Henriette Lerner, Uli Hauschild, Robert Sader & Shahram Ghanaati

Abstract
Guided implant surgery is considered as a safe and minimally invasive flapless procedure. However, flapless guided surgery, implant placement in post-extraction sockets and immediate loading of complete-arch fixed reconstructions without artificial gum are still not throughly evaluated. The aim of the present retrospective clinical study was to document the survival and success of complete-arch fixed reconstructions without artificial gum, obtained by means of guided surgery and immediate loading of implants placed also in fresh extraction sockets.

Magazine PIP • Practical implantology and implant prosthetics • 08 June 2022

Dentist Michael Weiland: excellent care is important to me!

In times of skilled labor bottlenecks and a fundamental lack of staff, the first thing that many lose is the services that were once seen as so essential. But the more a piece of hardware is interchangeable and discount battles want to be avoided, the more a company stands out from the customer with the many free little help.
Interview with dentist Michael Weiland and his team

pip: How did your first contact with the implant manufacturer C-Tech and Mr. Lütfü Agic come about?
Michael Weiland: I’ve known Mr. Agic for a very long time, for more than ten years, from my time in practice. Four years ago I set up my own practice, but at first I had too much to do with getting the practice up and running. At the same time, a lot was happening within our family – as it is at our age, that often happens alltogether. That’s why I didn’t deal with implantology myself at first and only provided prosthetics at first. Nevertheless, contact with Mr. Agic was never lost, especially since my basic interest continued to exist. Mr. Agic then drew my attention to the further training here at the municipal clinic with Prof. Anton Dunsche.

pip: What is particularly important to you at a training event?
Michael Weiland: Everyone is always talking about ‘take home messages’, and that’s actually what it’s all about. I would like to learn something that I can use in my practice in the relatively short term. In addition to the theory, which you can read up on or acquire through an online event, it is important to me to have the opportunity to try out and practice techniques yourself, preferably with someone at your side who can immediately give you one or two good ones can show tricks and tips. It’s about getting more security for me in my practice. The first course with Prof. Dunsche was just super organized, we learned theory, but also a lot of practice with exercises on the pig’s jaw and later the opportunity to assist Prof. Dunsche himself with surgeries.

pip: So it didn’t stop at this event?
Michael Weiland: No, after that I was given the opportunity to attend a four-day course in Palermo, Italy. They do things slightly differently there, with personal warmth and beautiful surroundings. Everything was very well organized, we even got two translators at our side, so there were no problems here either. For two days we were introduced to the C-Tech system and various surgical techniques, and we were able to use the third and fourth day very intensively for practical exercises and treatments directly on the patient. The two very experienced speakers also supervised this part and took over more complex situations myself, which I might never want to do myself in my practice, but which were exciting to watch. But I also learned an enormous number of new techniques for my areas of application and was able to practice them in such a way that I now feel safe with them. After all, I want to offer my patients the ‘state of the art’ of today’s implantology.

pip: How important is the support provided by Mr. Agic to you?
Michael Weiland: We work directly with and on people, and I personally prefer it if I too am seen as a person. Mr. Agic has never promised too much, is always available and implements my requests incredibly quickly, even if I reach him on the way. I receive all important information promptly and in Mr. Agic I have a good partner for the exchange of ideas, at the same time I never feel pressured. I sometimes think that my time is more important to Mr. Agic than his own, and I can feel that through this great service.

Magazine PIP • Practical Implantology and Implant Prosthetics • August 2022 | Issue 4′

Rehabilitation of the jaw by means of immediate implantation and immediate restoration Digital workflow

Catarina G. Rodrigues, DDS, MSc – Manuel D. Marques, DDS – Raquel Bandeira, CDT

The success of any complex dental treatment depends on proper diagnostics and treatment planning. Digital treatment planning, prosthetic backward planning and guided implant surgery can help improve success rates and predictability of complex rehabilitations. The 3D information about the bone anatomy obtained by means of digital volume tomography (DVT) of the patient form the basis for successful treatment planning.

