| content editorial To be continued … Drs Georg Bach & Rolf Vollmer research Professional implant management page 06 Marie-Therese Heberer & Prof. Nicole B. Arweiler SEM investigation of implant surface characteristics Drs Branislav Fatori & Inge Schmitz case report Mandibular dentigerous cyst Drs Fernando Duarte & Carina Ramos 03 06 14 16 Combining standard and ultrashort implants in full-mouth rehabilitation 22 page 14 Drs Giovanni Ghirlanda, Michele Vasina & Laura C. Campos Interproximal root spreading for narrow implant placement 28 Dr Mauro Marincola, Dr Laura Murcko, Dr Giorgio Lombardo & Prof. Rolf Ewers Immediate placement of a new fully tapered tissue-level implant 32 Dr Mario Roccuzzo practice management Practice strategies in the time of the coronavirus Dr Anna Maria Yiannikos page 28 news Cover image courtesy of TBR Dental Group www.tbr.dental manufacturer news news issn 1868-3207 • Vol. 21 • Issue 4/2020 4/20 implants international magazine of oral implantology about the publisher imprint research Professional implant management case report Combining standard and ultrashort implants in full-mouth rehabilitation case report Interproximal root spreading for narrow implant placement 04 4 2020 34 36 40 42

| research Professional implant management A balance between thorough but gentle cleaning Marie-Therese Heberer & Prof. Nicole B. Arweiler, Germany The treatment of peri-implant disease remains a great challenge for the practising dentist. In spite of current guidelines, a direct therapy recommendation for treating diseased implants is still lacking. Owing to demographic change and the wide range of indications for implants, peri-implant disease is becoming an increasingly rele- vant problem in everyday practice. Since peri- implantitis is an irreversible disease that can lead to pain, severe aesthetic impairments and implant loss, it is necessary to adequately care for implants and treat the first signs of peri-implant inflammation at an early stage. On peri-implantitis and how it can occur Peri-implant health and disease were classified in the context of periodontal and peri-implant diseases and conditions at the joint World Workshop of the American Academy of Periodontology and the European Federa- tion of Periodontology in 2017 for the first time.1 Table 1 provides an overview of the case definition of peri-implant health and peri-implant disease. Peri-implant health, on the one hand, is clinically defined as the absence of signs of inflammation such as erythema, bleeding on probing, swelling and suppuration. Peri-implant diseases, on the other hand, are classified as biofilm-associated diseases that are clinically conspicuous by inflammatory changes in peri-implant soft tissue accompanied by bleeding on probing and/or suppuration.2 Compared with mea- surements at the time of insertion of the superstructure (baseline), which are caused by progressive bone loss that goes beyond the initial remodelling, peri-implantitis shows increased probing depth.3 Given the lack of ra- diographs and probing depth measurements at baseline (directly after superstructure insertion), radiographic ev- idence of a bone level of ≥ 3 mm and/or a probing depth of ≥ 6 mm connected with heavy bleeding and/or sup- puration after probing are sufficient for the diagnosis of peri-implantitis. In contrast, peri-implant mucositis does not involve any decrease of the crestal bone level beyond the initial remodelling after insertion of the implant. Similar to periodontitis, which is almost always preceded by chronic gingivitis, peri-implant mucositis exists be- fore peri-implantitis arises. As mentioned earlier, this is marked by signs of inflammation, but does not yet in- volve bone resorption. Peri-implant mucositis is strongly associated with biofilm, which makes it—fortunately—re- versible by adequate biofilm management. The transi- tion to peri-implantitis is fluid and cannot be diagnosed clearly, and this must be taken into account when select- ing the treatment approach. The cause of the progres- sion of peri-implant mucositis to peri-implantitis has not been identified yet,1 but the risk factors described later certainly play a role. If no elaborated therapy for peri- implantitis is provided, rapid, often non-linear progres- sion of bone resorption and inflammation occurs,4 pre- sumably with faster spread and higher prevalence than in periodontitis. Peri-implantitis can already occur at the be- ginning of the maintenance phase, even shortly after the implantation. Noticeable problems can be expected af- ter five years, and 20 % of patients require peri-implantitis therapy after five to ten years.5 Some experts report the start of the disease two to three years after implantation.6 Risk factors for peri-implantitis The aetiology of peri-implantitis is comparable to that of periodontitis. Both are multifactorial events that are modi- Peri-implant health Peri-implant mucositis Peri-implantitis BOP and/or suppuration with gentle probing (possibly increased PD compared with baseline) Bone loss – – + – Table 1: Case definition of peri-implant health and disease according to the new classification.1 + + 06 4 2020

