Clinical and Research Experience with Bicon SHORT® Implants – Dr. Rainier Urdaneta [HD]

Good. We have Rainier Urdaneta. This is your microphone. Stick here. Put your chain put your chain on. Difficult for a Venezuelan just to be in one little corner on a dance. Perfect. Rainier Urdaneta. Please, Dr. Rainier Urdaneta is a long time friend, and he works for almost ten years now. With short and ultra short, he is the one who did most of the literature reviews and most of the publication. Please, Rainier. A pleasure and an honor to be here. I think this is probably the most prestigious, most beautiful theater I’ve ever presented and I’m honored to be here. I would like to present our clinical and research experience, but before I do that, I’d like to define scientific evidence as clinically significant findings that can be corroborated with research that I have done, statistical investigations, and that have been peer reviewed. I like to do that because whenever we utilize research, right, we hear a lot of opinions from many different people. But if we utilize this definition, the statements that large crown to implant ratio will lead to peri implant bone loss, and the statement that excessive forces will lead to peri implant bone loss, cannot be supported with the available scientific evidence. And cannot be supported because it is the exact opposite. In the mouth as well as in the rest of the body, the effect of forces in bone leads to either mineralization of the bone or fracture of the bone. There is no such thing as crestal bone loss due to excessive loading. That’s what I have understood and that’s what I have learned with my experience with ultra short implants. When we start with the effect, one of the first things we think about when looking at ultra short implants is very long crowns. So what is the effect of very long crowns on short implants? On the bone. And we did a retrospective investigation in which we evaluated exclusively single implant restorations. This is the only publication that evaluates crown to implant, the effect of crown to implant ratio on single implant restorations exclusively. As a prosthodontist, I do not understand how you can evaluate the effect of crown to implant ratio on implants that have been splinted. So for this purpose, we evaluate 326 implants on 81 patients and we found differences. Our results differ from the results of other investigations. We found that in eighty one of those implants, instead of the patients losing bone, the patients actually gain bone post crown insertion. We also documented this retrospective investigation with a significant number of variables, more than ninety variables were documented. We published the results of this study at the International Journal for Maxillofacial Implants. In that particular study, we reported the large crown to implant ratio was associated with a significant increase in prosthetic complications. The first complication was the loosening of abutments in the maxillary anterior area. We found a statistically significant correlation between the crown to implant ratio and the loosening of abutments in the maxillary anterior area. Bicon redesigned the system and now we have the two point five wells which are significantly more retentive and the ones that are now being used for maxillary anterior area. The second complication we reported in this particular study was the fracture of two millimeter post in posterior areas. We found that the longer the crown, the more likely it was for the two millimeter post to fracture in a posterior area. So titanium didn’t survive long crowns. At least not in millimeters, there were two millimeters. But what about bone? Bone was able to survive the challenge. Because bone changes its structure and according to the forces, we found that crown to implant ratios of almost five times the length of the implant. The crown had no statistical significant effect in implant crowns, failures, or in bone loss. In fact, what we found was, in some instances, reduction of the crown to implant ratio due to mineralization of the bone. In this particular case in here, we see that we have four times the length the crown into the bone. Because the implant who starts as an eight millimeter long implant is only three or four millimeters in bone. After three years in bone, we have significant coronal and apical mineralization of the bone. And now we have an implant that the patient itself has turned form into a six millimeter long implant for forty six millimeters, what is actually supporting this particular case. In this particular case, increased crown to implant ratio had a beneficial effect, a positive cat anabolic effect in peri implant bone. Crown to implant ratio went from four point three to two point seven six due to the bone growth. You can see in this case in here we have one year post significant crown length, very small. And why does this happen? Because like everything else in the body, whenever you lift weights, the bones and your arms grow. Whenever you use the bones and the maxilla and mandible, the response of the bone is usual mineralization. If we do not fracture the implant abutment interface. Another case, we have a four and a half by six Bicon implant that is only five millimeters of bone on the day that crown is inserted in 2007. But more than five years later, we have coronal opposition of bone, reduction in the crown to implant ratio due to bone growth. If you have a patient that has five millimeters of bone, what do you do in the implant dentistry center? And this is where I usually make the joke of the ex wife. What do you do in a situation like this? Well, you have two treatment plans. For the ex wife, you do the hip surgery, right? And then you make sure you place a five kilometer long implant. But for the patients you wanna keep in your practice, you actually place a five by five implant, which surgery takes very little. I actually did this surgery myself. Okay, if a prosthodontist can do it, anyone can. And this is four years post, and this is six years post. You can see clearly the quality of bone, the changes in the quality of bone from the moment that the implant was inserted to the