| content editorial Dental implantology in times of crisis 03 Dr Georg Bach case report page 06 Delayed immediate implant placement and direct soft-tissue management 06 Dr Haki Tekyatan Restorative simplicity for a challenging case with limited space Dr Fernando Rojas-Vizcaya & Jose de San Jose Gonzalez Immediate fi xed full-arch rehabilitation of periodontitis patients Prof. João Caramês Graft volumetric changes of collagenated xenograft Dr Livio Lo Faro, Dr Francesco Giachi Carù & Prof. Tiziano Testori Dental lasers against peri-implantitis page 24 Dr Bradley Labrecque Successful rehabilitation of an anterior tooth Dr Dr Branislav Fatori & Dr Inge Schmitz interview On remaining vigilant An interview wiith Julien Benhamou page 46 obituary The inventor of the Bicon system has passed away news manufacturer news news events Dental implant quality under scrutiny Dr Dirk U. Duddeck about the publisher imprint Cover image courtesy of TBR Dental / www.tbr.dental issn 1868-3207 • Vol. 22 • Issue 3/2021 3/21 implants international magazine of oral implantology case report Delayed immediate implant placement and direct soft-tissue management interview On remaining vigilant events Dental implant quality under scrutiny 04 3 2021 14 16 24 34 36 38 40 42 48 46 50

| case report Delayed immediate implant placement and direct soft-tissue management Dr Haki Tekyatan, Germany In the case of implant planning, the preservation of soft tissue and bone is essential for functional and aes- thetic long-term success. There are now various different techniques and materials available. The timing of implant insertion and soft-tissue shaping play a crucial role, as do the measures taken in advance of the planned ther- apy. A targeted strategy can generate favourable condi- tions before implant placement. In this context, the use of bone grafting materials in combination with intrave- nously collected autologous platelet concentrates (I-PRF and A-PRF) has become increasingly important in recent years. With this “biologisation” of specially developed bone grafting materials for alveolar management, stable preservation of the extraction socket and the bone can be expected while promoting wound healing. The great- est loss of bone and, as a result, soft tissue occurs in the first 12 months after tooth extraction. In the literature, loss rates of up to 60% are reported.3 In this regard, Tan et al. were able to show in a systematic review that six months after extraction there is a horizontal bone loss of 29–63% and a vertical bone loss of 11–22%. The transverse bone loss was found to be higher than the vertical bone loss.12 This was also confirmed by Araujo and Lindhe in their an- imal studies. They found that the greatest changes to the alveolar process in the area of the buccal wall occurred within three to six months after tooth extraction.2 In im- plant dentistry, these are limiting factors in daily practice. However, it is crucial to have sufficient hard and soft tis- sue both in quantity and in quality to achieve the goals of implant therapy.5 Preventive interventions can aid in counteracting bone loss and resorptive processes in order to preserve hard and soft tissue.7 In this regard, alveolar stabilisation is a method performed during or after tooth extraction to minimise external resorption of the alveolar process, pre- serve bone, and promote and support bone formation within the extraction socket.6 Various terms are used for this in the literature, such as alveolar ridge preservation (for three- or two-walled defects), socket preservation (for circularly intact alveoli), socket seal technique and alveolar preservation. The aim of these methods is to fill the fresh extraction socket with a bone grafting material and to achieve stabilisation of the alveolar walls.9 In this regard, the use of bone substitute materials biologised with platelet-rich plasma (I-PRF and A-PRF) is described in the literature as a successful means to preserve bone and soft tissue and to support the healing process.8, 11 In the following case report, socket preservation with CERASORB® Foam (curasan) and I-PRF (IntraSpin®, Bio- Horizons Camlog), obtained according to the Low Speed Centrifugation Concept (LSCC) of Prof. Shahram Ghanaati, was performed after extraction of tooth #12.15 Similar cases were reported by Palm et al. and Al-Nawas et al. in the past.13, 14 The implant was positioned and inserted six weeks later on the basis of external planning (DEDICAM, CAMLOG) and using a surgical guide with depth stop (CAMLOG Guide System®). An intra-oral scan (Medit i500®, Kulzer) was performed intra-operatively, and the first sur- gical phase concluded with submerged healing. During this period, a new type of healing abutment was fabri- cated entirely from PEEK material. After a healing pe- riod of three months, this PEEK healing abutment was used directly after implant exposure in order to shape the peri-implant soft tissue optimally and atraumatically in a few treatment steps. Finally, the prosthetic restora- tion was realised with a ceramic-veneered CAD/CAM- fabricated crown. Case report A healthy 55-year-old female patient presented to the practice with an unsalvageable tooth #12. Clinically, the oral situation was unremarkable. The patient reported that the crown was loose and that it rotated slightly. She also reported pain on biting. The radiographic evaluation revealed that the tooth had been endodontically treated and restored with a metal post. Dislocation of the post and core with the crown and a deep fracture were detected, and the patient was informed accordingly (Figs. 1 & 2). A few days later, tooth #12 was extracted gently and atraumatically with the aim of preserving the alveolar walls as far as possible. Special periotomes and instruments (KLACK set®, Geistlich Biomaterials) were used for this purpose (Figs. 3 & 4). Since an implant restoration was planned in this case, it was decided in advance, and together with the patient, that appropriate measures for bone preservation should be taken. The condition of the alveolus after extraction is an important criterion for de- ciding which treatment protocol should be used, that is, 06 3 2021

| case report resorbed and quickly incorporated into the auto genous bone. Socket preservation was performed with a -tricalcium phosphate collagen matrix (CERASORB Foam), which was biologised in advance with I-PRF (platelet-rich fibrin concentrate; Fig. 5). In its hydrated, biologised state, the collagen matrix can be excellently shaped and adapted to the alveolar walls under as little compression as pos- sible (Figs. 6 & 7). The augmentation site was covered crestally and sealed with a compressed A-PRF plug (Fig. 8). The site was then stabilised by means of cross-suturing (Fig. 9). Tight covering using the socket seal approach and a tissue punch was not necessary in this context. The gap was temporarily restored with an interim prosthesis, which was designed as a pon- tic in order to shape the soft tissue (Fig. 10). Lastly, a control radiograph was taken, and the optimal defect filling and almost structurally identical distribution of the matrix could be noted on the radiograph (Fig. 11). After the treatment, irritation-free, stable and, above all, pain-free healing was observed. As a result, planning for implant placement by means of CBCT (Orthophos XG 3D, Dentsply Sirona) could be carried out after only three weeks (Figs. 12 & 13). To achieve optimal 3D axial positioning of the implant in the vertical, mesiodistal and orovestibular directions, the CBCT/DICOM data sets were sent to an external planning centre (DEDICAM) via a secure channel and a surgical guide (CAMLOG® Guide, SMOP®, Swissmeda) was fabricated (Figs. 14 & 15). 2 4 Fig. 1: Initial clinical situation of tooth #12. Fig. 2: Radiograph of tooth #12 showing failed endodontic treatment with the dislocated post restoration and deep complicated fracture. Fig. 3: Gentle detachment of marginal gingiva and periodontal ligament fibres using periotomes. Fig. 4: Atraumatic extraction of the tooth and the fractured fragment. which bone grafting material with which resorptive prop- erties should be used and when the implants should be placed. In the case described here, the alveolar bone could be preserved in all directions. The decision was made in favour of delayed immediate implant placement and the use of a bone regeneration material that is rapidly 6 8 7 9 Fig. 5: Biologisation of the -tricalcium phosphate collagen matrix CERASORB Foam with I-PRF. Fig. 6: Insertion of the biologised CERASORB Foam into the extraction socket. Fig. 7: Gentle adaptation of the easily mouldable CERASORB Foam to the alveolar walls with slight material compression. Fig. 8: Crestal covering and sealing of the augmentation material using a compressed A-PRF plug. Fig. 9: Stabilisation and fixation by means of cross-suturing. Fig. 10: Temporary restoration of the gap with an interim prosthesis. Fig. 11: Radiographic control of the augmentation site. Note the almost structurally identical distribution of the bone grafting material throughout the extraction socket. 11 1 3 5 10 08 3 2021

