Prof. Andrea Cicconetti, MD, DMD, PhD
Associate Professor, Sapienza University, Rome
Good morning. Really, we are very honored to speak here today because what I say is what I want to report is the our experience after twenty years with short implant in the universities of Rome. And really, this type of implant, this type of design changes totally what they make before. And at the end of the presentation, I try to propose a classification for the atrophies. And I think that this is the way for the solution of all these type of atrophies. Because in the university, I see a lot of strange things because a lot of colleagues makes this type of surgery, but this is nonsense. It’s not logical. But I think this is only the mechanistic mode to see implantology. And so we see yesterday or today, this is the right way because this is a patient after ten years, and and they have to care only without problem. And we think that Bicon implant is really a biomimetic implants. So biomimetics means that the physiology, the implant meets physiology. And the TRINIA, so as Esteban says, meets the physiology of the bone. And this is the key factor for the good and modern implantology with short implant. Because we have a lot of problems in the literature, in evidence. Because in implant dentistry we have the three hundred most cited articles are only case series and cohort studies. So really, in the evidence of the medicine, we don’t have really the evidence. And we have, I think, a lot of marketing about culture. The market is a culture, I say it’s a culture of the brochure. Because we have a lot of opinions, but not really evidence in implantology. And so we see a lot of things, a lot of methods. But these lot of methods are, for my opinion, not so clinically proven and clinically good. So we have to return to the principle, biological principle. And so we cannot see these things. Or we have editorial too. They say that implantology is practiced with over treatment, and we can see our patients. We receive this type of patients. We receive this type of patients without nothing about design. We see here the colleagues don’t look about design. Design is nothing for him. And we see in the university this type of patient, I think in other university too, near the eyes. That is nonsense, totally nonsense. And we have zygoma of the, on the zygoma, the implants, sinusitis, or floor of the, nasal floor perforation, and these type of cases. And we see that in this type of cases, we cannot see nothing about the sign. But the key factor is really design of the patient. This is a lot of cases that we have, and they are so treated. And we make in these patients a resolution of this type of rehabilitation, and we insert only for ultrashort implant more than ten years ago. And then these patients go as a carcinoma of the renal pharyngeal carcinoma and go to the radiotherapy, chemotherapy, and so on. But after eight years, returned to us, and this was the situation. The gingiva, the soft tissue are better, very good, without bleeding, without nothing. And we can see that this is the situation clinically okay in a patient with xerostomia. This is the TRINIA bar. This is the situation without TRINIA. And we can see here that we have a corticalization. So we understand, really, that this is a good sign we have in all the implants, but in particular here, this is a dynamic interplay for the bone with the implant. And we can help this type of interplay only when we have first principles, and the first is the biocompatibility of the surface, but we have to form the cement line because we can study the biocompatibility in the cells of the osteoblast cells. We can see when we have cells on the calcium phosphate, they have an enlightening of the osteogenic hub. And so we know that these cells can promote the formation of bone, but really is very important that when we make the hole for the implant, we have not to screw an implant in the hole because we have the necessity to have the contact of osteogenesis with the formation of the cement line. The cement line is the translation of the biomechanical forces from the prosthesis to the bone. So when we have the cement line, we have the possibility to speak. The implant speak Italian and the bone speak Italian. In the screw implant, the bone speak German and the implant speak Italian. So cannot match the needs for the biomechanical forces. So it’s impossible to have short implant with screw implant. And they have another type of osseointegration. This osseointegration is distance osteogenesis, and the cement line is not on the implant, but is on the other part on the other part of the bone. So we have not this histological structure, and this is mechanotransduction from the implant to the rest of the bone. So we can begin really interplay from the implant to the bone. The other principle is the second principle is not screwing the implant in the bone because we have here so difficult cases and illogical cases, and then have to think about 4 per 18 Newton, but it’s not necessary. Because when we screw a implant in the bone, we have ischemia around the bone with a necrosis of the peri implant bone, And so we have a contact osteogenesis. So we have osteocyte necrosis and extensive bone remodeling without cement line. So we have not the translation from the implant for the of the implant to the bone. And so we have two type of osseointegration. One type is the screw implant. We can see here we don’t have vascularization around the implant. And without vascularization, we don’t have Haversian bone. And when we don’t have a right remodeling about the implant. And Albrektsson says that we have a absorbed IgG and foreign body reaction. When we have another design with healing chamber with calcium phosphate, we have an activation of type of cells M2 macrophage, and they attenuate the inflammation. And so we have a right integration, right osseointegration with short implant with healing chamber. And so we can say that one is a bioinert implant and that another is a bioactive implant. And all is for the design. And when implantology don’t know this, I don’t know how they can they can make the profession. And so we can see in the in the implant, we have appositional bone, and this is really different as the Haversian bone that we have in