moment that is six years later. The bone has mineralized because in the mouth, like in any area in the body, the bone mineralizes when it’s submitted to forces. And that is the strongest case we can make for ultra short and short implants. It is obvious that when we bite down, we distribute a higher amount of forces around the bone than on an ultra short implant than a longer implant. So the most significant background for that is that for short implants, or the most significant is the fact that forces are good for bone. That is before and after you can see how we have changed the quality of the treatment of the patient, the quality of the bone with minimal treatment. And that is, when a patient is satisfied, they ask for more implants. This patient would have never restored the second molar, if they didn’t have a good experience with the first molar. Another case, similar situation, five millimeters of bone, a five by five implants, and three years later you can see clearly a difference between the bone density before loading and after loading. And that is the clinical view of the integrated abutment crown. Very limited bone height, a case that even a prosthodontist can do. And, this is December 2011. This implant by the time is, this was when the implant was uncovered. And this is December twenty seventh, 2011, and this is 2015. So can a five millimeter by five millimeter implant support a first maxillary molar? Yes. And this is the CT scan showing the bone, on the buccal, and on the lingual, four years post crown insertion. When we have a case in which we have, you know, areas with more or less bone, in this particular case we chose a five by six and a five by eight together. And we restored it, this is a four years in occlusion, this is the radiograph. After four years, this is the radiograph after six years. After six years, the bone, it is pretty much the same in the short and the ultra short implant. So the question is, do we need to use an eight millimeter long implant when the six millimeter can do the job? And the answer is no. Another case, you can see Dr. Daher did a sinus lift and placed a short implant and you can see there the amount of mineralization surrounding the bone, the minimal treatment that this require. One, two, three millimeters of bone, sinus lift abutment, and implant placement at the same time. This is after six months of healing, significant mineralization of the bone. This is after two years of loading, after three, after four, and after five years of loading. Again, three millimeters of bone, sinus lift at the same time of implant placement. This is after six months of healing. And this is after six years of loads. Limited bone height, sinus lift, with placing a five by six and a sinus lift abutment. Next to a five by eight. This is after eight and a half months of healing. This is on the day of crown insertion in 2010. This is one year later, 2011, 2013, 2015. It is obvious to me that the bone surrounding the short implant, it is better five years post loads than on the day of insertion of the restoration. Another case, very limited bone height, this is 2011. And Dr. Daher placed the implant and placed it a little too distal, but we were able to restore it. This is at uncovering, this is 2011. This is June and now this is October 2011. This is after six months of implant placement, the implant is restored. Now, what’s gonna happen here? Is the bone gonna fracture? This is after one year of loads. Look at the bone and how the bone changes its structure during function. This is after four years of loads. Yes, the bone mineralizes when we use it. And this is after more than four years of loads, the bone resisted, the composite didn’t. And this is a new restoration with a TRINIA base in June 2016. The bone continues to function perfectly. Another case, so you can see that we’ve done this a significant amount of times in the implant dentistry center in Boston. They say it’s 2009. In December of 2009, the implant is placed. This is April of 2010, this is four months. Implant is uncovered. It’s restored in May 2010. And you have here two different restorations. One with a cantilever supported by a short implant and a single restoration. And this is 2012, that’s two years post loads. This is 2016, that is six years post loads. Start and end. Another case, 2010. I placed these implants and frankly you asked me why do I have a four by five, a five by five, and a six by five, just because I want it. I could have used different sizes, but I thought it was gonna look beautiful in a periapical radiograph. And this was 2010. Sometimes we have indications for things, and sometimes we thought, you know. And this is 2011, this is when we uncovered. I should have, I would have, if I were to go back, I would have placed the five by five and the six by five a little bit deeper. But again, this is 2000, April 2011 when we restored the case, and this is 2015. 2011 above, 2015 below. It is obvious that the bone has grown on the five by five and the six by five. Another case, 2006, placed with sinus lift, Dr. Daher did the surgery. This is in September 2006 when the case was restored, and this is 2014, this is eight years later. And this is the CT scan eight years post loading Of the second molar, this is a CT scan of eight years post loading on the first molar. So how much bone do we need to support a maxillary molar? You can see there the amount of bone in the buccal lingual view on the CT scan. And this is another case, same patient, but on the left side of the mouth. 