Unmatched Clinical Capabilities of TRINIA®

Hello, welcome to our presentation on the unmatched clinical capabilities of TRINIA. I am Vin Morgan, the general dentist and CEO of Bicon. Along with Dr. Estevam Bonfante from the University of Sao Paulo in Bauru, we shall hopefully present you with meaningful material about not only the composition and physical properties of TRINIA, but many examples of its clinical use, which should offer you and your patients many financial benefits. TRINIA is a ten year old revolutionary material comprised of roughly forty percent resin and sixty percent fiberglass. It’s a CAD/CAM material. It is similar to the material that comprises over fifty percent of Boeing 787 Dreamliner. It will allow you to treat your patients in less time, fewer appointments with greater flexibility, which all amounts to significant financial benefits to you and your family. For example, if you can treat a patient in only two clinical visits instead of three, or only two visits instead of four appointments, you can eliminate either thirty three percent or fifty percent of your potential failed appointments. A failed appointment is a very expensive event. Let’s take a look at a video that will demonstrate to you a significant difference between zirconia and TRINIA. Yes, with TRINIA, you’ll never have a catastrophic event. What a benefit to not only you, but to every dental technician. Think about it, you’ll never have a catastrophic event. Combined with the 360 degree positioning of the Bicon abutment. TRINIA can provide for you a whole new way of inserting prostheses. For example, the following video will demonstrate a revolutionary way of seating a four unit bridge. The impression for the prosthesis is nothing more than a round peg in a round hole. You put the impression post in, you slide the sleeve onto it, And then you take a conventional impression. The accuracy of the components and of the TRINIA itself and its framework provide you the opportunity of going directly to seating the finished prosthesis without a frame try in. On the second visit, you loosely apply the abutments into the prosthesis, you transport the abutments to the mouth in the prosthesis, they orient and seat the abutment, then you engage the abutment more definitively, you place vaseline over the pontic area of the prosthesis to facilitate the removal of extraneous cement. And you cement the prosthesis with any resin cement. It’s totally passive. And if it were not, you simply can use a finishing bur to adjust the internal bore of the prosthesis to make it passive, because it need not be a precise fit, mending with resin cement which bonds to the TRINIA and cements to the titanium post. The clinical capabilities of TRINIA have placed us in a situation where we can no longer justify using implant retained overdentures. Consider a tissue borne implant retained overdenture is time consuming and maintenance intensive. If you were to put a pencil to the paper, you too would realize this. For a tissue borne overdenture, the first thing you must do is record the mucobuccal fold in the impression. As opposed to for an implant borne prosthesis, you simply have to record a portion of the ridge and a portion of the impression post, significantly less time. Then when it comes time to inserting the prosthesis, the implant retained tissue supported has the potential for many sore spots. Whereas the TRINIA prosthesis has no contact with the soft tissue, and therefore you do not have the potential for sore spots. I don’t know about you, but I have often spent more time adjusting a denture than fabricating it. And yes, that’s time and that is money. Then it comes to the maintenance of the two prostheses. The tissue borne prostheses must be relined in order to maintain the support of the soft tissue, whereas the TRINIA implant prosthesis has no tissue contact and does not require the regular maintenance of being relined. This greater flexibility, apart from the scientific laboratory explanation of it, is simply understood by saying it’s easily modified with a finishing bur. Says a lot. Very difficult to cut zirconia, very difficult to cut chrome cobalt. Then additionally, everything bonds readily and well to TRINIA. Think about it, chairside restorations as opposed to laboratory procedures. The two physical or mechanical properties that enhance the merits of TRINIA are its modulus of elasticity and its flexural strength. As such, because of its flexural strength, you can have a canine positioned implant and provide your patient with a first molar occlusion. TRINIA cannot by definition be a lever or a cantilever. The definition of a lever and a cantilever requires a rigid structural object. TRINIA is not rigid. To help you understand why we say the longer the distal extension, the better. Possibly this graphic will help you. If you were to have a rigid bottle opener, the lever would facilitate the removal of the cap. However, if the bottle opener were flexible, it would not exert the necessary force to remove the cap as was done by the rigid object. And then the longer the bottle opener, you can see the less effective it would be to applying force to the bottle cap. So much for Ante’s law. Clinically, you can see an example of Dr. Ewers in Vienna. He had an implant that because of sensory dysfunction, he was unable to load the right implant. So the prosthesis has existed on only three implants for five years. And yet the most distal implant is the central incisor. So a central incisor positioned implant providing a first molar occlusion for his patient. This concludes our initial introduction to TRINIA. Now we will have Dr. Estevam Bonfante provide you with the science and his research projects associated with TRINIA. Esteban, please. Hello. It is a great honor to have you watching this webcast and which is a great initiative by Bicon. So moving on to our topic, we believe there are three very important questions that you might want to have answered before you start seeing other clinical applications of TRINIA. And these are what is TRINIA or where does it belong among the classes of restorative materials that you’re already familiar