Short Implants: A Reliable Treatment Option?

Here we go. So, dear colleagues, wonderful afternoon. Thanks a lot to Bicon company and all the people arranging this for inviting me. Wonderful venue. So impressive, and the only thing I have to say, I’m lucky I don’t have to sing, which would be not so nice for you. We lost some of our colleagues to the wonderful weather of Ferrara, and I’m happy to speak in before more Vincent Morgan because otherwise, you don’t dare to leave. So wonderful Ferrara, wonderful city, but I have to talk about implants. What’s the issue today? And I’m coming out of daily practice, out of another research clinic, just a normal dentist. And it’s about efficiency, simplicity, all the other things, maybe I already addressed. So we learned that shorter is maybe better. Took a while, But also we learned that the short implants, the ultra short implants, give us some benefits. Here a case out of, I don’t know, maybe early 2000s, late 90s, and you see a difference, left side, right side, and you see how the short implants really changed our way of doing our surgery, or treating our patients. You see, the one side was big augmentation, lots of implants. We were not so sure about our procedures, and today, you see the development, short implants, other kind of restoration materials. So something has changed over the years. So our treatment options have changed, and certainly we do what the patient expects. We have to take a look at the literature, something we heard this morning so much. And I wanted to show some statistics too, a change in the lunch break to show a little bit something else, and with the computers it’s quite easy to do today. So, when we take a look at all our treatments, we cannot, though, we don’t do all our fancy stuff anymore. And I like to show you those pictures because we as surgeons, we are so proud of ourselves of performing whatever fancy stuff, nerve transposition, and all the augmentation procedures. But we saw that they could fail, but today we were talking so much about success rates. I don’t think success rate is the right figure to address. Because when you take a look at the long implant augmentation procedures, you always hear those ninety six, ninety five percent. So, people don’t change because it’s quite the same. We have to give them some additional benefit. And when we take a look at cases like this, where we’re coming here, sure, we could do some three-dimensional build up, but we didn’t. Actually, one of our first very successful ultrashort implant. But the question is not success rate, and that is something we have to address. It’s the complication rate. And that’s a much more important figure. This gives us less complication. Maybe it’s the same success, depends on the hands who’s doing it, but it’s the same, it’s another complication rate. And that’s totally two different things. I think that’s something we have to address in the future. And how did those short implants develop? This is something coming not out of implant dentistry, it’s from Rogers in the nineteen sixties. How does a new technology develop? Short implants, telephone, TV, whatever, there are first some innovators. And those innovators and we have to really thank those innovators because they have to face all the criticism. And we, as maybe the first adopters, we say, okay, we do this, and then after a while, this is coming into the in the mass production, let’s say it. And this is, I think, the point we are right now. So now we have to not face that it’s working. I think we can trust this, but now we apply it. So two different things. It’s working. Now comes the time where we apply it. And I will go into edentulous cases because that’s something where the problems are a little different from those single tooth. We see a lot about single tooth restoration. The single tooth on a Bicon is a wonderful system. But let’s look at the edentulous cases. Bigger cases. How do we treat them? We have different options, sure, removable, fixed, and different kind of materials to restore it. But we always were focusing on our surgery. And surgery is not what the patient sees, patient sees something like this. Full set of teeth, upper lower jaw, he’s not counting implants, he’s counting teeth. And the easiest way to get there is the best for him. So where did we start? Maybe not the right concept, depending on which view you’re having. As an implant company, I think that is a quite reasonable approach of treating those implants, those patients. You sell a lot of your fixtures. But we started with many implants, sinus floor procedures in the two thousand, but there nothing changed too much. Then, okay, we were rethinking. We have to treat this patient. So maybe make it easier, faster, then we started with those crooked implants, and it’s the same cycle of of, invention as with the short implants. At the beginning, everybody was throwing stones and eggs at the ones who presented something like