2011, placed the implants and then they’re restored. This is July 2011. And this is January 2012, and this is October 2014. The most mesial implant, you can have here three years post loading and a CT scan demonstrating the bone stability. You have bone stability both mesial distal and buccal lingual. And the most posterior implant, you have stability of the bone, both mesiodistally and buccal lingual in the CT scan obtained three years post loading. In the mandible, the response of the bone is similar to the response of bone in the maxilla. We have a four and a half by six implant that has only five millimeters of bone. On the day of crown insertion, this is the year 2007. Under this loads for six years, we have significant, mineralization of the bone, we have reduction on the crown to implant ratio by coronal position of bone. Was the effect of forces in mandibular bone the same as the forces in the maxilla bone mineralizes in response to masticatory forces. Now some cases of long term, this is in 1999, implant place, and this is 2016. This is seventeen years post. The bone is better seventeen years post crown insertion. So under normal conditions, bone should not be lost. Bone should be stable or should grow under masticatory loads. That became one of my obsessions. After I saw that bone was growing, I said we need to find out what were the factors associated with crestal bone growth. And this was one of the cases that got me completely hooked into this particular research. In 2001 when I got to Bicon, I saw in front of my eyes over these years, how the bone mineralized towards the base of the abutment in this particular case. It caught my attention because the base of the abutment is polished titanium. And how it’s possible that bone is mineralizing towards the base of polished titanium. And you can see here that from the year 2001, 2003, to 2014, there was a significant mineralization of the bone. So what were the factors associated with this? We did an investigation and we found after one hundred and two different factors were investigated, there were five factors that were associated with changes, positive changes in crestal bone levels. The first factor was the presence of hydroxyapatite coating. A hydroxyapatite coating implant was significantly more likely to gain bone post crown insertion. The presence of a titanium spherical base turned out to be critical for the stability of the bone surrounding a Bicon implant. Implants that were opposing natural teeth were significantly more likely to gain bone than implants that were opposing implants supported restorations. An implant, the shorter of the implants, if they were five millimeter wide, we evaluated five by eight, and we also evaluated five by eleven. We were in the year 2001 in the market at that point. And the five by eight proved to gain more bone than the five by eleven. And the presence of the daily intake of non steroidal anti inflammatory medications turned out to be significant as well. We published the result of this study and what remains to be the only manuscript on factors associated with crestal gain on single tooth locking taper implants. We published it at the International Journal of Oral & Maxillofacial Implants. In that manuscript we reported that HA coated implants are significantly more likely to gain bone. The typical mineralization of the bone that is observed on an HA coated implant is mineralization as you can see from the arrows. Around the CP or hydroxyapatite coating on the implant. What would happen to a second maxillary molar? That is restored with a five by six Bicon implant. When we were all went to dental school, they all told us this is the area of the mouth in which we do not use ultra short implants because we’re going to have significant problems. And yet what happened in this particular case was significant mineralization of the bone on the distal part of the implant. And when you look at the radiographs, you can see that the mineralization of the bone was a slow but steady progress from the year 2007 to the year 2013. It’s not the angle of the radiograph. It’s the implant you use. So, the second factor associated with bone growth was abutment design. It turned out to be that the presence of titanium spherical base was significant, was very important in crestal bone stability. We found this because the technicians in some integrated abutment crowns removed the base of the abutment and substituted it with composite. And when that happened, they transformed a beautiful Bicon implant into a brand new implant, losing bone to the first and second thread. We found higher average bone loss on those implant restorations that had composite abutment bases when compared to titanium spherical basis and the difference was statistically significant. We published this result in the journal Clinical Oral Implants Research in the year 2014 in the manuscript, the effect of opposing structures on crestal bone levels surrounding single tooth implants. This is one case in which you can see clearly how the absence of titanium spherical base caused significant bone loss in the two longer implants and more mesial in this case. Whereas the shorter implant and most posterior implant still had some titanium spherical base maintained the stability of the bone. And so we decided in this case to change the spherical basis in some instances when the surface of the implant is not so contaminated, you can stabilize the bone. In this particular case here, we were able to stabilize the bone by changing the spherical base from, you can see here, from one year to two years, but we still don’t have perfect stability of the bone between the first two implants in the area as you can see from the radiograph of the 2016. Once the implant surface is contaminated, it is difficult for us to establish long term success. Some instances, we found however, that change in the spherical base changed completely the bone. And here we have missing spherical base for six years, and you can see that we have typical bone loss to the first thread. What would happen if in this case I change, the restoration and I place a titanium spherical base without not doing any other treatment? What would happen here is that six months after we replace the composite base for a titanium spherical base, there was significant mineralization of the bone. A stabilization that continued and maintained three years post treatment. So why is it that the base of the abutment is so important for Bicon implants? Because of implant design. This implant was designed for what is called load bearing implant abutment platform. Or what we call in our manuscript, bone loading implant, bone loading platform switching. It is well known that in order to maintain bone we have to load it. And the objective of the bone loading platform switch is actually