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| content editorial 50 years of DGZI—a strong indicator for European dental implantology 03 Dr Rolf Vollmer research page 20 The Implant Protection Plan (I.P.P.) 06 Drs Tiziano Testori, Giordano Bordini & Matteo Basso The role of metallic nano- and microparticles in peri-implantitis 14 Dr Ioannis Papadimitriou case report page 30 The Stable Tissue Concept Dr Kai Zwanzig 20 Sinus augmentation and simultaneous implant placement 24 Drs Fernando Duarte, Carina Ramos, Paulo Veiga & Marco Infante da Câmara Alveolar defi ciency management in maxillary lateral incisor agenesis 30 Dr Federico Berton page 42 Immediate functional implants in the aesthetic zone of a heavy smoker 32 Dr Dr Branislav Fatori & Dr Inge Schmitz interview Fine dentistry and creative engineering go hand in hand 34 An interview with Dr Kai Zwanzig and Ric Donaca news manufacturer news news events 50 plus one years into the future Dr Georg Bach about the publisher imprint Cover image courtesy of Argon Dental / www.argon-dental.de issn 1868-3207 • Vol. 22 • Issue 4/2021 4/21 implants international magazine of oral implantology research The Implant Protection Plan case report The Stable Tissue Concept events 50 plus one years into the future 04 4 2021 38 48 42 50

| research The Implant Protection Plan (I.P.P.) Innovative implant and periodontal maintenance protocol Drs Tiziano Testori, Giordano Bordini & Matteo Basso, Italy Introduction The last 30 years of world dentistry have undoubtedly been characterised by the exponential growth of im- plantology, which has gone from being a discipline in the hands of a few experts “to being a field of treatment at many dental practices. There are several reasons for this increase: firstly, surgical and prosthetic techniques have been simplified over the years, repeatable proto- cols being certified by decades of literature, reducing costs for the patient and limiting invasiveness and post- operative discomfort. In addition, many patients want an aesthetic and functional restoration by means of fixed implant prostheses as their first choice, rather than re- sorting to solutions such as removable prostheses or fixed prostheses on natural teeth involving the prosthetic “... modern implantology is trying to address the possibility of guaranteeing a clinical result that endures over time ...” preparation of healthy teeth. Ultimately, it should not be under-estimated that implantology has also increased because it represents a source of income for the eco- nomic balance sheet of many healthcare facilities that have decided to specialise in this field. However, the im- plementation of an oral implant rehabilitation, be it a sin- gle tooth or a complex solution, cannot and must not today represent the end point either for the patient or for the dentist and his or her team. Nowadays, thanks to our knowledge, we have no difficulty in achieving implant-based rehabilitation even in cases of severe bone atrophy using regenerative techniques. The critical point that modern implantology is trying to address, not always successfully, is the possibility of guaranteeing a clinical result that endures over time. To achieve this ambitious goal, it is crucial to design an effective and feasible implant and periodontal main- tenance protocol. We know that home maintenance around implants can be more difficult than around natural teeth because the techniques and instruments to be used, in many clinical cases, are inevitably differ- ent from those used for natural teeth. In addition, we may be confronted with the typical pathologies of im- plants, represented by mucositis and peri-implantitis, subtle pathologies that are difficult to control and whose differences from gingivitis and periodontitis we have learnt about.1 According to studies on the preva- lence of peri-implant disease,2 45% of patients show, after an average of nine years, signs of mild peri- implantitis and 14.5% medium to severe. In recent times, we have gained knowledge about oral biofilm, discover- ing that the biofilm changes in its characteristics when a pathology is established and that some pathologies, such as mucositis and peri-implantitis, are charac- terised by a repetitiveness in the type of pathogenic microorganisms present.3 Implant maintenance proto- cols, however, have not evolved alongside knowledge, sometimes only introducing new instruments or tech- nologies, such as laser therapy or phototherapy, and some new antiseptic principles. The concepts of periodontal and peri-implant eubiosis and dysbiosis One of the key points for the long-term success of a patient rehabilitated with implants, which is no different from that of a patient treated for periodontal disease, is to establish a correct programme of supportive ther- apy and periodic follow-up that includes differentiated recalls based on an analysis of risk factors and conse- quent classification into risk categories. The literature and our decades of clinical experience have shown that patients with treated periodontal disease are at risk of having setbacks and developing a new disease process.4 Thus, the implant patient or the periodontal therapy patient should not and must not be consid- ered a patient who after treatment, however success- ful, can return to being normal and be low risk. Based on this scientific and clinical evidence, we can begin to plan the future of our therapies, starting with the biological basis of the problem and the new assump- 06 4 2021

| research implant protection plan SUPPORTIVE THERAPY CLINICAL CHECKLIST Name and Surname Date RISK ASSESSMENT FOLLOW-UP I A II A STAGE I B/C II B/C STAGE III A IV A STAGE III B/C IV B/C STAGE TYPE 0 TYPE 1 TYPE 2 TYPE 3 EVERY 2 MONTHS EVERY 4 MONTHS EVERY 3 MONTHS EVERY 6 MONTHS CLINICAL CHECKLIST Full-mouth plaque score (FMPS) < 25% Full-mouth bleeding score (FMBS) < 25% Presence of periodontal pocket depth ≥ 5 mm Clinical signs of mucositis Clinical signs of peri-implantitis Tooth mobility Significant risk factor modification Patient compliance Is this follow-up frequency appropriate for the patient? 1 Fig. 1: Operational checklist for maintenance sessions. YES NO YES NO YES NO YES NO YES NO YES NO Better Worse Adequate Not adequate YES NO New follow-up frequency: ________________ tions linked to a more accurate knowledge of the oral microbiota. The oral microbiota is the set of microorganisms that live and coexist in the oral cavity. It should be distinguished from the concept of oral microbiome, which is the col- lective genomes of the microorganisms present. The microbiota is made up of more than 700 different bacte- rial species, as well as numerous other micro organisms, and in a healthy state it is in perfect balance with the host, causing no harm and providing numerous bene- fits through the predigestion of food, antibacterial action, and the secretion of enzymes. This state of equilibrium is called “eubiosis”. It is important to emphasise that a eubiotic microbiota may also contain species that are considered pathogenic but which as part of a balanced biofilm are not capable of inducing pathology. Thus, the mere presence of periodontopathogenic species or implant pathogens is no longer considered a sign of pa- thology, as it was in the past; they can at most be consid- ered risk factors to which more attention should be paid. However, when a pathological process of either peri- odontitis or peri-implantitis occurs, the oral biofilm changes and a picture of dysbiosis5 of the oral micro- biota emerges, there being a change in the relation- ships between the present species and that can trigger an immune and inflammatory response. It is precisely the inflammation created by the bacterial trigger that feeds and often maintains the dysbiosis itself, leading to chronicity of the condition. This alteration in the bal- ance leading to the onset of disease is affected by many variables or risk factors which can affect the patient’s clinical situation at several levels.6 There is a solid body of literature on the most important risk factors for peri- odontal disease, drawn from many clinical trials and a smaller number of longitudinal studies.7, 8 This has made it possible to identify some of these factors as being strongly correlated with periodontal disease and, at least regarding the current state of research, to sug- gest for others a correlation whose nature has yet to be validated in detail.9–14 Risk factors include some that are modifiable and others that are not. Among the most important modifiable fac- tors are smoking, stress and diabetes, which we know cannot yet be eliminated but is treatable and therefore modifiable. Among the non-modifiable factors is genetic predisposition, a generic and imprecise term that refers to a host’s ability to modulate the quality of the immune and inflammatory response differently and thus favour the onset of disease. Other risk indicators whose cor- relation with implant and periodontal disease has yet to be fully clarified include obesity, metabolic syndrome, hypertension, cardiovascular disease, and osteopenia/ osteoporosis. A cooperative patient–professional plan Once the biological bases currently considered valid for a more scientific and modern understanding of peri- implant pathologies have been clarified, other much more practical and organisational aspects of maintenance need to be investigated. First of all, not all patients are the same: the selection of a good candidate for peri- odontal treatment or implant therapy should always be made a priori, excluding those patients in whom the risk factors described, or even who display an unsuitable propensity and attitude regarding adhering to the prac- titioner’s requests and prescriptions (patients defined as having a low degree of cooperation or compliance), are not considered satisfactory. Sometimes it is not possi- ble to select only ideal candidates, and even these, in the course of their lives, may suffer a disease setback if not properly motivated and followed up. Although a number of periodontal and peri-implant risk assessment tools have existed for years to assist clinicians in setting up the most suitable maintenance programme possible,15, 16 there is no uniformity even among the most experienced 08 4 2021