2 Fig. 2: Powder air polishing systems with low-abrasive powder (glycine and erythritol powder) clean gently. for short-term ( 14-day) intensive bacterial reduction and therewith reduction of an acute inflammatory event, mouthrinses containing 0.06 % chlorhexidine, a special formulation of essential oils, a formulation with amine flu- oride or stannous fluoride, or a formulation with cetylpyr- idinium chloride can support insufficient mechanical oral hygiene for a variety of reasons. For implants, the spe- cific application of a 1 % chlorhexidine gel is also suit- able. Regular professional mechanical biofilm removal by trained persons as well as an improvement of biofilm management at home are the basis for the success of the therapy, both for prevention and in the case of already existing peri-implantitis.7, 17, 21–23 Professional prophylactic measures In addition to these prophylactic measures, the practitioner must identify the systemic and local risk factors already mentioned and at least provide the impetus to remove them, which should be done before implant placement if possible.8, 17 In order to confirm success, but also to be able to recognise the necessity of further therapy mea- sures, regular check-ups including measurements are also indispensable for the dentist throughout the patient’s life. Measurements, supragingival and, where necessary, subgingival cleaning (scaling and root planing) should be performed up to four times a year and should be carried out at regular intervals. Checking the complete periodon- tal status is recommended at least once a year in the case of six-monthly follow-up intervals and at least twice a year in the case of three-monthly intervals. Designing supportive peri-implant therapy cleaning must not be omitted owing to fears of possible surface damage. A compromise must be found between protecting the implant by gentle instrumentation to avoid deep scratches on its surface and thorough cleaning. Rough implant surfaces show not only more biofilm but also a more pathogenic flora, whereas surfaces that are too smooth disrupt soft-tissue attachment and fibroblast attachment. Hence, a good balance between bacterial adhesion and soft-tissue adhesion must be found.23 The practitioner has various therapy options for subgingival cleaning. Recently, Schmidt et al. conducted a series of studies to examine cleaning options for their balance be- tween bacterial adhesion and soft-tissue adhesion.24–26 The following conclusions were drawn: a) If curetting is necessary (i.e. radiographically visible deposits), titanium curettes should be used instead of the conventional steel curettes, as they are much gentler on titanium surfaces. b) Ultrasonic instruments with a plastic coating hardly change the surface roughness, but should be re- served for the removal of hard deposits. c) Air-powder prophylaxis units with low-abrasive pow- der (glycine and erythritol powder; air polishing) are ideal for biofilm removal. At probing depths of up to 5 mm, it is even possible to blast into the sulci. At higher probing depths, nozzle attachments should be used (Fig. 2). The spray jet of the nozzles is deflected laterally so that it does not radiate apically and the risk of emphysema formation is avoided. The mentioned approaches (titanium curettes, ultrasonic instruments, air polishing with low- abrasive powder) are gentle on the implant surfaces, show good clinical re- sults and do not differ significantly from each other. Steel curettes lead to greater surface roughness and should therefore be avoided.24–26 Considering teeth, the clinical and microbiological results of subgingival air polishing for moderately deep pockets are similar to those of ultra- sonic treatment.27 Compared with conventional scaling and root planing, subgingival air polishing actually per- forms better in terms of its effectiveness in subgingival biofilm removal.28 Good results for subgingival therapy with air polishing have also been demonstrated for im- plants with peri-implant disease.8 Good oral hygiene of the patient as well as regular, life- long maintenance care sessions at intervals of three to six months are the key to long-term success. The reg- ular recording of findings in order to determine both the oral hygiene status and the attachment level to implants and to diagnose changes at an early stage are the basis for this. Part of each session of supportive peri-implant therapy should include supragingival measures as well as regular motivation and instruction of the patient on good home biofilm management. An essential part of these maintenance sessions should, if necessary, be devoted to subgingival instrumentation of the implants. Necessary The effectiveness of hand instruments, adjuvant air pol- ishing (glycine powder) and ultrasonic scalers has been proved by clinical studies on implants with a significant im- provement in clinical parameters (especially bleeding on probing).29, 30 The elimination of inflammatory signs should be the primary goal of all procedures.17, 31 In addition to cleaning, an individual risk analysis and, if possible, the elimination of risks must also be part of maintenance care if they have developed after implant placement. This in- cludes advice on quitting smoking but also an exchange with the attending physician or internist to optimise the control of any diabetes that may be present. Subgingival 08 4 2020

PD up to 3 mm BOP positive with polish and if applicable mechanical cleaning air-polishing maybe antibacterial agents PD 4 – 5 mm BOP and API independent mechanical cleaning with polish, air-polishing, subgingival instrumentation possibly adjuvant antibacterial therapy no crater formation PD > 5 mm BOP and API independent mechanical cleaning with polish, air-polishing, subgingival instrumentation obvious crater formation < 2 mm resective or regenerative surgery bone loss > 2 mm Fig. 3: Therapy options for peri-implantitis therapy. PD = probing depth; BOP = bleeding on probing; API = approximal plaque index. 1% CHX-gel twice a day for 3–4 weeks (systemic or) local antibiotics photodynamic therapy cleaning can also be supplemented in the context of a re-evaluation or supportive peri-implant therapy by anti- bacterial therapy measures such as local antibiotics, pho- todynamic therapy and laser as part of re-evaluation. What if peri-implantitis occurs nevertheless? There is no standardised therapy scheme for peri- implantitis, but there are therapy suggestions that can be used to decide on the further course of action on an individual basis. These are shown in Figure 3 by a deci- sion tree and are briefly explained in the following. Non-surgical therapy for implants The non-surgical removal of biofilm is the basis for any therapeutic approach to peri-implant disease and in the case of peri-implant mucositis in particular. For peri- implantitis therapy, the non-surgical approach is the im- portant basic therapy and can be supplemented by fur- ther measures.17, 32 Nevertheless, the success in pockets with an initial depth of > 7 mm is considered to be low.17 In addition to an antiseptic home therapy to accompany biofilm control with chlorhexidine digluconate, it can be used as a complement to local mechanical debridement as pocket irrigation or as an application in gel form, which should lead to a significant improvement in probing depth after a control period of three or eight months. However, bleeding on probing is not affected by the use of chlorhex- idine.33, 34 Further antibacterial procedures are, as men- tioned before, local antibiotic therapy and photodynamic disinfection.12 Significant reductions in probing depth, re- cession and plaque in cases of initial peri-implantitis have been proved for both local antibiotic therapy and pho- todynamic therapy (–0.15 mm).35 For systemic antibiotic administration, no improvement in clinical and microbi- ological parameters has been found.36 Figures 4 and 5 show a heavy smoker with moderate oral hygiene who— with exclusively non-surgical therapy measures—could be kept stable as far as possible because professional intervention was carried out early on. An elimination of the 4 5 Fig. 4: In this peri-implantitis patient (heavy smoker, moderate oral hygiene), small successes could be achieved through early scaling and root planing, and thus the situation was kept largely stable. Nevertheless, smoking cessation and an improvement in oral hygiene should be aimed for in order to achieve greater success. Fig. 5: Radiographic image of the same patient as in Figure 4. 10 4 2020

