My Evolving Views on Bicon SHORT® Implants After Using Them Extensively for Eight Years

Hello, my name is Rolf Ewers. I’m from Vienna in Austria. Until 2012, I was for twenty three years head of the Department of Cranio Maxillofacial and Oral Surgery. And I enjoyed this position very much because I had thirty six residents to teach, and we had a fantastic team to treat our patients. In the moment, I’m head of the CMF Institute. This is for cranio maxillofacial surgery, and I’m dealing a lot with bone augmentation and treating patients with very little bone. And therefore, I decided to use, since 2010, Bicon implants, and I want to tell you my story, what I have learned using these implants, and how I could treat my very needed patients. My topic is short and ultrashort Bicon implants. And as you see on the slide, I work very close together with Paolo Perpetuini. He is dental laboratory technician in south of Rome. And all our results is out of a very large team of the Bicon company, Dr. Morgan, Prof. Marincola, and in my institute, it’s Prof. Seemann, Prof. Wudze, and many more residents who helped me achieve our very good clinical results. As I said in the introduction, we had been working a lot about augmentation and looking back to forty eight years of operative techniques. I always have to ask what I have done all these forty eight years. And I performed uncounted free osteocutaneous flaps, forty five horseshoe Le Fort I osteotomies, 554 sinus augmentations in general anesthesia, eighty five vertical distractions, twenty three vertical inlay PSPs, a more elegant method than distraction operations. And certainly, I performed uncounted onlay plasties and uncounted socket preservation. Whoever is interested in my thoughts about augmentation could look into my books. The first chapter, about two hundred and fifty pages, is in the book from Prof. Lambrecht, Oral and Implant and Implant Surgery from the Quintessence Company. And my topic is implant surgery. And then we had been asked by the publishing company, Quintessence, to publish a second book together with Prof. Lambrecht about oral implants and the bioactivating concepts with chapters from Bob Marx and Prof. Reddy. Very, very interesting summary of this very interesting field. The mother of bone surgery is soft tissue management and the vascularization, which is very important for the bone to survive. And according to this vascularization, we designed a new classification about bone classes. We are dividing it into five classes, and it starts with revascularized bone, distracted bone, and the bone itself, it’s always vascularized, and therefore it’s the second best class. And then comes the inlay. Inlay putting in a material which is not vascularized, but it is embedded in two good vascularized beds and therefore it’s class three. And then BMP bone squeezed in between and it’s an excellent method but very expensive. And the poorest method is very widely used onlay bone, but this is just an unvascularized material being put on a vascularized field, and therefore it’s just on one side the vascularization, and certainly it’s never as good as an inlay. When you’re doing augmentation, you always should try inlay method. If we have patients with a wish for implants and fixed prostheses like this maxilla on this mandible, certainly it is very demanding. And if you’re doing surgery and have results like you see in the maxilla stable for fourteen years or in the mandible stable for seventy years, then it’s an excellent result and the patient is happy also, he had a big operation either in the maxilla and the mandible. However, as you see in the lower picture, there is some kind of massive resorption and therefore we always say if you talk about resorption of augmented bone, you just have to wait long enough. It’s just a question of time that you see minor or massive resorption of the transplanted bone. We start to ask ourselves maybe the best augmentation would be no augmentation and where is this be possible to be done? And we learned in our study always to do the smallest possible operation just for the sake of the patient. So maybe less could be more. And let’s see what we achieved with these thoughts. Just for the nomenclature, implant shorter than eight millimeter and diameter less than three point seven five is a short implant, and ultra short implants are implants with less than six millimeter. To be honest, if you see a picture like that, what are you thinking about? Certainly, you have to do an augmentation, a sinus lift, there you may discuss a lateral or a crestal sinus lift, but at least you think about a sinus lift as I used to do too. And when I saw pictures like this ten years or more, what was my reaction? Unfortunately, I didn’t believe it, and I actually laughed at the picture like that because I said this is never to stay stable. And as you see here, also we have crown implant ratio of two point five to one. It’s stable now than more than thirty month loading and no problem at all. So how is this system functioning and how is this been able to stay in there? There must be something different. This I ask myself and now after using this system in the eighth year, I can tell you a little story about this. 2010 we decided to use Bicon implants because at this time they had been already 25 years in the market and I just didn’t pay enough attention to read enough literature to see that this is working and I should have changed much earlier. And what is so unique about this Bicon system is first the locking taper, the sloping shoulder, and the plateau design. These are three very unique features in this implant system. And in addition to this, the universal three hundred and sixty screwless abutment positioning. And this also makes it very handy for the prosthodontist to do the prosthetic work. So the Bicon short implant is a paradigm change, and I have to tell you about a little bit about this paradigm change. The bone around a Bicon implant and its functional response is different than the bone around the threaded implants. If you’re looking at the one point five