DDr. Rolf Ewers, MD, DMD, PhD
CMF Implant Institute Vienna, Austria
Theme is functional loading synergy. It’s very important to speak about synergy with Bicon short implants and TRINIA prosthesis. Well, until 2010, for thirty seven years, I was the big surgeon, did a lot of transplants and everything like this, augmentations. And the maxilla, as you see on the left side, a very atrophic maxilla, we designed together with my chief Härle in 1980 the so called horseshoe Le Fort I osteotomy. We interpositioned iliac crest bone from the hip, inserted implants, at this time always IMZ implants from my friend Axel Kirsch, and had been very successful, like in this lady over fourteen years until she passed away. Certainly you will see at this time we used far too many implants. This wasn’t positioned very well, but the rest nine implants was plenty enough, and certainly by now we know it’s far too much. And then the mandible, we also transplanted iliac crest bone from the hip. We stabilized this with a little osteosynthesis screw because the implants didn’t have enough threads. And the results also were very satisfying, over seventeen years until the patient passed away. But just see how much resorption we had on the bone, and she had to clean it very precisely, otherwise she wouldn’t have had this seventeen years. So big operations and everything. Unfortunately, 2010, I met again doctor, first Dr. Marincola, and then Dr. Morgan, Dr. Marincola convinced me to get to know Dr. Morgan because he always said, X rays don’t lie, just look at the X rays. And therefore he convinced me. And so, in 2010, I started to say, maybe less is more. I was fortunate enough to start with the Bicon, because the Bicon system is the less is more system, as I always call this. If you are sailing, you know that sailing in the beginning was always long, long, long ships are running better. By now we know short ships are running better, and why are they running better? Because they have fins. A name you will hear very often, a term very often will be used today. Again, as you have heard the last two days all the time, fins. So in 2010 we started the study in the maxilla and the mandible and also in the mandible and maxilla, as you heard yesterday, with free transplanted bone grafts. Fortunately, we also started with TRINIA at this time and all our prosthetics with TRINIA in our hands, done by Paolo, as you will hear later on. And fortunately, once again thanks for Bicon and his team, Dr. Morgan, that everything was supported financially by Bicon for all our poor patients with little bone and little money to be treated because they needed some kind of treatment. Let me show an example in a cross section of the fibula. Because the fibula is a wonderful bone to be transplanted, but unfortunately it’s just five millimeters thick. And in the middle there’s the marrow, but most of the time it’s a hole. So certainly, a five millimeters implant from Bicon is the best implant you could use. You have to be careful because sometimes the implant could slip into it and that you do not want to like and therefore we are able to use now for the five millimeters implant and also the six millimeters implant the thin crestal temporary abutment, a new design and very very useful. So you always ask, is it possible that this is going to work? And if it works, why does it work? Let me show a typical patient of mine where we had a very surprising result. This lady was supposed to have iliac crest transplant in Hannover, a big surgeon, and when we would have started the operation, he couldn’t operate because this was a big hole in the bone and in the sinus mucosa. So desperate as I was, I just applied a little four by five millimeter implant. By now, certainly I would use the thin temporal crestal abutment to prevent the implant slipping into the sinus. And here you see initial loading and certainly you will notice that the implant crown ratio is more than two point five to one. So everybody will say, and all my friends said, you’re crazy, this never will work. And this is a sister-in-law of mine, they said, how can you do something even in your family? You must be crazy. But just what you have seen the last two days in so many wonderful clinical cases, you see that this is going to work. But please pay attention a little bit what happened on top of the implant. Very surprising, you see, that we have bone gain in the sinus of this lady. How is this able that it’s going to work? And I will try to explain this a little bit. So the question always, do they function long term? And our answer is certainly yes, because I have to say this because Dr. Morgan stands behind me. But why do they function so well? Well, they function because they are short. And don’t misunderstand me, not also they are so short. And this is sometimes difficult to understand. And they must have self locking abutments, and as you see it like here, all these features we have heard the whole last two days, And I will go through the features step by step a little bit. I will have to hurry up a little bit because everybody of you wants to go home or have a drink and have the party after this session. So the locking taper is the clue of the whole system, and as you see, Zipprich will show you the difference. Do we have the tone? The audio? The audio for the Yeah. I said two are having audio. Zipprich shows that this… You see when it’s moving that you will have a gap in here. But if we have a look at this Bicon system, this Bicon interface, we can see below there is a micro gap. But the interesting thing is, if we load it with two hundred newtons, the micro gap didn’t change. So there is no micro movement inside. And that’s the