December 2018 The CAMLOG Partner Magazine 19 THE 6TH CAMLOG DENTAL TECHNOLOGY CONGRESS
logo 19 • CAMLOG Partner Magazine • December 2018 EDITORIAL 2 Dear readers it’s difficult to believe. But the key to success is really quite simple: listening to each other, talking to each other properly, questioning the familiar, realigning oneself mentally and being open to new ideas. Today you are holding our partner magazine logo in your hands, in which you can find the latest news and interesting facts about CAMLOG. Next year we will celebrate our 20th anniversary in Germany. During this period CAMLOG developed rapidly. New business fields, areas of responsibility and numerous new projects emerged. This also led to frequent changes. Accepting these changes and repositioning the company accordingly have made CAMLOG a market leader in Germany. And as everyone knows: success comes to those who inspire their patients or customers. But very few people are aware that it is the enthusiasm of employees that leads the way. One of the most important tasks is therefore not only to motivate our employees, but also to inspire them. We at CAMLOG have always placed great emphasis on a good communication and corporate culture. Our receptiveness to new ideas, our passion for working as a team and our foresight for the necessary changes are essential components of our success. In the future, competition among dental practices, laboratories and companies will be governed not only by the brands of products and services, but also by the employer as a brand. It is only in a good corporate climate that the economic success of a company can flourish. In an environment where work is fun, it is easier to become involved, tap one’s full potential, develop creativity and drive innovation. Times are changing and change in our industry opens up many opportunities. Everyone should therefore ask themselves what they can and must do to shape their future in a positive way. Digitization is in full swing not only in industry as a whole, but also in dentistry and dental technology. In recent years, medical research has created many smart medical devices that impress with their interactive capabilities. As a result, manufacturing technologies are moving at a rapid pace from analog applications to digital workflows. We at CAMLOG look to the future with great optimism and want to remain on course for the FUTURE together with our customers through excellent products and as many fresh and good ideas as possible. I wish you a pleasant Christmas Season, many good thoughts and a lot of pleasure while reading. Sincerely Michael Ludwig Managing Director CAMLOG Vertriebs GmbH THE HAPPINESS OF YOUR LIFE DEPENDS ON THE QUALITY OF YOUR THOUGHTS. Marc Aurel
logo 19 • CAMLOG Partner Magazine • December 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 • www.camlog.de, Editorial staff: Oliver Ehehalt (responsible), Michael Ludwig, Anela Mehic, Françoise Peters, Andrea Stix, Ingrid Strobel • Photos: all photos are by CAMLOG except the photos on pages 1, 25, 35, 27-30, 32-35: stock.adobe.com/de, p.4-5: INSIGHTS Dental, p.6-23: see list of authors, p.26-27: Anne Barfuß • Design: Kerstin Gerhardt • Print: Wurzel Mediengruppe, Esslingen • Print run: 18.000 copies. Note: Named contributions express the opinion of the author and not necessarily the opinion of the publisher. Trademarks mentioned in the articles may be legally registered trademarks, as indicated in each case when first mentioning a trademark in this publication. For better legibility we do not indicate the corresponding brand name in the rest of the document. CONTENT SCIENCE / CLINICAL RESEARCH • INSIGHTS Dental, the personalized knowledge platform and APP 8 CASE STUDY • Complex rehabilitation using implant-supported telescope constructions 10 Dr. Eleftherios Grizas • Implant esthetics – Interplay between superstructure and soft tissue 16 PD Dr. Gerhard Iglhaut • Reconstruction of a three-dimensional bone defect with patient-specific CAD/CAM titanium mesh 22 Dr. Amely Hartmann, Dr. Marcus Seiler MSc. MSc., Dr. Silke Stuff PRODUCTS • PROGRESSIVE-LINE is coming: new implant body – proven connection 32 INTERNATIONAL • Greater presence in Western Europe – CAMLOG acquires majority stake in Pro-CAM Implants B. V. 33 NEWS • iSy expert discussion at the University of Frankfurt – at the Round Table of the Deutscher Ärzteverlag 34 • New sales building in Wimsheim inaugurated – CAMLOG expands its location in Germany 36 PRACTICE MANAGEMENT • Leadership: unwritten rules in teams 38 LIFESTYLE • Frankfurt am Main – AWESOME metropolis for the advanced 50
SCIENCE / CLINICAL RESEARCH logo 19 • CAMLOG Partner Magazine • December 2018 4 INSIGHTS Dental, the Smart Companion platform, is designed for professional continuing education in dentistry. It was already introduced in April 2018 at the Oral Reconstruction Global Symposium in Rotterdam. Registered dentists have access to a dedicated community, use the personalized dental knowledge platform for expert discussions, benefit from exclusive features such as the Social Wall and current program updates. More than 140,000 surgeons covering a wide range of medical specialties are already using the network worldwide. INSIGHTS DENTAL, THE PERSONALIZED KNOWLEDGE PLATFORM AND APP The unique technology platform enables the provider, Medical INSIGHTS AG, to independently aggregate neutral medical content from different online sources in an appealing and innovative manner. The mission of Medical INSIGHTS AG, founded in 2011 in Basle, Switzerland, is to become the world’s leading, subject-specific, dynamic mobile magazine and information platform for individual medical specialties. A platform that allows specialists to stay up-to-date and to focus on the content that is most relevant to them while interacting with colleagues, thought leaders and industry partners. Time-independent selective further training opportunity In April 2018, Medical INSIGHTS provided the INSIGHTS Dental global knowledge community app free of charge to professionals working in dentistry and dental implantology. The Oral Reconstruction Foundation was one of the first partners to be integrated into this community platform. Join the knowledge communities and interact with dentists from around the world and exchange views with opinion leaders. Share your knowledge in a global community of practitioners and specialists. The members receive content specially tailored to their needs from dental journals, PubMed as well as reputable associations. By utilizing the subject-specific, personalized, up-to-date and mobile knowledge offers you are sent, you can train yourself further according to your needs and in your own time as well as contributing to the further training of others. Personal privacy and data protection are a central focus Medical INSIGHTS personalizes the service according to the individual interests of the community members. They have control over all data stored about you
logo 19 • CAMLOG Partner Magazine • December 2018 5 SCIENCE / CLINICAL RESEARCH in the Community at all times. In an online Personal Learning Record, you can evaluate these data and decide for yourself which of your CPD activities (Continuous Professional Development) are to be stored in your Personal Learning Record and who is allowed to view these data. Tailor-made further education according to individual preferences Assumption: amember of INSIGHTS Dental begins with the dental implantological care of his patients in his/her practice, becomes increasingly involved with research and development in this field and studies clinical trials and case studies. Based on his/her profile and implicit behavior in the Community, INSIGHTS Dental assigns him/ her topic-related, relevant content. He/she will then also be networked with peers and key opinion leaders according to his/ her needs for knowledge, and who will recommend suitable closed Study Clubs for the future. Focus on physicians INSIGHTS Dental is the open Community of and for dentists and related specialists. The main objective is to optimally support their Continuous Professional Development (CPD) processes. In its endeavors to optimally promote international exchange, the platform for example offers members opportunities for direct exchange in their native language. The translation services of the platform ensure overall communication in this process. Interested physicians receive free access via downloads of the mobile applications in AppStore and PlayStore or on the Internet directly from https:// dental.insights.md/.
