Geistlich News Edition 1-2018 English

GEISTLICH BIOMATERIALS

Photo: iStock / AGEphotography

VOLUME 12, ISSUE 1, 2018

FOCUS PAGE 5

OUTSIDE THE BOX PAGE 26

BACKGROUND PAGE 29

Minimally invasive approaches.

Gene therapy for the eyes.

Research and knowledge.

How to understand the concept of "minimally invasive" in regenerative dentistry.

The treatment of hereditary retinal diseases may no longer be a distant and unreachable horizon.

The collaboration between company and university is a secret for successful discoveries.

LEADING REGENERATION.

100

GEISTLICH NEWS 1-2018

CONTENTS

Issue 1 | 2018 EDITORIAL

4 There is only one original.

Since 1851.

FOCUS

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 patients Prof. Rogerio Belle de Oliveira | Brazil

17

Where we started and where we are going Dr. Amit Patel | UK

20

Minimally invasive approaches for major indications Dr. 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

3

Editorial

There is only one original. Since 1851.

Tradition and commitment go hand in hand and have been part of Geistlich’s long history for 167 years!

Photo: Roger Schuler

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 universities. Feedback from our customers and clinicians are fed into the further development of products, and esteemed scientists 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, especially 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 information and advice.

The Focus section of this magazine looks at “minimally invasive surgical techniques.” We hope you find it interesting. Your feedback and suggestions regarding the magazine are important 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.

Change Signature

We hope you enjoy reading the “Geistlich News” and learn plenty of new things!

This one is from Zingg Falk in attachment

4

GEISTLICH NEWS 1-2018

Dr. Matthias Dunkel Deputy Chief Operating Officer

FOCUS

MINIMALLY INVASIVE APPROACHES IN REGENERATIVE DENTISTRY.

Photo: iStock / AGEphotography

From recession coverage to ridge preservation – minimally invasive techniques for oral regeneration.

5

Ridge Preservation

Dealing with extraction sockets: What makes the difference?

Dr. Daniele Cardaropoli, Italy Scientific Director PROED, Institute for Professional Education in Dentistry Torino, Italy

Following tooth extraction, the maintenance of the original bone volume is paramount. But what parameters need to be considered? The expert opinion.

extraction. Mainly, the limited supply of cells coming from the periodontal ligament causes resorption of bundle bone. Also, when the cortical bone plate is thinner, the alveolar bone is resorbed crestally and more on the buccal than lingual side.2 Clinically this physiological remodeling results in horizontal and vertical ridge resorption.

“The placement of a proper biomaterial in an extraction socket promotes bone modeling and compensates for marginal ridge contraction.”

The healing process of post-extraction sockets is related to a series of biological 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 process is directly related to the presence of the natural dentition, and it follows different degrees of atrophy after tooth

6

GEISTLICH NEWS 1-2018

In the first six-months following tooth extraction, 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 principles that rule the dynamics of post-extraction site healing, it is essential to attempt to maintain the original volume of the ridge. It is a common experience that delayed post-extraction sites present inadequate bone volume for proper implant

placement. Therefore, if an implant placement is planned, additional ridge augmentation procedures are essential for counteracting ridge loss.

Two clinical situations, two solutions What are the solutions for retaining proper bone volume? First, we need to differentiate between cases with intact and non-intact bony walls.

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 Preservation 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.

1

Ridge Preservation: An all-in-one approach Ridge Preservation is a surgical procedure with a choice of different techniques that affect results:

›› Extraction by flap elevation or no flap elevation,

›› Type of filling material (autologous

FIG. 1: THE BENEFITS OF RIDGE PRESERVATION WITH BONE HEALING AND REMODELING

Bone without preservation

New bone formation

Bone preservation effect

Illustration: Quaint

Bone preservation effect

bone, allograft, xenograft or alloplastic material), ›› Use of a membrane or not.

Predictable ridge vertical dimension results 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 marginal ridge contraction.7 (Fig. 1) The physiological resorption of bundle bone and the likely loss of the original buccal plate cannot be avoided. However, proper biomaterial bone regeneration occurring within the alveolus creates a new volume of crest comparable to pre-extraction volumes. Therefore, technically, Ridge Preservation does not conserve the alveolus but rather preserves the volume of the alveolar ridge.

Clinical tips Slowly resorbing biomaterials seem to be most effective in maintaining the initial three-dimensional volume of the

ridge.8 With an intact socket, it is advisable to use a flapless approach to optimize results. Indeed, the elevation of a mucoperiosteal flap triggers a sequence of different biological phenomena and a transient hypoxia phase at the cortical level, which activates osteoclasts and subsequent bone resorption.9 Filling biomaterial: After extraction, the alveolus should be debrided and thoroughly rinsed with saline to decontaminate the site, before filling with a biomaterial. (Fig. 2) The ideal biomaterial must be biocompatible, osteoconductive and provide slow resorption to compensate for inevitable remodeling of the

FOCUS

7

FIG. 2, A-H: TREATMENT OF AN EXTRACTION SOCKET WITH MINIMALLY INVASIVE RIDGE PRESERVATION A

B

E

G

D

H

Photos: Daniele Cardaropoli

F

C

| A Baseline situation: Lateral view of a compromised upper right second premolar. | B Occlusal 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.

bundle bone. The deproteinized bovine bone mineral possesses these characteristics: It preserves on average 93 % of the initial crest volume at four-months follow-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 biomaterial, the extraction socket is sealed using a resorbable collagen membrane or, more

8

GEISTLICH NEWS 1-2018

recently, a tridimensional collagen matrix (Geistlich Mucograft® Seal). (Fig. 2) The thick, double-layer, porcine-derived, collagen matrix efficaciously protects the underlying bone graft and promotes secondary healing of soft-tissues without the risk of infection. The smooth and dense outer layer of the collagen matrix limits bacterial penetration and encourages the migration of epithelial cells. Full closure of the soft-tissue usually occurs between the third and fourth week following 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 applied to maintain the pre-existing hard and soft-tissue anatomy, provide a stable crest volume and optimize functional and aesthetic results that simplify clinical procedures. These positive outcomes can also be expected despite the initial thickness of the buccal bone plate.11

FIG. 2, I-P: TREATMENT OF AN EXTRACTION SOCKET WITH MINIMALLY INVASIVE RIDGE PRESERVATION J

I

N

L

O

P

Photos: Daniele Cardaropoli

M

K

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-operative 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

References 1

Cardaropoli G, et al.: J Clin Periodontol 2003; 30,

809–818.

