implants _ international magazine of oral implantology No. 2, 2021

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editorial | Dr Rolf Vollmer First Vice President and Treasurer of DGZI The agony of choice: To bone graft or not to bone graft? Dear colleagues, in dental implantology, we are quite often faced with cases involving reduced bone volume. When treating these challenging cases, we need to ask ourselves whether to employ bone augmentation tech- niques or not. Let us take a look back at the founding years of our association: In the seventies, we placed im- plants in sites where the jawbone would allow it. During this time, especially quite narrow blade implants were utilised, according to the principle of “implant follows bone”. In the eighties, there was a shift towards a “bone follows implant” approach, meaning that, during that time, cli- nicians tried to create the ideal implant positioning by means of bone grafting in sites when there was only little bone or none at all. This method, however, was found to be rather time- consuming with regard to overall treatment time and was especially prone to certain risks. The logical conclusion from past experiences is that now- adays there is a tendency to perform bone augmenta- tion procedures rather in areas where it is necessary for aesthetic reasons. In this context, we utilise autologous bone blocks, for instance, or materials of allogenic and xenogenic origin—always with a view to the optimal pro- spective outcome. Modern digital technologies aid in implant placement by means of guided surgery, and it is even possible to fabricate customised blocks from allo- genic material based on corresponding CBCT data, for example, and to insert these into defects in a custom-ﬁt way. In some cases in which coverdenture prostheses and screw-retained protheses according to Malo’s prin- ciple are to be fabricated, one can refrain from employing augmentative measures altogether without compromis- ing on cosmetic aspects and aesthetics. Ultimately, we as implantologists must always decide be- tween one or the other solution, based on the individual in- dication. With this in mind, I hope you enjoy reading the new implants—international magazine of oral implantology, and I am looking forward to meeting you in person at our third Future Congress for Dental Implantology, which is to be held in October in Cologne, where we will be celebrat- ing the 50-year anniversary of the German Association of Dental Implantology (DGZI). Sincerely yours, Dr Rolf Vollmer 2 2021 03

editorial The agony of choice: To bone graft or not to bone graft? 03 Dr Rolf Vollmer case report page 06 Successful immediate implant loading— According to the Socket Shield Technique Dr Ramón Gómez Meda Rehabilitation of the anterior maxillary area with immediate implant placement Drs Perla Della Nave & Alberto Vericat Queralt 06 12 A new approach for patients on direct oral anti-coagulant medication 18 Dr Stefan Grümer & Melissa Yüce Combining orthodontics with a zirconia collar implant page 34 Dr Kunal Shah Correction of a vertical fracture and a subsequent infection Dr Matthew J. Fien Full-mouth implant reconstruction using zygomatic and standard implants Dr James Kwok Fai Chow industry More room for new bone formation page 40 Branislav Kostadinov news manufacturer news news about the publisher imprint 22 26 28 34 36 40 42 | content Cover image courtesy of Camlog Biotechnologies AG www.camlog.com issn 1868-3207 • Vol. 22 • Issue 2/2021 2/21 implants international magazine of oral implantology case report Rehabilitation of the anterior maxillary area with immediate implant placement industry More room for new bone formation news Fifty years of implantology to be celebrated in Cologne 04 2 2021

| case report Successful immediate implant loading—According to the Socket Shield Technique Dr Ramón Gómez Meda, Spain osseointegration and may be beneficial in preserving the buccal bone plate. Since then, the Socket Shield Technique has been further evaluated clinically in its application as originally described by Hürzeler et al. or in complex situations such as multiple adjacent implants with pleasing aesthetic results.1–4 The latest critical literature review by Blaschke et al. about the clinical data support on the Socket Shield Technique summarised promising outcomes with the Socket Shield Technique, its high potential to reduce the need for invasive bone grafts around implants in the aesthetic zone, but also concluded that clinical data to support is very lim- ited.5 Nevertheless, this technique cannot be implemented in routine dental practice without caution as it is quite tech- nique-sensitive and thus, should be reserved for the experi- enced surgeon. The following case report describes an im- mediate implant placement, fully guided applying the Socket Shield Technique as an efficient treatment concept, with a favourable cost-benefit ratio and highly aesthetic outcome. Clinical case In the following case a 69-year-old male with good health condition (ASA I) presented in the office with a fracture of a central incisor. The full mouth had been previously restored with lithium disilicate crowns due to the severe attrition the teeth suffered as a consequence of the intense bruxism and clenching the patient reported. Anterior crowns were 1a 1b Figs. 1a & b: Initial situation before partial extraction of the fractured tooth and immediate implant placement. The epigingival fracture made a horizontal reduction of the root unnecessary. Introduction In 2010 a novel approach to preserve the soft and hard tis- sues following tooth extraction was reported.1 Clinical stud- ies had suggested that retaining roots of hopeless teeth may avoid tissue alterations after tooth extraction. The authors proposed the retention of a buccal aspect of the root during immediate implantation to prevent alveolar bone loss follow- ing tooth extraction. The proof-of-concept study in beagle dogs showed that retaining the buccal aspect of the root during implant placement does not appear to interfere with 2a 2b Figs. 2a & b: The DICOM files as well as the intra-oral STL files were imported into a software (Blue Sky Bio) to plan the ideal implant position. Finally, a surgical guide was printed. 06 2 2021

case report | 3 4c 5a 5d 4a 4d 4b 4e Fig. 3: After impression taking, the fractured crown was sent to the laboratory technician to copy the shape and colour. Figs. 4a–e: Partial tooth extraction with Socket Shield approach: bisection of the root, extraction of the palatal parts and contouring of the buccal shield. splinted but even so the crown of the tooth broke horizon- tally at gingival level. The pulp sensitivity test of the fractured tooth with CO2 snow was negative, the peri-coronal tissue was irritated, but showed absence of active purulent infec- tions. Hard and soft tissue showed no signs of bone loss or recession, in comparison of the soft tissue and bone sup- port of the two maxillary quadrants there was no difference from one quadrant to the other. Radiologically the root rem- nant showed no alterations or signs of fracture (Figs. 1a & b). Oral hygiene was good. Tooth conservation was assessed to be feasible but seemed rather unpredictable due to the lack of enough dentine to predictably support a crown in the long term. Another alternative was to extract the root and to retreat the adjacent teeth with a fixed bridge. After a discus- sion of the treatment options and the respective risks and benefits, the patient agreed to substitute the tooth by an implant. The crown of the fractured tooth was temporarily positioned in place with the help of flowable composite. An intra-oral scan of both maxillary and mandibular jaw (3Shape, TRIOS) to produce the guide template was taken. For planning of the implant position a CBCT scan was done 5b 6a 5c 6b Figs. 5a–d: Fully guided placement of the implant into the exact 3D prosthodontic position, in distance to the root shield. Care was given to not change the position of the buccal root shield. Figs. 6a & b: The interim restoration had been designed based on the intra-oral scan. It could be screwed onto the implant immediately after the surgery to close the extraction wound and preserve the soft tissue. 2 2021 07

| case report 7a 7b Figs. 7a & b: A scan body is used to immediately register the 3D position of the implant. (Planmeca Promax 3D Plus) paying special attention to the integrity of the cortical plate and the quantity of bone pres- ent in the apical area to be able to properly stabilise the im- plant. The DICOM files as well as the intra-oral STL files were imported into a software (Blue Sky Bio). These files were superimposed and a virtual wax-up helped to create the exact virtual position of the implant with an ideal prosthodon- tic emergence profile. Finally, a surgical guide was designed and immediately printed at the office with the help of a high- quality 3D printer (Nextdent 5100, 3D Systems; Figs. 2a & b). An alginate impression was taken to elaborate a thermoplas- tic vacuum formed provisional and the patient was released with a crown integrated into the removable template to tem- porarily solve the aesthetic problem. Antibiotics and AINEs were prescribed for the day of the surgery. Also, the patient was advised to rinse his teeth with an antiseptic solution (0.2% chlorhexidine, DENTAID) the day before the surgery to reduce the bacteria load in the mouth. The crown of the fractured tooth (Fig. 3) was handed to the dental technician for orientation to build the screw-fixed temporary restoration on the implant for day of surgery. The guide template—previously designed by superimposing the intra-oral scan. STL file and the CBCT.DICOM files—was tested for exact fit and after local anaesthesia (4% articaine with 1:200,000 epinephrine) partial tooth extraction was per- formed. Weighing tissue resorption due to flap mobilisation against good overview on the surgery site, a very small di- mensioned buccal full thickness flap preserving the papilla was mobilised in order to better control later tooth fragment preparation and the surrounding tissue. Before implant bed preparation, the root was bisected vertically and the palatal aspect of the root was removed (Figs. 4a–e). Further den- tine parts were removed in individual pieces, focusing to extract the entire root tip. The guide template was seated to prepare the implant bed through the root remnants. Sterile saline coolant was used during the entire drilling procedure. Only a small part of the root in the crestal area on the buccal side was intentionally left in place preserving the facial part of the periodontal ligament and as a consequence the bundle bone (Fig. 4e). As accurate tooth fragment preparation and implant placement is the key to successful treatment with the Socket Shield Technique,6 the buccal root piece needed a little reshape with a lancet drill to thin it and such to guar- antee that the dentine would not be in direct contact with the implant for proper bone formation. A PROGRESSIVE-LINE (CONELOG 3.8 x 13 mm) implant was placed fully guided in the palatal part of the extraction socket in the correct 3D prosthodontic position (Figs. 5a–d). As being an apically tapered implant and threads down to the apex, this implant was chosen for the surgery as it en- ables to anchorage well within the basal bone but still not endangering the buccal lamella in the apical area. Also, the pronounced thread design makes it easy to reach very good primary stability even in situations with poor quality bone. Reaching an insertion torque of more than 35 Ncm, the implant qualified to be restored immediately with a screw- 8a 8b 9 10 Figs. 8a & b: Radiological control of the position of the buccal root remnant and the implant. Fig. 9: After 8 weeks and removal of the provisional restoration the peri-implant region impresses by a voluminous and healthy soft tissue. Fig. 10: The final zirconia crown was produced following a fully digital workflow. 08 2 2021

