the mechanisms that take effect in the immediate placement of an implant with simultaneous application of the principle of the healing chamber.46, 47 Special techniques of biological GBR Disc abutment The already described technique in which the implant resembles a tentpole is enhanced by the use of a disc abutment, increasing the shadow effect of the implant tulip by screwing on a wide ceramic disc of zirconium dioxide to cover the alveolus. The implant itself is stabi- lised only by an internal elevation of the sinus floor and is anchored by the apical part of approximately 2 mm and by the aggressive thread (Figs. 2a–d). The postopera- tive radiograph shows complete bony filling with de novo bone over the complete 14 mm length of the implant (Fig. 2e). Balcony implants Balcony implants are mostly used as immediate implants and increase the shadow either to one side (in case of an asymmetric insertion) or both sides (when placed sym- metrically as a double balcony; Figs. 3a–d). Sinus implants Dr Karl Ulrich Volz introduced a new type of implant in 2017 with the intention of applying the tentpole and um- brella principle in the sinus cavity and dispensing with secondary materials (Figs. 4a–f). The umbrella effect of the disc at the apical end of the implant is enlarged by the authors by placing the lateral bone cover over it. This is enclosed in two PRF mem- branes and inserted between the Schneiderian mem- brane and the apical part of the implant. Thus, the for- mation of vital and perfectly vascularised lamellar bone can be facilitated without the use of secondary materials. This technique also reduces costs, considerably, as no additional positions are required for secondary materials, membranes or screws. This technique should be used with a residual bone height of 3–5 mm, depending on the width of the alveolar crest and density of the existing bone. Stable fixation of the sinus implant is an absolute requirement here. Application of autologous bone A possible site for harvesting autologous bone is the healthy cortical part of the tubercle region. In addition, using the Safescraper, it is possible to easily obtain 2 cm3 of cortical bone chips in the lateral maxillary sinus. This allows perforations to be closed vestibularly, as well as in the maxillary sinus. The maxillary sinus can be filled with these chips in addition to the insertion of PRF mem- branes. At the same time, the alveolar crest can be raised vertically and widened laterally (region #16; Figs. 5a–e). Figures 6a & b show in an impressive way the possible gain in bone volume when applying this technique. Literature Author details Author details contact Dr Karl Ulrich Volz SWISS BIOHEALTH CLINIC Brückenstr. 15 8280 Kreuzlingen, Switzerland Phone: +41 71 6782000 www.swiss-biohealth.com Prof. Shahram Ghanaati Universitätsklinikum Frankfurt Theodor-Stern-Kai 7 60590 Frankfurt am Main, Germany Phone: +49 69 63013744 shahram.ghanaati@kgu.de 16 implants 1 2020

| research Quality deficiencies of sterile packaged implants Sterile and yet dirty? Dr Dirk U. Duddeck, Germany In 2019, the FDA released two decades of previously un- published data and 2.1 million reports of failed dental im- plants from which more than 100,000 reports referred to 2018 alone. Most of these failures related to a lack of os- seointegration, raising major concerns among dentists in the US and abroad as the number of additional un- reported losses is likely to be much higher. Comments made by manufacturers, regarding these figures, focus on patients with unfavourable clinical preconditions and even blame dentists for their lack of experience and train- ing. Is this the whole truth? Alarming results—also for ceramic implants In a recent study, conducted by the non-profit CleanImplant Foundation in collaboration with the Charitè–University Medicine Berlin, more than 100 different sterile-packaged implants—including ceramic and titanium implants—from 80 implant brands were analysed. SEM imaging and ele- mental analysis (EDS) were performed in an officially ac- credited testing laboratory, according to DIN EN ISO/ IEC 17025. Almost every second implant sample that was unpacked under cleanroom conditions and analysed in the SEM showed considerable contamination, i.e. unwanted particles originating from the manufacturing, handling or packaging of the implant. These contaminants on sterile packaged implants, especially organic particles from the manufacturing or packaging process, can cause an uncon- trolled foreign body reaction resulting in osteoclastogene- sis, leaving rough areas of the implant surface exposed to bacterial colonisation.1,2 Significant amounts of foreign particles were detected on the sterile implant surfaces, with not only iron, chromium, molybdenum, copper, tin, tungsten and nickel but also major organic contamination. 1 2 Fig. 1: Numerous organic particles (black) on a ceramic implant (SEM 500 x). Fig. 2: Organic particles (black) on outer thread of titanium implant (SEM 500 x). 18 implants 1 2020

| overview Zirconium-dioxide as preferred material for dental implants A narrative review: Part I Profs. Curd M. L. Bollen1, 2 & Maher Al-Masri3 1 Professor for Implant Dentistry at the College of Medicine & Dentistry (Ulster University in Birmingham, UK); 2 EACIm Ambassador to the UK and The Netherlands; 3 Professor and Dean at the College of Medicine & Dentistry (Ulster University in Birmingham, UK) Introduction In a recent survey in Europe of > 250 people, by a respected dental im- plant company; most patients in- dicate to prefer a ceramic implant (35 %) over a titanium implant (10 %) to replace a tooth in their mouth, whereas 55 % had no specific preference in the latter. Presently however, the implant market is still dominated by tita- nium implants (> 95 %) and there- fore ceramic implants are still con- sidered as a sort of niche product in implant dentistry for the moment. But things are changing… Dentistry, in particular implant dentistry, is constantly in evolution and what was pioneering yesterday is generally ac- cepted today and probably out- dated tomorrow. Researchers and scientists all over the world con- tinue to look for new materials or enhance the characteristics of the available ones, in order to achieve better aesthetics, bet- ter manageability and/or better clinical results. This search oc- casionally leads to fundamen- tal changes in current treatment paradigms. Whereas 30 years ago, dentists were still trained to use grey- ish, toxic amalgam to repair cavities caused by caries, today all these cavi- ties are restored with white composite materials. This evolution not only ban- ished the toxic mercury from the pa- tient’s mouth, but also addressed the aesthetic aspect of these dark grey fillings. Today, we have a wide variety of products to repair caries or to replace old fillings for higher aesthetic demands. Sev- eral other examples in dentistry are available, but as always, also in the early phase of composite as a restorative material, there are supporters and opponents of these novelties. Because dental profession- als normally tend to be quite conserva- tive, a large majority believed that amalgam would remain for always the gold standard as a filling material. Only the many evidence-based scientific reports and extensive publicity helped composites to become gener- ally accepted over time. Meanwhile, amalgam is kept out of every mod- ern dental practice. A same sort of evolution is now slowly taking place in the field of dental implants. Although com- mercially pure titanium is still the gold standard to produce dental implants, there is now an import- ant transition to manufacture im- plants from inert and more biocom- patible materials.1 In the early days of implant dentistry, Prof. Sami Sandhaus experimented with the implant material 1 2 Fig. 1: The late Prof. Sami Sandhaus, a pioneer in the fi eld of ceramic implantology. Fig. 2: The German chemist Martin Heinrich Klaproth (1743–1817; Source: http://www.sil.si.edu/digitalcollections/hst/scientifi c-identity/explore.htm). 20 implants 1 2020