2 Araujo MG, Lindhe J: J Clin Periodontol 2005; 32: 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.

FOCUS

9

Recession coverage

A less invasive tunneling technique for multiple recession defects Dr. Sofia Aroca, France Private Practice, Paris, France Clinic for Periodontology, University of Bern, Switzerland

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

The tunneling technique for multiple recession coverage derives from the supraperiosteal envelope technique in combination with connective tissue grafts (CTG).2 One of the advantages of this method is preservation of the gingival papilla continuity

B

FIG. 1: SUSPENDED SUTURES FOR MODIFIED CORONALLY ADVANCED TUNNEL TECHNIQUE

10

GEISTLICH NEWS 1-2018

C

and creation of a pouch containing a CTG, which is slightly exposed over the recession. However, leaving the graft exposed can jeopardize the aesthetic result.

To overcome this problem, Azzi and Etienne proposed a modification to the supraperiosteal envelope technique.3 This variation consists of a full thickness elevation of the flap that continues beyond the mucogingival line to completely cover the CTG placed underneath. From a biological standpoint, the entire thickness dissection and the integrity of the papilla ensure optimal vascularization. Blood supply is of paramount importance, as the avas-

D

| 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.

Illustration: Quaint

The current, most commonly used techRecession coverage still niques for treating multi-tooth recesrepresents a challenge sions can be divided into two groups: when it comes to severe defects. But proper tech›› Multiple coronally advanced split thickness flap1 where the papillae nique and material can are incised, help guarantee a successful ›› Tunneling where the papillae are outcome. Discover how. not incised.

FIG. 2: RECESSION COVERAGE IN MULTIPLE MILLER CLASS I RECESSION DEFECTS A

B

D

Photos: Sofia Aroca

C

| 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.

cular surface is extensive in multi-tooth recession defects. 4,5 There are several reports in the literature with the supraperiosteal envelope technique used as initially described or with slight modifications.6-8

The modified coronally advanced tunnel technique During 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 micro-tunnel elevator. Then the mucoperi-

osteal dissection is extended beyond the mucogingival line and under each papilla to displace the flap together with the papillae in the coronal direction without tension. The muscles fibers or the remaining collagen bundles on the inner part of the flap alveolar mucosa are dissected with extreme care, using a blunt instrument to avoid perforation of the flap and to obtain a passive coronal positioning. After flap preparation, a CTG or a substitute (collagen matrix, acellular dermal matrix or enamel matrix derivative) can be placed underneath.

Several suturing techniques are available 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 contact point.3-5 According to the authors, the use of this particular suturing technique ensures an extended coronal stabilization of the flap during the first two weeks of wound healing (Fig. 1).

Clinical efficacy Clinicians still consider multiple recession defects a challenge, as they represent a complicated clinical situation.

Many factors, besides the extended avascular surface, can influence the clinical outcome, i.e., different reces-

FOCUS

11

FIG. 3: RECESSION COVERAGE OF CHALLENGING, MANDIBULAR MULTIPLE, MILLER CLASS III RECESSION DEFECTS A

B

E

| 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.

Photos: Sofia Aroca

D

C

sion depths, (Fig. 2) prominent roots, thin biotypes and interdental hard and soft-tissue loss. (Fig.3) All these factors have to be taken into account when planning a surgical technique, especially if the ultimate goal of the surgical procedure is complete root coverage. Systematic reviews evaluating the predictability of various surgical techniques for multiple 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 grafting are the most predictable ways to obtain complete root coverage in Miller Class I, II and III multiple recessions.11-14 Despite the predictability of these surgical techniques, not all of them are efficacious 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

12

GEISTLICH NEWS 1-2018

“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.” coronally advanced tunnel technique compared with subepithelial CTG (control group) could improve treatment outcomes for Miller class III multiple recessions 1-year post-therapy. In 20 patients 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 papilla (measured by the percentage reduc-

tion of the distance between the contact 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 multiple recessions. Stable results were obtained at 28 days, and there was no sig-

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. biomaterials An adequate thickness of the gingival margin is the key to ensuring long-term stability.15,16 In thin biotype clinical cases it is mandatory to apply the right surgical technique. As described, the most common and predictable procedure is an advanced coronal flap combined with a CTG. However, very often a patient 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 complications such as bleeding, numbness and sensitivity changes at the donor site.5 Attempts have been made to develop new biomaterials to replace CTG harvest.

Among the collagen matrix family, Geistlich Mucograft ® has been proposed as an alternative to subepithelial CTG in periodontal plastic surgery procedures. Its safety and clinical efficacy for root coverage procedures was reported in several preclinical17 and clinical studies.18,19

thickness. Complete root coverage was found at 42 % of test sites and 85 % of control sites, and the healing was uneventful in both treatment groups. The authors concluded that the use of collagen matrix may represent an alternative to CTG by reducing surgical time and patient morbidity.

A comprehensive surgical procedure The tunneling technique is a minimally invasive surgical procedure, as there are no vertical releasing incisions. Internal, gentle dissection of the muscles 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 dissection. This surgical technique, therefore, creates an optimal biological environment 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.

