Geistlich Biomaterials - Local and International News (Volume 15, Issue, 1, 2020) by Geistlich_Pharma

GEISTLICH BIOMATERIALS

LOCAL NEWS VOLUME 15, ISSUE UE E 1, 2020

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Climate Change - Are Trees the Forgotten Solution?

An interview with Prof Matteo Chiapasco - why did he make the switch to Yxoss CBRÂ®?

Osteology Symposium 2020 - Linking Science and Practice

Recent Events

Geistlich for Excellence 365 29 Oct, 19 & 28 Nov | Melbourne, Perth and Brisbane

The Geistlich team were excited to take Geistlich for Excellence 365 on the road again in 2019, visiting Perth – for the ﬁrst time and return visits to both Melbourne and Brisbane. A fantastic response from all of these cities with over 120 nurses, practice managers and implant coordinators attending the hands-on demonstration and networking evening. Senior Nurses Johanna San Martin and Margaret Nelson were on hand

in Melbourne speaking wonderfully about their own experiences with Geistlich products and sharing best practice knowledge and ideas. As always the table rotations are a great way for everyone to learn, be interactive and enjoy the social aspect of the evening, meeting and talking to peers from other practices, handling Geistlich biomaterials and viewing all of these under microscope. Stay tuned for 2020 Geistlich for Excellence 365 dates to be announced.

Dr Paolo Casentini 31 Oct & 5 Nov | Melbourne & Auckland

On his highly successful whirlwind tour down-under, Dr Casentini conducted three hands-on workshops, in conjunction with Geistlich, including the sold-out Mini-Symposium workshop in Sydney. Dr Casentini presented his two-part workshop on solutions for complex hard & soft-tissue augmentation cases. During the morning lecture a sequence of clinical cases and HD videos were shown to illustrate this new treatment philosophy. In the afternoon, the handson component involved attendees trialling the use of our biomaterials and devices (Yxoss CBR® system). Much praise for Dr Casentini was offered: “A fantastic speaker with generous 2

GEISTLICH LOCAL NEWS 1-2020

input and great tips; Paolo is an amazing, gifted clinician and his teaching concepts are beautifully illustrated with superb photography and live video. Absolute class! Worth the trip.” & “A very valuable handson course, all relatable and immediately implementable ﬁrst day back at work”. The Geistlich team would like to thank Dr Casentini for sharing his expertise with all of the attendees of our course.

Recent Events

Geistlich Mini – Symposium: Dr Stephen Chen & Dr Paolo Casentini 1 & 2 Nov | Sydney

Geistlich Pharma Australia hosted its ﬁrst ever Mini-Symposium in Sydney on Friday 1st and Saturday 2nd November 2019. Attendees were able to elect which sessions they attended; either the evening lectures, the hands-on workshop Saturday or both. Held at the beautiful Hotel InterContinental Sydney, the ﬁrst part of the Symposium consisted of evening lectures and discussion with two world-

renowned clinicians: A/Prof Stephen Chen OAM from Melbourne University and Dr Paolo Casentini from Milan, Italy. The evening was dedicated to the topic, 'Consideration for Ridge Preservation & Solutions for Complex Augmentation Cases' and was attended by practitioners from all over Australia. A/Prof Stephen Chen reviewed evidence for bone augmentation and ridge preservation procedures, and outlined the techniques involved. There was discussion on grafting materials and socket closure techniques.

A full-day hands-on workshop with Dr Casentini was held on Saturday, at the Park Hyatt Sydney. This highly popular workshop was attended by dentists, specialists, surgeons and observers. They were given a more detailed overview of the concept of PGR, with the opportunity to trial the use of Geistlich biomaterials and devices that can help the clinician to apply these concepts surgically.

Dr Paolo Casentini presented the concept of Prosthetically Guided Regeneration (PGR) to deal with complex implant cases involving both bone and softtissue defects.

IADR Brisbane 28-30 Nov | Brisbane The 4th Meeting of the International Association for Dental Research was organised by the Australia New Zealand Division for the ﬁrst time at the Brisbane Convention and Exhibition Centre. The event attracted a number of local and international dental researchers and experienced clinical professionals including keynote speakers – Prof. Raman Bedi, Prof. Jerry Feng, Prof. Jack Ferracane, Prof. Dana Graves, Prof. Tara Renton and Prof. Lone Schou. Geistlich was a proud supporter of this prestigious international event.

Recent Events

ADX20 13-15 March 2020 | Sydney

Held by the Australian Dental Industry Association at the International Convention Centre in Sydney, the ADX20 is Australia’s premier dental event. The extensive program included seminars on restorative treatments, cosmetic dentistry, oral surgery and non-scientiﬁc issues including marketing and practice management.

hand to answer any questions about its' properties and handling. If you were unable to attend ADX, but

would like us to visit your practice for a complimentary in-practice hands-on session, please contact our customer service team on 1800 776 326.

This year, Geistlich Pharma was stepping it up with mini Biomaterials in Practise sessions at our stand! These FREE handson sessions gave visitors the chance to get a feel for our biomaterials and how to handle them. The Geistlich team were on

Australian Society of Periodontology Biennial Conference 26-28 March 2020 | Melbourne

The Australian Society of Periodontology Biennial Conference was hosted in Melbourne for the ﬁrst time in 2020. Periodontology – a study of the delicate tissues supporting the teeth as well as the conditions that affect them is both an art and a science. Therefore, the theme in 2020 is "The Art and Science of Periodontics".

GEISTLICH LOCAL NEWS 1-2020

The extensive educational program built around this theme included local and international speakers who are leaders in the ﬁeld including Dr Alpdogan Katarci, Dr Hasturk, Dr Lisa Heitz-Mayﬁeld and many more. This meeting covered all aspects of periodontics from non-surgical therapy through to the latest regenerative techniques, prevention to systemic

interrelationships and therapeutics to digital dentistry.

Give Teeth A Chance

Protect Your Pa Patients atients FFrom rom U Unnecessary nnecessary Bone B Loss!

o i t era

re ven t

ion by Regen

Geistlich Pharma Australia has partnered with Carbon Neutral* and Trees That Count* to support landscape restoration and regeneration of natural ecosystems in Australia and New Zealand. During March to May 2020, Geistlich Biomaterials will plant a tree on behalf of your practice and send you a certiďŹ cate from Carbon Neutral or Trees That Count**

THANK YOU FOR HELPING RESTORE THE NATURAL BEAUTY OF AUSTRALIA & NEW ZEALAND! **

For more information please contact our customer service team on AU 1800 776 326 / NZ 0800 500 043 *www.carbonneutral.com.au / www.treesthatcount.co.nz 5

Focus

Carbon Sequestration is a Must to Beat Climate Change Are Trees the Forgotten Solution? There is no one solution to saving the planet from the impacts of climate change. We need to commit to a variety of approaches to tackle the issue from many directions to truly make a difference. Klaus Lackner, a professor at Arizona State University and director of the Centre for Negative Carbon Emissions, puts it best: “Our ignoring the climate change problem for so long has eliminated our other options, the problem, left to itself, only gets bigger.” The problem is indeed only getting bigger. So, while cutting our future emissions is a great ﬁrst step, the world still needs to absorb some of the CO2 currently trapped in the atmosphere. This can potentially be done in one of two ways. Reforestation The simplest solution is the most natural one; planting trees and shrubs. Trees and shrubs naturally gather CO2 as part of their growth method. This option is often overlooked by policy makers in favour of more marketable technologybased alternatives. Yet this inexpensive, leafy green option helps drastically reduce the effects of climate change. The value of reforestation cannot be understated. It’s cheaper, more efficient and needs less maintenance than technology-based alternatives. A 2017 peer reviewed study, led by scientists from The Nature Conservancy and 15 other institutions, calculated that 6

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natural climate solutions could reduce greenhouse gas emissions by 11.3 billion tonnes per year[1]. That is the equivalent of halting the burning of oil and offering 37% of the reductions needed to keep global warming below 2°C by 2030. And saving the trees we already have also goes a long way. Currently, deforestation is estimated to cause about 15% of emissions. Putting greater focus on preserving trees will not only cut back our emissions but will also boost the amount of carbon dioxide being sucked out of the atmosphere. It’s a clear win-win scenario. Carbon Capture and Storage Technologies Machine-based solutions, while more cumbersome and expensive, might be the answer where planting trees is not viable. The technology to suck CO2 out of the atmosphere and safely store it in geological formations already exists, but it is expensive and has been slow to catch on. Initial efforts to sequester carbon through technology have had several setbacks. One example is Chevron’s Gorgon gas facility in Western Australia. Its $60 million taxpayer funded project to absorb carbon from the atmosphere has been at the mercy of technical issues. The project has been delayed to the point that Gorgon have ﬁnally applied for the initial licence – more than two years after the company publicly stated they were planning to do so[2]. The pressure to act is building. The

Intergovernmental Panel for Climate Change clearly stated in its address to policy makers in 2018 that we were not likely to reach the necessary emissions goals to counteract climate change without carbon capture and storage policies[3]. Governments and large corporations are starting to invest massively in artiﬁcial carbon capture and storage technologies, but progress has been slow due to the associated high costs. Businesses of any size – businesses just like yours – can combat climate change by supporting reforestation or buying carbon credits to offset emissions. Carbon Neutral’s Plant-a-Tree program plants mixed native species in the Yarra Yarra Biodiversity Corridor. The natural environment is being restored while carbon is being sequestered from the atmosphere. Carbon Neutral also offers offsets from innovative projects around the world, which work to either

Focus prevent emissions or sequester carbon from the atmosphere Yarra Yarra Biodiversity Corridor Within the last 100 years, over 90% of the northern Wheatbelt (known as the Mid-West) has been cleared for agriculture. This has removed so much native habitat that many plant and animal species are extinct locally or regionally. Others, however, have hung on in woodland and shrubland remnants - usually on rocky ridges and commercially less productive upper valley slopes. Carbon Neutral have a vision to reconnect these valuable remnant vegetation sites and link 12 nature reserves across a vast tract of land covering approximately 10,000 square kilometres. How? By planting trees and shrubs at selected key sites, particularly on nonproductive farmland. This will help establish habitat stepping stones and links for biodiversity to move and disperse back through the landscape. By reconnecting drier inland habitats with their coastal counterparts, the Yarra Yarra Biodiversity Corridor will help protect and recover our endangered

Yarra Yarra Corridor, Prior to Planting

and declining woodland, and shrubland fauna such as Mallee fowl, Carnaby’s Black-Cockatoo, Crested Bellbird, Western Yellow Robin and Western Spiny-tailed Skink. Australia’s Largest Revegetation Project based on Carbon Capture and Biodiversity - The Lie of the Land The Yarra Yarra Biodiversity Corridor is located in Western Australia's northern agricultural region approximately 400 km north of Perth. The Corridor features diverse ancient landscapes, from heavily weathered forming sandplains to heavier, more fertile red brown clay loams. The landscape once supported extensive woodlands of York gum and Salmon gum. The ancient Yarra Yarra drainage line ﬂows intermittently from the east to the Yarra Yarra Lakes near Three Springs. Most of the lakes and channels are saline, some naturally and some because of the massive clearing of the Wheatbelt, which has led to rising hypersaline groundwater tables. To ensure carbon yields are achieved in the Yarra Yarra Biodiversity Corridor, Carbon Neutral undertakes a combination of both hand-planting seedlings and direct seeding. Carbon focused species are those that have been identiﬁed as being greater than two metres tall at maturity, and which make substantial contributions

to the local carbon pool through the accumulation of carbon in their woody stems, branches, and roots. These are mainly drought-tolerant Eucalypts and woody-stemmed Acacia species. The inclusion of hand-planted seedlings for those species with specific carbon sequestration capacities allows our Forester to control both the density and positioning of those individual trees. Why is biodiversity important? Planting 20 to 40 native tree and shrub species creates vital ‘co-benefits’, including biodiverse-rich habitat for wildlife. Native plants and animals thrive in large, well-connected patches of high-quality habitat that meet their life cycle needs of food, shelter and reproduction. Our planting management focus is on the process of assisting the recovery of an ecosystem that has been degraded, damaged, or destroyed. Some reforestation companies plant only a single species – a monoculture. Monoculture plantings provide limited ecological function and habitat benefits, and are less resilient than biodiverse plantings which help provide habitat in future forests and woodlands for our very special flora and fauna. References: Article – https://carbonneutral.com.au/carbonsequestration-is-a-must-to-beat-climate-change-aretrees-the-forgotten-solution/ https://carbonneutral.com.au/yarra-yarrabiodiversity-corridor/ Images – Pixabay.com/photos

Yarra Yarra Corridor, After Planting

Focus

The Story of Our Eucalypts Eucalypts—often called gum trees—are icons of the Australian ﬂora. With more than 800 species they dominate the Australian landscape, forming forests, woodland and shrublands in all environments except the most arid deserts. Karri and Mountain ash form tall wet forests, mallee species grow in semiarid regions and snow gums are stunted twisted trees of subalpine regions. Eucalyptus regnans (Mountain Ash) form tall, dense wet forests. A few tropical species extend the range of eucalypts north of the continent, with rainbow gum (Eucalyptus deglupta) found in the rainforests of New Guinea, Sulawesi and Mindanao in the Philippines, and White Gum (Eucalyptus alba) on Timor. Eucalyptus alba (is native to Australia, and the islands of New Guinea and Timor to Australia’s north. Evidence from sequencing DNA and the discovery of fossils indicate that the

eucalypts have their evolutionary roots in Gondwana, when Australia was still connected to Antarctica. Impression fossils of leaves and fruits with very good detail have been described from Patagonia in South America and dated at 52 million years old. Less wellpreserved fossils are known from sites in Australia and even in New Zealand. Ancient eucalypts were probably similar to some of the current day tropical wet forest species. They would have occurred among or on the edge of ancient rainforest. And as Australia drifted north, they adapted to drier climates, weathered soils and a ﬁreprone landscapes. As Australia reached southeast Asia the opportunity arose for range expansions to the north, where today we see Rainbow Gum. Eucalyptus deglupta is native to a number of islands to the north of Australia, including New Guinea, Sulawesi (Indonesia) and Mindanao (the Philippines). The remarkable ability of most eucalypts to quickly re-sprout from

Koala’s eat mainly eucalyptus leaves (gum leaves) living in tall open eucalypt forests.

