An interview with Dr. Sergio Piano, Italy. The “Straumann® Pro Arch” concept is an efficient and simple method to treat the edentulous patient with immediate loading providing a rehabilitation that not only produces high quality esthetic results but also proves cost-effective. This concept, supported by scientific literature, strongly focuses on the pre-operative planning allowing for a less invasive approach and a reduced number of implants. The pre-visualization of the final result, already available from the outset of the procedure, leads to an optimization of the implant placement and an improvement in the final esthetic appearance. Dr Piano, you are a very well reputed Straumann® Pro Arch fan and before Straumann’s edentulous treatment concept was globally rolled-out, you have developed the “Wonderbridge Protocol” for edentulous patients. We would like to know more about your expertise and this protocol. How did it originate? How did you treat edentulous patients before this protocol and what is different with this approach? Up to some ten years ago, the treatment used for edentulous patients was based on an elevated number of implants placed in the available bone followed by performing an immediate loading procedure. In the cases where the bone was lacking, it was necessary to carry out a bone augmentation and to load the implants once integrated. Obviously, this meant that a removable provisional prosthesis was needed. For these reasons, after a few years, I realized that, in many cases, this traditional approach was far too complex, lengthy and also costly and, although Dr. Malo had set a new standard for the treatment of edentulous patients, the simplified approaches available to us at the time more than often led to what I felt was not such a satisfactory esthetic result. Therefore, reflecting on this dilemma, I came up with the idea of creating a protocol whereby a reduced number of implants was placed, not only in line with the available bone but also on the basis of an ideal prosthetic planning. In this way, I succeeded in achieving a most satisfying final esthetic result whilst, at the same time, following the simplicity of the original treatment. Moreover, it also maintained a considerable reduction in the cost of the procedure, thus being more attractive to the patient. In defining the “Wonderbridge Protocol”, I would say that it is along the lines of an immediate loading technique on a limited number of implants but inspired by a different philosophy. That was the solution set before the Straumann® Pro Arch became fully available on a global scale. What are the key points of this protocol compared to other solutions currently available on the market? In addition to the advantages already mentioned, in my opinion, there are a couple of important aspects to be considered. The approach can be considered less invasive and radical in comparison to standard simplified approaches. In fact, with the latter type approaches, there is a fixed geometric positioning of the implants together with a pre-determined dramatic reduction of the alveolar bone in the frontal area. This leads to a pre-defined standard clinical situation that doesn’t actually allow for a completely personalized prosthetic solution whereas with Straumann® Pro Arch approach and the Wonderbridge protocol you have the option to replace the “geometric” approach by an “anatomical” one. What this means is that there is neither a dramatic reduction of bone nor a pre-determined angulation of the implants thanks to their positioning being in line with the anatomy of the jaw. This makes the procedure less invasive compared to complex treatments using bone grafting/augmentation, easier to be done by the dentists and, importantly for the patient, results in a more natural final appearance. Moreover, the most remarkable key point is that, thanks to carrying out the prosthetic planning stage at the outset, the dentist is able to have a pre-visualization of the final result prior to starting the surgical procedure. This set-up can then be shown to the patient so as to obtain their personal opinion in line with their expectations. In this way, from the very beginning of the procedure, the patient is already reassured of the final result. “With Straumann® Pro Arch and the Wonderbridge protocol you have the option to replace the “geometric” approach by an “anatomical” one. What this means is that there is neither a dramatic reduction of bone nor a pre-determined angulation of the implants thanks to their positioning being in line with the anatomy of the jaw. This makes the procedure less invasive, easier to be done by the dentists and, importantly for the patient, results in a more natural final appearance.” When and why would you recommend this protocol? It is a solution that is considered more than valid in cases where the patient has a reduced amount of bone in the posterior area due to the presence of anatomical obstacles and where a low invasive solution is of major importance. Furthermore, this protocol, in offering such an efficient and rapid solution, is strongly favoured for patients, who previously in expecting to have to undergo a long and lengthy procedure, could have easily been discouraged from embarking on the treatment in the first place. Such cases could include patients with hopeless teeth or those with fully-edentulous jaws. In the COIR article* we have seen documented cases in 2008. How long have you actually been applying this protocol to your patients? And in what way, if any, has it changed? I started in 2007, initially with just a couple of patients, using a basic technique that has, over the years, been perfected. Then, in 2008, a protocol was established which took into consideration the need of an affordable procedure whilst also achieving an esthetically-pleasing result. In fact, the 21 maxillary cases documented in the COIR study were treated with this approach – using a laser-welded framework and resin veneering – and led to extremely positive results: that is, neither issues with the implants nor with fractures or problems with the prostheses were noted. As a consequence, in order to reach a maximum level of quality for the protocol, over the years both the framework and the veneering material have been improved and new innovative approaches like CAD/CAM workflow, guided surgery, and others have been integrated, thus offering, not only an economically viable solution, but also a state-of-the-art prosthetic result. “We can say that, today, Straumann has created a comprehensive and complete range of products that fully support our various solutions for the treatment of edentulous patients.” Are the type of components used considered important in supporting this protocol? It is, in fact, thanks to the components available today that we are able to provide these high level results to our patients. When I initially started to carry out the Wonderbridge procedure, it was specifically with Straumann® Bone Level implants and the Straumann® MultiBase abutment portfolio. It was found that these parts performed really