SHORT® Implants vs. Zygomatic Implants – Dr. Tom de Wit [HD]

Thank you, Mauro, for this nice introduction. And, I must say I’m very happy to be here at the center of the automotive industry of Italy. I’m a huge car fanatic, and that’s why I chose to drive here. And when I was at the border between Austria and Italy, an Italian customs officer pulled me over and asked me to roll down my window. And all he said was, “due”, meaning two. And I asked him I said, no. It’s just me in the car. Not two. And then he said, “due a zero”, referring to the football game we had between Belgium and Italy last week. So this was my welcome. But maybe we are adversaries on the football field, but then again, here we are as friends and colleagues, and we’re all here because of short implants. So, I’m going to talk to you the next hour, the next half hour at least, about short implants versus zygomatic implants. And to me personally, that’s a matter of principle. I’m not going to tell you that zygomatic implants are bad, nor that they should no longer be used. And I’m not telling you neither that we can do everything with short implants without ever having the need for bone grafting. But what I am telling you is that we can do a lot more, a whole lot more with short implants than we think. I know people in here are mostly convinced of the capabilities of short implants, but worldwide there’s still a lot of skepticism. When we can do these procedures with short implants in such a way that it is as little invasive as possible. And I’m telling you that me as a clinician personally, I want the least invasive procedure as long as the outcome of my treatment is as good and preferably better than the alternatives that we have. Now, I know we’re talking about short implants, but I need to explain you a thing or two about zygoma implants. Zygoma implants were originally designed for patients with very little to no crestal bone. For instance, people who had had hemimaxillectomy, such as this patient here, you see the huge defect that you need to restore prosthetic wise. And this woman who was a very outgoing person was hiding away in her kitchen for almost twelve years. With implants positioned in the zygoma bone and with extra long implants, we created this arc like construction with a bar. And she’s smiling again. This is her obturating denture without comfort and now she’s back into the restaurant hosting people. Over the years, they evolved to a way to avoid bone grafts in the maxilla, especially as an alternative for autologous bone grafts, hip grafts, skull grafts, with more predictability. Plus, it meant a faster total treatment time compared to autologous bone grafts. In the last ten years or so, they are being used for all on four like treatments for extreme atrophic cases. Even with immediate loading, they’re called quad zygomas. You can see the extra long implants and here’s our short Bicon. What a difference. There are even decent success rates. If you look at the literature, we have ninety six percent of success after five years, which isn’t bad at all. And our zygomatic implant has an average length of between forty five and fifty five millimeters. It’s anchored on the inside of the zygomatic bone, meaning you have to make a crestal bone window, a sinus window. And afterwards, you have to graft this window. So you’re doing a sinus lift, which is invasive, meaning it’s a complicated surgery because you have to go all the way up to the zygoma bone. Plus, it’s an expensive procedure as well. The more difficult the procedure is, the more expensive it becomes. Plus these implants cost a lot more than any other implant on the market. The restorative procedures are also very, very delicate. You have to follow the rules very strictly in order not to get into trouble. You can have no cantilevers for your prosthesis, or at least as little as possible, always have group function, decreased cusp inclinations, so when a patient clenches or moves from left to right, there are no shear forces on these implants. Zygoma implants always need to be restored with a screw retained construction. But on the positive side, you can do immediate loading, if that is a positive side. This is your typical spread of zygoma implants, anchorage on the zygomatic bone on both sides, spread to the anterior, and going as far back as the second premolar to the dorsal. What is absolutely mandatory for these kind of implants is a construction, a superstructure that stabilizes your implants. Due to the length of these implants and the limited anchorage, it’s only anchored on the inside of the zygomatic bone for five to six millimeters, you can cause bending moments within these implants. You need the superstructure to be connected and the superstructure needs to be as rigid as humanly possible in order not to have any failures afterwards. This is what the average zygoma surgery implant site looks like. Huge flaps, major flaps all the way up to the orbital arch. There