6 7 Fig. 6: Patient with severe advanced peri-implantitis whose superstructures in regions #32 and 42 were difficult to clean, but with satisfactory oral hygiene. Fig. 7: Radiographic image of the same patient as in Figure 6. The bowl-shaped bone resorption around the implants is clearly visible. Defect type Surgical technique Deep bowl-shaped defect – Thorough cleaning and disinfection of the implant surface – Defect reconstruction No clear bone wall or significant horizontal bone resorption – Thorough cleaning – Reduction of the marginal mucosa with the aim of enabling effective oral hygiene by the patient Table 2: Selection of the surgical approach based on the bone defect (modified from Schwarz et al.21 and Renvert & Polyzois38). above-mentioned risk factors should be striven for in or- der to further improve the situation around the implants. Surgical therapy for implants If peri-implantitis has progressed to such an extent that these conservative approaches with scaling and root planing no longer allow inflammation control and no im- provement can be achieved (Figs. 6 & 7), resective or regenerative surgery or, in the worst case, explantation must be considered. When an implant has become loos- ened, explantation is the only therapy option.17 The sur- gical technique should be selected based upon the bony lesion (Table 2). A recommendation for the exact tech- nique cannot be given at this stage.17 Studies however show a correlation between the success of regenera- tive therapy and the defect configuration.37 Similar to a non-surgical approach, debridement and cleaning of the implant surface are the goals of the surgical procedure, which should be supplemented by defect reconstruction, reduction of probing depth and improvement of hygiene capability.31, 32 Additional surface decontamination with, for example, a 980 nm diode laser does not show any improvement in the clinical or radiographic outcome of implants.17 Unfortunately, as numerous publications em- phasise, aesthetic losses must be accepted to prevent the progression of peri-implantitis. Summary While a definitive concrete therapy recommendation for peri-implantitis therapy cannot be given at present, profes- sional biofilm management in the practice as well as oral hygiene at home are the basis for the resolution of inflam- mation around the implant (as well as the tooth) and must therefore be practised regularly and well taught. Supple- mentary therapeutic measures such as local antibiotics, photodynamic therapy and surgical approaches are pos- sible and should be carried out depending on the degree of progression of the disease. Measures that significantly change the implant surface, such as the use of steel cu- rettes or implantoplasty, should be avoided if possible. All images: © Marie -Therese Heberer & Nicole B. Arweiler Marie-Therese Heberer Author details Prof. Nicole B. Arweiler Author details Literature contact Marie-Therese Heberer Department of Periodontology and Peri-Implant Diseases Philipps University of Marburg, UKGM Georg-Voigt-Straße 3 35039 Marburg Germany heberer@med.uni-marburg.de Prof. Nicole B. Arweiler Department of Periodontology and Peri-Implant Diseases Philipps University of Marburg, UKGM Georg-Voigt-Straße 3 35039 Marburg Germany arweiler@med.uni-marburg.de 12 4 2020

| research SEM investigation of implant surface characteristics Drs Branislav Fatori & Inge Schmitz, Germany Implants have become an essential part of restorative dentistry. Their success and long-term prognosis mainly depend on design, accurate manufacturing of their sur- face structure, bone quality, clinical skill and individual risk factors. Titanium implants have been used in dentistry with great success for more than 50 years and various sur- face modifications have been made to improve osseointe- gration. An ideal implant requires high levels of surface cleanliness in order to minimise the risk of foreign body reactions. Different implant systems have different surface properties, leading to different cell adhesion results. Objective Contaminants from the manufacturing or packaging pro- cess can cause an uncontrolled foreign body reaction re- 1a 1c 1b 1d sulting in the formation of high amounts of connective tis- sue, which leads to insufficient osseointegration. Against this background, the authors examined the surface char- acteristics of a new implant prior to its clinical use in their private practice. The implant was analysed using scan- ning electron microscope imaging (SEM) and energy- dispersive X-ray spectroscopy (EDX) in order to deter- mine the elemental composition of potential impurities. Material The investigated implant was a DSI RBM Premium Line implant (Dental Solutions Israel) made of titanium alloy Ti-6Al-4V ELI, in accordance with ASTM-F136-02. It has a spiral thread design with twin cutting grooves. The coro- nal micro-threads are designed to increase bone–implant contact and, in turn, long-term stability in the crestal area. The micro-rings on the implant neck are designed to mi- nimise shear forces in the crestal zone and peri-implant bone loss. This tapered implant features a 2.42 mm in- ternal hex connection, one abutment platform for all im- plant diameters (3.5–5.0 mm) and an increased fixture- abutment contact area. The apex is rounded and features self-tapping threads for optimal surgical flexibility. Implant surface The investigated implant has a resorbable blast media (RBM) surface. During manufacturing, this surface is treated with high-speed particle blasting, using the re- sorbable bioceramic beta-tricalcium phosphate (-TCP). The surface is cleaned and etched from calcium particles with a low concentrated organic acid. This process does not change the titanium surface pattern and produces a uniform surface with homogenous pore diameters and a greater bone-to-implant contact value (BIC). -TCP, a resorbable material often used in synthetic bone grafts, dissolves during the healing process. The surface rough- ness value (Ra) is between 2.5 to 3.0 µm. The micro-pits in the surface measure 1–3 µm. SEM analysis Fig. 1: Overview (a), detailed view of spirals and inhomogeneous rough surface (b), roughness of the surface with organic deposition is clearly visible (c), rough surface (d). The Zeiss DSM 940 scanning electron microscope and the X-ray spectroscopy system NORAN System SIX 14 4 2020

| case report Mandibular dentigerous cyst Enucleation and bone reconstruction Drs Fernando Duarte & Carina Ramos, Portugal The dentigerous or follicular cyst is the most common type of developmental odontogenic cyst and the second most common among all that occur in the jaws, repre- senting about 20 % of all cysts.1, 2 By definition, a dentiger- ous cyst is attached to the tooth cervix (cementoenamel junction) and encloses the crown of the unerupted tooth. It is a benign lesion associated with the odontogenic ep- ithelium of the crown of an unerupted tooth and origi- nates from the separation of the follicle around the crown of the tooth in question, forming a cavity bounded by the reduced enamel epithelium and the tooth enamel, which is filled with cystic fluid.3 As with other cysts, expansion of a dentigerous cyst is related to epithelial proliferation, release of bone-resorbing factors and an increase in cyst fluid osmolality. Aetiology and pathogenesis Although its aetiopathogenesis is not fully known, it is believed that epithelial proliferation around a fluid-filled cavity grows continuously by osmotic pressure over an extended period, as long as the tooth does not erupt.3 If this pressure is removed by the tooth erupting, the cyst will no longer be a pathological entity.3 1a 16 Fig. 1a: Initial dental panoramic tomogram. 4 2020 Histopathology Histologically, the characteristics of dentigerous cyst are variable. If it is not inflamed, it has a loose and thin con- nective tissue capsule, covered by non-keratinised epithe- lial cells, composed of two or three layers of flat or cuboi- dal cells. When there is a secondary infection present, the connective tissue is denser and there is variable infiltration of chronic inflammatory cells. The lining epithelium may show variable levels of hyperplasia, developing epithelial ridges with more striking scaly characteristics.1 Differential diagnosis Differential diagnosis of pericoronal radiolucency should include odontogenic keratocyst, ameloblastoma and other odontogenic tumours. Ameloblastic transforma- tion of a dentigerous cyst lining should also be part of the differential diagnosis. Adenomatoid odontogenic tu- mour would be a further consideration with anterior peri- coronal radiolucencies, and ameloblastic fibroma would be a possibility for lesions occurring in the posterior of the jaws of young patients.3 Clinical features Dentigerous cyst occurs predominantly in the first three decades of life, has a predilection for the male sex and affects more Caucasian individuals. Although this pathol- ogy may occur in any unerupted tooth, the teeth most frequently affected are the mandibular third molars, max- illary canines and mandibular premolars.1, 4 The occur- rence in primary dentition is extremely rare.5 Clinically, these lesions are, in most cases, of slow and asymp- tomatic growth; however, they can grow considerably and cause expansion of the cortical bone, facial defor- mation, impaction or displacement of teeth and adjacent structures, paraesthesia and discomfort.6 They may be associated with some syndromes, when they present in multiple or bilateral forms, such as Maroteaux–Lamy syn- drome and cleidocranial dysplasia.6 Radiographically, in most cases, dentigerous cyst appears as a radiolucent unilocular cavity with a well-defined sclerotic margin, in- volving the crown of an unerupted tooth, starting from the cementoenamel junction, although multilocular aspects can also occur in large lesions.7, 8 While a normal dental

