Issue 13 | 2016 The CAMLOG Partner Magazine

6TH INTERNATIONAL CAMLOG CONGRESS IN KRAKOW 2 EDITORIAL

Dear Reader

The 6th International CAMLOG Congress Under the motto “Tackling everyday chal- who prefer learning in small groups and will take place from June 9 to 11, 2016, in lenges,” we will be concentrating on the completing practical exercises, we are of- Krakow, Poland. “Why in Krakow – aren’t basic principles in implant dentistry in the fering a number of different workshops on there more attractive locations for a con- daily practice. At the same time, however, the same day. gress?” I would have been asking myself we will also be looking at what the cur- the same question a few years ago. Since rent state-of-the-art science brings in this Now, life is not just about working and then I have met many people who have context. learning, but also about maintaining and visited Krakow and spoken of the city with celebrating friendships. Join once again enthusiasm. When the managing director Personally, I am particularly looking for- CAMLOG's legendary party which this of our Polish office showed me pictures ward to the Digital Dentistry Pre-Congress time will take place in the old tram depot of the International Conferences and En- on Thursday, June 9, 2016. The impor- in the Kazimierz district. You can find more tertainment (ICE) building that was under tance of digital technologies in both the information about the program for the 6th construction, we decided to visit Krakow clinic and the laboratory is undisputed. International CAMLOG Congress as well in the fall of 2014 after its opening. We There is a Chinese saying: “Fail to take as read about scientific studies and much were totally enthused by the brand-new care of the future and you will mourn the more on the following pages. ICE with its fascinating architecture, the present.” So take the opportunity to learn outstanding acoustics, and the modern more about this fascinating subject first I look forward to personally welcoming all stage technology. hand from top experts in dentistry and readers of logo in Krakow. dental technology. For those participants I can confirm that the city of Krakow is also well worth a visit. Krakow is the sec- ond largest city in Poland and has tradi- tionally been one of the major centers of Dr. Alex Schär Polish scientific, cultural, and artistic life. CAMLOG Foundation The city is famous for its numerous cultural Member of the Foundation Board landmarks and is the former royal capital of Poland.

Discover Krakow. Here you’ll find the trailer: COVER STORY 3

TACKLING Register now EVERYDAY CHALLENGES At the 6th International CAMLOG Congress we will focus on scientifically sound and practical solutions. Experience our practical hands-on workshops, an innovative pre- congress on digitalization and exciting lectures. Participate in interactive discussions and meet internationally renowned speakers in the Network Lounge in a relaxed atmosphere. The attractive ICE Congress center in Krakow offers the perfect platform. Krakow is a lively and fascinating UNESCO World Heritage Site and enthusiastic in many ways. Other congress highlights are the Special Speaker, the legendary CAMLOG Party and the attractive partner programs.

Register early – we look forward to meeting you!

Information and registration: www.camlogcongress.com 4 COVER STORY

6TH INTERNATIONAL CAMLOG CONGRESS JUNE 9-11, 2016 IN KRAKOW

The preparations for the sixth International CAMLOG Congress are in full swing. We have again managed to find a very attractive venue for the congress. After Lucerne and Valencia, we will meet up in Krakow, the former royal capital of Poland. The lively historic district is the perfect complement to the most modern con- ference building in Europe, the ICE.

Tried and true and something new perts has prepared a varied program. Un- The conclusion to the first day on implant on Thursday der the chairmanship of the two congress dentistry forms a block with an interac- presidents Prof. Frank Schwarz and Prof. tive team discussion. Successful teams will On Thursday before the two days of the Piotr Majewski, some 50 international present their clinical concepts and the au- congress, we can offer you a number of speakers, all renowned in their research, dience is welcome to ask questions at any attractive options. As was the case with teaching, clinical, and practical fields, will time. Questions about digital workflows recent congresses, on this day our tried present a representative cross-section of or the esthetically critical zone can be sent and true, practical workshops are held and practical aspects of implant dentistry in directly from iPads or iPhones to the speak- usually quickly booked out. Four full-day routine use. At the same time, an eye will ers. And speaking of interaction … and two half-day workshops will cover be cast over the background science. current topics such as 3D planning, bone A high point to end on augmentation, sinus lift, and suture tech- The Friday launches with a block with a niques in small groups, all presented by completely practical focus. Issues related In recent years there have been significant expert speakers with a focus on practical to “Basic principles in treatment planning, advances made in 3D facial modeling to aspects. surgery, and prosthetics” will be examined create special effects in the film industry. in depth by three speakers before contin- The technology has enormous potential A Digital Dentistry Pre-congress will be uing on to the esthetic zone. “How do I for use in medicine. Our guest speaker held in parallel to the workshops. During manage the esthetic zone?” This ques- Prof. Markus Gross will give us an over- this full-day event, top experts in den- tion will be answered by three specialists in view of 20 years of work on digital human tistry and dental technology will discuss their field with presentations on soft tissue faces. Markus Gross is Professor of Com- the interdisciplinary workflow and reveal management, the correct choice of mate- puter Sciences at the ETH Zurich, winner exciting prospects from across the entire rials, and the right timing. of numerous prestigious international range of digital options. We can strongly awards, and is Director of Disney Research. recommend that those interested have a Lunch is followed by an exciting topic: His presentation “The virtual man” will no look at the detailed program and book the “How do I handle the lateral area?” A pres- doubt enthrall the audience with its futur- day now. entation on clinical indications for short istic images and technologies. We are re- implants will certainly keep the audience ally excited about this highlight in Krakow. Tackling everyday challenges enthralled as will the other two presenta- tions on long-term success rates and bone The scientific committee of the CAMLOG transplants. Foundation with its thirteen renowned ex- COVER STORY 5

Tackling everyday challenges – part 2 many other options in our congress social program are available for you or your trav- The Saturday will focus on the science el partner. We urge you to extend your right from the beginning. Seven short stay in Krakow and take time to explore presentations on current research proj- this beautiful city. ects will be followed by a session on the transmucosal region. Current issues such Fair prices as the preservation of the crestal bone lev- el, peri-implantitis, and connective tissue CAMLOG customers have long been fa- grafts are explained by renowned experts. miliar with our fair prices for our qual- After lunch, the winners of the CAMLOG ity products and events. The fees we Foundation Research Awards will be cho- charge for attending the 6th International sen, followed by the climax of the two-day CAMLOG Congress are moderate. With congress. early registration by the end of February 2016, the congress fees are only €490. The debate! Students, research assistants, and dental technical staff pay €250. For the same Using case studies, speakers will highlight price, you can also take part in the Digital current controversial topics from different Dentistry Pre-Congress on Thursday. And perspectives. The audience will be asked you can even benefit twice: When you to play an important role here. Questions book for the pre-congress and the main can be asked of the speakers or statements congress, you receive a €50 discount on made at any time. “Should an implant be the total price. So, it’s worth your while to preserved in a case of peri-implantitis or not just book early but to book all three should I remove it?” and “Which implant- congress days at the same time. abutment connection is better: Conical or parallel walls?” Whether these questions Registration can be answered after the panel discus- sions remains to be seen. You can register at any time on our home- page where you can also find all the nec- Interaction and networking essary information. The QR code provides direct access to the congress website. Along with an outstanding scientific pro- We look forward to welcoming you. gram, the opportunity for personal con- tributions and communication. Using the interactive congress app, participants can access lots of useful information and func- tions even before the congress has started. And the app will also play an important role at the congress itself. The app allows participants to get in touch with specific speakers. In the networking lounge our speakers will be available for you at spe- cific times for discussions. In the Speaker’s Hard Rock CAMLOG Corner in the foyer participants in the post- er competition will have a platform to pres- After the future it’s back to the 1970s – the ent their posters to those interested. We wild times of Deep Purple, Led Zeppelin, are looking forward to lively exchanges. AC/DC, and many other bands that are just as popular today and and have made Cultural sideevents history. The Hard Rock CAMLOG party will be exactly what its name promises: it will Krakow offers a great variety of cultural rock. We guarantee lots of live music with highlights. In the historic district, which guitar and drum solos in an authentic hard escaped World War II unscathed, there rock atmosphere. For those participants are more than 100 churches, beautiful who like things a little quieter, we already buildings, and historical monuments. Visit have a plan. Of course, we will once again the Jewish quarter in Kazimierz, explore have plenty of surprises for you to make Krakow on the retro tram, try your hand at sure this is one party that will be long re- some graphic arts, marvel at one of the larg- membered. est salt mines in the world, or travel back in time to the Communist era - this and www.camlogcongress.com 6 SCIENCE / CLINICAL RESEARCH

160

140 7

120 6

100 5

80 4 60 3 Rotation in º

Vertical shift in µm Vertical 40 2

20 1 0 0 CONELOG Nobel Ankylos C/X Astra Tech Straumann Straumann CONELOG Nobel Ankylos C/X Astra Tech Straumann Straumann Active Bone Level Tissue Level Active Bone Level Tissue Level

Fig. 1: Spread of the vertical displacement Fig. 2: Spread of the rotation (image taken from Semper Hogg et al. (2015)). (image taken from Semper Hogg et al. (2015)).

