Prof. Estevam Bonfante, DDS, MS, Ph.D.
University of São Paulo, Bauru College of Dentistry, Department of Prosthodontics and Periodontology
Good morning. I feel truly honored to be part of the celebration that marks the forty years of Bicon and the birthday of Dr. Morgan. So I am Estevam. And in this brief lecture, I would like to show you how, but most importantly, why TRINIA can be both beneficial for both of you and your patients, and why it is quite a unique material. So to address this topic, I have divided this presentation in three main topics where we’re first going to talk about the research clinical outcomes of TRINIA, and then I have listed a few clinical attributes of TRINIA that will definitely convince you how and why this material is unique, especially when compared to other materials that are out there in the market. And I would like to close with a clinical case, where we’re now combining TRINIA with 3D printing materials to show you a path that it’s quite cost effective and fast. So if you think of every clinical application of TRINIA from a small fixed dental prosthesis, three to five unit to full arch reconstruction supported by four, three, or even one Bicon implant to vascularized flaps as we have just seen from Drago presentation, you will see that there’s plenty of research supporting everything from Bicon and TRINIA. And if you are able to scan this QR code, you have access to all, if not most of the publications, concerning what we’re going to address here. So the bottom line is TRINIA has been comprehensively, validated through research in the past virtually, fifteen years. And, I have listed five clinical attributes of TRINIA that are especially important for you and your patients, and one of them is modulus of elasticity, which in essence measures how rigid a material is. So TRINIA has a modulus of elasticity, which is very similar to cortical bone. So to give you a sensing numbers, the modulus of TRINIA is eighteen gigapascals and that of cortical bone, it’s exactly eighteen gigapascals. So that’s very important because when a a prosthesis is receiving load and transferring to the bone, if it has the same modulus, it means that it will deform in harmony with the bone. So it’s a natural process. And just as a matter of comparison, the modulus of elasticity of zirconia, it’s more than ten times that of trinia and that of cortical bone. And if you see cobalt chrome, it’s even stiffer. It’s two hundred and forty gigapascal. So that’s a huge difference. You’re making a very rigid splint in bone. So that’s not a natural situation. And if you think of a scenario, especially that of a distal extension, that brings some limitation when you’re working with rigid materials. For instance, if you really look at the literature, this to be on the safe side, you have to be, with a seven millimeter extension on zirconia or chrome cobalt. Okay? But if you go for a TRINIA framework, I would like to invite you to watch this video. What happens is when you apply load to the distal extension, there’s a slight flexing of TRINIA and of the entire restoration, which is especially beneficial to the distal implant. So you can observe within that resin that the distal implant goes through more remodeling than the other implants, and that stimulates bone formation. Okay? So that’s very beneficial. And we have seen that when the distal extension exceeds fifteen millimeters, that’s especially beneficial to the patients. And we have shown this through research. So this prosthesis was placed by Prof. Ewers, and he had a twenty millimeter distal extension. And as we have seen in this publication, which is also available in that QR code, we have observed the bone gain the distal implants, but that occurred when the distal extension was over fifteen millimeters. So this was the first time in the history of the literature, the scientific literature that this was shown. Okay? So this is very important to keep in mind. Another clinical attribute of TRINIA is that its aesthetic properties is very similar to those of human dentin. So to give you a a sense in numbers, the contrast ratio of TRINIA is zero point eight, while that of human dentin is zero, point sixty five. And that’s why, now we have TRINIA endodontic post and core blocks because that makes a fabulous transition to aesthetic restorations. So you can mill posts, endodontic posts, for aesthetic restorations. And, of course, if you think of implant therapy, TRINIA makes an optimal transition for titanium implant abutments to aesthetic restorations. Another clinical attribute of TRINIA, its repairability. So this is a big hit of TRINIA, and it’s quite unique to TRINIA. Keep this in mind. So I was placing this restoration, and it’s individually prepped teeth made of TRINIA, and it was already layered with Ceramage, the gingival part, with individual crowns. So while I was increasing the access hole to place the restoration in place, this was my fault. Okay? So I was increasing the access hole, and I fractured. I eventually fractured the central incisor, which is a tiny tooth. So think of this scenario. This is a very expensive restoration. What would you do if this were zirconia? You would throw it in the trash and do a new one. So I’ll show you how I solved this. So I drilled a parallel hole to the screw axis