My Journey from Augmentation to TRINIA®, a Non-Rigid Metal-Free CAD/CAM Material

Hello, my name is Rolf Ewers, I’m from Vienna, in Austria. What I will talk to you about today is that I did for 36 years, a lot of augmentation operations. And, as we saw more resorption than we ever thought of, but the resorption always bothered us, and therefore, I got acquainted with short implants and I was satisfied by the good results and x-rays. And, as I always say, x-rays do not lie, that I started to use the Bicon system in 2010. And now, I have nine years experience of this fantastic little short implant, and that’s what I’m going to tell you about. After 36 years of professional experience with augmentation procedures and observing the resorption of augmented bone, I asked, is augmentation really necessary? Maybe less is more. In 2010, at the University of Cranio-Maxillofacial and Oral Surgery in Vienna, Austria, we decided to use short and ultrashort implants. As only the Bicon system had proved long-term clinical success after its introduction in 1985, we decided to use Bicon implants. Their unique features include 360 degrees of abutment positioning, 1.5 degree locking taper abutment connection, a sloping shoulder, and a plateau design. Bicon system represents many paradigm changes. We believe that a significant part of our success is due to our use of a TRINIA substructure. It is a CAD/CAM produced metal-free fiber, reinforced hybrid resin material. It is comprised of about 40% resin, and about 60% fiberglass. The flexural strength of TRINIA is comparable to dentin, and about ten times more flexible than titanium. It is interesting to note that Boeing’s 787 Dreamliner is fabricated with a similar material. TRINIA also presents a paradigm change, because of its modulus of elasticity, it is not rigid. Therefore, it can be neither a lever nor a cantilever, since the definition of both pertain to rigid members. The longer the extension, the better. TRINIA is sold in three different shapes, disks, D shape, and blocks. The disks come in two different sizes and are available in pink and ivory. As of March, 2019, our studies are in the ninth year. During this time we have applied 125 TRINIA crowns, 46 TRINIA bridges, and 121 TRINIA full-arch prostheses. To date, our only prosthetic issues have been one chipping, one hairline crack, and two fractures. This image reveals the treatment for an atrophic mandible in 1998 with long implants, and in 2011 with ultrashort implants. Clearly, treatment with ultrashort implants and a TRINIA prosthesis was significantly more beneficial for the patient, since there was only one side, less risk of infection, less morbidity, and less time and financial expense. We had similar experiences in treating the maxilla, the panoramic radiograph reveals a 48-year-old female whom I operated in March, 2002. These ten implants were placed in April, 2002. The clinical image reveals a stable situation, and the panoramic radiograph reveals the implants after 14.5 years in function. Pre- and post-operative facial images reveal an excellent aesthetic transformation. Post-insertion images after almost six years of loading, and after 14.5 years in function, the aesthetic still is perfect. As Friedrich Hebbel stated, “It often takes much more “courage to change one’s own opinion, “than to remain faithful to it.” In 2010, I realized it may be better to use short and ultrashort implants, without bone grafting procedures, to achieve similar or even better results with less morbidity and risk for my patients. Professor Seemann and I designed three studies with four by five millimeter ultrashort Bicon Locking Taper Implants. In this presentation, we shall demonstrate the procedures performed for atrophic maxilla with less than six millimeters of bone in the anterior region; atrophic mandibles with approximately seven to 10 millimeters of bone in the interforaminal region; and transplanted fibulas in the mandible for tumor reconstruction. These images represent a 59-year-old female whose implants were placed in October, 2011. The panoramic radiographs reveal massive bone resorption with a mental foramina on top of the alveolar crest bilaterally. The lateral cephalometric radiograph with yellow markers indicating about seven millimeters of bone, reveals the magnitude of the extreme atrophy. We inserted the full-arch TRINIA prosthesis, comparing the length of the prosthesis with the lengths of the five millimeter implants, reveal a crown to implant ratio of at least five to one. The panoramic radiograph reveals only minimal bone loss around the right lateral ultrashort implant, which still remains stable. The clinical image shows healthy mucosa without inflammation. With these results, that one needs neither distraction procedures for ten millimeter atrophic mandibles, nor onlay graft with non-vascularized monocortical bone blocks from the iliac crest for atrophic mandibles, with seven millimeter of remnant bone. For the first ten patients, we compared the extension of the prosthesis to the horizontal span of the implants, and found the average ratio of 4.3 to one. In December, 2017, Professor Seemann, colleagues and I, published the measurements of marginal bone level for a prospective cohort study with up to five years follow-up, “on average we found minimal initial resorption “which subsequently stabilized.” Currently, our study includes 21 patients. We have not lost a single implant to date, however, one implant did not osseointegrate, and one was not loaded due to disturbances of the right mental nerve. The average