ceramic implants - international magazine of ceramic implant technology No. 2, 2020

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editorial | Prof. Michael Gahlert Specialist in oral surgery and ceramic implantology A beautiful smile— long-lasting and natural-looking Cosmetically, a great deal can be concealed nowadays. However, what about sustainability? Have we as dental professionals not made the attempt to achieve restitutio ad integrum our highest goal? In oral surgery, this ap- plies above all to the difﬁcile rehabilitation of tooth gaps in the anterior area, which has unfavourable anatomi- cal conditions for single-tooth restorations with dental implants. This so-called restoration of the original form and func- tion is challenging and can only be achieved through compromise, tricks and superior clinical expertise. To this end, we use materials that today promise high bio- compatibility, and it is at this very point that the wheat is separated from the chaff. What was considered highly biocompatible yesterday is already being critically ex- amined and called into question today. Consider how often, for instance, autologous bone grafting materials are scrutinised at prestigious conferences, whereas in contrast, artiﬁcial biomaterials only backed by sparse long-term results are being marketed. Unlike industrially produced biomaterials, there is no lobby for autologous bone grafting materials, although they have proved to be clinically reliable for decades. In modern-day implantology, tooth-coloured ceramic im- plants made of zirconium dioxide—zirconia—are consid- ered a viable alternative to established titanium implants when it comes to the replacement of teeth in the aesthetic zone. A 2018 meta-analysis by Roehling et al. concludes that these ceramic implants show a higher biocompatibil- ity in terms of plaque afﬁnity and soft-tissue healing and that peri-implantitis occurs signiﬁcantly less around these implants, as opposed to comparable titanium implants. If we were to expand the sound evidence base with more data, we would have made a small—or perhaps even a giant—leap forwards in terms of the development of bio- materials. We would then also be one step closer to imitat- ing nature in a sustainable manner and achieving restitutio ad integrum, at least in a cosmetic sense. I therefore urge you to stay critical and judge what is new always with a view to scientiﬁc evidence. This is the only way we will be able to debunk many of the fairy tales that have established themselves within our profession. With this in mind, I wish you an exciting read with this new issue of ceramic implants—international magazine of ceramic implant technology. Yours, Prof. Michael Gahlert implants 2 2020 03

| content Cover image courtesy of CAMLOG Biotechnologies GmbH www.camlog.com issn 1868-3207 Sondernummer • Vol. 4 • Issue 2/2020 2/20 ceramic implants international magazine of ceramic implant technology research Biological GBR and ceramic implants industry Age-friendly implants interview Laser-assisted prophylaxis around zirconia implants 04 implants 2 2020 editorial A beautiful smile—long-lasting and natural-looking Prof. Michael Gahlert research Clinical application of zirconia implants Dr Elisabeth Jacobi-Gresser page 06 Silent inﬂ ammation in the jaw and neurological dysregulation Dr Johann Lechner 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 overview Zirconium-dioxide as preferred material for dental implants Profs. Curd M. L. Bollen & Maher Al-Masri page 30 case report Single-tooth restoration using an all-ceramic implant solution Dr Thomas Mehnert Ceramic versus titanium implants Drs Simion Bran, Manea Avram, Onisor Gligor Florin, Horia Opris, Gabrial Armencea & Mihael Baciut Ceramic implants: an alternative or a primary choice? Dr Riccardo Scaringi, Dario Viera & Dr Michele Nannelli industry Age-friendly implants Dr Franco Giancola page 54 Ceramic implants—where do we stand? Dr Pooja Nair New ZrO2 touch by EACim bur kit Dr Philippe Duchatelard interview Dental implants rethought Laser-assisted prophylaxis around zirconia implants events Foundations for the future laid at members’ meeting of ISMI news manufacturer news news about the publisher imprint 03 06 14 16 20 24 28 30 36 40 42 50 52 54 44 56 58

| research Clinical application of zirconia implants Results from comparative studies Dr Elisabeth Jacobi-Gresser, Germany Since the market entry at the end of the 1990s, the number of inserted zirconium oxide implants has been steadily increasing. Today, however, they constitute only an estimated 3 to 5 % of all inserted implants worldwide. Market analyses predict a significant rise in the coming years (Dental Implants Market Research Report 2017). This trend is due to the increasing confidence in the ma- terial zirconium oxide, the evolution from one-piece to two-piece configuration, as well as optimised abutment connections on ceramic implants. Compared to titanium implants, one-piece zirconium ox- ide implants have shown equally good results in clinical studies with regard to osseointegration. In addition, they have obvious advantages in terms of soft-tissue accep- tance. Titanium and zirconium both belong to the group of transition metals in the periodic table of elements. However, the physicochemical properties of these two metals and their oxides differ significantly. While titanium inside of a biological system is subject to tribocorrosion and subsequently triggers immunological reactions, the completely oxidised and sintered material zirconium di- oxide is characterised by excellent corrosion resistance and therefore has a high biological compatibility.11, 19 In a meta-analysis on titanium implants, the weighted av- erage for the occurrence of mucositis was 43 % and for peri-implantitis it was 22 %.9 There is a correlation be- tween peri-implantitis and a reduced implant function time. The success rate of zirconium oxide implants of the younger generation is comparable to that of titanium implants.2, 15, 24, 26 For one-piece implants made of alu- mina toughened zirconia (ATZ), the three-year success rate is 98.5 % and five-year success rate is 94.3 %. The seven- year success rate for one-piece implants made of yttria- stabilised zirconia (Y-TZP) is 88.6 %. The occur- rence of fractures is generally rare, but it is observed with Y-TZP implants of the first generation owing to the use of diameter-reduced implants, aggressive surface treat- ment (aluminium powder blasting) during production, in- correct loading with an unfavourable implant-crown axis, occlusal overload, and bruxism.29 The availability of two-piece implants made of the more durable ATZ ceramics for ten years now extends the range of indications and facilitates clinical application. These factors contribute significantly to the further rise of ceramic implants and it is expected that they will be used even more strongly in the future. In addition to the advan- tages in the aesthetic zone owing to the white colour, the relatively low biofilm adhesion, as shown in in vitro and in vivo studies, and the higher corrosion resistance com- pared to titanium are emphasised in the literature.1, 5, 25, 26, 19 The aesthetic advantages that the implant material zirco- nium oxide has over titanium, especially in the anterior aesthetic zone, are particularly evident in patients with thin gingiva of less than 2 mm (Figs. 1 & 2).32 1 2 Figs. 1 & 2: Aesthetic advantages of the implant material zirconium oxide (region #22) compared with the titanium-based material. 06 implants 2 2020

| research ) m m ( s h t p e d s u c u s l 8 6 4 2 0 3 4 titanium zirconium vital Fig. 3: Microbial load around a titanium implant in a patient with peri-implantitis. Fig. 4: The sulcus depths of titanium implants differ in a statistically significant way from the ones of zirconium oxide implants (p = 0.03). The average value of titanium implants is 2.3 mm, whereas the average value of zirconium oxide implants is at 1.8 mm (personal and unpublished data). Possible effects of titanium implants Comparative studies have examined the toxicologi- cal effects of nano-/microparticle load in tissues in ad- dition to immunological-inflammatory parameters. They found increased formation of free radicals (ROS) in tita- nium particles compared to zirconium oxide particles.19 Lipopolysaccharides (LPS) in bacterial membranes of periodontal-pathogenic germs and titanium particles stimulate inflammasomes in macrophages, resulting in a release of the pro-inflammatory cytokine interleukin-1. The stimulation effect by titanium particles was enhanced in LPS-exposed (Aa, Pg, e.coli) macrophages. Titanium ions alone do not affect the transcription of inflam- masomes. The amount of titanium found in peri- implant tissues was enough to stimulate the release of IL-1b in vitro.22, 23 Microbial adhesion in the oral cavity addition- ally promotes the corrosion tendency on titanium implant surfaces. This milieu-altering microbial influence by peri- odontal early colonisers is reflected in the development of mucositis and peri-implantitis. It also triggers surface corrosion on the titanium implant which, in turn, leads to an increase in metal deposits (Fig. 3).30 As a consequence, the microbiome shifts from the “healthy” diversified to a pathological and less diversi- fied germ load. The correlation between the amount of titanium corrosion products in the peri-implant tissue and the presence of peri-implantitis has been proven. The amount of particles found in inflamed peri-implant tissue was eight times higher compared to the tissue around “healthy” implants, which had no or only a low particle load. The authors argue that these findings con- firm the correlation between corrosion products and peri- implantitis and that they also confirm the role of corrosion products in modifying the peri-implant microbial struc- ture and diversity.7, 28 An evaluation of various inflamma- tion markers in the tissue around implant healing caps made of titanium compared with zirconium oxide re- vealed that there is significantly higher evidence of in- flammation when titanium is used in relation to all markers investigated.8 Significantly increased systemic markers for “silent inflammatory” processes were also found in patients with grade V titanium implants (titanium alloy TiAl6V4), which had been in situ for more than ten years in combination with amalgam fillings, compared with the control group with neither implants nor fillings and also with the patient group who had amalgam fillings but no implants.18 Histopathological examinations of rare oral soft- and hard-tissue pathologies associated with ti- tanium implants show an increased particle load.21 In the various extra- and intraosseous tissue lesions (with the exception of the traumatic bone cyst and the intra- osseous metastasis of a renal carcinoma) an increased titanium particle load associated with inflammatory pro- cesses was found in 52.9 % of the 68 cases. The ques- tion arises whether these titanium particles could be involved in the development of these lesions as a pro- moting aetiological factor. Clinically stable peri-implant tissue conditions around zirconia Preclinical and clinical studies on periodontological pa- rameters around “healthy” titanium and zirconium im- plants have shown that there are statistically significant differences with regard to sulcus depths.16 The values prove to be higher for titanium implants than for zirco- nium oxide implants both in animals as well as in humans. As experience shows, sulcus probing on zirconium im- plants is more difficult owing to the dense fibrous tissue structure (Fig. 4). More than ten years of clinical experi- ence confirm the stable peri-implant soft-tissue condi- tions and the lower incidence of peri-implantitis, which can develop if adhesive residues remain after abutment and crown fixation or if titanium particles remain in the tissue after loss of a titanium implant and re- implantation of a zirconium oxide implant in the same site or in close proximity (Figs. 5–7). Comparative analyses of the struc- ture and the purity of ceramic implant surfaces were done on various Y-TZP and ATZ implants, which showed that all systems differ in their surface morphology and 08 implants 2 2020

The new standard for dental implants The Patent™ Dental Implant System is made of zirconia with a hydrophilic surface and metal free prosthetics. Patent™ is the only two-piece implant system with peer-reviewed long term clinical research1. Based on our demonstrated excellent results, we offer a lifetime guarantee. Clinical Training 2020 – 16th / 17th October, 2020, Innsbruck – 13th / 14th November, 2020, Bad Tölz – 27th / 28th November, 2020, Stuttgart – 04th / 05th December, 2020, Filderstadt Come see for yourself, register here: www.zircon-medical.com Zircon Medical Management AG, Switzerland 1 Becker J, John G, Becker K, Mainusch S, Diedrichs G, Schwarz F. Clinical performance of two-piece zirconium implants in the posterior mandible and maxilla: a prospective cohort study over 2 years. Clin. Oral Impl. Res. 28, 2017, 29–35 doi: 10.1111/clr.12610

| research 5 6 7 8 Figs. 5–7: Stabile peri-implant bone situations over the course of eight years. Fig. 8: Tissue collection at implant uncovering. none of them show any impurities that could cause un- desired adverse immunological reactions.4 In dynamic load tests and tests on the hydrothermal ageing of ATZ implants, high fracture resistance (> 1,100 N), low expan- sion of the monoclinic phase layer on the surface and no change in surface roughness were found.31 Histological and photometric tissue analyses In a pilot study on initially 43 tissue samples around two- piece ATZ implants, analyses were carried out with re- gard to the particle load in the tissue and correspond- ing inflammatory reactions. The tissue samples were collected at the uncovering of two-piece ZrO2 implants ( Zeramex® T implants, Dentalpoint; alumina- toughened 9 10 Fig. 9: Zirconium oxide particles are equally distributed in the peri-implant tissue (200 x magnification). Fig. 10: Titanium oxide particles in the tissue (200 x magnification). Element Weight % Atomic % C N O Al 54.41 18.93 26.21 0.17 60.14 17.94 21.75 0.08 Table 1: EDS analysis: control group without implants, aluminium detection in oral tissue. 10 implants 2 2020 zirconia = ZrO2 76 %, Al2O3 20 %, Y2O3 4 %) three to four months after implant insertion. Until today, more than 200 samples have been histologically and photo- metrically examined in another study (Fig. 8).14 The bi- opsies were fixated in 20 % formalin solution and em- bedded in paraffin. The evaluation of the histological preparations was done by the Department of Oral Pa- thology of the University of Buenos Aires (Prof. Daniel G. Olmedo). In all samples a fine-particle material was de- tected, they showed epithelial hyperplasia and dense cell infiltrates without detectable foreign giant cells. The his- tological findings differ from those around titanium im- plants, which show a loose tissue structure, focal accu- mulations of titanium particles of different shape and size with macrophage and lymphocyte infiltrations, as well as a higher number of blood vessels. In addition to various metals detected in the EDS analysis, the accumulation of aluminium is considered conspicuous, which is not only ubiquitously distributed in our environment but is also present in ATZ zirconium oxide ceramics in concentra- tions of up to 20 %. However, small amounts of alumin- ium could also be detected in the tissue of healthy vol- unteers without ATZ implants by means of multi-element analysis (Table 1). The remaining metals detected are for the most part not due to the use of the implant material zirconium oxide, but are relics from earlier dental resto- rations (Figs. 9–11). This could be demonstrated in indi- vidual patient cases. Studies on the corrosion resistance of zirconium oxide To analyse the corrosion resistance and the possible tis- sue load owing to particles released from the zirconium oxide implant surface, ten ATZ test discs were inserted in animals. The peri-implant tissues as well as the control tissues were examined after a period of six months. The test bodies were obtained by cutting them from the orig- inal ATZ implant bodies. Once the obtained tissue sam- ples had been plasma cleaned, they were divided and subjected to histological examination and EDS analysis (evaluation of particles) on the one hand and to multi-

research | Element Weight % C K O K Pd L Pt M Au M Totals 43.33 6.94 3.57 3.50 42.66 100.00 Fig. 11: SEM-EDS analysis (clinical case: evident residues of gold, platinum and palladium detected in tissue sample of patient with preceding year-long metal- ceramic bridge construction). element analysis (ICP-MS) on the other in order to assess the aluminium and zirconium concentrations. In addi- tion to the detected aluminium and zirconium particles between cells, and also intracellularly in macrophages, a significantly higher number of mast cells could be de- tected compared to the control tissues.14 Presumably, the particle debris is due to the test implant surface not being finalised and finished in the way that commercially- available implants usually are by the manufacturers. To clarify this, a similar series of investigations was done with ATZ test discs that had the certified implant surface by the manufacturer. Further histochemical examinations (CD 34, CD 45, VEGF, CD 68) to evaluate immunologi- cal reactions as well as investigations on particle migra- tion from peri-implant tissue around zirconium oxide im- plants into the body and the potential risk for organs are planned. Results of a recent study confirm the different corrosion behaviour of titanium and zirconium oxide sur- faces in animals. Twelve weeks after implantation in the maxillae of mini-pigs, titanium and zirconium deposits SUBSCRIBE NOW! ceramic implants — international magazine of ceramic implant technology issn 1868-3207 Sondernummer • Vol. 4 • Issue 2/2020 2/20 ceramic implants international magazine of ceramic implant technology ceramic implant technology issn 1868-3207 • Vol. 21 • Issue 3/2020 3/20 implants plants international magazine of oral implantology oral implantology Interdisciplinary, transparent & market orientated research Biological GBR and ceramic implants industry Age-friendly implants interview Laser-assisted prophylaxis around zirconia implants industry New zygomatic implant design feature The art of ultra- aesthetic dentistry DGZI Special Onward to new horizons Fax: +49 341 48474-290 I would like to subscribe for the following journals: Last Name , First Name Company  ceramic implants — international magazine of ceramic implant technology 2 issues p.a. % 30* Street, ZIP, City, Country AD ONLINE SUBSCRIPTION HERE www.oemus-shop.de  implants — international magazine of oral implantology 4 issues p.a. % 44* E-mail Terms & Conditions: The subscription may be cancelled in written form without due justiﬁ cation within 14 days of order by contacting OEMUS MEDIA AG, Holbeinstraße 29, 04229 Leipzig, Germany. Dispatching notiﬁ cation in good time will sufﬁ ce. The subscription is automatically extended by another twelve months if it is not cancelled in written form 6 weeks prior to the end of the reference period. Credit Card Number Expiration Date Security Code Stamp * All prices include VAT, shipping and handling. O EM U S M E D I A AG Signature 0 2 / 2 I C Holbeinstraße 29 · 04229 Leipzig · Germany · Phone: +49 341 48474-201 · s.schmehl@oemus-media.de