| overview Fig. 5: The structure of YTZP (Source: http://www.doitpoms.ac.uk/tlplib/ fuel-cells/printall.php). well as of tin mining. Zirconium (40 Zr) is a lustrous, grey- white, very strong transition metal that closely resembles Hafnium (72 Hf) and to a lesser extent … Titanium (22 Ti). Zirconium is in industry mainly used as a refractory and opacifier, although small amounts are used as alloying agent for its resistance to corrosion. Composition Like all other transition metals, zirconium forms inorganic (zirconium-dioxide) and organo-metallic (zirconia-dichlo- ride) compounds. There are five isotopes in nature, three of which are stable. The inorganic zirconium-dioxide (ZrO2) is called zirconia. It is often used in aerospace or as a cutting tool in the watch industry and in surgery.5 More- over, zirconium-bearing compounds are used in many biomedical applications: not only in dentistry (crowns, im- plants and abutments), but also in orthopaedics (knee and hip replacements) and ENT (middle-ear ossicular chain reconstruction). Although zirconium has no biolog- ical role, the human body contains on average 250 milli- grams of zirconium, with an average intake of 4,15 mg/d.6 Zirconia has excellent mechanical properties, such as high resistance to scratching and corrosion and a high re- sistance to load.7 It is a very stable product and it is highly biocompatible. One distinguishes three different crystal- line phases for zirconia (Fig. 4): a monoclinic phase, a cu- bic phase and a tetragonal phase. The phase is tempera- ture dependent: monoclinic below 1,170 °C, tetragonal between 1,170 °C and 2,370 °C, and cubic above 2,370 °C. The trend is for higher symmetry at higher temperatures, as is usually the case. A small percentage of the ox- ides of calcium or yttrium stabilise in the cubic phase. The tetragonal form is the clinically used form. Yttrium, a chemical element with the symbol Y and atomic number 39 (39 Y, a silvery metallic transition metal), is generally added to improve the stability. This creates a bio-inert 22 implants 1 2020 material with even higher mechanical properties: it is 6 times harder than stainless steel! That is why it is some- times called (wrongly) ceramic steel. The Yttrium-Tetragonal-Zirconia-Polycrystal (YTZP) shown in Figure 5, has even more interesting biological char- acteristics: it is electrically neutral and does not conduct electricity nor radiation; it has low thermal conductivity and high thermal shock resistance; and it is chemically totally stable.8 Because of all these criteria, zirconia is an excellent material for medical and dental applications. Editorial note: In the second part of this article, which is to be published later this year in the 2/20 issue of ceramic implants, further material-specific aspects of zirconia will be discussed in depth, a market overview will be given, and a prognosis for future developments will be made. Literature about the author Prof. Curd Bollen obtained his DDS in 1992 at the Catholic University Leu- ven, Belgium. In 1996, he received his PhD and in 1997, he finished his M.Sc. in Periodontology & Implantology. In 2016, he completed the MClinDent pro- gramme at the University of the Pacific in the US. As for his active clinical work, Prof. Bollen specialises in periodontology, implantology and halitosis. He recently joined the College of Medicine & Dentistry in Birmingham, UK, as an Associate Clinical Professor. contact Prof. Curd M. L. Bollen Ulster University in Birmingham College of Medicine and Dentistry 32 – 34 Colmore Circus Birmingham B4 6BN United Kingdom Phone: +44 121 3459847 c.bollen@comd.org.uk Author details

| case report Surgical aspects of two-piece ceramic implants A solution in compromised bone sites Dr Bernard Dahan, DCD, Israel Introduction Ceramic or zirconia implants have appeared in the liter- ature for more than 30 years and have been proposed as a solution for replacement of teeth in edentulous ar- eas. Clinical studies have also shown positive results, as opposed to with titanium implants. Throughout the last decade, ceramic implants have become a part of our implant treatment plans. Besides the aesthetic ad- vantage, the significant interest in zirconia implants is related to its good soft-tissue response. This material seems to have greater biological acceptance by the body, which could lead to a decline in peri-implantitis cases. However, more research is needed to confirm this hypothesis. To avoid mechanical obstacles, the first generation of zirconia implants was only available as a one-piece im- plant configuration. However, this specific implant was not suitable for clinical situations with a bone defi- ciency (quality or quantity), for instance in immediate im- plant placement procedures, in cases of a lack of bone volume or reduced primary stability, and in cases in which there was no indication for immediate loading with a one-piece implant. In recent years, a novel ceramic im- plant with a two-piece design has appeared, giving the 1 4 8 2 3 5 9 6 10 7 11 Case 1—Figs. 1 & 2: Radiographs before the extraction (first stage). Figs. 3–5: Healing of the socket preservation. Figs. 6 & 7: Implant insertion. Figs. 8–10: End of surgery. Two-piece ceramic implant at tissue level. Fig. 11: Successful tissue integration at two months. 24 implants 1 2020

| case report 12 15 18 22 13 16 19 23 14 17 21 24 20 Case 2—Figs. 12–14: Hopeless tooth. Fig. 15: Atraumatic extraction. Fig. 16: Bone allograft for socket preservation. Figs. 17–19: Two-piece ceramic implant placement at tissue level. Figs. 20–22: Collagen membrane placement and suture. Fig. 23: Radiograph showing successful tissue integration at two months. Fig. 24: Successful tissue integration at two months. opportunity to treat situations of deficient bone support and to allow healing without loading. In the following, five clinical cases involving surgery with two-piece ceramic implants are described. Immediate placement of a two-piece ceramic implant at tissue level was done along with socket preservation (allograft bone substitute and a resorbable collagen mem- brane). No loading was done at that point (Figs. 12–24). Cases Case 1: Implant placement in regenerated bone (two-stage approach) The implant insertion was preceded by endodontic treat- ment, which had failed. The first stage of implant treatment involved tooth extraction and socket preservation by means of an allograft and a collagen membrane. Six months after the initial treatment, a two-piece ceramic implant was in- serted into the bone, which had regenerated at that point, as part of the second treatment stage (Figs. 1–11). Case 2: Immediate implant placement The clinical diagnosis revealed a cracked premolar. As a consequence, atraumatic extraction was carried out. Case 3: Implant placement combined with lateral bone augmentation (guided bone regeneration) via a simultaneous approach The site in the mandibular molar area presented with an alveolar crest too narrow for predictable implant place- ment without augmentation. Two-piece zirconia implants were placed simultaneously with lateral bone augmenta- tion using an allograft and a resorbable collagen mem- brane (Figs. 25–34). Case 4: Implant placement in molar area with guided tissue regeneration A patient with an infrabony defect came to the practice explicitly demanding a zirconia implant in the molar area. Thus, a two-piece zirconia implant was inserted, and at 26 implants 1 2020

| case report 25 26 27 28 29 30 31 32 33 34 35 37 39 41 42 44 36 38 40 43 45 Case 3—Figs. 25 & 26: Narrow edentulous area compromised for implant Case 4—Figs. 35 & 36: Edentulous molar area before implantation. Fig. 37: placement. Figs. 27 & 28: Two-piece ceramic implant placement at tissue Exposure of the periodontal defect (the mesial aspect of the second mo- level. Figs. 29 & 30: Lateral bone augmentation (guided bone regener- lar). Figs. 38–40: Two-piece ceramic implant placement at tissue level. ation) with allograft bone substitute at the time of the implant placement. Fig. 41: Bone grafting and guided tissue regeneration at the mesial aspect Figs. 31–33: Placement of a collagen membrane as a barrier and sutures. of the second molar. Figs. 42 & 43: Micro-sutures. Figs. 44 & 45: Control Fig. 34: Control radiograph at two months. radiograph and good integration of the ceramic implant in the environment. 28 implants 1 2020