| research implant protection plan THERAPEUTIC ALLIANCE FIRST VISIT: RISK ASSESSMENT Name and Surname Date IMPLANT EVALUATION TYPE 0 PATIENT TYPE 1 PATIENT TYPE 2 PATIENT TYPE 3 PATIENT Implant patient Implant patient Implant patient Implant patient • Absence of tooth loss due to periodontitis • Absence of tooth loss due to periodontitis • History of tooth loss due to periodontitis • History of tooth loss due to periodontitis • No risk factors • No risk factors • Risk factors: Smoking Stress Diabetes Other__________________ • Risk factors: Smoking Stress Diabetes Other__________________ PERIODONTAL EVALUATION NOT TO BE FILLED IN FOR EDENTULOUS PATIENTS FRAMEWORK FOR STAGING: I II III IV INTERDENTAL CAL* AT SITE OF GREATEST LOSS RADIOGRAPHIC BONE LOSS PERIODONTITIS ASSOCIATED TOOTH LOSS *Clinical Attachment Loss STAGE I STAGE II STAGE III STAGE IV 1-2 mm 3-4 mm ≥ 5 mm ≥ 5 mm Coronal third (> 15%) No tooth loss from periodontitis Coronal third (15-33%) Extending to the middle third Extending to the middle third of the root or beyond of the root or beyond No tooth loss from periodontitis Tooth loss from periodontitis Tooth loss from periodontitis ≤ 4 teeth ≤ 5 teeth FRAMEWORK FOR GRADING: A B C GRADE A GRADE B GRADE C Direct evidence of progression Longitudinal data (radiographic bone loss or attachment loss) Evidence of no loss over 5 years < 2 mm over 5 years ≥ 2 mm over 5 years PRIMARY CRITERIA Indirect evidence of progression Percent bone loss/age < 0.25 0.25 - 1.00 > 1.00 Case phenotype Heavy biofilm deposits with low level of destruction Destruction commensurate Destruction disproportionate with biofilm deposits to biofilm deposits GRADE MODIFIERS Risk Factors Smoking Diabetes Non-smoker < 10 cigarettes/day ≥ 10 cigarettes/day Normoglycaemic with or without prior diagnosis of diabetes HbA1c < 7,0% in diabetes patient HbA1c ≥ 7,0% in diabetes patient 3 Fig. 3: Assignment of risk class. 1) In healthy patients or those with mild forms of peri- odontal disease, stable clinical conditions can be main- tained with six-monthly recalls. In patients with medium and severe forms of periodontal disease, the scien- tific evidence suggests a maintenance protocol with a greater frequency, varying in the literature from two to four months. 2) Data from retrospective studies shows that the pro- portion of residual affected sites (residual periodontal pockets with bleeding on probing) is an important vari- able in planning the frequency of visits. The efforts of health professionals should aim precisely at reducing these sites with disease both during the active phase of therapy and during supportive therapy. Less prolific in the literature are systematic reviews and longitudinal studies on implant patient retention and pre- vention of peri-implantitis. However, as peri-implantitis shares many risk factors with periodontal disease, it is intuitive that implant patient maintenance planning will also have many common variables to consider.20–22 However, the key to the prevention of peri-implantitis lies in the prevention of peri-implant mucositis. As re- ported by Jepsen et al., control of modifiable risk fac- tors—smoking and bleeding on probing of residual dentition—is crucial in controlling mucositis.23 Monje et al. in a meta-analysis on the impact of maintenance in the prevention of peri-implantitis emphasise the critical role of a history of periodontal disease as modifying the in- cidence of mucositis and peri-implantitis.24 Numerous works identify plaque control, bleeding on probing, smoking and diabetes as the most important biological variables to consider.25, 26 Having to classify, not a random sample of patients, but a subcategory (patients with previous periodontal disease and patients with implant restorations) with a higher intrinsic risk,4 we decided to maximise the impor- tance of the above-mentioned variables, set very strict cut-off values and establish rather tight recall intervals. Patients are thus divided into four classes of increasing risk, which are re-evaluated by the treatment team on a yearly basis with total transparency and in dialogue with the patient. It is much more effective to plan this phase for the duration of one year (12 months from the date of initial planning), as achieving good compliance and correct use of home oral hygiene instruments often requires several months and several professional recall sessions, during which time positive reinforcement by the hygienist and dentist will contribute to progressive improvement. The patient himself or herself is actively involved in this decision- making phase, promptly informed of his or her risk status and encouraged to excel in protecting the investment he or she has made during the active phase of therapy. The patient is motivated to scrupulously follow the instructions of the hygienist, who has the authority to suggest to the dentist after an observation period of one year a different maintenance protocol according to the degree of compliance demonstrated by the patient and the clinical results obtained. This patient–hygienist synergy has a twofold objective: it raises the status of the hygienist, who, in the eyes of the patient, becomes a professional figure empowered to propose a differ- ent treatment plan to the dentist; and it motivates the patient to follow the hygienist’s therapeutic indications, which, if put into practice, will save the patient both time, because by spacing out the recalls the patient will come to the practice fewer times, and economic re- sources, since reducing the maintenance sessions will reduce the costs. The tangible saving of time and money is an important motivating factor for most, if not all, patients and is far more motivating than a generic invitation to follow clinical indications, which are often under-estimated and experienced by the patient as an imposition. 10 4 2021

| research Finally, the IPP protocol is an important instrument of patient loyalty and involvement, similar to other con- tracts that patients sign every time they buy tangi- ble goods and want to protect an investment. In this specific case, the patient protects his or her own oral health, which, as we know, also has repercussions for systemic health,27, 28 an aspect that is increasingly clear from the literature and becomes a motivational lever “The therapeutic alliance involving the dentist, the dental hygienist and the patient is the cornerstone of long-term success ...” for patients to take care of their restorations. As men- tioned, patients increasingly demand a form of guar- antee for the professional service in which they have invested time and financial resources. It is universally accepted, including by legislation, that in many areas of medicine we cannot offer absolute guarantees similar to the purchase of material goods. The IPP protocol rep- resents, in our opinion and experience, a realistic and professional response to patients’ demands for a guar- antee that does not increase the risk of free prosthetic remakes because, by reviewing patients according to a tight and individually modulated recall schedule, muco- sitis can be intercepted and treated effectively before it becomes peri-implantitis. The protocol also allows the practitioner to have a powerful communication weapon should a clinical problem occur in patients who have refused the IPP. In this regard, it is advisable to write down any refusal in the medical record and have it countersigned by the patient. Clinical experience over the past 40 years has shown us that patients usually lose track of time and think that they have been out of treatment for a few years when in reality many more years have passed and the patient has never shown up for his or her sched- uled appointments. Having recorded even the non- acceptance of the PPI protocol allows the practitioner to demonstrate his or her diligence and protects him or her from possible medicolegal proceedings that patient appear increasingly willing to bring in the event of failure. We are convinced that, by protecting the patient from biological problems that may occur, we are fulfilling our professional duty in an ethical manner and protecting ourselves by demonstrating our com- petence and diligence. Conclusion The aim of establishing the IPP protocol is to help the dental team to assign a future risk profile designed specifically for the periodontal and implant therapy, not neglecting the many variables that contribute to the prognostic assessment but giving maximum emphasis to those that evidence suggests are the most relevant. The therapeutic alliance involving the dentist, the dental hygienist and the patient is the cornerstone of long-term success, there being a continuous flow of communi- cation between the parties and periodic feedback to recalibrate the most appropriate times and methods for continuing to maintain health. In its essence, the IPP protocol represents a modern and innovative approach to the patient that is aimed at: (1) effectively motivating the patient, who perceives real and tangible benefits; (2) building patient loyalty, because the practitioner offers protection that many other practitioners do not offer, thinking it too risky for the practice; (3) raising the professional profile of the hygienist, who becomes a key player in maintaining the results achieved by the dentist through treatment; and (4) protecting the dental practitioner from possible medicolegal proceedings, especially in those patients with inconsistent compliance. Author details Literature about the author Dr Tiziano Testori is head of the im- plant dentistry and oral rehabilitation section of the IRCCS Galeazzi Institute in Milan in Italy. He is an adjunct pro- fessor in the Department of Biomedical, Surgical and Dental Sciences of the Uni- versity of Milan and an adjunct clinical assistant professor in the Department of Periodontics and Oral Medicine at the University of Michigan School of Dentistry in Ann Arbor in the US. He obtained his MD in 1981, his DDS in 1984 and a specialty qualification in orthodontics from the University of Milan in 1986. contact Dr Tiziano Testori ttestori@umich.edu 12 4 2021