12 14 16 18 13 17 15 19 Figs. 12–19: Single crown and bridge construction on reversibly screw-retained zirconium oxide implants in situ and radiographic control images after insertion of the definitive prosthetics. were detected in the peri-implant tissue. The tissue load with the corresponding implant materials was twice as high around the titanium implants than around the zir- conium oxide implants. The cytotoxic effects and DNA damage caused by material nanoparticles, which were also measured, were significantly higher for titanium than for zirconium oxide. Literature However, there is currently still a lack of clinical evidence in this regard. As is expected, corresponding scientific studies on zirconium oxide implants to assess their long-term success and the associated biological compli- cations beyond ten years have yet to be completed. contact Conclusion In preclinical and clinical studies, zirconium oxide implants convince with good osseointegration, good material stability, good immunological/toxicological com- patibility, good hard- and soft-tissue stability and con- vincing aesthetic results (Figs. 12–19). Reversible screw- retained two-piece implant systems allow an expansion of the prosthetic indications beyond single-tooth and bridge restorations. In individual cases, hybrid prosthetic constructions with telescopes and locators as connect- ing elements have been realised in the past three years. Author details Dr Elisabeth Jacobi-Gresser c/o GP Dres. Igiel, Knierim und Kollegen Heidesheimer Straße 20 55124 Mainz Germany mail@jacobi-gresser.de www.jacobi-gresser.de 12 implants 2 2020

| research Silent inflammation in the jaw and neurological dysregulation Part one of a two-part article series Literature Dr Johann Lechner, Germany Editorial note: This is the first part of a two-part article series. The second part will be published in issue 1/21 of ceramic implants and will cover further aspects of fatty degenerative osteolysis of the jawbone in relation to a clinical case that is described in the first part. The transition from acute local inflammation after sur- gical removal of third molars to a chronic stage of silent inflammation could be a neglected cause of inexplicable medical symptoms. In this case report, we present an un- usual case of recurrent syncope in a 19-year-old woman, whose 12-month treatment in various clinics, including a wide range of medications, did not lead to an improve- ment in her condition. Background Autonomous dysregulation with poorly defined multi- system disorders often represents a challenging clini- cal situation for doctors.1, 2 With no apparent cause and insufficient research on this increasingly common phe- area 49 48 area 38 39 Fig. 1: Inconspicuous dental panoramic tomogram from December 2009 with no radiological abnormalities in the areas of the surgically removed teeth #18, 28, 38 and 48. The lower line shows the through-transmission alveolar ultrasonography scan; green corresponds to firm, that is, healthy jawbone; red indicates softened jawbone with inflammation potential. 14 implants 2 2020 nomenon, many representations of this form of idiopathic multi-morbidity are often assumed to be of psychogenic origin and pharmacological interventions in the form of psychoactive substances are common.3, 4 A case study from our clinic in Munich in Germany calls for a broader pathogenetic perspective in neurological dysregulation. Here we describe the case of recurrent syncope in an adolescent patient. In view of the unclear aetiology, we connect this case with the phenomenon of avascular and aseptic osteolysis in the jaw, which is also known collec- tively as “silent inflammation”. Case report The 19-year-old patient lost consciousness between two third molar extractions in October and December 2008. In the months that followed, the number of syncope inci- dents increased. After admission to a clinic, she was di- agnosed with postural orthostatic tachycardia syndrome (POTS) and a disorder of the autonomic nervous system. Numerous drugs (for treating adrenal insufficiency, high blood pressure and paroxysmal tachycardia) brought no improvement. After further tests, the patient was dis- charged as a psychological case after one year. After that, it was “normal” for the patient to lose conscious- ness several times a day. She could no longer leave the house unattended, and the syncope resulted in daily falls. From June 2009 to January 2010, a total of ten internal, neurological and psychiatric evaluations were carried out. The diagnosis of POTS and orthostatic hypotension was made repeatedly. In November 2009, the patient was last examined by a specialist in psychiatry and psychothera- peutic medicine, who noted “recurrent falls due to disso- ciation” and noted that the previous diagnosis of POTS from a clinical historical perspective and epileptic events was extremely unlikely or atypical. He recommended the rigorous discussion of the psychosomatic connections and the continuation of the accompanying psychother- apy consultations. Socio-therapeutic care was consid- ered necessary for the 19-year-old because her mobility and safety outdoors and in traffic were severely restricted owing to her frequent syncope episodes.

Materials and methods Diagnosis of silent inflammation in the jaw After the hospitalisation period mentioned, the patient brought a 2D dental panoramic tomogram to our clinic to assess the possibility of chronic inflammatory processes in the tooth and jaw area. This showed no anomalies or indications of silent inflammation or osteolysis in the third molar areas (Fig. 1). In previous publications, we pointed out the insufficient diagnostic presentation of silent in- flammation in the form of fatty degenerative osteolysis of the jawbone (FDOJ).5 2D radiographic technology alone is not suitable for a reliable diagnosis to rule out FDOJ. However, complementary through-transmission alveolar ultrasonography of bone density is suitable for diagnostic imaging of FDOJ.6 Such ultrasonic imaging enables tar- geted detection and, on this basis, treatment of osteo - necrotic and ischemic areas of the medullary alveolar bone.7 Morphology of FDOJ In the FDOJ areas, there is an irregular bone structure with thinned and hollowed cancellous and marrow cavi- ties. Clinically and macroscopically, FDOJ often presents as a fatty lump. The almost complete absence of trabec- ular cancellous bone structure is remarkable. Figure 2 shows an intraoperative FDOJ tissue sample with pre- dominantly fatty transformation and the extent of this FDOJ in the mandibular right retromolar area. Over-activated immune mediators in the osteolytic jawbone In previous studies, we were able to determine a 21-fold increase in RANTES/CCL5 (R/C) expression in 31 FDOJ samples compared with normal control samples (Fig. 3).8 The pathologically altered FDOJ samples from 31 jawbones were obtained from the third molar and retromolar areas. A total of seven cytokines were measured in FDOJ tissue from the FDOJ group (n = 31). The distribution of immune mediators shows the clear prevalence of R/C. The mean value of R/C in the FDOJ samples was 3,810.90 pg/ml. These high R/C values in the FDOJ tissue were observed in all 31 samples. Figure 3 compares the medians of seven cytokines in 19 healthy bone samples (149.9 pg/ml for R/C) with those in 31 FDOJ samples. The fact that the acute cytokines tumour necrosis factor- and inter- leukin-6 are almost absent in the FDOJ samples proves that FDOJ is a chronic, subliminal inflammatory process. FDOJ areas can be defined as osteolytic areas of the jaw with a non-acute but chronic inflammatory burden. Histology of the FDOJ areas The histological evaluation of this patient reads: “Vital, irregular cancellous bone tissue with no signs of active bone reconstruction. In the medullary spaces, there is not only internal bleeding but also moderate, chronic oste- itis. No florid inflammation, no osteomyelitis. The fat cells partially show a myxoid transformation or a vacuolar de- 3,810.9 2a 2b 149,9 11 1.6 20.3 42.2 7.5 92 101 343.1 196.5 731.6 27,6 536 0 500 1,000 1,500 2,000 2,500 3,000 3,500 4,000 4,500 3 Ctrl (n = 19) FDOJ (n = 31) Fig. 2: a) Typical fatty degenerative structure of FDOJ. b) Documentation of the extent of FDOJ in the mandibular right retromolar area with contrast medium intraoperatively, comparable to the case described here. Fig. 3: Comparison of the medians of seven cytokines in 31 FDOJ samples (red) and in 19 samples from healthy jawbone (blue); the inset shows the mandibular left retro- molar area after the FDOJ parts had been removed from the medullary canal. TNF- = tumour necrosis factor-; MCP-1 = monocyte chemoattractant protein-1; IL-8 = interleukin-8; IL-6 = interleukin-6; IL-1ra = interleukin-1 receptor antagonist; FGF-2 = ﬁbroblast growth factor-2. generation of the cytoplasm, which is consistent with tro- phic disorders.” The signs of FDOJ are present, but there is only a moderate inflammatory tendency without the clinical development of osteomyelitis. This histology with the long-term transition from an acute infectious wound to chronic inflammation is characteristic of FDOJ.9 about the author Since 1980, Dr Johann Lechner has been the head of a clinic for holistic dental medicine in Munich. He is a guest lecturer at Capital University of Washington DC, USA, and Beijing University Dental Clinic, China. He holds several medical patents for holistic systemic diagnostics and ultrasonic application in the jaw area. contact Dr Johann Lechner Grünwalder Straße 10 A 81547 Munich Germany Phone: +49 89 6970129 drlechner@aol.com Author details implants 2 2020 15

| research 1a 1c 3a 3b 16 1b 1d 2a 2b Fig. 1: Pre-op panoramic radiograph showing obvious horizontal resorption of the sinus area in the second quadrant (a), intra-oral imaging of region #26 after applying the dome technique (b), post-op control of the implants in the upper and lower jaws after placing fixed temporary restorations (c), post-op CBCT scan of region #26 after a healing phase of six months, displaying a considerable gain of bone (d). Fig. 2: Pre-op panoramic radiograph with distinct horizontal resorption in region #26 (a), post-op control after implant placement and major external sinus floor elevation in region #26 (b). Biological guided bone regeneration and ceramic implants The second of a two-part series Part I Dr Karl Ulrich Volz, Dr Stephanie Vergote, Dr Rebekka Hueber & Dr Josephine Tietje, Switzerland; Dr Tobias Wilck & Prof. Shahram Ghanaati, Germany Editorial note: The first part of this series was published in issue 1/20 of ceramic implants and can be accessed via the QR code to the left. Nowadays, there are still many patients who have lost significant bone volume as a result of tooth extractions and who therefore require bone augmentation mea- sures. In the following second part of the article series Fig. 3: Pre- and post-op CBCT scan of region #26 (a & b), intra-oral images after implant placement and a healing phase of six months (c & d), CBCT images of region #26 showing significant bone growth (e & f), CBCT image showing pronounced bone growth in region #26 (g). 3c 3d 3e 3g 3f

4a 4c 4b 4d 4e Fig. 4: Pre-op CBCT scan (a), intra-op image of regions #17 and 16 after insertion of the osteosynthesis screws (b), post-op panoramic radiograph (c), situa- tion after healing of the bone and implant placement in regions #17 and 16 (d), panoramic radiograph recorded after implant placement in regions #17 and 16 and restoration with long-term temporary restorations (e). “Biological guided bone regeneration and ceramic im- plants”, six further special techniques are discussed with a focus on the use of autologous materials. well-vascularised bone almost completely replaced donor bone after four months (Figs. 3a–g). Further special techniques of biological GBR Dome technique according to Drs Alain Simonpieri and Joseph Choukroun This technique is used for cases of extremely low resid- ual bone. A collagen sponge flattened to form a mem- brane is inserted cranially in a folded state, and the cavity is completely filled with PRF membranes. The folded membrane causes a thin bone layer to form a dome-shaped structure between the two membranes in two weeks, generating a stable cavity, necessary for the filling of the lamellar bone. After a healing phase of four to five months, implantation can then take place in a minimally invasive procedure (Figs. 1a–d). Live donor bone Live donor bone is used when the residual bone height is less than 3 mm or there are large perforations in the alveolar bone (Figs. 2a & b). As this example shows, Tentpole technique according to Dr Tobias Wilck A lateral window in the maxillary sinus is fixed with long screws for osteosynthesis and positioned longitudi- nally in the skull, cranially. In the following example, an umbrella screw was additionally placed according to Dr Markus Schlee (Figs. 4a–e). Osteosynthesis plate as a temporary placeholder This technique can only be used in patients without a titanium intolerance. In the case depicted here, this method was used to compensate for the loss of height caused by peri-implantitis (Figs. 5a–d). The volume was constructed in a procedure using an osteosyn- thesis plate and donor bone, as well as the brushing technique with apical mattress sutures. The open healing GBR concept according to Prof. Shahram Ghanaati The research group of Prof. Ghanaati has developed a standardised concept of low-speed centrifuga- tion, which allows reproducible treatment protocols and clini- cal results. Prof. Ghanaati has managed to show that the com- position and bioactivity of PRF depends on the centrifugal force and that a significantly greater 5a 5c 5b 5d Fig. 5: Pre-op panoramic radiograph (a), intra- oral image after fixation of the osteosynthe- sis plate and bone augmentation in regions #25–27 (b), intra-oral image after placement of a sinus implant into region #26 (c), post-op panoramic radiograph after implant place- ment in the upper and lower jaws (d). implants 2 2020 17