Eucalypts – aka Gum Trees come in more than 800 species

dormant buds located under the bark or in lignotubers following damage from drought or ﬁre is a feature that has helped them to survive and dominate the harsher environments that evolved with Australia's changing climate over the last 30 million years or so. These Eucalyptus behriana trees have obvious lignotubers at the base of their trunks. . Eucalypts are evergreens. Unlike many northern hemisphere trees that are deciduous in harsh times such as winter, eucalypts have leaves all year. Eucalypts are described as ‘sclerophylls’, meaning ‘hard-leaved’. The leaves are thick, leathery and tough due to lignin, and do not easily wilt. This enables them to survive hot and dry conditions. After periods of stress, like drought or ﬁre, eucalypts can sprout from dormant buds beneath the bark. Eucalypts also develop very different leaves as they grow from young juvenile plants to adult trees. Often the juvenile leaves are held horizontally to maximise light absorption but as adults the stalk of the leaf twists and the leaves

GEISTLICH LOCAL NEWS 1-2020

Focus

Eucalyptus Leaves

hang vertically to reduce exposure to high levels of radiation and water loss. The internal anatomy of the leaves also changes. Many eucalypts, like this Eucalyptus macrocarpa, have juvenile foliage that is quite different to the adult leaves. A unique feature of the eucalypts is the caps—called opercula—that cover the flowers when in bud. These caps are the equivalent of the showy petals and sepals of other flowering plant. The flowers themselves don’t have such petals, but display many stamens, often cream coloured, but pink and red in bird-pollinated species. The opercula prevent the flower from drying out and along with oil glands in the tissues, help protect it from insect attack. Evidence that these opercula provide a selective advantage to plants comes from the fact that they’ve evolved independently in different genera—in both the genus Eucalyptus and in genus Corymbia (the bloodwoods). After they are pollinated, the eucalypt flowers develop into woody fruits, known as capsules—that’s right, those gum ‘nuts’ we all collected as kids are

technically fruits! Eucalypt ﬂower buds have little caps, called opercula, seen here in Eucalyptus synandra (Jingymia mallee). They help protect the ﬂower bud from drying out and insect attack. Eucalypts have a notorious reputation for dropping branches, with many people considering them unsuitable for street trees or dangerous to have in their backyards. So, is this actually true? In times of drought or other stress, perhaps disease-induced, eucalypts will sometimes drop what looks to be a perfectly healthy branch with no apparent warning signs. During hot dry conditions, branches with insufficient water become brittle and can fall in windy conditions, especially from old trees. This can, understandably, instil a certain amount of apprehension in people. There are a few species in particular that are more prone to dropping their branches— manna gum (E. viminalis), river red gum (E. camaldulensis), yellow box (E. melliodora) and maiden’s blue gum (E. globulus). Some species of gum tree are more likely to drop their branches than others. So, if you’d like to plant one

Eucalyptus Flowers

(or several) of these quintessentially Australian trees in your yard, but have safety concerns, ﬁrst check the species. Make sure it’s appropriate for the size of your yard (there is a surprising number of smaller species) and plant it away from the house. Alternatively, enjoy gum trees by venturing out into the bush on the weekend and immersing yourself in the scents and atmosphere of the landscape.

References: This article has been reviewed by: Professor Pauline Ladiges AO FAA School of Biosciences, University of Melbourne ‘’The story of our eucalypts, viewed 20 January 2020, https://www.science.org.au/curious/ earth-environment/story-our-eucalypts Original Story https://www.science.org.au/curious/earthenvironment/story-our-eucalypts Images – Pixabay.com/photos

Indication Sheet Major Bone Augmentation

Watch more on

www.bio-brief.co

Prof. Matteo Chiapasco Dr. Grazia Tommasato

3D bone augmentation using CAD/CAM technology, biomaterials and autologous bone Do not miss Prof. Chiapasco at Osteology Sydney 19 -21 June 2020! visit: www.osteology-australasia.org

Focus

Customised Titanium Scaﬀold Yxoss CBR® Interview with Prof Matteo Chiapasco

Many, many techniques are available to gain vertical bone height—including meshes, non-resorbable membranes, bone blocks or osteotomies. Prof. Matteo Chiapasco, Italy, has successfully used most of them. Why did he make the switch to Yxoss CBR®? By Enea Simonato (Italy) and Verena Vermeulen (Switzerland) Prof. Chiapasco, what convinced you to try Yxoss CBR®? Prof. Chiapasco: The available titanium meshes can be difficult to manipulate and ﬁxate. Therefore, titanium meshes produced with CAD/CAM technology immediately fascinated me. I hoped that Yxoss CBR® could simplify the surgical procedure. What is the concept of Yxoss CBR®? Prof. Chiapasco: The surgeon creates a CBCT or CT image of a bony defect, be it a small or even an extensive one. Then they send the image in DICOM format to ReOss, the company manufacturing Yxoss CBR®. Based on the digital data, the company develops a threedimensional model of the bone defect and creates a customized titanium mesh

Customised Titanium Scaﬀold Yxoss CBR®

marketed by

the regeneration experts

"This technique reduces the difficulties to less than half" that subscribes exactly the bone contour needed for later implant placement. The surgeon receives a 3D printed titanium scaffold that is already perfectly shaped and adapted to the speciﬁc defect. How do you ﬁll the scaffold? Prof. Chiapasco: With autologous bone particles mixed with a reliable biomaterial, such as deproteinated bovine bone, in an approximately 1:1 ratio. Particulate material, unlike bone blocks, quickly vascularizes, supporting new bone formation. And the autologous bone particles have not only osteoconductive but also osteoinductive and osteogenic potential. The bone / bone substitute mixture is compressed into the grid outside the oral cavity, and then the grid is applied most easily and stabilized by a minimum number of titanium microscrews. The stability and accuracy of the reconstruction are amazing. Have you changed your approach with Yxoss CBR®? Prof. Chiapasco: I didn’t have to make

any radical changes. I obtain autologous bone from intra-oral sites with a bone scraper in the majority of cases. Only in case of extremely extended and severe atrophy, autogenous bone chips may require harvesting from extra-oral sites through small incisions. I avoid more traumatic harvesting and sampling of bone blocks. The recipient site is prepared in the same manner as for block grafting: removing any connective tissue residues, creating micro-perforations to accelerate revascularization, and releasing the access ﬂaps with care to obtain a tension-free suture. This remains the key to success, independent of the reconstructive technique used. Lack of hermetic tightness in the suture sets the scene for failure. Where do you see advantages for your clinical practice? Prof. Chiapasco: I have signiﬁcantly reduced operating times. Another advantage is that you can visualize the reconstruction in three dimensions before you start surgery. You can even have the manufacturer calculate the amount of graft material needed in cubic 11

Focus centimetres. With this, you will not find yourself with too little or, paradoxically, too much bone. You also treated patients with extensive defects or even edentulous ridges with Yxoss CBR®. What is your experience in these cases? Prof. Chiapasco: I was surprised by the simplicity of managing really “vast” defects without using huge autogenous blocks. This simplified the whole procedure and shortened the surgery time. However, to be honest, this kind of surgery should be performed by very experienced surgeons. Knowledge about anatomy, management of soft tissues and tension-free sutures is key. So far, I have treated almost ten sub-totally or totally edentulous patients with extreme atrophy. In some cases, I treated four edentulous sites including maxilla and mandible on both sides in one surgery. Do you also experience complications? Prof. Chiapasco: One sort of complication can clearly be avoided by the surgeon. Don’t load the regenerated area with a removal prosthesis. This really jeopardizes the treatment result. A partial exposure of the titanium mesh, however, may occur even in very “experienced hands” and despite perfect soft tissue release and tension-free, hermetic suture. I have experienced limited titanium mesh exposures in eight percent of the cases (unpublished data), but with no relevant consequences. I checked this when I removed the titanium mesh and placed the implant. There was no significant infection and only insignificant bone loss. How do you act in case of exposure? Prof. Chiapasco: If exposure occurs, optimal oral hygiene with the aid of chlorhexidine mouth rinse and frequent clinical controls are essential. I must stress, however, that a complication rate of eight percent is still lower than that reported for other regeneration procedures. And the consequences are less severe. A wide exposure of a block 12

GEISTLICH LOCAL NEWS 1-2020

Panoramic radiograph of initial situation showing the atrophic mandibular areas.

graft or other non-resorbable barriers may even be followed by the total loss of the graft. What would you say to a colleague to convince him or her to try Yxoss CBR®? Prof. Chiapasco: While it is important to be an expert in GBR, this technique reduces the difficulties to less than half and is predictable, effective, and precise. Try it to believe it. Professor Matteo Chiapasco will be visiting Sydney as guest speaker at the Osteology Symposium – Sydney 1921 June 2020 hosted by the Osteology Foundation. An outstanding scientiﬁc program will address strategies for predictable hard and soft tissue regeneration providing practitioners with cutting edge knowledge to provide the latest in regenerative dental medicine for the beneﬁt of patients. Visit Osteology-australia.org for registration information, full program and further details on the local and international speakers and lecturers.

Original Article: https://www.regeneration-expert.com/en/blogdetail/blog/182/blogtitle/this-technique-reduces-thedifficulties-to-less-than-half/

CT scans showing a relevant vertical and horizontal bone deﬁcit of the posterior mandible

Upcoming Events 2020

Dental Expo 2020 NZ 22-23 May 2020 | Auckland

Dental Expo 2020 will be open for 2 days and provide complimentary entry to all dental professionals. Delegates will have the opportunity to earn CPD points for attending FREE lectures and presentations at the event held by a variety of local and international experts. Come and see Dr Rebecca Ellis, a specialist Periodontist and Implant

Surgeon at the Institute of Dental Implants and Periodontics in Newmarket Auckland. Dr Ellis is actively involved in dental implant research and will be presenting a session on Socket Preservation After Tooth Extraction – the Do’s & Don’ts. This presentation will explore the concept of site preservation following tooth extraction and speciﬁcally address augmentation of extraction sockets at the time of tooth removal, as a means of preserving both the soft and hard tissue proﬁle prior to either implant tooth

replacement or restoration with a bridge pontic. Make sure to put this premiere event into your calendar for 2020.

Photo: Beau Compton

Practice Team Program - Osteology 2020 20 June 2020 | Sydney

For the ﬁrst time in 2020, the Osteology Foundation are proud to announce the Practice Team Session, designed to appeal to all members of the regenerative team including dental assistants, dental hygienists, therapists and practitioners.

Guided Bioﬁlm Therapy consists of treatment protocols based on individual patient diagnosis and risk assessment in order to achieve optimal results. The treatment is given in the least invasive way, with the highest level of comfort, safety and efficiency.

Hosted by EMS and covering all facet of Patient Care and Preparation, from Set Up for Surgery and Surgical Draping, Infection Prevention and Control, through to the Management of Dental Pain in a Post Codeine Era. This oneday workshop includes an afternoon hands-on workshop on Guided Bioﬁlm Therapy.

Guided Bioﬁlm Therapy includes Oral Hygiene Instructions plus patient education and motivation to maintain natural teeth and implants for as long as possible. Join the Osteology Foundation at 2020 Vision for Regeneration – Practice

Team Program. For more information visit www.osteology-australasia.org.

What is GBT? Guided Biofilm Therapy is the systematic, predictable solution for dental biofilm management in professional prophylaxis using state of the art AIRFLOW®, PERIOFLOW® and PIEZON® technologies, proven by scientific evidence.

Upcoming Courses 2020

Geistlich Hands-On Workshops 2020 Geistlich is specialised in regenerative medicine and is dedicated to developing products in collaboration with leading scientists, researchers and clinicians. With this in mind, we strive to provide practitioners with the most recent clinical science and for that reason we continue to organise ongoing practical workshops and presentations at national congresses. Our highly respected hands-on courses draw on a wide network of experts from around the world.

Hands-On

Pig Ja

GEISTLICH LOCAL NEWS 1-2020

Assoc Professor Mauricio Araújo (Brazil)

24 March | Brisbane

26 March | Melbourne

Extraction Socket and Soft Tissue Management

Soft Tissue Regeneration in Focus

This is a two-part Hands-On Workshop on How to Achieve Optimal Aesthetic Results: Part 1: Scientific and clinical evidence relating to the concept of extraction site management will be presented during the didactic session. The handson exercises will allow attendees an opportunity to learn and practice techniques that will: •Increase the probability of achieving an atraumatic extraction •Result in the optimal utilisation of biomaterials to minimise extraction site remodelling •Relate to pertinent surgical skills & considerations i.e. suturing, flap design & instrumentation Part 2: The lecture will include a review of the relevant data relating to soft tissue regeneration in a clinical setting, whilst the hands-on component will include: •Use of soft tissue substitutes for recession coverage & suturing technique to coronally advance the flap •Suturing technique to fix the connective tissue graft or collagen matrices • Techniques to accommodate the gain of keratinised tissue •Soft tissue augmentation with a volume-stable collagen matrix.

A/Prof Araújo embarked on his academic career in 1990, becoming the Assistant Professor of Periodontology at the State University of Maringa (Brazil), after which he became an Adjunct Professor in 1998, eventually taking up the Associate Professor role in 2006, a position he still holds to this day. He balances his commitments in his homeland with a senior research role at the Institute of Odontology in Göteborg University (Sweden). He is a past Osteology Foundation Board member and an ITI Fellow. Soft-tissue grafting procedures are considered an integral part of implant dentistry, with various techniques and materials applied at different time-points. Although autogenous transplants are still widely used and are still considered the gold-standard, they are associated with major disadvantages and most prominently the associated morbidity. Therefore, more recently, collagen-based softtissue substitutes have been developed and demonstrate favourable clinical success and less morbidity.

Upcoming Courses 2020

Professor Mariano Sanz (Spain)

Dr Markus Troeltzsch (Germany)

Professor Jürgen Hoﬀman (Germany)

31 August | Perth 2 September | Melbourne

10 October | Sydney

13-14 October | Melbourne 16-17 October | Sydney

Soft Tissue Plastic Techniques

The Art and Science of Augmenting the Alveolus: Current Knowledge, Techniques and Future Possibilities

Sinus Floor Elevation, Augmentation, Soft Tissue Handling and Management of Complications – A practical 2-day course on cadavers

Prof Mariano Sanz received his MD and DDS degree from the Universidad Complutense de Madrid. He then completed his graduate training in Periodontology at the University of California, Los Angeles (UCLA). Additionally, he is Doctor in Medicine (PhD Degree) from the University Complutense of Madrid. He is Professor of Periodontology, Dean of the Faculty of Odontology of the University Complutense of Madrid and Director of the Graduate Program “Master in Periodontology” also at the University Complutense of Madrid. Currently he is the Chairman of the European Council of Deans of Faculties of Odontology. Professor Mariano Sanz is the author of more than 200 scientiﬁc articles and book chapters and participates extensively in international lectures, courses and seminars in Periodontology, Implant Dentistry and Dental Education.

Dr. Markus Troeltzsch (MD /DMD) completed his dental training and received his DMD in 2005 from the Dental School at the University of Erlangen in Nuremberg in Germany. In 2010, Dr. Troeltzsch completed his medical education at the Medical School at the University of Erlangen, Nuremberg and received his MD. Attendees will learn the following: Classiﬁcation of osseous defects; Success rates of augmentative procedures managing these various defects; Selecting an appropriate biomaterial for a particular situation; Advantages and disadvantages of the different types of bio-materials available for hard and soft tissue augmentation; How systemic (medical) health can affect success and failure rates of augmentation procedures; How to make augmentation more predictable and increase success rates ; The technology and steps involved in planning and applying CAD-CAM designed titanium-mesh to achieve 3-dimensional bone augmentation in challenging situations. The hands-on workshop component of the program will enable attendees to practice some of the techniques used to manage lateral and vertical alveolar defects.

Dr. Jürgen Hoffmann qualified as an OMFS surgeon in 1997 at the University Hospital Tübingen and finished his PhD-Thesis in 1999. Working as consultant since 2000 he became Vice Chairman of the Dept. of Oral and Maxillofacial Surgery at the University Hospital Tübingen (Germany) in 2003. Since 2010 Professor Dr. Jürgen Hoffmann chairing the Dept. of OMFS at the University Hospital in Heidelberg, which is one of the major units in Germany, covering a broad scope of surgical techniques. His main focus is in the field of Reconstructive Surgery, he has special interests in image data-based planning, treatment of Vascular Anomalies and bone regeneration.

