Why I Need Bicon SHORT® Implants [HD]

Anyhow, I want to show you again why I think I need short implants, especially ultra short implants. And as always, I like to show my team. By now I have to say my former team, as I stepped down in September twelfth. So this was the farwell party and now I’m in my private CMF Institute. And these are the live surgery we demonstrate and also give worldwide lectures. And we are very proud that this is going to happen. And now I come to my core business. When we have young patients like this being hit by a snowblower, he certainly has many many fractures, and our question is, you see a lot of hardware, mandible fractures and skull fractures and maxillary fractures. By now the patient is edentulous, after all he lost his teeth, enough herd work, but he wanted to be reconstructed, and he has no double vision, very fortunately. Anyhow, a patient like this got reconstructed, completely reconstructed with a beautiful prosthetic work. But don’t ask me, sinus lift, re sinus lift on the right side after we lost bone and everything. So it’s an effort, and certainly additional iliac graft and everything, certainly it’s a huge morbidity for the patient, not mentioning all the money he had to spend. And also patients come and say I want to have some implants and fixed prostheses, and you tell the patient, that’s what I told the last thirty years, it’s nice that you want to have implants and it’s good for me because it’s going to be a lot of money, but you don’t have bone. So the patient says, well why don’t you build me up bone? And earlier times we certainly did, we had been happy, and we could do big operations. Here sinus lift, and there in the mandible, as I will show you this case a little later, we did an onlay graft taken from the iliac crest. So certainly we always talked about bone regeneration, we talked about gold standard, what is gold standard, and I will show you a little bit that gold is not gold. And certainly we have a classification concerning the vascularization, because the most important thing, you know, to cut bone it’s easy. To handle soft tissue it’s a little bit more difficult. And bone just will survive, as you saw yesterday by the beautiful lecture by Professor Calhoe, only survive if the bone is being vascularized. Therefore we have class one, it’s the revascularized bone with suturing vessels, the distracted bone from Ilizarov, what’s also vascularized. But that’s nothing for us in the office. For us, it’s our working horse, it’s the inlay. And the inlay, it’s the pedicle bone on both sides, vascularized, something being put in, but this is not vascularized. And then the next class is the onlay, and you heard it yesterday already, and today again. Onlay is most of the time resorbing because it’s just vascularized from one side, and then augmented allografts we don’t talk about because it’s just working with BMP, and this is just too expensive for you in the office. So certainly revascularized is the winner. The first loser is the distraction device used bone or distracted bone inlay and then onlay. So we will talk about a little bit about Class III, our working horse onlay, and a little bit about onlay if we are not going to a paradigm change called short implants. So let me show first class three, our working horse, and here you will see what we are able to do. You just heard this about the split. If you’re splitting and you have to uncover the bone, and as I said, the bone likes vascularization. And if you do a normal split and apply your implant, you will have class four bone and onlay around here. So as Shadi just said, three weeks we wait twenty eight days, and then we are applying our implant, and then this is class three bone, and this is certainly working much much better. We call this the two step transversal or horizontal PSP. Pedicle sandwich plasty, the British would say pediculated. I’m correct? Okay, you see? So let me show a case, an old case, how we use to solve problems like this. You see a thin cortical bone, I’m not able to move immediately, so therefore we do the four cuts. By now certainly, as Shadi said, we do this by piezo, or piezo surgery, as you say, Very elegant, this method by a huge invention. Then we are going on, and you see all on both sides, all the four cuts. Now the fourth you don’t see, but you just think I’m true, it’s true. And then twenty eight days later, we go on and just open a little bit. Later on I will talk a little bit more about this vascularization, applying the implants, and certainly the closing, always difficult, you have to make periosteal split on the lingual side, we fill the gap, maybe you don’t have to fill, depends on, we always use or TCP, or a mixture of both, but at least that’s the only thing I will talk about is it should be resolvable. Never you should use, never a non resorbable material like a bovine material. Okay. You see I never can stop teaching, and I’m convinced about this. So you see this eight years later, one kilometer long implants, as Rainier would say, But excellent results, and it worked. And it shows that the bone will survive being transported if it is vascularized. Therefore I want to show you. Okay, if you’re interested in all these methods, don’t hesitate to read my chapter in Professor Lambrecht’s book, in this bow tie book about implant surgery. And this book was so successful that company asked Professor Lambrecht and me to publish now my own book about oral implants and the bioactivating concepts. I think it’s very very interesting, and also we have now a paradigm change. Here you see how to handle bone, how to preserve soft tissue, and especially you see here what happens with your surgery if you just wait long enough. And I show here cases in this book older than fifteen-twenty years, and there you will see if you didn’t handle the soft tissue of the vascularization the proper way, you will have more resorption than you would like to think of. And therefore we are now at the premier thought that we have. I’m not sure if it’s Hippocrates who said this, and who was his major goal, But certainly everybody of us learns Primum non nocere. So