| case report 11a 12 11b 13 Figs. 11a & b: After seating the final prosthesis, slightly chipped adjacent crowns were repaired with composite. Fig. 12: Final situation the day the crown was delivered. Fig. 13: Follow-up 6 months later. retained one-piece provisional crown (Figs. 6a & b). There- fore, a scan body had been screwed in immediately after implant placement to register the 3D position of the implant and scanned digitally (Figs. 7a & b). The interim restoration was designed in the office after importing the STL file into a professional software (Exocad dentalCAD) and after half an hour the provisional was manufactured with a milling machine (Ceramill Motion 2 5X, Amann Girrbach). Afterwards the wound was microsurgically sutured (Cytoplast 6/0 PTFE) to fix the flap in position. The interim restoration was cemented onto a Ti-base (CONELOG Tita- nium base CAD/CAM crown, CAMLOG) with a resin cement (SpeedCEM plus, Ivoclar Vivadent). This provisional cus- tomised healing abutment placed immediately after the im- plant placement covered exactly the extractions wound and helped in maintaining the soft-tissue contours. A control radiograph confirmed the right position of the implant, the position stability of the shield and the correct distance from the tooth shield to the implant (Figs. 8a & b). After 2.5 months of healing, an optimal soft-tissue emergence profile was obtained (Fig. 9) and final restoration was delivered after 10 weeks (Figs. 10–12). Six months after insertion of the final restoration the crown is perfectly integrated (Fig. 13). inserted implant. Even if the clinical application of the Socket Shield Technique is still difficult to perform and very tech- nique sensitive, with an apically tapered implant geared to high primary stability like PROGRESSIVE-LINE, the dentist has good control of the implant position and can reach a rather favourable cost-benefit ratio when using this tech- nique. With this case it is also shown that the implant used is a reliable option for immediacy cases with fully-guided options, taking advantage of a fully digital workflow. about the author Dr Ramón Gómez Meda holds a degree in dentistry from the Univer- sity of Santiago de Compostela. In addition, he holds a Master’s degree in Occlusion and Temporomandibular Dysfunction and has completed a Post- graduate course in Periodontics and Implantology. Since 2001, he has been leading a private practice in Ponferrada in Spain. Dr Meda is an international lecturer on Periodontics, Implantology, Aesthetics and multidisciplinary treatments. Conclusion contact This case illustrates an experimental technique for preserv- ing a buccal root segment in conjunction with immediate implant placement and provisionalisation. The Socket Shield Technique shows to be a valuable technique to minimise buccal contour changes after tooth extraction, leading to increased volume stability of the mucosa adjacent to the Dr Ramón Gómez Meda MEDA Dental Education Ponferrada, León, Spain ramon@dentalmeda.com https://medaformacion.com Author details Literature 10 2 2021

| case report Rehabilitation of the anterior maxillary area with immediate implant placement Drs Perla Della Nave & Alberto Vericat Queralt, Spain 1 2 Figs. 1 & 2: Initial clinical situation. Introduction The alveolar process and other tissues of the periodon- tium are tooth-dependent anatomical elements;1 in fact, tooth loss is followed by a cascade reaction of biological phenomena that cause progressive atrophy of both hard and soft periodontal tissue.2 Such atrophy is character- ised on one hand by a total loss of the attachment fibres of the root cementum, the periodontal ligament and the bundle bone and on the other hand by vertical and hori- zontal volumetric alteration. It has been seen that the re- sorption of the alveolar ridge, with its consequent lingual repositioning, can reach 40–60%3–5 and that this phe- nomenon occurs on a maximum scale during the first three to six months after tooth extraction,1, 5, 6 but it also continues gradually throughout the whole life of the indi- vidual (about 0.5–1.0% every year).7 Specifically, during the first eight weeks, bone resorption occurs especially in the mid-buccal area, that is, the area anatomically fur- ther from the periodontal ligament of the adjacent teeth 3a 3b 3c Figs. 3a–d: Radiographic evaluation by means of CBCT. 12 2 2021

D A (if any), which help maintain the inter- proximal bone.8 Furthermore, in a thin biotype, the de- fect generated will be a two-walled de- fect, owing to the more or less consis- tent loss of the vestibular cortical bone; whereas, it will be three-walled in a thick biotype, thanks to the greater thickness of the external cortical bone.8 Soft-tissue changes, however, mainly take place in the first two weeks after extraction; nevertheless, in the presence of a thin biotype, a significant thickening of the gingival volume is observed in the early stages, mainly due to the resorption of the vestibular bone and the formation of granulation tissue in the crestal portion of the alveolus.8 Knowledge and consid- eration of these changes and the clini- cal repercussions of a similar process of physiological atrophy are fundamental in order to simplify any future therapeutic procedure aimed at the replacement of missing teeth, as well as to optimise the functional and aesthetic result. One of the current options for counteract- ing the post-extraction tissue remodelling phenomenon is alveolar preservation. There are several regenerative proce- dures, each with different therapeutic indications: preservation of soft tissue, of soft and hard tissue, and of hard tissue.7 Contemporary scientific literature high- lights the fact that alveolar preservation, regardless of the technique and type of biomaterial used, allows more favourable results than those of spontaneous alve- olar healing, considerably reducing the volumetric atrophy of the bone crest.6, 9 Nevertheless, its efficacy has been found to depend strictly on a large number of local and general factors, such as the inclination of the socket, the condition of the adjacent teeth, the periodontal bio- type, the vestibular cortical bone, sys- temic factors and the habits of the patient; for example, an essential precondition for an alveolar preservation protocol is the integrity of at least three of the four alve- olar walls and at least 80% of the non- intact wall.10 Another therapeutic option is immediate implant placement, which has the ad- vantage of significantly reducing treat- ment time and achieving better tissue maintenance and, therefore, a better aesthetic result.11 The psychological benefit and the high comfort that such a protocol can offer the patient should also be emphasised, especially if it is also associated with immediate occlu- sal loading. However, this technique is defined as straightforward, advanced and complex, since it requires ade- quate surgical experience and excellent evaluation by the surgeon in each of the different clinical situations where it can be applied. Clinical case We received in our private clinic a 33-year-old female patient who reported mobility regarding the maxillary incisors and some concern about their possible sudden loss (Figs. 1 & 2). A careful clinical analysis, a dental panoramic tomogram 3d EXPECTATIONS vs. REALITY ›

| case report 4a 4b 5a 5b Figs. 4a–7b: Immediate implant placement. and a cone beam computed tomography (CBCT) scan allowed us to observe the following clinical signs (Figs. 3a–d): Grade II mobility of teeth #12, 11, 21 and 22; marked gin- gival recession, the absence of papillae and a compro- mised periodontal situation in the same anterior maxillary area; and a periodontal lesion in the area of teeth #12 and 11 with destruction of the interproximal bony papilla. The treatment plan proposed to the patient was to extract the four teeth and replace them with four implants imme- diately placed and occlusally loaded and to simultane- ously graft the hard and soft tissue. The surgery began with the minimally invasive extraction of one of the teeth, followed by placement of the cor- responding implant with a flapless technique in order to retain the anatomical reference of the adjacent teeth. The same method was applied until the fourth implant had been inserted. All the implants placed were GTB TZERO implants of 3.6 m × 9.0 mm (Advan; Figs. 4a–7b). The GFA abutment for single crowns (Advan) was chosen as the prosthetic abutment (the reasons will be highlighted later). The height of the abutment was 5.5 mm for the implants in the first quadrant and 6.5 mm for the implants in the second quadrant. Posteriorly, subepithelial connective tissue was harvested from both sides of the palate, and multiple connective tissue grafts were placed using an en- velope technique, placing only one suture for each graft. To finalise the surgery, we proceeded with socket filling with a particulate bone biomaterial (Geistlich Bio-Oss, Geistlich Biomaterials; Figs. 8a–10b). Impressions were 6a 6b 7a 7b 14 2 2021