| case report The key to optimal implant aesthetics Dr Kunal Shah, UK Initial clinical situation A 58-year-old male patient presented with a dental gap where tooth #15 had been missing for many years. He had been recommended to the practice by another patient. He was fit and healthy with an unremarkable medical history. Having undergone extensive restorative treatment in the past, the patient was very aware of the different procedures that are currently available to restore teeth. As such, the challenge of this case was to effectively manage the patient—the restorative aspect of treatment was crucial to success, especially as the patient had high expectations of the overall result. All treatment options were discussed with the patient, in- cluding the advantages and disadvantages of each. The patient chose a dental implant, as he preferred a fixed solution. The different types of implants available were then discussed with him, including bone and tissue level systems. It is important for clinicians to explain treat- ment options to this level of detail, as patients need to know what each dentist can offer them and/or what else they could access through professional referral. Many patients are also very conscious of what will be put in their mouths. As improved aesthetics could be achieved with its zirco- nia collar design, the patient decided on the Z1 implant system from TBR Dental. This was the most superior, yet cost-effective, option compared with the alternatives 1 2 Fig. 1: Periapical radiograph showing the Z1-infinity implant in position #15 at the three-month review. Fig. 2: Intra-oral photograph showing the Z1-in- finity implant with a cover screw in position #15. 30 implants 1 2020 offered. As the Z1 is a tissue level system, the surgi- cal site does not have to be reopened for the implant to be accessed in order for the clinician to remove the cover screw and replace it with a healing abutment. This saves the patient from having to attend an additional appointment for this, thereby maximising on valuable chair time. Furthermore, the Z1 enables the clinician to place the implant in one surgical step, which helps op- timise operating room planning and sterilisation proto- cols, making the Z1 much more convenient for patient and practitioner. The versatility of the Z1 also optimises stock management for practices and helps to minimise maintenance treatments for patients. In addition, the Z1 itself was more affordable than the other implant sys- tems that were offered to the patient in this case, pro- viding further cost-saving benefits. Modern patients are increasingly more price-conscious, so they need solu- tions that can achieve the best clinical outcomes while meeting their budget. Treatment planning Standard treatment planning protocols were followed. This involved taking a cone beam computed tomogra- phy scan to assess the sinus and bone level, as well as to provide a 3D view of the proposed surgical site for improved visualisation. A comprehensive assessment confirmed that there was adequate width and height of bone to place an implant. Digital software ensured that the treatment planning process was very precise. A 4.0 x 10.5 mm tissue level Z1 implant was planned for, as this solution provides excellent aesthetics and, in this case, did not require a bone grafting procedure prior to surgical placement. Every aspect of treatment was discussed with the patient before informed consent was obtained for treatment to begin. Implant placement Surgery proved to be unremarkable. A delayed implant placement protocol was followed, which involved mak- ing a small incision in the gingiva and raising a flap. The surgical site was cleaned and prepared for the implant to be placed successfully and achieve primary anchorage. The zirconia collar was sunk 1 mm into the bone to pro-

| case report 9 10 11 12 Fig. 9: Intra-oral photograph showing the screw-retained implant crown seated. Fig. 10: Intra-oral photograph showing the screw-retained implant crown seated, buccal view. Fig. 11: Intra-oral photograph showing the screw-retained implant crown seated, palatal view. Fig. 12: Intra-oral photograph showing the screw-retained implant crown seated with PTFE tape to protect the access hole. Discussion In this case, the zirconia collar of the Z1 acted as a heal- ing abutment for the implant to encourage gingival flar- ing and soft-tissue healing for a good gingival profile to develop. This meant that a cover screw could be fitted to the implant and left for three months to achieve ex- cellent osseointegration. Simultaneous healing of the hard and soft tissue further emphasised the time-saving benefits that the Z1 provided throughout this case. The zirconia collar also promoted gingival attachment and served as an antibacterial shield to the crestal bone to prevent iatrogenic inflammation and infection.1, 2 This is the only implant system that encourages natural gingival growth, whereas other solutions tend to result in gingival recession over time. Moreover, there are fewer surgical steps involved with placing the Z1, as the clinician does not need to reopen the surgical site to access the implant for the restorative phase of treatment. Conclusion The success of a dental implant is always based on plan- ning treatment correctly. It is also important to offer an 13 Fig. 13: Post-op periapical radiograph showing the screw-retained implant crown seated. 32 implants 1 2020 implant solution that caters to the needs of the patient. Together, these elements can ensure outstanding results, as was demonstrated in this case. The unique design of the Z1 enabled placement of the implant at tissue level, thus minimising the number of surgical steps required, which ultimately ensured treatment was less invasive and more convenient for the patient. Literature about the author Dr Kunal Shah is the principal of LeoDental in London. He graduated from the University of Birmingham in the UK, was selected as a finalist for Young Dentist of the Year—South in the Den- tal Awards 2018 and has the accolade for the best implant and imaging clinic in London in 2018. He has a keen interest in the topics of digital dentistry, implan- tology and restorative dentistry specific to direct resin compos- ites and impression materials, and has published several articles in the professional press and lectured internationally. Dr Shah is also a clinical mentor for students on the year-long postgraduate implant course at LeoDental in conjunction with SmileTube.tv. contact Dr Kunal Shah LeoDental Bell Lane Dental Practice 19 Bell Lane, Hendon, London NW4 2BP, United Kingdom Phone: +44 20 82033155 referral@leodental.co.uk www.leodental.co.uk Author details

| case report Immediate restoration with one-piece zirconia implants Fabricating removable interim prostheses Dr Kazuhiko Okamoto, Prof. Shuji Ohkawa, Dr David Ashley & Prof. Yung-Tsung Hsu, Japan & USA Introduction Zirconia implants have been recommended as a possi- ble alternative to traditional titanium implants.1 Compared with titanium implants, zirconia implants show favour- able results regarding biocompatibility, soft-tissue reac- tion and aesthetic outcomes.2, 3 Although two-piece zir- conia implants are available in the market, the long-term prognosis of this design is still unknown.4, 5 One-piece zir- conia implants have demonstrated satisfactory results;6, 7 however, with the one-piece design, there are signifi- cant challenges for both clinicians and patients during the healing time. For clinicians, occlusal forces may be applied to the implants before they are osseointegrated. This increases the risk of failure if the forces are too great or if the initial implant stability is less than ideal.8 For patients, the main concerns are related to maintaining aesthetics and function during the healing time. If the initial stability after the implant placement is ideal and there are enough adjacent teeth to prevent heavy contact, immediate placement of an interim restoration on the implant is possible.9, 10 However, when multiple implants are placed in scattered positions or when there is a distal extension situation, the loading on the im- plants should be delayed to allow for better bone and soft-tissue healing. For two-piece designs, implants can be submerged and uncovered after osseointegration is achieved. For a one-piece implant, a prosthesis should be offered to provide aesthetics and function during the healing time. In addition, this prosthesis should provide protection of the implants to avoid occlusal contact be- fore sufficient osseointegration has occurred. In these situations, a removable interim dental prosthesis (IDP) could be suitable. Compared with a fixed IDP, a remov- able one may be less stable and comfortable; however, for one-piece dental implants, this prosthesis meets the needs mentioned and offers ease of adjustment and removal for cleaning by patients. The fabrication of a removable prosthesis supported on one-piece implants is different from the conventional technique. The replacement of the missing teeth must meet the traditional tooth arrangement requirements; in addition, any occlusal contact on the implants should be avoided to protect the implants from loading before osseointegration. A space between the intaglio surface of the removable IDP and the implants is necessary for this purpose. This prosthesis also must be fabricated in a short period, preferably in the dental office immediately after surgery. This article presents a case report with a technique for fabricating a removable IDP supported on one-piece zirconia implants immediately after surgery. Case report A 65-year-old female patient presented with a fractured tooth under an existing metal framework removable par- 1 2 Fig. 1: Frontal view, before surgery. Fig. 2: Maxillary arch, occlusal view. 34 implants 1 2020

