Partner Magazine logo 18 – July 2018


logo 18 • CAMLOG Partner Magazine • July 2018 EDITORIAL 2 Dear readers Digitization in the world of dentistry is picking up speed. Many other industries are already far ahead and are predominantly working indigital processes, nowthe dental industry and implant dentistry are catching up. CAMLOG is very well positioned here; our products are increasingly being used in digital workflows. In 2018, for example, more CAMLOG implants in Germany have already been restored using digital workflows via a titanium base or individualized prosthetics than with conventional standard prosthetics. This development is being driven forward by patients, dentists and laboratories alike. In addition to the desire for higher productivity, the demand for esthetic individual restorations is constantly increasing. However, this demand can no longer be met without the possibilities of digitization and has also been instrumental in moving CAMLOG into a new direction. In the future, the focus will be on the various services involving the entire implant restoration for implant planning, scanning, design and the complete caserelated delivery of all necessary analog and digital components. However, the services are not made possible by individual institutions, but only by networks of dentists, laboratories and industrial partners. The networks are now becoming more flexible and allow participants any number of entries and exits in the future. However, we are also responsible for mastering the increasing complexity of all workflows in the networks. Challenges such as large data volumes, different data formats and different in- and outsourcing possibilities will become more and more manageable through platforms in the future, without the users having to deal with this complexity. The change in dentistry is in full swing, but the most important element for CAMLOG remains you as our users and your patients, even in times of digitization. We will accompany you during these challenges and build your individual digital network for you, just as you wish. This automatically brings us closer to our customers and enables all CAMLOG users to move into digitization. As a manufacturer of implants, we have the opportunity to invest in innovative platforms and thus also to develop workflows that enable new forms of cooperation for the networks. I have been involved in IT for more than 30 years, and there have always been trends and developments, whereby every user had to decide for himself which development he wanted to participate in. But the speed of change is faster than ever, according to the futurologists Brynjolfsson and McAfee* we have been on the famous second half of the chessboard since 2006. With each new field, the performance of digital systems doubles according to Moore's law and enables techniques that were not feasible 18 months ago. The considerable social effects of this development are still largely ignored today and will still present us with great challenges over the coming decades. Markus Stammen Director CAD/CAM and IT DIGITIZATION BRINGS US CLOSER TO OUR CUSTOMERS. * The Second Machine Age: How the next digital revolution will change all our lives. Hardcover edition – October 1, 2014 by the authors Erik Brynjolfsson and Andrew McAfee

logo 18 • CAMLOG Partner Magazine • July 2018 3 logo – the CAMLOG Partner Magazine • Publication dates: twice per year• Publisher: CAMLOG Vertriebs GmbH • Maybachstr. 5 • D-71299 Wimsheim Telephone: +49 7044 9445-100 • Telefax: +49 800 9445-000 •, Editorial staff: Oliver Ehehalt (responsible), Michael Ludwig, Anela Mehic, Françoise Peters, Andrea Stix, Ingrid Strobel • Photos: CAMLOG and its licensers• Photos: all photos are by CAMLOG except the photos on pages.2, 30, 35-37, 38-39: stock., p.4-11: OR Foundation, p.12-27: see list of authors• Design: Kerstin Gerhardt, Duc-An Do • Print: Wurzel Mediengruppe, Esslingen. 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. CONTENT COVER STORY • Knowledge transfer in royal surroundings – 1,200 enthusiastic participants at the OR Global Symposium in Rotterdam 4 SCIENCE / CLINICAL RESEARCH • Research Award and Poster Competition 10 CASE STUDY • CERALOG® Implants – the solution for special patient needs 12 • Restoration of an edentulous maxilla – combined procedure with facial sinus lift 18 • Immediate fixed rehabilitation – the restoration of edentulous jaws with the aid of a modified practice concept 22 NEWS • 100% CAMLOG campaign – why every fourth implant in Germany comes from CAMLOG 28 • The new Medical Devices Directive – 2017/745 EEC 30 ABOUT CAMLOG • ALLTEC DENTAL in Austria – Interview with Alexander Jirku and Pierre Rauscher 32 PRACTICE MANAGEMENT • Avoiding leadership errors – communicating effectively and motivating employees 34 LIFESTYLE • Hello future, we're coming! 38

logo 18 • CAMLOG Partner Magazine • July 2018 COVER STORY 4 The motto of the World Symposium sounded as promising as the royal setting: "The Future of the Art of Implant Dentistry". To this end, the scientific committee, chaired by Professor Irena Sailer and Dr. Ben Derksen, had put together an attractive two-day main program of current focus topics: soft tissue management, digital workflow, restorative concepts especially for elderly patients, ceramic implants and much more. Twelve hands-on workshops plus a theoretical workshop in English, German and Spanish as well as two workshops with simultaneous translation into Chinese left nothing to be desired to deepen a topic that was of particular personal interest. The additional symposium for dental professionals included important aspects for the team. A total of 57 speakers, moderators and experts from twelve countries offered an excellent mixture of science and everyday clinical practice with enormous practical relevance. The World Symposium also showed greatness at the accompanying industrial exhibition. 21 companies highlighted their products and solutions for oral implant and restorative dentistry. The Oral Reconstruction (OR) Foundation hosted its global symposium in Rotterdam and honored King Willem-Alexander of the Netherlands by holding the meeting on his birthday – the "Koningsdag" on April 27. Rotterdam was thus enlivened by 1,200 congress visitors for three days, who flocked to the trendy Dutch metropolis from 39 countries. KNOWLEDGE TRANSFER IN ROYAL SURROUNDINGS – 1,200 ENTHUSIASTIC PARTICIPANTS AT THE OR GLOBAL SYMPOSIUM IN ROTTERDAM

logo 18 • CAMLOG Partner Magazine • July 2018 COVER STORY 5 "Functional" gingiva In the first session of the main scientific program, the internationally renowned speakers Professor Mariano Sanz, Professor Anton Sculean and Dr. Edward P. Allen acknowledged the importance of healthy peri-implant soft tissue for implant success and demonstrated techniques for thickening and widening the gingiva using different grafts and tunnel/pouch techniques. A sufficiently broad band of keratinized gingiva is crucial for both implants and recession covers of natural roots. According to Edward P. Allen, this consisted of both free and fixed gingiva and he therefore suggested speaking more accurately of "functional" gingiva. The best of both worlds How far has the digital workflow progressed and how mature is virtual impression taking in practice? This was the topic of the second session with the speakers Dr. Wiebe Derksen, Dr. Tabea Flügge and the team Dr. Peter Gehrke and DT Carsten Fischer. Both the moderator of these lectures, Professor Florian Beuer, and the speakers themselves agreed that digitization is a "game changer" and is making rapid progress. Even if the analog steps are still necessary to close the digital workflow, all speakers motivated the delegates to deal with the new technologies. According to Wiebe Derksen, digital planning is very efficient and team-oriented due to the matching of scanning and DVT data. He loves the design process and the exchange with the dental technician. In contrast, he considers 3D-printed models not to be very precise and surface-true and therefore relies on passivation models from the laboratory