this. Today, it’s state of the art. And then, we’re coming to where we are right now. Short implants, maybe six in the upper jaw because you’re not so sure, or at the time right now, we know our literature tells us that four ultra short implants are enough for the upper jaw. We can place something on it, whatever you want. So here they heal in. Question right now, all problems solved. And life is a beach, and nothing else to do, just to enjoy our lives. But then, and I don’t want to spoil the party here right now, we come to the final restorations. Okay? Oops. Right now, we have a little problem. Just as we might expect. So PowerPoint just wants to close. The first thing right now is to keep cool. Sorry? I don’t know. Oh, the other one. No. No. It wasn’t my office. Sorry about that. You saw that the girls might be, but I wasn’t. So just a second. I just gotta unplug this here. So by the time I reboot this, where I go on with my lecture, because actually, you don’t need too many too many pictures. The question is, where do we have those problems today? Do we have them in surgery, or do we have them in the final restoration? And when you look at the literature, and I will show this right away when I restart my computer, somehow, then you will see that our problems are definitely not in the surgery. It’s coming in the in the final restoration. And there we have to take a close look at. And here we go again. And if we are very lucky, we are back on track again. So first of all, that’s always what I talk to my girls when there’s something going wrong, is keep cool. So back again. So we have our four implants. Those two crowns will be lost soon. And we go through our procedures just as we learned from Vin. We place our TRINIA bridge. Okay. Four implants, a TRINIA bridge. And here you see we changed this, here we had to realign it. But after a while, this is how we send the patient home. Perfect. That’s it. Here you see the TRINIA. Vin will talk about us talk to us about this, and I don’t want to go into it. So, this is the final restoration. And I always like to see some pictures like this, and then I think implant therapy, it’s about prosthetics maintenance, repair. That’s something nobody talks about. Repair. Because when we go for prosthetics, have challenges, we have those big volumes. We have to think about fixed or removable. And the question is, cementation or screw retention, no tension on framework. Suddenly, we have to take care of this. And what’s coming out? What do we face? Let’s start with the first thing. You see, we have a wonderful bridge. We have this thing about cementation. Today was to talk about peri implantitis. A lot of peri implantitis is coming with cementation, with cement. Even in this wonderful bridge we said, you see, we had before, you see here the particles from the cementation. And then let’s take a look at the rest of the literature. And I always like to look at literature I don’t like because I can always find something that I like. Here’s something out of out of Belgium, and they’re telling us those big bridges, they have so much problems. After five years, ninety five percent are without chipping. So good. I don’t think so. This is not in my in my office. Totally different. Here you see another thing from the same group, by the way. They say, okay, that’s much more complications. And they count the chair time. We always say, okay, it can be repaired on the chair, but it takes a while, and that is cost. It’s an economic factor for something like this. So what do we face? We face bad hygiene. If this is fixed for all the time, you cannot clean this. We face chipping, and chipping is this I don’t think that I have one ceramic bridge without chipping. I don’t think I have one. Then we have to face maybe a little bit of trouble in the laboratory, bad gluing here, something that’s maybe bad handling of the material, bad framework materials. That is what I have much more trouble in daily work than with the surgery. Totally different approach right now, where I take a look at the at the prosthetics. And here, that’s something that comes close to what I see in my clinic. Eight percent of all restorations are without complications after a while. So repair is something we have to take a look at. We cannot just say our implants are healing in, and that’s it, and leave the prosthodontist alone. That’s the most problem. Why does this happen? People have occlusion problems. We know this for years, it didn’t change. We know that the mechanosensation, the bruxers, they just bite harder, doesn’t change, so we have to adapt to this. And when we make our frameworks, we have to be precise because when we are not precise, it will break. So when I take at my two, three cases I will show you right now, I take at different issues. I think about maintenance. Can I clean it? Can I avoid cement retention? Is it repairable, adjustable? Is it precise? Can I prove it by x-ray? And does it have a prosthetic workflow? I’m