well, even though in certain specific clinical situations, for instance in very low bone density or extreme implant inclination, it was, at times, possible to meet with some difficulties. However, today, this protocol is successfully based on the Straumann® Pro Arch solution and its main components, Straumann® Bone Level Tapered implants and the screw-retained abutment portfolio, and these components truly represent a notable improvement in the challenging treatment of edentulous patients. Principally, the introduction of the Straumann® Screw-Retained Abutment portfolio has enabled us to work with a wide range of components that can meet all the treatment criteria, allowing the dentist to find the ideal combination for each individual prosthetic re-alignment, without having to make compromises. This product family also includes components that facilitate the differentiation of prosthesis type used, in terms of material, technique and shape. In fact, gluing connectors (Straumann® Variobase copings) give a further option for the fabrication of the prosthesis, making the use of this system very flexible, also in the lab. Furthermore, we now also have at our disposal high quality additional alternatives for the final prosthesis, such as the customized framework produced in the Straumann® Milling Center, based in Germany, or the production of frameworks from one of Straumann’s partners, namely Createch Medical, a high-precision manufacturer of customized framework and prosthetic components based in Spain. In addition, the Straumann® Bone Level Tapered implant, launched a few years ago, has allowed us to gain increased implant stability for immediate loading when dealing with poor bone conditions. In fact, in my own practice in Genoa on a daily basis, BLT implants replace BL ones, each time a Straumann® Pro Arch procedure is performed. We can, therefore, say that today Straumann has created a comprehensive and complete range of products that fully support our various solutions for the treatment of edentulous patients. “Nowadays, the patient’s request for an implant-supported fixed prosthesis that combines an esthetically-pleasing result with an affordable cost is very high and consequently, dentists are having to turn to alternative and viable solutions, like Straumann® Pro Arch.” To what extent do you think this kind of solution is needed today? Nowadays, the patient’s request for an implant-supported fixed prosthesis that combines an esthetically-pleasing result with an affordable cost is very high and consequently, dentists are having to turn to alternative and viable solutions, like the Straumann® Pro Arch. For this reason, over the past two years, there has been a great demand for getting better informed about, and adopting this protocol to the point that a large number of courses have been set up in several countries to meet this need. To give you a rough idea of the interest toward this approach, over just the past 4 years, I have held more than 20 one-to-two-day courses as well as several lectures, talking to nearly 1000 colleagues and participants in countries ranging from the Balkan region, Arabia and Eastern Europe. In just Italy alone, we have held a dozen events for more than 500 participants. Personally speaking, I believe that in the everyday dental practice, a solution like the Straumann® Pro Arch should not be overlooked as it can be considered a most viable and invaluable solution for the Dentist whilst also successfully meeting the patient’s expectations, both in terms of affordability and esthetics. * Clin Oral Implants Res. 2015 Mar 24. doi: 10.1111/clr.12580) Sergio Piano, DDS Italy Private practitioner in Genoa, Italy. Graduated DDS cum laude at the University of Genoa in 1988. Visiting Assistant in 1991 – 1992 at the University of Geneva, Departments of Fixed Prosthodontics (Prof. Belser), Periodontology (Prof. Cimasoni) and Oral Surgery (Prof. Fiore-Donno, Dr. Bernard). Active Member of SIO (Italian Society of Osseo-integration) and IAED (Italian Academy of Esthetic Dentistry). Fellow of the ITI (International Team for Implantology). Regular national and international lecturer on surgical and prosthetic topics in Implant Dentistry. email@example.com The post Sergio Piano: “With the Straumann® Pro Arch protocol, the patient is already reassured of the final result from the very beginning of the procedure” appeared first on STARGET COM.
A 65-year old woman presented at our clinic for implant and prosthetic restoration of upper left (#27) and lower left molars (#36, #37) (Fig. 1). The patient’s medical history revealed no contraindications to dental implant therapy and restorative treatment. According to the patient, her lower left molars had been extracted more than 30 years ago. For tooth #27 the patient reported discomfort due to contact with the opposing edentulous crest, sensitivity during mastication and mobility of the tooth. PICTURE DOCUMENTATION Fig. 1 finelle01 Fig. 2 finelle02 Fig. 3 finelle03 Fig. 4 finelle04 Fig. 5 finelle05 Fig. 6 finelle06 Fig. 7 finelle07 Fig. 8 finelle08 Fig. 9 finelle09 Fig. 10 finelle10 Fig. 11 finelle11 Fig. 12 finelle12 Fig. 13 finelle13 Fig. 14 finelle14 Fig. 15 finelle15 Fig. 16 finelle16 Fig. 17 finelle17 Fig. 18 finelle18 Fig. 19 finelle19 Fig. 20 finelle20 Fig. 21 finelle21 TREATMENT PLANNING Tooth #27 was diagnosed as non-conservable due to localized periodontal disease associated with furcation involvement (degree 2, mobility 2) and a probing depth of more than 10 mm in the distolingual areas (Fig. 2). The tooth was vital but sensitive to percussion. Moreover, the soft tissue position was intact. No signs of acute infection were noted at the time of clinical examination. Based on radiographic examination (Cone Beam Computerized Tomography), the class A septum configuration (Smith & al. 2013) and apical bone volume were favorable and compatible with: 1. predictable sufficient insertion torque 2. adequate 3-dimensional prosthetic position. Immediate implant placement after extraction of #27 was planned (Atieh & al. 2010) in order to reduce length of treatment and number of surgeries in comparison with the delayed approach. The implant selected for this procedure was a Straumann® Tissue Level Implant 4.8 × 12 mm, Wide Neck. SURGICAL PROCEDURE A major challenge encountered while undertaking immediate implantation in the molar area is the complexity of obtaining primary wound closure and coverage of the extraction site. Accordingly, this proposed protocol involves the chairside fabrication of a CADCAM abutment to seal the alveolar socket (SSA: Sealing Socket Abutment) immediately at the time of extraction-implantation (Finelle & al. 2016). Atraumatic flapless tooth extraction was performed by odontosection (Figs. 3,4) and separation of the supracrestal gingival fibers with periotomes. After extraction, the alveolar socket was liberally irrigated with sterile saline solution and cleaned with curettes to remove granulation tissue. A Straumann® Standard Plus Implant 4.8×12 WN was placed according to the instructions for use. The implant bed