glue of the whole system is, as you do not have any movement between the abutment and the implant, you have micro movement of the implant if the abutment is being pushed to the side. So the self locking connection makes this implant to a one piece implant. It’s an inflexible, rigid unit. And you saw this already from today in the short movie of Yu Chi and certainly if you have lateral, horizontal and lateral displacement on both sides and if they are changing from left to side, you will understand why this drawing by Müftü shows that you have some micro movement of the implant in the bone. And this is, in the beginning, very difficult to understand, but you have to know that the living bone actually is viscous. Therefore, if you have not threaded implants, but an implant with fins like the Bicon system, and you’re applying it into the osteotomy without pressure, we call this the callus principle and this is the paradigm change compared to the pressure principle with slow growing appositional bone. You have heard this already, so I may skip this a little bit. But important is that we do have osteoblastic activity, and the osteoblastic activity goes into callus bone formation, and this then leads to the Haversian like lamellar bone. And certainly, and we heard this today, that the implants have to be very very deep, especially for the Cartagena. And here you have two to three millimeters and as I will say at the end, deep, deeper, as deep as possible, and we will show you this a little later. So certainly, if you have the pressure principle, you always have to think that you will have a lot of osteoclasts around this due to the pressure, and you will have first always resorption. And this we had to learn in earlier times, in the late 70s, we tried to do osteosynthesis, and this is very important for you to understand. And we went to Strasbourg, to Prof. Champy and saw this funny looking screw. And why didn’t we think that this is a funny looking screw? Because we had been used to this beautiful looking screw from the Synthes company. But this screw had two narrow threads. And when we operated two weeks later, the fracture was instable and the screws had been loose. We went to Strasbourg to Prof. Champy and she said, no, our screws are tight and the fracture is well healed. And why did this happen? I gave this doctoral thesis to Thomas Kreusch, he used to be a professor in Hamburg and we operated ribs from beagle dogs (don’t be upset) and we applied screws with a little spring out of a screwdriver. And just look what happened. Most of the screws stayed stable, but the screw we used Synthes just fell out after two or three weeks. Why did it fall out? And that’s very simple to show. Because this happened because of the pressure the osteoclast took away the bone and the screw could slip out. So therefore these are the bad parts of a pressure like system, and little by little you have a very slow growing appositional bone, but certainly it’s much much better to use this system, the color system. You see with the screw from Prof. Champy, which was looking funny and we laughed a bit, we never have any osteoclastic activity. This is our polychrome sequential marking, the yellow is tetracycline, the green is calcein green. It’s a very sophisticated histological preparation, but here you see all the time new Haversian like lamellar bone because we do not have any pressure. Very, very important histology. All this worked up, Prof. Frost, and he published this in 1960, and he called this the mechanostat because he said modeling and remodeling we are able to calculate in measurement strains. And he made this principle system what Yu Chi also showed you already a little bit. If we are having inactivity and you saw this one lecture today, wonderful, with the fracture on the bone of the what was he a very well known cycle person, it was inactivity fracture or overload fracture. But the adaptive state is so important, and certainly when Driskell designed this whole system, he probably did not think precisely maybe he just was lucky I don’t know if I’m right but the Bicon implant is just in the stage between adaptive stage and overload, just in between, and therefore it’s so successful because the thresholds always keep the bone challenging to grow and increase their ability. Certainly, now we will come to the fins and plateaus, and Coelho showed the beautiful histology in the fins and plateaus, and as I will show you a little later now, my own histology from a patient we had to remove the implant because it was a three millimeters in the wrong position and a fracture, the only fracture I had until now. And you see in each fin and plateau in between in all chambers beautiful lamellar bone. So, if we come to the sloping shoulder and the hemispherical abutment, we call this double platform switching, and this we actually call a bone production chamber. So if we take the locking taper, bacterial seal, sloping shoulder, and the double platform switching, all of these features go to bone gain. And I just show you two clinical cases. Here it’s March fifteen, August 29, 2013, and 2012 and 2013, fifteen months loading, we applied this implant and just see how bone gained in here and again bone gained in the floor of the sinuses, second here, now generally, and you see an addition in the second implant and certainly bone gain in here and bone this. So after eight point eight years we still have bone gain due to these features in this implant system. Bacterial seal, we have heard already so much, so I may go through very quick, slight petechial bleeding and also with thin biotype you will see this because of the free of bacteria. Now let’s talk about sub crestal