TRINIA®: The Need to Select the Adequate Prosthetic Material – Dr. Vincent Morgan [HD]

Continue. We have to fix the computer. No. No. No. Well, thank you. It’s humbling. It’s embarrassing because there are many, many people that have made, Bicon what it is, and I just happen to be at the head of it, in name. But I’m grateful to so many people. And let me just start. And I could not have had a better introduction than Frank because in a sense I’m in a unique position in that I’ve seen the gamut I’ll go to the beginning. Okay? I’ve seen Bicon from its infancy, and my experience with implants started in nineteen seventy when I knew nothing about implants. I’ve had no formal training, but we’ve had common sense, a lot of luck, a lot of risk, and the people associated with me have done the same. When we look at the short implant, some of the people in our own clinic refused to place the first short implant in 1997, 5.7mm. And I said, That’s okay. There are others in the facility that will. And then when we came to the four by five, two of our clinicians that were placing a fair number of implants, they said no, not on my license. And then I said, that’s okay. There’s a young Dr. Murcko, she’ll do it. And then fortunately, Rolf Ewers, we’re truly grateful for, because he placed the four by fives in a university environment, and then Rolf had the courage. He was foolhardy too, And I said, Rolf, in addition to this four by five, would you consider using TRINIA? It’s a totally new product. And so he was the risk taker that innovators happened to be, and he did. And we did, I think, two or three of them in our our facility, but the for the first year, Rolf was responsible for the majority of TRINIA. As TRINIA has evolved, it has changed, and I’ll answer Frank’s questions. But let’s begin. I was charged with talking about materials, so let’s talk about materials, and I was also told this is a short implant, and so let’s think short. And there it is, the four by five, which is short, and there’s the capability. But watch what happens in four months. Bone gain. You’re seeing it. I do not know Dr. Millman. He just sent this slide to me, and does it not say at all? Four months bone gain, a broken whatever? So Bicon is different. It’s different by design. And ask yourself, which is logical? We know all implants work. They simply do. Which is logical? They both work. Which is easier? Our next speaker sent this film to me, but there’s a TRINIA prosthesis on Nobel long implants and on Bicon short implants. Which is logical? Why did they use the long implant first? So materials. And Frank touched on this beautifully, and you have to recognize the fact that Frank is not only gifted, but he runs a very successful business. And he mentioned something that most people who are not responsible for the profitability of a practice do not take into account. It’s the maintenance. It’s the laboratory fees. It’s the breakage. Sure, anyone can say this material, that material, if they’re not paying for it. But if you’re around a practice for twenty or thirty years, that’s your responsibility. That is why materials to me are very important and seemingly not important to other people. So let’s just look at materials. Three different materials. Same technician, Paolo Perpetuini. Same patient. Which is which? Are there differences? Yes, there are differences. Do you have a preference one or the other? Have your preference. I prefer the composite because I’ve been in a practice for forty six years now. What happens to that zirconia when it breaks, the porcelain when it breaks? It’s not as Frank mentioned, it’s the maintenance, the repairability. This is why composites to me are the future. You all have done this, and yet you still use these hard materials. Sure, they’re better today, but recognize the fact that I started in dentistry when there was no porcelain fused to metal. Think about it. Any of you who were practicing in the early sixties, we had a aesthetic issue in the anterior part of the mouth. We did gold pin ledges with Steele’s facings. Then, in those days, you had to have some dexterity to be a good dentist. Today, the materials are so good. And this is where the mother-in-law joke started. I said, yes. Excellent restoration for your mother-in-law, but not for your mother. And yet today, people are still enamored with these materials, but they have not been in practice for forty years in discerning and seeing the damage they do over forty years. So with Bicon, it can restore any any material you want, you can use. My love is not the zirconia, although you can use it. It’s not the zirconia core. I don’t see why, but you can. Gold? Sure you can. This is interesting. This man, we placed three Bicons, three gold crowns, and he apparently is a wealthy wealthy man, and he heard that there was a more expensive office in town that’s currently holding a a meeting