| case report 2a 3a 4a 2b 3b 4b 2c 3c 4c Fig. 2: Osteotomy with piezoelectric surgery (a), cystic capsule with impacted tooth 38 (b), intraoperative image of the cystic cavity (c). Fig. 3: Platelet- rich fibrin (a), CERASORB® Foam used to protect the inferior alveolar nerve (b), intraoperative image of inferior layer of bone reconstruction (c). Fig. 4: Sticky bone for cystic cavity reconstruction (a), Osgide® resorbable membrane covering complete area of bone reconstruction (b), intraoperative image after suturing (c). axial sections of the CT scan, it could be seen that the lesion was in close contact with the mandibular canal and there was cortical bulging (Figs. 1b & c). As initial options for diagnosis, the possibilities of odon- togenic keratocysts, unicystic ameloblastoma, adeno- matoid odontogenic tumour and dentigerous cyst were considered. Aspiration puncture was performed under local anaesthesia, producing a small amount of light- yellow liquid and thus confirming the cystic nature of the lesion and working as decompression to reduce the lesion size. Endodontic treatment of tooth #36 was per- formed prior to surgical intervention. The patient was operated on under general anaesthesia, with nasal intu- bation. An intra-oral incision was made in the left retro- molar region that extended to the canine region, where a discharge incision was made. The osteotomy for access to the cystic cavity was performed by piezoelectric sur- gery. Based on 3D control of ultrasonic microvibrations, a micrometric and selective cut is allowed, under good visibility (cavitation effect) that results in minimal dam- age to soft tissue and nervous structures (Fig. 2a).19 The equipment used was the VarioSurg3 (NSK). The cystic capsule was excised together with the extraction of in- cluded tooth #38 and tooth #37 (Fig. 2b). The remaining cavity was cleaned with saline solution, keeping the lower border of the mandible intact (Fig. 2c). Bone regeneration was performed with CERASORB® M (curasan) in granule and foam form combined with fibrin and Osgide® resorbable membrane (curasan). CERASORB® M is a resorbable and pure-phase beta- tricalcium phosphate ceramic for implantation filling, binding and reconstruction of bone defects, as well as bone fusion in the entire skeletal system. The granules have a polygonal shape, and owing to the open inter- communicating multi-porosity composed of micro-, meso- and macropores (about 65 %), the radiopacity is lower and absorption is effected faster. Over months in contact with the vital bone, the material is resorbed by 18 4 2020

| case report (Fig. 4b). Suturing was performed with simple stitches using non-resorbable thread (silk, 4/0; Fig. 4c). The patient underwent systemic antibiotic, analgesic and anti-inflammatory therapy for eight days. In postoperative care, the patient was instructed to maintain strict oral hy- giene. The material obtained from the cystic cavity was sent for pathological examination, and the findings were islands of odontogenic epithelium remains scattered in the fibrous connective tissue capsule, composed of three layers of flattened, non-keratinised cells. These findings confirmed the diagnosis of dentigerous cyst. At the time of writing, the patient was in the postoperative period of 12 months and had shown no hypoaesthesia or any sign of recurrence of the lesion. In the postoperative dental panoramic tomogram (Fig. 5a) and CT scan, there was evidence of bone neo-formation in the area previously occupied by the lesion (Figs. 5b & c). Discussion Among the possible treatment techniques for dentig- erous cyst, the most suitable for each clinical situation should be evaluated, considering all scenarios for each option.7 In the present clinical case, had the treatment been decided on considering only the size of the le- sion, enucleation would have been the most appropriate choice associated with the extraction of the impacted tooth #38. Owing to the proximity of the inferior alveo- lar nerve, decompression followed by cyst enucleation and extraction of the tooth in question was the most reasonable option. This allowed bone regeneration of the cystic cavity, as well as maintenance of nerve integ- rity. Enucleation is the technique of choice for cysts of smaller dimensions and when there is no involvement of important anatomical structures, since it provides the possibility of a histological study of the lesion.1, 12 Mar- supialisation and decompression with the use of a de- vice should be reserved for clinical cases of extensive dimensions, involving important anatomical structures and increased risk of fracture, as they promote the re- duction of intracystic pressure, consequently reducing the size of the lesion.7, 8, 10, 11, 18 Taking into account this objective of decompression, it was decided in this clin- ical case to maintain the lesion–oral cavity communi- cation created during the aspiration puncture, which, although reduced, was sufficient to regress the dimen- sions of the lesion. 1. It is mouldable, so it adapts well to various shapes of bony defects. 2. Micro- and macro-movement of grafted bone is pre- vented, so the volume of augmentation is maintained during the healing period. Therefore, the need for block bone and titanium mesh is minimised. 3. Fibrin network entraps platelets and leucocytes to re- lease growth factors, so bone regeneration and soft- tissue growth are accelerated. 4. No biochemical additives are needed to make sticky bone. 5. Fibrin interconnection minimises soft-tissue ingrowth into the sticky bone graft.21 Conclusion Dentigerous cyst is a frequent lesion which, despite be- ing a less aggressive pathology and without clinical symp- toms, has the potential to reach large proportions, caus- ing significant movement of teeth. The treatment decision must be based on objective criteria, such as age of the patient, size of the lesion, involvement of relevant anatom- ical structures, clinical importance of the tooth or teeth associated with the lesion, and risk of bone fracture. It is essential to perform a histopatho- logical examination for the differen- tial diagnosis, ruling out other types of lesions with similar clinical and radio- graphic characteristics, as well as to perform annual postoperative radio- graphic monitoring. Literature about the author Dr Fernando Duarte is a Portugal- based dentist who specialises in oral surgery. He holds a postgraduate quali- fication in oral and maxillofacial surgery and a master’s degree in oral and max- illofacial surgery from Eastman Dental Institute at University College London in the UK. Dr Duarte is the CEO and clinical director of the Clitrofa medical centre in Trofa in Portugal. contact Both marsupialisation and decompression are therapeu- tic modalities also indicated in the period when the bone repair capacity is high and the eruptive power of the teeth is present.10, 11 Sticky bone is biologically solidified bone grafting material which is entrapped in fibrin network. Sticky bone graft granules are strongly interconnected to each other by the fibrin network. Sticky bone has nu- merous advantages: Dr Fernando Duarte Clitrofa—Centro Médico, Dentário e Cirúrgico Avenida de Paradela 626 4785-342 Trofa Portugal Phone: +351 252 428960 fduarte@clitrofa.com Author details 20 4 2020