Bicon implant. We have the cement line and these structures, these are osteons, and then they have the possibility to respond to the first, the law of the of the bone. The law of the bone are Frost’s Law and Wolff’s Law. And Frost’s Law and Wolff’s Law can function principally with osteonal bone. In the other implant, we have a dysfunctional remodeling because we don’t have cement line and we don’t have osteocytes. And so we cannot speak about short implant screw with short implant. And then the third principle is that the bone is really a dynamic tissue, and we have to understand the complexity of the bone. And the bone is not only the one, the two, the three. This is not only the mineral part of the bone. And the bone really function with these things, bone cells, collagen fibers and biological apatite. And we have the necessity to understand this so we can insert a design that can function and interplay with the bone. And it’s not only the independent mineral density. This mineral density is the passive part of the bone, and the all the cells are the functional part of the bone. And so we know that every teeth have an optimal strain and burial bend. And so when we insert an implant in an area, we have the necessity to know this. And we see that this is for all the mandible. We have works about this. And we say, and the estimate says because before that we have a flexor of the mandible, a flexor of the maxilla. And we have to respect this type of functioning of the maxilla and the mandible. Because when we don’t respect it with a prosthetic material or long implant, we have crestal bone loss because we have a contrast from elastic properties of prosthesis or of the implant when we are more long and so have a crestal reduction, crestal restructure. We know that on the mandible, we have the same and in maxilla the same. And the fourth principle is the absence of microgap and micromovements. We know this from a lot of years. This is important. The other implant system make conometric, but it’s not the real conometric because the literature says that they have a limit precision limit during production. The only implant is a Bicon implant, this 1.5° Morse taper, and really a large contact, so we have really a fusion and a locking taper. And other new things that we can say that in the soft tissue, we have structures, and the soft tissue is the part that is attached to the hemispherical base. And these hemidesmosomes are really important because the new article says this, that the hemidesmosome is a specialization of the lamina, basal lamina, and they have filaments that goes to the abutment, and filaments, they they goes to the collagen structure under the implant, under the the metallic part. And this has the possibility to translate translate through hemidesmosome the function of the button, the function of the teeth. And we say that this hemidesmosome that are attached to the hemispherical base can organize the ECM, the extracellular matrix, under the epithelial structure of the teeth. This is very important. So we have two things. We have the cement line that speaks with bone, and we have hemidesmosomes that speaks with the collagen structure around the hemispherical base. And we make an article, and we see that around the implant, we have this organization of collagen fibers. It’s actually comprehensive organizations. But we see that where perpendicular fibers, they goes directly on the bone. But the Bicon implant has a model, crestal model, with a lot of bone in the apical part, in the coronal part. And so we know that these fibers goes directly on the perioste here. And when the teeth function, we have attraction on the periosteum, and the periosteum give the possibility to have the bone gain. So we see that after four months, we have an organization. After thirteen years, we have a better organization. So we have a greater organization of the collagen fibers when all is an interplay, all is dynamic, all is not static. This is very important for a successful implant. And we can see here the collagen fibers. And after thirteen years are so collected. And this is the reason because we have health, health without hygiene, professional hygiene without nothing. The implant has the capacity to this dynamic interplay with the bone and with the soft tissue. And this is then the explanation because we have bone gain. And these are article from ten years ago and the specialization of the osteocytes in the healing chamber. And this is one reason because, really, we can speak of short implant and success in short implant. And so we can revise the biological width. The biological width is a function. It’s not only a statical, anatomical things, but it’s a function of the implant, a function of the soft tissue. So we can explain because we have a corticalization here, and this is this dialogue that we have from the implant to the bone. The dialogue is represented from this corticalization. And the last is, explained it very well. And for me, I’m a surgeon, for me it’s simple. I can speak about anisotropic properties of TRINIA. And these anisotropic properties are what Esteban says, that the bone and TRINIA has the same elastic modulus. And this is important because we have to transmit the forces to the bone in a correct way from the abutment to the connection and to the to the implant and to the cement line and so on. And this is remodeling, continuous remodeling of this type of function in the bone and in the soft tissue. So these are articles displaying the function of TRINIA. And another point, I think this is very important, because we know from nineteen eighty five here that when we make anything to the our occlusal, our prosthesis, we have to not give restriction to the bone of the mouth, not to the mandible, not to the maxilla. Because this is really important because we know that when we breathe, we have a movement to the zygoma, movement in the maxilla, and in the septum of nasal septum and in the palatine bone. What make a lot of colleagues? They make implant in a zygoma, implant in the pterygoids, and then implant in the pterygoid, for example, block three bones. Three bones is the tuberosity of the maxilla, the pyramidal part of the palatine bone, and the pterygoid process of the sphenoid. That is not possible from an osteopathic