| case report 16 18 21a 22a 17 19 20 Figs. 16–18: Ventral and crestal views of the inserted surgical guide and guided implant placement in region #12. Fig. 19: Final position of the implant in region #12. Fig. 20: Insertion of the PEEK scan body. three weeks, and within the healing period. No further treatment steps, impressions or other measures were necessary. Not only is the treatment protocol shortened in this way, but the soft tissue is also protected from stress. The healing abutment is not radiopaque; thus, its position cannot be checked on radiographs at pres- ent. However, the correct position of the fixation screw is clearly visible. In this case, the focus was on the implant itself, the bone and tissue regeneration, and the con- trol of the healing of the implant site after three months. There was homogeneous and continuous bony healing of the implant site throughout (Fig. 26). 21b 22b 22c Figs. 21a & b: Determination of the final implant position by means of intra-oral 3D scanning. Figs. 22a–c: Different views: buccal view (a), vertical view (b), maxilla segmented on to the planned restoration (c). The emergence profile of the healing abutment was matched to a virtual crown and designed accordingly (3Shape CAD Software®). 10 3 2021

| case report 23 24 25 26 27 28 29 Fig. 23: Dental panoramic tomogram after implant placement in region #12 and post-op control at three months. Fig. 24: Healing abutment made of PEEK. Fig. 25: Inserted individual healing abutment and fixation of the peri-implant mucosa. Fig. 26: Periapical radiograph for radiographic control of the implant in region #12. Fig. 27: Vertical view shows the individually shaped mucosa immediately before the installation of the definitive superstructure. Fig. 28: Buccal view of the definitive crown in region #12. Fig. 29: Radiographic control of the implant in region #12 after installation of the definitive crown. After a healing period of nearly three months, the defin- itive restoration of the implant in region #12 was carried out. A fully-veneered zirconia crown was fabricated in a CAD/CAM procedure. The customised zirconia abutment was bonded to the titanium base. The crown was then cemented onto the abutment. Following the final resto- ration, a final radiographic control was taken. Since the crown was placed immediately after customisation, fur- ther aesthetic remodelling of the approximal peri-implant mucosa is to be expected over time. Overall, a non- irritant, aesthetically pleasing and satisfactory result was achieved (Figs. 27–29). Conclusion Restoration in the anterior region is one of the greatest challenges in implant dentistry. The demands and ex- pectations of patients regarding the aesthetic zone are very high.4, 7, 10 In order to meet these expectations and to achieve an aesthetically predictable and prognostically reliable aesthetic long-term result, it is vital to ensure the preservation of the soft tissue. Extensive augmentation of the bone and soft tissue should be avoided if possible, and the tissue should not be put under stress after im- plant placement.1 Preventive, predictable and minimally invasive measures aid in preserving bone and soft tis- sue. In the present case, implant surgery in the aesthetic zone was successfully carried out by means of a gentle extraction technique, alveolar management adapted to the situation using -tricalcium phosphate collagen ma- trix (CERASORB Foam) biologised according to LSCC, delayed implant placement, as well as direct soft-tissue management after exposure using a prefabricated cus- tomised healing abutment. The case demonstrates how adequately sized and contoured hard and soft tissue for implant restoration in the aesthetically relevant zone can be achieved in preventive and efficient treatment steps that are kept as short as possible. Author details Literature about the author Dr Haki Tekyatan is a Germany- based dentist who specialises in implant dentistry and maxillofacial surgery. He is currently in private practice in the German city of Simmern. contact Dr Haki Tekyatan Simmern, Germany info@dr-tekyatan.de www.dr-tekyatan.de 12 3 2021

| case report Restorative simplicity for a challenging case with limited space Dr Fernando Rojas-Vizcaya & Jose de San Jose Gonzalez, Spain & Germany 1 2 Initial situation and treatment planning Crown Abutment (Dentsply Sirona) was planned to be used to restore the appearance and function of the missing tooth. A 40-year-old male patient with a missing mandibular right lateral incisor and grafted area requested restoration with a dental implant. The challenge with this type of restoration is the limited space available and the proximity of the adjacent teeth. The clinical evaluation revealed the limited space (Fig. 1), and the periapical radiograph taken before the treatment showed both the grafted area into the bone and the limited space (Fig. 2). The treatment plan involved conventional implant placement using an OsseoSpeed EV implant (Dentsply Sirona) and im- mediate provisionalisation using a Temporary Abutment EV (Dentsply Sirona), and for the definitive restoration, an Atlantis Implant placement In the first step of implant placement, the biological aspects according to the 3A-2B rule were evaluated using a surgical guide (Fig. 3). The first drilling position was marked to ob- tain 2B and to create the osteotomy angulation using the Precision Drill EV (Dentsply Sirona). The angulation was con- firmed and the implant depth of the osteotomy was prepared with the Twist Drill EV (Dentsply Sirona; Fig. 4). The depth of the osteotomy was verified using the Implant Depth Gauge 3 7 4 8 14 3 2021 5 9 6 10