| case report Combining standard and ultrashort implants in full-mouth rehabilitation 18 months of follow-up Drs Giovanni Ghirlanda, Michele Vasina & Laura C. Campos, Italy Introduction The use of shorter implants was introduced in the early 1990s to overcome the necessity of complex and expen- sive bone augmentation procedures associated with im- plant therapies. In recent years, different proposals have been made regarding the length that would classify im- plants as short in comparison with standard implants. Now, there is consensus that implants with a length of ≥ 8 mm are considered as standard, 6–8 mm long im- plants are classified as short and implants with a length of < 6 mm are defined as ultrashort.1 Since 2011, the results of several clinical trials regarding the predictability and the clinical reliability of ultrashort implants have been published, considered by them- selves or in comparison with some of the most com- monly utilised guided bone regeneration procedures. In 2012, Felice and co-workers reported a significant mi- nor occurrence of complications in relation to 5 x 5 mm hydroxyapatite- coated implants compared with 11.5 mm long implants placed in augmented bone after six months of follow-up in a randomised clinical trial conducted on 80 patients (40 of them with a reduced height of bone below the maxillary sinus and 40 over the mandibular nerve).2 In a single cohort study on 110 implants, followed up for five years, Perelli and colleagues described a cumu- lative success rate of 90 % for the implants and 93 % for the prosthetic rehabilitation.3 In 2015, Esposito et al. pub- lished the results of three years of follow-up results of the same group of patients, who presented with significantly less marginal bone loss for the implants placed in the maxilla and no differences for the ones in the mandible.4 More recently, in 2016, the same researchers started a multicentre clinical trial on 4 x 4 mm implants. They pub- lished the preliminary report of a one-year follow-up, in which they did not find differences in the outcomes between ultrashort and standard (at least 8.5 mm long) implants.5 It should be pointed out that the pa- tients participating in the study received a three-unit implant-supported prosthesis, for which there was at least one standard implant, in the absence of significant bone atrophy. Diversely, a recent review by Papaspyri- dakos et al. compared the clinical efficacy of ultrashort implants and longer implants.6 The multivariate analysis described in this review assigned an odds risk ratio of 1.29 to the ≤ 6 mm implants compared with the standard ones. A common conclusion of papers on short implants is that they are advantageous in that they present signifi- cantly fewer postoperative complications and are faster and simpler for patients with significant bone resorption and that treatments are less expensive for such patients. Immediate loading is a therapeutic approach that has demonstrated long-term results regarding high reliability and efficacy.7 It is beyond the aim of this case report to describe the evidence that supports the predictability of this approach. However, it has been definitively stated that primary stability is a key factor for success. Achieving a sufficient degree of primary stability with short and, above all, ultrashort implants is a true challenge. Anitua pub- lished a case series of ten immediately loaded implants in the posterior maxilla with more than four years of follow-up.8 Among the implants placed, five were 7.5 mm in length and the other five 8.5 mm. Nine out of ten implants (cumulative success rate of 90 %) were considered sta- ble at the follow-up. In 2018, Weerapong et al. compared 23 immediately loaded short implants of 6 mm in length with 23 conventionally loaded standard implants of 10 mm in length.9 All the cases evaluated were intercalated mandibular first molars. They concluded that the results achieved with immediate loading of the short implants was comparable to those achieved for the standard implants in terms of implant survival, marginal bone level change and implant stability quotient value. To the best of our knowledge, there are no published papers reporting on immediate loading on ultrashort implants. The following case report describes an implant-supported full-mouth rehabilitation realised with a combination of ultrashort and standard implants with a follow-up of 18 months. Clinical case The 66-year-old male patient, classified as ASA II, pre- sented to the clinic complaining of pain, mobility and 22 4 2020

| case report 3 4 Fig. 3: Extraction of all compromised teeth and implants. Fig. 4: Prosthetic templates used to check occlusion and assure reproducibility. thetic copings with the template positioned in centric oc- clusion of the patient. Once the polymerisation process was complete and the perfect stability of the template to the copings had been checked, a light impression ma- terial was injected below the template through the small holes that had been prepared in advance. Afterwards, the mandibular prosthetic template was sent to the lab- oratory for the production of the temporary prosthesis. Thereafter, a full-thickness flap was elevated that ex- tended all along the maxillary arch. Careful debride- ment was performed to remove all the inflammatory and fibrous tissue and to expose all the bone defects. Af- terwards, the shallow defects were reshaped with bone chisels and round burs, while the deep defects were filled with xenograft (Geistlich Bio-Oss, Geistlich Biomaterials) and covered with a resorbable barrier (Geistlich Bio-Gide, Geistlich Biomaterials). In the anterior region, standard implants were inserted (blueSKY), while in the first mo- lar sites, two 5.2 x 6.0 mm fixtures (copaSKY, bredent medical) were inserted (Fig. 5). To maximise the degree of primary stability of the ultrashort implants, bicortical- ism was considered for the creation of an in-fracture of the sinus floor by means of osteotomes so that the ultra- short implants would have improved stability. The fixtures did not protrude into the sinus, nor was there evidence of elevation of the sinus mucosa. All the implants achieved a primary stability of ≥ 35 Ncm. The panoramic radiograph taken at the end of the surgery showed the correct posi- tioning of the implants (Fig. 6). Fig. 5: Back-tapered ultrashort implant being inserted into the posterior region of the maxilla. Fig. 6: Dental panoramic tomogram showing implants in good position. The ultrashort implants were well placed in relation to the sinuses, but surrounded by a low quantity of bone. 6 5 24 4 2020

