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edition logo 50 | the Camlog Partner Magazine Cover story | 1 THE CAMLOG PARTNER MAGAZINE logo Quo vadis Implant Dentistry? March 2023


logo 50 | the Camlog Partner Magazine Editorial | 5 Human resources strategy - the most important responsibility in 2023 Recent years proved to be difficult times for the dental industry. The Corona virus turned the world upside down. 2020 and 2021 were dominated by uncertainty, outside influences and changing framework conditions. There was no textbook, no empirical data, no blueprint for that. Quick responses and communication were needed, along with leadership, to provide the team with guidance. But it also provided opportunities to differentiate, to change and to take on responsibility. Companies with a good team and operating in a market which recovered quickly (such as the dental market) were able to experience strong growth, particularly from 2021 onwards, and felt positive about 2022. In February 2022, the world order changed with the Ukraine conflict causing instability across all sectors. The tense supply of energy, inflation and aggravated personnel situation added challenges for the industry. Instability seems to be the new normal, and something we have to deal with. There are no short-term solutions for this situation, however, there are empirical values from business management. Longterm strategies are required, in particular agile human resource management. All companies in the dental market need to take their responsibility for human resource management seriously. Too many qualified workers have migrated to other sectors and are now lacking. Not only do we wish to provide our customers with excellent products and constantly improve their safe use, we also wish to support entrepreneurial development at all stages. The cooperation with OPTI health consulting GmbH has expanded our range of business management training and services for the practice. You are more than welcome to contact us. In the Camlog Business Club, the experts from Camlog and OPTI pass on their know-how in the field of personnel management, analyze personnel development, identify personnel strategies and discuss practical approaches to implementation. Human resources strategies also include the continuous analysis and targeted improvement of employee satisfaction. Our expert Andrea Stix will be sharing valuable tips with you in this issue of logo. Professional further education in implant dentistry remains an integral aspect of Camlog's work. We had the opportunity to showcase this through the combined Oral Reconstruction Foundation International Symposium and our Dental Technology Congress in Munich. With the Oral Reconstruction Global Symposium in Rome, we are looking forward to adding yet another highlight. A roadshow will be making stops in 13 cities in Germany, Austria and Switzerland, where renowned experts will share many positive lessons learned from the use of human bone substitute materials. The most likely largest dental congress in Germany in 2023 will be the EAO Congress in Berlin at the end of September. As one of the main sponsors, we will be present there with an international team. As managing directors of Camlog, Martin Lugert and myself are convinced that we differentiate ourselves through our employees and their competencies. We have aligned our human resources strategy accordingly. Our aspiration is and remains: WE ARE IMPLANT DENTISTRY! Take on the challenges of 2023, as we do too! Sincerely Markus Stammen Managing Director REGISTER NOW Oral Reconstruction Foundation Margarethenstrasse 38 | 4053 Basel | Switzerland Information and Registration: QUO VADIS IMPLANT DENTISTRY? • What are today‘s standards? • What are the treatment methods of the future? • What are the state-of-the-art digital approaches? Latest tissue regeneration therapies | Interactive sessions | Leading-edge hands-on workshops | Young researchers in the spotlight | Science Slam & Poster Session | Dolce Vita Night ORAL RECONSTRUCTION GLOBAL SYMPOSIUM 18 - 20 MAY 2023 | ROME, ITALY Founding Sponsors: Dear readers

logo 50 | the Camlog Partner Magazine | 7 Table of contents We are Implantology Combined forces. Accelerated evolution. Inspired to achieve excellence in oral reconstruction, we use our combined forces to accelerate evolution within global implantology. Since 2016, BioHorizons and Camlog have been strategically joining forces under the umbrella of the Henry Schein Global Oral Reconstruction Group. Cover story » Quo vadis Implant Dentistry? 8 Science » Camlog and science - concise in one brochure 12 Case study » COMFOUR® in the edentulous jaw - patient-oriented solution (not just) in dental anxiety | Dr. M. Wienke, DT S. Kirchmaier 14 » Success factor of an implant restoration - the Personalized Tissue Support Concept Dr. M. Berthold, MDT O. Prandtner 20 Products » High biological regenerative capacity - MinerOss® A, the human bone substitute material 28 b.aware » On the journey to becoming a climate-neutral company 30 » Tree sponsors take responsibility for climate protection in the region 31 » Social commitment 32 News » The shell of the building is erected 33 » Learning from the bottom up 34 International » An unbeatable team at the EAO 2022 36 Practice management » Indifferent or loyal? Lessons learned 38 Events » More biological, faster, less invasive 40 » Pre-congress workshops at the ORIS - practical and inspiring 44 » Fascination Implant Prosthetics 7th CAMLOG DENTAL TECHNOLOGY CONGRESS in Munich on October 15, 2022 46 » The CAMLOG BUSINESS CLUB – further education with a "network" 50