References 1

Zucchelli G, De Sanctis M: J Clin Periodontol

2000; 30(10): 862-870.

2 Allen AL: Int J Periodontics Restorative Dent 1994; 14(4): 302-315.

3 Azzi R, Etienne D: J Parodontol Implant Orale 1998; 17: 71-77.

4 Aroca S, et al.: J Clin Periodontol 2010; 37(1): 88-97.

5 Aroca S, et al.: J Clin Periodontol 2013; 40(7): 713-720.

6 Zabalegui I, et al.: Int J Periodontics Restorative Dent 1999; 19(2):199-206.

7 Tozum TF, Dini FM: Quintessence International 2003; 34(1): 7-13.

8 Zuhr O, et al.: Int J Periodontics Restorative Dent 2007; 27(5): 457-463.

9 Allen EP: Int J Periodontics Restorative Dent 2010; 30(5): 479-85.

10 Zuhr O, et al.: Eur J Esthet Dent Winter 2009; 4(4): 338-47.

11 Miller PD: Int J Periodontics Restorative Dent 1985; 5(2): 8-13.

12 Hofmänner P, et al.: Quintessence Int 2012; 43(7):545-54.

13 Graziani F, et al.: J Clin Periodontol 2014; 41(15): S63–S76.

14 Chambrone L, Tatakis DN: J Periodontol 2015: 86(2): S8-S51.

15 De Sanctis M, Zucchelli G: J Clin Periodontol 2007: 34(3): 262-8.

16 Cortellini P, Pini Prato G: Periodontol 2000 2012; 59(1):158-84.

17 Vignoletti F, et al.: J Clin Periodontol 2011; 38(9): 847-55.

18 McGuire MK, Scheyer ET: J Periodontol 2010; 81(8): 1108-17.

19 Molnár B, et al.: Quintessence Int 2013; 44(1): 17-24.

In 2013 Aroca et al. performed a 1-year prospective, randomized, controlled, split-mouth study to evaluate the clinical 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, compared with the baseline, both treatments resulted in statistically significant improvements for complete root coverage, mean recession coverage, keratinized tissue width and gingival

FOCUS

13

Guided Bone Regeneration

The challenge of treating cancer patients Prof. Rogerio Belle de Oliveira, Brazil Pontifical Catholic University of Rio Grande do Sul Department of Oral and Maxillofacial Surgery Porto Alegre, Brazil

When dental practice faces neoplastic patients, risk and failure increase. Proper education and information 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. Education and knowlege are essential to avoid the main contributing factors and to improve early cancer detection. Global campaigns, like Pink October (breast prevention campaign), Blue November (prostate prevention) and campaigns against tobacco use increase awareness.

Access to diagnosis and treatments influence the possibility for improving knowledge. But early diagnosis is the most critical element, because it increases 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

14

GEISTLICH NEWS 1-2018

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 cancer therapy, especially in cases of breast cancer. In contrast, males are most vulnerable to bone metastases secondary to prostate or lung cancer. 2-4 Younger patients have higher rates of success after cancer therapy. Accordingly, Guided Bone Regeneration (GBR) performed after cancer therapy on younger patients will result in higher rates of graft effectiveness and implant success.5,6 Patients must receive overall oral health and radiographic assessments. Before performing cancer therapy, the clinician must pay attention to the removal of ill-fitting prostheses, plaque and caries, gingivitis or periodontitis, and the extraction of hopeless teeth. Treatment of these conditions can prevent future undesirable oral compli-

cations during cancer therapy. During this phase of treatment, successful socket grafting 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 options Cancer treatment depends on several factors, including the cell-cause relationship, location, and timing. The best options are separate or combined treatments of surgery, chemotherapy and/ or radiotherapy. In the dental office, patients 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. Osteopenia and osteoporosis are possible complications that could impair treatment after cancer therapy.2,3,5,9,10

“Education and knowlege are essential to avoid the main contributing factors and to improve early cancer detection.”

FIG. 1: GBR IN A NON-HODGKIN LYMPHOMA PATIENT - A CASE REPORT

A 38 year-old male patient, treated for non-Hodgkin lymphoma with chemotherapy. 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 secondary dental implant therapy.

A

B

D

G

H

E

F

Photos: Rogerio Belle

C

| 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.

Radiotherapy is a high-energy radiation targeted at the cancer site, damaging the DNA synthesis of highly mitotic 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 location, tumor size and associated lymphatic chain. The energy ranges from

30 to 70 Gy in 20 to 40 irradiations. The clinical dose-related consequences expected are tumor regression, xerostomia, 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 intervals decrease the chances of osteora-

dionecrosis development. Osteoradionecrosis is a well-described condition characterized by a hypovascular medullary bone deterioration, impossibility of bone repair and a primary inflammatory process leading to severe bone loss. Irradiation residual effects on bone are permanent, and even 24 months after radiation, lower levels of vascularization are observed, especially in the

FOCUS

15

mandible and posterior maxilla. 4,5,8,11-13 Hyperbaric oxygen therapy is one option for preventing osteoradionecrosis and for improving bone graft and dental implant success, but there is limited scientific evidence for its use.14 Chemotherapy has a systemic cytotoxic effect on target neoplastic cells as well as normal cells. The worst side effects include myelosuppression, thrombocytopenia 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 occurs 180 days after the last chemotherapy dose. Some patients’ treatment regimes may include monoclonal antibody to RANKL with or without systemic bis­ phosphonates, and these patients require 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 reconstruction, GBR is a well-described graft technique with successful results.3 (Fig. 1) GBR in cancer patients is a time-dependent technique. Minimally invasive approaches can be performed with appropriate results after 180 days of chemotherapy and after 360 days of radiotherapy. When monoclonal antibodies to RANKL and/ or systemic bisphosphonates are employed, during active therapy or for maintenance, GBR must be delayed for 24-months. Also, in this case, minimally invasive surgical approaches and short implants are preferable, but evaluation of the patient-specific situation is highly recommended.8,13,15-17 Before surgery, the patient should undergo a global clinical and radiograph-

