Private Prosthodontic Practice
Our next speaker is Rainier Urdaneta. As I told you, he came to us from academia, and his work will speak for itself. So let him show you what he has done. Right. So I I came to Bicon from here, from Harvard. I was teaching full time at the Harvard Dental School. And I was using you know, Brånemark, ITI implants, etc. And then I went to take a presentation with Vin and he was showing me all these restorations without cement, implant without screw, and my first thought was, are you mad? Anyway, I was given a chance to do an opportunity to do research. And this is what I have found in the last ten years doing research with implants. I was told that large crown to implant ratios will lead to bone loss. I came to Bicon thinking that splinted implants were necessary to protect bone, that longer implants were necessary in type four bone. That highest biting forces were created with implant prosthesis. This is what I was taught in my prosthodontic training. That excessive forces led to bone loss. And that the dental implants could not be placed in close proximity to neighboring teeth. I am going to challenge these statements. For these statements cannot be supported with the available scientific evidence. The first one was crown to implant ratio. Unlike Dr. Schulte, I did research in the subject. We went back and evaluated single implant restorations. I found, to my surprise when I first started with this, that the majority of the research done on implant, crown to implant ratio was done on splinted implant restorations. Frankly, the only research that has been done with single implant restorations were done with Bicon implants by Dr. Schulte and by our group. How do you evaluate the effect of crown to implant ratio on implants that are splinted is beyond understanding to me. But that’s how it was done prior to this research. We have been following these cases prospectively since the year two thousand and three. We have gathered information in three twenty six implants on eighty one patients. Eighty one implants out of this, instead of losing bone post crown insertion, they gained bone post crown insertion. We evaluated more than ninety different factors. And we published the results of this investigation, International Journal of Oral Maxillofacial Implants. In that particular study, we found out that an increased crown to implant ratio has a significant effect in prosthetic complications. But with regards to relationship with crestal bone levels, we found that crown to implant ratios of up to four point nine five did not lead to a significant increase in peri implant bone loss. In fact, what we observed was the exact opposite effect. Let’s look at this particular case, crown to implant ratio, this is a 4.5 x 6.0mm Bicon implant. As you can see, not all of the implant is in bone at crown insertion, about five millimeters of it is in bone. And yet, more than three years post crown insertion, we have had bone growth now. All the implant is within patient’s bone and we now have a smaller crown to implant ratio in response to the forces, in response to the bone growth. What I have realized over the years, and I think if you ask me what is the most significant finding of my research is that, like everybody else in the body, the response of bone to forces is mineralization. If you have osteoporosis, your physicians don’t tell you, please sit down and be careful because excessive forces are going to lead to bone loss. They tell you the exact opposite. Your bones need you to work them in order to grow them. So forces lead to mineralization. If you have a case like this with five millimeters of bone remaining, what do you do in your practice that way? This is what we did in our practice in two thousand and nine and I placed this implant. Small internal sinus lift and a 5.0 x 5.0mm implant. How much pain does a patient go through when this particular procedure takes about, you know, half an hour to be done. Very minimal. This is after healing. This is a crown at insertion. And this is three times the length of the crown. As you can see, the crown is significantly larger than the implant. And that bone response, two years post crown insertion, is mineralization. It is obvious that the forces distributed over a smaller surface area, in this case, a 5.0 x 5.0mm implant, those occlusal forces are distributed and then you get more forces between reaching the bone. And the bone’s response is not bone loss to the first thread and rather is mineralization. Another similar case, and as you can see before and after, after more than three years of function, the bone has changed its architecture and in an obvious way in the radiograph. Forces, and we can agree all that the quality of the bone in the maxilla is the worst, and you can see here that the response of maxillary bone is to change its architecture. This is all, as we know, what Wolff’s law is all about. Forces will lead to changes in the bone, and those changes will be mineralization. Very minimal bone loss remaining in this particular patient. And what was the treatment provided at the implant center? Did we do an external sinus lift in two thousand and eight? No. An internal sinus lift done by Dr. Shadi Daher in a webcast to London with a placement of two 6.0 x 5.7mm Bicon implants. And as you can see, the implants are pretty much swimming into sinus grafting. Nine months later, the implants were restored with