| research The role of metallic nano- and microparticles in peri-implantitis Dr Ioannis Papadimitriou, Germany Dental implantology has become a fundamental com­ ponent of oral rehabilitation and is closely associated with prosthetic therapy. The aim of both implantology and prosthetics is to replace a lost natural tooth and to achieve restitutio ad integrum. To attain this goal, attempts have been made with different materials and techniques for many centuries. In the last few decades, metal implants in particular have established themselves extremely suc­ cessfully as an alternative to purely prosthetic therapies; however, the extent to which these may have a negative impact on the organism and the reasons for which they can lead to inflammatory reactions must be examined more closely.1, 2 In the middle of the twentieth century, Brånemark’s Gothenburg research group first researched the bio­ compatibility of different materials with bone and has since triggered an uninterrupted upswing in dental im­ plantology. It was found that implants made of pure titanium have the ability to heal in the bone without any signs of inflammation or rejection. Brånemark defined this process as osseointegration, which includes all elements of biocompatibility, a bio­inert material and bioactivity.1, 3 The term “biocompatibility” defines materials that have no negative effects on living organisms. This is extremely important with implants, as they remain in the living tissue for a long time. Implant materials must also be bio­inert, which means that no toxic substances may be released from them over time. Bioactivity involves the creation of a chemical bond between the implant and the surrounding tissue.1, 3 Since Brånemark was able to demonstrate these properties of pure titanium, it is now the material of first choice for implants. An alternative to pure titanium is zir­ conium dioxide, which also has very good biocompatible properties. In addition, in medicine, other metals, metal alloys, polymers and ceramics are used as biocompatible materials.1, 3 Bone deposition on the titanium implant sur­ face, important for osseointegration, was also confirmed in many studies. Primary stability is achieved through mechanical blocking. While natural teeth develop simultaneously with perio­ dontal tissue to form a functional unit, endosteal implants, being artificial, are made of inorganic material, for which no artificial periodontium has yet been found. This consti­ tutes a weak point regarding later peri­implant inflamma­ tion.4, 5 The morphological differences between a natural tooth and a titanium implant cause implants to be more prone to inflammation.32 Overall, metals have good me­ chanical properties, but their susceptibility to corrosion and their possible release of metal ions and consequently the sensitisation of the organism represent disadvan­ tages. Therefore, collar­shaped stable soft tissue around the implant protruding into the oral cavity is essential for long­term success of an implant, including the prosthetic restoration. The healing processes after implantation can only start from a vital bone.6, 7 Periodontitis and peri-implantitis Biofilm is mandatory for the development of periodontitis. The bacteria from this infiltrate the periodontal tissue, resulting in inflammatory reactions and subsequent irre­ versible tissue damage. Risk factors such as nicotine and 1a 1b Figs. 1a & b: Clinical peri-implantitis. 14 4 2021

| research 3a 3c 3b 3d Figs. 3a–d: SEM images of the effect of Streptococcus sanguinis on the titanium surface. Titanium surface in artificial saliva enriched with S. sanguinis. Scale: 100 μm (a) and without S. sanguinis. Scale: 100 μm (b). Enlarged view of Figure 4a (the arrows show S. sanguinis). Scale: 10 μm (c). Enlarged view of Figure 4c. Scale: 5 μm.24 (d). to this, because the aspects of particle formation during implantation have been investigated in more detail only in the recent last few years. Titanium properties The grey colour of titanium is caused by the oxide layer that forms on the surface immediately after the metal comes into contact with oxygen and is 2–5 nm thick. This nor­ mally very dense and chemically stable oxide layer gives titanium its biocompatibility and mediates osseointegra­ 4a 4b 4c 4d Figs. 4a–d: Detailed images of two implant–abutment connections under masticatory load.31 16 4 2021 tion by allowing cellular adhesion molecules to accumu­ late. In some cases, however, different types of corrosion can be observed clinically: pitting, crevice and stress cor­ rosion, and erosion (Figs. 2a & b).7, 21, 22 Pitting corrosion occurs primarily and predominantly at the connection point between the implant and the abutment, which can cause crevice corrosion. As a result, a concentration of chloride ions is created, which lowers the pH in the immediate vicinity of the implant. Thus, the oxide layer on the titanium implant dissolves irreparably and cannot renew itself due to Streptococcus sanguinis. These bacteria form a barrier to oxygen through a biofilm formed around the implant; owing to the lack of oxygen, titanium ions and particles are released from the complex titanium structure. On the one hand, this inflames the tissue, and on the other hand, the titanium implant continues to corrode. The saliva, which can act as an electrolyte, also contributes to the perma­ nent damage to the oxide layer because the corrosion is supported by electrochemical processes in the mouth.23, 24 The extent of damage to the implant surface, which is sig­ nificant, is shown in Figures 3a–d.24 In addition, Nakagawa et al. found in a further study that pure titanium and tita­ nium alloys corrode faster owing to the influence of fluo­ rides at a low oxygen content, whereas without fluoride they showed a higher corrosion resistance at the same oxygen concentration.25 For this, the fluoride concentration in commercially available toothpastes was considered, which turned out to be too high and does not protect the metals from corrosion damage.25

| research Metal abrasion during insertion and its consequences The original implant surface and shape can be modified by the insertion procedure. A very deep insertion causes greater damage to the bone and implant than a less forced insertion. By torsion and friction of the implant on the bone, titanium particles are released from the surface structure of the implant into the already damaged bone tissue. The size of the released titanium particles varies between 10 nm and 20 μm. At the sharp edges of the implant, the entire oxide layer is partially lost as a result of the insertion. The loss of the oxide layer also depends on the type of implant.26–28 Martini et al. showed that im­ plants coated with fluoro­hydroxyapatite were less sus­ ceptible to abrasion during insertion than plasma­coated implants. Titanium particles released by plasma­coated implants were found at a distance of 200–250 μm from the implant surface and prevented neo­osteogenesis. A deformation of the implant thread can be seen in the area of the bone, especially in the form of microfractures. Titanium abrasion can be found both in the peri­implant mucosa and in the newly formed bone. Titanium particles have even been detected in organs further away: the liver, kidneys, lungs and heart.29, 30 In addition to the implant insertion, the high mechanical loads on the connection between the implant and the abutment are another factor that contributes to the release of metallic particles. Com­ plete implant failure can also occur as a result. In addition, micro­gaps can form at the implant–abutment connec­ tion, where titanium and metal particles can also loosen. Microleakage, material wear, material fatigue and screw loosening are other possible consequences that can result from the micro­gaps. Microleakage is particularly evident in hexagonal connections with a loose fit (Figs. 4a–d) through which—in addition to metal abrasion and material damage—liquids and bacteria gain entry to the interior of the implant and cause internal corrosion of the implant. The microgap movements can be reduced by a conical connection between the implant and the abutment.31 Conclusion At the beginning of the implantology era, the focus was on the euphoria about solving the problem of osseointe­ gration, but in recent years, the question of the reasons for a shortened lifetime of implants has moved increas­ ingly into focus. Peri­implantitis, which sometimes turns out to be therapy­resistant, was seen as a further indi­ cation that, in addition to a lege artis insertion, factors that lay the foundation for peri­implantitis during insertion can be responsible for achieving osseointegration. Nano­ and microscale titanium and zirconium dioxide parti­ cles detach themselves from both the instruments and the implants during insertion and the surgical, prosthetic and aftercare phases. They can be detected in bone and other tissue and have only recently been shown to be cytotoxic. According to the current research, the release of these particles cannot yet be prevented regardless of the implant surface. The metal and titanium ions and particles dispersed into the peri­implant hard and soft tissue trigger cellular reactions that can be compared to aseptic chronic inflammation. This can lead to therapy­ resistant peri­implantitis and thus to failed osseo­ integration. Although these clinically and radiographically visible peri­implant changes are very similar to periodontitis, peri­implantitis is not always bacterial. For this reason, the classic treatment concept for periodontitis cannot gen­ erally be transferred to peri­implantitis. A concept for the treatment of peri­implantitis that is not caused by bac­ teria is not yet available. Particle­induced peri­implantitis is often accompanied by osteolysis, which is clearly not considered to be bacterial. In such cases, explantation with thorough lavage of the bone cavity is necessary. Further investigations are required to determine whether and to what extent bone regeneration measures need to be taken. Overall, however, the prevailing opinion is that metallic nano­ and microparticles are of no impor­ tance in dental implantology. For this reason, the 2017 World Workshop on the Classification of Periodontal and Peri­Implant Diseases and Conditions defined peri­ implantitis without including factors such as metal parti­ cles and their cytotoxicity. However, it is expressly advised that further research regarding metallic nanoparticles is absolutely necessary owing to their potential danger. Author details Literature about the author Dr Ioannis Papadimitriou specialised in oral surgery and holds an MSc in oral implantology and periodontics from the German Association of Oral Implantology and the Steinbeis University in Berlin in Germany. He is a senior physician at the department of oral and maxillofa- cial surgery at the St Lukas hospital in Solingen in Germany. contact Dr Ioannis Papadimitriou giannis.papadimitriou_4@hotmail.com 18 4 2021