THE INFLUENCE OF THE TIGHTENING TORQUE OF CONICAL IMPLANT-ABUTMENT CONNECTIONS ON THE POSITIONAL STABILITY OF THE ABUTMENT

Semper Hogg W, Zulauf K, Mehrhof J, Nelson K. (from the original publication in English)

How does repeatedly tightening the abutment screw using a system-specific torque after repositioning of the abutment affect the positional stability of the implant-abutment connection? A new study investigated this question using six different implant systems.

Introduction S5: Straumann Bone Level 15°, S6: Strau- observed. The smallest deviations were mann Tissue Level 8°) were fixed in a pre- seen for S1, S5, and S6. The canting mo- When implant components are repeatedly fabricated metal block at different angles ments of S4 had the largest spread. tightened hand-tight, this produces posi- to the longitudinal axis. Two testers disas- tional changes in the abutment [1, 2]. These sembled and reassembled the abutment Conclusion changes should be as small as possible for test body complexes twenty times each. implants with a conical inner connection After tightening with a system-specific It is also not possible to achieve positional if the abutment screw is tightened with a torque and system-specific torque wrench, stability of the abutment by repeatedly system-specific torque during all interme- the position of the test body was meas- tightening the abutment screw with a sys- diate prosthetic steps before insertion of ured after each test using a coordinate tem-specific torque. Changes in the positi- the final suprastructure [3, 4]. The research measuring machine and the change in the on of the abutment during the restoration group headed by Katja Nelson evaluated height, the rotation, and the canting of the process lead to the prosthetic suprastruc- how repeatedly repositioning the abut- abutment were determined. ture not fitting. ment and tightening the abutment screw using a system-specific torque affected the Results rotation, vertical displacement, and cant- ing of the abutment using an established A change in the abutment position was experimental setup [1, 2]. identified for all three parameters meas- ured (Fig. 1 to 3, Tab. 1). The implant sys- Materials and method tem evaluated had a significant effect on the results (p=0.001, p<0.001, p=0.006). Six commercial dental implant systems with conical implant-abutment con- nections and different cone angles (S1: The values for the vertical displacement Conelog 7.5°, S2: Nobel Active 12°, S3: ranged as far as 144 µm (S5). Rotation- Ankylos C/X 5.7°, S4: Astra Tech 11°, al deviations of up to 6.02° (S4) were SCIENCE / CLINICAL RESEARCH 7

Dr. Wiebke Semper Hogg 5 2002–2007 Dentistry study, Charité – Universitätsmedizin Berlin 4.5 2008 Doctorate 4 2008–2010 Clinic for Oral and Maxillofacial Surgery, Implant Den- 3.5 tistry & Special Prosthetics Department, Charité – 3 Universitätsmedizin Berlin 2.5 2010–2012 Department for Oral and Maxillofacial Surgery, Cen- 2 ter for Dentistry and Maxillofacial Medicine, Universi- ty Hospital Freiburg 1.5 since 2014 Head of the Imaging and Facial Surgery Section, 1

Canting moment in ° Department for Oral and Maxillofacial Surgery, Cen- 0.5 ter for Dentistry and Maxillofacial Medicine, Universi- 0 ty Hospital Freiburg CONELOG Nobel Ankylos C/X Astra Tech Straumann Straumann Active Bone Level Tissue Level

Fig. 3: Spread of the canting (image taken from Semper Hogg et al. (2015)).

S1 S2 S3 S4 S5 S6

(1) 3 μm 6 μm 2 μm 14 μm 20 μm 4 μm Vertical dis- placements (2) (3 μm : 4 μm) (5 μm; 7 μm) (2 μm; 3 μm) (9 μm; 18 μm) (14 μm; 30 μm) (3 μm: 5 μm) (3) *vs. S2, S3, S4, S5 *vs. S1, S3, S5, S6 *vs. S1, S2, S4, S5, S6 *vs. S1, S3, S6 *vs. S1, S2, S3, S6 *vs. S2, S3, S4, S5

(1) 0.40º 0.72° 0.74° 0.84° 0.47° 0.12° Rotation (2) (0.30º, 0.54º) (0.39°; 0.98°) (0.46°; 0.93°) (0.61°; 1.10°) (0.38°; 0.70°) (0.08°; 0.44°) (3) *vs. S2, S3, S4 *vs. S1, S4, S6 *vs. S1, S6 *vs. S1, S2, S5, S6 *vs. S4 *vs. S2, S3, S4

(1) 0.02° 0.10° 0.05° 0.07° 0.09° 0.04° Canting moments (2) (0.02°; 0.03°) (0.07°; 0.17°) (0.02°; 0.09°) (0.04°; 0.12°) (0.05°; 0.12°) (0.03°; 0.08°) (3) *vs. S2, S4, S5, S6 *vs. S1, S3, S6 *vs. S2 *vs. S1 *vs. S1 *vs. S1, S2

Tab. 1: Vertical displacement, rotation, and canting moment for the six implant systems evaluated. S1: Conelog, S2: Nobel Active, S3: Ankylos C/X, S4: Astra Tech, S5; Straumann Bone Level, S6; Straumann Tissue Level. (1): Median – (2): (25% and 75% percentiles) – (3): * p < 0.05 versus other implant system.

LITERATURE Original publication in English: Semper Hogg W, Zulauf K, Merhof J, [1] Semper W, Heberer S, Mehrhof J, Schink T, Nelson K. Effects [3] Kim KS, Lim YJ, Kim MJ, Kwon HB, Yang JH, Lee JB, Yim Nelson K. The influence of torque tighte- of repeated manual disassembly and reassembly on the positional SH. Variation in the total lengths of abutment/implant assem- stability of various implant-abutment complexes: an experimental blies generated with a function of applied tightening torque ning on the position stability of the abut- study. Int J Oral Maxillofac Implants. 2010 Jan-Feb;25(1):86-94. in external and internal implant-abutment connection. Clin ment in conical implant-abutment connec- Oral Implants Res. 2011 Aug;22(8):834-9. tions. Int J Prosthodon 2015;28(5):538-541 [2] Semper-Hogg W, Kraft S, Stiller S, Mehrhof J, Nelson K. Analytical and experimental position stability of the abutment [4] Lee JH, Kim DG, Park CJ, Cho LR. Axial displacements in in different dental implant systems with a conical implant-abut- external and internal implant-abutment connection. Clin Oral ment connection. Clin Oral Investig. 2013 Apr;17(3):1017-23. Implants Res. 2014 Feb;25(2):e83-9. 8 CASE STUDY

Fig. 1: The radiograph illustrates the current Fig. 2: The upper jaw bridge had jutting crown margins. Fig. 3: The bridge was broken in several places and the ceramic oral situation. veneers were sheared off.

A TOTAL CONCEPT FOR TREATING AN UPPER JAW WITH INDICATION CLASS IIIa

Dr. Albert Holler, Arzberg, Dr. Marc-André Grundl, MDT Kurt Illing, both Marktredwitz

The indications and the success rates for implant-supported restorations are far greater today than at the start of implant development (1960 to 1980). Nowadays implant-supported restorations are a scientifically established and essential part of modern oral treatment concepts. According to the scientific gold standard, in cases of complete edentulism in the upper jaw eight implants are usually sufficient for a high-quality fixed reconstruction [1]. Our patients often want fixed and esthetic restorations instead of removable restorations or complete dentures. Rehabilitation of an edentulous upper jaw with a cemented zirconium bridge on eight DEDICAM titanium abutments after 3D planning and template-guided implant insertion is described below.