6a 6b 6c 6d 6e 6f 6g 6h Fig. 6: Representative clinical image of the augmentation and implantation using a small titanium mesh after preparation of a full-thickness flap (a), placement of the titanium mesh and fixation according to the virtual planning (b), covering of the titanium mesh with a PRF-loaded collagen matrix (c), a horizontally pressed solid PRF matrix is placed over the loaded collagen matrix (d), two weeks after augmentation, newly formed soft tissue was observable under the mesh (e), seven months after augmentation, the mesh was removed and healthy and thick soft tissue was observable under the mesh (f), preparation of the implantation bed in newly formed bone with good mechanical properties (g), healing abutment four months after implant insertion (h). number of thrombocytes and leucocytes accumulate at a low centrifugal force, thus releasing higher concentra- tions of different growth factors.48–50 This extremely in- teresting, innovative and promising technique elegantly solves the old problem of augmentation coverage with almost complete loss of the keratinised gingiva. The flap is sutured at the basal level and the titanium mesh filled with donor bone is covered only with a collagen membrane and several layers of PRF (low-speed cen- trifugation) membranes. For initial protection, a sterile latex skin is sutured over the PRF. After healing, the tita- nium mesh is exposed and can be easily removed. The special feature of this concept is the keratinised gingiva found in the augmented area (Figs. 6a–h). Khoury layer grafting technique This technique describes distance osteosynthesis with bone chips (Figs. 7a–d). The extension of the alveolar process/crest of the left mandible was obtained by re- moving a bone block from the left linea obliqua. The distance screws were inserted for osteosynthesis at a distance, and the defect was filled with bone chips and EthOss (EthOss Regeneration). The defect was covered with PRF membranes, and tight suture closure followed after mobilisation of the mucosa. After three follow-ups, the mucosa was tightly closed. The healing time will be six months in total. We assume that, after the healing phase, well-vascularised bone will be found. Conclusion In summary, it can be stated that innumerable biolog- ical GBR techniques can be applied. They allow the durable treatment of almost all patient cases. Together with the correct axial positioning of the implant and a prosthetic restoration of lege artis, long-term success depends exclusively on the increased blood supply of the augmented bone (see Mammoto’s law).51 Hence, all of the grafting techniques in this article aim at creating a well-vascularised lamellar de novo bone. contact Literature Author details Dr Karl Ulrich Volz SWISS BIOHEALTH CLINIC Brückenstr. 15 8280 Kreuzlingen Switzerland Phone: +41 71 6782000 www.swiss-biohealth.com 7a 7c 7b 7d Fig. 7: Intra-oral image of the obviously resorbed alveolar bone in regions #37–33 (a), situation after separation of the cortical plates (b), intra-oral image after horizontal augmentation of the jawbone using Khoury plates (c), coverage of the augmented bone with PRF membranes (d). 18 implants 2 2020

| overview © MStock – stock.adobe.com Zirconium-dioxide as preferred material for dental implants A narrative review: Part II 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) Part I Editorial note: This is the second of a two-part article series. The first part, involving an introduction, a historical context and a chapter on composi- tion, was published earlier this year in the 1/20 issue of ceramic implants. It may be accessed as an online version by scanning the QR code to the left. Titanium type IV Y-TZP Density (g/cm3) 4.5 6.05 Hardness (HV) 250 1,100–1,500 Strength (MP) 680 Elasticity (gp) 110 1,200 200–220 Table 1: Comparison between titanium type IV and yttria-stabilised tetra- gonal zirconia polycrystal (Y-TZP). Characteristics Zirconia has several other interesting characteristics what makes it an ideal product to apply in dentistry, not only for crowns, but also for dental implants and implant abut- ments. General The dental implant company Straumann® made an in- ternal comparison between their SLA-titanium (sand- blasted large-grit acid-etched) implant and their ZLA-zir- conia (SLA but on zirconia) implant. Their data showed significantly better properties for the zirconia implants (Table 1). Whereas alumina-oxide was a weak material that often led to fractures of the implants, zirconia tends to be stron- ger than titanium in the most relevant criteria. It is there- fore a very suitable material for the production of dental implants. As mentioned already, zirconia is highly bio- compatible, this is due to the rapid osteoblast adhesion and subsequent cellular proliferation that are responsi- 20 implants 2 2020

ble for an optimal bone–implant interface.9, 10 Biologists thought that these features contrast with titanium, which affects cell viability and induces apoptosis, leading to a reduction in viable osteoblasts and a significant reduc- tion in peri-implant bone quality.11 In addition, zirconia showed no induction of any toxic effect compared to tita- nium. Tests were performed on fibroblasts, lymphocytes, monocytes, macrophages, connective tissues, immuno- logical and bone tissues (Table 2).12, 13 Titanium Zirconia Ion-release/corrosion Y Toxicity Plaque adherence low low N N very low Table 2: Biological comparison between titanium and zirconia. In several studies on intra-oral plaque formation, only cocci and some short rods were found on zirconia sur- faces by dark phase contrast microscopy. Pathogens, such as mobile microorganisms (e.g. Peptostreptococ- cus micros) and spirochetes (e.g. Treponema denticola), were not detected on zirconia surfaces.14 It also appears that the early adhesion and colonisation of bacteria on zirconium surfaces is much more limited than on tita- nium surfaces. Due to these characteristics, we see an extremely good soft-tissue reaction and a rapid healing of the soft tissues around intra-oral zirconia structures.15 Corrosion Titanium is widely used in biomedical devices due to its recognised biocompatibility. However, implant fail- ures and subsequent clinical side effects are still recur- rent.16 Body fluids and relative motion between implant and bone lead to synergistic degradation reactions, which cause failed implantation or adverse tissue re- actions for implant materials used in human body. This was detected for several titanium alloys. This process can induce non-specific immunomodulation and auto- immunity, leading to a proven sensitisation to titanium; it has been suggested that some autoimmune diseases (e.g. multiple sclerosis and rheumatoid arthritis) may be caused by this sensitisation.17 It has been also labelled that up to 6 % of the popula- tion is thought to have an allergic reaction to titanium.18 This form of foreign-body reaction is also progressively associated with the loss of implants (non-integration or rejection) and the phenomenon of peri-implantitis. How- ever, more scientific evidence is certainly needed here.19 All these problems are rarely or not detected at zirco- nia implants.20 overview | Osseointegration Recent studies show little or no difference in the initial osseointegration between titanium and zirconia den- tal implants. However, when looking at this literature, it is clear that there is still a significant lack of long-term studies (randomised controlled trials) on zirconia im- plants.21 When “periodontal integration” (healthy and firm soft tissue vs integrated material contact) is eval- uated, it was described that there is a better fibroblast adhesion to zirconia, leading to a stronger “cuff” for- mation around these implants. This results in reduced pocket depths with a predominantly non-inflammatory environment.22, 23 Ageing At normal room temperature, zirconia is kept in a meta- stable tetragonal phase by the addition of stabilising agents (such as yttria). The ageing of zirconia consists of the return to a more stable monoclinic phase. This transformation takes place on the surface of ceramics of tetragonal zirconia. It has been shown that tetragonal to monoclinic transformation at the surface of zirconium ceramics is promoted by the presence of water mole- cules in the environment (e.g. saliva in the oral cavity). Subjected to an increase in volume, this stress trans- AD Latest 3D ultrasound technology for dentists Illustration of bone density Checking the bone bed before implantation Identification of jawbone cavities Register & Order: shop.cavitau.de CaviTAU® | Gruenwalder Str. 1 | 81547 Munich | Germany Ph. +49 89 244 15 44 60 | F. +49 89 244 15 44 69 www.cavitau.de | office@cavitau.de

| overview formation induces the formation of surface microcracks and therefore an increase in surface roughness. Micro- cracks can lead to a deterioration of the mechanical properties.24, 25 On long-term they can become macro- cracks (chipping). Radioactivity Zirconia implants are slightly radioactive. Radioactivity of the ZrO2 ceramics studied recently showed negligi- ble radionuclide activity that can be considered lower than many hazardous radioactive appliances in our en- vironment.26 While a femoral head of about 100 g yields 0.5 mSv/year, a dental implant ( 2 g) is responsible for a dose of 0.01 mSv/year. By comparison, a transatlantic flight yields 0.16 mSV and the average normal exposure is 2.4 mSv/year. The additional radiation from implants (and crowns) therefore is not really worth mentioning.27 Material/Processing Surface roughness Glazed surface 0.42–0.76 µm Surface finished with diamond burs 0.89 µm Surface finished with diamond burs and polishing 0.49 µm Only polishing 0.17 µm Table 3: Surface roughness of zirconium crowns. Manufacturer Nobel Biocare Straumann Z-Systems Dentalpoint Oral Iceberg Product NobelPearl PURE Ceramic, SNOW Z5m, Z5c, Z5s … ZERAMEX XT, P6 CeraRoot SDS Swiss Dental Solutions SDS1.2, SDS2.2 … bredent TAV Medical CAMLOG ZiBone WhiteSky TAV White CERALOG ZDI 1 Fig. 1: Shimmering titanium in a thin biotype. (© A. Sculean)29 Aesthetics Since titanium can have a greyish shadow and twilight (Fig. 1), zirconia has proven its aesthetic values in im- plant dentistry. Most zirconia implants are available in an A2 colour. This gives them a significant advan- tage in patients with a thin biotype.28 Implant compa- nies hope to produce zirconia implants in more differ- ent white shades, adapted to the patient tooth colour, in the near future. Surface roughness Quirynen & Bollen found that 0.2 µm is the threshold sur- face roughness for microbial adhesion: an equal or lower surface roughness does not give any additional decrease nor increase in plaque growth, while a higher surface roughness is clearly linked to more plaque adhesion.30 Several recent studies focus on the surface roughness of zirconia crowns in the oral cavity. When the surface roughness of crowns is investigated, the different fin- ishing protocols determine the final roughness (i.e. the plaque retention potential; Table 3).31, 32 The surface roughness of zirconium abutments is be- tween 0.2 and 0.3 µm.33 For zirconia implants, there is a difference between the screw section (1.2–1.6 µm) and the collar (0.3 µm). The smooth collar prevents plaque ad- hesion and stimulates periointegration, while the rougher surface of the screw section promotes osseointegration.34 Surface free energy The surface free energy of titanium is much higher than that of zirconia, so therefore more bacterial adhesion can be detected on titanium surfaces compared to zirconia surfaces.35, 36 Market Further companies include: VITA, WITAR, FairImplant, Medical Instinct, Champions … Table 4: Main products on the zirconia implant market. There are several international companies in the market that produce or sell zirconia dental implants (Table 4). However, only a limited number of these companies/ 22 implants 2 2020

overview | products can show peer-reviewed research associated with their products. Mostly, in vitro studies or case pre- sentations are available. Future perspectives The field for dental implants is constantly evolving. An implant that fits directly into a fresh extraction cavity may well be the future solution. There are currently more than 250 implant companies producing thousands of different implant types, all of which unfortunately do not fit per- fectly into the bone cavity after extraction. Extraction and direct implantation with a perfect fitting implant could be the future. BioImplant® (FACE YOUR FACE) is a dental implant specially designed for immediate implantation after ex- traction. It is fundamentally different from screw-type implants and can in no way be compared to them. The extracted root is scanned and moulded in zirconia: a copy of the lost root(s). The implant fits exactly into the tooth socket and therefore does not require operations such as grafts, augmentations with autologous/xenol- ogous/synthetic bone. Eventually some PRP/L-PRF could be applied additionally. Only the periodontal lig- ament is removed, but never the bone. Since there is no surgical procedure (the implant is inserted into the tooth socket), there are no complicated guidelines to fol- low. Drill guides, bone replacements, membranes, and product-specific surgical sets and drilling sequences are therefore not applicable. BioImplant® is a one-piece implant, adapted in shape and colour to the patient’s in- dividual tooth, both single and multiple rooted. The pre- fabricated stump can be grinded at any time in the same way as a natural tooth.37 This evolution in dentistry may be the necessary push to help turn current implant den- tistry into a “white and metal-free” discipline.38 Discussion Will titanium soon be completely replaced by zirconia as the implant material of choice? Probably not! The material has still many advantages: cheap and simple production making the implants economically “affordable”, a huge volume of scientific publications over a period of more than 50 years and numerous specific designs of screws for various indications. That’s why titanium will certainly remain the gold standard as an implant material for the next decade. Therefore, it is legitimate to conclude this narrative re- view with the question: Is zirconia just a temporary “eco- logical” hype? We believe it is certainly not. We consider there is a clear niche for zirconia implants that is likely to grow further once the material is fully developed, espe- cially for aesthetic reconstructions in the anterior region (in patients with a thin gingival biotype); for gingival re- cessions where a white coloured implant is a great ad- vantage; for patients with a proven titanium allergy (con- firmed by an ELISA-test); and for patients who prefer a complete bio-holistic/metal-free dental approach, ex- cluding (tribo-)corrosion and conduction of temperature or radiation by metals. Having reviewed all the above, further research is cer- tainly required to enlarge our understanding of these dif- ferent materials and their applications. Three themes in particular need further to be explored: firstly, how “unde- sirable” the use of titanium as a dental implant material is for the general health; secondly, what the correlation is between the corrosion of titanium and the development of peri-implantitis; and thirdly, what the long-term clinical results of zirconia are as an implant material. 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 implants 2 2020 23

| case report Single-tooth restoration using an all-ceramic implant solution Inserting a two-piece implant in the anterior region Dr Thomas Mehnert, Germany The latest generation of two-piece ceramic implants (zirconia) is considered an alternative treatment option to titanium implants owing to their excellent biological and material properties.1–11 Their handling and workflow now meet the requirements of modern implantology.12 In the following, a clinical case is described to demonstrate the use of a two-piece ceramic implant. Clinical case A 40-year-old female patient presented to our dental sur- gery with an irreparable tooth #21 (Fig. 1). The periapical radiograph revealed an approximately 7 mm periapical translucency with widening of the periodontal ligament in the upper third of the root (Fig. 2). Owing to the clinical conditions (high smile line and good oral hygiene), we de- cided to use a two-piece ceramic implant, ZERAMEX XT (Dentalpoint). Surgical phase After extraction of tooth #21, the apical granulation tissue was excochleated through a semilunar incision (Fig. 3). A two-stage procedure was performed to prevent failure of osseointegration of the ceramic implant and to preserve the soft-tissue structures (papillae and attached gingiva). A claspless prosthesis made from Valplast (Valplast In- ternational) served as a temporary restoration. The im- plant site in region #21 was uncovered after five months (Fig. 4). A two-piece ceramic implant (diameter: 4.2 mm; 1 2 3 4 5a 5b 6a 6b Fig. 1: Initial clinical situation. Fig. 2: Initial radiographic examination. Fig. 3: After the extraction, the apical granulation tissue was excochleated. Fig. 4: The im- plant site was uncovered after five months. Figs. 5a & b: A two-piece ceramic implant was inserted. Figs. 6a & b: Transversal bone augmentation was performed. 24 implants 2 2020

case report | length: 12.0 mm) was then inserted (Figs. 5a & b). The guidelines for implant placement in the aesthetic zone and the drilling procedure specified by the manufacturer were observed.13, 14 Both vertical and transverse insertion depth are decisive for prosthetic success. The implant can be placed between 1.6 mm and 0.6 mm supracre- stally because of a special thermal etching procedure in the collar region; the insertion depth is determined by the gingival height and the existing bone of the adjacent teeth. The implant positioning should be approximately 2–3 mm subgingivally because the abutments are added 1 mm above implant shoulder level. Transversal bone augmentation was performed with a mixture of autoge- nous bone chips (retrieved from the retromolar mandi- ble), xenograft (Geistlich Bio-Oss, Geistlich Biomaterials) and guided bone regeneration (Jason membrane, botiss biomaterials; Figs. 6a & b). The exposure was performed after four months using a PEEK gingiva former (Fig. 7). Prosthetic phase A provisional crown made of GRADIA (GC), a microce- ramic composite, was fabricated to achieve optimum con- touring of the marginal gingiva in the highly aesthetic zone. A PEEK abutment (ZERAMEX Provisional RB; 180-day maximum period of wear), with a screw (maximum torque of 15 Ncm), acted as the base for the long-term tempo- rary restoration (Figs. 8a & b). After eight weeks and ad- justing the long-term temporary restoration in the basal area twice to optimise the emergence profile, the defin- itive zirconia crown (Ceramill substructure, Amann Girr- bach; Creation veneer) was fixed to the customised abut- ment made of alumina-toughened zirconia (Figs. 9 & 10). After exact positioning (checked by probing or by taking a radiograph) the abutment is firmly fixed by utilising the VICARBO screw which is part of the ZERAMEX system. This unique screw made of carbon fibre-reinforced high- performance polymer is tightened to a torque of 25 Ncm. The final result is shown in Figure 11. The examinations after six and 12 months found no irritation of the soft tis- sue, and the BOI test was negative. The pink aesthetic score according to Fürhauser was 12 out of a maximum of 14 points (Figs. 12a & b).15 The process of peri-implant bone remodelling was of particular interest. Examinations were performed with periapical radiographs (right angle technique) and DBSWIN software (Dürr Dental). Bone resorption was detected six months after exposure (mesial bone: 0.6 mm; distal bone: 0.4 mm), and a gain of bone was observed 12 months after exposure (mesial bone: 0.0 mm; distal bone: 0.3 mm; Figs. 13a–c). In ac- cordance with the findings in the relevant literature, bone resorption in our patient was the greatest in the first six months.16 However, the literature findings are in reference to one-piece ceramic implants, in contrast to the two- piece implant system used in this case. This phenomenon of bone resorption is a relatively rare occurrence in im- plantology and should be confirmed by evidence-based 7 9a 8a 9b 8b 10a 10b Fig. 7: Implant exposure after another four months. Figs. 8a & b: A PEEK abutment as the base for the long-term temporary restoration. Figs. 9a–10b: The definitive zirconia crown was fixed to the customised abutment made of alumina-toughened zirconia. implants 2 2020 25

