Theory andpractice. Theory alveolarridgevolume? How tomaintain After toothextraction. FOCUS |PAGE 5 niques, newtherapies.Anoverview. New biomarkers, newimagingtech- Periodontal regeneration. JOURNAL CLUB | PAGE 18 think. An interview with researchers.think. Aninterview Collagen candomore thanyou The wondermolecule. BACKGROUND | PAGE 26 VOLUME 8 | ISSUE 2,2015 8|ISSUE VOLUME ’ d Illustration: © Büro Haeberli Zürich 2 Geistlich News 02 | 2015 CONTENTS Issue 2 | 2015 Your opinion EDITORIAL matters! 4 “The Geistlich Way” Survey on Page 35 FOCUS 5 Ridge Preservation. 6 Extraction sockets: the key facts Dr. Maurício G. Araújo | Brazil 8 The new thinking post tooth extraction Prof. Ronald E. Jung | Switzerland 11 Socket Sealing with collagen matrix Dr. Stefan Fickl | Germany 12 Ridge Preservation instead of ? Prof. Giulio Rasperini | Italy 14 “Ridge Preservation simplifies treatment” Dr. Dietmar Weng | Germany 16 Ridge Preservation in the anterior : a case study Dr. Beat Wallkamm | Switzerland

JOURNAL CLUB 18 Key studies selected. 18 Periodontal regeneration Dr. Hector Rios | USA

OUTSIDE THE BOX 22 Substitute skin with a supply system.

GEISTLICH PHARMA | OSTEOLOGY FOUNDATION 25 Background. 26 A conversation with the collagen experts 30 Global reach 31 Studies pass the 1,000 mark 32 Osteology Foundation has a new President 33 Osteology Monaco 2016 – Registration opens in October 33 New: Large Clinical Grants and Osteology Research Scholarships

INTERVIEW 34 On a lab tour with Todd Scheyer

15 Imprint

Geistlich News 02 | 2015 3 EDITORIAL “The Geistlich Way”

We can let the numbers speak for themselves. As most of you know: 1+1=3, when you can exploit successful synergies. But Geistlich has even more to offer: 20+30=1000. Are you still following us? We have much to celebrate in 2016: 20 years of experience with collagen membranes and 30 years with bone replacement biomaterials – all supported by 1,000 scientific publications. This is the “Geistlich Way”, which has clearly proven that this pioneering company’s products and concepts always work superbly well.

I hope that you enjoy reading “Geistlich News” and find the content engaging and helpful.

Geistlich Pharma’s collagen researchers have two clients: you, our distinguished readers, and the body’s own cells. For you, our researchers work to optimize product handling. Is Mario Mucha, the biomaterial intended to create volume? Should it simply Chief Operating Officer be easy to hydrate? And for the cells, our researchers make sure our collagens remain as similar as possible to “original tissue” – because only then will the somatic cells that contact collagen react naturally. Over the past 160 years Geistlich Pharma has dedicated itself to building its collagen expertise. The guiding principle behind all of our efforts remains the same: “Geistlich’s collagen membranes and matrices should lead to predictable success by providing the solution to a patient’s problems.”

4 Geistlich News 02 | 2015 FOCUS RIDGE PRESERVATION.

Each extracted tooth presents a new challenge. What can Ridge Preservation measures achieve?

Geistlich News 02 | 2015 5 Illustration: © Büro Haeberli Zürich FOCUS Extraction sockets: the key facts

Dr. Maurício G. Araújo | Brazil Department of State University of Maringa

Following tooth extraction, about 30 % (for individual tooth gaps lost completely after a tooth has been how much surrounding in the first year following extraction). extracted. Accordingly, the net bone The remaining , the basal bone, is loss is lowest in the incisor region, but bone is lost? Can this resorbed to a lesser extent, i.e., about the percentage of bone reduction is process be slowed? Our 10 %4. The amount of bone resorption the highest (37 %). current understanding. depends on anatomical factors, site of extraction and function. Often the bone of the Lack of bone vs. lack of is made up of very thin socket walls, volume In a jaw that has been edentulous for especially at the buccal aspect, and years, the alveolar ridge can resorb parts of the alveolar process are often There is another phenomenon to be completely1. Also, single tooth gaps are outside the envelope of the jaw. In ad- considered. Despite alveolar process subject to dramatic contractions. In or- dition, since the purpose of the alveo- and basal bone reduction, there is der to describe such dimensional alter- lar process is to support a tooth, once more bone after tooth extraction than ations following tooth extraction, the the tooth has been removed, bone is before – because new bone is formed edentulous ridge has been measured resorbed because the body adapts to in the space previously occupied by the in numerous studies, clinically, radio- the new, edentulous state. root. graphically and using casts. Thus, frequently we will have bone According to the Osteology Consensus enough to hold an implant, especially Conference, the mean ridge reduction Bone loss in posterior and a narrow diameter implant. But to re- is 3.8 mm horizontally and 1.24 mm anterior sites store a tooth with implants, not only is vertically2,3. bone necessary but also ridge volume The extent of bone loss varies accord- to provide the mucosa profile for aes- ing to the site and the patient. Our thetics. Adaptation to a new, studies show that net loss of bone is Now, if we have enough bone for pla- edentulous state greater in the posterior than the ante- cing the implant but not enough vol- rior regions. Fortunately, the posterior ume, in reality we don’t necessarily What are the reasons for bone resorp- sites contain so much bone that re- need more bone but any graft that tion following tooth extraction? First sorption is often not a major clinical could provide volume, whether it is a we have to be clear that the jaw is problem. gingival graft, a soft-tissue matrix, a made of basal bone and alveolar pro- On the other hand, due to the limited bone substitute or anything that is cess. It is the bone of the alveolar pro- amount of anterior bone, the loss of compatible and stable. However, the cess that is mainly resorbed. In addi- less bone in the anterior region can be best-documented way to preserve vol- tion, it is not the entire alveolar problematic. As alluded to above, fa- ume after tooth extraction is Ridge process but a significant part of it, cial bone walls are very thin and often Preservation with biomaterials.

6 Geistlich News 02 | 2015 FOCUS

Less bone loss through References 1 Bergman B & Carlsson GE: J Prosthet Dent Ridge Preservation 1985; 53: 56–61. 2 Lang NP, et al.: 2012; Clin Oral Impl Res Ridge Preservation prevents volume 23(Suppl 5): 39–66. loss after tooth extraction, but not al- 3 Hämmerle CHF, et al.: Clin Oral Impl Res 2012; ways 100 %5. Results depend, again, on 23(Suppl 5): 80–82. 4 Unpublished data the tooth region and the patient. We 5 Araújo MG, et al.: Clin Oral Implants Res 2015; have recently shown that, for the vast 26(4): 407–12. majority of patients, preserving ridge 6 Monica M, et al.: Clin Oral Implants Res dimension provides enough bone tis- (submitted) 7 Araújo MG, et al.: Int J Periodont Restaurat sue to place an implant in a proper Dent 2008; 28: 123–35. 3-dimensional orientation and with an 8 Araújo MG & Lindhe J: Clin Oral Impl Res ideal amount of bone surrounding the 2009; 20: 433–40. These factors influence bone loss 6 9 Araújo MG, et al.: 2000 2015; implant . Animal studies have shown 68: 122–34. Facial bony walls are that in extraction sockets Geistlich 10 Jung RE, et al.: Clin Oral Implants Res 2013; Bio-Oss® Collagen supports new bone 24(10): 1065–73. frequently thinner than 1 mm12, and these thin walls formation, particularly in the cortical 11 Traini T, et al.: J Periodontol 78(5): 955–62. 12 Januario AL, et al.: Clin Oral Impl Res 2011; 10: are almost exclusively

region, and contributes to ridge profile 1168–71. bundle bone. Because it is Photo: ©iStock.com/unkas_photo preservation7,8. Given these studies, we a completely tooth- can assume that Ridge Preservation dependent structure, the modifies bone modelling and alleviates bundle bone is resorbed after tooth extraction. buccal bone loss9.

