Geistlich News - Edition 2, 2021 (English) by Geistlich_Pharma

GEISTLICH BIOMATERIALS

VOLUME 17, ISSUE 2, 2021

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OUTSIDE THE BOX PAGE 24

OUTSIDE THE BOX PAGE 34

New Daily Practice.

Ridge Preservation.

The truly patientcentered solution.

Starting a new chapter in dental offices: will it all stay different after the pandemic?

Clinicians from three countries discuss the considerations to be made for Asian vs. Caucasian patients.

A clinical need drove the innovation of 3-D printed mesh for major bone augmentation.

Cover photo: ©Stockphoto, Skynesher

LEADING REGENERATION.

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GEISTLICH NEWS 2-2021

Editorial

When will life get back to normal? Most likely never, if you mean life being like it was before. And many people think, not without justification, that COVID has not really changed but rather sped up the inevitable. Digitization has been given a push by distancing rules and empty offices. Working from home and video conferencing have profoundly changed the work environment. Our work-life balance, in any case, has changed. And all these changes beg the question: post-pandemic, which changes will be permanent? Which rules will guide the “new normal” or “new daily practice”, the term used for changes affecting your dental office work. The “new daily practice” is the main theme of the Geistlich News that you are currently holding in your hands or looking at on your screen. In the crisis we have learned that it is good to rely on science. We expect a general return to the value of science and the value of premium quality in the post-pandemic “new normal”. Regarding these aspects, I recommend you read the interview with Mario Roccuzzo. And it is not only daily clinical routine that will change. The field of education and congresses already underwent massive changes during the crisis and will not be the same in the future. We asked five renowned experts what this will mean in concrete terms. You can find the answers in our “five questions for five experts” section, where leading educators share their experiences of new education formats in dentistry. For further information about the “new daily practice” in regenerative dentistry please visit www.new-daily-practice.com We hope you enjoy this edition of the Geistlich News.

Yours, Dr. Friedrich Buck

Photo: Roger Schuler

Director Scientific Education, Geistlich Pharma

Issue 2 | 2021

NEWS

“Time to unleash Geistlich’s energy!” Interview with Dr. Ralf Halbach | CEO of Geistlich Pharma AG

8 One image for humanity A real life story, Turma do Bem 9 New Regeneration Expert Hub

10 New daily practice The pandemic changed the way we interact, learn, teach and treat patients. Starting a new chapter now we ask: Will it all stay different forever? FOCUS

11 Five ingredients of an effective social media account Dr. Mohamad Bassam | Lebanon

“Girls with dreams become women with a vision.” Interview with Prof. Ashvini Padhye | India

16 “Everything may work in the short term – but not necessarily in the long-term.” Interview with Dr. Mario Roccuzzo | Italy

19 “Why should we settle for 40-year old implant success criteria?” 22 “The patient’s experience is key for us.” Interview with Dr. Drew Rossi | USA

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Illustration: Quaint

Interview with Prof. Tomas Linkevičius | Lithuania

OUTSIDE THE BOX

24 “These patients will lose much alveolar bone if we do nothing.” Interview with Drs. Mauricio G. Araújo | Brazil, Yoshihiro Iwano | Japan, and Alvin Yeo | Singapore

Five questions for five experts

Periodontal regeneration with Geistlich Fibro-Gide® Dr. Jean-Claude Imber | Switzerland

A head without a body Dr. Klaus Duffner

34 The truly patient

centered solution How Dr. Marcus Seiler invented a new bone regeneration method for large defects.

Illustration: © Studio Nippoldt, Berlin

OSTEOLOGY FOUNDATION

From Bern out into the world INTERVIEW

38 39

A chat with Dr. Fazeela Khan-Osborne Publishing information

IMPRINT Magazine for customers and friends of Geistlich Biomaterials Volume 17, Issue 2, 2021 Publisher ©2021 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. Marjan Gilani, Verena Vermeulen Layout Niki Bossert Publication frequency 2 × a year Circulation 20,000 copies in various languages worldwide 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.

Regeneration contributes to a better quality of life

“Time to unleash Geistlich’s energy!” Interview with Dr. Ralf Halbach conducted by Thomas Pfyffer

Geistlich has had a long tradition as a pioneer in regeneration. What achievements do you hope to achieve next?

Having started at Geistlich Pharma in July 2021, Dr. Ralf Halbach took the reins as CEO. We review his first few months in the company and hazard a guess at what might be expected for Geistlich in the future. Dr. Halbach, what was it like to join Geistlich? Ralf Halbach: My start was of course marked by the pandemic, which made it more difficult for me to meet people faceto-face. There was a bit of a void during this time due to the absence of spontaneous company meetings, which were replaced by more video conferences and virtual meetings. But I found ways to interact with my co-workers within the company, for example, a blog or a series of “Let's Talk” video meetings in which we could connect. In a nutshell, this “onboarding” was special, requiring extraordinary responses to an extraordinary situation.

What will be the first thing you want to resume as soon as the situation allows? A major concern of mine is face-to-face visits with customers and meetings with our partners. I look forward to using these

opportunities, especially when Geistlich can once again be active and in attendance at congresses, symposia and industry events.

What are your first impressions of the company? I sense an inner fire and a great passion among our co-workers. At Geistlich we consider ourselves lucky to have many longstanding employees. Many of our staff have lived through a time of expansion and sustained success at Geistlich. These employees are proud of their joint achievements and commitments to regeneration. But I also notice great energy and a mood of invigoration, a wish to reboot after the pandemic and come to grips with new projects and topics – in line with the mantra: “Time to unleash Geistlich’s resources!”. All in all, this is a marvelous starting place for shaping the future together with my co-workers.

“Our competent network includes research institutes, leading experts and commercial partners.”

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Regeneration is where we come from – this is where our roots are. We have spent decades creating unique expertise in this area, expertise which is unmatched. Within this complex and challenging topic we are aiming at further partnerships and breakthroughs. Our competent network includes research institutes, leading experts and commercial partners. We will continue to improve in order to achieve what we are: the regeneration expert, par excellence. The focus of our activities is and continues to be the patients for whom we are developing solutions.

What is your approach to innovation, and what sort of corporate culture will facilitate its achievement? For me it is important to have a pervasive culture of innovation. There is no way that innovation can be dictated from above! There must be courage to venture something, and, of course, innovation at Geistlich is not just confined to R&D. I am focused on a global approach, which includes, in part, our business model, marketing, our implementation of digitization and company training opportunities. To help our customers we contemplate optimal ways to organize and impart our trainings in such a way that they are accessible anywhere in the world. Techniques in the field of regeneration are often not necessarily learned at university but are introduced later on. This is where our expertise can render valuable service.

If you had to summarize your approach in a formula? Courage, freedom to experiment and go new ways – coupled with a willingness to become smarter from new insights and errors. That is the essence.

Photo: Geistlich Pharma

What do you envision for women in dentistry? Inclusion and diversity are two topics which are close to my heart. It is a fact that dentistry is becoming more “female.” As Geistlich we want to anticipate and co-sponsor this development by focusing on our

own diversity. This is the only way we can push regenerative dentistry forward. In a nutshell, if we reflect on the increasingly female market we gain new perspectives on diverse topics such as training or, for example, R&D.

We work on solutions for our patients and customers to satisfy their needs. Accordingly, I am convinced that we – along with our partners – will continue to be the leading regeneration experts for the next 170 years.

The Olympic Games were held last Summer. In which category would Geistlich enter and win?

What fascinates you about medical technology and the pharmaceutical sector?

Geistlich’s DNA is very close to that of a long-distance athlete! With a tradition going back to 1851, Geistlich clearly demonstrates that it has abundant endurance, passion and a sense of permanence. We especially concern ourselves with challenges that lead to sustainable solutions. So our credo continues to be:

My ongoing fascination is with patients. In our sector we enjoy the privilege of being able to help people. Our R&D and our solutions benefit patients. Taking Geistlich as an example, you can see in an impressive way how regeneration can contribute to a better quality of life. I am very pleased to commit myself to that.

Where will Geistlich be in five years? My predecessor Paul Note did an excellent job. During his tenure the company expanded steadily into new geographic markets with innovative products. We are building on a very solid base, and we will continue to invest in our R&D. Pioneering solutions continue to be a goal. We are endeavoring to remain the regeneration experts and to even expand on this position. I am convinced that our expertise and our lifeblood will guide us to new breakthroughs. Dr. Halbach, thank you for this conversation.

NEWS

One image for humanity In summer 2021, Geistlich created a new social media campaign. For every shared photo on LinkedIn, Instagram and Facebook, with the hashtag #myregeneration,

Geistlich donated 5 USD, in total 5,000 USD to the Global Dental Relief organization. This donation tends to aid free dental care for children in India.