with. The second question, do we need TRINIA, is here because we would like to present you some very recent evidence showing how the other all ceramic materials such as zirconia, how they perform clinically from very recent and reliable publication sources. And to answer the third question which is what is TRINIA’s laboratory and clinical performance, We’ll show you some research results that started from ten years ago. So perhaps hopefully when you start using TRINIA in your practice you know what to expect. So what is TRINIA anyway? Well according to the latest American Dental Association definition of porcelain and ceramics, and this is public information, it’s available at their website, they define porcelain and ceramic as a pressed, fired, polished, or milled materials containing predominantly inorganic compounds, including porcelains, glasses, and ceramics. So note that the word predominantly changes everything. It means that materials that are highly filled with glasses or with ceramics embedded in a polymer matrix and available for blocks or discs in CAD/CAM, they’re now considered since twenty thirteen by the ADA as porcelain and ceramics. So with that in mind we have proposed a new classification system for all ceramic and ceramic like restorative materials where you see two families of materials that you’re mostly familiar with, which are the polycrystalline and the glass matrix ceramics and based on the ADA classification, we have proposed a classification of ceramic like materials called the resin matrix ceramics and that’s where TRINIA belongs since it has sixty percent of glass fibers and forty percent of resin. Now there are two very important things to know in this slide, Among the three materials that we see here, pretty much all of them, it’s what we use in our practices, and all of them are available for CAD/CAM. But two families exclusively made for CAD/CAM, which are the polycrystalline and the resin matrix ceramics. And the second important thing to know here is that you can combine families in order to make aesthetic restoration. For example, you can combine a polycrystalline zirconia framework to a porcelain which belongs to the first family of glass matrix ceramics. But TRINIA is such a universal system that you can actually combine them with any material of these three families or to most of them. Let’s say you’re a lithium disilicate user and you want to make a full arch restoration and well you can bond the lithium disilicate crowns to TRINIA. The same with feldspathic porcelain and even if you’re a zirconia fan, you can bond up a monolithic zirconia or a veneered zirconia to a TRINIA framework. But as you shall see today, believe that the most rational use of TRINIA is with materials that belong to the same family of resin matrix ceramics such as Shofu HC blocks, Cerasmart (GC) and some others that we’ll show you today. So I believe that some of you may be wondering why glass fiber reinforced composite was chosen as a material for TRINIA, and the reason is pretty simple. It’s because of its lightweight, it is somehow straightforward to mill, because of its flexibility and yet very strong mechanical properties and especially the ability to be repaired. Also, if you look around, fiber reinforced composites are in many, many engineering and biomedical applications such as to replace tendons, ligaments, intervertebral discs which only proves its very high biocompatibility. And I wanted to take a closer look at the Boeing seven eighty seven, the Dreamliner case because this was a game changing in aviation industry. For the first time, a plane was now comprised of fifty percent of advanced composites, including fiber reinforced composites. A big part of it is on the wings, on the mainframe and the cabin and the bottom of the plane and the fuselage. And obviously not only because the wings need some degree of flexing, reduces the overall weight of the plane so it will eventually take up less fuel, but most importantly and the key reason for the Boeing seven eighty seven having so much composite in it and fiber reinforced composites is the ability to perform bonded composite repairs. So the airline companies, they are able to do this within just a few hours. So they can do very efficient repairs within hours instead of days or even weeks, which used to be the case with other materials made up for an airplane. And if you think of a financial aspect, it’s a disaster to have a plane grounded for one day or a few days for maintenance. From financial perspective, it’s really not good. And so this strategy of having so much composite eventually reduced the overall maintenance costs and maximized airline revenues. So I want you to think of TRINIA with the very much same rationale here. TRINIA, if you design it properly and you will see that there are some specific design parameters that Dr. Morgan will show you, but if you design them properly, the framework itself will rarely fail. But the composite that goes on top of it to veneer it, just like any other material, it may chip. But if it chips, you have the ability to repair it chairside very quickly, just like in the Boeing seven eighty seven. I know that this all makes up a very nice story, but the main question is do we really need TRINIA? And I’ll put this question in a different way. Should we expect any technical complications with the other all ceramic materials that are available for implant supported reconstructions? I believe that you likely agree with me that if the other materials are behaving phenomenally well, then perhaps TRINIA is just a very, very attractive additional alternative, which happens not to be the case. So I’ll divide this answer in two sections. So we’ll first talk about fixed partial dentures and then full arch. And these are the results from the latest European Academy of Osseointegration consensus that was published a couple of years ago, where they showed that for fixed partial dentures supported by implants, they have observed a twenty to fifty percent rate of porcelain fracture that only within five years. So think of it, if you think back in your practice, almost half of your patients