logo 19 • CAMLOG Partner Magazine • December 2018 6 Dr. Eleftherios Grizas, Dogern COMPLEX REHABILITATION USING IMPLANT-SUPPORTED TELESCOPE CONSTRUCTIONS Fig. 1: Initial clinical findings of the fixed reconstruction after 25 years in situ. In addition to restoring chewing function and chewing comfort, the focus of a complete dental restoration is on taking esthetic and phonetic factors into consideration. Furthermore, risk factors for both technical as well as biological complications should be minimized as far as possible. This case report describes how a practice concept for functional and esthetic implant-supported rehabilitation can be developed and therapeutically implemented through consistent planning. Initial situation The 48-year-old patient presented in the practice with the wish for a new complete restoration of her dentition (Figs. 1 to 3). According to the patient, the existing fixed reconstructions have been in situ for over 25 years. Due to multilocal secondary caries and chipped veneers, the existing restoration was classified as being insufficient. The X-ray revealed generalized horizontal bone resorption to a medium degree as well as multiple apical osteolysis zones (Fig. 4). There were no functional complaints. The patient wished for an esthetic, functional and long-lasting restoration of the upper and lower jaw. There were no known general medical disorders and she was a non-smoker. Due to the numerous lesions, it was decided to perform extensive surgical reconstruction and to realize rehabilitation with a purely implant-supported restoration using double crowns. To keep the duration of treatment as short as possible and also to maintain the patient’s accustomed chewing comfort during the healing period, immediate implant placement with an immediate temporary restoration was to be aimed for. Implantological restoration in the upper jaw The three-dimensional X-ray examination showed that placement of the implant in the upper jaw would only be possible with bilateral bone augmentation in the sense of an external sinus lift on both sides. After extraction of the teeth, a mucoperiosteal flap was prepared to expose the lateral wall of the maxillary sinus. To gain access to the sinus, a bone cover was prepared osteoplastically using piezo surgery (Figs. 5 and 6). The Schneider’s membrane was then shifted cranially until the medial maxillary sinus wall was exposed (Fig. 7). A Mem-Lok collagen membrane (BioHorizons®) was inserted to stabilize the elevated mucosa (Fig. 8). The prepared bone bed was filled with MinerOss® XP Cancellous (BioHorizons) (Fig. 9). The bone cover was repositioned and fixed in the opening to give a precise fit (Fig. 10). A total of six CAMLOG® SCREW-LINE Implants (region 15, 14, 24, 25 Ø 4.3 mm/L 11 mm, region 13, 23 Ø 4.3 mm/L 13 mm) were inserted (Fig. 11). To protect the implants during the healing phase, we decided to use two LODI® implants in region 12 and 22 (Ø 2.9 mm/L 10 mm) for the stable anchoring of the interim restoration (Figs. 12 and 13). Within the context of lateral augmentation, existing bone deficits were reconstructed using Mem-Lok® and MinerOss XP Cancellous (Figs. 14 and 15). For submerged healing, the soft tissue was closed saliva-proof over the CAMLOG SCREW-LINE Implants. Tooth 16 CASE STUDY Fig. 2: The insufficient restoration in the upper jaw with a unilateral free-end situation. Fig. 3: The lower jaw presented with multiple acrylic chipping of the cemented gold bridges.
logo 19 • CAMLOG Partner Magazine • December 2018 7 Fig. 4: The panoramic tomographic image confirms the inadequate restoration of both jaws. Fig. 5: The lateral window was opened using piezo surgery. Fig. 7: The Schneider´s membrane was prepared cranially and the medial wall was exposed. Fig. 9: The sinus was filled with porcine bone substitute material MinerOss XP (BioHorizons). Fig 8: To protect Schneider´s membrane, a Mem-Lok membrane (BioHorizons) was inserted into the sinus. CASE STUDY Fig 11: The CAMLOG SCREW-LINE Implants (Ø 4.3 mm D/ L11 mm) were placed simultaneously. Fig. 12: Two LODI implants (Ø 2.9 mm/L 10 mm) were used to anchor the temporary restoration in a stable position. Fig. 10: The bone cover was repositioned exactly over the window. Fig. 13: Insertion of the LODI implant. Fig. 14: Existing bone deficits in region 13 were reconstructed by lateral augmentation with porcine bone substitute material. Fig. 6 : The prepared bone cover was stored in saline solution for later use. Fig. 15: The augmented region was initially covered with a Mem-Lok membrane.
