March 2018 The CAMLOG Partner Magazine 17 INNOVATIVE AND INSPIRING THE OR GLOBAL SYMPOSIUM
logo 17 • CAMLOG Partner Magazine • March 2018 EDITORIAL 2 In the last issue of our partner magazine (logo 16), we reported on the renaming of the CAMLOG Foundation to the independent Oral Reconstruction (OR) Foundation. The next logical step was to rename the International CAMLOG Congress the Oral Reconstruction Global Symposium. As early as next year, we will continue the successful CAMLOG congresses with our Global Symposium “The Future of the Art of Implant Dentistry” held in Rotterdam from April 26 to 28, 2018, with more than 55 renowned speakers presenting and discussing the latest scientific findings. After our last congress in Krakow, the bar for the OR Foundation has been set very high. The successful symbiosis of a largely unknown but very impressive venue, instructive workshops, and an exciting scientific program with first-class speakers will be continued with the Oral Reconstruction Foundation Symposium 2018 in Rotterdam. Rotterdam is known as a port and industrial city, less as a tourist attraction or party city, and even less as a venue for an international medical and implant dentistry congress. We will not be able to change that in 2018. However, we would like to point out – with all due modesty – that the Foundation and CAMLOG enjoy an excellent reputation in the professional world not only as implant specialists but also as congress organizers. The highlights of the 2018 Symposium’s scientific program can be found on page 4 and you can look forward to a scientific congress, international exchange, exciting best practices, the cool city of Rotterdam, and an atmospheric get-together. See you in Rotterdam for “The Future of the Art of Implant Dentistry”! Sincerely Dr. Alex Schär Oral Reconstruction Foundation CEO and Member of the Foundation Board Dear readers
logo 17 • CAMLOG Partner Magazine • March 2018 3 logo – the CAMLOG Partner-Magazine • Publication frequency: Twice annually • Publisher: CAMLOG Biotechnologies AG • Margarethenstr. 38 • 4053 Basel Switzerland • www.camlog.com, Editorial team: Oliver Ehehalt (responsible), Michael Ludwig, Anela Mehic, Françoise Peters, Andrea Stix, Ingrid Strobel • Photos: CAMLOG and its licensors • Design: Kerstin Gerhardt, Duc-An Do. Note: Named contributions express the opinion of the author and not necessarily the opinion of the publisher. Names marked with ® are registered trademarks of their respective manufacturers. CAMLOG Biotechnologies AG may market products only upon approval by the competent authorities. Not all products may be available in every country. CONTENT COVER STORY • Top event at the Oral Reconstruction Foundation – April 26 to 28, 2018, in Rotterdam 4 SCIENCE / CLINICAL RESEARCH • Synergy of the elements: The functionality and biocompatibility of biomaterials 8 CASE STUDY • Anterior tooth rehabilitation with implants 12 • Insertion of two-piece ceramic implants with simultaneous GBR 20 • Mem-Lok® RCM in use 23 • Prosthetic restorations with iSy Implants 24 PRODUCTS • The new R-Tx® Abutment System 30 • DEDICAM – Communicating in a network 32 • New aligning tools for the COMFOUR® Abutment System 33 PRACTICE MANAGEMENT • Assessing employees correctly 34 • Personal fulfillment in self-employment 38 EVENTS • 2. CAMLOG start-up days 2018 40 LIFESTYLE • Rotterdam, a bustling port metropolis with high lifestyle potential 42
logo 17 • CAMLOG Partner Magazine • March 2018 COVER STORY 4 And last but not least, the Rotterdam Symposium, “The Future of the Art of Implant Dentistry”, organized by the Oral Reconstruction (OR) Foundation, is intended to help with this by showcasing the current status of theory and practice of this therapy, which is now a standard evidence-based treatment used in countless modern dental practices, and by emphasizing future prospects. The Future of the Art of Implant Dentistry In line with the mission statement of the OR Foundation, the Rotterdam Global Symposium aims to provide training and continuous education in the field of implant dentistry and related fields as well as to promote research projects and basic and applied research. The focus throughout is on academic exchange between universities, practitioners, and industry. The Foundation’s main purpose is to promote both clinical research as well as teaching for the benefit of patients, which constitutes the heart of all its activities. Supporting young talent is a further interest of the OR Foundation. The future prospects of the “Art of Implant Dentistry”, digital networks and workflows, prosthetic Erasmus von Rotterdam (1466–1536), a great European and pioneer of humanism, combined entertainment and philosophy in his socio-critical work “Morias enkomion seu laus stulticiae” (In Praise of Folly) in such a readable manner that this satirical essay remains highly relevant, even in the digital age. “Praise of Folly” unerringly conveys that folly is the true wisdom and imagined wisdom is the true folly. From here, it is not difficult to make the connection to the “Art of Implant Dentistry” and its ongoing viability, as one can well argue that continuous training and further education shows “imagined” wisdom the door while inviting “true” wisdom in. TOP EVENT AT THE ORAL RECONSTRUCTION FOUNDATION VISIT THE GLOBAL SYMPOSIUM FROM APRIL 26 TO 28, 2018, IN ROTTERDAM
logo 17 • CAMLOG Partner Magazine • March 2018 COVER STORY 5 and surgical concepts, and the numerous research projects currently supported by the Foundation will be presented to the professional audience during the symposium. For the first time ever, specialist dental staff will also be included in the symposium. On Friday, parallel to the main program, a professional development course on current topics will be offered. Learning by doing “All theory is gray”, and we all know that people learn quickest and most effectively when they actively participate and get stuck in. This key aspect of learning will be put into practice on April 26, 2018, with a whole range of workshops. A total of twelve workshops will be offered in different languages, including German and English: • 3D implant planning and the CAMLOG® Guide System (English) • The one crown one time concept (English) • Soft-tissue augmentation and corrections for the prevention and management of peri-implant disease (English) • COMFOUR® Concepts – Indications and their implementation (German and English) • Top performance thanks to two-piece ceramic implants (German and English) • Key factors for success with implants in the esthetic zone (German) • The digital implant workflow in routine practice (German) • The special workshop: successful soft‑tissue grafting: a hands-on workshop presented by the Center for Advanced Dental Education. The renowned American speaker Dr. Edward P. Allen will present the tunnel technique methods using allogeneic and xenogeneic graft materials. The minimally invasive procedures demonstrated here – with practical exercises – are state-of-the-art in the microsurgical tunnel technique. The limited number of spots for attending the workshops will be allocated according to the principle of “first come, first served”; please register as soon as possible because our experience from the international CAMLOG congresses shows that demand will be high! THE FUTURE OF THE ART OF IMPLANT DENTISTRY
logo 17 • CAMLOG Partner Magazine • March 2018 COVER STORY 6 The scientific program After the welcoming address and opening of the scientific part of the congress by President Prof. Dr. Irena Sailer and President Dr. Ben Derksen, the kaleidoscope of lectures, presentations, and discussions will begin on Friday, April 27, 2018, in Session 1 with the topic of peri-implant soft tissue management. The crucial factors for stability, aspects of soft tissue transplantation, and the management of defects using minimally invasive techniques will be covered. Session 2 is devoted to the very topical issue of digitization. Have we really already reached the stage where we can speak of complete digitization in dentistry? Or does this sound more like wishful thinking, and we are still faced with numerous challenges? And what are the tangible advantages of digital implant prosthetics? Which new surgical procedures are feasible with the CAMLOG® Implant System, the choice of optimal implantation time, and clever treatment concepts with iSy® to achieve even better esthetic results: all this will be covered in Session 3. Session 4 is devoted entirely to science with the scholarship holders of the OR Foundation presenting the preliminary results of their ongoing research. In Session 5, the authors of the selected posters will each present their work in eight-minute short presentations. The motto of the evening is: “Let’s celebrate King’s Day!“ – In the spectacular ambience of the Gothic Laurenskerk, the only remnant of medieval Rotterdam, the guests will be spoiled with food and drink as if they were King Willem Alexander himself, who celebrates his birthday exuberantly with the entire population on this day, “Koningsdag”. A live band plus DJ will provide the appropriate festive atmosphere. The second day of the scientific program will start on Saturday, April 28, 2018, with Session 6 providing an informative comparison of the biological properties and tissue integration ability of “innovative” zirconium dioxide and “classic” titanium implants. In particular, the indications for CERALOG®, the CAMLOG ceramic implant system, will be the subject of the presentations, rounded off by the presentation of the four-year results with CERALOG® Implants. The fundamental question as to when and where “white roots” have their right to exist is the final part of Session 6. As a result of demographic developments in industrialized countries, dentistry must also deal with the issue of aging populations. What are our options for edentulous patients? The “facts & fiction” of this topic, restorative concepts, and options for immediate restoration will be discussed in Session 7. This will be followed by the award ceremony of the Foundation Research Prize and the presentation of the awards for the winning posters. At the end of the symposium, the scientific program in Session 8 will focus on complications and failures. Based on some practical cases we want to jointly learn from problem cases. To ensure that the participants learn even more effectively,
PROGRAM OVERVIEW logo 17 • CAMLOG Partner Magazine • March 2018 The scientific program is divided into eight sessions, each of which ends with a joint discussion: SCIENTIFIC PROGRAM – DAY 1 • SESSION 1 Soft tissue management and dental implants • SESSION 2 Digital workflow in implant dentistry • SESSION 3 Treatment concepts • SESSION 4 Primary results of research supported by the Oral Reconstruction Foundation • SESSION 5 Poster presentations SCIENTIFIC PROGRAM – DAY 2 • SESSION 6 Are ceramic implants an alternative to titanium? • SESSION 7 Restorative concepts • SESSION 8 Problems, complications and failures – what can we learn from them? COVER STORY 7 1 Dutch for bicycle this last program item of the symposium is designed to be interactive, and by using smartphones the audience can actively participate in the debate, ask questions, and present arguments. Comments on the current activities of the OR Foundation as well as a glimpse of the future will round off the symposium and help ensure that all participants can return home certain that they have experienced what can justifiably be called “The Future of the Art of Implant Dentistry” in Rotterdam. What else needs to be said It goes without saying that the OR Foundation in Rotterdam 2018 not only offers a high-class symposium at a favorable price-performance ratio but it also provides an attractive partner program: • A day in Delft: historic city center, idyllic canals, the world-famous porcelain factory; all definitely worth a visit… • Rotterdam Harbor Cruise: a harbor must be explored from the element that brings it to life, the water. A discovery cruise through Europe’s largest trading port in a specially chartered barge. • Rotterdam by bicycle: what could be more Dutch than riding through Rotterdam on a guided tour with “fiets”1? And the boat trip by water taxi could hardly be more typical of the city. • T he architectural capital of the Netherlands: that’s what insiders call Rotterdam. Our guided tour through the city with emphasis on its architecture is a must for those interested in architectural history. Further information can be found in the brochure enclosed with this issue of “logo” and on the Internet at: www.orfoundation.org/globalsymposium. You can register directly online. The OR Foundation and CAMLOG as Founding Partner look forward to welcoming you!