coming back for a repair or likely a replacement of a zirconia bridge, that’s really not profitable and not really good for your practice. And moving on to full arch reconstructions supported by implants on zirconia veneered, these fracture rates within five years reached almost thirty five percent. So all these very high rates of failure within the porcelain veneer for zirconia reconstructions led the authors to eventually conclude that these are clinically unacceptable. So we obviously need new materials and this is a very important and interesting publication that I highly recommend you to read because it compiles everything that has been published on zirconia fixed and full arch prosthesis of the best designed clinical studies. And if you really want to stay away from maintenance issues as Dr. Morgan mentioned, literature has shown that overdentures have been associated with very high biological and mechanical complications. And these include the need to replace the retentive elements, need of constant relining sessions, repair of the resin portions and even implant fractures. And if you look at this other study which shows the use of the three very very commonly used systems for over denture retention, this study showed that all of them required maintenance of the retentive elements. That’s only within one year. So overall, this doesn’t seem to be very encouraging nor profitable for your practices. And the other aspect is that we all know that our mandible flexes. So the human mandible presents three different and simultaneous patterns of functional deformation. So while we open our mouths, while we do some protrusion, while we chew, and basically when you insert a cemented or screw retained full arch zirconia or titanium or any metal reconstruction, you’re basically doing a rigid splinting in the mandible. So you see the cortical bone has a modulus of elasticity of eighteen gigapascals, whereas zirconia has a modulus of two hundred, which means it’s ten times more rigid. This number, it’s the modulus of elasticity which shows how much the material can bend without suffering permanent deformation. And titanium is five times more rigid than the natural mandible, while TRINIA has the same modulus of elasticity of cortical bone. The point is we don’t really know what’s the impact of mandibular deformation on the long term, but we can definitely not exclude the fact that all the stresses and the strain that may be imposed in the bone implant interface and at the prosthetic components will not eventually cause some type of clinical complication in the future. So bottom line is, TRINIA is compliant with bone deformation, mandibular deformation. And this video shows exactly the amount of deformation that TRINIA can suffer. So see there’s a load being applied in a typical flexural strength testing. You see that TRINIA is deforming. If I remove this load, TRINIA will come back to its original shape. So this is what a modulus of elasticity measures. And if I keep pushing until the material yields, then I can apply some formula to the load, to the area and eventually get the flexural strength properties of TRINIA. But you probably were able to see the amount of flexing that it’s able to carry. Now before we show the clinical capabilities of TRINIA, I would like to show you some of the research that has been carried out a few years ago regarding the use of TRINIA for three unit fixed partial dentures and five unit. So in the past we have compared TRINIA veneered prosthesis with porcelain fused to metal, with porcelain fused to zirconia, and we even had a group of TRINIA with a connector area of only three squared millimeters which is a heresy. You can never apply that in the posterior region for any any all ceramic material including zirconia. You could use that in the anterior region but not in the posterior area. What we have observed in these studies that we published five and ten years ago was that TRINIA survival was equivalent to porcelain fused to metal which is up to these days is understood as a gold standard material. And it was significantly higher than porcelain fused to zirconia. And what I really want you to keep in mind is that when TRINIA prosthesis fails under very high loads, this is what you usually see. We don’t observe, we have never actually observed a TRINIA framework fracture that was properly designed, but the composite that chipped, it’s a composite that can be roughened, you can apply some adhesive, and you can get it back to function right away with bonding composite chair side, just like in the Boeing seven eighty seven. Now, you do a repair in a porcelain fused to zirconia? Well, yes, you can, but you have to sandblast intra orally, then you have to apply hydrofluoric acid, which we all know it’s toxic. And at the end you end up having composite, a resin composite bonded to porcelain, which are materials of different optical properties and you will always have an interface that will eventually stain with time. Has zirconia improved over time? It certainly has but this is a very recent study that was published just a few weeks ago by Dr. Ryan and his team from Beirut Arab University and again they showed that TRINIA survival was significantly higher than porcelain fused to zirconia. So there are still a lot of challenges for improvement. This is something that we are sure of. This is what makes TRINIA a very interesting material. So moving on to TRINIA as five unit bridges and this pretty much represents a segmented full arch reconstruction. And we believe that the shape that you see, which is a TRINIA prepped tooth shape framework design, it’s really a state of the art because it reduces the amount of veneering material, it reduces time to fabricate a prosthesis and obviously reduces overall costs. What we were actually investigating was what would be the best way to use it as a material that would be manually veneered or just with CAD/CAM blocks cemented to TRINIA. And as you see, these are the two configurations that we have tested and actually both of them worked very well. They both fractured under loads that were very, very high and way above a maximum bite force for