16

GEISTLICH NEWS 1-2018

ic assessment. Evaluation of bone mineral density and laboratory exams are essential diagnostics for planning minimally invasive bone graft procedures. According to the latest systematic review, C-terminal cross-linking telopeptide of type-1 collagen (b-CTx) has no predictive value in determining the risk for osteonecrosis in bisphosphonate patients,14 and the same applies to cancer therapy. The best option is evaluation of serum levels: calcium (Ca), alkaline phosphate, parathyroid hormone (PTH), vitamin 25-hydroxyvitamin D3 (vitamin OHD), albumin (Alb) and also assessment of bone mineral density (g/cm2) at the lumbar spine (L1-L4) and femoral neck. Another significant diagnosis using radiographic or cone beam computed tomography examination of the target area is the evaluation of previous surgical sites or sockets for proper bone healing. Poor healing is a significant indication for higher risk of bone necrosis.3,8,10,16,17 Because of its less vascularized bone structure, the posterior maxillary region is more prone to complications, and, in order to avoid a second surgical harvest site, autogenous bone grafts are not recommended for patients after cancer therapy.11,16 The best option for this kind of patient is xenografts and collagen membranes. A minimally invasive flap approach helps correct horizontal and vertical bone defects for immediate or delayed insertion of dental implants with excellent stability. With minimal residual bone, shorter and smaller implants can be a good choice.8,13 Moreover, careful manipulation of the mucoperiosteal flap and primary closure of the flap are essential during the surgical procedure.

Rinsing the surgical site with a solution of 500 mg tetracycline in 20 ml sterile saline may improve outcomes.

References 1

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 Implants 2017; 32: 611–616.

8 Edher F, Nguyen CT: J Prosthet Dent 2017; pii: S0022-3913(17)30426-2.

9 Martin TJ, Seeman E: Best Practice & Research Clinical Endocrinology & Metabolism 2008; 22(5): 701–722.

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.

Periodontal regeneration

Where we started and where we are going Dr. Amit Patel, UK Private Practice Birmingham, United Kingdom

Regenerative surgical procedures 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 develop? And what can we expect in the future?

Every dentist aims to improve and restore proper function and aesthetics in patients affected by periodontitis. Accordingly, it has been argued that periodontally 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 affected 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

FIG. 1: ONE-, TWO- AND THREE-WALL PERIODONTAL BONE DEFECTS.12

Illustration: Quaint

ONE WALL DEFECT

TWO WALL DEFECT

THREE WALL DEFECT

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 question to answer, as both clinicians and patients are becoming aware that implants are not a permanent solution.

Nowadays peri-implantitis reports are increasing, and many factors influence its risk, including bacterial and possible 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 beginning In 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 rapid proliferation of the epithelium and gingival connective tissue formed long junctional epithelium. Later, a study by Nyman et al. demonstrated that the isolation of epithelium and gingival connective tissue from a periodontal defect using a barrier allowed the periodontal defect to heal with bone, periodontal

FOCUS

17

FIG. 2: MINIMALLY INVASIVE APPROACH FOR PERIODONTAL REGENERATION IN A VERTICAL BONY DEFECT

A 41-year old non-smoking female developed generalized chronic periodontitis. She underwent a course of successful non-surgical therapy. Only one localized periodontal pocket did not

A

resolve: the upper left lateral retained a vertically bony defect. Periodontal regeneration was discussed as an option to improve the long-term prognosis.

Therefore, a minimally invasive surgical

B

E

C

D

F

H

I

G

J

N

K

L

O

Photos: Amit Patel

M

technique was utilized preserving the papillae. The bony defect was curetted, and the root surface was prepared for enamel matrix proteins and the placement 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.

18

GEISTLICH NEWS 1-2018

“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 question to answer.”

References 1

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 Periodontology 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

ligament and cementum.7 This study heralded the technique of Guided Tissue Regeneration (GTR) for periodontal regeneration by first utilizing a non-resorbable expanded polytetrafluoroethylene (ePTFE) and later a resorbable collagen membrane placed over a periodontal defect,8 sometimes filled with a bone graft.9,10

Current concept The bony defects that allow greater predictably of periodontal regeneration 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 Cortellini 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 expose 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 stabilized by the flap alone or by placing a bovine bone graft, sometimes mixed with enamel matrix proteins, enhances the outcome though less invasive periodontal regeneration. (Fig. 2)

Surgery 1962; 44B: 424.

7 Nyman S, et al.: J Clin Periodontol 1980; 7(5): 394-401.

8 Scantlebury T, Ambruster J: J Evid Based Dent Pract 2012; 12(3 Suppl): 101-17.

9 Mellonig JT, Bowers GM: J Am Dent Assoc 1990;121(4):497-502.

10 McClain PK, Schallhorn RG: Int J periodontics Restorative Dent 1993;13(1):9-27.

11 Cortellini P, Tonetti MS: J Clin Periodontol 2007; 34(1): 87-93.

12 Goldman HM, Cohen DW: Journal of Periodontology 1958; 29(4): 272-291.

Future perspectives Raising large periodontal flaps is turning into a treatment of the past, while performing minimal flaps is growing more common in everyday practice.

Due to greater predictably of the techniques and better understanding of the biology of periodontal disease and healing, we can now reduce the morbidity involved with more extensive surgical procedures, and we can avoid placing dental implants in younger patients – improving the prognosis for teeth before considering implants. And it is clear that we need to acknowledge periodontal regeneration as a predictable modality.