Global Dental Relief aims to bring free dental care to children around the globe.

Scan and explore

The Geistlich charity walk and run in October 2020 supported Turma do Bem, the NGO which makes dental treatment available for the victims of violence in Brazil.

“Having a smile gave back my life and dignity,” she says. “I got my voice back, to help other victims of domestic violence.”

One of the beneficiaries is Joanildes. She lived for 45 years in an abusive relationship, with no access to dental care and treatment. She was almost edentulous when she learned about Turma do Bem in 2013 – a connection which restored her smile after full-mouth rehabilitation.

GEISTLICH NEWS 2-2021

Joanildes smiles again after full-arch rehabilitation.

Photoc: ©iStockphoto, Swissmediavision | Global Dental Relief | Turma do Bem

A real life story from Turma do Bem

Availa from aut ble umn 202 1

New Regeneration Expert Hub covers all relevant aspects of oral tissue regeneration.

VIDEO CLINICAL CASE INTERVIEW

N O I T A R REGENE B U H T R E EXP .

e accessible

Photo: ©Stockphoto, Milindri, Sujit Kantakad | Image montage, Geistlich Pharma

ad Expertise m

EXPERT ARTICLE PODCAST INFOGRAPHIC

Your top 3 reasons to visit the newly launched Regeneration Expert Hub!

To get inspired by clinical insights from leading experts

To stay up-to-date with the latest scientific studies, without reading long journal manuscripts

To learn about the treatment concept of your choice following a stepby-step clinical case www.regeneration-expert.com NEWS

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New daily practice

Illustration: Quiant

The pandemic changed the way we interact, learn, teach and treat patients. Starting a new chapter now we ask: Will it all stay different forever?

The rise of digital opinion leaders

Five ingredients of an effective social media account Dr. Mohamad Bassam | Lebanon DDS, DESS Periodontology & Implant Dentistry Maidan Clinic, Sabah Salem Branch Manager, Kuwait

Even before the Covid-19 outbreak, the use of virtual platforms was already on the rise. With the pandemic, many new platforms were launched to adapt to the “new normal”. It was the time for the emergence of the new thought leaders who adopted the modern evidence-based dentistry, with all its digital features. Social media includes several internetbased tools including, but not limited to, blogs, internet forums, content communities and social networking sites such as Twitter, YouTube, Facebook, LinkedIn, GDPUK, Instagram and Pinterest.¹ Today there are more than 4.3 billion social media users worldwide, almost half the world’s population.²

A new era

“Missing information can be as dangerous as ‘misinformation’ in social media.”

With the outbreak of Covid-19, many new platforms were launched, to adapt to the “new normal” during lockdowns and curfews. Online conferences were broadcasted, like “Geistlich+You”, and the “new normal” opened new opportunities for young clinicians to share their talent and skills with the dental community. It was the time for the emergence of new speakers and mentors who adopted modern evidence-based dentistry with all its digital features, biomaterials, techniques, and professional documentation. My social media journey started with Instagram, the most popular social media application in the country I reside. Ins-

tagram has a suggestion mechanism – it informs your Facebook friends and suggests your account to other Instagram users with similar interests. I first posted some of my old clinical cases. I also tried to observe the other high-impact influencers and learned that high-quality clinical case images, procedures, and surgical techniques are the most interesting for clinicians, with the highest level of engagement. I upgraded my photography skills and equipment, e.g. used a more advanced camera and lighting system. Then I started to post clinical cases with high quality on a daily basis, and with a detailed description of the surgical protocol in the captions. I answered all the comments, as well as the private messages. Sometimes, I had to consult digitally with my colleagues and help to identify the right treatment for their patients. Sometimes I sent them the related references and scientific articles. My account started to grow, and I noticed the inspiration I was spreading with every post.

1. Start with strategy In the dental community, social media is used not only to extend our professional network, but also to educate patients, build trust, influence, and help to develop our practice. To use it to benefit the community and build a successful page, we need to make our purpose clear and follow a strategy. It starts with being transparent about who we are. For example, in Instagram, having an attractive and informative “Bio” which shows the domain of expertise, level of education, and a link to

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other personal social media pages like twitter, Facebook, YouTube, and website is important.

2. Find your audience We need to target and decide who our audiences are, and then plan the right content for each group of them. For example, dentists often tend to “like” and “comment” on multidisciplinary posts, complex surgeries, full-mouth rehabilitations, and full-arch reconstructions. For them, the presentation of the case is particularly important and professional high quality intra-oral and extra-oral photography is crucial. On the other hand, patients choose to skip and unfollow pages that posts lots of surgery and unpleasant medical case images. Instead, they prefer delightful transformations, before and after photos, and awareness posts.

3. Content matters Audiences crave for good content. Plan to stay consistent with the content. Include interesting cases, use quality materials, and show new techniques and evidence-based dentistry. Describing the procedure and including annotations make the viewer understand the purpose of the posted clinical case. Also, including questions in the captions, addressed

GEISTLICH NEWS 2-2021

to either patients or clinicians, improves the chance for starting a conversation. Clinical case posts sometime create a lot of interaction and a high range of criticism, as each dentist has his own approaches and scientific belief. To build trust with the audience, having a scientific approach, and citing the evidence and references is crucial, and increase the creditability of the clinical work.

Follow-up with your posts, and your “reposts” by other accounts and pages on daily basis and respond the comments. And promote your page on other platforms like twitter, Facebook, and others.

4. Interact and optimize the relationship “When to post?” The most active time of the audience in social media is often early morning, at lunch break, and evening. Posting during the peak of audience activity will get you the most reach and engagement and help to grow your account. Posting on daily basis, e.g. the Instagram stories is also important. We may use voting polls, or use questions and answers in stories, for more interaction and getting in direct contact with the followers. One way to come into direct conversation with the audience is “live stream”. The topic can be sharing experience, protocols, tips and tricks or anything interesting. A weekly or monthly live stream conversation can give you a hint of what the audience are truly interested in, and inspire you with more ideas. Hashtags will help to spread the post and reach more people. It is possible to use up

High-quality clinical case images, procedures, and surgical techniques are the most interesting for clinicians, with the highest level of engagement.

Photo: Dr. Mohamad Bassam

“Adopting a scientific approach in social media builds trust with the followers.”

to 30 hashtags in an Instagram post. Try to find the top hashtags that targets the audience you want and use them all. Such strategy might make you hit the explore page (where Instagram curates content for its users). Also tagging people, other pages and locations will increase the rate of engagement and your page visibility. When you have set multiple posts on your page and your account starts to grow, you may start tagging your friends, and even the social media influencers and large accounts, to invite them to view your posts, and ask if they are willing to collaborate.

5. Digital liabilities Success in a digital era requires digital liabilities. It is crucial to acquire a legal consent form signed by the patients to allow the dental practitioners to take photographs and share them in lectures and social media. Practitioners will be liable if this information/data is shared or misused without patient’s approval. The General Dental Council (GDC), which is main regulatory body for dental professionals in the UK, sets standards for their dental professionals. “You must not post any information or comments about patients on social networking or blogging sites.¹ If you use professional social media to discuss anonymized cases for the purpose of discussing best practice you must be careful that the pa-

tient or patients cannot be identified”. Even the online discussions between patients and dentists must be avoided since it can introduce legal complexities and lawsuits, especially if inappropriate comments are made.³

The future is here Social media is a double-edged instrument. It led the market and became an important educational platform in the world especially during Covid-19 pandemic by offering a wide range of content for dental students, and even the experienced dentists. Educational content has become easy to access, with a reduced cost, making it an important source of learning for trainees and newly graduated dentists. But it is also

crucial to choose the educational materials carefully prior to embracing them. Without review and supervision, the quality of information might be insufficient sometime. Everyone with an account can post any clinical case, or statements without evidence or reference. This can spread a large array of false information. “Missing information” can be as dangerous as “misinformation” in social media. It is on the qualified clinicians and dental professionals to be aware and not re-post false or potentially harmful information, guide the trainees and newly graduated dentists, and patients for the best treatment options, materials, and workflows in dental practice, and use the social media for the benefit of the dental community. References 1

General Dental Council. Guidance on using social media. Effective from 27 June 2016.

2 Hootsuite and We Are Social, retrieved from https://datareportal.com/reports/digital2021-april-global-statshot 3 Chauhan B. et al.: J Med Pract Manage 2012;

28: 206-209.

“The only way to do great work is to love what you do.” Dr. Bassam and his team at Valentine’s day 2020 on Instagram.