Upcoming Courses 2020

Osteology Symposium - Hands-On Workshops Sunday 21 June | Sydney

NOW

Professor Istvan Urban (Hungary) Lateral Bone Augmentation and Soft Tissue Reconstruction Advanced ridge defects present one of the greatest challenges of bone regeneration in implant dentistry. There are several techniques available to reconstruct these deﬁciencies: • The Sausage Technique presents one of the least invasive techniques that provide good bone support for implants • Re-establishment of the vestibule and keratinised tissue after vertical and horizontal augmentation • The use of strip gingival graft in combination with a collagen matrix to reconstruct the aforementioned soft tissue. Watch Professor Istvan Urban demonstrate these techniques at his workshop while observer seats are still available!

Professor Ronald Jung (Switzerland) Horizontal Bone Augmentation: An Exploration of Alternate Approaches Is guided bone regeneration a safe therapy and what is known about long-term results? Join Prof Ronald Jung as he demonstrates new and innovative clinical approaches to solve the problem of hard and soft tissue volume stability. Find out if there are reliable off-the-shelf solutions that will bring us to the next level of soft tissue regeneration. Prof Jung trained in oral surgery, prosthodontics and implant therapy. He is currently Head of the Division of Implantology and Vice Chairman of the Centre of Dental Medicine of the University of Zurich Clinic for Fixed and Removable Prosthodontics and Dental Material Science. He is an accomplished and internationally renowned lecturer and researcher, best known for his work in the ﬁeld of hard and soft tissue management and his research on new technologies in implant dentistry.

Professor Matteo Chiapasco (Italy) Bone Augmentation and Soft Tissue Reconstruction Recently, customised, CAD/CAM titanium meshes are available on the market with the aim of offering results similar to those obtained with the traditional reconstructive procedures, whilst also allowing for the relevant simpliﬁcation of the surgical procedure. The production of these Ti-Meshes is in fact performed on personalised 3D models obtained by CBCTs of the atrophic area of each patient, allowing an extreme precision and simpliﬁcation of the adaptation of the mesh to the defect to be reconstructed. The aim of this workshop is to teach all participants how to perform all of the surgical steps of the reconstructive procedure of partially edentulous jaws with customized Ti-Meshes with the aid of both didactic (including detailed slides & procedural videos) and hands-on (using both animal, pig jaw, and synthetic models) sessions.

Professor Rino Burkhardt (Switzerland) Mechanosensitive Surgery in the Field of Periodontal & Peri-implant Management of the Oral Mucosa New insights into structural anatomy of the oral mucosa and the biological processes support the hypothesis that control of flap tension is crucial for optimal wound healing. On the other side, there is evidence in the literature that clinicians cannot control flap tension without training of their psychomotor and visual-spatial skills, especially when tensions are low. It is the goal of the present hands-on course to evaluate the variability of applied flap tensions of the individual trainee and to present bench models how to practice the control of flap tension. Additionally, based on clinical situations, we will show the participants how biomaterials can help to increase wound stability and influence the tensions applied on wound margins. The course is focused on skills training in mucosal surgery and on selection of the biomaterials based on clinical models. For more information on Osteology Symposium Sydney 2020, go to osteology-australasia.org or call Michelle Henry on 1800 776 326 16

GEISTLICH LOCAL NEWS 1-2020

ER2020 GISTCourses REUpcoming

UNDER THE PATRONAGE OF THE

NOW

2ND NATIONAL

OSTEOLOGY SYMPOSIUM International Chairman Prof Istvan Urban

SYDNEY 2020 19 – 21 JUNE 2020

National Chairmen Prof Lisa Heitz-Mayfield Prof Sašo Ivanovski

WWW.OSTEOLOGY-AUSTRALASIA.ORG

Upcoming Events 2020

Osteology Sydney 2020 continues to build momentum ready for June event! Preparations for Osteology Sydney 2020, taking place on June 19-21, 2020 at the new ICC at Darling Harbour, are almost complete. The event presents a stellar lineup of top local and international speakers in a format that incorporates lectures for clinicians and the clinical team, a variety of comprehensive hands-on workshops and a gala dinner. We caught up with the legendary Dr Frank Schwarz at the International Osteology Symposium in Barcelona to find out why Osteology events are so vital. ADP: Thank you for your time Dr Schwarz. Osteology is an amazing event. Can you explain why regeneration is so significant for implant dentistry and implant clinicians? FS: We’ve been placing implants on a regular basis for more than 30 years and in that time, we’ve come to realise that while implant placement is a relatively simple process from a surgical perspective, it’s inherently complex biologically. The biology needs to be addressed in the proper way to avoid complications and it’s at this point that regeneration comes into the picture. We have compromised sites in the vast majority of cases where we’re placing implants. We cannot always place implants in a perfect, wide and well dimensioned ridge. We have to accept the fact that, in most cases, implant placement goes hand-in-hand with bone deficiencies. Or more correctly, bone dimension or quality that needs to be improved to support the long-term success of the implant. Bone regeneration, therefore, has become a mandatory tool for the implant dentist. This is also not limited to cases where we have a bone deficiency that is immediately obvious. We now understand, for instance, that even a thin bone plate may compromise the longterm stability of the implant. 18

GEISTLICH LOCAL NEWS 1-2020

Bone augmentation procedures need to be applied in the vast majority of cases to support the implant and also to support the soft tissue aesthetics. ADP: What would you say to dentists who have never done any training in regeneration? FS: Bone regeneration is a complex biological phenomenon and for the clinician, it’s important to have the proper skills and training. You have to understand that bone formation is a crucial element. We need to think carefully about proper flap design, correct incision techniques and methods for proper handling of biomaterials. In addition, not all patients behave the same and therefore, proper surgical training enables you to be able to customise a procedure and adapt it to the specific needs of your patient. Without having the training and understanding the biological consequences of treatment, you cannot customise anything. My particular expertise is the treatment of implant-related complications and implant infections are one of my major research topics. Biological complications were ignored for many years but are now seen as a regular occurrence in implant dentistry. Implant clinicians need to learn which treatment and procedure should be chosen for a specific diseased entity around an implant. For example,

for peri-implantitis, should we choose a regenerative approach or should we choose a non-surgical approach? This is what you have to learn. A membrane may be seen as just a piece of collagen, but there are many, many different ways to apply it, to adapt it to the defect and to adapt it to the clinical situation. This is what you cannot understand from reading a textbook or scientific article. You need to learn it with your own hands. And there are so few occasions where you can learn it properly. This is the mission of the Osteology Foundation - to spread knowledge and to link science with clinical practice. ADP: So, at the Osteology events, would you recommend participating in the hands-on workshops? FS: Well, when you want to get to the next level, when you want to reduce complications, and of course, when you want to improve your knowledge in a very specific area, then I don’t see many alternatives to the Osteology Foundation and the Osteology events. The Osteology Foundation primarily supports research for young dentists that have a certain skill and a certain ambition to start their scientific careers. This is one of the major missions of the Osteology Foundation - providing funds for research and also funds for training in how to do research correctly.

Upcoming Events 2020

At a certain point, however, the clinician becomes the crucial component, hence the Osteology Foundation also support clinicians looking to improve their clinical knowledge and skills. This is where we link the science to clinical practice. At Osteology events, we bring everyone together in a very positive atmosphere where these two paths can intersect. In the past, research and clinical practice existed in parallel - scientists versus clinicians. And this is how Osteology events would be run. On plenary one, we had the scientists and on plenary two, the clinicians. But this was not at all appropriate. So we have now linked the two. And this is what Osteology now does, in a very strategic and professional

way, supporting both parties at every step of their careers. ADP: How does the Osteology Foundation create these amazing events? FS: The Osteology Foundation has a board and the board is also a mixture of practitioners and scientists from all over the world. The national symposia, such as the event taking place in Sydney, always have a local chair from the host country, even though that country may not have a member on the board. And in this way, we try to tailor events to local circumstances so that the content and format will meet local expectations. For countries like Australia, where clinicians are well-advanced and have

been placing implants for decades, meetings like the upcoming National Osteology Symposium Sydney 2020, 19-21 June at Darling Harbour are a place where they can still learn a lot, particularly about all the new things that are happening. Even someone like myself, who is considered to be at the forefront of scientiﬁc research, realises that there are many, many things that I don’t know or, let’s say, haven’t interpreted fully. So you can always learn, particularly from being in such a positive environment surrounded by so much knowledge and experience.

Article written by Joseph Allbeury – Australasian Dental Practice

Joseph Allbeury, Dr Frank Schwarz

Don’t miss the 2nd National Osteology Symposium Sydney, June 19-21 2020. Visit www.osteology-australasia.org

Upcoming Events 2020

Osteology Sydney 2020 FRIDAY, 19 JUNE 2020

SATURDAY, 20 JUNE 2020

AFTERNOON

MORNING

OPENING Istvan Urban (HU) /LVD +HLW] 0D\ÀHOG $8

SESSION 1 - BONE AUGMENTATION IN FOCUS Istvan Urban (HU) Ronald Jung (CH) Matteo Chiapasco (IT)

SESSION 1 CASE COMPETITION Moderators: Istvan Urban (HU) Wendy Gill (AU)

Moderator: Sašo Ivanovski (AU)

TEAM SESSION PATIENT CARE AND PREPARATION (PART 1) Moderator: Fritz Heitz (AU)

COFFEE BREAK

SESSION 2 - PERIODONTAL REGENERATION Mark Bartold (AU) Axel Spahr (AU) Mike Danesh-Meyer (NZ)

SESSION 2 - HOT TOPICS

LUNCH BREAK

SESSION 3 - SOFT-TISSUE AUGMENTATION Rino Burkhardt (CH) Istvan Urban (HU)

SESSION 3 - MANAGING COMPLICATIONS Rino Burkhardt (CH) Matteo Chiapasco (IT) Janina Christoforu (AU)

COFFEE BREAK

SESSION 4 - EMERGING TECHNOLOGIES

SESSION 4 - CHALLENGES IN DECISION MAKING Moderators: Istvan Urban (HU) Lisa Heitz-Mayfield (AU)

EVENING

Matteo Chiapasco (IT) Jung Chul-Park (KO)

RESEARCH SESSION

TEAM SESSION PATIENT CARE AND PREPARATION (PART 2) Moderator: Lydia Lim (AU)

Ronald Jung (CH) Lisa Heitz-Mayfield (AU) Sašo Ivanovski (AU) LUNCH BREAK

LUNCH BREAK TEAM SESSION PATIENT CARE AND PREPARATION (PART 3 : HANDS-ON) Guided Biofilm Therapy (EMS)

COFFEE BREAK

COFFEE BREAK CLOSE DAY 2

CLOSING BY CHAIRMEN DAY 2 GALA DINNER

FREE PROGRAM

AFTERNOON

MORNING

SUNDAY, 21 JUNE 2020 WORKSHOP 1 - LATERAL BONE AUGMENTATION AND SOFT-TISSUE RECONSTRUCTION

WORKSHOP 2 MODERN HARD AND SOFT-TISSUE MANAGEMENT BEFORE AND DURING IMPLANT PLACEMENT

WORKSHOP 3 VERTICAL AUGMENTATION OF MAJOR BONY DEFECT USING CUSTOMISABLE 7, 0(6+

Istvan Urban (HU)

Ronald Jung (CH)

Matteo Chiapasco (IT)

Rino Burkhardt (CH)

LUNCH

NLY

VERS O

OBSER

WORKSHOP 1 CONTINUED NLY VERS O OBSER

WORKSHOP 2 CONTINUED

Istvan Urban (HU)

Ronald Jung (CH)

62/' 2

87 3 WORKSHOP 62/' 2 CONTINUED

Matteo Chiapasco (IT)

GEISTLICH LOCAL NEWS 1-2020

WORKSHOP 4 CONTINUED

62/' 2

OFFICIAL END OF CONGRESS 20

WORKSHOP 4 MECHANOSENSITIVE SURGERY IN THE FIELD OF PERI-IMPLANT MUCOSA MANAGEMENT

62/' 2

Rino Burkhardt (CH)

PATIENT EDUCATIONAL PROGRAM

NOW

FREE FOR YOUR PRACTICE ALSO AVAILABLE IN CHINESE AND KOREAN LANGUAGES

Patient Information Brochures Patients brochures with common indications and their therapy PATIENT INFORMATION EXPOSED TOOTH ROOTS – NOW WHAT?

PATIENT INFORMATION WHAT HAPPENS AFTER TOOTH EXTRACTION?

PATIENT INFORMATION HOW TO PREVENT YOUR IMPLANTS BECOMING VISIBLE

PATIENT INFORMATION TREATMENT OF LARGER BONE DEFECTS

Recession Coverage

Extraction Sockets

Minor Bone Augmentation

Major Bone Augmentation

+ Chinese & Korean

+ Korean

PATIENT INFORMATION WHEN YOUR BACK TEETH ARE MISSING

PATIENT INFORMATION INFLAMED GUMS – NOW WHAT?

Sinus Floor Elevation

Gain of Keratinised Tissue

+ Chinese

+ Korean

PATIENT INFORMATION WHEN TEETH BECOME LOOSE

Periodontitis

Patient Regenerative Passport Provides patients and dental professionals with the conﬁdence that our products are safe, traceable and do not prevent your patients from donating blood.

Indication Notepads Providing dentists with the opportunity to demonstrate the recommended surgical procedure on an illustrative notepad.

EXTRACTION SOCKET MANAGEMENT

MINOR BONE AUGMENTATION

SINUS FLOOR ELEVATION

SOFT-TISSUE REGENERATION Gain of keratinised tissue

SOFT-TISSUE REGENERATION Recession coverage

Give Teeth A Chance

Protect Your Patients From Unnecessary Bone Loss!

Special Oﬀer+ DEAL 1 - $100 oﬀ 3 x Geistlich Bio-Oss® Collagen 100mg 3 x Geistlich Bio-Gide® Shape

DEAL 2 - $100 oﬀ 3 x Geistlich Bio-Oss® Collagen 100mg 2 x Geistlich Bio-Gide® Shape 1 x Geistlich Mucograft® Seal

For more information plea please se contact our cus customer stomer service team m on AU - 1800 776 6 3326 | NZ - 0800 500 043 +

GEISTLICH LOCAL NEWS 1-2020

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New at Geistlich

New Team Members Charmaine Abuan Sales Support Consultant Charmaine Abuan joined the Sydney office as our new Sales Support Consultant in July 2019 working very closely with the Geistlich Product Specialists looking after our regional customers in Australia and NZ. Charmaine has a Bachelor of Biomedical Science from the University of Technology Sydney and for the last 3 years she has worked in a busy Tele-sales role at Blamey Saunders, a specialised hearing aid manufacturer where she was responsible for sales and trouble-shooting hearing aids giving her extensive experience communicating with specialised medical products. Her passion is in sales and healthcare, so her role here at Geistlich was a great ﬁt. Jennifer Lutterbeck Marketing & Administration Assistant Jennifer Lutterbeck joined the Geistlich team as a Marketing and Administration Assistant in September 2019. She holds a Bachelor of Arts Degree in Secondary Teacher Education, which she completed in Germany before moving permanently to Australia in 2015. Jennifer brings a mix of skills to Geistlich from her previous positions in event management support, administration assistance and retails sales and is currently completing her Bachelor of Science in Economics on a part time basis. She is looking forward to her exciting journey ahead with Geistlich Pharma Australia.