was prepared in the middle of the septum as virtually planned at the diagnostic stage (Fig. 5). The insertion torque was recorded during the placement and reached 30N/cm. Xenograft bone substitute (botiss cerabone®, granules 0.5-1mm, 1×0.5cc, Botiss) was packed to fill the alveolar socket surrounding the implant (Fig. 6). (Chu et al. 2012). To obtain closure of the socket at the time of extraction, an innovative protocol has been established to allow digital impression and immediate customized CADCAM abutment at the time of the surgery. A scan body (Cerec, Sirona) was connected to the platform of the implant to allow the intra-oral scanner (Omnicam, Sirona) to capture virtually the 3D position of the implant (Fig. 7). Immediately after acquisition, the SSA was designed on the prosthetic software (Fig. 8). The design process consists of: 1. Reproducing the outline of the previous freshly extracted molar in order to create a mechanical seal between the oral cavity and surgical site. The transmucosal portion is designed with a concave shape in order to accommodate for proper biological space (Finelle 2011, COIR). 2. Creating an ideal emergence profile to guide soft healing and positioning during the maturation process (Dual Zone concept Tarnow, Chu). The digital file was then exported to an in-office milling system (MCXL, Sirona) for fabrication of the SSA abutment (telio CAD 16, Ivoclar) in a chairside manner (Fig. 9). During the milling (15 minutes), sterile gauze was placed on the surgical site and post-operative recommendations were given to the patient. After milling, adhesive cement (Multilink abutment, Ivoclar) was used to assemble the SSA device onto the Variobase abutment for Cerec (Variobase C WN, Straumann) (Fig. 10). Finally, the SSA was inserted into the implant (with manual insertion torque) to support the surrounding soft tissues and provide a seal to the bone substitute material without the use of a biological membrane (Fig. 11) (Chu & al. 2012). Immediately after the surgery, post-operative periapical radiographs were taken to verify the proper position of the implant (Fig. 11). At the one week follow-up, the patient reported an uneventful post-operative recovery. The clinical examination at one week showed favorable soft tissue healing with minor inflammation (Fig. 12). After 12 weeks of osseointegration, soft tissue around the SSA abutment was healthy, and the buccal contour was maintained (Fig. 13). Removal of the abutment at the time of impression-taking showed a healthy and anatomical prosthetic emergence profile and a well-designed transmucosal portion (Fig. 14). A digital impression (Omnicam, Cerec, Sirona) using Scanbody for Cerec was taken for implant-supported restoration (Fig. 15). Finally, an implant screw-retained crown was designed (Fig. 16) on the Cerec Software (Cerec 4.4) and milled out of a monolithic lithium disilicate block (Emax CAD, Ivoclar) (Kapos & al. 2014). Before sintering, a blue CAD crown was tried in to validate the shape, contact point and occlusion (Figs. 16). The emergence of the implant screw axis allowed for a screw-retained prosthesis as originally planned (Fig. 17). The crown was stained and the occlusal grooves were readjusted to improve occlusal anatomy. The implant crown was bonded to a titanium base abutment adapted for the Cerec implant block (Variobase C, Straumann) with a resin cement (Multilink Hybrid Abutment, Ivoclar). At the time of final crown delivery (Fig. 18), we noticed the adequate emergence profile of the peri-implant soft tissues precisely fitting with the transmucosal anatomy of the ceramic crown. Final insertion torque (35N/cm) was applied, and the access hole was covered with restorative composite (Gænial A2, GC) (Fig. 19). A post-operative periapical radiograph was taken to verify the seating and marginal integrity after insertion (Fig. 19). While #27 was undergoing restoration, #36 and #37 were treated by surgical and restorative procedures, and two screw-retained single crowns were inserted (Fig. 20) in order to restore adequate prosthetic space (Fig. 21). FINAL RESULT At the 6 month follow-up, the clinical situation was stable. No biological or technical complications were reported. Clinical assessment showed a stable soft tissue position and volume (buccal contour and papilla). This case report demonstrates the clinical benefits in terms of the surgical and prosthetic aspects of the molar treatment after extraction: 1. Surgically, the CADCAM device behaves as a mechanical barrier that ensures stabilization of the blood clot in a confined alveolar socket space favorable for the regeneration process. The SSA aims to “seal” the socket without the use of invasive techniques such as flaps, incisions and sutures. As there is no attempt at a primary closure procedure, the mucogingival junction is not displaced and the papilla architecture is maintained in its original anatomical position. Consequently, post-operative discomfort is expected to be very low. 2. From a prosthetic standpoint, the transmucosal portion of the SSA is shaped as described: a. Submergence profile (closer to the implant) with a narrow portion to accommodate for biological space and proper soft tissue healing (Finelle & al. 2015). B. Emergence profile (closer to the cervical margin) matching the anatomy of the previous existing natural crown (Chu & al. 2012). CONCLUSION This case report describes an innovative approach based on a chairside fabrication of a suitable intra-operatively milled CADCAM healing device after immediate implant placement. As more and more clinics and dental offices are equipped with chairside milling machines, the protocols detailed in this article aim to offer a simplified workflow for single molar implant treatment (from extraction until final crown delivery) by reducing the length of treatment and the number of surgeries and clinical steps (and the morbidity). References Smith RB1, Tarnow DP. Classification of molar extraction sites for immediate dental implant placement: technical note. Int J Oral Maxillofac Implants. 2013 May-Jun;28(3):911-6. doi: 10.11607/jomi.2627. Finelle G, Papadimitriou DE, Souza AB, Katebi N, Gallucci GO, Araújo MG. Peri-implant soft tissue and marginal bone adaptation on implant with non-matching healing abutments: micro-CT analysis. Clin Oral Implants Res. 2015 Apr;26(4):e42-6 Atieh MA, Payne AG, Duncan WJ, de Silva RK, Cullinan MP. Immediate placement or immediate restoration/loading of single implants for molar tooth replacement: a systematic review and meta-analysis. Int J Oral Maxillofac Implants. 2010;25:401–15 Chu SJ, Salama MA, Salama H, Garber DA, Saito H, Sarnachiaro GO, Tarnow DP. The dual-zone therapeutic concept of managing immediate implant placement and provisional restoration in anterior extraction sockets. Compend Contin Educ Dent. 2012 Jul-Aug;33(7):524-32, 534 Finelle G, Papadimitriou DE, Souza AB, Katebi N, Gallucci GO, Araújo MG. Peri-implant soft tissue and marginal bone adaptation on implant with non-matching healing abutments: micro-CT analysis. Clin Oral Implants Res. 2015 Apr;26(4):e42-6 Finelle G, Popelut A Immediate implantation after extraction: focus on the use of CAD-CAM Sealing Socket Abutment (SSA) – JPIO -2016 (Accepted for Publication, French) Kapos T, Evans C. CAD/CAM technology for implant abutments, crowns, and superstructures. Int J Oral Maxillofac Implants. 