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Editorial
Prof. Dr Heiner Weber
As recently selected President of the DGZI, it is important to me to welcome you all and to gain your trust and assistance in this journey ahead of us. From my previous honorary executive positions, I am convinced that the executive board of a society has to establish a close contact with its members and, moreover, that this contact has to be re-established continuously...
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CAMLOG Biotechnologies AG 1
Retromolar bone grafts prior to implant placement - Outcomes and complications (Part II)
Andreas Sakkas, Carsten Winter, Frank Wilde & Alexander Schramm, Germany
The dental rehabilitation of partially or totally edentulous patients with oral implants has become common practice with reliable long-term results.1 However, unfavourable local conditions of the alveolar ridge due to atrophy, periodontal disease, trauma sequel, malformation or neoplasia may cause insufficient bone volume, which may complicate the therapy of the masticatory function with dental implants.2 When alveolar ridges lack the appropriate bone volume, additional surgical reconstructive procedures are required. This article concludes Part I (implants 3/2013) with results, an extensive discussion and the conclusion...
Nobel Biocare Deutschland GmbH
A new technique for the preparation of the implant site - Through Piezoelectric Surgery (PES)
Prof. Mauro Labanca, Prof. Lugi F. Rodella & Prof. Paolo Brunamonti Binello, Italy
Piezosurgery (PES) is a surgical technique born in the 90s; because of its versatility and effectiveness, it immediately spread from the oral surgery field to many other specialised surgical branches, such as, for example, maxillofacial surgery, orthopaedics and neurosurgery...
Straumann AG
Implant Direct Europe AG
Ridge augmentation for an atrophied posterior mandible - NanoBone block versus allograft bone block (Part III)
Dr Omar Soliman, Prof. Dr Dr Mohamed Nassar, Ass. Prof. Dr Mahmoud Shakal & Ass. Prof. Dr Eman Mohy El-din Megahed, Egypt
The aim of the present study was to compare the clinical outcome and radiographic bone changes in augmented ridges utilizing a synthetic NanoBone block versus an allograft bone block, and to investigate histologically the success of a synthetic NanoBone block versus an allograft bone block for ridge augmentation. In the previous issues of implants: international magazine of oral implantology, the authors gave a detailed introduction to their topic and explained the materials and methods used in their study (implants 1/2013) and the results of clinical outcomes & radiographic bone changes (implants 2/2013). In this issue, their report is completed by the histological results of their investigations and an extensive discussion.
Vertical bone augmentation procedures (Part I)
Prof. Dr. med. Dr. med. dent. Florian Draenert, M.D. D.D.S. Ph.D.
The success of an implantological procedure largely depends on the alveolar situation and the bone supporting the soft tissues. Until today, complex augmentation procedures pose high demands on the clinician and there is still a great need for research in this field. The following article discusses the basics of implantology relevant to bone augmentation and presents an overview on complex bone augmentation techniques. Part I of this consecutive article series introduces basics in bone morphology, biomaterials and transplants. To be continued in 2014 with issue 1/2014...
Dentaurum GmbH & Co. KG
A revision of an unaesthetic reconstruction
Dental Campus
Has it happened to you? You’ve heard an excellent talk at a continuing education course, but when you want to apply the new knowledge, you realize that you lack the necessary practical details. Dental Campus closes this gap. The new e-learning platform created especially for implant dentistry is practice-oriented and offers important theoretical, technological and product-related details in one single resource. It has a structured and innovative design and allows for interactive communication. The quality of the content on Dental Campus is constantly assured by the Implant Campus Board whose members include internationally recognized experts...
Extensive implant-supported restoration in generalised aggressive periodontitis
Dr Dr Philipp Plugmann, Germany
Particularly young patients under the age of 30 experience high levels of psychological strain when faced with episodic loss of several teeth as a result of generalised aggressive periodontitis. The influence of this disease on the patients' social life and their careers can be enormous...
Immediate implant placement with the NNC implant
Joachim S. Hermann, Switzerland
In the past, the restoration of narrow tooth gaps with Straumann® Soft Tissue Level implants (maxillary lateral incisors/mandibular incisors) was only possible with the Straumann® Narrow Neck Implant (NN). Due to the prevailing external, hexagonal connection geometry and correspondingly larger dimensioned abutment components it was somewhat difficult to achieve hygienic and aesthetically demanding restorations, particularly in the anterior region of the mandible. The new Straumann® Narrow Neck CrossFit® implant (NNC) now offers an established internal taper connection which allows more intricate prosthetic work in the emergence profile region. Due to the harder implant material—NNC made of TiZr (Straumann® Roxolid®) vs. NN made of pure titanium grade 4, cold-worked—one can expect multi-unit bridges, as described in this case, to also have a better long-term prognosis from a biomechanical point of view...
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Practice-oriented implantology at the DGZI Annual Congress
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„From practice—for the practice“ is the DGZI’s main topic leading the way for the 43rd International Annual Congress, which took place from 4 to 5 October at the Berlin Hotel Palace. Dr Roland Hille, Vice President of the DGZI and scientific director of the congress stated that “Compiling practicable and proved concepts ‘from practice—for the practice’ has always been one of the DGZI’s main topics”. “Each year, we invite speakers from around the world—this is a DGZI trademark.
22nd Annual Scientific Meeting of the EAO
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Implants have come a long way since they were introduced to dentistry in the early 1950s. Future concepts and trends in the field were recently discussed by experts at the 22nd Annual Scientific Meeting of the European Association of Osseointegration (EAO) in Dublin, which took place from 17–19 October at the city’s new state-of-the-art Convention Centre. Held for the second time in the Irish capital after 1995, the event did not only focus on current issues in the field, like periimplantitis and the challenges linked to the treatment of an increasing elderly population, but also reflected on new developments and methods in the field, such as computer-assisted implant rehabilitation and tissue regeneration. Moreover, a number of sessions also focused on risk factors, treatment planning and different learning techniques...
Schütz Dental and DGZI host “Implantology and Anatomy”
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From 11 to 12 October, Schütz Dental hosted a special implantological event in cooperation with the German Society for Implantology (DGZI). While students of dental medicine gathered information on theory and practice of the surgical anatomy in the special seminar “Implantology and Anatomy”, an international expert group discussed implantological techniques in the DGZI Curriculum lead by Dr Mazen Tamimi.
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Mitgliedsantrag: DGZI - Deutsche Gesellschaft für Zahnärztliche Implantologie e.V.
Planmeca Vertriebs GmbH

editorial I Dear colleagues, Prof. Dr Heiner Weber _As recently selected President of the DGZI, it is important to me to welcome you all and to gain your trust and assistance in this journey ahead of us. From my previous honorary executive po- sitions, I am convinced that the executive board of a society has to establish a close contact with its members and, moreover, that this contact has to be re-established continuously. While some dental societies do not admit non-academic members but nevertheless represent- ing major important professions contributing essentially to our common goal of optimal patient care, I will definitely and consequently continue and enhance the idea of DGZI (German Association of Dental Implantology) of implantology as a team approach including dental technicians and den- tal hygienists. Our new era of knowledge transfer which has been introduced recently by the DGZI via e-learn- ing is an advancement from which both international and local residents can benefit. Likewise, the establishment of forums and podiums for scientific discussions by gathering speakers and partici- pants from all over the world must be further promoted by the DGZI. In addition, I would like to contribute my personal scientific and practical experience in this spe- cial disciplines as well as my international contacts to ensure the DGZI’s future success. This en- compasses possible congress topics, potential speakers as well as the expansion of international net- work, building especially on my close contacts to China and the Russian speaking countries. Based on the fact that a prosperous, successful future of any kind of human society is founded on well ed- ucated, trained young generations, the DGZI must invest in dental students and other related pro- fessional apprentices. Not only in our clinical professional science, but also in industry, sports etc. it is a well-known fact that only a team can achieve highest levels of success and recognition. Team leaders do need team players, thus, I am happy to be in the “orchestra” of DGZI. The board as well as its members provide all the support being needed and possible for promoting our special discipline of implantology—and, thus, continuously strive for our patient`s sake. With this in mind, I would like to ask all of you to contribute to our aims and endeavours. Thank- ing you in advance for your support, I remain with best regards, Warm regards, Prof. Dr Heiner Weber (Medical Director University of Tuebingen , President of the DGZI, Guest Professor of Bejing Uni- versity, School of Stomatology/China, and Kyung Hee University, Seoul/Korea) implants 4_ 2013 I 03

I research Retromolar bone grafts prior to implant placement Outcomes and complications—Part II Authors_Andreas Sakkas, Carsten Winter, Frank Wilde & Alexander Schramm, Germany _Introduction The dental rehabilitation of partially or totally eden- tulous patients with oral implants has become common practice with reliable long-term results.1 However, un- favourable local conditions of the alveolar ridge due to atrophy, periodontal disease, trauma sequel, malforma- tion or neoplasia may cause insufficient bone volume, which may complicate the therapy of the masticatory function with dental implants.2 When alveolar ridges lack the appropriate bone volume, additional surgical reconstructive procedures are required. This article con- cludes Part I (implants 3/2013) with results, an extensive discussion and the conclusion. _Results Fig. 1_Separation of the patients in men and women, according smoking habit. One hundred and four retromolar bone graft proce- dures were performed in 86 patients, 77 men and nine women, with a mean age of 37.9 (range 20.2–58.4 ±10.78 years). Of the 86 patients receiving grafts, 29 were smokers (Fig. 1). Seven patients were pre-diag- nosed with general-advanced periodontitis, which was successfully treated before bone grafting and one pa- tient with diabetes mellitus Type II. Twenty-two procedures involved the maxilla and 82 the mandible. Also, fifteen patients were treated multi- ply in different alveolar sites. Regarding the alveolar crest situation, 32 cases were recorded as free-end sit- uation, 27 as multiple teeth gap and 39 as single teeth gap. These as well as the intraoral area separation are presented in Table 4. In ten patients, two bone blocks were harvested in one single augmentation position. Of the 104 onlay bone grafts, 81 (77.8 %) were de- fined absolutely successful and 23 (22.2 %) had minor adverse effects, such as incision-line dehiscence, swelling or wound infection with pus exit, or temporary paraesthesia. Only eight grafts (7.6 %) in seven patients were defined as failures (i.e. graft exposure and screw mobilization). Of all the areas with complications, 15 were defined in the donor site, 23 in the recipient area and in four patients experienced complications in both donor and recipient site. Regarding postoperative swelling following the bone grafting procedure, most of the patients suffered a minimal facial deformity lasting not longer than three days. Swelling was otherwise an expected complication after surgery. At two weeks after the operation, none of the 86 patients reported persistent pain. There was no significant association between periodontitis and com- plications (p=0.43) (Fig. 2). There was also no relation between complications or failure rates of the recipient site and jaw areas (p=0.21) (Fig. 3). No major complications were observed regard to donor sites. One patient developed a wound infection with exit pus, and two patients developed an abscess, which had to be opened surgically in local anaesthesia. 06 I implants 4_ 2013

research I No incision-line dehiscence occurred in the donor site areas. Eleven patients mentioned sensory deficits in the lower lip and mental foramen area and three of them ex- perienced altered sensation in the mental and lower lip area as well as in the tongue. None of the patients expe- rienced altered sensation localised in the region of the buccal nerve terminal branch. The incidence of tempo- rary mental nerve paraesthesia was 10.5% (11/104). At the time of implant insertion, there were no reports of symptoms other than the persistence of altered sensa- tion in two patients who had reported pareasthesia dur- ing suture removal. One of the patients experienced postoperative bleeding and was treated with local haemostasis (Tab. 5). A relation between smoking or medical history and complications of the donor site is not possible, because these incidents are usually caused iatrogenically. In the ten patients who underwent impacted third molar tooth extractions combined with bone harvest- ing, a temporary paraesthesia or wound infection were observed in six of them. In the recipient sites, the fre- quency of complications was higher than in donor sites. Except the minor complications such as wound infec- tion with pus exit or incision-line opening, graft expo- sure and screw mobilization as well as combinations of them (Tab. 6). In Figure 4, some complications in recipi- ent sites are presented. Seven (31.8%) of them were observed in smokers and 15 (68.2%) in nonsmokers in a total of 22 bone grafts. The temporary paresthesia on the percipient site observed by one patient was not taken in consideration. Figure 6 presents the separation of the postoperative complications both of the donor and recipient site ac- cording to smoking. Statistic significance between smoking and complications was to be considered (p=0.009). In one diabetic patient, loss of bone particles after infection was observed and no implantation was realizable. Wound infection and graft exposure were also observed in two patients with preoperatively diag- nosed general-advanced periodontitis. However, no as- sociation was found in this study between retromolar bone grafting complications and medical history, be- cause of the low number of patients. A great value was given to the management of the postoperative complications. Minor effects were treated conservatively with mouth rinse included chlorhexamid and antibiotics either orally or intra- venously. Patients with abscess had to be treated surgi- cally and were also covered with antibiotics. By graft ex- posure, the bone sequesters were removed and the bone block was refreshed, while the wound was closed with a buccal fat pad under antibiotic cover. By patients with screw mobilization, healing was uneventful after the re- moval of the screw. In eight (7.6%) of the cases, the bone graft was totally exposed combined with wound infec- tion and exit of pus. The surgical removal of the graft was Fig. 2_Association between periodontitis and complications of the recipient site. Table 1_Complications associated with retromolar bone grafts. Complications Etiology Prevention Management Infection, membrane contamination Microbial contamination Antibiotics and aseptic surgical procedure Remove infection source, systemic antibiotics and antimicrobial mouth rinse Incision line opening, membrane Tension-free closure not achieved exposure, wound dehiscense, perforation of mucosa Achieve tension-free primary closure systemic antibiotics and antiseptic mouth rinse Nerve dysfunction Damage to infra-alveolar nerve Know the anatomy, wait and some- times palliative treatment may be needed Graft mobilization Inadequate fixation (insufficient screws, screw loosening) Secure fixation screws, use >1 screw, ensure no-mobility and no Remove and regraft at later time dead space principle Loss of bone graft particles Primary closure not achieved Achieve tension-free primary Do nothing and allow for proper closure, use of membrane healing implants 4_ 2013 I 07