logo 50 | the Camlog Partner Magazine logo 50 | the Camlog Partner Magazine 8 | Cover story Cover story | 9 After Rotterdam in 2018, the second OR Global Symposium 2023 will be held in Rome. With its top-class scientific program, it will continue the long success story of the international Camlog congresses as well as the more recent history of the OR Foundation Symposia, which took place in Munich 2022 (see page 40 ff.). The new president of the OR Foundation, Dr. Luca Cordaro, who was elected last year, brought the Global Symposium to his home country of Italy. So it is only natural that he took over the chairmanship of the congress at the same time and thus heads the scientific committee, which also includes Juan Blanco (Spain), Dehua Li (China), Michael Stimmelmayr (Germany), Irena Sailer (Switzerland), Anton Sculean (Switzerland) and Homa Zahed (USA) as members. They have put together a differentiated, groundbreaking program aimed at dental professionals from all areas of implant dentistry. The close to 30 world-renowned speakers will be presenting in English. Simultaneous translation into German will be provided. Location: Auditorium Parco della Musica The Auditorium Parco della Musica, designed by star architect Renzo Piano, was chosen as the location. All the colors and materials used to build the auditorium reflect Roman architectural tradition, ranging from white travertine to red bricks and the lead-gray of the most famous domes such as the Pantheon. Usually a venue for music and other artistic genres, the cultural complex will provide a particularly beautiful and tasteful setting with its strong expressive character. Workshops At the beginning of the symposium on Thursday (Ascension Day), a number of different practical and theoretical workshops will be offered in the morning. Participants can sign up for workshops based on their preferences, where they will learn many hands-on techniques which they can incorporate into their daily professional lives immediately after the weekend. » All roads lead to Rome, also in implant dentistry! From May 18-20, 2023, the BioHorizons Camlog family will be meeting in the Eternal City at the invitation of the Oral Reconstruction Foundation. The OR Global Symposium will be addressing the topic of "Quo vadis Implant Dentistry?" and discussing it with numerous users from all over the world. Don't miss this event! COVER STORY Quo vadis Implant Dentistry? Roma

logo 50 | the Camlog Partner Magazine logo 50 | the Camlog Partner Magazine 10 | Cover story Cover story | 11 Practical Workshops: » Digital prosthetic workflow in full-arch restorations (Vincent Fehmer, Matteo Cordaro) » One-crown one-time concept (Joao Pitta, Christina Zarauz) » The digital approach in autogenous bone augmentation procedures: from the computer guided bone harvesting to the computer guided Khoury‘s technique (Luca de Stavola) » Soft-Tissue Augmentation around implants in day-to-day practice (Andres Pascual) » Guided Bone Regeneration – pushing the limits in day-to-day clinical practice (Frank Schwarz) Theoretical Workshops: » Grafting with acellular dermal matrix: science and techniques (Gerhard Iglhaut, Pat Allen) » Optimizing space for implant therapy with clear aligners (Homa Zadeh) Pre-Symposium The workshops will be followed in the afternoon with a pre-symposium entitled: "Technical innovation helps the clinic". The pre-symposium is included in the registration fee. Topics and Speakers: » Success factors in the treatment of gingival recession defects (Katja Nelson) » Update Augmentation – new techniques and materials (Markus Schlee) » Predictable and high-quality bone regeneration (Massimo Simion) » Digital and guided surgery (Nick Fahey) » Is full-arch implant dentistry the panacea for life? (Fazeela Khan Osborne) » Stick with me! Utilizing L-PRF for enhanced hard and soft tissue oral regeneration (Mia Geisinger) » Modern Wound Management – the use of autologous growth factors in everyday dental practice (Marc Quirynen) » Novel aspects of tissue engineering for bone regeneration (Siddharth Vivek Shanbhag) Main Scientific Program The main program is divided into eight sessions according to the focus topics. For example, different options for hard and soft tissue augmentation, including guided bone regeneration with blocks or shells, or computer-assisted bone augmentation will be discussed. The speakers will discuss topics such as to whether or how bone and soft tissue healing around implants can be influenced, discuss options in treatments for gingival recession, as well as the use of autologous bone or allogeneic, xenogeneic, or synthetic bone substitute materials, membranes, and soft tissue matrices. The question as to when is the right time for implant placement and what are the advantages of digitization will be discussed, as will prosthetic solutions for older, and also edentulous patients. Young researchers whose studies are supported by the OR Foundation will be presenting their latest findings in a separate session on the main podium on Saturday morning. The best researcher will receive the OR Foundation Research Award. In addition, the symposium will feature a poster exhibition. The best abstracts will be presented on the main stage on Friday afternoon. Session 1: Treatment planning in the digital era (Katja Nelson, Dehua Li) » Digital planning in the esthetic zone (Florian Beuer) » The ABCD Algorithm: A comprehensive philosophy in treatment planning for full arch cases (Udatta Kher, Ali Tunkiwala) » Analogic planning – is it still viable? (Sergio Piano) Session 2: Timing in implant treatment (Homa Zadeh) » Post-extraction socket development (Mauricio Araujo) » Delayed placement (Ronny Jung) » Immediate placement (Ramón Gómez-Meda) Session 3: Treatment of soft tissue defects: do we have relevant innovation? (Mariano Sanz) » The role of keratinized mucosa (Ignazio Sanz Martin) » Is peri-implant tissue management using CTG still golden standard? (S. Marcus Beschnidt) » Soft-tissue defects treated with heterologous materials (Anton Sculean) Session 4: CAD/CAM implant supported restoration – are they a must? (Irena Sailer) » CAD/CAM fixed dental prosthesis: state of the art (Jan Frederik Güth) » One-crown one-time concept (Christina Zarauz, João Pitta) » Digital Workflow or analog approach? (Julián Conejo) Session 5: Young OR Foundation Researchers und Research Award Session 6: Can we influence bone and soft tissue healing around implants? (Luca Cordaro) » Can we increase soft tissue dimensions in the long-term? (Hom-Lay Wang) » Ideal abutment emergence profile anatomy (Ana Torres) » Aggressive implant macrodesigns (Marius Steigmann) Session 7: Do digital technologies really help the implant surgeon? (Juan Blanco) » Efficient modern