Congress Scientific Report EAO 24Th Annual Scientific Meeting Stockholm, 24–26 September 2015 Contents

Congress Scientific Report EAO 24th Annual Scientific Meeting Stockholm, 24–26 September 2015 Contents

Introduction ��1

Acknowledgements ��1

Methodology ��1

effectiveness in implant dentistry ��2

Per-Ingvar Brånemark concept. ��2

André Schroeder concept ��3

Willy Schulte concept ��4

Effectiveness in implant dentistry ��5

Chairpersons’ conclusion ��5

Tissue reconstruction/regeneration ��6

What the dentist needs to know about tissue reconstruction/regeneration ��6

Extracts from the video ‘Cell-to-Cell Communication’ ��7

Regeneration/reconstruction of peri-implant soft tissues �� 8

Tissue regeneration via the use of L-PRF ��10

Challenges for implant treatment of the ageing population ��11

Bisphosphonates; a threat or an option? �� 11

No teeth, no money: what to do in the elderly patient? ��13

Minimal number of implants in the upper jaw? �� 15

Minimal number of implants in the lower jaw? ��16

Implants in the future: CAD-CAM, precision of fit ��17

The future implant crown: chairside vs. labside ��17

Is ceramic the material of choice for future implants? ��19

CAD/CAM in removable prosthodontics �� 20

To learn from complications ��21

Maxillary sinus grafting complications and how to avoid them. ��21

The surgeon as the complicating factor. ��23

On the evolution of complications in implant prosthodontics. ��24

What have we learned from mucogingival complications? ��25

What have we learned from immediate implant placement and immediate restoration? ��25

Treatment and outcome challenges ��26

The current use of patient centred/reported outcomes in implant dentistry. ��26

Quality of life in patients undergoing bone grafting procedures ��27

Management of bone defects in the aesthetic zone. ��27

Implants in the future: virtual planning, 3D printing and more ��30

The virtual patient: how far away are we? �� 30

The origin, present and future of 3D printing ��31

3D printing in maxillofacial surgery ��31

3D printing in prosthodontics ��32 Consensus Conference 2015 �� 34 The patient undergoing implant therapy ��34 Digital technologies to support planning, treatment, and fabrication processes

and outcome assessments in implant dentistry. ��36

Soft and hard tissue aspects. ��37

Therapeutic concepts and methods for improving dental implant outcomes. �� 39

Successful supportive treatment – evidence for clinical efficacy ��41 Peri-implantitis: diagnosis and prevention through case selection

and proper treatment execution ��41

Supportive therapy following treatment of peri-implant disease ��43

How successful is supportive therapy in prevention of peri-implant disease ��43

Imaging (radiology) in treatment planning and follow-up �� 45

Presurgical imaging in implant treatment: from guidelines to clinical use �� 45

Do we still need to use Hounsfield scores in presurgical planning? ��46

Radiographic bone quality aspects in planning implant surgery ��47 Creating the virtual patient: how to integrate facial, optical

and radiological imaging components �� 48

Peri-implantitis ��49

The relevance of implant materials for peri-implantitis �� 49

The patient and the problem awaits Monday morning. What do I do? ��50

Challenges in the treatment of peri-implantitis ��51

A comparison between periodontitis and peri-implantitis lesions ��52

Emerging surgical concepts �� 53

Do we still need autogenous bone for ridge augmentation or can we use growth factors? �� 53

Soft tissue grafts out of the box. What can we expect in clinics? �� 55

Emerging concepts in maxillofacial surgery: indications for graft materials ��56

The future of wound healing: can it still be improved? ��57

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European Association for Osseointegration

europeanassociationforosseointegration

eao_association Introduction

This report provides a summary of the 12 principal sessions that took place at the EAO’s 24th annual Scientific Meeting. The report was written by a group of delegates at the meeting, who have previously prepared a similar summary for circulation among their friends following past EAO meetings.

As described in the methodology below, all speakers were given the opportunity to review and amend the editorial that had been written about their presentation, although a significant minority did not respond to the editors’ requests for feedback. The EAO wishes to emphasise that this is not a peer reviewed scientific report. It was written by the team of volunteer delegates, albeit with input from a large number of the speakers represented. The contents do not necessarily represent the view of the EAO and readers are responsible for independently evaluating any information contained in the report. Nonetheless, the EAO hopes that the report will provide a useful and informative summary of the proceedings of its 24th annual Scientific Meeting.

Acknowledgements

The EAO would like to gratefully acknowledge the substantial work carried out by Lino Esteve and Alberto Salgado in writing this report. They were supported by Ambrosio Bernabeu, David Esteve, Guillem Esteve, Emilio Sánchez Talaverano, and Andres Valdes.

Methodology

The methodology underpinning this report is as follows:

1. A team of dentist delegates volunteered to write the report and arranged to attend all the sessions covered in it during the EAO’s 2015 meeting in Stockholm 2. They provided a draft summary of each presentation to the EAO, which arranged for a copywriting team to edit it. This was not a scientific editing process, and instead concentrated on grammar and consistency 3. The editors returned the edited contributions to the dentist delegates highlighting any questions they had 4. On receipt of responses to their questions, the editors updated the contributions, then forwarded them to each of the speakers featured, along with a request for a selection of their slides (selected by the writers) 5. Each author was emailed up to three times to request their feedback. The majority replied, and around 50% also supplied slides. Some speakers provided textual corrections but declined to provide copies of their slides 6. A small number of speakers did not respond to any of the emails sent to them, and as a result the editorial on their sessions has not been reviewed by them

A number of speakers allowed a selection of their slides to be included in this report. Readers should be aware that copyright in any original content included in these slides remains the property of the speakers, and/or any other third-party copyright holders. These slides must not be circulated other than as part of this report, and should not be copied or reused without the express permission of the relevant speakers.

Congress Scientific Report: EAO 24th Annual Scientific Meeting Stockholm, 24–26 September 2015 1 50 years of clinical osseointegration – the early contributions and current effectiveness in implant dentistry

As is often the case with significant scientific developments, the early research that underpinned the development of osseointegrated implants occurred in several locations. Per-Ingvar Brånemark made the initial discovery and subsequently defined the term osseointegration, and as he began to publish his research, other centres conducted their own experiments into different aspects of this rapidly developing field. The three most important European foci of the early development of modern implant dentistry were Gothenburg, Bern and Tübingen. The first three speakers of this session discussed the work that was taking place in each of these centres. The final speaker went on to talk about the global consequences of implant therapy and its current impact and effectiveness.

Per-Ingvar Brånemark concept. Tomas Albrektsson

In the late 1950s P-I Brånemark was working in The term osseointegration first appeared in a book the field of micro-circulation at the University of in 1977, although Brånemark certainly claimed there Lund, and it was the knowledge he gathered there was direct anchorage to bone beforehand. Initially, that led to his later discovery. While studying the limits of histology meant that he was not able to micro-circulation in rabbit bone, he noticed that objectively demonstrate osseointegration. the device he had implanted was stable in the bone and he couldn’t remove it. He saw the potential of P-I Brånemark was a brilliant clinical scientist this discovery, and three years later placed his first who chose to explore the possibilities offered by implant in a patient. osseointegration, rather than working on cellular research. Most of what he postulated in the 1960s The initial results weren’t very good, with a success was later verified, but not even he would have rate of the order of 50% in the first five years. There estimated the number of oral implants that are was a strong academic struggle and Brånemark’s placed annually today. The official figure is 20 ideas were initially considered dangerous. However, million, but some people say it is more. Either way three independent Swedish professors subsequently it is an astonishing figure, and although he was wrote a positive statement about implants and convinced of his success he could not possibly have opinion began to move in his favour. estimated the extent of that success.

Congress Scientific Report: EAO 24th Annual Scientific Meeting Stockholm, 24–26 September 2015 2 André Schroeder concept Daniel Buser

The late Professor André Schroeder was an his team pioneered the use of a titanium plasma- endodontist at the University of Bern. In the late sprayed (TPS) surface. This was probably one 1960s he began to experiment with various implant of the first modified titanium surfaces, and was materials in animal studies. introduced in an effort to achieve maximum bone anchorage In close collaboration with Straumann, his team they introduced the conical connection, which developed various kinds of prototype titanium was quite different from Brånemark’s hexagon implants based on the later abandoned concept of and has now become almost universal hollow-cylinder implants. The results of his animal Professor Schroeder’s third contribution is experiments were published in German in the probably the most important: the introduction of Swiss Dental Journal in 1976, 1978, and 1981. These non-submerged healing of one-piece implants that were the first studies to demonstrate direct bone has led to today’s concept of tissue-level implants anchorage to implants using his own histologic method with non-decalcified sections. He called the In addition to the direct scientific contributions he anchorage he observed ‘functional ankylosis’. made, Professor Schroeder co-founded the ITI in 1980, followed by the ITI Foundation in 1988. Today, Schroeder’s work has enriched the development of the majority of the ITI’s activities are educational. the field in three main aspects: The ITI Foundation has supported more than 400 studies throughout the world and granted more than $45 million for these studies.

Rough implant surface and a non-submerged healing

• All implant prototypes in the mid 1970’s had a TPS implant surface and were 1-piece implants A non-submerged healing was mandatory ✓ At that time, implants were only placed in healed sites with sufficient bone volume ✓

early 1970’s late 1970’s late 1970’s 2013: 30 years follow-up

Figure 1.2.1

Non-submerged healing of Implants

• In 1986, after 12 years of clinical testing, André Schroeder initiated a new implant system with 2-piece implants Hollow-cylinder, hollow-screw and solid screw implants are integrated into one implant system ✓ In the beginning, a non-submerged healing was used, with GBR cases, a submerged healing was also applied ✓

Buser, Weber, Lang: Tissue integration of non-submerged implants. 1-year results of a prospective study with 100 ITI hollow-cylinder and hollow-screw implants. Clin Oral Implants Res 1: 33, 1990 Buser, Mericske-Stern, Bernard, Behneke, Behneke, Hirt, Belser, Lang: Long-term evaluation of non-submerged ITI implants. Part I: An 8-year life table analysis of a prospective multi center study with 2359 implants. Clin Oral Implants Res 8:161, 1997 Chappuis, Buser, Bragger, Bornstein, Salvi, Buser: Long-term outcomes of dental implants with a titanium plasma-sprayed (TPS) surface: A 20-year prospective case series study in partially edentulous patients. Clin Impl Dent Rel Res 15:780-90, 2013

1986

Figure 1.2.2

Smooth vs. micro-rough vs. rough Implant Surfaces

• In 1988, an animal study was performed together with Sam Steinmann and Bob Schenk to examine implant surfaces 80 Goal: Find a better, non-coated titanium surface 3 weeks 6 weeks ✓ 60

0 E SMP SL TPS SLA HA Buser, Schenk, Steinemann, Fiorellini, Fox, Stich: Influence of surface characteristics on bone integration of titanium implants. J Biomed Mater Res 25: 889, 1991

Figure 1.2.3

Congress Scientific Report: EAO 24th Annual Scientific Meeting Stockholm, 24–26 September 2015 3 Willy Schulte concept Joerg Meyle

The Frialit I immediate implant (Tuebingen implant) in the smaller diameters. It was also based on the was developed in 1975 at the University of Tübingen concept of filling the whole alveolar volume at the and started being used in clinical practice in the same time of tooth extraction. The next evolution 1980s. It was made of a polycrystalline ceramic of was the Frialit-II, made of titanium, whose design aluminium oxide and had an increased surface evolved to a threaded but still stepped cylinder. area due to its roughness in the endosseous part. Conceived to fill the post-extraction alveolar socket The main contribution this concept made to the after an impacted flapless insertion, its design took field was pioneering the immediate insertion of the form of a stepped cylinder. Problems arose implants post-extraction, which has now become a because the material was more fragile, especially routine treatment.

The Schulte Concept and the Tuebingen Implant The Schulte Concept and the Tuebingen Implant

Principles Schulte W, Heimke G: [The Tuebingen immediate implant] . Increase of surface area compared with root surface of extracted tooth

Concept

Development

Clinical Application

Consequences Prof. Dr. Dr. h.c. Willi Schulte Quintessenz 27, 1 (1976) 1929 - 2009

100% 114% 145% 140%

Dtsch Zahnaerztl Z 33, 319 - 325 (1978) Polycristalline Aluminumoxide Ceramics

Figure 1.3.1 Figure 1.3.2

The Schulte Concept and the Tuebingen Implant The Schulte Concept and the Tuebingen Implant Principles . Immediate insertion after tooth extraction . Flapless insertion . Primary stability Concept

Development

Clinical Application

Consequences

D‘Hoedt B: Dental Implants of polycrystalline aluminum oxide ceramics - healing and longterm results - Habilitation Thesis (1991)

Figure 1.3.3 Figure 1.3.4

Congress Scientific Report: EAO 24th Annual Scientific Meeting Stockholm, 24–26 September 2015 4 Effectiveness in implant dentistry Jan Derks

Existing research does not provide insight into the clinician performing the treatment (specialist the overall effectiveness of implant dentistry, i.e. vs. general practitioner) outcomes in a general population treated in everyday conditions. The majority of papers published Implant loss in the implant literature are case series, which The occurrence of implant loss was evaluated. Early usually include small, selected patient groups implant loss was assessed in patient files, while late (evaluation of efficacy)1 and are limited to reports on loss was scored at the 9-year clinical examination3. It implant survival or implant success. To extend our was found that: understanding, additional parameters, such as patient satisfaction and the occurrence of complications, have 7.6 % of all patients were affected by implant loss moved into focus. In addition, it was suggested to over the 9-year period identify the patient as the unit of analysis, rather risk indicators for early implant loss were: than considering the single implant, thus facilitating periodontitis; smoking; implant length and the clinical relevance of research data. Assessments implant brand of effectiveness require large and randomly selected risk indicator for late implant loss was: implant patient cohorts in which both rare and more common brand events may be studied. Assessments of risk, i.e. risk indicators, can be performed. Peri-implantitis A further study, under preparation at the time of The speaker presented results from a project recently the presentation but now published, presented the performed at the Department of Periodontology, The prevalence of peri-implantitis4. Peri-implantitis was Sahlgrenska Academy at University of Gothenburg. assessed in 596 patients attending the clinical and The included patient cohort represented a radiographic examination 9 years after therapy. The background population of 25,000 Swedish citizens data revealed that: who had all been provided with implant-supported therapy in 2003. The cohort was identified in the 23% of all patients presented with peri-implant database of the Swedish Social Insurance Agency health (absence of bleeding on probing) at all and, thus, included patients treated by various implant sites clinicians in different clinical settings. Patient files 32% of all patients presented with peri-implant of 2,765 individuals were obtained and, in addition, mucositis (bleeding on probing but no bone loss 596 patients were clinically and radiographically >0.5 mm) examined 9 years after therapy. 45% of all patients presented with peri-implantitis (bleeding on probing and bone loss >0.5 mm) Patient satisfaction 14.5 % of all patients presented with moderate/ In an initial questionnaire study on patient-reported severe peri-implantitis (bleeding on probing and outcomes, performed 6 years after completed bone loss >2 mm) therapy, it was concluded that patient satisfaction risk indicators for moderate/severe peri- was generally high2. Outcomes were related to the implantitis were: periodontitis; number of following background factors: implants; clinician providing the restoration; implant brand; jaw of treatment; distance from age and gender of the patient prosthetic margin to crestal bone at baseline the extent of implant-supported restorative therapy

1 Berglundh & Giannobile J Dent Res 2013 3 Derks et al. J Dent Res 2015 2 Derks et al. Clin Oral Impl Res 2015 4 Derks et al. J Dent Res 2016

Chairpersons’ conclusion Other European pioneers also took part in the initial development of osseointegrated implants, along with some Americans, but the three groups described in this session were those which paved the way for the fundamental concepts of today’s implants. From this initial diversity, there was a pattern of convergence to the proven concepts that have successfully passed the filter of scientific evidence. The three historical contributions described (among many others) have led to the current situation, in which implant-based treatment has become, or is becoming, the worldwide standard for edentulous patients.

Congress Scientific Report: EAO 24th Annual Scientific Meeting Stockholm, 24–26 September 2015 5 Tissue reconstruction/regeneration

This session provided an overview of current indications for predictable hard tissue augmentation, along with the latest understanding of the relationship between peri-implant soft tissue and crestal bone loss, plus techniques for harnessing the regenerative benefits of L-PRF. It also featured a discussion of how complex biological concepts can be communicated using the latest animation techniques, with a description of a series of films entitled ‘Cell to cell communication’.

What the dentist needs to know about tissue reconstruction/regeneration Luca Cordaro

In recent years, tissue augmentation has become However, vertical augmentation in the mandible and an increasingly routine tool within the dentist’s in the aesthetic zone seems to be less predictable. armoury. Current best practice dictates that implants are placed in a prosthetically driven way, and this The results of a recent systematic review2 were frequently results in the need for peri-implant summarised by the speaker in a table indicating the augmentation procedures. This general trend different defects and the corresponding techniques towards augmentation has created some clinical available. challenges. It has developed alongside demands for increasingly simple treatment protocols, as well For small defects, when it is possible to carry out as a desire to reduce patient morbidity, along with grafting simultaneously with implant placement, the ever-growing pressure to deliver predictable, do we need to submerge? aesthetically excellent results without complications. The evidence indicates that for a single implant in the aesthetic zone, with simultaneous bone In order to achieve these goals, it is necessary to augmentation for a moderate peri-implant defect, understand the predictability of each of the clinical both transmucosal and submerged healing provide situations in which tissue augmentation may be similar outcomes. Hence there is no need to used. The key factor underlying this is the type of submerge an implant in this clinical situation3. defect. These can be categorised as follows. What are the indications for block grafts, and horizontal self-maintaining what is the associated morbidity? horizontal The use of block grafts for staged augmentation vertical is well documented. The morbidity of intraoral combined bone harvesting seems to be lower than previously reported. Opinion differs as to the preferred choice Situations in which bone augmentation can be of intraoral site in order to minimise complications. considered predictable are as follows: What is a short implant? GBR for fenestration/dehiscence defects at the The definition of a short implant is currently time of implant placement the subject of some controversy. There are three staged GBR or block grafting for horizontal definitions in use: augmentation in partially edentulous patients sinus floor elevation. There is evidence that a conventionally short implant is defined as being autogenous bone grafting of the sinus shows a less than 10mm long higher implant success rate, when compared with the EAO Consensus Conference 2015 defined bone substitutes, in cases of residual ridge height a short implant as one with an infrabony of less than 5mm1 component of ≤ 8mm

2 Milinkovic & Cordaro. Int J Oral Maxillofac Surg. 2014 1 Pjetursson et al. J Clin Periodontol 2008 3 Cordaro et al. Clin Oral Impl Res. 2012

Congress Scientific Report: EAO 24th Annual Scientific Meeting Stockholm, 24–26 September 2015 6 a recent new definition is based on an implant Narrow diameter implants (NDIs) length of ≤6 mm NDIs have well documented clinical indications, including reduced mesio-distal space or reduced Regardless of the definition, the literature tends ridge volume, provided that the rules of implant to demonstrate acceptable outcomes in posterior positioning are followed. Despite this, the risk of maxillary and mandibular ridges for short implants biomechanical complications, especially implant when compared with conventional implants. Hence, fracture, should be taken in account. short implants may be considered instead of vertical augmentation in posterior zones.