humans. But we were really interested in the SHOFU blocks bonded to TRINIA because it’s time effective. You can mill the blocks and bond them to TRINIA as we will show subsequently. So we designed this study and I’m showing this video so you will see how the bonding protocol should be done. And for this study, used eighteen five unit bridges. We milled a total of ninety crowns. And one very important thing to do both on TRINIA and on the surfaces of the composite blocks of the Shofu HC Blocks is to perform some sand blasting. So we do that with fifty micron aluminum oxide particles for ten seconds. And that’s a very very important step because it will eventually increase the surface area for bonding and it significantly improves the bond strength. So we always want to sandblast the surfaces prior to bonding. Then we clean the surfaces with ethanol, we do the try in which is usually a blessing if you use the correct milling strategies and if everything has been digitally designed, you usually have no issues. We have been using Shofu Ceraresin Bond as a bonding agent. So they come into two separate bottles, one with primer, the other one with a bonding agent. So you apply both of them into the the cementation surfaces of TRINIA and of the SHOFU blocks and you really have to apply a very very thin layer not to interfere with the seating of the crown. But basically you apply a thin layer of the primer, let the primer evaporate, give it one minute for solvent evaporation, then you apply the bonding agent, also a thin layer, you photo cure it, and then you can choose any type of resin cement that you like. It should be dual cured or even self cured. We don’t recommend photo cured cements obviously because of the ability of the light to reach the surfaces. And at the end you seat each and every one of the crowns, you remove excess cement and then you perform a final photo cure for twenty seconds on each surface and then you have your bridge ready to be cemented. And for this study we wanted to see how the prosthesis, the five unit behaved as a whole. So we delivered loads into the first bicuspid, into the second molar and in the very center of the pontic where we believed that the worst results would be observed because that’s where most of the bending and of the flexing would be. And then we statistically combined all the data to see how the system behaved. So when everything was combined we have observed that the three occluding surfaces resulted in very very high loads to failure during fatigue above twelve hundred newtons. And to our surprise in the area where most flexing occurred, that’s the point where TRINIA was most resistant. So overall the TRINIA framework worked very, very well. And just like we have observed previously, all the failures were confined to the Shofu HC Blocks, which means that we can still repair them. But remember these with such high bite forces, we probably won’t see such extended failures as you see here. But even if you do, you’re able to repair chair side. So as a take home message, remember, according to the latest EAO consensus, the current materials that are available, the all ceramic ones for implant supported short and long span prostheses, still fail to deliver the best performance. They are still clinically unacceptable and TRINIA’s laboratory findings support clinical use and clinical research that has been conducted over the past ten years do support routine use. Just to give you one example, this prospective clinical study of TRINIA used for full arch reconstructions supported by only four short implants showed a ninety four prosthetic survival rate over five years. So please stay with us and I’m sure you’ll enjoy the clinical applications that Dr. Morgan will show you. So back to you Vin. Thank you, Estevam. Now to show you our ten years of clinical applications, which should convince you to the merits of this revolutionary material. As I have spoken for years around the world, I’ve used the phrase hearing is one thing, seeing is believing, and doing is knowing. So let us show you so that you can believe what you see. TRINIA can be used on natural teeth as a coping. The merits are you’ll have excellent aesthetics. And if you were to have an open margin, it’s readily sealed chairside with poly ceramic material or with a resin cement. And you no longer will have metallic looking margins, you just won’t. Additionally, for removable prosthetics, TRINIA is an excellent framework. In designing it, you would use the software of the clasp, you’d use the settings for gold clasps. The merits of a TRINIA partial are not initially seen, but in the elderly patient who has a four or five unit porcelain bridge that fails all at one time, it’s not an issue because you simply can bond four or five, six units directly to the framework. You do not have to look for mechanical retention. Additionally, TRINIA can be used as an obturator. Although most of you probably have never fabricated an obturator, it can be challenging because if it’s a little too long, it’ll irritate the soft palate. But that’s simply adjusted for the finishing bur. Big difference between that and chrome cobalt. And if it’s a little too shy, then you’ll have water coming through the nostrils of your patient. But that’s not a problem because a minimal amount can be added to the prosthesis like cured and removed. So the flexibility of being easily modified and readily bonded to enhance the fabrication of obturators. But temporization, the wings of a Maryland bridge, if you will, can be very beneficial either bonded or mechanically locked to the adjacent teeth because they’re very strong and very thin dimensions. Now, TRINIA can be cement retained as you can see on the Bicon abutments or screw retained, as you can see on the zygomatic implants. So for Tom De Wit in Belgium, a one piece TRINIA prosthesis was minimal chair time. Think about it. No issues about being passive or rocking, etc. It’s a boon. It’s a boon to all of us. Let’s take a look at another four unit bridge done in two restorative visits. This time, a mandibular prosthesis. And in order to facilitate the transporting of the abutments, place a little