A Three-Year Retrospective Clinical and Radiographic Study of Short Implants – Prof. Giorgio Lombardo [HD]

Okay, thank you very much for the kind invitation to Professor Marincola and to the all the Bicon staff, especially for the president, Dr. Morgan. And my thanks to all the Bicon people for his support, for the support they gave me in this year. And before but before beginning, I would like to thank two persons. The first is my director, Professor Nocini, who allowed me to do part of the research, which results I am discussing with you, I’m sharing with you. And the other person that I would like to thank is Professor Deporter. Where are you? How are you professor? Because professor de Porter was the one who opened my mind at the some days ago, opened my mind and probably without him, I should not have have had the capacity to understand the meaning and the secret of the Bicon implant. Thank you very much, professor. Well, I think that I can start my presentation. Okay. I take the opportunity to to thanks Leonardo for hosting us here in in Ferrara. I didn’t know how much how beautiful is this town. And sorry, no. Okay. Okay. Okay. And finally, I would like to thank all the boy, all my boy who worked with me in university and without them, I could not be here to share anything with you. So, we know that, sorry, echo. We know that for many here, dentists and oral surgeon have aimed for the placement of the longest possible implant in any given site. Despite the fact that this could put a risk neighboring vital structure. Overheating bone, crestal bone, and inviting underlying nerves. So, from the meta analysis of the literature, we know that with machine surface implant, we can have a cumulative survival rate after five years of ninety five percent. And when the rough surfaces implant replaced the smooth surface implant, the cumulative survival rate rose to ninety seven percent after five year. But unfortunately, in many cases, we don’t have such abundant bone volume. And so augmentation procedure have been proposed in literature, and to allow the placement of long implant. The guided bone regeneration and the internal sinus lift by osteotomes, with osteotomes, is some example of those. Guided bone regeneration, we know, is a procedure based on the use of membrane. It’s not an easy procedure. It’s very demanding. It’s very demanding for the patient and the needs very skilled and expert surgeon to be performed. And if we look to the survival rate, we see that in literature, the cumulative survival rate is quite high for some authors, not so high for other authors. But for all the authors, if we look at the patient satisfaction, the community success rate, it did not mean survivor rate, but success rate, the clinical success, success, is not quite high. And this is due, without any doubt, to the high incidence of the premature exposure of the membrane. With all the consequence and the complication from the clinical aesthetic point of view that this brings. On the other side, maxilla, internal sinus elevation is considered a simpler procedure. But nevertheless, this procedure require a certain level of expertise. And it’s not necessarily results in one hundred percent of success. So, this is the bone augmentation procedure. And even if carried out by an expert dental surgeon, the optimal results are not always achieved with this procedure. And we must remember that they are very demanding from the point of view of the patient. Given this situation, the use of short implants have been proposed in such cases in the past. Can be this a realistic alternative? Some researchers raised many doubts at the beginning, Because they thought that short implants couldn’t work. The controversy arose because in the first experimental studies, only machine surface, smooth surface, have been used. And machine surface implant failed to give long term good results. But when rough surface implant replaced a short implant, the machine surface implants, the results were completely different. So the skepticism towards shorter implants was partially overcome in the last decades. At least for what regards seven and eight millimeter length implant. And if we look the results of the literature, we see how the success of this procedure can be compared very well with the results that we achieve with augmentation procedure. In my own experience, my own personal experience, accords with the literature, using Bicon eight millimeter implants, with similar results being achieved with eight millimeter implant. We can see that there is no doubt that we can use these implants with a high degree of reliability. But remind the questions of whether an overall reach of less than seven millimeter can be effectively treated with implants shorter than seven millimeter. Sorry. This is a no way infrequent situation. We found this situation in the sixty two percent of the maxillary, maxillary posterior ridge, and in the fifty percent of the posterior mandible, we find less than millimeter height ridge. When a vertical bone augmentation of more than four millimeter has been attempted in conjunction with the long implant placement, Literature told us that the survival rate