Extracts from the video ‘Cell-to-Cell Communication’ Bernd Stadlinger

Using visual techniques to illustrate and explain Reactions’, ‘Periodontal Regeneration’ and ‘Oral biological processes has been a challenging Health and Systemic Health’. issue for scientists for centuries. As science has evolved, different approaches have been employed The films illustrate the cellular and molecular to help communicate the new knowledge that processes that are the basis of therapies scientists have gained through their research. Early underpinning implant dentistry. The animations examples of this desire to communicate visually they feature are based on current scientific are the drawings created by neuroanatomists at the knowledge, and represent the processes in 3D. They beginning of the twentieth century. were produced by combining scanning electron microscopic images of relevant structures with the New imaging technologies are now providing most up to date research on cells and molecular additional opportunities to illustrate biological mediators. To illustrate what occurs at macro-, micro- processes, and can be used to create important and submicroscopic levels, the camera perspective educational tools. Computer animation has a crucial shifts between three image planes. This enables role to play in this process. viewers to gain a better understanding of the timeline of cellular processes, and uniquely offers a This lecture described and introduced the series view of them in three dimensions. In the presenter’s of 3D computer animated films called ‘Cell-to- words, the ultimate goal is to facilitate biological Cell Communication’. There are four films in the understanding and to stimulate an interest in the series, entitled: ‘Osseointegration’, ‘Inflammatory underlying science.

Figure 2.2.1 Figure 2.2.2

Congress Scientific Report: EAO 24th Annual Scientific Meeting Stockholm, 24–26 September 2015 7 Regeneration/reconstruction of peri-implant soft tissues Tomas Linkevičius

Crestal bone loss (CBL) is thought to result from a data is consistent with another clinical observation combination of multiple factors, including implant of a correlation between CBL and abutment height7. hardware; crestal position; patient factors; and clinical handling, although the precise mode of its Given these results, how should clinicians best progression continues to be controversial. Early CBL manage cases that involve thin mucosa (Figure arises at the time of establishing the biological width, 2.3.5)? The proposals put forward depend on the while resorption at a later date can be seen in an bone height: ailing or failing implant. if bone height is >8mm, the three options are: Early CBL could be a predisposing factor for bone reduction to passively augment soft tissue subsequent biological problems, since it may result proportion; subcrestal placement to try and in peri-implant pockets. Moreover, CBL may also achieve greater soft tissue contact; or a ‘tent’ lead to soft tissue recession, impairing the aesthetic technique that involves covering the abutment result. This lecture discussed the contribution that with the flap to provide soft tissue growth (only mucosal thickness makes to CBL (Figures 2.3.1 and viable if a major flap relapse can be obtained) 2.3.2). if bone height is <8mm, vertical augmentation of the soft tissue is recommended. This can In an experimental study, peri-implant bone loss be carried out simultaneously with implant after abutment connection was correlated with placement a thin mucosa (<2mm)4. These results have been confirmed clinically in cases where it can be clearly Three alternatives for soft tissue augmentation stated that initial gingival tissue thickness at the were put forward: using an autograft; a xenograft; crest was the significant factor influencing marginal or a dermis-derived allograft. Autografts produce peri-implant bone stability5, in both supra- and significant soft tissue augmentation but do not equi-crestal placements. Another clinical study by appear to prevent bone loss. Collagen-matrix the same group concluded that platform-switching xenografts result in less augment of volume, since abutments did not preserve crestal bone better than some recession is likely to occur. In a prospective conventional ones after one year of observation if controlled clinical trial, the authors used an allograft thin mucosal tissues were present at the crest when (human dermis-derived; Alloderm) and reported implants were placed6 (Figures 2.3.3 and 2.3.4). This significantly less bone loss, probably due to its membrane effect8 (Figures 2.3.6 and 2.3.7).

4 Berglundh et al. J Clin Periodontol 1996 5 Linkevicius et al. IJOMI 2009 7 Galindo-Moreno et al. J Dent Res 2014 6 Linkevicius et al. JOMS 2010 8 Linkevicius et al. CIDDR 2013

Figure 2.3.1

Figure 2.3.2

Congress Scientific Report: EAO 24th Annual Scientific Meeting Stockholm, 24–26 September 2015 8 Figure 2.3.3

Figure 2.3.4

Figure 2.3.5

Figure 2.3.6

Figure 2.3.7

Congress Scientific Report: EAO 24th Annual Scientific Meeting Stockholm, 24–26 September 2015 9 Tissue regeneration via the use of L-PRF Marc Quirynen

Platelet degranulation happens in the very early L-PRF’s role as a primary wound matrix, combined moments of the healing cascade, giving place to with its antibacterial activity and its ‘membrane coagulum formation and the release of cytokines effect’ seems to offer additional explanations for its to orchestrate the inflammatory process. The idea clinical benefits. of concentrating platelets to improve the wound healing process is not a new one. Platelet rich plasma The lecturer continued with a demonstration of a concentrates (PRPs) have been investigated since variety of indications for L-PRF, including: the 1990s and their use has become increasingly widespread across a range of medical disciplines. treating osteonecrosis of the jaw protecting surgical wounds and providing better Faced with conflicting data and frequently biased and faster healing with less post-operative reporting (closely linked to undisclosed commercial symptoms, for example in third molar extractions interests) the use of PRPs was almost abandoned (RCT) in oral and maxillofacial surgery. However, what replacing connective tissue grafting (several appears to be their inconsistent performance may be RCTs) explained by the wide variety of products that were regenerating infra-bony periodontal lesions produced during a rush for patents. (several RCTs) replacing graft materials when augmenting the Second generation platelet aggregates called platelet ridge (new RCT) rich fibrin (PRF) are now available, with claims covering a lateral window or as a sole graft made that they have overcome the major drawbacks material in sinus lifts (case series) of the first generation products. PRF is designed to as a coating on implants for better early stability have a low cost and to be simple to prepare, without and fewer losses the need to add activators, enabling it to provide to perform ridge preservation instead of using high concentrations of platelets without altering current grafting biomaterials their activity. In all cases, the presenter provided references, with Leukocyte content and fibrin architecture seem most of the documentation published in the last to be the two key characteristics of all platelet three years. concentrates. These are responsible for PRF’s clinical effects and are the basis for its classification9. L-PRF, what about the future? L-PRF can become a standard in regenerative In the meantime L-PRF (leukocyte-platelet rich treatments. However, first of all, the classification fibrin) can be defined as follows. of PRPs and PRFs (including L-PRF) has to be decisively standardised, along with the key L-PRF should be considered as a living human parameters for their preparation and use. Even ‘tissue graft’ though many studies are in progress, well the preparation process was first described by designed clinical studies are welcome. The effect of Choukroun et al10 biomaterials in current use has to be compared with it is easily made: blood is taken without L-PRF for each of the clinical indications. A standard anticoagulant and is immediately centrifuged 3D automated method would be very useful to to obtain a dense fibrin-platelet clot made of objectively quantify the bone formation11. Hopefully, a strong fibrin mesh with the platelets and these steps will all be achieved in the near future. leukocytes distributed within it. This architecture may be the cause of its ability to release multiple factors over a longer time frame

9 Ehrenfest et al. Curr Pharm Biotechnol 2012 11 Van Dessel et al. Poster 613 presented at EAO 24th 10 Choukroun et al. Implantodonie 2001 meeting in Stockholm 2015

Congress Scientific Report: EAO 24th Annual Scientific Meeting Stockholm, 24–26 September 2015 10 Challenges for implant treatment of the ageing population

the first speaker, Per Aspenberg, discussed bisphosphonates. The use of bisphosphonates is growing worldwide, and they are commonly prescribed as a means of preventing osteoporosis. It is increasingly common to encounter patients who are candidates for dental implant treatment who are also taking bisphosphonates. As such, it is necessary to understand the issues that are associated with them the second speaker, Martin Schimmel, reviewed current approaches to treating elderly patients who are seeking implant treatment and are increasingly poor and frail, along with the particular factors that need to be taken into account among this population the other two speakers, Anja Zembic and Gerry Raghoebar, explored the possibility of reducing the number of implants in the upper and lower jaw respectively. They also looked at issues around morbidity and cost, both of which have particular relevance to older patients

Bisphosphonates; a threat or an option? Per Aspenberg

Bisphosphonates have a strong affinity with bone area. This then becomes isolated by granulation and bind to hydroxyapatite, producing a strong tissue, before being expelled as a sequestration. inhibitory effect against bone resorption. Their In ONJ, this sequence of events fails, as does the mechanism involves the inactivation and apoptosis osteoclastogenesis, and as a consequence necrotic of osteoclasts, leading to decreased bone resorption bone remains and infection spreads, establishing and remodelling (Figure 3.1.1). itself as ONJ (Figure 3.1.2).

As dentists we need to be particularly aware On the other hand, when applied locally, of a severe side effect of bisphosphonates (and bisphosphonates have a ‘good’ side, changing the other antiresorptive drugs such as denosumab): local balance between formation and resorption osteonecrosis of the jaw (ONJ). Although this is of bone (Figures 3.1.3–3.1.6). In one experimental a multifactorial condition whose pathogenesis study1, a 28% (p=0.0009) higher pull-out force and is not yet fully understood, its action can be 90% increased pull-out energy was observed for summarised in a few words. Bone resorption is a bisphosphonate-coated screws, supporting the idea protective mechanism that fails when osteoclasts that implant surface immobilised bisphosphonates are inactivated by bisphosphonates. When bone is can be used to improve fixation in bone. These traumatised or infected, osteoclasts are activated and rapidly resorb the neighbourhood of the infected 1 Tengvall et al. Biomaterials 2004

Figure 3.1.1 Figure 3.1.2

Congress Scientific Report: EAO 24th Annual Scientific Meeting Stockholm, 24–26 September 2015 11 Figure 3.1.3 Figure 3.1.4

Figure 3.1.5 Figure 3.1.6

Figure 3.1.7 Figure 3.1.8

Figure 3.1.9 Figure 3.1.10

Figure 3.1.11 Figure 3.1.12

Figure 3.1.13 Figure 3.1.14

Congress Scientific Report: EAO 24th Annual Scientific Meeting Stockholm, 24–26 September 2015 12 results have been repeatedly confirmed in various (bisphosphonate-coated) showed significantly higher animal models2 (Figures 3.1.7–3.1.9). The same group implant stability quotient values and less marginal carried out an experiment on 16 patients, each of bone resorption (Figures 3.1.10–3.1.13). whom received two implants. The test implants The speaker concluded by saying that systemic 2 Wermelin et al. Acta Orthop 2007; Bobyn et al. J Bone Joint Surg use of bisphosphonates may cause ONJ, but local Am 2009; Abtahi et al. J Dent Res 2012; Agholme et al. J Mater Sci application can improve implant fixation (Figure Mater Med 2012 3.1.14).

No teeth, no money: what to do in the elderly patient? Martin Schimmel

Although the incidence of edentulism is falling Apart from the technical difficulties of treating in Europe, it still persists in some groups of the medically compromised patients, there is a need to population who are at risk of being unable to minimise the treatment burden and simultaneously benefit from treatment because they cannot meet keep the cost low. We need to consider how that its cost. The impact of edentulism on the patient’s might be possible. health is important, and it is usually accompanied by some comorbidities, making treatment difficult Complete removable prostheses can now be made (Figures 3.2.1 and 3.2.2). using CAD-CAM technology. Chair-side work can be simplified using a standardised procedure, and costs reduced using semi-industrial fabrication.

Figure 3.2.1 Figure 3.2.2

Figure 3.2.3 Figure 3.2.4

Congress Scientific Report: EAO 24th Annual Scientific Meeting Stockholm, 24–26 September 2015 13 Despite these opportunities, the pros and cons are also good, with a positive impact on quality of still need to be precisely established because the life (Figure 3.2.5). technique is still in the early stages of development (Figures 3.2.3 and 3.2.4). The trend towards conservative surgery in elderly patient has led to the increased use of reduced Often, the first prosthetic option to be considered length and reduced diameter implants. Shorter in elderly patients is a conventional denture in the and narrower implants allow more placements upper jaw and a two implant overdenture in the without bone augmentation surgery, thus helping lower jaw. Overdentures can also replace the volume to simplify treatment and reduce patient morbidity, lost in atrophic jaws in a less invasive way than fixed cost and time. In a recent systematic review4, narrow implant-supported prostheses, and are easier to implants were demonstrated to have a high mean clean. The McGill Consensus (2002) stated that the cumulative survival rate. This held true even for mandibular overdenture on two implants should be the narrowest (<3 mm) implants and mini implants considered the recommended standard of care3. The (Figures 3.2.6–3.2.8). Such treatments must always be cumulative survival rate of implants placed as part part of ongoing dental care approach, especially in of this treatment is high. Patient satisfaction levels frail elders.

3 Feine et al. Int J Prosthodont 2002; Thomason et al. Br Dental J. 2009;207(4):185–6 4 Klein et al. IJOMI 2014

Figure 3.2.5 Figure 3.2.6

Figure 3.2.7 Figure 3.2.8

Congress Scientific Report: EAO 24th Annual Scientific Meeting Stockholm, 24–26 September 2015 14 Minimal number of implants in the upper jaw? Anja Zembic

When providing dental implant treatment to elderly Patient satisfaction and number of implants patients, the goal is typically to keep the costs low Patient-centred outcome measures suggest that the while minimising surgical risks. One way to do this number of implants placed does not affect patient is to reduce the number of implants required to satisfaction8. Levels of patient satisfaction are successfully support the restoration. Unfortunately, considered to be an essential aspect of evaluating the number of implants cannot always be presumed treatment outcome. to be the same as the number of teeth that would be required to support the same restoration. What is preferable, fixed or removable? Overdentures are associated with more Until recently, it was recommended that maxillary complications, but are easier to clean, cheaper, and overdentures were supported by four implants, as provide superior patient satisfaction in terms of a high failure rate was observed with two implants. aesthetics, taste and speech. The duration of the However, these conclusions were based on the use period of edentulism is a crucial factor in the choice. of machined implants, and increased survival rates The longer the patient has been edentulous, the have recently been reported for rough implants. greater their preference for overdentures. A shorter These surface-modified implants represent a new period of edentulism is associated with a preference treatment option which requires further study, so the for fixed prostheses. Generally speaking, removable question of the ‘optimal’ number of implants is still a prostheses are the treatment of choice for the elderly. matter of debate. Is fewer than four implants in the maxilla an Survival rates and number of implants option? The literature yields insufficient and low quality One three-year study involving 40 patients used evidence about the success and survival rates of both only three narrow diameter implants to retain a maxillary overdentures and fixed prostheses, with maxillary overdenture. Participants found this regard to the number of implants: option to be successful, and it was effective whether the implants were splinted or not; both for total or in a recent overall comparison5, implant partial palatal coverage; and whether the method of loss rates for maxillary overdentures on < 4 attachment was a bar or a ball9. Another study which implants were significantly higher than for involved using two single implants in the canine four implants. Maxillary bone quality may be region of the maxilla to support a removable denture a factor influencing these findings. In a recent yielded an 86% four-year survival rate with balls10. one year randomised controlled trial comparing A similar study involving a telescopic connection maxillary bar overdentures on 4 or 6 implants, no yielded 82% survival after two years, although it significant differences were observed6 was concluded that this type of connection might for fixed implant-supported prostheses, using 4–6 be too rigid, thus leading to overloading11. There implants is a well-documented treatment option have been attempts to secure fixed prostheses on with a 95% estimated 10-year survival7. The both three implants12 and even on two, and a viable indication for more than six implants is unclear treatment concept was found. from the current evidence 8 De Bruyn et al COIR 2015 9 Al-Zubeidi et al. Clin Implant Dent Rel Res 2011 5 Kern et al. COIR 2015 10 Zembic et al. in preparation 6 Slot et al. J Clin Periodontol 2013 11 Weng & Richter Int J Periodontics Rest Dent 2007 7 Heydecke et al. COIR 2012 12 Oliva et al. IJOMI 2012

Congress Scientific Report: EAO 24th Annual Scientific Meeting Stockholm, 24–26 September 2015 15 Minimal number of implants in the lower jaw? Gerry Raghoebar

Patients with conventional mandibular dentures Is age a problem? are often dissatisfied by the lack of stability they The influence of patient age on clinical outcomes for offer, as well as problems with retention. This can two-implant mandibular overdentures has recently lead to pain during mastication, with a potentially been compared in a 10-year observational study16. The significant impact on their nutritional and data obtained for the younger and older groups was psychosocial condition, resulting in a reduction in similar. Based on this, age should not be considered their quality of life. To treat this problem, the ‘gold as the sole factor on which to exclude a patient. standard’ is the mandibular overdenture supported by two implants, as has been corroborated by a A treatment proposal for the mandible based on 10-year randomised controlled trial13. bone height and width:17 12mm–6mm/ 6mm: no significant differences in In cases of extreme resorption of the mandible, is implant survival, prosthetic aftercare and patient bone augmentation needed or can short implants satisfaction between≧ two or four implants during also do the job? a 10-year evaluation period, even with 6mm Three different treatment options were compared implants in an RCT: a transmandibular implant; a sandwich 12mm–6mm/< 6mm: the same as with osteotomy and implants; and short implants. Patient simultaneous augmentation satisfaction was the same, regardless of the option, <6mm: augmentation with iliac crest, with the and no differences were demonstrated with regard placement of two or four implants at a second to masticatory function14. Over the 10-year follow-up stage period, survival rates were slightly superior in the short implant group, where no retreatment was Might one implant be sufficient? needed. No differences were recorded in radiographic A five-year RCT that compared mandibular bone levels15. As a result, the evidence is categorically overdentures retained with one or two implants in favour of short implants. recorded no significant differences between the two groups18. The same conclusion has recently been reached in a systematic review and meta-analysis19.