Vaseline into the prosthesis, and that’ll prevent gravity from having the abutments fall out. They’re loosely positioned and transported to the well of the implant, wiggled and jiggled and seated. Once they’re initially engaged, remove the prosthesis and once again apply Vaseline to the undersurface to facilitate the removal of extraneous cement. This concept of using the prosthesis or a seating jig to transport, orient and seat the Bicon abutments will be seen throughout this presentation and it will be particularly important on the full arch restorations as you shall see. Two restorative visits, Think about it. No longer do we use the words cut, solder, they just have not been part of our dental jargon for ten years. You too will enjoy this benefit. Another example of the merits of TRINIA, even when implants are not parallel. Clearly these implants are not parallel, however, the first restorative visit is simply placing two round pegs into two round holes. Couldn’t be simpler, of course you have to wait for four minutes for the impression material to set. Once the model is fabricated, then scanned, the TRINIA framework is milled, the poly ceramic material, Ceramage is handcrafted onto it. And now the prosthesis is going to initially orient the canine abutment. Once it is engaged, the prosthesis is removed and the distal abutment is inserted into it and transported to the third molar implant. Yes, two clinical visits, effort, minimal time, and clearly non parallel implants. And once again, Vaseline is applied to facilitate the removal of extraneous cement. The following video will demonstrate the immediate placement of an implant and the impression of the prosthesis on the day the implant was placed. And on the second clinical visit, the final prosthesis was inserted. On the first visit, the fractured tooth and bridge was removed, as well as a six year old IAC on the upper right, the implant was placed, an impression was taken of the newly placed recently immediately placed implant and the six year old implant. After the impression, the implant was covered, healing plug was cut bone was grafted over it. Then IAC received a universal abutment and a temporary prosthesis was fabricated, which was mechanically locked to the left central. Three months later to the day, as a matter of fact, the newly placed implant was uncovered and the final prosthesis had been sitting on the shelf waiting to be inserted for two and a half months. And it was initially tried in with the abutments and then subsequently a seating jig was used to definitively tap the two abutments. Once the abutments were tapped into place, then the prosthesis was again tried in and adjusted where the extraction site had been and finally cemented with a resin cement. So there you have it, only two visits to place the implant and take a final impression on the first visit and on the second visit seat the final prosthesis. Hard to believe, not really. And subsequently, the patient had the TRINIA prosthesis placed on his upper left two years later. Now let’s discuss the full arch prosthesis with TRINIA. In order to achieve clinical success, certain techniques must be followed in the lab. This video provides an overview of those critical techniques. Use only three or four appropriately spaced implants to facilitate the fabrication of the prosthesis. Five or more implants unnecessarily complicates the prosthesis. If possible, place three implants while there are still teeth present and then extract them when the final prosthesis is being inserted. The prosthesis can be cemented directly onto an abutment. It can also be retained with screws with fixed detachable abutments, or you can have telescopic restorations with custom cast copings. And finally, which is our preference is to have a telescopic prosthesis with retentive copings, which is clearly the most cost effective and the one that we prefer to use. Cement retained, it’s nothing more than what you saw with the cementing of the four unit and five unit bridge previously. Resin Vaseline on the pontic resin cement. One caveat that you should be aware of is that for strength, you must maintain two millimetres of TRINIA over an abutment. This is where the TRINIA prosthesis gains its strength. So please remember that you must not reduce the occlusal thickness of TRINIA. This was one of our first TRINIA prostheses. And you can see we use Candulor composite teeth for the interior for aesthetics onto which we lengthen the teeth chairside by adding poly ceramic material to the Candulor teeth. There’s the aesthetics after eight years in function Screw retained prosthesis. As you will note, because of the positioning of the implants, this entire prosthesis is a distal extension. Think about it, the entire prosthesis is distal to the implant. And yet it works and has for some seven or eight years with a screw retention. Custom telescopic copings is a ubiquitous treatment in parts of Europe, not in the United States. But the coping is inherently retentive on the abutment. Yes, each coping is inherently retentive and resists displacement on each abutment. It’s fabricated by a wax pattern with a little plastic insert which provides retention and can be exchanged. There’s a white, yellow and red all having different degrees of retentiveness. But it’s a laboratory intensive procedure, and it is not our preference. However, because of the positioning of the implant, sometimes it is necessary for aesthetic reasons to use these custom copings. The following video will show you the use of these custom cast copings. The temporary abutments are removed. That’s what you’re looking at the soft tissue well, guide pins are placed to indicate the trajectory and also to support a sulcus former, which prepares the sulcus of the implant so it will receive the appropriate five millimeter universal abutment. After the wax try in, the copings are seated on the abutment, and then they’re picked up or rather cemented the resin cement into the bores of the TRINIA prosthesis. Note the distal extension of the prosthesis. That’s it. It’s a resin cement, the bores of the TRINIA can be very passive. Doesn’t does not have to