Medical University of Vienna
Professor and former Chairman, University Hospital for Cranio Maxillofacial and Oral Surgery, Medical University of Vienna
Director, CMF-Institute of Vienna for Cranio Maxillofacial and Oral Rehabilitation and Telemedicine
Introduction by:
William H. Bell, DDS, AAOMS Life Fellow • Stowe, VT
New York University • University of Texas
Clinical Professor, Department of Oral and Maxillofacial Surgery, University of Texas
Adjunct Professor, Department of Oral and Maxillofacial Surgery, New York University
Prof. Bell is going to introduce our keynote speaker speaker. Good morning. It’s a great honor to be here to introduce another one of our wonderful speakers here this morning. And I’d like to introduce him to you with this thought in mind, that every truly great accomplishment is at first impossible. After hearing some of the beautiful talks we’ve just heard, I’m convinced ever even more that somebody in our profession will soon be a Nobel Prize laureate. We have the talent. We have the wonderful challenges out there to do it. And our next speaker certainly qualifies. These are great words by two Nobel Prize laureates. Right from the beginning, you must work with somebody else. And their thought was that it had to do with this marvelous resonance between two great minds, Francis Crick and James Watson. They stated that that high state where one plus one, it didn’t equal two. It meant possibility. It meant one plus one could be ten or it could be a hundred. Out of their great research came molecular biology, and with a possibility to cure cancer, it’ll happen. It’ll happen through the human genome. It’ll be wonderful through this kind of research. Nobody in the world ever had it more difficult than this man who did this research and received a Nobel Prize Laureate for him, Mario Capecchi. Off the streets in Germany after World War two, he looked at the United States as a place paved in gold, but he loved the opportunity of research and doing humanitarian care. And on the day that he received this Nobel Prize, he said that creativity comes from the abrasive juxtaposition of life experiences. Mario Capecchi. He showed that gene targeting allows us to genetically dissect the most complex biological problems to create animals that carry specific animals, that carry specific genetic alterations. The work of Mario Capecchi. This is how he looked at science and its evolution, that there were too many people right in the small circle doing the kind of the same thing, but what we need are those kind of researchers on the outskirts, the nerds, the people doing different things. The James Watson, Bill Gates, Mario Capecchi, and Godfrey Hounsfield, and those kind of people you’ve already heard from today. This is one of those wonderful example of Godfrey Hounsfield. He didn’t even have a medical degree. I’m not sure he even had a degree, but he learned electrical engineering, asking what was inside the box. Five brothers. He was the nerd. He wanted to see what was in that box. And through his research, he discovered the great CT scanner that has helped save so many lives. And on it went to performing digital osteotomies, and you’ve seen these, yesterday, and we’ll see them in the future. The evolution of cell phones is a fascinating thing. You look back about thirty years, forty years ago, and you see on the left hand side these kind of instruments that weighed about many pounds. They cost about four thousand dollars, and they gave you only 30 messages or so. But in time, it changed. As all of you know, it must happen. Greater new designs have faster, better, cheaper outcomes for sure. Starting out with the big one on the left hand, getting smaller, getting smaller, costing less. That’s the way technology must go, must be faster, cheaper, and better outcomes. Here’s one as an example, one of our former residents who applied many of the things that Dr. Ewers will tell you about today. And he did the first computer studies of the long face and the short face syndrome. And he did it in this mainframe technology building about 1970 or so, where there were three or four different PhDs and many sophisticated scientists, including himself. And he did this beautiful work. And yet now I would tell you that this little instrument in my pocket, my cell phone, can do everything that this instrument did at that time. It’s a wonderful thing that this tsunami of information that’s coming out. And here’s one of the people who brought this forward in the world, and that is Rolf Ewers and the many people he worked with in Austria. And it shows you the great importance of having a great man at the leadership, to give the chances to the many talented young people that are around. And we’ve heard some beautiful talks today. And he has continued to move forward and show where our place in the future will be. This represents Rolf Ewers as a man. His words oof a great actor. And he said that when you provide another with comfort, when you lend a hand or simply be there for someone who needs help, you transfer the health of our country. Big change doesn’t require a hero’s effort. Just one small act of kindness can make you a hero to somebody else. Question, how will you, how will our profession respond? It has a great challenge. Half of the world has no surgical expertise. Our country itself has fifty thousand people who do not have any kind of surgical help. There’s our challenge. And I think we have a wonderful specialty, a unique specialty, one that can do it better than any other specialty, can bring forward this change, this dynamic change which must produce care for all of those underserved people in the world. It’s possible. It will happen and will happen because of our great specialty. Well, seventy years ago or so, I lived in Saint Louis where I went to school. All my schooling was there. And it was popular at that time for families to go down to downtown. And you would see a movie or you might see a great play. And this was one of the plays that that that I saw a long time ago. For some reason, I can remember the exact details of this play very well. It was called Harvey. And it was a wonderful play. And it’s a dialogue between a six foot tall rabbit and his master who was Edward P. Dowd. And they dialogue and they wait till the end of the of the dialogue of the play, which is just one person and the rabbit. And he sits at the end of the stage and he says, the rabbit has been misbehaving some, in this world, I would, you must be oh so smart or oh so nice. For years, I was smart. I recommend nice. Well, I’d like to give a toast and an introduction to a great man, a great scientist who shows those manifestations that I told you about, the characteristics of a Nobel laureate and a a great human being. And so I would like to it should be a virtual toast to Rolf Ewers, one of those rare individuals who personifies both of these great qualities of being oh so smart and oh so nice. Yes, he does manifest those wonderful qualities of science and humanitarianism. And I would also add that he is a a very gracious person and would like to end with just a few words, and that is some great words by a poet, one of our greatest poets. And he said that I shall be telling this with a sigh, somewhere ages and ages past. Two roads diverged in a wood, and I I took the one less traveled by. I invite you to travel that road that science and humanitarianism, the road that Dr. Ewers has taken for many, many years, and we have wonderful science because of his efforts. It’s my privilege to introduce to you Dr. Rolf Ewers. Prof. Bell, I’m very humble to be introduced like this, especially from a person like you. I know you by now many, many years. First I knew about you, about your publications and about the liver one osteotomy. But when I got to know you, I knew you’re one of these persons I always was looking up as a real professor. Always doing your research, asking questions and telling yourself every morning, what can I can I do new to this profession in the evening before you go to bed? Why I was important for our field today? I’m missing something very important. Yeah. And now I would like to thank Bicon. I would like to thank Dr. Morgan. First of all, that he asked Prof. Bell to give a little introduction to me of me. And I’m very honored to be here, supposed to give the keynote lecture. Also, I’m actually a Bicon youngster. And if I’m sitting there looking here around and counting together, are more more several hundred years of experience in Bicon. And therefore, I choose the theme, why do I need Bicon short implants? And I will try to show you why I do need these little implants. And my whole academic career after finishing studying was building bone reliably, a solution found, and after forty years of searching, I think I thought something new. And that’s what I want to show you today in these short two hours. You saw already the older picture by Prof. Bell in the University Hospital of Vienna with my team, my academic team, doctors and researchers. And actually, I have to say my former team. Then on the twenty second of September this year, I stepped down, and my farewell party was in a similar beautiful room as in this Harvard club, and I’m very honored to give a be allowed to give a lecture in here. And here you see all the speakers of my team who gave wonderful lectures. But what’s so fascinating is the next picture. Just look how happy they are that I stepped down. But I have to live with this. So I’ll try to live with this, and they’re still very friendly to me. And all what I achieved until now was with this team and other