Clinical Evidence of the Bicon Implant

Okay, perfect. Okay, so I would like to talk to you about the clinical research with Bicon dental implants. I have been working with this system for several years now and I am here to present what it is our experience at the implant dentistry center. I would like to talk to you about the several myths in implant dentistry. And I would like to talk to you about several different areas in which we think we know what’s happening and yet our understanding of those clinical facts is really not supported by scientific evidence. Some of those areas are the effect of increased crown to implant ratio. Those factors that are associated with changes in bone levels. I’m going to talk to you about factors associated with peri implant bone gain, as well as factors associated with peri implant bone loss based on our research experience with this system. We’re going to learn about the use of non steroidal anti inflammatories to actually help regenerate bone in cases in which we have lost it. We’re going to talk about and compare the survival of short and ultra short Bicon implants. We’re going to talk about the effect of loading on implants and whether there is a threshold or not at least a clinical threshold. We’re going to use ultra short implants in areas with limited interproximal space. Whenever possible in this presentation, I’m going to support my statements with available scientific evidence. And scientific evidence is not an opinion of a dentist published in a manuscript. Scientific evidence, the way I’m going to define it for us, be clinically significant findings that have been statistically tested and peer reviewed. May I suggest that the cause effect between peri implant bone loss and increased strain is not scientific evidence. May I suggest that a lot of the things we have understood supposedly over the years in dentistry is not supported by scientific evidence. We’re going to look into some of this in detail. We begin with the subject of, and some of that knowledge, some of that knowledge that we’re given in dental school is that large crown to implant ratio is going to lead to peri implant bone loss. That we need to splint implants in order to protect bone. This is tantamount to you having osteoporosis and going to the physician and the physician telling you that you need to go to bed, lift the legs and splint them because you are losing bone, because you’re over stressing your bones. No practitioner in medicine protects bone from loads. Only in dentistry do we dare to say that bone is unable to withstand forces and bone is going to go and disappear suddenly because we put bone to function? I’m going to suggest that the bone in the maxilla and in the mandible is exactly the same as the bone in the rest of the body. If you use it, you keep it. If you don’t use it, you lose it. I’m going to suggest that some of the implant systems were designed to lose bone to the first thread. That’s how they were designed. This implant system was designed to actually have bone coronal to the implant abutment interface. And that’s why it has bone in that particular area. We have been taught that the highest biting forces are created with implant prosthesis. When we know that every single piece of research says the exact opposite. That the highest biting forces occurs in humans with natural dentition. And that the excessive forces will lead to peri implant bone loss, even though every single review article in the subject has says that the relationship between peri implant bone loss and increased loss has not been demonstrated. On the other hand, what’s most interesting is that the relationship between increased stress and bone remodeling is a well known fact in medicine. We do know that if you lift weights, the bones in your body will be bigger than if you run for example. That the size of the bones will be directed to the forces or will be correctly related to the forces they receive. Yet in dentistry, we are thinking, oh we are losing bone, let’s protect the bone from loads because we’re going to continue losing it. Isn’t this interesting? Let’s look at the first of those myths. The myth that having a long crown on a short implant leads to peri implant bone loss. We did a retrospective cohort study. And as a prosthodontist, when they asked me to do an investigation of the subject, the first thing that came to my mind was to say, Okay, we need to have single implant restorations. How do you evaluate the effect of forces on implants that are splinted is beyond me. But prior to this investigation, every single research in the Soviet of crown to implant ratio had been done on splinted implant restorations. If two implants are splinted, they are distributing the forces between them, it doesn’t matter what you put on top of it, you can put a house on top of them. It’s when they are single units that you can actually see what the effect of forces can be in them. So that for me was extremely important. So of course, the results of our study would differ from some other studies because we started with appropriate methodology. We’ve been following these cases. We have by the time we published this manuscript, we have seen these patients up to seventy two months. But we continue to follow these patients up to today. Out of those three twenty six implants that we evaluated, eighty one of them in eighty one patients in forty six patients, instead of losing bone post crown insertion, they had more bone after loading than they had the day the crowns were inserted. We evaluated more than ninety different factors. And we published the results of this study, the Journal International Journal of Thorough and Maxillofacial Implants. In that study, we demonstrated a larger crown to implant ratio was associated with a significant increase in prosthetic complications. We demonstrated that the longer the crown, the most likely was an abutment in the maxillary anterior area to come loose. And that the difference was significant, statistically significant. So, what is the effect of crown to implant ratio in the maxillary anterior area? That abutments and crowns and for those of you still using screws and screws, will be more likely to loosen if the crown is longer. That’s what we demonstrated in this particular study. For that reason, or maybe not for that reason, but Bicon redesigned and designed an implant specifically for the maxillary anterior area and that is the two point five well, which is the one you’re going to be using. So, if you want to have if you’re using Bicon implants and you want to have minimal loosenings of abutments in the maxillary anterior area, you’re going to use the two point five well because that is the one that was designed specifically for that particular area of the mouth. The second complication we observed on Bicon implants that was correlated with increased crown to implant ratio was the fracture of two millimeters abutments in posterior areas. The longer the crown, the most likely it was that an abutment of two millimeters could fracture in a posterior area. So we no longer use two millimeters abutments in posterior areas. There is the two point five and there is the three millimeters where we prefer to be used in those particular situations. So it is obvious that increased crown to implant ratio has a negative effect and the negative effect is prosthetic. The metals do not withstand cannot withstand the forces, especially in the mouth, in those particular, if they are not thick enough. But there is one difference. A very big difference between metal and wood and an implant in a human being, and bone. And the big difference is that bone changes with forces. Whenever they were designing this particular implant, they did not go to a, you know, Black and Decker catalog and they chose whatever screw