D A WE HAVE MORE TO OFFER THAN TEST RESULTS.* * The CleanImplant Foundation conducts one of the world’s largest ongoing quality assessments of dental implants – made of zirconia and titanium. We do not only award our quality mark to clean implant systems. WE CERTIFY DENTAL PROFESSIONALS WHO REALLY CARE. For their patients. For their reputation. And for their legal safety. 8a 8b Figs. 8a–9: Bone augmentation around the implants. taken immediately after the surgery in order to fabricate four provisional single crowns in resin and to place them on the same day of the surgery. The patient was examined after one week for a check-up and for the removal of the sutures in the area of the con- nective tissue grafts. At one month and three months after the operation, a fol- low-up CBCT check was performed in order to check the conditions of the buc- cal bone. This was not a routine exam- ination, but was carried out in this case given the delicacy of the patient’s bone conditions and the importance of main- taining the external cortical bone as sup- port to the soft tissue and, therefore, as fundamental for a satisfactory aesthetic result. The tightening torque of the abut- ments and the effective osseointegra- tion of the four implants were confirmed at this appointment too. The definitive impressions were taken with four cus- tomised impression copings using the open-tray technique in order to retain the gingival emergence profile. Subse- quently, four new provisional crowns in polymethylmethacrylate were designed using CAD/CAM to redefine in detail the 9

| case report 10a 10b Figs. 10a & b: Situation after implant surgery. emergence profiles and the dental anatomy before copy- ing the latter in zirconia, the material in which the defini- tive crowns were to be made (with the vestibular addition of layered ceramic). Both the bone and the emergence profile were acceptable and made it possible to obtain, in association with careful and personalised prosthetic work, a functional and aesthetic result that was satisfac- tory for the patient. “Immediate implant placement is a technique that has undergone great evolution in recent years...” Discussion Immediate implant placement is a technique that has undergone great evolution in recent years; in fact, many of the conditions once considered contra-indications (such as active infection and lack of integrity of the ex- ternal cortical bone, especially if associated with a thin periodontal biotype) today constitute a clinical situation in which this technique is predictable if used with some complementary protocols. As demonstrated by the most recent scientific literature, the survival rate of immediately placed and occlusally loaded implants is now comparable to that of immediately placed implants restored according to the conventional loading protocol, but some key funda- 16 2 2021 mental factors for the aesthetic and functional therapeu- tic success of immediately placed and occlusally loaded implants do exist. Firstly, the 3D palatal positioning of the implant is a key element for the preservation of the buccal bone and for the reduction of the risk of bone dehiscence and gingival recession.4 Indeed, vestibular placement is associated with a greater resorption of the external cortical bone.12 Secondly, the gap generated between the implant sur- face and the buccal bone should ideally be at least 2 mm, in order to be able to leave adequate 3D space for socket filling and the formation of a good blood clot; in fact, recent studies show a negative correlation between a greater gap and the amount of vertical bone resorption.13 Thirdly, it is well established that the use of immediately loaded provisional crowns is crucial for the stability of the buccal gingival margin,11, 14, 15 for the protection of the surgical wound, clot and bone graft,12 for soft- tissue support and for the creation or maintenance of aesthetic papillae.11 Furthermore, the same result in terms of soft-tissue stability would be achieved regard- less of the biotype.11 Finally, it has been observed that non-immediate provisionalisation is associated with greater bone remodelling.16 Fourthly, the flapless technique, associated with min- imally invasive extraction, is another key factor for the success of immediately placed and occlusally loaded implants, mainly because it avoids any interruption of vascularisation, something crucial for the tissue regen- eration potential. In fact, recent studies recommend the use of a flapless protocol whenever possible to minimise marginal remodelling;16 nevertheless, there are clinical situations in which raising a surgical flap is indispens- able and prudent, especially in the presence of major bone defects or very unfavourable alveolar conditions. Fifthly, it has been suggested that, in association with the correct 3D placement of the implant, the connective tissue graft is an important factor for volumetric augmen- tation and soft-tissue maintenance, thus avoiding gingi- val recession and important aesthetic problems.17 More- over, it would also be able to provide adequate support to the underlying bone, thus contributing to its stability.18 Sixthly, the choice of prosthetic components is a key el- ement for tissue maintenance. Both the one abutment, one time protocol and the use of platform shifting favour- ably affect the stability of the tissue, as the use of abut- ments with narrower diameters than those of the implant platforms is essential to reduce marginal bone loss11, 19–21 and, in the presence of a thin biotype, to ensure sufficient biological width.11 In the case described, the therapeutic strategy regarding the number of implants and the type of prosthetic connec- tion and restoration proved to be essential for obtaining the final result. Specifically, the placement of four implants

D A (for four crowns) was motivated by the need to minimise tissue atrophy and op- timise the volume throughout the anterior maxillary area. The GTB TZERO implant, thanks to the morphology of the threads in the apical portion, is particularly suit- able for immediate loading protocols and was, in this case, combined with the GFA abutment, with a conical connection and internal anti-rotational octagonal index, which is normally used for a single res- toration on a single implant. The use of this prosthetic element, instead of a con- ventional multi-unit abutment, has a dual purpose. On the one hand, though main- taining sufficient platform shifting, it has a diameter 0.8 mm narrower than the diameter of the multi-unit abutment, thus allowing 3.2 mm greater biological space overall. On the other hand, the anti- rotational connection was employed for the abutments of all four single crowns, producing a better aesthetic result owing to a more individualised prosthetic res- toration. Conclusion The rehabilitation of four maxillary inci- sors with four immediately placed im- plants, simultaneous regeneration with bone and connective tissue grafts, and an immediate loading protocol allowed us to obtain a satisfactory result thanks to the combination of key factors taken into ac- count both in the surgical technique and the prosthetic strategy (in terms of com- ponents and type of restoration). The use of four implants placed in correct 3D po- sition and combined with socket filling, the GFA abutments with platform shift- ing associated with the connective graft to generate a biotype change and the four single crowns placed into immedi- ate function achieved adequate mainte- nance of hard and soft tissue and a nat- ural and satisfactory appearance of the definitive restorations, despite the un - favourable bone conditions and the thin periodontal biotype observed in the preoperative phase. about the authors R E G I S T E R T O D AY ! Dr Perla Della Nave is a Spain-based dentist who specialises in dental implantology. She studied dentistry at the European University of Valencia in Spain and obtained her degree in 2016. In addition, she holds master’s degrees in oral surgery and implantology. She is currently in private practice in Valencia. CLEANIMPLANT CERTIFIED DENTIST Exclusive. Ethical. Exemplary. Dr Alberto Vericat Queralt is an oral surgeon who specialises in immediate implant loading. He has over 17 years of clinical experience in this field. In his private practice in Valencia in Spain, he also offers advanced solutions for complex cases such a zygomatic implant placement. contact Dr Perla Della Nave Dr Alberto Vericat Queralt Vericat Implantologia Inmediata Valencia, Spain +39 348 5475270 pdellanave@vericatimplantologia.com https://vericatimplantologia.com/en Dr Perla Della Nave Author details Dr Alberto Vericat Queralt Author details Literature More information www.cleanimplant.com/dentists

| case report A new approach for patients on direct oral anti-coagulant medication Dr Stefan Grümer & Melissa Yüce, Germany 1 2a 2b Fig. 1: The reduced size of position #14. Figs. 2a & b: Dental panoramic tomogram (a) and periapical radiograph (b) prior to implant placement. Implant placement is a surgical procedure employed in accordance with the individual wishes of patients. It can often be avoided by choosing conventional, non-surgical alternatives. In particular, in cases of patients with haem- orrhagic diathesis or patients undergoing anti-coagulant therapy with direct oral anti-coagulants (DOACs), the risk of undesired side effects, with even life-endangering consequences, necessarily led to a strict selection of patients who are suitable for dental implants. A new laser- supported approach in implantology for patients under- going anti-coagulant therapy has been developed by the Aachen Institute for Continuous Medical and Dental 3 Fig. 3: The initial osteotomy for the implant being performed with the pilot drill. 18 2 2021 Education in cooperation with the Clinic for Cardiology, Pneumology, Angiology and Internal Intensive Medicine of the RWTH Aachen University hospital in Germany. Case presentation Nowadays, the number of implants placed in patients with a higher average age and in medically compromised cases is rising. Particularly cases of patients undergoing DOAC therapy, with the advantage of no need to perma- nently control the coagulation parameters, are rising sig- nificantly. Despite the advice of cardiologists not to stop or interrupt the medication, these patients often request implants. In addition, for only two DOACs does an an- tagonist drug exist. For three other DOACs, there is no antagonist drug yet, leading to an increase in possible postoperative complications. Nevertheless, among this group of patients, the demand for implants is rising as well. To fulfil these wishes while following the advice of the cardiologist, a new transgingival, nearly blood-free surgi- cal protocol has been developed. The following case de- scribes this procedure in general and points out differ- ences in relation to conventional treatment. Clinical and radiographic situation A 62-year-old male patient with moderate general health attended the prosthetic consultation. His medical his- tory revealed that he had had three bypasses between 2014 and 2016 and signs of anginal attacks. Also, there