be a precise fit. You can add to if there’s a void around the coping, you can add to it, remove the excess but notice the distal extension. There it is a few years later, note the distal extension of twenty five millimeters, seeing is believing. Our preference, as I mentioned, is the universal abutment retentive coping. It’s used with the five series universal abutment of either a standard profile or a tall profile. It is not used with low profile. The coping is not retentive inherently on any one universal abutment. It gains its retention from being attached to another coping. So it’s the divergence amongst the abutments that gives the retention to the retentive coping. The beauty of these copings is they can still provide retention, even though the entire coronal portion of the coping has been removed. A couple of millimeters of the cervical coping ring will provide the necessary retention. An example, the abutments are readily removed from the implant analog with a simple cotton pliers. Vaseline is placed into the seating jig so the abutment is placed in loosely and transported to the implants with the seating jig. The seating jig will definitively seat abutments in the well of the implant, then the seating jig is given an initial tap to engage the abutments and then removed, then a definitive tapping of the abutment is applied directly. And once again, the cotton pliers facilitates the removal of the abutments from the implant analog. And once again, Vaseline applied to the seating jig, which facilitates the removal of the jig without displacing the recently seated abutment. Essentially the same technique you saw when we were using the prosthesis to orient and seat the abutment. The jig is initially tapped and then the individual abutments definitively seated by tapping on them. That’s it. The jig is removed without removing the abutments, Then the prosthesis is tried to see whether it fits over the abutments. And if it does, then the coping is placed onto the abutments and the prosthesis is once again tried in. And if it fits, you may have to do nothing. Or you may have to just reduce the internal bore of the prosthesis and you cement it with a resin cement. Vaseline is placed into the retentive copings to facilitate their removal when they are attached to one another with the prosthesis. Remember, the prosthesis gains its retentiveness from the divergence amongst the abutments. The prosthesis is tried in over the copings, removed and checked to see if there’s any adjustment necessary. There’ll be a little black mark inside the prosthesis. And if there is none that has to be adjusted, replace the Vaseline to facilitate the removal of the extraneous cement from the pontic areas, inject your resin cement into the bore of the TRINIA, and cement the prosthesis. It’s as simple as that. The following presentation rather will demonstrate the fabrication and two year follow-up of two full arched retentive telescopic restoration. Impression is taken, the model is poured, recording of the vertical dimension of occlusion, the traditional recordings that we do for any denture patient, gothic arch we find very helpful relation. Then the laboratory fabricates the seating jigs to facilitate the removal of abutment once again, we use a simple cotton pliers, the seating jig transports the abutments loosely to the implants, they’re tapped in place, then the prosthesis tried on to the abutments, no adjustments are necessary. Then we apply Vaseline to the retentive copings, seat the retentive copings and then try in the prosthesis again. If there’s a little black mark, we’ll do an adjustment of the bore of the trinea with a finishing bur, and we’ll apply Vaseline to the pontic area, add resin cement to the bore, seat the prosthesis. There is finished prosthesis, the occlusion, the aesthetics. After two years you can see there’s staining and it can be readily removed. That’s after the cleaning. Note the occlusion is still balanced after two years in function even with very thin shim stock, soft tissues quite happy after two years radiographically at the two year follow-up. You can see on the radiograph that you have the TRINIA framework, then you have milled anatomic teeth. If friction wears and you get rotation or you have loss of retentive, this all you have to do is simply rotate an abutment, just increase the divergence amongst the abutments and you will achieve a newly retentive prosthesis. It’s as simple as that. Just a slight rotation, as you can see the patient immediately knows it’s more retentive. Yeah, I’m happy. Relining. This is also very beneficial procedure for both you and the patient. You do not have to coordinate patient’s time, your time and the laboratory’s time. It’s a chairside event. You simply clean the surface, prepare it with the bonding agents, and then use a poly ceramic material. Poly ceramic material comes in many gingival shades, place Vaseline into the bores of the prosthesis to facilitate its removal. And then after kneading the poly ceramic material to soften it, you apply it and you can apply the entire prosthesis or just an inch. And unlike do a chair side reline with methyl methacrylate, which has a bad taste and you’re under time pressure to achieve it. There is no pressure with this and there’s no bad taste. Use the spatula to facilitate the movement of the material. The more you spatulate, the less you’ll have to polish. On your final addition of light curing use the oxygen barrier and then mechanically polish it. That’s it, no involvement of a laboratory technician coordinating in schedules are necessary. What a boon to you and your patients. Full arch re line, no bad taste, no time pressure, no coordination with the laboratory. Full arch prostheses on two and three implants. Well, we restored our full arch prostheses on four, however, for a variety of reasons we found out that three implants are perfectly sufficient in both the mandible and the maxilla? Yes, well, some people discuss the all on four technique, which they’re now saying maybe all on five or all on six. We’re saying to our surprise all on three instead of all on four. And we’ll show you. Look at that