Dr George Alexopoulos Clinical Science and Education Manager George joins the Geistlich senior management team as the Clinical Science and Education Manager. George is a qualified dentist, has a Masters’ of Science in Oral Implantology (Frankfurt, Germany) and a Masters of Business Administration (Monash). Furthermore, he is completing a clinical trial at The University of Melbourne as part of a PhD qualification. In his most recent role, George was managing the Dental Teaching Clinics at The Royal Dental Hospital of Melbourne. George possesses extensive clinical experience and a solid understanding of the dental industry, having previously served as Business Development Manager of implantology at DENTSPLY Australia for over six years. George looks forward to combining his academic and clinical experiences to assist the Geistlich team to achieve and exceed its goals. George will be based in Melbourne, loves his sport and is an avid follower of Liverpool, Richmond, and Formula 1 racing. He also enjoys a good coffee and the odd glass of fine wine!

Raksha Rughani Product Specialist - New Zealand Raksha Rughani joins the Geistlich Pharma New Zealand team as our new Product Specialist moving from the United Kingdom in 2005 after falling in love with New Zealand’s natural beauty. Raksha has extensive experience and a wealth of knowledge in the pharmaceutical industry in sales and account management for GlaxoSmithKline in the UK, continuing her career in New Zealand she enjoyed new challenges discovering the dental industry, working with dental professionals. Raksha enjoys tramping, yoga, meditation and reading and gains a lot of pleasure from travelling around the world.

Publisher ©Geistlich Pharma AG Subsidiary Australia / New Zealand The Zenith, Tower A, Level 21 821 Paciﬁc Highway Chatswood NSW 2067, Australia Phone +61-(1)-800 776 326 Phone +64-(0)-800 500 043 Fax +61-(1)-800 709 698 Fax +64-(0)-800 500 044 www.geistlich.com.au www.geistlich.co.nz

GEISTLICH BIOMATERIALS

Photo: ©gettyimages.ch / Westend61

VOLUME 15, ISSUE 1, 2020

FOCUS PAGE 10

OUTSIDE THE BOX PAGE 24

OUTSIDE THE BOX PAGE 34

Prevention by Regeneration.

Phenotype Modification Therapy.

Out of the palate.

Are there smart ways to prevent foreseeable damage and save surgical time?

This new approach was discussed in a Best Evidence Consensus. What does it stand for?

Our comic shows how to treat recession defects minimally invasive: the VISTA-X technique.

LEADING REGENERATION.

100

GEISTLICH NEWS 1-2020

Editorial

Early intervention beats a rescue mission “Wouldn’t it make better sense to help a patient, before problems occur in the first place?” This idea is brought up by Prof. Kenneth Kornman and Dr. Richard Kao, who describe the benefit of so-called Phenotype Modification Therapy (PhMT) in our interview. The question vividly illustrates the core topic of this Geistlich News issue: regenerative treatments which are preventive, not corrective! Through numerous contributions and interviews from experts, this Geistlich News issue gives you an abridged version of particularly interesting and relevant aspects of preventive care.

Prof. Jeong Hye Kim (KOR) and Dr. Alfonso Rao (UK) report on studies and their clinical experience in soft tissue regeneration. Geistlich Mucograft® and Geistlich Fibro Gide® make valuable contributions toward improving clinical success; contributions you should be aware of. Dr. Hector Rios (USA), an expert in periodontology, who sees orthodontic treatment as an interdisciplinary field, sheds light on a rather different aspect, which should be the subject of special attention in the future. His interview explains briefly and concisely the challenges of orthodontic treatment and how biomaterials can help enhance treatment outcomes. All this and much more is to be found in this new, extremely varied edition of Geistlich News. So we wish you exciting reading!

Photo: Roger Schuler

Prof. Jan Cosyn (BEL), Dr. Jun-Yu Shi (CHN) and Dr. Hong-Chang Lai (CHN) present the latest scientific data and their personal clinical experience in immediate implant placement. This procedure is experiencing an increase in international significance. On the other hand, it also harbors certain risks, which are mitigated by filling the buccal “gap” with Geistlich Bio-Oss®/ Geistlich Bio-Oss® Collagen and Geistlich Bio-Gide®. Thus patient well-being can be effectively enhanced in the spirit of “prevention by regeneration.”

Mirko Zingg Director International Marketing

Issue 1 | 2020

NEWS

6 Investment in the tens of millions: prepared for the future 6

OsteoScience Foundation: Going global

Taking it slowly

8 New look – quality assured 9

Latest studies on preventive strategies

10 Prevention by Regeneration

Regenerative dentistry includes several corrective measures such as rebuilding of lost bone and tissue volume. How about taking action before tissue loss takes hold? FOCUS

11 “I would fill the gap in any case.” Prof. Dr. Jan Cosyn | Belgium

14 Soft tissue management to prevent complications Prof. Jeong Hye Kim | Korea

16 One surgery – even for more extensive defects Dr. Alfonso Rao | United Kingdom

18 “Periodontists and Orthodontists should together develop protective strategies” Ass. Prof. Dr. Hector Rios | USA

21 Preventing alveolar bone resorption: Possibilities and limitations Drs. Jun-Yu Shi & Hong-Chang Lai | China

GEISTLICH NEWS 1-2020

OUTSIDE THE BOX

“It is about helping patients before problems occur” Interview with Prof. Kenneth Kornman and Dr. Richard Kao

Five questions for five experts

Yxoss CBR® – a closer look at bone formation Prof. Claudia Dellavia | Italy

31 New beginning for wound healing?

Healing problem in diabetes. 34

Out of the palate

Magazine for customers and friends of Geistlich Biomaterials Issue 1/2020, Volume 15 Publisher ©2019 Geistlich Pharma AG Business Unit Biomaterials Bahnhofstr. 40 6110 Wolhusen, Switzerland Tel. +41 41 492 55 55 Fax +41 41 492 56 39 biomaterials@geistlich.ch Editor Dr. Giulia Cerino, Verena Vermeulen Layout Larissa Achermann

Dr. Ulrike Schulze-Späte | Germany

Publication frequency 2 × a year

OSTEOLOGY FOUNDATION

Circulation 20,000 copies in various languages worldwide

«A life-changing experience» INTERVIEW

38 39

IMPRINT

A chat with Susana Noronha Publishing information

GEISTLICH NEWS content is created with the utmost care. The content created by third-parties, however, does not necessarily match the opinion of Geistlich Pharma AG. Geistlich Pharma AG, therefore, neither guarantees the correctness, completeness and topicality of the content provided by third parties nor liability for damages of a material or non-material nature incurred by using third-party information or using erroneous and incomplete third-party information unless there is proven culpable intent or gross negligence on the part of Geistlich Pharma AG.

Investment in the tens of millions: prepared for the future Location: Wolhusen, Switzerland

Planning and construction period: October 2016 to May 2019

Clean room operating area: 1'310m2

Photo: Roger Schuler

In order to meet increasing demand, Geistlich Pharma AG has decided to increase its production capacity. On 30 August 2019, in the presence of numerous guests, company and city leaders inaugurated building 888 after a two-year construction period and an investment of tens of millions. "The new production building makes us more flexible and prepares the company for the growing demand," says Paul Note, CEO of Geistlich Pharma.

President of the Board Dr. Andreas Geistlich, Municipal Councillor Rita Brunner-Lipp, Wolhusen, and Project Manager Thomas Waldleben at the inauguration (from left to right)

OsteoScience Foundation: Going global Osteo Science Foundation was founded in 2013 by Dr. Peter Geistlich and Geistlich Pharma to promote the regeneration of hard and soft tissue in Oral and CranioMaxillofacial Surgery in North America.

GEISTLICH NEWS 1-2020

From 2020 on, the foundation will be expanding to reach an international audience. The first global initiatives will bring regenerative education programs to like-minded Oral and CranioMaxillofacial organizations worldwide.

Website Each subsidiary maintains its own website, including information about products and treatments plus educational opportunities and the latest news. www.geistlich-pharma.com

Blog Want to dive deep into the world of oral regeneration? Find latest studies, expert interviews and cases on: www.regeneration-expert.com

Social Media Things to know about products, treatments, webinars, events, studies, jobs, best practice and live streaming of congresses â&#x20AC;&#x201C; follow us on our social media channels. Geistlich Pharma AG @geistlichpharma @geistlichpharma Geistlich Pharma

BioBrief Here you can find cases, including surgical videos from experienced clinicians. www.geistlich-biobrief.com

Webinar World Tour Geistlich Biomaterials offers free webinars held by recognized experts from all over the world. Watch past webinars or sign up for future webinars. www.geistlich-pharma.com/webinar

Illustration: Geistlich Pharma

Webshop Order your Geistlich products online. (webshop availability may vary from country to country)

NEWS

Photos: Geistlich Pharma AG

Mastergraft® (β-TCP Hydroxyapatite composite)

Geistlich Bio-Oss® (xenogenic bone substitute)

> Green: cytoskeleton stained with Actin > Red: osteoclasts marker TRAP Actifuse®® (Hydroxyapatite)

> Light blue: nuclei stained with DAPI

Taking it slowly Being in close contact to a bone substitute can trigger monocytes to differentiate into osteoclasts. Consequently, the biomaterial they grow on gets resorbed. This fluorescence-staining series shows that when growing on Geistlich Bio-Oss®

for two weeks, monocytes barely turn into osteoclasts – although ideal conditions for osteoclast differentiation were provided, e.g., with growth factors. The two synthetic bone substitutes Actifuse® and Mastergraft®, on the oth-

er hand, triggered osteoclast formation. This is in line with the clinical observation that Geistlich Bio-Oss® is degraded very slowly. Therefore, it acts as a scaffold for an extended period and the augmented volume is maintained in the long run.

New look – quality assured Have you seen that something changed? Since the beginning of 2020, each product group in the Geistlich product line has been packaged in its own specially color-coded box, making it easier for you to find the product you need when the boxes are stacked on the shelf. The quality inside has remained the same. Every 15 seconds a Geistlich product is used somewhere around the globe.1

References 1

Data on file. Geistlich Pharma AG.

ONE ICON

for one product

GEISTLICH NEWS 1-2020

ONE COLOR

for one product family

BONE SUBSTITUTE MATRIX MEMBRANE COMBI

Can Ridge Preservation prevent sinus lift? This question has been investigated in a prospective randomized clinical trial.1 The authors found that without Ridge Preservation 100 % of patients needed sinus floor elevation (72% transcrestal, 28% lateral window approach). With Ridge Preservation, 43 % of patients received implants without sinus floor elevation, only 7% needed a lateral window approach.

Can widening of keratinized tissue prevent complications?

LATEST STUDIE S

The authors of a systematic review and meta-analysis2 tried to answer this question. They concluded from the literature that surgically creating more keratinized tissue revealed a significant reduction in bleeding on probing (gingival inflammation), probing depth and plaque index, plus higher marginal bone levels.

es i g e t a r t s e v i t n on preve

Can corticotomy-assisted orthodontic therapy (CAOT) plus simultaneous bone augmentation prevent bone dehiscences?

Can soft tissue thickening prevent bone loss?

Illustrations: Geistlich Pharma

This question has been investigated in a prospective clinical trial.3 The authors concluded that thickening of thin tissues with an allogeneic membrane on average "reduces crestal bone loss from 1.81 mm to 0.34 mm after 1-year follow-up.”

A systematic review4 was conducted to answer this question. The authors concluded that “CAOT with [bone grafting] could limit crestal bone remodeling or achieved thicker hard tissue dimensions compared to non [grafted] groups. Those results supported the effectiveness of [Phenotype Modification] Therapy prior or during orthodontic treatment … limiting crestal bone remodeling and reducing dehiscence defects.”

References 1

Cha, JK, et al.: Clin Oral Implants Res. 2019; 30(6): 515-23. (40 consecutive patients, Spontaneous healing vs Ridge Preservation with Geistlich Bio-Oss® Collagen and

Geistlich Bio-Gide® (20 patients each)) 2 Thoma DS, et al.: Clin Oral Impl Res 2018; 29(Suppl. 15):32–49. (10 studies included) 3 Linkevicius T, et al.: Clin Implant Dent Rel Res 2015; 17( 3) : 497-508. (103 patients, 3 groups including patients with 1) naturally thin tissue that had not been thickened, 2) thin tissue that had been surgically thickened, 3) naturally thick tissue (34 - 35 - 34 patients)). 4 Wang CW, et al.: doi: 10.1002/JPER.19-0037. (8 studies included) NEWS

FOCUS

Prevention by Regeneration

GEISTLICH NEWS 1-2020

Illustration: Quiant

Regenerative dentistry includes several corrective measures such as rebuilding of lost bone and tissue volume. How about taking action before tissue loss takes hold? Here you will find possible solutions to save patients from invasive treatments and to save surgical time.

Immediate implant placement

“I would fill the gap in any case.” Prof. Dr. Jan Cosyn | Belgium Oral Health Sciences Department of Periodontology and Oral Implantology, Ghent University Interview conducted by Dr. Giulia Cerino

Prof. Jan Cosyn, Ghent University, has a lot of experience in the controversial field of implant placement timing. We asked him to shed some light on the question: Immediate implant placement - when is hard and soft tissue grafting indicated? Immediate implant placement is an appealing treatment for patients. Where do you see the biggest advantages? Prof. Cosyn: The time gain is the biggest advantage. First, from the perspective of the patient, because he or she presents with an urgent problem, and the tooth replacement is performed in one day — the implant and the temporary crown. Second, the practitioner performs only one surgical procedure and one prosthetic procedure. This is really time optimization.

Do you see a global trend towards more and more immediate implant placement? Prof. Cosyn: Yes, the trend is increasing everywhere. More and more practitioners are performing immediate implant placements,

because there is more knowledge about the treatment concept, and clinicians are more aware of the pitfalls. However, this does not mean that the risks of immediate implant placement are fully respected. What worries me most is that the treatment is also expanding into untrained hands.

You have recently published a systematic review showing that immediate implant placement has a higher risk for early implant loss than delayed implant placement.1 What are the reasons? Prof. Cosyn: We did several subgroup analyses on the data, because the entire study was composed of eight different clinical comparative studies. Thanks to the analysis, what has become clear is that the use of post-operative antibiotics has a relevant impact on early implant failure. Not prescribing antibiotics with immediate implants results in a 7% higher risk of failure (Fig. 1).

