SHORT® Implants: The Key to Grow Your Implant Practice – Dr. Drauseo Speratti

Hello and welcome from a cold night in Boston, Massachusetts. My name is Drauseo Speratti, and I’ll be glad to share a little of our experience with all of you about short implants and the key to growing your implant practice. I am a professor at Midwestern University. And interesting enough, Midwestern University has a unique program, dental implant program, where dental students actually place implants in patients. This is our multi specialty clinic for you to see where the dental, the clinic of the dental school is located. We occupy two floors there. And this is how we place implants with dental students. It’s undergraduate dental students, not postgrad, not specialty. It’s third and fourth year dental students that place and restore implants. This is just a view of our campus that I took picture last week when I was there. But this unique dental school program allows the students from the third and fourth year to place and restore implants as part of their curriculum. We average about eight fifty implants placed every year there with the dental students and the students do most of the procedure. You know, I’m there to supervise make sure everything goes well. I do the pilot drill very often. But the students do the entire procedure beginning to the end. These students they restore single crowns, bridges and full arches with TRINIA restoration is going to learn what it is today if you haven’t learned yet, and implant supported overdentures. After graduation, most students feel comfortable placing and restoring dental implants as they enter their practices. From this work we do at the university, we already have two articles presented at AADOCR last year in twenty twenty five in New York. We also have our articles submitted for publication in a scientific journal waiting for approval and to be published as well. We also have a presentation approved for this coming March in San Diego at IADR meeting, International Association for Dental Research, all showing the incredible data that we have from these implants placed since twenty eighteen at Midwestern University in our successful implant program. The success rates for this program at Midwestern is higher than industry standards. So we have a very, very high success rate, and we are very proud of it. Students have a unique experience during the dental school. If you think about when you went to dental school, if you have opportunity to actually place implants in patients, and this is open for all the students, not just a select group. But now let’s talk about short implants. And everything you’re gonna see in this presentation, all the procedures, all the cases you see, these students also do at Midwest University just for you to understand. That’s why it’s important and the simplicity of this short implants that we’re talking today for you bringing this simplicity and these techniques to your private practice. We will increase your implant practice quite a bit in a simple, safe way. But clinicians, when they think about using short implants, very often is a very common answer. They think about using short implants when there is limited bone availability. That’s the first step that most clinicians think about it. So in cases like this, have about seven millimeters of bone availability. So what can we do there? What situation we do? The only option is usually a short implant. So people still do lateralization of the nerve, which is kind of risky and very high chances to create paresthesia, permanent paresthesia to the patient. But the best and safest way is always using a short implant for a limited case like that. But can we use short implants even when bone availability is not an issue? The answer is yes. Of course, you can. We can use short implants anywhere. Doesn’t have to be necessary only when you have a very limited bone. Short implants can be used if you have plenty of bone. I personally use short implants everywhere. I only use short implants actually for no matter how much bone availability the patient has, I only use a short implant. Usually, implants I use is six millimeter longer for no matter how much bone I have. I was not trained initially this way. I was trained traditional method using screw type implants and placing twelve, fourteen millimeter long implants. But now after twenty five years exclusively using short implants, of course, I can say that I do that with total relaxation, placing those implants without any concerns whatsoever. But what is considered a short implant? Well, according to the European Association of Dental Implantologists, there’s a consensus done in twenty sixteen, a short implant is an implant with less than eight millimeters long, and an ultra short implant is six millimeters or shorter. The implants I place, I’ve been placing for twenty five years, they are usually six and five millimeters long. Okay, those are the majority of implants I place in the practice, in private practice, but also at university with the students. But one thing is very important to make sure you guys understand is that are all short implants the same? No, they are not. They are different. So a short implant, to be successful, it must be designed to be short. We cannot just have a traditional implant design like a traditional threaded implant design, eleven millimeters long and cut it and shortened and manufactured in six millimeters length. That doesn’t work. An implant has to be designed to be a short implant. And this is the implant we use. Taper plateau root form design, one point five degree locking taper connection between the abutment and the implant. I’m gonna explain to you very soon what this is what this is. And this locking taper connection provide us a bacterial seal connection. So there’s no bacteria in the connection between the implant and the abutment. And these implants are designed to be placed subcrestal, so we place the implant slightly below the crestal portion of the bone. Now going back to the design you’re more familiar with, we’re talking about the sloping shoulders, the plateau taper design, and here is the locking taper connection. The connection between the abutment and the implant. This is a one point five degree taper between the abutment and implant, allowing when we tap this abutment in, it locks in place, implant and abutment become one single piece. But what is the importance about these sloping shoulders? One of the many important things is the fact that when implant is in function, majority of the forces that occur over implants occurs right here at the crestal portion of the implant. Having the sloping shoulders, it helps dissipate the forces throughout the entire body of the implant, avoiding the