to load bone coronal to the implant abutment interface. In a conventional platform switch case, we cannot load bone coronal to the implant abutment interface because the abutment is smaller than the implant. Therefore, there are no masticatory forces distributed to the crest of the bone. We introduced a concept of a bone loading platform switching, a manuscript we published at the International Journal of Oral & Maxillofacial Implants. In that manuscript we presented that bone loading platform switching has two different components. The first component is a space creating component, which is the is by design by the way. The sloping shoulder, this is how this implant was designed many years ago. The sloping shoulder creates a space for bone to be coronal to the implant abutment interface. Creates a space so that the second element, and the second one represents a reversing platform switch, is the loading element as well, and it is the base of the abutment. Now, masticatory forces can be distributed to bone via the spherical base. Yes, via the titanium spherical base, which is polished titanium. How is this achieved clinically? Well, we have here three different platform switches, and three different designs, and two different bone responses. Load-bearing platform switch is achieved by preparing the bone and matching the spherical base of the abutment with the use of a sulcus reamer. Now, is it possible for the spherical base to actually load bone? And does it happen? Since we know that the majority of the loads are usually accumulated on the first thread of the implant, is it then possible that the base of the abutment is the one loading the bone. But this was one of the objects of this particular study published in the Journal of Prosthetic Dentistry in the year 2010. What they did is they placed Bicon implants one and two millimeters below the crest of the bone. And they demonstrate that when a Bicon implant is placed one or two millimeters below the crest of the bone, the majority of masticatory forces are concentrated not on the first thread of the implant, but rather on the base of the abutment. So if this is so, what would happen to an actual clinical case in which we have an implant that was placed in 1998? If in fact, it is the base of the abutment, the one that loads the bone, what would happen to the bone in close proximity to the titanium spherical base? What happens is significant mineralization of that bone because now masticatory forces are being distributed to bone via the spherical base. And this is thirteen years post, and this is sixteen years post. Now, let’s look at that CT scan of this case. What would we see if we do a CT scan of this particular case? We see that the bone is surrounding the spherical base. The bone has adapted perfectly because of the anatomy, of how well this implant was designed. This has become part of this patient’s job. And yes, in the areas where the loads were concentrated, is the areas where the bone has grown over the years. Another case, the year 2000, 2009, significant mineralization of the bone, in close proximity to the polished titanium spherical base of the abutment. And I know I say this, and probably every periodontist in the room is thinking, but we know that if you have polished titanium, you cannot have osseointegration. And that is correct. You don’t have osseointegration. You have intimate contact and force distribution. So, this is another case, thirteen years post crown insertion. I think the bone under the spherical base, after thirteen years of loads, is telling us a story. There is forced distribution to the bone. The engineer who designed this implant was brilliant. It is brilliant because it’s still alive. This is fourteen years post loads. This is an implant that was placed in 1995. This is eighteen years post loads. Eighteen years post loads. Have you seen bone growing towards the base of the abutment? Eighteen years post loads with any other implant system? 2010, the implant is placed. The implant is placed in April, by October the implant is restored. 2013, you can see how the bone Now we ask, what would the bone show if we take a CT scan three years post loading? And this is what you will see. Mesiodistal and buccal lingual bone, in close proximity to the base of the abutment. A third factor associated with bone growth was the type of opposing structure. We found that the implants that were opposing natural dentition were significantly more likely to gain bone. And we published the result of that study in the manuscript, the effect of opposing structures, natural teeth versus implants, and crestal bone levels surrounding single tooth implants, and clinical oral implants research. We hypothesized in that study that the bone mineralization was a response of the increased masticatory loads engendered by the natural opposing teeth when compared to opposing implants. The four factors associated with bone growth was the actual implant size. And we found that five by eight implants were significantly more likely to gain bone. Five by six and five by five were not in the market when we selected this group in the year 2003 to 2001. So we could only evaluate five by eight and five by elevens. We found that five by eights more likely to gain bone, five by elevens more likely to lose bone. We also found that five by eights function better for posterior mandible than for posterior maxilla. And we reported that a five by eight was significantly more likely to gain bone if it was placed in posterior mandible. And we were crazy enough to have this peer reviewed by the Journal of Periodontology, one of the toughest reviews I’ve ever undergone. And it was published in the manuscript, The Effect of Implant Size 5.0 x 8.0mm on Crestal Bone levels Around Single Tooth Implants in the Journal of Periodontology. And this was the case we present there. You can see significant mineralization of the bone under the spherical base after four years of loads on five by eight single implants restored in posterior mandible. But now our patients take medications for significant amounts. One of the questions we asked in our manuscripts were, what is the effect of those medications