teams worldwide around. And we also had privilege to train many people also from the United States like Brian Bell, the son of Prof. Bell. He stayed several months with us. And I think he got the clue about cranium maxillofacial surgery and knows now about something, what’s so important for all maxillofacial also to do free flaps. But you see now, this chair is empty. And I have to live with this, and therefore I’m going to ask me, what was my core business the last forty two years? And I’m I hope I won’t shock you because you will not be used to pictures like this, but that was our daily life. And whenever we did this surgery, we always knew during surgery, when we are removing bone, we have to build up this bone. What are we going to do? And therefore bone surgery was one of my main courses. This lady came to us with a fourth recurrence of a squamous cell carcinoma from Romania, from Bucharest in Romania. And they ask us, can you help this lady? We are not able to operate this anymore, but this is horrible and this is a thirty nine year old lady. So two of my fellows, a special shopper and myself operated, And you’ll certainly read it correct, it was a twenty one hour operation. I sneaked off after eight hours removing the tumor as you see here on the left side. I have the whole tumor on my hand after cleaning up, doing the neck dissection, and then also cleaning the skull of the base of the skull, everything here cleaning up. All foramina, everything had to be cleaned, otherwise she wouldn’t survive. And unfortunately we had to remove the eye. You see here nine hundred and ninety two point nine grams of tumor inclusive the eye, what certainly is one of the worst thing for the patient. But we reconstructed this with a latissimus dorsi and she survived first operation. And as you see later on, also pretty much what we have done to her face, especially we had to remove half of the mandible, half of the maxilla, and also the eye. We reconstructed this with a titanium plate inclusive the joint. But in the Panorex, you see even more how much bone is missing by now. If a lady like this survives, we start about three, four years later to reconstruct and augment, rebuild bone. This is in September 2009, almost a year. This is two years later. But don’t ask me how bad the mouth opening is because we have to reconstruct now the bone. She is fortunate. She still lives. And now in February, after four years, my former team is going to reconstruct at least intra oral and start reconstructing the bone. Just remember how she looked like before. So when I started it very early in 1981, this was my first patient being younger than myself. We did all the neck dissection and this time it was my first operation preserving the accessorial nerve. At this time, a no no. Everybody screamed, you’re crazy. You’re going to kill this patient. By now, It’s normal. And we cleaned up all of the mandible, reconstructed everything, reconstructed this with a jejunal transplant. And he was so happy that he was the first patient being able to lift his hands. Otherwise, he could just lift the hand like this on the right side with a resected accessorial nerve. And I’m very proud when he sends me a picture like this, that he was jumping because he was lifting his hand. And he passed the marathon something in three hours in New York and was very happy after such an operation, thanking the operator what he did for him. But most of the important thing is this picture. After thirty one years, he is living. And we reconstructed him perfectly with just a little scar, all the bone and everything is reconstructed, and this therefore our core business. Our next patient and the last patient out of this series, it’s a twenty nine year old patient hit by a snowblower. Father died. And you see on the SL model there’s actually nothing not fractured in this skull. So first of all, we always reconstruct the mandible in our hands always from intraoral so he has no scars, especially we are taking care also of the nerve. And you see the plates have been done beneath the nerve, above the nerve, and the x-ray shows you an excellent result without any immobilization because here it was not possible. Everything freehand from intra oral approach. Then we are starting to fix the mid face with these horrible forceps, but this works. Then opening coronal incision, opening the skull and fixing all the dura perforations and closing everything to the nose, then rebuilding the face and the skull with many, many plates. And one of the most difficult part is the epicanthus. The widening of the eyes, you have to get them together, and this is very, very difficult, and then to prevent diplopia. And the x-ray you will see, then later on it was pretty well done. Then came the maxilla, this is the last, and here you see actually nothing is not fractured in this maxilla, and this is going to be then also later on, everything was fixed, and later on you will see we had a lot of difficulties. The x rays now show excellent result, and it looks like not many more titanium plate would have been fitted in there, and the result speaks for itself. No additional scars, just this one scar from when the hair will grow. For me, this incision would be much, much more difficult. You had to cut here, all the way back here. But in a young man, you can do it here, and the most important thing is he has no diplopia. And it’s a real good result. But then he comes and says, I want to be reconstructed. I want to have teeth. And that’s in the upper, the maxilla we had a lot of difficulties, we lost some bone, and then I did a sinus lift bilateral, then it got infected, I had to do and we lost this bone I showed you, and I had do a re sinus lift, we lost here the implants, but finally we reapplied implants, and everything was reconstructed, reconstructed, young man, and this is now the final result with a very happy person being able to chew. And this is the importance in a big reconstructive hospital to grow bone, to keep bone, and have a happy smile like from this boy or so he lost his father. Patients are coming like this and ask them, I wish some implants. What are we going to do? Certainly, we have to see what’s going to happen and what’s possible to do. And certainly, when I saw this thirty years ago, I had completely different therapy concepts, and when I saw this two years ago, I had different concepts, much, much more advanced, And then today, even different because I learned and learned and learned. Here, I applied after sinus lift these implants. I made a little mistake because they had been too close, so I let them sleep. In this system we couldn’t do anything else. Eleven years stable, and it will stay stable down there. I did an iliac crest, I will talk a little bit later about this, and it’s now thirteen and a half years stable, Lot of resorption, but still the patient is very, happy. So you see, due to our core business, we always had to think about bone regeneration, and then we have learned, well, why don’t you use gold standard? But what does it mean gold standard? Is it like the Olympic steps? Which position? And therefore, I worked a lot about bone regeneration, but about bone quality classified due to the vascularization. So vascularization always is the red line in all my research. And therefore the classification is class one, it’s revascularized bone with anastomosis, that’s when we’re doing free flaps, and I will show you what we’re doing with this. Distracted bone, distraction osteogenesis, everybody talks about this, so certainly it’s a vascularized bone as I will show you, and it’s class two. Pedicled inlay bone. This means I’m putting in between two vascularized parts a non vascularized material, and as I will show you later, this is our working horse, and not gold standard. And then autogenous only bone, this is a non vascularized material, but being put on. And this then should be gold standard impossible. And class five is augmented allograft. The companies will sell us so much material and everything, and they say it’s perfect, perfect, and it won’t go away. It will stay stable, everything. Don’t believe it. It’s the least good method at all. So if you have five Olympic steps, certainly the real vascularized bone is the best one. Then comes the distraction. But in the Olympics, you know, the second person who won second place is the first loser. And it’s also in bone regeneration. Nothing is comparable to revascularized bone, even not distracted bone. Then you have inlay, our working horse as I will show you, and then the onlay being put on the so called gold standard, is very poor, and the poorest is the allograft. So when we have bone regeneration, class two, bone transport or osteo distraction. You see this in between is always vascularized, the colors always is vascularized. And you have here vascularization, and you have here vascularization. Lexa has said 1906, also the German, working about bone. If you’re doing transplants, you have to see if it’s a good vascularized or a poor vascularized bone. And this is a good vascularized bone and perfect situation. Then if you’re putting in something in between too vascularized, then Lexa would say it’s also an excellent vascularized bed, but the transplanted material is non vascularized. But still it’s a good situation, so it’s class three. And now comes class four, it’s the onlay. And this onlay is just vascularized from one side, and has put in non vascularized material, so this certainly never can be better as good as this, or as good as this, or even as a revascularized bone. If you do a decision tree, and when we are working, you