| case report 9 11 10 12 Fig. 9: Implant placement in the maxillary arch, occlusal view. Fig. 10: Implants on the maxillary right side, buccal view. Fig. 11: Implants on the maxillary left side, buccal view. Fig. 12: Panoramic radiograph, after surgery. The remaining root was removed. Implants were placed in the areas of the right first molar (Ø 5.0 × 11.5 mm), right second premolar (Ø 4.0 × 11.5 mm), right canine (Ø 4.0 × 14.5 mm), left second premolar (Ø 4.0 × 11.5 mm) and left second molar (Ø 5.0 × 11.5 mm; Figs. 9–12). The final insertion torques were between 25 and 40 Ncm. The facial side of the socket in the right canine area was filled with bone grafting material (MinerOss Cortical, BioHorizons) and covered with a membrane (AlloDerm, BioHorizons) after the implant was inserted. The wound was closed with synthetic resorbable sutures (4/0 Monocryl, Ethicon). Amoxicillin (500 mg, four times daily for two weeks) and an oral rinse with 0.12 % chlorhexidine were prescribed for postoperative care. After the surgery, an occlusal record with a polyvinylsi- loxane (PVS) material (Regisil PB, Dentsply Sirona) in the centric relation position was taken. The maxillary and condylar relationships were transferred to a semi-adjust- able articulator with a facebow record. Plastic impres- sion posts (COHO Biomedical Technology) were inserted on to the abutments (Fig. 13). The impression was made with a PVS impression material (Aquasil Ultra Monophase, Dentsply Sirona). The tray with the impression material 13 14 15 Fig. 13: Impression posts on the implant abutments. Fig. 14: Impression with the impression posts in position. Fig. 15: Analogues inserted into the impression posts. 36 implants 1 2020

20 21 22 23 Fig. 20: Vacuum-formed matrix on the cast. Fig. 21: Tooth-coloured acrylic resin on the cast. Fig. 22: Pink acrylic resin on the palatal area. Fig. 23: PVS as a space indicator. appointment, the low-viscosity PVS impression was used to ensure a space between the acrylic base and the im- plant abutment. Discussion The zirconia implants used in this case were implants fabricated with yttria-stabilised tetragonal zirconia poly- crystals. Compared with two-piece zirconia implants, one-piece implants have less risk for bacterial accu- mulation at the gap between the abutment and implant and better fracture strength. Immediate replacement of an extracted tooth in the maxillary aesthetic zone with a zirconia implant has been documented as a feasible treatment option.13 Immediate loading on one-piece tita- nium or zirconia implants may result in a higher failure rate and bone loss;14, 15 therefore, a protective device must be provided to patients to avoid loading, especially for one- piece zirconia implants. A removable IDP could be fabricated before surgery; however, this prosthesis must be relieved intra-orally, and it will take too much time when multiple implants are placed. In addition, it will apply too much force on 24 25 26 27 Fig. 24: Final prosthesis, front view. Fig. 25: Final prosthesis, occlusal view. Fig. 26: The definitive restorations, occlusal view. Fig. 27: The definitive resto- rations, frontal view. 38 implants 1 2020

| case report 1 3 5 2 4 6 7 8 9 Fig. 1: Free-end situation in regions #26 and 27. Fig. 2: Preoperative three-dimensional planning. Figs. 3 & 4: Straumann® PURE Ceramic Implant. Fig. 5: Sur- gical situation with cover screw. Fig. 6: Post-op radiograph. Fig. 7: Situation after exposure. Fig. 8: Healthy marginal gingiva. Fig. 9: Taking an impression with an open impression post. Single-tooth restoration of an upper molar with a ceramic implant Dr Frank Hoffmann, Germany Baseline A 60-year-old man presented with a free-end situation in regions #26 and 27 which had been this way for about eight years. Three years ago, a PURE Monotype was successfully implanted in position 36 and fitted with a prosthetic restoration. His dental hygiene was excellent and region 36 was not irritated in any way. The patient now wanted to treat position 26 with a ceramic implant without major surgical intervention. 3D imaging (CBCT) showed sufficient transverse bone and a vertical height of approximately 5–6 mm to the maxillary sinus and thus, the use of a two-piece implant with an internal sinus lift was planned. The poor vertical bone supply and the reduced quality compared with the lower jaw would have posed a risk for successful osseointegra- tion, if a single piece implant with transgingival healing had been selected. In preparation of the treatment a mild basal mucosal membrane swelling was checked by an ENT specialist and the patient performed nasal irrigation on a daily basis. Surgical procedure Following local anaesthesia, a crestal incision was made with only minimal mobilisation of the mucoperi- osteal flap. For the internal sinus lift (performed accord- ing to the Summers technique), the pilot marking stops approximately 1 mm short of the margin of the maxil- lary sinus and is then widened with various osteotomes (Straumann Institute) depending on bone availability and quality. Here, it is essential that the Schneider- ian membrane is regularly checked via a “Nasal pa- tency test” to ensure that it is not perforated during the procedure. Following the successful preparation of the bony bed, an implant size 4.1/10 mm was inserted with very good primary stability. This was followed by wound closure with 5/0 monofilament sutures. After 40 implants 1 2020