| case report Immediate fixed full-arch rehabilitation of periodontitis patients Prof. João Caramês, Portugal 1a 1b 1c Figs. 1a–c: Initial pre-op dental and osseous conditions. Frontal view (a), panoramic radiograph (b), CBCT scan visualising the osseous and dental anatomical conditions (c). Background Untreated edentulism can have a profound impact on a patient’s oral health, general health and well-being by causing functional limitations, and it can lead to socio- psychological impairments, metabolic changes and even a reduced life expectancy.1–4 Implant-supported complete dentures have established themselves as a viable treat- ment modality for edentulism, since they lead to an im- proved quality of life and patient satisfaction and are dis- tinguished by long-term clinical success.5, 6 Among these, implant-supported fixed complete dentures (IFCDs) have demonstrated long‐term implant survival rates of ≥ 95% and ≥ 97% after five years in the maxillary arch and after ten years in the mandibular arch, respectively.7 Immedi- ate placement and loading represent an increasingly es- tablished option for reducing the overall time required for IFCD rehabilitation for both the patient and the clinician. Optimised implant surface properties and designs result in optimised primary stability and accelerate bone inte- gration irrespective of bone quality, supporting immedi- ate protocols.8–10 Immediate loading protocols might re- quire specific placement and loading criteria in order to ensure clinical efficacy.11 Meta-analyses of clinical data indicating equivalent five-year post-loading implant sur- vival rates when comparing immediate and delayed load- ing protocols suggest that these criteria can be achieved in the case of immediately loaded IFCDs.12–14 IFCD rehabilitation requires the careful consideration of a variety of factors, including the available surgical proto- cols, prosthodontic options, patient’s medical condition and patient’s preferences. Specific consideration should be given to the osseous condition, potential risk factors, patient’s expectations and experience of the treating clinician.11 With the aim of standardising treatment ap- proaches for IFCDs and in agreement with the conclu- sions of the sixth ITI Consensus Conference, Caramês recently reported on a clinical decision support system (CDSS) to standardise the treatment approach for IFCDs based on the osseous anatomical conditions and level of alveolar atrophy of the patient.15, 16 This system clas- sifies five levels of treatment complexity and is applica- ble for straightforward cases with sufficient bone quantity to complex cases with limited bone quantity and quality. The CDSS further provides specific guidance for the choice of implant rehabilitation scheme and assists in identifying any need for bone augmentation to improve the osseous support in the context of the patient’s facial aesthetics.16 Consideration of the local alveolar anatomy and bone quality after tooth extraction may become even more im- portant in the case of any compromised endodontic or periodontal conditions prior to treatment.17, 18 A growing amount of evidence suggests that successful implant osseointegration of immediately placed implants can be reliably achieved even in infected sites. Clinical workflows for such conditions need to allow for additional measures, such as disinfection and debridement of the extraction sites before implant placement.18 Surgical manipulations such as alveoloplasty at placement to potentially reduce 16 3 2021

| case report 2b 2e 2c 2f 2h 2i 2j 2l 2m Figs. 2a–m: Surgical procedure in the mandible. Situation after tooth extraction (a). Preparation of the alveolar crest, including removal of sharp edges after elevation of a mucoperiosteal flap, thorough debridement of extraction alveoli, removal of periosteum and alveoloplasty (b–d). Placement of four implants involving placement of a surgical guide, verification of the correct depth and angulation of the osteotomies using alignment pins, placement of bone-level implants and preparation of the emergence profile using a bone profiler (e–k). Placement of the screw-retained abutments (l). Primary wound closure after placement of protective caps (m). 3b 3e 3c 3f Figs. 3a–f: Surgical procedure in the maxilla involving tooth extraction (a), placement of a surgical guide (b), implant placement (c), placement of screw- retained abutments (d), guided bone regeneration (e), placement of protective caps and primary wound closure (f). 18 3 2021 2a 2d 2g 2k 3a 3d

| case report 4a 4c 4b 4d Figs. 4a–d: Open-tray impression taking and immediate provisionalisation involving placement of impression posts and coverage of wound margins with dental dams (a), impression taking after splinting of impression posts using cold acrylic (b), placement of titanium copings and mounting of acrylic provisional prostheses (c & d). Visual and radiographic assessment indicated that all implants had successfully osseointegrated with no signs of inflammation. Definitive restoration started with open- tray impression taking of the fully healed maxillary and mandibular arches with screw-retained copings in place (Figs. 5a & b). Abutment-level impressions of the detailed soft-tissue contours with splinted impression posts in place were taken with standard silicone impression ma- terial (AFFINIS putty super soft and regular body; Fig. 5c). The prosthetic procedures followed the standardised protocol recently reported by Caramês et al.20 The defin- itive restoration was designed and milled by CAD/CAM with a zirconia structure (Prettau, Zirkonzahn) with feldspathic veneering porcelain (ICE Zirkon Ceramics, Zirkonzahn) on the non-functional buccal areas. The prosthetic restoration fitted with the implant base opti- mally (Figs. 5d & e), and the final aesthetic outcome was considered satisfactory (Fig. 5f). Discussion and conclusion With this case report, the author has aimed to illustrate a possible workflow for a bimaxillary fixed full‐arch resto- ration using immediate placement and immediate loading in a partially edentulous periodontitis patient with atro- phied bone. The most important aspects of the work- flow are as follows: 1) The decision for the treatment plan was guided by a CDSS based on the anatomical osse- ous dimensions of the alveolar arches (Caramês classi- fication).16 2) The concept involved immediate placement and loading in extraction sites of teeth affected by chronic periodontitis. 3) Horizontal contour augmentation of the apical aspects of the anterior maxilla was performed based on an analysis of the patient’s facial aesthetics in order to provide lip support. 4) Screw-retained zirconia restorations were chosen after immediate provisionali- sation with metal-reinforced acrylic prostheses. The choice for the specific type of implant rehabili- tation was guided by an osseous anatomy-based CDSS for full-arch restoration.16 Compared with the SAC Classification in Implant Dentistry, which helps clinicians to identify the degree of complexity and poten- tial risk involved in individual cases, this type of system gives additional recommendations for the specific type of rehabilitation within the group of full-arch restorations. The system is supported by the current state of knowl- edge on mandibular and maxillary full-arch restora- tions and consensus statements of the recent sixth ITI Consensus Conference.15, 16 According to the CDSS, the patient was classified as treatment option IIb, defin- ing the placement of four and six implants in the man- dible and maxilla, respectively. Posterior implants in the individual arches were tilted by 30°. The tilted placement of implants as part of full-arch rehabilitation in order to reduce prosthetic cantilevers and prevent additional sur- gical interventions can be considered well established. A recent consensus report concluded that for IFCD rehabilitation axial or tilted implants can be considered equivalent with regard to implant and prosthetic survival and complication rates, peri-implant marginal bone loss, and the risk of soft- and hard-tissue complications.21 20 3 2021