Is it not a general recommendation to prescribe antibiotics after treatment? Prof. Cosyn: Prescribing antibiotics is not a general recommendation in the context of any implant procedure. This has not been shown, or at least there has been no solid data to confirm it. The number needed to treat is quite high to have

Illustration: Quiant

“The use of post-operative antibiotics has a relevant impact on early implant failure.”

a benefit in the context of standard implant placement, but this is not the case when you are dealing with immediate implants. It is not possible to generalize for all procedures, but for type I implant placement the use of antibiotics should be considered, and this result is also in accordance with the systematic review of Lang et al. already published in 2012.2

Do you think that hard and soft tissue in the context of immediate implant placement, e.g., “filling the gap”, could make immediate implant placement more predictable? Prof. Cosyn: I honestly do think so. Ten years ago, there was a debate about the need for socket grafting following immediate implant placement. Now we have three randomized controlled clinical studies,3-5 and the last one by Sanz et al.5 is clearly showing a statistically significant difference in favor of socket grafting versus no grafting. So, for maintaining the integrity of the buccal bone wall, it is imperative to perform grafting. However, we also know that this grafting may not be good enough, as it only reduces buccal bone resorption, it does not eliminate it. Different case series from various research groups show that advanced midfacial recession occurs in about 20% of the cases, which is still too high despite socket grafting and a proper diagnosis. Therefore, the need to compensate opens the indication for soft tissue grafting, in most of the cases.

FOCUS

In patients in need of a single implant, will immediate as compared to delayed implant placement result in different implant survival? Immediate implant placement â&#x2030;¤ 24h post-extraction

233/473

Delayed implant placement â&#x2030;Ľ 3 months post-extraction

240/473

94.9%

98.9%

Implant survival

+ 7% Risk of failure without antibiotic prescription

FIG. 1: Summary of the systematic review and meta-analysis published by Cosyn et al.1

What are the situations in which you would advise including regenerative treatment as part of the overall treatment? Prof. Cosyn: In the anterior especially. I think there is no longer a single situation where I would leave out socket grafting. Interestingly, for the first time it has been shown by Sanz et al.5 that the additional effect of socket grafting does not depend on the size of the gap. The proportional effect is the same for either large or small gaps. So, the clinical recommendation is to fill the gap in any case.

GEISTLICH NEWS 1-2020

And how do you fill the gap? Prof. Cosyn: I add bovine bone mineral and gently push the biomaterial in an apical direction using a fine plugger. Over-compression should always be avoided. (Fig. 2)

When is soft tissue grafting indicated in the context of immediate implant placement? Prof. Cosyn: I would say frequently. But let's start with the worst scenario â&#x20AC;&#x201C; situations where there is no buccal bone. If you have this situation around a tooth, we know that root coverage procedures are pre-

dictable, but only if there is at least 1.5 mm of gingival thickness. With an implant case, the thickness must be greater, 2 mm, for the simple reason that there are no inserting supracrestal collagen fibers. There are no data on this, only common sense. Since 2 mm soft tissue thickness is only present in about 10% of the cases, starting with the worst case, this means that, in order to be completely predictable in 90% of cases, soft tissue grafting is necessary.

To fully understand this point: If there is a bone dehiscence, soft tissue augmentation becomes more relevant? Prof. Cosyn: Soft tissue grafting is nearly always indicated for an optimal and stable outcome. It becomes even more important when there is a bone dehiscence, in my opinion.

What is in your opinion the minimum amount of buccal bone needed to predictably perform immediate implant placement? Prof. Cosyn: I only perform immediate implant placement when the buccal bone wall is intact. There are some data supporting the concept with small bone dehiscences, but there are no randomized controlled clinical trials or long-term studies on cases lacking more than 50% of the buccal bone wall. Given current knowledge, I don't believe immediate implant placement can be promoted when dealing with compromised buccal bone walls.

Can there be a need for soft tissue thickening even in the presence of intact buccal bone, if the gingival thickness is less than 2 mm? Prof. Cosyn: I believe there is. In the short term, soft tissue grafting leads to less midfacial recession, as shown in the ran-

FIG. 2: A 58-year-old female patient presented with a broken upper lateral incisor. Because of an

intact buccal bone wall and the presence of bone apical and palatal to the extraction socket, type I placement was planned. B

Photos: Prof. Dr. Jan Cosyn

| A Pre-operative occlusal view of tooth 22 that needs to be replaced with an implant. | B Occlusal

view following tooth extraction and immediate implant placement in a palatal position. Note that the bone gap was filled with deproteinized bovine bone mineral (Geistlich Bio-Oss® particles). | C A thin connective tissue graft from the palate was inserted into the buccal pouch and secured with monofilament suture material. | D Occlusal view two days following surgery upon placement of the provisional crown.

domized controlled clinical trial by the Groningen group.6 What I can tell from a 10-year prospective follow-up on single immediate implants in ideal situations in Ghent, is that the soft tissues are more stable when soft tissue grafting was performed. In my view, it is all about longterm tissue stability. Clearly the current knowledge on that is scarce.

Do new techniques, such as 3D imaging, guided surgery or new implant designs, make immediate implant placement more predictable for less experienced surgeons as well? Prof. Cosyn: They can certainly help. My recommendation is to have a CBCT before tooth extraction or immediate implant placement to make an appropri-

ate diagnosis and to evaluate the risks. It is the only way to visualize the buccal bone wall, its thickness and morphology, and the thickness of the soft tissue, if lip retractors are used. Guided surgery is also important because in type I implant placement, the critical mistake is an implant placed too far buccally. This can happen easily in untrained hands, and no CTG can treat the resulting midfacial recession. So to prevent this possibility, the use of guided surgery is a plus, especially for less experienced surgeons.

Could short and narrow implants circumvent regenerative procedures? Prof. Cosyn: No, I don’t think so. Short implants are difficult to use in an alveolus, because you need proper bone anchor-

age. Usually we use longer implants, 11 to 13 mm implants are quite standard for this treatment approach. It’s more important to use small diameters, 3.5 – 3.6 mm, even in the central incisor position, to stay away from the buccal area. And don’t forget, graft the gap in any case. References 1

Cosyn J, et al.: J Clin Periodontol. 2019;46 Suppl

21:224-241 (Systematic review and meta-analysis). 2 Lang NP, et al.: Clin Oral Implants Res. 2012;23

Suppl 5:39-66 (Clinical study). 3 Sanz M, et al.: Clin Oral Implants Res.

2017;28(8):902-910 (Clinical study). 4 Chen ST, et al.: Clin Oral Implants Res.

2007;18(5):552-62 (Clinical study). 5 Mastrangelo F, et al.: Implant Dent.

2018;27(6):638-645 (Clinical study). 6 Zuiderveld EG, et al.: J Periodontol.

2018;89(8):903-914. (Clinical study).

FOCUS

Immediate implant placement

Soft tissue management to prevent complications Prof. Jeong Hye Kim | Korea Department of Periodontics Samsung Medical Center, Seoul

Implant placement in post-extraction sites for single teeth in the esthetic zone is a frequent indication. Immediate implant placement obviously has some benefits, but paying attention to the risks is crucial. Pre-operative clinical and radiographic analysis and assessment of the patient's risk profile are essential to appropriately choose between immediate, early and late implant placement.1 Immediate implant placement is attractive, as it avoids post-extraction healing periods of six months or longer. However, because of high surgical risks and more esthetic demands, immediate implant placement in the esthetic zone is a complex and challenging procedure.

Is immediate implant placement a risky procedure? Immediate implant placement into a fresh extraction socket is considered a complex surgical procedure. Implant bed preparation in the sloping anatomy of the palatal bone structure is difficult due to unstable drilling position and impaired visibility. Also, an unnoticed apical perforation of the facial bone â&#x20AC;&#x201C; if an incorrect axis of preparation is used â&#x20AC;&#x201C; could represent a

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risk. In addition, a facial malposition of the implant is a common mistake and could lead to a 20-30% risk of a mucosal recession greater than 1 mm, according to several studies.2-6

When is immediate implant placement indicated? Immediate implant placement can be used in the following clinical conditions:7 > A fully intact facial bone wall (thick>1 mm) at the extraction site. > A thick gingival biotype. > No acute infection at the extraction site. > Enough apical and palatal bone volume at the extraction site to allow implant insertion in a correct 3D position with enough primary stability.

What are the risks and benefits? In real clinical situations, ideal immediate placement conditions are seldom encountered in the anterior maxilla, where, according to various CBCT studies, a thick wall phenotype is rarely present.8,9 Also, facial soft tissue thickness is generally thin.10 In addition, the facial bone wall is often not intact, but damaged by pathological processes associated with vertical root fractures and endodontic complications. Immediate implant placement is associated with a higher frequency of mucosal recession of >1 mm, mid-facially (median 26% of sites), when compared with early implant placement.11 When

compared with thick biotypes, sites with thin tissue biotype should be regarded as having a greater risk of marginal tissue recession, particularly if the implants are positioned buccally (85.7% for thin biotype vs. 66.7% for thick biotype).4 What are the benefits? It reduces patient morbidity and the number of surgical interventions. Overall the treatment period can be shortened.

What is the effect of soft tissue management? The primary objective of implant therapy in the esthetic zone is an optimal esthetic treatment outcome with high predictability and low risk of complication.12 The stability of the facial hard and soft tissues is paramount to achieving positive esthetic outcomes in the longterm. Thoma et al. reported the effects of soft tissue augmentation procedures on peri-implant health or disease13, concluding that soft tissue grafting procedures result in more favorable peri-implant health and gain of: > Keratinized mucosa using autologous grafts, with a greater improvement of bleeding indices and higher marginal bone levels, > Mucosal thickness using autologous grafts with significantly less marginal bone loss. At esthetically sensitive sites, facial gingival biotype conversion through subep-

FIG. 1: Immediate implant placement in combination with soft tissue augmentation procedure. B

Photos: Prof. Jeong Hye Kim

| A Pre-operative clinical situation. | B CBCT showing thin buccal bone plate, periapical lesion and secondary caries. | C The connective tissue graft was

taken from the right palate and sutured with 6-0 Vicryl. | D Provisional restoration performed 2 months after healing. Gingiva around the upper right lateral incisor appeared thickened. | E Clinical situation after 7.5 years.

ithelial connective tissue grafting procedures at the time of implant placement has been proven to be successful in preserving soft tissue levels by rendering the gingival tissue more resistant to recession. 4,14,15 More stable results were observed when a treatment approach of flapless extraction and implant placement was combined with bone grafting, connective tissue grafting and attachment of an immediate provisional crown.14-16 In addition to a favorable implant success rate and peri-implant tissue response, the facial gingival level around single, immediately placed implants can also be maintained following connective tissue grafting, when proper 3D implant positioning is achieved, and bone is grafted into the implant-socket gap.17

Procedure tips and tricks, outcomes and recommendations The clinical case in Figure 1 shows a 46-year-old female patient referred for replacement of the upper right lateral incisor. The tooth was endodontically treated, but a periapical lesion and secondary caries developed. We extracted the tooth due to non-restorability and placed an immediate implant. 3D assessment using CBCT showed a very thin buccal bone plate, the periapical

lesion and secondary caries. The gingival tissue was also a thin biotype. The plan was to augment the soft tissue before extraction in order to have predictable gingival margin height and tissue thickness. Immediate implant placement was performed after extraction of the upper right lateral incisor, and the gap between the implant and the facial bone wall was filled with Geistlich Bio-Oss® and covered with Geistlich Bio-Gide®. Since the gingival margin of the left upper anterior had receded and did not match the contralateral teeth, a connective tissue graft was performed to improve esthetics. This treatment approach has been successful in the longterm; the gingival margin around the implant and on the contralateral teeth is well maintained without gingival recession, except the left canine, for about seven and a half years.

References 1

Hammerle CH, et al.: Int J Oral maxillofac Implants

2004;19 (suppl):26-28. (Consensus statement) 2 Chen ST, et al.: Clin Oral Implants Res

2007;18(5):552-562. (Clinical study) 3 De Rouck T, et al.: J Clin Periodontol 2008;35(7):649-

657. (Clinical study) 4 Evans CD, Chen ST: Clin Oral Implants Res

2008:19(1):73-80. (Review) 5 Kan JY, et al.: J Oral Maxillofac Implants

2011;26(1):179-187. (Clinical study) 6 Lindeboom JA, et al.: Oral Surg Oral Med Oral

Pathol Oral Radiol Endod 2006;101(6):705-710. (Clinical study) 7 Buser D, et al.: Periodontol 2000, 2017;73(1):84-102

(Review) 8 Braut V, et al.: Int J Periodontics Restorative Dent

2011;31(2):125-31. (Clinical study) 9 Januario AL, et al.: Clin Oral Implants Res

2011;22(10):1168-1171. (Clinical study) 10 Chen ST, Darby I: Clin Oral Implants Res

2017;28(8):931-937. (Clinical study) 11 Chen ST, Buser D: Int J Oral Maxillofac Implants

2014;29 (Suppl):186-215. (Systematic review) 12 Buser D, Chen ST: Chicago: Quintessence Publishing

Co., Inc., 2009:153-194. (Book chapter) 13 Thoma D, et al.: Clinical oral Implants Research

2018;29 (Suppl)15:32-49. (Systematic review and meta-analysis) 14 Chung S, et al.: J Oral Implantol 2011;37(5):559-569.

(Clinical study) 15 Bianchi AE, Sanfilippo F: Clin Oral Implants Res

2004;15(3):269–277. (Clinical study) 16 Kan JY, et al.: J Oral Maxillofac Surg 2009; 67(11

Suppl):40–48. (Clinical study) 17 Tsuda H, et al.: Int J Oral Maxillofac Implants

2011;26(2):427–436. (Clinical study)

Soft tissue management for large bone augmentation

One surgery – even for more extensive defects Dr. Alfonso Rao | United Kingdom Private practice, Bristol Delta Dental Academy, Bristol

allowing the conformation of an ideal Soft tissue augmentation The stability of hard and 3 strategies soft tissues plays a pivotal profile with the use of a pontic. Periodontal or peri-implant plastic surrole in oral rehabilitation gery procedures have been successfully The significance of soft tissue success – both functionperformed to restore the shape and diaugmentation Clinical evidence shows that soft tis- mensions of soft and hard alveolar tissues ally and esthetically. This sue augmentations contribute to more before, during or after implant placement. makes the achievement than 40% of the final soft tissue vol- These procedures include ridge augmenof optimal results more ume at implant sites, 4 result in supe- tation with soft tissue, where autologous challenging and leads to a rior esthetics,5 higher papilla scores6, 7 subepithelial connective tissue grafts are greater consideration of all and less mucosal recession.6-8 In addi- considered the gold standard.10, 11 the contributing factors.1,2 tion, initial gingival tissue thickness at The collapse of the alveolar ridge in an edentulous area in patients who will undergo oral rehabilitation impedes the harmonic relationship between pontic and ridge. To correct this type of defect there are several surgical techniques that aim to achieve soft tissue augmentation,

the crest might be considered important for marginal bone stability around implants. Linkevicius et al. were indeed able to demonstrate that, if tissue thickness is 2 mm or less, crestal bone loss of up to 1.45 mm may occur, despite a supracrestal position of the implant-abutment interface.9

Nevertheless, the use of autologous tissues is associated with disadvantages. Typically the quantity and quality of tissue that can be harvested vary depending on the shape of the palatal vault and the patient’s sex and age,12 along with anatomical factors, such as a thick alveolar process, exostosis, and the palatine

FIG. 1: Soft tissue augmentation procedure using Geistlich Fibro-Gide® in a patient presenting maxillary lateral incisor agenesis. B

| A Pre-operative situation after removal of the old adhesive bridge. | B After elevation of a partial thickness flap, Geistlich Fibro-Gide® is inserted in the

recipient area using a pouch technique. | C Primary closure of the flap with no exposure of the matrix. | D, E Clinical situation 3 months after fixation of the bridge. Restorative work performed by Dr. Richard Field, Technician: Stephen Lusty.

