logo 49 | The Camlog Partner Magazine Cover story | 1 THE CAMLOG PARTNER MAGAZINE logo Big reunion in Munich July 2022 49
IMPLANT RESTORATIONS Single-tooth replacement Implant-borne bridge Single crowns on several implants Fixed bridge on eight implants Removable restoration on four implants "DENTAL IMPLANTS – AN INSPIRED INVENTION FOLLOWING THE EXAMPLE SET BY NATURE" Increased quality of life through dental implants. Ask your dentist or inform yourself at www.camlog.com
logo 49 | The Camlog Partner Magazine | 3 Contents Cover Page » Big reunion in Munich 4 Science » Single tooth replacement on titanium bases CAD/CAM – stable restorations supported by scientific results | Peter Thommen 8 Practice case » Digital dentistry intelligently combined with analog craftsmanship| Dr. Blume 12 » Guided Surgery – minimally invasive, scar-free, tissue preserving| Dr. Wenninger, Dr. Schmidtner 18 » Immediate restoration with Guided Surgery and the Socket Shield Technique | Dr. Gómez Meda 24 Products » The truFIX fixation system – the all-in-one bone fixation and membrane stabilization solution 30 » New: Titanium bases CAD/CAM free – flexible solution for the angled screw channel 31 » NovoMatrix, expanded range of indications in the GBR technique 33 Practice Management » Cross-media marketing of ratings – knowing how! 36 News » We say thank you – and wish you an exciting start to the new stage of life 39 » Camlog Group on course for growth: Groundbreaking ceremony for Altatec‘s extension building 42 » New: Defect Regeneration – a casebook 43
logo 49 | The Camlog Partner Magazine 4 | Cover story Frank Schwarz (Co-chairman) Katja Nelson (Co-chairman) Mario Beretta S. Marcus Beschnidt Vincent Fehmer MDT Gerald Krennmair Otto Prandtner MDT Mariano Sanz Alex Schär Michael Stimmelmayr SCIENTIFIC COMMITTEE
logo 49 | The Camlog Partner Magazine Cover story | 5 Following a four-year forced break, everything has now been perfectly prepared to continue in the tradition of the earlier Camlog congresses, or rather today's OR Foundation symposia. The modern atmosphere and the spatial conditions of the Infinity Hotel in Unterschleißheim create the perfect framework conditions for an optimal transfer of knowledge, exchange of experience and personal encounters. The combination of science and practice is a living philosophy at the OR Foundation. This is already reflected in the line-up of the scientific committee and is also expressed by the scientific program, which this time follows the theme of the congress "Dreams and Realities - Treatment Concepts and Trends". "The top-class scientific committee and the commitment of the internationally renowned speakers guarantee that you can expect a differentiated and groundbreaking program in Munich," is how Mariano Sanz (President OR Foundation) and Martin Schuler (Executive Director OR Foundation) summarized the event. On Friday (14 October 2022) you will have the opportunity to enjoy twelve presentations - nine of them in German and two in English: • Session 1: Timing in Implant Dentistry (Ilaria Franchini, Markus Schlee, S. Marcus Beschnidt). Moderation: Frank Schwarz. • Session 2: Treatment Concepts for Demanding Situations (Arndt Happe, Peter Randelzhofer, Anette Strunz). Moderation: Katja Nelson. • Session 3: Treatment Concepts for Elderly or Edentulous Patients (Knut A. Grötz, Sandra Maniewicz, Mario Beretta (EN)). Moderation: Luca Cordaro. • Session 4: Advances in Digital Workflow in a Team Approach (Benedikt Spies, Vygandas Rutkunas (EN), Claudio Cacaci and Uwe Gehringer). Moderation: Vincent Fehmer. The Saturday (15 October 2022) begins with short presentations on research projects supported by the Oral Reconstruction Foundation: • Session 5: Focus on Innovations (Stefan Krennmair, Sarah Al-Maawi (EN), Andres Pascual (EN), Joao Pitta (EN), Ana Molina (EN)). Moderation: Fernando Guerra. The following sessions are dedicated to tissue regeneration: • Session 6: State-of-the-art Procedural Techniques for Tissue Regeneration (Juan Blanco (EN), Katja Nelson). • Session 7: Management of Soft and Hard Tissue (Michael Stimmelmayr, Andreas van Orten, Jan Klenke). Moderation: Sönke Harder. The final highlight of the symposium will be three case presentations discussed by an international panel of experts (Kerem Dedeoglu, Tobias Fretwurst, Gerald Krennmair, Jörg-Martin Ruppin, Rémy Tanimura): • Session 8: Solutions for Demanding Situations (Ramon Gomez-Meda, Frederic Hermann, Duygu Karasan). Moderation: Gerhard Iglhaut, Mariano Sanz. Kick-off: Workshops The symposium will kick off on Thursday (13 October 2022) with 17 workshops covering a wide variety of topics in the field of oral reconstruction; one workshop will be dedicated to the topic of personality development and one will focus in depth on patient communication. Ten workshops will be offered in German, seven in English. The technical and scientific workshops will focus on soft tissue management, augmentation techniques, » The Oral Reconstruction (OR) Foundation invites you to its International Symposium in Munich, Germany, October 13-15, 2022. After the inaugural OR Foundation Global Symposium in Rotterdam in 2018, Camlog, being a Founding Sponsor of the OR Foundation, is now truly looking forward to the big "family" reunion in the cosmopolitan city with a heart. «The top-class scientific committee and the commitment of the internationally renowned speakers guarantee that you can expect a differentiated and groundbreaking program in Munich.» COVER STORY Big reunion in Munich
logo 49 | The Camlog Partner Magazine 6 | Cover story The OR Foundation International Symposium in Munich promises to be a first-class event. implant dentistry (immediate implantation and immediate restoration, COMFOUR) and implant prosthetics in the digital workflow. With workshops starting in the morning, there are also eleven workshops held during the afternoon and also three full day workshops throughout the day. Hands-on or practical exercises are compulsory in most cases to achieve the learning objectives. Take advantage of the opportunity to specifically explore one of the many topics in depth during the symposium and discuss it with our experts. The course fees are priced reasonably at EUR 190 (half day) and EUR 350 (full day). A format in its own right: THE 7TH CAMLOG DENTAL TECHNOLOGY CONGRESS And there is more to come, because on Saturday (15 October 2022), the 7th CAMLOG DENTAL TECHNOLOGY CONGRESS will be held in parallel with the scientific program. This gives dental technology and thus the team concept in reconstructive dentistry a platform of its own. Since it was first held in 2009 (also in Munich, by the way), the CAMLOG DENTAL TECHNOLOGY CONGRESS has built up an excellent reputation in the world of