single implant restoration. So, you’re probably thinking, well, this will be the case in which you will be asked to splint, right? Let’s use the technique that has been, you know, given to us, let’s splint and pray, right? And yet, what was done at the implant dentistry center was we didn’t splint, for we knew that the response to bone, to these forces, is mineralization. And as you can see, the radiograph speaks by itself. Two years post crown insertion, the bone has grown in response to those forces. Another very limited case, what would you do when the patient like this arrived to your office? I suggest that you do an internal sinus lift. And as you can see, the implant is placed and you lift the sinus and it’s being held by the abutment, another beautiful surgery by Dr. Daher. And six months later, you have some bone healing, you put it to restore and this is two years post crown insertion. This is how you start and this is what you give the patient. This is minimal treatment with maximum effect. I know the case, so that you know we’re not just showing you the first two that work well for us, but rather something that we do all the time. And internal sinus lift, right? And this is what was obtained, four millimeters of bone during healing, and this is two years post loading. The bone response to forces is mineralization. We have a case with four point three three of crown to implant ratio at crown insertion. This is two thousand and nine. What’s going to happen in here when we know that this particular implant has is eight millimeters long, but only four millimeters of those eight are in bone. This has to be the case in which we’re going to lose bone to the first thread, right? Let’s see what happens. This is three years post crown insertion. What happens here is bone growth in response to the forces of, now we have six millimeters of the implant in bone. We have had bone growth coronally and apically. Now the crown to implant ratio is no longer four point three three, but two point seven six. The response in the mandible is the exact same thing. We have a 4.5 x 6.0mm Bicon implant placed. It’s restored with an integrated abutment crown, crown to implant ratio of two point five. What’s going to happen with this particular restoration with four years in this occlusion? It has to be bone loss to the first thread, right? Because that’s what we were taught in dental school. This is what happened. Crown to implant ratio now is smaller for implant, for bone growth surrounding the implant have now made the crown to implant ratio smaller. Why does this happen? My belief is strongly that the increase in forces has the bone changing its shape, and in this case, increasing mineralization. All these cases with bone growth led us to start evaluating why this case is bone growth, I have to accept that for me it became an absolute obsession to understand why were these cases gaining bone. And when we define bone growth, this is what we were talking about. We have, as in the illustration on the first molar, as you can see, this is two thousand and one and this is two thousand and eight. It is obvious that in this particular case, we had a significant amount of bone growth over the eight years of function. But what were the factors that were associated with this particular clinical finding? And as you can see, in this particular, for those of you thinking that I just brought you the toothpaste x rays, you can see here what happened over the years, two thousand and one, two thousand and three, to twenty ten, and how the bone growth was slow but steady over the years. This is the reason why these manuscripts were published. They were published because you can argue with radiographs. These factors associated with bone gain manuscript was published in the International Journal of Oral & Maxillofacial Implants in November of the year twenty eleven. In that manuscript, we evaluated more than ninety different factors, and frankly, you could have asked me, I became so obsessed, you could have asked me what, you know, medications were taking the patients. Every single thing they were doing during the day and we knew exactly what they were doing before. We needed to know exactly what were the factors associated with bone gain. Of those factors, we had thirteen that were correlated to bone loss and ten that were correlated to bone gain. Of those ten factors, after placing them into a multi variant analysis, we found that five of them were correlated with a significant increase in peri implant bone levels over time. The first factor was the presence of a hydroxyapatite coating. The type of restorative technique. Implants opposing natural teeth were significantly more likely to gain bone when compared to implants opposing fixed implant supported restorations. One implant size out of ten, five millimeter wide by eight millimeter long implants were significantly more likely to gain bone, and the daily intake of non steroidal anti inflammatory medications for the treatment of arthritic pain and or cardiovascular prevention. The first factor was the HA coating and we found the similar findings when comparing different coatings. H A coated implants were significantly correlated to bone gain and titanium plasma sprayed implants were correlated with bone loss. The observation that coated implants maintain osseous crest is not new. It is known since the 1990s. The typical growth that you will observe on an coated