2014;29 Suppl:117–36 Smith RB1, Tarnow DP. Classification of molar extraction sites for immediate dental implant placement: technical note. Int J Oral Maxillofac Implants. 2013 May-Jun;28(3):911-6. Gary Finelle DDS Dr Finelle graduated from Dental School in Paris (University Paris 7) in 2009. To complete his DDS degree, he defended his thesis about peri-implant soft tissue wound healing around dental implants. After two years of general dental practice in France, he joined the Advanced Implant Program at Harvard School of Dental Medicine, from which he graduated in May 2013. Throughout his program, he has been trained with the latest technology available during his clinical activity, as well as for research purpose. He is involved in researches and has published articles in international scientific journals related to digital impressions, computer guided implant surgery, and implant rehabilitations. The special research interests are the development/application of Digital Dental Technology from treatment planning, implant placement to restoration. The post Gary Finelle: Sealing Socket Abutment technique (SSA) – immediate implant placement in molar site (Straumann® Tissue Level Implant, botiss cerabone®, Variobase®) appeared first on STARGET COM.
Correcting a qualitative or quantitative reduction in the bone bed before implantation can greatly improve the implant outcome. In addition to the gold standard of autologous bone grafting, the bone substitute materials currently available for this purpose can be subdivided into allogenic, xenogenic and alloplastic materials. Developments in the field of synthetic BSMs are constantly changing, and the selection of appropriate materials depends on the indication, availability and the individual treatment plan. The common goal of these BSMs is to achieve stable, long-term anchorage of the implants in the bone. A knowledge of the advantages and limitations of their principal properties in respect of osteoconduction, osteoinduction and osteogenesis, and the adequate selection, based on this knowledge, can ensure high-quality, evidence-based treatment. Introduction As well as the need for physical and mechanical integrity and stability in terms of adequate moldability during application, early load-bearing and ideal porosity, the focus of current research efforts is on the development of optimal biomolecular parameters in the area of osteogenesis (bone formation in the graft by osteoblasts), osteoconduction (creation of a scaffold for vascularization of the adjacent bone) and osteoinduction (differentiation of multipotent mesenchymal cells into osteoblasts, by proteins bound in the graft). In an ideal scenario, these parameters interact to achieve successful osteointegration of the BSM during the course of healing. In this case, the direct bonding of the bone substitute material to adjacent healthy bone without the formation of a separating layer of connective tissue can create the best possible basis for successful long-term implant provision. The implant-related indications determined by the dentist for the use of bone substitute materials predominantly involve horizontal and vertical bone defects of the alveolar ridge. Autogenous bone substitute materials Autogenous bone is considered to be the gold standard for hard tissue augmentation techniques. Apart from the physiological interaction between the aforementioned physical and mechanical parameters and outstanding performance in terms of osteoinduction, osteoconduction and osteogenesis, the use of autologous bone avoids complications such as contrary cellular and humoral immune reactions and transmission of diseases. However, the use of these grafts is associated with certain limitations: These include the need for a second intervention site with additional risks such as inflammation, pain or sensory disorders at the site of harvesting. Depending on the harvesting site (retromolar, mandibular symphysis, iliac crest), specific advantages and disadvantages in respect of the differing biological significance and the possible reconstruction volume will need to be taken into account [1, 2]. Although autogenous bone is still considered to be the gold standard for long-term implant success, studies involving specific indications, such as lateral augmentation or the sinus lift, have shown that the use of bone substitute materials can achieve equivalent results. Moreover, the procedure of autogenous bone harvesting can significantly prolong operation time and the hospitalization rate in cases of bone harvesting of the iliac crest [3, 4]. Allogenic bone substitute materials In order to counter the donor morbidity associated with the use of autogenous grafts, the use of allogenic grafts can be considered. Allogenic describes the transfer of the graft between genetically dissimilar individuals. Since the grafts count as medicinal products authorized e.g. by the Paul Ehrlich Institute in Germany or local accredited tissue banks, their use is guaranteed to be safe both for the therapist and patient. However, the risk of infection resulting from the transfer of biological tissue from human to human, as well as the risks of fractures or pseudarthroses associated with an allogenic graft, cannot be ruled out completely . Through stringend donor screening and recovery protocols, as well as a highly controlled processing environment, the risks of disease transmission are countered at every step. To date there are no known cases of transmission triggered by processed, freeze-dried bone preparations in dental applications. Two distinct approaches can basically be adopted for processing allogenic BSMs: The material is freed from a given mineralized bone substance by decalcification in order to optimize the osteoinduction potential of the remaining growth factors in the collagen. This approach of demineralized bone matrix (DBM, also known as demineralized freeze-dried bone allograft, DFDBA), can be contrasted with the processing of the mineralized components of the donor tissue (mineralized freeze-dried bone allograft, FDBA). In this approach the tissue is freed of potentially infectious or immunologically active constituents. This leaves the natural bone structure with the trabecular matrix, with preservation of both the organic phase (collagen) and the mineral phase. (Click on the image for a larger resolution) Cancellous Allograft Particles used as dental bone substitute. Cortical AlloGraft Particles used as dental bone substitute. Since the physical and mechanical properties are equivalent to those of autogenous graft, allogenic BSM is considered to be comparable with autologous bone in respect of its osteoconductivity potential. One bone substitute material of human origin that is available in many European countries is the