case report | 4a 4b Figs. 4a & b: The guide for a conventional rotating soft-tissue punch with a central guide pin matching the pilot drill hole (a). The laser handpiece used (b). were periodically recurring events of sinus arrhythmias. For a duration of three years, he had been on dabig- atran etexilate (Pradaxa), which is a direct thrombin inhibitor. He was slightly overweight and a non-smoker. Upon intra-oral examination, restoratively and prostheti- cally rehabilitated dentition and missing teeth #14, 27 and 35 were noted, and it was observed that position #14 had reduced in size (Fig. 1). The patient maintained good oral hygiene. The panoramic radiograph revealed an apically compromised tooth #47 with furcation involvement and good bone structure in positions #14 and 35 (Figs. 2 & b). The patient was thoroughly informed regarding the treat- ment options. He asked for an implant replacement for tooth #14 and possibly, at a later stage, for tooth #35. After an explanation about the medical compromises regarding a surgical intervention and after consulting the cardiologist regarding the DOAC therapy, it was mutually decided not to interrupt medication with Pradaxa and to opt for trans- gingival, laser-supported implant surgery in position #14. The initial bone contours showed a sufficient amount of bone in all three dimensions. If the bone width appears critical, a 3D radiograph is highly recommended to evalu- ate the amount of bone in the third dimension. Laser treatment and implant insertion After local anaesthesia, the initial osteotomy for the im- plant was performed with a pilot drill (locator drill; Fig. 3). A guide for a conventional rotating soft-tissue punch with a central guide pin that matched the pilot drill hole was placed in situ as an outline guide for the blood-free laser punch procedure (Figs. 4a & b). The laser unit used was an Er,Cr:YSGG laser operating at a wavelength of 2,780 nm (Waterlase iPlus, BIOLASE). The laser was set to the parameters shown in Figure 5. After the laser incision, the punched tissue was removed with a curette (Figs. 6a & b). Thereafter, following the drill protocol of the implant sys- tem placed, a ProActive Tapered implant of 4 mm in diameter and 13 mm in length (Neoss) was inserted to a 32 Ncm torque (Figs. 7 & 8). The healing abutment was inserted to 15 Ncm. Slight pressure on the surrounding tissue is important, for which the diameter of the healing abutment should be at least 1 mm larger than the punch diameter. In this case, the tissue punch diameter was 4.3 mm and the healing abutment was 5.5 mm in diame- ter (Fig. 9). The definitive restoration is shown in Figure 10. Discussion After three months of healing, the implant can be loaded and the superstructure can be installed. Following the protocol described, 143 implants have been inserted during the last three years. The retrospective analysis of this method showed postoperative haemorrhage with the need for additional intervention for ten of these. Seven 5 Fig. 5: The laser settings. 2 2021 19

| case report 6a 6b 7 8 9 10 Figs. 6a & b: Removal of the punched tissue with a curette (a). The tissue removed with the punch (b). Fig. 7: The implant placed. Fig. 8: Periapical radiograph immediately after implant insertion. Fig. 9: Slight anaemia was visible around the healing abutment, demonstrating the pressure on the surrounding tissue required to prevent post-op haemorrhage. Fig. 10: The definitive restoration. of the ten appeared during the first 30 implantations. After finding the right relation between size of the tissue punch and size of the healing abutment (diameter and height), only three cases of postoperative haemorrhage were en- countered. The main precondition for this kind of treat- ment is a sufficient amount of bone in the implant site. Any augmentative procedures more demanding than a punch technique to gain 1–2 mm in the neck area of the implant are not compatible with the protocol described. In cases of reduced horizontal bone volume, case suit- ability for the laser-supported protocol should be eval- uated by 3D radiography. The postoperative evaluation by the Clinic for Cardiology, Pneumology, Angiology and Internal Intensive Medicine showed no negative effects on the general health of the patients treated. This protocol is officially recommended by the clinic. Conclusion cause seizures or strokes during the interruption of anti- coagulant therapy, and such interruption is no longer essential with this laser-supported protocol. about the author Dr Stefan Grümer, MSc, is a special- ist in implantology and laser dentistry. In 2013, he was appointed clinical director of the first academic teaching clinic in dentistry in Germany accredited by RWTH Aachen University. He is the head of clinical education in the MSc in lasers in dentistry programme at RWTH Aachen University. In addition, he is a member of the board of directors of the German Society for Laser Dentistry and the International Society for Laser Dentistry. The use of laser in this delicate zone of soft tissue and bone of the implant site is very beneficial and does not harm the bone (or soft tissue) through high temperatures or carbonisation. In addition, the positive effect of biostim- ulation leads to quicker and better healing by accelerating the fibroblast activity around the implant. Of course, the primary benefit for patients is the reduction of the general risk of blood clotting and thrombosis, which can possibly contact Dr Stefan Grümer Zahnärzte an der Theaterstraße Aachen, Germany +49 241 36461 doc@gruemer.de zahnaerzte-theaterstrasse.de Author details 20 2 2021

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| case report Combining orthodontics with a zirconia collar implant Dr Kunal Shah, UK 1 2 3 Fig. 1: Front view in occlusion. Fig. 2: Lower occlusal view. Fig. 3: Pre-operative intra-oral view of LL4. A male patient in his thirties presented with a submerged LL4 that was very mobile and had a poor prognosis. The patient was fit and well with no medical issues. He came to the practice on a recommendation and his main con- cern was the position of his teeth—he had an increased overjet and wanted straighter teeth. The patient’s dentition was healthy and his periodontal condition was good. Treat- ment options were discussed with the patient. These initially included no treatment or orthodontics—through either myself or a specialist orthodontist—to correct the position of the teeth, in addition to extraction and replacement of the LL4. Replacement options for the LL4 were also offered, including no treatment, dentures, a dental bridge or a dental implant. The patient did not want a fixed orthodontic appli- ance. Instead, he preferred a discreet removable solution, as he was conscious of being in a client-facing job role. As such, he decided on extraction of the LL4, orthodon- tics with transparent aligners system and replacement of the LL4 with an implant. Following extraction of the LL4, we knew from the outset how much space needed to be maintained ready for implant placement (Figs. 1–3). Aligners procedure was performed over 18 months to level out and align the lower arch, as well as to correct the patient’s increased overjet to the point where he was happy. Orthodontic treatment effectively maintained the space left behind in the LL4 for the implant to be placed. Implant consultation When the patient returned to the practice to discuss implant treatment, different implant systems were presented. The pa- tient chose the Z1 implant (TBR Dental) as he had a thin gingi- val biotype, so the zirconia collar design of this implant would enable better aesthetics to be achieved. The patient had the bone structure to support either a bone- or tissue-level implant, so we were fortunate enough to be able to choose a solution that met the clinical needs of the patient best. Treatment planning Treatment planning began with taking CBCT scans (Figs. 4 & 5) to determine the position of the inferior alveolar nerve (IAN) and the mental nerve. This was essential to plan optimal placement of the implant. Injury to the IAN as a result of 4 5 Fig. 4: CBCT scan close up of LL4. Fig. 5: Prosthetic-driven implant planning model. 22 2 2021

case report | 6 7 8 9 Fig. 6: 3D render with prosthetic-driven implant planning model. Fig. 7: Buccal view of TBR drill. Fig. 8: Lingual view of countersink. Fig. 9: Prepared site for implant placement following countersink. implant surgery can cause severe pain and altered sensa- tion in the face, which can affect everyday activities such as speaking and eating.1 The CBCT scans also facilitated visualisation and assessment of the patient’s bone density, so that treatment could be planned from a 3D perspective (Fig. 6). An implant (3.5 mm in diameter, 10.5 mm in length; TBR Dental) with a zirconia collar height of 1.5 mm was chosen. Each stage of the procedure was discussed with the patient, before he consented to treatment and surgery could begin. velop. This procedure allows the hard and soft tissue to heal at the same time as the gingiva is not handled sev- eral times—as it would be with a bone level implant. In this case, a cover screw could be fitted to the implant and left for 3 months to achieve excellent osseointegration. The surgi- cal site had been sutured. A radiograph was taken to con- firm that the implant was positioned correctly. The patient was sent away with appropriate post-surgery care instruc- tions, which involved wearing his retainers as normal to maintain the space in the LL4 during healing. Implant placement Restoration The surgical aspect of treatment was straight-forward, as it had been planned meticulously in advance. A delayed implant placement protocol was followed that included raising a flap. This technique involved making an incision in the gingiva and lifting a flap to provide access to the bone. The patient’s bone density ensured that a bone graft pro- cedure was not necessary for implant placement, which enabled countersinking of the implant (Figs. 7–9), meaning the bone was prepared for the zirconia collar of the implant to be placed slightly below the crestal bone (Figs. 10 & 11). This is a protocol the author typically follows to achieve better integration of the implant with the bone and, conse- quently, improved gingival attachment to the zirconia collar for enhanced aesthetics. The zirconia collar of the implant acts like a healing abutment to encourage gingival flaring and soft tissue healing for a good gingival profile to de- The implant was reviewed after three months and found to be stable. The soft tissue was pink, healthy and firm, and the LL4 space had been effectively maintained as a result of the patient wearing his retainers. The implant was restored through a digital workflow. A CS 3600 intra-oral scanner was used to scan the lower and upper arches with the implant cover screw in place, which was then removed and the focus area scanned again to capture the emergence profile (Fig. 12). A TBR scan body was then placed (Fig. 13) and a final scan taken (Figs. 14 & 15). This was checked and sent to the laboratory to produce a screw-retained e.max crown on a pre-manufactured, titanium-base abutment from TBR. The patient was invited back to the practice to have the final restoration fitted. The e.max crown was seated correctly onto the implant (Figs. 16 & 17) and the access hole was sealed with PTFE tape (Fig. 18), before being filled with 10 11 12 13 Fig. 10: Buccal view of implant placement. Fig. 11: Occlusal view of TBR 3.5 x 10 mm implant placement. Fig. 12: Intra-oral scan of lower arch with cover screw present on implant. Fig. 13: Buccal view of scan body seated in LL4. 2 2021 23

