Prof. Dr. Mauro Marincola
University of Cartagena
Clinical Director, International Implantology Center
Prof. Dr. Leonardo Trombelli
University of Ferrara
Professor of Periodontology
Good morning, ladies and gentlemen. Good morning. Good morning. I hope you enjoy the selection of our location, and you enjoyed the yesterday’s location too. We are here in a beautiful city beautiful city of Ferrara, which is not very well known, but it’s a jewel of the Italian Renaissance. And talking about jewels, we have a diamond of our profession today who will inaugurate and open our international forum, the Ultra Short Forum. I beg Prof. Leonardo Trombelli to come on the stage. I’m not quite sure that I am a diamond, but thank you anyway for this kind introduction. It’s a real pleasure for me to welcome you here at Ferrara and and to thanks the organizing committee and Mauro and Prof. Ewers, to give me the opportunity to be here in this podium, which is a well known podium for us that we live in Ferrara because it’s part of the cultural activity of our city. And the reason Mauro why I’m proud to be here and to join you for this one day meeting is twice. The first reason is that I’m positively surprised that you have selected this city for this important meeting. Surprised because, as you said, few only few know that Ferrara is a UNESCO World Heritage, and that it’s one of the most beautiful Renaissance city that we have, at least in the northeastern part of Italy. And only if you know that Ferrara guessed one of the oldest university in Italy, and I’m really proud to welcome you also on behalf of the School of Medicine of the University of Ferrara, which I’m honored to chair for these three years. Ferrara University was founded back in thirteen ninety one by Pope Bonifaceo Tao, and now it’s a very important issue in our city. Think about that, basically, in a city that counts one hundred and thirty thousand people, we are close to twenty thousand students. So, the university is not only important for us for the scientific and cultural activity, but also for financial reasons, as you may possibly understand. The second reason why I’m really happy to be here and introduced this morning is that, in our research centre, in Ferrara, in the School of Dentistry, we have dedicated so much effort in order to develop procedures and techniques that we call minimally invasive, and I’d rather call simplified technique. Simplified means that this procedure may be well accepted by the patient by reducing costs, disadvantages, drawbacks, limitations, but by optimising what is the treatment outcome. We have developed surgical techniques for periodontal regeneration, simplified surgical technique for sinus lifting, and so today we are very proud and very consistent in opening this meeting, because talking by ultra short implants is a consistent way to approach a delicate issue, which is the prosthetic rehabilitation supported by implant in a minimally invasive fashion. So, again, since it’s a meeting on ultra short implant, I want to have an ultra short introduction. And so again, I welcome all of you, ladies and gentlemen, my dear colleagues, to Ferrara, and wish you a very unpleasant stay here in our city. Thanks a lot, Leonardo. You were very clear about the situation at the universities. And a very fast announcement. Maybe somebody is not listening to the translation. The translation for Italian is number one. You have to push the number one, and translation for English is for excuse me, for German is number thirty two. Number one Italian, number thirty two is German. Excuse me. I am speaking in Italian. I’m completely confused with the translation. Okay. We are here. We’re here to introduce you a concept which is the ultra short. And I don’t know if it’s so necessary for most of you to have an introduction on ultra short implants, but by the way, we have to respect certain aspects of consensus, international consensus, and so there were a decision made this year in February at the International Consensus report on short angled and diameter reduced implants, where the implant sizes were decided or defined. And in this report you can see that ultra short is all implant length, which is less than six millimeters. Now the short implants are between eight and six millimeters, and so you will question yourself, what is this one millimeter of difference? What is it doing? Why we stop by six with the short, and why we stop with the ultra short? We start with the five millimeters with the ultrashort. Stopping, I don’t know, because maybe you stop in the future in two or three millimeters. This is the promise of Dr. Vincent Morgan. You’re promised this. Okay. But important is now, what is it? Do we have enough literature? Do we have enough studies on ultrashort implants? Following our consensus conference, we don’t have that. We still don’t know the evidence of ultrashort implants worldwide. What happened? I’m talking about we because, you know, I don’t have to hire a tier, almost all Bicon users. The Bicon implant is the one who has these shorts, ultra short implants for different years, but there are now actually new ultra short implant companies, and we have to look at what this means. We have to see if ultra short is like ultra short, if short is like shorts. There are big differences. And we have to respect these differences and look at the differences. Looking at the literature, like you see, we have not so many literature reviews, but it starts in two thousand and five with Prof. Sean and his group from the Harvard University. Two thousand and five, then we have two thousand and eight, ultrashort sintered porosus, a porous implant surface. And Prof. Deporter, which I can’t see now, Prof. Deporter should be here. Yes, we have a special guest, Prof. Dracos Deporter. Please, an applause for him. And then we will see twenty ten, twenty eleven. We have almost more and more in the last years. We have different researches and follow ups and long term studies done on ultrashort implants. But it’s not enough. And if you look at the market, actually, that’s the reality of the world market. I’m not talking about the local market, because local markets are not the real reality of what happened worldwide. And so, the world market looks like that. Companies, there’s five companies actually, who shows up with implants, ultra short implants and ultra short implant studies. Starting from back in two thousand and two, like you see, always the pioneer in short and ultra short implants, and so on. But, if you look at the particular aspect of that two definitions, we will see that two of them are also for single crown restoration. The other three are for additional or auxiliary implant placement. That means they can’t hold in the posterior a single crown, which reduces our therapy a lot. You can’t place two implants only because they are ultra short and the company is telling you the ultra short has to be splinted. So, when and why using the ultra short? For sure, if you have this extreme atrophic bone, there is no other way. Maybe augmentation, but here you see a big and important group of researchers, guided by Esposito, is telling us, for many years now, this is one of many studies done, that vertical augmentation, we don’t know where to go with them. What happened after two, three, four, five years, and we talked