higher concentration of forces at the crestal portion. This is one of the reasons the majority of screw type implants lose bone. And locking taper connection provides a bacterial seal connection inside between the implant and the abutment. What does that mean for us clinically? It means that if you have to remove this abutment after being there for a year, maybe two months, six months, three months, five years, you take the abutment out and there is no odor, there is no bad smell. Those of you that restore implants know very well that if you remove a screw that connects the abutment to the implants after being in the patient’s mouth for maybe a month, three months, a year, that screw has a bad odor because there’s bacteria in there showing that it’s not a bacterial seal connection. So here you can see the features of the system not in graphic, the hemispherical base of the abutments is also helps to stimulate the bone around here. So keeping the bone in shape. Combination of all these design features allows these implants not to lose bone over time. If you took implant courses before, you probably probably learned that it’s very common to lose one millimeter of bone a year or so throughout the life of the implant. That’s not common with this design. Usually, you don’t lose any bone at all. In certain cases, according to our research and shoulder research proving that, you gain bone in certain cases. But how reliable are they? Let’s check. Let’s check the literature. Let’s check the facts. These implants are available since nineteen eighty five. There has been forty years of clinical use. So there’s nothing new. It’s not something that started the other day or a launch new design five years ago, two years ago or this year. No, it has been the exact same design for forty years. If you have a patient tomorrow in your practice with this implant placed in nineteen eighty five, the components for you to restore these implants will be exactly the same components of implant placed three months ago. So that tells you a lot. That means that they don’t have to keep changing the design to improve it. Many other companies, you see, they always change design after five, four, five, four or five, six years. Oh, this is a better design. The other one doesn’t work anymore, you know. So you have a patient replace those implants and in part sometimes it’s difficult to find. This one, no, is the same parts, the same concept since nineteen eighty five. He designed these implants. But among other things, he had over two thousand patents under his name. So imagine creating over two thousand things that nobody had thought about. So let me show some of the inventions he had. One of them that probably most people know is the exterior lighting from Empire State Building. Inspired before his invention, if you look at the lightning, you always see the bulb and just a bulb to provide lights. But he create this special lightning. We don’t see the bulb. We just see the illumination. This is very common now you see everywhere. But he was the one that actually invented and created that. Other amazing invention he did is for those of you that are pilots or even if you’re just a passenger, just look next to the runway for any major airport in the world. You always see this set of lights here. This set of lights is called the visual approach slope indicator, tells the pilots if it’s too low or too high to land the airplane. He’s the one that invented as well, along with the navigation lighting for the Panama Canal. So clearly, he was extremely bright. And he also invented a locking taper implant system because in his mind, he knew that screws don’t work for implants. One screw will always come loose, no matter what, it’s just a matter of time. So he designed this incredible implant system with incredible geometry with all these features, as I showed before, including sloping shoulders, plateaus and fins design, bacterial seal connection, and the three sixty degrees of universal abutment position. You don’t have a hex limitation. You can rotate the abutment any position you want until you select the proper position, you tap in place, and locks in place. Interesting enough, for this design, the plateaus and fins, imagine this situation. You have a traditional design implant and plateau design implant. We apply the same lateral force to both implants. This force has to be dissipated to the adjacent bone. This implant’s traditional design, because of the design itself, majority of the forces will occur right here at the crestal portion of the bone. There’s too much force. The bone doesn’t like that. What happens when the bone receives too much force? It resorbs. So the forces will be concentrated here and a little bit down here. These blue rectangles you see are not doing anything to dissipate this force to the adjacent bone. Differently, a plateau taper design and sloping shoulder design are receiving the same force. The tendency is also to rotate like this one. However, it provides force dissipation throughout the entire surface of the implant, dissipating the force to the adjacent bone. So you don’t have one specific location with a huge concentration of forces creating bone loss. So that’s one of the reasons these implants don’t lose bone. So this is the plateau taper design. It provides a better bone quality, more surface area, better distribution of stresses, and this is all done by publications. Okay. You don’t have to believe one on ten, it’s all done in publications. Now let’s talk a little bit about osteoclasts and osteoblasts activity. Most of us know that when you have osteoclasts, you have bone resorption. And when you have osteoblasts, you have bone formation. So most dental implants, when you put it in, you create a torque. When the bone receives pressure, it creates an osteoclastic activity activity to resorb bone. When the bone receives the proper stimulation, we have osteoblast activities that produces bone. So when you place a screw type implant like this, you, those of you that already placed the screw type implants, you know that you have to under prep the osteotomy. So prepare the osteotomy in a smaller diameter than implant you intend to place, and then you screw the implant into the bone. When you do the screw when do screw the implant into the bone, creates a pressure to the bone, therefore creating an osteoclastic activity. After a few weeks, you start having a bone formation with a position of bone formation to heal the implant and create the osseointegration. The implant also integrates, yes, but you have appositional bone formation around the threads. Differently for this plateau design implant, the diameter of the implant is the exact diameter of the last reamer you prepared the osteotomy, not