is used in wood to be used in the mouth. They actually designed an implant to be placed in bone. And unlike metal, bone can strengthen or weaken itself. Unlike wood, bone can strengthen and change it’s architecture in response to forces. And that’s exactly what happened and why we found that increased crown to implant ratios. Crown to implant ratios are above to four point nine five, that is the crown was almost five times longer than the implant in bone, did not have a statistically significant negative effect in bone. Why? Because we discover what is been known in medicine for all these years. The forces are good for bone. So now we started for example with this particular case. This, by all means, is an ultra short implant. This implant is six millimeters long by four point five millimeters wide. It’s restoring the first maxillary molar. This is the day of crown insertion, it’s 2007. The crown to implant ratio when measured was two point six. And then after four years of loading, after three years of loading, we now have a crown to implant ratio that is two point two. Why? Because we have bone growth coronal to the implant abutment interface. Instead of actually losing bone over the three years of function, what happened was the exact Bone grew in response to load. But isn’t it exactly what happens everywhere in the body? Isn’t that exactly what happens when we lift weights? So if, the rationale here being that if the forces, the masticatory forces are a certain amount of forces and you’re going to distribute it over a very long surface, like a long implant or a very short, you’re going to get more forces surrounding the bone of a short implant. It’s Wolff’s Law. So, over the years we have changed our you know, treatment plans to now adapting to the patient. When the patient came here to us to do this particular treatment, she has five millimeters of bone and she had gone to several dentists in town and everybody told her she needed to have, at that point in time several years ago, an external sinus lift and a five kilometer long implant. May I suggest that we should have two different treatment plans? The treatment plans for the patients we want to keep in our practice and the treatment plan for our ex wife and our ex husband. So if your ex wife or ex husband comes to your practice and with a case like this, and we’re going to say, we need to keep take a piece of your hip, because you were always very hippie, and we’re going to put it right there and we’re going to put a five kilometer long implant for you. Suddenly, because of course in a first maxillary molar there’s going to be some forces but not enough to maintain the bone in a five kilometer long implant. Right? Then she’s going to lose bone, or he is going to lose bone because of this huge atrophy. Because it’s not needed. Because you don’t need a five kilometer long implant to support the first maxillary molar. And then you’re going to need some very painful implant, you know peri implant tissue therapy. Or alternatively, can just place a 5.0 x 5.0mm Bicon implant, restore it with a crown that is three times the length implanting bone. And we can see that, as you can see on the bone on the right side, the actual quality of the bone has changed over time. For it mineralizes in response to masticatory loads. May I suggest that the response of bone to excessive loads is only one, fracture? May I suggest that if the bone cannot take the loads, the bone fractures. There is no such a thing as bone lost to the first thread because the bone was being overload just magically at the top part of the implant and decided that in the absence of movement was going to disappear one thread at a time. That is unheard of anywhere but in dentistry. So, we start with bad quality of bone and we have changed and we now know from the studies so marvelously done in NYU by Dr. Coelho and collaborators, of what type of bone gets formed and how this implant changes the actual bone that exists in the mouth. Of course, when you have a patient that imagine the amount of pain this patient went through for a five by five implant with a small sinus lift. How many pain killers do you think this patient took the next day? And this is actual fact. One ibuprofen. Because I told her to. Then after that she said, I didn’t need anymore, it wasn’t painful. How many ibuprofens would a patient that has the huge implant and the sinus lift, external sinus lift will take? Do you honestly believe that a patient that goes through that particular traumatic surgery will ever go back to you to get more implants? Well, when a patient is satisfied, they go back to you and say, you know what, the back tooth is now hurting me, let’s take it out and put an implant. Because that implant wasn’t painful at all. It was really easy, the procedure, to be done. So, as you can see we’ve done this many times, it’s another case. We have five millimeters of bone, then a five by five implant is placed and restored. And this is three years later. You don’t need to be a dentist in order to know that the bone after three years is more mineralized. That we have actually changed the anatomy, we have to change the configuration of this particular bone by loading this bone. Which by the way, is exactly what happens everywhere else in the body. So we have a situation like this, we could place a longer implant and this is exactly what we did in the area where we had more bone. So, the implants, you can agree with me that the biggest difference between these implants is pretty much their length. Right? So we use a shorter implant where the bone was less and a longer one where we have more bone. If I were to go back, I would place two short, two ultra short implants. For I learned over the years, and this was the occlusion in this particular case, four years in this occlusion, that the bone ended up being better at the ultra short implant. It is not needed. It is not necessary that we place those, that we drill the hole that is deeper. It is unnecessary. It is also unnecessary that we splint this implant in order to protect bone. Bone does not need to be protected from forces. Bone needs to be loaded to stay alive. So very minimal bone, as you can see and this was a webcast that Dr. Daher did many years ago to London. The implants were placed as you can see, we begin with no bone, very minimal bone, Right? And now we place the implants and the internal sinus lift abutments are the ones actually holding the implants in place. The implants are pretty much swimming in sinus grafting. So much for primary stability. So much for all the things we are taught are absolutely necessary. Of course, you need the implants to stay in the place where you want them to, if you want to restore them and that’s the reason why it’s important to have the sinus lift abutment. That and of course you don’t want them to go into the sinus, unless if you want to lose five pounds in one morning, which has happened to me. My first implant, my first sinus lift that went into the sinus, I lost you know like three pounds just trying to remove it. Then I learned how important it is to use the sinus lift abutment. And four years post loading, what happens to bone? Did we lose bone to the first thread? No. Bone is actually stronger four years later. Patient comes to your practice, we have two millimeters of bone, so if the patient is your ex wife, we know exactly what the treatment plan is. We need a major grafting and a five kilometer long implant. But this patient actually we wanted to keep in the practice, so we placed a 5.0 x 6.0mm Bicon implant, or Dr. Daher did, with an internal sinus lift. Right? Primary stability, anyone? Six months after the healing, of course in situations like this, in which you actually completely regenerate in the bone, you want to allow enough time for