| case report RHS At insertion At 18 months LHS 11a At insertion At 18 months 11b Fig. 11a: Dental panoramic tomogram at the 18-month follow-up, showing increased bone density around the ultrashort implants. Fig. 11b: Comparison of the bone quality to the right and left of the ultrashort implants at time of insertion and at 18 months. were placed in the sites with poor bone quality. Ultrashort implants have already demonstrated substantial reliability in situations where the anatomy of the site does not allow the placement of a standard implant.5, 12 Even shorter im- plants than those used in the case described here have been successfully used. However, it has to be highlighted that the loading protocol utilised in the study design of those papers was a conventional one. Nowadays, im- mediate loading is considered a valid option among the possible approaches in implant treatment, especially us- ing standard implants that are inserted into bone of good quality.7 In the literature, there is only one clinical trial in which single short implants of 6 mm in length were com- pared with standard measures in the rehabilitation of a mandibular first molar.9 There are some differences, be- yond the negligible differences in length, between the de- sign of the cited study and this case report. First, whereas our ultrashort implants were placed in an edentulous arch, in the study of Weerapong and colleagues, they were placed in the saddle area between the second mo- lar and the first premolar.9 Second, the implants were in- serted into the mandible, whereas in our case they were placed in the maxilla in the regions of poor bone quality. Anitua’s case series reported a nine out of ten success rate for 8.5 and 7.5 mm long implants. The present case was followed for 18 months, during which only a minor prosthetic complication was noted.8 The radiographic control showed perfect stability of the bone levels around all the implants. An improvement of the bone height and quality around the ultrashort implants was also evident. Theoretically, this evidence can be related to the anchor- age to the sinus floor cortical bone that was intention- ally searched in order to improve the degree of primary stability. Furthermore in Anitua’s cases, no other proce- dure was performed, nor was grafting material used in the sites of the ultrashort implants. Conclusion This case report has shown the successful outcome of an immediately loaded full-mouth implant-supported prosthetic rehabilitation. The medium-term follow-up, 18 months, and the radiographic evidence support a positive clinical outcome of the case presented. Further studies and clinical series are neces- sary to validate the choice of ultra- short implants in relation to the im- mediate loading approach as a useful means of overcoming anatomical challenges related to the placement of standard implants. Literature about the author Dr Giovanni Ghirlanda specialises in oral surgery, periodontics and implan- tology. He graduated in dentistry and dental prosthetics and later completed a master’s programme in implantology at the University of Murcia in Spain. In 1992, he was a visiting lecturer at Har- vard School of Dental Medicine in Bos- ton in the US. From 1996 to 1999, he was an adjunct professor at the Sapienza University of Rome in Italy. He is a member of the Italian Society of Osseointegration. contact Dr Giovanni Ghirlanda Via Mantova 1 00198 Rome RM, Italy Phone: +39 06 8840120 www.dentistiromacso.it Author details 26 4 2020

| case report Interproximal root spreading for narrow implant placement Dr Mauro Marincola, Dr Laura Murcko, Dr Giorgio Lombardo & Prof. Rolf Ewers, Italy, Austria & USA Introduction Congenitally missing lateral incisors are quite common. In some communities, we observe an incidence of up to 3 % in the young population. Today, these teeth can be successfully replaced with dental implants.1 Very often, these patients must undergo orthodontic treatment to obtain the adequate mesiodistal and buccooral dimen- sions. In many of these cases, the distances between the two neighbouring teeth remain critical because the orthodontist has moved the coronal part, but the roots still remain critically close to one another.2 Narrow im- plants are becoming the ideal treatment option in case of reduced bone volume.3–6 An accurate literature review on the correct protocol to follow during treatment planning for narrow spaces in the maxillary anterior region leads us to the conclusion that the minimum width for narrow implant placement (3.0–3.3 mm diameter) to replace a maxillary anterior tooth should respect a 5 mm distance between the neighbouring roots and a 5 mm buccopal- atal measurement for a minimum width which would as- sure a good prosthetic outcome and avoid the phenom- enon of pressure necrosis. Areas involving dense bone seem to be at increased risk of compression necrosis.7, 8 According to Salama et al., Tarnow et al. and Carda- ropoli et al., it is important for the correct insertion of threaded implants, both in simple and complex cases, to maintain a minimum distance between implants (3 mm) and between the implant and an adjacent tooth (1.5–2.0 mm) in order to maintain an adequate interprox- imal bone crest and therefore the possibility of having a natural papilla as well as having a correct prosthetic design.9–11 Sometimes, these cases present a Cawood and Howell Class IVa bone anatomy, and ridge expan- sion procedures can be performed to widen the crest. In cases with a Cawood and Howell Class IVb, where the crest has a bicortical fusion and no expansion proce- dures are possible, only bone grafting procedures such as guided bone regeneration or Khoury’s box technique can resolve the situation.12, 13 The following case report demonstrates that, with the spreading technique, nat- ural roots can be displaced, and demonstrates how important the implant design can be. Plateau-form press-fit implants do not compress the adjacent bone structures because of the presence in their design of healing chambers throughout most of the implant body. Only the edges of each plateau are in direct contact with the osteotomy walls, avoiding pressure necrosis. Also, 2 .7 mm 1 2 Fig. 1: Panoramic radiograph. Note the narrow space at position #22. Fig. 2: Periapical radiograph of congenitally missing maxillary left lateral incisor. The interproximal space between tooth #21 and tooth #23 remained critical after orthodontic treatment. 28 4 2020

| case report Fig. 7: Radiographic follow-up of the interproximal root spreading technique. Note the 2.5 mm and 3.0 mm hand reamers sliding between the roots and making space for the 3.0 mm diameter implant, which was placed 3.0 mm under the crestal bone level. involved during this procedure. The final 3 mm diameter hand reamer was equally pressed into the osteotomy and directed between the roots. Continuous and slow pres- sure was applied on the straight handle. Sometimes the help of a mallet is needed to move the reamer 10–11 mm down to the crest (Figs. 3 & 4). The implant was inserted with a special instrument (im- plant inserter), allowing the operator to push the implant with firm and precise pressure into the previously pre- pared osteotomy (Fig. 5). The last step was the final tap- ping with the mallet using the seating tip mounted on to the straight handle. The narrow implant was therefore compressed between the two roots (Fig. 6). The 3 mm diameter and 8 mm long implant was inserted with pres- sure into the finished osteotomy and tapped with the seating tip and the mallet 3 mm down to the crestal bone (Fig. 7). After six months of healing, the second-stage procedure was performed and the implant well was ex- posed. An abutment with a 2 mm diameter shaft and a 4 mm diameter hemispherical base was selected to sup- 8 9 port the temporary crowns. It is paramount to let the soft tissue heal around the appropriate crown profile, and this aspect can be achieved by modifying the emer- gence profile of the temporary crown until the papillae are formed. Once the soft tissue had completely healed, the final impression was taken and the definitive crown cemented on to the titanium abutments (Figs. 8 & 9). Discussion In the case of congenitally missing lateral incisors in the maxilla, planning of implant treatment depends on the following factors: condition of the neighbouring teeth, occlusion, space requirements and anterior relation- ships. There are several possible problems that need to be taken into consideration, such as close proximity of the apices of adjacent teeth to the proposed implant site, space limitations for implant placement and prost- hodontic restoration, insufficient ridge thickness that re- quires augmentation and insufficient bone support for the gingival papillae.21 Close proximity of the apices of neighbouring teeth often makes orthodontic treatment for angulation correction necessary. The adjacent roots should ideally be slightly divergent or parallel. A minimum of 1 mm between the implant and the adjacent roots is recommended.10 In our case, the spreading procedure had to be performed with both reamers (2.5 and 3.0 mm) with a very slow motion. The pressing involves placing the palm of the hand on the straight handle wrench and at the same time rotating the handle less than 45° in or- der to engage the cutting tip in the cancellous bone. Once the reamer has been inserted into the bone to the desired depth, the reamer should be left inside the osteotomy for some minutes. That allows the bone and the ligament of the adjacent roots to adapt to the new positioning.23, 24 Fig. 8: Final radiographic control after three years of function. Note the platform switching be- tween the neck of the implant and the hemispherical base of the abutment. Fig. 9: Intra-oral control of the crown and surrounding soft tissue at three years. Note the stability of the papillae, being supported by bone formed over the sloping shoulder. No excessive pressure is exerted by the implant be- cause no torque is used for the insertion. The special design of the implant (Bicon Dental Implants) with its 30 4 2020