under. So you place the implant on the exact diameter. No torquing because these are not threads. Just push the implant into place. Allow the blood to fill the voids and form bone. So you have a much stronger osseointegration, having Haversian bone all around the fins. So you have a fantastic osseointegration around these implants. This is another interesting feature that connection of these implants have differently than the screw type implants, as you can see here. This was done by Dr. Zipprich, as you can see there. And on this video here, Dr. Zipprich says, shows you that when you apply force to the implants abutment connection, to a screw implant abutment connection, no matter how torque you use, the proper torque you do, will create motion as you saw in the video differently than you have an implant system without a gap like this. There is no space. There is no motion. So for zero newton, there is no motion. If you apply two hundred newton, the result is the same. There is no micro motion between the abutment shaft and the implant well. So that’s another reason there is no space for any bacteria to get into that area. Because of this bacterial cell connection and implant placement below the crestal portion of the bone, when you take an abutment out that’s been there for a while, you have a beautiful sulcus like this, always nice and healthy sulcus. Okay? And if you take an abutment that’s been there for a while, you see something unique. It’s called the petechial bleeding, because it shows the intimate contact between the abutment, hemispherical base of the abutment, and the soft tissue. To prove that, we did that study. We we presented at IADR, International Association for Dental Research, in two thousand and five in Baltimore, showing this intimate contact. Those of you that are placing implants and restoring implants is very, you know, that’s a very common procedure to simply call the patient back six months later, a year later or so, go with a perio probe and probe the area. Very often you can probe directly all the way down to the implants because you have a little pocket in there. You won’t be able to that with these implants because the soft tissue is very attached to the abutment, titanium, and the spherical base of the titanium abutment. So if you push it, you’re gonna hurt. So the implant is nice and protected, which is in contact with the oral environment, is part of the abutment and the crown, most likely the crown. Now talking about the connection, you have that bacterial cell connection. There are many researchers proving that, like this one done in University of Illinois in Chicago, Harvard, and a Harvard dental school, proving that this disconnection is too small for any bacteria to pass it through it. Even if select the smallest bacteria we know of, the bacteria cannot pass through disconnection. Analogy that I always use to make people understand that is, you know, it’s kind of hard to see bacteria. It’s always think about microscopic level. But the analogy is try to put an adult elephant inside your car. So as you know, it’s impossible because the elephant is too big. The bacteria here is the elephant, your car is this little connection there. Another study showing improving the bacterial cell connection of this implant system was published. Again, as I told you, have several publications to show that. So this bacterial cell connection and the connection with the soft tissue around the abutments shows no inflammation around the soft tissue when you take an abutment out after being in mouth for seventeen years or ten years, as you can see on these pictures. This is all because of the locking taper self locking conus, as you see on this graphic. So there is no space here. Once you tap it, abutment and implants become one single piece, also called cold welding. So short and ultrashort implants can be restored as though they were a post and core restoration for natural teeth. So how difficult, you know, to restore implants could be a little difficult? No. It could be extremely simple. There are many ways of doing it, but one way is similar to a post and cord restoration over natural tooth. Using these non shouldered abutments, they are available since nineteen eighty five. They come in zero, fifteen, and some of them in twenty five degrees. You can just select the ideal abutment for the case, tap into place, and you’ve decided you can prep the abutment similar to a prep a tooth any way you want. You can make a shoulder, you can put your initials on, you can prep any way you desire using a carbide bur and irrigation if prepped intraorally. But it would be nice. Sometimes it’s difficult to prep intraorally. With these abutments, you can do the prep outside the mouth extra orally. It would be nice if you could that could do that with natural teeth. Correct? Extract the tooth, prep it, and put it back in the mouth is easy to see. But of course, we can’t. But with implants, we can. So you can prep it, the abutment, the shape you want, usually is a shoulder margin, and tap the abutment in. Once you tap the abutment in, just treat it as if it were a natural tooth, similar to a post and core. Take an impression, send the impression to the lab. The lab, you pour the model, make the crown for you, that’s a PFM for you to see it, and you cement it, put Vaseline around the margins. And it’s a very good trick for you to prevent the cement to going under the gingiva, is to put a little piece of a dental dam under the abutment. So you put the abutment, punch a hole on the dental dam, put over and put the abutment in, tap the abutment in, and cement the crown into place. So the dental dam or the rubber dam prevents the cement to go subgingivally. So you could go ahead and clean up the cement easily, supragingival because there’s no cement, subgentually. It’s a nice way to do it. This, you have a final restoration there. Why would you use a short implant if I could place a longer implant? That’s a very common question. Well, I have twenty millimeters of bone. Why would you place a short implant then? You know, it’s a waste of bone. Actually, it’s not because you have the simplicity of placing a short implant. Okay? Look at that. Short implants provide less risks, provides less advanced skills required because you drill much less than you have to drill for longer implants. It provides less time, so we can do the procedure quicker. Usually, average placement in private practice is fifteen minutes. So it’s a very quick procedure and very beneficial and very profitable. Less costs for you and for the patient, less discomfort. Our patients usually they take maybe one ibuprofen, one acetaminophen on the day off, and next day, they don’t take anything. So most patients have very, very