the bone to form and to be of quality enough for you to be able to load it. So six months of healing, significant amount of bone and this is two years post crown insertion. Minimal treatment, maximum results and a patient that is satisfied. This is how we started and the end result. Another case with three millimeters of bone and sinus lift at the same time as implant placement. As you can see, we are pretty much using the patients remaining bone to hold their sinus lift abutment. And this is after six months of healing and this is after four years of loading. The bone response is going to be directly related to the masticatory forces. So may I suggest that if under function we cannot break the connection between bone and the implant, which would be the exact the actual effect of excessive loading. That bone actually gets harder. Patient comes to your practice of failing fixed partial denture, you have three point five millimeters of bone, replace a 5.0 x 6.0mm Bicon implant with an internal sinus lift, I did this case. And let it heal. This says add crown insertion and this lets you see some of the capabilities of this particular implant system. This is not a three unit bridge. This is two crowns, these are two IACs. One of the implants is supporting two teeth and the other one is supporting one and then we bond it with composite directly in the mouth. This is twenty ten, this is twenty eleven, this is twenty thirteen. The latest craze in implant dentistry is that bone likes to be loaded. That we dentists finally have figured it out that what happens in the mouth is exactly the same that what happens in the rest of the body. So, the patient comes to the practice and the crown to implant ratio is four point three. Why? Because this eight millimeters long implant is only four millimeters in bone. It’s restoring the first maxillary molar. So what is going to be the response of bone when this patient comes several years after crown insertion? That three years later, the bone has grown apically and coronally and the crown to implant ratio is no longer four point three three, it’s two point seven six. What is the effect of forces in bone if it cannot break the connection between the implant and the bone, bone will grow in response to masticatory forces. Another case in the mandible, crown to implant ratio at crown insertion of two point five. This was the occlusion for six years and this is the bone after six years. The crown to implant ratio is now smaller because bone has grown coronal to the implant, coronally was and towards the implant abutment interface. So, if we’re going to lose bone to the first thread, wouldn’t this be the cases in which we’ll be losing bone? These are short implants, these are maxilla, this is mandible and we have, you know, very big teeth being supported by very small implants. What we realized in this first study is that there were a lot of patients that were gaining bone instead of losing bone over time. So I became obsessed with the subject of crestal bone gain. I needed to know what is it that made that was in common, that these patients had in common and why in some instances we would lose bone and in others we would gain bone. So, the bone growth we observed, it was this. This was the first case I saw in 2001 when I arrived at Bicon and the one that caught my attention. So, in 2008, you can see there has been a significant amount of bone growth towards the spherical base of the abutment. No bone loss to the first thread, but bone growth to the base of the abutment. The base of the abutment which is polished titanium. What if I told you that this happened not by chance, but because the engineer who designed this implant, who is sitting down in here in this first row, designed it this way. He planned bone, coronal to the implant abutment interface to be loaded with the base of the abutment. That’s how this implant system was designed. The bone grows the base of the abutment, it is our belief because forces are distributed to bone through the spherical base. Even through soft tissues as you can see it in this particular case. But that’s how it was designed. That’s exactly you see, know you want to know why this implant system doesn’t have a screw? Because we needed, or the engineer needed this in order to be able to have a post small enough so that spherical base would be on top of bone and be able to load it. You no longer have a space for a screw. Everything comes down to the design of the spherical base and the implant shoulder of the implant to maintain bone. A design that is called Load Bearing Platform Switching and we’re going to talk about it later. So when I got here in 2001, you can see in 2003, what I saw. I saw that there was some mineralization towards the implant abutment interface. And for me, coming from Harvard Dental School and working with Straumann dental implants, this was a tremendous, know, new thing. I couldn’t believe it. I said, I have been working with Straumann implants for all these years, I have never seen this type of bone growth around those implants. Or three eye and all those implant systems I was using before, so I got hooked. I learned that day that bone gain is a drug. And I am addicted to it. So I go to bone gain, you know, groups that Bicon has and we all go every Friday and we say, Yes, I’m a bone gain addict and I can’t live without it. We put all these man all these can you imagine how difficult was this particular manuscript to be reviewed when I had all the researchers from all the other implant systems that are used to losing bone, reviewing a manuscript about factors associated with peri implant bone gain on single tooth implant restorations. It was gruesome. The comments from the reviewers were, But you know, you cannot argue with radiographs. It is or it isn’t. So, we found that of the ninety factors that were correlated with changes in para implant bone levels, thirteen were correlated to bone loss and ten were correlated to bone gain. We found that the factors that were associated with bone loss in the multi body analysis were composite in the spherical base of the abutment. If you bring composites all the way down to the abutment, you lose bone. That was the single strongest predictor of peri implant bone loss on this particular implant system. If you extract an adjacent tooth, you’re going to lose bone on that implant on that side. The longest implant used in this particular study was also the one losing the most bone. Five millimeters wide by eleven millimeters long implants were associated with significant bone loss. The effect of implant coating. Titanium plasma spray implants, which Bicon used to have back then, were significantly more likely to lose bone. And those patients with probing depths, almost you know deeper probing depths, reach statistical significance. And I think that the explanation for that is, it comes down to history of periodontal disease. That’s how I have learned to understand it over the years. There are some patients that have, simply, the propensity to lose bone and those patients with a history of periodontal disease, you know, you look at them and they lose bone. What were the factors that were associated with the exact opposite effect? What were the factors that were associated with actually crestal bone gain? The presence of hydroxyapatite coating. If the implant had hydroxyapatite coating, it was significantly more likely to gain bone. The presence of a titanium spherical base. Implants that were opposing natural dentition were significantly more likely to get born when compared to implants that were opposing implant restorations. Five by eight. So here I am, I find that the longest implant used is losing the most bone, five by eleven. And I find that five by eight is losing significantly less bone, it’s actually