with a cylindrical diamond bur just to fit an endodontic fiber post, a prefabricated one. K? Then I cemented it onto TRINIA. I built a resin composite, core to refit the crown, and that’s it. It’s a brand new restoration. I could repair TRINIA, and I could cement the restoration back in place. Resolved. Okay? So that’s that’s a very interesting clinical attribute. TRINIA is repairable. You can bond TRINIA to every other material you can think of. So let’s say that you like different materials. So you can combine TRINIA to every material you can think of. So if you are an acrylic dentist, you like acrylic, you can combine a TRINIA framework with acrylic teeth and acrylic gingiva, as you can see in this first case on the left. But if you’d like to customize with individual crowns and do a more, digital workflow with CAD/CAM, you can do individual teeth, and you can bond individual hybrid ceramic or even ceramic teeth, if you like. It doesn’t matter. That’s your choice. And for even more streamlined workflow, now the technician, he can build a one piece monolithic structure with combining teeth and gingiva, which is very, very, straightforward process as you can see there. So the technician then layers a small a thin layer of Ceramage on the top of it, which is a resin composite, then you need a TRINIA framework to reinforce everything, which is bonded to this monolithic one piece. That’s the TRINIA try in and that the one piece monolithic structure is cemented on the top of it, but that structure was milled. Okay? And now the last attribute of TRINIA, we could talk of several other ones. It’s the clinical and scientific evidence because this is what this is about. Okay? And we’re not talking two years, three years. We’re talking more than ten years. So if you think of fixed dental prosthesis, for example, as I mentioned early, the survival of the Bicon implants over fixed dental prosthesis made of TRINIA, we have published, and you have access through that QR code. It’s almost ninety seven percent for the implants and almost ninety five percent over ten years for TRINIA restorations. Think of full arch now supported by four extra short or ultra short and short Bicon implants. You have a ninety seven percent survival rate supported by only three. That’s a multicenter study. Clinical study, ninety six percent for Bicon ultra short implants and ninety seven point eight percent for TRINIA. Even vascularized flaps, which Prof. Ewers will show later, ninety seven point one percent. So that’s huge. And in all these scenarios, we’re talking more than ten years. So every scenario that you can think of, I would like you to keep in mind that TRINIA has been thoroughly investigated for more than ten years. And most importantly, in recent research, as Barbara had shown yesterday, it’s improving significantly patients’ quality of life. And to close the presentation, I would like to show you this clinical case of this twelve year old boy. So he has ectodermal dysplasia. And, as you can look at the pictures, especially the ones on the left, he is a very sad kid because he can chew food. He cannot chew food. He doesn’t smile. And most importantly, he is one hundred percent sure he will never get a girlfriend. So he’s very concerned about this. And as you can see in this first picture here, he does not only have his missing laterals, but but he has not, several congenitally missing teeth. So on the occlusal view, you can see that he’s almost edentulous in the mandible. You can see he has a very thin, ridge. But as we had seen later, he he did have sufficient bone for the placement of three implants in the mandible, and he’s missing the four premolars, and he’s also missing the laterals. So he cannot chew food, and he cannot speak properly. And as you can see in this view also, he has a very limited prosthetic space for a new reconstruction. So in order to place any kind of restoration here, we needed more room, and that was achieved only by an increase in the vertical dimension of occlusion. So I remember talking about this case with Dr. Morgan, and, and I I said, you may be wondering, so I are you even considering dental implants in a twelve year old kid? And I remember talking and and Dr. Morgan said, well, it’s logical to do it. Think of the entire scenario. This kid has a very poor removable prosthesis, anesthetic. He’s not happy with it. His social acceptability is very low. He has a a poor self esteem. He has zero function and aesthetics that is kind of compromised. His quality of life is zero, and that overall, it’s imposing him a very negative psychosocial impact. And I decided to look at the literature to see if that wasn’t a crazy move. And if you look at that paper, that paper is talking about placing implants in children with ectodermal dysplasia and congenitally missing teeth. So what happens in these cases in particular is that bone in the absence of teeth, it simply does not grow. There’s minimal growth. So if you think of all the burden that this kid is going through, you know that these burden certainly are outweighed by the benefits of dental implant therapy. So what the literature show is that there is minimal bone growth, especially in the anterior mandible because of the absence of teeth of congenitally missing teeth. And if you place implants, that’s the