in Boston with contestants. So after seeing us, where we just cemented a gold crown, There was two thousand twelve. He went to a higher priced practice to have the bicuspid treated, and he had a failed threaded implant. And there’s the look at the bone loss. He just chose the wrong implant. The IAC, which we’re grateful for Mauro and Paolo, particularly Paolo, my idea. I say I’m the father, and Paolo’s the mother. You know the difference. So we started, and it’s all because of the three hundred and sixty degree positioning of the Bicon abutment allows you to do this. Not possible with any other restoration. And for the Germans in the audience, this is the ideal telescopic crown. Think about it. Like a mother, Vincent. Like a mother. Like Ben Manuela told. See? I should start out by saying thank you for this wonderful venue. Thank you so much. But I started to mention it’s all of our clinicians and people around the world that have helped us, but we give Mauro the the praise for this venue and event when, in fact, it’s Daniela, Manuela, and Antonio. So thank you, Mauro. So the three sixty degree positioning. And we’ve learned in using these materials that they need minimal metal support. The manufacturers told us, taking from porcelain, that, more metal was better, and yet one morning I said I never saw a broken composite denture tooth without any metal. Estevam Bonfante took that concept, tested it, and you only need actually less than four millimeters height of a prosthetic post. It works. So originally, we had metal supporting. Now we have less metal. Less metal means more aesthetic capabilities, particularly if implants are not in the right trajectory. Short implants, and the point being made this morning is that they’re unsplinted. They can stand by themself. Rainier published a paper on the integrated abutment crown in two thousand seven. But look at the bone, as Rainier says. This is fifteen years, three PFMs, and the lateral incisor was becoming darker than the PFMs, so we changed the PFMs simply by twisting and pulling the PFM out. Look at the papillae after fifteen years, the impression for the IAC. Insertion of the IAC is now twenty one or twenty two years since the implants are placed papillae, and there’s the bone. So it was restored for a number of years as PFMs, then changed to integrated abutments. This is what Frank was talking about, maintenance. Occlusion. The reference is made to loose anteriors. And yes, there is a problem with loose anteriors. It’s probably the Achilles heel in the minds of many, but most of it is related to occlusion and the unwillingness of a clinician to direct it, the occlusion. These three teeth kept coming out, and yet they were not in occlusion until you asked the patient to protrude the mandible and then retrude it while clenching, and then you found that the crowns were not too thick. They were not too long, they were too thick. This is how they had interference when they’re bruxing. Once that was adjusted, these three never came out again. So there are many factors that go into the loosening of a single maxillary anterior tooth. In the ideal world, it can easily be handled, but in a busy practice, frustration enters into it, and people take drastic means such as cementing, etcetera. But I could go on with many cases, but check the occlusion as you’re retruding the mandible from a protrusive position while clenching, and you’ll you’ll find that you should have reduced an extruded lower incisor quite frequently as being the cause. Enough said. We’ll go on to that. The advantages of the integrated abutment crown, if we look at exposed metal margins, because of the ideal telescopic restoration, if you will, you can just, in seconds, remove it. You can cut back on the titanium because there’s no female bore with threads. Only possible with the locking taper connection. So there are other factors when you look at an implant. It’s not just the implant, the surgery, the initial placement, it’s the maintenance. This is why my preference is these composite materials. You can’t add to a Emax zirconia chairside. So if you’re not responsible for the finances of the practice, then sure, put these restorations in. But when it comes time, five years, six years, ten years later, there’s a difference. And as Frank said, his time is valuable. You sure, Frank? So and it is. Most dentists, they look at the cost of a component. It’s not the cost of a component. It’s the cost of your time. I know Frank, and I know his practice, and if you don’t know him, you should be he’s experienced. He knows of what he speaks, so, he gave you good wisdom. It’s maintenance, and the maintenance over the long term is what you should consider, and this is what I’ve shown you with these materials for the individual tooth. Now I’ll show you for the framework. We have used TRINIA for six years, and I can tell you it’s a