I research Autors No. of patients Girdler & Hosseini 1992 Raghoebar et al. 1996 Von Arx et al.1996 Misch 1997 Schlegel et al. 1998 Von Arx et al. 1998 Cordaro et al. 2002 Clavero 2003 Schwartz-Arad 2005 Schwartz-Arad 2005 12 7 4 19 5 13 15 24 10 18 Reported complications Temporary lingual paraesthesia none none Incision dehiscence none Hypoaesthesia n. V3, massive postop. bleeding 39 in the maxilla and 116 in the mandible. All these im- plants were placed using the CoDiagnostiX® (IVS Solu- tions AG) program for guided surgery. All the implants were integrated at the abutment connection. To date (mean of six months after prosthetic loading) all the im- plants were successful, according to the Albrektsson criteria.62 In eight of the cases (7.6%), implant installa- tion was not possible due to insufficient bone after aug- mentation procedures. Despite the complications, a sig- nificantly higher loss of bone grafts was not found. Af- ter the prosthetic rehabilitation, the oral function was completely re-established in all patients. Bone resorption _Discussion Hypoaesthesia n. V3 Graft exposure, Hypoaesthesia n. V3 Incision dehiscence, Graft exposure, Hypoaesthesia n. V3 The use of endosseous implants may be limited by in- sufficient quality and quantity of available bone. Several grafting procedures have been described to create suf- ficient volume of bone for implant placement.33 Auto- genous grafts still remain the “gold standard” in recon- structive surgeries due to their osteoinductive, osteo- conductive, and osteogenic potential, essential for bone morphogenesis.34-35Serra e Silva et al. conclude that au- togenous bone grafts are the best option compared with allografts and xenografts due to its properties and constitute a viable form of treatment for patients with alveolar bone loss.36 The placement of implants into healed bone grafts as a secondary procedure is similar to their use in jaws that have not been grafted.37 Several studies have reported on harvesting of grafts from the retromolar region.13, 20, 22, 24, 26, 28 However, the number of complications is discordant when the differ- ent trials are compared. This seems to be because none of the studies is prospective and based on objective tests for the function of inferior alveolar and lingual nerves. Advantages of retromolar bone grafts are the use of lo- cal anaesthesia instead of general ansesthesia, no need to stay in hospital postoperatively, less morbidity at the donor sites, and lower costs.38, 39 A disadvantage is the small volumes of bone offered. Performing ridge augmentation and implant place- ment as two-stage surgery is still said to be more suc- cessful than the single-stage procedure.31, 40 A healing period for mandibular grafts of four months has been recommended.5, 13, 31 There is experimental evidence that grafts from membranous bone show less resorp- tion than endochondral bone due to early revascular- ization, better potential for incorporation in the max- illofacial region because of a biochemical similarity in the protocollagen, and the inductive capacity is greater because of a higher concentration of bone morpho- genetic proteins and growth factors. The early revascu- larization seems to explain the good maintenance of volume of the retromolar graft.41 However, a major dis- advantage of retromolar grafts remains. Only a con- fined amount of bone can be harvested from this donor Table 2_Review of the literature on harvesting of retromolar bone grafts. then inevitable. The wound healing was subsequently uneventful, but there was not enough bone for insertion of implants. A second augmentation procedure was then performed in only two cases. The patients with temporary paraesthesia by the suture removal always had control appointments until the healing of their nerve dysfunction (Tab. 7). Bone resorption was easily visible on removing the osteosynthesis screws since the heads of the screws were always 1 to 2 mm above the grafted bone. On re- opening, the shape of the grafted block was rarely visi- ble in most of the cases. Of the 104 bone reconstruc- tions, 19 (18.2%) required simultaneous augmentation at the time of dental implant placement. Fig. 3_Association between jaw and complications of the recipient site. The average healing period after bone harvesting was 125.8 days or 4.49 months, ranged from 91–276±66.23 days. 155 dental implants were placed, 08 I implants 4_ 2013

site. It has been described that the volume is half of what can be achieved from the mandibular symphysis.13 The dense structure of cortical portion of the grafts offers the benefit of improved implant stability during place- ment and healing and may even improve interfacial stress transmission on implant loading.5, 30, 42 The aim of this study was to report clinical results of alveolar ridge augmentation in partially edentulous pa- tients prior to implant placement, using bone blocks from the retromolar region and firmly secured to the re- cipient site with osteosynthesis screws with the use of barrier membranes. The clinical indication for the pro- cedure was the lack of sufficient alveolar bone, a situa- tion that could interfere with the correct placement of implants of the desired length. In this retrospective study, the data reported were readily collected from the authors after the postopera- tive phase. The sample studied was small and the aug- mented sites differed in location and type of defect. In the absence of a control group, the statistical signifi- cance of the means calculated was not tested. A new surgical devise with piezoelectric ultrasonic generator (Mectron, Deutschland Vertriebs GmbH) recently devel- oped, offers an alternative way of safely removing hard tissue without damaging soft tissue and is a useful tool of harvesting procedures from the ramus. Barrier membranes have been used to achieve alve- olar ridge augmentation in implant surgery in a staged approach, or at the same time as implant place- ment.6, 10, 43 The use of barrier membranes in combina- tion with particulate grafts and implants to augment the alveolar ridge and obtain ideal positioning of im- plants is reported to be an effective procedure in both humans and experimental animals.6, 31, 44 The use of bar- rier membranes over particulate bone grafts seems to reduce the tendency for bone graft to be reabsorbed during the healing phase. It must be pointed out that the tendency of bone grafts to resorb during the healing phase also occurs if the graft is protected by a mem- brane and no complications arise.6 However, the use of barrier membranes generally may be followed by soft tissue dehiscence, membrane exposure and plaque col- onization and, in very few cases, by the need to remove the barrier. This complication jeopardizes the whole pro- cedure.45-46 According to Buser et al (1996), if a staged approach is used, complications involving membrane exposure, suture dehiscence and loss of the graft are minimal.6 Fixation of an onlay graft to the recipient site can in- fluence the revascularization of a graft.47 A loose graft may become nonunioned and encapsulated. Fixation screws for the onlay graft should be tightened to ensure close adaption. Infection is usually a consequence of poor aseptic control of the surgical field. Rinsing with research I Table 3_Etiology of tooth lost. N 97 3 4 104 Maxilla Mandibula Summary 37 28 39 104 Table 4_Distribution of alveolar ridge situation and jaw separation prior to implant placement. Table 5_Type and number of post- surgical complications in donor sites. 30 16 36 82 N 1 2 11 3 1 18 Etiology Caries/Periodontitis Trauma Hypodonty Total Alveolar ridge Situation/ jaw Free-end situation Multiple teeth gap Single tooth gap Summary 7 12 3 22 Type of complication Wound infection with pus Swelling/abscess Hypoesthesia N. mental Hypoesthesia N. mental and lingual Postoperative bleeding Total chlorhexidine before surgery is a preventive measure to reduce the risk of infection. Tension-free flap closure is essential so exposure of the membrane or fixation screws can be prevented.48 The limits of the retromolar area are dictated by clin- ical access, as well as the coronoid process, molar teeth, and inferior alveolar canal. A rectangular piece of bone up to 4 mm in thickness may be harvested from the ra- mus. This morphology conforms especially well as a venner graft to gain additional ridge width.49 A vestibular incision that extends well beyond the mucogingival junction creates easier access but pro- duces more soft tissue bleeding and intraoral scar for- mation. Haemostatic materials are placed into areas of osseous bleeding, and postoperative pressure dressings reduce the development of haematoma formation, inci- sion line dehiscence and infection. The use of glucocor- ticoids is helpful in reducing postoperative oedema.50-52 The ramus graft patients appeared to have fewer diffi- culties in managing postoperative oedema and pain. Pain is also reduced in the first day after surgery. No adverse effects for single dose or a negative effect on implants 4_ 2013 I 09

I research Table 6_Type and number of postsurgical complications in recipient sites. Type of complication Incision line opening Swelling/wound infection with pus Swelling/abscess Graft exposure Wound infection with pus und graft expo- sure Graft exposure und screw mobilization Hypoesthesia N. infraorbital Total N 4 6 4 1 5 2 1 23 wound healing have been reported. Since our patients were sent home a day after the end of the bone graft- ing procedure, our aim was to reduce swelling as much as possible. Intraoral or intravenous antibiotic therapy postoperative was not given. There is no evi- dence that prolonging antibiotic therapy after the first day gives additional protection if antibiotic pro- phylaxis is correctly prescribed.47 Besides these con- siderations, many surgeons when using bone grafts or membranes describe the use of intraoral antibiotics for a period varying from three to ten days postoper- atively.6, 53 The potential for damage to the inferior alveolar nerve, as opposed to its peripheral mental branches, is of greater concern with the ramus graft technique. To prevent nerve injury, harvest of bone from this area re- quires knowledge of the mandibular canal anatomy. Al- though the position of the canal is variable, anatomic averages are helpful in surgical planning. The mean an- teroposterior width of the ramus is 30.5 mm, with the Fig. 4_Incidence of complications noticed in donor and recipient sites according to smoking. 10 I implants 4_ 2013 mandibular foramen located about two thirds of the distance from the anterior border.54, 55 The mean vertical distance between the superior edge of the canal and the cortical surface along the ex- ternal oblique ridge is approximately 7 mm in the sec- ond molar region, 11 mm in the third molar region, and 14 mm at the base of the coronoid process.55 Although the buccolingual position of the mandibular canal is variable, the distance from the canal to the medial as- pect of the buccal cortical plate (medullary bone thick- ness) was found to be greatest at the distal half of the first molar (mean= 4.05 mm).55 Therefore, when larger grafts are planned, the anterior vertical bone cut should be made in this area.56 Damage to the neurovascular bundle could also occur during sectioning of the graft. Care must be taken to parallel the lateral surface of the ramus when using the thin chisel along the external oblique osteotomy. If the inferior ramus cut is below the level of the inferior alveolar canal, graft separation should not be completed until it can be ascertained that the neurovascular bundle is not entrapped in the graft. Sometimes, the exposure of the inferior alveolar nerve is accompanied by massive bleeding, because of injury to the inferior alveolar artery.22 Patients were less able to discern neurosensory dis- turbances in the posterior buccal soft tissues than in the lower lip. Although the incision along the external oblique ridge could possibly damage the buccal nerve, reports of postoperative sensory loss in the buccal mu- cosa are rare, and most go unnoticed by the patient.57 No specific treatment was required, and all patients re- covered completely. It is noteworthy that the failure rate was, in reality, lower because graft exposure was considered as fail- ures, even though part of the graft remained intact in most of these cases. Leaving part of the exposed graft in place usually was adequate to allow sufficient bone for implantation. Generally, patients who suffer from diabetes show significantly higher failure rates and have more postop- erative complications. Since diabetes increases the risk of infection and delays wound healing, it is possible that this kind of ridge augmentation is not suitable for these patients. A significant failure of diabetics in this study was, because of lack of fails, not presentable. However, more research should be conducted to determine how to perform a harvesting procedure in diabetic patients without the risk of graft failure.58 Smokers demonstrate a high failure rate and more postoperative complica- tions.59Smoking was found to impair the revasculariza- tion of the bone in regenerative procedures such as bone grafting, mainly due to its effect on vasoconstriction of the artery.59 The altered oral flora from smoking in- creased the infection rate by two to three times in smok-

I research Method of treatment Frequency Chlorhexamid mouth rinse Chlorhexamid mouth rinse and antibiotic per os Chlorhexamid mouth rinse and antibiotic intravenous Wound-freshening and plastic recovering Bone graft removing Abscess-incision and antibiotic i.v. Re-bone harvesting Abscess-incision, wound-freshening and antibiotic i.v. 2 6 1 4 6 3 2 1 1 26 Haemostasis Total Table 7_Management and surgical treatment of the postoperative complications after retromolar bone grafting. 12 I implants 4_ 2013 ers, which adversely influenced the complications of bone grafting procedures.60 Patients with history of smoking have a higher failure rate of implants, regard- less of the amount of cigarette consumed.61Association between retromolar bone grafting complications and smoking habits was also found in this study. Dentists, oral surgeons and treating physicians should urge their patients to quit smoking since it reduces the success rate of ridge augmentation. Higher implant failure rates have been reported when implants are placed into grafted sites.22 However, in this study, despite the num- ber of complications, rehabilitation with oral implants was not possible in only 7.6 % of all bone grafting pro- cedures. Aghaloo and Moy have already indicated sim- ilar success rates between implants placed into grafted sited compared with implants placed into native bone.38 Small amounts of particulate bone grafts may be collected from the implant area during implant site preparation, and the resulting bone chips can then be used to fill small defects. The main disadvantage of this technique is the contamination with oral bacteria. In ac- cordance with Chiapasco, only bone blocks maintain the architecture of bone and appear to adapt easily to the recipient area, whereas particulate bone grafts were as- sociated with bone blocks in case of simultaneous graft- ing procedures or as a filling material around or between bone blocks.2 Reports on simultaneous bone grafting and implant placement have revealed complications such as graft fracture and wound dehiscence with ex- posure of implants and graft, with a higher implant fail- ure rate than that of a staged approach.15, 27, 29, 42 A staged surgery permits implant placement for ideal prosthetic alignment without the concern of graft fixation or remodelling.56 Staged implant placement also allows for any initial graft resorption and thus should provide a more stable foundation. None of the complications influenced the success of rehabilitation significantly. Despite the need for two surgical proce- dures, the patients were compliant with the entire treat- ment. Not only was the planning a key factor of every successful case, it was also essential to learn exactly what the patient expected from the surgery and to de- sign the surgical procedure to achieve that goal. _Conclusion The clinical data presented in this study showed that onlay block grafts harvested from the retromolar region are a safe, effective and simple method of treating lo- calized alveolar ridge hypoplasia in partially edentulous patients for implant placement. It must be considered that the postoperative phase of stage-one surgery is comparable to the discomfort felt following major den- toalveolar surgery and that the procedure can easily be carried out in an outpatient environment. The risks and morbidity of retromolar bone grafting can be associated with some complications, which do not significantly compromise rehabilitation when appropriate treat- ment is established. This retrospective study of bone grafting surgeries can serve as a guide in the prevention of possible fail- ures and consequently improve the quality of future procedures. More studies to determine which donor sites provide sufficient bone with the least patient dis- comfort and risk of complications are needed. Addi- tional studies are needed to evaluate the long-term re- sults of the described method with regard to implant stability and resorption of bone around the implants._ Disclosure The authors do not have any financial interests, either directly or indi- rectly, in the products listed in the study. Editorial note: A list of references is available from the pub- lisher. _contact implants Andreas Sakkas Oral Surgeon Department of Oral and Maxillofacial Surgery, Facial Plastic Surgery Military Hospital Ulm and Academic Hospital University Ulm Ulm, Germany Tel.: +49 731 17101701 andreaszfc13@yahoo.gr

_RITTER IMPLANTS SYSTEM _Simple. Efﬁcient. German. Founded in 1887 by the German Frank Ritter in New York, Ritter is one of the oldest prestige brands of ﬁnest dental equipment worldwide. Due to innovative ideas and a great entrepre- neurial spirit, Ritter produced the ﬁrst dental units already more then 125 years ago. Today Ritter products are more than ever an es- sential element in dental practices worldwide. Users appreciate the Ritter product range for the high-quality aspects and the reliability - Made in Germany. Due to their functionality and user orientated construction, Ritter dental units contribute constantly to an optimized workﬂow of today’s modern dental practices. In the course of the last years, Ritter has started to write a new success story with the launch of an innovative, state of the art implant sys- tem. The Ritter Implant Ivory Line provides Two Piece Implants (Implant plus separate Abut- ment) as the QSI Spiral Implant and TFI Twin Fissure Implant as well as One Piece Implants (Implant and Abutment already connected) called Mono Compress Implant MCI. The system contains logically reduced and clearly arranged components of tools and abutments with the best features for all clinical cases. Due to the super Nano-Surface, a quick and reliable Os- Implant Expo Frankfurt, 27.-30. Nov. Booth 107 ADF Paris 29.-30. Nov. Booth 2L23 seo-Integration is guaranteed. Clever and easy handling is provided by self-tapping threads and a coloured system of drills and implants according to their diameters. All Ritter Implants and Accessories are made by high modern CNC manufacturing machines. A combination of advanced machining and hand-ﬁnishing create the most accurate tools possible for the marking of ceramic drills. The Ritter brand stands for high quality, state of the art technology and innovative pro- ducts Made in Germany. The credo is to always provide customers and clients with the best services and prices combined with the most comprehensive dental solutions in the market. More information: www.ritterimplants.com N E W T o o l K i t f e r s ! t e r : f e r t o f t a r I m p l a n t s , A n a l o g s , T r a n s s , H e a l i n g C a p s a n d S t a r s p e c i a l s i c e , i n c l . k f o r y o u r A b u t m e n t S e t p r . . . . a s % FAX VOUCHER YES, I want to save my beneﬁt ! Please contact us as soon as possible. I conﬁrm with my address and signature / stamp Number of Sets (max.10) STREET CITY / ZIP FON DATE NAME EMAIL SIGNATURE VAT-NO. COUNTRY Ritter Implants GmbH & Co. KG | Gruener Weg 32 | 88400 Biberach | GERMANY Fon 0049 7351. 52 925-10 | Fax 0049 7351. 52 925-11 info@ritterimplants.com | www.ritterimplants.com Fax 0049 7351. 52 925-11