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Women in Regenerative Dentistry

“Girls with dreams become women with a vision.” Prof. Ashvini Padhye | India Department of Periodontics MGM Dental College & Hospital, Private practice restricted to Periodontics and Implantology, Mumbai Interview conducted by Dr. Marjan Gilani

With more women enrolling in dental schools, gender demographics are becoming more diverse. Nevertheless, the percentage of women as thought leaders at the forefront of dentistry is still less than their male peers. Prof. Ashvini Padhye answered our questions about her journey and how she sees the future of the women in regenerative dentistry. Prof. Padhye, how did you decide to become a periodontist? Prof. Padhye: As a child I wanted to become a physician. but later I learned that I could not study medicine in my city, and I did not want to go to a boarding school, so I chose dentistry instead, and never regretted it for a single day. Both my parents were dentists. And I always wanted to get a postgraduate education in a surgical discipline. I love surgery. At the time in India, more advanced surgery was available only at a postgraduate level. I took up periodontics, went on to learn more , and then there was no looking back.

Was being a woman ever a hurdle? Not really. I think it was a very smooth ride. My mentors were very supportive. Even though I had both male and female colleagues, I was always encouraged to come forward or present things, for example, at conferences. But it was also because my family was extremely supportive throughout my journey. In a country like India one needs a lot of backing to be able to take the path I took. My parents and then my husband and children wanted me to be brave, fight for what I wanted and pursue my dreams.

“The key is facing the challenges and learning to manage them by hitting the right balance.”

GEISTLICH NEWS 2-2021

We see more female thought leaders in dentistry than in the past. What does this mean for students and young dentists? When female key opinion leaders present at conferences, hold seminars and are so well-read and knowledgeable, it sends a very positive message. I think it is extremely inspiring when the students see so many women heading different departments at the university. In our college, seven department heads and the dean are all women. The students look up to them and feel that someday they can get there too.

Can we say the gap between the number of female graduates and those who advance in their career is closing? Well, the gap is fortunately closing. But it is still huge. There is a lot to be done to actually close the gap. A lot of women still cannot prioritize or compartmentalize what they want to do professionally and personally, and that's where we tend to fall back. Women take on many responsibilities just because they are women. Don’t get me wrong. Despite managing my career, I have played various roles and duties on a personal front. I have been actively involved in upbringing my children who are now well-accomplished adults, I am an ardent cook, cater to everyone's taste buds, and besides all this, I find time to pursue my passions. I am a certified advanced deep-sea diver, a trained classical dancer, and I love sketching and painting. it's about trying to find that right balance. I think a lot of women don’t feel good about doing something like professional training for themselves if it keeps them away from their families. We need to stop feeling that way; we need to stop denying our dreams.

Is this gap uniformly distributed over the different domains of dentistry? Not at all. In India more women enroll in dental schools than men. However, when you look at the forefront, speakers at conferences and the recognized opinion leaders, most are men. Women tend to stay in their comfort zone, e.g., in general practices instead of going ahead and flying high where they want to be.

What can break this glass ceiling? The key is facing the challenges and learning to manage them by hitting the right balance. Women have a great deal to offer: they are skilled, compassionate, creative and natural multi-taskers. Maybe we are critiqued more than our male counterparts, even by patients. They may ask, for example, when they learn their young female dentist needs to do a tooth extraction: “Doctor, will you be able to manage?” This is typical for an oral surgeon in the real world. But we need to change that and achieve our potential. Once this is done, then nothing can stop us.

Prof. Ashvini Padhye in Women Regeneration Meeting hands-on course

tistry. Hands-on courses and training, especially if the speakers and mentors are women, will help change this. A very good venture started by Geistlich India two years ago was the women-only events and training courses on the occasion of International Women’s Day. In an allwomen zone, women who might be quiet elsewhere speak up, ask questions, share experiences and gain confidence speaking on the other platforms.

Who are the international female leaders who inspire you the most?

citizens and the economic burden, we see the most successful countries were headed by women, e.g., New Zealand, Germany, Ethiopia, Finland, Iceland and Slovakia. They were fast, objective, effective and, of course, inspiring. Christine Lagarde, president of the European Central Bank says, “Women’s role in our economy is no less than revolutionary.” We need them in the work force for a better future. Being a minority might be hard, but it is also an opportunity. I tell girls: go, grab your opportunity and defy the odds. Girls with dreams become women with a vision.

When we look at the Covid19 data and how countries handled the safety of their

Photo: ©iStockphoto, Levent Konuk | Geistlich Pharma, Prof. Ashvini Padhye

To achieve this potential, should women work more? Women are usually hardworking by nature. But they can learn to channel the way they work. They should also learn to sell their skills. Today men may still be better heard better than women when speaking on the same platform. To change that women need to work diligently towards what they want, stay focused to achieve it and present themselves to the public to be heard and seen.

Is there anything that the industry can do to inspire and engage female dentists? A lot of women are less confident when it comes to regenerative and advanced den-

Dr. Padhye taking selfie with the participants after the Women Regeneration Meeting. Mumbai, March 2020

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Photo: Geistlich Pharma

“As clinicians, one of the most important criteria of biomaterials we look for is long-term predictability.”

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Biomaterials’ role in long-term success

“Everything may work in the short term – but not necessarily in the long-term.” Dr. Mario Roccuzzo | Italy Corso Tassoni Alessandro 14, 10143 Torino Interview conducted by Dr. Marjan Gilani

What makes a biomaterial “premium”? We discussed with Dr. Mario Roccuzzo, Italy, about design, manufacturing standards, long-term outcomes – and his journey of using biomaterials in the last 30 years. Dr. Roccuzzo, you have treated many compromised patients with bone defects. What was the first biomaterial you ever used? Dr. Roccuzzo: It was Biocoral®, a resorbable coralline calcium carbonate graft material. Later I used several other bone substitutes, until I found Geistlich Bio-Oss®, and then Geistlich Bio-Oss ® Collagen, and I continue to use them.

What has changed over those years? A lot of things. But patient expectation is the most prominent one. In the past, implants were so unique, and patients were always happy, as long as they had a replacement for their lost teeth. Nowadays, most patients have extremely high demands. Particularly my patients, who are usually referred to me because of the complications they have. Dr. Mario Roccuzzo as the scientific coordinator of the study day event: “Long-term success. How to select the best therapy for the patients?” Torino, September 2017

Is it possible to avoid recurrent complications? In the real world, complications happen no matter what.¹, ² We treat patients with high peri-implantitis risk factors and

follow them for over 20-years. There is no way to completely avoid complications, but there are certain approaches and choices we can make to reduce their recurrence. Among them is the choice of biomaterials.², ³

How does the choice of biomaterial contribute to predictability? Certainly every medical device should be tested in vitro and in the clinic and have the right physical and biological properties to comply with the medical device regulations.³ But as clinicians, one of the most important criteria we look for is long-term predictability. And when I say long-term, I mean a minimum of 10-years. When I look into the scientific literature, most studies are short-term. It seems everyone is in a rush to publish. They often forget that in the short-term everything we do may work, but not necessarily in the long-term.

“There are certain choices we can make to reduce the recurrence of complications.”

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Has this happened to you? That you were convinced of a biomaterial or treatment concept but over time it turned out to be unsuccessful? There was a time I was convinced that synthetic biomaterials would be the right choice, but their behavior in the long run was not what I expected, so I stopped using them.

What drives innovation in biomaterial science? Unmet clinical needs? Research is part of human nature. We always want more: better products, better solutions, less expensive procedures, less risk and unlimited supply. Even with excellent results we always want better outcomes, and that’s good.

Dr. Mario Roccuzzo giving a hands-on workshop on the reconstruction of hard and soft tissue for esthetic, function, and reduced risk of

Are you cautious when it comes to new products? In general, when a company that has a reputation for doing things properly launches a new product, clinicians are open to trying it. Nevertheless, we should always be cautious, especially when using new products in difficult cases. It’s not much different than the automobile industry: cars are tested and introduced to the market after hundreds of tests, but once in the market, they may have a problem and must be recalled. We don’t want this to happen to our patients. This is why companies with premium products advertise that their products have been used for so many decades in so many million patients and in so many clinical studies. This is the ultimate proof that a product works.

complications. Verona, May 2021

website and read about the products. But in the end, if we want to promote highend dentistry, we should explain products to our patients and tell them why we use them. This is part of patient education and a way to improve quality of care. The more we ask patients to be responsible for compliance and hygiene, the more information we need to give them. And they appreciate it.

Do you have a biomaterial wish list? One is a problem-free bone block for vertical bone augmentation: avoiding

harvest, vascularization issues and other complications. Also, a soft tissue alternative as good as a connective tissue graft. A thick connective tissue graft is still my number one choice when I treat peri-implantitis, but maybe in the future we will have an even better substitute biomaterial.