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Photos: Dr. Alfonso Rao

The Expert's Recommendations WHY? nerves and blood vessels.14 In addition, because of the harvesting procedure, which leads to a prolonged healing time at the donor site, patients often complain about pain and numbness for several weeks after surgery.14, 15 Therefore, to reduce the morbidity and overcome the disadvantages of autologous grafts, soft tissue substitutes represent a great advantage, particularly because bigger areas can be treated in a single surgery.16-18

Our alternative experience In recent clinical studies comparing a xenogeneic, volume-stable collagen matrix (Geistlich Fibro-Gide®) to autologous connective tissue grafts at implant sites, at one year follow up the matrix showed no significant differences in terms of quality and quantity of the stable, augmented soft tissue. In addition, there was no need for a second surgical site, and patients benefited from a lower pain perception.7,11,19 Similarly, in esthetic sites, Chappuis et al. demonstrated that using the matrix for soft tissue augmentation simultaneously with Guided Bone Regeneration and implant placement is safe and feasible.20

ply do not have the quantity or quality necessary for graft harvest. So, now there is a valuable alternative to the connective tissue graft, making the surgeon’s life easier. References 1

D'Addona A, et al.: Int J Biomater. 2012; 531202.

(Review) 2 Maiorana C, et al.: Case Rep Dent. 2016; 8468763.

(Clinical study) 3 Zuniga Araya ME, et al.: Open Journal of

Stomatology. 2018; 8(6):189-19. (Clinical study) 4 Schneider D et al.: Clin Oral Implants Res. 2011;

WHEN? Geistlich Fibro-Gide® can be used at the time of implant placement, or alternatively it can be placed during implant uncovering. It can also be used for conventional prosthetic rehabilitation.

22(1):28-37. (Clinical study) 5 Thoma DS, et al.: Clin Oral Implants Res. 2018; 29

Suppl 15:32-49. (Systematic review and meta-analysis) 6 Thoma DS, et al.: J Clin Periodontol 2017; 44: 185-

194. (Pre-clinical study) 7 Thoma DS, et al.: J Clin Periodontol 2016;

43(10):874-85. (Clinical study) 8 Moraschini V, et al.: Acta Odontol Scand.

2019;77(6):457-467. (Review) 9 Linkevicius T, et al.: Clin Implant Dent Relat Res.

2015; 17(6):1228-36. (Clinical study) 10 Nascimiento de Melo LG, et al.: Perio. 2006; 3(1)

:49-56. (Clinical study) 11 Zeltner M, et al.: J Clin Periodontol. 2017;

44(4):446-453. (Clinical study) 12 Benninger B, et al.: J Oral Maxillofac Surg. 2012;

70(1):149-53. (Clinical study) 13 Yu SK, et al.: J Clin Periodontol. 2014; 41(9):908-

13. (Clinical study) 14 Zucchelli G, et al.: J Clin Periodontol. 2010;

37(8):728-38. (Clinical study) 15 Cairo F, et al.: J Clin Periodontol. 2012; 39(8):760-

In our practice we have been using Geistlich Fibro-Gide® to treat mild or moderate ridge defects, for which soft tissue augmentation is generally enough to repair the deformity. The aim of the clinical case in Figure 1 was to increase the thickness of the soft tissue at the pontic site. Visibly the matrix was secured in the desired area and helped to achieve a good outcome. Although long-term studies are still required, reduced morbidity, unlimited quantity and standardized quality make Geistlich Fibro-Gide® a good option and open doors for patients who fear autologous graft harvesting procedures or sim-

Thickening of soft tissue is beneficial to improve the esthetics of restorations but even more important for marginal bone stability around implants.

8. (Clinical study) 16 Vignoletti F, et al.: J Clin Periodontol. 2014; 41

Suppl 15:S23-35. (Review) 17 Zuhr O, et al.: J Clin Periodontol. 2014; 41 Suppl

15:S123-42. (Review)

HOW? It is important to trim Geistlich Fibro-Gide® to the desired size to fit into the defect. The device will transiently gain approximately 25% in volume upon wetting, so consider the swelling when determining the final dimensions. The mobilization of a generous flap is key to managing particularly large defects and to assuring full coverage of the matrix. To achieve predictable results, Geistlich Fibro-Gide® should be submerged without exposure. Close to wound margins, reducing the thickness of the matrix by 2-3 mm might be beneficial to avoid dehiscences during the healing phase.

18 Gargallo-Albiol J, et al.: Int J Oral Maxillofac Im-

plants. 2019;34(5):1059–1069. (Systematic review and meta-analysis) 19 Huber S, et al.: J Clin Periodontol. 2018; 45(4):504-

512. (Clinical study) 20 Chappuis V, et al.: Int J Periodontics Restorative

Dent. 2018; 38:575-582. (Clinical study)

WHAT IF? A dehiscence and exposure of the matrix can happen. Nevertheless, in our experience no infections have been detected and no premature removals of the matrix have been necessary. Suturing the device to the underlying soft tissue is advisable to secure the matrix, reducing the risk of dislocation.

Orthodontics’ effect on periodontal phenotype

“Periodontists and Orthodontists should together develop protective strategies” Ass. Prof. Dr. Hector Rios | USA Private Practice in Holland, Michigan Department of Periodontics and Oral Medicine School of Dentistry, University of Michigan Interview conducted by Verena Vermeulen

Orthodontic tooth movement can increase the incidence of bony dehiscence and gingival recession. Dr. Hector Rios, USA, investigates how this effect can be minimized. We talked to him about healthy conditions, short treatment time and long-term success.

tooth movement and the local anatomy—these effects can be physiologic, or they can increase the vulnerability of the surrounding tissue.1

Dr. Rios, what is the challenge for the bone when teeth are moved for orthodontic treatment?

Dr. Rios: 20-35 percent of patients develop gingival recessions after orthodontic treatment.1 The incidence of bony dehiscence and gingival recession is higher in teeth surrounded by thin periodontal phenotypes.2 Lower incisors and upper or lower canines are especially prone to soft tissue breakdown. The problems mostly start years after the treatment.1 So, for the patient the cause is not apparent.

Dr. Rios: Orthodontic tooth movement has two different effects on bone. On the compression side, we see a catabolic effect, leading to bone resorption. And on the tension side, new bone is formed, so we see an anabolic effect. Depending on several factors—such as the magnitude of the force, direction of

Does tooth movement influence soft tissue as well? Dr. Rios: Yes. Often, gingival recessions are the more tangible signs for the underlying cause, which is bone loss.

Do problems often occur? If so, which and when?

“20-35 percent of patients develop gingival recessions after orthodontic treatment.”

Surgically accelerated orthodontics is a relatively new treatment option. What does it mean? Dr. Rios: It’s not really a new treatment option, but it is definitely more in demand now. Surgically accelerated orthodontics includes dentoalveolar bone decortication. This accelerates tooth movement in a certain time frame after an injury.3 There are many different treatments that fall under this category. The decortication can, for example, be combined with bone and/or soft tissue augmentation, and it can be done in a minimally-invasive way or with flap elevation.

What is the effect of the decortication? Dr. Rios: On the one hand, it is obviously a mechanical effect. The bone is slightly damaged and a tooth can be moved more easily in this damaged zone. But there is also a biochemical effect. Damaging the cortical layer induces the release of pro-inflammatory cytokines such as interleukin 1-beta or interleukin receptor-antagonist. These molecules cause a transient osteopenia. During this “window of opportunity” tooth movement is accelerated.3

What is the advantage compared to conventional orthodontic treatment? Dr. Rios: Most adult patients undergoing orthodontic treatment want a quick solution. And with this option, treatment time

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FIG. 1: Surgically accelerated orthodontics and Phenotype Modification Therapy.

Illustration: Quiant

FIG. 1: | A Pre-operative clinical situation of a patient under orthodontic treatment. | B Vertical and interradicular gingival incisions are performed on

the buccal aspect of the mandibular arch, starting 2-3 mm below the interdental papilla with enough depth to allow the piezotome to reach alveolar bone. | C A tunnel is created, and the collagen matrix is pulled into the tunnel. | D The sutures for the collagen matrix are located in the inter-proximal / interradicular space and engage at least half of the material.

can be reduced significantly, by about 50 percent.4 Patients also report less pain.5 And the combination of dentoalveolar bone decortication and bone augmentation with a bone substituteâ&#x20AC;&#x201D;known as surgically facilitated orthodontic treatment (SFOT) or periodontally accelerated osteogenic orthodontics (PAOO)â&#x20AC;&#x201D;can create additional space for tooth movement and maintain the thickness of the buccal bone after mandibular decompen-

sation. This can be highly beneficial for the overall treatment plan and avoid unnecessary tooth extractions. Finally, surgically accelerated orthodontics should reduce the level of orthodontic relapse.

So, the risk of iatrogenic sequelae is lower compared to non-surgical orthodontic treatment? Dr. Rios: Yes, just recently a Best Evidence Review from the American Acad-

emy of Periodontology concluded that SFOT enhances post-orthodontic stability of the mandibular anterior teeth3. But long-term tissue loss after orthodontic treatment has not yet been fully investigated. What we can say today is that orthodontic treatment in general might add to the susceptibility of the tissue and that understanding both treatments better will make them both safer.

“It requires a change of mindset from correcting defects to protecting tissues.”

You did a study on the combination of SFOT and phenotype modification therapy. What did you want to find out? Dr. Rios: The study included 40 patients in need of orthodontic treatment.5 They were divided into four groups. First: control group with conventional orthodontics, second: orthodontics plus piezocision, third: orthodontics plus piezocision plus collagen matrix and fourth: orthodontics plus collagen matrix without piezocision. So, on the one hand, we compared conventional orthodontic treatment with SFOT. On the other hand, we investigated whether combining decortication with a collagen matrix on the periosteum has a positive effect. (Fig. 1)

How so? Dr. Rios: Our idea is that the spongy layer of the collagen matrix serves as a reservoir for the pro-inflammatory cytokines that are produced in the bone because of the corticotomy. Collagen is known to have this capability. By storing the cytokines and releasing them over a longer period, Geistlich Mucograft® may extend the window of opportunity in which tooth movement is facilitated. On the other hand, the denser layer of the

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matrix should protect the buccal perio dontium from invasion of soft tissue fibroblasts. This gives fibroblasts from the periodontium the space to become bone forming cells and thereby support new bone formation. It’s beneficial to separate these two tissues for a while so that the new osteoblasts are not suppressed by faster growing soft tissue fibroblasts.

Did you see this effect? Dr. Rios: We could see a positive effect on vestibular bone height and gingival thickness and certainly a positive effect on treatment time.5 The latter was in the collagen matrix group even shorter than in the SFOT group without collagen matrix. We would expect further improvements in buccal bone thickness in the two collagen-matrix groups over time. But we don’t have the results yet.

What does this mean for clinical practice? Do you advise protecting the bone with a collagen matrix in the context of orthodontic treatment? Dr. Rios: Absolutely. And I think it is important that periodontists and orthodontists together develop protective strategies to ensure a healthy periodontal phenotype in the long run. This includes

standard treatment goals to minimize an increase in tissue vulnerability through orthodontic treatment. It also requires a change of mindset from correcting defects to protecting tissues.

References 1

Renkema AM, et al.: Am J Orthod Dentofacial Or-

thop. 2013 Feb;143(2):206-12. (Clinical study) 2 Jepsen S, et al.: J Periodontol. 2018 Jun;89 Suppl

1:S237-S248. (Consensus report) 3 Wang CW, et al.: J Periodontol 2019 Oct 31. [Epub

ahead of print] (Best Evidence Review) 4 Zimmo N, et al.: J Int Acad Periodontol 2018; 20: 153-

62. (Systematic Review and Meta-Analysis) 5 Unpublished data

Ridge Preservation

Preventing alveolar bone resorption: Possibilities and limitations Drs. Jun-Yu Shi & Hong-Chang Lai | China Department of Oral Implantology Shanghai Ninth Peopleâ&#x20AC;&#x2122;s Hospital Shanghai JiaoTong University

Osseointegration is no longer the only criteria for implant success. Sufficient peri-implant bone volume also plays a decisive role in maintaining long-term stability and esthetics. Thus, prevention of alveolar bone resorption has become a lively topic. Spontaneous socket healing vs. immediate implant placement

FIG. 1: A case for flapless immediate implant placement: stable mid-facial mucosal level, buccal

bone plate resorption 21%. A

The protocol for placing implants immediately in fresh sockets was introduced in 1978.2 Several studies have demonstrated that the timing of implant placement does not influence socket remodeling. Similar alveolar width reduction (up to 56%) was reported following immediate implant placement (IIP).3,4 In these studies, all implants were placed in the center of the socket without any bone grafting procedures. In other words, IIP alone does not interfere with sequential socket healing but also does not prevent ridge resorption.

Photos: Drs. Jun-Yu Shi & Hong-Chang Lai

Alveolar ridge dimensional changes following spontaneous socket healing have been investigated in a series of clinical studies. In the first year following tooth extraction, alveolar ridge resorption results in 2.6-4.5 mm loss of width (about 50%) and 0.4-3.9 mm loss of height.1

| A Before surgery. | B At crown delivery. | C 1-year examination. Radiographic assessment.

Alveolar ridge preservation vs. immediate implant placement with gap grafting

Illustration: Quaint/Geistlich Pharma AG, based on Avila-Ortiz et al.6

Alveolar ridge preservation (ARP) is one of the best documented technologies for preventing alveolar bone resorption and compensating for socket remodeling.5 A recent meta-analysis reported that ARP, as compared to spontaneous socket healing, can prevent 1.99 mm horizontal, 1.72 mm vertical mid-buccal, and 1.16 mm vertical mid-lingual bone resorption.6 Another study has demonstrated that ARP can prevent about 15-25% horizontal bone resorption compared with spontaneous socket healing and allows implant placement into the prosthetically driven position without further bone augmentation procedures in 90.1% of the ARP sites but only 79.2% of the control sites.7

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We have already demonstrated that IIP alone can’t prevent resorption of the alveolar ridge; however, results can be totally different when guided bone regeneration (GBR) procedures are used. A previous prospective study reported that Geistlich Bio-Oss® can significantly reduce horizontal resorption of buccal bone following IIP (Geistlich Bio-Oss ® group: 15.8±16.9% resorption, Geistlich Bio-Oss ® + Geistlich Bio-Gide® group: 20.0±16.9% resorption, control group: 48.3±9.5% resorption).4 A recent review also concluded that the original shape of the ridge can be maintained by placing implants palatally and filling gaps with grafting materials.8 In our center IIP is a routine treatment option for replacement of single teeth in the anterior region with

limited buccal bone dehiscences (less than 20%). The resorption rate of buccal bone ranges from 18% to 25%, and advanced recession of mid-facial mucosal is rare (<5%). (Fig.1) The resorption rate of buccal bone (1520%) following IIP combined with GBR is similar to ARP. Theoretically, healing processes of ARP and IIP combined with GBR are similar, since the implant itself will not interfere with socket remodeling. So it makes sense that IIP combined with GBR procedures can achieve similar outcomes preventing alveolar bone resorption, as long as implants are placed in an optimal 3D position, which is a challenging surgical procedure. It will be interesting to examine in experimental animal models whether sockets with ARP and

â&#x20AC;&#x153;Compared with early implant placement, several studies have concluded that IIP increases esthetic risk.â&#x20AC;? IIP combined with GBR show any differences in sequential healing .