implant is, as you can see on this particular x-ray and the arrow showing, is bone growth towards that coating and towards the implant abutment interface. And finding that replicated in different patients and was statistically significant. So what would happen if you have a five millimeter wide by six millimeter long Bicon implant and a maxillary, restoring a second maxillary molar in occlusion with a natural tooth, what would happen over the years? Are we going to continue to lose bone to the second thread, third thread, or what is going to happen? What happened over forty years is that bone growth towards the implant abutment interface, as you can see, has slowed steady growth around the implant around the coating on this particular implant. So does excessive forces lead to bone loss, or do they lead to bone mineralization? Of course, one of the limitations of short implants, and we have to understand when to use them and when to now use them, is the fact that we cannot restore the profile, the soft tissue profile. So in maxillary anterior areas, there may be moments in which you need to do graftings. But for posterior areas, we can all agree that is not necessary. The second factor associated with bone gain was the presence of a spherical base on the abutments. As you can see here, restorations either porcelain and fistula crowns or integrated abutment crowns, if they had the titanium spherical base, they were significantly more likely to gain bone. When that spherical base was removed, like in the case on the right side, and replaced with composite, then a Bicon implant lost significantly more bone. The placement of composite on the base of an above and what’s the most significant factor associated with bone loss, and it was a factor that was, as you can see, highly statistically significant. So the presence of the titanium spherical base then one very important factor in bone stability and bone growth. The reason for this is the fact that of course composite accumulates more plaque, but also force distribution. This implant was designed so that forces would be distributed to bone, be at the base of the abutment, and by loading that area, coronal to the implant abutment interface, then we maintain bone. This is a theory that is obviously supported by clinical cases. In this case, thirteen years post crown insertion, you can see that below the spherical base, we have had a significant amount of mineralization to, and it seems obvious to me, to my eye, that is related to force distribution. This case is nine years post crown insertion, as you can see, again, mineralization. And what’s most interesting about this is that the base of the abutment and the Bicon implant is polished titanium. So we obviously do not have osseointegration, but what type of relationship do we have in which we see further mineralization in that base? I believe one of force distribution. So what happens if we change the composite abutment base with a titanium spherical base? Can we regrow the bond that’s lost? This is what we did in this particular case. This was the daughter of one of our dental assistants, and soon as she heard that spherical base was needed, she said you better change the restoration of my daughter. So six years, as you can see in here, six years post crown insertion, we’ve had bone loss to the first thread and second thread in some areas with the use of composite. When we replace that spherical base for titanium, we were able to remineralize that bone and regain some of the bone loss in a period of only six months. The third factor associated with bone gain was implants opposing natural teeth. That was a complete first for me, and I went to Dr. Morgan and I said, Dr. Morgan, what do you think this is? Why would teeth with implants opposing with natural teeth would gain more bone than implants opposing implant supported restorations. We have this, this is my last manuscript, it’s going to be published next year, the Clinical Oral Implants Research, and in this particular manuscript, we debated this particular theory. We found that significantly lower bone loss was documented on implants opposing natural teeth when compared to implants opposing implant supported restorations. We also found out that an opposing natural tooth was associated with bone gain for H A cord and implants placed in the mandible. But why? And we see that the majority of the cases that gained bone, they were occluding natural dentition. And it didn’t matter if the cases were occluding non restored teeth, teeth with crowns, or what matter was that they were opposing a natural tooth instead of an implant. Some authors, in this case, latest edition of his book has suggested that lack of proprioception on opposing implants that magnify the load around fixed implant supported prosthesis in partially, and in those cases, you’re in parafunction and that the highest forces as created in implant prosthesis. There are two things we’re saying in here. One, that implants lack proprioception. And two, that the highest forces are created with implant prosthesis. Neither of these two statements can be supported with available scientific evidence and this is the reason why this statement in the book has no references. So, we know that implants have proprioception and it’s called osseous perception. Osseous perception has been evaluated in teeth and in implants in the same way, in a way of active and passive discrimination. It