What is your final recommendation for future research and development? Stay cautious interpreting the outcome of studies with short-term follow-up, and invest in more long-term studies.

We have two different types of patients: those who don’t care what treatment we use, and those who want to know everything – what we use, and how we use it. These patients even check the company

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References 1

Giovannoli JL et al.: Int Dent J 2019 ;69 Suppl 2:7-11. (consensus report)

2 Jepsen S, et al.: J Clin Periodontol. 2019;46 Suppl 21:277-86. (consensus report) 3 Sanz M, et al.: J Clin Periodontol. 2019;46 Suppl 21:82-91. (consensus report).

Photo: Geistlich Pharma

Are your patients curious about the biomaterials they get?

Zero bone loss after implant placement

“Why should we settle for 40-year old implant success criteria?” Prof. Tomas Linkevičius | Lithuania Institute of Odontology, Faculty of Medicine, Vilnius University Interview conducted by Dr. Marjan Gilani

Is a couple of millimeters of bone remodeling around implants normal? Is this implant successful? Prof. Tomas Linkevičius believes that with the advance of science and biomaterials it is not too ambitious to expect no bone loss after implant placement.¹ Prof. Linkevičius, most clinicians believe that bone remodeling around implants is inevitable. Do you disagree? Prof. Linkevičius: Yes, I do. For many years we were trained that bone loss is inevitable. One of the most cited references in implant dentistry is from Albrektsson et al in which a few millimeters of bone remodeling around an implant is an expected physiological reaction and does not impair implant success.² In the past this was okay. But today, with all the new biomaterials, technology and knowledge, why settle for 40-year old implant success criteria? Would we expect the same for cancer treatment, stroke or heart attacks?

Believing that bone remodeling should stop after one year makes our job easier, but we can’t say for sure that it will actually stop. And a certain amount of bone remodeling makes these implants more susceptible to soft-tissue inflammation, peri-implantitis and other complications.

Advances in esthetic dentistry have brought more attention to soft tissue management. And, indeed, soft tissue is as important as bone for implant success – not only for esthetics but also function.

Can you give an example? Consider implant placement in the posterior region. Buccal bone resorption in this area is not a threat to implant stability. But it creates a defect in the soft tissue contour – a site prone to food collection that should be cleaned after each meal.

Should we shift our mindset to preventive considerations? What role does soft tissue management play?

One could say this is not a big deal, but why should patients live with this inconvenience, when, with proper soft tissue management, we can make the treated site easier to clean and more like natural teeth?

It’s an important paradigm shift. For many years bone was our main concern, but today patients have higher esthetic demands.

Patients don’t often complain. They think this is a normal condition with which they have to live. It’s our job to inform them

You advocate a “zero bone loss” approach? Yes. In some indications we might still lose some bone, but for most implants we can have zero bone loss after implant placement. We should raise the bar of our expectations and get rid of the old mindset. And this is what I teach in my online course.

“Soft tissue is as important as bone for implant success – not only for esthetics but also function.”

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Classic implant placement: up to 1.5 mm of marginal bone remodeling is expected

2 mm Bone level implant

Geistlich Fibro-Gide®

3–4 mm

Zero bone loss after soft-tissue managment

Fig. 1: Classic implant placement vs the “zero bone loss concepts” by T. Linkevičius –

thicker soft tissue protects the bone around implant from remodeling.

about the risks and bring soft tissue health back into focus.

How do you help the patients decide? I show them pictures of the ridge, stable implants and soft-tissue contour defects. And I tell them: “If we don’t place a soft-tissue substitute in this area, you will have food impaction, and you will remember me after every meal (smile).” In addition, bacteria can accumulate in this site and make it more susceptible to complications. I also show them clinical cases where the soft tissue has been thickened with Geistlich Fibro-Gide® so the patient can see the difference: an implant that simply works on the one hand, and one that looks and feels like their natural teeth on the other.

Short and sweet: horizontal soft tissue thickness matters? Horizontal tissue thickness is often considered less important in the con-

GEISTLICH NEWS 2-2021

text of crestal bone and implant stability. But it is just as important, not only in the anterior region for esthetics, but also in the posterior region for hygiene and comfort.

What other biological factors do you take into account? The other biological factor we clinicians have forgotten for so many years is vertical soft-tissue thickness. It is still a mystery to me why the 1996 Berglundh and Lindhe publication³ did not draw more attention to this topic. We reinvestigated the impact of vertical soft tissue thickness on marginal bone loss and showed that a vertical soft-tissue thickness of 3–4 mm is needed for optimal outcomes. It protects the bone after implant placement and creates an esthetic emergence profile (Fig. 1).⁴ And last but not least are the keratinized tissue dimensions. We all know that immobile gingiva and attachment of the soft tissue are essential for implant success.

How often do you decide to perform vertical soft tissue augmentation? Every delayed implant I place is a candidate for horizontal and vertical soft tissue augmentation. It’s part of my protocol. Maybe in some cases we can avoid vertical soft tissue thickening, if we have a lot of bone and can place the implant deeper, depending on implant design. But for horizontal soft tissue augmentation, there is no alternative. You need a graft in this area, whether it is autologous soft tissue or an off-the-shelf product.

And which do you prefer? Soft-tissue management is a central part of my protocol, and in general I do not use connective tissue grafts from the palate for the obvious reason of avoiding additional harvest graft surgery. Patients hate it! When I try to explain harvesting connective tissue from the palate, I have patients who want to avoid the procedure at any cost, or prefer to leave the implant as it is. For the past three years I have been using Geistlich Fibro-Gide® for both horizontal and vertical tissue thickening. One benefit of substitute biomaterials is their unlimited availability. For example, when I use Geistlich Fibro-Gide® I can cut it in half and use it for both vertical and horizontal thickening without going to the palate. For augmenting keratinized tissue I may use both connective tissue and substitute biomaterials. But most important for me is creating immobile and attached tissue around the implant. This stops bacterial invasion and increases implant longevity.

Do the patients accept the cost of using biomaterials? Should we go back to bridge restorations because they’re cheaper than implants?

Illustration: Quiant

Healing abutment

Of course, we need to explain all options to patients so they can make their own, informed decisions. But we should help them understand that, even if it costs more, using substitute biomaterials can change their implant therapy outcomes.

What are the pros of biomaterials? Compared to connective tissue grafts there are fewer complications when substitute biomaterials are used. In general, all the additional steps, e.g., harvest pro-

cedures and de-epithelialization, may increase surgery time and complications… and in the end you may have more bone loss while the soft tissue is healing. Of course, this may depend on the experience of the surgeon. Predictability may be compromised if the surgeon is less experienced.

References 1

Linkevičius T: Quintessence Publishing Co Inc., ISBN: 978-0-86715-799-4; 9780867157994 (book)

2 Albrektsson T, et al.: Int J Oral Maxillofac Implants. 1986;1(1):11-25. (review study) 3 Berglundh T, Lindhe J: J Clin Periodontol 1996;23(10):971-3. (clinical study) 4 Linkevičius T, et al.: Clin Implant Dent Relat Res 2015;17(6):1228-36. (clinical study)

First, I think the clinician needs to be convinced about the benefits of a treatment protocol. Then the patients will naturally follow.

Photo: Prof. Tomas Linkevičius

“It’s our job to inform the patients about the risks, and bring soft tissue health back into focus.”

Prof. Tomas Linkevičius in Zero Bone Loss concept online course, https://education.tomaslinkevicius.com

FOCUS

Patient Reported Outcomes

“The patient’s experience is key for us.” Dr. Drew Rossi | USA Periodontal Health Professionals LLC, Houston Interview conducted by Verena Vermeulen

For patients it’s not only the outcome that matters but also the convenience. Dr. Drew Rossi gave us insights into how he educates patients, why he switched to non-autologous grafts and why he invests time in lecturing and mentoring. If you need medical or dental treatment, are you someone who wants to know everything about the therapy, or are you someone who completely trusts your health care professional? Dr. Rossi: I tend to be very exacting – that’s my personality. I tend to research things, talk with my healthcare colleagues and educate myself.

Do you Google diagnoses and treatments? Sometimes. But what I really like to do is talk to colleagues. I don’t think you can trust everything you see on the internet.

How about your patients – do they have specific expectations? A lot of them do. Many of our pateints are referrals. Often their primary care dentists have already explained what I do and what I will probably recommend. And many of them are well educated professionals themselves. I don’t like them YouTubing treatments because this tends to frighten them away. But they do it anyway.