logo 18 • CAMLOG Partner Magazine • July 2018 COVER STORY 6 for large-span reconstructions. This was confirmed by Tabea Flügge in her statement that the precision of digital impressions decreases with increasing span and number of implants. The scanner itself and the scanning protocol have a significant influence on the accuracy of digital impressions of implants. Dr. Peter Gehrke and Carsten Fischer believe that ready-to-use standard parts make no sense in the digital workflow. In the past, they have also dealt very intensively with the various quality criteria of CAD-CAM-manufactured reconstructions in their own studies, such as precision and surface quality, and very often rely on the DEDICAM® manufacturing services. Despite the CADCAM technology, which they regard as being indispensable, manual reworking and finishing by the dental technician is always necessary in addition. Trend to early protocols Professor Bilal Al-Nawas opened the session "Treatment concepts" with an analysis at the time of implantation. However, for him, an ideal implant position, sufficient primary stability and adequate augmentation measures are more important than the time of implant placement. Wherever possible, he strives for immediate or early implant placement, as his patients benefited from shorter treatment times and less extensive soft tissue augmentation. In the case of infected alveoli or the need for GBR measures, immediate implant placement should be avoided. The trend towards earlier loading protocols is also followed by the PROGRESSIVELINE implant design presented to the public in Rotterdam for the first time by Dr. Kai Zwanzig and Christian Rähle (Director of Research and Development, CAMLOG). This is very well suited for soft bone and compromised implant sites and follows a standard surgical protocol without the use of special instruments. The design of the implant body (apical conical, cranial cylindrical) and the thread (sawtooth-like) allow a wide range of indications and allow safe insertion torques in all bone classes through a multi-stage drilling protocol. The new PROGRESSIVE-LINE will be available as of IDS 2019 in a CAMLOG® version (Tube-inTube® connection) and subsequently in a CONELOG® version (conical connection), according to Rähle. According to Dr. Jan Klenke, the iSy® Implant System is ideal for immediate implantation and immediate restoration concepts. Tooth extraction, implant placement, soft tissue thickening and temporary restoration using a multifunctional cap on the pre-mounted implant base can be performed very comfortably in just one session. Studies and his own experiences have proven that transmucosal healing has no negative influence on implant success. According to the "One-shift" concept, the implant is "opened" for the first time by removing the implant base for the final restoration and then appears very "clean" – an intelligent concept with advantages for biology and esthetics. Ceramic implants – an alternative to titanium? PD Dr. Daniel Thoma and a research group at the University of Zurich have been working on comparative studies between titanium and zirconium dioxide implants for a long time and presented some of these studies and their results. Seen overall, osseointegration and marginal bone preservation are the same for both implant materials. With the latest generation of zirconium dioxide implants, they had observed a greater overall soft tissue volume compared to titanium implants. Furthermore, it appears that zirconium dioxide implants

logo 18 • CAMLOG Partner Magazine • July 2018 COVER STORY 7 are better suited to minimize bone loss and recessions in cases of dehiscence. This resumé from the research was a great opportunity for the two subsequent speakers – Professor Vladimir Kokovic and Dr. Frank Maier – who have both already dealt intensively with the CERALOG® Implant System. In the past, Vladimir Kokovic has conducted intensive clinical research into the primary stability of CERALOG® Implants, also in order to explore the possibility of immediate loading protocols. In one of his studies he observed initial ISQ values of just over 60, a drop in Week 3 to values around 54 and an increase in Week 16 to areas around 64. He sees the possibility of immediate loading protocols in the mandibular posterior region with CERALOG®. Singletooth reconstructions are the system's domain and the advantages are best realized in the anterior region – due to the material and its dual surface texture of 1.6 µm endosseous and 0.5 µm in the neck region for the transition zone. Vladimir Kokovic firmly believes in the future of ceramic implants and explained this by the high user-friendliness and positioning precision of the two-piece hexalobe implant. This is also preferred to the one-piece monobloc implant by Frank Maier. He considers the biological aspects of implant materials to be important (zirconium dioxide, unlike titanium, does not release ions), but at the same time considers it appropriate to remove the stigma of alternative medicine and place ceramic implants on a broader scientific basis. For example, he does not consider ceramic drills to be a good choice, because they have poor thermal conductivity and therefore present a greater risk of heat necrosis. Frank Maier comes from the Tübingen School and sees an indication for zirconium dioxide implants both in combination with PEKK abutments and with zirconium dioxide abutments for single teeth and smaller bridges up to a maximum of five pontics. In one female patient, he inserted a four-pontic bridge on three implants, which were restored once with PEKK abutments and once with zirconium dioxide abutments for comparison purposes. The clinician and the patient assessed both restorations as being equivalent, but the patient ultimately opted for the zirconium dioxide abutments for biological reasons. Restorative concepts Due to demographic developments, the focus in the practice is increasingly on older patients. This requires concepts that take advanced age into account or, better still, "the aging process" – and therefore do not at some point pose unsolvable problems for patients with decreasing visual and manual abilities. The speakers in this session, Dr. Luca Cordaro, Dr. Claudio Cacaci and Dr. Rémy Tanimura, agreed that it was therefore important to strategically consider which restorative concept to recommend to older people. Whereby the individual situation of the patient is the top priority. Dr. Luca Cordaro advocated several smaller bridges for total restorations, incorporating the residual dentition whenever possible. Dr. Claudio Cacaci and co-authors already presented the Munich concept "One dental prosthesis for two life phases" about ten years ago. This is characterized by a fixed cemented restoration that can be converted into a removable telescopic restoration. The functional elements for this are 2° milled zirconium dioxide abutments on CAMLOG® Implants and electroplated abutments. Even at the time, this concept was very convincing, as well as being new. Based on 13 to 14 year old patient cases, Dr. Claudio Cacaci can today prove that this worked exactly as envisioned and could accompany people through the different stages of age. According to Claudio Cacaci, regular follow-up checks and professional dental hygiene are an indispensable part of this concept.