1. Frontal view with centric occlusion preoperative.
2. Preoperative close-up of the patient’s smile.
3. Image data for the preoperative intraoral scan.
4. Virtual simulation of the prosthetic reconstruction using 2D CAD software (Smile Cloud Biometrics; ADN3D Bioetch SRL).
5. Virtual planning of the shape and position of the anterior teeth according to the measurement criteria ..
6. … the red-and-white aesthetic, planned with the 2D Facial Smile design.

PROCEDURE
The DVT data is imported and processed by means of appropriate software in order to plan the implant positions. The planning data is then used to virtually design the drilling template for guided implant placement, which is then 3D printed and used for optimal positioning of the implants. The use of 2D dental CAD software enables the development of a face-related digital smile design. This two-dimensional data can then be imported into 3D CAD software to design 3D mock ups and immediate temporary restorations.

Advantages of immediate implantation
Immediate implantation of implant-supported prostheses is a predictable treatment option in the restoration of an edentulous jaw, as it can contribute to the preservation of the peri-implant soft and hard tissue and enable rapid patient assistance from an aesthetic and functional point of view. Important advantages of using digital technologies for the planning and execution of implant placement as well as for interim restoration are higher accuracy and precision in the fabrication of the overall rehabilitation, low invasiveness and optimal soft tissue shaping by the temporary prosthesis.

7. Frontal view of the 3D-printed model created from the diagnostic wax-up.
8. Frontal view of the preoperative mock up after transfer to the patient, checking the planning of the 2D facial smile design.
9. Superimposition of the STL data of the preoperative intraoral scan with the DVT data in the planning software (RealGUIDE, 3DIEMME).
10. Digital planning of the implants based on the anatomical situation and the previously planned prosthetic restoration.
11. Once the final implant positions were determined, they were transferred to the surgical template design.
12. Planning of the implant positions.
13. Adjustment of the drilling template on the model.
14. Gentle extraction of the teeth not worth preserving in order to preserve the hard and soft tissue dimensions.

Patient case
The 40-year-old patient presented to our dental practice complaining in particular of difficulty eating and worsened aesthetics in the maxillary anterior region (Figs. 1, 2). The clinical and radiographic examination revealed a bilateral interdental gap in the maxillary posterior region. In addition to a fracture of tooth 13 at gingival level, insufficient amalgam and composite fillings as well as carious defects were diagnosed. There were also increased probing depths and generalised, radiographically visible, horizontal bone loss. After comprehensive diagnostics, it was decided, in consultation with the patient, to extract all of the upper anterior and posterior teeth, and proceed with immediate implantation of a total of eight implants and immediate provisional restoration with screw-retained dentures made of polymethyl methacrylate (PMMA). Intraoral scans (Fig. 3), a DVT and intraoral and extraoral photos (Fig. 4) were taken as part of preoperative diagnosis. In addition, a 2D digital facial smile design was created to enable planning of the position as well as the shape and size of the teeth for the future interim prosthesis (Figs. 5, 6). A digital diagnostic wax-up was then created using 3D CAD software and transferred to a corresponding model using 3D printing (Fig. 7).

Based on the model, a silicone index was created to enable the transfer of the acrylic resin trial restorations to the patient situation and 2D smile planning was undertaken for the patient’s mouth by means of a mock-up (Fig. 8). After adjusting and matching the shape and aesthetics of the anterior teeth, all three-dimensional data (DVT, preoperative intraoral scan and 3D mock-up) were imported into software (Fig. 9) and used to plan the implant position and fabricate the surgical guide (Figs. 10-12). In the patient case under discussion, a mostly fully-navigated implant placement was planned. Special guide sleeves adapted to the implant system were therefore integrated into the surgical template (Fig. 13). The surgical guide was stabilised with tooth support on teeth 16, 12, 22, 26 and 27 and with two palatal bone screws for which two screw channels had been integrated into the surgical guide. Implant preparation was initially fully navigated in the extraction sockets of teeth 13, 11, 21, 23 without opening and in region 15 and 25 with the formation of a mucoperiosteal flap.