locking taper, it’s a conical connection, and this means it’s a bacterial seal. In all technical questions where you have to have a connection propeller for the airplanes, the propeller for the ship, there you have to have a conical connection, there you could not use a screw. And this bacterial seal around the abutment leads to fantastic soft tissue response. And if you remove sometimes the abutment, which you actually do not have to do, you will see slight potential bleeding even in very thin biotype cases. The locking taper design is a bacterial seal without micro movements, and this means it’s a component to prevent peri implantitis. And the bacterial seal and the so called double platform switching, this means with the hemispherical base of the abutment, you have something like a healing chamber in this area and this leads sometimes to bone gain as you have seen in this picture. This implant was applied after acute sinusitis and loss of a very long implant And after waiting quite a time, we applied this implant without a sinus lift, without a crestal sinus, just applied it into the alveolar crest. And you see fifteen months later on this side bone gain towards the abutment and what’s so fascinating in that addition as this implant seems to move a little bit as I will explain in a few minutes. We have bone gain inside on the floor of the sinus because of functional load. Very fascinating results we have on our fibular transplant as I will explain later. And here you also see the little groove between the two left posterior implants and fifty six months loading time shows that the bone grew toward the abutment, the bone straightened out and you even can imagine how the collagen fiber got mineralized and make this beautiful bone grow up to the level of the abutment. So the double platform switching actually is a bone production chamber as we see very often and the Bicon plateau design which exists now since fifty years having three sixty degrees around the implant also growing chambers because the fins have a lot of space in between each other. So all these ideas are going back to Wolff who published this book in eighteen, not nineteen, 1892. It was in Leipzig and it was about this means the transformation, the the law about the transformation of bone. And he followed that bone always follows function. And there, if you have some movement of this little implant and enough healing chambers, we will find a very special bone as I will tell you. So if you have a screw connection and you have a bacterial film, you always will see some kind of bone loss, which you never will see in a screw less connection without any bacterial film and this certainly is the second component to prevent peri implantitis. Now comes the next paradigm change and this is when you apply a threaded implant then you have the so called pressure principle because you are turning with thirty, forty or even more RPMs, Newton centimeters to apply this implant. And the result is a slow growing appositional bone. In contrary to this, if you’re applying an implant, just tapping it in and not having a lot of pressure to the bone, the healing will be like the Callus principle. And this leads to intramembranous, fast growing bone with Haversian like structures. And the next paradigm change is handling the bone during performing the osteotomy. We also apply the pilot drill without irrigation. And the advantage is if you are using very slow turning instruments with fifty RPMs, you do not need any irrigation and you are able to collect the bone as you see on the right side of the slide. This bone we are collecting as you now see in the sequence and the covering the implant and closing with autogenous collected bone so that when you’re uncovering the implant, you see the implant is completely closed with wonderful bone. The next important part of using Bicon implants is that you have to apply or insert the implant at least one millimeter sub crestal, and only the bacterial seal with our micromovement guarantees and allows a subcrestal implant insertion. So these two implants are perfectly positioned. The third one is not so perfectly. It could be a little bit deeper. And all this is the third component to prevent peri implantitis, which results in bone loss. So whenever you have a peri peri implantitis, you may expect bone loss. And if you do not have any peri implantitis, you will have no bone loss. Therefore, you are able to put in the implant sub crestally and you will have some kind of bone gain, especially in single loaded implants or crowns with implants. As I mentioned already, as this implant shows no primary stability, it has no pressure onto the bone and therefore also no starting necrosis or first step necrosis of the bone and then a positional, following appositional bone. Here you always will have lamellar bone and therefore you have to give the implant a healing time and we do this in the maxilla four to six months and in the mandible two to three months. There are many publications by Mufti who showed with finite element analysis that this short implant is very active, and it seems to be as it’s not three times as long. It will turn a little bit functional turns very microturns and this leads to the bone according to the law of wolf that function will lead to mineralization of the surrounding bone as Coelho could show in his human histology that these chambers and these functional load, as Mufti showed, are leading to long term lamellar bone with Haversian like bone morphology. And you see the lamellars growing in between the fins into these healing chambers with beautiful Haversian canal in the middle with the vessels and veins and arteries, arterioles, and also some of the nerves. You actually never should believe histology except you have done it yourself. Here I have an own histology of a patient. The patient had a three millimeter implant with a two millimeter well and it broke because it was positioned on the anterior mandible where it shouldn’t be positioned and it broke and therefore you have this same beautiful histology as you see from