I research A new technique for the preparation of the implant site Through Piezoelectric Surgery (PES) Authors_Prof. Mauro Labanca, Prof. Lugi F. Rodella & Prof. Paolo Brunamonti Binello, Italy − Standardisable procedure − High accuracy (linear and conservative incisions) − Minimal to no trauma to the surrounding soft tissues compared with traditional techniques − Drastic reduction in harmful complications suffered by the sensitive anatomical structures of the orofacial region (Schneiderian membrane, inferior alveolar nerve, arteries, etc.), in the event of direct accidental contact. For the above-mentioned reasons, PES has de- servedly gained immediate success even in implantol- ogy. Considering the current state of the art, in fact, many rehabilitation protocols involve the use of PES not only in more advanced and complex medical conditions (split-crest, sinus floor lift, etc.)3-10, but also in less com- plex cases, like the normal preparation of individual im- plant sites.6, 11,12 In fact, even in not-advanced implan- tology, that does not involve the simultaneous regener- ation of the residual alveolar process for the insertion of the fixture, there are clinical conditions that pose real difficulties, at least during the early stages of prepara- tion of the surgical site. Here are some examples of such situations: − Positioning of immediate post-extraction implants at the level of the anterior region. − Positioning of immediate post-extraction implants at the level of inter-radicular bifurcation. − Positioning of implants at the level of the edentulous alveolar process with morphological irregularities at the crest level or with very low residual profile. − Positioning of implants at the level of the edentulous alveolar process with the presence of buccal-lingual undercuts (or buccal-palatal if the upper jaw is con- cerned, Figs. 1–4). For the experienced operator, such circumstances do not pose particular problems, but they still encumber Fig. 1 Fig. 2 Fig. 3 Fig. 4 Fig. 1_PA Rx with a residual root in a _Introduction alveolar process (4.5 position). Fig. 2_PA Rx after insertion with the described combined technique. We can see the periapical defect after the extraction. Fig. 3_Three months after, good healing of the periapical defect. Fig. 4_After three months of loading, good osseointegration with no residual bone defect and perfect maintenance of the bone profile around the implant neck. 14 I implants 4_ 2013 Piezosurgery (PES) is a surgical technique born in the 90s; because of its versatility and effectiveness, it im- mediately spread from the oral surgery field to many other specialised surgical branches, such as, for exam- ple, maxillofacial surgery, orthopaedics and neuro- surgery.1 This method exploits the well-established physical principle of cavitation according to which the ultrasonic microvibrations with modulate amplitude ranging be- tween 60 and 200 microns are able to perform incisions even on markedly mineralised tissues, such as bone tis- sue, tooth enamel and dentin.2 These incisions are characterised by the following features: − Ease of execution − Reproducibility

research I the initial preparation of the implant site, using only the pilot dental drills available in all implant-prosthetic sys- tems on the market (Figs. 13–14). This is due to the fact that the rotation of the bur, and therefore its macro- movement, makes its stabilisation exactly where de- sired by the operator in the initial phase extremely diffi- cult, also in case a lance-tip bur is used. In this sense, the use of the PES is an important improvement for the cli- nician, as it is a safe and reliable method with clear ben- efits from both an intraoperative (technology-related) and biological point of view (see Labanca et al 2008 for review, Figs. 5–10). The main technical-executive advantages for the operator can be summarised as follows: − It allows for more stable positioning of the guide in- sert on the crestal profile for the creation of the first implant hole. − It allows the definition of a more correct implant axis, favouring the success of the implant-prosthetic re- habilitation. − It allows for possible intra-operative corrections of the implant axis above mentioned. − It makes the crestal cortical osteotomy procedure safer, since the piezoelectric ergonomic handpiece is not subject to tilt and therefore does not pose those “shaking” phenomena, specific to each rotating system initial working phases. − It makes the initial osteotomy less traumatic, fully exploiting the cavitation process with constant irri- gation. − It reduces the emotional impact on the patient, who does not feel the annoying vibrations caused by the dental drill. The biological advantages are in any case technical- related and consist of (Figs. 20–23): − Reduction of thermal stress on bone tissue; − better bone vitality; − greater respect of the osteoblastic turnover and bet- ter bone response after resection; − preservation of soft tissue and of any noble anatom- ical structures (inferior alveolar nerve, Schneiderian membrane, etc.) adjacent to the osteotomy. This paper will therefore illustrate the fundamen- tal execution techniques, aimed at achieving the best possible clinical success both from a biological and functional and aesthetic point of view, in order to achieve implant-prosthetic rehabilitation more likely to meet the daily demands of both the clinician and the patient. SMALL IN SIZE, GREAT IN PERFORMANCE... AD (cid:42)(cid:46)(cid:49)(cid:45)(cid:34)(cid:1)(cid:46)(cid:74)(cid:79)(cid:74)(cid:14)(cid:68)(cid:80)(cid:79)(cid:70)(cid:85)(cid:80)(cid:81)(cid:27) (cid:84)(cid:81)(cid:70)(cid:68)(cid:74)(cid:246)(cid:1)(cid:68)(cid:66)(cid:77)(cid:77)(cid:90)(cid:1)(cid:69)(cid:70)(cid:87)(cid:70)(cid:77)(cid:80)(cid:81)(cid:70)(cid:69)(cid:1)(cid:71)(cid:80)(cid:83)(cid:1)(cid:84)(cid:86)(cid:81)(cid:81)(cid:80)(cid:83)(cid:85)(cid:74)(cid:79)(cid:72)(cid:1) (cid:67)(cid:66)(cid:83)(cid:1)(cid:68)(cid:80)(cid:79)(cid:84)(cid:85)(cid:83)(cid:86)(cid:68)(cid:85)(cid:74)(cid:80)(cid:79)(cid:84) (cid:42)(cid:46)(cid:49)(cid:45)(cid:34)(cid:1)(cid:46)(cid:74)(cid:79)(cid:74)(cid:14)(cid:67)(cid:66)(cid:77)(cid:77)(cid:85)(cid:80)(cid:81)(cid:27) (cid:70)(cid:89)(cid:68)(cid:70)(cid:77)(cid:77)(cid:70)(cid:79)(cid:85)(cid:77)(cid:90)(cid:1)(cid:84)(cid:86)(cid:74)(cid:85)(cid:70)(cid:69)(cid:1)(cid:85)(cid:80)(cid:1)(cid:85)(cid:73)(cid:70)(cid:1) (cid:80)(cid:87)(cid:70)(cid:83)(cid:69)(cid:70)(cid:79)(cid:85)(cid:86)(cid:83)(cid:70)(cid:1)(cid:85)(cid:70)(cid:68)(cid:73)(cid:79)(cid:74)(cid:82)(cid:86)(cid:70) IMPLA Mini Implants » 50 years’ experience in implantology » sand-blasted and acid-etched surface » minimally invasive procedure » short drilling protocol = shorter surgery times » economic implant restoration (cid:39)(cid:86)(cid:83)(cid:85)(cid:73)(cid:70)(cid:83)(cid:1)(cid:74)(cid:79)(cid:71)(cid:80)(cid:83)(cid:78)(cid:66)(cid:85)(cid:74)(cid:80)(cid:79)(cid:27) (cid:88)(cid:88)(cid:88)(cid:15)(cid:84)(cid:68)(cid:73)(cid:86)(cid:70)(cid:85)(cid:91)(cid:14)(cid:69)(cid:70)(cid:79)(cid:85)(cid:66)(cid:77)(cid:15)(cid:68)(cid:80)(cid:78) (cid:47)(cid:70)(cid:88)(cid:84)(cid:77)(cid:70)(cid:85)(cid:85)(cid:70)(cid:83)(cid:1)(cid:83)(cid:70)(cid:72)(cid:74)(cid:84)(cid:85)(cid:83)(cid:66)(cid:85)(cid:74)(cid:80)(cid:79)(cid:27)(cid:1) (cid:37)(cid:83)(cid:15)(cid:1)(cid:78)(cid:70)(cid:69)(cid:74)(cid:68)(cid:15)(cid:1)(cid:9)(cid:51)(cid:48)(cid:10)(cid:1)(cid:36)(cid:73)(cid:15)(cid:1)(cid:43)(cid:70)(cid:83)(cid:70)(cid:68)(cid:74)(cid:79)(cid:84)(cid:76)(cid:74)(cid:13)(cid:1)(cid:46)(cid:52)(cid:68)(cid:15)(cid:13)(cid:1)(cid:49)(cid:66)(cid:69)(cid:70)(cid:83)(cid:67)(cid:80)(cid:83)(cid:79) (cid:118)(cid:42)(cid:46)(cid:49)(cid:45)(cid:34)(cid:1)(cid:46)(cid:74)(cid:79)(cid:74)(cid:1)(cid:74)(cid:78)(cid:81)(cid:77)(cid:66)(cid:79)(cid:85)(cid:84)(cid:1)(cid:66)(cid:83)(cid:70)(cid:1)(cid:69)(cid:70)(cid:246)(cid:1)(cid:79)(cid:70)(cid:69)(cid:1)(cid:67)(cid:90)(cid:1)(cid:85)(cid:73)(cid:70)(cid:74)(cid:83)(cid:1)(cid:87)(cid:70)(cid:83)(cid:90)(cid:1)(cid:73)(cid:74)(cid:72)(cid:73)(cid:1) (cid:81)(cid:83)(cid:74)(cid:78)(cid:66)(cid:83)(cid:90)(cid:1)(cid:84)(cid:85)(cid:66)(cid:67)(cid:74)(cid:77)(cid:74)(cid:85)(cid:90)(cid:1)(cid:66)(cid:79)(cid:69)(cid:1)(cid:85)(cid:73)(cid:70)(cid:1)(cid:71)(cid:66)(cid:68)(cid:85)(cid:1)(cid:85)(cid:73)(cid:66)(cid:85)(cid:1)(cid:85)(cid:73)(cid:70)(cid:90)(cid:1)(cid:68)(cid:66)(cid:79)(cid:1)(cid:67)(cid:70)(cid:1)(cid:70)(cid:66)(cid:84)(cid:74)(cid:77)(cid:90)(cid:1) (cid:74)(cid:79)(cid:84)(cid:70)(cid:83)(cid:85)(cid:70)(cid:69)(cid:15)(cid:105) (cid:15) (cid:1) (cid:70) (cid:78) (cid:79) (cid:66) (cid:68) (cid:52) (cid:73)(cid:85)(cid:85)(cid:81)(cid:27)(cid:16)(cid:16)(cid:84)(cid:69)(cid:70)(cid:79)(cid:85)(cid:15)(cid:70)(cid:86)(cid:16)(cid:79)(cid:70)(cid:88)(cid:70) (cid:52)(cid:68)(cid:73)(cid:224)(cid:85)(cid:91)(cid:1)(cid:37)(cid:70)(cid:79)(cid:85)(cid:66)(cid:77)(cid:1)(cid:40)(cid:78)(cid:67)(cid:41)(cid:1)(cid:116)(cid:1)(cid:37)(cid:74)(cid:70)(cid:84)(cid:70)(cid:77)(cid:84)(cid:85)(cid:83)(cid:15)(cid:1)(cid:22)(cid:14)(cid:23)(cid:1)(cid:116)(cid:1)(cid:23)(cid:18)(cid:18)(cid:26)(cid:18)(cid:1)(cid:51)(cid:80)(cid:84)(cid:67)(cid:66)(cid:68)(cid:73)(cid:16)(cid:40)(cid:70)(cid:83)(cid:78)(cid:66)(cid:79)(cid:90) (cid:53)(cid:70)(cid:77)(cid:15)(cid:27)(cid:1)(cid:12)(cid:21)(cid:26)(cid:1)(cid:9)(cid:17)(cid:10)(cid:1)(cid:23)(cid:17)(cid:17)(cid:20)(cid:1)(cid:25)(cid:18)(cid:21)(cid:14)(cid:20)(cid:23)(cid:22)(cid:1)(cid:116)(cid:1)(cid:39)(cid:66)(cid:89)(cid:27)(cid:1)(cid:12)(cid:21)(cid:26)(cid:1)(cid:9)(cid:17)(cid:10)(cid:1)(cid:23)(cid:17)(cid:17)(cid:20)(cid:1)(cid:25)(cid:18)(cid:21)(cid:14)(cid:26)(cid:17)(cid:24)(cid:1)(cid:116)(cid:1)(cid:88)(cid:88)(cid:88)(cid:15)(cid:84)(cid:68)(cid:73)(cid:86)(cid:70)(cid:85)(cid:91)(cid:14)(cid:69)(cid:70)(cid:79)(cid:85)(cid:66)(cid:77)(cid:15)(cid:68)(cid:80)(cid:78)(cid:1)(cid:116)(cid:1)(cid:70)(cid:89)(cid:81)(cid:80)(cid:83)(cid:85)(cid:33)(cid:84)(cid:68)(cid:73)(cid:86)(cid:70)(cid:85)(cid:91)(cid:14)(cid:69)(cid:70)(cid:79)(cid:85)(cid:66)(cid:77)(cid:15)(cid:69)(cid:70) implants 4_ 2013 I 15

I research Fig. 5 Fig. 6 Fig. 7 Figs. 5–7_Implant site preparation with only the use of piezo inserts. The technique proposed by the authors is intended to use the piezoelectric surgery in the initial stage of preparation (Fig. 11), in order to benefit from its undis- puted advantages, namely in the drilling phase of the cortex, the definition of the working length and the inclination of insertion and complete, however, the implant site preparation with dedicated burs (Fig. 12). The authors think that in the final stages of prepa- ration the level of friction, and therefore the over- heating level of the bur on the bone, is remarkably re- duced, while it is essential for a correct fitting of the implant, and a proper compliance with the surgical protocol suggested by the various dental implant manufacturers, that the burs have the shape and length suitable and specifically dedicated to the im- plant concerned. The universality of the implant insert does not allow a final preparation that is exactly con- gruent with the multiplicity of existing implants, thus risking losing retentive capability or fitting accuracy. The paper is aimed at describing the results ob- tained and observed after a 36-month trial, assessing the effectiveness of the technique from both a clini- cal and histological point of view; a technique which provides for the use of piezoelectric inserts, instead of other surgical methods, during the first stage of preparation of the implant site. _Materials and methods Figs. 8 & 9_Final result of the implant site preparation; a modest vestibular dehiscence is evident. As already pointed out in the introduction, the goal of the research was to set up—on a random sample of patients—a comparison between the preparation of Fig. 8 Fig. 9 16 I implants 4_ 2013 the implant site using piezoelectric inserts only dur- ing the early stages, compared to the conventional technique with dental drills, or that is the exclusive use of piezoelectric inserts. The main evaluation parameters considered were the following: − Immediate biological response, assessed by histol- ogy of tissue removed during surgery (Figs. 15–16). − Successful implant-prosthesis on medium (12 months) and long term (36 months), checked with intraoral periodic X-rays (Figs. 17–19), and peri-im- plant plaque and bleeding indices every six months from the placement of the final prosthesis. Thirty patients were randomly selected. In order to create protocol uniformity, the patients were required to necessarily meet the following basic requirements: − Aged between 30 and 50; − good general health (absence of decompensated systemic diseases); − no smoking; − interlayer edentulism; − residual alveolar process in the edentulous area sufficient to the insertion of an implant not less than 10.0 mm long and not less than 4.0 mm wide; − lack of necessity for regenerative surgery. In order to standardise the surgical procedures, the following common features were chosen: − Use of submerged implants with surface obtained by subtraction. − Implant dimension not <10.0 mm in length and not <4.0 mm in diameter. − Use of grafting materials avoided. − Bone density between values 2 and 4, according to the classification of Misch. − Implant placement only in edentulous areas with the exception of the incisal areas and distal ones at the sixth teeth . − Implant placement through surgical “full thickness” flap. − Implants inserted at least four months after tooth extraction.