| case report 5a 5d 5b 5e 5c 5f Figs. 5a–f: Occlusal view of healed maxillary and mandibular ridges six months post-op (a & b). Occlusal view of the gingival impression with impression posts (c). Definitive prostheses after installation (d). Post-op panoramic radiograph six months after definitive restoration (e). Frontal view of facial aesthetics after definitive restoration (f). contour augmentation.36 Insufficient crestal bone height however might be compensated for by adapting the maxillary cervical edge of the transition line between the prosthetic gingiva and teeth of the IFCDs. These aspects were specifically considered in the case described. the application of this CDSS may help to standardise the workflow and rehabilitation plan of immediate IFCD rehabilitation in daily clinical practice and future clinical research. For the definitive restoration, screw-retained zirco- nia prostheses were chosen to replace the metal framework-supported acrylic provisional restorations. Ceramic prostheses have the advantage of fabrication via a CAD/CAM workflow. Recent consensus reports indicate comparable survival and biological complication rates to those of metal–ceramic prostheses and a lower risk of complications in the aesthetic area.33 Specifically, in the case described, fixed monolithic zirconia prosthe- ses veneered with porcelain only in non‐functional areas were chosen. This recently introduced type of prosthe- sis has been researched by the author of this article and colleagues with regard to the risk of prosthetic compli- cations as part of IFCDs. This new type of restoration specifically showed a lower incidence of complications, for example ceramic chipping, when compared with conventional full-arch ceramic‐veneered zirconia pros- theses.20, 37 In summary, this case report has described the bimaxillary full-arch restoration of a partially eden- tulous periodontitis patient based on a CDSS that may help to standardise the rehabilitation plan based on the local alveolar osseous anatomy and level of atrophy. The case report has illustrated and discussed the most essential clinical and anatomical aspects that might be relevant for the design of the treatment plan and individ- ual clinical workflow specifically with regard to the treat- ment of patients with active periodontitis. In conclusion, Author details Video Literature about the author Prof. João Caramês is professor of oral surgery and director of the Faculty of Dental Medicine of the University of Lisbon in Portugal. He is coordinator of the implantology research group at the faculty’s oral and biomedical sciences research unit. Prof. Caramês is direc- tor and founder of the Implantology Institute in Lisbon. This private practice is focused on oral surgery and implant dentistry. contact Prof. João Caramês Lisbon, Portugal +351 91 9727353 carames@campus.ul.pt 22 3 2021

| case report Graft volumetric changes of collagenated xenograft For the 3D reconstruction of atrophic maxillae Literature Dr Livio Lo Faro, Dr Francesco Giachi Carù & Prof. Tiziano Testori, Italy 1 2 Fig. 1: Intra-oral image. Fig. 2: Pre-operative radiograph. Introduction Placement of dental implants is an increasingly com- mon approach to the replacement of missing teeth.1 Implant-supported prostheses can be used as an alter- native to traditional bridgework or removable dentures in case of partially and completely edentulous patients. How- ever, the posterior region of the maxilla is usually a chal- lenge for surgeons owing to the bone resorption that oc- curs after tooth extraction.2–3 Moreover, the maxilla mainly consists of spongy bone, which is one of the least dense in the oral cavity.4 To compensate for atrophy and increase the bone volume available for the insertion of implants, various techniques have been developed.5 Maxillary sinus elevation is a predictable and well-documented method to increase bone volume for maxillary implant placement.6, 7 This procedure may even increase bone quality by aug- menting the sinus cavity with a bone grafting material that generates a denser bone. The standard maxillary sinus elevation methodology involves creation of an external window, careful lifting of the sinus membrane and packing of the sinus floor under the lifted membrane with a bone graft. Its predictability and safety have been demonstrated since 1980 by evaluating bone formation, noting low com- plication rates and high implant success rates8, 9 regard- less of the residual crestal bone height.10 Instead, for minor and moderate horizontal ridge deficiency, guided bone regeneration (GBR) offers the possibility of restoring the bone architecture through the application 3 4 Fig. 3: Antrostomy design by means of piezo-surgery. Fig. 4: Elevation of the Schneiderian membrane. 24 3 2021

| case report 8a 8b 9 10 11 Figs. 8a & b: Second horizontal augmentation of the right side (a) and the left side (b) with the implants already placed. Fig. 9: Flap design of the uncovering phase. Fig. 10: Split thickness-flap during the uncovering phase with healing abutments placed. Fig. 11: Final sutures of the fourth surgical step. to increase vascularisation and bone regeneration. A col- lagenated heterologous sticky bone substitute in a collagen matrix (OsteoBiol GTO, Tecnoss) was then inserted directly into the antrostomy of the right sinus (Fig. 5a) and a pre- hydrated heterologous bone substitute (OsteoBiol mp3, Tecnoss) into the left sinus (Fig. 5b), and both of them were compacted. A collagen membrane (OsteoBiol Evolution, Tecnoss) was fixed through micro-screws above the an- trostomies (Fig. 6), a first layer of bone substitute (GTO) was placed on the buccal side of the right sinus because of the horizontal atrophy and the membranes were folded beneath the palatal wall. Before suturing, a layer of PRF membranes was arranged to protect and enhance the healing of the sites. Both of the sides were sutured, for healing by primary intention. Owing to the limited bone height under the sinus floor, implant placement was delayed for graft consolidation until three months later. A CBCT scan was taken to examine the degree of aug- mentation, and two other measurements on each side were taken in order to have a starting point for evaluating the future volumetric changes of the biomaterials. The patient returned after three months for CBCT exam- ination to decide whether the healing was optimal for the implant surgery. Unfortunately, owing to medical prob- lems, she delayed the surgery. When the patient was able to come back, after three additional months, another CBCT scan was taken before implant surgery to assess the further volumetric change of the biomaterials and to plan appropriate implant surgery. A full-thickness flap was elevated to evaluate the results of the previous bone augmentation on both the right (Fig. 7a) and the left sides (Fig. 7b). Eight implants then were placed, and another layer of biomaterial (GTO) was placed on the buccal site of both sides. Thanks to the properties of this collagenated sticky biomaterial, there was no need to hydrate it because it adhered where it was placed, removing the risk of los- ing granules during the procedure (Figs. 8a & b). The bio- material was then covered with a membrane (OsteoBiol Evolution) and both sides were sutured. Four months later, the patient was scheduled for the final surgical step: the uncovering phase. Before proceeding with the final step, a last CBCT scan was taken to eval- uate the positions of the implants and how the height of the new sinus floor had adapted to the implants placed. The uncovering phase was scheduled after implant osse- ointegration in order to recreate keratinised tissue on the buccal side and to re-establish the correct fornix depth. This time, a partial-thickness flap was elevated, starting from the palatal side (Fig. 9), to expose the cover screws of the implants while leaving the connective tissue around the implants. The cover screws were removed and replaced with healing abutments of the desired heights (Fig. 10). The flap was then sutured, leaving all the keratinised tissue on the vestibular side while allowing the palatal side to heal by secondary intention (Fig. 11). After complete healing of the tissue, after about eight weeks, an impression was taken and the provisional prosthesis was fabricated and delivered. After complete maturation of the tissue, after about four months, another impression was taken and a definitive prosthesis was fabricated and delivered (Figs. 12a & b). 12a 12b Figs. 12a & b: Intra-oral image (a) and periapical radiograph (b) of the definitive prosthesis. 26 3 2021