significantly more likely to gain bone. So what this is telling me is, again, that forces are good for bone. At least that’s how I rationalize it. So from this implant we got, I got finally I went to Dr. Mauro and I said, you know what, you’ve been telling me all these years that short implants are better? I used to think that short implants were as good as longer implants and now I know that a short implant is better for my patients. Why don’t we know this already in implant dentistry? Because for as long as we’re using five kilometer long implants and we are splinting them to protect bone from forces, the only, the only clinical finding we’re going to observe would be bone loss. Because we’re creating and replicating an environment for peri implant bone loss. So, the other factor that was complete surprise was the daily intake of non steroidal anti inflammatory medications. The patients that were taking an aspirin a day for cardiovascular prevention, or other non steroidal anti inflammatories for the treatment of arthritic pain, were significantly more likely to gain bone around Bicon implants. I came with these results and I go to Shadi and I tell Shadi look at this, oh for Christ sex Rainier. You have to do those numbers again. Because we all know that NSAIDs are no good. When you have a fracture and you take it, it just doesn’t heal. That can’t be. So we went back and what convinced me was the radiographs. I put the radiographs of the patients taking NSAIDs and they want them not taking NSAIDs. And I’m looking at them and I’m seeing yes, the F word. So, the first factor associated with bone gain was the coating. Implants with a haloxia appetite coating significantly more likely to gain bone. Implants with titanium plasma spray significantly more likely to lose bone. The observation that H A coated implants are more likely to gain bone is not new. It was reported in the 1990’s in several animal studies. The typical bone growth you observe on an coated implant is bone growth on that coating. Like for example, you can see it on that area here, the whole implant has an coating and then you see mineralization towards that coating. Mineralization, that replicated, As you can see in different patients. And look at this one. This is an IAC. This is a five millimeters wide by six millimeters long Bicon implant with an H A coating and this is biting against natural dentition. This is a second maxillary molar. So what’s going to happen in type four bone, when we have a small implant that is occluding and getting all these extra forces? We already have bone loss to the first thread right? When we insert the crown. So what’s going to happen? We’re going to continue with bone loss to the second thread and go ahead. Well let’s see what happens in this human. So this is six years later. No, I did not paint this bone white. The patient happened to function. And for those of you who think it was just I selected the angle of the best two x rays and you can see, 2008, 2009, and 2013. Slow but steady bone growth. And this is the occlusion and you can see here that one of the limitations of a short implant is that you don’t build up the soft tissues. If you don’t take a piece of someone’s hip, you cannot really build up. Well even if you take a piece of someone’s hip, may not be able to build it up. But, you get what I’m saying. One of the limitations of a short implant, if you don’t do a grafting is you cannot build up the contours. Which may make it perhaps more likely for food to get trapped around here. But, let me ask you this, how many in this room will choose to have a block graft in here and a longer implant instead of a short implant and a single crown just like this? How many of you will choose to have the grafting? And why don’t we do the same to our patients? Because suddenly you know, we treatment plan all these things that you wouldn’t dare do in our mouth. I wouldn’t dare go put myself through a nerve you know therapy or moving the nerve out of place or anything like that. And yet, it’s indicated for certain patients. But in a situation like this, do you need to have block grafting in order you don’t. What the patient is asking you, is for you to put a tooth there so they can chew. That’s what they mainly care. If it’s a maxillary anterior area, okay. The maxillary anterior area is a different story. You may need to build it up for aesthetic purposes. But in posterior areas, that rationale simply does not hold. What are the concerns of H. Coatings? That, it could get contaminated easily. So if the patient is a dirty, dirty patient, which we have them all in our practices, then you know it will get contaminated easier. But one of the reasons why this is not usually a per limb or bicone implant is because the implant is placed two to three millimeters below the crest of the bone. So it cannot get contaminated. We’ve known from studies done, that Dr. Paolo did, that there is no damage to the H A coating and the H A coating stays pretty much after thirteen years in function. These were retrieval studies. The second factor associated with bone gain was the presence of a spherical base. We found that the restorations that had a spherical base in titanium were significantly more likely to get more. It did not matter if it was a porcelain fused to metal crown, or a non shoulder abutment, or an IAC. What mattered was that there was a spherical base. Look what happened when the spherical bases were removed. You see? This one has some spherical base, look at this, this is plastic, all the way down in here. So, if you want to transform a beautifully functioning Bicon implant into a Brånemark implant, the only thing you have to do is put plastic on the base of the abutment and then you have bone loss to the first thread. Because the bacteria no longer is going to be coming from the external hex connection, it’s going to be coming from the base of the abutment. Because you have changed immediately the distribution of forces, of masticatory forces, they are not going to reach now the bone through composite. So we found significantly higher peri implant bone loss in those implant restorations that have been restored with composite spherical bases. And as you can see, a significant difference. -1.45 which is Brånemark-bad, to -0.29. And the difference was statistically significant. This difference and this particular clinical finding was peer reviewed for clinical oral implants research and published in January of this year, so now it can be considered scientific evidence. So, look at this particular case. The implant was placed in 2006, restored there. Look at this. This is the shortest implant. This is the one with the best bone. Why? In this particular case, because we have a spherical base. This have composite bases and look to what happens with the bone. Look what happens to the bone. So, this is ultra short implant, these are short implants and look what happens to the bone. The forces are supposed to be strongest and the more posterior you go, right? And yet I had this shortest implant, but what matters in here is the bacteria that’s accumulating and how the forces are not reaching bone anymore. So what happens if we have a case in which we don’t have the spherical base, we lost some bone, can we regrow it back? And Dr. Morgan showed some of this earlier. If you have plastic spherical base, the bone, you know, goes away. But what happens if I were to place here a spherical base, can I regain the bone back? That’s what we did in this particular case. So we changed the spherical base in six months post change of the spherical base, you can see how we now have remineralization of the bone. Why? Because the engineer who designed this implant system did not take a Black and Decker catalog, close his eyes and chose a screw that is supposed to be used in