this means, first you should not do harm to your patient. And therefore we always would think, are all these operations I showed in the book, I taught all the last thirty years, are they really necessary? And this seventy six year old patient, who had Parkinson’s, but was a very well known television gentleman, he actually was too old to do an operation. At this time, what operation I would have done? Probably an onlay, or as I will show you later. So at this time, already 1995, I decided to do little short. At this time I used IMZ implants. The shortest IMZ implant was nine millimeters. I applied six implants and as you see only five integrated. But if you see the result, you think that this is going to be successful and with his Parkinson’s he was not able to clean this, he lived in Rome, very rarely he came back to Vienna, and still he took it with him and it was stable for six years. So certainly we have to think about a paradigm change, and after forty years handling with bone, I finally got to a solution thanks to a friend of mine. Before this I heard already Mauro Marincola in lectures, and I discussed with him, but I thought — no, these little things, they can’t work. I never laughed about it, but I thought no, I don’t believe it. Finally Dr. Boyd Tomasetti, a friend of mine, I worked together in 1973 in Kings County Hospital in Brooklyn with him, so I still believe him. He said, Rolf, you go to Boston and you check all the x rays, and you know x rays don’t lie, and they will convince you, and they will show you long lasting cases. So finally I got convinced, and I thought maybe less is more. Especially more for the patient, and this we shouldn’t forget. So together with my resident Professor Rudolf Seemann, decided to start a study at our university hospital to study on tumor patients after transplanting fibular transplant to their mandible. As we had been very successful, we continued also with very atrophic mandibles, and finally also with atrophic maxillas. And I will show you now already little longer results than the last time I was standing here. You see here the resection of the mandible, you see here the application of the fibula, and the beautiful result of this case. A person who had never saw a jejunal mucosa in the mouth will be horrified to see this. But the patients are very happy with this because they have a complete closure with soft tissue in her mouth after resecting a big part of the tongue, floor of the mouth, elbow ridge, and they’re able to swallow, and the saliva is going backward. Also this peristaltic stays a long time, also in the mouth. And it goes wave like this, and you have to see that it’s api peristaltic, so the peristaltic has to go from front to the back, because otherwise the saliva would be transported forward. Bad mistake if you do this. Anyhow, we like this situation very much, because we can do vestibuloplastics and everything, as I will show you a little later. So we started applying our implants, and as you heard today already, over the cortex of the mandibular canal, It’s not very good vascularized the bone. This bone certainly is also not good vascularized, this very tough cortical bone. Applying then inserting and covering this with the bone we are getting out of it. Certainly I did a core specimen just to visualize how little vascularization you have in this type one very hard bone. Here you see the good positioning of the four little implants, and when I saw this on the first patient I thought Rolf, you never should have listened to this Dr. Morgan, I think you’re crazy, this never is going to work. The poor patient, but the patient knew about this. We said, it’s an experiment, never this was done before worldwide in any patients, I don’t know if it’s going to function, but maybe if we are lucky, you will eat schnitzel in three months. Yeah, you’re laughing. This lady didn’t have had anything to eat for more than three years. She couldn’t swallow, she couldn’t eat, nothing, just a soft diet. So patients like this take rest. So uncovering five months later, certainly we waited a little longer than in Boston, had waited just a few weeks. Anyhow, and the problem in this patient was, unfortunately, she had dentition in the maxilla. So it made it a little bit more difficult, she had a crossbite there, but everything worked out. Now you see here a little mistake, not by me applying the implant, but to get the curve, the curvature of this long fibula is very difficult, and here it was not the curve perfect. So therefore this is not well positioned, and later on as you will see we kept it sleeping. This is now the bridge work, and you will see a little later with what material it was. So we started loading six months later, and the lady was very happy. Here still all four implants are loaded, and this is the first panoramic picture. Very good situation, you see also the bridge work in this picture. And here if you see the mucosa around the jejunum, no problem. We had here a little bit problem, so therefore I started a free vestibulome plastic with jejunal graft. Anybody in this room did this? I’m sure not. But we specialized in this, and it really is excellent as you will see. So we’ve freed this, and the special is we are also able to elongate our lower lip, and makes it more comfortable for the patient. Sutureing in the free mucosa, and hoping that it’s healing in, then we are taking some dressing and just see the beautiful result how the mucosa was taken, and certainly the perforation of the implants will look much better later on as you see. Now putting to sleep, this one implant, now sixteen months loading, excellent results and a very happy patient. You see now how the mucosa looks beautiful after this vestibuloplasty. This I left by purpose just to see the difference and show the difference of a free vestibuloplasty with free jejunal graft, and none. And we know from other cases that implants also work in this tissue. But now, probably the most interesting pictures of my lecture today will be these following pictures, and please pay attention because this is for me very sensational. Nobody thought of, nobody believed