position, and I’m sure that Dr. Morgan will agree that we are tending now to more deeper and deeper, and why, what is your experience about this? I agree totally. Yeah? Yeah. Wonderful. But the long shaft is important. And the long shaft is important. So again, and here are pictures from Dr. Morgan, maybe he will explain a little bit about these pictures, what he has seen here. These are just examples of our long term success. You can see the four years. The radiographs speak for themselves, and ask yourself, have you seen any other system with this type of bone gain? Bone gain, not loss, gain. And please pay attention to this, what I have written here. Diminished translucency, I will talk a little bit later again, means bone gain. You see, the translucent is diminishing. It’s getting less translucent and this means you do have more mineralization and this is so important. And the same like here, better distribution of compressive forces. I just want to show you this old lady. We started sixty six years old, now nine point one years later she is age seventy four. And there you see how bad I’m also I was 2010 I was almost sixty, sixty five. That’s right, and you still have the ability to think. And I have ability to think, but I didn’t pay attention because this young gentleman always said, you have to do it sub crestally. I’m only younger by one year. Yeah, but you see, I didn’t pay attention and I didn’t put this sub crestally, but for my excuse, the osteotomy wasn’t large enough, and I put it in and I couldn’t take it out anymore. That’s what I told him. Anyhow, but now just look at these fantastic results. You see the difference between sub crestal and epi crestal. There is no bone gain. And here, as you will see in the next, here you have perfect bone gain from here to here and from here to here. So certainly you have two or three millimeter bone gain. Also the lady is between now sixty nine and now seventy five, also she’s pretty old, the bone is able to gain. And what do you see in these abutments? You see the long shaft, and that’s so important. And this is something like also Bicon is now adapting more and more to the long shaft, and a picture from Dr. Morgan again, and this is the beautiful example of losing translucency. You see the translucency here, and you see no translucency. If you just look at this picture, you see all hundreds of collagen fibers being mineralized. And why are these fibers mineralized? Because of functional loading of the implant through the crown. And the same phenomenon you see beautiful at this crestal sinus lift also done in Boston. So certainly if you see all these fantastic features, and if you imagine that Leonardo da Vinci would have been acquainted with implant and implantology, I’m sure he would have designed a Bicon implant because he always says simplicity is the ultimate sophistication. And I would say I do not know any other implant which is so sophisticated as your implant certainly, and congratulations. Thank you, no Tom Driskell. Yeah, Tom Driskell. And you made my retirement very, very interesting, and I’m very happy because I could have treated many needed patients. You. Thanks to you. Yeah. And certainly this goes back to 1892, that’s not a mistake, not 1992, but 1892, and Julius Wolff always described, as also Dr. Morgan always says, every change in the function of a bone is followed by certain we do not know always which kind but certain definite changes in the internal architecture and its external conformation. And this is so important that we are saying bone follows function. He was working on the hip bone, and he noticed that always the collagen fibers are going along the most used stress line between tension and positive and negative tension and compression. And he found this actually because he worked on fractured hip and in malunion function and he found the same principle like here, also in here, and talked to a very important person, or a very smart person, Karl Culmann, He lived both lived in Leipzig and Culmann lived in Zurich, so at this time very far away. And he was working he’s the graphic static pope, that he did all the statics, tried to make drawings out of this, and they agreed that this hip system is the same like a crane. And therefore they could say where the most tension lines are in this region here in the crane and the hip in this region, and therefore the collagen fibers are collecting and then they are mineralizing and making cortical bone. And that’s what’s also happening around your Bicon implants. So we started our study, Paolo always did the prosthetic work, and certainly if you see for implants like this, in the beginning everybody said, yeah, Haversian, you’re crazy, the poor patients, you shouldn’t be so cruel these patients. The implant insertion and initial loading, and certainly the ratio is at least five to one. So very very critical, and now we are certainly proud and Dr. Morgan is happy that he initiated this study because after twelve point three years you see this fantastic result, and this is before oral hygiene. She comes from South Serbia once a year, with her daughter and visiting us, and that is before cleaning how beautiful this position lives. So we published this study in 2021, twenty 18 patients, 72 implants, good result, survival rate ninety seven. We don’t have to go through these states, but what is much more important is that we fortunately applied fifty two subcrestals, unfortunately nineteen epicrestals, as I told you, I didn’t pay attention, and one supracrestal you have seen already. Why is this so important? Because the subcrestal implants had bone gain, and the epicrestal had little bone loss, but fortunately we had