is well known that active discrimination between teeth and implants is very similar. The question becomes, what is the difference in passive discrimination? We do know that the threshold of minimal pressure perceived in implants is significantly higher than on teeth. What does this mean, however? This means that implants are able to discern forces from three point four newtons and on, whereas teeth are able to discern forces from zero point three newtons and on. So the difference between teeth and implants is the difference between zero point three newtons and three point four newtons. How is this clinically relevant? How many of you have patients with occlusal forces that are averaging three point four newtons or less? How about four hundred newtons for an average? Or a hundred and fifty or two hundred and fifty? Those are the averages. So the fact that patients cannot discern between three point four and zero point three has no clinical significantly relevant for us. For patients, if they can discern between three point four newtons or more, they can discern all the biting forces and much more, all the biting forces that are received. So, in this particular, with regards to forces, we know that every single piece of research done in the subject have shown the same thing. Forces on patients with natural dentition are higher than forces in patients with fixed implant restorations. Every single piece of research have said the exact same thing. In fact, there is not one that says that forces on implant restorations are higher than forces on natural dentition and yet, we are educated in dental school that forces on implant restorations are higher. I don’t know where that is taken from, but certainly not from research. So occlusal forces higher on teeth than on implants. So we conclude, we actually hypothesized in this new investigation that the crestal bone mineralization observed on those implants opposing natural dentition was a response to the increased local strains engendered by the natural opposing teeth during functional occlusal loading. In other words, higher forces led to mineralization. The fourth factor associated with bone gain was an implant size four and a half, 5.0 x 8.0mm. We found out that 5.0 x 8.0mm implants were significantly more likely to gain bone. This, we also found that there was a significant difference between maxilla and mandible and that the 5.0 x 8.0mm was significantly associated with bone gain in posterior mandible. We were crazy enough to have this particular information peer reviewed by the Journal of Periodontology. And after a grueling review, it was published. On the October issue of twenty twelve of the Journal of Periodontology in this particular manuscript, we concluded that 5.0 x 8.0mm implants demonstrated statistically significant less per implant bone loss in posterior mandible. There were two findings that are found in this particular study. One, that 5.0 x 8.0mm gained more bone, and two, that short implants give periodontists a stomachache. So the second factor, okay, so, all right. Now, the final factor associated with bone gain here were the patients taking, the medications the patients were taking, and this was a completely, a complete finding for us. We evaluated every single medications the patients were taking. For the first time in the literature by the way, there is an older research that has been published that has shown even though our patients are taking all these medications for the treatment of systemic conditions, we have not consider any of these medications in previous research. I can tell you now that patients taking the most common medications, which are statins, were not correlated with changes in peri-implant bone levels. But patients with diabetes, taking or not taking medications to lower blood sugar were significantly more likely to lose bone. And patients taking non steroidal anti inflammatory medications were significantly more likely to gain bone. An implant was significantly more likely to gain bone if the patient was taking non steroidal anti inflammatory medications, an effect that was specific to coated implants. This is not the first time in the literature that the intake of NSAIDs have been shown to reduce bone loss, and in this case, even increased bone density that was done in the year nineteen ninety five by a randomized clinical control trial with a different implant system. Fifth, this factor, as you can see here, the first case that I show you had a patient that was taking non steroidal anti inflammatories. And when we asked, and in some instances, we actually had to go back to the medical and the pharmacy records to know exactly how much medication the patients were taking. We figured that this patient was taking sixteen hundred milligrams of ibuprofen a day to control arthritic pain. And you can see the significant amount of bone growth that was correlated with this. Seven years post crown insertion, you can see a significant increase in cholesterol bone levels in these patients taking six hundred milligrams of ibuprofen one day, six fifty milligrams of aspirin the other day. And significant amount of bone growth as you can observe here with the patient taking three twenty five milligrams of aspirin four years post ground insertion. Another significant case, another significant case in patients taking non steroidal anti inflammatory medications. Another significant case, but the patients were