In complex clinical situations, good com- possible or requires excessive effort. The were prepared for analysis. An impression munication between the treatment team, precision of a CAM-prepared restoration is was taken of both jaws to create models of the dental technician, and the patient no longer an issue. the situation. So that the models could be is essential for the long-term stability of articulated relative to the skull, a facebow a rehabilitation. A thorough preliminary Findings and planning of the com- was inserted. The periodontal screening examination and carefully determining plete concept was normal. A functional analysis did not the indication help to avoid any fail- reveal any signs of craniomandibular dys- ures. It is important here that before the In March 2013 a complete surgical and function. treatment starts all members of the team prosthetic concept was prepared for the are focused on achieving the best possi- 56-year-old patient. The bridge in the Because the patient did not want a full ble functional design of the prosthesis, patient’s upper jaw was broken in several prosthesis, we presented her with two respecting the wishes of the patient places. Radiographs revealed that the ab- prosthetic restoration options. One was a in terms of esthetics, and promptly iden- utment teeth were periodontally compro- removable telescopic bridge that would be tifying any complications or clinical or mised and could not be retained apart from realized with five implants and a telescop- technical limitations. Using CAD/CAM the terminal molar in the second quad- ic crown on tooth 27 in the upper jaw, technology enables precisely fabricat- rant. The bridge from 35 to 37 required or alternatively a fixed cemented bridge ed restorations to be constructed from rejuvenation and the edentulous space in restoration supported on eight implants. biocompatible materials such as high- the fourth quadrant needed to be closed To restore optimal chewing function, two performance polymers, titanium, or up (Fig. 1 to 4). So that a comprehensive bridges on natural teeth in the lateral zirconium oxide. Fabricating these restora- plan could be prepared, panoramic radio- lower jaw were suggested. After explain- tions using an analog process is often not graphic images of the current oral situation ing the differences between the various CASE STUDY 9

Fig. 4: To enable optimal chewing function, the Fig. 5: The temporary prosthesis was inserted after the extrac- Fig. 6: After the extraction sockets had healed, the virtual lower jaw bridge had to be replaced on the left and tion of the abutment teeth in the upper jaw. implant planning was carried out. the gap in the fourth quadrant needed to be closed. treatment options to the patient, she four months later, we allowed bleeding Using the set-up, a radiology template was opted for a fixed reconstruction. Using a in the extraction sockets. The blood clots prepared and the patient was transferred set-up on the models, we prepared the fol- favor the migration of growth cells from to the radiologist for a CT scan. During the lowing integrated treatment plan in close the surrounding vessels so that about eight CT scan, the patient wore a restoration pre- consultation with the surgeon, the dental weeks after the extraction the sockets pared from radiopaque material with an ana- technician, and the patient [2, 3]: were filled with freshly formed cancellous tomical emergence profile that showed the bone and closed over with stable epitheli- desired subsequent prosthetic situation in - Extraction of the non-retainable al tissue [4]. This bone will then undergo the CT images. Using the med 3D software abutment teeth in the upper jaw various remodeling processes over the fol- and together with specialists from the labo- - Removable prosthesis in the upper jaw lowing months. After the primary wound ratory, we evaluated the images and defined during the healing phase closure, we fitted the temporary prosthe- the optimal implant positions and lengths. - 3D implant diagnostics sis. It prevents the accumulation of traces We planned four implants in the first quad- - Virtual implant planning of food in the extraction sockets (Fig. 5). rant in the lateral area regio 14, 15, each of - Preparation of the surgical template Ø 3.8 mm × 11 mm length and Ø 3.3 mm × for the implant insertion Virtual implant planning 13 mm long implant in regio 12, in regio 16 - Implant surgery Ø 5.0 mm × 11 mm. In the second quadrant - Implant exposure, soft tissue manage- In the lateral area of the upper jaw, certain two implants are inserted in the lateral area ment and contouring with a direct criteria must be considered for esthetic regio 24 (Ø 3.8 mm × 11 mm length) and 26 screw-retained plastic bridge restoration using bridges. Special attention (Ø 3.8 mm × 9 mm length) as well as two - Implant impression taking must be placed on the soft tissue situation implants in regio 22 and 23 (each with Ø - Insertion of the temporary restoration here. So that saliva bubbles do not form 3.8 mm × 11 mm length) (Fig. 6). Using the and fine-tuning of the esthetics in the interdental spaces or to prevent data acquired, the planning specialists fabri- - Preparation in the lower jaw including traces of food being trapped here, im- cated a surgical template with the two-part taking an impression of the natural teeth plants should be designed to satisfy the CAMLOG CT-tubes for implantation. - Fabrication of zirconia bridges on eight prosthetic requirements and positioned individual CAD/CAM titanium abutments with optimal distance between them. They In February 2014 the implantation was - Try-in of the upper and lower jaw not only stabilize the bone but also sup- performed in the oral surgery clinic of restoration to check the function and port the surrounding soft tissue. Thanks to Dr. Grundl. After induction of local anes- esthetics the pontic element of the bridge, pseudo- thesia, the surgeon exposed the jaw bone - Insertion of the final restoration papillae can be reconstructed, creating a in the surgical field. When exposing the natural transition from the ceramic resto- bone, ensure that the drilling template Our dental technician used the set-up as a ration to the soft tissue. CAD/CAM tech- can be positioned stably. He made alveo- guide to fabricate a prosthesis for the tem- nologies offer us a number of options to lar ridge incisions oriented slightly palatal porary restoration for the extraction ap- satisfactorily take these conditions into ac- (inside the linea alba) that end distally at pointment in October 2013. After query- count in many cases. For optimal planning regio 16 and around tooth 27 with pa- ing the general health of the patient and of the restoration and positioning of the ramedial curve-shaped relief incisions. examining the current oral situation, we implants, the dental technician fabricated To minimize the risk of absorption in the carried out the atraumatic extraction of all a wax try-in without the vestibular gingival anterior esthetic zone, the surgeon left a non-retainable abutment teeth in the up- section in the anterior area. Using this set- central ridge of about one centimeter of per jaw apart from tooth 27 in our clinic. up, we checked the esthetics, clarified the soft tissue, a technique introduced by S. We were particularly cautious when ext- length of the anterior teeth, and defined Schmidinger in 1981 in Vienna (Fig. 7 and racting the anterior teeth so that we could the occlusal planes. The temporary resto- 8) [5]. The minimal bleeding tendency and preserve the very thin vestibular bone la- ration was relined and adjusted to the new the stability of the wound margin with a mella as completely as possible. Because occlusal position. crestal incision are beneficial for the rest of we planned to insert the implants about the operation and good wound healing. 10 CASE STUDY

Fig. 7: Using a crestal incision and subsequent Fig. 8: Leaving a central ridge provides support for the temporary Fig. 9: Backward planning is a prerequisite for flap preparation, the jaw bone was exposed. prosthesis and simplifies the precise repositioning of the soft prosthetically correct positioning of the implants. tissue.

Fig. 13: The wound margins were precisely ad- Fig. 14: The implants were exposed with a simple stab incision Fig. 15: To produce a CAD/CAM-fabricated screw-retained apted and the soft tissue was tightly closed up and the mucosa in regio 22 was widened with a roll flap. plastic bridge, immediately after exposure the abutments were using simple interrupted sutures and mattress attached to take an indirect impression. sutures.

Full thickness mucoperiosteal flaps were thanks to the inherent consistency. The soft tissue (Fig. 15). To provide better sup- then prepared. Using the surgical tem- soft tissue was then sutured without ten- port for the model, we placed the bite reg- plate, the surgeon prepared the implant sion using mattress and simple interrupted ister over the impression posts. We then bed corresponding to the lengths and sutures (Fig. 13). The temporary prosthesis took an impression of the situation using diam-eters of the implants and inserted the was well supported over the gingiva, the an individually prepared tray. After the CAMLOG® SCREW-LINE implants in ac- terminal tooth 27, and the stable ridge impressing taking, the impression posts cordance with the surgical protocol (Fig. around the incisive papilla. After eight days were replaced by straight healing caps 9). To avoid a sinus lift, a short implant we were able to remove the sutures. Once that remained in the mouth until the pa- (length 9 mm, diameter 3.8 mm) was in- the soft tissue had healed, we relined the tient attended the appointment to insert serted in regio 26 (Fig. 10) [6]. An insert- temporary prosthesis with plastic a few a screw-retained temporary plastic bridge. ion post was screwed in and the implant days later. The temporary prosthesis was milled by us was covered with the cover screws. The around the implants. In the laboratory the flap was mobilized using a periosteal slit. In Exposure and contouring a natural impression posts were screwed onto the regio 23 the surgeon augmented the buccal emergence profile lab analogs, inserted into the impression, bone lamella with a mixture of autologous and injected around with silicone for the bone chips and an alloplastic bone graft ma- The patient attended our clinic at removable gingival mask. After the mask terial (easy-graft™ CRYSTAL). Smaller bone the start of June 2014 for prosthetic had cured, the upper jaw master model defects in the surgical field were evened restoration. We exposed the implants was fabricated. out using autologous bone chips harvest- with simple stab incisions and apically ed from the threads of the drill (Fig. 11). To positioned flaps. In regio 22 we expanded In our clinic the focus is always on the encourage wound healing, the entire im- the gingiva with a roll flap so that a natu- natural appearance of a restoration. This plantation area in the upper jaw was cov- ral and attached soft tissue situation could includes not only the anatomical design ered with PRF membranes (Fig. 12). Over be preserved around the implant and the of the crown emergence profile but also a period of seven days, the membrane re- crown (Fig. 14). the basal contouring of the pontics [8]. To leases the integrated growth factors and achieve this, the dental technician places accelerates and improves wound healing Because we wanted to individually con- the esthetic set-up on the model and [7]. The matrix obtained by concentrating tour the soft tissue, we screwed on the draws the cervical contours of the crowns the patient’s own platelets is a cost-effec- platform switching impression posts for and pontics onto the master model [9]. tive preparation and is easily processed the closed tray technique and sutured the The gingival mask in the areas of the pon- CASE STUDY 11

Fig. 10: To avoid a sinus lift, a 9-mm CAMLOG® Fig. 11: Using a mixture of autologous bone and bone graft Fig. 12: To encourage wound healing, the bone was covered SCREW LINE implant was inserted in regio 26. material, smaller bone defects were evened out. with PRF membranes and the soft tissue was closed up.