SCIENCE / CLINICAL RESEARCH logo 17 • CAMLOG Partner Magazine • March 2018 8 Numerous factors play a role in the selection of a suitable biomaterial. The reactions triggered by the material used are related to its biocompatibility as well as its chemical, physical, and mechanical properties. The combination of these properties and the ability of the material to augment or replace the body’s own tissues determine its quality. SYNERGY OF THE ELEMENTS: THE FUNCTIONALITY AND BIOCOMPATIBILITY OF BIOMATERIALS Structure and composition of the biomaterial The contact surface of the biomaterial and both the humoral and cellular components of the body interact in many different ways that are influenced by the topography of the material (Fig. 1). Bones and soft tissue are structures that are not easy to replicate. The functionality of a biomaterial results from the sum of its biological interactions [1]. If functionality meets biocompatibility, this leads to a biomaterial that effectively supports tissue regeneration. When choosing a biomaterial, the central question is how the implanted material interacts with the surrounding tissues. For example, sintered bone replacement materials tend to be absorbed relatively quickly [2]. Excessively rapid resorption, however, can lead to a weakening of the newly formed bone, which can lead to complications. In contrast, MinerOss® X and MinerOss® XP have a slow absorption rate [3]. This allows substantial new bone formation. From a biological point of view, the ideal bone graft material should promote the formation of a stable blood clot because granulation tissue will then grow around the bone. This soft callus is subsequently converted into woven bone and then to lamellar bone. Ultimately this is referred to as remodeling [4]. The biomaterial should be both functional as well as biocompatible and promote the healing process. From a clinical point of view, the bone replacement material must therefore meet several requirements: • Porosity, as well as pore size and interconnectivity, are decisive factors for the use of bone replacement materials. The material has to provide a three-dimenFig. 1: The inorganic porcine bone mineral matrix of MinerOss® XP in 75-fold and 25-fold SEM magnification. Image courtesy of Dr. S-T Li.
logo 17 • CAMLOG Partner Magazine • March 2018 9 SCIENCE / CLINICAL RESEARCH sional framework for the formation of new bone. The properties of the framework in turn influence the success of the bone graft material (Fig. 2). • Autologous bone is still the gold standard but it is associated with higher costs and longer treatment times, and it requires an additional surgical procedure which can lead to increased donor site morbidity. Potential complications should be reduced [2,5]. • F urther aspects are the handling of the material – the easier the better for the clinician – as well as the cost efficiency. • A side from these factors, it is vital to bear in mind that bone augmentation surgery is often performed as part of a dental implant surgery. Therefore, the biological potential of the bone graft material should also be taken into account [1]. Biological interactions In two animal studies Li et al. [6] compared two bone graft materials of animal origin – isolated porcine cancellous bone (PCA/MinerOss® XP) (see Fig. 1) and commercially used carbonate apatite of bovine origin. The authors concluded that both materials in the intraoral and orthopedic bone defect functioned as an osteoconductive matrix that promoted bone regeneration. A study conducted by Roberts et al. [1] showed a correlation between the behavior of progenitor cells and the composition of the material. The study showed that the calciumphosphate ratio and cell attachment play a decisive role in new bone formation (Fig. 3). In another study, Yuen et al. [7] showed that the dense Mem-Lok® RCM Fig. 2: MinerOss® X: the bimodal pore structure. Fig. 3: Of the compared materials, MinerOss® X generates more new bone. 30 25 20 15 10 5 0 Number (%) 0.1 1.0 Pore diameter (μm) Pore diameter (μm) 200 600 The capillary effect is created by the mesopores and leads to fast uptake of the material in the blood. The interconnected macropores enable the migration of cells and blood vessels and the integration of the particles, which allow effective osseointegration. A B C D E 14 12 10 8 6 4 2 0 Bone volume (%)
SCIENCE / CLINICAL RESEARCH logo 17 • CAMLOG Partner Magazine • March 2018 10 membrane improves mechanical stability (Fig.4). Li et al´s [8] preclinical tests using Mem-Lok® Pliable have shown that the tensile strength is three times higher than with a comparable collagen membrane. Furthermore, the same tests show a lower degree of inflammation and fewer foreign body reactions. Clinical Application Comparative studies [3,5] have shown that choosing a bone graft material can be difficult. The needs and preferences of the clinician play as important a role as the needs of the patient. In a histomorphometric human study, Garnieri et al. [3] compared and evaluated the bone reactions of a bovine (MinerOss® X) and porcine xenograft (MinerOss® XP) that were inserted into adjacent extraction sockets. The histological results suggested that both materials were both biocompatible and osteoconductive. Gonshor and Tye [5] evaluated the behavior of inorganic xenogeneic bone graft materials (MinerOss® X and MinerOss® XP) in 10 patients with biopsies performed after 6 months. The results showed that the newly formed vital bone was in close contact with the biomaterial (Fig. 5). Conclusion The appropriate bone graft material has to be selected based on knowledge of both its properties and also its clinical outcome. The ultimate goal is predictable results, clinical success and reproducibility. The xenogeneic bone replacement materials MinerOss® X and MinerOss® XP promise the best possible “synergy of the elements”. Fig. 4: Biomechanical strength of the membrane. 400 350 300 250 200 150 100 50 0 Tensile strength (g) Comparable collagen membrane available on the market 350 ± 80 74 ± 10 Mem-Lok® RCM Histology of the alveolar ridge with bovine bone replacement material MinerOss® X (Trichrome stain X 10): blue arrow = bone replacement material; yellow arrow = vital bone; red arrow = newly formed bone (osteoid) 100 micrometers Histology of the alveolar ridge with bovine bone replacement material MinerOss® X (Trichrome stain X 20): yellow arrow = vital bone; red arrow = newly formed bone (osteoid) 50 micrometers Histology of the alveolar ridge with porcine bone replacement material MinerOss® X (Trichrome stain X 20): yellow arrow = vital bone; red arrow = newly formed bone (osteoid) 50 micrometers 100 micrometers Histology of the alveolar ridge with porcine bone replacement material MinerOss® XP (Trichrome stain X 10): blue arrow = bone replacement material; yellow arrow = vital bone; red arrow = newly formed bone (osteoid) Fig. 5: Histological examinations of the alveolar ridge with the xenogeneic bone replacement materials MinerOss® X and MinerOss® XP six months postoperatively – integration and bone healing. Courtesy of Renzo Guarnieri MD DDS
