FOCUS PAGE 5 Minimally inva- sive approaches. How to understand the concept of "minimally invasive" in regenerative dentistry. BACKGROUND PAGE 29 Research and knowledge. The collaboration between company and university is a secret for success- ful discoveries. OUTSIDE THE BOX PAGE 26 Gene therapy for the eyes. The treatment of hereditary retinal diseases may no longer be a distant and unreachable horizon. GEISTLICH BIOMATERIALS Photo: iStock / AGEphotography VOLUME 12, ISSUE 1, 2018
Transcript
FOCUS PAGE 5
Minimally inva-sive approaches.How to understand the concept of "minimally invasive" in regenerative dentistry.
BACKGROUND PAGE 29
Research and knowledge.The collaboration between company and university is a secret for success-ful discoveries.
OUTSIDE THE BOX PAGE 26
Gene therapyfor the eyes.The treatment of hereditary retinaldiseases may no longer be a distant and unreachable horizon.
GEISTLICH BIOMATERIALS
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VOLUME 12, ISSUE 1, 2018
100 GEISTLICH NEWS 1-2018
LEADING REGENERATION.
3
Issue 1 | 2018CONTENTS
EDITORIAL
4 There is only one original. Since 1851.
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5 Minimally invasive approaches. 6 Dealing with extraction sockets: What makes the difference?
Dr. Daniele Cardaropoli | Italy
10 A less invasive tunneling technique for multiple recession defects Dr. Sofia Aroca | France
14 The challenge of treating cancer patientsProf. Rogerio Belle de Oliveira | Brazil
17 Where we started and where we are goingDr. Amit Patel | UK
20 Minimally invasive approaches for major indicationsDr. Alexander Volkmann | Germany
JOURNAL CLUB
22 Milestone studies. 23 From A to Z, an overview about surgically assisted orthodontics
Dr. George A. Mandelaris and Dr. Jim Janakievski | USA
OUTSIDE THE BOX
26 Gene therapy for the eyes.GEISTLICH PHARMA AG | OSTEOLOGY FOUNDATION
29 Background. 30 When the company meets the university: A win-win situation!
33 Gappy Preserve the Ridge
34 Can half a commitment earn all of your trust? Exactly.
35 All good things come in three’s
36 Latest news from the Osteology Foundation
INTERVIEW
38 @EAO 2017 with Alberto Sicilia. 39 Publishing information
4 GEISTLICH NEWS 1-2018
There is only one original. Since 1851.Editorial
Tradition and commitment go hand in hand and have been part of Geistlich’s long history for 167 years!
But what makes up the DNA of Geistlich? As it happens, you are its DNA. Our symphonic composition comes from a finely tuned, harmonic mix of important partnerships from a global network. Our researchers are in daily contact with leading uni-versities. Feedback from our customers and clinicians are fed into the further development of products, and esteemed scien-tists provide us with lively discussions on studies and courses.
A product of such interaction was the successful development of Geistlich Fibro-Gide®. We are delighted about the European launch of this resorbable, volume-stable collagen matrix, espe-cially designed for soft-tissue regeneration. You will be hearing more about this through all our communication channels. We are pushing forward with the registration and market launch and will roll the product out successively in other countries. Your local organization will be happy to provide you with infor-mation and advice.
The Focus section of this magazine looks at “minimally inva-sive surgical techniques.” We hope you find it interesting. Your feedback and suggestions regarding the magazine are import-ant to us. Also take the opportunity to check out our website and social media channels. Even better: talk to us in person – the ‘original’ regenerative dentistry supplier. An overview of courses and congresses can be found on our website.
We hope you enjoy reading the “Geistlich News” and learn plenty of new things!
Dr. Matthias DunkelDeputy Chief Operating Officer
Change Signa-ture
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MINIMALLY INVASIVE APPROACHES IN REGENERATIVE DENTISTRY.From recession coverage to ridge preservation – minimally invasive techniques for oral regeneration.
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extraction. Mainly, the limited sup-ply of cells coming from the periodon-tal ligament causes resorption of bun-dle bone. Also, when the cortical bone plate is thinner, the alveolar bone is re-sorbed crestally and more on the buccal than lingual side.2 Clinically this physi-ological remodeling results in horizon-tal and vertical ridge resorption.
In the first six-months following tooth ex-traction, the alveolar ridge can develop a mean horizontal width resorption of 3.8 mm and a mean vertical height resorption of 1.24 mm.3 Moreover, one year after tooth extraction the ridge can lose up to 50% of its original horizontal width.4 Starting with biological, anatomical and clinical princi-ples that rule the dynamics of post-ex-traction site healing, it is essential to at-tempt to maintain the original volume of the ridge. It is a common experience that delayed post-extraction sites present in-adequate bone volume for proper implant
placement. Therefore, if an implant place-ment is planned, additional ridge augmen-tation procedures are essential for coun-teracting ridge loss.
Two clinical situations, two solutionsWhat are the solutions for retaining proper bone volume? First, we need to differentiate between cases with in-tact and non-intact bony walls.
1 When an alveolus with three bony walls is 100 % intact, and the fourth wall displays no more than 20 % bone loss, and not exceeding 1-1.5 mm vertical loss5, Ridge Preser-vation preserves the ridge volume within the bony envelope existing at the time of extraction.3
2 In the case of partial or complete loss of one or more bony walls, Ridge Augmentation is recommended in order to increase the ridge volume beyond the skeletal envelope existing at the time of extraction.
Ridge Preservation: An all-in-one approachRidge Preservation is a surgical pro-cedure with a choice of different tech-niques that affect results:
› Extraction by flap elevation or no flap elevation,
› Type of filling material (autologous
Following tooth extraction, the maintenance of the original bone volume is paramount. But what parameters need to be considered? The expert opinion.
The healing process of post-extraction sockets is related to a series of biologi-cal events, including the formation of a coagulum replaced over time by:
› A provisional connective tissue matrix,
› Woven bone, › Lamellar bone and bone marrow.1
The development of the alveolar pro-cess is directly related to the presence of the natural dentition, and it follows different degrees of atrophy after tooth
Dr. Daniele Cardaropoli, ItalyScientific Director PROED, Institute for Professional Education in DentistryTorino, Italy
Dealing with extraction sockets: What makes the difference?
Ridge Preservation
“The placement of a proper bio-material in an extraction socket promotes bone modeling and compensates for marginal ridge contraction.”
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bone, allograft, xenograft or alloplas-tic material),
› Use of a membrane or not.
Predictable ridge vertical dimension re-sults can vary between an average gain of 1.3 mm to an average loss of 2.48 mm. And horizontal ridge results can vary between an average 3.25 mm gain to an average 2.5 mm loss.6
Clinical findings demonstrate that Ridge Preservation preserves the volume of the alveolar ridge predictably according to a biological compensation mechanism. The placement of a proper biomaterial in an extraction socket promotes bone
modeling and compensates for margin-al ridge contraction.7 (Fig. 1) The physio-logical resorption of bundle bone and the likely loss of the original buccal plate can-not be avoided. However, proper bioma-terial bone regeneration occurring with-in the alveolus creates a new volume of crest comparable to pre-extraction vol-umes. Therefore, technically, Ridge Pres-ervation does not conserve the alveolus but rather preserves the volume of the al-veolar ridge.
Clinical tipsSlowly resorbing biomaterials seem to be most effective in maintaining the initial three-dimensional volume of the
ridge.8 With an intact socket, it is advis-able to use a flapless approach to opti-mize results. Indeed, the elevation of a mucoperiosteal flap triggers a sequence of different biological phenomena and a transient hypoxia phase at the cor-tical level, which activates osteoclasts and subsequent bone resorption.9
Filling biomaterial: After extraction, the alveolus should be debrided and thor-oughly rinsed with saline to decontam-inate the site, before filling with a bio-material. (Fig. 2) The ideal biomaterial must be biocompatible, osteoconduc-tive and provide slow resorption to com-pensate for inevitable remodeling of the
Bone withoutpreservation
New boneformation
Bone preservation effect
Bone preservation effect
FIG. 1: THE BENEFITS OF RIDGE PRESERVATION WITH BONE HEALING AND REMODELING
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| A Baseline situation: Lateral view of a compromised upper right second premolar. | B Oc-clusal view showing the poor residual tooth structure. | C Periapical radiograph at baseline showing the deep carious lesion and the underfilling of the root canal system. | D Cone beam computed tomography (CBCT) evaluation showing a clear periapical lesion and no bone availability between the root apex and the maxillary sinus floor. The situation represents a contra-indication for immediate implant placement. | E Occlusal view of the extraction site after flapless approach. | F Geistlich Bio-Oss® Collagen placed in the fresh post-extraction socket after proper debridement. | G Geistlich Mucograft® Seal placed on top of Geistlich Bio-Oss® Collagen to protect the graft and seal the socket. The tridimensional matrix is sutured using 5/0 non-resorbable polytetrafluoroethylene. | H Lateral view 4-months post-operative. The soft-tissue healing is complete, and the initial anatomy of the ridge is preserved in its vertical dimension.
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libundle bone. The deproteinized bovine bone mineral possesses these character-istics: It preserves on average 93 % of the initial crest volume at four-months fol-low-up, the alveolus volume is virtually preserved, and histologically it consists of approximately 26 % new bone and 18 % residual bovine bone granules.5
Protective biomaterial: Typically, after the placement of the filling biomateri-al, the extraction socket is sealed using a resorbable collagen membrane or, more
FIG. 2, A-H: TREATMENT OF AN EXTRACTION SOCKET WITH MINIMALLY INVASIVE RIDGE PRESERVATION
recently, a tridimensional collagen ma-trix (Geistlich Mucograft® Seal). (Fig. 2) The thick, double-layer, porcine-derived, collagen matrix efficaciously protects the underlying bone graft and promotes sec-ondary healing of soft-tissues without the risk of infection. The smooth and dense outer layer of the collagen matrix limits bacterial penetration and encour-ages the migration of epithelial cells. Full closure of the soft-tissue usually occurs between the third and fourth week fol-lowing extraction.