always should have this in your mind. What I’m going to do and how will be the vascularization. I just want to show you one revascularized case out of our many, many hundred cases we do. We do once a week, And here you see a gentleman with a very, very malignant bone sarcoma. He was lucky because he just had this in this location and nowhere else. He could have been very perfect, been treated by chemotherapy. Then at this year, ninety three, we had already these models developed. We had pre bended plate, and we had this template which we could sterilize, and then take the iliac crest, which was then revascularized, applied this. And at this time we had been crazy enough to implant the implants immediately. By now I would navigate it in better positions, anyhow here I had to a little second resection because I got cold feet, maybe it’s not in sano and it was not in sano, so I really was lucky and the patient was lucky. And now what is your question? When I’m applying here in a revascularized bone, what are you looking for? What’s going and it’s IMZ at this time, IMZ implants. What are you going to look for? Well I would say, the resorption. The resorption around the implants. And just look that you find nineteen years later no resorption. Why? Because the vascularization is so superb, it never was not vascularized, you do not have any resorption and therefore the implants are so superior. So this is class one, and now we are going to class two, just also one example. This lady, Jehovian Wittnis, parents never allowed to operate because of the blood transfusions, she had a big hole into the nose and into the sinus, and very unpleasant, and we started to do this distraction device, and again, Prof. Bell worked very much and also helped design careless marketing with this sometimes extra all used device, distraction device, and we fixed this also on a big bar, straight wire, because the bone has to be moved in a circle. Very, very difficult, but we have an orthodontist who is very good. And then later on we also did this from the other side. So we moved both sides together, we call this bone transport. But it is fascinating to see this, but more fascinating is what? What do you see? This papilla became this soft tissue. It’s something like, if a lady gets pregnant, the belly gets bigger and bigger, and then later on it goes back again. And a beer belly, unfortunately, does not get back. But anyhow, this is not only new bone, it’s also new soft tissue. And by now, after we have so many complications with distraction osteogenesis, we distract when we need soft tissue. And just see what happened here, out of this papilla, went up to here. And now it’s the question, is it bone? Is it really bone? And Ilisanoff, is this right? And certainly it is bone. Here you see again the beautiful soft tissue now, and certainly we have to take a biopsy, and you see here perfect vascularized new bone out of vascularized callus, as good as it ever could be. Then, I also closed this huge hole with a pedicle tongue flap. The ladies who hear this, will be horrified because this lady was not able to talk for three weeks because it was fixed to the palate, but it worked perfect, it’s up to here, it’s tight, she has no liquid anymore going out of the nose or out of the mouth. You see then both implants, fixed prostheses, and bridges, and perfect result. So I just wanted to show you on these two cases that these two bone qualities are the best, but this is certainly nothing you’re going to do in your office. So it’s just to know good to know. And then we are coming now to the inlay, our working horse, and that’s socket fill, ridge preservation, augmentation, and pedicle sandwich plasty, what I will show you. And this is all class three hour working horse. If you’re doing socket fill, and if you have this situation, you certainly are taught to use a membrane, and if you use a membrane, why not also using some material, some resorbable material, who can fill up the whole defect, and I will show you a little bit. Buza, Daherlin, and Shanks certainly have been right when they showed 1994 these fantastic also histology as you just saw beautiful histology today. Histology results, and he could they could show that bone is growing if you have a membrane, and it’s no question by now, do I need a membrane or do I not need a membrane? I just want to show you a case of augmentation. This lady lost from Switzerland, coming lost two implants, so I filled this. I thought maybe it should be a little bit bone also. I took this from the tuberosities, and what did I do then? Or what do I have to do then? With a big defect like this, putting a membrane. And at this time, we use titanium membrane. And you see this little fold fixing with always have to fix this, so it won’t move with titanium tags. You can do this also with both soluble materials by now. And just look at this little fold. What are you expecting under this fold? Clot. We are building up bone. Blood clot is in between, but after the blood clot is after six months? Bone. Perfect. So after six months reopening, we had been lucky with titanium, we had thirty percent perforations, therefore we don’t use it anymore, but we had been lucky in this case, and just look what’s happened. That’s the former little cortical chip, and you see here under the fold bone also there was no material. Very interesting. Applying this just one implant, then she was stable for twelve years, and you see here there’s no defect, no volume loss with resorbable material, and therefore you should use a resorbable, not nonresorbable avatogrelate. And then she wanted to have a telescope work, and it was in 2000 She lives in Switzerland. She’s so happy she doesn’t come to Rico, but I know by telephone everything is perfect. Let’s just come to the pedicle sandwich plasty. As I said, putting some in between, and this, therefore, it was such a fantastic idea of Prof. Bell, which he published 1975. He became world famous due to his Le Fort I osteotomy, because he did excellent experiments on monkeys, applying dyes and seeing with the angiograms what is going to happen with the vascularization of this bone? What has happened if I do injure the palatine artery? And this was the breakthrough of orthognatic surgery worldwide, what Prof. Bell really researched there. But for us, for the preprosthetic demands, Prof. Haller, my former chief, and I designed an addition because we knew when we are lowering the left o one and the patients don’t have any maxilla, the dome will be very low, so we decided then to have better bone support, we decided to leave the palatal bone up there, and therefore we call this a Horschel’s LFR one osteotomy. Very difficult to operate, big operation, because we are applying iliac crest in between here, and you know later on the patients have beautiful implants, beautiful prosthesis, but are limping a little bit. So it’s not only pain, it’s really very annoying, such a big operation. But the result speaks for itself. You see, the maxilla was taken in front, was taken forwarded, and how much are you and then we are applying one centimeter of iliac crest in between and then being able to apply implants. But why are we not able to advance the maxilla more than nine millimeter? What we could do with fifteen millimeter? Vascularization. And what would we destroy? Two vessels are in our way? The palatal artery. And that’s what Prof. Bell always researched and always checked how which can the operation be done and everything. In our hands, we never got more than nine, maybe ten millimeters forward, and that’s it, but most of the time it was sufficient. As you see in this lady, you see nine years later, she looks different, not only because she went to the barber shop, and here you also see after nine years, what a change. Why did she change so much? It’s now stable for sixteen years. Again, some patients when they’re really doing fine and living not more in Vienna, they don’t want to come, but they call, I call them, and they say everything’s fine. Raising the vertical heights, that’s the prosthetic part. Everybody of you know and you do daily by day if you’re putting prosthesis fixation. This is the difference between this picture. It’s between this, the vertical height, and here’s the vertical height. And there you see the difference in an operation like this. We did, or I did, these operations on thirty six patients, and Prof. Yerit did all the recall and everything, and we had been very proud because just eight implants did not as integrated. All patients, less than one millimeter of bone in the maxilla. Just actually nothing. And altogether we lost eight point seven percent of implants, so it’s a long, long study, and as we know, they stay ten years, they stay twenty years, so it’s perfect. Let’s come to the next, the osteodistraction. Ten years ago everybody was doing this like crazy, and everybody thought this is the answer of all our problems. And we saw pretty soon that this is not the answer, and why? You see this on this picture, what’s the problem with a distraction osteogenesis? It always perforates the mucosa somewhere, because the distractor has to be activated. So therefore, we abandon this method and just do a similar method. We do the same osteotomy, but then we are stabilizing this with micro or mini plates, applying some material into there, you can do cold standard, but also we use resorbable material. And three to four months later, we stabilize this with a screw like implant and call this the pedicle sandwich plasty, and it is class three, an inlay method. The indications for the is either the