dental technology and well beyond. It stands for the team approach in implant dentistry and dental prosthodontics and provides a clear focus on both dental technology and on establishing the link between dentistry and oral surgery with an appropriate program. The 7th CAMLOG DENTAL TECHNOLOGY CONGRESS will be hosted by Dr. Martin Gollner and MDT Otto Prandtner. The program will be opened by DT Oliver Brix. This will be followed by three team presentations: firstly, Dr. Monika Bjelopavlovic, Dr. Maximilian Blume and MDT Alexander Müller; secondly, MDT Sebastian Schuldes and Dr. Alexander Volkmann; and thirdly, Dr. Benedikt Schebiella and MDT Bastian Wagner. After the lunch break, the auditorium can look forward to a talk session or panel discussion with all team speakers on the topic: "Cooperation at eye level - what are the mutual expectations?" MDT Ilka Johannemann and DT Andreas Nolte will round off the discussion. The professional program reflects the current challenges in prosthetic dentistry. In addition to a high professional standard, the organizers also attach great importance to ensuring that the personal character of the speakers is not neglected - after all, in addition to the scientific "hard facts" based on materials science, biology and anatomy, dental technology is also very much about the individuality of the patients and their encounter with a service-oriented and empathetic treatment team. Joint Bavarian Night The supporting program of the OR Foundation Symposium and the 7th CAMLOG DENTAL TECHNOLOGY CONGRESS will have its highlight on Friday evening in the legendary event location "Paulaner am Nockherberg". Experience an unforgettable "Bavarian Night" and celebrate the reunion of the "family" with us in the traditional style - quite deliberately a contrast to the otherwise modern setting of the symposium. And of course, this will be accompanied by one or two surprises. We look forward to welcoming you!
logo 49 | The Camlog Partner Magazine Cover story | 7 A few quick questions Dr. Martin Schuler took over from Dr. Alex Schär as Executive Director of the OR Foundation at the beginning of 2022. A good reason to ask him a few questions about this as well as the upcoming OR Foundation International Symposium. Dr. Schuler, you've been in office as Executive Director for over six moths now, you must feel at home at the OR Foundation by now ... That's right, I feel at home again in the dental world. Having worked in the dental sector between 20072015, it was like returning home for me. But the environment is so dynamic that every day presents new and exciting challenges and permanent development is crucial. What kept you most busy early on? As a new Board of Trustees was also elected in November 2021, I was mostly busy setting up the new organization and structures as well as getting to know as many of the stakeholders as possible. Bumping into a lot of familiar people was also very helpful for sure. What's your main task at the moment? Together with the Board, we're currently defining the OR Foundation strategy for the next five years. On the operational side of things, our team is already pulling out all the stops organizing our Global Symposium in Rome next May. What's more, we're creating several new formats for continuing education and hope to be able to report more on this in the coming months. Certainly the biggest challenge is to perform all these tasks most efficiently with our small team. Where are you looking to make the most impact for the OR Foundation? Thanks to my predecessor and the former Foundation Board members, the OR Foundation is very well positioned and enjoys an excellent reputation. My goal is now to make the OR Foundation better known globally, to offer more content and work together digitally, and to create new and innovative concepts in continuing education, as well as in research, in close collaboration with our KOLs and our Founding Sponsor. Not least, we strive to be a valuable and reliable partner for the OR Foundation Community. What are your personal expectations for the OR Foundation Symposium in Munich? At long last, we are able to host an international symposium in Europe again. That's why we're all working flat out on this project with heart and soul. We're looking forward to an exciting and interesting scientific program and plenty of workshops. The Dental Technology Congress will also be held at the same time. So, there'll be something for everyone and I'm really looking forward to this flagship event this fall and hope for a lot of participants! Many thanks for your time, Dr. Schuler. symposium2022.orfoundation.org faszination-implantatprothetik.de For more information and registration at Dr. Martin Schuler Executive Director Oral Reconstruction Foundation
logo 49 | The Camlog Partner Magazine 8 | Science » Study results on the question of which materials for restorations on titanium bases and which pre-treatments of the bonding surfaces allow the greatest possible mechanical stability of implant restorations. Introduction The use of prefabricated titanium adhesive bases as abutments opens up numerous options for the practitioner in the choice of workflow - digital or analog - as well as the materials for the abutments. The advantages of these generally screw-retained restorations are known: the extraoral bonding of the mesostructure and/or the crown allows cement residues to be avoided, the emergence profile can be customized, and the titanium implant-abutment connection allows for secure and wear-free stability [1]. With the majority of CAD/CAM technologies in use today, titanium bases are becoming state-of-the-art in daily practice, particularly for single-tooth restorations. The numbers for this indication have increased markedly in recent years due to the healthy lifestyle and good hygiene of patients as opposed to larger restorations [2]. Due to the digital workflow, patients benefit from an efficient treatment protocol with excellent esthetics, fewer treatment appointments and lower costs [3]. The processing and combination of the various materials, such as titanium and ceramics, often determine the long-term stability of the restoration. The basic rule here is to follow the manufacturer's instructions. However, a variety of products and methods is available on the market for the pretreatment of the bonding surfaces, for cementation and for the suprastructures. Not all appear to be equally suitable and universally applicable. Research at then University of Geneva – Prof. Sailer and Team A research group at the Clinic for Fixed Prosthetics and Biomaterials at the University of Geneva, headed by Professor Irena Sailer, is focusing on the long-term performance of restorations with titanium bases with