Implant: Four to six-months after Ridge Preservation an osseointegrated implant can easily be inserted into a preserved bone ridge, with appropriate crest volume and ideally healed soft-tissues.10 (Fig. 2) A bone crest preservation technique is ap-plied to maintain the pre-existing hard and soft-tissue anatomy, provide a sta-ble crest volume and optimize functional and aesthetic results that simplify clinical procedures. These positive outcomes can also be expected despite the initial thick-ness of the buccal bone plate.11
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I Occlusal view 4-months post-operative. The horizontal width of the ridge is maintained and is comparable to the original volume. | J Periapical radiograph 4-months post-opera-tive showing complete bone fill of the extraction site. | K CBCT evaluation 4-months post-operative showing the preservation of the ridge volume both in the vertical and in the horizontal dimensions. | L After flap elevation, new tissue filling the socket, and an adequate horizontal width of the bone ridge suitable for implant placement. | M A 4.1 mm diameter implant is placed. More than 2 mm of bone thickness both buccal and lingual are available to maintain long-term stability. | N Diagram of the implant insertion: Primary stability increases during insertion (suggesting a complete contact between the implant threads and the bone surface) and ends with 35 Ncm final seating torque, which in this case is also the real insertion torque. | O Periapical radiograph after implant placement showing the implant in adequate bone volume. | P Histological evaluation of a Ridge Preservation site biopsy 4-months after extraction. The image reveals the abundant presence of newly formed bone and it is compatible with the insertion of an implant (magnification 100x).12, 13
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FIG. 2, I-P: TREATMENT OF AN EXTRACTION SOCKET WITH MINIMALLY INVASIVE RIDGE PRESERVATION
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References1 Cardaropoli G, et al.: J Clin Periodontol 2003; 30,
212–218.3 Hämmerle C, et al.: Clin Oral Impl Res 2012;
23(Suppl 5), 22-38.4 Schropp L, et al.: Int J Periodontics Restorative
Dent 2003; 23:313–323.
5 Cardaropoli D, et al.: Int J Periodontics Rest Dent 2012; 32: 421-430.
6 Vignoletti F, et al.: Clin Oral Implants Res 2012; 23 Suppl 5:22-38.
7 Araujo MG, et al.: Int J Periodontics Restorative Dent 2008; 28:123-135.
8 Avila-Ortiz G, et al.: J Dent Res 2014; 93(10):950-95.9 Nobuto T, et al.: J Periodontol 2005; 76:1346-1353.
10 Cardaropoli D, et al.: Int J Periodontics Restorative Dent 2015; 35(5):677-85.
11 Cardaropoli D, et al.: Int J Periodontics Rest Dent 2014; 34(2):211-217.
12 Haas R, et al.: Clin Oral Implants Res 1998; 9(2):117-22.
13 Zitzmann NU, et al.: Int J Periodontics Restorative Dent 2001; 21:288–295.
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Recession coverage still represents a challenge when it comes to severe defects. But proper tech-nique and material can help guarantee a successful outcome. Discover how.
The goal of a surgical procedure aimed at treating multiple recessions is to achieve complete root coverage that blends with the surrounding soft-tissue and ensures long-term stability with a sulcus depth no greater than 2 mm.
| A Initial gingival recession - mucogingival line. | B Gingival pouch and tunnel is dissected beyond the mucogingival line, and the collagen bundles are separated by curettes beneath the elevated flap. Papillae are then released.| C The connective tissue graft is placed slightly beneath the cementoenamel junction. | D The pouch covers the connective tissue graft completely and is maintained in a coronal position by sutures around the contact point. These sutures may or may not go through the graft, depending on the need for a coronal or interproximal displacement of the connective tissue graft.
FIG. 1: SUSPENDED SUTURES FOR MODIFIED CORONALLY
ADVANCED TUNNEL TECHNIQUE
Dr. Sofia Aroca, FrancePrivate Practice, Paris, FranceClinic for Periodontology, University of Bern, Switzerland
A less invasive tunneling technique for multiple recession defects
Recession coverage
The current, most commonly used tech-niques for treating multi-tooth reces-sions can be divided into two groups:
› Multiple coronally advanced split thickness flap1 where the papillae are incised,
› Tunneling where the papillae are not incised.
The tunneling technique for multiple reces-sion coverage derives from the supraperi-osteal envelope technique in combination with connective tissue grafts (CTG).2 One of the advantages of this method is pres-ervation of the gingival papilla continuity
and creation of a pouch containing a CTG, which is slightly exposed over the reces-sion. However, leaving the graft exposed can jeopardize the aesthetic result.
To overcome this problem, Azzi and Eti-enne proposed a modification to the su-praperiosteal envelope technique.3 This variation consists of a full thickness eleva-tion of the flap that continues beyond the mucogingival line to completely cover the CTG placed underneath. From a biolog-ical standpoint, the entire thickness dis-section and the integrity of the papilla en-sure optimal vascularization. Blood supply is of paramount importance, as the avas-
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| A Different depths of recessions visible at baseline. | B Connective tissue graft under the tunneled flap. | C Suspended sutures around the contact point. | D Clinical results after 18-months.
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FIG. 2: RECESSION COVERAGE IN MULTIPLE MILLER CLASS I RECESSION DEFECTS
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cular surface is extensive in multi-tooth recession defects. 4,5 There are several re-ports in the literature with the supraperi-osteal envelope technique used as initially described or with slight modifications.6-8
The modified coronally advanced tunnel techniqueDuring a modified coronally advanced tunnel technique, the exposed root is planed, and contact point composites stops are placed to prevent collapse of suspended sutures in the interproximal spaces.3-5 Initial sulcular incisions and flap separations are made with a mi-cro-tunnel elevator. Then the mucoperi-
osteal dissection is extended beyond the mucogingival line and under each papil-la to displace the flap together with the papillae in the coronal direction with-out tension. The muscles fibers or the remaining collagen bundles on the inner part of the flap alveolar mucosa are dis-sected with extreme care, using a blunt instrument to avoid perforation of the flap and to obtain a passive coronal po-sitioning. After flap preparation, a CTG or a substitute (collagen matrix, acellu-lar dermal matrix or enamel matrix de-rivative) can be placed underneath.Several suturing techniques are avail-able to stabilize grafts and the tunneled
flap coronally.9,10 Azzi and Etienne, and Aroca et al. stabilized the flap using suspended sutures around the con-tact point.3-5 According to the authors, the use of this particular suturing tech-nique ensures an extended coronal sta-bilization of the flap during the first two weeks of wound healing (Fig. 1).
Clinical efficacyClinicians still consider multiple reces-sion defects a challenge, as they repre-sent a complicated clinical situation. Many factors, besides the extended avascular surface, can influence the clinical outcome, i.e., different reces-
12 GEISTLICH NEWS 1-2018
sion depths, (Fig. 2) prominent roots, thin biotypes and interdental hard and soft-tissue loss. (Fig.3) All these fac-tors have to be taken into account when planning a surgical technique, especially if the ultimate goal of the surgical proce-dure is complete root coverage. System-atic reviews evaluating the predictability of various surgical techniques for multi-ple recessions indicate that the multiple coronally advanced split thickness flap with and without soft-tissue grafting and the modified coronally advanced tunnel technique using soft-tissue graft-ing are the most predictable ways to ob-tain complete root coverage in Miller Class I, II and III multiple recessions.11-14 Despite the predictability of these surgi-cal techniques, not all of them are effi-cacious for class III multiple recessions. A randomized controlled clinical study by Aroca et al. evaluated whether the addition of enamel matrix derivative (experimental group) with an modified
coronally advanced tunnel technique compared with subepithelial CTG (con-trol group) could improve treatment outcomes for Miller class III multiple re-cessions 1-year post-therapy. In 20 pa-tients with 139 recessions, the authors found that both treatments resulted in a root coverage of 82 % for test and 83 % for control groups. After one year, the gain in the vertical height of the papil-la (measured by the percentage reduc-
tion of the distance between the con-tact point and the top of the papilla) was 58.6 % for test and 59.2 % for control. Complete root coverage was achieved in eight of the surgeries (38 %) for both groups. The authors concluded that the modified coronally advanced tunnel technique provides predictable results for the treatment of Miller class III mul-tiple recessions. Stable results were ob-tained at 28 days, and there was no sig-
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FIG. 3: RECESSION COVERAGE OF CHALLENGING, MANDIBULAR MULTIPLE, MILLER CLASS III RECESSION DEFECTS
E
“The minimally invasive tunneling technique creates an optimal biological environment where healing processes can take place undisturbed, which, in turn, provides better predictability in complicated clinical situations.”
| A Multiple Miller class III recessions at baseline. | B Visible shallow vestibule and limited amount of keratinized tissue at baseline. | C Tunneled flap with connective tissue graft and suspended sutures around the contact point. | D Clinical results at 2-years follow-up. Changes in tissue thickness and depth of the vestibule are visible. | E Clinical outcome after 2-years.
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nificant difference within and between groups for the position of the gingival margin and papilla after 28-days and up to 12-months post-surgery.
CTG vs. biomaterialsAn adequate thickness of the gingival margin is the key to ensuring long-term stability.15,16 In thin biotype clinical cas-es it is mandatory to apply the right sur-gical technique. As described, the most common and predictable procedure is an advanced coronal flap combined with a CTG. However, very often a pa-tient with multiple recessions has a thin biotype, and, therefore, the harvesting of adequate CTG may be associated with increased patient morbidity, prolonged surgical time and postoperative compli-cations such as bleeding, numbness and sensitivity changes at the donor site.5 At-tempts have been made to develop new biomaterials to replace CTG harvest.
Among the collagen matrix family, Geistlich Mucograft® has been pro-posed as an alternative to subepithe-lial CTG in periodontal plastic surgery procedures. Its safety and clinical effi-cacy for root coverage procedures was reported in several preclinical17 and clinical studies.18,19
In 2013 Aroca et al. performed a 1-year prospective, randomized, controlled, split-mouth study to evaluate the clin-ical outcome when treating Miller class I and II multiple recessions using modified coronally advanced tunnel technique and using either Geistlich Mucograft® or CTG.5 At 1-year, com-pared with the baseline, both treat-ments resulted in statistically signifi-cant improvements for complete root coverage, mean recession coverage, keratinized tissue width and gingival
thickness. Complete root coverage was found at 42 % of test sites and 85 % of control sites, and the healing was un-eventful in both treatment groups. The authors concluded that the use of col-lagen matrix may represent an alterna-tive to CTG by reducing surgical time and patient morbidity.