| case report 1 5 2 6 3 7 4 8 Fig. 1: Frontal view, showing the fracture of the maxillary right first premolar. Fig. 2: Pre-op radiograph. Fig. 3: Occlusal view, showing caries into the root and involvement of the distal furcation. Fig. 4: The extracted tooth. Fig. 5: The socket was measured with a periodontal probe. Figs. 6 & 7: Insertion of the implant. Fig. 8: View of the implant immediately after insertion. Immediate placement of a new fully tapered tissue-level implant Dr Mario Roccuzzo, Italy Initial situation In September 2019, a 53-year-old non-smoking male pa- tient came for a consultation after the fracture of his maxil- lary right first premolar (Fig. 1). The patient presented with minimal periodontal problems, including multiple gingival recessions. The radiographic image confirmed the pres- ence of a large periapical radiolucent area and some dis- tal interproximal bone loss (Fig. 2). A thorough examination was carried out and revealed caries into the root and in- volvement of the distal furcation (Fig. 3). Upon clinical exam- ination, the amount of healthy dentine was considered in- sufficient for a stump preparation for a conventional crown. Moreover, the patient was unwilling to undergo orthodontic extrusion of the tooth. Additionally, an apically repositioned flap, after endodontic treatment, would have most likely pro- duced a very long crown. Subsequent to the clinical evalua- tion, the patient gave his informed consent for the extraction of tooth #14 and immediate implant placement. Surgical procedure In order to minimise the trauma during treatment, a care- ful separation of the tooth into two parts was carried out before extracting both roots (Fig. 4). No incisions were made, in order to reduce the risk of soft-tissue dehiscence. Before implant insertion, meticulous cleaning and care- ful curettage/debridement was carried out. The dimen- 9 10 11 12 Fig. 9: Placement of a flexible composite cone of synthetic and porcine origin. Fig. 10: Fixation of the mesial papilla with a suture. Fig. 11: Post-op radiograph. Fig. 12: Frontal view of the sutured implant site. 32 4 2020

| practice management Practice strategies in the time of the coronavirus Dr Anna Maria Yiannikos, Cyprus We all have been experiencing an extremely difficult period in the past few months. In the following, I would like to show you how you can utilise your social media channels more wisely and provide you with 5 important tips which will make the communication between you and your patients on social media during the current pe- riod even more effective. You will learn what to say and how to say it and attract new patients as a result—after all, we are not only dentists but also entrepreneurs with businesses to run. Tip 1: Seek to become closer to your patients Use your social media channels to foster a closer rela- tionship with your patients by giving them information on different useful topics during this difficult period. For in- stance, make short videos in which you explain to your patients how they can put on their protective face masks and remove them safely afterwards. The caption for such a video could something along the lines of: “My beloved patients—friends—I would like you to know that it is totally normal to be unsure of whether you are properly following the advised safety measures, which have become an es- sential part of our everyday lives in these unprecedented times. To all of you, I wish good health and prosperity from the bottom of my heart.” Tip 2: Give advice on dental hygiene Share important advice with your patients regarding their oral hygiene. Such advice should be based on their new routines in order to keep their mouths healthy. For in- stance, if your patients take vitamin C in order to boost their immune systems, you can give advice on which form would be the most suitable for their teeth. Or you could publish a post or a video on helping patients keep their teeth healthy during the pandemic. Tip 3: Offer online consultations Give your patients the opportunity to conduct an on- line meeting with you. You could use the following script in a social media post in order to promote this service: “ BECAUSE WE CARE—the health and safety of you, our m o c . e b o d a . k c o t s – i l i i o c s a B o r d n a s s e A © l 34 4 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 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 36 4 2020