less epicrestal than subcrestal position and therefore it’s equalized and we just have point zero two millimeters bone loss. We had been lucky, but we would have had much better results if I would have paid attention because all these implants I applied so I couldn’t tell. You know my younger residents did these problems. So let’s talk about the grayscale value, and this means that the lower the translucency, the higher the mineralization, and the pictures you know already, but just see the difference in translucency between here and here and the bone gain, so after eight point two years loading. So if this works in a single loading and we agree and we heard this today a single loaded implant should be loaded all the time. But what is happening if you’re splinting? And Giorgio just talked about this problem again, also splintered implants. And why may they work even if they are splintered? Because this material which is splinting the implants is elastic or flexible, as also Estevan showed already with his excellent lecture, and whatever I’m talking about I know from Estevan. But the Dreamliner also has this flexible material in their wings, and you see when you are on the ground and then in the air you see the flexibility, and they are testing it, And the bending upward and downward is twenty five feet, seven point six two meters, and by now we know that also the new Airbuses are having flexible wings, but just see what Estevan shows in his test how TRINIA is being flexible the same as these wings are flexible, as you know already this sheen. So what also Yuchi said, that Dr. Morgan doesn’t like to talk about a cantilever, and the cantilever here is if you have metal or zirconia, and you know very often that you have four implants with zirconia, you’re losing the middle implants because they are lifted out here because over the fulcrum. And therefore, Dr. Morgan always said, TRINIA is no cantilever anymore, it’s an extension and this system is much much better working. You know these pictures from me already. This lady has sensational problems when we loaded this implant that’s now thirty two millimeters long, the extension, and it’s stable now more than ten years. And just to see what artist our Paolo is, When he saw these x rays from this patient of mine, he called me and asked if I would have been drunken when I applied this wrong positioned implant. Why did this happen to me in the beginning? We had been so afraid that we put the patients into general anesthesia. And I didn’t operate the implants from the front, I was behind the patient and applied the implants and therefore I applied these in such a very bad position, but Paolo saved my life and the life of this patient, but he had this horrible long extension, and here you see like this is shown like this. But therefore we say the longer the extension, the better by now, as we have statistics and Yuchi showed one already, and certainly this is only possible because we have a flexible prosthetic base. If we have a 55 year old patient, she had a fracture, we treated the fracture, I applied this implant unfortunately in this position, and this is in our whole study until now the only implant which did not integrate or we have not lost yet any other implant in our study in the mandible, and this now is working six point three years until the patient passed away. And this brought me to the idea, why don’t we use just three implants in the mandible? As we know, stool with three legs are much much more stable, like a tree part always uses just three legs. So we started doing just three implants, three on TRINIA in the mandible. And you see here, very big atrophic patient, and you don’t see this so much, but here you see it. Unfortunately, this is a case I operated with a beginner in Dresden, and unfortunately he applied this middle implant too low, but we couldn’t bring it back, so you see how deep this implant is, and now after seven years of loading, it’s a perfect position and therefore in the cone beam you also see it’s no problem in the middle implant. The lateral implants are also perfect, osseointegrated, and this is the clinical situation before oral hygiene. This we also published together with Yuji, he was already here in first position in twenty three, and we had it was a two center study, Boston and Vienna, forty five patients, one hundred and thirty eight implants, and again wonderful results, survival rate ninety seven and ninety five, but also similar statistic like Yuchi showed. Again, this was the first time we saw that the posterior implant with the long extension has better bone situation and a better survival rate than none, and this is from the Mitchell experiment. And I just want to show this to you again because it was not explained. These are photoelastic experiments. And the more pressure, the longer the extension is, the more pressure is around the implant. And the more lines you have, it’s isochromatic and isoclinic lines, it’s tension lines, the more lines you have, the more tension you have around the implant. And therefore he also could show this in a statistic that the higher the tension, the more the implant is getting loaded around in the bone. Very, very interesting experiment. And now what about the maxilla? We wanted to be on the limits, we wanted to avoid augmentation and just apply implants and therefore in the beginning we applied four implants and this is now nine point nine years later. Again you have more than 5.5:one ratio between the prosthesis and the implant. It just looks funny, this little implant and this huge, huge material, and also a very long extension from the implant. And it works because the implant is getting loaded functionally. And