A comprehensive surgical procedureThe tunneling technique is a minimal-ly invasive surgical procedure, as there are no vertical releasing incisions. In-ternal, gentle dissection of the mus-cles and collagen bundles allows for a passive coronal positioning of the flap. The vascularization is ensured by maintaining intact papillae and by performing a full thickness dissec-tion. This surgical technique, there-fore, creates an optimal biological en-vironment where healing processes can take place undisturbed, which, in turn, provides better predictability in a complicated clinical situation, such as in Miller class III recessions and with thin biotypes.
References1 Zucchelli G, De Sanctis M: J Clin Periodontol
2000; 30(10): 862-870.2 Allen AL: Int J Periodontics Restorative Dent
81(8): 1108-17.19 Molnár B, et al.: Quintessence Int 2013; 44(1): 17-24.
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are, for example, age and gender related functional and structural changes in soft and hard tissues, metabolic impairment and physical limitations. Women are prone to bone mineral loss during aging, and special care is necessary after can-cer therapy, especially in cases of breast cancer. In contrast, males are most vul-nerable to bone metastases secondary to prostate or lung cancer.2-4 Younger patients have higher rates of success af-ter cancer therapy. Accordingly, Guided Bone Regeneration (GBR) performed after cancer therapy on younger patients will result in higher rates of graft effec-tiveness and implant success.5,6
Patients must receive overall oral health and radiographic assessments. Before per-forming cancer therapy, the clinician must pay attention to the removal of ill-fitting prostheses, plaque and caries, gingivitis or periodontitis, and the extraction of hope-less teeth. Treatment of these conditions can prevent future undesirable oral compli-
cations during cancer therapy. During this phase of treatment, successful socket graft-ing can be done with Geistlich Bio-Oss® and Geistlich Bio-Gide® in alveolar sockets 90-days before radiotherapy and 45-days before chemotherapy, with final healing at six months.6-8
Cancer treatment optionsCancer treatment depends on several factors, including the cell-cause rela-tionship, location, and timing. The best options are separate or combined treat-ments of surgery, chemotherapy and/ or radiotherapy. In the dental office, pa-tients who win the battle against cancer require the most challenging treatment planning for reconstructive therapy. Surgical procedures, chemotherapy and radiotherapy entail comorbidities that affect function and structure of bone and soft-tissues for a long time. Os-teopenia and osteoporosis are possible complications that could impair treat-ment after cancer therapy.2,3,5,9,10
When dental practice faces neoplastic patients, risk and failure increase. Prop-er education and infor-mation are useful allies for successful therapy. However, what else should we consider? An overview of influencing factors and suitable treatments. Cancer is a worldwide disease with high rates of mortality. The International Agency for Research on Cancer (IARC) works constantly to update information about cancer-causing agents, key origin factors and prevention strategies. Ed-ucation and knowlege are essential to avoid the main contributing factors and to improve early cancer detection. Glob-al campaigns, like Pink October (breast prevention campaign), Blue November (prostate prevention) and campaigns against tobacco use increase awareness. Access to diagnosis and treatments in-fluence the possibility for improving knowledge. But early diagnosis is the most critical element, because it increas-es treatment success and survival rates.1
Influencing factors The combination of aging and cancer is a significant factor, with an increase in cancer prevalence in the elderly. There
The challenge of treating cancer patients
Guided Bone Regeneration
Prof. Rogerio Belle de Oliveira, Brazil Pontifical Catholic University of Rio Grande do SulDepartment of Oral and Maxillofacial SurgeryPorto Alegre, Brazil
“Education and knowlege are essential to avoid the main con-tributing factors and to improve early cancer detection.”
15
Radiotherapy is a high-energy radia-tion targeted at the cancer site, dam-aging the DNA synthesis of highly mi-totic and healthy cells and decreasing soft-tissue and bone vascularization around primary and secondary sites. Therapeutic radiation doses in the head and neck region will depend on the lo-cation, tumor size and associated lym-phatic chain. The energy ranges from
30 to 70 Gy in 20 to 40 irradiations. The clinical dose-related consequences ex-pected are tumor regression, xerosto-mia, oral mucositis, possibility of severe trismus, radiation-induced fibrosis and risk of developing osteoradionecrosis. The risk for osteoradionecrosis is age, time and energy dependent. Therefore, lower doses and fewer irradiation in-tervals decrease the chances of osteora-
dionecrosis development. Osteoradio-necrosis is a well-described condition characterized by a hypovascular med-ullary bone deterioration, impossibili-ty of bone repair and a primary inflam-matory process leading to severe bone loss. Irradiation residual effects on bone are permanent, and even 24 months af-ter radiation, lower levels of vascular-ization are observed, especially in the
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| A CBCT at baseline showing the right maxillary canine with an apical osteolytic area. | B Axial CBCT at baseline showing bone loss. | C Clinical situation before the treatment starts. View of the apical inflammatory lesion. | D Clinical view of the extraction socket. After extraction and enucleation of the inflammatory lesion, the socket was rinsed with a solution of 500 mg tetracycline in 20 ml sterile saline. | E Geistlich Bio-Oss® graft placed in the socket. | F Use of Geistlich Bio-Gide® to cover the socket filled with Geistlich Bio-Oss®. | G Axial CBCT at 6-months follow-up showing the newly formed bone. | H CBCT showing the clinical outcome at 6-months follow-up.
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FIG. 1: GBR IN A NON-HODGKIN LYMPHOMA PATIENT - A CASE REPORT
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A 38 year-old male patient, treated for non-Hodgkin lymphoma with che-motherapy. Five months after the last chemotherapeutic session, the patient
developed an inflamed apical lesion on the right maxillary canine. Clinical and laboratory exams were standard, and the treatment plan performed included
dental extraction and socket grafting for alveolar bone preservation and second-ary dental implant therapy.
16 GEISTLICH NEWS 1-2018
mandible and posterior maxilla.4,5,8,11-13 Hyperbaric oxygen therapy is one op-tion for preventing osteoradionecrosis and for improving bone graft and dental implant success, but there is limited sci-entific evidence for its use.14
Chemotherapy has a systemic cytotoxic effect on target neoplastic cells as well as normal cells. The worst side effects in-clude myelosuppression, thrombocyto-penia and an increased risk of infection. There is also a decrease in the number of stem cells and a reduced function in bone marrow, though cell recovery oc-curs 180 days after the last chemother-apy dose. Some patients’ treatment re-gimes may include monoclonal antibody to RANKL with or without systemic bis-phosphonates, and these patients re-quire more attention for the increased risk of bone necrosis.4,8,10,14-16
Focus on the patient When quantity and quality of bone are crucial for implant success and re-construction, GBR is a well-described graft technique with successful re-sults.3 (Fig. 1) GBR in cancer patients is a time-dependent technique. Mini-mally invasive approaches can be per-formed with appropriate results after 180 days of chemotherapy and after 360 days of radiotherapy. When mon-oclonal antibodies to RANKL and/ or systemic bisphosphonates are em-ployed, during active therapy or for maintenance, GBR must be delayed for 24-months. Also, in this case, min-imally invasive surgical approaches and short implants are preferable, but evaluation of the patient-specific sit-uation is highly recommended.8,13,15-17
Before surgery, the patient should un-dergo a global clinical and radiograph-
ic assessment. Evaluation of bone mineral density and laboratory exams are essential diagnostics for planning minimally invasive bone graft proce-dures. According to the latest system-atic review, C-terminal cross-linking telopeptide of type-1 collagen (b-CTx) has no predictive value in determin-ing the risk for osteonecrosis in bis-phosphonate patients,14 and the same applies to cancer therapy. The best option is evaluation of serum lev-els: calcium (Ca), alkaline phosphate, parathyroid hormone (PTH), vita-min 25-hydroxyvitamin D3 (vitamin OHD), albumin (Alb) and also assess-ment of bone mineral density (g/cm2) at the lumbar spine (L1-L4) and femo-ral neck. Another significant diagnosis using radiographic or cone beam com-puted tomography examination of the target area is the evaluation of previ-ous surgical sites or sockets for proper bone healing. Poor healing is a signifi-cant indication for higher risk of bone necrosis.3,8,10,16,17
Because of its less vascularized bone structure, the posterior maxillary re-gion is more prone to complications, and, in order to avoid a second surgical harvest site, autogenous bone grafts are not recommended for patients af-ter cancer therapy.11,16 The best option for this kind of patient is xenografts and collagen membranes. A minimal-ly invasive flap approach helps correct horizontal and vertical bone defects for immediate or delayed insertion of dental implants with excellent sta-bility. With minimal residual bone, shorter and smaller implants can be a good choice.8,13 Moreover, careful ma-nipulation of the mucoperiosteal flap and primary closure of the flap are es-sential during the surgical procedure.
Rinsing the surgical site with a solu-tion of 500 mg tetracycline in 20 ml sterile saline may improve outcomes.
References1 Torre LA, et al.: CA Cancer J Clin 2015; 65(2): 87-
108. 2 Purton LE, et al.: Journal of Bone and Mineral
Research 2015; 30(5):886–897. 3 Sharifian RA, et al.: Caspian J Intern Med 2017;
8(2): 91-98.4 Sörensen HT, et al.: BMJ Open 2017; 7: e016022. 5 Demian NM, et al.: Oral Maxillofacial Surg Clin N
Am 2014; 26: 193–207.6 Stavropoulos F, et al.: Oral Maxillofacial Surg Clin
N Am 2002; 14: 15–27. 7 Jansisyanont P, et al.: Int J Oral Maxillo Fac
10 Pérez MGS, et al.: J Clin Exp Dent 2011; 3(1): e31-42. 11 Romanos GE, et al.: Clinical Implant Dentistry
and Related Research 2015; 17(3): 598-609.12 Nooh N: Int J Oral Maxillo Fac Implants 2013; 28:
1233–1242. 13 Grötz KA, et al.: Clin Oral Investig 2014; 18(3):
687-98.14 Esposito M, Worthington HV: Cochrane Database
of Systematic Reviews 2013; 9.15 Kovács AF: Int. J. Oral Maxillofac Surg 2001; 30:
144–147.16 Romanos GE, et al.: Oral Oncology 2010; 46:
854–859.17 Claudy MP, et al.: Clin Implant Dent Relat Res
2015; 17(2): 402-11.