logo 19 • CAMLOG Partner Magazine • December 2018 8 was left temporarily and incorporated into the temporary restoration. Using two Locators® screwed onto the two Lodi implants, the interim prosthesis could be secured securely and reliably to protect the definitive implants (Figs. 16 and 17). Implantological restoration in the lower jaw In terms of restoration of the lower jaw, it was decided to combine extraction of the teeth not worthy of preservation with immediate implant placement and a fixed temporary immediate restoration. After tooth extraction, four CAMLOG SCREW-LINE Implants (region 35, 33, 43 Ø 4.3 mm/L 11 mm, region 45 Ø 4.3 mm/L 9 mm) were inserted with primary stability. Next, straight COMFOUR® Bar abutments were placed on the four implants (Fig. 18). For temporary immediate restoration, we screwed the titanium caps onto the bar abutments without a rotation lock (Fig. 19). To prevent the polymer from flowing into the screw access channels of the titanium caps when bonding the acrylic bridge fabricated beforehand, we sealed them with wax prior to polymerization. After intraoral “bonding”, the bridge was removed and the excess acrylic was removed from the bonding areas, the transitions were carefully finished and polished (Figs. 20 and 21). After insertion, the construction was checked for a tension-free fit and cleanability. Exposure of the implants in the upper jaw After a healing period of four months, the six implants in the upper jaw were exposed. In the first quadrant, exposure of the implants was combined with soft tissue augmentation to improve the thin gingival situation of the implant in region 13. Volume augmentation of the peri-implant gingiva was achieved with a palatally reinforced connective tissue graft (Figs. 22 to 24). In the second quadrant, the volume of peri-implant gingiva was found to be adequate. However, keratinization of the peri-implant gingiva was insufficient in the area of the implant in region 23. A zone of keratinized gingiva was achieved buccally to the implants using an apical displacement flap (Figs. 25 and 26). Impression taking and bite registration of the implants The primary impression of the implants was taken 8 weeks after exposure at implant level using impression posts for the closed impression and a prefabricated impression tray (Figs. 27 and 28). Two registration templates were fixed to the sulcus formers to determine the bite registration. The esthetic and functional criteria such as the dental center, the canine lines and the maximum smile line were defined and marked in the wax wall. The bite height was taken from the temporary prosthesis. Registration material applied to the templates encoded the bite registration (Fig. 29). Facebow registration was used for extraoral registration. Intraoral bonding – pick-up impression In the laboratory, the models were fabricated and a complete diagnostic setup was implemented in wax. A wax try-in is indispensable to ensure a functionally ideal and esthetically appealing prosthetic Fig. 17: The interim restoration was fixed via locators that had previously been screwed onto the LODI implants. Fig. 16: The soft tissue was sutured salivaproof and tension-free. Fig. 18: In the lower jaw, the remaining teeth were extracted, four CAMLOG SCREW-LINE Implants were placed and COMFOUR Bar abutments screwed in. CASE STUDY Fig. 22: The implants in the upper jaw were exposed via crestal incision. Fig. 23: To improve the soft tissue volume in region 13, a palatally reinforced graft was inserted. Fig. 24: Single button sutures were used to close the soft tissue around the screw-retained gingiva formers.
logo 19 • CAMLOG Partner Magazine • December 2018 9 restoration (Fig. 30). The preparatory measures for the fabrication of the individual CAD/CAM abutments were taken on the basis of this set-up. These were designed virtually and ordered from the DEDICAM fabrication service. The individual telescope abutments were inserted definitively and mounted with the torque recommended by the manufacturer (Figs. 31 to 33). The galvanically fabricated secondary crowns were placed on the primary crowns (Figs. 34 and 35). Tooth 16 as well as the LODI implants were extracted. The treatment protocol calls for intraoral bonding of the secondary crown to the tertiary framework, under confirmation of the determined bite registration (Figs. 36 and 37). A pick-up impression of the framework was then realized using an individual tray. As the abutments remain in the mouth with this concept, a specially Fig. 20: The prefabricated restoration was checked intraorally for tension-free status. Fig. 19: The COMFOUR Titanium caps were screwed on before closure of the soft tissue. CASE STUDY Figs. 25 and 26: In the second quadrant, an apical displacement flap was prepared during exposure to increase the keratinized peri-implant mucosa. Fig. 27: The impression was taken eight weeks after exposure. Fig. 28: The primary impression was taken with prefabricated trays and the impression posts for the closed technique. Fig. 29: The registration templates were fixed in a stable position on the gingiva formers during determination of the bite registration. Fig. 21: The titanium caps for the immediate screw-retained temporary restoration were polymerized using PMMA plastic. Fig. 30: A wax try-in is indispensable for checking the functional and esthetically pleasing overall restoration.
logo 19 • CAMLOG Partner Magazine • December 2018 fabricated replacement prosthesis was used for the intermediate restoration. This so-called travel prosthesis can serve as a temporary solution for the patient in the event of repairs to her restoration. (Figs 38 and 39). Finishing The placement of the final denture takes less time, as the supraconstruction fits precisely due to the exact intraoral bonding and no longer makes any friction correction necessary. (Figs 40 and 41). The consolidation of the BRM as well as the good peri-implant bony conditions are shown in the x-rays (Figs. 42 to 45) after placement of the definitive denture. Discussion The double crown technique on implants is able to offer esthetically appealing solutions while at the same time offering patients a high level of safety in terms of function and stability [1]. Furthermore, the fixed but removable prosthetics offer universal sustainability when external help is needed in old age or in case of repairs, and last not least in case of dental treatment. The removable denture also guarantees good hygienic capability and a desirable good prognosis as a result [2,3]. Due to their easy handling and small diameter, the one-piece LODI implants can be used to stabilize the temporary restoration for implant-protected healing. In the present case, we decided to integrate them into the treatment plan as interim implants. The integration on the resilient locators was not an option for the treating team for the telescope restoration. Acknowledgements My sincere thanks go to the friendly patient as well as to my consistently motivated professional treatment team. I am especially indebted to MDT Robert Russek, who supports me daily with advice and assistance with his profound dental technical knowledge. Fig. 32: The individual DEDICAM abutments or primary parts were screwed in. Tooth 16 and the LODI implants in region 12, 22 were removed in this session. CASE STUDY 10 [1] Koller B, Att W, Strub JR. Survival rates of teeth, implants, and double crown-retained removable dental prostheses: a systematic literature review. Int J Prosthodont 2011; 24:109-117 [2] Verma R, Joda T, Brägger U, Wittneben JG. A systematic review of the clinical performance of tooth-retained and implant-retained double crown prostheses with a follow-up of ≥ 3 years. Int J Prosthodont. 2013;22:2-12 [3] Weng D, Richter EJ. Maxillary removable prostheses retained by telescopic crowns on two implants or two canines. Int J Periodontics Restorative Dent. 2007;27:35-41 LITERATURE Fig. 38: The temporary restoration in the upper jaw was smoothed at the points of the primary parts and relined there with permanent soft relining material. Fig. 39: As the telescope abutments remain in the mouth until the final restoration, a prefabricated travel prosthesis was placed in the lower jaw. Fig. 31: The telescope solution was realized with custom-made CAD/CAM telescope abutments and galvanic caps. Fig. 33: The screw-retained temporary restoration and the COMFOUR Abutments were removed from the lower jaw and the four DEDICAM telescope abutments were placed. Fig. 37: The splints for determining bite registration had been prepared in the laboratory on the tertiary frameworks.