logo 17 • CAMLOG Partner Magazine • March 2018 11 [1] Roberts SJ Geris L, Kerckhofs G, Desmet E, Schrooten J, Luyten F. The combined bone forming capacity of human periosteal derived cells and calcium phosphates. Biomaterials 2011;32: 4393-405. [2] Figueiredo M, Fernando A, Martins G, Freitas J, Judas F, Figueiredo H. Effect of the calcination temperature on the composition and microstructure of hydroxyapatite derived from human and animal bone. Ceramics International 2010;36(8): 2383–93. [3] Guarnieri R, Devilliers P, Grande M, Stefanelli LV, Di Carlo S, Pompa G. Histologic evaluation of bone healing of adjacent alveolar sockets grafted with bovine- and porcine-derived bone: A comparative case report in humans. Regenerative Biomaterials 2017; 1–4 doi: 10.1093/rb/rbx002. [4] Schindeler A, McDonald MM, Bokko P, Little DG. Bone remodelling during fracture repair: The cellular picture. Semin Cell Dev Biol. 2008; 19(5): 459-66. [5] Gonshor A, Tye C L. evaluation of anorganic bovine bone mineral in post-extraction alveolar sockets: A case series. J Osseointegration, 2010;1(2):25-30. [6] Li ST, Chen HC, Yuen D. Isolation and characterization of a porous carbonate apatite from porcine cancellous bone. Science, Technology, Innovation, Aug. 2014: 1–13. [7] Yuen D, Junchaya C, Zuchich G, Usreich JB, Lin HB, Li ST. A resorbable, reconstituted type I collagen membrane for guided tissue regeneration and soft tissue augmentation. Society for Biomaterials. 2000; 1228. [8] Li ST, Yuen D, Martin D, Lee NS. A comparative study of a new porcine collagen membrane to BioGide®. Science, Technology, Innovation. 2015;February:1–5. LITERATURE Periodontal defects Extraction sockets Horizontal ridge augmentation Sinus augmentation Vertical ridge augmentation Dehiscence defects Block grafting Immediate implantation MinerOss® X Cancellous a aaaaaaaa aa a a MinerOss® X Cortical MinerOss® X Collagen a aa a a a MinerOss® XP Cancellous aa aa aaaaa a aa a aa Mem-Lok® RCM aa aaa aaa aa aa aaa a Mem-Lok® Pliable aaa aa aa aaa a* aa a asuited aa well suited aaa very well suited Depending on the indication, mixing with Cancellous is recommended. Strong dense structure of tissue fibers. Suitable for additional stability of the graft and for resorption protection. Indication-related application options SCIENCE / CLINICAL RESEARCH
logo 17 • CAMLOG Partner Magazine • March 2018 12 Dr. Hajo Peters, Vienna IMPLANT-BASED ANTERIOR TOOTH REHABILITATION WITH MAXIMUM INTERDISCIPLINARY CONCEPT Fig. 1: Clinically normal initial situation five years after endodontic restoration of tooth 11. Fig. 2: Radiological 3D representation of the upper jaw defect with erosion in the incisive foramen (axial layer) as well as loss of the labial compact bone in sagittal reconstruction. This case study describes the one-year surgical and prosthetic therapy, the special dental features as well as the current one-year follow-up of a 24-year-old patient who was treated with an anterior tooth implant (CAMLOG® SCREW-LINE). In order to meet the demands of the patient as a professional musician both functionally and esthetically, the Viennese esthetic protocol developed by MDT Christian Koczy, Dr. Otto Exenberger, and Dr. Hajo Peters was used, which is based on the close interdisciplinary approach between dental technician, prosthodontist, and surgeon. This protocol is a maximum concept which will be presented in all its details. The documentation describes the diagnosis and clinical procedure from anterior tooth removal in the maxilla with extensive cystectomy, via the temporary restoration, reconstruction of the alveolar process, implant positioning, and augmentation of the soft tissue through to shaping and restoration using individual ceramic prosthetics. Case history and clinical examination During a routine dental examination and subsequent diagnosis by means of panoramic tomography, an extensive radiological translucency around the anterior maxilla was detected in the patient, who was 22 years old at the time of the examination (2014). According to initial information provided, the patient was free of symptoms and had a normal oral situation for both soft tissue and hard tooth substance (Fig. 1). The patient is a professional musician (saxophonist) and specific questioning with regard to the suspect anterior tooth region finally resulted in the patient mentioning an occasional sensitivity under the upper lip, which the patient himself attributed to daily practice with the woodwind instrument and a possible overstressing of the lip musculature but he had never considered this to be due to an illness. [1–2] Endodontic treatment of tooth 11 five years previously was revealed in the case history. The root canal treatment was necessary because of a mechanical-traumatic dislocation of the tooth, which, after initial splinting and subsequent sensitivity checks, exhibited no positive vitality and thus no re-innervation/ vascularization of the damaged pulp. To better assess the suspected apical pathology, a three-dimensional X-ray diagnosis was performed, which showed the full extent of the bone defect: a sharply defined osseous translucency of approx. 2×3×1 cm in the frontal alveolar process of the maxilla with bony erosion to the incisive foramen and close relation to the endodontically treated tooth 11. Extensive vestibular loss of the alveolar process was dominant in the sagittal section (Fig. 2). Surgical rehabilitation The radiological findings correlated with the almost complete fenestration of the labial alveolar bone in the subsequent surgical therapy (Fig. 3). Due to the minimally invasive oriented tooth extraction using a piezosurgery device (mectron, Cologne) to separate the periodontal anchorage CASE STUDY