doing similar things. They were taking some of them, significant amount of non steroidal anti inflammatory medications. Why do we think this happened? We have placed a theory in the manuscript that Dr. Daher helped me figure out, in which the, as we know, non steroidal anti inflammatory medications block the formation of cyclooxygenase enzymes, reducing the formation of prostaglandins. What I didn’t know was that prostaglandins have a bifasic effect in bone. That is, if you have prostaglandins or lower amount of prostaglandins in the tissues surrounding the implant, you have an environment that increases the replication or differentiation of osteoblasts and leads to bone growth. If you have an increase in prostaglandins in the tissues surrounding the implants, the effect is the reverse and you lead to bone loss. So our hypothesis in this study is that the daily intake of non steroidal anti inflammatory medications reduced the amount of prostaglandins in the tissues surrounding the implants, creating an environment that was conducive to peri implant bone growth. We have now started using aspirin to regrow bone in patients that have been lost. We use aspirin because it’s widely used and because animal studies have shown that there are several pathways in which aspirin can actually lead to peri implant to bone growth. This was one of first case we did utilizing the aspirin to regain bone. In this particular case, you can see we have a patient that had been stable for three years. As a prosthodontist, I saw the interproximal contact being lost and I saw no, no, no, no. I have to immediately add this. Now I have changed my mind and I prefer bone to interproximal contacts any day now. Anyway, we removed this restoration and we replaced, added interproximal contact and six months later the patient came with an infection and bone loss on the implant. I had two choices, to treat this or to move to main. I chose to treat the case and then said, all right, we have five factors associated with bone gain. This patient has, this is a 5.0 x 8.0mm implant. This is occluded against natural teeth. It’s an implant that has an coating, but I have two factors that I could change. I could add a spherical base to this restoration, and I could place the patient in non steroidal anti inflammatory medications. This patient was placed on them. We removed the restoration, took an impression for a new restoration, and placed a known shoulder abutment with a spherical base. We placed arrestin in the on their base of the abutment, and we instructed the patient, we also placed the patient on five hundred milligrams of amoxicillin for ten days, and we instructed the patient to take aspirin, three twenty five milligrams of aspirin. In his particular case, he took it twice a day. This is the before and after of the treatment. We were able to remineralize the bone surrounding this particular implant with the use of aspirin. The question became, what happens if you reduce the three twenty five milligrams to eighty one milligrams, because that’s what the physician had suggested, and this is a year and a half after the amount was reduced to eighty one milligrams showing that the bone remained stable. Then I was sent another case. We uncovered this case in twenty ten. We placed a non-shouldered abutment and the dentist restored it with a porcelain-fused-to-metal (PFM) crown. A year and a half later, he sent us a case, we’re losing more bone. Again, two choices, main or restoring the case. So I went with restoring the case. We did diode laser, placed arrestin, and asked the patient take three twenty five milligrams of aspirin, and after six months of treatment, we were able to remineralize the case, and we sent this particular view back to the dentist, which we were able to then remineralize this and restore some of the bone loss. The next manuscript we investigated, and Dr. Chuang has already talked about it, I’m not going go over too much, is the survival of ultra short locking taper implants, which was published in this year’s May issue of the International Journal of Oral and Maxillofacial Implants, and there was no statistically significant difference in the survival of ultra short when compared to short Bicon implants, and we demonstrated that the survival of five by six Bicon implants was similar to a survival of eight millimeter long Bicon implants. So what happens if you restore a maxillary premolar with a five by five implant, even though you have kilometers of bone, you choose to utilize a five by five implant. What would happen? What happens, I think is obvious from this radiograph. Bone response to increasing forces is mineralization. We have several techniques and alternatives, but we have to consider them seriously. For if we have seven millimeters or less of bone height remaining in posterior mandible, what is the best alternative for our patients if not the placement of a short, an ultra short implant? This is what I believe was yesterday’s implant dentistry, splinting shorter implants and then placing a long implant. In this particular case, you can see the mandibular nerve was damaged, and the patient lost the sensibility in the lower right lip because the dentist was using the whole rationale. If I am going to place, you know, a single implant restoration in the mandible, I better use something really long. Came to us, Dr. Daher evaluated the area and said, oh, I don’t think so. We can place five by