I research AD Fig. 10 Fig. 11 Fig. 12 Fig. 13 Fig. 14 Fig. 15 The patients selected for the trial were subsequently divided into three groups of ten each, according to the following criteria: − Group 1: Ten patients undergoing implant site preparation through exclusive use of conventional dental drills, dedicated to the corresponding im- plant system. − Group 2: Ten patients undergoing implant tech- nique with site preparation carried out only using piezoelectric inserts. − Group 3: Ten patients undergoing initial prepara- tion of the implant site with piezoelectric inserts, while the final phase of preparation of the same surgical site was completed with the burs specifi- cally dedicated to the implant system (technique proposed by the authors and subject to the verifi- cation of this study). For each patient treated—after a specific consent form—samples of bone tissue were taken during sur- gery at the area corresponding to the implant site, im- plementing the three different methods described above, in order to compare, histologically, the extent of bone tissue damage created during each different preparation method. sorbable suture, Triclosan-coated, in order to improve prevention against surgical site infection. Therefore, ac- cording to the above parameters, a total of 64 implants were inserted, including 28 in the lower jaw and 36 in the upper jaw. The 36-month follow-up after surgery also included the following steps: − 1 intraoral X-ray examination approximately every month; − 1 intraoral X-ray examination when uncovering; − 1 intraoral X-ray examination at the end of definitive prosthesis placement; − 1 intraoral X-ray examination every six months after definitive prosthesis placement. As regards the prosthesis, the following criteria were chosen and applied: − Traditional prosthesic timing (a waiting time of three months for the implants placed in the mandible (lower jaw) and six months for those placed in the maxilla (upper jaw). − ISQ value detected through Ostell® compared with that recorded at the end of the surgical procedure. − Prosthetic procedure with provisional abutment and provisional, screwed resin crown. − Reduced intercuspidation of posterior elements. All patients treated were subjected to antibiotic therapy as follows: − Amoxicillin + Clavulanic acid 1 g tablets, 1 tablet every 8 h (3 tablets/day) for 6 days, Start therapy p.o. (by mouth) 1 day before surgery. All patients were also prescribed post-surgical daily mouthwashes with 0.2 % Chlorhexidine Gluconate up to the removal of the sutures. All patients were sutured with Ethicon Vicryl Plus 4.0®, braided synthetic ab- After an appropriate period of load and clinical and functional checking (on average three months) the de- finitive prosthesis was placed, always subject to verifi- cation of the ISQ value, by placing the titanium abut- ment tightened with a torque wrench according to the instructions of the implant company and cementing the metal-ceramic crown with ImplaCem Precision (Den- talica). The following steps were carried out for the preparation of the implant sites with the mixed tech- nique object of this trial. Fig. 10_Implant in site. It is visible the neck profile exposed in the vestibular aspect. Fig. 11_Implant site preparation with the authors suggested technique: first steps with piezo inserts. Fig. 12_Final preparation of the same area with drills suggested by the implant company. Figs. 13 & 14_Implant site preparation with rotating instruments. Figs. 15 & 16_It is evident how the bone chips remain around the drill. 18 I implants 4_ 2013

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I research Fig. 16 Fig. 17 Fig. 18 Fig. 19 Fig. 17_Rx pre op. _Mixed technique for the initial Fig. 18_Rx after three months of loading (preparation with mixed preparation of the implant site through piezoelectric inserts technique). Fig. 19_Rx after six months of temporary loading with a perfect bone level. Once an appropriate full-thickness flap is executed in order to expose the edentulous area, the technique of initial preparation of the implant site through piezo- electric inserts provides the following three intra-surgi- cal fundamental phases: 1) Initial pilot osteotomy by using a Mectron IM 1S piezoelectric insert. 2) Use of the IM 2 insert (A or P depending on the area treated). Optimization of the concentricity of the implant site preparation between 2/3 mm in diam- eter through an IP 2–3 piezoelectric insert, OT 4 in case of need for correcting the inclination. 3) If required, further enlargement of the implant site through a Mectron IM 3 piezoelectric insert (A or P depending on the area treated). The next stage of completion and optimisation of the implant-prosthesic site was carried out using a handpiece implant rotating bur specifically dedicated to the system used, needed to obtain, at the end of the preparation, the exact diameter expected by the op- erator for both the implant and the type of bone con- cerned. It is known that, depending on the chosen im- plant system or the type of bone concerned, different preparation methods are required (over- or under- preparation).The authors believe that this approach of- fers the following advantages: − High precision; − possibility to optimise the inclination of the implant axis; _Results In total, 64 implants were inserted, including 25 in the lower jaw and 39 in the upper jaw, divided as follows: − 21 implants placed in Group 1 (exclusive use of con- ventional dental drills, specifically dedicated to the corresponding implant system), including 13 in the upper jaw and 8 in the lower jaw. − 22 implants placed in Group 2 (exclusive use of piezo- electric inserts), including 12 in the upper jaw and 10 in the lower jaw. − 21 implants placed in Group 3 (use of piezoelectric in- serts only during the initial preparation of the implant site, while the last phase of preparation of the same surgical site was completed with the burs specifically dedicated to the implant system implemented), in- cluding 14 in the upper jaw and 7 in the lower jaw. The terms of clinical success were divided in short (removal of the suture knots in the eighth day), medium (6/8 weeks after surgery) and long term (about 36 months after the definitive prosthesis placement). As mentioned above, the following criteria were used to assess the clinical success: − Primary stability measured by the torque in Nm (and detected using the surgical motor Bien Air model iChi- ropro, Fig. 24) and with verification of the Implant Sta- bility Quotient (ISQ) through Ostell® (Fig. 25) − Secondary stability (through ISQ) − Periimplant bleeding indices (from 1 to 3) − Plaque indices (from 1 to 3) − Degree of Patient's satisfaction (from 1 to 3). In all rehabilitated cases, the long-term success was noticed and none of the 64 implants inserted failed. However, due to the aforementioned intraop- erative histological samples taken (see the previous section “Materials and Methods”), considering the histological point of view, significant differences were observed in the bone tissue damage between the three different methods of implant site preparation implemented (Figs. 20–23). In particular, in the cases treated with mixed technique (Group 3), better results were noticed in terms of: − Correct positioning of fixtures; − healing in the medium-and long-term; − localised tissue trauma. With respect to the histological findings, in both techniques providing the use of piezoelectric inserts, a better health condition of the bone margin adjacent to the implant site preparation was observed. − reduced tissue trauma; − compliance with the operating sequence of the im- _Conclusions plant system implemented; − more predictable clinical success. Based on the results achieved, as well as on data reported in the literature12, we can say that the use of 20 I implants 4_ 2013

piezoelectric inserts—limited to the initial prepara- tion of the implant site and combined with the use of handpiece rotating burs specifically dedicated to the implant system during the final phases of the proce- dure—improves clinical outcomes, allowing the achievement of the following key objectives: − Correct positioning of fixtures. − Excellent initial fitting and excellent primary reten- tion. − Excellent secondary bone retention and excellent maintenance of bone peaks. − Optimal recovery in the medium and long-term. − Extremely reduced local tissue trauma. The above is more predictable and repeatable than the techniques of preparation exclusively carried out with rotating burs or with piezosurgery inserts. Technical advantages together with the biologi- cal benefits are valid only if the piezoelectric instru- ment is used in a proper and correct manner, and of course if the piezosurgery system chosen meets the characteristics described in the introduction of this paper. Actually, there are studies that show how, under certain circumstances, an improper use of the piezo- surgery may be potentially risky, even iatrogenic, when compared with traditional osteotomies made with dental drills. In particular, some studies show that an excessive and prolonged pressure exerted by the operator on the handpiece (and then on the vi- brating insert) during cutting, as can erroneously oc- cur in the case of extended osteotomies and in the presence of particularly high bone densities, can gen- erate temperatures greater than those generated by traditional burs on hard tissues.13-16 As known, the thermal stress induces a conse- quent significant tissue damage and interferes with the neoangiogenesis. Such an intraoperative case is particularly important, especially when the bone di- mensions are minimum, as is usual in implantology or, more generally, in oral surgery.17 In addition, it should be noted that not everything that vibrates falls within the field of piezosurgery. It is possible to find systems on the market that, although described as useful for this procedure, do not have the appropriate characteristics, are not accompanied by the necessary validating histological studies or do not allow the appropriate mode and frequency of use. It follows that the unwary purchase of a wrong system may lead the operator to rely purely and simply on the benefit of piezosurgery concepts but, because of the in- correct choice, obtain a clinical and biological result worse than that achievable with conventional rotary instruments. In view of these considerations about the research I Fig. 20 Fig. 21 Fig. 22 Fig. 23 Fig. 24 Fig. 25 pros and cons on the use of piezosurgery in oral surgery and objective data provided by a rich literature of EBM and in that sense exhaustive, the authors deem the im- plementation of a surgical protocol advisable, repro- ducible and standardized, which provides for the use of piezoelectric device only during the initial phase of preparation of the implant site, then completing the site preparation with the burs provided by the implant protocol chosen by the operator. Finally, these highly satisfactory results, therefore, encourage clinical research in this direction and the procedure described is, in the opinion of the authors, a viable alternative—albeit not a substitute—to con- ventional techniques already thoroughly discussed in the literature._ Editorial note: A complete list of references is available from the publisher. _contact implants Prof. Dr Mauro Labanca Consultant Professor in Oral Surgery Corso Magenta, 32 20123 Milano, Italy maurolab@tin.it Fig. 20_Histologic of bone tissue in mixed technique for the initial preparation of the implant site through piezoelectric inserts with a visible reduction of the cortical and basal level. Fig. 21_Drawing of bone tissue in mixed technique for the initial preparation of the implant site through piezoelectric inserts with only an initial reduction of cortical level. Fig. 22_Histologic of healthy bone tissue in technique for the preparation of the implant site only with piezoelectric inserts. Fig. 23_Histologic of bone tissue in technique for the preparation of the implant site only with dental drills. We can see an objective tissue’s damage, with a lot of necrotic areas. Fig. 24_The example of torque measurement. Fig. 25_The example of ISQ measurement. implants 4_ 2013 I 21

I research Ridge augmentation for an atrophied posterior mandible—Part III NanoBone block versus allograft bone block Authors_Dr Omar Soliman, Prof. Dr Dr Mohamed Nassar, Ass. Prof. Dr Mahmoud Shakal & Ass. Prof. Dr Eman Mohy El-din Megahed, Egypt _Introduction The aim of the present study was to compare the clinical outcome and radiographic bone changes in augmented ridges utilizing a synthetic NanoBone block versus an allograft bone block, and to investigate histo- logically the success of a synthetic NanoBone block ver- sus an allograft bone block for ridge augmentation. In the previous issues of implants: international magazine of oral implantology, the authors gave a detailed intro- duction to their topic and explained the materials and methods used in their study (implants 1/2013) and the results of clinical outcomes & radiographic bone changes (implants 2/2013). In this issue, their report is completed by the histological results of their investiga- tions and an extensive discussion. _Bone regeneration process Figs. 1a & b_X100, H&E stained section showing ostoid bone formation. Phase 1: Bone regeneration1 Within the graft, whether for a mandibular continu- ity defect, a sinus augmentation surgery or dental im- plant is placed in a dead space filled with clotted blood. The platelets entrapped in the clot degranulate within Fig. 1a Fig. 1b 22 I implants 4_ 2013 hours of graft placement, releasing PDGF, TGF-b1 and TGF-b2. Both of these factore begain the bone regener- ative process. PDGF binds to endothelial cells to initiate the ingrowth of capillaries, while TGF-b1 and TGF-b2 bind to the endosteal osteoblasts and marrow mes- enchymal stem cells to initiate mitosis to increase their numbers as well as stimulate their production of os- teoid. This continues during the first 3 days of the graft, at which time capillaries are already seen to be entrap- ping the graft. However, by this time, the platelets have degranulated and are no longer a primary source of growth factors to drive the bone regenerative process. At these times, macrophages take over this role. Macrophages were initially attracted to the graft as cir- culating monocytes of free tissue cells by inherent oxy- gen gradient in the graft. Thus, the inherent properties of the wound, particularly the oxygen gradient, PDGF and TGF-b, initiate early angiogenesis from surrounding capillaries and mitogenesis of the transferred osteo- component cells. The complete revascularization of the graft is seen by day 14. By this time, the endosteal os- teoblast have already laid down osteoid on the original bone trabeculae and the marrow stem cells have dra- matically increased in number and have begun differ- entiating into osteoblasts. The stem cell population and endosteal osteoblasts produce small amount of osteoid. During the first 3 to 4 weeks, the biochemical and cel- lular phase of bone regeneration proceeds to clinically consolidate the graft by coalescing individual osteoid islands, surface osteoid on cancellous trabeculae and host bone. This process is essentially transplanted os- teogenessis. However, it uses the fibrin network of the grafts as a framework. This is referred to as osteocon- duction, which provides a scaffold for what has been call (creeping substitution). That is, the normally non motile

osteoblasts can be somewhat motile via the process of endocytosis along a scaffold like fibrin. The process of endocytosis is merely the transfer of cell membrane from the retreating edge of the cell, through the cytoplasm as a vesicle, to the advancing edge to reform a cell membrane and thus increase the cellular surface area at the advancing edge. This mech- anism slowly advances the cell and allows it to secrete its product in the process. In this case, the product is os- teoid on the fibrin network. This cellular regeneration is often referred as phase 1 bone regeneration or woven bone phase. By the time it is nearly complete (4 to 6 weeks), sufficient osteoid production and mineraliza- tion have occurred to permit graft function. At this stage, the bone has formed without going through a chondroblastic phase and histologically appears as ran- dom cellular bone that a pathologist would refer to as woven bone. Phase 2: Bone regeneration1 The cellular bone regeneration that has occurred in phase 1 produces this disorganized woven bone that is structurally sound but not the degree of mature bone. The random organization and hypercellular nature of this bone is similar to that seen in fracture callus. This bone will undergo an obligatory resorption and re- research I Fig. 2a Fig. 2b Fig. 2c Fig. 2d placement type of remodeling. Eventually, it is replaced by phase 2 bones, which is less cellular, more mineral- ized and structurally more organized into lamellar bone. Figs. 2a–d_X400, H&E stained section showing new bone formation. The replacement of phase 1 by phase 2 bone (woven bone by lamellar bone), like all bone remodelling, is ini- tiated by osteoclast. Osteoclasts are fused monocellular cells that arrive at the graft site through the newly de- AD 5,0 x 6,0mm 6,0 x 8,0mm 5,0 x 6,0mm 5,0 x 5,0mm 4,5 x 6,0mm 5,0 x 6,0mm 6,0 x 5,7mm 4,0 x 5,0mm ,4 mm0,5 0 x 5 5,0 x 5,0mm 6,0 x 5,0mm 14 Years 6,0 x 5,7mm 5,0 x 5,0mm 6,0 x 5,7mm 14 Years 4,5 x 6,0mm 5,0 x 5,0mm 4,5 x 6,0mm 5,0 x 6,0mm 6,0 x 5,7mm Since 1985 Sinc e 1985 » e 1985 Simple .dte Lporun EociB (cid:81) (cid:81) 1. rtstpuaH (cid:81) (cid:81) reubnehcueB19455 ner (cid:81) (cid:81) nyamreG (cid:81) (cid:81) 56)0(9 4+e nohP 34 002818 (cid:81) (cid:81) mo.cnoic@byanmreg (cid:81) www.bicon.de.com om.cde.oncib.www m (cid:81)