gift. We cannot go back. One, I could not execute the frameworks that that Frank did. I just could not. It’s too complicated for me, so I’d rather stay a simple guy. And I have said often in Germany, the Bicon implant is too simple for the German mind to comprehend, and it’s true. And also, the Germans have the rules. The rules. If it’s one word that drives me wild in Germany, it’s when the Lufthansa reps say it’s the rules. Like, the rules. These pardon? I’ll quote you. The rules. I hear it all the time from Lufthansa. Great airline, but they have too many rules. So TRINIA is the same material as the Boeing Dreamliner is made of. It’s a fiberglass resin, has great flexural strength, and very thin dimensions, seventy percent lighter than zirconia. I mean, than, zirconia. And just watch. This is kindness of Richard Rodriguez, and he’s gonna drop them. That’s what Frank is talking about. It’s the catastrophic result that happens, whether it happens at day one or day ten years. There is a difference. So be in love with whatever material. Use your irrational responses of why you like it, it’s shinier, it’s cleaner, it’s better. But if you are responsible for the running of the the practice and the making of the money, you do not want a catastrophic failure. So think about it. The versatility of this material has been amazing. The people are always enamored with immediate loading, and the issue with immediate loading has always been for Bicon is to prosthetically stabilize the implants. And the resin materials, the composites, were never strong enough and thin enough dimensions. But this is a stabilizing prosthesis made of TRINIA, the abutments reduced to universal abutment coping. This is Dr. Murcko. She’s extracting these incisors. Now the universal abutment is what has made this practical. Use a four tall profile, five tall profile, and then the reduced sleeves. But prior to that, try the stabilizing prosthesis on. Make sure it fits. Even try it on before you put the abutments in. Then make these copings very thin, and if necessary, just have a cervical portion, just a ring. And then cement the prosthesis. It’ll be stable and strong. We did not have that reliability with other materials, so you always had to monitor the patient. But there it is, the universal abutment, the implants, the temporization sleeve, the TRINIA prosthesis cemented. There it is after healing. So now we left the abutments in, and we chose to take an abutment level transfer impression and submit the final prosthesis. Narrow implants also benefit from TRINIA. Also note, these are four lower incisors. What other implant could you place for individual teeth? Do you need four? No. Does your wife need a Gucci handbag? No. But if you can afford it, she needs it. What other system could do this? This is a case that Dr. Murcko did. She uncovered them. Sulcus reamer or sulcus formers, it’s now called. The temporization is done with the universal abutment components, which are so superior to the stealth components, so superior. And the height, the core was CAD/CAM TRINIA. As you’ll see the so that’s the CAD/CAM designed for TRINIA coping. Ceramage buildup of the and the insertion, a round peg in a round hole. Four individual incisors with room for the papillae. One is not seating fully, as you can see, and it’s a matter of going back with the sulcus former. Little smidgen of bone, all that it takes, seemingly nothing, but it’s a big dimension. No other design. There it is just four days later. Four unit bridge. The important thing to recognize is it’s two clinical visits. Two. That’s not only profitable for you but your patient. Successful people do not want to be going to the dentist for multiple visits. Let me get in and let me get out. And as Frank referenced, the CAD/CAM is very reliable, and the impression post, the components of this system, are quite accurate. So one visit to take the impression, and the next visit, the final restoration. We no longer use the terms cut, solder. No longer use the terms framework try-in. This morning, you saw surgery. That’s all well and good. That’s only half the story. It’s been said that people do not come for an implant. They come for a tooth. They want a restoration. They tolerate. They endure the surgical procedure to get the aesthetics and function. What could be simpler? The prosthesis orients and directs the seating of the abutment. Only possible with a locking taper connection. When we look at implant designs by competitors, we discount them almost immediately because the years of experience has taught us what is essential. And what’s essential is a locking taper that doesn’t have micro movement. And you need a sloping shoulder if you want a papilla. And if you think differently, you just don’t understand implants. Why you would choose something that has micro movement and not a sloping shoulder. Maybe it’s an attractive