Fig. 16: In the laboratory the data from the backward Fig. 17: The fit of the direct screw-retained temporary plastic Fig. 18: The basal view shows the anatomical, pontic-shaped planning were matched with the current scan of the restoration was checked on the model. support of the bridge elements. model.

the articulator situation were captured dig- restoration, we prepared tooth 27 and itally and matched to the data used to de- adapted the implants in the upper jaw to sign the screw-retained plastic bridge (Fig. the surrounding soft tissue situation. Our 16). To design the emergence profile, the dental technician screwed the impression abutment bases were prepared and the dig- posts onto the master model for the open ital set-up was positioned with the help tray technique and splinted with Pattern of the in situ scan. The digitally designed Resin. He separated the plastic bar into construction was milled in tooth-colored individual segments using a fine cutting plastic (Tembase, Zirkonzahn) with the wheel. We screwed in the impression implant connection fabricated completely posts in the mouth and splinted the gaps in plastic. The fit of the construction was before taking the impression with Pattern Fig. 19: The stably seated plastic bridge was inserted to checked on the model, and the holding Resin. Noting all the relevant technical cri- contour the soft tissue. pins were separated and ground off (Fig. teria, the model was fabricated in the lab- 17 and 18). The teeth were contoured ful- oratory, articulated, and then scanning tics is trimmed as a pontic. This exerts a ly anatomically. Twelve days after exposure posts were screwed on and the model was slight pressure on the gingiva to produce of the implants, we inserted the temporary scanned. The data for the set-up stored in an anatomical soft tissue scalloping and bridge, checked the occlusion and the bite the software were compared to the cur- the interdental spaces are closed by pa- height, closed the screw access channels, rent data. We checked that the implants pillae. The diagnostic set-up was trans- and discussed tooth shape and size. We had been precisely transferred by having a ferred to a screw-retained plastic base and recorded the minor changes the patient CAD/CAM bridge fabricated from machin- the tension-free fit of the bridge as well requested so that they could be incorpo- able green plastic. We placed this in the as function, phonetics, and esthetics were rated into the final restoration(Fig. 19). mouth and checked that the restoration fit checked in the clinic. The dental technical free of tension. We then prepared the late- then carried out the necessary CAD/CAM Fabrication of the full ceramic ral teeth in the lower jaw to fabricate the processes. The scan marker was screwed restoration on eight DEDICAM zirconia bridges from the first premolar to onto the lab analogs and the model was abutments the second molar. We used the green plas- scanned in the strip-light scanner (Zirkon- tic bridge to determine the occlusal dis- zahn) both with and without the gingival After five weeks during which the pa- tance (Fig. 20). After the bite registration mask. The set-up, the opposing jaw, and tient had become accustomed to the fixed and impression taking in the lower jaw, 12 CASE STUDY logo 37 • CAMLOG Partner Magazine • December 2015

Fig. 20: For the final impression taking, the im- Fig. 21: The image shows the optimal prosthetic positioning Fig. 22: The epigingival position of the palatal abutment pression posts were splinted with pattern resin. of the implants and the abutment design below the bridge shoulder is checked. In the esthetic zone the shoulder is about restoration. 1.5 mm subgingival.

Fig. 26: The model with the attached titanium Fig. 27: The zirconia bridges and the IPS e.max® CAD crowns Fig. 28: After sintering the zirconia bridge with the labial abutments was scanned and the data fed into were adapted to the abutment transitions and the gingival reduction for the individual veneering, the bridge was tried in the CAD software. situation and positioned in the blanks for milling. the mouth.

we screwed the green bridge off, insert- tion on the abutments, reworking the ves- by the dental technician with appropriate ed the tooth-colored plastic bridge again, tibular part of the zirconia bridge, which ceramic compounds. The color of the mon- and restored the lateral area temporarily was to be individually veneered, for the olithic crowns was adjusted with the help with prefabricated temporary veneers. To ceramic veneers. These parts were marked of stain firing and the crowns were then implement the CAD/CAM restoration, the for the reduction and virtually reduced by glazed and polished (Fig. 30 and 31). dental technician used the construction 0.6 millimeters. To avoid chipping of the data acquired for the temporary restora- labial surfaces, the incisal edges must re- After the finishing, the restorations for the tion as the basis for designing the individu- main in zirconia. The zirconia bridges from upper and lower jaws were inserted in the al titanium abutments (Fig. 21). He con- 14 to 22, 34 to 37, and 44 to 47 were clinic. The screw-retained plastic bridge structed this beneath the virtual bridge. positioned in the blank and milled. The was removed and the implant connection He placed the abutment-crown transition software enables free positioning of the was cleaned with 2% chlorhexidine solu- with a pronounced milled chamfer in the bridges in the zirconium oxide blank and tion. The DEDICAM titanium abutments visible area about 1.5 mm below the gin- the generation of an optimally designed must be promptly inserted so that the con- gival margin. This ensures harmonious es- sintering stabilizer that ensures that no toured soft tissue does not collapse (Fig. thetics and enables access to remove any warping occurs during sintering. The splint- 32). The bridges and the splinted crowns excess cement. The construction data for ed implant crowns 23, 24, 26, and 15, 16, were then attached for a final check of the the eight titanium abutments were up- and the individual crown on 27 were fab- esthetics (Fig. 33 and 34). Because the loaded to the Dental Manager and they ricated as monoliths in IPS e.max® CAD. requests of the patient and the functional were ordered from the DEDICAM fabrica- The crowns and bridges were sintered and requirements had been incorporated into tion service (Fig. 22 to 24). The polished the fit was checked on the model. At this the screw-retained temporary restoration DEDICAM abutments were delivered after stage of the fabrication, we made a raw fir- and “frozen” in the scan, we prioritized two days. The dental technician screwed ing try-in to check the fit, occlusal planes, checking the red and white esthetics. This them onto the model implants, checked tooth length, and function. The pontics was encouraged by the immobile attached the design using a silicone index, and were clearly contoured through the plastic keratinized gingiva, which we had a- checked the location of the abutment bridge (Fig. 29). After checking the occlusi- chieved by thickening with roll flaps at 22 shoulders (Fig. 25). He then scanned the on, the finishing was carried out in the lab- and apically repositioned flaps during the model again, and matched the data with oratory. The vestibular parts of the upper exposure (Fig. 35 and 36). the data saved in the software (Fig. 26 to jaw anterior bridge and the premolars in 28). He constructed the three-part restora- the lower jaw were individually veneered CASE STUDY 13

Fig. 23: In the abutment design program, the anato- Fig. 24: Before uploading the abutment onto Dental Fig. 25: The DEDICAM titanium abutments supplied mically contoured subgingival areas were checked. Manager, the machinability was checked in the image of the were screwed onto the model and the position of the preform. abutment shoulders was checked.

Fig. 29: The basal gingival support for the pontics Fig. 30: The monolithic occlusal surfaces and palatal parts of Fig. 31: The photograph shows the precise transition from the was anatomically shaped. Pseudopapillae formed the zirconia bridges were individually stained. highly polished subgingival parts of the DEDICAM titanium between the anterior teeth. abutments to the zirconia crowns.

Fig. 32: The individual subgingival design of the DEDICAM abutments integrates Fig. 33: The zirconia bridges and full ceramic crowns were into the contoured soft tissue without exerting any pressure. cemented. Excess cement was easy to remove because of the optimal positioning of the crown-abutment transitions.