| case report The Stable Tissue Concept Dr Kai Zwanzig, Germany In order to achieve long-term stable results, it is im- portant not to disregard biological principles. Bone and soft-tissue management should be an integral part of the portfolio of implantologists, since stable tissue is the basic prerequisite for implantological success. To this end, hard- and soft-tissue augmentation must be per- formed with materials adapted to the situation and in- dication. Another important factor is the choice of the implant system, because this can also be decisive for whether the bone level is maintained. Conical internal connections are therefore recommended, as they ensure the necessary stability of the abutment. Many reasons for bone resorption around implants are described in the literature. Firstly, implants are often screwed into bone that is too thin; a circumferential bony layer of at least 2 mm is required to keep an implant stable.1 In addition, two-piece implant systems usually have the disadvan- tage that the abutment has some mobility. Twenty years ago, Hermann et al. were able to prove that it is not the gap between the implant components that induces bone resorption, but that this process is caused by micro-movements between the implant and abutment.2 It is therefore important to select an implant system that completely eliminates these micro-movements. Numer- ous studies show that implant systems with tapered internal connections can avoid such movements.3 However, there are also major differences between these implant systems. Systems with self-locking ta- pered connections show the least movement between implant and abutment, and that is particularly the case for the Morse taper connection.4 The Morse taper was developed to secure tool components in the spindle of a tool. It is characterised by a taper angle of a maximum of 1.5°, transmitting the torque from the hollow cone of the operating tool spindle to the shaft of the tool, which is clamped in it, in a friction-fit manner by static friction as a result of self-locking. The implant system (K3Pro, Argon Dental) used in the following case has such an internal connection. These implants do not show any gap formation in radiographic analysis, even at the maximum load of 200 N, and do not exhibit any micro-movements. In this case report, a clini- cal procedure according to the Stable Tissue Concept is described. Clinical case The patient visited the practice in 2016 after the removal of tooth #36 elsewhere to have the gap restored with a dental implant (Fig. 1). A bone defect was visible on the preoperative radiographic image (Fig. 2). After elevation of a mucoperiosteal flap and careful curettage of the surgical site, it became obvious that augmentation was required 1 3 20 4 2021 2 4 5

| case report 18 19 20 21 22 23 autologous soft-tissue graft was taken from the palate and fixated vestibularly to ensure that there was no move- ment whatsoever (Fig. 14). The thickness of the tissue above the implant shoulder also plays an important role; it should not be less than 3 mm, otherwise bone resorp- tion will occur.9 Prosthetic restoration Two months after exposure, the prosthetic restoration was carried out. Since an individual anatomical healing abutment was used in this case, the implant shoulder was completely covered by the connective tissue chimney described (Fig. 15). In order to expose the shoulder, the entire chimney was removed again with the aid of a sulcus former so that the impression post could be placed on the implant shoulder without a gap (Figs. 16 & 17). However, the entire biologically built structure was destroyed as a consequence (Fig. 18). At the time of crown installation, the situation was macroscopically completely free of irri- tation and healed (Fig. 19). An individually tailored hybrid abutment made from zirconia was attached to a titanium adhesive base and placed in the patient, and a lithium disilicate crown was cemented intra-orally (Fig. 20). The postoperative radiograph shows the gap-free fit and the removed bone in the apical region of the abutment (Fig. 21). Clinically, a perfectly integrated restoration without tis- sue loss was seen four years after placement (Fig. 22). The CBCT scan showed that complete remineralisation of the bone in the interface appeared to have occurred (Fig. 23).10, 11 Discussion This procedure, which was very experimental at the time, has since become the standard procedure in the author’s practice and is the basis of the Stable Tissue Concept. The parts required for the Stable Tissue Concept are now available preassembled. This means that all the parts, from the anatomical healing abutment to the abut- ment, have been modified to the required geometry and matched to each other in such a way that no tissue needs to be removed in the interface. The impression post no longer rests on the implant shoulder for reference, but is attached deep in the index of the implant to enable precise impression taking without being inhibited by the taper. The implant used here serves as the basis of this concept. The internal connection with the Morse taper cone fulfils creates the prerequisite that any movement in the abutment is eliminated and no bone resorption occurs. The standard insertion depth of the implant is 2 mm sub-crestally. Such a procedure is only possible with this internal connection; it is possible to insert the implant even deeper without causing any biological complications. Of course, hard- and soft-tissue augmentation must be performed in such a way that the biological conditions for long-term success are created. The augmentative pro- cedure must be adapted to the specific clinical situation. No matter the case, sufficiently thick soft tissue ensures that there is little bone resorption. In the author’s prac- tice, the aim is always to generate 4–5 mm of keratinised gingiva above the implant shoulder. about the author Germany-based Dr Kai Zwanzig studied dentistry at the University of Münster in Germany and received his PhD from the same university. He com- pleted a four-year specialisation in oral surgery. Since 2007, he has been in private practice together with Dr Bodo Zwanzig in Bielefeld in Germany, which he established as a referral practice for oral surgery specialising in complex implant cases, plastic peri- odontal surgery, anterior aesthetics and ceramic restorations. He has authored specialist articles in numerous dental journals. Author details Literature contact Dr Kai Zwanzig info@praxis-zwanzig.de www.praxis-zwanzig.de 22 4 2021

| case report Sinus augmentation and simultaneous implant placement using one-stage Sandwich Technique Drs Fernando Duarte, Carina Ramos, Paulo Veiga & Marco Infante da Câmara, Portugal 1 Fig. 1: Initial CT scan with coronal and sagittal sections. Introduction The posterior sector of the maxilla consists of an ex- tremely thin facial lamina, with the underlying trabecular bone having a low mineral content. The loss of maxillary posterior teeth is a typical bone resorption pattern that implies a decrease in the bone width available at the ex- pense of the labial plate.1 This is the explanation why the width in the posterior sector of the maxilla decreases at a faster rate compared to other regions.2 It should also be noted that the lack of vascularisation accelerates the phenomenon of bone resorption and initial Class D3 or D4 trabecular bone. Even if it decreases by 60%, however, the residual ridge is wide enough in the posterior maxilla for root-form implants. Progressive resorption shifts the alveolar crest towards the palate at the expense of bone width.3 The posterior maxilla continues to atrophy until the entire alveolus is ablated to basal bone. The vestibular cusp of definitive prosthetic rehabilitation must result from a balance between aesthetic requirements, biomechani- cal conditions, and bone availability in moderate to severe atrophic crests.4 Maxillary sinus resorption The inner anatomy of the maxillary sinus maintains its full size while the teeth remain in arch and function, but expands when the posterior teeth are lost.1 There is an ex- pansion of the antrum in the inferior and lateral directions, potentially invading the canine region and even the lateral piriform sinus. After the loss of teeth, sometimes related to periapical infectious processes, the amount of bone available in the posterior region of the maxilla for implant placement is greatly reduced. This phenomenon is likely the result of atrophy caused by reduced bone tension due to lack of occlusal function. Implants placed under the ungrafted sinus floor are known to stimulate increased bone formation in the sinus floor. Among the main criteria for the success of treatment with implants, bone quality and quantity stand out. In a limited literature review, it can be seen that, statistically, implants with a height of 10 mm or less have a 16% lower survival rate than implants with more than 10 mm in height.5 It is therefore important to emphasise that, bone height is a factor to consider in predictability and longevity of implant-supported reha- bilitation. In periodontal compromised patients, a phe- nomenon known as pneumatic trifurcation is frequently observed, whereby the maxillary sinus extends between the roots almost to the furca in the area of the first molar. Tooth extraction leaves 4–5 mm of bone available as a result of this anatomical peculiarity of the sinus. The limited vertical dimension further aggravates the problem of the position of the medialised crest and the already compro- mised alveolar width. As a general rule, bone quality in 24 4 2021