it, and even Dr. Morgan did not dream of expecting this. You heard yesterday again Rainier about bone growing toward the top of the implant. I’m handling now my first implant, it was in Biegelbach in 1970, together with Axel Kirsch in Freiburg, after we stopped studying dentistry. So I’m dealing now almost forty four years with, and everything we had been afraid of, of losing bone. So this was now half of my life, followed me losing bone. So certainly we expected here too, and all these publications I thought, well, it’s interesting, but I’ll wait. If you see now eleven, the original x-ray, and twenty four months later the newer x-ray, at the end you will see even more recent x-ray. Here you will see now too much difference, but now we will start getting it enlarged. You see here, it’s no straight line around the bone. See that? You see it’s straightening out up here? Everybody sees that? You see the difference from here to here? So let’s enlarge again, just concentrate on the two implants on the right side. The same is also on the left side, but on the right side. Look how the bone looks oh sorry, look how the bone looks around here, and how the bone looks here. These are original Kodak films. By purpose I never changed to electronic films, because electronic films you are able to cheat with Photoshop. These are original panoramic pictures, and if you do not believe me, just come and visit me, you’re most welcome, and see the original films. That’s very very important, because otherwise many people would say no, it’s not right. So you certainly see a straightening out of these cortical, these had been not cortical, but these are now cortical structures. And this certainly is according to Julius Wolff, who published 1892, Das Gesetz der Transformation der Knochen, Law of Transforming the Bone. And he always said, form follows function. And he was discussing, and here now you see even later on how this looks beautiful, the tissue, and even now after twenty eight months loading, it straightens out and straightens out. Here again, an enlargement. So certainly there is something like Müftü is publishing about these Bicon implants with the finite element analysis, and it looks like there is a better distribution of the compressive force, and showed yesterday in his wonderful lecture again, that this is leading to a unique Haversian like bone morphology, well some bone, but especially a lot of lamellar bone. And here you will see this is also according to Frost’s paradigm change with the Utah paradigm of skeletal physiology, and he showed this mechanostat, and it was remodeling. Just see that we have a little area between adapted state and overload, and just in this area we will have bone gain. So in this area the Bicon implants must be situated and located, because going more up here you would have fractures. And this is out of fracture treatment and fracture theory. But this also is the same with the implants. And Culman was a physicist and he started the graphic statics. And Wolff later on, and this was published 1865, and Wolff started 1870 to think about the transforming of the bone, And they discussed very often together, he was in Leipzig, and they discussed and later on in Zurich, and he discussed this was both. And they could show according to these forces the same to the hip, because Wolff worked most of the time on the hip, that according to these forces the collagen fiber will collect, will gather and be a cortical structure in here. Very very interesting. And this means if we take this little panoramic x-ray of this lady, just turn it to the right side, and we can follow that from the condyle going down to the forces, it’s gathering all the cortical, all the fibers and all the collagen fibers and everything is collecting, gathering, being together into a new cortical structure. Very logical, very fascinating, and for us it is fascinating that these little implants seem to have the right compression, the right dynamic compression to change the bone in a transplanted fibula from the right side to the left mandible. I don’t know if you understand my fascination, but I’m really fascinated, and I’m fascinated for the patient because it works and the lady is very very happy. When the lady came and the husband says, you know, yesterday we went to the restaurant and we had the first time schnitzel, she was having tears in her eyes when the schnitzel came, and it’s the first time she took a bite. Anyhow, now we had been so successful with our tumor fibula patients, we said why don’t we have a patient like this, with this little bone? What would we have done in a patient like this ten years ago, fifteen years ago, twenty years ago? Well, very simple. Either I would have done a bone transport class-two, this means a distraction device, as I will show you in a second, I would do an interposition class three, as I will not show, because otherwise it would be too long, it would be longer than two hours clip. And then, maybe I would do an apposition and only, as I will show you in a second. So this lady, how old is she? What do you think? Fifty, yeah. Okay, little exaggerated. So she would be mad at you. Thirty eight year old lady, and she had other operations before, but it would take too long. And I did a distraction device, and this little lady. And just look what she had. It was July, now it’s January. What happened? What happens very often with this? Dislocation to the lingual side because of the muscle sling. Do you want to have an instrument like this in your mouth for how many months? Seven months. Okay. Would you operate this to your mother? I would do it to my mother-in-law. Oh, you’re still awake. Okay. No, no. I had a very nice mother-in-law, but anyhow. No, I wouldn’t do this anymore. And why and furthermore, why I wouldn’t do it? What happened to this? We had a huge atrophy of the bone, and we had a fracture. Because this was too thin. So I was lucky and the person upstairs helped me, And it was like an osteosynthesis, it healed by itself, so I made so many mistakes. So finally I also did a sinus lift, as always at this time. She had a lot of hardware, and this is the