17FOCUS
Every dentist aims to improve and re-store proper function and aesthetics in patients affected by periodontitis. Ac-cordingly, it has been argued that peri-odontally compromised teeth should be treated for as long as possible and should only be extracted when periodontal and endodontic treatments are no longer possible.1,2 The extraction of teeth af-fected by periodontitis will not resolve the underlying host response problems contributing to the disease. Moreover, periodontally compromised but treated teeth are known to have survival rates equal to the survival rates of implants in well-maintained patients.3
Therefore, the question we should ask ourselves on a daily basis is: should we extract the tooth and replace it with a dental implant? This is a difficult ques-tion to answer, as both clinicians and patients are becoming aware that im-plants are not a permanent solution. Nowadays peri-implantitis reports are increasing, and many factors influence its risk, including bacterial and pos-sible occlusal factors. But when one looks at the evidence, a tooth can last a lifetime if maintained correctly by both the patient and the clinician.
The concept of periodontal regeneration in the beginningIn the past, periodontal regeneration was considered a treatment modality that allowed the patient to keep a tooth that was periodontally involved. The concept arose from the understanding of the healing of a periodontal pocket based on the studies of Murray et al., Hurley et al., and Melcher et al., where they noted that the epithelium had a protective role for the root surface.4-6 The authors also showed that the rap-id proliferation of the epithelium and gingival connective tissue formed long junctional epithelium. Later, a study by Nyman et al. demonstrated that the iso-lation of epithelium and gingival con-nective tissue from a periodontal defect using a barrier allowed the periodontal defect to heal with bone, periodontal
Regenerative surgical pro-cedures have long been considered a suitable method for restoring lost periodontal structure and functional attachment using the regeneration of cementum, periodontal ligament, and alveolar bone. But how did the regenerative concept de-velop? And what can we expect in the future?
Where we started and where we are going
Periodontal regeneration
Dr. Amit Patel, UKPrivate PracticeBirmingham, United Kingdom
FIG. 1: ONE-, TWO- AND THREE-WALL PERIODONTAL BONE DEFECTS.12
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18 GEISTLICH NEWS 1-2018
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FIG. 2: MINIMALLY INVASIVE APPROACH FOR PERIODONTAL REGENERATION IN A VERTICAL BONY DEFECT
A 41-year old non-smoking female de-veloped generalized chronic periodon-titis. She underwent a course of suc-cessful non-surgical therapy. Only one localized periodontal pocket did not
resolve: the upper left lateral retained a vertically bony defect. Periodontal re-generation was discussed as an option to improve the long-term prognosis. Therefore, a minimally invasive surgical
technique was utilized preserving the papillae. The bony defect was curetted, and the root surface was prepared for enamel matrix proteins and the place-ment of Geistlich Bio-Oss®.
| A Clinical situation before treatment: buccal view of an 8 mm pocket at the maxillary left site #11, mesial. | B Periapical long cone radiograph showing the vertical bony defect. | C No pocketing at site upper left one. | D Minimally invasive surgical technique: buccal incision. | E Minimally invasive surgical technique: flap is raised palatally. | F A two wall vertical defect is observed. | G Enamel matrix protein is placed into the defect. | H Geistlich Bio-Oss® is placed into the defect. | I Suturing with 5/0 polypropylene non-resorbable sutures (Laurell Gottlow Suture). | J Clinical situation 1-week post-op and suture removal. | K Buccal view at 1-year follow-up. | L Occlusal view at 1-year follow-up. | M-N No pocketing resolution of the vertical defect is observed at 1-year follow-up. | O Periapical long cone radiograph showing resolution of the vertical bony defect.
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“The question we should ask our-selves on a daily basis is: should we extract the tooth and replace it with a dental implant? This is a difficult question to answer.”
ligament and cementum.7 This study heralded the technique of Guided Tis-sue Regeneration (GTR) for periodontal regeneration by first utilizing a non-re-sorbable expanded polytetrafluoroeth-ylene (ePTFE) and later a resorbable collagen membrane placed over a peri-odontal defect,8 sometimes filled with a bone graft.9,10
Current conceptThe bony defects that allow greater predictably of periodontal regenera-tion are three- and two-wall defects.(Fig. 1) Three-wall defects provide the highest amount of regeneration due to the number of walls surrounding the bony defects able to stabilize the blood clot for proper healing and maturation and able to contribute the most bone cells for bony healing at the site. Over time surgical technique and technology have advanced to the point where we are now raising the tissues only slightly using the minimally invasive surgical technique (MIST) as suggested by Cor-tellini et al.11 The concept focuses on not elevating the gingiva too much to evaluate and treat periodontal defects. If the defect extends to another tooth or is circumferential, then the gingival tissues can be elevated further to ex-pose the defect, and more traditional periodontal regeneration techniques
can be performed by placing a bovine bone graft and a collagen membrane. On the other hand, if the bony defect is localized, then curetting the defect and assessing if the clot can be stabi-lized by the flap alone or by placing a bovine bone graft, sometimes mixed with enamel matrix proteins, enhances the outcome though less invasive peri-odontal regeneration. (Fig. 2)
Future perspectivesRaising large periodontal flaps is turn-ing into a treatment of the past, while performing minimal flaps is growing more common in everyday practice. Due to greater predictably of the tech-niques and better understanding of the biology of periodontal disease and healing, we can now reduce the mor-bidity involved with more extensive surgical procedures, and we can avoid placing dental implants in younger pa-tients – improving the prognosis for teeth before considering implants. And it is clear that we need to acknowledge periodontal regeneration as a predict-able modality.
References1 Lang NP, et al.: Ann Periodontol 1997; 2(1): 343-
356.2 Schwarz F, et al.: Peri-implant Infection: Etiology,
Diagnosis and Treatment. Quintessence Publishing. 2007.
3 Roccuzzo M, et al.: Journal of Clinical Periodon-tology 2011; 38(8): 738–45.
4 Murray G, et al.: American Journal of Surgery 1957; 93: 385–387.
5 Hurley LA, et al.: The Journal of Bone and Joint Surgery 1959; American volume 41-A: 1243–1254.
6 Melcher AH, Dreyer CJ: Journal of Bone and Joint Surgery 1962; 44B: 424.
plants could be inserted simultaneously (3.8 and 4.3 diameter). (Fig. J) The two implants were surrounded with autolo-gous bone chips obtained during drill-ing. Correct positioning was checked radiographically. (Fig. H) Wound healing progressed uneventfully, and orthodontic treatment was performed. After six months the implant abut-ment was placed for soft-tissue mod-eling. (Fig. L)
Why this treatment?Dental implant success depends on ade-quate bone support. In the case present-ed, it was necessary to build up vertical as well as horizontal ridge dimensions. Major ridge deficiencies, especially ver-tical and combined horizontal/ vertical defects, require bone augmentations with form-stable support to realize suc-cessful and uneventful Guided Bone Re-generation (GBR). Current major ridge
augmentation procedures employ mem-branes, conventional titanium meshes, bone shields, bone blocks and/ or na-tive bony walls with interposition-al grafting or distraction osteogenesis. Conventional titanium meshes are rec-ommended for combined bony defects of more than 3 mm. As they are adapt-ed to the ridge defect, titanium mesh-es require advanced surgical skills, and the procedure is often time-consuming. Furthermore, a high risk (up to 50%) for soft-tissue dehiscences has been record-ed.1,2 The new Yxoss CBR® titanium scaf-fold is a three-dimensional (3D)-printed scaffold that combines the advantages of titanium, 3D-imaging, planning tools and 3D-printing. Customized, the mesh has an optimized fit and preserves vol-ume for osteogenesis. Also, surgery time and the risk of soft-tissue dehiscences may be reduced. Compared with other techniques, the Yxoss CBR® technology
A significant ridge defi-ciency with horizontal and vertical dimensions. How shoud a three-tooth gap augmentation be treated with Yxoss CBR®? A 66-year-old female patient was re-ferred to receive implant therapy for a three-tooth gap in the left mandible. The clinical and radiographic evalua-tions demonstrated a significant ridge deficiency with horizontal and verti-cal dimensions. The horizontal ridge width was between 1 to 2 mm. Using dental digital volume tomography, an augmentation with a Yxoss CBR® was planned. (Figs. A, B) In the first step, a Yxoss CBR® titanium scaffold was in-serted. A ridge incision was performed, and a flap was prepared. (Fig. C) The Yxoss CBR® titanium mesh was fit-ted and filled with autologous bone, obtained using a SafeScraper Twist®, and Geistlich Bio-Oss® in a 50:50 mix. (Figs. D, E) The Yxoss CBR® was fixed using two screws (1.7 mm) and cov-ered with Geistlich Bio-Gide®. (Fig. F) The flap was adapted to ensure com-plete soft-tissue closure. During the following weeks wound healing was uneventful. After 14-weeks, the Yxoss CBR® was removed. (Figs. G-I) Horizontal ridge width was approxi-mately 5-6 mm, and two endosseous im-
Minimally invasive approaches for major indications
Case study
Dr. Alexander Volkmann, GermanyPrivate practiceJena and Eisenach, Germany
“Major ridge deficiencies, es-pecially vertical and combined horizontal / vertical defects, require bone augmentations with form-stable support to realize successful and uneventful GBR.”
38: 95–101.3 Buser D, et al.: J Periodontol 2013; 84(11):1517-27.4 Testori T, et al.: Int J Periodontics Restorative
Dent 2013; 33(4):467-75. 5 Galindo-Moreno, et al.: Clin Oral Implants Res
2014; 25(3):378-84.6 Testori T, et al.: Int J Periodontics Restorative
Dent 2013; 33(4):467-75.
allows combined autologous and xe-nogeneic bone graft augmentation. Geistlich Bio-Oss® offers protection from ridge volume loss due to resorp-tion, and given its osteoconductivi-ty, rapid and integrated bone growth.3-5 Autologous bone combines osteogene-sis, osteoconductivity and osteoinduc-tivity.6 The combination of autologous and xenogeneic products placed under the Yxoss CBR® scaffold gives us the pos-sibility to rebuild major 3D defects in our daily ambulant office.