treatment plans: 5.0 immediate loading (Tiziano Testori) » Controlling errors in guided surgery (Tali Chackartchi) » Computer-assisted bone augmentation techniques (Bilal Al-Nawas) Session 8: Hard tissue augmentation with the conventional approach (Michael Stimmelmayr) » Principles and Long-term Results of Hard Tissue Grafting with Autogenous Bone (Fouad Khoury) » Block Grafts: Are they a must or becoming obsolete? (Tara Aghaloo) » Guided Bone Regeneration (Juan Blanco) Over the rooftops of Rome Italian elegance is called for at the Dolce Vita Night on Friday evening. The OR Foundation has booked the noble Villa Miani on Monte Mario. A breathtaking view over Rome and an exclusive ambience of frescoes and marble characterize this location, charmed by the international audience of the OR Symposium. Enjoy an unforgettable congress weekend in the Eternal City with groundbreaking impulses for your everyday practice and that very special flair. The Board Members of the OR Foundation: President Luca Cordaro, Irena Sailer, Past-President Mariano Sanz, Executive Director Martin Schuler Over the roofGo to the information and registration:

the Camlog Partner Magazine logo 50 | the Camlog Partner Magazine 12 | Science Science| 13 SCIENCE Peter Thommen Clinical Research Associate Camlog » Clinicians and patients expect medical devices to perform their function and comply with safety requirements. Manufacturers, on the other hand, are compelled by directives and regulations to thoroughly test and document products before placing them on the market. Even more important are scientific data which confirm the performance of the products preclinically and clinically. Camlog has supported studies and their publication in collaboration with universities and clinicians right from the beginning. The brochure "Camlog and Science" will be republished shortly and contains a summary of the current scientific evidence for the CAMLOG® and CONELOG® Implant Systems with the objective of strengthening the confidence of dentists and dental technicians in our systems on the basis of facts and science. The importance of science For the benefit of the patient, a restoration with a dental implant should ideally last a lifetime. Numerous factors and parameters are responsible for a successful outcome, including the choice of implant system. A prerequisite for predictable clinical outcomes in dental practice is scientific data, in other words, evidence-based implant systems. Preclinical and clinical studies and the knowledge gained help to understand and optimize the interface between the dental implant and the surrounding oral tissues. For Camlog, science represents a cornerstone in the development of its implant systems. In addition, efficacy and safety of the products are continuously supported by long-term clinical data. In collaboration with universities and clinics, new product features, such as the introduction of the Platform Switching concept, were first investigated in preclinical and ex-vivo studies and finally the positive effect was verified in clinical trials. Over the years, this commitment to science has led to numerous publications and their number continues to increase. New edition of "Camlog and Science" Due to new product lines such as the PROGRESSIVE-LINE, the availability of long-term data and new findings in the digital field, the time has come for a new edition of our well-known customer brochure "Camlog and Science". The new documentation in English will provide a clear presentation of key study results on the CAMLOG® and CONELOG® Implant Systems. Emphasis is also placed on the clinical benefits of the scientific results for applications in dental practice. "Camlog and Science" is designed to help our customers understand the evidence-based benefits of the CAMLOG® and CONELOG® Implant Systems, despite the high volume of publications. Questions regarding the effect of the Promote® Implant surface, the precision of the implant connection, the behavior of oral tissue surrounding implant restorations and the different clinical therapy concepts are substantiated with numerous data and summarized in a topic-specific manner. The document will be ideally suited for reference purposes and to assist in the selection of treatments. Furthermore, it assists dentists, clinicians and dental technicians to stay abreast of the latest scientific developments and to effectively apply the derived knowledge in clinical practice. Delivering science to customers "Camlog and Science" is part of an initiative to bring science and its implications for clinical practice in implant dentistry closer to our customers. The intention is to differentiate between the different needs of customer groups in terms of science and to present the content in a comprehensible manner. Specific questions and areas of interest should be easy to access. Depending on the needs, the information ranges from brief summaries to full publications. In future, the "Camlog and Science" brochure will be supplemented periodically with new study results. And of course, Camlog as a company will continue to invest in ongoing and future research in implant dentistry. Summary The CAMLOG® and CONELOG® Implant Systems are evidence-based and new products and properties are investigated continuously in scientific studies. The new edition of the "Camlog and Science" brochure summarizes the most important studies on the safety and performance of the two systems and highlights their benefits for patient treatment. The document will soon be available in the Media Center at Send an e-mail to and we will inform you as soon as it is available. A printed version can also be requested using the same address. Available soon! The new "Camlog and Science" brochure will be published in English Preclinical and clinical study results with the CAMLOG® and CONELOG® Implant System - a documentation of clinical success Camlog and science - concise in one brochure