result. Certainly a wonderful result, but today is it necessary to do all these operations? I hope you will give your answer yourself. Other method, doing an iliac crest, general anesthesia, taking a piece of iliac crest bone, apply this, ninety-ninety five, then ninety six, it looks good. And what happened two zero four? What do you see here? Bone up here, IMZ implants at this time. And I told you long term results, you just have to wait long enough. We have on the left side about thirty-forty percent of bone loss. Here we have more than fifty percent of bone loss. But what’s so interesting on this x-ray? What do you see? Now you have to wake up. Don’t wait for coffee break, otherwise it will stop and you don’t get coffee. You see here? You see here? What happened here? Function forms bone. She has no dentition in the upper, little by little she learned to chew again and everything, and due to the function the bone grew. The transplanted bone vanished, but her own bone grew. No Photoshop. Reality. Anyhow. And she did not have so bad a dislocation, she is happy, happy as could be, and now fifteen years later the resorption goes on a little bit, but she keeps it very clean and also these IMZ implants are in her mouth. It still works, but it’s a lot of effort, lot of pain for the lady. She was limping for half a year, had crutches all the time for a long time, that’s a big effort. Anyhow, same patient, not the same patient, but a similar case. So eleven, I learned a little bit. You see seven millimeters in height, and maybe forty five minutes, maybe one hour of operation, very simple as you always see with this system, and that’s the result. On most local anesthesia, maybe an hour then uncovering, doing the prosthetic work, and here we just may show the material we also started to work with, TRINIA. Maybe I started to do this because I didn’t know where are the pitfalls and where are all the problems. I just went, started together with Dr. Morgan and with Paolo Perpetuini, we had been very lucky, it’s very easy, and to be honest it’s so easy that I am as an oral maxillofacial or cranium maxillofacial surgeon do this by myself with my lab technician’s ladies. It’s very very easy and here we just may go a little bit faster, we’ll have to tap first this with the bridge later on abutments by himself again and then apply this prosthesis. And here already, just to mention this, you see different length of cantilever. As we on the university clinic, always have to test something, we always have to try something different. And here we are testing if the cantilever length will have an influence on the cortical structure of the implants. We will see, time will show. Now sixteen months loading, so time lapses as my speaking time, and certainly it’s going on, and just see how beautiful this situation is with four implants and the patient is very happy. So now we’re having already ten patients in this series for the implants, and the measurement protocol shows that the bridge span compared to the implant span is four point three to one. That’s a pretty long span and we are very happy that it seems to work. And time will show if it continues. This is our Kaplan Meier N40, and it’s more than half an hour, one and a half year, almost two years by now, and we have lost one implant. Very bad, because I want to have it one hundred percent, And Doctor Morgan said, Rolf, what did you make wrong? Which mistake did you do? And I can give you the answer. You see this lady, she had a fracture, And this is a nightmare for a young oral surgeon resident at night to apply an osteosynthesis plate which is thicker than the mandible. But he did an excellent job, young man, and here you see the result. And again the bridge work, perfect, I don’t see any mistakes, so Paolo did not make any mistakes, but here you see the result, one implant is lost. The lady certainly spoils our statistics, we are very mad about this. But I made the mistake. She had this huge osteosynthesis plate, titanium, and she had a lot of screws. And during the operation from above we couldn’t see and we didn’t notice that there are still and you see still the holes you see a little bit. It’s not completely osseointegrated and I was stupid enough to apply one of the implant just over the hole. So this is no problem. Certainly I could go back and say, yeah, I reinsured an implant to save my statistic again, but she says, you know, I had enough aberrations, I don’t want anymore, just leave it. So now we have a statistic and see if this system also works on three implants. So let’s see what time will show. That’s the result on three implants and it’s working. So now, as we are successful in the tibia, and we’re successful in the mandible, very successful in the mandible just with one implant loss. We thought, let’s go to the maxilla. Maxilla case like this. What would we have done? We would choose our working horse, we would do inlay. One of the best inlay, one of the most successful inlay methods are sinus lifts, you saw already beautiful pictures today by Shadi. And this is the standard sinus lift I did the last twenty years. Everybody thinks, that’s not so interesting. But just imagine twenty, twenty four, twenty three years ago, when I came to Vienna, everybody used a sinus lift plus What material? You’re right, iliac crest. Nothing else. I had big problems. Being a foreigner in Vienna and Austria, we didn’t have that in EU, and you know that sometimes it’s a little difficult between Austria and Germans, and obviously the Germans, and I’m a big one, you know, Germans wouldn’t be so difficult, but a big German coming to Vienna, and I said no, no, I don’t take iliac crest. I take an algae derived material, like sold in the United States, very similar to SynthoGraft. This is GCP, but this material is resorbable. And more than twenty years ago, September ninety, we started to do not iliac crest or autogenous bone, but synthetic bone. And this is a normal sinus lift. And at this time, believe me, we had been proud like crazy that this worked with ten, fifteen, thirteen millimeter long implants. And I myself operated five fifty four sinus lifts between