| case report 2a 2b Figs. 2a & b: Osteotomy by piezoelectric surgery and sticky bone for reconstruction. the posterior maxilla is worse than in any other intra-oral anatomical region.6 The bone density of the maxilla is of- ten five to ten times lower than that of the anterior mandi- ble, namely the symphysis and para-symphysis regions.7 Bone mineral density directly influences the amount of contact between the implant and the bone surface, which in turn transmits the load to the bone.8 The tension pattern spreads more towards the apex of the implant in low- density bone than in dense bone.9 When tension is ex- cessive, bone loss occurs in the trabecular bone, which begins in the cervical and may travel throughout the entire body of the implant. Strategies to increase bone–implant contact, both surgically and by modification of implant topography, are being developed. Bone mineral density is extremely important for the survival of the implant in function.6 Implants have an increased risk of failure in conditions of poor mineralisa- tion. Deficient bone structure compromises not only the primary stability of the implant, but also the ability to sup- port occlusal forces. The absence of cortex on the ridge crest compromises the primary stability of the implant and, since the buccal cortical plate is generally very thin and the crest is relatively wide, it does little to increase stability. The occlusal forces in the posterior region are greater than in the anterior region of the oral cavity by up to five times.10 The maximum occlusal force in the anterior region varies from 241 to 345 Pa, compared to the maximum occlusal force in the molar region which varies from 1,378 to 1,723 Pa.11 Natural maxillary molars 3a 3b 3c Figs. 3a–c: Intra-op images of bone reconstruction and implant placement. 26 4 2021 have 200% more surface area as well as a significantly larger diameter than premolars,1 and clearly the combi- nation of the two factors contributes to the reduction in bone tension. In accordance with the clinically observed morphology, in the oral cavity, the support of the implant should be greater in the molar region, thus allowing a more functional and aesthetic prosthetic rehabilitation.1 It should be noted that the decrease in bone quantity and quality, as well as the increase in occlusal strength, should be highly considered aspects in the treatment of the posterior maxillary region. Sinus floor approach Tatum was the first clinician to suggest a crestal approach to sinus floor elevation and placement of submerged im- plants.12 The technique, used in thin residual crestal bone, involved an upfracture into the sinus using a socket- forming instrument. A bone graft was placed beneath the tented sinus membrane. Later, a modified Caldwell–Luc procedure was developed in which the lateral sinus wall was infractured and the wall was used to help elevate the sinus membrane. Autogenous bone was then placed into the area.13 Since then, a variety of techniques have been described for augmenting the maxillary sinus floor. Two general procedures for sinus elevation for dental implant placement are currently in use: a two-stage technique using a lateral window approach and a one-stage technique using a lateral or a lateral from the crest approach.14–17 The decision to use a one- or two-stage technique is made based on the amount of bone present at the alveolar crest. Piezoelectric surgery has certain fundamental char- acteristics that make it safer and more precise than the instruments (manual and motorised) traditionally used in this type of surgery. Morphological and histo-morphometric studies have found that the tissue responds better to piezo-surgery than to the drill.18, 19 The extreme preci- sion and safety of the method are assured by the following: a) Micrometric cutting action allows effective cutting of mineralised structures but is inactive on soft tissue; b) Absence of macro-vibrations permits better handle

| case report 4a 4b Figs. 4a & b: Autologous fibrin membranes and sutures. control, thus assuring completely safe access to the most difficult anatomical zones and high cutting precision; c) Cavitation with the cooling saline solution that is gen- erated from the characteristic ultrasonic vibrations pro- duces tiny sprayed particles of water that keep the area cool and free of blood, thus avoiding overheating of the tissue and allowing optimal intra-operative visibility. Sandwich Technique additional membrane. Sticky bone (CERASORB M, curasan; and platelet-rich fibrin) is placed and compressed in the posterior (palatal) portion of the bone window. It is easy to manipulate and accelerates tissue healing and minimises bone loss during the healing period. Subsequently, the implant is placed, the existing cervical bone acting as the primary stability source. Finally, new sticky bone is placed in the anterior portion (vestibular) and membranes of autologous fibrin are applied as a cover of the bone graft. This technique recommends 3D bone reconstruction around the entire body of the implant in cases of eleva- tion of the sinus floor by 4–5 mm and implant placement in the same stage. The technique recommends that two vertical osteotomies be performed on the lateral wall of the maxillary sinus to delimit the bone area to be grafted. A third inferior horizontal osteotomy is performed accord- ing to the bone availability shown on a CT scan and a fourth superior horizontal osteotomy to delimit the height of the graft. The bone window produced is reflected into the maxillary sinus with the intention of functioning as a ceiling for the grafted area. Whenever possible, it is advisable to maintain the integrity of the Schneiderian membrane. If it is eventually perforated during the osteo- tomy or is already perforated, it is necessary to place an CERASORB M is a resorbable beta-tricalcium phosphate, pure phase, biomimetic and totally resorbable to fill, join and rebuild bone defects of small, medium and large dimensions; as well as to promote bone fusion throughout the skeletal system. CERASORB M is made of biocom- patible synthetic ceramic material with a phase purity of approximately ≥ 99%.20 CERASORB M granules have a polygonal shape which allows for better structural adap- tation between them, they have an open interconnected micro, meso and multiporous structure macropores (about 65%), radiopacity is lower and absorption and re- modeling in autologous human bone are achieved more quickly than with conventional biomaterials. Over the course of months in contact with vital bone, the CERASORB M material is resorbed and simultaneously replaced by autol- 5 Fig. 5: Final CT scan with coronal and sagittal sections. 28 4 2021

| case report Alveolar deficiency management in maxillary lateral incisor agenesis Dr Federico Berton, Italy 1a 1b 2 Background The second most common dental agenesis is that of the maxillary lateral incisors, after agenesis of the mandibu- lar third molars.1 This common agenesis has important functional and aesthetic impacts for the patient and is challenging to manage for the dental professional. Several approaches to address this condition, both for unilateral and bilateral, have been reported. From least to most in- vasive, these are (1) the conservative or prosthetic adap- tation of the canine to replace the incisor and of the first premolar for canine function (with or without orthodon- tic assistance); (2) the orthodontically assisted creation of space for the incisor and prosthetic replacement with a fixed prosthesis (employing several approaches); and (3) the orthodontically assisted creation of space for the inci- sor and implant-supported fixed rehabilitation; removable prosthetic rehabilitation can also be used, but only for pro- visional necessity when a fixed provisional prosthesis can- not be used.2 Although implant-supported rehabilitation has many advantages, it also has several dis advantages, such as age constraints, surgical invasiveness, and high hard- and soft-tissue aesthetic demands, given the loca- tion of the incisor in the aesthetic zone. Moreover, early implant insertion should anticipate the long-term progno- sis of the rehabilitation according to the age of the patient. Finally, incisor agenesis results in a soft- and hard-tissue deficiency that has to be managed to guarantee an op- portune aesthetic result and a long-term prognosis for the implant rehabilitation. Therefore, implant replacement of a missing lateral incisor is challenging for the oral surgeon and the prosthodontist. Case presentation An otherwise healthy 21-year-old patient was evaluated for implant insertion after a careful evaluation of treatment alternatives. The patient underwent 12 months of fixed orthodontic therapy for space creation and tooth align- ment. Afterwards, the patient wore a removable retainer until musculoskeletal growth was reasonably complete. The CBCT scans showed sufficient mesiodistal space but a width deficiency (Figs. 1a & b). Clinical examination high- lighted a generous band of attached gingiva. Therefore, the treatment plan involved an initial surgery for implant insertion and bone regeneration, then the positioning of a healing abutment and soft-tissue augmentation after six months, and finally the definitive prosthetic rehabilitation. 3a 3b 4 30 4 2021