We cemented the implant-supported zir- Conclusion conia crowns and bridges and the IPS e.max® CAD crowns with dual-cure, semi- In complex clinical situations, preparing a permanent Harvard luting cement and comprehensive treatment concept as well the zirconia bridges on natural teeth with as good and expert technical communica- glass ionomer luting cement from 3M Espe tion between all parties is essential for a (Ketac® Cem). Due to the optimal posi- functional and esthetic restoration that is tioning of the crown-abutment transitions, stable over the long term. An immobile, the cement excesses could be easily and attached and possibly keratinized gingiva precisely removed. After another check of around the implant penetration point pro- the occlusion and function, we took im- tects against bone loss and ensures natu- pressions to prepare an occlusal splint for ral red and white esthetics. In the surgical Fig. 34: The photograph shows the full ceramic reconstruction protection at night. phase, it must be ensured that tension due of the lower jaw lateral teeth. to cheek ligaments and mobile mucosa in 14 CASE STUDY

Fig. 35 and 36: The radiograph of the overall reconstruction with a satisfactory full ceramic restoration. After the cementing and a final functional check, a happy patient left the clinic.

the implant regions is eliminated. Keratin- fabrication process (CAD/CAM technique). zirconium oxide plays an active role in soft ized gingiva and thickening of the soft Numerous in vitro and in vivo studies have tissue healing and attachment, thus min- tissue can be achieved using appropriate been published on this subject and con- imizing the accumulation of plaque and surgical flap techniques. firm the outstanding biocompatible prop- bacteria [12]. erties of the material [10, 11]. Because of Familiarity with surgical techniques and the biologically inert character of the ma- In addition to successful osseointegration the use of biocompatible materials and terial, corrosion does not occur when it of the implants, close adaptation of the their processing play a considerable role comes into contact with other metals or soft tissue to the suprastructure is impor- in ensuring a successful final outcome. Zir- alloys in the oral cavity. As a result of the tant for the long-term clinical success of conium oxide has good mechanical prop- lack of toxicity of the material in a wide the implant restoration. erties in addition to its precise industrial range of cells, studies have confirmed that

LITERATURE

[1] Heydecke G., Zwahlen M. , Nicol A., Nisand D., Payer [5] Steiner AE, Schmidinger S, Schnittverläufe am resorbier- [10] Kutkut A, Abu-Hammad O, Mitchell R. Esthetic Consi- M., Renouard F., Grohmann P.,Mühlemann S., Joda T., What ten Kiefer, Orale Implantologie, Quintessenz Berlin 1977: 2. derations for Reconstructing Implant Emergence Profile Using ist he optimal number of implants for fixed reconstrations: Titanium and Zirconia Custom Implant Abutments: Fifty Case a systematic review. Clin Oral Implants Res 2012;23 Suppl [6] Nisand D, Renouard F., Short implant in limited bone Series Report. J Oral Implantol. 2013 Oct 31. [Epub ahead 6:217-228. volume. Periodontol 2000. 2014 Oct;66(1):72-96. doi: of print] 10.1111/prd.12053. [2] Ackermann KL, Kirsch A., Nagel R., Neuendorff G. Mit [11] Schmitter, M., Mussotter, K., Rammelsberg, P., Gabbert, Backward Planning zielsicher therapieren. Teil 1 Teamwork [7] J. Choukroun et al., Platelet-rich fibrin (PRF): A second- O., Ohlmann, B.: Clinical performance of long-span zirconia 2008;4:466-484. generation platelet concentrate. Part IV: Clinical effects on frameworks for fixed dental prostheses: 5-year results. J Oral tissue healing, Oral Surg Oral Med Oral Pathol Oral Radiol Rehabil 39, 552-557 (2012). [3] Schley JS. Terheyden H, Wolfart S., Implanatprothetische Endod 2006;101:E56-60. Versorgung des zahnlosen Oberkiefers. S3-Leitlinie. AWMF- [12] Kajiwara N1, Masaki C, Mukaibo T, Kondo Y, Nakamoto Tegisternr. 083-010. DZZ 2013;68:28-41. [8] Schweiger J., Beuer F., Stimmelmayr M., Edelhoff D. Wege T, Hosokawa R. Soft tissue biological response to zirconia zum Implantatabutment. dental dialogue 2010;11:76-90. and metal implant abutments compared with natural [4] Araújo MG, Silva CO, Misawa M, Sukekava F, Alveolar tooth: microcirculation monitoring as a novel bioindica- [9] Linkevicius T, Vindasiute E, Puisys A, Linkeviciene L, Mas- socket healing: what can we learn? Periodontol 2000. 2015 tor. Implant Dent. 2015 Feb;24(1):37-41. doi: 10.1097/ lova N, Puriene A. The influence of the cementation margin Jun;68(1):122-34. doi: 10.1111/prd.12082. D.0000000000000167. position on the amount of undetected cement. A prospecti- ve clinical study. Clin oral Implants Res. 2013;24(1):71-6. CASE STUDY 15

AUTHORS

Contact details Dr. Albert Holler Dr. Albert Holler studied at the Friedrich Alexander University in Erlangen- Praxis Nürnberg and graduated as a dentist in 1987. During his dental residency, Dr. Holler und Kollegen he earned his doctorate and took up private practice in 1990 in Arzberg. He Marktplatz 5 completed specialist training in prosthetics with Professor Gutowski and spe- 95659 Arzberg cialist training in plastic periodontal surgery and implant dentistry at IPI with Germany Dr. Bolz, Professor Hürzeler, Professor Wachtel, and Dr. Zuhr. Since 2000 Dr. Telephone: 0 92 33 16 44 Albert Holler has operated his clinic with Astrid Eichler. He became certified [email protected] as a specialist in periodontology in 2006 and in implant dentistry in 2008. Dr. Holler is a member of DGZMK, DGP, DGI, and Prophylaxe e.V.

Contact details Dr. Marc-André Grundl After completing his dentistry studies in Regensburg, Dr. Marc-André Dr. med. dent. Marc-André Grundl Grundl graduated in 2003 as Dr. med. dent. He was employed as a prep- Oral Surgeon aration assistant in Straubing and then worked as a training assistant for Schillerhain 1-8 Professor R. Dammer, a oral and maxillofacial surgeon in Straubing. In 95615 Marktredwitz 2007 he obtained accreditation as a dental specialist in oral surgery and Germany took up private practice in the joint clinic with Professor Dammer. After certification as a specialist in implant dentistry, he established his own clin- ic in Marktredwitz. Dr. Grundl is a member of the DGZMK, DGI, and the Bavarian Society for Dental, Oral and Maxillofacial Surgery.

Contact details MDT Kurt Illing In 1992 Kurt Illing graduated from the master school in Munich after com- Dentallabor pleting his training as a machine builder and subsequent dental technician Kurt Illing training. He founded his dental laboratory in Marktredwitz where, to- Egerstrasse 34, gether with Dr. Albert Holler, he organizes professional education courses 95615 Marktredwitz focusing on the combination technique and full ceramic and implant-sup- Germany ported restorations. Since 2005 he has been fabricating complex implant- supported restorations in full ceramic and zirconia with the help of his own CAD/CAM system. 16 CASE STUDY

Fig. 2: The initial clinical situation is characterized by gaps between Fig. 3: Large gap regio 12. the upper and lower anterior teeth.

Fig. 1: Tooth 12 was horizontally fractured Fig. 7: Positioning of the iSy implant below the dental tubercle Fig. 8: Soft tissue augmentation using a thick connective tissue and therefore had to be removed. for palatal screw retention. Bone chips from the drilling site were transplant harvested from the palate. inserted buccally.

ESTHETICS AND FUNCTION IN THE ANTERIOR AND LATERAL AREAS − EFFICIENTLY IMPLEMENTED WITH iSy

Dr. Andreas Kraus, Peiting

The iSy Implant System was launched on the market at IDS in 2013. Along with high quality standards, iSy is also characterized by outstanding efficiency and cost effectiveness. Both these aspects formed the heart of the iSy System concept right from the start and represent the added value of the product concept. At the same time, the completely redeveloped iSy Implant System was provided with quality features and properties that ensure outstanding functional and esthetic treatment outcomes. Dr. Andreas Kraus has been an iSy user from the word go. He uses the system for a wide range of indications and presents two of his own patient cases here.

iSy in everyday use Anterior reconstruction regio 12

The iSy Implant System attracted our in- hardly any restrictions on its clinical use. The 53-year-old patient presented in our terest right from the start thanks to its Our experiences refer to 142 iSy implants clinic with a horizontally fractured tooth sophisticated product and application con- that we inserted from April 2013 to Sep- 12 with root fillings(Fig. 1). cept. After testing the product in the clinic tember 2015. The two case studies de- for the standard indications, we extended scribed below reveal the various options The clinical findings eight weeks after tooth the range of indications of the system that the system offers us in routine clinical extraction are shown in Figures 2 to 4. extensively and now feel that there are use. CASE STUDY 17

Fig. 4: From the incisal approach there appears to be a Fig. 5 and 6: Photograph of the implant region. Using the Luer bone rongeur, a plateau was prepared in the soft tissue and bone defect. correct vertical position. Incision with no vertical relief incision.

Fig. 9: Suturing around the iSy gingiva former mount- Fig. 10: The soft tissue lies close to the iSy gingiva former ed on the implant base (suture material Glycolon®, (PEEK). Resorba, 5.0 absorbable).