one to five millimeter remnant bone. It looked before like this, then like this, half a year like this, and a year later it was loaded. So I was very proud and I gave many many lectures. And out of these, I worked up the implants I was allowed on the patients myself with six fourteen implants. Not so much, but the rest are just referrals. But I was very proud and I published this, that we just lost 4.4%. So it’s an excellent safe method. Safe method for the patient, but a lot of morbidity. So certainly I’m very happy by now that we are able to do together with Bicon this study. And you see this patient does not have very much bone, and here are the sinus, and at this earlier time we would have done sinus lift. Now we are doing these four little implants. Just also less than an hour in operation. Here already putting in the horseshoe like bridge. And certainly the patient is so happy to have a free gum because now the red wine tastes good again. The cooks are able to taste their food. And certainly very happy patients. With this result, in the meantime he also got in the mandible, his implants, and everything worked. And now it’s stable, stable for nine months, and it works, and we are very surprised. And if it works nine months, it also works ninety months. No question, and we are looking forward. And just also look his aesthetic change, because of the vertical height improved so much more. Now after we had been successful with all these cases, then I thought, well, let’s do even more difficult ladies, mostly ladies, with almost no bone. And what kind of operation would I have done in earlier times for these patients? Very simple. In 1980 my former chief Professor Haile and I designed together with Professor Bell, who showed us the Le Fort I osteotomy in 1975, with wonderful animal experience with monkeys and dye marketing, everything he could show that this works. So we changed this method on leaving the palatal bone and the rest of the maxilla looks like a horseshoe, and therefore we call this the horseshoe like osteotomy. A very difficult operation, the first one we did together with Obwegeser because we had been afraid that this is not going to work. It’s a difficult operation between six and some more hours, But the most important thing is we have an inlay class three, because the bone is situated in between vascularized bone. Here the vessel and here this bone is also vascularized due to the palatal, greater palatal artery. Big operation, but also very successful for the patient. But certainly iliac crest, one centimeter, and the patient is limping at least for several months. But we had been able to advance the maxilla, so it doesn’t have a pseudo progenic situation. Advance and add one centimeter of bone in between with a very good result, as you will see now on this lady. Wonderful rejuvenation of this lady now, she is sixteen years stable and you see in the lateral what changed with this operation, and certainly it makes her happy and makes her functioning. But a lot of morbidity. Obwegeser always said, Rolf, it’s not going to be stable. You’re going to have a relapse of the maxilla. We do not have because it’s good occlusion with the prosthesis, and checked this. And then on thirty six patients, my resident who did his PhD with this, he did the workup and he could show that we just had eight point seven percent implant losses, and the Kaplan Meier shows two years failure free ninety five percent, very good. And it’s an excellent result and we have been very very proud. We had this good result over thirteen years because the onlay, the bone what resorbs, something like Blumquist had also in a two stage operation after four years, seventy percent survival. So he had lost already twenty five percent of implants after such a short time, after four years. So we had been really proud and we published everything about our beautiful method and now somebody comes and says I think you don’t need this. So I really had to jump over my little trough and say, trough which I would call pride because I’m such a good surgeon, and said let’s try on this lady implants, as many implants I’m able to apply in this little bone, because half of the implants I’m going to lose. Probably. And with sinus lift, with sinus lift abutments and everything, small ones, a little thicker, but there was no more bone. She and I was lucky she didn’t lose one single implant of this. Now the workup again, the upper and the lower, we don’t have to go through this again, but here you see the TRINIA. We had been trying this first. It’s just fantastic to have the base cut come prepared, and now just look, these implants are not straight like soldier by soldier, side by side. We just slide it where it was bone. And this is possible. You see how they stay so different, and this is just possible because of the three sixty degree freedom with these abutments. And you’re able to apply this, and it’s sometimes tricky, you have to wait and you have to position this till you all have it in the implants built in, but it’s going, it’s able, you position and finally you have it in position, you start tapping it with this base, bridge base, then you tap single by single your implants, I think here it’s eight, and then you have this situation. Then certainly we take, and Paolo always insists also, it’s a lot of sending the parcels between Vienna to Rome and back and forth, but anyhow we do a wax try, and I think it’s very important, that’s good prosthetic workup, and this is now in the mandible. And also again try in, then checking the occlusion, and here you see how important it is that we did the try in. Certainly this occlusion is not satisfactory, and we do a new bite registration, then again the vertical height, and we’re doing with the basis again mandible taking the mandible position again and again with different materials just to have the right position. And at the end we are taking the mucosa lining again so that the bridge work will be perfect fitting at the end and the speech will be good. And just twenty days later you just get this beautiful artwork. I get this from Paolo, this beautiful artwork. Metal