| case report Immediate functional implants in the aesthetic zone of a heavy smoker Dr Dr Branislav Fatori & Dr Inge Schmitz, Germany compliance. Immediate loading protocols increase the com- plexity of treatment planning and the surgical procedure it- self. Immediate implant loading should be planned ahead of tooth extraction and should be limited to clinical situations that allow for primary stability (> 30 Ncm) and correct pros- thetic positioning. Additionally, the procedure can help to re- duce bone resorption. However, there can be complications when carrying out immediate implant loading in the anterior region. When immediate loading is performed there should be no indication of inflammation, periodontitis or gingivitis. Furthermore, a good concept for Antibiosis is necessary and tooth extraction should be carried out in minimally invasive fashion. In the anterior region the vestibular lamella should not be incriminated. Immediate implant placement in combi- nation with immediate loading can lead to a better clinical and aesthetic treatment outcome. Fixed prostheses on implants show significantly better results than removable prostheses. Materials and methods The 75-year-old male patient was a heavy smoker who smoked approximately 40 cigarettes per day (Fig. 1). Heavy smoking can be a contraindication for implant insertion. There is evidence in the literature pointing to a lower surviv- ability of dental implants in smokers. One possible mecha- nism by which smoking may affect osseointegration is the reduced blood flow rate due to increased peripheral resis- tance and platelet aggregation. Smoking directly affects osteoblast function. In general smoking is a major risk factor for implant failure. When smokers are treated with implants good bone quality is required. 1 Dental implant placement represents the most cost- effective and long-term solution for the replacement of missing teeth and it can be argued that dental implants have a high average life expectancy. Immediate or early implant loading procedures are well documented in cases of eden- tulous sites in the mandible and the maxilla. It is often diffi- cult to obtain good results in the anterior region and it is es- sential for practitioners to understand the anatomical basis for and the limitations of implant dentistry in the aesthetic zone. To achieve satisfactory implant survival rates, it is vital to have reproducible treatment protocols that reinforce indi- vidual expertise and help to achieve high treatment quality. To this end, the following factors should be taken into consid- eration: Prior to tooth extraction, immediate loading requires the careful selection of patients and a high level of patient 2 3 32 4 2021

| interview Fine dentistry and creative engineering go hand in hand An interview with Dr Kai Zwanzig and Ric Donaca Many problems in implantology are self-made be- cause biological principles are disregarded. Bone and soft-tissue management should be firmly anchored in the implantologist’s portfolio, as stable tissues are the basic prerequisite for implantological success. With the new Stable Tissue Concept from Dr Kai Zwanzig, it is possible to preserve all structures to the maxi- mum, in which the implant system in particular plays a paramount role. The new K3Pro product line from Argon Dental offers the best prerequisites for this. In this interview, Dr Kai Zwanzig and Ric Donaca, Manag- ing Director of Argon Dental, discuss the advantages of this system. Dr Zwanzig, please describe your motivation to personally commit to the new implantology con- cept “Stable Tissue”. Dr Kai Zwanzig: I love teeth. My patients love their teeth. If a tooth cannot be preserved, I am not satisfied with “tooth replacement”. And no colleague, no dental technician and no patient should be satisfied with “replacements”. The focus of my medical practice is Fig. 1: Dr Kai Zwanzig (left) and Ric Donaca, Managing Director of Argon Dental. 34 4 2021 to take into account the entire biology surrounding a healthy tooth, set in healthy soft tissue and stable bone. Nothing else should apply to lasting implantological success. Why do the majority of implant manufacturers pay so little attention to these scientifically quantifiable biological factors of the healthy tooth, forcing me to work around the considerable design-related problems of their systems—which I locate in a professionally driven “faster, simpler, more productive”—with all my skills? It is time to commit to a new value orientation in implan- tology and to pave the way for it. This can only be done hand in hand with an industry partner who ticks similar boxes and is prepared to continue to substantially im- prove a good product. I have known and appreciated Argon for ten years now. Mr Donaca, your K3Pro implant system is consid- ered by insiders to be particularly innovative and proven at the same time. Why is that? Ric Donaca: The principle of our conical implant- abutment connection—a particularly long cone of 3.1 mm with such strong friction that micromovements are ex- cluded, no bacterial colonisation of the implant interior can take place and a loaded retaining screw is basically ob- solete thanks to the friction lock—comes from mechanical engineering and was adapted for implantology in my early days in the 1980s. It is not a pseudo-cone with a flat an- gle, which actually only corresponds to a phase for sealing between the implant and abutment, but does not prevent movement and continues to load the screw. As a result, the force fit equals the solidity of a monolithic implant, with all the dental advantages of a two-piece system. The innovation lies in the devel- opment of a practical prosthetic han- dling of this special connection, which allows easy try-in, precise height of the crowns even without butt joint and defined forces. But this, too, is now proven.

| interview every respect. This principle opens up every conceiv- able option for prosthodontists thanks to the subcrestal implant position. Narrow, particularly tissue-friendly emergence profiles are clearly the trend. Dr Kai Zwanzig: From a scientific point of view, it should be added that studies have shown the following: It is not so much the microgap with the bacterial pumping effect in the implant–abutment connection that is problem- atic, but rather the constant movement between abut- ment and implant, however minimal. The objective for bone and gingiva preservation is to completely eliminate this movement. This has been achieved with K3Pro— hence my personal commitment to this philosophy with full conviction. As a friend of biological dentistry, I must not forget that thanks to this principle, no titanium oxide abrasions are released and the organism is not gradually contaminated with them. “The practical handling with complete preservation of the biology of bone and soft tissue is in the foreground.” So what is the innovation that came out of the collaboration? Dr Kai Zwanzig: By exploiting the entire as yet undis- covered biological potential of K3Pro. We proceeded step-by-step. I let my first cases heal in the classic closed subcrestal way and regretted having to “search” for the cover screw in the tissue when uncovering it. With the use of the high cover and membrane fixation screw of 2 mm height, everything changed. I was thrilled with the stable bone and tissue channel that formed completely over the implant shoulder, and so this became my per- sonal standard protocol. The goal was not only to take the impression and gingival design directly through this tissue channel of unique biology, but also to have the abutments precisely pick up this geometry, thus provid- ing the maximum stable support of the bone over the entire length of at least 2 mm. This was unique among all implant systems known to me and also takes into ac- count recent scientific findings that lengths of 8 to 9 mm are completely sufficient and only in immediate implan- tations more bone should be grasped apically due to the alveolar anatomy. Ric Donaca: For this we had to extend all the im- pression posts, gingiva formers, scanposts and, above all, the abutments to an emergence length of 2 mm. In addition, with regard to the transfer aids, we switched from a butt-joint principle on the implant shoulder to impression-taking purely via indexing by means of a hexagon and depth stop in the implant, because at this stage the cone fit is not yet desirable; practicable han- dling with complete preservation of the biology of bone and soft tissue is paramount. This is how the new pros- thetic line of the K3Pro was developed within the frame- work of the Stable Tissue Concept—it stands for one millimeter more. Quite a challenge for the engineer. Dr Zwanzig, is it difficult for implanting people who are changing over to this new system to adjust to it? Dr Kai Zwanzig: It always takes conviction to decide to fundamentally change learned techniques. With re- gard to the 2 mm subcrestal positioning, experience in implantology is of course an advantage. But thanks to Argon’s optimised instrumentation and optional digital planning in the full-guided procedure, the changeover is easy. As soon as you have gotten rid of old habits of placing the implant supra- or equicrestally and instead place it deep and leave it to biology with the high heal- ing screw, you immediately recognise the superiority of this concept. Such reliable and rapid osseointegration is unparalleled! Especially with immediate implant place- ment. Uncovering, gingiva shaping, transferring or scanning is extremely simple, since the dimensions of this healing screw already specify the appropriate com- ponents. Only the gingival height needs to be deter- mined. My technicians are delighted with the innovative model analog, which completely eliminates the han- dling dis advantages of a friction-fit tapered connection and makes prosthetic work as easy as with a butt fit. And last but not least, there are our courses under the sign of the Stable Tissue Concept: At Argon in Bingen or at my place in Bielefeld. Dr Kai Zwanzig Author details Argon Dental Company details contact Argon Dental Bingen, Germany info@argon-dental.de www.argon-dental.de 36 4 2021