| case report OsteoBiol GTO First measurement Second measurement Post-op 3 months of healing 6 months of healing At uncovering (after 10 months) 22.20 mm 15.61 mm 12.88 mm 9.63 mm 21.61 mm 15.40 mm 13.20 mm 9.60 mm % shrinkage after 3 months 6.59 mm (22.20–15.61 mm; 29.7%) 6.21 mm (21.61–15.40 mm; 29.7%) % shrinkage after 6 months 9.32 mm (22.20–12.88 mm; 42.0%) 8.41 mm (21.61–13.20 mm; 38.9%) % shrinkage after 10 months 12.57 mm (22.20–9.63 mm; 56.6%) 12.10 mm (21.61–9.60 mm; 55.6%) Table 1: OsteoBiol GTO: Graft volume evaluation over time. OsteoBiol mp3 First measurement Second measurement Post-op 3 months of healing 6 months of healing At uncovering (after 10 months) 21.80 mm 17.60 mm 14.60 mm 10.81 mm 25.20 mm 17.82 mm 14.82 mm 10.83 mm % shrinkage after 3 months 4.20 mm (21.80–17.60 mm; 19.30%) 7.38 mm (25.20–17.82 mm; 29.30%) % shrinkage after 6 months 7.20 mm (21.80–14.60 mm; 33.00%) 10.38 mm (25.20–14.82 mm; 41.20%) % shrinkage after 10 months 10.99 mm (21.80–10.81 mm; 50.41%) 14.37 mm (25.20–10.83 mm; 57.02%) Table 2: OsteoBiol mp3: Graft volume evaluation over time. Clinical outcome Before the final surgical step (the uncovering phase), a CBCT scan showed the exact positions of the implants and the height of the new sinus floor. The bone height augmentations were considered successful for implant placement under good conditions. After a healing period of four months, the CBCT scan showed that both sides had healed well. Recovery was uneventful, and there was no complaint of pain and no signs of infection. The same positive results could be deduced from the radiographic controls taken over time. All the measurements were col- lected in two charts, depending on the biomaterial used, to evaluate how the bone substitute used changed vol- ume over time. The heights of the augmented sinuses decreased at a similar pace. Between the postopera- tive CBCT scan and the healing at three and six months, the right sinus, in which GTO was used, decreased from 22.20 mm to 15.61 mm (29.7% volumetric change) to 12.88 mm (42.0% volumetric change) and from 21.61 mm to 15.40 mm (29.7% volumetric change) to 13.20 mm (38.9% volumetric change). Similarly, the left sinus, where mp3 was used, decreased from 21.80 mm to 17.60 mm (19.3% volumetric change) to 14.60 mm (33.0% volumet- ric change) and from 25.20 mm to 17.82 mm (29.3% vol- umetric change) to 14.82 mm (41.2% volumetric change). Therefore, the augmented sites were of sufficient volume for implant placement. It is worth noting that the bone re- modelling did not stop after the implants had been placed. In fact, when the last CBCT scan was taken at ten months of healing (before the uncovering phase), further resorp- tion, to the tips of the implants, corresponding to around 55% resorption, was found (Tables 1 & 2). Nevertheless, it can be appreciated how both of the biomaterials allowed reconstruction of the crest height and how GTO allowed restoration of even the diameter of the crest. What is more, the morphology of these biomaterials resembled that of the natural bone. In fact, it was difficult to notice a differ- ence between the bone grafts placed and the bone of the patient. However, it must be pointed out that GTO had a slightly greater resorption compared with mp3, probably due to its greater collagen gel component. 28 3 2021

| case report 13a 13b 13c Figs. 13a–c: Pre-operative intra-oral images. Case 2: Maxillary sinus surgery and simultaneous implant placement This patient also presented at Lake Como Institute, having been referred by a colleague, requesting fixed rehabilitation of the edentulous areas of his posterior maxilla. A careful clinical examination was conducted (Figs. 13a—c) and a CBCT scan taken to plan proper implant surgery (Figs. 14a & b). The patient requested as few surgeries as possible and completion of the treatment in the shortest possible time. Bilateral sinus eleva- tion with bilateral horizontal augmentation and simultaneous implant placement was the chosen treatment plan. The ap- proach was similar to that of the first case: two flaps with two vertical incisions were elevated to expose the lateral sinus walls and then two antrostomies were opened with the help of piezo-surgery inserts. The sinus membranes were elevated, paying attention not to perforate them, and two collagen sponges were inserted into the posterior recesses to keep the membranes elevated so that the osteotomies could be made. The biomaterial (GTO) was inserted through the antrostomies and compacted. The implants were then placed, since this time there was greater residual bone height (Fig. 15), and a layer of biomaterial was used to compensate for the horizontal atrophies. To stabilise the biomaterial, a double layer of col- lagen membranes (Evolution) was used, a final layer of L-PRF (leukocyte- and platelet-rich fibrin) membrane was placed to enhance soft-tissue healing and the flaps were sutured. A CBCT scan was taken to evaluate the degree of vertical and horizontal augmentation, and the patient was scheduled for the last surgery four months later. During the uncovering phase, two split-thickness flaps were elevated, exposing the underlying implants, and a connective graft was collected by thinning the palatal flap. The cover screws of the implants were replaced with healing abutments, and the connective graft was placed on the vestibular side to further expand the crest diameter (Fig. 16). A final layer of L-PRF was put around 14a 14b 15 16 Figs. 14a & b: Digital implant planning: 2D (a) and 3D (b) view. Fig. 15: Insertion of the implants. Fig. 16: Connective graft sutured to the periosteum with healing abutments positioned. 30 3 2021

| case report 17a 17b 17c Figs. 17a–c: Clinical and radiological follow-up at five years. (Images © P. Zappavigna DDS) the healing abutments and the flaps were sutured. The patient then returned to his dentist for finalisation of his treatment. Clinical outcome The implants and the soft tissue healed uneventfully, and the patient underwent just two surgeries. The implants were still stable after five years of loading (Figs. 17a–c). operative discomfort. The current results are in agreement with those of previous studies,21, 22 as well as systematic reviews,23, 24 illustrating that implant survival rate and peri- implant bone level in the grafted bone are comparable to those of implants placed in native bone. A similar outcome has been observed for implants placed in augmented sinuses.7 Conclusion Discussion The two cases demonstrate how there might be perfect timing for placing implants after the first vertical augmentation. The idea is not to let the bone substitutes remodel too much, in order to allow easier implant placement and the use of longer implants to obtain a correct implant–prosthesis pro- portion. Probably, as can be seen from Tables 1 and 2, four months would be the best time to proceed with the implant placement, because the biomaterials act like natural bone: they will continue to remodel over time if not stimulated by occlusal forces. Instead, when the implants are placed simultaneously with sinus elevation, the implants create a tenting effect that serves as support to the Schneiderian membrane, arresting bone physiological resorption. That is why, when possible, often the best treatment may be placing the implants simultaneous to sinus augmentation. Edentulous maxillary segments have several anatomical and physiological limitations, such as deficiency of spongy maxillary alveolar bone and increased pneumatisation of the maxillary sinuses. These factors render rehabilitation of the region challenging. In these two cases, maxillary sinus elevation procedures through lateral access were success- fully performed using GTO or mp3. Horizontal augmentation was successfully performed using only GTO. These mate- rials were able to increase vertical bone height and hori- zontal bone diameter and allowed for the placement of the requested implants. A follow-up panoramic radiograph was obtained at the delivery of the prosthesis and demonstrated what appeared to be new bone formation in the maxillary areas and the areas at the tips of the implants. It is important to emphasise the benefits of this approach for maxillary recon- struction via GBR and sinus augmentation over other treat- ments (e.g. autogenous block grafting): no complications at the donor site, no need for hospitalisation and less post- Complete reconstruction of atrophied maxillae can be success- fully achieved by means of GBR for horizontal and/or vertical bone gain, including bilateral sinus augmentation when GTO and mp3 are used. In fact, the morphology of these grafted sites resembles the anatomy of a natural sinus, the bone remodel- ling at the level of the tips of the implants, and has the same radiographic appearance as the natural lost bone of the patient. Moreover, it appears that the best time to place the implants after sinus augmentation, in a delayed approach, might be around four months, to ensure as little graft resorption as pos- sible. Peri-implant bone level in the completely reconstructed maxilla showed minimal changes. Furthermore, proper training in hard- and soft-tissue management is imperative for achiev- ing successful outcomes and avoiding potential complications. about the authors Dr Livio Lo Faro Dr Francesco Giachi Carù Prof. Tiziano Testori contact Prof. Tiziano Testori Lake Como Institute, Como CO, Italy, +39 031 241652, www.lakecomoinstitute.com 32 3 2021