in crestal bone levels? And we found that the majority of the medications such as statins, cholesterol medications, bisphosphonates, or any others, have no statistically significant effect in changes in bone levels. We found however, that patients with diabetes were significantly more likely to gain bone. And patients taking non steroidal anti inflammatory medications post crown insertion were significantly more likely to gain bone. When I told this to the oral surgeon at the practice, they laughed at me. They said, Oh, only a prosthodontist could say that taking aspirin is gonna make the patient gain bone. Only a prosthodontist right now. So I said, Okay. I put the radiographs of the patients taking aspirin next to the radiographs of the patients not taking aspirin, and I said, One of these two groups takes aspirin, you tell me which. And he said, no, it’s not possible. Well it is. We reported in the manuscript that an implant was significantly more likely to gain bone if the patient was taking non steroidal anti inflammatory medications daily. We found an effect that was specific to coated implants. I’m going fast because I have like five hundred slides. And every time I’m caught, it’s like Rainier, we’re going to lunch. So I’m trying to get everything. If I have time, I go slower. Don’t worry. Okay. Okay. Perfect. So remember the case that I showed you at the beginning in which you had that significant amount of bone growth, the one that got me hooked into the whole research? This patient was taking sixteen hundred milligrams of ibuprofen daily for arthritic pain. And with it, a significant amount of bone growth. I don’t know what happened with the kidney, but certainly the bones were growing. A patient taking one aspirin a day, you can see on the day of crown insertion and six years post crown insertion, significant mineralization of the bone. Another patient significant mineralization of the bone, a patient taking both aspirin and ibuprofen. Significant crestal bone growth in other patient after thirteen years of the patient taking daily ibuprofen. But why is it that a patient taking non steroidal anti inflammatories is going to gain bone? And the hypothesis may have to do something with prostaglandins. We know that prostaglandins have a biphasic effect in bone. That means, at lower levels, prostaglandins activate all the methods in order to create bone growth. But at higher levels, prostaglandins have the exact opposite effect. It create an environment that leads to bone loss. Well, what we hypothesize in our study is, that when the patients are take that in the mouth, we have a constant state of heightened prostaglandins. We all have gingivitis, we all have inflammation in our gums. In case if you don’t brush well one day, then they’re bleeding the next. So it’s obviously that we have high prostaglandins in the tissues, or at least that’s what we think. But what happens when those patients take aspirin or aspirin like medications? They lower the levels of prostaglandins to levels in which an activating of crestal bone growth. So now, can we use aspirin in order to regrow bone? That’s exactly what we’re doing at the implant dentistry center in Boston. Our current techniques allows for the use of eighty one mg of aspirin to 325 mg of aspirin as part of our bone growth and bone regeneration techniques. The first case that I did was in the year 2010, believe, 2009. With a patient in which we were missing an interproximal contact. I removed an IAC, I added the contact, and I replaced the IAC. And there was bone loss. So I had two choices. I didn’t know Ferrara existed, because I could have moved here and hide from the patient. But, I said I need to solve this problem. At that point in time, I knew that there were five factors associated with crestal bone growth. So I looked at this case as a researcher and I said, okay, I’m missing two factors. The case doesn’t have a spherical base, and the implant is not, the patient is not taking aspirin. I have the other three factors, so what happens if I change the factors I don’t have? I replaced the restoration with one with a spherical base, took an impression and I asked the patient to start taking aspirin daily. And this is after six months of treatment of replacing the spherical base and the patient taking aspirin. No other treatment was done. And this is one and a half years post treatment. And this is five years post treatment. Then we are the newer thing that we’re doing at the implant dentistry center is we are using diode laser. And we’re using resolvins. In our last investigation, we found that the patients that were taking aspirin and the patients that were taking fish oil together were the patients that had the best bone levels. I didn’t know, I’m a prosthodontist, what do I know about, you know, fish oil and all these things? So I Google it. And then I found that whenever you take aspirin and whenever you take fish oil in your bloodstream, you get bioactive compounds that are called resolvins. And there had been done Boston, in which they have used resolvins in order to regain bone on animals with periodontitis induced. So I said, okay, if my own patients, if I’m seeing in my own cases in which, you know, that aspirin and fish oil together works, why don’t I use it in my patients? And that’s what we started doing. So this patient came to our practice, this is 2013, the patient is losing bone. What do we do in a situation like this? First, we evaluate the case. So you could actually have drawn a castle in the amount of tartar. This case had all around the restoration. So I said, okay, if we remove the tartar, that’s going to go a long way. We didn’t have an interproximal contact and that’s where all the bacteria and the majority of the food was going down into the implant abutment interface. And the restoration was not in occlusion, so I figured, okay, we have an environment, let’s try to fix this. So I removed the restoration, then we used laser around the implant surface. Then we place Arestin, which is tetracycline around, and a black healing plug. And we instructed the patient to start taking three 25 milligrams of aspirin a day, as well as a thousand