| case report 11 12a 12b 13a 13b 13c Fig. 11: The final result. Fig. 12: Clinical situation at the examinations after a) six and b) 12 months. Figs. 13a–c: Bone resorption was detected after six months and bone gain after 12 months. The yellow line represents the actual implant length (13.6 mm). The red lines indicate the mesial and distal distances from the top of the implant to the first bone contact. long-term studies before a definitive conclusion can be drawn. Evaluations are in progress. about the author Summary Ceramic implants are a viable alternative to titanium im- plants. Having experienced the advantages of zirconia ce- ramics yourself, you will appreciate them and will never look back. Besides providing the option of metal-free res- torations, they offer a practical addition to the existing range of treatments for many risk groups, taking into account the respective in- dications. I would recommend user training courses for this relatively new, but somewhat different, material. This is a requirement that is increasingly ad- dressed in the literature.12, 17 Literature Acknowledgement: The author would like to thank den- tist Frank van Doorn (Meckenheim in Germany) and master dental technician Jürgen Hopp (Mund Zauber Zahntechnik in Meckenheim) for their kind support in the field of prosthetics. Cologne-based Dr Thomas Mehnert is a specialist in maxillofacial sur- gery, implantology and plastic surgery. He studied dentistry at the Friedrich Schiller University Jena and medicine at the Dresden University Hospital “Carl Gustav Carus”, both in Germany. In 1992, he began practising privately in Cologne in Germany. Dr Mehnert is a member of various professional associations, including the European Society of Ceramic Implantology. contact Dr Thomas Mehnert Praxis Mehnert/Stember Neumarkt 36–38 50667 Cologne Germany Phone: +49 221 2577221 www.mehnert-stember.de Author details 26 implants 2 2020

ONLINE COURSE with Dr. Ulrich Volz CERAMIC IMPLANTS AND BIOLOGICAL DENTISTRY Learning Contents Ceramics is easier – but diﬀerent. Today we are able to set more than 85% of SDS implants immediately (imme- diate implantation and immediate restoration with long- lasting temporary restorations). This requires a special protocol and the corresponding training. In this online- course, we will provide you the perfect introduction to the biological dentistry and ceramic implantology and explain the main diﬀerences from titanium implants. We have learned to think in ceramics. You too can proﬁt from the expertise of SDS company owner and director of SWISS BIOHEALTH CLINIC, Dr. Ulrich Volz. Special treatment protocols have been developed from our 20 years of experience and the 20,000 ceramic implants which have been set to date. No matter whether it is the surgical ALL-IN-ONE concept or the SWISS BIOHEALTH CONCEPT that is redeﬁning biological dentistry – all treatment steps have been carefully developed by users for users and are being put to use and optimized further on a daily basis at SWISS BIOHEALTH CLINIC. Introduction to biological dentistry • • Treatment sequences and algorithms according to biological-immunological criteria • The SWISS BIOHEALTH CONCEPT • Thinking in ceramics: the special properties of zirconium oxide • Product overview: which implants in which situa- tion? • Biological Implant forms and prosthetics on SDS implants • The SCC short-cut and all-in-one concepts acc. to Dr. Volz: The Holy Grail of implantology • Before / after documentation, incl. patient testimonials 53 Chapters / 680 minutes • The Online course is in english and gives you access to the learning content optimized for e-learning that you can watch through as often as you want. You can stop the course at any time and continue watching it at a later time or rewind it. There is no time limit. SWISS BIOHEALTH® EDUCATION Register now: www.swiss-biohealth-education.com SDS Swiss Dental Solutions AG Konstanzerstrasse 11 CH-8280 Kreuzlingen www.swissdentalsolutions.com

| case report Ceramic versus titanium implants Three-year follow-up and a split mouth study Drs Simion Bran, Manea Avram, Onisor Gligor Florin, Horia Opris, Gabrial Armencea & Mihael Baciut, Romania In this study, we followed up the comparative tissue re- action to titanium dental implants versus ceramic dental implants. Both types of dental implants used were mainly those produced by TAV Dental. Only two-piece dental implants were used in this research. The following pa- rameters were evaluated in each step of the procedures: quality of the prosthetic attachment, gingival attachment, dental plaque adherence, and primary and secondary stability. In all of these cases, implant uncovering and prosthetic loading were done ten weeks after implanta- tion. In the two cases described here, there were no ob- servable complications after implant insertion. The two cases The patient of the first case described had four zirconia dental implants (TAV Dental) inserted in the right side of the maxilla. These implants were 4.2 mm in diameter and 10.0 mm in length. In the left side of the maxilla, she had two titanium implants (Silhouette, TAV Dental) inserted. These implants were 3.75 mm in diameter and 10.00 mm in length. Loading was performed ten weeks after im- plantation. At that point, no inflammation at soft-tissue level was observed and there was perfect gingival at- tachment (Figs. 1–3). The patient of the second case described had two zir- conia implants (TAV Dental) inserted in the left maxilla. These were first-generation implants with a diameter of 4.2 mm and a length of 12.0 mm. In the mandible, titanium dental implants (Biomicron) of 3.75 mm in diameter and 10.00 mm in length had been inserted and functioned for a total of 14 years. A radiograph was taken at ten weeks after uncovering and loading. The impression was done by means of the open-tray technique. The patient re- ceived a metal-ceramic prosthetic build-up. Mechanical failure of a titanium implant occurred after 14 years of function and 2.5 years after loading of the zirconia im- plants (Figs. 4–7). Findings In our three-year follow-up of the cases presented, we found that the gingival attachment was better for the zir- conia implants than for the titanium ones. Also, the in- flammatory response was better for the zirconia implants. There was less peri-implantitis and less bone loss for the duration of the follow-up. The osseointegration process 1 2 3a 3b Case 1—Fig. 1: Initial radiograph of the patient with zirconia implants in the right side of the maxilla and titanium implants in the left side. Fig. 2: Ten weeks after implantation. Clinical examination revealed no inflammation at the soft-tissue level and perfect gingival attachment. Fig. 3a: Impression with open-tray technique. Fig. 3b: Final prosthetic result. 28 implants 2 2020

4a 5a 5c 6 5b 5d 4b 7 5e Case 2—Fig. 4a: Radiograph showing the situation after implantation of two zirconia implants in the left maxilla. The mandibular titanium dental implants functioned for a total of 14 years. Fig. 4b: Radiograph at ten weeks after uncovering and loading. Fig. 5a: Uncovering. Fig. 5b: Impression with open-tray technique. Figs. 5c–e: Metal-ceramic prosthetic build-up. Fig. 6: Mechanical failure (fracture) of the titanium implant in region #34 (after 14 years of function) 2.5 years after loading of the zirconia implants. Fig. 7: Clinical intra-oral aspect after the prosthetic restoration of the maxillary right implants and failure of one of the mandibular right implants. of the zirconia dental implants was comparable to that of the titanium implants. Prosthetic loading can be done safely for both types of implants at ten weeks. The me- chanical resistance of the zirconia implants and their su- perstructure was similar to that of the titanium implants. For example, the second case showed failure of one of the titanium dental implants. about the author Dr Simion Bran is an associate profes- sor at the Iuliu Hat¸ieganu University of Medicine and Pharmacy in Cluj-Napoca, Romania. He specialises in maxillofacial and orthognathic surgery with over 20 years of experience. His research in- terests include bone regeneration tech- niques and fundamental science. contact Dr Simion Bran IMOGEN Medical Research Institute Strada Louis Pasteur, FN 400349 Cluj-Napoca Romania Phone: +40 264 296928 Author details implants 2 2020 29

| case report Ceramic implants: an alternative or a primary choice? Clinical aspects and operating procedures Dr Riccardo Scaringi, Dario Viera & Dr Michele Nannelli, Italy Introduction Today, grade 2 titanium is considered the standard mate- rial for prosthetic implant rehabilitation in all situations that may arise in the dental field. The excellent bone integra- tion, good tissue biocompatibility, resistance to corrosion and biomechanical stress mean that titanium implants are an optimal clinical solution, including with regard to the standardisation of surgical protocols that have made it possible to obtain solutions with an acceptable result even in the hands of less experienced practitioners.1 In light of this, one might wonder: what is the reason for us- ing zirconia implants and in what circumstances could they be a primary choice compared to titanium implants? Since the introduction of titanium replacement materials, there has been an evolution in ceramic materials, cul- minating in zirconia, due to its mechanical properties associated with the characteristic biological responses resulting in high biocompatibility and low affinity to bac- terial plaque. Zirconia also offers excellent tissue mime- sis thanks to its whitish colour that simulates the colour of teeth.2 In 1969, Sandhaus was the first to make aluminium oxide (Al2O3) implants;3 in 1974, the Tubingen implant, made of polycrystalline alpha-alumina, was introduced and clini- cally tested.4 Despite the excellent bone integration re- sults, there was the drawback of implant fracture due to factors related to the mechanical properties of alu- mina itself, as it has low bending strength. This problem is largely resolved with the use of zirconia, a material which replaces the values of titanium.5 Long-term success not only requires osseointegration but, above all, an excel- lent response to soft tissue by creating a mucous barrier around the implants in order to develop a kind of seal be- tween the marginal bone and oral cavity. It is well-known that, after implant insertion, the formation of soft tissue around the implant collar is characterised by the gradual transition from a clot to granulation tissue and conse- quently the formation of an epithelial barrier that turns into the maturation of connective tissue.6 Any gaps that may remain between the implant and connective tissue could promote bacterial growth. The epithelial barrier contains Langerhans cells and local immune defence cells.7 The peri-implant epithelium adheres to the implant through hemidesmosomes and internal basal lamina of the lower region of the interface between epithelium and implant, with poor adhesion to the titanium surface.8 The rapid epithelial growth at the expense of the connective tissue generates gaps where the seal is not guaranteed, with consequent bacterial colonisation. In addition, if epithelial growth were to occur along the implant axis during heal- ing, osseointegration would not be adequate, resulting in consequent bone resorption.9 Additional studies were conducted to determine appro- priate surface treatment with regard to implant shape and the possibility of having one-piece or two-piece implants that could obtain comparable data to that obtained for ti- tanium implants.10 The demand for aesthetics in the an- terior regions of single and multiple restorations highlights the disadvantage of having submucosal areas with grey- ish shades that emphasise the need to combine zirco- nia abutments and crowns, allowing greater translucency compared to titanium with metal-ceramic.11, 12 The low ad- hesion of oral cavity bacteria to ceramic surfaces makes their use beneficial, also enhancing the use of zirconia coronal insert implants.13 Yttria-stabilisation of tetragonal zirconia polycrystal (Y-TZP) has made it possible to ob- tain an endosseous implant able to withstand breaking loads sometimes higher than titanium.14 One-piece im- plants were the first to be introduced in clinical practice because of their optimal biological and functional integra- tion and, despite the prosthetic limitations, they are still recommended in implant sections reduced to less than 4.0 mm. Their prosthetic peculiarity means that they are suitable for partial edentulism, even in aesthetic frontal regions and thin biotypes, and in areas where the mas- ticatory load is at its maximum. The strong prosthetic limitation is an important element, especially in cases of interconnection where the disparallelism could generate difficulties in the construction of the primary structure. In fact, the abutments, which are usually represented by a conoid-like geometry or similar, are difficult to treat with diamond drills in the oral cavity because the polycrystal- line structure could undergo stress due to modification of 30 implants 2 2020

case report | 1 3 2 Fig. 1: Pre-surgical situation shows the lack of connective tissue and residual bone atrophy. To be taken into account when comparing the result obtained after completion of the implant restoration. Fig. 2: Representative axial sections of CBCT at sites of surgical interest. Fig. 3: Positioning of the surgical template for correct implant placement in the transverse space and axial direction. the internal lattice, leading to the fracture of the implant itself. In addition, the presence of an abutment limits the regenerative potential of the site and forces the abutment to become exposed, with inevitable immediate, and even indirect, load caused by the movement of the tongue and related to chewing and functional cycles.15 The presence of two-piece zirconia implants represent an evolution compared to one-piece implants, providing the possibility to customise a dedicated abutment or to choose among a range of abutments, which, although limited, provides the clinician with a prosthetic variable which is able to optimise the prosthesis according to aes- thetics and biomechanics. We are fully aware of all the limitations of implant geometries in titanium implants but, above all, we know that the micro-gap generated be- tween implant and abutment leads to a bacterial build-up that causes the soft and hard tissue to suffer.16, 17 This has led some authors to restudy the behaviour of the respec- tive implants, without making substantial notes on the dif- ferences between titanium and zirconia implants for both prosthetic connections.18–20 When analysing two-piece implants, it is important to establish that the abutment can be held within the implant by cementing or screwing. The screw-retained connection is the most common one on the market, can be easily reproduced in the labora- tory and can be made of different materials, ranging from titanium to gold, PEEK and carbon-reinforced PEEK. Al- though not in contact with tissues, in the holistic view, the metal screw does not define the restoration as Total Metal Free (TMF). Carbon-reinforced PEEK is a PEEK (polyether ether ketone) screw reinforced with carbon fibre, having the following characteristics: – Radiotransparent, i.e. not visible on radiographs; – Elasticity modulus > 160 GPa; – Flexural Strength > 1,100 MPa; – Tensile Strength 2,000 MPa; – Biocompatible according to ISO 10993. In terms of intrinsic structure, we find that the carbon fibres have a continuous longitudinal trend at 60 % in- serted in a 40 % PEEK matrix; this promotes adequate stability and high resistance to the stress to which it will be subjected during screwing, in the abutment retention phase and during chewing. Clinical case In the case in question, the female patient ASA 1 presented with edentulous molars in the third quadrant. The patient had already undergone implant-prosthetic rehabilitation with the insertion of two titanium implants which, after a short period of function, began to show pain and bleeding according to the patient. Despite maintenance treatment administered both at home and professionally, the clinical situation did not improve and, after a few months, the pa- tient had to remove the entire implant restoration, resulting in circumferential bone resorption at both implants (Fig. 1). One year after the extraction, we decided to re-examine the edentulous area by subjecting the patient to CBCT (Fig. 2). The diagnostic examination showed vertical bone resorption while maintaining an adequate size for the in- implants 2 2020 31