| case report Patent™ zirconia implant system A case report Dr Sebastian Horvath, Germany Introduction Growing health concerns of patients have led to an increas- ing demand of metal-free restorations. The same is true for dental implants. As dental professionals it is our goal to ful- fil this demand of our patients in the most predictable way. When it comes to implant treatments the two most cru- cial aspects regarding a treatment success are the osseo- integration of the implant and the prosthetic workflow. The 1 2 3 4 42 implants 1 2020 Patent™ implant system features a novel zirconia implant design with an innovative prosthetic connection. In a pro- spective cohort study by Becker et al. 2017, the Patent™ implant system was evaluated for posterior single tooth ap- plications with good results. The survival rate was 95.8 % after two years. A very positive soft tissue response was also reported. This is in line with what was reported by Brüll et al. 2014, in a 3-year retrospective follow-up. The follow- ing case report shows the replacement of a lower molar using the Patent™ zirconia implant system. Initial situation A 54-year old female patient presented at the author’s office, asking for a general restoration of her teeth. As a part of this complex case the lower right quadrant was restored (Figs. 1 & 2). The treatment of this area is the subject of this case report. The patient reported that the old restoration was placed about 20 years ago after tooth #46 was lost due to endodontic complications. A few years after the placement of the restoration tooth #45 was endodontically treated through the placed res- toration. Now the patient reported an increasing sensitiv- ity on tooth #47 due to ill-fitting margins. It was planned to restore the area with two all-ceramic crowns on teeth #45 & 47, and an implant-retained restoration in site #46. The implant-retained restoration was preferred to a new fixed dental prosthesis in order to reduce the load on the endodontically treated tooth #45 and to reduce future risks by incorporating an endodontically treated tooth in a larger restoration. Initially, a CBCT was made in order to evaluate the bone volume in the edentulous areas and to evaluate existing root canal treatments. Pre-treatment The CBCT revealed sufficient bone volume in site #46 to place an implant (Fig. 3). A custom implant was designed in order to get the optimal transgingival design for this in- Fig. 1: Initial situation in the lower right quadrant. The patient reported about increasing sensitivity on tooth #47. Fig. 2: Initial radiograph showing the lower right quadrant. Note the ill-fitting margin distal on tooth #47. Fig. 3: A CBCT revealed sufficient bone volume in site #46 to place an implant. Fig. 4: Clinical situation prior to the surgery.

13 16 19 22 14 17 20 23 15 18 21 24 Fig. 13: Clinical situation three months after implant placement. Healing was uneventful. Fig. 14: The implant was stable and the soft tissue presented itself as healthy. Fig. 15: Occlusal view. Fig. 16: For the prosthetic reconstruction a glass fibre post and core assembly was adhesively cemented on the implant. Fig. 17: The post and core assembly is pre-fabricated and tightly fits into the implant connection. Fig. 18: Following this build-up, the implant was prepared for a full-crown restoration just like a natural tooth. Fig. 19: Occlusal view. Fig. 20: An intra-oral scan was performed for a lab-side prosthetic workflow. Fig. 21: Three monolithic zirconia crowns were fabricated (Ceramics: MDT Claus-Peter Schulz). Fig. 22: Intra-oral view of the treatment result. Fig. 23: Occlu- sal view. Fig. 24: Radiographic evaluation of the treatment result. Prosthetic reconstruction about the author The prosthetic phase was commenced three months after implant placement. The provisional restoration was removed and final preparations performed on the abutment teeth. Following an uneventful healing phase, the implant was stable and the periimplant soft tissue healthy (Figs. 13–15). For the prosthetic recon- struction a glass fibre post and core assembly was adhesively cemented on the implant (Figs. 16 & 17). The post and core assembly is pre-fabricated and tightly fits into the implant connection. Following this build-up, the implant was prepared for a full-crown restoration just like a natural tooth (Figs. 18 & 19). An intra-oral scan was performed and three monolithic zirconia crowns fabricated using a lab-side workflow (Figs. 20 & 21; Ceramics: MDT Claus- Peter Schulz). The final restorations were cemented. Figures 22 to 24 show the final treatment result. Literature Dr Sebastian Horvath specialises in aesthetic-restorative dental treatments. He works together with his wife and fa- ther in a joint practice in Jestetten, Ger- many. He studied dentistry at Freiburg University, where he also obtained his doctorate. He then worked at Freiburg University Hospital as a research assis- tant and completed a training as a listed specialist for prosthodontics. Dr Horvath teaches at the University of Pennsylvania, USA, and Düsseldorf University Hospital, Germany. contact Dr Sebastian Horvath Bahnhofstraße 24 79798 Jestetten, Germany Phone: +49 7745 7211 www.drhorvath.de Author details 44 implants 1 2020

| industry Ceramic Excellence Program CAMLOG, Switzerland The Ceramic Excellence Program is an online train- ing programme for the use of the CERALOG® ceramic implant system. It takes place on an innovative online platform: Dental Campus. The content of the Dental Campus educational programme is provided by an inter- national network of teaching centres. It is reviewed by a global independent committee of renowned experts and divided into different modules that cover the entire field of implantology. CAMLOG Biotechnologies GmbH offers the Ceramic Excellence Program for the CERALOG® ceramic implant system. It includes lectures by renowned experts, and these can be viewed on demand at any time and feature both theoretical and practical content. In a virtual class- room setting, participants will exchange information inter- actively and present and discuss their own cases—from clinical planning to prosthetics restoration. The experts, among them Prof. Florian Beuer (Germany), Prof. Jérôme Chevalier (France), Prof. Christoph Häm- merle (Switzerland), Prof. Ronald Jung (Switzerland) and Prof. Irena Sailer (Switzerland), as well as experienced cli- nicians like Dr Mario Beretta (Italy), Dr Frederic Hermann (Switzerland) and Dr Laurens Wiggers (Netherlands), are very familiar with the CERALOG® implant system and convey scientific findings on and the latest techniques for the use of ceramic implants. They explain the surgical and prosthetic possibilities with the CERALOG® implant 46 implants 1 2020 system and explain the material characteristics of zirco- nia regarding implant insertion and restoration. After the first (theoretical) phase, participants complete an examination to ensure that all participants have a sim- ilar level of knowledge in order to progress to the clinical phase. The second phase (focusing on clinical cases) is then conducted in a small virtual classroom setting su- pervised by two experts. Participants will be taught the techniques required for placing their first CERALOG® ceramic implant in their own patient case. To perform the practical phase, the participants need to ensure ac- cess to the CERALOG® implants and surgical set in their practices. Virtual online classrooms will be held pre- and post-sur- gery. Participants will upload case planning and case documentation. Based on this information, the specific clinical case will be discussed with the experts, online and live. Individual patient surgery and prosthetics res- torations will be performed by the participants them- selves. To ensure personal interactions and mentoring, the number of participants in the virtual classroom is lim- ited to ten. After successful completion and discussion of their documented patient cases, participants receive the Ceramic Excellence Program certificate for CERALOG®, which is recognised with 11 continuing education credits. Advantages: – Understand the science behind Ceramic implants – Plan and place your first CERALOG® ceramic implant – Benefit from experienced renowned experts – Enjoy flexible on-demand learning – Interact live with experts and fellow participant – Earn 11 CE credit points More information on www.dental-campus.com/lounges/ camlog-lounge. contact CAMLOG Biotechnologies GmbH Margarethenstr. 38 4053 Basel, Switzerland Phone: +41 61 5654100 www.camlog.com