regard to the choice of crown material and preparation respectively pretreatment of the bonding surfaces. They have published their findings on this subject in several publications over the past three years. Various test setups were used to investigate the mechanical stability and bonding strength between titanium bases and different abutment materials such as zirconia, lithium disilicate and others in the laboratory. The various prosthetic options were also taken into consideration here: the use of the titanium bases as temporary restorations with PMMA and as hybrid abutments or hybrid abutment crowns was also tested. The results show significant differences in some cases and are therefore of valuable use for applications in the dental practice or the laboratory. Insights into five publications of the research group General test setup: thermo-mechanical aging An almost identical test setup, which is also used in a similar form in the industry for the load testing of dental implants (ISO 14801 standard), was selected for each of the five differentiated questions. The test models to be investigated - 12 identically fabricated specimens per test group - each simulating an anterior incisor in the maxilla, were subjected to dynamic loading in the chewing simulator for artificial aging. Analogous to the standard, the implants were embedded with a simulated bone loss of 3 mm and clamped at an angle of 30° to the loading axis. To better replicate the clinical oral environment, the test samples passed through an alternating thermal bath between 5° and 55° for 120 seconds each in parallel to the chewing load. The load exposure lasted over 1,200,000 cycles and reflected a chewing load in practice over a period of approx. five years. After completion of artificial aging, the restorations were examined microscopically. Then, depending on the study question, the retention force of the crown, respectively the bond, was measured by means of a pull-off test, or the bond was statically loaded using a universal testing machine up to mechanical failure and from this the bending moments which cause compressive and tensile stresses in the implant bond were calculated. Single tooth replacement on titanium bases CAD/CAM – stable restorations supported by scientific results SCIENCE Peter Thommen Clinical Research Associate Camlog
logo 49 | The Camlog Partner Magazine Science| 9 Methods for improving bonding strength by pretreating the bonding surfaces of titanium bases Corundum blasting of the bonding surfaces [4] The surfaces of the titanium bases CAD/CAM intended for bonding to the meso- and suprastructure are usually corundum blasted first. This abrasive surface treatment, which is also recommended by the manufacturer, inevitably leads to a rougher surface and thus to improved bonding strength during cementing. Different grit sizes from various manufacturers are available on the market for this abrasion method. To determine the stability of the bond and the bonding strength between titanium bases CAD/CAM and lithium disilicate crowns after applying different methods, a total of 60 samples were divided into four groups: prior to bonding with Multilink Hybrid Abutment (Ivoclar Vivadent), the titanium bases were blasted with either 30-µm, 50-µm or 110-µm aluminum oxide (Al2O3) particles. The control group received no pretreatment. Finally, the prepared restorations were screw-retained to the embedded implants. After artificial aging, a number of bonds already failed. In the control group, 73% of the crowns loosened, and in the 30-µm and 110-µm groups respectively, micromovement was observed in 40% of the samples. Significantly better results were obtained with 50-µm blasting. Only 7% in this group failed the load test. In comparison, the highest pull-off forces (420 ± 139.5N; pull-off test) were measured in this group at the same time, due to the highest measured surface roughness across all groups. Conclusion: In conjunction with lithium disilicate crowns, pretreatment with 50-µm Al2O3 particles (in the test: Cobra Aluoxyd; Renfert GmbH) can be recommended in particular. Cleaning of blasted titanium bases [5] During a try-in of the abutment, for example when using a chairside workflow or when taking a digital impression at abutment level, the previously blasted abutments are contaminated with saliva. The manufacturer specifies that the parts should be cleaned and disinfected before and after each use on the patient without naming specific agents. This study tested which cleaning steps are necessary after contamination with saliva to restore ideal adhesion levels of the surfaces. Again, the titanium bases were bonded to lithium disilicate crowns for the load test. After 1.2 million cycles, all samples treated prior to cementation with the cleaning methods a) water spray, b) alcohol bath, c) suspension of zirconium particles, or d) repeated blasting exhibited significantly increased bonding failures at a micro level compared to uncontaminated titanium bases. However, the retention strength of the abutment-lithium disilicate-crown connection was comparable in all but one case. Only the group cleaned with ultrasound in an alcohol bath exhibited a significantly reduced retention strength and therefore appears to be less suitable when compared with the other cleaning agents. Conclusion: After contamination of the pre-treated bonding surfaces with saliva, the cleaning method with water (spray), treatment with a suspension of zirconium particles or repeated blasting are suitable for re-establishing a good bonding effect. Mechanical stability of various material compounds under load Modern ceramics for the fabrication of dental restorations should address characteristics such as time efficiency in fabrication (CAD/CAM), low chipping risk, but also protection of the implant-abutment connection against overloading. When bonding with titanium