5 4 6 7 Fig. 4: Selection of the CERALOG zirconia implant (BioHorizons Camlog). The image shows the handpiece mounter in order to control the implant insertion for torque and speed. Fig. 5: Detail of the Hexalobe connection and its representation using a mathematical fi nite element method, showing the reduction of me- chanical stress related to zirconia in the connection cavities. Fig. 6: The need for the residual connective tissue to be preserved has dictated open fl ap surgery, even if with less trauma. Fig. 7: Impression copings according to the tear-off technique using silicone. sertion of two 10 mm implants and leaving adequate safety space from the mandibular canal. The bone quality proved to be D3 type. In our therapeutic protocol, we prefer a dig- ital approach and, where possible, we prefer to produce a surgical template in order to optimise the position between the implants and the antagonists, with a view to optimis- ing the result (Fig. 3). Given the previous implant failure, we have given the patient an alternative in the choice of mate- rials compared to the previous project, offering the possi- bility of performing a Total Metal Free treatment. Evaluat- ing the choice of implant was aimed at making it possible to use a two-piece zirconia implant due to the relative ver- tical dimension present with respect to the antagonists, the abrasion marks on the residual teeth and the relative bone quality. Moreover, during the treatment of a relapse, I believe that any practitioner wants to minimise the risk of another failure. The decision was made to go with a new generation implant with some special features that were suitable for resolving the case. Materials and methods The zirconia implant chosen for the patient is produced by moulding, in contrast to other zirconia implants made 8 10 9 11 Fig. 8: Same view from another angle that amplifi es the view of crowns and abutments. The DEDICAM milling centre is able to make products by confi rming the abutment connections in accordance with the parent company’s protocols. Fig. 9: Full view of the abutments; note the framework beyond the connection that highlights the anatomical shape of the abutment base. Fig. 10: This detail relates the through-hole to the anatomy of 37, while the image on the left, in addition to a numerical reference value, shows the part of the crown and abutment. Fig. 11: Same image, only dedicated to 36, the numerical value shows a larger crown. 32 implants 2 2020

Fig. 12: From this image, it is possible to compare the gain of keratinised tis- sue surrounding the implant collar. You can also see the optimal tissue health which is typical of zirconia implants. Fig. 13: The designed and fabricated abutments are placed on the implants and stabilised with a 15 Ncm torque. The abutments were supplied with titanium fixation screws. Fig. 14: The 12 crowns were housed and cemented using temporary resin cement so as to be able to act over time if necessary. High precision between structures requires special care during the cementation phase because of the thickness that could prevent them from fitting perfectly, resulting in inaccuracies in occlusal con- tact points and possible residues in the borderline areas of the abutments, which are often in the aesthetic submucosa area. In this case, we prefer to in- sert refractory threads that are removed after cementation, limiting the incon- venience of residual cement. Fig. 15: Fabrication of a screw-retained, bonded provisional restoration. Given the available space, conventional modelling of 13 two molar elements is preferred. Fig. 16: Positioning involves screwing in the through screws and sealing the holes with composite. Fig. 17: Digitally model- ling the crowns also involves making abutments by subtraction, depending on the material that will be used for the final crowns and abutments. by drilling (CERALOG, BioHorizons Camlog; Fig. 4). Ceramic injection moulding (CIM) results in an implant whose geometrical and surface structure was created in a mould prior to sintering and hot isostatic pressing (HIP). The variable geometry, smooth on the collar and rough in the endosseous area, optimises soft- tissue healing and bone integration. The internal cornerless connection (Hexalobe) also promotes abutment passiv- ation within the implant, improving the fixation action of the screw for better torque transmission to a ceramic implant (Fig. 5). Positioning took place according to the assisted guided surgery technique. Although it could be performed following the flapless technique, we preferred to elevate a flap in order to better condition the tissues around the implant collar due to the initial peculiarity of the tissues present and to exaggerate their transforma- tion after healing (Fig. 6). After a healing period of three months, we took the first impression to make a screw- retained provisional restoration held for two months. Only after a new radiographic finding, we made the fi- nal structure following a new impression to establish the exact shape of the conditioned tissue. In both cases, the impression was made in a comparable way based on the use of silicone, with a generic tray. To date, the further changes made to the systems have made it pos- sible for this step to be digitised as well, streamlining some procedures (Fig. 7). 14 15 16 After developing the impression, the dental technician digitally acquired data in the laboratory that enabled the underlying elements and abutments to be modelled. The final anatomical design of the crowns is produced by tak- ing the chewing function as a basis, performed by sub- tracting from the anatomy of the underlying abutments (Figs. 8–11). The material used determines the variabil- ity of the thickness present in the residual spaces, em- phasising an aesthetic, resistant result. The shape of the 17 implants 2 2020 33

| case report 18 Fig. 18: In addition to CBCT, we always produce intra-oral images with a centring machine, so that we can evaluate the changes that will be generated over time; more specifically, follow-up will be 36 months. tissue-level implant allows the collar to be placed in a variable position while maintaining soft-tissue stability without affecting the aesthetics of the prosthetic resto- ration (Fig. 12). Therefore, the entire prosthetic design must take into account the various factors that all con- tribute to final success (Figs. 13 & 14) and ensure easy long-term maintenance. Conclusions We can identify some aspects worthy of particular atten- tion with regard to the use of zirconia implants and, in this specific clinical case, we evaluate them in both the sur- gical and prosthetic phases. Although worthy of particu- lar attention, some features are typical of implant surgery and it is worth noting that: – Surgical positioning should be performed using drills in excellent condition, at a low rpm and high torque, pay- ing attention to cooling the surgical site; – We believe that conditioning with provisionals for a rea- sonable period can also determine a preload of the im- plant that allows the implant to heal for a time period which is adequate for the anatomy and a little longer than usual, making it possible to improve bone trabec- ulation and full cortical maturation (Figs. 15 & 16); – Analog impression copings are disposable and can- not be hot-sterilised. Their good retention makes it possible to detect correct insertion by engaging the Hexalobe connection (Fig. 7); – In the phase of the provisional restoration, the screwed technique is undoubtedly the most versatile, making it possible for the provisional restoration to be removed while preserving the soft tissues; – Today, the digital flow implemented enables a more widespread and versatile use, facilitating communica- tion with the patient and speeding up some practices. Moreover, the clinician can simplify the surgical act using guided surgery; – Another important element for the final result is making sure that dental technicians are adequately trained in handling such high-performance and technologically- advanced materials, knowing their limits and uses in order to optimise the result with Total Metal Free im- plantology (Fig. 17). In this case, the connection of the elements required a change of engagement due to the peculiarity of the im- plant system. The same change is impractical in the final phase. Perhaps this is a limitation of the system that is still in development for the prosthetic component, aiming for a screwed, bonded solution. The three-year follow-up en- courages the implant type to be more widely used, even though it is limited in terms of time and procedure (Fig. 18). In terms of aesthetics, the two-piece zirconia implant is an excellent alternative to conventional implantology with tita- nium implants. A recommendation to the surgeon is to only use zirconia implants after appropriate clinical training. Literature Acknowledgements: Thanks to Mr Dario Viera, dental laboratory owner and dental technician, who, with his technical skills and in-depth knowledge of materials, made obtaining the results described in this document possible. about the author Dr Riccardo Scaringi is a Professor of specialisation courses in dental implant prosthesis and digital support technol- ogies, at various national universities. He is a frequently invited speaker at national congresses on topics related to surgical prosthetics. He is also an active member at the most prestigious inter- national scientific associations in the field of technological and digital surgery. Scaringi is the author of various scientific publications and texts. contact Dr Riccardo Scaringi Kiral Dental srl Via Lattanzio 23 20137 Milan, Italy Phone: +39 02 5511620 info@riccardoscaringi.com kiraldental.com Author details 34 implants 2 2020

| industry Age-friendly implants Dr Franco Giancola, Italy Ageing patients—risks and opportunities Life expectancy in the world population is gradually in- creasing thanks to better living conditions, more wide- spread healthcare and greater economic resources. The ageing of the individual is accompanied by changes in some bodily functions, such as a decrease in sensory activities, flexibility, nutrition, blood circulation and cogni- tive abilities. Normal tissue involution, poor hygiene and insufficient care often lead to periodontal disease with tooth loss and bone atrophy, often aggravated by os- teoporosis and concomitant systemic disease. The el- derly patient, despite physiological decay, wishes to re- main autonomous, be socially active and enjoy life. The management of the geriatric patient requires greater cau- tion owing to the fragility of tissue and the often compro- mised metabolic functions, but it represents a great op- portunity for modern dentistry. Elderly patients are more motivated to recover chewing and smiling because they allow them to stay young, be more independent, have a greater self-esteem and remain socially integrated. Den- tal implants have allowed elderly patients a better qual- ity of life and greater independence. Unfortunately, tradi- tional titanium implants bring with them pitfalls, as they favour the accumulation of bacterial plaque and the re- lease of metal particles that lead to the onset of peri- implantitis, unaesthetic greyish gingival margins, loss of implants, unpleasant breath and debilitating systemic disease (chronic fatigue syndrome, allergies, fibromyal- gia and metabolic decompensation). Zirconia as a medical prescription Zirconia, unlike titanium, has poor bacterial adhesion and fewer inflammatory phenomena; therefore, the breath is always pleasant and the gingival tissue well adhered to the implant collar. In elderly patients, mouth hygiene is easier and more effective in the presence of zirconia crowns and implants. The simple use of a toothbrush, im- plant brushes and rinses with mildly aggressive washes (grapefruit seed or calendula extracts), the mouth is al- ways clean and healthy (Figs. 1a & b). Zirconia is osteo- conductive and it allows calcium to deposit on its sur- face, thus favouring excellent implant osseointegration, and the calcium tends to consolidate over time even in the presence of osteoporosis (Fig. 2). Furthermore, zir- conia is an inert material; it does not irritate the immune system and does not disturb the metabolism, which is often already compromised owing to the patient’s age or systemic disease (Fig. 3). The new-generation zirco- nia implants now make it possible to rehabilitate any clin- ical situation with a fixed prosthesis. In the elderly pa- tient, even if not self-sufficient, it is therefore possible to guarantee good oral hygiene and health and no pres- 1a 1b 36 implants 2 2020 3 Fig. 1: Homogeneous layer of cocci and fi lamentous bacteria covering the surface of titanium (a), a small number of bacteria on the surface of zirco- nia (b).1 Fig. 2: Bone-to-implant contact at eight weeks.2 Fig. 3: Scanning electron microscope image of osteoblasts in culture on the surface of zir- conia after 48 hours of incubation (5,000 x magnifi cation).3 2

industry | 4 5 6 Fig. 4: Features of the standard ZiBone implant. Fig. 5: Features of the Zircasso implant. Fig. 6: Features of the ZBI Ceramica. sure sores or accidental ingestion of removable prosthe- ses. Any informed and conscientious dentist who wants to help their elderly patient to maintain or restore health should prescribe zirconia implants, as they are healthier and safer. roughness and depressions of the surface of the fixture favour its osseointegration. The ZBI Ceramica, unlike the other two implants, was designed to be inserted by im- pact without screwing in in compliance with the bone microarchitecture (Fig. 6). The ZBI Ceramica has coronal protrusions for immediate mechanical retention and an Biology-driven implantology The approach to the elderly patient requires not only highly biocompatible and immune-compatible materi- als but also multidisciplinary management. First of all, it is necessary to analyse the sociocultural context and the expectations of the patient or of the family mem- bers who take care of him or her. It is advisable to know the general health conditions and diseases that the pa- tient suffers from and, in agreement with the specialist, to provide for any precautions or changes to the ther- apeutic prescriptions. It must always be remembered that the elderly patient is more delicate, is more easily decompensated and has longer healing times; there- fore, treatment must be less traumatic and must not require too much cooperation. Implant planning must be very accurate and include essential, fast and safe steps. It is desirable to prefer flapless techniques and placement of monobloc implants in areas of sufficient bone quantity and quality. Excessive trauma with lifting of mucosal flaps, delayed two-piece implant placement and complex techniques for bone augmentation could expose the patient to complications that are difficult to manage, such as bleeding, metabolic decompensation or bacterial infection. One-piece ZiBone implants The ZiBone implant system (COHO Biomedical Technol- ogy) has different types and sizes of one-piece implants, ideal for single-session rehabilitation of the alveolar ridge for elderly patients. The manufacturer produces three types of one-piece implants: the standard ZiBone im- plant, the Zircasso implant and the ZBI (Zirconia Bioactive Implant) Ceramica. The standard ZiBone implant is cy- lindrical in the coronal portion and conical at the apex, which has vertical grooves that act as a bone reserve (Fig. 4). The orientation of the threads allows easy screw- ing in of the implant without excessively damaging the surrounding bone. The Zircasso implant, marketed by Zircosol, has regular V-shaped coils and a pointed apex that favours screwing (Fig. 5). The implant is ideal for post-extraction positioning and immediate loading. The 7 8 9 Fig. 7: Frontal view of the arches at the dental examination. Fig. 8: Clinical situation after removal of the prosthesis. Fig. 9: Dental radiograph four years after the placement of a zirconia implant (ZiBone; 4 x 14 mm). implants 2 2020 37

10 13 16 11 14 17 12 15 18 Fig. 10: Detachment of the dental root from the bone by means of a piezosurgical technique. Fig. 11: Atraumatic tooth extraction. Fig. 12: Withdrawal of oxygen–ozone gas mixture (MEDICAL 99 IR, Multiossigen). Fig. 13: Disinfection of the extraction socket by local application of ozone. Fig. 14: Initial prepara- tion of the implant site with a pointed diamond piezoelectric insert. Fig. 15: Screw for non-traumatic bone expansion before implant placement in region #11. Fig. 16: Surgical kit of the ZiBone implant system. Fig. 17: Zircasso implant mounted on automatic adapter. Fig. 18: Screwing in of the Zircasso implant. apical through slot for better biological integration (sec- ondary retention). The preparation of the implant site is performed with the piezoelectric technique (or zirconia burs with slow rotation and without irrigation) and the im- plant positioned with light taps with an osteotome and hammer. The ZBI Ceramica is ideal for the rehabilitation of the upper jaw in bone of D3 or D4 density according to the Misch classification, as is often found in elderly patients with osteoporosis. Clinical case The 88-year-old female patient, apparently in good health, presented owing to the appearance of mobility of the maxillary fixed prosthesis and discomfort in the area corresponding to the maxillary incisors. The removal of the prosthesis revealed a softening of the dentine of the affected teeth, and the examination of the radiograph showed periapical infection (Figs. 7–9). The patient, sat- isfied with the result obtained from the placement of a zirconia implant four years earlier, asked for removal and replacement of her damaged teeth with bioceramic im- plants. In consideration of the patient’s advanced age, it was decided to perform atraumatic extraction of the af- fected teeth and immediate implant placement. Dislocation of the tooth roots was performed with ded- icated piezoelectric inserts (PIEZOSURGERY, mectron) and appropriate forceps (Figs. 10 & 11). The extraction sockets were suitably cleaned with alveolar excavators and disinfected with local application of medical ozone at a concentration of 20 mg/ml (Figs. 12 & 13). The prepa- ration of the implant sites was performed initially with a diamond piezoelectric insert and subsequently with dif- ferent techniques depending on the implant to be placed (Fig. 14). For the socket of tooth #11, bone condensa- tion was initially carried out using the Dr Sentineri’s tech- nique bone expander kit (mectron; Fig. 15) and subse- quently with slow screwing in of the Zircasso implant (4.1 x 10.0 mm; Figs. 16–18). For the socket of tooth #12, however, the preparation was carried out using slowly rotating zirconia burs (250 rpm) without irrigation and a ZBI Ceramica (4 x 9 mm; Figs. 19–24) was subsequently positioned using impact. At the end of the operation, the 38 implants 2 2020