logo 18 • CAMLOG Partner Magazine • July 2018 COVER STORY 8 Sponsored research projects The Scientific Working Group of the OR Foundation, consisting of Professor Fernando Guerra, Professor Robert Sader, Dr. Alex Schär, Professor Thomas Taylor and Professor Wilfried Wagner, oversees the scientific research and the related use of funds. The presentation of the results of selected research projects was also given due consideration in the main program of the symposium. The research projects dealt with the following topics: 3D accuracy of the implant position during templateguided implant insertion (Dr. Sigmar Schnutenhaus), maxillary overdentures supported on two implants (Dr. Florian Kernen), dental implants in aggressive periodontitis (Assoc. Professor Pinar Meric), microscopic investigations of peri-implant soft tissue cell adhesion on different abutment materials (Assoc. Professor Hanae Saito), effectiveness of home care and professional procedures for biofilm removal on different materials and surfaces (Dr. Gordon John). Oral Reconstruction Foundation Research Awards In addition, Professor Jürgen Becker and Professor Fernando Guerra awarded the three OR Foundation Research Prizes, which were endowed with € 10,000, € 6,000 and € 4,000 respectively. The poster exhibition also attracted great attention and included 50 peer-reviewed posters from nine countries. The Poster Award of € 2,000 each was presented in the categories Clinical Research, Preclinical Research and Case Reports. You can read more about this in the scientific report starting on page 10. Case presentations from practice One of many highlights of the varied scientific program was the final session moderated by Dr. Karl-Ludwig Ackermann and Professor Thomas Taylor "Problems, complications and failures – what can we learn from them?" on particularly challenging patient cases by Professor Michael Stimmelmayr, Professor Juan Blanco and Dr. Mario Beretta. The initial situations were presented by the respective clinicians and the treatment options were then discussed by an international group of experts. Afterwards the clinician presented the actual realized solution. Successful transition The OR Foundation's global symposium was not an easy legacy. Since the CAMLOG Foundation was renamed to the Oral Reconstruction Foundation at the end of 2016, a new name had to be established for the biennial world congress, which was able to build on the great success of the international CAMLOG congresses. The OR Global Symposium in Rotterdam impressively proved that this transition has proved successful. The members of the Board of the OR Foundation – Professor Robert Sader (President), Oscar Battegay (Legal Counsel), Professor Fernando Guerra, Professor Irena Sailer, Professor Mariano Sanz, Dr. Alex Schär (Managing Director), Professor Thomas Taylor and Professor Wilfried Wagner – have succeeded in seamlessly transferring

logo 18 • CAMLOG Partner Magazine • July 2018 COVER STORY 9 the existing values and contents into the new organization. The close relationship of the Board to the previous Chairman Professor Jürgen Becker also contributed to this and he was expressly thanked for his services. CAMLOG is the Founding Partner of the new, independent organization. During the press conference, Dr. René Willi, Member and Delegate of the CAMLOG Board of Directors, emphasized the close partnership between the OR Foundation and CAMLOG, particularly in the areas of research and training. The objective of the OR Foundation to promote the oral health of patients by supporting science and education, links scientists, practitioners and the industry and was the central theme of the first OR Global Symposium throughout the partner network – a truly custom-tailored prelude in a royal environment! And what happens next? Simply stay connected to the OR Foundation via your smartphone! You can meet the online community "INSIGHTS Dental“ at on the Internet or the mobile app (see AppStore or PlayStore), which already accompanied you during the symposium. Create your individual profile – you will be informed daily about everything worth knowing in your areas of interest. Exchange ideas with peers on current topics and benefit from the latest publications from recognized experts in a rapidly developing online community. And of course you will also be provided with the latest information on the OR Global Symposium from 30 April to 2nd May 2020 in New York.