Prof. Coelho. And certainly if you see x rays like this comparing after ten years from the left to the right side and we always say x rays don’t lie and here you see very extensive bone gain toward the abutment and in addition to the bone gain you see also the difference in mineralization as it used to be after unloading. So you have bone gain and a huge amount of increase of mineralization around the implant of the collagen fibers. And also this phenomenon you see in the maxilla after a crestal sinus lift. First it is just augmentation material around the implant and due to the function of the single loaded implant you see increase of mineralization and bone gain toward the abutment. And certainly the old ratio one to one between crown and implant certainly does not exist as you see on the left side in the maxilla and the right side in the mandible that this exceeds up to six seven times more than what we have learned. And certainly we know this in the sequoia tree, we know this from the Empire State Building. Why shouldn’t it work in the human body if you use the right implant system and apply the sufficient crown like you see here on this picture you know already. So certainly if you are interested in these many paradigm changes, you may read this book which was published 2017 by Dr. Morgan and it’s called the Bicon short implant a thirty year perspective. And this is a very worthwhile reading because there’s everything explained why this system works so fantastic. So certainly short is not like short. Only this long lasting many years in the market system could prove and has a trademark for short and is in the market since 1985 and I certainly believe in this system very much by now after using it for eight years. So short to memorize, first it’s important the plateau design, second screw less connection with bacterial seal, third double platform switching and for at least one millimeter sub crestal implant positioning. So now I would like to go to our studies which we start 2010. We designed studies with four by five millimeter ultra short Bicon locking taper implants on the maxilla with less than six millimeter bone, the mandible less than seven millimeter bone, and as I mentioned already with patients after transplantation of fibular bone to the mandible after being revascularized and well incorporated into the mandible. And also at this time we started with a new material called TRINIA fabricated with a base of metal free fiber reinforced resin. And I will talk about this a little later. First we started with a study in the mandible and you see here this very thin mandible. You see the image of Prof. Seemann. He’s not only a dentist, a medical doctor, an oral and maxillofacial surgeon, but he also studies statistics and he is an informatics professor and he’s doing also our statistic evaluations which you will see during this lecture. So here you see the fifty nine year old female patient and as you see not more than seven millimeter of bone. What would I have done in earlier times? The bone is too thin to be cut in between so we could not do here any distraction osteogenesis methods. Here we would have to do an augmentation and onlay from the iliac crest knowing that there you will have at least fifty percent or even more of resorption after a few years. So here we decided to apply these four implants, five millimeter long. Also with this implant system, certainly you have to do the normal prosthetic workup with wax try in and then you apply the prosthesis on these implants, putting in the abutment. And here you see on the panoramic X-ray certainly that there is ratio between the implant and the prosthesis with the teeth is something like five to one, and certainly we ask us at this time, 2012, if this is going to work. After sixteen month loading, we had been already very happy that we could show a very, very good result. And you see that the situation almost is pseudo class three, and still it seems to work with the Bicon implants. And now I can show you the x-ray and the clinical picture after sixty nine month loading with a superior result. No problems around the implants, no bone loss, and certainly a very, very satisfied patient. Also, she had this very severe atrophy of the mandibular bone. And certainly, we can say osseo distraction in this case would not have been possible. And if you use a screw tack device and there, it actually would have to have sixteen millimeter of bone, I wouldn’t know why we should do a distraction operation like this. The first statistic we did our on our first ten patients, Prof. Seemann calculated this and he found a bridge span compared to the implant span of four point three to one, which is a real big amount. And this means we have a very long cantilever behind the implant, and we really are surprised that this is going to work. So our statistic of seventeen patients with sixty eight implants showed that we have lost until now just one single implant. We have now a follow-up of more than five point six years with a survival rate of one, two and three years of ninety eight point four percent. The complete statistic workup, Zeeman and his colleagues already published this and you can find this in the December issue from 2017 in the Journal of Oral Maxillofacial Surgery with all measurements of the marginal bone, the bone level, and what the bone situation is. As this patient, this one single patient used her total arch prosthesis after forty months on three implants, this means that we actually have a hundred percent prosthetic success on these seventeen patients. Now let’s come to the maxilla. We started this in March 2012, again, with Prof. Seemann. Here you see a sixty nine year old male patient, and you see the atrophy in the maxilla very extensive, also with a slight pseudoprogenic class three situation. Here you see the application of these small implants, and as the anterior part was too thin, we applied diameter reduced implants three millimeter thin and eight millimeter long. Here, after unloading and inserting the abutments with the prosthesis, it’s here cemented and you