product maxgraft® from botiss biomaterials GmbH. This processed allogenic bone substitute is available in different standardized forms of granules, blocks, rings etc., or alternatively as an individually milled and shaped block graft, and can therefore be used for various indications. In case of large defects, a block-like matrix can be prepared from processed human donor bone, thus avoiding invasive harvesting of bone from the iliac crest or cranial areas. After organ donor selection and donor testing for infectious agents like HIV, HBV and HCV, the BSM undergoes chemical cleaning, preparation and sterilization. A solution tailored to the individual defect involves the use of a patient-specific bone block that is planned on the basis of imaging and then milled (maxgraft® bonebuilder, botiss biomaterials GmbH). As an individual allogenic graft solution, individual implants customized for the patient can be created by means of CBCT scanning in the CAD/CAM technique. These are constructed by botiss and then produced by the “Cells and Tissuebank Austria (CTBA)”. As a prefabricated ring structure (maxgraft® bonering), the allogenic graft supplied by the company botiss allows the bone augmentation and implantation to take place at the same time, avoiding the need for a second procedure. These grafts can be used in sinus floor augmentations or horizontal and vertical bone defects with simultaneous implant provision. The latest literature findings show results comparable with the use of demineralized allogenic BSM in sinus floor augmentations. The results of evidence-based studies also support the use of this type of BSM for alveolar ridge augmentations, intrabony defects and implant provision [6-9]. Xenogenic bone substitute materials In contrast with an allogenic BSM, xenogenic tissue is of animal or plant origin. In this context, BSMs of bovine origin are by far the most widely used materials. As with allogenic bone substitute materials, the matrix component is left in place during the processing of xenogenic grafts in order to control osteoconduction. The trabecular framework remains after thermal processing. Here, the osteoconductivity of the tissue as a scaffold for vessel formation and subsequent ingrowth of osteoblasts in the graft are particularly advantageous. As a result, biomolecular effective components are deactivated, leaving a matrix of hydroxyapatite ceramic. The lack of pathogen transmission due to this deactivation process is particularly beneficial. Additionaly, the immunological action can be considered to be low. Most of the commercially available products are designed to create a trabecular matrix for the formation of new bone. One example is cerabone® (botiss biomaterials GmbH), a material processed from bovine bone. Bone substitute materials obtained from equine bone or marine algae are also available. By far the most scientific evidence is available for the group of bovine xenogenic BSMs. Bovine bone material possesses physical and mechanical properties that are similar to those of human bone, thus comparable results can be achieved in terms of osteoconduction and vascularization. (Click on the image for a larger resolution) botiss® cerabone®: bovine dental bone substitute; surface structure of a single particle in high magnification botiss® cerabone®: bovine dental bone substitute; surface structure of a single particle in high magnification Product presentation botiss® cerabone® Cerabone® is prepared by a unique high-temperature process that reliably removes potential infectious agents while at the same time preserving the natural cancellous bone structure. Due to the remaining trabecular support structure a maintenance of the original bone substitute volume can be achieved. [10, 11]. The advantages of cerabone® include its high purity and volume maintenance, an interconnecting pore structure and minimization of the infection risk by its processing . A feature common to all BSMs of bovine origin is the comparatively low remodeling potential during healing. As a result, the bone substitute material remains in situ as a slowly-resorbable osteoconductive scaffold. Alloplastic bone substitute materials Alloplastic bone substitute consists of synthetically produced materials. By imitating the trabecular bone matrix of human bone, the synthetic material possesses similar osteoconductive and osteointegrative capabilities. Depending on the starting material, the alloplastic materials can be subdivided as follows: ceramics (tricalcium phosphate, hydroxyapatite, bioglasses, glass ionomers), polymers (polymethyl methacrylate, polylactides/polyglycolides and other copolymers), cements (calcium phosphate cements) and metals (titanium). Durability and resorbability are particularly important when selecting these materials. Ceramics Alloplastic hydroxyapatite ceramics [Ca10(PO4)6(OH)2] are the most common representatives of this group. The sintering of calcium phosphates (hydroxyapatit (HA), alpha-tricalcium phosphate (α-TCP) and beta-tricalcium phosphate (β-TCP)) produces a biocompatible, non-immunogenic and a slowly-resorbable matrix with osteoconductive and osteointegrative properties [13-16]. Since hydroxyapatite in crystalline form provides the basis for the hard substance of human bone, making up around 40 % of its content, ceramics of this type are likely candidates for use in bone replacement. Innovative sintering techniques can create the conditions that are favorable for osseointegration and biodegradation. Here, pore diameters of 150–600 μm are considered to be ideal for these purposes . (Click on the image for a larger resolution) botiss® maxresorb®: synthetic dental bone substitute; surface structure of a single particle in high magnification. Product presentation botiss® maxresorb®. A fully synthetic commercially available representative of this group is maxresorb® (botiss biomaterials GmbH). Consisting of 60% hydroxyapatite (HA) and 40% beta-tricalcium phosphate (ß-TCP), maxresorb® possesses a uniform interconnecting pore structure thanks to the standardized manufacturing process. With pore sizes ranging from 200 to 800 μm and an overall porosity of ~80%, it provides a suitable scaffold for vascularization and cell migration . Indications for the dentist in practice Returning to the initially mentioned indications for the use of bone substitute materials in implantology, the following recommendations can be made on the basis of the latest guideline on “Implantology-related indications for the use of bone substitute materials”: Dehiscence defect (intrabony defect): In most cases, the use of BSMs resulted in complete defect regeneration. Horizontal/vertical defects: The use of BSMs produced horizontal (3.6–5.6 mm) and vertical (2.0–5.6 mm) dimensional gains after 6 months with values of less than 5 % for augmentation and implant losses. Xenogenic BSMs were superior to allogenic grafts in respect of the newly-formed bone. Sinus floor elevation: Xenogenic BSMs (95.6 %) and allogenic BSMs (93.3 %) were superior to alloplastic materials (81 %). External sinus floor elevation: The