success rate. Ninety percent. It’s just like in adults. Okay? So we’re safe to do it. And that’s what we did. We placed three implants in the mandible and six in the maxilla. And here, we have already increased the vertical dimension of occlusion by placing, composite resin the posterior teeth. So you can see already placed on the right side and then on the left side of the patient. That’s the amount that we have increased. And a few days after surgery, the kid is happy. He’s leaving with provisionals, and that was the first time we saw him happy because he was being able to chew. So this is an occlusal view. He’s still going through orthodontic treatment just to to get a better positioning of the canines. So we decided to go through a work flow here where we would have a TRINIA framework combined with a 3D printing. And we have done all the planning in exocad. And you may think, do we really need a TRINIA framework to support a 3D printed final material, final restoration? Yes. We do, and I’ll show you why. You have probably seen this video yesterday, but this is a final 3D printed material from SprintRay, and you can see the amount of deformation, of plastic deformation. That means that it deforms and it never comes back. Different from TRINIA that suffers elastic deformation that once the load is applied, it does flex, but it returns to its original position. So that amount of deformation, it’s quite negative to the implants and to the case itself. So you do need a TRINIA framework to avoid this undesired deformation. And so we decided to go through a workflow where we have 3D printed separately the gingival portion and the teeth portion, and then we have combined them. The system that we have used here is Lucitone Digital Print Denture System, which is not a provisional material. It’s made for final restorations, and the entire 3D printing was done in the Primeprint system from Dentsply. So here are the separate, teeth and gingival parts. Now they’re combined together with the proprietary resin from Dentsply, and we don’t very much like the pink uniform color. So what we usually do, we have a technician not doing a staining. He does apply a thin layer of resin composite to make it look more natural. So you have a 3D milled TRINIA and the gingival and teeth combined, and this structure fits perfectly onto the TRINIA framework. Fits very, very nicely. So first, you do the trying of the TRINIA framework, and you cement everything on the titanium interfaces and the mouth, and then you can cement the TRINIA into the one piece monolithic structure extra orally. So this is how this is accomplished, and TRINIA can be cemented extra orally. So that’s the TRINIA. So it cannot be more passive. Once you you capture and you cement all the titanium interfaces in the mouth, it cannot be more passive of a fit. And then you cement the one piece monolithic structure. And you as you can see, the screw access holes remain open for retrievability, which is a nice thing for the future. And what we always do, we place a layer of Ceramage in the gingival portion to make it easier for the patient to clean. So this is the final aspect of the restoration. The patient was very happy. And as a closing remark, Bicon has a timeless quality for forty years. And some may say that remained unchanged, but it evolved a lot significantly. But once you have a very nice implant design where bone evolves into the Haversian like structure, you don’t need to change it. Different from every other company where they have to launch, you know, one different design every other year or every IDS here in Cologne. So that’s a very important thing. And keep in mind that over ten years of follow-up for full arch reconstructions, the TRINIA restorations over short and extra short Bicon implants have shown very, very high survival. And 3D printed one piece structures cemented onto TRINIA can be a repairable, fast production, cost effective, way of restoration and may well be the wave of the future. And to close this presentation, I would like to invite you to watch a video, where we celebrate the legacy of Bicon and all the leadership of Dr. Morgan. This year, we celebrate a remarkable milestone, forty years of Bicon, a company that forever changed the landscape of implant dentistry. Bicon introduced the first truly successful short implant in history, including the revolutionary 4×5 ultrashort implant. Nobody believed it worked, right? But it did. It’s all about implant design and its unique osseointegration pathway. And of course, the hermetically sealed implant abutment connection. This combination along with TRINIA have shown a huge impact on the long term success of simple and complex reconstructions. But most importantly, it improved tremendously the well-being of patients. Much of these innovations is thanks to the vision of Dr. Morgan, who also celebrates eighty incredible years. I have had the privilege of knowing Dr. Morgan for almost twenty years, and he has not only inspired me as a clinician and researcher, but also encouraged me to ask the bold questions. Because of his friendship, I have pursued research that helped validate answers for several relevant questions. It’s been a joy to learn from Dr. Morgan and an honor to celebrate this moment with him and the entire Bicon family. Thank you.