comfortable post op because you drill less, you’re doing slow speed as you’re gonna see very soon, and is much more conservative procedure than a traditional screw time. There’s no pressure on the bone for you to put a screw implant in. Also requires provides fewer ridge augmentations and fewer complications. All this combined allow us to have a greater patient acceptance. So it’s a great way to provide more treatment, easy for you to sell your treatment plan for your patients just showing all these benefits that short implants can provide. So short and ultra short implants can be used in different bone heights. They are they are a solution for many, many clinical situations, as you can see, as we’re going see right now. Look at this case. We have plenty of bone height, correct? Menumental, plenty of bone height. But which implants would you rather place? Which implant offer less risks? This or this one? Okay, patients aren’t aware of what it is. But for you as a clinician, this is much easier. You go in, it doesn’t have to go all that. You just drill six, eight millimeters instead of fourteen, fifteen. Another example, good bone availability, but you could place a lower implant. Definitely you could. But there’s no need. It’s an unnecessary risk. Why you risk going closer to the IAN if a six-five hundred meter implant can’t take care of business? You don’t have to. Look at the bone in between the implants. So there’s no need for that. Or in this case, that’s the simplest option to avoid inferior alveolar nerve. If a patient comes to your practice and you have this amount of bone, that’s this proximity to the IAN, how are going to treat this patient? What are going to offer to this patient? Think about it. You’re going to most likely, you do a partial, Right? Removal partial. Not all the patients want that, but there’s an option. That’s the only option. But it’s not the only option. You can have a short implant placed, and patient has fixed restorations and chew anything they want similar to natural teeth. You’ll be the hero of this patient. Of course, I’m not advocating for you the first case, do a case like that because it’s very challenging, but is an option for you and your patients to do. And those of you who might be concerned about, well, but look at the size of these crowns and how long this is in place. Well, this is in place for eleven years. That’s eleven years post op of this radiograph. And like cases like that, there are many of them. So this solution for you to see, these implants can be a solution for many clinical cases. Look at the situation here, Very tight spot. You place a short implant in between the areas. And that’s the restoration and that’s the aesthetics. It’s very common for the orthodontist to move the roots, I mean, move the crowns and not move the roots. Another interesting case, this is case by Dr. John Morgan, oral surgeon, fantastic, and he placed this implant. Patient, you don’t want to take this tooth out. That’s a canine in a bowel. Place that and restore, no issues, no problems whatsoever. You can use narrow implants to have four single lower incisors. Do you have to make single units? No, you can have two and make a bridge, that’s fine. But if you want a single unit, you can do it, you can deliver it. The patient wants single units, the patient wants to floss, you can provide that to the patient, allowing bone, allowing the space here between the implants. You can have a long crown implant ratio like on these cases without any issues, without any concerns about how successful the implants will be. This is a case done by our colleague, Professor Dr. Rolf Ewers from Vienna, Austria. He had this patient with this case with very little bone, as you can see here. He had a perforation of the sinus there. So he went back and tried to place the implant again. And he did place a five meter long implant. Then he restored his implant, as you can see, a few months later, about six months later, look at the crown implantation. And he thought, well, let’s see what happens. But what happens is the implant is fantastic. It’s been seven years, almost seven years, and the bone is good, the crown is good, the patient is happy, everybody’s happy there. So you can do that with the Scharn implants. Or another case from Dr. Ewers, when you have a very atrophic ridge, look how atrophic this mandible is. He placed five millimeters long implants. Has been there for years. As you can see, the CBCT, no bone loss, no issues. The patient is chewing on a fixed prosthesis without any problems. As a case by our colleague, Professor Marincola from Italy. Another example, again, I’m not advocating for you guys to do that to place this implants with a very challenging case very close to the IAN. But this is at the procedure. The patient doesn’t have paresthesia, of course. You can see here on the CBCT is not actually touching the nerve. It’s very close. But if you don’t have a short implant, you can treat this patient for implants. That is very difficult situation to do it unless you do a lateralization, as I told you, but could be very dangerous. Interesting case by Dr. Milman from Texas. Patient has this broken implant. He placed a five by five implant and said, well, how the bone is going to last? Well, the bone actually improved. As you can see here, over time, the bone has been improving. Another situation where the short implant worked beautifully well. This is for adolescents. Some people place implants in adolescents. And you this case, the patient was fifteen years old when they placed this implant. As you can see here, the implant was placed. Time goes by, patient starts to grow, right? Well, no, it starts to grow, continue to grow, I should say. This is when the patient was twenty three years old in here and the crown was a little short. So what they did, they add material to the crown or depending on the material you make the crown, you can replace the crown. We just added and these aesthetics. This is the patient who is thirty seven years old. There is a study showing these techniques. This is published as well for you to see if you’re curious to understand how this technique works, you just can visit there. Another study done with these implants is on free fibula grafts. So this is a study done in Europe. Some surgeons when patients are extremely compromised, they use, they remove a piece of the fibula, place the implants in the fibula and then transport to the mouth, recreating a mandible there. So it was a is a multicenter fourteen year follow-up fibula vascular grafts of mandibles and maxilla restored with short and extra short implants. It’s incredible what it can do. Of course, this is beyond the general dentist or most people that place implants do. But