SCIENCE / CLINICAL RESEARCH logo 18 • CAMLOG Partner Magazine • July 2018 10 The global symposium is always an excellent opportunity to not only promote science but also to encourage young scientists, devoted practitioners to present their work to a large audience. Great importance was also attached to this tradition at the Oral Reconstruction Global Symposium 2018 in Rotterdam. This year, the Research Award, the Poster Competition and the Short Poster Presentation offered excellent opportunities to achieve this goal. RESEARCH AWARD AND POSTER COMPETITION Research Award 2016/2017 Since its creation in 2008, the Research Award has been dedicated to young, talented scientists and applicationoriented clinicians interested in scientific advances. Within the plethora of themes and interesting publications from several countries, the Scientific Evaluation Committee this year again had a difficult decision to take for the selection of the three best publications. At the 5th edition of this award, the winners were honored at the Oral Reconstruction Global Symposium – the former International CAMLOG Congress. Professor Jürgen Becker, past president of the Oral Reconstruction Foundation, presided over the ceremony. The first prize, endowed with € 10,000, went to Dr. Nicole Passia from the Clinic for Dental Prosthetics, Propaedeutics and Materials Science at the Christian Albrechts University in Kiel for her publication: “Survival and complications of single dental implants in the edentulous mandible following immediate or delayed loading: A randomized controlled clinical trial”. J Dent Res. 2018;97(2): 163-70. E-Publication: 18. October 2017 https://www.ncbi.nlm.nih. gov/pubmed/29045800 Dr. Tobias Fretwurst, from the Department of Oral and Maxillofacial Surgery at the Dental Center of the University Hospital in Freiburg, received thesecond prize, endowed with € 6,000. His publication was entitled: “The impact of force transmission on Narrow-Body dental implants made of commercially pure titanium and titanium zirconia alloy with a conical implantabutment connection: an experimental pilot study” Int J Oral Maxillofac Implants 2016; 31: 1066-77. https://www.ncbi.nlm. The third prize with a value of € 4,000 was awarded to Assoc. Professor Erhan Çömlekoğlu from the Department of Prosthetic Dentistry at the Faculty of Dentistry of Ege University Bomova in Izmir (Turkey). On behalf of Dr. Çömlekoğlu, who was unable to attend the ceremony, Assoc. Professor Pinar Meric from the same university accepted the prize for the publication: “Immediate definitive individualized abutments reduce peri-implant bone loss: a randomized controlled split-mouth study on 16 patients”. Clin Oral Investig. 2018; 22(1): 475-86. E-Publication: 31. May 2017. pubmed/28567530 Poster Competition 2018 More than 50 posters were accepted by the jury for the poster competition 2018. Five of them were selected for a short presentation during the session on Friday afternoon. The oral presentation is an excellent opportunity to present the works done over the years to a large audience. The speakers presented the results of several clinical trials which included: three prospective trials with five-year and three year follow-ups (PD. Dr. S. Rocha, PD. Dr. M. Moergel, Dr. L. Fierravanti), a retrospective study with up to 13 years of follow-up (Dr. Y. Duan) as well as a case report (Dr. T. Page). from left to right; Prof. Jürgen Becker, Dr. Tobias Fretwurst, Dr. Nicole Passia, PD Dr. Pinar Meric representing PD Dr. Erhan Çömlekoğlu, Prof. Fernando Guerra

logo 18 • CAMLOG Partner Magazine • July 2018 11 SCIENCE / CLINICAL RESEARCH In addition to the selection for the oral presentations, the best case report, the best clinical study and the best preclinical research work were selected from all participating posters. The three winners each received a monetary prize with a value of € 2’000. The Poster Jury selected the posters, which will be published in International Poster Journal of Dentistry and Oral Medicine as well as on the Oral Reconstruction Foundation website. Members of the Poster jury: Prof. Pedro Nicolau, Prof. Fernando Guerra, Françoise Peters, Dr. Ben Derksen THE THREE WINNING POSTERS Category Pre-clinical Research Dr. Anders Henningsen Title: Influence of UV-light and nonthermal plasma on rough titanium surfaces in vitro Co-authors: Smeets R, Cacaci C, Heuberger R, Heinrich O, Hartjen P, Hanken H, Precht C. InfluenceofUV-light andnon-thermalplasma on rough titaniumsurfaces in vitro • UV-lightandNTP treatment didnotalter the surfacestructureor roughness parameters • UV light andNTPsignificantly increasedwettability on the titanium surfaces (P< 0.001,Fig. 2) • UV-lightandNTPsignificantlydecreased carbon remnants (P< 0.002,Fig.3) • NTPwasevenmoreeffective in carbon removal thanUV light (P=0.03,Fig.3) • UV light andNTPsignificantly increased cellattachment compared to thenon-treated disks (P<0.001,Fig.4) • NTP significantly increased cell proliferation (P = 0.002, Fig. 5) compared to the non-treated aswell as to the UV-treateddisks • NeitherNTPnorUV-light treatment resulted in cytotoxiceffects ORALRECONSTRUCTIONGLOBALSYMPOSIUM 2018 26.–28.APRIL2018 I ROTTERDAM,NETHERLANDS 1 Department ofOral andMaxillofacialSurgery,UniversityHospitalHamburg-Eppendorf,Hamburg,Germany 2 Division „RegenerativeOrofacialMedicine“,UniversityHospitalHamburg-Eppendorf,Hamburg,Germany 3 ImplantCompetenceCentrum,Munich,Germany 4 RMSFoundation,Bettlach,Switzerland 5 Department ofOralandMaxillofacialSurgery,GermanArmedForcesHospital,Hamburg,Germany SmeetsR.1,2,CacaciC.3,HeubergerR.4,HeinrichO. 