The extent of surgical trauma influences bone How long does Ridge loss after tooth extraction, Preservation last? so there are good reasons not to extract teeth with dental pliers but with a Many studies on Ridge Preservation periotome or vertical tooth are limited to a six-month observation extractor9. period. There is, however, reason to be- lieve that extraction sockets filled There is no current with Geistlich Bio-Oss® continue agreement about whether to be stable much longer. Long- the extent of a flap influences superficial bone term studies measuring lateral resorption9. augmentations10 and sinus floor elevations11 have re- Loss of functional vealed that, if there is no stimulation of the bony loss caused by inflamma- walls is a confirmed factor tion, Geistlich Bio-Oss® contributing to bone loss after tooth extraction9. preserves ridge volume long term. Further extrac- tion socket studies would, however, be helpful in con- firming this assumption.

GeistlichGeiG ststltllichich NewsNeewws 020 | 20152020115 7 Photo: ©iStock.com/webking FOCUS

The Modern The new thinking post Minimalist

Ridge Preservation: tooth extraction Bone retention after tooth extraction, implantation or bridge restoration after Prof. Ronald E. Jung | Switzerland 4–6 months Center for Dental and Oral Medicine University of Zurich

+ Non-invasive

Ridge Preservation is easy to perform and hardly invasive at Immediate implantation, tion has its part to play in this new ap- all. It preserves the ridge spontaneous healing or proach, it is not just another technique volume for implants or bridge in the treatment repertoire, it is much restorations. Ridge Preservation – these more significant. Invasive GBR-measures are five-times less likely to be are the available options required after a Ridge after a tooth has been Preservation9. Three options after tooth extracted. Which option is extraction – No 100 %-guarantee the best, and when? The first decision that the dentist must Even Ridge Preservation cannot preserve 100 % of bone make: Should I let the extraction socket volume1. A second augmenta- There is new thinking in implant den- heal spontaneously, fill it with a bone tion may be necessary in the tistry, much like the new thinking that replacement material or insert an anterior maxillary area, if the occurred with cariology some 50 years immediate implant? The best proce- aesthetics depend on 100 % ago. Treatment in cariology used to in- dure depends on different factors in bone volume. volve the “Extension for prevention” day-to-day clinical practice: tooth approach: the more hard tooth sub- location, the condition of the bone stance that could be replaced with an and soft tissue, as well as the patient’s amalgam filling, the less that could go general state of health, his or her wrong. But since the 1960s, dentists personal circumstances and financial have made retention of hard tooth sub- situation, to name but just a few When should the ridge be stance their aim. And between 1964 factors. preserved? and today, a prevention program has It is important that the treatment de- helped reduce the prevalence of caries cision is discussed before the tooth is In our clinic, Ridge Preservation is in Switzerland by over 90 %. extracted. Depending on the option, always carried out if no implant is And a similar new thinking is happen- the bone lost during the first four to six placed within the first 8 weeks after ing today at the “alveolar process” level. months is: tooth extraction (Fig. 2, Page 10). Again, retention instead of replace- › 50 % for spontaneous healing1, There is another approach, however, ment is the key. At conferences we › 56 % for immediate implantation2, which involves Ridge Preservation af- should no longer be measuring our- › 15–20 % for immediate implantation ter every tooth extraction, if an im- selves against those who can regener- with “gap filling”3, and plant or bridge restoration is planned. ate the largest bone defects, but rather › 15 % for Ridge Preservation4. Above all, private practitioners claim we should seek to impress others with The advantages and disadvantages that this pre-emptive measure gives our predictable and low-risk proce- of the treatment options are depicted them a greater degree of security. The dures. Because alveolar ridge preven- in Fig. 1. alveolar ridge is always sufficiently

8 Geistlich News 02 | 2015 FOCUS

The Diva The Classicist

Immediate implantation: Early implantation: Implantation immediately First spontaneous healing, Illustration: ©iStock.com/4x6 after tooth extraction, then implant insertion potentially with simultaneous 6–8 weeks after tooth augmentation in the buccal extraction with simultaneous gap (“gap filling”) lateral augmentation FURTHER TREATMENT

1 Three options after tooth extraction + Fewer interventions + Tried and tested

The shorter treatment time The soft tissue has almost and the reduced number completely healed by the time of surgical interventions are of implantation, but not too complications. Using a periodontal major advantages of an much bone volume has been probe – and a CBCT scan, if one is avail- immediate implantation. lost. The survival rate of able – it is possible to establish wheth- Also, blood-thinning medica- implants in augmented bone is er the buccal socket wall is intact. The tion taken by older patients just as high as in native bone procedure depends on this diagnosis. has to be discontinued only (approximately 92 %)5. once (lower risk). Histologically, well-integrated If at least 50 % of the buccal bone la- Geistlich Bio-Oss® particles mella has been resorbed, volume show no signs of inflammatory – Comply with the indication should be gained by contouring. After activity6. a flap has been prepared, the bone re- Immediate implantation can placement material is poured into the cause bone and soft tissue – Technically demanding socket and applied in a buccal direc- recessions. tion. A collagen membrane is laid over Anterior teeth should only be The implant procedure is as replaced with immediate demanding as an immediate the graft and ridge to stabilize the graft implants when the buccal implant. As an implant has to and prevent soft tissue invasion. Pri- socket wall is sufficiently thick. be inserted into a socket, there mary wound closure improves progno- Increased bone absorption can is always the danger of placing sis. The membrane itself does not need occur in the molar region7. the implant too far in the to be sutured. buccal direction. Optimization: If the buccal lamella is largely intact, Fill the gap between the the bone replacement material is buccal socket wall and the poured into the socket without it being implant with a bone replace- opened up, and the socket is then ment material and cover the defect with a membrane.8 sealed – with a disc of collagen matrix ® Some surgeons close the Geistlich Mucograft Seal or with an socket over the implant with a The right procedure autologous soft tissue punch graft or a connective tissue transplant in connective tissue palatal harvest graft. order to gain additional The tooth should be extracted atrau- This “sealing” procedure has an advan- volume. matically after the soft tissue has been tage over the contouring approach, as released using a desmotome or scalpel. the mucogingival border is not dis- Orthograde apparatuses can help with placed. If a collagen matrix is used, the extraction, but they can be complex which means that no harvest graft to use. In general you can say: the gen- needs be taken from the palate, then broad, and one can feel certain about tler, the better. the procedure is even less invasive. If, the quality of the regenerated bone The extraction socket should then be however, the soft tissue has to be thick- before implant placement, so this ap- curetted. This step must be performed ened, an autologous transplant is ab- proach is also legitimate. carefully, as it can help prevent later solutely necessary.

Geistlich News 02 | 2015 9 FOCUS

Is implant insertion within 2 months possible / indicated?

NO YES

Are there bone defects in the socket? Can the soft tissue situation be improved?