| manufacturer news Argon Medical Perfect and aesthetic mucosal stability The preservation of tissue is essential for long-term implantological success in terms of aesthetics and function alike. Our K3Pro and the new K4Pro have always been optimised for subcrestal inser- tion, so the optimum biological width can always be maintained. The implant with its anatomically designed shoulder is reliably sealed by vital bone. Science and practice determined that strict adherence to a 3 mm minimum rule is a basic prerequisite for the application of the zero bone loss concept and thus the sustainability of implanto- logical success. Users of crestally placed implants face the problem that a minimum 3 mm thick gingiva must be present for this protective mucosal sleeve to remain stable. Users of the subcrestal K3Pro and K4Pro are always on the safe side here. Argon Dental is again signifi cantly increasing the range of indications. New components with identical emergence profi les for healing, impression taking, laboratory and prosthetics allow for the fi rst time 2 mm subcrestal inser- tion with gingival heights of 1, 2 or 3 mm. The unique biology created by this subcrestal philosophy of healing remains untouched after surgery. Healing screws and abutments, impression posts and abutments precisely matched to the respec- tive insertion depth and gingival height function in unison like a fi rst-class orchestra. The results are unparalleled, and the unique systematic approach to application makes it easy for new users. Argon Medical, Germany +49 6721 30960 www.argon-medical.com curasan Dentsply Sirona The perfect union of form and function The new DS PrimeTaper is a demonstration of science and art in harmony. Its innovative design enables predictable, secure place- ment across the widest range of bone densities. DS PrimeTaper is a self-tapping implant with a tapered design and progressive self-cutting threads that have been crafted to cut quickly and engage without excess torque, the result is immediate installation stability. A simple drilling protocol ensures excellent control and supports the workfl ow. Lasting performance is further enhanced by the unique MicroThread design that provides long-term biome- chanical bone stimulation, improved aesthetics and lasting satis- faction for both patient and clinician. Building on Astra Tech Implant System’s proven reputation for fast, predictable osseointegration, the DS PrimeTaper OsseoSpeed surface bonds with more bone, more rapidly. The outcome is long-term bone care and stability that outperforms the competition at both 1- and 5-year intervals (Norton MR, Astrom M. Int J Oral Maxillofac Implants 2020; 35:1099–111). Dentsply Sirona, Sweden +46 31 376-3000 www.dentsplysirona.com/en/explore/implantology/ds-primetaper.html Maximum fl exibility 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 fi lling bone defects. The multiporosity of the granules embedded in the collagen helps bone to grow in faster. Blood com- ponents and body fl uids can permeate the bone regeneration material unhindered and rapidly to accelerate osseous integration, vascularisation, and resorption. Due to the specifi c 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 38 4 2021

| manufacturer news BioHorizons Camlog The next generation soft-tissue augmentation material When choosing a biomaterial, there is a strong demand in clinical practice for predictable outcomes. For over 20 years, LifeCell, a leading global medical technology company, has developed inno- vative 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 inflammation. 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 5654100 www.biohorizonscamlog.com AD

| events 50 plus one years into the future An anniversary congress for German implantology Dr Georg Bach, Germany “Everything had been perfectly prepared, but the little matter of a virus got in the way”—with this open- ing statement, the congress president of the German Association of Dental Implantology (DGZI) opened the third Future Congress for Dental Implantology, which took place on 1 and 2 October in Cologne in Germany. Indeed, last year’s 50th anniversary congress, which was planned to be held in the founding German city of Bremen, fell victim to the coronavirus. However, DGZI made a virtue of necessity and celebrated its 50th birthday in the 51st year of its existence—with 50 speakers and about 250 participants (the corona- virus-related regulations did not allow for more). The focus on the first congress day on the Friday was on 75 table clinics, the livestreaming of two surgeries into the conference hall and a highly regarded digital poster presentation. The Saturday was all about science: renowned speakers—the who’s who in German im- plantology—presented outstanding scientific lectures, rounded off with courses for practice staff and a huge dental exhibition with 25 hand-picked industry partners. Future-oriented congress structure In terms of content, the course of events and the structure of the congress, Europe’s oldest professional society deliberately and unquestionably succeeded in breaking new ground, even in its 51st year of existence. The organisers aimed at realising a congress that was future-oriented, even in its organisation, featured attrac- tive content and allowed the presentation of new points of view. Undoubtedly as a consequence of the corona- virus-related restrictions, the congress was somewhat smaller than in previous years. “We are pleased that so many participants came despite the pandemic, but we naturally would have appreciated even greater participa- tion numbers,” said DGZI vice president Dr Rolf Vollmer. “Our overriding focus is on a structural reorientation and, above all, quality.” Dr Arzu Tuna, the DGZI vice president who represents the younger generation of implantologists, added: “The reactions of our col- leagues and their feedback show that we have taken the right path!” 1 Fig. 1: The DGZI board members: Dr Rainer Valentin, Prof. Gyula Takacs, Oliver Beckmann, Dr Navid Salehi, Dr Rolf Vollmer, Dr Elisabeth Jacobi-Gresser, Dr Georg Bach and Dr Arzu Tuna (from left). 42 4 2021

| events 6 7 Fig. 6: The winners of the Implant Dentistry Award 2021 around Dr Arzu Tuna. Fig. 7: The speakers at the MUNDHYGIENETAG 2021: Prof. Thorsten M. Auschill, Prof. Nicole B. Arweiler, Prof. Mozhgan Bizhang and Prof. Stefan Zimmer (from left). Fig. 8: Prof. Daniel Grubeanu (left) and Dr Wolfgang Jakobs. Fig. 9: The table clinics on Friday afternoon: a wide variety of implantology topics were discussed at 25 tables. Fig. 10: Impression of the well-attended table clinics on Friday afternoon. Fig. 11: From left: Katrin Wolters (DGZI secretariat), Dr Torsten Hartmann (DGZI managing director and member of the company management of OEMUS MEDIA AG) and Katrin Mielke (DGZI secretariat). directly for a CBCT scan. A thorough clinical examination remains irreplaceable.” For Prof. Nelson, defining clear rules and adhering to them is a basic prerequisite for successful implant surgery. She then moved on to digital dentistry, paying special attention to data collection as the basis for creating dental restorations with the high- est accuracy of fit. “You can do a lot with a CBCT scan and a digital scan,” she said. According to Prof. Nelson, segmentation is followed by manipulation of the data set. Thereafter, Dr Bach summarised one of the central mes- sages of the three introductory lectures as follows: “Today, we are able to do a lot, but frankly, we have to be able to do a lot.” As part of the first round of the panel discus- sion, both Prof. Nelson and Prof. Ghanaati emphasised that the safe application of their preferred procedures re- quires an intensive and time-consuming training phase. Live surgeries Now it was time to put what had been learned into prac- tice or, rather, to see it put into practice: multi-channel livestreaming of surgical operations into the conference hall enabled the participants to gain a unique and fasci- nating insight into the work of renowned practitioners— in high definition. Live surgeries are a tradition at DGZI congresses. In introducing this novel format, DGZI broke new ground in continuing education at the time. Ham- burg-based specialist Dr Jan Klenke carried out the first surgery, which involved an elaborate recession coverage with an acellular dermal matrix using the tunnel technique. Owing to the dual site (donor and recipient) morbidity, peri- odontal recession coverage employing autologous graft harvesting is not that frequently used these days. How- ever, Dr Klenke proposed a novel therapeutic approach: with the insertion of an acellular dermal matrix, postop- erative morbidity is significantly minimised, since there is no need to harvest an autologous connective tissue graft. 44 4 2021 In the second livestreamed surgery, German Society of Oral Implantology President Prof. Daniel Grubeanu from Trier in Germany presented his ideas, approach and ex- periences in relation to immediate restoration concepts by means of a quite challenging patient case in which an unsalvageable tooth #23 had to be extracted. Immediate implant placement with immediate loading was planned, and he detailed this step-by-step, including planning, im- plant placement and placing the temporary prosthetic restoration. For this purpose, the extracted tooth was shortened and hollowed out and then converted into a soft-tissue stabilising crown. It was impressive to see that the soft tissue was supported in such a way (also using a PRF membrane) that there was no post-traumatic loss whatsoever. His approach was unquestionably technique- sensitive and complex, but the treatment result proved the appropriateness of his procedure. Table clinics and the digital poster presentation For some, it was an unfamiliar sight: instead of the usual rows of seats facing towards the podium, round tables 9