| case report Dental lasers against peri-implantitis Dr Bradley Labrecque, Canada Background The replacement of lost teeth with dental implants rep- resents a modern approach in restorative dentistry. Among various complications, including bleeding from the implant site, infection, and pain are early signs of prob- lems. Severe complications may result in peri-implant mucositis and peri-implantitis, which are infectious bacterial diseases with inflammatory processes that are similar to gingivitis and periodontitis.1–3 Peri-implant mucositis is de- fined as a reversible inflammatory reaction in the soft tissue surrounding the implant, and peri-implantitis is associated with pathological pocket formation and loss of supporting bone around the implant, resulting in implant failure.1, 2, 4 1 Fig. 1: Pre-op radiograph. Bacterial biofilm plays a major role in peri-implant dis- ease and implant failure.5–8 Modern dental implants have a structure with a rough surface that facilitates microbial colonisation and enhances the formation of biofilm, which is not easy to remove.9 Several methods have been pro- posed for the prevention and treatment of peri-implant dis- ease (e.g. the use of chemical agents and mechanical de- bridement with curettes, ultrasonic devices, air abrasion and laser therapy), but no approved therapeutic protocol has been established.10, 11 Owing to the major role of mi- croorganisms in the formation of peri-implant disease, the primary goal of any treatment is to remove the biofilm from the implant surface. The results of using different tech- niques for biofilm removal suggest that none of the cur- rently used methods is sufficiently effective or superior to the others.12–14 The limited effectiveness observed of these 34 3 2021 methods is most likely due to directly inaccessible sites during the therapy. The inaccessible implant micrograph facilitates microbial colonisation and accelerates biofilm formation.15 In recent years, lasers have shown a prom- ising effect in the treatment of peri-implantitis, producing many positive treatment outcomes. Medical, dental and social anamnesis The patient was a 64-year-old male in good health with no significant medical issues and took no medication other than vitamin supplements. He was a smoker, smoking approximately three to four cigarettes per day. He main- tained good oral health, but had a history of oral ne- glect and was on a three-month hygiene recall. He had been wearing a complete maxillary denture for ten years. He was missing teeth #47, 46, 45, 36 and 37. He had undergone implant treatment on the mandibular arch five years previously. The temporomandibular joints showed no significant findings. He had a Class I occlusion. Diagnosis After the implant placement, the patient had started to smoke, which he had been recommended to stop. It was noticed there was a slight alveolar breakdown of the areas around implants #47 and 45. Regular hygiene vis- its and the cessation of the smoking were tried to arrest the breakdown of the alveolar bone. Radiographic exam- ination determined that these measures were not achiev- ing the desired results, and more extensive periodontal treatment was required (Fig. 1). It was determined that deep cleaning of the infected area was needed to remove the pathogens, in a minimally invasive manner for pa- tient comfort. After the patient stopped smoking, which is known to affect the integrity of implants, further treatment was considered. Treatment plan A dual-wavelength laser procedure using Er:YAG and Nd:YAG (Fotona) was selected, considering the benefits of the treatment over traditional periodontal flap surgery. The erbium laser would be used to clean the surface of the implant photo-thermally, creating no heat on the tita- nium surface. The laser energy would be absorbed by the water of the surrounding tissue, vaporising the infected tissue and removing it as well. This laser energy would be best for cleaning the implant surface, which was fluted.

| case report Successful rehabilitation of an anterior tooth Dr Dr Branislav Fatori & Dr Inge Schmitz, Germany 1 2 3 Fig. 1: Radiograph of the initial clinical situation. Fig. 2: View of the old crown. Fig. 3: Situation after crown removal. Replacing a tooth in the anterior region with a dental implant is a demanding task. When it comes to aesthet- ics, it virtually always poses a challenge for the clinician, since his or her primary objective is to preserve the smile line as effectively as possible. Ideally, the transition from implant to crown should not be visible. If there is too little gingiva or if it is thin, there is a risk that the implant and abutment connection will show through the gingiva. To ensure that the colour of the crown does not differ from the colour of the adjacent teeth, close cooperation with a skilled dental technician is always required. If the transition between the implant (or tooth) and the gingiva is not visible when smiling, the problem of aesthetics can usually be solved well. However, if the smile line is rela- tively high, the gingiva and bone volume play a crucial role in the aesthetic treatment. In the following, a clinical case is presented in which the successful restoration of an anterior tooth in a patient with a high smile line is de- scribed. The patient had an old restoration which needed replacement after 15 years of wear. 4 5 Fig. 4: Bone augmentation. Fig. 5: Radiographic view of the freshly inserted implant. 36 3 2021 Materials and method The 51-year-old female patient was a non-smoker. Her medical history did not reveal any peculiarities. The peri- odontal examination did not reveal any pathologies. Her dentition was largely free from caries. However, tooth #21 was deemed unsalvageable, owing to apical osteitis (Fig. 1). It was decided to replace the tooth (Fig. 2) with a 3.75 mm × 12.0 mm DENTAL RATIO implant (Meisinger). Premedication and implant insertion As for premedication, microbiological examination before surgery and optional therapy with antibiotics have been proved to be successful. To this end, the authors usually pre- scribe amoxicillin–clavulanic acid (Augmentin 875 mg/125 mg, GlaxoSmithKline), to be administered three times a day. Be- fore surgery, plaque was removed by means of professional dental cleaning. In addition, HELBO therapy was carried out. The principle of this approach is based on the binding of photoactivated substances to the bacterial cell wall and their activation by light of a defined wavelength. Local anaesthe- sia was administered with Ultracain D-S forte (Sanofi-Aventis Deutschland). For the incision, a 14C scalpel (Aesculap) was employed while optimally preserving the gingival mucosa (Fig. 3). The preparation of the osteotomy commenced with a pilot drill (1.80 mm), which was then continued with a drill (2.28 mm) and a final drill (3.20 mm). The machined implant was inserted to a torque of 40 Ncm. The thorough evaluation of the peri-implant soft tissue and the bony tissue at bottom of the osteotomy was carried out by means of standardised methods. The gingiva was evaluated according to the papillary bleeding index by Saxer and Mühlemann.1 Also, an evaluation by means of the sulcus bleeding index was done.