logo 50 | the Camlog Partner Magazine logo 50 | the Camlog Partner Magazine 14 | Case study Case study | 15 Dr. Maximilian Wienke Dentist Krestales Verankerungsgewinde Sägezahngewinde mit verbreiterter Flankenhöhe Konischer Bereich Promote®plus Oberfläche Parallelwandiger Bereich Gewinde bis zum Apex Für zusätzlichen Halt bei begrenzter Knochenhöhe2 Tief eingreifende Gewindeflanken Optimierte Verteilung axialer Kräfte1 Gezielte Knochenkompression1 Exzellente Primärstabilität Reduzierter Durchmesser in Bereichen mit wenig Knochen 1,2 Bewährte gestrahlte, säuregeätzte Oberfläche Ideal für Sofortimplantationen1,2 Kontur Formbohrer PROGRESSIVE-LINE CONELOG® PROGRESSIVE-LINE Implantat COMFOUR® in the edentulous jaw- a patient-centric solution also for patients with dental anxiety PRACTICE The etiology of dental anxiety, fear, or phobia is complex and multifactorial [2]. In the current S3 guideline [3], dental anxiety is interpreted "as an intense emotional reaction to elements of the dental treatment situation which causes suffering for the person affected and which appears excessive in view of the actual dangers in the situation." Nevertheless, such patients are more likely to accept intraoral defects and the risks of organic sequelae instead of necessary treatment. This is accompanied by social withdrawal, as people are ashamed of their supposedly poor tooth structure. Only when the pain becomes unbearable is a dentist consulted. Various studies suggest to openly address these obvious fears in such patients even before treatment begins, to allow them to participate in the therapy decision and give them the opportunity to influence treatment. In this context, empathy of the entire treatment team, free of prejudice and reproach, plays a decisive role for sustained therapeutic success with a permanent commitment to compliance on the part of the patient, as well as for long-term patient loyalty. Even patients suffering from "dental anxiety with a disease status" generally show good follow-up behavior after successful therapy, which is comparable to non-sufferers. This positive development can be reinforced by good communication skills and a treatment team trained in dealing with anxious patients. In the present case, the 50-year-old female patient had avoided making dental appointments for years due to her "dental phobia". However, her physical and psychological suffering had meanwhile increased to such an extent that therapy became unavoidable. On the one hand, her greatest wish was to be able to "laugh carefree and chew without pain" again as quickly as possible. On the other, there were strong reservations about augmentative interventions and a limitation on the part of the costs. The COMFOUR method succeeds in reconciling both aspects. Workflow The various treatment options available after the necessary extraction of all remaining teeth were discussed in great detail with the patient during the preliminary consultation, taking into account possible consequences, and the anticipated course of treatment was described to her in detail. In this context, the patient's desire for fixed dentures became apparent based on her painful experiences with her massively dysfunctional dentition. After assessing the various aspects, the patient opted for a restoration in the upper and lower jaw on four implants each using the COMFOUR method. In this technique, the distal implants are placed in an angled position to achieve sufficient stability even in a vertically reduced alveolar ridge without augmentation. For the patient, this procedure offered the advantage that extraction, implant placement and interim restoration could be performed painlessly under intubation anesthesia within a single day. » The primary focus of implant therapy in the edentulous jaw is the patient's satisfaction with the course of therapy. Due to the clinical and time requirements as well as the cost burden, treatment concepts with extensive augmentative measures entail the risk that the patient will switch to alternative restorations, which may, however, bear certain risks from a longer-term perspective. For example, pressure exerted by the denture can cause incorrect loading of the jawbone and lead to bone loss over the course of time. In contrast, bone recession does not occur with implant-supported restorations. Here, the COMFOUR concept with distally angled implants offers a convincing solution which is also patient-oriented in terms of cost. It generates an esthetic and long-term stable result with reduced invasiveness, less surgical effort and shorter treatment times. Sandra Kirchmaier Dental technician 1. Clinical examination of the initial situation had already revealed the desolate intraoral situation with root remnants, destroyed crowns, posterior tooth losses in four quadrants, massive calcified deposits (calculus) on all remaining teeth, as well as severely inflamed soft tissue. 3. Following extraction of the residual dentition, the site was disinfected by means of antimicrobial photodynamic therapy (aPDT) and four 3.8 mm Conelog® Progressive-Line implants were inserted via SMOP drilling templates. While the implants in the upper jaw healed under a covered implant denture due to the soft bone substance, the lower jaw was immediately restored with an interim denture. 5. Scans of the initial situation and printed situation models formed the basis for the further digital workflow, such as a slotted mandibular orientation template for rechecking the alignment of the implants as well as a prefabricated full denture made of a milled dental arch and manually applied pink plastic as interim restoration of the upper jaw. 2. The X-ray confirmed the impression gained during clinical examination. The massive loss of hard tissue made any form of tooth preservation impossible and demonstrated the necessity of extracting the tooth fragments as well as the remaining teeth in a manner that was also comprehensible for the patient. 4. The Progressive-Line® Implant with its typical sawtooth thread and deeply engaging thread flanks compresses the soft bone and optimally distributes axially acting forces. Due to the conically tapered apex, insertion is also possible in sites with reduced bone volume. 6. X-ray control image of the titanium caps screw-retained on the distally 30 degree angled COMFOUR bar abutments (for the bar abutment for bridges) for retention of the interim temporary in the lower jaw.