FOCUS

19

Case study

Minimally invasive approaches for major indications Dr. Alexander Volkmann, Germany Private practice Jena and Eisenach, Germany

A significant ridge deficiency with horizontal and vertical dimensions.

How shoud a three-tooth gap augmentation be treated with Yxoss CBR®?

A 66-year-old female patient was referred to receive implant therapy for a three-tooth gap in the left mandible.

The clinical and radiographic evaluations demonstrated a significant ridge deficiency with horizontal and vertical 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 inserted. A ridge incision was performed, and a flap was prepared. (Fig. C) The Yxoss CBR ® titanium mesh was fitted 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 covered with Geistlich Bio-Gide®. (Fig. F) The flap was adapted to ensure complete 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 approximately 5-6 mm, and two endosseous im-

20

GEISTLICH NEWS 1-2018

“Major ridge deficiencies, es­ pecially vertical and combined horizontal / vertical defects, require bone augmentations with form-stable support to realize successful and uneventful GBR.”

plants could be inserted simultaneously (3.8 and 4.3 diameter). (Fig. J) The two implants were surrounded with autologous bone chips obtained during drilling. Correct positioning was checked radiographically. (Fig. H) Wound healing progressed uneventfully, and orthodontic treatment was performed.

After six months the implant abutment was placed for soft-tissue modeling. (Fig. L)

Why this treatment?

Dental implant success depends on adequate bone support. In the case presented, it was necessary to build up vertical as well as horizontal ridge dimensions.

Major ridge deficiencies, especially vertical and combined horizontal/ vertical defects, require bone augmentations with form-stable support to realize successful and uneventful Guided Bone Regeneration (GBR). Current major ridge

augmentation procedures employ membranes, conventional titanium meshes, bone shields, bone blocks and/ or native bony walls with interpositional grafting or distraction osteogenesis.

Conventional titanium meshes are recommended for combined bony defects of more than 3 mm. As they are adapted to the ridge defect, titanium meshes require advanced surgical skills, and the procedure is often time-consuming.

Furthermore, a high risk (up to 50%) for soft-tissue dehiscences has been recorded.1,2 The new Yxoss CBR® titanium scaffold 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 volume for osteogenesis. Also, surgery time and the risk of soft-tissue dehiscences may be reduced. Compared with other techniques, the Yxoss CBR® technology

FIG. 1: A THREE-TOOTH GAP TREATED WITH YXOSS CBR® A

F

C

H

G

L

allows combined autologous and xenogeneic bone graft augmentation.

Geistlich Bio-Oss ® offers protection from ridge volume loss due to resorption, and given its osteoconductivity, rapid and integrated bone growth.3-5 Autologous bone combines osteogenesis, osteoconductivity and osteoinductivity.6 The combination of autologous and xenogeneic products placed under the Yxoss CBR® scaffold gives us the possibility to rebuild major 3D defects in our daily ambulant office.

D

I

Photos: Alexander Volkmann

K

B

E

J

| A Cone beam computed tomography (CBCT) showing the horizontal and minor vertical buccal bone defect. | B Clinical situation before the augmentation. | 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 Intraoperative site during the removal of the Yxoss CBR®. | I Bone situation directly after the removal of the Yxoss CBR®. | J Intraoral situation after implantation. | K Lateral radiograph of the implant placement with the full restore bone volume. | L Clinical situation after implant cover placement.

References 1

Jensen SS, Terheyden H, J Oral Maxillofac Surg

2009; 24(Suppl): 218–236.

2 Kaner D, Friedmann A, J Clin Periodontol 2011; 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.

21

JOURNAL CLUB

MILESTONE STUDIES.

Photos: © iStock.com/dtmiraos

From A to Z, an overview about surgically assisted orthodontics.

22

GEISTLICH NEWS 1-2018

Dr. George A. Mandelaris Private Practice, Oakbrook Terrace, Illinois, USA Adjunct Clinical Assistant Professor University of Illinois, College of Dentistry; Chicago, USA

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 move­­­ment, 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 orthodontics; 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 complex is improved.

INTRODUCTION

Dr. Jim Janakievski Private Practice, Tacoma, Washington, USA Affiliate Assistant Clinical Professor School of Dentistry, University of Washington, USA

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 unintentionally 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 retainer (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 assessment 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 – periodontally accelerated osteogenic orthodontics (PAOO) which was first publicized by Wilcko in 2001,10 and surgically facilitated 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.

JOURNAL CLUB

23

A

B

C

D

E

F

G

H

I

J

Photos: Mandelaris, Janakievski

FIG. 1: SURGICALLY ASSISTED ORTHODONTICS USED TO FACILITATE MOVEMENT OF ANTERIOR MANDIBULAR TEETH

| 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.

Corticotomy surgery is used to injure cortical bone, often extending 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 period of time (months). The phenomena is referred to as a “regional acceleratory phenomena or RAP.” Guided periodontal tissue regeneration and alveolar augmentation techniques are used to augment bone volume so that teeth are provided with an expanded

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 interactive orthodontic cone-beam computed tomography (CBCT) scan imaging software is depicted in Fig. 2 A-C.

FIG. 2: CBCT DIAGNOSIS, PLANNING AND OUTCOME

DIAGNOSIS AND TEAM PLANNING

B

C

| A 3D regional anatomy presentation. | B Interactive 3D desired tooth position for expansion orthodontia and theoretical consequence on the dentoalveolar complex. | C Actual outcome using surgically assisted orthodontics.

Photos: Mandelaris, Janakievski

A

24

GEISTLICH NEWS 1-2018

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 Accordingly, sites with ≤ 2 mm of attached gingiva should receive gingival 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. Mandelaris 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 therapy cannot be overemphasized.