| case report 14 15 Fig. 14: Buccal view of lower arch IO scan with scan body. Fig. 15: Comparison model of LL4 region with and without scan body. a temporary dressing. This was removed after a week and the crown tightened to 25 Ncm (Fig. 19). PTFE tape and composite were used to seal the screw-access hole. The patient was delighted with the overall outcome (Figs. 20 & 21). 16 17 18 19 Discussion In this case, a combination of orthodontics and implant treatment ensured that a predictable and highly satisfactory result could be achieved. The unique design of the Z1 implant makes it a highly versatile system that can be adapted according to the clinical situation. The zirconia collar also limits the adhesion and proliferation of bacteria to help avoid infection and promote a longer life-span of the dental im- plant. Moreover, its zirconia collar facilitates treatment by protecting the crestal bone and soft tissue from infection and promoting natural gingival growth.2, 3 Conclusion This case emphasises the importance of careful treatment planning and choosing a top-quality implant that allows to achieve excellent aesthetics and function. about the author Dr Kunal Shah is the principal of LeoDental in London. He graduated from the University of Birmingham in the UK, was selected as a finalist for Young Dentist of the Year—South in the Dental Awards 2018 and has the accolade for the best implant and imaging clinic in London in 2018. He has a keen interest in the topics of digital dentistry, implan- tology and restorative dentistry specific to direct resin compos- ites and impression materials, and has published several articles in the professional press and lectured internationally. Dr Shah is also a clinical mentor for students on the year-long postgraduate implant course at LeoDental in conjunction with SmileTube.tv. 20 21 Fig. 16: Occlusal view of screw-retained e.max crown seated in LL4. Fig. 17: Post-op palatal aspect of LL4 showing initial seating of final crown. Fig. 18: Screw-retained e.max crown with PTFE tape in access hole. Fig. 19: Post-op PA LL4—showing final seating of screw-retained e.max crown. Fig. 20: Buccal view of final screw-retained e.max crown. Fig. 21: Lingual view of final screw-retained e.max crown. contact Dr Kunal Shah LeoDental London, United Kingdom +44 20 82033155 referral@leodental.co.uk www.leodental.co.uk Author details 24 2 2021

| case report Correction of a vertical fracture and a subsequent infection Dr Matthew J. Fien, USA 1 3 4 5 26 2 2021 2 Fig. 1: Pre-op buccal view. Fig. 2: Pre-op radiograph. Fig. 3: Full-thickness flap reflection. Fig. 4: Extraction and degranulation. Fig. 5: Membrane stabilised with resorbable sutures over the allograft particulate bone graft. A 46-year-old female patient with a non-contributory medical history presented for evaluation and treatment of swelling in her maxillary left quadrant. The intra-oral ex- amination revealed moderate swelling and a buccal fistula 3 mm from the gingival margin of tooth #25 (Fig. 1). The ra- diograph revealed severe bone loss as a result of fracture and subsequent infection of tooth #25 (Fig. 2). Treatment planning included tooth extraction and subsequent tissue debridement. Tooth replacement with a dental implant was planned to be carried out once the site had regenerated. Extraction and bone grafting In a first surgical step, a full-thickness flap was reflected (Fig. 3). Once the infected tooth had been extracted, all granulomatous tissue was meticulously debrided from the defect (Fig. 4). The defect was then grafted with a freeze-dried bone allograft, and an OSSIX Plus mem- brane (Dentsply Sirona) was adapted to the buccal– occlusal–palatal line angle and secured with a resorbable suture (Fig. 5). At the follow-up two weeks after surgery, slight soft-tissue dehiscence at the incision line was noted (Fig. 6). There were no longer any signs of an infection. At four weeks postoperatively, the tissue over the graft– membrane complex had healed almost completely (Fig. 7). After four months, the patient had fully recovered (Fig. 8). At that point, a significant increase in the contours of the ridge in the area of the previous infection was notable.

case report | 6 9 12 7 8 10 11 13 Fig. 6: Occlusal view of healing at two weeks post-op. Fig. 7: Occlusal view at four weeks post-op: almost complete healing over the graft–membrane complex. Fig. 8: Full recovery after four months. Fig. 9: Radiograph at four about the author months post-op revealing complete defect filling and incorporation of the bone graft. Fig. 10: Occlusal view of the regenerated ridge at the time of implant placement. Fig. 11: Buccal view of the regenerated ridge at the time of implant placement. Fig. 12: Occlusal view after initial osteotomy preparation and place- ment of a guide pin. Fig. 13: Buccal view after implant placement. A radiograph was taken which revealed complete defect filling and incorporation of the bone graft (Fig. 9). The verti- cal height of the alveolar ridge could be maintained despite the severity of the defect at the time of extraction. Implant placement Ahead of implant placement, six months after extraction, a flap was reflected (Fig. 10). At that point, the ridge had fully regenerated. Remnants of the OSSIX Plus membrane can be seen in Figure 11, protecting the healed ridge. The initial osteotomy was prepared and a guide pin was placed. At that point, a significant increase in ridge width beyond the confines of the alveolar housing was noted (Fig. 12). After implant insertion, imprinting of the herring bone pat- tern on the regenerated bone and re-establishment of the buccal–occlusal line angle could be seen (Fig. 13). Dr Matthew J. Fien graduated from the Columbia University College of Den- tal Medicine in New York in the US in 2006. He received his specialty training in periodontics from Nova Southeastern University in Florida in the US and his diplomate status from the American Board of Periodontology in 2009. He has published articles in various den- tal journals and lectures throughout the US on bone grafting techniques and all aspects of implant dentistry. He is an active member of the American Academy of Periodontology and the Academy of Osseointegration and maintains a private practice in Fort Lauderdale in Florida. contact Dr Matthew J. Fien Fort Lauderdale, FL, USA +1 786 5202995 fienodontics.com Author details 2 2021 27

| case report Full-mouth implant reconstruction using zygomatic and standard implants Dr James Kwok Fai Chow, China 1a 1b 1c 1d Immediate implant insertion is indicated when treating patients with terminal dentition. In the case of full-arch im- plant reconstruction, clinicians usually couple immediate implant placement with immediate loading if the primary stability of these implants is adequate. If the residual bone volume is limited in the posterior maxilla, a zygomatic im- plant is often employed by experienced surgeons to mini- mise the extent of grafting and to support immediate load- ing. This article describes the dental implant treatment of an elderly lady who was suffering from terminal dentition. This patient had undergone full mouth clearance followed by double-arch immediate implant reconstruction using zygomatic and conventional implants. Initial situation A 76-year-old lady who complained of gum swelling and tooth mobility was a known case of hypertension and hy- perlipidemia (Figs. 1a–d). She was taking antihypertensives regularly (amlodipine 5 mg at night; losartan 50 mg QD). In addition, this patient had undergone a left hemithyroid- ectomy in 2018, as well as a spinal fusion many years ago. The patient was fit and ambulatory without any acute dis- tress. Preoperative blood tests showed that she had mild vitamin D deficiency. Clinically, this patient suffered from multiple missing posterior teeth in her upper and lower jaws. The remaining teeth were diagnosed with second- ary caries, chronic periodontal disease with clinical attach- ment loss, defective fillings and failing crown and bridge- work (Figs. 2a–c). Radiological examination further revealed 2a 2b 2c 28 2 2021