always talking to Vincent that jiggling is not something precise. I need something for my dentist that go from step a to step zed, and then it’s fitting. And that is missing sometimes. So I like the CAD/CAM things because they are right up to date. I like screw retained because I can remove it easily. Also, removing it without having to hammer because hammering down something is not, how you call it? This has not the definitive way of working. And I like to have it repeatable, so every step can be repeated by anyone. Okay. We know those pictures, or those films, they look fascinating. Actually, the only thing that we should take a look at is it’s so precise. So nothing like, oh, a little bit here, little bit there. It’s precise. It’s fitting passively on our model, so we have to take care of this model. That’s the problem. Actually, it makes you it makes you wonder how to achieve it. So we have to bridge those big distances. And now just take a look at a couple of cases, and I will go on like this till Mauro will tear me down here. Again, ultra short implants. Four of them. And in this case, this patient didn’t have much money. We’ve just played some very, very easy prosthetic work on it. Some ball attachment. But when you see the ball attachment, for me, it’s something that’s not too bad. Let’s go through the way of thinking. Here you see our implants. That’s routine right now. But if you see this work, it’s maintainable, wonderful. Hygiene is no problem, no cement, adjustable, repairable, removable, repeatable. So, with this kind of bridge work, I know in the future, for me as a prosthodontist, this will not be a big problem. So I can live with this. Just follow my way of thinking. Let’s go to something more fancy. Something we like in Germany very much precision, milling, metal frameworks, just like yesterday in the factory. That’s something we love. So let’s take a look at this patient. You think that’s that’s a patient for something fixed? I don’t think so. We have to have the lip support, we have to bridge the distances. So in a case like this, I rather go for something removable. Better picture. Those are bar constructions. CAD/CAM milled. Both of those parts are milled in one piece, so it’s fitting wonderful. The patient has the feeling like a bridge, it’s very small, and they can remove it. So far so good. But how to produce this precision? That’s the problem. And here we have the trouble, and as Stefan Koenig already said, we have the trouble with our colleagues. Because for them, they are so used to their old ways. And we will come to this, why they are so used to it. Because not because the system is too simple. That’s not because it’s too simple, because it’s intuitive. You can do it by intuition. And any beginner does not do something by intuition, but it does something by the book, and that’s the problem. So take a look at a case like this. Again, you see I like always to have some final radiographs to check if everything’s fitting correctly. So I don’t even have to look at this bridge work from the beginning at the final stage. I just want to see the x-ray. And if you see a case like this, starting point, we go to different steps, lead a lot of models. Here you see the x-ray, so this is part one, but the final part is the more difficult one because this is was the patient much longer than this surgical phase. So we have our first copings here, our healing copings, and we make our first impression. That’s just how we learned it. And then I need another platform where to begin with. And here we do our try ins. That’s something very, very down to earth. But then, we need another kind of impression. We need some splinted impression. So we now choose our bar abutments, and that’s something that I like to do for my other colleagues, myself. So I choose the right abutments, and we prepare some kind of splinting for the second impression. And the next step is then placing those abutments, and right now, I hope my computer likes me. Yeah. It’s working. Here we go. And I just go a little bit farther because I’m maybe late. So those are the abutments, those bar abutments, and I place them myself. And then they stay in there forever. I don’t even touch them no more. And from this platform, we go for the final restorations. Right now, we can work just like the workflow that everybody of our colleagues is used to. Stefan showed that he does his own own abutments. I think we have them already. And then, to be precise, and I think that’s something that everybody knows, we splint those abutments in the patient’s mouth, so that we have no tension, very few resin, then we make some kind of, we take another impression, and I will stop here. And we have our final model. Here’s some pictures in between that I don’t need because the computer just fall down. So we have this impression, and we have our master model. And then this master model, which is precise, we start going in the in the computer and preparing