SMALL < 50 % LARGE > 50 % NO YES Socket Seal Technique Bone augmentation = GBR Spontaneous healing Soft tissue retention

Geistlich Geistlich Geistlich Bio-Oss® Collagen Bio-Oss® Collagen Bio-Oss® Collagen + + +

or or

Geistlich soft tissue Geistlich connective tissue soft tissue Mucograft® Seal punch graft Bio-Gide® transplant punch graft

Type 4 implantation Fixed dental prosthesis Adhesive bridge Partial tooth replacement Type 1 or Type 2 implantation Type 3 implantation

2 Decisions after tooth extraction

There is very little convincing evidence augmentation will be necessary later. References for an approach using only bone re- In such cases, soft tissue management 1 Araújo MG, et al.: Periodontol 2000 2015; 68: placement material, i.e., without a soft at the time of tooth extraction can be 122–34. tissue transplant, wound closure, mem- of enormous help. 2 Botticelli D, et al.: J Clin Periodontol 2004; 31(10): 820–28. brane or matrix. A randomized compara- An autologous connective tissue or 3 Chen ST, et al.: Clin Oral Implants Res 2007; tive study from our group has shown soft tissue punch graft from the palate, 18(5): 552–62. that, in the event of a Ridge Preserva- or a disc of collagen matrix can be 4 Jung RE, et al.: J Clin Periodontol 2013; 40(1): 90–98. tion without a collagen membrane or used. After such a procedure, the soft 5 Jung, RE, et al.: Clin Oral Implants Res 2013; matrix, even more bone volume is lost tissue should be allowed to mature for 24(10): 1065–73. than with spontaneous healing (bone at least two months before an implant 6 Jensen SS, et al.: J Periodontol 2014; 85(11): material used: beta-tricalcium phos- is inserted. 1549–56. 7 Wagenberg B, Froum SJ: Int J Oral Maxillofac 4 phate with a special coating) . Implants 2006; 21(1): 71–80. 8 Araújo MG, et al.: Clin Oral Implants Res 2011; 22(1): 1–8. 9 Weng D, et al.: Eur J Oral Implantol 2011; 4 When and how to optimize Supplement: 59–66. the soft tissue?

Above all, in the anterior maxillary re- gion a sufficient quantity of keratinized soft tissue can be critical for aesthet- ics. At extraction, sometimes it is pos- sible to predict when a larger bone

10 Geistlich News 02 | 2015 FOCUS Socket Sealing with collagen matrix

Dr. Stefan Fickl | Germany Department of Periodontology University Hospital Würzburg

1a Clinical situation: tooth 12 is not 1a worth retaining. 1b Situation after filling with Geistlich Bio-Oss Collagen® and sealing with Geistlich Mucograft® Should the extraction socket Seal. be sealed with a soft tissue 1c Clinical situation after treatment with an adhesive bridge and punch graft or with a pontic in Region 12. 1b 1d Crestal view shows good volume collagen matrix? The matrix retention through using Socket has some advantages over Sealing. the autologous punch.

Studies over the past few years have tissue graft3. At the same time, postop- 1c clearly shown that Ridge Preservation erative levels of patient morbidity are significantly reduces ridge volume clearly lower (Fig. 1 a,b). It also appears loss after tooth extraction. Animal and that the collagen structure of Geistlich clinical trials have demonstrated that Mucograft® Seal reduces the risk of the combination of a xenogeneic bone scar formation, ensuring a more pleas-

replacement biomaterial (Geistlich ing tissue match with surrounding 1d Bio-Oss® Collagen) with an autologous native tissues (“Blending”, Fig. 1 c,d). soft tissue punch graft can achieve The preconditions for a successful ap- the most effective volume preserva- plication of the Socket Seal technique tions1,2. are an inflammation-free marginal soft

But this technique is not without its tissue situation, precise suturing and Photos: Fickl clinical disadvantages, which include an intact extraction socket with re- high patient morbidity and the danger tained buccal bone lamella. of scar formation in the buccal region In these cases – and as found by the due to incomplete healing. Geistlich Mucograft® Seal Advisory Board Meeting in February 2013 in Ge- neva – no additional Preconditions for is needed. Socket Sealing An early implantation time (8–10 weeks after extraction) is possible. If portions References A xenogeneic soft tissue replacement of the buccal bone lamella are de- 1 Fickl S, et al.: Clin Oral Implants Res 2008; 19: material for the sealing of the extrac- hisced, a membrane should also be 1111–18. tion socket (Geistlich Mucograft® Seal) used to protect the bone replacement 2 Thalmair T, et al.: J Clin Periodontol 2013; 40: 721–27. appears to provide Ridge Preservation biomaterial, and the healing time 3 Jung RE, et al.: J Clin Periodontol 2013; 40: results similar to an autologous soft should be extended. 90–98.

Geistlich News 02 | 2015 11 FOCUS Ridge Preservation instead of sinus lift?

Prof. Giulio Rasperini | Italy University of Milan Dental Practice Prof. Giulio Rasperini Piacenza

Interviewed by Dr. Mireia Comellas and Susanne Schick

Sinus floor elevation is still Geistlich Bio-Oss® Collagen and treatment time is shortened, so they a major surgical intervention Geistlich Bio-Gide® was compared to have less pain and, of course, they spontaneous healing. We focused on avoid possible post-operative compli- and is associated with the the posterior maxilla, which means first cations. risk of complications. How and second molars. Our goal was to can one avoid it? evaluate the ridge alterations after You have also evaluated the healing tooth extraction and the need for a process histologically. What did you subsequent sinus lift. find? Prof. Rasperini: Our histological evalua- Prof. Rasperini, the benefits of Ridge Did you find an advantage for Ridge tion revealed normal healing with a Preservation appear to be confirmed Preservation over spontaneous heal- lack of inflammatory cells. Geistlich by the latest systematic reviews1–5. In ing? Bio-Oss® Collagen as well as Geistlich your opinion, what are the benefits of Prof. Rasperini: After 6-months the ma- Bio-Oss® appeared to be surrounded Ridge Preservation in the posterior jor benefit was a significantly reduced by newly formed bone. This is advanta- region? need for sinus floor elevations6. The geous for the dentist: on the one hand, Prof. Rasperini: Ridge Preservation is bone is almost completely mature at the bone is stable – due to the mineral performed in posterior regions in order that time, and a flapless implant place- component of the graft that resorbs to reduce the need for a sinus lift. The ment can be performed easily, because slowly; and on the other hand, the bio- upper jaw has limited basal bone due of the ridge volume obtained with the logical activity of the new and vital to significant pneumatisation of the si- grafting biomaterials. The simple pro- bone promotes osseointegration of the nus and, of course, incurs additional cedure makes a big difference com- implant. bone loss after tooth extraction. So, a pared with sinus floor elevation, which sinus lift is needed to create sufficient is a major surgical procedure. Your publication includes a finding of bone for implant placement. However, “delayed bone formation process and peremptory Ridge Preservation re- What is the patient benefit? incomplete resorption of bovine bone duces the need for bone regeneration Prof. Rasperini: Most of the patients particles” at the grafted sites. How do at the time of implant placement. who undergo molar extractions are you interpret this finding? more than 70 years old. They are often Prof. Rasperini: It is well known that the You have investigated the effects of on medications like Coumadin, Aspirin body’s own cells incorporate the graft- Ridge Preservation in the posterior or other anticoagulants, and they can ing granules in the bone remodelling area6. What was the goal of this study, be diabetic. These are factors that in- processes6. In the case of the Geistlich and how was it designed? fluence wound healing and the out- bovine bone mineral particles, this pro- Prof. Rasperini: Within this random- come of any surgery. The patients ap- cess takes place over a long period of ised study, Ridge Preservation with preciate avoiding a major surgery, and time.