anterior mandible or the posterior mandible, and certainly if you do the anterior mandible, it helps a lot, because when you do a distraction you have to have this device in your mouth for at least how long? Six weeks, six months? Six months? And you would do this to your mother-in-law? Okay. As two are meeting each meeting each other, and one says, you know, my mother-in-law, she is an angel. He says, oh, you’re lucky. You’re really lucky. He said, why? I said, mine still lives. Okay. So not even my mother-in-law, I would do this operation because she’s not able to wear a prosthesis. She has to wear this and it’s instable and it’s dislocating everything. And I did it, I did produce three fractures, in my hospital altogether six, six fractures. Because if you have it if it’s very small, then you have you do a cut. You have seven millimeters of mandible, you do a cut. Then you have three millimeters up there, three millimeters down there, and this breaks. If you have fifteen millimeters and then you do the cut, it’s not indicated. And that’s the problem. And it’s really tough. So when it’s indicated like in a case like this, or at least two or three, I thought this is indicated, and you will see my paradigm change a little later. But still it’s very stable, it’s a very stable operation nine years later, you see this result, and the particles being put in here, you see perfectly also integrated and excellent result. In the posterior mandible, you have the same operation. This was unfortunately not socket filled, so therefore we had difficulties to apply. We do the operation, do the mini plates, actually very easy procedure, filling it with our resorbable algae derived material. And the next day the very smart resident comes to me and says, oh professor, you see, you forgot to put in your material. There’s nothing to see. No, it’s a very non opaque material because it’s little hydroxyapatite, O3 calcium phosphide, it’s very porous and therefore also so resorbable. Because you see it a few weeks later, you see it’s starting to ossify, to mineralize. But what’s so interesting about this picture? Because we are talking about vascularization. Where is the remineralization coming from? From the lower part. You see that? Up here, there’s no mineralization, just from the better vascularized part. Also, the upper part is good vascularized because the periosteum was left there, still it’s coming from down here, and you will see this later on, applying the implants, then later it’s stable and it comes like here. And it’s then short after, and if you have nine years later, you see everything is ossified. Normal bone, the material has vanished, it’s going away because it’s a resorbable material, what is so very important. Let’s come to the next part, to the horizontal. If we are talking about bone splitting, and if you’re doing this split, deflecting this mucoperiosteal flap, then fracturing and putting an implant in this, What kind of bone is this? What classification of bone is this? Class III? Vascularized bone? No, it’s class IV bone. It’s something like an onlay. This is not vascularized after you’re cutting here, you’re removing the periosteum here, it’s not vascularized. You always will see from Dr. Daher, a very elegant method, but this most of the time has just been able in the maxilla. He’s also just opening it up here, and then the rest of the operation he’s doing without deflecting. This is something in between. This is possible, whenever you remove the periosteum from here and then fracture, you have an only class four, and it’s prone to resorption. So therefore we do a two step operation, we close everything, and after twenty eight days we just open it like up here, like Daher also shows this, then doing the cut and the distraction or the widening with these widening instruments or whatever you want to take chisels. And then you’re going in there, and then this is vascularized and certainly this is a class three. So it’s the two step, we call this the two step transversal PSP, a very elegant method, especially for the mandible. Case like this, I never could have done this without doing a two step, because you see here it’s very narrow and it’s a very hard type one cortical bone. We do the four cuts. Oh, we do the four cuts. Doesn’t matter which instruments you prefer, and then you see the result bilateral on the x rays. And then twenty day days later, I just open it up there and continue the operation widening, putting in the implants, filling the little defects with the resorbable material and having this beautiful result. And you see this cortical bone lives and survive because it was vascularized. And that’s the result eight years later, very, very stable. Just come that’s part of last part of this, I performed myself five hundred and fifty four sinus lifts. One would say unnecessary sinus lifts. Maybe he’s right. But at this time we did this, and we had just show you the results of it with an over twelve years. I did this and published this in the Journal of Oral Maxillofacial Surgery, and with an implant loss of four point four percent, this is a very stable procedure without golden standard, without autogenous bone, just little collector bone and a resorbable material. So this is good, this is a standard, and it’s difficult to fight against this. So therefore you see we learned many, many procedures and had actually pretty good results when the patient had the wish for implants. But it was a lot of operations, big efforts, and lot of pain to the patient. I published this in a big sector of the oral implant book from Prof. Lambrecht, The Implant Surgery, two fifty pages about this, and it’s so successful that quintessence asked me to publish a own book together with Prof. Lambrecht, and Prof. Bell will like to see, especially when he’s reading this, or Coelho is reading this bio activating concepts, and he’s certainly right, not only the surface, but the socket has to be bio activated, and therefore it was such an interesting lecture to see what’s going in the future. But whenever I like these operations and I like to help the patients with these huge difficult operation, sometimes I ask myself, this couldn’t be all, and what I’m going to do on a seventy six year old patient. So I looked for short implants, here I found an IMZ, eight millimeter implants. I applied six implants, five integrated, was a TV speaker, lived in Rome. And once he lost his prosthesis during the interview, being live on TV. You can imagine how embarrassed he was, he said, no, I want to have implants. But with seventy six, I thought I shouldn’t do a distraction osteogenesis or anything else. I started to do short implants. And he lived six years without cleaning, because he had a little Parkinson’s. So therefore, I was looking forward. I was open to something, and certainly we always had to ask us what are we doing? Is this correct? Or should be there something different? And therefore I was open when my good, I don’t want to say old friend, my long lasting friend, Boyd Tomasetti approached me again and said, why don’t you go, I know Dr. Morgan, why are you not going to Boston? I will go with you and I will introduce you to them. So in July ten, I went to Boston. As you know, all this wonderful facility when you had been there yesterday. And we had long talks with Dr. Morgan and all his teams. And then finally we said, well, why don’t we start something new? As I always like to do something new. And we decided to use the ultra short implants four by five, and started this, a prospective study, January eleven, together with my former president, Sehman, our fellow, now he’s a fellow, he’s already a PhD. And we thought, when we start this, and if Dr. Morgan says four by five are going to work, but then we will do it on our most difficult patient, and that’s our fibular transplants. As you see here, it’s a fibular transplant, I will show you the patient, and then if it works on the fibular transplant, why not on very atrophic mandible and also an atrophic maxillary. So therefore, this is the study design. Unfortunately, as it looks to work now, Rome is participating and other universities cleaning are going to go with us, so we will have more and more patient just to see what’s happened. And I just want to show you two patients. Here you recognize immediately the defect after a tumor surgery, this bone is missing, being stabilized by titanium plate. Then the operation fitting in a fibula, in here. What’s the difficulty of a fourteen centimeter long fibula? Well, it’s very long, know, and you want to have it like this. You have to cut, and by now, as also Prof. Bell is very much in it and so fascinating, that we by now, we are navigating this. By now, we are having templates. And he had a special big convention two years ago in Dallas. He’s one of them. He’s always pushing us and always says, I’ll do a convention, and we meet all together, and then we have a discussion. So by now, we are having templates, preplanned templates, that things, what I will show you in a few minutes, will not happen anymore. Anyhow, you have to cut this, but you have to be careful that the vessel which is supplying this bone is not being cut because somewhere down here is the vessel, the artery, and the vein, and it has to be reannounced the most. But I have a very good team by now, at the end of the third year, my residents are doing free flaps, and I’m very, very proud about this. But it’s a big operation, and this is the result. You see the mandible is completely closed, and everything works. Now you will be surprised and said, God Lord, what’s in there? All our