sales girl, maybe the company’s giving you an eighty five percent discount, maybe they’ve invited you to speak, but you’re not thinking of your patient. So that’s on the maxilla. Now how does one use a mandibular prosthesis to orient and seat the abutment? Too simple for the German, but I’ll show you, Frank. You got it? So to fight gravity, Newton told us all about Vaseline. You simply put a little Vaseline into the prosthesis, and you can put the abutment in and turn it upside down. Amazing. If you don’t see the abutment fully into the prosthesis, you give it some wiggle room. Voila. Seeing is believing. So Tommaso said years ago, well, today today you’ve seen a good deal. I show you this in the next next clinical treatment just to let you know that there’s a basis for our foolhardiness risk taking going forward. For whatever reason, not everybody’s willing to take the risk or can see the future or see the possibilities. Fortunately, we we have some very talented people. And we’ll conclude I’ll show you something after that, but we’ll show you Bicon’s latest innovation, which is mill coping. This was the first case that told us that we could think differently. It was these two non parallel implants that we treated in two visits. We initially did it in metal, and then when TRINIA came along, we changed it for this video. This is the longest bridge you’ll do. Third molar to canine. Five unit bridge with a TRINIA framework. But it’s probably as convergent abutments as you’ll deal with. And yet we’re going to do it in two clinical visits. One to take the impression, which is nothing more than a round peg in a round hole, and the bite registration. Now we’re gonna use the prosthesis to orient and seat the abutments. The canine is in place. Now you take the third molar. You believe? Frank doesn’t believe. I believe you can do it. It’s eyes closed. It’s early of, two o’clock tonight. I believe. You believe. I smile because I’ve had decades of relationship with so many of you, and I was entertained by Frank on multiple evenings, beautiful restaurants, and oh, he was really Saint Thomas. But he came around. He followed a woman. So I’ve had the most enjoyable time with this Bicon implant. But with this with this bridge, this was the introduction to using TRINIA prostheses today. So a Bruxer. Some of these have not worked for him, particularly in the anterior on his natural teeth, because the teeth were too prepared. But there is aesthetic restorations with TRINIA copings. We’ll show you TRINIA used as an obturator, TRINIA used as partial dentures. And as I mentioned at the outset, the kindness of Dr. Ewers, he not only tried the ultrashort implant, the four by five, but he also restored them with TRINIA. And I’ll show you just two or three of his cases. I’m sure he’ll show you more. But as a maxillofacial surgeon, he not only did the surgery, he did the prosthetics. Full arch restoration. Note the cantilever. You’ll see it in the radiograph. Two visits. The take home message is that you can do full arch reconstructions in two restorative visits over and over again. This was before we had the telescopic copings. That’s what the well for those of you unfamiliar with Bicon, that’s what the well normally looks like. No inflammation. The seating jig. The technician will indicate the two most parallel. You seat those two first, and then you. TRINIA, long span, two restorative visits. We’ll skip by this relining of TRINIA, once again going to Frank’s theme, the maintenance. The maintenance is the key. An air abrasion, ceramage. You can add to this material chairside. You’re totally in control all the time you want. Layer it. Light cure it in the mouth, take it out, polish it. You can’t do this with metal. You can’t do it with zirconia, and yet the alveolar ridges resorb. We all know it. Do these materials lose their luster? They can, but they’re easily restored. Thirty seconds, your hygienist takes a Versal Brush diamond polishing paste from shofu, and it’s back. We learned the same issues with extraneous cement. As watchful as you are, extraneous cement can be very harmful. So we we tried with Paolo. We did telescopic copings, and then we did cast copings. I hear Mauro’s footsteps in the background making me nervous. So sure, you can fabricate custom copings, but there’s a laboratory expense to it, but doable. And the beauty is that any discrepancies, you can easily adjust the TRINIA, and then the void is filled by the resin cement. Everything bonds to TRINIA. TRINIA is easily adjusted with a 7404 carbide bur, and it’s easily or readily bonded to with any resin. So unlike chrome cobalt, which is possible to cut on these non precious alloys, very difficult to cut, modify it. And if you want to add a little bit of acrylic, add it and polish it. Have an open margin. It’s readily rectified, whether it be the day you insert it or eight, ten years