yesterday in the pre congress about that. Where to go? The other aspect is, like I told you before, is short like short or ultra short is like ultra short? No. We have to look at the features and we have to look at the design like, you know, of what happened. And here you see two different designs. Here you need always bone grafting procedure, a GBR, to cover that implant because there’s nothing else to do because the geometry of this implant doesn’t allow you to bury completely the implant into the crest. And the crest is not always slight and smooth. Like you see here, the first millimeters are very thin, and then you can bury this implant design slightly under the crest. And then a sloping shoulder is helping you and helping the situation, to bury completely the implant in native bone. And here we have the aspect. You see that? That’s the design we have actually at crest level. The neck of the implant becomes very important. As short as you go, then finally you’ll end up to have only a neck. If Dr. Morgan promises us three millimeter, it will be a neck implant. There is nothing else. And so, as short as you go, what’s more important is what happened there at crest level, how much of the implant is engaged with the crest. And that makes the big difference between one and the other design if we go short or ultra short. Also, if we go standard. But very important becomes this aspect if we go shorter. And here we have, also at the consensus, there’s only two pages, but there ‘s so many information in there. Yesterday, we discussed half an hour about certain things, and we still continue to discuss about that. For example, we didn’t touch yesterday in the pre congress that phrase here, which says improvement in implant design and surface alone, is important. We have to change the idea of ultrashort changing the mentality of geometry and design of the implant, otherwise it does not work. And we know that, and not only we, but also other companies. And which are the other features outside of the crest model, is for sure the implant design for itself, appositional bone versus trabecular bone is completely different. The healing is something else. We’re talking about what can I say, Lamborghini versus Fiat? Almost like that. And so here we are. Appositional bone is not giving us the same stability of an ultrashort implant as plateau form implant systems. And we will see and we will have some of the lecturers talking about it. So we have cantilever like bone formation inside the design, which makes the implant design possible to be shorter. We have the BIC and the augmentation of this surface is made by the healing chambers. And then we can have that aspects here, nine, twelve, fifteen, twenty years, one to five, one to four implants, crown or crown to implantation. The other aspect of the consensus conference was modification of the surgery. Many are forgetting that. That means it’s not only the implant design, but we need also an instrument which allows that we can place the implants in very critical situations without hurting the patient. So, for example, if you have no bone in the posterior lower, we even do don’t do block anesthesia or infiltration with this system because it’s possible, because we have that atraumatic drilling techniques, which are, you know, the latch reamers are not cutting at the edge, and then I can do this or can go closer. Now we regained fifty RPM and so on. Very important aspects to do even this kind of surgeries, getting to the shafts, connective shaft of the nerve, open the nerve. It’s a lateral transportation. No. It’s a compression towards the apical. Nothing else. So we we earn and we gain. We can gain, in certain cases, one to one and a half millimeters, which is very important if you talk about ultrashort and atrophic bone situations. So here we are. That’s what I told you before. If we don’t have a sloping shoulder, it becomes a little bit more difficult, or really difficult without bone grafting procedure, to cover these very tiny implants and to embed them completely in native bone, which is important. As less titanium surface I have, the more I have to be sure that all the implant is buried into native bone. And here we see, we go on the nerve. Like the Germans used to say, This is what we have here in aspect Without block, it’s possible. Atraumatic, same thing in the upper. We can feel what we do. And it becomes very important. We are back in surgery. Yeah, that’s right. Not everybody can do it, maybe. We’ve told also that you need training for it, but once you are trained, you can. And that’s not a big problem. So immediate loading. We have to be careful with ultrashorts. We have to be careful if you talk about immediate load of single units, single units, about immediate placement, and type four bone voids. Pay attention. But this is normally for all kinds of treatments the same. And so here we see the comparison. What is this? This is an ultra short implant because we’re talking about zygomatic implants. Are engaged five millimeters into the zygomatic bone, and so once again we are talking about ultra short with a very long lever. And here we are, the opposite. What to do? Immediate function, or let’s wait three months and then have something maybe less traumatic and more predictable. Here we are with an immediate load. Immediate loading doesn’t mean that we we are not going shorter. Like you see here, once again, you can go shorter. These are eight millimeter implants, so these are fifteen to thirteen millimeter implants. And so there are ways to do it, but you cannot use ultrashort for that kind of treatment until now. Same thing as immediate placement. We have to respect that thing, The size of the alveolar cavity. How big is the alveolar cavity? I take out a canine. The alveolar cavity is fifteen millimeters long. The first engagement to the bone is very far away. Good, you can place an ultra short, but it will be very deeply buried. So pay attention with that kind of treatments. Same thing, you plan to place an ultra short, but then you have to place a long implant due, because you get into a hole, the famous bone voids we’re talking about very often, which is very important to have in mind if we are talking and we are working with a trophic bone situation. And it happens very often. Recently, at Midwestern University, I was training with other colleagues, and they didn’t believe this bone voids. I can tell you that of ten cases, we had seven bone voids. And so, if you don’t know about it, maybe you don’t look at it. But once you know that they exist, you have to pay attention. Mostly, if you go ultra short, then you have to graft, like in this case, and maybe take a longer implant. So what would affect you during the day? We have our eight speakers here, and some of them will talk about the general use on ultra short implants in every kind of situation. Use them fifteen millimeters of bone height, ten, twelve millimeters. The width is not important. Use the ultrashort implants, and they will show us how to use them in all conditions. The other group will show us the opposite. Extreme cases, extreme situations, like we talked before, ultrashort, atrophic bone situations. There is no other way. And so the one is an option, maybe a treatment, future treatment planning, And there is no other than ultra short implant. Thanks a lot.