ADVANTAGES, DISADVANTAGES AND CAUTIONS SAO expands the treatment envelope for patients with malocclusion. 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) optimize anterior articulation parameters; (4) enhance long-term orthodontic stability and retention; and, (5) respect airway dimensions by increasing oral cavity volume opportunities via reducing the need for extraction/retraction orthodontia, when appropriate. By providing an adequate/augmented dentoalveolar bone complex post-orthodontically, SAO simultaneously promotes periodontal regeneration, alveolar augmentation and root coverage / mucogingival augmentation, but most importantly improves the prognosis for the entire dental complex 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 overcome 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 incidence of relapse.21 Despite these advantages, there are no human clinical studies demonstrating long-term efficacy of SAO. Patients should be guided to understand the benefits and limitations of this combined surgical procedure so they can make the best decisions for their treatment.

FIG. 3: DENTOALVEOLAR BONE PHENOTYPE CLASSIFICATION FOR SURGICALLY ASSISTED ORTHODONTICS

Position/type

Thick Bone > 1mm

Thin Bone < 1mm

Crestal Phenotype Bone 4mm from CEJ

x

x

Radicular Phenotype Bone half root length

x

x

References 1

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.

RECOMMENDATIONS

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.

CBCT diagnosis is recommended, particularly in patients requiring expansion with thin alveolar phenotype. Applying heavy orthodontic forces to take advantage of the demineralized bone matrix produced from SAO surgery should begin within 7-10 days of surgery. At this time, the regional acceleratory phenomena within the dentoalveolar complex will be present, 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 orthodontics.22 Interdisciplinary planning and treatment sequencing are keys to SAO success.

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: Corticotomy-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

25

OUTSIDE THE BOX

GENE THERAPY FOR THE EYES.

Photo: Š 23rf.com/Kirch

What sounds like science fiction could become reality in the near future: People with hereditary retinal diseases are given new genes in their eyes to prevent them from going blind.

The first drugs are about to be approved.

26

GEISTLICH NEWS 1-2018

Dr. Klaus Duffner

Our sophisticated retina is susceptible to all kinds of mutations and hereditary diseases. For example, so far over 250 different genetic visual impairments have been cataloged.1 According to an extensive study published in the scientific journal “Nature,” just for age-related macular degeneration (AMD) alone, 52 gene variants, which are associated with increased susceptibility to the disease, have been found at 34 points in the human genome.2 In the western world AMD is the principal cause of severe 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 figure to double to 22 million by the year 2050 due to rising life expectancies.3

Transfection of helpful genes About 15 percent of AMD sufferers have the neovascular “moist” form (nAMD).

Due to the ingrowth of small blood vessels 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 endothelial growth factor (VEGF). Currently, although 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 effectiveness of these antibodies.

A consortium of 13 scientific teams from nine European countries (TargetAMD) is working on an alternative research approach: A gene transferred into the eye enables endogenous cells to multiply production of a particular protein that counteracts vascular ingrowth and, thus, the lo-

cal destruction of retinal cells. The gene is transferred outside the body using a “gene transporter” in previously harvested endogenous pigment-epithelial cells. The project’s coordinator Prof. Gabriele Thumann, Director of the Eye Clinic at the University Hospital of Geneva, stressed that the transporter is not a typical viral vector but a molecule named “sleeping beauty transposase:” “Although viruses are very effective as gene shuttles, they harbor the risk of menacing immune responses or oncogenic 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 supplying the pigment epithelium-derived factor (PEDF) proteins to the area of concern and inhibiting VEGF. Transfection of the helpful genes into the cells has already been successfully confirmed by an extensive series of in-vitro tests. The initial in-vivo experiments on rats demonstrated the inhibition of blood vessel ingrowth and, therefore, the therapy’s efficacy. When these investigations are completed, the first 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 sufferers, scientists believe that it could revolutionize ophthalmology.

Gene therapy about to be approved

Photo: iStock / vchal

An ophthalmological gene therapy, which could also benefit small children, is about to be approved by the US-American Food and Drug Administration. In early childhood, retinal degeneration mutations

OUTSIDE THE BOX

27

occur in the gene RPE65 causing a reduction 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

available for producing the missing enzyme. “The treatment has proved to be safe in all the studies published,” says Prof. Birgit Lorenz, Director of the Clinic for Ophthalmology at the University Clinic Giessen in the “Ärzteblatt.”6

Seeing better in twilight Despite the therapy’s inability to restore previously dead sensory cells and en-

“Although viruses are very effective as gene shuttles, they harbor the risk of menacing immune responses or oncogenic reactions.

Therefore, we opted for a nonviral enzyme transposon system.”

Prof. Gabriele Thumann – Eye Clinic at the University Hospital of Geneva

mobility parkour under different lighting conditions. According to study leader 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 benefitted in poor lighting conditions. The gene therapy is currently being tested for other hereditary eye diseases. For example, in the future new genes in the eye might also help patients with congenital night blindness and progressive visual field restriction (choroideremia) or extreme color blindness.

References 1

http://www.pro-retina.de/newsletter/2017/erstegentherapie-am-auge-vor-der-zulassung.

2

Fritsche LG, et al: Nature Genetics 2016; 48:

134–143.

3 4

Pennington KL, et al: Eye Vis (Lond) 2016; 3: 34.

Kropp M: Gentherapie zur Behandlung der

nAMD: Das Target AMD-Projekt. Augenspiegel 2016: 22-24.