it’s incredible what the potential of these short implants can do. This is fourteen year follow-up of internal sinus lift case. That’s the pre op implant placement two thousand and nine. Four years later, look how the bone is. And this is fourteen years later for you to see. But the bone stays the same. As I mentioned to you before, it’s very rare to have bone loss on these implants. So the bone stays the same. You can be very confident using these short implants in a variety of situations. This is a seven years follow-up. As you can see, similar case, internal sinus lift done. Look at the side, the crown implant ratio, huge. That’s seven years later, bone continues to be fine. Patient’s in function, crown is in function. Patient’s happy. Patient’s unaware that has that. Another example here is a six years post op. Look at the amount of bone we have. We have availability for longer implants. Do we need it? No, we don’t. A short implant takes care of the business. This is six years post op. Another example, we didn’t do a sinus lift. We were very close to the to the rest of portion of the the floor of the sinus without perforating the sinus, but this is a ten years post op. Look at the bone. Look at the crown. Everything looks fine. Another example, eight years post op. Again, you can place a longer implant, there is no need for that. Six millimeter takes care of business. I know emphasizing that a lot. But I personally, in practice here and also at university, ninety five percent of the cases I do is three implant sizes only. So it keeps the inventory easy for you to manage. I use a four by six, four point five by six and five by six. So ninety five percent of the cases I can do with the three implant sizes. Every now and then, mean, maybe a five millimeter short implant, like on this case, for example, or a six millimeter wide implant, for example, I can do it. I needed to do it for a molar, immediate placement for molar. But other than that, with these three sizes, most of the cases are solved. This interesting case I showed you in the beginning that amount of bone the patient had about seven million. This patient here, she was in several dental offices, nobody wants to see her because of the proximity to the IEM. And they offered to do a partial, but she didn’t want to. She wanted something fixed. So she came to us. We did a CBCT and look at it. We placed two five millimeter long implants, as you can see. We restore it, and that’s the restorations there without touching the nerve. The patient has no paresthesia. The patient is extremely happy with these two teeth there. So she can chew it. She can have fun. She can have a close to normal life. She was so happy that she came back for the other side. She had the same situation on the left side, and she came back, replaced implants on the left side as well. So these short implants, the ultra short implants, short implants have been available since nineteen eighty five, eighteen millimeters long implants. The ultra short implants we have, this, for example, the six by six available since two thousand and one. Then we have the ultra, all the ultra short shears, the six by five, the five by five, five by six, and four and a half by six, though they all come a little later than the six by six. And after that came the four by five and four by six. These previous implants that I mentioned, their indications for any tooth in dental arch can be replaced with them. Four by six, four by five, you can restore premolars and forward, premolars, canines, and incisors. And a three by six, four lower incisors or maybe maxillary laterals. Of course, this is you only use this if you have limited of bone limited availability of bone. You don’t wanna extract the canine, maxillary canine, and put a four by five. It doesn’t make any sense. For you to have an idea how small they are, that’s the actual picture of a four by five. But scary, very small. When I saw the first time, I also was kind of skeptical about it. Would they work or not? But they do work and work well. I’m very confident now placing these implants without any issues. Look at the situation. You have the foramen here, four by five implant there supporting a big crown, no issues whatsoever. Similar situation here. Look at that. This is three years post op. Then you come here for a five year post op, both cases, and a nine year post op for both cases. So they do work and they do work well, as you see it from that. Okay? Another example here for you to see, five years post op. And also, these implants, because of the design, provides long term aesthetics. This is a case where you have five years post op, look at the interdental papillae. Why you have papillae? Graft? No, it’s just because the sloping shoulder design allows the bone to be formed and to be kept above the implant here. Without the bone, there is no papillae. With bone, we have papillae. Okay, so this is what we have on this case. Another example, bone, papilla, as simple as that. We don’t do any specific procedure, anything differently. We just place the implant, follow the technique that you’re about to see it, and the final result is what you see here. Even in complex clinical situations, you have the same result. You have bone, you have a belly. Simple as that. This case, you have plenty of high availability, very little width. But you could place a lung implant. Yes, for sure, you could place a lung implant, especially here. But there’s no need. They take care of business and provide function and aesthetics, all because of this sloping shoulder design, and the design of the abutment supports the papillary. These implants can also be done used, as you saw some cases already for internal sinus lift procedures. We can we always do that with so it’s a much conservative one. Instead of doing lateral sinus lift, all that, we can do everything internally with this ultra short implant. So here you can see the patient doesn’t have much bone availability. We just do a sinus bump, and you have short implants, six millimeter length, lift to the sinus, implant there to be restored. Another example, not much bone in here. We drill about millimeter right to the crest, to the floor of the sinus, lift to the sinus, and place the implant, as you can see. There’s no time for us to explain all this technique, but maybe another opportunity to go over these advanced cases. Another example here with a sinus lift for you to see. And another one here, that’s the graph material right there. Retrograph evidence of this case is some of these cases, minimum bone there implants placed in two thousand and eight. This is May two thousand and nine for you to see it. And this is day of the crown insertion. This is one year post op all the bone in there