see here the TRINIA prosthesis with a wide TRINIA base and the resin material and the teeth starting to load 2013 and the abutments are positioned and located with the prosthesis before cementing and then tapped into the implant and the patients are very, very happy that the gum is free, so the red wine tastes good again. Now here, stable after fifteen months, the system seems to work. He also was in the study for the mandible. And here, fifteen months in the cephalometric x-ray, you see the problematic position between the mandible and the maxilla, and we always had been afraid that maybe the thin three millimeter implant with a two millimeter well could break in the front of the maxilla, but certainly it stays stable. The aesthetic result is very satisfactory. And now we can show you the results after fifty four month loading without any problems of bone loss or whatsoever and very stable situation with a very happy patient again. And our statistics is with eighteen patients and seventy two implants and we have lost in the meantime two implants in two patients. And here it’s a one year survival rate because the publishing company where we published this, Wagner, Seemann et al, also in the Journal of Oral Maxillofacial Surgery, they just wanted to have the one year results and this is published now in January 2018. Both patients had used their total arch prosthesis until the fourth implant had been replaced, so therefore we also have a hundred percent prosthetic success. I’ll just show you a little movie how easy it is to apply the abutments with the prosthesis and now you’re starting to tap and my dental technician started to tap and I had to tell her at the end we just will see your left hand so please change your hands and she changed the hand. So actually we would have taken less than one minute and fifty seconds. Now you see it’s being tapped over the prosthesis, the abutments into the implant. Then now it’s the difficult situation. You have to remove the prosthesis and hopefully all four abutments will stay in their right position in the implant. Now it’s getting cleaned. The Vaseline for isolation used will be removed and now everything is being tapped permanently into the implant and then you’re able to use cement. In the beginning we always use temporary cement and later permanent cement. Now it’s getting cleaned and then it’s going to be cemented. You certainly can use other system than cementing abutments. Here you see thirty three months loading with retentive telescopic methods and here beautiful retention due to the telescopic abutment and very happy patients. Now we come to the most difficult group. This is the group with fibular transplant. As we do not have so many fibular transplants, we cooperate with other university clinics with Prof. Politis in Leuven in Belgium, with Prof. Lauer in Dresden in Germany, with Prof. Poruban in Bratislava in Slovakia and our clinic. Here you see this patient, what I have shown the x-ray already. One implant we had to keep sleeping because the position of the implant was not so good because the bow of the actually primary long fibula was not bent so well that this implant is too far outside of the arch and therefore it’s sleeping. But now she is therefore on three implants and it’s stable for seventy eight months, so it’s almost seven years. Here you see these x rays again, and here you see how the bone changed in between these six point eight years, and it became much better mineralized bone and bone gain toward the middle abutment on the left side. So actually with these good results I’m very happy that I did not stop to become better. Certainly I operate less big bone operation and just use implants which are shorter than the implants I used to do, but I think I became much better and did not stop to be being good as Oliver Cromwell says, he who stops being better stops being good. Now we’ll show you a little about TRINIA. TRINIA is available in pink and ivory. The discs are different sizes and blocks. TRINIA is a fiberglass bonded resin hybrid material which also is CAD/CAM being produced. TRINIA is also used in the wings of the Dreamliner, the Boeing seven eighty seven, and if this is stable there, it should be stable enough for prosthesis. The ratio between fiberglass and resin is forty to sixty or four to six and this flexural strength between TRINIA and titanium is something like ten times different but it’s very similar to dentin. And therefore, if it’s so flexible, we are able to have fifteen millimeter cantilevers even longer than fifteen millimeter cantilever is possible. And certainly I may show you my statistics, and it’s until May eighth 2018, we used one hundred and thirteen metal free TRINIA crowns, thirty nine bridges, and one hundred and twelve TRINIA full arch prosthesis. And problems, we just had one chipping, one hairline crack, and two fractures which had been long cantilevers and behind the posterior implant it broke, and we think in these parts we did not apply enough TRINIA, but it’s a very, very rare complication. So as we have seen so good results in the maxilla and in the mandible with these four short implants or some diameter reduced implants, we thought maybe as we know a chair is very stable on three poles. Therefore, we thought maybe we should try also just to use three implants. And we started again with a mandible because there’s no difficult difficulties. In the maxilla it’s a little bit problematic and I will show you how we solve this problem. So in the mandible you may use fixed detachable abutments, you may use retentive telescoping abutments, you may use locator abutments or bar abutments. They are all free, all work, all with all systems the patients are satisfied. However, when they’re getting very very old they are able to handle it much easier, a bar abutment, than a telescopic abutment. And certainly also may use an individual casted titanium bar, which also is very elegant and very positive for the handling for the patient. Our statistics in the mandible are thirteen patients. The average time is twenty seven months. The