logo 49 | The Camlog Partner Magazine 10 | Science bases, it is of interest to achieve stable constructions that will ideally last for years without complications and aftercare. Temporaries with titanium bases [6] The suitability of titanium bases in temporary restorations was investigated with the question of how different cementation protocols affect the stability of the adhesive bond between titanium bases and temporary abutments made of PMMA. Whereas all bonding surfaces of the titanium bases were blasted with 50-µm Al2O3, the inner surface of the PMMA crowns was treated as follows: a) conditioning with MMA-based liquid (SR Connect, Ivoclar Vivadent), b) blasting with 50-µm Al2O3 and silanizing (Monobond Plus, Ivoclar Vivadent), c) blasting with 30-µm silicate-coated Al2O3 (Rocatec-Plus, 3M ESPE) and additional conditioning with MMA-based liquid (SR Connect) or d) abrasion with 30-µm silica-coated Al2O3 (Rocatec-Plus) and subsequent silanization (Monobond Plus). All samples were cemented with Multilink Hybrid Abutment. Result: variant c), in which the provisional inner surface was blasted and conditioned with a bonding agent, exhibited a higher mean pull-out force of the samples than the other test groups. In terms of retention failures following artificial aging, this group was also slightly better at 83% than the others, each with a 100% retention failure rate. However, in a direct comparison the conventional temporary abutments performed significantly better. Conclusion: It is preferable to select conventional temporary abutments for provisional restorations. When applying PMMA crowns to titanium bases, it is recommended to blast the bonding surfaces of the crown with 30-µm and additionally condition with an MMA-based liquid to provide better retention of the bond. Two-piece components: hybrid abutment crown [7] One option for fabricating a final restoration is to completely extraorally bond a monolithic CAD/CAM fabricated crown directly to a titanium base as a single unit. In a study, the longevity, in other words the stability, of 12 screw-retained restorations each with either lithium disilicate, zirconia or a material consisting of a polymer-infiltrated ceramic network (PICN) was examined. Prior to cementation with Panavia 21 (Kuraray Noritake), the bonding surface of the titanium bases was blasted (50-µm Al2O3) and, in addition, the bonding surfaces of the crowns were pretreated in a material-specific manner: zirconia with blasting (30-µm Al2O3), lithium disilicate and PICN with etching (5% HF). After applying load in the chewing simulator, the following picture emerged: the restorations with lithium disilicate demonstrated no fractures and thus a success rate of 100%. With zirconia, a total of three abutment and one crown fracture were observed (67% success) and in the PICN group, a total of five fractured crowns (58% success). Closer examination of the remaining samples under the microscope revealed loosening in all groups. With 58% complications, the lithium disilicate compounds also performed much better in this respect than the zirconia and PICN compounds with 88% and 86% respectively. In a few PICN crowns, additional cracks were found in the material. Conclusion: The authors concluded that hybrid lithium disilicate abutment crowns can be used for restorations. Zirconia and PICN are less recommended due to their high complication rates. Three-piece components: hybrid abutment and crown [8] The same issue regarding mechanical stability was applied in another study to abutments consisting of a titanium base - meso-abutment - crown, whereby
logo 49 | The Camlog Partner Magazine Science| 11 the individual mesostructure was made of zirconia. The crowns were milled from either lithium disilicate, zirconia or PICN. The bonds were pretreated in a material-specific manner analogous to the above test. The inner and outer surfaces of the meso-abutments were also blasted (30-µm) and the parts were cemented finally with Panavia 21. In this test setup, the samples of all groups survived the chewing simulation and no fractures or adhesive failures were observed. In the subsequent fracture test, all constructions fractured at the same point, namely with a fracture of the abutment screw in the implant. Further evaluation showed that the titanium-zirconia-zirconia connection resulted in the highest and statistically significant flexural moment in comparison and, in addition, exhibited no other failure patterns, such as cracks in the crown. Lithium disilicate and PICN crowns, on the other hand, exhibited small cracks after the fracture test, but these could have been test-related. Conclusion: This study showed that all tested material combinations of crowns in combination with zirconia meso-abutments on titanium bases could possibly successfully withstand the load in the mouth. In this respect, the choice of material for the crown would appear to be secondary in this indication. Summary Titanium bases are suitable for esthetic and durable single-tooth restorations. Stable restorations which can withstand the chewing load can be fabricated in laboratory work by applying specific pretreatments to the bonding surfaces. The results of the research group in Geneva can be utilized as recommendations for this purpose. However, the mechanical tests cannot accurately reproduce the performance in everyday clinical practice and still need to be confirmed by longterm clinical data. Professor Sailer's group continues its work on this topic and will be publishing further papers, for example on the type of bonding. [1] Fischer C, Gehrke P. Taktische Einheit: CAD/CAM-Hybridabutments. Quintessenz Zahntech 2017;43(11):1526-1542. [2] Graf T, Mielke J, Brandt S, Stimmelmayr M, Güth JF. CAD/ CAM-gefertigter Einzelzahnersatz auf Implantaten: Was ist möglich, sinnvoll und effizient? Eine Übersicht. Implantologie 2021;29(3):285-299. [3] Hermann F. Der volldigitale Chairside-Workflow in der Implantologie. Digital ist effizient. Teamwork 2017;3:1-12 [4] Pitta J, Burkhardt F, Mekki M, Fehmer V, Mojon P, Sailer I. Effect of airborne-particle abrasion of a titanium base abutment on the stability of the bonded interface and retention forces of crowns after artificial aging. J Prosthet Dent 2021;126:214-21. https://pubmed.ncbi.nlm.nih.gov/32921422/ [5] Burkhardt F, Pitta J, Fehmer V, Mojon P, Sailer I. Retention forces of monolithic CAD/CAM crowns adhesively cemented to titanium base abutments – effect of saliva contamination followed by cleaning of the titanium bond surface. Materials 2021;14(12):3375. https://pubmed.ncbi.nlm.nih. gov/34207110/ [6] Pitta J, Bijelic-Donova J, Burkhardt F, Närhi T, Sailer I. Temporary implant-supported single crowns using titanium base abutments: an in vitro study on bonding stability and pullout forces. Int J Prosthodont; 2020;33:546-552. https://pubmed.ncbi.nlm.nih.gov/32956436/ [7] Pitta J, Hjerppe J, Burkhardt F, Fehmer V, Mojon P, Sailer I. Mechanical stability and technical outcomes of monolithic CAD/CAM fabricated abutment-crowns supported by titanium bases: an in vitro study. Clin Oral Implants Res 2021;32(2):222-232. https://pubmed.ncbi.nlm.nih.gov/33258267/ [8] Pitta J, Hicklin SP, Fehmer V, Boldt J, Gierthmuehlen PC, Sailer I. Mechanical stability of zirconia meso-abutments bonded to titanium bases restored with different monolithic all-ceramic crowns. Int J Oral Maxillofac Implants 2019;34:1091-1097. https://pubmed.ncbi.nlm.nih.gov/30934031/ Literature