decreased. So, this is not a trustable solution To try to rise the membrane of more than three, four millimeter. Or at least it’s not a solution that works in the hand of the majority of us, or at least in my hand. Literature in this case suggests to use the sinus lift with a lateral approach. This is a well known, very proven technique. With polished surface implant, the cumulative survival rate achievable is ninety one point two percent after five years. And with RAS surface implant, the cumulative survival rate rose to ninety six percent. But even if this procedure may be effective, there are many, for the literature, a four hour daily practice, we know that some complication can follow, or can arise after or during this procedure. For example, the most frequent is the perforation of the sinus membrane. But the most dangerous is the infection of the graft, with the following purulent sinusitis. And even if everything goes well, this procedure require free intervention, and over a period of nine months, or even more. In such a situation, would it not to be better to use implants of five to six millimeter in length? Well, this is now begin the topic of my discussion, because I am here with the to share with you the results we obtained in the school of dentistry overall. In about 301 Bicon implant placed in maxilla and in mandible, short and ultra short Bicon implant. In posterior maxilla, now I show you some cases. Of course, not such cases, such wonderful cases as those we have seen before of Dr. Koenig. I am a periodontist, so I’m feeling more confident when I have not to do big surgery. So this is what exactly you can do, everybody of us can achieve in our daily practice with this kind of implant. So, let’s see. Oops. Because this is Windows eight, and, okay. Okay. Now, the presentation will be focused to check how stable is the bone level, are the bone levels around this implant following during the time. You can see that this is the loading. This is the situation after one year, and this is the situation after three years. There are very, very few changes. We calculated that the average resorption of the first bone contact point is, after three years, of zero point two millimeters with this implant. So very, very few. Almost difficult to check. Another case. As you can see, this is work done in university with the limitation of the fingerprints of the students. But we can follow the pet to the guilty. So, no resorption of the bone. Another five millimeter implants. This is the loading. And this is what we have after three years. This is not not something special at all. I’m just showing you what you have in it, what we find, what you see every day in your clinics. After three year, this is the situation. And I can go home for all the day like you could do. Because this is not the surgeon here who do who does the great part of the job, but it is the design of the implant. Very stable, without any morbidity for the patient. The patients are happy. And they finally, when they smile to me, they really smile to me. Not like before when I performed more complicated and invasive procedure. Another case, the loading, the position of the bone at the moment of the loading, and this is after one year. And this is what we have after three years. And this is a case that I like to show. This is one of the first cases, so I made some errors. And I always, at that time I thought that bigger is better, no? Longer is better. So the concept is that I lose, I lost the implant. But look what happened with this kind of implant. I waited. This is what happened after six months. This is what happened after twelve months. And this is what I found after sixteen months. So, how can I say, the spare tire that can fix the problem, the 4.0 x 5.0 implants, I placed the 4.0 x 5.0 implants, and now the patient is happy and confident with me, in me? So, we wonder, is this a realistic alternative to the sinus grafting? From my experience, yes. This is the cumulative survival rate after three, almost four years of follow-up with this kind of procedure. In the literature, there are article that compare five, six millimeter with seven, eight millimeter. And we see that the results we achieved are comparable with those of seventy eight millimeter implants present in literature. And in my experience, both implants, five millimeter and six millimeter, show it to be very reliable. So short, ultra short. And also, this is the problem with the changing of computer. I’m sorry. But I’m sure that you will do the best to read what effectively is difficult to read. But the meaning is that you can trust on this implant when you have all, at least five millimeter of notched bone. From the results I obtained. But what approach can be taken when the alveolar ridge is less than five millimeter height? Ultrashort implant, in conjunction with internal sinus lift, can be a valid alternative to the lateral approach, even if when the reach is less than five millimeter, I. E, for example, three millimeter. Let’s see what just an explicative case. This is the situation. This is the procedure to place with the I just use the internal sinus lift abutment. And with the SynthoGraft, I