without any issues. Another case, this is January twenty eleven, implant place twenty eleven, January twenty eleven. And this is already after restoration after being functioned is eighteen months later, you can see the nice bone around the implant fin. So you can do sinus lift with this implants without any issues. Another example here, thirteen years in function. Okay, so they do work and they do work well and they do increase the benefits you can provide your patients in our implant practice. This is a CBCT scan done by this case with eleven years of loading. Let’s learn how to use these implants. So these are surgical techniques, you can have the two stage, one stage, immediate stabilization and loading and guided surgery. For time reasons, we’re going to focus today on the two stages and one stage. So the two stage technique, we do this geometry preparation. So these are specific sites we use the first instrument we use is the pilot drill. So the pilot drill goes in and you have the markings six, eight, eleven, fourteen, the same for the other reamers. Pilot drill is the only one that rotates in high speed and requires external irrigation. Initially, regardless of the implant size you’re going to place, you drill to six millimeters only to verify your osteotomy using a paralleling pin. As you can see here, as you see in the clinic, you put a paralleling pin, check the direction among the adjacent teeth. And at this point, we always recommend taking a periapical radiograph so you can see and measure the distance you are from the IAN or from the sinus if that’s the case, or if the osteotomy is going through the center of the space and not going towards any adjacent teeth. After you confirm that you can go to the full depth, you still with a pilot drill. Most cases you go to eight millimeters. So the implants are placed two millimeters usually below the crestal portion of the bone. After finishing the pilot drill, we start using the latch reamers. The latch reamers, they rotate only at fifty RPM, and therefore they don’t need irrigation. Using these reamers at this speed, there’s no need for irrigation because there’s no heating of the bone. Another benefit of these reamers is that they are made of titanium alloy, and they perform over one hundred and fifty osteonomies. When you place an implant with other systems, you don’t take in consideration the cost of the burs you have to replace. These burs are almost never replaced. They last over one hundred and fifty perforations. Well, they last a long time for you and no irrigation needed. This is a sequence for placing a five by six implants. As you can see, the first lateral memory is two point five in diameter, followed by the three, three point five, and so on. So the increase in half a millimeter increments. And placing a five by six implant, the last one use is a five millimeter diameter, and the length will be for eight on this case. These reamer, besides all the features that drill and last too long, they also do something really interesting. They save the bone for us. So they harvest the bone you’re drilling. So you have like their autogenous bone for you to harvest without using any equipment, any device to save the bone. So you have there harvesting the bone one by one, and you save the bone on a silicone appendage that comes with a kit. Like so, not glass because the glass, you can chase the bone around. The silicone appendage is easy to squeeze and grab the bone that you have. After harvest the bone reduced osteotomy, the implant comes back to a small plastic bag, and you take from the bag and insert directly using the most precise tool we have at your disposal, your fingers. No torque drivers, no wrenches, you just put it in, and you can drive. Some people tap directly on the black healing plug. But most people do, the best way to do is probably remove the plug and tap directly inside the implant well. So this is assured implant is placed correctly without any issues, tap it in, the implant reaches the bottom of osteotomy, you put it back the plug and cut the plug flush with the bone, as you can see here. So this is covers is a cover screw, let’s say, cover screw, but it’s not exactly a cover screw because there’s no screws in there, but just to prevent the bone to grow inside the implant well. So remove the collagen plug, the the healing plug, back the bone that you harvest on top of the implant, unless you have some place that you need a graft to the graft. So you can use a patient’s autogenous bone for this grafting procedure. Otherwise, you cover the implant with the graft so the implant has a protective healing now, has blood and bone all around it to provide a fantastic osseointegration. After this, the radiograph is taken right after the placement. So after a few months, you uncover that implant and make a small incision just to expose the black healing plug, like so. Take the plug out using a healing plug removal tool, endo file, or even a soft tissue rongeur, whatever instrument you want, the instrument is easier to do it, to be honest. Take it out, put the guide pin in to check, verify the osseointegration, make sure the implant is solid, and usually is because I told you it has a very high success rate. And this point, you have many options. You can start a restoration on the same day we uncover the implant if you want, or you can just put a healing button there and let the soft tissue heal and come back a couple of weeks later to take impressions. Now let’s talk about the one stage technique. The one stage surgical technique is very similar to the two stages. The difference is a small variation at the end that you don’t suture the implant over, you just put a healing button on that. This is a pre op of the case. This patient is quite interesting because she has this tooth here that you can see is a beautiful color, right? Interesting color. But she loved the tooth. She didn’t want to change the tooth. She said, no, that’s my favorite tooth. It’s my unique tooth. Only I have a tooth this color. Anyways, she likes the tooth, so we can’t touch the tooth. But she has a missing tooth here. That’s where we’re placing with implants. So we make an incision, making a full thickness flap. Again, you can use any flap you want. People use tissue punches. I don’t like tissue punches personally. Nothing against who use who use them. If you like it, use it. I I just don’t like tissue punch. And I we have a love and hate relationship. It’s much more hate than love, to be honest. It doesn’t work well in my hands. I don’t like it, but that’s okay. And you can make a flap or a tissue punch. If you make a flap, you use a retraction suture on the palatal, so you don’t have to use any hands. You or the assistant don’t have to use any