TAV Dental State-of-the-art dental zirconia products Zirconia healing caps, zirconia locators, multi-units with zirconia ring and last but not least zirconia implants are just some of the special products TAV Dental is manufacturing using the advanced ceramic injection technology. The passion behind developing zir- conia products for dental implantology is to provide patients with products that are much healthier for their bodies along with the advantage of uncompromising aesthetic results. Zirconia prod- ucts from TAV Dental are designed by a highly professional and dedicated team and manufactured using high-end ceramic injec- tion moulding technology, resulting in state-of-the-art products to improve patient’s quality of life. The vision of our team is to redefi ne—better than ever—the quality and the performance of dental zirconia products and to make our premium zirconia lines a global standard. TAV Dental Shlomi, Israel www.tavdental.com PreXion Superior 3D image quality with low radiation exposure 100 μm voxel size. 74 μm voxel size (PreXion3D EXPLORER). 3D image with a 150 x 160 mm fi eld of view. With many 3D-imaging systems today, good image quality is usually accompanied by high radiation exposure. Developed specifi cally for the European and US-American market, the new CBCT system PreXion3D EXPLORER offers the highest possible image quality at the lowest possible radiation levels. With a specifi cally controlla- ble pulse generator, radiation is generated only when necessary to achieve the highest imaging quality. For a 20-second-long scan in ultra-HD 3D-mode, radiation exposure is only between 4.4 and 5.8 seconds. For a 10-second-long scan in standard scan 3D-mode, it is a mere 3.2 seconds. The small voxel size enables a more de- tailed representation of even the fi nest hard and soft tissue struc- tures in ultra-high defi nition. The short image reconstruction times ensure a seamless workfl ow. The PreXion3D EXPLORER convinces with easy handling and extensive planning programmes that cover the entire range of indications. With the 3D-analysis function, fi elds of view (FOV) sizes of 50 x 50, 150 x 80 and 150 x 160 mm can be generated, offering numerous fl exible diagnostic options for oral surgery, implantology, periodontology, endodontics, orthodontics, and general dentistry. PreXion (Europe) GmbH Stahlstraße 42 65428 Rüsselsheim, Germany www.prexion.eu 48 implants 1 2020

Straumann Natural ceramic—proven quality PURE ceramic implants have an ivory colour that resembles nat- ural tooth roots. This gives the most natural look even in thin gin- giva biotypes. ZLA, the surface of the PURE ceramic implant, is characterised by macro- and micro-roughness which is similar to the original Straumann SLA surface. In several studies, the ZLA surface has also demonstrated similar healing patterns, healing times and osseointegration qualities with regards to peri-implant bone density and bone-to-implant contact (BIC). In addition, the zirconia-based ZLA surface of PURE implants shows a favourable formation of the epithelial attachment, as well as signifi cant lower bacterial accumulation compared to titanium-based SLA surfaces. Compared to titanium implants, a higher degree of soft-tissue integration around the PURE ceramic implant was observed in scientifi c studies. By placing the Straumann PURE ceramic im- plant system, excellent aesthetic outcomes with favourable soft- tissue attachment and papilla formation around the implant can be achieved. Institut Straumann AG Peter Merian-Weg 12 4052 Basel, Switzerland www.straumann.com ClaroNav State-of-the-art navigation for every day Similar to the way that a GPS system guides you while driving, Navident by ClaroNav guides clinicians by using the CBCT image as a map. It offers surgeons an easy to use, accurate, highly portable and affordable way to plan restorations and implant placements. With Navident 2, clinicians will no longer need to do a special extra scan. They can use the diagnostic scan already available for the patient. The stress of stent making is also gone because a stent is no longer required. Trace and Place (TaP) is a game-changing development for dynamic navigation. With TaP, the Navident workfl ow is streamlined, effi cient, user-friendly and seamlessly integrated into the daily practice. “Trace and Place is a real tipping point for dynamic navigation guidance,” said user Dr George Mandelaris, a periodontist from Chicago, USA. “It has streamlined and simplifi ed the workfl ow in both the diagnostic and surgical phases to allow state-of-the-art technology to be an everyday component of my surgical implant practice. I can’t imagine going back.” Clinicians are invited to learn from masters and interact with peers at ClaroNav’s annual DNS Symposium in Toronto, Canada on 24 and 25 July 2020. ClaroNav Inc. 1140 Sheppard Avenue West, Unit 10 M3K 2A2 Toronto, Canada www.claronav.com 50 implants 1 2020

| manufacturer news Dentalpoint/Zeramex Your competence centre for digital solutions torations. Model your crown or the individual abutment as usual in your 3Shape or exocad software to create the desired design. Send us the digital data conveniently as an STL file. Zeramex Dig- ital Solutions will produce the complete restoration including the Zeramex implant connection. This can be in the form of an indi- vidual abutment or as a one-piece monolith crown without joints and adhesive gap. It is also possible to order a custom crown for Zerabase or other abutments directly from us. As required, these can be supplied with and without screw hole. All of our custom zirconium crowns are also available coloured and glazed. Within just one week you will receive the precisely fitting prosthetic res- toration you require—ready for immediate use. Simplify your work processes and the life of your patient. Use the digital workflow from Zeramex (available in Germany and Switzerland). Dentalpoint AG Bodenäckerstr. 5 8957 Spreitenbach, Switzerland digitalsolutions@zeramex.com Get to know the complete digital workflow for implant systems from Zeramex. Improve the experience of your custom- ers and make your own job easier. In addition to the production of 100% metal-free screw-retained customised abutments and monolithic crowns with Zeramex XT implant connections, the dig- ital workflow from Zeramex offers you a service for processing your digital data or for the finishing of semi-finished blank res- bredent medical Highest primary stability—now with conical-parallel connection The new copaSKY implant line from bredent is particularly dis- tinguished by the stable and retrievable conical-parallel-walled interface, which enables easy removal of the prosthetics. The unique neck design and short implant–abutment connection also allows ultrashort implants. Due to the deposition of bone chips on the backtaper, a subcrestal implant position can also be selected. copaSKY uses the same surgical tray as all other SKY implants. And the enhanced prosthetic offering one connection that fits all diameters of implants, simplifying storage and reduc- ing inventory. The material of choice is BioHPP, which provides a natural chewing sensation and built-in shock absorber effect to protect implants. Also new is the form-fit connection for bolted bridge components. The high accuracy of fit directs the lateral load directly onto the abutment, i.e. the risk of screw loosening and fractures is greatly reduced. The integrated angled screw channel provides excellent aesthetic results when transversally threaded. bredent medical GmbH & Co. KG Weißenhorner Straße 2 89250 Senden, Germany www.bredent-implants.com

| interview A new solution in the field of digital workflows tomised and 100 % metal-free solutions from the new Zeramex Digital Solutions competence centre. Our customers now have the possibility of sending digital data to our competence centre by secure data exchange, which enables them to order, for instance, customised abutments directly from us. But that is by no means all. Our product portfolio embraces fully customised abut- ments, one-piece monolithic crowns, and custom-made crowns with and without screw holes for ZERABASE abutments, all made to the highest degree of precision. Whether for restorations of anterior or posterior teeth, we have the perfect solution for each and every situa- “In the near future, the competence centre will certainly provide users with innovations as well as enhancements of existing products.” 1 Fig. 1: Adrian Hunn was elected new CEO of Dentalpoint at the beginning of 2020. In this interview, new Dentalpoint CEO Adrian Hunn talks about the new competence centre for Zeramex Digital Solutions and master dental technician Peter Hölldampf, laboratory manager at the Germany-based machining centre Geiger Dentaltechnik, a close partner of Zeramex, discusses material-specific aspects of zirconium dioxide. Mr Hunn, the company Dentalpoint, which owns the Zeramex brand, opened its new competence cen­ tre for Zeramex Digital Solutions last year. There are probably at least some users, dental technicians and dentists who have not heard of it yet. Can you explain exactly what a competence centre is and how the customer can benefit from it? Hunn: The market is demanding new solutions in the field of digital workflows, so it is a logical step for the R & D department at Zeramex to find new ways, approaches and, ultimately, solutions for our two-part and 100 % metal- free systems to meet this demand. And our R & D de- partment has done a great job in this regard over the past two years. We are now able to offer fully cus- tion. In addition, customers can choose to have their crowns ready coloured and glazed. A 3D-printed model can also be produced on request so that the practitioner can check the restoration before insertion and show it to the patient as a tangible model. Of course, every order comes as standard with the required 100 % metal-free VICARBO screw. In addition to the direct implementa- tion of the orders, our competence centre offers advice in the field of data processing and in the selection of the perfect product for the individual needs of the customer. It has been a few months now since Zeramex Dig­ ital Solutions was first launched. How much has the new competence centre appealed to users and how strong is the demand? Hunn: As I pointed out earlier, the ordering process is very simple and uncomplicated and therefore runs very smoothly. This meant that, at start-up, only minor changes to the ordering process were necessary. The simplicity with which customers can get high-quality, customised and, above all, metal-free solutions adapted 54 implants 1 2020