span. Hard to believe it’s reality, however, there’s the copings seated nineteen millimeter seventeen millimeter distal extensions on three implants. A twenty five year old implant retained overdenture was replaced with a TRINIA prosthesis. The patient came back for his first visit after twenty five years, at which point he had lost an implant and we fabricated both an upper and lower TRINIA prosthesis on twenty five year old implants. And it’s the same same technique as you’ve seen, use the seating jig to transport the abutments to the wells of the implant. Once you tap them in, you put the copings on, you try the prosthesis onto the copings. If they fit, use a resin cement to pick the copings up, you remove the resin cement measure the twenty five millimeter distal extension. Yes, canine position implants first molar occlusions and twenty five year old implants to full arch TRINIA prostheses. Another is incumbent upon you not to remove all of the patient’s teeth. We kept these four broken down lower incisors because they provided for us landmarks, especially for the technician. Think about it. No need to worry about orthodontic restoration. The first visit after the consult, we placed the implants and three months later, our first restorative visit began where we uncovered the implants, the sulcus former to shape the sulcus of the implant, and then we recorded the impression with two blue two point five millimeter impression posts and two three millimeter impression posts and the existing teeth. Patient went home, impressions went to the laboratory, laboratory chose the abutment, reduced the anterior teeth from the model, fabricated the appropriate seating jigs and the final prosthesis. On our second visit, we remove the temporary abutments extracted the four anterior teeth use the seating jigs to apply the universal abutments. Then the abutments were in place three retentive copings and one custom coping were applied the prosthesis was fitted and you can see needed to be adjusted those are black marks. So we adjusted it picked up the four copings then we had to realign the prosthesis because of the extraction site and the resorption. Another first restorative visit, we took the impression patient had three existing integrated abutment crowns, the patient is in poor health, ninety some odd years of age, three hours from our practice. And in two visits, we’re going to treat this woman. First visit, take the impression, send the bite and the impression to the laboratory. The laboratory chooses the abutment, has a wax up comparable to the existing teeth that she had. There are the abutments, the seating jig laboratory fabricated plastic framework. It’s easier for most technicians to see and touch the framework rather than just viewing it digitally. Once it was approved and modifications were made to the initial plastic framework, it was scanned and the final TRINIA prosthesis was fabricated. And then anatomic teeth were milled of millable poly ceramic material. It’s easier for a technician to fabricate or design rather milled CAD/CAM teeth as if they were individual teeth on post than trying to mill a full arch on a simple bar. So there it is. And on the second restorative visit for this ninety year old patient, we have the final prosthesis. We extract the remaining teeth, use a sulcus former on her existing implants and just watch. As we said, hearing is one thing, seeing is believing, and doing is knowing. You shall see exactly what we do and have done for ten years. Seating jig transports and orients the abutments and initially seats them. Then the tapping of the jig more definitively seats them. And then tapping directly on the abutments is the final seating of the abutment. So there’s two abutments on the left, the jig is removed that has been vaseline the facilities removal, then a definitive seating of the abutments. And now we’ll go to the right side where there’s only one abutment and once again a seating jig will transport it. Remember, this is the second visit for a ninety year old woman who’s in poor health and who lives some three hours from our dental office. The three abutments are now in place. And now it’s a matter of trying the copings on and the prosthesis. Once again, Vaseline is applied to the coping so that when they’re united in the prosthesis, it will facilitate their removal without removing the abutment. When we deliver a prosthesis to a patient, we also place Vaseline to facilitate the initial removing and inserting of the prosthesis. So the three retentive copings are in place. Now we’ll try the framework and then if it fits, then we will fill the bores of the TRINIA with resin and cemented. In this particular case, we adjusted one of the bores where the TRINIA framework was not fully seated. Vaseline is placed as you’ve seen over and over to facilitate the removal of extraneous cement. In this particular case, since the extraction site were significantly without bone, we had to reline the prosthesis on the same visit. And that is simply done by cleaning the pontic area using the bonding agent and then poly ceramic material is kneaded. And the more you knead it, the greater the handling capabilities it becomes soft. And then the use of a spatula is highly recommended. The more you spatulate, the less you’ll polish. And you’re under absolutely no time pressure whatsoever. There’s no bad taste and you have no time pressure to get it right, if you will. As you can see, we use the rubber dam to facilitate the application of the relining poly ceramic material, Ceramage, spatula as I just mentioned, the more you use it the less polishing you’ll have to do. The initial light curing is done, then it’s removed. And the final light curing is done after the application of an oxygen barrier. And we try the prosthesis in. Once again, this is the second restorative visit. Think about it, it’s meaningful. It’s a benefit not only to this elderly woman, but also to you. All because of the clinical capabilities of TRINIA. This will be still pictures of the retentive copings, the prosthesis, the reline prosthesis because of the extraction site discrepancy, the aesthetics, two visits, radiographic