patients with these huge resections, they get first, during the first operation, a jejunal transplant. A small bowel transplant to replace all the defects of the mucosa inside. This is a wonderful healed mucosa from the jejunal transplant. The peristaltic will stay a life long time, so you have to be careful to suture this in isoperistaltic, otherwise the mucosa comes up in front. And this works perfect, and then if they survive one, two or three years, depends on the age, then we build up, as you just saw, we build up the bone. So inside you have mucosa, plenty of abundant mucosa, and then here we are going to start apply the implants, and then that’s the next big problem, it’s class one minus minus type bone minus minus one because it’s very hard. And as you see on these little pieces, it’s almost not vascularized. And that’s the problem with normal implants to apply, and therefore we lose a lot of long implants because of the missing vascularization of this bone. So we applied these little four by five wide and long implants in January eleven, and as you see, very important, always covering with all this huge amount of material, bone material, And then as a researcher, I couldn’t stop myself just to take a core on the side of the fibula just to see, just to have a wonderful histology, and there Credo will certainly admit that this is very less remodeling bone. Where is he sitting? Over there. And you see just little, oh sorry, you just see little remodeling around here, but this is just very purely vascularized bone. And that’s the bone where we are applying our Bicon implants. So there you see post operative the Bicon implants, then three, four, five months later we are freeing the implants, taking the impression posts, and then after this suturing you see the mucosa. And I can tell you already partially the problems of the mucosa due to the jejunal graft. That’s the TRIN, and then here you hear this already, this fantastic material. We are just crazy about this. It’s the TRINIA. Here it’s the case with putting in screws, but you see it here the problem, what I said, by now with navigation this will be better. You see this kink here, yeah? It’s not round, and therefore this implant is not in a good position and will make difficulties. And you see now that’s the prosthesis and being applied into the patient. This patient, unfortunately for her fortunately, has upper teeth. It makes the whole situation even more difficult. Anyhow, she has occlusion. Now she can eat again after four years, is very, very happy, but you see here the little bump that’s difficult because of this malposition. But then a few months later, very well intake, and you see beautiful that here the implants are in place with the cantilever and it’s no problem at all, and we are very surprised. Now twelve, just a year ago, I decided we have to do something with this soft tissue. And we know how to handle this, so I’m taking abundant mucosa, jejunal mucosa, you see here there’s enough jejunal mucosa, so I take this jejunal mucosa and make a little mucosa graft, thin this out, and then put this, then prepare the vestibulum, and then I’m suturing it in all the way here around, just to get a larger vestibulum and just to get the alveolar crest better fixed with fixed mucosa, then putting in the bridge and later on you see how beautiful then the mucosa went on. We decided also, Dr. Morgan was not so in favor, decided then to get this sleeping and now she’s working on three. And Rudy is screaming, says, well, our statistics, our statistics, but the comfort of the patient I think here is more important and she is very happy with this situation. After all her tumor operation and after all these reconstruction, I think it’s very rewarding to help these patients, and I’m very happy that Bicon is supporting us with this study to do this, because with another system until now, we hadn’t been able to do this. Now at sixty nine, just don’t forget, it’s old patients, old patients, sick patients, and they have survived a big tumor operation. Here, the patient has a much better curved mandible, but still the application of these implants because they have a very small mouth opening. That’s the other difficulties. But now if you’re using these TRINIA base plates, and with this system here, it’s just unbelievable. Simple to do, and as this is a study, I do now the prosthesis myself together with Dr. Seemann, And here you see also the he doesn’t have upper teeth, so it’s not so bad. And here again you see the bridge being incorporated and everything is stable also almost two years. But unfortunately, and this is very happy, unfortunately, he has part of his outer skin from the fibula also been transplanted into the mouth. And here we have even more difficulties with the mucosa, or here with the keratinized skin around our implants, so you see these are very, very difficult patients. So now we just did the twentieth, last week or week before, we just did the same, we freed now here the vestibulum. We are taking out of the inner cheek just two five centimeters long transplants, mucosa transplants here, mucosa transplants. Then we are fixing and this works, I did this very often, we are just freeing the implant, and we are putting all the implant, this little piece of mucosa. And you believe me, I did this very often, other implants and it works, then the rest it’s sutured in here, and then fixed with some dressing. And as it’s such a new case, cannot show you how good it will be, but I’m sure that this is going to help, and this is certainly much better for the perforation around the abutments. The same we do now in our series in a very atrophic maxilla, what would I have done years ago? I would have done a horseshoe Le Fort I osteotomy. Deciding if the maxilla is very far back, I would do a horseshoe Le Fort I osteotomy. Now we decided to do this Bicon study, and certainly as we are in the beginning and just have two years result, we are not showing you long term result as I do with all my other methods, but I hope this is going to work, and I hope especially for the patient that this is going to work. And here you see we did all the tricks, and here I have to thank Prof. Marincola, who also helped me here, and also Dr. Shadi, I will say this at the end, I wouldn’t have been able to do this without all out of the help of these gentlemen, especially that Dr. Morgan several times, I counted it seven times came to Vienna, I think Dr. Murcko by now four or five times came, I wouldn’t be able to do all this. These experienced persons did everything what you see here, also with sinus abutments and everything, and we are very happy because it seems to work, and it’s perfect, then freeing, taking impressions, and again TRINIA. TRINIA, it’s just an unbelievable material, and you see you’re just applying these, having it fixed, and certainly this situation, when you see the implants had not been all been straight because it’s impossible, just because of this trick that it’s really three sixty degrees, you can position wherever you want to. And this helps, and it’s just going to work. And here you see you’re putting it with a hand, and during the lecture it takes two minutes. In the operation it takes maybe up to twenty minutes, if most. It’s very fast, then you’re tacking it in, removing, tacking the taps in perfectly, and then you have this situation. Then you’re taking the TRIN, and certainly I always have to say this now in a second, then you see the lower, and TRIN, then we are refining this again, the occlusion, so at the end we have little little grinding, and then again the vertical height, which is so important, and then again with the TRINIA, and then refining, also again the mucosa situation, and then you have this beautiful artwork. And this beautiful artwork Paolo Perpetuini is doing in Rome, and it’s just I always say he’s the Michelangelo, and beautiful, beautiful work. And then it comes like this, and really in a very short time, you apply these abutments and you put them in and make the patient perfectly happy, everything by hand, refixing it, relining it, tapping it, and then finally with this beautiful smile. So this is really a method we are doing as oral maxillofacial surgeons with the help of these persons I mentioned, then it is really possible to do this with this beautiful result. And this is already a year later, perfectly resolved. And if you have patients like this, what would I have done with a patient like this few years ago? Well, we may discuss, we may argue, distraction osteogenesis, PSP, onlay, sure, there are many, many methods. Nowadays, we are convincing the person that we are doing the study, they will work with, and just see how much bone she has. Seven millimeter. It’s one to one. That’s all. Can you do a distraction osteogenesis in here? No. You would have to do an augmentation, as I will show you a little later. So now at eleven ten applying the implants, five, few months later freeing it, uncovering it, and you see she has such an unfavorable position between the mandible and the maxilla, she has a pseudo progenic bite that we have to apply these screws up in front. And if anybody looks at this says, this is not going to work. Period. This balance, this cantilever, the cantilever starts from here, or actually from the middle of here all the way back there. And then maybe it’s a very, very friendly lady, but she says, I like to eat hard food. Perfect. And she does it since then. And just look how it looks like here, and we are not able as Rainier always can show, in three, four, five years maybe we will have more bone. And if I am