logo 50 | the Camlog Partner Magazine logo 50 | the Camlog Partner Magazine 16 | Case study Case study | 17 7. While the implants in the upper jaw healed under the mucosa-supported full denture, the patient's lower jaw was restored with the interim provisional milled from a multichromatic PMMA blank. 8. Four months later, the upper jaw had healed without inflammation and with sufficient soft tissue volume, so that the COMFOUR bar abutments could be screw-retained on the implants after disclosure. 9. The lower jaw also revealed a well-healed soft tissue situation around the implants after removal of the interim provisional. The angled COMFOUR bar abutments are clearly visible distally. 10. After an intraoral scan at abutment level and a squeeze bite, the functional and esthetic work for the planned prosthetics was started. To do this, an initial digital setup was made, which was also the starting point for subsequent blocking of the open impression taking and served as the basis for the digital centric registration. 11. Using the scans of the upper and lower jaws, a centric registration was created digitally with the Centric Guide® (theratecc, Chemnitz) as a basis for planning and milling the temporaries designed according to the planned final restoration. 12. X-ray check of the impression posts in the upper jaw for a gap-free fit prior to open impression taking for the esthetic-functional final temporaries. COMFOUR bar abutments are screw-retained in the lower jaw. 13. The precise transfer of the oral situation to the model and the check for a tension-free fit of the final temporaries as full-arch frameworks on angled implants was performed intraorally with autopolymerized splinted impression posts. For open impression taking of the implants at abutment level in the upper jaw, a FU tray was printed digitally on the basis of a new scan. Impression taking itself was performed according to the Landsberg concept for an optimum esthetic result as an analog impression using the double-mix technique. 17. After an initial check of the fit on the duplicated master cast, DEDICAM® returned the materials to the laboratory where, after rechecking the fit, the titanium bases were CAD/CAM bonded tension-free to the framework on the master cast. 18. The designed superstructures were first milled from plastic and connected to the metal framework for try-in. As there were no problems whatsoever in terms of fit, fabrication of the ceramic crowns could be started by scanning the final wax-up again. 15. Plastic temporaries designed along the principles of esthetics, phonetics and function for a trial run of several months for acceptance or correction by the patient. For this purpose, the first set-up of interim temporaries was uploaded as in-situ models and adapted to the new situation via matching. The patient wore the final temporary restoration for two months on a trial basis. After she had no correction requests and "coped very well" with the temporary restoration, fabrication of the final restoration could commence. To this end, the temporary restoration was digitally reduced and sent as an STL file to DEDICAM® for milling a titanium framework.

logo 50 | the Camlog Partner Magazine logo 50 | the Camlog Partner Magazine 18 | Case study Case study | 19 19. The sintered crowns were personalized with stains and bonded in blocks of three to the opaque frameworks according to the manufacturer's processing instructions, after having previously visualized their surface structures with texture powder for esthetic optimization. 20. After layering and characterizing the soft tissue structures with pink composite, the optical impression of natural single crowns was created as intended and hoped for by the patient. 21. and 22. The finalized superstructures for the upper and lower jaw in situ and in the X-ray control image after their final insertion. Final photos of the visibly relieved patient. Even though the lip and cheek appearance may not meet esthetic ideals, it still reflects the patient's regained individuality and self-confidence. [1] Bayer G, Kistler F, Kistler S, Sigmund F, Adler S, Neugebauer J. Versorgungsmöglichkeiten ohne Sinusbodenelevation mit angulierten Implantaten - 6 Jahre Erfahrungen. Implantologie 2012;20:195–204. [2] Beaton L, Freeman R, Humphris G. Why are people afraid of the dentist? Observations and explanations. Med Princ Pract. 2014;23(4):295-301. [3] DGZMK. S3-Leitlinie Zahnbehandlungsangst beim Erwachsenen (Langfassung) AWMF-Registernummer 083-020, Stand 31.10.2019, Internet: detail/083-0209. [4] Malo P, Rangert B, Nobre M. „All-on-Four“ immediate function concept with Branemark System implants for completely edentulous mandibles: a retrospective clinical study. Clin Implant Dent Relat Res 2003;5(Suppl 1):2–9. [5] Tallarico M, Canullo L, Pisano M, Penarrocha-Oltra D, Penarrocha-Diago M, Meloni AM. An up to 7-Year Retrospective Analysis of Biologic and Technical Complication With the All-on-4 Concept. J Oral Implantol 2016;42(3):265–271. [6] Tallarico M, Meloni SM, Canullo L, Caneva M, Polizzi G. Five-Year Results of a Randomized Controlled Trial Comparing Patients Rehabilitated with Immediately Loaded Maxillary Cross-Arch Fixed Dental Prosthesis Supported by Four or Six Implants Placed Using Guided Surgery. Clin Implant Dent Relat Res. 2016 Oct;18(5):965-972. » Since 2016 dental technician in joint practice Dr. Bayer & Colleagues » Specialist in the field of CAD/CAM, ceramics and implant restorations » Attends continuing education courses and professional lectures on dental technology topics and dental photography Dr. Bayer & Colleagues Von-Kühlmann-Straße 1 86899 Landsberg am Lech Sandra Kirchmaier References » Study of dentistry at the Ludwig Maximilian University of Munich » Since 2018 in joint practice Dr. Bayer & Colleagues » Focus on implant dentistry, esthetic dentistry and endodontology Dr. Bayer & Colleagues Von-Kühlmann-Straße 1 86899 Landsberg am Lech Dr. Maximilian Wienke 24. After many years of suppressing her smile, it still looks a bit tense, but it is the first time she proudly shows her teeth again. Discussion / Summary CAD/CAM-fabricated, screw-retained bridge constructions according to the COMFOUR procedure can meanwhile be considered a clinically evaluated, evidence-based implant prosthetic restoration in the edentulous jaw [1, 4, 5, 6]. CAD/CAM fabrication guarantees a high accuracy of fit here, particularly in the area of the angled screw channels. This, in turn, significantly expands the range of indications for implant-supported rehabilitation, even in cases where augmentation surgery is not indicated or is rejected by the patient. Any necessary repairs and hygiene measures such as PTC can also be performed more easily and thoroughly with partially removable superstructures, which in turn reduces the risk of peri-implantitis. However, the success of an immediate complete implant prosthetic restoration in patients who have a desolate dental status in the upper and lower jaw as a result of marked dental anxiety is strongly influenced by other factors, such as sustained and committed compliance and regular recall to support continued oral health. This requires a participatory therapy decision in advance, based on the professional as well as communicative competence of the entire treatment team. Given a suitable bone structure, a COMFOUR restoration, even with only four implants per jaw, can restore positive self-esteem in such, not so motivated patient who will then have teeth that match his/her personality and with which he/she can “simply live normally again”..