wood to be used in the mouth. The engineer who designed this, designed the implant to be placed in humans and for forces to be distributed through the spherical base to bone. So that is six months post changing of the spherical base. And this is three years after the spherical base was changed. As you can see, significant stability on the bone. So, but why is it that the spherical base is so important? And I figured this out on my own after doing all these years and then finally the engineer came to me and said, Okay fine Rainier, I’m going to tell you how he designed this. So it is interesting how something that was designed in paper, in a laboratory, is now now we have the clinical evidence to show and go around and say, Yes, what you designed Mr. Driscoll in that laboratory, it now is in patients mouth and what you designed is now giving us exactly what you planned. So, the presence of titanium spherical base is associated with bone growth because it was designed to lead to bone maintenance. Because of what is called load bearing platform switching. The concept of load bearing platform switching is to transform the transcrestal portion of an implant into a load transferring structure. So that we know that in conventional implant systems, we have bone loss to the first thread. But the first thread is also the first area of an implant in which we get bone loaded in compression, in conventional implant abutment interfaces. So those implants, for all intents and purposes, were designed to have bone on the first thread. It’s a miracle when they don’t have bone there. It’s a miracle when they have bone above that thread. So, the rationale of so for external hex conventional systems, when the occlusal forces are reached from mastication, they are stopped in bone by the first thread. So no wonder the bone stays there. That’s how it was designed. On conventional platform switching, it is not physically possible to load bone coronal to the implant abutment interface. Why? Because the abutment is smaller than the implant and all the masticatory forces are going to come from the patient and I’m not going to be able to reach bone in this particular area. They will reach bone right here, if the implant has a roughened surface. So it is not physically possible to load bone coronal. So don’t expect bone coronal to the implant abutment interface in those cases, because you’re not loading bone there. Bone stays if you load it. The objective of load bearing platform switching is to load bone coronal to the implant abutment interface. In the same way that bone is loaded apical to that thread. Load bearing platform switching was designed with two elements. The first element was, you need it first. If you want to have bone coronal to the implant abutment interface, you need space. Right? If the implant and the abutment are the same size, you have no space for bone coronal to the implant abutment interface. So the first thing he did, he designed the sloping shoulder to provide space for the bone to be there. So that’s the element. The first element is a platform switch that allows for a gradual vertical and horizontal change in the size of the implant to the abutment. The second element of load bearing platform switching, as it was designed, is the loading element. The spherical base of the abutment now loads bone that can be located on top of that area where the where the space that was created by the reverse platform switching of that sloping shoulder. As you can see here, it is our belief that Bicon has bone, coronal to the implant abutment interface, because bone can be loaded and maintained in that location. Now, does the spherical base actually load bone? This rationale was studied at for the Journal of Prosthetic Dentistry and published in twenty ten. In this particular study, what the investigators did, is they placed Bicon implants and did a finite element study and they placed the Bicon implants one millimeter below the crest of the bone, or two millimeters below the crest of the bone, or supracrestal. Only when the implants were placed, one and two millimeters below the crest of the bone, forces were observed on the spherical base of the abutment. As you can see here, the highest forces concentration was not actually on the first thread, was on the spherical base of the abutment. And that’s how it was designed. This was not, oh let me just you know, oh my God we got this by this is how the engineer designed this implant system. So, we found high Von Mises stresses on the base of the abutment and the bone in contact with the spherical base. So let’s look at a clinical case. Right? This is an actual Bicon implant in an actual human and this is 1998. Okay? And this is what the Finite Element Study is telling us is going to happen. That the forces are going to be concentrated in here. So what’s going to happen with bone thirteen years post loading? There you have it. What happens to bone thirteen years post loading? That it is being loaded where the loads are accumulating and this is a polished spherical base. Right now I am going through a gruesome review of this load bearing manuscript and some of the comments from the reviewers, some of the ones that are you know, some of them are R rated, but the regular you know, that can be used for the general audience, that they say that how can we have contact between this abutment and this? That is not possible. That is well this is how it was designed. When you actually insert the Bicon abutment, you prepare the bone in order to insert the abutment and you create physical contact between the spherical base of the abutment and bone. And you don’t create that because you know, you create it because that’s how the engineer designed it for you to do it. And what we have learned over the years is that, not only does this happen, but in cases in which you don’t have the contact to begin with, the contact may reach over the years or the growth and the mineralization just by distribution of forces from the spherical base. Is this different? Absolutely. Welcome to my life trying to publish these manuscripts and trying to educate the reviewers. Anyway, you can see here this is nine years post crown insertion. What happens to the bone? The bone is significantly more mineralized and close to the spherical base. This is thirteen years later. Thirteen years later. Okay? So what happened here? What happened over the years? From 1999, twenty eleven, It takes years and it slowly and it doesn’t happen in every patient because the patient needs to clean, needs to maintain in order for this particular clinical observation to occur. But this is the clinical you know corroboration of what it was designed in paper in the 1980’s. As you can see, have different implant sizes and we have growth towards the spherical base. And this is a scan, cone beam CT scan showing the bone in close proximity to the spherical base on a buccal lingual direction. The third factor associated with bone gain was an implant opposing a natural tooth. Another surprise for me because when I went to dental school or when I went to prosthodontics, told me that the graded forces were with implant supported prosthesis. And now I’m getting, you know, this implants with natural teeth losing bone and I’m thinking perhaps it’s because the natural forces will be less and then the implant forces will be too much. Perhaps that’s what it is. No? That’s not what it is. We found significantly lower bone loss on those implants opposing natural teeth, compared to the implants that were opposing implant supported restorations. And we published this in January of this year, this manuscript, in which we concluded that the opposing structure has a significant effect in peri implant bone levels. So implants that were occluding against natural teeth were significantly