still is some crestal bone here, and you can see the implant running through the sinus all the way up. And this is what our patients look like for about a week, a week and a half afterwards. They look like they’ve been hit by a bus, but luckily they’re not in any pain. If we look at our ultra short implants, they’re supported by crestal bone. Since these implants are very small, we only need very little bone to begin with. Okay. Sometimes there is a need for augmentation, but not that much. It is little invasive and straightforward surgery. I’m not saying it is easy, but if you can perform implant surgery, you can do this. Our short implants have a length of five up to eight millimeter, but our ultra shorts are about five to six millimeters in length. They give you excellent, and I mean truly excellent long term results. Plus it’s a reasonably priced procedure because there’s hardly any need to do any additional surgery before you can start. Prosthodontics are also very straightforward. We can do fixed bridges on four to six implants, cement retained, screw retained, or even telescopic as we’ve just heard. And this is what my average full arch operated site looks like. I even do my flaps a little smaller than I did in this case, but this is not very major surgery. If we look at our zygoma implant and we put our short implant right next to it, this is true scale. I know this is not mathematics, but I would like to say if I do a short implant, I am being eight times less invasive at least to do this procedure. Immediate loading, is this really an issue? Yes, if we do zygomatic implants, we can do immediate loading, immediate function, but this means that we add to the cost. We have to make a provisional prosthesis, and by doing so, we add to difficulty. Add a difficulty because you as a dentist need to be there in operatory theater. You need to be ready to do impressions under general anesthesia. You have to run off to the dental lab. They have to work day and night to get this ready within twenty four to forty eight hours. And if you look at it from an objective perspective, you get a longer overall treatment time with these immediate loadings compared to a treatment with short implant. Often we don’t start with permanent prosthesis before nine to twelve months after initial implant insertion. Short implants or ultra short implants at least, and I’m talking about five to six millimeters, at this point I’m not contemplating on doing immediate loading with those implants. But since we have a fairly short integration time, waiting is not such a bad thing. Plus we don’t add extra costs due to extra temporary prosthesis nor extra expensive procedures. And is a fast treatment truly what every patient wants? I’ve never had a patient step into my office saying, I want my teeth the very next day. I think this is mostly what we as dentists would like to have, but this is not mandatory for the patient. Plus, I can have a case finished with short implants, a full arch case within six months of time, which means I am finished six months early compared to an immediate loading quad zygoma. If you look at the alternatives on the more broad side, we’ve had this covered this morning as well. How well do they perform? Well, myself and my colleague and friend, Andy Theppermann from the University of Leuven, have done a literature study comparing, and I’m missing one image, lateral window sinus lift, internal sinus lifts, bone grafts, zygoma implants, and short implants in terms of morbidity, treatment time, additional costs, difficulty, and survival rate. And if you look at the bigger picture, our short implants are performing extremely well. And you can see by the success rates, they are talking about 92% to 99% of success. And I can tell you that those low ninety percentages are always studies that are talking about shortened standard implants. Just take a regular implant, a regular screw retained implant, cut it in half, and call it a short implant. But that’s not what a short implant is all about. It’s all about geometry. But it’s a whole different story. I’m not going to go into detail about that right now. So if they’re so good, why don’t we use them more often? I for sure do. Our patients get no major surgery. They get no expensive surgery. I’m not saying that implants are cheap or have to be cheap. But compared to all the alternatives, all the extra treatments that you need to do in order to do treatment with traditional implants or even with zygoma implants, the expenses are very acceptable. Because even though we sometimes need extra procedures, these occasions are very rare, very limited. Our patients have little to no discomfort after our procedures, plus they get an excellent result. And I always like to use big quotes, usually by a famous person, but this time being a Star Wars fan, and I know I’m not the only one. Right, Richard? This little green guy, although he’s a fictional character, he’s judged by his size. And