16 Hoeksema et al. Clin Implant Dent Rel Res 2015 13 Raghoebar et al. Int J Oral Maxillofac Surg 2003 17 Raghoebar et al. IJOMI 2011 14 Stellingsma et al. J Oral Rehab 2005 18 Bryant et al. J Dent Res 2015 15 Stellingsma et al. COIR 2014 19 Srinivasan et al. COIR 2015

Congress Scientific Report: EAO 24th Annual Scientific Meeting Stockholm, 24–26 September 2015 16 Implants in the future: CAD-CAM, precision of fit

The first lecture in this session described the role of monolithic zirconia in manufacturing frameworks and implant crowns, underpinned by CAD-CAM procedures as tools for planning, designing and manufacturing dental reconstructions. The second speaker described his clinical experiences of one-piece ceramic implants, which are now a real therapeutic option. The third lecture looked at CAM manufacturing technologies as applied to removable prosthodontics.

The future implant crown: chairside vs. labside Per Vult von Steyern

More than 80% of conventional impressions 4.1.1). In order to improve its aesthetic appearance, a have observable errors that may affect the fit. To promising idea could be to add a vestibular veneer address this, the use of intraoral scanners is highly protected by an occlusal flange incorporated into the recommended, particularly since manufacturers zirconia itself (Figure 4.1.2). have now improved the integration of their hardware and software with dental laboratories. To properly handle these zirconia frameworks, some limitations must be overcome, as the material is Monolithic zirconia hard to reshape and therefore it is difficult to make Monolithic zirconia is perhaps the most interesting occlusal adjustments or to correct any imprecision or new material that is available. It can be used to lack of passivity. The dimensions of the framework fabricate the frameworks of implant-supported (which are different from metal-based restorations) restorations. Although there have been few clinical also lead to some aspects that can be uncomfortable studies to evaluate its use for crowns, monolithic for the patient. The speakers’ method is as follows: translucent zirconia can be used to create a one-piece crown without veneering, and unlike traditional take a conventional impression veneered zirconia, which is associated with frequent to assure the accuracy of this, verify the model chipping, it is highly resistant to fracture1 (Figure using an acrylic jig

1 Johansson C, Kmet G, Rivera J, Larsson C, Vult oxide-stabilized zirconium dioxide compared to Von Steyern P. Fracture strength of monolithic all- porcelain-veneered crowns and lithium disilicate crowns. ceramic crowns made of high translucent yttrium Acta Odontol Scand 2014;72(2):145–53.

Material alternatives Semi-monolithic zirconium dioxide 900-1200 MPa

Monolithic translucent Traditional ”Zircona” zirconium dioxide

Figure: Fahad Bakitian

Figure 4.1.1 Figure 4.1.2

Congress Scientific Report: EAO 24th Annual Scientific Meeting Stockholm, 24–26 September 2015 17 scan the master cast, with the scan bodies placed temporary crown with composite material. To this on to the implant analogues end it is useful to have an acrylic veneer made on ask the lab to create an acrylic pre-shape made the CAD file that mirrors the contralateral tooth. from the CAD file (Figure 4.1.3) This means the technician has to imitate a proven this will be used functionally by the patient for design that has been sculpted in the mouth. An two weeks to permit a full evaluation by the alternative, faster technique is for the lab to send the dentist and to get feedback from the patient practice the restoration directly, but in this case a during this test period necessary adjustments skilled technician is required, along with very good can be made, such as adjusting the occlusion, or communication between the clinician and the lab reshaping for improved comfort or hygiene (Figures 4.1.4 and 4.1.5). when the patient is happy with the pre-shape, it is scanned by the lab and the zirconia framework A new technique to objectively assess changes of is ordered from the milling centre volume the lab then makes the white and pink porcelain The results of augmentation techniques are difficult veneering on the zirconia framework and to assess objectively. Intraoral scanning could prove cements the titanium interfaces between the to be a valuable method for standardising the results, implants and the zirconia structure enabling comparison of the different techniques (Figure 4.1.6). A prospective comparative clinical Peri-implant soft tissue modelling: direct and study was due to be published by the end of 2015. indirect methods Peri-implant soft tissue around single crowns can be sculpted by repeatedly remodelling the

Disadvantages Evaluation under function using an acrylic preshape made Time and expense from the completed CAD-file… Disturbs the tissue healing • Repetead removal of the provisionals • Composite (irritation)

Advantages? Believed to be predictable Visualizes the design for the DT The patient can see the result before making the permanent reconstruction

Figure 4.1.3 Figure 4.1.4

The direct method Evaluation: using intraoral scanner to measure soft tissue volume changes

Starting before surgery, then… Advantages? Disadvantages Fast/inexpensive Require good communication during surgery with the DT after surgery No material induced after healing inflammation/irritation Require a skilled DT at follow-ups Uninterrupted healing Risks with the ischemia? Preliminary results?

Figure 4.1.5 Figure 4.1.6

Congress Scientific Report: EAO 24th Annual Scientific Meeting Stockholm, 24–26 September 2015 18 Is ceramic the material of choice for future implants? Eric Van Dooren

Managing ‘the eternal dilemma’: thin biotype and This leads on to the question of whether this discoloured substrate material, when used with a concave profile, has Zirconia is highly biocompatible and not prone to sufficient resistance. Biomechanical studies have corrosion or chemical reactions. It is the strongest demonstrated that the impact fracture of one-piece restorative ceramic material available, and improves zirconia implants does not differ from two-piece aesthetic appearance with its white colour. It titanium implants when they are embedded in a currently represents the ideal option for patients material with a similar elastic modulus to alveolar requiring metal-free restorations. bone4. This investigation also showed that the fracture line in the zirconia implants was in the first In the anterior maxilla, due to the gingival thread and not around the transmucosal waist, as translucency, the grey of the titanium substrate could have been expected. Even after occlusal and becomes visible at the margin of the restoration. It buccal reduction, one-piece zirconia implants barely is necessary to have a soft tissue thickness of about lose their fracture resistance5. 3mm to mask this grey effect2, and this gingival thickness is rather unusual in the aesthetic zone. Thickening the buccal aspect by means of soft tissue With this in mind, the speaker described a zirconia grafting is another way of optimising the colour monoblock implant that had been designed by of the peri-implant mucosa. The speaker’s usual Drs Rompen, Van Dooren and Touati to overcome protocol for patients with a thin biotype involves this negative aesthetic effect. The challenge is that socket preservation, combined with a connective its position has to be precisely controlled both tissue graft as coverage. It is also worth noting that horizontally and vertically. irrespective of the bone or soft tissue dimensions6, zirconium implants always offer an aesthetic benefit Prosthetic manipulation offers an additional compared with titanium implants. opportunity to improve the appearance of the soft tissue margin, even in cases with compromised With zirconium implants, the emergence profile is implant positions. For example, abutments with difficult to configure. Due to the abutment diameter concave transmucosal profiles seem to allow for of the one-piece implant, it is dependent on the better and more predictable soft tissue stability and crown. This can create a problem with subgingival less mucosal recession than divergent profiles3. cementation.

4 Silva et al. Impact Fracture Resistance of Two Titanium- 2 Jung et al. In Vitro Color Changes of Soft Tissues Caused Abutment Systems Versus a Single-Piece Ceramic by Restorative Materials. Int J Periodontics Restorative Implant. Clin Implant Dent Rel Res 2011;13(2):168–73 Dent. 2007;27(3):251–7 5 Silva et al. Reliability of one-piece ceramic implant. J 3 Rompen et al. Soft tissue stability at the facial aspect Biomed Mater Res. 2009;88B: 419–26. of gingivally converging abutments in the esthetic 6 Thoma et al. Discoloration of the Peri-implant Mucosa zone: A pilot clinical study. J Prosthet Dent 2007; 97(6): Caused by Zirconia and Titanium Implants. Int J S119–S125 Periodontics Restorative Dent. 2016;36(1):39–45

Congress Scientific Report: EAO 24th Annual Scientific Meeting Stockholm, 24–26 September 2015 19 CAD/CAM in removable prosthodontics Daniel Wismeijer

CAD/CAM-fabricated implant-supported The workflow is as follows (Figure 4.3.1): during the restorations first appointment the dentist takes the impressions, Digitally fabricated removable prostheses are creates inter-occlusal records and positions the teeth. a reality today. The prostheses can be CAM Once these records have been scanned, the data are manufactured using either subtractive or additive imported into a program which allows the teeth technologies. The former involves a milling process to be virtually articulated and the prosthesis to be and uses a pre-polymerised acrylic block. The virtually designed (CAD) (Figure 4.3.2). The file is latter is achieved using stereo-lithography or other then exported to a milling device or 3D printer for 3D printing systems. It is slowly replacing the the fabrication of the denture (CAM) which is ready subtractive technique. CAM fabrication lowers costs to be placed during the second appointment. and reduces chair time. In the near future it will be possible to capture The current commercially available systems all begin the ‘whole patient’ digitally by merging data from with analogue impressions which are subsequently different scans with the bone dimensions recorded scanned in the laboratory. Occlusal aspects and tooth and virtual representations of the real smile, positions have to be adjusted with the restoration surrounded by the patient’s facial soft tissues (Figure in position. So, instead of talking about a fully 4.3.3). There are still some problems in achieving digital process, we should instead describe it as an this goal. These include the ability to take dynamic analogue technique with some digital components. impressions of the patient; the ability to digitally record jaw border movements; and finally the ability to superimpose all data with sufficient precision.

Avadent production process 1 2 3 4 5

Scan impressions Scan AMD Digital design Milling Finishing denture

CAD CAM in removable prosthodontics CAD CAM in removable prosthodontics

Figure 4.3.1 Figure 4.3.2

CAD CAM in removable prosthodontics

Figure 4.3.3

Congress Scientific Report: EAO 24th Annual Scientific Meeting Stockholm, 24–26 September 2015 20 To learn from complications Maxillary sinus grafting complications and how to avoid them. Pascal Valentini

Sinus grafting is a well-documented and complications, and both are closely linked to frequently used augmentation technique. In a infection. recent retrospective study, 54.2% of maxillary posterior implants were associated with a sinus How to prevent these complications? augmentation1. There are two main ways of preventing complications prior to surgery, and both relate to Although the procedure is undoubtedly predictable2, appropriate case selection: a variable percentage of complications have been reported, some of which are severe. The having precise knowledge of the anatomy of the complications can be intra- or postoperative. Intra- sinuses in order to foresee and to manage intra- operative complications may lead to postoperative operative complications diagnosing the health status of the sinus and 1 Seong et al. 2013 the anatomical particularities of the sinus to 2 Valentini & Abensur. IJOMI 2003

Schwarz L, Schiebel V, Hof M, Ulm C, Watzek G, Pommer B. Prevention: Risk Factors of Membrane Perforation and Postoperative Complications in Sinus Floor Elevation Surgery: Review of 407 Augmentation Procedures. Dissection by erosion (ultra sonic sugery)

J Oral Maxillofac Surg. 2015 Jul;73(7):1275-82.

- Septa - Bone height < 3.5 mm - Smokers - 31.4% sinusitis in case of perfo (even treated with adsorbable membranes)

pascal/valentini pascal/valentini

Figure 5.1.1 Figure 5.1.2

Idiopathic Deviation of nasal septum Concha bullosa

Del Gaudio & Wise 2006 Orlandi 2010 Ozkiriş M et al 2013

Uncinectomy Septoplasty Turbinectomy

pascal/valentini

Figure 5.1.3

Congress Scientific Report: EAO 24th Annual Scientific Meeting Stockholm, 24–26 September 2015 21 rule out disturbed drainage in order to prevent the sinus drainage as teeth which can induce a postoperative complications postoperative infection of the sinus graft (Figure 5.1.4). In most cases, an ear, nose and throat The most common intra-operative complication is examination during the presurgical evaluation of the perforation of the membrane lining the sinus the patient is recommended if they have any of the (Figure 5.1.1). The prevalence of these perforations is following history: reported with great disparity by different authors as ranging from 14 to 56%. The risk factors associated sinus inflammation with sinus membrane perforation, listed in order of polyps statistical significance, are3: thickened sinus membrane nasal or sinus obstruction septa and complex sinus morphology seasonal allergies residual bone height less than 3.5mm smokers Generally speaking, if the patency of the ostium is insufficient, a functional endoscopic sinus Membrane perforation is not easy to handle. The surgery (FESS) procedure is indicated to restore the lecturer illustrated a closure procedure using one ventilation of the sinus (Figure 5.1.5). resorbable collagen membrane and titanium pins. In cases of membrane perforation, there was a The risk of postoperative infection is also increased higher prevalence of sinusitis (31.4%), even after by systemic factors. The patient’s medical status intra-operative closure, due to bacterial graft should be evaluated when planning sinus surgery to contamination or graft migration into the sinus identify the following: cavity. allergic patients (penicillin allergy?) The second common complication is a vascular osteoporosis treated with bisphosphonates damage due to the presence of the alveolar antral immunocompromised patients artery with an intra bony passage. The best way to diabetes (Hb1Ac>7%) prevent intra- or postoperative bleeding is to dissect haemostasis problems this vessel using ultrasonic surgery (Figure 5.1.2). vitamin D deficiency

Postoperative complications The following conclusions can be drawn: The most frequent is an acute sinusitis which can occur 3 to 4 weeks post surgery. According 1. A preoperative 3D radiographic study of the sinus to the literature, sinusitis seems to principally is mandatory to assess the anatomical risks occur in patients who are predisposed to it. This 2. The patient’s medical history must be checked to predisposition can be diagnosed with a pre- evaluate for systemic risks operative cone beam CT , CT scan or a presurgical 3. Sinus grafting procedures should involve a endoscopic evaluation. Those examinations will team approach that includes ear, nose and allow us to detect a sinus pathology which can be throat colleagues in case selection and patient a relative or an absolute contraindication. It is also preparation, as well as management of possible possible to detect some anatomical particularities postoperative complications (Figure 5.1.3) which could disturb postoperatively

3 Schwarz et al. J Oral Maxillofac Surg 2015

Endodontics antrostomy

acute sinusitis

Greenstein G, Cavallaro J Jr. Management of a perplexing sinus lift complication J Periodontol. 2010 pascal/valentini polyposis FESS Figure 5.1.4 Figure 5.1.5

Congress Scientific Report: EAO 24th Annual Scientific Meeting Stockholm, 24–26 September 2015 22 The surgeon as the complicating factor. Franck Renouard

Although some complications can be considered to example in anaesthesiology). Statistics from the be the result of errors, the role of ‘human factors’ is USA which categorise deaths that are attributable to hardly ever taken into account when considering human errors are overwhelming (Figure 5.2.1). complications4. It is time to start examining the role that human behaviour and human attitudes play as The bad news is that, unlike complications, medical complicating factors in implant dentistry. errors are rarely reported, and that is because we are scared to admit errors (Figure 5.2.2). Thus it is very Understanding the difference between faults and hard to learn from our mistakes. errors Mistakes can be divided into two main categories: In one study which looked at 11,074 implant faults and errors. A fault is a deliberate deviation operations performed over 28 years, different levels from the rules of a particular protocol. An error is an of failure rates were observed between different inadvertent divergence from what the practitioner surgeons7. These differences could have been due to wanted to do. Fault or negligence has been found individual surgeons’ attitudes and their capacity to to be a factor in 27.6% of all serious adverse cope with the stress. medical events5. A series of so-called ‘hazardous attitudes’ (for example being macho, impulsive or Some tools to improve safe workplace practice anti-authority; or attitudes of resignation, feeling The Sterile Cockpit Rule is an FAA regulation that invulnerable, or over-confidence) have been requires pilots to refrain from non-essential activities identified in the commercial aviation field. They during critical phases of flight. A similar model have also been found to be present in 30% of a could be applied in surgical settings (Figure 5.2.3), cohort of orthopaedic surgeons6. for example, avoiding non-essential conversation during key stages of surgery. Errors reduce safety margins When an error occurs in a simple case, it can The average risk of fatal events in general normally be resolved without difficulty, but when anaesthesia dropped progressively between 1970 to margins are tight an error can lead to a disaster (for 2014, and has reached a safe level, partly thanks to a better understanding and grasp of human factors. The same progression is possible in the field of 4 Timmenga et al. J Oral Maxillofac Surg 1997 implant dentistry (Figure 5.2.4). 5 Brennan et al. Qual Saf Health Care 2004 6 Bruinsma et al. Clin Orthop Relat Res 2015; Kadzielski et al. Clin Orthop Relat Res 2015 7 Jemt et al. Clin Implan Dent Rel Res 2015

errors complications

98,000 Estimated number of deaths per year in the US hospital system attributable to medical error: incidents

5th Death by medical error, ranking in list of most common causes of death in the US:

24% Percentage of anesthesiologists who, when surveyed anonymously, admitted to errors (unreported occurrences) committing an error with fatal results:

Sources: IOM To Err is Human, , WrongDiagnosis.com Kaiser Health Poll Report 2003, Anesthesiology, 63:A497, 1985

Human attitude

Figure 5.2.1 Figure 5.2.2 Tools 4 safety Better understanding of how our Incorporation of bodies react to Human Factors the placing of dental implants Improvements in technology

The Sterile Cockpit Rule is an FAA regulation requiring pilots to refrain from 1990 2000 non-essential activities during critical phases of flight,normally below 10,000 1980 time feet

Figure 5.2.3 Figure 5.2.4 Congress Scientific Report: EAO 24th Annual Scientific Meeting Stockholm, 24–26 September 2015 23 On the evolution of complications in implant prosthodontics. Bjarni Pjetursson

Dental implant survival rates have been a suboptimal fit, leading to a harmful stress demonstrated to be very high. Real success means concentration. a long-term functional and aesthetic result that satisfies the patient’s needs – that is to say, one that Recommendations to reduce the incidence of is free of complications. When looking at survival technical complications rates, many studies have also assessed biological In the case of a single restoration, the lecturer complications. However, technical complications recommended connecting directly to the implant have received significantly less attention. This using a single screwed interface. For a restoration on lecture looked at the incidence of different technical two implants, he recommended that at least one of complications, and what we can learn from these. these should take advantage of a full connection to the implant platform and, depending on the passive Incidence fit, the other could have an intermediate connection. The average complication rate reported over a 5-year For abutments with a reduced contact area, ie multi- period in one meta-analysis was 38.7%, and only unit abutments, he recommended using at least 61.3% of patients were free of any complications8. three implants to gain a degree of tripod resistance Rates of complications that affect the function of and reduce the associated forces. In posterior zones, implant-supported reconstructions tend to increase it would be advisable to join the units together, over time. In a recent review, the 5-year rate of although care should be taken to ensure they can technical complications ranged from 16.3% to 53.2%9. still be cleaned.