After insertion of the six standard implants in the anterior region, the surgical template was removed, followed by extraction of teeth 16, 12, 22, 26 and 27 (Figs. 14-25). The placement of the two short implants was carried out freehand in region 16 and 26 after removal of the posterior teeth. All implant preparations were carried out according to the manufacturer’s recommended drilling protocol. The provisional prosthesis (Fig. 26) was screwed onto the six anterior implants via abutments and immediately loaded (Fig. 27). A postoperative X-ray was taken (Fig. 28). The patient is very satisfied with her new restoration, both aesthetically and functionally (Figs. 29-31).

15. Teeth 12 and 22 were initially left in place to stabilise the surgical guide.
16. A full thickness flap was mobilised buccally in the premolar region of the quadrants to increase the soft tissue thickness.
17. Check the intraoral fit and stability of the surgical guide.
18. Additional stabilisation of the surgical guide via palatal fixation screws.
19. Template-guided implant drilling using the C-Guide drill..
20. … for C-Tech implants (C-Tech Implant, Bologna).
21. Template-guided implant placement (Esthetic Line implants, C-Tech Implants).
22. Occlusal view after placement of the six fully-navigated anterior implants.
23. Control: The markings on the transfer post correspond to the surgical guide sleeves.

24. Occlusal view of the final implant position in apicocoronal direction (subcrestal positioning of the implants!).
25. Placement of the Multi Unit abutments.
26. Temporary denture made of PMMA.
27. Situation after insertion of the temporary denture with good postoperative soft tissue condition.
28. Radiograph showing postoperative check overview.
29. Intraoral situation one week after the procedure with…
30. … healing without complications and good soft tissue condition.
31. Comparison of the patient situation before (left) and one week after the intervention (right).

by Doctor Henriette Lerner, HL-DENTCLINIC DR. STOM. MEDIC.

by Dr. Luigi Ciacci, Dentist, expert in guided surgery, ODT Andrea Sessa

Magazine PIP • Practical implantology and implant prosthetics • November 2019

Small but powerful. High-quality range with C-Tech system implants.

Full Smile, under the direction of business owner Lütfü Agic, well-known in the field of dental implantology, advises on a high-quality range with C-Tech system implants, biomaterials such as Bioteck, as well as dental and surgical instruments and tools from devemed. How can such a small unit survive in times of ever greater global players in the field of dentistry and what is the reason for a dentist to look for the partnership, asked pip and talked to Stefan Grümer, M.Sc., who runs together with colleagues a large referral practice on Theaterstrasse in Aachen.

pip: Don’t you kind of lose touch with international developments and trends with such a small partner like Full Smile?
Dr. Grümer: That may well be, regarding these international trends. Here, in the Theaterstraße in Aachen, we are a practice with an impressive range of modern services, especially in the field of restorative and aesthetic dentistry. From 3D diagnostics and computer-based functional diagnostics to laser dentistry, we use state-of-the-art and exceptionally gentle treatment methods that are comfortable for the patient. We are focusing strongly on training programs so that our range of services stays up to date with the latest state of science and research. But we do not have to follow any pseudo innovation. Much more important to us is a certain consistency with our commercial partners, because as well as between us and our patients, the cooperation between us and a medical device manufacturer is a matter of trust. It would bother me to have to adjust to a new contact person every few months, who knows neither me nor my treatment philosophy nor knows what my experiences are and what might actually enrich and interest me. Since 2013 I have been running the first university teaching practice in Germany in cooperation with the RWTH Aachen, an international academy with many foreign and extensive research projects – above all in the field of implantology and laser dentistry. Therefore, we are demanding a certain level of consulting expertise and a portfolio at eye level from our partners.

pip: What impressed you most about the C-Tech Implant System?
Dr. Grümer: As a referral practice we naturally work with different systems. Personally, I especially appreciate the C-Tech Implant System because of its system-related features. It is a fully engineered system that provides different implant diameters and lengths for all common indications – up to special designs such as one-piece mini-implants for narrow spaces, abutments or anchoring of dentures. At C-Tech we experience a very high primary stability and a very easy handling and thus a method which is absolutely suitable for everyday use. Furthermore, the aesthetic demands of our patients have increased significantly. With the EL – Esthetic Line – C-Tech offers a special design for these more demanding challenges. Refinements, like the platform switch, a generous apical threading, the morse taper connection and the concave aesthetic concept create a good stability with excellent shaping of the surrounding tissue. Despite a high prosthetic design freedom, the system is very easy to use, but the prosthetic connection is identical to the other implant diameters of the series. So you can get by with a straightforward instrumentation. I also like a whole new service of Full Smile, which I have never experienced before: As a dentist, I can search for any product via Full Smile and, if I found one, I will only pay the same list price as in the catalogue!