hands to retract the palatal tissue. You start with a pilot drill, as I showed you before, same thing, eleven hundred RPMs external irrigation, you go to six millimeters and then to the full depth. Once established a full position and depth, we start using the latch reamers, fifty RPMs, no irrigation needed, just increasing the diameter of the osteotomy to the final diameter, which in this case would be a four, as you see here. And that’s the variation from one stage in comparison to the two stage. You just use one size wider reamer that is implanted in tend to place to countersink the crestal portion of the bone here for just a couple of millimeters. This allows us to insert the implant and the abutment at the same time. We harvest the bone, insert the implant, remove the black healing plug, tap the implant into place, and then we tap the implant in. As you can see, let the tissue go and measure the soft tissue height to select the appropriate, in this case, scannable abutment height. Put the abutment in. Gentle tap so the abutment is seated inside the implant, suture back. We’ll let it heal. Once the tissue is settled, we can scan it and have the crown made. When the patient, when the implant is ready to be to be uncovered, we just take the abutment out and insert the crown into place. You’re going to see this soon. Now let’s talk about restorative options. But before I talk about restorative options, just a quick mention, these implants, you can also do guided surgery with these implants. And you can also do immediate load and immediate placement. You can extract the tooth and place the implant at the same time. Everything can be done with the system naturally when you do the others. This is an interesting case for restoration is a thirty two year restoration of the left maxillary canine. I didn’t do this case, somebody else did for the time reasons, obviously. But this tooth was extracted, the patient has lost a lot of bone, as you can see that a bone graft was done on the case on the site. Suture, this is after the bone is taken, they place an implant and uncover after a few months, of course, they uncover implants and insert a non shoulder abutment, as I showed you before. So this abutment is the same situation as a post and core, as I mentioned before, and they can be prepped. So they prep a shoulder on the buccal surface of the abutment, take an impression, then lab technicians pull the model and make the crown. So there’s the final restoration for you to see it. This is the radiograph. This is thirty five years later. Look at the bone. This is the insertion. This is thirty five years later. This is the radiograph I mean, the clinical picture thirty five years later. Fantastic, no bone loss, no issues whatsoever. Another way to restore these implants is use universal abutments. Universal abutments, they come with a pre machined shoulder. They can be scanned directly in the mouth, chair side, or you can take a conventional impression of them. It’s up to you. They come zero and fifteen degrees, like so. And this is the case. We uncovered an implant and placed an universal abutment there, six millimeter in diameter. That’s why you’re six in there. We go ahead and this is how a video showing how you insert the abutment, how simple it is for you to insert an abutment in place. You put it in and gentle tap about three times or so, and the abutment is seated. If you can scan it, if you don’t want to scan it, or if you can’t scan it for whatever reason, you can snap on a sleeve and take an indirect abutment left impression. So you just use the light body and the heavy body on the tray, like so. Once you take it out, this leaf will come out on the tray like that. And you can always put this as a healing cuff for you to do it, snap on it and let the tissue heal. Right? This is in this case, we did that. We took an impression, center of lab, the lab makes the crown. And a beautiful thing about this is you can you can do intraoral cementation and use the rubber dam or dental dam, as I showed before, or you can just take the abutment out and do the cementation extra orally. So we clean up the cement outside the patient’s mouth, which makes easier for everyone. Clean up the cement and insert both as one unit. The patient can just bite down to it. We don’t have to tap in place. If you as long as the patient has a crown mesial and distally to that tooth, you can the patient, they can just bite down and the crown is inserted. Simple as that. Okay? Another this is showing how to insert a crown. We call the simplicity of the insertion. You push it in like so. Check the contacts, make sure the contacts are fine. And Yep, and then gently tap into place. You can tap with that or can tap with a wooden tongue depressor as well. Break a piece and just go right on the occlusal surface of the crown. Now digital dentistry, we can do implant level scanning using scan posts. That’s another straightforward if you have a scanner in your office that has a bevel. These scan flags have a bevel, you always put to the buccal unless the implant is angled. So the implant is angled like this. You just put the bevel towards the angulation. This is a case. Implant was uncovered using the healing plug removal instrument. Insert the scan post, the scan flag. And this is how the scan flag is inserted for you to see. Simple. Finger pressure, your round peg into a round hole. Very simple. You go ahead and take the scan like that. You remove it and put it back, the healing button or whatever you have there to keep the soft tissue open. This is very simple, very straightforward, as you can see that scanning directly there. Use your favorite scan. Alright. That’s the patient’s scan. And on the model design, there’s a final restoration. Again, doing a extra oral cementation. Patient bites down. Crown is seated. Now you can also do a scannable temporary abutments. You can the case you saw, so you can tap the abutment in. This is for you to see. You just tap the abutment in, and they’ll go ahead and scan the temporary abutment, okay, like so. Okay. That’s what you see on the scan. Once you scan the central lab, the lab will make the crown for you. When the crown is ready, you just take the scannable abutment, put the crown into place. That’s the case I showed you before. We scan it up, inserting the crown. Using alignment jig, the lab providers give gentle taps, and that’s the crown is inserted, which you see. Simple, straightforward, very beneficial for you to do it. And this max two point five implants are implants designed for the maxillary anterior region, provides a more retentive connection. This is a case for a congenital missing lateral incisors for this young lady. So once the implants were uncovered, they were