Problems with the screw and implant-abutment How to avoid implant fractures connection Implant fractures are an infrequent complication During occlusal loading, the most critical area is with a cumulative incidence of 0.4% at 5 years and around the abutment screw head, where the highest 1.8% after 10 years8. Despite their low incidence, they torque and stress are concentrated. Hence, the are the most severe category of complication as they most frequent technical complication reported is lead to failure of both the implant and the prosthesis, loosening or fracturing of the abutment screws. In with the associated surgical hazards of eventual one systematic review, the angle of loading and the reimplantation. Implant diameter has been shown type of connection were shown to be factors that to have a significant effect on fatigue performance influenced strength values in laboratory studies10. during cyclic loading, but this effect is not consistent Internal conical connections exhibited significantly across different implant designs or implant materials. greater strength and resistance to bending than These findings should be taken into account when external hexagonal connections. As a result, the designing the restoration, particularly in posterior occurrence of problems with abutment screws was regions and when parafunctional forces are to be lower in internal connections. However, this result expected. is highly dependent on achieving a perfect fit. The lecturer showed a comparison between original and Finally, comparisons between older and newer cloned abutments, with the latter demonstrating studies shows some improvements9, although there is still much work to be done before technical complications are reduced to an acceptable level.

8 Pjetursson et al. Clin Oral Impl Res 2004 9 Pjetursson et al. IJOMI 2014 10 Sailer et al. Clin Oral Impl Res 2009

Congress Scientific Report: EAO 24th Annual Scientific Meeting Stockholm, 24–26 September 2015 24 What have we learned from mucogingival complications? Rino Burkhardt

An initial analysis: complications and errors Is the absence of keratinised mucosa around To answer the question posed in the title, we first implants an unfavourable feature with regard to have to establish a definition of what successful soft tissue health? The number of studies that do therapy is. The results of mucogingival therapy or do not find significant differences in plaque and must be assessed in four areas: biology; function; bleeding scores are roughly equal. There is a similar aesthetics; and patient-centred outcomes. Failures lack of clarity with regard to soft tissue dehiscences: in any of these four areas can result from some studies conclude that the width of keratinised complications or errors. A complication is an mucosa is not a predictor of recession and that unfavourable evolution of an expected result of this only occurs in the early stage, while others the therapy, i.e. unaesthetic recession of the soft cite mucosal thickness as a predictor of further tissue margin. An error is an adverse effect resulting recession, together with facial PPD11. To summarise, from an unsuitable indication or the incorrect keratinised mucosa width may not be a critical factor, implementation of the treatment procedure. but mucosal thickness affects the stability of the peri-implant tissue seal. Regardless of the type of The controversial keratinised mucosa bordering tissues, significant positive correlations It has been well-documented that the traditional have been reported between plaque scores and belief in the need for an adequate width of bleeding on probing. masticatory mucosa in order to prevent loss of attachment of teeth is not scientifically founded. But what about for implants? Four features of the peri-implant mucosa have to be assessed: width; thickness; mobility; and surface characteristics. 11 Wennström & Derks Clin Oral Impl Res 2012

What have we learned from immediate implant placement and immediate restoration? Markus Hürzeler

An evidence-based decision-making process should Although implants that have been immediately result from the combination of internal and external loaded demonstrate high survival rates, the results evidence, along with patients’ preferences and from one meta-analysis have shown that they have demands. a higher risk of failure, especially when they are unsplinted13. Primary stability, as well as the presence and dimensions of the buccal bone plate, are the main Among other parameters, case selection should considerations used when deciding whether to be based on the amount of buccal bone. With this place an immediate implant. In a recent systematic in mind, it is sometimes possible to drill through review, good aesthetic results were reported the tooth before extraction, and to use narrow with the immediate approach, including positive abutments plus a one-piece provisional. assessment using the Pink Esthetic Score (PES). However, marginal recession was present in 11% of In summary, comparing attitudes and results in 1997 the cases12. Another study, currently in preparation, to those 2015, patient demands are still the same, but reports a continued loss of volume after five years we have more clinical experience and more internal of observation, lowering the one-year success rate. and external evidence relating to immediate implant Factors which may influence the aesthetic outcome placement and immediate restoration. Despite this, in cases involving immediate implant placement and we still need to evaluate the treatment concept with immediate restoration are yet to be fully identified. caution.

12 Khzam et al. J Periodontol 2015 13 Sanz et al. Clin Oral Impl Res 2015

Congress Scientific Report: EAO 24th Annual Scientific Meeting Stockholm, 24–26 September 2015 25 Treatment and outcome challenges The current use of patient centred/reported outcomes in implant dentistry. Jan Cosyn

Implant treatment outcomes are usually assessed not. These are all factors that may introduce bias into using objective parameters such as: implant and the conclusions. prosthesis survival rates; marginal bone loss; complications; and aesthetic indexes. However, the Are fully edentulous patients satisfied with outcomes that patients care about may be quite implant treatment? different from these objective indicators. Assessing Mandibular overdentures consistently yield a treatment on the basis of patient-centred outcomes higher satisfaction score than conventional dentures is an increasingly common feature of research, in when assessed on parameters of comfort, chewing which the evaluation of patient satisfaction is ability and stability. The outcomes for both types of considered crucial. Furthermore, if we want to know prosthesis are comparable for speech, aesthetics and the real benefit of implant treatment as perceived ease of cleaning. No differences in PROMs have been by patients, we have to look through the eyes of the observed with regard to the number of implants or patient. the type of attachments used. There is only limited PROM evidence on maxillary overdentures. How can a subjective issue such as patient satisfaction be assessed? When comparing fixed versus removable implant As well as basic questionnaires focusing on prostheses, it seems that patients choose between the general patient satisfaction, there is a need to ask stability of the former or cleansability of the latter more specific questions that examine the impact in a specific pattern, depending on factors including of different aspects of implant treatment on the their age and the length of time they have been patient’s quality of life. A systematic review has edentulous. As a result, patient attitudes should be recently been published on the use of Patient- taken in account during treatment planning. Reported Outcome Measures (PROMs) in implant dentistry1. The aim of this has been to try and What are patient perceptions of partial implant update the list of PROMs and compare them against supported prostheses? different types of implant treatments. Although the number of controlled studies looking at PROMs as they relate to partial implant Is it possible to draw clear conclusions from prostheses is scarce, it can be noted that: PROMs? The authors of the systematic review noted that the timing of implant placement does not seem to non-standardised questions and different scoring affect patient satisfaction methods are commonly employed, compromising patients prefer straightforward surgery over the validity and reliability of PROMS. Thus their complex surgical procedures or bone grafting first conclusion was that there is an urgentneed for a single implant is only chosen in one in five cases standardised reporting of PROMs. In addition to oral health related quality of life (OHRQoL) this heterogeneity, it was not always clear if patients improves with a single or partial implant in the studies had actively sought implant treatment; prosthesis if they had been dissatisfied with their existing patients express a clear desire to save natural prostheses; or if they had paid for the treatment or teeth whenever possible

1 De Bruyn et al. Clin Oral Impl Res 2015

Congress Scientific Report: EAO 24th Annual Scientific Meeting Stockholm, 24–26 September 2015 26 Quality of life in patients undergoing bone grafting procedures Guido Heydecke

Bone grafting is indicated to achieve stable implant levels of morbidity. A significant deterioration in placement if the available bone is insufficient. physical HRQoL was reported from 3 days (process- Some adverse effects of bone grafting have to be related) to 4 weeks (output- related) following bone considered, such as pain, swelling and impaired grafting surgery. Levels were reported as being quality of life during the procedure and its healing lower and longer-lasting for extra-oral donor sites. process. Thus it seems highly appropriate to take the By comparison, the impact of intra-oral grafting perspective of the patient into account during the procedures on OHRQoL was quite modest. The decision-making process. figures showed similar changes regarding pain. Based on these findings, intra-oral donor sites How is the burden of bone grafting perceived by should considered preferable and selected wherever the patient? possible. Several studies have investigated patient perceptions of bone grafting surgery, but comparison of the Is the patient’s perceived impact of implant results is very difficult due to non-standardised placement higher than that of other surgical approaches. The Health-Related Quality of Life procedures? (HRQoL) and Oral Health-Related Quality of Life Recent studies3 have shown that patients consider (OHRQoL) tools are standardised, and both are well- implant placement to be less burdensome than accepted methods for assessing patient perceptions. practitioners imagine. Results also show that Recently, HRQoL data (measured using the SF-36 they rate it as significantly less burdensome than questionnaire) and OHRQoL (obtained using the practitioners even when bone and soft tissue OHIP-49 questionnaire), along with pain data manipulation is required, when compared with (assessed using the Visual Analogue Scale) was surgical tooth removal or apicectomy. The part of the collected from 23 patients following intra- and extra- procedure that patients consider most burdensome oral bone grafting2. In addition, patients were asked is local anaesthesia. Therefore, patients should be a series of previously validated questions focusing reassured that implant surgery is less burdensome on different aspects of their general and oral and uncomfortable than other commonly performed health, with the aim of quantifying and comparing oral surgery procedures.

2 Reissmann et al. Clin Oral Impl Res 2013 3 Reissmann et al. J Dent 2015

Management of bone defects in the aesthetic zone. De-Hua Li

Aesthetic appearance is a well-established criteria recent systematic review found evidence of average for implant success. Localised bone defects are survival rates of 95.4% for implants placed in either anatomical challenges since they can compromise augmented bone or pristine bone. Nevertheless, the the placement of implants in a prosthetically ideal mean defect resolution was 81.7%, and complete position. Thus, sufficient bone volume is considered defect fill was only reported in 68.5% of the cases4. to be a prerequisite for good aesthetic results. Clinical management of defects to solve this The prevalence of cases in which there is insufficient perceived unpredictability should be based on the bone can be estimated to be over 50%, although in following GBR principles (Figure 6.3.1 and 6.3.2): situations involving anterior restorations it could be over 90%. In these clinical situations, guided bone stable barrier protection regeneration (GBR) is often indicated, although there adequate space for bone formation is a general perception that bone defect resolution is not 100% predictable in daily practice. Despite this, a 4 Jensen et al. Int J Oral Maxillofac Implants 2009

Determinants to the stability of the grafting area Guided bone regeneration

Essentials of this technique • The topography of alveolar bone defects • Stable barrier protection • • Adequate space for bone formation The location of bone defects • Stability of the grafting area • The modality of grafting procedure • Osteogenic capacity of the local site

Figure 6.3.1 Figure 6.3.2

Congress Scientific Report: EAO 24th Annual Scientific Meeting Stockholm, 24–26 September 2015 27 stability of the grafted area same time as implant placement. One particular type osteogenic capacity of the local site of case requires special mention: immediate post- extraction implant placement. These cases should be The determinants of grafting stability are dependent treated as 4-wall or 3-wall defects (Figures 6.3.7 and on three factors (Figures 6.3.3–6.3.5): 6.3.8).

the topography of the alveolar bone, including In the aesthetic zone, immediate implant placement the number of walls is a demanding procedure, given the high the location of the defect, and whether it is prevalence of gingival recession. Only cases with a circular, vertical or features a perforation/ thick biotype should be selected, and the implant dehiscence should always be placed palatally and away from the modality of the grafting procedure the buccal wall, thus creating a vestibular gap to be filled with particulate graft. It is important to use an evidence-based defect classification when planning the treatment. Each When dealing with 2-wall or 1-wall defects, type of defect has an associated surgical approach, particularly in vertical deficiencies, the technique level of difficulty and prognosis. A table combining should be considered advanced and a staged topography and location can be used to classify the approach is mandatory in most situations. These surgical complexity (Figure 6.3.6). cases should be handled using onlay grafting or titanium mesh to maintain space (Figures 6.3.9 and In self-containing defects, the procedure is 6.3.10). straightforward and GBR can be performed at the

Determinants to the stability of the grafting area Determinants to the stability of the grafting area

• The topography of alveolar bone • The topography of alveolar bone defects defects

• The location of bone defects • The location of bone defects

• The modality of grafting procedure • The modality of grafting procedure

Figure 6.3.3 Figure 6.3.4

Grafting techniques Strategy of bone managements

one-wall two-wall three-wall four-wall • Particulate grafting advanced advanced • Block grafting vertical (staged) (staged) • Reinforcements advanced relatively dehiscent complex (staged) simple

relatively relatively perforative complex simple simple simple

circular simple

To simplify the procedure of bone management! Figure 6.3.5 Figure 6.3.6

Figure 6.3.7 Figure 6.3.8

Congress Scientific Report: EAO 24th Annual Scientific Meeting Stockholm, 24–26 September 2015 28 In difficult cases with proper topographies of alveolar treatment planning for this include: an angled ridges, instead of using conventional bone block abutment; a cantilever; pink ceramic; and narrow augmentation, the ridge expansion approach can diameter implants. optimise the grafting conditions and simplify the procedure, transforming a 1-wall defect into a 4-wall Paraphrasing the Fourth ITI Consensus, there are defect (Figure 6.3.11 and 6.3.12). Sometimes a ridge specific indications for each technique and the split/expansion procedure can be carried out alone to simplest and least risky technique should be chosen. enable implant placement (Figure 6.3.13 and 6.3.14). The classification of bone defects will help with decision-making relating to bone augmentation Of course there is always the possibility of managing (Figure 6.3.15). insufficient bone volume prosthetically. Modified

If in a conventional way

Figure 6.3.9 Figure 6.3.11

Figure 6.3.10 Figure 6.3.13

Crest extension + GBR Summary Figure 6.3.12 • Every surgical procedure presents speciÞc indications, advantages and disadvantages, which must be carefully evaluated before surgery. It is therefore difÞcult to provide clear indications with respect of which procedures are actually needed. y Priority should bebe givengiven toto thosethose procedures procedures which which look look simpler simpler,, • The classification of bone defects would help with lessless invasive,invasive, involveinvolve lessless riskrisk ofof complications,complications, and and reach reach their their the decision-making of bone augmentation goals within the shortestshortest timetime frame.frame. Ñ ITI Consensus Conference 2008

The classification of bone defects would help with the decision-making of bone augmentation

Figure 6.3.14 Figure 6.3.15

Congress Scientific Report: EAO 24th Annual Scientific Meeting Stockholm, 24–26 September 2015 29 Implants in the future: virtual planning, 3D printing and more The virtual patient: how far away are we? Thabo Beeler

Entertainment meets digital dentistry photogrammetry, a technology that uses two Despite a significant improvement in rendering (or more) slightly displaced images of the same quality, modelling human faces realistically still object and combines them into one 3D image on remains a challenge for computer graphics. The the computer. Working with various matching speaker is a member of the research team at Disney algorithms, the software makes a computer model Research Zurich. Working in collaboration with ETH that is later meshed and refined at different scales. (Swiss Federal Institute of Technology, Zurich) the company has been involved in a research project to It is also possible to use this system to capture acquire and model at high resolution the geometry dynamic information and accurately measure the and appearance of the face. Although the research deformation of skin, for example a subject slapping is mainly aimed at the entertainment industry, it himself and causing a shockwave in his face. has a direct application in the field of dentistry for developing virtual patients. The system does, however, have its limitations. It works well for the skin, but it is not suited for Creating a virtual patient is a specialist development hair and eyes. In the case of the hair, the hidden of computer graphics that follows a well-known episurface is estimated from reconstructed hair process which can be outlined in five steps: that has to be added to the computed model of the skin. The eyes play a central role in the appearance capturing the subject’s geometric data of the face. Their features vary widely, defining the reconstructing the shape of the patient’s face as a person’s individuality, and this needs to be captured computer model with high fidelity. The proposed system works in manipulating this model three different steps (sclera, cornea and iris) which simulating the desired changes to be carried out are combined to the complete eye model. visualising the virtual results The acquired skin geometry is accurate to a scale of This workflow is about to become the state-of-the- 100µ. Recently, facial scanning techniques have also art in imaging, planning and evaluating treatment been developed using consumer-grade binocular for orthodontics, reconstructive dentistry and stereo cameras, video cameras and even a smart maxillofacial surgery. phone, indicating that the technology is ready to expand beyond the professional domain. It might Capturing a high-quality model of the patient’s soon even be possible to obtain a realistic skin face mask as a 3D object using the latest-generation 3D Traditional data acquisition systems incorporated printers. artefacts due to their long duration. As a result their accuracy was limited, and in addition the process Superimposing CBCT data, intraoral scanning, was complex and the cost was high. The goal of imaging of the face and brief motion data can the project in Zurich is to make capturing the 3D create the virtual patient. This enables treatment geometry of the face with sub-millimetre resolution to be simulated and can help illustrate treatment and fidelity as easy as taking a photograph. A outcomes to patients. It is an extremely effective seven-camera system is used to make a single- communication tool, the extent of whose benefits are shot stereoscopic capture. The procedure is called yet to be totally identified.

Congress Scientific Report: EAO 24th Annual Scientific Meeting Stockholm, 24–26 September 2015 30 The origin, present and future of 3D printing Dianne Rekow

3D printing or additive manufacturing is the abutments; crowns; metal sub-structures; base plates; process of making three dimensional solid objects guides; splints; and complete or partial dentures can layer by layer from a digital file. This technology be manufactured using 3D printing. Implants can originated in the 1980s with the use of photo- even be made using sequential layering. hardening polymers. The evolution of 3D printing has produced a large number of additive printing The production process continues to be one-at-a- processes. time, at least for most processes, and the machine is the major cost. As a result, 3D printing is carried out An overview of the different systems reveals that almost exclusively in laboratories. there are fundamentally two families: The future of 3D printing those that spray materials though some kind 3D printing has the promise to replace the milling of syringe or nozzle, such as fused deposition machine. If that occurs, it would be prudent to modelling (FDM), laser engineered net shaping rethink restoration design to capitalise on the (LENS) and PolyJet structural advantages and intrinsic potential those that bind raw materials using laser available with this new technology. New materials or adhesion, such as stereolithography (SL), may need to be developed. Complex geometries laser sintering (LS) and laminated object – accurate to micrometre dimensions – are now manufacturing (LOM) possible. There is still much room for innovation and development, and an array of dental products could In all cases, the material options are tied to the be printed chairside in the future. Many children system type and to date most machines can are already learning about 3D printing in school, only handle one class of materials (for example, and this is a field that will generate numerous photopolymers or metals). innovations in the near future. A possible application will likely include being able to deliver the right The current state-of-the-art drugs in the right locations by incorporating them An amazing variety of possibilities are now available into resorbable scaffolds. The bioprinting of ‘living for fabricating objects. Applications demonstrated ink’ is already possible. In the future – in fact in the include jewellery, engines, body parts, aeroplane very near future – it may be possible to incorporate parts and even multi-storey apartment buildings. the appropriate cells for organ generation into In dentistry, a wide range of components including printed scaffolds.