loading time for these 21 patients was 52 months, the longest loading time was 94 months, and the shortest was nine months. Seven patients have been loaded their prosthesis more than 72 months. Since the patient with the non-osseointegrated implant was able to use her full-arch TRINIA prosthesis on the remaining three implants for 76 months, prior to replacing the implant, and the patient with the sensory issue was also able to function on three implants, we can report 100% prosthetic success for our 21 patients. The following images show you some of our oldest treatments. The first series of radiographs is of a 59-year-old female. And, the final image shows her TRINIA prosthesis after 94 months of loading. The second series of radiograph is of a different 59-year-old female, and the image shows her TRINIA prosthesis after 83 months of loading. The third series of radiograph is of a 55-year-old female, who had a mandibular fracture which was initially stabilized with an osteosynthesis. The middle image was taken after the placement of ultrashort implants, her left middle implant did not osseointegrate, therefore, her TRINIA prosthesis was loaded on only three implants. And the final image is after 76 months of loading. The fourth series of radiographs is of a 52-year-old female. The left image shows her pre-operative situation, and the right image shows her TRINIA prosthesis after 70 months of loading. The second patient that I presented in the previous images had a most interesting clinical situation. Also, the extreme atrophy did not create any difficulties in placing the ultrashort implants. The implants were placed with a labial angulation that caused a prosthetic complication, as seen in the clinical image. However, the panoramic radiograph after 94 months of loading shows not only excellent osseointegration of the Bicon implants, but also you can readily see bone gain of the horizontal rami, and in the chin region. Knowing that the stool with three legs is more stable than one with four, we initiated a new study in 2017 using only three implants, and restored with a full-arch TRINIA prosthesis. Preferably, we used fixed-detachable or copings on universal abutments. Alternatively, Locator® or bar abutments can be used. Our longest-lasting prosthetic experience with three implants is for a cancer patient who had a three mandibular microvascularized anastomosed fibula graft. Which was performed after an extensive squamous cell carcinoma resection. We performed the resection of her tumor. A post-operative panoramic radiograph is seen on the right. A partial mandibular resection was stabilized with an osteosynthesis resection plate. The mucosal defect was covered immediately with three microvascularized reanastomosed jejunal graft. After one year of being free of tumor recurrence, we bridged the mandibular defect with three reanastomosed fibular transplant, as shown in the lower panoramic radiograph. Since the curvature of the fibular graft was not perfectly symmetrical, as seen on the right radiograph, the positioning of the left central implant was too far buccal, and not within the appropriate curvature of her resected mandible, the clinical image reveals a TRINIA prosthesis on only three implants. Her prosthesis has been functioning very well for 91 months on three implants. After 91 months of functioning with a flexible TRINIA prosthesis, this patient’s treatment demonstrates a fascinating example of Wolff’s law, as initially seen at the time of loading, there is a slight depression of the cortical bone between the two left implants. However, after 91 months of function, there is radiographic evidence of bone gain and straightening. As the collagen fibers straightened and completely mineralized, there was a transformation of the fibular graft into cortical bone. This phenomenon is consistent with Wolff’s law. Our TRINIA studies in the mandible include 14 patients, with an average loading time of 27.4 months. I ask, “Is augmentation necessary also for the maxilla?” Maybe, less will be more. The pre-operative radiographic images of a 69-year-old female reveals the bone atrophy. And her OR slide reveals a large bone defect, with a significant perforation of the sinus mucosa, which presents challenging clinical situations, since a sinus lift with augmentation would not be possible. This difficult situation was readily resolved with our placement of an ultrashort four by five millimeter implant. After 43 months of loading, with a crown to implant ratio of at least 2.5 to one, this implant remains solid without any bone resorption. In 2012, we began our maxillary study. These radiographic images of a 69-year-old male reveal massive resorption in the maxilla. In November, 2012, we placed two four by five millimeter implants in his premolar region, and two three by eight millimeter short implants in his anterior maxilla. The implants were loaded with a cement retained full-arch TRINIA prosthesis. These images show the full-arch TRINIA prosthesis before and after its cementation onto the four abutments. The cephalometric radiograph shows the stability of the maxillary prosthesis after 15 months of loading. The images show his enhanced aesthetic result. The 66-month post insertion clinical and radiologic images show irritation-free mucosa, without any bony resorption around the implants. Professor Wagner, other colleagues and I published measurements of the marginal bone level. “On average we found minimal initial resorption “which subsequently stabilized.” Our study included 18 patients, with 72 implants. As published, we