19 22 25 20 23 26 21 24 27 Fig. 19: Preparation of implant site #12 using zirconia burs. Fig. 20: ZBI (Zirconia Bioactive Implant) Ceramica. Fig. 21: Placement of the ZBI Ceramica into the prepared socket. Fig. 22: Compaction of the implant using an osteotome and hammer. Fig. 23: Final position of the implants. Fig. 24: Adaptation of the prosthesis immediately after surgery. Fig. 25: Clinical situation after one week. Fig. 26: Condition of the peri-implant tissue after two months. Fig. 27: Radio- graphic control of the implants. implants were protected by means of a temporary resin prosthetic product previously prepared in the laboratory and relined in the office. At the check-up after seven days, the patient reported that she was very satisfied and had no pain, swelling or bleeding but only slight ten- derness (Fig. 25). Conclusion Dentists are often afraid of treating elderly patients, as they often think that treating these patients might be risk- ier and that implant failure would be more likely to oc- cur. However, clinical experiences show that, if elderly patients are managed well, treating them is rewarding and satisfying to dentist and patient alike. Monobloc zir- conia implants (such as those of the ZiBone implant system) and minimally invasive techniques reduce interven- tion times and post-surgery discom- fort significantly and lead to good periodontal integration and implant stability (Figs. 26 & 27). Literature about the author Dr Franco Giancola is a Rome-based dentist who specialises in implantology. He organised the first Italian congress of ceramic implantology, held in Pescara, Italy, in 2016. He is also the director of the first International Master Class of Ceramic Implantology, which is set to take place in Rome in Italy at the be- ginning of next year. Dr Giancola is the author of the book Impianti Ceramica: La Sfida Vincente. contact Dr Franco Giancola Casa di Cura Privata Nuova Villa Claudia Via Flaminia Nuova 280 00191 Rome, Italy Phone: +39 388 0913583 info@francogiancola.com www.nuovavillaclaudia.it Author details implants 2 2020 39

| industry Ceramic implants— Ceramic implants— where do we stand? where do we stand? A scientiﬁ c literature review A scientiﬁ c literature review Dr Pooja Nair, Switzerland Dental implants made of titanium and titanium alloys made of titanium and titanium alloys are considered a gold standard in implant dentistry due are considered a gold standard in implant dentistry due to their exceptional mechanical properties and long- to their exceptional mechanical properties and long- term clinical success.1 However, the main drawback of However, the main drawback of a titanium implant is its dark grey colour, which may oc- a titanium implant is its dark grey colour, which may oc- casionally be visible through the peri-implant mucosa, hence inﬂuencing aesthetic outcomes, speciﬁcally in thin mucosal areas and anterior region. Therefore, a ceramic implant is turning out to be a more and more popular treatment option designed in anticipation of achieving a better aesthetic outcome. What is ceramic/zirconia? The entry of zirconia transformed the market as a prom- ising material with good mechanical properties, high biocompatibility and excellent aesthetics, all of which encouraged researchers to investigate its possible use as a material for endosseous implants.2 The one used in the production of dental implants is yttria(Y2O3)-stabilised tetragonal zirconia polycrystal (Y-TZP) which has proven to be an attractive metal-free alternative to titanium as it exhibits more signiﬁcant corrosion and wear resistance, an excellent ﬂexural strength2–5 and furthermore, the compressive strength of zirconia implants is adequate Fig. 1: The Straumann® PURE Ceramic Implant System. in occlusion, and it can withstand occlusal loads for a more extended period.6 Straumann® has established an innovative manufacturing process followed by a rigorous 100 % proof test in which every single implant from the Straumann® Implant System is tested mechanically be- fore leaving the production site. Is zirconia as good as titanium? One of the most essential criteria for the success of im- plant treatment is osseointegration, which is the direct structural and functional interface between the living bone and surface of a load-bearing implant.7 Bone ap- position takes place on different types of implant sur- faces and greatly depends on the implant surface topog- raphy. The highest level of bone-to-implant contact (BIC) is associated with moderately rough surfaces.8 There- fore, it was crucial to obtain appropriate values of sur- 2a 2b Fig. 2a: The SLA® surface of Straumann® titanium implants. Fig. 2b: The ZLA® surface of the Straumann® PURE Ceramic Implant System. 40 implants 2 2020

industry | face roughness on the zirconia implants. The surface of the Straumann® PURE Ceramic Implant System (ZLA®) is characterised by roughness values similar to those of Straumann® implants with SLA® surface9 widely known from optimal surface topography that enhances BIC and facilitates osseointegration.10–15 In preclinical studies, ce- ramic implants with ZLA® surface demonstrated similar healing and osseointegration as observed for the SLA® surface.16, 17 Also, removal torque values were equivalent to titanium SLA® implants.14 These reports were further conﬁrmed by clinical investigations demonstrating sur- vival rates of the monotype implants from 97.6 to 100 % after one year. These are values within the range of re- ported one-year survival and success rates for a titanium or titanium alloy implant.18–21 A recent multi-centre study reported survival and success rates of 97.2 % after ﬁve years (manuscript in preparation). Is it biocompatible? The biocompatibility of an implant material depends on its chemical, physical, and structural properties that may inﬂuence the cell response at the tissue-material inter- face. Roughened Y-TZP was found to be an appropriate substrate for the proliferation and spreading of osteoblas- tic cells.22 Zirconia did not exert a cytotoxic effect on os- teoblasts in vitro and made the cells capable of growth and development.23 When compared to titanium sur- faces, the zirconia surface showed increased ﬁbrinogen adsorption, platelet adhesion, activation, and thrombo- genicity.24 Studies on bacterial adhesion on the zirconia surface determined that plaque formation on this sur- face might be less.25, 26 Also, a signiﬁcantly reduced three- species bioﬁlm thickness, human bioﬁlm mass, and hu- man plaque thickness was seen in vitro when compared to SLA® surfaces.27 A higher degree of soft-tissue integra- tion around the ceramic implant than titanium was ob- served28 and an ideal papilla-crown proportion around zir- conia implants was reported in a 3-year follow-up study.29 What about aesthetics? Most patients perceive treatment as successful when they are satisﬁed with the overall aesthetic appearance after the procedure. The Straumann® PURE Ceramic Implant System is ivory-coloured, which resembles nat- ural tooth roots which is an advantage in patients with a thinner mucosal biotype or a high lip line smile.30–32 The review of peri-implant soft-tissue colour suggested that the colour outcome might be inﬂuenced by both the im- plant and the abutment material. Ceramic components, when compared to metallic ones, appear to provide an improved colour matching between peri-implant soft tissues and soft tissues around natural teeth.33 Excel- lent aesthetic outcomes and papilla formation around ceramic implants have been reported in several clinical studies,20, 21, 31 even for challenging indications. 3 Fig. 3: Confocal laser scanning microscopy visualising seeded bone cells and pronounced ﬁ brin network on the ZLA® surface after incubation in human whole blood. Fibrin network (red), actin cytoskeleton (green), nuclei (blue). Image courtesy: © Dr M. Rottmar Is it clinically proven? Ceramic implants have rapidly demonstrated numerous beneﬁts on par with titanium as an implant material in various clinical trials.12, 34, 35 They have had FDA approval since 2007, and the ceramic material has been used to make dental implants in Europe since 1987. As the technology and methods have evolved with titanium im- plants and undeniably the ﬁeld of dentistry overall, many amendments have also been executed to the concept of ceramic implants that have signiﬁcantly improved their standard.36 Ceramic implants become more and more popular treatment option, and the amount of published scientiﬁc evidence supporting their clinical application is continuously growing.12, 19, 34 There is more than enough data to conﬁrm the long-term sustainability of zirconia dental implants, even by conventional standards.35 The Straumann® Ceramic Implant Systems are the re- sult of more than 12 years of uncompromising research and development. They combine quality and precision, strength, clinical success, and ﬂexible treatment proto- cols in an innovative solution that helps you to meet the needs of your patients. Moreover, the above discussed clinical evidence on excellent clinical performance con- ﬁrms that ceramic implants can be considered a safe and predictable treatment alternative. contact Literature Dr Pooja Nair Global Scientiﬁ c Communications Manager Straumann Group Peter Merian-Weg 12 4052 Basel, Switzerland Phone: +41 61 9651111 www.straumann.com implants 2 2020 41

| industry 1 2 3 New ZrO2 touch by EACim bur kit Designed by EACim for EACim members Dr Philippe Duchatelard, France Zirconia is the hardest material used to make dental implants. Its 3D positioning when used in its monobloc form determines prosthetic success without impinging on biological requirements. It is common to have a ves- tibular edge of the shoulder corrected in order to avoid over-burial and follow the mucosal margin for aesthetics or a vestibular edge of the abutment to respect a more palatal or lingual insertion axis and spare the vestibu- lar bone wall. These corrections must be limited in vol- ume and time in order to avoid permanent damage to the zirconia and jeopardising of its mechanical strength by hindering crystallographic healing. the red-ringed burs will be used in the great majority of cases, they compose the ﬁrst line of the kit. Technically, it is preferable to alternate between grit sizes to control the thickness of the corrections, given the performance of these burs and to avoid overheating. The kit includes two polishing options in both grit sizes, which allows the user to achieve a perfectly polished surface ﬁnish. It is rec- ommended that the user works with the burs of the new kit at the optimal speed of 160,000 rpm, with low con- tact pressure (< 2 N) and under maximum spray coolant ( minimum of 50 ml/min). There is no silicone polisher, in order to avoid any swarf pollution of the mucosa. The new S2400 ZrO2 touch by EACim bur kit from Komet, the leading manufacturer of dental burs, offers white-ringed burs speciﬁcally designed for working on all- ceramic restorations. The coating is made with a di- amond grain concentration of more than 80 % com- pared with conventional burs with a reinforced binder. This allows zirconia to be machined without generating sparks, reducing the formation of cracks or intergranu- lar ﬁssures to a minimum and optimising the cutting per- formance as a result. Users can choose between two types of granulometry: red (ﬁne crystals of 46 μ in size) and blue ( medium crystals of 126 μ in size). The bur with the red ring comes in four different shapes designed with a view to the usual clinical situations of retouching. Since The photographs above show the ZR8863 (Fig. 1) and the ZR8972 (Fig. 2) burs in clinical application. The com- plete bur kit (Fig. 3) made by Komet is exclusively avail- able to EACim members only. contact European Academy of Ceramic Implantology (EACim) 65 avenue du Prado 13006 Marseille France www.eacim-ceramic-implantology.com 42 implants 2 2020

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 Z-SYSTEMS Z-SYSTEMS Ceramic Implants—100 % Ceramic, 100 % Swiss Ceramic implants have been at the cutting-edge of dental implant technology for over a decade, and are becoming increasingly popular with patients and practitioners worldwide. As a mar- popular with patients and practitioners worldwide. As a mar- ket leader, Z-SYSTEMS has taken another leap forward with ket leader, Z-SYSTEMS has taken another leap forward with its innovative Z5-BL (Bone Level) and soon- its innovative Z5-BL (Bone Level) and soon- to-be-released Z5-TL (Tissue Level): the to-be-released Z5-TL (Tissue Level): the world’s fi rst two-part, screw-retained world’s fi rst two-part, screw-retained implants made entirely of ceramic. For implants made entirely of ceramic. For the fi rst time, completely submerged the fi rst time, completely submerged healing is now also possible with healing is now also possible with ceramic implants. ceramic implants. The Z5-BL’s advantages are evident The Z5-BL’s advantages are evident in its beautiful bone level design in its beautiful bone level design and a unique variety of abutments. A high-precision, extremely stable conical connection between the abutment and the implant makes it possible to use this material even for the occlusal makes it possible to use this material even for the occlusal screw. Many practitioners also like to work with tissue level screw. Many practitioners also like to work with tissue level implants—especially in biological dentistry. In recognising implants—especially in biological dentistry. In recognising these clinical demands, Z-SYSTEMS is rapidly following the these clinical demands, Z-SYSTEMS is rapidly following the release of the Z5-BL with an equally-revolutionary Z5-TL. release of the Z5-BL with an equally-revolutionary Z5-TL. These latest releases build on the proven platform of Z- SYSTEMS These latest releases build on the proven platform of Z- SYSTEMS heritage line: the Z5m, Z5m(t) and Z5c. Each Z-SYSTEMS prod- heritage line: the Z5m, Z5m(t) and Z5c. Each Z-SYSTEMS prod- uct features the technology’s unique, patented laser surface for outstanding osseointegration. The company’s proprietary manufacturing process has produced a top-quality implant family renowned for its great durability. In addition to fi xed restorations, removable locator-like abutments are also possible on all two-piece Z-SYSTEMS implants. Available lengths are 8, 10 and 12 mm and diam- eters are 3.6, 4.0 and 5.0 mm. Z-SYSTEMS Ceramic Implants Switzerland contact@zsystems.com www.zsystems.com 44 implants 2 2020

manufacturer news | Dentalpoint Zeramex launches new products In order to be able to provide optimum restoration of anterior teeth in the lower jaw and lateral incisors in the upper jaw, the Zeramex XT implant system portfolio now also includes implants with an endosseous diameter of 3.5 mm. The new Small Base (SB) implants are available in lengths of 8, 10 and 12 mm. In addition to the already familiar Regular and Wide Base platforms with endosseous diameters of 4.2 mm for the RB implant and 5.5 mm for the WB implant, these new products complete the Zeramex XT implant range. The SB implant system has also been expanded with the addition of new abutments. Zeramex Docklocs® Abutments are the first 100 % metal-free, reversible screw-in abutments for removable dentures. They are available in heights of 2, 3 and 4 mm. A smaller adhesive base is now available to further optimise the digital workflow. Like the existing Zerabase adhesive base, the new Zerabase X is available with and without abutment bases for single crowns or bridge res- torations (engaging/non-engaging) as well as for all SB, RB and WB platforms. The new SB implants, Zeramex Docklocs® Abutments and the new Zerabase X adhesive base are all available now. Dentalpoint AG Bodenäckerstr. 5 8957 Spreitenbach, Switzerland digitalsolutions@zeramex.com SDS Swiss Dental Solutions SDS1.2 and SDS2.2 ceramic implants launched in the US The concept of Biological Dentistry with ceramic implants ac- cording to Dr Karl Ulrich Volz is the central component of the SWISS BIOHEALTH CONCEPT. Another major part of this con- cept—our ceramic implants—are now available in the US. Made in Switzerland, the new SDS implants SDS1.2 and SDS2.2 are now FDA-approved and available from our North American of- fice. These new and continuously improved implants comprise all the little improvements and ideas of the last years, directly out of the SWISS BIOHEALTH CLINIC of Dr Volz in Switzerland and other SDS specialists in Europe. The SDS USA Inc. is located in Plymouth, MA, and offers clients the same level of service and expertise as in Europe. Our first four SDS user courses success- fully took place in New York, Denver, Santa Monica and New Orleans. Other USA courses will follow soon. Additionally, SDS of- fers the monthly SDS user course with Dr Karl Ulrich Volz as well as other courses on Biological Dentistry and Biological Medicine in the SWISS BIOHEALTH EDUCATION Center. The dates for the 2021 SDS courses in the USA will be published shortly on www.swissdentalsolutions.us. SDS Swiss Dental Solutions USA Inc. 34 Main St Ext #202 Plymouth, MA 02360, USA www.swissdentalsolutions.us