12 Geistlich News 02 | 2015 FOCUS

Ideally, when the bone is mature, the 1 Three months 1 post-surgery. A newly formed bone of the regenerated large amount of area will be mineralised. With Geistlich Geistlich Bio-Oss® (BO) particles are ® Bio-Oss we place mineralised particles surrounded by in the socket from the beginning. After highly cellular, fibrous connective six to nine months, histopathology tissue (CT). No shows that biologically active tissues inflammatory infiltrate is surround these particles, i.e., newly detectable. NFB = formed woven and lamellar bone6. With newly formed bone (Magnification: 4 ×) grafting we achieve ideal physical and 2 Nine months mechanical results. post-surgery. 2 According to a study performed by Remnants of the 7 biomaterial are Prof. Cattaneo’s group , less than 20 % surrounded by of Geistlich Bio-Oss® is still present af- newly formed bone (NFB) in lamellar ter ten years. So at that time we have shape as well as over 80 % mature, mineralised bone. woven bone (WB) to some extent. (Magnification: 10 ×) You used Geistlich Bio-Gide® as a col- lagen membrane to protect the aug- mented site. What makes you sure that this membrane has the right barrier Photos: courtesy of [6] function for this indication? Prof. Rasperini: Wound healing consists of three phases: first comes the inflam- matory phase, which takes about three days, then the proliferative phase, which takes about 15 days, and finally the maturation phase, which continues over three months8. In the beginning a scaffold is needed that prevents any provides this evidence9. If, on the other References shrinkage of the tissue and graft loss. hand, a non-resorbable membrane is 1 Avila-Ortiz G, et al.: J Dent Res 2014; 93(10): But after one month, every cell in the used, the graft receives nutrition from 950–08. wound “knows” exactly what to do, and the bone site only and lacks nutrition 2 Morjaria KR, et al.: Clin Implant Dent Relat Res 2014; 16(1): 1–20. the barrier function is no longer need- from the flap. 3 Horvath A, et al.: Clin Oral Investig 2013; 17(2): ed. That’s why Geistlich Bio-Gide® with But there is another fact to be consid- 341–63. its short barrier function is appropriate. ered: how quickly the graft resorbs. 4 Vittorini Orgeas G, et al.: Int J Oral Maxillofac The advantage of Geistlich Bio-Gide® Geistlich Bio-Oss® resorbs slowly and, Implants 2013; 28(4): 1049–61. 5 Vignoletti F, et al.: Clin Oral Implants Res 2012; compared to other non-resorbable thereby, preserves volume in the aug- 23 Suppl 5: 22–38. membranes is that is does not interfere mented site. Autologous bone, in con- 6 Rasperini G, et al. Int J Periodontics Restora- with vascularization and nutrition pro- trast, resorbs quite quickly so that vol- tive Dent 2010; 30(3): 265–73. 7 Sartori S, et al.: Clin Oral Implants Res 2003; cesses between the soft tissue flap and ume is lost. To compensate for this loss, 14(3): 369–72. the underlying graft. Cells and blood a different type of membrane that re- 8 Polimeni G, et al.: Periodontol 2000 2006; 41: vessels from the flap integrate with the sorbs slower than the scaffold is need- 30–47. 9 Pellegrini G, et al. Int J Periodontics Restora- membrane quickly and start to deliver ed – not for the barrier function, but tive Dent. 2014; 34(4): 531–39. nutrients and oxygen to the surgical for volume stability. With Geistlich site, contributing to the maturation of Bio-Oss ® and Bio-Gide® we achieve the the graft and the healing process. A re- ideal combination of volume stability cently published paper from our group and barrier function.

Geistlich News 02 | 2015 13 FOCUS “Ridge Preservation simplifies treatment”

Dr. Dietmar Weng | Germany Practice for Dentistry Böhm & Weng Starnberg

Interviewed by Verena Vermeulen

Ridge Preservation creates sion must often be performed after a In your view, when should Ridge Pres- better bone conditions lateral bone augmentation so that the ervation be recommended? soft tissue can close without being un- Dr. Weng: I would always carry it for later implantation and der tension, which can cause both out – both in the anterior and lateral provides more forgiving haematomas and swelling. tooth areas – if an implant is planned, implant placement The time aspect, on the other hand, is but not when an immediate implant- of secondary importance. If one per- ation is under consideration. And then conditions for dentists forms a Ridge Preservation, the tooth I always fill the gaps between the with less experience, says extraction takes longer, because one implant and the socket walls! Dr. Dietmar Weng. wants to remove the tooth more gen- tly and damage the bone structure as Which situations do you find unsuit- little as possible. Ridge Preservation able for immediate implant placement? done correctly also takes time. Dr. Weng: Molar sockets, severely in- To put the question as simply as pos- flamed sockets, or sockets with de- sible: Isn’t it always “Tooth out – bone How can you tell beforehand whether monstrable wall dehiscences are not replacement in”? a Ridge Preservation is necessary in cases for an immediate implantation, Dr. Weng: No, you really can’t make order to avoid a later GBR? in my view. I would carry out a Ridge such a generalization. It depends on Dr. Weng: According to ’s re- Preservation first in such cases. several variables, for example: the search, the thickness of the buccal treatment you are planning, the bone bone lamella plays a role here. The loss Does the patient’s biotype play a role? condition and the level of inflamma- of buccal-lingual alveolar ridge width Dr. Weng: Over the years I have devel- tion. with a thick buccal bone lamella, shall oped my treatments so that I can op- we say wider than 0.8 mm, is less than erate independently of biotype. As for The German Society for Implants in its in sockets with a thin buccal wall. Un- Ridge Preservation, I would say it is 2011 Consensus Conference noted that fortunately, the latter defects exist al- just as effective for patients with thick GBR-measures are five-times less like- most exclusively in the anterior maxil- or thin bony walls. ly to be needed at the time of the im- lary area of bundle bone, which is plantation if a Ridge Preservation was resorbed after tooth extraction, at Would you also carry out a Ridge Pres- already performed1. That is going to least up to a height of 2–3 mm from ervation in order to preserve the vol- save a considerable amount of operat- the ridge. ume under pontics? ing time and pain for the patient, don’t In practice, it is hard to measure the Dr. Weng: Probably not, because of the you think? socket walls accurately either before financial considerations involved. Dr. Weng: Ridge Preservation, above all, or after an extraction, and without a When someone decides on a bridge is less traumatic for the patient than flap it is also difficult to judge the bone reconstruction instead of an implant, later GBR-measures. A periosteal inci- situation. he or she tends to do so on the

14 Geistlich News 02 | 2015 FOCUS

Dietmar Weng presents his treatment concepts after tooth extraction at congresses. He is photographed here at the 2014 EAO Congress in Rome. Photo: Geistlich

grounds of cost. For such patients, itself is uncomplicated and minimally References Ridge Preservation is also a financial invasive. And it creates a sufficiently 1 Weng D, et al.: Eur J Oral Implantol 2011; 4 matter. wide alveolar ridge, which means that Supplement: 59–66. a later implantation can be performed Often the person who removed a by less experienced dentists. tooth does not insert an implant later himself, but refers the patient on to an So we should have “more confidence oral surgeon… when it comes to implants”? Dr. Weng: Many dentists don’t feel con- Dr. Weng: Yes. When you use a suitable fident about implants, because they procedure, the whole treatment from are associated with complex augmen- extraction to prosthetic restoration tations. But Ridge Preservation makes can be done in a minimally invasive treatment much simpler. The measure way.

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Geistlich News 02 | 2015 15 FOCUS Ridge Preservation in the anterior maxilla: a case study

Dr. Beat Wallkamm | Switzerland Praxis Wallkamm Langenthal

A case series investigation bone had matured by this time, and Aftercare planning of whether it is possible there was sufficient primary stability. After a further two-month healing Cooperation with the referring dentist to insert an implant just phase, the reopening took place, and a is of great importance for a successful four months after a Ridge conical healing cap was inserted. The treatment. The patient’s Preservation. patient was referred back to the den- barely fulfilled the requirements for im- tist treating her for the prosthetic res- plant placement. We recommended toration and the extraction of tooth 22. that the dentist arranges more fre- A 75-year-old female patient was re- Two years later, the probe values quent recall appointments for profes- ferred for the extraction of teeth 21 around the implant were 3 mm. The ex- sional tooth cleaning. and 22. An implant restoration in re- tension of the crown (tooth 22) had no gion 21 (screw-retained) with an exten- contact in the articulation. The patient sion bridge was planned. Both teeth was very happy with her treatment. had gingival recessions, although the patient had a thick biotype. The pa- tient had a deep smile line. What should be taken into After the careful removal of tooth 21, consideration? the extraction socket was filled loose- ly up to the crestal edge of the socket The case is part of a case series, in walls with Geistlich Bio-Oss® Collagen. which the effectiveness of Ridge Pres- A disc of collagen matrix, Geistlich ervation in combination with a late im- Mucograft® Seal, was adapted to the plantation was tested. One of the ob- deepithelialised wound margins over jectives of the case series was to the bone replacement material and evaluate the earliest possible time for stabilized with a mattress suture. implantation after Ridge Preservation. Tooth 22 was initially left in situ and For this reason, the implant was insert- served as an anchoring point for the ed after just four months, although this temporary Flieger crown x22. is a relatively early implantation time The healing progressed smoothly. Af- after bone regeneration with bovine ter three weeks, the epithelisation over bone replacement material. the collagen matrix was complete. Af- A biopsy was taken in order to assess ter four months, the implant (Strau- the condition of the bone after four mann Bone Level NC Implant Roxolid months. The degree of maturity of the SLActive) was inserted in the correct new bone was sufficient for a primary prosthetic position. The newly formed stable implant insertion.