D A See the Feeling Light, but strong. Simple, but so functional. Modular, but always comfortable and stylish. The new F47 by laservision: Not only laser safety spectacles, but so much more. See for yourself. uvex-laservision.de 3a that the three anterior mandibular implants had extensive peri-implant bone loss, which was consistent with a clinical diag- nosis of severe peri-implantitis. Treatment planning After undergoing a CBCT scan, the patient’s DICOM files were exported for computer- aided implant planning (Figs. 3a & b). Third-party software was used for seg- mentation and simulation. To respect the biology and biomechanics for optimal functional and aesthetic outcomes, the treatment plan was formulated according to the principles of prosthetically driven implant planning (Figs. 4a & b). Important planning considerations included the dis- tribution of the dental implants in a wider arc, the placement of dental implants ac- cording to the future tooth position, and the elimination of a distal cantilever on the prosthesis. Based on the clinical and ra- diological findings, this patient was found to have the following problems: 1) Termi- nal condition of the remaining upper and lower teeth; 2) Low-lying maxillary sinus floor bilaterally with limited residual bone volume; 3) Peri-implantitis of the anterior mandibular implants. To solve these problems, the following treatment plan was explained and rec- ommended to the patient and her family to consider: 1) Clearance of all remaining teeth; 2) Removal of the anterior mandib- ular implants; 3) Six conventional dental implants in the mandible for full-arch re- construction; 4) Six dental implants in the maxilla for full-arch reconstruction includ- ing four conventional dental implants in the anterior maxilla and single zygomatic implants bilaterally; 5) Immediate loading using abutment-level screw-retained pro- visional prostheses; 6) Surgery under gen- eral anaesthesia. Once the patient had agreed with the proposed treatment plan, the CBCT DICOM files were segmented, and 3D printed jaw models were produced. These real-size jaw models were used for visualisation of anatomical structures and the mental rehearsal of the surgical steps (Fig. 5). In addition to CBCT diagnostic imaging and computer-aided planning, 3D printing is an invaluable technology in the digital workflow of implant dentistry. BLX and ZAGA™ zygomatic implants (Straumann) were selected for this patient. The BLX Implant System is designed for immediacy. Straumann® Zygomatic Im- plants ZAGA™ flat and round were recently introduced to the market to provide implant surgeons with an extra tool to manage pa- tients with severely atrophic maxilla. In this case report, a ZAGA™ round implant was selected based on the current ZAGA™ concept. According to the ZAGA™ classi- fication,1 a zygomatic implant may take an intra-sinus or extra-sinus path depending on the lateral maxillary sinus wall configu- ration. When an intra-sinus path is antici- 3b uvex-laservision.de protecting people

| case report 4a 4b pated, a ZAGA™ round implant with threaded coronal por- tion is considered favourable. The BLX and the ZAGA™ zygomatic implant both share the same prosthetic platform. The SRA abutments are available for both implant systems, and these abutments are selected and connected immedi- ately after implant placement to facilitate immediacy. Surgical procedure Surgery was performed under general anaesthesia with naso-endotracheal intubation. After disinfection and draping, the patient underwent the following procedures: 1) Clearance of all the remaining teeth, excision and cu- rettage of any granulation tissue; 2) Removal of the three implants in the anterior mandible; 3) Osseous reduction was conducted using piezoelectric surgery in the upper and lower jaws to provide adequate restorative space and to create a bone platform with sufficient width to support the chosen implants (Figs. 6a & b); 4) Implant placement in the mandible was completed by free-hand surgery (Figs. 7a & b); 5) Implant placement in the anterior max- illa was performed by free-hand surgery (Figs. 8a & b); 6) Prior to a zygomatic implant osteotomy, an extended lateral window was cut on both sides for an open sinus lift procedure (Figs. 9a & b); 7) Elevation of the maxillary sinus membrane was carried out by leaving the bone win- dow attached to the Schneiderian membrane (Figs. 10a & b); 8) By locating the starting point and end point for the zygomatic implant placement, a zygomatic implant oste- otomy was completed by sequential drilling (Figs. 11a & b); 9) Grafting of the sinus floor with xenografts (Bio-Oss collagen, Geistlich; Fig. 12); 10) Placement of zygomatic implants bilaterally (Figs. 13a & b); 11) Grafting of the cor- onal portion of the zygomatic implants with xenografts (Bio-Oss collagen, Geistlich; Fig. 14); 12) Covering the grafted site with collagen membrane (Bio-Gide, Geistlich); 13) Connection and tightening of SRA abutments; 14) Wound closure around the abutments and impression copings (Fig. 15); 15) Silicone impressions were made, and bite registration was taken for immediate prostheses. An extended sinus lift is a technique introduced by Chow et al.2 to eliminate the risk of maxillary sinusitis in zygomatic implant patients. In ZAGA™ type 0 and type 1 patients, the extended sinus lift technique keeps the zygomatic im- plant external to the maxillary sinus despite the fact that the implant has an intra-sinus trajectory. When an extended sinus lift is performed, it is recommended to graft the sinus for the following reasons: 1) To provide bone sup- port around the coronal region of the zygomatic implant; 2) To increase the bone thickness to minimise the risk of development of an oral–antral communication. Implants with sufficient insertion torques were used for immediate loading (Table 1). In this case, except for the BLX implant 5 30 2 2021

at the lower right first premolar location, all implants, in- cluding the zygomatic implants, were seated with insertion torques not less than 30 Ncm. Since the BLX implant at the lower right first premolar location had a low insertion torque, it was submerged for healing. The upper and lower working impressions and the bite registration were sent to the laboratory for fabrication of the screw-retained upper and lower acrylic prostheses. After the surgery, the patient was monitored in the recovery room. When the patient was fully awake and her vital signs were stable, she was discharged home. The patient was prescribed an oral analgesic (etoricoxib 120 mg QD), oral antibiotic (amoxicil- lin 250 mg TDS) and chlorhexidine mouthwash for 5 days. Immediate loading and prosthetic procedure The patient returned for a follow-up visit 5 days after surgery. She presented with moderate facial swelling and bruising without complaining of pain. Clinically, the oral wounds were clean, and there was no bleeding or any signs of infection. Provisional acrylic, metal- reinforced prostheses were delivered for immediacy (Fig. 16). All the prosthetic screws were tightened manually, and screw access holes were sealed with a light-curing tempo- rary composite resin (Fermit, Ivoclar Vivadent). An OPG was taken after the delivery of the immediate prostheses (Fig. 17). In this case, the following occlusal scheme for full-mouth implant reconstruction was adopted: 1) Pros- thetically driven implant planning; 2) Dental implants with a moderately rough and hydrophilic surface; 3) No cantile- ver in the prostheses; 4) Even contacts in centric relation; 5) Shallow anterior guidance; 6) Group function on excur- sion; 7) Use of soft night guard. The patient was sched- uled for regular review for wound healing and occlusal adjustment. The definitive prostheses were scheduled to be fabricated three to four months later. Treatment outcomes A significant proportion of patients scheduled for full-arch reconstruction suffers from terminal dentition. Immedi- ate implant placement and an immediate loading proto- col help these patients cope with the implant treatment by minimising the stress and inconvenience associated with the edentulous phase. Meta-analyses have shown that immediate implant placement is just as successful as delayed implant placement in full-arch reconstruction. Moreover, immediate loading is predictable, with high implant survival rates compared to conventional loading. Of course, certain criteria exist for immediate loading, and good primary stability is considered essential. The BLX implant is designed for immediacy, and this implant system is indicated for all types of bone quality. In ad- dition, in this case of a ZAGA™ type 0 classification, a ZAGA™ round implant was chosen. In order to achieve a more distal location to eliminate a cantilever effect, the starting point of the zygomatic implant is usually located 6a 7a 8a 9a 6b 7b 8b 9b 10a 10b 11a 11b 12 13a 13b case report | 2 2021 31

| case report 14 16 15 17 around the zygomatic alveolar crest region. Before per- forming the zygomatic implant osteotomy, a lateral sinus lift procedure was performed, and an extended window was opened from the sinus floor to the base of the zygoma bone. The Schneiderian membrane was elevated with the bone wall of the lateral window attached. It was important to preserve the integrity of the Schneiderian membrane. The purpose was to keep the zygomatic implant external to the maxillary sinus to reduce the risk of maxillary si- nusitis. Grafting of the sinus floor and around the coronal portion of the zygomatic implant was performed. In prin- ciple, grafting increases the crestal bone support for the zygomatic implant and helps by distributing the functional loading more favourably compared to a situation without bone. Moreover, the increased bone thickness surround- ing the coronal portion of the zygomatic implant creates a more robust hard tissue barrier between the oral cavity and the sinus cavity. This may prevent the development of an oral–antral communication after zygomatic implant treatment. To investigate the sinus reaction after zygo- matic implant treatment, CBCT examination is useful to evaluate the sinus membrane thickness and patency of the osteo-meatal complex. In this case, the CBCT taken 3 months after surgery showed that there was no sinus membrane thickening and no obstruction of the ostium (Figs. 18a & b). about the author James Kwok Fai Chow BDS, MDS obtained his Bachelor of Dental Surgery and Master of Dental Surgery from the University of Hong Kong. In addition, he holds a Bachelor of Medicine and Bachelor of Surgery degree from the same University. He is a specialist in Oral and Maxillofacial Surgery. Dr Chow holds a Diploma in Implant Dentistry from the Royal College of Surgeons of England and is a Fellow of the International College of Dentists as well as an Honorary Clinical Associate Professor in Oral & Maxillofacial Surgery at the Faculty of Dentistry of the University of Hong Kong. Author details Literature contact Dr James Kwok Fai Chow Sheung Wan – Dental Implant & Maxillofacial Centre Hong Kong, China +852 2851 4888 www.aboc.com.hk 18a 18b Table 1 Table 1: Recommended insertion torques of the zygomatic and standard implants used. 32 2 2021