use of BSMs resulted in a cumulative implant survival rate of almost 97 %. Autologous bone is inferior to particulate grafts. Internal sinus floor elevation: The use of BSMs resulted in implant survival rates of 94.8-100 %. No general recommendation was issued for the use of BSMs in this context. It can therefore be assumed that the use of alloplastic bone substitute materials can achieve very good results particularly in the management of alveolar dehiscence defects (up to a height of 8mm) and also in sinus floor elevations. Augmentations with purely allogenic grafts in the whole vertical-horizontal situation and for fairly large defects should be handled more critically. Current recommendations point to the benefits of additive supplementation with allogenic BSMs in procedures with autologous bone substitute materials. Extensive defects should generally be reconstructed with large-pore BSMs, ideally with pore diameters in the range of 150 to 600 μm, in order to facilitate better neovascularization, cell permeation and osteoconduction. Summary Depending on the individual indication, the dentist can currently choose from a wide range of evidence-based bone substitute materials. Both natural and allogenic BSMs can basically be used, either on their own or in addition to endogenous bone, for the reconstruction of jaw defects. To this end, the advantages and disadvantages and possible contraindications of the respective material groups will need to be assessed and used on a case-by-case basis. Before planning the treatment, the dentist must conduct an individual, patient-oriented evaluation of the osteogenic efficiency and relative risks for the patient arising from the use of allogenic or xenogenic bone substitute materials. Given the complexity and diversity of the subject of “bone substitute materials”, careful and comprehensive briefing of the patient is extremely important before any augmentation measure, regardless of the material that is ultimately used. Relative and, where applicable, absolute contraindications to the use of alloplastic materials are an immunocompromised patient (immune deficiency, interleukin-1 polymorphisms), generally poor oral hygiene (dental status not worth preserving, severe chronic periodontitis), treatment with drugs that inhibit bone resorption (bisphosphonates) and previous oral-maxillofacial radiotherapy. Finally, it should be stressed that the correct technique is of crucial importance when using the respective bone substitute material. Apart from the choice of suitable bone substitute material, key factors for long-term success of the implant are the membrane application, the appropriate incisions and the soft tissue management. References Z. Sheikh, S. Najeeb, Z. Khurshid, V. Verma, H. Rashid, and M. Glogauer, “Biodegradable Materials for Bone Repair and Tissue Engineering Applications,” Materials 8(9), 5273 (2015). D. E. Tolman, “Reconstructive procedures with endosseous implants in grafted bone: a review of the literature,” Int J Oral Maxillofac Implants 10(3), 275-294 (1995). E. Nkenke and F. Stelzle, “Clinical outcomes of sinus floor augmentation for implant placement using autogenous bone or bone substitutes: a systematic review,” Clin Oral Implants Res 20 Suppl 4(124-133 (2009). M. Peleg, A. K. Garg, C. M. Misch, and Z. Mazor, “Maxillary sinus and ridge augmentations using a surface-derived autogenous bone graft,” J Oral Maxillofac Surg 62(12), 1535-1544 (2004). K. U. Gomes, J. L. Carlini, C. Biron, A. Rapoport, and R. A. Dedivitis, “Use of allogeneic bone graft in maxillary reconstruction for installation of dental implants,” J Oral Maxillofac Surg 66(11), 2335-2338 (2008). G. Chaushu, O. Mardinger, S. Calderon, O. Moses, and J. Nissan, “The use of cancellous block allograft for sinus floor augmentation with simultaneous implant placement in the posterior atrophic maxilla,” J Periodontol 80(3), 422-428 (2009). G. Chaushu, M. Vered, O. Mardinger, and J. Nissan, “Histomorphometric analysis after maxillary sinus floor augmentation using cancellous bone-block allograft,” J Periodontol 81(8), 1147-1152 (2010). A. Acocella, R. Bertolai, E. Ellis, 3rd, J. Nissan, and R. Sacco, “Maxillary alveolar ridge reconstruction with monocortical fresh-frozen bone blocks: a clinical, histological and histomorphometric study,” J Craniomaxillofac Surg 40(6), 525-533 (2012). R. A. Wood and B. L. Mealey, “Histologic comparison of healing after tooth extraction with ridge preservation using mineralized versus demineralized freeze-dried bone allograft,” J Periodontol 83(3), 329-336 (2012). F. Riachi, N. Naaman, C. Tabarani, N. Aboelsaad, M. N. Aboushelib, A. Berberi, and Z. Salameh, “Influence of material properties on rate of resorption of two bone graft materials after sinus lift using radiographic assessment,” Int J Dent 2012(737262 (2012). D. Panagiotou, E. Ozkan Karaca, S. Dirikan Ipci, G. Cakar, V. Olgac, and S. Yilmaz, “Comparison of two different xenografts in bilateral sinus augmentation: radiographic and histologic findings,” Quintessence Int 46(7), 611-619 (2015). D. Tadic and M. Epple, “A thorough physicochemical characterisation of 14 calcium phosphate-based bone substitution materials in comparison to natural bone,” Biomaterials 25(6), 987-994 (2004). M. Bohner, “Calcium orthophosphates in medicine: from ceramics to calcium phosphate cements,” Injury 31 Suppl 4(37-47 (2000). H. Schliephake, N. Zghoul, V. Jager, M. van Griensven, J. Zeichen, M. Gelinsky, and T. Wulfing, “Effect of seeding technique and scaffold material on bone formation in tissue-engineered constructs,” J Biomed Mater Res A 90(2), 429-437 (2009). S. Takagi, L. C. Chow, M. Markovic, C. D. Friedman, and P. D. Costantino, “Morphological and phase characterizations of retrieved calcium phosphate cement implants,” J Biomed Mater Res 58(1), 36-41 (2001). R. Smeets, A. Kolk, M. Gerressen, O. Driemel, O. Maciejewski, B. Hermanns-Sachweh, D. Riediger, and J. M. Stein, “A new biphasic osteoinductive calcium composite material with a negative Zeta potential for bone augmentation,” Head Face Med 5(13 (2009). M. Hallman and T. Nordin, “Sinus floor augmentation with bovine hydroxyapatite mixed with fibrin glue and later placement of nonsubmerged implants: a retrospective study in 50 patients,” Int J Oral Maxillofac Implants 19(2), 222-227 (2004). K. Zurlinden, M. Laub, D. S. Dohle, and H. P. Jennissen, “Immobilization and Controlled Release of Vascular (VEGF) and Bone Growth Factors (BMP-2) on Bone Replacement Materials,” in Biomedical Engineering / Biomedizinische Technik, (2012), p. 989. Prof. Ralf Smeets Dr. med. Dr. med. dent Executive Senior Physician and Head of Research, University Medical Center Hamburg-Eppendorf, Head and Neurocenter of the Clinic and Outpatients for Oral and Maxillofacial Surgery, Hamburg, Germany Studied chemistry (specialist subject: macromolecular chemistry) and human medicine and dentistry at RWTH Aachen University. Surgeon specialized in oral and maxillofacial surgery. Dentist specialized in oral surgery Hans-von-Seemen Prize awarded by the German Association for Plastic and Restorative Surgery. Since 2011, Executive Senior Physician and Head of Research in the Clinic and Outpatients for Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf. 2011 W2 University Professor of Maxillofacial and Oral Surgery in the Medical Faculty of Hamburg University. The post Augmentation of hard tissue – an overview of regenerative techniques in dentistry appeared first on STARGET COM.