Could you give an example? The Pinhole Technique is very well marketed in the US. A lot of people come and request this treatment, because they saw it on TV or on the internet. It’s the same

“We will not be scrutinizing about half a millimeter soft tissue gain any more, but about patient experience and comfort.”

GEISTLICH NEWS 2-2021

with other soft tissue augmentation procedures. I am always honest with my patients. If I am not convinced of a procedure or biommaterial because it is not backed by research, I don’t offer it.

What is key for you when you explain treatments to your patients? To be aware of their wishes and how they respond. We can talk about scientific literature or the amount of keratinized tissue needed, but they tend not to respond to that. Most patients respond to emotions, like before and after pictures. For example, if they are coming in for soft tissue treatments, they want to look better, and they want to reach this goal with a convenient procedure. Sometimes they are also afraid. Fear is a frequent problem in dental offices, so we have to deal with this. The patient’s experience is key for us.

“Nowadays I tend to use more non-autogenous tissue and offer a palate free approach.” when general dentists graduate from dental school they are not aware of, for example, the importance of keratinized tissue. If it is hard to sell this idea to dentists, it is even harder to sell it to the public.

These treatments might take an initial investment but pay off over time... “What matters for the patients, apart from the treatment outcome, is the time they spend in the operation chair and post-operative pain.”

Patient reported outcome measures are becoming more and more relevant. Do you measure patient satisfaction systematically? When we do research we do – to quantitatively measure their opinions. But in our daily practice we don’t. We care a lot about patient experience, even if we don’t analyze it in a scientific way. Patient satisfaction with treatments and outcomes drives our referrals and helps us attract more patients by word of mouth.

Photo: Dr. Drew Rossi

Has your approach changed over time? Yes, definitely. What matters for the patients, apart from the treatment outcome, is the time they spend in the operation chair and post-operative pain. When I started practicing, I used autologous tissue every single time because it was the

gold standard. But when I moved into private practice I realized that patients tend to be way more satisfied when we use non-autologous tissue, and we are still getting excellent results. Nowadays I tend to use more non-autogenous tissue and offer a palate free approach.

Sometimes regenerative treatments do not aim at correcting a defect but rather preventing tissue loss or decreasing vulnerability. In the US this is called “phenotype modification therapy.” Are these proactive and preventive regenerative treatments more difficult to sell and explain? Yes, because patie0nts do not typically ask us for this kind of therapy. We educate our referral base on such treatments and patient cases. Often patients don’t even realize that they have an issue. Also,

If we are doing a large implant case, we know that augmenting the keratinized tissue is going to increase long-term success. We are performing phenotype modification therapy to protect our results. We don’t want to fix peri-implantitis or peri-implant mucositis later on for free.

What is the future of regenerative dentistry? I am sure that preventative therapies will become more and more relevant, but this involves a lot of patient education. And the focus on patient reported outcome measures will increase, also in the literature. We will not be focusing on a half millimeter soft tissue gain but rather patient experience and comfort.

What are the biggest challenges in this respect? One hundred percent education. After finishing dental school most dentists have only basic knowledge. A topic like phenotype modification is covered very briefly, if at all. Therefore, we must educate our fellow colleagues, for example, at congresses or through mentoring. I lecture for my referral base and continually mentor. Education does not stop with school.

FOCUS

Ridge Preservation in Asian and Caucasian patients

“These patients will lose much alveolar bone if we do nothing.” Interview conducted by Verena Vermeulen

Thin vs thick biotypes, tooth-root angulation – what are the differences between socket anatomy in Asian and Caucasian patients? And what do these differences mean for implant placement? We talked with three experts from two continents about small differences with big impacts. Dr. Araújo, you are one of the first investigators of the sequence of biological events after tooth extraction. In brief, what happens? Dr. Araújo: The healing process is divided into three phases: inflammatory, proliferative and modeling/remodeling. In the last phase, the osteoclast activity promotes extensive bone resorption that reduces the alveolar ridge dimension. Facial bony walls are frequently thinner than 1 mm, and these thin walls are almost exclusively bundle bone.1 Because it is a completely tooth-dependent structure, the bundle bone is resorbed after tooth extraction.

“In the esthetic zone, 30 % of the volume of the alveolar ridge is lost.” Dr. Mauricio G. Araújo

GEISTLICH NEWS 2-2021

How much volume is lost on average? There are so many studies, site-specific factors, measurement points and methods… do you have an easy answer? Dr. Araújo: On average, in the esthetic zone, about 50 % of the width and 30 % of the volume of the alveolar ridge is lost.2 This amount is very significant.

Is the process of bone resorption similar in all patients and sites? Dr. Araújo: The process is the same in all patients, but the clinical outcome is different. A thin buccal bone wall, a narrow alveolar socket and a socket outside the bone envelope may significantly increase the volume loss.

Dr. Yeo, you investigated one of these conditions that affect bone resorption after tooth extraction in more detail: tooth-alveolus angulation. What does this term mean? Dr. Yeo: Tooth-alveolus angulation is the angle measured where the axial planes of tooth-root and the alveolus converge (Fig. 1). A small angle suggests that the entire tooth-root is expected to be positioned within the alveolar housing. In case of a large angle, the root will be positioned very close to the buccal bone wall or even out of the buccal aspect of the alveolar housing.

How frequent is this condition? Dr. Yeo: To the best of my knowledge, we have many reports of angulation issues

Dr. Yoshihiro Iwano | Japan Iwano Dental Clinic, Tokyo

Dr. Mauricio G. Araújo | Brazil Department of Dentistry State University of Maringa Dr. Alvin Yeo | Singapore Faculty of Dentistry National University of Singapore

in Asian populations but limited or none in Caucasians.

Illustration: Geistlich Pharma

In a study from China, 50 % of the study population (n=300) had tooth-alveolus angulations of more than 20 degrees.3 In our study in Singapore we measured an average tooth-root angulation of 13.6 degrees.4 Almost 36 % of our study population (n=100) had tooth-root angulations of more than 15 degrees.4 Also in my own clinical practice, about 20 % have moderate to severe tooth-alveolus angulations.

In case of severely angulated teeth, what are the consequences for bone healing after tooth extraction? Dr. Yeo: These sockets often already show buccal bone dehiscences, fenestrations or perforations before tooth extraction,

“People with thin hard tissue often require soft tissue augmentation.” Dr. Yoshihiro Iwano

leading to significant bone defects after healing. In the publication from Chappius et al in 2013, there was almost seven times more mid-facial bone loss when the original tooth socket presented with a thin and compromised bone phenotype.5

Dr. Iwano, you also investigated the differences between extraction sockets in Asian, especially Japanese, and Caucasian patients. What

were your findings? Dr. Iwano: Compared with the data for Caucasians, it seems that the buccal bone walls of Japanese patients are clearly thinner, especially in the maxillary anterior teeth.6 At 5 mm from the alveolar crest, we have on average 0.24 mm thickness, and at 6 mm only 0.20 mm.6 It is assumed that the alveolar bone thickness is very thin not only in the central part but also in the mesiodistal part of the anterior tooth.

OUTSIDE THE BOX

What does this mean for tooth extraction? Dr. Iwano: The bundle bone is about 0.2 to 0.4 mm thick – just like the reported average bone width.⁶ So, in the case of Japanese people, we can assume that the alveolar bone in the central part of the labial side will fully resorb after tooth extraction.

“About 20 % of my patients have moderate to severe tooth-alveolus angulation.” Dr. Alvin Yeo

Let’s discuss how to deal with these conditions for implant placement. Dr. Yeo, you once said that you had several “oops-moments” when you wanted to perform early implant placement on your patients in Singapore. What caused the “oops”? Dr. Yeo: Standard and proven protocols for tooth extraction followed by early implant placement somehow did not work out for about twenty percent of my maxillary cases. When opening the flap I realized that implant site preparation and implant placement were not possible. The amount of bone loss and remodeling following tooth extraction was too extensive, so I had to perform a staged-approach GBR instead.

Which is more invasive and costs additional time for the patient... Dr. Yeo: Yes. Patients are subjected to more treatment morbidity, cost and the overall treatment time is longer.

How do you deal with such cases in your daily practice? Dr. Yeo: In esthetically and anatomically demanding cases, we routinely take a CBCT image to evaluate the tooth-alveolus angulation profile. Based on this we can decide whether to perform Ridge Preservation following tooth extraction.

GEISTLICH NEWS 2-2021

By doing so we have managed to perform implant placement in most of these cases using a ‘delayed’ early implant placement approach after around twelve to sixteen weeks, instead of a two-stage GBR approach.

So you don’t perform Ridge Preservation to avoid a GBR but to avoid two-stage GBR? Dr. Yeo: Absolutely. Simultaneous GBR or contour augmentation during implant placement is still required.