| industry m o c . k c o t s r e t t u h S / e c n a r e / s k r o w i l r o m a t e m © More room for new bone formation Branislav Kostadinov, Switzerland In a randomised comparison study of bovine-derived (MinerOss X) and porcine-derived bone grafts (MinerOss XP) in molar or premolar extraction sockets covered with a collagen membrane (Mem-Lok® Pliable) in 18 patients, Guarnieri and colleagues detected no differences in terms of dimensional vertical and horizontal changes at the extraction sockets between the two groups.1 In sockets that were grafted using the bovine-derived bone material, the mean ridge width and the average heights of the vestibular and the lingual crest were re- duced by 1.25 ± 0.7 mm, 1.18 ± 0.8 mm and 1.12 ± 0.9 mm, respectively. For the group whose sockets were aug- mented using porcine-derived bone, the reductions were 1.19 ± 0.4 mm, 1.21 ± 0.8 mm, and 1.09 ± 0.6 mm respec- tively (Fig. 1). In the assessment of the histo-morphometric parameters, statistically signiﬁcant differences were detected between the two groups (Fig. 2). The percentage of newly formed bone was signiﬁcantly higher in the group that was treated with porcine-derived bone material compared to the bovine xenotransplant group at four months post grafting (57.13 ± 2.8% vs. 49.0 8± 3.7% of new bone). Conversely, non-mineralised connective tissue (16.37 ± 4.9% in bovine vs 13.65±3.6% in porcine), residual graft particles and The correct choice of biomaterials is crucial to achieve optimal clinical results—in functional, structural and aesthetic terms. The aim of any tissue regeneration tech- nique, and bone grafting in particular, is to achieve for- mation of living and reactive tissue. This should be able to regenerate itself such that the mechanical and biological function is maintained sustainably. 34 2 2021

industry | 1 2 Fig. 1: Horizontal and vertical changes at re-entry surgery. HVC: height of the vestibular bone ridge; HLC: height of the lingual bone crest; RW: ridge width; MB: bovine-derived bone graft group; MP: porcine-derived bone graft group.1 Fig. 2: Histo-morphometric mean values. CT: connective tissue, NFB: newly formed bone; OST: osteoid tissue; RG: residual graft; MB: bovine-derived bone graft group; MP: porcine-derived bone graft group.1 osteoid tissue were present at a higher extend in the sockets treated with bovine material (13.49 ± 2.8% and 21.06 ± 3.8% in bovine vs 11.74 ± 4.7% and 17.63 ± 3.8% in porcine). The data also suggest that alveoli treated with a mem- brane and porcine bone grafts (MinerOss XP) leave less residual bone replacement material compared to alveoli treated with bovine bone grafts (MinerOss X). This might indicate a different impact of the bovine- and porcine- derived materials on the bone healing process. This hypoth- esis is also supported by the higher percentage of osteoid tissue (bone in maturation phase) found after four months in extraction sockets grafted with bovine-derived bone. The different histological results between the two groups. Bone mineral matrices must be biocompatible and fulﬁl four key properties to promote bone formation and to allow efﬁcient tissue regeneration. In summary, the prop- erties of an “ideal” bone graft enable bone growth in the augmented site and lead to stable osseointegration with minimal host response. Osseointegration is deﬁned as the formation of new bone at the direct interface between an endosteal implant or bone substitute material and the native bone without intervening soft tissue.2 Compared to bone of bovine origin (MinerOss X), porcine bone (MinerOss XP) therefore appears to facilitate accelerated alveolar bone healing.1 Author Details Literature contact Branislav Kostadinov Camlog Biotechnologies AG Senior Product Manager Biomaterials Europe Basel, Switzerland +41 61 5654100 info@camlog.com www.biohorizonscamlog.com 2 2021 35 Fig. 3: REM: MinerOss XP macro and micro pores resemble human bone.

| manufacturer news Argon Medical K3Pro Compress Implants for immediate implant placement The successful K3Pro implant line from Argon Medical will be expanded by another innovation: the C(ompress)-Line. The wish of ambitious implantologists to provide their patients with ﬁ xed temporaries immediately after major implantological surgery requires an implant with excep- tionally high primary stability, especially in soft bone (D4 bone quality). For immediate implant placement after extraction, however, it is often necessary that self-tapping thread ﬂ anks ﬁ x the implant securely to the alveolar wall and that there is generous free space for healing through blood coagulation. The new C-Line fulﬁ ls both wishes without neglecting the classic virtues of K3Pro—the optimisation for subcrestal insertion and outstanding aesthetics and the unshakably stable long conical connec- tion for sustainable tissue preservation as part of the stable tissue concept. The spiral-shaped progressive cutting thread for easy and pre- cise insertion in soft bone has a plateau design and offers unique primary stability for immediate loading. With immediate implant placement, the slightly conical, slim implant body offers plenty of space between the threaded lamellae for the blood clot to form. The implant diameter is measured according to the width of the thread ﬂ ank if the implant body remains similarly slim. Thus, the choice of diameter regulates the degree of primary stability. Argon Medical, Germany +49 6721 30960 www.argon-medical.com BioHorizons Camlog TBR Dental Discover Z1®—The tissue-level implant with a zirconia collar The Z1 tissue-level implant requires only one surgery, which is time- saving for the practitioner and more comfortable for the patient. In addition, its transgingival position allows the surgeon to easily see the connection, which facilitates his work. Moreover, it allows a healing of the soft tissues of ﬁ rst intention as well as simultaneous healing of the hard and soft tis- sues, which reduces the overall treatment time and leads to improved ﬁ nal aesthetics. Moreover, the absence of mobility between the abutment and the implant at bone level avoids associated bone loss.1 The transgingival zirconia collar of the Z1 protects the bone from bacterial inﬁ ltration. Indeed, zirconia reduces bacterial colonisation compared to titanium.2 In addition, the attachment and proliferation of ﬁ broblasts is improved, leading to a strong attachment between the soft tissues and the zirconia collar, which leads to a natural reconstruction of the papillae and to an optimal aesthetic result.3 Aesthetics are additionally accentuated by the natural colour of zirconia, which resembles the colour of natural teeth.4 Discover the Z1 to combine the advantages of a tissue-level implant and a transgingival zirconia collar! Literature TBR Dental Group, France +33 5 62167100 contact@tbr.dental The next generation soft-tissue augmentation material When choosing a biomaterial, there is a strong demand in clini- cal practice for predictable outcomes. For over 20 years, LifeCell, a leading global medical technology company, has developed innovative products for use in a wide range of applications. BioHorizons Camlog expands its soft-tissue portfolio to bring NovoMatrix, an innovative soft-tissue augmentation material. NovoMatrix is an acellular extracellular dermal matrix consisting of tissue-engineered porcine material. It is a breakthrough in xenogeneic processing ensuring a structurally intact, undamaged scaffold that supports cell and microvascular ingrowth. The proprietary tissue processing allows for rapid revascularisation, cell repopulation and minimal inﬂ ammation. NovoMatrix comes pre-hydrated and ready to use and offers a true alternative to autogenous soft-tissue grafts and current products on the market. The NovoMatrix indications include guided tissue regeneration procedures in recession defects for root coverage, localised gingival augmentation to increase keratinised tissue (KT) around implants and natural teeth, and alveolar ridge reconstruction for prosthetic treatment. Camlog Biotechnologies GmbH Switzerland +41 61 5654141 www.biohorizonscamlog.com 36 2 2021