lost only one implant in two patients during the first year of this study. Since the two patients who lost one implant were able to use their full-arch prosthesis on the three remaining implants prior to replacing their lost implant, we can report 100% prosthetic success. Alternative to cemented full-arch TRINIA prosthesis, telescopic-retained restorations, as shown in this panoramic radiograph are an excellent option. These clinical images reveal a telescopic prosthesis with four abutments after 33 months of loading. Since we enjoyed success with four ultrashort implants in the atrophic maxilla, we initiated a new study using only three implants. The pre-maxilla exhibits the least resorption. However, it has an incisal foramen and nasopalatine canal, which may be either very wide or very narrow. They are best seen in a sagittal slice of a DVT. Sometimes you can see tiny incisal nerve canals. The axial slice of this DVT image reveals a very large nasal palatal canal. The axial and sagittal slices of this DVT image shows a very narrow incisal foramen and nasal palatal canal. These clinical and radiographic images of a 74-year-old male with five non-restorable teeth, and very infected tissues reveal extensive bone defects, as shown in the axial and sagittal slices of the DVT image. Eight weeks after the removal of the teeth, a second DVT image was taken and revealed significant bone defects. There was only bone in the area of the nasal palatal canal to place an implant. A 4.5 by six millimeter implant was placed in the nasal palatal canal, and two four by five millimeter implants were positioned bilaterally in the premolar areas. The DVT images show a perfectly-positioned implant in the nasal palatal canal. These images show the uncovering of implants after six month of healing. A round bur had to be used to remove bone, which had formed over the black healing plug. A full-arch implant level transfer impression was made, this images show the final milled TRINIA prosthesis with three cast sleeves for their screw fixation to the three fixed-detachable abutments. This was achieved by performing an osteotomy in a special manner. Initially, we shortened the anterior alveolar crest to avoid having the implant too deeply positioned. Then, a round bur was used to prepare a starting point for the pilot drill, which must be positioned anterior to the orifice. After initiating the pilot osteotomy, subsequent reamers were used to widen the osteotomy in half millimeter increments by only removing bone anterior to the orifice. Only the final reamer should contact the very thin bone on the palatal side of the nasal palatal canal. Then, the Bicon implant may be placed during the implant. Uncovering it may be necessary to blunt the anterior maxilla even a bit more. As of March, 2019, our TRINIA studies in the maxilla include 11 patients with an average loading time of 14.5 months. This image represents a 75-year-old female who has been edentulous since she was 18. Sadly, she not only has minimal bone throughout her maxilla, she also has a progenic class three occlusion with an extensively advanced mandible, and a very small retruded maxilla. We initially placed three Bicon implants in her mandible, also her difficult progenic class three occlusion is not evident in the panoramic radiograph. It is evident in the positioning of the titanium impression posts, as well as in the image of the three fixed-detachable abutments. Fortunately, her challenging occlusal relationship was solved by positioning all the prosthetic teeth of the prosthesis lingual to the three implants. This design clearly defies the dental profession’s conventional wisdom about the length of prosthetic cantilevers. Since TRINIA is not a rigid material, it is not subject to the limitation of other rigid materials. The unconventional design of this prosthesis and its satisfactory occlusion and aesthetics is well demonstrated with these images. After experiencing the comfort of her mandibular trio-TRINIA prosthesis, she requested a maxillary trio-TRINIA prosthesis. To achieve some bone stability in the maxillary premolar region, we performed bilateral crestal ridge splits with split-thickness flaps. Unfortunately, especially on the left, our results were not satisfactory. During the uncovering, we noticed that our poorly positioned left implant did not completely osseointegrate, therefore we augmented the defect with SynthoGraft™ and covered the graft with a slowly resorbable porcine collagen membrane. Fortunately, the implant in the incisal foramen and nasal palatal canal was well osseointegrated, so we recorded its position with an implant-level impression. And, subsequently, fabricated an overdenture prosthesis retained with one Brevis™ abutment. These clinical images reveal the satisfactory occlusion and aesthetics of an uno-TRINIA retained maxillary overdenture, and a trio-TRINIA implant supported mandibular prosthesis, despite the patient’s extreme progenic class three jaw relationship. Facial images reveal a very satisfied patient despite her challenging treatment and unfortunate dental experiences. Having enjoyed such success for the results with TRINIA prosthesis with short or ultrashort implants, I can now say, less is more! And, with this, I would like to thank you for your attention. If you should have any questions for the lab technical work, please contact Paolo Perpetuini who did all the lab technical work you saw in my lecture. And, if you have other questions, please do not hesitate to contact me by my mail account. Thank you very much for listening.