milligrams of omega-3s in the form of fish oil. This is a regrowth on the right of one month post treatment. That is six months post treatment. That is before and after eleven months post treatment. We were able to remineralize the bone without the use of any grafted, by eliminating the cause of the bone loss, which was the bacteria and the bacterial accumulation, and by creating an environment that was conducive by reducing the bone response and the inflammatory response from the patient. So that is eleven months later, that is one year post. This is two years post. That is before treatment and two years post. We need changes. As you can see, we have a spherical base that is closer to the bone, so I’m sure Dr. Morgan is happy. We have interproximal contacts and we have an occlusal contact. For occlusal loads in the presence of soft tissue health, have a positive effect in crestal bone levels. Another case, significant bone loss. Dr. Daher told me, Oh Rainier, for crying out loud, remove that implant. It will take you three seconds to remove it. But as a researcher, the patient said, If you could treat it, you know, I’ll bring you a chocolate cake. And say, okay, I love chocolate cakes. So I’ll do it. So I remove the restoration. Laser, Arestin, aspirin in the form of 325 milligrams of aspirin, and omega-3s. This is the day of treatment. The implant was two stages you can see, this is three months post. That is nine months post. Nine months post before and after treatment. This is one year post. This is two years post treatment. This is before and after two years post treatment. With the regeneration of the bone, without the use of any grafting material, by just using the patient’s very own. Now we have this case, right? Even I didn’t wanna try this case because I figured when I removed the crown, okay? And then you can see there that the crown doesn’t have a spherical base. Spherical base is composite. Can you mineralize this bone? You know, I told the patient, if I don’t remove the implant with a crown, I will try. Okay? So, the implant, the crown came out, so I said, okay, let’s start. Laser, Arestin, aspirin, and fish oil. And this is March 2014. And this day, and this time, I got smart, and I took a CT scan. Because there are some dentists around there saying that the bone growth around Bicon implants is because of the angle of the radiographs. Well, too bad for them, because now we have CT scans. Well, let me show you this. So we measure, this is 2014, and you can measure clearly the bone, and there on that mesial distal bone in 2014. And this is the buccal lingual view of the bone in 2014, before treatment. And this is after four months of treatment. Okay, and I was looking at the x-ray and I was saying, maybe if I change the glide, I put a little lighter, maybe I see better, but I couldn’t really see a significant difference. This is after seven months of treatment. After seven months of treatment, I decided to place a new restoration with with a titanium spherical base. And this is after one and a half years of treatment. The patient decided to continue to take aspirin and fish oil for one and a half years. And this is the CT scan, one and a half years post treatment. This is the buccal lingual view of the bone, and this is a mesial distal view of the bone. And this is a comparison of CT scans of before treatment and after treatment, where you can clearly see that there was one point five millimeters of bone growth on the distal, and zero point six millimeters of bone growth on the mesial. Irrefutable evidence. And on the buccal lingual we have one point six millimeters of bone growth on the facial, and one point five millimeters of bone growth on the lingual. Irrefutable evidence. And we have, after one and a half years of treatment, significant mineralization of the bone without the use of any surgery. These are some of the other cases we have in our prosthetic study, in our prospective study. As you can see, before and after treatment. Before and after treatment. And then one year later. Before and after treatment. Before, after treatment, and one year later. So, longer implants have better survival, right? Wrong. We’re gonna show you some long term cases and the cases that were done at the implant dentistry center. So this is 1999. The surgeon cut the implant because there was no seven millimeter long implant back in 1998. So he cut the implant in order to fit it in the space. And this is after fifteen years of loads. Another case, six millimeter long didn’t exist back then, the surgeon cut the implant to make it fit, and this is after sixteen years of loads, This is after seventeen years of loads. The implant’s still there, the adjacent teeth not necessarily. 1998, six and seven millimeter long implants, the surgeon cut this seven millimeter long implant in order to fit it into this jaw. And this is fourteen years later, and this is seventeen years later. The bone survived the forces. The two millimeter titanium post did not. 1995, 2008, thirteen years post. 2000, 2014, fourteen year loads, and sixteen years. This is 1998. I need my glasses, getting older, sixteen years old. Then eighteen years post. Eight millimeter long implants, 1998 or seven, seventeen years post. Eighteen years post. A seven millimeter long implant, 2003, the implant was placed in 1998. Again, there was no implant that was this height, this length in 1998. The implant was cut to fit this particular environment. And this is fifteen years post loads. Now why would be what would be observed if we actually take a CT scan of this case? Fifteen years post loads. At least seventeen years post loads, sorry. Seventeen. And this is a CT scan, seventeen years post crown insertion. Look at the bone. Yeah. Look at the bone. I mean, there is no other way we can say it. But the bone in the mandible adapts perfectly to this particular implant abutment design. This is fourteen years post. Then another case, 2000. And then ten years later, look at the crest at the distal of the molar. Another case, 1999, fourteen years later, 1995, nineteen years later. Now, I want to present the results of my study, the survival of ultra short locking taper implants. And