I research Fig. 3a Fig. 3b Fig. 4a Fig. 4b Figs. 3 & b_X400, H&E stained section showing NanoBone granules undergoing degeneration by osteoclast cells, surrounded by dense connective tissue with plentiful osteoblast cells. Figs. 4a–c_X100, H&E stained section showing numerous blood vessels in NanoBone graft. Figs. 5a & b_X100, H&E stained section showing numerous inflammatory cells, few blood vessels and few new bone formation in the Fisiograft group. Fig. 6_X400, H&E stained section showing less vascular vessels and large remnants of Fisiograft. Fig. 7_X100, H&E stained section showing small remnants of NanoBone graft. Figs. 8a & b_Showing NanoBone block immediately after augmentation (a) and six month after augmentation which was firm and strongly attached to natural bone (b). Fig. 4c Fig. 5a Fig. 5b veloped vascular network. It is theorized that these os- teoblasts resorb phase 1 bone in a normal remodelling replacement cycle. As both the phase 1 bone and non- viable original cancellous bone trabeculae are resorbed, bone morphogenic protein and IGF-I and IGF-II are re- lease. As with normal bone turnover, BMPs, IGF-I and IGF-II act as the link between bone resorption and new bone apposition. Such growth and differentiation fac- tors are deposited into the mineral matrix of bone by os- teoblasts during osteoid production. Stem cells in the graft from local tissues and the circulation respond to the released BMPs, IGF-1 and IGF-II by osteoblast dif- ferentiation and new bone formation. This new phase 2 bone forms as the jaw and graft in function. It responds to the demands placed on it and develops mature Havarsian systems and lamellar bone capable of with- standing the normal shear forces placed on the jaw. The bone is capable of tolerating the forces typically of im- plant prosthetic functions. Histologically, the grafts en- ter a long-term remodelling consistent with normal skeletal turnover. A periosteum and endosteum develop as part of this long term remodelling cycle. The graft cor- tex never becomes as thick as a normal jaw cortex, and the graft itself remains a dense, cancellous trabecular pattern. This pattern is advantageous in promoting os- seointegration and is adaptable to a variety of func- tional stresses. Over several years, the graft takes on the radiographic morphology and cortical outlines of a mandible or maxilla. _Histological results During processing of NanoBone and Fisiograft sam- ples, we noticed that the samples of augmented bone do not need more than ten days to be decalcified in EDTA while the remaining part (normal bone) of the bone core still calcified. A microscopic analysis at x100 magnifica- tion allowed the author to observe numerous miner- alised areas of newly formed bone of various sizes, which were scattered in all the NanoBone group (Figs. 1–3), and limited in the Fisiograft group (Fig. 5). These bone areas were surrounded by an osteoid layer com- posed of osteoblasts, which synthesize the organic component of the extracellular matrix (the osteoid sub- stance) and control its mineralization. Microscopic ob- servation of the sample at higher magnification showed some osteoclast cells were found near the remaining spicules of the bone graft, multiple osteoblasts and nu- merous osteocytes situated within well-defined lacu- nae (Fig. 3). In some areas, new bone contained small is- lands of residual bone graft; these could be distin- guished from live bone by empty osteolytic lacunae (Figs. 5–7). They were showing signs of continuous re- sorption by osteoclasts and simultaneous deposition of bone. The presence of large amount Fisiograft remnants was seen in all group sections (Fig. 6), while in NanoBone group specimens the NanoBone graft remnants were few and at the periphery of the specimens (Fig. 6). The presence of blood capillaries, defined by endothelial Fig. 6 Fig. 7 Fig. 8a Fig. 8b 24 I implants 4_ 2013

research I Fig. 9a–c_Showing copious bleeding during drilling in NanoBone graft six months after augmentation. implants 4_ 2013 I 25 Fig. 9a Fig. 9b Fig. 9c cells, demonstrated well differentiated capillary vascu- larization was numerous in all NanoBone group speci- mens (Fig. 4), while it was few or absent in the Fisiograft group specimens. There was no evidence of acute or chronic inflammatory infiltrate in all sections of NanoBone group. Inflammatory cell infiltration within the new bone, primarily mononuclear cells such as lym- phocytes and macrophages, was seen in all samples of the Fisiograft group (Fig. 5). The inflammatory cells were considered indicative of a significant inflammatory or immune response. Histologically, NanoBone granules exhibited adequate vascularization and high biocom- patibility comparable to Fisiograft bone, as indicated by the fact that in NanoBone groups, signs of angiogene- sis and large vessels and cells could be observed in the center of the tissue (Fig. 4), while Fisiograft bone was in- vaded by small vessels and cells (Fig. 5). _Discussion Bone substitutes act as space maintainers by pro- viding a scaffold that allows them to colonize by bone- promoting cells and to replace by newly formed bone.2 One of the major challenges in the application of bone substitutes is adequate vascularisation and biocompat- ibility3 and rapid vascularisation of the block graft is paramount for successful neo-osteogenesis.4 Our his- tological results showed that NanoBone architecture allows better vascularisation (Fig. 4), as well as coloni- sation of the bone graft by the host progenitor cells and promotes the osteoconductive properties of the mate- rial. On the other hand, the Fisiograft samples showed less vascularisation (small vessels and cells, Figs. 5 & 6). Our histological results showed furthermore that in- flammatory cells infiltration within the new bone, pri- marily mononuclear cells such as lymphocytes and macrophages, was seen in all samples of Fisiograft group (Fig. 6). The inflammatory cells considered in- dicative of a significant inflammatory or immune re- sponse. This finding is not consistent with the finding of Scarano et al., who stated that Fisiograft is free from in- flammation effect.5 Our histological results showed that, in the NanoBone group specimens, the NanoBone graft remnants were few and at the periphery of the specimens, ongoing resorption and surrounded by os- teoclasts. This is consistent with Heinemann et al., who postulate that nanocristalline HA has osteoconductive and biomimetic properties and is integrated into the host’s physiological bone turn over at a very early stage.6,7And it is also consistent with Cannolo et al., who proposed that the newly formed bone in NanoBone was already found at three months of healing and new tra- becular bone was found at six months of healing.8,9Dur- ing implant placement, the quality of grafted bone was evaluated clinically, especially during drilling and im- plant placement. In all NanoBone group patients, the grafted bone was firm and strongly in contact to the natural bone (Fig. 8). Copious bleeding occurred during drilling in the grafted bone (Fig. 9). This is consistent with the histological results which showed better vasculari- sation, as well as colonisation of the bone graft by the host progenitor cells and promotes the osteoconduc- tive properties. We also noticed that, during crestal in- cision and flap reflection, it was difficult to dissect the mucosa over the augmented NanoBone block and we used a scalpel to dissect it. We refer that to an absence of the periosteum that covers the grafted NanoBone block. On the other hand, in Fisiograft group patients, the grafted bone had no string contact to natural bone and little bleeding occured during drilling in the grafted site. _Conclusions NanoBone block (NanoBone, ARTOSS) showed faster bone formation, better vascularisation, as well as colonisation of the bone and less inflammatory cells, while Fisiograft showed less vascularisation and nu- merous inflammatory cells. NanoBone graft degraded earlier than Fisiograft._ _contact implants Dr Omar Soliman PhD candidate Perioimplant dentistry Tel.: +20 1009634358, +20 1201005457 Omar.Soliman77@yahoo.com Prof. Dr Dr Mohamed Nassar Professor of Perioimplant dentistry Faculty of Dentistry, Tanta University, Egypt. Tel.:+20 1121522221 Prof_Nassar@yahoo.com

I overview Vertical bone augmentation procedures—Part I Authors_Prof. Dr Dr Florian G. Draenert & Dominic Hützen, Germany _Introduction The success of an implantological procedure largely depends on the alveolar situation and the bone sup- porting the soft tissues. Until today, complex augmen- tation procedures pose high demands on the clinician and there is still a great need for research in this field. The following article discusses the basics of implantology relevant to bone augmentation and presents an overview on complex bone augmentation techniques. Part I of this consecutive article series introduces basics in bone morphology, biomaterials and transplants. To be continued in 2014 with issue 1/2014. _Basics Bone morphology The histomorphology of bone distinguishes be- tween lamellar bone of complex structure and plexiform bone.1 Plexiform bone does allow fast healing and growth, but only simple structures of orthogonal pri- mary osteone structure with a mechanical overall weakness of evolutionary relevance in large organisms. It is therefore often found in small mammals like mice, rats, and in part rabbits. Larger mammals including pigs, dogs and humans have a complex lamellar bone struc- ture. Ontogenesis of bone in humans starts with em- bryonal plexiform bone structures leading to the mature bone structure with secondary osteons (Haversian sys- tem). The two morphological forms of bone are cancel- lous and compact bone. Cancellous bone shows a tra- becular structure with an internal lumen containing bone marrow with several function including pluripo- tent stem cells and vessels. Healing starts in a lamellar fashion from the bone marrow space. Cortical bone is a compact more stiff structure with higher mechanical stability and no internal remodelling capabilities. The in- ternal structure of both bone tissues is lamellar as de- scribed above. Osteons with central Haversian canal containing osteocyte and vessels surrounded by miner- alised matrix lamellae is the structure principle of com- pact bone and surrounded by interstitial lamellae (Fig. 1). Osteocytes are connected with each other via gap junctions through the Canaliculi ossei. The bony part of cancellous bone is similar in structure. Periosteum sep- arates bone from surrounding connective tissue and consists of two layers Stratum fibrosum (external) and Stratum osteogenicum (internal) containing nerves, vessels and also osteogenic progenitor cells allowing chemotactic migration during bone healing. Bone tis- sue consists of cells and matrix (ossein). Ossein contains anorganic minerals, mostly hydroxyl apatite, and or- ganic molecules mostly collagen type I.2 The organic matrix also contains several other molecules with com- plex functions including proteoglycans like aggrecan with its glycosaminoglycan arms and multiadhesive proteins but also its hyaluronic acid cores or newly dis- covered fibrils and other structures under current re- search.3-5 Cortical bone Bone healing Fig. 1_Bone Augmentation with compacta and spongiosa (left). Sequence marking with tetracycline in the rabbit at two different times makes the shell-like bone structure observable. Volkmann’s canal Spongy bone Osteon with Haversian canal & speical lamellae Interstitial lamellae of old osteotomes Haversian canal with blood and lymphatic vessels Fig. 1 26 I implants 4_ 2013 Healing of augmented bone transplants and bioma- terials at the interface site is analogous to defect frac- ture healing1, 6-16 aseptic inflammation and chemotac- tic cell migration; loose preliminary tissue (soft callus); mineralised immature bone (hard callus); remodelling resulting in full functional bone (Fig. 2).17 This mode of healing concerns all free avascular transplants includ- ing guided bone regeneration (GBR) and block aug- mentations contact healing is therefore not an issue in all of these augmentations and would require both sides of the healing site to be vasculated vital bone tissue (Fig. 2). The gap healing in bone augmentations includes lamellar healing at the interface site and the periosteum

I overview ogy of the transplant or mesh graft with biomaterial as well as biological factors. Those factors are osteocon- ductivity, osteoinductivity/vasoinductivity and os- teogenicity present in the bony implant bed and the graft or mesh. Osteoconductivity concerns macro and micromechanical and morphological properties that to promote a bone tissue specific activity and differentia- tion including matrix-cell-interactions, but also pore- size, surface properties and interconnectivity of pores in biomaterials and bone grafts, and finally also external mechanical influences like shock waves.29-34 Osteoin- ductivity leads to bone growth and differentiation by specific ligand-dependent cell activation by growth factors and other molecules, that are mostly related to the TGF-ß family, like BMPs (bone morphogenic pro- teins) e.g. BMP-2 oder BMP-7, or basic FGF and VEGF.16, 35-44 The last ones are also strong vasoinductive factors. There are several approaches to apply growth factors in clinics.45-53 However, this application will re- main limited to specific problematic conditions due to some main reasons. On the one hand, tissue healing is limited by cell activity, including the described phases of bone healing with cell recruitment, chemotaxis, differ- entiation and specific tissue matrix production that cannot be accelerated beyond biological limits and ex- ternal growth factors are therefore not relevant even if certain effects can be shown in vitro and in vivo.17, 54 On the other hand, it is a fact that application of growth fac- tors bears the immanent risk of carcinogenic transfor- mation.55, 56 Osteogenic properties concern the conti- nuity of living bone cells after transplantation that can be achieved with small bone pieces combined with fast revascularisation (e.g. particulate bone augmentation), press-fit in cancellous bone healing (clinically not rele- vant in oral- and maxillofacial surgery), and microvas- cular transplants like fibula flaps. Main signal transduc- tion in bone cells includes classic general elements like ras und MAP-kinases, but also Smad-dependent path- ways and integrin-associated signaling.57-60 Smad-de- pendent signalling includes specific second messengers like RunX2 and consists of a complex system of sub-el- ements depending on the associated ligand-system. BMPs activate Smad 1, 5 and 8 complex that binds Smad 4 and others as DNA-binding complex.58-60 Inte- grins on the other hand represent an element of signal transduction activation by specific matrix binding.32-34 _II. Biomaterials and transplants Bone transplants and alloplastic biomaterials We will not discuss the wide field of biomaterial products in depth as already published elsewhere.61, 62 Materials for bone augmentation are divided into allo- plastic (artificial) biomaterials and transplants along- side with their natural xenogenic, allogenic or autolo- gous derivatives.63-73 Most common alloplastic materi- als are: ß-tricalciumphosphate,72 bioactive glasses,71 and hydroxylapatite.73 Bone material can be further Contact healing Defect healing (cid:2)Haversian canals bridge over the fracture line. (cid:2)A: Inflammation: haematoma ? chemotaxis/migration ? granulation tissue (cid:2)CAVE: Here, remodelling is essential for com- plete stability as well. (cid:2)B: Soft callus. (cid:2)C: Hard callus. (cid:2)D: Remodelling. Fig. 2 Fig. 2_Synopsis of the types of bone healing: contact healing (left), defect healing (right). Periosteum Lamellar healing in the matrix Appositional healing superiostal Fig. 3_Synopsis of the subperiosteal implant healing. 28 I implants 4_ 2013 Spongy bone Cortical bone Implant Fig. 3 Contact healing at the interface, only in vaskularized material with cell recruitment from blood, bone marrow and the periosteum depending on the local anatomy (Fig. 3). This cell recruitment includes local osteoblast progeni- tors (human trabecular bone derived cells - HTBs), and blood-derived CD-34-positive embryogenic progenitor cells (EPCs).18-21 Differentiation of local adult stem cells is not well understood yet. However, the differentiation of EPC follows a stepwise change into an osteoblast while losing pluripotent capabilities from the EPC with high CD34-positive cells, followed by the stage of "cir- culating osteoblast lineage cell" towards the "blood mesenchymal precursor cell" (BMPC) direct differentia- tion into osteoblasts with continuously rising percent- age of stromal cell-derived factor-1 (SDF-1) CXCR4–re- ceptor.18 Vascular cells in newly formed bone tissue are also derived from EPCs.22, 23 Osteoclast however are part of the mononuclear phagocyte system and derived syn- cytia formations of these cell lineages.24 Vicerocranial bone of the facial area is mesektodermal tissue derived from the branchial arch rather than mesenchymal tissue derived bone in the remaining skeleton.25-28 This issue is often not fully considered when discussion bone of the skull. Cell induction in bone tissue: osteoinduction and neoangiogenesis The time course of bone healing is influenced by many factors. This includes the stability and morphol-