1,Hartjen,P.1,HankenH.1,PrechtC.1,HenningsenA.1,5 Introduction andPurpose Various studies described positive effects of ultraviolet (UV) irradiation or non-thermal plasma (NTP) treatment on titanium and zirconia surfaces. The aim of this studywas to determine and compare the effects ofUV-light and non-thermal plasma treatment on rough titanium surfaces regarding the changes in wettability, surface chemistry as well as cell attachment and proliferation ofmurine osteoblast-like cells in vitro. Methods Results Conclusions Disclosure Contact: Prof.Dr.Dr.RalfSmeets DepartmentofOral andMaxillofacialSurgery DivisionofRegenerativeOrofacialMedicine UniversityHospitalHamburg-Eppendorf Email: Phone:+49 (0)40– 741053259 Surface treatment by UV-light or NTP led to a significant reduction of carbon remnants and a significant increase inwettability on rough titanium surfaces. Both methods are able to increase the bioactive capacity of titanium surfaces in vitro with slight advantages for NTP in carbon removal and cell proliferation compared to UV-light. However, further studies are needed to confirm the identified effects aswell as the determinedadvantage ofNTP in vitroand in vivo. Fig. 1: Electronmicrograph of a non-treated titanium disk Fig.2: Drop shape analysis A) nontreated B) UV-light C) NTP Fig. 3: Surface composition of the disks.Mean concentration of the elements in at% and standard deviation. Ti: titanium; C: carbon; CC-O : carbon bound to oxygen; CCOOX : ester, carboxylic or carbonategroups,OI :oxides;OII :OH-groups;OIII : adsorbedwater. * statistically significant differences • Sandblastedandacid-etched titaniumdisks (grade 4,Fig.1)weredivided into a non-treated control groupand twoexperimental groupseither treatedbyUV-light (0.05mW/cm2at λ=360 nmand 2mW/cm2 at λ= 250nm)orbyNTPofargon (24W; -0.5mbar) for12minuteseach • Wettabilitywas assessedusing dynamic contact anglemeasurement (SurtensUniversal,OEG,Germany) • X-ray photoelectron spectroscopy (XPS)analysiswas performed (KratosAxisNova,KratosAnalytical,UK) • Murineosteoblast-like cells (MC3T3-E1,SigmaAldrich,Germany)wereused for in vitro experiments • Cellattachmentwas assessedusing fluorescindiacetate /propium iodidestaining (live-dead-staining) after2, 24and72 hours and cytotoxicityassay (LDH) • Proliferationwasdetermined using an XTTassay Fig. 5: Proliferation assay (XTT) after 48 hours of incubation. * statistically significant differences This research project was granted by the Oral Reconstruction Foundation (CF11501). The UV and NTP devices were provided free of charge by the manufacturers. Titanium diskswere provided byCamlogBiotechnologiesAG. The authors declare no conflictof interest. Fig. 4: Cell attachment of MC3T3-E1 cells after 2, 24 and 72 hoursof incubation. * statistically significant differences Category Clinical Research Dr. Ludovica Fierravanti Title: The effect of one-time abutment placement on marginal bone levels and peri-implant soft tissues: 3 years results from a prospective randomized clinical trial Co-authors: Ambrosio N, Molina A, Sanz I, Martin C, Blanco J, Sanz M. Radiographic assessment DIB(Distanceimplantshoulder-firstbone contact) Distancebonecrestto contactpoint CONCLUSION " $ ! & % # $! $ ! ' Theeffectofone-timeabutmentplacementonmarginalbone levels andperi-implantsoft tissues:3yearsresults fromaprospective randomizedclinical trial INTRODUCTION -AIM Oneofthemaingoalsofcurrentimplantdentistryisnotonlytoachieveosseointegration,butalsotomaintainthelong-termstabilityofthesoftandhardperi-implant tissues.Themanipulationoftheimplanttoabutmentinterphasecomponentsmayinfluencethestabilityofthesurroundingtissues.Inexperimentalstudies(1)repeated dis-andreconnectionofprostheticcomponentscouldcompromisethemucosalbarrieraroundimplantsandresultedinanapicalshiftoftheconnectivetissueattachment andtheunderlyingbone.Thisexperimentalevidencepromptedthedevelopmentofthe“oneabutmentatone-time”protocolconsistingontheplacementofthedefinitive restorativeabutmentatthetimeofimplantsurgery.Thescientificevidenceonitsefficacywhenappliedtoimplantsplacedinhealedsitesis,however,unclear(2,3). Therefore,theaimofthisstudywastocomparetheeffectofplacingthedefinitiveabutmentatthetimeofimplantplacementversusatalaterstage,onthesoftandhard tissuechangesarounddentalimplants. Theoneabutment–onetimeconceptisassociatedwithlessmarginalbone loss.Furthermore,peri-implanttissuesstabilityseemstoendureinthelong term(3years). o STUDYDESIGN:Prospective,randomized,parallel,controlledclinicaltrial o TARGETPOPULATION: o SAMPLESIZECALCULATION Patientswithatleastonemissingtoothintheposterior maxillaormandible(positions4-7),willingtoreceive implantsupportedrestorations Meandifferenceof0.20mm Standarddeviationof0.157mm Powerof95% Levelof significanceof5% Dropoutsof10% 40patients Inclusion criteria Exclusion criteria Maleorfemale≥18yearsold Oneormoreadjacentmissingteethintheposteriormaxillaormandible(positions4-7) Naturaltoothmustbepresentmedialtotheimplantsite Opposingdentitionmustbenaturalorimplantsupportedfixedrestorations AdequatebonequalityandavailabilityforCamlogConelog®Screw-Lineimplants placementofdiameter3.8mmor4.3mm,andlengthsof9mm,11mm,or13mm. Patientswillingtoparticipateandattendtheplannedfollowupvisits SYSTEMIC:Uncontrolleddisorders,medicationinterferingbonemetabolism,physical handicaps,smokers>10cigs/dayortobaccochewers,alcoholismordrugabuse LOCAL:boneaugmentationonimplantsite<3monthsbefore,intraoralinfectionand inflammation,mucosaldiseases(i.e.Erosivelichenplanus),historyofimplantfailure, post-extractionsiteswith<6weekshealing,severebruxism. INTRA-SURGICAL:lackofprimarystabilityatsurgery,needforboneaugmentation procedures,inabilitytoplacetheimplantaccordingtotheprostheticrequirements CamlogConelogScrew-LineImplants Ø3.8–4.3mm Length9-11-13mm patients recruited 2excluded intrasurgically Testgroup:96.6% Controlgroup:100% NoSSD NoSSD NoSSD MATERIALANDMETHODS RESULTS Screening& Informed Consent SutureRemoval (1week) Impressions (6-12weeks) Loading (8-14weeks) 6Months Periapical x-ray Adverseevents ImplantPlacement& Randomization 12Months 36Months Adverseevents Periapical x ray /Clinical variables (QM,mPLI,mSBI) /Soft tissue parameters /Patient relatedoutcomes /Adverseevents SS increase inpapilla filling intragroup NoSSD intergroupatany timeand variable BONELEVELCHANGES CLINICALVARIABLES PAPILLAFILLING –JemtScore SS reductions intragroup NoSSD intergroupduring thewhole studyperiod SURVIVALRATES 98.3% patients 60 39 implants 41 patients 36 6months 56 implants patients 35 12months 55 implants patients 33 36months 52 implants A tendencyofgreaterbone losswasobserved in the controlgroup over time,beingonly statistically significantat6months. Between12monthsand36months,aslightbonegainwas observedinbothgroup. ADVERSEEVENTS Screw loosening:at impression (1:T),6months (3: 1C,2T),12months (2:1C,1T) VarioSRabutment fracture: (1:C) PATIENTSATISFACTION NoSSDintergroup during the whole studyperiod (1) Abrahamsson,I.,Berglundh,T.