16 Geistlich News 02 | 2015 FOCUS

CASE

1 2 3 1 Radiograph of teeth 21 and 22, which were not worth retaining 2 Clinical situation of the area Photos: Wallkamm to be treated 3 De-epithelialisation of the sulcus after tooth extrac- tion 4 Geistlich Bio-Oss® Collagen 4 5 placed in the extraction socket 5 The extraction socket sealed with Geistlich Mucograft® Seal 6 Stabilisation suturing 7 Healing after one week 8 Installed implant with a 6 7 sealing screw 9 New healing cap for the emergence profile after 2 months 10 Radiograph 2 months after implant insertion 11 Clinical situation 2 years after extraction 8 9 12 Radiograph 2 years after extraction

10 11 12

Geistlich News 02 | 2015 17 JOURNAL CLUB KEY STUDIES SELECTED.

Dr. Hector Rios | USA Department of Periodontics and Oral Medicine University of Michigan Ann Arbor

18 Geistlich News 02 | 2015 Photo: ©iStock.com/dtimiraos JOURNAL CLUB

INTRODUCTION Early Diagnosis

Can novel therapeutic approaches regenerate the peri- odontal ligament? And which findings contribute to Today, our understanding of wound healing and periodon- personalized periodontal therapy? tal regeneration should incorporate gene, protein and me- tabolite information into a dynamic, biological network that Over 30 years have passed since the first successful appli- includes disease initiation, susceptibility, and resolution. cation of regenerative therapy for treatment of periodon- But today is diagnosed based on clini- tal diseases. A plethora of biomaterials and protocols have cal findings such as probing pocket depth, bone loss, loss been developed since then and are now available for clini- of attachment and other clinical measures. How can we an- cal application. Nonetheless, periodontal regeneration is ticipate severe disease progression early and prevent peri- still a challenging task. Once the integrity of the tissue at- odontal destruction? What is needed is a proper under- tachment is compromised and the alveolar bone starts standing of the biological processes of the PDL. And this deteriorating, restoring the function and structure of the understanding should help us discover new “early stage” periodontal organ to its original state becomes an unpre- markers for periodontal disease. In this paper the most im- dictable clinical outcome. portant features of a biomarker are discussed – that it must be highly specific, highly sensitive, biologically stable for How do we overcome this situation? Key developments in feasible detection, predictive (i.e., proportionate to the de- periodontal research have included: gree of disease) and noninvasively measurable.

› The establishment of advanced diagnostic methods `Rios HF: Dimensions of Dental Hygiene 2012; that help anticipate and prevent severe periodontal 10(10): 19–22. disease progression, › 3D imaging to better diagnose defects, › Optimized biomaterial scaffolds, e.g., in combination with biologically active molecules or genes for the A Potentially Novel Biomarker? “holy grail” of periodontal ligament (PDL) regenera- tion, and › New surgical protocols and instruments that mini- Molecules such as periostin are potential biomarker targets mize trauma and enhance wound healing. that could help us with our understanding of periodontal cell-matrix dynamics and homeostasis. Periostin is found The following collection of recent papers sheds light on the within the periodontal ligament and is a key extracellular current state of knowledge and gives hope for the future. matrix protein involved in periodontal tissue homeostasis. In periostin-knock-out mice, the loss of periostin leads to rapid deterioration of the structural and functional integ-

Geistlich News 02 | 2015 19 JOURNAL CLUB

rity of the , advanced alveolar bone loss, se- combinations of scaffolds with living cells and/or biologi- vere and a significant widening of cally active molecules. the PDL space. Periostin expression in the PDL is strongly induced during cell differentiation and mineralization. The Scaffold matrices: In the last two decades, scaffold matri- identification of PDL biomarkers such as periostin could ces have been investigated extensively for periodontal re- help us predict regenerative outcomes and complement tra- generation. Current research is focused on the optimization ditional clinical measures. of physicochemical and mechanical properties of novel scaf- folds to overcome contemporary structural and biological `Yamada S, et al.: J Dent Res 2014; 93(9): 891–97. limitations that have hindered the predictability of peri- odontal regeneration. One possibility is region-specific vari- ations in microstructure porosity and scaffold surface to- pography. Another potential is the combination of scaffolds with cell- or gene-based therapies. 3D-imaging for diagnosis Cells: Mesenchymal stem cells (MSCs) from oral or extra- oral sources are able to differentiate into a variety of cell Cone beam computed tomography (CBCT) gives an undis- types, such as osteoblasts, fibroblasts and cementoblasts, torted 3-D assessment of a tooth and surrounding struc- and thus promote regeneration. Though theoretically pos- tures and provides axial, coronal and sagittal multi-planar sible, the use of MSCs for regeneration has so far lacked the reconstructed images without magnification. What are the sophistication to be predictable in mainstream clinical prac- advantages of this imaging technique compared to conven- tice. tional radiography, when it comes to the diagnosis and A more recent technology utilizes confluent cell sheets. treatment of periodontal defects? Cells from the PDL are grown on a temperature-sensitive sheet in culture plates, and the entire sheet, which includes Acar & Kamburoğlu’s paper highlights advantages of 3D im- not only cells but also an intact extracellular matrix with aging for the assessment of intrabony defects, the diagno- cell-cell junctions, can be harvested by simply lowering the sis of interradicular bone loss and the measurement of re- temperature. The sheet can then be implanted directly into generative therapy outcomes. For example, CBCT imaging the intended site of therapy. The advantage of this tech- of maxillary molars gives more detailed information about nique lies in its improved preservation of cells within an ex- furcation involvement than conventional radiology. In this tracellular environment. sense, the volumetric assessment of the periodontal struc- tures assists us with case selection and helps us anticipate Genes: The idea behind gene therapy is the transfer of ge- challenging anatomies. It helps us choose surgical options, netic material to direct a patient’s cells to produce a thera- such as apically repositioned flaps with or without tunnel peutic effect. Using gene therapy for PDL regeneration has preparations, root amputation, hemi-/trisection or root sep- several advantages over cell therapy. For example, it avoids aration. the challenges associated with ex vivo protein expression and purification, and the genes can be expressed in vivo for `Acar B, Kamburoğlu K: World J Radiol 2014; 6(5): weeks to years. Possible target genes for gene therapy are 139–47. PDGF, BMP and glycoproteins from the WNT pathway. Nonetheless, due to the safety and efficacy issues involved in regulatory approvals, the clinical application of gene ther- apy for periodontal defects remains more of a theory than Tissue engineering, cells and a mainstream clinical practice.

genes Limitations and lessons learned: Our outcome limitations when working with growth factors frequently relate to our Tissue engineering has the potential to improve the regen- limited understanding of the biology of the healing perio- eration of lost periodontium in a more predictable manner dontium, i.e., specific target cells and their differentiation than conventional therapies. Novel approaches include requirements, release kinetics of growth factors delivered

20 Geistlich News 02 | 2015 JOURNAL CLUB to the site and stability of the regenerated tissues. In addi- agent teriparatide acts on preosteoblasts to increase tion, many scaffold-based strategies have failed because proliferation and on osteoblasts to decrease apoptosis. Its the investigators confused tissue ingrowth with tissue mat- main indication could be for patients with known metabolic uration. A defect filled with immature tissue should not be disorders. considered “regenerated,” and premature scaffold degrad- ation can adversely affect treatment outcomes. `Rios HF, et al.: Clinic Adv Periodontics 2015; 5(1): 40–46.