After explaining the available treatment Simple prosthetic transfer options in detail, the patient opted for an implant-supported prosthetic restoration. The prosthetic restoration was completed The implantation was done eight weeks after three months’ healing. The healing after tooth extraction as a delayed imme- proceeded without any complications diate implant placement. The iSy implant and the soft tissue was very nicely con- was positioned so that it sits below the toured (Fig. 12 and 13). dental tubercle and the restoration can be screwed in from the palatal direction (Fig. The prosthetic concept behind the iSy Im- 5 to 7). plant System enables subsequent steps to be carried out very easily on the implant Transgingival healing base: impression taking, bite registration, and the temporary restoration. Fig. 11: Control radiograph after implant placement (iSy im- Even though subgingival healing is also plant diameter 3.8 mm, length 11 mm). possible with the iSy Implant System, we almost always prefer transgingival healing. This is very easily implemented with iSy using the premounted implant base, which also acts as an insertion post, and the PEEK gingiva former that can be attached to the implant base (Fig. 8 to 11). We know from the literature that a transgingival approach in the esthetic zone has no drawbacks, even with moderate bone augmentation [1]. During the healing period, no prosthet- ic restoration was inserted at the patient’s request.

Fig. 12: Situation after three months’ healing. Fig. 13: View of the iSy implant base after removal of the iSy gingiva former. The soft tissue appears nicely thickened and robust. 18 CASE STUDY

Fig. 14: The multifunctional cap is mounted Fig. 15: The retentions were filled with impression material Fig. 16: The multifunctional cap shortened on the implant base. It enables highly precise (Impregum™, 3M Espe). according to the terminal occlusion. impression taking.

Fig. 20: Taking the impression of the gingiva Fig. 21 and 22: Situation two weeks after the soft tissue conditioning. using the custom gingiva former prepared chairside.

Fig. 26: The long-term temporary restoration. Fig. 27: Closing the very large gap was not forced. Fig. 28: Situation after removal of the long-term temporary restoration.

For the impression taking and bite registra- cludes two multifunctional caps) is short- tion we used the multifunctional cap that ened on the basis of the occlusal situa- The modified gingiva former is replaced is mounted on the implant base precise- tion and the bite registration is performed after about two weeks with a long-term ly and which is secured against rotating. using the Shimstock protocol (Fig. 16 and temporary restoration (Fig. 23 to 27). The During the impression taking, ensure that 17). final restoration of zirconium oxide ce- the retentions on the multifunctional cap ramic is then attached (Fig. 28 to 33). are filled with impression material. This en- Soft tissue conditioning and pros- sures that the multifunctional cap is held thetic restoration I would like to thank MDT Verena Grumber, securely in the impression material and the Weilheim, for her assistance with the den- implant position can be transferred to the To condition the soft tissue in accordance tal technician aspects of this case. model with a high degree of precision (Fig. with the planned emergence profile, the 14 and 15). gingiva former was modified extraorally with composite material and reinserted The bite registration is done in the standard (Fig. 18 to 22). The initial slight anemia intercuspation position. To do this, another disappeared after a few minutes and the multifunctional cap (each iSy implant in- soft tissue subsequently looked very good. CASE STUDY 19

Fig. 17: The bite registration (LuxaBite, DMG) was Fig. 18: The iSy gingiva former was modified extraorally with Fig. 19: Situation after insertion of the modified carried out using the Shimstock protocol. composite to form a trapezoid. gingiva former. Slight anemia is apparent.

Fig. 23: When the gingiva former was removed, the Fig. 24: Occlusal view of the iSy implant base. Fig. 25: Funnel-shaped soft tissue contouring around the soft tissue was completely free of irritation. implant.

Fig. 29: Immediately before insertion of the final Fig. 30: The final zirconium oxide ceramic restoration blends restoration. harmoniously into the dental arch.

Fig. 31: Close-up of the final restoration from Fig. 32: … and the incisal direction. Fig. 33: The control radiograph reveals the outstanding osseoin- the labial direction … tegration with the platform switching achieved with the system. 20 CASE STUDY

Fig. 34: Second case study: Insertion of two iSy Fig. 35: Situation after two months’ transgingival healing. Fig. 36: Occlusal view of the implant bases. Preparation of implants with diameter of 4.4 mm, length 11 mm. tooth 35 for a full ceramic crown.

Fig. 40: Two weeks after the impression Fig. 41 and 42: The hybrid abutment crowns were screwed in Fig. 43: The clinical result immediately after the placement. taking and the bite registration the implant from the occlusal approach. The screw channel was sealed with bases were removed. a filling composite.

ceramic surface in the screw channel was premounted implant base offers a number Second case study: Functional etched extraorally with 5% hydrofluo- of advantages. The final restoration can be restoration in the lateral area ric acid and silanized (Monobond Plus, carried out with this two-part implant sys- Ivoclar Vivadent). After insertion of the tem with only a single abutment change, For the second case study, two iSy implants hybrid abutment crowns, these were tight- with corresponding positive outcomes for were used in the lateral area regio 36 and ened with 20 Ncm. The screw channel was the biology of the hard and soft tissue [2]. 37. The implant placement was carried then sealed up completely and esthetically Platform switching will soon be incorporat- out in August 2013. The surgical and with filling composite(Fig. 34 to 44). ed into the system with a conical implant- prosthetic protocol could be reduced to a abutment connection and also offers a minimum in accordance with the underly- The clinical and radiographic situation 25 number of advantages [3, 4]. A slightly ing concept of the iSy Implant System. No months after implant placement can be subcrestal positioning of the iSy implant additional augmentation measures were seen in Figures 45 and 46. The treatment encourages adequate gingival thickness carried out apart from buccal insertion of outcome is functionally and esthetically when combined with platform switching bone chips harvested during the prepara- stable. The highly efficient and safe use of – and soft tissue augmentation where tion of the implant bed. The clinical pro- the iSy Implant System was able to maxi- necessary – which has positive outcomes tocol adhered to the familiar iSy concept mize the cost/benefit ratio for the patient. for preserving the crestal bone level [5]. with transgingival healing. We achieved the final restoration very quickly from im- I would like to thank MDT Herbert Hasler, That iSy is also economically very attrac- plant placement, osseointegration, and Murnau, for his assistance with the dental tive for all those concerned may encour- soft tissue healing as well as impression technician aspects of this case. age opting for an implant therapy concept taking and bite registration. and satisfies patient requests for prosthet- Conclusion ic restorations that combine esthetics, The final full ceramic restorations (IPS function, and long-term stability. e.max® Press, Ivoclar Vivadent) were The iSy Implant System is an absolute plus screw-retained occlusally. The ceramic for our implant dentistry treatment spec- crowns were fabricated in the laboratory trum. The motivation for us to use iSy as a single unit, stained and glazed, and lies in the well thought-out and patient- bonded to the iSy titanium bases with appropriate product concept. The obvious Multilink® implant using CAD/CAM. The transgingival approach resulting from the CASE STUDY 21

Fig. 37: The iSy multifunctional caps are easily mount- Fig. 38: Adequate vertical space is seen in the inter- Fig. 39: Determination of the jaw relations in the termi- ed on the implant bases for impression taking. cuspation position. nal occlusion. The registration material (LuxaBite, DMG) is applied only in the areas missing occlusal contacts.

Fig. 44: The radiographic outcome immediately Fig. 45: Stable conditions 25 months after surgery. Fig. 46: An impressive result seen in the after the placement. radiograph 25 months after surgery.

LITERATURE AUTHOR

[1] Cordaro L, Torsello F, Chen S, Ganeles J, Brägger U, Hämmerle C. Implant-supported single tooth restorati- on in the aesthetic zone: transmucosal and submerged healing provide similar outcome when simultaneous bone Contact details augmentation is needed. Clin Oral Implants Res. 2013 Oct;24(10):1130-6. Praxisklinik Pfaffenwinkel Kraus & Reichenbach [2] Becker K, Mihatovic I, Golubovic V, Schwarz F. Impact of abutment material and dis-/re-connection on soft and hard Hauptplatz 10b tissue changes at implants with platform-switching. J Clin 86971 Peiting Periodontol. 2012 Aug;39(8):774-80. doi: 10.1111/j.1600- Germany 051X.2012.01911.x. Epub 2012 Jun 7. Telephone +49 8861 6024 [3] Schwarz F, Alcoforado G, Nelson K, Schaer A, Taylor T, E-mail [email protected] Beuer F, Strietzel FP. Impact of implant-abutment connection, positioning of the machined collar/microgap, and platform switching on crestal bone level changes. Camlog Found- ation Consensus Report. Clin Oral Impl. Res. 0, 2013, 1-3 doi:10.1111/crl.12269. Dr. Andreas Kraus [4] Atieh MA, Ibrahim HM, Atieh AH. Platform switching for marginal bone preservation around dental implants: a Dr. Andreas Kraus completed his state examination after his study of dentistry at systematic review and meta-analysis. JPeriodontol. 2010 Julius Maximilian University Würzburg in 2000. After several years as a partner in the Oct;81(10):1350-66. doi: 10.1902/jop.2010.100232. Implantatzentrum Bad Wörishofen Dres. Masur, Kraus, Märkle, he has worked in the [5] Linkevicius T, Puisys A, Steigmann M, Vindasiute E, Linke- joint practice Praxisklinik Pfaffenwinkel Kraus & Reichenbach since 2011. His field of viciene L. Influence of Vertical Soft Tissue Thickness on Crestal Bone Changes Around Implants with Platform Switching: A specialization is implant surgery and prosthetics. In 2010 he was nominated as an Comparative Clinical Study. Clin Implant Dent Relat Res. 2014 implant dentistry specialist (EDA). Memberships: Kempten working group, DGZMK, Mar 28. doi: 10.1111/cid.12222. [Epub ahead of print]. DGI, BDIZ, EDA, ITI. 22 CLINICAL MANAGEMENT

STRATEGIC POSITIONING PLANNED DEVELOPMENT AND EMPHASIS ON STRENGTHS AND QUALITIES

Patients selectively choose a dentist or a practice these days. Particularly in areas of dense population where the density of dental clinics is disproportionately high, the image of the clinic becomes an economic necessi- ty. Clinics and practices can no longer be managed without taking into account business management issues. The economic reality overtakes every clinic sooner or later. The role played here by strategic positioning is illustrated in this article using three clinics as examples.