logo 17 • CAMLOG Partner Magazine • March 2018 13 of the tooth, a cervical bone bridge was retained coronal to the defect. The previous formation of a vestibular pedicle mucoperiosteal flap provided an overview of the pathological process on the one hand and protection for the adjacent papillae on the ohter hand. The cystectomy revealed an infected radical cyst which was later histologically confirmed, and which could be enucleated in full. The clinical dimensions of the extracted cyst tissue are shown in Figure 4. To stabilize the clot, a collagen cone (Parasorb, Resorba, Nuernberg) was inserted into the socket without applying pressure (Fig. 5). Since the volume of the bone resorption had already reached such an extent at the time of tooth extraction, adequate reossification of the defect was not expected. This applied in particular to the cancellous alveolar process of the maxilla compared to similar defects in the mandible with a broad cortical bone and higher regeneration potential. For this reason, and because of the presence of an infected cyst, immediate filling of the defect using a socket preservation technique was omitted. In primary wound care, the main objective was therefore soft tissue coverage and healing of the defect to achieve optimal conditions for surgical re-entry for bone augmentation after about 6 weeks. The post-operative course was accompanied with systemic antibiotic treatment (amoxicillin) and a local chlorhexidine gluconate rinse (0.2%) until the sutures were removed after one week. Soft tissue healing and temporary restoration The clinical findings of the anterior tooth segment revealed the expected optical defects after completion of soft tissue healing. Both vertical and transversal losses were apparent when the patient returned. On the other hand, the wound healing was free of irritation, which included complete soft tissue closure of the extraction socket and an inflammation-free gingiva and socket mucosa (Fig. 6). Throughout the entire treatment, starting with tooth extraction and continuing through to the insertion of the implant crown, the patient wore the temporary thermoformed splint (Fig. 7), which was functionally and esthetically acceptable to the patient. To ensure undisturbed soft tissue healing, it is essential to use a temporary restoration which does not apply pressure to the mucous membrane tegument. This implies the use of either splints or adhesive bridges fastened using the acid etching technique. The latter offers the advantage of a greater wearing comfort for the patient (no impairment of the occlusion), however, it does require time-consuming removal and post-operative reattachment to the adjacent teeth for all subsequent treatment steps. In this case, the patient’s needs have to be discussed and taken into account accordingly. Our patient opted for an easy-to-use temporary splint that could be adapted or replaced during the course of the therapy. Bone grafting As was to be expected at the time of the cystectomy and tooth extraction, the extensive bone defect was revealed when the site was reopened, and this had increased even further due to the resorption of the painstakingly preserved cervical bone bridge (Fig. 8). Once again, this shows that any expectations about bone preservation after tooth extraction in the region of the tooth-supporting Fig. 3: Intraoperative site after tooth extraction and cystectomy. Delicate preserved cervical bone bridge. Fig. 4: In toto enucleated radical cyst from the apical region of tooth 11. Fig. 5: Clot stabilization in the cyst defect and the extraction socket using xenogeneic collagen cone. Fig. 6: Clinical defect situation six weeks after tooth extraction. Fig. 8: Expansion of the bony defect with complete resorption of the buccal bone wall prior to bone augmentation. Fig. 7: Thermoformed splint as a long-term temporary restoration throughout the entire treatment. CASE STUDY
logo 17 • CAMLOG Partner Magazine • March 2018 14 alveolar process are uncertain and do not allow a reliable prognosis despite a careful and minimally invasive surgical technique. For this reason, it is essential to explain the necessity of bone augmentation to patients before tooth extraction and to inform them about the different clinical measures and treatment options for regeneration. Augmentation of the bony hard tissue defect was performed using two autologous bone blocks (Fig. 9). These were harvested under local anesthesia in the region of the right ascending mandible. In order to ensure maximum adaptation of the vertical block inserted in the area of the extraction socket, the block was extracted with a trephine bur and the recipient site was reshaped using a milling machine (Fig. 10) with a corresponding diameter. Oro-vestibular oversizing of the augmentation area is necessary in order to compensate for subsequent resorption during the healing phase. Due to the insufficient coverage of the vertical defect, a second block had to be applied to the remaining apical defect in the form of a bone cover. The defect was first filled with a mixture of autologous chips and xenogeneic particulate bone replacement material (Bio-Oss, Geistlich, Wolhusen). Both blocks were fixed to the underlying alveolar process with osteosynthesis screws (Ustomed, Tuttlingen) in a stable position. The combination of two blocks shown illustrates the legitimacy of the two established bone flap augmentation procedures with distance osteogenesis and congruent block adaptation with contact osteogenesis. In order to level the transitions between bone blocks and the outer curve of the alveolar process and as resorption protection, particulate bone graft material was coated and covered with a resorbable collagen membrane (Bio-Gide, Geistlich, Wolhusen) as part of guided bone regeneration (Fig. 11). Implantation The drilling template was fabricated in the laboratory in preparation for the implantation, which was performed approximately four months after bone block augmentation (Fig. 12). For this purpose, a model and a thermoform film of the initial state prior to tooth extraction were created in which the assembled drill sleeve was inserted according to the positioning and axial direction of the original tooth 11. Wherever possible, initial models should be prepared before tooth extraction in order to provide sufficient anatomical references for the further steps. Otherwise, the drill sleeve is primarily aligned towards the later prosthetic insertion direction under consideration of the adjacent neighboring teeth. Since the technician was aware that maximum bone reconstruction of the implant bed was planned, it was possible to fabricate the