logo 19 • CAMLOG Partner Magazine • December 2018 Dr. Eleftherios Grizas Dr. med. dent. Eleftherios Grizas has been practicing as a dentist and oral surgeon at MKG Hochrhein in Dogern near Waldshut since 2013. His clinical specialties include the complex complete implant-based rehabilitation, peri-implant soft tissue management as well as implant prosthetics. After his studies at the University of Athens in Greece, he received his doctorate in 2010 under Prof. Dr. Lauer at the Polyclinic for Dental Prosthetics at the University Hospital Frankfurt. He completed his 3-year specialist training as an oral surgeon in 2013 at the Polyclinic for Dental Surgery and Implantology under Prof. Dr. Nentwig at the same dental faculty. Between 2013 and 2015, he worked as a tutor for Dr. Weigl in the Department of Postgraduate Education as part of the Master of Science (MSc.) in Oral Implantology. Contact details Dr. med. dent. Eleftherios Grizas Specialist in oral surgery MKG Hochrhein Hauptstraße 25, 79804 Dogern el.grizas@googlemail.com AUTHOR Fig. 35: The galvanic caps were silanized for bonding in the mouth. Fig. 36: The prefabricated tertiary framework was prepared for intraoral bonding. Bite registration was determined on a precisely fitting tertiary framework. Fig. 40: Incorporation, functional testing and checking of the hygienic capability proceeded smoothly and quickly due to the intraoral bonding. 11 Fig. 34: The galvanic caps were attached to the abutments. Fig. 41: The lateral view shows the individuality of the telescope restoration. Fig 43: The bone substitute material is consolidated very well. Figs. 44 and 45: In the lower jaw too, the peri-implant bony conditions are irritation-free after insertion of the definitive restoration. Fig. 42: The radiological condition in the upper jaw after insertion of the final dental prosthesis.
logo 19 • CAMLOG Partner Magazine • December 2018 12 PD Dr. Gerhard Iglhaut, Memmingen IMPLANT ESTHETICS INTERPLAY BETWEEN SUPERSTRUCTURE AND SOFT TISSUE Fig. 1: The initial situation revealed inflammatory tissue in the anterior region of the upper jaw. Fig. 3: The DVT showed clear apical resorption of tooth root 11 and apical lesions on all three anterior teeth. An important interface for implant-prosthetic restorations in the esthetic region is the emergence profile of the superstructure. In addition to correct implant positioning, an adequately and anatomically shaped jawbone is therefore just as essential as a thick, fixed gingiva for a long-term stable reconstruction – both from an esthetic and biological point of view. The following clinical case presentation describes a treatment concept following anterior tooth trauma with immediate implant placement as well as hard and soft tissue augmentation [1]. Immediate implant placement is a challenge for the treating team, especially in the esthetic zone. Despite high survival rates, the risk of postoperative complications is relatively high [2]. The reason being resorption of the periimplant hard tissue and subsequent buccal recession of the soft tissue. This often leads to the exposure of titanium surfaces and consequently to considerable esthetic impairment. Furthermore, these defects are rather difficult to correct. A proactive treatment protocol taking which takes the biological remodeling processes into consideration is indispensable for the reconstruction or preservation of stable peri-implant tissue. Patient’s medical history In January 2015, a 49-year-old man with complaints in the anterior region of the maxilla presented in the practice. He stated that he had been in an accident over 20 years ago and had suffered a trauma in the anterior region. The anterior teeth 12 and 21 were treated endodontically alio loco and restored with post abutments and ceramic veneered crowns. Over time, both teeth had been resected several times. During intraoral examination, a loosening of teeth 12, 11 and 21 was observed. The DVT showed intact alveoli on 12 and 21, partial bone loss of the facial lamella in region 11 as well as a distinct apical resorption of tooth root 11. All three anterior teeth exhibited apical foci (Figs. 1 to 6). Therapy planning The prognosis for the preservation of the above mentioned anterior teeth was judged to be very unfavorable. Consequently, the resulting indication implied extraction of teeth 11, 12 and 21. For esthetic reasons, a bridge reconstruction on two implants in region 12 and 21 was planned. Treatment with immediate implantation was chosen to counteract the natural healing of the alveolar socket, which may result in a flattening of the interdental papillae and the facial contour of the alveolar process. By considering the biological remodeling processes and adequate hard and soft tissue augmentation, an esthetic result can be planned proactively. With three implants, the required minimum distance of 4 mm between the implants (Ø 3.8 mm) would not have been given. In addition to the height of the alveolar bone, the thickness of the vestibular lamella is a prerequisite for creating an ideal emergence profile. The bone also supports and stabilizes the harmonious contour of the gingival profile – the criterion for the long-term success of an esthetic reconstruction. To preserve esthetics, the positioning of the implants is just as important as the consideration of biological factors. For sufficient stability of the buccal bone wall, the circular bone in the region of CASE STUDY Fig. 2: During the intraoral examination the loosening of the multiple resected anterior teeth 11, 21 and 22 was ascertained.