evidence. Another example on three Bicon short implants, the patient had IMZ implants some forty years or thirty five years ago, and the fracture screws necessitated the placement of three Bicon implants. In the first restorative visit, the implants were uncovered, impression posts were inserted, impression was taken, the wax try in of the teeth vertical dimension was recorded, gothic arch was also recorded. If you’re unfamiliar with the gothic arch technique, there are excellent videos on YouTube that can facilitate your understanding and learning. On three maxillary implants, the abutments have a one and a half degree divergence, seating jigs and verification jigs are fabricated. The verification jig confirms the fact that there’s a path of insertion and withdrawal of the prosthesis, as well as a retentiveness of the final prosthesis. And it’s only used in the laboratory. Then the digital milling, designing and milling of the TRINIA framework as we mentioned, we design it so that it appears as though individual crowns as opposed to a simple bar. The milled anatomic teeth that are cemented to the TRINIA, then the TRINIA material aesthetically is enhanced by adding poly ceramic material. And on the second restorative visit, the seating jigs are used to transport orient initially engage the universal abutments into the well of the implants Vaseline is applied to the copings to facilitate their removal once they’re cemented in the same prosthesis. So it’s the same technique over and over again, if there’s a void in the resin cement can be added after the removal of the prosthesis, the aesthetics. So there’s a cement retained prosthesis on the lower TRINIA prosthesis a number of years and then the retentive telescopic prosthesis on the upper with the milled anatomic teeth that you can see cemented. And in this particular case, because of the presence of Alzheimer’s disease, the telescopic restorations were cemented with a temporary cement. Another example of the clinical flexibility of converting a twenty five year old overdenture, the one implant with bone loss was not in function. And as you can see, it has bone loss. The first restorative visit, you simply remove the brevis abutments, you take the three impression posts, red because of the two millimeters well, take the impression, you pour the model, gothic arch recording, then the silicone mask which confirms the facing for the abutments as well as for the teeth. The digital designing and milling of the TRINIA and then the cementing of the anatomic teeth onto the TRINIA. This image depicts a verification jig on the bottom seating jig in the middle and the final prosthesis on the top. And the second restorative is it the same technique is the transportation orientation and seating of the abutments with the seating jig and then the copings removal of the seating jig trying of the copings Vaseline the TRINIA enhanced aesthetically with the poly ceramic material. The bores of the TRINIA are filled with a resin cement and the copings are picked up. This final video will clearly demonstrate the mechanical properties of TRINIA once again seeing is believing. Patient after multiple bone grafting she was advised that she could not have any implants. However, Dr. Stefano Carelli in Rome was successful in placing Bicon implants, he placed four on the maxilla, and he provided this patient with a TRINIA full arch telescopic restoration of the upper and with an overdenture on the lower two implants for an overdenture. At the one year appointment, she expressed great gratitude for all, but particularly for the TRINIA telescopic restoration of the upper. She said, if I could only have the same comfort on the lower as I had from the upper, I’d be overwhelmed. Stefano places additional implants on the lower and then converted the lower overdenture into a TRINIA. Actually, he did. He took the overdenture and the impression, he chose the abutments, milled them with the divergence. Then he placed the copings use the silicone mask to determine the room fabricated verification jig to confirm the path of insertion withdrawal as well as the retentiveness of the copings. Here’s the seating jig. It’s light cured resin that is relined to have more accurate adaptation to the abutments. He indicates the path of insertion which abutment should be used, which. Now this is the interesting aspect of the clinical properties of TRINIA. The bores of the TRINIA were placed into the existing prosthesis to drill away easily done. Then he put the bonding agent, puts the silicone in and in bonds and he adapts it to the copings. So the existing over denture was hollowed out to form the bores to fit into the copings. And then the distal extension of the tissue borne overdenture were readily removed as you can see. If this were metal from cobalt or zirconia, you could neither create a bore within the framework, nor could you remove the distal extension with such facility. And then the material is hand polished. Think about it. We told you that at the outset, the TRINIA is readily modified and bonding to it with any number of materials is readily and well done. So seeing is believing. So it goes from the overdenture abutments, Brevis abutments, the bores and the TRINIA. This visual evidence of why the patient is happier with the TRINIA. Look at the size of the extension necessary for an overdenture relative to a implant retained telescopic restoration significantly less material. So at the outset, we told you that we no longer justify recommending tissue borne overdentures now that we have TRINIA with the capability of distal extensions. Happy? I would say so. I thank you for your attention throughout this presentation. And hopefully we have demonstrated as we said we would, that you can achieve treatments in less time, fewer clinical appointments, greater flexibility, and significant financial benefits for you and your family. So remember, if you can treat somebody in two visits instead of three or two visits instead of four, you eliminate fifty percent of your potential failed appointments. And a failed appointment is a significantly expensive event. Thank you for your attention.