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FIG. 1: A THREE-TOOTH GAP TREATED WITH YXOSS CBR®
| A Cone beam computed tomography (CBCT) showing the horizontal and minor vertical buccal bone defect. | B Clinical situation before the augmenta-tion. | C Intraoperative situation after opening the flap. | D Defect-specific 3D-printed Yxoss CBR®. | E Yxoss CBR® filled with autologous bone and Geistlich Bio-Oss® (50:50). | F Yxoss CBR® covered with a Geistlich Bio-Gide® membrane. | G Clinical situation 4-months after the augmentation. | H Intra-operative site during the removal of the Yxoss CBR®. | I Bone situation directly after the removal of the Yxoss CBR®. | J Intraoral situation after implanta-tion. | K Lateral radiograph of the implant placement with the full restore bone volume. | L Clinical situation after implant cover placement.
22 GEISTLICH NEWS 1-2018
MILESTONE STUDIES.From A to Z, an overview about surgically assisted orthodontics.
INTRODUCTION The idea of using surgery to speed orthodontic movement while also protecting and improving periodontal outcomes is not new. In 1959 Köle postula-ted that teeth would move more quickly if corticotomies were used to free them from surrounding dense alveolar bone. He made interproximal and apical cuts that allowed easier and faster tooth move ment, with the goal of maintaining the teeth within an adequate alveolar housing. He termed the phenomena as a “bony block movement.”1 Today, modern digital diagnostics can help determine which patients might benefit from and how to plan surgically assisted ortho-dontics; and relatively recent periodontal tissue and alveolar ridge augmentation techniques have provided a regenerative approach for enhancing and insulating the periodontium, so that the prognosis for the entire dentoalveolar bone com-plex is improved.
Dr. George A. Mandelaris Private Practice, Oakbrook Terrace, Illinois, USAAdjunct Clinical Assistant ProfessorUniversity of Illinois, College of Dentistry; Chicago, USA
Dr. Jim Janakievski Private Practice, Tacoma, Washington, USAAffiliate Assistant Clinical ProfessorSchool of Dentistry, University of Washington, USA
JOURNAL CLUB
THE PROBLEM
Even though they do not show clinical signs of attachment loss, roughly 12% of maxillary central incisors lack facial bone.2 In patients with thin buccal bone, orthodontics can unintention-ally move teeth outside alveolar boundary conditions, leading to loss of alveolar bone height and width changes. This can lead to significant buccal bone dehiscences – particularly around re-tainer (banded) teeth and first premolars – and development of intraosseous defects at orthodontic extraction sites.3,4 With malocclusions (proclined teeth), 35-55% of cases present with fenestrations and dehiscences, especially in the anterior, so that, when treated orthodontically without surgical intervention, these thin alveolar phenotypes may lead to fenestrations, root resorptions and gingival lesions.5-7 However, improved risk as-sessment can be identified using state of the art diagnostics, and soft and/ or hard tissue augmentations can be planned to reduce the incidence of iatrogenic sequelae. Diagnostic imaging can provide simulated outcomes that can be shared with patients to avoid problems and provide improved informed consent.8
THE SOLUTION
There have been several procedures developed to deal with limited alveolar anatomy; however, all surgically assisted orthodontic procedures facilitate orthodontic movement by nature of the procedure. Perhaps more importantly, complex orthodontic tooth movement must be performed within the available dentoalveolar bone envelope, sometimes referred to as the “orthodontic walls.”9 Two procedures that combine corticotomy and dentoalveolar decortication with particulate bone grafting have received considerable attention – peri-odontally accelerated osteogenic orthodontics (PAOO) which was first publicized by Wilcko in 2001,10 and surgically facil-itated orthodontic therapy (SFOT) which was published by Roblee in 2009.11 There are subtle differences between the procedures (for example, with SFOT, ridge augmentation is generally provided only in the direction of proposed tooth movement whereas PAOO infers corticotomy surgery on both buccal and lingual sides), but for the purposes of this review, the term “surgically assisted orthodontics” (SAO) is intended to represent any surgical orthodontic procedure that employs a corticotomy accompanied with bone augmentation.
24 GEISTLICH NEWS 1-2018
Corticotomy surgery is used to injure cortical bone, often extend-ing into the medullary bone, depending on need, and “freeing” teeth to move more quickly. The injury produces a demineralized bone matrix that facilitates tooth movement for a transient peri-od of time (months). The phenomena is referred to as a “regional acceleratory phenomena or RAP.” Guided periodontal tissue re-generation and alveolar augmentation techniques are used to aug-ment bone volume so that teeth are provided with an expanded
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FIG. 1: SURGICALLY ASSISTED ORTHODONTICS USED TO FACILITATE MOVEMENT OF ANTERIOR MANDIBULAR TEETH
FIG. 2: CBCT DIAGNOSIS, PLANNING AND OUTCOME
| A Presentation. | B Flap reflection. | C Corticotomies. | D Application of Geistlich Bio-Oss® as bone graft outer layer/ protection. | E Closure at surgery. | F 1.5-months post-operative. | G 2.5-months post-operative. | H 9-months post-operative. | I-J Initial and final occlusion.
| A 3D regional anatomy presenta-tion. | B Interactive 3D desired tooth position for expansion orthodontia and theoretical consequence on the dentoalveolar complex. | C Actual outcome using surgically assisted orthodontics.
orthodontic envelope within which they can move. At the end of treatment, the periodontium is enhanced in terms of both hard and soft-tissue characteristics. SAO techniques also vary in degree, for example, employing less invasive approaches with no vertical incisions or “piezocisions.” 12,13 A typical SAO case is depicted in Fig. 1 A-J, and a case diagnosed, planned and followed with in-teractive orthodontic cone-beam computed tomography (CBCT) scan imaging software is depicted in Fig. 2 A-C.
DIAGNOSIS AND TEAM PLANNING
When planning orthodontics, thick dentoalveolar bone phenotypes are less prone to iatrogenic sequelae secondary to tooth movement when compared to thin dentoalveolar bone phenotypes.14 Accord-ingly, sites with ≤ 2 mm of attached gingiva should receive gingi-val augmentation prior to orthodontics,15 and sites with ≤ 1 mm of bone around tooth roots may benefit from corticotomy with ridge augmentation.16,17
Using CBCT and clinical photos, a Tx plan can be developed based on risk assessment of dentoalveolar bone phenotype. Mandelar-is published a helpful CBCT-based dentoalveolar bone phenotype classification and risk assessment in 2013.18 A simplified version is depicted in Fig. 3. Such an assessment can be used, along with the CBCT images and clinical photos, to develop a treatment plan shared between surgeon, orthodontist and restorative practitioners. The value of such a synergistic, proactive and team-planned ther-apy cannot be overemphasized.
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FIG. 3: DENTOALVEOLAR BONE PHENOTYPE CLASSIFICATION
FOR SURGICALLY ASSISTED ORTHODONTICS
References1 Kole H: Oral Surg Med Oral Pathol 1959; 12:515-529.2 Nowzari HM, et al.: Clin Dent Imp Rel Res 2012; 14: 595-602.3 Lombardo L, et al.: Prog Orthod 2013; 14:29. 4 Lund H, et al.: Eur J Oral Sci 2012; 120:201-211.5 Yagci A, et al.: Angle Orthod 2012; 82: 67-74.6 Castro IO, et al.: Angle Orthod 2013; 83: 196-203. 7 de Freitas JC, et al.: Dental Press J Orthod 2013; 18: 104-112.8 McGuire MK, et al.: J Periodontol 2009; 80: 550-564.9 Handelman CS: Angle Orhtod 1996; 66: 95-101, discussion 109-110.10 Wilcko WM, et al.: Int J Periodont Restor Dent 2001; 21:9-19.11 Roblee RD, et al.: Compend Contin Educ Dent 2009; 30: 264-275.12 Murphy KG, et al.: J Oral Maxillofac Surg 2009; 67: 2160-2166.13 Dibart S, et al.: Compend Contin Educ Dent 2009; 30: 342-344, 346, 348-350.14 Chambrone L, Tatakis DN: J Periodontol 2015; 86(Suppl. 2): S8-S51.15 Kim DM, Neiva R: J Periodontol 2015; 86(Suppl. 2); S8-S51.16 Coscia G, et al.: J Oral Macillofac Surg 2013; 71: 1760.e1-e9.17 Wang B, et al.: J Oral Macillfac Surg 2014; 72: 596-602.18 Mandelaris GA, et al.: Int J Periodont Restor Dent 2013; 33: 62-69.19 Al-Naoum F, et al.: J Oral Maxillofac Surg 2014; 72: 1880-1889.20 Wlcko MT, et al.: Semin Orthod 2008; 14: 305-316.21 Makki L, et al.: Angle Orthod; 85:743-9.22 Suya H: Meachankcial and Biolaogical Basics in Orthodontic Therapy 1991;
1991: 207-226. 23 Zimmo N, et al.: Compend Contin Educ Dent 2017; 38(1):17-25.24 Mandelaris GA, et al.: J Periodontol 2017; 88(10):960-977.