`Rios HF, et al.: J Periodontol 2011; 82(9): 1223–37. `Bartold PM, et al.: J Periodontal Res 2015, Apr 21. [Epub ahead of print] Regeneration of periodontal defects in daily practice 3D printed scaffolds

The last paper is a literature review and provides an excel- Imaging-based and computer-aided scaffolds provide a per- lent overview of the contemporary management of peri- sonalized tissue engineering solution. The three-dimension- odontal osseous defects by the periodontist-hygienist team. al anatomical geometry of a defect is acquired by high-reso- According to the authors, key principles for successful peri- lution computed tomography data, which can function as odontal regeneration are: (1) case selection, identification a template for a scaffold. The scaffold is fabricated with de- and resolution of etiologic and contributing factors, (2) the sired biomaterials by 3D printing that, in turn, will precise- proper surgical technique, including defect , ly match the spatial dimensions of the defect volume. root preparation and materials selection and (3) follow-up. Due to the complexity of the periodontal apparatus, appli- Currently used biomaterials are bone grafts, bone graft sub- cation of this technique requires a heterogeneous internal stitutes, barrier membranes and bioactive agents such as scaffold design, including region-specific variations in po- growth factors. rous microstructure and scaffold surface topography. These structural variations, in turn, help regulate the fate of in- `Schallhorn RA, McClain PK: J Evid Based Dent Pract 2014; 14 Suppl: 42–52. growing cells in a spatial specific manner. The scaffold test- ed in this study featured a fiber guiding structure and was able to compartmentalize different cell phenotypes within the volume of the scaffold.

`Park CH, et al.: Biomaterials 2012; 33(1): 137–45.

Results from the AAP workshop

The report from the 2014 AAP Regeneration Workshop sheds light on emerging therapies like systemic anabolic agents, local delivery of growth factors and cell therapy. As emerging therapies, most of these treatments lack high levels of evidence, i.e., randomized and controlled trials. Nonetheless, the report provides some clinical scenarios and gives background information on mode of action and indications. For example, the well-known bone anabolic

Geistlich News 02 | 2015 21 SUBSTITUTE SKIN WITH A SUPPLY SYSTEM. Recently developed natural artificial skin could revolutionize skin regeneration.

Cell biologist Ernst Reichmann has developed a substitute skin.

22 Geistlich News 02 | 2015 Photo: Universitätskinderspital Latzel Zürich / Marc OUTSIDE THE BOX

Dr. Klaus Duffner

At the University Children’s Moreover, the transplants can cause Hospital in Zurich a substi- new wounds and disfiguring scars. For children there is another serious prob- tute skin has been success- lem, as the scar tissue will not keep fully cultured for the pace with the body’s future growth. On first time, which, along with the contrary, scars tend to contract over time, which can lead to restric- other cell types, also con- tions in movement or physical distor- tains blood and lymph tions that mean many stressful subse- vessels. With this develop- quent operations could be necessary. ment, “cultured skin” is becoming more like natural Vessels to supply the skin human skin. Whether it is for burn victims, for people with chronic open wounds or Although generations of scientists for a substitute to animal testing – the have already tried to reconstruct a demand for artificial skin is enormous. natural skin substitute, the results To date, skin substitutes have con- have not been satisfactory. This largest tained no blood or lymph vessels, no of human organs seemed to be too pigmentation, no sweat glands or hair complex, with its various functional follicles, and no nerves. Due to the lack layers and multitude of cell and tissue of a vessel system, which in natural types, all of which have to be brought skin is responsible for supplying oxy- together in artificial skin to form a gen and nutrients as well as removing functional unit. excess water, there is an immediate oxygen and nutrient deficiency in the critical, initial healing phase, which Juvenile skin: a special clearly reduces the artificial skin’s problem chances of survival. But now for the first time, scientists As long ago as the 1970s, doctors in working with Ernst Reichmann, Mar- Boston, USA, attempted to develop a tin Meuli and Clemens Schiestl at the new skin from bovine skin, collagen University Children’s Hospital in Zu- and shark cartilage. But the powerful rich have succeeded in creating a dou- defence mechanism of the human im- ble-layer artificial human skin consist- mune system meant that all these at- ing of hypodermal cells (fibroblasts), tempts came to nothing. By the end of epidermal cells (keratinocytes), mel- the 1980s, scientists were able to cul- anocytes and the endothelial cells of ture certain skin cells, although they blood and lymph vessels. In these trials, were still very far from achieving a true skin biopsies one to two centi meters skin substitute. in size are divided into layers and then Until now burn victims have received broken down by enzymes into individ- mostly endogenous skin transplants. ual cell types. The cells are then placed This is disadvantageous in particular in special nutrient media to allow for small children for whom only them to multiply. The remarkable limited donor surfaces are available. thing about the artificial skin is that

Geistlich News 02 | 2015 23 OUTSIDE THE BOX

Baby skin in danger

According to one study, about 25,000 children and juveniles under the age of 15 scald or burn themselves in England and Wales every year; and some 3,800 have to be hospitalized1. 1-year-old babies suffer ten times as many burns and scald injuries as school-age children. Photo: Universitätskinderspital Zürich

1 New capillary vessels (red) have formed in the collagen scaffold (turquoise) of the new skin. Our skin is always changing

The epidermis renews itself completely approximately the epithelial cells from the blood and in a clinical trial at the University Chil- every 28 days. New skin cells form during this time lymph capillaries reform themselves dren’s Hospital in Zurich; and, accord- in the lower epidermal spontaneously into the two vessel ing to the lead researcher, Ernst Reich- layers and migrate toward types on a jelly-like carrier matrix. mann, it is the best in clinical use the surface. As a result, the These tiny capillaries have all the char- anywhere in the world. older cells lying above them acteristics of their natural counter- Such skin substitutes are urgently are pushed upwards and parts and are fully functional. The new needed. Approximately 1,000 people are shed. This is how we sections of skin are 7×7 cm square and are burnt so severely that they require lose about one to two grams take about three weeks to grow before hospitalisation every year in Switzer- of skin every day. they can be transplanted. land alone – to which can be added hundreds, perhaps even thousands, of people who, because of extensive It has been a long road birthmarks, accidents, infections or cancerous ulcers, have to have large Taking a closer look at skin Over the last decade and a half, it has sections of skin removed. If these trials taken a huge technical effort and enor- are successful and the substitute skin One square centimeter of mous financial outlay for the 15-person can grow with natural skin in the long skin contains 600,000 team to reach this stage. It took five term, this will mean fewer operations to 2 million skin cells, 5,000 sensory cells, 100 sweat years alone to develop a suitable car- for paediatric patients and, above all, glands, one meter of the rier substance for culturing skin cells. fewer scars. smallest blood vessels, 15 And it was this special matrix that sebaceous glands (although paved the way for the creation of real not on the palms of the skin transplants. The recently devel- hands or the soles of the References oped laboratory-grown skin with its feet), five hairs and 150,000 1 Kemp AM, et al.: Arch Dis Child (online) own supply capillaries is being tested 3. Februar 2014 pigment cells. Photos: ©iStock.com/filipw | ©iStock.com/Tassii | ©iStock.com/luna4 | ©iStock.com/Tassii Photos: ©iStock.com/filipw

24 Geistlich News 02 | 2015 BACKGROUND.

Geistlich Pharma & Osteology Foundation

Geistlich News 02 | 2015 25 1

GEISTLICH PHARMA

A conversation with the collagen experts

Interview by Verena Vermeulen Photos: Alfons Gut Photos: Alfons

Collagen plays an Eleven scientists working at Geistlich important role in Pharma have dedicated themselves exclusively to collagen research. the regeneration of Dr. Lothar Schlösser, Niklaus Stiefel tissue. This is why and Daniel Suppiger have advanced Geistlich Pharma has the company’s 160 years of collagen expertise with their work, as they have devoted itself to developed innovative biomaterials collagen expertise. for tissue regeneration.