logo 50 | the Camlog Partner Magazine logo 50 | the Camlog Partner Magazine 20 | Case study Case study | 21 PRACTICE Otto Prandtner Master dental technician Dr. Michael Berthold Oral surgeon Transmucosal zone 1. Arian, a 26-year-old student, presented in the practice with pain in the area of the central incisor as well as a persistent fistula. Resulting from an anterior tooth trauma during childhood, multiple root canal treatments, two apicoectomies and restoration with a metal-ceramic crown followed. 2. Due to the apicoectomy, the root of tooth 21 was shortened. A further revision attempt had a poor long-term prognosis. As the tooth had to be extracted, an immediate restoration protocol was discussed by the interdisciplinary team. The cross-sectional image of the DVT revealed sufficient bone volume apical to the tooth for immediate implantation. Fenestration due to the fistula did not represent a contraindication. 6. The submucosal design of the temporary restoration is intended to support the existing gingival margin and papilla height. The anatomical emergence profile of the original clinical tooth crown should be preserved accurately here. The design areas of the transition zone are divided into the biological areas and geometric shaping. 4. Taking into account all the biological criteria for hard and soft tissue preservation, the implant was placed correctly three-dimensionally. Based on the defined temporary restoration, a drilling sleeve is positioned for the fully-guided drilling template. Attention must be paid here to ensure that the edges of the sleeve do not touch the soft tissue structures to avoid traumatization when inserting the drilling template. 3. Pre-surgical planning includes digital volume tomography (DVT), a facial scan and the digital wax-up. The exact tooth position, alignment and length can be defined with the aid of the superimposed data. This forms the basis for optimal implant positioning - slightly oriented towards palatal to ensure palatal screw-retention of the restoration and sufficient space for peri-implant augmentation. 5. The natural tooth root acts as a model for the submucosal design of the abutments/gingiva formers. The root of tooth 21 was extracted from the DVT data set by surface rendering, converted into an STL data set and merged with the data from the scan of the upper jaw. A reliable method to achieve the basis for an exact anatomical crown emergence profile which corresponds to the natural tooth. Success factor of an implant restoration - the Personalized Tissue Support Concept Using an immediate temporary prosthetic restoration which mirrors the submucosal contours of the extracted tooth at the time of implant placement is the basis for promoting peri-implant soft tissue healing. An anatomically shaped individual gingiva former or the temporary implant crown assume the function of the soft tissue wound closure during immediate implantation. Both forms stabilize the blood coagulum and thus contribute to tissue preservation during immediate implantation. In the Personalized Tissue Support Concept the focus is on the "transition zone" - the transition area from the circular implant shoulder to the emergence profile of the restoration from the gingiva. Information on the tooth root and the gingiva profile, which can be transferred from the DVT into an STL data set, is essential for the design of the individual gingiva former. Virtual implant positioning as well as the commissioning of a drilling template for guided implant surgery is performed on the basis of 3D X-ray diagnostics and the digital recording of the clinical oral situation. Taking biological criteria into account, the individual PEEK gingiva formers are designed on this basis and manufactured by DEDICAM. Impression posts for open or closed impression taking are manufactured from the same data set to be able to transfer the anatomically shaped soft tissue precisely to the master cast. The fact that the impression post is fabricated from the same data set is crucial for the controlled preservation of the gingival geometry. The gingival geometry as well as the undulating profile of the healed gingiva are thus optimally communicated between the dentist and the dental technician. An essential part of the concept is that the implant abutment is fabricated with the same submucosal contour to avoid an uncontrolled gingival change due to over- or under-contouring. Over-contouring of the "transition zone" generally leads to uncontrolled apical positioning of the gingival margin and thus to an optically extended crown. Under-contouring creates a gap into which the gingiva collapses, which also results in apical positioning of the gingival margin. When designing according to biological criteria, a zone is created in which the connective tissue can attach to the suprastructure - the connected tissue zone. The decisive factor here is the concave shape of the suprastructure from the implant shoulder in direction of the epithelial attachment, which creates sufficient space for the formation of a stable mucosa cuff. The exact copy of the root geometry is essential in the area of the epithelial attachment (approximately 1mm) of the so-called "critical contour" [2]. This promotes primary wound closure as well as stabilization of the blood coagulum. The sulcus influences the level of the gingival margin, gingival color and architecture of the facial emergence profile as well as papilla height and is controlled by the prosthetic structure. During the healing phase, manipulation in the sulcus region could negatively alter the undulating gingival profile. In nature, the gingiva is situated at the enamel-cement border. The design of this border zone should only be completed during the final restoration to be able to define the shape of the sulcus. Highly esthetic implant solutions have been fabricated for years with customized gingiva formers created in the laboratory. The shaped profiles are then transferred to impression posts, which in turn are used for the accurate transfer to the master cast. With the objective of optimizing surgical procedures as well as predictable esthetic and functional implant restorations, patient-specific gingiva formers and impression posts as well as temporary restorations with the same emergence profile can now be fabricated in collaboration with DEDICAM via digital planning based on backward planning and taking into account the biological criteria of soft tissue support. The following patient case describes an immediate implantation with a fully digital solution approach from fully-guided implantation, the use of the customized DEDICAM PEEK gingiva former to preserve the soft tissue contour up to the final restoration. » From the patient's point of view, the success of an implant restoration is evaluated by the appearance of the dental crown and, above all, by a harmonious profile of the peri-implant soft tissue as well as the natural color transition from the white to the red zone [1]. A natural clinical appearance of an implant restoration in the anterior tooth region can be realized predictably by virtue of digital preplanning during surgery using the Personalized Tissue Support Concept.