taking them there. That’s a black healing plug that’s been removed. We took an implant lab impression. Very simple to take. It’s one of the simplest way to take impressions as well. This is a video for you. Just insert the impression post or the finger pressure, snap on the sleeve, and take the impression. Only this leaf will come out on the impression tray. Like so. Always recommend, you know, injecting the material continuously, not having a space, but putting the the tray, take an impression, and only, again, only the sleeve will come out, not the post. That’s the sleeve out. For this case, patient had temporaries. We remove the temporaries, ready to insert the crowns, push the crown into place, give a gentle tap. That’s the final results. Look at the aesthetics again. You always have great gingival aesthetics. Naturally, you don’t have to do anything specific. The system just provides that to you. Okay, that’s the radiograph of the case. Now, full arch restorations you can do over dentures, yes, can do over dentures. But today we’re going to focus just the fixed TRINIA fixed prosthesis briefly here for you. So you go to TRINIA, TRINIA comes in blocks and different pucks for you to see. So TRINIA can be used for single crowns, small bridges and full arch restorations. It’s very efficient, can use a block. And TRINIA composition is about forty percent resin and sixty percent fiberglass. So you see here the block of TRINIA and the puck. The pen, any lab with milling capabilities can work with this material. This material is great because avoids the use of metal and heavy metals. And TRINIA also represents a paradigm shift because it has a modulus of elasticity and flexure strength. So TRINIA bends a little bit without deforming permanently deformation. So allows us because of that, allows long extensions. It’s not a cantilever. Any rigid structure, that’s a cantilever. Okay? But TRINIA, since TRINIA has mobility, is not considered a cantilever, but considered an extension, as you can see that. So here is showing the zirconia and TRINIA. TRINIA is seven percent lighter than zirconia. So full arch restoration is done. One with TRINIA, look at the weight. One with zirconia, look at the weight. It’s a much, much, much lighter material than zirconia. There are many studies published about this this this material for you to see. Again, go through website, the company, the bicon dot com, and you can see this is studies there. Here, one case, two years of function, look at extensions, long extension seventeen millimeters, fourteen millimeters. Another case for you to see, look at the gap, the span between one abutment and the other seventy millimeters. And another case here, just extension sixteen point eight and nineteen point four millimeter distal extension. So TRINIA works well, beautifully, it’s been working for years for many, many patients. This is a study done showing the severe atrophic mandibles with TRINIA restorations. Again, if you like studies, it’s all available online for you. Now fourteen years of clinical applications, you can also use TRINIA four wing transitional prosthesis. As you can see, this is provided. We can also use copings for natural teeth. This case is a full mouth restoration. All the aesthetics is done with Ceramage by Shofu, but the copings inside all done with TRINIA. It’s a beautiful case. Turns out really nice. Patient is extremely happy about the aesthetics of the case. Now how can you integrate these short implants into your practice? How can you do that? There are many different ways. You can take a hands on practical course, or you can take a live surgical course. Okay? The hands on practical course, they’re available in Boston, Massachusetts, and other locations in the US. This week, actually on Friday, we are in Los Angeles, California. You’ll be there teaching this course. If you’re in a local area in the area, you want to know more about the system, just register quickly. You have a couple of spots available. It’s a one day course recommended for clinicians with implants or surgical experience. If you have experience implants or surgery, it is a good course for you. You do placements on hands on models, including coverage of coverage of surgical and restorative techniques. We’re going to show you all the techniques, the surgical techniques and the restorative techniques for these implants. The other option is a three day live surgical course in Phoenix. Next one is in in March in Phoenix. And we only have, I believe, two spots available. Two are already taken. That’s a maximum of four participants. Actually, one is available. Three are already taken. But it’s a course Think about life. You may see some advertisements for life patient course. Usually have several students there, several people there, like ten, twenty. This is only for four people, because you have a very individualized attention and allows you to work a lot and to get a lot of experience. At least guarantee seven implant placements, but most people place ten or more. If you’re not placing an implant, you are assisting the other participants of their surgery so you can learn with the others as well. You have a very close personal attention from the instructor. You have a live patient restorative procedure as well. So you learn how to place and also how to restore these short implants. And no international travel is required, you know, all done in the USA. And after taking the course, you should be confident enough to place and restore Bicon implants in your practice. So this is a beautiful Phoenix area. You know, the weather usually is very good there, except in the summer. That’s why we don’t have courses in summer. But if you want to bring your family, there are many places you can visit, which are family touristic locations nearby. You can see it. This is the facility we use is a charitable institution called Saint Vincent du Paul, and it’s a fantastic institution and provides all the treatments will be free for the patients. So they receive implants for free. And the institution, it is incredible because they provide over seven thousand meals a day for people that need. It’s incredible thing they do over there. Here’s a picture for our last group and the institution. So it’s a great place for you to learn implants and short implants. You’ll leave the course knowing how to place and how to restore them. And you have the chance to do that in live patients. So it’s a great opportunity for you. So I hope you enjoyed this presentation. If you have any further questions or information about courses, feel free to email me. That’s my email address that I believe you guys received. Feel free to ask questions. I’ll be glad to answer them, as you know. And thank you very much for watching.