later. And if you’re responsible for the profitability of the practice, you cannot rationally use porcelain fused in metal, etcetera, etcetera. Go ahead. Satisfy your ego, but it’s not helping you, neither you nor the patient. The universal abutment is what gave us the capability of having milled titanium copings. They’re not telescopic copings because there’s no retention of each coping with an abutment. It’s just what falls right off. They gain their retention by the slight discrepancy in parallelism from the two abutments. They are both retentive and nonretentive. The marketing people, they can tell you about it, but the retentive are basically red, and the nonretentive is metal color. There’s a low profile which only accommodates the low profile universal abutment, and then the standard and the tall of the other, coping. So that’s all you really need to know about them. They come in five millimeter diameter at the moment, But it’ll afford you a great deal of clinical flexibility, profitability, cleanliness, all the things, once again, that Frank, an experienced person, is talking about. He knows of what he speaks. So let’s just view how you go about it. You cement the copings onto the framework. Make whatever adjustment you need to the trinia. If it isn’t passively fitting, hollow it out, and you wind up with a coping that is precise to the abutment. You look good radiographically, and any void or discrepancy is filled up with resin cement. If it’s too retentive, cut one of the retentive copings out and replace it with a nonretentive. So let’s look at our clinical cases. The important take home message is that you can structure your treatment into two clinical visits. And the way of doing that is to keep the two, three, or four teeth that the patient has. Place your implants. Allow them to integrate. Once they’ve integrated, then you take your impression of the implants and of the several teeth that remain as we’re doing here. This is our first restorative visit. Universal abutment in his healing cap. Patient goes home. The laboratory fabricates the prosthesis with a seating jig. Second restorative visit. How long did that first visit take you? You bring it back, and you know you have the right vertical dimension. The technician knows the midline. He knows the size of the tooth. And you put the abutments in with the jig, not shown here, and then you put the retentive coping on, and the retentive coping fits precisely the abutment. You look good radiographically, and you’ve done virtually nothing to achieve that distinction or honor. And you cement the prosthesis on. This is a patient that we treated some forty six years ago. He had a benign mixed tumor of his palate. He had his natural teeth, day one. He had porcelain jacket crown, porcelain fused to metal, and he had a partial removable obturator. And he subsequently had integrated abutment crowns. His hygiene over forty six years has been atrocious. We’re not going to change him. So what do we do? We remove his IACs all but for two of the canines. We recorded his bite, then we took the impression of his nine previous IACs. They’re not parallel. On on the second restorative visit, we’re going to seat. Let me go back. L. We’ll go around again. So he’s been our patient for forty six years. First treated him when I was right out of dental school. So we left his two canine in so we could record the bite, and Paolo could get an idea of the size of his canines and his midline, made the bite registration. Then we removed the two IACs. We took the full arch implant level impression. The model shows the non parallel nature of all of the implants. TRINIA was designed on the computer and milled. Second restorative visit. We have the seating jig, and we begin using the jig to seat the abutments. Yes. Nine non parallel implants, and yet we’re able to seat nine prosthetically parallel abutments with ease. Second visit. You haven’t gotten your torque driver out, let alone removal of cement, let alone the passive casting, the checking in the back of the Does that translate into German? It does? I told the the interpreters or the translators that I would speak minimally because the images speak for themselves to those of you who are experienced and discerning clinicians who are responsible for the financial profitability of your practice. Another. How would you restore this? What are the rules for this, Frank? The first visit, take the impression, record the bite. Now the vertical dimension of occlusion is minimal. So minimal, you cannot use the retentive copings. So you simply convert the retentive copings into retentive rings. The only retention comes from the cervical two millimeters. Second clinical visit. I keep mentioning that because it’s not the cost of a component. It’s not the laboratory fee. It’s your time. I’m so grateful for Frank’s introduction, and yet we had no collusion beforehand, but