Limitations for immediate implant placement It must be noted that, compared with early implant placement, several studies have concluded that IIP increases es-

thetic risk.9,10 Although some clinicians advocate a flapless procedure, palatally-positioned implants, narrow-diameter implants, gap filling with grafting materials, augmentation of soft tissue at implant surgery and socket shield procedures when implants are placed in fresh sockets,11 excellent esthetic outcomes can only be achieved in strictly-selected cases.12 Another important concern is the slightly higher early implant failure for IIP compared with delayed implant placement (5.1% vs. 1.1%),13 especially when prophylactic antibiotics are not used.

bone regeneration procedures can reduce alveolar ridge resorption rates (1525%). However, strict indications and a potentially higher early failure rate must be taken into consideration before making clinical decisions. References 1

Van der Weijden F, et al.: J Clin Periodontol

2009;36(12):1048-58. (Systematic review) 2 Schulte W, et al.: Dtsch Zahnarztl Z 1978;33(5):348-

59. (Clinical study) 3 Botticelli D, et al.: J Clin Periodontol

2004;31(10):820-8. (Clinical study) 4 Chen ST, et al.: Clin Oral Implants Res

2007;18(5):552-62. (Clinical study) 5 Jung RE, et al.: Periodontol 2000 2018;77(1):165-175.

In conclusion, compared with spontaneous socket healing, both alveolar ridge preservation and immediate implant placement combined with guided

(Review) 6 Avila-Ortiz G, et al.: J Clin Periodontol 2019;46 Suppl

21:195-223. (Systematic review and meta-analysis) 7 Willenbacher M, et al.: Clin Implant Dent Relat Res

2016;18(6):1248-1268. (Meta-analysis) 8 Clementini M, et al.: J Clin Periodontol

2015;42(7):666-77. (Systematic review and meta-analysis) 9 Araujo MG, et al.: Periodontol 2000 2019;79(1):168-

177. (Review)

Ridge Preservation prevents:

10 Buser D, et al.: Periodontol 2000 2017;73(1):84-102.

(Review) 11 Kan JYK, et al.: Periodontol 2000 2018;77(1):197-212.

(Review) 12 Vignoletti F, Sanz M: Periodontol 2000

mm mm horizontal bone resorption

2014;66(1):132-52. (Review) 13 Cosyn J, et al.: J Clin Periodontol 2019;46 Suppl

21:224-241. (Systematic review and meta-analysis)

mm vertical mid-lingual bone resorption

mm mm vertical mid-buccal bone resorption

Phenotype Modification Therapy

“It is about helping patients before problems occur” Interview with Prof. Kenneth Kornman and Dr. Richard Kao conducted by Verena Vermeulen

In August 2019 the American Academy of Periodontology (AAP) organized a Best Evidence Consensus (BEC) about Phenotype Modification Therapy. What were its findings? We discussed with Prof. Kenneth Kornman and AAP president Dr. Richard Kao. Phenotype Modification Therapy (PhMT) was the overall topic of the Best Evidence Consensus 2019. What does the term “phenotype” mean?

And “phenotype modification” then means to change a thin phenotype into a thicker one? Dr. Kao: Yes. Because in case of implant placement or orthodontic treatment, patients with a thin phenotype, for example thin buccal bone or thin soft tissues, are more prone to developing gingival recessions. These patients will benefit if we change the conditions and modify their phenotype to achieve sustainable results.

Prof. Kornman: I agree. Phenotype Modification Therapy is about recognizing patients’ individual situations and helping them before problems occur. We see this as an important area to focus on for the future. The starting point for the BEC is to determine where there is a true clinical need. If there is a need, how are clinicians managing those needs today? The BEC process produces summaries of evidence and clinical experiences that are currently available to help increase confidence in certain specific clinical applications. We are certainly broadening the ability of our clinicians to help more patients live well longer.

You discussed several indications, where PhMT could benefit patients. Which indications were these? Dr. Kao: We focused on the tissues around teeth1, around implants2, in the context of

Photos: Daniele Micieli

Dr. Kao: Phenotype means what you see, but it’s also based on genetic fac-

tors. Asians for example have shorter roots and a different crown-to-root ratio. Their tissues are overall thinner compared to Caucasians, and they have more bone dehiscenses. They have different phenotypes. Minor gum disease, bone loss or attachment loss may have a greater impact in these patients.

Discussing with Dr. Richard Kao (left) and Prof. Kenneth Kornman at the AAP’s 2019 Annual Meeting in Chicago.

GEISTLICH NEWS 1-2020

orthodontic treatment3. The main questions were: When is it beneficial to thicken soft tissues, to create more keratinized tissue or to thicken the bone? For example, in the context of implant placement: Is there a benefit in thickening the soft tissue in addition to augmenting the bone?

One reason could be that the peri-implant mucosa is more vulnerable than the gingiva around a tooth. Is this the case? Dr. Kao: Yes, the tissues around an implant are more susceptible to tissue damage or tissue loss than around teeth. There are no Sharpeyâ&#x20AC;&#x2122;s fibers and cementum. The connective tissue contains fewer blood vessels and fibroblasts. Literature shows that the bony housing in the front area is very thin in most patients.1 With time and age, this is one of the most predictable areas for gum recession, even around teeth. With an implant the risk is even higher, independent of how well an implant has been placed. So, there are good reasons to better prepare the ridge before placing an implant.

What did the consensus group conclude with regards to soft tissue around implants? Dr. Kao: Dr. Guo-Hao Lin and colleagues prepared a meta-analysis on the significance of surgically modifying soft tissue phenotype around fixed dental prostheses. One of the conclusions was that increasing soft tissue thickness and the amount of keratinized tissue may be beneficial for providing more favorable peri-implant tissue health.1 And in the consensus statement it is stated that phenotype modification

Bridging the gap between evidence and opinion Prof. Kornman explains the main idea behind the Best Evidence Consensus concept.

Prof. Kornman, you are called the inventor of the Best Evidence Consensus format. How did the idea start? Prof. Kornman: For several years, the Journal of Periodontology has been receiving large numbers of well-constructed systematic reviews on valuable clinical topics. But given the limited evidence that is often available, the authors rarely concluded with what would be useful for clinicians to incorporate into specific types of cases now.

They typically end with â&#x20AC;&#x153;further research is needed.â&#x20AC;? Prof. Kornman: Exactly. So, at some point, we stopped considering for publication systematic reviews that were initiated by the authors themselves. We spent years discussing how we could provide perspective on clinical application of certain technologies that lots of people are using, although there may not be as much published data as we would like. This is when the idea for the Best Evidence Consensus started.

In the consensus meeting, the existing evidence is combined with the clinical expertise of the consensus group. How does this combination work? Prof. Kornman: We came up with a very formal and effective process to fill the gap between evidence and opinion. An important factor is that we are always very clear on what the sub-questions are to the primary questions. Then we commission extensive systematic reviews on the sub-questions, and that exercise often provides more knowledge that moves us closer to broader clinical applications than many were aware. During the meeting itself, the results are discussed by knowledgeable clinicians who have used the technology, have opinions about it and can talk about their experience. We want to know where they see specific opportunities and weaknesses and how that fits with the existing evidence. The results of these intense discussions are put together in a consensus report that allows us to communicate with interested clinicians around the world.

OUTSIDE THE BOX

therapy around fixed dental prostheses can improve esthetics—e.g., create a more harmonious soft tissue architecture and decrease show-through of restorations, abutments and implants—and that it also improves comfort, hygiene and maintenance.4

The third topic was phenotype modification in the context of orthodontics. Why is there a need to modify? Dr. Kao: Literature shows that 20-35% of patients develop facial gingival recession two to five years after orthodontic treatment.3 This is dependent on the phenotype, but also on the cranial and facial arrangement. If bone and soft tissue are thin, recessions will develop very soon after orthodontic treatment. If the bone is thin, but the tissue is thick, recessions will be visible only years later.

How is phenotype modification done in this context? Which method was discussed in the systematic review and during the meeting? Dr. Kao: For most orthodontic treatments, there is usually adequate volume of bone and soft tissue. Where there are concerns for gingival recession, clinicians can proactively “thicken” the gingiva with grafting procedures. When the orthodontic treatment planning and analysis indicate the

Dr. Kao and two of his colleagues have together treated 1,500 patients with an SFOT approach. “The three of us came out with the same strategy for about 90 percent of the treatment. On the other 10% we disagreed.”

required orthodontic movements would be beyond the bony and soft tissue envelop, surgically facilitated orthodontic therapy, SFOT, periodontally accelerated osteogenic orthodontics, PAOO, and corticotomy-assisted orthodontic therapy, CAOT , are the most common procedures. They involve corticotomy surgery and decortication of the dentoalveolar complex with or without particulate bone grafting. The goal is to enable faster tooth movement and widen the jaw bone. Chin-Wei Wang et al. focused on these techniques in their meta-analysis on the question: Is periodontal phenotypic modification

therapy beneficial for patients receiving orthodontic treatment?3

What do they conclude from the literature? Dr. Kao: Treatments such as SFOT, PAOO and CAOT may shorten treatment time and accelerate tooth movement. But they also supported an increased scope of tooth movement. They achieved thicker hard tissue dimensions and reduced dehiscence defects. And finally, they enhanced post-orthodontic stability of the mandibular anterior teeth—a typical area with very thin bony envelops—and had a potential

Definition box Phenotype is the appearance of an organ based on genetic traits and environmental factors. With regards to the oral cavity, the phenotype includes, for example, bone thickness and soft tissue quality and thickness.

GEISTLICH NEWS 1-2020

Phenotype Modification Therapy refers to surgical intervention involving soft and/or hard tissue augmentation/modification to convert phenotype from thin to thick in both natural dentition and dental implants (or from thick to even thicker).

Illustration: Quiant

FIG. 1: These three topics were discussed at the AAP Best Evidence Consensus 2019.

Does the modification of gingiva

What is the effect of surgically modifying

Is periodontal phenotype modification

from a thin to a thick phenotype maintain

soft tissue phenotype around fixed

therapy beneficial for patients receiving

periodontal health?

dental prosthesis?

orthodontic treatment?

to reduce the level of orthodontic relapse over a 10-year follow-up period.4

tion Therapy should be pursued prior to orthodontic treatment in patients with thin phenotype when the necessary orthodontic tooth movement would compromise the bony housing.4 And there will be situations in which both bone and soft tissue augmentation are necessary.

ing a paper on how this interdisciplinary work between orthodontists, periodontists and possibly also oral surgeons can be organized most efficiently.

Few studies have been published in this field so far. What was the experience in the consensus group? Dr. Kao: Three of us have treated a total of 1,500 cases with these techniques. So, we shared our documentation and notes. What are the materials we used? What was the sequence of events? What were the watch-out points, the diagnostic tools we needed? What have we tried that did not work? In about 90 percent of content the three of us came up with the same strategy. On the other 10% we disagreed. But thatâ&#x20AC;&#x2122;s okay. It shows us where there is some clinical flexibility.

Did the consensus group conclude that PhMT is beneficial in the context of orthodontic treatment? Dr. Kao: Yes, the consensus group concluded that Phenotype Modifica-

Are orthodontists aware of these developments? Dr. Kao: Yes, orthodontists nowadays have computer modelling systems based on CBCT data, where they plan how much they are going to move the teeth and what this will mean for the bony housing. So, we can together plan how to protect the envelope and prevent longterm complications with an interceptive thickening of the gum and bone.4

Is this interdisciplinary work also a source of error? Dr. Kao: Collaboration is certainly beneficial and the way to go for the future. Dr. George Mandelaris is currently prepar-

Is there also a broader collaboration planned between periodontal and orthodontic societies? Dr. Kao: The AAP and the American Orthodontic Association are both very interested in collaboration. We have a joint conference set for 2021, and we are currently thinking about teaming up for an e-learning platform. This will definitely help to disseminate this kind of information to a broader population.

References 1

Kim DM, et al.: J Periodontol 2019 Nov 6. [Epub

ahead of print] (Review) 2 Lin GH, et al.: J Periodontol 2019 Oct 31. [Epub

ahead of print] (Review) 3 Wang CW, et al.: J Periodontol 2019 Oct 31. [Epub

ahead of print]. (Review) 4 Kao, R. et al.: J Periodontol 2020 Jan 13. [Epub

ahead of print]. (Consensus)

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Points of view

Five questions for five experts We asked five research, award winning clinicians to answer five questions about research. Results: 25 professional and personal insights. And a generation comparison!

Prof. Giovan Paolo Pini Prato | Italy

Gabriel Leonardo Magrin | Brazil

University of Florence

Medical University of Vienna â&#x20AC;&#x201C; Federal University of Santa Catarina

What research award makes you the proudest?

The EFP Distinguished Scientist Award 2019. It is a recognition of my long career as a researcher and clinical practitioner.

The 2019 European Prize for Basic Research in Implant Dentistry from the EAO.

What do you think was the winning factor? The meticulous gathering of all short- and long-term data. They are essential!

What advice would you give to those who start doing research? When planning a clinical or basic research project, ask yourself just one question, and answer with a precise protocol.

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What do you think was the winning factor? The collaboration between the research groups in Austria and Brazil. The mentorship I had in Vienna and the motivation of being involved in an innovative study led to the goal.

What advice would you give to those who start doing research? I think that being proactive and working in synergy with colleagues are good starting points!

Have you ever stopped a research project?

I recall just two projects that could not be conducted due to high costs and difficulties in finding financial support.

So far only projects in the concept phase. I'm learning that planning activities and sharing responsibilities help manage the workload.

How much time do you spend doing research vs. treating patients?

I believe more time should be devoted to research. In my case, the ratio is 4:2.

I am enrolled in a full-time PhD program involving both basic and clinical research. So, I would say 50:50.

Dr. Jennifer Chang | USA

Simone Cortellini | Italy

Prof. Ki-Tae Koo | Korea

University of Texas

Catholic University of Leuven

Seoul National University

What research award makes you the proudest?

The first prize in Clinical Research for the 2018 National Osteology Symposium USA.

The 2018 European Prize for Clinical Innovations in Implant Dentistry from the EAO.

The first prize in Clinical Research at the 2019 International Osteology Symposium.

What do you think was the winning factor?

Probably the fact that our results can help clinicians better understand how PRF enhances tissue regeneration.

The award is based on both the proÂ ject and the quality of the presentation. It was a RCT comparing L-PRF block vs xenograft alone in lateral sinus lift procedure. As for the quality, I admit that having a good teacher at home helps! (Pierpaolo Cortellini).

The depth and quality of the data. Also, I think the topic and the fact it was an RCT helped a lot.

What advice would you give to those who start doing research? Find a topic you love and the people with whom you are comfortable working. Then the entire research process can be very enjoyable.

Have you ever stopped a research project? Not yet! And I have a positive attitude... If you donâ&#x20AC;&#x2122;t give up, the result can be even better than you could imagine.

How much time do you spend doing research vs. treating patients? At school I spend half of my time treating patients. The rest is dedicated to research.