&Lindhe,J.(1997)Themucosalbarrierfollowingabutmentdis/reconnection.Anexperimentalstudyindogs.JournalofClinical Periodontology24:568–572. (2) Degidi,M.,Nardi,D.&Piattelli,A.(2011)Oneabutmentatonetime:non-removalofanimmediateabutmentanditseffectonbonehealing aroundsubcrestaltaperedimplants.ClinicalOralImplantsResearch22:1303–1307. (3) Grandi,T.,Guazzi,P.,Samarani,R.&Garuti,G.(2012)Immediatepositioningof definitiveabutmentsversusrepeatedabutmentreplacementsinimmediatelyloadedimplants:effectsonbonehealingatthe1-yearfollow-upofamulticentrerandomised controlledtrial.EuropeanJournalofOralImplantology5:9–16. SOFTTISSUESMARGIN mPLI mSBI PD Controlgroup Controlgroup Controlgroup Testgroup Testgroup Testgroup CLI IP Healing abutment VarioSR abutment Controlgroup Testgroup Controlgroup Testgroup Surgery -Loading 12Months -36Months 6Months -12Months Loading -6Months Loading -6Months Controlgroup Testgroup Controlgroup Testgroup Loading -12Months Loading -36Months Testgroup Controlgroup Middle Satisfied Very satisfied Clinical variables Presence/absence QueratinizedMucosa PD mSBI (Mombelli1987) mPLI (Mombelli1987) 6 sites/implant Periodontal probePCP-UNC 15 Papilla filling Papilla Index(Jemt1997) Softtissue margin CLT (Crown lenghttooth) CLI (Crown lenghtimplant) IP (Distancetop of papilla to incisaledge) Patientrelated outcomes Patientsatisfaction:comfort,appearance, masticatoryfunction, taste,overallsatisfaction 5 itemsscale: verydiscontented,discontented, fair, satisfied, verysatisfied Adverse events Nature and frequencyof occurrence Implantrelated/Non implantrelated PRIMARY SECONDARY 3 1 2 Category Case Report Dr. Roman Beniashvili Title: Management of extractions sites new approach for compromised conditions in the posterior maxilla Co-authors: Kern B. Clinic forOralSurgery,MaxillofacialSurgery and ImplantDentistry Results After a 3-month healing period, average vertical bone dimensionsmeasured 10.2mm (7.1mm – 13.8mm). In comparison with preoperative condition, an average increase of the primary sub-antral bone height of 3.4mm (1.2 – 7.6mm) was observed. The number of regions with vertical bone dimensions < 7mm was 0. According to this, the number of cases with an indication for an external sinus floor elevationwas reduced by 100% (7 vs. 0) [4]. 10 Camlog® - implantswith lengths from 11 - 13mmwere placed, such as: one 3.8 x 11mm, one 4.3 x 11mm, two 5.0 x 11mm, three 6.0 x 11mm, two 4.3 x 13mm, and one 5.0 x 13mm implant (Figs. 8 - 10). All implants weremechanically stable. Considering that theminimum length of the implants was 11mm, implants were placed in combination with an osteotome sinus floor technique in 6 cases (60%). The average sub-antral bone height, prior to sinus floor elevation was 8,7mm (7.1 – 10.5mm). In no case (0%), the implant placement was performed utilizing a simultaneous conventional sinus floor elevation with lateral window and no additional vertical augmentation was indicated. In no case was a two-step procedure for sinus floor elevation necessary.An additional lateral augmentation procedurewas performed in three cases (33.3%); in one case due to presence of a dehiscence and in 2 cases to prevent resorption of a thin buccalwall.After a healing period of 3months, all 10 implantswere uncovered.No further soft tissue correctionswere needed, second stage surgerywas performed,minimally invasively, or justwith a small apicaly positioned flap.All implantswere restored. Single-crown restorations or fixed bridgeswere placed on all implants.Osseointegration and periimplant healthwere evaluated at the time of implant uncovering and after restoration using radiographs, clinical examination and stability tests (Periotest).All implantswere clinically stable at the time of uncovering and examination after restoration (Figs. 11 - 12). The Periotest valueswere between -8 and -2 (average: -5). Tagesklinik fürOralchirurgie,Mund-, Kiefer-,Gesichtschirurgie und ImplantologieDr. Roman Beniashvili und Prof.Dr.Dr. KonradWangerin, Schorndorf,Germany. Literatur 1.Araujo et al. (2008) Inluence of Bio-Oss Collagen onHealing of an Extraction Socket:An Experimental Study in theDog. International Journal of Periodontics and RestorativeDentistry 28: 123–135. 2.Weng et al. (2011)WelcheMassnahmen sind sinnvoll zum Strukturerhalt desAlveolarfortsatzes nach Zahnextraktion? European Journal ofOral Implantology 4: 123-130. 3.Fugazotto PA (1999) Sinus FloorAugmentation at theTime ofMaxillaryMolar Extraction:Technique and Report of Preliminary Results. International Journal ofOral andMaxillofacial Implants 14(4): 536-542. 4.Jensen SS, KatsuyamaH PreoperativeAssessment and Planning for Sinus Floor Elevation Procedures. ITI TreatmentGuide Volume 5 - Sinus Floor Elevation Procedures. Management of Extractions Sites -ANewApproach for CompromisedConditions in the PosteriorMaxilla Roman Beniashvili,DDS, dent, Bastian Kern,DDS, dent. Tagesklinik fürOralchirurgie,Mund-, Kiefer-,Gesichtschirurgie und ImplantologieDr. Roman Beniasshvili und Prof.Dr.Dr. KonradWangerin, Schorndorf,Germany Materials andMethods The described technique,wich is themodification of a technique described by Fugazotto [3]was performed in 10 sockets following tooth extraction (7molars and 3 premolars) in 7 patients.All ten patients were femalewith an age ranged between 32 to 74 years. Tooth extractionwas performedwith special careminimizing trauma to the surrounding hard and soft tissues. Therefore, a sulcular incisionwas made around the tooth to preserve the approximal papilla structure. Preserving the interradicular bone and the buccalwall in case ofmolars and premolarswith two roots, the toothwas trisected/bisected and the rootswere gently removed individually (Figs. 1 - 3). Based on the radiographs and the existing clinical situation, a