logo 19 • CAMLOG Partner Magazine • December 2018 13 the implant neck should be developed or preserved to a thickness of approximately 2 mm. For this reason, it is necessary to align the implant position in the sagittal dimension towards palatal and to build up a distance of approx. 2 mm [3;4] (“jumping distance”) between the facial bone wall and the buccal implant neck. The cavity between the implant and the bone lamella should be filled with modern bone substitute materials to ensure safe filling of the gap with bone. Implant surgical intervention To avoid postoperative wound infections, the patient was given antibiotic cover preoperatively. 1000 mg amoxicillin three times a day for one week was given as preventive treatment. First, the teeth were extracted gently using a periotome to preserve the bony structures and the alveoli were cleaned of inflammatory tissue residues using a bone curette. Implant positioning was performed using the 3D implant positioning system [5]. To preserve the buccal bone wall, the sagittal orientation was aligned palatally. The vertical positioning depends on the buccal bone margin level and the implant hardware and is determined by measuring the biological width of the adjacent tooth. The distance between the gingival margin to the bone was 3 mm in each case. The expansion of the sleeves corresponds to the most common implant diameters (3.3; 3.8 and 4.3 mm), taking into account the required distance of 2 mm to the adjacent tooth or 4 mm between two implants. First, the implant positions in region 12 and 21 were determined by placing the 2 mm extension of the sleeve against the buccal wall of the alveolus (Figs. 7 and 8). Pilot drilling for the exact 3D alignment was performed centrally through the sleeve. The implant sites were prepared for the insertion of two implants (tapered internal implant Ø 3.8 mm/L 11 mm, BioHorizons, Birmingham, AL) with the appropriate system drills. The implants were inserted with primary stability and the “Jumping Distance” of approx. 2 mm was filled with bovine bone substitute material (MinerOss® X Granulate/BioHorizons) to stabilize the bone wall. Subsequent augmentation of the alveolar bone in region 11 to reconstruct the buccal wall was performed with the alveolar protector (KLS Martin, Tuttlingen). The shape of the protector made of resorbable poly-D-L lactide allows the threedimensional construction of the alveolar ridge with a minimally invasive procedure. [6]. The protector is dimensionally stable and the degradation process begins after about 4 months. Bone augmentation is essential to create an anatomically shaped alveolar ridge and to maintain a natural mucogingival margin. After the minimally invasive preparation of a mucoperiosteal flap, the alveolar protector was inserted into the prepared pocket (Fig. 9). Owing to this flap formation, the protector could be inserted exactly, so that the system-inherent fixation using a pin with ultrasound (Sonic Weld) became unnecessary. Augmentation was performed with MinerOss X (BioHorizons). The bone substitute material is well suited for alveolar management. With a particle size of 250 to 1000 µm, it can easily be inserted into the defect site. The bimodal pore structure leads to rapid blood uptake of the material (Fig. 10). The natural consistency and the complex trabecular framework promote ideal new bone formation. Slow resorption rate provides the required stability for the buccal wall. Fig. 4: The alveoli on 12 and 21 were intact, but partial bone loss was visible on the facial lamella in region 11. Fig. 5: The sectional view of tooth 21 showed congested root filling material and the fractured root tip. Fig. 6: The sectional view shows the loss of facial lamella and root resorption of tooth 11. Fig. 7: After gentle extraction of the teeth, the implant positions were determined using the 3D implant positioning system. Fig. 9: To create an anatomically shaped alveolar ridge, an alveolar protector was inserted into the prepared mucoperiosteal pocket. Fig. 8: To preserve the buccal bone wall, the sagittal orientation of the implants was aligned palatally. CASE STUDY
logo 19 • CAMLOG Partner Magazine • December 2018 14 Fig. 16: The peri-implant soft tissue, which was thickened with the rolled flap technique during exposure, had healed stably by the time the impression was to be taken. Fig. 17: During impression taking (open tray technique), the attached soft tissue with a clearly developed incisal papilla was visible. Fig. 18: A removable gingival mask is essential for the design of the subgingival abutment portion. Covering the defect site A saliva-proof primary wound closure is essential for the success of bone reconstruction. The bacteria-tight wound closure prevents inflammatory-resorptive remodeling processes. In the present case, the extraction wounds were covered with free combined connective tissuemucosa grafts taken from the palate in regions 13 to 15, 23 to 25 and 16 to 18. The grafts were de-epithelialized by approximately half. The combined grafts were placed on the alveolar openings with the epithelial supporting section and under the vestibular mucosa with the connective tissue section. Then the grafts were sutured saliva-proof (Figs. 11 and 12). The bilaminar provision of connective tissue increases nutrition to the grafts and thus ensures complicationfree closed healing [7]. In addition to better integration, soft tissue thickening and stabilization occurs both vertically and horizontally in the esthetic zone. This preventive procedure is indispensable for achieving a natural emergence profile. In addition, it minimizes the shrinkage of the localized fixed gingiva [8]. The preoperatively fabricated temporary restoration was used in the form of an interim prosthesis with a palatal plate. The bases of the three replaced front teeth had been shortened to avoid unfavorable pressure during the swelling phase. The prosthesis also served as a dressing plate to protect the graft harvesting sites (Fig. 13). A stable soft tissue situation was observed following suture removal after two weeks and after healing without complications (Figs 14 and 15). The implants were exposed four months after insertion. The incision was placed slightly palatal around the implants. Next to exposure, this cutting technique allowed the formation of two rolled flaps for additional soft tissue thickening. The flaps were deephitalized, buccally wrapped in tunnels and fixed with sutures. An impression taken six weeks later revealed a stable, fixed peri-implant soft tissue with a clearly developed incisal papilla. The transfer posts for the open tray technique were used to take an impression of the two implants and the entire upper jaw (Figs. 16 and 17). In the laboratory, the dental technician fabricated the master cast with removable gingival mask and mounted it in the articulator in which the temporary restoration had previously been fabricated with facebow transfer. Using a matrix from the esthetic set-up, he drew the crown emergence profile on the removable gingival mask and contoured the subgingival area to the implants and the pontic according to the anatomical profile (“ovate pontic design”). The design of the subgingival portion of the abutments and pontics is essential for a natural crown emergence profile. Zirconium dioxide (ZrO 2 ) has proven itself for superstructures in the anterior region, not only because of the stability and flexural strength of the material, but also because of the significantly reduced microbial colonization of ZrO 2 . In a systematic review [9], Nakamura et al. (2010) conclude that zirconium dioxide abutments can be used for single-tooth restorations in the anterior region with a high degree of reliability. The transition to the mucous membrane is free of irritation, which ensures long-term stable clinical results. Due to the root-like color, CASE STUDY Fig. 10: Augmentation of the defect site and filling of the jumping distance was performed with the bovine bone substitute material MinerOss X. Fig. 11: The free combined connective tissue-mucosa grafts were placed on the alveolar openings with the epithelial supporting part. Fig. 12: The connective tissue part of the combination graft was placed under the vestibular mucosa and the grafts were then sutured saliva-proof.