free, between seven and nine gram, just nothing, and then you apply this to the patient and again just with your fingers in few minutes chair side time. And it must be very easy, otherwise I couldn’t do this as an oral maxillofacial surgeon. Maybe you can say, yeah, you did your life, long time, treating TMJ patient always going and working with splints, you’re right, because I know something about occlusion, but still this is very easy to make patients happy like this. So certainly, and it’s stable now for eleven months, and it looks like we started it yesterday, and certainly she’s happy. And even in this situation, the occlusion is not this situation, the bite situation is not so perfect, but still everything works. So, now I will show you some difficult cases, and certainly you can see that on all these slides you see what kind of education and what kind of development I did. 2006 I was very proud when I announced in Montreux on a Camlog meeting, the international Camlog meeting, I announced the first tailor navigated implant position, and this was a patient operated in Vienna, televised live to Montreux, and we could show how our newly designed Camlog guide system is going to work. And on the maxilla you see how beautiful I was able to apply six implants in the maxilla in this lady and bypassing the sinus. It couldn’t be better. And certainly I could not do this without navigation. And I was very very happy because we had been the first ones and we had been so successful. But you see, we are learning in everything. And then the lady came to me and said I want to be treated in the mandible. And this was ten. 2010. Shortly before I went to Boston in July. And you see how thin in this area the mandible is. What would you do? What kind of operation would you suggest me to do? Don’t tell me Bicons. They’re not able to. But I will show you other tricks. So certainly I had to do the PSP. The two times or two step pedicle sandwich plasty, the horizontal pedicle sandwich plasty, what I just showed to you. And in the second stage, when I tried to widen, as Shadi this morning showed you already, with all the beautiful special instruments widen and widen, I failed completely on the right side, and I failed completely on the left side because the bone started breaking. It just was too thin. Or I made mistakes, or you know, I have two left thumbs compared to your right thumbs you have. Anyhow, I failed, and in between I got to know Bicon, and you see, a year later I started to apply these implants. And this is certainly a crooked position, But I couldn’t do anything else in this horrible, just remember this x-ray, horrible thin bone. And the position is not perfect, but at least she has on both sides two implants. And now it’s three months later, four months loading, twenty months loading. Is it a good compromise? Instead of a failed operation? Certainly. And I made the patient lucky. She’s a delivering nurse, she never has time, and now she says, you know professor, why did you do so much hack about my maxilla? It would have been much easier to do these small implants too. And I said, yeah, you’re right, but at this time I didn’t believe in this system yet. Anyhow, a patient I operated in 1999, you see I was always very busy, he had no bone in the maxilla. And at this time I said, yeah, if you want to have eleven-twelve millimeters long implants, you have to have an iliac crest transplant. Everybody accepts that this wasn’t the right indication. And why, and even if I would have managed a nine millimeters or ten millimeters implant somewhere in here, what would my teacher say, Rolf, you’re wrong. You’re not able to apply up there implants, because the ratio between implant to crown has to be one to one, thank you. Okay, so I said I have to be cruel to you, you will be limping for half a year, because it’s an older gentleman, sixty nine, so no, this time he wasn’t sixty nine, he was a young man. Anyhow, I applied an iliac crest. And I thought I was perfect, successful, wonderful, and you saw I built up here, bow, and you still see some leg screws and everything. But he’s a psychiatrist, and he’s very stubborn. And he said, now I have so beautiful alveolar ridge, I take a normal removal prosthesis and everything will be fine. I said no, no, no, you should not do this, because the bone is going to resorb again. Oh no, I know better. I’m a psychiatrist, I know everything. So to make it short, this looks twelve years later. No bone, even less bone than before. Now he came and he didn’t know that he has so much resorption. Now he came and said, you know, I would like to have implants. And I said, wonderful. But I told him, you’re lucky, now I have an implant I’m able to apply. These are short implants, and this is possible, and just see what I did. Wonderful. And now, you may say that my teacher was wrong between the ratio one to one. You see the ratio here? I would say one to at least seven, and it works. Beautiful bridge by Paolo Perpetuini, back and forth, and that’s the situation with the implants in the mouth and his smile. The patient still is very stubborn, but at least we could show that with this system it is possible to have it one to seven. Very nice gentleman came with this. Rainier would say with a kilometer long implant, with an infected sinus. He had this less than half a year in his sinus, this implant was loose, I removed it with my two fingers and pus came out. So what are you doing in May ten? What would you do with this? In a situation like this? You would do anything after removing the implant. You do any flaps? Any You do a lot of irrigation? Oh come, be fair to me, say yes or no. You have to do something when it comes in your office. Or you just give him a bill. Now I was taught at this time, irrigation. I was in the private vault of my chief, Haile Schilley in Freiburg, and every weekend we had to irrigate at least seven sinuses. No irrigation. Don’t touch it at all, wait. Antibiotics, if the patient is happy, lucky, it closes by itself. It closes. If it doesn’t close, we use a Bichard transplant, the fat pad. We stick it in after two or three weeks if it’s not getting