| manufacturer news curasan Complete bone regeneration with CERASORB® Foam CERASORB® Foam is a multi-porous composite ma- terial made from collagen and pure-phase ␤-TCP granules of different sizes and densities. The gran- ules are embedded in the collagen component and are fi xed by its fi bres. CERASORB® Foam has partic- ularly user-friendly properties. Moistened with blood from the defect or mixed with autologous throm- bocyte and fi brin concentrate, the material can be modelled and inserted into the defect precisely and comfortably. The large contact area with the sur- rounding vital bone allows bone-forming cells to tap into the material and also facilitates the absorption of nutrients and proteins. In addition, CERASORB® Foam is an ideal scaffold for various antibiotics. The special CERASORB® collagen matrix ensures a high level of volume stability after the collagen, which is more rapidly absorbed, has broken down. The high porosity of the gran- ulate, in turn, offers the newly forming bone a stable framework. CERASORB® Foam is completely broken down and replaced by autologous, healthy bone. Over 200 publications prove its success (a list of literature can be provided by curasan upon request). curasan AG Lindigstraße 4 63801 Kleinostheim, Germany 63801 Kleinostheim, Germany www.curasan.de www.curasan.de PreXion Special autumn deal for CBCT system Special autumn deal for CBCT system The Japanese CBCT specialist PreXion offers customers based in Ger- The Japanese CBCT specialist PreXion offers customers based in Ger- many, Austria and Switzerland a special autumn deal. The special price many, Austria and Switzerland a special autumn deal. The special price for the PreXion3D EXPLORER includes the CBCT system, installation, for the PreXion3D EXPLORER includes the CBCT system, installation, instruction, fi ve-year warranty, and a computer running the PreXion instruction, fi ve-year warranty, and a computer running the PreXion Viewer Software. Additionally, customers can opt for the attractive Viewer Software. Additionally, customers can opt for the attractive package including the pre-installed SICAT Suite and receive a special package including the pre-installed SICAT Suite and receive a special discount (66 per cent on the subscription price). With a focal point of discount (66 per cent on the subscription price). With a focal point of 0.3 mm and a voxel size of just 74 μm, the PreXion3D EXPLORER brings 0.3 mm and a voxel size of just 74 μm, the PreXion3D EXPLORER brings an extraordinary combination of great image detail and low ra- an extraordinary combination of great image detail and low ra- diation exposure to dental practices and clinics. diation exposure to dental practices and clinics. Another highlight is the integrated cephalometric Another highlight is the integrated cephalometric “One-Shot” mode, which allows the work in limited “One-Shot” mode, which allows the work in limited spaces. Interested ones are warmly invited to live spaces. Interested ones are warmly invited to live demonstrations of the PreXion3D EXPLORER at the demonstrations of the PreXion3D EXPLORER at the PreXion showroom in Rüsselsheim in Germany. Ap- PreXion showroom in Rüsselsheim in Germany. Ap- pointments can be made online at www.prexion.eu, pointments can be made online at www.prexion.eu, via e-mail at info@prexion-eu.de or by phone under via e-mail at info@prexion-eu.de or by phone under +49 6142 407855. +49 6142 407855. PreXion (Europe) GmbH PreXion (Europe) GmbH Stahlstraße 42 65428 Rüsselsheim, Germany 65428 Rüsselsheim, Germany www.prexion.eu 38

| news Focus on implant dentistry at This year’s Dentsply Sirona World From 14 to 20 November 2020, Dentsply Sirona World was held virtually. The event offered participants the unique opportunity to dive into more than 70 lectures out of twelve education tracks including digital dentistry, imaging, orthodontics, dental hygiene, restorative dentistry, and endodontics. More than 65 speakers shared their industry advice and expertise in a multi-discipline panel of educational options. A special focus this year was on im- plantology with a myriad of lectures that covered virtually every aspect of this special discipline within dentistry. For instance, in a session titled “Azento Workflow with Immediate Implant Place- ment”, Dr Doug Smail showed the entire process from tooth ex- traction to immediate implant insertion and temporisation in less than an hour. Dr Fahrad Botchi, on the other hand, spoke about digital implant dentistry strategies that can aid in treating hopeless teeth in the aesthetic zone. He presented a clinical case in which CEREC technology in combination with an Astra Tech Implant System was used to treat an anterior tooth gap. Botchi argued that, by adding a connective tissue graft at the time of immediate implant placement, postoperative recession can be reversed and tissue can be gained. Apart from that, the advanced CEREC trainer Dr Dan Butterman discussed a truly crown down approach to implant dentistry by means of CEREC and CBCT integration. In his online session, he performed a guided implant placement and evaluated custom healing abutment and temporary options in about thirty minutes. The aim was to compare and contrast CEREC Guide 3 and Azento implant solutions. Those who weren’t able to participate in this year’s virtual mega event can already look forward to 23 September 2021, when the Ultimate Dental Meeting will kick off again in Las Vegas, USA. More information can be found on www.dentsplysirona.com/en-us/ds-world.html. Source: Dentsply Sirona TBR Dental acquisition opens New perspectives in Spain Driven by the development of the Z1 Tissue Level implant and the Index digital workflow, TBR Dental integrates SAS Exclu- sivas Dentales, S.L. into its group and consolidates its long- term presence 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 tech- nical excellence 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 40 4 2020 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. Source: TBR Dental Group

| about the publisher Congresses, courses and symposia implants 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 implants international magazine of oral implantology is published in cooperation with the German Association of Dental Implantology (DGZI). DGZI DGZI Central Offi ce Paulusstraße 1 40237 Düsseldorf, Germany Tel.: +49 211 16970-77 Fax: +49 211 16970-66 offi ce@dgzi-info.de www.dgzi.de www.oemus.com www.implants.de IDS Cologne 10–13 March 2021 Cologne, Germany www.ids-cologne.de 6th Annual Meeting of ISMI 7–8 May 2021 Düsseldorf, Germany www.ismi-meeting.com 50th DGZI International Annual Congress— Visions in Implantology 1–2 October 2021 Cologne, Germany www.dgzi-jahreskongress.de 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 Chief Editorial Manager Dr Torsten Hartmann (V. i. S. d. P.) hartmann@dentalnet.de Editorial Council Dr Rolf Vollmer info.vollmer@t-online.de Dr Georg Bach doc.bach@t-online.de Dr Suheil Boutros SMBoutros@aol.com Editorial Offi ce Georg Isbaner g.isbaner@oemus-media.de Johannes Liebsch j.liebsch@oemus-media.de Executive Producer Gernot Meyer meyer@oemus-media.de Product Manager Timo Krause t.krause@oemus-media.de Art Director Alexander Jahn a.jahn@oemus-media.de Copyright Regulations implants international magazine of oral implantology is published by OEMUS MEDIA AG and will appear with one issue every quarter in 2020. The magazine and all articles and illustrations therein are protected by copyright. Any utilisation without the prior consent of editor and publisher is inadmi ssible and liable to prosecution. This applies in particular to duplicate copies, translations, microfi lms, and storage and processing in electronic systems. Reproductions, including extracts, may only be made with the permission of the publisher. Given no statement to the contrary, any submissions to the editorial department are understood to be in agreement with a full or partial publishing of said submission. The editorial department reserves the right to check all submitted articles for formal errors and factual authority, and to make amendments if necessary. No responsibility shall be taken for unsolicited books and manuscripts. Articles bearing symbols other than that of the editorial department, or which are distinguished by the name of the author, represent the opinion of the aforementioned, and do not have to comply with the views of OEMUS MEDIA AG. Responsibility for such articles shall be borne by the author. Responsibility for advertisements and other specially labeled items shall not be borne by the editorial department. Like- wise, no responsibility shall be assumed for information published about associations, companies and commercial markets. All cases of consequential liability arising from inaccurate or faulty representation are excluded. General terms and conditions apply, legal venue is Leipzig, Germany. 30th annual scientifi c meeting of EAO 14–16 October 2021 Milan, Italy www.eao.org 42 4 2020

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