logo 19 • CAMLOG Partner Magazine • December 2018 15 Fig. 22: The crown margin was placed 0.5 mm to 1 mm below the mucosa border in order to remove cement residues effortlessly. Fig. 19: The zirconium dioxide abutments were fabricated using the CAD/CAM process and bonded to titanium bases. Fig. 23: Due to the anatomically shaped emergence profile, the peri-implant mucosa was displaced vestibularly with slight pressure. Fig. 20: The zirconium dioxide bridge framework was designed digitally, milled and fully veneered with corresponding zirconia materials. Fig. 24: The soft tissue was supplied with blood after a short time. The oral view shows the anatomical shape of the augmented jaw region. Fig. 21: The subgingival part of the abutments and the “ovate pontic design” design of the bridge pontic support an esthetic crown emergence profile. CASE STUDY the subgingival part closely resembles the natural appearance of a tooth. The abutment design was created digitally, fabricated using a CAD/CAM process and bonded to titanium bases. The crown margin was placed 0.5 mm to 1 mm below the mucosal border so that the cement could be removed effortlessly when inserting the bridge. Then the zirconium bridge framework was designed digitally, milled and fully veneered with the corresponding zirconium materials (Figs. 18 to 21). The definitive implant restoration was inserted in mid-December 2015. After the gingiva formers had been removed, the internal configurations of the implants were rinsed and the hybrid abutments screwed in. Due to the submucous anatomical shape of the emergence profile, the round shaped peri-implant mucosa was displaced vestibularly with slight pressure (Figs. 22 to 24). A diamond was used to contour the gingiva for the pontic support in the form of an ovate pontic. The peri-implant gingiva was well supplied with blood after approximately ten minutes. After checking the esthetics, function and phonetics, the bridge was integrated definitively to the satisfaction of all concerned (Durelon, 3M Espe, Herrsching). With the help of analog abutments, excess cement was removed before insertion and surplus cementing was avoided (Figs. 25 to 27). In the follow-up after three years, both the control X-ray and the clinical image show the successful esthetic and longFig 13: To avoid unfavorable pressure during the swelling phase, the interim prosthesis was shortened in the anterior region. Fig. 15: The augmented anterior tooth region presented itself with an anatomically shaped contour prior to exposure surgery. Fig. 14: After healing without complications, a stable soft tissue situation was observed two weeks postoperatively.
logo 19 • CAMLOG Partner Magazine • December 2018 16 CASE STUDY term stable anterior tooth reconstruction with a healthy fixed gingiva and the harmonious contour of the gingival garland (Figs. 28 and 29). Conclusion Esthetic maxillary anterior reconstruction is one of the greatest challenges in dental implantology. When extracting non-sustainable teeth, it is important to preserve the intact facial lamellae or to regenerate both the alveolar ridge as well as the alveoli by augmentation. The stabilization of the bone lamella around implants with slowly resorbable bone substitute materials has proven successful. The design of the subgingival abutment portion plays a decisive role for the long-term stability of the esthetic result. The individually fabricated CAD/CAM zirconium abutments support the periimplant soft tissue, are biocompatible and reduce the risk of inflammation around the implant/abutment interface. The emergence profile is determined by the anatomically correct design of the superstructure and contributes significantly to the harmonious overall impression of the reconstruction. The prosthetically oriented placement of the implants and the indication-related design of the abutments optimally transfer the occurring chewing forces to the internal configuration of the implants and prevent damaging shearing forces on the implant neck. This supports periimplant bone preservation and promotes gingival adaptation. Fig. 28: In the follow-up after three years, the anterior tooth reconstruction is stable. Fig. 29: The clinical picture at the follow-up shows the healthy fixed gingiva and the harmonious contour of the gingival garland, which was supported by contouring the gingiva with a diamond for the bridge support prior to the insertion of the reconstruction. Fig. 25: With the help of analog abutments, excess cement was removed before insertion and surplus cementing was avoided. Fig. 26: After the functional and esthetic check, the bridge was inserted definitively to the satisfaction of everyone involved. Fig. 27: The X-ray control image at the time of insertion.