six Bicon implants. We can restore them three months after the placement. We can then do them with single implant restorations with molar sized teeth, instead of premolar sized teeth, one year post loading, the bone is better than at loading. And interestingly enough, in the same patient, similar areas of the mouth, the longest five kilometer implant is the one losing the most bone. And when you have here, you have three implants to restore two teeth on one side, yesterday’s implant dentistry, and today’s dentistry, three implants restoring normally sized teeth. On the left, this is important because the patient has much more surface area to bite on one side than on the other. Why is the survival of ultra short implants the same as the survival of longer implants? Because the case supporting the strain induced by a large response of bone is compelling. If you type in midline, forces and bone, you get a myriad, an amount, an excessive amount of information. If you type excessive forces and bone loss, you find a lot of publications poorly done and in dentistry. In fact, the last evaluation of the literature in the subject of excessive forces and bone loss concluded, and this is taken from the abstract, a causative relationship between loading conditions and marginal bone loss has not been demonstrated. So why are we taught in dental school that excessive loads lead to bone loss when this relationship has not been demonstrated is something I just don’t understand. The other reason why these implants work, I think, is because they are wider than conventional implants. I truly believe this is a factor. How do we define excessive loading in dentistry? We define it by cantilevers, right? We define it by grinding, and we define it by short implants, right? We define it this way, count to implant ratio. So what if we put all these things together? We have a patient that obviously grinds. We have lack of posterior support, another factor that increases forces. We have a cantilever mesial to that implant, and we have a patient that grinds. What is going to happen here? The consequences are prosthetic. Prosthetic restorations may not be able to take the load. The bone on the other hand can. As you can see clearly here, bones respond to an increasing force, increasing forces, it’s mineralization, not bone loss. So how short is too short? Is that a threshold? I believe you’re going to restore an implant, a molar or a premolar with a two point eight millimeter wide by eight millimeter implant, that is too small. That is not enough. And this case, and why is this possible? Why is this the case? This particular study, I think explains the relationship in a very clear way. If you have two implants of similar length, they are twelve millimeters long, and you increase from four from three point six to five millimeters in width, only increasing the width by one point four millimeters, it reduces stress by almost fifty percent. Now if you have implants of similar width, in this case three point six millimeter width, and you increase length from eight to seventeen millimeters, you reduce stress by only seven percent. Width is much more important than length any day. So in this particular case, give us an idea of how this is so. We have a 2.8 x 8.0mm implant restored, that we decided to restore. It was placed there temporarily just to help us immediately build the case, but we decided to let’s restore it. And we had also 4.5 x 6.0mm Bicon implants next to it working two years after the implant, the two and a half, the 2.8 x 8.0mm implant loss integration. But if you were to measure bone loss from the crest, we didn’t lose any bone. For the rationale of bone loss to the first grade and then second thread and all these things, it’s simply not true. What happened here is what I believe is the effect of excessive forces in bone. If you can break the bone, if you can fracture the connection, and in this case, occlusal forces fracture, they could be very weak connection between a very thin implant and bone, then you have excessive loading. In the same case, 4.5 x 6.0mm Bicon implants continue to perform perfectly. So for an ab by six to restore molys and premolar is just more than enough. For you as surgeons, this gives you the opportunity to restore cases like this, very close to the nerve, five by five implants placed and restore on right and left in this particular patient, very close to the mandibular nerve, and you can restore them and you can expect that in unsplinted implant restorations, the results were positive. The last research I want to talk to you about today is locking taper implants placed in close proximity to adjacent teeth. We found out, what do you think it happens when you place a Bicon implants in close proximity to an adjacent tooth? We found in our first investigation that in some instances, there is no negative effect. The implant’s really close to an adjacent tooth and yet what happens is significant mineralization of the bone. Now the prognosis of the adjacent tooth is better four years, actually five years post insertion when compared to this initial placement. So for me it became a question, what is the effect? If I’m gonna do something in the mouth, I need to research it first. I need to know that what I’m doing, I’ve looked at many different records over the years, but I need to have an effect. I need to know that if I place a Bicon implant one millimeter or less to an adjacent