logo 50 | the Camlog Partner Magazine logo 50 | the Camlog Partner Magazine 22 | Case study Case study | 23 8. The digital design was passed to the DEDICAM manufacturing service. There, the models were manufactured using the 3D printing process, as were the drilling template, gingiva former and impression post, as well as the temporary implant crown. These were delivered after four days and were available for surgical intervention in the dental practice. The deep-drawn splint with acrylic tooth was on hand for temporary restoration in case primary stability proved insufficient. 9. On the day of surgery, the anterior tooth was gently extracted. To retain the surrounding tissue structures, extraction was performed minimally invasive. Due to the fistula, the vestibular lamella was fenestrated. After removal of the ceramic crown, the focus was placed on preserving the intact soft and hard tissue structures. Tooth 21 was removed with a microscalpel, periotomes and desmotomes, and the fistula tract was freshened with the microscalpel. 10. During root extraction, the inflammatory tissue adhered to the root tip, also no bone fragments were visible on the surface - suggesting that the buccal lamella had remained intact. In the case of late implantation, the root would be cleaned and sent to the dental laboratory for adaptation of an anatomical emergence profile to explore measures for tissue support in the analog world. 11. De-epithelialization of the alveolus was performed with diamond balls as well as with the scalpel blade. This is critical for complete healing of the tunnel connective tissue graft. 12. The printed SMOP drilling template was inserted and stability of the position was checked. The skeletonized design and the intricate construction provide a good overview of the surgical site. This permits using a minimally invasive surgical technique, does not interfere with the cooling process and does not exert pressure on the soft tissue due to the previously selected positioning of the sleeve. 13. The implant site was prepared according to protocol using the drills of the PROGRESSIVE-LINE Guide System. And although the drill is guided very well in the drill sleeve, care should be taken to align the drill with the palatal alveolar wall, especially in the case of immediate implantation. Autologous bone chips can be collected with careful preparation and subsequently used for augmenting the buccal gap. To provide correct three-dimensional placement, the implant was inserted through the drilling sleeve until the insertion post was seated on the sleeve. Due to the apically conical implant area, the implant achieved a sufficiently high primary stability of 35 Ncm in the residual bone. This allowed the concept of temporary immediate restoration to be pursued further. 17. To support peri-implant tissue healing and dense stabilization of the blood coagulum, the treatment protocol called for thickening of the soft tissue. For this purpose, a connective tissue graft was removed from the palate at region 24/25 and de-epithelialized extraorally based on the technique according to Zucchelli [3]. 18. With the aid of positioning sutures, the graft was pulled into a previously prepared envelope and placed precisely in the position envisaged beforehand in the subgingival design of the suprastructure. 15. Precise alignment of the inner implant geometry is essential for the correct fit of the individual components fabricated prior to surgery. This is done by aligning the orientation line on the insertion post/insertion instrument with the marking on the drilling sleeve. 16. The jumping distance - the cavity between the buccal bone wall and the implant - was filled with autologous bone (collected during implant bed preparation with the guide drills) for resorption protection and stabilization of the vestibular lamella as well as for supporting the soft tissue. 7. The Personalized Tissue Support Concept envisages that the customized gingiva former or temporary restoration ensures preservation of the existing soft tissue architecture, avoids compression of the soft tissue and leaves sufficient space for stable tissue regeneration. [2]. The subcritical concave designed area offers space for a stable blood coagulum as well as a possibly required connective tissue graft.

logo 50 | the Camlog Partner Magazine logo 50 | the Camlog Partner Magazine 24 | Case study Case study | 25 Discussion Immediate restoration concepts are becoming increasingly popular and can be implemented successfully if certain criteria are taken into account. They represent a minimally invasive approach and are valued by patients due to fewer treatment sessions as well as a reduction in surgical procedures. Digital technologies improve diagnostics, analysis, planning and clear communication in the collaboration with tight deadlines between surgeons and dental technicians. Another advantage of immediate restoration concepts is the preservation of the peri-implant hard and soft tissue contours, also by employing pre-surgically fabricated customized temporary components with controlled healing. The individual PEEK gingiva formers can offer a new innovative approach by designing according to biological criteria, which eliminates the need for repeated surgery and time-consuming conditioning of the mucosal contour [7]. The concave submucosal design of the abutments is absolutely essential to provide sufficient space for the tissue to form a new biological width. Immediate restoration concepts require proactive planning. The surgical procedure should provide the framework for natural red and white esthetics. This means preserving the papillae and providing the required soft tissue support. The macrodesign of the implant system used should achieve predictable primary stability. Especially if the implant only attaches via the lower third in the residual bone and if there is only palatal bone contact. Arian's Story lively. View the patient case, filmed by rezotto production. 19. Immediately after tissue thickening, the individual PEEK gingiva former was placed for demonstration purposes. With its specific design, this promotes the natural attachment of the peri-implant mucosa while supporting the interdental papilla at the same time. In immediate implantation it provides the same soft tissue support as the temporary crown, and reduces the risk of overloading to protect implant healing. 20. If primary stability proved to be too low for immediate prosthetic restoration, a splint with integrated acrylic tooth would provide sufficient protection against overloading as an interim solution. This represents a compromise for an esthetic temporary solution. 21. In the presented case, the treatment team decided to insert a screw-retained temporary implant crown. This was largely excluded from function. The proximal contacts were also removed so that the adjacent teeth do not transfer any movement to the implant restoration during function. Close recall intervals were maintained during the healing phase. 22. One week after the surgical procedure, the soft tissue was free of irritation and created naturally. Due to the inserted connective tissue graft, the gingiva will attach to the connected tissue zone in a controlled manner. 23. The further measures for definitive reconstruction were able to be performed three months after surgery. 24. Removal of the temporary restoration revealed a stable and anatomically shaped soft tissue cuff. The concave shaped submucosal area is visible in the occlusal view. Minimal bleeding emphasizes implementation of the biological criteria for connective tissue accumulation in the area of the connected tissue zone. 25. The individual design of the PEEK impression post served to transfer the absolutely identical soft tissue situation to the master cast. In a three-dimensional study, Galibourg et al demonstrated that the soft tissue volume of the emergence profile collapses significantly when deprived of its support for 30 seconds [4]. 26. In his approach to perfect esthetics, Otto Prandtner, MDT, Munich, invested considerable time in analyzing the initial situation based on digital images according to the concept of "Digital Smile Design". This includes checking the tooth shade of the zirconium crown framework with so-called polarization filters. In this process, the chroma of natural teeth, the internal play of light and the characteristics are reproduced precisely [5,6]. 27. Four months after the surgical procedure, the definitive hybrid crown was placed. The crown design met all esthetic criteria, such as shape, shade, light guidelines and gingival adaptation. The chosen procedure contributed to maximum structural preservation without any scarring and an excellent esthetic outcome. 28. Emotion at its best. Arian was delighted with the successful esthetic implant reconstruction, the patient information and the competent care provided during the entire treatment process.