create my internal sinus lift, elevation of the membrane, and I place the implant, I followed the implant, the process of healing of the implant. And this is what I found after one year of loading. And this is what I found after four years of loading. Very stable results. Confirmed from the PCA, from the tomography. So this is the principle of the internal sinus lift elevation. But everybody knows what I’m talking. But let me show some cases. This is the beginning, the baseline, this is the implant placement, and this is the loading. And this is what we have after three. This is not something special. This is the implant placement. This is the loading. And this is what we have after three years. This is the preparatory picture. This is implant placement. This is the loading. And this is what we have after three years. So, are a reliable is a reliable procedure to perform an internal sinus lift in conjunction with an ultra short implants in case of severe resorbed ridge. From my own experience, yes, it seems to me a valid, valid, valid and effective procedure. And no statistical difference have been found between the use of five millimeter or six millimeter implant. In literature, there are very few paper dealing with the topics of the internal sinus lift with the ultra short Bicon implant. I found one. And after a follow-up of two years, the authors found cumulative survival rate of one hundred percent with this kind of procedure in an average of three millimeter. My experience compared very well. I was surprised, but I didn’t I didn’t I was surprised that I don’t have the one hundred percent, but because one hundred percent is something that sounds strange to me in all the activity of the human being. So, what? Follow-up. After three years, I had a follow-up of, after three years of follow-up, my results was a cumulative survival rate of ninety eight percent. Very good result. So may the use of five, six millimeter length Bicon implant in association with an internal sinus lift to be a valid alternative to the lateral approach? In my opinion, for me, definitely yes. Let’s move now to the mandible. What can we do if the ridge offers only five to six millimeter? In literature, vertical regimentation will be proposed. Like, for example, the graft from the chin, the ramus. And the cumulative survival rate with this procedure, after a few years, is ninety four percent. But the problem is not that it is a very demanding for the patient procedure that require a very skilled and very expert surgeon. Is as the very problem, the real problem is that the graft undergo progressively to a big, big recession. And you can see during the, you can see watching the day, looking at the picture, how the graft, the greatest part, is resorbed. Another case, just to follow the fate of the grafted bone during the time. One year after loading, five years after loading, ten years after loading. And this is not something that happened to me. It happens to the majority of the surgeon because it not depends from the surgeon, but depends from the type of vascularization on the posterior mandible. And the presence of a thick cortical bone. And at the end, what we found that implants survive thanks to five millimeter height available in the native bone. So at the end, they become short implants, but not with the right design for being a robot with a short implant. So, could we use implants of five or six millimeter without any graft at all? Let’s see some cases. Implant placement, loading. After three years, another case, preparative implant placement, loading. After three years. Loading after one year, after three years. First two implant placed, loaded the first two implant, another implant placed. The third implant loaded, after three years. Implant placement, loading, Six months, something happened. I really, I don’t know what’s happened, but I lost this implant. But look with this implant, what can we do? Twelve months after, the bone was healed, and so I placed another implant, just like everybody of us do. And I could, after restore this implant, with the total complete satisfaction for the patient, and with no problem for me. So this is a trustable solution to use five, six millimeter length implant, the Bicon legs, five, six millimeter length implants in a very resorbed ridge in posterior mandible. Yes, with the ninety seven percent of the survival rate, I think that, yes, this is a very good procedure with ninety eight percent with six millimeter, and ninety six percent with five millimeter cumulative survival rate with no statistical difference between the two kind of implant. Reliable results have been achieved with both the six and the five millimeter implants. In the literature, we find that the cumulative survival rate found for this kind of implant is quite high, ninety eight percent. But only after one year of follow-up. Our results are comprehensive of the results during a period of three years of follow-up, and the cumulative results we obtained are quite satisfaction for me. So the results after this experience of three zero one short and ultra short Bicon implant is that the cumulative survival rate is highly comparable with