Note: This article owes its content to and is based on two 2017 reviews: Corticoto-my-Accelerated Orthodontics: A Comprehensive Review and Update by Zimmo et al.,23 and a Mandelaris et al. American Academy of Periodontology Best Evidence Review focusing on risk assessment of dentoalveolar bone changes influenced by tooth movement.24
ADVANTAGES, DISADVANTAGES AND CAUTIONSSAO expands the treatment envelope for patients with maloc-clusion. SAO can (1) place teeth in the correct position for facial esthetics; (2) transform the dentoalveolar bone phenotype to enable correct tooth placement to occur and reduce the risk of adverse sequela, especially in vulnerable phenotypes; (3) opti-mize anterior articulation parameters; (4) enhance long-term orthodontic stability and retention; and, (5) respect airway di-mensions by increasing oral cavity volume opportunities via reducing the need for extraction/retraction orthodontia, when appropriate. By providing an adequate/augmented dentoalve-olar bone complex post-orthodontically, SAO simultaneous-ly promotes periodontal regeneration, alveolar augmentation and root coverage / mucogingival augmentation, but most im-portantly improves the prognosis for the entire dental com-plex post-therapy. In this regard, SAO may reduce the risk of periodontal problems, namely recession based attachment loss, which is the critical post-orthodontic problem to over-come with expansion. SAO is, on average, three times faster than traditional orthodontic therapy.19,20 In addition, it expands what is possible with tooth movement and reduces the inci-dence of relapse.21 Despite these advantages, there are no hu-man clinical studies demonstrating long-term efficacy of SAO. Patients should be guided to understand the benefits and lim-itations of this combined surgical procedure so they can make the best decisions for their treatment.
RECOMMENDATIONS
CBCT diagnosis is recommended, particularly in patients re-quiring expansion with thin alveolar phenotype. Applying heavy orthodontic forces to take advantage of the deminer-alized bone matrix produced from SAO surgery should begin within 7-10 days of surgery. At this time, the regional accelera-tory phenomena within the dentoalveolar complex will be pres-ent, but the opportunity to move teeth at an increased rate will slow as bone heals. Orthodontic movement should be planned to occur within 3-4 months, which underscores the importance of planning and co-ordination between surgery and orthodon-tics.22 Interdisciplinary planning and treatment sequencing are keys to SAO success.
Position/type ThickBone > 1mm
ThinBone < 1mm
Crestal PhenotypeBone 4mm from CEJ x x
Radicular PhenotypeBone half root length x x
26 GEISTLICH NEWS 1-2018
GENE THERAPYFOR THE EYES.What sounds like science fi ction could become reality in thenear future: People with hereditary retinal diseases are givennew genes in their eyes to prevent them from going blind.The fi rst drugs are about to be approved.
Our sophisticated retina is susceptible to all kinds of mutations and hereditary dis-eases. For example, so far over 250 diff er-ent genetic visual impairments have been cataloged.1 According to an extensive study published in the scientifi c journal “Na-ture,” just for age-related macular degener-ation (AMD) alone, 52 gene variants, which are associated with increased susceptibil-ity to the disease, have been found at 34 points in the human genome.2 In the west-ern world AMD is the principal cause of se-vere visual impairment in people over the age of 60. There are currently some eleven million people living with AMD in the USA alone. Experts expect this fi gure to double to 22 million by the year 2050 due to rising life expectancies.3
Transfection of helpful genesAbout 15 percent of AMD suff erers have the neovascular “moist” form (nAMD).
Due to the ingrowth of small blood ves-sels into the retinal pigment epithelium, this macular degeneration can give rise to retinal cell necrosis and blindness within two years, if left untreated.4 The cause is an increased concentration of vascular endo-thelial growth factor (VEGF). Currently, al-though conventional therapy can delay the progression of nAMD through treatment with VEGF antibodies, patients have to be administered a complicated and expensive injection in the eye every six weeks due to the relatively short-term eff ectiveness of these antibodies.
A consortium of 13 scientifi c teams from nine European countries (TargetAMD) is working on an alternative research ap-proach: A gene transferred into the eye enables endogenous cells to multiply pro-duction of a particular protein that coun-teracts vascular ingrowth and, thus, the lo-
OUTSIDE THE BOX
Dr. Klaus Duff ner
cal destruction of retinal cells. The gene is transferred outside the body using a “gene transporter” in previously harvested en-dogenous pigment-epithelial cells. The project’s coordinator Prof. Gabriele Thu-mann, Director of the Eye Clinic at the Uni-versity Hospital of Geneva, stressed that the transporter is not a typical viral vec-tor but a molecule named “sleeping beau-ty transposase:” “Although viruses are very eff ective as gene shuttles, they harbor the risk of menacing immune responses or on-cogenic reactions. Therefore, we opted for a non-viral enzyme transposon system.”5 When the cells have received the desired gene, they are re-transplanted into the eye in the same surgical session. There they act like a long-term drug, continuously sup-plying the pigment epithelium-derived factor (PEDF) proteins to the area of con-cern and inhibiting VEGF. Transfection of the helpful genes into the cells has already been successfully confirmed by an ex-tensive series of in-vitro tests. The initial in-vivo experiments on rats demonstrat-ed the inhibition of blood vessel ingrowth and, therefore, the therapy’s effi cacy. When these investigations are completed, the fi rst clinical studies are set to begin in the near future. If the procedure is successful and if it is able to retain eyesight in AMD suff erers, scientists believe that it could revolutionize ophthalmology.
Gene therapy about to beapprovedAn ophthalmological gene therapy, which could also benefi t small children, is about to be approved by the US-American Food and Drug Administration. In early child-hood, retinal degeneration mutations
the neovascular “moist” form (nAMD).
OUTSIDE THE BOX
in-vivo experiments on rats demonstrat-ed the inhibition of blood vessel ingrowth and, therefore, the therapy’s effi cacy. When these investigations are completed, the fi rst clinical studies are set to begin in the near future. If the procedure is successful and if it is able to retain eyesight in AMD suff erers, scientists believe that it could revolutionize ophthalmology.
Gene therapy about to beapprovedAn ophthalmological gene therapy, which could also benefi t small children, is about to be approved by the US-American Food and Drug Administration. In early child-hood, retinal degeneration mutations
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28 GEISTLICH NEWS 1-201828 GEISTLICH NEWS 1-2018
occur in the gene RPE65 causing a reduc-tion in the protein RPE65. This protein is a crucial enzyme in the visual cycle. If light falls on a photoreceptor, the visual pigment11-cis-retinal decays, generating a light stimulus perceived by the brain. Regenerating the visual pigment for the next light stimulus requires the enzyme RPE65. As rods rely 100 percent on the 11-cis-retinal from the visual cycle, their
loss is linked to full night blindness. Con-versely, cones seem to be less severely af-fected by the disease, although, at least at the beginning, a residual visual capacity is retained. In Germany 150 to 200 peo-ple suff er from this particular retinal dis-ease.1 The new treatment involves intact versions of the RPE65 gene packaged into empty virus shells and injected beneath the retina in a complicated operation. The virus shells thus serve as gene shut-tles that infect the visual cells and then discharge the new RPE65 genes into the interior of the cell, where they are then
available for producing the missing en-zyme. “The treatment has proved to be safe in all the studies published,” says Prof. Birgit Lorenz, Director of the Clinicfor Ophthalmology at the UniversityClinic Giessen in the “Ärzteblatt.”6
Seeing better in twilightDespite the therapy’s inability to restore previously dead sensory cells and en-
abling improved visual acuity, further disease progression is slowed. For ex-ample, a recently published, random-ized, phase-3 study included 31 patients with RPE65-related retinal dystro-phy, aged between three and 44, whose eyesight and peripheral fi eld of vision were already restricted.7 In the 20 pa-tients treated there was improvement in multi-luminance mobility testing by 1.8 light levels, compared to a gain by 0.2 light levels in the untreated control group. Multi-luminance mobility testing evaluates patients’ ability to complete a
“Although viruses are very effec-tive as gene shuttles, they harbor the risk of menacing immuneresponses or oncogenic reactions. Therefore, we opted for a non-viral enzyme transposon system.”Prof. Gabriele Thumann – Eye Clinic at the University Hospital of Geneva
mobility parkour under diff erent light-ing conditions. According to study lead-er Dr. Stephen Russell at the University of Iowa, USA, 13 of the 20 treated patients who were examined in a follow-up were able to orient themselves at the lowest luminance level (1 lux). This maximum possible improvement demonstrates the patients benefi tted in poor lighting con-ditions. The gene therapy is currentlybeing tested for other hereditary eye dis-eases. For example, in the future new genes in the eye might also help patients with congenital night blindness and pro-gressive visual fi eld restriction (choroi-deremia) or extreme color blindness.
7 Russel S, et al: Lancet 2017; 390, 10097: 849–860.
29BACKGROUND
BACKGROUND.GEISTLICH PHARMA AG | OSTEOLOGY FOUNDATION
30 GEISTLICH NEWS 1-2018
A synergic research
When the company meets the university: A win-win situation!
Prof. Sailer, you started a new position at the University of Geneva four years ago. What is new compared with your previous job at the University of Zurich?Prof. Sailer: My duties as Head of the Division of Fixed Prost-hodontics and Biomaterials at the University of Geneva are dif-ferent from the tasks that I had as Scientific Head of Unit at the Clinic for Fixed and Removable Prosthodontics and Material sci-ence at the University of Zurich. In Zurich I was responsible for the laboratory and clinical research in prosthodontics. Today, my most important tasks are the definition of the division’s fu-ture mission, its research areas and the teaching, mentoring and supervision of pre- and post-graduate students. Together with my faculty co-workers and biomaterials scientists, we are defin-ing pre-clinical and clinical research collaborations with the aim of establishing an orchestrated future development. Moreover, today I am more involved with management. Finally, I had to im-prove my French to be able to communicate and teach, and I had
Dr. Giulia Cerino | Geistlich Pharma AG
to learn to understand the mentality of the population. All in all, the move was a fantastic, horizon-widening challenge!
How is the educational path organized within your university? Prof. Sailer: Our division performs education on two levels. We teach pre-graduate students, the future dentists, in recon-structive dentistry and biomaterial sciences. The undergrad-uate students learn how to treat patients in the beginning on phantom heads and then in the pre-graduate student clin-ics. We are responsible for the teaching of “fixed prosthodon-tics”, “occlusions” and “biomaterials.” Besides this pre-gradu-ate education, the prosthodontic divisions are accredited for a three-year post-graduate specialization program in recon-structive dentistry (SSRD), and part of our academic activities is educating future specialists. With this our university has a major role for future specialists within the French speaking part of Switzerland.
Geistlich believes in strategic collaborations with universities, and with the University of Geneva, Geistlich found a new partner for quality research. Prof. Irena Sailer, Head of Geneva’s Division of Fixed Prosthodontics and Biomaterials, and Dr. Birgit Schäfer, Geistlich’s Executive Scientific Manager, talk about synergies between the two organizations.