more likely to gain bone. So when you read a book like this one, this is Dr. Misch’s book, you read statements like this. Some authors have suggested that lack of proprioception on opposing implants, they magnify the load around implant supported prosthesis and that the highest masticatory forces are created with implant prosthesis. This statement is not supported with available scientific evidence. For once, implants have less proprioception, but implants have proprioception. Patients with implant restorations have proprioception and it’s called osseoperception. And it is the threshold of minimal pressure the difference. Because that’s basically what this is saying. If the forces are higher than three Newtons, a patient with implants can detect those forces. So it’s not proprioception. It is well known that forces with natural dentition are significantly higher than patients with implant supported prosthesis. Not lower, higher. When we take teeth out from a patient and we place implants, the masticatory forces go down. And this is a statistically significant difference and every single study has shown that. So this is what we’ve done. We have taken the patients out, we have placed five kilometer long implants, we have splinted the implants, we have put in them to occlude with forces that the bone much less than the forces that the bone were used to get and we whine when we lose bone. We have created an environment for peri implant bone loss. That’s what we have done. And that’s exactly what we see in clinical practice then. For as long as we’re protecting bone from loads, we are creating an environment in which we’re going to have peri implant bone loss. And yes, it’s not the only reason why we lose bone. We have bacteria and we have all these other things, but absolutely an important one. So in this particular manuscript, we hypothesized that the patients with the implant restorations that were occluding against natural dentition, gained more bone because the forces were higher on those that were occluding against natural teeth, than on those implants that were occluding against implant supported restorations. The fourth factor associated with changes in bone levels were implant size. We found that five by eight implants were significantly more likely to gain bone whereas five by eleven were significantly more likely to lose bone. From that, we suggest that there is an ideal length for each implant width and for five millimeters wide implants, shorter is better than longer. So, look at this case, it’s a five by eight posterior maxilla and we have some growth towards the cervical base. We also found that five by eight maxillary implants lost more bone than mandibular implants. And we found that a five by eight was significantly more likely to gain bone if it was located in posterior mandible. And I was insane enough to have periodontists for the Journal of Periodontology review this manuscript. And I’m still alive, I don’t know how, but I survived. The manuscript was published after you know, long review process. I just don’t back down. I don’t accept you know rejections without scientific evidence to support them, I fight them. And when the editor is honest, like the editor of the Journal of Preodontology, then science prevails. So, we publish that five by eight implants lead to bone stability in posterior mandible. That are associated with significantly less bone loss in posterior mandible. And these were some of the cases of the study as you can see. We had bone growth towards the Spherical base after few years of loading. Patients are taking medications for all these different conditions. When they come to our practice, we always ask them, Okay, what medications are you taking? And if you ask them, like we did for this particular retrospective study, then you will know that a lot of them are not taking any medications, that the most commonly taken medication for our patients is actually statins. Patients that are taking for cardiovascular prevention, cholesterol lowering medications. That is probably the single most commonly taken medication. And you’re going to find out how many of the patients you have in your practice are taking an aspirin a day for cardiovascular prevention. A lot of them are these days. But prior to this study there was no study done in which the relationship between the medications the patients were taking and changes in peri implant levels was investigated. What this means is that if you went to study or to any university and you got a study on peri implant bone levels and you were part of the study, They didn’t ask you whether you were taking non steroidal anti inflammatories and they didn’t even corroborate it whether that factor was associated with the changes in bone levels. What we did was consider every possible factor, a possible reason for bone loss. And when we asked this question, we found that patients taking non steroidal anti inflammatory medications for the treatment of arthritic pain or for cardiovascular prevention were significantly more likely to gain bone, were significantly less likely to lose bone around Bicon implants. An effect that was specific to coated implants. So, remember the first case I showed you, in which the one that got me hooked in this whole thing? This case, the patient was taking eight ibuprofen a day. Eight ibuprofen a day during the whole process, during the whole study, during the whole time of investigation. This patient here, bone grows towards the implant abutment interface. This is for six years post crown insertion, takes one aspirin a day. Bone grows again towards the base of the abutment. Patients taking Diclofenac and took Biox for one year. Look at this, significant mineralization surrounding the spherical base. Patients taking aspirin and ibuprofen. Both of them. Look at this mineralization. Patient taking again eight ibuprofen a day. What we realize is that when we ask them what medications they are taking, we don’t necessarily ask them how much are they taking. But for this particular study, I had to go back and in this particular patient, we had to go back to the medical records. So we had to go back to the pharmacy records to see how much was she being prescribed at that point in time. That’s how we figured out she was taking eight Ibuprofen’s daily. Now why would taking osteoidal anti inflammatories have an effect in peri implant bone growth? As it turns out, this is well known evidence. This is not new. As it turns out, the NSAIDs as we know, we know this part. We know NSAIDs lower the production of prostaglandins. We know that patients that are taking NSAIDs have lower levels of prostaglandins. What I didn’t know prior to this study was, that lower levels of prostaglandins activate a chain of events that leads to an increased replication and differentiation of osteoblasts and to bone growth. It is well known that non steroidal anti inflammatories, or that by reducing prostaglandins have this effect. This is not new. In fact this part of the manuscript is not even argued. They said yes, we know this. Now, what we concentrate on is the fact that when prostaglandins have higher levels, it leads to exactly the opposite effect. And may I suggest that our patients, in our practice, and our average patient has gingivitis and our average patient has an increased level of prostaglandins in the tissues surrounding the mouth. This is just the average. This is what happens. This is just the everyday thing that we obtain. So what we think happened in this particular study is, that the patients who were taking non steroidal anti inflammatories daily, they lowered the levels of prostaglandins to a point that they were conducive to peri implant bone growth. Now, of course once you learn something because of research, is impossible to undo it. Especially if