clean, and then it closes again. No flaps, never any flaps. Since more than twenty years my residents are not allowed to do any flaps in the maxilla. That’s a no no, because of the vestibular. Anyhow, so we had been very lucky. He was waiting more than a year. Still had a little sinusitis up here, a little mucosa change, but then I said by now I will use a little Bicon. I applied a Bicon and certainly I removed some bone just to see how, if the bone really regenerated, and you see here also a beautiful hard section as you have seen yesterday, hundreds by Paolo, and you can’t imagine how difficult it is to get so beautiful hard sectioning of bone. That’s really tough work. No scratches, nothing, and you see beautiful. And therefore I knew it’s going to integrate perfectly. And you see now the clinical aspect, and you see short after this, almost a year, you see how beautiful this is integrated. But if you compare this now, seventeen months loading, you see how beautiful the bone gained and Rainier really is right. You see the difference in seventeen months how bone gained. In a situation where you had an acute sinusitis, pus coming out, and then it’s also fascinating that you see even up there some remodeling is happening and some bone is due to the balance, due to the stress transportation, something is happening up there. A very good friend of ours came and she said I want to have implants. So we did at this time the normal work up with all these navigation tools, and the person who planned this, the dentist who sent it to me said Well we have to sacrifice this tooth at least to have one normal implant. And then he planned a lingual bypass, and it’s just nothing. But if you see this situation as Shadi just showed, Sometimes there will be not enough bone even for a Bicon. And therefore it’s so important, like in my hands, that I’m able to know what indication of bone surgery would be given in here, and what would you do in a case like this to elongate the bone? Well, in my hands I do a pedicle sandwich plasty, or pedunculated plastic. This means I do the same procedure as if I would do a sandwich. I would do a distraction device. I’m opening this, I stabilize this with little microplates, I fill this with SynthoGraft or other resorbable material like our algae material, And then these plates stabilize the whole situation, and three-four months later I stabilize this with implants. In a big situation like this with a long implants, but this case I certainly used Bicon. Here you see that it’s a very difficult area and Shadi showed you already today the mental nerve. And you here see it a little bit more visualized. You see here the freed mental nerve. And you see the piezo is cutting just over the mental nerve. With piezo this is possible. But never do this with a rotating instrument and the whole nerve is gone. And I know what I’m talking of because I operated a lot of things like this before piezo, before had this brilliant idea. So we cut this. And don’t be mistaken, the mandible is very low. But the mandible is more than one centimeter deep. Very difficult. Okay, then we stabilize this with these micro or mini plates. And I took a little piece of bone from here and squeezed it in between here, and you see the second piece here. So one piece is here, I took the bone from here, squeezed in one here and back here. Also the plates are in place, it could fall down a little bit, so to make sure that this is because then it also would squeeze the nerve and this is not good. The patient still has normal sensation, filling this with our material and closing and waiting, and nine months later applying these two Bicon implants, and just the follow-up, nine months later was the application, and twenty one months later you see the clinical aspect and the beautiful x-ray as if nothing would have happened. Everything is healed. In the meantime I have removed the osteosynthesis plate and it’s a perfect result. So you see certainly also, not in every case, and I do get difficult cases, not in every case you’re just able just to apply these implants, but if you have to do augmentation, if you have to do sandwich plastic, patent plastic, whatever it is, you are able to do this operation a little bit smaller than with these long implants, and it’s less morbidity and less danger for the patients. I’ve shown you already the two step transversal PSB, and if you learn how to handle apicaliosteal preparation, everybody who hears this says, it’s difficult. Yeah, it’s difficult, but it’s learnable. And if you’re used to it, and with special instruments, you’re able to split the mucosa above the periosteum. And if you manage to do this, you can do this preparation one step, because you’re leaving the periosteum in here. And then you can split whatever you do and this bone will stay class III, because the bone is vascularized. So a one step transverse PSP. If epiparyostal preparation is possible, it’s very elegant. And I showed to you in a very difficult situation, in the mandible anterior part, there is very little space and this bone is class one, as hard as rock. Concrete. So you see here, you see how thick the bone is? Almost as thick as the Curie saw. Zero point five millimeter the Curie saw is thick. And I prepared just the mucosa and the periosteum stays on the bone. Then I start inserting the finest bur you can have. And start drilling just after I used beaver knives, and this bone is so hard, this bone you’re not able to break with a chisel. It breaks in thousand pieces. It breaks like a China cup. If you try this China cup to separate, it’s not possible. Just with a bur. And now I’m using these widening instruments. Very slow widening, turning, turning, turning. It takes a lot of time, but it’s worth it. And I widen this and everything is still the bone is still vascularized because periosteum is still on the bone. And now you see I have widened it up to three millimeter, so I’m able to apply a three millimeters 3×6 or 3×8 mm implant. Now on the other side, and that’s the result. So whenever you are able to do an epiperiosteal preparation, much easier on the maxilla, but also in the mandible, then