logo 49 | The Camlog Partner Magazine 12 | Case study Digital dentistry intelligently combined with analog craftsmanship PRACTICE CASE Even in a digital age, the decision about the type and scope of restoration is a very personal one and is determined by the patient. Our task is to provide them with all the information they need and to share our knowledge to enable them to make this decision in a self-reflective manner. Every patient is unique and each treatment plan must be tailored to the individual patient's wishes, but also to the patient's anatomical conditions and compliance. When the only tool available is a hammer, then every problem looks like a nail, however, patients should be approached with a well-stocked toolbox. It is incorrect to claim that every periodontally damaged dentition precludes an immediate restoration on 6 implants. After all, our goal is to preserve teeth and, together with the patient, to exhaust all conservative options. The patient in the following case was 82 years old at the time of initial presentation and was still very active both mentally and physically. He goes skiing several times a year, is an enthusiastic hiker and also actively participates in the grape harvest every year. He complained of highly mobile teeth in the upper jaw which would make painless chewing increasingly difficult. A removable denture was unthinkable for him, and he also wanted to avoid palatal coverage under all circumstances. The concept of immediate prosthetic restoration with implants is basically nothing new. However, this has been greatly facilitated in many of the work steps in recent years through digital planning and production options. As a result, even comprehensive work can be precisely planned, as well as being fabricated cost-effectively and therefore made accessible to a broader patient clientele. The restoration options for existing or impending edentulism must be discussed in great detail. These range from removable dentures, both on Locator abutments as well as on galvano telescopes, to screw-retained fixed implant restorations. They depend very much on patient compliance, motor skills as well as patient preferences. Given the fact that complex alveolar ridge reconstructions are sometimes difficult to design in advanced age, as they often lead to postoperative complaints and prolonged treatment times, the screw-retained solution with the COMFOUR abutment system is recommended for older edentulous patients in the author's practice concept. Its implementation meets the wishes of many patients: usually only one surgical procedure, a short treatment period, no complex augmentative measures and a modest financial outlay. With fixed occlusal screw-retained bridges on four or more implants, augmentation measures can be largely dispensed with due to the option of inserting implants at an angle. Digital imaging capabilities [1] are a prerequisite for the implementation of the concept. They not only facilitate planning, but also patient education. Even before a tooth is extracted, the patient can view his future dental prosthesis using the digital display options. Based on the 3D planning, the temporary restoration is fabricated pre-surgically, either in the laboratory or by a manufacturing service provider, so that the patient leaves the practice after the procedure with a fixed screw-retained but temporary prosthesis. With foresighted planning and exact implementation, such immediate loading concepts, which make optimum use of the available bone volume, are comfortable, economical and low-risk restoration options. » Dentistry is and remains a tangible and craft-based discipline, which has always utilized the latest production techniques, processes and high-quality materials. For many decades, the dental workflow in particular was dominated by materials such as wax, plaster and cast metal. If one exploits the potential of today's dentistry, then very precise plans can be created on the digital model, which visualizes all the treatment phases ranging from surgery through to prosthetic restoration. Implementation, too, can also be accomplished in a precise and targeted manner by applying modern CAD/CAM processes together with the dental laboratory and the industry. Dr. Maximilian Blume Oral surgeon
logo 49 | The Camlog Partner Magazine Case study | 13 1. An 82-year-old patient presented in the practice for the first time following recommendation by a friend. He complained that the teeth in the upper jaw were very mobile and it was becoming increasingly difficult to chew without pain. He was very active mentally and physically, and goes skiing and hiking several times a year. A removable denture was unthinkable for him, and he also wanted to avoid palatal coverage under all circumstances. 3. Systematic periodontitis treatment was conducted at the beginning of therapy. As part of the anti-infective therapy, the teeth that were not worth preserving were extracted and a removable temporary denture was provided. Digital implant planning and fabrication of the implant template as well as the CAD/CAM-fabricated temporary restoration were performed by DEDICAM in close coordination with the dentist and dental technician (Müller-Edelhoff Laboratory/Wörrstadt). 5. Final corrections to the implant position and axis inclinations were made in the planning meeting and the implant-prosthetic components for the restoration of the case were selected. The bridge was milled from a TELIO CAD blank in one piece. In addition to other advantages, such as the accuracy of fit and the correct milling of the adhesive channels, fractures, which occur frequently with conventionally manufactured temporary restorations, can be avoided. 2. Due to the periodontal condition in the upper jaw, the prognosis for tooth-preserving therapy was not good. The lower jaw was free of complaints except for tooth 36; tooth 34 had received an alio loco root tip resection a few months ago. The patient was currently not participating in a prophylaxis recall or in supportive periodontal therapy (PPT), and systematic periodontal treatment had last been performed approximately 7-8 years ago. 4. The situation models with the original tooth status, which were scanned and digitized, were used together with the patient's DVT to plan the drilling template and the pre-surgically created temporary CAD/CAM bridge. The CAD/CAM-fabricated temporary restoration was to be based on the initial findings with regard to the shape and position of the teeth, which we modified in favor of esthetics as we proceeded. 6. On the day of surgery, the remaining teeth, which served to stabilize the interim prosthesis, were extracted in a bone-conserving manner. Attention was paid to protecting the vestibular lamella. Only a sufficiently high primary stability averaging 30 Ncm allows for a directly screw-retained temporary restoration in the edentulous jaw.