asked, where will be the most bone around these implants? If I pull again Wolff’s Law, which implant will show more bone gain? The distal one. Perfect. Wolff will accept this. And here you see it with the cantilever, it’s two twelve and eleven twelve. At least you’re not seeing any resorption or whatsoever. And just look what horrible position these screws are in like. But it had to be, and Paolo said, this has to be like this, and it works, and we are very happy, and she smiles. I think until now this is the most thinnest I did, but I saw a colleague showed me yesterday already even a thinner one. I would love to do that. And I hope he’s going to do this because you will see it’s going to work. Now again, see between six and seven millimeters of bone. And perfect situation, applying the four Bicons here, putting it as low as possible, filling it again with bone, and I’m always so fascinated, and I also saw this in other lectures already, at reopening sometimes I have to take the round bur and I have to remove bone. At the beginning I was so upset because I wasn’t prepared, but do you really have to remove the cone because it’s even in these horrible cases, it’s like this. Now you see it, I always and you see now I’m always putting it a little bit deeper, burying a little bit deeper, and then you see later on freeing, and then again beautiful, this workup of Paolo, and with this TRINIA, and it’s unbelievable how easy. And as you see this with an instrument, you’re just either you’re doing two and two, sometimes you have single, or sometimes it even happens that if I operated it pretty parallel, I’m able to apply all four in one situation and just get this into the implants. And that’s just tapping it, then tapping the abutment, and fixing it with some kind of cement, temporary cement, and later on with final cement, and that’s the result. And I tell you, six six twelve, if this had would have been six six eight, she would have had the bone in there. No question. And maybe for a long time she had pain and would be limping, and that’s unnecessary. This lady came to our hospital with a fracture. We have fractures we have mandibles like this, now collected fifty six fractures like this. These fractures we have most of the time from extraoral approach, but I think this lady was done yeah, you will see this was done from intraoral approach, applying this huge plate, it was in eleven, and then finally we had this study, and we asked her if she wants to participate, and now you see a wonderful picture. You see this atrophy, it’s again around six, seven millimeter. But what is this? Yeah. And it’s so fascinating, this is not atrophying, why? Function. It’s so fascinating to see, and that’s a problem for the prosthodontist because this isn’t the way. But fortunately when she has implants, this doesn’t do any harm anymore. And you see by now, I’m pretty more experienced. By now, I’m pretty much straight ahead as Shadi always shows. And at the end you’re really able to line them out and really get them straight. Little little tricks, it helps. So I’m very happy I was taught by these gentlemen. Then taking the impression a few months later, and again a wax try in and occlusion, everything, so it’s all the prosthetic workup, the abutments, and then you see this few weeks later in twelve with the abutments, and later on then coming with TRINIA, putting this in. And this is another one. This jig is an excellent help if you are using this jig and reline this perfectly, and it’s much, much easier then later to apply the prosthesis. This is a very nice helping gadget. You see, first I did the lateral, then I’m putting in the medial. Here you see the lateral, then the medial, and it’s perfectly done. And try in, as we always do, a try in in wax and see everything that fits, and then later on, few weeks, no, few days, about ten days or something like this, Later we get the finished prosthesis by Paolo and everything works perfectly. Now I may show you some trouble patient. That was our study. And as I saw that this study runs much better than I was afraid of, but I hoped it’s going to work. Trust my fingers, or I could say I prayed. And then I got used to apply these implants, these little implants. At the beginning, always said, apply these little Tracy implants. I stopped doing this. And this lady you see, it’s my favorite way how I used to apply or solve a problem like this. This lady did not want to have sinus lifts, and then she said, I heard you have designed a special navigation system with templates. I designed this for the company with template navigation as we worked since 1989 with navigation together with Dr. Tropper and Professor. Our work, very advanced. And you see the Marlowe concept, it couldn’t be better. Perfect, just a side of the mucosa of the sinus and everything perfect. Then this worked, and then she said, but now I want to have implants in the mandible. I said, okay, no problem. I made these CT scans. Well, that’s not a very nice situation, but I said, oh, I have the puri saw. I’m going to split this and this is going to go, and I will do which method? Two stage. Very good. So I did it, and now you see my second stage on the right side and on the left side. Perfect. It perforated. It was so thin that all my bones perforated. Very rarely I have to tell the patient, waking up, if they have a pseudo analgesia, they’re waking up and I said, you know, I’m sorry, very sorry, but I stopped. I couldn’t do it. It’s impossible. You see, it’s April ten, so she said, what I’m going to do, and said, well, at least half a year or something like this it has to heal. Then July ten came, and Bicon came up. So certainly what I’m doing oh, that’s the wrong way, I’m sorry. I’m starting to use Bicons. And this was possible. This was very difficult, and you see it’s a very crooked position. But she didn’t had any bone there, and I thought, good lord, I read all these materials, I saw all these movies, these beautiful movies in the in in the Internet of bicon dot com, and I said, let’s try it, it has to work. And you see this crooked position, but I knew three hundred sixty degree will allow us, and certainly it does. Just look at this. What other implant system could I have used? What could I have used without any further augmentation? I could have done, what other augmentation could I have done? And you just say it, and I always will say immediately the complication which will come. You can do lateral augmentation with autogenous bone, what’s the result? Fifty percent resorption, at least. You’re doing a split was not able, you can do an allograft. You take five thousand bucks BMP, if you’re lucky it works, if you’re unlucky it resorbs. So whatever you do, you always know there are some difficulties. And here for me now, by now, Bicon is the answer. And you see how the prosthesis was worked up, has a good occlusion and certainty. It’s also a year later very stable, and nothing ever would have happened, and she’s happy as ever. Forty five year old lady comes with this situation, also very narrow, as you see this in the CT scan. She’s a coworker of mine, so I see her daily, and she says, do something, I need something. O eight, a gentleman came, you know, people are coming to your office and selling something very new, and from the technical aspect it was fascinating. This little torpedo is an osmotic growing, due to osmosis is this growing inside the soft tissue? I thought, terrific, let’s try. I asked my lady and she said, yeah, why don’t you do it? So I put this under the mucosa, five zero nine, five nine. Seven ten she called me, or a few days before this she called me and said, I was windsurfing in the black sea and suddenly something popped in my mouth, And it perforated on the lingual side and came into her mouth. Fortunately she didn’t swallow it, but she kept it and it was double sized. So the osmosis worked, but the tissue didn’t like it. Anyhow, so by now I knew Bicon, I applied Bicon and just see how thin this is, as also Shadi showed this, how difficult it is. You see how high the lingual part is just to fix this deep enough, otherwise you would have to augment on the buccal side. But it is possible, you see this beautiful prosthesis from Paolo, and the intraoral aspect, and the lady is very, very happy, and just here in February this year, and now you see it just a few days ago, perfect stable and no problem whatsoever. So it really solves me problem by now if I have to do troubleshoot. This lady comes with this huge hole, the dentist really didn’t extract very carefully, she had this hole, what to do? By this still I do an onlay transplant because here we do have pretty good results, doing onlay from the mandible angle, good x-ray, and then applying the Bicon implant. And she didn’t want, I told her already, why don’t we take this move away so we have clean position, everything will work. So we did the workup, and you see the result a year later. But then she started to get difficulties with this tooth, so applied a fourth Bicon implant and just last week with a very, very good result, again troubleshooting without any problem. Now we come to a headache patient, Dr. Morgan knows him also, very stubborn person, and sometimes you have to handle them too. He’s in headache since more than fifteen years, but always comes back to me, and just few weeks ago, no, already a few months ago, said, doctor, I hope you will have a long living. I looked at him, and said, do you mean? He said, because you are the only one who can treat me. Very nice. Okay. Anyhow, he came and he had it. It’s very difficult. I didn’t find a better x-ray. I