3D printing in maxillofacial surgery Lawrence Brecht

The Jaw-in-a-Day procedure interdisciplinary team to pre-plan the surgical Resection of jaw tumours requires the replacement ablation; create selective laser sintered (SLS) of bone, soft tissue and teeth. In the mandible, cutting guides; and to have an occlusally-designed the fibula free flap has become the routine bone restoration fabricated digitally prior to surgery. reconstructive procedure. But re-establishing These measures maximise surgical accuracy during adequate facial contours requires proper complex reconstructions involving osteotomies; orthognathic relationships and appropriate dental bone segmentation and reshaping; the placement of rehabilitation. These are both major challenges and implants; and occlusal restorations. demand high levels of precision. This precision is hard to achieve freehand, but maxillofacial surgeons In the NYU Langone Medical Center, digital can now plan the treatment virtually and transfer planning and 3D printing has been stimulating it to the surgical field. CAD/CAM technologies a progressive optimisation of template designs. can now be used to create highly accurate models, The current (fourth) generation offer custom surgical splints, implant placement guides and reconstruction plates with z-axis control. Although cutting jigs, and have revolutionised these surgical surgeons have less experience of using it in this field, interventions. Using the previous protocols, dental the protocol also works in the reconstruction of the restoration was delayed for 3 to 6 months, but it can maxilla. now be performed in one stage. The ‘jaw-in-a-day’ technique has had a significant impact on the field The speaker also described other types of of maxillofacial reconstruction, offering increased cases which had been treated using these new accuracy while improving the patient’s function and technologies. These included acquired facial quality of life. deformities, such as a paediatric patient with osteoradionecrosis who underwent a virtually Virtual surgical simulation and stereolithographic guided resection of the orbit, along with fibula models based on CT scan data allow the reconstruction and adhesive prosthesis. Other cases

Congress Scientific Report: EAO 24th Annual Scientific Meeting Stockholm, 24–26 September 2015 31 involving the replacement or reconstruction of printing. Finally, the author talked about his early the nose or ear have been successfully addressed experience of these techniques when applied to face using virtual planning and prostheses made by 3D transplantations.

3D printing in prosthodontics Vincent Fehmer and Irena Sailer

Why 3D printing in prosthodontics? it has the capacity to reproduce complex Early CAD/CAM systems relied almost exclusively geometries with cavities and undercuts, with on milling a restoration out of prefabricated blanks highly predictable outcomes of different materials. This kind of subtractive fabrication accurately creates the desired shape, Digital diagnostics and 3D printing although at the expense of time, high cost and with The ‘digital workflow’ begins with the capturing almost 90% of the material wasted. of digital intraoral scans and continues with the creation of virtual diagnostic setups from which 3D printing is a rapidly emerging additive high-resolution diagnostic models can be printed. technology that is gradually changing the manufacturing protocol for dental prosthodontics. Conventional mock-ups are an efficient tool A variety of components are now being made for communication with the patient, helping using 3D printing . These include surgical guides; to anticipate results and offering enhanced wax patterns for fixed/removable prostheses; opportunities to obtain informed consent for moulds for metal or ceramic processing; metal or the treatment before it commences. But creating ceramic frameworks; and maxillofacial prostheses. these conventional mock-ups is a time-consuming 3D printing is becoming the preferred process as procedure that results in only a single version of it offers a range of advantages compared with the possible treatment outcome. Digital mock-ups subtractive alternatives: using 3D diagnostic digital wax-ups or set-ups can be straightforwardly printed out of resin, and enable it has improved accuracy1 and doesn’t induce the try-in of multiple possible treatment solutions micro cracks (Figures 7.4.1–7.4.4). it offers improved efficiency, both in terms of cost and time Final reconstructions and 3D printing less raw material is wasted and there is less wear/ It is now increasingly practical to fabricate a variety abrasion of cutting tools of final restoration parts – such as copings, crowns and frameworks for fixed and removable prostheses – using 3D printing technologies. A typical workflow involves planning implant placement using data captured from the 3D CBCT, followed by the 1 Örtorp et al. The fit of cobalt-chromium three- creation of a 3D-printed surgical guide, then the unit fixed dental prostheses fabricated with four adaptation of the provisional bridge printed out different techniques: A comparative in vitro study. from the same file during the surgery (Figures Dent Mater. 2010; 27(4:356–63) 7.4.5–7.4.7).

Digital diagnostics & 3D printing Digital diagnostics & 3D printing

conventional impression optical impression

Advanced smile diagnostics using CAD/CAM mock-ups; M Sancho-Puchades, V Fehmer, CHF Hämmerle, I Sailer, The Inernational Journal of esthetic dentistry 07/2015;10(3):374-391 Advanced smile diagnostics using CAD/CAM mock-ups; M Sancho-Puchades, V Fehmer, CHF Hämmerle, I Sailer, The International Journal of esthetic dentistry 07/2015;10(3):374-391 Figure 7.4.1 Figure 7.4.2 Digital diagnostics & 3D printing Digital diagnostics & 3D printing

Advanced smile diagnostics using CAD/CAM mock-ups; M Sancho-Puchades, V Fehmer, CHF Hämmerle, I Sailer, The International Journal of esthetic dentistry 07/2015;10(3):374-391 Advanced smile diagnostics using CAD/CAM mock-ups; M Sancho-Puchades, V Fehmer, CHF Hämmerle, I Sailer, The International Journal of esthetic dentistry 07/2015;10(3):374-391 Figure 7.4.3 Figure 7.4.4

Congress Scientific Report: EAO 24th Annual Scientific Meeting Stockholm, 24–26 September 2015 32 3D printing can also be harnessed for the fabrication Zurich, the University of Zurich and Disney of metal structures, either indirectly by creating Research to develop a 3D face scanning system burn-out resins or waxes for lost-wax processes, or tailored for medical applications (Figure 7.4.8). The directly by printing using metals or metal alloys. ‘virtual patient’ consists of a merged dataset from Although still in development, ceramic printing is CBCT, intraoral scans and facial scan files. Successful an emerging procedure which can be used to make development of virtual patient models opens up monolithic crowns and frameworks. the possibility of virtual diagnostics; printed try-in tools; guided treatment (surgical guides, preparation The ‘virtual patient’ guides); digital colour assessment; and printed final The speaker described her involvement in the reconstructions. previously cited research project involving ETH

New Methods and Materials in todays treatment concepts New Methods and Materials in todays treatment concepts

Cerec OmniCam Vita Enamic

Figure 7.4.5 Figure 7.4.6 Final reconstructions & 3D printing The future of 3D in prosthodontics utilizing new technologies

ETHZ: Mörzinger R, Solenthaler B, Wu C, Gross M UGE: Sailer I Private practice: Lübbers T Disney Research Zurich: Beeler T

Figure 7.4.7 Figure 7.4.8

Congress Scientific Report: EAO 24th Annual Scientific Meeting Stockholm, 24–26 September 2015 33 Consensus Conference 2015

What is a consensus conference and how is it these drafts and work towards developing the final organised? consensus statements. The EAO held its 4th Consensus Conference in Switzerland from 11–14 February 2015. This brought Why is it important? together experts in implant dentistry from across The field of implant dentistry has been almost the world to discuss a range of key topics. After overwhelmed by very rapid changes as new the conference, the findings were published in a protocols, materials and strategies emerge. The supplement of Clinical Oral Implants Research. research community does its best to respond as rapidly as possible to these new developments The process for the 2015 conference began with the in order to assess their safety and efficacy. appointment of the three chairs who would organise Unfortunately, the evidence gathered is often not it, namely Björn Klinge, Christoph Hämmerle optimal, either in terms of quantity or quality. and Marc Quirynen. They then identified an Problems can arise if sample sizes are too small; international group of scientists and practitioners there is an absence of long-term evidence relating to collectively recommend potential topics to be to efficacy; or there is bias in the study. As a result, discussed at the conference. Having approved the there is a need for guidance on which procedures are list of topics, the committee selected the reviewers appropriate in which cases. The EAO tries to bridge and participants (experts on individual topics) and this gap between research and clinical practice formed four working groups. through its Consensus Conferences.

The second step consisted of scrutinising the Why the EAO Consensus Conference is unique literature published on each topic in a systematic Much of the research available to practitioners is way to identify relevant scientific papers that related led or sponsored by industry, and it is often difficult to each subject. These reviews were circulated to to distinguish information that may be biased from participants to be read before the meeting. independent research. Findings from events like the EAO consensus conference, which receives no Once all the participants were face to face at the industry funding whatsoever, provide valuable conference, the meeting was structured around four independent perspectives and conclusions which are working groups and two types of sessions. During not influenced by commercial interests. the work sessions, members of each of the four groups prepared draft conclusions on the topics they The findings of all the EAO’s Consensus were examining. In the regular plenary sessions, Conferences, including the 2015 conference, all participants came together to discuss/agree are available with open access from http://www.eao.org/consensus-paper

The patient undergoing implant therapy Group 1 (speaker: Thomas Flemmig)

Perioperative antibiotics in conjunction with The value of this modest figure must be put in the dental implant placement context of the growing problems with antibiotic With the aim of assessing the effect of antibiotic resistance before antibiotic prophylaxis is adopted prophylaxis on implant survival in conjunction as a guideline. The final consensus conclusion was with dental implant placement, an extensive review that antibiotic prophylaxis is not recommended yielded 7 systematic reviews and 9 primary clinical in uncomplicated cases and healthy patients. In trials. The result was a 2% overall reduction in risk complicated cases, the beneficial effect can not be of implant loss when using antibiotic prophylaxis excluded. compared with placebo (Figure 8.1.1).

Congress Scientific Report: EAO 24th Annual Scientific Meeting Stockholm, 24–26 September 2015 34 Risk indicators for peri-implantitis affected either by the number of implants, or by the The existing evidence identifying risk indicators attachment system. Although individual perceptions for peri-implantitis was reviewed in MEDLINE up may vary widely, in the maxilla no major difference to October 2014. It can be clearly stated that peri- in patient satisfaction was seen. There were implant plaque accumulation is the cause that insufficient data to compare PROMs relating to triggers the inflammatory response leading to peri- overdentures with fixed prostheses or to draw implant mucositis/peri-implantitis. A complex conclusions from partially edentulous patients. Nor microbiota has been demonstrated to be involved did the timing of implant placement have any effect in the process. There is overwhelming evidence that on PROMs. smokers and patients with a history of periodontal disease have an increased risk of developing peri- Economic evaluation of implant-supported implantitis. There is also some evidence to support prostheses the role of genetic polymorphism, diabetes, and Economic evaluations measure the efficiency of excess cement as risk indicators for the disease. different healthcare interventions and can provide As a consequence, regular maintenance care useful information for decision-making. Cost- and treatment of periodontitis prior to implant effectiveness analysis relates measures of outcome placement must be strongly recommended (Figure to treatment costs and is most valuable for assessing 8.1.2). interventions that are more effective and cost more than their alternatives, in terms of incremental cost- The current use of patient-centred/-reported effectiveness ratios (ICERs) (Figure 8.1.4). outcomes in implant dentistry The aim of this review was to provide an update Various clinical scenarios were analysed and the on the use of Patient-Reported Outcome Measures following conclusions drawn: (PROMs) in implant dentistry and to compare PROMs for implant-supported prostheses with alternative for central incisors with irreversible pulpitis and treatment options or a healthy dentition (Figure coronal lesions root canal treatment was the most 8.1.3). The search (up to December 2014) yielded 635 cost-effective treatment option publications, 300 of which had been published in the for replacing a single missing tooth, an implant- last 6 years. 84 controlled studies could be identified, supported crown seems to be more cost-effective including 38 RCTs and 31 cohort studies. that a fixed bridge for the edentulous mandible, overdentures The authors feel there is an urgent need for improved oral health-related quality of life, but standardised reporting of PROMs in the field of cost more than conventional dentures implant dentistry. There is plenty of evidence for molars with furcations, periodontal therapy that patients with a fully edentulous mandible was found to be more effective and less costly experience higher satisfaction with an implant- than implant-supported single crowns, but this retained overdenture when compared with a finding may need to be interpreted with caution conventional denture. The PROMs were not

EAO Consensus Conference 2015 EAO Consensus Conference 2015 Group 1 The Patient Undergoing Implant Group 1 The Patient Undergoing Implant Therapy Therapy General conclusions from the paper and Group’ s consensus General conclusions from the paper and Group’ s consensus (cont.) Antibiotic prophylaxis - 2% overall reduction in risk of implant loss Preventive - NNT 50 - Treatment of periodontitis - Regular maintenance care Uncomplicated cases and healthy patients - No benefit - Not recommended

Complicated cases - Beneficial effect cannot be excluded Perioperative Antibiotics in Conjunction with Dental Implant Placement. Complex Systematic Review Risk Factors for the Development of Peri-implantitis. A Narrative Review Lund B, Hultin M, Tranaeus S, Naimi-Akbar A, Klinge B Renvert S & Quirynen M Clin Oral Impl Res 26(Suppl. 6) 2015 Clin Oral Impl Res 26(Suppl. 6) 2015 Figure 8.1.1 Figure 8.1.2 EAO Consensus Conference 2015 EAO Consensus Conference 2015 EAO Consensus Conference 2015 Group 1 The Patient Undergoing Implant Group 1 The Patient Undergoing Implant Therapy Therapy Aim of the review Material & Methods Cost

Costs more Costs more Patient reported outcome measures (PROMs) MEDLINE and Cochrane Library Less effective More effective - In implant dentistry Until December 2014 ICER - Implant-supported prostheses vs. alternative Effectiveness treatments Cost-minization analyses (CMA) Costs less Costs less Cost-effectivenes analyses (CEA) Less effective More effective Cost-benefit analysis (CBA) Adapted from Higgins et al. 2012

Current Use of Patient Centered/Reported Outcomes in Implant Dentistry: A Systematic Review Economic Evaluation of Implant-supported Prosthesis. A Narrative Review De Bruyn H, Raes S, Matthys C, Cosyn J Beikler T & Flemmig TF Clin Oral Impl Res 26(Suppl. 6) 2015 Clin Oral Impl Res 26(Suppl. 6) 2015 Figure 8.1.3 Figure 8.1.4

Congress Scientific Report: EAO 24th Annual Scientific Meeting Stockholm, 24–26 September 2015 35 Digital technologies to support planning, treatment, and fabrication processes and outcome assessments in implant dentistry. Group 2 (speaker: Christoph Hämmerle)

Computer-supported implant planning and stress reduction in the operating room as a guided surgery result of guided surgery may be a considerable The literature search aimed to provide an overview additional benefit of computer-supported implant planning and computed tomography (CT) does not offer guided surgery from examination to planning and advantages over cone beam computed execution, including possible errors and pitfalls, in tomography (CBCT) regarding guided implant order to justify the indications for guided surgery. surgical procedures The conclusions are: the clinical situations and the categories of patients who benefit the most from guided guided implant surgery clearly reduces surgery should be identified more clearly inaccuracy as compared with freehand surgery the accuracy obtained when following guided CAD/CAM-fabricated implant-supported implant surgery protocols increases the possibility restorations of delivering an ideal final reconstruction Having identified and summarised the available transferring the implant planning data to the literature related to CAD/CAM-fabricated implant- operative field remains the most difficult part supported restorations, promising short-term results tooth-supported guides render the highest have been observed (Figure 8.2.2). Overall, the accuracy and mucosa supported guides offer current evidence is quite limited due to the quality of higher accuracy than bone supported guides studies and the paucity of data on long-term clinical (Figure 8.2.1) outcomes. future improvements may come from reducing the steps needed for guided surgery Digital technology is used for the design and if the predictability of the treatment can be manufacture of implant prosthetic components, increased, the number of clinical implications can specifically for abutments, crown and bridge be further expanded frameworks and associated veneers. Clinical as guided surgery adds precision to flapless feasibility has been demonstrated for most of them, surgery, it has implications in geriatric as well as offering technical, clinical and procedural benefits. medically compromised patients No information is presently available on monolithic

EAO Consensus Conference 2015 Group 2 Digital technologies General conclusions from the paper The findings of all the EAO’s • Tooth supported guides render the highest accuracy Consensus Conferences, including • Mucosa supported guides offer higher accuracy the 2015 conference, are than bone supported guides available with open access from http://www.eao.org/consensus-paper

Computer-supported implant planning and guided surgery Marjolein Vercruyssen, Isabelle Laleman, Reinhilde Jacobs, Marc Quirynen Clin Oral Impl Res 26(Suppl. 11) 2015: 69-76 Figure 8.2.1 EAO Consensus Conference 2015 EAO Consensus Conference 2015 Group 2 Digital technologies Group 2 Digital technologies

General conclusions from the paper General conclusions from the paper • Recent technological progress has provided useful tools for assessing • Overall, the current evidence in the literature is outcomes of oral rehabilitation with dental implant including the following quite limited, but short-term results are techniques: promising - Cone-beam computed tomography • Publications on single crowns and FDPs are - Magnetic resonance imaging very few - Ultrasonography • 10 papers on full-arch screw-retained FDPs - Optical scanning reported survival rates ranging 92% – 100% - Optical coherence tomography during observation times of 1–10 years. - Spectrophotometry.

CAD/CAM-fabricated implant- supported restorations Novel digital imaging techniques to assess the outcome in oral rehabilitation with dental implants Sebastian Berthold Maximilian Patzelt, Benedikt C Spies, Ralf J Kohal Goran Benic, Moustafa Elmasry, Christoph Hammerle Clin Oral Impl Res 26 (Suppl. 11) 2015: 77-85 Clin Oral Impl Res 26 (Suppl. 11) 2015: 86-96 Figure 8.2.2 Figure 8.2.3

Congress Scientific Report: EAO 24th Annual Scientific Meeting Stockholm, 24–26 September 2015 36 reconstructions made entirely using CAD-CAM Optical scanning is being used for the 3D procedures. assessment of changes in the soft tissue contour. The combination of an optical scan with preoperative In many clinical situations, computer-aided CBCT allows the determination of the implant reconstructive dentistry can offer specific benefits position and its spatial relation to anatomic relating to standardisation and data acquisition, structures. communication tools, and industrialised fabrication with a reduction in time, efforts and costs. Spectrophotometry is commonly used to assess the colour match of prostheses and peri-implant mucosa But there are important research implications: the to natural dentition and gingiva. rapid development of CAD-CAM technologies has added a multitude of new parameters to be tested, When available, multiple patient-related data sets and researchers have to identify the most relevant (eg CBCT, intraoral and laboratory scans, virtual clinical questions and the appropriate control groups. planning of implants and restorations) should From the point of view of evidence-based dentistry, ideally be integrated to maximise their synergistic the authors recommend further studies designed as diagnostic value: the so called ‘virtual patient’. randomised controlled clinical trials and reported according to the CONSORT statement. Regarding research on this subject, there is a need for validation and standardisation of the majority of Novel digital imaging techniques to assess the novel digital imaging techniques and dedicated the outcome in oral rehabilitation with dental software. At the same time, computer algorithms implants have to be improved to enable accurate matching Diverse digital imaging devices (Figure 8.2.3) have of different 3D data sets (eg facial scan and CBCT) recently been introduced allowing precise and and integration into specific software. Research is reproducible assessment of implant-related outcome required to validate these novel methods before they parameters, and therefore a standardisation of the are used in daily clinical practice. results.