medicine or from or for anatomic reasons. That is not a good, it’s not a choice. This is a iatrogenic choice. Only iatrogenic choice because when we have this problem with the implant, we have a alternative. We have other possibilities. Why? A zygoma implant. Why? And this interferes with the craniosacral rhythm. And we can see here, oral tissue must allow for complete freedom of motion. So the oral tissue can make problems to the craniosacral rhythm and to the liquid, the cephalorachidin liquid, and though the worst of the cephalorachidin liquid remain in the endemic, then we have the possibility to have Alzheimer and so on with our iatrogenic therapies of the mouth. And we can see it’s not only opinion, but we have a lot of articles, and they say that cranial osteopathic treatment modify the salivary the salivary markers as cortisol. So osteopathic treatment reduced cortisol in the salivary in the salivary, markers. And so it’s very important to know these things so we can make this type of rehabilitation. We have not so only technical mechanistic aspect, but rehabilitate the occlusal function in individualized way with short implant and TRINIA. So these are articles we have right in Sapienza. And so we can see a series of cases, Bicon, the technique we know all the techniques. So we insert only short implant, This is a patient after ten years. And these are patients after ten years. Always ultra short implant with TRINIA. And when this interplay begins, this is long lasting. And we see ten years after with prosthesis without problem, ten years without problem, ten years without problem. When we change, this was in the University of Cartagena, when we change the prosthesis, we have a problem with this elastic contrast. And then we make TRINIA, and that is the solution. Nothing problem. And then TRINIA Trio. I see now that the TRINIA Trio went for implants for TRINIA, And this is the future reduction of the dimension of the implant, the reduction of the number of the implant. And so is the article for Laura Murko, Mauro. And these are cases for the mandible. This was a patient with a lot of other surgery. She came in Sapienza. We make four implants in the symphysis. And this works with this extension since ten years. And the same other patients, the same other patients, this is anorexic patients with extension of TRINIA. The same, The same. The same. These are patients after ten years. So we have when we have complex cases, we have the possibility to make Khoury technique in the premaxilla and Khoury technique in the premaxilla and then the reconstruction, and then insert the implant in a local anesthesia in the Khoury technique and split in the premolar area and transcrestal sinus surgery in the the molar area in both parts. And then we have the possibility to insert over short implant with our technique with TRINIA, with telescopic connection, and the patients are here twelve years without problems twelve years without problems. So we can make these things with a standard technique. It’s not so difficult to see. It’s difficult we have to know but it’s possible to make in local anesthesia without difficulty. This is another patient with this reconstruction. This is nonsense reconstruction. A lot of implant. Removal all, we have the destruction of the man, of the maxilla. We study how we have the TC, and we see this is without bone. And the same. We make a transnasal here in front, a transcrestal in the molar part, and you utilize the tuberosity of the maxilla, both part. And so in the same, we have the resolution of this type of atrophy with the connection, telescopic connection, the work of Paolo, and this is eight years. Patient’s happy. And in the third classes, when we don’t make orthogonatics, TRINIA gives the possibility to make this solution. We have here a very important different from maxilla and mandible. We insert implants, so and the TRINIA. This is Sicily patient without nothing here, and she had implants. And we make this type of surgery. We have insert the implant near endodontic material, and the patients lost this implant. But TRINIA gives the possibility to make this extension. And this prosthesis work very good, but now we insert another implant. This is the versatility of the TRINIA. We have a locator now in this moment. The patient is very happy. And so the locator and this is standard. For us, it’s standard. So for implant in the maxilla, two and four when it’s possible in the mandible, and patients after always ten years. And this is the inspirational work of Prof. Ewers. And from Prof. Ewers, I learned a lot. And this the the beautiful thing is they’re utilizing of the of the nasopalatine duct. And when we have really the difficult atrophies, it’s possible to utilize this point. We can see another patient without nothing. We have only here a little quantity of bone. We insert the nasopalatine duct, and this is the solution. The patient is there, is very happy without zygoma, without the rigodeus implant. And so since twenty years, we utilize only always short implant for single implant, for big reconstruction, so with the other schools. And I think that the results are really, really good. And so we base it all to the the on what we say in this moment. So we utilize this biomimetic implant design. Bicon implant is really biomimetic. We respect the craniofacial biodynamism, so we don’t have contrast from the implant with the material, prosthesis material, and so we have simplified the procedures. So complex cases become standard cases. And we make this classification, and we think that with two types of mandible rehabilitation in the symphysis, and this type in six type here in the maxilla, we can resolve all the atrophies of the maxilla. And this is our experience. We have sixty five patients. We have statistically ninety eight percent of success. And really is a simplification, because before I make a lot of things, bone grafts, implants, but really are not necessary. And this is why I have to thank Vincent. And this is important, I think. Only that fish go with the flow. So Bicon is this, but I think that this is really the right way in my experience. I know that this is an experience for a lot of, Biconists. And, this is, the way for a minimally invasive technique and, really for happy patients. Thank you.