The future-oriented process of strategic as well as the opportunities offered by the Listen to your heart positioning is often underestimated, but competitive environment. The aim of posi- ignoring positioning can result in time- tioning is to shape the long-term success In the first example, the owner of the clinic consuming and expensive adaptations or of the clinic in a way that can be planned. has harbored a passion for surgery from strategy changes. Every clinic would do In this regard, positioning corresponds to his time as a resident and continues his well to invest in strategic planning well the desired image that the clinic wants to education with a relevant Master’s course. before launching a business venture. This anchor in the minds of potentially interest- When facing a decision about becoming begs the question of which factors can ed parties. self-employed in the middle of the 1990s, be drawn on to strategically position and he weighs up the various options for his differentiate a clinic in the market envi- Various positioning opportunities are planned business venture. The business ronment. Even if a clinic has been long available to clinics, the most common of goal is strongly oriented towards business established, casting a critical eye over the which are determined by the personality management. The owner of the clinic business at regular intervals is worthwhile. of the dentist. The trend to specialization plans to appeal to the largest possible pa- Acquiring new specialist qualifications, ex- means that more and more clinics are po- tient clientele to rapidly shift from the loss panding the treatment portfolio, adapting sitioned using specialist certification. Po- to the profit zone. Prosthetics appears to to a changing market, or wanting to ac- sitioning using a target group or price is be a lucrative source of income that will quire a new patient clientele may be rea- also possible. Market niches can be used be secure in the long term. For this reason, sons to modify the image. to focus on services or to place innovations purchasing an established and renowned at the heart of the clinic. Before entering clinic with its own laboratory is chosen as Strategic positioning outlines the position private practice, dentists should also care- the most sensible alternative. The focus of of a clinic in the market. The positioning fully consider market conditions using a the clinic is not surgery, which goes against uses creative approaches to plan the orien- site analysis along with an analysis of the the owner’s personal preferences. The key tation of the clinic with foresight and with market behavior of the target patient cli- component of the clinic concept is now a view to sustainability. It is therefore es- entele. shaped by general dentistry and the clinic’s sential to honestly consider personal pref- laboratory. erences together with specialist expertise CLINICAL MANAGEMENT 23

In the initial years of his business, the own- and again, this does not differentiate the er of the clinic often feels dissatisfied with clinic from others. To justify this approach, his job. After just two years he decides to the clinic places enormous value on the change his strategy and includes implant professional development of both the den- dentistry in his treatment portfolio. In the tists and the support staff. High quality, following 2.5 years he inserts 250 implants. interdisciplinary, and friendly collaboration He finds the work easy and enjoys his new with colleagues in other disciplines is also tasks. It is also clear that this shift explicit- a key component of the clinic concept. ly enables the clinic to reach its financial To intensify the collaborations, the clinic goals. For these reasons, a second strategy offers a fixed event concept with in-house change is implemented: Implant dentistry training programs and live surgery. is now the specialist focus of the clinic. The target patient clientele shifts primarily The target patient clientele will be heter- to older patients. Because his clinic has its ogeneous and be very interested in their own laboratory and because the clinic had own health. The insurance status does not a fixed position in the market as a pros- play a role. thetic clinic for many years, it is clear that is not possible to now build up a stable The clinic owners are perfectionists and group of regular referrers. The clinic there- passionate about their work, and they are fore continues to operate autonomously. convinced that you can only be really good The owner of the clinic passionately places if you really love your work. The fun and himself at the center of the communica- pleasure experienced by all members of the tion and in this way uses his own personal- team at work are palpable in the clinic. ity to differentiate his clinic in the market. The ingenious communication concept for Summary: The high level of specialist ex- the clinic considered a range of communi- pertise, the interdisciplinary collaborations cation instruments such as a patient event with other medical practitioners, and the concept to penetrate the market environ- pleasure in the work are the factors that ment to an appropriate degree and thus are drawn on in the communication and to ensure a continuous intake of new pa- contribute to differentiation in the market tients wanting implants. The autonomous environment. alignment in turn allows the clinic to catch the attention of potential patients. Go your own way

Summary: Formulating a strategic position- In the final example, the clinic owner ini- ing – particularly taking your own preferenc- tially narrows the potential target group of es into account – combined with specialist her clinic before the clinic positioning: Her expertise would have resulted in the clinic dream patients are well-off clientele, pri- focusing on implant dentistry. Changing marily international business clients, who strategy twice over the course would not want high-quality restorations. have been necessary. This preliminary strat- egic work would have critically influenced For the clinic owner, a high standard of important areas such as the type of busi- living is important and she would like to ness established, the communication mod- experience this in her clinic as well. The el chosen, and ultimately even the choice clinic is intended to be an expression of of staff. her personality. Unlike most of her den- tal colleagues, she therefore restricts her Be yourself target patient group dramatically. From a demographic perspective, income, age, In the second example, a clinic positions and profession play a role. Psychographic itself as an ultra-modern referral clinic with variables such as class identity and lifestyle multiple practitioners and a clearly defined are also critical. treatment portfolio – the complete range of dental surgery. However, this does not Deciding where to locate the clinic is differentiate the clinic in the local area be- based on this segmentation. The owner cause a dental colleague offers the same of the newly established business se- clinic concept. lects a combination of innovation, target group, and service positioning: The clin- The clinic wants to offer state-of-the-art ic will be an innovative clinic, tailored to dentistry at a continuously superior level a specific homogeneous target group 24 CLINICAL MANAGEMENT

and incorporating a high level of service. Even the treatment spectrum is aligned and sustainable positioning to know your The clinic is perceived from the outside with the needs of these target patients: own worth and to take it into account. as a highly modern lifestyle clinic. Differ- High-end dentistry, esthetic dentistry, oc- entiation through technical progress is clusal disease, bruxism, bite elevation. Personal attitude, internal disposition, and the motto. Patients view innovations as Clinics oriented towards target groups not least personal preferences play an im- state-of-the-art dentistry with high-end rarely have to discuss prices because of portant role. An honest look at your own restorations. The communication presence the strong bond. It is therefore no surpri- personality is therefore essential when plan- harmonizes with the clinic concept: From se that the clinic has a turnover compara- ning a clinic. Along with market and loca- presentation in the media to visiting the ble to larger clinics despite a lower patient tion analyses, an honest appraisal of the clinic – all efforts are systematically aimed frequency. target patient clientele is another critical at meeting the requirements of the delib- factor. I will dedicate the next article to the erately selected positioning. The additional Summary: This unusual and also polar- subject of “target patient groups” for this benefits conveyed to the patient are high izing type of positioning has produced the reason. quality, exclusivity, and modernity. desired result in terms of the target patient clientele, the type of work, and ultimately The target patient clientele has high ex- the business goals aimed for: Positioning pectations. To satisfy these expectations, the clinic as an innovative clinic effectively to ensure that the service processes are ensures the acquisition of new patients. focused on the customer, and to convey a The specific combination of target group sophisticated atmosphere, the clinic devel- and service positioning then binds the pa- oped an exceptional service concept. The tient to the clinic for the long term. aim of this is to create the most relaxed and pleasant environment possible for all To appropriately differentiate a clinic, the those involved. The result of this approach question of wherein lies the uniqueness of is a highly emotional patient bond that the clinic in a defined environment must be means greater loyalty and attachment and asked. As a result of the very close contact ultimately a greater willingness to pay. with customers, it is critical for long-term

ONLY THE ONE WHO WALKS HIS OWN WAY CAN’T BE OVERTAKEN

Marlon Brando, American actor (1924–2004)

Andrea Stix, M.Sc., MBA Consultant for communication strategy and practice marketing Syst. Business Coach, NLP Coach, Business Trainer EVENTS 25