logo 19 • CAMLOG Partner Magazine • December 2018 17 CASE STUDY PD Dr. Gerhard Iglhaut Assistant Professor Dr. Gerhard Iglhaut is a graduate of the Justus Liebig University in Giessen and has been working in private practice in Memmingen since 1987. In addition, he has been involved in continued dental education for more than two decades. Today, Dr. Iglhaut is a national and international speaker in the fields of implant dentistry, periodontology, plastic periodontal surgery and periodontal microsurgery. He also teaches as a lecturer and is a research associate at the University Hospital of Freiburg. From 2012 to 2015, Dr. Gerhard Iglhaut was President of the German Society of Implantology (DGI) – the largest scientific implantological association in Europe for three years. Contact details Praxis für Zahnheilkunde und Oralchirurgie Bahnhofstraße 20 87700 Memmingen praxis@dr-iglhaut-praxis.de AUTHOR [1] Fu J-H, Lee A, Wang H-L. Influence of tissue biotype on implant sthetics. Int J Oral Maxillofac Implants 2011;26:499-508 [2] Chen ST, Buser D. Clinical and esthetic outcomes of implants placed in postextraction sites. Int J OraL Maxillofac Implants 2009;24(Suppl):186-217 [3] Tarnow DP, Cho SC, Wallace SS. The effect of inter-implant distance on the height of inter-implant bone crest. J. Periodontol. 2000;71(74):546-9 [4] Choquet V, Hermans M, Adriaenssens P, Daelemans P, Tarnow DP, Malevez C. Clinical and radiographic evaluation of the papilla level adjacent to single-tooth dental implants. a retrospective study in the maxillary anterior region. J Periodontol 2001;72:1364-71 [5] Iglhaut G, Implant Surgical Guide and Positioning System A Case report. International journal of Oral Implantology 2003_1;22-26 [6] Iglhaut, G, et al., Shell technique using a rigid resorbable barrier system for localized alveolar ridge augmentation. Clin Oral Implants Res, 2012 [7] Iglhaut G, Terheyden H, StimmelmayrM. Der Einsatz von Weichgewebstransplantaten in der Implantologie. Z Zahnärztl Impl 2006;22: 56–60 [8] Iglhaut G, Schliephake H. Weichgewebemanangement und –augmentation in der Implantatchirurgie.Dtsch Zahnärztl Z 2010;65:304-18 [9] Nakamura K, Kanno T, Milleding P, Ortengren U. Zirconia as a dental implant abutment material: a systematic review. Int J Prosthodont 2010;23: 299–309 LITERATURE With our impressive portfolio, we offer you solutions for different treatment concepts and needs in implant dentistry. What all our products have in common: they are perfectly adapted to the requirements of daily practice routines to let you focus fully on your patients. Write your success stories with CAMLOG too. We look forward to welcoming you. www.camlog.com The resorbable collagen membrane Mem-Lok® RCM | Mem-Lok® Pliable The xenogenic bone substitute material MinerOss® X | MinerOss® XP The hemostyptic BioPlug | BioStrip BIOMATERIALS – FOR DIFFERENTIATED INDICATIONS
logo 19 • CAMLOG Partner Magazine • December 2018 18 Dr. Amely Hartmann, Dr. Marcus Seiler MSc. MSc., both Filderstadt, Dr. Silke Stuff , Pforzheim RECONSTRUCTION OF A THREE-DIMENSIONAL BONE DEFECT WITH PATIENT-SPECIFIC CAD/CAM TITANIUM MESH Fig. 1: The initial situation on the OPG. Tooth 26 is not worth preserving due to a perio-endo lesion. Digital workflows in implant dentistry, surgery and prosthetics have found their way into many dental practices today. The scientific topicality and relevance of this field of research also becomes clear when one considers the number of recently published publications on the subject [1-4]. This case report describes a surgical digital workflow in which a single-tooth implant-prosthetic prosthesis is performed with an individual bone reconstruction. Clinical and radiological results after 2 years are presented. The trend towards individualized (dental) medicine enables patient-specific therapy concepts far detached from ready-made molded parts and procedures. Therapeutic measures are offered on the basis of Computer Aided Design/Computer Aided Manufacturing (CAD/CAM) technologies and 3-dimensional (3D) printing. This also includes patient-specific titanium meshes [5-7], which are used in the course of surgical bone augmentation. Generally speaking, this should shorten the intervention time through the associated digital workflows. This is possible as the intervention is simulated virtually on the computer beforehand. The three-dimensional implant position and prosthetic restoration are part of the initial planning here. The contour of the mesh is also designed digitally such that the bone is later rebuilt at the prosthetically ideal position calculated through backward-planning. Studies indicate that intraoperative pre-bending, as is the case with ready-made meshes, is eliminated, reducing patient co-morbidity through faster intervention [5, 8]. The active principle is that the lumen to be augmented is supported, thus avoiding soft tissue collapse. Bone grafts protected by titanium meshes exhibit significantly lower bone resorption [9]. Individual titanium meshes can be used for all types of jaw defects, especially the pronounced vertical and threedimensional reconstructions [10]. Classical alternatives for vertical reconstruction would include segment osteotomy, the onlay technique, distraction osteogenesis or block augmentation. [11, 12]. Purely transversal deficits can be compensated by the ridge-splitting technique, classically by the membrane technique of Guided Bone Regeneration (GBR), or the use of block augmentations [13]. Three-dimensional defects can also be treated using block augmentations or interposition plasty. Here, the autologous blocks are harvested from intraoral and extraoral donor sites. Transplant resorption is to be expected via remodeling of the bone. This knowledge requires distinct overcontouring in planning, as melting of a part of the transplant is to be expected. Increased morbidity of the patient due to a larger harvesting site can result as a consequence as can more difficult soft tissue management at the recipient site. Patient case The 44-year-old patient presented for the first time on 03.02.2015 with complaints in region 26. The patient did not report any abnormalities in her general medical history. She is a non-smoker. When the dental anamnesis was taken, tooth 26 was not worth preserving (Fig. 1) due Fig. 3: Clinical, healed situation three months after extraction. There is only a slight transversal deficit from occlusal. CASE STUDY Fig. 2: Radiologically, there is a pronounced vertical defect in region 26.