| manufacturer news Fotona EmunDo® for successful periodontal treatments Fotona’s EmunDo® Photo Thermal & Photo Dynamic Therapy is an innovative 810 nm diode laser concept for precise, non-invasive and highly effective bacteria reduction in periodontitis and periimplantitis treatments. The therapy is based on the administration of a photo- sensitive activator that accumulates only in inﬂ amed areas and on bacterial bioﬁ lm. The combination of photothermal and photochemical effects works in a synergetic way to eliminate all types of bacteria. The treatment does not stain the vital tissues and the activator can be washed out easily without any residue after the procedure, reducing the use of antibiotics as a result. To learn more, go to www.fotona.com. Fotona d.o.o., Slovenia +386 15009100 www.fotona.com Dentsply Sirona LASERVISION F47—The sporty, lightweight 2-lens glasses for every use The new, sporty, lightweight laser protection frame F47 is particularly characterised by its 2-lens design. It is designed for the absorbing plastic laser protection ﬁ lters from the laservision product portfolio. The frame- less ﬁ lters with base curve 8 ensure excellent all-round visibility without restrictions and, thanks to the ﬁ lter height, offer a large coverage area that also includes the eyebrows. Together with the laser protection ﬁ lters the sporty designed F47 eyewear weighs only 25 g. It is equipped with 2-component soft temples and an adjustable nose pad, which all in all ensures a high level of comfort and an individual ﬁ t. At launch the F47 is available with the P1M03, P1L12 or P1P10 ﬁ lters. Flexibility in use is achieved through the central adapter preparation, which currently allows two different expansion options. Together with the appropriate special adapter from laservision, the F47 can, for example, be equipped with an LED or a binocular magnifying glass from HEINE. LASERVISION GmbH & Co. KG, Germany +49 911 9736-8100 info@lvg.com uvex-laservision.de OSSIX regenerative solutions portfolio The OSSIX® portfolio consists of OSSIX Plus, OSSIX Bone and OSSIX Volumax. OSSIX Plus is a porcine-derived, ossifying, resorbable collagen membrane. OSSIX Bone is a porcine-derived, sponge-like ossifying block for true bone formation, and OSSIX Volumax is a porcine-derived, volumising, thick collagen scaffold. Powered by the patented GLYMATRIX technology, OSSIX Plus, OSSIX Volumax, and OSSIX Bone are supported by over 100 scientiﬁ c publications and extensive clinical experience. The OSSIX products use the proprietary GLYMATRIX core technology, a proven process that uses naturally occurring sugar to cross-link collagen biomaterial, for guided bone regeneration (GBR) and guided tissue regeneration (GTR). These products have enabled clinicians in hundreds of thou- sands of procedures to safely provide predictable, long-term results to their patients over the past 20 years. With innovative products driven by the GLYMATRIX core technology, OSSIX bio- durable de- sign will ensure long-term predictable and superior results, while supporting and enhancing the future of implant dentistry and oral care. Making work ﬂ ow in implant dentistry revolves around identifying the smoothest and most convenient workﬂ ow for each customer, and making sure to deliver whatever is needed to ensure that. With a vast, world-class assortment of products and solutions for implant treatment, Dentsply Sirona offers complete solutions that create the best possible workﬂ ow and make work ﬂ ow better. Dentsply Sirona, Sweden +46 31 3763000 www.dentsplysirona.com/implants 38 2 2021

m m o o c c . . k k c c o o t t s s r r e e t t t t u u h h S S / / v v o o s s i i r r o o B B S S © © . . The 50-year anniversary of the German Association of Dental Im- plantology (DGZI) was initially planned to be celebrated last year in Bremen, Germany, the association’s founding city. However, owing to the COVID-19 pandemic-related restrictions imposed by the federal government at that time, the congress had to be postponed. The new date has been set to 1 and 2 October 2021, and the new venue will be the Maritim Hotel in Cologne. For the third Future Congress for Dental Implantology, which is also the 50th International Annual Congress of DGZI, the association is gathering a high-proﬁ le group of renowned speakers in perfect keeping with the special occasion. Presidents, past presidents and board members of the German Association of Oral Implantology (DGI), the German Society of Oral Implantology (DGOI), the professional association of German oral surgeons (BDO), the German society for endodontology and dental traumatology (DGET) Registration Fifty years of implantology... ...to be celebrated in Cologne ...to be celebrated in Cologne and DGZI will hold scientiﬁ c lectures as part of the main programme, according to the event’s theme “Visions in Implantology: 50 Years— From single Implant to digital Workﬂ ow”. Attendees can look forward to a congress that reﬂ ects on the past 50 years of dental implantology, addresses topical questions, and envisions the future of this special discipline of dentistry. With an updated structure and content, the or- ganisers have succeeded in eliminating the previous fragmentation of the congress into various separate lecture rooms, workshops and side programmes, sharpening the congress’s proﬁ le as an event for practi- tioners as a result. All lectures, panel discussions, livestreamings and the table clinics will take place in the main hall, which will also serve as the industry exhibition area for the myriad of manufacturing companies which will be showcasing their product innovations at the event. For fur- ther information, visit www.dgzi.de or contact event@oemus-media.de. In addition, feel free to register for the event via the QR code. Source: German Association of Dental Implantology (DGZI) “CleanImplant Certiﬁ ed Dentists” in 19 countries Initiative creates safety for implantologists and patients For many years, CleanImplant has been performing quality assess- ment studies on sterile packaged implants in accredited testing laboratories. The “Trusted Quality” seal for clean implants can only be awarded after an independent evaluation of test results that 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. Signiﬁ 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 compounds 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 initiative for residue-free implants on the internet. We never dreamed that we would have more than 100,000 dental professionals following us on Facebook in such a short time.” In the meantime, implantologists from 19 coun- tries are registered as a “CleanImplant Certiﬁ ed Dentist”. They can be sure that they only use implants that have been tested as clean. On the new website 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: www.cleanimplant.org. Source: CleanImplant Foundation CIF GmbH CleanImplant-Certiﬁ ed Practices. 40 2 2021

5th GLOBAL CONFERENCE MIS announces new dates For its ﬁ fth Global Conference A Straumann Virtual Symposium “New opportunities in immediacy and beyond” Based on 35 years of tissue-level heritage, Straumann is hosting a two-day online symposium on its upcoming TLX implant. Whether you are a keen user of the Straumann® Tissue Level Implant or an experienced clinician in immediate treatment protocols, the new Straumann® TLX Implant System will open up new opportunities for you. In this event, you will discover what happens when 35 years of heritage meet one of the major trends in dentistry, and how it can add value to your own practice. Renowned international experts and leading clinicians will present the development history and the clinical advantages of this new system in various indications: Abid Faqir (UK), André Chen (PT), Barbara Sobczak (PL), Daniel Buser (CH), Dean Morton (USA), Edgard El Chaar (USA), Eik Schiegnitz (DE), Faresh Desai (UK), German Gallucci (USA), Leonello Biscaro (I), Louwrens Swart (ZA), Matthieu Collin (F), Ophir Fromovich (IL), and Shakeel Shahdad (UK). The event takes place on 15 and 16 June 2021 (2.5 hours per day from 16:30 CET). Register now at https://tlx.virtualevents.straumann.com/?utm_ source=website&utm_medium=&utm_campaign=tlx-symposium MARRAKECH, MOROCCO MAY 19–22, 2022 Following the long-awaited an- nouncement of the new dates for the ﬁ fth MIS Global Confer- ence, the MIS team is hard at work getting ready for Marrakech, Morocco, where the company will be hosting the event from 19–22 May 2022. The conference will feature a three-day scien- tiﬁ c programme ﬁ lled with lectures by world-renowned experts, hands-on workshops, as well as exciting social celebrations. As in previous Global Conferences, the scientiﬁ c committee is determined to address the most relevant and important topics and cases as part of the scientiﬁ c programme. Speakers have been carefully selected to present new concepts and breakthroughs, and provide insight into their vast professional knowledge and clinical experience. With a location such as Marrakech, conference guests can look forward to a myriad of beautiful and colourful sights, as well as exotic tastes and fragrances, making for a truly unique and unforgettable experience. The meticulously planned and spectacular evening celebrations, which are part of every MIS Global Conference, are an integral part of this next, highly anticipated event as well. Source: Straumann Source: MIS DGZI Online Campus International online training wherever you are The structure and content of DGZI’s successful implantol- ogy curriculum was revised in 2019. All participants now have access to the ITI Academy, where young dentists with little experience in implantology can learn the basics of implant dentistry. All participants in the curriculum will start their training in the new “DGZI Online Campus”. This has been completely rede- signed and enables e-learning from all devices and from anywhere you have online access. The theo- retical basics of implant dentistry are well presented and taught in separate modules. Each module ends with a learning success check, which can be practised as often as required in advance in test examinations. After successful online training, three practice-related compulsory modules and two therapy- related optional modules follow. The curriculum is supported by special learning materials of the DGZI Online Campus. Start with the new concept of the DGZI online training at home or wherever you are—that is Blended Learning! Now at DGZI! Contact: sekretariat@dgzi-info.de; info.vollmer@t-online.de m o c . k c o t s r e t t u h S / s s u m a e s / a d o o v a d © 2 2021 41

| about the publisher Congresses, courses and symposia implants IDS Cologne 22–25 September 2021 Cologne, Germany www.ids-cologne.de 50th DGZI International Annual Congress— Visions in Implantology 1–2 October 2021 Cologne, Germany www.dgzi-jahreskongress.de 30th annual scientiﬁ c meeting of EAO 14–16 October 2021 Milan, Italy www.eao.org AAID Annual Conference 10–13 November 2021 Chicago, IL, USA www.aaid.com/annual_conference Designer Franziska Schmid f.schmid@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 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 2021. 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. 42 2 2021

EDENTULOUS PATIENTS Straumann® Pro Arch Edentulous Solutions > Removable Straumann® Mini Implant System Mini Implant. Maximum trust. SCIENTIFIC EVIDENCE PROVEN QUALITY High and consistent survival rates are documented in several long-time studies. A0033/en/A/00 04/2 The successful use of Roxolid®, our high-strength implant material, is DURABILITY & EFFICIENCY The space-saving design of Optiloc® provides excellent wear resistance documented in numerous and reduces maintenance. clinical studies. Contact your local Straumann representative or visit www.straumann.com/mini-implants.