drilling guide according to purely anatomical and prosthetic design features without having to take into account any bone deficits which were anyway difficult to detect in the model. Figure 13 shows the orthopantomogram with inserted drilling template and radiopaque sleeve as well as the two osteosynthesis screws in situ. The frontal view of the clinical situation four months post-augmentation is shown in Figure 14. In this context, the improvement in the vertical alveolar ridge dimension in comparison to Figure 6 is of particular importance. The Fig. 15: Occlusal view corresponding to Fig. 14 with rehabilitated alveolar ridge width. Fig. 16: Opened augmentation area with osteosynthesis screws in situ. Fig. 17: Template-guided implant pilot hole after removal of the osteosynthesis screws. Fig. 10: Trephine drill for bone block removal and ablative bur for preparing the recipient site with a corresponding diameter. Fig. 11: Collagen membrane covering of the augmentation site as part of guided bone regeneration. Fig. 9: Bone blocks fixed with osteosynthesis screws for augmentation (horizontal block: bone cover method; vertical block: sitecongruent block). CASE STUDY
logo 17 • CAMLOG Partner Magazine • March 2018 15 Fig. 12: Drilling template in thermoforming process with prefabricated sleeve with positioning and axial direction aligned with the original tooth. Fig. 18: Occlusal view of the inserted implant with very well regenerated vestibular ridge contour. Fig. 21: Palatal pedicle connective tissue graft for soft tissue augmentation. Fig. 13: Orthopantomogram with drilling template before removal of osteosynthesis screws and implantation. Fig. 19: Frontal view with paracrestal implant shoulder at maximum vertical bone regeneration. Fig. 14: Frontal view with clinical findings after four months of healing of the block grafts. Fig. 20: Orthopantomogram for radiological evaluation after implantation 11. occlusal view (Fig. 15) already showed clinically a physiological alveolar ridge transversal, which gave rise to the hope of corresponding bone regeneration. The surgical field was opened using a mucosal split flap to allow the possibility of simultaneous soft tissue augmentation after implantation. After preparation of the two-layer vestibular flap, bone regeneration of the previous defect could be easily assessed (Fig. 16). The bone blocks were fully integrated and showed both excellent transverse regeneration as well as maximum vertical regeneration. After removing the osteosynthesis screws, template guided pilot drilling was performed (Fig. 17). Extension of the drilling shaft up to the diameter of final form drilling was performed freehand. After completion of the bony preparation, the drilling shaft is to be probed for an intact bony boundary on all sides with a blunt button probe in the form of bone mapping. This rules out perforations to the nasal floor and a possible need for subsequent augmentation – especially vestibular – can be determined. Subsequent augmentation was not necessary in this case. The manually inserted implant (CAMLOG® SCREW-LINE) was surrounded in the occlusal view by a sufficiently dimensioned and well perfused vestibular bone wall. The curvature of the jaw arch was also completely restored (Fig. 18). The frontal view shows the crestal bone profile and the paracrestal implant shoulder position as well as the positioning of the implant in mesiodistal direction while maintaining the anatomical minimum distances to the adjacent teeth (1.5 to 2 mm), so that the subsequent formation of papillae could be ensured with sufficient nutrition of the interdental bone (Fig. 19). In this case, a 4.3 mm wide and 13 mm long CAMLOG® SCREW-LINE implant was inserted and radiologically documented after surgery (Fig. 20). In order to increase the volume of the periimplant gingiva, simultaneous soft tissue augmentation with a palatal pedicle connective tissue graft had already been performed with the placement of the implant. For this purpose, the paramarginal palatal, subepithelial prepared tissue was driven into the tooth gap over the anterior pedicle pole (Fig. 21) and fixed with the previously prepared periosteum of the split flap with an absorbable suture. This CASE STUDY
logo 17 • CAMLOG Partner Magazine • March 2018 allowed the mucosal portion of the split flap to be closed without tension, resulting in a significant tissue increase with complete plastic coverage of the implant region. The connective tissue transplanted in this manner brings with it the genetic information for the long-term formation of keratinized gingiva at the implantation site. Postoperatively, there is often swelling present which, in combination with soft tissue augmentation, causes a visual reduction in the clinically visible adjacent crowns (Fig. 22). It is essential to inform the patient about this and to adjust the temporary restoration accordingly. After ten weeks, the new soft tissue situation had been fully established (Fig. 23). This also corresponded to the initial state for the subsequent implant prosthetic measures for soft tissue shaping. At this point in time, all hard and soft tissue augmentation treatment steps have been completed. It must be ensured that the soft tissue even has an oversized reconstruction if possible, to ensure sufficient reserves for soft tissue shaping. Gingiva forming Following the implantation, the intraoperative impression of the implant was taken with an individual tray (Fig. 24). This served as the basis for the fabrication of an individual healing cap (Fig. 25). This healing cap is milled from either plastic or zirconium oxide, based on the scanned prosthetic set-up of the tooth to be replaced, and bonded with a temporary abutment. The healing cap, inserted after surgical exposure using a displacement procedure, protrudes about 2 mm beyond the gingival margin and has its widest extension at the emergence point (Fig.26). The objective of this individual healing cap is to shape the emergence profile of the subsequent implant abutment in the gingiva. For this purpose, the axial incision must optimally replicate both the orovestibular and the mesiodistal dimensions of the crown anatomy at the gingival level (Fig. 27). We consider the introduction of the concept of an individual healing cap to be the decisive link in our esthetic treatment protocol between the surgical rehabilitation of the implant site and the prosthetic replica of an anatomical crown. The retention time of the individual healing cap in the mouth for gingiva forming varies from individual to individual and between eight to twelve weeks can transpire before the implant impression can be taken. Individual abutment and implant crown After removing the individual healing cap, it was necessary to ensure that the delicate gingiva funnel was not deformed while the impression of the implant was being taken. For this reason, a prefabricated impression post was wrapped in lowviscosity plastic and hardened in the gingival funnel (Fig. 28). The model thus obtained reflects the implant situation with the gingival emergence profile of the future crown at the same time. On this basis, an individual abutment was fabricated that fulfils three essential tasks: color-coded individualization of the tooth core; final manipulation of the gingiva through varying subgingival design; maximum basal width comparable to a prepared natural tooth crown with approx. 