3 4 Figs. 3–5: ZERAMEX Digital Solutions offers customised and completely metal-free abutments, crowns and even one-piece mono- lithic crowns. 5 Are there still problems with fitting with zirconium dioxide, and does this require product in original manufacturer quality that we can use to create our custom restorations. a lot of reworking? Hölldampf: Actually, this is no longer really the case. Above all, owing to improvements in the software in re- cent years, it is now possible to work much more pre- cisely in scanning and then digitally designing the im- plant. As a result, significantly less reworking has been required in recent years. “Especially in the area of the geometry of implant connections, it is important to use extremely stable ceramic material.” Are there comparable products on the market with regard to customised abutments or customised monolithic crowns? Hölldampf: In the past few years, we have had products from various zirconium dioxide implant manufacturers. I would say that there are comparable products, yes, but there have never been other products where you can safely assume there will never be complications when it comes to fitting in the patient’s mouth. In Zeramex, we have found a partner whose product simply works. The product is carefully considered and planned down to the last detail and perfectly harmonised with other compo- nents. The system is logically structured, all parts fit to- gether perfectly, and the great thing for us is that we can rely on finding the best solution for every job, regardless of the size. We have never had any other product in our laboratory that comes close to the quality of Zeramex. Zeramex Digital Solutions offers customised and completely metal­free abutments, crowns and even one­piece monolithic crowns. To what extent have you, in the laboratory, been able to benefit from these innovations? Hölldampf: The issue is really the connection geometry of the abutment, that is, the prosthetic restoration of the dental implant. Milling this connection geometry in zir- conium dioxide is highly problematic, since no manual post-machining should be carried out in this area. Only a perfect first-time fit in the transition area will provide a product that functions perfectly. Because this connec- tion geometry is milled directly by the Zeramex Digital Solutions competence centre, you have to be able to simply count on it being a perfect first-time fit. And this means that we immediately get a super-functioning contact Adrian Hunn Dentalpoint Bodenäckerstr. 5, 8957 Spreitenbach, Switzerland Phone: +41 44 3883636 info@zeramex.com Peter Hölldampf Geiger Dentaltechnik GmbH Gottlieb-Daimler-Straße 3 73529 Schwäbisch Gmünd, Germany Phone (laboratory): +49 7171 9806-11 Phone (milling centre): +49 7171 9806-29 info@geiger-dentaltechnik.de millingcenter@geiger-dentaltechnik.de 56 implants 1 2020

| interview Dr Noumbissi: We have worked and supported each other as individuals but also as associations for the last ten years. The IAOCI from its creation had global ambitions, which we continue to work toward achieving. ISMI had the fortune of being founded and led by Ulrich, who is a man with a broad vision and a lot of perseverance. We are joining forces at this stage because a lot of the ground- work laid by ISMI and the IAOCI to educate our colleagues and the general public is now yielding positive results. I can confidently say that, had we not had the courage and temerity to push forward with our respective goals, ce- ramic implants would not have drawn the attention and interest we are seeing now. If you look at the ceramic im- plant market today, it constitutes no more than 2 % of the global implant market, as manufacturers are just starting to understand that there is a demand and even a need for metal- free implants. Therefore, as the leaders in the field, we thought that it would be best to join forces to adequately educate the world on ceramic implants, be- cause we believe that there is a need for a uniform and organised message. Academic institutions, researchers and the industry respond better to firmly established and well-organised groups. This is why we now offer ISMI and IAOCI members a dual membership programme and we aim at aligning our educational initiatives more strongly in the future on the basis of shared educational standards. Against this background, ISMI’s Curriculum for Biological Dentistry is now also fully recognised by the IAOCI. Dr Noumbissi, you formed the IAOCI in 2011. What were the reasons for founding an academy that is solely dedicated to ceramic implants? Dr Noumbissi: When I introduced ceramic implants in my practice, I was one of ten or 15 dentists in the Americas who were placing ceramic implants. Even though I am a trained implantologist, the start was not easy because there were no firm guidelines, and documentation was scarce and was for the most part produced by manufac- turers of the few systems available at the time. Ceramic implants, although they look like their counterparts, re- quire a tremendous amount of attention to detail in all phases of treatment. Biology, physiology and immunol- ogy, to name just a few, are important factors to take into consideration if one wants to be successful with ceramic implants. Furthermore, research findings and unbiased literature were hard to come by. There was a big void for the early adopters, so we had to learn from one another and do so quickly, because the demand for metal-free implants was and continues to be mainly driven by pa- tients, rather than dentists. The only way to meet these initial challenges was to organise ourselves. Many clinicians would approach me and Ulrich asking for training courses and resources. These are some of the few reasons that played a great part in the creation of the IAOCI; we wanted to create an environment in which dentists could freely share with one another their experi- ences, but above all get proper training and knowledge about ceramic implants. We wanted to create an eco- system in which clinicians, manufacturers and research- ers could exchange, communicate and contribute to one another’s growth. Seven years into the academy’s exis- tence, we created the Zirconia Implant Research Group, whose objective is to give some direction to the science, improvement and development of ceramic implants. ISMI has done the same: they—in some cases collaboratively with the IAOCI—are conducting important research proj- ects across the globe in order to properly document and scientifically consolidate daily clinical facts long proven and accepted by early adopters and clinicians. Dr Volz, founded in 2014, ISMI is the first expert so- ciety for ceramic implants in Europe. What is ISMI’s approach to modern-day dentistry? Dr Volz: Dental implantology actually started with ceramic implants, and Prof. Willi Schulte, the inventor of the first ceramic implants, wrote me a personal letter shortly be- fore he passed away in which he said that, at the begin- ning, he received no approval to compare his ceramic implants with titanium implants because at that time the relevant ethics committee didn’t expect them to be safe. Titanium intolerance is expected to be somewhere be- tween 10 and 25 %, and according to the 2006 Euro- pean Consensus Conference, the rate of peri-implantitis is around 50 %. This peri-implantitis tsunami has become one of the main topics at all mainstream implantology congresses. Even the U.S. Food and Drug Administration launched an investigation in November 2019 not only into amalgam but also into metal-containing implants. Ac- cording to the latest studies, ceramic implants are at least as good as their titanium counterparts in terms of osseo- integration, success rate, bone loss and overall stabil- ity. They even outperform them significantly in terms of soft-tissue reaction and aesthetics, and no intolerance or peri-implantitis occurs with them. Employing ceramic im- plants as an alternative in the daily practice has become a feasible option for many well-known surgeons all over the world, especially those with an affinity for biological dentistry, which I predict will become a new megatrend in dentistry in the future. Prof. Ghanaati also states that we dentists need to put an increasing focus on biology in dentistry. ISMI is an organisation which not only ad- 58 implants 1 2020