overview I characterized as: autologous (fresh or frozen), allo- geneic (e.g. DBM "demineralized bone matrix"), and xenogeneic. Important material properties concerning bone healing are pore size and interconnectivity, re- sorbability without severe inflammation and macro stability of particle material.74Some of these factors are evaluated scientifically like pore sizes and surface prop- erties, while other factors are mostly clinically bases ex- periences like macro stability.29.30Materials can be fur- ther characterized by their potential to influence bone healing:6 osteoconductive (promotes bony ingrowth); osteoinductive (induces bone tissue generation by re- ceptor-mediated cell activation); osteogeneic (mater- ial contains living bone cells or bone cell precursors). Most common particulate materials are bone chips from the implant site, milled bone blocks, scraped bone chips, mesh grafts with alloplastic materials (Fig. 4). Growth factors and tissue engineering are future op- tion in compromised bone healing and complex recon- structive surgery.18, 22, 39, 41, 44-47, 75-81 Conceptional prob- lems arise, if these novel techniques concerning cost and carcinogenic risks of growth factors are not ad- dressed.18, 22, 45, 45, 47, 76, 82, 83 Dental implantology therefore offers limited indications for these options. Donor sites for bone transplants Choosing the appropriate donor site for bone trans- plants is the second step after analysis of the defect and augmentation planning. Most common donor sites are:74 – Mandible (chin, angle, linea obliqua, corpus mandibulae)84 – Maxillary (tuber, spina nasalis, crista zygomaticoalveolaris) – Calvaria (tabula externa) – Pelvic rim – Tibia. Local donor sites are of special interest for applica- tions in oral and maxillofacial surgery. Intraoral donor sites are shown to be less painful for patients (Fig. 5).85 Big defects require extraoral donor sites mostly from the pelvic rim region. Quality and healing properties of var- ious bone transplants concern their ontological origin in particular. While local skull bone is branchial tissue of mesektodermal origin, pelvic and most other bone transplants are mesenchymal tissues.25-28 Mandibular bone is the most common transplant in dentistry with several donor regions: chin, linea obliqua, angle, corpus mandibulae, lingual exostosis.69, 74 ,85, 86 Bone is har- vested as a block for either immediate transplantation or generation of particles in a bone mill or similar de- vice.84, 87Using a scraper is a modern way of directly gen- erating bone chips.87 The chin region bears more donor site morbidity problems due to the mental muscle at- tachment and should be limited to augmentations in the same region to avoid a second surgery site or other serious indications.85 The linea obliqua area offers a ver- Fig. 4a Fig. 4b Fig. 4c Fig. 4d Fig. 4e Fig. 4f satile donor site with limited risks and complications if the anatomy of the alveolar nerve is carefully evaluated.74 The area of the mandibular angle is an- other site in the same area and similarly difficult with risks for the local nerve like the lingual ex- ostosis. The maxilla offers only limited amounts of bone mate- rial. However, using tuber bone or scraping chips from the ante- rior wall in combination with sinus lift surgery can be the right option.Harvesting bone from the pelvic rim is the method of choice for most indications requiring large amounts of autologous bone due to limited risks and good approach.88-90 There is an anterior and a posterior approach.88, 89, 91 It is discussed that the rarer posterior approach is offering more bone and less morbid- ity.88, 89, 92 Complications of this donor site are pain, bleeding, nerve lesions (N. cutaneus femoris lateralis), and fractures of the pelvic bone.88_ Editorial note: To be continued in implants 1/2014 with osteotomy and complex bone augmentation techniques. A complete list of references is available from the publisher. _contact implants Prof. Dr Dr Florian Draenert Devissi Implantology Institute Xaver-Weismor-Str. 60a 81829 Munich, Germany Tel.:+49 160 6127828 draenert@floriandraenert.com Fig. 4a–f_Common augmentation materials: a) bone chips from the implant bed, b) bone mill for particularization of blocks, c) bone scraper, d) commercial biomaterial. Fig. 5_Bone harvesting sites in the jaw: metal, Crista zygomaticoalveolaris and Tuber maxillae; Linea oblique of the mandibula and the angle of the jaw. implants 4_ 2013 I 29

I case report A revision of an unaesthetic reconstruction Author_Dental Campus _Introduction Has it happened to you? You’ve heard an excellent talk at a continuing education course, but when you want to apply the new knowledge, you realize that you lack the necessary practical details. Dental Cam- pus closes this gap. The new e-learning platform cre- ated especially for implant dentistry is practice-ori- ented and offers important theoretical, technologi- cal and product-related details in one single re- source. It has a structured and innovative design and allows for interactive communication. The quality of the content on Dental Campus is constantly assured by the Implant Campus Board whose members in- clude internationally recognized experts. Learning modules can be individually combined to meet the user's specific needs. Online lectures of world-renowned experts provide you with up-to- date expertise and help you to plan cases of varying difficulty levels. Each of the lectures is linked to cor- responding implant specific product information to enable rapid transformation of your new knowledge into practical treatment know-how. Besides these lectures, the many clinical cases of- fered by Dental Campus are key features. Each case presentation realistically simulates the clinician's situation when planning a case on his office desk. The cases range from simple to advanced and are all structured in the same way: from initial findings to diagnosis, prognosis and planning through the treatment sequences and the final check-up. You have the opportunity to follow all the relevant treat- ment steps in detail and discuss the case in Dental Campus forums with your colleagues. Users are given a wealth of information, as shown in the following sample case study. This case study is the first in a series of articles designed to introduce you to Dental Campus. The complete case is available as a demo on Dental Campus free of charge. We hope you enjoy your planning and treatment of this case. _Initial examination A 70-year-old female patient was referred for a prosthetic revision. She was unsatisfied with the aesthetics of her old maxillary bridge (Fig. 1). She was particularly displeased with the yellowish color and bulky size of the crowns. In addition, a tooth in the mandible was extracted due to a root fracture. Be- sides chronic periodontitis, this patient also pre- sented with wear facettes on the lower front teeth. The patient was healthy and a non-smoker. Clinical charts and periapical radiographs as well as other relevant patient information were collected in the initial consultation (Fig. 2). _Interactive diagnosis Detailed information on this case and different treatment options can be found online on Dental Campus. With a few clicks you make your own diag- nosis, define a prognosis for each tooth and plan the case with the help of an electronic dental scheme (Fig. 3). Give this feature a try! Compare your assess- ment with that of the responsible dentist and start to discuss it in the forum. _Treatment a) Pre-treatment After removal of the maxillary bridge, sufficient remaining dental structure was revealed. The abut- ment teeth would allow to be restored with a new fixed one-piece bridge (Fig. 4). The use of implants could allow for a segmented restoration design in the 30 I implants 4_ 2013

case report I Fig. 9 Fig. 10a Fig. 10b Fig. 10c Fig. 10d Fig. 10e maxilla assuring short span bridges. Since the patient was unable to bear the additional costs of a fixed re- construction in both jaws, a removable reconstruc- tion was planned in the maxilla. In the lower left jaw, an abutment tooth needed to be extracted (Fig. 5). Implant-supported fixed partial dentures were planned to restore the extended edentulous spaces in the lower jaw. b) Surgical phase In both sides of the mandible two implants were placed (Fig. 6). Peri-implant bone dehiscences were simultaneously augmented with a bone substitute material and a collagen membrane. During abutment connection, the soft-tissue quality was improved with a free gingival graft from the palate. The soft-tis- sue volume gained could be conditioned with tempo- rary dentures to optimally shape the pontic area. c) Prosthetic treatment After a short time, the mandibular implants were restored with provisional screw-retained bridges. In the upper jaw, endodontic revisions were performed on two teeth and all teeth were shortened. Subse- quently, the definitive set-up could be established (Fig. 7). In the maxilla, four abutment teeth were pre- pared for root caps. The mandibular framework try- in took place simultaneously with the maxillary framework try-in, onto which the definitive set-up was transferred (Fig. 8). This enabled a verification of the correct bite before the final veneering of the bridgeworks was performed. Subsequently, the den- tal technician completed both dentures in the upper and lower jaws. At the end the lower front teeth needed to be elongated due to the rise of the bite. The teeth were prepared traditionally to receive veneers (Fig. 9). The final outcome revealed a highly appeal- ing full restoration, both functionally and aestheti- cally. The patient was extremely satisfied (Fig. 10). _Join in the discussion The presented case is a typical example of Dental Campus' case studies and is available as a free demo case (www.dental-campus.com/DTEcase1). Com- prehensive background information and the de- tailed presentation of the treatment steps enable you to closely follow the planning and the treatment. This maximizes the practical benefit for your own pa- tients. Do you agree with the case assessment and the selected treatment as presented here? Register as a user and create your own treatment plan. Then, com- pare and discuss this plan with those provided by your fellow dental colleagues._ Dentist: Dr. Sven Mühlemann Dental technician: Andreas Graf _contact implants Dental Campus Englischviertelstr. 32, 8032 Zürich, Switzerland Tel.: +41 44 5156010 Fax: +41 44 5156011 info@dental-campus.com www.dental-campus.com Fig. 10f Fig. 9_Preparation of veneers for raising the bite. Fig. 10_Final examination. implants 4_ 2013 I 33

I industry report Extensive implant-supported restoration in generalised aggressive periodontitis Author_Dr Dr Philipp Plugmann, Germany _Introduction Particularly young patients under the age of 30 ex- perience high levels of psychological strain when faced with episodic loss of several teeth as a result of generalised aggressive periodontitis. The influence of this disease on the patients' social life and their ca- reers can be enormous. _Case presentation In February of 2012, the patient presented in my practice at the age of 28. Despite his young age, he had already lost several teeth. The probing pocket depth was 3.5–5 mm, the plaque control record (PCR) was at 100 % and the gingival bleeding index (GBI) was at 90 %. Several different treatments were necessary: teeth 21 and 23 needed endodontic treatment and root canal fillings, a long-term temporary restoration was necessary for teeth 21 to 23, and a ceramic inlay was indicated for tooth 46. In addition, the patient suffered from halitosis. The combination of the symp- toms proved a great burden on the patient. Fig. 1_Presurgical panorama X-ray. Fig. 2_Flap exposing the surgical field, first quadrant. Fig. 3_Display of the vestibular bone structure, first quadrant. The patient described an episodic loss of teeth in the course of the past four years and a family history of tooth loss starting at the early ages of 20 to 25. The patient smokes. The patient was healthy otherwise and there were no further pathological findings. The patient gave up smoking in March of 2012 and improved his oral hygiene, thereby lowering the PCR to 12 % and the GBI to 8 % and permanently es- tablishing them below a value of 10–15 %. The pre- servative treatment was finished and the treatment of the periodontitis was concluded with a closed curettage. During regular follow-up care, the patient re- ceived supporting periodontitis therapy and showed excellent compliance. In March of 2013, we started to plan an implant-supported restoration. The patient’s oral situation before proceeding: Multiple gaps in the upper and lower jaw. Addition- ally, a terminal gap can be seen at the far end of the upper jaw (right side on the patient). Good amount of bone available in the posterior tooth area. Less bone available in the upper incisal area. The presurgical panorama X-ray shows the initial situation before the implantation (Fig. 1). The implants were inserted in March of 2013. Fig. 1 Fig. 2 Fig. 3 34 I implants 4_ 2013

_Surgical procedure First, I exposed the bone using a scalpel and a sharp curette. Because this case deals with a D4 bone, I de- cided to use an IMPLA Cylindrical implant from Schütz Dental. Thanks to the cylindrical structure and espe- cially coordinated thread sides, this implant offers a high primary stability in cases such as this one (Figs. 2–4). Thanks to the self-tapping thread of IMPLA Cylin- drical implant, I only had to apply the pilot and exten- sion drilling techniques. With the help of the acrylic insertion aid and "no-touch" technology, I could in- sert and screw the implants quickly and easily into the drill holes (Figs. 5–7). After taking off the insertion posts and screwing on the healing caps, the mucous membrane was fit- ted with several 4.0 interrupted sutures (Ethicon, braided silk, non-absorbable, Fig. 8). While I was exposing the bone in position 12, I noticed that the available bone structure would not be sufficient (Fig. 9). Here, I chose an augmentative bone construction using the bone augmentation material CERASORB from the company Riemser as well as a resorbable Epiguide membrane. After I inserted the implant and screwed on the healing cap, I remodelled the bone structure using bone augmentation material. This made sure that the neck of the implant wouldn’t be seen after surgery (Figs. 10–13). After inserting the implants and removing the insertion posts, the im- plants were sealed with the healing caps. While treating the lower jaw, I came across a D1 bone. Once again, I chose to use the IMPLA Cylindrical implant, only this time for its self-tapping properties. This made the screwing in of the implant so much eas- ier in such compact bone as this (Figs. 14 and 15). The postsurgical panorama X-ray shows the situation with the inserted implants (Fig. 16). _Implant prosthetics In September of 2013, six months after implanta- tion, the implants in the upper and lower jaw were ex- posed. Then, the appropriate gingiva formers in gin- giva heights 2 and 3 were inserted (Figs. 17 and 18). Subsequently, alginate impressions were taken to produce plaster models and individual impression trays. The individual impression trays were to serve for individual impressions with impression posts and the posts 21 and 23 to be prepared. The forming posts and according inner screws for the impressions were un- screwed directly after removing them from the pack- Fig. 31 age (Figs. 19–21). Afterwards, an extensive function analysis and function diagnostics were performed. At our own lab, the necessary models were pro- duced from the impressions, taking into account the results of the function diagnostics. Next, the models were articulated. Finally, the designated abutment were screwed onto the model and worked on (Figs. 22–26). During the next session, the implant abutments and the framework were fitted intraorally. The fit of the abutments was additionally documented by and checked with a panorama X-ray (Fig. 27, panorama X-ray with abutments). At a later date, the abutments were screwed in permanently and the openings were covered with Cavit. The restoration was set in for a test period of two weeks. At the end of September, the restoration was permanently fixed (Figs. 28–30). Finally, a panorama X-ray was taken for documen- tation and to check the result (Fig. 31). _Conclusion When dealing with major tooth loss after a gener- alised aggressive periodontitis, implant-supported individual crowns are an excellent solution, as they offer the patient optimal possibilities for oral hygiene. First, however, a complex and tedious pre-treatment phase is necessary, as only a highly motivated and contributory patient, who will show up to each fol- low-up care session, can avoid a recidivism and com- plications of peri implantitis in the long run._ _contact implants Dr Dr Philipp Plugmann, MSc MSc MBA Doctor of Dental Medicine (DMD) Master of Science Periodontology and Implant Therapy (DGParo) Ludwig-Erhard-Platz 1 51373 Leverkusen, Germany industry report I Fig. 31_Panoramic X-ray of the final result. implants 4_ 2013 I 37