Dr. Araújo, how do you see this from an economic perspective? Does Ridge Preservation also “pay off” in these cases? Or is it more of a patient investment in a less invasive treatment? Dr. Araújo: In Alvin Yeo’s example, Ridge Preservation helps to avoid a two-stage GBR procedure and thereby makes the treatment less invasive. So, perhaps it is not an obvious economical benefit, but it is definitely a way to reduce surgical morbidity.

From an economic perspective, Ridge Preservation pays off in cases where it helps to avoid a further GBR procedure. It is important to obtain a CBCT of the alveolar socket before extraction and confirm that it has at least 9 mm of thickness so that, even with minor volume loss after Ridge Preservation, the dimension is sufficient for implant placement. And one needs to check whether the buccal bone is intact or not, etc.

Dr. Iwano, is Ridge Preservation a standard treatment after tooth extraction in Japan? Dr. Iwano: Not yet. In 2018 we completed a questionnaire with 248 implant dentists, including 103 specialists from the Japanese Society of Oral Implantology. In that questionnaire we asked whether clinicians perform Ridge Preservation when extracting teeth on the premise of implant treatment. 32.3 % of the participants said “yes”.⁷ I am one of those who answered “yes,” because I personally always perform

Fig. 1: Angulation | A Illustration of tooth-root angulation | B Mild angulation | C Moderate angulation

| D Severe angulation Convergence of 2 planes = angle alpha

Ridge Preservation and think that it is useful. But the current situation is that it is not yet the standard of treatment in Japan.

In which patients do you support Ridge Preservation? And why? Dr. Iwano: It is performed for all patients who have thin buccal bone plates, because these patients will lose a considerable amount of alveolar bone if we do nothing. Consequently, they will need large amounts of bone augmentation in case of subsequent implant placement. Ridge Preservation is a simple and minimally invasive surgical procedure that – if performed simultaneously with tooth extraction – will enable implant treatment without the need for large bone augmentations.

resorption of the alveolar ridge to a minimum using Ridge Preservation will bring great benefits.

Short & sweet: what role does soft tissue play? Dr. Iwano: In patients with thin hard tissues, the presence of thick soft tissue is extremely important for maintaining esthetics. People with thin hard tissue often require soft tissue augmentation.

References 1

Januario AL, et al.: Clin Oral Impl Res 2011;

10: 1168–71. (clinical study) 2 Misawa M, et al.: Clin Oral Implants Res 2016;

27(7): 884-9. (clinical study) 3 Wang HM, et al.: Int J Oral Maxillofac Implants

2014; 29(5): 1123-29. (clinical study) 4 Lee WZ, et al.: 2021 – in preparation

llustrations: Quaint

(clinical study)

Bone resorption after tooth extraction also causes problems for bridge restorations. Since esthetic problems and poor cleaning may occur due to the lengthening of the pontic, keeping the amount of

5 Chappuis V, et al.: J Dent Res. 2013;

92 (12 Suppl): 195S-201S. (clinical study) 6 Ezawa T.: J Jpn. Soc Periodontol. 1984;

26: 243-56. (clinical study) 7 Iwano Y et al.: The Clinical Question. Tokyo;

Quintessence, 2018: 148-149. (book chapter)

OUTSIDE THE BOX

Points of view

Five questions for five experts We asked five experts to answer five questions about events and education after the pandemic. Results: 25 professional and personal insights.

Prof. Ronald Jung | Switzerland

Ms. Erin O’Donnell Dotzler | USA

University of Zurich

American Academy of Periodontology

What was your educational highlight during the pandemic?

Geistlich vLab. We could reach out to people we could never reach at that large of a scale in a live hands-on workshop.

The AAP 14+ webinars, which ranged from epidemiological information about COVID-19, to considerations about patient care.

How did you change your own event organization? We are still planning the international events such as EAO purely online. When participants join from around the world, it is impossible to predict whether the next gathering will be hybrid or, once again, live.

What can be done to compensate for the lack of personal contact?

I’m looking positively at what the new normal has offered. A few years ago, clinicians were skeptical about online education. This mindset has changed.

What is your new, ideal course format?

A blended concept with online exchange of theoretical knowledge, live practical exercises and an online mentoring program that would bring the new concept into practice.

Multi-dimensional offerings for education including a curriculum for that learning to occur, e.g., an online course with a live follow-up opportunity.

The reliable courses are those offered by the universities or the companies that work with independent lecturers.

GEISTLICH NEWS 2-2021

Through the virtual platforms we amplified the newly developed multidimensional content curated from the global community of experts.

The virtual format does not replace personal contact, but it has the benefit of making the thought leaders more approachable, e.g., using the chat feature, during an online lecture.

How can young clinicians navigate the huge offering of online courses?

How did you change your own event organization?

How can young clinicians navigate the huge offering of online courses? Having a larger pool of options means the clinicians should be more thoughtful about discerning the objectivity and the integrity of the content.

Prof. Michael Payer | Austria

Prof. Chunbo Tang | China

Prof. Daniel Buser | Switzerland

Dental School Med Univ. Graz

Nanjing Medical University

University of Bern

What was your educational highlight during the pandemic?

The EAO Digital Days in September 2020. Outstanding speakers were broadcasted from a TV studio in Paris for participants from all over the world.

Last summer our college conducted its annual oral implantology debating competition online. The scale of the event was larger than ever.

The progress made with hybrid continuing education (CE) courses, including live or on-demand streaming.

How did you change your own event organization?

We learned a lot about online education and the power of social media, but I will be happy when we go back to normal events.

Online education was already becoming a trend, which only accelerated because of the pandemic. We chose more interesting topics and invited speakers with strong communication skills.

What can be done to compensate for the lack of personal contact? I think we will never be able to fully compensate for the lack of personal interactions, but online education definitely helped a lot during the pandemic.

What can be done to compensate for the lack of personal contact? We should take full advantage of all digital technologies. A more advanced mobile application might help.

How did you change your own event organization? I gave countless webinars and organized online courses such as the GBR Master Course in Bern. I believe the future of CE courses will be hybrid offerings, when participants are either personally onsite or online with a live or on-demand stream.

What can be done to compensate for the lack of personal contact? When this pandemic is over, pure online offerings will disappear.

What is your new, ideal course format?

It offers both personal contact and scientific exchange onsite with all the safety concepts, plus live streaming for those who cannot attend.

A combination of both online and live courses. Live events are indispensable, but online courses reach more clinicians and solve the problem of long-distance travel in larger countries.

Hybrid CE courses. They clearly foster the international knowledge exchange.

How can young clinicians navigate the huge offering of online courses? There is a clear duty for scientific societies and universities to provide quality online education. However young colleagues are already very capable in assessing the quality level of online courses.

How can young clinicians navigate the huge offering of online courses? This generation has grown up in the digital era and can quickly adapt when we deliver the right and interesting courses that stimulate their interest and enthusiasm.

How can young clinicians navigate the huge offering of online courses? That’s not so easy. Four aspects will help them decide: (1) speakers and their reputation, (2) platform and landing page, (3) social media marketing and (4) the discounting strategy for tuition fees.

OUTSIDE THE BOX

Histology

Periodontal regeneration with Geistlich Fibro-Gide® Dr. Jean-Claude Imber | Switzerland Department of Periodontology & Robert K. Schenk Laboratory of Oral Histology, School of Dental Medicine University of Bern

Fig. 1:

NB VCMX

defect regenerated with the use of the volume-stable collagen matrix (VCMX) Geistlich

aJE

Fibro-Gide®; apical end of the juntional epithelium (aJE).

NPL

GCT

| B, C Integration of VCMX in new periodontal ligament (NPL),

NC NPL

| A Overview of a periodontal

new bone (NB), gingival connective tissue (GCT), and

NB NB

new cenentum (NC).

“This histological study revealed the potential of Geistlich Fibro-Gide® to promote periodontal regeneration.”

GEISTLICH NEWS 2-2021

Due to its known biocompatibility and structural configuration (e.g., high porosity and interconnectivity), a porous, volume-stable collagen matrix (VCMX, Geistlich Fibro-Gide®) was preclinically tested in acute periodontal defects.¹ After a healing period of twelve weeks, residual Geistlich Fibro-Gide® was still present and integrated in newly formed bone (Fig. 1A, B), periodontal ligament (Fig. 1A, C), cementum (Fig. 1C), and connective tissue (Fig. 1A). New cementum and bone formation were significantly greater in the test group (with

Geistlich Fibro-Gide®) than in the control group (without) (p = 0.009 and p = 0.037, respectively). This histological study revealed the potential of this specific collagen scaffold to promote periodontal regeneration. Nevertheless, additional preclinical and clinical trials are needed to establish the use of VCMX in periodontal regenerative surgery. Reference 1

Imber et al.: J Clin Periodontol 2021; 48(4): 560-69

(pre-clinical study)

Histology: Dr. Jean-Claude Imber

VCMX

Miracles of regeneration

A head without a body

Sacoglossan sea slugs have the ability to rid themselves of – and subsequently regenerate – their entire body, including their heart and digestive system. Japanese researchers suspect that parasites and algae play a vital role in this phenomenon.