couldn’t have been better, Frank. So even with a broken seating jig, We learned one thing from this particular case, and now we use a clear vacuum press suck down to tell us if, in fact, the teeth have been adjusted or the alveolar ridge has been adjusted identically to how the technician adjusted the stone model. If it’s too retentive, you simply cut out one of the retentive copings and replace it with a nonretentive. Alternatively, it’s too loose, Cut out one of the nonretentive and replace it with a retentive. When you cut them out, I fail to show it, you don’t go around and remove the circumference, but rather you just cut through the coping and you fold it in on itself. And to reline it, chair side, like your patient doesn’t have the taste of methyl methacrylate, you don’t have the anxiety of hurrying. So we’re at the Catholic University of Leuven last fall, I think it was, and Stan Politis, the chief of maxillofacial surgery, said to me, Vin, do you use can you use Bicon on, adolescents? And I immediately said, sure, Stan. And then I said, oh, can we? And I went back and we checked the database, the same wonderful database that Rainier uses. We have a database of some nineteen thousand implants, and it makes it easy for researchers like Rainier to go back and cull it out. The two hygienists that maintain it can give you any data you want. They mine the database, so it makes research easier for people. We went back and we asked them, What have we done for juveniles? And they said, Over twenty years, we’ve treated fifty four adolescents, and we’ve placed eighty four implants. And I said, Oh, good. I told Stan. So let me show you some cases. Age fourteen, age sixteen, Age seventeen. Age twenty three, he decides to have orthodontics. He’s able to afford orthodontics, so we have this ankylosed implant, and there it is after orthodontic treatment. You simply change the integrated abutment crown, which is twist and pull, and you make a different one. There it is age twenty three. There it is, age twenty seven. And as Rainier would say, look at the bone. So that’s thirteen years after the implant was placed when he was fourteen. This was one of the earlier ones, and when we used eleven millimeters, never again. We actually used this tiny abutment very effectively a handful of times. Age twenty eight. Age fifteen. Papillae coming. And as Rainier pointed out, in a very small percentage of the time, the adjacent teeth will continue to erupt, leaving you with a restoration that is too shy. But having used a composite material, ceramage, it was added to chairside. That’s Paolo Perpetuini adding to it chairside. You can’t do this with zirconia. You can’t do it with e.max. You can’t do it with porcelain fused to metal. Did we know seven years before that we had to do this? No. This is why my strong preference is to use these materials and watch the result. There it is. Wow. How old is this patient? Eight years old. Would you place an implant in an eight year old child? No. We would not either. However, having done this presentation around the world, everybody knows Bicon from their perspective. I fortunately have a a broader view. I was doing the presentation in Singapore, and there was an oral surgeon there who thought that fourteen well, if fourteen is good, eight is as good. So he placed an implant at age eight, as you saw. There was no doubt this patient is eight years old, not photoshopped, is it? Seven? No. No no question. Even you know that. Okay. So age fifteen, once again, the natural tooth continued to erupt. But it was not only the eruption of the adjacent tooth, there was appositional bone on the facial of the alveolus. So that the implant that was at one time placed in the middle of the ridge was now palatally positioned, as you can see. But with the versatility of the locking taper, this is not a ridge lap. This will have an emergence profile. They have insertion. So Prof. Seemann in Vienna has just collected the data from the same database that Rainier uses, and he’s publishing a paper on juvenile implants, which will benefit you and some of your patients. I can’t tell you the gratitude that these teenagers have when they’re sixteen or seventeen, and you can take their orthodontic appliance away, or you don’t tell them they have to wait another two years in braces or three years. I’m going to the senior dance. So there’s a lot of psychological benefits simply because this implant can be placed below the crest of the bone. It’s bacterially sealed, and there’s no micro movement. Until you can have another implant that has a sloping shoulder, bacterially sealed, with no micro movement, They cannot have the unmatched clinical capabilities of the Bicon. Choose another implant, whatever motivation, but it will not be for its clinical capabilities. So I said thank you. Where’s Mauro? We all thank Mauro. Thank you very much.