calibrated trephine burwas used,whichwas in sufficient dimension to include the complete interradicular septum and at least 50% of the extraction socket, but kept aminimum distance of 1.5 - 2mm to adjacent teeth and 1mm to the buccal and palatal walls. Utilizing preoperative radiographs andmeasurements, a sitewas prepared using the trephine bur towithin approximately 2mm of the sinus floor (Figs. 4 - 5). In cases of premolars andmolarswithout interradicular bone, and tapered roots, an appropriate dimension of the trephine bur,was selected to reach the socketwalls 3 - 4mm before the expectedmaxillary sinus floor.Osteotomes selected corresponding the diameter of the trephine preparation. The osteotomeswere used under gentle force of amallet, to a depth of 3 - 5mm. The residual socketwas filledwith a slowly resorbing, xenograft (Bio-Oss®) (Fig. 6). Because of the existence of the buccalwall, nomembraneswere used. In order to avoid tomobilize themucogingival line coronally and to create a thick and adequate soft tissue,mucoperiostal flap elevationwas not used forwound closure. Socketswere closed by free or connective gingival grafts / tissue grafts (palatal pedicle tissue) (Fig. 7). Disclosure The described procedure verified that it improves the clinical condition for future implant placement in compromised initial situations,when distinct alveolar defects and reduced residual bone height are expected. Fig. 1: initial clinical condition Introduction In unfavorable situations, likemaxillary atrophy and/or distinct pneumatization of themaxillary sinus in combinationwith an attachment loss of the teeth due to advanced periodontal disease, leading to severe vertical bone loss, new therapeuticmodalities are needed. Preservation or even improvement of the height andwidth of the alveolar ridge is essential in order to avoid or reduce the frequency and size of augmentation procedures [1,2]. The aim of the presented techniquewas to reduce the need of augmentation and avoid the sinus floor elevation or at least to provide treatment options for a onestage approachwhen at the time of tooth removal a deficit in the alveolar bone could already be expected and the need of a later sinus lift procedurewas conceivable. Fig. 6: augmentedExtraction sites Fig.7: connective tissue graft (tunnel technique) Fig.4: surgical technique Fig. 5:Osteotome Fig. 2: preoperative radiograph Fig. 8: radiograph 3-months postoperative Fig. 9: Implant placement Fig. 12: 4-year follow-up The authors declare no financial interest inanyof the productsmentioned herein.The authorsmention their gratitude to dentistHorstDieterich for theprosthodontics in the caseherein. Fig. 3:Extraction sites Fig. 10: radiograph at the time of implant placement Fig. 11:FinalRestauration from left to right: Prof. Jürgen Becker, Dr. Ludovica Fierravanti, Dr. Anders Henningsen, Françoise Peters, Prof. Fernando Guerra

logo 18 • CAMLOG Partner Magazine • July 2018 12 Dr. Detlef Hildebrand, Berlin CERALOG® IMPLANTS THE SOLUTION FOR SPECIAL PATIENT NEEDS Fig. 1: The initial situation: a unilateral free-end situation in the left upper jaw: teeth 26-28 are missing. Fig. 3: To condense the soft bone over the sinus floor, the bone site was prepared using an osteotome. Patient demand for metal-free implant solutions is steadily increasing. Although titanium implants are biocompatible and well tolerated [1], studies have found titanium oxide burdens in the body after implantation [2]. It is being discussed that an inflammatory reaction of varying intensity is detectable in a few patients, depending on the genetic disposition [3]. In contrast, fewer reactions have been observed with zirconium dioxide particles. A further advantage of zirconium dioxide implants is their good tissue compatibility. In the following, a patient case is presented in which two-piece CERALOG® Hexalobe implants were inserted in the maxillofacial free-end situation and systematically documented. Ceramic implants have been on the market for many years, but the percentage share of the total dental implant market remained largely modest. One reason for this was the bad experiences in the 1980s and 1990s with many ceramic fractures – particularly with one-piece implants made of aluminium dioxide, the socalled Tübingen and Munich immediate implants – and the lack of scientifically based data at that time [4]. Intensive material research in recent years has led to the newer generation, the yttrium-tetragonal-stabilized zirconium dioxide, which defines the new industrial standard. It proves convincing, for example, in the crown and bridge technique and as an abutment material. Thus, the material strength for implants no longer proved a challenge, the focus was now primarily on the inner surface quality of the ZrO 2 material, which was identified as a possible source of error during integration, as well as a reversibly screw-retained two-piece version. Newer hightech manufacturing processes to achieve a bone-friendly surface texture on zirconium dioxide implants, such as the injection molding process, now create significantly more confidence in this technology. [5]. If we interpret the signs of the times correctly, we are on the verge of being able to treat patients with special, in part medically justified requirements, with these new materials in terms of implants and longterm stability. Findings and therapy planning A 38-year-old female patient presented in our practice with a free-end situation in the second quadrant. As the residual dentition was completely intact, she wished for a fixed, metal-free restoration to replace the two missing molars. After detailed explanation of the implant treatment as well as reference to the little documented study situation on zirconium dioxide implants, we planned the restoration on the two-piece CERALOG® Hexalobe implants. The X-ray showed a sufficiently high alveolar bone for insertion of two 10 mm long implants without elevation of the sinus floor (Figs. 1 and 2). CASE STUDY Fig. 2: The X-ray shows the sufficiently high bone in the area of the maxillary sinus to accommodate two implants.