“The future will be fruitful for both sides. For us, a further collaboration means access to specific information; the opportunity to evolve further and develop directions in which Geistlich is interested,” says Prof. Irena Sailer (right) . And Dr. Birgit Schäfer (left)adds: “Geistlich will benefit from an exchange of knowledge. On the one hand, we can provide extensive knowledge and experience con-cerning our marketed biomaterials. On the other hand, the University of Geneva offers clinical expertise, patient surgery perspectives, surgical techniques and equipment.”
Phot
os: A
lfons
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31BACKGROUND
How big is your team, and how is it organized? Prof. Sailer: In our division more than 30 collaborators are work-ing together synergistically: eleven full-time and part-time faculty members, eight post-graduate specializing students, five biomate-rials researchers. Finally, clinical staff and secretaries. As academic leader of the dental technical laboratory of our University Dental Clinics, I am responsible for the development of the dental tech-nical laboratory staff. With respect to the biomaterials research, we are mechanically testing restorative materials like ceramics with one part of the group, but more intensely developing biologically oriented biomaterials research, an area that we also aim to evolve within our collaboration with Geistlich. Moreover, recently, we started also to develop the regenerative field concerning digital technologies to foster personalized dentistry, with the expectation of a better clinical outcome for our patients.
What are your primary current scientific interests concerning clinics and basic research?Prof. Sailer: The interest on the clinical side is fixed-prosthodon-tics and dental implantology, tooth-, and implant-supported re-constructions, including all the aspects of digital technology for diagnostics, treatment planning, treatment execution, selection of the material and therapeutic options. Concerning basic research, we benefit from the biomaterials group. Together we are working on translational projects concerning the development of new re-generative procedures, including 3D technologies.
How does your current research relate to your previous work in Zurich?Prof. Sailer: I started restorative and digital technology research when I was in Zurich. As team member, I was responsible for the prosthodontic aspect of research activities with Prof. Hämmerle’s group. Now we can expand surgical research, creating our exper-tise with the support of the biomaterials scientists.
How does the University of Geneva foster your research? Equipment, facilities? Prof. Sailer: We just moved into a new dental clinic – really a beau-tiful environment, highly luxurious, with a lot of new equipment for clinical and scientific work. We have research labs for the ba-sic scientists with modern equipment. Recently, a scanning elec-tron microscope was aquired thanks to the sponsorships of the Swiss Society of Dentistry and several local foundations. In ad-
dition, the institution offers numerous opportunities to benefit from cutting-edge fundamental research equipment in collabo-ration with the medical faculty scientists, as micro-computed to-mography , microscopy analysis and magnetic resonance imaging. Moreover, we have the equipment to perform biomechanical tests, such as mastication simulation devices, and recently we acquired a 3D-bioprinter.
These research capabilities allowed the beginning of a collabora-tion between the University of Geneva and Geistlich. On what? Prof. Sailer: As a first project, we proudly participated in a multi-center study evaluating the performance of Geistlich Fibro-Gide® around dental implants. Prof. Hämmerle was the principal inves-tigator, so we appreciated this collaboration very much. Dr. Schäfer: For Geistlich the collaboration with the University of Geneva is entirely new. We are delighted to expand our portfolio of academic partnerships to the French part of Switzerland! Moreover, the proximity of the University of Geneva with Wolhusen offers us a quick connection for discussions linking scientific findings in ba-sic and clinical research. For both sides this is a win-win situation!
You are also interested in Geistlich Bio-Oss® Collagen. Why?Prof. Sailer: The interest for Geistlich Bio-Oss® Collagen is for several clinical reasons, such as the ease of application. Geistlich Bio-Oss® Collagen can easily be shaped and the application is less technique sensitive than the use of Geistlich Bio-Oss® granules.Dr. Schäfer: We are interested in understanding Geistlich Bio-Oss® Collagen in more detail: the architecture of the material, how the collagen component incorporates the granules, and how it behaves in vitro and in vivo. This knowledge could provide us with param-eters for improving “Geistlich Bio-Oss® Collagen version 2.0,” with even better performances.
“The mutual goal of our collabora-tion is to evolve the field of regen-eration and to exchange expertise and research.”Prof. Irena Sailer, Head of Geneva’s Division of Fixed Prosthodontics and Biomaterials.
What is the goal of the collaboration? Prof. Sailer: The mutual goal of our collaboration is to evolve the fi eld of regeneration and to exchange expertise and research.Dr. Schäfer: We would like to establish standardized in vivo pre-clinical models to improve testing meaningfulness. Indeed, it is fundamental that the applied models are validated to obtain reproducible results comparable with pre-defi ned and stringent criteria. This will ensure the generation of trustworthy data, with proper controls, based on which we can decide if tested new prod-ucts are safe and perform as expected. Moreover, since Geistlich products are our bench marking products, with these test systems we are able to document and demonstrate, with high confi dence, whether a newly developed material meets Geistlich's high qual-ity expectations.
What are basic in vivo pre-clinical models? Prof. Sailer: In vivo pre-clinical models allow performance testing of a new biomaterial and are required before clinical trials start in humans. Of course they can vary depending on the study ques-tions. At the University of Geneva, we can provide studies using small animals such as mice, rats, and rabbits, but also sheep and pigs. We do not have canine models, but in case a dog study is re-quired, we could take advantage of our proximity to and our collab-oration with the University of Lyon, established years ago.Dr. Schäfer: Small animal models help to characterize the ma-terials, particularly when used as screening models. Regarding Geistlich Bio-Oss® Collagen, we are interested in testing the ma-terial in rabbit calvaria defect models. It is a rather simple test sys-tem for investigating performance of biomaterials in bony tissue resembling the mesenchymal bone of the jaws. In collaboration with Prof. Sailer we are currently evaluating whether it is feasi-ble to test our biomaterials in other locations of the skull. If so, we could better align our test systems with the “real” dental applica-tion of Geistlich Bio-Oss® Collagen – namely alveole and maxilla.
What milestones have been achieved, and what remains to be done? Prof. Sailer: As in all projects, a preliminary study represents the fi rst milestone. We established the procedures and the respective analytical methods, we started to validate the early results, and then… I would say the sky is the limit (laughs)! Dr. Schäfer: Once it is clear which models apply, we will start with the “real” investigation. We will draft a detailed plan concerning
the biomaterial tested – timelines, experimental groups (controls, and test groups), and animal populations needed for each condi-tion in order to provide proper statistical evaluations and get sig-nifi cant results.
Last question: How do you see your future with Geistlich, and what do you need to continue this fruitful collaboration? Prof. Sailer: The future will be fruitful for both sides. For us, a fur-ther collaboration means access to specifi c information; the oppor-tunity to evolve further and develop directions in which Geistlich is interested. Moreover, as always and what all universities seek, we need the fi nancial support to pursue our scientifi c interests. Based on the results we achieve, we plan to submit grant propos-als to the Osteology Foundation. Competitive grants, like the one off ered by the Osteology Foundation, are highly desirable from the academic point of view. We will certainly apply to other competi-tive fellowships, and we are regularly collaborating with industry.Dr. Schäfer: Geistlich will benefi t from an exchange of knowledge. On the one hand, we can provide extensive knowledge and expe-rience concerning our marketed biomaterials, collagen and natural bone mineral. On the other hand, the University of Geneva off ers clinical expertise, surgical techniques, equipment , and last but not least, the patients' perception of the surgical intervention. Thus, we can develop biomaterials with a translational approach - combining surgical conditions, patient and surgeon expectations, clinical and basic science – all in a 3rd party, objective environment. So every-thing we need to develop biomaterials appropriately can be realized with such a collaboration!
“Everything we need to developbiomaterials appropriatelycan be realized with such acollaboration!”Dr. Birgit Schäfer, Geistlich’s Executive Scientifi c Manager.
Register now:www.gappy-game.com
Exactly like no other.
Gappy preserve the ridge: The new online video game by Geistlich Biomaterials
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Register your highscore and win 6x free registration
for the
International Osteology Symposium
in Barcelona25 – 27 april 2019
32 GEISTLICH NEWS 1-2018
33BACKGROUND
Register now:www.gappy-game.com
Exactly like no other.
Gappy preserve the ridge: The new online video game by Geistlich Biomaterials
preserve the ridge
Register your highscore and win 6x free registration
for the
International Osteology Symposium
in Barcelona25 – 27 april 2019
Register your highscoreRegister your highscore
34 GEISTLICH NEWS 1-2018
Several implant companies sell biomaterials. However, their core business, expertise and focus remain with implants. Is this half a com-mitment to bone and soft-tissue regeneration all you deserve?
Can half a commitmentearn all of your trust?
Collagen Processing
Dr. Mireia Comellas | Geistlich Pharma AG
Exactly. We, at Geistlich Biomaterials, are 100 % committed to regenerative biomaterials. Regeneration isn’t just part of our business, it’s all of our business. 10 % of our revenue is reinvest-ed in research and development. More than 35 employees are fully dedicated to R&D, pre-clinical and clinical investigations. We own and control 100 % of our manufacturing process. Our experience, gained over generations, is your asset when it comes to treating patients with the best possible regenerative solutions. An example.
The challenge
You probably know the situation – a patient gets an implant, but the lack of soft-tissue thickness around the implant could compromise implant success and esthetic outcome. As the his-torical "gold standard" connective tissue grafts have proved ef-fective, but a second surgical site for graft harvesting always in-volves additional pain and risks such as bleeding or infection.1
And the amount of autologous tissue that can be harvested is limited. Is this necessary?
The Process
Driven by the goal of simplify ing regenerative treatments and minimizing patient’s discomfort through the use of the very best substitute biomaterials, Geistlich has built a solide and unique expertise in collagen processing. This allows us to: › Purify collagen from select and safe raw materials (puri-
fi cation) › Extract the right collagen for the right application (sepa-
ration) › Re-assemble collagen for the intended application with a
smart and innovative cross-linking process that – unlike other outdated cross-linking methods, such as aldehyde technology2 – is biocompatible and more eff ective3 (re-as-sembly and stabilization).