Dr. Schlösser, collagen performs so many different functions in the body. Is it also the same for the collagen in Geistlich biomaterials?

26 Geistlich News 02 | 2015 GEISTLICH PHARMA

Dr. Schlösser: It certainly is. The Geistlich And which approach does Geistlich How do the cells react when you alter Bio-Gide® collagen membrane is a good use? the collagen? example. The dense collagen of the up- Dr. Schlösser: Both strategies have a D. Suppiger: That is the crucial question per layer acts as a dividing wall be- role to play for us. Some of our prod- for our cell laboratory. We continually tween a bone graft and the soft tissue. ucts, for example, if they should be optimize our collagen products until The lower layer has a more open struc- strong to retain sutures, contain native the right cells do what we want them ture in comparison. It adheres well to organized collagen tissue obtained us- to: mucosal cells, bone cells, cartilage the tissue, allows cells to colonize and ing a gentle preparation process. cells, etc. contains fibers that serve as “guiding In other cases we have designed our And to go back to the analogy of houses templates” for somatic cells. Although collagen tissue completely from scratch for a moment, after doing the cell tests, these are very different properties, using natural collagen components in we can really say: here’s the nursery, Geistlich Collagen has them all. order to obtain a specific effect, for ex- there’s the living room and that’s the cel- ample, to achieve good volume stabil- lar, i.e., testing particular “rooms” to How can one modify a protein so that ity when healing. make sure they “attract” the right cells.` it has either this or that property? N. Stiefel: Many people think that it has Is the competition doing the same 1 Niklaus Stiefel says: “We optimize our products something to do with which one of the thing? on the one hand for the 30 different types of collagen one uses, Dr. Schlösser: Other membranes are sake of the body’s cells, and on the other hand but in fact it is a question of the origi- frequently assembled from collagen to make them easier for nal tissue and how it is processed. It’s components, but in order to make dentists to use.” like when you are looking for a house. them strong for suture retention, they 2 Daniel Suppiger (left) You can either buy a complete, ready- must be chemically cross-linked, which and Dr. Lothar Schlösser are quite certain: built detached house, or you can buy can compromise the biology and heal- “Collagen products must the individual bricks and assemble ing response, which is exactly what we be made in such a way that cells can behave something completely new. don’t want! naturally in them.”

2

Geistlich News 02 | 2015 27 GEISTLICH PHARMA

How would you complete the sen- tence: “When a clinician uses Geistlich collagen membranes or matrices he can be sure that... ” N. Stiefel: ...the outcome is predictable, that no surprises will occur, and that he will be able to send his patient home happy. That’s why we do our research: to push for successful out- RISK comes, no matter how experienced a Collagen I is the most clinician might be. important protein in bone matrix. If collagen synthesis is genetically impaired, patients How can this be guaranteed? can suffer from brittle bone D. Suppiger: A large part of our work disease. consists of optimizing the handling of a product without compromising its proper effect on cells. Our focus is on the clinician from the very beginning. What’s important to the dentist or orthopedic surgeon? Does the product have to create volume? Must it be easily hydrated? For the requirement analysis, we work together with many clinicians around the world, from top surgeons to less experienced dentists. Dr. Schlösser: And we test the proto- FACTS ABO types in the same way, of course. Final- ly, we always have animal cadaver models in the lab so that in-house and external specialists can test how the new products perform in use. PREVALENCE Approximately one fifth of our One last question: What is a collagen body weight is made up of protein, of which one third is researcher’s dream? collagen. There are 30 different N. Stiefel: In principle, all tissue can be types of collagen. regenerated using the right collagen. It really would be a dream come true to be able to facilitate this: to be able to help cells so that they themselves proteins can regenerate tissue that has been lost or destroyed, like skin, heart or collagen liver tissue. In this regard, we hope to body mass “turn back the clock” – to encourage tissues to regenerate to their former, healthy states.

28 Geistlich News 02 | 2015 GEISTLICH PHARMA

QUANTITY If all the collagen molecules in a human body were unfolded and laid out end to end, they would reach from the Earth to the Moon.

POTENTIAL Collagens can absorb tensile forces up to ten thousand UT COLLAGEN times their own weight.

APPLICATION In the pharmaceutical industry collagen is used, above all, for × 10 coating tablets. Illustrations: © Büro Haeberli Zürich

Geistlich News 02 | 2015 29 GEISTLICH PHARMA Illustration: ©iStock.com/cundra

Establishment of Geistlich Pharma affiliates

1960: UK Global reach 1996: Germany Italy Thomas Pfyffer 2003: 2008: France & China 2010: Brazil 2011: South Korea Geistlich Pharma has further consolidated its network 2012: USA of biomaterial providers with the opening of its ninth 2014: Australia / New Zealand affiliate. Along with its nine agencies, about 60 licensed distribution partners work to ensure that Geistlich’s Success is predictable products are available in almost 100 countries around “We want to give patients some of their quality of life back. the world. As a specialist in regenerative medicine, we are always explor- ing new avenues,” is how CEO Paul Note outlines Geistlich’s What is the benefit of this impressive network to you, the philosophy. customer? Geistlich’s expertise is based on 160 years of ex- Our company developed the market for oral regenerative bio- perience. This accumulated knowledge and an active net- materials, and today we are a world leader in this field. More- work of exceptional researchers working around the world over, our company is the leading supplier of natural medical all influence our products and procedures. devices for cartilage and bone regeneration in orthopaedics, What’s the difference? The products originate from a single and we also supply other medicinal products for selected in- source – all the research, development and production takes dications. place in Switzerland. This is why we enjoy such a high level Our strictly scientific approach is one of the most important of confidence. Our family-run company has an extraordinar- pillars of our lasting success – yesterday, today and tomorrow. ily high proportion of staff involved in research and devel- You can benefit from this comprehensive knowledge by tak- opment. We are continuously making considerable invest- ing part in the advanced training courses we offer. They will ments – both our research and our corporate philosophy are let you see for yourself just how much our safe and quality- designed for the long-term. assured products can achieve.

30 Geistlich News 02 | 2015 GEISTLICH PHARMA Studies pass the 1,000 mark Evelyn Meiforth

Over one thousand publications1 attest to the Committed to dental regeneration high scientific and clinical standards of Geistlich Geistlich will be celebrating two important anniversaries Biomaterials. next year: 30 years of Geistlich Bio-Oss® and 20 years of Geistlich Bio-Gide®. But today the company has already set a new benchmark for regeneration with over 1,000 sci- If we assume that a typical study in dental regeneration entific publications – works that have made a decisive con- takes about a year and a half with at least six researchers tribution to the field of oral regeneration and provided suc- intensively involved, then 1,000 publications represent cessful treatments for patients around the world. 6,000 scientists, who have spent the equivalent of 9,000 years investigating Geistlich’s Biomaterials. This is why, when it comes to bone replacement and membranes References for oral regeneration, Geistlich Bio-Oss® and Geistlich 1 Pubmed Search: Bio-Oss OR Bio-Gide OR Mucograft (13. Juli 2015) Bio-Gide ® are considered the No. 1 referenced biomaterials 2 Traini T, et al.: J Periodontol. 2007; 78(5): 955-61. around the world. 3 Becker J, et al.: Clin Oral Implants Res 2009; 20(7): 742–49. 4 Jung R, et al.: Clin Oral Implants Res 2013; 24(10): 1065–73. 5 Schmitt CM, et al.: Clin Oral Implants Res 2015 Feb 27. [Epub ahead of A pioneering achievement print]. The close cooperation between Geistlich and researchers at various universities began in the 1980s. The potential for regenerative biomaterials was only a possibility when Dr. Peter Geistlich had an unusual idea for a new biomate-

rial solution. Together with Professors Myron Spector (Har- Photo: ©iStock.com/Dimedrol68 vard University) and Philip J. Boyne (Loma Linda Universi- ty), he developed a new kind of bone replacement material: Geistlich Bio-Oss®. Geistlich Bio-Oss® was followed in the 1990s by Geistlich Bio-Gide®, which was distinguished by its special bilayer structure and by the way it simplified the GTR and GBR techniques used at the time.