I am happy to be presenting to Dr. De Porter, who was the investigator that I use as a guide in order to do this investigation. In fact, I named this manuscript the Survival of Ultrashort Locking Taper Implants. And following his research in the Journal of Periodontology, he was the one who introduced the subject of ultrashort implants to the literature. So I am extremely honored to be here and having him as part of the audience. I published the survival of ultra short implants in this manuscript in the International Journal of Oral & Maxillofacial Implants. In that manuscript, we evaluated 410 five millimeter wide implants. The only difference between these implants were their length. We had two hundred and eleven of them that were either five or six millimeter long, and we have one hundred and ninety nine of them that had eight millimeters long. All of them had five millimeter wide. 93.4% of the restorations were single tooth implants. We found that there was no statistically significant difference between the survival of ultra short compared to short Bicon implants. And we reported that their survival was comparable. Now this is how we were taught to do dentistry when I went to dental school. If you were going to use single implants, then you would use long implants. Right? And if you were going to use short implants, you will splint them together. And you will go so far as to then go to the nerve of the patient and damage the nerve. In this particular case, the patient lost the sensitivity of the lip because of the implant being so long. And on the left side, she came to us and she said, do I have the same risk? And we said, no, you do not have the same risk. We can place three five by six Bicon implants. They were placed by Dr. Daher in the year 2009. And they were restored four months after placement with single restorations. And this is after three years of loads. And this is after three years of loads, you can see that the bone is better after three years of loads. And this is after six years of loads. The bone is better after six years of loads than before. But what happens if we were to look at a CT scan of these implants three years post load? This is a CT scan of the most anterior implant. You can see how the crest of the bone has adapted perfectly to the implant abutment design. This is the CT scan, three years post loading, of the middle implant. And this is a CT scan, three years post loading, of the most posterior implant. Can we do different things? Yes, we can. But for the ex wife. So if we have, in this particular case, it became obvious to me over the years that the longest implant is the one losing the most bone. And yesterday’s implant dentistry on the left, today’s implant dentistry on the right. Another case, a sinus lift that I did and I corroborated that there was no perforation with a CT scan. And this is, can we do longer implants? Yes. But the possibility of complications if we go with longer implants increases. And this is after four months of placing the implant, the implant is already restored. This is a CT scan, one year post loading. Posterior mandible, significant bone, very little bone remaining. That was the implant that was placed by Dr. Daher in that particular case. Now the case, limited bone height, five by five. So the last part of the research I’d like to present to you would be how close can implants be placed to adjacent teeth. And the use of ultra short implants proved to be very valuable in the areas of the maxillary anterior area when we have very close proximity. We published the results of this investigation at the International Journal of Oral & Maxillofacial Implants in the manuscript, a retrospective radiographic study on the effect of natural tooth implant proximity. In that particular study, we evaluated two zero six patients who received two thirty five ultra short Bicon implants. They were followed for an average of forty two months. Forty three of those implants were placed less than one millimeter to an adjacent tooth, and in some instances apparently touching the adjacent tooth. The first question we asked was, does placing an implant so close to an adjacent tooth, does it have an effect in the survival of the implant? And we found that implants that were placed less than one millimeter to an adjacent tooth had the exact same survival that implants that were placed three or more millimeters to the adjacent tooth. So distance to the adjacent tooth was not a risk factor for the survival of the implant. The second question we asked is, does it cause bone loss? And we found that placing a Bicon implant one millimeter or less to an adjacent tooth was not associated with crestal bone loss. And the final question we asked was, does it damage the adjacent root? We found that there were no cases of root resorption, no cases of endodontic treatment, no significant correlation with pain, did not lead to the extraction of the adjacent tooth and or caries. And we concluded in that particular study that the placement of a Bicon implant less than one millimeter to an adjacent tooth did not damage the adjacent tooth. And one of the reasons why this happens is because the first, even if the first implant thread is touching the adjacent tooth, because of the load bearing platform switch, you have this space for bone at the crest. This is an actual case on the day of the crown insertion on the left, and on the right, one year post crown insertion. One year post crown insertion that is better bone than on the day the crown was inserted. And this is the actual case. You can see the radiograph. This is 2011, and that’s 2014. 