logo 49 | The Camlog Partner Magazine 14 | Case study 7. The SMOP template was designed by DEDICAM in consultation with the clinician. The skeletonized SMOP drilling template offers several advantages when compared to other templates. For one, the fit is achieved by punctiform support at selected points. They can be positioned such to allow flap preparations. Another advantage is the good view of the surgical site. 8. To increase the size of the loading polygon, the two terminal implants were inserted at a 30° angle. No difference is observed between orthograde or obliquely placed implants both in terms of survival rates or bone loss (BDIZ-EDI Consensus Conference 2016) [2]. 9. The implant sites are prepared according to the Guide System protocol for SCREW-LINE implants (13 mm L / Ø 3.8 mm). The correct alignment of the implant's inner configuration is extremely important for the insertion of the angled COMFOUR bar abutments. To do this, the markings on the guide sleeves must correspond with those on the insertion instruments. 10. The COMFOUR bar abutments are inserted with the aid of the flexible plastic handle. The handle is fixed in the thread of the prosthetic screw and holds the pre-mounted abutment screw in the bar abutment in place. The handle can easily be bent sideways to tighten the screw. 11. Before the titanium caps are bonded into the temporary bridge, a check is made to ensure a tension-free fit. Sometimes it is necessary to widen the channels to be able to bond the titanium caps intraorally without stress and tension. First, the titanium caps are blasted with 70 µm zirconia to achieve a better adhesive bond with the plastic. 12. They are then inserted into the bridge, which is placed above the bar abutments. Only then are the titanium caps screw-retained to the abutments and bonded to the bridge with light-curing plastic. Shortening of the titanium caps is performed extraorally, as is the finishing of the bonding sites. The uniform polygonal load is checked and ground if necessary.
logo 49 | The Camlog Partner Magazine Case study | 15 13. A conventional impression is taken six months after surgery to manufacture the definitive restoration. To do this, the temporary bridge is unscrewed and the COMFOUR abutments are cleaned. The impression is taken at the level of the bar abutments. 14. The posts for the closed tray technique were screwed on at abutment level and hand-tightened. The impression was taken using a modified plastic tray (Impregum/3M Espe). A master cast with removable gingival mask is created in the laboratory. 17. The wax-up is scanned and merged with the previously obtained data. This results in the anatomically reduced design of the screw-retained bridge construction. This design is transferred to DEDICAM together with the physical master cast. In the case of comprehensive or directly screw-retained reconstructions, the model data are tactilely scanned by the manufacturing service provider and matched with the CAD laboratory data. 18. The connection points of the NPM framework to the abutments are machined and polished to the highest fit by the milling center. In the laboratory, the correct stress-free fit of the bridge construction is first checked by performing a Sheffield test. It is therefore essential to remove the gingival mask for an optimum check. 15. A correction splint is created on the master cast, which is used to check the accuracy of the impression in the patient's mouth. The passive fit is checked via the Sheffield test. This intermediate step is an important measure before the metal framework is designed and ordered. If there are any deviations in fit, the splint can be separated, re-bonded in the patient's mouth and the model corrected. 16. Bite registration is then performed in the mouth by applying a wax wall on the splint. Following bite registration and a functional-analytical diagnosis of the patient, the transfer is made to the articulator using a facebow. A wax-up is made from prefabricated teeth on the splint, which is screw-retained in the mouth and checked for esthetics and function.