those reported in literature with for long implants after three years. The cumulative survival rate is similar for maxilla and for mandible. In maxilla, I lost five out of one hundred and thirty nine implant. But no statistical significant differences between classes of implant lengths have been found as regard to the survival rates. Similarly, in the mandible, the cumulative survival rate was ninety seven percent, and no statistical difference was found among the various classes of implant lengths. Now let’s go to the topic of the health status of this implant. I found the real majority of this implant in a completely status of health. They were healthy. Only two percent of resorption of bone, the only eight percent of inflammation of soft tissue around this implant. The ninety percent of the implant after three years, the ninety percent of these short and ultra short implants are healthy. If we look to eventually present the eventual presence of some difference between maxilla maxilla and mandible, I found that in mandible, there seems to be a little more prevalence of biological problems. But the majority of problem is related to the presence of inflammation of the soft tissue. So, if we try to find what are the predictor for mucositis with this kind of implant, I found that there are more probability to find mucositis in implant placed in the and when the material for the prosthetic reconstruction is resin and not in ceramic. But we are talking of inflammation, of soft tissue. We are not talking of pre implantitis. We are not talking of loss of bone. Because if we go for, try to check if we have some predictor for risk, I found only the three percent of peri implantitis. And in literature, the prevalence range from eighteen after five year to fifty one or more after nine, ten years. So I found something strange, but real. Too few per implantitis to find any correlation. What if I have a time, a little time more, I would address a new topic. But for me very interesting because with this kind of implant, yes, it’s important to know that we have a little, a low prevalence of pre implantitis. But it’s, for me, similar importance is to know that with the simpler we can treat peri implantitis. And not have I said because we are the greatest surgeon and the greatest periodontist in the world. No, but just because of this unique and particular and special designs who allow us to place this implant routinely two or three millimeter under the level of the crest. Because with other implants, when the peri implantitis take place, there is the absorption of the bone, and the implant that have been placed at the level of the crest after the pre implantitis protrude, will protrude over the bone. With this implant, that have been placed under the level of the crest, we will find an intrabony defect. And we know that the intrabony defectis the defect with the greatest chances for regenerate. So what do we have to do? Here is to run for deep, complete, thoroughly disinfection, and the debridement, defector, the disinfection of the implant, the surface implant. And after we feel the material, I feel the, yes, what did is to feel graft, to graft the defect. And I tried to achieve a very good suture, to achieve a primary intention closure that is very, very important. Very, very important to every generation. And so, what I had to do is to wait. And this is what I found after two years. Before. After. Before and after. Another case, deep pocket, bleeding on probing, intrabony defect at the hick’s ray. In this case, the patient allowed us to remove the prosthesis. Not always the patients are happy that if we remove the prosthesis. Prosthesis. This is the defect once rise the flap. The same procedure for the debridement of the defect, for the disinfection of the implant surface, and after the graft, the grafting of the defect. And the suture for primary tension. And this is what we have with the fund after two years. Before, after two years. Before, after two years. Another case, I have now I reached, I think eleventh cases, and I’m going to publish, I hope, if I find the strength and the time, but I think that this is a topic that deserve to be known from the dentists, because it seems that this protocol really works. Another case. A defect, intrabony defect, the pocket, bleeding on probing. The intrabony defect, We with the simplest, I repeat. We have intrabony defect. What do we have to do in this situation is to clean, and to try to have the much sterilization if we can reach, but it’s infection at least of the surface of the implant. And after, we graft the implant and suture. And after, to wait. And this is what we had after two years. So, conclusion. David Nisand and Franck Renouard, in 2014, wrote that short length implants can be successfully used to support single and multiple fixed reconstruction. And they wish that additional studies should also investigate to answer the question if is, is there a real possibility of using ultra short implants in theextremely resorbed posterior jaws. And from the results of my research for this preliminary data, my answer is that definitely, yes, we can. Thank you very much for your kind attention.