| manufacturer news Fotona Peri-implantitis treatment with TwinLight Fotona’s dual-wavelength LightWalker dental laser system is the ideal tool for effective minimally-invasive treatment of peri- implantitis. The system’s TwinLight (Er:YAG and Nd:YAG) treatment option successfully addresses infection control, detoxification of implant surfaces, regeneration of lost tissues, and plaque-control regimens with no mechanical or chemical trauma, no danger of thermal damage to the surrounding bone and no significant al- terations of the implant surface. First, the Er:YAG laser is used to remove microbial composition on the implant and to treat the damaged alveolar bone around the implant. Following Er:YAG treatment, the Nd:YAG laser wavelength is used for bacterial re- duction and biostimulation. Inflammation, swelling, and bleeding of soft-tissue lesions, can be handled without surgery, and healthy peri-implant tissue assures greater long-term implant success. 1 2 3 Fig. 1: Removal of the soft-granulation tissue and ablation of the infected bone with Er:YAG. Fig. 2: Removal of the bacterial biofilm on the implant sur- faces with Er:YAG. Fig. 3: Bacterial reduction and biostimulation of the bone tissue with Nd:YAG. Fotona d.o.o. Stegne 7 1000 Ljubljana, Slovenia www.fotona.com CAMLOG Natural aesthetics with the CERALOG® Implant System The demand for highly aesthetic, natural-looking restorations is continually increasing. This trend favours ceramic implant solu- tions with high levels of biocompatibility, particularly zirconia, known for its excellent soft-tissue compatibility. The CERALOG® Implant AESTHETICS The ivory colour, which is close to the natural tooth colour and the properties of zirconia supports high aesthetic results. System is established and has been in clinical use for more than seven years. It offers a high level of predictability and provides aesthetically pleasing results. The two-piece design of the system that allows for screw-retained prosthetics offers great benefits. CERALOG® is easy to use, owing to the simplified prostheses, lean instrumentation, and clearly struc- tured surgical procedure. Options for the treatment workflow include flexible trans- or submucosal healing of the two-piece CERALOG® Hexalobe implant and transmucosal healing of the CERALOG® Monobloc implant. The implants are made of yttria-stabilised tetragonal zirconia, which is a ceramic widely used in the dental industry and other highly demanding medical fields. The ivory colour of the material, which is very close to that of a natural tooth, and the properties of zirconia lead to natural-looking results. Zirconia is chemically inert, making it especially suitable as an implant material. Due to its manufacturing process called ceramic injection mold- ing (including sintering and hot isostatic pressing), it offers an outstanding combination of excellent mechanical properties and high strength. IDEAL CONNECTION Hexalobe – the ideal implant–abutment connection for ceramic implants. The torque is transmitted tangentially to the implant, which allows a much higher torque compared to hexagonal connections, and also more rotational stability. CAMLOG Biotechnologies GmbH Margarethenstr. 38 4053 Basel, Switzerland www.camlog.com 46 implants 2 2020

manufacturer news | 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 BECOME AN AUTHOR for ceramic implants — international magazine of ceramic implant technology Interdisciplinary, transparent & market orientated 0 2 / 2 I C issn 1868-3207 Sondernummer • Vol. 4 • Issue 2/2020 2/20 ceramic implants international magazine of ceramic implant technology Become part of a successful network and beneﬁ t from a wide reach and high level of awareness AD www.oemus.com research Biological GBR and ceramic implants industry Age-friendly implants interview Laser-assisted prophylaxis around zirconia implants O E M U S M E D I A A G Please contact Mr Georg Isbaner: g.isbaner@oemus-media.de Phone: +49 341 48474-123 Holbeinstraße 29 · 04229 Leipzig · Germany · Phone: +49 341 48474-0 · info@oemus-media.de

| manufacturer news COHO Biomedical Technology Straumann A total, functional and The fi rst step to harmonious aesthetic solution soft-tissue healing soft-tissue healing Dental treatment has entered an era of aesthetic functional restorations. With the ZiBone zirconia implant, ZiBone offers a metal- free implant system that meets the highest aesthetic de- mands. Zirconia is increasingly being used today as a suitable material for dental restorations for a variety of reasons: it has a natural white colour, it allows for great healing of the surrounding soft tissues and leads to excellent osseointegration, it convinces with outstanding biocompatibility, and it causes no allergic reactions. Zirconia allows doctors to treat their patients with a material that is superior to titanium in many ways. Further- more, ZiBone has succeeded in making special improvements to the surface of the ZiBone implant based on years of clinical use and scientifi c evidence. As a profes- sional manufacturer of zirconia products, ZiBone understands that a single zirconia implant cannot solve all issues. ZiBone therefore provides a line of zirconia instru- ments that help dentists to master complex surgeries and periods of postoperative care. Made from zirconia, the new Straumann® Made from zirconia, the new Straumann Ceramic Healing Abutments offer favour- Ceramic Healing Abutments offer favour- able conditions for soft- tissue attachment, able conditions for soft- tissue attachment, with blood circulations similar to that around with blood circulations similar to that around a natural tooth.1, 2 Their known Their known zirconia material will support zirconia material will support surgeons and prosthodon- surgeons and prosthodon- tists looking for less plaque tists looking for less plaque attachment and allow for a attachment and allow for a more mature and pronounced more mature and pronounced soft-tissue integration compared to conventional materials.3–7 With a smoother surface in con- trast with titanium,2, 3, 8, 9 those new healing abutments promote soft-tissue healing from the day of surgery. In a nutshell, the fi rst ceramic healing abutments in Straumann history bring clinicians the opportunity to have a complete ceramic prosthetic workfl ow from the healing phase, followed by Straumann CARES ceramic options for the fi nal restoration; achieving health, function and aesthetics from the day of surgery. COHO Biomedical Note: References can be found on www.straumann.com/ceramic-healing- Technology CO., LTD. abutments.html No. 21 Dafeng Street, Luzhu District Taoyuan County 338, Taiwan (R.O.C.) www.zibone.com Institut Straumann AG Peter Merian-Weg 12 4052 Basel, Switzerland www.straumann.com TBR Dental Acquisition opens new perspectives in Spain Driven by the development of the Z1 Tissue Level implant and the Index digital workfl ow, TBR Dental integrates SAS Exclusivas Dentales, S.L. into its group and consolidates its long-term pres- ence in Spain. Based in Valencia and with more than 30 years of experience in the Spanish market, SAS Exclusivas Dentales supports dental professionals in their search for technical ex- cellence through a practical and local approach. The company’s portfolio offers specialised and innovative products with a perfect knowledge of the needs of the dental community. “We are pleased to welcome Sally Bustos and Sergio Aldazosa, directors of SAS Exclusivas Dentales, to the TBR Dental Group. Their involvement, their experience and the dynamism of their talented team have enabled SAS Exclusivas Dentales to become an important player in the Spanish dental market”, explains Julien Benhamou, CEO of TBR Dental. Today, TBR Dental and SAS Exclusivas Dentales are pushing forward the deployment of unique and exclusive products in a Spanish market that is as dynamic as ever. TBR Dental Group 24, impasse René Couzinet 31500 Toulouse, France www.tbr.dental 48 implants 2 2020

Dental implants rethought tients demand sustainable well-being and we are the only ones able to guar- antee this. Ceramic implants still constitute a niche on the dental implant market. One of the main criticisms is that there is still a great lack of long-term clinical studies and scientiﬁc docu- mentation. What’s your take on that? You are right in saying that ceramic implants still occupy a niche in the dental implant market. Yet even before the COVID-19 pandemic, one of the most important global trends in dentistry was the increasing desire of patients to improve their overall systemic health and well-being. As a direct consequence, patients are looking for “metal- free” alternatives. When it comes to research, Zircon Medical Management is a ceramic implant manufacturer that has dedicated its efforts to generating long-term, peer- reviewed clinical data. We want to make sure that we can provide solid evidence of success both to the den- tists using our Patent™ dental implant system as well as to their patients. Where is your implant system positioned? Our Patent™ dental implant system represents the be- ginning of a new era for dental implants. We will continue to focus our efforts on relevant research and develop- | interview Available in both one- and two-piece conﬁguration, the novel Patent™ dental implant system is based on the central idea that “less is more”—fewer surgical steps and no screws or other components that are not necessar- ily needed. In this interview, Frédéric Wehrli, Director of Product Management, reveals the details about the fully customisable ceramic implant system. “You snooze, you lose” or “the last shall be ﬁrst”— “You snooze, you lose” or “the last shall be ﬁrst”— what applies more to you? Why are you only now what applies more to you? Why are you only now entering the market again? As the old saying goes, “timing is everything”—not miss- As the old saying goes, “timing is everything”—not miss- ing the perfect time and being rewarded with the per- ing the perfect time and being rewarded with the per- fect thing in return is of utmost importance. As opposed fect thing in return is of utmost importance. As opposed to our competitors, the Patent™ dental implant system to our competitors, the Patent™ dental implant system underwent a successful “proof of concept” and is now underwent a successful “proof of concept” and is now mature enough to be marketed. Furthermore, we be- mature enough to be marketed. Furthermore, we be- lieve that now is the perfect time to share this great tech- lieve that now is the perfect time to share this great tech- nology with the industry and our patients. Today’s pa- nology with the industry and our patients. Today’s pa- “Today’s patients demand sustainable well-being and we are the only ones able to guarantee this.” 50 implants 2 2020

interview | Machined Patent™ implant surface Rough and hydrophilic Patent™ implant surface ment in order to sustainably provide well-documented solutions for our clinicians and our patients in the long term. The two-piece Patent™ dental implant system is the only commercially available system with published long-term clinical studies for this speciﬁc implant design (according to Röhling et al.) that show successful results. What’s the backstory of your company? The idea for our Patent™ dental implant system (formerly ZV3) was born 18 years ago. In 2006 we received CE cer- tiﬁcation and the manufacturing process was patented. In 2009 we introduced the two-piece implant. In 2014 a retrospective study of the University of Groningen in the Netherlands with our one- and two-piece implants was published. This was followed by the publication of a pro- spective study in 2017 by the University of Düsseldorf con- ducted over the course of two years with our two-piece implant system. As I mentioned earlier, this is the only pro- spective study available on two-piece ceramic implants. Both studies show success rates of over 96 per cent. We also have a large number of documented clinical cases, which are also peer-reviewed. Hence, today we can look back on a long history with a mature “proof of concept” and more than 10,000 placed implants. and more than 10,000 placed implants. What sets your system apart? Our system has several striking features that our custom- Our system has several striking features that our custom- ers beneﬁt from. The entire implant system is reduced ers beneﬁt from. The entire implant system is reduced to the minimum in order to reach its maximum potential. to the minimum in order to reach its maximum potential. The initial investment for users is relatively low because, The initial investment for users is relatively low because, since only a few instruments are required and there is no since only a few instruments are required and there is no need for additional implant components. The implant de- need for additional implant components. The implant de- sign concept is biomimetic and therefore our customers sign concept is biomimetic and therefore our customers do not require additional training, which helps to reduce do not require additional training, which helps to reduce actual chair times and the overall number of treatment actual chair times and the overall number of treatment visits. We also have a patented manufacturing process visits. We also have a patented manufacturing process by which we are able to manufacture ultra-strong, hydro- by which we are able to manufacture ultra-strong, hydro- philic implants. We believe that these are the reasons why philic implants. We believe that these are the reasons why there is such a great deal of documented success in our there is such a great deal of documented success in our long-term studies. long-term studies. For which indications is your system suitable? For which indications is your system suitable? With Patent™ you can treat all restorative conditions With Patent™ you can treat all restorative conditions such as single crowns, bridges, telescopic reconstruc- such as single crowns, bridges, telescopic reconstruc- tions and bar constructions. This offers the restorative dentist a vast spectrum and a high degree of ﬂexibility without having to invest heavily in prefabricated compo- nents and instruments. There is a growing trend that dentistry plays a crucial part in the general and systemic health of patients. What’s the signiﬁcance of ceramic implantology in this context? Most clinicians have known for some time now that there is a direct link between oral health and general, systemic health and well-being. Technological and medical ad- vances have made it possible to prolong and improve life and, as a result, the “older” part of the world’s population is growing rapidly. These people demand a better and more vital quality of life. Today, many patients reject older technologies and lean towards “metal-free” solutions in- stead. Ceramic implantology can meet these demands. Your system appears to be quite sophisticated and well-documented. Where and how can potential us- ers get to know it? Thank you very much. We are very proud of our history and scientiﬁc heritage. We will continue to build on our success and provide even more solutions in the future. We invite all dentists and dental technicians to learn more about us at www.mypatent.com. There you will ﬁnd an abundance of information on our products and how you can reach us. Thank you for the conversation, Mr Wehrli. contact Zircon Medical Management AG Churerstr. 66 8852 Altendorf, Switzerland info@mypatent.com www.mypatent.com implants 2 2020 51

| interview Laser-assisted prophylaxis Laser-assisted prophylaxis around zirconia implants around zirconia implants France-based dentist Dr Fabrice Baudot has specialised in periodontics, laser- France-based dentist assisted surgery and implant dentistry and has a particular interest in zirconia assisted surgery and implant dentistry and has a particular interest in zirconia implants. In this interview with laser, Dr Fabrice Baudot, founding member and sci- implants. In this interview with entific leader of the European Academy of Ceramic Implantology (EACim), explains entific leader of the European Academy of Ceramic Implantology (EACim), explains why dental lasers have become an essential part of his daily practice and sheds why dental lasers have become an essential part of his daily practice and sheds light on the clinical benefits of combining laser-assisted surgery and ceramic implantology. Peri-implantitis is an increasing problem today. It is especially associated with titanium implants. What treatment benefits does the laser offer in this context? Indeed, peri-implantitis is a real scourge for which we do not yet have good therapeutic solutions. Dr Stefan Renvert said in his 2012 book, “As in all pathologies, the best form of treatment is very often prevention and peri- implantitis is no exception.”1 From this point of view, the Er:YAG laser can provide us with certain solutions for the daily practice. The cause of peri- implantitis might be mul- “Indeed, peri-implantitis is a real scourge for which we do not yet have good therapeutic solutions.” tifactorial, but the microbiological aspect and the con- tamination of implant surfaces by biofilms seems to be a key point. With its well- demonstrated bactericidal prop- erties, the Er:YAG laser is an excellent complementary instrument to conventional instrumentation for regulating the development of biofilm around implants and cleaning contaminated implant surfaces. When it comes to oral surgeries, we usually exploit the photo-ablative effects of the Er:YAG laser, which are used for the micro-ablative cleaning of implant surfaces and the removal of inflammatory tissue, and which allow us to clean so-called peri-implant wounds. If we compare the Er:YAG laser to air polishers, which appear to be the reference for cleaning implant surfaces, the Er:YAG la- ser shows similar results on rough titanium surfaces, but without leaving powder debris on the surgical site. It can be argued that it is as effective and at the same time cleaner than conventional instruments. As opposed to other lasers, the Er:YAG laser is the only laser that can safely treat hard and soft tissue simultaneously without generating uncontrolled thermal effects. It can particu- larly be used on bone without the risk of thermal dam- age and even in confined spaces, as is often the case in dental implantology. In peri-implant maintenance, we exploit the photoacoustic effects, leading to an emulsify- ing of biofilm without altering the delicate tissue–implant interface. The shock waves generated by Er:YAG radia- tion with a wavelength of 2,940 nm cause a 3D expan- sion of the irrigation solution, and the agitation effect of the solution destabilises the biofilm in a way well beyond what conventional instrumentation is able to achieve. These repeated preventive measures which are tailored to the patient’s individual physiology make it possible to maintain peri-implant homoeostasis without altering the surrounding tissue environment. The treatment proto- cols are very simple to follow and clinical application only takes a few minutes. Ceramic implants are not particularly associated with peri-implant inflammation. Are there useful la- ser applications designed for ceramic implants too? What is possible and what isn’t? I use the Er:YAG laser for peri-implant maintenance on a daily basis. This concept of clinical application is based on the emulsion of biofilm that develops around the trans- gingival part of implant restorations and even beyond, in cases of peri-implantitis. A 1997 article by Dr Kenneth S. Kornman made me realise the importance of exposing 52 implants 2 2020