you are obsessive compulsive like me. You go home and then you start dreaming, I spray, what I’m going to do? And then you get a patient with bone loss and then you’re thinking, okay, but I just figured out that patients that were taking NSAIDs will lose bone. What if I give the patients that are losing bone, aspirin? So that’s what we decided to do and of course Shadi was laughing at me. Oh, you’re an aspirin. I don’t think so. Anyway, I started and this was my first case. In this first case, you know, I removed the crown because the crown fractured and I wanted to add the interproximal contact. So I removed this crown, right? And I added the interproximal contact and then I go to sleep very happy, oh yes, now we have interproximal contact, I’m such a good prosthodontist. My, you know, like Dr. Morgan says, scratching my ear with the other hand and I’m so happy. Patient comes back six months later and what happens? I have peri implant bone loss. So I have two choices. I move back to Venezuela or I solve this problem that I created. I like the States and Venezuela has this crazy president that hopefully will finally leave or be helped leaving. Anyway, so we have this bone loss and now what do I do? Well I happen to know by my own research that there are five factors associated with bone gain. Right? I know that the presence of a spherical base is necessary. I have learned that the daily intake of aspirins makes a difference. I also learned that an H A coating and implants occluding against natural teeth and an implant size are important. Guess what happens here. This is an H A coated implant, it’s occluding against natural dentition and it’s an implant size five by eight. So what I can change is whether to add the spherical base or to put the patient on NSAIDs. So why don’t we do both? This was the first case I did, so what we did is, there was an abscess. So you could see in this particular case, pus coming out of the sulcus. So I put the patient on amoxicillin to treat that and then we placed ARESTIN on the base, we changed the crown, placed an abutment with a spherical base, placed ARESTIN in there and told the patient that if he took an aspirin daily, and I told him, the more you take the better, but I didn’t put that in the record. And then the patient liked me, because you know, you tend to start developing patients that are exactly like you. So all the obsessive compulsive are my patients. So this one immediately said, Okay, yes. But if you tell me more So he ended up taking six fifty milligrams of aspirin for six months. Daily. That’s two aspirins a day for six months. Okay? And this was what we observed when we inserted the new crown. We inserted the new crown at the three months mark and this is at the six month mark. We were able to remineralize some of the bone that we lost with the use of non steroidal anti inflammatory medications and with the replacement of a spherical base. From here again, I was hooked. So that Friday, on the you know, on the group for bone growers, I told everybody, Hey you know, now Enphase is the new drug, so we should start taking aspirin, all of us. And they said after a year and a half. As you can see, whatever we obtained back then remains to be the case, a year and a half after treatment. So for six months the patient took six fifty mg of aspirin. And then went back to eighty one mg of aspirin, which is what the physician tells him he needs to do. And with eighty one mg of aspirin, this is after a year and a half of that. What we have added to our treatment of peri implant bone regeneration is the use of laser. And that is the peri implant sterilization mode and this I always get the questions. What is the watts and all these things. And I never know the answer so I have it here for you. You can write it down. Because for me it’s easy using the laser, I just turn it on, peri implant sterilization, and then turn it off. So I don’t necessarily know all the settings. So this patient comes back to a practice, we have a five millimeter wide implant, we insert an IAC and a month later I have an abscess. I actually have a little fistula coming into the mouth. So what I do in this particular case is, I remove the IAC, I debrided the area and placed laser in the area and ARESTIN, put the patient on clindamycin and an aspirin a day. This is after three months of treatment. This is after nine months of treatment. And this is before and after. This is before the infection and after treatment. So we were almost able to get it back to what she was at the beginning. This is how, this is when I inserted the crown and this is the final after treatment. So as you can see, a significant improvement from the clinical condition. Now, I’ve seen this treatment of peri implant bone loss as a soup in which I keep adding ingredients. So I started with aspirin, then I added laser, which worked well. Now the latest ingredient in the soup is the concept of Resolvins. We found in our last retrospective study that the patients that were taking fish oil and aspirin in combination, the best performing patients in terms of peri implant bone growth. Even though there was no statistically significant difference between the patients taking only the aspirin and the ones taking aspirin and fish oil, it caught my attention. So I go into the med line and I say, aspirin and fish oil. And then I come down with this particular concept. As it turns out, acetyl salicylic acid in combination with omega-3 EPA forms Resolving E. And acetyl salicylic acid in combination to DHA omega-3 forms Resolving D. Resolvins are a family of bioactive products that are anti inflammatory products. That there is one animal study in which they have actually shown significant improvement in para implant bone loss on mice. So I figure, okay, a lot of people are taking fish oil as well, so I’m going to add that particular. So that’s what we’re doing nowadays. So let’s look at this case. How can we regenerate this bone and can we regenerate this bone? The first thing we need to understand is why did we lose the bone to begin with? If we don’t understand why we lost the bone to begin with, we cannot regenerate the bone. That is the most important thing. So, looking at the clinical condition we found no interproximal contact. Okay? There’s another thing in here. When we uncovered this particular implant, I placed a spherical base that was bigger than the spherical base the crown was made of. It is very important that whenever you uncover the implant and prepare the bone and place a spherical base in there, that the technician makes the crown with the exact same size of abutment that you designed. Because if your temporary abutment creates sorry about that it creates this emergence profile for the tissue, now you place this crown, you have a perfect environment for bacteria to get into very floppy tissue, and then if you don’t have interproximal contact, you have the perfect environment for bone loss. So I understood what the rationale was for bone loss in this particular case, therefore I can attempt to improve it. So what we did is, we removed the crown and then we lasered the area. We put a black healing plug and we let it heal. This is three months, this is one month after the treatment. Okay. This is three months later. This is six months later. The patient is taking aspirin, a full aspirin three twenty five and a thousand milligrams of omega-3s. In the United States you can actually give a prescription for omega-3s. And is exactly a thousand milligrams so the patient takes that. That’s what we do. But you can also do simply fish oil and tell the patient to take sufficient in order to get to that point. So we were able as you can see, to remineralize the bone. The patient comes this way and now I have regenerated the bone. So this is what happens when you