5

loss is linked to full night blindness. Conversely, cones seem to be less severely affected by the disease, although, at least at the beginning, a residual visual capacity is retained. In Germany 150 to 200 people suffer from this particular retinal disease.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 shuttles that infect the visual cells and then discharge the new RPE65 genes into the interior of the cell, where they are then

28

GEISTLICH NEWS 1-2018

abling improved visual acuity, further disease progression is slowed. For example, a recently published, randomized, phase-3 study included 31 patients with RPE65-related retinal dystrophy, aged between three and 44, whose eyesight and peripheral field of vision were already restricted.7 In the 20 patients 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

Thumann G: “Es gibt niemals nur einen Weg zum

Glück.” Schweizerische Ärztezeitung. Interview.

2017; 42.

6

https://m.aerzteblatt.de/news/the-

7

Russel S, et al: Lancet 2017; 390, 10097: 849–860.

ma-11878-2-79453.htm.

BACKGROUND.

GEISTLICH PHARMA AG | OSTEOLOGY FOUNDATION

BACKGROUND

29

A synergic research

When the company meets the university: A win-win situation!

Dr. Giulia Cerino | Geistlich Pharma AG

Photos: Alfons Gut

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.

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 Prosthodontics and Biomaterials at the University of Geneva are different from the tasks that I had as Scientific Head of Unit at the Clinic for Fixed and Removable Prosthodontics and Material science 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 future 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 defining 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 improve my French to be able to communicate and teach, and I had

30

GEISTLICH NEWS 1-2018

“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 concerning our marketed biomaterials.

On the other hand, the University of Geneva offers clinical expertise, patient surgery perspectives, surgical techniques and equipment.”

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 reconstructive dentistry and biomaterial sciences. The undergraduate students learn how to treat patients in the beginning on phantom heads and then in the pre-graduate student clinics. We are responsible for the teaching of “fixed prosthodontics”, “occlusions” and “biomaterials.” Besides this pre-graduate education, the prosthodontic divisions are accredited for a three-year post-graduate specialization program in reconstructive 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.

How big is your team, and how is it organized?

Prof. Sailer: In our division more than 30 collaborators are working together synergistically: eleven full-time and part-time faculty members, eight post-graduate specializing students, five biomaterials 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 technical 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-prosthodontics and dental implantology, tooth-, and implant-supported reconstructions, 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 regenerative 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 expertise 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 beautiful environment, highly luxurious, with a lot of new equipment for clinical and scientific work. We have research labs for the basic scientists with modern equipment. Recently, a scanning electron 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 collaboration with the medical faculty scientists, as micro-computed tomography , 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 collaboration between the University of Geneva and Geistlich. On what?

Prof. Sailer: As a first project, we proudly participated in a multicenter study evaluating the performance of Geistlich Fibro-Gide® around dental implants. Prof. Hämmerle was the principal investigator, 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 basic 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 parameters for improving “Geistlich Bio-Oss® Collagen version 2.0,” with even better performances.

“The mutual goal of our collaboration is to evolve the field of regeneration and to exchange expertise and research.”

Prof. Irena Sailer, Head of Geneva’s Division of Fixed Prosthodontics and Biomaterials.

BACKGROUND

31

What is the goal of the collaboration?

Prof. Sailer: The mutual goal of our collaboration is to evolve the field 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-defined and stringent criteria. This will ensure the generation of trustworthy data, with proper controls, based on which we can decide if tested new products 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 confidence, whether a newly developed material meets Geistlich's high quality 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 questions. 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 required, we could take advantage of our proximity to and our collaboration with the University of Lyon, established years ago.

Dr. Schäfer: Small animal models help to characterize the materials, particularly when used as screening models. Regarding Geistlich Bio-Oss® Collagen, we are interested in testing the material in rabbit calvaria defect models. It is a rather simple test system 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 feasible to test our biomaterials in other locations of the skull. If so, we could better align our test systems with the “real” dental application 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 first 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

32

GEISTLICH NEWS 1-2018

“Everything we need to develop biomaterials appropriately can be realized with such a collaboration!”

Dr. Birgit Schäfer, Geistlich’s Executive Scientific Manager.

the biomaterial tested – timelines, experimental groups (controls, and test groups), and animal populations needed for each condition in order to provide proper statistical evaluations and get significant 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 further collaboration means access to specific information; the opportunity to evolve further and develop directions in which Geistlich is interested. Moreover, as always and what all universities seek, we need the financial support to pursue our scientific interests.

Based on the results we achieve, we plan to submit grant proposals to the Osteology Foundation. Competitive grants, like the one offered by the Osteology Foundation, are highly desirable from the academic point of view. We will certainly apply to other competitive fellowships, and we are regularly collaborating with industry.

Dr. Schäfer: Geistlich will benefit from an exchange of knowledge.

On the one hand, we can provide extensive knowledge and experience concerning our marketed biomaterials, collagen and natural bone mineral. On the other hand, the University of Geneva offers 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 everything we need to develop biomaterials appropriately can be realized with such a collaboration!

preserve the ridge

Register your highscore and win 6x free registration for the

International Osteology Symposium in Barcelona Exactly like no other.

25 â&#x20AC;&#x201C; 27 april 2019

Gappy preserve the ridge: The new online video game by Geistlich Biomaterials Register now: www.gappy-game.com BACKGROUND

33

Collagen Processing

Can half a commitment earn all of your trust?

Dr. Mireia Comellas | Geistlich Pharma AG

Several implant companies sell biomaterials.

However, their core business, expertise and focus remain with implants. Is this half a commitment to bone and soft-tissue regeneration all you deserve?

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 reinvested 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 Process Driven by the goal of simplifying 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 (purification) › Extract the right collagen for the right application (separation) › 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 effective3 (re-assembly and stabilization).

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 historical "gold standard" connective tissue grafts have proved effective, but a second surgical site for graft harvesting always involves 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 Breakthrough Geistlich invented this unique process to create its latest biomaterial 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 limitations 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!

A

B

References | A Lack of soft-tissue volume, Dr. Thoma, Switzerland. | B Harvesting of connective tissue graft, Prof. Jung, Switzerland.