interview | pathogens to defence systems to preserve periodontal and peri-implant homoeostasis.2 The Er:YAG laser and its photoacoustic effects enable the meeting between the pathogenic agents and the immune defence sys- tem, as explained by Kornman in his article. In an ex- cellent journal article, Belgium-based Prof. Eric Rompen elaborated on the importance of implant materials re- garding the nature of tissue attachment.3 Only titanium and zirconia allow hemidesmosome attachment, cre- ating a kind of barrier against biofilm. Other materials used for transgingival connections, such as gold or fired ceramics, do not favour attachment. A real pocket is formed around this type of connection, which can pose a risk factor for the development of peri-implantitis. Deep laser-assisted peri-implant maintenance is partic- ularly indicated around gold or UCLA-type fired ceramic connections. “I use the Er:YAG laser for peri-implant maintenance on a daily basis.” With zirconia and titanium connections, the attachment is of better quality and the use of the Er:YAG laser is less justified when it comes to maintenance. When treat- ing established peri-implantitis, the Er:YAG laser with its micro-ablative properties makes, in my opinion, a real difference compared with conventional instrumentation. It disinfects the treated sites without altering the adja- cent surrounding tissue. Numerous studies have shown its safety on titanium, but there are, as far as I know, very few studies showing the effects of the Er:YAG laser on zirconia implants. I have only in vitro experience under an operating microscope of the use of the Er:YAG laser on zirconia implant surfaces (Z-Systems and CERALOG) because I have not had to deal with any cases of peri- implantitis around these implants. According to my observations, the implant surface of zirconia implants appears to be completely inert to Er:YAG radiation and reacts much less than titanium. The organic materials which are present on a ceramic implant surface are lit- erally vaporised owing to the micro-ablative effect of the Er:YAG laser, leaving a perfectly clean and visibly unal- tered surface as a result. It therefore appears that the Er:YAG laser is very effective in cleaning ceramic implants. different circumstances and for different exposure times. Micro-ablative effects on zirconia should be observed by means of a scanning electron microscope (SEM) and possible surface alterations, especially in the microtex- ture, should be evaluated. One thing that seems funda- mental to me is the aspect of the thermal rise of zirconia under the effect of Er:YAG radiation. There is only one in vitro SEM study, which evaluates the effect of radia- tion from three different lasers on zirconia.4 The carbon dioxide laser seems to alter the surface of zirconia, and the Er:YAG laser penetrates the surface of zirconia. The diode laser appears to be more suitable, but this study has not been confirmed yet by other studies. The clinical application of the diode laser seems to me, when looking at it in vitro, much more problematic than the Er:YAG la- ser, especially in areas close to the bone as is systemat- ically the case in implantology. The risk of collateral ther- mal effects especially on the bone is of major concern with diode laser radiation. Alterations of the implant surface under the effect of la- ser radiation appear to occur only at powers well beyond those effective in destroying biofilm and organic mate- rial. Owing to its peak water absorption, the wavelength at 2,940 nm of the Er:YAG laser is effective at the lowest energy levels and therefore cannot, in clinical use, sig- nificantly alter the implant surface. The important thing is to be able to manipulate Er:YAG radiation under visual control at high magnification to optimise power settings at the lowest effective energy levels and at tangential in- cidence to the surface to limit the concentration of en- ergy transmitted to the implant support and thus limit the potential effects of the radiation on the implant surface to be treated. The clinical experience and mode of use of the laser is fundamental and de- serves to be widely studied to con- firm the safe clinical efficacy of lasers on zirconia implant surfaces. Literature about the interviewee Dr Fabrice Baudot is a French dentist specialised in peri- odontics and implantology. He currently leads a practice that is specialised in laser-assisted microsurgery. His therapeutic ap- proach is always based on minimally invasive surgery. Dr Baudot is frequently invited to speak at international dental conferences, and he is the author of numerous scientific publications. Are there any material-specific factors that need to be particularly considered when treating ceramics with lasers? In my opinion, the only laser that is truly effective and safe in peri-implant spaces is the Er:YAG laser. As has been done for titanium implants, the effects of laser ra- diation should be tested at different power levels, under contact Dr Fabrice Baudot Impasse des Trois Pointes 65 34980 Saint-Gély-du-Fesc, France Phone: +33 4 99060060 dr.baudot34@orange.fr Interviewee details implants 2 2020 53

| events 1 2 Fig. 1: View into the meeting room, where the autumn conference of the International Society of Metal Free Implantology was held on the last weekend of September. Fig. 2: At the members’ meeting of the International Society of Metal Free Implantology, Dr Karl Ulrich Volz (left) was elected as the new president of the expert society. He takes over from Dr Dominik Nischwitz (right), who will serve as vice president from now on. Foundations for the future laid at members’ meeting of ISMI Jürgen Isbaner, Germany Owing to the travel and other restrictions that have arisen from the COVID-19 pandemic, the annual meet- ing of the International Society of Metal Free Implan- tology (ISMI), originally scheduled to take place in May in Berlin in Germany, was postponed, and with it also the regularly held members’ meeting. On the last week- end of September, however, an autumn conference of ISMI was organised in the SWISS BIOHEALTH CLINIC in Kreuzlingen in Switzerland, and within this context, the postponed members’ meeting took place. At that meeting, the expert society took the opportunity to reposition itself. The managing board of ISMI highlighted the most recent positive developments of the society and the many contributing factors, among them stable mem- bership growth, attractive continuing education offerings and effective efforts in public relations. In addition to the novel challenges that followed the establishment period of ISMI, the members’ meeting was concerned with staff- ing matters and developing broader strategies for the future. Besides the clinical experiences of practitioners, ISMI is aiming to place a stronger focus on the scientiﬁc research on the use of ceramic implants. For this rea- son, it has granted € 10,000 towards funding of a scien- tiﬁc study. The managing board of ISMI and the newly formed board of directors, under the direction of Frank- furt am Main-based Prof. Shahram Ghanaati, will be plan- ning and executing this project. Additionally, it was dis- cussed how membership of the professional association as well as the topic of ceramic implantology in general can be made more attractive, particularly to younger gen- erations. How this can be achieved will also be the topic of discussion in future ISMI board meetings. With its newly expanded leadership team, ISMI feels con- ﬁdent and well prepared for the tasks that lie ahead. After the successful autumn conference, which is planned to be an annual event from now on, attention is now being directed towards preparation for the annual meeting of ISMI, which is set to take place on 7 and 8 May 2021 in Düsseldorf in Germany. The new management of ISMI is composed of Dr Karl Ulrich Volz as president and Dr Dominik Nischwitz as vice president. Additionally, the board of directors is composed of Prof. Ghanaati, Dr Johann Lechner, Dr Benjamin Roth and Dr Tobias Wilck. For more informa- tion, visit www.ismi.me. contact International Society of Metal Free Implantology Holbeinstraße 29 04229 Leipzig, Germany Phone: +49 800 4764000 ofﬁ ce@ismi.me 54 implants 2 2020

The innovative specialist society for modern metal-free implantology Beneﬁt from the dual membership offer: Join ISMI and IAOCI now Beneﬁts ISMI and IAOCI join forces interview | Effective public relations Drs Sammy Noumbissi (US) and Karl Ulrich Volz (Swit- zerland) are two of the most experienced surgeons world- wide when it comes to modern one-piece and two-piece ceramic implants. In the past 20 years, the two combined have successfully placed several thousand ceramic im- plants. Moreover, they are the founding presidents of the first two international expert societies for ceramic implan- tology—the International Academy of Ceramic Implantol- ogy (IAOCI) and the International Society of Metal Free Implantology (ISMI). Ceramic implants had the opportu- nity to interview the two about future joint activities. Editorial note: The ISMI initially planned to hold its 2020 annual congress in May in Berlin, for the first time in co- operation with the IAOCI. Owing to the current COVID-19 pandemic, however, the decision was made to postpone the event to 2021 and it is now set to take place on 7 and 8 May 2021 in Düsseldorf. For more information, contact the organiser at events@oemus-media.de. Drs Noumbissi and Volz, you two have been friends and colleagues for many years. Now, the IAOCI has also officially joined ISMI as an educational partner for its 2021 annual congress. What’s the main reason behind you two joining forces? Dr Volz: Sammy, whom I extremely respect as a great surgeon, ambitious teacher and very honest friend, is truly committed to pushing the paradigm shift regard- ing ceramic implants forward. He dedicates and com- mits himself entirely to his expert society, the IAOCI. Yet, ceramic implants represent only a small share of the entire dental implant market. It thus makes a lot of sense to join forces and to support each other in our activities and conferences. ISMI will be organising congresses in the German-speaking countries and in northern Europe, and the IAOCI will take care not only of the US but also of Latin America, Africa, Australia and possibly Asia. Beneﬁt from a strong community that elevates the marketing of your practice through effective public relations strategies. Personal online member proﬁle ISMI provides a personal proﬁle of all active members on their website — free of charge. In addition, the ISMI patient platform provides important information for patients and features a search tool with which patients can ﬁnd their perfect dentist. implants 1 2020 57 Discount on congress fees Come and join us: attend the Annual Meeting of ISMI in Düsseldorf on 7 and 8 May 2021 and beneﬁt from ﬁrst-rate continuing education. ISMI members receive a special dis- count on the participation fee. Online archive for specialists Enjoy free and exclusive access to ISMI’s extensive online archive where you will ﬁnd a wide range of training videos and clinical case reports. There, you can also discuss all relevant questions regarding metal-free implantology with experts and colleagues from around the world. Newsletter The ISMI newsletter keeps you up to date with the latest scientiﬁc trends, products, and events on a regular basis. It also features user reports as well as a wide range of information about metal-free implantology. Specialist magazine As a member of ISMI, your membership fee includes a subscription of the inde- pendently published English language magazine “ceramic implants — international magazine of ceramic implant technology”. Published twice a year, the magazine offers specialist articles and event reports as well as industry- and science-related news from the international world of metal-free implantology. In addition, “ceramic implants” pro vides information about manufacturers and their latest products. ISMI e.V. Ofﬁce Leipzig Holbeinstraße 29 | 04229 Leipzig | Germany Phone: +49 800 4764-000 | Fax: +49 800 4764-100 Become a dual member of ofﬁce@ismi.me | www.ismi.me ISMI and IAOCI now! 7–8 May 2021 | DüsseldorfHotel InterContinentalCeramic Implants – State of the Art6TH Annual Meeting of© sutham/Shutterstock.comUP TO 16 CREDIT POINTS HOURS VERIFIABLE CPD16Simultaneous translation German/EnglishIn cooperation with:

| news 1st International Master Class of Ceramic Implantology In late December of 2020, the ﬁ rst of several training events of the 1st International Master Class of Ceramic Implantology will be held at the New Villa Claudia polyclinic in Rome in Italy. Three further training courses will follow in January and February of next year. Dr Franco Giancola will helm the event as scientiﬁ c director. In the four training courses, various important aspects of ceramic implantology will be discussed. Different ceramic im- plant systems will be compared, zirconia within the context of regenerative medicine will be discussed, the topic of minimally invasive implantology will be covered and prosthetic possibili- ties with all-ceramic implants will be addressed. The overriding objective will be to further the awareness and understanding about the global increase in diseases related to metal hypersen- sitivity and to train dentists in the effective clinical application of bio-inert zirconia implant systems. Register for the event on- line at www.zirconiamedical.eu. For more information, contact info@ceramic-implantology.com. Source: COHO Biomedical Technology ESCI is getting A new face The European Society for Ceramic Implantology (ESCI) has ap- pointed Dr Frank Maier (Germany) and Prof. Andre Chen (Portugal) as new members of its Board of Directors. It also welcomes the man- ufacturing companies TAV Dental, ZiBone, Metoxit and CeramTec as new industry partners. Moreover, since the professional associ- ation considers dental technicians the most important partners of dentists in the care of patients with ceramic implants, dental tech- nology has been incorporated into ESCI as an independent “ESCI Division Dental Technician”. Also, ESCI has developed the “ESCI Ambassador” programme and already installed ﬁ rst ambassadors in order to take individual regulations of different countries better into account. Furthermore, with its website www.esci-online.com, ESCI aims at establishing a Europe-wide and active community, generating added value for members, developing special content about ceramic implants and offering continuing education. The content featured on ESCI Online is created by ESCI members or provided by industry partners, and is published only after it has been reviewed by the Scientiﬁ c Advisory Board. With an updated further training concept, ESCI members obtain in-depth knowledge on surgical techniques via face-to-face courses held in the ESCI training centres as well as extensive e-learning courses on the ESCI online platform. In cooperation with their educational partner Dental Campus, ESCI offers its members free access to more than 120 lectures, 60 clinical cases and over 680 surgical videos. Source: European Society for Ceramic Implantology (ESCI) 56 implants 2 2020

Poor oral hygiene could affect Accuracy of SARS-CoV-2 tests A study conducted at a hospital in Tokyo has found that poor oral hygiene could lead to prolonged viral shedding in patients with COVID-19. The researchers evaluated the course of treatment of eight COVID-19 patients who were admitted to the Department of Neurol- ogy at Tokyo Metropolitan Neurological Hospital between 30 April and 14 May 2020. In the study, it was observed that patients with inadequate oral health regimes returned positive results in polymerase chain reaction (PCR) tests for the virus long after their clinical recovery, leading the researchers to believe that oral hygiene could affect the accuracy of testing for the virus. In response to the ﬁ ndings, the researchers are proposing that ef- fective toothbrushing and gargling could improve the accuracy of COVID-19 testing and reduce the duration of hospital stays. The study, titled “Effects of oral care on prolonged viral shedding in news | m o c . k c o t s r e t t u h S / S K S K © coronavirus disease 2019 (COVID-19)”, was published online on 24 July 2020 in Special Care in Dentistry, ahead of inclusion in an issue. Source: Dental Tribune International “CleanImplant Certiﬁ ed Dentists” in 19 countries Initiative creates safety for implantologists and patients For many years, CleanImplant has been performing quality as- sessment studies on sterile packaged implants in accredited test- ing laboratories. The “Trusted Quality” seal for clean implants can only be awarded after an independent evaluation of test results has successfully been completed in a strict peer-review process. “Alarming contamination on many other test samples should raise concerns for every practitioner,” says Dirk Duddeck, dentist and founder of the non-proﬁ t CleanImplant Foundation. Study results show quite clearly that neither the exposed market position of manufacturers nor the country of production or the price alone can provide any certainty that the implants sold are actually clean. Sig- niﬁ cant residues of detergents, silicon compounds or polyacetal— even on ceramic implants—from the production and packaging process have been found on sterile packaged samples. “We’ve also seen metallic particles with nickel- or copper-containing com- pounds on dental implants. Implant quality seems to be getting out of hand—and we are no longer alone with this criticism. Three years ago, we launched an ini- tiative for residue-free implants on the internet. We never dreamed that we would have almost 100,000 dental professionals following us on Facebook in such a short time”. In the mean- time, implantologists from 19 countries are reg- istered as a “CleanImplant Certiﬁ ed Dentist”. They can be sure that they only use implants that have been tested as clean. On the new web- site www.cleanimplants4you.org, launched as an information campaign directed at patients, a list of practices that have already joined the initiative can be found. For more information, go to www.cleanimplant.org. Source: CleanImplant Foundation CIF GmbH CleanImplant-Certiﬁ ed Practices. implants 2 2020 57

| about the publisher Congresses, courses and symposia Art Director Alexander Jahn a.jahn@oemus-media.de Designer Sandra Ehnert s.ehnert@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 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 2nd EACim Congress 16–17 April 2021 Brussels, Belgium www.eacim-ceramic-implantology.com 6th Annual Meeting of ISMI 7–8 May 2021 Düsseldorf, Germany www.ismi-meeting.com 10th IAOCI World Congress 20–22 May 2021 Las Vegas, NV, USA www.iaoci.com/iaoci2021 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. 30th annual scientiﬁ c meeting of EAO 14–16 October 2021 Milan, Italy www.eao.org 58 implants 2 2020