longest loading time is eighty three months, six point nine years. And fortunately until now we have been not losing any implant. Now let’s come to the maxilla. Where to put in the middle one? And you can do this in the incisal foramen and nasopalatal canal which are having very often or most of the time two incisal nerves. So stop. If you’re applying there an implant how about the problems with sensational loss? Bleeding is not so big but the sensational loss everybody is expecting saying well this should be difficult. Here you see large foramen and a large canal. Here you see a very small canal. And here you see even two little canals. So the variation is very high and certainly it is very easy to apply an implant in the large canal. Here you see it preoperative and here it’s postoperative, no problem at all. But if you have a little canal like this, very small, you have to use, be very tricky to apply this correct and you see this on the graphs. You have to start to drill eccentric and in the sagittal section you see it much better, you have to start eccentric just in the anterior and then you have to enlarge the osteotomy holes and just with the last, like here with the five diameter reamer, you just touch the first time the palatal part of the canal. So we will not lose too much bone and then you are able to apply like in this case very nicely into the canal and through the foramen, apply this five millimeter thick and five or six millimeter long implant. I just want to show you a very difficult case. This patient had loose teeth which had to be removed with lot of infections. And after we wait a few weeks, we did a new cone beam and there you see there’s not enough in the front to apply an implant except in the foramen and in the nasopalatal canal. Here you see the operative site starting to operate. You see in the left side even still some bone defect, but enough bone around the canal. Applying the implant and that’s the cone beam after implantation with a very, very good position, so it is an excellent result. Uncovering, you see the implant is a little bit covered by bone, now completely freed of bone and worked up with impression and the plaster cast wonderful prosthesis as you see here with three screw abutments and the prosthesis, the TRINIA prosthesis, and the abutments and the final prosthesis with a very, very good result and no sensational problems as there are many, many publications. And in December last year, she had a big meta analysis, and she showed that applying implants out of ninety applied implants they just had one loss of sensation after a lateral sensation. So this is no problem and we had no disturbances. Also the literature says there’s no dangerous as we do this in the Le Fort I osteotomy for orthognathic surgery, routinely that the nerve is cut. And our statistic is nine patients on average eight point eight months. Longest loading time is twenty seven months and certainly we are also happy to announce that we have not lost in one single implant. So to come to the end I will show you again this one patient. You saw already that this patient was operated in 1997. She had an iliac crest transplant. At this time I used IMZ implants which had no threads so therefore I had to use an osteosynthesis screw to stabilize the bone and it’s an excellent result over seventeen years. But a lot of bone resorption and the patient just kept my result due to excellent oral hygiene and she was lucky that she did not lose finally the implants due to the massive resorption of the Class V augmented, nonvascularized onlay bone. Today, I operate a patient like this in half an hour or forty five minutes, apply this, it’s stable now, almost six years, and with a perfect result. Low morbidity and very low pain and certainly also lots less costs. So it certainly often needs more courage to change one’s own opinion than to remain faithful to it, as Friedrich Hebel said this. As I started with this slide that I said resorption of augmented bone is just a question of time. I just want to show you my long lasting experiences. And here you see a patient came with this problematic implant and it was removed because it was loose. We did an onlay transplant fixed with two screws. The bone was taken from the mandible angle and you see the bone was well taken applying two long implants and see just what happened fourteen years later. You see the augmented bone is completely gone. It’s one hundred percent resorbed and as I was lucky enough to use my Algipore augmentation material in between the onlay bone and the original bone, it became the Algipore bone and the implant after fourteen years, the implants with the crowns, after fourteen years, are located in the augmented Algipore bone and no onlay bone is left. And that a patient like this was operated in my hospital 2003 with this augmentation method, I really have to tell you I’m ashamed about that we did at this time still distraction osteogenesis and not using short Bicon implants to solve this situation and treat this patient well enough. We are very happy that there was a consensus conference in Cologne in February 2016 and the consensus conference agreed that the use of short implants be a reliable treatment option compared to the risk associated with the use of standard dimension implant in combination with augmentation procedures. So this means by now, at least in the European countries, that the doctors are forced to inform the patient before they do an augmentation and then use long implants, there is an alternative without augmentation with same good results using short implants. So certainly after eight years of my own experience, I can say less is more. It prevents big bone operation and again short to memorize is plateau design, screwless connection with bacterial seal, double platform switching, and at least one millimeter sub crestal implant positioning. And with this, I would like to thank you for your attention. And certainly if anybody wants to ask something, they contact me by my mail. My mail address is Rolf at c m f minus Vienna dot com. Thank you very much.