1 mm subgingival crown margin (Fig. 29). Our master casts are always fabricated Fig. 23: Ten weeks after soft tissue augmentation. Initial situation for tissue shaping. Fig. 24: Intraoperative implant impression with individual tray. Fig. 22: Postoperative swelling one week after soft tissue augmentation. Fig. 28: Implant impression with customized impression post for stabilization of the gingival funnel. Fig. 29: Individual abutment in situ. Fig. 30: Ceramic veneered zirconium oxide crown on the master cast without gingival mask. 16 CASE STUDY
logo 17 • CAMLOG Partner Magazine • March 2018 without gingiva masks, as we want to transfer the surgically and prosthetically elaborately formed gingival margin exactly as a defined limit to the model, a purpose for which resilient gingival masks are not indicated (Fig. 30). The zirconium crown framework was milled (Cercon ht light, Degudent, Hanau) and veneered with ceramic materials (Cercon ceram Kiss, Degudent, Hanau). By powdering neutral, highly-fluorescent ceramic materials onto the framework, all the necessary light properties can be imparted with minimal layer thickness. Shade selection beforehand in the laboratory is of crucial importance because up to 20 shades and mixed hues are required for the individual esthetic design of anterior tooth crowns (Fig. 31). The shade nuances were determined directly on the patient and transferred into an esthetic layering scheme (Fig. 32). [3] The crown fabricated in this way was cemented and the clinical gingival conditions were documented with photos as a reference after one month in situ (Fig. 33). The clinical follow-up was performed after 15 months (Fig. 34): The result of the esthetic rehabilitation with a single-tooth crown implant after bone and soft tissue regeneration and soft tissue forming is reliably stable and the patient is fully satisfied with the esthetics and function. Discussion/ Conclusion The present patient case describes the detailed course of treatment of an esthetic anterior tooth rehabilitation after tooth loss, loss of parts of the alveolar process due to an extensive cyst, and the gradual regeneration of hard and soft tissue as a prerequisite for implant surgery and prosthetic therapy. The sequence of treatment steps, which can extend over one year, must be strictly coordinated in terms of time in order to eliminate delays and to allow sufficient time for the biological regeneration processes in particular. This requires applying a comprehensive therapy plan in the form of a standardized protocol, which sets milestones for the treatment, which are then adapted to the individual patient case. For this purpose, the surgical, prosthetic and dental work steps are worked out in an interdisciplinary conference and, after Fig. 25: Individual healing cap on the model. Fig. 31: Individual shade guide for shade selection for the patient. Fig. 34: Follow-up after 15 months shows perfect biological and prosthetic conditions. Fig. 26: Frontal view of the individual healing cap in situ. Fig. 32: The patient’s layering scheme for shade customization of the implant crown. Fig. 27: Occlusal view of the individual healing cap with anatomically optimal emergence profile. Fig. 33: Inserted implant crown after one month. 17 CASE STUDY
logo 17 • CAMLOG Partner Magazine • March 2018 reaching a consensus, discussed in a joint meeting with the patient where they are informed about the various options. [4–7] Our patient was informed from the very beginning about the treatment steps to be carried out. As a saxophone player, complete functional rehabilitation was of fundamental importance to him, which is why alternative treatment options were eliminated in the preliminary discussion with the patient [1–2]. The consent of the patient to such a maximum concept, as presented here, requires the treatment team to make additional planning efforts, to ensure perfect interdisciplinary communication, and to maintain a mutual understanding of the disciplines involved. Finally, the technical treatment milestones, which we consider essential for the application of the Viennese esthetic protocol, should be summarized: • D etailed jaw models and photo documentation of the initial situation (data back-up) • M inimally invasive tooth extraction • A pathogen-free surgical field • 3 D hard tissue reconstruction • P ressure-relieved temporary restoration • P rosthetically oriented implant position (drilling template) • S ufficient soft tissue reconstruction • I ndividual gingiva forming • Individual abutment • S hade selection with layering scheme • Z irconium oxide framework with veneer My thanks to the entire team for their interdisciplinary cooperation. Special mention goes to my colleague Dr. Otto Exenberger, for his involvement in the prosthesis, as well as to the master dental technician Christian Koczy, both from Vienna. [1] Prensky DH, Shapiro GI, Silverman SI. Dental diagnosis and treatment for musicians. Special Care in Dentistry 1986;6(5):198-202 [2] Yeo DKL, Pham TP, Baker J, Porter SAT. Specific orofacial problems experienced by musicians. Review. Australian Dental Journal. 