34

GEISTLICH NEWS 1-2018

1

Griffin 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

Webinar

All good things come in three’s Dr. Giulia Cerino | Geistlich Pharma AG

In 2018, for the third consecutive year, Geistlich will continue its successful Webinar World Tour series offering 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® product anniversary. Thanks to a great success the series continued also in 2017. And again this year the offer meets demand with six new webinars.

The speaker will focus on new therapeutic solutions, will reveal key factors for treatment success and using scientific-based data show the methods with the best supporting evidence.

Can you learn from an expert? Exactly.

How it works? Easy.

Register

Watch

Ask

Did you miss past webinars?

Check them out and register now.

GEISTLICH

WEBINAR WORLD TOUR 2018

The following webinars are planned, all the lectures to be held in English: Dr. Marcus Beschnidt / Germany Soft-tissue regeneration: New options to connective tissue grafts 6 March 2018, 7 pm CET UTC +1hour Dr. Helmut Hildebrandt / Germany 3D printed solutions for major bone augmentation 15 May 2018, 7 pm CEST UTC +2hours Dr. Alvin Yeo / Singapore Management of extraction sockets: An Asian perspective 27 June 2018, 7 pm SGT UTC +8hours Dr. Tara Aghaloo / USA Peri-implantitis: Key factors for treatment success 11 September 2018, 7 pm PDT UTC -7hours Dr. Mauricio Araujo / Brazil Do's and don'ts in extraction sockets management 30 October 2018, 7 pm BRST UTC -2hours Prof. Matteo Chiapasco and Dr. Paolo Casentini / Italy Clinical indications and guidelines for soft-tissue augmentation at implant sites 27 November 2018, 7 pm CET UTC +1hour

BACKGROUND

35

Upcoming Osteology education events Dr. Heike Fania | Osteology Foundation

In keeping with its mission to provide a high degree of knowledge about regenerative therapies, in 2018 the Osteology Foundation offers a series of educational events.

Upcoming National Osteology Symposia

Save the date: Osteology Barcelona 2019 The international Osteology Symposium takes place every three years – in 2019 for the first time in the exciting metropolis 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 speakers 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

Osteology London, UK 20 April 2018

Osteology Turin, Italy 27-29 September 2018

Osteology Frankfurt, Germany 20-21 April 2018

Osteology Paris, France 18-20 October 2018

Osteology São Paulo, Brazil 9-10 August 2018

Further information: www.osteology.org/education/ national-symposia

Osteology Research Academy Gothenburg, Sweden 16-18 May 2018

Vienna, Austria 5-7 November 2018

Lucerne, Switzerland 10-14 September 2018

Beijing, China 19-22 November 2018

Ann Arbor, USA 17-20 September 2018

Further information: www.osteology.org/education/ research-academy Osteology Symposia take place all over the world, e.g., in Shanghai, China, in September 2017, with almost 2000 participants.

36

GEISTLICH NEWS 1-2018

2nd Osteology Consensus Meeting on peri-implant tissues Dr. Heike Fania | Osteology Foundation

The Osteology Consensus Meeting 2017 group

On 13 June 2017, the 2nd Consensus Meeting of the Osteology Foundation took place in Weggis, Switzerland on the topic: “Evidencebased knowledge in the aesthetics and maintenance of peri-implant soft tissues.”

In two groups under the chairmanship of Ronald E. Jung, Switzerland, and Frank Schwarz, Germany, the effects of hard and soft tissue augmentation procedures on the maintenance of peri-implant tissues, as well aesthetics of peri-implant soft-tissues, 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 Research, together with four systematic reviews that were done in preparation for the consensus meeting.

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 clinical attachment level of the tooth. In cases with two adjacent implants, it is not possible to determine the ideal horizontal distance between implants restored with fixed dental prostheses.

›

Osteology Surgical Checklist Templates Human errors occur daily, everywhere and in many different arenas. Also, minor medical procedures and dental treatments can be affected by human mistakes and can lead to harm. That is why the Osteology Foundation has developed surgical 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 create 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!

BACKGROUND

37

Interview

@EAO Madrid 2017 with Alberto Sicilia Interview conducted by Dr. Giulia Cerino

“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 shortterm product-oriented research, and we have seen a lot of preventable 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 patients 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 respected and maintained, while at the same time new projects have been developed. We launched new publications, established 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.

This issue of Geistlich News is dealing with minimally invasive 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 microscope since 1997, and, thanks to digital dentistry, I try to avoid incisions whenever possible. In this context, I wholeheartedly 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 Periodontology" 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 training. In our master program we accept only two residents per year, which means that we manage continuously six students, with more than ten clinical professors. Students perform 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 summer 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 Photo: Daniele Micieli

sional organizations. Besides being the president of

38

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.

GEISTLICH NEWS 1-2018

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

IMPRINT

Magazine for customers and friends of Geistlich Biomaterials Issue 1/2018, Volume 12 Publisher ©2017 Geistlich Pharma AG Business Unit Biomaterials Bahnhofstr. 40 6110 Wolhusen, Switzerland Tel. +41 41 492 55 55 Fax +41 41 492 56 39 biomaterials@geistlich.ch

Editor Dr. Giulia Cerino, Verena Vermeulen Layout Larissa Achermann Publication frequency 2 × a year Circulation 25,000 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.

BACKGROUND

39

Publisher ŠGeistlich Pharma AG Business Unit Biomaterials Bahnhofstr. 40 6110 Wolhusen, Switzerland Tel. +41 41 492 55 55 Fax +41 41 492 56 39 www.geistlich-biomaterials.ch

6 0 1 8 2 0 / 1 8 0 3 /e n

More details via our sales partners: www.geistlich-pharma.com