The following case report illustrates from experience how one-piece all-ceramic implants with one surface are comparable to the very well-documented Straumann® SLA® surfaces. The dental implant treatment in the anterior maxillary region took place in collaboration with Dr. Bettina Koch-Heinrici (Hamburg), who carried out the prosthetic restoration. PRODUCT INFORMATION BY THE MANUFACTURER The Straumann® PURE Ceramic Implant is the result of more than 9 years of research and development. It has a natural looking ivory color, a feature that makes the implant look more like a natural tooth and supports the clinician in cases of thin gingiva biotype or soft tissue recession. It has a monotype design based on features of the Straumann® Soft Tissue Level Standard Plus and Straumann® Bone Level Implants. According to a survey (data on file at Straumann), patients would prefer tooth-colored implants, if given the choice between ceramic and metal implants. With the Straumann® PURE Ceramic Implant, clinicians can offer their patients a natural and highly esthetic solution, benefitting from favorable soft tissue attachment around zirconia implants. MORE? All about the STRAUMANN® PURE CERAMIC IMPLANT on STARGET at a glance. Click here PICTURE DOCUMENTATION Fig. 1 The orthopantomogram shows the preoperative starting position (approximately three months after the removal of teeth 21, 22, 11) Fig. 2 Intraoperative initial clinical position Fig. 3 Situation after six months of healing and preparation of drilling channels to accommodate the implants Fig. 4 Insertion of Straumann Pure Ceramic implants in the region of 11, 22, 23 (diameter 4.1 mm; in the region of 22, a reduced diameter implant was used.) Fig. 5 Orthopantomogram - recorded postoperatively, implants in situ Fig. 6 Front view of inserted ceramic crowns INTRODUCTION Over the last few years, there has been increasing demand from patients for completely metal-free (implant) provision, and many patients prefer ceramic to titanium implants . All-ceramic prosthetic restoration with ceramic implants results esthetically in a natural dental and mucosal appearance, for example in patients with a thin gingival biotype or a high smile line [3.10]. In addition, in our practice, patients who are intolerant to titanium and have elsewhere described “chronic fatigue syndrome” symptoms following titanium implant insertion have indicated their wish for a metal-free alternative to titanium implants. Specialized information issued by the Institute for Medical Diagnostics in Berlin, has concluded that titanium intolerance is not an allergy, but rather the result of an increased propensity to infection of tissue macrophages on titanium oxide particles [12, 14, 16]. I offer my patients a blood test to determine titanium intolerance. In patients with positive findings, delayed or impaired healing of dental titanium implants can result, where even the macrophages in the implantation area can react hyperactively to released titanium particles and trigger both local and systemic inflammation. My basic motivation in our referral practice is to offer our patients implants, which, wherever possible, do not burden bone or the immune system. With this in mind, I have made increased use of ceramic implants. A great advantage of ceramics is their biocompatibility. With regard to the healthy maintenance of peri-implant tissue, it is extremely beneficial to monitor early plaque accumulation on zirconium dioxide . This results in less gingival recession, and the formation of the papilla around the implant is more esthetically pleasing [9, 15]. Zirconium oxide implants have a lower tendency to extended peri-implant infections . SPECIAL SURFACE ZIRCONIA CERAMICS The Straumann® Pure Ceramic Implant impressed me particularly in this respect. It consists of a one-piece implant body made of 100% high-performance zirconia ceramic (Y-TZP). Its shape is based on features of both the Straumann® Soft Tissue Level Standard Plus and bone level implants. In the past three years, the proportion of ceramic implants inserted, compared with recent insertions using titanium implants, has risen steadily in our practice and is currently at about 60 percent. I have since placed 300 Straumann® Pure Ceramic implants and, in our referral practice, I only recommend ceramic implants to my patients. Straumann’s background, combined with over 60 years of experience in material innovation, gives me confidence as a user and offers safety in treatment. With the official launch of the one-piece implant following a seven-year development process, Straumann offers an all-ceramic implant system with reliable, scientific processing for predictable treatment success [2,10]. The Straumann® ZLA® ceramic implant surface is characterized by macro- and micro-roughness, which is similar to the topography of the proven Straumann® SLA surface (SLA stands for sand-blasted, large-grit, acid-etched). Animal studies have shown osseointegration with respect to peri-implant bone density and BIC value (bone to implant contact), which corresponds to Ti-SLA [5, 11]. The SLA surface is one of the best documented rough surfaces in implantology and, due to its osseointegration properties, reduces the healing time of implants [4, 6]. Studies show a much improved accumulation of fibroblasts on the ceramic surface and subsequently a good soft tissue graft is expected [8, 18]. FINDINGS AND PLANNING A 28-year-old patient was transferred to our practice with an unremarkable general history: He had a naturally healthy bite, but was dissatisfied with the esthetics and chewing function of the upper jaw. Teeth 11, 21 and 22 had been endodontically treated after trauma to the front teeth suffered as a child. Due to complications, multiple apicoectomies were carried out and, over a period of ten years, there has been severe bone resorption in the anterior maxillary region. After a discussion on possible treatment options (from removable dentures or bridge to titanium implants), the request was quickly made for completely metal-free treatment following the extraction of teeth 11, 21 and 22. I made the patient aware of possible compromised gingival esthetics, as even a three-dimensional bone graft can result in dehiscence, and further augmentation may be necessary. Both the patient and his family dentist agreed with the metal-free treatment concept. About three months after extraction of teeth 11, 21 and 22, a CBCT was prepared to evaluate bone and subsequently show the reconstruction to the patient using photographic examples. After scheduling the procedure, the patient was fitted with a temporary form by the family dentist. Then a new CBCT was made using a template