| events 12 13 Fig. 12: CAMLOG dual leadership: Martin Lugert (left) and Markus Stammen. Fig. 13: A highlight was the digital poster presentation, the winners of which were awarded prizes on Saturday afternoon. refined, however, and new options were added. In this con- text, the focus on titanium as the implant material repre- sented an important step, according to Prof. Al-Nawas. The 1990s were distinguished by the development of new im- plant systems, some of which are still on the market today. In the same period, new procedures with predictable results were established, such as the sinus lift. The years after the turn of the millennium were characterised by observations on late complications of implant treatment that are of a bio- logical and technical nature. The speed of osseointegration was significantly increased by the development of new im- plant surfaces, and handling of the gingival cuff was signifi- cantly improved in implants with platform switching, which is vital when it comes to the interaction between gingiva and bone. Prof. Al-Nawas noted that the most recent achieve- ments have included reduced-diameter and extremely short implants, as well as implants made from zirconia. Prof. Christian Gernhardt, a university lecturer from Halle in Germany, continued to push boundaries, introducing himself as “the preserver of teeth who stands in the way of implant dentists”. In his lecture, he outlined when tooth preservation and when implant treatment is the better choice. Decision-making today is increasingly moving in the direction of tooth preservation and root canal therapy mainly owing to new techniques and procedures and industrial developments in the field of endodontics, he explained, and the debate around peri-implantitis has only spurred this on. According to Prof. Gernhardt, root canal therapy is the treatment of an infectious disease and the interface between endodontics and medicine plays a major role in this regard in the sense of individ- ualised medicine. Prof. Gernhardt concluded his lecture by arguing that “tooth preservation always comes first”. Session 2: Novel concepts Following on from his impressive live surgery on the pre- vious day, Prof. Grubeanu once again emphasised the importance of immediate implant placement in daily practice as part of his lecture. He stressed that resorptive processes always occur—regardless of way the socket is filled up. Placement of the implant 1 mm sub-crestally and in an optimal 3D position is a key prerequisite for this implantation protocol. Based on Wolff’s postulates from 1892, Prof. Grubeanu asserted that bone must loaded in order for it to be preserved, substantiating his argu- ment for immediate implant placement and immediate loading. Excellently documented case studies supported Prof. Grubeanu’s conclusion: “Immediate loading and im- mediate implant placement brings joy for both patient and dentist.” Prof. Smeets then defined risk factors in implant dentistry and pointed to the need to consider patients’ vitamin deficiencies, metabolic diseases and medica- tions. He reported that 30% of patients have inadequate vitamin D levels, and he recommends supplementation ahead of major implant procedures, such as sinus lift. He also discussed the consequences of taking proton pump inhibitors—information that was met with great in- terest on the part of the attendees. Dr Wolfgang Jakobs, chairman of the Berufsverband Deutscher Oralchirurgen (professional association of German oral surgeons), sub- sequently elaborated on his main discipline: anaesthetic procedures in implantology. Dr Jakobs noted that psy- chosomatic disorders have increased by over 30% in recent years, and he provided practical tips on local anaesthesia in dentistry, current sedation procedures and general anaesthesia. According to Dr Jakobs, the titrated administration of midazolam has established itself as the gold standard for sedation owing to its high level of safety. Session 3: Soft tissue and its management The question of material was posed by Prof. Florian Beuer, who discussed different materials for implant prostheses. “Very often I see implant-supported restorations with excel- lent implant placement but only average prostheses,” said Prof. Beuer, chairman of the Department of Prosthodon- tics, Geriatric Dentistry and Craniomandibular Dis orders at Charité—Universitätsmedizin Berlin. “That’s really a shame!” He believes that a remedy can be found in the continued exploration of material-specific potential, such 46 4 2021

| news CleanImplant Ambassadors’ Summit 2021 Safeguarding the established—Daring the new On 3 November 2021, members of the scientific advisory board and ambassadors from 16 different nations met for the second CleanImplant Ambassadors’ Summit at Lake Como in Italy. The independent foundation evaluates the quality of implants world- wide in officially accredited testing laboratories and awards its prestigious trusted quality award for implant types with a particu- larly clean surface. Prof. Tomas Albrektsson from the Sahlgrenska Academy in Gothenburg, Sweden, emphasised the necessity and the requirement that implants must not only be sterile when delivered from the factory but also free of foreign particles. Prof. Hugo de Bruyn, University of Nijmegen, Netherlands, presented interim results of a study analysing the presence of metal parti- cles in the peri-implant sulcus fluid in correlation to the respec- tive peri-implantitis status. Madris Kinard Tomes, data specialist and former FDA employee, broadcasted live from Pennsylvania to help interpret the rapidly increasing adverse events of oral implants. Dr Dirk U. Duddeck, CEO and head of research of the foundation, summarised the results of a recent comparative study of more than 100 implants. The participants discussed strategies for supporting manufacturers delivering uncompro- mised medical devices and how to defend the foundation against unjustified legal threads from manufacturers providing implants of inferior quality. Members of the scientific advisory board and CleanImplant ambassadors at the Summit 2021 in Como, Italy. Source: CleanImplant Foundation Dr Elisabeth Jacobi-Gresser joins DGZI board as new education officer With the new election of Dr Quitzke, the DGZI also takes an important step forward in placing younger dentists in important positions of the association and thus ensuring a long-term generational change. Source: DGZI On the day before the 3rd Future Congress and 50th International Annual Congress of the DGZI, the annual general meeting took place. In addition to the reports of the various board members and the pre- sentation and approval of the budget, elections were held and import- ant board positions were reassigned. Dr Elisabeth Jacobi-Gresser, an oral surgeon from Mainz, was elected the new ed- ucation officer to the DGZI board. Dr Jacobi-Gresser has been associated with the DGZI for a long time and has already been intensively involved in the associa- tion’s work in the scientific support of the Lernbuch Implantologie, the online campus and the continuing educational programme. The new training officer was also actively involved in the redesign of the successful im- plantology curriculum. Dr Jacobi-Gresser was and is the DGZI delegate to the guidelines conference of material incompatibility. There was also a change in the position of the DGZI auditor. The long-standing 1st cash auditor Dr Uwe Ryguschik was bid farewell and the Hamburg dentist Dr Marcus Quitzke was elected in his place. President Dr Georg Bach and the entire board of the DGZI welcomed the new election of Dr Jacobi-Gresser and see in the experienced dentist and oral surgeon a confirmation and the possibilities for further develop- ment of the innovative training activities of the DGZI. 48 4 2021 Part of the new DGZI board (from left): Dr Georg Bach, Dr Arzu Tuna, Dr Elisabeth Jacobi-Gresser and Dr Rolf Vollmer.

| about the publisher Congresses, courses and symposia implants ADI Team Congress 2022 26–28 May 2022 Manchester, UK www.adi.org.uk AAID Annual Conference 21–24 September 2022 Dallas, TX, USA www.aaid.com/annual_conference 29th annual scientifi c meeting of EAO 29 September–1 October 2022 Geneva, Switzerland www.eao.org 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 Janine Conzato j.conzato@oemus-media.de Executive Producer Gernot Meyer meyer@oemus-media.de Product Manager Timo Krause t.krause@oemus-media.de Copyright Regulations 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 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. 51st International Annual Congress of DGZI 30 September–1 October 2022 Berlin, Germany www.dgzi-jahreskongress.de Premium Partner: 51T H I N T E R N AT I O N A L ANNUAL CONGRESS OF DGZI 30 September/1 October 2022 Hotel Berlin Central District © Alexandr Bakanov – stock.adobe.com © Alexandr Bakanov – stock.adobe.com 50 4 2021

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