beautiful intraoral situation, the patient has a free gum and it’s very important for him. So Bicon solving problems, what I will show you just a very quick case, forty nine year old patient, having applied this implant, nine years later the patient lost the implant and you see this big hole. That’s very bad for the patient, but fortunately this resorbable material which is good, vascularized, it’s a hydroxyapatite and a free calcium phosphate out of algae, very similar to the SynthoGraft material, and three months later it was almost closed and now I’m using certainly a Bicon implant. Just look at what five months later what’s happening, initial loading, now it’s so interesting again, then he lost this tooth, we applied the second implant. Now you see after thirty four month loading of implant number one, now seven point eight years loading of the first implant, six years of the second, and just see what’s happening, and it’s again interesting. Here we have a short abutment, now we have already a long abutment, and you see more bone around the long abutment than about the short one. Just see the difference here, and you see we are learning. We are learning the deeper, the better, the longer the shaft, the better. And here, just short, a case with Bio-Oss. You know, is nonresorbable, sometimes it’s getting infected. The lady lost the implants and unfortunately some of the material stayed in there and everything is still infected as you see in the histology. A little later we tried to revise the infection and it was a lot of pus, we cleaned everything because otherwise she never would get rid of the pus, and then a year later we thought we should augment again with our algae material, we augmented and we had been very fortunate it didn’t infect or reinfect, but three point two years later, you see the result I did with my augmentation was not so perfect. So at this time I knew already Bicon and I said, Well, Bicon are used in critical situations, so I applied these three implants in ‘fourteen, initial loading, four month loading, and now just see ten years later with this little augmentation bone here, and an additional implant, and ten years loading. So I think here, there’s no discussion. I wouldn’t know any other implant system, would you know anybody, Dr. Morgan, could you tell me an implant system? No, I’m biased. No, oh, you’re biased. No, I’m trying not, but I wouldn’t know of anything. It’s just unbelievable, and if colleagues look at me and say, You must have been crazy to be encouraged enough to do this, but I was crazy enough and I’m very happy that these patients can function so well with this. And everything goes back to these two gentlemen, and they say bone follows function and the transformation of bone is so important to understand. And if anybody discusses with you about implants, one kilometer long implants or threaded implants like this, as you said, well go into the literature and see which implant is able to be functionally loaded, which has fins and healing chambers, which is able to be functionally loaded and which implant system shows that it has bone gain, crestal and also on top, and you will see that everything goes back to them. They always said function changes the bone, and just see on this patient, you know already with 17 years loading, just look at this and it’s so fantastic. What happened on the left, it’s not so left mandible it’s not so much. Just see what happened on the right side, on the right horizontal mandible. You see this, you recognize this. It tripled. Why did it triple? Because the lady now is using these implants there and she’s loading the mandible and the mandible is growing over seventeen years. And the same we see in this lady you know already. Also this lady gained bone in these twelve years, and here I say also she has Bicon implants, but this still is functioning because this is Wolff’s Law. Sorry to say We have to close because We are closing, two minutes, and I never would have expected that implantology also will be fitting in all the theory of these two gentlemen. You mentioned digital dentistry, as you said I designed in 1984 the Camlog Guide system, then you certainly adapted this guided surgery with Bicon and it’s excellent and it’s much easier to use. Thank And I just want to show you the limits which are possible with digital medicine. Everything goes back to my friend and former resident, Dr. Michael Truppe. We started in 1989 with augmentation techniques, he finally patented this in the United States, 1998, the first patents and everybody has to cite him brain lab everything. He is the brain of it. And this lady had a failed augmentation and tenting augmentation, and we planned this with our system and had a beautiful guide, and this I would say, this is going to the limits, and she has no sensational disturbances, and there’s no other system, no other than Bicon, which could solve this problem. So we hope we could explain this, because they are short and also they have self locking abutments, unique features, and because they are synergized with TRINIA. So this is the system: short implants, prosthetic components and TRINIA really fits together, and certainly we are able to do this. And by now I would say lengthwise, the shorter the better. The deeper, the longer, the better. And I would say, deep, deeper and as deep as possible. And longitude wise, we always see the longer the implant is in the bone, the better will be the bone. You want to have this lecture, you just write Dr. Morgan or me, and if you have questions, please feel free to mail me and ask your questions. Again, congratulations, we talked about this and certainly we would not be here without you.