logo 49 | The Camlog Partner Magazine 16 | Case study 19. In addition to the basic type of prosthetic restoration, removable or fixed, the type and method of veneering were also discussed. Due to the higher susceptibility to repair of ceramic veneers and the higher costs, the patient opted for resin veneers. A silicone matrix had been fabricated based on the wax-up. Based on this, the spatial conditions for the veneer are checked. 20. Both the acrylic shells as well as the metal framework are blasted with zirconia and silanized by applying a silane primer to achieve a better bond between the two materials. Then, an opaquer is applied to prevent the metal framework from shining through. Retentive elements can be dispensed with due to the possibility of surface activation [3]. 21. After a renewed functional and esthetic check, the bridge was completed. The screw channels were sealed with Teflon tape and filling composite. The two distal channels were sealed with tooth-colored composite and the four channels in the anterior, non-visible area were sealed with a translucent material, which makes it easier to locate the screws in future check-up appointments. 22. The biological and physiological load of the entire reconstruction is achieved with this concept. The necessary domestic oral hygiene is indispensable for long-term success. This is now mainly the patient's own responsibility. The patient is trained in the use of aids such as dental floss or interdental brushes. In addition, the restoration features a basal convex design and cleaning channels in the area of the implants. 23. Six months after the surgical procedure, a stable hard and soft tissue situation is evident. As the temporary restoration matched the original tooth position, the patient, his wife and we too, decided to correct the tooth position and shape during the treatment period to achieve a more esthetic overall result. 24. At the time of insertion, a stable bone bed around the implants is evident to provide long-term preservation of the prosthetic restoration. During the course of treatment, tooth 36, which was already conspicuous at the initial presentation, had to be extracted.
logo 49 | The Camlog Partner Magazine Case study | 17 Discussion A screw-retained fixed bridge on four or six implants is a scientifically documented treatment therapy for the edentulous jaw. Implant survival rates ranged from 95.5 to 100 percent in a retrospective review for a time period up to ten years [4] and in a prospective study up to seven years [5]. The method, first introduced by Paolo Maló, is one option for restoring edentulous jaws without bone augmentation procedures. This form of therapy based on the Malo Clinic protocol has been successfully performed in our practice for a long time. The indication is given when a patient who is either already edentulous or where the residual teeth are not worth preserving wishes a fixed denture that is both time- and cost-efficient. The prerequisites for immediate restoration protocols, such as bone height and width, should be evaluated prior to surgery using a 3D scan [1]. Implementation follows clear guidelines in terms of backward planning, surgery and prosthetics - in the immediate restoration phase as well as in the second phase: the manufacturing of the definitive screw-retained bridge as well as the professional hygiene measures or recall appointments. It is well known that workflows in practices and laboratories can be optimized through digitization. Thus, a predictable outcome is possible through planning and guided surgery. Cooperation with a partner or service provider specializing in digital processes is advantageous and cost-efficient. Cooperation with the DEDICAM services is absolutely flexible. The technicians of the Implant Planning Service create a drilling template on the basis of the model documents and the DVT, in close consultation with the dentist and laboratory technician, order the temporary immediate restoration from the data records created and send all the components required for restoration at the same time. The framework for the definitive restoration is manufactured in a CAD/ CAM process on high-precision milling machines with a perfect fit, following prior measurement with tactile scanners. The time required to produce the reconstruction can be reduced. It can already be ready for use after one session. Conclusion The CAMLOG COMFOUR system and the cooperation with DEDICAM have proven their value to our practice for a long time and provide us with the option of a wide variety of occlusally screw-retained large-span restorations. This combination offers both the practitioner and the dental technician enormous creative leeway in the implementation of customized work for the patient. [1] Rugani P, Kirnbauer B, Arnetzl GV, et al. Cone beam computerized tomography: basics for digital planning in oral surgery and implantology. International journal of computerized dentistry 2009; 12: 131-145 [2] Konsensuspapier 2016 11. Europäische Konsensuskonferenz (EUCC) 2016 in Köln; Update: kurze, angulierte und durchmesserreduzierte Implantate. 6. Februar 2016 [3] Manfred Rasche: Handbuch Klebtechnik. Carl Hanser Verlag, 4. Oktober 2012, ISBN 978-3-446-43198-0, S. 195–196. [4] Malo, P., et al., A longitudinal study of the survival of All-on-4 implants in the mandible with up to 10 years of follow-up. J Am Dent Assoc, 2011. 142(3): p. 310–20. [5] Ayub, K.V., et al., Seven-Year Follow-up of Full-Arch Prostheses Supported by Four Implants: A Prospective Study. Int J Oral Maxillofac Implants, 2017. 32(6): p. 1351–1358. • Study of dentistry at the Medical School of the University Mainz • License to practice dentistry and doctorate under Prof. Dr. Dr. Wagner at the Medical School of the University Mainz • Specialization in the field of dental implant dentistry under Prof. Sader at Frankfurt University Clinic • Specialist for oral surgery in own practice with a focus on oral surgery, implant dentistry and periodontology • Lecturer and clinician within the framework of the Masters of Science in Oral Implantology for postgraduate education at the Carolinum of Frankfurt University Practice for dentistry and oral surgery Erthalstraße 1 55118 Mainz maximilian@zahnmedizin-blume.de Dr. Maximilian Blume References OP video