The Breakthrough
Geistlich invented this unique process to create its latest bio-material Geistlich Fibro-Gide®. The volume-stable collagen matrix provides the alternative to connective tissue grafts for gaining soft-tissue thickness – without the need for or limita-tions of autologous graft harvest. Our goal is to provide you with exactly what you need for your daily clinical challenges. And we are 10o % committed!
References1 Griffi n TJ, et al.: J Periodontol 2006 ;77(12): 2070-79.2 Evans CE, et al.: J Hand Surg Br 1999; 24(6):658-61.3 Thoma DS, et al.: Clin Oral Implants Res 2012; 23(12): 1333–9
A
B
| A Lack of soft-tissue volume, Dr. Thoma, Switzerland.| B Harvesting of connective tissue graft, Prof. Jung, Switzerland.
35BACKGROUND
All good things comein three’s
Webinar
Dr. Giulia Cerino | Geistlich Pharma AG
In 2018, for the third consecutive year, Geistlich will continue its successful Webinar World Tour series off ering worldwide, on-line training, free and interactive.
The Webinar World Tour began in 2016 as part of the 20 years of Geistlich Bio-Gide® and 30 years of Geistlich Bio-Oss® prod-uct anniversary. Thanks to a great success the series continued also in 2017. And again this year the off er meets demand with six new webinars.
The speaker will focus on new therapeutic solutions, will reveal key factors for treatment success and using scientifi c-based data show the methods with the best supporting evidence.
Can you learn from an expert? Exactly.How it works? Easy.
Did you miss past webinars?Check them out and register now.
Register Watch Ask
The following webinars are planned, all the lectures to beheld in English:
Dr. Marcus Beschnidt / GermanySoft-tissue regeneration: New options toconnective tissue grafts6 March 2018, 7 pm CETUTC +1hour
Dr. Helmut Hildebrandt / Germany3D printed solutions for major bone augmentation15 May 2018, 7 pm CESTUTC +2hours
Dr. Alvin Yeo / SingaporeManagement of extraction sockets:An Asian perspective 27 June 2018, 7 pm SGTUTC +8hours
Dr. Tara Aghaloo / USAPeri-implantitis: Key factors for treatment success11 September 2018, 7 pm PDTUTC -7hours
Dr. Mauricio Araujo / BrazilDo's and don'ts in extraction sockets management30 October 2018, 7 pm BRSTUTC -2hours
Prof. Matteo Chiapasco and Dr. Paolo Casentini / ItalyClinical indications and guidelines for soft-tissueaugmentation at implant sites27 November 2018, 7 pm CETUTC +1hour
WEBINAR WORLD TOUR 2018
GEISTLICH
36 GEISTLICH NEWS 1-2018
Upcoming Osteologyeducation events Dr. Heike Fania | Osteology Foundation
Osteology Research Academy
Gothenburg, Sweden16-18 May 2018
Lucerne, Switzerland10-14 September 2018
Ann Arbor, USA17-20 September 2018
Vienna, Austria5-7 November 2018
Beij ing, China19-22 November 2018
Osteology Symposia take place all over the world, e.g., in Shanghai, China, in September 2017, with almost 2000 participants.
In keeping with its mission to provide a highdegree of knowledge about regenerative therapies,in 2018 the Osteology Foundation off ers a series of educational events.
Save the date: Osteology Barcelona 2019The international Osteology Symposium takes place every three years – in 2019 for the fi rst time in the exciting metro-polis of Barcelona. The preparations are already in full swing. Chairmen Christoph Hämmerle, Switzerland, and Mauricio Araujo, Brazil, have put together an exciting program under the title "The next ReGeneration" with many renowned speak-ers from all around the world, and featuring new formats and distinct sessions addressing novel and innovative techniques and technologies – all emphasizing the younger generation. Further information: www.osteology-barcelona.org
Upcoming NationalOsteology Symposia
Osteology London, UK20 April 2018
Osteology Frankfurt,Germany20-21 April 2018
Osteology São Paulo, Brazil9-10 August 2018
Osteology Turin, Italy27-29 September 2018
Osteology Paris, France18-20 October 2018
Further information: www.osteology.org/education/national-symposia
Further information: www.osteology.org/education/research-academy
37BACKGROUND
On 13 June 2017, the 2nd Consensus Meetingof the Osteology Foundation took place inWeggis, Switzerland on the topic: “Evidence-based knowledge in the aesthetics andmaintenance of peri-implant soft tissues.”
In two groups under the chairmanship of Ronald E. Jung, Swit-zerland, and Frank Schwarz, Germany, the eff ects of hard and soft tissue augmentation procedures on the maintenance of peri-implant tissues, as well aesthetics of peri-implant soft-tis-sues, were discussed, and the outcomes were summarized in three consensus reports. The reports have been published in February 2018 in a supplement to Clinical Oral Implants Re-search, together with four systematic reviews that were done in preparation for the consensus meeting.
2nd Osteology Consensus Meetingon peri-implant tissues Dr. Heike Fania | Osteology Foundation
The Osteology Consensus Meeting 2017 group
The conclusions of the consensus meeting were, in synopsis: › The limited evidence available supports the use of
soft-tissue augmentation procedures to promote peri-implant health.
› Lateral bone augmentation procedures are associated with peri-implant tissue stability for short (one to three years) and mid to long term (>three years) follow-ups.
› For single tooth implants, the papilla height between an implant and a tooth depends primarily on the clini-cal attachment level of the tooth. In cases with twoadjacent implants, it is not possible to determine the ideal horizontal distance between implants restored with fi xed dental prostheses.
Osteology Surgical Checklist TemplatesHuman errors occur daily, everywhere and inmany different arenas. Also, minor medical proce-dures and dental treatments can be affectedby human mistakes and can lead to harm. That is why the Osteology Foundation has developedsurgical checklist templates for minimizing risks.
Osteology Surgical Checklists, which are available on the Osteology Foundation’s online platform THE BOX, contain
essential criteria that can be checked off during treatment planning, as well as before and after surgery. The use of checklists can protect both clinicians and patients from avoidable errors. Users of THE BOX can customize and cre-ate their own surgical checklists for their daily practices.
Surgical Checklists on THE BOX:www.box.osteology.org/practice/surgical-checklists Note: Registration for THE BOX is free of charge!
38 GEISTLICH NEWS 1-2018
“Twenty-five years of implant dentistry. What have we learned?” What is your opinion?Prof. Sicilia: This question is especially relevant today when rapid developments lead us to reconsider our workflows. The industry is playing an essential role in the development of osseointegration science and technology, and we are thankful for that. However, with so many sources of knowledge the avalanche of information is so huge that the clinician might feel disoriented and lost, being unable to identify the evidence-based information. In the last 25 years many techniques have been adopted based only on short-term product-oriented research, and we have seen a lot of pre-ventable complications. The EAO wants to make a mission of that, and promote evidence-based long-term research, prospective or retrospective, with the aim of helping dentists to provide their pa-tients with safe treatments and long-lasting restorations. To cut a long story short, what I’ve learnt during these 25 years is that it is of paramount importance to base my decisions on long-term results!
In 2016 you were elected president of the EAO. What are your most significant achievements and your future goals?Prof. Sicilia: On the EAO Board we have a team-approach, and no personal merit may be attributed to any particular individual. I entered the EAO Board in 2010, together with my friends Luca Cordaro and Henning Schliephake, and together we’ve seen an exponential development. The traditional values have been re-spected and maintained, while at the same time new projects have been developed. We launched new publications, estab-lished our headquarters in Paris, and we developed the social media policy and communication strategies. As an indication of success, we’ve doubled the number of members, and we’ve been able to attract 5600 participants to our congress in Madrid, with close to 1000 scientific abstracts evaluated.
Interview
This issue of Geistlich News is dealing with minimally inva-sive approaches. What are your thoughts?Prof. Sicilia: From a personal perspective I define myself as a dentist who is committed entirely to minimally invasive strategies. I have been working with an operating micro-scope since 1997, and, thanks to digital dentistry, I try to avoid incisions whenever possible. In this context, I whole-heartedly celebrate any scientifically proven initiative in this area. My congratulations to those in this line of work!
In 1993 you became Director of the "Master in Periodontol-ogy" at the University of Oviedo. What are your strategies to help young clinicians become successful periodontists? Prof. Sicilia: I firmly believe in face-to-face clinical train-ing. In our master program we accept only two residents per year, which means that we manage continuously six stu-dents, with more than ten clinical professors. Students per-form surgeries with a clinical supervisor; after the second year they receive training using an operating microscope; and in the third year all of the procedures are done with this approach.
Is there any time for hobbies?Prof. Sicilia: I have more hobbies than time to practise them! Mostly I am a sports fanatic. I returned to playing rugby in my late forties, which is crazy for a dentist, since I broke a finger on three occasions! I get enough exercise with training 4-5 days a week, and I love to surf in the sum-mer and ski in the winter. However, I must say that, since I’ve become a member of the EAO Board, my hobby time has been significantly reduced - not evidence-based, but I can assure you, considerably!
Since 1993 Prof. Alberto Sicilia Felechosa has been the Professor of Periodontology and Director of the "Master in Periodontology" at the University of Oviedo in Spain. He is the Medical Director of Clinica Sicilia, a private practice dedicated to periodontology and implant surgery. He belongs to several profes-sional organizations. Besides being the president of the EAO, he is an active member and specialist at SEPA since 1986. He is also a member of the AAP and SEPES. He received several prizes and recognitions during his career for his scientific papers, research and scientific communications.Ph
oto:
Dan
iele
Mic
ieli
@EAO Madrid 2017 with Alberto SiciliaInterview conducted by Dr. Giulia Cerino
39BACKGROUND
Issue 2 | 18
will be published in August/September 2018. FOCUS
Anterior area and aesthetic JOURNAL CLUB
Stem cells in regenerative dentistry OUTSIDE THE BOX
Learning regeneration from the axolotl genome
Magazine for customers and friends of Geistlich BiomaterialsIssue 1/2018, Volume 12
Circulation25,000 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 negli- gence on the part of Geistlich Pharma AG.
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