Dr. Klaus Duffner

For some species of animals, the voluntary amputation (and subsequent regeneration) of certain body parts is an effective mechanism for escaping from danger. Lizards are one well-known example of this process, which is known as “autotomy” or self-amputation. The reptiles can avert predators by shedding their tail – which then grows back again, albeit in a shorter form.¹ In response to danger, African species of spiny mouse from the genus Acomys also shed their skin, which is then regenerated in all of its layers along with the fur and glands.2

“The energy obtained from the chloroplasts appears to be sufficient to regenerate the rest of the body.” Likewise, the Atlantic ghost crab has the ability to shed multiple extremities at predetermined breaking points and to then regenerate these bit by bit during subsequent molting processes.³

day she observed that one of her slugs’ heads had separated from its body and was moving around on its own.⁵ Of the 15 specimens from the species Elysia marginata kept in the laboratory, a third of them spontaneously amputated their head from the rest of their body over a period of time. Prior to this division, an indentation could be discerned across the slugs’ “necks”, acting as a sort of predetermined breaking point.

A new body within 20 days Immediately after amputation, the head would begin to move around autonomously, and the wound in the slug’s neck would close up within a day. “We thought that the slug would die soon without a heart and other important organs, but we were surprised again to find that it regenerated the whole body,” explains Mitoh.⁵ The sea slug’s heart regenerated within seven days, and its entire body within 20 days. In addition to the heart, the kidneys, digestive system, a large part of the reproductive organs and the wing-like side appendages had also grown back.

However, as Japanese researchers have recently reported, the true masters of regeneration are the sacoglossan sea slugs.4 These sea-dwelling animals are able to amputate their head and then completely regenerate their body.

Interestingly, the body only regenerated in young animals, whereas the older ones died off within 10 days. Likewise, the headless bodies could not be regenerated, but they continued moving around for days or even months and responded to touch before they ultimately shrank and perished. By that point, 80 % to 85 % of the total body mass had been lost.

Spontaneous separation of head and body

Are parasites the reason for autotomy?

As is so often the case in science, chance played a crucial role in this discovery. The doctoral student Sayaka Mitoh was actually keeping sea slugs of the genus Elysia in order to study their life cycle. But one

Of the second species kept in the laboratory, Elysia atroviridis, 82 individuals were infested with parasites known as copepods. Three of these specimens autotomized and regenerated as described

GEISTLICH NEWS 2-2021

above, thereby ridding themselves of their parasites. A further 39 lost precisely the parts of their bodies that were infested with their uninvited cohabitants. In contrast, none of the 64 unaffected individuals severed a body part. According to the authors, the obvious conclusion is therefore that sacoglossan sea slugs evolved this capacity for autotomy in order to free themselves of such parasites. Indeed, thanks to their effective camouflage and the presence of toxins in their bodies, sea slugs have relatively few predators⁶ – who are, of course, the reason for the voluntary abandonment of certain extremities in many other animals.

Predetermined breaking point

The body dies after days to months (view from below) The sea slug Elysia marginata

More reproductive success without parasites Moreover, “feeding experiments” revealed no autotomic behavior. At the same time, the parasites are more than just a nuisance: they fill the majority of the space within the sea slugs’ bodies and thereby hinder their reproduction. If the parasites are “thrown away,” a considerable improvement is seen in terms of reproductive success. Other theories suggest that discarding the body might also be a way for the animals to prevent themselves from becoming entangled in algae or to dispose of toxic substances in the body.

They live only from light Another unusual characteristic of the sea slugs appears to play a decisive role in this extreme form of autotomy. Specifically, sacoglossan sea slugs feed on algae, ingesting their chloroplasts and storing them as “kleptoplasts” in special intestinal areas under the skin via their highly branched digestive systems.⁶ The Japanese researchers suspect that the amputated heads acquire energy from the chloroplasts’ photosynthesis. Indeed, they have observed that the heads of young sea slugs begin feeding on algae within just a few hours. As the complete lack of a digestive system meant it was no longer

As yet, it is not clear how the sea slugs are able to extend the life span of the chloroplasts, especially given that the environment inside animal cells is characterized by completely different conditions to those in plant cells.⁷ Fluorescence analyses suggest that the animals make the inside of the chloroplasts more resistant, thereby protecting them from lightinduced damage.

Sufficient energy to regenerate the body Although the efficiency of these tiny sugar producers is reduced, the quantity of energy appears to be sufficient to regenerate the body and to keep the sea slug alive – even for its entire lifetime.

The servered head moves around on its own

In another study, sea slugs of the genus Elysia survived in an aquarium without food for up to nine months simply due to the influx of light.⁸ This is a period equivalent to their typical life span in the wild.

Day 0

A fully grown slug

possible to digest algae in the normal way, the energy obtained from the chloroplasts appears to be sufficient to regenerate the rest of the body.

Day 7

The heart grows back References 1

Higham TE, et al.: Physiol. Biochem Zool 2013;

86: 603-10. 2 Cormier Z: Nature. September 26, 2012. 3 Pfeiffenberger JA, et al.: J Exp Biol (2021) 224 (10):

Day 22

jeb233536. 4 Mitoh S, et al.: Current Biology 2021; 31 (5) 233-34.

llustration: Quaint

Day 14 All organs have been restored

5 https://www.sciencealert.com/self-decapitating-seaslugs-can-grow-a-whole-new-body-internal-organsand-all 6 Rumpho ME, et al.: Plant Physiology 2000;

The wing-like appendages are visible

123 (1): 29-38. 7 Havurinne et al.: eLife2020 Oct 20;9:e57389. 8 Giménez-Casalduero F, et al.: Anim Biodivers

Conserv 2011; 34: 217-27.

OUTSIDE THE BOX

THE TRULY PATIENT- CENTERED SOLUTION .

How MARCUS SEILER invented a new bone regeneration method for large defects Has the bone block resorbed?

Yes. I wish there was a way we could have more vascularized and predictable bone after grafting. Something which could save the patient from harvesting morbidity and us from such surprises.

Could 3-D printing help to create a titanium, ridge-shaped scaffold that would guide new bone formation?

Filderstadt, 2006 Full-arch rehabilitation after grafting with autologous bone block

Titanium Clinically tested material 1 3-D printed Customized for each patient and each defect – no need to adjust in-situ 2

GBR principle I use my trusted and predictable Geistlich biomaterials

3-D printed ridge-shaped scaffold for bone regeneration

Geistlich Pharma HQ, 2010 GBR with a 3-D printed customized mesh becomes a clinical reality

Clinical evidence

R&D

Business support

Market approval Quality and manufacturing

Here are the quality control requirements.

GEISTLICH NEWS 2-2021

Intellectual property

Let’s make sure clinicians use tested and approved tools and not poor copies.

It can reduce surgery time and improve precision and predictability. 2-3

These are the requirements for regulatory approval.

SEVEN STEPS of GBR with Yxoss CBR®

Send the CBCT or intraoral data to ReOss®.

Order the products after design and planning by ReOss®.

Place implants and prothesises in the new bone.

Geistlich Bio-Oss® serves as a scaffold for new bone and ensures predictable bone regeneration. 4

Protection, wound stabilization and homogeneous vascularization with Geistlich Bio-Gide®. 5-6

When the mesh is removed, the newly built bone is vascularized and vital.

3 Production of the customized solution, Yxoss CBR® by ReOss®.

Receive the Yxoss CBR® and the regenerative biomaterials at your clinic.

Scan and explore

Fill the mesh with Geistlich Bio-Oss® and cover it with Geistlich Bio-Gide®.

I thought 3-D printing for medical use is something for the far future. A truly “personalized” solution for me sounds like the future is today!

It all started with an idea!