5TH IMPLANT DENTISTRY MEETING 2015 NATIONAL CAMLOG CONGRESS AUSTRIA, SEPTEMBER 17-19 SEPTEMBER, 2015, FUSCHLSEE

The 5th Austrian CAMLOG congress was Reports from customers formed a picture hits. Despite the late night, the hall filled held in the congress hotel Sheraton of a congress conducted at a superior level again on Saturday punctually at 9 in the Fuschlsee with its beautiful setting in the with very good presentations. morning. The lecture program continued forested mountain region of Salzburg with more presentations. The very interest- Flachgau. On the Thursday morning em- Culinary delicacies and the opportunity to ing specialist dental presentations by Dr. ployees from Alltec greeted the first partic- find out more about new products from Claudio Cacaci and Dr. Florian Beuer were ipants to the two workshops. The attend- CAMLOG from the Alltec employees en- followed by a dental technical digression ees had selected either the microsurgery sured that there was plenty of distractions by Andreas Nolte. Prof. Rudolf Seemann course with Dr. S. Marcus Beschnidt or from the speakers during the breaks. provided a glimpse of an ongoing study the workshop on the use of bone graft- of the true number of implant failures and ing with Dr. Stephan Beuer, M.Sc. Twenty implant dentistry assistants at- the resulting inferences for surgery. The theoretical presentation was followed tended a workshop led by Dr. Laurenz by intensive hands-on exercises, profes- Maresch that was conducted in parallel to The congress was crowned with a lottery sionally instructed by the experts. They the scientific program. The materials tech- with the first prize a weekend away in the enabled the participants to practice what nology and administrative preparation for luxurious hide-away Hotel Schloss Pichlarn. they had just learnt using animal models. implant surgery, interaction during surgery, Children of participants played the role of A number of techniques, instruments, and and support providing during exposure, im- the lucky fairy and drew the winner: Mr equipment were presented and could be pression taking, and cementing were dealt Andreas Radl, Dental Technician. We congrat- tested. with in the workshop. ulate him and hope he enjoys his prize.

On the Friday morning a great number of Oktoberfest comes to Schlossremise After a standing buffet, it was farewell to expectant congress participants filled the a great congress location, two impressive foyer, spotting familiar faces, and obvious- The date and the proximity to Munich were days of constructive discussions, fun festivi- ly feeling right at home in the comfortable certainly the key reasons for organizing an ties, helpful input, and the pleasure of look- atmosphere surrounding the Alltec team. Alltec Oktoberfest party. In proper style in ing forward to the 6th National CAMLOG dirndl and lederhosen, the group walked Congress in Austria. In front of 140 specialists Alexander or took the shuttle bus to nearby Schloss- Jirku opened the congress, which promised remise, a magnificent location. Pierre exciting times thanks to the selection of is- Rauscher had the honor of opening the sues covered and the presentations by re- festivities by tapping the keg. The var-ious nowned speakers. Dr. S. Marcus Beschnidt, buffets offered a range of sumptuous Bava- Prof. Werner Millesi, Dr. Stefan Beuer, Prof. rian delicacies, a succulent spit roast temp- Gerald Krennmair, Dr. Hajo Peters, and Dr. ted all, and the beer flowed generously. A Herbert Hulla provided a top quality pro- trio of musicians created a great atmos- gram for the first day of the congress. phere, pumping out familiar Oktoberfest 26 LIFESTYLE

WHITE GOLD AND ITS ECONOMIC INFLUENCE ON KRAKOW

What do you know about salt? Because salt was only found in a few re- The salt trade was a profitable business gions, but was used everywhere, even in and many cities became wealthy thanks to When you think about salt − without read- ancient times there was a brisk trade in salt salt. Many names of locations in Germa- ing any further, what comes spontaneous- that bound together different peoples and ny refer to the earlier importance of the ly to mind? cultures. Long trade routes developed that harvest-ing of rock salt (“Salz” in German) were known as salt roads. such as Salzdetfurth, Salzgitter, Salzbrunn, Certainly table salt. The gourmets amongst Salzuflen, and Salzburg as well as place us think immediately of sea salt, then a few Rock salt, which is extracted from salt names containing the stem “hall” from seconds later comes the softening salt for mines, is the raw material for about 70 the German “vault” such as Halle, Bad the dishwasher, and possibly also thawing percent of table salt produced world- Friedrichshall, Schwäbisch Hall, Hallstatt, salt for icy roads depending on the time wide. The rest is harvested from sea salt. and Hallein. of the year. As medical practitioners, you Rock salt is an evaporite and sedimen- certainly know about smelling salts and tary rock that was produced naturally In Europe there are extensive and deep salt anyone who is familiar with the practice in the geological past by precipitation deposits that were formed during the Per- of preserving meats and sausages knows of concentrated sea water and survives mian north of the Central German Uplands about pickling salt. in fossil form. It is made up exclusively in an area ranging from France across of the mineral halite (sodium chloride, Germany and extending to Poland (the for- But do you know what salts are made of NaCl), and contains traces of potassium, mer Zechstein Sea). In some areas the salt and that in their elemental form they are calcium, bromine, iron, zinc, iodine, and domes reach so high that they came into essential for our survival? Along with the magnesium and belongs to the halide contact with the groundwater and formed primary components sodium and chloride, group of minerals. salt springs. In the past, salt was harvested these salts also contain important minerals from those salt domes that were near the such as calcium, magnesium, potas- surface. sium, iron, zinc, and other trace ele- ments. In earlier times salt was an im- portant commodity and was called “white gold”. It was not only a nutrient but was also used to preserve food and was also used in ancient medicine. It’s not something simply to flavor food. We shall spare you a digression about the composi- tion and vital properties of salts and refer you to Wikipedia. What is more interes- ting is the question of where salt actually comes from. LIFESTYLE 27

The Wieliczka salt mine

The Wieliczka (magnum sal, big salt) salt mine, one of the oldest salt mines in Europe, is located in Poland near Krakow. Here the traces of salt mining dating back to 3500 years BCE can be found. When the salt springs were exhausted by the middle of the 13th century, miners searched for underground salt springs, discovering the rock salt deposits in the process. Since the 15th century, machines were used below ground to mine the salt as well as hors- es from the 17th century on. Until the 18th century the mine extended only to a depth of 60 m with four additional lev- els later created below the existing mines that reached to a depth of 340 m. From the 14th century until 1772, the Wieliczka and Bochnia salt mines were combined as the Royal Salt Mines and thus formed the largest mining company in Poland.

The income from the salt trade, which made up to one-third of the Polish national income during its heyday from the 14th to the 16th centuries, was used to meet the costs for the construction of the Wawel, the Gothic royal palace, the academy, and the city fortifications in Krakow as well as being used to pay soldiers. The mining workforce comprised about 2000 people at this point, producing about 30,000 tons of salt a year.

In 1913 the salt works, which are still oper- ating today, were built. After 1918 the mine became the property of the Republic of Poland which held the state monopoly on salt from 1932. In 1976 the mine was entered on the list of Polish national cultur- al monuments and in 1978 it was included The mine extends across an impressive by enormous salt crystal lanterns. A fa- on the UNESCO list of World Cultural and 300 kilometers and reaches to a depth mous relief that was found in the salt mine Natural Heritage. of 327 meters below the city. There is a is the Last Supper that was based on the special tourist tour for visitors to Krakow. original by Leonardo da Vinci. Salt extraction only stopped in 1993. Since On the 2.5 kilometer long route, visitors then, the mine has been used only for tour- first travel to a depth of 64 meters in a There is also a health resort deep under- ism and as a sanatorium. To prevent the miner’s lift. From there, the tour moves ground that specializes in the treatment of mine and the city collapsing in case of pen- along stunning walkways carved out by respiratory diseases, halls for parties, a res- etrating water, any water is pumped to the hand down wooden steps to a depth of taurant, overnight accommodation, and surface and used to harvest evaporated 134 meters. Every year, more than a mil- several meeting rooms. salt. Wieliczka thus continues to be an im- lion visitors are attracted to the salt statues portant Polish salt producer. In 1989 the salt and galleries that the miners carved out of Those participating in the 6th International mine entered the list of endangered World the salt blocks during the long nights un- CAMLOG Congress can visit the Wieliczka Heritage and in 1994 became a monu- derground, the enchanting underground salt mine. We can heartily recommend this ment forming part of the history of Poland. lakes, original mining equipment, or the excursion and we guarantee that you will magnificent St. Kinga Chapel that is lit up learn quite about “halite” there. 28 LIFESTYLE

English-Polish English Polish Pronunciation PHRASEBOOK Salt sól [sool] Coffee kawa [kava] Part 3 Milk mleko [mlehko] Sparkling mineral water woda gazowana [wodah gasovana] Still water woda niegazowana [wodah nigasovana] Beer piwo [pivo] Wine wino [vino] How much does it cost? Ile to kosztuje? [ileh toh koshtooye] The bill please! Rachunek proszę! [ratshooneck proshe]