tooth, that I am not going to lead to root resorption. That I am not going to lead to the adjacent tooth needing a root canal or extraction. For that, we set up this particular retrospective cohort study, two zero three patients received two forty two Bicon short implants that were followed for an average of forty two months. Forty six of these implants were placed less than one millimeter to an adjacent tooth. There were nine implant failures for a Kaplan Meier survival rate of ninety six point three percent, but there were no implant failures in the less than one millimeter group. Placement of a Bicon implant less than one millimeter to an adjacent tooth was not associated with root resception. There were no cases of root resception. No cases of endodontic treatment. No cases in the patient reported pain post surgery. And no extractions of adjacent teeth in this particular cohort. We found also that there was no significant difference between crestal bone levels of implant placed in close proximity or further apart. There was no relationship simply between placement or distance to an adjacent and crestal bone levels. But why is it so? This implant has a sloping shoulder. So if you place an implant, like in this case, less than one millimeter to an adjacent tooth, you still have a significant amount of space between the implant abutment interface and the implants for the implant narrows to the abutment, is much smaller in size, providing significant space for bone growth and papilla. In this particular case here, we have three years post crown insertion, it’s a 5.0 x 8.0mm Bicon implant, and as you can see, very close proximity to an adjacent tooth, what we have is actually significant amount of space for bone growth over the years. Very close proximity to an adjacent tooth, no significant changes in peri implant bone levels three years post implant placement. Very close proximity to an adjacent tooth, no significant difference in crestal bone levels with a five by five in the mandible. Very close proximity to an adjacent tooth, no significant difference in bone levels. So I have seen Shadi Daher and Donohoe and all the famous surgeons and Dr. Morgan, and all the surgeons placing these implants so close to an adjacent tooth over the years, I’ve looked at the x rays, and I have never found any case in which we have root resorption. So I’ve, you know, for example, I placed this particular case myself. And of course, yes, I sweat a lot that day, and you know, but we did it very slowly, and then we realized. And then you see another case here, a 5.0 x 8.0mm. We have obviously more space on one side than on the other, but no significant differences in bone four years post crown insertion. So we conclude in this particular study that short plateau design implants placed less than one millimeter of an adjacent natural tooth did not cause damage to the adjoining tooth and demonstrated similar pre implant bone stability when compared to implants placed more than one millimeter. And some of the clinical cases we’ve done over the years, as you can see in here, we have a four point five by six Bicon implant, that’s in close proximity to an adjacent tooth, restored with an integrated abutment crown. This is one year post crown insertion and this is the clinical view of the restoration, one year post crown insertion. Of course, as the years go by, then we get to get a more and more close to an adjacent tooth and I did this case and I am a prosthodontist, all of you are oral surgeons, so if I can do this, you can do this with your eyes closed. So we measured this particular case and we found that we had, you know, seven millimeters coronally, but when we went down to the two roots, you know, this is typical post ortho treatment. They open up the spaces but the root don’t move, right? So we have now this particular situation, what do we do? Enter a 4.0 x 5.0mm. A 4.0 x 5.0mm implant has four millimeters at the coronal part and three millimeters in the most apical part. A perfect implant for a clinical situation like this. It was placed, as you can see, we have plenty of bone because the implant in the most, in the top part comes out as a two point five abutment, giving you significant space for papilla. So this is placement and after healing, And this is when I uncovered, as you can see, we were having bone growth. This was three months after uncovering, and we were starting to get bone growth on top of the implant. And we took an impression and the same day as the uncovering, and then we inserted the crown next day. Of course, breaking all the rules as usual, right? So we inserted the crown. As you can see the tissue is fully mature. And we inserted the crown and this was our crown insertion, and this is nine months post crown insertion. You tell me where is the bone better when I placed it or nine months later? And what is the bone response surrounding a 4.0 x 5.0mm implant? Is it bone loss or mineralization? And do you see any damage to adjacent roots or root resorption or root canals in any of the adjacent And for those of you thinking you cannot have papilla, in this case we had what could even call an oversized papilla, you know, growth. Five kilometers of growth of papilla in this case. And a patient that is happy. So if the question is, is there scientific evidence to support the use of ultra short Bicon implants, the answer is a definite yes. Thank you very much for your attention.