References: see page 39

OUTSIDE THE BOX

First Osteology-EFP Virtual Live Surgery

From Bern out into the world Drs. Sonya Sharma and Heike Fania | Osteology Foundation

Broadcasted live from Bern, over 1000 attendees from more than 80 countries attended the first Virtual Live Surgery Day organised jointly by the Osteology Foundation and the European Federation of Periodontology (EFP). The event consisted of two sessions, one on recession coverage, the other on peri-implantitis treatment. First session: recession coverage After the welcome and introduction by the two presidents, William Giannobile for the Osteology Foundation and Lior Shapira for the EFP, the session started with the keynote lecture by Martina Stefanini. She talked about “recession coverage in the mandible: possibilities and limits”. Stefanini explained that recession coverage treatment in the mandible is often complex due to the unfavourable anatomical condition. It is influenced by several factors, e.g. tooth position, vestibulum depth and tissue phenotype. The Vertically Coronally Advanced Flap (VCAF) and the Laterally Closed Tunnel (LCT) are two new procedures that can obtain complete root coverage, increased vestibular depth, soft tissue depth, decreased morbidity of the harvest area and aesthetics. Stefanini said that compared to the traditional techniques, the CAF Difficulty Score across different parameters is high for the VCAF, but the surgical technique itself is more difficult. After Stefanini’s lecture, Mariano Sanz as moderator, introduced the patient. Anton Sculean performed the surgery on a thin phenotype patient with an RT2 (Miller’s class III) recession in region 41. The treatment aimed to improve oral hygiene, alleviate the pain and improve aesthetics. The technique used to treat this recession was the LCT or the Modified Coronally Advanced Tunnel (MCAT) in conjunction with a palatal subepithelial connective tissue graft (CTG). The LCT has advantages in a thin phenotype with limited or no attached gingiva. Tension-free mobilisation of soft tissue can be obtained without any incision on the papilla or the flap to optimise wound stability. The procedure started with mechanical debridement of the root followed by an intrasulcular incision in the depth of the recession

GEISTLICH NEWS 2-2021

to enable the tunnel. Following this, detachment of the periosteum and frenulum was performed. A 1 mm CTG was harvested from of the palate, stabilised over the recession area and closed with mattress sutures. Lots of questions arrived from the audience during the surgery, which were addressed live and in the panel discussion following the surgery. Whilst Sculean was finishing the surgery, the panel discussion started with Martina Stefanini, Andreas Stavropoulos and Giovanni Salvi. One of the topics discussed was that verticality is restored with both VCAF and LCT. Stefanini said that it is immediate in VCAF, whereas verticality is restored after some time in LCT. Stavropoulos pointed out that compared to the maxilla, the mandible has a shallow vestibule and shorter alveolar ridge, which leads to a less stabilised wound. Hence, the techniques need to be adapted accordingly. When Sculean joined the panel, he highlighted the fact that 80 % of young patients develop recession post orthodontic treatment because activation of the retainers during orthodontic treatment pushes the teeth both labially and lingually. His recommendation was CBCT to check if enough bone is present both labially and lingually as part of the pre-treatment planning phase.

Second session: treatment of peri-implantitis The session which was moderated by Giovanni Salvi, started with a lecture by Frank Schwarz on surgical techniques for peri-implantitis treatment. He explained that selection of the approach depends on the category of the defect. He also recommended a non-reconstructive approach for implants with a machined surface, a reconstructive approach for class 1 defects with four walls present, and a combined approach for the more challenging cases. He explained that the combined approach consists of open flap debridement, implantoplasty and the application of a bone filler material. Regarding decontamination protocols, Schwarz highlighted that there is no scientific evidence that favours any decontamination protocol. Therefore, he recommends keeping it simple. The most important factor for successful treatment is the implant surface. Furthermore, he also explained the importance of concomitant soft

“Lots of questions arrived from the audience during the surgery, which were addressed live and in the panel discussion following the surgery.”

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tissue volume grafting (CTG or collagen matrix) to compensate for the insufficient thickness of the mucosa and to overcome soft tissue recession postoperatively.

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Salvi then introduced the patient of the second live surgery, which was performed by Andreas Stavropoulos: a systemically and periodontally healthy 34-year-old female patient with congenitally missing teeth 12 and 22 replaced by implants. Due to peri-implantitis on implant region 12, the cemented crown was removed one month ago and replaced with a temporary bridge to allow mucosal healing. A mesial defect with an infrabony component was visible in the radiograph. Buccal bone dehiscence was present. After opening the flap, the surface was cleaned with an air polishing device and implantoplasty was performed on the buccal side of the implant. The soft tissue situation was fragile in the central position over the implant and very difficult to manage. After implantoplasty, he harvested autologous bone chips locally to fill the defect and covered it with a collagen membrane cut into shape to cover the defect.

Photos: Basil Gürber

Mariano Sanz, Anton Sculean and Frank Schwarz joined Giovanni Salvi for the panel discussion after the live surgery. Andreas Stavropoulos also joined once he had finished the surgery. One of the topics discussed was whether implants should be placed at all in high-risk patients because of a periodontitis history. Sculean said yes and that also in those patients, predictable results can be achieved. However, he advised that an implant should never be placed in a periodontally compromised patient before systemic periodontal therapy has been completed, and only if the amount of bone and soft tissues is sufficient for implant placement and prosthetic planning. It requires a comprehensive treatment approach. When asked which factors minimise peri-implantitis, Sculean explained that prosthetics play an essential role to allow cleaning; also, the position of the implant, sufficient bone around the implant, the amount of attached mucosa and the thickness of the mucosa. Thank you very much to all the speakers, the attendees and the EFP to make this exceptional event happen.

After panel discussion

Mariano Sanz on the stage

Technical team behind the scene

OSTEOLOGY FOUNDATION

Interview

A chat with Fazeela Khan-Osborne Interview conducted by Dr. Marjan Gilani

You decided to build the new Harley Street dental center during the national lockdown in the UK? What were your hopes? Dr. Khan-Osborne: My lease was about to expire in May 2020. This required me to move and rebuild my existing practice. I knew this was going to be my last ever practice, so I wanted to take the lessons learned over 25-years and build the best clinic I could imagine: a happy and safe environment for my patients and team, and incorporating new features such as filtered clean air, a CBCT scanner and an in-house dental laboratory. Building a practice with top notch facilities during the lockdown sounds impossible. How did you make it happen? Yes, the plan was disrupted by the Covid-19 pandemic. No businesses were open. No building work was allowed. We met with four of my clients from a former project, galvanized their expertise and formed a new team to design, plan and build the center. The contractors were my patients, and the architect was my daughter.

What was the biggest challenge? I was stressed over the safety of all the workers, their social distancing, constant delays with materials and making sure my patients had service at the same time. But the result was amazing for all of us. We were like a family and helped each other make this dream come true. When were you able to start the courses and activities again? We were able to return to face-to-face activities, with social distancing, in October 2020. I was looking forward to it and to a brighter future. Today we need training more than ever. When you look back, what was your proudest achievement? I am immensely proud of the team. We all pulled together to make sure we were safe and did not compromise on the standard or quality of our work. The future is indeed looking bright.

BEFORE

Dr. Fazeela Khan-Osborne is an implant and restorative surgeon, and founding clinician of Harley Street practice in London. She teaches implant dentistry at her one-to-one dental implant course, one of the longest-running and well-known private courses in the UK.

GEISTLICH NEWS 2-2021

Photo: Dr. Fazeela Khan-Osborne

AFTER

Issue 1 | 22 will be published in February / March 2022. FOCUS

Complications: handling & prevention > Human Factors and medical errors > Expectation management with patients > Peri-implantitis: prevention is easier than cure > How to deal with dehiscences?

References for page 34-35 1

Sidambe AT. Materials (Basel) 2014 19; 7(12):8168-88. (review)

2 Chiapasco M, et al.: Clin Oral Implants Res 2021; 32(4): 498-510. (clinical study) 3 Sumida T, et al.: J Craniomaxillofac Surg. 2015; 43(10):2183-8. (clinical study) 4 Jung RE et al.: J Clin Periodontol 2013; 40 (1), 90-8. (clinical study) 5 Schwarz F et al.: Clin Oral Implants Res 2008; 19 (4), 402-15.(pre-clinical study) 6 Perelman-Karmon M et al.: Int J Periodontics Restorative Dent 2012; 32 (4), 459-65. (clinical study)

BACKGROUND

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Geistlich News - Edition 2, 2021 (English)

Articles inside

A chat with Dr. Fazeela Khan-Osborne

From Bern out into the world

Publishing information

A head without a body

Five questions for five experts

“Girls with dreams become women with a vision.”

“Why should we settle for 40-year old implant success criteria?”

“These patients will lose much alveolar bone if we do nothing.”

“The patient’s experience is key for us.”

Five ingredients of an effective social media account

One image for humanity A real life story, Turma do Bem

“Everything may work in the short term – but not necessarily in the long-term.”

“Time to unleash Geistlich’s energy!”