| interview On remaining vigilant An interview with Julien Benhamou, TBR, France Johannes Liebsch, Germany uct demonstrations and training videos, and a new online ordering tool through which to order implants, prosthetic components and instruments. TBR has also made the decision to support practitioners and labs even more actively by launching the #GetReadyWithTBR initiative. We selected and proposed a range of anti-coronavirus products dedicated to the protection and safety of dental practices around the world. This range is, of course, also available on our website. With a view to growing vaccination rates and in- creasingly easing travel restrictions, further training is likely to become a reality again soon. How are you planning to introduce clinicians to working with your systems, such as Z1, in the near future? Despite easing of COVID-19-related restrictions, we are well advised to remain collectively vigilant. This pan- demic has taught us many lessons and has given us the opportunity to adapt and renew ourselves. In this light, I can proudly say that—even during the midst of the pan- demic—we have never stopped offering content ded- icated to informing and training clinicians through new channels, mainly online. Today, with the ongoing lifting Julien Benhamou The Toulouse-based implant manufacturer TBR Dental has created quite a stir with its Z1 dental implant system with a titanium base and a zirconia collar. In this interview with implants, TBR Dental CEO Julien Benhamou dis- cusses how the company has managed to weather the effects of the COVID-19 pandemic, in what productive ways it has utilised this most unusual time and what cus- tomers can expect from TBR Dental in the near future. Despite the last year being filled with significant challenges due to the COVID-19 pandemic, many companies have taken the opportunity to reflect and develop new concepts. In what productive ways has TBR Dental used this unprecedented time? The coronavirus crisis has undoubtedly made significant adaptations necessary on part of all TBR teams. All of our team members have shown strong responsiveness and a great team spirit that allowed us to maintain our business activities and to remain very close to our users. Already before the pandemic, our strategy was geared towards making our products and services available online. We therefore took advantage of this time to accel- erate our current projects by promoting the creation of dematerialised media. Now, an entire range of products is available online: downloadable support material, prod- 38 3 2021

| obituary The inventor of the Bicon system has passed away Thomas Driskell, 1928—2021 Thomas David Driskell passed away on 15 July 2021. During his lifetime, he has helmed the invention of count- less innovative medical devices and products, including the implant system established by the company Bicon, as well as the synthetic bone grafting material SynthoGraft. Tom was an entrepreneur and inventor, who profoundly influenced many fields, including aviation, lighting, med- icine, and dentistry. He had the primary role in the de- sign and development of the FAA-standard VASI system ( Visual Approach Slope Indicator), which is still used in airports around the world. He developed high-output lamps employing tungsten, tantalum carbide, halogen, and xenon, that were used to light many structures in- cluding the Empire State Building, Guggenheim Museum and the Panama Canal. He designed and constructed the first heart-lung ma- chine in Central Ohio, which was used to treat over 600 patients. He designed and produced the first free- standing dental implants (now known as Bicon implants), as well as a synthetic bone grafting material, SynthoGraft. Additionally, he published the first paper on zirconia, which is a widely used dental material. Tom received two coveted I-R 100 awards (known as the “ Oscars of invention” or “the Nobel Prize for technology”), one for SynthoGraft in 1982 and one for the development of an infant respirator in 1973. Tom was born 18 August 1928 in Columbus, Ohio, to Thomas Edgar Driskell and Eleanor Kauffman Driskell. Tom was an avid sportsman, friend, and supportive mentor, who used his intellectual gifts to improve our world. Tom shall be missed! Source: Bicon Dental Implants 40 3 2021 m o c . k c o t s r e t t u h S / a c i r f A w e N ©

| manufacturer news Amann Girrbach Digitisation pays off with AG.Live Amann Girrbach is all about supporting laboratories in organising digital dental workflows. With the AG.Live digital platform, this project reaches a new dimension. AG.Live helps dental technicians to manage all digital activities locally and to connect with a global network of digital dental professionals. Patient case management is at the core of the platform, which replaces the previous C3 customer portal—this is where the patient case is created, managed and processed digitally. Patient cases can be shared with partner laboratories for further processing and in the foreseeable future also be exchanged between the dentist and the laboratory. Not only will laboratories and clinicians be networked, but also machines and ma- terials—for example, to access material availability or to the operating modes of milling machines and many other relevant factors of a dental fabrication process. Thus, AG.Live will enable keeping track of all digital activities—from one place, anywhere and at any time. In doing so, it is Amann Girrbach's intention to create a network of optimised as well as new partnerships. Network participants will be able to work and collaborate more efficiently, to focus on their strengths and thus better position themselves in the market. In a further step, Amann Girrbach will implement access to the company's own “AG Academy” training portal with numerous training and further education opportunities. Dentsply Sirona Superior in marginal bone maintenance For the first time, a meta-analysis looks at how three premium brand implant surfaces influence marginal bone maintenance. The story, co-authored by Dr Michael R. Norton and statistician Mikael Åström, came about for two reasons. First, no meta-analysis existed to com- pare the marginal bone loss due to different surface modifications among current premium brands. Second, articles by Dr Dirk Duddeck et al. suggest that premium implants are free of foreign materials. In contrast, cheaper implants may be riddled with impurities. Is this the case? And if so, was there any difference between premium brands too? The answer is essential as the surface affects osseointegration and marginal bone maintenance. In the case of cheaper clones, the research suggested that these may cause peri-implant infections and compromised function. Key takeaways of the meta-analysis include: OsseoSpeed (Astra Tech Implant System) has, on average, the least marginal bone loss in both 1-year (–0.29 mm) and 5-year (–0.35 mm) follow-ups; There is a statistically significant difference between OsseoSpeed and two other premium brand implant surfaces in both 1-year and 5-year follow-ups; OsseoSpeed offers more predictable outcomes with less variation around the mean and less spread. In conclusion, the authors state that OsseoSpeed demonstrates superior marginal bone levels—which is vital to achieving the best possible functional, biologic and aesthetic outcomes over the long term. Amann Girrbach AG, Austria +43 5523 62333-200 https://expo.aglivecon.digital/de/planets/ag-live Dentsply Sirona, Sweden +46 31 376-3000 www.dentsplysirona.com/implants/science curasan Maximum flexibility with CERASORB® Foam CERASORB® Foam is a multiporous composite material for bone augmentation consisting of collagen and resorbable bioceramics. The use of phase-pure -tricalcium phosphate with regular interconnect- ing porosity and primary particle size results in the degradation of the biomaterial simultaneous to bone formation. The shapeable variant of the CERASORB® Foam with low density allows plastic deformation and can be individually adapted to the defect. CERASORB® Foam is miscible with blood and I/A-PRF at a ratio of 1:1, producing an ideal kneadable mass for filling bone defects. The multiporosity of the granules embedded in the collagen helps bone to grow in faster. Blood com- ponents and body fluids can permeate the bone regeneration material unhindered and rapidly to accelerate osseous integration, vascularisation, and resorption. Due to the specific composition of CERASORB® Foam, a high degree of volume stability is achieved even after degradation of the more rapidly resorbable collagen, while high radiographic density is maintained. In addition to the round granule form, which has only interconnecting micropores, CERASORB® Foam consists of polygonally broken -tricalcium phosphate with micro-, meso- and macro- pores with a pore size up to 500 μm. curasan AG, Germany +49 6027 40900-57 www.curasan.de 42 3 2021