augmented the maxilla here with onlays from iliac crest, 1999. Standard therapy at this time, and the lateral ceph you see it a little bit better. And then what did I tell the patient after the operation, after the transplants had been well taken? What did I tell them? Well I have to put in implants. And he said, no, no, you know this looks so good, and I have a partial, it will work, I don’t want to have implants, and you just want to make more money. He’s a psychiatrist. I said, okay, fine. This is four ninety nine. Shall I show you what happens to one eleven? Twelve years later, all bone is gone. It’s even worse than it was twelve years before the bone transplant. So he had one hundred and twenty percent of bone resorption. So what did we decide? Bicons. Applying in, Bicons, and now you just will know how will be the difference, the length between these Bicons and the crowns. And there you just have to ask Paolo. He is doing all the technical work, and you see, it’s a horrible position, but still he’s able to do this with this beautiful prosthesis with a TRINIA base, and now everything is going to work. It’s with the abutments, and that’s intraoral. He’s still complaining, no question. Dr. Morgan three times always had to calm him down because always something is not correct, but finally he has this occlusion, and I couldn’t have done this without these little implants. This now, routinely, you heard this already, so we go over very quickly. Earlier times I would have done sinus lift, now just with these sinus lift abutments, and with a very happy patient, so we just go, oh this is no question. But a patient like this comes, and the lady doctor tried to put in the crown, and she had a little bit difficulty with the screw, and then she said, professor, this implant is loose, could you help me? So he comes, and I take out the implant. What are you doing with this hole? Well, it’s a hole in there, and it’s a hole in the sinus, I would say. If the worst thing is pus is coming out. No, pus is not coming out. But what are you doing then? You cover? I don’t. I pray. And I was lucky, he was lucky, it closes. Sometimes it closes, because if it’s not infected, nothing, and this implant actually was stable, she loosened it, this Brandenmark implant. Anyhow, but if it would not close, what would you do then? Mucosa incision or something like this? We What? Flap? Yeah, no, we don’t do this anymore. If you do a flap somewhere else, from somewhere, the vestibular always is smaller than it used to be. Accept it? Boy, it knows me. I do a Bichat fat pad transplant, the buccal fat transplant. I’m taking the buccal fat pad out from behind, from the tuber, get it forward, stuff it in, no mucosa insertion, nothing, and it’s perfect working. We do this also when we remove I always say we have cadaver courses in Vienna and we show these, and it’s very elegant, Even if you extract the tooth, pus is coming out, take the Bichon, just stuff it in, close it, and everything is done. Anyhow, so I was very lucky it was closed, and it healed like this. So what would you do there? Certainly. I take by now a Bicon, and it looks very good, and I thought, good lord, when I take I’m interested how this bone healed, so I took a little bone specimen, and you see perfectly new form bone, very vital, very good remodeling, excellent re bone regeneration, so certainly why should this little Bicon not work? And perfect solution, it’s a fantastic troubleshooter. I showed you the elevating bone in a PSP. Most of the time, I do not need this anymore, but here you see sometimes even with Bicon, I need indications to operate. But as you will see, the operation will get much easier, smaller, not so extensive, and predictable. So here we had the three d implant navigation, and just imagine how in the average world, the thinking is this person is doing fifty planning a day, and he suggested me, professor, why don’t you remove this tooth? Then we can apply implants. You see, this good living, not living tooth, it’s root filled, but this perfect tooth, he thought I should remove just to apply a good implant. Certainly I could use my developed method of the lateral bypass, and here’s the lateral bypass, I would bypass with navigation, and I did this very often and very successful without nerve disturbances, I bypass the inferior alveolar nerve by perforating the lingual bone, the cortical bone, and applying a bicortical implant. This works, but it’s not necessary anymore. So I did my PSP. First I freed my mental nerve, as you see here, but not too much, and then I went with a pizza in here, opened this, and you see I just operated certainly over the nerve, but with pizza this is no problem. Then stabilized this and took some bone from here, and stuffed this in between so I will have the altitude which I want. You see I removed bone from here, and put a little piece in here, and a little piece in here, stabilized this, filled this with our material, and then later on applied the Bicons. I couldn’t use any other implant because our other would be longer than these ultra short Bicons, and with this result, and I solved this very very difficult case with a little operation, but here the other operation would have been much, much more extensive and much, much more difficult to do. This is one of my really most difficult patients. If you look at the joints, you will see horrible joints. She was operated on the side twenty times in the last fifty years, and she was operated on the right side twenty one years. Steinhardt, everybody operated her, and this lady has no function or had no function, and what are these people are having? Pain. She has so bad pain that we are always discussing her suicide. Since years she’s more than ten years now with me. Finally, we succeeded and we applied two artificial joints with a temporal part together with professor my former fellow, Prof. Un. Very successful. She has good function, but she has pain. Anyhow, in the meantime, she was treated by all surgeon, and he applied on the left and right side a bovine and non bovine sinus resorbing sinus lift, both sides. She left she lost already the implants on the right side. I applied o seven temporary implant back here, so we could fix this again, and after she has lost her Brunner mark, no, experimental implants with this sinus lift. You see here the problem. If you have non resorbing bovine material, and this is close to the implant, this dead body material, which is infected, will loosen the implant and the whole implant gets out. So this is the problem. So finally I managed with a re sinus lift, at my knowledge at this time, with my re sinus lift, I applied this implant, and I made her happy with this also, I had a big operation. But in August last year, she came back, and on the left side now, this nonresorbed bovine material got infected, and I had to remove this bridge. And again, this was opened, and what I do, pray and hope that this is going to close. She was pretty happy. Again, here you see this experimental implant, and with a horrible surface infected as you will see in here. Then I applied two Bicons, I did not do any re sinus lift anymore as I would have done a few years ago, but you see also the two holes into the sinus, so I cover this with a membrane, suture this, and when I do an operation like this, then I always do an envelope flap, I do a periosteal, pedicle periosteal flap as the first layer of closure, and then I’m closing the mucosa just to get this together. Here you see again the very badly osseointegrated non resolving bovine material which got infected and continues with the infection, so it’s very very problematic. Now in November, good situation with these two little implants. We had been very lucky because we had primary healing, and now in six six twelve, and applying this bridge, again very very easy with these abutments, and with an excellent result for this patient, for this very difficult patient with a lot of pain, and unnecessary to have problems with her occlusion and with her sinus lift, so this is the situation now in September twelfth, and she’s very happy about this. Another horrible case. Cases we’re always getting into the hospital. What do you see in here? A beautiful implant, and an infection. A huge infection around an augmented material. So I had to open this, you see the implant and you see here this horrible infected augmentation material. Certainly I do histology, anybody knows what material this is? The doctor does not know anymore what material he applied into it, but it looks like easy graft, but I have to be careful, but it looks like non osseointegrated because you don’t see any bone anywhere around at all. I cleaned this up, and according to from 1948, I was London, he described this, just taking the periosteum and close this, don’t put any foreign body and nothing into it, maybe it’s going to regenerate. I’m stabilizing things like this with an osteosynthesis plate so I won’t have a fracture, and then in February you see closing this and having beautiful, slowly slowly bone regeneration, and certainly a wonder it was able and possible to apply a little Bicon implant, again four by five, covering this with bone, and that’s the result. Would you have any idea what else I could have done? I could have done an iliac crest, put in an iliac crest, make a big operation, and then apply some kind of implant or something like this. I just let the bone regenerate as much as possible. Certainly, the implant is not in such a good position. It’s very low back here, but it’s a molar, and this lady certainly does not want to have any any other