Soft and hard tissue aspects. Group 3 (speaker: Alberto Sicilia)

Soft tissue augmentation around dental implants: tissue grafting is able to increase the peri-implant its impact on soft and hard tissue stability soft-tissue thickness and the width of keratinised The systematic review prepared by this group aimed tissue (Figure 8.3.1) to answer the following question: ‘What is the long- in posterior mandibular areas with thin crestal term effect of soft tissue augmentation procedures tissue, marginal peri-implant bone loss may around dental implants with respect to the soft and be reduced by means of vertical soft tissue hard tissue stability?’. thickening procedures (Figure 8.3.2) only two 1-year case series studies were Articles on peri-implant soft tissue augmentation appropriate for meta-analysis, and showed a were systematically searched for, with only reduction of 1.65 ± 0.01 mm in marginal recession prospective studies with at least 10 patients and after peri-implant plastic surgery (Figure 8.33) 1 year of follow-up included. Of 4,327 articles subjective and objective aesthetic results may identified, 47 were read in full and 10 were finally also be improved by soft tissue augmentation selected: 2 RCTs, 5 CCTs and 3 prospective clinical techniques (Figures 8.3.4 and 8.3.5) studies. Group’s consensus statement: There are clear The outcome variables considered for analysis were: indications for the use of soft tissue grafts to improve the peri-implant tissue situation as well as peri-implant attached/keratinised tissue width the aesthetics. However, we have to bear in mind peri-implant soft tissue changes that there is no long-term evidence to strongly peri-implant marginal soft tissue level changes recommend peri-implant soft tissue augmentation peri-implant marginal bone level changes procedures. The decision must at this stage be left aesthetics, evaluated by patients to the clinician’s judgement after a thorough patient aesthetics, evaluated by dentists evaluation.

The general conclusion of the review was that there Long-term outcomes of bone augmentation on is no long-term evidence for whether augmented soft and hard tissue stability soft tissues can be maintained over time and are The review analysed the current literature regarding able to influence peri-implant bone levels. But over medium- and long-term data concerning the shorter observation periods, some limited evidence stability of peri-implant tissues after hard tissue can be identified: augmentation prior to or at the same time as implant placement. some clinical data seems to support the theory that soft tissue augmentation based on connective

Congress Scientific Report: EAO 24th Annual Scientific Meeting Stockholm, 24–26 September 2015 37 The search focused on prospective clinical studies One study using CBCT evaluation found absent assessing peri-implant bone and soft tissue stability buccal hard tissue at 7 years in 36% of implants, over time, with a minimum follow-up of 12 months leading to a pronounced soft tissue recession. and a sample of at least 10 patients. From 1,687 However, GBR augmentation associated with articles yielded by the electronic search, 37 met the immediate implant placement may not be inclusion criteria, of which 10 were RCTs and 27 recommendable, as further bone loss of the buccal were CCTs. Taken together, the studies evaluated 274 plate may occur (Figure 8.36). implants in 230 patients. There is a lack of data about the medium- to Great heterogeneity was observed in the studies long-term stability of augmented bone using regarding the materials and techniques used for surgical techniques other than GBR, although augmentation, as well as the methods used for stability has been reported in the short-term with evaluation. The outcome variables analysed were: techniques using autogenous bone, with or without deproteinised bovine bone mineral, and titanium mean marginal interproximal bone loss (peri- mesh or fibrin glue acting as stabilisers of the graft apical Rx’s) (Figure 8.3.8). 3D evaluation by CBCT examination (three studies) The effect of zirconia or titanium as abutment soft tissue recession (periodontal probing or materials on peri-implant soft tissues calibrated photographs) The aim was to analyse research with regard to the soft tissue dimensions with radiopaque markers effect of zirconia or titanium as abutment materials (CBCT) on peri-implant soft tissues. To this end, a search was made of articles showing a direct comparison of Having reviewed all the studies, it can be concluded both types of abutment material in the same patient. that there is limited information regarding both The inclusion criteria include a sample of at least 10 stability of the soft tissue and the underlying patients, a follow-up of at least 1 year and reporting regenerated bone. However, some studies on on at least one of the outcome measures. Of 454 simultaneous GBR procedures show significant bone initial results, 11 met the inclusion criteria: 4 RCTs gain and a positive relationship between the two and 7 CCTs. tissues over a medium-term period (Figure 8.3.7).

EAO Consensus Conference 2015 EAO Consensus Conference 2015 Group III Group III

Group’s Consensus Group’s Consensus 1.- Soft tissue augmentation procedures are able to increase the peri- 2.- In posterior mandibular areas with thin crestal tissue, marginal peri- implant soft tissue thickness and the width of keratinized tissue. implant bone loss may be reduced by means of vertical soft tissue thickening procedures.

1.2 mm

1.6 mm

Long-term stability of peri-implant tissues after bone or soft tissue augmentation. Effect of Zirconia or titanium Long-term stability of peri-implant tissues after bone or soft tissue augmentation. Effect of Zirconia or titanium abutments on peri-implant soft tissues. Consensus Report of Group 3. abutments on peri-implant soft tissues. Consensus Report of Group 3. Sicilia A, Quyrinen M et al. Clin Oral Impl Res 26 (Suppl. 11) 2015. Sicilia A, Quyrinen M et al. Clin Oral Impl Res 26 (Suppl. 11) 2015. Figure 8.3.1 Figure 8.3.2 EAO Consensus Conference 2015 EAO Consensus Conference 2015 Group III Group III

Group’s Consensus Group’s Consensus 2.- In posterior mandibular areas with thin crestal tissue, marginal peri- 3.- The coverage of exposed implant/abutment surfaces related to shallow implant bone loss may be reduced by means of vertical soft tissue marginal soft tissue recessions may be achieved by means of CAF+CTG. thickening procedures.

Full Coverage 65% 1.5 mm 1.7 mm -1.8 mm -0.3 mm Mean Coverage 92% -1.1 mm -0.2 mm

Figure 8.3.3 Figure 8.3.4

The findings of all the EAO’s Consensus Conferences, including the 2015 conference, are available with open access from http://www.eao.org/consensus-paper

Congress Scientific Report: EAO 24th Annual Scientific Meeting Stockholm, 24–26 September 2015 38 EAO Consensus Conference 2015 EAO Consensus Conference 2015 Group III Group III

Group’s Consensus Stability of the augmented bone: 4.- Subjective and objective aesthetic results may be improved by means of soft tissue augmentation procedures. Only one study (CCT) examined the use of GBR techniques simultaneously with implant placement, immediately after tooth extraction. This paper reported that at 7 years and 36% of the implants treated (Pat) p<0.01 showed almost a non-detectable buccal (Dent) plate. p<0.001 (Benic et al 2012). (Dent) p<0.0001 Long-term tability of peri-implant tissues after bone or soft tissue augmentation. Effect of Zirconia or titanium abutments on peri-implant soft tissues. Consensus Report of Group 3. Sicilia A, Quyrinen M et al. Clin Oral Impl Res 26 (Suppl. 11) 2015. Figure 8.3.5 Figure 8.3.6 EAO Consensus Conference 2015 EAO Consensus Conference 2015 Group III Group III

Clinical recommendations: Clinical recommendations: Post GBR Consistent bone ridge reconstructions obtained by There is a lack of information about three- means of GBR procedures may facilitate the dimensional hard and soft tissue evolution maintenance of a stable buccal soft tissue contour. following the use of other kinds of hard tissue augmentation techniques.

Implants & Provisional Prostheses 2 years follow-up Long-term tability of peri-implant tissues after bone or soft tissue augmentation. Effect of Zirconia or titanium Long-term tability of peri-implant tissues after bone or soft tissue augmentation. Effect of Zirconia or titanium abutments on peri-implant soft tissues. Consensus Report of Group 3. abutments on peri-implant soft tissues. Consensus Report of Group 3. Sicilia A, Quyrinen M et al. Clin Oral Impl Res 26 (Suppl. 11) 2015. Sicilia A, Quyrinen M et al. Clin Oral Impl Res 26 (Suppl. 11) 2015. Figure 8.3.7 Figure 8.3.8

The outcome variables considered were: The consensus statement: no significant differences were seen in clinical outcomes in terms of PPD, biological: pocket probing depth (PPD); bleeding BOP, MBL and mucosal recessions when comparing on probing (BOP); soft tissue recession (REC); zirconia and titanium as abutment materials. Zr marginal bone level (MBL); and biological abutments may be associated with more biological complications complications, whereas they showed significant aesthetic: soft tissue colour; aesthetic patient- superiority in achieving natural soft tissue colour. reported-outcome; and objective aesthetic evaluation

Therapeutic concepts and methods for improving dental implant outcomes. Group 4 (Speaker: Mariano Sanz)

Short implants versus sinus lifting with longer crestal bone levels measured radiographically implants to restore the posterior maxilla (reported by only three studies) did not The focused question of this paper was: ‘Are show significant differences between the two short implants superior to longer implants in therapeutic options the augmented sinus in terms of survival and complications were predominantly of biological complication rates of implants and reconstructions, origin; mainly occurred intraoperatively as patient-reported outcome measures (PROMs) and membrane perforations; and were almost three costs?’ times more frequent for longer implants in the augmented sinus compared with shorter implants To answer this question a systematic literature search with regard to PROMs, morbidity, surgical time was performed with the objective of supporting and costs, the results were in favour of shorter the clinician in the decision-making process and implants providing information to the patient about both procedures. 8 RCTs were selected from an initial Conclusion: Given the higher number of biological search of 851 titles. The results were as follows: complications, increased morbidity, costs and surgical time involved in placing longer implants survival rates were similar for both longer and in the augmented sinus, shorter implants may shorter implants represent the preferred treatment alternative.

Congress Scientific Report: EAO 24th Annual Scientific Meeting Stockholm, 24–26 September 2015 39 Short implants compared to implants in vertically improved survival/success rates and marginal augmented bone bone loss of implants Focused question: ‘Are short implants comparable to longer implants placed in vertically augmented Furthermore, no biomaterial or type of intervention bone in terms of survival and complication rates of used for alveolar ridge preservation can be claimed implants and reconstructions, radiographic bone to be superior than others in terms of implant levels, and patient-reported outcome measures outcomes. (PROMs)?’ Therefore, the aim of this systematic review and The interventions considered were: meta-analysis was to investigate the following:

short implants (≤ 8 mm) supporting fixed 1. The additional effect of alveolar ridge restorations preservation on implant-related outcomes in longer implants (> 8 mm) supporting fixed comparison with unassisted socket healing restorations 2. To estimate the extent/dimensions of the above- mentioned outcomes according to the type of After identifying 3,387 titles initially, only 4 fulfilled intervention (socket filling, socket seal, GBR) the inclusion criteria. The 4 RCTs with follow-up of between 1 and 5 years reported similar high implant Regarding the feasibility to place implants, the survival rates for both groups of interventions investigation yielded similar results for alveolar (95.1% vs. 96.2%). Fewer surgical complications were ridge preservation compared with unassisted socket observed when using short implants vs implants healing. Survival rates were similarly high in both placed in vertically augmented bone (56% of patients groups. Significant differences appeared in the with temporary nerve paresthesia, compared with additional ridge augmentation needed at the time of 17% respectively). There were similar crestal bone implant placement (7/111 vs. 50/103), with a relative level changes (1.51 mm vs. 1.23 mm, respectively). risk of 0.15 (0.07–0.3).

These results must be interpreted with caution as all Within the limitations of present study, the following studies were performed by the same research group conclusions can be drawn: and the quality assessment was ranked as having a high risk of bias. Well-designed RCTs to properly 1. Alveolar ridge preservation procedures may compare long-term (> 5 years) success are needed. decrease the need for further ridge augmentation during implant placement in comparison with The group’s consensus was that vertical ridge unassisted socket healing augmentation is the preferable option when the 2. There is no evidence to support the fact that available bone is less than the available implant implant placement feasibility is increased length. When the bone available is between following alveolar ridge preservation in 5mm and 8 mm, both short implants and vertical comparison with unassisted socket healing augmentation are valid therapeutic options, 3. The survival, success and marginal bone levels although the latter requires a favourable anatomical of implants placed in alveolar ridges following site (bone availability and shape, patient’s mouth alveolar ridge preservation are comparable aperture, surgical access conditions, etc.). Patient to those of implants placed in untreated sockets factors such as general health conditions, habits and 4. No evidence was identified regarding the preferences may favour the short option. possible superior impact of a particular type of intervention (GBR, socket filler and socket seal) Does ridge preservation following tooth on implant outcomes. It is not currently known if extraction improve implant treatment outcomes one particular biomaterial or treatment protocol Alveolar ridge preservation, also known as ‘socket is superior to another preservation’, involves any procedure developed to 5. The majority of studies evaluating implant- limit post-extraction resorption and maintain the soft related outcomes after ARP procedures present a and hard tissue contour of the ridge. Different types high or unclear risk of bias; therefore, any clinical of procedures have been described in the literature, recommendation derived from these studies including guided bone regeneration (GBR), socket should be applied with caution filler and socket sealing. For the time being there is a lack of consensus as to whether alveolar ridge The findings of all the EAO’s Consensus preservation, in comparison with unassisted socket Conferences, including the 2015 conference, healing, directly improves implant-related outcomes are available with open access from such as: http://www.eao.org/consensus-paper

improved implant placement feasibility reduced need for further augmentation during implant placement

The findings of all the EAO’s Consensus Conferences, including the 2015 conference, are available with open access from http://www.eao.org/consensus-paper

Congress Scientific Report: EAO 24th Annual Scientific Meeting Stockholm, 24–26 September 2015 40 Successful supportive treatment – evidence for clinical efficacy

The clinical outcome of implant treatment has to be judged over the long-term, with the main objective of success being benefit to the patient. With this in mind, it is disturbing that levels of peri-implant inflammation appear to be extremely high. This has the potential to become a significant area of concern for public health in the growing population that has been treated with dental implants.

Addressing this problem will involve developing standardised supportive treatment that can be applied universally. At the moment, this approach seems to offer the only effective way of preventing the biological problems that have been associated with oral osseointegration.

This session described some of the available evidence relating to this serious problem:

Hugo De Bruyn provided a comprehensive update on peri-implantitis, including its diagnosis, prevalence and preventive measures for each of the factors involved Lisa Heitz-Mayfield discussed the practical steps involved in supportive care for implant patients. Evidence for the efficacy of supportive peri-implant therapy following treatment of peri-implant disease was also presented Mariano Sanz focused on the options available to prevent these problems from occurring, looking at the issue from primary, secondary and tertiary perspectives

Peri-implantitis: diagnosis and prevention through case selection and proper treatment execution Hugo De Bruyn

Having begun by emphasising the significance peri-implantitis can be considered to vary widely of peri-implantitis, the speaker continued with depending on the chosen diagnostic criteria. a description of the condition based on the four interfaces where it occurs. He described how the At bone level, the implant surface appears to be a pathogenic factors interact with bone, soft tissue, the possible predisposing factor. Based on recent studies, abutment and the restoration (Figure 9.1.1). an association exists between roughness and peri- implantitis, although this should not be considered Contamination of implant sites by oral micro- as a simple and direct pathogenic mechanism organisms has been clearly demonstrated, as has the (Figures 9.1.4 and 9.1.5). A recent long-term study pathogenic contribution of the oral biofilm, although with a mean follow-up of 15 years indicated an opinion differs as to whether this is a primary incidence of 4.1% for peri-implantitis and concluded cause of peri-implantitis, or instead contributes that implant treatment in the edentulous jaw has to a secondary infection of the local pathological a predictable long-term outcome with limited environment. complications.1

The adaptive bone loss that follows the early Next, the speaker described the relationship between establishment of biological width must be clearly crestal bone and abutment height (Figures 9.1.6 and distinguish from peri-implantitis. In order to 9.1.7). He discussed the need for a certain degree make this distinction, a baseline is required so of soft tissue thickness to protect the tissue-implant that the progression of bone loss can be compared interface. He also described the failure to leave and a diagnosis of peri-implantitis made, if enough bone around the implant when placing it appropriate (Figures 9.1.2 and 9.1.3). As previously described in systematic reviews, the prevalence of 1 Vandeweghe et a. Clin Oral Impl Res 2015;00:1–6

Congress Scientific Report: EAO 24th Annual Scientific Meeting Stockholm, 24–26 September 2015 41 as a risk factor for bone loss. Problematic situations Turning to the patient factor, he noted included location of the implant too close to the that periodontitis and smoking have been vestibular wall; inappropriate diameter of either the unquestionably demonstrated as predictors for implant or abutment; and compromised morphology peri-implantitis, while cement remnants have been of the residual bone. These scenarios have the identified as restorative factors that can lead to potential to lead to adaptive bone loss, rather than peri-implantitis. peri-implantitis itself. He concluded by saying that peri-implantitis is With regard to bone, the speaker raised an interesting a complex condition with multiple predisposing issue that requires further discussion: would grafted factors. Understanding each one is important in bone eventually lead to peri-implantitis? And in a order to prevent the subsequent development of the more general way, would initial bone loss lead to peri- disease. implantitis? (Figure 9.1.8)

Peri Interfaces Peri Crestal bone remodeling - - implantitis: myth, hype or evidence implantitis: myth, hype or evidence  10% of the individual implants have a bone level position 2 mm below abutment-implant interface already initially  20% lost above 2 mm in total after 3 years  Less than 5% increased over time = bone loss = possibly peri-implantitis

3,0 Based on mean bone loss <0.2 mm yearly -> no peri-implantitis

2,5 10% 20% Albreksson & Isidor Quintessence 1993; 365-369

2,0 Based on 2 mm additional bone level reduction (from the 1,5 expected and after 1 year) -> peri-implantitis is less than 10%