2002;47(1):2-11 [3] Witzel T. Klinische Untersuchung computergestützter Zahnfarbbestimmung im Vergleich zu visueller Abmusterung durch das menschliche Auge. Clinical survey of computer-aided tooth color determination as compared to visual detection by the human eye. 2005. Dissertation Universität Würzburg, Deutschland, urn:nbn:de:bvb:20-opus-11549 [4] Simeone P, De Paoli C, De Paoli S, Leofreddi G, Sgró S. Interdisciplinary treatment planning for single-tooth restorations in the esthetic zone. J Esthet Restor Dent. 2007;19:79-89 [5] Yao J, Li M, Tang H, Wang PL, Zhao YX, McGrath C, Mattheos N. What do patients expect from treatment with dental implants? Perceptions, expectations, and misconceptions: a multicenter study. Clin Oral Impl. Res. 2017;28:261-271 [6] Deeb G, Wheeler B, Jones M, Carrico C, Laskin D, Deeb JG. Public and patient knowledge about dental implants. J Oral Maxillofac Surg. 2017;75(7):1387-1391 [7] Jivraj S, Corrado P, Chee W. An interdisciplinary approach to treatment planning in implant dentistry. British Dental J. 2007;202(1):11-18 LITERATURE 18 Dr. Hajo Peters Dr. med. dent. Hajo Peters is a dentist and oral surgeon with his own private practice in Vienna. His clinical specialties include the complex implant-based rehabilitation in the anterior tooth region. After his studies at the Private University of Witten/Herdecke (state examination 1999), Dr. Hajo Peters was a research assistant in the Faculty of Dentistry for a further two years. In 2001 he obtained his doctorate with summa cum laude and moved to the Charité Berlin, where he worked for five years in the Department of Oral Surgery. In 2004, after three years of university specialist training, he was appointed an oral surgeon. From 2007 to 2010 he was a partner in a joint oral surgery practice in Filderstadt near Stuttgart. Since 2010 he has been running the specialist practice mundgerecht in Vienna. Dr. Peters is a national and international speaker and author. Together with Prof. Jackowski from the University of Witten/Herdecke and Prof. Hölzle from the University of Aachen, Dr. Hajo Peters is the editor of a surgical clinic guide, which was published by the Springer-Verlag in August 2017 and is already an Amazon bestseller. Its predecessor (published in 2007 by Elsevier-Verlag) is considered standard literature. Memberships: • German Association for Implant Dentistry (DGI) • German Association for Dental and Oral Medicine (DGZMK) • Working Group for Maxillofacial Surgery (AGKi) • Working Group for Forensic Odontostomatology (AKFOS) • Working Group Oral Pathology and Oral Medicine (AKOPOM) • International Association of Student Clinicians- American Dental Association (SCADA) Contact details mundgerecht Specialist practice for oral health Dr. Hajo Peters Weimarer Strasse 5/21 A-1180 Vienna www.mundgerecht.at AUTHOR CASE STUDY
logo 17 • CAMLOG Partner Magazine • March 2018 Sophisticated two-piece construction with innovative abutment solution, ceramic-specific design and high-tech 'Ceramic Injection Molding' manufacturing process – that is CERAMIC EXCELLENCE. · Dual surface texture: Osseointegration and soft tissue attachment · Two-piece design, screw-retained reversible prosthetic solutions · Ceramic-specific design with Hexalobe connection · Innovative PEKK abutment with stress shield reduction · Ivory colored for highly esthetic restorations · 100 % quality control Become a CERAMIC EXCELLENCE partner now www.camlog.com/en/implant-systems/ceralog INNOVAT VE CERAMIC-SPECIFIC DESIGN WITH HEXALOBE CONNECTION
logo 17 • CAMLOG Partner Magazine • March 2018 20 Dr. Alexander Volkmann, Jena INSERTION OF TWO-PIECE CERAMIC IMPLANTS WITH SIMULTANEOUS GBR – A SUCCESSFUL PROCEDURE WITH COORDINATED COMPONENTS Fig. 3: Mixing the bone augmentation material MinerOss®-X with autologous bone chips and autologous blood of the patient. Edentulous gaps in older patients are usually associated with atrophied alveolar ridges. In such cases, bone augmentation measures are usually required in order to align the implants correctly for the prosthesis and thus maintain function and esthetics over the long term. Membrane-protected Guided Bone Regeneration (GBR) is an extensively documented procedure for the restoration of sufficient and stable bone volume [1,3]. Inorganic alloplastic granules such as MinerOss®-X and resorbable membranes such as Mem LOK Pliable (both BioHorizons from CAMLOG, Wimsheim) have a proven track record and are the clinical standard. Implant prosthetic restorations with ceramic implants require a strictly planned and considered procedure in all respects. This applies not only to the selection of a suitable implant system but also to the use of a suitably matched material for bone augmentation. Only an augmentation material with an absorption rate more or less equal to bone growth results in the desired bone regeneration by essentially degrading completely, allowing newly formed bone to attach to the implant surface and produce the necessary BIC. The augmentation material is stabilized with an absorbable barrier membrane. The bone augmentation material MinerOss®-X from BioHorizons (CAMLOG, Wimsheim) is extracted from bovine bone and has a mineral structure similar to that of human hard tissue. During the production process, all protein structures are removed, leaving behind a de-proteinized inorganic matrix with no cellular or organic components. The resulting hydroxyapatite skeleton has a purely osteoconductive effect. As the formation of new bone is linked to blood vessels, endothelial cells and preosteoblasts can grow or revascularize into the framework from adjacent tissue (angiogenesis and ossification). Implantation with simultaneous GBR The atrophied bone is exposed using a mucoperiosteal flap and the implantation is performed according to the protocol. Three CERALOG® Hexalobe ceramic implants, each with a diameter of 4 mm, were placed subgingivally in regions 16, 14 and 13 at 12–30 Ncm. The two-piece ceramic implant has a reduced roughness in the neck area of 0.5 µm RA compared to the endosteal area with a roughness of 1.6 µm RA. This optimizes attachment of peri-implant soft tissue and bone cells. Before filling with the bone augmentation material MinerOss®-X, the implants are covered with a cover cap for submerged healing. In order to fill the buccal bone deficit, MinerOss®-X cancellous bone granules are mixed with autologous bone chips extracted from the drilled shafts as well as with the patient’s blood. In order to promote optimal ossification, the bone augmentation material should only be applied in direct contact to well-vascularized bone. The membrane for covering the augmentation material is first inserted from the palatal side. (Figs. 1 to 6) Fig. 2: Inserted CERALOG® Hexalobe ceramic implants in regio 16, 14 and 13 with buccal fenestration in regio 14. Fig. 1: Exposure of the bone defect with a mucosal flap. CASE STUDY
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