I industry report Immediate implant placement with the NNC implant Author_Joachim S. Hermann, Switzerland _Introduction In the past, the restoration of narrow tooth gaps with Straumann® Soft Tissue Level implants (maxillary lat- eral incisors/mandibular incisors) was only possible with the Straumann® Narrow Neck Implant (NN). Due to the prevailing external, hexagonal connection geom- etry and correspondingly larger dimensioned abutment components it was somewhat difficult to achieve hy- gienic and aesthetically demanding restorations, par- ticularly in the anterior region of the mandible. The new Straumann® Narrow Neck CrossFit® implant (NNC) now offers an established internal taper connection which allows more intricate prosthetic work in the emergence profile region. Due to the harder implant material—NNC made of TiZr (Straumann® Roxolid®) vs. NN made of pure titanium grade 4, cold-worked—one can expect multi-unit bridges, as described in this case, to also have a better long-term prognosis from a biomechanical point of view. _Initial situation At the beginning of the treatment, the patient was 48 years old and in good general health. For decades, the patient had suffered from a severe, aggressive, gener- alised periodontitis (type III B, Fig. 1), which could be healed completely prior to implant restoration (Perio- Healing™ Concept; Fig. 2). _Procedure Treatment planning At first, the diseased anterior mandible was to be healed in a regenerative and biological manner and without bone replacement materials, among others Fig. 1_Initial situation. Fig. 2_Radiographic status after periodontal healing. Fig. 3_Clinical situation after periodontal healing. Figs. 4-6_Clicinal and radiographic status with depth gauges in situ immediately after extraction. Fig. 1 Fig. 2 Fig. 3 Fig. 4 Fig. 5 Fig. 6 38 I implants 4_ 2013

industry report I Fig. 7 Fig. 8 Fig. 9 Fig. 10 Fig. 11 Fig. 12 by employing enamel matrix proteins (Straumann® Emdogain) in the sense of ’Socket Preservation‘ prior to immediate implant placement at 32 and 42 (Fig. 2). From the Cone-Beam Computer Tomogram (CBCT) it could already be presumed preoperatively that simultaneous augmentation in the sense of a less invasive procedure could be dispensed with by precise implant placement at the soft tissue level, and that a four-unit fully functional porcelain-fused-to-metal bridge (PFM) could be inserted without difficulties due to the more stable implant material (Roxolid®). Surgical procedure. Following periodontal healing (Fig. 3), teeth 32 and 42 could each be extracted in toto from the healthy tis- sue without fracturing, in particular of the buccal lamellae. The clinical and radiological examination employing combined depth gauges showed a four- unit anterior bridge to be possible under these condi- tions (Figs. 4–6). There had also never been the neces- sity for simultaneous bone augmentation (Osteogenic Jumping Distance). Using the NNC profile drill, the crestal bone was ex- panded minimally in the present type 2 bone prior to implant placement of the two 10 mm NNC implants in each case (Ø 3.3 mm to 3.5 mm; Figs. 7 & 8). Attention was paid during the implant placement of the two NNC implants, that the Microgap could be placed precisely 2 mm coronal of the buccal limbus alveolaris, so as not to obtain crestal bone or soft tis- sue loss following appropriate tissue maturation (Tis- sue-directed Implant Placement1, 2; Figs. 9–11). The new NNC insertion device enables perfect aesthetic analysis of the insertion depth in relation to the variable thickness of the periimplant gingiva (Biologic Width: 2.25–3.75 mm1, 2) and can be fixated again in the im- plant at any time for fine adjustment prior to suturing due to the tapered press-fit design (Fig. 12), which al- lows obtaining an optimal, biocompatible intrasulcular position of the Microgap following complete healing and remodeling. During the final alignment of the implants, one then needs to again ensure that the semi-spherical recesses on the insertion devices are placed precisely in buccal di- rection, so that the prosthetic abutment components can be aligned precisely later on. Using 3 mm NNC heal- ing caps (Figs. 13 & 14) provides ideal conditions for soft tissue maturation (up to six months) in combination with an appropriate temporary restoration (Fig. 15). This also dispenses with the need for a second surgical in- tervention (uncovery). Prosthetic procedure The base of the temporary prosthetic restoration, which should be supported occlusally (Fig. 15), must not touch the healing caps statically and functionally dur- ing initial healing. This can be checked with a silicone paste (Fit Checker®). Five months post implantationem the Biological Width1,2has become perfectly established in the healthy mouth (see comparison Figs. 13 & 16). Us- ing a screw-retained, open implant impression (Fig. 17) it was possible to fabricate the 4-unit PFM bridge 32xx42 with great precision (Fig. 18*), which allowed an adequate outcome in terms of hygiene, chewing com- fort, aesthetics and phonetics (Fig. 19). Here it is recom- mended to communicate the exact dimensions of the individually determined interdental tooth brushes (Fig. 19), which are to be tested in vivo on the patient and re- Figs. 7 & 8_New NNC crestal profile drill adjustment. Figs. 9–11_Tissue-directed Implant Placement.1,2 Fig. 12_New NNC press-fit insertion devices. implants 4_ 2013 I 39

I industry report Fig. 13 Fig. 14 Fig. 15 Fig. 16 Fig. 17 Fig. 18 Figs. 13 & 14_3 mm healing caps in situ. Fig. 15_Temporary restoration. evaluated during try-in (gingiva resilience vs. plaster cast). implants they provide good aesthetics, while at the same time offering good preservation of the periim- plant hard and soft tissue architecture._ Fig. 16_ Clinical status five months _Final outcome post-op. Figs. 17 & 18_Fabrication of the porcelain-fused-to-metal-ceramic bridge using a screw-retained, open implant impression technique. The one-year long-term follow-up showed stable and healthy hard and soft tissue conditions analogue to established biological principles for Soft Tissue Level im- plants (Figs. 20 – 22).1, 2The probing measurements were all at ≤ 3 mm with negative BOP bleeding values (Bleed- ing-on-Probing) as well as a broad band of attached periimplant gingiva. Surprisingly, the implant mobility values (PTV Periotest Values) were significantly lower (i.e. reduced mobility) than known from the Strau- mann® Narrow Neck implants (NN) to date, which may be due to the harder implant alloy and/or better hard tis- sue integration of the hydrophile SLActive® surface. Fig. 19_Insertion of the bridge with _Conclusion the use of individually determined interdental tooth brushes. Figs. 20–22_Follow-up showing stable hard and soft tissue conditions. Straumann® Narrow Neck CrossFit® implants are a further asset to the comprehensive Straumann® prod- uct portfolio and extend the indication field, particularly in very narrow spatial conditions. As Soft Tissue Level Editorial note: A complete list of references is available from www.straumann.com/stargetref. Capitalisation is subject to the author. *Technical dental work by MDT Thomas H. Seitner, Stuttgart-Ostfildern/Ger- many. _contact implants Prof. Dr Joachim S. Hermann FICOI, FITI, FPFA Periodontology SSO Swiss Board Certified ZP ZurichPeriodontics® Stationsstr. 53 8606 Zurich-Nänikon Switzerland joachim.hermann@zurichperiodontics.com www.zurichperiodontics.com Fig. 19 Fig. 20 Fig. 21 Fig. 22 40 I implants 4_ 2013

I manufacturer news Manufacturer News Omnia LC Implant Suite The multifunctional surgical trolley LC Implant Suite by Omnia is developed to improve the organization of the dental office. Thanks to LC Implant Suite, electronic equipments are properly stored, cables and wirings are hidden, the level of hy- giene in the whole office is improved, and the organi- sation of the surgical room is quicker as all the instru- ments are ready for usage. LC Implant Suite is an es- sential instrument for those who practice oral surgeries and implants using Phisio - dispenser or Piezosurgery instruments and for those who practice endodontics and par- odontics. LC Implant Suite is the ideal solution for the equipment in any modern surgical room. movable supports for cooling liquids. It is available with three removable shelves with safety stop and adjustable height (ref. 30.E0050) or two removable shelves with adjustable height and an internal drawer (ref. 30.E0060). In addition, Teflon support for three handpieces/contrangles is in- cluded—inside part removable and auto- clavable. Furthermore, the scratch proof front glass window can be opened at 270°. Whereas the lower part is for pedals or var- ious accessories, the lateral opening is for equipment cables and/or cords. The socket comes with an automatic spool. Omnia S.p.A. Via F. Delnevo, 190sx 43036 Fidenza, Parma, Italy Dentaurum Implants Flexibility meets efficiency The newly developed instrument set in the tioLogic©ADVANCED surgical tray of- fers maximum flexibility for the implant site preparation with fewer instruments. The drilling protocol of the ADVANCED instruments allows an atraumatic preparation individually adapted to the bone quality and an individual regulation of the drilling depth for maximum primary stability. All preparation instruments in the tioLogic©ADVANCED surgical tray can be used for the insertion of tio- Logic© and tioLogic© ST implants. Main features are the flat tray with scratch proof sur- face and integrated handle (45 x 54 cm) and two re- info@omniaspa.eu www.omniaspa.eu Straumann New implants reduce treatment invasiveness Straumann is introducing Roxolid SLActive implants in a new range of sizes that help dental profession- als to avoid bone augmentation procedures, saving patients trauma, discomfort, time and money. The key to the new implants is the unique material Ro - xolid, which is considerably stronger than pure tita- nium. Roxolid implants also feature the SLActive sur- face for accelerated osseous healing and Loxim, a new transfer piece that detaches faster and easier from the implant after placement in the patient. Ex- perience gained in an extensive clinical program has provided the basis for Straumann to supply all its im- plants in Roxolid with the goals of minimising inva- bone. siveness and making treat- ment possible for patients with insufficient Conse- quently, Straumann Soft Tissue Level and Bone Level Implants are now available in Roxolid in 3.3, 4.1 and 4.8 mm diame- ters. Straumann is also launching a new short im- plant, which is just 4 mm in length—making it the company’s smallest implant. Designed to avoid ex- tensive augmentation procedures in patients with insufficient vertical bone for conventional implants, the new implant is available in a soft tissue level de- sign and in 4.1 mm and 4.8 mm diameters. For the tioLogic© ST implant, the macro and micro design of the tioLogic© implants has been further developed under biomechanical aspects. The new modified self-tapping thread geometry combined with the reduced thread pitch allows a fast and atraumatic implant insertion with a constant inser- tion torque, as well as high primary stability. In addi- tion, the tioLogic© ST 7.0 mm implant expands the range of indication for reduced vertical bone avail- ability. The tioLogic© ST implant also follows the well-proven S-M-L-concept of the tioLogic© im- plant system and is, thus, compatible with all exist- ing prosthetic abutment lines of tioLogic© implants. They are perfectly aligned with the accredited tioLogic© product range. Institut Straumann AG Dentaurum Implants GmbH Peter Merian-Weg 12 4052 Basel, Switzerland Turnstr. 31 75228 Ispringen, Germany info@straumann.com www.straumann.com info@dentaurum-implants.de www.dentaurum-implants.de 42 I implants 4_ 2013

manufacturer news I Schütz Sunstar GUIDOR Congress & presentation [Website] Small in size, great in performance Preparing for the future of implant dentistry Only three steps lead you to a safe implant restoration: a pilot hole, extension-drilling and the insertion of the implant. If a two-piece- implant is not an option for your patient, you can now offer an economic alter- native: one-piece IMPLA Mini implants. They feature a blasted and etched sur- face and are available with two different heads: Mini-balltop is excellently suited to the overdenture-technique while Mini-conetop was developed specifically for supporting bar constructions, if there is limited space available. The one- piece implants offer you a minimally invasive procedure and a short drilling pro- tocol. The result: shorter surgery times. This means both you and your patient will benefit from a more economic implant restoration. IMPLA Mini implants can be inserted with the IMPLA surgery tray. Alternately, you can use the small IMPLA Mini surgery tray, especially put together for this purpose. Of course, all these products are “quality made in Germany”. Schütz Dental GmbH Dieselstr. 5–6 61191 Rosbach, Germany impla@schuetz-dental.de www.schuetz-dental.com The 22nd Annual Meeting of the European Association for Osseointegration (EAO) took place in Dublin and Ireland from 17–19 October 2013, with the theme “Preparing for the Future of Implant Dentistry”. Nearly 70 speakers and more than 3,000 dele- gates from around the world were expected to participate in the con- gress. The Sunstar Foundation sponsored the Breakfast Symposia on Friday, October 18, 7:45–8:45 am where Prof. Dr Dr Engelke, University Göttingen, lectured about „Alveolar Ridge Preservation using Endoscopically assisted Root Enucleation in Anterior Maxillary Extraction Sites“. As a silver sponsor Sunstar presented their products at the commercial exhibition which ran throughout the period of the congress. Distributor in Germany: Sunstar Deutschland GmbH Sunstar GUIDOR Tel: +49 7673 885-10855 AD Ritter Quality. Flexibility. Innovation. Made in Germany. arranged components of tools and abutments with the best features for all clinical cases. Due to the super nano-surface, a quick and reliable osseointegration is guaranteed. Clever and easy handling is provided by self-tapping threads and a coloured system of drills and implants according to their diameters. All Ritter implants and accessories are made by highly modern CNC manufacturing machines. A combina- tion of advanced machining and hand-finishing cre- ates the most accurate tools possible for the marking of ceramic drills. The Ritter brand stands for high quality, state-of-the- art-technology and innovative products made in Ger- many. Our credo is to always provide customers and clients with the best services and prices combined with the most comprehensive dental solutions in the market. Ritter Implants GmbH Grüner Weg 32 88400 Biberach, Germany info@ritterconcept.com www.ritterconcept.com www.ritterimplants.com Founded in 1887 by the German Frank Ritter in New York, Ritter is one of the oldest prestige brands of finest dental equipment worldwide. Today Ritter products are more than ever an essential element in dental practices worldwide. The Ritter implant-ivory-line provides two-piece-im- plants (implant plus separate abutment) as the spiral- implant (QSI) and twin-fissure-implant (TFI) as well as one-piece-implants (implant and abutment already connected) called mono-compress-implant (MCI). The system contains logically reduced and clearly You are n°1! don’t be satis(cid:2)ed with a second choice, Pick up Omnia irrigation system! OMNIA S.p.A. OMNIA S.p.A. Via F. Delnevo, 190 - 43036 Fidenza (PR) Italy Via F. Delnevo, 190 - 43036 Fide Tel. +39 0524 527453 - Fax +39 0524 525230 39 0524 527453 - Fax +3 711860344 - R.E.A VAT. IT 01711860344 - R.E.A. PR 173685 Company capital € 200.000,00 capital € 20 www.omniaspa.eu implants 4_ 2013 I 43

sAD e l u n a r g y k c i t s c i n o i b Ingenious: Simple handling and accelerated osteocon- duction for long-term volume preservation. Degradable Solutions AG A Company of the Sunstar Group Wagistrasse 23 CH-8952 Schlieren / Zurich www.easy-graft.com L A T S Y R C ® t f a r g - y s a e Geistlich Pharma Mucograft Seal for good soft tissue outcome Aesthetic treatment results are important to patients. A key factor for success is the condition of the soft tissue. Many dentists take the op- portunity to optimise soft tissue immediately after an extraction by sewing a tissue punch from the palate into the new socket. However, graft removal from the palate is painful and creates a second wound. By using a Geistlich Mucograft® Seal collagen matrix instead of autologous soft tissue, the dentist spares the patient pain and surgery time. The 8 mm disk is made of the same proven material as Geistlich Mucograft® collagen matrix and displays the same properties. It protects the graft and creates soft tissue that matches perfectly the colour and texture of its surroundings. Geistlich Mucograft®Seal is sewn over an extraction socket that has been filled with Geistlich Bio-Oss® Collagen during a ridge preservation pro- cedure. An undamaged buccal bone plate is a prerequisite for this. Prod- ucts from Geistlich Biomaterials are marketed only after they have been scientifically tested and have demon- strated clear clinical value. This also applies to Geistlich Mucograft® Seal. An international advisory board, under the direction of Prof. Mariano Sanz, Spain, assessed the new product and observed that a combination treatment of Geistlich Bio-Oss® Colla- gen and Geistlich Mucograft® Seal prepared the soft tissue well for different therapeutic options. The ex- perts’ clear opinion was that ridge preservation in combination with Geistlich Mucograft® Seal is a pre- dictable and recommended approach. Geistlich Pharma AG Bahnhofstr. 40, 6110 Wolhusen, Switzerland www.geistlich.ch Nobel Biocare Delivering predictable outcomes for dental implant patients With its heritage dating back to Per-Ingvar Bråne- mark’s discovery that titanium could integrate with human bone in 1952, Nobel Biocare has long been synonymous with innovation. One of the latest in the company's long line of pioneering solutions for den- tal professionals is the NobelClinician Software— advanced diagnostics and implant planning soft- ware offering a predictable outcome for the patient. The NobelClinician Software allows dentists to plan dental implant treatments with precision and confi- dence by assessing detailed 3-D patient scans. Im- plant options can be brought to life on screen, taking into account important factors such as the availabil- ity of bone and prosthetic needs. Precise measure- ments can be taken and the software has the ability to advise caution when a treatment proposal sees implants placed close to areas marked by the user as sensitive, such as nerves or roots. Teeth can also be extracted virtually, meaning all possible treatment options can be explored. The world has changed a lot since Per-Ingvar Brånemark’s pioneering discov- ery but the value of a healthy looking smile has not. NobelClinician brings together the latest technology to make selecting the right dental implant treatment as smooth as possible for dentist and patient alike. The software showcases Nobel Biocare’s continuing capability to push the frontiers of dentistry as it has done for over 40 years, spurred on by the mission “Designing for Life”. Nobel Biocare PO Box 8058 Zurich Airport, Switzerland info.switzerland@nobelbiocare.com www.nobelbiocare.com