1,0 Sanz & Chapple JCP 2012; 39 (Suppl 12); 202-206

0,5 Based on any bone loss with or without pocketing -> peri- implantitis is much higher 0,0

initial 3 months 12 months 24 months 36 months Zitzman & Berghlundh JCP 2008; 35 (Suppl):286-291 niches –

gaps – De Bruyn & Collaert COIR 2008; 19:717-23 reservoirs

Figure 9.1.1 Figure 9.1.2

Peri Diagnosis of peri-implantitis Peri Peri-implantitis: moderately rough or machined surfaces - - implantitis: myth, hype or evidence implantitis: myth, hype or evidence  Peri-implant disease following successful integration  A results of an imbalance between the bacterial challenge and the host respons.  36 patients with 218 Southern Implants  Imbalance may affect only the peri-implant mucosa without bone loss = peri-implant mucositis  Mean follow-up:161 months (SD 52) [48-252]  According to the European workshop criteria peri-implantitis is characterised by mucosal inflammation with additional bone loss after the first year of loading including increasing pocket depth and bleeding or suppuration  Bone level: 1.57 mm 21 years  It is not specified how much bone loss !  Probing depth: 3.61 mm

Baseline Peri missing Peri-implantitis ? Crestal YES bone loss associated with abutment height - implantitis: myth, hype or evidence  CBL may occur for reasons other than infection

Lindhe et al. JCP 2008; 35 (suppl. 8):282-285 Vandeweghe et al. COIR 2015 Apr 9 [Epub ahead of print] Figure 9.1.4 Figure 9.1.5

Peri Peri-implantitis: moderately rough or machined surfaces - implantitis: myth, hype or evidence

 34.9% = turned surface (Sa 0.7)  65.1% = modified surface (Sa 0.7-1.2)  No significant difference  bone loss [median & mean] is equal

 All outlyers are in the moderately rough group

10% 25% 2.4 mm Abutment height, reflecting soft tissue thickness, affects CBL

Vandeweghe et al. COIR 2015 Apr 9 [Epub ahead of print] Figure 9.1.6 Figure 9.1.7

Peri Crestal bone loss associated with abutment height Peri Bone condition and peri-implantitis risk - - implantitis: myth, hype or evidence  Mean bone loss ranges from 0.2 to 1.2 mm implantitis: myth, hype or evidence  Regenerative procedures with biomaterials are wide spread mainly for aesthetic purposes  Abutment height reflecting soft tissue thickness  Ranging from 4 -1  What is the risk of this bone condition to induce future peri-implantitis  Abutment affects CBP S. Vervaeke, M. Dierens, J. Besseler & H. De Bruyn . The influence of initial soft tissue thickness on peri-implant bone remodeling Clin. Impl.. Dent Rel Res. Clin Implant Dent Relat Res. 2014; 16:238-47.

Abutment Bone loss

1 mm => 1.2 mm 2 mm => 1.1 mm 3 mm => 0.4 mm Biomaterial Socket preservation 4 mm => 0.2 mm

S. Vervaeke, M. Dierens, J. Besseler & H. De Bruyn . The influence of initial soft tissue thickness on peri-implant bone remodeling Clin. Impl.. Dent Rel Res. Clin Implant Dent Relat Res. 2014; 16:238-47. Figure 9.1.8 Figure 9.1.9

Congress Scientific Report: EAO 24th Annual Scientific Meeting Stockholm, 24–26 September 2015 42 Supportive therapy following treatment of peri-implant disease Lisa Heitz-Mayfield

The speaker began with an overview about Compliance with supportive therapy is an important supportive therapy, including its goals; the factor in achieving good long-term results. It has recommended frequency and protocols; the been correlated with lower complication rates, supporting evidence; and patient compliance. especially if the patient had a previous history of periodontitis. Even though it has been well documented through comparative studies that the absence of maintenance The recommended protocol for supportive therapy (a lack of patient compliance and poor plaque for patients who have been treated for peri-implant control) is associated with a high incidence of peri- disease consists of four steps: implantitis, an acceptable standard of supportive therapy is rarely described. Few studies include an 1. Examination, re-evaluation and diagnosis in-depth description of the protocol for supportive 2. Motivation, re-instruction and instrumentation therapy used in their materials and methods, despite 3. Treatment of re-infected sites the fact that this is a key factor to long-term success. 4. Risk assessment The speaker reviewed the most relevant studies addressing supportive therapy and 5-year implant Having completed these steps the recall interval outcomes and presented studies that followed should be determined. The periodontal risk patients receiving supportive therapy following assessment is a useful tool for establishing the recall treatment of peri-implantitis. frequency and is available for download from the University of Bern website www.perio-tools.com.

How successful is supportive therapy in prevention of peri-implant disease Mariano Sanz

This presentation looked at prevention of peri- maintain good implant health (expressed in terms implantitis at three levels, and asked if each of these of stable bone levels) by performing supportive was possible: therapy two or three times per year. In a second study3, maxillary implants placed immediately 1. Prevention of mucositis and maintenance of peri- following extraction showed neither inflammatory implant health (primary prevention) nor marginal bone level impairment three years after 2. Control of mucositis to prevent the onset of peri- restoration. It should be noted that a clustering of implantitis (secondary prevention) failures was observed in a few patients, and in all 3. Early detection and successful treatment of peri- cases a high level of discipline and compliance was implantitis to achieve long-term maintenance of required from the patients. The evidence presented implants (tertiary prevention) suggested that scenario 1 is possible, and this seems to be the main condition for a successful prevention. Scenario 1 At present there are no studies on primary Scenario 2 prevention. However, a five year prospective Mucositis is defined as the presence of inflammatory observational study on patients susceptible to signs without bone loss. Assessment using periodontitis2, stated that it should be possible to standardised probing is the clinical measure that is

2 Wennström et al. JCP 2004 3 Sanz et al. COIR 2014

Figure 9.3.1 Figure 9.3.2

Congress Scientific Report: EAO 24th Annual Scientific Meeting Stockholm, 24–26 September 2015 43 used to distinguish between peri-implant health and disease. Bleeding on probing is considered to be a predictor for mucositis, although there is no reliable indicator of further progression of bone loss leading to peri-implantitis4 (Figure 9.3.1). Once mucositis has been established, managing it to prevent the development of peri-implantitis is of key importance (Figure 9.3.2). Current data from RCTs indicates that the resolution of inflammation is possible, although it is not achieved in all patients5. Up until now, patient-administered mechanical plaque control has been the primary measure used to prevent the progression of the disease. However, inadequate plaque control often results from prostheses that are hard or impossible to clean properly (Figure 9.3.3). As a result, appropriate implant placement and prosthesis design are of key importance. Figure 9.3.3 Scenario 3 To illustrate the third question, the speaker presented a clinical case following all stages from diagnosis, to non-surgical treatment, re-evaluation and surgery, showing a drastic improvement of the clinical situation after regenerative surgery.

Conclusion Early detection of peri-implant disease involves establishing a baseline, then assessing the patient at maintenance visits using peri-implant probing. This will identify the onset of inflammation and its further progression (Figure 9.3.4).

4 Dierens et al COIR 2012 5 Jepsen et al. JCP 2015 Figure 9.3.4

Congress Scientific Report: EAO 24th Annual Scientific Meeting Stockholm, 24–26 September 2015 44 Imaging (radiology) in treatment planning and follow-up Presurgical imaging in implant treatment: from guidelines to clinical use Michael Bornstein

The use of ionizing radiation must always be CBCT should only be used when the question justified and optimised. Nevertheless, proper for which imaging is required cannot be guidelines for the use of CBCT in implant dentistry, answered adequately by lower dose conventional based on sound scientific research, are still lacking. (traditional) radiography 2D radiology has been used extensively for many years. The advent of 3D radiology has provided In 2012, the EAO published its recommendations on superior tools for diagnosis and treatment planning. the clinical indications for CBCT: Its use can be justified for assessing the morphology and dimensions of the ridge and the anatomical extensive bone augmentation; sinus floor boundaries, as well as for determining bone elevation; evaluation of intra-oral donor sites; orientation, but it must always be used according to special surgical techniques; computer treatment the ALARA principle of radiation exposure (As Low guided; post-operative complications As Reasonably Achievable). The ITI Consensus in 2014 stated: There are three recently published sets of guidelines1: significant dose reduction can be achieved by In 2008 the European Academy of using CBCT instead of CT, by adjusting exposure Dentomaxillofacial Radiology (EADMFR) published parameters and reducing the FOV (Field Of View) its statement on the use of CBCT. This stated: that should be restricted to the ROI (Region Of Interest) CBCT examinations must be justified for each patient to demonstrate that the benefits outweigh How often is CBCT used in dentistry? the risks Use of CBCT peaks in two age groups: those aged CBCT examinations should potentially add new around 20 who have experienced dentoalveolar information to aid the patient’s management injury; and those aged around 55 who are being treated for partial edentulism2

1 Horner et al. Dentomaxillofac Radiol 2009; Harris et al. COIR 2012; Bornstein et al. IJOMI 2014 2 Bornstein et al IJOMI 2015

CBCT imaging for implant treatment planning in the CBCT imaging for implant treatment planning in the anterior maxilla posterior maxilla Relevant clinical questions Relevant clinical questions • Is correct 3-dimensional (3D) implant positioning • Is correct 3-dimensional (3D) implant possible? positioning possible? • Can we achieve good primary stability in the • Can we achieve good primary stability? desired position? • If primary stability is not achievable: site • If primary stability is not achievable: decide develoment using sinus floor elevation (SFE) between site develoment using guided bone procedures or an alternative treatment concept not using dental implants. regeneration (GBR) procedures or an alternative Anatomic structures of treatment concept not using dental implants. interest • When SFE is needed, can we use a • When GBR is needed, can we use a simultaneous • Nasal floor simultaneous approach with implant insertion or approach with implant insertion or do we need a • Nasopalatine canal do we need a staged procedure? staged procedure? • Anterior superior • When a simultaneous SFE is possible, do we Healthy maxillary sinus Maxillary sinusitis of alveolar canal and odontogenic origin • When GBR is not indicated, can we place the canalis sinuosus use a lateral window or a transcrestal implant using a flapless approach? osteotome technique?

Figure 10.1.1 Figure 10.1.2 Congress Scientific Report: EAO 24th Annual Scientific Meeting Stockholm, 24–26 September 2015 45 What is CBCT used for? (Figures 10.1.1–10.1.4)

CBCT imaging for implant treatment planning in the CBCT imaging for implant treatment planning in the anterior mandible posterior mandible Relevant clinical questions Relevant clinical questions • Is correct 3-dimensional (3D) implant positioning • Is correct 3-dimensional (3D) implant positioning possible? possible? • Can we achieve good primary stability in the • Can we achieve good primary stability in the desired position? desired position? • If primary stability is not achievable: decide • If primary stability is not achievable: decide between site develoment using guided bone between site develoment using guided bone regeneration (GBR) procedures or an alternative regeneration (GBR) procedures or an alternative treatment concept not using dental implants. treatment concept not using dental implants. Anatomic structures of interest Anatomic structures of interest •Mandibular canal (+) •Mental foramina (*) • When GBR is needed, can we use a • Lingual foramen (*) • When GBR is needed, can we use a simultaneous approach with implant insertion or simultaneous approach with implant insertion or •Sublingual fossa / “lingual • Incisive canal undercut“ do we need a staged procedure? do we need a staged procedure? • Genial tubercles •Retromolar canal • When GBR is not indicated, can we place the von Arx T, Matter D, Buser D, Bornstein MM: Evaluation of location and dimensions of • When GBR is not indicated, can we place the von Arx T, Friedli M, Sendi P, Lozanoff S, Bornstein MM: Location and dimensions of the implant using a flapless approach? lingual foramina using limited cone-beam computed tomography. J Oral Maxillofac Surg mental foramen: a radiographic analysis using cone-beam computed tomography. J Endod, 2011;69:2777-85. implant using a flapless approach? 39: 1522-1528, 2013

Figure 10.1.3 Figure 10.1.4

Do we still need to use Hounsfield scores in presurgical planning? Reinhilde Jacobs

Changing concepts regarding bone quality standardised bone density measures, known as assessment Hounsfield scores for multislice CT imaging, could Historically, presurgical planning of implant no longer be used in CBCT devices (Pauwels et al placement focused on good bone density as a 2014). Nonetheless, as stated above, implants may quality measure of the host bed. Yet as time went no longer need such bone density measures. Instead, by, implant surfaces were roughened which structural analysis of the trabecular bone matrix altered the requirements of potential bony implant via bone morphometric software may offer some sites. Presurgically, one should now focus on the solution (Huang et al 2014; Van Dessel et al 2014; vascularisation of the bone bed, which can be Huang et al 2015) (Figure 10.2.1). Unfortunately, the indirectly qualified by a structural bone analysis. shortcoming remains the lack of visualisation of the It can be assumed that a moderately dense, initial non-mineralised bone matrix via hard tissue homogeneously trabecularised bone, represents imaging modalities such as CBCT (Van Dessel et al a healthy vascularisation during the initial 2015) (Figure 10.2.2). remodelling around the placed implant. References Meanwhile, as the bone quality requirement for Van Dessel et al. DMFR 2014; Huang et al Bone Res implant sites changed, CBCT was introduced for 2014; Pauwels et al DMFR 2014; Van Dessel et al presurgical planning. The latter confronted clinicians EAO Stockholm 2015 poster #613; Huang et al EAO with information presented in other data formats, Stockholm 2015 poster #548 as well as introducing new variables. Apparently,

Figure 10.2.1. Example of structural analysis of human trabecular and cortical Figure 10.2.2. Structural bone analysis of bone with MicroCT and CBCT (Huang et al 2015) traditional socket healing after tooth extraction. The red part represents the mineralised bone after 3 months of healing, with the yellow part indicating the remaining non-mineralised inner part of the socket (Van Dessel et al 2015)

Congress Scientific Report: EAO 24th Annual Scientific Meeting Stockholm, 24–26 September 2015 46 Radiographic bone quality aspects in planning implant surgery Christina Lindh

There is overwhelming evidence to show that bone How to measure bone quality quality is a key factor in the success or failure of Bone structure has a hierarchical pattern and a implant dentistry. Since the early 1990s the density trabecular arrangement, which can vary between of bone at the surgical site has been considered a being closely packed or sparse.(Figure 10.3.2). Cross- significant factor in the prognosis and likely success sectional CBCT imaging can reveal a visual grading of implants. in the bone structure, but in a rather subjective way. Inter-observer variability is a problem. Some semi- How to define bone quality automated systems for evaluating bone quality are in There are many different classification systems for the process of being developed, but for the moment defining bone quality, and significant heterogeneity radiographic density should be used with caution, as is revealed when the results of different studies ability to evaluate the image depends on factors such are compared. At present there is no consensus on as brightness and contrast variation. The current either what bone quality means or how to assess standard measure of bone quality is bone mineral the quality of bone3 (Figure 10.3.1). The most widely density (BMD), calculated in Hounsfield units used classification (Lekholm & Zarb 1985) is based derived from the CT scan. A significant correlation on radiograph evidence and tactile perception has been observed between BMD, RFA (ISQ values), achieved during drilling, and derives from a purely anti-rotational stability and L-Z classification4. structural approach. Conclusion There is now a growing understanding that type IV Computed tomography and tactile perception are may not be the worst bone quality. Current thinking currently the most predictable methods of evaluating on bone quality takes into account both bone bone quality before implant placement. Various mineral density (BMD) and the three-dimensional enhanced evaluation methods are being developed, microstructure of the bone. and at present no technique is available to precisely determine bone quality as single factor (Figures 10.3.3 and 10.3.4).

3 Ribeiro-Rotta Clin Oral Impl Res 2011; Lindh et al. Clin Oral Impl Res 2014 4 Bergkvist et al. IJOMI 2010

What is bone quality?? Bone quality in the field of osteoporosis and fracture prediction

Good Bad Radiographic bone quality aspects in the implant field

Five anatomical levels of bone organization Adapted from Chappard D et al., 2011; Donelly E 2011.

Figure 10.3.1 Figure 10.3.2 Semia-automated calculations of trabecular CONCLUSIONS structure • Density and structure of jaw bone tissue vary between and within the jaws - site specific assesment can be recommended before implant installation

• The Lekholm&Zarb classification based of radiographs and tactile perception is a valid method to assess jaw bone before implant installation

• Intraoral and panoramic radiographs can be used to assess trabecular structure of jaw bone tissue

Region of interest • Newer radiographic technologies might be useful - has to be prooven! (ROI)

Figure 10.3.3 Figure 10.3.4

Congress Scientific Report: EAO 24th Annual Scientific Meeting Stockholm, 24–26 September 2015 47 Creating the virtual patient: how to integrate facial, optical and radiological imaging components Ali Tahmaseb

New technologies are now permitting the creation The superimpositions require reference points and of a ‘virtual patient’ that integrates data from a strict protocol of data acquisition. This can be bone, teeth, oral soft tissue and the facial surface. challenging in a fully edentulous patient because of Superimposing software can merge 3D bone the instability of templates (Figure 10.4.2). anatomy, intraoral scanned data and extraoral facial information obtained from a surface scanner (Figure Once the ‘virtual patient’ has been built, it is possible 10.4.1). to create a virtual set-up and develop fully milled provisional prostheses (Figures 10.4.3 and 10.4.4). It Some limitations in the 3D skeletal data acquisition is anticipated that this will become an increasingly come from artefacts, patient movement and the common way of working in the future. registration of data in the open and closed mouth.

Figure 10.4.1 Figure 10.4.2

Figure 10.4.3 Figure 10.4.4

Congress Scientific Report: EAO 24th Annual Scientific Meeting Stockholm, 24–26 September 2015 48 Peri-implantitis

Peri-implantitis is one of the major challenges in implant dentistry. There is a lack of deep understanding about its pathogenic process, and while numerous treatment protocols have been proposed, there is no adequate solution to it in many cases. As such, it is a key topic for discussion at an implant meeting.