this is what we all do. I think it’s a bit of human nature. If you have to choose between something very small and very large or big, the automatic idea that we get is bigger must be better. But I can assure you that in case of implants, bigger is not better. We want smaller. So the case that won me over, and some of you have seen this case before, or maybe you have seen this pass by on the internet, is a case where we had a need to remove zygomatic implants. What options do you have when you have to remove them? But why would you remove them in the first place? What are the reasons to remove zygomatic implants? Because they don’t integrate, sometimes it happens. Dehiscences, infection of both the sinus or the zygomatic bone, or they can simply break. Can they break? Sure they can. They can very much break and my image is gone. Nope, no image. I’m sorry, this was a very spectacular image of zygoma implants that broke just because they weren’t treated in the correct way. So do we have a backup plan? In case of a problem with a zygoma implant, do we have a backup plan? Because in my book, a quad zygoma was supposed to be the very last resort. We could not do anything else, then we would do a quad zygoma. Before we knew Bicon, we would try to place new zygomatic implants. If there was still some room left on the zygoma bone or perhaps a pterygoid implant, which was an even more difficult procedure. If this wasn’t possible, we would try to salvage the implants that we would still have. And if this wasn’t even possible, then we would do nothing. We would put the cover screws back on and send the patient home with a full denture. Now I know better. Now I know Bicon. When Bicon came into our lives about ten years ago now, it meant a huge expansion in treatment options. We could do a lot more for patients where before we had to say, I’m sorry, there’s nothing much we can do. It meant for us to have even less bone grafts than before and a possible treatment for the cases that failed. If you look at a case that changed my life, and the patient’s life, We have a female of about sixty years old. She was a non smoker and had a full denture for most of her life. And she wants a fixed solution. She is desperate for a fixed solution. Not even her husband was allowed to see her without a denture. When we saw her first in 2009, she still had three teeth left, periodontically compromised, and they were extracted. After a bit of healing, we took a cone beam CT, and unfortunately, I cannot share the images with you. They were lost due to a data crash. But I can assure you that bone volume was very poor. We were used to doing or quad zygoma or all on four at the time. For all on four, that was impossible. So, it was treatment plan going between only bone grafts and bilateral sinus lifts or quad zygoma. Why not Bicon? Because at that moment in time, Bicon was relatively new to us. We had some experience for solitary tooth replacement, but we did not have experience enough to try and challenge for a full arch. Plus, our patients did not want major surgery, hip grafts or bilateral sinus lifts. So we had a relative success. It was a nice planning. Implants were placed. You can see the bone tags, the bone screws around the zygoma implants. Well, these were there to hold a SynPOR plate in the right position. Why a SynPOR plate? SynPOR is a material that’s used for facial reconstruction after facial trauma. We’ve had some issues with dehiscence in the past due to mucosa rubbing against the exposed threads of zygomatic implants. And the surgeon was hoping that this might be the solution not to have dehiscence. Unfortunately, the plan backfired. Instead of not having dehiscence, even after a month or two, we had major dehiscence and an infection. This SynPOR plate was removed and since the implants were stable enough and integrated well enough to continue, my associate was assigned to make a nice overdenture. But this wasn’t enough. It never rains, but it pours and the situation continued to get worse. More dehiscence, recurring sinus infections no matter what kind of antibiotics or nasal sprays we would prescribe, plus the infection spread to the soft tissue of the cheek, giving our patient lots of pain. But still we had perfectly integrated and fully functional implants. So you have to make a choice since your patient requires your help. We had already removed the SynPOR plate. We had recovered the site, cleaned it out and performed procedures to get a nice clean sinus. But without any success whatsoever, everything we did was a measure for nothing. More dehiscence, more infection, and worst of all, worse and worse and worse pain. So the patient has at this point lost her trust in the oral surgeon. And from the patient’s point of view, I can understand this. If you have procedure after procedure after procedure and nothing works, you start having doubts. So we needed to do something. So, what can you do? You can remove those two implants