2011, 2014, This is three years post loads. Even though the first thread is apparently touching the adjacent tooth, we still have significant space for mesial bone. Another case four and a half by six, 2009, this is 2012. This is three years later, no damage to the adjacent roots. And this is six years later, no damage to adjacent root, and no crestal bone loss. Another case, a five by six, four years post loading. This is interesting because on the distal side, the implant is much closer to the adjacent tooth than on the mesial side. And yet, four years later, there are no changes in bone levels, either on the mesial or the distal sides. And after seven years, the situation continues to be the exact same. Congenital missing lateral incisor, very limited bone height, a four by five implant is placed and is then restored. We inserted an IAC one one day after it was uncovered. That’s the insertion of the restoration. This is one month post crown insertion. This is the year 2011. And this is the year 2013. This is two years. Significant growth of the papilla, Significant mineralization of the bone. Another case, one of the first ones we didn’t need so close that I remember. And this was a four and a half by six Bicon implant. We no longer use this size for the maxillary anterior area because it has a three millimeter post. But it was done back then in 2008. And this is and the crown was placed. And this is one year post. This is 2008. And that is six years post. That’s 2013. And that is one year post. That is one year post crown insertion. And this is six years post crown insertion. So as you can see, some of the polish of the restoration has been lost, but the majority of the restoration remains in. One of the issues is that the adjacent tooth, the central, continued to supra erupt, and now we have an implant that is shorter. So therefore, we decided to add composite. We did a retouch, so a composite veneer was on top of the integrated abutment crown, And that is before and after the composite retouch. A very limited space for bone, as you can particularly see in this case. And I placed a four by five, very limited amount of bone. Now what would happen to the adjacent root? Well, we seated the implant without pressure to the adjacent roots. This is 2011. May 2011, the implant was restored. And this is two years post on April 2013. And we have papilla growth, 2012. Okay. Now we’re going to go over just the last few things. It’s just the latest research we’ve been doing. We’ve been working on two implants supporting at two premolars. So we’ve done a lot of these cases for patients that cannot afford having one implant and two premolars works really well. So this is an IAC before and after. Another case, that’s the radiograph. And that is one year post. Another case, restore with a two unit IAC. This one has a TRINIA base. And insert it. So two premolars with one ultra short implant. And that’s the radiograph. And another case is in the prospective study. We have the year 2010 and then 2013. As you can see in the restoration there, there is more bone on the actual cantilever to premolar restoration. Another restoration for now by six, supporting two premolars. Another case, two premolars, two premolars. Now the last thing I’d like to talk to you is the use of leukocyte and and platelet-rich fibrin. We’re using this technique with a significant amount of success in areas or in combination with the graftings. So we basically take blood from the patient, we put it in a centrifuge, and we separate the white cells from the red cells. We can actually grab the white cells, and we can then separate them. And we have in the pouch of fibrin, we have leukocytes, we have platelets, and we have mother cells, all alive and ready to be placed. Then we press them down with this press, and then we utilize this particular as a grafting material. So when I went to see this presentation, the dentist told me that if I had a patient with one hundred percent bone loss, in which we had no crestal bone, that what I needed to do and as you can see here, there is no crestal bone on the facial part. He told me that the only thing I had to do was to take the tooth out and then place four of these membranes. And I said, that is crazy. That cannot possibly work. But I did it. Okay? This is December 2014. This is CT scan after the extraction, the placement of the membranes, but before healing. And that’s a CT scan on March twenty four, 2015, three months post placement. You can see how we have remineralized the crest of the bone, just with the use of the crest. So three months after, I was able to place a short implant. And this is, and uncover it in June, and restore it in July thirtieth, 2015. This is a CT scan at crown insertion. So we go from zero bone in December to some bone in March and do restoration in July. No other grafting material but L-PRF (Leukocyte- and Platelet-Rich Fibrin). We have prospective group of patients in which we are doing sinus lifts with three months wait, with the use of only leukocyte and platelet rich fibrin. The technique is basically the same sinus lift technique, but then we utilize under as a grafting material below apical to the implant only L-PRF. And that is a case January twelve, 2015. And this is March ten, 2015. This is two months post crown insertion. And this is three months, seventy eight days the implant is restored. And the technique is basically just doing the sinus lift the same way. But instead of placing any other material, we place L-PRF. And we use it as, as you can see there, that’s the L-PRF membrane. And then you place the implant on top of that. You place another L-PRF membrane coronal to the implant, and then you suture the area. This is the case May fifth, and this is three months later, August sixth, and this is four months later, implant is restored September 2015. Another case, significant, very little bone, implant placed December 2014. Three months later in March, the implant is uncovered. Four months later in April, it is restored. Before and after treatment, with only use of leukocyte and platelet rich fibrin. The other cases that I used L-PRF for is when I have a tooth that is bombed out and I want to place the implant the same day. This is what we did in this case. We extracted the tooth, placed the implant, and placed a lot of membranes on top of it. You can see from the mineralization, the amount of mineralization. And when you look at it, this is three months no, this is more like five months post treatment. No, actually three months. You can see clearly how the bone has grown. You can see the trabeculation of the bone. Okay? You can talk to the bone, and the bone talks back at you. Thank you very much. It was a pleasure to be here.