logo 50 | the Camlog Partner Magazine logo 50 | the Camlog Partner Magazine 26 | Case study Case study | 27 References Online Tutorials online! Be inspired by Arian's patient story and see how Arian's aspirations for his dental health and esthetics were met through an innovative treatment approach with immediate implantation in the anterior maxilla. Arian's story is a lively professional publication and emotional patient story, which was filmed by rezotto production and documented in a comprehensible manner in the form of multi-part video tutorials. Find out here how it's done. Arian's story – the Personalized Tissue Support Concept [1] Vermylen K, Collaert B, Linden U, Bjorn AL, De Bruyn H. Patient satisfaction and quality of single-tooth restorations. Clin Oral Implants Res. 2003;14(1):119-24. [2] Huan Su 1, Oscar Gonzalez-Martin, Arnold Weisgold, Ernesto Lee; Considerations of implant abutment and crown contour: critical contour and subcritical contour; Int J Periodontics Restorative Dent . 2010 Aug;30(4):335-43. [3] Zucchelli G, Mele M, Stefanini M, et al. Patient morbidity and root coverage outcome after subepithelial connective tissue and de-epithelialized grafts: A comparative randomized-controlled clinical trial. J Clin Periodontol 2010;37: 728–738. [4] Galibourg A. , Dumoncel J. Cormary J., Maret D.; Volume of unsupported peri-implant soft tissue over time: A cross-sectional observation study; J Prosthet Dent . 2021 Jun; 125(6):883-889. doi: 10.1016/j.prosdent.2020.03.010. Epub 2020 Jun 2. [5]. Coachman C, Calamita MA. Digital Smile Design: a tool for treatment planning and communication in esthetic dentistry. Quintessence Dent Technol 2012;35:103-111. [6]. McLaren EA, Garber DA, Figueira J. The Photoshop Smile Design Technique (Part 1): Digital Dental Photography. Compendium 2013;34(10):772-779. [7].M. Beretta, P. Poli, S. Pieriboni, S. Tansella, M. Manfredini, M. Cicciù, C.Maiorana; Peri-Implant Soft Tissue Conditioning by Means of Customized Healing Abutment: A Randomized Controlled Clinical Trial. 2019 Sep 19;12(18):3041. doi: 10.3390/ma12183041. » Dentist and specialist for oral surgery; study of dentistry, Johannes-Gutenberg-University Mainz » Advanced dental training and senior physician at the private dental clinic Schloss Schellenstein (Prof. F. Khoury) » Since 2015 Research Associate, Polyclinic for Dental Prosthetics, LMU Munich (Prof. D. Edelhoff) » Practice and inclusion in the list of specialists in England, Luxembourg as well as in Germany » 2021–2022 Master studies Soft tissue management around teeth and implants, Università di Bologna (Prof. Giovanni Zucchelli), Italy » Since 2022 Establishment in own practice at Promenadeplatz Practice for Periodontology & Implant Dentistry Promenadeplatz 11 D-80333 Munich E-mail: Dr. Michael C. Berthold, M.Sc. » 1999–2008 Educational years from Salzburg to Stuttgart, California and Munich » 2014 Founding of the "Platform for the Finest Dental Technology" with Hubert Schenk and Stefan Frei » 2017–2018 Part of a scientific group, 12 peer-reviewed articles listed in pubmed. » Focus: www.dentale-persö Platform for the Finest Dental Technology Goethestr. 47 D-80336 Munich E-mail: MDT Otto Prandtner Conclusion We already define the treatment goal at the planning stage and have developed structured procedures as a team. By applying clearly defined procedures and using the same geometry for each treatment step, teaches one to work in an interdisciplinary manner and to avoid mistakes. Digital tools promote minimally invasive, biological and functional implant dentistry. They are effecient and economical and are therefore regarded by us as being an essential basis. In implant dentistry, this structured detailed advance planning is always unbeatable compared to spontaneous creative procedures on the patient. To achieve a long-term stable esthetic outcome, the focus is on soft tissue management during the surgical phase and on the design of the prosthetics in the submucosal critical area.