logo 18 • CAMLOG Partner Magazine • July 2018 13 Implant bed preparation with bone condensation After a ridge incision and the preparation of a full flap, the implant position was marked with a round bur. A pilot drill (Ø 2.0 mm) was used to set the implant axis at a depth of approx. 6 mm and to check the implant position with the direction indicator. As the bone quality in the distal maxilla was very soft, the bone site was prepared using osteotomes. Primary stability was achieved by condensation of the bone. Another advantage of osteotome preparation is the prevention of penetrating the Schneider´s membrane, which could be caused by careless handling of the drills. Using the osteotome, the tunnel was widened to correspond to the four millimeter implant diameter. The implant bed was advanced to the full implant length, in this case 11.5 mm, as the implant was to be placed approximately epicrestally (Fig. 3). After the complete preparation of the implant site, the sterile packed CERALOG® Hexalobe implants were removed from the packaging with the insertion tool and prepared for insertion. (Figs. 4 and 5). Epicrestal implant placement Before inserting the CERALOG® Implants, the surface was wetted with the bone-active cells of the PRGF liquid. In our practice, the innovative PRGF® procedure, in which the patient's own growth proteins are used to accelerate healing processes and reduce the risk of discomfort and complications, is used for all implant procedures, irrespective of the material composition. (Figs. 6 and 7). As zirconium dioxide is a poor thermal conductor, slow, pressure-free insertion must be ensured when inserting the zirconium dioxide implants. Implantation was performed with a defined torque of max. 35 Ncm and 15 rpm. The implants were placed minimally supracrestally so that the implant shoulder was approximately 0.5 millimeters above the alveolar bone. (Figs. 8 and 9). The cover caps were clicked into the implant interface to protect against ingrowing bone and tissue ingrowth. The mucoperiostal flap was repositioned tension-free and sutured saliva-tight over the cover caps and a control X-ray was taken. (Figs. 10 and 11). In the invisible region of the maxilla in regions 26 and 27, we dispensed with an interim restoration to protect the implants. The healing of the two CERALOG® Implants was completely symptom-free. The patient had no atypical symptoms whatsoever. Discussions on the healing period for ceramic implants is still ongoing. Longer healing times than with titanium implants are suggested Fig. 4: The presentation of the CERALOG® Hexalobe implants in the packaging. Fig. 5: The insertion tool fits into the inner configuration of the all-ceramic CERALOG® Implant. Fig 6:The mechanical insertion option for the implants. Fig. 7: The implants were immersed in the growth-promoting PRGF liquid prior to insertion. Fig. 9: The correctly positioned and stably inserted CERALOG® Implants before soft tissue closure. Fig. 8: When screw-retaining the zirconium dioxide implants, it is essential to avoid too high a torque. CASE STUDY

logo 18 • CAMLOG Partner Magazine • July 2018 14 Minimally invasive exposure In the present case, the implants were exposed after 14 weeks. In addition to the manual and visual control, a control X-ray was taken to check healing of the implants. At this time, the cover cap of the implant region 26 was partially exposed due to soft tissue resorption (Figs. 12 and 13). The exposure was performed minimally invasive without flap technique. Access to the cover caps was created with a puncture incision. These were removed and 2.5 mm high gingiva formers were used to form the peri-implant soft tissue (Figs. 14 and 15). The impression was taken only one week after exposure and healing of the mucosa. The impression posts for the open tray technique were used for this purpose. In cases where several implants are placed side by side for planned prosthetic splints, our Berlin concept always involves connecting the impression posts. Splinting with Pattern resin (GC) avoids possible transfer errors during impression taking (Figs. 16 and 17). A conventional impression procedure with an individual tray is then selected for the subsequent workflow. This procedure ensures a high-precision implant transfer to the dental laboratory. Although this high-precision impression technique is complex to perform, it guarantees reliable, result-oriented further processing in the laboratory with the required quality for the CAD/CAM processing techniques (Figs. 18 and 19). Prosthetic reconstruction − splinted and screw-retained During cast fabrication in the laboratory, the emphasis is placed fully on the exact transfer of the implant positions and the surrounding soft tissue. After screwretaining the lab analogs, the material for the removable gingival mask was injected and after curing, the impression was filled with plaster. (Fig. 20). Using a face bow and a bite registration, the maxillary master cast and the Fig. 16: Posts for the open tray technique were selected for impression taking. Fig. 17: For safe transfer of the implants, the impression posts were blocked intraorally with plastic. Fig. 18: The long screws of the impression posts allow easy intraoral loosening. Fig. 11: The postoperative X-ray image shows the excellent positioning of the two CERALOG® Implants in regions 26 and 27. Fig. 12: At the time of exposure, the implant was exposed in region 26. Fig. 10: The implants were covered with the cover cap, which is part of the implant pack. CASE STUDY

logo 18 • CAMLOG Partner Magazine • July 2018 15 mandibular counter model were mounted in the articulator and the two CERALOG® PEKK abutments of the occlusion were shortened accordingly. The crowns were to be splinted and screw-retained directly. The situation was scanned and the crowns were designed digitally and fabricated from zirconium dioxide. After stain firing, the crowns were finalized. Both the crowns and the PEKK abutments were activated and then bonded to the cast. A special focus was placed on the good hygienic ability of the implant crowns (Figs. 21 to 23). Overall, the two occlusally screw-retained crowns were fabricated without any problems. Despite the new materials and system components, this case with the CERALOG® System, which was new for us, was performed expertly and routinely by the dental technicians. Finally, the crowns were placed in the patient's mouth. A well-healed intraoral situation was present. The crowns were inserted and screw-retained with the titanium abutment screws and a defined torque of 15 Ncm. After the final functional and esthetic check, the screw access channels were sealed with cotton pellets and the Sinfony-Flow Composite (Espe). The patient was pleased, as was the treating team, about the very successful restoration (Figs. 24 to 27). Fig. 13: The post-healing control OPG confirms the good osseointegration of the two CERALOG® Implants. Fig. 19: The impression of the two CERALOG® Implants with open tray technique and IMPREGUM precision impression material. Fig 22: The precisely positioned screw access channels. Fig. 14: The 2.5 mm high gingiva formers were used to shape the soft tissue. Fig. 15: The occlusal view of the two gingiva formers directly after the exposure surgery. CASE STUDY Fig. 20: The master cast with removable gingival mask. The shape of the soft tissue is clearly visible. Fig. 21: The milled, splinted crowns were bonded to the PEKK abutments. Fig. 23: The precise transition of the crowns to the PEKK abutments.