that are exposed, thus eliminating the cause of the problems. But then again, you would only have retention of two zygomatic implants. And as I said earlier, it is of the utmost importance to have a connection on both sides of the arch, the trans arch stabilization. But since we could not leave our patient in excruciating pain, it was decided to remove those implants, leaving us as a prosthodontist with a very critical situation, a huge cantilever on this bar. Even though we removed the riders and there was no retention on the cantilever, this is a situation that cannot last for very long. These implants, though are still there, they will break. So we needed some time to let the tissues heal, to let the bone heal, and we needed some time for us as a treatment team to find a new plan, to think what else we could do. Was there a next move? We didn’t know. So we took a new cone beam CT and at which point the patient was extremely desperate, she would be calling us every two days asking if we had a solution. But we had even less bone than before. This is an extreme atrophy. Since we had some more experience with Bicon by that time, we decided what about using as many Bicons as we can find a place for. We do this with a lateral sinus lift, which was the preferred procedure of the oral surgeon at the time. And so it was decided to place four implants in the hope that we would have two. Here’s the surgery. You can see the apexes of the implants sticking right through. The site was covered with a bone substitute and a membrane, sutured nicely. And then after six months of integration, oh ye of little faith, instead of two, we have four. Which was the point where I came into play. I as a prosthodontist within our team, I am the department of the lost causes and the impossible tasks. So it was up to me to find a good prosthetic solution for this case. We have two extra long implants on one side and four ultra short implants on the other. What can you do with this? Do we go for an overdenture or do we go for a fixed bridge? And by having done quite a few TRINIAs at that time with great success. I love this material. I was saying, What about TRINIA? How can TRINIA be of help? Dr. Morgan has already explained to you what TRINIA actually is, so I’m going to not go into great detail with this CAD/CAM designed and milled fiber resin superstructure, which is extremely strong. You can use this for single crown replacement, but that was not going to help our case here. Some beautiful work by Paolo Perpetuini. Fixed bridges, short, was getting closer to helping us. But then we already had some full arches on only four implants with cantilevers up to twenty one millimeters working beautifully. Or maybe an overdenture with telescopic where we would cement the secondary copings on the inside of the TRINIA bar. We would have to decide between full arch cemented or telescopic. So how can TRINIA be of help in this specific case? Can we go hybrid? And by hybrid, I mean we need to combine the restorative features of extra long implants and ultra short implants into one adequate prosthesis in one patient. And as we’ve said earlier, our zygoma implants need trans arch stabilization, a connection between left and right. I prefer to have them screw retained because it’s not the first zygoma reconstruction that I need to remove due to hygienic reasons or just some plain maintenance. And if I need to remove a superstructure on zygomatic implants, I want to do this atraumatically as possible. I don’t want to be tapping away trying to break a cement bonding. But for my Bicon bridges, I prefer to go cement retained. I contemplated on doing a telescopic, but then again, I want the most rigid connection for the extra long implants. So, it was decided to go for a hybrid bridge, screw retained on one side, cemented on the other. I always do a model check, especially in case of zygoma implants where I always need to have a passive fit on those implants. This was fine, use a jig for that. And we have a master cast which looks like this. Strange marriage, no? Three millimeter well implants, two multi unit abutments. We have our try in where we check occlusion and articulation, aesthetics of course as well. And again, we check the passive fit of all components. And you can see by the way the soft tissue looks that the overdenture really isn’t working for this patient. We approved our try in. We had our digital design. It was milled, then we got our finished TRINIA Bridge back. If you take a look at this, this is TRINIA with Ceramage as it’s supposed to be made. And this is a very beautiful bridge if I say so myself. It’s very natural. But it’s as hybrid as it can get. Cemented, screw retained, extra long and extra short in one patient. So did we make an aesthetic screw up? I don’t think so. I always leave my patients alone for about two minutes after the final bridge insertion. And when I came back, she turned around looking like this, asking me if