What advice would you give to those who start doing research? Don't do research alone; a well performed research is the result of a team effort. And if you do research, do it at the top level to improve your scientific and clinical knowledge!

Have you ever stopped a research project?

What advice would you give to those who start doing research? Be patient and enjoy. Also, allow time to get to the expert level.

Have you ever stopped a research project? Not really! I have been taught to accept biology objectively. Even if your data are not aligned with your goals, you can still achieve meaningful results.

Not yet, but it is true that I am still young and there will be time!

How much time do you spend doing research vs. treating patients?

Being honest, I do receive a good salary from the University, so I have to contribute accordingly. I would say 40:60.

I work full-time in academia, doing my PhD. I would roughly say 40:60.

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Histology

Yxoss CBR® – a closer look at bone formation Prof. Claudia Dellavia | Italy Department of Biomedical, Surgical and Dental Sciences University of Milan

Photos: Claudia Dellavia

FIG. 1: Toluidine Blue and Pyronin Yellow staining of one representative sample. Osteoid and cells (blue), tissue in phase of mineralization (purple), Geistlich Bio-Oss® and highly mineralized bone (brown). | A Overview. | B-C 200X. | D-E 400X.

A 50:50 mix of autologous bone and Geistlich Bio-Oss® granules was grafted on human atrophic alveolar crests, stabilized with Yxoss CBR®, fixed with titanium micro-screws and covered with Geistlich Bio-Gide®. After nine months, histological anal-

GEISTLICH NEWS 1-2020

ysis showed highly mineralized and well-organized new bone (A) with dense osteoid matrix, mainly located in the coronal portion (B). Geistlich Bio-Oss® remnants were perfectly osseointegrated and surrounded by marrow spaces populated by numerous

blood vessels without inflammatory infiltrates (C). Many fronts of bone remodelling rich in osteoblasts depositing new matrix (D) and osteoclasts in a resorption lacuna (E) confirmed the vitality of the regenerated bone.

New beginning for wound healing? Healing problem in diabetes

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Dr. Klaus Duffner

Approximately one in three diabetes patients develops a foot wound over the course of his life.1 Why doesn't tissue regeneration work anymore in such cases? And can better understanding bring about new therapies? Natural healing of a wound is a highly complex and at the same time well-organized biological process. It operates in four phases: hemostasis, inflammation, proliferation and remodeling.

From emergency care to regeneration Following an injury, thrombocytes are activated unleashing the coagulation cascade in the area of the bleeding wound. Both form part of primary “emergency care”, i.e., bleeding must be stopped. From this first step there very swiftly follows an inflammatory phase in which neutrophil granulocytes, macrophages and T-lymphocytes are sent to the wound on the very first day. They are tasked with removing bacteria and damaged tissue.2,3 This inflammation reaction is fueled by various cytokines. It moves seamlessly into the subsequent proliferative phase in which new tissue, new blood vessels and a new extracellular matrix fill up the wound area. In this phase various growth factors and cytokines are released to support the process of rebuilding. Under the influence of epidermal or keratinocyte growth factors the migration of fibroblasts and construction of an extracellular matrix are promoted.3 Matrix metalloproteinases (MMP) are also integrated into different stages of wound healing. They stimulate cell migration and the restoration of the

GEISTLICH NEWS 1-2020

epithelium. Towards the end of the healing process there is an influx of keratinocytes from the edges of the wound. The strong circulation of blood decreases, and a new epithelium forms.

sites.3 Lastly, stem cells, which after an injury normally differentiate into different cells in the epidermis also exhibit functional disorders, especially in the wounds of the elderly.

The core problem – Inflammation

Bacteria create their own environment

“These processes are extremely complex, as a great many factors also play a part,” says Prof. Dr. David Armstrong of the University of Southern California/Los Angeles.4 At least as complex are events revolving around chronic diabetic wounds, in which the described natural wound healing processes are disrupted. “This is like a sluggish computer in which various programs are active in the background,” says the wound expert. “We have immune cells, inflammatory cytokines, chemo kines, cell-cell interactions, none of which continue to be under control. They prevent the normal process of wound healing.”5 In fact, neutrophils, macrophages and T-cells are over-activated and the quantity of proinflammatory cytokines and tissue-reducing proteases remains permanently elevated.3 Fibroblasts and endothelial cells do not multiply - and so the last phase of wound healing simply ceases to be. The wound remains open.

As if that were not enough, over half of diabetic wounds are infected with bacteria.6 In western countries these are chiefly aerobic gram-positive bacteria such as Staphylococcus and Streptococcus.4 “Bacteria are interested in a wound remaining open. They create their own milieu, produce a biofilm and develop barriers which are meant to prevent jeopardy to this environment, i.e., an improvement in the wound,” says David Armstrong. The biofilm consisting of polymeric sugar, proteins, and bacterial DNA protects the microbes from endogenous cells.3 If the condition of the wound worsens over time, the bacterial flora also becomes more complex and more diverse. Furthermore, fungi often populate this environment too.

Aggressive M1 macrophages play a role An imbalance of activated M1 macrophages and M2 macrophages plays a key role, notes Armstrong.4 Whereas inflammation-promoting M1 macrophages are normally replaced by the “gentler” M2 macrophages at some point, the level of the aggressive M1 macrophages remains high in chronic wounds. “They then function as permanent fire accelerants,” says the American expert. High levels of reactive oxygen species and the increase in free iron also characterize such open

Supporting the healing process People have long been trying to promote the healing of chronic wounds through a wide range of different measures. Thanks to fundamentally new scientific findings on the molecular and cellular formation process of wounds, it has been possible to develop new treatment strategies in the last few years. Thus, attempts are being made to stimulate the production of substances and cells which promote healing by using growth factors. Gene therapy approaches are also being researched. In negative pressure wound therapy a vacuum is applied to the wound, which promotes blood vessel formation and in turn boosts the oxygen and nutrient

425

Illustration: Geistlich Pharma, based on diabeticfootonline.com

MILLION diabetics worldwide

(50% of them are not aware)

MILLION inhabitants with chronic wounds

20% of these wounds end in amputation

80% of amputations not caused by accidents are due to diabetes

200% RISK

50% 30%

The risk of dying is double for diabetics with wounds.

of them have bacterial infections

of diabetics worldwide develop foot wounds

FIG. 1: Diabetes is frequent and can have severe consequences.

supply in the wound area, which can be very beneficial for wound healing.

Geistlich conducts research in this area Geistlich developed a purified reconstituted bilayer matrix which shows very promising effects in the healing of chronic wounds.7 The upper compact layer mimics the basement membrane and supports migration of keratinocytes. It provides for the binding of growth factors and mechanical protection of the wound. It also allows suturing of the matrix to the wound if addi-

tional fixation of the matrix is desired by the healthcare professional. The lower porous layer modulates the activity of metalloproteinases and provides an optimum structure for migration of cells. It also absorbs wound fluid readily. In a study in patients whose wounds were an average 3.3 square centimeters in size, the median time until wound closure was 2.7 weeks with this advanced wound matrix.7 “Geistlich Derma-Gide® provides a scaffold for a ‘friendlier’ environment,” notes Armstrong. “This enables a new beginning for healing.”

References 1

diabeticfootonline.com

2 Patel S, et al.: Biomedicine & Pharmacotherapy

Volume 112, April 2019 3 Matrankonaki E, et al.: JDDG 2016. 4 Prof. Dr. David Armstrong (interview) 5

Armstrong DG, Gurtner, GC: Nat Rev Endocrinol

2018; 14(9): 511-12. 6 diabeticfootonline.com 7 Brochure: Geistlich Derma-Gide®, Advanced

Wound Matrix

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GEISTLICH NEWS 1-2020

References: see page 39 OUTSIDE THE BOX

Focus on Ausra Ramanauskaite

«A life-changing experience» Basil Gürber | Osteology Foundation

If one looks at Ausra Ramanauskaite's professional career over the past five years, one can see that the Osteology Foundation has always been her loyal companion. At the EAO Congress 2019 in Lisbon she reflects on the last years. Balancing a cup of hot coffee in her hand, Ausra Ramanauskaite passes through the vestibule of the«Centro de Congressos de Lisboa». The EAO Congress is in full swing. The first break of the day attracts visitors from all over the world to the bright vestibule, where the many conversations blend to a monotonous buzz. «At this event, nine years ago in Copenhagen, I discovered the Osteology Foundation for the first time», she says and smiles. This is where she met Kristian Tersar, the Foundation's current Executive Director, on the Osteology Foundation stand. He ultimately encouraged her to attend an Osteology Research Academy course.

The journey begins

Research, progress and friends Looking back, Ramanauskaite says, the months in Düsseldorf passed in a flash. She was given the opportunity to participate in various research projects. She investigates the effects of prior bone grafts on the efficacy of peri-implantitis therapy. Despite all these exciting projects, she says, it was the human contacts that made the academic year a completely new experience for her. Working together in an international group of like-minded people opened up new horizons for her. She was able to present her projects at various events and exchange information with other experts in the field. In retrospect «This year had a pronounced influence on my development as a researcher and also my personal development», says Ramanauskaite.

Photos: Osteology Foundation, Ausra Ramanauskaite

And she tells how it all started. On Monday, 15 September 2014, she boards the plane to Zurich in Vilnius. She then took the train to the heart of Switzerland, where the Research Academy course of the Osteology Foundation is held every year in Lucerne. During the next days she acquired the basic tools for her future research activities in lectures, workshops and discussions with experts in the field of oral tissue regeneration. Her personal highlight? «Definitely the career seminar with Niklaus Lang. He shared his wealth of experience from his long research career with us. That was very inspiring», remembers Ausra.

During this course in Lucerne she also learned about the Osteology Research Scholarships for the first time. She can't get the prospect of an environment in which she can deepen her expertise in clinical research and basic research together with a mentor out of her head. Back home in Kaunas, she immediately starts on her application. At that time she is engaged in research on a gel for the treatment of peri-implant tissue infections at the Lithuanian University of Health Sciences. Therefore, she would like to complete her research year in Düsseldorf at the Centre for Oral Medicine and Peri-implant Infections under the chairmanship of Frank Schwarz - particularly as the Heinrich Heine University is the leading institution for research into peri-implant pathology at the time. She logs on to the global Osteology Community Platform, THE BOX, fills in the application form and clicks on "submit application".

GEISTLICH NEWS 1-2020

Peri-implantitis remains her passion Today, Ausra is still doing research with Frank Schwarz - but meanwhile at the Goethe University in Frankfurt. She has received an Osteology Researcher Grant for her research project that investigates the influence of antiresorptive therapy on the treatment of peri-implantitis. In addition, she was elected to the Expert Council of the Osteology Foundation in early 2019 and will thus be able to help shape future projects of the Foundation. «I would like to encourage enthusiastic people in our field to take advantage of the support provided by the Osteology Foundation. The Foundation has influenced me a lot on my way and has supported my career», she says looking over the «Ponte de 25 Abril» in Lisbon. She says goodbye and returns to the hustle and bustle of Congress. She is about to moderate the session "How to treat peri-implantitis" together with Frank Schwarz.

Osteology Research Scholarships 2015 – 2019

Facts and Figures 21 Research Scholars from 15 countries 10 Scholarship Centres 9 Mentors 735’000 CHF granted

Meet Miha Pirc – Osteology Research Scholar Would you like to get some insights into the everyday life as an Osteology Research Scholar? On the social media channels of the Osteology Foundation you can now find a video that brings you closer to the tasks and experiences of Miha Pirc at the University of Zurich. @osteologyfoundation @osteologyfoundation Osteology Foundation @OsteologyORG

OSTEOLOGY FOUNDATION

Interview

A chat with Susana Noronha Interview conducted by Verena Vermeulen

You were co-chair of the EAO congress 2019 – in preparing for that event, what was the biggest challenge? Dr. Noronha: (laughs) My biggest challenge was, undoubtedly, to keep up with the extraordinary dynamism of my dearest friend Gil Alcoforado, the Chairman of EAO Lisbon 2019! Of course, promotion of the scientific program amongst the Portuguese dentists was also demanding. “Bridge to the future” was the congress motto. Will future dentistry be very different? Very digital, for example? Dr. Noronha: The theme “bridge to the future” reflects a strong belief that implant dentistry is undergoing a transitional period. I hope future dentistry will help us understand themes that are not yet fully clear but are present in our daily clinics, for example, why some treatments work well in some situations but not in others. Where do you see the biggest room for improvement? Dr. Noronha: As a periodontist, I think there is still a long way to go in relation to the biological complications around dental implants. It is necessary to improve treatment strategies and find alternatives. Such as: save more teeth? Dr. Noronha: Absolutely! Nobody would think of removing a finger because it has problems, or an ear. With teeth we are too

quick thinking how to replace them. If you can keep teeth longer it’s always better. Even if you just postpone implant placement for some years.

And which of today’s practices are “really worth staying the same” for the years to come? Dr. Noronha: In my daily practice it`s important to maintain a strong focus on prevention. I believe that’s the best way to detect changes early and implement appropriate measures to control known etiological factors of periodontal and peri-implant diseases. The focus of this Geistlich News issue is “preventive measures” – which include all regenerative measures that are not conducted to correct defects but rather to prevent tissue loss or prevent complications. Could this be the regenerative treatment of the future – smart preventive measures instead of major corrections of defects? Dr. Noronha: I hope so. Measures and materials that help us prevent volume loss or avoid complications after implant placement are undoubtedly good options. “Prevention” is the key word! Final question. What do you like to do in your free time? Dr. Noronha: Spending time with my family! And I love reading. I try to read every day; however, it`s not always possible.

Dr. Susana Noronha studied Dentistry at the Instituto de Ciências de Saúde Sul and finished her master’s degree and PhD in Periodontology and Photo: Luís Gomes

Implants at the Complutense University of Madrid.

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She is assistant professor of Periodontology and vice-coordinator of the Master's Degree in Periodontology at the University of Lisbon. She is President of the Portuguese company of Periodontology and Implants (SPPI).

Issue 2 | 20 will be published in July / August 2020. FOCUS

Prevent tooth loss > Saving "hopeless teeth": long-term outcomes > Guided Tissue Regeneration: concepts and indications > Guided Tissue Regeneration: minimally invasive approaches > Latest evidence from scientific literature

References for page 34-35 1

Zadeh HH. Int J Periodontics Restorative Dent. 2011; 31(6):653-60. (Clinical study)

2 Instructions for Use. Geistlich Fibro-Gide®. Geistlich Pharma AG, Wolhusen, Switzerland. 3 Data on file. Geistlich Pharma AG, Wolhusen, Switzerland (Pre-clinical study). 4 Thoma DS, et al.: Clin Oral Implants Res. 2012; 23(12): 1333–9. (Pre-clinical study) 5 Thoma DS, et al.: J Clin Periodontol. 2016; 43(10): 874–85. (Clinical study). 6 Thoma DS, et al.: Clin Oral Implants Res. 2015; 26(3): 263–70. (Pre-clinical study). 7 Zeltner M, et al.: J Clin Periodontol. 2017; 44(4): 446–453. (Clinical study) 8 Huber S, et al.: J Clin Periodontol. 2018; 45(4):504512. (Clinical study) 9 Schulze-Späte U, Lee CT. Int J Periodontics Restorative Dent. 2019; 39(5):e181-e187. (Clinical study)

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