meetings I Practice-oriented implantology at the DGZI Annual Congress _„From practice—for the practice“ is the DGZI’s main topic leading the way for the 43rd International Annual Congress, which took place from 4 to 5 Octo- ber at the Berlin Hotel Palace. Dr Roland Hille, Vice President of the DGZI and scientific director of the congress stated that “Compiling practicable and proved concepts ‘from practice—for the practice’ has always been one of the DGZI’s main topics”. “Each year, we invite speakers from around the world—this is a DGZI trademark. These speakers present the par- ticipants with practicable and sustainable treatment concepts which can be decisive for the participants’ implantological success.” International speakers im- pressed the audience with their scientific knowledge on the international podium with simultaneous in- terpretation on the first day of the congress, among them Prof. Dr Monish Bhola and Dr James R. Winkler/ University of Detroit Mercy, US, Dr Keiichi Naruse, Yamagata, Japan, Dr Khaled A. Abdel-Ghaffar, Kairo, Egypt. At the same time, speakers from the fields of dentistry and dental technology discussed prosthet- ically-oriented points of view. However, the congress also addressed the implantological assistants and qualified dental assistants. One of the press conference’s most important as- pects was the new education concept introduced by Dr Roland Hille. This concept is based on the latest e-learning modules and a complex international net- work. In this regard, DGZI member of the board and dental technician Christian Müller pointed out the specialist exams for dental technologists which specifically address dental technicians with implan- tological ambitions. Dr Rolf Vollmer, DGZI Vice President and treasurer, informed about the works of the numerous DGZI study groups, which meet regularly all over Germany. In addition, he presented the extensive specialist lit- erature which has been distributed successfully by the DGZI for years. Among them are the “Glossary of Oral Implantology English/German” and the com- pendium “Topographical and Clinical Anatomy of Maxillofacial Surgery”. Finally, Dr Vollmer pointed out Fig. 1 Fig. 2 Fig. 3 Fig. 4 Fig. 5 Fig. 6 the DGZI “Practical Guide”, which gives advice for the daily routine in an implantological practice. In the end, the newly elected DGZI President Prof. Dr Heiner Weber introduced himself at the “President’s Minute” and formulated his ideas on his new tasks in the DGZI. He confirmed his wish to promote innova- tion and thanked the DGZI members of the board for the trust they have invested in. Prof. Dr Weber hopes that he can make “a humble contribution” to the DGZI’s internationalization. He stated that especially China and Russia will become more central to the DGZI’s efforts. In addition, Prof. Dr Weber wants to include students and dental assistants more strongly in education programmes offered by the DGZI. Con- cluding, he expressed his wish for good cooperation and success._ Fig. 1_Past President of the DGZI Prof. Dr Dr Frank Palm. Fig. 2_Prof. Dr Heiner Weber, President of the DGZI. Fig. 3_Dr Roland Hille, scientific director of the congress. Fig. 4_Dr Georg Bach. Fig. 5_Dr Rolf Vollmer, Dr Georg Bach, Prof. Dr Herbert Deppe and dental technician Christian Müller. Fig. 6_Prof. Dr Mazen Tamimi, Dr Rolf Vollmer and Dr Rainer Valentin. implants 4_ 2013 I 45

I meetings 22nd Annual Scientific Meeting of the EAO Source_Dental Tribune _Implants have come a long way since they were introduced to dentistry in the early 1950s. Future con- cepts and trends in the field were recently discussed by experts at the 22nd Annual Scientific Meeting of the Eu- ropean Association of Osseointegration (EAO) in Dublin, which took place from 17–19 October at the city’s new state-of-the-art Convention Centre. Held for the sec- ond time in the Irish capital after 1995, the event did not only focus on current issues in the field, like periimplan- titis and the challenges linked to the treatment of an in- creasing elderly population, but also reflected on new developments and methods in the field, such as com- puter-assisted implant rehabilitation and tissue regen- eration. Moreover, a number of sessions also focused on risk factors, treatment planning and different learning techniques. “There is a discrepancy between what a general den- tist is expected to know/perform in implant dentistry and what the current education in most schools is teaching, “ explained Dr Nikos Mattheos from the Uni- versity of Hong Kong’s Faculty of Dentistry, EAO presen- ter and co-organiser of an implant education workshop recently held in Hungary. “All dental schools have in- creased the amount of teaching in the area of implant dentistry in the past five years and in many cases pre- clinical and clinical education components have been introduced. However, it is clear that there is still room for improvement.” New products for treatment outcomes that are more predictable and an improved workflow in dental prac- tices and laboratories were also presented at an indus- try exhibition, which was supported by 87 corporate sponsors from around the world this year. Among oth- ers, MIS and Henry Schein showcased their latest tools for a complete digital workflow. In addition, Danish dig- ital dental solutions provider 3Shape had its recently launched TRIOS intra-oral scanning system on display. New and improved implant systems were presented by Implant Direct and a number of other companies. Strau- mann, for example, announced that its dental implant material Roxolid is now available for all diameters and all implant lines. In addition to the Royal College of Surgeons in Ire- land and the Oral Surgery Society of Ireland, the meet- ing received support from the Irish Society of Periodon- tology and the Prosthodontic Society of Ireland. Atten- dance figures for the congress were not available when this edition of implants went to print, but first predica- tions indicate that less dental professionals set off for Dublin that originally expected by the organiser. Last year’s anniversary gathering in Copenhagen saw more than 2,500 professionals participating. The associa- tion’s next Scientific Annual Meeting will take place in Rome in Italy next year. The event is scheduled to take place from 25–27 September. More details are expected to be announced by the EAO in the upcoming weeks._ 46 I implants 4_ 2013

meetings I Schütz Dental and DGZI host “Implantology and Anatomy” Fig. 1 Fig. 2 Fig. 3 Fig. 4 Fig. 5 Fig. 6 _From 11 to 12 October, Schütz Dental hosted a special implantological event in cooperation with the German Society for Implantology (DGZI). While students of dental medicine gathered infor- mation on theory and practice of the surgi- cal anatomy in the special seminar “Im- plantology and Anatomy”, an international expert group discussed implantological techniques in the DGZI Curriculum lead by Dr Mazen Tamimi. The clearly structured concept consisting of a theoretical introduc- tion, live demonstrations on human cadavers and practical exercises was designed exclusively for the field of anatomy and has become an integral part of the DGZI Curriculum Implantology in more than ten years. In two days, both students and experi- enced implantologists can benefit from this balanced mix of theory and practice by gaining extra confidence for their future work as sur- geons or implantologists. Students of the 9th semester took part in the trial course which took place at the anatomic dissection hall of the MTZ (Medical and Theoretical Center) of the Fig. 1_Anatomic dissection hall of the University of Dresden. Fig. 2_Students of the 9th semester took part in the trial course anatomy. Fig. 3_Prof. Dr Martina Vollmer and Prof. Dr Rolf Vollmer during their live preparation on Friday. Fig. 4_Prof. Dr Rainer Valentin (left) und Prof. Dr Mazen Tamimi. Fig. 5_Participants of the international DGZI Curriculum. Fig. 6_Prof. Dr Werner Götz. University of Dresden/Germany. The speakers Prof. Dr Martina and Prof. Dr Rolf Vollmer, Prof. Dr Rainer Valentin, Prof. Dr Werner Götz und PD Dr Wolfgang Schwab as well as Dr Uta Voigt and Prof. Dr Mazen Tamimi introduced the lat- est implantological techniques, especially the restoration of the edentulous maxilla, in the course of their theoretical presen- tations as well as live demonstrations and practical exercises on human ca- davers. At the same time, the speakers held the international DGZI Cur- riculum on topics such as sinus lift, bone spreading, bone extraction and trans- plantation as well as surgical implantation and CAD/CAM diagnostics. ] I I I H T S © I : E R U T C P [ Afterwards, the theoretical knowledge was extended by practical application in the anatomic dissection hall. On Saturday, the speakers continued to inform their speakers about sinus lift, piezo surgery, bone splitting, autologous bone harvesting and transfer as well as suture techniques. The event ended on Sunday by a final discussion and exams._ implants 4_ 2013 I 47

NEWS Straumann sets New standards with Roxolid SLActive Demographic data shows that populations around the world are becoming increasingly older, which leaves dental professionals with a high number of compromised patients and risk factors when it comes to dental implant treat- ment. Therefore, the demand for products that might reduce the need for invasive grafting pro- cedures is high. Straumann intends to meet the demand by broadening its Roxolid SLActive implant portfo- lio. At the EAO congress in Dublin, the global market leader in dental implantology introduced its unique dental implant material Roxolid for all diameters and all implant lines. Moreover, the company announced the launch of a new 4 mm short Roxolid SLActive implant line to be used in clinical cases with limited vertical space, as with severely atrophied jawbone. All Roxolid SLActive implants feature the new Loxim transfer piece to simplify the handling. The combination of the high mechanical strength of Roxolid with the ex- cellent osseo integration properties of the hy- drophilic SLActive surface may allow dental pro- fessionals to avoid GBR procedures by choosing smaller sized implants, Straumann said. Research has shown that the use of smaller di- ameters or shorter implant lengths can reduce the invasiveness of implant treatments and in- crease patient acceptance if invasive grafting procedures can be eliminated. Therefore, clini- cians can reduce the treatment time, preserve vital peri-implant structures, decrease post- surgical complications, and gain new implant patients by offering products that seek to elimi- nate guided bone regeneration procedures. In these cases, patients can beneﬁt from a less traumatic, less expensive and shorter treatment with a lifelong implant solution. All implants are covered by Straumann’s lifelong implant war- ranty. Breath tests may help Diagnose lung cancer quickly New research has suggested that samples of exhaled breath could be a cost-effective and cheap alternative for diagnosing lung cancer compared to conventional methods. In the most extensive study to date, the researchers were able to diagnose the majority of cases of lung cancer correctly using a special screening tech- nology. In the study, researchers at the University of Latvia collected breath samples from 252 lung cancer patients, 223 patients diagnosed with other lung diseases and healthy individuals, 265 non-smokers, and 210 smokers. Assessing the samples with an electronic nose, a technology that detects different proﬁles of volatile organic compounds (VOCs) in breath samples, 128 non- smokers and 114 smokers were correctly diag- nosed as having lung cancer. Overall, only ten people were misdiagnosed. Although the re- searchers have not yet clearly identiﬁed which VOCs are linked to different diseases, this study 48 I implants 4_ 2013 [PICTURE: ©SEBASTIAN KAULITZKI] suggests that this method can be used to differ- entiate between lung cancer, other lung dis- eases and healthy people. According to the Eu- ropean Lung Foundation, lung cancer is the leading cause of cancer mortality in Europe and worldwide. It accounts for an estimated 20 per cent of all cancer deaths. The ﬁndings were pre- sented at the European Respiratory Society’s annual congress that was held from 7 to 11 Sep- tember in Barcelona. Boston welcomes International VIP Meeting 2013 From 13 to 15 September, Boston/USA became the meet- ing point of renowned speakers from Germany, Italy and the USA. They all followed the exclusive invitation by Bicon Dental Implants to their International VIP Meeting 2013 at the Harvard Club of Boston. In addition to numerous implantological presen- tations and exceptional evening events, a visit to the Bicon headquarters was an essential part of the diversified pro- gramme. The event was hosted by Prof. Dr Mauro Marincola/Rome, Italy. His opening remark was that shortness does not always mean a disadvantage—a reference to the Bicon Short Implants, which have been ap- plied in the practice successfully for over 28 years and for which Bicon has become famous. SHORT® Implants were introduced to the market in 1985. Since then, they offer innovative solutions for implantolo- gists worldwide. The special plateau design makes the ap- plication of short implants possible. In contrast to other im- plant systems, the Bicon system shows restorative flexi- bility which is achieved by the 360° universal positioning of the abutments. In addition, the “sloping shoulder” re- sults in excellent aesthetics of the gingiva. Since the bone is supported by the implant shoulder, it can in turn support and thus preserve the interproximal papilla. Numerous international speakers gave recent insight into the world of implantology, among the Bicon president Vin- cent J. Morgan, DMD, USA, with his speech “Past, Present, and Future of Bicon”.

I about the publisher implants international magazine of oral implantology Executive Producer Gernot Meyer meyer@oemus-media.de Designer Sarah Fuhrmann s.fuhrmann@oemus-media.de Customer Service Marius Mezger m.mezger@oemus-media.de Published by OEMUS MEDIA AG Holbeinstraße 29 04229 Leipzig, Germany Tel.: +49 341 48474-0 Fax: +49 341 48474-290 kontakt@oemus-media.de Printed by Silber Druck oHG Am Waldstrauch 1 34266 Niestetal, Germany implants international magazine of oral implantology is published in cooperation with the German Association of Dental Implantology (DGZI). DGZI President Prof. Dr Heiner Weber DGZI Central Office Paulusstraße 1, 40237 Düsseldorf, Germany Tel.: +49 211 16970-77 Fax: +49 211 16970-66 office@dgzi-info.de Publisher Torsten R. Oemus oemus@oemus-media.de CEO Ingolf Döbbecke doebbecke@oemus-media.de Members of the Board Jürgen Isbaner isbaner@oemus-media.de Lutz V. Hiller hiller@oemus-media.de Chief Editorial Manager Dr Torsten Hartmann (V. i. S. d. P.) hartmann@dentalnet.de Editorial Council Prof. Dr Heiner Weber Dr Roland Hille dr-hille@t-online.de Prof. Dr Dr Kurt Vinzenz kurt.vinzenz@aon.at Dr Torsten Hartmann hartmann@dentalnet.de Dr Suheil Boutros SMBoutros@aol.com Editorial Office Georg Isbaner g.isbaner@oemus-media.de Claudia Jahn c.jahn@oemus-media.de Copyright Regulations www.dgzi.de www.oemus.com _implants international magazine of oral implantology is published by Oemus Media AG and will appear in 2013 with one issue every quarter. The magazine and all articles and illustrations therein are protected by copyright. Any utilization without the prior consent of editor and publisher is inad- mi ssible and liable to prosecution. This applies in particular to duplicate copies, translations, microfilms, and storage and processing in electronic systems. Reproductions, including extracts, may only be made with the permission of the publisher. Given no statement to the contrary, any submissions to the editorial department are understood to be in agreement with a full or partial publishing of said submission. The editorial department reserves the right to check all submitted articles for formal errors and factual authority, and to make amendments if necessary. No responsibility shall be taken for unsolicited books and manuscripts. Articles bearing symbols other than that of the editorial department, or which are distinguished by the name of the author, represent the opinion of the afore-mentioned, and do not have to comply with the views of Oemus Media AG. Responsibility for such articles shall be borne by the author. Responsibility for advertisements and other specially labeled items shall not be borne by the editorial department. Likewise, no responsibility shall be assumed for information published about associations, companies and commercial markets. All cases of consequential liability arising from inaccurate or faulty representation are excluded. General terms and conditions apply, legal venue is Leipzig, Germany. 50 I implants 4_ 2013

Titel

Editorial

Content

CAMLOG Biotechnologies AG 1

Retromolar bone grafts prior to implant placement - Outcomes and complications (Part II)

Nobel Biocare Deutschland GmbH

A new technique for the preparation of the implant site - Through Piezoelectric Surgery (PES)

Straumann AG

Implant Direct Europe AG

Ridge augmentation for an atrophied posterior mandible - NanoBone block versus allograft bone block (Part III)

Vertical bone augmentation procedures (Part I)

Dentaurum GmbH & Co. KG

A revision of an unaesthetic reconstruction

Extensive implant-supported restoration in generalised aggressive periodontitis

Immediate implant placement with the NNC implant

Manufacturer News

Practice-oriented implantology at the DGZI Annual Congress

22nd Annual Scientific Meeting of the EAO

Schütz Dental and DGZI host “Implantology and Anatomy”

News

Thanks

Imprint

Mitgliedsantrag: DGZI - Deutsche Gesellschaft für Zahnärztliche Implantologie e.V.

Planmeca Vertriebs GmbH