the central incisors weren’t a bit too long. This picture says it all. At this point I knew we had restored function, aesthetics, but most of all the trust of our patient in the treatment. This is a nice bridge, a nice occlusion, fully functional. And if we look at prosthesis from start to finish, going from regular prosthesis to an overdenture, ending up with this, I know what I would choose. I would choose the TRINIA Bridge every day of the week. So our patients had quite a history within our treatment team going from a full denture to the quad zygoma, losing the implants, inserting short implants. And I can surely say this is a case of shrinking the implants. So we turned the failure into a success. We got a better result than before. The patient is very, very happy. It’s strong. It’s aesthetic. And it’s a fixed bridge which actually was the patient’s request from the very beginning of her treatment. We we have a follow-up of about three years now. She has absolutely no more pain, still fully functional. The TRINIA bridge with Ceramage looks like brand new and we have an extremely grateful patient. Despite all the difficulties during the initial treatment, we have a very happy patient. And was this our last patient we did this way? No, it wasn’t. We had several more. Same case, two implants due to an infection on the zygoma bone had to be removed. It was only space for three short implants. But this case is special as well. Look at the size of that TRINIA bridge. It can handle it. The implants can handle it without any issues whatsoever. So why don’t we use ultra short implants in the first place? Why not make this the standard treatment? You can have less complicated surgery compared to all the alternatives. There is less risk during the surgery, which is always a bonus for the patient and for yourself. You can have a more ideal implant position. You can position this nicely on the crest. You can do this even in a less invasive way using an internal sinus lift, if it’s possible, and it’s a more accessible surgery as well. More surgeons can perform this surgery compared to hip grafts, bone grafts, and especially zygomatic implants. So more patients can get treated even in these extreme circumstances. Plus, you can do it with the implant with the most bacterially sealed connection. It is the only biological thing to do with the emphasis on the logical. This case was originally planned as a quad zygoma. And once I got the patient into my chair where I had to do a prosthetic study, She asked me, I cannot afford this kind of treatment. I have to go all the way to zero on my bank account if I want a quad zygoma treatment. Plus, I’m only thirty nine years of age. I am not looking forward to any major surgery. Isn’t there anything else you can do? And that’s the point where you have to make a choice between your treatment team and your patient. And in my book, it’s always the patient that comes first. So, we looked at the bone, there was very little bone to work with, but still we managed to place six nice implants without any issues whatsoever. She was treated with a telescopic overdenture. This patient wouldn’t allow me to show any picture of her, except for the one for the surgery, but she is a nice looking woman and we have a nice looking prosthesis. Great work by Paolo again, Paolo Perpetuini, Italy’s very own, you can be very proud. And this is the same story, another patient planned as a quad zygoma, treated with, in this case, eight short implants. Why eight? I had to do some pretty extensive sinus lifts, plus he was a very heavy smoker and I did not want to take any risks. I wanted six implants and luckily I I got seven. One of the sinus lifts didn’t integrate, so we lost one implant, but still we have a telescopic prosthesis on seven implants. Seven wells where we have room for secondary copings. And this is the patient after one year. You can see he’s a heavy smoker. I can clean this up and it will look very white. And after two weeks time, it will be just like this again. But the implants are doing perfect. And look at the bridge, no staining, looks good. Need just a little bit of polishing, but we have a happy patient who had no need for extensive surgery whatsoever. So if you were the patient and if you had to choose between this as extra long or these extra short implants, what would you choose? Would you go for five would you go for fifty? All I can say is that being short or in this case using short implants has its advantage. So I’d like to kindly thank you for your attention. If you have any questions later on, always send me an email. I will always answer you right back. Or you can join us at the Bicon dental implant group on LinkedIn or the Bicon Benelux Facebook group, both which I created to have discussions with patients, sorry, not with patients, with colleagues over treatment, over questions they have on the system. So feel free to contact me anytime. I kindly thank you for your attention.