you are able to do it one step, otherwise you do it in the two step, as Shadi just showed you. This is standard and these are always very very good results if you give three or four weeks time to revascularize the bone. Another case, so I have just four minutes left, I will make it in time. This lady came to me, she’s from South Africa, huge infection, but she’s not coming from South Africa just for me, but she’s in the UN working, But it sounds always good, somebody from far away. With a big starting osteomyelitis. Where do I see that this is a starting osteomyelitis? Because of the mandibular nerve is very dark and the infection goes up and up and up. This is the clinical situation. She has some beautiful material I just heard, or Shadi mentioned. You shouldn’t have mentioned this material anyhow. This infected material with this implant, loose. This is the histology result. Just infection, no bone. Bone would be blue. The only, now we are in between here, some new bone, this is the only new bone formation in this whole thing. All infected, horrible, shouldn’t be in this place, so I removed and cleaned it. What would you do in a situation like this? Which filling material would you use? SynthoGraft? Nothing. Thank you. In an infected situation, please never ever use any material. No material could work. So leave it open and certainly I stabilize this with an osteosynthesis plate, because otherwise it could fracture, and I used the method suggested 1948, shortly after the war, to use an envelope flap, use periosteum and close the whole situation. And here you see the periosteum from the envelope flap out of the buccal side, just close this and wait. And wait and pray if their bone will get into existence. February ten, twenty months later, just look how much bone regenerated without any material. Periosteum by itself, applied an implant and covered it with own bone, and here you see four months loading, you see the result, and now just compare sixteen months loading and again see how much sclerosing, new bone formation, wonderful bone formation, and also some gain already over the implant in a huge former hole. Nothing was in there before. So you see how good this is. So that’s an infected implant in the lower and the upper, all in bovine bone beds. Horrible situation, everything infected. Then this implant got removed by the dentist and he filled this again with bovine bone and was still infected. And I removed part of the infected material, and you see this bovine bone, just everything infected, horrible. Then later on I applied two implants, good position, and I took some histology and you see still no bone, just horrible partially infected bovine bone without any regeneration. And it’s a foreign body, life long time for the patient. But you see the Bicon implants are so positive that everything worked and it stays in place now already since nineteen months, and loading and perfect situation. Gentleman came after fourteen years in situ with this situation, one implant just we could leave, it’s like Swiss cheese. I applied again just in places where I had a little bit bone, some of these little implants. This one I left, this implant, and we had been very successful with this situation. And here you can see the TRINIA bridge, how we apply this with a jig, and then the final situation in November twelve. And he was actually satisfied, but he said no, no, my friend has a telescope bridge, and he removes it every evening, and he removes it in the restaurant to clean it. I would like to have that too. So I called Paolo, and he said, you know, he must be crazy. It’s so much work, but Paolo, as friendly as he is always, he said, Okay, I’ll do this to make this gentleman happy. You see here now telescopic crown, this also is possible with the Bicon system, and you see it here with telescopic crowns, the patient is able to remove it, take it out and clean it, and put it in again. So with this system you just bars, screw retentions with telescopes, and you are able to do the cemented method. So I hope I could show you why I use or why I have to use Bicon implants by now, after I had done so many operations and I had made so many patients happy with huge augmentations and everything, because they at this time didn’t know that there had been an alternative. If you ask me now, I will not do these operations anymore. Also it’s very touching for me that I did this and I was successful, because I know there is an alternative. And I just wanted to show you this one patient again. You see she had an iliac crest transplant, and it’s interesting to see, and certainly and the other lady just was operated one hour in a very bad occlusion situation, so she had to have here screw retention just in front, just to have an occlusion. Both ladies are happy. No question. But the first lady doesn’t know the alternative. And the second, I’m not able to do the other operation anymore, because I know the alternative, and I shouldn’t do as little harm as I know to do. So certainly, it’s always the same that the greatest enemy of progress, and everybody of us should think about progress of themselves as misapprehension and it’s not in your lens. So I think I could have shown you that less may be more, or less is more. Maybe you will say short is sexy. That’s no question. It’s something about it. And I would like to thank these persons for teaching me, Dr. Morgan, Mauro Marincola, Shadi, who you just heard, and he certainly is the surgeon, so also does these difficult things. Dr. Laura Murcko and Dr. Boyd Tomasetti who brought me into this team. And certainly, I mentioned already our Michelangelo of the dental lab technician, our Paolo Perpetuini, who’s doing all our fantastic work and works with us. So with this I would like to thank you. Certainly you saw that I did a lot of big operations. I changed a little bit to little small implants. And with this I would like to thank you and whenever something doesn’t believe me, just contact me by email, come to Vienna, look at all my x rays and certainly I would be happy to welcome you together with my wife in Vienna. Thank you very much for your attention.