logo 49 | The Camlog Partner Magazine 18 | Case study Guided Surgery – minimally invasive, scar-free, tissue preserving PRACTICE CASE “The ultimate goal of long-term stable implant therapy, besides patient satisfaction, is an esthetic and durable reconstruction. Anatomical preservation of the peri-implant tissue structures is paramount. Perfectly coordinated communication between the surgeon, prosthodontist, dental technician and patient is the key to success here. Optimal pre-surgical 3D planning and minimally invasive guided surgery help achieve these goals predictably with immediate implant placement in the anterior region, provided certain criteria are met and the facial lamellae are largely intact. Dr. Christoph Schmidtner Dentist Dr. Christoph Wenninger Dentist If a tooth that cannot be preserved has to be extracted in the esthetic region, then immediate implant placement should be taken into consideration. Here, it is imperative to consider any complications that may arise vis-à-vis the potential biological compromises associated with delayed implantation. These could include surgical reconstruction of the resorbed buccal bone lamella as well as thickening of the soft tissues. An immediate implant can largely preserve the surrounding tissue structures, provided that the buccal alveolar wall is intact or that only minor bone defects are present, that the tooth socket is free of inflammation and that there is sufficient bone in the apical region for the primary stable anchorage of a sufficiently long implant. The patient’s wish for a temporary immediate restoration must be balanced in line with the functional load. If, for example, therapy-resistant parafunctions occur, then immediate loading is an increased risk for osseointegration of the implant. The macrodesign of the implant system as well as the structural and auxiliary components matching this concept are essential for the success of immediate implantation. In the case described in the following, the CAMLOG® PROGRESSIVE-LINE implant was selected. In addition to the quality of the implant bed preparation, the thread flanks, which penetrate deeply into the alveolar bone, and the apically tapered implant body meet the requirements for immediate restoration protocols. The precise Tube-in-Tube® internal configuration eliminates micromovements to a large extent and the platform switching option allows creating sufficient space for the soft tissue cuff. Correct, positionally stable insertion of the implant can be achieved with the aid of a drilling template created on the basis of 3D planning. The guidance of the drills in the template ensures accurate axial implant bed preparation without any lateral deviation. This prevents an undesired change in direction of the drills and the inserted implants. In addition, the drilling protocol which is adapted to different bone qualities leads to achieving predictable primary stability. Minimally invasive surgery following tooth extraction reduces surgical trauma due to flapless surgery, implant placement without creating flaps, and shorter times for surgery. Associated postoperative symptoms, such as swelling or pain, are also minimized. Particularly in surgical practices with a referral structure, immediate restoration concepts should be discussed in detail by the treatment team, consisting of surgeons, prosthodontists, dental technicians and also the patients, to avoid any misunderstandings and to understand the different expectations. However, the correct digital positioning of the implant always remains the responsibility of the implantologist. He/she will plan the prosthetically oriented placement based on a digital or digitized wax-up. It is advantageous to realize manufacturing of the tooth-supported drilling template as in the present case within a short space of time between the scan and implantation. Due to possible loose teeth or tooth migration, this increases the accuracy of the template fit and subsequently of insertion and contributes to therapeutic safety.
logo 49 | The Camlog Partner Magazine Case study | 19 1. A 52-year-old patient presented in the practice. Medically inconspicuous, he had been referred by his family dentist with a request for a treatment proposal after a defective ceramic crown 21 and a fracture of tooth 22 had been diagnosed. The dentist had removed the defective crown and replaced it with a temporary. 3. The soft tissue in regio 22 was anatomically shaped and presented as a thick biotype. At first sight, good conditions to consider immediate implantation. However, due to the functional abnormalities, immediate loading had to be refrained from. The therapeutic concept of immediate implantation was now clarified via DVT diagnostics. 5. This revealed an intact buccal lamella with moderate deterioration of the crestal alveolar bone. The apical lesion at 22 as well as the epicrestal fracture line were clearly visible. Due to the lack of a ferrule effect, a revision of the root filling with a post build-up did not promise a stable long-term prognosis. 2. The clinical findings revealed significant abrasion of the natural anterior teeth and a sunken jaw relation and function-related changes in the horizontal plane. Tooth 22 was deeply fractured subgingivally, painful and exhibited an apical lesion. 4. Due to the large number of pretreatments, complex overall evaluation using three-dimensional imaging (DVT 10 x 10) was performed following the clinical diagnostics. With the opportunity of viewing the imaged structures from all sides, treatment planning improves as does patient safety. 6. At the same time, digital impressions were taken of the maxillary and mandibular situations. For one, to meet the requirement of adequate time management. For the other, to appropriately shape or support the soft tissue with the aid of a pre-surgically manufactured temporary restoration.
logo 49 | The Camlog Partner Magazine 20 | Case study 7. Many of the more popular implant systems are integrated in the planning software. For immediate implantation, a PROGRESSIVE-LINE implant was selected, which is particularly suited for immediate restoration protocols due to its macro design. However, at the time of planning, the data were not yet stored in the software (exoplan). A SCREW-LINE implant (same diameter and length) was used for the correct virtual positioning of the implant. 8. The X-ray and surface scan data of teeth and jaw sections were superimposed in the software to establish the relationship of the virtually planned implant with regard to the tooth surface and mucosa. When placing the implant, attention was paid to place the screw access channel of the subsequent hybrid crown in the palatal surface. 9. The preparation of tooth 21 and the fabrication of an acrylic temporary with attachment were performed in the practice of the family dentist. For this purpose, dental technician (MDT Oliver Förster, Gauting, Germany) removed tooth crown 22 in the digital model and designed the base in the form of an ovate pontic to stabilize the peri-implant soft tissue during the healing phase and to maintain an anatomical emergence profile. 10. On the day of surgery, tooth 22 was extracted using microsurgical instruments in a tissue-sparing manner with the aim of preserving the buccal alveolar bone and without damaging the interdental papillae. Exposure of the alveolar bone was to be avoided because of esthetic limitations due to scarring. At the same time, the associated resorption of the bone lamella is minimized. 11. The bone compartment was cleaned and the apical lesion was completely curetted. The preparation was to be flap-less, according to the standard drilling protocol of the PROGRESSIVE-LINE implants with a pre-surgically prepared drilling template. The implant bed was prepared precisely with the completely guided drills of the guide system, whereby its sleeves prevent any deflection. 12. The virtual template design was converted into a delicately designed navigation template after approval. As the template was supported on the natural teeth, it was essential to keep the time span between impression taking and surgery as short as possible, as potential movement of the teeth could have a negative impact on the precise fit of the template and thus on the correct implant bed preparation and implant positioning.
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