all our bridge work. And this is coming back very precise. Here it has to fit tightly, and it’s a wonderful kind of work because this is milled in one piece, so no different metals, only titanium. Working beautiful. So we go into the patient’s mouth, and again I’m sorry I removed those pictures before, but the down booted computer just gave them back to me. But here you see something out of the laboratory. And this is actually our most used product right now for our patients, for our elderly patients. And this is in the patient’s mouth, and maybe I can show you still a little bit here. This is the way we put it, and it’s right now easy to put it because we can use our screwdrivers again, and we don’t have to hammer something, and we can always remove it, repair it, hygiene it. It’s something for the next twenty years to work, and that’s the important thing. It’s not it’s repairable, repeatable. That’s what I like to see. And let’s stop here with the with the removable things. I just have to hop over because this rebooted version didn’t do the way I like to have it, so I have to spare you some of the pictures. So we go to the final restorations, and we do the same for our for our fixed restorations. So we go through the same steps, and you see this is a case that we did the regular way. And just our implants impression, and this is our TRINIA bridge. And you will see in the patient’s mouth, we already have when we removed it, and it was we removed also some of the abutments. And if I remove some of the abutments, nobody else but me can place them back. So and my time is precious. That’s the problem. My time is precious. And I’m maybe not available, So somebody else has to do it. And you see here, this is a nice guy, but his hygiene is below average, let’s say. And I cannot easily handle this. I cannot easily hygiene it. It looks perfect at the moment, but I’m not so sure about this. It’s a wonderful nice guy. By the way, he’s from from Belgium. And this is our final bridge work. Looks good, but I’m not so happy because I cannot give it to somebody else. Only me. And I don’t like it. So right now, we do the same as we did before with our removable things. Here are our four implants. That’s standard procedure right now. But we go through our motions, do our splinting, and prepare some removable, some screw retained bridge. And here you go from the beginning, all the steps. Here, you all I already have placed the the the bar abutments. They stay in the patient’s mouth, never be moved again. And this is the final bridge work. This is titanium, and this can be serviced just the way I like it. Maybe I’m thinking wrongly. I can also check, is it precise? Does it fit? That’s the things I like to see. This is done by my very young assistant doctor. He just followed all the rules. And something good came out of it. And the same thing for the same thing for the lower jaw here with our four implants here. And we did the same with the TRINIA. You can also use the TRINIA for this. Screw retained, all the same motions. It’s always a workflow. And you will ask myself, why do I emphasize those workflows so much? And we will come to this in a second. Here you see the final final result, always x rays. I want to see if everything is fitting. That’s repeatable. I can really have a good prosthetic workflow, and I can check it. I can really check it. And here’s something. This is so called Dreyfus model. The Dreyfus model of learning has nothing to do with implant dentistry. It’s about ping pong, tennis, whatever you want to do. But in the beginning, the people don’t work by intuition. They work by the book, by step one to step two. It’s just like cooking. If I ask my mother how she cooks this wonderful cake, she says, take a little bit of this, take a little bit of this, and take a little bit of that. You think I can make it? No way. If I have a recipe, twenty gram of this, twenty gram of this, it’s working. And this next thing is everybody wants to be an expert. And also, that is something that we don’t like. No matter what we want to do, not everybody of us is becoming an expert. It’s not possible. So this intuition is the problem. And coming to my final slide, we we could think that Vincent, Mauro, they are out of work. But if we go into the mass production, there’s something happening to also whatever kind of technology. We have a big amount of expectations. Also, companies will come into this market for short implants. And by the time many, many unexperienced people use it, there will be some kind of disillusionment. And therefore, we need Vincent and Mr. Mauro to get us through this this little ditch and make it a system, the short the ultrashort implants that is usable for generations. So also in our clinic, it’s just teamwork, nothing only done by myself. And here are some pictures of my also some old city Lüneburg where I’m coming from, and I’d like to thank you so much for your attention. Thank you so much. Thanks a lot.