pip: What about service and accessibility – how can such a small company compete with companies that are quite different staffed?
Dr. Grümer: In fact, we sometimes ask ourselves the famous question of how often Mr. Agic has been cloned. He’s really frequently on the move and also visits us regularly to exchange ideas with us or to prepare ourselves for a new technique. However, we always reach someone in the office or receive a callback within a very short time – and also in such a short time our request is accepted, a delivery is initiated or a technical question is answered. In fact, with other companies I sometimes spent a lot more time in some telephone loop with automated speech before I can speak to a human being. With individual consultation, the reliable assurance of the desired delivery times and practical training, Full Smile is a professional partner for us in the field of dental implantology, periodontology and surgery.

Dr Fabrizia Luongo, DDS, MS, Periodontist, Rome, Italy

Introduction
The use of Cone Beam Computerised Tomography (CBCT) scanning is becoming more commonplace in today’s implant dentistry. These scans combined with increasingly sophisticated software technology has led to greater accuracy in digital planning and guided surgery and is gradually being adopted across general practice. Furthermore, the restorative planning can be digitised and combined with the CBCT data in appropriate planning software.
In conjunction with these technology advances, dental implant design has evolved to incorporate the latest concepts of biomechanical design, which include sophisticated thread profiling, platform switching and a Morse locking taper on the implant/abutment interface.
The following case details brings these advances in implants and digital technologies together.

Dr Fabrizia Luongo, DDS, MS, Periodontist, Rome, Italy

Introduction
There has been a considerable evolution in implant dentistry over recent years that has seen the design of dental implants adopt sophisticated thread profiles which leads to a better primary stability. Simultaneously these new geometries aid cortical bone maintenance through to platform-switching capabilities again designed to minimise bone loss. When combined with improved implant-prosthetic connections such as a Morse-locking conical connection it contributes to a good long-term prognosis and an aesthetic outcome.
Concurrent with this evolution in implant design have been substantial advances in digital technologies across the field of dentistry. These digital advances include Cone-beam CT scanning combined with appropriate 3D planning software, navigated surgery technology, 3D intra-oral scanning to create a ‘virtual impression’ and 3D printing technologies. These digital technologies can minimise the number of appointments found in a conventional treatment protocol as well as enabling greater accuracy and will be considered in this case study.

Clinical case of guided surgery by Doctor Marco Cernicchi. From computer design and model creation to the operation on the patient.

Magazine PIP • Practical implantology and implant prosthetics • August 2018

Italian passion for German precision

When visiting the impressive manufacturing facility, with 25 CNC machines alone, you will also come across the “Mercedes” of manufacturing technology such as the Swiss Tornos, a five-axis machine, which at C-Tech is purely tasked with the manufacture of mini-implants. Currently they are the largest manufacturer in Europe for this specific type of implant. Mini-implants are popular as a minimally-invasive option for creating an immediate restoration, which is currently a highly sought-after alternative for fast and good functional care of older patients. An impressive neighbour is the Willemin Macodell (the Rolls-Royce of CNC machines), which can be fitted with 48 different CNC cutters. It can change tools in 1.4 seconds and can be used in any conceivable axis, including for the manufacture of angled mini-abutments. C-Tech was one of the first companies to move over to cooling all computer-controlled machine tools using water-miscible bio-lubricants. The plant-based oil is odour-free, improves machining and even has a wider range of applications than mineral oil products. “And even though of course we run extensive cleaning processes for the finished parts, it’s still one risk factor less”, comments Lütfü Agic with respect to the recently published independent surface study by the University of Cologne, where the C-Tech implant surfaces were tested as an example, in testing applied to very few dental implant surfaces on the dental market.