operation. Next complication. This gentleman comes in, and he has lost this implant. So what what shall I do? Do another big implant. This is infected, very badly infected. And why is it infected? Because it has a nonresorbing bovine material in there, unnecessary wise for these stupid two kilometer long implants with augmentation, very unnecessary. Then I applied this with these two positioned Bicons, and you see I also removed some of the material. I took a trephine drill, and this material is so sintered. It’s so it’s six hundred eighty degrees sintered, it’s like a tea cup. If you smash a tea cup, you would have the same picture. As you see, no bone around, just foreign body in here. And it was so hard that my trefine drill got not out of the material, so I had to put it in and make the histology with a trephine drill. Applying these two implants, and that’s now the result. Fortunately, in the moment it’s not infected, but maybe because it’s so much bovine material, maybe it’s going to get infected, but hopefully because it doesn’t have a biofilm around the implant, maybe it’s not going to infect. And I think this is a good troubleshooting situation, and this was a good solving this problem. Lady comes from Romania, she is in charge of six thousand dogs collecting from the street. And I looked at that lady and she said, no, I don’t touch her. She must be so infected dealing with six thousand dogs. But her sister, she is a very important medical director of a city hospital in Vienna, we know each other, and she said, please do something. I said, okay, I’ll imply. I removed these very loose, I removed them by hand. You see the histology, and what did I do? I applied for Bicon’s. That’s primary healing. I was very surprised, but I said, as long as she’s going to heal, she stays in Vienna and not going to her dogs. So she stayed two weeks with us and had a beautiful primary healing. Now taking the impression very fast, again, this beautiful jig which helps helps a lot, relining all these abutments, applying this, putting it in like this. You see this? Then you’re applying this very easily, and that’s the result just a few weeks ago. Again, troubleshooting. I wouldn’t know what to do. Otherwise, I would have to wait long long healing, augmentation, and I believe as the implants, and we see this around the soft tissue, that the biofilm really must be different or not present due to this abutment, that I can do much more risky operation in a shorter time to solve these horrible cases. Like this. What in doing this? Okay, it was fourteen years in situ, and unfortunately he lost it, but also broke this one. So I had to remove this, then I discussed with Dr. Morgan, and I said, you know, this one, this we leave because at least he has stabilization for his overdenture, and certainly this looks like, I would say, a Swiss cheese. Accepted? Okay. Actually, you should have to fill something, you have to do something, but with these little Bicons, with these ultra short Bicons, you’re just able to play around, that’s bad to say in medicine play. But to do something and just where you think you have some bone, just apply them in there. Just risky. But you see, I applied seven implants in here, and oh wonder, or not oh wonder, it’s stable. This one later on with this locator, we are going to remove. But here, you see everything seems to be stable, try in, then send it to Paolo, and he’s doing this with a TRINIA base, again with the jig, and to refix everything, and then you have this beautiful result. And we have sent this lady home to Romania to her six thousand dogs, and we hope that this is not going to infect. So now, my last horrible difficult case, not horrible case, very nice man from the UN. He was operated in 1998 in Helsinki by Prof. Lindquist, and who everyone should know Prof. Lindquist, he’s an excellent surgeon as you see this on this picture, but also an excellent piano player, what I always envy that I’m not able to play piano. And he reconstructed him with a radialis, partially bone from the radius, radialis bone after this tumor surgery, and he applied these implants. And this implant now is very loose, we had to remove this because it always was infected, and this is going to be, but I said, well, I just leave this as you will see, and it’s maybe three threads in the bone, and later when the Bicons are stable, I also will replace it. So this one implant which was about fifty percent in the bone, I removed with this special Trifine from Straumann, this works very fine, remove this implant, and here you see it’s certainly partially osseointegrated, as the histology will show you a little later. But again, our problem of this transplant bone, it’s almost no bleeding. It’s a very tough type, minus one bone. Then applying our Bicon implants and covering it again with as much bone as possible, but you see how many free threads you have, and then it’s always a wonder that this whole thing is not going to be infected. I’m always afraid I’m giving antibiotic, and certainly we are pretty lucky. This implant we are not able to remove, it never was loaded, but it will stay like this. Then we have now the Bicons around, and then we’ll see, and you see, and it’s pretty well taken. Paolo would then just explain what kind of bone this is, lamellar bone, and that’s healed, I’m always amazed how these Bicons really heal, because this certainly is infected and later on we will remove this implant after we have been applying these Bicon, loaded these Bicon implants with some bridges. So I hope I could show you why I use by now Bicon, and with this comparison I will show you again. You see, 1997 I had this patient, and this certainly is a paradigm change. I applied here an iliac crest, ninety eight, certainly with IMZ implants, and as these had been not screw like, I applied an additional osteosynthesis leg screw. And you see I applied here iliac crest bone. It was ninety eight. After thirteen and a half years, it’s working, and it’s working as you see down here. But what happened to this patient? She has to clean it very fine, she has to be very careful, she knows that she’s not able to chew too much or have this apple, and what do you see else on these pictures, on these x rays? And it’s very, interesting. But it was a lot of effort, a lot of pain for the patient. Sixty year old patients, they have pain for half a year on their hip. It doesn’t matter who is removing this hip with which golden hands. But what else do you see on these panoramic x rays? I heard opposition. If I’m right, this mandible on this side doubled. Function, function produces bone. Wolff’s Law, as Dr. Morgan always says, due to function, but what’s difficult, if she would have had teeth in the maxilla, maybe she would have had a fracture. Unfortunately, she just had a bad overdenture, and therefore everything worked. By now, I would be able to apply something in the upper, in the maxilla, and then maybe it would triple. But now it’s stable and she’s not able to have more heart diet because her upper dentals don’t work. But it’s very interesting what function is to us, but this is a huge, huge effort. And you, to the Bicon implants, you see how we solve cases like this, you know this case, May ten, in November ten, and now just four days ago with this huge cantilever, and it’s a long and it’s already one year in place with this situation. And certainly, as Dr. Morgan says, I changed myself a lot also. I experimented so much on so many operations and everything, and you can say that it’s like coin of two sides. One side you say, well, he’s getting now so old, and I just turned yesterday sixty nine, and he doesn’t want to operate anymore, so he’s just using these Bicons. But what? They work, so what? But on the other hand, you can say, maybe as also Prof. Bell pointed out, I’m very academic and very scientific, but still I’m very smart enough to understand that the development goes on and on, and many, many operations I have designed and I have worked on, and I have applied many patients very successful, they are not necessary anymore. So then, therefore we’re using Bicon, and the patients the the patient’s sake, because the patients have less mobility and have the same result. And as he says, you may scratch it like here or like here, and I’m now here. Okay. And with this, I certainly with these two smiles, I would like to thank certainly, both ladies smile, but this one lady has less morbidity, and I think it’s fantastic that there is an implant system which will provide almost as good or even sometimes better with less morbidity and less effort and much more efficiency. And certainly, as I said in the beginning, I have to say many, many persons thank you for teaching me. Also I’m pretty old, I’m still learning and I was willing to learn, and Dr. Morgan explained me everything and did all the prosthetic work, and Dr. Marincola and Daher and Murcko showed me how to operate. They took my hand and said, you know, you have to use this scalpel like this. Okay, I accepted this. And Boyd Tomasetti said he always gave me all the hints, we discussed everything. He said, yeah, listen to these people. I’m sure, and I’m using this too, and this is going to be the right way. And, again, to Paolo Perpetuini, he is our artist in the lab, and I’m doing everything with him. Thank you very much. And with this, I would like to thank you for your in for your attention. And certainly, if you’re willing, I’m completely open for discussions. And if you don’t want to discuss, you may go into Internet and mail me your questions, and I will be happy to answer them. Thank you very much.