and from this, three Straumann® Pure Ceramic implants were navigated and inserted (region of 11, 21: endosteal diameter 4.1 mm; region of 22: diameter-reduced ceramic implant 3.3 mm). A navigated procedure is the basic prerequisite for successful insertion and prosthetic implant care. Given that it is a one-piece implant system, detailed planning of the spatial position of the implant by prosthetically orientated “backward planning” is required. Unlike with two-piece implants, angled construction axis correction is subsequently not possible. However, the one-piece design offers an outstanding advantage: Due to its one-piece design, a micro-gap within the implant is eliminated, which reduces the risk of the patient developing periimplantitis. TREATMENT PROCEDURE For the three-dimensional reconstruction, I removed autologous bone from the jaw angle region and cut it into thin slices. An outer contour was subsequently reconstructed and then the new bone walls were screwed at a distance. PRGF bone chips were mixed and condensed into the gap. If the gap is too large, in our practice we use Straumann® Bone Ceramic, a synthetic bone substitute material. This supports the regeneration of vital patient bone and at the same time restores and retains bone volume. In this case, a collagen membrane was used. After an approximate six-month healing period, guided implant placement was carried out. This allowed precise insertion of a one-piece zirconia implant in the correct axial alignment (drilling protocol corresponded to the bone level implant). Pure Ceramic implants are available with an endosteal diameter of 4.1 mm and a reduced diameter of 3.3 mm, as well as in two heights and four implant lengths of 8, 10, 12 and 14 mm. Please note: The implant body cannot be ground down at a later date. Any microcracks would reduce the breaking strength. Therefore, great care must be taken during pre-implant diagnostics and planning in the selection of the height of the prosthetic platform (here 5.5 mm). After a period of approximately four months of implant healing with temporary forms, implant care was provided by the family dentist Dr. Bettina Koch-Heinrici. The zirconium framework was constructed and milled using CAD/CAM (milling by Amman Girrbach), blending was carried out using Creation Zi-CT leucite crystal containing feldspar ceramic (Willi Geller). CONCLUSIONS FOR CLINICAL PRACTICE I am completely convinced by these zirconia implants with special surface features: I am able to offer my patients a product that, as far as possible, does not burden bone or the immune system, has excellent esthetic and mechanical properties and, due to its one-piece design, only a single intervention is required, trauma is minimized and subsequent morbidity reduced, and in addition, due to its one-piece design, the risk of the patient developing periimplantitis is reduced. The one-piece Straumann® Pure Ceramic implant is both user-friendly and patient-friendly and has the advantage of scientifically supported results and a reduced diameter option. In my opinion, for the benefit of patients, metal-free restorations should become routine for implantology. I am willing to be part of a research team: As far as I’m concerned they are already the “next generation of dental implants” . Note: this case report is the English translation of an article first published in “DZW Orale Implantologie 3/16, Fachmagazin zur DZW – Die ZahnarztWoche”, Germany – No. 42/16, October 2016. References  Barfeie A, Wilson J, Rees J. Implant surface characteristics and their effect on osseointegration. Br Dent J. 2015 Mar 13;218(5):E9. doi: 10.1038/sj.bdj.2015.171.  Becker W. Neues Keramikimplantat von Straumann. Dent Implantol 2014:18,3,230-231.  Bidra AS, Rungruanganunt P. Clinical outcomes of implant abutments in the anterior region: a systematic review. J Esthet Restor Dent. 2013 Jun;25(3):159-76. doi:10.1111/jerd.12031. Epub 2013 May 3.  Bischof M, Nedir R, Abi Najm S, Szmukler-Moncler S, Samson J. A five-year life-table analysis on wide neck ITI implants with prosthetic evaluation and radiographic analysis: results from a private practice. Clin Oral Implants Res. 2006 Oct;17 (5): 512-20.  Bormann KH, Gellrich NC, Kniha H, Dard M, Wieland M, Gahlert M. Biomechanica evaluation of a microstructured zirconia implant by a removal torque comparison with a standard Ti-SLA implant. Clin Oral Implants Res. 2012 Oct; 23(10):1210-1216.  Cornelini R, Cangini F, Covani U, Barone A, Buser D. Immediate loading of implants with 3-unit fixed partial dentures: a 12-month clinical study. Int J Oral Maxillofac Implants. 2006 Nov-Dec; 21(6):914-8.  Engelhardt-Wölfler H. Patientenstudie Basel-München. Abschlussbericht: Verhaltensanalysen durch Prof. Dr. Henriette Engelhardt-Wölfler, Universität Bamberg, aus: Mehr als PURE Ästhetik. Die natürliche, stabile Versorgung. Starget 2014:1,35-39.  Erbshäuser M. Einteiliges Keramikimplantat im ästhetisch sensiblen Frontzahnbereich – die richtige Alternative zu bewährtem Titan? Implantologie Journal 2016 (11):32-40.  Gahlert M, Kniha H, Weingart D, Schild S, Gellrich NC, Bormann KH. A prospective clinical study to evaluate the performance of zirconium dioxide dental implants in single-tooth gaps. Clin Oral Implants Res. 2015 Apr 1. doi:10.1111/clr.12598. [Epub ahead of print].  Gahlert M, Kniha H, Weingart D, Schild S, Eickholz P, Nickles K, Bormann K-H (Gemeinschaftspraxis Kniha/Gahlert, Munich, Germany). Prospective Open Label Single Arm Study to Evaluate the Performance of The Straumann PURE Ceramic Implant in Single Tooth Gaps in the Maxilla and Mandible. Poster 252 beim 22. Wissenschaftlichen Jahreskongress der European Association of Osseointegration, 17.-19. Okt. 2013, Dublin, Irland.  Gahlert M, Roehling S, Sprecher CM, Kniha H, Milz S, Bormann K. In vivo performance of zirconia and titanium implants: a histomorphometric study in mini pig maxillae. Clin Oral Implants Res. 2012 Mar;23(3):281-6. doi:10.1111/j.1600-0501.2011.02157.x. Epub 2011 Aug 2. Dr. med. dent. Tobias Wilck Dr. Tobias Wilck has been a specialist in implantology, oral and maxillofacial surgery since 2004. After studying medicine in his hometown of Hamburg, he gained international experience in Kingston (Jamaica) and Vienna before studying dentistry in Hamburg and Tübingen, where he also worked as a training assistant. He completed specialist training in Hamburg and Tübingen, as well as in Krefeld-Uerdingen, where he was most recently employed as a senior physician. In recent years, Dr. Wilck has been involved in humanitarian work in Vietnam (University of Hanoi), caring for facially disfigured children, primarily with cleft lips and palates. CLINICAL REVIEW The clinical facts behind the Straumann® PURE Ceramic Implant. BROCHURE Download the brochure for the Straumann® PURE Ceramic Implant. SUBSCRIBE Subscribe to our monthly STARGET newsletter to receive the latest news about implant dentistry. The post Tobias Wilck: One-piece and esthetically sensitive ceramic implants for the front teeth area (Straumann® Pure Ceramic Implant) appeared first on STARGET COM.