| interview Ceramic implantology in Europe Initiating change and creating synergies In 2018, the European Academy of Ceramic Implantology (EACim) was founded to help promote advancements in ceramic implantology in Europe. In this inter- view with ceramic implants, EACim President Dr Giancarlo Bianca elaborates on the need for an additional expert society dedicated to zirconia implants. Dr Bianca, thank you for your time. In 2018, you and your colleagues founded the EACim. As President of one of the most ambitious projects in recent ceramic implants initiatives, can you tell us what the EACim stands for and what its goals are? Implantology is a European innovation and the ceramic implant has been European ever since its development by Prof. Sami Sandhaus in 1968 and since its current evolution of the zirconia implant. We, the six founding members of this European academy, are private prac- titioners, teachers or lecturers with at least ten years of experience in the practice of zirconia implants. Our ob- jectives are to develop clinical research and to share experiences with as many as possible of those colleagues who are interested in and who wish to practise ceramic oral implantology. We wish to be able to influence the in- dustrial development of these products and to create confraternal links between practitioners from different European countries, with ambassadors in each of them to help federate the whole academy. These objectives will be based on three devel- opmental axes: (1) training through congresses, workshops, universities or private teaching in ceramic implantology as an alternative to titanium; (2) the sharing of our clinical experiences in order to evaluate current zirconia implant systems or influence those in develop- ment, so that the voices of clinicians can be heard by the industrialists involved in research and development; and (3) the initiation of multicentre clinical studies. 1 Fig. 1: From left: Dr Simon Tordjman (EACim Vice President), Dr Philippe Duchatelard (EACim Partnership Manager), Dr Fabrice Baudot (EACim Scientific Leader), Dr Stéphanie Gouiran (EACim Treasurer), Dr Franz-Jochen Mellinghoff (EACim Ambassador for Germany), Dr Pascal Eppe (EACim Secretary), Dr Giancarlo Bianca (EACim President) and Dr Pascal Valentini (EACim Honorary President). 60 implants 1 2020

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| news Change in leadership at SDS Swiss Dental Solutions In late 2019, the dental implant manufacturing company SDS Swiss Dental Solutions was merged with the SWISS BIOHEALTH CLINIC to form the SWISS BIOHEALTH GROUP. Against this back- drop, Dr Karl Ulrich Volz handed over his management duties to Joachim Amann, who had previously been active as Regional Sales Manager for Straumann, and who will now serve as CEO of SDS Swiss Dental Solutions, starting at the beginning of 2020. Accord- ing to Dr Volz, Joachim Amann will “[…] use his professional skills to bring the crucial areas of marketing and sales to peak perfor- mance.” In addition, this change in leadership will allow Volz to The key to a healthier life Starts in your mouth American health professionals are beginning to discover what their European counterparts have long understood: Many common chronic conditions—obesity, stroke, diabetes, Alzheimer’s, heart disease, cancer, among others—often have their origins in the mouth. In a groundbreaking new work, German dentist Dr Dominik Nischwitz presents the principles of biological dentistry along with emerging scientific research on the mouth’s vital role in the body’s microbiome—a key to whole body wellness. Challenging conven- tional dental wisdom that teeth are separate from the rest of the body, and conventional dental practices that often cause more harm than good, It’s All in Your Mouth delivers the latest research about the microbiome and the mouth, critical information on the dangers of root canals and amalgam filling, the important role of nutrition in oral health and hygiene, and a clarion call for a new ap- proach to dentistry. Sensible, holistic, and humane, It’s All in Your Mouth presents a necessary new approach to natural immunity to chronic disease and integrating dental hygiene with whole body wellness. The book was published in the US on 18 March 2020. focus more strongly on his personal strengths, which include up to twenty immediate implant surgeries each day, lecturing activities around the globe, considerable research efforts, and publishing endeavours. Amann commented in an interview with the German language news outlet ZWP online: “[…] we are looking to expand the reach of our SDS zirconia implants and our SWISS BIOHEALTH CONCEPT on both a national and an international level.” For more information, go to www.swissdentalsolutions.com. Source: SDS Swiss Dental Solutions Source: Chelsea Green Publishing Zeramex Expert Days 2020 An event “Made in Switzerland” Do I need to offer ceramic implants at my practice? How do they tie in with the strategy at my practice? What are the benefits for my patients? If these are the kind of question you ask yourself, then the Zeramex Expert Days, to take place on 20 and 21 November 2020, are perfect for you. Meet experienced users and learn about the benefits of Zeramex implants. At Dentalpoint, we are committed to identifying the shortcomings of ceramic implants, so that we can develop the Zeramex implant system as a unique and metal-free system. Our team will show you the capabilities of Zeramex, new features of the system, and exactly what lies at the heart of our success: our in-house manufacturing that uses the latest technologies and meets the highest quality standards. We have also arranged the perfect end to your visit to our headquarters in Spreitenbach—a cosy evening of typical Swiss ambience and local cuisine. For more information, go to www.zeramex.com. Source: Dentalpoint/Zeramex 64 implants 1 2020

| about the publisher Congresses, courses and symposia Imprint Publisher Torsten R. Oemus oemus@oemus-media.de CEO Ingolf Döbbecke doebbecke@oemus-media.de Members of the Board Jürgen Isbaner isbaner@oemus-media.de Lutz V. Hiller hiller@oemus-media.de Editorial Council Dr Michael Gahlert (Germany) Dr Sofi a Karapataki (Greece) Dr Franz-Jochen Mellinghoff (Germany) Editorial Manager Georg Isbaner g.isbaner@oemus-media.de Editorial Offi ce Johannes Liebsch j.liebsch@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 Sandra Ehnert s.ehnert@oemus-media.de Theresa Weise t.weise@oemus-media.de Customer Service Marius Mezger m.mezger@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 www.oemus.com EAO Congress 2020 8–10 October 2020 Berlin, Germany www.eao.org 50th DGZI International Annual Congress— Visions in Implantology 6–7 November 2020 Bremen, Germany www.dgzi-jahreskongress.de 2nd EACim Congress 16–17 April 2021 Brussels, Belgium www.eacim-ceramic-implantology.com Copyright Regulations ceramic implants international magazine of ceramic implant technology is issued twice per year and is a special edition of implants international magazine of oral implantology — the fi rst issue was published in October 2017. 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 res- ponsibility 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 labelled items shall not be borne by the editorial department. Likewise, no responsibility shall be assumed for in- formation 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. 6th Annual Meeting of ISMI 7–8 May 2021 Düsseldorf, Germany www.ismi-meeting.com 66 implants 1 2020

ZIRCONIA IMPLANTS BENEFITS Natural white color Biocompatible material No ion release www.tavdental.com