Curaden TBR Dental A new generation of Discover Z1®—The tissue-level antiseptics with less CHX implant with a zirconia collar Curaprox Perio plus preludes a new generation of oral antiseptics containing just the right amount of chlorhexidine (CHX) for each case and patient. The secret ingredient? Citrox. This organic an- tibacterial sourced from bitter oranges breaks down biofilm and slows down its regrowth. Because it enhances the overall effect of Perio plus, a lower dose of CHX can be used after treatment, minimising side effects. The unique combination of Citrox and polylysine prolongs Citrox’s substantivity, while a pleasant fresh mint flavour enhances patient compliance. Perio plus contains no alcohol or sodium lauryl sulphate. Perio plus mouthwash is avail- able in different CHX concentrations, ranging from a bacteriostatic 0.05 per cent up to a bactericidal 0.20 per cent, for adequate, individualised treatment, while the Perio plus support toothpaste contains a balanced 0.09 per cent. The 0.5 per cent CHX gel is per- fect for localised treatment of wounds, infections or implant compli- cations. Moreover, the toothpaste, gel and regenerate mouthwash contain hyaluronic acid, which promotes tissue regeneration. 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 first intention as well as simultaneous healing of the hard and soft tis- sues, which reduces the overall treatment time and leads to improved final 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 infiltration. Indeed, zirconia reduces bacterial colonisation compared to titanium.2 In addition, the attachment and proliferation of fibroblasts 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 Curaden AG, Switzerland +41 44 7444646 perioplus.com Straumann TBR Dental Group, France +33 5 62167100 contact@tbr.dental Straumann® Pro Arch—Tailored to fit, designed to last Of the millions of people facing dental problems, there are no two cases the same. Straumann® Pro Arch is a tailored treatment solution for fixed, immediate, full-arch restorations, and enables flexible treatment options. With Roxolid® for reduced invasiveness1, 2 and SLActive® for en- hanced bone regeneration3 you can deliver high predictability and achieve peace of mind even in challenging clinical situations. Learn more at: www.straumann.com/proarch Literature Institut Straumann AG Switzerland +41 61 9651111 www.straumann.com 44 3 2021

| events m o c . k c o t s r e t t u h S / e v i l o d r a w d e © 1 Fig. 1: SEM testing station at the International Dental Show. 46 3 2021 Dental implant quality under scrutiny Dr Dirk U. Duddeck, Germany On-site SEM analysis of implants at IDS 2021 “Sterile-packaged” does not mean an implant is neces- sarily free of contaminants. This disturbing realisation is slowly dawning on dentists not only in Europe but also in the US. Exceeding 100,000 subscriptions on CleanImplant’s Facebook page, the number of dentists worldwide intrigued by this revelation increased tenfold over the past two years. For the International Dental Show (IDS) in Cologne in Germany coming up in Sep- tember, the non-profit CleanImplant Foundation based in Berlin in Germany will once again showcase quality checking of dental implants under a scanning electron microscope (SEM). Installed exclusively for this event in Hall 10.2 in collaboration with Thermo Fisher Scientific and the Medical Materials Research Institute, the set-up will provide full transparency of the foundation’s qual- ity assessments (Fig. 1). Dentists and manufacturers alike will be able to witness the meticulous and inde- pendent quality check of dental implants in detail, from start to finish. The open and public demonstration will allow for spectators to learn about the extent of factory- related contamination of sterile-packaged implants and, most importantly, its direct consequences. The SEM unveils whether an implant meets the strict consensus- based CleanImplant quality guidelines, and dentists are encouraged to participate in finding out whether the implant system used in their practice is actually safe (Fig. 2). Dentists and patients want clarity Ever since the “Implant Files” became public in the media, dentists’ concerns about substandard medical prod- ucts worldwide have grown immensely—and rightly so. Current study data demonstrates that one out of three

| news CERASORB® Foam now approved... ...for use with antibiotics CERASORB® Foam, a resorbable, osteoconductive and cancellous bone-like bone regeneration material prepared from -tricalcium phosphate and collagen, was recently recertified by curasan AG’s notified body with the additional claim for use with antibiotics. The intraoperative combination of CERASORB Foam with a wide range of commercially available antibiotics provides surgeons with a novel option in filling and bridging degenerative and traumatic bone defects. “This is a major milestone in minimising the risk of a reinfection at the defect site. We have been evaluating various antibiotics in combination with our industry leading synthetic bone regenera- tion materials under laboratory conditions for years and collected important insights and data on the commercially available composite materials in comparison to our products”, marks Dirk Dembski, CEO at curasan AG. “With the approval of the claim we have found a consensus for the patients and surgeons”, he continues. “Our in-vitro studies have proven that CERASORB® Foam can be soaked to saturation with antibiotic solutions that have been pre- pared according to the manufacturer's instructions. Vancomycin, Gentamicin, Tobramycin, Refobacin, Imipenem/Cilastatin and Meropenem solutions were tested in the investigations. Our studies have shown, that antibiotically loaded CERASORB Foam shows an excellent initial burst release of the antibiotics into the en- vironment, followed by a long-term elution of the substrates.” states Florian Früh, Head of Global Product Management at curasan AG. First successful revision surgeries of infected hip prosthesis and treatment of infected bone areas have been carried out with very promising results. Further clinical investigations are ongoing. Source: curasan AG 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 48 3 2021 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 ©

| 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 Art Director Alexander Jahn a.jahn@oemus-media.de Designer Franziska Schmid grafi k@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 Member of the Board Lutz V. Hiller hiller@oemus-media.de Chairman Science & BD Jürgen Isbaner isbaner@oemus-media.de Chief Editorial Manager Dr Torsten Hartmann (V. i. S. d. P.) hartmann@dentalnet.de Editorial Council Dr Rolf Vollmer info.vollmer@t-online.de Dr Georg Bach doc.bach@t-online.de Dr Suheil Boutros SMBoutros@aol.com Editorial 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 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. 50 3 2021

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