During this session:

Andrea Mombelli explored the possibility of using different materials in order to achieve a better resistance to biofilms Stefan Revert looked at current treatment protocols and their outcomes, with suggestions for daily practice Olivier Carcuac presented a comprehensive review of the factors involved in different treatment outcomes Tord Berglundh described the experimental research being carried out at his department which is shedding light on the histopathologic nature of the disease

The relevance of implant materials for peri-implantitis Andrea Mombelli

Zirconia has become established as an alternative Next, he focused on biofilm adhesion on implant material to titanium for dental implants due to its surfaces. A lower mean total bacterial count was aesthetic properties, high biocompatibility and a observed on zirconia, compared with titanium2. In potentially lower susceptibility to bacterial adhesion. addition, an immunohistochemical study comparing Recently, a new two-piece zirconia implant tissues adjacent to healing caps made of zirconium (ZERAMEX® T Implant System), with an etched or titanium demonstrated greater expression of zirconia surface, has been introduced. The speaker several pro-inflammatory markers around titanium presented the first prospective clinical study to use caps3. this system1. Data are available currently from a mean observation time of 3.5 years after loading. Despite the lack of long-term clinical observation, The survival rate one year after loading was 87%. no peri-implantitis has been reported on zirconia The failures were all the result of aseptic loosening. implants, and their cumulative survival rates are Interestingly, no further complications of this kind high. As a result they may represent a promising were noted thereafter and no peri-implantitis was new technology. seen, strongly suggesting a different pattern of failure than in the case of titanium implants.

2 Nascimento et al. Clin Oral Impl Res 2014 1 Cionca et al. Clin Oral Impl Res 2015 3 Degidi et al. J Periodontol 2006

Congress Scientific Report: EAO 24th Annual Scientific Meeting Stockholm, 24–26 September 2015 49 The patient and the problem awaits Monday morning. What do I do? Stefan Renvert

Answering the question posed in the title peri-implant pathology at two-year follow-up4. After an appropriate diagnosis of the patient’s Based on this, we have to consider that the clinical condition, the first step in treating peri-implantitis success of surgery for peri-implantitis is low. should always be non-surgical, based around reinforcing plaque control and improving the oral Do certain techniques provide better results than periodontal condition. This is also an appropriate others when treating peri-implantitis? stage at which to assess the patient’s compliance One RCT found better resolution of defects when more carefully. carrying out augmentation using porous titanium granules versus open flap debridement alone5. In If the infection has not been controlled when another RCT, peri-implantitis patients were treated the patient is re-evaluated, the case should be with Algipor®, with or without membrane, and considered to be advanced. In these circumstances, there were no significant differences in the outcome6. surgery is necessary to provide better accessibility The speaker presented a chart in which the to the affected area and to achieve pocket reduction morphology of the defect was the key factor used to (Figure 11.2.1). select the surgical technique (Figure 11.2.2). He also made some recommendations about treatment for What about the outcomes of surgery for peri-implantitis (Figure 11.2.3). peri-implantitis? Having undergone surgical resective treatment, 42% of patients do not heal completely and have 4 Serino & Turri. Clin Oral Impl Res 2011 5 Jepsen et al. J Dent Res 2015 6 Roos-Jansaker et al. J Clin Periodontol 2014

6 › TREATMENTS

Diagnosis of peri-implantitis

Nonsurgical therapy Removal of implant

Infection Infection Re-evaluation controlled not controlled

Adequate Soft tissue Not adequate conditions

Figure 11.2.1 Gingival grafting Based on limited available evidence

Infection Infection (and long time clinical practice I would suggest) Re-evaluation not controlled controlled • Always start with non-surgical therapy- it may work

• In case of no healing surgery may be needed Regenerative therapy • Expose implant surface

Maintenance • Remove granulation tissue

• Mechanically clean the implant surface

Fig 6-39 Decision tree for the selection of treatment based on the condition of the soft tissue around the peri-implantitis–affected • Chemically remove remaining debris and smear-layer (H2O2 3%) implant, and the therapeutic process in managing the soft tissue if deemed necessary before regenerative therapy. • In 3 and 4-wall defects consider regenerative therapy 167

Figure 11.2.2 Figure 11.2.3

Congress Scientific Report: EAO 24th Annual Scientific Meeting Stockholm, 24–26 September 2015 50 Challenges in the treatment of peri-implantitis Olivier Carcuac

Goals of treatment for peri-implantitis use of adjunctive systemic antibiotics. The potential As peri-implantitis is caused by bacteria, treatment benefit of antibiotics, however, was not known. of the disease should include anti-infective measures and the goals of the therapy should include disease In a prospective randomised controlled clinical trial resolution and preservation of supporting bone. A on 100 patients, the effect of adjunctive systemic consensus report from the 8th European Workshop antibiotics on surgical treatment of peri-implantitis on Periodontology stated that treatment success was evaluated10. Treatment success was defined should be described as a composite outcome using a composite outcome, including PPD ≤ 5mm, including a combination of findings from clinical absence of bleeding/suppuration and no further and radiological assessments7. Such assessments bone loss at the 12-month examination after surgical include pocket closure, resolution of peri-implant therapy. inflammation and no further loss of supporting bone. It was demonstrated that: Non-surgical therapy Non-surgical therapy alone does not seem to be treatment success was detected in 45% of the effective in the resolution of moderate/ severe implants/38% of the patients forms of peri-implantitis. However, non-surgical the local use of chlorhexidine had no overall procedures should always precede surgical therapy effect on treatment outcome in all peri-implantitis cases in order to establish implant surface characteristics influenced the appropriate soft tissue conditions and optimal self- outcome of surgical treatment of peri-implantitis performed infection control. a positive effect on treatment success was observed at implants with modified surfaces, Surgical therapy while adjunctive systemic antibiotics had no Surgical therapy is required in the treatment of impact on treatment success at implants with peri-implantitis to provide access for debridement non-modified surface of contaminated implant surfaces. The use of the likelihood for treatment success using different decontamination procedures has included adjunctive systemic antibiotics in patients with mechanical and chemical techniques, but no single implants with modified surfaces, however was method or combination of methods has been shown low to be superior. Risk for recurrence Results from pre-clinical in vivo studies on While publications have presented favourable short- surgical treatment of experimental peri-implantitis term results, several studies also reported findings demonstrated (i) that resolution of the disease is on lack of disease resolution, recurrence of disease possible in the absence of adjunctive use of local and implant loss. Studies reporting long-term data of antimicrobial therapy8, 9, and (ii) that implant surface 5 years and longer from well-designed prospective characteristics do influence treatment outcome8, 9. controlled clinical trials, and using composite outcomes of treatment success, are therefore needed. Previous studies describing outcomes of surgical therapy of peri-implantitis have often included the

7 Sanz & Chapple J Clin Periodontol 2012 8 Albouy et al J Clin Periodontol 2011 9 Carcuac et al J Clin Periodontol 2015 10 Carcuac et al J Dent Res 2016

Congress Scientific Report: EAO 24th Annual Scientific Meeting Stockholm, 24–26 September 2015 51 A comparison between periodontitis and peri-implantitis lesions Tord Berglundh

Periodontitis and peri-implantitis11 represent a animal models. Based on these animal studies, and global problem and it is essential that we advance corroborated by analyses of human biopsies, the our understanding of their onset and progression. histopathological differences between periodontitis and peri-implantitis lesions have been thoroughly There is a continuum from healthy mucosa to described. In periodontitis a ‘self-limiting’ process mucositis and from mucositis to peri-implantitis. occurs due the presence of an attachment of The host response to oral biofilms does not differ periodontal fibres into the teeth, leading to a whether they are present around a tooth or an connective encapsulation that separates the implant, and in both cases an inflammatory lesion inflammatory cell infiltrate from the bone. In peri- develops12. Peri-implant mucositis represents implantitis, however, tissue destruction is more the obvious precursor to peri-implantitis as does pronounced as the lesion is not surrounded by non- gingivitis to periodontitis. infiltrated connective tissue. The inflammatory cell infiltrate reaches a more apical location, with a huge Various studies of ‘experimental peri-implantitis’ number of polymorphonuclear neutrophils (PMNs) that mimic the real process have been conducted in and macrophages13, 14.

11 Kassebaun et al J Dent Res 2014, Derks et al. J Dent Res 2015 13 Berglundh et al. J Clin Periodontol 2011 12 Lang et al. J Clin Periodontol 2011 14 Carcuac & Berglundh, J Dent Res 2014

Congress Scientific Report: EAO 24th Annual Scientific Meeting Stockholm, 24–26 September 2015 52 Emerging surgical concepts

A variety of new materials are currently being introduced into general practice to facilitate regeneration in an attempt to simplify treatment and lower patient morbidity. In the case of these new materials, it is important to distinguish between commercial claims and what has been scientifically proven. This session looked at growth factors; soft tissue substitutes; provided an update on biomaterials for hard tissue grafts; and explored a new development in the field of leucocyte-platelet rich fibrine: L-PRF.

Do we still need autogenous bone for ridge augmentation or can we use growth factors? Ronald Jung

Autogenous bone continues to be considered the accelerate guided bone regeneration1. The long- ‘gold standard’ in bone regeneration, but due to term results revealed no significant differences, associated patient morbidity, research is currently demonstrating the safety of rhBMP-2, the stability of focused on growth factors. Originally an area of the results and the absence of complications2. animal research, within the last seven years new clinical studies have been undertaken in humans, In another RCT by the same group, which included particularly using recombinant human bone CBCT measurements and histologic analysis, morphogenetic protein-2 (rhBMP-2). These have rhBMP-2 was tested together with xenogeneic bone been limited because the carrier used – absorbable blocks in comparison with autogenous bone blocks collagen sponge (ACS) – lacks the consistency as a control group 3. The clinical assessment was needed for lateral augmentation. Two alternatives similar in the test and control sites, but the patient have been proposed to overcome this problem: using morbidity made the big difference. a titanium mesh to provide space and stabilise the wound, and mixing rhBMP-2 with a consistent graft So, why don’t we use rhBMP-2 more frequently? material as a carrier. Because it is for now an emerging and expensive technology – although in the words of the speaker In an RCT involving 11 patients with 34 implants, one that has already has very exciting potential. where bone fill-in test and control sites were clinically similar, histomorphometric analysis revealed more lamellar bone in the sites that received rhBMP-2, along with an increased contact to the graft. The authors concluded that rhBMP-2 1 Jung et al. Clin Oral Impl Res 2003 enhances the maturation process of bone, and 2 Jung et al. Clin Oral Impl Res 2009 consequently has the potential to improve and 3 Thoma et al. manuscript in preparation

The effect of rhBMP-2 on guided bone regeneration in humans rhBMP-2 Jung RE, Glauser R, Schärer P, Hämmerle CHF, Weber FE rhBMP-2 „When I see these results, why do we Clin Oral Impl Res 2003 not use rhBMP-2 more in clinical Histomorphometric results practice?“

• Stat. significant more

DBBM lamellar bone at the DBBM test sites

• Stat. significant more bone to graft contact at the test sites

control test preoperative 6 mo post

Figure 12.1.1 Figure 12.1.2

Congress Scientific Report: EAO 24th Annual Scientific Meeting Stockholm, 24–26 September 2015 53 rhBMP-2 Results rhBMP-2 Results clinical assessment Patient morbidity

* no statistical difference

preop 4 mo preop 4 mo Horizontal ridge width im mm days of medicatioin/swelling 12 patients 12 patients * no statistical difference autogenous bone rhBMP-2

Figure 12.1.3 Figure 12.1.4

Do we still need autogenous bone „How hard do we have to work for ridge augmentation? Mike to get a good result?“ „How hard do we have to work to get a good result?“ ? ?

Figure 12.1.5 Figure 12.1.6

Overall Conclusions rhBMP-2 reveal the highest potential for bone regeneration. BMP-2 shows the best documentation, however, it is only approved for extraction sockets and for sinus floor elevations. It is expensive and need high clinical doses. rhBMP-2 combined with a mechanically stable xenogenic bone block revealed similar results as an autogenous bone block

With an increased body of literature it might be possible to Carrier/expand the indication spectrum of rhBMP-2 in order to replace autogenous bone blocks bone matrix Cells/tissues regeneration We should stay excited for the sake of our patients with challenging defects

Figure 12.1.7

Congress Scientific Report: EAO 24th Annual Scientific Meeting Stockholm, 24–26 September 2015 54 Soft tissue grafts out of the box. What can we expect in clinics? Otto Zuhr

Although written evidence lacks relevant datas minimising postoperative pain and reducing the for the most part, among available augmentation risk of complications at its best materials, autogenous subepithelial connective 4. The limited amount of grafting tissue and the tissue grafts (SCTGs) are still considered as the increased patient morbidity are substantial ‘gold standard’ to increase the width of keratinised disadvantages of autogenous SCTGs. For tissue and for soft tissue volume augmentation to this reason the search for suitable soft tissue date4. However, there is a restrictive core of critical substitutes is currently at the centre of numerous elements that can be summarised as follows: efforts by scientists and manufacturers, and will be an important field of future research – for the 1. The term ‘gold standard’ implies a well-defined good of the patient! and consistent standard of harvesting procedure. 5. Many questions with regard to graft healing and However, different donor sites that can be volumetric stability remain presently unknown – selected from the palate and varying harvesting this relates both to soft tissue substitutes, and also techniques that can be applied result in different to autogenous SCTGs. Patient-centred outcome kinds of SCTGs that vary in their histological measures, quantitative three-dimensional and composition, obviously leading to different qualitative-aesthetic assessment of treatment characteristics that might require selective clinical results, as well as long-term follow up data, are application scarcely available at present 2. At present, the clinical decision as to where to 6. Thus, more research is needed to further progress harvest SCTGs from is hardly based on scientific and increase knowledge regarding soft tissue evidence, but rather depends on the amount of volume augmentation procedures in plastic available tissue at the eligible donor sites; the periodontal and implant surgery. Ultimately, indication in which the transplant is supposed the goal cannot be considerably different from to be used; and in particular on the personal developing appropriate soft tissue substitutes preference of the treating surgeon for all conceivable indications and by doing so 3. Independent of the selected donor site, the rendering soft tissue autografts unnecessary, clinical procedure of SCTG harvesting from the and eliminating their clinical application to the palate is basically characterised by the challenge greatest possible extent of obtaining an adequate amount of tissue while

4 Zuhr et al. J Clin Periodontol 2014;41:123–142

Sonntag, 20. Dezember 15 Sonntag, 20. Dezember 15 Figure 12.2.1 Figure 12.2.2

Sonntag, 20. Dezember 15 Sonntag, 20. Dezember 15 Figure 12.2.3 Figure 12.2.4

Congress Scientific Report: EAO 24th Annual Scientific Meeting Stockholm, 24–26 September 2015 55 Emerging concepts in maxillofacial surgery: indications for graft materials Henning Schliephake

The concept of the ‘skeletal envelope’ is one of percentage of bone filling, implant survival or the fundamental principles that underlies bone complication rates regeneration. Wound healing is a process that is taking into account the defect morphology, in dependent on both the characteristics of the graft dehiscence defects (within the skeletal envelope), material and the morphology of the defect. To particulate graft materials provide an 80% defect achieve the best result, the material must have filling, slightly less than synthetic materials osseoconductivity (a quality that is closely related in lateral/vertical defects, outside the skeletal to its porous structure) and the defect should be envelope, particulate graft material can be auto-containing. Regeneration will be quite different expected to gain about 3.5mm in width and within or outside the biological limits of the skeletal height with acceptable stability envelope (Figure 12.3.1). block shaped grafts can increase this gain by 1mm, but are unlikely to produce greater height, The speaker went on to discuss a systematic review, with the exception of extraoral autogenous bone still in preparation, on the efficacy of grafting (Figures 12.3.2 and 12.3.3) materials in ridge augmentation. Having selected 184 studies, involving 6,373 augmentations, he drew These conclusions may change in the near future the following conclusions: when the biological quality of graft materials is enhanced. allowing for the standard deviations of the mean values, the different types of graft materials did To this end, there are two emerging technologies not appear to have a significant effect on the that are relevant: growth factors and stem cells. At present, evidence for the efficacy of these is limited to early clinical observations based on case series without controls. The use of concentrate Indications for graft materials bone marrow aspirates in sinus grafting has Basic considerations been evaluated in a chairside technique, without demonstrating significant differences. The use of in vitro cultivated stem cells requires Good Manufacturing Practices and Good Laboratory Practice (GMP/GLP) environments, and is for the moment beyond the scope of daily practice (Figures 12.3.4 and 12.3.5). Within the „Skeletal Envelope“ Outside the „Skeletal Envelope“

Figure 12.3.1 Indications for graft materials Indications for graft materials Clinical evidence Clinical evidence Systematic Review / Defect Characteristics / Outside the Skeletal Envelope Systematic Review / Defect Characteristics / Outside the Skeletal Envelope

Block shaped Graft Material / Ridge Dimensions Horizontal gain Vertical gain p=0.001 14,0

12,0

10,0

8,0 8,8

6,0

4,0 4,6 4,5 4,4 mm Change in Dimension in Change mm 3,7 3,3 3,5 2,0 2,3

0,0 Allogenic Xenogenic Autogenous e.o. Autogenous i.o.

Tröltzsch et al. Efficacy of grafting materials in ridge augmentation – a systematic review (in preparation) Figure 12.3.2 Figure 12.3.3 Indications for graft materials Indications for graft materials Emerging concepts? Emerging concepts? Enhanced biological quality / Stem cells Enhanced biological quality In vitro expansion

• Growth Factors CaPO 4 PLA

CD 105 CD 45 CD 90 CD 34 CD 73 CD 14

Domicini et al. 2006 • Stem Cells CaCO 3 Min. Coll.

Figure 12.3.4 Figure 12.3.5

Congress Scientific Report: EAO 24th Annual Scientific Meeting Stockholm, 24–26 September 2015 56 The future of wound healing: can it still be improved? Nelson Pinto

L-PRF (leukocyte-platelet rich fibrin) is one of the four main families of platelet concentrates5. It is applied as a membrane to protect the wound and to stimulate cell proliferation in the healing process by the local release of numerous growth factors. It works in a more prolonged way than platelet concentrates without leucocytes. However, at the moment there is a lack of controlled studies to compare the effects of different types of platelet-rich plasma.

The speaker presented various challenging clinical cases where he has used L-PRF with good results, especially in alveolar ridge preservation (Figure 12.4.1). He claimed that besides its regenerative effect, L-PRF also has antibacterial properties. Following his early experience of using L-PRF to treat wounds in horses, he has successfully applied the technique in chronic human wounds. He illustrated many impressive cases relating to the diabetic foot and venous ulcers.

The potential osseoinductive effect on the recruitment and differentiation of bone precursor cells has been explored using the so-called ‘floating implant’ study. Implants with different surfaces were placed in oversized osteotomies in presence of L-PRF with no primary stability. Early results have been promising.

Figure 12.4.1

5 Ehrenfest et al. Muscles Ligaments and Tendons J. 2014

Congress Scientific Report: EAO 24th Annual Scientific Meeting Stockholm, 24–26 September 2015 57