logo 19 • CAMLOG Partner Magazine • December 2018 19 to a perio-endo lesion with buccal fistula and putrid secretion. The results for circular pocket depth measurement were 6/10/10/10/12/4. The adjacent teeth were vital and not periodontally damaged. As a future restoration, the patient wanted a fixed, implant-prosthetic rehabilitation with a single-tooth crown. The patient rejected a conventional bridge restoration as a treatment alternative. The patient was in the professional dental cleaning recall program of the referring family dentist’s office. Atraumatic extraction on 06.02.2015 resulted in an interdental gap with threedimensional; largely vertical, bone deficit (Fig.2). The patient was provided with a temporary restoration by her family dentist using a Walplast interim prosthesis. In situ, the soft tissue situation presented itself free of irritation and without scars (Fig.3). Planning In addition to clinical diagnostics, digital volume tomography (DVT) was performed as the basis for further implantological therapy. The bone defect was also pronounced (Fig.4), so that transversal and vertical augmentation had to be planned. This was to be realized by means of an individually fabricated titanium mesh. A one-stage procedure was planned. Compensation of the volume deficit was to be purely additive in the direction of the oral cavity for the later prosthetic restoration; a sinus lift as well as a two-stage procedure were to be avoided (Fig.5). On the one hand, insertion of the customized mesh over the implant would lend itself to avoiding mechanical stress during bone healing. On the other hand, the required augmentation volume would be fixated. A slight overcontouring of the defect was also to be performed. A digital 3D model of the defect was created with the DICOM data (Digital Imaging and Communications in Medicine) of the DVT. Based on the virtual model, a patient-specific mesh (Yxoss®, ReOSS) was designed (Figs. 6 and 7), which was printed in 3D after consultation with the clinician (Figs. 8 and 9). In addition, a virtual and analog model analysis was performed. An analog set-up of tooth 26 was performed to determine the three-dimensional position of the implant. To this end, an X-ray splint was fabricated for precise virtual planning. This could later be used as a surgical splint. Surgical technique A slightly palatally displaced incision was performed in region 25-28 under local anesthesia (Ultracain DS Forte, Hoechst, Germany). This was performed Fig. 4: The virtual 3D model for implantological planning confirms the defect situation. As an additional finding, a restapical ostitis is recognizable in tooth 24. Fig. 5: Planning of the correct implant position according to the prosthetically harmonious implant-to-crown ratio and the required augmentation area. Fig. 6: 3D presentation of the planned mesh from lateral on the basis of the DICOM data set. CASE STUDY Fig. 7: The 3D representation from occlusal. Fig. 9: 3D-printed titanium mesh (Yxoss CBR, ReOSS, Filderstadt) from basal after sterilization. Fig. 8: 3D-printed titanium mesh (Yxoss CBR, ReOSS, Filderstadt) from lateral after sterilization.
logo 19 • CAMLOG Partner Magazine • December 2018 20 without mesial relief and with papillary preservation in the anterior region. Vestibular relief was performed in the retromolar region. After preparation of a mucoperiosteal flap, the threedimensional defect was exposed (Fig. 10). The soft tissue volume was increased by periosteal slitting and tunneling in the vestibule. The fit of the mesh was checked intraoperatively (Fig. 11). Preparation of the implant bed (Fig. 12) was performed in accordance with the usual procedures using the positioning splint parallel to the adjacent teeth. The final apical height was prepared with bone condensers (SCREW-LINE osteotomy set/angulatedconvex, CAMLOG), the bone quality was condensed and the predrilled bone compartment enlarged. The basal sinus floor was checked intraoperatively for completeness. The implant (CAMLOG SCREW-LINE, diameter 5/0, length 11) was inserted under the mesh in the ideal position for the implant prosthesis, which had been calculated in advance (Fig.13). The implant could be inserted primary stable (bone quality 2 according to Adell) in spite of anchorage in the bone only being possible apically. Compensation of the coronal deficit was performed with autologous bone and bone substitute material (Bio-Oss® 1-2 mm, Geistlich Pharma) at a mixing ratio of 1:1. Autologous bone was harvested from the retromolar region and the facial sinus wall using a Safescraper. The prepared mesh was filled with described augmentation material. It was then fixed to the remaining bone with an osteosynthesis screw (Medicon Mikro 1.2/7, Medicon) inserted mesio-bucally to the implant (Figs. 14 and 15). In addition, a collagen membrane was applied occlusally to the mesh (Bio-Gide®, Geistlich Pharma). The wound was closed tightly and tension-free over the titanium framework with single button and deep mattress sutures (5.0 Gore-tex suture, Gore). The postoperative X-ray showed the implant at the planned position with significant vertical bone gain (Fig.16). Continuity of the basal maxillary sinus boundary was still preserved. Postoperatively, the patient received instructions on prosthesis abstention and adequate oral hygiene. The sutures were removed after 10 days at clinically irritation-free wound conditions. After a healing period of 4 months, explantation of the titanium mesh and exposure of the implant were performed in the second intervention. The same local anesthesia was used during the procedure and a minimally invasive ridge incision was made from 5 to 7 without relief. After preparation of a full flap, the fixation screw was removed and the mesh was separated at the coronal predetermined breaking point. The two individual parts could be removed with gentle extrusion movements using the raspatory. The augmented bone volume displayed stable peri-implant dimensions and good vascularization. There were no signs of any inflammation. The cover screw on the implant was replaced by a wide-body gingiva former and tensionfree wound closure was performed. The periotest value (8.0) indicated stable bone integration. The sutures were removed one week later. Radiological control after 6 months revealed no vertical collapses and stable osseous conditions. The maxillary sinus continued to remain free of irritation (Fig 17). The patient was then referred back to the family dentist for further prosthetic Fig. 17: The OPG taken after exposure and mesh removal, displays a stable vertical bone level without losses. Fig. 18: Radiologically, the vertical bone level appears stable even after 2 years. The maxillary sinus is inconspicuous. Restapical ostitis at 24 has disappeared. Fig. 16: : Radiological documentation after insertion of the implant without sinus lift and with titanium mesh. CASE STUDY Fig. 10: Defect situation in region 26 after mobilization of the mucoperiosteal flap – slight transversal deficit. Fig. 11: The sterile titanium mesh for the area to be augmented was tried in situ. Fig. 12: The implant bed was prepared to Ø 5.0 mm / L 9 mmwith drills, followed by further preparation with convex bone condensers.
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