Inspired to research The exceptional biofunctionality of Geistlich biomaterials has fascinated scientists and clinicians around the world. Numerous studies have demonstrated that Geistlich Bio-Oss® is highly osteoconductive2, because of its ex- tremely porous structure and hydrophilicity. Geistlich Bio-Gide ®’s natural collagen fibers promote vascularized wound healing3. The slow resorption of Geistlich Bio-Oss® and the ideally matched protective function of Geistlich Bio-Gide® favor long-term volume stability of the augment- ed bone4. As the most recent development, Geistlich Mucograft® has inspired numerous research groups to conduct studies in which the new 3D collagen matrix has been used in the regeneration of soft tissue. Geistlich Mucograft ® has provided successful treatments for over five years5.

GeistlichGeGGeieiststlsttlliichiccchh NewsNNeewsws 0202 | 201520120201015 3131 Osteology Foundation has a new President Dr. Heike Fania

For over twelve years and since its establishment, Advanced training and research Prof. Christoph Hämmerle has been the President The successful development of the Osteology Foundation of the Osteology Foundation. His successor, has been a continual step-by-step process. Christoph Häm- Prof. Mariano Sanz, took office on 1 June 2015. The merle pointed to the National and International Symposia official transfer of the presidency took place at held by the Foundation, which have grown steadily in size the Osteology Board Meeting on 22 June 2015 in and reputation over the years. Zurich. Alongside these symposia, an important mainstay of the Foundation has been its grant program, providing support Looking back, Christoph Hämmerle stated that the key to for research projects. The grants have produced important the Osteology Foundation’s success has been, on the one knowledge about oral regeneration along with correspond- hand, the outstanding teamwork within the Foundation ing publications. itself and, on the other hand, the financial support and And as a truly special and innovative development of the academic freedom that Dr. Peter Geistlich granted to the Foundation, Christoph Hämmerle points to the Osteology Foundation. Research Academy, in which prospective researchers re- ceive advanced training in scientific method.

Driving expansion forward Christoph Hämmerle stated that, with Mariano Sanz as his successor, he knows the Foundation is in good hands. He has known Mariano Sanz for a long time and has worked with him on various projects over the years, and he knows Dr. Sanz has a great deal of experience in both science and practice, and as a leader. Mariano Sanz said on the occasion of this change in lead- ership that under Christoph Hämmerle’s guidance the Foundation had succeeded in achieving the highest levels of quality in both science and practice: “I have no inten- tion of changing anything, but rather I will follow the same path and keep on working to increase the Foundation’s im- portance as well as continue to drive its geographical ex- pansion.” What is important is to make even greater use of new technologies and media in order to continue to en- sure long-term growth and continuous development.

A new Osteology Foundation Board Simultaneous with this change at the top, there have been other changes in personnel: Professors Myron Nevins, Friedrich Neukam and Massimo Simion have stepped down from the Foundation Board, as their time in office had come to an end. They were succeeded in June 2015 by Dr. Pamela Photo: Osteology Stiftung McClain and Professors Frank Schwarz and Istvan Urban. Prof. Christoph Hämmerle of Switzerland (right), handing the Osteology presidency over to Prof. Mariano Sanz of Spain.

32 Geistlich News 02 | 2015 Osteology Monaco 2016 – Registration opens in October NEW Large Clinical Grants Dr. Heike Fania The promotion of research has always been one of the Osteology Foundation’s core activities. Now large Clinical Grants will also be awarded,

+ in addition to the estab- SCIENCE lished Young and Advanced Researcher Grants. Research groups already LEARNING THE «WHY» AND THE «HOW» established in the field of IN REGENERATIVE THERAPY oral regeneration are eligible to apply. A maxi- mum grant of 350,000 CHF will be awarded per project for a period of up to three years.

+ NEW PRACTICE INTERNATIONAL SYMPOSIUM Osteology Research OSTEOLOGY MONACO Scholarships The Osteology Foundation 21 – 23 APRIL 2016 has been awarding Young Researcher Grants since WWW.OSTEOLOGY-MONACO.ORG 2015. These one-year scholarships are intended for young scientists aspiring to a scientific Great events cast their shadows before them, and in April career in the field of oral 2016 it will be that time again: The International Osteology regeneration. In the first Symposium will return to Monaco! round, numerous The congress’s Chairmen, Prof. Friedrich W. Neukam and applications have already Prof. Myron Nevins, have put together a truly outstanding been received for the scientific program under the slogan “Learning the WHY and Osteology Scholarship Centres in Zurich the HOW in regenerative therapy”. (Christoph Hämmerle), With 85 internationally renowned speakers, interactive ses- Vienna (Reinhard Gruber), sions, innovative technologies and concepts, approximately Gothenburg (Christer 20 workshops and three new Master Clinician Courses You can find more Dahlin) and Ann-Arbor (which are included in the registration fee), Osteology information about (William Giannobile). the Osteology In the next round of Monaco 2016 will once again be the highlight of next year’s Foundation’s applications, requests will congress calendar! grants, along with its other activities, be accepted for the The latest research discoveries will be presented and dis- at the website: Osteology Scholarship cussed in the Research Forum and Poster Presentation. The www.osteology.org Centres in Bern (Daniel deadline for submitting abstracts is 1 December 2015. Buser), Madrid (Mariano Sanz), Dusseldorf (Frank Schwarz) and Harvard/ You can find all the details of the program, a schedule Boston (David Kim). and organization on the congress’s homepage. You can register online starting in October 2015. The application period ends on 1 December 2015.

Geistlich News 02 | 2015 33 INTERVIEW

Dr. E. Todd Scheyer is currently in private practice at the periodontics and implant reconstructive dentistry office Perio Health Professionals in Houston, Texas. He is a partner with Dr. Michael McGuire and a founding member of the McGuire Institute – a practice- based clinical research network. Photo: Alfons Gut Photo: Alfons

For more information about On a lab tour with the McGuire Institute: Todd Scheyer

The interview was conducted by Verena Vermeulen

We are on tour in Geistlich’s research National Institute of Dental and Cra- bone grafts have usually meant “allo- and production departments. What is niofacial Research is looking for grafts” – that’s what we know best, your first impression? PBCRN’s to collaborate with academic and because of the relative regulatory Dr. Scheyer: Very interesting, especial- centers for critical research efforts ease of using tissue bank biomaterials, ly because my own research began us- over the next ten plus years. research has been driven in that direc- ing Geistlich biomaterials in 1998. So, tion. But my view has broadened so now, to finally see how it all happens What is the major advantage of a much just through my research. is really fascinating. PBCRN compared with academic re- There’s a lot of opportunity to find the search? similarities between Europe and the You have helped establish a practice- Dr. Scheyer: The results are very trans- US and use them for future research. based clinical research network latable to patient care. And with such (PBCRN) called The McGuire Institute an efficient organisation, it doesn’t If you were not a dentist, what would in the United States. What’s the main take years to transition from an initial you like to be? idea behind the network? idea to a clinical application. Dr. Scheyer: Maybe a traveling adven- Dr. Scheyer: It’s a non-profit organisa- turer… I love to travel, and I love sports tion that helps translate research ideas Are there major differences between like mountain biking and fly fishing. into clinical applications – the first one dental research in Europe and the US? But this would probably only be nice in the US built around private practice Dr. Scheyer: I think the differences are for a while... before missing patient in- Periodontists. Meanwhile, even the based on history. For example, in the US teraction and scientific advances!

34 Geistlich News 02| 2015 Issue 1 | 16 appears in April 2016.

FOCUS 30 years of oral regeneration Biological basis, applications, outlooks

JOURNAL CLUB Membranes in GBR Just a barrier – or more?

BACKGROUND Celebrate anniversaries with us 30 years of Geistlich Bio-Oss®, 20 years of Geistlich Bio-Gide®

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