concentrate your efforts in doing research and you actually look at the patients and you learn from the patients. You don’t close your mind and say, Oh, we’re going to lose bone because that’s the way it is, I’m going to put an implant. You actually look at the cases and you learn. We learn that NSAIDs can help us regain the bone, then we apply it. We learn that a short implant is better, then we use it. So, look at this case. Same exact thing. Look at this healing abutment, this was the healing abutment that was used, and look at the crown that was used, right? Big emergence profile, very small emergence profile, so when the crown was done here, and no interproximal contact, we have huge bone loss. Now, I show this to Shadi and she said, Oh for Christ sake here. Remove the implant. That’s going to be super easy to remove. Just remove it and put a new one. And frankly, that’s a very acceptable rationale. But I went to the patient and I said, Do you want me to remove it or want me to try to treat it? No, please try to treat it. She said, Great! So we removed the crown and then we lasered and we put the patient on aspirin and fish oil. This is a month after. And when you check, it is very important that you check the patient one month after you do the treatment. The reason for that is because you need to see the tissue closing completely and you need to see that there is no pus coming out of there. You may very well have a small little fistula, which is quite common at that point in time. And if you do not treat it, you’re for as long as you have infection in the area, you’re not going to regain the bone. So you see the patients on the first month after you do this treatment and then you see, do I need to laser again or do I need to put more ARESTIN in the fistula to have the fistula close-up. That’s what we do. If you get the fistula to close-up and the tissue to then, then you can have an environment that’s sterilized and then you can get to have the peri implant bone growth. So, one month we check it out and then this is three months post op, okay. This is nine months post op. So after nine months, we have significant improvement. We put a new crown and at this time what we do, as you can see, is we have a spherical base closer to the so this is short post and we have interproximal contact. I have identified the reason why I lost the bone and now I have treated it. The next topic I’d like to talk to you about is ultra short implants. We did a study in the subject and we published it at International Journal of Oral & Maxillofacial Implants (IJOMI). And in that study, we evaluated we set out to discover whether length was a significant difference for Bicon implants. So my question was, if we want to know oh my God, time is flying. I think I’ve been talking too much. We had four ten Bicon implants. Of those, two eleven of them. All of them were five millimeters wide. So I figured if we are going to evaluate the effect of you know, length, all of the implants need to be the exact same width. So four ten, five millimeter wide implants. The only difference between them is that two eleven of them were five or six millimeter long and one hundred and ninety nine of them were eight millimeters long. So and the majority of them were single implant restorations. We found that there was no statistically significant difference between the survival of short and ultra short implants. And we concluded in that study that the survival of ultra short implants was comparable to the survival of short eight millimeters long implants. This was a very meaningful comparison because we coming from understanding that a five by eight implant was the first best performing implant. And now we were comparing a five by eight implant against a five by five and a five by six. So the ultra short implants were being compared with a very strong control, Which was the five by eight. So, what happens to bone when you load it? It grows. So, when we have posterior mandible, what are our alternatives? If the patient comes to our practice and we have seven millimeters of bone or less in posterior mandible, what is what are the choices we can offer the patient? We can offer nerve displacement surgery, for our ex husband or wife. We can offer osteo distraction. We can offer a piece of a hip. Or we can offer an ultra short implant. Is there even a question of what we would do in our mouths? Why is there then a question? What are we going to do in our patients? So, yesterday’s implant dentistry, this patient came to us with a five kilometer long implant. The dentist told her that just in case the neck were to give in the future, this particular implant can hold the neck, the brain and even the house on top of it. That this will be the solution. So they place this long implant, they touch the mandibular nerve, the lip is frozen. Do you imagine the stress the dentist went through putting this, you know, humongous thing in this patient’s mouth. You know, the stress that that takes and then you lose the sensitivity of the nerve to be, you know, on top of that, just because someone in dental school told you the longer the better. You gotta be kidding me. Now, patients come to us and then we have the left side, right? So the dentist told her that the same risks exist on this side and she said, I better get a second opinion. You know. So she came to us, three five by six millimeter implants were placed by Dr. Daher and they said, after three months of uncovering, restore with single implant restorations. And as you can see here, after three years of loading, the bone is better three years after the crowns were inserted than before. And when you look at the actual comparison, you look at this particular case and if you see it on a CT scan, this is what the bone looks like Around this particular implant restoration, three years post crown insertion. And if you look at this one in the middle, that’s what the bone looks like. And the last one, this is what the bone looks like. So what are the alternatives? We could have placed a much longer implant, right? We could have done this. Or this. Okay? But why? And these are the consequences. We touch the nerve, we damage, we do things that we don’t need to because we have an old rationale that tells us that yes, the implants are supposed to be longer. So interestingly enough, when you compare yesterday’s implant dentistry with today, the longest implant is the one losing the most bone. And how exactly they taught us, right? They taught us that whenever we use short implants, we’re going to splint them and we’re going to do premolar sized teeth. So with three implants, one of which can support the patient’s hip, if you let it, you have only two teeth. With three Bicon implants you have a premolar and two molars. All single unit. And the bone is much better for it. The reason why short implants work is because bone likes to be loaded. Just going to go a few more minutes and then I know the light just changed. How do we define excessive loading in implant dentistry? I want to just finish with what I think is the threshold. We define excessive load in dentistry as patients that grind, right? So this is a grinder. Lack of posterior support, right? Check. And cantilever. This is not bonded in here, this has a mesial cantilever. Right? So now, this is a perfect condition for bone loss. Right? This is increased loads. What happens with this restoration? The restoration fails, fractures. But what happens with bone? What happens with bone is, bone can take the load. That’s what happens with bone. That we have underestimated bone. The bone in the maxilla and in the mandible are exactly the same that bone in the rest of the body. Bone is crying to be loaded. That’s all bone wants. I think I should finish here and I thank you very much for your attention.